Emin Özmert

Rapid improvement of retinal and iris neovascularization after a single intravitreal bevacizumab injection in a patient with central retinal vein occlusion and neovascular glaucoma

AbstractBackground Intravitreal injections of bevacizumab have been reported to have anatomical and functional success in treating choroidal neovascularization, macular edema and neovascular glaucoma. We report a case with neovascular glaucoma due to central retinal vein occlusion who demonstrates rapid resolution of anterior and posterior segment neovascularization after a single intravitreal bevacizumab injection. Case A 46-year old man with a 6-month history of central retinal vein occlusion presented with neovascular glaucoma. Fluorescein angiography revealed marked leakage from new vessels on the iris, disc and retina. Bevacizumab was used after incomplete panretinal photocoagulation because of inadequate fundus visualization. About a week after intravitreal bevacizumab injection, new vessels were no longer visible. IOP improved and additional laser photocoagulation was performed. Conclusion Intravitreal bevacizumab injection may be a useful alternative or adjuvant treatment for patients with neovascular glaucoma in whom inadequate visualization precludes adequate panretinal photocoagulation.

Fundus Autofluorescence before and after Photodynamic Therapy for Chronic Central Serous Chorioretinopathy

Background: To determine the effect of photodynamic therapy (PDT) in chronic central serous chorioretinopathy (CSCR) and to describe fundus autofluorescence (AF) patterns before and after PDT. Methods: Seven eyes of 7 patients with chronic CSCR were included. Patients underwent complete ophthalmic examination and macular optical coherence tomography (OCT) scans were taken. Fluorescein and indocyanine green angiographies and fundus AF images were obtained by Heidelberg Retinal Angiography 2 (HRA2). PDT was performed according to the standard TAP protocol on the site of leakage area and submacular fluid. The mean follow-up period was 5.4 months. Results: Submacular fluid disappeared in all eyes 1 month after PDT and there was no recurrence during the follow-up. Visual acuity increased two or more lines in 5 eyes. Hyperautofluorescence in the area of previous retinal detachment significantly increased in the first month of PDT compared to preoperative findings. After the first month during the follow-up, increased AF in the area of previous retinal elevation returned to the baseline intensity. Conclusion: PDT of CSCR may result with resolution of subretinal fluid and visual improvement. Fundus AF may be an additional tool for monitoring the functional status of retinal pigment epithelium.

The Effect of Multiple Injections of Ranibizumab on Retinal Nerve Fiber Layer Thickness in Patients with Age-Related Macular Degeneration

Abstract Purpose: To evaluate the effects of multiple intravitreal injections of ranibizumab on retinal nerve fiber layer (RNFL) thickness in patients with wet age-related macular degeneration (AMD). Methods: This observational, comparative study included patients with 10 or more total ranibizumab injections and involved the measurement of RNFL thickness at baseline. Twenty-nine eyes of 29 consecutive patients were evaluated via intraocular pressure (IOP) and measurements of the total and nasal RNFL thicknesses at the initial and final follow-up by using optical coherence tomography. The RNFL thickness values of the fellow eyes and 27 healthy eyes were used as the control group. The mean total and nasal RNFL thicknesses of the injection group were compared with those of the other two groups. At each visit, at every three injections, the IOP values of the study group were recorded and compared. The relationship between the number of injections and the mean RNFL thickness was assessed. Results: The mean number of injections was 13.88 ± 3.81 (10–24). The mean RNFL thickness of the injection group was 92.3 ± 7.7 μm at baseline and 92.46 ± 8.1 μm at the last follow-up (p = 0.7). There were no statistically significant differences between the mean total and nasal RNFL thicknesses of the eyes with injections and the fellow eyes with no injections (p = 0.379, p = 0.897, respectively) or between those with injections and the healthy control group (p = 0.159, p = 0.273, respectively). There were no correlations between the number of injections and the mean total and nasal RNFL thicknesses (p = 0.854, p = 0.25, respectively). There was no statistical difference between the initial and final IOPs (p = 0.760). Conclusion: Long-term treatment with anti-vascular endothelial growth factor (VEGF) agents did not lead to significant changes in RNFL thickness in a patient population with wet AMD. Chronic therapy with intravitreal anti-VEGF agents does not appear to adversely affect RNFL thickness.

