Chul Gu Kim

Risk Factors for Geographic Atrophy After Intravitreal Ranibizumab Injections for Retinal Angiomatous Proliferation

PURPOSE To describe the risk factors for the development of geographic atrophy (GA) following intravitreal ranibizumab injection treatment for retinal angiomatous proliferation (RAP). DESIGN Retrospective interventional series. METHODS Forty-three eyes (38 South Korean patients) from patients being treated for naïve RAP with intravitreal ranibizumab injection were included in this study. All patients were treated with an initial series of 3 monthly loading injections, followed by further injections as required. Baseline ocular characteristics and lesion features assessed using fluorescein angiography (FA), indocyanine angiography (ICGA), and spectral-domain optical coherence tomography (SD OCT) were evaluated as potential risk factors for GA through 2 years of follow-up. RESULTS At 2 years follow-up, GA had developed in 16 of 43 eyes (37.2%). The mean number of ranibizumab injections was 7.52 ± 2.11. Using multiple logistic regression, thinning of the subfoveal choroid at baseline (odds ratio [OR], 0.955; 95% confidence interval [CI], 0.929-0.982; P = .002), presence of reticular pseudodrusen (OR, 1.092; 95% CI, 1.017-1.485; P = .039), and presence of GA in the fellow eye at baseline (OR, 1.433; 95% CI, 1.061-1.935; P = .025) were identified as significant risk factors for GA development. CONCLUSIONS GA developed in 37.2% of eyes with RAP during the 24 months following intravitreal ranibizumab injections. Subfoveal choroidal thinning at baseline, the presence of reticular pseudodrusen, and the presence of GA in the fellow eye at baseline were associated with increased risk of GA development after treatment.

Short-term Effectiveness of Intravitreal Bevacizumab vs. Ranibizumab Injections for Patients with Polypoidal Choroidal Vasculopathy

Purpose To compare the effectiveness of intravitreal injections of bevacizumab and ranibizumab in patients with treatment-naive polypoidal choroidal vasculopathy (PCV). Methods Records from 106 consecutive patients who received intraviteral bevacizumab (n = 58, 1.25 mg) or ranibizumab (n = 52, 0.5 mg) for treatment of PCV were retrospectively reviewed. After three initial monthly loading injections, injection was performed as needed. The main outcome measures included best-corrected visual acuity (BCVA), foveal central thickness (FCT) as assessed by spectral domain optical coherence tomography, and the changes in polypoidal lesions based on an indocyanine green angiography. Results The average number of injections was 3.31 ± 1.25 in the bevacizumab group and 3.44 ± 0.92 in the ranibizumab group. Mean logarithm of the minimum angle of resolution of BCVA from baseline to 6 months after injection improved by 0.17 in the bevacizumab group (p = 0.03) and by 0.19 in the ranibizumab group (p = 0.01). Average FCT decreased from 322 ± 62.48 µm to 274 ± 40.77 µm in the bevacizumab group (p = 0.02) and from 338 ± 50.79 µm to 286 ± 36.93 µm in the ranibizumab group (p = 0.02). Polyp regression rate was 20.7% (12 of 58 eyes) in the bevacizumab group and 21.2% (11 of 52 eyes) in the ranibizumab group. There was no statistically significant difference between groups in BCVA improvement achieved, FCT improvement achieved, and polyp regression rate between groups. Conclusions Intravitreal injections of bevacizumab and ranibizumab have similar effects in stabilizing of visual acuity, macular edema, and regression of polypoidal complex in PCV eyes over the short term.

Anti-vascular endothelial growth factor monotherapy in the treatment of submacular hemorrhage secondary to polypoidal choroidal vasculopathy.

