Author: Ophthalmology

Retinal Layer Segmentation in Patients with Multiple Sclerosis Using Spectral Domain Optical Coherence Tomography – Corrected Proof

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Purpose: To evaluate the thickness of the 10 retinal layers in the paramacular area of patients with multiple sclerosis (MS) compared with healthy subjects using the new segmentation technology of spectral domain optical coherence tomography (OCT). To examine which layer has better sensitivity for detecting neurodegeneration in patients with MS.Design: Observational, cross-sectional study.Participants: Patients with MS (n = 204) and age-matched healthy subjects (n = 138).Methods: The Spectralis OCT system (Heidelberg Engineering, Inc., Heidelberg, Germany) was used to obtain automated segmentation of all retinal layers in a parafoveal scan in 1 randomly selected eye of each participant, using the new segmentation application prototype.Main Outcome Measures: The thicknesses of 512 parafoveal points in the 10 retinal layers were obtained in each eye, and the mean thickness of each layer was calculated and compared between patients with MS and healthy subjects. The analysis was repeated, comparing patients with MS with and without previous optic neuritis. Correlation analysis was performed to evaluate the association between each retinal layer mean thickness, duration of disease, and functional disability in patients with MS. A logistic regression analysis was performed to determine which layer provided better sensitivity for detecting neurodegeneration in patients with MS.Results: All retinal layers, except the inner limiting membrane, were thinner in patients with MS compared with healthy subjects (P < 0.05). Greater effects were observed in the inner retinal layers (nerve fiber, ganglion cells, inner plexiform, and inner nuclear layers) of eyes with previous optic neuritis (P < 0.05). The retinal nerve fiber layer and ganglion cell layer thicknesses were inversely correlated with the functional disability score in patients with MS. The ganglion cell layer and inner plexiform layer thicknesses could predict axonal damage in patients with MS.Conclusions: Analysis based on the segmentation technology of the Spectralis OCT revealed retinal layer atrophy in patients with MS, especially of the inner layers. Reduction of the ganglion cell and inner plexiform layers predicted greater axonal damage in patients with MS.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Author reply – Corrected Proof

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Esmaeli’s request for clarification of issues regarding our study involves 11 points related to both the intra-arterial cytoreductive chemotherapy (IACC) protocol design and our analysis. First, the introductory quotation attributed to us was not a sta…

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Low-Fluence Photodynamic Therapy versus Ranibizumab for Chronic Central Serous Chorioretinopathy: One-Year Results of a Randomized Trial – Corrected Proof

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Purpose: To compare the efficacy and safety between low-fluence photodynamic therapy (PDT) and the intravitreal ranibizumab in the treatment of chronic central serous chorioretinopathy (CSC).Design: Prospective, randomized, single-center, parallel-arm, controlled trial.Participants: Thirty-four eyes of 32 patients with chronic CSC with >6 months’ duration of symptoms or recurrent CSC were randomly placed into the low-fluence PDT group (n = 18) or the ranibizumab group (n = 16).Intervention: The patients underwent a single session of low-fluence PDT or 3 consecutive monthly injections of ranibizumab. Rescue treatment was available from month 3 if the subretinal fluid (SRF) persisted or recurred after primary treatment; low-fluence PDT was given to the ranibizumab group and intravitreal ranibizumab to the low-fluence PDT group.Main Outcome Measures: The primary outcome was the proportion of eyes with complete resolution of SRF without rescue treatment. Secondary outcomes included the mean changes in logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA), central retinal thickness (CRT), and angiographic findings from baseline to 12 months.Results: At month 12, 16 eyes (88.9%) of the low-fluence PDT group maintained complete resolution of SRF without rescue treatment versus 2 eyes (12.5%) in the ranibizumab group (P < 0.001). Two eyes (11.1%) in the low-fluence PDT group and 11 eyes (68.8%) in the ranibizumab group met the criteria for rescue treatment (P = 0.001). In the low-fluence PDT group, the mean decrease in CRT from baseline was significantly greater than that in the ranibizumab group until month 6 (P < 0.05), but the differences became insignificant thereafter. The improvement in BCVA from baseline was superior in the low-fluence PDT group to that in the ranibizumab group, but the differences were not statistically significant except at month 3 (P = 0.025). On indocyanine green angiography, a significantly greater proportion of the low-fluence PDT group (16 eyes; 88.9%) showed a marked reduction in choroidal hyperpermeability after primary treatment than that of the ranibizumab group (0 eyes; P < 0.001). No serious adverse events related to the drugs or procedures were observed.Conclusions: This study represents the overall superiority of low-fluence PDT compared with intravitreal ranibizumab in the treatment of chronic CSC.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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Author reply – Corrected Proof

