Chang-Sue Yang

Idiopathic polypoidal choroidal vasculopathy.

Idiopathic polypoidal choroidal vasculopathy (IPCV) has been recognized as a peculiar form of choroidal neovascularization. The clinical features of recurrent serous retinal leakage and retinal hemorrhage may vary from single lesion to multifocal, from self-limited to recurrent. Caucasian and Japanese patients with IPCV have been reported in the literature. However, research and case reports about IPCV in Chinese patients are relatively rare. We present 2 Chinese patients with IPCV in Taiwan with 2 different clinical pictures and visual outcomes during long-term follow-up. Further study for the etiology, clinical courses and treatments of the different subtypes of IPCV in Chinese is necessary.

Treatment and Outcome of Traumatic Endophthalmitis in Open Globe Injury with Retained Intraocular Foreign Body

Purpose: Our aim was to evaluate the incidence, risk factors, pathogens, use of systemic and intravitreal antibiotics, and outcome of traumatic endophthalmitis after open globe injury with retained intraocular foreign body (RIOFB). Methods: Patients with open globe injury and RIOFB complicated by endophthalmitis were enrolled and retrospectively studied in Taiwan over a 20-year-period from 1981 to 2002. Results: There were 125 patients, who sustained open globe injury and RIOFB, which required surgical management. In 15 patients (12%) traumatic endophthalmitis was identified. Thirteen (87%) of these 15 cases had signs of endophthalmitis at their initial presentation. The patients’ mean age was 41 years; all of them were male. Invading micro-organisms were isolated in 8 patients, and the positive culture rate was 53%. Gram-negative bacteria were the most commonly isolated organisms in 6 patients and 1 eye with multiple organisms. One eye with culture-proven Bacillus cereus had a very fulminant course and ended with phthisis bulbi. All 15 patients received topical and systemic intravenous antibiotic treatment; 9 eyes (60%) were given intravitreal antibiotic injection with broad-spectrum combined vancomycin and ceftazidime in 5 eyes. Pars plana vitrectomy was performed in 9 patients, with successful removal of RIOFB. The final visual acuity improved in 8 patients (53.5%), was unchanged in 1 (6.7%) and worse in 6 (40.0%). Five patients (33%) got a visual outcome of 6/60 or better. There were also 5 patients (33%) with a poor outcome of no light perception. Eleven (73%) of 15 patients had treatment delayed for >24 h after injury, and 5 out of these 11 patients had a very poor visual outcome (1 hand motion, 4 no light perception). Delay of presentation for >24 h after injury was associated with a tendency to increased risk of endophthalmitis [11/71 (15.5%) vs. 4/54 (7.4%)]. Conclusions: Early intravitreal antibiotics and prompt vitrectomy to remove the contaminating IOFB may salvage useful vision in some patients with traumatic endophthalmitis with RIOFB. Delay of treatment for >24 h was associated with increased risk of traumatic endophthalmitis.

Management of Retained Intravitreal Lens Fragments after Phacoemulsification Surgery

Purpose: To evaluate the clinical features of eyes with retained intravitreal lens fragments after phacoemulsification surgery and to assess the guidelines of management and the visual outcome after vitrectomy. Methods: Twenty-five consecutive patients referred to our institute for retained intravitreal lens fragments after phacoemulsification cataract surgery were evaluated retrospectively over a 7-year period. Results: The clinical features of retained lens fragments included deceased visual acuity of 6/60 or worse (68%), uveitis (60%), glaucoma (48%), corneal edema (44%) and retinal detachment in 2 patients (8%). There were 24 patients who underwent pars plana vitrectomy; 1 patient was managed with medical therapy. After vitrectomy, 17 eyes (71%) showed visual improvement, and final visual acuity was 6/12 or better in 13 eyes (54%). The causes of poor final visual outcome of 6/60 or worse included retinal detachment and cystoid macular edema. The time interval between vitrectomy and phacoemulsification was within 4 weeks in 17 patients (71%), ranging from on the same day to 97 days. There was only a trend of better visual outcome in early vitrectomy patients (within 1 week). There was no statistical difference between the initial intraocular lens status and final visual acuity. Conclusion: Vitectomy with removal of retained intravitreal lens fragments is beneficial for patients with persistent uveitis and glaucoma after phacoemulsification. In the majority of patients, visual improvement was achieved after vitrectomy. However, poor visual outcome may occur secondary to retinal detachment and cystoid macular edema.

