Arthur D. Fu

Intravitreal Bevacizumab For Previously Treated Choroidal Neovascularization From Age-related Macular Degeneration

Purpose: To report the optical coherence tomography (OCT) findings and visual results in a series of patients treated with intravitreal bevacizumab for choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD), and to determine if a difference in treatment effect exists between previously treated and treatment naïve patients. Methods: A retrospective review of all patients treated with intravitreal bevacizumab for CNV from AMD with visual acuity greater than or equal to 20/320 between September 2005 and February 2006 was performed. OCT data recorded included central macular thickness and the presence or absence of cystic intraretinal fluid, subretinal fluid, or pigment epithelial detachment at the time of the initial injection, at 1-week, 1-month, and 3-month intervals, as well as at the end of follow-up. Visual acuity measurements were recorded using Early Treatment Diabetic Retinopathy Study charts. Any ocular or systemic adverse events were recorded. Statistical analysis was performed to determine if OCT and visual acuity results were significant and to determine if a difference in outcomes existed between previously treated patients and treatment naïve patients. Results: Fifty-four eyes of 51 patients treated with intravitreal bevacizumab for CNV from AMD were identified. A total of 178 injections were performed. Mean number of days of follow-up was 138 with 91% of patients having at least 90 days of follow-up. Seventy percent of patients had undergone previous treatment for CNV. The mean number of intravitreal bevacizumab injections per eye was 3.3. Combined treatment with photodynamic therapy was provided in 20% of cases at the initial intravitreal injection. OCT data for all patients revealed an initial mean thickness of 362 &mgr;m, which was decreased at 1 week to 278 &mgr;m (P = 0.001), 235 &mgr;m at 1 month (P < 0.0001), 238 &mgr;m at 3 months (P = 0.0004), and 244 &mgr;m for the end of follow-up (P < 0.0001). Cystic retinal edema, subretinal fluid, and pigment epithelial detachment resolved in the majority of cases, but pigment epithelial detachment frequently took longer to resolve. Initial mean visual acuity was 20/125 (logMAR 0.8), and final mean visual acuity was 20/100 (logMAR 0.7) (P = 0.03). There was no difference in OCT or visual acuity outcomes (P = 0.62 and P = 0.28, respectively) between previously treated and treatment naïve patients. There was no difference in OCT or visual acuity outcomes (P = 0.67 and P = 0.21, respectively) between patients who received combination therapy and those who received monotherapy with intravitreal bevacizumab. No systemic or ocular adverse events were recorded. Conclusion: Intravitreal bevacizumab for CNV from AMD results in a rapid decrease in OCT-measured retinal thickness in a majority of cases. Visual acuity also improved in this series, suggesting a potential corresponding visual benefit. This series suggests that previously treated and treatment naïve patients have similar outcomes.

Multifocal electroretinography evaluation for early detection of retinal dysfunction in patients taking hydroxychloroquine.

Purpose To evaluate macular function using multifocal electroretinography (mfERG) in a cohort of asymptomatic patients taking hydroxychloroquine and a patient with maculopathy secondary to hydroxychloroquine treatment. Methods mfERG recordings were obtained for both eyes of 11 patients taking hydroxychloroquine without clinical signs of toxicity and 1 patient with toxic maculopathy. Initially, the classic m-sequence paradigm for the first-order kernel (103 hexagons; 2.7 candela × seconds/m2 peak luminance) was recorded. After that, another special stimulation mode was applied, which emphasized second-order adaptational effects (modulated multifocal flashes with interleaved global flashes, MF0F0 paradigm). Results The patient with toxic maculopathy and one patient without toxicity had multiple areas of decreased retinal responses bilaterally (classic m-sequence). The patient with toxicity and another three patients without toxicity presented with multiple areas of decreased retinal function in both eyes with the second-order component of the MF0F0 paradigm. Repeated recordings of 1 patient 8 months after the initial recording demonstrated evidence for reproducibility of the second-order adaptive effects. Conclusion Clinically asymptomatic patients receiving hydroxychloroquine treatment can have substantial local decreases in their retinal function, as reflected by the changes in mfERG recordings, possibly indicating a preclinical stage of drug-related toxicity.

Emerging concepts in the management of acute retinal necrosis

Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.

