British Journal of Ophthalmology

Outcome of peripheral iridotomy in subjects with uveitis
Thomas David Betts, Joanne L Sims, Sonya L Bennett, Rachael L Niederer
Background/aims Peripheral iridotomy (PI) may be required in subjects with uveitis to manage iris bombe, seclusio pupillae and primary angle closure glaucoma. The aim of this study was to identify risk factors for failure of both laser and surgical PIs in patients with uveitis and determine survival durations.
Methods Retrospective study of subjects with a history of uveitis undergoing yttrium-aluminium-garnet (YAG) laser or surgical PI at Auckland District Health Board over an 11-year period. Failure of PI was defined as loss of patency or recurrence of iris bombe. A mixed effects shared frailty model was constructed with PI nested within eyes nested within patients, to examine time to failure.
Results 131 PIs were performed in 52 eyes of 39 subjects during the study period (111 YAG PIs and 20 surgical PIs). Median age at time of PI was 46.6 years and 60.5% of subjects were female. HLAB27 positive uveitis was the most common diagnosis (25.6% of subjects). Median survival time was 70 days for YAG PI and 11.0 years for surgical PI. On multivariate analysis, younger age at time of PI (HR 0.933, p<0.001) and iris bombe (HR 2.180, p=0.046) were associated with risk of failure. Surgical PI was associated with a lower risk of failure (HR 0.151, p<0.001) compared with YAG PI. Glaucoma developed in 19 eyes (36.5%), of which 13 required glaucoma surgery.
Conclusion Surgical PI had longer survival than YAG PI, and should be considered in subjects presenting with iris bombe and in young subjects with uveitis.

Correlation of changes in serum level of VEGF and peripapillary retinal thickness in patients with POEMS syndrome
Hirotaka Yokouchi, Takayuki Baba, Sonoko Misawa, Toshiyuki Oshitari, Satoshi Kuwabara, Shuichi Yamamoto
Aim To determine whether changes in the serum levels of vascular endothelial growth factor (VEGF) after thalidomide therapy will affect the peripapillary retinal thickness (pRT) associated with optic disc oedema (ODE) in patients with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome.
Methods This was a retrospective, observational case series of 23 right eyes of 23 treatment-naïve patients with POEMS syndrome and ODE whose intracranial pressure was within the normal range. The pRT was determined by spectral-domain optical coherence tomography, and the serum level of VEGF was determined by ELISA at baseline and 6 months after the thalidomide therapy. We determined whether a change in the pRT from baseline was significantly correlated with the serum level of VEGF from that at 6 months after the thalidomide treatment.
Results Six months after treatment, the mean serum level of VEGF was significantly reduced from 7153±۴۲۱۴ pg/mL to 1067±۷۶۹ pg/mL (p<0.001), and the pRT was significantly decreased from 471.2±۲۰۳ µm to 318.1±۵۳.۹ µm (p<0.001). The change in the pRT from baseline was significantly and linearly correlated with the change in the serum level of VEGF from that at 6 months after treatment (r=0.67, p=0.00039).
Conclusions The close relationship between the pRT and the serum level of VEGF may offer clues on the pathogenesis of POEMS syndrome and potentially add a new candidate cause for the pathogenesis of ODE.

Factors associated with extended remission in neovascular age-related macular degeneration on pro re nata treatment protocol
Tiezhu Lin, Kunny C Dans, Ilkay Kilic Muftuoglu, Amit Meshi, Manuel J Amador-Patarroyo, Lingyun Cheng, William R Freeman
Aim To show the characteristics and outcomes of patients with neovascular age-related macular degeneration (nAMD) who had extended remission (ER) while on a pro re nata (PRN) treatment protocol.
Methods This was a retrospective case–control study of a consecutive series of patients with nAMD treated with a PRN antivascular endothelial growth factor (anti-VEGF) drug regimen. ER was defined as the absence of haemorrhage, intraretinal/subretinal fluid on optical coherence tomography and leakage on fluorescein angiography for 52 weeks after cessation of anti-VEGF therapy. Matching patients with nAMD who did not achieve ER were included as control group. Cox regression analysis was fitted to identify predictors of time to achieve ER and time to recurrence. A logistic regression analysis of baseline characteristics was used to identify predictors of achieving ER.
Results Of 830 eyes treated with anti-VEGF monotherapy, 77 (9.2%) eyes achieved ER during a median follow-up of 236 weeks (range 70–۵۲۵ weeks). Cox regression analysis showed that ER was achieved earlier in eyes with isolated intraretinal fluid (HR, 2.05; 95% CI 1.929 to 4.520; p=0.045) at presentation. Logistic regression analysis showed that type 3 choroidal neovascularisation (OR, 0.090; 95% CI 0.021 to 0.382; p=0.001), thinner choroid (OR, 0.993; 95% CI 0.988 to 0.998; p=0.004) and absence of macular atrophy (OR, 0.233; 95% CI 0.065 to 0.839; p=0.026) at baseline increased the likelihood of achieving ER.
Conclusion ER is achievable in 9.2% of patients under PRN therapy for nAMD. At presentation with nAMD, anatomical features on retinal imaging may predict the likelihood of achieving ER and a shorter time to achieve ER.

