Update on Management of Non-proliferative Diabetic Retinopathy without Diabetic Macular Edema; Is There a Paradigm Shift?

Diabetic retinopathy (DR) is the major cause of visual impairment and blindness in the working-age population. Conventional management for nonproliferative diabetic retinopathy (NPDR) without diabetic macular edema (DME) is derived from the findings of the Early Treatment Diabetic Retinopathy Study (ETDRS). Although the ETDRS protocol basically includes observation, selected cases of severe NPDR may undergo scatter laser photocoagulation. Post-hoc analysis of recent trials has shown that patients with NPDR receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) for DME would experience improvement in the DR severity scale (DRSS). In addition, recent randomized trials (PANORAMA and Protocol W) have revealed that early intervention with intravitreal aflibercept in eyes with moderately severe to severe NPDR is associated with significant improvement in DRSS and reduced vision-threatening complications of DR. Based on recent studies, it seems that the therapeutic approach to NPDR may undergo a substantial change and a paradigm shift toward considering early intervention with the administration of intravitreal anti-VEGF injections. However, the long-term results and the duration of adherence to anti-VEGF therapy for eyes with NPDR are not yet defined. It is also not apparent whether improvement in DRSS is a true disease modification. Studies showed that DRSS improvement is not associated with retinal reperfusion. In addition, DRCR.net Protocol W showed no visual acuity benefit with the early intravitreal aflibercept injection in moderate to severe NPDR as compared with performing observation plus intravitreal aflibercept applied only after progression to proliferative DR or vision-impairing DME. The cost–benefit ratio is also a challenge. Herein, we look at different aspects of early anti-VEGF application and discuss its pros and cons in the process of treating NPDR

Choroidal Thickness in Acute Non-arteritic Anterior Ischemic Optic Neuropathy

Purpose: To compare the choroidal thickness in eyes with acute non-arteritic anterior ischemic optic neuropathy (NAION) with healthy contralateral eye and normal controls. Methods: Thirty-eight eyes with NAION, thirty-eight unaffected fellow eyes, and seventy four eyes from 37 healthy, age- and sex-matched subjects were included in this prospective comparative case-control study. Choroidal thickness was measured by enhanced depth imaging (EDI) of spectral domain optical coherence tomography (SDOCT). Peripapillary choroidal thickness (PCT) was measured at 1000 and 1500 μm from Bruch's membrane opening (BMO). Subfoveal choroidal thickness (SFCT) was measured in central subfoveal area, and 500 microns apart in temporal and nasal sides. Choroidal thickness among NAION eyes, uninvolved fellow eyes, and control eyes were compared. Results: The mean of PCT at 1000 μm was significantly thicker in NAION and fellow eyes compared to control eyes (169.7 ± 47, 154.4 ± 42.1, and 127.7 ± 49.9 μm, respectively, P < 0.001 and P = 0.42). The mean PCT at 1500 μm was also significantly thicker in NAION and fellow eyes compared to control eyes (178.6 ± 52.8, 162.6 ± 46.1, and 135.1 ± 59 μm, respectively, P = 0.007 and P = 0.048). The mean PCT at 1000 and 1500 μm was significantly greater in NAION compared to fellow eyes (P = 0.027 and P = 0.035, respectively). The mean of SFCT was significantly thicker in NAION compared to control eyes (P = 0.032); however, there was no significant difference between uninvolved fellow and control eyes (P = 0.248). Conclusion: Thicker choroidal thickness in acute NAION and uninvolved fellow eyes compared to normal eyes suggests a primary choroidal role in NAION pathophysiology

