C. Rosina

Clinical Characteristics of Reticular Pseudodrusen in the Fellow Eye of Patients with Unilateral Neovascular Age-Related Macular Degeneration

PURPOSE To describe associations between reticular pseudodrusen, individual characteristics, and retinal function. DESIGN Cohort study. PARTICIPANTS We recruited 105 patients (age range, 52-93 years) who had advanced neovascular age-related macular degeneration (AMD) in only 1 eye from 3 clinical centers in Europe. METHODS Minimum follow-up was 12 months. The eye selected for study was the fellow eye without advanced disease. Clinical measures of vision were distance visual acuity, near visual acuity, and results of the Smith-Kettlewell low-luminance acuity test (SKILL). Fundus imaging included color photography, red-free imaging, blue autofluorescence imaging, fluorescein angiography, indocyanine green angiography, and optical coherence tomography using standardized protocols. These were used to detect progression to neovascular AMD in the study eye during follow-up. All imaging outputs were graded for the presence or absence of reticular pseudodrusen (RPD) using a multimodal approach. Choroidal thickness was measured at the foveal center and at 2 other equidistant locations from the fovea (1500 μm) nasally and temporally. Metrics on retinal thickness and volume were obtained from the manufacturer-supplied automated segmentation readouts. MAIN OUTCOME MEASURES Presence of RPD, distance visual acuity, near visual acuity, SKILL score, choroidal thickness, retinal thickness, and retinal volume. RESULTS Reticular pseudodrusen was found in 43 participants (41%) on 1 or more imaging method. The SKILL score was significantly worse in those with reticular drusen (mean score ± standard deviation [SD, 38±12) versus those without (mean score ± SD, 33±9) (P = 0.034). Parafoveal retinal thickness, parafoveal retinal volume, and all of the choroidal thickness parameters measured were significantly lower in those with reticular drusen than in those without. The presence of RPD was associated with development of neovascular AMD when corrected for age and sex (odds ratio, 5.5; 95% confidence interval, 1.1-28.8; P = 0.042). All participants in whom geographic atrophy developed during follow-up had visible RPD at baseline. CONCLUSIONS Significant differences in retinal and choroidal anatomic features, visual function, and risk factor profile exist in unilateral neovascular AMD patients with RPD compared with those without; therefore, such patients should be monitored carefully because of the risk of developing bilateral disease.

Clinical experience with pegaptanib sodium

Pegaptanib sodium (Macugen®) blocks the extracellular vascular endothelial growth factor (VEGF) isoform VEGF165, whose elevated levels are associated with the development of choroidal neovascularization (CNV). This selective inhibition prevents binding to the VEGF receptors and the development of the increased vascular permeability and the CNV associated with neovascular age-related degeneration (AMD). The VEGF Inhibition Study In Ocular Neovascularization (VISION) demonstrated that pegaptanib sodium confers clinically meaningful benefit in the treatment of all angiographic subtypes of neovascular AMD. It also has a favorable safety profile after 1 and 2 years of continuous treatment, and recent data suggest that the agent has a disease-modifying effect. Post hoc analysis of VISION suggests that treatment benefit may be greatest in patients with early lesions, in whom 80% achieved the primary endpoint of <15 letters lost, 47% maintained visual acuity (VA), and 20% gained ≥15 letters of vision. Similarly, our own clinical experience indicates that pegaptanib sodium achieves better outcomes in early lesions than in established lesions, particularly in patients with previously untreated minimally classic and occult lesions in whom VA improvement and lesion size stabilization has been recorded. Observations indicate that pegaptanib sodium has a slower mode of action than unselective VEGF inhibitors, resulting in an average of 3–4 injections being required to stabilize VA and lesion size. Pegaptanib sodium has good efficacy and safety profiles and represents a good treatment option for patients with early CNV membranes associated with neovascular AMD.

