Publications by authors named "Fabiana Q Silva"

27 Publications

  • Page 1 of 1

Twenty-Four-Month OCTA Assessment in Diabetic Patients Undergoing Fixed-Interval Intravitreal Aflibercept Therapy.

Ophthalmic Surg Lasers Imaging Retina 2020 08;51(8):448-455

Background And Objective: Evaluate capillary perfusion density (CPD) in patients with diabetic macular edema (DME) undergoing fixed intravit-real aflibercept injections (IAI) through 24 months.

Patients And Methods: Prospective, interventional, single-arm study enrolling 20 patients with persistent DME. Patients received IAI every 4 weeks until DME resolution followed by extension to every 8 weeks. Optical coherence tomography angiography was obtained at baseline, 6, 12, and 24 months.

Results: Sixteen of 20 eyes completed the study. Baseline mean central subfield thickness was 420 µm, which improved to 251 µm (P < .001). The mean best-corrected visual acuity (BCVA) improved by 5.5 letters (P = .042). The whole superficial CPD decreased by 5.3% (P = .001) and the deep CPD decreased by 4.4% (P = .009). Better BCVA correlated with less CPD loss within the superficial parafovea (r = +0.66 [0.23, 0.88]; P = .006) and whole (r = +0.60 [0.12, 0.85]; P = .017) areas.

Conclusion: Superficial and deep CPD decreased despite fixed IAI through 24 months. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:448-455.].
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http://dx.doi.org/10.3928/23258160-20200804-05DOI Listing
August 2020

Prevention of Macular Edema in Patients With Diabetic Retinopathy Undergoing Cataract Surgery: The PROMISE Trial.

Ophthalmic Surg Lasers Imaging Retina 2020 03;51(3):170-178

Background And Objective: To determine the safety and efficacy of intravitreal aflibercept injection (IAI) in patients with diabetic retinopathy (DR) in the prevention of macular edema (ME) following cataract surgery.

Patients And Methods: This phase 2, prospective, interventional, single-masked, randomized trial at a single academic center included 30 patients who were 18 years of age or older with nonproliferative DR and undergoing cataract surgery with phacoemulsification. Patients received 2 mg intravitreal aflibercept (0.05 mL) or sham injection during cataract surgery. Main outcome measures included treatment adverse events (AEs), best-corrected visual acuity (BCVA), and incidence of ME (defined as presence of cystoid abnormalities as detected by optical coherence tomography at any follow-up visit), a 30% or greater increase from preoperative baseline in central subfield macular thickness, or a BCVA decrease of more than 5 ETDRS letters from Day 7 due to retinal thickening.

Results: There were similar incidences of AEs between the two groups and no clinically serious ocular AEs in either group. The IAI group had fewer ME events at Day 14 (13% vs. 53%; P = .022), but there was no significant difference in ME events at Day 30 (27% vs. 60%; P = .057), Day 60 (27% vs. 60%; P = .057), or Day 90 (40% vs. 67%; P = .161). Compared to the study group, the control group had a significantly greater increase in central subfield thickness (CST) at Day 30 (50.05 μm vs. 7.95 μm; P = .040) and Day 60 (56.45 μm vs. 3.02 μm; P = .010). However, the difference in CST between groups was no longer significant at Day 90 (50.31 μm vs. 18.48 μm; P = .12). There were no significant differences in BCVA gains between the IAI and sham group at the end of the follow-up period (Day 90, ETDRS letters: 9.88 vs. 8.52; P = .66).

Conclusions: Use of IAI in patients with DR for prevention of ME following cataract surgery showed no significant AEs. Although there were significant differences in ME incidence and retinal thickness at periods of time, there was no clinically meaningful benefit in terms of VA. Further larger trials are needed to validate these findings. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:170-178.].
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http://dx.doi.org/10.3928/23258160-20200228-06DOI Listing
March 2020

Diabetic macular edema treated with intravitreal aflibercept injection after treatment with other anti-VEGF agents (SWAP-TWO study): 6-month interim analysis.

Int J Retina Vitreous 2019 23;5:17. Epub 2019 Jul 23.

1Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, i32, Cleveland, OH 44195 USA.

Background: Diabetic macular edema (DME) is an important cause of vision loss and despite the anatomical and functional improvement achieved with treatment, there are reports of persistent DME regardless of continuous anti-VEGF therapy. The purpose of this study is to examine the effect of patients with DME previously treated with other anti-VEGF agents who are transitioned to intravitreal aflibercept (IAI) on a fixed dosing regimen.

Methods: This prospective study included 20 patients presenting with DME with a history of previous anti-VEGF treatment with ranibizumab or bevacizumab. Patients received a 2 mg (0.05 mL) IAI every 4 weeks until no evidence of fluid by optical coherence tomography (OCT) followed by a fixed dosing schedule of 2 mg IAI once every 8 weeks through 24 months. There was a pre-planned interim analysis of the mean absolute change from baseline central foveal thickness at month 6 as measured by OCT. Secondary outcomes included mean change from baseline in ETDRS visual acuity and anatomic parameters. Optical Coherence tomography angiography (OCTA) capillary perfusion density (CPD) after transitioning to IAI therapy were also reported.

Results: Average central subfield thickness on OCT at baseline was 419.7 ± 92.0 and improved to 303.8 ± 73.1 at 6-months ( < 0.001). At 6 months after IAI treatment, BCVA increased + 1.5 letters from baseline ( = 0.38). OCTA CPD analysis revealed significant increase from baseline in the foveal avascular zone in non-proliferative diabetic retinopathy group ( = 0.02).

Conclusions: Patients with prior anti-VEGF therapy who were transitioned to IAI therapy revealed significant anatomic improvements through 6 months. Treatment of Diabetic Macular Edema With Aflibercept in Subjects Previously Treated With Ranibizumab or Bevacizumab (SwapTwo), Trial registration number: NCT02559180. Date of registration: September 24, 2015.https://clinicaltrials.gov/ct2/show/NCT02559180.
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http://dx.doi.org/10.1186/s40942-019-0167-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647124PMC
July 2019

Long-Term Assessment of Macular Atrophy in Patients with Age-Related Macular Degeneration Receiving Anti-Vascular Endothelial Growth Factor.

