Factors affecting prognosis and need for anti-vascular endothelial growth factor injections in wet age-related macular degeneration.

PURPOSE: To understand factors affecting visual prognosis and the number of intravitreal antivascular endothelial growth factor (anti-VEGF) injections needed to stabilize wet age-related macular degeneration (AMD). METHODS: In this retrospective cohort, 119 treatment-naïve wet AMD patients were followed for two years. In patients with bilateral disease, the eye with worse best-corrected visual acuity (BCVA) or that received more intravitreal injections was recruited as the study eye. In all visits, BCVA was recorded, ophthalmological examination was performed including macular optical coherence tomography imaging. Twenty health status/lifestyle questions were asked to the patients via phone as potential risk factors. All patients received 3 loading doses of intravitreal bevacizumab injections and received repeat injections of aflibercept or ranibizumab when the eye had a new, active neovascular lesion. RESULTS: Patients who took regular micronutrition had similar visual outcome and injection numbers compared to the ones who did not. Patients with bilateral disease needed less intravitreal injections compared to unilateral AMD patients (p = 0.016) and women on hormone replacement therapy (HRT) required less injections compared to the women who were not (p = 0.024). Female patients had a mean gain of 2.7 letters while male patients lost 3.8 letters (p = 0.038). Wet AMD started at an earlier age in smokers (p = 0.002). Patients with a better education level presented earlier with better BCVA (p = 0.037). CONCLUSION: HRT and anti-VEGF injections to the fellow eye improved the prognosis of wet AMD, while male patients had slightly worse prognosis. Estrogen's protective effects and potential contribution in wet AMD needs further attention. Retrospectively registered: 2020/0622.

Visual Outcomes, Endothelial Loss, and Complications Following Iris-Claw Intraocular Lens Implantation and Trocar-Assisted Sutureless Scleral Fixation of Intraocular Lenses.

Objectives: Iris-claw intraocular lens (IC-IOL) implantation and sutureless scleral fixation of intraocular lenses (SSF-IOL) are two commonly preferred surgical approaches for the management of aphakic patients without sufficient capsular support. The aim of this study was to compare the outcomes of IC-IOL implantation and trocar-assisted SSF-IOL implantation. Methods: The medical records of secondary IOL implantation patients were retrospectively reviewed. All patients had a detailed ophthalmological examination, including LogMAR best-corrected distance visual acuity (CDVA), intraocular pressure (IOP), and endothelial cell density (ECD) preoperatively and postoperatively. SPSS 21.0 software was used for the statistical analysis. Results: There were 15 patients in the IC-IOL group and 12 patients in the SSF-IOL group. Age and gender distributions were similar between the groups (p=0.456 and p=0.398, respectively). Similarly, patients in both groups had similar CDVA preoperatively and postoperatively (p=0.51, p=0.48, respectively). Both IC-IOL and SSF-IOL implantation significantly increased CDVA (p=0.001 and p=0.005, respectively). IOP remained unchanged in both groups. However, ECD reduced significantly following both IC-IOL and SSF-IOL implantation (p=0.001 and p=0.005, respectively) and trocar-assisted SSF-IOL implantation resulted in significantly more endothelial loss compared to IC-IOL implantation (439.5±89 vs. 164.4±53, p=0.013). Conclusion: Both surgical approaches increased CDVA significantly and at similar levels. However, trocar-assisted SSF-IOL implantation resulted in significantly more endothelial loss compared to IC-IOL implantation. None of the patients developed bullous keratopathy, but this difference should be kept in mind, especially in patients with critically low ECD.

Endothelial loss following postoperative intracameral triamcinolone acetonide and subconjunctival dexamethasone injections.

OBJECTIVES: To compare endothelial toxicity and efficacy of two local steroid injections (intracameral triamcinolone acetonide and subconjunctival dexamethasone) in controlling postoperative inflammation following pars plana vitrectomy (PPV) combined with phacoemulsification cataract surgery. METHODS: This cohort included 54 patients that underwent combined surgery and received either intracameral triamcinolone acetonide injections (n = 27, IC-TA group) or subconjunctival dexamethasone (n = 27, Sc-Dex group) injections at the end of the surgery. All participants had at least 4 months or longer follow-up. A detailed ophthalmologic examination including intraocular pressure (IOP) measurement and specular microscopy was performed at every visit. RESULTS: Endothelial cell density (ECD) reduced significantly in IC-TA group postoperatively (2418 vs. 2249, p = 0.019), while it did not change significantly in Sc-Dex group (2541 vs. 2492, p = 0.247). Postoperative ECD was also significantly lower in IC-TA group compared to Sc-Dex group (p = 0.011). Preoperative and postoperative IOP values remained unchanged both in IC-TA and Sc-Dex groups (p = 0.424 and p = 0.523, respectively). However, 4 patients in IC-TA group and 5 patients in the Sc-Dex group needed glaucoma medications. The postoperative need for glaucoma medications was similar between the groups (p = 0.347). Postoperative inflammation was well controlled in both groups and none of the patients developed fibrin membrane or synechiae postoperatively. CONCLUSION: Both treatments were effective in controlling postoperative inflammation, but patients in IC-TA group experienced significantly higher endothelial loss. Sc-Dex injections are safer in terms of endothelial loss and preferable to control postoperative inflammation following complex intraocular surgeries.

