Comparison of safety and effectiveness of micropulse transscleral cyclophotocoagulation and "slow cook" diode laser transscleral cyclophotocoagulation in patients with refractory open-angle glaucoma

ABSTRACT Purpose: This study aimed to compare the safety and effectiveness of intraocular pressure reduction between micropulse transscleral cyclophotocoagulation and "slow cook" transscleral cyclophotocoagulation in patients with refractory primary open-angle glaucoma. Methods: We included patients with primary open angle glaucoma with at least 12 months of follow-up. We collected and analyzed data on the preoperative characteristics and postoperative outcomes. The primary outcomes were a reduction of ≥20% of the baseline value (criterion A) and/or intraocular pressure between 6 and 21 mmHg (criterion B). Results: We included 128 eyes with primary open-angle glaucoma. The preoperative mean intraocular pressure was 25.53 ± 6.40 and 35.02 ± 12.57 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean intraocular pressure was reduced significantly to 14.33 ± 3.40 and 15.37 ± 5.85 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups at the last follow-up, respectively (p=0.110). The mean intraocular pressure reduction at 12 months was 11.20 ± 11.46 and 19.65 ± 13.22 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The median preoperative logMAR visual acuity was 0.52 ± 0.69 and 1.75 ± 1.04 in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean visual acuity variation was −0.10 ± 0.35 and −0.074 ± 0.16 in the micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p=0.510). Preoperatively, the mean eye drops were 3.44 ± 1.38 and 2.89 ± 0.68 drugs in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p=0.017), but those were 2.06 ± 1.42 and 1.02 ± 1.46 at the end of the study in the "slow cook" and micropulse transscleral cyclophotocoagulation groups, respectively (p<0.001). The success of criterion A was not significant between both groups. Compared with 11 eyes (17.74%) in the "slow cook" transscleral cyclophotocoagulation group, 19 eyes (28.78%) in the micropulse transscleral cyclophotocoagulation group showed complete success (p=0.171). For criterion B, 28 (42.42%) and 2 eyes (3.22%) showed complete success after micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p<0.001). Conclusion: Both techniques reduced intraocular pressure effectively.

Survival rates in pregnancies complicated by twin-to-twin transfusion syndrome undergoing laser therapy: a systematic review and meta-analysis: Survival rates in twin-to-twin transfusion syndrome.

OBJECTIVES: Twin-to-twin transfusion syndrome (TTTS) is associated with excess perinatal mortality and morbidity. Even though Quintero staging is commonly used to assess its severity, the limitations of its prognostic value have been highlighted by researchers over the years. Recent literature indicates that fetal survival, whether for both twins or at least one, following fetoscopic laser photocoagulation of the placental anastomoses is similar in TTTS Quintero stages I and II (combined) and III and IV (combined). In this context we perform a systematic review and meta-analysis of the published literature to elucidate the survival rate of twins according to the stage of TTTS and to compare the survival rates in pregnancies complicated by stage I and II (combined) vs those with stages III and IV (combined). DATA SOURCES: Medline, Embase and Cochrane databases were searched. STUDY ELIGIBILITY CRITERIA: The inclusion criteria were studies reporting the outcome of MCDA twin pregnancies with TTTS undergoing laser therapy according to the Quintero stage of the disease. The primary outcome was double survival at birth. The secondary outcomes were no survival, and survival of at least one twin. All the explored outcomes were reported according to the Quintero staging system. Furthermore, we aimed to compare all the observed outcomes in pregnancies complicated by TTTS affected by stage I and II vs those with stages III and IV. STUDY APPRAISAL AND SYNTHESIS METHODS: Random-effect meta-analyses were used to combine data, and the results reported as pooled proportions or odd ratios (OR) with their 95% confidence intervals (CI). RESULTS: 26 studies were included. Survival of both fetuses was observed in 72.9% (95% CI 68.2-77.3) of pregnancies complicated by stage I, 67.9% (95% CI 62.3-73.3) with stage II, 48.1% (95% CI 42.5-53.8) with stage III, and 53.4% (95% CI 42.5-64.3) with stage IV TTTS (Table 3). At least one survivor was reported in 89.4% (95% CI 86.9-91.9) of cases with stage I, 87.1% (95% CI 82.9-90.7) with stage II, 77.3% (95% CI 71.7-82.5) with stage III, and 80.1% (95% CI 69.4-89.0) with stage 4. The corresponding figures for no survivors were 10.7% (95% CI 7.7-14.0), 11.4% (95% CI 7.8-15.6), 20.4% (95% CI 15.6-25.8), and 16.7% (95% CI 8.3-27.2), respectively. When comparing the different outcomes according to the different TTTS stages, there was no significant difference in the incidence of double survival (p=0.933), at least one survivor (p=0.688), and no survivors (p=0.866) between stages I and II TTTS. There was also no significant difference in the incidence of double survival (p=0.201), at least one survivor (p=0.380), and no survivors (p=0.947) between stages III and IV. Conversely, when comparing the outcome of pregnancies with stage I/II (combined) vs stages III/IV (combined), the incidence of double survival was significantly higher in pregnancies with stages I/II (OR 2.19; 95% CI 1.9-2.6, p<0.001) (Table 5). Likewise, the incidence of at least one survivor was significantly higher (OR 1.85, 95% CI 1.5-2.6, p<0.001) while that of no survivor (OR 0.56, 95% CI 0.4-0.7, p<0.001) significantly lower in pregnancies with stages I/II compared to III/IV. CONCLUSION: Perinatal survival of MCDA twin pregnancies complicated by TTTS and treated with fetoscopic laser coagulation of placental anastomoses is not significantly different between stages I and II, or between stages III and IV, apart from a higher chance of one survivor in stage III compared to stage IV. The findings from this systematic review will be useful in individualised risk assessment of twin pregnancies complicated by TTTS and tailored counselling of the parents. It also highlights the need for studies aimed at better characterizing the prenatal risk factors for mortality in pregnancies complicated by TTTS. CONDENSATION: Perinatal survival of MCDA twin pregnancies complicated by TTTS and treated with fetoscopic laser coagulation of placental anastomoses is not significantly different between stages I and II, or between stages III and IV.

