Intracanalicular Dexamethasone Insert or Topical Prednisolone Following iStent and Hydrus Surgery for Glaucoma.

PRCIS: Using an intracanalicular dexamethasone insert or topical prednisolone following iStent and Hydrus surgery provided similar short-term control of postoperative inflammation. PURPOSE: The purpose of this study was to compare postoperative inflammation in patients who received an intracanalicular dexamethasone insert or topical prednisolone after iStent or Hydrus insertion during cataract surgery. PATIENTS AND METHODS: Patients receiving a dexamethasone insert after iStent or Hydrus insertion were included and compared with age-matched controls who received topical prednisolone. Preoperative data were recorded. Postoperative inflammatory cell and the proportion of patients with zero anterior chamber cells was recorded at month 1. Postoperative intraocular pressure (IOP) and rate of cystoid macular edema were recorded at months 1 and 3. RESULTS: Forty eyes receiving topical prednisolone were compared with 35 eyes receiving a dexamethasone insert after iStent or Hydrus insertion. The mean postoperative inflammatory cell for the topical group at month 1 was 0.2±0.3, and the dexamethasone group, 0.3±0.5 ( P =0.816). Overall, 70% of patients in the topical group had zero anterior chamber cell at postoperative month 1 compared with 75.8% in the dexamethasone group ( P =0.583). The mean preoperative IOP for the topical group was 18.8±5.5 and the dexamethasone group was 17.1±4.1 ( P =0.064). Mean postoperative IOP for the topical group at months 1 and 3 was 17.6±6.4 and 15.1±3.1, respectively and the dexamethasone group, 17.5±4.8 and 15.0±3.4, respectively ( P =0.772 and 0.884). One patient developed cystoid macular edema in each group. CONCLUSION: There was no statistically significant difference in the proportion of patients who had zero anterior chamber cell at postoperative month 1 between groups receiving intracanalicular dexamethasone insert or topical prednisolone.

Hydrogel Sealant for Closure of Clear Corneal Incisions in Combined Glaucoma Procedures.

Purpose: The purpose of this study is to determine whether ReSure hydrogel sealant is superior to standard suture for closure of clear corneal incisions in the setting of combined glaucoma procedures. Setting: Glaucoma Department, Duke University Eye Center. Design: This is a retrospective case series. Subjects studied were patients in a 6-year period undergoing combined phacoemulsification and glaucoma surgery. All cases were performed by the same surgeon. Wound closure methods correlated with discrete timeframes, as ReSure replaced suture midway through the study period, thereby establishing sutured closure as an analogous control group. Methods: All cases included a phacoemulsification procedure requiring a 2.4 mm clear corneal incision. Upon completion of the phacoemulsification portion of the case, the wound was closed with either ReSure hydrogel or standard 10-0 suture closure. The researchers assessed the rate of Seidel-positive corneal wound leak on postoperative day one. Results: In all cases employing ReSure, no wound leak was observed at postoperative day one. Within the suture group, 3 cases showed Seidel positivity of the corneal incision. This equates to a statistically significant difference in wound leak frequency of 2.04% (P = 0.012); confidence interval, 0.21 to 5.82. Conclusion: ReSure was able to maintain closure 100% of the time over hundreds of combined cases. Suture, though the standard of practice, did not perform to this level, presenting with 3 cases of spontaneous wound leak. We conclude that ReSure is highly effective and superior to suture in closure of clear corneal incisions in combined glaucoma procedures.

Biomarkers for central serous chorioretinopathy.

Central serous chorioretinopathy (CSCR) is a common chorioretinal disease characterized by serous retinal detachment that most commonly involves the macular region. Although the natural history of the acute form shows a self-limiting course, a significant number of patients suffer from recurrent episodes leading to chronic disease, often leaving patients with residual visual impairment. Visual morbidity is often worsened by a delay in the diagnosis due to the incorrect understanding of the particular biomarkers of the disease. The aim of this review is to provide clinical understanding of the biomarkers of CSCR with an emphasis on the most recent findings in patient demographics, risk factors, clinical imaging findings, and management options. Patients with these biomarkers, age 30-44 years, male gender, increased stress levels, hypercortisolism (endogenous and exogenous exposures), sleep disturbance, pregnancy, and genetic predisposition have increased susceptibility to CSCR. Also, biomarkers on optical coherence tomography (OCT) such as choroidal thickness (CT) and choroidal vascularity index (CVI) showed good diagnostic and prognostic significance in the management of CSCR. There are nonspecific features of CSCR on OCT and OCT angiography such as choroidal neovascularization, photoreceptor alteration/cone density loss, and flat irregular pigment epithelium detachment. We described rare complications of CSCR such as cystoid macular edema (CME) and cystoid macular degeneration (CMD). Patients with CME recovered some vision when treated with anti-vascular endothelial growth factors (anti-VEGFs). Patients with CMD had irreversible macular damage even after treatment with anti-VEGFs.

