Review of Ophthalmology Online
FROM THE EDITORS OF REVIEW OF OPHTHALMOLOGY:






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Volume 18, Number 30
Monday, July 23, 2018
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JULY IS UV SAFETY MONTH



In this issue: (click heading to view article)
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######### IVB & Posterior Sub-Tenon's Injection of Triamcinolone Acetonide in ME Secondary to RVO
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######### Early Phacoemulsification After Acute Angle Closure with Coexisting Cataract
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######### Fixation Status After Resolution of Macular Edema Associated with BRVO
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######### SD-OCT Guidance for Diagnosing Glaucoma
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  Briefly

 

IVB & Posterior Sub-Tenon’s Injection of Triamcinolone Acetonide in ME Secondary to RVO

Researchers compared the efficacy and safety between posterior sub-Tenon’s injection of triamcinolone acetonide (PSTA) and intravitreal injection of bevacizumab (Avastin) (IVIA) in the treatment of macular edema secondary to retinal vein occlusion.

In the study, the investigators retrospectively studied a total of 45 eyes (23 eyes with intravitreal bevacizumab and 22 eyes with posterior sub-Tenon’s triamcinolone acetonide). Main endpoints included logMAR of best-corrected visual acuity, central macular thickness and intraocular pressure after treatment at six months.

At six months, the mean logMAR vision improved from 0.78 (around 20/125) to 0.56 (slightly better than 20/80) for intravitreal bevacizumab (p=0.001), and from 0.91 (about 20/160) to 0.79 and 0.87 at three and six months (p=0.038 and 0.13), respectively, for sub-Tenon’s triamcinolone acetonide. At six months, the BCVA was significantly better in the bevacizumab group (p=0.02). Both groups’ mean CMT significantly improved, from 478 µm at baseline to 295 µm at six months in the IVIA group (p<0.001) and from 419 µm at baseline to 350 µm in the PSTA group (p=0.012); however, this was not different between the groups at six months (p=0.065). Recurrence of macular edema was not different between the groups either (p=0.08). Poorer final vision was associated with poorer baseline BCVA and diagnosis of central retinal vein occlusion after adjustment for age and sex (p<0.001 and 0.012, respectively). Significant elevation of IOP was noted at three months in the PSTA group, but declined at six months compared with baseline (p=0.002 and 0.41, respectively).

Intravitreal bevacizumab seemed to achieve better visual acuity compared with posterior sub-Tenon’s injections of triamcinolone acetonide at six months, while CMT was comparable. PSTA still resulted in transient IOP elevation.

SOURCE: Tsai MJ, Hsieh YT, Peng YJ, et al. Comparison between intravitreal bevacizumab and posterior sub-tenon injection of triamcinolone acetonide in macular edema secondary to retinal vein occlusion. 2018;12:1229-35





Early Phacoemulsification After Acute Angle Closure

A group of investigators performed a study to evaluate the effect of early phacoemulsification on the management of acute angle closure glaucoma in patients with coexisting cataract after initial treatment with medical therapy and laser peripheral iridotomy.

This study was a retrospective analysis of patients presenting to Netherlands’ Maastricht University Medical Center+ with acute angle closure and coexisting cataract between 2005 and 2015. Patients were included after initial treatment with a standard protocol composed of topical and systemic medical therapy and laser peripheral iridotomy. Patients underwent small-incision phacoemulsification with intraocular lens implantation into the capsular bag by experienced surgeons within three months of the acute angle closure episode. The physicians assessed the treatment effect on IOP, number of glaucoma medications used, visual acuity and complications.

A total 35 patients were included in the study (mean age: 71 ±10 years; 20 percent male; mean refractive error: +1.6 ±1.8 D). The mean duration between the acute angle closure episode and phacoemulsification was 37±22 days. There were no complications. IOP decreased in all patients from 17.0 ±8.2 mmHg to 13.2 ±3.9 mmHg after three months (p=0.008), whereas the mean number of glaucoma medications decreased from 2.9 ±1.1 to 0.7 ±0.9 (p<0.001), with 56 percent of patients discontinuing all medications. Visual acuity improved from 0.9 (20/160) ±0.9 logMAR to 0.2 (20/32) ±0.3 logMAR (p<0.001).

The researchers say that early phacoemulsification with IOL implantation results in a reduced intraocular pressure and number of glaucoma medications after an acute angle closure glaucoma crisis in patients with coexisting cataract. Although surgery may be challenging, the results are promising, with significant improvement in visual acuity in most patients, the physicians say.

SOURCE: Römkens H, Beckers H, Schouten J, et al. Early phacoemulsification after acute angle closure in patients with coexisting cataract. J Glaucoma 2018; July 12. [Epub ahead of print].



Fixation Status After Resolution of Macular Edema Associated with BRVO

Researchers say that fixation status of eyes with branch retinal vein occlusion (BRVO) is associated with vision and other clinical parameters.

The researchers looked at 57 consecutive eyes with BRVO after resolution of macular edema. They used microperimetry to determine fixation status. Defect length of the foveal ellipsoid zone band was measured by optical coherence tomography, and retinal perfusion status was assessed by OCT angiography.

In microperimetry, researchers found the mean fixation rate around the gravitational center of all fixation points (defined as the fixation center) to be 79.8 ±18.9 percent, which was significantly associated with defect length of the foveal ellipsoid zone band (p<0.001) and the distance between the foveal and fixation centers (p=0.012). The integrity of the ellipsoid zone band at the fixation center was intact in 55 eyes (96.5 percent). Fixation centers were located within and outside the foveal avascular zone in 33 (57.9 percent) and 24 (42.1 percent) eyes, respectively; in the latter group, all fixation centers were perfused. Downward deviation of fixation points was rare, despite variations in the occluded area; there was a significant difference in distribution of deviation between eyes with superotemporal and inferotemporal BRVO (p<0.001).

