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  • Amazfit on track with latest flagship wearable, Balance 2

    Amazfit on track with latest flagship wearable, Balance 2

    Amidst a competitive summer of athletics, Amazfit‘s latest flagship wearable, the Balance 2, is endeavouring to support elite athletic performance from training through recovery.

    Gabby Thomas, an established Amazfit partner and the most decorated US track and field athlete of the 2024 Paris Olympics, is among several elite athletes leveraging a number of Amazfit track-specific features – alongside athletes such as Morgan Pearson and Yeman Crippa.

    The Amazfit Balance 2 includes Track Run Mode, which delivers real-time performance metrics – from VO₂ Max to stride cadence – to analyse aerobic and anaerobic effort throughout a session. With the updated technology, runners can choose which data to monitor, customising each session to their specific needs. This data includes post-training and recovery insights such as ATL, CTL, HRV, and mental and physical fatigue.

    Leveraging Amazfit’s BioTracker technology, the device also captures advanced biometric data and parameters, using what the brand cites as the latest generation biometric sensor. Available data includes cadence, stride, running power – all seen as vital for sprinters and long-distance runners aiming to optimize efficiency and speed.

    Post-session insights via the Zepp App provide an overview of athletic performance, including training load, training effect, recovery time, and detailed performance charts.

    www.amazfit.com

     

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  • Scientists may have discovered a new mineral on Mars

    Scientists may have discovered a new mineral on Mars

    Researchers have pinpointed a previously unknown mineral on Mars, indicating the red planet’s surface may be more actively changing than previously believed.  While scientists have a solid understanding of Mars’ surface appearance, uncovering its precise composition remains a challenge.

    Recently, a team of researchers believes they have identified a completely new mineral, derived from an unusual layer of iron sulfate exhibiting a distinctive spectral signature. In a paper published on August 5 in Nature Communications, astrobiologists led by Janice Bishop from the SETI Institute detailed the detection of an uncommon ferric hydroxysulfate mineral near Valles Marineris, a colossal canyon that runs along Mars’ equator. The region, thought to have once hosted flowing water, could hold vital clues about the natural forces that shaped the planet’s surface and whether microbes once inhabited Mars.

    Sulfur, a common element on both Mars and Earth, frequently bonds with other elements to create sulfate minerals. These sulfates dissolve readily in water, but because Mars has been dry for so long, these minerals likely remained on the surface since the planet lost its liquid water. Examining these minerals can reveal crucial insights into Mars’ early environmental conditions.

    The research team focused on sulfate-rich zones near Valles Marineris, targeting areas that displayed unusual spectral signals from orbit, as well as layered sulfate deposits and notable geological features, Bishop explained in a statement.

    In one region, they discovered layered deposits of polyhydrated sulfates, beneath which lay monohydrated and ferric hydroxysulfates.

    Laboratory experiments showed that the ferric hydroxysulfate observed on Mars could only have formed in the presence of oxygen, with the formation process releasing water. These conditions also suggest it formed at high temperatures, pointing to volcanic activity as a likely source. The mineral’s unique structure and thermal properties indicate it may be entirely new to science.

    Bishop explained that the material we produced in the lab seems to be a new mineral due to its unique crystal structure and thermal stability. However, we must find this mineral on Earth first before we can officially recognize it as a new mineral species.

    This is not the first time researchers have potentially discovered new minerals on Mars. Back in March 2025, Roger Wiens, a Mars exploration expert and a professor of earth, atmospheric, and planetary sciences at Purdue University in Indiana, directed NASA’s Perseverance rover to target some unusually pale rocks on the Martian surface with its laser. He and his team found that these rocks contain unusually high levels of aluminum linked to the mineral kaolinite. This finding was notable on its own, but what truly made it remarkable is that kaolinite typically forms only in very warm and wet conditions. Their discovery, published in Nature Communications Earth & Environment, indicates that Mars might have been more Earth-like—warmer, wetter, and more complex—than scientists previously believed.


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  • Karma Amaris, The World’s First Hybrid EREV Luxury Coupé, Takes Center Stage at Monterey Car Week

    Karma Amaris, The World’s First Hybrid EREV Luxury Coupé, Takes Center Stage at Monterey Car Week

    As the world’s first Hybrid EREV performance luxury coupé, Amaris fully delivers the exceptional driving dynamics and sheer speed promised by its purposeful stance and dramatic proportions. Packing 708 horsepower and 676 ft. lbs. torque, Amaris will launch from 0-60mph in less than 3.5 seconds, continuing-on to an electronically governed top speed of 165mph. Its Hybrid EREV powertrain consists of two electric motors driving the rear wheels, powered by a 41.5 kw/H battery which is maintained by a 4-Cylinder turbocharged ICE generator. This Hybrid EREV powertrain delivers over 100 miles of electric-only driving range, and over 400 miles of combined driving range (electric and ICE).

    Amaris begins production in Q4/2026, and will be priced from approximately $200,000USD.

    “Amaris delivers all the joys and indulgences of a thoroughbred performance coupe – staggering pace, exuberant style and opulent interior appointments – balanced with an ultra-low emissions Hybrid EREV powertrain which offers the freedom to refuel with gasoline or recharge with electricity, whichever is more convenient,” says Marques McCammon, President and Chief Executive, Karma Automotive. “Amaris delivers pure desire paired with eco-conscious driving like no other vehicle in the world.”

    The powerful yet timelessly elegant carbon fiber and aluminum body of the Amaris, specified for Monterey Car Week in Solar Blaze Red paintwork, features the latest evolution of the Comet Line design language first established with the upcoming Karma Kaveya super-coupe. With Amaris, the Comet Line originates in the sculpted cowl aft of the nose, continuing rearward in an arc across the sides of the hood, descending rearward to amplify the wide, aggressive rear track. 22″ Constellation wheels, crafted in forged aluminum, fully-establish the purposeful, fluid stance of the Amaris. The voluptuous clamshell hood – incorporating Karma’s Target Lighting signature – creates a seamless transition and visual flow to the front fenders. The Backslash design element punctuates the space between the front wheels and the “swan doors,” which gracefully pivot upwards to dramatic effect. Its sleek rear glass profile concludes with an aero pass-through spoiler that reduces aerodynamic drag while creating rear axle downforce for increased stability at high speeds. The Americana-inspired side exhaust further signals performance and capability. 

    Inside, the cabin of the Amaris is specified in Crimson Orbit leather and suede, with carbon fiber and piano black accents. Like the Kaveya super-coupe, Amaris features an electro-chromatically adjustable full glass roof; and “orbits” which visually define the driver and passenger environments. Amaris is shown in its 2-seater configuration, with its rear compartment sculpted to accommodate travel bags.

    Carbon fiber adorns the doors, center console and rear support brace, creating the visual effect of an exposed carbon fiber monocoque with floating leather and suede panels. The door panel forms are drawn forward, descending from shoulder height towards the footwells, creating a sense of speed and acceleration. This same dynamic effect applies to the center console, which houses the gear selector and—concealed beneath a hinged leather ignition cover to further heighten anticipation for the driving experience ahead—the “Start” button.

    Following Karma Automotive’s “reductionary” approach, non-essential features remain hidden until called upon, including the co-pilot’s display which illuminates once the passenger is seated; and cupholders that are concealed by the wireless phone charger until it is retracted with a gentle touch. The interior environment also hides atmospheric lighting that can be adjusted by the user, or changes according to the drive mode selected.

