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Purpose To develop consensus terminology in the setting of polypoidal choroidal vasculopathy (PCV), and to develop and validate a set of diagnostic criteria not requiring indocyanine green angiograph (ICGA) for differentiating PCV from typical neovascular age-related macular degeneration (nAMD) based on a combination of OCT and color fundus photograph findings. Design Evaluation of diagnostic test Participants Panel of retina specialists. Methods As part of the Asia-Pacific Ocular Imaging Society (APOIS), an international group of experts surveyed and discussed the published literature regarding the current nomenclature and lesion components for PCV and proposed an updated consensus nomenclature, which reflects our latest understanding based on imaging and histology reports. The workgroup evaluated a set of diagnostic features based on OCT and color fundus photographs for PCV that may distinguish it from typical nAMD and assessed the performance of individual and combinations of these non-ICGA features, aiming to propose a new set of diagnostic criteria which does not require the use of ICGA. The final recommendation was validated in 80 eyes from 2 additional cohorts. Main Outcome Measures A consensus nomenclature system for PCV lesion components and non-ICGA-based criteria to differentiate PCV from typical nAMD. Results The workgroup recommended the terms ‘polypoidal lesion’ and ‘branching neovascular network’ for the two key lesion components in PCV. For the diagnosis of PCV, the combination of 3 OCT-based ‘major criteria’ (sub-RPE ring-like lesion, enface OCT complex RPE elevation, and sharp-peaked PED) achieved an area under the receiver operating characteristic curve of 0.90. Validation of this new scheme in a separate subset 110 eyes achieved an accuracy of 82%. Conclusions We propose updated terminology for PCV lesion components which better reflect the nature of these lesions which was based on international consensus. A set of practical diagnostic criteria that are easily applied to SD-OCT can be used for diagnosing PCV with high accuracy in clinical settings in which ICGA is not routinely performed.

Background/AimsTo analyse the long-term anatomic and visual outcomes of patients with peripapillary pachychoroid syndrome (PPS), a recently described entity in the pachychoroid disease spectrum.MethodsThis study retrospectively included patients from several retina centres worldwide. Visual acuity (VA), retinal thickness and choroidal thickness at baseline, 6 months and final follow-up were assessed. Temporal trends in VA and anatomic characteristics were evaluated. Visual and anatomic outcomes in eyes that were observed versus those that were treated were analysed.ResultsFifty-six eyes of 35 patients were included with mean follow-up of 27±17 months. Median VA was 20/36 at baseline and remained stable through follow-up (p=0.77). Retinal thickness significantly decreased subfoveally (p=0.012), 1.5 mm nasal to the fovea (p=0.002) and 3.0 mm nasal to the fovea (p=0.0035) corresponding to areas of increased thickening at baseline. Choroidal thickness significantly decreased subfoveally (p=0.0030) and 1.5 mm nasal to the fovea (p=0.0030). Forty-three eyes were treated with modalities including antivascular endothelial growth factor injection, photodynamic therapy, and others. VA remained stable in treated eyes over follow-up (p=0.67). An isolated peripapillary fluid pocket in the outer nuclear layer was characteristic of PPS.ConclusionPatients with PPS experienced decreased retinal oedema and decreased choroidal thickening throughout the course of disease. While some patients experienced visual decline, the overall visual outcome was relatively favourable and independent of trends in retinal or choroidal thickening.

PurposeTo compare the efficacy and safety of brolucizumab versus aflibercept in eyes with polypoidal choroidal vasculopathy (PCV) over 96 weeks in the HAWK study.DesignHAWK was a global, 2-year, randomised, double-masked, multicentre phase III trial in participants with neovascular age-related macular degeneration.MethodsOf the Japanese participants with PCV, 39 received brolucizumab 6 mg and 30 received aflibercept 2 mg. After 3 monthly loading doses, brolucizumab-treated eyes received an injection every 12 weeks (q12w) but were adjusted to q8w if disease activity was detected. Aflibercept-treated eyes received fixed q8w dosing. Mean change in best-corrected visual acuity (BCVA), the proportion of participants on q12w, retinal thickness, retinal fluid changes and safety were assessed to Week 96.ResultsMean change in BCVA (early treatment diabetic retinopathy study (ETDRS) letters) from baseline to week 48/week 96 was+10.4/+11.4 for brolucizumab and +11.6/+11.1 for aflibercept. For brolucizumab-treated eyes, the probability of only q12w dosing after loading through week 48 was 76%, and 68% through week 96. Fluid resolution was greater with brolucizumab than aflibercept: respective proportions of eyes with intraretinal fluid and/or subretinal fluid were 7.7% and 30% at week 48% and 12.8% and 16.7% at week 96. Brolucizumab exhibited an overall well-tolerated safety profile despite a higher rate of intraocular inflammation compared with aflibercept.ConclusionIn Japanese eyes with PCV, brolucizumab q12w/q8w monotherapy resulted in robust and consistent BCVA gains that were comparable to q8w aflibercept dosing. Anatomical outcomes favoured brolucizumab over aflibercept, with 76% of brolucizumab participants maintained on q12w dosing after loading to week 48.

PurposeTo develop and validate OCT and color fundus photography (CFP) criteria in differentiating polypoidal choroidal vasculopathy (PCV) from typical neovascular age-related macular degeneration (nAMD) in eyes with suboptimal response to anti–vascular endothelial growth factor (VEGF) monotherapy and to determine whether OCT alone can be used to guide photodynamic therapy (PDT) treatment.DesignClinical study evaluating diagnostic accuracy.ParticipantsPatients with nAMD who received 3-month anti-VEGF monotherapy but had persistent activity defined as subretinal fluid or intraretinal fluid at month 3 assessments.MethodsIn phase 1, international retina experts evaluated OCT and CFP of eyes with nAMD to identify the presence or absence of features due to PCV. The performance of individual and combinations of these features were compared with ICGA. In phase 2, these criteria were applied to an independent image set to assess generalizability. In a separate exercise, retinal experts drew proposed PDT treatment spots using only OCT and near-infrared (NIR) images in eyes with PCV and persistent activity. The location and size of proposed spot were compared with ICGA to determine the extent of coverage of polypoidal lesions (PLs) and branching neovascular network (BNN).Main Outcome MeasuresSensitivity and specificity of CFP and OCT criteria to differentiate PCV from nAMD and accuracy of coverage of OCT-guided PDT compared with ICGA.ResultsIn eyes with persistent activity, the combination of 3 non–ICGA-based criteria (sharp-peaked pigment epithelial detachment [PED], subretinal pigment epithelium [RPE] ring-like lesion, and orange nodule) to detect PCV showed good agreement compared with ICGA, with an area under the receiver operating characteristic curve of 0.85. Validation using both an independent image set and assessors achieved an accuracy of 0.77. Compared with ICGA, the OCT-guided PDT treatment spot covered 100% of PL and 90% of the BNN.ConclusionsIn nAMD eyes with persistent activity, OCT and CFP can differentiate PCV from typical nAMD, which may allow the option of adjunct PDT treatment. Furthermore, OCT alone can be used to plan adjunct PDT treatment without the need for ICGA, with consistent and complete coverage of PL.