Peripapillary choroidal vascularity quantification and characterization in healthy individuals.

INTRODUCTION: To characterize the peripapillary choroidal vasculature in healthy individuals using the choroidal vascular index (CVI), a previously established more robust tool of measurement of choroidal vascularity than choroidal thickness. METHODS: The peripapillary choroid in healthy individuals was analyzed using optical coherence tomography. OCT B-scan were analyzed using automated binarization, a previously established technique. This separates the choroidal layer into the stromal and vascular areas. Choroidal vascular index (CVI), the vascular area/total area, was computed for each image over the macula and the peripapillary area of the optic disc. Regression analysis and generalized estimating equation (GEE) were used to analyze various demographics, and CVI in the macula and each quadrant of the optic disc. RESULTS: Fifty eight eyes of 29 healthy individuals were included. Mean age was 42±17 years. Average CVI at the macula was 0.583. Average peripapillary CVI was 0.643 (nasal), 0.598 (temporal), 0.621 (superior) and 0.623 (inferior). Regression analysis of variables demonstrated there was no significant relationship between the demographic variables and macular CVI. However, the analysis demonstrated age and CVI of the peripapillary area were significantly correlated. Further stratification revealed significantly higher CVI in the optic disc in subjects over 45. CONCLUSION: Peripapillary CVI in all quadrants is higher than macular CVI in all age groups. CVI significantly increases after the age of 45 in the peripapillary area but not macular area. This suggests that stromal area decline is greater than the decline of the luminal area in the choroid at the peripapillary area as age increases.

Choroidal Vascularity in Non-arteritic Anterior Ischaemic Optic Neuropathy.

This study evaluates the peripapillary choroidal vascularity in eyes with non-arteritic anterior ischaemic optic neuropathy (NAION) and compares it with the vascularity of healthy fellow eyes and age-matched subjects. The peripapillary choroidal vascularity index (CVI), a new tool of measurement, was calculated using horizontal swept-source optical coherence tomography scans. CVI was calculated using a previously validated automated algorithm. CVI in NAION and fellow eyes of NAION patients were compared with age-matched eyes of healthy individuals using Kruskal-Wallis test. A total of 20 eyes of 20 patients with acute unilateral NAION with healthy fellow eyes (20 eyes) and 40 eyes of 40 healthy patients were included in the study. The average age of patients with NAION was 56 ± 8 and 55 ± 7 years in age-matched healthy controls. NAION eyes had a significantly lower CVI than age-matched controls in both nasal and temporal areas. NAION nasal CVI was 0.47 ± 0.47 compared to 0.62 ± 0.04 in controls (p < 0.001). NAION temporal CVI was 0.45 ± 0.48 compared to 0.58 ± 0.04 in controls (p < 0.001). Temporal CVI was 0.45 ± 0.48 in NAION eyes and was significantly lower than counterpart healthy fellow eyes 0.48 ± 0.02 (p = 0.007). In conclusion, NAION eyes have significantly reduced vascularity in the peripapillary area. CVI is lower in the nasal and temporal of the optic disc compared to healthy individuals. This may suggest those with smaller CVI are more prone to ischaemia from reduced vascularity resulting in NAION.

Quantitative Assessment of the Choriocapillaris in Patients With Retinitis Pigmentosa and in Healthy Individuals Using OCT Angiography.

BACKGROUND AND OBJECTIVE: To characterize the choriocapillaris (CC) vasculature in patients with retinitis pigmentosa (RP) and healthy controls using optical coherence tomography angiography (OCTA). PATIENTS AND METHODS: The CC of patients with RP and controls was analyzed using OCTA. Areas of no-flow, termed flow voids (FVs), were denoted in both. Comparisons between groups were done using Wilcox tests and generalized estimating equations. RESULTS: Fifty-four patients were included. There was a significant difference in spherical equivalent (P < .001). The number of FV was 55.5 ± 20.1 in the RP eyes versus 30.7 ± 16.3 in the controls (P < .001). The average FV area was 0.33 ± 0.12 mm2 in the RP eyes and 0.18 ± 0.10 mm2 in the controls (P < .001). CONCLUSIONS: There are significantly more FV in patients with RP than in healthy subjects, suggesting it is vital to understanding pathophysiology of RP. Further studies should be done to determine if the compromised CC is a result or cause of RP. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e122-e128.].

