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Background/aimsTo evaluate the diagnostic accuracy of spectral-domain optical coherence tomography (SD OCT) combined with OCT angiography (OCTA) for myopic myopic macular neovascularisation (MNV) activity.MethodsBoth eyes of patients with myopic MNV diagnosed with fluorescein angiography (FA), SD OCT and OCTA were assessed by unmasked investigators. The images were deidentified and randomised before graded by masked investigators, who determined the presence of active myopic MNV by using SD OCT together with OCTA without FA and by FA alone, respectively. The findings of masked investigators were compared with unmasked investigators.Results213 eyes of 110 patients comprising 499 imaging episodes were eligible for grading. For diagnosing new-onset myopic MNV without FA, combined use of SD OCT and OCTA had a sensitivity of 0.94, specificity of 0.84 and area under the curve (AUC) of 0.92. FA had a sensitivity of 0.52 (p<0.01), specificity of 0.80 (p=0.38) and AUC of 0.66 (p<0.01). For recurrent myopic MNV, the combination of SD OCT and OCTA had a sensitivity of 0.98, specificity of 0.78 and AUC of 0.88. FA had a sensitivity of 0.50 (p=0.04), specificity of 0.76 (p=0.85) and AUC of 0.63 (p=0.01). Myopic traction maculopathy was more frequently associated with recurrent myopic MNV (p<0.01).ConclusionSD OCT with dense volumetric scan was highly sensitive for diagnosing myopic MNV. The addition of OCTA improved the diagnostic specificity without FA. Monitoring of the longitudinal changes on SD OCT and judicious use of FA is a reliable surveillance strategy for myopic MNV.

PurposeTo evaluate the efficacy of a combined macular buckle under direct vision and 23-gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in refractory macular hole retinal detachment (MHRD) with extreme high axial myopia.DesignProspective, randomised controlled study.ParticipantsThe study included 98 eyes of 98 patients of MHRD with extreme high axial (>30 mm) myopia.InterventionPatients were randomly assigned to undergo PPV with ILM peeling (group 1, n=52) or PPV with ILM peeling combined with macular buckle under direct vision (group 2, n=46).Main outcome measuresComplete ocular examination included best-corrected visual acuity (BCVA) (LogMAR), applanation tonometry, optical biometry, slit-lamp biomicroscopy, colour fundus photography, ultrasound examination and optical coherence tomography at baseline and every follow-up visit.ResultsInitial retinal reattachment rate was significantly higher in group 2 than in group 1 at 12-month postoperatively (χ2 test, p=0.020). Macular hole closure rate in group 2 was significantly higher than that in group 1 at 3, 12, 18 and 24 months postoperatively (Fisher's exact test, p<0.05). In initial retinal reattachment cases, the mean BCVA decreased significantly in group 2 than in group 1 at 3 months postoperatively (Wilcoxon matched pairs signed rank test, p=0.036), and had increased significantly in group 2 than in group 1 since 6 months postoperatively (Wilcoxon matched pairs signed rank test, p<0.05). Mean axial lengths in group 2 were significantly shorter than that of group 1 at each follow-up time point (Wilcoxon matched pairs signed rank test, p<0.05).ConclusionsCombined macular buckle under direct vision and PPV with ILM peeling is more effective in treatment of MHRD with extreme high axial (>30 mm) myopia.

Purpose To report the long-term results of anti-vascular endothelial growth factor (VEGF) therapy for choroidal neovascularization (CNV) secondary to pathological myopia (PM). Methods Prospective interventional study with extension phase. Eyes affected by CNV due to PM included. All patients received an intravitreal bevacizumab injection (1.25 mg/0.05 ml) at baseline. Re-treatment was considered at each follow-up visit. Results The study included 101 consecutive eyes of 86 patients. All patients reached 24 months of follow-up. After 24 months, mean best-corrected visual acuity (BCVA) improvement was −0.13 (95 % CI: −0.2; −0.05) logMAR (p < 0.001) and central retinal thickness (CRT) decreased on average by 67 (95 % CI: 27; 102) μm (p < 0.01). The chorioretinal atrophy (CRA) area increased significantly after 2 years of follow-up (+7.82 mm 2 , p < 0.0001). Patients received 4.1 treatments, on average. Thirty-two eyes were included in the extension phase (from 24 to 60 months of follow-up). Visual acuity improved on average by −0.05 (95 % CI: −0.2; 0.1) logMAR (p > 0.05) compared to baseline. Mean reduction in CRT was 102 (95 % CI: 64;141) μm (p < 0.01). The CRA area enlarged significantly after 5 years of follow-up (+14.15 mm 2 , p < 0.0001). Patients received a mean of 6.7 treatments in 60 months. Conclusions An individualized regimen with intravitreal bevacizumab to treat CNV secondary to PM resulted in BCVA improvement and CRT decrease at 2 and 5 years. The main visual benefit was obtained between month 3 and month 24. A gradual loss of the initial BCVA gain was observed starting from month 30 to month 60 due to progression of CRA.