Pre- and Periviable PPROM after Fetoscopic Laser Surgery: Are Survival Outcomes Better than We Think?

INTRODUCTION: Limited data exist regarding outcomes when pre- and periviable PPROM (PPROM ≤26 weeks of gestation) occurs as a complication of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). METHODS: This is a retrospective cohort study of FLS cases performed at a single institution between January 2015 and May 2021. Study inclusion was limited to patients with monochorionic-diamniotic twin pregnancies complicated by TTTS who underwent FLS. Patients were grouped by pPPROM status, and further stratified to those continuing with expectant management, and outcomes were compared between groups. The primary outcome was survival to live birth of at least one twin. RESULTS: During the study period, 171 patients underwent FLS and a total of 96 (56.1%) subjects satisfied inclusion criteria. Among included subjects, 18 (18.8%) experienced pPPROM after FLS and 78 (81.2%) did not. Baseline characteristics were similar between groups. Among patients with pPPROM, 11 (61.1%) pursued expectant management and 7 (38.9%) opted for pregnancy termination. Among expectantly managed subjects, median pPPROM-to-delivery interval was 47.0 days (6.0-66.0 IQR) with a median gestational age at delivery of 29+1 weeks (24 + 4-33 + 6 IQR). Rates of survival to live birth of at least one twin (90.9% vs. 96.2% p = 0.42) were similar between those with pPPROM undergoing expectant management and those without pPPROM. Dual survivorship (45.5% vs. 78.2%, p = 0.03), perinatal survival to live birth (68.2% vs. 87.2%, p = 0.05), and perinatal survival to newborn hospital discharge (59.1% vs. 85.9%, p = <0.01) were all significantly lower among those with pPPROM. Gestational age at delivery was lower among those continuing with pregnancies complicated by pPPROM (29 + 1 vs. 32+5 weeks, p = <0.01). CONCLUSION: Survival of at least one twin to live birth remained high among those pursing expectant management after experiencing post-FLS pPPROM, suggesting that the outlook after this complication is not necessarily poor. However, this complication was associated with lower chances of dual survival and greater prematurity.

Neonatal hemodynamics of recipient twins after fetoscopic selective laser coagulation for twin-to-twin transfusion syndrome: An unicist classification.

To characterize the neonatal hemodynamic profiles in recipients born after twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic selective laser coagulation (FSLC). Retrospective analysis during the first month of life of recipient twins. Of the 480 newborns born during an 11-year period, 138 recipient twins with prenatal FSLC were classified into four groups: no hemodynamic impairment (NoHI, n = 102, 74%), isolated high blood pressure (HighBP, n = 18, 13%), right ventricular outflow tract obstruction (RVOTO, n = 10, 7%), and cardiac failure (CF, n = 8, 6%). The time (median (IQR)) between FSLC and birth was significantly shorter in the HighBP (36 days (23-54)) and CF (44 days (18-54)) groups than in the RVOTO (91 days (68-112)) and NoHi (82 days (62-104)) groups (p < 0.001).     Conclusion: Four distinct and well-characterized groups of recipients were identified based on their hemodynamics. High blood pressure and heart failure occurred in approximately 20% of the infants and were associated with a time between laser coagulation and birth of less than 2 months. What is Known: • Twin-to-twin transfusion syndrome (TTTS) is characterized by a hemodynamic imbalance that leads to high fetal and neonatal mortality if left untreated. One-third of recipient twins born without prenatal fetoscopic laser coagulation (FSLC) develop a life-threatening cardiac failure. What is New: • Four distinct groups of recipient twins with prenatal FSLC have been identified based on their hemodynamics. High blood pressure and cardiac failure occurred in 20% of the infants and were associated with an interval between FSLC and birth of less than 2 months.

