Journal club – 17-4-2021


. 2021 Mar 9;S0161-6420(21)00195-0. doi: 10.1016/j.ophtha.2021.03.009. Online ahead of print.

Ocular Findings in Infants with Congenital Toxoplasmosis Following a Toxoplasmosis Outbreak

Aline Reetz Conceição ۱Lilian Missio ۱Deisi Nara Belucik ۱Luiz Gustavo Brenner Reetz ۱Matheus Henrique Monteiro Leber ۱Kleber Silva Ribeiro ۲Deise Fialho Costa ۲Maria Clara da Silva Valadão ۱Alessandra Gonçalves Commodaro ۲João Rafael de Oliveira Dias ۳Rubens Belfort Jr ۲Affiliations expand


Purpose: We investigated the prevalence of ocular abnormalities in infants vertically exposed to Toxoplasma gondii infection during an outbreak in Santa Maria City, Brazil.

Design: Consecutive case series.

Participants: A total of 187 infants were included in this study.

Methods: The infants were recruited from January 2018 to November 2019. All mothers were screened for syphilis and human immunodeficiency virus before delivery. Toxoplasmosis infection was confirmed in all mothers and infants based on the presence of serum anti-T. gondii immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies. All infants underwent an ophthalmologic examination; ocular abnormalities were documented using a wide-field digital imaging system. Neonatal cranial sonography and/or head computed tomography were performed in 181 infants, and the cerebrospinal fluid (CSF) was screened for anti-T. gondii IgG and IgM antibodies in 159 infants. Peripheral blood samples from nine infants and their mothers were analyzed for the presence of T. gondii DNA by real-time polymerase chain reaction.

Main outcomes measures: Ocular abnormalities associated with congenital toxoplasmosis.

Results: A total of 187 infants were examined. Twenty-nine infants (15.5%) had congenital toxoplasmosis, of whom 19 (10.2%) infants had ocular abnormalities, including retinochoroiditis in 29 of 38 (76.3%) eyes, optic nerve abnormalities in five (13.2%) eyes, microphthalmia in one (2.6%) eye, and cataract in two (5.3%) eyes. Bilateral retinal choroidal lesions were found in 10 of 19 (52.6%) infants. Nine eyes of six infants had active lesions, with retinal choroidal cellular infiltrates at the first examination. Thirteen (7.2%) of 181 infants screened presented with cerebral calcifications. Eighty-three percent of the screened infants were positive for anti-T. gondii IgG and negative for IgM antibodies in the CSF. Congenital toxoplasmosis was higher in mothers infected during the third pregnancy trimester, and maternal treatment during pregnancy was not associated with a lower rate of congenital toxoplasmosis.

Conclusions: High prevalence rates of clinical manifestations were observed in infants with congenital toxoplasmosis after a waterborne toxoplasmosis outbreak, the largest yet described. Cerebral calcifications were higher in infants with ocular abnormalities and maternal infection during the third pregnancy trimester was associated with a higher rate of congenital toxoplasmosis independent of maternal treatment.

Ophthalmology. 2021 Jan 12doi: ۱۰.۱۰۱۶/j.ophtha.2021.01.007 [Epub ahead of print]PMCID: PMC7801188PMID: ۳۳۴۴۴۶۶۰

Face Masks and Bacterial Dispersion Toward the Periocular Area

Joseph J. Raevis, MD,۱Genti Gjyzeli, BS,۲Mihai Mititelu, MD, MPH,۱Jeremy Rogers, PhD,۳Michael Lasarev, MS,۴ and Jonathan S. Chang, MD۱,∗

JAMA Ophthalmol

. 2021 Mar 18;e210221. doi: 10.1001/jamaophthalmol.2021.0221. Online ahead of print.

Intravitreal Aflibercept Injection vs Sham as Prophylaxis Against Conversion to Exudative Age-Related Macular Degeneration in High-risk Eyes: A Randomized Clinical Trial

Jeffrey S Heier ۱David M Brown ۲Sumit P Shah ۳Namrata Saroj ۴Sabin Dang ۵Nadia K Waheed ۶Charles C Wykoff ۷Jonathan L Prenner ۸David S Boyer ۹Affiliations expand


Importance: Anti-vascular endothelial growth factor (VEGF) agents may provide a prophylactic effect in high-risk eyes with intermediate dry age-related macular degeneration (AMD) against conversion to exudative AMD (eAMD), lowering the risk of vision loss.

Objective: To evaluate intravitreal aflibercept injection (IAI) as prophylaxis against the conversion to eAMD in high-risk eyes at 24 months.

