Journal of VitreoRetinal Diseases最新文献

Purpose: To evaluate the association between central subfield thickness (CST) fluctuations and visual acuity (VA) outcomes in eyes with diabetic macular edema (DME) undergoing antivascular endothelial growth factor (anti-VEGF) therapy. Methods: We conducted a retrospective review of patients with DME who initiated treatment between 2016 and 2017 at a multicenter retina practice. Eligible eyes had a follow-up period of 40 weeks or longer and received 3 or more anti-VEGF injections. CST fluctuations were determined using the SD of CST measurements across visits and stratified into quartiles. Stepwise linear regression analysis determined the impact of factors on best-corrected VA (BCVA). Results: A total of 499 eyes from 333 subjects were included. Eyes received a mean of 15.7 anti-VEGF injections (range, 3-50) over 18.8 visits (range, 3-67) across a mean of 121.3 weeks (range, 40.6-230.3). Mean (± SD) CST at DME diagnosis and at the final visit was 353.7 ± 134.8 µm and 287.2 ± 78.9 µm, respectively; mean change was 42.4 ± 47.3 µm. Eyes with the greatest CST fluctuations had worse baseline and final VA, as well as baseline and final CST (P < .0001). Each 100 μm increase in CST SD was independently associated with 12.9 fewer letters read at 121.3 weeks. Factors independently associated with better final VA were smaller CST SD, smaller final CST, a greater number of anti-VEGF injections, and younger age. Conclusions: Consistent with previous analyses, increased CST fluctuation was independently associated with worse final BCVA. Large CST fluctuations may serve as a poor prognosticator for visual outcomes among patients with DME.

Purpose: To describe a novel surgical approach for eyes with persistent macular edema (ME) complicated by intracystic hyperreflective material. Methods: Pars plana vitrectomy and dye-assisted internal limiting membrane (ILM) peeling were performed in cases with chronic and/or refractory intracystic hyperreflective material. Microscope-integrated optical coherence tomography (OCT) was used to localize cysts and intracystic hyperreflective material, perform cyst puncture, and monitor cyst collapse. Functional and structural outcomes were assessed longitudinally over a minimum follow-up of 3 months. Results: Decimal visual acuity improved from a median of 0.28 (20/71.4) to 0.50 (20/40) over a median follow-up of 6 months. No patient required repeat intravitreal injection or experienced recurrence of intracystic hyperreflective material. Conclusions: ILM peeling combined with integrated OCT-guided cyst puncture may improve outcomes and reduce treatment burden in eyes with persistent ME and intracystic hyperreflective material. Additional controlled studies are needed to establish the broader utility of this technique.

Purpose: To use time-driven activity-based costing to calculate the complete cost profile of new uveitis patient visits. Methods: A multicenter cohort of consecutive patients referred for new uveitis evaluation, including all anatomic locations of uveitis, was included for economic analysis. Process flow mapping, electronic health record time logs, and manual validation were used for time-driven activity-based costing analysis. Imaging time and resources, which are billed separately, were excluded. Results: Time-driven activity-based costing analysis of new uveitis patient visits resulted in an average total cost of $550.50 per visit, including $56.78 of overhead (95% CI, $493.74 to $607.27). On average, patient visits required 36.6 minutes of physician time pre-visit, 30.1 minutes during the visit, and 31.7 minutes post-visit. Relative to Medicare reimbursement, the average cost resulted in losses of $325.78 for Current Procedural Terminology (CPT) code 99205 and $380.16 for CPT code 99204. The G2211 add-on CPT code compensated for 3.23 minutes of in-visit physician time. Conclusions: The cost of new uveitis patient visits exceeds maximum Medicare reimbursement in both academic and private practice settings. These findings may inform policy discussions on reimbursement to better reflect the time and expertise required for complex uveitis patient evaluation and management.

Purpose: To better understand patient experiences associated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection techniques. Methods: A total of 1111 patients receiving anti-VEGF injections at 5 Retina Consultants of Texas clinic locations completed surveys about their experiences during and after injection. Responses were compared using t-test, analysis of variance, and Tukey-Kramer test. Results: Patients rated overall discomfort with injection techniques as a mean visual analog scale score < 2 (scale 1-10, ranging from mild to worst possible). Techniques for anesthetization, lid retraction, and povidone-iodine (Betadine) application varied. Lidocaine pledgets were associated with the most discomfort (P < .05). Patient preference was significantly higher for manual lid retraction over speculum use (P = .0017). Betadine-soaked cotton tips were considered significantly more comfortable than Betadine drops, and drops more comfortable than Betadine swabs (each P < .05). Regarding side effects ever experienced after injection, subconjunctival hemorrhages were reported by 64.0% of participants (n = 702), floaters by 64.4% (n = 685), and eye irritation by 51.1% (n = 530), resolving within 2 days for 37.9% (n = 215), 51.1% (n = 334), and 48.6% (n = 254), respectively. Of returning participants, 41.1% found injections administered by physicians on the survey day more comfortable than injections administered by previous physicians. Common complaints included inadequate anesthesia and irritation from Betadine. Conclusions: Most patients tolerate anti-VEGF injections well, with minimal side effects. Surveyed patients preferred topical gel or subconjunctival injections, manual lid retraction, and Betadine-soaked cotton tips. Future studies may consider the safety associated with each technique.

