Elisete Brandão

Switch to Aflibercept in the Treatment of Neovascular AMD: One-Year Results in Clinical Practice

Purpose: To report the clinical outcomes of intravitreal aflibercept therapy in eyes with refractory and recurrent neovascular age-related macular degeneration (AMD) switched from intravitreal bevacizumab or ranibizumab. Methods: This is a retrospective review of eyes with neovascular AMD switched to intravitreal aflibercept with at least 1 year of follow-up after the switch. All patients had had a minimum of 3 injections of bevacizumab or ranibizumab before the switch. Aflibercept was used in patients considered refractory to bevacizumab (group 1) and in recurrent patients on therapy with ranibizumab due to an institutional policy decision (group 2). Changes in best-corrected visual acuity, fluid on optical coherence tomography (OCT), central retinal thickness (CRT) and the frequency of injections were compared. Results: Eighty-five eyes of 69 patients were analyzed, 39 eyes in group 1 and 46 in group 2. The mean follow-up time was 31.6 months prior to the switch and 14.7 months on treatment with aflibercept. One year after the switch, there was a nonsignificant mean decrease of 2 letters in visual acuity in both groups (group 1: from 58.2 to 55.8 letters, p = 0.086; group 2: from 56.4 to 54.5 letters, p = 0.168), but the mean number of injections per month was significantly lower (from 0.76 to 0.57, p < 0.001). With the switch, 90.6% of the patients showed anatomic improvement with a reduction of fluid on OCT, and both groups presented significant improvement in CRT (group 1: 65.3 µm, p = 0.051; group 2: 91.0 µm, p < 0.001). Conclusion: Aflibercept appears to be a valuable tool for the management of patients with poor responses to other anti-vascular endothelial growth factor drugs. These patients could have anatomic improvement, and the injection intervals could be extended.

Spectral-domain optical coherence tomography of the choroid during valsalva maneuver.

PURPOSE To evaluate the influence of Valsalva maneuver on the morphology and thickness of the choroid at the macular area. DESIGN Prospective interventional case series. METHODS Institutional setting. Nine healthy volunteers performed macular spectral-domain optical coherence tomography using enhanced-depth imaging at rest and during a Valsalva maneuver. Horizontal and vertical B-scans centered on the fovea were acquired. Subfoveal and average choroidal thickness in the central 3 mm were compared in the resting position and during the Valsalva maneuver using manual and semiautomatic measuring tools. Changes in choroidal thickness were evaluated. RESULTS There was no statistically significant difference in choroidal thickness at rest or during Valsalva maneuver in any of the compared groups. The subfoveal thickness difference was -4.1 μm on horizontal scans (P = .28) and 1.4 μm on vertical scans (P = .75). The mean choroidal thickness difference in the central 3000 μm was 8.5 μm on horizontal scans (P = .73) and -5.3 μm on vertical scans (P = .41). CONCLUSIONS Valsalva maneuver does not change choroidal thickness at the posterior pole. The increase in ocular pressure caused by this maneuver cannot be explained by an increase in choroidal thickness in this portion of the uveal tract.

Choroidal and macular thickness changes induced by cataract surgery

Background The aim of this study was to evaluate the effect of uneventful phacoemulsification on the morphology and thickness of the macula, the submacular choroid, and the peripapillary choroid. Methods In 14 eyes from 14 patients, retinal macular thickness, choroidal submacular thickness, and choroidal peripapillary thickness were measured preoperatively and at one week and one month after phacoemulsification using enhanced depth imaging spectral domain optical coherence tomography. Changes in thickness of the different ocular tissues were evaluated. Results There was a statistically significant increase in mean retinal macular thickness at one month. In horizontal scans, the mean increase was +8.67±6.75 μm (P<0.001), and in vertical scans, the mean increase was +8.80±7.07 μm (P=0.001). However, there were no significant changes in choroidal morphology in the submacular and peripapillary areas one month after surgery. In vertical scans, there was a nonsignificant increase in choroidal thickness (+4.21±20.2 μm; P=0.47) whilst in horizontal scans a nonsignificant decrease was recorded (−9.11±39.59 μm; P=0.41). In peripapillary scans, a nonsignificant increase in mean choroidal thickness was registered (+3.25±11.80 μm; P=0.36). Conclusion Uncomplicated phacoemulsification induces nonpathologic increases in retinal macular thickness probably due to the inflammatory insult of the surgery; however these changes are not accompanied by significant changes in choroidal thickness. In the posterior segment, the morphologic response to the inflammatory insult of phacoemulsification is mainly observed at the retinal level, and seems to be independent of choroidal thickness changes.