Safety and tolerability of ranibizumab in uni/bilateral neovascular age-related macular degeneration: 12-month TWEYEs study
Francesco Bandello, Giovanni Staurenghi, Federico Ricci, Edoardo Midena, Francesco Viola, Tommaso Lupieri Sinibaldi, Laura Colombo, Elena Peruzzi, Stefania Bassanini
Background To evaluate the safety and tolerability of ranibizumab 0.5 mg in patients with uni/bilateral neovascular age-related macular degeneration (nAMD) and best-corrected visual acuity (BCVA)<2/10 and/or second eye affected, regardless of BCVA.
Methods In this 12-month, prospective, multicentre, open-label, single arm, pragmatic interventional study, patients (N=941) aged ≥ ۵۰ years were to receive ranibizumab as per approved label, monthly until maximum stable visual acuity (VA) was achieved (initially, three or more injections may be required). Thereafter, patients were to be monitored monthly for VA and treatment was to be resumed if VA was reduced due to disease activity.
Results Of the 936 patients treated with ranibizumab at least once during the study, 823/113 were unilaterally/bilaterally (not simultaneously) treated . The mean (SD) number of ranibizumab injections during the study was 5.4 (2.9)/10.6 (5.0) injections in uni/bilaterally treated patients. Three systemic drug-related adverse events (AEs) (all serious, all in unilaterally treated patients) and 18 systemic AE of special interest (AESIs) (11 serious, 16/2 in unilaterally/bilaterally treated patients) occurred during the study. The annual incidence rate (AIR) (events/1000 person-years) for systemic drug-related AEs, considering a 15-day/30-day risk period, 11.0/8.5 for unilaterally treated patients. Considering the same risk period, the AIR (events/1000 person-years) for systemic AESIs for unilaterally treated patients was 22.1/19.9. Considering a 30-day risk period, the AIR (events/1000 treated eye-years) of ocular drug-related AEs was 23 and AESIs was 11.5.
Conclusions The low incidence of AEs and AESIs demonstrated the good safety and tolerability of ranibizumab in unilaterally/bilaterally treated patients with nAMD in this real-world setting.

Risk factors for disease progression in low-teens normal-tension glaucoma
Sung Uk Baek, Ahnul Ha, Dai Woo Kim, Jin Wook Jeoung, Ki Ho Park, Young Kook Kim
Background/Aims To investigate the risk factors for disease progression of normal-tension glaucoma (NTG) with pretreatment intraocular pressure (IOP) in the low-teens.
Methods One-hundred and two (102) eyes of 102 patients with NTG with pretreatment IOP≤۱۲ mm Hg who had been followed up for more than 60 months were retrospectively enrolled. Patients were divided into progressor and non-progressor groups according to visual field (VF) progression as correlated with change of optic disc or retinal nerve fibre layer defect. Baseline demographic and clinical characteristics including diurnal IOP and 24 hours blood pressure (BP) were compared between the two groups. The Cox proportional hazards model was used to identify the risk factors for disease progression.
Results Thirty-six patients (35.3%) were classified as progressors and 66 (64.7%) as non-progressors. Between the two groups, no significant differences were found in the follow-up periods (8.7±۳.۴ vs 7.7±۳.۲ years; p=0.138), baseline VF mean deviation (−۴.۵۰±۵.۶۵ vs −۳.۵۶±۴.۳۰ dB; p=0.348) or pretreatment IOP (11.34±۱.۲۱ vs 11.17±۱.۰۶ mm Hg; p=0.121). The multivariate Cox proportional hazards model indicated that greater diurnal IOP at baseline (HR=1.609; p=0.004), greater fluctuation of diastolic BP (DBP; HR=1.058; p=0.002) and presence of optic disc haemorrhage during follow-up (DH; HR=3.664; p=0.001) were risk factors for glaucoma progression.
Conclusion In the low-teens NTG eyes, 35.3% showed glaucoma progression during the average 8.7 years of follow-up. Fluctuation of DBP and diurnal IOP as well as DH were significantly associated with greater probability of disease progression.

