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ImportanceDiverse enrollment and adequate representation of racial and ethnic minority groups in randomized clinical trials (RCTs) are valuable to ensure external validity and applicability of results.ObjectiveTo compare the distribution of race and ethnicity in RCTs of diabetic macular edema (DME) and macular edema from retinal vein occlusion (RVO) to that of US Census data.Design, Setting, and ParticipantsThis was a cross-sectional retrospective analysis comparing racial and ethnic demographic characteristics of US-based RCTs of DME and RVO between 2004 and 2020 with 2010 US Census data. PubMed and ClinicalTrials.gov were searched to screen for completed phase 3 RCTs with published results. Of 169 trials screened, 146 were excluded because they were incomplete, did not report race and ethnicity, or were not based in the US, and 23 trials were included (15 DME and 8 RVO). The number and percentage of American Indian or Alaska Native, Asian, Black, Hispanic, Native Hawaiian or Other Pacific Islander, and White participants was recorded in each RCT. The demographic distribution and proportion was compared to the reported distribution and proportion in the 2010 US Census using the χ2 test.Main Outcomes and MeasuresOverrepresentation, underrepresentation, or representation commensurate with 2010 US Census data in the racial and ethnic populations of RCTs of retinal vascular disease.ResultsIn 23 included RCTs of DME and RVO, there were a total of 38 participants (0.4%) who identified as American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander (groups combined owing to small numbers), 415 Asian participants (4.4%), 904 Black participants (9.6%), 954 Hispanic participants (10.1%), and 7613 White participants (80.4%). By comparison, the 2010 US Census data indicated that 1.1% of the US population self-reported as American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander (groups combined for comparison in this study), 4.8% self-reported as Asian, 12.6% as Black or African American, 16.3% as Hispanic, and 63.7% as White. American Indian or Alaska Native and Hawaiian or Other Pacific Islander participants were underrepresented in 2 trials, neither overrepresented nor underrepresented in 20, and not overrepresented in any of the included trials. Asian participants were underrepresented in 10 trials, overrepresented in 4, and neither overrepresented nor underrepresented in 8. Black participants were underrepresented in 9 trials, overrepresented in 2, and neither overrepresented nor underrepresented in 11. Hispanic participants were underrepresented in 15 trials, overrepresented in 2, and neither overrepresented nor underrepresented in 5. White participants were underrepresented in 2 trials, overrepresented in 14, and neither overrepresented nor underrepresented in 7. The χ2 values comparing RCT demographic distribution to US 2010 Census data were significantly different in 22 of 23 included RCTs.Conclusions and RelevanceThe findings in this study indicated a discrepancy between racial and ethnic demographic data in RCTs of DME and RVO and the US population according to the 2010 Census. White study participants were most frequently overrepresented, and Hispanic study participants were most frequently underrepresented. These findings support the need for more efforts to recruit underrepresented racial and ethnic minorities to improve external validity in trial findings.

Objectives To characterize the use of virtual visits, as well as compare the characteristics to in-person visits during the pandemic period. Methods This retrospective study included patients who had virtual and in-person ophthalmology visits from March 19, 2020, to July 31, 2020, in a large multispecialty ophthalmic center. Exclusion criteria included patients aged less than 18 years old; canceled, incomplete, mislabelled, and duplicated visits. 2943 virtual and 56,174 in-person visits were identified. A random sample of 3000 in-person visits was created. Each visit was analyzed as an individual data point. Results 2,266 virtual visits (2,049 patients, 64.3% female, mean [SD] age 64.3 [16.6] years old) and 2590 in-person visits (2509 patients, 59.5% female, 65.9 [15.8] years old) were included. Most virtual visits were classified as comprehensive ophthalmology (34.6%), optometry-related (19.5%), and oculoplastics (13.0%). For in-person visits, the most common specialties were optometry (29.8%), comprehensive ophthalmology (23.9%), and retina and uveitis (17.3%). The most common diagnoses in the virtual group were from the eyelids, lacrimal system, and orbits group (26.9%), while in the in-person groups were choroid and retina conditions (19.3%). Conclusions Numerous ocular conditions were evaluated and managed through virtual visits, and external complaints and oculoplastic consults appear to be well-suited to the virtual format. Further studies focusing on visual outcomes and patient experience will be beneficial.

Purpose To examine the effect of delay in care on visual acuity (VA) in patients requiring intravitreal injections (IVIs). Design Retrospective cohort study. Participants Patients 18 years of age or older with diabetic macular edema (DME), proliferative diabetic retinopathy (PDR), or both; neovascular age-related macular degeneration (nAMD); or retinal vein occlusion (RVO) scheduled to see a retina specialist during the mandated lockdown period (March 14 - May 4, 2020 [the coronavirus disease 2019 period]) and who had received an IVI in the 12 weeks prior. Methods Chart review was performed and demographics, diagnoses, procedures, and VA were recorded. Main Outcome Measures VA in patients who completed, canceled, and no-showed for the scheduled visit. Results Of the 1041 total patients, 620 (60%) completed the scheduled visit, whereas 376 (36%) canceled and 45 (4%) no-showed. In patients who missed the visit, the average delay in care was 5.34 weeks. In those who missed a visit, VA was assessed at the subsequent visit. Patients who canceled a visit were older, and patients who no-showed had lower baseline vision (mean Early Treatment Diabetic Retinopathy Study letters ± standard error [SE]: no-show, 53.27 ± 3.21 letters; canceled, 60.79 ± 1.11 letters; and completed, 62.81 ± 0.84 letters; P = 0.0101) and were more likely to have DME, PDR, or both (no-show, 13 patients [29%]; canceled, 56 patients [16%]; completed, 81 patients [13%]; P = 0.0456). Patients who missed a visit lost vision as compared with the patients who completed one (no-show, –5.024 ± 1.88 letters; canceled, –1.633 ± 0.65 letters; completed, 0.373 ± 0.50 letters; P = 0.0028). Patients with DME, PDR, or both (–3.48 ± 1.95 letters vs. 2.71 ± 1.75 letters; P = 0.0203), with RVO (–3.22 ± 1.41 letters vs. 0.95 ± 1.23 letters; P = 0.0230), and, to lesser degree, with nAMD (–1.23 ± 0.70 letters vs. –0.24 ± 0.56 letters; P = 0.2679) lost vision compared with patients with same diagnoses who completed the scheduled visit. Conclusions In patients requiring IVIs, a delay in care of 5.34 weeks resulted in vision loss. It was seen in all patients, but was more prominent in patients with DME, PDR or both and RVO. Further studies are necessary to examine whether these vision changes persist over a longer duration.

