Edwin H. Ryan

Combined photodynamic therapy with verteporfin and intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration.

Purpose: To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Methods: This is a retrospective series of 24 eyes with juxtafoveal or subfoveal CNV secondary to AMD. Patients were treated with PDT with verteporfin and 1.25 mg of intravitreal bevacizumab. All patients were naive to treatment and had either treatment within a 14-day interval. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and retreatment rate. Results: At the 7-month follow-up, 20 (83%) of 24 patients had stabilization of visual acuity. Sixteen eyes (67%) had improvement in visual acuity. Mean improvement in visual acuity (n = 24) was 2.04 Snellen lines. Fifteen eyes (63%) required only a single combined treatment for CNV resolution. There were no complications, including endophthalmitis, uveitis, and ocular hypertension. Conclusion: The results of this study suggest that combined treatment of PDT with verteporfin and intravitreal bevacizumab may be useful in treating neovascular AMD by reducing retreatment rates and improving visual acuity. Further investigation with large, controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Diabetic macular edema associated with glitazone use.

Purpose: To describe diabetic macular edema (DME) in patients who developed fluid retention as a consequence of glitazone use. Methods: A chart review identified 30 patients who used pioglitazone or rosiglitazone and had both lower extremity edema and macular edema. Clinical reports, photographs, and fluorescein angiograms were reviewed. Patients followed for >3 months were analyzed separately. Results: Seventeen patients took oral pioglitazone, 11 took rosiglitazone, and 2 took both drugs at different times. Eleven patients were observed for >3 months after cessation of glitazones. Mean weight gain during drug administration in this group was 30 lb, and mean weight loss after drug discontinuation was 19 lb. Rapid reduction in macular edema off drug occurred in only 4 of 11 patients, but 8 of 11 had reduced edema over 2 years. Mean visual acuity in this group at the initial visit was 20/60, and at the final visit, it was 20/85. Four eyes of three patients had resolution of diffuse macular edema with improved vision after cessation of glitazones without laser treatment. Conclusions: Fluid retention occurs in 5% to 15% of patients taking glitazones. In some of these patients, glitazone use appears to be a cause of macular edema, and drug cessation appears to result in rapid resolution of both peripheral and macular edema. Fluid retention associated with glitazone use should be considered when assessing treatment options for patients with DME, especially those with concomitant peripheral edema.

Intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy for choroidal neovascularization in age-related macular degeneration.

Purpose: To report the outcome for eyes treated with intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy (PDT) for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). Study Design and Participants: Interventional, consecutive, retrospective case series including 40 eyes of 40 patients with newly diagnosed juxtafoveal or subfoveal CNV secondary to AMD. Methods: The charts of patients treated with a 1.25-mg intravitreal injection of bevacizumab followed by PDT within a 2-week period were reviewed. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and need for retreatment. Results: Thirty-three (83%) of 40 eyes had stabilization of visual acuity. Mean improvement in visual acuity was 1.73 lines. Twenty-six eyes (65%) required only a single intravitreal injection of bevacizumab combined with PDT. Of the 23 eyes with 12 months of follow-up, 17 (74%) had stabilization of visual acuity, while 9 (40%) had improvement in visual acuity (mean, 1.22 Snellen lines). Eleven eyes (48%) required only a single combined treatment for CNV resolution at the 12-month follow-up. Fifteen (88%) of 17 eyes with only 6 months of follow-up required only a single combined treatment. There were no complications such as endophthalmitis, uveitis, or ocular hypertension. Conclusion: These findings suggest that eyes treated with both intravitreal injection of bevacizumab and PDT require none to a minimal number of re-treatments to have stabilization of vision, even at 12 months of follow-up. Further investigation with large controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

DRUG-INDUCED ACUTE TRANSIENT MYOPIA WITH RETINAL FOLDS

A patient was seen with acute bilateral transient myopia, shallowing of the anterior chamber, and radiating perimacu-lar folds. This was believed to be a drug reaction. A fluores-cein angiogram was performed which showed no retinal edema. A number of pathophysiologic mechanisms have been proposed for acute transient myopia, but the findings in this patient support ciliary body swelling as the cause of the changes in the eye. This swelling of the ciliary body results in a forward rotation of the lens-iris diaphragm and the vitreous, which causes both the myopia and the retinal folds.