Short-term outcomes of switching anti-VEGF agents in eyes with treatment-resistant wet AMD

BackgroundTo investigate the short-term outcomes of treatment with intravitreal aflibercept in cases with wet age-related macular degeneration (AMD) resistant to ranibizumab.MethodsThe study included patients who had been undergoing follow-up for a minimum of three months at the Ankara University Faculty of Medicine Ophthalmology Department’s Retina Unit with a diagnosis of wet AMD. All cases had received intravitreal aflibercept injection due to the presence of intraretinal/subretinal fluid and pigment epithelial detachment (PED), as detected by optical coherence tomography (OCT), despite having received intravitreal ranibizumab. Medical records of the cases were investigated retrospectively and the demographic data, treatments administered before aflibercept injection, best-corrected visual acuity (BCVA) before and after aflibercept injection, central macular thickness (CMT), and the presence of intraretinal/subretinal fluid and the height and presence of PED were recorded.ResultsA total of 29 eyes from 11 females and 17 males were included in the study. The mean age was 73.89 ± 7.49 (62–92). The average number of intraocular injections administered before aflibercept injection was 11.75 ± 5.73 (6–25). The mean duration of follow-up following aflibercept injection was 4.55 ± 2.14 (3–11) months, with a mean of 3.44 ± 0.73 (3–5) aflibercept injections during this period. The mean BCVA values before and after aflibercept injection were found to be 0.83 and 0.77 LogMAR, respectively. The mean CMT values before and after aflibercept injection were 471.3 (97–1365) and 345.1 (97–585) microns, respectively (p < 0.001). The PED height before and after aflibercept injection was 350.4 ± 151.7 (129–793) and 255.52 ± 156.8 (0–528) microns, respectively (p < 0.05).ConclusionSwitching to intravitreal aflibercept appears to be an effective treatment modality for patients with AMD who are resistant to ranibizumab. While anatomic success including the effect of reducing the PED height was achieved in the short term following aflibercept injection in all cases, no concomitant increase in visual acuity occurred. This is attributed to the long-term presence of chronic fluid and the development of scar tissue before the treatment.

Low-Fluence Photodynamic Therapy versus Subthreshold Micropulse Yellow Wavelength Laser in the Treatment of Chronic Central Serous Chorioretinopathy

Purpose. To compare the efficacy and safety of subthreshold micropulse yellow wavelength laser (SMYL) and low-fluence photodynamic therapy (PDT) in the treatment of chronic central serous chorioretinopathy (CSC). Methods. Thirty-three eyes of 30 patients with chronic CSC received either PDT (18 eyes) or SMYL (15 eyes) therapy. Best corrected visual acuity (BCVA), subretinal fluid (SRF) height, and central macular thickness (CMT) were evaluated at the baseline visit and one, three, six, nine, and 12 months after the therapy. Results. After 12 months, mean BCVA improved from 67.3 ± 14.2 to 71.5 ± 21.4 ETDRS letters in SMYL group and from 60.7 ± 16.3 to 64.4 ± 24.9 ETDRS letters in PDT group (p = 0.285 and p = 0.440, resp.). Mean CMT decreased from 242.8 ± 80 μm to 156.9 ± 60 μm in the PDT group and from 287.3 ± 126 μm to 138.0 ± 40 μm in the SMYL group (p = 0.098 and p = 0.003, resp.). SRF resolved completely in 72.2% and 80.0% of the eyes in the PDT and SMYL groups, respectively. Mean SRF height decreased from 117.2 ± 58 μm to 31.3 ± 56 μm in the PDT group and from 130.0 ± 104 μm to 12.5 ± 21 μm in the SMYL group (p = 0.031 and p = 0.014, resp.). Conclusions. Subthreshold micropulse yellow wavelength laser seems to be effective in the treatment of chronic CSC without any side effect and results in the resorption of SRF without causing visible retinal scarring.