Purpose The intravitreal injection (IVI) of pharmacologic agents is the most commonly performed ocular procedure and is associated with a host of complications. Most IVI-related complications data are derived from randomized controlled clinical trials, which report a high adverse event rate. The nature of these protocol-driven trials limit their applicability to the diverse circumstances seen in routine clinical practice. The goal of this study was to determine the prevalence of patient-reported IVI-related complications, their risk factors, and the manner in which patients sought treatment at a tertiary eye care center. Design Retrospective, institutional review board–approved study. Participants Forty-four thousand seven hundred thirty-four injections in 5318 unique patients at the Cleveland Clinic Cole Eye Institute from 2012 through 2016. Methods Intravitreal injection. Main Outcome Measures Complication occurrence within 15 days of injection. Results From 2012 through 2016, a total of 44734 injections were performed in 5318 unique patients. Overall, complication rates were low, representing 1.9% of all injections, with 1031 unique complications in 685 patients (12.9%). The most common minor complications, or those not requiring intervention, were irritation (n = 312) and subconjunctival hemorrhage (n = 284). The most common serious complications, or those requiring intervention, were corneal abrasion (n = 46) and iritis (n = 31). Most complications (66%) were managed adequately by a telephone or Epic (Epic Systems Corp., Verona, WI) electronic message encounter only. Importantly, no injection protocol parameter, such as type of anesthesia, preparation, or post-injection medication, increased the risk of a complication. However, a patient’s gender, age, number of previous injections, and provider strongly influenced the risk of patient-reported complications. Conclusions Overall, complication rates seen in routine clinical practice were low compared with clinical trial reporting. Providers should feel confident in the safety and administration of IVI during times when follow-up office visits and resources may be limited. When performing an IVI, factors such as a patient’s gender, age, number of previous injections, and provider must be taken into account to ensure the best possible outcomes.

BACKGROUND AND OBJECTIVES: This study aims to characterize check-in kiosk usage within a multi-disciplinary ophthalmic clinic. PATIENTS AND METHODS: Chart review of patients aged 18 or older seen at Cole Eye Institute, Cleveland Clinic, from August 1, 2019, to October 31, 2019. Primary endpoint was percentage of patients who used a check-in kiosk. Secondary endpoints were demographic characteristics and visual acuity (VA) of the two groups. RESULTS: Of 13,752 patients, 3,542 (26%) used a check-in kiosk. Kiosk users were significantly younger than kiosk non-users (median [interquar-tile range (IQR)]: 63.6 [49.4–72.6] vs. 66.6 [55.0–75.4]; P < .0001), had a lower proportion of Medicaid patients (282 [8%] vs. 930 [10%]; P < .0001), and lived in areas with a greater median income (mean [± standard error]: $58,421 [± 399) vs. $54,992 [±236]; P < .0001). On average, they also had better VA (mean ETDRS [95% confidence interval]: 80.5 [80–80.9] vs. 78.3 [78–78.6]; P < .0001). CONCLUSIONS: Significant demographic and VA differences were observed between kiosk users and non-users and may influence kiosk usage. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:684–690.]

Objective To determine if the Argus II retinal prosthesis can operate during functional MRI (fMRI) and diffusion tensor imaging (DTI) acquisitions and if currents induced in the prosthesis by imaging are at safe levels. Materials and methods One Argus II retinal prosthesis was modified to enable current measurements during imaging. Active electronics were modified to enable operation during scans. Induced current was measured during diagnostic scans, which were previously shown to be safe for implanted patients, and during fMRI and DTI scans. All measurements were performed using an ASTM phantom to ensure reproducible placement. Results The prosthesis was able to maintain communication with the external RF coil during the fMRI and DTI scans except briefly during pre-scans. Current levels induced during fMRI and DTI scans were consistently below those measured during diagnostic scans. Conclusions fMRI and DTI may be safely performed while the Argus II retinal prosthesis is operating.

Background/aimsThis study aimed to characterise the clinical outcomes and utility of intraoperative optical coherence tomography (iOCT)-assisted macular hole (MH) repair.MethodsThis was a post hoc analysis of eyes in the Determination of feasibility of Intraoperative Spectral domain microscope Combined/integrated OCT Visualization during En face Retinal and ophthalmic surgery (DISCOVER) study undergoing surgical MH repair with use of iOCT. Functional and surgical outcome data were collected through 12 months postoperatively. MH closure rate, postoperative visual acuity (VA), percentage of cases in which iOCT provided valuable feedback and altered surgical decision making were measured.ResultsEighty-four eyes were included in this study. The mean preoperative VA measured 20/114. The mean postoperative VA improved to 20/68 (pConclusionThis study suggests that iOCT may have important utility in MH surgery, including impacting surgical decision making. iOCT-assisted MH surgery resulted in significant improvement in VA and high single-surgery success rate.

Purpose To compare optical coherence tomography angiography (OCTA) review strategies for optimizing choroidal neovascularization (CNV) detection. Methods Eyes with CNV in the differential diagnosis were imaged with the Avanti RTVue XR HD (Optovue, Fremont, CA). Three modalities of review for CNV presence were used in each case: a single report generated using automated segmentation within Avanti software; a continuous slab descent video OCTA export; and a manual segmentation approach using cross-sectional OCT with decorrelation signal overlay. Scans were reviewed by two masked expert reviewers; a third reviewer was used for discrepancies. Results The study included 421 eyes, and 350 eyes had reports deemed sufficient quality for interpretation. Choroidal neovascularization was in the differential diagnosis in 107 of 350 patients. Overall CNV was identified in 55% (59/107) eyes. In those eyes with CNV, the automated segmentation identified CNV in 56% (33/59) of cases, continuous slab descent method identified CNV in 53% (31/59) of cases, and the manual segmentation group identified CNV in 92% (54/59) of cases. Conclusion Review strategies for detection of CNV on OCTA were highest using the manual segmentation method as compared to both the automated report and continuous slab descent methods. Although the manual segmentation method had a higher rate of detection, the practical aspects of the time required for segmentation make this method challenging in routine clinical practice.

Purpose To characterize the longitudinal panretinal retinal vascular dynamics in diabetic macular edema (DME) and retinal vein occlusion (RVO) over a 12-month period while being treated with intravitreal aflibercept injections (IAIs). Design Prospective open-label study ( clinicaltrials.gov identifier, NCT02503540 ). Participants Thirty-one treatment-naive eyes with foveal-involving retinal edema secondary to DME and RVO. Methods Participants received 2 mg IAI every 4 weeks for the first 6 months, followed by 2 mg every 8 weeks. Ultra-widefield fluorescein angiography (UWFA; California Optos [Optos, Dunfermline, United Kingdom]) and spectral-domain OCT (Cirrus; Zeiss, Oberkochen, Germany) scans were obtained and analyzed using a novel quantitative assessment platform. Visual acuity, central subfield thickness, and adverse events also were collected. Main Outcome Measures The primary end point was the mean change in panretinal leakage index at month 12 from baseline as measured by UWFA. Results Mean age was 67.1 years. At month 12, visual acuity significantly improved by a mean of 18.4±21.4 letters (P Conclusions Intravitreal aflibercept injections resulted in a dramatic reduction in panretinal leakage index. Panretinal ischemic index did not improve and trended toward worsening.

