OCTA changes following loading phase with intravitreal aflibercept for DME.

OBJECTIVE: To quantify changes in optical coherence tomography angiography (OCTA) parameters following intravitreal anti-vascular endothelial growth factor treatment for diabetic macular edema (DME), and to assess associations between pretreatment OCTA parameters and visual outcomes. DESIGN: Prospective cohort study. METHODS: Twenty-nine patients with DME received 5 monthly intravitreal injections of aflibercept. OCTA data obtained at baseline and at 6 months were compared using the Wilcoxon signed-rank test. OCTA parameters were foveal avascular zone (FAZ) area, FAZ perimeter, FAZ circularity, vessel density in the superficial vascular plexus (segmented into central, inner, outer, and full Early Treatment of Diabetic Retinopathy Study [ETDRS] map regions. Subanalysis divided patients into treatment responders (reduction of central subfield thickness >50 µm over treatment) and nonresponders. Associations between pretreatment OCTA parameters and visual acuity outcomes were analyzed using multivariable linear and logistic regression. RESULTS: A total of 29 patients were included: 25 patients (86.2%) had nonproliferative diabetic retinopathy, and 4 patients (13.8%) had proliferative diabetic retinopathy. Vessel density was reduced in the central (p = 0.004) and inner (p = 0.013) ETDRS map regions. This effect was significant only among treatment responders (central p = 0.002; inner p = 0.017). Pretreatment OCT and OCTA parameters were not associated with final visual acuity outcomes. CONCLUSION: Following intravitreal aflibercept treatment for DME, there was a significant decrease in vessel density of the superficial vascular plexus at the central and inner ETDRS map regions. This was seen only among treatment responders. Observations here are likely to represent the limits of OCTA technology itself, where pretreatment vessel density may have been artifactually overestimated by suspended scattering particles in motion. Pretreatment OCTA parameters did not serve as biomarkers for visual outcome following anti-vascular endothelial growth factor therapy.

Imaging Biomarkers and Their Impact on Therapeutic Decision-Making in the Management of Neovascular Age-Related Macular Degeneration.

These recommendations, produced by a group of Canadian retina experts, have been developed to assist both retina specialists and general ophthalmologists in the management of vision-threatening neovascular age-related macular degeneration (nAMD). The recommendations are based on published evidence as well as collective experience and expertise in routine clinical practice. We provide an update on practice principles for optimal patient care, focusing on identified imaging biomarkers, in particular retinal fluid, as well as current and emerging therapeutic approaches. Algorithms for delivering high-quality care and improving long-term patient outcomes are provided, with an emphasis on timely and appropriate treatment to preserve and maintain vision. In the context of nAMD, increasing macular fluid or leakage on fluorescein angiography (FA) may indicate disease activity regardless of its location. Early elimination of intraretinal fluid (IRF) is of particular relevance as it is a prognostic indicator of worse visual outcomes. Robust referral pathways for second opinion and peer-to-peer consultations must be in place for cases not responding to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy.

Outcomes of Using Sutureless, Scleral-Fixated Posterior Chamber Intraocular Lenses.

Background. Implantation of sutureless, scleral-fixated posterior chamber intraocular lenses (SSFIOL) is a promising option in the surgical management of patients unable to undergo standard cataract surgery due to insufficient capsular support. The purpose of this study was to describe the indications, visual outcomes and complications of SSFIOL implantation.Methods. Retrospective, investigational cohort study of 112 consecutive SSFIOL implantations between July 2013 and August 2017. Pre-operative ocular morbidity, operative indications, postoperative outcomes, complications, and reinterventions were summarized. Visual and refractive outcomes were compared between the pre- and latest postoperative visit using Wilcoxon signed-ranked test.Results. Mean follow-up: 13.0 ± 10.4 months. Primary surgical indication was dislocated IOL due to zonular weakness (77 eyes (68.8%)). At latest follow-up, there was improvement in uncorrected visual acuity (1.3 ± 0.8 to 0.64 ± 0.60 logMAR, p < .01), best-corrected visual acuity (BCVA) (0.6 ± 0.5 logMAR to 0.36 ± 0.40 logMAR, p < .01). Postoperative complications included transient IOP elevation >30 mmHg (26.8%), cystoid macular edema (CME) (14.3%), transient hypotony (13.4%), iris capture (12.5%), uveitis-glaucoma-hyphema (UGH) syndrome (11.6%), vitreous hemorrhage (VH) (6.3%). Operative reinterventions included SSFIOL exchange (3.6%), SSFIOL repositioning (5.4%), SSFIOL removal (2.7%). Ten (8.9%) patients required multiple re-interventions.Conclusion. SSFIOL implantation is a reasonable option for eyes with inadequate capsular support, resulting in visual improvement in most patients. Many of the surgical complications were related to a floppy iris-lens diaphragm (UGH syndrome, iris capture), which were predisposed in eyes with complex pathology. Surgical modifications can be made to minimize the iris-related complications.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

BACKGROUND: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. OBJECTIVE: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. METHODS: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. RESULTS: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. CONCLUSIONS: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Retinal degeneration in autoimmune polyglandular syndrome type 1: a case series.

