Alfredo Pece

Photocoagulation scar expansion after laser therapy for choroidal neovascularization in degenerative myopia.

The authors performed a prospective study of 36 eyes affected by pathologic myopia with macular subretinal neovascularization (SRNV) successfully treated with either argon green, dye orange (590 nm), or krypton red lasers. Re-treated eyes were excluded. Evolution of the laser scar was carefully monitored for 12 months. Scar expansion was noted in 35 cases (97%), without a significant loss of visual acuity during the first year after treatment. The scar enlarged more conspicuously during the first 3 months after photocoagulation, with a mean increase of 103% in the first year. Expansion was not related to laser wavelength, patient age, SRNV size, or degree of myopia. Scar enlargement was greatest in the same direction as that of maximal extension of the myopic peripapillary crescent; inspection of the morphologic configuration of the peripapillary crescent before laser treatment may be helpful in evaluating the potential risk of post-laser scar expansion toward the fovea.

Outcome of choroidal neovascularization in angioid streaks after photodynamic therapy.

Purpose: To evaluate the visual and anatomic outcomes of photodynamic therapy for choroidal neovascularization (CNV) in patients with angioid streaks. Methods: The authors retrospectively evaluated 40 consecutive patients (48 eyes) with visual acuity of 20/200 or greater who were treated at 6 referral centers for CNV associated with angioid streaks. Main outcome measures were visual acuity, greatest linear diameter of the lesion, and, in patients with nonsubfoveal CNV, distance from the foveola. Results: Of 34 eyes with subfoveal CNV, 21 were followed up for at least 12 months (range, 5–33 months). Median visual acuity was 20/50 at baseline and 20/120 at the final examination. The 12-month estimate of the percentage of eyes with vision loss of fewer than 3 lines was 68% (95% confidence interval, 50%–85%) by using survival analysis, whereas eyes with no increase in the greatest linear diameter were 45% (95% confidence interval, 27%–62%). Fourteen eyes had extrafoveal (n = 11) or juxtafoveal (n = 3) CNV, 12 of which were followed up for at least 10 months (range, 4–36 months). Visual acuity was 20/40 or greater in all eyes with extrafoveal lesions at baseline and in 5 of 12 eyes at the last examination, when 3 cases of CNV had become subfoveal. At baseline, visual acuity was low in two eyes with juxtafoveal CNV and nearly normal in the third. It remained substantially stable at the end of follow-up (range, 10–36 months), when two lesions were subfoveal. Conclusions: Most of our patients had good baseline visual function and, thus, were at high risk for losing vision because of the poor prognosis of CNV in angioid streaks. Because most had no or limited vision loss after 1 year, the authors suggest that photodynamic therapy can be used to try to limit or delay visual damage caused by this aggressive disease.

Ranibizumab for exudative age-related macular degeneration: 24-month outcomes from a single-centre institutional setting

Background To analyse the 24-month outcomes of intravitreal ranibizumab injections for choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD). Methods The authors reviewed the charts of all consecutive eyes with CNV secondary to AMD, who underwent one intravitreal ranibizumab injection (followed by a pro re nata (1+PRN) decision to retreat or to not retreat) at least 24 months before. Best-corrected visual acuity (BCVA) changes and central macular thickness (CMT) were retrospectively assessed, from baseline (m0) to month 12 (m12), and 24 (m24). Results Ninety-six eyes of 79 patients (23 male, 56 female, aged 63–90 years) were included for analysis. The number of intravitreal injections administered ranged from 1 to 16. The mean BCVA significantly improved from m0 (0.78±0.33) to m12 (0.61±0.39, p<0.001), and m24 (0.65±0.38, p<0.001). The mean CMT significantly decreased from m0 (323.7±118.1) to m12 (254.6±92.3, p<0.001), and m24 (259.0±89.9, p<0.001). At m24, subretinal fluid, cystoid macular oedema and pigment epithelium detachment were present in fewer eyes (13, 31 and 31 eyes respectively), compared with m0 (33, 61 and 72 eyes, respectively). Overall, at m12 and m24, 91 eyes (94.8%) and 84 eyes (87.5%) lost fewer than 15 letters, and 25 (26%) eyes and 24 eyes (25%) improved by 15 letters or more, respectively; five eyes (5.2%) and 12 eyes (12.5%) lost more than 15 letters, at m12 and m24, respectively. Conclusion In this study, similarly to other studies of variable dosing regimen over 24 months, intravitreal ranibizumab was effective in significantly increasing BCVA and reducing CMT.

