Publications by authors named "William Feuer"

365 Publications

Treatment Outcomes of Slow Coagulation Transscleral Cyclophotocoagulation In Pseudophakic Patients with Medically Uncontrolled Glaucoma.

Am J Ophthalmol 2021 Apr 11. Epub 2021 Apr 11.

Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Fl 33136, USA. Electronic address:

Purpose: Reporting treatment outcomes of slow coagulation transscleral cyclophotocoagulation (TSCPC) as an initial surgical intervention in pseudophakic glaucomatous patients.

Design: Retrospective case series.

Methods Setting: Single academic center.

Study Population: Seventy-four pseudophakic patients (mean age of 82.6 ±12.5 years and mean follow-up of 18.7±9.1 months) with a diagnosis of glaucoma and no previous glaucoma surgeries.

Intervention: Slow coagulation continuous-wave TSCPC (1250-milliwatt power and 4-second duration) MAIN OUTCOME MEASURES: Primary outcome measure was surgical success defined as an IOP 6 - 21 mmHg with reduction ≥ 20% from baseline, no reoperation for glaucoma, and no loss of light-perception vision. Secondary outcome measures include glaucoma medication use, visual acuity (VA), and complications.

Results: IOP decreased from 27.5±9.8 mmHg preoperatively to 16.1±6.3 mm Hg postoperatively (P< 0.001). The preoperative number of glaucoma medications was 4.1±0.9 and 3.1±1.3 post-TSCPC (p< 0.001). The cumulative probability of success at 1 and 2 years were 60.6 % and 58.5%, respectively. When patients were divided into 2 groups based on their baseline IOP being > 21 mmHg (high group) or ≤ 21 mmHg (low group), success rates at 2 years were 64.9% and 45.5%, respectively (P = 0.144). Mean logMAR VA changed from 0.70 ± 0.64 to 1.04±0.87 at the last follow-up visit (P= 0.01). No serious complications were observed and most of the complications were mild and transient.

Conclusions: Slow coagulation TSCPC has good efficiency, especially in patients with baseline IOP > 21 mm Hg, and safety profile as an initial surgical intervention in pseudophakic glaucomatous patients.
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http://dx.doi.org/10.1016/j.ajo.2021.04.003DOI Listing
April 2021

Tube Versus Trabeculectomy IRIS® Registry One-Year Composite Outcome Analysis with Comparisons to the Randomized Controlled Trial: (60 characters or fewer): Tube vs Trab IRIS Registry 1-Year Composite Outcome Analysis.

Am J Ophthalmol 2021 Feb 28. Epub 2021 Feb 28.

Bascom Palmer Eye Institute, Miami, FL.

Purpose: Compare one-year results for the composite treatment outcome from the Tube Versus Trabeculectomy (TVT) Randomized Controlled Trial (RCT) to those from an Intelligent Research In Sight (IRIS®) Registry cohort of analogous eyes.

Design: Retrospective clinical study with comparison to an RCT.

Methods: Subjects: Eyes in the IRIS Registry receiving either a glaucoma drainage implant (tube) or trabeculectomy after a previous trabeculectomy and/or cataract extraction with data for one-year follow-up analyses.

Outcome: Eyes were classified as failing if, they had hypotony (intraocular pressure (IOP)≤5 mmHg) or inadequate IOP control (IOP>21 mmHg or not reduced at least 20% below baseline) on two consecutive follow-up visits after three months, a reoperation for glaucoma, or no light perception vision; and as successful otherwise. Failure risk was compared by treatment, demographic, and clinical variables, and compared to analogous failure risks from the TVT RCT.

Results: The TVT IRIS Registry cohort included 419 eyes, 236 tube eyes (56.3%) and 183 trabeculectomy eyes (43.7%). In this cohort, there was no significant failure risk difference (12.3% for tube eyes and 16.4% for trabeculectomy eyes, P=0.231). Comparting the studies, there was a significantly greater risk of failure in the TVT IRIS Registry tube eyes than in the TVT RCT tube eyes (3.8%; P<0.001). Failure reasons included reoperations for glaucoma (none in the TVT RCT at one-year).

Conclusion: Our results were different from the TVT RCT. Possible reasons include non-Baerveldt tubes, greater severity among tube eyes, and practice patterns that reflect real-world data, which are different than RCTs.
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http://dx.doi.org/10.1016/j.ajo.2021.02.023DOI Listing
February 2021

Persistent Hyper-Transmission Defects on En Face OCT Imaging as a Stand-Alone Precursor for the Future Formation of Geographic Atrophy.

Ophthalmol Retina 2021 Feb 18. Epub 2021 Feb 18.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

The presence of persistent choroidal hyper-transmission defects on custom en face OCT images can be used as a stand-alone precursor for the progression of drusen to geographic atrophy in age-related macular degeneration.
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http://dx.doi.org/10.1016/j.oret.2021.02.004DOI Listing
February 2021

Multidisease Deep Learning Neural Network for the Diagnosis of Corneal Diseases.

Am J Ophthalmol 2021 Jan 30;226:252-261. Epub 2021 Jan 30.

Bascom Palmer Eye institute, Miller School of Medicine, University of Miami, Miami; Electrical and Computer Engineering, University of Miami, Coral Gables; Biomedical Engineering, University of Miami, Coral Gables, Florida, USA. Electronic address:

Purpose: To report a multidisease deep learning diagnostic network (MDDN) of common corneal diseases: dry eye syndrome (DES), Fuchs endothelial dystrophy (FED), and keratoconus (KCN) using anterior segment optical coherence tomography (AS-OCT) images.

Study Design: Development of a deep learning neural network diagnosis algorithm.