Ranibizumab Treatment for Choroidal Neovascularization from Causes Other than Age-Related Macular Degeneration and Pathological Myopia

Aim: Evaluation of safety and efficacy of intravitreal ranibizumab in the treatment of choroidal neovascularization (CNV) secondary to causes other than age-related macular degeneration (AMD) or pathological myopia (PM). Methods: Retrospective and multicentric analysis of 21 eyes with CNV. Nine eyes had angioid streaks, 5 inflammatory chorioretinal diseases, 3 central serous chorioretinopathy and 4 idiopathic CNV. Follow-ups lasted ≧3 months. Best-corrected visual acuity (BCVA), ocular coherence tomography (OCT) and fundus examination were assessed monthly. Results: Sixteen eyes (76%) completed 180 days of follow-up. Overall BCVA increased by +9.8 letters with treatment (p = 0.015). Visual acuity improvements ≧15 letters occurred in 43%. A significant reduction in OCT central thickness was observed. No cases of severe visual acuity loss, systemic or ocular side effects were registered. Conclusion: Short-term results of intravitreal ranibizumab for CNV unrelated to AMD or PM are encouraging. This treatment may constitute the only option for some of these patients.

Characterization of neovascular age-related macular degeneration patients with outer retinal tubulations.

Purpose: To characterize the neovascular lesions of patients with age-related macular degeneration (AMD) and outer retinal tubulations (ORTs). Methods: A retrospective study of 377 eyes with exudative AMD, submitted to intravitreal anti-angiogenic treatment. Patients were divided into 2 groups according to the presence or absence of ORTs on spectral-domain optical coherence tomography (SD-OCT; group 1 - with ORTs; group 2 - without ORTs). Age, best corrected visual acuity (BCVA), fluorescein angiography characteristics, presence of subretinal fibrosis and subfoveal photoreceptor integrity on SD-OCT were analyzed. Results: Although both groups had a BCVA gain during the follow-up period, initial and final BCVA were lower in group 1 (p = 0.020 and p = 0.042, respectively). There was no statistically significant difference in the BCVA variation between the 2 groups (p = 0.907). Regarding the initial angiographic lesion type, there was a statistically significant difference between the 2 groups (p = 0.008): group 1 had more lesions with a classic component and group 2 had more occult lesions with no classic component. There was a statistically significant difference concerning the loss of subfoveal photoreceptor integrity (p = 0.0007). Conclusions: Even though AMD patients with ORTs were associated with poor visual outcomes, we reported BCVA improvement. AMD patients with a classical component in their lesions are prone to develop ORTs.

Comparative study of 1+PRN ranibizumab versus bevacizumab in the clinical setting.

Purpose We compared the efficacy of intravitreal ranibizumab and bevacizumab for treating neovascular age-related macular degeneration using an on-demand regimen. Methods A total of 186 wet age-related macular degeneration eyes of 186 treatment-naïve patients were compared retrospectively (67 eyes treated with ranibizumab with 91 treated with bevacizumab). At baseline, mean age, best corrected visual acuity, and angiographic lesion types were similar in both groups. Best corrected visual acuity and ocular coherence tomography were evaluated. Results Sixty eyes treated with ranibizumab and 85 eyes treated with bevacizumab completed a 12-month evaluation. At 12 months, mean best corrected visual acuity increased by +6.65 letters with ranibizumab treatment and by +5.59 with bevacizumab treatment (P = 0.64). Visual acuity improved by ≥15 letters in 15 eyes treated with ranibizumab and in 21 eyes treated with bevacizumab (P = 0.75). An overall reduction in ocular coherence tomography central thickness occurred for all time points. The mean number of injections per eye was 5.97 with ranibizumab and 5.92 with bevacizumab (P = 0.90). Conclusion Intravitreal therapies with ranibizumab or bevacizumab have similar visual and anatomical results. These results confirm those of comparison of Age-Related Macular Degeneration Treatment Trials in as-needed cohorts in clinical practice. Randomized long-term clinical trials are necessary to examine the systemic safety of these treatments.

Intravitreal bevacizumab for neovascular age-related macular degeneration with or without prior treatment with photodynamic therapy: one-year results.

Purpose: The purpose of this study was to elucidate the effect of prior photodynamic therapy (PDT) on the efficacy of intravitreal bevacizumab for the treatment of neovascular age-related macular degeneration. Methods: One hundred and nine eyes of 102 patients with neovascular age-related macular degeneration were evaluated—80 eyes without prior treatment (group 1) and 29 with prior PDT (group 2). Best-corrected visual acuity, ocular coherence tomography, and funduscopy were assessed monthly. Results were evaluated at 1, 3, 6, and 12 months. Results: One hundred and one eyes completed a 12-month evaluation. At 12 months, best-corrected visual acuity increased 5.6 letters with treatment (P = 0.001): +5.7 letters in group 1 and +5.4 in group 2 (P = 0.92). Overall, visual acuity improved ≥15 letters in 22.5% of eyes: 24.0% of naive eyes versus 18.5% with prior PDT (P = 0.56). Best-corrected visual acuity loss ≥15 letters occurred in 6 eyes, 5 with naive lesions. An overall reduction in ocular coherence tomography central retinal thickness was observed at all time points. Mean number of injections per eye per year was 5.6, 6.13 in group 1 versus 4.22 in group 2 (P = 0.01). Two retinal pigment epithelial tears, one subretinal macular hemorrhage, and two strokes occurred in naive lesions. Conclusion: The authors showed similar efficacy for intravitreal bevacizumab independently of prior PDT treatment. Eyes with prior PDT needed a statistically significantly lower number of injections to control their lesions.

