Molecular epidemiology, clinical features and significance of Shiga toxin detection from routine testing of gastroenteritis specimens.

After introduction of faecal multiplex PCR that includes targets for stx1 and stx2 genes, we found stx genes were detected in 120 specimens from 111 patients over a 31-month period from 2018-2020 from a total of 14,179 separate tests performed. The proportion of stx1 only vs stx2 only vs stx1 and stx2 was 35%, 22% and 42%, respectively. There were 54 specimens which were culture positive, with 33 different serotypes identified, the predominant serotype being O157:H7 (19%). Eighty-two patients had clinical data available; we found a high rate of fever (35%), bloody diarrhoea (34%), acute kidney injury (27%), hospital admission (80%) and detection of faecal co-pathogens (23%). Only one patient developed haemolytic uraemic syndrome. We found no significant association with stx genotype and any particular symptom or complication. We found a significant association of serotypes O157:H7 and O26:H11 with bloody stool, but no significant association with any other symptom or complication.

Long-Term Outcomes in Patients on Life-Long Antibiotics: A Five-Year Cohort Study.

BACKGROUND: Little is known about the impacts at an individual level of long-term antibiotic consumption. We explored health outcomes of long-term antibiotic therapy prescribed to a cohort of patients to suppress infections deemed incurable. METHODS: We conducted a 5-year longitudinal study of patients on long-term antibiotics at Monash Health, a metropolitan tertiary-level hospital network in Australia. Adults prescribed antibiotics for >12 months to suppress chronic infection or prevent recurrent infection were included. A retrospective review of medical records and a descriptive analysis was conducted. RESULTS: Twenty-seven patients were followed up during the study period, from 29 patients originally identified in Monash Health in 2014. Seven of the 27 patients (26%) died from causes unrelated to the suppressed infection, six (22%) ceased long-term antibiotic therapy and two (7%) required treatment modification. Fifteen (56%) were colonised with multiresistant microorganisms, including vancomycin resistant Enterococci, methicillin resistant Staphylococcus aureus, and carbapenem resistant Enterobacteriaciae. CONCLUSIONS: This work highlights the potential pitfalls of long-term antibiotic therapy, and the frailty of this cohort, who are often ineligible for definitive curative therapy.

Infectious diseases physician attitudes to long-term antibiotic use.

Background In Australia, it is not known how much antibiotic prescribing by infectious diseases physicians is long-term, or how confident they are with the evidence behind this practice. Objective Survey Australian infectious diseases physicians to assess attitudes and prescribing practice prescribing prolonged courses of antibiotics. Methods An online questionnaire was distributed to the mailing group for the Australian Society of Infectious Diseases. Responses were collected from 29th October to 12th November 2015. Results The majority of respondents practiced in Australia as Infectious Diseases physicians, microbiologists, or trainees. 88% had prescribed long-term antibiotics. Heterogeneity was noted in the indications for prescription, including recurrent UTIs, cellulitis or chest infections, prosthetic joint infection and vascular graft infection. Beta-lactams antibiotics were prescribed most frequently. 22% of respondents had prescribed rifampicin/fusidic acid most frequently, while 11% could not identify a single antibiotic that they used most frequently, due to the heterogeneity of indications for prescribing. 95% stated that they would stop long-term antibiotic therapy if appropriate, and 74% were willing to enrol their patients into a randomised control trial looking at stopping long-term therapy. Conclusion Most infectious diseases physicians who responded to the survey prescribe long-term antibiotics, with great heterogeneity in the indications for which these antibiotics are prescribed.

Surveillance of life-long antibiotics: a review of antibiotic prescribing practices in an Australian Healthcare Network.