Robot assisted Fetoscopic Laser Coagulation: Improvements in navigation, re-location and coagulation.

Fetoscopic Laser Coagulation (FLC) for Twin to Twin Transfusion Syndrome is a challenging intervention due to the working conditions: low quality images acquired from a 3 mm fetoscope inside a turbid liquid environment, local view of the placental surface, unstable surgical field and delicate tissue layers. FLC is based on locating, coagulating and reviewing anastomoses over the placenta's surface. The procedure demands the surgeons to generate a mental map of the placenta with the distribution of the anastomoses, maintaining, at the same time, precision in coagulation and protecting the placenta and amniotic sac from potential damages. This paper describes a teleoperated platform with a cognitive-based control that provides assistance to improve patient safety and surgery performance during fetoscope navigation, target re-location and coagulation processes. A comparative study between manual and teleoperated operation, executed in dry laboratory conditions, analyzes basic fetoscopic skills: fetoscope navigation and laser coagulation. Two exercises are proposed: first, fetoscope guidance and precise coagulation. Second, a resolved placenta (all anastomoses are indicated) to evaluate navigation, re-location and coagulation. The results are analyzed in terms of economy of movement, execution time, coagulation accuracy, amount of coagulated placental surface and risk of placenta puncture. In addition, new metrics, based on navigation and coagulation maps evaluate robotic performance. The results validate the developed platform, showing noticeable improvements in all the metrics.

Fetal and neonatal neuroimaging in twin-twin transfusion syndrome.

OBJECTIVES: To describe the types of brain injury and subsequent neurodevelopmental outcome in fetuses and neonates from pregnancies with twin-twin transfusion syndrome (TTTS). Additionally, to determine risk factors for brain injury and to review the use of neuroimaging modalities in these cases. METHODS: This was a retrospective cohort study of consecutive TTTS pregnancies treated with laser surgery in a single fetal therapy center between January 2010 and January 2020. The primary outcome was the incidence of brain injury, classified into predefined groups. Secondary outcomes included adverse outcome (perinatal mortality or neurodevelopmental impairment), risk factors for brain injury and the number of magnetic resonance imaging (MRI) scans. RESULTS: Cranial ultrasound was performed in all 466 TTTS pregnancies and in 685/749 (91%) liveborn neonates. MRI was performed in 3% of pregnancies and 4% of neonates. Brain injury was diagnosed in 16/935 (2%) fetuses and 37/685 (5%) neonates and all predefined injury groups were represented. Four fetal and four neonatal cases of cerebellar hemorrhage were detected. Among those with brain injury, perinatal mortality occurred in 11/16 (69%) fetuses and 8/37 (22%) neonates. Follow-up was available for 29/34 (85%) long-term survivors with brain injury and the mean age at follow-up was 46 months. Neurodevelopmental impairment was present in 9/29 (31%) survivors with brain injury. Adverse outcome occurred in 28/53 (53%) TTTS individuals with brain injury. The risk of brain injury was increased after recurrent TTTS/post-laser twin anemia-polycythemia sequence (TAPS) (odds ratio (OR), 3.095 (95% CI, 1.581-6.059); P = 0.001) and lower gestational age at birth (OR per 1-week decrease in gestational age, 1.381 (95% CI, 1.238-1.541); P < 0.001). CONCLUSIONS: Based on dedicated neurosonography and limited use of MRI, brain injury was diagnosed in 2% of fetuses and 5% of neonates with TTTS. Adverse outcome was seen in over half of cases with brain injury. Brain injury was related to recurrent TTTS/post-laser TAPS and a lower gestational age at birth. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Comparability of input parameters in the German Retina.net ROP registry and the EU-ROP registry - An exemplary comparison between 2011 and 2021.