PurposeTo evaluate the various patterns of subretinal fluid (SRF) in eyes with age-related macular degeneration (AMD) in the absence of macular neovascularisation (MNV) and to assess the long-term outcomes in these eyes.MethodsThis retrospective study included only eyes with non-neovascular AMD and associated SRF. Eyes with evidence of MNV were excluded. Spectral-domain optical coherence tomography (SD-OCT) was obtained at baseline and at follow-up, and qualitative and quantitative SD-OCT analysis of macular drusen including drusenoid pigment epithelial detachment (PED) and associated SRF was performed to determine anatomic outcomes.ResultsForty-five eyes (45 patients) were included in this analysis. Mean duration of follow-up was 49.7±36.7 months. SRF exhibited three different morphologies: crest of fluid over the apex of the drusenoid PED, pocket of fluid at the angle of a large druse or in the crypt of confluent drusen or drape of low-lying fluid over confluent drusen. Twenty-seven (60%) of the 45 eyes with fluid displayed collapse of the associated druse or drusenoid PED and 24 (53%) of the 45 eyes developed evidence of complete or incomplete retinal pigment epithelial and outer retinal atrophy.ConclusionNon-neovascular AMD with SRF is an important clinical entity to recognise to avoid unnecessary anti-vascular endothelial growth factor therapy. Clinicians should be aware that SRF can be associated with drusen or drusenoid PED in the absence of MNV and may be the result of retinal pigment epithelial (RPE) decompensation and RPE pump failure.

Pachychoroid is characterized by dilated Haller vessels and choriocapillaris attenuation that are seen on optical coherence tomography (OCT) B-scans. This study investigated the feasibility of using deep learning (DL) models to classify pachychoroid and non-pachychoroid eyes from OCT B-scan images. In total, 1898 OCT B-scan images were collected from eyes with macular diseases. Images were labeled as pachychoroid or non-pachychoroid based on strict quantitative and qualitative criteria for multimodal imaging analysis by two retina specialists. DL models were trained (80%) and validated (20%) using pretrained convolutional neural networks (CNNs). Model performance was assessed using an independent test set of 50 non-pachychoroid and 50 pachychoroid images. The final accuracy of AlexNet and VGG-16 was 57.52% for both models. ResNet50, Inception-v3, Inception-ResNet-v2, and Xception showed a final accuracy of 96.31%, 95.25%, 93.40%, and 92.61%, respectively, for the validation set. These models demonstrated accuracy on an independent test set of 78.00%, 86.00%, 90.00%, and 92.00%, and an F1 score of 0.718, 0.841, 0.894, and 0.920, respectively. DL models classified pachychoroid and non-pachychoroid images with good performance. Accurate classification can be achieved using CNN models with deep rather than shallow neural networks.

AimsAutomatic identification of pachychoroid maybe used as an adjunctive method to confirm the condition and be of help in treatment for macular diseases. This study investigated the feasibility of classifying pachychoroid disease on ultra-widefield indocyanine green angiography (UWF ICGA) images using an automated machine-learning platform.MethodsTwo models were trained with a set including 783 UWF ICGA images of patients with pachychoroid (n=376) and non-pachychoroid (n=349) diseases using the AutoML Vision (Google). Pachychoroid was confirmed using quantitative and qualitative choroidal morphology on multimodal imaging by two retina specialists. Model 1 used the original and Model 2 used images of the left eye horizontally flipped to the orientation of the right eye to increase accuracy by equalising the mirror image of the right eye and left eye. The performances were compared with those of human experts.ResultsIn total, 284, 279 and 220 images of central serous chorioretinopathy, polypoidal choroidal vasculopathy and neovascular age-related maculopathy were included. The precision and recall were 87.84% and 87.84% for Model 1 and 89.19% and 89.19% for Model 2, which were comparable to the results of the retinal specialists (90.91% and 95.24%) and superior to those of ophthalmic residents (68.18% and 92.50%).ConclusionsAuto machine-learning platform can be used in the classification of pachychoroid on UWF ICGA images after careful consideration for pachychoroid definition and limitation of the platform including unstable performance on the medical image.

Central serous chorioretinopathy (CSC) is a chorioretinal disorder characterized by serous detachment of the neurosensory retina, associated with serous retinal pigment epithelial (RPE) detachment, angiographic leakage at the level of the RPE, and choriodal hyperpermeability (Nicholson et al. 2013). It is usually idiopathic but might also be secondary to high levels of endogenous or exogenous corticosteroids. CSC typically affects young to middle-aged men, and the lesion is usually located at the posterior pole (Kitzmann et al. 2008). CSC can be classified according to its clinical course: acute or chronic (persisting for more than 3–6 months). Acute CSC usually resolves spontaneously within 2–3 months with good visual prognosis. However, some patients in chronic CSC may suffer from persistent or recurrent serous macular detachment with subsequent progressive visual loss (Gilbert et al. 1984).

PURPOSE: To investigate outcomes of combined photodynamic therapy (PDT) and intravitreal bevacizumab in association with choroidal morphology in polypoidal choroidal vasculopathy (PCV). METHOD: Eighty-six PCV eyes (83 patients) treated with PDT in combination with intravitreal bevacizumab and followed for 1 year were evaluated. Choroidal morphological features including subfoveal choroidal thicknesses, diameter of pachyvessel, and choroidal vascularity were analyzed for association with responsiveness and recurrence. RESULT: Total choroid, Haller’s layer, and pachyvessel were thicker in responders (n = 70) compared with non-responders (n = 16) at baseline (298 vs. 227 μm, 213 vs. 144 μm, and 276 vs. 210 μm, respectively; all P ≤ 0.001). Choroidal vascularity was significantly higher (0.68 vs 0.60, P

The aim of the present study was to evaluate the efficacy of the inverted internal limiting membrane (ILM) flap technique that involved the use of a perfluorocarbon liquid (PFCL) bubble for the selective prevention of indocyanine green (ICG) staining of the parts of the inverted flap in contact with the retinal pigment epithelium for large macular hole (MH) closure.This retrospective, interventional, comparative study included 26 patients with idiopathic large MHs (minimum diameter, 400 µm) who underwent vitrectomy using the inverted ILM flap technique with conventional ILM staining with ICG (n = 14, Group 1) or PFCL-mediated selective ILM staining with ICG (n = 12, Group 2). The hole closure rate, best-corrected visual acuity (BCVA), and optical coherence tomography findings were analyzed at baseline and 1, 3, and 6 months after surgery in both groups.Hole closure was achieved in all the eyes. BCVA significantly improved after surgery in both groups (p 0.001 for both groups), although Group 2 exhibited significantly better values at 3 and 6 months after surgery (p = 0.008 and 0.001 at 3 and 6 months, respectively). The sizes of ellipsoid zone defect significantly decreased after surgery in both groups (p 0.001 relative to the baseline width in both groups), and it was significantly smaller in Group 2 than in Group 1 at 3 (p = 0.006) and 6 (p = 0.001) months after surgery.The findings of this study suggest that recovery of the photoreceptor layers and, consequently, the postoperative VA are better with the inverted ILM flap technique employing PFCL-mediated selective ILM staining with ICG than with the technique employing conventional ILM staining with ICG methods for patients with large MHs.