Purpose To assess the use of aflibercept for the treatment of subfoveal myopic choroidal neovascularization (CNV). Methods Thirty-two patients (33 eyes) with myopic subfoveal CNV were consecutively enrolled in this prospective open-label case series. All patients were treated with an off-label 2-mg intravitreal injection of aflibercept. After the first injection, administration of aflibercept followed an “on demand” pro re nata (PRN) regimen. The primary outcome was change in best-corrected visual acuity (BCVA) score after 12 months. Results Mean follow-up was 12 months, and the median number of aflibercept injections was 2.0 (range 1–4). Overall, mean BCVA improved from 0.59 ± 0.37 logMAR at baseline to 0.38 ± 0.33 logMAR at 12 months, a change of −0.21 ± 0.23 logMAR ( p  < 0.0001), and from 70.5 ± 18.5 to 81.1 ± 16.4 letters, a change of 10.6 ± 11.4 ( p  < 0.0001). Improvements were similar among patients irrespective of previous PDT. The Increase in BCVA was greater in younger patients (aged < 50 years) and those with baseline BCVA of ≤ 75 letters. Conclusion Intravitreal aflibercept in a PRN regimen is effective for the treatment of myopic CNV, with no apparent short-term safety effects. Treated eyes had BCVA gains after 12 months, with a median of two injections.

Background To demonstrate the efficacy of intravitreal ranibizumab (IVR) in combination with reduced-fluence photodynamic therapy (RF-PDT) in patients with choroidal neovascularization (CNV) secondary to pathologic myopia. Methods Sixty patients affected by myopic CNV (mCNV) were randomized to receive either ranibizumab 0.5 mg monotherapy (RM; n  = 20), standard fluence PDT (SF-PDT, n  = 20) or RF-PDT combination therapy ( n  = 20). Subsequently, IVR was injected as needed. All patients were evaluated for 48 weeks. Results Mean BCVA change at 48 weeks was + 0.2 and +15 letters with SF or RFPDT plus ranibizumab, respectively, compared with +16.8 letters with RM. At 48 weeks, mean central foveal thickness (CFT) decrease from baseline was 58 ± 15 μm, 91.4 ± 43.8 μm, and 85 ± 41.5 μm for the verteporfin SF, RF and RM groups, respectively. Macular sensitivity improvement was + 0.4 db, + 1.9 dB and + 2.7 dB for the verteporfin SF, RF and RM groups, respectively. Conclusions Ranibizumab monotherapy or combined with RF-PDT improved BCVA and macular sensitivity in patients affected by mCNV, whereas CFT results were reduced. SF-PDT combination regimen mostly stabilized vision at 48 weeks. Among all groups, the RF-PDT seemed to reduce the number of ranibizumab retreatments.

AimTo assess the efficacy and safety of ranibizumab in the treatment of choroidal neovascularisation (CNV) caused by pathologic myopia (PM).DesignProspective, multicentre, interventional case series.Methods40 eyes of 39 consecutive patients with PM and CNV were treated with ‘on demand’ intravitreal injection of ranibizumab 0.5 mg. Final best corrected visual acuity (BCVA) and its change from baseline were the main outcome measures. Changes in optical coherence tomography (OCT) central retinal thickness (CRT) were a secondary outcome.ResultsMean age was 53±13 years and mean refractive error –13.5±6.5 D. Median follow-up was 13.3±2 (range 12–18) months. Fifteen eyes (37.5%) had previously been treated with photodynamic therapy (PDT). The mean baseline logarithm of the minimum angle of resolution (logMAR) BCVA (Early Treatment Diabetic Retinopathy Study (ETDRS) vision chart) was 0.68±0.34 (Snellen equivalent 20/131) and 21±16 letters. The final mean logMAR BCVA was 0.27±0.2 (p = 0.008) (20/42) and 40.5±14 letters (p = 0.01). Mean final VA improved in 82.5% of patients, in 60% by 3 or more lines (median number of lines gained 2.9). Even six out of seven cases of low vision (≤1.1 logMAR) at the final examination has improved vision. Mean OCT CRT reduced from 218±70 to 175±46 μm (p 0.02). Age and previous PDT did not influence the results (p>0.05). The mean number of injection was 2.8±1.2 (range 1–6). No ocular or systemic side effects were observed.ConclusionRanibizumab was an effective treatment for stabilising and improving vision with a low number of injections in 92.5% of patients with myopic CNV in a long-term follow-up.

