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Ahmed Roshdy Alagorie, Osama A Sorour, Hesham Eltoukhy, Elsayed Nassar Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, EgyptCorrespondence: Ahmed Roshdy Alagorie, Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt, Email ahmed.alagorie@gmail.comPurpose: To assess the impact of the COVID-19 pandemic on urgent retina practice and factors influencing adherence of physicians and patients to safety measures.Methods: In this clinical audit, urgent or emergent vitreoretinal surgical disorders that presented to our hospital during the period of 15th March– 15th May 2020 were compared with the period just before the pandemic declaration (15th December 2019– 15th February 2020). Additionally, two questionnaires assessing the adherence to safety measures were circulated to the medical personnel and a sample of patients. The collected data were analyzed, and accordingly, recommendations were proposed to the hospital administration and specific corrective measures were applied. The outcome of applying these corrective measures was assessed in the re-audit cycle during the period of 15th June– 15th August 2020.Results: There was a significant decrease in the number of urgent or emergent vitreoretinal surgical disorders that presented to our hospital during the pandemic (161 versus 302 cases in a similar period before the pandemic; p = 0.022). Just with the pandemic recession, there was a significant increase in the number of urgent cases (391 versus 161 cases during the pandemic; p = 0.006), also there was an increased number of complex cases. Residents and fellows were less compliant than attending physicians in adherence to safety measures.Conclusion: Delayed presentation of urgent retinal cases during the pandemic highlights the importance of public awareness of urgent conditions that need immediate medical or surgical care. Attention to young physicians during the pandemic is crucial as they are less adherent to safety measures due to work overload.Keywords: COVID-19, retina practice, audit

Ayman G Elnahry,1 Alia M Noureldine,1 Ahmed A Abdel-Kader,1 Osama A Sorour,2 David J Ramsey3 1Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt; 2Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt; 3Division of Ophthalmology, Lahey Hospital & Medical Center, Tufts University School of Medicine, Boston, MA, USACorrespondence: Ayman G ElnahryDepartment of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, 11956, Egypt, Tel +20 1224927604, Fax +20 223682030, Email ayman_elnahri@hotmail.comPurpose: To identify biomarkers that may predict an early anatomical response to the treatment of diabetic macular edema (DME) with intravitreal bevacizumab (IVB) by means of optical coherence tomography angiography (OCTA).Methods: This study is a retrospective study of treatment-naïve patients with DME who underwent 6 × 6 mm OCTA imaging of the macula at baseline and after three monthly IVB injections. Thirty-six eyes of 23 patients were included. Eyes that demonstrated evidence of an early anatomical response, consisting of a > 10% decrease in central macular thickness (CMT) (n = 18), were compared with those eyes that failed to show such an improvement (n = 18).Results: At baseline, early-response eyes had worse starting best-corrected visual acuity (BCVA, LogMAR 0.84 ± 0.41 versus LogMAR 0.51 ± 0.15, p = 0.004) and a larger CMT (490 ± 135 μm versus 356 ± 33 μm, p = 0.001), but smaller foveal avascular zones (FAZ) (0.309 ± 0.098mm versus 0.413 ± 0.095 mm, p = 0.003) compared with eyes that proved refractory to three monthly injections of IVB. The vascular density (VD) in both the foveal superficial and deep capillary plexuses was significantly greater in eyes that showed an early-treatment response compared with eyes that were non-responders (24.86 ± 6.90% versus 19.98 ± 7.13%, p = 0.045 and 32.30 ± 4.88% versus 26.95 ± 7.25%, p = 0.028, respectively). Early-treatment response to IVB was predicted by starting CMT (r2= 0.266, p = 0.001), FAZ size (r2= 0.234, p = 0.003), and VD in the superficial parafovea (r2= 0.217, p = 0.004) and deep fovea (r2= 0.157, p = 0.037).Conclusion: Projection-resolved OCTA may be useful in predicting an early anatomical response of DME to treatment with IVB.Keywords: anti-VEGF agents, bevacizumab, biomarkers, diabetic macular edema, macular ischemia, macular perfusion, optical coherence tomography angiography

