Intravitreal conbercept injection with panretinal photocoagulation for high-risk proliferative diabetic retinopathy with vitreous hemorrhage

AIM:To assess the clinical efficacy and safety of combining panretinal photocoagulation(PRP)with intravitreal conbercept(IVC)injections for patients with high-risk proliferative diabetic retinopathy(HR-PDR)complicated by mild or moderate vitreous hemorrhage(VH),with or without diabetic macular edema(DME).METHODS:Patients diagnosed with VH with/without DME secondary to HR-PDR and received PRP combined with IVC injections were recruited in this retrospective study.Upon establishing the patient’s diagnosis,an initial IVC was performed,followed by prompt administration of PRP.In cases who significant bleeding persisted and impeded the laser operation,IVC was sustained before supplementing with PRP.Following the completion of PRP,patients were meticulously monitored for a minimum of six months.Laser therapy and IVC injections were judiciously adjusted based on fundus fluorescein angiography(FFA)results.Therapeutic effect and the incidence of adverse events were observed.RESULTS:Out of 42 patients(74 eyes),29 were male and 13 were female,with a mean age of 59.17±12.74y(33-84y).The diabetic history was between 1wk and 26y,and the interval between the onset of visual symptoms and diagnosis of HR-PDR was 1wk-1y.The affected eye received 2.59±1.87(1-10)IVC injections and underwent 5.5±1.02(4-8)sessions of PRP.Of these,68 eyes received PRP following 1 IVC injection,5 eyes after 2 IVC injections,and 1 eye after 3 IVC injections.Complete absorption of VH was observed in all 74 eyes 5-50wk after initial treatment,with resolution of DME in 51 eyes 3-48wk after initial treatment.A newly developed epiretinal membrane was noted in one eye.Visual acuity significantly improved in 25 eyes.No complications such as glaucoma,retinal detachment,or endophthalmitis were reported.CONCLUSION:The study suggests that the combination of PRP with IVC injections is an effective and safe modality for treating diabetic VH in patients with HR-PDR.

Analysis of the etiologies,treatments and prognoses in children and adolescent vitreous hemorrhage

AIM:To determine the etiologies,treatment modalities and visual outcomes of vitreous hemorrhage(VH;range from birth to 18 y).METHODS:A total of 262 eyes from 210 patients between January 2010 and September 2016 were included.All children underwent an appropriate ocular and systemic examination.Data collected included demographics,clinical manifestations,details of the ocular and systemic examination,management details,final fundus anatomy and visual acuity(VA).RESULTS:The most common etiologies were nontraumatic VH(64.89%),most of which were due to retinopathy of prematurity(ROP;37.10%);while traffic accidents,including 16(21.00%)eyes,was the most common ocular traumas.Surgery,performed in 143(54.58%)eyes,was the most common management modality.The initial mean baseline visual acuity was 2.77±0.21 logarithm of the minimal angle of resolution(log MAR)in children and adolescent with traumatic VH,which was significantly improved to 2.15±1.31 log MAR(P<0.05).CONCLUSION:VH in children and adolescent has a complicated and diverse etiology.ROP is the primary cause of non-traumatic VH,which is the most common etiology.Appropriate treatment of traumatic VH is associated with obvious improvement in visual acuity.The initial VA is one of most important predictors of outcome.

Long-term observation of vitrectomy without subretinal hemorrhage management for massive vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

AIM: To describe the long-term observation of vitrectomy without subretinal hemorrhage(SRH) management for massive vitreous hemorrhage(VH) secondary to polypoidal choroidal vasculopathy(PCV). METHODS: This is a retrospective, consecutive case series. A total of 86 eyes of 86 patients with >14d of massive VH associated with PCV were included. All patients underwent vitrectomy without SRH management, followed by intravitreal ranibizumab injections and/or photodynamic therapy(PDT) as needed. The main outcome measures were best-corrected visual acuity(BCVA), postoperative adverse events and the recurrence of VH. RESULTS: The average follow-up period was 25.5±9.2 mo(range 12-35 mo). Mean BCVA at baseline(2.16±0.39 logM AR)had improved significantly, both 3 mo after surgery(1.42±0.66 log MAR, P<0.001) and by the last visit(1.23±0.74 logM AR, P<0.001). The common postoperative complications included macular subretinal fibrosis in 14 eyes(16.3%) and ciliary body detachment in 4 eyes(4.7%).Nineteen eyes(22.1%) received following treatment with ranibizumab injections without/with PDT, and 15(17.4%)were resolved. Four eyes(4.7%) had recurrent hemorrhage during the follow-up period. In multiple regression analysis,thicker SRH(beta=0.33, P=0.025) in the preoperative B-scan and the presence of foveal subretinal fibrosis(beta=0.28, P=0.018) in the follow up were associated with poor postoperative BCVA. CONCLUSION: Vitrectomy without SRH management for massive VH secondary to PCV improved/stabilized visual function in the long-term observation. Eyes presenting with thicker SRH preoperatively and forming foveal subretinal fibrosis in the follow-up period tended to have worse BCVA.

