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Abstract To investigate how sodium-glucose co-transporter 2 inhibitors (SGLT2is) add-on therapy for metformin affects diabetic retinopathy (DR) progression in patients with type 2 diabetes mellitus (T2DM). This nationwide population-based study conducted from January 1, 2016, to December 31, 2018 involved 3,432,911 adults with T2DM in Taiwan. To adjust for potential confounders, data on sex, age, income, comorbidities, diabetes complication severity index score, staging of kidney disease, anti-diabetic medications, and index year were included. The outcome was DR progression, determined by procedure codes or the addition of ICD-9-CM or ICD-10-CM codes to the medical records of the patients during the study. Sensitivity analyses were performed to validate the findings. The adjusted hazard ratio (aHR) of DR progression was 0.89 for the SGLT2is add-on group, relative to the control group [95% confidence interval (CI) 0.81–0.99, P = 0.026]. The Kaplan–Meier curve of the cumulative incidence rate showed that the cumulative incidence of DR progression was considerably decreased in the SGLT2is cohort (log-rank P = 0.0261). The use of SGLT2is for less than 1 year and 1–2 years were associated with a significant increase in the risk of DR progression (aHR 1.56 and 1.88, respectively); however, the risk markedly reduced if the SGLT2is regimen was used for more than 2 years (aHR 0.41, 95% Cl 0.35–0.48; P

Abstract Coronavirus disease 2019 (COVID-19) vaccines are associated with several ocular manifestations. Emerging evidence has been reported; however, the causality between the two is debatable. We aimed to investigate the risk of retinal vascular occlusion after COVID-19 vaccination. This retrospective cohort study used the TriNetX global network and included individuals vaccinated with COVID-19 vaccines between January 2020 and December 2022. We excluded individuals with a history of retinal vascular occlusion or those who used any systemic medication that could potentially affect blood coagulation prior to vaccination. To compare the risk of retinal vascular occlusion, we employed multivariable-adjusted Cox proportional hazards models after performing a 1:1 propensity score matching between the vaccinated and unvaccinated cohorts. Individuals with COVID-19 vaccination had a higher risk of all forms of retinal vascular occlusion in 2 years after vaccination, with an overall hazard ratio of 2.19 (95% confidence interval 2.00–2.39). The cumulative incidence of retinal vascular occlusion was significantly higher in the vaccinated cohort compared to the unvaccinated cohort, 2 years and 12 weeks after vaccination. The risk of retinal vascular occlusion significantly increased during the first 2 weeks after vaccination and persisted for 12 weeks. Additionally, individuals with first and second dose of BNT162b2 and mRNA-1273 had significantly increased risk of retinal vascular occlusion 2 years following vaccination, while no disparity was detected between brand and dose of vaccines. This large multicenter study strengthens the findings of previous cases. Retinal vascular occlusion may not be a coincidental finding after COVID-19 vaccination.

Choroidal ruptures occur in 5% to 10% closed-globe injuries with wide variation in visual prognosis, which depending on the visual acuity at presentation, the location of the rupture, and other associated ocular injuries. We reported a case of bilateral traumatic choroidal rupture with a large macular hole. We performed surgery in the right eye of microincisional vitrectomy, temporally inverted internal limiting membrane (ILM) flap, and C3F8 tamponade; then microincisional vitrectomy, fibrotic scar removal, double inverted ILM flap, and C3F8 tamponade in the left eye. After surgery, she achieved both good anatomical and visual acuity improvement in the right eye, but limited visual acuity improvement in the left eye due to subfoveal choroidal scar formation.

