To investigate choriocapillaris (CC) blood flow in unaffected fellow eyes of patients with central serous chorioretinopathy (CSC) using quantitative optical coherence tomography angiography (OCTA) ...analysis.
Case-control study.
Patients with acute, recurrent, or persistent CSC, along with healthy sex- and age-matched subjects, were included. Objective assessment of CC blood flow was performed using OCTA measurements. Total area of flow signal voids was quantified at baseline, 3 months, and 6 months. Active serous retinal detachment (SRD) was considered as a potential source of false-positive flow impairment; affected eyes were therefore excluded at onset and during follow-up, if this finding was unresolved at the time of measurement.
Sixty patients with CSC and 60 control subjects were included in this study. The total average flow signal void area was significantly higher in the unaffected eyes of CSC patients at baseline (2.70 ± 0.53 mm2 vs 2.23 ± 0.43 mm2, P < .001). At 3 months, the total average flow signal void area was greater in the affected eyes of CSC patients with resolved SRD compared with unaffected eyes (3.25 ± 0.77 mm2 vs 2.67 ± 0.68 mm2, P < .001). This total average flow signal void area was larger in unaffected eyes at baseline in recurrent/persistent cases of CSC compared to acute forms (3.74 ± 0.66 mm2 vs 2.93 ± 0.69 mm2, P = .01).
Vascular abnormalities in CSC involve CC hypoperfusion, suggestive of a primary choroidopathy including ischemic processes. These microvascular flow deficits may constitute one of a number of underlying subclinical changes preceding CSC and other pachychoroid spectrum disorders.
The most frequent site of ocular metastasis is the choroid. The occurrence of choroidal metastases has increased steadily due to the longer survival of metastatic patients and the improvement of ...diagnostic tools. Fundoscopy, ultrasonography, and fluorescein angiography are now complemented by indocyanine green angiography and optical coherence tomography. Choroidal tumor biopsy may also confirm the metastatic nature of the tumor and help to determine the site of the primary malignancy.
There is currently no consensus on the treatment strategy. Most patients have a limited life expectancy and for these complex treatments are generally not recommended. However, recent advances in systemic therapy have significantly improved survival of certain patients who may benefit from an aggressive ocular approach that could preserve vision. Although external beam radiation therapy is the most widely used treatment, more advanced forms of radiotherapy that are associated with fewer side effects can be proposed in select cases.
In patients with a shorter life expectancy, systemic therapies such as those targeting oncogenic drivers, or immunotherapy can induce a regression of the choroidal metastases, and may be sufficient to temporarily decrease visual symptoms. However, they often acquire resistance to systemic treatment and ocular relapse usually requires radiotherapy for durable control. Less invasive office-based treatments, such as photodynamic therapy and intravitreal injection of anti-VEGF, may also help to preserve vision while reducing time spent in medical settings for patients in palliative care.
The aim of this review is to summarize the current knowledge on choroidal metastases, with emphasis on the most recent findings in epidemiology, pathogenesis, diagnosis and treatment.
•Choroid is the most common ocular site for metastatic spread, especially for breast and lung cancer.•Enhanced imaging of the choroid allows better understanding and precise diagnosis of choroidal metastases.•In case the primary remains unknown, tumor biopsy may help identify the primary and guide treatment.•To date, fractionated radiotherapy remains the treatment of choice for choroidal metastases.•The place of systemic targeted therapy and “office-based” treatment such as PDT or intravitreal antiVEGF should be considered.
Purpose: Primary Macular Holes (MH) have a closure rate of 85%–90%. However, for large or recurrent MH, there is an ongoing debate regarding the best technique. Recent studies have highlighted the ...use of amniotic membrane in the treatment of recurrent MH. For this purpose, easy‐to‐use small disks of freeze‐dried and sterile human amniotic membrane (hAM) can be proposed. A phase II open and prospective clinical trial was conducted to evaluate the efficacy of a hAM in the closure of recurrent MHs.
Methods: Patients between 18 and 75 years old with full thickness MHs of all etiologies that failed to close after previous pars plana vitrectomy were included. Small disks of 3 mm or 5 mm diameter of virally inactivated, freeze‐dried and sterile hAM, with intensive microbiological controls was proposed for this study. After inclusion, all patients underwent vitrectomy and hAM placement on the MH. Closure of recurrent MH (primary objective), clinical tolerance, functional restoration and impact of hAM on the retina area (secondary objectives) were assessed in the 6 months following the surgery.
Results: Ten eyes of 10 patients with large recurrent MH of 412–1324 μm (mean = 715 μm) were treated in the study. Closure was complete in six eyes (60%). For two patients (20%), MH closed partially before recurring. Best corrected visual acuity improved for four of the six eyes who achieved complete MH closure (67%). No safety issue related to the hAM were reported. hAM can be persistent on MH after 6 months.
Conclusions: Early results of the study suggest that freeze‐dried hAM is a safe and effective option for the treatment of recurrent MH.
To evaluate the relative efficacy and safety profile of bevacizumab versus ranibizumab intravitreal injections for the treatment of neovascular age-related macular degeneration (AMD).