Optical coherence tomography angiography characterisation of Best disease and associated choroidal neovascularisation.

AIMS: To characterise the vasculature of the retina in patients with Best vitelliform dystrophy, including those with choroidal neovascularisation (CNV), using optical coherence tomography angiography (OCTA) and correlate with fluorescein angiography (FA). METHODS: This prospective observational study included 19 eyes of 10 patients with Best disease. Using OCTA, all layers of retina were qualitatively characterised for each eye. Patients with CNV also underwent FA, and areas of CNV were measured by OCTA and FA and correlated. RESULTS: Retinal characteristics revealed 14 (74%) eyes with abnormal foveal avascular zone (FAZ) in the superficial layer, 19 eyes (100%) had an abnormal FAZ in deep layers, 11 (58%) eyes had a hyper-reflective centre in the superficial layer, 18 (95%) had patchy vascularity loss in the deep layer, 17 (89%) eyes had hyporeflective centre in the choriocapillary (CC) layer and 12 (63%) of those eyes had hyper-reflective material within the hyporeflective centre. Also, notably 6 (86%) CNV eyes had a "halo" or a hypolucent area surrounded in the CNV complex in the outer retinal layer. CNV patterns resembled dense net, loose net, mixed and a new found pattern of a ring shape. CNV measurements revealed an average area of 1.66±1.18mm2 using OCTA and an average area of 0.88±0.76mm2 using FA (p=0.15). CONCLUSION: OCTA reveals that eyes with Best disease have abnormal FAZ, patchy vascularity loss in the superficial and deep layers of the retina and capillary dropout with a hyporeflective centre in CC layer. Further, OCTA is superior to FA in measuring CNV.

Comparative analysis of autofluorescence and OCT angiography in Stargardt disease.

AIMS: To characterise the vasculature of the retina in patients with Stargardt disease (STGD) using optical coherence tomography angiography (OCTA) and to compare these functional findings with fundus autofluorescence (FAF) imaging. METHODS: This observational study included consecutive patients with STGD. The choriocapillaris (CC) layer was analysed on OCTA and retinal pigment epithelium (RPE) changes were assessed on FAF. Areas of CC and RPE impairment were quantified and correlated. RESULTS: Twenty-two patients suffering from different stages of STGD were enrolled. OCTA revealed a vascular rarefaction with vascular prominence in 15 (35%) eyes while the remaining cases had pure vascular rarefaction. On FAF imaging, 25 (58%) eyes had a peripapillary halo, a hypofluorescent lesion in foveal area and the presence of both hypofluorescent and hyperfluorescent changes. On FAF imaging, the average area of RPE impairment was 6.7±4.4 mm2 while on OCTA a hypointense area of 4.2±3.6 mm2 was shown at the level of the CC layer. Mann-Whitney U test showed a statistically significant difference in terms of lesion extension between these two findings (p=0.004). CONCLUSION: RPE damage on FAF appears to be significantly larger than CC layer vessel loss on OCTA, which suggests that RPE damage might precede that of CC.

Ultra-widefield fundus autofluorescence in age-related macular degeneration.

BACKGROUND: Establish accuracy and reproducibility of subjective grading in ultra-widefield fundus autofluorescence (FAF) imaging in patients with age-related macular degeneration (AMD), and determine if an association exists between peripheral FAF abnormalities and AMD. METHODS: This was a prospective, single-blinded case-control study. Patients were consecutively recruited for the study. Patients were excluded if there was a history of prior or active ocular pathology other than AMD or image quality was insufficient for analysis as determined by two independent graders. Control patients were those without any evidence of AMD or other ophthalmic disease apart from cataract. Using the Optos 200Tx (Optos, Marlborough, MA, USA), a ResMax central macula and an ultra-widefield peripheral retina image was taken for each eye in both normal color and short wavelength FAF. Ultra-widefield photographs were modified to mask the macula. Each ResMax and ultra-widefield image was independently graded by two blinded investigators. RESULTS: There were 28 AMD patients and 11 controls. There was a significant difference in the average age between AMD patients and control groups (80 versus 64, respectively P<0.001). There was moderate, statistically significant agreement between observers regarding image interpretation (78.4%, K = 0.524, P<0.001), and 69.0% (K = 0.49, P<0.001) agreement between graders for FAF abnormality patterns. Patients with AMD were at greater risk for peripheral FAF abnormalities (OR: 3.43, P = 0.019) and patients with FAF abnormalities on central macular ResMax images were at greater risk of peripheral FAF findings (OR: 5.19, P = 0.017). CONCLUSION: Subjective interpretation of FAF images has moderate reproducibility and validity in assessment of peripheral FAF abnormalities. Peripheral FAF abnormalities are seen in both AMD and control patients. Those with AMD, poor visual acuity, and macular FAF abnormalities are at greater risk.