The purpose of the current study is to examine how nonmodifiable sociodemographic, disease, appointment, management, and survey factors correlate with provider rating. This was a retrospective cross-sectional study conducted on 29 857 patient Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys collected from January 2017 to January 2019 at a tertiary eye center. We included surveys of patients aged 18 years or older, who answered at least 4 of 6 subfield questions, and completed the survey within 90 days of the appointment. The main outcome was the odds of receiving top box score (TBS) of 10/10 on the survey question regarding overall provider rating. The results showed that the variables with higher odds of TBS included higher overall appointment attendance (odds ratio [OR]: 2.66 [95% CI: 1.23-5.75], P = .013); older patient age (OR 2.44 [95% CI: 2.08-2.87], P < .001]; higher percentage of survey questions completed (OR: 2.02 [95% CI: 1.79-2.27], P < .001); better best corrected visual acuity (OR: 1.85 [95% CI: 1.3-2.64], P = .001); optometry clinic visit (OR: 1.25 [95% CI: 1.15-1.36], P < .001); having procedures (OR: 1.19 [95% CI: 1.04-1.36], P = .013), surgery scheduled (OR: 1.18 [95% CI: 1.03-1.36], P = .020], or refraction done (OR: 1.16 [95% CI: 1.08-1.25], P < .001); being seen by male providers (OR: 1.11 [95% CI: 1.04-1.17], P = .001); and having additional eye testing performed (OR: 1.06 [95% CI: 1.00-1.13], P = .048). Variables associated with lower odds of TBS included longer time to complete survey (OR: 0.42 [95% CI: 0.3-0.58], P = .001); new patient encounter (OR: 0.62 [95% CI: 0.58-0.65], P < .001); and glaucoma (OR: 0.66 [95% CI: 0.59-0.75], P < .001), cornea (OR: 0.79 [95% CI: 0.71-0.87], P < .001), or comprehensive clinic visits (OR: 0.86 [95% CI: 0.79-0.94], P < .001). Thus, nonmodifiable factors may affect the provider rating, and these factors should be studied further and accounted for when interpreting the results of patient experience surveys.

BACKGROUND AND OBJECTIVE: To evaluate the impact of drusen burden on the detection of subclinical choroidal neovascularization (CNV) on optical coherence tomography angiography (OCTA) in nonexudative age-related macular degeneration (AMD). PATIENTS AND METHODS: A subanalysis of the AVATAR study, subjects diagnosed with nonexudative AMD without subfoveal atrophy were included. Subclinical CNV was assessed using OCTA software, and drusen burden was graded utilizing the advanced retinal pigment epithelium (RPE) analysis. RESULTS: Among eligible 58 eyes, 26 eyes (45%) had high drusen burden. Of the three eyes (5%) that demonstrated subclinical CNV, only one eye had high drusen burden, and all three eyes had neovascular AMD in the fellow eye. Extrafoveal RPE atrophy (odds ratio [OR] = 20.0; 95% confidence interval [CI], 1.53–261) and older age (OR = 1.27; 95% CI, 1.01–1.59) were predictive factors for subclinical CNV. CONCLUSION: Extrafoveal RPE atrophy, older age, and fellow-eye CNV were significant risk factors for underlying subclinical CNV in nonexudative AMD. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:22–30.]

Author(s): Feiler, Daniel L; Browne, Andrew W; Rachitskaya, Aleksandra V; Taban, Mehran; Sonnie, Christine; Hayden-Loreck, Brandy C; Sharma, Sumit; Sears, Jonathan E

BACKGROUND AND OBJECTIVE: To identify choroidal neovascular membrane (CNVM) associated with spectral-domain optical coherence tomography (SD-OCT)-defined pigment epithelial detachment (PED) using SD-OCT angiography (SD-OCTA). PATIENTS AND METHODS: Sixty-nine patients with same-day OCT and OCTA imaging were reviewed, and 41 eyes of 29 patients with PEDs were included. OCTs were analyzed for PED type, fluid, and subretinal hyperreflective material (SHRM). RESULTS: Twenty-seven eyes (66%) demonstrated CNVM on OCTA beneath all subtypes of PED. Twenty-two eyes (75.9%) with fluid or SHRM demonstrated CNVM on OCTA ( P = .036). Fluid corresponded in a statistically significant manner with treatment ( P = .0032), whereas SHRM did not ( P = .613). OCTA-defined CNVM showed borderline statistically significant correlation to treatment ( P = .05). Increased choroidal flow signal seen in 50% of eyes did not demonstrate statistically significant correlation to the presence of fluid on SD-OCT ( P = .2798) or treatment decision ( P = .678). A subset of 14 untreated eyes with CNVM was analyzed, 21% of which required treatment at subsequent visits. CONCLUSIONS: OCTA-defined CNVM was seen in all subtypes of PED in clinically active and inactive disease. The role of OCTA in predicting need for treatment remains to be established. [ Ophthalmic Surg Lasers Imaging Retina. 2019;50:620–626.]

BACKGROUND AND OBJECTIVE: To evaluate a novel measure of compliance, follow-up appointment delay, and assess its relationship with clinical and sociodemographic factors in patients undergoing treatment for diabetic macular edema (DME). PATIENTS AND METHODS: This is a comparative case series of patients treated for DME. The novel measure of compliance — the time in days from the intended day of return and actual day of return, or follow-up appointment delay — was studied and compared to a traditional measure: the percentage of visits missed. These were correlated with clinical and sociodemographic characteristics: best-corrected visual acuity, hemoglobin A1C percent (HbA1c), median household income, smoking status, type of insurance held, marital status, gender, and age. Univariate and multivariable analyses were conducted. RESULTS: One hundred fifty-five patients (212 eyes) were included in the study. The median times between recommended and actual appointments was 5.0 days (range: 2.0–14.0 days). The mean percentage of visits missed was 31.7% (± 13.3%). The two measures of compliance were positively associated, but the correlation was moderate (r = 0.44). Non-white race, lack of bilateral injections, and higher baseline HBA1c were significant predictors of a median time greater than 7 days between the intended and actual follow-up dates. CONCLUSIONS: The current study identified a novel method of measuring compliance of DME patients seen by retina specialists and has identified non-white race, lack for bilateral treatment, and poorer glycemic control as risk factors for noncompliance. [ Ophthalmic Surg Lasers Imaging Retina. 2021;52:200–206.]

To provide a comparative assessment of clinical outcomes between patients undergoing intraoperative OCT (iOCT) and conventional surgery for pars plana vitrectomy (PPV) with epiretinal membrane (ERM) peel.Case-control retrospective, comparative assessment.Patients undergoing PPV with membrane peel for ERM with eyes pooled from the prospective Determination of Feasibility of Intraoperative Spectral Domain Microscope Combined/Integrated OCT Visualization During En Face Retinal and Ophthalmic Surgery (DISCOVER) iOCT study and eyes undergoing conventional ERM surgery without iOCT.Visual acuity and OCT assessment before ERM surgery and at 1-, 3-, 6-, and 12-month follow-up after standard small-gauge PPV with iOCT feedback (iOCT DISCOVER group) or PPV with compulsory internal limiting membrane (ILM) peeling (conventional group). Visual acuity, central subfield thickness (CST), reoperation rate, and ERM recurrence were determined by record review and post hoc assessment of clinical OCTs after ERM peel.Visual acuity and ERM recurrence.A total of 262 eyes were included. Visual acuity (VA) improved 11.9 letters in the iOCT group (P 0.0001) and 12.1 letters in the conventional group (P0.0001) at 12 months after ERM surgery. Visual acuity improvement did not differ between the iOCT and conventional groups at 1, 3, 6, or 12 months after surgery (P 0.05 for each time point). Preoperative mean CST decreased in the iOCT group (P0.0001) and conventional group (P0.0001) with no difference between groups in CST reduction at 12 months (P = 0.36). No reoperations or visually significant recurrent ERMs occurred in either cohort.Intraoperative OCT-guided ERM removal without mandated ILM peeling provided similar VA and anatomic results to conventional ILM peeling for ERM. Future randomized prospective studies are needed to assess fully the possible role of iOCT in ERM surgery and to evaluate the potential impact of nonfoveal ERM persistence or recurrence in comparison with conventional surgery.

