Alain Zourdani

Changes in visual acuity in patients with wet age-related macular degeneration treated with intravitreal ranibizumab in daily clinical practice: the LUMIERE study.

Purpose: The real-life LUMIERE study on patients with wet age-related macular degeneration treated with intravitreal ranibizumab in 2006 to 2009 showed that failure to follow recommendations was associated with lower efficacy than had been observed in the development phase. The TWIN Study reviewed the situation in 2010 to 2011. Methods: Retrospective, descriptive purely observational study of data acquired after 12 months of treatment with intravitreal ranibizumab. Results: In 881 patients (68% women, mean age, 79 years) treated by 21 ophthalmologists, the mean gain in visual acuity was +4.3 ± 15.4 letters (up from 3.2 ± 14.8 in 2006–2009; NS). Significant improvements were documented in the mean interval between diagnosis and treatment initiation (down from 12.6 ± 26.4–7.7 ± 10.9 days; P < 0.001), and in the percentage of patients who received a full course of induction treatment (56.6 vs. 39.6%; P < 0.001). After induction, hardly any patients were monitored every month as recommended, although retreatment was more assiduous (5.6 ± 2.3 vs. 5.1 ± 2.1 injections; P < 0.001). Conclusion: Despite improvements in key parameters, the effectiveness of intravitreal ranibizumab is still compromised by poor compliance with the guidelines, especially the frequency of postinduction monitoring that is now the most important determinant of successful treatment.

Effect of isovolemic hemodilution in central retinal vein occlusion.

Abstract. Background: Hemorheologic abnormalities have recently been shown to play a role in the pathogenesis of retinal vein occlusion (RVO), and several studies have demonstrated the efficacy of isovolemic hemodilution in these eyes. This study was designed to investigate further the effects of hemodilution, with regard to the duration of symptoms before the treatment. Methods: In a prospective study, 142 eyes with central or hemicentral RVO were treated by isovolemic hemodilution. The target hematocrit value was 35%. Mean duration of follow-up was 10 months. A subgroup of 50 patients treated within 2 weeks of the onset of symptoms was compared first with patients treated later by hemodilution, and then retrospectively with controls with central RVO and without hemodilution. Results: Hemodilution therapy resulted in a decrease in hematocrit level from 42% to 32% on average, with no major side effect. After treatment, a significant decrease was observed in hemorheologic parameters (fibrinogen, erythrocyte aggregation), except in plasma viscosity. Retinal circulation times were significantly shortened. Visual acuity (VA) improvement immediately after treatment (in 43% of eyes) was correlated with better final visual outcome (P<0.05). At the end of follow-up, VA was better in patients treated within the first 2 weeks than in those treated later and in controls (41% had VA of 20/40 or more in the early-treatment group versus 23% in the late-treatment group, P<0.01). Final retinal ischemia was also greater in the late-treatment group and in controls. Hemodilution in 12 patients with long-standing RVO and macular edema was ineffective. Conclusion: Our study is consistent with previous investigations that confirmed the efficacy of isovolemic hemodilution in RVO on hemorheologic parameters, retinal circulation times and final VA. It also underlined strongly the benefit of early treatment within the first 2 weeks of the RVO. Further studies are required to confirm these results.

Oral Docosahexaenoic Acid in the Prevention of Exudative Age-Related Macular Degeneration: The Nutritional AMD Treatment 2 Study

OBJECTIVE To evaluate the efficacy of docosahexaenoic acid (DHA)-enriched oral supplementation in preventing exudative age-related macular degeneration (AMD). DESIGN The Nutritional AMD Treatment 2 study was a randomized, placebo-controlled, double-blind, parallel, comparative study. PARTICIPANTS Two hundred sixty-three patients 55 years of age or older and younger than 85 years with early lesions of age-related maculopathy and visual acuity better than 0.4 logarithm of minimum angle of resolution units in the study eye and neovascular AMD in the fellow eye. METHODS Patients were assigned randomly to receive either 840 mg/day DHA and 270 mg/day eicosapentaenoic acid (EPA) from fish oil capsules or the placebo (olive oil capsules) for 3 years. MAIN OUTCOME MEASURES The primary outcome measure was time to occurrence of choroidal neovascularization (CNV) in the study eye. Secondary outcome measures in the study eye were: incidence of CNV developing in patients, changes in visual acuity, occurrence and progression of drusen, and changes in EPA plus DHA level in red blood cell membrane (RBCM). RESULTS Time to occurrence and incidence of CNV in the study eye were not significantly different between the DHA group (19.5±10.9 months and 28.4%, respectively) and the placebo group (18.7±10.6 months and 25.6%, respectively). In the DHA group, EPA plus DHA levels increased significantly in RBCM (+70%; P<0.001), suggesting that DHA easily penetrated cells, but this occurred unexpectedly also in the placebo group (+9%; P = 0.007). In the DHA-allocated group, patients steadily achieving the highest tertile of EPA plus DHA levels in RBCM had significantly lower risk (-68%; P = 0.047; hazard ratio, 0.32; 95% confidence interval, 0.10-0.99) of CNV developing over 3 years. No marked changes from baseline in best-corrected visual acuity, drusen progression, or geographic atrophy in the study eye were observed throughout the study in either group. CONCLUSIONS In patients with unilateral exudative AMD, 3 years of oral DHA-enriched supplementation had the same effect on CNV incidence in the second eye as did the placebo. However, RBCM fatty acid measurements revealed that CNV incidence was significantly reduced in DHA-supplemented patients showing a steadily high EPA plus DHA index over 3 years. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Intravitreal ranibizumab for macular oedema secondary to retinal vein occlusion: a retrospective study of 34 eyes.

