Central Retinal Vein Occlusion: The Effect of Antiplatelet and Anticoagulant Agents.

Purpose: This work evaluates the effect of antiplatelet and anticoagulant agents on clinical outcomes, optical coherence tomography (OCT) parameters, and macular ischemia in eyes with central retinal vein occlusion (CRVO). Methods: A retrospective longitudinal cohort study was performed to evaluate patients with CRVO. Demographics, OCT parameters before and after treatment, macular ischemia on fluorescein angiography, and clinical outcomes including the number of injections received were analyzed. Results: A total of 365 patients with CRVO were identified. The average follow-up was 36 months. Antiplatelet or anticoagulant agent use was not associated with a significant difference in visual acuity (VA), prevalence of macular edema, or central subfield thickness on OCT at presentation or final visit. The use of 81-mg aspirin alone was associated with an increased prevalence of foveal hemorrhage at presentation. Patients who were taking an antiplatelet agent, an anticoagulation agent, or both and had an ischemic CRVO with logMAR VA of less than 1.0 experienced improved VA at the final study visit. Patients given antiplatelet or anticoagulant agents had a similar incidence of neovascular sequelae compared with patients not administered these agents. Conclusions: In eyes with CRVO, the use of antiplatelet or anticoagulant agents at CRVO onset was not associated with significantly different functional outcomes, except in ischemic CRVO eyes with VA of less than 20/200. The use of 81-mg aspirin was associated with foveal hemorrhage at CRVO presentation. Otherwise, the use of any antiplatelet agent or anticoagulation was not associated with any CRVO structural outcomes.

Characteristics of Branch Retinal Vein Occlusion in African American Patients.

BACKGROUND AND OBJECTIVES: To describe the presentation, management, and clinical outcomes of branch retinal vein occlusion (BRVO) in African American patients compared to patients of other racial or ethnic backgrounds. PATIENTS AND METHODS: This retrospective cohort study included eyes diagnosed with BRVO and macular edema at a tertiary referral center. Presenting features, treatment, and outcomes were compared based on racial or ethnic backgrounds. RESULTS: The study included 285 eyes: 21.8% African American, 78.2% other. African American patients were more likely to have comorbid diabetes (P = .012), open-angle glaucoma (P < .001), and to present with subretinal fluid (P = .049); multivariate analysis showed race and ethnicity alone may not fully explain presenting subretinal fluid (odds ratio = 2.807; 95% CI, 0.997 to 7.903; P = .051). There was no difference in other comparisons of clinical outcomes or treatment burden, including visual acuity, duration, or treatment method. CONCLUSIONS: Despite significant differences at presentation, the management and outcomes of BRVO did not differ significantly between African American patients and patients of other racial and ethnic backgrounds. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:492-497.].

The Ophthalmology Surgical Competency Assessment Rubric for Intravitreal Injections (ICO-OSCAR:IVI).

(1) Background: Intravitreal injections (IVIs) are the most commonly performed intraocular procedure worldwide. Ensuring correct learning is essential to avoid complications. Our purpose was to develop an internationally valid tool to assess skill in performing IVIs. (2) Methods: A panel of six content experts designed a rubric for assessing the IVI procedure by using a modified Dreyfus scale of skill acquisition, dividing it into steps and providing objective behavioral descriptors for each level of skill in each category, following the International Council of Ophthalmology (ICO) guidance. The rubric draft was then critically reviewed by 12 international content experts, and their constructive comments were considered for the final rubric. (3) Results: The Ophthalmology Surgical Competency Assessment Rubric for IVI (ICO-OSCAR:IVI) is the proposed tool for assessing healthcare professionals training to perform IVI. (4) Conclusions: The ICO-OSCAR:IVI is the result of the consensus of an international expert panel. The methodology used for its development provides this rubric with face and content validity. It can be used globally to assess healthcare professionals training to perform IVI, as well as the impact of different teaching methods on performance. Further studies are required to establish intra- and inter-rater reliability, as well as the predictive validity of this tool.

Characteristics of Central Retinal Vein Occlusion in African Americans.

Purpose: This article studies whether the characteristics and clinical course of African American patients with central retinal vein occlusion (CRVO) differ from other racial groups. Methods: This retrospective cohort study included consecutive patients diagnosed with CRVO at Duke Eye Center, Durham, North Carolina. Presenting characteristics, examination findings, treatment course, and functional and structural outcomes were compared based on patient-reported race. Results: A total of 479 patients with CRVO were included (64.7% white, 22.2% African American, 1.7% mixed race, and 11.4% other races). African American patients were older (68.1 vs 64.3 years, P = .049), more likely to be hypertensive (P = .001) and diabetic (P = .000), and had higher rates of open-angle glaucoma (P < .000). Presenting visual acuity (VA) was worse in African Americans (logarithm of the minimum angle of resolution 1.25 vs 0.96, P = .010). There were no significant differences in the proportion of patients requiring panretinal photocoagulation, intravitreal antivascular endothelial growth factor (anti-VEGF), or intravitreal corticosteroid; however, analysis of treatment-naive individuals showed a higher number of anti-VEGF injections in the first year in African Americans. Final VA was not significantly different between groups, but African Americans had higher rates of neovascular sequelae (25.0% vs 11.8%, P = .019; odds ratio, 2.295, P = .088). Conclusions: African Americans with CRVO presented with more severe visual impairment and more systemic and ocular risk factors for CRVO. Treatment-naive African Americans had a greater treatment burden during the first year of follow-up.