This is a case report of Epstein–Barr virus (EBV) uveitis confirmed via aqueous humor polymerase chain reaction (PCR) and metagenomics. This 72-year-old male with a history of diabetes and herpes zoster complained of redness and blurred vision in his right eye for eight months. Mild conjunctival injection, anterior chamber cells, mutton-fat keratic precipitates, and vitreous haze were noted. Fluorescein angiography revealed dye leakage from retinal vessels without retinal ischemic changes. Only the serum anti-cytomegalovirus (CMV) IgG was positive while the aqueous humor PCR for VZV (Varicella-zoster virus), HSV (Herpes simplex viruses), CMV, and EBV was initially negative. Inflammation recurred and vitreous haze worsened after discontinuing nine-month topical ganciclovir and oral prednisolone. the aqueous humor PCR was repeated due to persistent low-grade inflammation. The EBV PCR turned out to be positive. Shotgun metagenomics revealed 1459 classified sequences (1.62%) and confirmed the EBV infection. Topical ganciclovir and methylprednisolone treatment was resumed. Conjunctival injection improved while pigmented keratic precipitates lessened. Elderly patients with diabetes or under immunosuppression may be susceptible to chronic uveitis associated with subsequent EBV infection. Repeated aqueous humor PCR and shotgun metagenomics are important tools in the diagnosis of this case of chronic indolent panuveitis.

PurposeTo determine the risk of ptosis among diabetic retinopathy (DR) patients.MethodsThis is a population-based, retrospective, matched-cohort study where DR patients were recruited from the Taiwan National Health Insurance Research Database (NHIRD) to investigate the risk of developing ptosis. Preexisting co-factors of interest included smoking status and medical comorbidities of hyperlipidemia and hypertension. Statistical analysis was performed using T-test, Cox-proportional hazard ratios adjusted for comorbidities (aHR), Wilcoxon rank sum test, Kaplan–Meier estimators, and log rank tests.ResultsFollow-up data of 9,494 patients with DR and 37,976 matched control cohort (non-DR) from 2000 to 2012 were analyzed. DR patients were found to have significantly increased risk of developing ptosis (adjusted hazard ratio (HR) [95% CI]: 2.76 [1.74–4.38], p

We reported a 74 year old Asian female with a uveal tumor with subretinal fluid (SRF) and cystoid macula edema. Since she declined biopsy, multimodal imaging study was performed, including fundus photography, ultrasonography, optical coherence tomography, fluorescein angiography, and magnetic resonance imaging. Uveal melanoma was diagnosed. However, despite aggressive treatment with TTT and three adjuvant intravitreal bevacizumab doses, SRF, and cystoid macula edema were persistent. Therefore, aflibercept was administered, resulting in anatomical and functional improvement within 1 month, which lasted for 12 months. Aflibercept offered great efficacy in improving refractory macular edema in this case of primary uveal melanoma. Multimodal imaging can provide us with more diagnostic clues in differentiating the nature of intraocular tumors.

PurposeTo identify optical coherence tomography (OCT) biomarkers that may predict functional and anatomical outcomes in diabetic macular edema (DME) patients treated with intravitreal dexamethasone (DEX) implant.Materials and MethodsSixty-four eyes from 50 patients with DME were enrolled. Best-corrected visual acuity (BCVA) and OCT biomarkers including central retinal thickness (CRT), subretinal fluid (SRF), intraretinal cysts (IRC), ellipsoid zone disruption (EZD), disorganization of retinal inner layers (DRIL), hard exudate (HE), hyperreflective foci (HRF), epiretinal membrane (ERM), and vitreomacular interface (VMI) changes were evaluated at baseline and at 3, 6, and 12 months after treatment. Multiple logistic analysis was performed to evaluate each OCT biomarker as a predictive factor for functional and anatomical improvement at the end of treatment.ResultsThe presence of SRF at baseline was associated with a favorable outcome, with CRT improving by more than 100 μm after treatment from multivariate logistic regression analysis [odds ratio 6.16 (1.75–21.6)]. In addition, baseline SRF predicted a greater CRT improvement from multiple regression analysis (model R-square 0.11, p = 0.006). The reduction of DRIL, SRF, LONLC, IRC, and EZD were correlated with better CRT improvement (more than 100 μm) (P < 0.05). SRF and EZD recovery can also predict better visual prognosis (P < 0.05).ConclusionOCT biomarkers can be used to predict who may benefit the most after DEX treatment. We suggest that the DEX implant should be considered as a first line treatment in DME patients with SRF.