BACKGROUND: Autoimmune polyglandular syndrome type 1 (APS1) is a rare autosomal recessive disorder due to mutations in the AIRE gene. AIM: To report the ocular features and characterise the retinal phenotype in molecularly confirmed APS1. METHOD: This retrospective case series reviewed five molecularly confirmed cases with APS1 known to have ocular involvement (age range: 19 months-44 years; mean follow-up of 8 years). The medical history, ocular history and evaluation, visual field testing, full-field electroretinogram (ERG) and antiretinal antibody results were reviewed. RESULTS: All but one case had decreased vision at first presentation. All cases had peripheral pigmentary retinal changes; macular atrophy was noted in 80% of cases. The most common feature on spectral-domain optical coherence tomography was a disruption of the external limiting membrane and inner segment ellipsoid band (n=3). Fundus autofluorescence imaging demonstrated a parafoveal ring of hyper-autofluorescence (n=1) or a stippled and patchy autofluorescence pattern in the macula (n=1). The visual fields were constricted in all tested patients (n=3). The rod ERG was abnormal in all cases; the relative involvement of rods and cones differed. Four patients who were tested for antiretinal antibodies were found positive by immunohistochemistry (n=3) and/or western blot (n=2). CONCLUSIONS: Photoreceptor degeneration is part of APS1 phenotype and the presence of antiretinal antibodies strongly supports an aetiology similar to that of non-paraneoplastic autoimmune retinopathy. Periodic retinal evaluation and imaging, visual field testing and ERG would assist in monitoring the retinopathy in APS1-related disease.

Contemporary management of diabetic retinopathy in Canada: from guidelines to algorithm guidance.

Recent advances in the therapeutic options and approaches for diabetic retinopathy (DR) and diabetic macular edema (DME) have resulted in improved visual outcomes for many patients with diabetes. Yet, they have also created many clinical dilemmas for treating ophthalmologists and retina specialists, including treatment selection, initiation, frequency and duration. With this in mind, a panel of Canadian retina specialists met and discussed the current clinical evidence as well as specific situations and scenarios commonly encountered in daily practice. They also shared their experiences and therapeutic approaches. This document, containing a consensus on treatment algorithms for various clinical scenarios, is the result of their lengthy and in-depth discussions and considerations. The intent is to provide a step-by-step approach to the treatment of DR and DME. Although clinicians are encouraged to use and refer to these algorithms as a guide for various situations, they are not meant to be a replacement for sound clinical judgment.

Canadian expert consensus: optimal treatment of neovascular age-related macular degeneration.

BACKGROUND: New therapeutic approaches, particularly anti-vascular endothelial growth factor (anti-VEGF) therapies, prevent, and in some cases reverse, vision damage caused by age-related macular degeneration (AMD). Unequal access to care across Canada remains a problem for many retina specialists and their patients. OBJECTIVE: To develop a consensus concerning the management of patients with exudative age-related macular degeneration (AMD). DESIGN: Consensus document. PARTICIPANTS: Ten Canadian retina specialists. METHODS: The development of a consensus among Canadian experts concerning optimal treatment of AMD began with a review of the clinical evidence, daily practices, existing guidelines, and current national and international approvals and policies. The experts met on June 29, 2010, in Quebec City to discuss their findings and to propose strategies for consensus. RESULTS: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists who are treating patients with or at risk for developing neovascular AMD. CONCLUSIONS: The consensus provides guidelines to aid retina specialists in managing exudative AMD. Currently, ranibizumab is the only agent with sufficient Level I evidence and a Health Canada-approved indication for the treatment of wet AMD. Bevacizumab has been shown to be noninferior in preserving and improving visual acuity when compared to ranibizumab. Potential safety differences between the 2 drugs remain to be elucidated. The positioning of ranibizumab in this therapeutic area will be further defined as additional data for existing and emerging therapies become available. Until then, this agent remains the therapy of choice for individuals with neovascular AMD.

Indoor soccer-related eye injuries: should eye protection be mandatory?

