-Kuo Cheng

One-year outcomes of intravitreal bevacizumab (avastin) therapy for polypoidal choroidal vasculopathy.

Purpose: To report on 1-year visual, anatomical, and angiographic responses with intravitreal bevacizumab for the treatment of polypoidal choroidal vasculopathy. Methods: Patients with macula-involved, symptomatic polypoidal choroidal vasculopathy with initial best-corrected visual acuity of 20/400 or better and a minimal follow-up period of 12 months were retrospectively enrolled. Eyes were treated with intravitreal bevacizumab (2.5 mg) at baseline and monitored monthly for best-corrected visual acuity and central retinal thickness (by optical coherence tomography). Indocyanine green angiography was evaluated on a 6-month basis. Eyes were retreated on an “as-needed” basis according to visual and anatomical changes. Results: A total of 35 eyes of 33 patients were treated with a mean of 3.3 (range, 1-8) times of injection. Best-corrected visual acuity significantly improved from a mean logarithm of the minimum angle of resolution of 0.79 ± 0.42 at baseline (Snellen equivalent, 20/123) to 0.69 ± 0.47 (20/94), 0.66 ± 0.45 (20/87), 0.67 ± 0.44 (20/87), 0.67 ± 0.48 (20/87), and 0.67 ± 0.51 (20/87) at 1, 3, 6, 9, and 12 months, respectively (P = 0.002, 0.0003, 0.0008, 0.017, and 0.02, respectively; paired Students t-test). Central retinal thickness also significantly improved from a mean of 297 ± 94 μm at baseline to 215 ± 58 μm, 214 ± 59 μm, 218 ± 79 μm, 213 ± 75 μm, and 221 ± 61 μm at 1, 3, 6, 9, and 12 months, respectively (all P < 0.0001, paired Students t-test). Indocyanine green angiography showed 3 of 32 eyes (9.4%) and 5 of 31 eyes (16.1%) with completely resolved polyps and 11 of 32 eyes (34.4%) and 10 of 31 eyes (32.3%) with reduced polyps at 6 and 12 months, respectively. No systemic complication or severe local complication, such as endophthalmitis, was found. Conclusion: Intravitreal bevacizumab therapy has a favorable outcome in improving visual acuity and macular exudative changes in patients with polypoidal choroidal vasculopathy. It can also moderately reduce polypoidal lesions on indocyanine green angiography.

COMPARISON OF PHOTODYNAMIC THERAPY USING HALF-DOSE OF VERTEPORFIN OR HALF-FLUENCE OF LASER LIGHT FOR THE TREATMENT OF CHRONIC CENTRAL SEROUS CHORIORETINOPATHY.

Purpose: To compare the efficacy and the detrimental effects of half-drug dose and half-laser light fluence of photodynamic therapy (PDT) for the treatment of chronic central serous chorioretinopathy. Design: We conducted a prospective randomized, observer-masked comparison study. Methods: Forty eyes (40 patients) with chronic central serous chorioretinopathy were enrolled in this study and were equally divided into 2 groups. The first (half-dose) group received only half the standard dose of verteporfin infusion (3 mg/m2) and were irradiated by the standard 83 seconds of laser light (50 J/cm2) for the PDT treatment; the second (half-fluence) group received the standard dose of verteporfin infusion (6 mg/m2) and were irradiated by only 42 seconds of laser light (25 J/cm2). Patients were examined at baseline and 1 week, 1 month, 3 months, and 6 months after PDT treatments with best-corrected visual acuity and optical coherence tomography. Fluorescein angiography and indocyanine green angiography (ICGA) were performed at baseline and at 1 month, 3 months, and 6 months after PDT treatment. Primary outcome measures were the changes in the best-corrected visual acuity and in central retinal thickness and subretinal fluid in optical coherence tomography. Secondary outcomes were the changes in the choroidal perfusion in the ICGA, which was measured as the fluorescein ratio of the PDT-treated area to a nontreated reference area in ICGA. Results: Best-corrected visual acuity was significantly improved at post-PDT 1 month, 3 months, and 6 months (all P < 0.01) in both the half-dose and the half-fluence group. Central retinal thickness was significantly improved at all post-PDT time points in both groups (P < 0.05). All patients in the half-dose group and 19 patients (95%) in the half-fluence group had complete absorption of subretinal fluid at post-PDT 3 months and 6 months. The choroidal perfusion (as reflected by the decrease of the ratio of fluorescence) in ICGA was significantly decreased at all post-PDT follow-up time points in both groups (P < 0.01). However, there were no significant differences in all the measurements between the two groups, including best-corrected visual acuity, central retinal thickness, and hypofluorescence in ICGA at baseline and at each post-PDT follow-up time point. Conclusion: Both half-dose and half-fluence modifications of PDT were similarly effective in improving the visual acuity and subretinal fluid for chronic CSC. Both types of modification of PDT were also similar in causing postlaser choroidal hypoperfusion.