PURPOSE To evaluate the effect of intravitreal anti-vascular endothelial growth factor (VEGF) injections on submacular hemorrhage secondary to polypoidal choroidal vasculopathy. DESIGN Retrospective, interventional case series. METHODS Twenty-seven eyes from 27 polypoidal choroidal vasculopathy patients with submacular hemorrhage involving the fovea were included in the analyses. All patients were treated by anti-VEGF injection with an initial 3 loading injections by month, followed by an as-needed reinjection. Visual acuity, central macular thickness, submacular hemorrhage size, and the occurrence of vitreous hemorrhage were examined during a 12-month follow-up period. RESULTS The mean number of injections administered over the course of 12 months was 3.59 ± 1.04. The size of submacular hemorrhages averaged 18.2 ± 13.8 mm². The mean logarithm of the minimal angle of resolution (logMAR) visual acuity at baseline was 1.02 ± 0.51 (Snellen equivalent, 20/204) and improved significantly to 0.76 ± 0.48 (Snellen equivalent, 20/115) at 12 months (P = .02). Mean central macular thickness decreased from 311.7 ± 124.5 μm at baseline to 246.8 ± 102.8 μm at 12 months (P = .01). At 12 months, visual acuity improved by 0.3 logMAR or more in 10 eyes (37%), stabilized (change between 0 and 0.3 logMAR) in 11 eyes (40.7%), and decreased by 0.3 logMAR or more in 6 eyes (22.2%). Three eyes (11.1%) were subjected to vitrectomy to clear a vitreous hemorrhage that occurred after anti-VEGF therapy. CONCLUSIONS Intravitreal anti-VEGF injection monotherapy may be a valuable therapeutic option in treating eyes with submacular hemorrhage associated with polypoidal choroidal vasculopathy.

PREVALENCE OF SUBTYPES OF RETICULAR PSEUDODRUSEN IN NEWLY DIAGNOSED EXUDATIVE AGE-RELATED MACULAR DEGENERATION AND POLYPOIDAL CHOROIDAL VASCULOPATHY IN KOREAN PATIENTS.

Purpose: To evaluate the prevalence and characteristics of subtypes of pseudodrusen in newly diagnosed exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). Methods: This retrospective cross-sectional study included 321 eyes of 321 patients who were newly diagnosed with exudative AMD or PCV. Reticular pseudodrusen was classified into dot pseudodrusen and ribbon pseudodrusen; the prevalence of each subtype was estimated and compared between exudative AMD excluding retinal angiomatous proliferation (RAP), PCV, and RAP. Patient age and choroidal thickness were compared between patients with dot pseudodrusen only and those with ribbon pseudodrusen. Results: The prevalence of reticular pseudodrusen was 13.9% (15 of 108 eyes) in exudative AMD excluding RAP, 3.4% (6 of 175 eyes) in PCV, and 68.4% (27 of 38 eyes) in RAP. Among the eyes with pseudodrusen, dot pseudodrusen and ribbon pseudodrusen were noted in 100% and 40.0%, respectively, in exudative AMD excluding RAP, 100% and 16.7%, respectively, in PCV, and 96.2% and 69.2%, respectively, in RAP. Ribbon pseudodrusen was more frequently observed in RAP (P = 0.032). Patients with ribbon pseudodrusen were significantly older (77.3 ± 6.6 years vs. 72.9 ± 8.1 years, P = 0.042) than those with dot pseudodrusen only. Conclusion: The markedly higher incidence of ribbon pseudodrusen in RAP may suggest possible influence of ribbon pseudodrusen on the development of RAP.

Short-term choroidal thickness changes in patients treated with either ranibizumab or aflibercept: a comparative study

Purpose To compare, in neovascular age-related macular degeneration (AMD) patients, short-term choroidal thickness changes in eyes treated using ranibizumab with those in eyes treated using aflibercept. Methods This retrospective, observational study included 240 eyes from 240 patients who had been diagnosed with treatment-naive neovascular AMD and treated using three monthly injections of either ranibizumab (ranibizumab group) or aflibercept (aflibercept group). The choroidal thickness change between the time of diagnosis and 3 months later was compared between the two groups. Eyes were then classified into three disease groups: typical neovascular AMD, polypoidal choroidal vasculopathy (PCV) and retinal angiomatous proliferation (RAP). Within each disease group, choroidal thickness change was again compared between the two treatment groups. Results In the ranibizumab group (n=155), the mean choroidal thicknesses at diagnosis and at 3 months were 255.3±103.9 μm and 242.9±104.8 μm, respectively. In the aflibercept group (n=85), the values were 277.5±119.1 μm and 254.7±114.5 μm, respectively. The decrease was significantly greater in the aflibercept group (p<0.001). In the PCV group, the decrease was greater in the aflibercept group (p=0.001), whereas the difference was not significant in either the typical neovascular AMD group or the RAP group. Conclusions A greater decrease in choroidal thickness was noted in eyes treated with aflibercept than in eyes treated with ranibizumab. This difference was more marked in PCV than in other subtypes of neovascular AMD.

