An update on autoimmune retinopathy Dutta Majumder, Parthopratim; Marchese, Alessandro; Pichi, Francesco ...
Indian Journal of Ophthalmology/Indian journal of ophthalmology,
09/2020, Letnik:
68, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Autoimmune retinopathy (AIR) refers to a group of rare autoimmune retinal degenerative diseases presumably caused by cross-reactivity of serum autoantibodies against retinal antigens. The ...pathogenesis of AIR remains largely presumptive and there are a significant number of antiretinal antibodies that have been detected in association with AIR. The diagnosis of AIR is largely based on the demonstration of antiretinal antibodies in the serum along with suggestive clinical features and ancillary investigations. A high index of suspicion along with early diagnosis and treatment may play a critical role to lower the risk of irreversible immunological damage to the retinal cells in these patients. A multi-disciplinary approach for complete management and evaluation is helpful in such conditions. Various therapeutic options have been described for the treatment of AIR, though there is no consensus on standard treatment protocol.
The treatment and prevention of dry age-related macular degeneration (AMD) traditionally involve lifestyle modifications and antioxidant supplementation, including the AREDS2 formula. We present a ...case of a woman with dry AMD in her right eye with several large, confluent central drusen on her exam and optical coherence tomography B-scan. Over the course of a year, the drusen almost completely disappeared, but the retinal layers were preserved without the development of geographic atrophy or choroidal neovascularization. While the exact cause of this phenomenon is unclear, it was thought to be associated with this patient's strict daily use of numerous dietary supplements. This case highlights the potential in exploring alternative medicine supplements in the treatment of AMD.
Objectives:
To study the clinical features, optical coherence tomography (OCT) findings, treatment options and follow-up outcomes of post-fever retinitis (PFR).
Subjects:
A total of 19 eyes of 13 ...patients, diagnosed with PFR (retinitis following febrile episode) over 2 years were retrospectively studied.
Methods:
Documented history, baseline clinical features and systemic investigations performed for PFR were reviewed. Fundus findings, foveal architecture on swept-source OCT, the treatment options and the follow-up outcomes including best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were reviewed and analyzed.
Results:
Common fundus findings included whitish retinitis lesions (100%), macular star (95%, 18eyes), retinal flame-shaped hemorrhages (63%, 12 eyes), inflammatory retinal vessels (30%, 6 eyes), vitreous hemorrhage (one eye) and OCT findings included neuro-sensory detachment (79%, 15 eyes), intraretinal white dots (89.5%,17 eyes). The baseline median log MAR BCVA and CFT were 1.30 (interquartile range (IQR):0.8–1.8) and 423 microns (IQR:182–555). Overall, nine patients (12 eyes) received a combination of oral doxycycline and oral steroids and four patients (7 eyes) received a combination of oral doxycycline, oral steroid and intravitreal anti-vascular endothelial growth factor (IVA). Significant improvement was evident at 8 weeks in median BCVA (0.50, IQR: 0.3–0.8, p < 0.05) and median CFT (223 micron, IQR: 170–256, p < 0.05) though only 26% (5 eyes) attained BCVA > = 6/12.
Conclusion:
Our study puts forth certain characteristic fundus and OCT features of PFR. A combination of oral doxycycline and oral steroids as a treatment option showed improvement in BCVA and CFT. Additional IVA helps in faster visual recovery in patients presenting with severe macular edema at onset.
Age-related macular degeneration (AMD) is a leading cause of irreversible vision loss in people over the age of 50 worldwide. Exudative or neovascular AMD is a more severe subset of AMD which is ...characterized by the presence of choroidal neovascularization (CNV). Recent advancements in multimodal ophthalmic imaging, including optical coherence tomography (OCT) and OCT-angiography (OCT-A), have facilitated the detection and characterization of previously undetectable neovascular lesions and have enabled a more refined classification of CNV in exudative as well as nonexudative AMD patients. Subthreshold exudative CNV is a novel subtype of exudative AMD that typically presents asymptomatically with good visual acuity and is characterized by stable persistent or intermittent subretinal fluid (SRF). This review aims to provide an overview of the clinical as well as multimodal imaging characteristics of CNV in AMD, including this new clinical phenotype, and propose effective approaches for management.
Background
Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other ...systemic or ocular abnormalities. PCG results in considerable morbidity even in high‐income countries.
Objectives
To compare the effectiveness and safety of different surgical techniques for PCG.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020.
