Sustained Visual Acuity Research Articles

Long-term Visual Outcomes in Patients With Idiopathic Macular Hole Surgery.

This study assesses long-term outcomes following surgical repair of idiopathic full-thickness macular holes (FTMHs) in patients with at least 5 years of postoperative follow-up. A retrospective study evaluated patients diagnosed with idiopathic FTMH who received surgical repair at a single tertiary center with at least 5 years of postoperative follow-up. Data collection included demographic and preoperative characteristics along with macular hole structural integrity as determined by spectral-domain optical coherence tomography (OCT). Functional and structural improvement were assessed by collection of visual acuity and findings on OCT at determined time points until 9 years of follow-up. The study comprised 90 eyes of 80 patients with a mean age of 67.2 ± 6.8 years, with an average postoperative follow-up of 80.8 ± 17.4 months (range 54 to 130 months). The mean macular hole diameter was 239.7 µm ± 92.2. Macular hole reoperation occurred in four eyes (4%) at a mean duration of 5.5 ± 6 months (range 0.3 to 13 months). Over the study duration, ellipsoid zone (EZ) integrity was maintained in 67.8% of eyes, with an absence of intraretinal fluid (IRF) in 96% on final OCT. The preoperative mean Early Treatment Diabetic Retinopathy Study (ETDRS) best visual acuity (BVA) of 51 improved to a mean BVA of 76 at 5 years postoperatively, with an average gain of 24 letters at one year that remained stable over 5 years (P < 0.05). Eight years after surgical repair, more than 80% of patients achieved a BVA > 65. Vitreoretinal surgery for idiopathic FTMH resulted in successful hole closure and sustained visual acuity improvement over long-term follow-up. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Good Initial Visual Acuity in Patients with Macular Edema due to Retinal Vein Occlusion - Management and Outcomes.

The approach to managing patients with retinal vein occlusion (RVO) and cystoid macular edema (CME) with good initial visual acuity (VA) better than 6/12 has not been investigated. This study aimed to evaluate functional and anatomical outcomes of intravitreal treatment and observation in patients with CME due to RVO, who presented with good initial VA. Methods: Multicenter retrospective cohort study. Seventy-nine eyes of 79 patients with CME secondary to RVO and initial VA better than 6/12, either treated with anti-VEGF therapy or observed. Clinical parameters and OCT measures were recorded. Main Outcome Measure: Proportion of patients losing ≥1 line of VA at 12 months. Secondary outcomes: Visual and anatomical results at 12 and 24 months, and correlation between number of injections and VA outcomes. Fifty-three percent of patients maintained VA at month 12. VA of 6/6 - 6/7.5 was maintained in 59% and 57% at 12 and 24 months, respectively. At 24 months, the number of anti-VEGF injections was strongly correlated with VA among patients with BRVO and CRVO. This study marks the first exploration of patients with RVO and initial VA better than 6/12, indicating that most patients sustained good VA, and anti-VEGF treatment maintained and improved VA.

The Fate of RPE Cells Following hESC-RPE Patch Transplantation in Haemorrhagic Wet AMD: Pigmentation, Extension of Pigmentation, Thickness of Transplant, Assessment for Proliferation and Visual Function-A 5 Year-Follow Up.

(1) Background: We reviewed a stem cell-derived therapeutic strategy for advanced neovascular age-related macular degeneration (nAMD) using a human embryonic stem cell-derived retinal pigment epithelium (hESC-RPE) monolayer delivered on a coated, synthetic basement membrane (BM)-the patch-and assessed the presence and distribution of hESC-RPE over 5 years following transplantation, as well as functional outcomes. (2) Methods: Two subjects with acute vision loss due to sub-macular haemorrhage in advanced nAMD received the hESC-RPE patch. Systematic immunosuppression was used peri-operatively followed by local depot immunosuppression. The subjects were monitored for five years with observation of RPE patch pigmentation, extension beyond the patch boundary into surrounding retina, thickness of hESC-RPE and synthetic BM and review for migration and proliferation of hESC-RPE. Visual function was also assessed. (3) Results: The two study participants showed clear RPE characteristics of the patch, preservation of some retinal ultrastructure with signs of remodelling, fibrosis and thinning on optical coherence tomography over the 5-year period. For both participants, there was evidence of pigment extension beyond the patch continuing until 12 months post-operatively, which stabilised and was preserved until 5 years post-operatively. Measurement of hESC-RPE and BM thickness over time for both cases were consistent with predefined histological measurements of these two layers. There was no evidence of distant RPE migration or proliferation in either case beyond the monolayer. Sustained visual acuity improvement was apparent for 2 years in both subjects, with one subject maintaining the improvement for 5 years. Both subjects demonstrated initial improvement in fixation and microperimetry compared to baseline, at year 1, although only one maintained this at 4 years post-intervention. (4) Conclusions: hESC-RPE patches show evidence of continued pigmentation, with extension, to cover bare host basement membrane for up to 5 years post-implantation. There is evidence that this represents functional RPE on the patch and at the patch border where host RPE is absent. The measurements for thickness of hESC-RPE and BM suggest persistence of both layers at 5 years. No safety concerns were raised for the hypothetical risk of RPE migration, proliferation or tumour formation. Visual function also showed sustained improvement for 2 years in one subject and 5 years in the other subject.

