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JAMA Ophthalmology Jun 2024The Diabetic Retinopathy Clinical Research Network Protocol S suggested that vitrectomy for vitreous hemorrhage (VH) or tractional retinal detachment (TRD) was more...
IMPORTANCE
The Diabetic Retinopathy Clinical Research Network Protocol S suggested that vitrectomy for vitreous hemorrhage (VH) or tractional retinal detachment (TRD) was more common among eyes assigned initially to panretinal photocoagulation (PRP) vs anti-vascular endothelial growth factor (anti-VEGF) for proliferative diabetic retinopathy (PDR). These clinical implications warrant further evaluation in the clinical practice setting.
OBJECTIVE
To explore outcomes of PDR treated with PRP monotherapy compared with matched patients treated with anti-VEGF monotherapy.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective cohort study using an aggregated electronic health records research network. Patients with PDR who received PRP or anti-VEGF monotherapy between January and September 2023 were included before propensity score matching. Patients were excluded with 6 or fewer months' follow-up after monotherapy or with a combination of PRP and anti-VEGF. Data were analyzed in September 2023.
EXPOSURES
Patients with new PDR diagnoses stratified by monotherapy with PRP or anti-VEGF agents using Current Procedural Terminology code.
MAIN OUTCOME MEASURES
Incidence of pars plana vitrectomy (PPV), VH, or TRD.
RESULTS
Among 6020 patients (PRP cohort: mean [SD] age, 64.8 [13.4]; 6424 [50.88%] female; 3562 [28.21%] Black, 6180 [48.95%] White, and 2716 [21.51%] unknown race; anti-VEGF cohort: mean [SD] age, 66.1 [13.2]; 5399 [50.52%] male; 2859 [26.75%] Black, 5377 [50.31%] White, and 2382 [22.29%] unknown race) who received treatment, PRP monotherapy was associated with higher rates of PPV when compared with patients treated with anti-VEGF monotherapy at 5 years (RR, 1.18; 95% CI, 1.05-1.36; RD, 1.37%; 95% CI, 0.39%-2.37%; P < .001), with similar associations at 1 and 3 years. PRP monotherapy was associated with higher rates of VH at 5 years (relative risk [RR], 1.72; 95% CI, 1.52-1.95; risk difference [RD], 7.05; 95% CI, 5.41%-8.69%; P < .001) and higher rates of TRD at 5 years (RR, 2.76; 95% CI, 2.26-3.37; RD, 4.25%; 95% CI, 3.45%-5.05%; P < .001), with similar magnitudes of associations at 6 months, 1 year, and 3 years, when compared with patients treated with anti-VEGF monotherapy.
CONCLUSIONS AND RELEVANCE
These findings support the hypothesis that patients with PDR treated with PRP monotherapy are more likely to develop VH, TRD, and undergo PPV when compared with matched patients treated with anti-VEGF monotherapy. However, given the wide range in relative risk, confounding factors may account for some of the association between PRP vs anti-VEGF monotherapy and outcomes evaluated.
PubMed: 38842828
DOI: 10.1001/jamaophthalmol.2024.1844 -
American Journal of Ophthalmology Case... Sep 2024We report the case of a 16-year-old boy with partial optic nerve avulsion (ONA) and submacular hemorrhage (SMH) resulting from blunt ocular trauma who underwent...
PURPOSE
We report the case of a 16-year-old boy with partial optic nerve avulsion (ONA) and submacular hemorrhage (SMH) resulting from blunt ocular trauma who underwent pneumatic displacement and subsequent monitoring with optical coherence tomography (OCT) and fundus photography.
OBSERVATIONS
Reduced visual acuity was observed in the right eye at presentation (20/2400). Vitreous hemorrhage, partial ONA, and SMH were observed during dilated fundus examination. SMH was managed via pneumatic displacement. Subsequent examination revealed improvement in the visual acuity of the right eye with a substantial reduction in the subfoveal hemorrhage. Further improvement in visual acuity was observed 6 months after the injury (20/150). A smaller optic nerve head excavation defect, foveal atrophy, and reabsorption of SMH were observed during fundus examination. OCT of the optic nerve revealed that glial growth had covered the avulsion excavation. However, atrophy of the outer retinal layer of the fovea was observed during macular OCT.