Ophthalmol Retina 2018 06 19;2(6):550-557. Epub 2017 Dec 19.

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Purpose: Although intravitreal anti-vascular endothelial growth factor (VEGF) injection has become the mainstay treatment for neovascular age-related macular degeneration (nAMD), emerging studies suggest that anti-VEGF may be correlated with the development of macular atrophy (MA) in chronic therapy. The purpose of the current study is to determine the prevalence and progression of MA in nAMD treated with chronic anti-VEGF in a routine clinical practice.

Design: Retrospective cohort.

Participants: Patients with nAMD who were previously treatment-naïve and treated with anti-VEGF at the Cole Eye Institute for at least 4 years.

Methods: This is chart review on anti-VEGF treated patients with nAMD with baseline and yearly follow-up spectral domain-OCT for at least 4 years. Retinal pigment epithelium subillumination analysis was used to automate identification of atrophy. Segmentation errors were manually corrected by 4 expert raters using a standardized grading protocol to quantify MA size. Patient baseline characteristics and treatment course were analyzed to identify predictive factors for the development of MA.

Main Outcome Measures: MA growth rate and prevalence in cohorts with and without baseline atrophy.

Results: A total of 79 eyes from 66 patients (79.8±7.4 years, 63% were female) with nAMD and 4 years of follow-up with anti-VEGF injections were identified. The mean baseline visual acuity was 0.48±0.25 logarithm of the minimum angle of resolution (20/60 Snellen equivalent), and the mean final visual acuity was 0.48±0.49 logarithm of the minimum angle of resolution (20/44 Snellen equivalent, P = 0.23). The average number of injections was 19.8±9.8. MA was observed in 12.7% of eyes at baseline with an average annual growth rate of 0.7±0.5 mm. In eyes without baseline MA, atrophy developed in 53.6% eyes by year 4 with a growth rate of 0.2±0.4 mm per year. Multiple linear regression analysis revealed that the progression of MA was positively correlated with age (R = 0.02, P = 0.009).

Conclusions: More than half of patients with nAMD treated with anti-VEGF injections for 4 years developed new MA. Atrophy progression was most strongly correlated with age, which suggests that baseline disease characteristics may be more predictive of MA progression than cumulative anti-VEGF treatment.
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http://dx.doi.org/10.1016/j.oret.2017.10.010DOI Listing
June 2018

Difference in Treatment Effect Between Intravitreal Aflibercept Injection and Laser by Baseline Factors in Diabetic Macular Edema.

Ophthalmic Surg Lasers Imaging Retina 2019 03;50(3):167-173

Background And Objective: To evaluate the effect of baseline factors on differences in vision gains with intravitreal aflibercept injection (IAI) versus laser control in patients with diabetic macular edema (DME).

Patients And Methods: This was an integrated post-hoc subanalysis of two phase 3 trials (VISTA, VIVID) in patients with DME. Least square (LS) mean differences of patients treated with IAI compared to laser control in best-corrected visual acuity (BCVA) change from baseline at week 100 were evaluated for association with baseline demographics and baseline systemic disease characteristics.

Results: At week 100, LS mean differences in BCVA change from baseline with IAI compared to laser control were not significant for association with baseline age, gender, and race or status of glycosylated hemoglobin, body mass index, renal impairment, hypertension, cerebrovascular disease, and ischemic heart disease.

Conclusion: Vision gains with IAI were significantly greater than laser control and were not influenced by demographics and systemic disease control at baseline. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:167-173.].
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http://dx.doi.org/10.3928/23258160-20190301-06DOI Listing
March 2019

Characterization of Patients With Geographic Atrophy in Routine Clinical Practice.

Ophthalmic Surg Lasers Imaging Retina 2019 02;50(2):93-98

Background And Objective: Geographic atrophy (GA) affects millions of patients with age-related macular degeneration (AMD) worldwide, leading to significant, irreversible visual impairment. This study aims to characterize the visual impairment of patients with GA in a routine clinical practice.

Patients And Methods: This single-center, cross-sectional study used a novel natural language processing to select 1,045 GA cases utilizing the macula examination records from 19,359 patients with AMD.

Results: Patients were classified based on the diagnosis of the fellow-eye as follow: 502 in group 1 (GA:GA), 403 in group 2 (GA : choroidal neovascularization), and 234 in group 3 (GA : early / intermediate AMD). Best-corrected visual acuity (BCVA) in the affected eye was 50.3 (± 22.1) letters in group 1, 52.5 (± 21.3) letters in group 2, and 48.5 (± 23.6) letters in group 3 (P < .05). Visual impairment (ineligibility for an unrestricted driver license) was present in 70.5% of group 1, 59.7% of group 2, and 39.6% of group 3. Legal blindness (BCVA < 20 letters in the best-seeing eye) was seen in 2.2% of group 1, 3% of group 2, and 0.8% of group 3.

Conclusion: Differences in visual impairment between subgroups of patients with GA can be seen in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:93-98.].
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http://dx.doi.org/10.3928/23258160-20190129-05DOI Listing
February 2019

Baseline Ocular Characteristics of Patients Undergoing Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema.

Ophthalmic Surg Lasers Imaging Retina 2019 02;50(2):69-75

Background And Objectives: Patients with diabetic macular edema (DME) have variable anatomic and visual responses to anti-vascular endothelial growth (VEGF) treatments based on their presenting visual acuity (VA). The aim of study is to report the baseline ocular and imaging characteristics of patients presenting with DME who were treatment-naïve and who initiated anti-VEGF in routine clinical practice.

Patients And Methods: Single-center, cross-sectional study of 638 patients. Subjects were divided into two VA groups: Early Treatment Diabetic Retinopathy Study (ETDRS) less than 70 and ETDRS greater than 70 and ocular variables were compared between groups.