PURPOSE: The German Retina.net ROP registry and its Europe-wide successor, the EU-ROP registry, collect data from patients treated for ROP. This analysis compares input parameters of these two registries to establish a procedure for joint analyses of different registry data using exemplary datasets from the two registries. METHODS: Exemplary datasets from the two databases over a 1-year period each (German Retina.net ROP Registry, 2011, 22 infants; EU-ROP Registry, 2021, 44 infants) were compared. The parameters documented in the two databases were aligned and analysed regarding demographic parameters, treatment modalities, complications within first 24 h and retreatments. RESULTS: The current analysis showed that data can be aligned for joint analyses with some adjustments within the data structure. The registry with more detailed data collection (EU-ROP) needs to be reduced regarding granularity in order to align the different registries, as the registry with lower granularity determines the level of analyses that can be performed in a comparative approach. In the exemplary datasets, we observed that the overall most common ROP severity in both registries was zone II, 3+ (2011: 70.5%; 2021: 65%), with decreasing numbers of clock hours showing preretinal neovascularisations (2011: 10-12 clock hours in 29% of cases, 2021: 4-6 clock hours in 38%). The most prevalent treatment method was laser coagulation in 2011 (75%) and anti-VEGF therapy in 2021 (86.1%). Within the anti-VEGF group, all patients were treated with bevacizumab in 2011 and with ranibizumab in 2021. Retreatment rates were comparable in 2011 and 2021. CONCLUSION: Data from two different ROP registries can be aligned and jointly analysed. The analysis reveals a paradigm shift in treatment modalities, from predominantly laser to anti-VEGF, and within the anti-VEGF group from bevacizumab to ranibizumab in Germany. In addition, there was a trend towards earlier treatment in 2021.

Prenatal Risk Factors and Outcomes of Pseudoamniotic Band Sequence following Fetoscopic Laser Surgery: Systematic Review, and Meta-Analysis.

BACKGROUND: Pseudoamniotic band sequence (PABS) is a rare iatrogenic consequence of invasive fetal interventions, most commonly fetoscopic laser surgery (FLS) in monochorionic multiple pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). OBJECTIVES: The aim of this study was to investigate prenatal risk factors and perinatal outcomes for pregnancies involving PABS after FLS for TTTS and compare outcomes between those undergoing fetoscopic band release versus not. METHOD: We conducted a systematic search of PubMed, Scopus, and Web of Science on studies reporting PABS following FLS for TTTS. A meta-analysis of pooled proportions was conducted. RESULTS: There were 16 studies covering 47 pregnancies complicated by PABS following FLS, mostly case series and case reports. The incidence of PABS was 2%, with the recipient twin affected in 94% of the cases. Pregnancies complicated by PABS were associated with inter-twin septostomy in 32% and chorioamniotic separation (CAS) in 90%. The mean gestational age (GA) at FLS and delivery were 17.7 and 30.9 weeks, respectively. Preterm premature rupture of membranes (PPROM) happened in 62% of pregnancies. The risk of preterm birth (PTB) <34 weeks, <32 weeks, and <28 weeks were 94%, 67%, and 31%, respectively. There were 41% fetal demises and 64% live births among the affected fetuses. Results of fetoscopic band release versus not were comparable, including GA at delivery, PPROM, and PTB at 32 weeks. It was noted that the likelihood of PTB by 28 weeks (67% vs. 23%) and fetal death (50% vs. 39%) were higher in the band release group. It was similar between groups in terms of postnatal amputation. CONCLUSIONS: PABS causes amputations or fetal death in more than one-third of cases. Pregnancies with an inter-twin septostomy, CAS, advanced TTTS staging, and early GA are more likely to experience PABS. In addition, more than a third of FLS-treated TTTS resulted in PTB and PPROM. PABS cases with prenatal band release showed higher rates of PTB and fetal death, but the data were from small, heterogeneous studies.

Treated Cases of Retinopathy of Prematurity in Germany: 10-Year Data from the Retina.net Retinopathy of Prematurity Registry.