BACKGROUND AND OBJECTIVE: To identify factors associated with successful treatment discontinuation in eyes with retinal vein occlusions (RVOs) and macular edema (ME) in real-world settings. PATIENTS AND METHODS: Retrospective study of 214 eyes with RVO and ME with 24-month follow-up at five academic centers. Regression analyses identified factors associated with (1) successful treatment discontinuation for at least 6 months without fluid recurrence and (2) best-corrected visual acuity (BCVA) at 24 months. RESULTS: Forty percent of eyes with branch RVO and 35% with central RVO (CRVO) / hemi-retinal RVO (HRVO) successfully discontinued therapy without fluid recurrence, with median time to discontinuation of 6 and 7 months, respectively. Lower 6-month central subfield thickness was associated with greater likelihood of treatment discontinuation within 24 months for eyes with CRVO/HRVO ( P = .001), whereas better 6-month BCVA was associated with better 24-month BCVA for all RVO subtypes ( P < .001). CONCLUSION: Early anatomic response at 6 months is associated with greater likelihood of stopping treatments. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:84–92.]

BACKGROUND AND OBJECTIVE: To determine which optical parameter profiles (OPPs) can be utilized to improve the visualization of epiretinal membranes (ERMs) and the internal limiting membrane (ILM) using a three-dimensional heads-up microscope during 25-gauge pars plana vitrectomy. PATIENTS AND METHODS: Fourteen independent graders were asked to complete a questionnaire comparing each of the OPPs against the unaltered control image for each given surgical case. RESULTS: Analysis of the graders' responses indicated that higher values of hue are correlated with better visualization of ERM/ILM before and after dye application. There was overall agreement that OPPs could be used to enhance the visualization of the ERM and ILM during surgery. CONCLUSIONS: The use of OPPs to improve the visualization of specific structures is still new and heavily dependent on surgeon preference. The authors' study shows that some OPPs may enhance the visualization of the ERM and ILM during macular surgery. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:584–587.]

Purpose: This article characterizes widefield fundus autofluorescence (WF-FAF) patterns in retinoschisis (RS), retinal detachment (RD), and combined retinoschisis-detachment (RS/RD), and to correlate them with spectral-domain optical coherence tomography (SD-OCT) findings. Methods: A retrospective case series of 13 eyes with senile RS, RD, or RS/RD is presented. One eye underwent imaging of 2 areas within the retina, resulting in 14 data points. Independent, masked graders classified pathology on SD-OCT as RS, RD, or RS/RD and graded WF-FAF images for either hypoautofluorescent areas or mixed autofluorescence (AF) (hyper-AF, iso-AF, hyper-AF with hypo-AF, hyper-AF with iso-AF, or hypo-AF with iso-AF). Results: There was no statistically significant correlation between the autofluorescence pattern and the type of retinal abnormality ( P = .74). Conclusions: High variability was found in the characterization of WF-FAF in patients with RS and RD. SD-OCT remains the criterion-standard imaging modality in distinguishing RS from RD in clinically ambiguous cases.

BACKGROUND AND OBJECTIVE: Evaluate capillary perfusion density (CPD) in patients with diabetic macular edema (DME) undergoing fixed intravit-real aflibercept injections (IAI) through 24 months. PATIENTS AND METHODS: Prospective, interventional, single-arm study enrolling 20 patients with persistent DME. Patients received IAI every 4 weeks until DME resolution followed by extension to every 8 weeks. Optical coherence tomography angiography was obtained at baseline, 6, 12, and 24 months. RESULTS: Sixteen of 20 eyes completed the study. Baseline mean central subfield thickness was 420 µm, which improved to 251 µm ( P < .001). The mean best-corrected visual acuity (BCVA) improved by 5.5 letters ( P = .042). The whole superficial CPD decreased by 5.3% ( P = .001) and the deep CPD decreased by 4.4% ( P = .009). Better BCVA correlated with less CPD loss within the superficial parafovea (r = +0.66 [0.23, 0.88]; P = .006) and whole (r = +0.60 [0.12, 0.85]; P = .017) areas. CONCLUSION: Superficial and deep CPD decreased despite fixed IAI through 24 months. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:448–455.]

Purpose To evaluate the use of OCT angiography (OCTA) to detect choroidal neovascularization (CNV) in eyes with indeterminate CNV features on conventional imaging. Design Prospective observational study of OCTA in patients undergoing routine spectral-domain optical coherence tomography (SD-OCT) for macular disease. Participants Participants enrolled in the Observational Assessment of Visualizing and Analyzing Vessels with Optical Coherence Tomography Angiography in Retinal Diseases for which CNV was considered as part of a differential diagnosis based on clinical examination, prior imaging, or both, but in whom the presence of CNV was not definitive on SD-OCT and fluorescein angiography (FA) imaging. Methods All patients underwent imaging with the Avanti RTVue XR HD (Optovue, Fremont, CA) and the Cirrus HD-OCT (Zeiss, Oberkochen, Germany) systems. Main Outcome Measures OCT angiography scans were assessed for the presence or absence of CNV. Spectral-domain OCT scans were assessed for the presence of fluid, hyperreflective material, serous pigment epithelial detachment (PED), shallow irregular PED, vitreomacular adhesion, epiretinal membrane, retinal pigment epithelium (RPE) atrophy, and central subfield retinal thickness. Univariate and multivariate logistic regression analyses were performed to identify features on SD-OCT associated with the presence of CNV on OCTA. Results Twenty-nine eyes of 29 patients met the criteria for inclusion. A CNV lesion was detected on OCTA in 8 eyes (28%); 21 eyes (72%) showed negative results for CNV. After adjusting for age, gender, and central subfield retinal thickness, the presence of shallow irregular PED (odds ratio [OR], 148; 95% confidence interval [CI], 3.22–6830; P = 0.011), as well as the combinations of intraretinal fluid and sub-RPE material (OR, 16.8; 95% CI, 1.43–198; P = 0.025) on SD-OCT were associated significantly with the presence of CNV on OCTA. Conclusions OCT angiography enabled the identification of CNV that was otherwise indeterminate with prior imaging in select eyes. The presence of a shallow irregular PED as well as intraretinal fluid combined with sub-RPE material both were associated with the presence of CNV. OCT angiography may be a valuable adjunct to conventional SD-OCT and FA imaging in the detection and surveillance of CNV, particularly in diagnostic dilemmas.

The MIRAgel implantation was popularized in the 1980s as an alternative to silicone for scleral buckle retinal detachment repair. However, long-term follow-up has revealed that the implants can expand, creating globe compression and potentially visually devastating intraocular invasion. The authors document a 33-year-old monocular male patient presenting 20 years after MIRAgel implantation with extensive expansion, posterior migration, globe compression, and possible optic nerve compression. Debulking of the MIRAgel stabilized the vision and restored affected extraocular movements. The authors highlight that posterior MIRAgel migration can cause optic nerve compression, and implant debulking may require a multi-disciplinary approach. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:815–818.]