Long-Term Visual Outcomes in Patients With Idiopathic Epiretinal Membrane Surgery.

Our aim was to assess long-term outcomes following surgical repair of idiopathic epiretinal membrane (ERM) with pars plana vitrectomy (PPV) and membrane peel (MP). A retrospective study evaluated patients with idiopathic ERM who underwent surgical repair at a single academic tertiary center with five to nine years of postoperative follow-up, assessing preoperative characteristics, surgical techniques, best visual acuity (BVA), and optical coherence tomography biomarkers at various time points. The study involved 67 patients (72 eyes) with an average postoperative follow-up of 82.8 ± 18.8 months. Patients with cone outer segment tips integrity at initial presentation and 1-year follow-up and patients with external limiting membrane and ellipsoid zone integrity at 1-year follow-up were noted to have significantly better long-term visual acuity than those without. More than 85% of patients achieved a BVA > 70 seven years after surgical repair. Vitreoretinal surgery for idiopathic ERM resulted in improved anatomical recovery and sustained visual acuity gain over long-term follow-up. [Ophthalmic Surg Lasers Imaging Retina 2024;55:70-77.].

Poster Session II: The impact of eye's longitudinal chromatic aberration on visual acuity and accommodation response.

Chromatic composition of displays might affect vision and accommodation,possibly influencing myopia development.We investigated differences in visual acuity(VA) and accommodative lag(AccL) for steady accommodative demands (up to 5D,1D steps) with visual stimuli illuminated by monochromatic wavelengths (mono-λ 480,555&630nm,3nm bandwidth) and white light (WL).Data was obtained on 3 young emmetrope using an Adaptive Optics system with a supercontinuum laser,a DMD for stimuli,and a optunable lens to change vergence.Best focus for far was set at 555nm.VA was measured using QUEST(tumbling E).AccL was obtained from the peak shift of through-focus Visual Strehl,calculated from HS aberrometry.All subjects showed myopic shifts in blue consistent with longitudinal chromatic aberration.However,the response to wavelength differed across subjects.S#1 showed a sustained VA across distances(average VA standard deviation 0.054,-0.005logMAR),low AccL(slope:0.3 D/D) and systematic SA negative shift (slope:-0.04um/D),similar across mono-λ and WL.S#2 showed a more sustained VA,lower AccL and higher SA change in blue (0.09logMAR std,0.3D/D,-0.02um/D) than in WL(0.14logMAR std,0.52D/D,-0.013um/D).S#3 showed a steeper decrease in VA at near and higher AccL for mono-λ(0.218logMAR std,0.78D/D,on average)than in WL(0.05logMAR std,0.38D/D).Different subjects use chromatic cues in different ways to accommodate,likely affected by the interplay of chromatic blur,depth-of-focus and defocus sign perception.