Selection criteria
We included randomized controlled trials (RCTs) and quasi‐RCTs comparing different surgical interventions in children under five years of age with PCG.
Data collection and analysis
We used standard Cochrane methodology.
Main results
We included 16 trials (13 RCTs and three quasi‐RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow‐up ranging from six to 80 months.
The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta‐analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) −0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (‐1) and imprecision (‐2). Hyphema was the most common adverse outcome in both groups (no meta‐analysis due to considerable heterogeneity; I2 = 83%).
Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta‐analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD −1.64, 95% CI −5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83).
Two trials (on 95 children) compared microcatheter‐assisted 360‐degree circumferential trabeculotomy to conventional trabeculotomy. Meta‐analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD −2.44, 95% CI −3.69 to −1.19; 100 eyes) and at 12 months (MD −1.77, 95% CI −2.92 to −0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (−1).
Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data.
Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear.
Authors' conclusions
The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360‐degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow‐up of at least one year.
To study the wider field (WF) swept-source OCT angiography (SS-OCTA) metrics, especially the nonperfusion area (NPA), in the diagnosing and staging of diabetic retinopathy (DR).
Cross-sectional ...observational study (November 2018 to September 2020).
A total of 473 eyes of 286 patients (69 eyes of 49 control patients and 404 eyes of 237 diabetic patients).
We imaged using 6 × 6 mm and 12 × 12 mm angiograms on WF SS-OCTA. Images were analyzed using the ARI Network and FIJI ImageJ. Mixed effects multiple regression models and receiver operating characteristic (ROC) analysis were used for statistical analyses.
Quantitative metrics such as vessel density (VD); vessel skeletonized density (VSD); foveal avascular zone (FAZ) area, circularity, and perimeter; and NPA in DR and their relative performance for its diagnosis and grading.
Among patients with diabetes (median age, 59 years), 51 eyes had no DR, 185 eyes (88 mild, 97 moderate-severe) had nonproliferative DR (NPDR), and 168 eyes had proliferative DR (PDR). Trend analysis revealed a progressive decline in superficial capillary plexus (SCP) VD and VSD, and increased NPA with increasing DR severity. Additionally, there was a significant reduction in deep capillary plexus (DCP) VD and VSD in early DR (mild NPDR), but the progressive reduction in advanced DR stages was not significant. The NPA was the best parameter to diagnose DR (area under the curve AUC, 0.96), whereas all parameters combined on both angiograms efficiently diagnosed (AUC, 0.97) and differentiated between DR stages (AUC range, 0.83–0.97). The presence of diabetic macular edema was associated with reduced SCP and DCP VD and VSD within mild NPDR eyes, whereas increased VD and VSD in SCP were observed in the moderate-severe NPDR group.
Our work highlights the importance of NPA, which can be measured more readily and easily with WF SS-OCTA compared with fluorescein angiography. It is quick and noninvasive, and thus can be an important adjunct for DR diagnosis and management. In our study, a combination of all OCTA metrics on both 6 × 6 mm and 12 × 12 mm angiograms had the best diagnostic accuracy for DR and its severity. Further longitudinal studies are needed to assess NPA as a biomarker for progression or regression of DR severity.
Component corneal surgery: An update Maharana, Prafulla K; Sahay, Pranita; Singhal, Deepali ...
Indian Journal of Ophthalmology/Indian journal of ophthalmology,
08/2017, Letnik:
65, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has ...led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal "so-called component corneal surgery" depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.
Retinal imaging remains the mainstay for monitoring and grading diabetic retinopathy. The gold standard for detecting proliferative diabetic retinopathy (PDR) requiring treatment has long been the ...seven-field stereoscopic fundus photography and fluorescein angiography. In the past decade, ultra-wide field fluorescein angiography (UWF-FA) has become more commonly used in clinical practice for the evaluation of more advanced diabetic retinopathy. Since its invention, optical coherence tomography (OCT) has been an important tool for the assessment of diabetic macular edema; however, OCT offered little in the assessment of neovascular changes associated with PDR until OCT-A became available. More recently, swept source OCT allowed larger field of view scans to assess a variety of DR lesions with wide field swept source optical coherence tomography (WF-SS-OCTA). This paper reviews the role of WF-SS-OCTA in detecting neovascularization of the disc (NVD), and elsewhere (NVE), microaneurysms, changes of the foveal avascular zone (FAZ), intraretinal microvascular abnormalities (IRMA), and capillary non-perfusion, as well as limitations of this evolving technology.