Design, setting, and participants: This single-masked, sham-controlled, randomized clinical trial performed at 4 US clinical sites enrolled patients with intermediate AMD in 1 eye (study eye), defined as presence of more than 10 medium drusen (≥۶۳ to <125 μm), at least 1 large druse (≥۱۲۵ μm), and/or retinal pigmentary changes, and eAMD in the fellow eye. Patients were treated from June 23, 2015, to March 13, 2019.

Interventions: Intravitreal aflibercept injection (2 mg) or sham quarterly injection for 24 months (1:1 randomization).

Main outcomes and measures: The primary end point was the proportion of patients with conversion to eAMD at month 24 characterized by development of choroidal neovascularization, as assessed by leakage on fluorescein angiography and fluid on spectral-domain optical coherence tomography by an independent masked reading center.

Results: Of 128 patients enrolled, 127 (63 in the IAI group and 64 in the sham group) were included in the primary analysis (68 men [53.5%]; mean [SD] age, 76.5 [8.1] years). Baseline demographic and clinical characteristics were balanced between the groups. By month 24, 6 patients (9.5%) in the IAI group and 7 (10.9%) in the sham group developed eAMD (P = .98). Patients with a history of eAMD for longer than 2 years in their fellow eye at baseline showed a lower rate of conversion to eAMD in the study eye compared with those with a history of eAMD for 2 years or less in the fellow eye. Safety was consistent with previous studies involving intravitreal anti-VEGF injections.

Conclusions and relevance: In this evaluation of quarterly anti-VEGF exposure as prophylaxis to reduce conversion of eyes with high-risk dry AMD to eAMD, the rates of conversion were not lower in the IAI group compared with the sham treatment group at month 24. Understanding the mechanism of conversion to eAMD and therapies that could prevent this event remains an important unmet need.

Trial registration: Identifier: NCT02462889.

JAMA Ophthalmol

. 2021 Mar 30. doi: 10.1001/jamaophthalmol.2021.0606. Online ahead of print.

Effect of Intravitreous Anti-Vascular Endothelial Growth Factor vs Sham Treatment for Prevention of Vision-Threatening Complications of Diabetic Retinopathy: The Protocol W Randomized Clinical Trial

Raj K Maturi ۱Adam R Glassman ۲Kristin Josic ۲Andrew N Antoszyk ۳Barbara A Blodi ۴Lee M Jampol ۵Dennis M Marcus ۶Daniel F Martin ۷Michele Melia ۲Hani Salehi-Had ۸Cynthia R Stockdale ۲Omar S Punjabi ۳Jennifer K Sun ۹DRCR Retina NetworkAffiliations expand


Importance: The role of anti-vascular endothelial growth factor injections for the management of nonproliferative diabetic retinopathy (NPDR) without center-involved diabetic macular edema (CI-DME) has not been clearly established.

Objective: To determine the efficacy of intravitreous aflibercept injections compared with sham treatment in preventing potentially vision-threatening complications in eyes with moderate to severe NPDR.

Design, setting, and participants: Data for this study were collected between January 15, 2016, and May 28, 2020, from the ongoing DRCR Retina Network Protocol W randomized clinical trial, conducted at 64 US and Canadian sites among 328 adults (399 eyes) with moderate to severe NPDR (Early Treatment Diabetic Retinopathy Study severity level, 43-53), without CI-DME. Analyses followed the intent-to-treat principle.

Interventions: Eyes were randomly assigned to 2.0 mg of aflibercept injections (n = 200) or sham (n = 199) given at baseline; 1, 2, and 4 months; and every 4 months through 2 years. Between 2 and 4 years, treatment was deferred if the eye had mild NPDR or better. Aflibercept was administered in both groups if CI-DME with vision loss (≥۱۰ letters at 1 visit or 5-9 letters at 2 consecutive visits) or high-risk proliferative diabetic retinopathy (PDR) developed.

Main outcomes and measures: Development of CI-DME with vision loss or PDR through May 2020, when the last 2-year visit was completed.

Results: Among the 328 participants (57.6% men [230 of 399 eyes]; mean [SD] age, 56 [11] years), the 2-year cumulative probability of developing CI-DME with vision loss or PDR was 16.3% with aflibercept vs 43.5% with sham. The overall hazard ratio for either outcome was 0.32 (97.5% CI, 0.21-0.50; P < .001), favoring aflibercept. The 2-year cumulative probability of developing PDR was 13.5% in the aflibercept group vs 33.2% in the sham group, and the 2-year cumulative probability of developing CI-DME with vision loss was 4.1% in the aflibercept group vs 14.8% in the sham group. The mean (SD) change in visual acuity from baseline to 2 years was -0.9 (5.8) letters with aflibercept and -2.0 (6.1) letters with sham (adjusted mean difference, 0.5 letters [97.5% CI, -1.0 to 1.9 letters]; P = .47).

