From the editors of Review of Ophthalmology:
Monday, February 10, 2020
FEBRUARY IS AGE-RELATED MACULAR DEGENERATION AWARENESS MONTH
In this issue: (click heading to view article)
VF Changes in Patients Treated with PRP or Ranibizumab for PDR
Preservation of peripheral visual fields is considered an advantage for anti-vascular endothelial growth factor agents compared with panretinal photocoagulation for treatment of proliferative diabetic retinopathy, researchers wrote. Since long-term data on VF are important when considering either treatment approach, researchers aimed to evaluate VF changes through five years among eyes enrolled in the Protocol S clinical trial, conducted by the DRCR Retina Network.
This post hoc analysis of an ancillary study within a multicenter, randomized clinical trial included individuals with proliferative diabetic retinopathy enrolled in Protocol S. Data were collected from February 2012 to February 2018, and analysis began in June 2018.
Subjects received panretinal photocoagulation or intravitreous injections of 0.5-mg ranibizumab. Diabetic macular edema, whenever present, was treated with ranibizumab in both groups. Panretinal photocoagulation could be administered in eyes in the ranibizumab group when failure or futility criteria were met.
Main outcomes and measures included mean change in total point score on VF testing with the Humphrey Field Analyzer 30-2 and 60-4 test patterns. Of 394 eyes enrolled in Protocol S, 234 (59.4 percent) were targeted for this ancillary study. Of these, 167 (71.4 percent) had VFs meeting acceptable quality criteria at baseline (median age: 50 [interquartile range: 43 to 58] years; 90 participants were men [53.9 percent]). At five years, 79 (33.8 percent) had results available. Here were some of the findings:
• The mean change in total point score was -305 ±521 dB in the PRP group and -36 ±486 dB in the ranibizumab group at one year, increasing to -527 ±635 dB in the PRP group and -330 ±645 dB in the ranibizumab group at five years (p
• After filtering VF results post-PRP treatment in the ranibizumab group, the five-year mean change in total point score was -201 (442) dB.
• In a longitudinal regression analysis of change in total point score including both treatment groups, laser treatment was associated with a mean point decrease of 208 (CI, 112 to 304) dB for the initial PRP session, 77 (CI, 21 to 132) dB for additional PRP sessions and 325 (CI, 211 to 439) dB for endolaser.
• No association was found between the change in point score and the number of ranibizumab injections during the previous year (-9 per injection [CI, -22 to three]).
Researchers wrote that the limited data available from Protocol S suggested that factors besides PRP were associated with VF loss in eyes treated with PDR. They added that further clinical research is needed to clarify the finding.
SOURCE: Maguire MG, Liu D, Glassman AR, et al. Visual field changes over 5 years in patients treated with panretinal photocoagulation or ranibizumab for proliferative diabetic retinopathy. JAMA Ophthalmol 2020; Jan 30. [Epub ahead of print].
OCTA Macula Vessel Density for Glaucoma Diagnosis
Scientists evaluated the diagnostic accuracy of 3 mm2 and 6 mm2 macula OCTA scans for classifying healthy, mild glaucoma, and moderate to severe glaucoma eyes.
Participants enrolled in the Diagnostic Innovations in Glaucoma Study (DIGS) with good quality 3 mm2 and 6 mm2 OCTA images of the macula acquired on the same day were included in this cross-sectional study. Area under the receiver operating characteristic curves were calculated to assess the diagnostic accuracy of vessel density of both scan sizes for differentiating between three diagnostic groups.
A total of 279 eyes (89 healthy, 127 with mild glaucoma, and 63 with moderate to severe glaucoma) from 190 subjects were included in this study. Here were some of the findings:
• The vessel density of the outer area of the 6 mm2 scan size had higher diagnostic accuracy compared with the vessel density of the inner area of the 3 mm2 scan when differentiating between healthy and mild glaucoma (3 mm2 AUC=0.71 and 6 mm2 AUC=0.79, p=0.032).