RETRACTED: Résultats à long terme de la kératoprothèse de Boston de type I au Canada

To evaluate long-term visual outcomes of Boston type I keratoprosthesis (KPro) surgery and identify risk factors for visual failure. Single surgeon retrospective cohort study including 85 eyes of 74 patients who underwent KPro implantation to treat severe ocular surface disease, including limbal stem cell deficiency, postinfectious keratitis, aniridia and chemical burns. Procedures were performed at the Centre hospitalier de l'Université de Montréal from October 2008 to May 2012. All patients with at least 5 years of follow-up were included in the analysis, including eyes with repeated KPro. Main outcome measures were visual acuity (VA), visual failure, defined as a sustained VA worse than the preoperative VA, postoperative complications, and device retention. Mean follow-up was 7.2±1.3 years (±SD). Mean VA was 2.1±0.7 (logarithm of minimal angle resolution) preoperatively and 1.9±1.2 at last follow-up. In total, 2.4% of patients had VA better than 20/200 preoperatively vs. 36.5% at last follow-up. Maintenance of improved postoperative VA was seen in 61.8% of eyes at 7 years. Preoperative factors associated with visual failure were known history of glaucoma (HR=2.7 [1.2 to 5.9], P=0.02) and Stevens-Johnson syndrome (HR=7.3 [2.5 to 21.4], P<0.01). Cumulative 8-year complication rates were 38.8% retroprosthetic membrane formation, 25.9% hypotony, 23.5% new onset glaucoma, 17.6% retinal detachment, 8.2% device extrusion and 5.9% endophthalmitis. The majority (91.8%) of eyes retained the device 8 years after implantation. Nearly two-thirds of patients exhibited improved VA 7 years after KPro implantation. Preoperative risk factors for visual failure were known glaucoma and Stevens-Johnson syndrome.

0.18 MG FLUOCINOLONE ACETONIDE INSERT FOR THE TREATMENT OF CHRONIC POSTOPERATIVE PSEUDOPHAKIC CYSTOID MACULAR EDEMA.

To report the outcomes of the 0.18 mg fluocinolone acetonide insert (FAi) in the treatment of chronic (>6 months) postoperative cystoid macular edema after cataract surgery. This was a retrospective consecutive case series of eyes with chronic postoperative cystoid macular edema treated with the FAi. Visual acuity, intraocular pressure, optical coherence tomography metrics, and supplemental therapies were extracted from the charts before and at 3, 6, 12, 18, and 21 months after FAi placement, when available. Nineteen eyes of 13 patients with chronic postoperative cystoid macular edema after cataract surgery underwent FAi placement with an average follow-up of 15.4 months. Ten eyes (52.6%) had a ≥2-line gain in visual acuity. Sixteen eyes (84.2%) had a ≥20% reduction in optical coherence tomography central subfield thickness. Eight eyes (42.1%) had complete resolution of CME. Improvements in central subfield thickness and visual acuity were sustained throughout individual follow-up. Compared with 18 eyes (94.7%) requiring local corticosteroid supplementation before FAi, only six eyes (31.6%) required supplementation after FAi. Similarly, of the 12 eyes (63.2%) that were on corticosteroid drops before FAi, only 3 (15.8%) required drops after FAi. Eyes with chronic postoperative cystoid macular edema after cataract surgery treated with the FAi had improved and sustained visual acuity and optical coherence tomography metrics, along with a reduction in supplemental treatment burden.

Ethnic differences on long term outcomes of polypoidal choroidal vasculopathy after predominantly bevacizumab monotherapy

BackgroundA 3-year single-centre, retrospective, comparative, non-randomized cohort study to describe the long-term outcomes of treatment-naïve, Caucasian and non-Caucasian eyes with polypoidal choroidal vasculopathy (PCV) after treatment with predominantly Bevacizumab monotherapy or in combination with rescue photodynamic therapy (PDT).MethodsDemographics, visual outcomes, optical coherence tomography (OCT) and treatment data were collected up to 3 years after the first visit. Stratified analysis according to ethnicity and baseline vision was performed to identify factors predictive of long-term visual improvement and maintenance.ResultsA total of 89 eyes with PCV were identified, of which 14 received rescue verteporfin PDT. There was an equal distribution between Caucasian and non-Caucasian individuals. Non-Caucasians present at a younger age (67.3 vs. 76.0 years, p = 0.002), have a higher proportion of foveal involvement (80.9%, vs.54.2% p = 0.007), choroidal hyperpermeability (50% vs 25.8%, p = 0.013) and lower baseline visual acuity (53.1 vs. 63.3 letters, p = 0.008). Mean visual acuity (VA) gain was + 8.9 letters and + 5.0 letters at 1 and 3 years of follow-up, respectively. Non-Caucasian individuals had a lower mean final visual acuity (VA) (54.7 vs. 70.5, respectively; P < 0.001) and net gain in VA (+ 2.0 vs. + 7.6 letters, p = 0.581) compared to Caucasian individuals. The mean total number of injections given over 3 years was 14.ConclusionsMost patients treated with predominantly Bevacizumab anti-vascular endothelial growth factor (VEGF) monotherapy achieved sustained visual acuity gains out to 3 years. Due to ethnic-specific differences in presenting PCV phenotypes, non-Caucasians presented with lower baseline VA and had poorer long-term visual outcomes.