Acute Retinal Pigment Epitheliitis: Spectral-Domain Optical Coherence Tomography Findings in 18 Cases

PURPOSE To describe the imaging characteristics and to investigate the prognostic factors of acute retinal pigment epitheliitis. METHODS In this retrospective observational case series, a total of 18 patients (18 eyes) with acute retinal pigment epitheliitis were included. The features of acute retinal pigment epitheliitis were analyzed by spectral-domain optical coherence tomography (SD-OCT). RESULTS Spectral domain-OCT images obtained at baseline revealed abnormal reflectivity in the RPE inner layer in every case (18 eyes, 100%). The line corresponding to the RPE inner layer, the inner segment ellipsoid (ISe), showed abnormal reflectivity in 16 cases (89%). Among patients with ISe abnormalities, three eyes (17%) also showed external limiting membrane (ELM) disruption and two expanded abnormal reflectivity in the outer nuclear layer (ONL). With time, SD-OCT images showed disappearance and gradual resolution of the ONL hyperreflectivity, and disruption of the ELM or ISe. Sixteen eyes (89%) fully recovered their BCVA within 2 months. However, two eyes (11%) with involvement of the ELM or ONL at baseline, with BCVA of less than 20/70 at baseline, showed incomplete BCVA recovery after more than 1 year of follow-up. CONCLUSIONS Spectral domain-OCT findings indicated that the initial lesion in acute retinal pigment epitheliitis is located at the junction between the photoreceptor outer segments and the apical sides of the RPE cells. Poor visual acuity at baseline and involvement of the ELM or ONL on SD-OCT at baseline were associated with the incomplete recovery of visual acuity.

Effects of vitreomacular adhesion on anti-vascular endothelial growth factor treatment for polypoidal choroidal vasculopathy.

Purpose: To evaluate the effect of posterior vitreomacular adhesion (VMA), documented by optical coherence tomography, on the outcome of anti–vascular endothelial growth factor treatment of polypoidal choroidal vasculopathy. Methods: Medical records of 102 patients (104 eyes) with polypoidal choroidal vasculopathy were retrospectively reviewed and categorized according to the presence of posterior VMA into 2 subgroups: VMA positive (+) group (23 eyes) and VMA negative (−) group (81 eyes). Best-corrected visual acuity and central macular thickness after antivascular endothelial growth factor treatment were compared between the 2 groups at baseline and at 1 month, 3 months, 6 months, and 12 months. Results: At the last follow-up, average number of injections was 4.82 ± 1.27 in the VMA (+) group and 4.92 ± 1.45 in the VMA (−) group. After injection, the mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved from 0.81 ± 0.53 (Snellen equivalent, 20/129) to 0.67 ± 0.52 (Snellen equivalent, 20/93) in the VMA (+) group (P = 0.01) and from 0.79 ± 0.50 (Snellen equivalent, 20/123) to 0.64 ± 0.58 (Snellen equivalent, 20/91) in the VMA (−) group (P = 0.02). Average central macular thickness decreased from 354.4 ± 124.5 &mgr;m to 249.6 ± 112.5 &mgr;m in the VMA (+) group (P = 0.01) and from 361.2 ± 140.2 &mgr;m to 267.3 ± 103.5 &mgr;m in the VMA (−) group (P = 0.01). Polyp regression rate was 21.7% (5 eyes of 23 eyes) in the VMA (+) group and 22.2% (18 eyes of 81 eyes) in the VMA (−) group. There was no statistically significant difference in the best-corrected visual acuity improvement, central macular thickness improvement, and polyp regression rate between the groups. Conclusion: Unlike typical age-related macular degeneration, posterior VMA was not associated with a visual outcome after intravitreal antivascular endothelial growth factor for polypoidal choroidal vasculopathy.