To compare choroidal vascular characteristics of age-related macular degeneration (AMD), polypoidal choroidal vasculopathy (PCV), and central serous chorioretinopathy (CSC) by qualitative and quantitative analyses using swept-source en face optical coherence tomographic (OCT) images. Eyes with non-neovascular AMD (n = 32), neovascular AMD (n = 30), thick and thin choroid PCV (n = 33 and 27), and CSC (n = 34) were enrolled. Subfoveal choroidal thickness (SFCT) and the presence and patterns of pachyvessels were assessed. En face images of the large choroidal vessel layer were converted to binary images for the analysis of vascular density. Pachyvessels were identified in 8 (25%), 14 (46%), 28 (85%), 26 (96%), and 34 (100%) non-neovascular AMD, neovascular AMD, thin choroid PCV, thick choroid PCV, and CSC eyes, respectively (P

To describe the features of peripapillary pachychoroid syndrome (PPS), a novel pachychoroid disease spectrum (PDS) entity.Medical records of 31 eyes (16 patients) with choroidal thickening associated with intraretinal and/or subretinal fluid in the nasal macula extending from the disk were reviewed (patients with PPS). Choroidal thickness was compared with 2 age-matched cohorts: typical PDS (17 eyes with central serous chorioretinopathy or pachychoroid neovasculopathy) and 19 normal eyes.The patients with PPS were 81% men aged 71 ± 7 years. Peripapillary pachychoroid syndrome eyes displayed thicker nasal versus temporal macular choroids, unlike PDS eyes with thicker temporal macular choroids (P0.0001). Peripapillary intraretinal and/or subretinal fluid was often overlying dilated Haller layer vessels (pachyvessels). Fundus autofluorescence and fluorescein angiography illustrated peripapillary pigmentary mottling without focal leakage. Most PPS eyes (70%) exhibited other PDS findings including serous pigment epithelial detachment or gravitational tracks. Indocyanine green angiography illustrated dilated peripapillary pachyvessels and choroidal hyperpermeability. The disk was usually crowded, with edema noted in 4/31 (13%) eyes and mild late fluorescein disk leakage identified in half of the cases. Choroidal folds (77%), short axial lengths (39% less than 23 mm), and hyperopia (86%) were common.Peripapillary pachychoroid syndrome is a distinct PDS variant, in which peripapillary choroidal thickening is associated with nasal macular intraretinal and/or subretinal fluid and occasional disk edema. Recognition of PPS is important to distinguish it from disorders with overlapping features such as posterior uveitis and neuro-ophthalmologic conditions.

BACKGROUND AND OBJECTIVE: To evaluate the retinal morphologic characteristics of patients with macropsia caused by epiretinal membrane (ERM) based on spectral-domain optical coherence tomography (SD-OCT). PATIENTS AND METHODS: A cross-sectional, non-interventional study was performed to compare the characteristics of retinal structures in eyes with ERM according to the presence or absence of macropsia. Twenty-six patients with ERM and macropsia were defined as the macropsia group and 26 age-matched patients with ERM without macropsia were the control group. All participants underwent a full ophthalmologic examination and SD-OCT examination. Macropsia was diagnosed and quantified using a double dot chart. The thickness of retinal layers, including the outer nuclear layer (ONL) and inner segment / outer segment / retinal pigment epithelium (IS/OS/RPE) at the central fovea, were measured by electronic calipers of the SD-OCT system. The interocular ratio of each parameter was calculated for each patient and compared between the two groups. The integrity of the external limiting membrane (ELM), IS/OS junction, and cone outer segment tips (COST) line were evaluated. RESULTS: The thickness of the IS/OS/RPE differed significantly between both eyes in the macropsia group ( P < .001), whereas the control group was not significantly different ( P = .161). The ONL in the diseased eye was significantly thicker in the macropsia group than in the control group ( P = .020), whereas these two groups did not differ significantly in the thickness of ONL in the control eye ( P = .860). More patients had a disrupted COST line in the macropsia group ( P < .001 for macropsia group, P = .252 for control group). No eye showed disrupted ELM and IS/OS junction, regardless of the presence of macropsia. CONCLUSIONS: Eyes with macropsia showed thicker foveal ONL, IS/OS/RPE, and more frequently disrupted COST lines. This may indicate that the contractile strength of ERM can lead to centralization of photoreceptor cells. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:656–663.]

Polypoidal choroidal vasculopathy (PCV) is an age-related macular degeneration (AMD) subtype and is seen particularly in Asians. Previous studies have suggested disparity in response to intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents between PCV and typical AMD, and thus, the preferred treatment for PCV has remained unclear. Recent research has provided novel insights into the pathogenesis of PCV, and imaging studies based on OCT suggest that PCV belongs to a spectrum of conditions characterized by pachychoroid, in which disturbance in the choroidal circulation seems to be central to its pathogenesis. Advances in imaging, including enhanced depth imaging, swept-source OCT, en face OCT, and OCT angiography, have facilitated the diagnosis of PCV. Importantly, 2 large, multicenter randomized clinical trials evaluating the safety and efficacy of anti-VEGF monotherapy and combination with photodynamic therapy (PDT) recently reported initial first-year outcomes, providing level I evidence to guide clinicians in choosing the most appropriate therapy for PCV. In this review, we summarize the latest updates in the epidemiologic features, pathogenesis, and advances in imaging and treatment trials, with a focus on the most recent key clinical trials. Finally, we propose current management guidelines and recommendations to help clinicians manage patients with PCV. Remaining gaps in current understanding of PCV, such as significance of polyp closure, high recurrence rate, and heterogeneity within PCV, are highlighted where further research is needed.

Purpose To investigate vascular endothelial growth factor (VEGF) level according to the clinical and imaging features, and to explore its relationship with the responsiveness to anti-VEGF treatment in eyes with polypoidal choroidal vasculopathy. Methods Aqueous samples were collected from 62 eyes of 62 patients with treatment-naive polypoidal choroidal vasculopathy. Vascular endothelial growth factor levels were measured using enzyme-linked immunosorbent assay. Baseline best-corrected visual acuity, central macular thickness, subfoveal choroidal thickness, greatest linear dimension of the lesion, and the presence of hemorrhage were included in the analysis. The effects of 3 monthly intravitreal ranibizumab injections on best-corrected visual acuity and central macular thickness were assessed. Results Baseline VEGF level was negatively correlated with subfoveal choroidal thickness (r = -0.33, P = 0.01). Other variables had no correlation with VEGF level. The mean change in central macular thickness after anti-VEGF treatment was -51 ± 64 μm, which is positively correlated with VEGF concentration (r = 0.30, P = 0.04) and negatively correlated with subfoveal choroidal thickness (r = -0.35, P = 0.02). Conclusion Vascular endothelial growth factor level demonstrated a negative correlation with baseline subfoveal choroidal thickness and was associated with response to anti-VEGF treatment. These findings suggest that VEGF has a variable contribution to the pathogenesis of polypoidal choroidal vasculopathy depending on choroid thickness.

Purpose To determine the impact of choroidal vascular morphology on clinical outcomes in patients with polypoidal choroidal vasculopathy/aneurysmal Type 1 neovascularization. Methods Sixty-six eyes with polypoidal choroidal vasculopathy/aneurysmal Type 1 were included. Eyes were subdivided according to the choroidal vascular morphology of the large vessel layer on optical coherence tomography en face images: focal (n = 39) versus diffuse (n = 27) pachyvessels. All patients were treated with intravitreal ranibizumab pro re nata with or without rescue photodynamic therapy. Results Best-corrected visual acuity at baseline, 6, and 12 months did not differ between groups (P = 0.394, 0.142, and 0.292). At Month 3, best-corrected visual acuity was worse, and the proportion of eyes with fluid was higher in the focal group (P = 0.016 and 0.024). Among responders, the number of injections during 12-month follow-up was higher in the focal group (P = 0.033). During the total follow-up period, photodynamic therapy was required in 15 eyes (10 focal and 5 diffuse group, P = 0.497). The injection-free period after the photodynamic therapy was shorter in the focal group (P = 0.018). Conclusion The polypoidal choroidal vasculopathy/aneurysmal Type 1 eyes with a diffuse pattern of pachyvessels required fewer injections during 12-month follow-up and showed a longer injection-free period after rescue photodynamic therapy.