    About Karma Automotive

    Karma Automotive is America’s only full-line ultra-luxury vehicle manufacturer, and a pioneer of EREV (Extended-Range Electric) vehicles which it manufactures at its Karma Innovation and Customization Center (KICC) in Moreno Valley, CA. Its Executive, Product Development, and Design headquarters are located in nearby Irvine, CA. The Karma portfolio embodies California’s spirit of innovation and entrepreneurial boldness, reflected by the signature Comet Line which is the central hallmark of Karma’s new design language. Sales of the 3rd Generation Karma Revero sport sedan, the world’s first luxury Hybrid EREV, are now underway in the USA and EU, offering luxury balanced with conscientiousness delivered without compromise. Sales of Revero’s ultra-exclusive, performance-tuned stablemate, Karma Invictus, are also now underway, to be followed by the Gyesera Hybrid EREV four-seater in Q4 2025, and the Amaris coupe in Q4 2026. The Karma Kaveya super-coupe, with up to 1,000HP and butterfly-doors, will arrive in 2027, and the Karma Ivara GT-UV will arrive in 2028: both will incorporate SDVA (Software-Defined Vehicle Architecture) developed with the world’s leading technology companies. Further, Karma Automotive will provide Tier 1’s and Original Equipment Manufacturers (OEMs) with business-to-business SDVA solutions, as it does today with Karma Connect, its proprietary Vehicle Data Management and Over-the-Air services platform, which presently provides services to the world’s second largest OEM. Karma Automotive’s dealer network spans North America, Europe, South America and the Middle East. (www.karmaautomotive.com) 

    Media Contact:                                                                                                                                                         
              Joe Richardson, (917) 716-6617                                                                           
              [email protected]

    SOURCE Karma Automotive

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  • Israeli jazz bassist in NYC comes home to compose North African sounds

    Israeli jazz bassist in NYC comes home to compose North African sounds

    When Israeli Andalusian Orchestra Ashdod performs a new jazz work composed by acclaimed jazz bassist Omer Avital later this month, it will be a collaboration decades in the making.

    The orchestra, under the artistic direction of Elad Levi, will perform “North African Dream,” composed and conducted by Avital.

    The work will be performed on August 27 at Elma in Zichron Yaakov, on August 28 at the Jerusalem YMCA, and on August 29 at the Tel Aviv Museum of Art.

    Avital, a classically trained jazz musician, collaborated with Elad Levi, artistic director of the Andalusian orchestra, first composing a piece for the orchestra at last year’s Ashdod jazz festival.

    “I knew everybody involved,” said Avital. “It was like a Moroccan synagogue.”

    Now they’ll perform it again in August, followed by another series of performances in November and then take it on the road to Paris in November, with a tour planned for spring 2026 in the US.

    It’s a poignant piece of music in four movements — Piyut / Father, The Dream, Eastern Melancholy, The Return of the African Jew — that yearns and pines for the almost lost cultural traditions of past generations of Avital’s family.

    These days, Avital looks for opportunities to come to Israel, particularly after the Hamas terrorist attack of October 7 and the concurrent burst of anti-Israel sentiment and antisemitism in his hometown of New York as the Gaza war drags on.

    “People who I thought were on my side or were my friends are now on the other side,” said Avital. “But life goes on, and I think making music in Israel is my calling right now. I love working with Israelis. I think we’re very talented people, and at the moment, the jazz scene in Israel is one of the more bubbling scenes in the world.”

    “People are on fire with their music in Israel,” added Avital. “We say what we need to say musically.”

    New York has become a more complicated place for Avital, who said he isn’t worried about his personal safety but feels the growing hatred for Jews and Israelis around him.

    At the same time, he’s happy to have excuses to come home to Israel.

    When he was younger and growing up in Israel, Avital focused on studying classical music, learning the masters with Russian instructors. It was during a stint in Israel in the early 2000s that he spent time studying Jewish Arabic music, including his family’s Yemenite and Moroccan sounds.

    “It’s our music, it’s Jewish Arabic music,” he said. “When I was growing up, we didn’t talk about being Mizrachi, about our music, so this was a welcome renaissance.”

    Each time he has returned to Israel over the last two decades, Avital has engaged more with local music and helped create a new trend in music, combining Arab Jewish music with jazz elements.

    Avital wasn’t the only one.

    With several generations of Israeli-born jazz musicians, alongside a surge of curiosity in traditional Jewish Arabic music, such as the Andalusian tunes, there has long been a trend of melding classical strings with Middle Eastern instruments, creating a new melange of Israeli sound.

    As Avital, 53, traveled back and forth between Israel and the US, he saw how the younger generation of musicians knew and recognized jazz. The current Andalusian Orchestra is comprised of musicians in their late 20s who grew up on jazz as well as the modern music of North Africa.

    “The time was ripe to come back and work with this orchestra that can do anything,” said Avital.

    The Ashdod orchestra, founded nearly 30 years ago in the southern port city, initially included some 30 musicians who were mostly of Tunisian, Moroccan and Russian origin, and focused solely on traditional Andalusian music and liturgical poetry, playing on a variety of instruments that range from the violin to the oud.

    Now the orchestra includes younger, more mainstream Israeli musicians who are very used to melding modern sound with ancient liturgical poetry and instruments.

    “When I started doing it, it was still very strange,” said Avital. “People wondered why we were mixing jazz with liturgical singers?”

    But he — along with other musicians such as the orchestra’s Elad Levi, conductor Tom Cohen, Yemen Blues’ Ravid Kahalani — began exploring this new sound, and it stuck.

    “I’ve realized that this is my real music,” said Avital. “I learned jazz, but I’m Israeli, and I can bring my knowledge into this classical Israeli music and help make it the future music of Israel.”


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  • Studying chiropractic science in Australia? Here’s the reality

    Studying chiropractic science in Australia? Here’s the reality

    What’s it like, trying to cement your name in an industry that’s not being taken seriously? To prove that you’re truly standing on business despite what the media throws on the ground?

    When Chanathon Charas Virojna — 27, from Penang, a childhood gamer — first took a liking to chiropractic science in Year 12 of high school, the stakes weren’t as high. The industry had been present in Malaysia since the 1920s, but it wasn’t until the 2010s that it really started to take off. The first degree programme was established at International Medical University (IMU) in Bukit Jalil, and by 2014, the number of qualified practitioners had increased by 50%.

    “I discovered chiropractic from a bunch of friends, and even parents talked about it — it was a booming thing in Malaysia back then,” says Virojna. “I really enjoyed that, like physio, you do have a lot of hands-on [work], but instead of rehabilitating in the hospital, you spend time outside of it, which I preferred.”

    So why did its reputation take a turn for the worse?

    For starters, it’s widely viewed as a pseudoscience, drawing speculations as if it were astrology or aromatherapy. There are multiple reasons for this, from people thinking the job is as simple as cracking your back in place to the fact that practitioners aren’t required to spend 10 years of their life on a Doctor of Medicine.

    Then, there’s social media.

    Virojna finds it rewarding to be able to help people heal. Source: Chanathon Charas Virojna

    In 2020, the coronavirus pandemic spurred a new era of low back pain (LBP), with 619 million people worldwide affected by the phenomenon. As a result, chiropractors gained traction, but not exactly for the right reasons. Despite lacking scientific evidence, many individuals with a social media presence began to claim that chiropractic care could cure COVID-19, thereby spreading misinformation.

    As if that’s not enough, chiropractic influencers would resort to filming “sensationalised content,” or in other words, sexualised videos featuring half-naked models making sounds that would require parental guidance.

    One Reddit user even asked a practitioner: “Do you try to treat hot chicks to drive up views?”

    For the record, there’s so much more to chiropractic care than 30-second loops on TikTok. First off, it’s not a pseudoscience. Peer-reviewed journals back it up as an effective treatment for LBP, neck pain, headaches, and more. Chiropractors are required to attain a degree, and their profession is a regulated healthcare field that’s evidence-based — imperfect, but evolving.