Multiresistant enterococci: a rare cause of complicated corneal ulcer and review of the literature

Because of antibiotic abuse in human and animal populations, normal intestinal microflora such as enterococci have emerged as important nosocomial pathogens. We describe a community-acquired case of multiresistant Enterococcus faecalis corneal ulcer because of a cat scratch, and review previous enterococcal isolations from cornea. A 23-year-old woman was referred because of a painful left eye for 2 days. She worked as a groomer at a pet care store and her left eye had been scratched by a cat days earlier. On examination, her left vision was 20/50. A 2.0 mm × 2.0 mm paracentral corneal infiltration was revealed, associated with ground-glass edema and an immune ring (Fig. 1). A 2.0 mm × 4.5 mm wedge-shaped corneal melting with prominent superficial neovascularization was also demonstrated adjacent to the inferior nasal limbus. Initial treatment included topical cefazolin sodium (50 mg/mL) and amikacin (20 mg/mL) eye drops. The next day, 0.3% ciprofloxacin was added because of larger epithelial defects and progressive stromal reaction and thinning. However, the treatment was ineffective and an impending perforation was observed. Both the reports of corneal scrapings and the cat’s fecal culture showed E. faecalis resistant to many antibiotics other than vancomycin. Topical 2.5% vancomycin eye drop hourly and debridement of necrotic stroma resulted in decrease of epithelial defect, resolution of stromal infiltration, and gradual regression of neovascularization. After 1 month, a paracentral corneal scar remained. The best-corrected visual acuity in the left eye was 20/20. The presence of multiresistant E. faecalis has been reported to have been found in the intestinal tract of healthy humans and farm and pet animals. In hospital settings, high levels of antimicrobial resistant such as vancomycinresistant enterococci have developed to outbreak. Intermediate levels (7%–91%) of resistant E. faecalis are shown in healthy farm and pet animals, and humans are infected by contact or via the food chain. Enterococcus faecalis is a rare pathogen for corneal ulcer. In a review of the literature, all 10 cases with enterococcal corneal ulcer were nosocomial, and up to 8 cases occurred after surgery (Table 1). To the best of our knowledge, this is the first case with community-acquired and animal-related multiresistant E. faecalis corneal ulcer. Almost all cases need to be treated with vancomycin. Another feature that needs to be emphasized is rapid corneal melting. Initial failed treatment led to impending perforation, and delicate debridement of necrotic tissue is necessary for drug penetration. In laboratory studies, E. faecalis is able to release elastase and collagenase-2. These potent elastolytic and proteolytic activities can contribute to rapid necrosis and melting, as in our case. Ophthalmologists are encouraged to be aware of the potential risk of complicated E. faecalis infection from the environment, particularly in communities with high levels of antimicrobial-resistant reservoirs. Fig. 1—Slit-lamp photography showing marked corneal melting with neovascularization in the inferior nasal cornea. Paracentral corneal ulcer with immune ring (arrow) is visible. has not been detected and external radiotherapy has been effective in achieving complete local remission. In conclusion, we present a case of primary uveal lymphoma diagnosed with a biopsy of the extraocular component that led to an accurate diagnosis and adequate treatment with external radiotherapy, which allowed for the preservation of the patient’s eye and visual function.