To analyze features of the choriocapillaris in eyes with earlier stages of pachychoroid spectrum, this study included 46 eyes with PPE, 32 age-matched eyes with pachychoroid without epitheliopathy, and 30 normal controls. Macular 3 × 3 mm2 angiographic images were obtained with swept-source optical coherence tomography. Vascular density and signal void area in the choriocapillaris were analyzed. Topographical correlation of signal voids with the dilated choroidal large vessel (pachyvessel) was assessed. Choriocapillaris vascular density was significantly lower in eyes with PPE compared with controls (p = 0.003). The number, the total area and the average size of signal voids was the highest in the PPE group followed by the pachychoroid without epitheliopathy and then controls (all p ≤ 0.001). 89.0% signal void area colocalized with pachyvessels. The average size of the signal void was higher if it was colocalized with pachyvessel (p

To describe the clinical characteristics and courses for eyes with retinoschisis associated with pachychoroid. A retrospective interventional case series study. Twenty-one eyes (18 patients) with pachychoroid that showed retinoschisis without evidence of neovascularization that had been followed for 1 year were included. Multimodal imaging, including fundus photography, spectral-domain optical coherence tomography (OCT) with an enhanced depth protocol, fluorescein angiography (FA), and indocyanine green angiography (ICGA), was provided and treatment outcomes were analyzed. Focal RPE atrophy was present below or adjacent to the schisis in all eyes, and the mean atrophy area was 1.38 ± 1.37 mm2. Intraretinal fluids of the schisis originated from the atrophy area and involved the retinal layer which was correlated with the extent of outer retinal defect. Dilated Haller layer vessel and choroidal vascular hyperpermeability were observed under the area with atrophy in all eyes. After 1 year of treatment, 11 eyes (52%) still had fluid and 7 of them had fluid at the macula. Nonetheless, the mean central macular thickness decreased (144.4 to 121.8, P

Background Limited data exist on real-world treatment patterns for diabetic macular edema (DME) in Korea. In this study, we investigated DME treatment patterns from 2009 to 2014 and the impact of baseline treatment on healthcare resource utilization and visual acuity (VA) outcomes. Methods A retrospective cohort chart review of DME patients treated at 11 hospital ophthalmology clinics between January 1, 2012 and December 31, 2013 was conducted. We collected data on demographics, healthcare resource utilization (clinic visits, treatment visits, and visits for ocular investigations), distribution of DME treatments, and VA. Results Overall, 522 DME patients (men, 55.2%; mean age, 59 years; mean HbA1c [n = 209], 8.4%) with 842 DME eyes were evaluated. For all treatments, healthcare resource utilization was significantly higher during the first 6 months versus months 7–12, year 2, or year 3 (P ≤ 0.001), but was highest for patients whose first treatment was an anti-vascular endothelial growth factor (VEGF) treatment (visits/quarter; anti-VEGF, 1.9; corticosteroids, 1.7; laser, 1.4). Use of macular laser therapy decreased (44% to 8%), whereas use of anti-VEGF injections increased (44% to 69%) during the study period. However, VA improvement was not commensurate with healthcare resource utilization of anti-VEGF treatment (mean VA gain, 2.7 letters). Conclusion A trend toward increasing use of intravitreal anti-VEGF injections for DME treatment was observed in Korea. However, the frequency of dosing and monitoring was lower in clinical practice versus major clinical trials, which may have led to the less-than-favorable improvements in visual outcomes., Graphical Abstract

This study is for reporting the outcomes of internal limiting membrane (ILM) peeling on persistent submacular fluid (PSF) after otherwise successful pars plana vitrectomy (PPV) for diabetic tractional retinal detachment (TRD). In this retrospective case series, five consecutive patients (5 eyes) who exhibited PSF following successful repair of diabetic TRD were included. The second operation was performed to remove ILM. The area of ILM peeling was expanded up to the major vascular arcade. Only air tamponade was used. The median interval between the first PPV and the second PPV with ILM peeling was 4.8 months (range: 4–6 months). PSF resolved completely within one (2 eyes) or 2 months after ILM peeling. The median logMAR best-corrected visual acuity (BCVA) was improved from 1.00 (Snellen equivalent 20/200) to 0.70 (Snellen equivalent 20/100). In conclusion, wide ILM peeling is an effective treatment option for PSF subsequent to successful repair of diabetic TRD. ILM peeling might increase the elasticity of retina, thereby allowing the retina to flatten. This procedure can induce faster retinal reattachment in diabetic TRD involving the macula.

Purpose To study the efficacy of deep convolutional neural networks (DCNNs) to differentiate pachychoroid from nonpachychoroid on en face optical coherence tomography (OCT) images at the large choroidal vessel. Methods En face OCT images were collected from eyes with neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and central serous chorioretinopathy. All images were prelabeled pachychoroid or nonpachychoroid based on quantitative and qualitative criteria for choroidal morphology on multimodal imaging by two retina specialists. In total, 1188 nonpachychoroid and 884 pachychoroid images were used for training (80%) and validation (20%). Accuracy for identification of pachychoroid by DCNN models was analyzed. Trained models were tested on a test set containing 79 nonpachychoroid and 93 pachychoroid images. Results The accuracy on the validation set was 94.1%, 93.2%, 94.7%, and 94.4% in DenseNet, GoogLeNet, ResNet50, and Inception-v3, respectively. On a test set, each model demonstrated accuracy of 80.2%, 83.1%, 89.5%, and 90.1% and an F1 score of 0.782, 0.824, 0.904, and 0.901, respectively. Conclusions DCNN models could classify pachychoroid and nonpachychoroid with good performance on OCT en face images. Automated classification of pachychoroid will be useful for tailored treatment of individual patients with exudative maculopathy. Translational Relevance En face OCT images can be used by DCNN for classification of pachychoroid.

Purpose: To evaluate the safety and efficacy of dexamethasone intravitreal implant (Ozurdex, DEX implant) 0.7 and 0.35 mg in the treatment of patients with diabetic macular edema (DME).Design: Two randomized, multicenter, masked, sham-controlled, phase III clinical trials with identical protocols were conducted. Data were pooled for analysis.Participants: Patients (n = 1048) with DME, best-corrected visual acuity (BCVA) of 20/50 to 20/200 Snellen equivalent, and central retinal thickness (CRT) of ≥300 μm by optical coherence tomography.Methods: Patients were randomized in a 1:1:1 ratio to study treatment with DEX implant 0.7 mg, DEX implant 0.35 mg, or sham procedure and followed for 3 years (or 39 months for patients treated at month 36) at ≤40 scheduled visits. Patients who met retreatment eligibility criteria could be retreated no more often than every 6 months.Main Outcome Measures: The predefined primary efficacy endpoint for the United States Food and Drug Administration was achievement of ≥15-letter improvement in BCVA from baseline at study end. Safety measures included adverse events and intraocular pressure (IOP).Results: Mean number of treatments received over 3 years was 4.1, 4.4, and 3.3 with DEX implant 0.7 mg, DEX implant 0.35 mg, and sham, respectively. The percentage of patients with ≥15-letter improvement in BCVA from baseline at study end was greater with DEX implant 0.7 mg (22.2%) and DEX implant 0.35 mg (18.4%) than sham (12.0%; P ≤ 0.018). Mean average reduction in CRT from baseline was greater with DEX implant 0.7 mg (−111.6 μm) and DEX implant 0.35 mg (−107.9 μm) than sham (−41.9 μm; P < 0.001). Rates of cataract-related adverse events in phakic eyes were 67.9%, 64.1%, and 20.4% in the DEX implant 0.7 mg, DEX implant 0.35 mg, and sham groups, respectively. Increases in IOP were usually controlled with medication or no therapy; only 2 patients (0.6%) in the DEX implant 0.7 mg group and 1 (0.3%) in the DEX implant 0.35 mg group required trabeculectomy.Conclusions: The DEX implant 0.7 mg and 0.35 mg met the primary efficacy endpoint for improvement in BCVA. The safety profile was acceptable and consistent with previous reports.

