Gaurav K. Shah

Intravitreal triamcinolone as primary treatment of cystoid macular edema secondary to branch retinal vein occlusion.

Purpose: To describe six patients treated with intravitreal triamcinolone (IVT) as primary therapy for cystoid macular edema (CME) secondary to branch retinal vein occlusion (BRVO). Methods: Retrospective case series. Results: The age of the patients ranged from 53 years to 87 years (mean, 66 years). The time between BRVO and treatment with IVT ranged from 2.0 months to 4.7 months (mean, 3.5 months). Pretreatment visual acuity ranged from 20/40 to 6/200 (mean, 20/166). Length of follow-up ranged from 107 days to 175 days (mean, 149.5 days). Final visual acuity ranged from 20/40 to 3/200 (mean, 20/137). Three of six eyes showed improvement in vision. All three patients who did not have vision improvement were treated with a second injection. At the final follow-up visit, all six eyes had improved vision from baseline. Five (83.3%) of six eyes showed an improvement of ≥2 lines of vision. One patient had a postoperative rise in intraocular pressure requiring a trabeculectomy. Final visual acuity in the 6 eyes ranged from 20/200 to 20/30 (mean, 20/106). Conclusion: IVT may be of potential use in treating CME due to BRVO, as either a primary or an adjunctive treatment modality. A prospective, randomized trial to clarify this role is warranted.

Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma

OBJECTIVE To show the utility of ultrasound biomicroscopy (UBM) in imaging small ocular foreign bodies of the anterior segment. DESIGN Retrospective case series. PARTICIPANTS Twelve eyes of 12 consecutive patients evaluated in the emergency department or referred to specialty services at 1 institution between August 1994 and November 1997 were examined. INTERVENTION Ocular ultrasound biomicroscopy was performed. MAIN OUTCOME MEASURES Detection and localization of an ocular foreign body were measured. RESULTS An intraocular or superficial foreign body was detected by UBM in 9 (75%) of 12 eyes. The foreign body was classified as corneal in two eyes, subconjunctival in two, intrascleral in three, and intraocular in two eyes. The foreign body was not visible by ophthalmic physical examination in seven of the nine eyes with a confirmed ocular foreign body. In the remaining two eyes, UBM was used to determine the depth of a visible foreign body. In three of the eyes with a confirmed foreign body, computed tomography and/or contact B-scan ultrasonography was obtained and failed to show a foreign body. Six of the foreign bodies were nonmetallic. CONCLUSIONS Clinical detection of ocular foreign bodies after trauma can be hindered by small size, haziness of the optical media, poor patient cooperation, or hidden location. Ultrasound biomicroscopy is a valuable adjunct in the evaluation of suspected ocular foreign bodies, especially in cases involving small, nonmetallic objects.

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.

The cost-effectiveness of early vitrectomy for the treatment of vitreous hemorrhage in diabetic retinopathy.

Diabetic vitrectomy has been found to be efficacious for the treatment of vitreous hemorrhage secondary to diabetic retinopathy. The purpose of this study is to determine the cost-effectiveness of early vitrectomy for the management of vitreous hemorrhage secondary to diabetic retinopathy. The analysis was performed from the perspective of a third-party insurer. A cost-utility Markov model was used to determine the cost per quality-adjusted life year (QALY) gained from early versus deferral of vitrectomy. The model used 2-, 3-, and 4-year results from the Diabetic Retinopathy Vitrectomy Study, patient-based utilities, life expectancy data, and incremental medical costs. Early vitrectomy was the dominant strategy and was associated with a gain of 0.41 QALYs over the 57-year expected life span for a hypothetical patient. The cost per additional QALY gained from early vitrectomy treatment was

OUTCOMES OF MACULAR HOLE SURGERY AND SHORTENED FACE DOWN POSITIONING

1910 (US

Photodynamic therapy with verteporfin for peripapillary choroidal neovascularization.

discounted at 3%). When sensitivity analyses were performed by varying efficacy probabilities and utilities across their 95% confidence intervals, early treatment was always the dominant strategy. Additionally, even at the extreme sensitivity values, the cost per QALY of early vitrectomy treatment remained under

Verteporfin combination regimens in the treatment of neovascular age-related macular degeneration.

10,000. Overall, early vitrectomy for the treatment of vitreous hemorrhage secondary to diabetic retinopathy is highly cost-effective.

