Universal Adversarial Perturbation Attack on the Inception-Resnet-v1 model and the Effectiveness of Adversarial Retraining as a Suitable Defense Mechanism

In this study, we analyse the impact of the Universal Adversarial Perturbation Attack on the Inception-ResNet-v1 model using the lung CT scan dataset for COVID-19 classification and the retinal OCT scan dataset for Diabetic Macular Edema (DME) classification. The effectiveness of adversarial retraining as a suitable defense mechanism against this attack is examined. This study is categorised into three sections-The implementation of the Inception-ResNet-v1 model, the effect of the attack and the adversarial retraining. © 2023 IEEE.

Long-term safety of 3 years of ozanimod in moderately to severely active ulcerative colitis: an interim analysis of the True North open-label extension

Background: The phase 3, randomised True North (TN) study demonstrated the efficacy and safety of ozanimod for up to 52 weeks in patients (pts) with moderately to severely active ulcerative colitis (UC). The ongoing TN open-label extension (OLE) aims to assess the long-term efficacy and safety of ozanimod in UC. This analysis evaluated the cumulative long-term safety of ozanimod in these studies, which included pts with up to ~3 years of treatment exposure. Method(s): In TN, pts were randomised to once-daily ozanimod 0.92 mg or placebo, or to open-label ozanimod for a 10-week induction period. Ozanimod clinical responders were rerandomised at Week 10 to ozanimod or placebo in the maintenance period through Week 52. TN pts were eligible to enrol in the OLE and receive ozanimod if they did not achieve clinical response at the end of induction (Week 10), lost response during maintenance, or completed maintenance at Week 52. This interim analysis of the TN OLE (data cutoff: 10 January 2022) included all pts who entered the OLE from TN (n=823). Safety was monitored from the first dose of ozanimod in TN and throughout the subsequent OLE. Exposureadjusted incidence rates per 100 patient-years (PY) were calculated. Result(s): The average age of TN OLE study participants was 41.7 years (+/-13.6), 41% were female, 62% had left-sided UC disease, and 35% had prior exposure to tumor necrosis factor inhibitors. Total PY exposure to ozanimod was 2219 years (mean [SD] exposure = 2.7 [1.6]). The most frequent treatment-emergent adverse events (TEAEs) reported through OLE Week 94 (up to 146 weeks of continuous treatment) are listed in the Table. Most TEAEs were nonserious;TEAEs leading to discontinuation were uncommon. Bradycardia was reported in 3 pts (0.4%;EAIR 0.1/100 PY;2 in TN and 1 in OLE;no pts were discontinued from treatment). Macular edema was reported in 2 (0.2%;EAIR 0.1/100 PY) pts. Reductions in ALC were common (470 [57.1%] had ALC < 500 cells/mm3), as previously described, but ALC reductions were not associated with the occurrence of TEAEs. Malignancies were uncommon (n=13 [1.6%];EAIR 0.6/100 PY), and included 6 basal cell carcinomas and 3 colorectal neoplasms. Two deaths were reported: 1 due to COVID-19 and 1 sudden death. Investigators deemed both to be unrelated to treatment. Ozanimod was not associated with an increased risk of ischemic heart disease or thromboembolic events. Conclusion(s): Long-term exposure to ozanimod for up to 3 years was well tolerated in pts with moderately to severely active UC. No new safety signals were observed with long-term ozanimod use in UC (2219 PY exposure). Safety findings are consistent with previous reports from the UC and multiple sclerosis development programs (>16,512 PY exposure). (Table Presented).

Tracheotomy In Patients With Covid-19

Relevance. The coronavirus rush, which has appeared since December 2019, has an impact on economic, medical, and social development in all countries of the world. There are still no standard diagnostic and therapeutic plans aimed at limiting this infection. Purpose. To determine the therapeutic role of tracheostomy with patients with coronavirus infection. Material. The prospective study of 100 patients with coronavirus infection was carried out on the basis of State Budgetary Healthcare Institution "Interdistrict Multidisciplinary Hospital" in Nartkala city. When patients were admitted to the clinic, they were randomized into 2 groups depending on the therapy: the first group (comparison, n=50) - patients received traditional therapy in intensive care;the second (main, n=50) group - patients underwent tracheostomy in addition to standard therapy. The average age was 56.2+/-4.8 years. The women's average age was 55 years (55.0%), and the men's - 45 years (45.0%). Methods. Determination of the syndrome of endogenous intoxication, taxation of lipid peroxidation intensification. The local microcirculation was investigated by the apparatus LAKK-02. The activity of the coagulation-lytic blood system was found by thrombelastograph TEG 5000. Results. Early COVID-19 infection demonstrates signs of intoxication, oxidative depression, phospholipase activity, microcirculatory and hemostatic disorders. These changes were the cause of the development of life-threatening complications (neurological, pulmonary, cardiac, etc.). They were associated with the type of treatment. Traditional treatment and the use of mask oxygen turned out to be ineffective, since the homeostasis system disorders remained throughout the investigation period. The inclusion of tracheostomy in traditional therapy makes it possible to quickly improve the course of pathology as it purposefully affects the pathogenetic links of the homeostasis system. Conclusion. The use of tracheostomy in the scheme of standard treatment of coronavirus infection allows improving the effectiveness of general therapy of COVID-19 patients, especially with severe forms.Copyright © 2023, Codon Publications. All rights reserved.

