Andrea Scupola

Intravitreal bevacizumab (Avastin®) in proliferative diabetic retinopathy

Purpose:  To evaluate the efficacy and safety of intravitreal bevacizumab in proliferative diabetic retinopathy (PDR) patients.

PHOTODYNAMIC THERAPY FOR VASOPROLIFERATIVE RETINAL TUMORS

Purpose: To report our experience with photodynamic therapy (PDT) with verteporfin for patients with vasoproliferative retinal tumors (VPRTs). Methods: Three patients with VPRTs who presented with macular exudative changes were treated with one session of PDT with 6 mg/m2 body surface area of verteporfin and a light dose of 100 J/cm2 at 689 nm delivered in 166 seconds. Biomicroscopy, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and ultrasonography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment; visual acuity was measured using Early Treatment Diabetic Retinopathy Study criteria. Results: At the 1-year follow-up, all tumors responded with a reduction in size (mean height: pretreatment, 2.96 mm; posttreatment, 1.32 mm), and optical coherence tomography showed complete resolution of macular exudates. For all patients, fluorescein angiography evidenced reduction of leakage from the lesion, and indocyanine green angiography verified nonperfusion of the vascular channels. An improvement in visual acuity (average, 4.7 Early Treatment Diabetic Retinopathy Study letters) was observed. No retreatment was needed. Conclusion: PDT may represent an effective and safe modality of treatment for VPRTs because of its selectivity. Our study supports the application of a light dose of 100 J/cm2, although further studies with larger numbers of cases and longer follow-ups are required.

Photodynamic Therapy with Verteporfin for Symptomatic Circumscribed Choroidal Hemangioma: Five-Year Outcomes

OBJECTIVE To evaluate the long-term efficacy of verteporfin photodynamic therapy (PDT) as the primary treatment for symptomatic circumscribed choroidal hemangioma (CCH). DESIGN Prospective consecutive, 2-centered, noncomparative, interventional case series. PARTICIPANTS Twenty-five subjects with symptomatic CCH. All patients had recent onset of visual symptoms and evidence of exudative macular changes on fluorescein angiography (FA) and optical coherence tomography (OCT). METHODS Verteporfin 6 mg/m(2) body surface area was administered intravenously over a 10-minute interval. Five minutes after infusion, a 689 nm laser was applied with a light dose of 50 J/cm(2) for the first 3 patients and a light dose of 100 J/cm(2) for all the other patients. Retreatments were performed in case of persistent exudation found on OCT. Evaluation of best-corrected visual acuity (BCVA) using Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria, FA, indocyanine green angiography (ICGA), OCT, and ultrasound were performed before PDT and on follow-up examinations. All patients were followed for at least 5 years. MAIN OUTCOME MEASURES Primary outcome measures were changes in BCVA and foveal center thickness (FCT) between baseline and month 60. Secondary measures were tumor thickness decrease, absence of leakage on FA, and adverse events. RESULTS Twenty-two patients received 1 PDT session at 100 J/cm(2), and no recurrences were detected. Three eyes, treated with 50 J/cm(2), received a second PDT session at 100 J/cm(2) 1 month after the first session. After a follow-up of 60 months, BCVA improved an average of 18.5 ETDRS letters (P<0.001); BCVA improved by > or =2 lines in 19 eyes (76%). The FCT decreased from a mean of 386.20 microm to 179.2 microm, and OCT showed the complete resolution of macular exudation in all cases. All tumors responded with a reduction in size. No treatment-related adverse events or complications were identified. CONCLUSIONS The 5-year results of PDT in treating symptomatic CCH support treatment with a light dose of 100 J/cm(2) after slow intravenous infusion of verteporfin to stabilize or improve visual acuity and resolution of macular exudation.

Macular functional changes evaluated with MP-1 microperimetry after intravitreal bevacizumab for subfoveal myopic choroidal neovascularization: one-year results.

Purpose: The purpose of this study was to evaluate 1-year functional and structural effects of intravitreal bevacizumab for subfoveal choroidal neovascularization secondary to pathologic myopia (myopic choroidal neovascularization). Methods: Fifteen eyes with myopic choroidal neovascularization participated in this prospective interventional, noncomparative case series. All patients were treated with one intravitreal injection of 1.25 mg bevacizumab. Retreatments were performed in case of persistent or recurrent leakage on fluorescein angiography and/or intraretinal fluid on optical coherence tomography. Evaluation of best-corrected visual acuity using Early Treatment of Diabetic Retinopathy Study criteria, MP-1 microperimetry, optical coherence tomography, and fluorescein angiography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment. Results: After a follow-up of 12 months, best-corrected visual acuity improved on average of 0.23 logarithm of the minimum angle of resolution. Mean macular sensitivity within the central 8° increased on average of 2.62 dB at 12-month postinjection. The mean number of measurement points within the central absolute scotoma reduced significantly from 12.47 before treatment to 6.27 at 1-year follow-up. An improvement of fixation stability from baseline was observed in 9 patients (60%). No treatment adverse events were evidenced. Conclusion: Improvement of macular sensitivity and fixation stability 1 year after intravitreal bevacizumab for myopic choroidal neovascularization suggest a stable and progressive macular function recovery. The mean treatment session was 1.53, with 53.3% of patients needing only a single intravitreal bevacizumab injection, supporting a potential long-lasting efficacy of intravitreal bevacizumab treatment.