Characterization of Poor Visual Outcomes of Diabetic Macular Edema: The Fight Retinal Blindness! Project

To investigate the incidence, characteristics, and baseline predictors of poor visual outcomes in eyes with diabetic macular edema (DME) receiving intravitreal therapy in routine clinical practice. Observational study. Treatment-naïve eyes starting intravitreal therapy for DME between 2014 and 2018 tracked in the Fight Retinal Blindness! registry. We examined 2 groups with poor visual outcomes: (1) those with sustained vision loss of > 10 letters from baseline without recovery of visual acuity (VA); and (2) those with a VA of < 55 letters at 2 years. Respective controls were eyes that did not experience poor visual outcomes. Kaplan-Meier curves analyzed the proportion of eyes that experienced poor outcomes. Cox proportional hazards models evaluated the potential baseline predictors of poor outcomes. The proportion of eyes that experienced poor visual outcomes within 2 years of treatment initiation and its baseline predictors. The proportion of eyes with sustained VA of ≥ 10 letter loss was 14% at 2 years; 16% of eyes had VA of ≤ 55 letters 2 years after starting intravitreal therapy. Initial treatment with intravitreal corticosteroid was independently associated with a higher incidence of ≥ 10 letter loss (hazard ratio [HR], 3.21; 95% confidence interval [CI], 1.60-6.44; P < 0.01). No improvement in the VA at 3 months after starting treatment was associated with ≥ 10 letter loss (HR, 6.81; 95% CI, 4.11-11.27; P < 0.01) and VA of ≤ 55 letters at 2 years (HR, 4.28; 95% CI, 2.66-6.89; P < 0.01). The other factors related to higher risk of VA of ≤ 55 letters were older age (HR, 1.02 per year; 95% CI, 1-1.04; P = 0.04) and poor baseline VA (HR, 0.68 per 5 letters; 95% CI, 0.65-0.72, P < 0.001). Fourteen percent of eyes managed with intravitreal therapy in routine clinical care experienced ≥ 10 letter loss and 16% had VA of ≤55 letters 2 years after starting the treatment for DME. The identification of the incidence and predictors of poor outcomes provides a more accurate assessment of the potential benefit from intravitreal therapy.

Outcomes and prognostic factors of cataract surgery in cytomegalovirus-related anterior uveitis.

To evaluate the outcomes of cataract surgery in patients with cytomegalovirus (CMV) anterior uveitis and factors associated with final visual outcome. Hong Kong Eye Hospital, Hong Kong. Retrospective case series. History, clinical characteristics, corrected distance visual acuity (CDVA), medications, and complications of CMV anterior uveitic eyes that underwent cataract surgery between 2010 and 2020 were reviewed. This study included 26 eyes of 26 patients undergoing phacoemulsification. The median duration of disease was 4.8 years, and the median quiescent period preoperatively was 2.3 years. None required pupil manipulation or had significant intraoperative complications. The median CDVA improved from 20/100 (interquartile range [IQR] 20/200 to 20/50) preoperatively to 20/30 (IQR 20/40 to 20/25) at 1 year and 20/35 (IQR 20/50 to 20/30) at the last follow-up at a median of 4.9 years postoperatively ( P < .001). CDVA improved in 19 eyes (73.1%) and was ≥20/40 in 18 eyes (69.2%). In the multivariate regression model, preoperative use of topical 0.15% ganciclovir (β = 0.33, 95% CI 0.17 to 0.48, P < .001) and adjunctive intraoperative intracameral dexamethasone 0.4 mg (β = 0.19, 95% CI 0.01 to 0.36, P = .043) were associated with a better final CDVA. Loss of CDVA and poor postoperative CDVA visual acuity were mostly attributed to uveitic glaucoma, but preoperative glaucoma or the number of antiglaucoma medications did not affect final CDVA. Cataract surgery in eyes with CMV anterior uveitis was safe and CDVA significantly improved and remained sustained postoperatively. Topical ganciclovir 0.15% preoperatively and intracameral corticosteroid intraoperatively seem to maximize the final visual outcome.