Methods: A total of 158,220 AS-OCT images from 879 eyes of 478 subjects were used to develop and validate a classification deep network. After a quality check, the network was trained and validated using 134,460 images. We tested the network using a test set of consecutive patients involving 23,760 AS-OCT images of 132 eyes of 69 patients. The area under receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), and F1 score and 95% confidence intervals (CIs) were computed.

Results: The MDDN achieved eye-level AUROCs >0.99 (95% CI: 0.90, 1.0), AUPRCs > 0.96 (95% CI: 0.90, 1.0), and F1 scores > 0.90 (95% CI: 0.81, 1.0) for DES, FED, and KCN, respectively.

Conclusions: MDDN is a novel diagnostic tool for corneal diseases that can be used to automatically diagnose KCN, FED, and DES using only AS-OCT images.
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http://dx.doi.org/10.1016/j.ajo.2021.01.018DOI Listing
January 2021

Treatment Outcomes of Primary Transscleral Cyclophotocoagulation.

Ophthalmol Glaucoma 2021 Jan 8. Epub 2021 Jan 8.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To report treatment outcomes of primary transscleral cyclophotocoagulation (TSCPC) in glaucomatous eyes.

Design: Retrospective noncomparative study.

Participants: Forty-eight eyes with a diagnosis of glaucoma and no previous incisional ocular surgery.

Methods: Continuous-wave TSCPC was applied to the ciliary body.

Main Outcome Measures: The primary outcome measure was surgical success defined as an IOP ≤ 21 mmHg and reduced by 20% or more from baseline, IOP > 5 mmHg, no reoperation for glaucoma, and no loss of light perception vision. Secondary outcome measures included visual acuity (VA) and complications.

Results: Glaucoma eyes were stratified into 2 groups: (1) those with pretreatment IOP >21 mmHg (high group) and (2) those with pretreatment IOP ≤ 21 mmHg (low group). Mean ± standard deviation (SD) IOP at baseline was 30.6 ± 6.3 mmHg in the high group and 16.2 ± 2.8 mmHg in the low group. Mean ± SD number of glaucoma medications at baseline was 4.1 ± 0.8 in the high group and 3.6 ± 1.1 in the low group. Based on our success criteria, the cumulative probability of success during the first year of follow-up was 58.3% in the high group and 28.1% in the low group (P = 0.052). Postoperative mean IOP was significantly lower than baseline IOP in the high group at 1-, 3-, 6-, 12-, and 18-month postoperative visits (P < 0.05). No significant change was observed in IOP at follow-up visits after 1 month in the low IOP group. Throughout the first year of follow-up, both groups required fewer glaucoma medications compared with baseline at the 1-, 3-, 6-, and 12-month postoperative visits (P < 0.05). The most frequent cause of postoperative decrease in VA was cataract in 9 eyes. Decrease in vision resulting from glaucoma was observed in 3 eyes. Complications included prolonged inflammation (11 eyes), iris neovascularization (2 eyes), cystoid macular edema (4 eyes), and hyphema (1 eye). No severe or long-term complications were observed.

Conclusions: Continuous-wave TSCPC was effective in lowering IOP in glaucoma patients without prior incisional ocular surgery whose disease was recalcitrant to medical therapy, particularly those with baseline IOP of more than 21 mmHg.
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http://dx.doi.org/10.1016/j.ogla.2020.12.014DOI Listing
January 2021

Correlations Between Choriocapillaris and Choroidal Measurements and the Growth of Geographic Atrophy Using Swept Source OCTImaging.

Am J Ophthalmol 2020 Dec 24;224:321-331. Epub 2020 Dec 24.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

Purpose: Correlations among enlargement rates (ERs) of geographic atrophy (GA) and choriocapillaris (CC) flow deficits (FDs), mean choroidal thickness (MCT), and choroidal vascularity index (CVI) were investigated using swept source-optical coherence tomography (SS-OCT) in age-related macular degeneration (AMD).

Design: A retrospective review of prospective, observational case series.

Methods: Eyes with GA from AMD were imaged with SS-OCT using 6 × 6-mm scan pattern. GA lesions were identified and measured using customized en face structural images, and annual square root ERs of GA were calculated. At baseline, choriocapillaris FDs from different regions outside the GA were measured, and MCT and CVI from the entire scan area were measured. All measurements were performed using previously published and validated algorithms.

Results: A total of 38 eyes from 27 patients were included. The CC FDs within each region around GA lesions were highly correlated with ERs of GA (all P < .005). CVI inside the GA region was correlated with the ERs (P = .03), whereas other choroidal measurements had no significant correlation with the ERs of GA (P > .06).

Conclusions: Statistically significant correlations were found between the ERs of GA and CC percentage of FD (FD%) from the entire scan region outside the GA and not just the region immediately adjacent to the GA. These results suggest that abnormal CC perfusion throughout the macula contributes to disease progression in eyes with GA. CVI inside the GA region could also be a potential indicator for the growth of GA.
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http://dx.doi.org/10.1016/j.ajo.2020.12.015DOI Listing
December 2020

Rates of RNFL Thinning in Patients with Suspected or Confirmed Glaucoma Receiving Unilateral Intravitreal Injections for Exudative AMD.

Am J Ophthalmol 2020 Dec 24;226:206-216. Epub 2020 Dec 24.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

Purpose: This study evaluated whether the rate of retinal nerve fiber layer (RNFL) thinning is faster in eyes receiving intravitreal injections than in fellow uninjected eyes among patients suspected of having or confirmed to have glaucoma and exudative age-related macular degeneration (AMD).

Design: Retrospective comparative cohort study.

Methods: Patients with a diagnosis of unilateral exudative AMD and confirmed to have or suspected of having glaucoma in both eyes receiving unilateral intravitreal injections were identified. Those with ≥3 RNFL optical coherence tomography scans and ≥6 injections were included in the study. Rates of RNFL thinning in the injected eye versus the uninjected eye were estimated using linear mixed models. The main outcome measurement was the differences in rates of RNFL thinning in the injected versus the fellow uninjected eye. The effects of postinjection elevation of intraocular pressure (IOP), injection frequency, and number of injections were also evaluated.