Intravitreal Bevacizumab for the Treatment of Refractory Diabetic Macular Edema

Purpose: Internal limiting membrane (ILM) peeling in macular hole surgery may allow a shortened period of face down positioning. This study reports the results of macular hole surgery combined with shortened (3-day) face down positioning. Methods: The study was a retrospective review of data for 21 patients (21 eyes) treated for a macular hole by a single surgeon (G.K.S.). All patients underwent standard 3-port pars plana vitrectomy with triamcinolone-assisted ILM peeling and gas tamponade with 16% C3F8 or 25% SF6. Patients were instructed to remain in a face down position for 3 days at least 8 hours a day and to avoid flat on back positioning. Results: The main outcome of anatomical closure was achieved in 20 (95%) of 21 eyes. Snellen visual acuity improved >2 lines in 76% (16/21) of patients. No patient lost >1 line of Snellen visual acuity. Two patients had postoperative increased (>24 mmHg) intraocular pressure that was successfully treated with pressure-lowering drops. Initial surgery failed to achieve hole closure in one patient, but with a second surgery and similar face down positioning, the hole was closed. Conclusions: This study found that macular hole surgery with ILM peeling and a shortened period of face down positioning achieves excellent anatomical closure and is not associated with significant adverse outcomes.

Branch retinal vein obstruction secondary to retinal arteriovenous communication

Purpose: To evaluate the efficacy of photodynamic therapy with verteporfin in the management of symptomatic extrafoveal peripapillary choroidal neovascularization (CNV). Methods: Seven eyes of seven patients with symptomatic peripapillary CNV underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography to evaluate the results of photodynamic therapy with verteporfin. Patients were offered treatment following the development of hemorrhage, subretinal fluid, or lipid if it was associated with visual symptoms. A standard nomogram was used to dose Visudyne, application was performed in three separate 30-second zones confluent over the extent of the lesion. The light dose per unit area applied to the retina was approximately 18 J/cm2. Results: Five of the seven had CNV limited to the peripapillary area associated with age-related macular degeneration; the remaining two eyes had presumed ocular histoplasmosis syndrome. In five of the seven eyes, two treatments were needed and in two eyes only one treatment was necessary to elicit resolution of active leakage. Retreatment was performed at an average of 76 days after initial treatment. Baseline best-corrected visual acuity (BCVA) ranged from 20/20 to 20/150. Final BCVA ranged from 20/20 to 20/80. In all eyes except for one, which had a pretreatment vision of 20/20, at least two lines of Snellen visual acuity improvement were achieved. Resolution of submacular fluid, hemorrhage, or exudates was noted in six eyes; in the remaining eye there was persistence of subretinal lipid. There were no complications including optic neuropathy in any of the treated eyes. Follow-up ranged from 6 to 13.5 months following last treatment (mean, 10 months). Conclusion: Photodynamic therapy with verteporfin for extrafoveal symptomatic peripapillary CNV appears to be effective in improving vision and promoting the resolution of subfoveal exudates, hemorrhage, or fluid. A randomized controlled study with longer follow-up is justified.

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

Background: Neovascular age-related macular degeneration is characterized by choroidal neovascularization that has a complex pathogenesis. Combining agents that have different mechanisms of action (i.e., verteporfin photodynamic therapy, antivascular endothelial growth factor, and/or anti-inflammatory therapies) could maximize clinical benefits through potential complementary effects. This review discusses findings from studies investigating this hypothesis. Methods: Articles were retrieved from PubMed using relevant search terms. Abstracts from recent scientific meetings and details of ongoing trials from clinicaltrials.gov were also included. Results: Following its approval, verteporfin was important in the management of choroidal neovascularization due to age-related macular degeneration for several years. Improved visual outcomes have now been reported with antiangiogenic agents (e.g., intravitreal ranibizumab), especially when frequently administered. Results from investigator-sponsored trials, retrospective case studies and Registries, which have provided insights into the latest findings from clinical practice in the “real-world” setting, as well as randomized controlled trials, suggest that a combination approach is generally well tolerated and may maintain improvements in visual and anatomic outcomes with fewer retreatments. Conclusion: A rationale exists for investigating combination approaches to target different processes in choroidal neovascularization pathogenesis, which may optimize treatment benefits in neovascular age-related macular degeneration. Encouraging data suggest that combination strategies are not associated with major adverse events.