Altered regional homogeneity in patients with diabetic vitreous hemorrhage

BACKGROUND Diabetic vitreous hemorrhage(DVH)is a common complication of diabetes.While the diagnostic methods nowadays only concentrate on the eye injury in DVH patients,whether DVH leads to abnormalities of other visual systems,including the eye,the visual cortex,and other brain regions,remains unknown.AIM To explore the potential changes of brain activity in DVH using regional homogeneity(ReHo)and their relationships with clinical features.METHODS Thirty-one DVH patients and 31 matched healthy controls(HCs)were recruited.All subjects were examined by resting-state functional magnetic resonance imaging.The neural homogeneity in the brain region was estimated by ReHo method.Pearson correlation analysis was used to evaluate the relationships between average ReHo values and clinical manifestations in DVH patients.RESULTS Compared with HCs,the ReHo values in the bilateral cerebellar posterior lobes,right superior(RS)/middle occipital gyrus(MOG),and bilateral superior frontal gyrus were significantly increased.In contrast,in the right insula,bilateral medial frontal gyri,and right middle frontal gyrus,the ReHo values were significantly decreased.Furthermore,we found that best-corrected visual acuity of the contralateral eye in patients with DVH presented a positive correlation with the mean ReHo value of the RS/MOG.We also found that depression score of the DVH group presented a negative correlation with the mean ReHo values of the right insula,bilateral medial frontal gyrus,and right middle frontal gyrus.CONCLUSION We found that DVH may cause dysfunction in multiple brain areas,which may benefit the exploration of pathologic mechanisms in DVH patients.

Dramatic resolution of vitreous hemorrhage after an intravitreal injection of dobesilate

Vitreous hemorrhages are important clinical manifestations of proliferative diabetic retinopathy. Non-cleared vitreous hemorrhages could lead to hemosiderosis bulbi and glaucoma. Here, we describe the case of a type 2 diabetic patient presenting anterior segment and vitreous hemorrhages that resolved three days after treatment with a single intravitreal injection of dobesilate.

Vitreous hemorrhage and fibrovascular proliferation after laser-induced chorioretinal venous anastomosis

·AIM:To describe a case in which vitrectomy was required for vitreous hemorrhage and fibrovascular proliferation after laser-induced chorioretinal venous anastomosis (LCVA) for non-ischemic central retinal vein occlusion (CRVO).·METHODS:Observational case report.·RESULTS:A 72-year-old man complained of central scotoma in the left eye,and was diagnosed as suffering from non-ischemic CRVO.LCVA was performed in another hospital.Although favorable visual function was briefly maintained postoperatively,severe vitreous hemorrhage developed in his left eye,necessitating vitrectomy.·CONCLUSION:Considering that LCVA carries a risk of serious complications,we must apply this treatment with caution,especially in ethnic groups,such as the Japanese,in whom pigmentation reacts to photocoagulation excessively.·

Mechanism of panax notoginseng in treating vitreous hemorrhage based on network pharmacology

