Feasibility and utility of intraoperative optical coherence tomography during vitreoretinal surgery:A 4-year report in Chinese population

The objective is to introduce the application of intraoperative optical coherence tomography(iOCT)in pars plana vitrectomy(PPV)for various vitreoretinal diseases,and to report the 4-year assessment of feasibility and utility in Chinese population.We reported a retrospective case series of patients who underwent PPV and iOCT scan at Eye Hospital of Wenzhou Medical University from January 2016 to January 2020.Clinical characteristics were documented before operation,and we intraoperatively recorded the time and results of iOCT scanning,specific surgical maneuvers performed,the consistency with the planned strategies before surgery,the type of OCT images obtained,and adverse events(AEs).The surgeon feedback was collected to evaluate the utility of iOCT during surgery.In total 339 eyes successfully completed iOCT scan,with an average scanning time of 3.54±2.3 min,including 59 cases of idiopathic macular hole(iMH),134 cases of idiopathic epiretinal membrane(iERM),33 cases of lamellar macular hole(LMH),40 cases of high myopic maculopathy,13 cases of vitreous macular traction(VMT),60 cases of dense vitreous hemorrhage(VH).The iOCT findings were not consistent with exami-nation under the operating microscope in 49 cases(14.5%),including 29 cases(8.6%)which changed the operation strategies during surgery.The Hole-door phenomenon arose in 20 cases(33.9%)of iMH and 3 cases(25%)of high myopic MH after ILMs peeling.Moreover,the residue ERM was observed in nine cases(6.7%)of iERM and two cases(14.3%)in high myopic ERM after ILMs peeling.Some new surgical methods could also be confirmed using iOCT.The ap-plication of iOCT has a significant clinical functionality in vitreoretinal surgery,providing the surgeon with a new surgical understanding,guiding the selection of a more reasonable operative procedure during surgery,predicting postoperative recovery and improving postoperative outcomes.

Volumetric fluid analysis of fixed monthly anti-VEGF treatment in patients with neovascular age-related macular degeneration

·AIM:To evaluate visual outcomes and changes in fluid after administering monthly anti-vascular endothelial growth factor(VEGF)injections to treat neovascular agerelated macular degeneration(n AMD)with subretinal fluid(SRF)and pigment epithelial detachment(PED).·METHODS:This prospective study included eyes with n AMD previously treated with as-needed anti-VEGF injections.The patients were treated with six monthly intravitreal injections of ranibizumab.Quantitative volumetric segmentation analyses of the SRF and PED were performed.The main outcome measures included best-corrected visual acuity(BCVA),and SRF and PED volumes.·RESULTS:Twenty eyes of 20 patients were included in this study.At the 6-month follow-up,BCVA and PED volume did not change significantly(P=0.110 and 0.999,respectively)but the mean SRF volume decreased from 0.53±0.82 mm3 at baseline to 0.08±0.23 mm3(P=0.002).The absorption rate of the SRF volume was negatively correlated with the duration of previous antiVEGF treatment(P=0.029).Seven of the 20 eyes(35%)showed a fluid-free macula and significant improvement in BCVA(P=0.036)by month 6.·CONCLUSION:Quantifying the SRF can precisely determine the patient’s responsiveness to anti-VEGF treatment of n AMD.

Temporal pattern of resolution/recurrence of choroidal neovascularization during bevacizumab therapy for wet age-related macular degeneration

AIMTo characterize temporal pattern of resolution and recurrence of naive choroidal neovascularization (CNV) secondary to wet age-related macular degeneration (AMD) treated with intravitreal bevacizumab on as needed regimen, and to analyze baseline risk factors for CNV resolution or recurrence.

Predictors of visual outcome in eyes with choroidal neovascularization secondary to age related macular degeneration treated with intravitreal bevacizumab monotherapy