Multicenter, ...prospective, noninferiority, double-masked, randomized clinical trial performed in 38 French ophthalmology centers. The noninferiority limit was 5 letters.
Patients aged ≥50 years were eligible if they presented with subfoveal neovascular AMD, with best-corrected visual acuity (BVCA) in the study eye of between 20/32 and 20/320 measured on the Early Treatment of Diabetic Retinopathy Study chart and a lesion area of less than 12 optic disc areas (DA).
Patients were randomly assigned to intravitreal administration of bevacizumab (1.25 mg) or ranibizumab (0.50 mg). Hospital pharmacies were responsible for preparing, blinding, and dispensing treatments. Patients were followed for 1 year, with a loading dose of 3 monthly intravitreal injections, followed by an as-needed regimen (1 injection in case of active disease) for the remaining 9 months with monthly follow-up.
Mean change in visual acuity at 1 year.
Between June 2009 and November 2011, 501 patients were randomized. In the per protocol analysis, bevacizumab was noninferior to ranibizumab (bevacizumab minus ranibizumab +1.89 letters; 95% confidence interval CI, -1.16 to +4.93, P < 0.0001). The intention-to-treat analysis was concordant. The mean number of injections was 6.8 in the bevacizumab group and 6.5 in the ranibizumab group (P = 0.39). Both drugs reduced the central subfield macular thickness, with a mean decrease of 95 μm for bevacizumab and 107 μm for ranibizumab (P = 0.27). There were no significant differences in the presence of subretinal or intraretinal fluid at final evaluation, dye leakage on angiogram, or change in choroidal neovascular area. The proportion of patients with serious adverse events was 12.6% in the bevacizumab group and 12.1% in the ranibizumab group (P = 0.88). The proportion of patients with serious systemic or ocular adverse events was similar in both groups.
Bevacizumab was noninferior to ranibizumab for visual acuity at 1 year with similar safety profiles. Ranibizumab tended to have a better anatomic outcome. The results are similar to those of previous head-to-head studies.
Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence ...tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.
Purpose
To report the effectiveness of intravitreal aflibercept (IVT-AFL) treatment for diabetic macular edema (DME) in French clinical practice.
Methods
APOLLON (NCT02924311) was a prospective, ...observational cohort study of patients with DME. Effectiveness was evaluated by change from baseline in best-corrected visual acuity (BCVA) at 12 months in treatment-naïve patients (i.e., had not received any anti-vascular endothelial growth factor anti-VEGF agent, laser, or steroid at IVT-AFL treatment start) and previously treated patients (i.e., previously treated with anti-VEGF agents other than IVT-AFL, laser, or steroids at IVT-AFL treatment start). Secondary endpoints included change in central retinal thickness (CRT) over 12 months, frequency of injections, and proportion of patients with safety events.
Results
Of the 147 patients followed for at least 12 months and included in the effectiveness analysis, 52.4% (
n
= 77) were treatment-naïve and 47.6% (
n
= 70) were previously treated. Mean (standard deviation SD) BCVA score at baseline was 62.7 (14.3) Early Treatment Diabetic Retinopathy Study (ETDRS) letters in treatment-naïve patients and 60.0 (13.7) ETDRS letters in previously treated patients. At month 12, mean (SD) change in BCVA was + 7.8 (12.3) letters in treatment-naïve patients and + 5.0 (11.3) letters in previously treated patients. Mean CRT decreased in both patient cohorts. The mean (SD) number of IVT-AFL injections at month 12 was 7.6 (2.5) for treatment-naïve patients and 7.6 (2.3) for previously treated patients. Of 388 patients included in the safety analysis, ocular treatment-emergent adverse events occurred in 54.1% (
n
= 210) of patients.
Conclusion
IVT-AFL treatment was associated with improvements in functional and anatomic outcomes in both treatment-naïve and previously treated patients with DME in France.
To determine a threshold for interleukin (IL)-10 and IL-10/IL-6 ratio in the aqueous humor (AH) and the vitreous for the screening of vitreoretinal lymphoma (VRL).
One hundred nineteen patients for ...whom IL-10 and IL-6 in the AH and/or vitreous had been measured were included: 16 patients with a final diagnosis of VRL and 103 patients with final diagnosis of uveitis. Groups were compared according to IL-10 and IL-6 levels and demographic data.
In patients with VRL (Group 1), mean IL-10 values were 5,636 pg/mL, and in patients with uveitis (Group 2), 6.7 pg/mL in the vitreous and 190 pg/mL in Group 1 and 8.6 pg/mL in the AH. In Group 1, the mean IL-10/IL-6 ratio was 29.02 in the vitreous and 10.9 in the AH; in Group 2, ratio was 0.1 in both humors. These values were significantly different between patients with VRL and with uveitis (P < 0.001). A cutoff of 65 pg/mL and 30 pg/mL IL-10 in the vitreous and AH, respectively, was associated with sensitivity of 93% and 78%, respectively, and specificity of 100% and 97%, respectively. A ratio higher than 1 in the vitreous had sensitivity of 93% and specificity of 100%.