BACKGROUND: The rise of antimicrobial use in the twentieth century has significantly reduced morbidity due to infection, however it has also brought with it the rise of increasing resistance. Some patients are on prolonged, if not "life-long" course of antibiotics. The reasons for this are varied, and include non-infectious indications. We aimed to study the characteristics of this potential source of antibiotic resistance, by exploring the antibiotic dispensing practices and describing the population of patients on long-term antibiotic therapy. METHODS: A retrospective cross-sectional study of antibiotic dispensing records was performed at a large university hospital-based healthcare network in Melbourne, Australia. Outpatient prescriptions were extracted from the hospital pharmacy database over a 6 month period in 2014. Medical records of these patients were reviewed to determine the indication for prescription, including microbiology, the intended duration, and the prescribing unit. A descriptive analysis was performed on this data. RESULTS: 66,127 dispensing episodes were reviewed. 202 patients were found to have been prescribed 1 or more antibiotics with an intended duration of 1 year or longer. 69/202 (34%) of these patients were prescribed prolonged antibiotics for primary prophylaxis in the setting of immunosuppression. 43/202 (21%) patients were prescribed long-term suppressive antibiotics for infections of thought incurable (e.g. vascular graft infections), and 34/43 (79%) were prescribed by Infectious Diseases doctors. 66/202 (33%) patients with cystic fibrosis were prescribed prolonged courses of macrolides or fluoroquinolones, by respiratory physicians. There was great heterogeneity noted in indications for prolonged antibiotic courses, as well as antibiotic agents utilised. CONCLUSION: Our study found that that continuous antibiotic therapy represented only a small proportion of overall antibiotic prescribing at our health network. Prolonged courses of antibiotics were used mainly to suppress infections thought incurable, but also as primary and secondary prophylaxis and as anti-inflammatory agents. More research is needed to understand the impact of long-term antibiotic consumption on both patients and microbial ecology.

Differential diagnosis of macular edema of different pathophysiologic origins by spectral domain optical coherence tomography.

PURPOSE: To develop a classification approach based solely on spectral domain optical coherence tomography to differentiate macular edema (ME) of different disease entities and to determine underlying pathology. METHODS: A cross-sectional study including 153 participants: 27 with Irvine-Gass, 31 with uveitic ME, 24 with ME after branch retinal vein occlusion, 13 with central retinal vein occlusion, 44 with diabetic ME, and 14 controls. Spectral domain optical coherence tomography was graded according to a standardized reading protocol. Grading characteristics were: ME pattern in the central line (horizontal/vertical) and in volume scans, distribution of cysts in Early Treatment Diabetic Retinopathy Study grid, morphologic features, and quantitative parameters such as individual layer thickness. The parameters in a best-fitting multivariate model were evaluated for reliability to predict the underlying pathology using a leave-one-out crossover-validation analysis. To evaluate clinical reliability, two masked clinicians graded spectral domain optical coherence tomography images according to the assessed parameters. RESULTS: The best-fitting multivariate model revealed that microfoci, ME pattern in vertical line scan, and foveal retinal nerve fiber layer thickness are the best indicators of the underlying pathology of ME. Classification accuracy of this model was 96%, mean cross-validated test classification accuracy was 84% (r² = 0.95, P < 0.0001). Clinical relevance was examined with 2 independent readers, yielding classification accuracies of 86% in both cases. CONCLUSION: Macular edema demonstrates characteristic patterns, morphologic features, and layer thicknesses dependent on the underlying disease process. Diagnostic recognition of these features may allow clinical and automated disease identification based primarily on spectral domain optical coherence tomography analysis.

A systematic correlation of morphology and function using spectral domain optical coherence tomography and microperimetry in patients with geographic atrophy.

AIMS: This study has been designed to describe the functional impact of distinct pathologies within the retinal layers in patients with geographic atrophy (GA) by means of a point-to-point correlation between optical coherence tomography (OCT) and microperimetry. METHODS: Retinal morphology and function of 23 patients suffering from GA of the retinal pigment epithelium (RPE) have been investigated using the Spectralis OCT (Heidelberg Engineering) and the MP1 microperimeter (Nidek Technologies). The point-to-point overlay of morphology and function has been done using proprietary software, allowing OCT image grading to define distinct alterations of the neurosensory retina, the RPE and the choroid. By overlaying the retinal sensitivity map on the OCT data set, retinal layer alterations could be evaluated regarding their impact on visual function. RESULTS: A total of 1005 stimulation points in the lesion area in 2107 spectral domain OCT B-scans were graded in 43 eyes of 23 patients (mean best corrected visual acuity=20/70). Retinal sensitivity decreases with an increasing number of morphological alterations graded (p<10(-13)). Alterations of the RPE and the external limiting membrane (p<0.02) were associated with absolute scotomas. Furthermore, the loss of the external limiting membrane as the largest area of morphological alteration among our patients with GA (mean area=5.65 mm(2)), had a significant impact (p<10(-4)) on sensitivity (-1.3 dB). CONCLUSIONS: Mapping retinal sensitivity to distinct retinal pathologies revealed outer retinal layers, in addition to the RPE, as significant for sensitivity loss. Therefore in GA the RPE loss and the alteration of outer retinal layers should be analysed, which could also provide insight into lesion progression.