BACKGROUND: Our objectives were to present the spectrum of eye injuries caused by indoor soccer, as seen at our institution, and to initiate discussion as to whether eye protection should become mandatory for this indoor sport. METHODS: Chart review of patients presenting to our institution with eye injuries from indoor soccer. RESULTS: Five cases were identified from 2001-2005, all occurring during the winter or late fall. Each injury was due to contact with the soccer ball itself. Initially, all 5 patients presented with commotio retinae (1 with a prominent retinal and vitreous hemorrhage and 2 with smaller retinal hemorrhages), 2 with hyphema and traumatic mydriasis, 1 with subconjunctival hemorrhage, and 1 with upper lid edema and ecchymosis. Three resolved uneventfully with 20/20 or better vision; however, in 2 there were findings of choroidal rupture with chorioretinal scarring. One of these had 20/20 vision and a discontinuous choroidal rupture peripherally, and the other had 20/40 vision and extensive chorioretinal scarring. One patient also showed a peculiar persistent iris scar. INTERPRETATION: Soccer-related eye injuries have been recognized as an important ophthalmologic problem in Europe and now increasingly so in North America. With the increasing popularity of indoor soccer in Canada, serious eye injuries have become more prevalent. On the basis of the prevalence and the nature and mechanism of the ocular trauma, we believe there may be a need to make eye protection mandatory for all forms of soccer.

Maculopathy associated with mefloquine (Lariam) therapy for malaria prophylaxis.

CASE REPORT: We report maculopathy occurring in a patient after 18 months of weekly mefloquine for malaria prophylaxis. Macular retinal pigment epithelium changes bilaterally were visually insignificant, with the patient demonstrating 20/20 corrected visual acuity bilaterally. COMMENTS: Retinal change as an adverse effect of mefloquine has not previously been reported.

West Nile chorioretinitis.

CASE REPORT: The clinical course of 2 Canadian cases of West Nile chorioretinitis is described. The patients developed visual-field disturbances shortly after flu-like illnesses and were referred for retinal evaluation. Full ophthalmologic examination included Snellen visual acuity testing, applanation tonometry, slit-lamp examination, dilated fundus examination, fundus photography, and fluorescein angiography. Both patients developed self-limited cases of chorioretinitis exhibiting characteristic fundus and fluorescein angiographic findings. COMMENTS: Since the introduction of West Nile virus to Canada and its progressive spread across the country, more patients will present to their eye specialists with chorioretinitis. In cases of chorioretinal inflammation, West Nile virus infection should be included in the differential diagnosis.

The effects of exposure to a 1.5-tesla magnetic field on intravitreous metallic foreign bodies in rabbits.

BACKGROUND: The study was performed to determine (1) whether intravitreous ferromagnetic foreign bodies (FBs) are sufficiently mobile in a magnetic field to induce acute injury in vivo, and (2) whether the length of time from implantation of the intravitreous FB affects mobility. METHODS: A 3 mm x 0.72 mm magnetic FB (MFB) and a non-magnetic metallic FB (NMFB) of similar dimensions were surgically implanted into the right and left eyes, respectively, of 20 New Zealand white rabbits. On days 0 (FB implantation) and 30, all rabbits underwent computed tomography (CT) prior to and immediately following exposure to a 1.5-tesla (T) magnetic field. Pre- and post-magnetic field CT image FB angles and distances, together with ophthalmic examinations, were used to assess FB mobility. Rabbits were killed at 31 days. The globes were processed for light microscopy (LM) and scanning electron microscopy (SEM). RESULTS: Angle measurements revealed that the MFBs developed significant angular motion and were scattered more widely than NMFBs on the day of FB implantation and 30 days later, although the angular motion and scatter of MFBs were less on day 30. There were no significant differences among distance measurements for MFBs or NMFBs on or between days 0 and 30. Throughout the 30-day study, ophthalmic examinations revealed dorso-ventral FB movement and focal vitreous degeneration and retinal hemorrhage within both MFB- and NMFB-containing globes. Mild vitreous hemorrhage was noted around a NMFB. Focal retinal degeneration was confirmed by LM ( n=1 MFB). SEM revealed intravitreous erythrocytes and spindle cells adjacent to all FBs examined. CONCLUSIONS: (1) Angle measurements show that MFBs are significantly mobile when exposed to a 1.5-T magnetic field on the same day as FB implantation and 30 days later. (2) Angular mobility of MFBs is less at 30 days. (3) Magnetic field exposure did not induce ocular injury in MFB-containing globes. (4) Intravitreous metallic FB retention induces ocular pathologic changes.