Andrew Kaines

A Prospective Randomized Trial of Intravitreal Bevacizumab or Laser Therapy in the Management of Diabetic Macular Edema (BOLT Study): 12-Month Data: Report 2

PURPOSE To report the findings at 1 year of a study comparing repeated intravitreal bevacizumab (ivB) and modified Early Treatment of Diabetic Retinopathy Study (ETDRS) macular laser therapy (MLT) in patients with persistent clinically significant diabetic macular edema (CSME). DESIGN Prospective, randomized, masked, single-center, 2-year, 2-arm clinical trial. PARTICIPANTS A total of 80 eyes of 80 patients with center-involving CSME and at least 1 prior MLT. METHODS Subjects were randomized to either ivB (6 weekly; minimum of 3 injections and maximum of 9 injections in the first 12 months) or MLT (4 monthly; minimum of 1 treatment and maximum of 4 treatments in the first 12 months). MAIN OUTCOME MEASURES The primary end point was the difference in ETDRS best-corrected visual acuity (BCVA) at 12 months between the bevacizumab and laser arms. RESULTS The baseline mean ETDRS BCVA was 55.7+/-9.7 (range 34-69) in the bevacizumab group and 54.6+/-8.6 (range 36-68) in the laser arm. The mean ETDRS BCVA at 12 months was 61.3+/-10.4 (range 34-79) in the bevacizumab group and 50.0+/-16.6 (range 8-76) in the laser arm (P = 0.0006). Furthermore, the bevacizumab group gained a median of 8 ETDRS letters, whereas the laser group lost a median of 0.5 ETDRS letters (P = 0.0002). The odds of gaining > or =10 ETDRS letters over 12 months were 5.1 times greater in the bevacizumab group than in the laser group (adjusted odds ratio, 5.1; 95% confidence interval, 1.3-19.7; P = 0.019). At 12 months, central macular thickness decreased from 507+/-145 microm (range 281-900 microm) at baseline to 378+/-134 microm (range 167-699 microm) (P<0.001) in the ivB group, whereas it decreased to a lesser extent in the laser group, from 481+/-121 microm (range 279-844 microm) to 413+/-135 microm (range 170-708 microm) (P = 0.02). The median number of injections was 9 (interquartile range [IQR] 8-9) in the ivB group, and the median number of laser treatments was 3 (IQR 2-4) in the MLT group. CONCLUSIONS The study provides evidence to support the use of bevacizumab in patients with center-involving CSME without advanced macular ischemia.

Ischemic index and neovascularization in central retinal vein occlusion.

Purpose: To explore the association of angiographic nonperfusion with anterior segment and posterior segment neovascularization in central retinal vein occlusion (CRVO). Methods: An imaging database at one institution was searched for the diagnosis of central retinal vein occlusion. Ultra wide field fluorescein angiograms were graded for image quality, the presence of retinal neovascularization, and the quantity of nonperfusion; an ischemic index (ISI) was calculated. Charts were reviewed to exclude eyes with previous treatment and to determine which eyes had anterior segment or posterior segment neovascularization on the day of the angiogram. Time from onset to presentation could not accurately be ascertained. Results: In a 39-month period, there were 69 eyes that met inclusion criteria. The mean ISI was 25% (SD, 26%; range, 0-100%), and 15 eyes (21%) with neovascularization had a mean ISI of 75% (range, 47-100%) compared with eyes without neovascularization that had an ISI of 6% (range, 0-43%). Ischemic index significantly correlated to neovascularization, and eyes that had evidence of neovascularization had an ISI >45% (P < 0.0001). Conclusion: Ultra wide field fluorescein angiography provides visualization of nonperfusion in eyes with central retinal vein occlusion. Eyes with neovascularization on the day of the angiogram were found to have significantly larger areas of retinal nonperfusion compared with eyes without neovascularization. A prospective study is indicated to know if early treatment of peripheral retinal nonperfusion in CRVO improves outcomes.

Update on treatments for diabetic macular edema.