Results: Average central subfield thickness (CST) was 363.5 μm, cube volume was 11.7 mm, and cube average thickness (CAT) was 326.1 μm. Additionally, 21.5% had subretinal fluid (SRF), and 50.5% had hard exudates on presentation. Eyes with ETDRS less than 70 had greater CAT (338.5 μm vs. 313.2 μm; P < .001), greater cube volume (12.2 mm vs. 11.3 mm; P < .001), greater CST (383.5 μm vs. 350.0 μm; P < .001), and SRF (25.5% vs. 17.3%; P = .012). Furthermore, 7.64% had glaucoma, 1.3% had dry age-related macular degeneration, 4.5% of patients were vitrectomized, and 28.7% were pseudophakic. Regarding diabetic stage, 37% had proliferative diabetic retinopathy (PDR) and 63% presented with nonproliferative diabetic retinopathy. Patients presenting with ETDRS less than 70 were more likely to have a history of vitrectomy (7.1% vs. 1.9%, P = .002) and presence of PDR (42.3% vs. 31.4%, P = .004).

Conclusion: The results describe a population of patients from a routine clinical practice not entirely represented in clinical trials, with key differences in ocular characteristics seen between VA groups. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:69-75.].
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http://dx.doi.org/10.3928/23258160-20190129-02DOI Listing
February 2019

Characterization of the Systemic Findings of Patients Undergoing Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in Routine Clinical Practice.

Ophthalmic Surg Lasers Imaging Retina 2019 01;50(1):16-24

Background And Objectives: Previous studies have validated that baseline visual acuity (VA) can predict a variance response to anti-vascular endothelial growth factor (VEGF) treatment. However, little is known about the initial systemic presentation of diabetic macular edema (DME) in clinical practice. The aim of this study is to report the baseline systemic findings of patients presenting with DME who received anti-VEGF in clinical practice.

Patients And Methods: A retrospective chart review of patients with DME presenting between April 2012 and December 2016 was performed.

Results: Data from 638 patients were retrieved. The average patient age was 63.1 years (±11.6 years), and 53% were male. There were 95.6% type II diabetics with an average HgA1c of 8.1% (range: 5.1% to 14.5%). Insulin use was present in 67%, biguanides in 43%, sulfonylureas in 32.8%, DDP4 inhibitors in 11.8%, thiazolidinediones in 3.9%, and D-phenylalanine derivatives in 0.94%. Hypertension was present in 78.4% of patients, cardiac comorbidities in 29.3%, peripheral vascular disease in 16.5%, and renal insufficiency in 22.6%. Patients were then split into two different cohorts based on VA (ETDRS < 70 and ETDRS ≥ 70), and variables were compared between groups.

Conclusion: It was shown that older age, hypertension, elevated creatinine, elevated high-density lipoprotein cholesterol, and decreased biguanide use were positively associated with worse presenting VA. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:16-24.].
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http://dx.doi.org/10.3928/23258160-20181212-03DOI Listing
January 2019

Outer Retinal Tubulation and Neovascular Age-Related Macular Degeneration: A Review of the Pathogenesis and Clinical Implications.

Ophthalmic Surg Lasers Imaging Retina 2018 11;49(11):870-876

Outer retinal tubulation (ORT) is a retinal finding that can mimic intraretinal fluid and has been identified with spectral-domain optical coherence tomography in patients with age-related macular degeneration (AMD). The purpose of this review is to summarize the findings related to the pathogenesis of ORT and its clinical implications. Studies reporting the pathogenesis and the clinical implications of ORT in patients with AMD were identified and summarized. A total of 18 studies were included in this review. The body of evidence to date regarding ORT in patients with AMD indicates that ORT is a structure associated with advanced macular diseases that does not require anti-vascular endothelial growth factor treatment. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:870-876.].
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http://dx.doi.org/10.3928/23258160-20181101-08DOI Listing
November 2018

Association of Disorganization of Retinal Inner Layers With Visual Acuity Response to Anti-Vascular Endothelial Growth Factor Therapy for Macular Edema Secondary to Retinal Vein Occlusion.

JAMA Ophthalmol 2019 01;137(1):38-46

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.

Importance: Disorganization of retinal inner layers (DRIL) has demonstrated significant correlations with visual acuity (VA) in center-involved diabetic macular edema. In patients with retinal vein occlusion (RVO) and secondary macular edema, DRIL may be a useful biomarker in determining VA outcomes.

Objective: To examine whether DRIL at baseline and after treatment is associated with VA in RVO.

Design, Setting, And Participants: A retrospective review of records of 147 patients 18 years or older with treatment-naive branch RVO (BRVO), central RVO (CRVO), or hemispheric RVO (HRVO), with a minimum of 12 months of follow-up, who presented to a tertiary ophthalmic center from December 1, 2010, to January 1, 2016, was conducted. Data collection continued through January 2017. Exclusion criteria included active confounding retinal or ocular disease, history of pars plana vitrectomy, or prior intravitreal injections. Two masked graders calculated a DRIL score based on DRIL presence in 3 predefined regions on spectral-domain optical coherence tomography at baseline, 6 months, and 12 months. A third masked grader was used for discrepancies.

Exposures: Anti-vascular endothelial growth factor (AVF) therapy (ranibizumab, aflibercept, or bevacizumab) determined by the treating physician.

Main Outcomes And Measures: The DRIL score at baseline for determining VA outcomes and correlation of VA with changes in DRIL burden in response to AVF therapy.

Results: In the 147 patients (mean [SD] age, 68.9 [13.1] years; 75 [51.0%] female), baseline DRIL was seen in 91 eyes (61.9%). In the BRVO group but not the CRVO group, baseline DRIL was associated with lower baseline Early Treatment Diabetic Retinopathy Study (ETDRS) score (score of 66.7 for no DRIL vs 54.6 for DRIL, P = .002). Absence of DRIL at baseline in the CRVO/HRVO group correlated with greater VA gains at 6 months, adjusting for baseline VA (score change of 19.50 for no DRIL vs 12.72 for DRIL; P = .04). During 12 months, continued DRIL presence in BRVO was associated with less VA gain up to 6 months (score change of 6.2 for the DRIL increase group vs 18.6 for the DRIL decrease group vs 2.9 for the DRIL stable group; P = .02). Increasing DRIL scores in CRVO/HRVO were associated with reduced VA improvement at 6 months (score change of -0.12 for the DRIL increase group vs 16.90 for the DRIL decrease group vs 8.45 for the DRIL stable group; P = .002) and 12 months (score change of -1.91 for the DRIL increase group vs 17.83 for the DRIL decrease group vs 6.97 for the DRIL stable group; P < .001).