PURPOSE: To assess the retinal anatomy and array position in the Argus II Retinal Prosthesis recipients. DESIGN: Prospective, non-comparative cohort study METHODS: Setting: international multicenter study Patients: Argus II recipients enrolled in the Post-Market Surveillance Studies. Procedures: Spectral-domain Optical Coherence Tomography images collected for the Surveillance Studies (NCT01860092 and NCT01490827) were reviewed. Baseline and postoperative macular thickness, electrode-retina distance (gap), optic disc-array overlap, and preretinal membrane presence were recorded at 1, 3, 6, and 12 months. Main Outcome Measures: Axial retinal thickness and axial gap along the array’s long axis (a line between the tack and handle), maximal retinal thickness and maximal gap along a B-scan near the tack, midline, and handle. RESULTS: Thirty-three patients from 16 surgical sites in the United States and Germany were included. Mean axial retinal thickness increased from month 1 through month 12 at each location, but reached statistical significance only at the array midline (p- value=0.007). The rate of maximal thickness increase was highest near the array midline (slope=6.02, p=0.004), compared to the tack (slope=3.60, p

AimsTo investigate the relationship between subfoveal choroidal thickness (SFCT), visual acuity (VA), optical coherence tomography (OCT) features and total anti-vascular endothelial growth factor (VEGF) treatments to determine whether SFCT serves as a prognostic factor in age-related macular degeneration (AMD).MethodsThis is a retrospective case series of 62 consecutive treatment-naive patients with exudative AMD followed for 1 year and treated with treat-and-extend or pro re nata anti-VEGF protocols. SFCT was measured at three locations using Cirrus HD-OCT (the foveal centre and 500 um nasal and temporal to the fovea) at presentation, 3, 6 and 12 months. Demographic characteristics, OCT imaging biomarkers and VA were recorded.ResultsMean SFCT at baseline was 187 µm (range: 70–361 µm). There was a trend of decreasing SFCT at 1 year (173 µm) compared with 3 months (175 µm) and baseline (188 µm) (p=0.2). There was no correlation between baseline SFCT and presence of subretinal fluid (p=0.2), intraretinal fluid (p=0.6) or subretinal hyper-reflective material (p=0.4) at baseline. The mean number of injections at 1 year was 6.6 (range: 2–12). Increased SFCT at baseline showed statistically significant correlation with a higher number of intravitreal injections at 1 year (p=0.004). Eyes with SFCT>1 SD above the mean required 50% more injections compared with others. There was no association between SFCT on presentation with baseline and 1 year VA (p=0.7 and p=0.2).ConclusionsSFCT in naïve patients with exudative AMD may be an important prognostic tool in determining treatment burden. Patients with thicker subfoveal choroid may require increased intravitreal injections.

Purpose To report the 3-year assessment of feasibility and usefulness of microscope-integrated intraoperative OCT (iOCT) during ophthalmic surgery. Design Prospective, consecutive case series. Participants Adult participants undergoing incisional ophthalmic surgery with iOCT imaging who consented to be enrolled in the Determination of Feasibility of Intraoperative Spectral-Domain Microscope Combined/Integrated OCT Visualization during En Face Retinal and Ophthalmic Surgery (DISCOVER) study. Methods The DISCOVER study is a single-site, multisurgeon, institutional review board-approved investigational device prospective study. Participants included patients undergoing anterior or posterior segment surgery who underwent iOCT imaging with 1 of 3 prototype microscope-integrated iOCT systems (i.e., Zeiss Rescan 700, Leica EnFocus, or Cole Eye iOCT systems). Clinical characteristics were documented, iOCT was directed by the operating surgeon at predetermined surgical time points, and each surgeon completed a questionnaire after surgery to evaluate the usefulness of iOCT during surgery. Main Outcome Measures Feasibility of iOCT based ability to obtain an OCT image during surgery and usefulness of iOCT based on surgeon reporting during surgery. Results Eight hundred thirty-seven eyes (244 anterior segment cases and 593 posterior segment cases) were enrolled in the DISCOVER study. Intraoperative OCT demonstrated feasibility with successful image acquisition in 820 eyes (98.0%; 95% confidence interval [CI], 96.8%–98.8%). In 106 anterior segment cases (43.4%; 95% CI, 37.1%–49.9%), the surgeons indicated that the iOCT information impacted their surgical decision making and altered the procedure. In posterior segment procedures, surgeons reported that iOCT enabled altered surgical decision making during the procedure in 173 cases (29.2%; 95% CI, 25.5%–33.0%). Conclusions The DISCOVER iOCT study demonstrated both generalized feasibility and usefulness based on the surgeon-reported impact on surgical decision making. This large-scale study confirmed similar findings from other studies on the potential value and impact of iOCT on ophthalmic surgery.

Background/aimsSplit-spectrum amplitude decorrelation angiography for spectral-domain optical coherence tomography has enabled detailed, non-invasive assessment of vascular flow. This study evaluates choriocapillaris and retinal capillary perfusion density (CPD) in diabetic eyes using optical coherence tomography angiography (OCTA).MethodsRecords of 136 eyes that underwent OCTA imaging at a single institution were reviewed. Eyes were grouped as non-diabetic controls (37 eyes), patients with diabetes mellitus (DM) without diabetic retinopathy (DM without DR, 31 eyes), non-proliferative diabetic retinopathy (NPDR, 41 eyes) and proliferative diabetic retinopathy (PDR, 27 eyes). Quantitative CPD analyses were performed on OCTA images for assessing perfusion density of the choriocapillaris and retinal plexus for all patients and compared between groups.ResultsEyes with NPDR and PDR showed significantly decreased choriocapillaris CPD compared with controls, while DM eyes without DR did not show significant change. Choriocapillaris whole-image CPD was decreased by 8.3% in eyes with NPDR (pConclusionsChoriocapillaris and retinal CPD are reduced in diabetic retinopathy, while FAZ area is increased in eyes with PDR. Vascular changes captured by new imaging modalities can further characterise diabetic choroidopathy.

Purpose: To evaluate long-term visual and anatomical outcomes of anti–vascular endothelial growth factor (VEGF) therapy for macular edema (ME) secondary to retinal vein occlusion (RVO) in routine clinical practice. Methods: Patients with ME secondary to hemi-RVO (HRVO), central RVO (CRVO), or branch RVO (BRVO) after initiating anti-VEGF therapy were followed for at least 36 months. Main outcomes were change in best visual acuity (BVA) and mean absolute change in central subfield thickness (CST) at 12, 24, 36, and 48 months. Results: Patients with BRVO showed significant increases in BVA that were maintained after 12, 24, 36, and 48 months (+11.03, +12.06, +10.71, and +9.26 letters, respectively; P < .05). CST significantly decreased after 12, 24, 36, and 48 months (−83.51, −67.93, −97.52, −127.85 µm, respectively; P < .05). In patients with CRVO/HRVO, significant improvements in BVA were seen at 12 and 24 months (+9.39 and +8.54 letters, respectively; P = .023). At 36 and 48 months, the visual gain was not significant (+2.64 and +3.42 letters, respectively; P > .05). For CST changes, there were significant decreases at 12, 24, and 36 months (−146.23, −149.54, and −166.44 µm, respectively; P < .05). At 48 months (−97.66 µm, P = .130), changes in CST were not significant. Conclusions: In routine clinical practice, visual and anatomical benefits of anti-VEGF agents in patients with BRVO were sustained at 36 and 48 months. For patients with CRVO/HRVO, anatomical improvements were maintained for 36, but not 48 months, while visual improvements were no longer maintained by 36 months.