Visual acuity and microperimetric mapping of lesion area in eyes with inflammatory cystoid macular oedema.

PURPOSE: To evaluate the effect of fluid accumulation on local visual function in inflammatory cystoid-macular-edema (ICME). METHODS: This cross-sectional study applied optical-coherence-tomography over a 12×12 fovea-centered field in 50 patients with ICME and mapped the extent of fluid-filled spaces in various retinal layers, of subretinal-fluid and of diffuse-edema. Regression analysis examined effect of planimetric fluid-distribution on best-corrected-visual-acuity (BCVA) and mean microperimetric-sensitivity. RESULTS: BCVA decreased with increasing central-neuroretinal-thickness (r= 0.52, p= 0.001), total central-retinal-thickness, including subneuroretinal-fluid (r= 0.41, p= 0.006), total cystoid-and-diffuse edema-area (r= 0.35, p= 0.036) and cystoid inner-nuclear-layer area (r= 0.39, p= 0.02). Mean retinal-sensitivity decreased with increasing diffuse edema-area (r= -0.86, p<0.0001), total cystoid-and-diffuse edema-area (r= -0.54, p= 0.001), cystoid inner-nuclear-layer area (r= -0.46, p= 0.008) and cystoid ganglion-cell-layer area (r= -0.6, p=0.049), central-neuroretinal-thickness (r= -0.42, p= 0.028) and total central-retinal-thickness (r= -0.34, p= 0.039). In multivariate-analyses BCVA was best described by central-neuroretinal-thickness, duration of edema, total cystoid-and-diffuse edema-area and cystoid inner-nuclear-layer area (R(2) = 0.5, p= 0.002). Mean retinal-sensitivity was best described by diffuse edema-area, total cystoid-and-diffuse edema-area and central-neuroretinal-thickness (R(2) = 0.75, p< 0.0001). Subretinal-fluid area and cystoid outer-nuclear/Henle's layer area had no effect on either BCVA or microperimetry. CONCLUSIONS: Thickening of the neurosensory-fovea, not subfoveal-fluid, had major impact on both BCVA and retinal-sensitivity. The extent of edema in inner retinal layers also had major impact on both of these two functional parameters. Visual-impairment seems to differ depending on the layers involved, thus different types of fluid accumulation may potentially be given varying treatment priorities.

Influence of orthostasis and daytime on retinal thickness in uveitis-associated cystoid macular edema.

AIM: To identify influence of orthostasis and daytime on retinal-thickness in cystoid-macular-edema (CME) using SD-OCT. METHODS: In this cross-sectional study 18 eyes with uveitis-associated CME (uvCME) were included. Orthostatic-changes of retinal-thickness were analyzed using a Cirrus™ SD-OCT. Retinal-thickness was measured with patients lying horizontally on their side, followed by a fast sitting-up and OCT-measurement in sitting-position. Diurnal-change in thicknesses were assessed by Spectralis™ OCT between 8 AM and 8 PM. RESULTS: Approximately 20 s elapsed between position-change and the following OCT-measurement. In horizontal-position, the mean central retinal thickness (CRT) was 496 ± 37 µm, in upright position, the mean CRT was reduced to 412 ± 43 µm (p=0.032), thus position-change led to a 17% decrease in CRT. None of the other ETDRS-subfields showed a statistically significant decrease in thicknesses (p>0.05). In the second experiment, diurnal-CRT decreased over time, whereas the main decrease happened in the morning (8 a.m. 559 ± 35 µm, 12 p.m. 533 ± 36 µm, 4 p.m. 538 ± 32 µm, 8 p.m.551 ± 38 µm, p=0.01). Thicknesses in all other ETDRS-subgrids did not decrease statistically significantly. CONCLUSIONS: Intraretinal-fluid in uvCME may show a high mobility: CRT decreases within seconds after a patient changes position, indicating that position effects retinal-thickness. Main diurnal-decrease in CRT occurs before noon, which is likely due to a position-change in the morning. Patient-population (walk-in patients versus hospitalized, lying patients) and previous waiting-position should be considered when interpreting retinal-thickness in clinical-practice.