Conclusions And Relevance: Baseline DRIL presence and DRIL burden changes with AVF therapy for macular edema secondary to RVO may be useful biomarkers of ETDRS score improvements.
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http://dx.doi.org/10.1001/jamaophthalmol.2018.4484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440246PMC
January 2019

Repeatability of Split-Spectrum Amplitude-Decorrelation Angiography to Assess Capillary Perfusion Density Within Optical Coherence Tomography.

Ophthalmic Surg Lasers Imaging Retina 2018 09;49(9):e9-e19

Background And Objective: To evaluate the repeatability of retinal thickness and vascular density measurements using split-spectrum amplitude-decorrelation angiography (SSADA) with optical coherence tomography (OCT).

Patients And Methods: Forty patients were divided into seven categories according to their diagnosis: no retinopathy (control), retinal vein occlusion, diabetes with no retinopathy, diabetes with retinopathy, non-exudative age-related macular degeneration (AMD), exudative AMD, and epiretinal membrane. Capillary density and retinal thickness measurements were taken and evaluated for reliability by determination of statistically significant differences and coefficient of variability (CoV) between measurements.

Results: No significant differences (P > .05) were found in any of the within-visit measurements. CoVs ranged from 0.26% to 52.76%, depending on the measure and the disease settings.

Conclusion: The SSADA OCT angiography analysis has a low level of variability between measurements and, thus, is a reliable tool for evaluation of retinal perfusion. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e9-e19.].
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http://dx.doi.org/10.3928/23258160-20180907-02DOI Listing
September 2018

36-Month Evaluation of Intravitreous Aflibercept Injection for Wet Age-Related Macular Degeneration in Patients Previously Treated With Ranibizumab or Bevacizumab.

Ophthalmic Surg Lasers Imaging Retina 2018 03;49(3):179-185

Background And Objective: In the ASSESS study, patients with neovascular age-related macular degeneration transitioned from other anti-vascular endothelial growth factor therapies to intravitreous aflibercept (Eylea; Regeneron, Tarrytown, NY) injections (IAI). The purpose was to determine the 36-month outcomes following the change from a fixed 24-month IAI dosing regimen to a routine clinical practice regimen.

Patients And Methods: Patients were treated with a fixed bimonthly regimen for the first 2 years. In the third year, patients were managed according to routine clinical practice.

Results: A total of 18 patients completed the 36 months and were considered for statistical analyses. At 36 months, a nonsignificant decrease of -37.8 μm in central subfield thickness and a nonsignificant gain of 5.8 letters from baseline were observed.

Conclusion: Despite the significant visual and anatomical gains observed in the 2 years of fixed-dosing IAI, there was gradual decline in these improvements when patients were transitioned to a variable regimen. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:179-185.].
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http://dx.doi.org/10.3928/23258160-20180221-05DOI Listing
March 2018

Switching Anti-Vascular Endothelial Growth Factors in Refractory Neovascular Age-Related Macular Degeneration.

Ophthalmic Surg Lasers Imaging Retina 2018 03;49(3):166-170

Background And Objective: Anti-vascular endothelial growth factor (VEGF) therapy is the treatment of choice for cases with neovascular age-related macular degeneration (AMD). Switching to an alternate anti-VEGF has been suggested as a possible option for resistant cases. The purpose of this review is to evaluate whether the timing of switching affects treatment outcomes.

Patients And Methods: A review of published literature was performed looking at all studies where patients with refractory neovascular AMD were switched to an alternative anti-VEGF. Studies were then stratified based on the timing of switching into early (< 12 previous injections) and late (> 12 previous injections).

Results: A total of 38 studies were identified: 18 where patients were switched early and 20 where they were switched late. Both subgroups showed anatomic improvement after switching, with limited visual gains.

Conclusion: There are insufficient data to recommend early versus late switching. However, both groups showed a reduction of fluid on optical coherence tomography and visual gains in 25% to 30% of patients. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:166-170.].
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http://dx.doi.org/10.3928/23258160-20180221-03DOI Listing
March 2018

Long-term Clinical Outcomes of Pars Plana Versus Anterior Chamber Placement of Glaucoma Implant Tubes.

J Glaucoma 2018 05;27(5):440-444

Cole Eye Institute, Cleveland Clinic, Cleveland, OH.

Purpose: To compare long-term surgical outcomes and complications of pars plana (PP) tube implantation with conventional anterior chamber (AC) tube implantation.

Materials And Methods: Records of patients undergoing glaucoma tube implant surgery at a single institution between 2007 and 2015 were retrospectively reviewed. Eyes were matched for glaucoma diagnosis and patient age. Demographics, baseline characteristics, and treatment outcomes were recorded. Surgical success was defined as intraocular pressure (IOP) between 6 and 21 mm Hg, no subsequent glaucoma surgeries performed, and at least light perception vision.

Results: Fifty-seven eyes that underwent Ahmed or Baerveldt glaucoma drainage device surgery with PP tube placement were compared with 57 eyes with AC tube placement. Mean follow-up was 43.5 months in the PP group and 35.3 months in the AC group (P=0.02). Forty-nine (86.0%) PP eyes and 46 (80.7%) AC eyes achieved surgical success (P=0.45). At last follow-up, mean IOP decreased from 29.0 to 15.1 mm Hg in the PP group (P<0.01) and from 32.7 to 15.6 mm Hg in the AC group (P<0.01). Mean number of medications decreased from 2.9 to 1.1 in the PP group (P<0.01) and from 2.8 to 1.3 in the AC group (P<0.01). Mean IOP and number of medications were similar between PP and AC groups at baseline, last follow-up, and all interim time points (P>0.05 for all). There were 16 complications in the PP group and 14 in the AC group (P=0.67).

Conclusions: Long-term results of glaucoma tube implant surgery with PP versus AC implantation shows effective IOP control with similar rates of surgical success.
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http://dx.doi.org/10.1097/IJG.0000000000000931DOI Listing
May 2018

The Prevalence of Adverse Ocular Hemorrhagic Events in Patients Utilizing Oral Anticoagulant and Antiplatelet Therapy in Routine Clinical Practice.

