We report clinical and imaging features of Valsalva-induced choroidal hemorrhage (VICH) in high myopia, highlighting choroidal venous congestion, and hyperpermeability in dominant vortex vein systems, and luminal compression at the crest of deep myopic staphylomas.
Objective: To describe the sequential morphological changes of the outer retina after full-thickness macular hole formation, utilizing a novel, objective staging system based on optical coherence tomography (OCT), and to determine its association with baseline visual acuity, duration of symptoms, and postoperative visual acuity at 3 months.
Design: Retrospective, observational, multicenter study.
Participants: Patients with idiopathic full-thickness macular hole (FTMH) presenting to St. Michael's Hospital, Toronto, Canada, and Retina Consultants of Texas, Houston, USA, from 2009-2022.
Methods: The medical charts of 1000 patients with FTMH were reviewed and those with at least two preoperative SD-OCTs were analyzed. A staging system was developed by assessing outer retinal morphology on successive SD-OCT central foveal scans.
Main outcome measures: Sequential outer retinal morphological changes with SD-OCT over time and their association with baseline visual acuity, duration of symptoms, and postoperative functional outcomes.
Results: Fifty-two eyes of 52 patients with a mean age of 65.4 ±8.4 years were included. Sequential outer retinal morphologic changes at the FTMH borders occurred in 4 distinct and reproducible stages as follows: Stage A: separation of the neurosensory retina from the RPE with the well-defined external limiting membrane (ELM), ellipsoid zone (EZ) and interdigitation zone (IDZ) (4/52, 7.6%); Stage B: thickening of EZ (27/52, 51.9%); Stage C: patchy (moth-eaten) photoreceptor loss (16/52, 30.7%) and Stage D: severe or complete loss of ISs and OSs and/or bare ELM (5/52, 9.6%). When assessing the preoperative OCT scans closest to the time of surgery, over a mean follow-up period of 288.9 days (SD 350.4,[5 -1841]), 28.8%(15/52 ) of eyes were in Stage B, 28.8% (15/52) were in Stage C and 42.3 %(22/52 ) were in Stage D. There was a statistically significant association between increasing stage at baseline and longer duration of macular hole symptoms (p=0.032) and worse visual acuity at baseline (p<0.001). Additionally, patients presenting with Stages B and C at the time point closest to surgery had better visual acuity outcomes three months postoperatively compared to those with Stage D(P=0.04).
Conclusions: This SD-OCT staging system describes the sequential in vivo morphologic changes after FTMH formation providing a novel imaging biomarker.
Purpose: To test the diagnostic performance of an artificial intelligence algorithm for detecting and segmenting macular neovascularization (MNV) with optical coherence tomography (OCT) and OCT angiography(OCTA) in eyes with macular edema from various diagnoses.
Design: Prospective cross-sectional study.
Participants: Study participants with macular edema due to either treatment-naïve exudative age-related macular degeneration (AMD), diabetic macular edema (DME), or retinal vein occlusion (RVO).
Methods: Study participants were imaged with macular 3x3-mm and 6x6-mm spectral-domain OCTA. Eyes with exudative AMD were required to have MNV in the central 3x3-mm area. A previously developed hybrid multi-task convolutional neural network for MNV detection (aiMNV) and segmentation was applied to all images, regardless of image quality.
Main outcome measures: Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of detecting MNV; and intersection over union(IoU) score and F1 score for segmentation.
Results: Of 114 eyes from 112 study participants, 56 eyes had MNV due to exudative AMD and 58 eyes with macular edema due to either DME or RVO. 3x3-mm OCTA scans with aiMNV detected MNV with 96.4% sensitivity, 98.3% specificity, 98.2% PPV, and 96.6% NPV. For segmentation, the average IoU score was 0.947 and the F1 score was 0.973. 6x6-mm scans performed well; however, sensitivity for MNV detection was lower than 3x3-mm scans due to lower scan sampling density.
Conclusion: This novel aiMNV algorithm can accurately detect and segment MNV in eyes with exudative AMD from a control group of eyes that present with macular edema from either DME or RVO. Higher scan sampling density improved the aiMNV sensitivity for MNV detection.
Purpose: To determine proportion of eyes with neovascular age-related macular degeneration (nAMD) with retinal fluid and/or central subfield thickness (CST) fluctuations and evaluate their impact on best-corrected visual acuity (BCVA) in eyes treated with the Port Delivery System with ranibizumab (PDS) versus monthly intravitreal ranibizumab injections.
Design: Post-hoc analyses of phase 3 Archway trial (NCT03677934).
Participants: Adults with nAMD responsive to anti-vascular endothelial growth factor therapy.
Intervention: 418 patients randomized 3:2 to the PDS (100 mg/mL) with refill-exchanges every 24 weeks (Q24W) or monthly intravitreal ranibizumab (0.5 mg) for 96 weeks.