Conclusions and relevance: In this randomized clinical trial, among eyes with moderate to severe NPDR, the proportion of eyes that developed PDR or vision-reducing CI-DME was lower with periodic aflibercept compared with sham treatment. However, through 2 years, preventive treatment did not confer visual acuity benefit compared with observation plus treatment with aflibercept only after development of PDR or vision-reducing CI-DME. The 4-year results will be important to assess longer-term visual acuity outcomes.


. 2021 Jan 8;S0161-6420(21)00001-4. doi: 10.1016/j.ophtha.2020.12.036. Online ahead of print.

Age Effect on Treatment Responses to 0.05%, 0.025%, and 0.01% Atropine: Low-Concentration Atropine for Myopia Progression Study

Fen Fen Li ۱Yuzhou Zhang ۱Xiujuan Zhang ۱Benjamin Hon Kei Yip ۲Shu Min Tang ۳Ka Wai Kam ۴Alvin L Young ۴Li Jia Chen ۵Clement C Tham ۶Chi Pui Pang ۷Jason C Yam ۸Affiliations expand


Purpose: To investigate the effect of age at treatment and other factors on treatment response to atropine in the Low-Concentration Atropine for Myopia Progression (LAMP) Study.

Design: Secondary analysis from a randomized trial.

Participants: Three hundred fifty children aged 4 to 12 years who originally were assigned to receive 0.05%, 0.025%, or 0.01% atropine or placebo once daily, and who completed 2 years of the LAMP Study, were included. In the second year, the placebo group was switched to the 0.05% atropine group.

Methods: Potential predictive factors for change in spherical equivalent (SE) and axial length (AL) over 2 years were evaluated by generalized estimating equations in each treatment group. Evaluated factors included age at treatment, gender, baseline refraction, parental myopia, time outdoors, diopter hours of near work, and treatment compliance. Estimated mean values and 95% confidence intervals (CIs) of change in SE and AL over 2 years also were generated.

Main outcome measures: Factors associated with SE change and AL change over 2 years were the primary outcome measures. Associated factors during the first year were secondary outcome measures.

Results: In 0.05%, 0.025%, and 0.01% atropine groups, younger age was the only factor associated with SE progression (coefficient of 0.14, 0.15, and 0.20, respectively) and AL elongation (coefficient of -0.10, -0.11, and -0.12, respectively) over 2 years; the younger the age, the poorer the response. At each year of age from 4 to 12 years across the treatment groups, higher-concentration atropine showed a better treatment response, following a concentration-dependent effect (Ptrend <0.05 for each age group). In addition, the mean SE progression in 6-year-old children receiving 0.05% atropine (-0.90 diopter [D]; 95% CI, -0.99 to -0.82) was similar to that of 8-year-old children receiving 0.025% atropine (-0.89 D; 95% CI, -0.94 to -0.83) and 10-year-old children receiving 0.01% atropine (-0.92 D; 95% CI, -0.99 to -0.85). All concentrations were well tolerated in all age groups.

Conclusions: Younger age is associated with poor treatment response to low-concentration atropine at 0.05%, 0.025%, and 0.01%. Among concentrations studied, younger children required the highest 0.05% concentration to achieve similar reduction in myopic progression as older children receiving lower concentrations.


. 2021 Apr 1;41(4):761-767. doi: 10.1097/IAE.0000000000002952.

COMPARISON OF SCLERAL FIXATION OF INTRAOCULAR LENS: Sutureless Intrascleral Fixation Versus Conventional Sutured Scleral Fixation

Kyu Hwan Jang ۱Mingui Kong ۱ ۲Byung Gil Moon ۳Gisung Son ۱ ۲Affiliations expand


Purpose: To compare the clinical outcomes of sutured scleral and sutureless intrascleral fixations of the intraocular lens.

Methods: Medical records of patients who underwent sutureless intrascleral fixation (sutureless group) and the conventional sutured scleral fixation (sutured group) were retrospectively reviewed. Patient demographics and the clinical outcomes of the two techniques were compared before and 1, 3, and 6 months after surgery.

Results: Seventy patients were followed up for 6 months after the surgery: 25 patients in the sutureless group (25 eyes) and 45 in the sutured group (45 eyes). Surgery time was shorter in the sutureless group than that in the sutured group (73.00 ± ۱۵.۶۸ vs. 107.39 ± ۲۵.۳۰ minutes, P < 0.001). The visual acuity gradually improved throughout the postoperative period in both groups, and a faster visual acuity recovery was observed in the sutureless group. The cylindrical error at 6 months after the surgery was significantly lower in the sutureless group than that in the sutured group (-1.33 ± ۰.۵۵ vs. -2.29 ± ۱.۱۹ diopter, P < 0.001).

Conclusion: Sutureless intrascleral fixation is an effective and reliable surgical technique that provides more favorable visual and refractive outcomes than the conventional sutured scleral fixation method.

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