Ophthalmic Surg Lasers Imaging Retina 2018 01;49(1):27-34

Background And Objective: Previous literature assessing ocular hemorrhagic complications of anticoagulant/antiplatelet medications in routine clinical practice is limited. This study evaluates the prevalence of spontaneous ocular hemorrhagic events associated with anticoagulation/antiplatelet therapy.

Patients And Methods: A retrospective study was performed to identify patients taking anticoagulants (rivaroxaban [Xarelto; Janssen Pharmaceuticals, Beerse, Belgium], bivalirudin [Angiomax; The Medicines Company, Parsippany, NJ], lepirudin [Refludan; Bayer HealthCare Pharmaceuticals, Berlin, Germany], dabigatran [Pradaxa; Boehringer Ingelheim, Ingelheim am Rhein, Germany], and argatroban) and antiplatelet agents (clopidogrel [Plavix; Bristol-Myers Squibb, New York City, NY], prasugrel [Effient; Lilly Medical, Indianapolis, IN], and ticagrelor [Brilinta; AstraZeneca, Cambridge, UK]) who presented for an eye examination. Location of hemorrhage, relevant systemic and ocular comorbidities, baseline demographics, and concomitant aspirin use were noted.

Results: A total of 44 patients with spontaneous ocular hemorrhage were identified. Thirty patients had a single episode, whereas 14 patients had multiple episodes (two or more hemorrhagic events). Prevalence of spontaneous ocular hemorrhage on prasugrel (7.2%) and rivaroxaban (3.1%) was higher compared to dabigatran (1.9%), clopidogrel (2.0%), and ticagrelor (2.7%).

Conclusion: Prevalence of spontaneous ocular hemorrhage with use of anticoagulant/antiplatelet agents is higher in routine clinical practice as compared to previously reported literature. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:27-34.].
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http://dx.doi.org/10.3928/23258160-20171215-04DOI Listing
January 2018

Non-Mydriatic Ultra-Widefield Imaging Compared With Single-Field Imaging in the Evaluation of Peripheral Retinal Pathology.

Ophthalmic Surg Lasers Imaging Retina 2017 12;48(12):962-968

Background And Objective: To report clinical feasibility of non-mydriatic ultra-widefield (NMUWF) imaging and determine the prevalence of peripheral retinal pathology in comparison to standard single-field imaging in a primary care setting.

Patients And Methods: Six hundred and thirty-two subjects (1,260 eyes) who underwent NMUWF imaging during annual health screening from October 2015 through March 2016 were retrospectively identified. An automated algorithm processed the raw images into: (1) NMUWF image with mask/grid outline that delineates the center 45° field simulating standard single-field photograph and (2) single-field image comprising 45° posterior pole extracted from the corresponding NMUWF image.

Results: Mean age of patients was 59.6 years ± 7.5 years. Of the 1,260 eyes, 1,238 eyes (98.3%) were considered optimum for grading. NMUWF images detected peripheral retinal pathology in 228 eyes (18.4%) that were not visible on corresponding single-field images.

Conclusions: NMUWF imaging is feasible in a primary care setting, allows improved visualization of peripheral retinal pathology, and may therefore be useful for telemedicine screening. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:962-968.].
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http://dx.doi.org/10.3928/23258160-20171130-02DOI Listing
December 2017

OUTCOMES OF PATIENTS WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION TREATED WITH ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR THREE OR MORE YEARS: A Review of Current Outcomes.

Retina 2018 08;38(8):1500-1508

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.

Purpose: To summarize the findings of long-term outcomes of anti-vascular endothelial growth factor (VEGF) therapy (≥36 months) in patients with exudative age-related macular degeneration.

Methods: Studies reporting long-term outcomes (≥36 months) of anti-VEGF therapy (n = 11) were identified and analyzed for changes in visual acuity (VA), optical coherence tomography, and safety findings.

Results: Six prospective extension studies of Phase 3 clinical trials and five retrospective evaluation studies were identified. The largest improvements in VA with anti-VEGF treatment were found in Years 1 to 2 after treatment initiation. In five studies, VA ultimately declined below patients' pretreatment initial baseline; in three studies, VA ultimately returned to patients' baseline; in three studies, VA decreased but ultimately remained improved over patients' baseline. There was a trend demonstrating that a higher frequency of intravitreous injections showed a better maintenance in VA. Rates of adverse events were similar to previous registration studies of anti-VEGF drugs.

Conclusion: The body of evidence to date regarding long-term anti-VEGF treatment indicates a variable course at greater than 36 months follow-up and seems to be dependent on the treatment protocol. Consistent dosing with fluid-free interval is suggested to maintain VA gains in patients with exudative age-related macular degeneration. There is no evidence suggesting that there are additional adverse events from long-term anti-VEGF use.
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http://dx.doi.org/10.1097/IAE.0000000000001753DOI Listing
August 2018

Comparison of Ranibizumab and Bevacizumab for Macular Edema Secondary to Retinal Vein Occlusions in Routine Clinical Practice.

Ophthalmic Surg Lasers Imaging Retina 2017 06;48(6):465-472

Background And Objective: To determine outcomes of intravitreal ranibizumab (IVR) (Lucentis; Genentech, South San Francisco, CA) versus bevacizumab (IVB) (Avastin; Genentech, South San Francisco, CA) for treatment of macular edema (ME) secondary to retinal vein occlusion (RVO) in routine clinical practice.

Patients And Methods: A retrospective study identified treatment-naïve patients with ME secondary to RVO where treatment with either IVB or IVR was initiated. Retreatment criteria were based on ophthalmic examination and/or spectral-domain optical coherence tomography findings.

Results: Central RVO/hemi-RVO cohort: At 12 months, change in visual acuity (VA) (IVR: +12.9 letters, IVB +6.9 letters; P = .53), central subfield thickness (CST) (IVR: -144.1 μm, IVB: -153.9 μm; P = .88), and number of injections (IVR: 5.40 injections, IVB: 5.64 injections; P = .70) were not different between groups. Branch RVO cohort: At 12-month follow-up, no differences in change in VA (IVR: +15.2 letters, IVB: +10.6 letters; P = .46), CST (IVR: -23.1 μm, IVB: -91.4 μm; P = .16), or number of injections (IVR: 5.93 injections, IVB: 5.13 injections; P = .15) were noted.