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Beaumont et al and Ueta raise concerns about the systemic safety of aflibercept for intravitreal injection, particularly regarding cerebrovascular risk and stroke, based on their analysis of safety data from the VIEW studies comparing aflibercept to r…

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Macular Morphology in Patients with Optic Nerve Head Drusen and Optic Disc Edema – Corrected Proof

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Purpose: In this study we investigated macular morphology, including individual retinal layers, in patients with optic nerve head drusen (ONHD) and optic disc edema (ODE) compared with healthy participants, using high-resolution spectral domain optical coherence tomography (OCT).Design: Prospective, cross-sectional, observational study.Participants: A total of 67 patients with ONHD, 36 patients with ODE, and 57 healthy participants.Methods: High-resolution spectral domain OCT (Copernicus [OPTOPOL Technology S.A., Zawiercie, Poland] 3-μm resolution, 7×7×2-mm volumetric scans) was used to image macula morphology. Average retinal nerve fiber layer (RNFL) thickness was measured using a semiautomated method with manual correction of the internal limiting membrane, RNFL, and retinal pigment epithelium (RPE). Retinal and RNFL thicknesses were measured and analyzed in 3 circular zones (Early Treatment Diabetic Retinopathy Study protocol). Individual retinal layers at the macula were quantified by analyzing tomograms using ImageJ (http://rsbweb.nih.gov/ij/; Accessed June 1, 2013).Main Outcome Measures: Average retinal and individual retinal layer thickness in patients with ODE or ONHD, and healthy controls.Results: Patients with ONHD had thicker retinae in the inner annulus compared with patients with ODE and controls (significant in the temporal segment compared with those with ODE [P = 0.013] and in the superior segment compared with controls [P = 0.05]). Patients with ONHD had a significantly thinner inner plexiform layer (IPL) (P = 0.02), nerve fiber layer (P = 0.05), and RPE (P = 0.0001), and thicker ganglion cell layer (P = 0.003) and outer plexiform layer (OPL) (P < 0.001) compared with controls. Patients with ODE demonstrated the thickest retina and RNFL in the outer annulus (significant in the inferior segment compared with controls, P = 0.02 for both) with significant thickening in the IPL (P = 0.004), OPL (P < 0.003), and outer segment layer (P ≤ 0.02), and severe ganglion cell loss (P = 0.004) and RPE (P = 0.0001) thinning compared with healthy volunteers.Conclusions: Our study shows that optic nerve diseases are associated with selective changes in different retinal layers in patients with ODE and ONHD. These findings may be of diagnostic value and could be taken into consideration in assessing patients and studying the pathogenesis of these conditions.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Descemet’s Membrane Endothelial Keratoplasty: Clinical Results of Single Versus Triple Procedures (Combined with Cataract Surgery) – Corrected Proof

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Purpose: To compare the outcomes of triple Descemet’s membrane endothelial keratoplasty (DMEK) versus DMEK alone in pseudophakic eyes.Design: Retrospective, comparative, interventional case series.Participants: Patients with Fuchs’ endothelial dystrophy, secondary corneal edema, and prior failed endothelial keratoplasty with or without prior cataract extraction.Methods: Outcomes of 492 DMEK procedures performed between April 2010 and August 2012 were reviewed; 292 pseudophakic eyes underwent DMEK (group 1) and 200 eyes had concurrent cataract surgery with DMEK (group 2).Main Outcome Measures: Corrected distance visual acuity, endothelial cell loss, immediate and early postoperative complications.Results: The mean age at the time of surgery was 70 years (range, 47–94 years) in group 1 and 64 years (range, 46–90 years) in group 2 (P < 0.0001). At 6 months, the median corrected distance visual acuity was 20/25 (range, 20/16–20/80; n = 164) in group 1 and 20/20 (range, 20/16–20/100; n = 121) in group 2 (P < 0.0001), excluding 21 eyes with retinal or optic nerve problems. The DMEK graft failed to clear in 9 eyes (3.1%) in group 1 and 7 eyes (3.5%) in group 2 (P = 0.34); all were regrafted successfully with DMEK. No further graft failures occurred during the follow-up period. The air reinjection rate was 30% in group 1 and 29% in group 2 (P = 0.69). The air reinjection rate dropped significantly in both groups, from 45% to 16%, after use of viscoelastic was eliminated during the tissue insertion step. The median endothelial cell loss at 3 to 6 months did not differ significantly between groups (26% in both).Conclusions: Triple DMEK was not associated with any higher risk of complications than DMEK alone. Compared with sequential management of patients with concomitant cataract and endothelial dysfunction, triple DMEK is an effective strategy in rapid visual rehabilitation and offers the advantage of a 1-stage procedure, with reduced risks and costs.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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Natural History and Retinal Structure in Patients with Usher Syndrome Type 1 Owing to MYO7A Mutation – Corrected Proof