Systematic correlation of morphologic alterations and retinal function in eyes with uveitis-associated cystoid macular oedema during development, resolution and relapse.

PURPOSE: To evaluate morphological changes due to uveitis-associated cystoid macular oedema (uvCME) and their impact on central retinal sensitivity (CRS) before and after intravitreal triamcinolone-acetonide (IVTA). METHODS: 28 eyes with uvCME were examined with microperimetry and spectral-domain optical-coherence-tomography (SD-OCT) before and after IVTA. Microperimetry-maps were superimposed on SD-OCT and morphological-alterations were correlated point to point with CRS and followed-up for 3 months. The effects of morphological-alterations on CRS over time were evaluated with a linear mixed-model. RESULTS: Mean-CRS increased significantly after IVTA (p=0.009). Proportion of cysts correlated negatively with corresponding CRS (estimate/95% CI -3.8 dB/-6.6 to -0.9, p=0.011). Proportion of diffuse macular-oedema (DifME) had no significant effect on mean-CRS (-0.76 dB/-4.9 to 3.3, p=0.71). The proportion of serous retinal detachment (SRD) had a borderline significant effect on mean-CRS (-9.5 dB/-19.1 to 0.1, p=0.052), however the initial presence of SRD at baseline had no significant negative effect on mean-CRS (-1.3 dB/-4.9 to 2.3, p=0.46). Patients with epiretinal-membrane showed lower mean-CRS than patients without (-3.3 dB/-6.5 to -0.008, p=0.05). The lowest percentage of morphological-alterations was achieved 30 days post IVTA concordant to best visual-acuity (logMAR 0.16 ± 0.26), while best mean-CRS was achieved 90 days post IVTA (16.9 ± 1.8 dB). Fixation-stability showed no significant improvement. CONCLUSIONS: UvCME Morphological-alterations were associated with specific CRS-decreases. DifME showed no significant- and SRD only a borderline effect on mean-CRS, which implicates that their presence should be considered when interpreting SD-OCT and making treatment-decisions.

One year follow-up of functional recovery in neovascular AMD during monthly anti-VEGF treatment.

PURPOSE: To identify neurosensory recovery, testing different functional variables during monthly intravitreal standard anti-vascular endothelial growth factor (VEGF) therapy in neovascular age-related macular degeneration (AMD). DESIGN: Prospective interventional cohort study. METHODS: Sixty-four treatment-naïve neovascular AMD patients with subfoveal lesions were treated and examined monthly for distance visual acuity, reading acuity, maximum reading speed, and contrast sensitivity and with microperimetry evaluating the percentage of absolute and relative scotoma and mean central retinal sensitivity weighted by area. Improvements in reading acuity, distance acuity, reading speed, contrast sensitivity, mean central retinal sensitivity, and scotoma area in dependence of age, lesion type, lesion size, and mean central retinal sensitivity were evaluated by a random-slope and random-intercept model. Recovery pattern of parameters was compared by correlating the individual slopes of each variable. RESULTS: Initially, a rapid short-term effect of anti-VEGF treatment was documented throughout all functional variables. Progressive functional gain over 1 year was observed for distance visual acuity (P = .011), contrast sensitivity (P ≤ .0001), and mean central retinal sensitivity (P ≤ .0001), but not for reading acuity (P = .31) and maximum reading speed (P = .94). Decrease of absolute scotoma area missed statistical significance over time (P = .053) and also fixation stability did not improve (P = .08). However, lesion size influenced the course of absolute scotoma area (P = .0015), while lesion type had no effect on any visual function variable evaluated. The individual slopes of reading acuity and distance visual acuity showed a moderate correlation; however, all other variables showed only a weak or no significant correlation among each other. CONCLUSION: Visual recovery in anti-VEGF therapy is reflected in a characteristic pattern of functional changes over time, whereas distance visual acuity does not seem to comprehensively reflect overall visual function gain.

