Treatment Algorithm in Proliferative Diabetic Retinopathy - From Protocols to the Real World

Diabetes mellitus is a global epidemic that leads to multiple macrovascular and microvascular complications. The complex interrelated pathophysiological mechanisms triggered by hyperglycemia underlie the development of diabetic retinopathy (DR). Proliferative diabetic retinopathy (PDR) is a microvascular complication, considered the main cause of irreversible blindness in patients of productive age in the world. On the other hand, diabetic macular edema (DME) remains the clinical feature most closely associated with vision loss. In general, both manifestations are due to an increase in inflammatory factors, such as specific pro-inflammatory prostaglandins, interleukins and angiogenic substances including vascular endothelial growth factor (VEGF). Laser photocoagulation and VEGF inhibitors have been shown to be effective in the treatment of PDR and DME. Currently, randomized protocols suggest that VEGF inhibitors therapy could displace laser photocoagulation in the treatment of PDR with and without the presence of DME. The ongoing discussion still prevails about the different treatment modalities for both retinal manifestations in real-world settings

Pharmaceutics

The purpose of this study is to evaluate the visual acuity (VA) gain profiles between patients with drug-naive diabetic macular edema (DME) treated by dexamethasone implant (DEX-implant) and assess the baseline anatomical and functional factors that could influence the response to the treatment in real-life conditions. A retrospective, multi-center observational study included 129 eyes with drug-naive DME treated by DEX-implant. The Median follow-up was 13 months. Two groups of VA gain trajectories were identified-Group A, with 71% (n = 96) of patients whose average VA gain was less than five letters and Group B, with 29% (n = 33) of patients with an average gain of 20 letters. The probability of belonging to Group B was significantly higher in patients with baseline VA \textbackslashtextless 37 letters (p = 0.001). Ellipsoid zone alterations (EZAs) or disorganization of retinal inner layers (DRILs) were associated with a lower final VA (53.0 letters versus 66.4, p = 0.002) but without a significant difference in VA gain (4.9 letters versus 6.8, p = 0.582). Despite a low baseline VA, this subgroup of patients tends to have greater visual gain, encouraging treatment with DEX-implant in such advanced-stage disease. However, some baseline anatomic parameters, such as the presence of EZAs or DRILs, negatively influenced final vision

Scleral buckling surgery using multiple radial buckles: A valid option?

Purpose: To determine whether radial buckling surgery using two or more radial buckles with or without circumferential silicone tires is still a treatment option for rhegmatogenous retinal detachment (RRD) in the current scenario. Methods: Retrospective chart review. Patients with RRD with two or more horse-shoe tears with/without proliferative vitreoretinopathy up to grade C1 who underwent buckling surgery using at least two radial buckle segments without encircling bands or drainage and with at least a 3 year follow up were included in the study. Data collected included demographics, corrected distance visual acuity (CDVA) at baseline and final follow up, details of the examination, surgical procedure(s) and complications noted, if any. Appropriate statistical analysis was done. Statistical significance was set at p < 0.05. Outcome measures: Proportion of patients who had an attached retina at final follow up, improvement in CDVA and complications. Results: 25 patients (25 eyes; 12 males and 13 females; 9 pseudophakic) were included. Median age: 35.15 ± 8.32 years. Median baseline CDVA: 1.97 ± 1.12 logMAR. Median final CDVA: 0.65 ± 0.37 logMAR (significant improvement). Most common presenting complaint was decreased vision (87.5%). Number of radial buckle segments placed varied between 2 and 4 per eye. One patient required vitrectomy for persistent retinal detachment. One required buckle removal for infection 5 years after the primary procedure. One patient required strabismus surgery. Median follow up: 12.25 years ± 2.14 years. None of the other patients had any complications. Conclusion: Radial buckling surgery (two or more segments) is a reasonably safe and valid alternative to vitrectomy for RDs with multiple breaks in different planes. Keywords: Radial buckle, Scleral buckling, Rhegmatogenous retinal detachmen

Minimal surgery for tractional retinal detachment secondary to branch retinal vein occlusion: a case report

Abstract Background Tractional retinal detachment secondary to retinal vein occlusion is a complex entity that can be extremely difficult to manage due to an intricate association of the retinal tissue with the fibrovascular proliferation, making vitreous dissection an extraordinarily difficult procedure. Minimal surgery without endo-tamponade can reduce recovery time and avoid complications of surgery, which in some cases can lead to blindness and even phthisis. Case presentation A 64-year-old Indian woman presented with progressive worsening of vision (right eye) due to fovea involving tractional retinal detachment secondary to supero-temporal branch retinal vein occlusion. After anterior, core and peripheral vitrectomy, the epicenter of the fibrous bridge causing foveal split was identified and released. The corrected distance visual acuity improved from 6/60 pre-operatively to 6/12 post-operatively. At the 5-year follow-up, the patient remains stable both anatomically and visually. Conclusions This case illustrates how careful identification of the epicenter of traction helps maximize visual gain in patients with minimal risk of iatrogenic retinal tears and eliminates the need for endo-tamponade with either gas or silicone oil. Minimal surgery for tractional detachment provides excellent visual gains with minimal risks in select cases

Retinal circulation and its role in macular disorders in patients without systemic disease

