A European study has demonstrated a high level of correspondence between different choroidal neovascularization patterns identified using optical coherence tomography angiography and treatment decisions established on conventional multimodal imaging in patients with exudative age-related macular degeneration. While fluorescein angiography remains the gold standard for determining the presence of leakage, OCTA may offer a noninvasive option for monitoring CNV.
The study was a prospective case series of 80 eyes of 73 consecutive patients (39 women, 34 men) with exudative AMD (mean age: 79.4 ±5.3 years) diagnosed with different types of CNV (58 Type 1; two Type 2; six mixed Type 1 and Type 2; three retina angiomatous proliferation; 11 AMD-related polyps). The data obtained from traditional multimodal imaging, based on fluorescein angiography, indocyanine green angiography and OCT were used to assess the need for treatment; the data obtained from OCTA was used to identify two different patterns of CNV. Traditional multimodal imaging and OCTA findings were then compared to evaluate possible correspondence between treatment decision and CNV aspect on OCTA.
A CNV lesion was identified as Group A (requiring treatment) in 58 eyes (72.5 percent) in traditional multimodal imaging. With OCTA, 59 eyes (73.7 percent) had lesions defined as Pattern 1; the remaining 21 (26.3 percent) were defined as Pattern 2. There was a 94.9-percent correspondence between the Pattern 1 CNV on OCTA and the Group A cases on conventional multimodal imaging. A 90.5-percent correspondence was also computed between Pattern II CNV on OCTA and Group B (not requiring treatment) cases on conventional multimodal imaging. There was a high interobserver agreement (p<0.05) both for treatment decision in conventional multimodal and for Patterns (1 or 2) defining on OCTA imaging analysis.
Coscas G, Marco L, Coscas F, Gagini C, Souied E.
No Long-term Protection from NSAIDs after Cataract Surgery
A review of the available data shows a lack of level 1 evidence to support long-term benefit of prophylactic topical nonsteroidal anti-inflammatory drugs in preventing vision loss from cystoid macular edema after cataract surgery. Although dosing of NSAIDs before surgery may hasten the speed of visual recovery in the first several weeks after cataract surgery, there is no evidence that this practice affects long-term visual outcomes. However, because there is no uniform method of reporting CME in the literature, standardized reporting of CME based on OCT may allow for more uniform quantification of its incidence and more reliable assessment of treatment outcomes.
Literature searches of the PubMed and the Cochrane Library databases were last conducted on January 21, 2015, with no data restrictions. The searches retrieved 149 unique citations. The first author reviewed the abstracts of these articles and selected 27 articles of possible clinical relevance for full-text review. Of these 27 articles, 12 were deemed relevant to analyze in full. Two additional articles were identified from the reference list of the selected articles, and another article was identified from a national meeting. The panel methodologist assigned ratings of level of evidence to each of the selected citations.
NSAID therapy was effective in reducing CME detected by angiography or optical coherence tomography and may increase the speed of visual recovery after surgery when compared directly with placebo or topical corticosteroid formulations with limited intraocular penetration. However, the use of NSAIDs did not alter long-term (≥three months) visual outcomes. Furthermore, there was no evidence that the benefits observed with NSAID therapy could not be obtained similarly with equivalent dosing of a corticosteroid. The reported impression that there is a pharmacologic drug synergy from the use of both an NSAID and a corticosteroid is not supported by the literature.
Kim S, Schoenberger S, Thorne J, Ehlers J, Yeh S, Bakri S.
Treat-and-Extend vs. Monthly Dosing for Neovascular AMD
A prospective, randomized, controlled trial using a treat-and-extend neovascular age-related macular degeneration management strategy with ranibizumab resulted in visual and anatomic gains comparable with those obtained via monthly dosing.
Sixty patients with treatment-naïve neovascular AMD with Early Treatment Diabetic Retinopathy Study best-corrected visual acuity from 20/32 to 20/500 (Snellen equivalent) were randomized 1:2 to receive intravitreal 0.5 mg ranibizumab monthly or according to a treat-and-extend protocol. The treat-and-extend patients were treated monthly for at least three doses, until resolution of clinical and spectral-domain optical coherence tomography evidence of exudative disease activity; the interval between visits then was individualized according to a strict prospective protocol. Main outcome measures were mean ETDRS BCVA change from baseline.
At baseline, mean age was 77 years (range: 59 to 96), mean BCVA was 20/60 (Snellen equivalent) and mean central retinal thickness was 511 μm. Fifty-seven eyes (95 percent) completed month 12, at which point mean BCVA improved by 9.2 letters in the monthly cohort and 10.5 letters in the treat-and-extend cohort (p=0.60). The mean number of injections administered through month 12 was 13.0 and 10.1 (r: seven to 13) in the monthly and treat-and-extend cohorts, respectively (p<0.0001). Among the treat-and-extend patients, seven (18 percent) were maximally extended; four (10 percent) demonstrated fluid at every visit; and at month 12, 18 (45 percent) had achieved an extension interval of eight weeks or more; the mean maximum extension interval between injections after the first three monthly doses was 8.4 weeks (r: four to 12 weeks). Most treat-and-extend patients who demonstrated recurrent exudative disease activity (17/24, 71 percent) were unable to extend beyond their initial maximum extension interval.