Therapeutic interventions for macular diseases show characteristic effects on near and distance visual function.

PURPOSE: To compare therapy-induced reading and distance visual acuity (dVA) increases in neovascular age-related macular degeneration (nAMD) and uveitis-associated cystoid macular edema. METHODS: This longitudinal study included 68 treatment-naive eyes: 39 subfoveal nAMD eyes with disrupted photoreceptor layers treated with monthly ranibizumab and 29 uveitis-associated cystoid macular edema eyes with intact photoreceptor layer treated with 1 triamcinolone injection. Patients were examined with high-definition optical coherence tomography, Early Treatment Diabetic Retinopathy Study dVA (logarithm of the minimum angle of resolution), reading acuity (logRADscore), and maximum reading speed (words per minute) over 3 months of therapy. RESULTS: In uveitis-associated cystoid macular edema, logarithm of the minimum angle of resolution and logRADscore improved 1 day post treatment, from 0.49 ± 0.28 to 0.39 ± 0.3 (P = 0.018) and 0.71 ± 0.53 to 0.56 ± 0.49 (P = 0.012), respectively. In nAMD, logarithm of the minimum angle of resolution improved 1 week after anti-vascular endothelial growth factor therapy from 0.59 ± 0.29 to 0.49 ± 0.24 (P = 0.002), with no change in logRADscore. One month after treatment, logRADscore improved from 1.09 ± 0.65 to 0.90 ± 0.60 (P = 0.002). In uveitis-associated cystoid macular edema, the recovery course of reading and dVA was comparable, and in nAMD, reading acuity recovery was delayed. Irrespective of disease, a small reduction in dVA resulted in a larger reading acuity decrease. CONCLUSION: Cystoid macular edema resolution was associated with rapid synchronous reading and dVA improvement, whereas nAMD was followed by faster recovery of distance than reading acuity. In both conditions, reading acuity expressed by critical angular resolution was more suppressed by active disease and recovered relatively more than distance acuity. These discrepancies indicate that reading acuity might be a more sensitive measure for vision decrease in macular diseases than dVA. Reading acuity seems to be an important adjunct assessing intravitreal therapy efficacy.

Morphologic and functional evaluations during development, resolution, and relapse of uveitis-associated cystoid macular edema.

OBJECTIVES: To describe progression and resolution of uveitis-associated cystoid macular edema (uvCME) using spectral-domain optical coherence tomography and find predictive factors for successful intravitreal triamcinolone acetonide (IVTA) therapy. METHODS: Twenty-nine eyes with treatment-naive uvCME were examined before and at 5 scheduled visits within 3 months after intravitreal triamcinolone acetonide administration. Distribution, resolution, relapse, and development of uvCME were evaluated using spectral-domain optical coherence tomography to describe morphology, progression, and relapse according to a standardized reading protocol. Applying repeated measures analysis of variance, morphologic findings were evaluated as predictive factors of the treatment outcome. RESULTS: At baseline, 89.3% presented with focal CME; 65.6% had outer nuclear/Henley's layer and inner nuclear layer cysts. Following intravitreal triamcinolone acetonide administration, cysts of outer nuclear/Henley's layer diminished before those of inner nuclear layer (P = 0.0004). Small-pointed subretinal detachment (SRD) resolution synchronized with inner nuclear layer cyst extinction, whereas dome-shaped SRD resolution lagged behind (P = 0.014). Relapses of CME appeared in 71.4% of eyes with parafoveal inner nuclear layer cysts. Cysts of outer nuclear/Henley's layer were present in an additional 28.6%. None of the eyes developed SRD during CME relapse. The main effect variables "SRD" and "absence of epiretinal membrane" were associated with greater best-corrected visual acuity improvement (P = 0.05 and P = 0.047), whereas the side effect variables "CME duration", "age," and "uveitis location" had no additional effect on best-corrected visual acuity. Baseline SRD predicted a relapse-free clinical course within the observational period (P = 0.025). CONCLUSION: Different morphologic patterns in uvCME may represent different stages in uvCME progression, and initial morphologic appearance can be linked to the clinical prognosis after the treatment.

