Gabriel Quentel

Prevalence of reticular pseudodrusen in age‐related macular degeneration with newly diagnosed choroidal neovascularisation

Aim: To investigate the prevalence of reticular pseudodrusen (RPD) in eyes of patients presenting with newly diagnosed choroidal neovascularisation (CNV) in age-related macular degeneration (AMD), and to analyse the association between RPD, age-related maculopathy (ARM) and AMD. Method: Two observational consecutive prospective series. In series 1, patients with AMD with newly diagnosed CNV were sampled to determine the incidence of RPD. Eyes with and without RPD were compared by the Mann–Whitney non-parametric test and Fisher’s exact test for age, sex of patients, the eye involved and type of CNV. Series 2 comprised 100 patients referred for fundus photography, fluorescein and/or indocyanine green angiography, for whom pictures showed RPD. This second cohort was then selected from a larger group of patients. Results: Patients with newly diagnosed CNV in series 1 comprised 67 women and 33 men, aged 57–96 years (mean 79.5). CNV was “classic” (32 eyes), “occult” (41) or exhibited vascularised pigment epithelial detachment (PED, 11), retinal angiomatous proliferation (RAP) with or without PED (13), or haemorrhagic or fibrovascular scarring (3). In all, 24 (24%) eyes had RPD. The prevalence of RAP was significantly higher in eyes with RPD than in those without (p = 0.0128), despite the small number of patients with RAP. In series 2, 100 patients with RPD were enrolled in 3 months, and corresponded to 8% of the overall cases referred to our centre (Centre Ophtalmologique d’Imagerie et de Laser, Paris, France). There were 77 women and 23 men, aged 54–93 years (mean 79.2). Eyes with RPD (n = 155) usually exhibited signs of ARM or AMD, including soft drusen (101 eyes) and/or retinal pigment epithelium abnormalities (70), geographical atrophy (27) and/or CNV (61). In both studies, examination of blue-light fundus pictures was extremely helpful in diagnosing RPD. Conclusion: RPD have a high prevalence among patients with AMD with newly diagnosed CNV (24% of cases). RPD were commonly associated with ARM or AMD. This study suggests that eyes with RPD could be classified as a phenotype of ARM.

Results of one-year's treatment with ranibizumab for exudative age-related macular degeneration in a clinical setting.

PURPOSE To evaluate the results of 1 year of treatment with intravitreal ranibizumab for exudative age-related macular degeneration (AMD) in a clinical setting. DESIGN Nonrandomized, single-center, retrospective, interventional case series. METHODS Retrospective analysis of consecutive charts and angiograms of patients with previously untreated exudative AMD, treated in one or both eyes with ranibizumab between January 2 and October 31, 2007. The following were recorded for each patient: age at presentation, gender, treated eye, type of choroidal neovascularization, visual acuity (VA) measured on an Early Treatment Diabetic Retinopathy Study chart at baseline and at 52 +/- 6 weeks, the number of performed intravitreal (IVT) injections, and follow-up examinations. RESULTS The 122 patients comprised 85 women (70%) and 37 men ranging in age from 56 to 91 years (mean +/- standard deviation, 78.3 +/- 7). In all, 124 eyes were treated on a pro re nata basis after 1 or 3 initial IVT injections. The mean number of IVT injections was 3.79 +/- 1.39 (range, 1 to 7). The mean number of follow-up visits was 8.07 +/- 1.44 (range, 4 to 12). Mean VA +/- standard deviation changed from 56.15 +/- 14 to 56.89 +/- 17 letters (VA gain, +0.7 letters). CONCLUSIONS The results showed that VA stabilized rather than improved and compared unfavorably with the gains found in randomized clinical trials and the Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with intraOcular Ranibizumab (PrONTO) Study. However in this study, patients were examined less frequently and were treated far less frequently. The present results suggest that a long, regular follow-up is necessary for patients treated with ranibizumab to obtain and preserve significant visual gain, and not only to achieve visual stabilization.

