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Introduction: Few studies have explored Multicolor™ imaging (MCI) in evaluating retinal vascular diseases, particularly branch retinal vein occlusion (BRVO). This study aimed to compare the identification of retinal vessel whitening in BRVO using MCI by scanning confocal laser versus conventional white flash color fundus photography (CFP). Methods: Paired images of consecutive patients diagnosed with BRVO who underwent same-day MCI and CFP were reviewed. Visualization of vessel whitening on MCI and CFP was graded and scored using a scale by two masked graders. A longitudinal analysis of the vessel grading score was performed to evaluate the vessel whitening detection by MCI. A correlation analysis was conducted between vessel whitening on MCI and the measured area of retinal ischemia on fluorescein angiography to evaluate the MCI performance. Results: Forty-four eyes of 41 patients (mean age 69±14 years; 61% female) were analyzed. MCI demonstrated superior vessel whitening visibility score than CFP (p

Purpose To study the natural history of optical coherence tomography (OCT) imaging-based findings seen in non-exudative age-related macular degeneration (neAMD) and model their relative likelihood in predicting development of incomplete retinal pigment epithelium and outer retinal atrophy (iRORA), complete retinal pigment epithelium and outer retinal atrophy (cRORA), and neovascular AMD (nAMD). Methods Retrospective chart review was performed at two academic practices. Patients diagnosed with neAMD for whom yearly OCT scans were obtained for at least 4 consecutive years were included. Baseline demographic, visual acuity, AREDS staging, and OCT data were collected. OCTs were assessed for the presence or absence of eleven features previously individually associated with progression of neAMD, both at baseline, and on all subsequent follow-up scans. Likewise, charts were reviewed to assess visual acuity and staging of NEAMD at all follow-up visits. A multivariate regression analysis was constructed to determine predictors of iRORA, cRORA, and nAMD. Results A total of 107 eyes of 88 patients were evaluated. Follow-up included yearly OCTs obtained over at least 4 consecutive years follow-up (range: 50-94 months). During the follow-up period, 17 eyes progressed to iRORA while 25 progressed to cRORA and 16 underwent conversion to nAMD. Predictors of conversion to iRORA and cRORA included integrity of the external limiting membrane (p = 0.02), the ellipsoid zone (p = 0.01), and the cone outer segment line (p = 0.003) and the presence of intraretinal hyporeflective spaces (p = 0.009), drusen ooze (p = 0.05), and drusen collapse (p = 0.001). OCT features predictive of conversion to nAMD included outer nuclear layer (ONL) loss (p = 0.01), presence of intraretinal (p = 0.001) and subretinal (p = 0.005) hyporeflective spaces, and drusen collapse (p = 0.003). Conclusion Of these multiple factors predictive of progression of neAMD, the OCT feature most strongly correlated to progression to iRORA/cRORA was drusen collapse, and the feature most predictive of conversion to nAMD was the presence of intraretinal hyporeflective spaces.

Objective To validate the newly proposed multimodal-imaging-based classification for central serous chorioretinopathy (CSCR). Methods This was a retrospective study performed in a total of 87 eyes of 44 patients with a diagnosis of CSCR. Multimodal images in the form of auto-fluorescence, fundus fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT) images, of all the patients, were presented to two masked retina specialists. The masked observers graded each eye into simple or complex; primary, recurrent, resolved; and specific features such as foveal involvement, outer retinal atrophy, and choroidal neovascularization (CNV). Interobserver agreement was assessed using Cohen's kappa. In areas of non-consensus, a detailed discussion was carried out with a third independent grader. Results The mean age of the 44 patients (32 males and 12 females) was 49.2±9.3 years. We found a moderate-strong agreement between the two observers in all subclassifications, that included "simple or complex" (kappa value=0.91, 95% CI 0.82-0.99, p0.001); "primary/recurrent/resolved" (kappa value=0.88, 95% CI 0.80-0.96, p0.001) and "foveal involvement" (kappa value=0.89,95%CI 0.8-0.98, p0.001). However, there was less agreement between the two graders with respect to classification of "outer retinal atrophy" (kappa value=0.72, 95%CI 0.57-0.87, p0.001) and "presence/absence of CNV" (kappa value=0.75, 95% CI 0.58-0.92, p0.001). Non-consensus in categorizing "outer retinal atrophy" was seen in eyes with sub-retinal hyper-reflective material (SHRM) and outer nuclear layer (ONL) thinning overlying subretinal fluid, and non-consensus in categorizing "CNV" was seen in eyes with inner choroidal atrophy. Conclusion Our study reports the validity and strong interobserver agreement in several aspects of the multimodal-imaging-based classification. This could support its implementation in clinical practice and pave way for appropriate treatment guidelines.