PURPOSE: To analyze changes in demographic parameters and retreatment patterns over a 10-year period in a clinical routine setting of infants with retinopathy of prematurity (ROP) requiring treatment documented in the German Retina.net ROP registry. DESIGN: Multicenter, noninterventional, observational registry study recruiting patients treated for ROP. SUBJECTS: A total of 692 eyes of 353 infants treated for ROP were documented in the Retina.net ROP registry over a 10-year period between 2011 and 2020. These cases cover about 15% of all infants treated for ROP in Germany. METHODS: The Retina.net ROP registry was established in 2012 to jointly collect information on infants treated for ROP. The database collects information on demographic parameters (gestational age [GA], birth weight, neonatal comorbidities) as well as treatment parameters (type of treatment, weight and age at treatment, and stage of ROP). A total of 19 centers contributed to the analysis. This is the 10-year analysis of data from 2011 to 2020, in which we focus on changes over time regarding the respective parameters. MAIN OUTCOME MEASURES: Changes over time in demographic parameters and treatment patterns for ROP in Germany. RESULTS: The overall incidence of treatment requiring ROP was 3.5% of all infants screened for ROP at participating centers. Gestational age, weight at birth, and weight at treatment remained stable over the 10-year period, whereas postmenstrual and postnatal age at treatment increased moderately but statistically significantly over the years. The most prevalent ROP severity stage at treatment was stage 3+ in zone II (76.6% of all treated eyes). Treatment patterns changed considerably from predominantly laser treatments in 2011 (75% of all treated eyes) to predominantly ranibizumab treatments in 2020 (60.9% of all treated eyes). The overall retreatment rate was 15.6%. Retreatment rates differed between initial treatment modalities (14.1% after laser coagulation, 12% after bevacizumab and 24.5% after ranibizumab). Treatment-associated systemic or ophthalmic complications were rare. CONCLUSIONS: This data analysis represents one of the largest documented cohorts of infants treated for ROP. The data on demographic parameters and treatment patterns provide useful information for further improvement of ROP management. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Arabin cervical pessary for the prevention of preterm birth in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation: a multicenter randomized controlled trial.

BACKGROUND: Miscarriage and preterm birth are leading causes of loss and disability in monochorionic twins after laser treatment of twin-twin transfusion syndrome. OBJECTIVE: This study aimed to investigate the use of cervical pessary to reduce preterm birth before 32 weeks of gestation in monochorionic diamniotic twin pregnancies after fetal surgery for twin-twin transfusion syndrome. STUDY DESIGN: In this open-label multicenter randomized trial, pregnant women carrying monochorionic diamniotic twins requiring fetoscopic laser coagulation for twin-twin transfusion syndrome were randomly assigned in a 1:1 ratio to pessary placement or conservative management. The primary outcome was birth before 32 weeks of gestation. The secondary outcomes were birth before 28, 30, 34, or 37 weeks of gestation; preterm premature rupture of membranes; fetal and neonatal survival; and a composite of maternal and neonatal complications. The estimated sample size was 364 patients, with 182 cases in each arm of the study. The analysis was performed according to the intention-to-treat principle. Moreover, 2 interim analyses were planned. RESULTS: The trial was stopped prematurely after the first planned interim analysis for futility. Overall, 137 women were included in the analysis, 67 in the pessary group and 70 in the conservative management group. Preterm birth before 32 weeks of gestation occurred in 27 of 67 women (40.3%) in the pessary group and in 25 of 70 women (35.7%) in the conservative management group (adjusted odds ratio, 1.19; 95% confidence interval, 0.58-2.47; P=.63). No differences between groups was observed in the rate of deliveries before 28, 30, 34, and 37 weeks of gestation. Overall survival to delivery was 91.2% (125/137) for at least 1 twin, and 70.8% (97/137) for both twins, with no difference between groups. Neonatal survival at 30 days was 76.5% (208/272). There was no difference between the groups in maternal or neonatal morbidity. CONCLUSION: In monochorionic diamniotic twin pregnancies requiring fetal therapy for twin-twin transfusion syndrome, routine use of cervical pessary did not reduce the rate of preterm birth before 32 weeks of gestation.

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management.

INTRODUCTION: A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS: Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS: Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION: MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

Flexible Video Fetoscopy: Feasibility and Outcomes of a Novel Modality for Laser Therapy in Twin-to-Twin Transfusion Syndrome Presenting with Inaccessible Anterior Placenta.

INTRODUCTION: Identification of intertwin anastomosis may be challenging during fetoscopy in cases with complete anterior placenta. The aim of this study was to describe the technique, feasibility, and outcomes of flexible video fetoscopy for laser coagulation in monochorionic (MC) twin pregnancies with twin-to-twin transfusion syndrome (TTTS) presenting with inaccessible anterior placenta. METHODS: From April 2021 to March 2022, a prospective cohort of consecutive MC twin pregnancies complicated with TTTS presenting with anterior placenta after 20 weeks was recruited. Cases with inaccessible anterior placenta during standard technique were converted into flexible video fetoscopy for completion of laser coagulation of placental anastomoses using a 270° flexible video endoscope through the same uterine port. Descriptive analysis includes feasibility, remaining anastomoses requiring laser photocoagulation, and perinatal outcomes. RESULTS: A total of 45 pregnancies with TTTS were treated with fetoscopic laser therapy during the 1-year study period. Twenty-one pregnancies presented with anterior placenta after 20 weeks, in which an inaccessible vascular equator was observed in 33.3% (7/21). Flexible video fetoscopy was successfully performed in all 7 cases at a median gestational age of 22+2 (20+0-27+1) weeks+days. Visualization of the entire placental surface, coagulation of selected vessels, and exploration of the entire vascular equator were achieved in all cases. Six cases (85.7%) required additional laser coagulation due to either vascular patency despite initial coagulation with conventional fetoscopy (1/6, 16.7%) and/or remaining noncoagulated anastomoses (5/6, 83.3%). Perinatal survival of at least one twin and both twins was achieved in 85.7% and 57.1%, respectively. DISCUSSION: Flexible video fetoscopy for completion of laser coagulation of placental anastomoses is feasible and represents a good option for TTTS cases presenting after 20 weeks with inaccessible anterior placenta.