Optical coherence tomography and Scheimpflug imaging of the iridocorneal angle following intravitreal injection of different medications: A longitudinal analysis.

PURPOSE: Intravitreal injection of medications induces a sudden increase in posterior segment volume and pushes iris plane anteriorly to narrow iridocorneal angle. The aim of this study to follow and define longitudinal course of these changes following intravitreal injection of 3 different anti-vascular endothelial growth factor (VEGF) medications or dexamethasone implant. MATERIALS AND METHODS: This prospective, longitudinal study included 89 eyes of 89 patients that had an intravitreal injection of bevacizumab (n = 20) or ranibizumab (n = 26) or aflibercept (n = 22) or dexamethasone implant (n = 21). All the participants had a detailed ophthalmological examination including anterior segment optical coherence tomography (AS-OCT) and Scheimpflug imaging of the iridocorneal angle, evaluation of anterior chamber depth (ACD), axial length with optical biometry and endothelial cell counts with specular microscopy just before the injection, at post-injection day 1, and post-injection 1st month. RESULTS: Iridocorneal angle became significantly wider following intravitreal injection of dexamethasone implant at nasal and temporal quadrants at the post-injection 1st month both in AS-OCT (p = 0.006, p = 0.002, respectively) and Scheimpflug imaging (p = 0.003, p = 0.004, respectively). Small changes were observed in iridocorneal angle following anti-VEGF injections but these small could not be confirmed in both imaging techniques. There were also no changes in ACD, axial length and endothelial counts in all groups. CONCLUSION: Dexamethasone implants induced widening of iridocorneal angle that persisted at the post-injection 1st month both at nasal and temporal quadrants. However, intravitreal injection of anti-VEGF agents did not have a comparable effect on iridocorneal angle.

Long-term follow-up of choroidal changes following COVID-19 infection: analysis of choroidal thickness and choroidal vascularity index.

OBJECTIVE: To investigate subclinical choroidal involvement in patients with systemic coronavirus disease 2019 (COVID-19) infection and evaluate its long-term course. MATERIALS AND METHODS: This prospective, longitudinal study included 32 eyes of 16 COVID-19 patients and 34 eyes of 17 age-matched healthy control subjects. All the participants had a detailed ophthalmologic assessment, including visual acuity assessment, slit-lamp examination, and indirect ophthalmoscopy. Enhanced depth optical coherence tomography imaging of the posterior pole and peripapillary region was performed in the early (days 15-40) and late (ninth month) postinfectious periods. Choroidal vascularity index (CVI) was calculated using ImageJ software (National Institutes of Health, Bethesda, Md.). RESULTS: None of the patients had any examination finding associated with the ocular involvement of COVID-19. Subfoveal choroidal thickness (SFCT) decreased significantly in the early postinfectious period compared with the healthy control individuals (p = 0.045). SFCT increased significantly in the late postinfectious period compared with the early period (p = 0.002), and the difference between patients and control individuals became statistically insignificant (p = 0.362). There was a similar trend for the peripapillary choroidal thickness measurements. CVI remained unchanged (p = 0.721) despite the significant decrease in SFCT and total choroidal area (p = 0.042), indicating that this decrease occurred both in choroidal stroma and in blood vessels. CVI remained unchanged in the late postinfectious period (p = 0.575) compared with the early period, indicating that recovery occurred in the entire choroidal tissue. CONCLUSION: This study demonstrates that choroidal thickness was reduced in all measured areas and that this decrease affected all choroidal layers. This choroidopathy was reversible and recovered in the ninth postinfectious month.

The influence of corneal incision size on endothelial cell loss and surgically induced astigmatism following phacoemulsification cataract surgery.