Introduction: We report a male who presented with acute visual defect and was diagnosed with urticarial vasculitis with recurrent branch retinal artery occlusion (BRAO) after systemic disease survey, fluorescein angiography (FA), and MultiColor imaging (MCI). Case report: A 47-year-old male with a history of urticarial vasculitis presented with visual defect OD. Fundus examination showed two foci of ischemic retinal whitening beneath the inferior arcade and above the superior arcade. MCI demonstrated a greenish tinge in the corresponding area. FA revealed segmental arteriolar staining and arterial occlusive changes. BRAO with retinal arteritis was diagnosed. Toxoplasma IgG was positive. Sulfamethoxazole 400mg plus trimethoprim 80mg was given. His vision worsened after 1-week of treatment. The established lesions improved, but new lesions occurred. Interferon-gamma release assay was positive but tuberculosis DNA qualitative amplification test of sputum was negative. Sputum acid-fast stain was positive and culture revealed nontuberculous mycobacteria. Left facial itching and reactive lymphadenopathy developed. Prednisolone and cyclophosphamide were started. The initial retinal artery lesions regained perfusion. Conclusions: Urticarial vasculitis with recurrent BRAO is an immune complex-mediated disease. Greenish-tinged occlusive lesions were noted from MCI with high resolution and contrast. MCI could be a valuable method for retinal vessel occlusive disease detection before FA and follow up.

Abstract Background A cyclodialysis cleft often leads to direct communication between the anterior chamber and the suprachoroidal space. It is a rare condition that is encountered with blunt trauma, and less commonly, after surgery. Hypotony is the major sequelae that may lead to hypotonous maculopathy, optic disc edema, corneal folds, and astigmatism. These may cumulatively lead to visual loss. We describe how endoscopy in a cyclodialysis repair allowed us to accurately locate the cleft and guided its appropriate management avoiding unnecessary cryopexy. Case presentation A 41-year-old male experienced a traumatic cyclodialysis cleft, which resulted in persistent hypotony. Pars plana vitrectomy was performed to treat vitreous hemorrhage. Scleral indentation was attempted to visualize the cyclodialysis cleft. However, the depression distorted the visualization. Intraocular endoscopy was therefore used to evaluate the cleft. Guided by this assessment, only intraocular gas tamponade was used to reposition the ciliary body. The patient’s intraocular pressure was restored to 13 mmHg 3 days after the operation, and OCT confirmed cleft closure 1 month after the operation. Conclusion Endoscopy-assisted repair of cyclodialysis is an approach that enhances visualization and can guard against common causes of persistent cleft and hypotony, as well as reveal the causes of recurrent failure. Hence, it can eliminate unnecessary cryopexy that might worsen the hypotonous state. In our case, intraocular endoscopy was effective for the evaluation of a cyclodialysis cleft and the subsequent selection of an appropriate management technique, gas tamponade, that was more conservative than other approaches initially considered.

Purpose: To evaluate the efficacy of microincision vitrectomy surgery (MIVS) for the treatment of post-cataract surgery endophthalmitis, and to report the factors which influence the outcome. Methods: This retrospective case series included eyes with post-cataract surgery endophthalmitis that had received MIVS between June 2014 and May 2017. The anatomical and functional results were analyzed. Results: 24 eyes of 24 patients were included with mean age 72.0 ± 8.6 years old. Best-corrected visual acuity (BCVA) improved in 70.8% of patients with a significant mean logMAR BCVA change of −0.6 ± 0.9. Positive culture rate was 25%. In all study eyes, inflammation became silent after MIVS. In univariate analysis, patients with improved BCVA have shorter duration between cataract surgery and MIVS and less likely to have positive culture results. Using degree of BCVA improvement as a continuous variable, it showed that duration between cataract surgery and MIVS had significantly negative correlation with BCVA improvement. Patients with positive culture results had significantly lower BCVA improvement. Multiple regression models also confirmed the most important outcome-influencing factors. Conclusion: MIVS is an efficient management for post-cataract surgery endophthalmitis. BCVA is significantly improved after MIVS. No matter in univariate or multivariate analysis, positive culture results and longer duration between cataract surgery and MIVS have significant negative effects on the outcome of post-cataract surgery endophthalmitis. Multicenter collaboration should be conducted in order to formulate better management protocols of this vision-threatening complication of cataract surgery. Keywords: Cataract surgery, Microincision vitrectomy surgery, Exogenous endophthalmitis, Wide-angle viewing systems