Objective:To investigate the possible molecular mechanism of panax notoginseng in the treatment of vitreous hemorrhage(VH).Methods:The active components of Panax notoginseng were screened by TCMSP database and the corresponding targets were collected.Vh-related gene targets were derived from GeneCards and OMIM database,and the target of Panax notoginseng was mapped to disease target genes.STRING database and Cytoscape 3.7.2 software were used to construct the protein-protein interaction(PPI)network diagram and the interaction network of"Pantoginseng-active ingredient-VH-target protein",and the core action target genes were screened out.Finally,gene body(GO)biological process and metabolic pathway enrichment analysis of KEGG were performed on the potential therapeutic targets.Results:We identified 8 active components,162 active component targets,1387 VHrelated genes and 75 candidate targets for VH.In the"Panax notoginseng-active ingredient-VH-target protein"interaction network,there are 82 nodes in total.The core target genes include AKT1,CASP3,VEGF-A,IL-6 and MMP-9.143 major enrichment pathways were identified by GO and KEGG enrichment analysis.The key signal pathways include age-RAGE signaling pathway,fluid shear stress and atherosclerosis,etc.,and the significant molecular functions include cytokine activity,receptor ligand activity,cytokine receptor binding,etc.Conclusion:The potential molecular mechanism of panax notoquinone in the treatment of VH is closely related to the biological processes of anti-angiogenesis,anti-inflammation,regulation of apoptosis and oxidative stress,and AKT1,CASP3,VEGF-A,IL-6 and MMP-9 may be the core target genes.

Comment on “Ultrasound reliability in detection of retinal tear in acute symptomatic posterior vitreous detachment with vitreous hemorrhage”

Dear Editor,We were interested to read the paper by Kuzmanovic Elabjer et al.The purpose of the authors was to assess ultrasound reliability in detecting retinal tears in patients with acute symptomatic posterior vitreous detachment （ASPVD）. They performed transpalpebral ultrasound of the eye and the orbit followed by fundus examination initially and in 6wk period.

Visual prognosis of vitrectomy for polypoidal choroidal vasculopathy with breakthrough vitreous hemorrhage

Aim:The objective of this study was to investigate the prognosis of massive vitreous hemorrhage(VH)secondary to polypoidal choroidal vasculopathy(PCV)after vitrectomy.Methods:Forty-nine eyes in 48 patients with PCV and breakthrough VH who underwent 23-gauge pars plana vitrectomy between January 2015 and December 2020 were enrolled.The main outcome parameters were best-corrected visual acuity,postoperative adverse events,and reoperation.Results:The average follow-up time was 20.0±15.82 months.The average preoperative best-corrected visual acuity(BCVA)was 2.12±0.65 logarithm of the minimum angle of resolution(logMAR),the BCVA at six monthswas 1.65±0.64 logMAR,and the six-month follow-up BCVA was 1.67±0.76 logMAR.Compared to the average preoperative BCVA,the six-months and last follow-up BCVA after vitrectomy improved(P<0.05).The BCVA at the final follow-up was better than 1.3 logMAR only in 14 eyes(28.6%).Postoperative complications were observed in 10 eyes(20.4%),including recurrent retinal detachment,recurrent vitreous hemorrhage,macular hole,hyphema and lens dislocation.Fourteen eyes(28.6%)underwent cataract surgery procedure an average of 10.16±5.14 months after vitrectomy.BCVA one week and three monthsafter cataract surgery improved compared toBCVA before cataract surgery(P<0.05).Hypertension was associated with BCVA six months after vitrectomy(P=0.017).The BCVA at baseline and three months after PPV were worse in patients who underwent vitrectomy combined with silicone oil filling(P<0.05).Eyes with postoperative complications had worse BCVA at six months,12 months,and at the final follow-up after PPV(P<0.05).The duration of VH is related to the BCVA 12 months after PPV visual acuity after surgery.Patients who underwent vitrectomy within one month of the onset of vitreous hemorrhage had better BCVA 12 months after vitrectomy than those who underwent vitrectomy surgery one month later(P=0.015).Conclusions:Although the prognosis of vitrectomy varies greatly,cataract surgery could be considered to improve BCVA if polypoidal lesions are inactive six months after vitrectomy.

Sickle cell retinopathy and systemic disease

Sickle cell disease(SCD)is a widespread hemoglobinopathy that results in significant patient morbidity and mortality.Vascular occlusion can cause acute pain,acute chest syndrome,and avascular necrosis,while hemolysis and endothelial disruption can cause ischemic stroke,leg ulcers,pulmonary hypertension,and priapism.All ocular and orbital structures can be affected by SCD ischemic events,including orbital bone infarction,ischemic optic neuropathy,retinal artery occlusion,hyphema,secondary glaucoma,sickle cell maculopathy,and sickle cell retinopathy.Proliferative sickle cell retinopathy(PSR)is the most common cause of vision loss.Untreated PSR can lead to macular ischemia,vitreous hemorrhage,and tractional retinal detachment.Ophthalmic screening exams and multimodal imaging can lead to earlier detection of sickle cell retinopathy and improved patient outcomes.SCD patients undergoing vitreoretinal surgery may require coordination of care with hematologists to avoid ischemic complications.While hydroxyurea was the only United States Food and Drug Administration approved treatment for several decades,patients with SCD now have several more treatment options.Despite the United States screening all infants for SCD,there can be delays in diagnosis and treatment.This review article aims to provide an overview of sickle disease for the ophthalmologist,and to discuss emerging treatment options and current management of SCD ocular complications.

