Dynamics and patterns of recurrence in neovascular AMD during real-world management using automated fluid monitoring.

In this retrospective longitudinal observational study, data from one site of the Fight Retinal Blindness! Registry (University of Zurich, Switzerland) was used to investigate the quantity and distribution of recurrent fluid in neovascular age-related macular degeneration (nAMD). Study eye eligibility required treatment-naïve nAMD, receiving at least three anti-vascular endothelial growth factor injections, followed by a treatment discontinuation of at least six months and subsequence fluid recurrence. To quantify fluid, a regulatory approved deep learning algorithm (Vienna Fluid Monitor, RetInSight, Vienna, Austria) was used. Fifty-six eyes of 56 patients with a mean age of 76.29 ± 6.58 years at baseline fulfilled the inclusion criteria. From baseline to the end of the first treatment-free interval, SRF volume had decreased significantly (58.0 nl (IQR 10-257 nl) to 8.73 nl (IQR 1-100 nl), p < 0.01). The quantitative increase in IRF volume from baseline to the end of the first treatment-free interval was not statistically significant (1.35 nl (IQR 0-107 nl) to 5.18 nl (IQR 0-24 nl), p = 0.13). PED also did not reach statistical significance (p = 0.71). At the end of the second treatment discontinuation there was quantitatively more IRF (17.3 nl) than SRF (3.74 nl). In conclusion, discontinuation of treatment with anti-VEGF therapy may change the fluid pattern in nAMD.

Advancing the visibility of outer retinal integrity in neovascular age-related macular degeneration with high-resolution OCT.

OBJECTIVE: To compare the visibility and accessibility of the outer retina in neovascular age-related macular degeneration (nAMD) between 2 OCT devices. METHODS: In this prospective, cross-sectional exploratory study, differences in thickness and loss of individual outer retinal layers in eyes with nAMD and in age-matched healthy eyes between a next-level High-Res OCT device and the conventional SPECTRALIS OCT (both Heidelberg Engineering GmbH, Heidelberg, Germany) were analyzed. Eyes with nAMD and at least 250 nL of retinal fluid, quantified by an approved deep-learning algorithm (Fluid Monitor, RetInSight, Vienna, Austria), fulfilled the inclusion criteria. The outer retinal layers were segmented using automated layer segmentation and were corrected manually. Layer loss and thickness were compared between both devices using a linear mixed-effects model and a paired t test. RESULTS: Nineteen eyes of 17 patients with active nAMD and 17 healthy eyes were included. For nAMD eyes, the thickness of the retinal pigment epithelium (RPE) differed significantly between the devices (25.42 µm [95% CI, 14.24-36.61] and 27.31 µm [95% CI, 16.12-38.50] for high-resolution OCT and conventional OCT, respectively; p = 0.033). Furthermore, a significant difference was found in the mean relative external limiting membrane loss (p = 0.021). However, the thickness of photoreceptors, RPE integrity loss, and photoreceptor integrity loss did not differ significantly between devices in the central 3 mm. In healthy eyes, a significant difference in both RPE and photoreceptor thickness between devices was shown (p < 0.001). CONCLUSION: Central RPE thickness was significantly thinner on high-resolution OCT compared with conventional OCT images explained by superior optical separation of the RPE and Bruch's membrane.

OCTA Biomarker Search in Patients with nAMD: Influence of Retinal Fluid on Time-Dependent Biomarker Response.

PURPOSE: Previous studies have identified a link between optical coherence tomography (OCT)-derived and OCT angiography (OCTA)-based parameters in patients with neovascular AMD (nAMD); the latter may serve as direct biomarkers for macular neovascularization (MNV) activity. The aim of this study was to assess the individual influence of retinal thickness (RT) as well as intra- and sub-retinal fluid (IRF, SRF) presence on the treatment response over time as assessed by previously identified OCTA-derived MNV vascular parameters. METHODS: During the first 3 months of anti-VEGF therapy patients were prospectively followed. RT, SRF and IRF were determined from SSOCT/A (PlexElite, Zeiss) images and using the semi-automated AngioTool software, vessel area (VA), total vessel length (TVL), total number of junctions (TNJ), junction density (JD), vessel density (VD) as well as MNV area were exported. IRF and SRF were identified manually on OCT volume scans .The associations between RT, IRF, and SRF and SSOCTA vascular parameters were analyzed using linear mixed models. RESULTS: 31 eyes of 31 patients with treatment-naïve and OCTA-positive nAMD MNV were included in this analysis. VA, TVL, TNJ, and MNV area show a statistically significant change over time in response to anti-VEGF treatment, even after correcting for the presence of SRF, IRF, or RT (all p < 0.05). This is not the case for JD and VD (both p > 0.05). CONCLUSIONS: OCTA-based parameters VA, TVL, TNJ, and MNVarea show a strong response to anti-VEGF therapy over time, independent of the presence of IRF, SRF or RT. We conclude that the above listed OCTA parameters could contribute to our understanding of MNV biology and to guide individualized treatment in the future. TRIAL REGISTRY: The authors confirm that all ongoing and related trials are registered. ClinicalTrials.gov Number: NCT02521142.