Purpose of review Due to modest outcomes with macular laser, other treatment modalities for diabetic macular edema have been evaluated. Intravitreal triamcinolone acetonide, pars plana vitrectomy, oral protein kinase C inhibitors and, from more recently, anti-vascular endothelial growth factor therapy are reviewed. Recent findings Intravitreal triamcinolone acetonide may be more effective than laser. Intravitreal triamcinolone acetonide followed by laser may be more effective than intravitreal triamcinolone acetonide alone. Ruboxistaurin, a selective protein kinase C βinhibitor, reduced retinal vascular leakage in patients with diabetic macular edema and reduced the rate of sustained moderate visual loss in those with moderately severe to very severe non proliferative diabetic retinopathy. Several anti-vascular endothelial growth factor agents are under evaluation. Intravitreal pegaptanib sodium (0.3 mg) improved vision and reduced central retinal thickness compared to sham. Data on the other anti-vascular endothelial growth factor agents is limited, but there are promising results, with ranibizumab (0.5 mg) and bevacizumab reducing foveal thickness and improving visual acuity in some patients with diabetic macular edema. Summary There remains no proven intervention that consistently prevents or reverses visual loss from diabetic macular edema in all patients. A variety of promising new medical and surgical therapies are under investigation, but further research is required to determine their role alone or in combination.

Bilateral central serous chorioretinopathy resolving rapidly with treatment for obstructive sleep apnea

BackgroundCentral serous chorioretinopathy (CSR) is a common disorder that affects many individuals, often for unknown reasons; we present a case of bilateral CSR that rapidly resolved with treatment of obstructive sleep apnea (OSA).MethodsObservational case report.ResultsBilateral decreased vision to 20/30 OD and 20/40 OS due to typical CSR lesions. Systemic evaluation led to a diagnosis of OSA, which was treated and resulted in rapid resolution of the CSR and improvement of visual acuity in both eyes.DiscussionWe present the first case of rapidly resolving bilateral CSR due to the treatment of OSA.

A Pilot Study Of Normative Data For Macular Thickness And Volume Measurements Using Cirrus High-definition Optical Coherence Tomography

Purpose: To establish preliminary normative data for macular thickness (MT) and macular volume (MV) by Cirrus high-definition optical coherence tomography (Carl Zeiss Meditec, Dublin, CA). Methods: Retrospective case series of 192 eyes of 192 subjects (age, 20–90 years) without retinal disease or surgery with best-corrected visual acuity ≥20/25, intraocular pressure <21 mmHg, and cup-to-disc ratio ≤0.5 were enrolled. Retinal thicknesses in nine Early Treatment Diabetic Retinopathy Study subfields (including central subfield thickness [CST]), MT, and MV were measured with Cirrus high-definition optical coherence tomography. Effects of age, gender, lens status, and diabetic status on these measurements were analyzed. Results: The mean ±SD CST, MT, and MV were 262.4 ± 22.8 μm, 281.3 ± 14.5 μm, and 10.1 ± 0.6 mm3, respectively. Although CST and age were not associated (P = 0.45), both mean MT and mean MV declined with age (P < 0.0001). Central subfield thickness (P = 0.002), mean MT (P = 0.021), and MV (P = 0.041) were higher in men compared with women. Neither lens status nor diabetic status affected CST, MT, or MV. Conclusion: A pilot study showed that preliminary normative CST, MT, and MV values were obtained by Cirrus high-definition optical coherence tomography. The authors propose that CST ranges from 216.8 μm to 308 μm in normal eyes. Older age and female gender were associated with thinner MT.

Patterns of Periphlebitis in Intermediate Uveitis using Ultra Wide Field Fluorescein Angiography

Intermediate uveitis is a collection of diseases which can be caused by sarcoidosis in approximately fifty percent of patients. We performed a retrospective chart review of 6 patients with acquisition and interpretation of ultra wide field fluorescein angiograms. Two eyes had central, large vessel staining; six eyes had peripheral, small vessel staining; and two eyes had both patterns of staining. We conclude that ultra wide field fluorescein angiography is important to detect inflammation early and follow treatment in patients with intermediate uveitis. Future studies with ultra wide field fluorescein angiography may help to diagnose different types of intermediate uveitis and offer insights into the pathogenesis of disease.

Ultrawide angle angiography for the detection and management of diabetic retinopathy.

