G. Lo Giudice

Acute visual loss and chorioretinal infarction after photodynamic therapy combined with intravitreal triamcinolone

Purpose To report acute visual loss associated with dynamic vascular changes after photodynamic therapy (PDT) combined with intravitreal triamcinolone (IVTA) for the treatment of occult choroidal neovascularization (CNV). Methods An 86-year-old woman complained of visual loss in her left eye. Angiographic examination showed a serous pigment epithelium detachment complicated by CNV. She underwent combined treatment with IVTA (4 mg) followed by standard verteporfin PDT administered after a 5-day interval. Results The patient developed vision loss 1 day after PDT. Ophthalmoscopic examination disclosed an acute serous neurosensory retinal detachment. Fluorescein angiography showed a large area of early hypofluorescence in correspondence to and extending beyond the photodynamic spot. Neurosensory retinal vessels involvement with dilation of the retinal arterioles and capillary nonperfuion were also revealed. Indocyanine green angiography showed choroidal infarction within the collateral choroid included in the area of light exposure, with associated nonperfusion of medium and large choroidal vessels being revealed. Five days after PDT, spontaneous severe bleeding with breakthrough into the vitreous occurred, in addition to an RPE tear. Conclusions Acute loss of vision associated with vascular changes in retinal and choroidal circulation represents an uncommon but serious complication following combined PDT and IVTA. These risks should be carefully considered in combination therapies.

Is there any relationship between photodynamic therapy for exudative age-related macular degeneration and choroidal neovascolarization recurrence? A rationale for combined treatments.

Purpose Photodynamic therapy (PDT) is the treatment of choice for subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). Interpretation of PDT mechanism of action is not yet fully understood and causes of CNV recurrences are unclear. The authors have conducted a retrospective analysis of fluorescein and indocyanine green angiographies in patients treated with multiple PDT in order to identify risk factors for recurrence. Methods A total of 342 eyes of 342 patients (207 women and 135 men) with ARMD and subfoveal CNV were treated with at least two PDT. Angiographic (fluorescein and indocyanine green) features of recurrences were confronted to pretreatment examinations in all patients. RESULTS. Post-PDT angiographies showed in all eyes a dark circle corresponding to the laser spot even 1 year after treatment. Persistence or progressive regrowth of CNV developed in an area adjacent or corresponding to the original lesion, without any specific relationship with the location of fluorescein and indocyanine green late leakage or with presence of abnormal fluorescence due to pigment abnormalities. At the 3-month angiographic follow-up, 23 patients (6.7%) showed a recurrent CNV resembling shape and dimension of the laser spot used for the PDT treatment. Conclusions The authors failed to identify angiographic signs helpful to predict the risk of CNV persistence or recurrence. PDT leaves minor but persistent changes in the choroidal vasculature within the treatment area. In some cases, the recurrent CNV seems to be related to the laser spot of the PDT.