MS-CAM: Multi-Scale Class Activation Maps for Weakly-Supervised Segmentation of Geographic Atrophy Lesions in SD-OCT Images.

As one of the most critical characteristics in advanced stage of non-exudative Age-related Macular Degeneration (AMD), Geographic Atrophy (GA) is one of the significant causes of sustained visual acuity loss. Automatic localization of retinal regions affected by GA is a fundamental step for clinical diagnosis. In this paper, we present a novel weakly supervised model for GA segmentation in Spectral-Domain Optical Coherence Tomography (SD-OCT) images. A novel Multi-Scale Class Activation Map (MS-CAM) is proposed to highlight the discriminatory significance regions in localization and detail descriptions. To extract available multi-scale features, we design a Scaling and UpSampling (SUS) module to balance the information content between features of different scales. To capture more discriminative features, an Attentional Fully Connected (AFC) module is proposed by introducing the attention mechanism into the fully connected operations to enhance the significant informative features and suppress less useful ones. Based on the location cues, the final GA region prediction is obtained by the projection segmentation of MS-CAM. The experimental results on two independent datasets demonstrate that the proposed weakly supervised model outperforms the conventional GA segmentation methods and can produce similar or superior accuracy comparing with fully supervised approaches. The source code has been released and is available on GitHub: https://github.com/ jizexuan/Multi-Scale-Class-Activation-Map-Tensorflow.

Surgical management of pediatric eye injuries.

BACKGROUND:Eye injury is a leading cause of unilateral childhood blindness. The purpose of this research was to study the management and visual outcome of pediatric eye injuries necessitating hospitalization and surgical repair.MATERIALS AND METHODS:This is a retrospective study of children having eye injury that needed surgical repair over the period of 2012 and 2017. Demographic data, place of occurrence, activity at the time of injury, place and cause of injury, presenting signs, surgical interventions, visual acuity (VA) before and after surgery, and causes for vision limitations were studied.RESULTS:Thirty-nine eyes of children were surgically treated. The mean (range) age of the patients was 3 years (1–15 years). Nearly 61.5% were males. Almost 80% of injuries occurred at home and while playing (71.8%). Trauma with sharp objects (35.8%) was the most common cause of injury. Majority presented to the hospital in <6 h (89%), mainly with eye pain (95%). Corneal laceration (53.8%), traumatic cataract (15.3%), and foreign body (15.3%) were the most common clinical findings. Twenty-one (53.8%) eyes sustained open-globe injuries. Fifteen percent had vision of 20/200 or worse at follow-up. The VA improved significantly at follow-up (P < 0.05). The major cause of vision limitation was the cornea (33%).CONCLUSIONS:Eye injury is a major cause of vision loss in children. Despite early presentation to our hospital and prompt interventions, significant number of our pediatric patients sustained limited VA in ruptured globe injuries.

Twenty-four-month outcomes of inflammatory choroidal neovascularisation treated with intravitreal anti-vascular endothelial growth factors: a comparison between two treatment regimens

Background and aimThere is still no established treatment regimen for eyes with inflammatory choroidal neovascularisation (iCNV) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections. This study compared the 24-month...

Characterization of Poor Visual Outcomes of Neovascular Age-related Macular Degeneration Treated with Anti–Vascular Endothelial Growth Factor Agents

To investigate the incidence, characteristics, and baseline predictors of poor visual outcomes in eyes with neovascular age-related macular degeneration (nAMD) receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in daily clinical practice. Observational study. Treatment-naive eyes starting anti-VEGF therapy for nAMD between 2007 and 2012 tracked in the Fight Retinal Blindness! registry. Eyes had sustained ≥15 letters of loss from baseline without recovery of visual acuity (VA) at final end point. A subgroup analysis included eyes that sustained ≥30 letters of loss. Controls had not sustained ≥15 letters of loss. Kaplan-Meier curves estimated time to first development of loss of ≥15 letters. Cox proportional hazards models evaluated predictors of loss of ≥15 letters. The proportion of eyes with sustained VA loss within 5 years, the time to development of sustained VA loss, and baseline predictors of sustained VA loss. There were 1760 eyes in total and 856 eyes that completed 5 years follow-up. The proportion of eyes with sustained VA loss of ≥15 letters at 5 years was 22.9% (95% confidence interval [CI], 20.7%-25.1%) and VA loss of ≥30 letters was 10.8% (95% CI, 9.1%-12.5%). Factors independently associated with higher incidence of sustained ≥15-letter loss included age >80 years (odds ratio [OR], 1.33 for patients >80 years vs. ≤80 years; 95% CI, 1.05-1.69; P= 0.02), fewer injections (OR, 0.97 per injection; 95% CI, 0.96-0.98; P=0.0005), and more visits at which the choroidal neovascularization was graded as active (OR, 1.97 for eyes in upper quartile of active visits vs. eyes in lowest quartile of active visits; 95% CI, 1.39-2.79; P= 0.0001). Baseline VA ≥70 letters was associated with reduced risk of sustained ≥30-letter loss (OR, 0.61; 95% CI, 0.38-0.98; P=0.04). Baseline angiographic lesion criteria were not significantly associated with sustained VA loss. Twenty-three percent of eyes with nAMD developed sustained VA loss of ≥15 letters over 5 years of anti-VEGF therapy. Baseline predictors of poor outcomes provide more accurate assessment of the potential benefit from anti-VEGF therapy.