    “We have so much we were taught in Macquarie University,” says Virojna. “We are taught the same units as physiotherapy throughout the whole bachelor’s degree. That means we got all the base knowledge.”

    Rather than forming an opinion based on the authority of social media, why not hear from an actual chiropractor? Someone truly passionate about helping people?

    chiropractic science

    Virojna decided to stay in Australia after graduating to gain experience. Source: Chanathon Charas Virojna

    Virojna’s shaky, uncertain beginnings in chiropractic science

    After staining its reputation, chiropractic science is losing institutional support. In Australia — where Virojna studied and is now living — only four universities offer programmes, including Macquarie University, his alma mater. The Friends of Science in Medicine (FSM) Association has heavily campaigned against the industry in the past, and the ban on spinal manipulation for infants was reinstated by the Chiropractic Board of Australia, as demanded by health ministers.

    “The medical board doesn’t trust us because they think we’re just whack jobs,” he says. “I don’t blame them, because we are seen like that. Chiropractic has been presented this way for a long time. But the more we promote ourselves like this, the more it feeds into that cycle. Trying to break that cycle is hard.”

    Despite that, after graduating with his bachelor’s and master’s at Macquarie, Virojna decided to stay in Australia anyway. He has got a rough vision of where he wants to be further out in his career, which looks like returning home to Malaysia with groundbreaking expertise — but of course, he needs experience. He interned at Marquarie’s Chiropractic Clinic as a student, then moved onto his first post-grad job at a practice in a suburb of Sydney.

    Virojna’s considering opening a practice in Malaysia, but that’s a goal for a distant future. For now, the job’s to learn. Source: Chanathon Charas Virojna

    “It was a very humble beginning, being a graduate, thinking, ‘Oh it was going to be so great,’” says Virojna. “The first two years were so bad. There was no support, and you had no mentorship. You don’t even know what you’re doing. You barely make any living…the dropout rate is crazy.”

    Still, the trials weren’t enough to break his spirit, even if it took too many cups of coffee. It wasn’t until Virojna found a job at a different clinic hosting a proper mentorship programme that he received guidance on crawling his way out of the pit. That perseverance; it felt rewarding.

    “It’s satisfying to be able to provide relief or allow people to feel better after each consultation,” he says. “It’s like a drug, in a good way. My goal is to be able to gain as much experience as I can in the years that I have to learn, which is probably the first 10 years of my career, to be able to set myself up in the right way.”

    The biggest lesson Virojna has learned over the years is managing expectations. He’s a chiropractor, not a magician. He’s trained to treat and prevent biomechanical disorders, not hand out miracles.

    “Everyone wants to hear good news, but sometimes, we can’t be the bearer of good news,” he says. “We have to be realistic, and we have to draw a fine line between reassuring and kind of lying.”

    chiropractic science

    Whether it was due to passion or not wanting to return to university, he’d make this career work. Source: Chanathon Charas Virojna

    Finding steady ground

    This year, Virojna co-founded a new practice. It’s called Wally’s Health, and offers chiropractic and physiotherapy services in the city — a pursuit he balances with a part-time job at a different clinic. He’s tracing his steps back to those humble beginnings, renting a single room in a medical centre. Still, the upside is that he’s working to collaborate with general practitioners and others in the same space.

    “My other company was trying to offload, so my mate and I found it to be the perfect gap for us to start something in a safe net environment, where they already had a reputation with the general practitioners,” he says. The name “Wally’s” was inspired by a street in Macquarie, with its upbeat vibe resonating with Virojna and his business partner, who both felt it reflected the good they were trying hard to achieve.

    It had always been Virojna’s goal to start something on his own; he was simply waiting for the right opportunity to break away and take the challenge. Years of struggle had enabled him to develop his skills as a clinician. Though he’s 99% convinced he might fail, he’s still got that 1% of hope pushing him forward.

    It’s been just over four months since he opened his practice, and progress has been smooth. By now, Virojna’s a permanent resident in Australia, which has made setting up his business easier, especially since he earned his degree from a local university. There were numerous hidden red tape fees, but working with general practitioners has gradually allowed them to build up their clientele through word of mouth.

    “I thought to myself, I’m definitely going to make this work because I don’t want to go back to studying. I don’t want to go back to university,” he says. “I had that confidence in me, that I knew I was going to make it work. It’s just a matter of when and how, but I was going to find a way.”


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  • Surfshark launches FastTrack to deliver up to 70% faster VPN connections

    Surfshark launches FastTrack to deliver up to 70% faster VPN connections

    Surfshark B.V.

    Surfshark_FastTrack_connection_1304x638

    Surfshark FastTrack
    Surfshark FastTrack

    Surfshark, a leading VPN (Virtual Private Network) provider, introduces FastTrack, an innovative technology that optimizes users’ traffic paths for improved speed and performance. Built on Nexus infrastructure, this solution routes traffic through a network of servers rather than a single VPN tunnel, boosting internet speeds by up to 70%. As a result, users can now experience enhanced VPN connectivity to Sydney, Seattle, and Vancouver.

    “We understand how VPN speed and low latency are important to our users. For this reason, we are proud to introduce a technology that can optimize network routing by finding the best data paths to increase connection speeds and reduce latency in real time. Surfshark Nexus infrastructure was designed with a goal in mind to build future improvements like FastTrack, by allowing us to connect users not just to a VPN server, but to a single, global Surfshark VPN network,” says Karolis Kaciulis, Leading System Engineer at Surfshark.

    Optimized network for better VPN speed and performance

    Many people believe their internet connection follows a direct, straightforward path, just as it appears at first glance when looking at a world map. However, this is a common misconception, similar to the belief that ISPs (Internet Service Providers) will always optimize user connectivity through the best routes.

    In reality, data often travels across a complex web of overground and submarine cables located around the globe. These cables define the actual physical routes that data packets take, which can be very different from what we might think. For example, due to the layout of global network infrastructure, a data packet traveling from one city to another may be routed through multiple cities, countries, or even across continents and oceans.

    There’s a similar misconception about ISPs. While they generally prioritize delivering acceptable speeds, they often do not focus on optimizing the actual network routes your data follows. Instead, ISPs typically choose paths based on cost, selecting the most economical routes for them rather than the fastest or most efficient ones for user data.

    “By optimizing data paths and selecting the most efficient routing, our technology substantially enhanced VPN performance, delivering high connection speeds regardless of users’ geographic location to Sydney, Seattle, and Vancouver. Notably, the most effective routes are not always the most direct, as it might seem. In some cases, longer paths with additional network hops can boost performance by using higher-capacity cables and more powerful routers. As a result, we have gained up to 70% in VPN speed,” explains K. Kaciulis.

