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Diabetic macular edema is a common cause of vision loss in the working-age population, and its prevalence is increasing in Asian countries. Managing diabetic macular edema encompasses effective control of systemic factors and intraocular treatment including anti-vascular endothelial growth factor therapy, corticosteroid implants, and laser photocoagulation. Based on several guidelines and the available evidence, we present consensus on managing diabetic macular edema in Hong Kong to ensure optimal anatomical and visual outcomes. Although anti-vascular endothelial growth factor agents are recommended first-line treatment for patients with diabetic macular edema experiencing vision loss, the frequent dosing regimen imposes great clinical and patient burden. Longer-acting anti-vascular endothelial growth factor agents are needed to allow for longer intervals between treatments. As demonstrated in the KITE and KESTREL studies, brolucizumab, an antivascular endothelial growth factor A agent, is associated with fewer cases of intraretinal or subretinal fluid than aflibercept, despite fewer injections. Similarly, faricimab, a bispecific antibody targeting both vascular endothelial growth factor A and angiopoietin-2, demonstrated comparable vision gains with longer treatment intervals and larger improvements in anatomical outcome in the YOSEMITE and RHINE trials. Early intensive antivascular endothelial growth factor therapy leads to greater improvements in visual acuity and anatomical outcomes. Patients who respond inadequately to anti-vascular endothelial growth factor therapy, as monitored by optical coherence tomography, should switch treatment modality. [ABSTRACT FROM AUTHOR]

Brolucizumab is a next-generation anti-vascular endothelial growth factor (VEGF) agent for the treatment of neovascular age-related macular degeneration. It is highly potent and thus appropriate for those unresponsive to other anti-VEGF agents and those undertreated owing to the low adherence or the heavy burden of repeated injections. An expert panel of 10 retina specialists from Hong Kong and Germany convened in February 2021 to discuss the benefit-risk profile and clinical use of brolucizumab. Evidence suggests that brolucizumab provides comparable visual outcomes to aflibercept at a more relaxed injection schedule. Brolucizumab is superior to aflibercept in resolving intraretinal and subretinal fluids and decreasing disease activity. Brolucizumab is suitable for patients unresponsive to other anti-VEGF agents, especially for those with persistent intraretinal and subretinal fluids or disease activity. Injection intervals of brolucizumab can be extended to 8 to 12 weeks. However, brolucizumab has higher risk of adverse events such as intraocular inflammation, retinal vasculitis, and retinal occlusion, compared with aflibercept. Thus, regular monitoring for signs of intraocular inflammation and prompt management are important before and during treatment. [ABSTRACT FROM AUTHOR]

Retinal dystrophies (RD) refer to a group of clinically and genetically heterogenous degenerative conditions of the retina. We aim to summarize emerging gene therapies for RD and their efficacy in restoring photoreceptor or bipolar cell functions. In patients with retinitis pigmentosa, injection of adeno-associated virus containing RPE65, RPGR or MERTK results in improvements in outcomes of the multi-luminal mobility test and full-field light sensitivity threshold test. In animal models of congenital stationary night blindness, gene augmentation of Cacn1f, LRIT3 or Nyx increases ON-bipolar cell signaling cascade and preserves retinal morphology. Patients with achromatopsia show improved visual acuity, contrast sensitivity, and cone responses after injection of a vector comprising CNGA3 or CNGB3. In patients with Leber congenital amaurosis, administration of a vector containing RPE65 or RDH12 results in improved full-field sensitivity to white light and photoreceptors responses, particularly in pediatric populations. Some patients have improved dark-adapted spectral sensitivities and pupillary light responses after injection of vectors. For choroideremia, REP1 gene therapy has been shown to improve visual acuity and retinal sensitivity. Nonetheless, voretigene neparvovec-ryzl (Luxturna) remains to be the only approved gene therapy in patients with biallelic RPE65 mutation. In the Chinese population, RPGR, Lrit3, Nyx, CNGA3, RPE65, RDH12, and CHM gene therapies may be beneficial, because the mutated genes are compatible with the genes investigated in previous clinical trials. A thorough understanding of gene therapies for different RD subtypes may allow more personalized management of retinal degeneration. [ABSTRACT FROM AUTHOR]