Hemorrhoid laser dearterialization: systematic review and meta-analysis.

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

Effect of conbercept combined with whole retina laser photocoagulation on visual prognosis and retinal blood flow in patients with ischemic central retinal vein occlusion with Macular edema / 中国医师杂志

Objective:To investigate the clinical efficacy of conbercept combined with whole retina laser photocoagulation in the treatment of ischemic central retinal vein occlusion (iCRVO) with macular edema (ME) and its effect on visual prognosis and retinal blood flow.Methods:A prospective study was conducted on 80 patients (80 eyes) with iCRVO and ME admitted to the Chongqing Aier Eye Hospital from January 2019 to November 2020. They were randomly divided into two groups using a random number table method, with 40 patients in each group. Among them, the observation group was treated with conbercept combined with whole retina laser photocoagulation, while the control group was treated with whole retina laser photocoagulation alone. We compared the clinical efficacy and safety between two groups. Before and after treatment, the best corrected visual acuity (BCVA), central macular thickness (CMT), and retinal blood flow parameters [retinal superficial capillary plexus (SCP) blood flow density, and macular foveal avascular zone (FAZ) area] were examined in both groups of patients. The Low Vision Quality of Life Scale (CLVQOL) was used to evaluate the quality of life of patients before and after treatment.Results:The total effective rate of the observation group was 95.00%(38/40), which was higher than 77.50%(31/40) of the control group ( P<0.05). The BCVA at 1 week, 1 month, and 3 months after treatment in both groups was significantly higher than that before treatment in this group, while the CMT was significantly lower than that before treatment in this group (all P<0.05). The BCVA of the observation group at 1 week, 1 month, and 3 months after treatment was significantly higher than that of the control group at the same time point (all P<0.05), while the CMT of the observation group at 3 months after treatment was significantly lower than that of the control group at the same time point (all P<0.05). There were no significant changes in SCP blood flow density and macular FAZ area before and after treatment in both groups (all P>0.05). The CLVQOL scale scores and total scores at 1 week, 1 month, and 3 months after treatment in the observation group were significantly higher than before treatment (all P<0.05). After 1 week, 1 month, and 3 months of treatment, the scores and total scores of the CLVQOL scale for distant vision, movement and light perception, and regulatory ability in the control group were significantly higher than those before treatment (all P<0.05); At 1 and 3 months after treatment, the scores of reading, fine work, and daily living ability on the CLVQOL scale were significantly higher than those before treatment (all P<0.05). The CLVQOL scale scores and total scores of distant vision, movement and light perception, reading and fine work in the observation group at 1 and 3 months after treatment were significantly higher than those in the control group at the same time point (all P<0.05); The regulatory ability dimension score of the CLVQOL scale at 3 months after treatment was significantly higher than that of the control group at the same time point (all P<0.05). There was no serious adverse event in both groups during the treatment. Conclusions:Conbercept combined with whole retina laser photocoagulation for iCRVO with ME can safely and effectively improve patients′ vision, promote ME regression, and improve their quality of life. Although the impact on retinal blood flow is not significant, it is beneficial for delaying the progression of the disease.

Fetoscopic laser coagulation for placental chorioangioma: a report of three cases and literature review / 中华围产医学杂志