For the last 50 years, fluorescein angiography (FA) has played a pivotal role in the evaluation and management of retinal diseases including diabetes. Patterns of hyperfluorescence and hypofluorescence provide insights into the pathophysiologic processes and guide treatment. Despite recent advances in other imaging techniques, including indocyanine green angiography and optical coherence tomography, FA still plays a primary role. FA remains a vital method to assess indications and outcomes of treatment methods including laser photocoagulation, intraocular pharmacologic therapy such as steroid and antivascular endothelial growth factor (anti-VEGF) agents, and surgical intervention. The ability to capture a single image of the entire ocular fundus has been limited until recently. Standard FA using film or digital cameras typically capture an image 30 degrees across. A new fluorescein imaging technique that captures fundus images up to 200 degrees in breadth is discussed herein. Optomap fa dynamic ultrawide field angiography is a digital panoramic technique performed with the Optos P200 MA scanning laser ophthalmoscope (Optos plc, Dunfermline, UK). The ability to image the peripheral retina using Optomap fa provides a more comprehensive assessment of the extent of a retinal disease process, and

Short-duration focal pattern grid macular photocoagulation for diabetic macular edema: four-month outcomes.

Purpose: To evaluate the visual acuity (VA) and optical coherence tomography thickness results of short-duration pattern scanning laser macular photocoagulation in the treatment of clinically significant macular edema because of diabetes. Methods: Consecutive retrospective analysis of VA and optical coherence tomographic data from eyes treated in a modified Early Treatment Diabetic Retinopathy Study style using a short-duration pattern scanning laser. Results: A total of 100 eyes from 70 patients met study criteria. All subjects were treated with the same PASCAL (pattern scanning laser) photocoagulation unit. Parameters varied according to media and pigmentation status, but typical settings were 100-μm spot size, 10-millisecond pulse duration, 225-mW power, and 29 J/cm2 fluence to give a pale but visible lesion. At 4 months posttreatment, there was an average improvement in VA of 0.060 logMAR (an improvement from 20/45 to 20/40, or approximately 3 Early Treatment Diabetic Retinopathy Study letters; P = 0.0007) and a reduction of central optical coherence tomographic thickness of 40 μm and 37 μm (spectral domain and time domain optical coherence tomography groups, respectively), both of which were statistically significant (P = 0.0049 and 0.012, respectively). Conclusion: Short-duration PASCAL macular photocoagulation has a biological treatment effect at 4 months for the treatment of clinically significant macular edema. While caution must be used when converting between different VA measurement methods and when using literature-based controls, the observed VA improvement seems equivalent to 3 Early Treatment Diabetic Retinopathy Study letters. These findings are similar to the recently published results from the diabetic retinopathy clinical research network cohort. PASCAL laser photocoagulation for clinically significant macular edema appears safe and effective in the short term and may have significant long-term advantages.

Ultra-wide-field and autofluorescence imaging of choroidal dystrophies.

The authors retrospectively identified 2 cases of gyrate atrophy, 3 cases of choroideremia, and 1 case of the carrier state of choroideremia who underwent ultra-wide-field fundus photography and fluorescein angiography. The findings were studied and compared to standard fundus photography and fluorescein angiography. Gyrate atrophy demonstrated a diffuse confluent extent of chorioretinal atrophy extending from the anterior to the posterior pole to the periphery. Choroideremia demonstrated a patchy irregular pattern of chorioretinal atrophy extending from the posterior pole to the periphery. Peripheral reticular degeneration without chorioretinal atrophy was appreciated in the carrier state. Ultra-wide-field imaging of these choroidal dystrophies demonstrated distinctive patterns that may aid in their identification and diagnosis.

Nasal Retinoschisis Associated with Glaucoma.

The authors describe a case of nasal and macular retinoschisis in a patient with open angle glaucoma. A 75 year-old female with optic nerve head damage secondary to chronic open angle glaucoma developed macular schisis and a separate area of retinoschisis nasal to her optic disk. There were no other identifiable causes for her retinoschisis. Glaucoma related structural defects offer a plausible explanation for multiple cavities of retinoschisis in favor of multiple occult congenital pits of the optic nerve head.