Choroidal Vascular Hyperpermeability and Punctate Hyperfluorescent Spot in Choroidal Neovascularization

PURPOSE To evaluate the prevalence of choroidal vascular hyperpermeability and punctate hyperfluorescent spots in eyes with choroidal neovascularization (CNV). METHODS This retrospective, observational study included 382 eyes with typical exudative AMD (97 eyes), polypoidal choroidal vasculopathy (PCV, 163 eyes), retinal angiomatous proliferation (RAP, 37 eyes), or myopic CNV (86 eyes). The prevalence of choroidal vascular hyperpermeability and punctate hyperfluorescent spots was estimated based on available indocyanine green angiography (ICGA) images. RESULTS Choroidal vascular hyperpermeability was noted in 12.4% (12 eyes) and 26.9% (42 eyes) of eyes with typical exudative AMD and PCV, respectively. Choroidal vascular hyperpermeability was not noted in any eye with RAP or myopic CNV. Punctate hyperfluorescent spots were noted in 43.3% (42 eyes), 72.4% (118 eyes), 10.8% (4 eyes), and 4.7% (4 eyes) of eyes with typical exudative AMD, PCV, RAP, and myopic CNV, respectively. Of the 56 eyes with choroidal vascular hyperpermeability, punctate hyperfluorescent spots were noted in 55 eyes (98.2%). CONCLUSIONS Choroidal vascular hyperpermeability and punctate hyperfluorescent spots may have a common pathophysiology. Although choroidal vascular hyperpermeability and punctate hyperfluorescent spots have been thought to be associated with pathologic conditions, the markedly low prevalence of these findings in eyes with RAP and myopic CNV may not be a normal finding. It is possible that compromised choroidal perfusion, with or without associated with choroidal thinning, may lead the low prevalence of these abnormalities in eyes with these two disorders.

Small retinal haemorrhages accompanied by macular soft drusen: prevalence, and funduscopic and angiographic characteristics

Purpose To investigate the prevalence and clinical significance of small retinal haemorrhages accompanied by macular soft drusen in exudative age-related macular degeneration (AMD). Methods This observational case series included patients who had first been diagnosed with exudative AMD. Small retinal haemorrhages were defined as preretinal or intraretinal haemorrhages, no larger than half the disc diameter in size and located within 3000 μm of the fovea centre. If there was more than one haemorrhage, the entire affected area was less than two-thirds of the disc diameter. Macular soft drusen was defined as the presence of soft drusen (≥125 μm in diameter) within the macular area. The presence of retinal angiomatous proliferation (RAP) was estimated based on the results of indocyanine green angiography (ICGA). The prevalence of reticular pseudodrusen was also estimated. Results Among the 1921 eyes from 1604 patients who were newly diagnosed with exudative AMD during the 40 months prior to the study, 101 eyes (5.3%) from 79 patients presented with the fundus characteristics described above. ICGA images were available for 69 eyes. Among these eyes, 28 eyes (43.1%) and 25 eyes (38.5%) were found to have type 1 and 2 RAP, respectively. A chorioretinal anastomosis (type 3 RAP) was identified in 12 (18.5%) eyes. Reticular pseudodrusen were noted in 78 eyes (77.2%). Conclusions The presence of small retinal haemorrhages accompanied by macular soft drusen was highly predictive of RAP. The high prevalence of both soft drusen and reticular pseudodrusen in these eyes may suggest a profound decrease in choroidal perfusion in these eyes.

Hemorrhagic complications after intravitreal ranibizumab injection for polypoidal choroidal vasculopathy

OBJECTIVE To evaluate clinical features and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) after intravitreal ranibizumab injection. DESIGN Retrospective case series. PARTICIPANTS The charts of 54 patients with PCV who had received intravitreal ranibizumab 0.5 mg. METHODS The study was conducted as a retrospective chart review of 54 patients with PCV who had received intravitreal ranibizumab 0.5 mg. Analysis of 2 groups was based on mean PCV lesion size: < 15mm(2) (n = 24); or ≥ 15mm(2) (n = 32). The occurrence of fresh postoperative subretinal hemorrhage, best corrected visual acuity, systemic disease, and medication history were documented and analyzed. RESULTS The mean injection number was 3.3 ± 0.7 (range, 1 to 6), with a mean follow-up of 7.4 ± 2.8 months (range, 4 to 14 months). During the follow-up period, postoperative subretinal hemorrhage was observed in 5 (8.9%) of 56 eyes. Occurrence of postoperative hemorrhage was significantly increased in the group with large PCV size (p = 0.01). Pars plana vitrectomy was performed for postoperative bleeding that resulted in vitreous hemorrhage in 1 eye (1.8%). Various systemic diseases and medication with an anticoagulant had no correlation with occurrence of hemorrhagic complications. CONCLUSIONS Subretinal hemorrhage after ranibizumab injection can occur in patients with PCV. When considering ranibizumab injection for treatment of a large PCV lesion, the risk for hemorrhagic complications should be considered.