Results: A total of 53 patients met the inclusion criteria, receiving 26.4 ± 15.9 intravitreal injections. The average rate of RNFL thinning in uninjected eyes was -0.620 μm/year (P = .029). Injected eyes had an additional incremental loss of -0.385 μm/year, but this value was not statistically significant (95% confidence interval [CI]: -1.147 to 0.379 μm/year; P = .324). Subgroup analysis with only glaucoma patients (n = 33) also demonstrated a nonsignificant effect of injections (-0.568 μm/year; 95% CI: -1.454 to 0.319 μm/year; P = .212). Postinjection IOP elevation, injection frequency, and total number of injections were not associated with faster RNFL loss.

Conclusions: Among exudative AMD patients with glaucoma or suspected of having glaucoma, the rate of RNFL thinning in eyes receiving intravitreal injections did not significantly differ from that of fellow uninjected eyes.
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http://dx.doi.org/10.1016/j.ajo.2020.12.016DOI Listing
December 2020

Conjunctival Vessels in Diabetes Using Functional Slit Lamp Biomicroscopy.

Cornea 2020 Dec 16;Publish Ahead of Print. Epub 2020 Dec 16.

University of Miami Miller School of Medicine, Miami, FL; Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL; Division of Endocrinology, Diabetes and Metabolism, Comprehensive Diabetes Center Miami, FL; and Surgical Services, Miami Veterans Administration Medical Center, Miami, FL.

Purpose: This study used functional slit lamp biomicroscopy (FSLB) to quantify conjunctival microvessel parameters in individuals with and without diabetes and examined whether these metrics could be used as surrogate markers of diabetes-related complications.

Methods: A cross-sectional study of 98 controls (C), 13 individuals with diabetes without complications (D-C), and 21 with diabetes and related complications (D+C), which included retinopathy, nephropathy, neuropathy, and cardiovascular-, peripheral vascular-, and cerebrovascular diseases, was performed. Bulbar conjunctival metrics (venule diameter, length, axial velocity [Va], cross-sectional velocity [Vs], flow [Q], and branching complexity) were measured using FSLB (digital camera mounted on traditional slit lamp).

Results: The mean age was 60 ± 11 years, and demographics were similar across the groups. Va and Vs significantly differed between groups. Va was 0.51 ± 0.17 mm/s, 0.62 ± 0.17 mm/s, and 0.45 ± 0.17 mm/s in the C, D-C, and D+C groups, respectively (P = 0.025). Similarly, Vs was 0.35 ± 01.12, 0.43 ± 0.13, and 0.32 ± 0.13 mm/s in the C, D-C, and D+C groups, respectively (P = 0.031). Black individuals had increased Va, Vs, and Q compared with White individuals (P < 0.05), but differences in velocities persisted after accounting for race. Among patients with diabetes, Va and Vs correlated with number of organ systems affected (Va: ρ = -0.42, P = 0.016; Vs: ρ = -0.41, P = 0.021). Va, Vs, and Q significantly (P ≤ 0.005) discriminated between diabetic patients with and without complications (area under the receiver operating curve for Va = 0.81, Vs = 0.79, Q = 0.81).

Conclusions: Bulbar conjunctival blood flow metrics measured by FSLB differed between controls, diabetic patients without complications, and diabetic patients with complications. FSLB is a quick, easily accessible, and noninvasive alternative that might estimate the burden of vascular complications in diabetes.
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http://dx.doi.org/10.1097/ICO.0000000000002623DOI Listing
December 2020

Comparison Between Graders in Detection of Diabetic Neovascularization With Swept Source Optical Coherence Tomography Angiography and Fluorescein Angiography.

Am J Ophthalmol 2020 Dec 11;224:292-300. Epub 2020 Dec 11.

Bascom Palmer Eye Institute, Miami, Florida, USA. Electronic address:

Purpose: We compared the ability of ophthalmologists to identify neovascularization (NV) in patients with proliferative diabetic retinopathy using swept-source optical coherence tomography angiography (SS-OCTA) and fluorescein angiography (FA).

Design: Retrospective study comparing diagnostic instruments.

Methods: Eyes with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy and a high suspicion of NV based on clinical examination were imaged using SS-OCTA and FA at the same visit. Two separate grading sets consisting of scrambled, anonymized SS-OCTA and FA images were created. The ground truth for presence of NV was established by consensus of 2 graders with OCTA experience who did not participate in the subsequent assessment of NV in this study. The 2 anonymized image sets were graded for presence or absence of NV by 12 other graders that included 2 residents, 6 vitreoretinal fellows, and 4 vitreoretinal attending physicians. The percentage of correct grading of NV using SS-OCTA and FA was assessed for each grader and across grader training levels.

Results: Forty-seven eyes from 24 patients were included in this study. Overall, the mean percentage of correct NV grading was 87.8% using SS-OCTA with B-scans and 86.2% using FA (P = .92). Assessing each grader individually, there was no statistically significant asymmetry in correct grading using SS-OCTA and FA.

Conclusions: Ophthalmologists across training levels were able to identify diabetic NV with equal accuracy using SS-OCTA and FA. Based on these results, SS-OCTA may be an appropriate standalone modality for diagnosing diabetic NV.
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http://dx.doi.org/10.1016/j.ajo.2020.11.020DOI Listing
December 2020

The Tube Versus Trabeculectomy IRIS® Registry Study: Cohort Selection and Follow-up and Comparisons to the Randomized Controlled Trial.

Am J Ophthalmol 2020 Dec 8;224:43-52. Epub 2020 Dec 8.