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  • Anatomical and functional outcomes of anti-VEGF therapy in pachychoroi

    Anatomical and functional outcomes of anti-VEGF therapy in pachychoroi

    Vasilena Sitnilska,1 Johannes Maximillian Pohl,2 Yuhe Tang,1 Katrin Löw,1 Jeany Q Lammert,1 Tim U Krohne,1 Lebriz Altay1

    1Department of Ophthalmology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany; 2Department of Ophthalmology, Faculty of Medicine and University Hospital of Bonn, University of Bonn, Bonn, Germany

    Correspondence: Vasilena Sitnilska, Department of Ophthalmology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, Cologne, 50924, Germany, Tel +49 221 478 86041, Fax +49 221 478 3526, Email [email protected]

    Background: Evaluation of real-life effectiveness of anti-VEGF therapy in patients diagnosed with pachychoroid neovasculopathy (PNV).
    Methods: This retrospective analysis included central serous chorioretinopathy (CSC) patients who developed PNV and underwent anti-VEGF treatment. Individuals with concomitant retinal diseases were excluded. Key measures included best-corrected visual acuity (BCVA), spectral domain optical coherence tomography (SD-OCT) features (intra-/subretinal fluid, central retinal thickness (CRT), and choroidal thickness (CT)), and potential risk factors such as age, sex, and corticosteroid intake, baseline neovascularization area in fluorescein angiography and in OCT-angiography, and time from PNV diagnosis to treatment initiation.
    Results: The study included 40 eyes of 40 patients (24 males, 16 females), with a mean follow-up period of 38.23± 19.73 months and a mean number of anti-VEGF injections of 27.47± 16.73. BCVA, CRT and CT improved significantly at the final visit compared to baseline (BCVA p=0.019, CRT p< 0.001, CT p< 0.001). 85% of eyes achieved a “completely dry” status on SD-OCT after a mean of 10.94± 11.22 months and a mean of 8.88± 9.17 injections. However, 82.4% of these eyes had a recurrence after a mean 3.32± 4.82 months. There was no significant association of the evaluated risk factors with the treatment response. At the end of the observation period, there was no significant difference in BCVA between the “completely dry” group and the non-responders (p=0.765).
    Conclusion: A majority of PNV patients exhibit anatomical and functional improvement following anti-VEGF therapy. However, the high rate of recurrences suggests a need for long-term treatment.

    Keywords: pachychoroid neovasculopathy, chronical central serous chorioretinopathy, anti-VEGF therapy

    Introduction

    Pachychoroidal neovasculopathy (PNV) is a novel term to describe macular neovascularization (MNV) in association with abnormally thickened and altered choroidal vessels. PNV is part of the pachychoroid spectrum, which also includes pachychoroid pigment epitheliopathy, central serous chorioretinopathy (CSC) and pachychoroid aneurysmal type 1 MNV (PAT1), formerly known as polypoidal choroidal vasculopathy.1,2 There is a pathophysiological overlap between these diseases, and in this continuum PNV is discussed as a secondary complication in the context of chronic CSC or other pachychoroidal diseases.

    Without intervention, PNV may result in a substantial decline in central vision. Recent research has demonstrated the efficacy of anti-VEGF in addressing PNV.3–10 In addition, photodynamic therapy (PDT) has been evaluated as a potential monotherapy and as an adjunct to anti-VEGF therapy.3,11–16

    The aim of this study was to examine the long-time effectiveness of anti-VEGF therapy in patients with PNV. Furthermore, we aimed to identify possible risk and protective factors for good anatomical and functional response.

    Materials and Methods

    Patients

    All available patients’ charts with a diagnosis of macular neovascularization (MNV) secondary to CSC who received anti-VEGF treatment between January 2015 and October 2023 at the Department of Ophthalmology, University Clinic of Cologne, were retrospectively reviewed. Only therapy-naïve patients without prior anti-VEGF treatment and with available multimodal imaging were included (Figure 1). Only one eye per patient was included. The diagnosis of PNV was documented by spectral domain optical coherence tomography (SD-OCT), OCT angiography (OCT-A), fundus autofluorescence (FAF), fluorescein angiography (FA), and indocyanine green angiography (ICGA). Patients with follow up less than 6 months and patients with signs of concomitant retinal diseases (myopia >6dpt, age-related macular degeneration, macular dystrophy, diabetic retinopathy, MNV due to other cause like trauma or tumor) were excluded.

    Figure 1 Multimodal imaging. (A) Optical coherence tomography (OCT) with flat irregular hyperreflective retinal pigment epithelium (RPE), macular subretinal fluid and thickened subfoveal choroid (B) OCT-angiography with neovascularization membrane (C) Late leakage on fluorescein angiography corresponding to the flat irregular hyperreflective retinal pigment epithelium (D) Mid-phase indocyanine green angiography with thickened choroidal vessels.

    Demographic information and medical history (corticosteroid intake, psychological stress, PDT treatment before and/or after diagnosis of PNV) were examined by reviewing patient records. Best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR) was obtained at baseline and at the end of the study for all eyes. The study was conducted in accordance with the tenets of the Declaration of Helsinki and the Medical Research Involving Human Subjects Act (WMO).

    Diagnosis and Grading of PNV

    All available images were reviewed for the diagnosis of CSC and MNV. Grading was performed on FA/ICGA (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg, Germany), OCT-A, FAF and SD-OCT (scan area 20° × 15° (5.9 × 4.4 mm), 37 B-scans, distance between B-scans 123 mm) by two independent graders (VS, LA). Any discrepancies between graders were resolved through open adjudication. Morphological features for the confirmation of CSC diagnosis included presence of macular subretinal fluid (SRF) on SD-OCT, alterations in the retinal pigment epithelium (RPE), focal or diffuse leaks/hyperfluorescent areas on FA/ICG-A and thickened choroid. The presence of neovascularization was defined by a late leakage on FA, corresponding to a late staining area on ICGA and a flat irregular, hyperreflective RPE elevation on SD-OCT.17

    Central retinal thickness (CRT), choroidal thickness (CT), presence of RPE atrophy or intraretinal cysts were graded on SD-OCT at baseline and at the final visit. (Figure 1) For all measurements, automated segmentation of Heidelberg Eye Explorer software was used, and all results were corrected manually. Hereby, CRT was measured from internal limiting membrane to Bruch´s membrane (BrM), CT was measured on a subfoveal centered SD-OCT image. Neovascularization area was manually graded on FA and on OCT-A at baseline visit. In OCT-A, the neovascularization area was identified after manual correction of the segmentation in the subretinal and sub-RPE spaces.

    Patient Treatment

    All included eyes underwent anti-VEGF treatment with either Bevacizumab, Ranibizumab or Aflibercept in the Department of Ophthalmology, University of Cologne. The following treatment regimens were assigned and decided upon within routine clinical practice: 1) One single anti-VEGF followed by injections as needed, 2) Pro re nata (PRN with upload: 3 consecutive monthly injections followed by injections as needed, 3) Modified Treat & extend (T&E): one single anti-VEGF followed by T&E. In general, patients who started therapy between 2015 and 2018 were mostly assigned to one single anti-VEGF followed by monthly OCT controls and injections as needed or to PRN. Patients who started treatment in 2018 or later were assigned directly to modified T&E (without upload). Therapy success was defined as complete SRF resolution (“completely dry”). Best-corrected visual acuity (BCVA) was obtained at each visit.

    Statistical Analyses

    Descriptive statistics were used to summarize the characteristics of all patients. Results were given as mean ± standard deviation (SD), median ± interquartile range (IQR) or number of eyes and percentage. Pearson’s chi² test was used for categorical variables and t-test or Mann–Whitney U-Test for continuous variables depending on the distribution. Statistical analyses were performed using SPSS (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corporation). P values <0.05 were considered as statistically significant.

    Results

    About, 97 patients’ charts were retrospectively reviewed. In total, 40 eyes of 40 patients fulfilled the inclusion and none of the exclusion criteria. Fifty-seven eyes were excluded due to one of the following reasons: 1) prior anti-VEGF injections (N=13), 2) follow-up less than 6 months (N=7), 3) missing retinal imaging data for the confirmation of CSC and MNV (N=9), 4) concomitant retinal diseases (N=28).

    The mean observation time was 38.23 months, during which a mean of 27.47 injections were administrated. The majority of eyes (N=30, 75%) had T&E regimen from the beginning of the treatment. Only three eyes received 3x monthly upload followed by PRN regimen: one case had a recurrence after discontinuation of the treatment and did not receive any further follow up, another case reached a completely dry status and did not receive any further follow up, the third case switched to T&E before reaching a completely dry status. Seven eyes received primary one single anti-VEGF followed by monthly OCT controls, in cases of disease activity another anti-VEGF was administrated. Over time, six of the seven patients were switched to T&E due to high disease activity. One case reached a completely dry status only after 2 injections (duration between the two injections 3 months) and did not receive any further follow up.