Raouf Gaber, Osama A Sorour, Amr F Sharaf, Hisham A Saad Department of Ophthalmology, Tanta University, Tanta, Gharbeya Province, EgyptCorrespondence: Raouf GaberTanta University Eye Hospital, The Faculty of Medicine, El-Gash St. Medical Campus, Tanta, Gharbeya Province, 31527, EgyptEmail Raouf.a.gaber@gmail.comAim of the Work: To evaluate the incidence and risk factors for development of retinopathy of prematurity (ROP) in the biggest neonatal intensive care unit (NICU) in Itay Elbaroud City, Behera province, Egypt.Methods: We studied data of 240 newly born infants with gestational age (GA) ≤ 34 weeks or birth weight (BW) ≤ 2000 g or infants with unstable course who were admitted to the biggest NICU in Itay Elbaroud City, Behera province, Egypt, between October 1, 2018 and October 31, 2020. There is no standard screening system in Egypt. Furthermore, we had screened babies more than 1500 g, more than 32 weeks and found signs of ROP, so we decided to expand our inclusion criteria to include babies up to 2000 g of birth weight and up to 34 weeks gestational age in addition to older and heavier babies with unstable course in NICUs. Clinical information about perinatal neonates was collected by reviewing medical charts. The main outcomes are the incidence and severity of ROP. The relationship of clinical risk factors and the development of ROP were analyzed.Results: The overall incidence of ROP was 34.1%, and the overall incidence of type 1 ROP was 26.3% of infants. ROP was significantly associated with GA (odds ratio; OR: 6.8; (3.7– 12.3), BW (OR: 4.1; 2.3– 7.3), apnea, supplementary oxygen administration, and thrombocytopenia.Conclusion: The incidence of ROP is high in Itay Elbaroud city, Behera Province, Egypt. Immaturity, low birth weight, low gestational age, oxygen administration, apnea, thrombocytopenia, and jaundice are important risk factors for development of ROP.Keywords: birth weight, gestational age, incidence, retinopathy of prematurity

Purpose: Although there is increasing evidence that phosphodiesterase-5 (PDE-5) inhibitors modify the effect of diabetes on different tissues, its effect on diabetic retinopathy is not well studied., Methods: Forty male Sprague-Dawley (SD) rats were divided into four groups: group I = control group that received no treatment; group II (diabetic group), in which diabetes was induced by a single streptozotocin injection; group III (sildenafil small dose, SSD), in which diabetes was similarly introduced (however, rats received daily oral 1 mg/kg sildenafil citrate (SC) for 3 months); and group IV (sildenafil large dose, SLD), which was as in group 3, but SC was 2.5 mg/kg. After 3 months, globes were removed and retinae were dissected; one globe from each rat was examined by light microscopy (LM), and the other by electron microscopy (EM)., Results: In contrast to the control group, diabetic rats in group II demonstrated well-established diabetic changes in the form of capillary congestion, decreased cell population, hyaline changes of capillary walls, and degenerated nerve fiber layer by LM. Similarly, EM demonstrated photoreceptor degeneration, mitochondrial cristolysis, and vacuolated depleted cells among other features in group II. These diabetic features were less prominent in group III and nearly absent in group IV., Conclusion: SC use in the early stages of DR may prevent/delay diabetic retinopathy development or progression in diabetic rat models, an effect that seems to be dose-related., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Background: Sildenafil citrate (SC) attenuates endothelial dysfunction. However, its effects on diabetic retinopathy (DR), which is mainly a microvascular disease, remain unclear. Vascular endothelial growth factor (VEGF) is known to be a critical mediator of DR. Therefore, we investigated the effects of SC on diabetic retina by measuring VEGF levels., Methods: In this study, twenty-eight rats were divided into the following groups: group I, the control group; group II, rats with streptozotocin-induced diabetes; group III, rats with streptozotocin-induced diabetes receiving daily oral sildenafil at 1 mg/kg; and group IV, rats with streptozotocin-induced diabetes receiving high-dose daily sildenafil at 2.5 mg/kg. After 3 months, VEGF was measured in the retina specimen in one eye and the vitreous body in the other eye by immunohistochemistry and enzyme-linked immunosorbent assay, respectively., Results: We found that VEGF expression in the retina was low in all rats from groups I and IV and in 30% of rats from group III; 80% of rats in group II demonstrated high VEGF expression in the retinae (P < 0.001). VEGF concentrations in the vitreous body samples were 32 ± 2, 61 ± 4, 44 ± 5, and 36 ± 3 pg/l in groups I-IV, respectively (P < 0.001)., Conclusion: VEGF decreased significantly in the eyes of diabetic rats after chronic oral sildenafil citrate treatment. SC may have a modifying/attenuating effect on DR. However, further studies are needed to evaluate its use as an adjunctive treatment., (© 2023. The Author(s).)