Abstract Background To evaluate the efficacy of micro-incision vitrectomy surgery (MIVS) using Lumera and Resight non-contact sutureless wide-angle viewing systems (WAVS) for primary rhegmatogenous retinal detachment (RRD), and to analyze the anatomical and visual outcomes. Methods The retrospective, non-comparative, interventional case series reported here was conducted from June 2014 through November 2016. Enrolled patients presented with primary RRD and received MIVS with/without cryopexy by one surgeon using the Lumera and Resight non-contact sutureless WAVS. All patients were followed-up for a minimum of 12 months. Variables collected included patient demographics, best-corrected visual acuity, and macular status. The number and position of retinal break(s), and the use of cryopexy, were also recorded. Outcome measures included operative time, single-operation anatomical success rate, final anatomical success rate, recurrent rate, postoperative best-corrected visual acuity, and surgical complications. The end points were operative time, anatomical outcome, and functional outcome. Results In total, 110 eyes from 110 patients (68 men and 42 women) were treated. Of these, 103 (93%) eyes were reattached after primary vitrectomy. One hundred ten eyes (100%) reached final anatomical success. The mean operative time was 50.55 min. Multivariate analyses were performed with best model selection principle based on general linear model by Akaike Information Criteria for detecting possible factors related to operation time, and with multivariate logistic regression analysis for revealing probable clinical parameters which might influence the anatomical outcome after first operation and final visual outcome. Intraoperative cryopexy and multiple breaks increased operative time significantly. More favorable BCVA was significantly correlated with shorter operation time and the preoperative macula-on status. Multivariate logistic regression on the group of patients who have received the cataract surgery revealed that the pre-operative BCVA is a significant factor which can predict the visual outcome after MIVS. Conclusions The outcome of primary RRD repaired by MIVS using the Lumera and Resight sutureless WAVS was not inferior to any other published method. This instrument combination resulted in a relatively rapid and comfortable procedure without serious postoperative complications. Cryopexy and multiple breaks affected operative time significantly. Shorter operative times and preoperative macula-on status are associated with better final visual outcomes.

Purpose: To review the clinical features, diagnosis, and treatment of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) and to report a case with the use of ultra-widefield fluorescein angiography (UWFA) for confirming the precise staging of IRVAN and aid in early treatment. The patient improved after being treated with intravitreal aflibercept injection. Results: A 26-year-old female complained of progressive blurred vision OD for one week. Her BCVA was 0.6 OD and 1.0 OS. Fundus examination showed vitritis, retinal hemorrhage, and vasculitis over bilateral eyes. Fluorescein angiography (FA) with a 55 degree of view revealed aneurysmal dilations of the peripapillary arteriole, peripapillary focal leakage, venous leakage, and capillary nonperfusion area. Stage 2 IRVAN was impressed OU. Oral prednisolone was administered. After four months, she experienced decreased visual acuity OS. Optical coherence tomography (OCT) revealed subretinal and intraretinal fluid with hyperreflective material. One posterior subtenon triamcinolone and one intravitreal aflibercept injection were performed OS, and macular edema subsided. A 105-degree ultra-widefield fluorescein angiography (UWFA) showed multiple peripheral background hypofluorescence areas corresponding to capillary nonperfusion. Retinal neovascularization (NV) was found OS, which had not been revealed by the previous 55-degree FA. Stage 3 IRVAN was made OS and panretinal laser photocoagulation (PRP) was performed. Oral prednisone and cyclosporine were prescribed. Her vision improved to 1.0 OU. Conclusion: UWFA provides visualization of peripheral retinal pathology and for precise staging. It also had direct implications in the follow-up and treatment strategy.

