Treatment choices for diabetic macular oedema: a guideline for when to consider an intravitreal corticosteroid, including adaptations for the COVID-19 era.

First-line treatment of centrally involved diabetic macular oedema (CI-DMO) is often with an anti-vascular endothelial growth factor (anti-VEGF) agent. Although this can provide efficacy in the majority of eyes, a sizeable proportion do not respond sufficiently and many continue to receive anti-VEGF therapy after it may be optimal. This imposes a treatment burden on both patients and clinicians and, most importantly of all, can be sight threatening. Changing treatment to an intravitreal corticosteroid implant at the appropriate time may help optimise patient outcomes and reduce injection frequency, thereby reducing treatment burden. Eight retina specialists convened to discuss how to ensure eyes with CI-DMO receiving intravitreal anti-VEGF therapy are evaluated for a potential change to intravitreal corticosteroid therapy at the most effective time in their treatment journey. They concluded that clear criteria on when to consider changing treatment would be helpful and so developed a consensus guideline covering key decision points such as when and how to assess response to anti-VEGF therapy, when to consider a change to corticosteroid therapy and when and how to assess the response to corticosteroid therapy. The guideline was developed before the COVID-19 pandemic but, with the additional challenges arising from this including even greater pressure on clinic capacity, it is more important than ever to reconsider current working practices and adopt changes to improve patient care while also easing pressure on clinic capacity, reducing hospital visits and maintaining patient safety. This publication therefore also includes suggestions for adapting the guidelines in the COVID-19 era.

Expanding the role of medical retina virtual clinics using multimodal ultra-widefield and optical coherence tomography imaging.

BACKGROUND: An increasingly elderly population with a corresponding increase in ophthalmic conditions has led to increased pressure on hospital eye services (HES). In this study, we evaluated the use of a medical retina virtual clinic (MRVC), which has expanded into assessing all new medical retina referrals, where the need for urgent treatment was not clear. METHODS: Retrospective analysis of all new patients who were seen in the MRVC between April 2016 and May 2018. Pro forma sheets were used in the MRVC to record the patient history, visual acuity, and type of imaging required. Two consultants reviewed the completed pro formas and images and provided a final diagnosis and management plan. These results and reasons for face-to-face (F2F) clinic appointment requests were analyzed. RESULTS: Six hundred ten new referrals were enrolled in the virtual clinic. The most common diagnosis was diabetic eye disease (59.9%). In the virtual clinic 44.1% were followed up, 28.1% were discharged, and 27.8% were booked an F2F clinic appointment (urgent/routine). The main reason for F2F clinic was to offer treatment. Urgent F2F appointments took place on average 11.9 days after virtual clinic attendance. In only two cases was the image quality felt to be inadequate to assess the retina. CONCLUSIONS: MRVC is an effective way of triaging medical retina referrals to allow those patients needing treatment to be seen promptly in the medical retinal service. The use of multimodal ultra-widefield and optical coherence tomography imaging allows assessment of a wide range of retinal pathologies and is a promising solution to alleviate the burden on HES.

New vessels detected on wide-field imaging compared to two-field and seven-field imaging: implications for diabetic retinopathy screening image analysis.

INTRODUCTION: Wide-field retinal imaging (Optomap), used for detecting diabetic retinopathy (DR), has been shown to compare well with seven-field early treatment diabetic retinopathy study (ETDRS) photographs. An Optomap 200° image covers 80% of the retinal surface, compared with the standard seven-field, 30° images, covering 30% of the retinal surface. In England, DR screening is performed by grading two, 45° images per eye, by the DR screening service (DRSS). PURPOSE: To assess how often retinal new vessels (NVs) are observed on Optomap imaging, outside the DRSS two fields and standard seven-field photography, in a cohort of patients referred by the DRSS. METHOD: A consecutive series of treatment naïve patients with DR, referred from DRSS with pre-proliferative or proliferative DR or diabetic maculopathy, were imaged with Optomap colour images, within 3 months of DRSS referral. The incidence and distribution of NVs were recorded in relation to two-field and seven-field areas. RESULTS: NVs were found in 102 of 1562 treatment naïve eyes (6.5%) of 781 patients. Of these, 72 were referred from DRSS as having NVs, but an additional 30 eyes (29% of NVs detected) from 25 patients were referred with a lesser degree of DR. In 25 of the 30 eyes without NVs reported on referral, NVs were located outside the standard two fields taken at DRSS, and in 12, NVs were outside the area covered on seven-field imaging (11.7% of eyes with NVs). CONCLUSIONS: Wide-field imaging with Optomap detected approximately 30% more NVs than standard two-field imaging in patients referred from a UK DRSS.

Information used to decide on retreatment of exudative age-related macular degeneration with anti-VEGF in clinical practice.

Purpose. To record the information used in order to make a retreatment decision in patients with exudative age-related macular degeneration (AMD) and to assess if an optical coherence tomography (OCT)-only follow-up clinic would suffice.
Methods. Two hundred patients under treatment with intravitreal anti-vascular endothelial growth factor injections (anti-VEGF) for exudative AMD were included. Each patient had previously received at least 3 intravitreal anti-VEGF injections (loading dose) (range 3-24 injections). Clinicians seeing the patients beyond the third injection were asked to document the criteria used to make a retreatment decision.
Results. Overall, in 171 (85.5%) cases the retreatment decision was based on OCT findings of intraretinal or subretinal fluid alone. Diagnosis of recurrence requiring treatment would have been missed in 12 cases (6%), if OCT-only data had been used and funduscopy or visual function criteria had been omitted. Decision was based solely on functional criteria in only 2% of the cases. The retreatment decision was based on evaluation of morphologic funduscopic or OCT criteria in 187 (93.5%) cases.
Conclusions. With the increasing number of patients having follow-up after anti- VEGF treatment, efficient systems of follow-up are required. Although most retreatment decisions could have been made by qualitative assessment of OCT images alone, the examination has considerable limitations. Optical coherence tomography in combination with color fundus photography could serve as screening tools for a rational implementation of other invasive imaging techniques such as fundus fluorescein angiography and indocyanine green angiography in decision-making.

Visual suppression in intermittent exotropia during binocular alignment.

PURPOSE: To investigate the cortical mechanisms that prevent diplopia in intermittent exotropia (X(T)) during binocular alignment (orthotropia). METHODS: The authors studied 12 X(T) patients aged 5 to 22 years. Seventy-five percent had functional stereo vision with stereoacuity similar to that of 12 age-matched controls (0.2-3.7 min arc). Identical face images were presented to the two eyes for 400 ms. In one eye, the face was presented at the fovea; in the other, offset along the horizontal axis with up to 12° eccentricity. The task was to indicate whether one or two faces were perceived. RESULTS: All X(T) patients showed normal diplopia when the nonfoveal face was presented to nasal hemiretina, though with a slightly larger fusional range than age-matched controls. However, 10 of 12 patients never experienced diplopia when the nonfoveal face was presented to temporal hemiretina (i.e., when the stimulus simulated exodeviation). Patients showed considerable variability when the single image was perceived. Some patients suppressed the temporal stimulus regardless of which eye viewed it, whereas others suppressed a particular eye even when it viewed the foveal stimulus. In two patients, the simulated exodeviation might have triggered a shift from normal to anomalous retinal correspondence. CONCLUSIONS: Antidiplopic mechanisms in X(T) can be reliably triggered by purely retinal information during orthotropia, but the nature of these mechanisms varies between patients.