We aim to summarize various emerging treatments for geographic atrophy (GA) secondary to dry age-related macular degeneration (AMD). The PubMed database was searched using keywords: 'treatment' and 'geographic atrophy' or 'dry age-related macular degeneration' on 19 June 2021. Of 121 articles yielded, 20 relevant clinical studies that were of 'English language' and 'published within 10 years' were included. The emerging treatments of dry AMD with GA were categorized into complement inhibitors, diet and supplement, cell-based therapies, and pharmacological agents. Complement inhibitors (C3 inhibitor pegcetacoplan, complement factor D, and C5 inhibitors) can significantly reduce the GA lesion area growth, as can Mediterranean diet and a-lipoic acid. Cell-based therapies such as palucorel and biosynthetic retinal pigment epithelium monolayer delivery can minimize GA lesion area and improve the best-corrected visual acuity. Pharmacological agents such as fenretinide, ciliary neurotrophic growth factor, trimetazidine, and brimonidine have prominent effects on GA, but emixustat hydrochloride, tandospirone, and sirolimus lack such effects. The Age-Related Eye Disease Study formulation remains important in reducing the risk of progression of GA secondary to dry AMD. A thorough understanding of the emerging treatment of GA may enable more personalized treatment. Nonetheless, the safety and efficacy of the treatment ought to be tested in trials with larger sample size, longer duration, and optimized dosage. [ABSTRACT FROM AUTHOR]

Anti-vascular endothelial growth factor (anti-VEGF) treatment is the gold standard of care for neovascular age-related macular degeneration (nAMD). To strike a balance between treatment burden and vision improvement, a treat-and-extend (T&E) regimen is the preferred approach to administer anti-VEGF treatment. To facilitate implementation of the T&E regimen for nAMD in Hong Kong, a panel of retinal experts, with the support of Bayer Healthcare, held an online meeting on 15 September 2020 to discuss the latest published evidence and clinical experiences regarding the suitability and safety of anti-VEGF agents in the T&E regimen, patient selection, retreatment criteria, considerations for treatment discontinuation, and barriers to implementing the T&E regimen. Compared with the 2019 recommendations, this 2020 version contains several major updates including differentiation of fluid compartments in retreatment criteria, additional considerations for patient selection, streamlined criteria for treatment cessation, and applicability of the T&E regimen in patients with polypoidal choroidal vasculopathy (PCV). These updated recommendations are expected to facilitate implementation of the T&E regimen for nAMD including PCV in Hong Kong, with the aims of improving patient visual acuity, lowering treatment burden, and facilitating service capacity planning over the long term. [ABSTRACT FROM AUTHOR]

We report the long-term outcome of two cases of free internal limiting membrane (ILM) transplant for unclosed macular holes after extensive internal limiting membrane peeling and silicone oil tamponade. Free ILM graft was harvested and then successfully tucked against the inner edges of the macular hole in two eyes. All macular holes closed. In one case, the ILM filled the macular hole 100% in all meridians and remained closed 7 years after surgery. In another case, the ILM filled the gap of the macular hole 100% in the horizontal meridian and approximately 70% in the vertical meridian and re-opened 5 weeks after surgery. Filling the entire macular hole area with the ILM graft may improve long-term anatomical outcomes. [ABSTRACT FROM AUTHOR]