Risk factors and outcomes of management of delayed suprachoroidal haemorrhage following Ahmed glaucoma valve implantation in children
Shantha Balekudaru1, Tamonash Basu2, Parveen Sen, Pramod Bhende, Vijaya Lingam, Ronnie George
Aims To assess the incidence, risk factors and outcomes of management of delayed suprachoroidal haemorrhage (DSCH) in children who had undergone Ahmed glaucoma valve implantation.
Methods A retrospective case-control study of eyes which developed DSCH in children <18 years of age who underwent surgery between January 2009 and December 2017 with a follow-up of at least 2 months was performed. Nine cases were compared with 27 age, gender and surgeon matched controls who had undergone surgery during this period. Results The incidence of DSCH was 4.7% (95% CL 1.5% to 7.7%, 9 eyes of 191 children). There were no significant differences between cases and controls in baseline details except for the number of intraocular pressure (IOP) lowering medications (p=0.01) and follow-up period (p=0.001). Risk factors identified on univariate analysis (p≤۰.۱) were axial length (p=0.02), diagnosis of primary congenital glaucoma (p=0.05), postoperative hypotony (p=0.07) and aphakia (p=0.1). None of them were found to be significant on multivariate analysis. Five eyes, three with retinal apposition and two with retinal detachment, underwent surgical drainage. There were no significant differences in the outcomes of eyes which underwent drainage compared with those which did not. Failures, defined as IOP>18 mm Hg despite use of medications, loss of light perception, phthisis or removal of the implant were more frequent in cases (three eyes, 33.3%) compared with controls (four eyes, 14.8%) (p=0.002).
Conclusions None of the risk factors analysed in our series proved to be significant. Failures were more common in eyes with choroidal haemorrhage, despite surgical intervention.

Two-year observation of posterior corneal elevations after small incision lenticule extraction (SMILE) for myopia higher than −۱۰ dioptres
Xueyi Zhou, Jianmin Shang, Bing Qin, Yu Zhao, Xingtao Zhou
Aim To investigate the change in posterior corneal elevations (PCEs) of eyes with extremely high myopia 2 years after small incision lenticule extraction (SMILE).
Methods We evaluated 39 eyes of 39 patients with spherical equivalent higher than −۱۰.۰۰ dioptres (D). Using a Scheimpflug camera (Pentacam), we measured change in PCEs at 1 day, 3 months, 6 months and 2 years after SMILE. Another 34 eyes of 34 patients who underwent femtosecond laser-assisted in situ keratomileusis (FS-LASIK) were examined before, at 1 day and long-term after surgery as the control group. For each eye, elevations at central, thinnest, maximal points and 24 other predetermined points were measured.
Results No significant forward displacements of PCEs were observed in both surgeries. The maximal but not significant forward displacement occurred around 3–۶ months following SMILE, and all returned to original levels 6 months postoperatively except superior area. The peripheral area tended to displace backward, while the central area tended forwardly. In both procedures, elevations along horizontal meridians, inferior and temporal hemispheres were significantly higher than those along vertical meridians, superior and nasal hemispheres, respectively (p<0.05). Elevation on the 4 mm, 6 mm diameters at 1 day and on the 6 mm diameter and temporal hemisphere at long-term follow-up postoperatively were significantly higher in FS-LASIK than SMILE (p<0.05). Change in elevations on the 6 mm diameter circle correlated with residual bed thickness (p=0.047).
Conclusions SMILE is a safe way to correct for myopia higher than −۱۰ D, with PCEs remaining stable 2 years after surgery.