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Purpose: To evaluate the phenotypic variability and natural history of ocular disease in a cohort of 28 individuals with MYO7A-related disease. Mutations in the MYO7A gene are the most common cause of Usher syndrome type 1, characterized by profound congenital deafness, vestibular arreflexia, and progressive retinal degeneration.Design: Retrospective case series.Participants: Twenty-eight patients from 26 families (age range, 3–65 years; median, 32) with 2 likely disease-causing variants in MYO7A.Methods: Clinical investigations included fundus photography, optical coherence tomography, fundus autofluorescence (FAF) imaging, and audiologic and vestibular assessments. Longitudinal visual acuity and FAF data (over a 3-year period) were available for 20 and 10 study subjects, respectively.Main Outcome Measures: Clinical, structural, and functional characteristics.Results: All patients with MYO7A mutations presented with features consistent with Usher type 1. The median visual acuity for the cohort was 0.39 logarithm of the minimum angle of resolution (logMAR; range, 0.0–2.7) and visual acuity in logMAR correlated with age (Spearman’s rank correlation coefficient, r = 0.71; P < 0.0001). Survival analysis revealed that acuity ≤0.22 logMAR was maintained in 50% of studied subjects until age 33.9; legal blindness based on loss of acuity (≥1.00 logMAR) or loss of field (≤20°) was reached at a median age of 40.6 years. Three distinct patterns were observed on FAF imaging: 13 of 22 patients tested had relatively preserved foveal autofluorescence surrounded by a ring of high density, 4 of 22 had increased signal in the fovea with no obvious hyperautofluorescent ring, and 5 of 22 had widespread hypoautofluorescence corresponding to retinal pigment epithelial atrophy. Despite a number of cases presenting with a milder phenotype, there seemed to be no obvious genotype–phenotype correlation.Conclusions: MYO7A-related ocular disease is variable. Central vision typically remains preserved at least until the third decade of life, with 50% of affected individuals reaching legal blindness by 40 years of age. Distinct phenotypic subsets were identified on FAF imaging. A specific allele, previously reported in nonsyndromic deafness, may be associated with a mild retinopathy.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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Pretreatment Anterior Segment Imaging During Acute Primary Angle Closure: Insights into Angle Closure Mechanisms in the Acute Phase – Corrected Proof

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Objective: To describe anterior segment optical coherence tomography (ASOCT) parameters during acute primary angle closure (APAC) before therapeutic interventions and comparative analyses of biometric parameters of APAC eyes with fellow eyes.Design: Prospective, comparative case series.Participants: Thirty-one consecutive patients with APAC.Methods: All patients underwent ASOCT imaging of both eyes during the attack, before therapeutic interventions were administered. Custom software was used to measure anterior chamber depth (ACD), anterior chamber area (ACA), anterior chamber volume (ACV), iris curvature (I-Curv), iris area (I-Area), lens vault (LV), and angle opening distance (AOD750), trabecular iris space area (TISA750), and iris thickness (IT750) at 750 μm from the scleral spur. Multivariate logistic regression modeling using forward selection was used to determine the most important biometric variables associated with APAC compared with the fellow eye during the attack.Main Outcome Measures: Anterior segment biometric parameters associated with APAC.Results: The mean age of the patients was 60.9±7.5 years, and 11 patients (35.5%) were male. The mean intraocular pressure was 3.8±9.2 mmHg in the APAC eye and 4.2±4.3 mmHg in the fellow eye before treatment (P < 0.001). After adjustment for pupil diameter, APAC eyes had smaller ACD, ACA, ACV, I-Curv (all P < 0.001), AOD750 (P = 0.037), TISA750 (P = 0.043), I-Area (P = 0.027), and IT750 (P = 0.002) and larger LV (P = 0.041) than fellow eyes. An optimal model consisting of 3 variables (pupil diameter, ACD, and I-Curv) explained 36.7% of the variance in APAC occurrence, with ACD accounting for 18.1% and I-Curv accounting for 14.1% of this variance.Conclusions: Shallower ACD and smaller I-Curv were the 2 main anterior segment biometric parameters associated with APAC during the attack. These findings present new insights into the anterior segment biometric parameters of APAC and fellow eyes before therapeutic interventions. Anatomic changes in the anterior segment explained only about one third of the variance in APAC occurrence, and the role of nonanatomic factors require further investigation.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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