25-Gauge Pars Plana Vitrectomy for Retained Lens Fragments in Complicated Cataract Surgery

Purpose: To verify the efficacy of 25-gauge pars plana vitrectomy (PPV) for the management of posteriorly dislocated lens material after complicated cataract extraction and to determine in what patients this approach offers the optimal benefit in terms of efficacy and safety, considering the amount of retained nuclear material and the duration of surgery. Methods: Forty eyes of 40 patients with retained lens fragments undergoing early (within 1 week) or late (within >1 week) 25-gauge PPV were retrospectively reviewed. The amount of dislocated nuclear material was graded by the surgeon intraoperatively, and the patients were divided into two groups according to the nuclear grading: group A (≤50% dropped nucleus) and group B (>50% dropped nucleus). The presence of brunescent nuclear pieces was considered. The outcomes measured included best-corrected visual acuity (BCVA) and postoperative complications such as retinal detachment, cystoid macular edema (CME) and postoperative ocular hypertension or hypotonia. Results: The patients had a mean age of 78 years. The mean preoperative logarithm of the minimum angle of resolution (logMAR) BCVA was 0.57 ± 0.24 (20/80). A significant positive correlation was found between nuclear material grade and PPV duration (R2 = 0.81, p < 0.0001). None of the patients had dislocation of brunescent nuclear pieces. On postoperative day 1, the mean postoperative intraocular pressure was 16.75 ± 2.7 mm Hg, with no case of ocular hypotonia. At 6 months of follow-up, the mean logMAR BCVA improved to 0.23 ± 0.3 (20/32). Retinal detachment developed in 4 patients (10%), occurring only in patients of group B (p < 0.002). Four patients with late PPV developed postoperative CME, with no case of CME among patients with early vitrectomy (p = 0.014). Conclusion: Removal of dislocated lens fragments after complicated cataract surgery can be effectively managed with 25-gauge PPV, although it appears to be most efficient for cases with a limited amount of dislocated lens material. In consideration of the higher rate of retinal detachment observed in cases of prolonged PPV time, the expected duration of surgery should be taken into account when choosing the best surgical approach. Visual outcomes are not affected by the timing of PPV, whereas early vitrectomy seems to prevent the onset of inflammatory macular edema.

BRACHYTHERAPY ALONE or with NEOADJUVANT PHOTODYNAMIC THERAPY for AMELANOTIC CHOROIDAL MELANOMA: Functional Outcomes and Local Tumor Control

Purpose: To compare visual outcomes and local tumor control between two groups of patients with amelanotic choroidal melanoma treated with brachytherapy alone, or neoadjuvant photodynamic therapy before brachytherapy. Methods: Patients diagnosed with amelanotic choroidal melanoma were recruited for the study and divided into two groups: brachytherapy alone (Group A) and photodynamic therapy preceding brachytherapy (Group B). Patients of both groups were selected to be comparable. Results: Twenty-six patients with amelanotic choroidal melanoma were enrolled in the study. Within Group B, 1 month after photodynamic therapy, ultrasonography showed reduction of tumor height in 11 patients (73.4%). The mean doses of irradiation to macula and optic nerve, at baseline were 74.37 and 52.07 Gy, whereas after photodynamic therapy there was a decrease of 17.26% (P = 0.008) and 21.22% (P = 0.025), respectively. In terms of visual acuity, a mean decrease of 14 ETDRS letters and 5 ETDRS letters was observed at 24 months follow-up, in Groups A and B, respectively (P = 0.001). Conclusion: Photodynamic therapy as neoadjuvant therapy before brachytherapy reduces tumor thickness in 73.4% of cases. As a result, a decrease of radiation toxic effects on visual function could be obtained, without compromising disease control.