Cost-effectiveness of alternative strategies for interferon-γ release assays and tuberculin skin test in tuberculous uveitis.

BACKGROUND: Although tuberculous uveitis remains a major cause of ocular morbidity in the developing world, there is no consensus on which diagnostic test or testing strategy is the most cost effective. In this study we carried out a cost-effectiveness analysis to determine the most cost-effective diagnostic test strategy. METHODS: In this prospective study, we recruited 102 patients from Singapore National Eye Centre with signs suggestive of tuberculous uveitis. Using prospective data from this cohort and from published meta-analyses, we modelled the incremental cost effectiveness of the following strategies: tuberculin skin test (TST) only; interferon-γ release assay (IGRA) only; IGRA following a positive TST result; and dual-test strategy, conducting TST and IGRA at presentation. Incremental cost-effectiveness ratios (ICERs) were calculated for each strategy and analysed using a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) gained. RESULTS: In our population, the least cost effective was the IGRA-only strategy. The dual-test strategy was the most cost effective, with an improvement of 0.017 QALY at an incremental cost of $190 relative to the TST-only strategy (ICER $11,500); while the TST-only strategy was more cost effective than the third strategy, using IGRA following a positive TST result (ICER $3610). This remained consistent while varying the costs of IGRA and TST, the incidence of tuberculosis and tuberculous uveitis, as well as the diagnostic accuracy of IGRA and TST found in previous studies in various populations. CONCLUSIONS: The dual-test strategy (performing TST and IGRA at presentation) was the most cost effective strategy for the diagnosis of tuberculous uveitis in our population.

Discordance of two interferon-γ release assays and tuberculin skin test in patients with uveitis.

AIMS: To describe interferon-γ release assay (IGRA) and IGRA/tuberculin skin test (TST) discordance and their associated factors in patients with uveitis. METHODS: Prospective study of 102 consecutive new patients presenting with uveitis to a tertiary referral centre. All patients underwent a complete ocular and systemic examination at presentation, with QuantiFERON-Gold in-tube (QFT), T-SPOT.TB and TST performed. Discordant results of TST/QFT, TST/T-SPOT.TB and QFT/T-SPOT.TB were analysed. Binary logistic regression was used to identify factors associated with discordant results. RESULTS: There was fair agreement between TST and T-SPOT.TB (κ=0.371, p<0.001); moderate agreement between TST and QFT (κ=0.471, p<0.001). Both IGRAs showed good agreement (κ=0.668, p<0.001). The discordance rate between the TST/QFT was 26.5%, while TST/T-SPOT.TB was 31.4%. The discordance rate between the IGRAs was 16.7%. There was a significant association between TST/IGRA discordance with increasing age (OR 0.95, 95% CI 0.92 to 0.99; p=0.022), less likely with panuveitis (OR 0.18, 95% CI 0.04 to 0.86; p=0.032), and with Indian ethnicity (OR 14.07, 95% CI 1.45 to 137.03; p=0.023). CONCLUSIONS: Discordance of IGRA and TST results is common and requires further study. In our study in patients with uveitis, we found that ethnicity, age, and type of uveitis were some significant factors associated with TST/IGRA discordance, which may need to be taken into consideration when interpreting these results.

Prospective head-to-head study comparing 2 commercial interferon gamma release assays for the diagnosis of tuberculous uveitis.

PURPOSE: To perform a head-to-head comparison of 2 commercially available interferon-gamma release assays, QuantiFERON-TB Gold In-Tube (Cellestis, Chadstone, Victoria, Australia) and T-SPOT.TB (Oxford Immunotech, Abingdon, Oxfordshire, UK), in the diagnosis of tuberculous uveitis. DESIGN: Prospective cohort to study diagnostic accuracy. METHODS: We recruited consecutive new patients who presented with uveitis to a tertiary institution over a 2-year period. All patients underwent complete ocular examination and systemic evaluation, including T-SPOT.TB, QuantiFERON-TB Gold In-Tube, and tuberculin skin test. Patients were followed-up for a minimum of 1 year after completion of antituberculous therapy where indicated. The main outcome measures were the sensitivity, specificity and accuracy of each test, estimated using Bayesian latent class analysis (presented with 95% Bayesian credible intervals) (Crl). Prior information was obtained from published meta-analyses for diagnostic tests: QuantiFERON Gold In-Tube sensitivity (0.64, 0.59-0.69) and specificity (0.99, 0.99-1.00); T-SPOT. tuberculosis sensitivity (0.50, 0.33-0.67) and specificity (0.91, 0.88-0.93). RESULTS: From our study in patients with uveitis, QuantiFERON-TB Gold In-Tube was more specific but slightly less sensitive (sensitivity: 0.64, 0.60-0.69; specificity: 0.995, 0.988-0.999) than T-SPOT.TB (sensitivity: 0.67, 0.60-0.74; specificity: 0.91, 0.88-0.93). However, QuantiFERON Gold In-Tube was significantly more accurate in identifying true-positive tuberculous uveitis cases than was T-SPOT.TB among discordant cases (QuantiFERON Gold In-Tube positive 98% vs T-SPOT.TB positive 76%; ratio 1.28, 95% Crl: 1.11-1.72, ie, 95% Crl >1.0, statistically significant). CONCLUSION: Based on statistical decision theory, our head-to-head study suggests that QuantiFERON-TB Gold In-Tube is the first-line test that should be performed in preference to T-SPOT.TB (and the tuberculin skin test) for diagnosing tuberculous uveitis.