Prospective evaluation of the effectiveness of combined treatment of macular edema secondary to retinal vein occlusion with intravitreal bevacizumab and dexamethasone implants / Estudo intervencionista prospectivo para avaliar a eficácia da associação do bevacizumabe intravítreo ao implante de dexametasona para edema macular secundário à oclusão da veia retiniana

ABSTRACT Purpose: To evaluate the effectiveness of in­­­travitreal bevacizumab injections following a single dexamethasone implant in the treatment of macular edema secondary to branch and central retinal vein occlusion. Methods: This was a prospective interventional non-comparative study, 44 eyes of patients with naïve macular edema related to branch and central retinal vein occlusion were treated with a dexamethasone implant. Patients were followed-up at four-week intervals from the second to the sixth month. If persistent or recurrent macular edema occurred during this period, the patient was treated with intravitreal bevacizumab injections on an as-needed basis. The outcome measures were best-corrected visual acuity and central macular thickness changes. Results: The mean best-corrected visual acuity changed from 0.97 ± 0.33 LogMAR at baseline to 0.54 ± 0.40 at the six-month post-implant examination (p<0.00001). Improvement ≥3 Snellen lines were seen in 20 eyes (45.54%). The mean central macular thickness at baseline was 670.25 ± 209.9 microns. This had decreased to 317.43 ± 112.68 microns at the six-month follow-up (p<0.00001). The mean number of intravitreal bevacizumab injections received in the six months post-implant was 2.32. The mean time from dexamethasone implant to first anti-VEGF injection was 3.45 months. Conclusions: Intravitreal bevacizumab injections following a single dexamethasone implant were found to improve best-corrected visual acuity and central macular thickness in patients with macular edema due to branch and central retinal vein occlusion at six months, with few intravitreal injections required.

RESUMO Objetivo: Avaliar a eficácia da combinação de in­jeções intravítreas de bevacizumabe em olhos com edema macular secundário à oclusão de ramo e da veia central da retina após um único implante de dexametasona. Métodos: Foi realizado um estudo prospectivo intervencionista não comparativo com 44 olhos de pacientes com edema macular relacionado à oclusão de ramo e veia central da retina, sem tratamento prévio e tratados com um único implante de dexametasona, que foram acompanhados em intervalos de quatro semanas do segundo ao sexto mês. Se fosse constatado edema macular persistente ou recorrente durante esse período, os pacientes eram tratados com injeções intravítreas de bevacizumabe em um regime ajustado conforme a necessidade. Foram estudadas a melhor acuidade visual corrigida e alterações da espessura macular central. Resultados: A média da melhor acuidade visual corrigida mudou de 0,97 ± 0,33 LogMAR iniciais para 0,54 ± 0,40 no exame de 6 meses (p<0,00001). Vinte olhos (45,54%) melhoraram 3 linhas de Snellen ou mais. A média da espessura macular central inicial foi de 670,25 ± 209,9 μm e diminuiu para 317,43 ± 112,68 μm na visita de 6 meses (p<0,00001). O número médio de injeções intravítreas de bevacizumabe em 6 meses foi de 2,32 e o tempo médio entre o implante de dexametasona e a primeira injeção de anti-VEGF foi de 3,45 meses. Conclusão: Injeções intravítreas de bevacizumabe após um único implante de dexametasona podem proporcionar um aumento da melhor acuidade visual corrigida e diminuição da espessura macular central aos 6 meses em pacientes com edema macular devido à oclusão de ramo e da veia central da retina, com poucas injeções intravítreas.

Prospective evaluation of the effectiveness of combined treatment of macular edema secondary to retinal vein occlusion with intravitreal bevacizumab and dexamethasone implants.