Branch Retinal Vein Occlusion Occurring After 2nd Dose of Sinopharm COVID-19 Vaccine: A Case Report

An old-aged woman was evaluated with branch retinal vein occlusion (BRVO) vision reduction in his left eye three weeks after the Sinopharm coronavirus disease 2019 (COVID-19) vaccination. Her best-corrected visual acuity (BCVA) was 1m counting finger in the left eye and 10/10 in the right eye. Initial retinal findings were superior retinal hemorrhage with prominent retinal vein dilation and tortuosity in the left eye. Fluorescein angiography (FA) and optical coherence tomography (OCT) confirmed a BRVO diagnosis. Blood reports showed no abnormalities. Antithrombotic treatment of 80 mg/d low-dose entrocoated ASA was administered. In addition, an intravitreal Aflibercept (Eylea) injection, monthly and ongoing, was prescripted, which led to a decrease in macular edema, retinal hemorrhage, and height of serous retinal detachment. Moreover, the BCVA improved to 2/10 after a three-week follow-up.Copyright © 2023, Journal of Kermanshah University of Medical Sciences.

Determination of Factors Influencing the Health Belief Model (HBM) and Adherence to Intravitreal Anti-vascular Endothelial Growth Factor (VEGF) Among Patients With Diabetic Macular Edema (DME).

Background Diabetic macular edema (DME) is becoming one of the leading causes of blindness worldwide with a significant impact on quality of life. The effectiveness of intravitreal (IVT) anti-vascular endothelial growth factor (VEGF) therapy has been established by clinical trials and has become the treatment of choice in the majority of DME patients in reducing macular edema and improving visual acuity. Frequent drop-out and discontinuation of treatment are major issues. Lack of compliance can lead to worsening outcomes and be a burden to patients and the healthcare system. Purpose The purpose of this study is to assess multiple factors that affect adherence to IVT anti-VEGF treatment among patients with DME, including socioeconomic causes and the Health Belief Model (HBM) domains, in addition to exploring the relationship between them. Methods This cross-sectional study was conducted among DME patients in Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia, from December 2020 to June 2021. We identified eligible patients using a retrospective chart review of clinical findings and optical coherence tomography (OCT) findings. Included subjects were of Malaysian nationality, aged 18 years and above, who were initiated or re-initiated IVT anti-VEGF treatment regime and on follow-up for at least six months from initial injection from January 2019 onwards. A translated and validated self-administered questionnaire was given to the respondents. Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). Demographics of the patient were summarized using descriptive statistics, independent sample t-test was used to compare the difference in components of the HBM questionnaire. Linear regression was further used to explore the relationship between patients' demographics and the HBM component. Results A total of 141 patients participated in this study, of whom 56.2% patients were adherent to treatment. The majority were aged 60 years and above (56.7%), male (52.5%), Malay (38.9%), and married (71.6%). There was a significant statistical difference in patients who were adherent to treatment, in terms of life entourage (p=0.004, Fisher Exact test). HBM domains that influenced adherence to treatment included perceived severity, perceived barriers, perceived benefits, cues to action, and self-efficacy (p<0.05, independent sample t-test). Further, multiple logistic regression tests on sociodemographic factors and HBM domains after eliminating confounding factors narrowed down the significant variables to perceived susceptibility (p= 0.023), perceived benefits (p< 0.001), and self-efficacy (p< 0.001). Conclusion Patients' adherence to IVT anti-VEGF is influenced by perceived susceptibility to complications from DME, perceived benefits to the treatment, and self-efficacy.

Synergic Effect of Intravitreal Bevacizumab and Systemic Corticosteroid in Treating Systemic Inflammatory Response Syndrome (SIRS) Associated Purtscher-like Retinopathy.