Clinical characteristics and antivascular endothelial growth factor effect of choroidal neovascularization in younger patients in Taiwan

Background/Purpose: The purpose of this study is to share experiences diagnosing and treating choroidal neovascularization (CNV) in young patients (age ≤ 50 years) at our hospital. Methods: The study reviewed retrospective data of patients (≤ 50 years old) with CNV who received antivascular endothelial growth factor treatment (anti-VEGF) between January 2007 and August 2012 at Shin Kong Wu Ho-Su Memorial Hospital. We recorded the total number of injections, types of drugs, preoperative and final best-corrected visual acuity (BCVA), central retinal thickness (CRT) in optical coherence tomography (OCT), and total follow-up times, and then used two-tailed paired t tests to compare mean changes in BCVA and CRT on OCT. Results: The study enrolled 59 patients ≤ 50 years of age with CNV diagnosed in 67 eyes. The mean age was 36.9 ± 10.0 years (range, 8–50 years). Twenty-one patients were male and 38 patients were female. Forty-two CNV lesions were subfoveal, 19 were juxtafoveal, and five were extrafoveal. The mean total follow-up time was 18.5 ± 19.9 months (range, 0.5–71 months). Pathologic myopia was the most common cause of CNV in this study (47.8%), followed by punctate inner choroidopathy (17.9%), idiopathic CNV (16.4%), polypoidal choroidal vasculopathy (13.4%), angioid streaks (3.0%), and choroidal rupture (1.5%). After anti-VEGF treatment, the mean BCVA improved from 0.69 ± 0.61 to 0.42 ± 0.59 (p < 0.05). CRT decreased from 257.5 ± 48.2 to 210.3 ± 35.7 (p < 0.05). The mean number of injections was 1.9 ± 1.6 (range, 1–9). Conclusion: In this study we found that pathologic myopia, punctate inner choroidopathy, and idiopathic and polypoidal choroidal vasculopathy comprised the four most common causes of CNV in patients ≤ 50 years of age in Taiwan. We also revealed that anti-VEGF treatment is highly effective in the treatment of CNV in this age group.

Clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization

Background/Purpose: This study aims to evaluate the clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization. Methods: We conducted a retrospective study of 55 patients with macular coin hemorrhage who were followed for at least 3 months from January 1997 to December 2013 at Shin Kong Wu Ho-Su Memorial Hospital (Taipei, Taiwan). All patients were evaluated using fluorescein angiography and optical coherence tomography for the detection of choroidal neovascularization (CNV). We also recorded clinical characteristics such as age, sex, refractory error, and myopic fundus, to determine the relationship between CNV and non-CNV associated macular hemorrhage. Results: A total of 55 patients (30 females, 54.55%) were reviewed. The mean age was 39.7 years old. The CNV group was found to be significantly older than the non-CNV group (p < 0.05), and there was no significant difference between sex, visual acuity myopic severity, and the prevalence of fundus findings between CNV and non-CNV groups. Twenty one patients (38.18%) were found to have CNV and were all treated with intravitreal antivascular endothelial growth factor (VEGF). The other 34 patients without CNV were not treated. In both groups, the visual acuity significantly improved (anti-VEGF treated, CNV associated group, 0.7 to 0.39, p = 0.002, and untreated, non-CNV associated group, 0.56 to 0.34, p = 0.0018, respectively). Conclusion: Age significantly correlated to the CNV formation in high myopia with macular hemorrhage. Favorable visual outcomes were found in pathological myopic macular hemorrhage either in the anti-VEGF treated, CNV associated group or in the untreated, non-CNV associated group.

Intravitreal Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion-A Short-Term Result

Purpose: To evaluate the short-term safety and efficacy of intravitreal bevacizumab for the management of macular edema secondary to branch retinal vein occlusion (BRVO). Methods: A retrospective, non-comparative, consecutive, interventional case series of twenty-four eyes from 24 patients. Patients received repeated intravitreal injections of 2.5 mg bevacizumab. Main outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) in a minimum follow-up of 3 months. Results: Patients presented at a mean age of 59.8 years (range 40-75). Mean duration of symptoms was 14 weeks (range 2-56), and mean follow-up period was 10.1 months (range 3-30). Mean (SD) BCVA at baseline was 1.17 (±0.51) logMAR, improving to 0.62 (±0.53) logMAR at the last follow-up (p＜0.01). Mean (SD) CRT at baseline was 439 (±112)μm, declining to 246 (±106)μm at the last follow-up (p＜0.01). No increased intraocular pressure, retinal tear, vitreous hemorrhage or endophthalmitis was noted during the follow-up period. Conclusions: Intravitreal injection of 2.5 mg bevacizumb appears to be an effective and safe treatment option for BRVO related macular edema. However, further studies are necessary to evaluate the long-term effect.