Anti-VEGF Therapy in Myopic Choroidal Neovascularization: Long-Term Results

Purpose: To evaluate the medium- and long-term efficacy of anti-VEGF agents in the treatment of choroidal neovascularization secondary to pathologic myopia (mCNV). Methods: We performed a retrospective analysis of patients with mCNV who had been treated with intravitreous anti-VEGF for at least 2 years. The best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were compared before and after the treatment. The number of injections per year was also assessed. Results: The results were analysed at 2 years for 67 eyes, at 3 years for 52 eyes, at 4 years for 28 eyes and at 5 years for 13 eyes. The mean change from baseline BCVA was significant at 2 years (+8.6 letters; p < 0.001) and this gain remained significantly stable for a period of 5 years. The mean CRT showed a significant decrease over time, with a nadir at 2 years (-104.0 μm; p < 0.001). The mean number of injections performed during the first year was 5.2, being lower in subsequent years (p < 0.001). Conclusion: In this subset of patients with mCNV, an intravitreous therapy with anti-VEGF agents proved to have effective results over 5 years, with a sustained increase in BCVA.

Evaluation of visual acuity, macular status, and subfoveal choroidal thickness changes after cataract surgery in eyes with diabetic retinopathy.

Purpose: Progression of diabetic macular edema has been reported as a common cause of poor visual acuity recovery after cataract surgery in patients with diabetes. Despite being responsible for the blood supply to the outer retina, the role of the choroidal layer in the pathogenesis of diabetic retinopathy (DR) is not yet understood. Our objective is to characterize macular and subfoveal choroidal thickness changes after cataract surgery in eyes with DR. Methods: Thirty-five eyes with clinically significant cataract of patients with DR were divided into three groups based on clinical and optical coherence tomography findings: patients with DR without macular edema, patients with DR and macular thickening detected on optical coherence tomography, and finally patients with clinically significant macular edema. All cases were submitted to ophthalmologic examination and spectral domain optical coherence tomography 1 week before cataract surgery and repeated 1 month after surgery. Patients with preoperative clinically significant macular edema were treated with intravitreal bevacizumab at the time of surgery. Results: All groups showed a significant increase in visual acuity 1 month after surgery (P < 0.001). Mean foveal thickness increased significantly in all groups, including controls (P = 0.013), except in patients who were simultaneously treated with intravitreal bevacizumab (P = 0.933). An increase of maximum macular thickness of at least 11% was found in 25.7% of the DR eyes, but no such increase occurred in the control eyes. No significant change was verified for subfoveal choroidal thickness in any of the studied groups. Conclusion: Surgical inflammation associated with cataract surgery caused a significant increase of macular thickness in control and DR eyes that were not treated with intravitreous bevacizumab. Such macular changes were not accompanied by subfoveal choroidal thickness changes in any of the study groups, suggesting that the changes in macular thickness associated with the surgery are not related to changes in choroidal thickness and that there is no relation between inner blood–retinal barrier status and diabetic choroidal angiopathy.

Comparison of Topical Dorzolamide and Ketorolac Treatment for Cystoid Macular Edema in Retinitis Pigmentosa and Usher's Syndrome

Purpose: To investigate the topical effect of dorzolamide versus ketorolac on retinitis pigmentosa (RP) and Ushers syndrome (US) macular edema. Methods: Prospective, randomized and interventional study. A total of 28 eyes of 18 patients were included. Five eyes had US, 23 had RP. Fifteen eyes were allocated to ketorolac tromethamine 0.5% (4 drops daily regimen) and 13 eyes to dorzolamide hydrochloride 2% (3 drops daily regimen) treatment groups. Snellens best-corrected visual acuity (BCVA), foveal thickness (FT) and foveal zone thickness (FZT) measured by Stratus® optical coherence tomography (OCT) were evaluated at baseline, 1, 3, 6 and 12 months after treatment. Results: Patients assigned to ketorolac had a baseline BCVA of 0.37 ± 0.17 logMAR which improved at the end of 1 year to 0.28 ± 0.16 (p = 0.02). Three eyes (20%) of 2 patients improved by 7 letters or more. Mean FT and FZT did not change significantly during the study follow-up. After 1 year of treatment, 4 eyes (27%) of 3 patients showed an improvement of at least 16% of FT and 11% of FZT. Patients assigned to dorzolamide had a baseline BCVA of 0.48 ± 0.34 logMAR which improved in the first 6 months (0.40 ± 0.30; p = 0.01), with a decrease at 1 year (0.42 ± 0.27; p = 0.20). Seven eyes (54%) of 5 patients had an improvement of 7 letters or more. Mean FT and FZT did not change significantly either. After 1 year of treatment, 3 eyes (23%) of 2 patients showed an improvement of at least 16% on FT and 11% on FZT. Conclusions: Results suggest that dorzolamide and ketorolac might improve visual acuity and therefore be of interest in selected cases. No relationship between retinal thickness fluctuation and visual acuity was found. Sample size was a limitation to the study.