CONCLUSIONS AND IMPORTANCE
This case emphasizes the importance of performing multimodal imaging in cases of ONA as it enables the identification of alterations in the retinal layers and optic nerve. The subretinal hemorrhage was displaced from the subfoveal region without any adverse effects.
PubMed: 38841154
DOI: 10.1016/j.ajoc.2024.102083 -
Ophthalmologica. Journal International... Jun 2024Retinal vasculitis (RV) signifies the inflammation of various retinal vessels. Noninfectious RV differs from infectious RV with regard to its pathogenesis and treatment.... (Review)
Review
BACKGROUND
Retinal vasculitis (RV) signifies the inflammation of various retinal vessels. Noninfectious RV differs from infectious RV with regard to its pathogenesis and treatment. It can have varied clinical presentations and may be associated with systemic vasculitic diseases.
SUMMARY
Noninfectious RV can be caused due to type-III hypersensitivity reactions, increased expression of intracellular adhesion molecules, and genetic susceptibility. Noninfectious RV is primarily classified on the basis of the type of retinal vessels involved. It can be further classified as an occlusive or nonocclusive. RV can be a major association of systemic diseases like Behcet's disease, sarcoidosis and systemic lupus erythematosus. Newer modalities, like ultra-widefield fundus fluorescein angiography, can help in the management of RV. Effective treatment of noninfectious RV requires anti-inflammatory and immunosuppressive therapy. The patients may require treatment with high-dose corticosteroids and biological agents. Anti-vascular endothelial growth factor injections and laser photocoagulation may be indicated to treat the occlusive disease. Prompt treatment may prevent complications like vitreous hemorrhage, neovascular glaucoma, and tractional retinal detachment. The treatment more often requires a multidisciplinary approach.
KEY MESSAGES
This review provides a comprehensive update on the various causes of noninfectious RV, including both systemic and isolated ocular conditions. It also details various complications and management strategies for this condition.
PubMed: 38830340
DOI: 10.1159/000539608 -
Ophthalmology Science 2024Automated machine learning (AutoML) has emerged as a novel tool for medical professionals lacking coding experience, enabling them to develop predictive models for...
PURPOSE
Automated machine learning (AutoML) has emerged as a novel tool for medical professionals lacking coding experience, enabling them to develop predictive models for treatment outcomes. This study evaluated the performance of AutoML tools in developing models predicting the success of pneumatic retinopexy (PR) in treatment of rhegmatogenous retinal detachment (RRD). These models were then compared with custom models created by machine learning (ML) experts.
DESIGN
Retrospective multicenter study.
PARTICIPANTS
Five hundred and thirty nine consecutive patients with primary RRD that underwent PR by a vitreoretinal fellow at 6 training hospitals between 2002 and 2022.
METHODS
We used 2 AutoML platforms: MATLAB Classification Learner and Google Cloud AutoML. Additional models were developed by computer scientists. We included patient demographics and baseline characteristics, including lens and macula status, RRD size, number and location of breaks, presence of vitreous hemorrhage and lattice degeneration, and physicians' experience. The dataset was split into a training (n = 483) and test set (n = 56). The training set, with a 2:1 success-to-failure ratio, was used to train the MATLAB models. Because Google Cloud AutoML requires a minimum of 1000 samples, the training set was tripled to create a new set with 1449 datapoints. Additionally, balanced datasets with a 1:1 success-to-failure ratio were created using Python.
MAIN OUTCOME MEASURES
Single-procedure anatomic success rate, as predicted by the ML models. F2 scores and area under the receiver operating curve (AUROC) were used as primary metrics to compare models.
RESULTS
The best performing AutoML model (F2 score: 0.85; AUROC: 0.90; MATLAB), showed comparable performance to the custom model (0.92, 0.86) when trained on the balanced datasets. However, training the AutoML model with imbalanced data yielded misleadingly high AUROC (0.81) despite low F2-score (0.2) and sensitivity (0.17).
CONCLUSIONS
We demonstrated the feasibility of using AutoML as an accessible tool for medical professionals to develop models from clinical data. Such models can ultimately aid in the clinical decision-making, contributing to better patient outcomes. However, outcomes can be misleading or unreliable if used naively. Limitations exist, particularly if datasets contain missing variables or are highly imbalanced. Proper model selection and data preprocessing can improve the reliability of AutoML tools.
