Hae Min Kang

Long-term Visual Outcome and Prognostic Factors After Intravitreal Ranibizumab Injections for Polypoidal Choroidal Vasculopathy

PURPOSE To evaluate long-term visual outcome and investigate the prognostic factors after anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV). DESIGN Retrospective study. METHODS Analyses were done among 36 eyes (36 patients) with naïve PCV that were treated with intravitreal ranibizumab injections and completed at least 3-year follow-up. All clinical data, including baseline characteristics; imaging data from fluorescein angiography, indocyanine green angiography, and optical coherence tomography; presence of recurrence; and best-corrected visual acuity (BCVA) were investigated. RESULTS During mean follow-up of 42.58 ± 12.59 months, mean numbers of anti-VEGF injection were 11.45 ± 7.81. Twenty-four eyes (66.7%) showed at least 1 recurrence during follow-up. Mean baseline BCVA was 0.68 ± 0.43 logMAR (20/95 Snellen equivalent), and 0.78 ± 0.53 logMAR (20/120 Snellen equivalent) at 36 months (P = .307). Mean BCVA was significantly improved at 1 month (P = .018), and improvement was maintained until 12 months (P = .044), then deteriorated. Among baseline characteristics, greatest lesion diameter (B = 0.219, P = .001) and pigment epithelial detachment (B = 0.362, P = .025) were significantly correlated with long-term visual outcome. Recurrence during follow-up (B = 0.371, P = .024) was also significantly correlated with long-term visual outcome. CONCLUSION Significant visual improvement by anti-VEGF therapy was maintained during the first year of initial treatment; however, vision then deteriorated during long-term follow-up. Smaller lesion size, absence of pigment epithelial detachment at baseline, and no recurrence during follow-up were significantly correlated with better long-term visual outcome.

New insights into the pathoanatomy of diabetic macular edema: angiographic patterns and optical coherence tomography.

Purpose: To describe the pathoanatomy of diabetic macular edema in optical coherence tomography and its correlation with fluorescein angiography patterns. Methods: Sixty eyes of 56 patients were analyzed. Diabetic macular edema was classified into typical focal leakage (from microaneurysm), typical diffuse leakage (the capillary plexus), or combined/questionable leakage using fluorescein angiography and retinal thickness profiles. The leakage and pooling patterns in fluorescein angiography were matched to the corresponding optical coherence tomography images and analyzed. Results: Focal leakage shows swelling predominantly in the outer plexiform layer (OPL). Deeply located microaneurysms directly leak into the loose fiber portion of OPL (Henle layer) through the “fluid conductivity barrier” (synaptic portion of OPL). Diffuse leakage caused swelling predominantly in the inner nuclear layer and secondarily in the OPL. The deep capillary plexus is located between the two “fluid barriers” (inner plexiform layer and OPL); thus, diffuse leakage is primarily related with swelling in the inner nuclear layer. In the combined/questionable leakage, partial sections consisting of inner nuclear layer swelling and much larger areas of OPL/outer nuclear layer swelling are noticed. Conclusion: Based on the concept of the fluid conductivity barrier, we revealed a correlation between the intraretinal location of the leakage source and where the fluid accumulated within the retinal layers.

Clinical and spectral-domain optical coherence tomography findings in patients with focal choroidal excavation.

OBJECTIVE To describe the clinical and spectral-domain optical coherence tomography (SD-OCT) findings in patients with focal choroidal excavation (FCE). DESIGN Retrospective case series. PARTICIPANTS Forty-one eyes of 38 patients with FCE identified in 2 tertiary medical centers in Korea. METHODS Clinical features, SD-OCT findings, and associated macular disorders of FCE were analyzed and detailed. MAIN OUTCOME MEASURES Statistical associations among clinical features, including lesion type, size, and choroidal thickness, and frequency of association with central serous chorioretinopathy (CSC), choroidal neovascularization (CNV), and polypoidal choroidal vasculopathy (PCV). RESULTS Mean patient age was 50.1 years (range, 25-76 years). The mean spherical equivalent of refractive error was -3.7 diopters (range, -10.0 to +1.5 diopters). Three patients (8%) had bilateral lesions, and 1 patient (3%) had 2 distinct lesions in the same eye. The mean FCE width and depth were 757 μm and 107 μm, respectively, with a positive correlation between width and depth (P = 0.003). The mean subfoveal choroidal thickness of FCE eyes was 284 μm, which was not statistically different from that of age-, sex-, and refractive error-matched normal subjects. Choroidal thickness in FCE was less in eyes with hyperreflective choroidal tissue under the excavation that was present in 22 eyes (54%) versus eyes without excavation (128 vs. 190 μm, respectively; P = 0.009). Twelve FCEs (29%) were the nonconforming type, revealing separation between the photoreceptor tips and the retinal pigment epithelium on SD-OCT. Nonconforming FCE was associated with visual symptoms (P < 0.001) and the presence of concurrent CSC (P = 0.001). Ten eyes (24%) were associated with CSC, and 9 eyes (22%) were associated with CNV, including 1 eye with PCV features. One eye with FCE and type 1 CNV developed a new excavation, and the excavated area in 1 eye with PCV enlarged slightly during follow-up. CONCLUSIONS Focal choroidal excavation is a relatively common entity and frequently associated with choroidal diseases, including CSC, CNV, and PCV. Although FCE is classically thought to be a congenital malformation, acquired FCE forms possibly exist.