Outcomes: Proportion of eyes in each treatment arm with subretinal and/or intraretinal fluid (SRF/IRF) overall and in central 1-mm; BCVA changes from baseline by treatment arm and fluid presence/location; proportion of eyes with CST fluctuations from baseline to week 48, week 48 to 96, and baseline to week 96; effects of CST fluctuations on BCVA.
Results: 415 eyes were assessed. In the PDS versus monthly ranibizumab arm, proportion of eyes with SRF/IRF, central SRF, and central IRF were 47.6% versus 50.9%, 29.0% versus 19.2%, and 11.7% versus 12.6% at baseline, and 57.8% versus 56.1%, 21.6% versus 14.8%, and 7.0% versus 8.4% at week 96. BCVA changes from baseline to week 96 were -1.1 letters with the PDS versus -1.4 with monthly ranibizumab in eyes with SRF/IRF, and -1.9 versus -1.8 in eyes with central SRF. In eyes with central IRF, BCVA changes from baseline to week 96 were -2.1 with the PDS versus -6.9 with monthly ranibizumab, respectively (mean BCVA at 96 weeks 68.9 [20/40] versus 64.6 [20/50]). CST fluctuations occurred in 32.1% and 29.7% of PDS versus monthly ranibizumab eyes; corresponding BCVA changes from baseline to week 96 were -2.5 versus -2.6 (mean BCVA at 96 weeks 72.7 [20/35] versus 71.5 [20/38]).
Conclusions: PDS Q24W maintained BCVA to 96 weeks regardless of SRF/IRF, central SRF, central IRF, or CST fluctuations, comparable with monthly ranibizumab, thus supporting the use of the PDS in stabilizing retinal anatomy without the need for monthly treatment in patients with nAMD.
Objectives: To profile a cohort of gyrate atrophy patients classified by widefield retinal imaging and correlate the structural, biochemical, and functional characteristics.
Design: Retrospective observational cohort study.
Participants: Sixty-five patients (129 eyes) with gyrate atrophy.
Methods: Data of participants with a diagnosis of gyrate atrophy were retrieved from their electronic medical records (January 2015 to December 2023). Retinal involvement was classified into three zones using widefield retinal images. Zone 3 had atrophic patches in the area anterior to the equator; Zone 2 had involvement limited to the arcades but posterior to the equator; Zone 1 had involvement within the vascular arcades and/or peripapillary region, with or without any other zone involvement. Macular assessment was performed using swept-source OCT (n=104). Flash ERG was performed in 40 eyes. serum ornithine levels (n=35) were measured, and genetic analysis was conducted (n=18).
Main outcome measures: Demography, patient profile, zone of retina involved, macular features, and serum ornithine levels.
Results: The average age at presentation was 26.4 (range: 5-67) years, majority were male. Nyctalopia (n=35, 53.8%) and blurred vision (n=29, 44.6%) were the most common symptoms. Positive family history was reported in 32.3% of patients. Most eyes were myopic (69.8%<-3 D). Posterior subcapsular cataracts were documented in 36.4% of eyes. The highest frequency of retinal area affected was Zone 1 (57.14%), followed by Zone 2 (33.33%) and Zone 3 (9.52%), correlating with age at presentation. Foveoschisis was observed in 57.7% of eyes, with a higher prevalence in eyes with Zone 1 disease. Elevated serum ornithine levels (>163 μmol/L) were found in 77.14% of patients. ERG showed non-recordable (n=32) or severely reduced (n=8) responses in scotopic and photopic phases. Genetic analysis of 18 patients identified mutations in the OAT gene, including a novel missense variant (c.290T>C).
Conclusions: This large cohort of patients with gyrate atrophy revealed symmetrical involvement, predominantly in Zone 1. Most patients presented between the first and third decades, experienced nyctalopia, vision reduction, early posterior subcapsular cataracts, and varying degrees of myopia. Zone 1 involvement was strongly associated with foveoschisis and visual compromise.
Purpose: To investigate the risk of retinal vascular occlusion in patients with Moyamoya disease (MMD).
Design: Retrospective, longitudinal cohort study using the Korean National Health Insurance Service database.
Participants: Newly diagnosed MMD patients (n=34,627), who were diagnosed between 2004 and 2022, and their propensity score matched controls (n=136,945) were included.
Methods: We identified retinal vascular occlusion events using diagnostic codes for central retinal artery occlusion, other retinal artery occlusion, and retinal vein occlusion. After a washout-period from 2002 to 2003, information on the diagnosis of retinal vascular occlusion was extracted in both MMD and control group during the follow up period. The association between MMD and the risk of subsequent retinal vascular occlusion was investigated using a time-dependent Cox proportional hazard model and Kaplan-Meier survival analysis with log-rank test adjusted for age, sex, and comorbidities.
Main outcome measures: Hazard ratios (HRs) and 95% confidence intervals (CIs) for retinal vascular occlusion development according to the MMD.
Results: MMD was associated with an increased risk of subsequent retinal vascular occlusion even after adjusting for confounding variables (HR, 1.22; 95% CI, 1.09-1.36). Among the subtypes of retinal vascular occlusion, central retinal artery occlusion showed a highest HR (2.23; 95% CI, 1.35-3.7). Incidence probability of retinal vascular occlusion was significantly higher among MMD patients than controls (P < 0.001, log-rank test).