Correlation of OCT characteristics and retinal sensitivity in neovascular age-related macular degeneration in the course of monthly ranibizumab treatment.

PURPOSE: To evaluate the functional treatment response 3 months and 12 months after monthly ranibizumab in neovascular age-related macular degeneration (NAMD). METHODS: Twenty-six eyes showing treatment-naïve NAMD were examined with the Heidelberg Spectralis OCT (SD-OCT) and the Nidek MP-1 microperimeter (MP) at baseline, after 3 months, and after 12 months of monthly ranibizumab therapy. Each test point of light sensitivity was transferred to the corresponding location on SD-OCT, and subsequently the microperimetric results were evaluated with respect to the following oct findings: neovascular complex (NVC), subretinal fluid (SRF), intraretinal fluid (IRF), intraretinal cystoid space (IRCS), serous pigment epithelium detachment (SPED), and fibrovascular pigment epithelium detachment (FPED). RESULTS: Loci of an initial NVC improved significantly from a mean retinal sensitivity value of 2.6 dB ± 0.8 dB at baseline to 7.4 dB ± 0.9 dB (P < 0.0001) at month 12. Initial SRF, IRF, and IRCS improved significantly from a mean value of 5.1 dB ± 0.9 dB to 12.4 dB ± 0.9 dB (P < 0.0001), 4.0 dB ±1.0 dB to 9.3 dB ± 0.9 dB (P < 0.0001), and 3.4 dB ± 0.9 dB to 8.2 dB ± 0.9 dB (P < 0.0001), respectively. An initial SPED improved significantly from a mean retinal sensitivity value of 1.9 dB ± 1.1 dB at baseline to 9.4 dB ± 1.1 dB (P < 0.0001) at month 12; a FPED improved significantly from 5.2 dB ± 0.9 dB at baseline to 7.6 dB ± 0.9 dB (P < 0.0001) at month 12. CONCLUSIONS: Functional benefit could be detected at all locations of macular pathology, with a lower benefit in the case of FPED and in the case of additional IRCS, and a marked benefit for all types of macular edema. (https://eudract.ema.europa.eu/, number 2006-005684-26.).

Correlation of SD-OCT features and retinal sensitivity in neovascular age-related macular degeneration.

PURPOSE: To correlate retinal sensitivity in patients with neovascular age-related macular degeneration (AMD) with specific characteristics of retinal morphology. METHODS: Thirty eyes of 30 patients presenting with active choroidal neovascularization were examined by spectral domain optical coherence tomography (SD-OCT) and microperimetry (MP-1). Image-processing software was used to match a fundus photographic (FP) MP-1 image with an infrared+OCT SD-OCT image. Each MP test point for retinal sensitivity was positioned at the corresponding SD-OCT location, and the microperimetric results were evaluated. RESULTS: An intact retinal configuration was associated with a median retinal sensitivity of 15.5 dB (quartiles: 12 dB, 18 dB). The median retinal sensitivities were 0 dB (quartiles: 0 dB, 1 dB) for the neovascular complex, 4 dB (0 dB, 9 dB) for the subretinal fluid, 1 dB (0 dB, 6 dB) for the intraretinal fluid, and 0 dB (0 dB, 3 dB) for intraretinal cysts. Pigment epithelium detachment was associated with a median retinal sensitivity of 3 dB (0 dB, 8 dB), and subretinal drusen had a median value of 8 dB (5 dB, 12 dB). Deep retinal layer analyses gave low median retinal sensitivities of 0 dB (0 dB, 3 dB) for an absent retinal pigment epithelium layer and 1 dB (0 dB, 5 dB) for an absent photoreceptor layer. CONCLUSIONS: Superimposition of morphological SD-OCT features and microperimetric retinal sensitivity allowed exact determination of the differential impact of retinal alteration on the corresponding sensitivity. Individual OCT-related indicators of neurosensory integrity were distinctly correlated with visual function. "Morphofunctional" findings could be relevant as prognostic factors and for (re)treatment decisions. (https://www.clinicaltrialsregister.eu/ number, 2006-005684-26.).