Vitreous haemorrhage:a population-based study of the incidence and risk factors in Taiwan

AIM：To report the epidemiology and incidence of vitreous hemorrhage and to evaluate risk factors for patients with vitreous hemorrhage（VH）in Taiwan.METHODS：A retrospective population-based study.Analyzing a sample of one million subjects from all enrollees of the Taiwan Health Insurance programme. All data were obtained from the Taiwan Health Insurance Research Database,which contained patient sex,date of birth,all records of clinical visits and hospitalizations,and diagnosis codes as included in the International Classification of Diseases,Ninth Revision,Clinical Modification（ICD-9-CM）. The main outcome measures were the incidence and risk factors of VH.RESULTS：From 2001 to 2010,the database claim 4379 newly diagnosed cases were identified with VH. The average incidence of VH in Taiwan was 4.8 cases per ten-thousand person-years generally and increased with time especially in subjects who aged between 40 and 59 y and when the VH was associated with proliferative diabetic retinopathies or retinal vein occlusions. A de-finitely upward trends in the incidence of VH from 2001 to 2010 were noted（P-value for increasing trend 〈0.001）. Univariate Cox＇s regression analysis pointed out that older age（for 40-59,P〈0.001,HR=9.39; for ≥60,P〈0.001,HR=11.39）,male gender（P=0.03,HR=1.07）and subjects who had been prescribed anti-coagulation drug included aspirin,warfarinand clopidogrel（P〈0.001,HR=2.20）were significant risk factors for suffering from VH.CONCLUSION：The incidence of VH is estimated being 4.8 cases per 10 000 person-years in Taiwan. Age,male gender and having been prescribed anti-coagulation drugs are associated with the incidence of VH.

Combined hamartoma of the retina and retinal pigment epithelium:A case report

BACKGROUND Combined hamartoma of the retina and retinal pigment epithelium(CHRRPE)is a rare congenital benign tumor which is commonly monocular.Typical CHRRPE comprises slightly raised lesions at the posterior pole,with proliferation membrane often leading to vascular distortion.In severe cases,macular edema,macular hole,retinal detachment or vitreous hemorrhage may occur.Patients with atypical clinical manifestations are prone to misdiagnosis by inexperienced ophthalmologists.CASE SUMMARY A 33-year-old man reported onset of right eye blurred vision for one week prior.Anterior segment and intraocular pressure were normal in both eyes.Left eye fundus photography was normal.Right eye ophthalmoscopy showed vitreous hemorrhage and off-white raised retinal lesions below the optic disc.Proliferative membranes on the lesion surfaces resulted in superficial retinal detachment and tortuosity and occlusion of peripheral blood vessels.A horseshoe-like tear in the temporal periphery was surrounded by retinal detachment.Optical coherence tomography revealed retinal thickening at the focal site with structural disturbance indicated by high reflectance.Right eye ultrasound showed retinal thickening at the lesion,stretching and uplifting of the proliferative membrane,with moderately patchy echo at the optic disc edge.Cytokines and antibodies were detected in vitreous fluids during the operation to rule out other diseases.Fundus fluorescein angiography(FFA)at postoperative follow-up led to final diagnosis of CHRRPE.CONCLUSION FFA is helpful in diagnosing retinal and retinal pigment epithelial combined hamartoma.In addition,other cytokine and etiological tests facilitate further differential diagnosis to rule out other suspected diseases.