AIM:To evaluate the predictors of visual improvement in eyes with naive choroidal neovascularization secondary to age-related macular degeneration (CNV -AMD) treated with intravitreal bevacizumab (IVB) monotherapy. METHODS:Fifty eyes with naive CNV-AMD with pretreatment best-corrected visual acuity (BCVA) better than 20/200 and treated with IVB monotherapy were evaluated. Several variables including age, sex, pre-treatment BCVA, CNV type and lesion size on fluorescein angiogram as well as SD-OCT parameters including pre-treatment central macular thickness (CMT), inner-segment/outer-segment (IS/OS) junction integrity, and external limiting membrane (ELM) integrity were analyzed to predict visual outcome.RESULTS:On univariate regression, pretreatment ELM damage was associated with less visual improvement after treatment (P =0.0145). However, ELM damage predicted only 10% of the visual outcome. On multivariate regression, pretreatment BCVA, IS/OS junction, and ELM integrity on SD-OCT were the significant predictors for the treatment effect and together predicted 37% of visual improvement. CONCLUSION:Pretreatment BCVA, ELM and IS/OS junction integrity on SD-OCT are of significant value inpredicting the visual improvement in naive wet AMD patients treated with IVB monotherapy.

Is there any correlation between vitamin D insufficiency and diabetic retinopathy?

AIM: To determine a relation between vitamin D level,which is an inhibitor of angiogenesis, and diabetic retinopathy and its risk factorsMETHODS: In a clinic-based cross sectional study two hundred and thirty-five type 2 diabetic patients older than 20 y were selected. Patients were classified according to ophthalmologic examination as following:no diabetic retinopathy(NDR)(n =153), non-proliferative diabetic retinopathy(NPDR)(n =64) and proliferative diabetic retinopathy(PDR)(n =18). Study subjects were tested for fasting blood glucose, glycated hemoglobin A1C(Hb A1C), lipid profile, microalbuminuria, Hs CRP,IGF1, insulin(in patients without history of insulin taking)and 25 hydroxy vitamin D [25(OH) D] levels. Vitamin D insufficiency was defined according to 25(OH) D level less than 30 ng/m L. The relationship between diabetic retinopathy and serum 25(OH) D insufficiency was evaluated.RESULTS: The prevalence of diabetic retinopathy was34.8% in our patients. Long duration of diabetes,hypertension, poor glycemic control, diabetic nephropathy, hyperinsulinemia and insulin resistance were risk factors for diabetic retinopathy but 25(OH) D level was not significant different between NDR, NPDR and PDR groups. Correlation between 25(OH) D level and other known risk factors of diabetic retinopathy was not significant.CONCLUSION: This study did not find any association between diabetic retinopathy and its severity and vitamin D insufficiency. Vitamin D insufficiency is not related to risk factors of diabetic retinopathy.

Effect of intravitreal conbercept treatment before vitrectomy in proliferative diabetic retinopathy

AIM： To evaluate the safety and efficacy of intravitreal conbercept（IVC） injections as pretreatment for pars plana vitrectomy（PPV） in severe proliferative diabetic retinopathy（PDR）. METHODS： This was a retrospective chart review of all patients who underwent PPV for PDR from January 2014 to October 2016. Patients who underwent IVC injection before PPV were assigned to the IVC group; the others were assigned to the control group. The IVC was performed 3-7 d before surgery in the IVC group. All the eyes in the two groups were operated by the same doctor to complete the vitrectomy. Intraoperative complications and the changes in best-corrected visual acuity（BCVA） before and after surgery were compared between the two groups. RESULTS： A total of 68 eyes of 63 patients（22 eyes in the IVC group and 46 eyes in the control group） were examined. The risk of intraoperative bleeding was lower in the IVC group（2/22） than in the control group（25/46, P=0.000）. Furthermore, the use of endodiathermy was significantly lower in the IVC group（1/22） than in the control group（12/46, P=0.047）. The surgical time in the IVC group（112.64±34.52 min） was significantly shorter than in the control group（132.85±40.04 min, P〈0.05）. Compared to the BCVA before surgery, the mean BCVA was significantly improved after surgery for both groups（P〈0.05）. CONCLUSION： PPV is an effective treatment and can improve vision in patients with PDR. Preoperative intravitreal injection of conbercept could reduce the chances of intraoperative bleeding and the use of endodiathermy and shorten the operative time, which are beneficial in the management of PDR.

Central serous chorioretinopathy:from glucocorticoids to light intensity

Central serous chorioretinopathy （CSC） is characterized by a localized accumulation of subretinal fluid and an idiopathic focal leakage from choroidal vessels. The exact pathogenesis of CSC, however, still remains obscure. In this paper, we hypothesized that CSC may result from a response of choroidal vessels to an acute increase in the environmental light intensity leading to a focal leakage from the choroidal vessels. High levels of glucocorticoids, in our proposed model, may cause persistence rather than initiation of the focal leakage, probably by suppressing the synthesis of collagen and extracellular matrix components and inhibiting fibroblastic activity.