PURPOSE: To demonstrate the treatment effect of combined intravitreal bevacizumab (IVB) and systemic steroid for systemic inflammatory response syndrome (SIRS)-related Purtscher-like retinopathy (PuR). METHODS: Retrospective case report. RESULTS: A 19-year-old patient experienced bilateral blurred vision after urinary tract infection-induced SIRS. Typical bilateral PuR was found in fundus examination and fluorescein angiography. Optical coherence tomography (OCT) revealed severe cystoid macular edema (CME) and OCT angiography revealed marked vascular defects in both superficial and deep plexuses. Intravitreal injection of bevacizumab 1.25 mg was first performed in the right eye along with systemic corticosteroid therapy. One week later, marked improvement in visual acuity and CME was noted in the right eye, but not in the non-IVB-treated left eye. IVB was then performed in the left eye and achieved much improvement 8 days later. CONCLUSION: This report clearly demonstrated the synergic effect of IVB and systemic steroids for CME on SIRS-related PuR.

Reasons for not improving visual acuity of DME patients due to interruption of anti-VEGF therapy during the pandemic and OCT imaging analysis

*AIM: To identify the reasons for not improving visual acuity of patients with diabetic macular edema (DME) and its correlation with optical coherent tomography (OCT) imaging characteristics. They were treated with anti - vascular endothelial growth factor (VEGF) again after an interruption of treatment due to the COVID - 19 pandemic. * METHODS: Retrospective cases study. A total of 31 patients (40 eyes) with DME and treated with anti-VEGF drugs in the Department of Ophthalmology of the First Affiliated Hospital of Xi' an Jiaotong University between December 2019 and July 2020 were selected. All patients had an treatment history of interruption due to COVID-19. Based on the behavioral standard of best corrected visual acuity (BCVA) at 1mo after re - treatment, they were divided into improved visual acuity group (14 eyes) and non-improved visual acuity group (26 eyes). All patients received comprehensive ophthalmic examinations, including BCVA, intraocular pressure, OCT, fundus photography, and fundus fluorescein angiography (FFA). The central retinal thickness (CRT), hyper - reflective retinal dots (HRD), subretinal fluid (SRF), intraretinal fluid (IRF), disorganization of the inner retinal layers (DRIL) and ellipsoid zone disruption (EZD) were quantified by Image J. The correlation between BCVA and CRT, the number of HRD, the diameter of SRF and IRF, and the height of DRIL and EDZ width at 1mo after treatment were analyzed by Spearman correlation. * RESULTS: The proportion of HRD in OCT was significantly higher in the non - improved visual acuity group than that in the improved visual acuity group (chi2 = 5.43, P = 0.0072);There was a positive correlation between the difference of BCVA (LogMAR) and CRT change in DME patients after treatment (rs = 0.406, P = 0.009);There was a positive correlation between BCVA (LogMAR) and EZD width after treatment (rs = 0.358, P = 0.023). There was no correlation between BCVA (LogMAR) after treatment and the number of CRT (rs = - 0. 086, P = 0. 600) and HRD (rs = - 0. 115, P = 0. 482), the diameter and height of SRF (rs = 0.102, P = 0.530;rs = 0.100,P = 0.538) and IRF (rs = 0.134, P = 0. 410;rs = - 0. 014, P = 0. 932), and the width of DRIL (rs = 0.089, P = 0.587). * CONCLUSION(S): The probability of retinal HRD was significantly higher in patients with no visual improvement than that in patients with visual improvement after the re - treatment with anti - VEGF due to the treatment interruption during COVID- 19. EZD width was also closely correlated to the prognosis of visual acuity. As for these patients, HRD manifestations in OCT should be comprehensively considered, taking intravitreal injection of glucocorticoid as an auxiliary strategy if necessary. Copyright © 2022 International Journal of Ophthalmology (c/o Editorial Office). All rights reserved.

Patient Experience With Anti-Vascular Endothelial Growth Factor (VEGF) Therapy in Neovascular Age-Related Macular Degeneration (nAMD) and Diabetic Macular Edema (DME): A Multinational Survey