The clinical application of optical coherence tomography angiography (OCTA) has been well documented in literature with its promising potential in dye-less evaluation of various retinal vascular ...pathologies. Recent advances in OCTA help us gather wider field of view with 12 mm × 12 mm and montage compared to the standard dye-based scans, which has a higher accuracy and sensitivity in detection of peripheral pathologies. The aim of this study is to build a semi-automated algorithm to precisely quantify the non-perfusion areas (NPAs) on widefield swept-source optical coherence tomography angiography (WF SS-OCTA).
All subjects underwent imaging on 100 kHz SS-OCTA device acquiring 12 mm × 12 mm angiograms centered on fovea and optic disc. After a comprehensive literature review, a novel algorithm using FIJI (ImageJ) was designed to calculate the NPAs (mm
) after excluding the threshold and segmentation artifact areas from the total field of view. Segmentation and threshold artifacts were first removed from enface structure images using the spatial variance and mean filter respectively. Vessel enhancement was achieved by using 'Subtract Background' followed by directional filter. The cut off for Huang's fuzzy black and white thresholding was defined from the pixel values based of the foveal avascular zone. Then, the NPAs were calculated using the 'Analyze Particles' command with a minimum size of ~0.15 mm
. Finally, the artifact area was subtracted from to give the corrected NPAs.
Our cohort had 44 eyes of 30 control patients and 107 eyes of 73 patients with diabetes mellitus (both median age 55 years, P=0.89). Of 107 eyes, 21 eyes had no evidence of diabetic retinopathy (DR), 50 eyes had non-proliferative DR and 36 eyes had proliferative DR. The median NPA was 0.20 (0.07-0.40) in controls, 0.28 (0.12-0.72) in no DR, 5.54 (3.12-9.10) in non-proliferative DR and 13.38 (8.73-26.32) in proliferative DR eyes. Using mixed effects-multiple linear regression analysis adjusting for age, there was significant progressive increase in NPA with increasing DR severity.
This is one of the first study to use the directional filter for WFSS-OCTA image processing which is known to be superior to other Hessian based multiscale, linear, and non-linear filters especially for vascular analysis. Our method could greatly refine and streamline the calculation of signal void area proportion, while being much quicker and accurate than manual delineation of NPAs and subsequent estimation. This combined with the wide field of view can have a great prognostic and diagnostic clinical impact for future applications in DR and other ischemic retinal pathologies.
Purpose
To evaluate the retinal vasculature and vasoreactivity of patients with hypertension (HTN) using spectral domain optical coherence tomography angiography (SD-OCTA).
Methods
Patients with and ...without a diagnosis of HTN were included in this cross-sectional observational study. All eyes were imaged with SD-OCTA using 3 mm × 3 mm and 6 mm × 6 mm centered on both the fovea and optic disk. A second 6 mm × 6 mm scan was taken after a 30 s breath-hold. Vessel density (VD), vessel skeletonized density (VSD), and fractal dimension (FD) were calculated using customized MATLAB scripts. Vessel diameter index (VDI) was obtained by taking the ratio of VD to VSD. Vasoreactivity was measured by subtracting the VD or VSD before and after breath-hold (∆VD, ∆VSD).
Results
Twenty-three eyes with HTN (17 patients) and 17 control eyes (15 patients) were included. In the 6 mm × 6 mm angiogram centered on fovea, the superficial capillary plexus (SCP) VD (ß = − 0.029,
p
= 0.012), VSD (ß = − 0.004,
p
= 0.043) and the choriocapillaris VD (ß = − 0.021,
p
= 0.030) were significantly decreased in HTN compared to control eyes. Similarly, FD was decreased in both the SCP (ß = − 0.012,
p
= 0.013) and choriocapillaris (ß = − 0.009,
p
= 0.030). In the 3 mm × 3 mm angiogram centered on optic disk, SCP VDI (ß = − 0.364,
p
= 0.034) was decreased. ∆VD and ∆VSD were both reduced in the DCP (ß = − 0.034,
p
= 0.032; ß = − 0.013,
p
= 0.043) and ∆VSD was elevated in the choriocapillaris of HTN eyes (ß = 0.004,
p
= 0.032).
Conclusions
The study used SD-OCTA to show significant differences in the retinal vasculature of hypertensive patients. It was also the first to demonstrate the potential of OCT-A to investigate retinal vascular reactivity in patients with HTN.
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