Age-related macular degeneration (AMD) is one of the most common causes of severe vision loss in the developed world. Advanced forms of AMD are seen in primarily 2 types, exudative AMD involving the presence of choroidal neovascularization and nonexudative or dry AMD with geographic atrophy. For the latter, the combination of vitamins and minerals known as the Age-Related Eye Disease Study-2 formulation has been shown to decrease the rate of progression of nonexudative to exudative AMD, as no other treatments are currently approved for nonexudative AMD. This review will highlight upcoming treatments for nonexudative AMD. Six upcoming agents have shown results at least in the 2A phase. This includes intravitreal agents that are inhibitors of integrin (Risuteganib), intravitreal agents that disrupt the complement pathway (Zimura, APL-2), neuroprotective implants (Brimonidine DDS), a subcutaneous injectable (Elamipretide), and photobiomodulation (Valeda Light Delivery System).

Age-related macular degeneration (AMD) is one of the most common causes of vision loss. Advanced forms of AMD are seen in primarily 2 types—neovascular AMD (nAMD) with the presence of choroid neovascularization and nonneovascular AMD (nnAMD) with geographic atrophy. Although there are 4 anti-vascular endothelial growth factor drugs either widely used or approved for the former, there are no current treatments for the latter. This review will highlight upcoming treatments for AMD currently in clinical trials. For nAMD: Abicipar pegol, an intravitreal anti-vascular endothelial growth factor based on designed ankyrin repeat proteins (DARP) in protein, is currently pending approval. Conbercept and Faricimab, 2 intravitreal anti-growth factors, are currently in phase 3. Nine other upcoming agents have at least produced results in the 2A phase including intravitreal injections (KSI-301, OPT-302, RGX-314, ICON-1, and DE-122), depot (GB-102), drug reservoir (PDS), topical drops (PAN-90806), and oral formulations (AKST4290). We summarize all the newer molecules.

Physicians have to play the role of a team leader and counselor and take written informed consent for high-risk surgeries in many cases. This is the first step toward initiating a mutually trustworthy relationship with the patient and family. The situation is more sensitive when vulnerable patients like small premature babies or the elderly are under consideration. In the event of a death, leadership and processes in place become extremely critical. We share our experience and practice pattern during this process, especially suited to India, but the broad principles would apply to most human situations. Hopefully, some of these can be incorporated into the existing training curriculum for team building and the art of effective physician-patient communication that should be intricately woven into the curriculum for the Science of Ophthalmic care.

Purpose To determine structural predictors of treatment response in neovascular age-related macular degeneration analyzing optical coherence tomography (OCT)-related biomarkers. Methods A retrospective review of patients undergoing treatment for neovascular age-related macular degeneration at a tertiary institute was performed at presentation. High-intensity regimen included eyes on long-term anti-vascular endothelial growth factor treatment with the inability to extend beyond a month without a relapse and needed double the dose of medication (n = 25). Low-intensity regimen had eyes that went into long-term remission after at least three injections and remained dry for more than a year until the last visit (n = 20). Multimodal imaging including fluorescein angiogram, OCT, and comprehensive ocular evaluation were done. Choroidal vascularity index, total choroidal area, luminal area, subfoveal choroidal thickness, choriocapillaris thickness and Haller and Sattler layer thickness were analyzed for statistical significance. Results The groups had no significant difference at baseline in age, gender, incidence of reticular pseudodrusen, polypoidal choroidal vasculopathy feature on OCT, type of choroidal neovascular membrane, and geographic atrophy. Multinomial logistic regression revealed that thicker subfoveal choroidal thickness and larger total choroidal area were the significant predictors of poor response to anti-vascular endothelial growth factor treatment (E = 0.02; P = 0.02; E = 1.82; P = 0.0075). Conclusion Thicker subfoveal choroidal thickness and higher total choroidal area are useful variables to predict a poor treatment response.

