Weekly Case Presentation 25-5-1401

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Weekly Case Presentation 25-5-1401

Vitreous Cysts

Vitreous Cyst.JPEG

Vitreous cysts are rare clinical entities that can occur in a normal eye or in an eye associated with other pathologies.

Disease Entity

ICD 10- CM Code H43.89- Other disorders of vitreous body

Disease

  • Floating vitreous cysts are extremely rare clinical entities that are regarded as ‘ocular curiosities’.
  • They can either be an incidental finding in a normal eye or associated with other ocular pathologies.
  • It was first described by Tansley in 1899 as an irregular spherical cyst that showed lines of pigment on its surface.

A red-free fundus photo showing a vitreous cyst anterior to the optic disc
Photo Courtesy- Rajan Eye Care Hospital, Chennai

Etiology

Vitreous cysts can be congenital or acquired.

Congenital Cysts

  • Remnants of the hyaloid vascular system
  • Located at hyaloid canal and found in conjunction with a Mittendorf’s dot or Bergmeister’s papillae
  • They are usually stable, do not progress and rarely interfere with visual acuity
  • They are usually non-pigmented pearl-gray cysts with a smooth surface, can be sessile or pedunculated
  • They are located anterior to the optic disc
  • Some can be limited in movement due to vitreous strands attaching the cyst to the optic disc


Acquired Cysts

  • They have been reported to occur secondary to or associated with:
    • Ocular trauma
    • Intraocular inflammation/infection/ uveitis eg. Intermediate Uveitis, Toxoplasmosis
    • Retinal diseases such as Retinitis pigmentosa, Choroidal atrophy, Retinoschisis, High myopia with uveal coloboma etc.
    • Retinal detachment surgeries
  • They are usually symptomatic and associated with a reduction in visual acuity.

Types

Pigmented Cysts

  • Likely originate from the pigment epithelium of the iris or ciliary body and later become detached into the vitreous
  • They are brown in color


Non-Pigmented Cysts

  • Congenital cysts are usually non-pigmented and originate from the hyaloidal vascular system
  • They are translucent, mobile and yellow-gray in color.

General Pathology

Histopathological examination:

  • Congenital cysts are choristomas (normal tissues growing in abnormal location) of the primary hyaloidal system
  • Derived from the pigment epithelium of the iris or ciliary body
  • Contains immature melanosomes


Light & Electron Microscopy:

  • Orellana et al studied aspirated pigmented cyst by light microscopy and electron microscopy.
  • They found that the pigmented layer of cuboidal cells contains large mature melanosomes and few immature melanosomes suggesting origin from the pigment epithelium.

Pathophysiology of Acquired Cysts

  • Trauma can cause damage to the pigment epithelium of ciliary body and create pigment cysts
  • Other theories: Vitreous reaction to underlying retinal degeneration can causes cysts, Ciliary adenoma breaking into the vitreous, cystic growths that occur at site of coloboma that enter the vitreous

Diagnosis

These are often noted on clinical examination at the slit lamp or with funduscopy.

History

  • History of ocular trauma
  • History of infections or inflammations of the eye
  • History of ocular surgery
  • History of ocular disease such as:  uveitis, uveal coloboma, retinoschisis, retinitis pigmentosa, retinal detachment and ocular malignancies

Clinical Presentation

  • Age of patients usually between 10-20 years
  • Mostly unilateral, but bilateral cases have also been reported especially in retinitis pigmentosa

Symptoms

  • Usually asymptomatic
  • When a cyst floats into and obstructs the visual axis, patients can complain of transient blurring of vision, floaters, shifting visual field defects and occasionally photophobia.

Signs and Morphological appearance of the cysts

  • Numbers and Positioning: Single unilateral, Single Bilateral, Multiple unilateral
  • Dimensions: 0.15-12 mm
  • Shapes: Spherical, Oval, Lobulated
  • Surface: Smooth or Crenated
  • Color: Yellow-gray (non-pigmented) or Brown (Pigmented)
  • Location:  Confined to the region of Cloquet’s canal

The cysts can move with a patient’s eye movements while examining with an indirect ophthalmoscope.A colour fundus photo showing a well-defined round parasitic cyst of cysticercosis in the vitreous cavity
Photo Courtesy- Rajan Eye Care Hospital, Chennai

Differential diagnosis

  • A detailed clinical examination is required to rule out other infectious and malignant conditions.
  • Pigmented cysts can mimic pigmented ocular tumors such as malignant melanoma.
  • Nonpigmented cysts can mimic parasitic cysts such as Cysticercosis, Echinococcus etc.

Investigations

General Investigations:

  • Complete blood count
  • Erythrocyte Sedimentation Rate
  • Serologies for Cysticercosis, Echinoccous, Toxpoplasma gondii, Toxocara canis
  • Stool examination for ova and cysts
  • Chest radiography
  • Abdominal Ultrasound
  • Brain computer tomography

Ocular Investigations:B scan Ultrasonography showing a vitreous cyst with a hyperechogenic wall and acoustically hollow interior with no connections to any part of the eye ie free floating. No scolex seen. Suggestive of a primary floating vitreous cyst. Photo Courtesy- Rajan Eye Care Hospital, Chennai

  • B Scan Ultrasound to look for scolex in case of cysticercosis
  • Optical coherence tomography (OCT) can also help characterize the cyst
  • Ultrasound biomicroscopy (UBM) to rule out anomalies of ciliary body or posterior iris
  • Fluorescein angiography – assists in characterization of intra and extra cystic vascularization