Impact of large choroidal vessels on choriocapillaris flow deficit analyses in optical coherence tomography angiography.

PURPOSE: To investigate the impact of large choroidal vessels (LCV) on Choriocapillaris (CC) flow deficit (FD) analyses with swept-source optical coherence tomography angiography (SS-OCTA). DESIGN: Prospective, cross-sectional study. METHODS: Macular 6x6mm SS-OCTA scans were obtained from intermediate age-related macular degeneration (iAMD) and healthy eyes. Images were captured and processed according to most common standards and analyzed for percentage of flow-deficits (FD%) within four 1x1mm squares at the corners of each image. Choroidal thickness (CT), iris color and refraction error were considered as potential influential factors for LCV visibility. A linear mixed model and logistic regression models were calculated for statistical evaluation. RESULTS: Sixty-nine iAMD and 49 age-matched healthy eyes were enrolled. LCV were visible in at least one sector in 52% of iAMD and 47% of healthy eyes. Within the iAMD group FD% were significantly lower in areas containing LCV (p = 0.0029). Increasing CT resulted in an odds ratio decrease of LCV (OR: 0.94, p<0.0001). Below a CT value of ≤118µm LCV could be expected with a sensitivity of 86% and a specificity of 85%. CONCLUSIONS: LCV can significantly affect CC FD analyses of SS-OCTA images. Their visibility is negatively associated with CT. The impact of LCV should be taken into account when performing CC FD assessments, especially in patients where reduced CT is to be expected and inclusion of affected areas should be considered carefully.

Intraretinal microvascular changes after ERM and ILM peeling using SSOCTA.

BACKGROUND: To prospectively investigate retinal vascular changes in patients undergoing epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling using swept source optical coherence tomography angiography (SSOCTA). METHODS: Consecutive patients were grouped based on ERM severity and followed using SSOCTA up to month 3 after surgical intervention. Superficial and deep foveal avascular zone (s/dFAZ) as well as foveal and parafoveal vessel density (VD) were correlated with ERM severity and visual acuity. Differences between groups were evaluated. RESULTS: Significant correlations were found between ERM severity and baseline sFAZ, dFAZ and best corrected visual acuity (BCVA), central retinal subfield thickness (CST) and ΔCST (r = -0.52, r = -0.43, r = -0.42, r = 0.58, r = 0.39; all p<0.05). Vascular flow parameters did not correlate with age, peeling size, pseudophakia or CST, but correlated with intraretinal cysts presence. No associations of BCVA with any of the OCTA parameters across time were found. Significant differences between ERM severity groups 1 and 2 were found for sFAZ at baseline (p = 0.005) and at the 3-month follow-up (p = 0.014), and for dFAZ at baseline (p = 0.017). Superficial foveal and parafoveal VD were not significantly different between groups (all p>0.05). CONCLUSIONS: This study clearly shows that ERM severity based on ERM staging has to be taken into account when undertaking studies in patients with idiopathic ERM using SSOCTA. Further, specific changes in the superficial and deep retinal vasculature in eyes undergoing ERM and ILM peeling were found. However, the clinical usefulness and prognostic value for post-surgical treatment BCVA of the SSOCTA-derived variables (sFAZ and dFAZ area, as well as foveal and parafoveal VD) used remains questionable.

Longitudinal Association Between Drusen Volume and Retinal Capillary Perfusion in Intermediate Age-Related Macular Degeneration.

Purpose: To evaluate vascular changes in the superficial and deep retinal capillary plexus (SCP, DCP) and their association with drusen volume changes in intermediate age-related macular degeneration (iAMD). Methods: Patients with iAMD were examined at baseline and 12 months thereafter. Drusen volume was extracted from 20° × 20° OCT scans using a 3-mm ETDRS grid using a customized algorithm with manual correction. Vessel density (VD) and flow area (FA) were extracted from 3 × 3 mm SD-OCT-A scans after manual correction of the segmentation. Associations were investigated using multiple regression models. Results: We used 31 eyes of 31 patients for evaluation. The mean age at baseline was 74.9 ± 5.4 years; 26 patients were female. Baseline visual acuity (VA) was 0.05 ± 0.08 logMAR (Snellen equivalent approximately 20/22). The initial mean 3-mm central drusen volume was 0.144 ± 0.136 mm3. A significant association with the signal strength index was consistently found, therefore all capillary measurements were corrected. VD in the same area was 49.88% ± 7.38% and 55.43% ± 9.31% for the SCP and DCP, respectively. The baseline FA resulted in 3.292 ± 0.218 mm2 and 3.433 ± 0.224 mm2 for the SCP and DCP, respectively. No association was found between changes in drusen volume and FA or VD after 12 months (all P > 0.05). VA worsened (P = 0.013) and the foveal FA of the SCP increased significantly (P = 0.014). Conclusions: No significant association was found between the increase in drusen volume in iAMD and capillary retinal perfusion over a 12-month follow-up. Although VA decreased statistically over this time period, the foveal FA of the SCP increased.

