The members of the Management and Therapy Subcommittee undertook an evidence-based review of current dry eye therapies and management options. Management options reviewed in detail included treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, surgical approaches, dietary modifications, environmental considerations and complementary therapies. Following this extensive review it became clear that many of the treatments available for the management of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due to a lack of appropriate masking, randomization or controls and in some cases due to issues with selection bias or inadequate sample size. Reflecting on all available evidence, a staged management algorithm was derived that presents a step-wise approach to implementing the various management and therapeutic options according to disease severity. While this exercise indicated that differentiating between aqueous-deficient and evaporative dry eye disease was critical in selecting the most appropriate management strategy, it also highlighted challenges, based on the limited evidence currently available, in predicting relative benefits of specific management options, in managing the two dry eye disease subtypes. Further evidence is required to support the introduction, and continued use, of many of the treatment options currently available to manage dry eye disease, as well as to inform appropriate treatment starting points and understand treatment specificity in relation to dry eye disease subtype.

TFOS DEWS II Management and Therapy Report

Central Serous Chorioretinopathy: Update on Pathophysiology and Treatment

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Steroids in susceptible individuals can cause a clinical condition similar to primary open-angle glaucoma. Five percent of the population are high steroid responders and develop an intraocular pressure (IOP) elevation of more than 15 mm Hg above baseline. IOP elevation may occur as early as 1 day to as late as 12 weeks after intravitreal triamcinolone in 20-65% of patients. On average, 75% of eyes with steroid implants require IOP-lowering therapy at some point within 3 years of follow-up. The exact mechanism of steroid-induced glaucoma is not totally understood, but decreased trabecular meshwork outflow is regarded as the main cause of IOP elevation. High-risk patients who receive steroids should be monitored closely and if they develop elevated IOP, steroids with lower potency or steroid-sparing agents should be used. The IOP usually returns to normal within 2-4 weeks after stopping the steroid. About 1-5% of patients do not respond to medical therapy and need surgery. Trabeculectomy, trabeculotomy, shunt surgery, and cyclodestructive procedures are among the methods employed. Removal of residual sub-Tenon or intravitreal steroids may help hasten the resolution of the steroid response. Early results with anecortave acetate, an analog of cortisol acetate with antiangiogenic activity, in controlling IOP have been promising.

/pdf/steroid-induced-iatrogenic-glaucoma-iqvdib5bub.pdf

Steroid-induced iatrogenic glaucoma.

PURPOSE
To evaluate intravitreal aflibercept injections (IAI; also called VEGF Trap-Eye) for patients with macular edema secondary to central retinal vein occlusion (CRVO).


DESIGN
Randomized controlled trial.


METHODS
This multicenter study randomized 189 patients (1 eye/patient) with macular edema secondary to CRVO to receive 6 monthly injections of either 2 mg intravitreal aflibercept (IAI 2Q4) (n = 115) or sham (n = 74). From week 24 to week 52, all patients received 2 mg intravitreal aflibercept as needed (IAI 2Q4 + PRN and sham + IAI PRN) according to retreatment criteria. The primary endpoint was the proportion of patients who gained ≥15 ETDRS letters from baseline at week 24. Additional endpoints included visual, anatomic, and quality-of-life NEI VFQ-25 outcomes at weeks 24 and 52.


RESULTS
At week 24, 56.1% of IAI 2Q4 patients gained ≥15 letters from baseline compared with 12.3% of sham patients (P < .001). At week 52, 55.3% of IAI 2Q4 + PRN patients gained ≥15 letters compared with 30.1% of sham + IAI PRN patients (P < .001). At week 52, IAI 2Q4 + PRN patients gained a mean of 16.2 letters of vision vs 3.8 letters for sham + IAI PRN (P < .001). The most common adverse events for both groups were conjunctival hemorrhage, eye pain, reduced visual acuity, and increased intraocular pressure.


CONCLUSIONS
Monthly injections of 2 mg intravitreal aflibercept for patients with macular edema secondary to CRVO resulted in a statistically significant improvement in visual acuity at week 24, which was largely maintained through week 52 with intravitreal aflibercept PRN dosing. Intravitreal aflibercept injection was generally well tolerated.

Iconographies supplémentaires de l'article : Intravitreal Aflibercept Injection for Macular Edema Secondary to Central Retinal Vein Occlusion: 1-Year Results From the Phase 3 COPERNICUS Study

/pdf/intravitreal-bevacizumab-for-treatment-of-chronic-central-35bed5g1o5.pdf

Intravitreal bevacizumab for treatment of chronic central serous chorioretinopathy

To evaluate the efficacy and safety of allogeneic serum in the treatment of persistent corneal epithelial defect (PED). Thirty-six patients with PED whose autologous serum was unavailable or unsuitable for use were included in the study. Blood was obtained from the patients’ family members who were healthy and had no history of hepatitis, bacteremia, or HIV. After standard serological testing used in blood transfusion, the allogeneic serum was prepared. The patients applied the serum eyedrops once every hour while awake and discontinued non-preservative artificial tears. If the epithelial defect was healing, the allogenic serum was gradually tapered. If the epithelial defect remained nearly the same size at day 14, amniotic membrane transplantation (AMT) was performed. Among the 36 patients, the epithelial defect healed in 6 patients (16.7%) within 1 week, in an additional 9 patients (25%) in 1–2 weeks, totaling 15 patients (41.7%) within 2 weeks. Twenty-one patients (58.3%) did not completely heal at the second week. Among these 21 patients, 10 (27.8%) underwent AMT and had subsequent healing of the epithelial defect, 8 completely healed within 1 month, and the remaining 3 healed within 2 months. None of the 36 patients reported any adverse events during therapy. In patients for whom serum treatment is indicated but autologous serum is unavailable or unsuitable for use, allogeneic serum offers an alternative option for therapy.

/pdf/allogeneic-serum-eye-drops-for-the-treatment-of-persistent-2sygnom3wy.pdf

Allogeneic serum eye drops for the treatment of persistent corneal epithelial defect.

Effect of Bevacizumab on Human Corneal Endothelial Cells: A Six-month Follow-up Study

Purpose To describe a rare case of early-onset Candida parapsilosis infection after laser in situ keratomileusis (LASIK) and review the published reports of post-LASIK fungal infections. Methods A 32-year-old woman presented with interface infiltration in the central interface in the right eye 2 days after LASIK surgery. The right eye flap was lifted, and the opacities were scraped. Two days later, a 3- x 3-mm-dense oval opacity and diffuse hazes were noted. Surgical intervention was arranged because of suspicion of interface infectious keratitis. Results After an apparent post-LASIK keratitis with related interface inflammation failed to respond to medical therapy, corneal culture results were positive for C. parapsilosis 2 weeks 6 days after presentation. The patient was started on topical drops of amphotericin B 0.15% every hour after the smear showed the presence of yeast. The opacities decreased, and the topical antifungal drops were tapered. One month later, her uncorrected visual acuity recovered to 20/20. Conclusions Candida parapsilosis interface keratitis after LASIK may occur in the early phase. Early diagnosis and proper treatment can result in good outcome.

Unilateral Candida parapsilosis interface keratitis after laser in situ keratomileusis: case report and review of the literature.

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

/pdf/outcome-of-primary-rhegmatogenous-retinal-detachment-using-290bizn5dj.pdf

Outcome of primary rhegmatogenous retinal detachment using microincision vitrectomy and sutureless wide-angle viewing systems.

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