Age-related macular degeneration (AMD) is one of the most common causes of severe vision loss in the developed world. Advanced forms of AMD are seen in primarily 2 types, exudative AMD involving the presence of choroidal neovascularization and nonexudative or dry AMD with geographic atrophy. For the latter, the combination of vitamins and minerals known as the Age-Related Eye Disease Study-2 formulation has been shown to decrease the rate of progression of nonexudative to exudative AMD, as no other treatments are currently approved for nonexudative AMD. This review will highlight upcoming treatments for nonexudative AMD. Six upcoming agents have shown results at least in the 2A phase. This includes intravitreal agents that are inhibitors of integrin (Risuteganib), intravitreal agents that disrupt the complement pathway (Zimura, APL-2), neuroprotective implants (Brimonidine DDS), a subcutaneous injectable (Elamipretide), and photobiomodulation (Valeda Light Delivery System).

Purpose To evaluate the follow up and treatment outcome of central serous chorioretinopathy (CSCR) based on the new multimodal imaging-based classification and identify the predictors for anatomic and visual outcome. Methods Retrospective, multicentric study on 95 eyes diagnosed with CSCR and a follow up of at least 12 months were included. Eyes with macular neovascularization, atypical CSCR or any other disease were excluded. Results At the baseline, observation was advised to 70% eyes with simple CSCR whereas photodynamic therapy (PDT) was performed in 49% eyes with complex CSCR. Over the follow up, decrease in CMT was significantly higher in simple CSCR as compared to complex CSCR ( P = 0.008) and the recurrences were significantly more in eyes with lower CMT at baseline ( P = 0.0002). Median time of resolution of SRF was 3 months and 6 months in simple and complex CSCR respectively ( P = 0.09). For the 12 months follow up, the median fluid free period was greater ( P = 0.03) while number of interventions performed was lesser in eyes with simple CSCR as compared to complex CSCR ( P = 0.006). Multiple regression analysis showed baseline best corrected visual acuity (BCVA) and baseline persistent SRF to be significantly predictive of BCVA and persistent SRF at 12 months ( P Conclusions Complex CSCR more often required PDT, was associated with shorter fluid free interval and longer time for SRF resolution. Baseline BCVA and persistent SRF were predictive of final visual and anatomical outcome. The new multimodal imaging based classification is helpful in establishing objective criteria for planning treatment approaches for CSCR.

Purpose Lidocaine gel was suggested to be highly effective in providing anesthesia for intravitreal injections but adverse effects include possibility of making sterilization of the conjunctiva difficult. Hence, we wished to determine the effect of using 0.5% proparacaine drops alone over the use of 3.5% lidocaine hydrochloride gel anesthesia during office based intravitreal injections. Methodology This was a case control study in patients who came routinely to the clinic for anti-vascular endothelial growth factor injections. Eyes were treated with one of two anesthesia modalities. Total of 216 injections in 120 patients were reviewed. One group (N = 107) underwent anesthesia with 0.5% proparacaine drops and the control group (N = 109) received 3.5% lidocaine gel. The pain perceived after injection was graded using the Numerical Rating Scale (NRS) and score immediately recorded by the 'masked' injecting physician. Results The mean pain score (± SD) for the proparacaine-only group vs gel group was 1.97 (± 1.17) vs 1.76 (± 0.92), P value = 0.3174. There was no statistical difference between the two groups. Conclusion 3.5% lidocaine gel is not superior to 0.5% proparacaine drops as patients attained good pain control and excellent rates of overall satisfaction with proparacaine drops alone.

