Choroidal imaging by spectral domain-optical coherence tomography

AbstractDespite the fact that the choroid plays an important role in the structure and function of the eye, it has not been studied in detail in vivo. Improvements in optical coherence tomography (OCT) imaging technology allow the routine imaging of the choroid and deep optic nerve structures in most patients. As with any new technology, it needs validation in both healthy and diseased eyes. Reproducible measurements of choroidal and lamina cribrosa thickness are possible. Several variables such as age, axial length, and time of day, affect choroidal thickness and must be taken into account when interpreting data on choroidal thickness. Lamina cribrosa thickness appears to be affected by age as well but other factors need to be determined. Choroidal thickness may be used to differentiate between central serous chorioretinopathy (CSC), polypoidal choroidal vasculopathy (PCV) and exudative age-related macular degeneration (AMD). Enhanced depth imaging-optical coherence tomography (EDI-OCT) of the choroid may detect tumors not detectable by ultrasound. Studying the choroid may help us gain insight into the pathogenesis of several diseases such as AMD, CSC, glaucoma, posteriorly located choroidal tumors, and PCV among others

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Chromovitrectomy: an Update

Adequate visualization and identification of the posterior hyaloid, epiretinal membranes and the internal limiting membrane are of paramount importance in modern vitreoretinal surgery. "Chromovitrectomy" is a term used for describing the vital dyes use in order to stain these transparent tissues and facilitate their manipulation during vitreous surgery. This article reviews the indications, applications and characteristics of vital dyes in vitreoretinal surgery. Various dyes are currently being used in routine clinical procedures, however the ideal staining agent has not yet been found. Any dye which is injected intravitreally has the potential to become toxic. Triamcinolone acetonide is used to highlight the vitreous and is particularly beneficial in determining the attachment of the posterior hyaloid to the underlying retina. Trypan blue stains epiretinal membranes and facilitates their complete removal. Both indocyanine green and brilliant blue G stain the internal limiting membrane properly, however concerns over indocyanine green toxicity have made surgeons switch to brillliant blue G as a safer alternative

INTRAOCULAR PRESSURE ELEVATION AFTER UNCOMPLICATED PARS PLANA VITRECTOMY Results of the Pan American Collaborative Retina Study Group

Purpose:To compare the incident rates of sustained elevation of intraocular pressure (IOP) after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane and the unoperated fellow eye.Methods:Retrospective multicenter study of 198 patients who underwent pars plana vitrectomy for an idiopathic epiretinal membrane that was followed for at least 12 months. the diagnosis of sustained IOP elevation was defined as an elevation of IOP 24 mmHg or an increase of 5 mmHg in the IOP from baseline on 2 separate visits that warranted the initiation of ocular hypotensive therapy. the main outcome measured was the development of sustained IOP elevation as defined above.Results:Patients were followed for an average of 47.3 24 months (range, 12-106 months). in the vitrectomized eyes, 38 of the 198 (19.2%) patients developed elevated IOP compared with 9 of the 198 (4.5%) unoperated fellow eyes (P < 0.0001, Fisher exact test; odds ratio, 4.988). Possible risk factors include a family history of open-angle glaucoma (P = 0.0004 Fisher exact test; odds ratio, 7.206) and cataract surgery (P = 0.0270 Fisher exact test; odds ratio, 2.506).Conclusion:Uncomplicated PPV seems to increase the IOP, particularly in those who are pseudophakic and have a family history of open-angle glaucoma. This increase in IOP may lead to glaucomatous damage if not managed appropriately. Patients with a previous PPV need to be followed by an ophthalmologist to monitor the IOP in the vitrectomized eye.Inst Cirugia Ocular, San Jose, Costa RicaUniv Puerto Rico, San Juan, PR 00936 USAUniv Rosario, Fdn Oftalmol Nacl, Bogota, ColombiaBrazilian Inst Fighting Blindness, Vitreoretinal Surg Unit, Assis Presidente Prudente, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilHosp Luis Sanchez Bulnes, Asociac Evitar La Ceguera, Mexico City, DF, MexicoHosp Univ Ramon & Cajal, Dept Retina, Madrid, SpainHosp Univ Ramon & Cajal, VISSUM Madrid Mirasierra Oftalmol Integral, Madrid, SpainClin Oftalmol Ctr Caracas, Caracas, VenezuelaClin Ricardo Palma, Lima, PeruKing Khalid Eye Specialist Hosp, Riyadh, Saudi ArabiaJohns Hopkins Univ, Wilmer Eye Inst, Baltimore, MD 21218 USAUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Intraocular pressure elevation after uncomplicated pars plana vitrectomy: Results of the pan American collaborative retina study group