Visual acuity and quality of life in dry eye disease: Proceedings of the OCEAN group meeting

Dry eye disease (DED) results in tear film instability and hyperosmolarity, inflammation of the ocular surface and, ultimately, visual disturbance that can significantly impact a patient's quality of life. The effects on visual acuity result in difficulties with driving, reading and computer use and negatively impact psychological health. These effects also extend to the workplace, with a loss of productivity and quality of work causing substantial economic losses. The effects of DED and the impact on vision experienced by patients may not be given sufficient importance by ophthalmologists. Functional visual acuity (FVA) is a measure of visual acuity after sustained eye opening without blinking for at least 10 s and mimics the sustained visual acuity of daily life. Measuring dynamic FVA allows the detection of impaired visual function in patients with DED who may display normal conventional visual acuity. There are currently several tests and methods that can be used to measure dynamic visual function: the SSC-350 FVA measurement system, assessment of best-corrected visual acuity decay using the interblink visual acuity decay test, serial measurements of ocular and corneal higher order aberrations, and measurement of dynamic vision quality using the Optical Quality Analysis System. Although the equipment for these methods may be too large or unaffordable for use in clinical practice, FVA testing is an important assessment for DED.

Managing Neovascular Age-Related Macular Degeneration: Is More Research Needed to Improve Real-world Practice?

Population-based data from registries of blind people confirm that antiangiogenic therapy has had a substantial role in reducing the burden of vision loss in patients with neovascular age-related macular degeneration (AMD).1 These data are also affirmed by results obtainedfromrandomizedclinical trials (RCTs). However, in contrast to RCTs, patientrelevantoutcomes fromobservational studies indicate that the initial gain in visual acuity (VA) is not maintained after a few years in thesepatient populations.A comprehensive analysis2 of real-world ranibizumab study data confirmed that patientrelevant outcomes are considerably poorer in observational studies than those reported in RCTs using fixed or as-needed (PRN) regimens, meaning that patients with neovascular AMD are often undertreated and undermonitored in many settings. Obviously, thebest strategy tomaximize the treatment effectof intravitreal antiangiogenicdrugs is fixed treatmentwith frequent injections, suchasmonthly ranibizumab. InPRNregimens, frequent (preferably monthly) monitoring is mandatory for themost effective treatmentoutcome. In clinical practice, extended follow-up intervalsmaybea threat to sustained VA, especially in patientswithdisease recurrence after an initially good response. In addition, the extent to which variation of care may hamper timely neovascular AMD diagnosis and their referral to retinal specialists is unknown. Published research3 suggests that social deprivation also acts as a potential barrier in accessinghealth care in patientswith this blinding condition. Therefore, health care policymakers should be aware of this medical issue. An early self-diagnosis test may possibly help patients becomeaware of the early signs of neovascularAMDor its recurrenceafter intravitreal treatment.Assessments of home-monitoring devices have been conducted, some of which provided encouraging results.4 Asystematic review5basedonhead-to-headstudiesofPRN comparedwithmonthly treatment found that PRN regimens, withmonthlymonitoring to guide retreatment, result in similar positive outcomes comparedwithmonthly treatment. The difference in VA was only 1.9 letters, favoring monthly treatment (95% CI, 0.5-3.3 letters), which is statistically significant but not clinically meaningful. This finding is important for physicians because indirect evidence fromRCTs suggests that patients in PRN studies with less strict monitoring, such as theSAILORstudy,or fixedquarterly injections, suchasPIER, did notmaintain average vision improvement after the first 3 monthly injections.2 In this issue of JAMA Ophthalmology, Stoller et al6 retrospectively analyze the data from HARBOR (Study of RanibizumabAdministeredMonthly or on anAs-neededBasis in Patients With Subfoveal Neovascular Age-related Macular Degeneration) anddescribe thecharacteristics ofpatientswho gained at least 15EarlyTreatmentDiabeticRetinopathy Study letters at 3monthsor later in the first year. Thesepatientswere respectively defined as early (within 3 months) or delayed (3 to 12months) responders andwere 25.2% and 13.7%of all patients, respectively. Thus, overall, 37.9%of patients gained 15 ormore letters at 12months.HARBORalso found that only approximately 5%ofpatients lost 15ormore letters at 12months. Therefore, the final VA of approximately 55% of patients was within±15 letters of baselineVAat 12months. They found that smaller lesionswith thicker retina and lowerVAatbaseline are found in early responders, whereas late responders more oftenhavepigment epithelial detachment. These findings in relation to early and late responders might be useful because identifyingpredictorsofdelayedVAgaincouldencouragephysicians to continue intensive treatment in an attempt tomaximizethepatient’sbenefit, rather thanswitchtoadifferentdrug. The limitation of these analyses is that they are restricted to a subgroup of responders and do not exploit the whole inRelated article page 545 Visual and Anatomical Response to Ranibizumab Original Investigation Research