To evaluate natural history of drusen ooze and its role as a predictor for progression of dry age-related macular degeneration (AMD) longitudinally. Multi-centric retrospective observational case series of 72 eyes (72 patients) with dry AMD with a minimum follow-up of 4 years. Drusen types were identified on volume scans on optical coherence tomography (OCT) and were characterized for occurrence of drusen ooze at baseline until last visit. Drusen ooze was defined as hyperreflective dots overlying a collapsing drusen or pseudodrusen, or hyperreflective RPE above drusen or isoreflective dots at the level of outer nuclear layer. The consequent incidence of incomplete retinal pigment epithelium and outer retinal atrophy (iRORA), complete retinal pigment epithelium and outer retinal atrophy (cRORA), and neovascular AMD (nAMD) were evaluated statistically. In total, 72 eyes with a mean follow-up of 68.89 (± 25.57 months) were studied. At presentation, 11 eyes (15.3%) had a single drusen type, whereas 61 eyes (84.7%) had mixed drusen. Reticular pseudodrusen were most common (84.7%) followed by soft drusen (66.6%). Drusen ooze was seen in 47 eyes (65.2%) at presentation. The presence of drusen ooze at baseline (p < 0.01) and baseline best corrected visual acuity (BCVA) (p = 0.04) significantly correlated with development of iRORA and cRORA. In total, 14 eyes progressed from iRORA to cRORA over a mean follow up of 29.14 (± 24.33) months. Odds of progression to iRORA or cRORA were 20.3 times greater for eyes with drusen ooze at baseline (95% C.I., 4.4–94.2). In dry AMD, drusen ooze is a useful sign for predicting progression to iRORA and cRORA over time.

An important goal of advancements in ocular imaging algorithms and devices has been to improve the image acquisition and resolution of deeper ocular tissues, namely the choroid and its vasculature that are otherwise inaccessible to direct clinical examination. These advancements have contributed to the understanding of the pathophysiology of a number of ocular inflammatory conditions. We focus on the imaging characteristics of clinical conditions where imaging the choroid has improved or radically changed the understanding of the disease, has helped in differentiation of phenotypically similar but distinct lesions, and where imaging features have proven vital for monitoring disease activity. The last two decades have seen some major developments in ocular imaging relevant to uveitis. The current review addresses both the imaging characteristics and their interpretation on conventional modalities such as fundus photography, fluorescein angiography, indocyanine green angiography, and fundus autofluorescence and the recent additions in the armamentarium including optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography.

Retinal pseudocysts can be seen overlying geographic atrophy in non-exudative age-related macular degeneration. Central retinal thickness and CVI decreased significantly in both groups. These pseudocysts would not increase the risk of GA progression and CNV.

Background/AimsTo evaluate the ability of optical coherence tomography angiography (OCTA) to identify the presence or absence of choroidal neovascularisation (CNV) and CNV activity in age-related macular degeneration (AMD).MethodsClinical parameters, fundus fluorescein angiogram and spectral-domain optical coherence tomography (SD-OCT) were used as the gold standard to determine disease activity. OCTA imaging was performed on the same day and was graded by two masked retina specialists for the presence or absence of CNV. Traditional multimodal imaging and OCTA findings were compared.ResultsOne hundred and fifty-two eyes of 106 patients with AMD were retrospectively reviewed. Of these, 59 eyes had wet AMD and 93 had dry AMD with high-risk drusen. OCTA had 85.4% and 79.3% specificity and sensitivity, respectively, in determining the presence or absence of CNV. OCTA was 69.5% accurate in determining active CNV. False positives and negatives were 21.6% and 8.0%, respectively.ConclusionsThis study suggests that en-face OCTA images allow a moderate ability to identify CNV and that OCTA alone is weak at recognising active CNV requiring treatment in AMD.