Indocyanine green angiography in birdshot chorioretinopathy

OBJECTIVE Birdshot chorioretinopathy (BC) is an ocular inflammatory disease involving both the retina and the choroid. The study goal was to evaluate indocyanine green angiographic features in BC to assess choroidal involvement. DESIGN Retrospective, observational case series. PARTICIPANTS Fifty-two patients with BC documented with at least 1 concomitant fluorescein and indocyanine green angiogram. INTERVENTION Indocyanine green angiography (ICGA) was performed according to a standard protocol used for inflammatory disorders. MAIN OUTCOME MEASURE Indocyanine green angiographic signs were correlated with fundus photographs, fluorescein angiography, degree of inflammatory activity, and stage of disease. RESULTS In active disease, three main features were observed. The principal finding, found in 100% of patients, was the presence of hypofluorescent dark dots during the intermediate phase of angiography; their evolutionary pattern was twofold, becoming either isofluorescent or remaining hypofluorescent at the late phase of angiography. The other two signs were fuzzy, indistinct choroidal vessels and late-diffuse choroidal hyperfluorescence. In chronic longlasting disease, the characteristic finding was the presence of hypofluorescent dark dots that persisted in the late phase of disease and is theorized to correspond either to chorioretinal atrophy (irregular geographic pattern) or to persistent choroidal granulomas (round oval form). CONCLUSIONS Consistent ICGA findings in 52 patients allowed the authors to establish a fairly precise ICGA semiology for BC. This procedure enabled the authors to assess choroidal involvement, and, in selected cases, it also was found to be of diagnostic help and useful to monitor therapeutic intervention.

Intravitreal Aflibercept for Macular Edema Secondary to Central Retinal Vein Occlusion: 18-Month Results of the Phase 3 GALILEO Study

PURPOSE To evaluate intravitreal aflibercept for treatment of macular edema secondary to central retinal vein occlusion (CRVO). DESIGN Randomized, double-masked, phase 3 study. METHODS A total of 177 patients with macular edema secondary to CRVO were randomized to receive 2 mg intravitreal aflibercept (n = 106) or sham (n = 71) every 4 weeks for 20 weeks. From weeks 24 to 48, patients were monitored every 4 weeks; the former group received intravitreal aflibercept as needed (PRN), and the sham group received sham. From weeks 52 to 76, patients were monitored every 8 weeks, and both groups received intravitreal aflibercept PRN. The primary endpoint (proportion of patients who gained ≥15 letters) was at week 24. This study reports exploratory outcomes at week 76. RESULTS The proportion of patients who gained ≥15 letters in the intravitreal aflibercept and sham groups was 60.2% vs 22.1% at week 24 (patients discontinued before week 24 were considered nonresponders; P < .0001), 60.2% vs 32.4% at week 52 (last observation carried forward, P < .001), and 57.3% vs 29.4% at week 76 (last observation carried forward; P < .001). Mean μm change from baseline central retinal thickness was -448.6 vs -169.3 at week 24 (P < .0001), -423.5 vs -219.3 at week 52 (P < .0001), and -389.4 vs -306.4 at week 76 (P = .1122). Over 76 weeks, the most common ocular serious adverse event in the intravitreal aflibercept group was macular edema (3.8%). CONCLUSIONS The visual and anatomic improvements seen after fixed, monthly dosing at week 24 were largely maintained when treatment intervals were extended. Patients with macular edema following CRVO benefited from early treatment with intravitreal aflibercept.

