Purpose
To report the 24‐month outcomes of vascular endothelial growth factor (VEGF) inhibitors for myopic choroidal neovascularization (mCNV) in predominantly Caucasian eyes in routine clinical ...practice.
Methods
Retrospective analysis of treatment‐naïve eyes starting intravitreal injection of VEGF inhibitors of either bevacizumab (1.25 mg) or ranibizumab (0.5 mg) for mCNV from 1 January 2006 to 31 May 2018 that were tracked in the Fight Retinal Blindness! registry.
Results
We identified 203 eyes (bevacizumab–85 and ranibizumab–118) of 189 patients. The estimated mean (95% CI) change in VA over 24 months for all eyes using longitudinal models was +8 (5, 11) letters with a median (Q1, Q3) of 3 (2, 5) injections given mostly during the first year. The estimated mean change in VA at 24 months was similar between bevacizumab and ranibizumab +9 (5, 13) letters for bevacizumab versus +9 (6, 13) letters for ranibizumab; p = 0.37. Both agents were also similar in the mCNV activity outcomes, treatment frequency and visit frequency.
Conclusions
The 24‐month treatment outcomes of VEGF inhibitors for mCNV were favourable in this largest series yet reported of predominantly Caucasian eyes in routine clinical practice, with approximately two lines of visual gain and a median of three injections given mostly during the first year. These outcomes are similar to those reported for predominantly Asian eyes. Bevacizumab appeared to be as safe and effective as ranibizumab.
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.
To evaluate the repeatability and reproducibility of retinal and choroidal thickness measured with Swept source Optical Coherence Tomography (SS-OCT) in eyes with Diabetic Macular Edema (DME).
42 DME ...eyes were imaged using SS-OCT standard Macular scanning protocols. Retinal and choroidal thickness were measured in the Total macular circle (TMC) and foveal central subfield (FCS) using device-integrated specific software. The coefficient of repeatability (CR) and intraclass correlation coefficient (ICC) were determined as a measure of repeatability and relative reliability within graders. Reproducibility was assessed using Bland-Altman plots and 95% limits of agreement (LoA) were determined as a measure of interobserver variability.
Intragrader CR of retinal and choroidal thickness were 8.37 and 12.20 microns for TMC and 22.24 and 32.40 microns for FCS, and intergrader 95% LoA were 7.37-8.69 and -27.2-27.71 microns for TMC and -34.21-41.93 and -30.46-24.84 for FCS, respectively. Retinal and choroidal thickness showed very good intraobserver reliability for both TMC and FCS (ICC 0.99, LoA 0.98-0.99 in all cases). Intraobserver and interobserver variability for retinal and choroidal thickness was not significantly different for TMC (p = 0.98 and p = 0.90, p = 0.98 and p = 0.91) or FCS (p = 0.97 and p = 0.85, p = 0.78 and p = 0.73), respectively.
Retinal and choroidal thickness in DME eyes can be quantified with good reliability, repeatability and reproducibility using new OCT devices that incorporate swept source technology. The technical advantages of this technology may provide new insights in the understanding of the choroidal changes related with DME.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose
The purpose of this study is to evaluate the predictive capacity of the baseline hyperreflective dots (HRDs) on the functional and anatomical response in patients with diabetic macular edema ...(DME). Additionally, we assessed the impact of the intravitreal dexamethasone (DEX) implant on the functional and anatomic outcomes.
Methods
Retrospective, multicenter study. The number of HRDs was graded in four different stages: A none HRDs; B few, 1–10 HRDs; C moderate, 11–20 HRDs; and D many, ≥ 21 HRDs. For statistical purposes, groups A and B were combined scarce HRDs (S-HRDs) and group D was renamed as abundant HRDs (A-HRDs). The primary endpoints were the mean change in best corrected visual acuity (BCVA) and central macular thickness (CMT) according to baseline HRD stage.
Results
One hundred eyes from one hundred patients were included in the study. Mean BCVA significantly improved from 52.9 (50.0 to 55.8) letters ETDRS at baseline to 57.2 (54.0 to 60.4) letters at month 6,
p
= 0.0039. There were no significant differences between the S-HRDs and A-HRD study groups in BCVA. As compared to baseline, CMT reduction was 106.3 (59.8 to 152.7) μm and 94.2 (34.7 to 153.7) μm in S-HRDs and A-HRD groups, respectively (
p
< 0.0001 each, respectively). Twenty-three (65.7%) and 18 (62.1%) eyes achieved a CMT reduction ≥ 10% in the S-HRD and A-HRD groups, respectively,
p
= 0.7640. DEX implant significantly reduced the presence of outer nuclear layer (ONL) disruptions (
p
= 0.0010).
Conclusions
The number of HRDs did not influence either functional or anatomic outcomes. DEX implant significantly decreases the number of eyes with ONL disruptions, which might improve retinal integrity.