Purpose: This retrospective case report describes the diagnosis, treatment, and clinical outcome of subacute Terson syndrome in a patient with monocular vision following craniofacial ballistic injury. Methods: A single case and its findings were analyzed. Results: A 26-year-old man presented to the retina clinic 5 weeks after a gunshot injury to the right craniofacial region. At presentation, the patient, who was rendered monocular from the gunshot injury, reported experiencing vision loss in the uninjured left eye during the postacute period. Dilated examination of the left eye revealed hand motion visual acuity with dense vitreous hemorrhage. A 25-gauge pars plana vitrectomy of the left eye was performed, during which multiple sub-internal limiting membrane hemorrhages characteristic of Terson syndrome were discovered and evacuated. Visual acuity was restored to 20/25 by postoperative week 2. Conclusions: The excellent visual outcome achieved by vitrectomy within 1 week of presentation demonstrates the importance of (1) retaining Terson syndrome in the differential diagnosis for patients with vision loss after nonaneurysmal central nervous system injury, and (2) expediting surgical intervention, particularly in patients with monocular vision.

Purpose: To describe a case of severe scleritis with uveitis as the initial presentation of underlying eosinophilic granulomatosis with polyangiitis. Methods: Case report from a university ophthalmology clinic describing ocular findings, diagnostic workup, and treatment for a 75-year-old woman presenting with severe anterior scleritis and panuveitis. Results: The patient was initially misdiagnosed and treated for presumed infectious scleritis for 1 month without improvement. Further workup revealed elevated perinuclear anti-neutrophil cytoplasmic antibodies, supporting a diagnosis of eosinophilic granulomatosis with polyangiitis. Prompt initiation of high-dose oral corticosteroids led to rapid resolution of ocular inflammation. Conclusions: Severe scleritis with uveitis can be the first manifestation of occult eosinophilic granulomatosis with polyangiitis. A high index of suspicion for underlying autoimmune disease and timely rheumatologic workup are essential for accurate diagnosis. Early systemic immunosuppressive therapy is critical to optimize visual outcomes and prevent irreversible ocular damage.

Purpose: To describe an atypical phenotype of retinal dystrophy in the setting of a heterozygous missense mutation (CRX-RD). Methods: The case is a 71-year-old woman previously diagnosed with advanced, non-neovascular, nonexudative age-related macular degeneration (AMD) who presented with longstanding blurry vision for consideration of intravitreal anti-complement factor therapy. Results: Ophthalmic examination showed geographic atrophy (GA) in both eyes, without evidence of drusen or drusenoid deposits. Genetic panel testing revealed a pathogenic, heterozygous missense mutation in CRX, the NM_000554.6(CRX) variant c.128G>A (p.Arg43His) (RCV001228802.6). Although CRX-RD is known to have phenotypic heterogeneity, cases with macular atrophy most commonly display bullseye maculopathy or benign concentric annular macular dystrophy. Conclusions: This case presenting with bilateral GA is consistent with a novel phenotype associated with a pathogenic variant of CRX and is an atypical presentation of RD simulating AMD.