Purpose To describe a novel macular phenotype that is associated with normal visual function. Design Retrospective, observational case series. Participants Thirty-six affected individuals from 23 unrelated families. Methods This was a retrospective study of patients who had a characteristic macular phenotype. Subjects underwent a full ocular examination, electrophysiologic studies, spectral-domain optical coherence tomography (OCT), and fundus autofluorescence imaging. Genomic analyses were performed using haplotype sharing analysis and whole-exome sequencing. Main Outcome Measures Visual acuity, retinal features, electroretinography, and whole-exome sequencing. Results Twenty-six of 36 subjects were female. The median age of subjects at presentation was 15 years (range, 5–59 years). The majority of subjects were asymptomatic and presented after a routine eye examination (22/36 subjects) or after screening because of a positive family history (13/36 subjects) or by another ophthalmologist (1/36 subjects). Of the 3 symptomatic subjects, 2 had reduced visual acuity secondary to nonorganic visual loss and bilateral ametropic amblyopia with strabismus. Visual acuity was 0.18 logarithm of the minimum angle of resolution (logMAR) or better in 30 of 33 subjects. Color vision was normal in all subjects tested, except for the subject with nonorganic visual loss. All subjects had bilateral symmetric multiple yellow dots at the macula. In the majority of subjects, these were evenly distributed throughout the fovea, but in 9 subjects they were concentrated in the nasal parafoveal area. The dots were hyperautofluorescent on fundus autofluorescence imaging. The OCT imaging was generally normal, but in 6 subjects subtle irregularities at the inner segment ellipsoid band were seen. Electrophysiologic studies identified normal macular function in 17 of 19 subjects and normal full-field retinal function in all subjects. Whole-exome analysis across 3 unrelated families found no pathogenic variants in known macular dystrophy genes. Haplotype sharing analysis in 1 family excluded linkage with the North Carolina macular dystrophy (MCDR1) locus. Conclusions A new retinal phenotype is described, which is characterized by bilateral multiple early-onset yellow dots at the macula. Visual function is normal, and the condition is nonprogressive. In familial cases, the phenotype seems to be inherited in an autosomal dominant manner, but a causative gene is yet to be ascertained.

BACKGROUND AND OBJECTIVE: To determine outcomes of intravitreal ranibizumab (IVR) (Lucentis; Genentech, South San Francisco, CA) versus bevacizumab (IVB) (Avastin; Genentech, South San Francisco, CA) for treatment of macular edema (ME) secondary to retinal vein occlusion (RVO) in routine clinical practice. PATIENTS AND METHODS: A retrospective study identified treatment-naïve patients with ME secondary to RVO where treatment with either IVB or IVR was initiated. Retreatment criteria were based on ophthalmic examination and/or spectral-domain optical coherence tomography findings. RESULTS: Central RVO/hemi-RVO cohort: At 12 months, change in visual acuity (VA) (IVR: +12.9 letters, IVB +6.9 letters; P = .53), central subfield thickness (CST) (IVR: −144.1 μm, IVB: −153.9 μm; P = .88), and number of injections (IVR: 5.40 injections, IVB: 5.64 injections; P = .70) were not different between groups. Branch RVO cohort: At 12-month follow-up, no differences in change in VA (IVR: +15.2 letters, IVB: +10.6 letters; P = .46), CST (IVR: −23.1 μm, IVB: −91.4 μm; P = .16), or number of injections (IVR: 5.93 injections, IVB: 5.13 injections; P = .15) were noted. CONCLUSION: There is no notable difference in outcome between IVR and IVB when treating ME from RVO in routine clinical practice. [ Ophthalmic Surg Lasers Imaging Retina. 2017;48:465–472.]

Purpose To analyze and provide an overview of the incidence, management, and prevention of conjunctival erosion in Argus II clinical trial subjects and postapproval patients. Methods This retrospective analysis followed the results of 274 patients treated with the Argus II Retinal Prosthesis System between June 2007 and November 2017, including 30 subjects from the US and European clinical trials, and 244 patients in the postapproval phase. Results were gathered for incidence of a serious adverse event, incidence of conjunctival erosion, occurrence sites, rates of erosion, and erosion timing. Results Overall, 60% of subjects in the clinical trial subjects versus 83% of patients in the postapproval phase did not experience device- or surgery-related serious adverse events. In the postapproval phase, conjunctival erosion had an incidence rate of 6.2% over 5 years and 11 months. In 55% of conjunctival erosion cases, erosion occurred in the inferotemporal quadrant, 25% in the superotemporal quadrant, and 20% in both. Sixty percent of the erosion events occurred in the first 15 months after implantation, and 85% within the first 2.5 years. Conclusion Reducing occurrence of conjunctival erosion in patients with the Argus II Retinal Prosthesis requires identification and minimization of risk factors before and during implantation. Implementing inverted sutures at the implant tabs, use of graft material at these locations as well as Mersilene rather than nylon sutures, and accurate Tenon's and conjunctiva closure are recommended for consideration in all patients.

The purpose of this study is to evaluate intraoperative OCT (iOCT) utility and outcomes during retinal detachment (RD) repair.The Determination of Feasibility of Intraoperative Spectral-Domain Microscope Combined/Integrated OCT Visualization during En Face Retinal and Ophthalmic Surgery (DISCOVER) intraoperative OCT study is a prospective Institutional Review Board-approved study.Participants in the DISCOVER study undergoing surgical repair for RD.This was a post hoc analysis of eyes in the DISCOVER study undergoing surgical repair for RDs. Inclusion criteria included iOCT after perfluorocarbon liquid placement and at least 6 months follow-up. Exclusion criteria included severe retinal pathology unrelated to RD. Surgeons completed standardized questionnaires after each case evaluating the iOCT instrument's utility. Functional and surgical outcome data were collected at the latest available time point between 6 and 12 months. Outcomes were evaluated in 2 groups: uncomplicated primary and complex cases.Intraoperative OCT utility, single-surgery success, and visual acuity outcomes.A total of 103 eyes were included in this study: 51 uncomplicated primary and 52 complex cases. Intraoperative OCT provided valuable information in 36% of cases. In 12% of cases, iOCT data directly altered surgical decision making. There was a significantly higher rate of valuable iOCT feedback in complex cases compared with primary cases (50% vs. 22%, P0.01). Among primary cases, 48 (94%) had successful single surgery repair with a mean postoperative visual acuity of 20/47 compared with the complex group's 75% single surgery success (n=39) and mean postoperative visual acuity of 20/92.This study affirms the potential impact of iOCT in assisting select cases of RD repair, particularly with complex pathology. The single surgery success rate was good with more than 80% of cases successfully repaired with 1 surgery.