Background: To compare the anatomical and visual outcomes in eyes with persistent diabetic macular edema (DME) after initial anti-VEGF therapy that were retreated continuously with the same anti-VEGF drug versus those that underwent two successive cycles of medication change in anti-VEGF drugs (double anti-VEGF switch)., Methods: Retrospective review of eyes with persistent DME after 3 initial consecutive monthly anti-VEGF injections. This cohort was divided into two groups: Group 1 continued to receive the same initial anti-VEGF drug for at least 18 months while group 2 eyes were switched to different anti-VEGF medications twice. Group 1 was further subdivided into: Group 1A composed of eyes with less than 20% reduction in central subfield thickness (CRT) at month 3; and group 1B eyes with greater than or equal to 20% reduction in CRT. The percentage of eyes that achieved greater than 10 letters visual acuity (VA) gain or loss was recorded as the primary end point (through month 18 in group 1 and month 6 after 2nd switch in group 2)., Results: Group 1A, 1B and group 2 were composed of 24, 18, and 14 eyes respectively. 34.7%, 56.2% and 36.3% of eyes achieved > 10 letters gain, while 4.3%, 6.2% and 27.2% of eyes lost > 10 letters in groups 1A, 1B, and 2, respectively. Analysis of the visual acuity (VA) letter change in this time interval revealed no significant difference between all groups (p = 0.11). Mean VA and CRT measurements at the primary endpoint in all groups were 0.5, 0.39, and 0.47 logMAR (p = 0.44), and 369.7, 279.9, 321 µm, (p = 0.01) respectively., Conclusions: There was no difference in the visual outcomes between the two treatment strategies in eyes with persistent DME after 3 consecutive anti-VEGF injections. This may indicate that anti-VEGF switching-even if it is done twice-may have comparable clinical outcomes to sustained treatment with one agent., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Background: To examine the baseline morphological characteristics and alterations in intraretinal microvascular abnormalities (IRMAs) in response to anti-vascular endothelial growth factor (anti-VEGF) treatment, documented by optical coherence tomography angiography (OCTA) in diabetic eyes., Methods: In this retrospective study, IRMAs were evaluated with multimodal imaging (fundus photography, fluorescein angiography, OCTA) in treatment-naïve diabetic eyes before and after anti-VEGF treatment for diabetic macular edema (DME) and/or proliferative diabetic retinopathy (PDR) and compared to diabetic control eyes with similar diabetic retinopathy (DR) severity that did not receive anti-VEGF therapy. The morphological characteristics of IRMAs on enface OCTA imaging were graded by masked readers at baseline, then after anti-VEGF therapy in treated eyes or after observation in control eyes. Characterization of interval changes in an IRMA were based on the following parameters: branching, vessel caliber and area of adjacent capillary non-perfusion., Results: The treated group included 45 IRMA foci from 15 eyes of 11 patients, while the control group included 27 IRMA foci from 15 eyes of 14 patients. Following anti-VEGF treatment, enface OCTA demonstrated that 14 foci of IRMA (31%) demonstrated regression with normalization of appearance of the capillary bed, 20 IRMAs (44%) remained unchanged, six IRMAs (13%) progressed with enlargement or development of new IRMAs and five IRMAs (11%) demonstrated complete obliteration defined as IRMA disappearance with advancing capillary drop-out. In the control group, 17 IRMA (63%) remained stable, 8 IRMAs (29.6%) progressed and 2 experienced total obliteration (7.4%). The difference in rank order between the two groups was statistically significant ( p  = 0.022)., Conclusions: In eyes with DR status post anti-VEGF therapy, foci of IRMAs have a variable course demonstrating one of four possible outcomes: regression, stability, progression or complete obliteration. In contrast, none of the untreated control diabetic eyes demonstrated regression of IRMAs, consistent with known progression of DR severity in high risk eyes. Morphologic evaluation of IRMAs with OCTA may help to monitor changes in retinal blood flow as well as the response to anti-VEGF treatment., Competing Interests: Competing interestsThe authors declare that they have no competing interests relevant to this study, and their detailed financial disclosure: OS: None; NM: None; CB: Consultant, Genentech, Speaker, Carl Zeiss Meditec, Novartis; AI: Speaker, Topcon Medical Systems, Inc., Nidek Medical Products, Inc.; KL: None; EK: none; SM: None; A.YA: None; MA: None; AW: None; JD: Consultant and Financial Support, Carl Zeiss Meditec, Inc., Optovue, Inc., Novartis Pharma AG., and Roche; NW: Financial Support, Macula Vision Research Foundation, Topcon Medical Systems, Inc., Nidek Medical Products, Inc., and Carl Zeiss Meditec, Inc., Consultant, Optovue, Inc., Regeneron, and Genentech., (© The Author(s) 2020.)