OBJECTIVE: Corneal incision size has influence both on corneal biomechanics and intracameral fluid dynamics during phacoemulsification cataract surgery. The aim of this study was to evaluate the impact of corneal incision size on endothelial cell loss and surgically induced astigmatism (SIA) following phacoemulsification cataract surgery. METHODS: This prospective, randomized, and comparative study included 61 eyes with senile cataracts. The patients were randomly assigned to 2.2 mm and 2.8 mm corneal incision sizes and were operated with the same phacoemulsification system. Phacoemulsifcation energy parameters, pre-operative and post-operative endothelial cell counts and corneal astigmatism values were specifically recorded. SIA was calculated according to Alpins method and the results of both groups were compared. RESULTS: There were 31 eyes in the microincisional (2.2 mm) group and 30 eyes in the standard incision (2.8 mm) group. There was no significant difference between the groups for age and gender distribution (p=0.09 and p=0.18, respectively). Similar levels of cumulative dissipated energy was used during phacoemulsification in both groups (p=0.70). SIA was slightly higher in the standard incision group compared to microincisional group (0.47D at 64° vs. 0.37D at 61°, p=0.30). Pre-operative and post-operative uncorrected visual acuity (UCVA) was similar between the groups (p=0.45 and p=0.27).Endothelial cell loss tended to be slightly higher in the microincisional group compared to standard incision group (174.87±132.27 vs. 160.84±121.58, p=0.75), but this difference was not statistically significant. CONCLUSION: Smaller corneal incisions slightly reduced SIA, but tended to induce more endothelial cell loss. This small difference in SIA did not cause a significant change in the postoperative UCVA. Therefore, the trend in reducing corneal incision sizes below 2.8 mm might not be contributing the surgical outcomes of the patients, especially when we consider potential corneal endothelial changes.

The use of Online Videos for Vitreoretinal Surgery Training: A Comprehensive Analysis.

Objectives: The current study aimed to test the quality and educational utility of the videos of retinal detachment surgery available on YouTube. Methods: YouTube was searched using the keywords "retinal detachment, retinal detachment surgery" in October 2019. The steps of pars plana vitrectomy surgery were standardized according to the literature. The videos were evaluated in a blinded fashion by two retina specialists with the use of the Modified DISCERN, Health on the Net Foundation (HON)code, the Journal of American Medical Association (JAMA) checklist, and the Global Quality Score (GQS). Results: A total of 125 videos were reviewed. The total surgery score was 3.11 (2.16-3.67 IQR), and the most commonly shown surgical stages were photocoagulation and core vitrectomy (n = 99 [79.2%] and n = 97 [77.6%], respectively). In the multivariate linear regression model, the duration of video (minutes) (ß- Coefficient 0.033, p<0.001), the HONcode score (ß-Coefficient 0.310, p=0.005), and GQS (ß-Coefficient 0.768, p<0.001) were associated with better educational content, whereas JAMA and Modified DISCERN scores were not. Conclusion: So far, the educational value of YouTube videos has been unsatisfactory. Assessing the videos using tools such as HONcode, video duration and GQS may provide better educational perspective to ophthalmology trainees.

Corneal Sensation and Nerve Fiber Changes in Patients With Interstitial Cystitis.

PURPOSE: Central sensitization syndromes are associated with ocular surface discomfort and certain changes in corneal sensation. The aim of this study was to evaluate corneal changes in patients with interstitial cystitis (IC). METHODS: Thirty patients with IC and 32 healthy control subjects were included in this study. All patients had a detailed ophthalmological examination including measurement of corneal sensation with Cochet-Bonnet esthesiometer, tear breakup time, Schirmer I test, and Ocular Surface Disease Index questionnaire. After these examinations, corneal subbasal nerve plexus of the patients was evaluated with in vivo corneal confocal microscopy (IVCM) and the images were analyzed using fully automated software (ACC Metrics Corneal Nerve Fiber Analyzer V.2). RESULTS: There was no significant difference between the groups regarding age and gender distribution. Corneal sensation was significantly higher in patients with IC (P = 0.03), whereas tear breakup time, Schirmer I test, and Ocular Surface Disease Index scores were similar between the patients and controls. IVCM demonstrated nerve fiber loss in patients with IC. Corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length were significantly reduced in patients with IC compared with healthy controls (P < 0.001, P = 0.04, and P < 0.001, respectively). CONCLUSIONS: Patients with IC had increased corneal sensation and decreased nerve fiber density in IVCM analysis. Corneal nerve fiber loss might decrease the induction threshold of the remaining fibers to induce peripheral sensitization, which may also trigger central sensitization in long term.

A Novel Use of Retinoscopy for the Evaluation of Binocular Balance of Spherical Refractive Errors.