<b>AIM:</b> To determine whether retinal circulatory changes play a role in the pathogenesis of macular disorders in patients who are otherwise healthy.<b>METHODS:</b>Patients with macular disorders that required angiographic imaging were included in this prospective case series. After a complete ocular exam, fluorescein angiography was performed using a standardized technique on the HRA-II (Heidelberg Engineering, Heidelberg, Germany) with special focus on the posterior pole. Only patients with good quality images were included in the analysis. Circulatory parameters recorded included the arm-choroid time, choroid-retinal artery, and finally the retinal artery-vein time. Zonal asymmetry (between the upper and lower zones divided by a line passing through the centre of the fovea) in transit times, if any was also noted. Appropriate statistical analysis was done. Circulation times were compared with age matched historical controls. Changes in retinal dye transit times relative to historical age matched controls, if any, were noted and compared between various disorders.<b>RESULTS:</b>A total of 156 eyes of 156 patients (120 males) were included in the study. Mean age:49.14±14.93y. Macular disorders studied were age related degeneration, polypoidal vasculopathy, central serous chorioretinopathy (CSCR) and parafoveal telangiectasia. Delayed circulation time was noted in CSCR patients only.<b>CONCLUSION:</b>CSCR patients appear to have delayed arterial filling, retinal circulatory disturbances do not seem to contribute to the pathogenesis of other macular disorders

Sustained Intraocular Pressure Rise after the Treat and Extend Regimen at 3 Years: Aflibercept versus Ranibizumab

Purpose. To determine the risk factors associated with sustained intraocular pressure (IOP) rise in patients enrolled in the treat and extend (T&E) protocol receiving aflibercept/ranibizumab therapy for 3 years. Design. Retrospective, observational chart review. Setting. Multicentric. Patients. 789 patients (1021 eyes; 602 males) enrolled in T&E using aflibercept/ranibizumab for diabetic macular edema (DME), wet age-related macular degeneration (AMD), or macular edema in retinal vein occlusion (RVO). Intervention. The history, examination (clinical and special investigations), and treatment records were thoroughly scrutinized. Sustained IOP rise was defined as a rise in IOP above baseline by ≥6 mmHg and/or >24 mmHg on 2 or more consecutive visits. The Wilk–Shapiro test was used for confirming normality of data. The Mantel–Haenszel test and generalized estimating equations were used to analyse multicentric data as well as to analyse data from both eyes of the same patients in the event that both eyes were under therapy. The relative risk, chi-square test (with and without Yates’ correction), and univariate and multivariate analysis were used wherever appropriate. Statistical significance was set at P<0.05. The primary outcome measure was the determination of risk factors for sustained IOP rise with ranibizumab/aflibercept therapy. Secondary outcome measures included determining the incidence of IOP rise (short term and sustained), visual field, and retinal nerve fibre layer (RNFL) changes. Results. The mean follow-up was 42.4 months. Male gender, South Asian ethnicity, older age, presence of AMD and vein occlusion, use of ranibizumab, higher number of injections, narrow angles, switch to bevacizumab/ranibizumab, and preexisting glaucoma were associated with sustained IOP rise. No significant visual field and RNFL changes were seen. The overall incidence was 8.91%. No patient required filtering surgery. No patient with IOP rise returned to baseline. Conclusion. IOP rise is an important consideration as the chronicity of the condition can eventually lead to glaucomatous changes in eyes with already compromised vision. Follow-ups and use of appropriate therapy can be determined correspondingly

Bilateral vitreous hemorrhage in children: Clinical features and outcomes

Purpose: To determine the etiology, clinical features and outcomes of bilateral vitreous hemorrhage (VH) in children. Methods: This retrospective chart review was performed on patients with bilateral VH under the age of 18 at a tertiary eye care center in India. Data included demographics, details of history and ocular examination, reports of investigations, surgeries or other interventions performed, and final anatomical and visual outcomes. Patients were divided into two groups i.e., traumatic and non-traumatic (spontaneous). Results: The traumatic group was comprised of 37 patients including 27 male and 10 female subjects with mean age of 13.47 ± 5.31 years, the most common complaint was decreased vision (96.45%) and the most prevalent etiology was firecracker injury in 16 (43.2%) patients. Mean baseline visual acuity (VA) was 2.34 ± 1.31 logMAR which was significantly improved to 1.08 ± 0.23 logMAR (P = 0.042). The mean number of surgeries was 2.72 ± 1.43 in the traumatic VH and mean follow up period was 23.14 ± 6.54 months. The spontaneous group included 48 subjects comprised of 27 male and 21 female cases with mean age of 14.48 ± 2.03 years. The most common cause was vasculitis in 21 (43.75%) subjects including four patients with tuberculosis. Mean baseline VA was 1.97 ± 1.13 logMAR which showed a significant improvement to 0.82 ± 0.24 logMAR (P = 0.012) after mean follow up of 34.2 ± 11.2 months. Eleven patients required at least one major surgery. Conclusion: Vasculitis was the most common cause of spontaneous bilateral VH; traumatic VH most prevalently occurred due to firecracker injury. Final VA was better in the spontaneous group

Brolucizumab for Choroidal Neovascular Membrane with Pigment Epithelial Tear and Subretinal Fluid

The aim of this study was to determine the utility of brolucizumab in the management of choroidal neovessels (CNV) with a retinal pigment epithelial (RPE) tear and subretinal fluid. We used a case series of patients with CNV who developed an RPE tear either spontaneously or following an intravitreal injection. All patients received intravitreal brolucizumab as primary or switch therapy. Appropriate data were collected. Follow-up was one year. The paired t-test was used to determine the significance of the results. The primary outcome measure was the change in best corrected visual acuity (BCVA). Secondary outcome measures were the change in subretinal fluid and complications, if any. A total of five patients were included in the analysis. The age range was 67−74 years and baseline BCVA was from 20/80 to 20/100. On average, all patients showed improvement in BCVA (p = 0.012) and also showed a significant anatomical improvement (p = 0.03). None of the patients had any complications, and all patients responded to additional anti-VEGF injections. In conclusion, all patients showed significant visual and anatomical improvement with brolucizumab; no complications were noted. All patients, including those who received switch, demonstrated a favorable anatomical and visual response to intravitreal brolucizumab without safety concerns