Purpose: To describe two methods of measuring Argus II array–retina distance and to correlate array–retina distance to electrode stimulation thresholds. Methods: This was a case series of eight patients implanted with the Argus II. Spectral domain-optical coherence tomography array–retina distance was measured by two methods and correlated to corresponding electrode thresholds: (1) array–retina distance at each array corner and the largest array–retina distance and (2) using manual optical coherence tomography segmentation, the average array–retina distance was determined for each group of four electrodes. Patients 1–5 and 6–8 were analyzed separately due to a different threshold programming software. Results: The Spearman’s rank coefficient between array–retina distance and thresholds was −0.006 ( p = 0.98) for patients 1–5, and 0.16 ( p = 0.59) for patients 6–8 with the first method. The Spearman’s rank coefficient was 0.25 ( p Conclusion: There is a positive correlation between array–retina distance and threshold measurements when measuring the entire array but not when using a faster measurement method of four corners and largest array–retina distance.

Purpose The field of retinal prostheses is expanding. However, the best approach to training and assessing the functional benefit of postoperative vision has not been established. The purpose of this single-center prospective interventional case series was to evaluate the feasibility and effectiveness of using the Computer Assisted Rehabilitation Environment (CAREN) system as a visual rehabilitation tool in Argus II patients. Design Single-center prospective interventional case series ( clinicaltrials.gov identifier, NCT03444961 ). Participants Four Argus II recipients (3 men and 1 woman). Methods Eight visual rehabilitation sessions using the CAREN system (twice weekly for 4 weeks). Main Outcome Measures Baseline and postintervention assessments consisted of visual function, mobility, and balance tests. Results All patients successfully completed training on the CAREN system. While the Argus II device was active, walking speed increased from baseline to immediately after the intervention on flat and undulating surfaces and while localizing objects by 20%, 10%, and 18%, respectively. An improved ability to complete the timed up and go test successfully was observed. Conclusions Novel methods of visual rehabilitation for retinal prostheses recipients, such the CAREN system, are feasible and may result in improved ability to use the Argus II while performing functional tasks. Immersive technology may provide a solution for the standardization of effective rehabilitation approaches to augment retinal prosthesis performance. Heterogeneity of results indicates that a larger sample size would be beneficial.

BACKGROUND AND OBJECTIVE: To compare conventional microscope-integrated intraoperative optical coherence tomography (iOCT) and digitally enabled microscope-integrated iOCT in vitreoretinal surgery. PATIENTS AND METHODS: In this post-hoc analysis of the DISCOVER prospective iOCT study, two surgical groups were compared: (1) conventional iOCT and (2) digitally enabled iOCT. Surgeon questionnaires were collected immediately following surgery. RESULTS: A total of 187 subjects were included in the study: 91 in the conventional iOCT group and 96 in the digitally enabled iOCT group. There were no differences in surgeon-perceived iOCT utility between the two groups. There was significantly higher surgical field-based visualization of the iOCT datastream in the digitally enabled iOCT group (67.7% vs. 3.3%; P < .0001). Reported significant back discomfort (1.0% vs. 18.7%; P < .0001) and headaches (5.2% vs. 20.9%; P < .002) were lower in the digitally enabled iOCT group. CONCLUSIONS: Feasibility and utility of iOCT were similar in both groups. Digitally enabled iOCT datastream enabled increased attention on the surgical field during OCT review. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:S37–S43.]

Background Diabetic macular edema (DME) is an important cause of vision loss and despite the anatomical and functional improvement achieved with treatment, there are reports of persistent DME regardless of continuous anti-VEGF therapy. The purpose of this study is to examine the effect of patients with DME previously treated with other anti-VEGF agents who are transitioned to intravitreal aflibercept (IAI) on a fixed dosing regimen. Methods This prospective study included 20 patients presenting with DME with a history of previous anti-VEGF treatment with ranibizumab or bevacizumab. Patients received a 2 mg (0.05 mL) IAI every 4 weeks until no evidence of fluid by optical coherence tomography (OCT) followed by a fixed dosing schedule of 2 mg IAI once every 8 weeks through 24 months. There was a pre-planned interim analysis of the mean absolute change from baseline central foveal thickness at month 6 as measured by OCT. Secondary outcomes included mean change from baseline in ETDRS visual acuity and anatomic parameters. Optical Coherence tomography angiography (OCTA) capillary perfusion density (CPD) after transitioning to IAI therapy were also reported. Results Average central subfield thickness on OCT at baseline was 419.7 ± 92.0 and improved to 303.8 ± 73.1 at 6-months (p p = 0.38). OCTA CPD analysis revealed significant increase from baseline in the foveal avascular zone in non-proliferative diabetic retinopathy group (p = 0.02). Conclusions Patients with prior anti-VEGF therapy who were transitioned to IAI therapy revealed significant anatomic improvements through 6 months. Trial registration Treatment of Diabetic Macular Edema With Aflibercept in Subjects Previously Treated With Ranibizumab or Bevacizumab (SwapTwo), Trial registration number: NCT02559180. Date of registration: September 24, 2015.https://clinicaltrials.gov/ct2/show/NCT02559180

Choroidal neovascular membrane (CNVM) is a rare complication of choroideremia. The authors report a case of a 13-year-old male presenting with metamorphopsia and decreased central vision of 1-year duration. Genetic testing was significant for a pathogenic c.1437dupA mutation in the CHM gene. Fundus biomicroscopy showed a subfoveal membrane; diagnosis of CNVM was substantiated with fluorescein angiography and swept-source optical coherence tomography angiography (SS-OCTA). The patient received six injections of intravitreal bevacizumab during a 13-month period with functional and anatomic improvement. Lesion area on SS-OCTA remained stable. CNVM should be suspected in young patients with choroideremia presenting with acute decrease in central vision. Treatment with anti-vascular endothelial growth factor should be considered even in chronic cases. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:e188–e192.]

A patient with bilateral diffuse uveal melanocytic proliferation (BDUMP) associated with endometrial cancer was treated with plasmapheresis, but failed therapy with progressive serous retinal detachment. We collected plasma before and after plasmapheresis therapy. Our goal was to determine if the cultured melanocyte elongation and proliferation (CMEP) factor and hepatocyte growth factor (HGF) was present in the IgG enriched fraction and understand why our patient failed plasmapheresis therapy. Melanocytes were cultured for 3-5 days in the presence of control medium, unfractionated pre-plasmapheresis BDUMP medium, IgG enriched or IgG depleted BDUMP medium, or unfractionated post-plasmapheresis BDUMP medium. Subretinal fluid was collected from patients with BDUMP and control retinal detachments and analyzed by electropheresis with immunoblotting. Medium with unfractionated BDUMP plasma stimulated melanocyte growth 1.4-1.5 fold compared to control medium on days 3-5 (p < 0.001 for all). Both IgG enriched and IgG depleted BDUMP medium mildly increased melanocyte growth 1.3 fold (p < 0.05 for enriched, p < 0.01 for depleted) compared to control. In comparison, unfractionated BDUMP medium caused a 1.7-fold increase in melanocyte growth, which was significantly more than the enriched (p < 0.01) and depleted (p < 0.05) fractions. Pre-plasmapheresis and post-plasmapheresis unfractionated BDUMP medium equally stimulated melanocyte growth 1.7-fold (p < 0.05) compared to control. HGF was present in IgG depleted, pre-plasmapheresis, and post-plasmapheresis samples, but absent in the IgG enriched fraction. There was no enrichment of IgG in the subretinal fluid from eyes with BDUMP. In conclusion, CMEP factor is not concentrated in the IgG enriched plasma fraction in our patient who failed plasmapheresis therapy. HGF levels have no correlation with melanocyte growth. Because plasmapheresis preferentially removes immunoglobulins from the plasma, our patient responded poorly to plasmapheresis treatment with worsening retinal detachment.