Intravitreal bevacizumab (avastin) in the treatment of macular edema associated with perfused retinal vein occlusion.

PURPOSE To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin) injection in patients with macular edema (ME) secondary to retinal vein occlusive diseases. METHODS A prospective, interventional cases series study was conducted in patients with ME secondary to perfused retinal vein occlusions (RVOs), who were treated with intravitreal bevacizumab (2.5 mg per injection in a volume of 0.1 mL). Patients underwent complete ophthalmic evaluation, including Snellen visual acuity, optical coherence tomography (OCT), and fluorescein angiography (FA) at baseline, 1 month, and 3 months after the first injection and at the final visit. RESULTS Twenty-five patients (25 eyes) received intravitreal bevacizumab injections. The mean follow-up time was 6.5 months. Mean Snellen visual acuity improved from 20/125 at baseline to 20/74 at 1 month, 20/69 at 3 months, and 20/57 at the last follow-up (P < 0.01). Five of the 25 eyes (20%) had vision gain of >3 lines. The mean central 1 mm macular thickness was 422 microm at baseline and decreased to 263, 333, and 239 microm at 1 month, 3 months, and the last follow-up, respectively. Recurrent macular edema with a rebound increase of central retinal thickness was observed 3 months after the first injection, and improved after repeated bevacizumab injections. Patients received an average of 2 injections (range 1-3). FA showed no evidence of increased nonperfusion avascular area. No adverse ocular or systemic events were observed following injections. CONCLUSIONS The observed anatomic and visual acuity improvements after intravitreal bevacizumab injection demonstrate that bevacizumab is a useful adjunctive treatment for ME secondary to RVO without safety concerns in a short term. However, repeated injections are needed to maintain visual improvement. Long-term study is warranted to assess the long-term efficacy and safety.

Comparison of the effect of reduced-fluence photodynamic therapy with intravitreal bevacizumab and standard-fluence alone for polypoidal choroidal vasculopathy.

Background: Photodynamic therapy (PDT) has previously been reported to be effective in treating polypoidal choroidal vasculopathy (PCV), with satisfactory polyp regression. However, the optimum treatment protocol remains controversial. This study compared the effect of reduced‐fluence PDT combined with intravitreal bevacizumab (rPDT/IVB) and standard‐fluence PDT (sPDT) alone for treating symptomatic PCV in Chinese patients. Methods: A retrospective review was carried out of the medical records of patients with PCV who were treated with rPDT/IVB (14 eyes of 13 patients) or sPDT (12 eyes of 12 patients) with at least 6 months of follow‐up. Results: The mean best‐corrected visual acuity of the rPDT/IVB group improved significantly at the 6‐month follow‐up (p = 0.041). Only one eye (7.1%) in the rPDT/IVB group showed a decrease in visual acuity, compared with four eyes (33.3%) in the sPDT group. A total of 40.0% of eyes in the sPDT group showed increased lipid exudate at follow‐up 1 month after treatment, whereas no increase in lipid exudate was observed in the rPDT/IVB group (p = 0.015). The mean maximum area of post‐treatment hemorrhage in the rPDT/IVB group was smaller than that in the sPDT group (2.57 ± 2.74 mm2 vs. 12.69 ± 10.28 mm2, p = 0.042). Conclusion: Combination therapy with rPDT/IVB for patients with PCV showed encouraging results in vision improvement, a lower decrease in visual acuity, significantly less post‐treatment lipid exudate and a smaller area of post‐treatment hemorrhage at the 6‐month follow‐up than patients treated with sPDT.

Combination photodynamic therapy and intravitreal bevacizumab used to treat circumscribed choroidal hemangioma

Circumscribed choroidal hemagioma (CCH) is an ocular tumor that can result in decreased vision or blindness. Numerous treatment methods have been reported without satisfying results. In recent years, photodynamic therapy (PDT) with verteporfin has been used to treat choroidal hemagioma and resolve the associated exudative retinal detachment, and the results have been inspiring. Here, we report the case of a 36-year-old man with longstanding CCH who suffered from blurred vision for 3 years. He underwent PDT with intravenous infusions of verteporfin, which was a treatment method based on a modified version of the standard macular degeneration PDT protocol, in addition to subsequent intravitreal administrations of bevacizumab as adjuvant therapy for macular edema. Twelve months after treatment, the CCH tumor remained noticeably shrunken, with the complete absorption of the subretinal fluid and the absence of macular edema. In terms of treating subretinal fluid retention, this combination treatment is a safe, effective, and long-lasting therapy for treating established CCH tumors. However, even though the patients visual field defects improved, the patients visual acuity remained stable at 6/60 without further improvement. Long-term CCH with prolonged macular edema might have affected the visual prognosis. Patients with CCH still require long-term follow-up examinations after receiving PDT treatments.