Conclusion: There is no notable difference in outcome between IVR and IVB when treating ME from RVO in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:465-472.].
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http://dx.doi.org/10.3928/23258160-20170601-04DOI Listing
June 2017

A retrospective study of the influence of the vitreomacular interface on macular oedema secondary to retinal vein occlusion.

Br J Ophthalmol 2017 10 3;101(10):1340-1345. Epub 2017 Mar 3.

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Aims: To compare anti-vascular endothelial growth factor (VEGF) treatment outcomes for macular oedema (ME) secondary to retinal vein occlusion (RVO) based on vitreoretinal interface (VRI) status.

Methods: This retrospective case series includes treatment-naive eyes diagnosed with RVO and treated with anti-VEGF injections. Eyes were stratified based on international VRI classification schema at baseline into three groups-vitreomacular traction (group A), no posterior vitreous detachment (PVD) (group B) and PVD without vitreomacular attachment (group C). Fifty-two eyes were identified based on inclusion/exclusion criteria. The primary endpoint was change in central subfield thickness (CST) on optical coherence tomography at 6 months.

Results: There were no statistically significant differences in baseline characteristics of patients with RVO when stratified by VRI subgroups. After 6 months of treatment, there was no statistically significant difference in the change in CST from baseline between VRI cohorts (p=0.11). There was a trend demonstrating the greatest improvement in CST in eyes in group A compared with eyes in groups B and C (-224.13 μm, -160.88 μm and -50.92 μm, respectively, p=0.11 between cohorts). Mean change in logarithm of the minimum angle of resolution visual acuity from baseline to month 6 in group A compared with groups B and C was -0.25, -0.14 and -0.13, respectively (p=0.64 between cohorts).

Conclusions: We did not identify an association between VRI status and treatment outcomes with anti-VEGF agents for ME secondary to RVO.
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http://dx.doi.org/10.1136/bjophthalmol-2016-309747DOI Listing
October 2017

Outcomes of Diabetic Macular Edema Patients by Baseline Hemoglobin A1c: Analyses from VISTA and VIVID.

Ophthalmol Retina 2017 Sep - Oct;1(5):382-388. Epub 2017 Apr 17.

Ocular Imaging Research and Reading Center, Omaha, Nebraska.

Purpose: To examine the relationship between glycemic control at baseline and response to anti-vascular endothelial growth factor treatment for diabetic macular edema (DME).

Design: Post hoc analysis of 2 similarly designed phase III trials, VISTA and VIVID.

Participants: Patients with central-involved DME.

Methods: Both VISTA and VIVID compared efficacy and safety of intravitreal aflibercept injection (IAI) with macular laser photocoagulation for DME. Current analysis focused on comparison within each treatment group in an integrated VISTA and VIVID dataset. Baseline hemoglobin A1c (HbA1c) was partitioned into 4 quartiles: 4.5% to <6.7% (n = 233), 6.7% to <7.4% (n = 206), 7.4% to <8.6% (n = 209), and 8.6% to <14.7% (n = 208). Outcomes were analyzed by mixed model for repeated measures. Intragroup differences were quantified by a regression model.

Main Outcome Measures: Change from baseline best-corrected visual acuity (BCVA), central subfield thickness (CST), and HbA1c.

Results: In the IAI group, mean BCVA improvement from baseline did not depend on baseline HbA1c at week 52 (P = 0.1852), but seemed to be dependent at week 100 (P = 0.0425). The mean CST reduction from baseline was independent of baseline HbA1c at both weeks 52 (P = 0.1857) and 100 (P = 0.7346). Mean HbA1c change from baseline in IAI group was small across all HbA1c quartiles. In the laser group, the mean BCVA gain decreased with increasing baseline HbA1c at both weeks 52 (P = 0.0421) and 100 (P = 0.0001). Similarly, the mean CST decrease was greater with decreasing baseline HbA1c, at both weeks 52 (P = 0.0065) and 100 (P = 0.0162). The mean HbA1c change from baseline in the laser group was minimal across HbA1c quartiles, although glycemic control tended to worsen in upper quartiles.

Conclusions: The benefit of IAI in patients with DME was less dependent on their presenting glycemic status as opposed to laser.
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http://dx.doi.org/10.1016/j.oret.2017.02.003DOI Listing
April 2017

A 24-Month Evaluation of Aflibercept for Wet Age-Related Macular Degeneration in Patients Previously Receiving Ranibizumab or Bevacizumab.

Ophthalmol Retina 2017 Mar - Apr;1(2):111-117. Epub 2016 Nov 23.

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Purpose: To report the 24-month results and predictive factors for outcomes in patients transitioned from other anti-vascular endothelial growth factor agents to aflibercept for the treatment of exudative age-related macular degeneration (AMD).

Design: A prospective, single arm, investigator-initiated study.

Participants: A total of 24 patients participated in the study and 87.5% (n = 21) completed the 24 month assessments. Patients were included if they had an active exudative AMD confirmed by fluorescein angiography, presence of fluid on spectral-domain optical coherence tomography (OCT) or new hemorrhage on clinical examination, Electronic Early Treatment Diabetic Retinopathy Study vision of 25 to 80 letters (Snellen equivalent of approximately 20/25-20/320), prior bevacizumab or ranibizumab injections within 3 months of enrollment, and an initial response on OCT defined as a decrease of retinal edema and/or subretinal fluid to anti-vascular endothelial growth factor injections.

Methods: Patients were treated the first 3 months with 2 mg of intravitreal aflibercept monthly, followed by a fixed bimonthly schedule for 24 months. At each study visit, visual acuity and a spectral-domain OCT scanning of both eyes were performed.

Main Outcome And Measures: The mean absolute change from baseline in central subfield thickness at month 24, mean change from baseline in best-corrected visual acuity (BCVA) score, change from baseline in macular volume, and cube average thickness by spectral-domain OCT. Additionally, predictive factors associated with final visual and anatomic outcomes at month 24.