Intravitreal bevacizumab for choroidal neovascularization secondary to angioid streaks: a long-term follow-up study

Purpose To evaluate the safety and efficacy of intravitreal bevacizumab (IVB) to treat choroidal neovascularization (CNV) in patients with angioid streaks. Methods Retrospective chart review of 16 eyes of 10 patients treated with IVB for CNV secondary to angioid streaks between November 2005 and November 2011. Intravitreal bevacizumab was performed in all patients with a pro re nata regimen. Seven eyes received an additional photodynamic therapy and 1 eye argon laser photocoagulation. The diagnosis of CNV was confirmed by fluorescein angiography (FA) and indocyanine green (ICG) angiography; central macular thickness (CMT) was evaluated by optical coherence tomography. Outcome measures included changes in best-corrected visual acuity, retinal thickness, and degree of leakage on FA and ICG angiography. Results The median number of IVB was 2.5 (range 1-6) during a mean follow-up of 52 months (range 30-67). Risk of recurrence increased during the first 50 weeks; then it remained stable. In 6 of 16 eyes, the CNV was obliterated with a single injection. Increasing CNV reactivation corresponded with an increased number of injections. Final visual acuity was related to initial VA and not to number of injections or shorter follow-up. Previous treatments, CMT, or baseline CNV size were not related to final visual acuity. Conclusions Intravitreal bevacizumab proved to be well-tolerated in patients with CNV secondary to angioid streaks and in our small cohort IVB was efficacious for long-term follow-up. Larger series of patients are needed to confirm the effects of this treatment.

Clinical features and long-term progression of reticular pseudodrusen in age-related macular degeneration: findings from a multicenter cohort

PurposeTo determine whether reticular pseudodrusen (RPD) confer a long-term increased risk of progression to late age-related macular degeneration (AMD) in the fellow eye of patients with unilateral wet-AMD.Patients and methodsThis was a multicenter, combined prospective and retrospective, longitudinal, observational, study. Patients with wet-AMD in one eye were recruited from two centers and evaluated on the risk of progression to late-AMD in the second eye (study eye). A minimum follow-up of 5 years was required, unless progression occurred first. Baseline retinal profile of patients was evaluated using multimodal imaging. Baseline images were graded by two separate centers.ResultsWe recruited 88 patients (48 female) with a mean age of 75.6±7.1 years and mean follow-up of 65.7±20.9 months. Baseline prevalence of RPD was 58% (n=51). There was no statistically significant association of RPD with increased age (P=0.29) or sex distribution (P=0.39). The most sensitive image modality for RPD was IR (93%), followed by FAF (92%), OCT (74%, RF (33%) and CFP (29%). After 5 years, 54.50% (n=48) of the study eyes progressed to late-AMD. Of those, 81.25% (n=39) developed CNV and 18.75% (n=9) geographic atrophy. After correcting for age and sex, the presence of RPD was significantly associated with development of late-stage AMD (OR=2.55, P=0.03).ConclusionA multimodal approach is mandatory for RPD detection. RPD are highly prevalent in the fellow eyes of patients with unilateral neovascular AMD. Presence of RPD is associated with increased long-term risk of progression, highlighting the importance of comprehensive multimodal retinal imaging and careful monitoring of at-risk patients.

Post-cataract surgery cystoid macular edema from choriocapillaris submacular leakage in a patient with crohn disease: a case report.

PURPOSE To describe an unusual case of cystoid macular edema after cataract surgery in a patient with Crohn disease. METHODS A confocal scanning laser ophthalmoscopic study was performed on one eye before and after systemic corticosteroid treatment. Both fluorescein and indocyanine green angiograms were used to visualize vascular leakage. RESULTS Both fluorescein and indocyanine green angiograms indicated early-phase leakage in the macular region. The early-phase indocyanine green leakage was from choroidal vasculature and suggested choriocapillaris vasculitis. In the later phases, the fluorescein angiogram showed the typical petaloid pattern of cystoid macular edema. After 1 month of treatment, the abnormal indocyanine green leakage disappeared with a concomitant increase in visual acuity. CONCLUSIONS We report possible choriocapillaritis associated with Crohn disease based on dynamic angiography that revealed indocyanine green leakage in combination with early-phase fluorescein leakage. To our knowledge, this is the first description of choriocapillaris vasculitis associated with Crohn disease.