Objectives: Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is efficacious for neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME). However, the frequent treatment and monitoring required for optimal real-world outcomes can be burdensome to patients and can impact adherence to treatment. This study aimed to understand patient treatment experience with anti-VEGF standard of care. Method(s): A cross-sectional survey was employed comprising de novo questions, patient-reported outcome (PRO) measures and medical chart extraction. Adult patients with nAMD or DME treated with intravitreal anti-VEGF injections for >=12 months were recruited via 38 clinical sites (6 Canada, 6 France, 4 Italy, 7 Spain, 6 United Kingdom, 9 United States). Result(s): Surveys were completed by 391 patients with nAMD and 183 patients with DME. PRO scores indicated that patients across both conditions had relatively high vision-related functioning and were generally satisfied with their current treatment. Mean number of anti-VEGF injections over 12 months across countries ranged from 6.3-9.7 for nAMD and 4.3-8.0 for DME. Nineteen patients with nAMD (19/391;5%) and 27 patients with DME (27/183;15%) missed >=1 injection or examination visit in the past 12 months. Reported barriers were mainly related to treatment (eg, pain and discomfort during/after anti-VEGF injection), clinic (eg, not having someone to accompany them to appointments) and, to a lesser extent, the COVID-19 pandemic. After treatment, the majority recovered in <=1 day;however, 24% (139/574) needed >1 day to recover. Impairment in daily activities due to treatment was reported by 45% (258/574) of patients. Among working patients 62% (41/66) reported productivity impairment from absenteeism. Conclusion(s): Patients reported impairment of daily activities, burden and barriers related to intravitreal anti-VEGF therapy, despite high adherence and treatment satisfaction levels. More durable therapy options, requiring less frequent treatments may be able to reduce treatment-related burden and barriers. Copyright © 2022

Impact of the COVID-19 Pandemic on the Metabolic Control of Diabetic Patients in Diabetic Retinopathy and Its Screening.

(1) Background: Diabetic retinopathy (DR) is a complication of diabetes mellitus (DM), screening programs of which have been affected by the COVID-19 pandemic. The aim of the present study was to determine the impact of the COVID-19 pandemic on the screening of diabetes patients in our healthcare area (HCA). (2) Methods: We carried out a retrospective study of patients with DM who had attended the DR screening program between January 2015 and June 2022. We studied attendance, DM metabolic control and DR incidence. (3) Results: Screening for DR decreased in the first few months of the pandemic. The incidence of mild and moderate DR remained stable throughout the study, and we observed little increase in severe DR, proliferative DR and neovascular glaucoma during 2021 and 2022. (4) Conclusions: The current study shows that during the COVID-19 pandemic, screening program attendance decreased during the year 2020, which then recovered in 2021. Regarding the most severe forms of DR, a slight increase in cases was observed, beginning in the year 2021. Nevertheless, we aimed to improve the telemedicine systems, since the conditions of a significant proportion of the studied patients worsened during the pandemic; these patients are likely those who were already poorly monitored.

Impact of the COVID-19 Pandemic on Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in Japan.

Anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME) improves visual acuity. However, repeated injections during routine outpatient visits are required to maintain this effect. The recent sudden global outbreak of coronavirus disease 2019 (COVID-19) had a major impact on daily life, including medical care, such as the provision of VEGF therapy. We retrospectively investigated the relationship between the number of anti-VEGF injections for DME and the number of new COVID-19-positive patients at 23 centers in Japan. We also surveyed ophthalmologists regarding the impact of the COVID-19 pandemic on anti-VEGF therapy. In the third and fourth waves of the pandemic, when the number of infected patients increased, the number of injections significantly decreased. In the first, third, and fourth waves, the number of injections increased significantly during the last month of each wave. Approximately 60.9% of ophthalmologists reported that the number of injections decreased after the pandemic. Of the facilities, 52.2% extended the clinic visit intervals; however, there was no significant difference in the actual number of injections given between before and after the pandemic. Although the number of injections temporarily decreased, Japanese ophthalmologists maintained the total annual number of anti-VEGF injections for DME during the pandemic.

COVID-19 impact on delayed clinical visits in diabetic retinopathy patients

Purpose : The COVID-19 pandemic created an unprecedented setback for diabetic retinopathy (DR) patients receiving routine anti-vascular endothelial growth factor (VEGF) injections. In this retrospective clinical study, we assessed visual and anatomical outcomes of “late follow-up” appointments cancelled or rescheduled during an 11-week quarantine period from March 15th- June 1st, 2020, due to the urgency to limit non-emergent clinical visits. This study tested the hypothesis that strict frequency of treatment is a requisite for successful therapy. Methods : To meet “late follow-up” requirements, all study patients had appointments scheduled within the quarantine period that were delayed past their previous physician recommended interval, beyond June 1st, 2020. Of the 7042 delayed patients, 5137 returned for examination. 2764 were injection patients, of which 616 were delayed beyond the quarantine period. These 616 patients were subsequently categorized by diagnosis. We then analyzed the electronic medical record (EMR) for 300 eyes with treatment-requiring diabetic retinopathy to establish baseline anatomical and visual status prior to the delayed clinical visit. The EMR of the follow-up appointment was subsequently viewed for comparison. Best-corrected visual acuity (BCVA) and retinal examination findings were recorded from both visits. All eyes received at least 1 anti-VEGF injection prior to March 15th, 2020. Results : 300 eyes were delayed beyond their previously scheduled interval an average of 14.04 weeks. Upon return, 37 eyes (12.3%) had improved BCVA, 169 (56.3%) remained stable, and 94 (31.4%) had worsened. Of the 300 eyes, there was an average of 2.2 lines lost (p=0.03). 29 delayed eyes (9.7%) returned with improved macular edema, 121 (40.3%) remained stable, and 143 (47.7%) had worsened upon examination. Due to vitreous hemorrhage, edema progression in 7 eyes (2.3%) was unknown. 290 eyes (96.7%) remained with non-proliferative DR, while 10 (3.3%) progressed to proliferative DR. 23 (7.6%) returned with new or worsened vitreous hemorrhages. No patients developed a retinal tear or detachment during this period. Conclusions : COVID-19 had a severe impact on routine clinical visits. Prolonged frequency of anti-VEGF treatment for DR is associated with increased risk for BCVA decline and negative anatomical outcomes. Effective therapy requires strict compliance with intravitreal injections and routine clinical appointments.