Management of acute submacular haemorrhage: Royal free hospital experience

PurposeTo evaluate visual outcomes of patients presenting with acute submacular haemorrhage (SMH) secondary to neovascular Age Related Macular Degeneration (nAMD) treated with pars plana vitrectomy (PPV), subretinal recombinant tissue plasminogen activator (rTPA) and air.MethodsRetrospective, clinical case series. 7 patients with acute SMH secondary to nAMD, underwent PPV, instillation of 50 μg/0.1 ml subretinal alteplase and air tamponade. Data was obtained from Electronic Medical Records (EDRM) of the Royal Free Hospital from October 2013 to March 2015. Patient demographics (age, gender, and laterality), duration between onset and treatment, visual acuity (VA) and any concurrent treatment were recorded.Results7 patients were included in our study with mean age ‐ 69.1 years (Range: 60–87). 3 patients had cataract. No other ocular comorbidities. Mean period between onset of symptoms to treatment was 13.7 days (Range: 1–56). At presentation, six patients had hand movement (HM) VA and one patient had counting fingers (CF) VA. At one month post‐operatively, 6 patients (85.7%) demonstrated VA improvement ≥1 line, of whom 3 (42.9%) improved by ≥2 lines. At 6 months post‐operatively however, only 3 (42.9%) patients had sustained VA improvement. Post‐operative OCT demonstrated complete displacement of SMH in 4 patients (57.1%), while 3 patients had residual submacular organised blood.ConclusionsSubretinal rTPA following vitrectomy with air tamponade may be used to dissolve submacular blood mass enabling physicians to resume NHS funded anti‐VEGF therapy. Long‐term visual outcome is often limited by underlying disease progression.

Five‐year results of ICG‐Guided Photodynamic Therapy combined with intravitreal Ranibizumab for juxtapapillary polypoidal choroidal vasculopathy with macular involvement

AbstractPurpose Long‐term results of the treatment of 3 patients with juxtapapillary polypoidal choroidal vasculopathy complicated by a serous macular pigment epithelium detachment (PED) are presented.Methods Two women and one man (70, 77, and 84 years of age, respectively) presented with recent vision decrease in one eye. Decimal visual acuity (VA) of the affected eye was 0.2, 0.6, and 0.3, respectively. Fluorescein and ICG angiography as well as optical coherence tomography revealed juxtapapillary polypoidal choroidal vasculopathy and a large, dome‐shaped, serous macular PED.Results Selective ICG‐guided photodynamic therapy (PDT) with verteporfin directed to the juxtapapillary polyps was performed, followed by 3 monthly intravitreal injections of ranibizumab (Lucentis®), resulting in complete regression of the serous macular PED and in sustained VA increase. One month after the third injection, VA of the affected eye was 0.6, 0.9, and 1.0, respectively. One year later, VA of the affected eye was 0.7, 1.0, and 0.9, respectively. During 5 years of follow‐up, no recurrence of exudation was observed and VA remained the same.Conclusion The association of selective ICG‐guided juxtapapillary PDT with intravitreal injections of ranibizumab apparently led to scarring of the source of subretinal fluid, to protection of the adjacent normal choriocapillary network, and to protection against the VEGF spike described after PDT, thus enabling significant vision improvement. Combined treatment with ICG‐guided PDT and intravitreal ranibizumab is beneficial for juxtapapillary polypoidal choroidal vasculopathy with macular involvement, offering excellent long‐term results.

