The Asia-Pacific Journal of Ophthalmology

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Articles appearing in this section have been peer-reviewed and accepted for publication and posted online before formal publication. Articles appearing here may contain statements, opinions, and information that have errors in facts, figures, or interpretation. Accordingly, the editors and authors and their respective employees are not responsible or liable for the use of any such inaccurate or misleading data, opinion or information contained the articles in this section.

Original Study - Clinical

Visual Acuity Improves in Children and Adolescents With Idiopathic Infantile Nystagmus Balzer, Ben W.R.; Catt, Caroline J.; Bou-Abdou, Milia; Martin, Frank J.
PURPOSE: Idiopathic infantile nystagmus is associated with reduced visual acuity. Recent work has linked extraocular muscle surgery to improvements in visual acuity through childhood but no work has reported long-term secular trends in visual acuity in infantile nystagmus. Our aim is to describe visual acuity changes for children and adolescents with idiopathic infantile nystagmus to allow comparison for future interventional studies.

DESIGN: Retrospective chart review.

METHODS: Review of patients attending our center up to the age of 18 with a diagnosis of idiopathic infantile nystagmus and visual acuity measured using Snellen visual acuity. Patients provided informed consent.

RESULTS: We observed improvements in best corrected visual acuity in 43 children and adolescents with idiopathic infantile nystagmus. Binocular best corrected visual acuity improved at a rate of -0.16 logarithm of the minimum angle of resolution (logMAR)/log year of age (P < 0.001), an improvement of 0.05 logMAR (half a Snellen line) as the age doubles. Intraclass correlation was 0.95 and interindividual correlation between visual acuity and age was significant (r = -0.24, P < 0.001).

CONCLUSIONS: We describe a natural history of gradual improvement in binocular visual acuity in infantile nystagmus and provide a baseline against which future interventional work can be compared.
Combined Cataract Extraction With Pars Plana Vitrectomy and Metallic Intraocular Foreign Body Removal Through Sclerocorneal Tunnel Using a Novel “Magnet Handshake” Technique Dhoble, Pankaja; Khodifad, Ashish
Purpose: To study the outcomes of combined cataract extraction with pars plana vitrectomy (PPV) and metallic intraocular foreign body (IOFB) removal through a sclerocorneal tunnel using the “magnetic handshake” technique.

Design: A retrospective review.

Methods: Retrospective review of case records of 14 patients from 2010 to 2016 with metallic IOFB and traumatic cataract was performed. Cataract extraction was combined with PPV. Two intraocular magnets (IOMs) introduced through 20-gauge vitrectomy port and sclerocorneal tunnel helped achieve safe delivery of IOFB outside the globe by the “magnetic handshake” technique.

Results: All patients were males with a mean age of 33.04 years. A final best corrected visual acuity (BCVA) of 20/60 or better was noted in 10 (71.42%) of 14 patients. Final reattachment with more than 1 surgery was achieved in 13 (92.85%) patients. Postoperative complications included retinal detachment (RD) and phthisis bulbi in 1 (14.28%) patient each.

Conclusions: Combined cataract extraction with PPV and metallic IOFB removal through sclerocorneal tunnel using the “magnet handshake” technique gives good visual and surgical outcomes.

