Faculty Bibliography

PURPOSE: To describe a possible causal association between the position of perforating scleral vessels and the position of lacquer cracks in eyes with pathologic myopia. DESIGN: Retrospective case series. METHODS: Medical records and multimodal imaging results, including confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography, were reviewed from patients with lacquer cracks secondary to pathologic myopia who presented between 2010 and 2014 to two institutions. Main outcome measure were the prevalence of perforating scleral vessels at the site of the lacquer crack, the position of the lacquer crack within the macula and the relationships between perforating scleral vessels and retinal-choroidal structures. RESULTS: A total of 35 eyes of 30 patients with lacquer cracks were included. The average number of lacquer cracks was 1.2+/-0.5/eye and in 37 out of 45 lacquer cracks (82%) retrobulbar vessels were found to perforate the sclera at the site of the lacquer crack. Lacquer cracks were more prevalent in the central macula (51%), than in the nasal (19%), temporal (14%), inferior (11%) and superior (5%) macula (P = 0.001). Transverse En Face images through the area of lacquer cracks were available for 8 cases and clearly depicted the perforating vessel's course through the sclera and its termination in the choroid, directly beneath the lacquer cracks. CONCLUSIONS: Perforating scleral vessels are often present beneath the site at which lacquer cracks form in pathologic myopia. We hypothesize that scleral expansion at the location of these perforating vessels may play a role in the formation of lacquer cracks.

BACKGROUND AND OBJECTIVE: To demonstrate a vascular pattern seen on optical coherence tomography angiography (OCTA) that appears to correlate with reduced rates of geographic atrophy (GA) in eyes receiving long-term anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD). PATIENTS AND METHODS: Non-consecutive, retrospective cohort study. Patients were included if they had received more than 50 anti-VEGF injections during a period of at least 4 years for neovascular AMD in at least one eye, with absence or minimal progression of GA. Clinical charts and imaging were reviewed retrospectively; study eyes underwent OCTA. RESULTS: Nine eyes of eight patients were included. Mean age was 82 years, and mean follow-up of study eyes 9.1 years; study eyes received a mean of 65.8 injections. OCTA revealed tangled networks of neovessels associated with type 1 lesions. CONCLUSION: With prolonged anti-VEGF treatment, GA appears to occur less commonly in eyes with type 1 neovascularization. OCTA shows mature tangled vessels with substantial flow within type 1 lesions. Mature, tangled networks may be associated with a decreased likelihood of developing GA despite the presence of choriocapillaris atrophy. [Ophthalmic Surg Lasers Imaging Retina. 2015;46:907-912.].

PURPOSE: To assess change in intraocular pressure (IOP) in patients with neovascular age-related macular degeneration (NVAMD) receiving intravitreal aflibercept injection (IAI) or ranibizumab in VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD (VIEW) 1 and 2 studies. DESIGN: Analyses from 2 randomized, active-controlled, phase III trials. PARTICIPANTS: A total of 2457 patients with NVAMD. METHODS: Patients received IAI 2 mg every (q) 4 weeks (2q4), 0.5 mg q4 weeks (0.5q4), 2 mg q8 weeks (after 3 monthly doses; 2q8), or ranibizumab 0.5 mg q4 weeks (Rq4) for 52 weeks. At week 52, patients were switched to a variable regimen requiring at least quarterly dosing and allowing interim injections based on anatomic and visual assessment. MAIN OUTCOME MEASURES: Pre-injection IOP was analyzed in study and uninjected fellow eyes from baseline to week 96. Prespecified end points included mean change in IOP from baseline and prevalence of a >21 mmHg and >10 mmHg increase in IOP from baseline. Cumulative incidence of sustained (at 2 consecutive visits) IOP >21 mmHg, a single event of IOP >25 mmHg, and sustained IOP increase from baseline (>/=5 mmHg) was also evaluated. RESULTS: Mean IOP change from baseline over 96 weeks in all IAI groups was consistently lower than in the Rq4 group, and this finding was replicated in both trials. In an analysis integrating both studies, the proportion of study eyes with IOP >21 mmHg at week 96 was 20.2%, 14.2%, 12.1%, and 12.5% in Rq4, 2q4, 2q8, and 0.5q4, respectively. Reduction in risk, relative to Rq4, of having sustained IOP >21 mmHg over 96 weeks was 62% (95% confidence interval [CI], 36%-78%), 50% (95% CI, 19%-70%), and 69% (95% CI, 45%-84%) for 2q4, 2q8, and 0.5q4, respectively. Risk reduction in the IAI groups for a sustained IOP increase >/=5 mmHg was 31% (95% CI, 8%-48%), 38% (95% CI, 17%-54%), and 47% (95% CI, 27%-61%), respectively. In uninjected fellow eyes, only sustained IOP >21 mmHg events were higher in the Rq4 group compared with all IAI groups. CONCLUSIONS: Incidence of elevated IOP in eyes with NVAMD was lower in all IAI groups than in the ranibizumab group.