Background: The purpose of this study was to investigate the association between diabetic retinopathy (DR) severity and macular choriocapillaris (CC) flow deficit percentage (FD %) in different macular regions using swept-source optical coherence tomography angiography (SS-OCTA)., Methods: Diabetic patients with SS-OCTA images were graded by severity and retrospectively assessed. CC FD % was calculated in four different regions of the OCTA image: inner, middle, outer, and full-field region. The generalized estimating equations (GEE) approach for clustered eye data was used to determine effect size and significance of age and disease severity on FD % for each region., Results: 160 eyes from 90 total diabetic patients met inclusion criteria. Out of 90 patients, 33 had no DR, 17 had mild nonproliferative DR (NPDR), 8 had moderate NPDR, 10 had severe NPDR and 22 had proliferative DR. Age and DR severity had a significant positive association with FD % for each region studied with a greater effect in the two centermost regions. The increase in flow deficit percentage per year of age by region was: inner 0.12 (p < 0.001), middle 0.09 (p < 0.001), outer 0.05 (p < 0.001, full-field 0.06 (p < 0.001). The increase in flow deficit percentage per increase in diabetic retinopathy severity stage by region was: inner 0.65 (p < 0.0087), middle 0.56 (p < 0.0012), outer 0.33 (p < 0.045), full-field 0.36 (p < 0.018)., Conclusions: Topographic analysis of the CC FD % in diabetic eyes suggests that CC flow impairment corresponds to DR severity, with all studied regions of the CC significantly affected. There was greater regional impairment due to age and disease severity in the inner and middle regions., Competing Interests: Competing interestsAI: Topcon Medical Systems, Inc. (Tokyo, Japan) (S), Nidek Medical Products, Inc. (Gamagori, Aichi, Japan) (S) CRB: Carl Zeiss Meditec, Inc. (Dublin, CA, USA) (S), Genentech (South San Francisco, CA, USA), Novartis (Basel, Switzerland) (S), Allergan (Dublin, Ireland) (C) JGF: Topcon Medical Systems Inc. (Oakland, NJ, USA) (C, F), Optovue, Inc. (Fremont, CA, USA) (C, R, S), Carl Zeiss Meditec, Inc. (Dublin, CA, USA) (R) JSD: Carl Zeiss Meditec, Inc. (Dublin, CA, USA) (C, F), Optovue, Inc. (Fremont, CA, USA) (C, F) NKW: Macula Vision Research Foundation (West Conshohocken, PA, USA) (F), Topcon Medical Systems, Inc. (Oakland, NJ, USA) (F), Nidek Medical Products, Inc. (Fremont, CA, USA) (S, F), Optovue, Inc. (Fremont, CA, USA) (C), Carl Zeiss Meditec, Inc. (Dublin, CA, USA) (F) ER: Regeneron Pharmaceuticals, Inc. (Tarrytown, NY, USA) (F)., (© The Author(s) 2020.)