Wykoff C, Croft D, Brown D, Wang R, Payne J, et al.
Predicting Wet AMD Patient Response to Ranibizumab
Consistent with other published reports, this retrospective exploratory analysis of the HARBOR study identified several baseline predictors associated with visual acuity outcomes at month 12 with ranibizumab treatment in patients with wet age-related macular degeneration: lower baseline best-corrected visual acuity; younger age; a smaller total choroidal neovascularization leakage area; a smaller area of occult CNV; and presence of subretinal fluid. Subretinal fluid thickness >118.25 μm at baseline predicted requiring more ranibizumab injections in the first 12 months of treatment.
Researchers used a retrospective, exploratory analysis of multicenter, randomized, controlled trial data, culling patients aged ≥50 years with subfoveal wet AMD who had best-corrected visual acuity measured at baseline and month 12 for the study population. Intravitreal ranibizumab 0.5 mg was administered monthly (n=249) or as-needed after three monthly loading doses (n=251). The main outcome measures that served as a basis for baseline predictors of visual acuity outcomes at month 12 were BCVA change from baseline at month 12; the proportion of patients with a BCVA gain of ≥15 ETDRS letters from baseline at month 12; and the proportion of patients with a Snellen equivalent of 20/40 or better at month 12 in the ranibizumab 0.5-mg monthly and 0.5-mg PRN groups. A post hoc analysis of the total number of injections in the first 12 months of patients receiving ranizibumab 0.5 mg PRN was also performed. Only variables that were statistically significant (p<0.05) remained in the final statistical model.
Am J Ophthalmol 2015;160:5:1014-1023.
Regillo C, Busbee B, Ho A, Ding B, Haskova Z.
Antibiotic Resistance in Ocular Pathogens in the United States
During the first five years of the Antibiotic Resistance Monitoring in Ocular Microorganisms surveillance study, methicillin resistance was present among staphylococcal isolates from ocular infections, with many strains demonstrating multi-drug resistance. These findings are consistent with resistance trends reported for nonocular staphylococcal isolates. Overall ocular resistance did not grow during the five-year study period.
ARMOR was performed at an independent central laboratory, with the goal of reporting resistance rates and trends among common ocular isolates collected during the first five years of the study. Clinical centers across the United States were invited to submit ocular isolates of Staphylococcus aureus, coagulase-negative staphylocci (CoNS), Streptococcus pneumoniae, Haemophilus influenzae and Pseudomonas aeruginosae. Isolates were collected from January 1, 2009 through December 31, 2013, and analyzed from January 16 to May 15, 2015.
Minimum inhibitory concentrations for various antibiotic classes were determined by broth microdilution according to the guidelines of the Clinical and Laboratory Standards Institute. Minimum inhibitory concentrations were interpreted as susceptible, intermediate or resistant based on established break points.
A total of 3,237 ocular isolates (1,169 S. aureus, 992 CoNS, 330 S. pneumoniae, 357 H. influenzae and 389 P. aeruginosa) were collected from 72 centers. Methicillin resistance was found among 493 S. aureus isolates (42.4 percent; 95 percent confidence interval, 39.3 percent to 45.1 percent) and 493 CoNS isolates (49.7 percent; 95 percent CI, 46.5 percent to 52.9 percent) and methicillin-resistant isolates had a high probability of concurrent resistance to fluoroquinolones, aminoglycosides or macrolides (p<0.001). Multi-drug resistance to at least three additional antibiotic classes was found in 428 methicillin-resistant S. aureus isolates (86.8 percent) and 381 methicillin-resistant CoNS isolates (77.3 percent). All staphylococcal isolates were susceptible to vancomycin. Resistance among S. pneumoniae isolates was highest for azithromycin (113 isolates; 34.2 percent) whereas resistance among P. aeruginosa and H. influenzae isolates was low against the antibiotics tested. Staphylococcal isolates from elderly patients were more likely to be methicillin-resistant, as were S. aureus isolates obtained from the southern United States (p<0.001). Methicillin resistance among staphylococci did not increase during the five-year study period (p≤0.22) and small decreases in resistance to ciprofloxacin among CoNS and methicillin-resistant CoNS and to tobramycin among CoNS (p≤0.03) were found.
JAMA Ophthalmol 2015;133:12:1445-1454.
Asbell P, Sanfilippo C, Pillar C, DeCory H, et al.