迁延性中心性浆液性脉络膜视网膜病变患者FFA荧光素渗漏点近红外自发荧光图像特征

目的观察迁延性中心性浆液性脉络膜视网膜病变(CSC)患者荧光素眼底血管造影(FFA)检查所示的荧光素渗漏点部位近红外自发荧光(NIRAF)的图像特征。方法回顾性临床研究。将2020年1月至12月于温州医科大学附属眼视光医院杭州院区就诊的迁延性CSC患者29例29眼纳入研究。使用共焦激光眼底血管造影仪行NIRAF和FFA检查,并分析FFA荧光素渗漏点部位的NIRAF图像特征。结果29例迁延性CSC患眼中有26眼(89.7%)FFA荧光素渗漏点位置在NIRAF出现异常改变,另3眼(10.3%)未见明显异常。在FFA荧光素渗漏点NIRAF异常的26眼中,按荧光强度统计,弱荧光占65.4%(17/26),斑驳荧光占34.6%(9/26),无强荧光表现;按病灶形态统计,点状病灶占42.3%(11/26),片状病灶占57.7%(15/26);综合统计,点状弱荧光占34.6%(9/26),片状弱荧光占30.8%(8/26),点状斑驳荧光占7.7%(2/26),片状斑驳荧光占26.9%(7/26)。结论迁延性CSC患者FFA荧光素渗漏点具有特征性NIRAF改变。NIRAF是无创性研究视网膜色素上皮的有效工具。

应用OCT客观分析HIV阳性患者HAART期的视网膜损害

Purpose: To assess retinal nerve fiber layer (RNFL) thickness in patients with human immunodeficiency virus (HIV) disease without cytomegalovirus retinitis (CMV). Design: A casecontrol study. Methods: The study included 113 eyes of 65 patients in one center. Thickness of RNFL along a 3.4- mmdiameter circle centered on the optic nerve head was evaluated using third- generation optical coherence tomography. Patients in group A (39 eyes of 22 patients) were human immunode- ficiency virus- negative control subjects. Group B (36 eyes of 18 patients) was composed of HIV patients with no history of CMVretinitis and CD4 counts consistently above 100. Group C (38 eyes of 25 patients) comprised HIV patients with no history of CMV retinitis but a history of CD4 count less than 100 at some point lasting for at least 6 months. Results: The average RNFL thicknesses in groups A, B, and C were 103.33± 8.50 μ m, 103.30± 9.28 μ m, and 90.10± 12.50 μ m, respectively. Group C had significantly thinner overall RNFL than either of the groups A and B (Tukey- Kramer). This difference was most prominent in temporal, superior, and inferior retinal areas. No differencewas in nasal retinal area, nor between groups A and B in any of the areas. Conclusions: Significant RNFL thinning occurs in HIV patients without CMV retinitis and with low CD4 counts compared with the same subgroup of patients with CD4 count increased to above 100 and HIV- negative control subjects. Third- generation OCT may be useful in diagnosis of early subclinicalHIV- associated visual functional loss.

高分辨光学相干断层成像术对棉絮状白斑进行活体组织学观察

PURPOSE:To provide optical characteristics of cotton-wool spots(CWS)on optical coherence tomography(OCT)and scan the retina after CWS have ophthalmoscopically disappeared.DESIGN:Observational case reports.METHODS:We studied four eyes of four patients with retinopathy due to human immunodeficiency virus(HIV)and hypertension.The StratusOCT Model 3000 in single-line mode was used for imaging of acute and resolved CWS and adjacent normal retina.The fundus photography served as a template for OCT scanning in localization of CWS.Retinal tissue reflectivity images were compared.RESULTS:There were differences in reflectivity of normal retina,the retina in the area of active CWS,and the retina in the same area after CWS has resolved.Most striking was that the OCT documented a persistent focal area of hyperreflectivity in the area of the resolved CWS,indicative of retinal gliosis that could be imaged.CONCLUSIONS:CWS show a hyper-reflective pattern on OCT that persists even after they become ophthalmoscopically invisible.