The natural history of pigment epithelial detachment associated with central serous chorioretinopathy.

Purpose: To determine the visual outcome of retinal pigment epithelial detachment (PED) associated with central serous chorioretinopathy (CSC), to further characterize the natural history of these lesions, and to provide a review of previous reports. Participants: Data for 340 consecutive patients with a diagnosis of CSC from January 2001 through December 2004 were retrospectively reviewed. Patients with CSC combined with angiographic evidence of PED were included in the study. Main Outcome Measures: Age, sex, use of corticosteroid medications, presenting visual acuity, and final visual acuity were recorded. Lesion characteristics including location, number of lesions, and laterality were recorded. Clinical outcome measures included resolution or persistence of the PED, progression to retinal pigmentary atrophy, or development of choroidal neovascularization. Fluorescein angiograms were obtained if available. Results: Thirty-four (9%) of 319 patients with angiographic evidence of CSC were diagnosed with PED over a mean follow-up of 49 months (range, 12–165 months; median, 36 months). Mean age of the patients was 47 years (range, 32–69 years; median, 48 years), most of whom were males (68%). Mean initial visual acuity was 20/32 (range, 20/13 to 20/400; median, 20/30). PEDs were commonly unilateral (88%), unifocal (76%), and extrafoveal (82%). Overall mean final visual acuity was 20/25 (range, 20/13 to 20/250; median, 20/25) for all patients. Mean visual acuity for the group of patients with subfoveal PED (18%) was 20/50 (range, 20/25 to 20/250; median, 20/50). Complete resolution of the PED occurred in 65% of patients, with resultant mean visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). In this group, localized retinal pigment epithelial atrophy developed in 86%, with mean final visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). Persistent PED was observed in 35% of patients, resulting in mean visual acuity of 20/25. There were no cases of choroidal neovascularization. Conclusions: CSC with associated retinal PED may be seen and generally has a good visual prognosis. The most frequent outcome is resolution with retinal pigment epithelial atrophy. Subfoveal PED occurs less commonly and may have a poorer visual prognosis.

Intravitreal triamcinolone acetonide treatment of macular edema associated with central retinal vein occlusion.

Purpose: To evaluate treatment of macular edema associated with central retinal vein occlusion (CRVO) using intravitreal triamcinolone acetonide. Methods: Retrospective review of data for 29 eyes of 29 patients with CRVO and macular edema treated with intravitreal triamcinolone acetonide. Initial visual acuity, intraocular pressure, and history of glaucoma were recorded. Final visual acuity, intraocular pressure, and adverse events were recorded during the treatment period. Results: Twenty-nine eyes were treated with intravitreal injection. The mean follow-up was 348 days. The median initial Early Treatment Diabetic Retinopathy Study visual acuity was 20/250 (median logMAR, 1.1). The median visual acuity 3 months after injection was 20/125 (median logMAR, 0.8). This difference was statistically significant. The median final visual acuity was 20/250 (median logMAR, 1.1). This difference in visual acuity was not statistically significant. Elevated intraocular pressure, excluding that related to neovascularization, occurred in 5 of 22 patients. Subgroup analysis revealed that patients who received multiple injections had better outcomes. Conclusion: Intravitreal triamcinolone acetonide may improve vision transiently but does not appear to result in a sustained visual acuity benefit for patients with macular edema associated with CRVO. Repeated injections may be necessary. The risk of glaucoma is significant, and additional study is required to further characterize this and other risks.

Massive spontaneous choroidal hemorrhage.

Purpose To describe the course, management, and prognosis of massive spontaneous choroidal hemorrhage. Methods The presenting visual acuity, ocular findings, duration to surgical intervention, and outcomes of five patients were retrospectively reviewed. Results Five eyes from four patients (median age, 80 years; range, 66–85 years) were studied. The patients were observed from 4 to 72 months (median, 33 months). Three patients were on anticoagulation therapy with warfarin; one patient had bilateral involvement with no history of anticoagulation therapy. Three patients were hypertensive, and three of the four had been diagnosed with age-related macular degeneration. Four eyes underwent choroidal drainage procedures, and one was observed. In all patients whose choroids were drained, the final vision was no light perception. Conclusions Massive spontaneous choroidal hemorrhage may be associated with hypertension, systemic anticoagulation, advanced age, and age-related macular degeneration. Final visual acuities are generally poor.