Impact of Drusen Volume on Quantitative Fundus Autofluorescence in Early and Intermediate Age-Related Macular Degeneration.

Purpose: Drusen volume (DV) and quantitative autofluorescence (qAF) are potential indicators of progression in age-related macular degeneration (AMD). This prospective and observational study examined the association between DV and qAF of the retinal pigment epithelium. Methods: Eighty-eight eyes of 52 patients with early and intermediate AMD were included. The mean follow-up was 9.2 ± 5.6 months, resulting in 312 examinations. DV was extracted from 6 × 6-mm spectral-domain optical coherence tomography scans. qAF was measured using a rotated Delori pattern. The associations between qAF and DV, age, sex, and lens status were investigated using linear mixed models. Results: Patients' mean age was 75.6 ± 5.0 years (range, 61.0-83.4 years). Sixty-eight eyes (77.3%) were from females. No significant association between DV and qAF was found, neither within the total outer Early Treatment Diabetic Retinopathy Study (ETDRS) grid nor for ETDRS segments six to nine (all P > 0.05). Sex and lens status were not associated with qAF (P = 0.429 and P = 0.213, respectively). A significant association between age and qAF (P = 0.025) was found, indicating a decrease of qAF with age. Conclusions: Quantification of DV and fundus autofluorescence did not reveal any correlation in early and intermediate AMD. qAF decreased with age, whereas DV increased in about half of the patients. This finding is a quantitative corroboration that fundus autofluorescence and the buildup of drusen are not correlated processes in AMD.

Repeatability and reliability of quantitative fundus autofluorescence imaging in patients with early and intermediate age-related macular degeneration.

PURPOSE: Quantification of fundus autofluorescence has only recently become available. We report our findings on the evaluation of the repeatability and reliability of quantitative fundus autofluorescence (qAF) measurements in patients with early and intermediate age-related macular degeneration (AMD), using the first approved and commercially available instrument. METHODS: A total of 43 eyes of 22 patients (aged between 52 and 84 years) diagnosed with early and intermediate AMD were included. All eyes were imaged at day 1, 3 months and 6 months using a modified scanning laser ophthalmoscope, equipped with an internal fluorescent reference. Mean qAF values were calculated for the fovea and for each concentric ring of the Delori pattern. Repeatability and reliability were calculated using Bland-Altman analysis and intraclass correlation (ICC). RESULTS: The mean patient age was 73.5 ± 7.9 years. Sixteen patients (73%) were female. qAF repeatability of the eight segments in the middle ring of the Delori pattern (qAFM 8 ) for between sessions was ±8.2%. Agreement at 3- and 6-month follow-up in eyes without retinal changes was ±8.3% and ±9.8%, respectively. Reliability of qAFM 8 was high for all images acquired [ICC = 0.98 (CI: 0.96-0.99), 0.97 (0.93-0.99) and 0.98 (0.92-0.99)]. Agreement at 3- and 6-month follow-up in eyes with retinal changes was ±18.1% and ±20.2%, respectively. Intraclass correlation (ICC) was slightly lower in eyes with retinal changes at 0.93 (0.84-0.97) and 0.96 (0.91-0.98), respectively. CONCLUSIONS: Quantitative autofluorescence shows excellent repeatability and reliability as well as follow-up agreement in patients with early and intermediate AMD without retinal changes. This is relevant when conducting longitudinal studies using qAF.

Irritable bowel syndrome and organic diseases: a comparative analysis of esophageal motility.