Review Article

Anti-VEGF Therapy for Neovascular AMD and Polypoidal Choroidal Vasculopathy Cheung, Gemmy Chui Ming; Lai, Timothy Y.Y.; Gomi, Fumi; Ruamviboonsuk, Paisan; Koh, Adrian; Lee, Won Ki
Anti‒vascular endothelial growth factor (anti-VEGF) therapy has revolutionized the treatment of neovascular age-related macular degeneration (AMD). This review will summarize the current evidence of anti-VEGF therapy in neovascular AMD, including subtypes of retinal angiomatous proliferation and polypoidal choroidal vasculopathy (PCV). Importantly, 2 large multicenter randomized clinical trials evaluating the safety and efficacy of anti-VEGF monotherapy and combination with photodynamic therapy (PDT) have recently reported initial first-year outcomes. In this review, we summarize the latest updates in the efficacy and safety of anti-VEGF monotherapy and combination with PDT in common lesion subtypes. Remaining gaps in current understanding are highlighted where further research is needed.
Intravitreal Ziv-Aflibercept: Clinical Effects and Economic Impact Singh, Sumit Randhir; Dogra, Avantika; Stewart, Michael; Das, Taraprasad; Chhablani, Jay
During the past decade, drugs that inhibit the actions of vascular endothelial growth factor (VEGF) have become standard-of-care treatment for a variety of chorioretinal vascular conditions. The off-label, intravitreal use of ziv-aflibercept (Zaltrap) has provided clinicians with an additional cost-effective drug. The commercial preparation of ziv-aflibercept contains the same aflibercept (VEGF-trap) molecule as Eylea but has a much higher osmolarity (1000 mOsm/kg vs 300 mOsm/kg). Initial concerns regarding cytotoxicity and long-term safety of intravitreal ziv-aflibercept have been largely negated after a series of publications failed to identify adverse ocular and systemic side effects. Both treatment-naive and anti-VEGF‒resistant cases of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), retinal vein occlusion (RVO), and choroidal neovascular membrane (CNVM) may respond as well to ziv-aflibercept as to aflibercept. A higher dose of ziv-aflibercept (2 mg in 0.08 mL) does not cause any adverse effects during short-term follow-up period (1 month). Data from various sources suggest that ziv-aflibercept may be as cost effective as bevacizumab, thereby making it an attractive treatment option in low- and middle-income countries. However, problems with off-label use, compounding, and counterfeiting limit its availability in many countries. Data from prospective, randomized, multicenter clinical trials are still required to convince physicians and regulatory bodies of its clinical efficacy and potential as early therapy.
Paradigms for Pediatric Cataract Surgery Vasavada, Viraj
Pediatric cataract surgery has seen several advances in techniques, technologies, and conceptual practices. Pediatric cataract management heavily depends on a combined effort, not only from the ophthalmologist, but also the parents, the anesthetists, and the supporting staff members (eg, optometrists, orthoptists, patient coordinators). Surgical management, though critical, is not the only consideration for these children. Continuing visual rehabilitation and monitoring for complications remain key elements even after the surgery is done. Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with the surgical paradigms and its long-term complications. Key components of surgery are management of posterior capsule and anterior vitreous and intraocular lens (IOL) implantation. It is a preferred practice today to perform a primary posterior capsulorhexis with anterior vitrectomy in younger children (up to 3 to 5 years old). Even in older children (up to the age of 8 years), performing a posterior capsulorhexis without anterior vitrectomy is the preferred approach. Above the age of 8 years, the posterior capsule can be left intact. In-the-bag IOL implantation is almost becoming a norm for children above the age of 1 year. Though there is no universal consensus regarding the earliest age for primary IOL implantation, many surgeons increasingly prefer primary IOL implantation even in infants. Alternate approaches that can avoid anterior vitrectomy like optic capture through the posterior capsulorhexis and bag-in-the-lens are also gaining more and more popularity.
Updates on the Epidemiology of Age-Related Macular Degeneration Jonas, Jost B.; Cheung, Chui Ming Gemmy; Panda-Jonas, Songhomitra
This meta-analysis reports on current estimates of the prevalence of age-related macular degeneration (AMD) based on a review of recent meta-analyses and literature research. Within an age of 45–85 years, global prevalences of any AMD, early AMD, and late AMD were 8.7% [95% credible interval (CrI), 4.3‒17.4], 8.0% (95% CrI, 4.0‒15.5), and 0.4% (95% CrI, 0.2–0.8). Early AMD was more common in individuals of European ancestry (11.2%) than in Asians (6.8%), whereas prevalence of late AMD did not differ significantly. AMD of any type was less common in individuals of African ancestry. The number of individuals with AMD was estimated to be 196 million (95% CrI, 140‒261) in 2020 and 288 million (95% CrI, 205‒399) in 2040. The worldwide number of persons blind (presenting visual acuity < 3/60) or with moderate to severe vision impairment (MSVI; presenting visual acuity < 6/18 to 3/60 inclusive) due to macular disease in 2010 was 2.1 million [95% uncertainty interval (UI), 1.9‒2.7) individuals out of 32.4 million individuals blind and 6.0 million (95% UI, 5.2‒8.1) persons out of 191 million people with MSVI. Age-standardized prevalence of macular diseases as cause of blindness in adults aged 50+ years worldwide decreased from 0.2% (95% UI, 0.2‒0.2) in 1990 to 0.1% (95% UI, 0.1‒0.2) in 2010; as cause for MSVI, it remained mostly unchanged (1990: 0.4%; 95% UI, 0.3‒0.5; 2010: 0.4%; 95% UI, 0.4‒0.6), with no significant sex difference. In 2015, AMD was the fourth most common cause of blindness globally (in approximately 5.8% of blind individuals) and third most common cause for MSVI (3.9%). These data show the globally increasing importance of AMD.