PURPOSE To subsegment the choroid in patients with polypoidal choroidal vasculopathy and to determine whether the ratio of choriocapillaris/Sattler layer thickness to total choroidal thickness is decreased at sites of polypoidal pathology. METHODS Retrospective, observational, cross-sectional study. A total of 320 eyes of 305 patients with polypoidal choroidal vasculopathy were studied with optical coherence tomography and dye angiography. The ratio of choriocapillaris/Sattler layer thickness to total choroidal thickness was calculated at polypoidal lesion sites in eyes with subfoveal choroidal thickness (SFCT) ≤200 μm. RESULTS Mean SFCT was 267.7 ± 118.5 μm for the entire cohort. Mean SFCT was 151.2 ± 35.0 μm in eyes with SFCT ≤200 μm (n = 124, 39%). In this subgroup, dilated Haller vessels (pachyvessels) were identified under the site of neovascular ingrowth in 117 eyes (94%). Choroidal thickness in the pachyvessel zone was greater (213.3 ± 52.2 μm) than SFCT (P < 0.001) with a significantly lower choriocapillaris/Sattler layer to total thickness ratio (P < 0.001). Qualitative alterations of the retinal pigment epithelium were observed in 60 eyes (51%). CONCLUSION Eyes with normal or subnormal SFCT exhibited extrafoveal choroidal thickening at sites of polypoidal disease. The choriocapillaris and Sattler layers were attenuated at these locations, but Haller vessels were markedly dilated. These changes were topographically associated with sites of neovascular ingrowth and support the classification of polypoidal choroidal vasculopathy as a pachychoroid disorder.

Purpose To describe the findings of enhanced depth imaging (EDI) optical coherence tomography (OCT) of the lamina cribrosa (LC) in glaucoma and pachychoroid spectrum diseases associated with peripapillary retinoschisis. Design Retrospective, observational case series. Participants A total of 16 patients from 1 institution. Methods Detailed medical case histories, optic disc and retinal imaging with EDI using the Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany), and clinical course were reviewed for patients with peripapillary retinoschisis without a known predisposing condition. Main Outcome Measures Clinical features and findings of the EDI OCT. Results Among the 16 eyes with peripapillary retinoschisis that had abnormal findings on EDI of the LC, 8 had glaucoma and 8 had pachychoroid spectrum diseases, including chronic central serous chorioretinopathy (CSC) (6 eyes), small pigment epithelium detachment (1 eye), and polypoidal choroidal vasculopathy (PCV) (1 eye). The abnormal LC findings were central or peripheral focal LC defects in eyes with glaucoma and LC disinsertions or peripheral focal LC defects in eyes with pachychoroid spectrum diseases. Central LC defects were related to inner layer retinoschisis, whereas LC disinsertions and peripheral LC defects were related to outer layer retinoschisis. The peripapillary retinoschisis did not show a topographic association with the underlying chronic CSC- or PCV-associated lesions. In 6 treated eyes with pachychoroid, peripapillary retinoschisis resolved along with subretinal fluid after anti–vascular endothelial growth factor injection in 4 eyes, whereas retinoschisis persisted after the resolution of subretinal fluid in 2 eyes. Conclusions Enhanced depth imaging OCT of the LC demonstrated alterations associated with peripapillary retinoschisis, pachychoroid spectrum diseases, and glaucoma.

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly people globally. It is estimated that there will be more Asians with AMD than the rest of the world combined by 2050. In Asian populations, polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative AMD, while choroidal neovascularization secondary to AMD (CNV-AMD) is the typical subtype in Western populations. The two subtypes share many common clinical features and risk factors, but also have different epidemiological and clinical characteristics, natural history and treatment outcomes that point to distinct pathophysiological processes. Recent research in the fields of genetics, proteomics and imaging has provided further clarification of differences between PCV and CNV-AMD. Importantly, these differences have manifested as disparity in response to intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) treatment between PCV and CNV-AMD, emphasizing the need for accurate diagnosis of PCV and in distinguishing PCV from CNV-AMD, particularly in Asian patients. Current clinical trials of intravitreal anti-VEGF therapy and photodynamic therapy will provide clearer perspectives of evidence-based management of PCV and may lead to paradigm shifts in therapeutic strategies away from those currently employed in the treatment of CNV-AMD. Further research is needed to clarify the relative contribution of specific pathways in inflammation, complement activation, extracellular matrix dysregulation, lipid metabolism and angiogenesis to the pathogenesis of PCV. Findings from this research, together with improved diagnostic technology and new therapeutics, will facilitate more optimal management of Asian AMD.

To evaluate the 1-year results of adjunctive photodynamic therapy in patients with Type 1 neovascularization associated with thickened choroid who were refractory to anti-vascular endothelial growth factor monotherapy.Data on 28 eyes of 28 patients with Type 1 neovascularization with a minimum subfoveal choroidal thickness of 300 μm were reviewed. All showed persistent subretinal and/or intraretinal fluid after at least 4 anti-vascular endothelial growth factor injections in the 6 months before adjunctive photodynamic therapy. No eyes had certain polypoidal lesions on indocyanine green angiography.At 3 months, complete fluid absorption was observed in 24 eyes (85.7%). The mean best-corrected visual acuity significantly improved (20/53-20/44, P = 0.040) and mean subfoveal choroidal thickness reduced (386 to 350 μm, P0.001) compared with baseline. Over a 1-year follow-up period, 17 eyes (60.7%) were free from recurrent fluid accumulation. Anti-vascular endothelial growth factor injection was mainly used in retreatment (mean: 1.5). At 12 months, best-corrected visual acuity improved by ≥0.3 logMAR or maintained compared with baseline in 27 eyes (96.4%).Adjunctive photodynamic therapy in eyes with Type 1 neovascularization with thickened choroid that were refractory to anti-vascular endothelial growth factor monotherapy resulted in complete fluid absorption in most eyes, which translated to visual improvement until 1 year.

The 2-year efficacy and safety of combination therapy of ranibizumab administered together with verteporfin photodynamic therapy (vPDT) compared with ranibizumab monotherapy in participants with polypoidal choroidal vasculopathy (PCV) are unclear.To compare treatment outcomes of ranibizumab, 0.5 mg, plus prompt vPDT combination therapy with ranibizumab, 0.5 mg, monotherapy in participants with PCV for 24 months.This 24-month, phase IV, double-masked, multicenter, randomized clinical trial (EVEREST II) was conducted among Asian participants from August 7, 2013, to March 2, 2017, with symptomatic macular PCV confirmed using indocyanine green angiography.Participants (N = 322) were randomized 1:1 to ranibizumab, 0.5 mg, plus vPDT (combination therapy group; n = 168) or ranibizumab, 0.5 mg, plus sham PDT (monotherapy group; n = 154). All participants received 3 consecutive monthly ranibizumab injections, followed by a pro re nata regimen. Participants also received vPDT (combination group) or sham PDT (monotherapy group) on day 1, followed by a pro re nata regimen based on the presence of active polypoidal lesions.Evaluation of combination therapy vs monotherapy at 24 months in key clinical outcomes, treatment exposure, and safety. Polypoidal lesion regression was defined as the absence of indocyanine green hyperfluorescence of polypoidal lesions.Among 322 participants (mean [SD] age, 68.1 [8.8] years; 225 [69.9%] male), the adjusted mean best-corrected visual acuity (BCVA) gains at month 24 were 9.6 letters in the combination therapy group and 5.5 letters in the monotherapy group (mean difference, 4.1 letters; 95% CI, 1.0-7.2 letters; P = .005), demonstrating that combination therapy was superior to monotherapy by the BCVA change from baseline to month 24. Combination therapy was superior to monotherapy in terms of complete polypoidal lesion regression at month 24 (81 of 143 [56.6%] vs 23 of 86 [26.7%] participants; P .001). Participants in the combination group received fewer ranibizumab injections (median, 6.0 [interquartile range (IQR), 4.0-11.0]) than the monotherapy group (median, 12.0 [IQR, 7.0-17.0]) up to month 24. The combination group required a median of 2.0 (IQR, 1.0-3.0) vPDT treatments for 24 months, with 75 of 168 participants (44.6%) requiring only 1 vPDT treatment.The 24-month data findings confirm that ranibizumab therapy, given as monotherapy or in combination with vPDT, is efficacious and safe for treatment of PCV. Combination therapy with vPDT added to ranibizumab achieved superior BCVA gain, increased odds of complete polypoidal lesion regression, and fewer treatment episodes compared with ranibizumab monotherapy.ClinicalTrials.gov Identifier: NCT01846273.