    Seventeen eyes received bevacizumab as an initial drug, 23 received ranibizumab as an initial drug and none of the eyes received aflibercept from the start. Twenty eyes (50%) switched the treatment to another drug during the course of observation. In general, until the last visit, each eye received a mean of 27.48±16.72 SD injections (median 25.00, range 55, min 2-max 57): bevacizumab mean 4.5±6.36 (median 0.00, range 24, min 0-max 24); ranibizumab mean 11.28±11.53 (median 9.00, range 40, min 0-max 40); aflibercept mean 11.70±13.42 (median 7.50, range 45, min 0-max 45). Further baseline characteristics are shown in Table 1.

    Table 1 Demographics

    Anatomical and Functional Outcome

    A positive effect of the treatment could be demonstrated in all eyes regarding anatomical features (presence of SRF, CRT, CT). The majority of eyes (85%) reached a completely dry status on the SD-OCT (85%) after a mean of 10.94±11.22 months and after mean of 8.88±9.17 injections. However, 82.4% of those eyes had a reactivation after a short period of time (within 3.32±4.82 months).

    Both CRT and CT were significantly reduced after treatment with anti-VEGF at the final visit, compared with baseline (mean change CRT 90.73±81.96 µm, p<0.001, mean change CT 36.76±30.00 µm p<0.001), regardless of the current activity of the neovascularization at the final visit (n=16 with dry SD-OCT, n=24 with presence of SRF).

    Additionally, a significant improvement of BCVA could be shown (mean change from baseline to final visit BCVA 0.12±0.30, p=0.019). There was no statistically significant correlation between visual outcome and age or outcome in the CRT parameters and age (Pearson test p>0.05). Interestingly, among the eyes which reached a dry status, there was a significant correlation between the baseline neovascularization area in OCT-A and time until reaching a dry status with smaller areas drying quicker (P=0.038). The baseline neovascularization area in fluorescein angiography showed a tendency regarding the velocity of reaching a dry status, but did not reach the threshold for statistical significance (P=0.057).

    PDT Treatment

    Sixteen of the examined eyes had a history of PDT treatment. About, 13 of those 16 eyes had at least one PDT treatment before developing PNV. The mean time between first PDT treatment and first intravitreal injection was 3.11±2.47 years. Only 5 eyes had PDT after diagnosis of PNV (2 of them had PDTs before and after PNV diagnosis, 3 had PDT treatment only after PNV diagnosis). Among these cases, 3 eyes successfully reached a dry status, and two eyes were complete non-responders.

    The remaining 24 eyes (60%) were never treated with PDT. 95.8% (n=23) reached a completely dry status during the anti-VEGF treatment, so no adjunctive PDT treatment was necessary.

    Almost all non-responders to anti-VEGF had at least one PDT treatment (5/6). One patient did not receive any PDT because that was the patient’s preference.

    Prognostic Factors for Complete SRF Resolution

    None of the evaluated demographic characteristics such as age, sex, time to treatment after diagnosis or corticosteroid intake could show a significant impact on reaching a completely dry status on SD-OCT. Also, none of the evaluated morphological features reached statistical significance (Table 2). History of PDT was highly significant.

    Table 2 Prognostic Factors for Reaching a Completely Dry Status

    Discussion

    In this retrospective study, we analyzed a long term treatment response of anti-VEGF therapy in cases diagnosed with PNV. The majority of eyes achieved complete resolution of SRF on SD-OCT, confirming the efficacy of anti-VEGF treatment in eyes with PNV demonstrated in previous studies (4–8, 20–22). Nevertheless, after a short period of time there was a recurrence of disease activity which required a continuation of the treatment.

    PNV is considered as a new disease entity that can occur directly or can develop after a long-standing chronic CSC.18–20 Most common treatment options for PNV include anti-VEGF injection or PDT, or a combination of both. Most of the previous studies documented significant anatomical and functional improvements following anti-VEGF injections in PNV patients.3,8,10,21–23 Yet, a recent retrospective study revealed that a relatively low rate of 41% of patients experienced successful treatment outcomes (characterized by complete resolution of symptoms), over a five-year period and reported no significant visual improvement.24 These observed discrepancies may be attributable to a number of factors, including the administration of only one anti-VEGF agent, patient compliance, treatment regimens (single injection, PRN or T&E) or disease recurrence. In our cohort, the anti-VEGF medication was switched in cases of non-response and most of the patients followed a T&E regime. A recent retrospective study with a small cohort over a 3-year period of treatment suggested a superior effect of aflibercept over bevacizumab und ranibizumab.25 Several studies have reported a comparable treatment effect of anti-VEGF treatment in patients with PNV and neovascular age-related macular degeneration (nAMD), with some even showing a reduced needed number of injections in PNV. (4–8, 14) Hata et al showed a significantly lower VEGF concentration in patients with treatment-naïve PNV in comparison to patients with treatment-naïve nAMD, suggesting a different influence of VEGF in PNV patients.26

    PDT is considered to be a successful potential treatment option for PNV cases as a monotherapy, with comparable results to monotherapy with anti-VEGF injections.3,20,27 Further, the efficacy of PDT in combination with anti-VEGF therapy has been evaluated for pachychoroidal neovasculopathy with or without polyps in several studies, demonstrating regression of MNV activity and a reduction in choroidal permeability.11,13,15,16,28 For instance, Lee et al showed a positive effect of adjunctive PDT treatment for patients with type 1 MNV and thickened choroid who were refractory to anti-VEGF monotherapy, with 85.7% of patients reaching a dry status.29 There are also a few long-term reports confirming the effectiveness of a combination therapy.25,30 In our cohort history of PDT showed a significant influence of the response, which is considered a bias, since only 6 eyes were non-responders and almost all of them had received previous PDT treatment, whereas a high number of eyes with completely dry results never underwent any PDT treatment.

    So far, there is no standard treatment protocol with focus on monotherapy or combination of both anti-VEGF and PDT for treatment of PNV.

    Even though 40% of our study population had a history of PDT treatment, in most cases, PDT was performed long before the development of PNV (mean 37.3±29.7 months). Only five eyes received an adjunctive PDT treatment to the anti-VEGF treatment, and three of these five (60%) achieved a completely dry status. Overall, almost all of the eyes in our study who did not have any PDT treatment still reached a completely dry status under anti-VEGF treatment (95.8%, n=23/24), showing that a good treatment outcome can also be reached without prior PDT. Nevertheless, the high recurrence rate remains an issue. There is a wide range of reported recurrence rate after successful treatment of PNV. Several studies report a positive effect of PDT treatment on recurrence rate and a possible preventive role.11,13,15,16,29 Due to the low number of non-responders in our study, no representative results of the possible positive influence of PDT on treatment response and on recurrence of MNV activity could be shown.

    In order to determine which is the best and most effective treatment regimen for PNV we need a better understanding of the pathogenesis of formation of neovascularization membranes and subretinal fluid accumulation. So far, the pathogenesis is only partly understood. There are hypotheses, that the neovascularizations in long lasting CSC occur mostly due to arteriogenesis and less or not at all due to angiogenesis process,23,31 and that the success of anti-VEGF treatment could be explained by causing a reduction of the choroidal vascular permeability followed by reduction of the CT and absorption of SRF;10 or that the presence of SRF might not always be a sign of MNV activity.23 Recent studies suggest an involvement of thickened sclera in the pathogenesis of CCS and PNV,32,33 indicating a thickened sclera in more complex CCS34 and even only a partial response to PDT treatment.35 The role of scleral thickness particularly in PNV patients and their treatment response is yet to be better understood.

