||Volume 9, Number 2
This e-newsletter is provided free to doctors through industry support from
THE DESK OF THE EDITOR
I was asked by the Review of Optometry to write the ARVO review for the posterior segment for their upcoming journal. I was honored to do so, and was in the difficult position of replacing Mark Dunbar, my co-editor of this Newsletter. Mark did a fantastic job summarizing the abstracts for several years, and I always looked forward to reading his article, to see what new studies and cutting edge information he reported. I had no idea how difficult of a task this was, nor was I properly warned (thanks Mark!) as there are literally hundreds of abstracts at ARVO in this area, many of which sounded interesting or promising. It was very hard to limit the number of abstract to include in my article. This is a true testament to the amount of ongoing research in the field of retinal disease. Some that I found most interesting dealt with some new genetic findings associated with AMD, a retinal prosthesis for RP, and novel treatments for AMD and macula edema.
What do you feel is the single biggest take-home from the results of the AREDS 2 study?
But the most interesting thing to come out of ARVO was the long awaited results of the AREDS2 study. (Please see later in the Newsletter). The results of the AREDS 2 were not I think what many of us expected, nor hoped for, as it still leaves many questions unanswered. Some questions I still have:
I encourage anyone interested in AMD and nutrition to take a look at the initial report, published in Jama Ophthalmology. I am hopeful that many more reports will be released from this study in the coming months that will help guide us as to the best treatment for our patients with AMD.
- If the high dose and low zinc dose seemed about the same, why did the authors not recommend we use a lower dose? It seems reasonable that if we can get the same effect, with less zinc, that should be a preferred tactic.
- If the omega-3's really had no benefit, should we stop recommending these to our patients with AMD, like I have been?
- The results seem to indicate that lutein and zeaxanthin had additional benefit in most patients, with the greatest benefit in those patients that had the lowest dietary intake of lutein and zeaxanthin. Does this mean in the future we need to somehow measure a patients lutein levels to know which supplement might be best? Might MPOD be able to help with this? Or would a detailed history of diet be sufficient?
- Could the patients individual serum level of things like lutein or other factors, combined with their genetic makeup, lead to individual therapy based on each patients genetic and biological makeup? Might one supplement NOT fit all?
Steven Ferrucci, O.D., F.A.A.O.
Editor in Chief
Summertime is Retina-time!
Joseph J. Pizzimenti, O.D. F.A.A.O.
As we head into these warmer months, our thoughts naturally turn to vacations at the
beach, cooling off in the mountains, or taking in one of the scenic National Parks.
Ballgames and barbecues. Family reunions. And retina.
I hope that you enjoy the clinically relevant information that our editors have put together
in this spring/summer edition of the ORS E-Newsletter. The literature updates, case
reports, and clinical pearls are designed to enhance the posterior segment knowledge base
of the busy practitioner and keep us all abreast of key developments in the world of
Medical retina continues to expand with JETREA® (ocriplasmin) intravitreal injection
completing its first quarter of FDA approved use in the US for symptomatic
vitreomacular adhesion. Eylea® (aflibercept) intravitreal injection has emerged as a
formidable new player in the treatment of AMD and macular edema due to diabetes and
retinal vein occlusion. Technology continues to improve with multi-modal imaging and
Controversies and questions remain: Is in-office genetic screening for AMD ready for
prime time? Does cataract surgery have an adverse effect on AMD? Is AREDS 2 an
"epic fail"? Our ORS Fellows continue to conduct research, publish, debate (sometimes
loudly), and present lectures on hot topics in posterior segment disease. Look for ORS-sponsored
CE tracks at Optometry's Meeting (June in San Diego) and Vision Expo East
Keep cool enjoy some down time this summer. Hope to see you soon!
MAKE THE DIAGNOSIS
Answer appears later in newsletter.
The Next Generation of Genetic Testing for AMD
By Steven Ferrucci , O.D., F.A.A.O.
Genetic testing has been available for patients with AMD for a while now. There is now a significant improvement in this technology, called Macula Risk NXG. Macula Risk NXG uses 15 genetic markers, along with age, body mass index (BMI), AMD status in both eyes, and smoking history to calculate the risk of conversion to advanced AMD at 2, 5 and 10 years. The patient is stratified into one of 5 macular Risk (MR) categories ranging from MR1 (less than 5% risk of conversion to advanced AMD within 10 years) to MR5 (60 to 90% risk of conversion to advanced AMD within 10 years). The clinician can then use this risk model to determine how frequently to examine the patient as well as help educate the patient regarding risk factors and their role in AMD progression. Further, it may help strengthen the message regarding the importance of vitamin therapy in at risk patients.