Author(s): Cavichini, Melina; An, Cheolhong; Bartsch, Dirk-Uwe G; Jhingan, Mahima; Amador-Patarroyo, Manuel J; Long, Christopher P; Zhang, Junkang; Wang, Yiqian; Chan, Alison X; Madala, Samantha; Nguyen, Truong; Freeman, William R | Abstract: PurposeThe purpose of this study was to evaluate the ability to align two types of retinal images taken on different platforms; color fundus (CF) photographs and infrared scanning laser ophthalmoscope (IR SLO) images using mathematical warping and artificial intelligence (AI).MethodsWe collected 109 matched pairs of CF and IR SLO images. An AI algorithm utilizing two separate networks was developed. A style transfer network (STN) was used to segment vessel structures. A registration network was used to align the segmented images to each. Neither network used a ground truth dataset. A conventional image warping algorithm was used as a control. Software displayed image pairs as a 5 × 5 checkerboard grid composed of alternating subimages. This technique permitted vessel alignment determination by human observers and 5 masked graders evaluated alignment by the AI and conventional warping in 25 fields for each image.ResultsOur new AI method was superior to conventional warping at generating vessel alignment as judged by masked human graders (P l 0.0001). The average number of good/excellent matches increased from 90.5% to 94.4% with AI method.ConclusionsAI permitted a more accurate overlay of CF and IR SLO images than conventional mathematical warping. This is a first step toward developing an AI that could allow overlay of all types of fundus images by utilizing vascular landmarks.Translational relevanceThe ability to align and overlay imaging data from multiple instruments and manufacturers will permit better analysis of this complex data helping understand disease and predict treatment.

Age-related macular degeneration (AMD) is one of the leading causes of blindness worldwide with increasing prevalence owing to increased life expectancy. Intravitreal injections of antivascular endothelial growth factor agents are commonly used in exudative AMD and oral antioxidant medication for nonexudative AMD; however, many disorders mimic exudative and nonexudative AMD, and misdiagnosis can seriously affect the management of these patients. We summarize the demographics and clinical and imaging characteristics of each of the conditions that masquerade as AMD. As some of the conditions have features of AMD, a short update on the classical features of AMD is also included.

Background The close structural and microcirculatory co-relation between anterior and posterior segments of eye make them very vulnerable to complications when one of them is affected surgically. With the advent of anti-fibrotic agents in the management of glaucoma, the rates of vitreoretinal complications have become more frequent. Main body Common retinal complications after glaucoma surgeries include choroidal detachment; ocular decompression retinopathy; haemorrhagic choroidal detachment; hypotony maculopathy; malignant glaucoma; vitreous haemorrhage; bleb endophthalmitis; retinal detachment. Similarly, intraocular pressure rise is often noted after scleral buckle; pars plana vitrectomy; intravitreal gas injection; silicone oil injection; intravitreal steroid injection. Conclusion The article provides some insight into some of the complications after glaucoma and retina surgeries, including the pathogenetic mechanisms behind each complication and available management options.