Bascom Palmer Eye Institute, Miami, Florida, USA.

Purpose: To assess the feasibility of replicating a randomized controlled trial (RCT) with a cohort of eyes, from IRIS® Registry data, analogous to the Tube Versus Trabeculectomy (TVT) RCT cohort and compare characteristics and follow-up.

Design: Comparison of RCT and IRIS Registry cohorts and follow-up.

Methods: We identified a cohort of IRIS Registry eyes (2013-2017) that received either a glaucoma drainage implant (tube) or trabeculectomy after a previous trabeculectomy and/or cataract extraction; extracted clinical and demographic characteristics for baseline surgery and follow-up visits through 1 year; and compared treatment groups in the IRIS Registry cohort and this cohort to the TVT RCT cohort.

Results: The IRIS Registry cohort included 419 eyes: 183 (43.7%) trabeculectomy; 236 (56.3%) tube. There were significant differences between treatment groups, including race (White: trabeculectomy 61.8%, tube 44.9%; Black: trabeculectomy 20.8%, tube 35.6%; P = .003) and the percentage of follow-up visits completed (trabeculectomy 88.4%, tube 83.8%, P = .004). There were also significant differences between the TVT IRIS Registry cohort and the TVT RCT cohort in the percentage of follow-up visits completed (IRIS Registry 85.6%, RCT 96.1%, P < .001) and in the probability of having a 1-year follow-up visit (IRIS Registry 81.4%, RCT 89.2%, P = .011).

Conclusion: The TVT IRIS Registry cohort had several significant treatment group differences at baseline, whereas there had been none in the TVT RCT cohort. Follow-up in the TVT IRIS Registry cohort was inferior to that of the TVT RCT. Some data needed to refine the selection of eyes for the cohort were not available in the IRIS Registry.
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http://dx.doi.org/10.1016/j.ajo.2020.11.014DOI Listing
December 2020

Investigating Vascular Complexity and Neurogenic Alterations in Sectoral Regions of the Retina in Patients With Cognitive Impairment.

Front Physiol 2020 9;11:570412. Epub 2020 Nov 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States.

Evidence is accumulating that cognitive function, and visual impairment may be related. In this pilot study, we investigated whether multifractal dimension and lacunarity analyses performed in sectoral regions of the retina may reveal changes in patients with cognitive impairment (CI) that may be masked in the study considering the whole retinal branching pattern. Prospective age-matched subjects ( = 69) with and with no CI and without the presence of any ophthalmic history were recruited (age > 55+ years). The Montreal Cognitive Assessment (MoCA) was used to measure CI, and full-field electroretinogram (ERG) was performed. Also, visual performance exams were conducted using the Rabin cone contrast test (CCT). Quantification of the retinal structure was performed in retinal fundus images [45 field of view (FOV), optic disk centered] with excellent quality for all individuals [19 healthy controls (HC) and 20 patients with CI] after evaluating the inclusion and exclusion criteria in all study participants recruited ( = 69). The skeletonized vasculature network that comprised the whole branching pattern observable in the full 45° FOV was obtained for each image and divided into nine equal regions (superotemporal, superior, superonasal, macular, optic disk, nasal, inferotemporal, inferior, and inferonasal). The multifractal behavior was analyzed by calculating the generalized dimension Dq (Do, D1, and D2), the lacunarity parameter (Λ), and singularity spectrum f(α) in the nine sectoral skeletonized images as well as in the skeletons that comprised the whole branching pattern observable in the full 45° FOV. The analyses were performed using the ImageJ program together with the FracLac plug-in. Independent sample -tests or Mann Whitney test and Pearson correlation coefficient were used to find associations between all parameters in both groups. The effect size (Cohen's ) of the difference between both groups was also assessed. A -value < 0.05 was considered statistically significant. Significant correlations between multifractal and Λ parameters with the MoCA and implicit time ERG-parameter were observed in the regional analysis. In contrast, no trend was found when considering the whole retinal branching pattern. Analysis of combined structural-functional parameters in sectoral regions of the retina, instead of individual retinal biomarkers, may provide a useful clinical marker of CI.
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http://dx.doi.org/10.3389/fphys.2020.570412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680898PMC
November 2020

Pain sensitivity and autonomic nervous system parameters as predictors of dry eye symptoms after LASIK.

Ocul Surf 2021 01 21;19:275-281. Epub 2020 Oct 21.

Department of Physical Medicine & Rehabilitation, University of Miami, Miami, FL, USA; Research Service, Miami Veterans Administration Medical Center, Miami, FL, USA.

Purpose: Differences in pain processing and autonomic function among patients have been implicated in the development of chronic pain after surgery. This study was designed to evaluate whether pain and autonomic metrics predict severity of chronic dry eye (DE) symptoms after LASIK, as there is increasing evidence that DE symptoms may be manifestations of persistent post-operative ocular pain.

Methods: Secondary analysis of prospective randomized clinical trial. Patients were treated with either pregabalin or placebo. As no significant differences in DE symptoms were detected by treatment allocation at six months, all participants were grouped together for the present analyses. Subjects were evaluated pre-LASIK with regard to evoked pain sensitivity (utilizing quantitative sensory testing), autonomic metrics and DE and ocular pain symptoms (via validated questionnaires). Measures of DE and ocular pain were assessed post-LASIK, and the Dry Eye Questionnaire 5 (DEQ5) score 6-months after surgery was the primary outcome of interest.

Results: 43 individuals were randomized to pregabalin (n = 21) or placebo (n = 22). 42 completed the 6-month visit. Several baseline autonomic metrics correlated with 6-month post-operative DEQ5 scores, including lower systolic (r -0.37, p = 0.02) and diastolic blood pressure (r -0.32, p = 0.04). Ocular pain at 6 months was also negatively correlated with blood pressure (r -0.31, p = 0.047). The presence of painful aftersensations was a significant predictor of chronic DE symptoms at 6 months (mean DEQ5 scores: 8.0 ± 1.9 versus 5.0 ± 5.0, p = 0.009).