PURPOSE: Binocular balancing is an important component of refractive correction to avoid asthenopic complaints. Polaroid filters are commonly used for binocular balancing; they rely on subjective examination and cannot represent daily visual activities. We describe a new examination approach to evaluate binocular balance with retinoscopy, which is an objective examination method and does not require strict patient cooperation. METHODS: Healthy young individuals with refractive errors (under the age of 40) were included in this study. Each patient was examined by three different ophthalmologists in the same room at 20-min intervals. The first ophthalmologist performed refractive examination separately for each eye, the second physician used binocular balance tests with polaroid glasses, and the third physician practiced binocular balance test with retinoscopy. After completion of clinical examinations, autorefractometry was repeated with cycloplegia. The difference between the spherical equivalents (SE) of the eyes was calculated for each method and compared with the SE difference obtained by cycloplegic autorefractometry. The SPSS 21.0 software was used for the statistical tests. RESULTS: The study included 30 patients (16 males, 14 females) and the mean age of the patients was 21 ± 8.5 years (range 10-37 years). There was no significant difference between the four groups for the interocular difference of SE (Greenhouse-Geisser F = 1.390, p = 0.257). The highest correlation was found between the retinoscopic binocular balance technique and cycloplegic autorefractometry (r = 0.878, p < 0.001). In addition, the intraclass correlation coefficient and the 95% limits of agreement supported strong agreement. CONCLUSION: Currently used binocular examination tests are subjective and some patients give inconsistent answers impairing the reliability of the outcome. These tests cannot be performed on patients with limited ability to cooperate. This study demonstrates that the use of retinoscopy in the evaluation of binocular balance delivers reliable results and is a low-cost, practical approach to address the above-mentioned problems.

Clinical outcome and endothelial loss following prepupillary and retropupillary implantation of iris claw intraocular lenses.

PURPOSE: Iris claw intraocular lenses (IOLs) were successfully used for the management of aphakia in patients that lack capsular support. The aim of this study was to compare the clinical outcome of prepupillary and retropupillary implantation of these IOLs. METHODS: The files of the 26 patients that had an iris claw IOL implantation between 2010 and 2020 were retrospectively reviewed. Detailed ophthalmological examination findings including corrected distance visual acuity (CDVA), intraocular pressure, endothelial cell counts, slit lamp and dilated fundus examination findings were specifically tabulated. Intraoperative and postoperative complications were also specifically recorded. RESULTS: There were 18 patients in the prepupillary implantation group and eight patients in the retropupillary implantation group. Age and gender distribution were similar between the groups. CDVA significantly increased in prepupillary and retropupillary implantation groups (p = 0.001 and p = 0.012, respectively). Median endothelial cell loss was 6.7% in prepupillary group and 7.2% in retropupillary group. The only intraoperative complication was iridodialysis (n = 1). Postoperative complications included retinal detachment (n = 1), cystoid macular edema (n = 2) and IOL tilt (n = 1). All of these complications occurred in the prepupillary implantation group. CONCLUSION: Prepupillary and retropupillary implantation of iris claw IOLs resulted with similar visual gain and endothelial loss rates in a follow-up time of 6 months. There was an insignificant trend toward a reduced complication rate following retropupillary implantation.

Surgical therapy versus observation for lamellar macular hole: a retrospective comparison study.

BACKGROUND: The purpose of this study was to compare anatomic and visual changes in patients with lamellar macular hole undergoing pars plana vitrectomy with those in patients undergoing follow-up only. METHODS: In this retrospective consecutive case series study, we evaluated two groups of eyes, comprising 19 eyes from 19 patients with lamellar macular hole who underwent pars plana vitrectomy with internal limiting membrane peeling and 21 eyes from 21 patients with lamellar macular hole who had follow-up only. Corrected distance visual acuity (CDVA, in logMAR) and optical coherence tomography findings, including measurements of maximum diameter of lamellar defect and foveal thickness, and whether the inner segment/outer segment band was intact or not were documented at initial and follow-up examinations. RESULTS: At initial examination, mean CDVA was 0.54 logMAR in the study group and 0.51 logMAR in the control group, and 0.33 logMAR and 0.55 logMAR, respectively, on final examination. In the study group, postoperative optical coherence tomography images were found to be normalized in ten patients (52.6%), improved in six (31.5%), unchanged in two (10.5%), and to have progressed to full-thickness macular hole in one (5.2%) in the intervention group, while all patients in the control group were found to have deteriorated within the follow-up period between March 2004 and June 2010. CONCLUSION: In patients with lamellar macular hole, combination treatment with pars plana vitrectomy and internal limiting membrane peeling appears to be effective, but further studies are required to establish new treatment modalities for patients who do not have a satisfactory outcome from treatment.