Anticoagulation with warfarin in vitreoretinal surgery.

Purpose: To describe the clinical course of patients undergoing vitreoretinal procedures while receiving systemic anticoagulation with warfarin. Methods: We reviewed patient demographics, ocular findings, and clinical courses for 25 patients receiving systemic anticoagulation with warfarin who subsequently underwent vitreoretinal surgery. Results: Patient ages ranged from 49 years to 81 years (median, 69 years). Indications for anticoagulation included atrial fibrillation, cerebrovascular disease, deep vein thrombosis, prosthetic heart valves, and hypercoagulable state. Follow-up ranged from 4 months to 36 months (median, 19.5 months). The international normalized ratio ranged from 1.5 to 3.1 (median, 2.0). Final vision after surgery ranged from 20/20 to 20/400 (median, 20/100). One patient who underwent scleral buckling and external drainage of subretinal fluid had an intraoperative subretinal hemorrhage associated with the drainage procedure. In all other patients, no intraoperative complications occurred. Conclusion: Cessation of therapy with warfarin may not be necessary in patients receiving anticoagulation who are undergoing vitreoretinal procedures. Successful visual and anatomical results may be achieved after vitreoretinal surgery for patients receiving anticoagulation with warfarin. The management of anticoagulation should occur in conjunction with the patient’s internist to allow a clear understanding of the potential systemic risks of cessation of warfarin treatment preoperatively.

Spectral domain optical coherence tomography findings in eyes with acute ischaemic retinal whitening

Acute retinal ischaemia presents in various forms depending on the type and location of the associated vascular occlusion. Cotton wool spots have been considered one manifestation of ischaemia and represent swelling in the nerve fibre layer. However, clinical retinal whitening also occurs in areas not affected by cotton wool spots, and has distinguishing spectral domain optical coherence tomography (SD-OCT) features. We present SD-OCT findings of hyper-reflectivity and thickening in four eyes with representative retinal arterial or retinal venous occlusions, specifically branch retinal artery occlusion, central retinal vein occlusion, Purtscher-like retinopathy and ophthalmic artery occlusion. The spectrum of retinal ischaemia from various causes was found to manifest in inner nuclear layer hyper-reflectivity and thickening on SD-OCT. En Face OCT imaging further characterises the topographical distribution of ischaemia, and reveals patterns which provide insight into the pathological processes involved.

Ocular bartonella infections.

What is now commonly known as cat scratch disease was first reported by Parinaud in 1889, when he described 3 patients with follicular conjunctivitis, regional lymphadenopathy, chronic fever, and previous contact with pets. Initially termed Parinaud’s oculoglandular syndrome (POGS), subsequent reports eventually bore out the intimate relationship between this condition and exposure to cats. Only recently has the etiologic agent for cat scratch disease been identified as Bartonella henselae, in part because of the development of biomolecular techniques allowing for the identification and diagnosis of previously unknown infectious organisms. This review discusses the basic and clinical biology of the various Bartonella species, and also summarizes the ocular complications that can accompany infection by these relatively common pathogens.

Retinal damage caused by air-fluid exchange during pars plana vitrectomy.

Purpose: To report two cases of retinal damage associated with air infusion during pars plana vitrectomy. Design: Observational case report. Methods: The authors reviewed the course of two patients who had retinal damage during par plana vitrectomy and air-fluid exchange for the treatment of macular hole and optic pit-related macular detachment, respectively. The intraoperative observations, postoperative course, and outcomes were reported. Results: As a result of high air infusion flow during air-fluid exchange, retinal damage was created in the area contralateral to the infusion port. In Case 1, an oval area of whitening was noted on the first postoperative day. This area subsequently developed into a large retinal break associated with retinal detachment. In the second case, retinal whitening was noted intraoperatively. This region of pallor resolved quickly during the early postoperative period but resulted in a corresponding inferotemporal visual field defect. Conclusions: High infusion flow during air-fluid exchange in eyes undergoing vitrectomy surgery may result in significant retinal damage. This pressure-induced trauma initially causes retinal whitening that may be seen intraoperatively or during the early postoperative period. The region of damaged retina may develop a retinal break and detachment or a corresponding visual field defect.