Conclusions: Heightened parasympathetic tone and prolonged pain sensitivity measured prior to surgery predicted greater DE symptom severity 6 months after LASIK.

Trial Registration: NCT02701764.
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http://dx.doi.org/10.1016/j.jtos.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867610PMC
January 2021

Dose-Response Relationship between Intravitreal Injections and Retinal Nerve Fiber Layer Thinning in Age-Related Macular Degeneration.

Ophthalmol Retina 2020 Oct 10. Epub 2020 Oct 10.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To determine if multiple intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors for unilateral exudative age-related macular degeneration (eAMD) are associated with thinning of the retinal nerve fiber layer (RNFL), we compared RNFL thickness measurements from the injected eye with that of the fellow eye with nonexudative age-related macular degeneration (neAMD).

Design: Retrospective, cross-sectional study.

Participants: Patients undergoing anti-VEGF therapy for unilateral eAMD.

Methods: Patients receiving anti-VEGF therapy secondary to eAMD in 1 eye with neAMD in their fellow eye were identified. Patients with a known diagnosis of glaucoma were excluded. Spectral domain OCT measurements of the peripapillary RNFL thickness from both eyes were performed and compared. The differences in the RNFL thickness measurements between eyes were correlated with the number of injections and the duration of therapy.

Main Outcome Measures: Correlation between the number of anti-VEGF injections and peripapillary RNFL thinning.

Results: A total of 108 eyes of 54 patients were evaluated in this study. The average peripapillary RNFL thickness measurements of the injected eye and fellow eye were 87.3 ± 9.6 μm and 89.0 ± 7.5 μm, respectively (P = 0.055). The RNFL thickness difference (fellow eye minus injected eye) was significantly correlated with the number of injections (r = 0.40, P = 0.002) and months of injections (r = 0.38, P = 0.005). The relationship between the difference in the RNFL thickness and the number of injections had a nonlinear dose-response relationship that became apparent after approximately 30 injections and 50 months of injections.

Conclusions: The difference in RNFL thickness measurements between injected eyes and uninjected fellow eyes was largely within the reported normal limits for interocular differences between healthy eyes. Nevertheless, there was a dose-response relationship between RNFL thinning and number of injections among patients receiving a greater number of injections, suggesting that anti-VEGF injections may have a modest effect on the RNFL thickness after several years of therapy in eyes requiring more anti-VEGF injections; however, we cannot exclude that the RNFL thinning may be secondary to active age-related macular degeneration (AMD) disease progression in both eyes.
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http://dx.doi.org/10.1016/j.oret.2020.10.004DOI Listing
October 2020

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Ophthalmology 2020 09;127(9):e81-e82

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.04.025DOI Listing
September 2020

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Ophthalmology 2020 09;127(9):e79-e80

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.04.014DOI Listing
September 2020

Corneal Nerve Pathway Function in Individuals with Dry Eye Symptoms.

Ophthalmology 2021 Apr 8;128(4):619-621. Epub 2020 Aug 8.

Department of Anesthesia, University of Miami, Miami, Florida.

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http://dx.doi.org/10.1016/j.ophtha.2020.07.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868519PMC
April 2021

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Ophthalmology 2020 10 29;127(10):e92-e93. Epub 2020 Jul 29.

Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ophtha.2020.05.019DOI Listing
October 2020

Separation and thickness measurements of superficial and deep slabs of the retinal nerve fiber layer in healthy and glaucomatous eyes.

Ophthalmol Glaucoma 2020 Jan-Feb;3(1):66-75. Epub 2019 Nov 20.

Department of Ophthalmology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States.

Purpose: Describe a new method to analyze retinal nerve fiber layer (RNFL) thickness maps.

Design: Cross-sectional study.

Subjects: RNFL thickness maps of healthy and glaucomatous eyes.

Methods: Optical coherence tomography (OCT) RNFL raster scans from 98 healthy and 50 glaucomatous eyes were analyzed. The RNFL thickness maps were separated into superficial (SNFL) and deep (DNFL) slabs through a partial thickness plane set at the modal thickness (mode). Association between mode and OCT signal strength (SS), age, axial length, and visual field mean deviation (VFMD) was tested (Pearson coefficient, ). Thicknesses of inferior and superior SNFL regions (i-,s-SNFL), and inferior, superior, nasal, and temporal DNFL regions (i-,s-,n-,t-DNFL) were calculated. The regions thicknesses were compared between healthy and glaucomatous eyes (t-test) and between glaucomatous eyes with early, moderate, and severe disease (ANOVA and linear regressions of thickness on VFMD). Diagnostic accuracy and correlation with VFMD of RNFL regions thicknesses were calculated as the area under the receiver operating characteristic curve (AUC) and Pearson respectively. <0.05 was considered significant.

Main Outcome: Thickness of regions in SNFL and DNFL slabs.

Results: The mode was not associated with SS, age, axial length, or VFMD, it circumscribed the thicker RNFL around the optic disc of healthy and glaucomatous eyes, and it was used to separate the SNFL and DNFL slabs of RNFL thickness maps. The thickness of the SNFL slab was less in glaucomatous eyes than in healthy eyes (<0.001). S-SNFL and i-SNFL thicknesses (respectively) were 86.0±8.2μm and 87.3±9.6μm in healthy eyes vs. 66.1±9.1μm and 63.4±8.2μm in glaucomatous eyes (<0.001 for both). The thickness of the DNFL slab was similar between groups (=0.19). T-DNFL thickness was 37.0±5.3μm in healthy eyes vs. 33.9±5.0μm in glaucomatous eyes (<0.001); thicknesses of all other DNFL regions were similar. The SNFL regions only thinned with progressively worse glaucoma severity, had excellent AUCs (AUC≥0.95, <0.001), and correlated strongly with VFMD (≥0.60, <0.001).