In eyes with BRVO, fixation status was strongly associated with visual acuity, morphologic damage, and retinal perfusion status both in the foveal area and at the fixation center after resolution of macular edema. This information regarding fixation status could facilitate vision management in patients with BRVO.

SOURCE: Kogo T, Muraoka Y, Ooto S, et al. Fixation status after resolution of macular edema associated with branch retinal vein occlusion. Retina 2018; July 13. [Epub ahead of print].




SD-OCT Guidance for Diagnosing Glaucoma

Researchers reviewed the current published literature on the use of spectral domain (SD) OCT to help detect changes associated with the diagnosis of glaucoma.

Researchers conducted searches of the peer-reviewed literature on June 11, 2014, November 7, 2016, August 8, 2017 and April 19, 2018, in the PubMed and Cochrane Library databases and included only articles published since the last glaucoma imaging Ophthalmic Technology Assessment, which included articles up until February 2006. The abstracts of these 708 articles were examined to exclude reviews and non-English articles. After inclusion and exclusion criteria were applied, 74 articles were selected and the panel methodologist assigned ratings to them according to the level of evidence. Two articles were rated level I and 57 articles were rated level II; 15 level III articles were excluded.

Spectral-domain OCT is capable of detecting damage to the retinal nerve fiber layer, macula, and optic nerve in patients with preperimetric and perimetric glaucoma (level I and II evidence). The most commonly studied single parameter was RNFL thickness. Of note, RNFL thickness measurements aren’t interchangeable between instruments. Various commercially available SD-OCT instruments have similar abilities to distinguish patients with known glaucoma from normal subjects. Despite different software protocols, all SD-OCT instruments are able to detect the same typical pattern of glaucomatous RNFL loss that affects primarily the inferior, inferior temporal, superior, and superior-temporal regions of the optic nerve (level II evidence). Across many SD-OCT instruments, macular imaging also can detect a preferential inferior, inferior-temporal, and superior-temporal thinning in patients with glaucoma compared with controls. Best disc parameters for detecting glaucomatous nerve damage are global rim area, inferior rim area and vertical cup-to-disc ratio. Studies suggest that newer reference-plane-independent optic nerve parameters may have the same or better detection capability when compared with older reference-plane-dependent disc parameters (level II evidence).

Researchers note that structural glaucomatous damage can be detected by SD-OCT. Optic nerve, RNFL and macular parameters can help the clinician distinguish the anatomic changes that are associated with patients with glaucoma when compared with normal subjects.

SOURCE: Chen TC, Hoguet A, Junk A, et al. Spectral-domain OCT: Helping the clinician diagnose glaucoma. Ophthalmology 2018; July 7. [Epub ahead of print].





  • Allergan Launches Refresh Repair
    Allergan recently added a product to its Refresh line of artificial tears: Refresh Repair. The company says the tear is the only artificial tear formulated with carboxymethylcellulose, hyaluronic acid (an inactive ingredient) and osmoprotectants that displace salt in the tear film to protect corneal epithelial cells from hyperosmotic stress. The company says its studies have shown an improvement in signs and symptoms of dry eye with use of Refresh Repair. Read more.



  • Mobile Retina App Detects Edema and Fluid in OCT Images
    Houston-based Retina-AI recently released a smartphone app, Fluid Intelligence, that the company says helps users detect macular edema and subretinal fluid on optical coherence tomography scans with “greater than 90-percent accuracy.” Retina-AI says the app can be useful in catching diseases such as diabetic macular edema, wet age-related macular degeneration and edema after retinal vein occlusions. It accomplishes this by using cloud-based, machine-learning AI algorithms. Read more.



  • Onefit Scleral Lenses Cleared for Dry Eye
    If you use scleral lenses to treat ocular surface disease, note that the Onefit line from Blanchard Contact Lenses has been cleared by the FDA for that indication, the company announced today. The approval is contingent on the use of the Optimum Extra, Optimum Extreme or Hexa 100 materials from lens-materials maker Contamac, however. Blanchard cites dry eye, Sjögren’s syndrome, graft-vs.-host disease and keratitis as some of the potential diseases amenable to therapy with this modality. The company says that the approval should give clinicians greater confidence in ordering Onefit scleral lenses. Read more.



  • Genentech to Provide Clinical Trial Updates at ASRS Meeting
    Genentech researchers will present several updates on their clinical trials at this year’s meeting of the American Society of Retina Specialists in Vancouver. Notable ones include: On Wednesday, July 25 at 10:50 a.m. Pacific Time, Genentech will present the first initial results from its Phase II LADDER study. The LADDER researchers are studying the company’s Lucentis Port Delivery System, a refillable implant designed to continuously deliver a specialized formulation of Lucentis over time, potentially avoiding the need for frequent anti-VEGF injections.
    The company will also be sharing 36-week results from its Phase II BOULEVARD study of RG7716, an anti-VEGF A/anti-angiopoietin-2 bispecific antibody used for the treatment of diabetic macular edema. The presentation is scheduled for Tuesday, July 24 at 8:52 a.m. PT.



  • Clearside Biomedical to Present Phase III Data at ASRS
    Clearside says that Emory Eye Center’s Steven Yeh, MD, will present Phase III data from the company’s PEACHTREE study at this week’s meeting of the American Society of Retina Specialists in Vancouver. PEACHTREE is a pivotal clinical trial of suprachoroidal triamcinolone acetonide, CLS-TA, in patients with macular edema associated with non-infectious uveitis. The data will be presented as a “late-breaker” session on July 25 at 10:40 am Pacific Time. Read more.




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