FINANCIAL DISCLOSURES
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
PubMed: 38827487
DOI: 10.1016/j.xops.2024.100470 -
[Zhonghua Yan Ke Za Zhi] Chinese... Jun 2024To evaluate the efficacy of sutureless intrascleral intraocular lens (IOL) fixation with the modified Yamane technique. It was a retrospective case series study....
To evaluate the efficacy of sutureless intrascleral intraocular lens (IOL) fixation with the modified Yamane technique. It was a retrospective case series study. Patients undergoing sutureless intrascleral IOL fixation with the modified Yamane technique were included at Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University from January 2022 to September 2023. Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), recorded as the logarithm of the minimum angle of resolution (logMAR), were measured before surgery and at 1 day, 3 days, 1 week, 1 month, and 3 months postoperatively. Refractive error and intraocular pressure were also checked. Anterior segment examination with a slit lamp microscope, fundus examination, anterior segment and posterior segment optical coherence tomography were performed. Intraoperative and postoperative ocular complications were documented. A total of 53 patients (53 eyes) were included in this study, comprising 40 males and 13 females, with a median age of 60 (49, 68) years. Among them, the proportion of a history of trauma was 22.6% (12/53). There was 1 eye with intraoperative vitreous hemorrhage (1.9%). All eyes had no obvious hypotony, no obvious inflammation in the anterior chamber, and no pupillary abnormalities at 1 week after surgery. The mean follow-up time was (8.0±3.3) months (range, 3 to 16 months). There was no iris capture, re-dislocation, or haptic exposure of the IOL during the follow-up. The corneal endothelial cell density was (2 236±704) cells/mm preoperatively and (1 964±628) cells/mm at 1 month, with significant difference (<0.001). The UCVA (logMAR) was 1.53±0.75 preoperatively, 0.18±0.17 at 1 month, 0.15±0.14 at 3 months, and 0.14±0.13 at the final visit (<0.001). The UCVA (logMAR) at 1 month was significantly different from that at 3 months and the final visit (both <0.05). At 1 month, 50.9% (27/53) of the eyes had an UCVA (logMAR)≤0.1, and the rate was 56.6% (30/53) at 3 months. The BCVA (logMAR) was 0.25±0.21, 0.03±0.06, 0.02±0.06, and 0.02±0.06 before surgery, at postoperative1 month, 3 months, and the final visit, respectively (<0.001). The BCVA (logMAR) at 1 month was not significantly different from that at 3 months and the final visit (both >0.05). The rate of the eyes with a BCVA (logMAR)≤0 was 81.1% (43/53) at 1 month and 83.0% (44/53) at 3 months. The IOL tilt was (5.18±2.60)° at postoperative 1 month and (5.08±2.48)° at postoperative 3 months, without statistically significant difference (>0.05). The IOL decentration was (0.35±0.24) mm at postoperative 1 month and (0.32±0.24) mm at postoperative 3 months, without statistically significant difference (>0.05). Sutureless intrascleral IOL fixation with the modified Yamane technique is simpler and more minimally invasive to achieve a stable and centered IOL implantation with fewer complications and good visual prognosis.
Topics: Humans; Middle Aged; Male; Female; Retrospective Studies; Aged; Lens Implantation, Intraocular; Lenses, Intraocular; Sclera; Visual Acuity; Sutureless Surgical Procedures
PubMed: 38825949
DOI: 10.3760/cma.j.cn112142-20240103-00008 -
Ophthalmology. Retina May 2024To study the safety and efficacy of intravitreal infliximab administered at the conclusion of pars plana vitrectomy (PPV) in the treatment of proliferative...
OBJECTIVE
To study the safety and efficacy of intravitreal infliximab administered at the conclusion of pars plana vitrectomy (PPV) in the treatment of proliferative vitreoretinopathy (PVR) associated with rhegmatogenous retinal detachment (RRD).
DESIGN
Randomized controlled phase 2 clinical trial.
SUBJECTS
Patients with primary RRD and Grade C PVR, according to the updated Retina Society Classification.
METHODS
Sixty-six Patients were randomized in a 1:1 ratio to undergo PPV and silicone oil (SO) injection with or without intravitreal injection of 1 mg/0.05 mL of infliximab in the air-filled globe before SO injection at PPV conclusion. Surgeons were masked to treatment allocation until PPV conclusion.