New Treatment Modalities for Geographic Atrophy Kandasamy, Rathika; Wickremasinghe, Sanjeewa; Guymer, Robyn
Age-related macular degeneration (AMD) is a significant cause of global visual morbidity and is projected to affect 288 million people by the year 2040. The advent of treatment with anti‒vascular endothelial growth factor (anti-VEGF) drugs has revolutionized the treatment of neovascular AMD (nAMD) but there have been no similar breakthroughs for the treatment of geographic atrophy (GA) to retard its progression. The advancements in imaging and new understanding of disease mechanisms, based on molecular and genetic models, have paved the way for the development of novel experimental treatment options for GA that aim to cater to a thus far largely unmet need. This review paper focuses on the recent clinical trials of new treatment options for slowing GA progression rates with emphasis on the agents that are currently undergoing, or have already undergone, significant clinical trial testing. Several new groups of drugs, including those targeting the complement cascade and agents considered as neuroprotective, have shown some promising results and could potentially pave the way forward in the treatment of this devastating disease.
New Treatment Modalities for Neovascular Age-Related Macular Degeneration Schlottmann, Patricio G.; Alezzandrini, Arturo A.; Zas, Marcelo; Rodriguez, Francisco J.; Luna, José D.; Wu, Lihteh
Age-related macular degeneration (AMD) is considered one of the main causes of severe vision loss in older adults. The neovascular form (nAMD) is an advanced stage, which is responsible for the most severe vision loss. Vascular endothelial growth factor (VEGF) is at present the main factor that leads to the development of a neovascular membrane and the increased leakage from the membrane to the retina. At present, anti-VEGF therapy is the only treatment that achieves vision gains in many patients and halts progression in most of them. VEGF blockade can be achieved with several molecules and various treatment regimens, which have been studied with excellent results. Unfortunately, real-world data has shown to be far less efficacious than clinical trials. This gap between clinical trials and real-world results is an unmet medical need that supports the necessity of new treatment modalities for nAMD. Of the various treatments being studied, anti-VEGFs of higher efficacy and longer durability are those more advanced in their development. Brolucizumab and abicipar pegol are 2 new anti-VEGF drugs that had positive results in phase 2 studies and are being tested in phase 3 trials at present. Other promising therapies are antiangiopoietin 2 molecules, which are in phase 2 development. At earlier stages of development but with promising results are squalamine, anti–VEGF-C and -D, and gene therapy. The future will give retina specialists a broad armamentarium with which patients may achieve high visual gains for the long term with a low treatment burden.
The Role of New Imaging Methods in Managing Age-Related Macular Degeneration Talks, Stephen James; Aftab, Akhunzada Muhammad; Ashfaq, Imran; Soomro, Taha
The use of imaging for age-related macular degeneration (AMD) depends on how it benefits clinical management and on reimbursement. The latter should relate to the former. This review assesses how different forms of AMD can be imaged and what information this provides. For nonneovascular AMD high-resolution optical coherence tomography (OCT), autofluorescence, and near infrared imaging can identify the type of drusen, such as reticular pseudodrusen, which influences prognosis, and the amount of atrophy, for which phase 3 trials are underway. Clarifying the correct diagnosis for late-onset Stargardt and macular telangiectasia, if treatment becomes available, will be especially important. Choroidal thickness can be measured and changes with anti‒vascular endothelial growth factor treatment, but how this influences management is less clear. The finding of a thick choroid may alter the diagnosis to pachychoroid neovasculopathy, which may have a different treatment response. Peripheral retinal changes are commonly found on ultrawide-field imaging but their importance is not yet determined. The mainstay of imaging is OCT, which can detect neovascular AMD by detecting thickening and be used for follow-up, as the presence or absence of thickening is the main determinant of treatment. Higher resolution systems and now OCT angiography are able to distinguish neovascular type, especially type 2 choroidal neovascularization but also polypoidal choroidal vasculopathy and retinal angiomatous proliferation. Fundus fluorescein and indocyanine green angiographies still have a role, although that partly depends on whether photodynamic therapy is being considered. Automated image analysis and machine learning will be increasingly important in supporting clinician decisions.
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