Brolucizumab-associated intraocular inflammation in Indian patients by VRSI study group.

CONTEXT: Concerns about brolucizumab's (Pagenax®) association with intraocular inflammation (IOI) limit its use despite its cost-effectiveness and efficacy. This multicentric study analyzes IOI incidence across 21 tertiary eyecare centers in India since its introduction in October 2020. PURPOSE: To determine the real-world incidence rate of IOI in Indian patients secondary to intravitreal brolucizumab across 21 tertiary eye care centers in India. SETTINGS AND DESIGN: Retrospective multicentric, survey-based study. METHODS: Data including number of patients treated, clinical indications, side effects encountered, and IOI case details was collected via Google Forms in 21 Indian tertiary eye care centers since October 2020. Mean, median, frequency, and standard deviation were calculated for statistical analysis. RESULTS: All centers used pro re nata protocol for brolucizumab injections with a minimum injection interval of 8 weeks. The incidence of IOI was 0.79% (21 events out of 2655 eyes). Treatment indications included idiopathic polypoidal choroidal vasculopathy, neovascular age-related macular degeneration, diabetic macular edema, and off-label uses. IOI was experienced after the first injection (57%) in majority of cases with a median onset of 14 days (range: 1-65 days). IOI was mild in 28.5%, moderate in 33%, and severe in 38% of cases. Eighteen out of 21 IOI eyes recovered preinjection best corrected visual acuity or better. CONCLUSIONS: Our study found a lower IOI incidence (0.79%) with brolucizumab (Pagenax) in Indian patients compared to previously reported literature. IOI events were mostly mild to moderate, and post-treatment, most patients improved or maintained BCVA. Larger prospective multicentric studies with PRN dosing protocol are needed to confirm these findings.

Secondary dengue retinitis with associated occlusive retinal vasculitis.

BACKGROUND: Dengue is endemic in tropical countries. Secondary dengue infections are generally more dangerous as they lead to an exaggerated response in the patient due to the severe immunological response caused by antibody-dependent enhancement (ADE) leading to severe ocular manifestations like retinitis. RESULTS: A 42-year-old female was diagnosed as secondary dengue retinitis with associated retinal vasculitis based on her past history, clinical presentation, IgG/IgM ratio, and enzyme-linked immunosorbent assay (ELISA) test for dengue and was successfully treated with oral corticosteroids. CONCLUSION: Secondary dengue infection may manifest as retinitis with signs of microvascular occlusions in the retina. A high level of suspicion and IgG/IgM ratio may help in confirming the diagnosis.

Retinal Detachment in 31 Eyes with Retinitis Pigmentosa.

OBJECTIVE: To describe clinical features and treatment outcomes of retinal detachment (RD) in eyes with retinitis pigmentosa (RP). DESIGN: Single-center, retrospective, interventional case series. SUBJECTS: All RP patients with RD examined between April 2003 and December 2013 and minimum 2 months of follow-up. METHODS: Medical records of RP patients were screened and 31 eyes with RD were included. Family history of RP, duration of symptoms, age at presentation, associated ocular and systemic findings, and detailed ophthalmic evaluation including presenting visual acuity, type and amount of refractive error, fundus findings, electroretinogram details, surgical details, and postoperative complications and outcomes were evaluated. Univariate analysis was done to determine risk factors associated with RD in eyes with RP and risk factors associated with poor visual outcomes after treatment. Subset analysis was also done for comparing the functional and anatomical outcomes between patients undergoing scleral buckling or vitrectomy. OUTCOME MEASURES: Final surgical reattachment rate, best-corrected visual acuity. RESULTS: Mean age at presentation was 22 years (median, 17; range, 4-63). Mean duration of symptoms was 12 months (median, 3 months: range, 3 days-60 months). Associated ocular findings included nyctalopia (n = 23), myopia (n = 21), and hyperopia (n = 10). Systemic associations included hearing loss (n = 5), deaf-mutism (n = 1), and Bardet-Biedel syndrome (n = 1). No association between degree of myopia and RD was noted (P = 0.63). Observed retinal breaks included horse-shoe-shaped tear (n = 15), lattice with hole (n = 7), atrophic retinal hole (n = 3), retinal dialysis (n = 3), and macular hole (n = 3). The most common location of breaks was superotemporal quadrant (n = 15). Younger age, male gender, and presence of posterior vitreous detachment were strongly associated with RD with odds ratio of 1.3 (P = 0.001), 8.3 (P = 0.010), and 6 (P = 0.003), respectively. Retinal reattachment was achieved in 13 of 13 eyes (100%) with scleral buckle and 9 of 10 eyes (90%) with vitrectomy. Vision improved from 1.63±0.52 to 0.87±0.25 logarithm of the minimum angle of resolution (P < 0.001) at a mean follow-up of 33 months (median, 24, range; 1-145). CONCLUSION: Rhegmatogenous RD in eyes with RP is rare. Precocious vitreous degeneration and sparse pigmentation in younger male patients has a role in etiopathogenesis. Visual prognosis remains poor despite satisfactory surgical outcomes.

Long-term outcomes of combination photodynamic therapy with ranibizumab or bevacizumab for treatment of wet age-related macular degeneration.