Telemedicine Assisted Postoperative Care Following Microincision Vitrectomy Surgery

Purpose : Microincision vitrectomy surgery (MIVS) studies have shown low complication rates. In the setting of the COVID-19 pandemic and rural satellite clinics, we investigated the role of telemedicine as an alternative to postoperative visit (POV) regimens after uncomplicated MIVS. Methods : This IRB approved, prospective single-site, and single-surgeon study included patients without any history of glaucoma, ocular trauma, or severe systemic or ocular disease who underwent uncomplicated MIVS for any indication between January-August 2021. Prophylactic topical pressure-lowering drops were prescribed if POV intraocular pressure (IOP) was ≥22 mmHg. POVs included the same day after surgery, week(s) 1, 2, 8, and 12. Patients were randomly assigned (1:1) into two arms: telemedicine (TM) or In-person (IP). Weeks 1 and 8 POV utilized protocol-based and questionnaire guided undilated exams performed by an ophthalmology fellow that were conducted either TM or IP, according to arm assignment. Any patients with concerning symptoms identified at these visits were scheduled for dilated exams with the surgeon. All patients underwent dilated exams performed by the surgeon on the same day after surgery, weeks 2 and 12. Primary endpoint was mean best corrected visual acuity (BCVA). Secondary endpoints included changes in intraocular pressure (IOP), retinal nerve fiber layer thickness, and number of additional visits. Statistical analysis included Mann Whitney U and chi-square tests. Results : Fifty-two eyes from 50 patients (33 female, 17 male;p-value=0.02) with mean ages of 68.4±6.8 years underwent 55 total surgeries with 25 or 27G MIVS platforms. Forty-seven patients have completed all POVs. Mean preop BCVA logMAR was 0.53±0.55 and 0.40±0.45, and at 12 weeks, they were 0.39±0.45 and 0.26±0.33 for the TM and IP groups, respectively. No significant between-group differences were found for primary or secondary outcomes. All cases of abnormal IOP resolved by the following POV with pressure lowering drops. Concerning symptoms were identified in five patients requiring additional visits, revealing two cases of worsening macular edema (1 TM and 1 IP) and one case each of cataract progression (TM), vitreous hemorrhage (IP), and macular hole recurrence (TM). No complications presented at the TM or IP visits. Conclusions : Telemedicine-assisted POV regimens may be a safe and convenient alternative for patients undergoing uncomplicated MIVS.

Expansion of a teleophthalmology program for diabetic retinopathy screening during the COVID19 pandemic

Purpose : The COVID-19 pandemic prompted efforts to encourage social distancing and minimize non-urgent in-person eye care. Here, we report the outcomes of a teleophthalmology program for diabetic retinopathy screening at an integrated health system in California that was expanded during the pandemic. Methods : We performed a retrospective review of patients who underwent remote retinal imaging as part of a teleophthalmology program for diabetic retinopathy (DR) screening using Current Procedural Terminology (CPT) codes 92227 and 92228 at the University of California, Davis Health system between May 31st , 2019 and June 8th , 2021. Retinal images were captured at primary care locations using a Topcon NW400, Nikon RetinaStation, or Optos Primary fundus cameras, and image grading were performed by trained ophthalmologists or optometrists using a store-and-forward method. Patient records were reviewed to collect demographic, follow-up, and clinical outcomes information. Results : During COVID19 pandemic, the teleophthalmology program screened 570 individuals (mean age 63.2 ± 13.7). There was a significant increase in the number of patients screened per month prior to and following the COVID-19 lock-down in March 2020 (5.0 ± 3.1 patients screened per month prior to and 39.1 ± 34.8 patients per month following, P = 0.0004). Among these, 204 patients received a recommendation for in-person eye care referral, of which 127 received a referral to the UC Davis Eye Center, 85 appointments were scheduled, and 82 patients were followed in person, with a median time of 108 days between screening and in-person follow-up. Follow-up rates were generally lower during the initial months after the pandemic and increased over time. Among the patients who followed in person (mean age 63.9 ± 13.8), 10% of eyes had mild non-proliferative DR (NPDR), 5% had moderate NPDR, 3% had severe NPDR, 2% had PDR, and 4% had diabetic macular edema (DME), with similar proportions before and after the COVID-19 lockdown. Conclusions : Expansion of a teleophthalmology program during the COVID19 pandemic demonstrated improved DR screening rates, increased referrals, and improved follow-up for diabetic eye care at an integrated health system in Northern California.