Conclusions: Glaucomatous RNFL thinning is predominantly detected within a slab with thickness greater than the mode. SNFL thickness has great AUC and correlation with VFMD in glaucomatous eyes. The usefulness for diagnosis and monitoring of glaucoma needs further study.
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http://dx.doi.org/10.1016/j.ogla.2019.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337289PMC
November 2019

Comparing Treatment Outcomes from the Tube Versus Trabeculectomy and Primary Tube Versus Trabeculectomy Studies.

Ophthalmology 2021 Feb 2;128(2):324-326. Epub 2020 Jul 2.

Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota.

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http://dx.doi.org/10.1016/j.ophtha.2020.06.059DOI Listing
February 2021

Validation of a Compensation Strategy Used to Detect Choriocapillaris Flow Deficits Under Drusen With Swept Source OCT Angiography.

Am J Ophthalmol 2020 12 2;220:115-127. Epub 2020 Jul 2.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

Purpose: A compensation strategy that was developed to measure the choriocapillaris (CC) flow deficits (FDs) under drusen was tested in eyes with large drusen from age-related macular degeneration (AMD) before and after the drusen spontaneously resolved without evidence of disease progression.

Design: Prospective, observational consecutive case series.

Methods: Patients with AMD were enrolled in a prospective swept-source optical coherence tomography (SS-OCT) imaging study. Consecutive eyes with large drusen were followed, and eyes that underwent spontaneous collapse of drusen without evidence of disease progression were identified retrospectively. The drusen-resolved regions were manually outlined. CC FDs were measured using a previously published compensation strategy that adjusted for the decreased signal intensity underlying drusen. Both the percentage of FDs (FD%) and the mean FD sizes (MFDSs) were measured before and after drusen resolution.

Results: Resolution of drusen was identified in 8 eyes from 8 patients. The average interval between the 2 visits was 7.8 months. The average drusen volumes measured between visits were 0.23 and 0.04 mm, respectively. After the drusen resolved, the average follow-up time without evidence of disease progression was 10.1 months. When the 2 visits were compared, there were no statistically significant differences in any of the CC parameters within the drusen resolved regions once the compensation strategy was applied (all P values >.22).

Conclusions: In this naturally occurring experiment in which drusen collapsed without evidence of disease progression, the CC parameters were similar once our compensation strategy was applied both before and after the drusen resolved.
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http://dx.doi.org/10.1016/j.ajo.2020.06.033DOI Listing
December 2020

Reply.

Ophthalmology 2020 07;127(7):e45-e46

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.02.033DOI Listing
July 2020

A Comparison Study of Polypoidal Choroidal Vasculopathy Imaged with Indocyanine Green Angiography and Swept-Source Optical Coherence Tomography Angiography.

Am J Ophthalmol 2020 09 21;217:240-251. Epub 2020 May 21.

Department of Ophthalmology, Kyung Hee University Medical Center, Kyung Hee University, Seoul, South Korea. Electronic address:

Purpose: Indocyanine green angiography (ICGA) was compared with swept-source optical coherence tomography angiography (SS-OCTA) for the detection of polypoidal choroidal vasculopathy (PCV).

Design: Retrospective, cross-sectional.

Methods: Patients with treatment-naïve PCV based on ICGA imaging underwent same-day SS-OCTA imaging at Kyung Hee University Medical Center between April 2017 and November 2018. ICGA and SS-OCTA images were graded independently. SS-OCTA images were graded using both flow and structural information. Images were graded for the number of polypoidal lesions and the total lesion area, which included both the polypoidal lesions and the branching vascular networks (BVNs).

Results: A total of 31 eyes from 30 patients were enrolled. Polypoidal lesions were identified in all eyes using both modalities, and there was agreement on the number of polypoidal lesions in 17 eyes (55%). In 12 eyes (39%), SS-OCTA graders identified a greater number of polypoidal lesions, and in 2 eyes (6%) ICGA graders identified more lesions. There was no significant difference in the lesion area measurements (standard deviation = 1.09, P = .08). The lesion with the largest difference in area measurements resulted from focal areas of atrophy, misdiagnosed as polypoidal lesions on ICGA, and a low-lying serous retinal pigment epithelial detachment erroneously identified as part of the BVN by ICGA graders. SS-OCTA imaging correctly diagnosed the focal areas of atrophy and the serous retinal pigment epitheial detachment.

Conclusions: SS-OCTA imaging was comparable to ICGA for the diagnosis of treatment-naïve PCV. However, SS-OCTA might be better than ICGA in correctly identifying both polypoidal lesions and BVNs in treatment-naïve PCV.
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http://dx.doi.org/10.1016/j.ajo.2020.05.017DOI Listing
September 2020

Visual Field Outcomes in the Tube Versus Trabeculectomy Study.

Ophthalmology 2020 09 4;127(9):1162-1169. Epub 2020 Mar 4.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To describe visual field (VF) outcomes in the Tube Versus Trabeculectomy (TVT) Study.

Design: Cohort analysis of patients in a multicenter randomized clinical trial.

Participants: A total of 122 eyes of 122 patients, with 61 eyes in both the tube shunt and trabeculectomy groups.