Purpose:  To evaluate the efficacy and the safety of intravitreal ranibizumab injection (Lucentis) in eyes with macular oedema secondary to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO).

Clinical Features and Natural History of AMD

Over recent years, OCT has become an essential part of the examination in routine follow up for AMD to guide clinical practice and analyze the response to treatment. OCT examinations can clearly demonstrate the efficacy of treatment by showing regression or persistence of leakage. Moreover, alterations of the outer retinal layers can also be analyzed.

Tomographie par cohérence optique et DMLA

L’examen par tomographie en coherence optique (ou OCT) est un nouveau procede d’imagerie diagnostique, analogue a l’ultrasonographie et capable de produire des images en coupe anteroposterieure des tissus du fond d’œil et d’apporter des elements nouveaux et utiles en pratique clinique pour la DMLA. C’est la confrontation des images obtenues par les angiographies en fluoresceine et en ICG et celles de l’OCT qui fournit les informations les plus utiles pour chacune des formes cliniques de la DMLA. Certains symptomes sont faciles a reconnaitre tels qu’un soulevement sereux retinien, un œdeme intraretinien diffus ou cystoide, un decollement de l’epithelium pigmentaire sereux ou fibrovasculaire et une eventuelle dechirure, ou encore une hyper-reflectivite liee a une fibrose cicatricielle. D’autres symptomes sont plus delicats a reconnaitre tels que la presence des neovaisseaux choroidiens, leur localisation par rapport a la fovea et par rapport a l’epithelium pigmentaire, les associations de lesions (decollement de l’epithelium pigmentaire, decollement sereux retinien, hemorragies, exsudats, fibrose, anastomoses et autres), et meme les lesions les plus rares telles que les vasculopathies polypoidales choroidiennes, neovaisseaux intra retiniens, surcharge de materiel. En clinique, au cours de l’evolution, les neovaisseaux choroidiens peuvent apparaitre le plus souvent sous forme de neovaisseaux choroidiens mixtes et intriques, et selon des modalites variables. L’OCT peut permettre de confirmer leur presence, de les localiser et de porter les indications therapeutiques avec precision. Dans le cas du suivi post-therapeutique, l’OCT est particulierement precieux pour affirmer la persistance d’une reaction exsudative, ou au contraire pour affirmer sa disparition.

Steroids and Macular Edema from Retinal Vein Occlusion

Purpose. The possibility of applying long-lasting steroids, such as triamcinolone and subsequently dexamethasone implant, directly in the eye, without the systemic side effects observed after their oral or intravenous administration, aroused great enthusiasm among ophthalmologists. Methods and Results. The SCORE study, a multicenter clinical trial, compared the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with observation in central retinal vein occlusion (CRVO) participants with macular edema secondary to perfused CRVO. This study marked a turning point in the management of retinal vein occlusion (RVO), since it was the first report on an effective treatment of macular edema due to CRVO. But in branch retinal vein occlusion (BRVO), the SCORE study showed no difference in visual acuity for the standard care group compared with the triamcinolone groups; however, the rates of adverse events (particularly elevated intraocular pressure and cataract) were highest in the 4-mg group. The authors concluded that laser grid photocoagulation should remain the benchmark against which other treatments should be compared. The Geneva Study, a randomized, controlled, clinical trial, conducted to evaluate the safety and efficacy of an intravitreal implant that delivers sustained levels of dexamethasone (Ozurdex™), studied the largest group of RVO patients with macular edema (1267 patients), including 35% CRVO and 65% BRVO. The study demonstrated that this slow-release device could both reduce the risk of vision loss and improve the speed and incidence of visual improvement in eyes with macular edema secondary to CRVO and BRVO, with fewer side effects, such as elevation of intraocular pressure or cataract. Other ongoing studies evaluate the safety and efficacy of anti-vascular endothelial growth factor injection; preliminary results showed that these therapies are effective in decreasing macular edema and improving visual acuity, with fewer ocular adverse effects, but their duration of action seems limited. Conclusions. These recent studies result in a great change in the management of macular edema from RVO. Unfortunately, long-term studies on safety and efficacy are not yet available, and further studies will have to show whether the short-term benefits are only transient or may finally lead to a long-lasting improvement in vision.

Classic Choroidal Neovascularization

Since Donald Gass’s pioneering work in 1967, which demonstrated the role of choroidal neovascularization (CNV) in wet (exudative) AMD, visible (classic) CNV, well demarcated and well-defined on fluorescein angiography, has become the most characteristic form of AMD.

Polypoidal Choroidal Vasculopathy

Polypoidal choroidal vasculopathy does not constutute part of the classical definition of AMD, but these two en tities have a number of features in common.

Clinical Features and Natural History of AMD on OCT

Despite recent progress, age-related macular degeneration (AMD) remains the leading cause of vision loss in high-income countries, and its incidence appears to be increasing, probably due to longer life span and improved methods of detection.