Ocular toxoplasmosis presenting as subretinal macrocyst

Purpose: To report a case of unilateral retinal detachment with a large subretinal macrocyst, representing an atypical presentation of ocular toxoplasmosis. Case Report: A healthy 30-year-old woman presented with a two month history of progressive visual loss in her right eye. Funduscopy revealed vitreous condensations, total retinal detachment with a large subretinal orange-red cystic mass and multiple retinal breaks sealed with surrounding retinal scars. B-scan echography showed a large subretinal cyst with non-homogenous tissue echogenicity. Pars plana deep vitrectomy and complete cyst removal were performed. Histopathologic examination of the excised cyst revealed intraretinal toxoplasma cysts containing bradyzoites. Analysis of intraocular fluids by polymerase chain reaction (PCR) and serologic tests also supported the diagnosis. After six months, the retina was completely attached with no signs of inflammation. Conclusion: Toxoplasma retinochoroiditis should be considered in the differential diagnoses of retinal detachment with subretinal cyst

Intravitreal tissue plasminogen activator for treatment of vitreomacular adhesion

AIM: To evaluate the role of a single intravitreal injection of tissue plasminogen activator(TPA)alone for treatment of vitreomacular traction and the effect of combined intravitreal TPA and bevacizumab on retinal vascular diseases.METHODS: In this prospective, interventional case series a total of 24 eyes from 24 patients were studied. There were 5 eyes with symptomatic vitreomacular traction syndrome(VMT)and 19 eyes with retinal vascular diseases including diabetic macular edema(DME), diabetic vitreous hemorrhage(VH), central retinal vein occlusion(CRVO)and neovascular age related macular degeneration(AMD). Measurement of visual acuity, B-scan and OCT were performed at the baseline and 1mo after injections. Three eyes with VMT received a single intravitreal injection of 50 μg and two eyes received 100 μg TPA. And 19 eyes with retinal vascular diseases received combined intravitreal TPA(50 μg)and bevacizumab(1.25 mg).RESULTS: The mean ages for retinal vascular diseases and VMT patients were 56.8y and 60.4y, respectively. Ten patients(41.7%)were male and 14 patients(58.3%)were female. And 22 eyes(91.7%)were phakic and 2 eyes(8.3%)were pseudophakic. The incidence of posterior vitreous detachment(PVD)was 0(0 of 5)and 57.8%(11 of 19)for VMT and retinal vascular diseases, respectively(P=0.04). Improvement of best corrected visual acuity(BCVA)and decrement of central macular thickness(CMT)were significantly greater in PVD positive eyes compared with PVD negative eyes.CONCLUSION: Intravitreal injection of TPA was not successful to induce complete PVD in VMT patients. Combined intravitreal injection of TPA and bevacizumab can induce PVD and improve BCVA and decrease central macular thickness in eyes with retinal vascular diseases

Pars plana lensectomy and iris-claw Artisan intraocular lens implantation in patients with Marfan syndrome

RATIONAL: The rationale of this study was to evaluate the visual and anatomical outcomes of pars plana lensectomy and iris-claw Artisan intraocular lens (IOL) implantation in patients with subluxated crystalline lenses secondary to Marfan syndrome. MATERIALS AND METHODS: In this retrospective case series, we evaluate the records of 21 eyes of 15 patients with Marfan syndrome and moderate-to-severe crystalline lens subluxation who underwent pars plana lensectomy/anterior vitrectomy and implantation of iris-claw Artisan IOL at referral hospital from September 2015 to October 2019. RESULTS: Twenty-one eyes of 15 patients (10 males and five females) with a mean age of 24.47 ± 19.14 years were included. Mean best-corrected visual acuity was improved from 1.17 ± 0.55 logMAR to 0.64 ± 0.71 logMAR at the final follow-up visit (P < 0.001). The mean intraocular pressure did not change significantly (P = 0.971). The final refraction showed a mean sphere of 0.54 ± 2.46 D and a mean cylinder of 0.81 ± 1.03 at the mean axis of 57.92 ± 58.33 degrees. One eye developed rhegmatogenous retinal detachment 2 months after surgery. CONCLUSIONS: Pars plana lensectomy and iris-claw Artisan IOL implantation seem to be a useful, impressive, and safe procedure with a low rate of complications in Marfan patients with moderate-to-severe crystalline lens subluxation. Visual acuity was significantly improved with acceptable anatomical and refractive outcomes