RESULTS OF THE AREDS2 STUDY
The Age-Related Eye Disease Study 2 (AREDS2) Research Team presented the results of the multi-centered randomized controlled clinical trial of oral supplementation with lutein/zeaxanthin (10 mg/2mg) and/or omega-3 long-chain polyunsaturated fatty acids (1000 mg) for the treatment of age-related macular degeneration (AMD) and cataract at the ARVO meeting. Unfortunately the results were not available at the time of publication.
This multi-centered trial was conducted in 82 clinical sites in the U.S from 2006 to 2012, in 4,203 participants, aged 50 – 85. The AREDS2 participants consented to either take the original AREDS formulation or a randomly assigned variation of the AREDS formulation.
The main outcome measurement was progression to advanced AMD, neovascular or central geographic atrophy. Progression to cataract surgery and progression of lens opacity, was a secondary outcome.
The addition of lutein and zeaxanthin, DHA and EPA, or both to the AREDS formulation in primary analysis did not further reduce the risk of progression to advanced AMD. However, because of increased incidence of lung cancer in former smokers lutein with zeaxanthin may be an appropriate carotenoid substitute of beta carotene in the original AREDS formulation. The comparison of low-dose vs. high-dose zinc showed no evidence of a statistically significant effect, so a clinical recommendation cannot be concluded. Lastly, daily supplementation with lutein/zeaxanthin had no statistically significant overall effect on rates of cataract surgery or vision loss.
It will take some time to digest these results and see how they should be implemented in practice.
Dietary Omega-3 Fatty Acids, Other Fat Intake, Genetic Susceptibility, and Progression to Incident Geographic Atrophy.
Geographic atrophy is a well-known end stage of AMD that can lead to irreversible blindness. This study investigated the associations between dietary omega-3 fatty acids and other fat intake, genes related to AMD, and progression to geographic atrophy. Patients without advanced AMD were evaluated at baseline and followed for progression to GA, with behavior and diet data collected at that time. Omega-3 fatty acids, omega-6 fatty acids, monounsaturated, saturated, polyunsaturated, and total fat were assessed. They also investigated eight single nucleotide polymorphisms in 7 genes (CFH, ARMS2/HTRA1, CFB, C2, C3, CFI, and LIPC). When controlled for genetic and behavioral risk factors, DHA and EPA were shown to reduce the risk of progression to GA. DHA was particularly beneficial in patients with the ARMS2/HTRA1 homozygous risk genotype, however did not reduce risk in the nonrisk group. This study supports the dietary intake of omega-3 fatty acids, which can lead to a reduced risk of developing geographic atrophy in those patients who are genetically susceptible.
Reynolds R, Rosner B, Seddon JM. Ophthalmology 2013;120(5):1020-1028.
Clinical Classification of Age-related Macular Degeneration.
There are currently several AMD classification schemes, grading systems, and severity scales used in the diagnosis and management of this important condition. The purpose of this study was to define a consensus recommendation on a simple, unified classification scheme that can be used worldwide. The committee was comprised of 26 AMD experts, 1 neuro-ophthalmologist, 2 committee chairmen, and 1 methodologist. Each member evaluated current AMD classification criteria on a 9-step scale and discussed the results, identifying important components to a classification system and refining a classification system. They also analyzed risk estimates related to the presence of various AMD lesions. Patients with small drusen (<63µm) are considered to have normal aging changes with no clinically relevant increased risk of late AMD development. Patients with medium drusen (63-<125µm) and no pigmentary abnormalities related to AMD are considered to have early AMD. Patients with large drusen or pigmentary abnormalities with medium drusen have intermediate AMD. Patients with neovascular AMD or geographic atrophy are considered to have late AMD. The five-year risk of progressing to late AMD increase approximately 100 fold from 0.5% risk with normal aging changes to 50% risk with the highest intermediate AMD changes. A consistent classification system may provide useful in communication and patient care.
Ferris FL, Wilkinson CP, Bird A, et al. Ophthalmology 2013;120(4)844-851.
The Prevalence and Risk Factors of Epiretinal Membranes: The Melbourne Collaborative Cohort Study.
The purpose of this study was to determine the prevalence of epiretinal membranes (ERM) and its potential risk factors in The Melbourne Collaborative Cohort Study (MCCS). The MCCS, a prospective study, was designed to investigate the role of diet and life style in relation to common chronic diseases. A total of 21,241 participants had retinal photography eligible for ERM grading. Photographs were evaluated and documented as cellophane macular reflex without folds or preretinal macular fibrosis (PMF) with retinal folds.