Results: A mean decrease in central subfield thickness of -41 μm (P = 0.004) was observed with a mean increase in ETDRS BCVA of +10.4 letters (P < 0.001). At study entry, BCVA was a significant predictive factor for BCVA change at month 24 (rho = -0.59; P = 0.003). Also, the duration between AMD diagnosis and study entry was a significant factor for central subfield thickness change at month 24 (rho = -0.51; P = 0.011).

Conclusions: In nonnaïve patients with active exudative AMD, treatment with a fixed intravitreal aflibercept dosing regimen for 24 months demonstrated sustained improvements in anatomy and vision in patients transitioned from other anti-vascular endothelial growth factor agents and stability when compared with 12-month outcomes. Patients who benefited most were those with worse vision at entry and longer duration of disease.
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http://dx.doi.org/10.1016/j.oret.2016.09.008DOI Listing
November 2016

Evaluation and Referral of Diabetic Eye Disease in the Endocrinology and Primary Care Office Settings.

Ophthalmic Surg Lasers Imaging Retina 2016 Oct;47(10):930-934

Background And Objective: The purpose of this study was to identify whether endocrinologists and primary care physicians (PCP) adequately screen for ophthalmic symptoms/signs within office visits and provide timely ophthalmology referrals in patients with diabetes.

Patients And Methods: Patients between the ages of 18 years and 80 years with diabetes who underwent an office visit with an endocrinologist or a PCP between January 1, 2014, and December 31, 2014, were identified. Demographics, ophthalmic assessments, and referral information were collected.

Results: A total of 1,250 patient records were reviewed. Providers asked about ophthalmic symptoms/signs in 95.5% and 71% of endocrinology and primary care office encounters, respectively (P < .0001). Past and/or future ophthalmology appointments were verified in 86.1% and 49.7% of patients during endocrinology and PCP visits, respectively (P < .0001).

Conclusions: Ophthalmic complications from diabetes are not adequately screened, especially within the primary care setting, and further quality improvement measures may improve adherence to recommended screening protocols. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:930-934.].
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http://dx.doi.org/10.3928/23258160-20161004-06DOI Listing
October 2016

Impact of initial visual acuity on anti-VEGF treatment outcomes in patients with macular oedema secondary to retinal vein occlusions in routine clinical practice.

Br J Ophthalmol 2017 05 8;101(5):574-579. Epub 2016 Aug 8.

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Aim: To determine the impact of initial visual acuity (VA) on anti-vascular endothelial growth factor (VEGF) treatment outcomes in patients with macular oedema secondary to retinal vein occlusions in routine clinical practice.

Methods: A retrospective study was conducted at a single academic institution to identify 177 treatment naïve patients with macular oedema secondary to branch retinal vein occlusion (BRVO), hemiretinal vein occlusion (HRVO) and central retinal vein occlusion (CRVO) treated with intravitreal anti-VEGFs. Exclusion criteria included prior intravitreal injection or presence of active confounding ocular disease. Patients were stratified by initial VA; main outcomes measured were average change in VA and mean absolute change in central subfield thickness (CST) at 6 and 12 months.

Results: Patients with BRVO with initial VA of 20/40 or better had no significant changes in average letters gained and CST from baseline (+2.6 letters, p=0.42; -48.94 µm, p=0.12) compared with patients with initial VA between 20/50 and 20/300 (+13.2 letters, p<0.001; -98.20 µm, p<0.001) after 12 months. Patients with CRVO/HRVO with initial VA of 20/320 or worse had the most improvement in average letters gained and CST from baseline (+42.2 letters, p<0.001; -182.84 µm, p=0.004) with anti-VEGF therapy compared with patients with initial VA between 20/50 and 20/300 (+9.4 letters, p=0.016; -160.87 µm, p<0.001) and patients with initial VA of 20/40 or better (-9.6 letters, p=0.14; -47.92 µm, p=0.38).

Conclusions: For macular oedema secondary to retinal vein occlusion, anti-VEGF treatment can result in a greater improvement in average letters gained and in CST for those with poor initial VA compared with those with better initial VA.
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http://dx.doi.org/10.1136/bjophthalmol-2016-308727DOI Listing
May 2017

A single-arm, investigator-initiated study of the efficacy, safety, and tolerability of intravitreal aflibercept injection in subjects with exudative age-related macular degeneration previously treated with ranibizumab or bevacizumab (ASSESS study): 12-month analysis.

Clin Ophthalmol 2015 22;9:1759-66. Epub 2015 Sep 22.

Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA.

Summary Statement: In subjects with active exudative age-related macular degeneration, treating with a fixed intravitreal aflibercept injection dosing regimen for 12 months demonstrated improved anatomic and vision endpoints from baseline.

Purpose: Switching therapies in neovascular age-related macular degeneration (AMD) may offer an advantage for some patients. This study evaluates the efficacy of intravitreal aflibercept injection (IAI) in subjects previously treated with ranibizumab and/or bevacizumab.

Methods: Subjects (n=26) were given monthly 2 mg of IAI for 3 months, followed by 2 mg once in every 2 months for up to 12 months. The mean absolute change from baseline in central subfield thickness (CST) measured by optical coherence tomography and the mean change from baseline in best-corrected visual acuity (BCVA) early treatment in diabetic retinopathy study (ETDRS) letter score were obtained. Additionally, the percentage of subjects who gained or lost ≥15 letters of vision and the percentage of subjects who are 20/40 or better or 20/200 or worse were evaluated.

Results: There was a mean decrease in CST of -50.3 μm (P<0.001) and a mean increase in ETDRS BCVA of +9.2 letters (P<0.001). Twenty-seven percent of subjects experienced a ≥15-letter improvement in visual acuity, and no subject lost ≥3 lines of vision from baseline. Fifty percent of subjects were 20/40 or better, and 11.5% of subjects were 20/200 or worse at month 12.

Conclusion: Fixed IAI dosing regimen for 12 months demonstrated improved anatomic and vision endpoints in subjects with active exudative AMD.
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http://dx.doi.org/10.2147/OPTH.S87043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590671PMC
October 2015

Association of blood and ocular perfusion pressure with structural glaucomatous progression by flicker chronoscopy.