Effectiveness and Safety of Resident-Performed Simultaneous Bilateral Selective Laser Trabeculoplasty in Patients With Open-Angle Glaucoma

Purpose : While its pathophysiology is not fully understood, there are a number of genetic and clinical risk factors associated with glaucoma;the primary risk factor is elevated intraocular pressure (IOP). Laser trabeculoplasty is a widely-used treatment method for glaucoma because it effectively reduces IOP without bearing the greater risks of invasive surgery. Selective laser trabeculoplasty (SLT) is a core competency skill that ophthalmology residents learn;however, competency in SLT is not well-defined, as experience in glaucoma procedures is variable by program. SLT is typically performed one eye at a time. During the COVID-19 pandemic, in-office visits were minimized and surgeries were limited to only the most vision-threatening at the University of Chicago. Bilateral SLT on the same day was used to keep IOP controlled during this period, while patients could not be monitored as frequently and surgeries were postponed. The goal of this study is to assess the effectiveness and safety of same-day bilateral resident-performed SLT in comparison to reported statistics of attending-performed SLT in the literature. Methods : A retrospective chart review of patients who underwent simultaneous bilateral SLT between January 2019-May 2021 was performed to quantify the effectiveness and safety of the procedure compared to published rates in the literature. Specifically, we examined the intraocular pressure (IOP) at the visits before and after the SLT procedure, type of glaucoma diagnosis, Age, Sex, and complications (IOP elevation, iritis, macular edema). Results : Preliminary data included a total of 51 patients (of which 32 were female) and 108 eyes (3 patients underwent SLT twice). Average age was 66. Average IOP was 18.7 mmHg (SD 5.0) on visit prior to SLT and 17.6 (SD 6.5) on day of SLT with the average IOP decreasing to 15.9 (SD 5.0) and 15.7 (SD 4.5) on the first and second follow-up. There were 2 patients in whom we documented IOP spikes on the visit after SLT was performed, one of whom had documented compliance issues on multiple visits. No macular edema or iritis was noted. Conclusions : We found a similar rate of decrease in IOP after bilateral SLT by residents compared to prior studies by attending physicians with very few complications. Resident-performed simultaneous bilateral SLT appears to be an effective and safe option for IOP-lowering.

Patient Experience with Anti-VEGF Intravitreal Injections in Neovascular Agerelated Macular Degeneration and Diabetic Macular Edema: A Multinational Observational Study

Purpose : Anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections are efficacious treatments for neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), but optimal real-world outcomes require frequent treatment and monitoring that can be burdensome to patients and hinder their ability or willingness to follow their management plan. This study aimed to understand patient treatment experience with anti-VEGF standard of care. Methods : This observational study employed a cross-sectional quantitative survey comprising de novo questions, patient-reported outcome (PRO) measures and medical chart extraction. Adult patients in the USA, UK and Canada with nAMD or DME, and treated with anti-VEGF injections for ≥12 months, were recruited via 21 (9 USA, 6 UK, 6 Canada) clinical sites. Results : Between January and August 2021, 148 (67 USA, 33 UK, 48 Canada) DME and 219 (98 USA, 54 UK, 67 Canada) nAMD patients completed their surveys. While 159 (43%) patients had a study eye visual acuity at most recent reading >70 approxETDRS letters, PRO scores indicated that patients across the two conditions had relatively high visionrelated functioning (NEI-VFQ-25) and were generally satisfied with their current treatment (MacTSQ and RetTSQ). Eighteen DME patients (12%;12% in the US, 27% in the UK, 2% in Canadian samples) and 9 nAMD patients (4%;3% USA, 3% UK, 4% Canada) missed at least 1 injection visit in the past 12 months. Reported barriers were mainly related to treatment, clinic and appointment factors, and the COVID-19 pandemic. Half of the patients reported some level of impairment in their daily activities due to the treatment. Following treatment, the majority recovered within 1 day;however, a sizable portion (24%;21% USA, 31% UK, 22% Canada) needed >1 day to recover. Among the working patients (N = 55), 34 (62%;58% USA, 67% UK, 65% Canada) reported some level of productivity impairment in the form of absenteeism. Conclusions : Despite high adherence and treatment satisfaction levels, patients reported impairment of daily activities, burden, and barriers related to treatment. In general, more DME patients missed at least 1 visit than nAMD patients. More durable treatments with longer intervals could further reduce treatment burden and address the current barriers faced by patients.