Five-Year Follow-up Results of Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

PURPOSE To evaluate the 5-year efficacy of photodynamic therapy (PDT) in patients with polypoidal choroidal vasculopathy (PCV). DESIGN Retrospective study. METHODS Forty-two eyes of 36 patients with PCV followed up for at least 60 months after PDT were reviewed. All eyes were primarily treated with PDT. Main outcome measure was best-corrected visual acuity (BCVA; logMAR [logarithm of minimal angle of resolution]) at baseline and at each follow-up visit. We also classified the eyes into 3 groups: improved (improvement ≥0.3 logMAR), decreased (deterioration ≥0.3 logMAR), and stable. RESULTS During the mean follow-up duration, 73.64 ± 13.47 months, the mean number of PDT was 2.21 ± 1.62 treatments. Recurrence was noted in 33 eyes (78.6%) during follow-up. The mean baseline BCVA was 0.78 ± 0.48 logMAR (20/120 Snellen equivalent), and the final BCVA at 60 months was 0.67 ± 0.52 logMAR (20/93 Snellen equivalent) (P = .050, paired t test). On the final evaluation at 60 months, the mean BCVA was improved in 14 eyes (33.3%), stable in 23 eyes (54.8%), and decreased in 5 eyes (11.9%). CONCLUSION At 60 months after initial PDT, 88.1% of PCV patients showed stable or improved BCVA after PDT. Despite a high recurrence rate, PDT remained effective for 5 years, and represents a good therapeutic approach to PCV.

Combined Photodynamic Therapy With Intravitreal Bevacizumab Injections for Polypoidal Choroidal Vasculopathy: Long-term Visual Outcome

PURPOSE To evaluate the long-term visual outcome after combination therapy of photodynamic therapy (PDT) with intravitreal bevacizumab injections for polypoidal choroidal vasculopathy (PCV). DESIGN Retrospective observational study. METHODS The medical records of 34 eyes (34 patients) with naïve PCV who were treated with combination therapy were analyzed. All patients completed at least 3 years of follow-up. All clinical data, including age, best-corrected visual acuity (BCVA, logarithm of the minimal angle of resolution [logMAR]), imaging data of fluorescein angiography, indocyanine green angiography, and optical coherence tomography, were investigated. RESULTS During a mean follow-up period of 46.8 ± 5.2 months, a mean of 1.4 ± 0.71 times of PDT and 9.2 ± 6.6 intravitreal bevacizumab injections were performed. During follow-up, 21 eyes (61.8%) showed at least 1 recurrence. Mean BCVA was 0.59 ± 0.35 logMAR (20/77 Snellen equivalent) at baseline and 0.39 ± 0.34 logMAR (20/49 Snellen equivalent) at 3 years (P = .004). At 3 years, 14 patients (41.2%) gained 0.3 logMAR or more BCVA and 4 patients (11.8%) lost 0.3 logMAR or more BCVA than baseline. Baseline polyp size (β = .551; P = .005) and location of polyps (β = -.400; P =.033) were significantly correlated with long-term visual outcome after combination therapy for PCV. CONCLUSIONS Combination therapy of PDT with intravitreal bevacizumab injections showed favorable visual outcomes, and significant visual improvement was maintained in PCV patients. A total of 88.2% of patients avoided visual loss at 3 years after treatments. Largest polyp size at baseline and location of polypoidal lesions were prognostic factors for long-term visual outcomes in these patients.

Ocular risk factors for recurrence of myopic choroidal neovascularization: long-term follow-up study.