Conclusion: In this nationwide population-based cohort study, patients with MMD in Korea had an elevated risk of retinal vascular occlusion, suggesting that the MMD is one of the risk factors for retinal vascular occlusion.
Objective or purpose: To evaluate the association between neighborhood socioeconomic deprivation, distance from ophthalmology clinics, and diagnosis of proliferative diabetic retinopathy (PDR).
Design: Retrospective cohort study.
Subjects, participants, and/or controls: Adult patients (≥18 years) with diabetes mellitus at Johns Hopkins Hospital and University of Wisconsin-Madison.
Methods, intervention, or testing: Patient addresses were geocoded and the block group was linked to the 2021 national Area Deprivation Index (ADI). ADI was divided into quartiles, with higher quartiles indicating greater socioeconomic disadvantage. The distance between patient's residence and ophthalmology clinics was calculated. Multivariable logistic regression models were used to analyze the association between ADI quartile, distance from clinic, and PDR, adjusted for demographics and insurance status. The interaction between ADI and distance was tested.
Main outcome measures: Diagnosis of PDR.
Results: 73,618 patients were included. A significant interaction was observed between ADI quartile and distance from ophthalmology clinics (P < .001). Among patients residing within 8 miles of clinics, those in higher ADI quartiles had increased odds of PDR compared to those in ADI Q1 (Q2: OR 1.36, 95% CI 1.12-1.65; Q3: OR 1.79, 95% CI 1.46-2.19; Q4: OR 2.60, 95% CI 2.09-3.25; P<.001 for trend). Conversely, for patients living more than 8 miles from clinics, the odds of PDR were similar across ADI quartiles (Q1: OR 0.85, 95% CI 0.73-0.98; Q2: OR 1.02, 95% CI 0.87-1.12; Q3: OR 1.08, 95% CI 0.90-1.30). However, patients in all ADI quartiles more than 8 miles had greater odds of PDR compared to those in the same ADI quartile within 8 miles (OR 3.15, 95% CI 2.61-3.80, OR 1.97, 95% CI 1.71-2.27, OR 1.79, 95% CI 1.51-2.12, and OR 1.31, 95% CI 1.07-1.61 in ADI Q1 to Q4 respectively).
Conclusions: Patients living in neighborhoods with greater socioeconomic disadvantage and further from ophthalmology clinics have greater odds of PDR. These findings suggest the potential utility of targeted interventions in socioeconomically deprived and distant areas to reduce PDR-related blindness.
Objective: To utilize a modified intravitreal (IVT) methotrexate (MTX) protocol for the prevention of proliferative vitreoretinopathy (PVR) after silicone oil (SO) removal (SOR).
Design: Single-center nonrandomized retrospective comparative case series.
Subjects: Eyes with grade C PVR who underwent retinal detachment repair and SO placement between 2019-2022 with at least 6 months of follow-up after SOR. A control group of age- and sex-matched eyes was included.
Methods: Eyes were treated with one of two MTX protocols. Eyes in Group 1 received 6 IVT MTX injections following SO placement, and another 6 IVT MTX injections following SOR. Eyes in Group 2 received 6 IVT MTX following SO placement only. Each series of 6 IVT MTX injections (400 μg/0.1 mL) consisted of 3 injections every 2 weeks followed by 3 injections every 4 weeks.
Main outcome measures: The primary outcome was the retinal attachment rate at 6 months post-SOR without re-detachment or re-operation. Secondary outcomes included change in visual acuity (VA) and rates of complications after SOR.
Results: Fifty-two eyes of 52 patients (13 Group 1, 13 Group 2, 26 control) (mean age 59.8 years, 80.8% male) were included with a mean follow-up of 31.0 months. In aggregate, Group 1 and Group 2 eyes received a median (IQR) of 6 (5.25, 7) IVT MTX injections pre-SOR; eyes in Group 1 received a median (IQR) of 5 (3, 6) IVT MTX injections post-SOR. Twelve (92.3%) Group 1 eyes, 11 (84.6%) Group 2 eyes, and 21 (80.8%) control eyes had primary retinal attachment at 6 months post-SOR (P > 0.05). VA outcomes did not significantly differ between groups (P > 0.05). Rates of epiretinal membrane (ERM) and cystoid macular edema (CME) were significantly lower in Group 1 eyes (7.7% and 15.4%) compared to Group 2 (53.8% and 92.3%) and control (44.3% and 65.4%) eyes, respectively (P < 0.05).
Conclusions: The use of IVT MTX injections in eyes with PVR undergoing RD repair was associated with a high rate of primary retinal attachment after SOR. Eyes that received IVT MTX injections after SOR had significantly lower rates of ERM and CME than eyes that did not.
We report changes in DR severity over time from the PANORAMA study of aflibercept versus sham in patients with moderately severe/severe NPDR that can help physicians and patients make informed management decisions for optimal outcomes.
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