AIM: To assess the esophageal motility in patients with irritable bowel syndrome (IBS) and to compare those with patients with autoimmune disorders. METHODS: 15 patients with IBS, 22 with systemic lupus erythematosus (SLE) and 19 with systemic sclerosis (SSc) were prospectively selected from a total of 115 patients at a single university centre and esophageal motility was analysed using standard manometry (Mui Scientific PIP-4-8SS). All patients underwent esophago-gastro-duodenoscopy before entering the study so that only patients with normal endoscopic findings were included in the current study. All patients underwent a complete physical, blood biochemistry and urinary examination. The grade of dysphagia was determined for each patient in accordance to the intensity and frequency of the presented esophageal symptoms. Furthermore, disease activity scores (SLEDAI and modified Rodnan score) were obtained for patients with autoimmune diseases. Outcome parameter: A correlation coefficient was calculated between amplitudes, velocity and duration of the peristaltic waves throughout esophagus and patients' dysphagia for all three groups. RESULTS: There was no statistical difference in the standard blood biochemistry and urinary analysis in all three groups. Patients with IBS showed similar pathologic dysphagia scores compared to patients with SLE and SSc. The mean value of dysphagia score was in IBS group 7.3, in SLE group 6.73 and in SSc group 7.56 with a P-value > 0.05. However, the manometric patterns were different. IBS patients showed during esophageal manometry peristaltic amplitudes at the proximal part of esophagus greater than 60 mmHg in 46% of the patients, which was significant higher in comparison to the SLE (11.8%) and SSc-Group (0%, P = 0.003). Furthermore, IBS patients showed lower mean resting pressure of the distal esophagus sphincter (Lower esophageal sphincter, 22 mmHg) when compared with SLE (28 mmHg, P = 0.037) and SSc (26 mmHg, P = 0.052). 23.5% of patients with SLE showed amplitudes greater as 160 mmHg in the distal esophagus (IBS and SSc: 0%) whereas 29.4% amplitudes greater as 100 mmHg in the middle one (IBS: 16.7%, SSc: 5.9% respectively, P = 0.006). Patients with SSc demonstrated, as expected, in almost half of the cases reduced peristalsis or even aperistalsis in the lower two thirds of the esophagus. SSc patients demonstrated a negative correlation coefficient between dysphagia score, amplitude and velocity of peristaltic activity at middle and lower esophagus [r = -0.6, P < 0.05]. CONCLUSION: IBS patients have comparable dysphagia-scores as patients with autoimmune disorders. The different manometric patterns might allow differentiating esophageal symptoms based on IBS from other organic diseases.

Human leukocyte elastase counteracts matrix metalloproteinase-7 induced apoptosis resistance of tumor cells.

Matrix metalloproteinase-7 (MMP-7/Matrilysin) is a component of the tumor microenvironment associated with malignant progression. Its expression in tumors protects tumor cells from CD95-mediated apoptosis and the cytotoxic activity of tumor specific CD8(+) T cells. In the present study, we show that human leukocyte elastase (HLE) secreted by polymorphonuclear leukocytes cleaves MMP-7 resulting in loss of enzymatic activity. The anti-apoptotic effect of MMP-7 is reduced in the presence of HLE for CD95-, doxorubicin- and CTL-mediated apoptosis. Our data indicates that HLE may be a natural inactivator of MMP-7 which can counteract MMP-7-induced apoptosis resistance.

In vivo subsurface morphological and functional cellular and subcellular imaging of the gastrointestinal tract with confocal mini-microscopy.

AIM: To evaluate a newly developed hand-held confocal probe for in vivo microscopic imaging of the complete gastrointestinal tract in rodents. METHODS: A novel rigid confocal probe (diameter 7 mm) was designed with optical features similar to the flexible endomicroscopy system for use in humans using a 488 nm single line laser for fluorophore excitation. Light emission was detected at 505 to 750 nm. The field of view was 475 microm multiply 475 microm. Optical slice thickness was 7 microm with a lateral resolution of 0.7 microm. Subsurface serial images at different depths (surface to 250 microm) were generated in real time at 1024 multiply 1024 pixels (0.8 frames/s) by placing the probe onto the tissue in gentle, stable contact. Tissue specimens were sampled for histopathological correlation. RESULTS: The esophagus, stomach, small and large intestine and meso, liver, pancreas and gall bladder were visualised in vivo at high resolution in n = 48 mice. Real time microscopic imaging with the confocal mini-microscopy probe was easy to achieve. The different staining protocols (fluorescein, acriflavine, FITC-labelled dextran and L. esculentum lectin) each highlighted specific aspects of the tissue, and in vivo imaging correlated excellently with conventional histology. In vivo blood flow monitoring added a functional quality to morphologic imaging. CONCLUSION: Confocal microscopy is feasible in vivo allowing the visualisation of the complete GI tract at high resolution even of subsurface tissue structures. The new confocal probe design evaluated in this study is compatible with laparoscopy and significantly expands the field of possible applications to intra-abdominal organs. It allows immediate testing of new in vivo staining and application options and therefore permits rapid transfer from animal studies to clinical use in patients.