Autofluorescence patterns as a predictive factor for neovascularization.

Purpose To investigate fundus autofluorescence (FAF) patterns in patients with nonexudative age-related macular degeneration (AMD) and to test if FAF patterns affect the development of choroidal neovascularization (CNV). Methods One hundred one patients with early AMD underwent a detailed ophthalmological examination. Fundus autofluorescence imaging was performed with a confocal scanning laser ophthalmoscope following a standard protocol. The classification of the International Fundus Autofluorescence Classification Group was used for the description of the FAF patterns. Results One hundred seventy-eight eyes of 101 patients (59 women, 42 men) with a mean (±SD) age of 66.4 (±6.1) years were included. The mean (±SD) follow-up was 41.3 (±27) months. One hundred seventy-eight eyes presented various types of drusen with or without hyperpigmentation or hypopigmentation at initial examination. During follow-up, a total of 22 (12.3%) eyes developed CNV. The most frequent pattern for CNV development was the patchy pattern in 30.4%, followed by linear in 25%, and reticular pattern in 20.8% of eyes. Conclusions Fundus autofluorescence imaging using a confocal scanning laser ophthalmoscope is a useful technique to identify FAF characteristics in patients with nonexudative AMD. Different patterns of FAF abnormalities can be obtained in these eyes. Our results indicate that patchy, linear, and reticular patterns are the specific patterns associated with CNV development in nonexudative AMD.

Intravitreal Ranibizumab for the Treatment of Cystoid Macular Edema in Irvine-Gass Syndrome

PURPOSE To evaluate the functional and anatomical outcome after intravitreal ranibizumab injection in 2 patients with cystoid macular edema (CME) related to Irvine-Gass syndrome. METHODS Two patients with pseudophakic CME refractory to current standard topical treatment were enrolled in this study. Intravitreal (0.5 mg/0.05 mL) ranibizumab injection was performed. Baseline visits included best-corrected visual acuity (BCVA), a fundus examination, optical coherence tomography (OCT), and fundus fluorescein angiography (FA). The main outcome measures were changes in visual acuity, retinal thickness on OCT, and complications related to treatment. RESULTS FA and OCT confirmed the diagnosis of pseudophakic CME in both cases. The initial BCVA was 5/100 in the first case. After 1 injection of intravitreal ranibizumab, retinal edema totally regressed and BCVA improved to 6/10. The central macular thickness (CMT) measured with OCT was 379 μm at baseline and decreased to 227 μm at the 16-month visit. The initial BCVA was 5/10 in the second case. It improved to 8/10 after 2 ranibizumab injections and remained unchanged at the 21-month visit. The CMT measured with OCT was 419 μm at baseline and decreased to 243 μm at the final follow-up. There were no ocular or systemic complications related to the intravitreal injections. CONCLUSION Intravitreal ranibizumab appeared to be an effective treatment of macular edema related to Irvine-Gass syndrome. Prospective controlled studies are warranted to compare the long-term safety and efficacy between intravitreal ranibizumab and other treatment options in cases of Irvine-Gass syndrome.

Geographic Atrophy Progression in Eyes with Age-Related Macular Degeneration: Role of Fundus Autofluorescence Patterns, Fellow Eye and Baseline Atrophy Area

Background/Objective: To evaluate if fundus autofluorescence (FAF) patterns around geographic atrophy (GA) and the status of the fellow eye have an impact on GA progression. Methods: We included 54 eyes of 35 patients with GA. Areas of GA were quantified by RegionFinder software. Results: GA progression rates in eyes with a diffuse trickling pattern (median 1.42 mm2/year) were significantly higher than in normal eyes (median 0.22 mm2/year) and eyes with other diffuse FAF patterns (median 0.46 mm2/year). Eyes with a banded pattern had a significantly higher progression rate (median 0.81 mm2/year) than those without any FAF abnormalities (p = 0.038). The group with baseline total atrophy of the eyes <1 disk area (DA; median 0.42 mm2) had an inverse relation with GA progression compared to the groups with baseline atrophy >1 DA (p < 0.05). Conclusion: Diffuse trickling and banded patterns may have an impact on GA progression and may serve as prognostic factors.