ERMs were observed in 8.9 % (1,882 out of 21,241) of the participants. Cellophane was reported in 4.9% and PMF was present in 3.9% of the participants. No sex predilection was noted. However, the prevalence of ERMs increased with age. Patients of Southern European origin, higher level of education, high BMI, current smoker, hypercholesterolemia, high WHR, bigger waist measurement, high blood pressure and diabetes were more likely associated with the development of ERMs. The study concluded that increasing age and ethnicity were statistically significant in the development of ERMs. ERMs were nearly two times more prevalent in Australians of Southeastern European origin than Northern European origin.
Aung K, Makeyeva G, Adams M et al. Retina. 2013:33(5):1026-1034.
Vascular Endothelial Growth Factor Promotes Progressive Retinal Nonperfusion in Patients with Retinal Vein Occlusion.
CRVO and BRVO cause hypoperfusion of the retina leading to high levels of VEGF, macular edema, and potentially vision loss. RVO can also lead to complete closure of retinal vessels leading to retinal non-perfusion, which can increase over time. This study evaluates the effect of anti-VEGF therapy on progression of retinal non-perfusion. The trials were conducted at two centers and included randomized, sham-injection controlled, subjects with macular edema due to CRVO or BRVO. At 6 months, it was shown that injection of ranibizumab injections significantly reduced the number of CRVO patients with retinal non-perfusion (67%). Reperfusion occurred in 6-8% of patients with previously non-perfused retina in patients injected with ranibizumab while only 1% of patients receiving sham injections showed reperfusion. The results of patients with BRVO were similar to those with CRVO. The result of this study suggests that timely intervention with anti-VEGF therapy in patients with CRVO and BRVO can prevent the worsening of retinal non-perfusion, promotes reperfusion of retina, and eliminates a positive feedback loop that can lead to further ischemia.
Campochiaro PA, Bhisitkul RB, Shapiro H, et al. Ophthalmology 2013:120(4)795-802.
Characterization of Birdshot Chorioretinopathy Using Extramacular Enhanced Depth Optical Coherence Tomography.
Birdshot chorioretinopathy is a rare, inflammatory disorder isolated to the posterior segment of the eye. Although the immunogenetics of this condition have been correlated to the HLA-A29 allele, there is seemly no systemic or ocular co-morbidities or associations to birdshot chorioretinopathy. The morphology and pathogenesis of this condition remains unclear. This study was an exploration on extramacular OCT and ED-OCT imaging to help understand the pathogenesis of birdshot chorioretinopathy in the retina and choroid. The study selected 24 eyes that had an established diagnosis of birdshot chorioretinopathy, and 18 eyes for the control group. The control group had similar demographics, with a higher portion of female participants and the average age of participants was about 55 years old. Results showed that extramacular OCT can detect disruption of the IS/OS junction, mostly seen as hyperreflective foci where the IS/OS junction is absent. Since the advent of OCT, the IS/OS junction has been observed as a marker for retinal vitality. Often loss of this layer, even loss of the intensity of this layer has been noted in diseases such as retinal vein occlusions, neovascular macular degeneration, and even inherited retinal degenerative disorders. It is feasible to quantitatively measure the IS/OS junction in order to monitor the disease. ED-OCT proved to be less helpful, due to our limited knowledge on this method and the wide variability already documented in the choroidal tissue. The choroid volume varies greatly based on age, sex, refractive error, even diurnal variation. In conclusion, extramacular OCT may be useful in the future to assist in diagnosis of birdshot chorioretinopathy, and it may also be utilized for quantitative measures for monitoring disease. ED-OCT needs further research on its application in choroidal inflammatory diseases.
Keane, P., Allic, M., Turner S., et al. Archives of Ophthalmology. 2013: 131(3):341-350.
Retinal Vasoproliferative Tumors: Comparative Clinical Features of Primary vs. Secondary Tumors in 334 Cases.