PURPOSE:: To compare the incident rates of sustained elevation of intraocular pressure (IOP) after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane and the unoperated fellow eye. METHODS:: Retrospective multicenter study of 198 patients who underwent pars plana vitrectomy for an idiopathic epiretinal membrane that was followed for at least 12 months. The diagnosis of sustained IOP elevation was defined as an elevation of IOP ? 24 mmHg or an increase of ? 5 mmHg in the IOP from baseline on 2 separate visits that warranted the initiation of ocular hypotensive therapy. The main outcome measured was the development of sustained IOP elevation as defined above. RESULTS:: Patients were followed for an average of 47.3 ± 24 months (range, 12-106 months). In the vitrectomized eyes, 38 of the 198 (19.2%) patients developed elevated IOP compared with 9 of the 198 (4.5%) unoperated fellow eyes (P less than 0.0001, Fisher exact test; odds ratio, 4.988). Possible risk factors include a family history of open-angle glaucoma (P = 0.0004 Fisher exact test; odds ratio, 7.206) and cataract surgery (P = 0.0270 Fisher exact test; odds ratio, 2.506). CONCLUSION:: Uncomplicated PPV seems to increase the IOP, particularly in those who are pseudophakic and have a family history of open-angle glaucoma. This increase in IOP may lead to glaucomatous damage if not managed appropriately. Patients with a previous PPV need to be followed by an ophthalmologist to monitor the IOP in the vitrectomized eye. Copyright © by Ophthalmic Communications Society, Inc

Intraocular pressure elevation after uncomplicated pars plana vitrectomy: Results of the pan American collaborative retina study group

PURPOSE:: To compare the incident rates of sustained elevation of intraocular pressure (IOP) after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane and the unoperated fellow eye. METHODS:: Retrospective multicenter study of 198 patients who underwent pars plana vitrectomy for an idiopathic epiretinal membrane that was followed for at least 12 months. The diagnosis of sustained IOP elevation was defined as an elevation of IOP ? 24 mmHg or an increase of ? 5 mmHg in the IOP from baseline on 2 separate visits that warranted the initiation of ocular hypotensive therapy. The main outcome measured was the development of sustained IOP elevation as defined above. RESULTS:: Patients were followed for an average of 47.3 ± 24 months (range, 12-106 months). In the vitrectomized eyes, 38 of the 198 (19.2%) patients developed elevated IOP compared with 9 of the 198 (4.5%) unoperated fellow eyes (P less than 0.0001, Fisher exact test; odds ratio, 4.988). Possible risk factors include a family history of open-angle glaucoma (P = 0.0004 Fisher exact test; odds ratio, 7.206) and cataract surgery (P = 0.0270 Fisher exact test; odds ratio, 2.506). CONCLUSION:: Uncomplicated PPV seems to increase the IOP, particularly in those who are pseudophakic and have a family history of open-angle glaucoma. This increase in IOP may lead to glaucomatous damage if not managed appropriately. Patients with a previous PPV need to be followed by an ophthalmologist to monitor the IOP in the vitrectomized eye. Copyright © by Ophthalmic Communications Society, Inc

Long-term safety and efficacy of benralizumab in patients with severe, uncontrolled asthma: 1-year results from the BORA phase 3 extension trial

International audienc

Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus.METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis.RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (&lt;45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]).CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791

Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial

Rationale &amp; Objective: It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kid-ney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagli-flozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study.Study Design: Secondary analysis of a random-ized controlled trial. Setting &amp; Participants: Participants in the CREDENCE trial. Intervention: Participants were randomly assigned to receive canagliflozin 100 mg/d or placebo.Outcomes: Primary composite outcome of kid-ney failure, doubling of serum creatinine con-centration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Out-comes were evaluated by age at baseline (&lt;60, 60-69, and &gt;_70 years) and sex in the intention-to-treat population using Cox regression models.Results: The mean age of the cohort was 63.0 &amp; PLUSMN; 9.2 years, and 34% were female. Older age and female sex were independently associ-ated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (acomposite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.4 8-0.82], and 0.89 [0.61-1.29] for ages &lt;60, 60-69, and &gt;_70 years, respectively; P = 0.3 for interaction) or sexes (HRs, 0.71 [95% CI, 0.5 4-0.95] and 0.69 [0.56-0.8 4] in women and men, respectively; P = 0.8 for interaction). No differences in safety outcomes by age group or sex were observed.Limitations: This was a post hoc analysis with multiple comparisons.Conclusions: Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants.Funding: This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical.Trial Registration: The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791