    Limitations of this study include the limited sample size, the retrospective study design and lack of data to examine the role of concomitant PDT treatment. The question regarding the ideal treatment regimen for PNV remains unanswered. No comparison could be made between different anti-VEGF agents due to the low number of patients and the switch of medication over time. Also, due to the limited sample size, the statistical power of the study may be insufficient to detect small to moderate effects. Further prospective studies are needed to address this. Nevertheless, this study provides additional evidence on treatment regimens for a positive outcome for patients with PNV after a long-lasting anti-VEGF treatment.

    Conclusions

    Most PNV eyes exhibited favorable anatomical and functional improvements with anti-VEGF therapy. However, the elevated recurrence rate underscores the necessity for continuous treatment. Future studies should focus on devising approaches to reduce recurrence and improve long-term patient outcomes.

    Data Sharing Statement

    The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

    Ethics Approval and Consent to Participate

    All methods were carried out in accordance with the tenets of the Declaration of Helsinki and ethics committee of University of Cologne. This study does not include any experimental protocols. According to the local ethics committee, informed consent and extra approval is not required for retrospective analyses. All patient information is confidential and pseudonymized.

    Consent for Publication

    This study involved retrospective analysis of pseudonymized patient data. According to the requirements of the local ethics committee, formal informed consent was not necessary for the retrospective use of such data (s. above). However, as part of standard institutional procedures, patients had previously provided general informed consent allowing the use of their pseudonymized medical data for research and publication purposes. This consent was obtained independently of this specific study.

    Acknowledgments

    Preliminary results of this work have been presented as an abstract at the 2024 ARVO Annual Meeting, held in Seattle, WA, May 5–9, 2024.36

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    There is no funding to report.

    Disclosure

    Prof. Dr. Tim Krohne reports personal fees from AbbVie, personal fees from Alimera, personal fees from Astellas, personal fees from Bayer, personal fees from Novartis, personal fees from Roche, personal fees from Stada, outside the submitted work. The authors declare that they have no other conflict of interest.

    References

    1. Brown R, Mohan S, Chhablani J. Pachychoroid spectrum disorders: an updated review. J Ophthalmic Vis Res. 2023;18(2):212–229. doi:10.18502/jovr.v18i2.13188

    2. Spaide RF, Jaffe GJ, Sarraf D, et al. Consensus nomenclature for reporting neovascular age-related macular degeneration data: consensus on neovascular age-related macular degeneration nomenclature study group. Ophthalmology. 2020;127(5):616–636. doi:10.1016/j.ophtha.2019.11.004

    3. Hikichi T, Kubo N, Yamauchi M. One-year comparison of anti-vascular endothelial growth factor and half-dose photodynamic therapies for pachychoroid neovasculopathy. Eye. 2021;35(12):3367–3375. doi:10.1038/s41433-021-01418-z

    4. Yoon J, Yoon W, Na SK, et al. Long-term outcome of intravitreal anti-vascular endothelial growth factor treatment for pachychoroid neovasculopathy. Sci Rep. 2021;11(1):12052. doi:10.1038/s41598-021-91589-2

    5. Kuranami A, Maruko R, Maruko I, Hasegawa T, Iida T. Pachychoroid neovasculopathy has clinical properties that differ from conventional neovascular age-related macular degeneration. Sci Rep. 2023;13(1):7379. doi:10.1038/s41598-023-33936-z

    6. Cho HJ, Jung SH, Cho S, Han JO, Park S, Kim JW. Intravitreal anti-vascular endothelial growth factor treatment for pachychoroid neovasculopathy. J Ocul Pharmacol Ther. 2019;35(3):174–181. doi:10.1089/jop.2018.0107

    7. Üney G, Hazırolan D, Ünlü N, Candan Ö. Pro re nata anti-VEGF treatment in pachychoroid neovasculopathy compared with age-related macular degeneration based on optical coherence tomography. Int Ophthalmol. 2024;44(1):164. doi:10.1007/s10792-024-03094-w

    8. Matsumoto H, Hiroe T, Morimoto M, Mimura K, Ito A, Akiyama H. Efficacy of treat-and-extend regimen with aflibercept for pachychoroid neovasculopathy and type 1 neovascular age-related macular degeneration. Jpn J Ophthalmol. 2018;62(2):144–150. doi:10.1007/s10384-018-0562-0

    9. Schworm B, Luft N, Keidel LF, et al. Response of neovascular central serous chorioretinopathy to an extended upload of anti-VEGF agents. Graefes Arch Clin Exp Ophthalmol. 2020;258(5):1013–1021. doi:10.1007/s00417-020-04623-w

    10. Padrón-Pérez N, Arias L, Rubio M, et al. Changes in choroidal thickness after intravitreal injection of anti-vascular endothelial growth factor in pachychoroid neovasculopathy. Invest Ophthalmol Vis Sci. 2018;59(2):1119–1124. doi:10.1167/iovs.17-22144

    11. Miki A, Kusuhara S, Otsuji T, et al. Photodynamic therapy combined with anti-vascular endothelial growth factor therapy for pachychoroid neovasculopathy. PLoS One. 2021;16(3):e0248760. doi:10.1371/journal.pone.0248760

    12. Wada I, Shiose S, Ishikawa K, et al. One-year efficacy of “rescue photodynamic therapy” for patients with typical age-related macular degeneration, polypoidal choroidal vasculopathy, and pachychoroid neovasculopathy refractory to anti-vascular endothelial growth factor therapy. Graefes Arch Clin Exp Ophthalmol. 2022;260(6):2029–2036. doi:10.1007/s00417-022-05553-5

    13. Matsumoto H, Mukai R, Kikuchi Y, Morimoto M, Akiyama H. One-year outcomes of half-fluence photodynamic therapy combined with intravitreal injection of aflibercept for pachychoroid neovasculopathy without polypoidal lesions. Jpn J Ophthalmol. 2020;64(2):203–209. doi:10.1007/s10384-020-00722-7

    14. Tanaka N, Azuma K, Aoki S, et al. Intravitreal anti-vascular endothelial growth factor and combined photodynamic therapy for pachychoroid neovasculopathy: long-term treatment outcomes. Graefes Arch Clin Exp Ophthalmol. 2024;262(6):1811–1818. doi:10.1007/s00417-024-06387-z

    15. Sato-Akushichi M, Ono S, Taneda T, Klose G, Sasamori A, Song Y. One-year outcome of combination therapy with full or reduced photodynamic therapy and one anti-vascular endothelial growth factor in pachychoroid neovasculopathy. Pharmaceuticals. 2022;15(4). doi:10.3390/ph15040483

    16. Kitajima Y, Maruyama-Inoue M, Ito A, et al. One-year outcome of combination therapy with intravitreal anti-vascular endothelial growth factor and photodynamic therapy in patients with pachychoroid neovasculopathy. Graefes Arch Clin Exp Ophthalmol. 2020;258(6):1279–1285. doi:10.1007/s00417-020-04661-4

    17. Shiragami C, Takasago Y, Osaka R, et al. Clinical features of central serous chorioretinopathy with type 1 choroidal neovascularization. Am J Ophthalmol. 2018;193:80–86. doi:10.1016/j.ajo.2018.06.009

    18. Jung H, Suh Y, Lee J, et al. Pachychoroid spectrum disease: comparison of patients with central serous chorioretinopathy complicated with pachychoroid neovasculopathy. Korean J Ophthalmol. 2024. doi:10.3341/kjo.2024.0020