This retrospective case series analyzed characteristics of primary versus secondary retinal vasoproliferative tumors in 334 cases. Vasoproliferative tumors (VPT) are gliovascular masses occurring typically in the inferotemporal retina. These tumors cause exudations, retinal detachments, epiretinal membranes, and edema. The literature has reported that the majority of cases are primary, or idiopathic (74%); and secondary tumors are related to other ocular disease entities (24% of all cases). Of all the cases reviewed in this study, primary VPT occurred in 80% of the cases, and 20% were secondary. Etiology of secondary tumors included retinitis pigmentosa (22%), pars planitis (21%), Coats disease (16%), previous retinal detachments (12%), idiopathic vasculitis (6%), FEVR (4%), and others (18%). According to the studies' analysis of characteristics, the diagnosis of secondary VPT was more ominous. Secondary VPT generally had younger age of onset, 38 years old, versus 46 years of age in primary VPT. Secondary also had more bilateral, multiple, and larger lesions than primary, as well as poorer visual acuity outcome and more intraocular inflammation noted. If the diagnosis of VPT is made, especially in a younger person, ocular and systemic investigation should be made.
Shields, C., Kaliki, S., Al-Dalamash, S., et al. Archives of Ophthalmology. 2013: 131(3): 328-334.
Pneumatic Retinopexy for the Repair of Primary Rhegmatogenous Retinal Detachment: A 10-year Retrospective Analysis.
This retrospective study observed the outcome over 10 years of patients that underwent pneumatic retinopexy (PR) for repair of a primary rhegmatogenous retinal detachment (RRD). Successful cases were defined as attached retina 2 months post PR. Cases that failed once after the first surgery were labeled as primary failure. This subgroup was also analyzed. The authors found that the outcome between success and primary failure were insignificant. In conclusion of their analysis, they decided pneumatic reinopexy is a good surgical option for primary RRD. In two-thirds of cases, the retina will be attached after the procedure. The rest will require additional surgery, but most will only have one additional operation, in which they are most likely to have good outcomes.
Fabian, I., Kinori, M., Efrati, M., et al. Archives of Ophthalmology. 2013: 131(2): 166-171.
A Longitudinal Study of Stargardt Disease: Clinical and Electrophysiologic Assessment, Progression, and Genotype Correlation.
The authors investigated the clinical and electrophysiologic natural history of Stargardt disease and correlated these findings with the genotype. This was a cohort study of 59 patients. Clinical history, examination, and electrophysiologic assessment were undertaken in a longitudinal survey. Patients were classified into 3 groups based on electrophysiologic findings, as previously published: Group 1 had dysfunction confined to the macula; Group 2 had macular and generalized cone system dysfunction; and Group 3 had macular and both generalized cone and rod system dysfunction. At baseline, there were 27 patients in Group 1, 17 in Group 2, and 15 in Group 3. Amplitude reduction of >50% in the relevant electroretinogram (ERG) component or a peak time shift of >3 ms for the 30 Hz flicker ERG or bright flash a-wave was considered clinically significant ERG deterioration. Molecular screening of ABCA4 was undertaken.
The authors determined that the mean age at baseline was 31.7 years, with the mean follow-up interval being 10.5 years. A total of 22% of patients from Group 1 showed ERG group transition during follow-up, with 11% progressing to Group 2 and 11% to Group 3. Forty-seven percent of patients in Group 2 progressed to Group 3. There was clinically significant ERG deterioration in 54% of all subjects: 22% of Group 1, 65% of Group 2, and 100% of Group 3. At least 1 disease-causing ABCA4 variant was identified in 47 patients.
The study concluded that all patients with initial rod ERG involvement demonstrated clinically significant electrophysiologic deterioration; only 20% of patients with normal full-field ERGs at baseline showed clinically significant progression. Such data assist counseling by providing more accurate prognostic information and are also highly relevant in the design, patient selection, and monitoring of potential therapeutic interventions.
Fujinami K, Lois N, Davidson AE, et al. AJO Issue 6, June 2013. Pages 1075-1088. E13.
Visual Outcome After Intravitreal Bevacizumab depends on the Optical Coherence Tomographic Patterns of Patients With Diffuse Diabetic Macular Edema.
The purpose of this consecutive prospective study was to determine the effectiveness of intravitreal Bevacizumab (IVB) injections on the reduction of diffuse diabetic macular edema (DDME) in patients with different OCT patterns. The study included 143 eyes with DDME. Patients were divided into 4 groups according to their OCT patter: 1) sponge like diffuse retinal thickening (SDRT), 2) cystoid macular edema (CME), 3) serous retinal detachment (SRD), and 4) FULL (CME + SRD + SDRT). All eyes received one dose of IVB (1.25 mg in 0.05 mL) and were followed every 2 weeks for 12 weeks with a OCT. Visual acuity and foveal thickness were recorded at each follow up visit. The results showed that the effectiveness of IVB was dependent on the OCT pattern. IVB was most effective for the resolution of SDRT followed by CME and FULL group and weakest in the group with SRD. Also, the results demonstrated that efficacy of IVB on the reduction of DDME also depended on the duration of diabetes. It was concluded that vascular endothelial growth factor plays an important role in the pathogenesis of SDRT and CME.