Is ranibizumab effective in stopping the loss of vision for choroidal neovascularisation in pathologic myopia? A long-term follow-up study

Aim To assess the efficacy and safety of ranibizumab in the treatment of choroidal neovascularisation (CNV) caused by pathologic myopia (PM). Design Prospective, multicentre, interventional case series. Methods 40 eyes of 39 consecutive patients with PM and CNV were treated with ‘on demand’ intravitreal injection of ranibizumab 0.5 mg. Final best corrected visual acuity (BCVA) and its change from baseline were the main outcome measures. Changes in optical coherence tomography (OCT) central retinal thickness (CRT) were a secondary outcome. Results Mean age was 53±13 years and mean refractive error –13.5±6.5 D. Median follow-up was 13.3±2 (range 12–18) months. Fifteen eyes (37.5%) had previously been treated with photodynamic therapy (PDT). The mean baseline logarithm of the minimum angle of resolution (logMAR) BCVA (Early Treatment Diabetic Retinopathy Study (ETDRS) vision chart) was 0.68±0.34 (Snellen equivalent 20/131) and 21±16 letters. The final mean logMAR BCVA was 0.27±0.2 (p = 0.008) (20/42) and 40.5±14 letters (p = 0.01). Mean final VA improved in 82.5% of patients, in 60% by 3 or more lines (median number of lines gained 2.9). Even six out of seven cases of low vision (≤1.1 logMAR) at the final examination has improved vision. Mean OCT CRT reduced from 218±70 to 175±46 μm (p 0.02). Age and previous PDT did not influence the results (p>0.05). The mean number of injection was 2.8±1.2 (range 1–6). No ocular or systemic side effects were observed. Conclusion Ranibizumab was an effective treatment for stabilising and improving vision with a low number of injections in 92.5% of patients with myopic CNV in a long-term follow-up.

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization secondary to pathologic myopia: long-term study.

Purpose: To assess the safety and effectiveness of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM). Methods: Sixty-two patients (62 eyes) with PM underwent PDT according to the guidelines of the Verteporfin in Photodynamic Therapy Study. Clinical evaluations performed at all study visits included measurement of best-corrected Snellen visual acuity, slit-lamp biomicroscopy, and fundus fluorescein angiography. Patients were followed up at 1 month and 3 months after treatment and thereafter at 3-month intervals. Results: The final visual acuity of the study patients, after a median follow-up of 31 months, improved by ≥1 Snellen lines in 8 patients (13%), deteriorated in 20 (32%), and remained stable in 34 (55%). The baseline visual acuity was similar in the various study groups. The final mean visual acuity in group A (55 years of age or younger) was 20/80 and significantly (P = 0.006) better than that (20/138) in group B (older than 55 years of age). The mean final visual acuity in eyes with higher refractive error at baseline (greater than −17 diopters) was significantly better (P = 0.014) than that in eyes with lower refractive error (−6 to −10 diopters). CNV size did not affect visual outcomes. Conclusion: PDT preserves vision in patients with CNV associated with PM. Younger patients and eyes with higher refractive error appear more likely to benefit from PDT with verteporfin.