• The vessel density of the outer area of the 6 mm2 scans had only similar diagnostic accuracy compared with the inner area of the 3 mm2 scan when differentiating between healthy and moderate to severe glaucoma eyes (AUC=0.90 for 3 mm2 and 0.92 6 mm2, p=0.279).
• The vessel density of the inner area of the 6 mm2 scan size had similar diagnostic accuracy as the corresponding area of the 3 mm2 scan in both diagnostic categories.
Scientists wrote that the diagnostic accuracy of vessel density using the 6 mm2 macula OCTA scan was better than the 3 mm2 scan when differentiating between healthy and mild glaucoma eyes, and similar to the 3 mm2 scan when differentiating between healthy and moderate to severe glaucoma eyes.
SOURCE: Penteado RC, Bowd C, Proudfoot J, et al. Diagnostic ability of optical coherence tomography angiography macula vessel density for the diagnosis of glaucoma using difference scan sizes. J Glaucoma 2020; Jan 21. [Epub ahead of print].
DMEK with a Pull-through Insertion Device
Investigators described a surgical technique for Descemet’s membrane endothelial keratoplasty using a pull-through, endothelium-in insertion device, the DMEK EndoGlide. They evaluated the endothelial cell loss associated with the EndoGlide-DMEK (E-DMEK) technique in ex vivo
and prospective clinical studies. (Two of the study authors disclose that they are inventors of the EndoGlide and receive royalties from the device’s maker.)
The ex vivo
study involved calcein acetoxymethyl staining and preparation of DMEK grafts, which were trifolded endothelium-in, loaded into the EndoGlide, pulled through and unfolded in imaging dishes. Investigators performed inverted fluorescent microscopy, and quantified ECL using trainable segmentation software. The prospective clinical series described the outcomes of consecutive surgeries using technique. Grafts were pulled through the EndoGlide with forceps and unfolded in the anterior chamber endothelium-down. The main outcome measure was ECL in both studies.
In the ex vivo
study with nine human donor corneas, mean ECL was 15.2 ±5.4 percent (n=9). In the clinical series of 69 eyes, the indications for surgery were pseudophakic/aphakic bullous keratopathy (47.8 percent), previous failed grafts (23.2 percent) and Fuchs’ endothelial dystrophy (18.8 percent). Here are some of the findings:
• Rebubbling rates related to E-DMEK were 11.6 percent, and primary graft failure rates were 1.5 percent.
• Among eyes with at least six months of follow-up, mean preoperative endothelial cell density was 2,772 (range: 2,457 to 3,448) cells/mm2
, and postoperative endothelial cell density was 1,830 (range: 541 to 2,545) cells/mm2
• Mean ECL was 33.6 percent (range: 7.5 to 80.4; n=32) at the 7.1 (range: six to 11) months follow-up.
Investigators determined that the ex vivo and pilot clinical studies suggested that E-DMEK showed acceptable rates of ECL, with safe and promising early clinical outcomes.
Source: Tan TE, Devarajan K, Seah XY, et al. Descemet membrane endothelial keratoplasty with a pull-through insertion device: Surgical technique, endothelial cell loss, and early clinical results. Cornea 2020; Jan 28. [Epub ahead of print.]
Non-exudative Macular Neovascularization Supporting Outer Retina in AMD
Researchers wrote that type 1 macular neovascularization (MNV) secondary to age-related macular degeneration may compensatorily sustain hypoxic and micronutrient-insufficient outer retinal cells. They explored this hypothesis using the histology of an eye with a shallow irregular retinal pigment epithelial elevation (SIRE) on optical coherence tomography and good vision.
The case study and clinicopathologic correlation included the imaging of untreated non-exudative neovascular AMD and 20/30 visual acuity (left eye) and neovascular AMD (right eye) in a white woman with nine years’ multimodal imaging before death at age 90.