AimsTo investigate aqueous humour changes in vascular endothelial growth factor (VEGF) and pigment epithelium-derived factor (PEDF) levels in patients with choroidal neovascularisation (CNV) secondary to pathological myopia (mCNV) before and after intravitreal ranibizumab injection (IVR).MethodsThis was a prospective, case–control study investigating aqueous levels of VEGF and PEDF in eyes with mCNV treated with IVR.ResultsMean VEGF and PEDF levels in the aqueous humour of control patients were 25.7±4.9 pg/mL and 12.6±3.5 ng/mL, respectively. Lower levels of both VEGF (19.5±5.4 pg/mL) and PEDF (4.7±2.2 ng/mL) were found in patients with mCNV before IVR. After IVR, aqueous VEGF levels significantly reduced to 6.5±2.7 pg/mL, while PEDF levels significantly increased to 35.8±11.4 ng/mL. VEGF and PEDF levels significantly correlated with each other, and with best-corrected visual acuity and central retinal thickness.ConclusionsThe VEGF and PEDF levels in aqueous humour were significantly lower in the myopic group than in controls. Moreover, IVR resulted in reduced VEGF and increased PEDF levels in patients with mCNV. In mCNV, neovascularisation is associated with inappropriate VEGF and PEDF expression. A balance between VEGF and PEDF is crucial to prevent CNV development.Trial registration numberNCT02175940.

Purpose The aim of this study was to evaluate the cost effectiveness of ranibizumab compared with verteporfin photodynamic therapy (vPDT) or no treatment (observation) in patients with visual impairment due to myopic choroidal neovascularization (CNV). Methods A Markov model with health states defined by best-corrected visual acuity and a 3-month cycle length was developed. It had a healthcare provider (UK National Health Service and personal social services) perspective, a lifetime time horizon, and was based on 2011 prices; future costs and health outcomes were discounted at 3.5 % per annum. Baseline characteristics were based on the phase III RADIANCE (Ranibizumab and vPDT Evaluation in Myopic CNV) study, and year 1 health-state transitions were based on this and the VIP (Verteporfin in Photodynamic Therapy) study. Extensive sensitivity analyses tested the robustness of the model. Results The lifetime cost of treating myopic CNV with ranibizumab was £12,866, whereas vPDT and observation were associated with total costs of £14,421 and £8,163, respectively. Ranibizumab treatment produced higher cumulative quality-adjusted life-years (QALYs; 12.99) than vPDT (12.60) or observation (12.45). Ranibizumab treatment was therefore dominant, with greater health gains and lower overall costs than vPDT. Ranibizumab was cost effective compared with observation, with an incremental cost-effectiveness ratio of £8,778/QALY. In the probabilistic sensitivity analysis, ranibizumab had a 100 % and 88 % probability of being cost effective compared with vPDT and observation, respectively, at a willingness-to-pay threshold of £20,000/QALY. Conclusion This study indicates that ranibizumab therapy is dominant over vPDT for the treatment of visual impairment due to CNV secondary to pathologic myopia in the UK healthcare setting and cost effective compared with observation.

Purpose To determine the pre-treatment ocular factors significantly associated with the visual outcome 24 months after intravitreal bevacizumab (IVB) for myopic choroidal neovascularization (mCNV). Methods A total of 23 eyes of 23 patients with mCNV were treated with IVB followed by as needed therapy. The efficacy of IVB was evaluated by the best-corrected visual acuity (BCVA) at 24 months after the initial treatment. Forward stepwise multiple linear regression analyses were performed to evaluate the influence of pre-treatment factors on the BCVA and the improvement of the BCVA at 24 months. Results The mean pre-IVB BCVA was 0.74±0.30 logarithm of the minimum angle of resolution (logMAR) units, and it improved to 0.43±0.31 logMAR units after 1 month ( P <0.001, paired t -test). The improvement was maintained at 24 months (0.46±0.40, P <0.005). The mean number of IVB performed during the 24 months was 1.35±0.71. Forward stepwise regression analysis showed that the pre-IVB CNV size (standardized β =0.52, P <0.01) and BCVA (standardized β =−0.44, P <0.05) significantly affected the visual acuity change after 24 months. The CNV size was the only factor that significantly affected the BCVA after 24 months (standardized β =0.56, P <0.01). Conclusions IVB with as needed therapy for mCNV led to a rapid and sustained visual improvement. Smaller CNV size was a significant prognostic factor that predicts better visual acuity. Patients with lower pre-treatment BCVA had better visual recovery than those with better pre-treatment BCVA, however, this may be due to a ceiling/floor effect.