Scleral buckling vs vitrectomy: the continued role for scleral buckling in the vitrectomy era.

RD. Soon after its introduction, PPV enhancedtheabilitytorepairRDs,particularlyinsettingsofcomplexcases, trauma, andproliferativevitreoretinopathy(PVR). TheuseofPPVhas expandedintherepairofRDs,particularly in patients with pseudophakic eyes.Asinstrumentationandsafety ofPPVcontinuetoimprovealongwith modernmicroscopesandwide-angle viewingsystems,somehavesuggested that PPV should be used alone for nearly all rhegmatogenous RDs. We assert that surgeons should offer the proceduremost likelytorepair theRD inasinglesessionwith the lowest risk of severe complications and with the best chance that a second operation will be successful should the first fail. In this light, we would argue that, although PPV alone has a role in the treatmentofselectedrhegmatogenous RDs,mostwouldbebestrepairedwith SB alone or SB plus PPV.

Photodynamic therapy for juxtafoveal choroidal neovascularization due to ocular histoplasmosis syndrome.

Purpose: To report the use of photodynamic therapy with verteporfin in patients with juxtafoveal choroidal neovascularization (CNV) for ocular histoplasmosis syndrome (OHS). Methods: Retrospective review. Data regarding the following variables were extracted from patient charts: demographic characteristics, previous surgeries, angiographic features, number and time of treatments, follow-up time, and change in visual acuity. Results: This study sample consisted of 23 eyes of 23 consecutive patients who were treated with photodynamic therapy for the management of juxtafoveal CNV. When post-treatment visual acuity (mean logMAR acuity = 0.321) was compared to baseline acuity (mean logMAR visual acuity = 3.89) vision improved by more than three Snellen lines in 30% of eyes, remained the same (±2 Snellen lines) in 52% of eyes, and worsened (greater than a two-line loss in visual acuity) in 18% of eyes. Although this series was uncontrolled, the patients had a trend toward a therapeutic benefit when compared to published natural history of similar cases (OR = 0.292, P value = 0.071 when compared to data from the Macular Photocoagulation Study for treatment of juxtafoveal lesions). Conclusion: Photodynamic therapy with verteporfin may be beneficial in patients with juxtafoveal CNV secondary to OHS in terms of both visual stabilization and improvement.

Nd:YAG Laser Photodisruption of the Lens Nucleus Before Phacoemulsification

We studied the use of Q-switched Nd:YAG laser pulses to soften sclerotic lens nuclei before phacoemulsification. We obtained 105 lens nuclei from extracapsular cataract extractions, graded them for degree of sclerosis, and randomized them into laser treatment (53 lenses) or control groups (52 lenses). The treated lenses received laser pulses until confluent pits and clefts were visible. All lenses were phacoemulsified and the times recorded. Nd:YAG laser pretreatment decreased phacoemulsification time in all grades. In moderately sclerotic nuclei, average phacoemulsification time was reduced from 40.1 to 23.9 seconds (40.4%). The nuclei of ten lenses obtained from intracapsular cataract extractions were treated intracapsularly, and the posterior capsule was inadvertently ruptured in five.

An instrument to aid intracapsular cataract extraction of dislocated lenses.

Techniques for surgical removal of a dislocated lens have evolved considerably in the past 30 years. There has been a change in preference from open-sky techniques to the use of automated vitrectomy instruments. We introduce an instrument which may be useful in selected patients with dislocated lenses. This instrument is placed through the pars plana to entrap the lens anteriorly without trauma to the retina or ciliary body. Cryoextraction of the lens through a limbal incision is then performed. We feel this instrument will be most useful in the management of a dislocated nucleosclerotic lens.