Utility of Remote Point-Of-Care Tele-Retinal Imaging for Screening and Diagnosis of Diabetic Retinopathy: A Pilot Study

Purpose : In the COVID-19 era, tele-retinal technologies are rising to the forefront of contactless ophthalmic care. Point-of-care Optical Coherence Tomography (OCT) and fundus photography remotely analyzed by an off-site retina specialist (tele-R) must be validated for screening retinal disorders. This study assesses the feasibility of tele-R as a screening tool for diabetic retinopathy (DR) in an outpatient clinical setting. Methods : A retrospective study was conducted on 16 patients (32 eyes, 28 with DR, and 4 controls) presenting to the retina clinic (RC) of an urban academic medical center. Automated OCT-B and 45 fundus photographs of the posterior pole were taken using a Topcon Maestro 3D OCT-1 unit, and 3D topographical maps of the macula were generated. Images were transmitted to a remote retina specialist (blinded to patient history and demographics) who assessed severity of DR and diabetic macular edema (DME). Primary outcomes included grading of DR and DME with fundus and OCT-B images, respectively, using the International Clinical Diabetic Retinopathy classification scale. The secondary outcome was identifying the severity grade of DME using the 3D macular map. Concordance was tested between diagnoses obtained from tele-R assessment and in-person examination by the retina specialist (gold standard) using Cohen's Kappa statistic (κ). Eyes that could not be assessed were removed from analysis. Results : 30 of 32 eyes with sufficient data for analysis were included. The average age was 57.9 (±11.2) years. 37% of patients were male, 69% were Hispanic, and 94% had Type 2 diabetes. The κ±standard error (SE) for DR severity was 0.738±0.099 (p<0.001), for DME severity was 0.588±0.122 (p<0.001), and for presence of DME was 0.727±0.122 (p<0.001). The retina specialist was able to grade the DME severity in only 10/14 (71%) eyes using the 3D macular map alone, but in 93% (13/14) eyes with OCT-B images. Conclusions : Tele-R is a reliable modality for diagnosis of DR severity;there was substantial agreement on identifying DR severity using tele-R vs in-person examination. There was substantial agreement in discerning DME using tele-R vs in-person while only moderate agreement on determining the severity of DME, which suggests that tele-R may useful in identifying presence of DME but not determining the severity of edema.

Assessing the impact of COVID-19 on visual acuity for diabetic macular edema patients treated with aflibercept in the UK

Purpose : Assessing the impact of COVID-19 on visual acuity (VA) in eyes treated for Diabetic Macular Edema. Methods : Anonymized data from 21 UK centers were extracted from Medisoft for eyes receiving treatment with aflibercept and with VA data in the pre-COVID baseline period (01/10/19 to 30/03/20, N=3,248). Comparisons for period 1 (01/04/20 to 30/09/20, N=2,077)-lockdown following RCOphth Medical Retinal Management Plan, period 2 (01/10/20 to 30/03/21, N=1,850)-intermittent lockdown and period 3 (01/04/21 to 30/09/21, N=1,111;20 centers)-easing of COVID-19 restrictions. VA change was compared for baseline VA, <7 vs. ≥7 injections before period 1 and for eyes losing ≥5 ETDRS letters in period 1. Results : The mean change in VA for eyes with a baseline VA of ≤35 letters, was +4.9, +2.5 and +1.7 letters from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of 36-55 letters, +0.6, +1.7 and -0.2 letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of 56-75 letters, +1.9, zero and -0.5 letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of >75 letters, -4.3, -0.5 and zero letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For eyes receiving <7 injections before period 1, the mean change in VA was -1.9 letters (N=1,335) from baseline to period 1, +0.5 letters (N=992) from period 1 to 2 and +0.1 letters (N=592) from period 2 to 3. For ≥7 injections before period 1, the mean change in VA was -3.4 letters (N=742) from baseline to period 1, -0.4 letters (N=515) from period 1 to 2 and -1.1 letters (N=303) from period 2 to 3. For eyes losing ≥5 letters before period 1, the mean change in VA when receiving ≥1 injection in period 2 was +3.9 letters (N=283) from period 1 to 2 and -0.1 letters (N=140) from period 2 to 3. For eyes not retreated in period 2, the mean change in VA was -2.9 letters (N=162) from period 1 to 2 and zero letters (N=73) from period 2 to 3. Conclusions : Visual gain between time periods was more likely for lower baseline vision. For eyes with <7 or ≥7 injections before period 1, the mean VA change was a loss in vision in the first period with little change in later periods. For eyes with ≥5 letter loss in period 1, subsequent visual gain was more likely if treatment continued.