MAIN OUTCOME MEASURES
The primary outcome measure was anatomic success (defined as complete retinal reattachment without a tamponade at 6 months post SO removal). Secondary outcome measures were final best corrected visual acuity (BCVA), single operation success rate (SOSR), rate of recurrent detachment, central macular thickness (CMT) by macular optical coherence tomography (OCT), macular function by multifocal electroretinogram and macular vascular density (VD) by OCT angiography.
RESULTS
60 eyes of 60 patients, 30 eyes in each group, completed the study. At baseline, there were no differences regarding age, gender, history of trauma, lens status, duration of RRD, BCVA, intraocular pressure (IOP), intra-ocular inflammation (IOI), detachment extent in clock hours, number/size of breaks, presence of vitreous hemorrhage, axial length, or grade/extent of PVR between both groups. For the outcome measures, 30 eyes in the infliximab group achieved anatomic success vs 29 eyes in the control group. The SOSR was higher in the infliximab group (26) vs the control (23), but this was not statistically significant (p = 0.317). Final BCVA was better in the infliximab group (mean logMAR (SD) = 0.96 (0.4), Snellen equivalent ≈ 20/180) vs the control (1.14 (0.4), Snellen equivalent ≈ 20/280) (p = 0.044). There were no differences regarding IOP, IOI, time of SO removal, macular function, CMT, or VD.
CONCLUSION
PPV with SO tamponade with or without intravitreal infliximab is effective in treating PVR-associated RRD. Infliximab may be associated with modest improvement in final visual outcomes but not anatomical outcomes.
PubMed: 38823559
DOI: 10.1016/j.oret.2024.05.016 -
Journal of Pediatric Ophthalmology and... May 2024To evaluate the demographic profile of premature infants presenting with stage 4B and stage 5 retinopathy of prematurity (ROP) at a tertiary referral center in South...
PURPOSE
To evaluate the demographic profile of premature infants presenting with stage 4B and stage 5 retinopathy of prematurity (ROP) at a tertiary referral center in South India.
METHODS
This was a retrospective review including all premature infants with stage 4B and 5 ROP between January 1, 2015 and December 31, 2022. Parameters included the newborns born at the tertiary care nursery of various institutes, gestational age, birth weight, age at presentation to the hospital, risk factors, screening details, neonatal intensive care unit details, reason for consultation, and timing of referral to the center.
RESULTS
Two hundred twenty eyes of 110 premature infants were included. Of 110 infants, 6 were born within the same city and 104 were from other districts or states. Mean birth weight was 1,125 ± 360 g and mean gestational age at birth was 28 ± 2 weeks. Mean age was 42 ± 82 weeks and median age at presentation was 17 weeks (range: 2.86 to 591 weeks). Male-to-female infant ratio was 1.34:1. Fifty (45.4%) infants had bilateral stage 5 ROP, 17 (15.4%) had stage 5 in one eye and stage 4B in the other eye, 15 (13.6%) had bilateral stage 4B and 23 (20.9%) had stage 4B in one eye and stage 4A/stage 3 in the other eye. Five (4.5%) had stage 5 in one eye and vitreous hemorrhage/stage 4A in the other eye. Among those with bilateral stage 5 ROP, 90% were from neighboring districts/states. Fifty-two (47.27%) infants underwent vitreoretinal surgery. Of 110 infants, 28 (25.45%) were self-referred (late presentation due to family-related issues), 80 (72.73%) were referred by ophthalmologists either after a few sessions of late screening or for further management, 1 (0.91%) was referred through telescreening, and 1 was referred from pediatricians directly to the hospital.
CONCLUSIONS
This study highlights the importance of awareness of the disease and screening of premature infants. Lack of these two factors leads to late presentation of these infants with advanced stages and serious implications. .
PubMed: 38815098
DOI: 10.3928/01913913-20240508-02 -
Indian Journal of Ophthalmology Jun 2024Submacular hemorrhage (SMH) is a sight-threatening disorder. Choroidal neovascularization secondary to age-related macular degeneration, polypoidal choroidal...