Early indirect laser photocoagulation to induce regression of retinal vascular abnormalities in incontinentia pigmenti.

a diagnosis of incontinentia pigmenti, which had been confirmed by biopsy findings from a hyperpigmented bullous skin rush on the anterior surface of both lower extremities (Fig. 1), was referred to our clinic for retinal evaluation. She weighed 3220 g at birth and had been born at 41 weeks gestation. Initial retinal examination with scleral depression of the right eye revealed a pale optic nerve, and markedly dilated and tortuous retinal vessels with an abrupt termination within the posterior pole, extending three disc areas temporally and inferiorly, two disc areas nasally and one disc area superiorly to the disc (Fig. 2A). The peripheral retina beyond the anastomotic ring was completely avascular. These findings resembled those of zone 1 aggressive posterior retinopathy of prematurity. Retinal examination of the left eye revealed a normal disc and macula with mild dilatation of the retinal veins at the posterior pole (Fig. 2B). These vessels terminated beyond the major vascular arcades. There appeared to be vascular anastomoses throughout 360 of the retina. The peripheral retina was avascular and demonstrated an ischaemic appearance with haemorrhages. There was no evidence of retinal detachment in either eye. The patient was scheduled for laser treatment to prevent severe complications such as tractional retinal detachment and vitreous haemorrhage. Indirect argon laser treatment of the peripheral avascular retina was performed the day after initial examination in both eyes. A moderate white laser burn was applied in a moderately dense fashion. The avascular retina was entirely ablated from the junction of the vascular ⁄ avascular retina throughout 360 to the ora serrata in both eyes in one session, without any complications. On follow-up, the retina was attached and laser scars were visible in both eyes. In the right eye, the anastomotic ring disappeared and the tortuosity was diminished. One month later, the retinopathy had almost completely regressed and the vessels progressed to the peripheral retina among the laser scars in both eyes (Fig. 2C, D). During follow-up, the skin lesions faded, leaving a mild hyperpigmented linear appearance. One year after laser photocoagulation, cycloplegic refraction was + 0.75 (+ 1.75 a 90 ) in the right eye and + 1.25 (+ 1.75 a 90 ) in the left eye. The patient developed esotropia of the right eye measuring 25 prism dioptres. Fundus findings remained stable without any signs of tractional retinal detachment 1 year after laser treatment. In cases of incontinentia pigmenti, retinopathy usually presents itself in the first year of life, and early diagnosis and management improves visual outcome. Peripheral retinal ablation by cryotherapy or laser photocoagulation may be beneficial in preventing progression to proliferative vitreoretinopathy and retinal detachment (Catalano et al. 1990; Rahi & Hungerford 1990). The first successful application of laser photocoagulation at the preproliferative phase of Diagnosis ⁄ Therapy in Ophthalmology

Fundus Autofluorescence Imaging in Age-Related Macular Degeneration

Abstract Fundus autofluorescence (FAF) is a noninvasive imaging technology that provides information on the distribution of lipofuscin within the retinal pigment epithelial cells. Progressive accumulation of lipofuscin within retinal pigment epithelial cells is involved in the pathogenesis of age-related macular degeneration (AMD). Fundus autofluorescence imaging using a confocal scanning laser ophthalmoscope is a useful technique to identify high-risk characteristics in patients with nonexudative AMD. It gives also some valuable knowledge and clues in differantial diagnosis of exudative age-related macular degeneration. This review comprises an introduction to fundus autofluorescence, a review of FAF imaging in AMD, and the recent classification of geographic atrophy (GA) and early AMD phenotypes by the Fundus Autofluorescence in Age-related Macular Degeneration Study. The association of phenotype and atrophy progression and choroidal neovascularization development are also summarized.