Supervised deep learning (DL) algorithms are highly dependent on training data for which human graders are assigned, for example, for optical coherence tomography (OCT) image annotation. Despite the ...tremendous success of DL, due to human judgment, these ground truth labels can be inaccurate and/or ambiguous and cause a human selection bias. We therefore investigated the impact of the size of the ground truth and variable numbers of graders on the predictive performance of the same DL architecture and repeated each experiment three times. The largest training dataset delivered a prediction performance close to that of human experts. All DL systems utilized were highly consistent. Nevertheless, the DL under‐performers could not achieve any further autonomous improvement even after repeated training. Furthermore, a quantifiable linear relationship between ground truth ambiguity and the beneficial effect of having a larger amount of ground truth data was detected and marked as the more‐ground‐truth effect.
Opening the AI blackbox. Artificial Intelligence is both amazing and yet a black box. This study shows how the inner gears of deep learning work in a similar way to how a student depends heavily on their teachers. The best trained networks segment almost as well as human experts. And yet, AI is limited and, unlike humans, cannot find its way very well with limited information.
To describe the role of local anaesthetic blocks as a potential cause of paracentral acute middle maculopathy (PAMM) after uneventful ocular surgery.
Retrospective, observational, international, ...multicentre case series. Nine cases of PAMM with associated visual loss following uneventful ocular surgery with local anaesthetic blocks were observed in a 9-year period (2011-2020). Demographic, ocular and systemic data, anaesthetic data and surgical details were collected. Visual acuity (VA), fundus photography, fluorescein angiography, optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) images were reviewed.
All nine cases were associated with decreased VA at 24 h postoperative check (ranging from hand movement to 20/200). A hyperreflective band within the middle retinal layers was observed in the structural OCT in the acute phase, evolving to thinning and atrophy of the inner retinal layers in sequential follow-up scans performed. Fluorescein angiography showed delayed perfusion in early arterial phase with normal perfusion in late venous phases. OCTA showed decreased perfusion in the deep capillary plexus. Visual recovery was variable between cases during follow-up (ranging from count fingers to 20/20).
A combination of a vasoconstrictive effect of the anaesthetic agent, an intraocular pressure spike and a mechanical effect of the volume of anaesthetic injected may result in decreased retinal artery perfusion and be evidenced as PAMM in OCT scans. PAMM may present as a potential complication of local anaesthetic blocks in cases of unexpected visual loss after uneventful ocular surgery.
Purpose
To compare the outcomes of two different antivascular endothelial growth factor treatment regimens for treatment-naive eyes with neovascular age-related macular degeneration in routine ...clinical care at 12 and 24 months in Spain.
Methods
Observational study using the Fight Retinal Blindness (FRB) outcomes registry platform. Eyes were treated with fixed bimonthly (FB) aflibercept group at one center and a treat-and-extend (TAE) regimen using either aflibercept or ranibizumab at the other center.
Results
We included 192 eyes. Of these, 160 eyes (83%) completed 12 months (86 TAE and 74 FB) and 79 (41%) completed 24 months (46 for TAE and 33 for FB) of follow-up. No statistically significant differences (
p
> 0.05) were found regarding mean visual acuity (VA, logMAR letters) at baseline (12 month cohort TAE 59.6 vs FB 57.9; 24 month cohort TAE 61.7 vs FB 62.6), final mean VA (12 month cohort TAE 61.1 vs FB 63.0; 24 month cohort TAE 64.8 vs FB 66.4), and median number of injections (12 months TAE 7 vs FB 7; 24 months TAE 11 vs FB 12). However, the distribution of injection frequencies for the TAE group was larger, with 35% of TAE eyes receiving ≤ 6 injections at 12 months compared with only 19% of FB eyes (
p
= 0.024).
Conclusion
Similar VA results were observed with TAE and FB regimens, with no differences in the median number of injections. However, the TAE approach seemed to deliver a wider distribution of injection frequencies due to its individualized approach, which may help reduce the burden of injections in some eyes.
Purpose
To assess whether serum cytokine and growth factor levels are associated with diabetic macular edema (DME) and uveitic macular edema (UME) objective severity.
Methods
Cross-sectional ...observational study of 81 patients (1 eye/patient) with DME (
n
=48) and UME (
n
=33). Macular edema (ME) was defined upon central macular thickness (CMT) ≥ 300 μm on spectral domain optical coherence tomography (OCT). Serum samples were obtained from peripheral blood and IL-1β, IL-6, IL-8, IL-10, MCP-1, TNF-α, and VEGF levels were determined by Luminex analysis. Main outcome measure was the correlation between mediators’ levels and CMT and macular volume (MV) on OCT for ME cases.