Bilateral Simultaneous Nonarteritic Anterior Ischemic Optic Neuropathy Associated with The Use of Sildenafil: A Case Report

Introduction Nonarteritic anterior ischemic optic neuropathy (NAION) is a rare condition but one of the most important ocular side effects of sildenafil. Case Presentation We presented a 65-year- old man with the history of sudden painless loss of vision in both eyes following taking sildenafil. Conclusions Fundus examination revealed blurred margin and elevated disc in both eyes. Visual field defects were bilateral inferior altitudinal defects, and optical coherence tomography (OCT) displayed a prominent nerve fiber layer edema in both eyes. We asserted that use of sildenafil may lead to reduce blood pressure and interfere with microcirculation in the optic nerve head. So, the potential risks of unregulated over-the-counter sexual enhancement supplements such as sildenafil must be educated to the patients using these supplements

Astigmatic Outcomes of Temporal versus Nasal Clear Corneal Phacoemulsification

&lt;!--[if gte mso 9]&gt;&lt;xml&gt; Normal 0 false false false MicrosoftInternetExplorer4 &lt;/xml&gt;&lt;![endif]--&gt;&lt;!--[if gte mso 9]&gt;&lt;xml&gt; &lt;/xml&gt;&lt;![endif]--&gt; &lt;!--[if gte mso 10]&gt; &lt;style&gt;&#13; /* Style Definitions */&#13; table.MsoNormalTable&#13; {mso-style-name:"Table Normal";&#13; mso-tstyle-rowband-size:0;&#13; mso-tstyle-colband-size:0;&#13; mso-style-noshow:yes;&#13; mso-style-parent:"";&#13; mso-padding-alt:0cm 5.4pt 0cm 5.4pt;&#13; mso-para-margin:0cm;&#13; mso-para-margin-bottom:.0001pt;&#13; mso-pagination:widow-orphan;&#13; font-size:10.0pt;&#13; font-family:"Times New Roman";&#13; mso-ansi-language:#0400;&#13; mso-fareast-language:#0400;&#13; mso-bidi-language:#0400;}&#13; &lt;/style&gt; &lt;![endif]--&gt; &lt;p&gt;PURPOSE: To compare the astigmatic outcomes of phacoemulsification cataract surgery using temporal versus nasal clear corneal incisions. METHODS: In a clinical trial, consecutive patients with senile cataracts underwent phacoemulsification and implantation of a hydrophobic acrylic foldable intraocular lens through a horizontal clear corneal incision (temporal in right and nasal in left eyes). Outcome measures included keratometric astigmatism and surgically induced astigmatism (SIA) calculated by the vector analysis method using the Holladay-Cravy-Koch formula. RESULTS: The nasal and temporal groups consisted of 20 eyes each. Mean preoperative keratometric astigmatism was 0.63±0.48 D and 0.38±0.39 D in the temporal and nasal incision groups respectively (P=0.09). Data on 10 eyes in each study group was available for the six-month analysis. Mean keratometric astigmatism was as follows in the temporal and nasal groups respectively: 0.85±0.47 D versus 1.95±0.45 D at 1 week (P &lt; 0.001), 0.73±0.46 D versus 1.79±0.55 D at 4 weeks (P &lt; 0.001), and 0.63±0.30 D versus 1.05±0.56 D at 6 months (P=0.053) after surgery. SIA at the same follow-up intervals was 0.71±0.20 D versus 1.80±0.22 D (P &lt; 0.001), 0.63±0.20 D versus 1.65±0.31 D (P &lt; 0.001) and 0.26±0.46 D versus 0.92±0.36 D (P=0.002) in the temporal versus nasal incision groups respectively. CONCLUSION: Temporal clear corneal phacoemulsification induces significantly less astigmatism as compared to similar surgery using the nasal approach.&lt;/p&gt; &lt;p&gt; &lt;/p&gt