PURPOSE: To evaluate the effectiveness of in---travitreal bevacizumab injections following a single dexamethasone implant in the treatment of macular edema secondary to branch and central retinal vein occlusion. METHODS: This was a prospective interventional non-comparative study, 44 eyes of patients with naïve macular edema related to branch and central retinal vein occlusion were treated with a dexamethasone implant. Patients were followed-up at four-week intervals from the second to the sixth month. If persistent or recurrent macular edema occurred during this period, the patient was treated with intravitreal bevacizumab injections on an as-needed basis. The outcome measures were best-corrected visual acuity and central macular thickness changes. RESULTS: The mean best-corrected visual acuity changed from 0.97 ± 0.33 LogMAR at baseline to 0.54 ± 0.40 at the six-month post-implant examination (p<0.00001). Improvement ≥3 Snellen lines were seen in 20 eyes (45.54%). The mean central macular thickness at baseline was 670.25 ± 209.9 microns. This had decreased to 317.43 ± 112.68 microns at the six-month follow-up (p<0.00001). The mean number of intravitreal bevacizumab injections received in the six months post-implant was 2.32. The mean time from dexamethasone implant to first anti-VEGF injection was 3.45 months. CONCLUSIONS: Intravitreal bevacizumab injections following a single dexamethasone implant were found to improve best-corrected visual acuity and central macular thickness in patients with macular edema due to branch and central retinal vein occlusion at six months, with few intravitreal injections required.

A Risk Prediction Model for Endothelial Keratoplasty After Uncomplicated Cataract Surgery in Fuchs Endothelial Corneal Dystrophy.

PURPOSE: To develop a risk prediction model for endothelial keratoplasty (EK) after uncomplicated cataract surgery in Fuchs endothelial corneal dystrophy (FECD) using Scheimpflug imaging. DESIGN: Prospective, observational cohort study. METHODS: The study was conducted at the Ramón y Cajal University Hospital (Madrid, Spain) on 127 eyes from 93 consecutive patients with vision loss, FECD, and cataracts. OBSERVATION: We assessed the corneas using Scheimpflug imaging pachymetry and elevation maps for loss of regular isopachs, displacement of the thinnest point, and posterior surface depression according to the Mayo Clinic subclinical corneal edema classification. We also recorded other preoperative data. Primary Endpoints: The primary endpoint was the need for EK after uncomplicated phacoemulsification within 2 years (median duration, 18 months). We calculated the risk using hazard ratios and the Kaplan-Meier cumulative incidence risk. RESULTS: Forty-four participants required EK, and those eyes with 1, 2, or all 3 tomographic features had a hazard risk of 21.8, 57.2, and 76.5, respectively (P < .005), compared with those eyes with normal tomographic patterns. The best predictive model was based on the number of tomographic features simultaneously present in an eye and the central corneal thickness (CCT) at the pupillary center. We aimed to develop a risk score from 0 to 8. The cumulative risk for EK ranged from virtually 0 for risk scores <4 to almost 100% for those with a score of 8. CONCLUSIONS: The combination of CCT values and tomographic features can be employed to make valid predictions of the risk of requiring EK after phacoemulsification.

Oscillopsia After Isolated Lateral Wall Decompression Versus Balanced or 3-Wall Decompression.

PURPOSE: To assess the incidence of postoperative masticatory oscillopsia after orbital decompression, comparing results between isolated lateral wall and balanced or 3-wall orbital decompression. METHODS: An observational retrospective study was performed, involving 161 consecutive patients who underwent orbital decompression between 2008 and 2018. Patients' clinical data were registered, and archives were revised for data compilation. Patients were divided into 2 groups according to the type of surgery: "lateral" group included patients who underwent isolated lateral wall decompression and "lateral plus" group involved patients with balanced or 3-wall decompression. Exclusion criteria were secondary decompressions, those not including lateral wall and asymmetrical surgeries, so analysis was performed among 131 remaining patients. Oscillopsia was self-reported and was registered as present or not. Diplopia was evaluated according to Paridaens grading system. RESULTS: Statistical analysis among the 131 patients with lateral wall decompression (isolated or in combination) was performed. Seven patients referred oscillopsia, 5 among "lateral" group, while 2 reported oscillopsia on "lateral plus" group (p = 0.001). The authors found no differences on new-onset or worsening of diplopia between groups (p = 1). CONCLUSIONS: Oscillopsia was significantly higher after isolated lateral wall decompression than after balanced or 3-wall decompression, while no differences were found between groups according to diplopia status. Transmission of temporal muscle contraction to the orbit seems to be the cause of the oscillopsia. The authors postulate that the absence of orbital floor or medial wall may act as a dampener for the temporalis muscle contractions, allowing the orbital contents to be expanded through them, and avoiding oscillopsia.