Sensitivity of tele-ophthalmic diagnosis of diabetic retinopathy when performed by resident physicians

Purpose : During the Covid-19 era, understanding the benefits and limitations of tele-ophthalmology has become increasingly important. In this study, we aim to assess the accuracy of tele-ophthalmic diagnosis of diabetic retinopathy (DR) and diabetic macular edema (DME) when performed by resident physicians. Methods : Retrospective study on 16 patients (32 eyes;28 DR and 4 controls) who presented to a retina clinic at an academic medical center. Automated OCT-B images with 3D topographic maps and fundus photographs of the posterior pole using a Topcon Maestro 3D OCT-1 unit were taken. Images were transmitted remotely to a resident physician who assessed the severity of the DR and DME on the basis of the fundus photographs and OCT. The same images were transmitted to a retina specialist for grading. Primary outcomes included DR and DME grade as defined by the International Clinical Diabetic Retinopathy classification scale. We then tested the concordance between diagnoses rendered via tele-OCT by the resident compared to the retina attending's remote diagnosis and the gold standard retina specialist's clinical examination using Cohen's Kappa statistic (κ). Results : Agreement between ophthalmology residents and attendings on tele-OCT diagnosis of DR was substantial (78% concordance on presence and 75% on severity), while agreement on identifying and grading edema was moderate (60% concordance on DME presence and 52% concordance on overall DME severity). Detection of DR by residents via tele-retinal imaging is highly sensitive (100% sensitivity), while detection of DME is highly specific (79-95% specificity). Discordance between residents and attendings on DME grading may owe to differences in opinion regarding what constitutes mild edema versus no edema;however, both concordance and predictive accuracy increase when identifying patients with moderate to severe DME. Conclusions : This study provides proof of principle for the sensitivity and specificity for remote diagnosis of DR via tele-OCT fundus and OCT-B images. This technology may be useful in identifying patients at risk of severe vision loss and enable early detection of patients who need referral for prompt treatment. These findings may be particularly relevant to training programs looking to implement tele-retinal diabetic screening or using tele-OCT where prompt access to a retina specialist may not be possible.

The effect of intravitreal dexamethasone implantation on diabetic macular edema refractory to anti-vascular endothelial growth factor treatment

Purpose: To evaluate the efficacy and safety of intravitreal dexamethasone (DEX) implantation for diabetic macular edema (DME) that proved unresponsive to previous anti-vascular endothelial growth factor (VEGF) treatment. Methods: This prospective interventional study recruited 91 patients with refractory DME after previous anti-VEGF treatments in one or both eyes. All patients were followed up for at least 12 months. Best-corrected visual acuity (BCVA), central subfield thickness (CST) and macular volume were measured. Results: Over the 12 months, a mean of 2.1 +/- 0.8 DEX implantations were administered per eye;26 eyes (28.9%) received 1 implantation, 31 (34.4%) received 2, and 34 (36.7%) received 3. BCVA was significantly improved in the first 6 months, from 54.8 to 59.5 letters. Both CST and macular volume decreased significantly after DEX implantation and maintained these improvements for at least 12 months. Subjects who needed the second DEX implantation had a greater number of prior anti-VEGF injections than did those who needed only one implantation (6.0 vs 3.0). Conclusions: Two-thirds of refractory DME required less than two DEX implantations to maintain a dry macula for 12 months. Early switching to intravitreal DEX can be considered as the second-line therapeutic option, especially during the COVID-19 pandemic.

Bilateral Cystoid Macular Edema after COVID-19: 1 Year Follow Up.

PURPOSE: The aim is to report a case of bilateral macular edema after COVID-19 pneumonia. CASE REPORT: A 66-year-old male patient with history of COVID-19 pneumonia presented to us with decreased vision. Examination showed bilateral cystoid macular edema (CME), which was confirmed on optical coherence tomography (OCT). There were no findings in the fundus examination. He had no systemic disease, drug or surgery history, or any factors that could explain the clinic presentation. Work-up for uveitis was unremarkable. After topical therapy with brinzolamide 1% and nepafenac 0.1%, macular edema regressed in a month. CONCLUSION: This is an unusual case of CME in previous COVID-19 infection. This presentation may be a parainfectious or a post-viral manifestation of COVID-19.