Real-world assessment of intravitreal dexamethasone implant (0.7 mg) in patients with macular edema: the CHROME study.

BACKGROUND: The purpose of this study was to evaluate the real-world use, efficacy, and safety of one or more dexamethasone intravitreal implant(s) 0.7 mg (DEX implant) in patients with macular edema (ME). METHODS: This was a retrospective cohort study of patients with ME secondary to retinal disease treated at ten Canadian retina practices, including one uveitis center. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), glaucoma and cataract surgery, and safety data were collected from the medical charts of patients with ≥3 months of follow-up after the initial DEX implant. RESULTS: One hundred and one patient charts yielded data on 120 study eyes, including diagnoses of diabetic ME (DME) (n=34), retinal vein occlusion (RVO, n=30; branch in 19 and central in 11), and uveitis (n=23). Patients had a mean age of 60.9 years, and 73.3% of the study eyes had ME for a duration of ≥12 months prior to DEX implant injection(s). Baseline mean (± standard error) BCVA was 0.63±0.03 logMAR (20/86 Snellen equivalents) and mean CRT was 474.4±18.2 µm. The mean number of DEX implant injections was 1.7±0.1 in all study eyes; 44.2% of eyes had repeat DEX implant injections (reinjection interval 2.3-4.9 months). The greatest mean peak changes in BCVA lines of vision occurred in study eyes with uveitis (3.3±0.6, P<0.0001), followed by RVO (1.3±0.5, P<0.01) and DME (0.7±0.5, P>0.05). Significant decreases in CRT were observed: -255.6±43.6 µm for uveitis, -190.9±23.5 µm for DME, and -160.7±39.6 µm for RVO (P<0.0001 for all cohorts). IOP increases of ≥10 mmHg occurred in 20.6%, 24.1%, and 22.7% of DME, RVO, and uveitis study eyes, respectively. IOP-lowering medication was initiated in 29.4%, 16.7%, and 8.7% of DME, RVO, and uveitis study eyes, respectively. Glaucoma surgery was performed in 1.7% of all study eyes and cataract surgery in 29.8% of all phakic study eyes receiving DEX implant(s). CONCLUSION: DEX implant(s) alone or combined with other treatments and/or procedures resulted in functional and anatomic improvements in long-standing ME associated with retinal disease.

Prospective evaluation of teleophthalmology in screening and recurrence monitoring of neovascular age-related macular degeneration: a randomized clinical trial.

IMPORTANCE: Teleophthalmology has the potential to reduce costs and inconveniences associated with frequent patient visits. Evaluating teleophthalmology in the management of age-related macular degeneration (AMD) will allow for future implementation of this technology. OBJECTIVE: To evaluate teleophthalmology as a tool for the screening and monitoring of neovascular AMD. DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized clinical trial that included 106 referral eyes for suspected neovascular AMD and 63 eyes with stable neovascular AMD. New referrals for patients with suspected neovascular AMD and patients with stable neovascular AMD were randomized into either routine or teleophthalmologic groups. In the routine group, patients received clinical assessment and diagnostic imaging at a tertiary hospital-based retina clinic. In the teleophthalmologic group, patients received basic examination and diagnostic imaging at a stand-alone teleophthalmologic site, where patient information and imaging studies were acquired and electronically sent over to tertiary hospital-based retina specialists. Patients in the teleophthalmologic group were called back to the tertiary treatment center if the teleophthalmologic data set suggested pathology or was inconclusive for diagnosis. MAIN OUTCOMES AND MEASURES: Patient wait times for diagnosis and/or treatment, referral accuracy, and visual outcome. RESULTS: For neovascular AMD screening, the average referral-to-diagnostic imaging time was 22.5 days for the teleophthalmologic group and 18.0 days for the routine group, for a difference of 4.5 days (95% CI, 11.8 to -2.8 days; P = .23). The average diagnostic imaging to treatment time was 16.4 days for the teleophthalmologic group and 11.6 days for the routine group, for a difference of 4.8 days (95% CI, 10.7 to -1.1 days; P = .11). For neovascular AMD monitoring, the average recurrence to treatment time was shorter for the routine group (0.04 days) compared with 13.6 days for the teleophthalmologic group, for a difference of -13.5 days (95% CI, -18.2 to -9.0 days; P < .01). There was no difference identified between end-of-study visual acuities in the 2 groups (P = .99). CONCLUSIONS AND RELEVANCE: A delay of referral to treatment time could not be identified when comparing teleophthalmologic screening for suspected neovascular AMD with retinal specialist-based screening. Teleophthalmologic monitoring for neovascular AMD recurrence resulted in longer wait times for treatment reinitiation, but no adverse visual outcomes were identified. TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT01581606.