Shimura M, Yasuda K, Yasuda M et al. Retina. 2013:33(4):740-747.
Ten-Year Incidence of Age-Related Macular Degeneration According to Diabetic Retinopathy Classification Among Medicare Beneficiaries.
Diabetic retinopathy and age-related macular degeneration are two of the major causes of visual loss in the country. To date, the relationship between these two diseases has not been established. The purpose of this study was to determine the rate of incidence of dry or wet AMD in patients with diabetes without retinopathy, nonproliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR) in comparison to patients without diabetes. The authors used 5% sample of Medicare claims data over a 10-year period (1995-2005). Patients from each group (DM without retinopathy, NPDR, PDR) were matched with controls (patients without diabetes) by age, gender, race, history of hypertension, atherosclerosis, stroke, coronary heart disease, hyperlipidemia, and Charlson index. The results showed that there is no significant difference between patients with DM without retinopathy and patients with no diabetes. However, patients with NPDR and PDR were at significantly higher risk of developing AMD. Patients with NPDR had in increase in risk for both wet and dry AMD. However, Patients with PDR had an increase risk of developing wet AMD only.
Hahn P, Acquah K, Cousins S et al. Retina. 2013:33(5):911-919.
TO "YOU MAKE THE DIAGNOSIS"
This OCT represents a case of Acute macular neuroretinopathy (AMNR). The OCT reveals disruption at the IS/OS junction. The FFA is unremarkable.
AMNR is a rare condition that occurs in healthy, young women and may result in transient or permanent vision loss. The condition was first described in 1975 by Bos and Deutman, who believed that the lesions involved the inner retina and the superficial retinal layers. The condition may be associated with the use of oral contraceptives or with a recent febrile illness. Ophthalmoscopically, these patients will present with lobular, reddish brown, wedge-shaped lesions in the macular region. Resolution of the lesions has been reported, however the lesions may persist for up to nine years.
The pathophysiology of this condition is unclear and there is no treatment. Eighty-three percent of cases affect younger women, nearly half of who report an associated viral illness. Other reported associations include oral contraceptive use and the intravenous administration of epinephrine, after intravenous contrast agents and after bodily trauma. AMNR has also been associated with heavy caffeine consumption. The association of this condition with oral contraceptive use and intravenous sympathomimetic administration suggests a vascular etiology, although angiography has failed to demonstrate a perfusion defect.
Close inspection of the OCT shows that the abnormality occurs in the outer retina, with disruption at the IS/OS junction (inner segment/outer segment junction). Close observation of the outer retina reveals a focal signal reduction. As a result, the photoreceptor outer segments are affected resulting in irregularity at the IS/OS junction. The thin line above the high signal bands of the outer retina, corresponding to the external limiting membrane are intact. The OCT further demonstrates that the structural changes in the outer retina may be reversible in patients with AMNR as can be visualized via serial observation of the OCTs as the retina is healing.
Julie Rodman, O.D., F.A.A.O.,
GALILEO Results Show Visual Acuity Gains Diminished With Less Frequent Monitoring
Visual improvements gained during the fixed dosing period of intravitreal aflibercept injection in the GALILEO trial were not sustained once an as-needed dosing regimen was implemented with reduced monitoring frequency, according to 18-month results presented at the Association for Research in Vision and Ophthalmology meeting.
Treatment with fixed monthly Eylea (aflibercept, Regeneron) over 24 weeks resulted in rapid and sustained gains in visual acuity, and those gains were largely maintained with monthly monitoring and less frequent as-needed dosing during weeks 24 to 52, Ogura said. However, the visual acuity gains were reduced with as-needed dosing and infrequent monitoring — every 8 weeks — during weeks 52 to 76.
The double-masked phase 3 trial randomized 106 patients with macular edema secondary to central retinal vein occlusion to receive intravitreal aflibercept 2 mg every 4 weeks for 24 weeks and 71 patients to receive sham injection every 4 weeks. From weeks 24 to 52, aflibercept patients were evaluated monthly and given injections as needed. Patients in the sham arm continued to receive monthly injections. From weeks 52 to 76, all patients were evaluated every 8 weeks and put on an as-needed regimen.