人类获得性免疫缺陷患者接受高效抗逆转录病毒治疗时眼压变化的长期研究

Purpose: To characterize a longitudinal relationship between highly active antiretroviral therapy immune recovery as defined by an increase in CD4 cell counts and any associated changes in intraocular pressure (IOP) in both patients with and patients without a history of cytomegalovirus (CMV) retinitis and to determine if human immunodeficiency (HIV)-induced reduction in IOP is reversible. Design: Retrospective analysis of patient data collected from 1997 through 2004. Participants: Cohort of patients from one eye center, including patients from the Longitudinal Study of Ocular Complications of Acquired Immunodeficiency Syndrome. Methods: Linear regression analyses were conducted within the CMV and non-CMV groups to determine the change in IOP per 100- unit change in CD4 count. Average changes in IOP per change in CD4 count were compared between the CMV and the non-CMV groups using a Wilcoxon rank-sum test. Linear regression analyses were conducted within the CMV and non-CMV groups to determine the linear relationship between the 12- month change in IOP per 12- month 100- unit change in CD4 count. Main Outcome Measure: Intraocular pressure in relation to changes inCD4 cell counts. Results: Compared with the non-CMV group, the median IOP change per change in CD4 count was not statistically different from the CMV group (0.9 vs. 1.7 mmHg/100 CD4 cells, respectively; P=0.20). Analysis of the linear relationship between the 12- month change in IOP and the 12- month change in CD4 count within both the CMV and non-CMV groups showed a strong linear relationship: 67% of the variability in a 12- month IOP change for the CMV group (P<0.0001) and 36% of the variability in a 12- month IOP change for the non-CMV group (P<0.001). Conclusions: Reduction in T-lymphocyte count in HIV infection is accompanied by a decrease in IOP in both CMV-infected and non-CMV-infected eyes, and immune recovery is associated with an increase in IOP.

采用图像叠加技术的激光扫描检眼镜可改良脉络膜新生血管的显影

Aims: To improve visualisation of angiographic features in patients with age r elated macular degeneration associated with choroidal neovascularisation (CNV) a nd related complications. To evaluate if image averaging can achieve this goal. Methods: 27 eyes of 20 sequential patients with age related macular degeneration over a 3 month period were studied. Indocyanine green angiograms (ICGA), fluore scein angiograms (FA), and oral fluorescein angiograms were recorded with a conf ocal scanning laser ophthalmoscope. Software was used to average multiple images from a 10-20 image series (over 0.5-1.0 seconds). Image quality was assessed by two masked observers and graded on a scale of 0-3. A more quantifiable gradi ng method was devised by adding a variable amount of Gaussian noise to the impro ved image until the original and image averaged image appeared equal. Results: M asked review showed mild to strong improvement of visualisation of structures in cluding borders of CNV. Improvement varied depending on the type and phase of th e angiogram. Improvement was highest in late phase FA, mid and late phase ICGA, and all phases of oral FA. Conclusion: Image averaging using software based algo rithms improves the quality of angiographic images, particularly late ICGA image s and oral FAs. This method may assist in the visualisation of choroidal neovasc ularisation in age related macular degeneration.

黄斑中心凹处视网膜前膜剥离术后出现的非进展性中心凹外视网膜裂孔

PURPOSE:To report an extrafoveal posterior retinal hole after surgical removal of foveal epiretinal membrane.DESIGN:Observational case reports.METHODS:We describe two patients who underwent vitrectomy surgery with an epiretinal membrane removal.Five months after vision improving surgery,a small retinal hole outside the macular area developed.RESULTS:Fundus photography and optical coherence tomography showed a full-thickness retinal holewith a surrounding cuff of subretinal fluid smaller than described in stage III or IV macular holes.The hole has been stable in shape and dimension,has not progressed to retinal detachment,and is not associated with an epiretinal membrane;the fluid is not impinging on the macular area.CONCLUSIONS:Asymptomatic full-thickness extrafoveal retinal holes,which do not progress to neurosensory detachment,can develop after epiretinal membrane peeling.These appear stable and have substantially smaller cuffs of subretinal fluid than typical macular holes.