Epidemiology of pseudomembranous conjunctivitis in a tertiary hospital: A 2-year retrospective study.

PURPOSE: To describe the incidence, duration, and complication rate of patients with a clinical diagnosis of pseudomembranous viral conjunctivitis. METHODS: A retrospective observational study is performed compiling the data of patients diagnosed as pseudomembranous conjunctivitis at the hospital's emergency department from June 2016 to May 2018. Demographic variables, duration of symptoms, and follow-up until resolution of the pseudomembranes and associated complications are collected. RESULTS: The incidence rate of pseudomembranous conjunctivitis is 3.47/10,000 people-year and 0.123% of emergency department consultations. The incidence of pseudomembranous conjunctivitis is approximately 20% of the total adenoviral conjunctivitis, with similar peak incidence rates and annual distribution. The presence of pseudomembranes shows a mean duration of 7.86 days. In this series of pseudomembranous patients, 38.4% had at least one of the following complications: 16.7% subepithelial infiltrates (IC 13.0%-21.1%), 20.81% corneal erosions (SE 0.0218, IC 16.7%-25.5%), 3.5% filamentary keratitis (SE 0.010, IC 1.8%-6.0%), and 6.1% subtarsal fibrosis (SE 0.128, IC 3.8%-9.1%). CONCLUSION: To the best of our knowledge, this is the first study to investigate the incidence and rate of complications of pseudomembranous conjunctivitis. Complications occurred in almost 4 out of 10 patients. The mean duration of the follow-up in the ED was higher in patients with any complication compared with non-complicated patients. The high complication rate makes a closely follow-up advisable, until pseudomembrane resolution, to assess possible complications and symptomatic treatment.

Preoperative Risk Assessment for Progression to Descemet Membrane Endothelial Keratoplasty Following Cataract Surgery in Fuchs Endothelial Corneal Dystrophy.

PURPOSE: To identify preoperative corneal tomographic features that predict progression to endothelial keratoplasty (EK) following cataract surgery in Fuchs endothelial corneal dystrophy (FECD) and establish a regression model to identify high-risk patients. DESIGN: Prospective, observational cohort study. METHODS: Setting: Hospital Universitario Ramón y Cajal, Madrid, Spain. STUDY POPULATION: Sixty-eight patients (84 eyes) with FECD who underwent phacoemulsification. INTERVENTION: We assessed preoperative best-corrected visual acuity; ultrasound central corneal thickness; pachymetric, anterior chamber depth, and corneal backscatter variables using Scheimpflug imaging; and endothelial cell density. MAIN OUTCOME MEASURES: Progression to EK. RESULTS: A total of 33 eyes (39.3%) needed EK after phacoemulsification to rehabilitate vision. On multivariate analysis, anterior layer (AL) corneal backscatter between 0 and 2 mm from the apex and relative increase in central corneal thickness from the "relative pachymetry display" by the Pentacam were significant predictors of the risk of progression to EK. Using these 2 variables, a risk score (RISC score) was derived from the regression model (area under the curve = 0.973; best cutoff point with a specificity of 95% representing a sensitivity of 96%). Excluding corneal backscatter data from the multivariate regression model, corneal thickness at the pupil center by the Pentacam and relative increase in central corneal thickness were significant predictors and provided a modified risk score (RIPT score) with similar performance. CONCLUSION: Both scores demonstrated accuracy in predicting progression to EK using easily accessible preoperative data. This approach, which can be readily implemented by surgeons, allows for individualized risk assessment.