Indocyanine Green Angiographic Features of Pathologic Myopia

PURPOSE To analyze indocyanine green angiographic findings of pathologic myopia and compare them with those of fluorescein angiography, with particular reference to the usefulness of indocyanine green angiography in the management of neovascular complications. METHODS Thirty-two consecutive patients (52 eyes) with pathologic myopia underwent a complete ophthalmologic examination including fluorescein and indocyanine green angiography. RESULTS Retrobulbar arteries and veins were visualized solely on indocyanine green angiography in 33 (63%) of 52 eyes. Choroidal arteries appeared attenuated and reduced in number. In the area of staphyloma, choroidal veins were less numerous, and in all eyes an absence of the normal choroidal flush caused by the choriocapillaris filling was observed. Subretinal and retinal hemorrhages were present in 28 (54%) of 52 eyes. Choroidal neovascularization was diagnosed in 16 eyes on fluorescein angiography and in 18 eyes on indocyanine green angiography. In seven eyes, indocyanine green angiography disclosed lacquer cracks (without choroidal neovascularization), appearing in the late phases as hypofluorescent lines, as the probable cause of the subretinal and retinal hemorrhages. In only one eye did indocyanine green angiography fail to disclose choroidal neovascularization detectable on fluorescein angiography. In two eyes, neither dye could clarify the origin of the hemorrhages. CONCLUSIONS Indocyanine green angiography allows identification of retrobulbar arteries and veins, and analysis of the altered choroidal vasculature. Moreover, indocyanine green angiography is a useful diagnostic tool to differentiate lacquer cracks from choroidal neovascularization in retinal and subretinal hemorrhages.

The burden of age-related macular degeneration: results of a cohort study in two French referral centres.

AbstractObjective: To describe the economic impact of age-related macular degeneration (AMD) and to assess its medical and non-medical costs. Design and settings: An observational study was carried out in 105 patients in two French centres in a sample of 105 French patients. All consecutive patients, consulting during a 3-week period, were included provided they were 60 years of age or older and they presented an exudative form of AMD with a distant visual acuity in the best eye ≤ 20/40. Data collected included clinical items, treatment modalities, medical follow-up, transport costs, impact of AMD on living conditions and welfare payments related to visual impairment. Costs were presented in 2000 values. Perspective: General payer perspective (Social Security, private health insurance and patient). Results: Mean age was 79.3 years and ranged from 62.8–95 years. Average length of disease evolution was 3.5 years. During a 3-month period, patients had a mean of 2.6 visits to the ophthalmologist. Thirty percent of the patients used vascular medications and 72.4% had been previously treated by laser photocoagulation. Only 10% had benefited from visual rehabilitation. Annual AMD cost per patient was 3660.29 euros (EUR) [95% CI: 2881.92–4438.62].Half of these annual costs were medical costs. Other major cost components were home help costs EUR904.91 [95% CI: 478.88–1330.94] and transport costs for care EUR542.73 [95% CI: 146.31–939.14]. Non-medical costs were significantly higher for patients with more severe disease. Conclusions: The economic argument that costs are higher in patients with the lowest visual acuity emphasises the necessity of early detection and treatment of patients with AMD.

Visual hallucinations and Charles Bonnet syndrome after photodynamic therapy for age related macular degeneration

Aims: To report on visual hallucinations and Charles Bonnet syndrome (CBS) that may occur in patients with age related macular degeneration (AMD) treated by photodynamic therapy (PDT) with verteporfin for choroidal neovascularisation (CNV). Methods: 100 consecutive patients were asked to respond to an orally administered questionnaire on visual hallucinations following PDT. Three groups of patients, respectively without visual hallucinations, with unstructured visual hallucinations, and with structured hallucinations—that is, CBS, were compared by ANOVA, Scheffe’s test, or the χ2 test, to establish whether age, sex, or visual acuity, as scored on ETDRS charts, are risk factors for the occurrence of visual hallucinations. Results: Five patients (5%) described transient structured visual hallucinations, including known or unknown faces and geometric patterns. Fifteen patients (15%) reported photopsias and flashing lights of various colours. These symptoms usually occurred a few days after PDT. There was no significant difference between the group of patients with structured visual hallucinations and the two other groups, with regard to age (p =0.435), sex (p =0.406), or visual acuity (p =0.835). Conclusions: Visual hallucinations and CBS appear to be a possible, although unrecognised, side effect of PDT for CNV, which occur just after treatment. These results suggest the need to include the possibility of visual hallucinations in the information given to patients before PDT.