PURPOSE: To characterize the longitudinal panretinal retinal vascular dynamics in diabetic macular edema (DME) and retinal vein occlusion (RVO) over a 12-month period while being treated with intravitreal aflibercept injections (IAI). DESIGN: Prospective open-label study (clinicaltrials.org identifier, ). PARTICIPANTS: Thirty-one treatment-naïve eyes with foveal-involving retinal edema secondary to DME and RVO. METHODS: Subjects received 2mg IAI q4 weeks for the first 6 months, followed by 2 mg q8 weeks. Ultra-widefield angiograms (UWFA, California Optos) and SD-OCT (Cirrus, Zeiss) scans were obtained and analyzed using a novel quantitative assessment platform. Visual acuity, central subfield thickness, and adverse events were also collected. MAIN OUTCOME MEASURES: The primary study endpoint was the mean change in panretinal leakage index at month 12 from baseline as measured by UWFA. RESULTS: Baseline mean age was 67.1 years (range, 46-84). At month 12, visual acuity significantly improved by a mean of 18.4 ± 21.4 letters (P < 0.0001), and CST also significantly improved with a mean reduction of 301.3 ± 250.3 μm (P < 0.0001). Mean panretinal leakage index significantly improved, decreasing from 3.4% at baseline to 0.5% at month 6 (P < 0.0001) and 0.4% at month 12 (P < 0.0001). Panretinal ischemic index did not demonstrate any significant change but showed a nonsignificant increase from 5.5% at baseline to 6.1% at month 6 (P = 0.315) and 8.7% at month 12 (P = 0.193). Subjects diagnosed with DME showed a decrease in leakage index from 3.5 ± 2.7% at baseline to 1.6 ± 0.8% at month 12 (P = 0.018) and overall stability in ischemic index from 5.0 ± 4.1% at baseline to 4.7 ± 3.5% at month 12 (P = 0.689). Subjects with RVO presented a decrease in leakage index from 3.3 ± 1.1% at baseline to 0.02 ± 0.03% at 12 months (P < 0.0001) and a non-significant increase in ischemic index from 5.9 ± 4.5% at baseline to 12.6 ± 9.8% at month 12 (P = 0.172). CONCLUSIONS: Therapy with IAI resulted in a dramatic reduction in panretinal leakage index. Panretinal ischemic index did not improve and trended towards worsening.

Background/aimsThe efficacy of mineralocorticoid receptor antagonist eplerenone to treat chronic central serous chorioretinopathy (CSCR) has been established. However, previous studies have been limited by small cohort size and short follow-up duration. This study aims to report 3-year clinical outcomes of patients treated with eplerenone for chronic CSCR.MethodsInstitutional review board-approved retrospective chart analysis at a single institution from 2012 to 2018. Baseline best-corrected visual acuity and anatomical measurements related to degree of subretinal fluid (SRF) were collected at eplerenone initiation. Follow-up data were collected at the closest date to 12, 24 and 36 months.ResultsData were obtained for 100 eyes of 83 patients at 1-year (mean 11.18 ± 4.00 months), 49 eyes at 2-year (24.01 ± 3.33 months) and 33 eyes at 3-year (mean 35.5 ± 7.89 months) follow-up visits. The rate of complete SRF resolution was 31%, 28% and 33%, respectively. At final follow-up, logarithm of the minimum angle of resolution visual acuity change from baseline was +0.10 ± 0.24 (p = 0.130). Average change from baseline at final follow-up for central subfield thickness was −97 ± 140.6 µm (p < 0.001), cube volume was –1.07 ± 1.71 mm3 (p < 0.001), macular thickness –28. 5 ± 47.5 µm (p < 0.001), maximum SRF height was −95.6 ± 160.5 µm (p < 0.001) and maximum SRF diameter was −1169.0 ± 1638.7 µm (p = 0.008).ConclusionAnatomical improvement occurs primarily within the first year of eplerenone treatment for chronic CSCR.

Purpose To analyze anti–vascular endothelial growth factor (anti-VEGF) agent–associated industry payments to ophthalmologists using the Centers for Medicare and Medicaid Services (CMS) Open Payments and Provider Utilization and Payment data. Design Retrospective database review using 2 national databases. Methods Payments from 2013 to 2014 were analyzed by anti-VEGF agent, payment category, and dollar amount. Ranibizumab and aflibercept usage was correlated by performing log-ratio analysis. Results A total of 3207 ophthalmologists received 13 449 payments totaling $4 454 325 associated with ranibizumab and aflibercept. As 7% of ophthalmologists received 90% of payments, the Gini index was 0.92, demonstrating unequal distribution of payments. Consulting fees and speaker fees were associated with highest payment amounts to fewest providers. For 2383 providers (74%), greater than 90% of the anti-VEGF payments were associated exclusively with either ranibizumab or aflibercept. A total of 1382 ophthalmologists were matched in both databases. Providers receiving >90% of payments from ranibizumab were more likely to use ranibizumab, and those receiving >90% of payments from aflibercept were more likely to use aflibercept over bevacizumab as compared to those who received no payments. Conclusions The distribution of all anti-VEGF payments is unequal. Ophthalmologists who received aflibercept or ranibizumab payments were more likely to receive the majority of payments from one source or the other, but not both. Those who received anti-VEGF payments were more likely to use ranibizumab or aflibercept, as compared to off-label bevacizumab, than those who did not receive any payment.

Purpose On clinical examination, it can be challenging to differentiate retinoschisis with outer retinal hole from schisis-detachment. This study examined the role of outer retinal hole spectral domain optical coherence tomography (SD-OCT) imaging in conjunction with imaging of the posterior schisis cavity edge in differentiating between these conditions. Methods This is a retrospective case series. Out of 500 subjects with ICD-9 diagnoses of senile retinoschisis (361.10, 361.11, 361.12, 361.19) from January 2004 to December 2014, 62 had evidence of retinoschisis on fundus photography or optical coherence tomography (OCT). Six eyes of five patients had outer retinal holes documented by fundus photography (Optos, Marlborough, Massachusetts, USA) and SD-OCT (Carl Zeiss Meditec, Dublin, California, USA). The OCT morphology of outer retinal holes, subjects9 symptomology, visual acuity, fundus examination, diagnosis and progression of the disease were analysed. Results All five patients were women; the mean age was 67.4 years. The correct diagnosis was recorded in the chart in 50% of cases. All, but one, were asymptomatic with visual acuity ranging from 20/20 to 20/200. Three types of outer retinal hole OCT morphology in conjunction with imaging of the posterior schisis cavity edge were established. (1) Outer retinal hole with both edges down and attached to retinal pigment epithelium (RPE) and the edge of the cavity showing a split in neurosensory retina corresponded to isolated retinoschisis. The outer retinal hole with (2) one or (3) both edges detached from the RPE and the edge of the cavity showing complete separation of retina from RPE corresponded to schisis-detachment. One patient underwent scleral buckle surgery for schisis-detachment. Otherwise, no treatment was performed and no progression was noted with the longest OCT-documented follow-up of 26 months. Conclusions The OCT morphology of outer retinal holes in conjunction with imaging of the posterior schisis cavity edge aids in the diagnosis of retinoschisis and schisis-detachment.