Background and Objectives: Intravitreal injections (IVI) of vascular endothelial growth factor (VEGF) inhibitors are guideline-indicated treatments for diabetic macular edema (DME). However, some recent data have suggested that IVI VEGF inhibitors might, through systemic absorption, lead to a reduction in renal function. Our study aims to compare changes in glycated hemoglobin A1c (HbA1c) and estimated glomerular filtration rate (eGFR) between patients who received IVI ranibizumab and aflibercept treatment and patients who have not received IVI treatments. Materials and Methods: There were 17,165 DME patients with documented ophthalmology visits in the China Medical University Hospital-Clinical Research Data Repository. Those with a history of ESRD or bevacizumab treatment history, and those with missing information on HbA1c or eGFR, were excluded. After matching by age (±2 years), gender, and the year of clinical visit, 154 patients with medical treatment (including ranibizumab and aflibercept) and 154 patients without medical treatment were included in the study. The difference between HbA1c and eGFR at baseline and 3 and 12 months after the index date between the two groups was assessed. Results: Mean HbA1c and eGFR decreased between baseline and 12 months after the index date in both groups (p < 0.05). Compared with the non-treatment group, the treatment group had significantly lower HbA1c 3 and 12 months after the index date. There was no significant difference in eGFR between the two groups. In the generalized estimating equations (GEE) model, HbA1c in the treatment group was lower than the non-treatment group (−0.44%, 95% CI = −0.75, −0.14), but eGFR was similar after adjusting for age, gender, and index-year. HbA1c and eGFR decreased with the time in the adjusted GEE model (p < 0.0001) in both groups. Conclusions: This study showed that eGFR decreased with age and time and was not related to IVI anti-VEGF treatments in our tertiary referral hospital. IVI anti-VEGF therapy was also associated with better HbA1c control. It is suggested that DME patients can receive intravitreal VEGF inhibitors without inducing more renal impairment.

Objective: We report the tri-center 1-year outcomes of a treat-and-extend (T&E) regimen in four-week intervals with ranibizumab for diabetic macular edema (DME).Methods: In this retrospective study, all eyes received 3 monthly loading injections of 0.5 mg ranibizumab, followed by a T&E regimen for DME. Regression models were used to evaluate the associating factors for visual and anatomical outcomes.Results: Ninety one eyes from 64 patients were enrolled. Mean LogMAR best-corrected visual acuity (BCVA) improved from 0.58 at baseline to 0.36 at month 12 and mean central retinal thickness (CRT) decreased from 411 μm at baseline to 290 μm at month 12. Younger age and eyes having thinner baseline CRT, with ellipsoid zone disruption (EZD), and without epiretinal membrane (ERM) were associated with better final CRT. Moreover, eyes with thicker baseline CRT tend to receive more injections. Among the parameters, only having ERM or EZD was associated with significant BCVA recovery.Conclusions: A T&E regimen with ranibizumab by 4-week intervals is effective in improving BCVA and reducing CRT with efficacy notable starting from the third month. Clinical parameters including age, initial CRT, and presence of ERM or EZD significantly influenced therapeutic outcomes. Moreover, the presence of ERM should not preclude DME patients from receiving anti-VEGF therapy. Future studies with larger cohorts are warranted.

Introduction: To evaluate the effectiveness and safety of intravitreal dexamethasone (DEX) implants in refractory diabetic macular edema (DME) treated by intravitreal ranibizumab.Materials and Methods: We retrospectively analyzed DME patients who received DEX implant treatment after being refractory to at least 3 monthly intravitreal ranibizumab injections. The main outcomes were best-corrected visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP).Results: Twenty-nine eyes of 26 patients who had previously received an average of 8.1 ± 4.4 ranibizumab injections were included. Patients received between one and three DEX implants during 12.4 ± 7.4 months of follow-up. The mean final CRT significantly decreased from 384.4 ± 114.4 μm at baseline to 323.9 ± 77.7 μm (p = 0.0249). The mean final BCVA was 51.4 ± 21.3 letters, which was not significant compared to baseline (44.9 ± 30.2 letters, p = 0.1149). Mean IOP did not increase significantly. All patients tolerated the treatment well without serious adverse events. Higher baseline CRT and worse BCVA correlated with better therapeutic responses.Conclusion: Switching to DEX implant is feasible and safe for treating patients of DME refractory to intravitreal ranibizumab in real world. Further larger-scale or multicenter studies would be conducted to explore different DEX treatment strategies for DME, such as first-line or early switch therapy, for better BCVA improvement.