Vitreoretinal lymphoma diagnosis is difficult, and tools like interleukin measurements in AH and vitreous can make it easier. The use of a cutoff for IL-10 and IL-10/IL-6 ratio could allow for an earlier diagnosis that may improve prognosis.
To determine the long-term visual and systemic outcomes of uveitis patients with biopsy-proven sarcoidosis.
A retrospective study of biopsy-proven sarcoid uveitis, with a 3-year minimum follow-up, ...seen at Lyon University Hospital, between April 2004 and January 2016.
A total of 83 patients were included, with a median age at onset of 52 (37-62) years and an unbalanced gender ratio (women 77.1%). Thirty-one patients had original systemic sarcoidosis in addition to ocular localisation, whereas 52 initially presented with isolated sarcoid uveitis. Among the latter, 7.7% (n=4) developed an extraocular disease after a median follow-up duration of 60 (44-110) months. The systemic spread in these patients included cutaneous sarcoids (n=2), arthritis (n=1) and multiple mononeuritis (n=1). Complete visual recovery was obtained for 60.2% of all patients and 89.2% had retrieved best-corrected visual acuity (BCVA) >20/50 in both eyes. A unilateral loss of BCVA of worse than 20/200 was documented in two patients in the isolated sarcoid uveitis group. No patient suffered from bilateral severe visual impairment or blindness. Factors linked to a poor visual prognosis, defined by BCVA ≤20/50 in at least one eye, were chronic macular oedema (p=0.009) and persistent ocular inflammation (p=0.0005).
In this large European series of biopsy-proven sarcoidosis to date, with a prolonged follow-up, sarcoid uveitis was suggestive of a favourable systemic and visual outcome. Clinically isolated uveitis that revealed sarcoidosis remained a strictly ocular condition in most cases.
To investigate the efficacy and tolerance of systemic treatments for the prevention of HLA-B27-associated acute uveitis (AU) recurrence.
Retrospective review of patients with HLA-B27-associated ...uveitis followed in our tertiary center over a 15-year period. Systemic treatments were prescribed to patients with frequent (more than 2 flares per year) or severe uveitis, according to a step-up strategy.
101 patients (51.5% of men, 88.1% of white Europeans) with a median age of 37 years. AU was mostly recurrent (68.3%) and associated with spondyloarthritis (60.4%). After a median follow-up duration of 22 months (3-73), 37.6% of the patients have received systemic treatment. 88.5% of the patients have been treated with sulfasalazine (SSZ) for ophthalmologic purposes (23/26). Methotrexate (MTX) and anti-TNFα agents have been initiated for a rheumatologic indication in 81.8% (9/11) and 100% of the patients (13/13), respectively. The annual uveitis relapse rate significantly decreased on SSZ (0.37 recurrences/year versus baseline 2.46 recurrences/year; p<0.001) and MTX (1.54 recurrences/year versus 4.17/year; p = 0.008). Patients under ADA for ophthalmologic purposes (n = 2) did not experience any recurrence.
We report an open-label strategy to prevent the recurrences of HLA-B27-associated AU. First-line sulfasalazine reduced uveitis relapses. The use of anti-TNFα agents for ophthalmologic purposes was unnecessary with rare exceptions.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Diagnosis of uveitis is difficult. Etiologic investigations should take into account the epidemiology of uveitis and should focus on the most severe forms of the disease and those which can be ...treated. This study was undertaken to establish recommendations for the diagnosis of uveitis.
Recommendations were developed by a multidisciplinary panel of 14 experts, including internists, ophthalmologists, and rheumatologists, and are based on a review of the literature and the results of the ULISSE study, which was the first prospective study to assess the efficacy of a standardized strategy for the etiologic diagnosis of uveitis. The following groups of patients are not included in these recommendations: children, immunocompromised patients, patients with severe retinal vasculitis, and those with specific eye diseases diagnosed by ophthalmologic examination only.
Diagnosis should be guided by the medical history of the patient and physical examination. Serologic screening for syphilis is appropriate in all forms of uveitis. If uveitis is not diagnosed at this stage, investigations oriented by the anatomic characteristics of uveitis are proposed. These consist of assays for HLA-B27 (in unilateral acute anterior non-granulomatous uveitis), serum angiotensin-converting enzyme, interferon-gamma release, chest computed tomography (chronic uveitis), cerebral magnetic resonance imaging and anterior chamber tap with interleukin-10 analysis (intermediate or posterior uveitis in patients >40years-old). Other investigations prescribed in the absence of orientation are usually unhelpful.
A strategy is proposed for the etiologic diagnosis of uveitis. The benefit of more invasive investigations remains to be determined.
•Etiologic diagnosis of uveitis should be guided by anatomic localization.•Syphilis serology is useful in all types of uveitis.•HLA-B27 typing is helpful in acute anterior non-granulomatous uveitis.•Measurement of ACE, IFN-γ release, and chest CT scans are useful in chronic uveitis.•Cerebral MRI and ACT with IL-10 analysis help in intermediate or posterior uveitis.
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