Choroidal thickness in healthy subjects

Purpose: To measure the choroidal thickness by enhanced depth imaging optical coherence tomography (EDI-OCT) in normal eyes. Methods: In a prospective case series, 208 eyes of 104 normal Iranian subjects were enrolled. Complete ophthalmic examination was performed. Inclusion criteria were best corrected visual acuity (BCVA) ≥20/20, ≤ ±1 diopter of refractive error in either spherical or cylindrical components, normal intraocular pressure (IOP) and no systemic or ocular diseases. The choroidal thickness was measured by EDI-OCT subfoveally, and 1500 μm and 3000 μm nasal and temporal to the fovea. Results: Mean age was 34.6 ± 9.8 years (range, 18–57 years). Mean subfoveal choroidal thickness was 363 ± 84 μm. Choroidal thickness was 292 ± 76 and 194 ± 58 μm at 1500 and 3000 μm nasal to the fovea, respectively, and 314 ± 77 and 268 ± 66 μm at 1500 and 3000 μm temporal to the fovea, respectively. There was no statistically significant difference in the choroidal thickness between sexes and laterality of the eyes. Choroidal thickness at fovea (P < 0.001) and at all extrafoveal locations decreased significantly for every 10 years increase in age. Conclusion: In normal Iranian subjects participating in this study, mean choroidal thickness was comparable with other reports

Intravitreal Injections and Face Masks: Endophthalmitis Risk Before and During the COVID-19 Pandemic

Abstract Purpose: To assess the added risk of acute endophthalmitis after intravitreal injections associated with the widespread use of face masks during the COVID-19 pandemic. Methods: In this retrospective, single-center study, records of patients with acute endophthalmitis following intravitreal bevacizumab (IVB) injections during the pre-COVID era—that is, March 1 st , 2013 to October 31 st , 2019 —and the COVID-19 era—that is, March 1 st , 2020 to April 1 st , 2021 —were reviewed and compared. Results: A total of 28,085 IVB injections were performed during the pre-COVID era; nine eyes of nine patients developed acute post-IVB endophthalmitis in this era, giving an overall incidence of 0.032% (3.2 in 10,000 injections). In the COVID era, 10,717 IVB injections were performed; four eyes of four patients developed acute post-IVB endophthalmitis in this era, giving an overall incidence of 0.037% (3.7 in 10,000 injections). The incidences of post-IVB endophthalmitis during these two eras were not statistically significantly different (P = 0.779). Conclusion: Face masking protocols seem unlikely to impose any additional risk of post-IVB endophthalmitis

Safety threshold of intravitreal clonidine in rabbit’s eyes

AIM: To determine the safe dose of intravitreal clonidine (IVC), a potential drug for neuroprotection and angiogenesis inhibition in rabbits. METHODS: A total of 28 rabbits were divided into four groups. Three groups received IVC with concentrations of 15 (Group A), 25 (Group B), and 50 (Group C) µg/0.1 mL and the control group (Group D) received 0.1 mL balanced salt solution (BSS). To investigate IVC safety, electroretinography (ERG) was performed at baseline, then at 1, 4 and 8wk after injection. After last ERG, all rabbits were euthanized, their eyes were enucleated and subjected to routine histopathological evaluation, immunohistochemistry for glial fibrillary acidic protein (GFAP) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) test. RESULTS: Based on ERG, histopathology, GFAP and TUNEL assay findings, 15 µg IVC was determined as the safe dose in rabbit eyes. While, the results of routine histopathology and TUNEL assay were unremarkable in all groups, toxic effects attributed to 25 and 50 µg IVC were demonstrated by ERG and GFAP tests. CONCLUSION: Totally 15 µg clonidine is determined as the safe dose for intravitreal injection in rabbits. Contribution of IVC in neuroprotection and inhibition of angiogenesis deserve more studies