Purpose: To characterize real-world use of intravitreal aflibercept 8 mg across 22 US retina practices. Methods: Retrospective review of patients who received at least 1 intravitreal aflibercept 8 mg injection for treatment of neovascular age-related macular degeneration, diabetic macular edema, or diabetic retinopathy through April 1, 2024. Data from health records were collected retrospectively, including best-corrected visual acuity (BCVA), interval between treatments, and adverse events. Results: A total of 8323 eyes of 6271 patients received 20 385 intravitreal aflibercept 8 mg injections. A total of 669 eyes (8.0%) were not previously treated. Among treatment-naive eyes, mean logMAR BCVA improved from 0.57 (Snellen equivalent ~20/80) at the time of the first intravitreal aflibercept 8 mg injection, to 0.47 (Snellen equivalent ~20/60) (P < .001), 0.46 (Snellen equivalent ~20/60) (P < .001), and 0.48 (Snellen equivalent ~20/60) (P = .012) at the second, third, and fourth intravitreal aflibercept 8 mg injections, respectively. Among previously treated eyes, mean logMAR BCVA improved from 0.46 (Snellen equivalent ~20/60) at the time of the first intravitreal aflibercept 8 mg injection, to 0.42 (Snellen equivalent ~20/50) (P < .001), 0.43 (Snellen equivalent ~20/50) (P < .001), and 0.45 (Snellen equivalent ~20/60) (P = .70) at the second, third, and fourth intravitreal aflibercept 8 mg injections, respectively. Treatment intervals to time of second, third, and fourth intravitreal aflibercept 8 mg injections increased compared to baseline intervals, by a mean of 2.2 days (P < .001), 2.5 days (P < .001), and 13.5 days (P < .001), respectively. Intraocular inflammation was observed in 11 eyes (1 in 1853 injections). Nine eyes (1 in 2265 injections) developed suspected endophthalmitis. Conclusions: In this real-world clinical setting, intravitreal aflibercept 8 mg treatment demonstrated improvements in BCVA outcomes, with increased intervals between injections. Rates of intraocular inflammation and endophthalmitis were low.

Purpose: To evaluate the efficacy of intravitreal (IVT) pegcetacoplan monthly vs avacincaptad pegol monthly (primary analysis), and pegcetacoplan every other month vs avacincaptad pegol monthly (secondary analysis), for geographic atrophy (GA). Methods: Matching-adjusted indirect comparisons (MAIC) were conducted across global phase 3 trials using individual patient data from 2 pegcetacoplan trials (OAKS, NCT03525613; DERBY, NCT03525600) and published aggregate data from the avacincaptad pegol GATHER2 trial (NCT04435366). GATHER2 inclusion and exclusion criteria were applied to the OAKS and DERBY individual patient data. Key baseline variables were balanced using propensity score weighting. GA lesion growth at month 12 was assessed. Results from the MAIC were combined using meta-analysis. Results: The primary analysis included 103 patients from OAKS and 102 patients from DERBY who met the GATHER2 inclusion and exclusion criteria, and 447 patients from GATHER2. In OAKS vs GATHER2, the adjusted difference in GA lesion growth at month 12 between pegcetacoplan monthly and avacincaptad pegol was -0.716 mm² (95% CI, -1.385 to -0.046; P = .04), statistically favoring pegcetacoplan monthly. In DERBY vs GATHER2, the adjusted difference was -0.234 mm² (95% CI, -1.354 to 0.885; P = .68), directionally favoring pegcetacoplan monthly. After meta-analysis, the pooled effect for pegcetacoplan monthly vs avacincaptad pegol was -0.589 mm² (95% CI, -1.164 to -0.014; P = 0.04), statistically favoring pegcetacoplan monthly. A numerically greater reduction in GA lesion growth was observed with pegcetacoplan every other month vs avacincaptad pegol monthly (95% CI, -1.130 to -0.300; P = .25). Conclusions: Matching-adjusted indirect comparisons support a greater reduction in GA growth with pegcetacoplan monthly vs avacincaptad pegol monthly and no significant difference between pegcetacoplan every other month and avacincaptad pegol monthly.

Purpose: Neurofibromatosis type 1 (NF1) is a multisystem neurocutaneous syndrome that includes ocular manifestations. This systematic literature review aimed to examine evidence of an association between NF1 and retinal detachment (RD). Methods: Ovid MEDLINE, EMBASE, and PubMed were searched from database inception to February 2024 for reports of RD related to NF1. An additional case of spontaneous RD in a young patient with NF1 is reported. Results: In total, 27 reported cases of NF1-associated RD were identified, of which 14 were associated with intraocular or intraorbital space-occupying lesions. Lesion-associated RDs were exudative and presented in patients at a median age of 19.6 years (range 10 to 36 years). The remaining 13 cases, and the novel case reported herein of a patient with RD secondary to a giant retinal tear, were spontaneous rhegmatogenous RD, presenting in patients at a median age of 19.1 years (range 22 months to 49 years). The most common presentation of spontaneous RD was an asymptomatic finding on routine exam (55% of reported cases). Conclusions: NF1 may increase the risk of RD through 2 mechanisms: exudation caused by space-occupying intraorbital lesions, or rhegmatogenous RD resulting from irregularities in vitreoretinal adhesion due to abnormal collagen production. While further evidence is needed, extended ocular screening of patients with NF1 into adulthood may be considered.