Management

Asymptomatic cysts

  • Observation and follow-up


Symptomatic cysts

  • Laser cystotomy by Argon laser or Nd:Yag laser
  • Pars plana vitrectomy with cyst excision

Journal Club 23-5-2021

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Journal Club 23-5-2021

Patients with Neovascular Age-Related Macular Degeneration Requiring Intensive Intravitreal Aflibercept Treatment: An ARIES Post Hoc Analysis

Sebastian Wolf , Frank G Holz , Edoardo Midena , Eric H Souied , George Lambrou , Tobias Machewitz , Helmut Allmeier , Paul Mitchell , ARIES Study Investigators

Abstract

Introduction: The aim of this post hoc analysis of the ARIES study is to explore the requirement for intravitreal aflibercept (IVT-AFL) treatment intervals of < 8 weeks (w) in patients with neovascular age-related macular degeneration (nAMD), and to assess vision and anatomic outcomes in such patients who require more intensive treatment.

Methods: ARIES was a multicenter, randomized, phase 3b/4 study that investigated the efficacy of two IVT-AFL proactive, individualized, treat-and-extend regimens over 2 years in treatment-naïve patients with nAMD. Patients were determined as injection-intensive if the study investigator identified that a treatment interval of < 8 w was needed and if they had ≥ 1 interval of < 8 w after three initial monthly doses. Treatment intervals could be extended subsequently if extension criteria were met. This is a post hoc analysis of patients enrolled in ARIES and statistical analysis is descriptive.

Results: Of 269 patients in the combined treatment arms, 23.0% (n = 62) were injection-intensive (Year 1: 13.8% [n = 37]; Year 2: 9.3% [n = 25]). Time from IVT-AFL initiation to injection-intensive determination varied (range, 16-100 w; median: 43.2 w). Mean treatment interval was 8.4 w before and 6.1 w after injection-intensive determination. Overall, 59.7% achieved treatment intervals of ≥ 8 w following injection-intensive determination. Vision improvements from baseline to Week 104 were smaller for injection-intensive patients than non-injection-intensive patients (mean [SD] best-corrected visual acuity change: + 2.3 [15.6] vs. + 5.9 [12.3] letters). Anatomic outcomes were similar between injection-intensive and non-injection-intensive patients (central retinal thickness change from baseline to Week 104: – 160 [154] vs. – 167 [136] µm).

Conclusions: In ARIES, 23% of treatment-naïve patients with nAMD experienced at least one treatment interval of < 8 w. Injection-intensive patients showed improved vision and anatomic outcomes. For most, treatment intervals could be extended to ≥ 8 w following injection-intensive determination.

N Engl J Med

  • 2022 Jul 14. Online ahead of print.

Aflibercept Monotherapy or Bevacizumab First for Diabetic Macular Edema

Chirag D Jhaveri , Adam R Glassman , Frederick L Ferris 3rd , Danni Liu , Maureen G Maguire , John B Allen , Carl W Baker , David Browning , Matthew A Cunningham , Scott M Friedman , Lee M Jampol , Dennis M Marcus , Daniel F Martin , Carin M Preston , Cynthia R Stockdale , Jennifer K Sun , DRCR Retina Network

Abstract

Background: In eyes with diabetic macular edema, the relative efficacy of administering aflibercept monotherapy as compared with bevacizumab first with a switch to aflibercept if the eye condition does not improve sufficiently (a form of step therapy) is unclear.

Methods: At 54 clinical sites, we randomly assigned eyes in adults who had diabetic macular edema involving the macular center and a visual-acuity letter score of 24 to 69 (on a scale from 0 to 100, with higher scores indicating better visual acuity; Snellen equivalent, 20/320 to 20/50) to receive either 2.0 mg of intravitreous aflibercept or 1.25 mg of intravitreous bevacizumab. The drug was administered at randomization and thereafter according to the prespecified retreatment protocol. Beginning at 12 weeks, eyes in the bevacizumab-first group were switched to aflibercept therapy if protocol-specified criteria were met. The primary outcome was the mean change in visual acuity over the 2-year trial period. Retinal central subfield thickness and visual acuity at 2 years and safety were also assessed.

Results: A total of 312 eyes (in 270 adults) underwent randomization; 158 eyes were assigned to receive aflibercept monotherapy and 154 to receive bevacizumab first. Over the 2-year period, 70% of the eyes in the bevacizumab-first group were switched to aflibercept therapy. The mean improvement in visual acuity was 15.0 letters in the aflibercept-monotherapy group and 14.0 letters in the bevacizumab-first group (adjusted difference, 0.8 letters; 95% confidence interval, -0.9 to 2.5; P = 0.37). At 2 years, the mean changes in visual acuity and retinal central subfield thickness were similar in the two groups. Serious adverse events (in 52% of the patients in the aflibercept-monotherapy group and in 36% of those in the bevacizumab-first group) and hospitalizations for adverse events (in 48% and 32%, respectively) were more common in the aflibercept-monotherapy group.

Conclusions: In this trial of treatment of moderate vision loss due to diabetic macular edema involving the center of the macula, we found no evidence of a significant difference in visual outcomes over a 2-year period between aflibercept monotherapy and treatment with bevacizumab first with a switch to aflibercept in the case of suboptimal response. (Funded by the National Institutes of Health; Protocol AC ClinicalTrials.gov number, NCT03321513.).