Methods: The TVT Study is a multicenter randomized clinical trial comparing the safety and efficacy of tube shunt surgery (350-mm Baerveldt implant) and trabeculectomy with mitomycin C (MMC) (0.4 mg/ml for 4 minutes) in patients with previous cataract or glaucoma surgery. Enrolled patients underwent perimetry at baseline and annual follow-up visits. The VFs were included if the false-positive rate was ≤20% and false-negative rate was ≤35%. The VFs were excluded if visual acuity <20/400 or loss of ≥2 Snellen lines from baseline was attributed to an etiology other than glaucoma. Longitudinal linear mixed-effects models with best linear unbiased predictions (BLUPs) were applied to estimate rates of change in mean deviation (MD) for each treatment group.

Main Outcome Measure: Rate of MD change during follow-up period.

Results: A total of 436 reliable VFs were analyzed, with an average of 3.6 VFs per eye. Baseline MD was -13.07 ± 8.4 decibels (dB) in the tube shunt group and -13.18 ± 8.2 dB in the trabeculectomy group (P = 0.99). The rate of change in MD was -0.60 dB/year in the tube group and -0.38 dB/year in the trabeculectomy group (P = 0.34). The 95% confidence intervals for the rates of MD change were -0.77 to -0.44 dB/year in the tube group and -0.56 to -0.20 dB/year in the trabeculectomy group. No significant difference in MD slope was seen when patients were categorized by percentage of visits with intraocular pressure (IOP) <18 mmHg or by average IOP. Univariable and multivariable risk factor analyses identified history of diabetes, elevated IOP, and worse MD as baseline factors associated with more rapid VF loss.

Conclusions: Slow rates of VF loss were observed after randomized surgical treatment in the TVT Study, but no significant difference in the rate of VF loss was seen after tube shunt implantation and trabeculectomy with MMC. Patients with diabetes, higher IOP, and more severe VF loss at baseline were at higher risk for VF progression.
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http://dx.doi.org/10.1016/j.ophtha.2020.02.034DOI Listing
September 2020

Ophthalmology Resident Surgical Competence: A Survey of Program Directors.

Ophthalmology 2020 08 20;127(8):1123-1125. Epub 2020 Feb 20.

Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ophtha.2020.02.017DOI Listing
August 2020

Reply.

Ophthalmology 2020 04;127(4):e26

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1016/j.ophtha.2019.11.023DOI Listing
April 2020

Long-term PERG monitoring of untreated and treated glaucoma suspects.

Doc Ophthalmol 2020 10 9;141(2):149-156. Epub 2020 Mar 9.

Mc Knight Vision Research Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 1638 NW 10th Ave., Room 101, Miami, FL, 33136, USA.

Purpose: To investigate long-term structural and functional progression of untreated and treated glaucoma suspects (UGS and TGS).

Methods: Retrospective analysis of serial steady-state pattern electroretinogram (PERG), mean retinal nerve fiber layer thickness (RNFLT), and standard automated perimetry mean deviation (SAP-MD) in UGS (N = 20) and TGS (N = 18). Outcome measures were the rates of change (linear regression slopes) of PERG amplitude, PERG phase, mean RNFLT, and SAP-MD over 9.8 ± 1.3 years (15.6 ± 4.2 visits).

Results: The number of patients with significant (P < 0.05) progression slopes for PERG amplitude, PERG phase, RNFLT, and SAP-MD was, respectively, UGS: 5, 0, 4, 2; TGS: 8, 2, 6, 5. In UGS, outcome measures were not correlated with each other. In TGS, both PERG amplitude and RNFLT were significantly (P < 0.05) correlated with SAP-MD (R ≥ 0.58), while PERG amplitude and RNFLT were not correlated with each other (R = 0.43, P = 0.064). The rate of change of SAP-MD was predicted (P < 0.05) by a linear combination of RNFLT slope and PERG amplitude slope.

Conclusions: Results substantiate and extend previous results showing that steady-state PERG amplitude progressively decreased over time in a proportion of glaucoma suspects, with relatively steeper slope in TGS compared to UGS. RNFLT progression also had a steeper slope in TGS compared to UGS; however, progressions of PERG amplitude and RNFLT were not significantly correlated. Both PERG progression and RNFLT progression independently contribute to prediction of visual field progression.
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http://dx.doi.org/10.1007/s10633-020-09760-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483546PMC
October 2020

Diagnostic Performance of 3-Dimensional Thickness of the Endothelium-Descemet Complex in Fuchs' Endothelial Cell Corneal Dystrophy.

Ophthalmology 2020 07 19;127(7):874-887. Epub 2020 Jan 19.

Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida; Electrical and Computer Engineering, University of Miami, Miami, Florida; Department of Biomedical Engineering, University of Miami, Miami, Florida. Electronic address:

Purpose: To describe the diagnostic accuracy of 3-dimensional (3D) endothelium-Descemet's membrane complex thickness (En-DMT) in Fuchs' endothelial corneal dystrophy (FECD) and determine its potential role as an objective index of disease severity.

Design: Observational case-control study.

Participants: One hundred four eyes of 79 participants (64 eyes of 41 FECD patients and 40 eyes of 38 healthy controls).

Methods: All participants received high-definition OCT imaging (Envisu R2210; Bioptigen, Buffalo Grove, IL). Fuchs' endothelial corneal dystrophy was classified clinically into early-stage (without edema) and late-stage (with edema) disease. Automatic and manual segmentation of corneal layers was performed using a custom-built segmental tomography algorithm to generate 3D maps of total corneal thickness (TCT) and En-DMT of the central 6-mm cornea. Regional En-DMT, regional TCT, and central-to-peripheral total corneal thickness ratio (CPTR) were evaluated and correlated to the clinical severity of FECD. Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to assess the reliability of the repeated measurements in all eyes.

Main Outcome Measures: Central-to-peripheral total corneal thickness ratio and average En-DMT and TCT of central, paracentral, and peripheral regions.