BACKGROUND
Submacular hemorrhage (SMH) is a sight-threatening disorder. Choroidal neovascularization secondary to age-related macular degeneration, polypoidal choroidal vasculopathy, trauma, angioid streaks, and pathological myopia are a few important causes. The conventional treatment of massive SMH is vitrectomy with manual removal of the clot with extensive retinectomy with/without tissue plasminogen activator (tPA). The usual dose of subretinal tPA is 10-25 µg.
PURPOSE
To describe a new surgical approach in a case of massive SMH with retinal detachment without retinectomy.
SYNOPSIS
In our case of near total hemorrhagic retinal detachment due to subretinal hemorrhage caused by trauma (road traffic accident), the patient presented with a visual acuity of counting fingers. Core vitrectomy was performed and posterior vitreous detachment was induced. The locations for retinotomy to inject and aspirate subretinal blood were selected at the maximum height of retinal elevation near the arcades. Recombinant tPA (10 µg/0.1 ml concentration; 0.3 ml injected in two locations) was injected subretinally with a 23-G soft tip cannula in the superotemporal and inferonasal quadrant causing subretinal bleb formation. Subsequently, the surgeon waited for approximately 20 min on the table for the liquefaction of the clot. The liquefied blood and tPA were drained with a silicone soft tip. Endolaser was performed at the retinotomy site and 1000cs silicone oil was injected. No signs of toxicity such as vitritis, vasculitis, or retinal necrosis were noted.
HIGHLIGHTS
Our unique technique of high-dose intraoperative subretinal tPA (60 µg) is safe and helpful in rapid clot lysis and recovery of visual acuity. The patient gained a visual acuity of 20/80 from counting fingers after 1 month of surgery and 20/60 after silicone oil removal. A high dose of tPA aids in the immediate aspiration of blood from a small retinotomy. A 23-G soft tip was used instead of a 41-G subretinal cannula to inject a large quantity of subretinal tPA.
VIDEO LINK
https://youtu.be/JzZBDUfa3NA.
Topics: Humans; Tissue Plasminogen Activator; Retinal Hemorrhage; Vitrectomy; Fibrinolytic Agents; Visual Acuity; Tomography, Optical Coherence; Male; Fundus Oculi; Fluorescein Angiography; Dose-Response Relationship, Drug
PubMed: 38804808
DOI: 10.4103/IJO.IJO_2295_23 -
European Journal of Ophthalmology May 2024To describe the clinical and imaging features of circumscribed choroidal hemangiomas (CCH) and their treatment outcomes with Ruthenium-106 (Ru) plaque brachytherapy.
PURPOSE
To describe the clinical and imaging features of circumscribed choroidal hemangiomas (CCH) and their treatment outcomes with Ruthenium-106 (Ru) plaque brachytherapy.
METHODS
Retrospective study of 24 patients (24 eyes) diagnosed with CCH and treated with Ru plaque between 2017 and 2022. Analysis included pre- and post-treatment clinical and imaging features such as tumor regression, reduction in height, subretinal fluid (SRF) resolution, and change in best-corrected visual acuity (BCVA).
RESULTS
The mean age at presentation was 36 years (range, 16-57). The most common tumor location was the temporal quadrant ( = 19) with macular involvement ( = 13). Associated features were macular SRF ( = 22) and inferior exudative retinal detachment ( = 10). Nineteen of the 24 patients underwent primary treatment, whereas 5 patients underwent plaque as a salvage treatment. The mean tumor apex dose was 40 Gy. At a median follow-up of 7.5 months (range 3-65 months), 18 eyes showed complete regression, whereas 6 eyes showed partial regression. The mean height decreased from 4.8 (SD 1.28) mm at presentation to 2.5 (SD 1.63) mm. Median BCVA improved from logMAR 1.2 (IQR 0.4-2) at baseline to logMAR 1.05 (IQR 0.1-1.95) ( = 0.4). Complete resolution of the macula and tumor SRF was observed in 15 (68%) and 13 (57%) eyes, respectively. The radiation-related complications observed were radiation maculopathy (4 eyes), retinopathy (1 eye), and vitreous hemorrhage (1 eye).
CONCLUSION
Ruthenium-106 plaque brachytherapy is effective for CCH (> 3 mm height) as a primary and salvage treatment for tumors unresponsive to other modalities.
PubMed: 38794917
DOI: 10.1177/11206721241257974