Intravitreal dexamethasone implant for acute exudative polymorphous vitelliform maculopathy

Purpose Acute exudative polymorphous vitelliform maculopathy is a rare retinal disease characterized by bilateral serous macular detachment and subretinal accumulation of yellowish deposits resembling Best dystrophy lesions. Corticosteroid systemic therapy has been used empirically in the attempt to treat this retinal disorder with mixed results. Thus, the benefit of corticosteroid remains undetermined. To our knowledge, we report the first case of acute exudative polymorphous vitelliform maculopathy (AEPVM) treated in one eye with intravitreal dexamethasone implant (Ozurdex; Allergan, Inc., Irvine, California, USA). Methods A 28-year-old man with AEPVM underwent intravitreal dexamethasone implantation in the left eye. Results Compared with the fellow eye, intravitreal dexamethasone implant did not significantly modify the clinical course of the disease. No implant-related complication was experienced during follow-up. Conclusions The lack of response to intravitreal dexamethasone seems to suggest that corticosteroids may be ineffective for the treatment of AEPVM.

Bovine pericardium for scleral closure in transscleral local resection of choroidal melanoma

Bovine Pericardium for Scleral Closure in Transscleral Local Resection of Choroidal Melanoma The current treatment of uveal melanoma aims to conserve the eye as well as useful vision. Conservative therapy includes brachytherapy, charged particle teletherapy, stereotactic radiotherapy, transpupillary thermotherapy, and transscleral local resection. Despite technical advances, local resection of posterior uveal melanoma (choroidectomy and cyclochoroidectomy) remains a challenging procedure, and therefore, it is indicated only in selected cases. Transscleral local resection should be performed for tumors whose larger basal diameter is less than 16 mm and whose thickness exceeds 8 to 9 mm; because in these cases, the incidence of complications related to radiotherapy increases and consequently the chances of conserving vision are reduced.1 Local resection, if performed in selected cases and by an experienced team, has been shown to obtain excellent results in terms of local tumor control and in preserving a good visual function.2,3 Retinal detachment is one of the main complications of this surgical procedure. Its main cause are retinal tears, which are most likely to occur if the tumor is adherent to the retina.4 When a retinal tear occurs, immediate vitreoretinal surgery, performed soon after the removal of the tumor, usually prevents postoperative retinal detachment.4 In addition, the ripping of the scleral flap constitutes a further complication of transscleral local resection. It mainly occurs when the site of a rectus muscle insertion is involved in the dissection because of thinner scleral tissue. In this study, we present our experience of using bovine pericardium patches allografts to strengthen globe stability, repairing possible iatrogenic defects in the scleral flap, and to assist immediate vitrectomy, thus avoiding fluid leakage at the margins of the sutured scleral flap.

Incidence and Factors Influencing Retinal Displacement in Eyes Treated for Rhegmatogenous Retinal Detachment With Vitrectomy and Gas or Silicone Oil

Purpose The purpose of this study was to study the incidence and factors influencing retinal displacement in eyes treated for rhegmatogenous retinal detachment (RRD) with pars plana vitrectomy (PPV) and gas or silicone oil. Methods This was a prospective observational case series. One hundred twenty-five eyes with macula-off RRD from 125 patients underwent 25-gauge PPV at two vitreoretinal institutional practices. Eyes without proliferative vitreoretinopathy (PVR) or PVR grade A were tamponated with sulfur hexafluoride (SF6) gas, whereas eyes with PVR grade B received 1000 centistokes silicone oil (SO). The patients postured face-down immediately after surgery. Blue-fundus autofluorescence (B-FAF) pictures were obtained at each follow-up examination. Main outcome measures were incidence and direction of retinal displacement. Results Ninety-seven eyes (77.6%) were tamponated with SF6 and 28 eyes (22.4%) with SO. After retinal reattachment, displacement was observed in 44 of 125 (35.2%) eyes (40 eyes in the SF6 group and 4 eyes in the SO group, respectively). The type of tamponade, specifically gas, was the only significant predictor of retinal displacement (P = 0.007). The displacement was downward in 39 (88.6%) eyes (36 tamponated with SF6 and 3 with SO) and upward in 5 (11.4%) eyes (4 tamponated with SF6 and 1 with SO). Conclusions Displacement of the retina after repair of macula-off RRD with PPV is observed using either SF6 gas or SO. Downward and upward displacements may occur with both tamponades, but downward dislocation is more common. Of the factors potentially implicated in favoring displacement that were studied, only the type of tamponade, specifically the gas, was significant.

Photodynamic Therapy in Ocular Oncology

Although introduced for the treatment of maculopathies, photodynamic therapy (PDT) is now largely used in some eye cancers treatment. The selective tissue damage with PDT is achieved by sequestration of the photosensitizer in the target tissue and focal activation of the photosensitizer by low energy directed light. In this way, it is possible to achieve the destruction of the tumor tissue by safeguarding the surrounding healthy structures. Our study describes the clinical uses and efficacy of photodynamic therapy in ocular oncology.