The left eye was preserved 6.25 hours after death and prepared for submicrometer epoxy resin sections and transmission electron microscopy aligned to clinical OCT B-scans. Researchers measured inside and outside the MNV area, layer thicknesses, phenotypes and vascular density of native choriocapillaris and new vessels with ImageJ. They measured the lengths of choriocapillaries and intervening gaps in the index eye, and in early AMD eyes and normal eyes with similar age (n=19 each) from the Project MACULA online histopathology resource with custom software (Caps and Gaps).
Main outcome measures included descriptive light and electron microscopic morphology, vascular density, histologic and OCT layer thicknesses, and distribution of choriocapillaries and intervening gaps. Here were some of the findings:
• The SIRE correlated to a type 1 MNV that expanded slowly without evidence of exudation and with numerous choroidal vessels traversing Bruch’s membrane defects, some visible on OCT.
• Tissue layers in and adjacent to the MNV area showed continuous RPE and characteristic AMD deposits.
• Capillary-like new vessels with fenestrations and caveolae resembling native choriocapillaris lined the RPE with a vascular density comparable to surrounding non-MNV areas.
• Relative to early AMD and normal-aged eyes, the index case had similar capillary lengths but larger gaps between vessels, indicating drop-out.
• ONL thickness was preserved and showed less photoreceptor degeneration over areas of relative choriocapillaris health, including the type 1 MNV.
Researchers concluded that eyes with non-exudative type 1 MNV in AMD may progress to exudation; however, this stable MNV complex supported the outer retinal structure for nine years. Distinguishing features were numerous connecting vessels, high density of new vessels, continuous RPE and slow growth. Researchers concluded that maintaining beneficial type 1 MNVs may be a therapeutic strategy.
SOURCE: Chen L, Messinger, Sloan KR, et al. Non-exudative macular neovascularization supporting outer retina in age-related macular degeneration, a clinicopathologic correlation. Ophthalmology 2020; Jan 28. [Epub ahead of print].
Prevent Blindness and B+L Raise Awareness of AMD
If you'd like another resource on macular degeneration for your patients, Bausch + Lomb and Prevent Blindness are collaborating throughout February for the fifth consecutive year to raise awareness of age-related macular degeneration. Throughout February, B + L and Prevent Blindness will post a variety of content on their social media pages to share facts and information about AMD. B + L will also donate $1 to Prevent Blindness and its sight-saving fund for every “share” or “like” of certain posts, up to $50,000, through Feb. 29, that promote this donation from the Bausch + Lomb SightMatters Facebook page, at https://www.facebook.com/SightMattersCommunity The companies also encourage patients to visit SightMatters.com, an educational online resource that Bausch + Lomb created to help people with AMD better understand the condition and its progression. Read more.
Product Pipeline Update
• The U.S. Food and Drug Administration has granted CooperVision approval for its new Biofinity toric multifocal contact lenses. The company says the lenses will be available later this year.
• I-Med Pharma announced that it has plans to launch a new artificial tear for evaporative dry eye, I-Drop MGD. The company hasn’t provided a release date for the product.
Prevent Blindness Calls for Nominations
Prevent Blindness issued a call for nominations for the 2020 Jenny Pomeroy Award for Excellence in Vision and Public Health, and the new Rising Visionary Award. Both awards will be formally presented at the Ninth Annual Prevent Blindness Focus on Eye Health National Summit at the National Press Club in Washington, D.C., on July 15, 2020. The Jenny Pomeroy Award for Excellence in Vision and Public Health recognizes an individual, team or organization that has made significant contributions to the advancement of public health related to vision and eye health at the community, state, national and/or international level. Read more.
Verana Health Acquires PYA Analytics; Announces $100 Million Financing
Verana Health, which aggregates datasets using the American Academy of Ophthalmology’s IRIS registry, announced that it acquired the technology assets and the staff of PYA Analytics (PYAA), which specializes in large-scale data architecture solutions, for $100 million. Read more.
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