    19. Mrejen S, Balaratnasingam C, Kaden TR, et al. Long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy. Ophthalmology. 2019;126(4):576–588. doi:10.1016/j.ophtha.2018.12.048

    20. Sartini F, Figus M, Casini G, Nardi M, Posarelli C. Pachychoroid neovasculopathy: a type-1 choroidal neovascularization belonging to the pachychoroid spectrum-pathogenesis, imaging and available treatment options. Int Ophthalmol. 2020;40(12):3577–3589. doi:10.1007/s10792-020-01522-1

    21. Schworm B, Luft N, Keidel LF, et al. Vanishing pachy-choroid in pachychoroid neovasculopathy under long-term anti-vascular endothelial growth factor therapy. BMC Ophthalmol. 2021;21(1):269. doi:10.1186/s12886-021-02022-1

    22. Schworm B, Luft N, Keidel LF, et al. Ranibizumab non-response in pachychoroid neovasculopathy: effects of switching to aflibercept. Sci Rep. 2020;10(1):8439. doi:10.1038/s41598-020-65370-w

    23. Sacconi R, Tomasso L, Corbelli E, et al. Early response to the treatment of choroidal neovascularization complicating central serous chorioretinopathy: a OCT-angiography study. Eye. 2019;33(11):1809–1817. doi:10.1038/s41433-019-0511-2

    24. Rabinovitch D, Shulman S, Goldenberg D, et al. Choroidal response to intravitreal bevacizumab injections in treatment-naïve macular neovascularization secondary to chronic central serous chorioretinopathy. Biomedicines. 2024;12(12):2760. doi:10.3390/biomedicines12122760

    25. Nomura Y, Aoki S, Kitamoto K, et al. Three-year outcome of photodynamic therapy combined with VEGF inhibitor for pachychoroid neovasculopathy. Graefes Arch Clin Exp Ophthalmol. 2024;262(10):3191–3200. doi:10.1007/s00417-024-06499-6

    26. Hata M, Yamashiro K, Ooto S, et al. Intraocular vascular endothelial growth factor levels in pachychoroid neovasculopathy and neovascular age-related macular degeneration. Invest Ophthalmol Vis Sci. 2017;58(1):292–298. doi:10.1167/iovs.16-20967

    27. Tanaka K, Mori R, Wakatsuki Y, Onoe H, Kawamura A, Nakashizuka H. Two-thirds dose photodynamic therapy for pachychoroid neovasculopathy. J Clin Med. 2021;10(10):2168. doi:10.3390/jcm10102168

    28. Takeuchi J, Ota H, Nakano Y, et al. Predictive factors for outcomes of half-dose photodynamic therapy combined with aflibercept for pachychoroid neovasculopathy. Graefes Arch Clin Exp Ophthalmol. 2023;261(8):2235–2243. doi:10.1007/s00417-023-06030-3

    29. Lee JH, Lee WK. One-year results of adjunctive photodynamic therapy for type 1 neovascularization associated with thickened choroid. Retina. 2016;36(5):889–895. doi:10.1097/iae.0000000000000809

    30. Karasu B, Celebi ARC. An efficacy comparison of combination of different anti-vascular endothelial growth factors and photodynamic therapy in patients with pachychoroid neovasculopathy. Int Ophthalmol. 2021;41(6):1989–2000. doi:10.1007/s10792-021-01754-9

    31. Spaide RF. Optical coherence tomography angiography signs of vascular abnormalization with antiangiogenic therapy for choroidal neovascularization. Am J Ophthalmol. 2015;160(1):6–16. doi:10.1016/j.ajo.2015.04.012

    32. Zarnegar A, Ong J, Matsyaraja T, Arora S, Chhablani J. Pathomechanisms in central serous chorioretinopathy: a recent update. Int J Retina Vitreous. 2023;9(1):3. doi:10.1186/s40942-023-00443-2

    33. Keidel LF, Schworm B, Langer J, et al. Scleral thickness as a risk factor for central serous chorioretinopathy and pachychoroid neovasculopathy. J Clin Med. 2023;12(9):3102. doi:10.3390/jcm12093102

    34. Imanaga N, Terao N, Wakugawa S, et al. Scleral thickness in simple versus complex central serous chorioretinopathy. Am J Ophthalmol. 2024;261:103–111. doi:10.1016/j.ajo.2024.01.025

    35. Forte P, Cattaneo J, Cardillo Piccolino F, et al. Influence of scleral thickness on photodynamic therapy outcomes in central serous chorioretinopathy. Acta Ophthalmol. 2024;103(3):e165–e175. doi:10.1111/aos.16779

    36. Sitnilska V, Pohl M, Altay L. Anatomical and functional outcome after anti-VEGF therapy in patients diagnosed with pachychoroid neovasculopathy. Invest Ophthalmol Visual Sci. 2024;65(7):218.

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  • Jannik Sinner Opens Up on Arm Sleeve — It’s Not for Style

    Jannik Sinner Opens Up on Arm Sleeve — It’s Not for Style

    On Saturday, ATP World No. 1 Jannik Sinner began his defense of his Cincinnati Open title. Sinner’s second round win over Daniel Elahi Galán was his first match since winning Wimbledon on July 13.

    While tennis fans were excited to see Sinner back on the court, many have been concerned about his ongoing use of an arm sleeve. Since taking a fall during a match at Wimbledon, Sinner has worn an arm sleeve in practice and matches.

    The media has asked Sinner about this multiple times, but the issue will not go away. Before his first match in Cincinnati, Sinner assured the ATP Press that his elbow was fine.

    “The elbow is good. Today was the first time that I put a sleeve on because I liked the feeling of the sleeve,” Sinner said during his media day press conference.

    “It gives a little bit more impact with the ball, it’s slightly more stable. That’s my point of view, and I liked it in Wimbledon. I have to see how it is when it’s very hot and humid, because it’s a little bit different, so it’s going to be something that I’m going to take into consideration, but I really love the feeling it gives of pure striking.”

    The question about Sinner’s decision to wear a sleeve came back up during another interview in Cincinnati. Was the Italian superstar wearing it as a fashion statement?

    “As I said when I came here, the impact of the ball is a bit different. And I feel it better if I would not wear it. I don’t wear things just because of style, you know?” said Sinner with a laugh.

    “At the moment I feel comfortable. With the heat, it’s actually ok. It’s not too much. I tried the black sleeve, it makes a difference, with the black sleeve. But the white one under these conditions is no problem.”

    Sinner faces unseeded Gabriel Diallo in the third round of the ATP 1000 Cincinnati. He currently has a record of 26-3 with two titles (Australian Open and Wimbledon).

    The Cincinnati Open runs through August 18. Stay locked into Sports Illustrated’s Serve on SI for all the most important news from the tennis court and beyond.

    Elena Rybakina’s coach has returned after the WTA lifted his ban.

    Iga Swiatek makes history with 300th Career win in Cincinnati.

    Naomi Osaka issued a statement apologizing for her post-match speech in Montreal.

    Ben Shelton wins first ATP Masters 1000 in Toronto.

    Montreal Magic: Victoria Mboko Wins First Masters 1000.


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  • Prince Andrew makes key gesture in first pictures since book allegations | Royal | News

    Prince Andrew makes key gesture in first pictures since book allegations | Royal | News

    Prince Andrew has been pictured for the first time since the bombshell book allegations were made against him.

    The 65-year-old and his former wife, Sarah Ferguson, also 65, were the focus of Andrew Lownie’s explosive new biography, ‘Entitled: The Rise and Fall of the Yorks’. The book discusses the couple’s life behind closed doors and focuses on areas such as their alleged rampant infidelity, “secretive money-making endeavours,” and “controversial friendships.”