Objective:To evaluate the outcome of laser coagulation under fetoscope for placental chorioangioma (CA).Methods:The clinical data of three pregnant women with giant CA treated by laser coagulation under fetoscope in Peking University Third Hospital from January 2018 to December 2020 were analyzed retrospectively. Relevant articles up to September 2022 were retrieved from Wanfang Database, China National Knowledge Infrastructure and PubMed, and the clinical data of all patients were retrospectively summarized. Indications and intervention effects of fetoscopic laser therapy were analyzed. Descriptive statistics was used to describe the data.Results:Thirteen patients were involved in this study including 10 cases retrieved from the databases. The average age of the pregnant women was (30.3±6.2) years old. There were 12 cases of single pregnancy and one case of twin pregnancy (monochorionic diamnionic twin pregnancy). Except for cases for which data were not available in the literatures, at the diagnosis of CA, the average gestational age was (19.9±4.5) weeks ( n=7) and the average maximum diameter of the mass was (6.1±4.1) cm ( n=6). The patients underwent fetoscopic laser therapy at an average gestational age of (25.0±2.0) weeks ( n=13) with the average maximum tumor diameter of (7.6±2.8) cm ( n=9). After treatment, the amniotic fluid volume of three cases decreased to normal. In one case, the amniotic fluid volume decreased but was still above the upper limit of the normal range. Moreover, the maximum tumor diameter decreased in four cases; the peak systolic velocity of the fetal middle cerebral artery decreased to normal in one case; fetal heart function became normal in two cases and fetal edema was relieved in one case. Among the three patients treated in our hospital, the blood supply of CA disappeared after treatment. Intrauterine fetal death occurred in two cases. The other 11 patients gave birth to live babies at the gestational age of (36.6±3.8) weeks with five through cesarean section (5/11), five through vaginal delivery (4/11) and two not reported. The birth weight of the neonates was (2 712±1 023) g and all of them survived. The gender of five neonates were reported and all were females, two of them were monochorionic diamnionic twins. No abnormality was found in the three neonates delivered in our hospital during a six-month follow-up. No abnormality was reported in the other neonates during ten days to six months of follow-up. Conclusions:Fetoscopic laser coagulation may help reduce the size of CA, decrease complications and improve pregnancy outcomes.

Pediatric Coats disease of stage 2 and greater managed with 532 nm wavelength laser using indirect ophthalmoscope combined with ranibizumab / 中华眼底病杂志

Objective:To investigate the efficacy of 532 nm wavelength laser using indirect ophthalmoscope combined with ranibizumab (IVR) in treating stage 2 and greater pediatric Coats disease.Methods:A retrospective, non-controlled clinical study. From February 2018 to August 2020, 21 eyes of 21 patients with Coats disease stage 2 and greater diagnosed by examination in the Eye Center of Beijing Tongren Hospital were included in the study. Among them, 20 patients were males; 1 patient was female. Mean age was 5.00±1.92 years old. Stage 2A, 2B, 3A, 3B, and 4 were 2, 8, 7, 2, and 2 eyes, respectively. All eyes underwent wide-field fundus color photography and fluorescein fundus angiography (FFA). Best corrected visual acuity (BCVA) was performed in 17 eyes. Abnormal dilated retinal blood vessels, interretinal and subretinal exudates were found in all eyes. Abnormally dilated capillaries and aneurysms in the retina was shown in FFA examination. All eyes underwent 532 nm laser photocoagulation using indirect ophthalmoscope combined with IVR. Patients with severe retinal detachment of stage 3B or greater were treated by external drainage of subretinal fluid (SRF). The subsequent treatment was the same as before. The follow-up time was 35.67±6.13 months. Relevant examinations were performed using the same equipment and methods before. The frequency of treatment, visual acuity changes, anatomic prognosis, and complications were observed.Results:The frequency of eye photocoagulation was 2.43±0.98. The number of IVR treatments was 2.00±0.89. Three eyes were treated with SRF drainage in the first time. At the last follow-up, visual acuity improved, no change, and decreased in 5, 11, and 1 eyes after BCVA examination, respectively. In 21 eyes, the retina was in situ in 17 eyes; 5 eyes with retinal cysts. During the follow-up, cataract and vitreous hyperplasia occurred in 1 eye, which was treated by vitrectomy, and mild vitreous hyperplasia occurred in 1 eye.Conclusion:Indirect ophthalmoscope 532 nm wavelength laser combined with IVR is an effective treatment for pediatric Coats disease.

Long-term outcomes of adjuvant intravitreal injection of conbercept therapy in juvenile Coats disease / 中华眼底病杂志