玻璃体腔注射雷珠单抗对老年PDR合并AMD患者的疗效研究

目的探究玻璃体腔注射雷珠单抗对老年增殖性糖尿病视网膜病变(PDR)合并老年性黄斑变性(AMD)的临床效果。方法选取2015年10月至2018年12月乔治华盛顿大学医院眼科和弗吉尼亚视网膜中心收治的87例老年PDR合并AMD患者,均行玻璃体腔注射雷珠单抗(0.5 mg)治疗,分别于治疗前和治疗后1个月采用视力表检测患者最佳矫正视力(BCVA),采用光学相干断层扫描测量黄斑中心凹厚度(CFT),采用超声诊断仪检查眼动脉(OA)和视网膜中央动脉(CRA)的收缩期峰值血流速度(PSV)和舒张末期血流速度(EDV),采用ELISA检测血管内皮生长因子(VEGF)和房水炎性因子[肿瘤坏死因子-α(TNF-α)、白细胞介素(IL)-6、IL-10],观察治疗后1个月不良反应发生情况。结果治疗后1个月患者BCVA提高,CFT、VEGF水平降低,房水TNF-α、IL-6水平也降低,差异有统计学意义(P<0.05),而IL-10、PSV、EDV无明显变化(P>0.05);治疗后1个月出现高眼压2例(2.30%),角膜水肿3例(3.45%),再出血2例(2.30%),前房炎性反应4例(4.60%),不良反应总发生率为12.64%。结论采用玻璃体腔注射雷珠单抗治疗老年PDR合并AMD效果良好。

A novel deletion mutation, c.1296delT in the BCOR gene, is associated with oculo-facio-cardio-dental syndrome

The purpose of the present study was to analyze the clinical phenotypes of a girl with oculo-facio-cardio-dental(OFCD)syndrome and to identify the potential pathogenic mutation responsible for her disease. The patient underwent detailed clinical examinations and phenotype data were collected over a follow-up period of 9 years. Mutation analysis of the candidate gene BCOR was performed with polymerase chain reaction and Sanger sequencing. BCOR of 60 unrelated normal individuals were also sequenced as a control group. Clinical phenotyping and follow-up study results indicate that this patient had multiple system anomalies including ocular, facial, cardiac, dental, and limb malformations. In addition, papilloma of the choroid plexus was identified, which represents the first report of this phenotype in an OFCD patient. A novel deletion mutation, c.1296 delT in exon4 of the BCOR gene, was identified in this patient and was not found in her parents or in 60 normal unrelated individuals. This deletion was a frameshift mutation and is proposed to encode a premature stop codon, thus producing a truncated protein. Our patient fitted the diagnostic criteria for OFCD syndrome and we report the first papilloma of the choroid plexus in an OFCD patient, expanding the recognized phenotypic spectrum of this disease. Meanwhile, we identified a novel deletion mutation that may cause OFCD syndrome.

Effect of intravenous sedation on patients’ visual experience and vital signs during cataract surgery under topical anesthesia: A randomized controlled trial

Purpose:Effect of intravenous sedation on patients’visual experience and vital signs during cataract surgery under topical anesthesia:a randomized controlled trial.Design:Prospective,double masked,randomized controlled trial.Methods:150 eyes of 150 patients undergoing phacoemulsification and IOL implantation under topical anesthesia were randomized to receive either intravenous midazolam(0.015 mg/kg)or normal saline.The patients’experience was evaluated using a questionnaire.Vital signs including blood pressure and heart rate were measured before,during and after surgery.Mean arterial pressure(MAP)was calculated.Results:Both groups were comparable except that fewer patients in the control group were pseudophakic in the fellow eye(25.3%vs.41.3%).More patients in the control group perceived hand movements(p<0.01),surgeon/medical staff(p?0.04)and sudden increase in vision during surgery(p<0.01)compared to midazolam group.More control group patients experienced fear(p<0.001),pain(p=0.06)and unpleasant surgical experience(20.3%vs.1.3%,p<0.001).They also experienced greater fluctuation in MAP(16.9±7.9 vs.7.2±5.3,p<0.001)and this was accentuated in hypertensives.After adjusting for age,gender,hypertension status and other eye lens status,multivariable logistic regression analysis revealed that subjects in the control arm(OR=11.7,95%[CI]=1.3-108,p=0.03),had a longer duration of surgery,experienced pain and more likely to report unpleasant experience.Adjusting for similar covariates,multivariable linear regression analysis showed that control group patients(β=8.5 mmHg,95%CI=6.2-10.8,p=0.03)had hypertension,experienced fear during surgery and greater fluctuations in the MAP.Conclusions:A sedative dose of intravenous midazolam during phacoemulsification under topical anesthesia significantly reduces patients’visual experience,fear and fluctuations in MAP and improves overall surgical experience.