Verteporfin PDT for non-standard indications—a review of current literature

BackgroundVerteporfin photodynamic therapy (PDT) is approved for the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD), as well as for subfoveal CNV due to pathologic myopia and ocular histoplasmosis syndrome. Verteporfin PDT addresses the underlying pathology of ocular vascular disorders through its angio-occlusive mechanism of action, which reduces both visual acuity loss and the underlying leakage associated with lesions. Verteporfin PDT has also been associated with encouraging treatment outcomes in case studies involving patients with choroidal vascular disorders such as polypoidal choroidal vasculopathy, central serous chorioretinopathy, choroidal haemangioma, angioid streaks, and inflammatory CNV, i.e. conditions currently considered as non-standard indications of verteporfin PDT. In many studies, outcomes were better than expected based on the natural courses of each of these conditions. Although the anti-vascular endothelial growth factor (VEGF) therapies, ranibizumab and pegaptanib, have been approved for CNV due to AMD, their role in these other choroidal vascular disorders remains to be established. We summarize current literature that has documented the use of verteporfin PDT in these conditions.ConclusionsThe complex pathogenesis of CNV provides a rationale for investigating combination approaches comprising verteporfin PDT and anti-VEGF therapies. Randomized controlled studies are warranted to confirm the preliminary results of verteporfin PDT as a monotherapy or in combination with anti-VEGF therapies in the treatment of a variety of choroidal vascular conditions.

Autofluorescence imaging of cystoid macular edema in diabetic retinopathy.

Aim: Our purpose was to assess fundus autofluorescence (FAF) images in patients with diabetic retinopathy and cystoid macular edema (CME) and their correlation with fluorescein angiography (FA) and optical coherence tomography (OCT) findings. Methods: Sixty-eight eyes of 34 consecutive patients with diabetic retinopathy were examined with autofluorescence imaging using a confocal scanning laser ophthalmoscope, FA and OCT. The eyes were divided into 2 groups, group 1 with CME and group 2 without. Results: In the 44 eyes of group 1 (65% of the series), we identified 3 patterns of FAF: (1) multicystic increased FA (57%), (2) a single cyst of increased FAF (16%), (3) combined single- and multicystic increased FAF (27%). FA and OCT gave a positive correlation between cystic increased FAF and CME (r = 0.95; p = 0.001). Visual acuity loss was not correlated with the size of the cystic area (p = 0.83), but it was related to significant macular thickening (p = 0.007). Conclusions: Confocal scanning laser ophthalmoscopy can selectively visualize autofluorescent, multilobulated spaces in eyes with diabetic CME. Even if OCT remains preferable for evaluating macular thickening and cysts, FAF might be another useful easy test to rapidly distinguish this entity noninvasively and with no risk.

Photodynamic Therapy With Verteporfin For Choroidal Neovascularization Associated With Retinal Pigment Epithelial Detachment In Age-related Macular Degeneration

Purpose: To assess the effectiveness of photodynamic therapy (PDT) with verteporfin for choroidal neovascularization (CNV) associated with retinal pigment epithelium detachment (PED) in age-related macular degeneration. Methods: Thirty eyes of 26 patients with CNV and PED were treated with PDT. The eyes were divided in two groups based on CNV location in relation to PED; group 1 included 13 eyes with CNV within PED, and group 2 included 17 eyes with CNV at the edge of PED. The median follow-up was 16 months. Results: Patients received a mean ± SD of 2.83 ± 1.26 treatments (range, 1–6 treatments). In the whole cohort, the mean preoperative visual acuity changed from 20/144 (0.86 ± 0.42 logarithm of minimal angle of resolution [logMAR]) to 20/182 (0.96 ± 0.51 logMAR; P = 0.39) at month 18. Five eyes (16%) gained a mean of 1.5 Snellen lines from baseline. Twelve eyes (40%) lost a mean of 1.7 Snellen lines of visual acuity. Vision in 13 eyes (44%) remained stable. In group 1, the mean visual acuity at month 12 was 20/303 (1.18 ± 0.51 logMAR) and significantly (P = 0.015) worse than that, 20/110 (0.74 ± 0.42 logMAR), in group 2. Conclusion: PDT can improve or stabilize visual function in 60% of eyes with vascularized PED. CNV at the edge of PED appears to respond more favorably to PDT. Appropriate patient selection and prompt treatment are essential to obtain the best outcomes after verteporfin therapy.