PURPOSE. To evaluate the depth and pattern of retinal hemorrhage in acute central retinal vein occlusion (CRVO) and to correlate these with visual and anatomic outcomes. METHODS. Retinal hemorrhages were evaluated with color fundus photography and fluorescein angiography at baseline and follow-up. Snellen visual acuity (VA), central foveal thickness (CFT), extent of retinal ischemia, and development of neovascularization were analyzed. RESULTS. 108 eyes from 108 patients were evaluated. Mean age was 63.6 ± 16.1 years with a predilection for the right eye (73.1%). Average follow-up was 17.2 ± 19.2 months. Mean VA at baseline was 20/126 and 20/80 at final follow-up. Baseline (P = 0.005) and final VA (P = 0.02) in eyes with perivascular nerve fiber layer (NFL) hemorrhages were significantly worse than in eyes with deep hemorrhages alone. Baseline CFT was greater in the group with perivascular hemorrhages (826 ± 394 μm) compared to the group with deep hemorrhages alone (455 ± 273 μm, P < 0.001). The 10 disc areas of retinal ischemia was more common in patients with perivascular (80.0%) and peripapillary (31.3%) versus deep hemorrhages alone (16.1%, P < 0.001). Neovascularization of the iris was more common, although this differrence was not significant, in the groups with peripapillary (14.3%) and perivascular (2.0%) NFL versus deep hemorrhages alone (0.0%). CONCLUSIONS. NFL retinal hemorrhages at baseline correlate with more severe forms of CRVO, with greater macular edema, poorer visual outcomes, and greater risk of ischemia and neovascularization. This may be related to the organization of the retinal capillary plexus. The depth and pattern of distribution of retinal hemorrhages in CRVO may provide an easily identifiable early biomarker of CRVO prognosis.

Purpose We sought to evaluate longer-term efficacy and safety of intravitreal aflibercept monotherapy (IAI) vs IAI plus rescue photodynamic therapy (rPDT) in patients with polypoidal choroidal vasculopathy (PCV). Design This was a prospective multicenter, double-masked, sham-controlled randomized clinical study across 62 centers. Methods In this phase 3b/4 study, patients with PCV with best-corrected visual acuity of 73–24 Early Treatment Diabetic Retinopathy Study letters (20/40–20/320 Snellen equivalent) received IAI 2 mg every 4 weeks until week 12, when they were randomized 1:1 to receive IAI or IAI plus rPDT if rescue criteria were met. Patients not requiring rescue received IAI every 8 weeks; those requiring rescue received IAI every 4 weeks plus sham/active PDT. At week 52 (the primary endpoint), IAI was noninferior to IAI plus rPDT. After week 52, treatment intervals could be extended beyond 8 weeks at the investigators' discretion. Noninferiority of IAI vs IAI plus rPDT for mean best-corrected visual acuity change from baseline to week 96 was evaluated. Results Over 96 weeks, 54 patients (17.0%) met rescue criteria. At week 96, IAI was noninferior to IAI plus rPDT in terms of Early Treatment Diabetic Retinopathy Study letters gained (+10.7 vs +9.1, P = .48). Proportions of patients with complete polyp regression (33.1% vs 29.1%) or without active polyps (82.1% vs 85.6%) were similar. In year 2, the mean number of injections was 4.6 in both arms. No new safety signals were observed. Conclusion IAI monotherapy was noninferior to IAI with rescue PDT up to 96 weeks, and functional and anatomical improvements achieved at 52 weeks were maintained. Few patients required rescue PDT, which provided no additional visual benefit.

To identify prognostic factors that may predict the amount of long-term visual improvement after idiopathic epiretinal membrane removal.A retrospective study of 114 patients who underwent epiretinal membrane removal was performed. The central foveal thickness, inner retinal layer thickness, inner retinal irregularity index, length of the cone outer segment tip line defect, and length of the ellipsoid zone defect were measured. The optical coherence tomography parameters that were associated with the amount of visual improvement were determined at 24 months postoperatively.Central foveal thickness and inner retinal irregularity index were not associated with best-corrected visual acuity at 24 months (P = 0.227 and P = 0.544, respectively), whereas the lengths of cone outer segment tip line defect and ellipsoid zone defect were associated with worse best-corrected visual acuity at 24 months (P = 0.015 and P0.001, respectively). Univariate regression analysis indicated that central foveal thickness and inner retinal irregularity index were associated with visual improvement (P = 0.011 and P0.001, respectively). Multivariate regression analysis indicated that inner retinal irregularity index, a marker of the inner retinal deformation, was associated with visual improvement after adjusting for age, gender, and other optical coherence tomography findings (P0.001).Patients with preoperative inner retinal deformation were found to have significantly improved long-term visual outcomes after epiretinal membrane removal.

Importance Polypoidal choroidal vasculopathy (PCV) is common in Asian populations, but an optimal treatment approach remains to be confirmed. Objective To evaluate intravitreal aflibercept injection (IAI) in participants with PCV and compare IAI monotherapy with IAI plus rescue photodynamic therapy (PDT). Design, Setting, and Participants This 96-week, double-masked, sham-controlled phase 3b/4 randomized clinical trial was conducted at multiple centers in Australia, Germany, Hong Kong, Hungary, Japan, Singapore, South Korea, and Taiwan from May 2014 to August 2016, and included adults 50 years or older with symptomatic macular PCV and a best-corrected visual acuity of 73 to 24 Early Treatment Diabetic Retinopathy Study letters (20/40-20/320 Snellen equivalent). Interventions Participants received 2 mg of IAI at weeks 0, 4, and 8. At week 12, participants with a suboptimal response were randomized 1:1 to receive IAI plus sham PDT (IAI monotherapy) or a “rescue” of IAI plus rescue PDT (IAI/PDT). Participants who did not qualify for rescue received IAI every 8 weeks; those qualifying for rescue received IAI every 4 weeks plus sham/active PDT. When the rescue criteria were no longer met, injection intervals were gradually extended to 8 weeks. Main Outcomes and Measures Noninferiority of IAI monotherapy to IAI/PDT for mean change in best-corrected visual acuity from baseline to week 52 (95% CI of the difference entirely above −5 letters). Results Of the 318 participants, the mean (SD) age was 70.6 (8.2) years, 96 (30.2%) were women, and 152 (47.8%) were Japanese. Monotherapy with IAI was noninferior to IAI/PDT for the primary end point (+10.7 vs +10.8 letters, respectively; 95% CI, −2.9 to 1.6;P = .55), with few participants requiring rescue therapy (19 [12.1%] vs 23 [14.3%], respectively). Participants in both treatment groups had similar reductions in central subfield thickness from baseline to week 52 (−137.7 [IAI monotherapy] vs −143.5 μm [IAI/PDT]). At week 52, 49 (38.9%) and 60 participants (44.8%) had no polypoidal lesions observed on indocyanine green angiography in the IAI monotherapy and IAI/PDT groups, respectively. Furthermore, 116 (81.7%) and 136 (88.9%), respectively, had no polypoidal lesions with leakage. The most frequent ocular adverse events were conjunctival hemorrhage (IAI monotherapy, 8 [5.1%]) and dry eye (IAI/PDT, 9 [5.6%]). Conclusions and Relevance Improvement in visual and/or functional outcomes was achieved in more than 85% of participants who were treated with IAI monotherapy, with no signs of leakage from polypoidal lesions in more than 80%. As fewer than 15% met the criteria of a suboptimal response to receive PDT, the potential benefit of adding PDT cannot be determined. Trial Registration ClinicalTrials.gov Identifier:NCT02120950