Photodynamic Therapy in the Treatment of Choroidal Neovascularization Complicating Central Serous Chorioretinopathy

We report the favorable anatomic and functional outcome of photodynamic therapy with verteporfin in a case of chronic central serous chorioretinopathy complicated with choroidal neovascularization (CNV). This 37-year-old Chinese male with bilateral chronic central serous chorioretinopathy presented with central scotoma, reduced vision and metamorphopsia in his right eye. Fluorescein angiography (FA) disclosed macular hemorrhage, exudate and subfoveal classic CNV. Photodynamic therapy (PDT) with verteporfin was applied to the CNV according to standard protocol with 2.2-mm spot size. Best-corrected visual acuity (BCVA) improved from 6/20 to 6/10 1 month after PDT. BCVA recovered to 6/7.5 without leakage on FA 3 months after PDT. Neither recurrent CNV lesion nor new hemorrhage was noted over 12 months of follow-up. Short-term results suggest that PDT with verteporfin for CNV secondary to central serous chorioretinopathy is a safe and effective treatment modality.

Refractory Severe Ocular Hypertension after Intravitreal Triamcinolone Acetonide Injection

Purpose: To report a serious complication following intravitreal triamcinolone acetonide injection. Methods: Observational case report. Results: In 2 patients, secondary intractable severe ocular hypertension occurred 2 months after a single 4-mg intravitreal injection of triamcinolone acetonide for macular edema. Both patients required trabeculectomy intervention to control intraocular pressure (IOP). Conclusion: We highlight the occurrence of intractable high IOP elevation as a serious complication 2 months after intravitreal triamcinolone ace- tonide. Cautious monitoring of IOP for several months after this therapy is recommended. The risks of this potentially devastating complication need to be weighed against the benefits of intravitreal triamcinolone in the individual patient.

Optical coherence tomography in spontaneous resolution of vitreomacular traction syndrome.

Vitreomacular traction syndrome (VTS) is a vitreoretinal interface abnormality. The disorder is caused by incomplete posterior vitreous detachment with persistent traction on the macula that produces symptoms and decreased vision. Most symptomatic eyes with VTS undergo a further decrease in visual acuity. Spontaneous complete vitreomacular separation occurs infrequently in eyes with VTS. Surgical intervention may be considered if severe metamorphopsia and decreased visual quality occur. Herein, we report 2 typical cases of idiopathic VTS with spontaneous resolution of vitreo-retinal traction demonstrated by optical coherence tomography. Optical coherence tomography is a sensitive and useful tool for the confirmation of diagnosis and for the serial anatomical evaluation of patients with VTS.

Retinal Arterial Macroaneurysms: Risk Factors of Poor Visual Outcome

Purpose: To evaluate the long-term natural course and to identify the risk factors of a poor visual outcome in patients with retinal arterial macroaneurysms (MA). Methods: In this observational case series, we retrospectively evaluated the consecutive patients with MA at our institution over a 17-year period. The visual outcomes of the different types of MA (presented as predominantly hemorrhagic or exudative) were compared. Results: A total of 31 patients with 46 confirmed MA were identified. The ocular manifestations of MA included retinal hemorrhage (96.7%), retinal exudate (61.3%), macular involvement (77.4%) and vitreous hemorrhage (12.9%). Among the 10 cases of hemorrhagic-type MA, visual acuity improved by 2 or more lines in 9 (90%) and decreased in 1 patient (10%). In the 15 cases of exudative-type MA, 4 improved (26.7%), 8 remained stationary (53.3%) and 3 had decreased visual acuity (20.0%). The average vision change in the minimum angle of resolution improved by 0.59 log units in hemorrhagic MA and decreased by 0.07 log units in exudative MA (p < 0.01). With respect to change of vision, the eyes with hemorrhagic-type MA showed greater improvement than those with the exudative type, but the final visual outcome was not different in the 2 groups. Foveal exudate was a statistically significant risk factor for final vision equal to or worse than 6/30 (odds ratio = 6.93, p < 0.05). Conclusions: Different types of MA may have different clinical presentations. In the majority of MA, there is gradual and spontaneous involution. However, poor visual outcome may occur secondary to foveal exudates and subfoveal hemorrhage.