Oral 9-cis retinoid for childhood blindness due to Leber congenital amaurosis caused by RPE65 or LRAT mutations: an open-label phase 1b trial

Leber congenital amaurosis, caused by mutations in RPE65 and LRAT, is a severe form of inherited retinal degeneration leading to blindness. We aimed to assess replacement of the missing chromophore 11-cis retinal with oral QLT091001 (synthetic 9-cis-retinyl acetate) in these patients. In our open-label, prospective, phase 1b trial, we enrolled patients (aged ≥6 years) with Leber congenital amaurosis and RPE65 or LRAT mutations at McGill University's Montreal Children's Hospital. Patients received 7 days of oral QLT091001 (10-40 mg/m(2) per day). We assessed patients at baseline and days 7, 9, 14, and 30, and then 2 months and every 2 months thereafter for up to 2·2 years for safety outcomes and visual function endpoints including Goldmann visual fields (GVF), visual acuity, and functional MRI assessment. We regarded patients as having an improvement in vision if we noted at least a 20% improvement in retinal area on GVF compared with baseline or a visual acuity improvement of five or more letters compared with baseline in two consecutive study visits (or any improvement from no vision at baseline). This study is registered with ClinicalTrials.gov, number NCT01014052. Between December, 2009, and June, 2011, we enrolled and treated 14 patients aged 6-38 years who were followed up until March, 2012. Ten (71%) of 14 patients had an improvement in GVF areas (mean increase in retinal area of 28-683%). Six (43%) patients had an improvement in visual acuity (mean increase of 2-30 letters). Self-reported or parent-reported improvements in activities of daily living supported these findings. After 2 years, 11 (79%) patients had returned to their baseline GVF retinal area and ten (71%) had returned to baseline visual acuity letter values. Thus, three (21%) patients had a sustained GVF response and four (30%) had a sustained visual acuity response. Four patients had functional MRI scans, which correlated with visual response or absence of response to treatment. No serious adverse events occurred, although we noted transient headaches (11 patients), photophobia (11 patients), reduction in serum HDL concentrations (four patients), and increases in serum triglycerides (eight patients) and aspartate aminotransferase concentrations (two patients). Non-invasive oral QLT091001 therapy is well tolerated, and can rapidly improve visual function in some patients with Leber congenital amaurosis and RPE65 and LRAT mutations. QLT, Foundation Fighting Blindness Canada, CIHR, FRSQ, Reseau Vision.

Transplantation of human central nervous system stem cells – neuroprotection in retinal degeneration

Stem cells derived from the human brain and grown as neurospheres (HuCNS-SC) have been shown to be effective in treating central neurodegenerative conditions in a variety of animal models. Human safety data in neurodegenerative disorders are currently being accrued. In the present study, we explored the efficacy of HuCNS-SC in a rodent model of retinal degeneration, the Royal College of Surgeons (RCS) rat, and extended our previous cell transplantation studies to include an in-depth examination of donor cell behavior and phenotype post-transplantation. As a first step, we have shown that HuCNS-SC protect host photoreceptors and preserve visual function after transplantation into the subretinal space of postnatal day 21 RCS rats. Moreover, cone photoreceptor density remained relatively constant over several months, consistent with the sustained visual acuity and luminance sensitivity functional outcomes. The novel findings of this study include the characterization and quantification of donor cell radial migration from the injection site and within the subretinal space as well as the demonstration that donor cells maintain an immature phenotype throughout the 7 months of the experiment and undergo very limited proliferation with no evidence of uncontrolled growth or tumor-like formation. Given the efficacy findings and lack of adverse events in the RCS rat in combination with the results from ongoing clinical investigations, HuCNS-SC appear to be a well-suited candidate for cell therapy in retinal degenerative conditions.