BACKGROUND AND OBJECTIVE: To correlate the appearance of a hyporeflective lucency on spectral-domain optical coherence tomography (SD-OCT) with a focal leak on fluorescein angiography (FA) in eyes with central serous chorioretinopathy (CSC). PATIENTS AND METHODS: Multimodal imaging of 18 patients with CSC who had hyperreflective fibrin surrounding a hyporeflective lucency on SD-OCT was analyzed to investigate any potential correlation with an active leak on FA. The lucent area was evaluated using en face imaging and followed for resolution of the active leak. RESULTS: High-resolution SD-OCT images of the lucency were found to correlate with the active leak. In certain cases, the lucent area could be visualized as communicating with a defect in a pigment epithelial detachment. En face imaging of the lucency revealed a smoke-stack appearance, and resolution of the leak correlated with the disappearance of the lucency on SD-OCT. CONCLUSION: Visualization of a lucency within surrounding fibrin may suggest an active leak. En face imaging of the lucency may provide insight into the pathophysiology of the smoke-stack leak on FA. [Ophthalmic Surg Lasers Imaging Retina. 2015;46:832-836.].

Macular holes in the setting of macular telangiectasia type 2 can be difficult to manage. The rates of anatomical closure after macular hole surgery are less favorable in patients with macular telangiectasia than in those with idiopathic macular holes. These differences may be due to the influence of unique pathogenic mechanisms that modulate macular hole dynamics in patients with macular telangiectasia. In this report, the authors document the multimodal imaging findings of a patient with macular telangiectasia demonstrating spontaneous macular hole closure. These findings may improve the understanding of the natural course of this entity and may have relevance for clinical management. [Ophthalmic Surg Lasers Imaging Retina. 2015;46:883-886.].

BACKGROUND AND OBJECTIVE: Patients with a symptomatic epiretinal membrane (ERM) typically complain of metamorphopsia and decreased visual acuity. We describe three patients who presented with the single complaint of a central microscotoma due to ERM, an infrequent initial symptom of this entity. PATIENTS AND METHODS: This is a retrospective, interventional, non-comparative case series. Three patients with the chief complaint of a central microscotoma related to ERMs who underwent pars plana vitrectomy by a single surgeon experienced full resolution of the preoperative microscotoma. Best-corrected visual acuity, fundus photography, and optical coherence tomography were obtained at each examination. A comprehensive neuro-ophthalmologic evaluation was performed in all cases, including magnetic resonance imaging of the orbits and brain, automated visual fields, multifocal electroretinography, multifocal visually evoked potentials, and blood tests. RESULTS: Three eyes of three patients who presented with the initial sole complaint of a central microscotoma due to ERM are included in this series. A comprehensive neuro-ophthalmologic evaluation ruled out non-retinal etiologies. After months of observation, a pars plana vitrectomy with ERM and internal limiting membrane peeling was performed in all patients. Postoperatively, the patients experienced a complete resolution of their initial, isolated complaint of a central microscotoma. CONCLUSION: Central microscotoma, as a rare stand-alone presentation of ERM, is described. This symptom resolved after a successful removal of the ERM. A greater awareness among clinicians that ERMs may present in this manner may help avoid excessive and costly medical evaluations.

PURPOSE: A review of treat-and-extend regimens (TERs) with intravitreal anti-vascular endothelial growth factor agents in retinal diseases. METHODS: There is a lack of consensus on the definition and optimal application of TER in clinical practice. This article describes the supporting evidence and subsequent development of a generic algorithm for TER dosing with anti-vascular endothelial growth factor agents, considering factors such as criteria for extension. RESULTS: A TER algorithm was developed; TER is defined as an individualized proactive dosing regimen usually initiated by monthly injections until a maximal clinical response is observed (frequently determined by optical coherence tomography), followed by increasing intervals between injections (and evaluations) depending on disease activity. The TER regimen has emerged as an effective approach to tailoring the dosing regimen and for reducing treatment burden (visits and injections) compared with fixed monthly dosing or monthly visits with optical coherence tomography-guided regimens (as-needed or pro re nata). It is also considered a suitable approach in many retinal diseases managed with intravitreal anti-vascular endothelial growth factor therapy, given that all eyes differ in the need for repeat injections. CONCLUSION: It is hoped that this practical review and TER algorithm will be of benefit to health care professionals interested in the management of retinal diseases.

PURPOSE: To examine the baseline factors associated with good (20/60 or better) versus poor (20/200 or worse) visual outcomes in eyes with treatment-naive neovascular age-related macular degeneration (AMD) receiving intravitreal antivascular endothelial growth factor (VEGF) on a treat-and-extend regimen (TER). METHODS: An observational, retrospective series of patients managed with a TER, identified as having either good or poor visual outcomes, was examined. A multivariate regression analysis of baseline characteristics identified factors associated with good and poor vision at 2, 3, and 4 years. Neovascular subtypes were identified using fluorescein angiography (FA) alone and the anatomic classification system with FA and optical coherence tomography (OCT). RESULTS: One hundred thirty-eight patients (154 eyes) fit the inclusion criteria at 2 years, 106 patients (113 eyes) at 3 years, and 72 patients (74 eyes) at 4 years. In the multivariate analysis, type 1 lesions, according to anatomic classification, had better vision at 24 months (95% CI: [3.1, 82.7], P = 0.01), 36 months (95% CI: [1.97, 24.17], P = 0.003), and 48 months (95% CI: [2.01, 65.47], P = 0.006). Clopidogrel use was associated with poor vision at 24 months (95% CI: [0.03, 0.68], P = 0.013). Vision at 3 months was the best predictor of vision at year 4 (beta = -4.277, P = 0.002). CONCLUSIONS: Eyes with neovascular AMD managed with a TER of anti-VEGF therapy having type 1 neovascularization at baseline were more likely to maintain good vision over 4 years, whereas clopidogrel use predicted poor vision at 2 years. Vision at 3 months was the best predictor for favorable long-term vision.