Severe visual loss secondary to retinal toxicity after intravenous use of bisphosphonate in an eye with known chloroquine maculopathy.

PURPOSE: To describe a case of retinal toxicity after intravenous administration of the bisphosphonate medication zoledronic acid. METHODS: A 61-year-old woman with known bull's eye chloroquine maculopathy presented with sudden decrease in vision within 1 week of receiving intravenous zoledronic acid (Aclasta). Complete ophthalmic examination including fundus photography, autofluorescence, optical coherence tomography, and visual field testing were performed over 1½ years of follow-up. RESULTS: Decreased visual acuity, central visual field depression, and loss of the outer retinal layers on optical coherence tomography were seen in the symptomatic eye. The patient's last dose of chloroquine was over 15 years ago, with stable visual acuity and visual fields over this period, making chloroquine maculopathy an unlikely cause for the acute visual decline. The temporal association with the administration of intravenous zoledronic acid suggests a causative role for this mediation. CONCLUSION: Exposure to zoledronic acid seems to have precipitated acute visual loss in an eye with known chloroquine toxicity after 15 years of quiescence. Retinal toxicity may represent a rare adverse reaction to zoledronic acid, but this case suggests that caution should be used when administering this medication to patients with compromised retinal integrity.

Intravitreal ranibizumab for the treatment of fibrovascular pigment epithelial detachment in age-related macular degeneration.

OBJECTIVE: To determine the response of predominantly fibrovascular pigment epithelial detachments (PED)-type lesions (secondary to age-related macular degeneration [AMD]) to intravitreal ranibizumab. DESIGN: This was an open-label prospective study. PARTICIPANTS: Thirty-two patients with predominantly fibrovascular PED-type lesions secondary to AMD were included in this study. Three patients were excluded from the final analysis. METHODS: Patients received monthly intravitreal ranibizumab injections for 6 months (induction). At 6 months, patients not experiencing a visual improvement from baseline Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity or not showing a reduction in PED height (based on optical coherence tomography [OCT]) were deemed ranibizumab nonresponders and received no further injections but underwent re-evaluation at 12 months. Patients deemed responders continued with OCT-guided active treatment on an as-needed basis for an additional 6 months. RESULTS: Twenty-four patients (82.8%) were ranibizumab responders and 5 were (17.2%) nonresponders. For ranibizumab responders, mean ETDRS visual acuity improved by 7.2 ± 9.8 letters at 6 months (p = 0.002) and 6.3 ± 8.6 letters at 12 months (p = 0.002). Ranibizumab nonresponders experienced a decline in mean visual acuity of 8.2 ± 4.6 letters at 6 months (p = 0.02) and 18.2 ± 10.11 letters at 12 months (p = 0.02). At baseline, responders had a mean PED height of 345.8 ± 96.0 µm, which decreased to 111.6 ± 133.2 µm at 6 months (p < 0.001) and had a slight increase at 12 months to 144.8 ± 146.3 µm (p < 0.001). Two responders (8.3%) and 2 nonresponders (40%) developed retinal pigment epithelium tears while on treatment. CONCLUSIONS: Intravitreal ranibizumab appears to be a well-tolerated treatment option for patients with fibrovascular PED. Further large-scale, prospective studies may assist in delineating the best treatment protocol.

Outcome of macular hole surgery in diabetic patients with nonproliferative retinopathy.

PURPOSE: To determine the outcome of macular hole surgery in a diabetic population with no evidence of proliferative retinopathy. METHODS: This is a retrospective chart review of 183 patients (194 eyes) undergoing pars plana vitrectomy for an idiopathic macular hole. RESULTS: The anatomic closure rate for the diabetic patients without proliferative retinopathy was 93.8% (15/16), compared with 94.9% (169/178) for nondiabetic patients. A best corrected visual acuity of 20/50 or greater was obtained in 50% of diabetic patients (8/16), compared to 58.4% of nondiabetic patients (104/178). There was no difference in postoperative complications between the two groups. CONCLUSION: The anatomic closure rate and visual outcome after macular hole surgery in diabetic patients without proliferative retinopathy is comparable to that of nondiabetic patients.