ICGA-GUIDED LASER PHOTOCOAGULATION OF OCCULT CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION

Purpose: To evaluate the efficacy of indocyanine green angiography (ICGA)‐guided laser photocoagulation in eyes with fluorescein angiographic evidence of occult choroidal neovascularization (O‐CNV) in patients with age‐related macular degeneration (ARMD) with or without pigment epithelium detachment (PED). Methods: Eighty eyes of 79 consecutive patients with O‐CNV underwent laser treatment of a clearly outlined extrafoveal ICGA hyperfluorescent area, presumed to be focal CNV. Four types of presumed CNV were treated: Group 1 (20 eyes), CNV beneath the PED; Group 2 (23 eyes), CNV at the margin of the PED; Group 3 (10 eyes), parapapillary CNV and PED; and Group 4 (27 eyes), macular CNV without PED. Median follow‐up was 17.5 months (range, 6‐24 months). Results: After 1 year, 15% of the eyes in Group 1, 30% in Group 2, 100% in Group 3, and 52% in Group 4 had obliteration of the presumed CNV. After 1 year, visual acuity was stable or improved in 18% of Group 1, in 37.5% of Group 2, in 100% of Group 3, and in 73% of Group 4. The remaining eyes worsened. Conclusions: Indocyanine green angiography‐guided laser treatment may improve or stabilize visual acuity in some eyes with O‐CNV. The best outcome is seen in eyes with presumed parapapillary CNV, probably made up of choroidal telangiectases in many cases. The type and location of the presumed CNV influence prognosis after laser treatment considerably. A randomized, controlled clinical study appears necessary to investigate the efficacy of ICGA‐guided laser treatment in different types of presumed CNV. The inclusion criteria for further trials need to be defined with precision, as data from patients with different choroidal vascular abnormalities have been pooled until now.

Efficacy and safety of anti-vascular endothelial growth factor (VEGF) therapy with intravitreal ranibizumab (Lucentis) for naive retinal vein occlusion: 1-year follow-up

Purpose To evaluate the efficacy and safety of intravitreal ranibizumab (Lucentis) in patients with treatment-naive retinal vein occlusion. Design Prospective, consecutive, non-comparative, interventional case series. Participants Seventeen eyes of 17 consecutive patients with naive retinal vein occlusion. Methods Consecutive patients were recruited and received, on demand, intravitreal 0.5 mg of ranibizumab; nine had central retinal vein occlusion (CRVO) and eight had branch retinal vein occlusion (BRVO). Pre- and postoperative clinical evaluation included measurement of best corrected visual acuity (BCVA) for distance, and near vision (MNREAD time, reading fluency), contrast sensitivity, colour fundus photography, fluorescein angiography and optical coherence tomography (OCT). All subjects were followed for a minimum of 12 months. Main outcome measures Change in BCVA, contrast sensitivity, angiographic leakage, OCT central macular thickness (CMT), number of treatments. Results Patients with CRVO had mean pre-treatment BCVA of 20/240 (1.08±0.25 logarithm of the minimum angle of resolution (logMAR)) and final BCVA of 20/46 (0.36±0.16 logMAR), with significant improvement at 1 year of follow-up (p<0.0001). At 12 months mean BCVA improved to 36.7 letters, with a gain of 6.4 lines, and OCT showed that the mean CMT was 271 μm, with a mean reduction of 360 μm (p<0.0001) from baseline (mean 631 μm). Patients with BRVO had mean pre-treatment BCVA of 20/126 (0.80±0.29 logMAR) and final BCVA of 20/50 (0.41±0.23 logMAR) (p<0.0001). The mean OCT CMT was 278 μm, with a mean reduction of 275 μm (p<0.0001) from baseline (mean 553 μm). Contrast sensitivity, MNREAD time and reading fluency improved significantly in the treated eyes. No ocular or systemic side effects were observed. Eyes with CRVO received an average of 3.0 injections (range 2–4) and those with BRVO 3.6 (range 3–4). Conclusions Intravitreal ranibizumab for the management of naive CRVO or BRVO can favourably modify the course of the occlusion, indicating that short- and long-term blockade of vascular endothelial growth factor (VEGF)-A may restore the integrity of the inner blood–retinal barrier, reduce CMT and significantly improve visual function, with a good safety profile. Further prospective long-term studies are warranted to confirm the efficacy, safety and optimal treatment regimen for intravitreal ranibizumab.