IMPORTANCE To reveal choroidal morphological profiles under pachydrusen. BACKGROUND Drusen in pachychoroid disorders show certain differences from conventional drusen and are recently named as "pachydrusen." This study analysed the specific choroidal morphology under pachydrusen. DESIGN This study is a cross-sectional case series. PARTICIPANTS Enrolled were 136 eyes with pachydrusen from 134 patients. METHODS The presence of pachydrusen in fundus area covered by a 12 × 9 mm2 optical coherence tomography (OCT) image was accessed in eyes with pachychoroid-related diseases or their fellow eyes using colour fundus photography and swept source OCT. Choroidal morphology under the pachydrusen was analysed using OCT B-scans and en face images. MAIN OUTCOME MEASURES Choroidal thicknesses and topographical correlation between pachydrusen and pachyvessels. RESULTS A total of 225 pachydrusen in 136 eyes were analysed. The mean number of pachydrusen was 1.65 ± 1.07 per eye. Most pachydrusen were located para- or perifoveally (37 subfoveal, 86 parafoveal and 102 perifoveal). The proportion of Haller's layer to total choroidal thickness was higher at the area of the pachydrusen compared to the subfovea (0.881 ± 0.081 vs 0.765 ± 0.111, P

Purpose This study analyzes a subset of patients with peripapillary polypoidal choroidal vasculopathy (PCV) to determine whether quantifiable pachychoroid features colocalize with disease foci. Methods Patients with PCV diagnosed by indocyanine green angiography were identified for the analysis of medical records and multimodal imaging and classified as having peripapillary or macular PCV. The ratio of Haller layer thickness to total choroidal thickness was calculated at the fovea and at the site of dilated Haller vessels that showed spatial correlation with the origin of neovascularization. Choroidal thickness was measured horizontally across the fovea and circumferentially around the temporal side of the disk to study its relationship to neovascularization. Results Three hundred and fourteen eyes of 299 patients with PCV were identified, of which 17 eyes (5%) had peripapillary disease. Although eyes with peripapillary PCV exhibited thinner subfoveal choroids than those with macular PCV, at the extrafoveal disease foci, choroidal thickness, Haller's layer thickness, and its ratio to total choroidal thickness were relatively high. Conclusion Quantitative indices of choroidal structure previously identified in macular PCV performed consistently when applied to a peripapillary PCV cohort, thus supporting the hypothesis that inner choroidal thinning and Haller vessel enlargement are mechanistically relevant to these related entities.

Pachychoroid is a relatively novel concept describing a phenotype characterized by attenuation of the choriocapillaris overlying dilated choroidal veins, and associated with progressive retinal pigment epithelium dysfunction and neovascularization. The emphasis in defining pachychoroid-related disorders has shifted away from simply an abnormally thick choroid (pachychoroid) toward a detailed morphological definition of a pathologic state (pachychoroid disease) with functional implications, which will be discussed in this review. Several clinical manifestations have been described to reside within the pachychoroid disease spectrum, including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, focal choroidal excavation, peripapillary pachychoroid syndrome. These conditions all exhibit the characteristic choroidal alterations and are believed to represent different manifestations of a common pathogenic process. This review is based on both the current literature and the clinical experience of our individual authors, with an emphasis on the clinical and imaging features, management considerations, as well as current understanding of pathogenesis of these disorders within the context of the recent findings related to pachychoroid disease.摘要: 肥厚型脉络膜疾病是近年来提出的新概念, 其描述了一类特征为脉络膜毛细血管层的静脉扩张, 并且与进行性视网膜色素上皮功能障碍和新生血管的形成有关的一类疾病。定义肥厚型脉络膜相关疾病的重点已经从简单的脉络膜厚度异常 (脉络膜肥厚) 转向影响功能的病理状态 (“肥厚型脉络膜疾病”) 的详细形态学定义, 这将在本综述中详细讨论。属于肥厚型脉络膜疾病谱的疾病, 包括中心性浆液性脉络膜视网膜病变, 肥厚型脉络膜色素上皮病变, 肥厚型脉络膜新生血管病变, 息肉状脉络膜血管病变/1型动脉瘤新生血管, 局灶性脉络膜凹陷, 视盘周围毛细脉络膜肥厚综合症。这些病症都表现出特征性的脉络膜改变, 并且被认为代表了常见致病过程的不同临床表现。 本综述基于目前已发表的文献和作者自身的临床经验以及最近在肥厚型脉络疾病的相关研究结果, 重点强调了临床表现、影像学特征、治疗要点以及目前对这些疾病发病机制的探讨。.

Objective The primary study hypothesis was that ranibizumab 0.5 mg monotherapy or combined with laser is superior to laser monotherapy based on mean average change in best-corrected visual acuity (BCVA) over 12 months in Asian patients with visual impairment resulting from diabetic macular edema (DME). Design A 12-month, randomized, double-masked, multicenter, laser-controlled, phase III study. Participants Three hundred ninety-six patients aged ≥18 years, with type 1 or 2 diabetes mellitus, BCVA of 78–39 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and visual impairment resulting from DME. Methods Patients were randomized to ranibizumab + sham laser (n = 133), ranibizumab + active laser (n = 132), or sham injection + active laser (n = 131). Ranibizumab/sham injections were administered on day 1 and continued monthly. As of month 3, monthly injections were continued if stable vision was not reached. Treatment was reinitiated if BCVA decreased because of DME progression. Active/sham laser was administered on day 1 and thereafter according to ETDRS guidelines. Main Outcome Measures Average change in BCVA from baseline to months 1 through 12, central retinal subfield thickness (CRST), and safety over 12 months. Results Ranibizumab monotherapy or combined with laser was superior to laser in improving mean average change in BCVA from baseline to months 1 through 12 (+5.9 and +5.7 vs +1.4 letters). At month 12, greater proportion of patients gained ≥15 letters with ranibizumab and ranibizumab + laser compared with laser (18.8% and 17.8% vs 7.8%). Mean CRST reduced significantly from baseline to month 12 with ranibizumab (−134.6 μm) and ranibizumab + laser (−171.8 μm) versus laser (−57.2 μm). Patients received a mean of 7.8 and 7.0 ranibizumab injections in the ranibizumab and ranibizumab + laser arms, respectively, and 1.5–1.9 active laser across treatment arms over 12 months. Conjunctival hemorrhage was the most common ocular, whereas nasopharyngitis and hypertension were the most common nonocular adverse events. Ranibizumab was not associated with any cases of cerebrovascular hemorrhage and cerebrovascular ischemia. No death related to study treatment was reported. Conclusions Ranibizumab monotherapy or combined with laser showed superior BCVA improvements over laser treatment alone in Asian patients with visual impairment resulting from DME. No new ocular or nonocular safety findings were observed and treatment was well tolerated over 12 months.

To investigate the clinical characteristics and treatment results of adult patients with ocular toxocariasis.A total of 54 consecutive patients who were clinically and serologically diagnosed with ocular toxocariasis were retrospectively reviewed.Among patients, 66.7 and 77.3% showed increases in eosinophil cationic protein (ECP) and total Ig E in serum, respectively. Four eyes (7.2%) initially presented as neuroretinitis with subsequent motile retinal lesion. The recurrence rates in the combination treatment group with albendazole and corticosteroids were significantly lower than those in the steroid-alone group during the mean follow-up of 27.6 months (p = 0.001).The adjunctive test of serum total IgE level may be helpful for the diagnosis of ocular toxocariasis. Ocular toxocariasis should be considered in the differential diagnosis of unilateral neuroretinitis with subsequent motile retinal lesion. Combined treatment with albendazole and corticosteroids appeared to be effective for reducing the recurrence of intraocular inflammation.