Br J Ophthalmol 2013 Dec 24;97(12):1569-73. Epub 2013 Sep 24.

Department of Ophthalmology, Weill Cornell Medical College, , New York, NY, USA.

Background: Vascular risk factors have been associated with glaucomatous visual field progression.

Aim: We determined the relationship between vascular risk factors and structural glaucomatous progression using serial flicker chronoscopy images.

Methods: Two glaucoma fellowship-trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from one eye of a cohort of glaucoma patients for features of structural progression in this retrospective cohort study. After adjudication, simple and multiple logistic models were constructed to determine variables associated with increased odds of progression, including systolic blood pressure (BP), diastolic BP and mean ocular perfusion pressure.

Results: Seventy-two eyes of 72 patients were analysed. Patients with any form of structural progression (n=40) were older (67.0 vs 58.8 years; p=0.005) and had lower diastolic BP (71.8 vs 76.5 mm Hg; p=0.02) than patients without progression (n=32). In the univariable model, diastolic BP was associated with progressive retinal nerve fibre layer (RNFL) loss (OR=0.2 per 10 mm Hg, 95% CI 0.1 to 0.6, p<0.006) and neuroretinal rim loss (OR=0.4 per 10 mm Hg, 95% CI 0.2 to 0.8, p<0.01). Diastolic BP was also significant in the multivariable model for RNFL loss (p=0.009) and neuroretinal rim loss (p=0.003).

Conclusions: This study is the first to use structural progression and flicker chronoscopy to identify vascular glaucoma risk factors. Older age and lower diastolic BP were associated with progression. By multivariable analysis diastolic BP was associated with RNFL and neuroretinal rim loss. These findings suggest that diastolic BP is associated with structural glaucomatous progression which may have implications for management.
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http://dx.doi.org/10.1136/bjophthalmol-2013-303655DOI Listing
December 2013

Relationship between corneal hysteresis and optic nerve parameters measured with spectral domain optical coherence tomography.

Graefes Arch Clin Exp Ophthalmol 2013 Jul 22;251(7):1777-83. Epub 2013 Mar 22.

Department of Ophthalmology, Weill Cornell Medical College, 1305 York Avenue, 11th Floor, New York, NY 10021, USA.

Background: Corneal hysteresis (CH) has been associated with visual field damage in glaucoma and is related to the velocity of perimetric glaucoma progression. We undertook this investigation to determine whether CH is associated with structural markers of glaucoma damage on spectral domain optical coherence tomography (SD-OCT).

Methods: In this retrospective study, 131 patients under glaucoma evaluation were evaluated with SD-OCT (Cirrus; Carl Zeiss Meditec, Dublin, CA) and had CH measurements with the ocular response analyzer (Reichert, Inc., Buffalo, NY). Pearson and partial correlation adjusting for age were preformed to examine the association between CH and variables of interest. Generalized estimating equations were used to construct simple and multiple linear models.

Results: While Pearson correlations were modest overall, CH best correlated with mean deviation (MD; r = 0.19) followed by average retinal nerve fiber layer (RNFL) thickness (r = 0.18) and vertical cup to disc ratio (r = -0.11) in the open angle glaucoma group. In univariable models, CH varied as a function of MD (ß = 0.1, 95 % CI 0.03, 0.1; p < 0.001) and of average RNFL thickness (ß = 0.2, 95 % CI 0.1, 0.4; p = 0.001). In a multivariable analysis including MD, age, average RNFL thickness, and glaucoma status, MD (p = 0.001) and age (p < 0.001) retained significant associations with CH.

Conclusions: In patients under evaluation and treatment for glaucoma, CH was more closely related to visual field MD than to structural markers of glaucoma damage as measured by SD-OCT.
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http://dx.doi.org/10.1007/s00417-013-2311-xDOI Listing
July 2013

Agreement of flicker chronoscopy for structural glaucomatous progression detection and factors associated with progression.

Am J Ophthalmol 2013 Jun 22;155(6):983-990.e1. Epub 2013 Feb 22.

Department of Ophthalmology, Weill Cornell Medical College, New York, New York 10021, USA.

Purpose: To evaluate agreement of flicker chronoscopy for structural glaucomatous progression detection and factors associated with progression.

Design: Retrospective cohort study.

Methods: Two glaucoma fellowship-trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from 1 eye of a cohort of glaucoma patients for features of structural progression. Agreement between graders was determined, as was accuracy for determining the temporal order of images. After adjudication, simple and multiple logistic models were constructed to determine baseline variables associated with increased odds of progression.

Results: Fifty of 103 included eyes/patients (48.5%) had at least 1 sign of structural progression. Temporal sequence was incorrectly determined in 14 of 206 cases (6.4%). Interobserver agreements for identifying baseline photographs (κ = 0.9), global progression (κ = 0.7), parapapillary atrophy (PPA) progression (κ = 0.7), disc hemorrhages (κ = 0.7), neuroretinal rim loss (κ = 0.5), and retinal nerve fiber layer (RNFL) loss (κ = 0.2) were calculated. Age was significantly associated with global (1.8; 1.3-2.6, P < .001) (odds ratio; 95% confidence interval, significance) and PPA progression (1.7; 1.2-2.4, P = .002). Lower corneal hysteresis was associated with global progression (0.78; 0.56-0.99, P = .049) and RNFL loss (0.5; 0.3-0.9, P = .02). Goldmann-correlated intraocular pressure (1.0, 0.7-1.4, P = .9), visual field mean deviation (1.0, 0.9-1.0, P = .2), and central corneal thickness (0.9, 0.8-1.0, P = .1) were not significantly associated with progression. On multivariable analysis, only age was associated with global progression (1.8; 1.2-2.5, P = .002).

Conclusion: Flicker chronoscopy demonstrated acceptable interobserver agreement in structural progression detection. Corneal hysteresis and age were both associated with progression, but age was the only significant factor on multivariable analysis.
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http://dx.doi.org/10.1016/j.ajo.2013.01.005DOI Listing
June 2013