Claudio Furino

Standard-Fluence versus Low-Fluence Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Nonrandomized Clinical Trial

PURPOSE To evaluate the efficacy of low-fluence compared with standard-fluence rate photodynamic therapy (PDT) for treating chronic central serous chorioretinopathy. DESIGN Prospective, multicenter, investigator-masked, nonrandomized clinical trial. METHODS Forty-two eyes (42 patients) with chronic central serous chorioretinopathy were enrolled; 19 eyes received indocyanine green angiography-guided standard-fluence PDT (50 J/cm(2)) and 23 eyes received indocyanine green angiography-guided low-fluence PDT (25 J/cm(2)). Primary outcome measures were the changes in mean logarithm of the minimal angle of resolution best-corrected visual acuity and the rate of eyes with complete subretinal fluid reabsorption. Secondary outcomes were the changes in central foveal thickness and choroidal perfusion. RESULTS Mean logarithm of the minimal angle of resolution best-corrected visual acuity improved significantly at all time points (P < .01), in the standard-fluence group from 0.43 to 0.24 at 12 months and in the low-fluence-group from 0.46 to 0.16, without significant difference between the 2 groups. At 12 months, a complete subretinal fluid reabsorption was seen in 15 standard-fluence-treated and 21 low-fluence-treated eyes (79% vs 91%; P = .5). In 1 standard-fluence eye, choroidal neovascularization developed at 3 months, and this eye received further PDT; in the other eyes, at 12 months, a moderate-significant choriocapillaris nonperfusion was seen in 8 standard-fluence-treated and 0 low-fluence-treated eyes (44% vs 0%; P = .002). CONCLUSIONS In most of the eyes, both standard-fluence PDT and low-fluence PDT resulted in complete subretinal fluid reabsorption with visual acuity improvement. Choroidal hypoperfusion related to PDT could be reduced by low-fluence PDT.

Triamcinolone-assisted Pars Plana Vitrectomy for Proliferative Vitreoretinopathy

Purpose To determine whether triamcinolone acetonide (TAAC) staining facilitates posterior hyaloid and epiretinal membrane (ERM) removal in patients undergoing pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR). Methods Ten consecutive pseudophakic patients (10 eyes) underwent PPV for RRD with PVR. After a core PPV, a few drops of a commercially available TAAC aqueous suspension (40 mg/mL) with vehicle were injected into the mid vitreous cavity to visualize the posterior hyaloid, thus allowing a complete posterior hyaloidectomy. Next, 0.1 to 0.2 mL of TAAC was applied on the retinal surface to visualize and peel the ERMs. The tamponading agent was silicone oil (1,300 cs) in eight eyes and perfluropropane (C3F8 14%) in two eyes. The minimal follow-up period in all patients was 4 months. Results In all patients, intraoperative staining with TAAC consistently improved direct visualization and delineation of the posterior hyaloid and ERMs and facilitated their removal. No adverse reaction related to the use of TAAC was observed immediately postoperatively or 4 months after surgery. Conclusions Intravitreal TAAC may be an important adjuvant tool in the delineation of posterior hyaloid and ERMs, allowing for a more complete and safer ERM removal in the surgical management of PVR complicating RRD. It is well tolerated with all its vehicle if used at low concentration and rapidly removed during surgery.

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

Purpose To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). Methods Seven eyes of six patients (age range: 50–74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1±1.2 (range 1 to 4) treatments were performed in four eyes (57.1%) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. Results After 11.1±3.9 months, mean best-corrected visual acuity (BCVA) increased (p=0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29±146.98 mm to a best value of 263.71±83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84±0.93 mm2 at baseline to a minimal value of 3.86±0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1%) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. Conclusions Intravitr eal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting.