Intravitreal Bevacizumab (Avastin) for Choroidal Neovascularization Secondary to Pathologic Myopia: A Short Term Result

Purpose: To report the short-term study and evaluate the safety and efficacy of intravitreal bevacizumab in the treatment for choroidal neovascularisation (CNV) secondary to pathological myopia (PM). Method: The non-randomized retrospective chart review recruited 15 eyes from 13 patients with primary or recurrent choroidal neovascularization secondary to pathological myopia who received intravitreal bevacizumab 2.5mg between April 2006 and March 2007 at the Shin-Kong Wu Ho-Su Memorial Hospital. Data from clinical examination, fundus photography, fluorescein angiography, central retinal thickness (CRT) determined from optical coherence tomography (OCT) and best-corrected visual acuity (BCVA) were collected. Results: The spherical equivalent refractive error of the 15 eyes was ranged from -6.0 D to -12.25D. Four of 15 eyes had been treated previously with photodynamic therapy, transpupillary thermal therapy, or subtenon injection of triamcinolone. The average number of injection was 1.7 with a maximum of 5 injections. The pre-injection mean of the minimum angle of resolution (logMAR) BCVA at baseline was 0.89 ± 0.59 (Snellen equivalent, 6/47). After a mean follow-up of 4.8 (range 1-10) months, the mean post-injection logMAR BCVA was 0.58 ± 0.61 (Snellen equivalent, 6/23) at the last follow-up. Two eyes received two bevacizumab injections and two eyes received five injections. Visual acuity improved by six or more lines in 5 eyes (33.3%), improved by three to five lines in 2 eyes (13.3%), no significant change in 7 eyes (46.7%), and decreased by three lines was in 1 eye (6.7%) at the last follow-up. Central foveal thickness improved from 282.13 ± 39.7 (range 227-370) μm to 226.4 ± 35.6 (range 174-290) μm at last follow-up, representing an average reduction of 55.73 (range 0 to -84) μm. No significant ocular or systemic injection complications or drug-related side effects were observed. Conclusions: The outcomes of this small case series suggest intravitreal bevacizumab to be a safe and promising treatment method for CNV secondary to PM with both visual and anatomic improvements.

Intravitreal Bevacizumab for Choroidal Neovascularization Secondary to Age-Related Macular Degeneration-A Short-Term Study

Purpose: To evaluate the short-term safety and efficacy of intravitreal bevacizumab for managing neovascular age-related macular degeneration (AMD). Methods: A retrospective review was conducted on patients with neovascular AMD treated with 2.5 mg intravitreal bevacizumab. All patients were followed up at one week and then monthly with or without additional injections for at least three months. Best-corrected visual acuity (BCVA), dilated fundus examination and optical coherence tomography were performed at each visit. Fluorescein angiography (FAG) was also performed before and after treatment. Main outcome measures included change in BCVA and central retinal thickness (CRT). Results: Thirty-five eyes of 30 patients were included. The average number of injection was 1.72 times per eye. Seventeen eyes (49%) had at least one prior treatment. No significant differences were noted between eyes with and without prior treatment in BCVA or CRT change at all visits. The mean BCVA improved from 6/119 at baseline to 6/95 and 6/68 at one week and three months respectively. (all p≦0.005) Fourteen eyes of 33 eyes (42%) had improvement in visual acuity defined as a halving of visual angle at three months. The mean CRT reduced from 306 μm at baseline to 255 and 232 Jim at one week and three months visit (p=0.005 and p＜0.001 respectively). Those with thicker CRT have greater reduction. (r=-0.84 to -0.80, Pearson correlation, p＜0.001 for all visits). Two eyes (6%) had mild anterior chamber reaction. No increased intra-ocular pressure, retinal tear, vitreous hemorrhage or endophthalmitis was noted. Conclusions: Intravitreal bevacizumab is a promising treatment for patients with choroidal neovascularization (CNV) secondary to AMD as a primary or rescue management. Significant improvements were noted in both visual acuity and CRT. No obvious short-term safety concerns were noted. The long-term safety and efficacy of this treatment need further study.