Oxygen Saturation of Retinal Vessels in All Stages of Diabetic Retinopathy and Correlation to Ultra-Wide Field Fluorescein Angiography.

PURPOSE: The purpose of this study was to determine retinal hemoglobin oxygen saturation (SO2) in patients with diabetic retinopathy (DR) using retinal oximetry (RO) and to correlate the degree of retinal ischemia using intravenous fluorescein angiography (IVFA). METHODS: This is a single-center cross-sectional cohort study. Twenty-seven controls and 60 adult patients with diabetes mellitus (16 without DR and 44 with DR) were enrolled. Patients were stratified according to DR severity. Using RO, SO2 was measured in major retinal arterioles (SaO2) and venules (SvO2). Using IVFA, the percentage of retinal ischemia in 31 patients with DR was calculated and correlated with RO. RESULTS: Pairwise one-way analysis of variance (ANOVA) showed a significant increase in SaO2 and SvO2 in patients with proliferative DR (PDR) compared with controls (SaO2: PDR, 100 ± 7% vs. controls, 91 ± 4% [P = 0.003]; SvO2: PDR, 66 ± 11% vs. controls, 53 ± 6% [P < 0.00001]). The percentage of retinal ischemia also increased with DR severity: ANOVA showed a significant difference in retinal ischemia between all categories of nonproliferative DR vs. PDR: 2.31 ± 2% vs. 7.92 ± 9% (P = 0.017), respectively. Pearson two-tailed correlation showed significant correlation between SaO2 and ischemia (R = 0.467, P = 0.011). CONCLUSIONS: Hemoglobin oxygen saturation of retinal arterioles and venules increases with DR severity; SaO2 correlates with increasing ischemia measured by IVFA. Retinal oximetry may complement current imaging strategies to noninvasively augment the diagnosis and risk stratification of patients with diabetes.

Longitudinal changes in intracardiac repolarization lability in patients with implantable cardioverter-defibrillator.

BACKGROUND: While it is known that elevated baseline intracardiac repolarization lability is associated with the risk of fast ventricular tachycardia (FVT)/ventricular fibrillation (VF), the effect of its longitudinal changes on the risk of FVT/VF is unknown. METHODS AND RESULTS: Near-field (NF) right ventricular (RV) intracardiac electrograms (EGMs) were recorded every 3-6 months at rest in 248 patients with structural heart disease [mean age 61.2 ± 13.3; 185(75%) male; 162(65.3%) ischemic cardiomyopathy] and implanted cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) [201 (81%) primary prevention]. Intracardiac beat-to-beat QT variability index (QTVINF) was measured on NF RV EGM. During the first study phase (median 18 months), participants made on average 2.4 visits. Then remote follow-up was continued for an additional median period of 3 years. Average QTVINF did not change during the first year after ICD implantation (-0.342 ± 0.603 at baseline vs. -0.262 ± 0.552 at 6 months vs. -0.334 ± 0.603 at 12 months); however, it decreased thereafter (-0.510 ± 0.603 at 18 months; P = 0.042). Adjusted population-averaged GEE model showed that the odds of developing FVT/VF increased by 75% for each 1 unit increase in QTVINF. (OR 1.75 [95%CI 1.05-2.92]; P = 0.031). However, individual patient-specific QTVINF trends (increasing, decreasing, flat) varied from patient to patient. For a given patient, the odds of developing FVT/VF were not associated with increasing or decreasing QTVINF over time [OR 1.27; (95%CI 0.05-30.10); P = 0.881]. CONCLUSION: While on average the odds of FVT/VF increased with an increase in QTVINF, patient-specific longitudinal trends in QTVINF did not affect the odds of FVT/VF.