    Andrew was photographed behind the wheel of his Defender on Sunday as he drove to Windsor Castle for an afternoon walk. Speaking about Andrew’s look as he drove around the estate, body language expert Jennie Bond told the Mirror: “It’s less about what has changed in Andrew’s body language here and more about what’s missing.

    “Caught in this one moment he appears to have lost the rounded-eyed, haunted expression.

    “His frown has melted slightly and there are no obvious signs of muscle tension in his facial expression. The royal known for looks of haughty arrogance appears less immersed in signals of status and entitlement and perhaps more reflective here.”

    The extracts, serialised in the Daily Mail, detailed Andrew’s close friendship with disgraced financier Jeffrey Epstein, as well as making claims about his ‘bullying’ of palace staff, vulgar sense of humour and brazen sex life.

    Andrew has always strongly and vehemently denied the claims in regards the sex scandals and previously reached an out-of-court settlement for an undisclosed amount with accuser, the late Virginia Giuffre.

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  • What Happened to All the Human Bird Flu Cases?

    What Happened to All the Human Bird Flu Cases?

    From the outset of the Trump administration, bird flu, or H5N1 avian influenza, has flown rather conspicuously — and in fact quite mysteriously — under the radar. So much so that [on July 7], the Centers for Disease Control and Prevention announced the end of its emergency response to bird flu, citing the lack of reported human cases. Updates, previously issued weekly, will now arrive monthly. But something isn’t adding up.

    At the end of 2024, infections in the United States were surging. From Ohio to California, and in a swath of intervening states, diagnoses were being made in growing numbers of farmworkers who came into contact with infected cattle and poultry.

    Most suffered a mild spectrum of symptoms — low grade fevers, muscle aches, inflammation in their eyes. As cases swelled, an older man in Louisiana fell critically ill. He would eventually become the first person in the U.S. to succumb to the virus since initial human cases were reported to the World Health Organization in 1997. We seemed then, for a moment, to be at a tipping point: bound to unleash something both larger and deadlier than we could foreseeably contain, and destined to dust off the cobwebs of a life grimly lived, again, under a pandemic.

    And yet, none of that came to pass. Instead, since February, the CDC, which still monitors infections in humans, has not recorded a single new case in the U.S. The count remains the same — stuck firmly at 70.

    Rationalizing the lull in infections has been puzzling. Researchers have tied wild birds, the virus’s largest reservoir, and their spring and fall migrations to periods of greater spread of contagion. Cuts to staff who monitored the virus, at the U.S. Department of Agriculture and the Center for Veterinary Medicine, might also be playing a role.

    But these ideas dismiss the deeper and more fundamental problem around our present grasp of bird flu. As an infectious diseases physician who works primarily with immigrant populations, my perspective often sits at the nexus between the people a novel disease affects and the apparatuses that exist to control it. Lately, the actions of each arm of that equation, no longer motivated by the ethos of a collective concern, are fractured by individual ambitions and epitomize our faltering response.

     

    Cases, in all likelihood, are being missed, in part because detecting infections is simply challenging. Foremost, it requires the ability to recognize an infected person. But this, as we’ve seen, is not always achieved. A number of bovine veterinarians, for example, were found earlier this year to harbor antibodies to the virus — a signature of infection — though none had influenza-like symptoms to suggest they’d been infected.

    Surveillance, therefore, is largely — and imperfectly — built around those who are exposed and symptomatic. It’s a system that also exposes the vulnerable contexts in which a person may have gotten infected.

    In vulnerable groups, this makes a willingness to be tested all the more fraught. According to the Center for Migration Studies, 45% of the agricultural workforce in the U.S. comprised undocumented persons in 2022. And according to USDA data from 2020 to 2022, an additional 19% don’t hold U.S. citizenship. Nearly 80% of American milk is supplied from dairies that employ immigrant labor. Consider a foreign-born dairy hand perplexed by redness in his eyes and a sore throat. He faces a dilemma: After ICE raids like “Operation Return to Sender” targeted farmworkers in California this winter, is getting to the root of his symptoms worth falling into an anti-immigrant governmental maw?

    “I can’t argue with anyone who would be risking getting shipped to a Salvadoran gulag for reporting an exposure or seeking testing,” Angela Rasmussen, a virologist at the University of Saskatchewan, told the Associated Press in May.

    For anyone in this situation, the personal calculus simply does not add up. And so, outreach programs and protective measures have not been sought; infections, if they happen, fester undetected. Lacking granular data from those that might be affected, we are without the empirical information we would typically use to form broader understandings, draw conclusions, and map out predictions.

    Indeed, while this political climate has caused the vulnerable to shrink from the public conscience, the dearth of cases doesn’t seem to be a concern for the government brass handling bird flu, who placed their priorities and interests above those of the widely accepted consensuses of scientists, virologists, and public health officials.

    In March, this was evident when Health and Human Services Secretary Robert F. Kennedy Jr. proposed allowing H5N1 to sweep through poultry flocks unabated, part of an unorthodox effort to gain insight into how surviving birds could become naturally immune to the virus. The scientific community balked at the danger of such an experiment, but the proposal garnered the support of Agriculture Secretary Brooke Rollins. She suggested in a February interview that farmers would be willing to try this on as a “pilot.”

    Animal studies in this realm have already been conducted in controlled settings. And our understanding of H5N1 — which has plagued humankind for almost 30 years — and the immune responses it elicits is fairly robust. But that didn’t dissuade the current administration from pressing for a redundant mandate.

    Instead, Mehmet Oz, administrator for the Centers for Medicare and Medicaid Services, went so far as to offer refuge on his personal 900-acre ranch in Okeechobee, Florida, to about 400 ostriches that the Canadian Food Inspection Agency had ordered to be culled. This was after dozens of the birds in a British Columbia farm’s flock had come into contact with and died from H5N1.

    Kennedy, in a post on X, displayed a copy of a letter to the president of the CFIA explaining that studying the ostriches would “help us understand how to better protect human and animal populations and perhaps lead to the development of new vaccines and therapeutics.”

    Soon after, likely as part of Kennedy’s vendetta against the technology, the HHS canceled a Biden-administration contract with Moderna to develop an mRNA-based vaccine (akin to the one successfully deployed against COVID-19) for bird flu.

    Bird flu is far from a passing peril. It has been detected in almost 1,100 cattle herds across the U.S. In Brazil, the world’s largest exporter of chickens, the first outbreak on a commercial poultry farm was confirmed in May while the country was also investigating about a dozen others. And in Mexico, a 3-year-old girl died from respiratory complications related to the virus. She was the country’s first confirmed human case and was infected by the same D1.1 variant that precipitated severe illnesses in the man in Louisiana and a teenager in British Columbia.

    Because infections are still largely constrained to animals and the marginalized people who work with them, bird flu has the distinction of being both omnipresent and barely visible. The way in which one country approaches it will, invariably, have rippling effects in others.

    As the focus shifts to the economics of maintaining stocks of chickens and rebalancing the price of eggs, incentives for the testing of farmworkers remain inadequate, and protections among those who are foreign-born are, at best, dubious. From bench to barn, earnest collaborations with scientists and experts are also being undermined.

    Public health is a delicate concept. To uphold it involves a complex interplay between forces large and, more importantly, small. We can predict the risk of a bird flu pandemic from a single mutation in the virus’s genetic code. An individual, we must also realize, can upend things all the same.

    Arjun Sharma is a physician specializing in infectious diseases whose writing has appeared in the Washington Post, L.A. Times, and the Boston Globe, among other outlets.

    This story was published by Undark on July 10, 2025. It is republished with permission.

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