Jay Chhablani, Mahima Jhingan, Abhilash Goud, Kiran Kumar Vupparaboina, Taraprasad Das Smt Kanuri Santhamma Retina Vitreous Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India Purpose: This study aimed to evaluate the effect of dexamethasone implantation on the hard exudates (HEX) in patients with diabetic macular edema (DME). Study design: This was a nonrandomized open-label single-center prospective trial. Methods: This study included 15 eyes of 11 subjects with DME. Key inclusion criteria were naïve eyes with DME with HEX within 3mm of fovea with center-involving DME; central macular thickness (CMT) >250µm at baseline; best-corrected visual acuity (BCVA) between 20/400 and 20/40. Key exclusion criteria were previous intraocular surgery and history of panretinal photocoagulation (PRP) in past 4months. The primary outcome measure was change in total HEX area at the macula (in mm2) measured by semiautomated algorithm. Secondary outcome measures were change in visual acuity, low-contrast visual acuity (LCVA), retinal sensitivity (RS) on macular microperimetry, and CMT. Results: The total HEX area reduced from 1.5 mm2 (±1.46 mm2) at baseline to 0.89 mm2 (±1.062 mm2) at the final visit (p=0.185). The CMT improved significantly (p=0.03) from 488.67µm (±240.66µm) to 326.93 µm (±135.84µm) at the final visit. Mean BCVA remained stable (p=0.95) (50.93±16.65 at baseline and 50.6±18.95 at final visit). The mean LCVA and RS showed insignificant improvement (p=0.31 and p=0.28, respectively). Conclusion: Our pilot study demonstrated an improving trend in reduction of total HEX area and other anatomical outcomes, with limited functional outcomes. Larger randomized studies with a larger sample size with a control group are warranted to establish management protocols for DME with significant subfoveal HEX. Keywords: dexamethasone implant, Ozurdex, hard exudates, diabetic macular edema

Aim To present the microbiological details and clinical outcomes of Acinetobacter spp. endophthalmitis with the first reported case of A. haemolyticus. Methods A retrospective study of microbiologically proven Acinetobacter spp. endophthalmitis was carried out from 2010 to 2015. The data collected included age, type of endophthalmitis, best-corrected visual acuity (BCVA), species involved, and antibiotic susceptibility pattern. The primary outcomes measured were anatomical outcomes in terms of globe integrity and functional outcome as BCVA at last follow-up. Results Eleven patients out of 3004 patients who underwent surgery for endophthalmitis were due to Acinetobacter spp. Seven cases (63.6%) were both smear and culture positive; there were two cases (18%) each of A. haemolyticus and A. baumanii. Four cases (36%) were only culture positive with negative smear. Three cases (27.2%) were polymicrobial. Ten cases (91%) were susceptible to amikacin and nine (82%) to ciprofloxacin. Six (54.5%) were resistant to ceftazidime. Mean logMAR BCVA improved to 1.8 (20/1330) from an initial 2.5 (20/6839). Pthisis bulbi was seen in two cases (18%). Conclusions Even though the outcomes of Acinetobacter spp. endophthalmitis are modest to poor, outcomes following intervention are relatively good for A. haemolyticus. These cases have good susceptibility to amikacin, but are often resistant to ceftazidime.

Mahima Jhingan,1 Abhilash Goud,1 Hari Kumar Peguda,1 Mitali Khodani,1 Jeffrey K Luttrull,2 Jay Chhablani1 1L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India; 2Ventura County Retina Vitreous Medical Group, CA, USA Aim: To compare the outcomes of subthreshold microsecond (STM) and continuous-wave laser (CWL) panretinal photocoagulation (PRP).Methods: In this randomized, prospective, pilot study, 20 eyes of 10 subjects with symmetric severe non-proliferative (NPDR) or low-risk proliferative diabetic retinopathy (PDR) were included. Each eye of the subject was randomized into either CWL or STM PRP group. Patients were evaluated at baseline and at months 3, 6, and 9 with color fundus photographs and visual field tests at each visit; however, electroretinography (ERG) was conducted at baseline and at month 9. The primary outcome measure was the difference in disease progression between the groups. Secondary outcome measures included change in visual acuity, contrast visual acuity, retinal sensitivity on visual field test, and change in ERG parameters.Results: During the 9-month follow-up, one eye of the STM group progressed to vitreous hemorrhage at the month 6 follow-up and required rescue conventional laser. The CWL group showed a drop in low-contrast visual acuity, visual field index, and scotopic b/a ratio in comparison to the STM group, although the difference was statistically insignificant (p>0.05).Conclusion: This prospective pilot study proposes microsecond PRP is non-inferior to CWL PRP and could be an alternative to CWL PRP to avoid associated complications in cases of severe NPDR and early PDR. Keywords: panretinal photocoagulation, diabetic retinopathy, proliferative diabetic retinopathy, micropulse laser, microsecond laser&nbsp