GEFAL Results Support CATT Findings
Like the CATT trial, the French Evaluation Group Avastin Versus Lucentis found also that bevacizumab is non-inferior to ranibizumab, the GEFAL investigators reported at the Association for Research in Vision and Ophthalmology meeting.
"We found that, for our primary outcome, which is visual acuity, bevacizumab is non-inferior to ranibizumab," study author Laurent Kodjikian, MD, PhD, said in a press briefing. The mean visual acuity difference between the two drugs was 1.89 letters, which is clinically meaningless, Kodjikian said.
In the double-masked, randomized, interventional GEFAL trial, 255 patients received 1.25 mg Avastin (bevacizumab, Genentech) and 246 patients received 0.5 mg Lucentis (ranibizumab, Genentech). All patients received monthly injections for the first 3 months and were assessed for treatment thereafter. A mean of seven injections was necessary per patient within the year for both drugs.
Both drugs resulted in rapid and substantial decrease in thickness and fluid, although neither drug eliminated fluid in all eyes.
There were no differences between the two drugs regarding safety, but too few patients were enrolled for too short a period to make a comment on safety of the drugs, Kodjikian said. More systemic serious adverse events were reported with bevacizumab, but individual data regarding each event is needed before a conclusion can be drawn, he said.
Novel VEGFR/PDGFR Inhibitor Well-Tolerated In Treatment Of Wet AMD
A new treatment for neovascular age-related macular degeneration was well-tolerated and showed potential efficacy, according to a news release.
At the Association for Research in Vision and Ophthalmology meeting, Xcovery Vision released preliminary data from a phase 1/2 clinical trial of the VEGFR/PDGFR inhibitor X-82.
"The data show that 50 mg of X-82 once daily achieves exposures well above the concentration required to inhibit new blood vessel formation, which suggests that the dose should be well-tolerated and could be efficacious in treating wet AMD patients," Chris Liang, PhD, executive vice president and chief scientific officer of Xcovery Vision, said in the release.
X-82 is a tyrosine kinase inhibitor in an oral formulation that blocks pathologic blood vessel growth and targets forms of neovascularization in ophthalmic settings, such as AMD and diabetic retinopathy, the release said.
Patient enrollment in the study began at five centers around the U.S. in November 2012.
According to ClinicalTrials.gov, the trial includes patients aged 50 years or older with active choroidal neovascularization associated with AMD, subretinal hemorrhage less than 50% of total lesion size, and best corrected visual acuity of 20/40 to 20/200 or 20/320 in the study eye and equal or better BCVA in the fellow eye. Patients who received previous anti-VEGF treatment, photodynamic therapy, external beam radiation, subfoveal focal laser photocoagulation, submacular surgery or transpupillary thermotherapy in the study eye are excluded.
Nonpenetrating Brachytherapy Device Shows Positive Early Safety, Efficacy Results
A new brachytherapy approach has been shown to increase best corrected visual acuity and was well-tolerated in a small group of patients with age-related macular degeneration, according to a poster presentation at the Association for Research in Vision and Ophthalmology meeting
Kamaljit S. Balaggan, MBBS, and colleagues presented a poster on the early results with the SMD-1 novel episcleral brachytherapy device developed by SalutarisMD. The class 1 medical device delivers 24 Gy of radiation for 5.5 minutes to the macula through a probe placed adjacent to the macular sclera via a sub-Tenon retrobulbar approach, according to the authors. The six patients treated in this study also received anti-VEGF injections.
The probe consists of a stainless steel cannula that is 1.8 mm in diameter.
The procedure was well-tolerated, and no serious adverse effects were reported, according to the authors. All patients experienced an increase in BCVA at 3 months, with a mean gain of 19 letters.
By 12 months, three patients maintained or improved BCVA, and three patients experienced a loss of BCVA. Two patients needed no further anti-VEGF injections at follow-up. All patients showed a reduction in macular thickness compared with baseline.
Higher Success With Ocriplasmin For Vitreomacular Traction Found In Certain Population Groups
When considering using ocriplasmin for vitreomacular traction, the most important consideration is the size of the macular traction, but age, presence of epiretinal membrane and whether the eye is phakic also need to be taken into account, according to a speaker Peter K. Kaiser, MD, at the Cole Eye Institute Retina Summit at held before the. Association for Research in Vision and Ophthalmology meeting,
"If epiretinal membrane is present, that is not a good sign. Phakic eyes are more likely to have release as well as in patients younger than 65," he said.
Kaiser said good candidates for Jetrea (ocriplasmin, ThromboGenics) have a vitreomacular adhesion of less than 1,500 µm.