Purpose: To report on the occurrence of endophthalmitis after intravitreal injections (IVI) in two different settings: office-based and operating room. Methods: Consecutive case series. Retrospective review of all patients who underwent IVI by 2 physicians between January 2009 and December 2011. Group A underwent IVI in the examination room in office-based setting and Group B underwent IVI in the operating room. Results: A total of 11,710 IVIs were performed during the study period. Group A: A total of 8,647 IVIs performed including 2,041 ranibizumab, 6,169 bevacizumab, and 437 triamcinolone acetonide. The diagnosis included neovascular age-related macular degeneration (5,376), diabetic macular edema (1,587), retinal vein occlusion (1,068), and miscellaneous diagnosis (616). Group B: A total of 3,063 IVIs performed including 683 ranibizumab, 2,364 bevacizumab, and 16 triamcinolone acetonide. The diagnosis included neovascular age-related macular degeneration (1,836), diabetic macular edema (771), retinal vein occlusion (189), and miscellaneous diagnosis (267). A total of 5 cases (0.043%) of clinically suspected endophthalmitis occurred in 11,710 injections. Three cases (0.035%) occurred in Group A, and 2 cases (0.065%) occurred in Group B. Conclusion: The rate of clinically suspected endophthalmitis after IVIs is low whether the procedure is performed in the office or operating room setting. The findings have implications in terms of the patient convenience, efficiency, and cost of administrating these treatments.

Fundus autofluorescence and multiple evanescent white dot syndrome.

Objective: To describe fundus autofluorescence (FAF) in a series of patients with multiple evanescent white dot syndrome. Methods: Three eyes of three patients with multiple evanescent white dot syndrome were evaluated with indocyanine green angiography and FAF imaging to evaluate the correspondence between FAF and ICG patterns and the nature of the focal hypocyanescent spots evident with ICG. Results: In the acute phase, all three eyes showed increased autofluorescence area corresponding precisely to the site of the focal hypocyanescent spots seen on ICG but less numerous. After 2 months, mean best-corrected visual acuity improved from 20/38 to 20/20 and FAF and indocyanine green angiography returned to normal pattern. Discussion: FAF is an useful noninvasive diagnostic adjunct to identify multiple evanescent white dot syndrome, suggesting the inflammatory nature of the disease, probably due to perturbation of the photoreceptor-retinal pigment epithelium complex affecting the function of these cells.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

Purpose The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. Methods Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 ± 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 ± 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 ± 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) – in the preoperative period it was 640.8 ± 171.1 μm – and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. Results In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 ± 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 ± 157.65 μm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 ± 5.72 mmHg was not significant. Conclusions Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization in age‐related macular degeneration

Purpose:  This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization (CNV) in age‐related macular degeneration (AMD).

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation

Purpose Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. Methods A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. Results Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. Conclusions Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.

Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus.

Purpose: To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin. Methods: The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution. Results: Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six. Conclusion: Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Combined cataract extraction and intravitreal bevacizumab in eyes with choroidal neovascularization resulting from age-related macular degeneration

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, intraocular lens (IOL) implantation, and a single intravitreal injection of bevacizumab in patients with coexisting visually significant cataract and subfoveal neovascularization due to age‐related macular degeneration. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: Eyes with predominantly classic subfoveal neovascularization and cataract had phacoemulsification, IOL implantation, and a 1.25 mg intravitreal injection of bevacizumab. One month after combined surgery, corrected distance visual acuity (CDVA), anterior chamber reaction, and intraocular pressure were evaluated and central foveal thickness was measured by optical coherence tomography. RESULTS: Twenty eyes of 20 patients were evaluated. One month postoperatively, the mean CDVA improved significantly, from 20/100 (range 20/160 to 20/80) at baseline to 20/63 (range 20/125 to 20/50) (P<.0001). The mean central foveal thickness decreased significantly, from 353.75 μm ± 12.50 (SD) (range 334 to 375 μm) at baseline to 275.7 ± 17.3 μm (range 255 to 323 μm) at 1 month (P<.0001). Intraocular pressure did not change significantly, and anterior chamber reaction was absent. No ocular or systemic adverse events were observed. CONCLUSION: Combined phacoemulsification, IOL implantation, and intravitreal bevacizumab was a safe and efficacious treatment in patients with visually significant cataract and active subfoveal neovascularization.