Post hoc analyses of the Asian subpopulation of the VIEW trials demonstrated that visual and anatomic outcomes were similar in eyes treated with intravitreal aflibercept and ranibizumab, and were similar to outcomes seen in white patients., Purpose: To assess the treatment effect of intravitreal aflibercept and ranibizumab in Asian patients with neovascular age-related macular degeneration. Methods: We evaluated data from VIEW 1 and VIEW 2, comparing functional and morphologic outcomes at Week 96 between intravitreal aflibercept 2 mg monthly (2q4) or 2 mg bimonthly after 3 initial monthly doses (2q8) versus ranibizumab 0.5 mg monthly among Asian patients (n = 269) and between Asian and white patients (n = 2044). Results: In Asian patients, there were no significant differences between intravitreal aflibercept 2q4 and 2q8 compared with ranibizumab in mean gain in best-corrected visual acuity (10.23 and 8.35 vs. 8.51 letters). Reduction in central retinal thickness was greater for intravitreal aflibercept 2q4 (150.43 μm, P = 0.0075) and 2q8 (148.15 μm, P = 0.0126) than ranibizumab (119.46 μm). The proportion of dry retinas was greater for intravitreal aflibercept 2q4 (65.7%, P < 0.01) than ranibizumab (41.7%). There were no differences in outcomes between Asian and white patients. Serious treatment-emergent ocular adverse events occurred in

PURPOSE To investigate changes in disease activity after a large subretinal hemorrhage in polypoidal choroidal vasculopathy. METHODS Fifty-two polypoidal choroidal vasculopathy eyes with large subretinal hemorrhage (at initial presentation [n = 33, Group 1] or developed during follow-up [n = 19, Group 2]) were enrolled. Thirty polypoidal choroidal vasculopathy eyes without subretinal hemorrhage were enrolled as controls. All subretinal hemorrhages were treated with pneumatic displacement. Other active lesions were treated with intravitreal ranibizumab on an as-needed basis. Injection-free period, 1-year injection numbers, and polyp presence on indocyanine green angiography were analyzed. RESULTS The injection frequency significantly diminished after hemorrhage (1.2 ± 1.8 in Group 1 and 1.1 ± 2.1 in Group 2) compared with control eyes (3.9 ± 3.0) in both groups (both P < 0.001) and the prehemorrhage period (4.7 ± 1.4) in Group 2 (P < 0.001). The median injection-free period after hemorrhage was 12.0 months in both groups. At least one polypoidal lesion disappeared after hemorrhage in 7 of 10 eyes (70%) with comparable indocyanine green angiography. CONCLUSION The activity of a polypoidal choroidal vasculopathy lesion diminished after a large subretinal hemorrhage, which was associated with rupture of major polyps.

Objective To evaluate the incidence and associated risk factors of massive subretinal hemorrhage (SRH) in patients with retinal angiomatous proliferation (RAP). Methods A total of 187 eyes of 135 treatment-naive patients diagnosed with RAP were evaluated retrospectively. Clinical records including the time between the initial visit, last anti-vascular endothelial growth factor (VEGF) treatment, last stable examination, and the date of massive SRH were reviewed. Imaging findings including indocyanine green angiography (ICGA) and optical coherence tomography (OCT) were analyzed. Results Massive SRH developed in 18 eyes (9.6%) a median of 20 months after the initial presentation. Kaplan-Meier survival analysis revealed that the incidence (2.8, 5.8, 13.1, and 21.0% after 1,2,5 and 10 years, respectively) continuously increased. Among 14 eyes with discernable vascular anastomosis on baseline ICGA, 13 (92.8%) showed retinal arteriole involvement. On spectral-domain OCT imaging of the last visit prior to the massive SRH, a layered lamellar tissue complex was noted under the retinal pigment epithelium in 9 of 13 eyes, which was significantly associated with massive SRH[hazard ratio(HR),5.883;P = .010]. The average time between the last stable examination/last injection and the massive SRH was 2 and 5 months, respectively. The patients were treated with anti-VEGF, gas and recombinant tissue plasminogen activator injection; however, all except one eye had visual acuity worse than 20/1000 at the final visit. Conclusions Massive SRH can occur in RAP in the course of anti-VEGF treatment, resulting in severe vision loss. A proactive dosing regimen may be more appropriate for these RAP eyes.

Purpose To summarize recommendations for the use of intravitreal aflibercept with a treat-and-extend regimen to manage neovascular age-related macular degeneration (nAMD) in the Asia-Pacific region. Although anti-vascular endothelial growth factor therapies have improved the quality of life of patients with nAMD, a leading cause of blindness and visual impairment, the high treatment frequency recommended by current guidelines places a significant burden on patients and healthcare providers. Design Recommended guidelines from a consensus panel. Methods An expert panel formed a consensus on recommendations for use of intravitreal aflibercept as treatment of nAMD in the Asia-Pacific region. Results After 3 initial monthly doses, treatment interval could be extended by 4-week increments, to a maximum of 12 weeks, in patients with inactive disease. Conversely, in active disease, treatment intervals should be shortened, by 4 weeks, or to 4 weeks in cases of severe recurrence. Treatment could be ceased in patients with stable disease activity after 12 months of treatment at 12-week intervals, as a means to prevent over treatent and lifelong injections. Conclusions These recommendations could potentially minimize the number of treatments while maintaining efficacy and improve compliance by reducing the number of clinic visits compared with existing recommendations.

Anti-vascular endothelial growth factor (anti-VEGF) therapy has revolutionized the treatment of neovascular age-related macular degeneration (AMD). This review will summarize the current evidence of anti-VEGF therapy in neovascular AMD, including subtypes of retinal angiomatous proliferation and polypoidal choroidal vasculopathy (PCV). Importantly, 2 large multicenter randomized clinical trials evaluating the safety and efficacy of anti-VEGF monotherapy and combination with photodynamic therapy (PDT) have recently reported initial first-year outcomes. In this review, we summarize the latest updates in the efficacy and safety of anti-VEGF monotherapy and combination with PDT in common lesion subtypes. Remaining gaps in current understanding are highlighted where further research is needed.

To evaluate the efficacy of intravitreal triamcinolone injection in diabetic macular edema unresponsive to intravitreal bevacizumab.Patients with diabetic macular edema unresponsive to at least three monthly intravitreal bevacizumabs were included. At least 2 months after the last intravitreal bevacizumab, intravitreal triamcinolone was performed after obtaining an aqueous humor sample. Multiplex cytokine array was used to assay vascular endothelial growth factor, interleukin (IL)-2, IL-6, IL-8, tumor necrosis factor-α, and transforming growth factor-β2. Best-corrected visual acuity and central subfield thickness were evaluated from Month 0 to 3.Twenty eyes were enrolled. The mean best-corrected visual acuity was 47.1 ± 18.9 letters at baseline, and significantly increased to 53.3 ± 19.7 letters at 1 month (P = 0.002) and 52.4 ± 19.1 letters at 2 months (P = 0.041). These visual gains were not sustained at 3 months (50.9 ± 18.6; P = 0.204). A decrease in central subfield thickness more than 11% of baseline occurred in 12 eyes at 1 month. Multivariate analysis showed that intraocular levels of IL-8 (β = 0.538 P = 0.006) was an independent factor for anatomic response at 1 month.Intravitreal triamcinolone has a role in patients who are unresponsive to intravitreal bevacizumab over the short-term. Elevated intraocular IL-8 levels were related to the efficacy.