"If someone is over 65, I would not say to not have it. It worked in all age groups, but it worked better in younger patients. It works for older patients, just not as well," he said.
TNF Inhibitor Effective In Patients With Severe Uveitis
Adalimumab may treat patients with severe uveitis even if a systemic disease is present, according to a study in the British journal of Ophthalmology. The retrospective study included 60 patients with uveitis; 41 patients had both uveitis and systemic disease. Patients underwent treatment with adalimumab with a mean follow-up of 87.9 weeks.
Effective outcome measures included visual acuity, anterior chamber cells, reduction of frequency of flares, decrease of macular edema and decrease of prednisone dose. Treatment was defined as effective when at least one factor improved and none worsened.
Forty-nine patients had at least one criterion improve and none worsen. Eleven patients did not meet improvement standards and were given supplemental or alternative treatment.
Forty-seven patients were still on adalimumab at the final follow-up visit. Adalimumab was discontinued in 13 patients. Of these, eight discontinued treatment due to ineffectiveness, three discontinued due to side effects, one discontinued due to pregnancy and one died from a heart attack unrelated to adalimumab. There were no noted severe side effects.
Useful Vision Restored In Retinitis Pigmentosa Patients Who Received Subretinal Implant
More than half of patients with severe retinitis pigmentosa who received the Alpha IMS subretinal implant recovered functional vision, according to results from a second human clinical trial of the device.
The trial examined nine patients for a 3- to 9-month period after subretinal implantation of the Alpha IMS a 3 mm × 3 mm, 1,500-pixel device designed to restore vision without externally visible equipment.
Each pixel has a photodiode, an amplification circuit and an electrode to allow an electrical impulse to be delivered to retinal layers corresponding to incoming light.
The chip, placed beneath the foveal region, works via inductive energy transfer from a battery pack in the control unit that allows the user to adjust brightness and contrast of perception. It offers a 10° × 10° diamond-shaped visual field that is roughly 15° diagonal.
One subject was excluded from follow-up due to intraoperative complications, but five of the remaining eight subjects reported functional vision improvements, including near vision recognition of facial characteristics and clothing patterns and ability to distinguish objects such as telephones, cutlery, door knobs and signs on doors. Far-vision improvements included ability to see the horizon and objects on the horizon.
A multicenter phase of the trial already has begun.
Another retinal implant for patients with advanced retinitis pigmentosa, the Argus II Retinal Prosthesis System (Second Sight Medical Products), was recently approved by the U.S. Food and Drug Administration.
Antibiotic Prophylaxis May Have Negative Effect On Safety Of Intravitreal Injections
A low rate of endophthalmitis after anti-VEGF intravitreal injections can be achieved without the use of preoperative and postoperative antibiotics. Antibiotic prophylaxis might, in fact, have a negative impact on the safety of the procedure, according to a speaker at the annual joint meeting of Ocular Surgery News and the Italian Society of Ophthalmology.
A study at the Bascom Palmer Eye Institute demonstrated that topical antibiotics before the day of injection did not reduce conjunctival bacterial counts more than the immediate pre-injection use of povidone-iodine. A Canadian study based on almost 16,000 injections suggested that the overall rate of intravitreal injection-related endophthalmitis is greater with the use of topical antibiotics compared with no antibiotics.
"In spite of this, the 2011 Patterns and Trends Survey of the American Society of Retina Specialists showed that 27% of retina specialists continue to use pre-injection antibiotics and 63% use post-injection antibiotics," according to the speaker.
Respiratory tract organisms of the streptococci species were found to be the most common cause of endophthalmitis with these procedures.
In each issue, a Fellow of the
Optometric Retinal Society will be highlighted. In this issue, Dr. Julie Rodham is highlighted.
Dr. Julie Rodman graduated from Brandeis University in 1994 with a B.A. in
Neuroscience. She received her optometry degree from the New England College of
Optometry in 1998. Dr. Rodman went on to complete a residency in hospital-based
optometry at the VAMC Brockton/West Roxbury, MA. Since completing her residency,
Dr. Rodman has worked in various settings, including an ophthalmology private practice
and an HMO-based practice. Dr. Rodman joined the Nova Southeastern College of
Optometry as a part-time faculty member in May 2000. In February 2008, Dr. Rodman
joined the Nova Southeastern faculty on a full-time basis as an Assistant Professor of
Optometry and now holds the rank of Associate Professor of Optometry.