Results
In DME, IL-6 levels were found to significantly correlate with MV (
r
=0.324;
p
=0.028) whereas in UME, IL-8 was significantly associated with both CMT (
r
=0.401;
p
=0.021) and MV (
r
=0.391;
p
=0.024). IL-8 independently correlated with CMT (
ß
=177.2;
p
=0.033) and MV (
ß
=3.17;
p
=0.008) in UME multivariate model.
Conclusion
Peripheral blood IL-6 and IL-8 levels could play a role in the severity of DME and UME, respectively. IL-8 even seems to be independently associated with CMT and MV in UME cases. Such systemic implications could enforce DME and UME personalized diagnostic and therapeutic approaches.
Several studies published so far used highly selective image datasets from unclear sources to train computer vision models and that may lead to overestimated results, while those studies conducted in ...real-life remain scarce. To avoid image selection bias, we stacked convolutional and recurrent neural networks (CNN-RNN) to analyze complete optical coherence tomography (OCT) cubes in a row and predict diabetic macular edema (DME), in a real-world diabetic retinopathy screening program. A retrospective cohort study was carried out. Throughout 4-years, 5314 OCT cubes from 4408 subjects who attended to the diabetic retinopathy (DR) screening program were included. We arranged twenty-two (22) pre-trained CNNs in parallel with a bidirectional RNN layer stacked at the bottom, allowing the model to make a prediction for the whole OCT cube. The staff of retina experts built a ground truth of DME later used to train a set of these CNN-RNN models with different configurations. For each trained CNN-RNN model, we performed threshold tuning to find the optimal cut-off point for binary classification of DME. Finally, the best models were selected according to sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) with their 95% confidence intervals (95%CI). An ensemble of the best models was also explored. 5188 cubes were non-DME and 126 were DME. Three models achieved an AUROC of 0.94. Among these, sensitivity, and specificity (95%CI) ranged from 84.1–90.5 and 89.7–93.3, respectively, at threshold 1, from 89.7–92.1 and 80–83.1 at threshold 2, and from 80.2–81 and 93.8–97, at threshold 3. The ensemble model improved these results, and lower specificity was observed among subjects with sight-threatening DR. Analysis by age, gender, or grade of DME did not vary the performance of the models. CNN-RNN models showed high diagnostic accuracy for detecting DME in a real-world setting. This engine allowed us to detect extra-foveal DMEs commonly overlooked in other studies, and showed potential for application as the first filter of non-referable patients in an outpatient center within a population-based DR screening program, otherwise ended up in specialized care.
To perform qualitative and quantitative analyses of retinal and choroidal morphology in patients with punctate inner choroidopathy (PIC) using enhanced depth imaging optical coherence tomography ...(EDI-OCT).
Cross-sectional, consecutive series.
A total of 2242 patients attending 2 tertiary referral uveitis clinics at Moorfields Eye Hospital were screened; 46 patients with PIC diagnosis were identified, and 35 eyes (35 patients) had clinically inactive PIC had EDI-OCT images that met the inclusion criteria.
Punctate inner choroidopathy lesions were qualitatively assessed for retinal features, such as (1) focal elevation of the retinal pigment epithelium (RPE), (2) focal atrophy of the outer retina/RPE, and (3) presence of sub-RPE hyperreflective deposits and choroidal features: (a) presence of focal hyperreflective dots in the inner choroid and (b) focal thinning of the choroid adjacent to PIC lesions. Quantitative analyses of the retina, choroid, and choroidal sublayers were performed, and associations with clinical and demographic data were examined.
Prevalence of each lesion pattern and thickness of retinal and choroidal layers.
A total of 90 discrete PIC lesions were captured; 46.6% of PIC lesions consisted of focal atrophy of the outer retina and RPE; 34.4% consisted of sub-RPE hyperreflective deposits; and 18.8% consisted of localized RPE elevation with underlying hyporeflective space. Focal hyperreflective dots were seen in the inner choroid of 68.5% of patients, with 17.1% of eyes presenting focal choroidal thinning underlying PIC lesions. By excluding high myopes, patients with "atypical" PIC had reduced retinal thickness compared with patients with "typical" PIC (246.65±30.2 vs. 270.05±24.6 μm; P = 0.04), and greater disease duration was associated with decreases in retinal thickness (r = -0.53; P = 0.01). A significant correlation was observed between best-corrected visual acuity and foveal retinal thickness (r = -0.40; P = 0.03).
In a large series of patients with clinically inactive PIC, one fifth of the lesions analyzed revealed RPE elevation with underlying hyporeflective space, described before as a sign of activity and suggesting subclinical inflammation. Retinal thickness seems to be associated with disease type and duration of disease in non-highly myopic eyes. Improved visualization of the inner choroid using EDI-OCT may allow noninvasive assessment of inflammatory status.
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