Results: In FECD, a significant increase in En-DMT, CPTR and TCT was found compared to controls (P < 0.001). For identifying FECD, average En-DMT of paracentral and peripheral regions achieved 94% sensitivity and 100% specificity (cutoffs, 19 μm and 20 μm, respectively), whereas CPTR showed 94% sensitivity with a 73% specificity (cutoff, 0.97). Regarding early-stage FECD, average En-DMT of central zones achieved 92% sensitivity and 97% specificity (cutoff, 18 μm), whereas CPTR showed 90% sensitivity and 88% specificity (cutoff, 0.97). The average En-DMT of central, paracentral, and peripheral regions was correlated highly with FECD clinical stage (Spearman's ρ = 0.813, 0.793, and 0.721, respectively; all P < 0.001), compared with CPTR and mean TCT of paracentral zones (0.672 and 0.481, respectively; P < 0.001). The ICC values ranged from 0.98 (En-DMT) to 0.99 (TCT) with a good agreement between the automatic and manual measurements.

Conclusions: Regional 3D En-DMT is a novel diagnostic tool of FECD that can be used to quantify the disease severity with excellent reliability.
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http://dx.doi.org/10.1016/j.ophtha.2020.01.021DOI Listing
July 2020

Age-Related Changes in Choroidal Thickness and the Volume of Vessels and Stroma Using Swept-Source OCT and Fully Automated Algorithms.

Ophthalmol Retina 2020 02 1;4(2):204-215. Epub 2019 Oct 1.

Department of Bioengineering, University of Washington, Seattle, Washington; Department of Ophthalmology, University of Washington, Seattle, Washington. Electronic address:

Purpose: To determine age-related changes in choroidal thickness and the volume of choroidal vessels and stroma using automated algorithms based on structural swept-source OCT (SS-OCT) scans.

Design: Prospective and observational study.

Participants: The study included 144 normal participants with ages ranging from 20 to 88 years.

Methods: A previously reported strategy was used to automatically segment the choroid using SS-OCT structural images. Attenuation correction was applied on B-scans to enhance the choroidal contrast and facilitate more accurate automatic segmentation of the 3-dimensional choroidal vessel and stroma. The parameters that we investigated included mean choroidal thickness (MCT), choroidal vessel volume (CVV), choroidal stroma volume (CSV), choroid vascularity index (CVI), and the choroidal stroma-to-vessel volume ratio (CSVR). Correlations between MCT and choroidal vessel metrics of CVV, CSV, CVI, and CSVR were studied. Regional distributions of MCT and CVI were analyzed using a grid centered on the fovea. Age-related changes in MCT, CVV, CSV, and CVI were studied in the entire scanning region, as well as in the subregions of the grids.

Main Outcome Measures: Age-related changes in MCT, CVV, CSV, and CVI using 6×6-mm and 12×12-mm SS-OCT scans.

Results: The automated choroid segmentations were validated against manual segmentations, and MCT measurements were shown to be in good agreement (P < 0.0001). Choroidal vessel volume and CSV showed significant correlations with MCT (all P < 0.0001). Interestingly, CVI and CSVR were constant, with little variation among all participants regardless of age and MCT (61.1±1.8% and 0.64±0.05, respectively). Measurements on 12×12-mm and 6×6-mm scans showed excellent agreement in all scan regions (all P < 0.0001). While choroidal thickness and choroidal volume, which includes both choroidal vessels and stroma, decrease with age (all P < 0.0001), the CVI and CSVR vary little among all ages in all regions.

Conclusions: Whereas MCT, CVV, and CSV decrease with age, the CVI and CSVR remain constant in all regions with age. Ongoing studies are using these automated algorithms on SS-OCT structural datasets to investigate the diagnostic usefulness of these choroidal parameters in a myriad of ocular and systemic diseases.
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http://dx.doi.org/10.1016/j.oret.2019.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812781PMC
February 2020

Retinal Nonperfusion in Proliferative Diabetic Retinopathy Before and After Panretinal Photocoagulation Assessed by Widefield OCT Angiography.

Am J Ophthalmol 2020 05 13;213:177-185. Epub 2020 Mar 13.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: Widefield swept source optical coherence tomography angiography (WF SS-OCTA) imaging was compared with ultra-widefield (UWF) fluorescein angiography (FA) imaging to better understand changes in retinal nonperfusion before and after panretinal photocoagulation (PRP) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR).

Design: Prospective, observational, consecutive case series.

Methods: Participants with treatment-naïve PDR were imaged using the SS-OCTA 12- × 12-mm scan pattern at baseline and at 1 week, 1 month, and 3 months after PRP. UWF FA was obtained at baseline and 3 months after PRP. Selected eyes were imaged using 5 SS-OCTA 12- × 12-mm scans to create a posterior pole montage, and 5 eyes also underwent SS-OCTA imaging at 6 months and 1 year. Areas of retinal nonperfusion (RNP) were drawn independently by 2 masked graders, and analysis of variance (ANOVA) tests were used to compare areas of RNP over time. Main outcome measurements consisted of areas and boundaries of RNP visualized using WF SS-OCTA and UWF FA.

Results: From January 2018 through January 2019, WF SS-OCTA was performed on 20 eyes with treatment-naïve PDR from 15 patients. Areas of RNP identified on UWF FA images co-localized with RNP areas visualized on WF SS-OCTA images. There were no statistically significant changes in RNP area on WF SS-OCTA images through 3 months after PRP. Even eyes that were severely ischemic at baseline had no significant changes in RNP area 1 year after PRP.

Conclusions: RNP in PDR can be identified at baseline and imaged serially after PRP using WF SS-OCTA. Retinal perfusion in PDR does not change significantly after PRP. The ability of WF SS-OCTA to longitudinally evaluate RNP areas provides additional justification for adopting WF SS-OCTA as the sole imaging modality for clinical management of PDR.
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http://dx.doi.org/10.1016/j.ajo.2020.01.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962743PMC
May 2020