We report the rescue effect of intravitreal aflibercept injections on retinal neovascularization and macular edema due to Eales disease. Case 1 was a 36-year-old female. Intravitreal aflibercept was administered as rescue therapy after persistent retinal neovascularization following retinal photocoagulation, periocular triamcinolone, and intravitreal ranibizumab injection. Retinal neovascularization initially regressed, but recurred after 5 months along with macular edema. Two more intravitreal aflibercept injections were given, and retinal neovascularization with macular edema regressed. Her vision improved to 20/25 and remained stable after 43 months. Case 2 was a 27-year-old female. Intravitreal aflibercept was administered after persistent retinal neovascularization and macular edema following periocular triamcinolone injection. The macular edema initially subsided but recurred after 3 months. Intravitreal aflibercept injections were then administered once every three months to maintain her vision 20/20. The patient has been followed up for 28 months. Intravitreal aflibercept was effective as a rescue therapy in the treatment of Eales disease to regress retinal neovascularization, though repeated injections were necessary in cases of recurrence.

This prospective comparative case series aims to compare best-corrected visual acuity (BCVA), retinal microvasculature, and retinal structural changes in patients treated with either ranibizumab or aflibercept for macular edema (ME) secondary to treatment-naïve branch retinal vein occlusion (BRVO) by optical coherence tomography angiography (OCTA). Ten patients were enrolled with macular capillary density of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and foveal avascular zone (FAZ) measured in both eyes before and after treatment. Final central retinal thickness and BCVA improved significantly (p < 0.05), and densities of SCP and DCP of BRVO sectors were significantly lower at baseline than fellow eye counterparts and remained persistently lower during treatment, particularly in the aflibercept group (p < 0.05). SCP density, DCP density of both BRVO sectors (p = 0.0001, p < 0.0001), and non-BRVO sectors (p < 0.0001, p < 0.0001) were significantly correlated with final BCVA for diseased eyes. Using multivariate general linear model analysis, and including OCTA parameters only, but not all of the available clinical data, DCP density of BRVO sectors in both eyes was the most predictive factor for final visual outcome (probability p < 0.0001). OCTA offered further qualitative and quantitative evaluation of treatment-naïve BRVO. Judging by OCTA parameters, not only in the diseased eye but also in the fellow eye, DCP density of BRVO sectors was the most predictive factor of final visual outcome.

The is a poem inspired by my conversations with several patients burdened with chronic pain and who found themselves dependent on opioids for relief. For these patients, pain is an omnipresent and debilitating force permeating their existence, curbed only by the use of opioids; I was struck by the vivid language these patients would use when describing their relationship with pain and with these medications?some of which are directly used in this poem. They would simultaneously express a torn affection for the opioids, while recognizing the danger of continuing to use them. The poem is structured as an imaginary conversation between the patient/narrator and a personification of the medication/addiction. With this poem, I hope to share with readers a sense of the nuanced struggle and affliction I witnessed.

PURPOSE: The aim of this study is to evaluate the clinical use of ultra-widefield angiography (UWFA) in uveitis. MATERIALS AND METHODS: We showed the UWFA and traditional 55° fluorescein angiography (FA) of four cases with Eales' disease, idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome, Behçet's disease, and idiopathic panuveitis in a tertiary medical center. Comparison of UWFA with traditional 55°FA in the diagnosis and management of uveitis and review of the literature is also presented. RESULTS: Ultra-widefield FA revealed far-peripheral vascular imaging. This information would not have been easily obtained from traditional FA. With more information of the peripheral retina, it may facilitate appropriate diagnosis and monitoring, and the management may be revised. CONCLUSION: University of Western Australia played an important role to confirm the diagnosis of uveitis and to determine the corresponding treatment.

Patella alta is a common pathoanatomic contributor to various knee pathologies, including patella instability, fat pad impingement, and patellar tendinopathy. The 2 most common surgical techniques used to treat patella alta include a distalizing tibial tubercle osteotomy and patella tendon imbrication. Although these 2 surgical techniques are effective, they are associated with significant surgical morbidity and a limiting postoperative course with prolonged rehabilitation. In this Technical Note, we propose a simple means of distalizing the patella and improving patella maltracking via the addition of a medial patellotibial ligament reconstruction. The described technique is easy to perform, has little postoperative morbidity, and is familiar to most knee surgeons who perform anterior cruciate ligament reconstruction.