AIM: To evaluate and compare the efficacy of combination of ranibizumab or bevacizumab with photodynamic therapy (PDT) in treating choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD) on long-term follow-up. MATERIALS AND METHODS: Of 42 eyes, 18 were treated with bevacizumab (Group A) and 24 with ranibizumab (Group B) in combination with verteporfin PDT. Treatment was initiated after informed consent. Complete ophthalmic examination including optical coherence tomography (OCT) was performed at presentation, 1 month, 3 months, and subsequent follow-up visits. OCT measures used were lesion thickness (LT) of the CNV, retinal thickness above the lesion (RT), and central macular thickness (CMT). Mean follow-up period was 33 months (median 18, range 1-84). Additional treatment on follow-up was left at treating surgeon's discretion. RESULTS: Visual acuity improved significantly from baseline by 0.3 LogMAR in Group A and 0.26 LogMAR in Group B. LT decreased significantly from 1(st) month onward and remained significant at all the subsequent visits, in both the groups. CMT and RT showed a decreasing trend in both the groups. No difference was seen in visual acuity (VA), LT, CMT, and RT between Group A and Group B at any of the visits. The mean number of additional anti-vascular endothelial growth factor injections given postcombination therapy were 1.5 (median 1, range 0-7) injections per eye. CONCLUSIONS: PDT in combination with either ranibizumab or bevacizumab was equally effective in preventing vision loss in eyes with wet-Age-related macular degeneration (ARMD). Such combination also reduces the economic burden of the treatment.

VITREORETINAL COMPLICATIONS IN EYES WITH BOSTON KERATOPROSTHESIS TYPE I.

PURPOSE: To describe the spectrum of vitreoretinal complications in eyes with Boston keratoprosthesis type I and evaluate the treatment outcomes. METHODS: This was a retrospective interventional case series of 23 of 45 eyes that underwent Boston keratoprosthesis from April 2003 to December 2013 and developed vitreoretinal complications. Types of vitreoretinal complications, surgical techniques, and anatomical and visual outcomes were analyzed. RESULTS: Vitreoretinal complications in eyes with Boston keratoprosthesis included retroprosthetic membranes (n = 11), retinal detachment (n = 6), endophthalmitis (n = 4), epiretinal membrane (n = 4), vitreous hemorrhage (n = 2), and choroidal detachment (n = 1). Twenty of 23 eyes (87%) underwent surgical intervention. Retinal reattachment was achieved in 5 eyes (83%) with significant visual improvement in 3 (50%). Mean preoperative visual acuity improved from 1.84 ± 0.89 logMAR to 1.5 ± 0.87 logMAR (P = 0.01) at the last follow-up. Mean 1.4 surgical procedures were performed per eye. Mean follow-up was 28 months (median: 28 months, range: 5-57 months). CONCLUSION: Retroprosthetic membrane and retinal detachment are most common vitreoretinal complications in eyes with Boston keratoprosthesis. Vitreoretinal complications can be managed by appropriate intervention in such eyes with encouraging anatomical and functional results.

Intra-arterial chemotherapy for retinoblastoma: First Indian report.

AIM: To describe treatment outcomes and complications of selective intra-arterial chemotherapy (IAC) for retinoblastoma (RB) in Indian eyes. MATERIALS AND METHODS: Single center, retrospective interventional case series of 6 eyes with RB who underwent IAC using Melphalan (3 mg/5 mg/7.5 mg) and topetecan (1 mg) (n = 4) or melphalan (3 mg/5 mg/7.5 mg) alone (n = 2) between December 2013 and June 2014. In all, 17 IAC procedures were performed using selective ophthalmic artery cannulation. Treatment outcomes were evaluated in terms of tumor control, vitreous and subretinal seeds control and globe salvage rates. RESULTS: IAC was employed as primary (n = 1) or secondary (n = 5) modality of treatment. Each eye received mean 3 IAC sessions (median: 3; range: 1-4 sessions). Eyes were classified according to international classification of RB as Group B (n = 1), C (n = 1), D (n = 2) and E (n = 2). Following IAC, complete regression of the main tumor was seen in 3 cases (50%), partial regression in 2 (33%), while 1 case (15%) showed no response. Of 4 eyes with subretinal seeds, 1 (25%) eye had complete regression while 3 (75%) eyes had partial regression. Of 5 eyes with vitreous seeds, 2 (40%) eyes had complete regression while 3 (60%) eyes had a partial response. Globe salvage was achieved in 5 of 6 eyes (83%). Diffuse choroidal atrophy and vitreous hemorrhage were observed in 1 (17%) eye, each. No hematologic toxicity or cerebro-vascular events were observed. Mean follow-up period was 5.5 months (median: 6 months, range: 1-6 months). CONCLUSION: IAC is an effective therapy for globe preservation in eyes with RB. Larger studies with longer follow-up are required to validate these results.

Using risk factors for detection and prognostication of uveal melanoma.

The early detection of malignancy, particularly uveal melanoma, is crucial in protecting visual acuity, salvaging the eye, and preventing metastasis. Risk factors for early detection of uveal melanoma have been clearly delineated in the literature and allow identification of melanoma when it is tiny and simulates a nevus. These factors include thickness >2 mm, presence of subretinal fluid (SRF), symptoms, the orange pigment, margin near optic disc, acoustic hollowness, surrounding halo, and absence of drusen. The importance of early detection is realized when one considers melanoma thickness, as each millimeter increase in melanoma thickness imparts 5% increased risk for metastatic disease. Newer imaging modalities like enhanced depth imaging optical coherence tomography and fundus autoflouroscence facilitate in detection of SRF and orange pigment. Additional molecular biomarkers and cytological features have been identified which can predict the clinical behavior of a small melanocytic lesion. Features that suggest a poor prognosis include higher blood levels of tyrosinase m-RNA, vascular endothelial growth factor, insulin-like growth factor; monosomy 3 and gains in chromosome 8. Management of uveal melanoma includes enucleation (for large), local eye wall resection, brachytherapy, charged particle irradiation, and thermotherapy (for small to medium tumors). Although the role of a good clinical evaluation cannot be underestimated, it is advisable to evaluate the various radiological, molecular, and cytological features, to enhance the accuracy of early diagnosis and improved prognosis.