The purpose of the present paper was to evaluate the visual outcome and recurrence rate of epiretinal membrane (ERM) formation following vitreoretinal surgery with and without internal limiting membrane (ILM) peel. The medical records of 42 consecutive patients who underwent surgery for macular ERM by a single surgeon were reviewed. All patients underwent pars plana vitrectomy and ERM removal with a subset undergoing ILM peel. Recurrence of macular ERM within 18 months and the final visual outcome after surgery were compared between patients with and without ILM removal. Twenty-five patients (59.5%) underwent ERM surgery with ILM peeling and 17 patients (40.5%) underwent ERM surgery without ILM peeling. The mean preoperative logMAR visual acuity was 0.77 and 0.96 for the ILM peeling and non-ILM peeling groups, respectively. Visual acuity improved significantly in both the ILM and non-ILM peeling groups after ERM surgery ( P < 0.001 and P = 0.003, respectively). Eighteen months after surgery, 3/17 eyes without ILM peeling (17.6%) developed recurrent macular ERM, compared with none of the 25 eyes with ILM peeling (log–rank test, P = 0.030). Internal limiting membrane removal during macular ERM surgery may minimize the recurrence of ERM, without adverse visual outcome. Further controlled prospective studies are needed to determine the role of ILM peeling in ERM surgery. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical outcome and quantify histologically the amount of microscopic internal limiting membrane (ILM) and epiretinal membrane (ERM) present in ILM and ERM specimens obtained from ERM surgery.Design: Interventional consecutive case series.Methods: Patients scheduled for ERM surgery were recruited prospectively. Pars plana vitrectomy, removal of ERM, and ILM peeling with indocyanine green (ICG) staining were performed in all patients. Epiretinal membrane and ILM specimens were sent for histologic examination. The amount of ERM present in ILM specimens and the amount of ILM present in ERM specimens were quantified by manual counting. Outcome measures include change in best-corrected visual acuity (BCVA), proportion of cases with 2 or more lines of visual improvement, anatomic outcome, proportions of microscopic ERM within ILM, and microscopic ILM within ERM.Results: Eighteen eyes in 18 patients were operated with a mean follow-up of 19.3 months. There were 13 primary ERMs and five secondary ERMs. The mean logMAR BCVA improved from 0.83 preoperatively to 0.49 postoperatively (P < .001). The mean lines of improvement in BCVA was 3.3 lines with 14 patients (77.8%) who had 2 or more lines of BCVA improvement. Histologic evaluation of the specimens showed no significant correlation with the final BCVA of 20/50 or better. Eleven (61.1%) of the ILM specimens showed various amount of microscopic ERM and 16 (88.9%) of the ERM specimens showed various amount of ILM fragments. The mean proportion of ERM within ILM specimens was 4.69% and that of ILM within ERM specimens was 51.5%. No significant recurrence of ERM was found.Conclusion: Recurrence of ERM may be minimized by removing residual microscopic ERM present on the ILM. Indocyanine green-assisted ILM peeling in ERM surgery appears to have favorable visual and anatomic outcomes. [Copyright &y& Elsevier]

: PurposeTo report the location of premacular hemorrhage in Valsalva retinopathy and epiretinal membrane formation with internal limiting membrane (ILM) wrinkling after neodymium;yttrium-aluminum-garnet (Nd:YAG) laser membranotomy.: DesignInterventional case report.: MethodsA 35-year-old man with a massive premacular hemorrhage due to Valsalva retinopathy underwent Nd:YAG laser membranotomy. After membranotomy, his visual acuity improved from 20/200 to 20/25. Ten months later, he developed metamorphopsia with visual acuity of 20/30. A semiopacified membrane with radiating striae was found, and pars plana vitrectomy was performed for membrane removal.: ResultsHistologic examination of the membrane showed hemosiderin deposits within macrophages on the retinal side of the ILM. One year later, the patient was asymptomatic with visual acuity of 20/20.: ConclusionsTo our knowledge, histopathologic confirmation of the sub-ILM hemorrhage in Valsalva retinopathy and epiretinal membrane formation with ILM wrinkling as a complication after Nd:YAG laser membranotomy have not been previously reported. [Copyright &y& Elsevier]

Purpose: To describe bilateral conjunctival chemosis and central serous chorioretinopathy in a patient with graft-vs-host disease after bone marrow transplant.Design: Interventional case report.Methods: A 45-year-old Chinese woman developed blurring of vision 16 days after bone marrow transplant for multiple myeloma. She had graft-vs-host disease 11 days after bone marrow transplantation. On examination, vision was 0.6 in the right eye and 0.3 in the left eye. Bilateral conjunctival chemosis and multiple central serous chorioretinopathy were present.Results: Treatment of graft-vs-host disease with high-dose systemic corticosteroid and cyclosporin led to the resolution of the conjunctival chemosis and central serous chorioretinopathy 3 months later. Visual acuity improved to 0.8 in both eyes.Conclusion: Choroidal infiltrate in graft-vs-host disease may contribute to choroidal hyperpermeability, which leads to the development of central serous chorioretinopathy in postbone marrow transplant patients. [ABSTRACT FROM AUTHOR]