Objective:To study the long-term effects and outcomes of adjuvant intravitreal injection of conbercept (IVC) therapy in juvenile Coats disease.Methods:A retrospective case series study. From January 1, 2015 to December 31, 2018, 40 patients (40 eyes) who were diagnosed as juvenile Coats disease at Beijing Tongren Hospital Affiliated to Capital Medical University were included in the study. Among them, there were 37 males (37 eyes) and 3 females (3 eyes). All patients had unilateral Coats disease. The average age was 55.00 (44.75, 81.25) months. Five eyes were in stage 2B, 15 eyes were in stage 3A, 19 eyes were in stage 3B and 1 eye was in stage 4. Idiopathic retinal vascular telangiectasia associated with extensive subretinal fluid (SRF) (stage 3 or above) or massive foveal exudation and edema (stage 2B) were found in fundus examination. All affected eyes underwent wide-field color fundus images and fluorescein fundus angiography. Thirty-one eyes underwent best corrected visual acuity (BCVA) examination. The BCVA was carried out using a standard logarithmic visual acuity chart, which was converted into the logarithmic minimum angle of resolution (logMAR) visual acuity. All cases received adjuvant IVC combined with treatments such as retinal photocoagulation. The average number of injections was 4 (1, 5). The average follow-up after initial treatment was 59.00 (52.50, 63.00) months. The changes in BCVA, occlusion of abnormal blood vessels in fundus, absorption of SRF and ocular and systemic complications were observed.Results:At last follow-up, among 31 affected eyes with the examination of BCVA, 13 (32.5%, 13/40) eyes had an improved vision, 12 eyes(30.0%, 12/40) had a stable vision and 6 eyes (15.0%, 6/40) had a decreased vision. The difference between average logMAR BCVA of the affected eyes in each stage after treatment and that before treatment was not statistically significant ( Z=-0.56, -1.80, -0.84; P>0.05). Abnormal blood vessels in fundus were all partially or completely occluded, and SRF was obviously or completely absorbed in all cases; of which, 28 eyes (70.0%, 28/40) were completely occluded, and 12 eyes (30.0%, 12/40) were partially occluded. No patient underwent eye enucleation. Nineteen eyes (47.5%, 19/40) developed vitreoretinal fibrosis; 8 eyes (20.0%, 8/40) developed tractional retinal detachment; 15 eyes (37.5%, 15/40) developed complicated cataract. None had ocular or systemic complications related to IVC therapy during follow-up. Conclusions:IVC combined with classic treatments such as photocoagulation in juvenile Coats disease can keep or improve the visual acuity in most juvenile patients by reducing SRF. IVC is a long-term safe and effective adjuvant therapy in juvenile Coats disease.

Keypoints in Evidence-based guidelines for diagnosis and treatment of diabetic retinopathy in China (2022) / 中华眼底病杂志

Evidence-based guidelines for diagnosis and treatment of diabetic retinopathy in China (2022) is based on evidences in recent clinical trials and a system of Grading of Recommendations, Assessment, Development and Evaluation of evidence quality and strength of recommendations. The main key points around why the diabetic macular edema (DME) changes the classification, what thresholds for initiating anti-vascular endothelial growth factor (VEGF) drug therapy; eyes with center-involved DME (CI-DME) and good vision for clinical significant macular edema still treated by focal laser even with good vision, the clinical pathway for CI-DME changes first-line treatment from laser to anti-VEGF, loading dose of anti-VEGF for CI-DME in non-proliferative diabetic retinopathy (DR) from 3 injections up to 4-5 injections is recommended; severe non-proliferative DR and proliferative DR with vision impairment but without hemorrhages and retinal traction could be considered first treatment of anti-VEGF comparing to initiate pan-retinal photocoagulation (PRP) (weakly recommended), PRP is still gold-standard for progressive non-perfusion area of retina. With the rapid development of DR evaluation devices such as optical coherence tomography, wide-angle optical coherence tomography angiography and wide-angle fluorescein fundus angiography, imaging biomarkers have been provided for the degree of DR lesion, treatment response and prognosis. It is believed that the clinical practice will be promoted a new height by the 2022 edition of Chinese DR guideline.

New advances in the study of subthreshold micropulse laser photocoagulation for central serous chorioretinopathy / 中华眼底病杂志

Central serous chorioretinopathy (CSC) is a common macular disease, which can lead to the loss of central vision in young patients. Although the disease is self-limited to some extent, there is no shortage of patients with prolonged course and recurrent attacks, eventually leading to irreversible visual impairment. Therefore, taking reasonable treatment in a certain period is particularly important for the visual prognosis of patients. Although thermal laser photocoagulation of leakage points and photodynamic therapy (PDT) have achieved good effects, there are risks of retinal damage and retinal pigment epithelium atrophy. Subthreshold micropulse laser (SMLP) is a kind of subthreshold short pulse laser, which does not cause visible damage to the retina and is safer. In the era of lack of PDT drugs, SMLP has gradually become an important means of clinical treatment for CSC, especially for patients with no obvious leakage point or subfoveal leakage point. An in-depth understanding of the mechanism of action of SMLP and its efficacy and safety in the treatment of CSC is helpful for the promotion and application of SMLP in the clinical treatment of CSC.