Evaluation of the safety of anterior capsule staining with trypan blue under air: a retrospective analysis

AIM: To evaluate the safety of using 0.03% trypan blue under air for anterior capsule staining in cataract surgery.METHODS: The current study involved a retrospective analysis of the medical records of 86 patients with vitreous hemorrhage, who underwent pars plana vitrectomy and cataract surgery.The patients were classified into two groups.The trypan blue group(n=45) comprised patients who underwent anterior capsule staining with 0.03% trypan blue under an air bubble.The control group(n=41) comprised of patients who underwent intracameral illuminator-assisted capsulorhexis.The status of endothelial cell density(ECD) in both the groups was analyzed.RESULTS: The trypan blue group displayed significant decline in ECD at 1 mo(7.91% loss, P<0.001) and 3 mo(9.65% loss, P<0.001) after the surgery, whereas no significant changes were observed in the control group.Moreover, the number of patients who did not display a postoperative decline in ECD was significantly higher in the control group(43.9%;18 patients) than in the trypan blue group(17.1%;7 patients, P=0.004).CONCLUSION: Anterior capsule staining with trypan blue under the air bubble would not be as safe as the intracameral illuminator.The ECD loss might be attributed to the air bubble rather than to the deleterious effects of 0.03% trypan blue.Further studies are required to clarify this.

Preoperative intravitreal bevacizumab and silicone oil tamponade for vitrectomy in diabetic retinopathy

AIM: To evaluate the outcomes and complications of vitrectomy for diabetic retinopathy using preoperative bevacizumab and silicone oil(SO) tamponade. METHODS: Eighty-four eyes(64 patients) that underwent vitrectomy to treat severe proliferative diabetic retinopathy were enrolled in this retrospective, interventional, serial case study. All patients provided signed informed consent preoperatively and the off-label use of bevacizumab was discussed with the patients and confirmed in the signed consent forms. Bevacizumab injections and SO tamponades were used in all cases and intraoperative complications, postoperative complications and postoperative outcomes were analyzed. The primary outcome was the occurrence of intraop-erative and postoperative bleeding during and after vitrectomy and SO removal. The secondary outcomes were other complications that occurred during the two surgeries, the surgical time and the postoperative best-corrected visual acuity(BCVA) in log MAR scale compared with the preoperative BCVA in logM AR. The statistical analysis was performed with GraphP ad Prism 5(Graph Pad Software, La Jolla, CA) using a column analysis(column statistics and frequency distribution) for the noncomparative analysis and a paired t-test for the comparative study;P < 0.05 indicated statistical significance. RESULTS: Eighty-four eyes of 64 patients were included in the study. Of the 88 eyes initially recruited, 4 eyes(0.45%) developed phthisis bulbi and were excluded from the statistical analysis. Bevacizumab was injected between 1 and 10 d before surgery, with a mean of 3.7 ± 2.2 d. Forty-six eyes(54.8%) had no complications during the surgery;6 eyes(7.1%) had vitreous hemorrhage;21(25%) had a single retinal tear;7(8.3%) had two or more retinal tears, one of which was in the posterior pole, temporal to the fovea;2(2.4%) had retinal tears associated with hemorrhage;1(1.2%) had choroidal detachment;and 1 eye(1.2%) had dialysis in the temporal entrance of the trocar. After the surgery and SO removal, 60 eyes(71.4%) had no complications, 8(9.5%) had vitreous hemorrhage, 2(2.4%) had a macular hole, 2(2.4%) had an epiretinal membrane, 7(8.3%) had rhegmatogenous retinal detachment, 2(2.4%) had neovascular glaucoma, 2(2.4%) had a corneal trophic ulcer, and 1(1.2%) had central venous occlusion. The surgical time ranged from 40 to 120 min, with a mean of 77.8 ± 20.7 min. The final status of the lens was 34 phakic eyes(40.5%) and 24 pseudophakic eyes(28.5%);in 26 eyes(31%), the lens was extracted via phacoemulsification combined with vitrectomy or SO removal. The preoperative BCVA in logM AR ranged from 0.1 to 3.0, with a mean of 1.6 ± 0.9;the postoperative BCVA in logM AR ranged from 0.0 to 3.0, with a mean of 0.9 ± 0.7;the preoperative and postoperativeBCVA values were significantly different(P < 0.0001). CONCLUSION: Bevacizumab may diminish intraoperative and postoperative bleeding, thus possibly facilitating intraoperative maneuvers, diminishing the complications and playing a role in the final outcomes of these eyes.

Surgical considerations in diabetic vitrectomy

High speed and small gauge vitrectomy systems have made surgical intervention in complications of diabetic retinopathy(DR)safer.The availability of anti-vascular endothelial growth factor(anti-VEGF)compounds for use in DR has significantly improved intraoperative and postoperative outcomes.This review discusses the indications for surgical intervention in DR.The role of anti-VEGF compounds is discussed as surgical adjuvants with an emphasis on timing of treatment before surgery.