Short-term progression of wet AMD and correlation with 1-year treatment results.

PURPOSE: Quantification of short-term progression of active neovascular age-related macular degeneration and correlation with 1-year outcome. METHODS: Sixty-five patients with newly diagnosed treatment-naive active subfoveal choroidal neovascularization (CNV), who had participated in clinical trials testing anti-vascular endothelial growth factor therapy, were retrospectively assessed. Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), Spectral Domain Optical Coherence Tomography (SD-OCT) and fluorescein angiography (FA) were performed twice during the pretreatment period. Changes in BCVA, central retinal thickness (CRT), average macular thickness (AMT) and leakage area were documented within this pretreatment period for all patients and for lesion type I (occult CNV, n=42) and type II (classic CNV, n=23). Three-month and 1-year BCVA were then correlated with the pretreatment period. RESULTS: The pretreatment period was 19±3 days (range: 2-108). Neither type I nor type II lesions showed a significant BCVA decrease or CRT/AMT increase during this period. On FA, mean leakage area increased significantly during the pretreatment period: in the pooled group from 5.50±0.62 (screening) to 7.60±0.86 mm2 (baseline) (p<0.0001), in type II from 4.65±0.90 to 7.83±1.62 mm2 (p<0.01) and in type I from 6.08±0.85 to 7.45±0.96 mm2 (p<0.0001). The mean increase in leakage area per day was 0.046±0.02 mm2, p=0.034. Type II showed a daily growth of 0.09±0.08 mm2 (p<0.042) and type I 0.045±0.008 mm2 per day (p<0.0001). However, neither leakage area increase nor pretreatment period was correlated with 3-month or 1-year BCVA outcome. CONCLUSIONS: SD-OCT and BCVA testing did not reveal deterioration during the pretreatment period. However, the leakage area progressed rapidly. Despite the rapid increasing leakage area, the 19-day waiting period was not associated with a poorer visual outcome at 3 months and 1 year.

Diagnostic evaluation of type 2 (classic) choroidal neovascularization: optical coherence tomography, indocyanine green angiography, and fluorescein angiography.

PURPOSE: To evaluate the diagnostic characteristics of type 2 (classic) choroidal neovascularizations secondary to age-related macular degeneration using spectral domain-optical coherence tomography (SD OCT), indocyanine green angiography (ICGA), and fluorescein angiography (FA). DESIGN: Observational case series. SETTING: Institutional. STUDY POPULATION: Thirteen treatment-naïve eyes with type 2 choroidal neovascularization without an occult component. MAIN OUTCOME MEASURES: Greatest horizontal dimension, based on the anatomic features of the neovascular complex by SD OCT (Spectralis; Heidelberg Engineering), ICGA, and FA; retinal leakage area in late-phase FA and ICGA; and the area of retinal edema in SD OCT. OBSERVATION PROCEDURES: For direct comparison, ICGA and FA images were overlaid manually on infrared plus SD OCT images using VirtualDub and Paint.NET software. Greatest horizontal dimension was measured using Image J software (National Institutes of Health). RESULTS: The mean greatest horizontal dimension of the neovascular complex and the retinal leakage area consistently were smaller on ICGA compared with the area of retinal edema on SD OCT. According to FA, the greatest horizontal dimension of early, well-demarcated hyperfluorescence was significantly smaller than the neovascular complex on SD OCT. In addition, the greatest horizontal dimension of the retinal leakage area in late-phase FA consistently was smaller than the area of retinal edema on SD OCT. CONCLUSIONS: In classic choroidal neovascularization, ICGA and FA seem to underestimate the extension of the neovascular complex and the associated retinal pathologic features compared with SD OCT imaging.