Photodynamic therapy for juxtafoveal choroidal neovascularization in myopic eyes

PURPOSE To report the results of photodynamic therapy in myopic patients with juxtafoveal choroidal neovascularization (CNV). DESIGN Interventional case series. METHODS Three consecutive myopic patients with juxtafoveal CNV were treated by photodynamic therapy with the same protocol as the one used to treat subfoveal CNV. Visual acuity was measured on Early Treatment Diabetic Retinopathy Study (ETDRS) charts by an independent observer. Fluorescein angiography was performed 6 and 12 weeks after photodynamic therapy and then every 12 weeks. RESULTS In all three patients, one treatment of photodynamic therapy using verteporfin resulted in the involution of the CNV and improvement in best-corrected visual acuity from 20/50 or 20/40 to 20/25 or more. No retreatment was required during follow-up, which lasted for 12 to 24 months (mean = 17 months). CONCLUSION Photodynamic therapy may be an effective treatment for juxtafoveal CNV in myopic eyes.

Flat Irregular Retinal Pigment Epithelium Detachments in Chronic Central Serous Chorioretinopathy and Choroidal Neovascularization

PURPOSE To evaluate the incidence of flat, irregular pigment epithelium detachments (PEDs) in chronic central serous chorioretinopathy (CSC) and to determine whether they are consistent with active choroidal neovascularization (CNV). DESIGN Retrospective case series. METHODS Review of medical records of patients with chronic CSC who were examined in the Ophthalmology Department of Lariboisière Hospital between June 1, 2007 and May 31, 2013. Multimodal imaging of the fundus, including optical coherence tomography (OCT), fundus autofluorescence, and indocyanine green and fluorescein angiography, was available in most cases. RESULTS One hundred and ten patients with chronic CSC were identified. Fifty-three eyes of 38 patients showed flat irregular PED on macular OCT examination. Mean age was 58.6 ± 13.2 years. Twenty-eight patients (73.6%) patients were male. Fifteen patients (39.4%) had bilateral flat irregular PEDs. The mean follow-up duration was 14.6 years (range: 2-39 years). PEDs were suggestive of type 1 CNV in 10 eyes, but no other signs of AMD, specifically no drusen, were present. In the remaining 43 eyes, flat irregular PEDs were stable over time (mean follow-up duration: 15 years) with no evidence of active neovascularization. CONCLUSION Although the possible occurrence of type 1 CNV complicating the course of chronic CSC should not be ignored, all cases of flat irregular PED should not be mistaken for active CNV and systematically treated with anti-VEGF. Nevertheless, in some cases with worsened vision not responding to usual CSC therapy, anti-VEGF could be considered as a therapeutic test to rule out the presence of secondary CNV.

Visual hallucinations immediately after macular photocoagulation

PURPOSE To evaluate the incidence of visual hallucinations after macular photocoagulation for choroidal neovascularization. METHODS After macular photocoagulation for choroidal neovascularization, 60 consecutive patients were asked to respond to an orally administered questionnaire. RESULTS Twenty-seven patients (45%) described photopsias, flashing lights of various colors. Ten additional patients (16.6%) also described structured hallucinations, including known or unknown faces, flowers, and geometric patterns, which occurred hours or a few days after photocoagulation. Patients with structured hallucinations were older (P =.04) and more often had subfoveal choroidal neovascularization (P =.005) and severe macular disease in both eyes or at least in the treated eye (P =.01). CONCLUSIONS Visual hallucinations appear to be a frequent, albeit unrecognized, side effect of macular photocoagulation of choroidal neovascularization. The provision of proper information to patients may avoid concern about a psychiatric origin of their hallucinations.