Dr. Rodman has taught in the Optometry Theory and Methods Laboratory and currently serves as an attending physician in the University’s primary eye care clinics. She is actively engaged in fourth year weekly case conference. She has been the recipient of numerous teaching awards, including the Golden Apple Award for Excellence in Clinical Precepting, and Preceptor of the Year.
Dr. Rodman is currently the Residency Education Coordinator and is responsible for arranging the didactic assignments for the Resident Conference Series as well as interdisciplinary presentations. Dr. Rodman mentors and guides the resident's with Grand Rounds Presentations, posters, and publications. Dr. Rodman is actively involved in the residency program and serves on the Residency Advisory Committee as well as a Residency Supervisor. Dr. Rodman is also a member of the ASCO Residency Affairs Committee.
Dr. Rodman has authored multiple posters at the American Academy of Optometry,
American Optometric Association, SECO and NECO on various ocular disease topics.
She became a Fellow of the American Academy of Optometry in 2007. Dr. Rodman is a
reviewer for multiple index medicus journals. Her scholarly interests include the impact of systemic disease on the eye. She is currently pursuing her Masters in Clinical Vision Research at Nova Southeastern University.
Julie lives in Miami, FL with her husband and two daughters. In her free time, she enjoys spending time with her family and friends, baking and exercising.
BECOME AN ORS MEMBER?
By Rex Ballinger, OD, FAAO
Chair, Membership Committee
Membership in the Society can provide several benefits. You may
receive discounts at annual meetings. You’ll receive regular
newsletters on new and exciting updates on retinal disease diagnosis
and management as well as other newsy items of interest. And you’ll
be associated with a body of knowledge and resources which can
help you in many other ways. So consider membership in the Society.
It will be worth your while in your quest for better understanding
of the retina.
If your interests extend beyond the general, if you want to become
part of the dynamic team involved in the Society to share your
interest and enthusiasm with your colleagues, consider becoming
a Fellow member. Details and applications can be found at
CIRRUS SmartCube™ offers a wealth of useful information from one scan
In less than 2 seconds, CIRRUS creates a tightly layered, insight-rich, multi-dimensional cube of data that allows you to visualize and analyze the vital dynamics of each patient's changing condition.
Cube Scan Pattern Spacing Between LinesTotal Data Points
512 x 128 >67 million 47 µm
200 x 200 >40 million 30 µm
- Spot small areas of pathology. Tightly spaced B-scans enable small areas of pathology to be imaged
- Visualize the fovea. Scans that are spaced further apart than in the CIRRUS cube may miss the central fovea
- Fuel for analysis...now. Millions of data points from the cube are fed into the ZEISS
proprietary algorithms for accurate segmentation, reproducible measurements and registration
for change analysis
- Fuel for analysis...in the future. New analysis features such as Ganglion Cell Analysis and
Advanced RPE Analysis may be used on previously acquired scans thanks to the SmartCube
- Automatic centering on the ONH or fovea. No longer an operator's "judgement call"
- See the tissue from different perspectives. View the cube data from all angles, with 3D
rendering, OCT fundus images and customized en face slabs
- Smart Analysis for Glaucoma. Macular and optic nerve SmartCubes provide data for
Guided Progression analysis, Ganglion Cell Analysis and precise measurements of
the neuro-retinal rim while accounting for tilted discs, disruptions to the RPE and other
TRUST THE SCIENCE
MacuHealth with LMZ3 is a Natural, Botanical and
patented nutritional supplement that contains all three carotenoids found in the macula.
MACUHEALTH with LMZ3 has been rigorously tested at leading global eye research institutions. It is the
only supplement of its kind with independent, peer reviewed scientific publications demonstrating its safety,
efficacy and the fact that regular intake of MacuHealth with LMZ3 has been shown to restore macular pigment
density, increase visual performance as well as improve symptoms associated with glare, contrast and night vision.
Our unique eye formula is scientifically designed to support macular health and vision quality and contains
ALL THREE of the macular carotenoids; lutein (L), zeaxanthin (Z) and meso-zeaxanthin (MZ).
MZ represents over 30% of the central carotenoids and resides over the most vulnerable foveal tissue,
that has the highest metabolic rate and greatest number of free radicals.
MACUHEALTH with LMZ3 is the ONLY available eye supplement with 10mg of meso-zeaxanthin — the only
carotenoid found exclusively in the macula, and has been endorsed by many eye care professionals worldwide.
Steven Ferrucci, OD, FAAO
Mark T. Dunbar, OD, FAAO
Renee Clark, OD
Yissell Sanchez, OD
Jacob Woldt, OD
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