A systematic comparison of spectral-domain optical coherence tomography and fundus autofluorescence in patients with geographic atrophy.

PURPOSE: To evaluate spectral-domain optical coherence tomography (SD-OCT) in providing reliable and reproducible parameters for grading geographic atrophy (GA) compared with fundus autofluorescence (FAF) images acquired by confocal scanning laser ophthalmoscopy (cSLO). DESIGN: Prospective observational study. PARTICIPANTS: A total of 81 eyes of 42 patients with GA. METHODS: Patients with atrophic age-related macular degeneration (AMD) were enrolled on the basis of total GA lesion size ranging from 0.5 to 7 disc areas and best-corrected visual acuity of at least 20/200. A novel combined cSLO-SD-OCT system (Spectralis HRA-OCT, Heidelberg Engineering, Heidelberg, Germany) was used to grade foveal involvement and to manually measure disease extent at the level of the outer neurosensory layers and retinal pigment epithelium (RPE) at the site of GA lesions. Two readers of the Vienna Reading Center graded all obtained volume stacks (20×20 degrees), and the results were correlated to FAF. MAIN OUTCOME MEASURES: Choroidal signal enhancements and alterations of the RPE, external limiting membrane (ELM), and outer plexiform layer by SD-OCT. These parameters were compared with the lesion measured with severely decreased FAF. RESULTS: Foveal involvement or sparing was definitely identified in 75 of 81 eyes based on SD-OCT by both graders (inter-grader agreement: κ=0.6, P < 0.01). In FAF, inter-grader agreement regarding foveal involvement was lower (48/81 eyes, inter-grader agreement: κ=0.3, P < 0.01). Severely decreased FAF was measured over a mean area of 8.97 mm(2) for grader 1 (G1) and 9.54 mm(2) for grader 2 (G2), consistent with the mean SD-OCT quantification of the sub-RPE choroidal signal enhancement (8.9 mm(2) [G1] -9.4 mm(2) [G2]) and ELM loss with 8.7 mm(2) (G1) -10.2 mm(2) (G2). In contrast, complete morphologic absence of the RPE layer by SD-OCT was significantly smaller than the GA size in FAF (R(2)=0.400). Inter-reader agreement was highest regarding complete choroidal signal enhancement (0.98) and ELM loss (0.98). CONCLUSIONS: Absence of FAF in GA lesions is consistent with morphologic RPE loss or advanced RPE disruption and is associated with alterations of the outer retinal layers as identified by SD-OCT. Lesion size is precisely determinable by SD-OCT, and foveal involvement is more accurate by SD-OCT than by FAF.

Encircling band, laser retinopexy and lens removal as standard procedure in complicated retinal detachment shows a good clinical outcome.

PURPOSE: To evaluate vitrectomy in conjunction with the use of perfluorocarbon, cerclage, laser retinopexy, lens removal and silicone oil as surgical treatment of proliferative vitreoretinopathy associated with retinal detachment. METHODS: Sixty-two eyes of 62 patients were treated for complicated retinal detachment following failed prior scleral buckling. Outcome measures were; retinal reattachment rate 6 months after silicone oil removal, status of the retina, visual acuity (VA), duration of silicone tamponade and frequency of reoperations. RESULTS: The final reattachment rate was 95%. Reoperations had to be performed in 25% of patients. Eighty-one per cent of these patients received one and 19% two or more operations following silicone oil implantation. The mean time to reoperation was 1.8 ± 1.4 months. Silicone oil was removed after 5.6 ± 4.1 months following the last vitreoretinal procedure in 90%, respectively, 95% with attached retina. Five per cent experienced retinal detachment after silicone oil removal. At the end of follow-up, the mean VA was 0.13 ± 0.26 Snellen. Seventy per cent of patients achieved a vision of 20/200 or better (mean 0.25 ± 0.27). CONCLUSION: Our study demonstrates good final outcomes when a rigorous surgical approach was used. Furthermore, this standard procedure reduces the need for reoperations and consequently improves the functional outcome.