Purpose: To investigate factors associated with long-term recurrence of myopic choroidal neovascularization (CNV) after treatment with photodynamic therapy (PDT) and/or intravitreal antivascular endothelial growth factor injections. Methods: Seventy-six eyes with myopic CNV completed at least a 48-month follow-up after treatments. The baseline characteristics of the eyes were compared, including age, gender, refractive errors, axial lengths, location of CNV, lacquer cracks, chorioretinal atrophy, dark rim, great linear dimension, and prior PDT. Results: During mean follow-up of 71.21 ± 26.43 months, 35 eyes (46.1%) experienced at least 1 recurrence. Mean interval between initial treatment and first recurrence was 24.15 ± 18.10 months. Presence of lacquer crack (P = 0.022, &khgr;2 test), absence of dark rim (P = 0.031, &khgr;2 test), and prior PDT (P = 0.041, &khgr;2 test) were significantly different between the eyes with and without recurrence. Among baseline characteristics, presence of lacquer crack (&bgr; = 1.272, P = 0.012) prior PDT (&bgr; = 1.607, P = 0.027), and absence of dark rim (&bgr; = −0.758, P = 0.020) were significantly associated with the recurrence of myopic CNV after treatment by multiple logistic regression. Conclusion: Long-term follow-up revealed recurrence of myopic CNV in 46.1% of the patients after treatment. Presence of lacquer cracks, prior PDT, and absence of dark rim were risk factors for recurrence of myopic CNV.

A retained lens fragment induced anterior uveitis and corneal edema 15 years after cataract surgery.

A 60-year-old male was referred to the ophthalmologic clinic with aggravated anterior uveitis and corneal edema despite the use of topical and systemic steroids. He had undergone cataract surgery in both eyes 15 years previous. Slit lamp examinations revealed a retained lens fragment in the inferior angle of the anterior chamber, with severe corneal edema and mild anterior uveitis. The corneal edema and uveitis subsided following surgical extraction of the lens fragment. That a retained lens fragment caused symptomatic anterior uveitis with corneal edema 15 years after an uneventful cataract surgery is unique. A retained lens fragment should be considered as one of the causes of anterior uveitis in a pseudophakic patient.

Association of Spectral-Domain Optical Coherence Tomography Findings with Visual Outcome of Macula-Off Rhegmatogenous Retinal Detachment Surgery.

Purpose: To identify prognostic factors for the visual outcome for patients with macula-off rhegmatogenous retinal detachment (RRD). Methods: The medical records of 27 patients (27 eyes) with macula-off RRD were retrospectively investigated. In addition to clinical characteristics, spectral-domain optical coherence tomography (SD OCT) images were analyzed. Results: The central foveal thickness at baseline was 923 ± 499.5 µm, and the mean height of the subretinal fluid was 697.8 ± 463.6 µm. Dropout of backreflection at the fovea was detected on preoperative SD OCT in 8 patients (29.6%). The external limiting membrane was disrupted in 5 patients (18.5%) as was the photoreceptor integrity in 9 patients (33.3%) at 12 months. On multiple regression analysis, backreflection integrity was the only predictive factor for postoperative visual outcome (B = 0.179, p = 0.020). Conclusions: Backreflection integrity on preoperative SD OCT seems to be helpful in predicting the postoperative visual outcome in macula-off RRD patients.

Two-Year Outcome after Combination Therapy for Polypoidal Choroidal Vasculopathy: Comparison with Photodynamic Monotherapy and Anti-Vascular Endothelial Growth Factor Monotherapy

Purpose: To compare treatment outcomes of photodynamic therapy (PDT), anti-vascular endothelial growth factor (VEGF) therapy and PDT combined with anti-VEGF therapy for polypoidal choroidal vasculopathy (PCV). Procedures: A total of 62 eyes of 62 patients who had completed at least 2 years of follow-up were retrospectively reviewed; 19 eyes received PDT only, 23 had anti-VEGF therapy only and 20 underwent combination therapy. Best-corrected visual acuity at baseline and each follow-up visit was investigated as a primary outcome measure. Results: At year 2, the PDT and combination groups maintained significant visual improvement (p = 0.041 and p = 0.021), whereas the anti-VEGF group failed to do so (p = 0.673) when compared with the baseline. The combination group showed better visual outcome during follow-up, and significantly better visual outcome than the PDT group (p = 0.038) and the anti-VEGF group (p = 0.012) at year 2. Conclusions: Combination therapy leads to significantly better visual outcome than PDT and anti-VEGF monotherapy and is therefore a superior method for treating PCV, with a favorable visual outcome.

Thinner subfoveal choroidal thickness in eyes with ocular ischemic syndrome than in unaffected contralateral eyes

Dear Editor: Ocular ischemic syndrome (OIS) is caused by ocular hypoperfusion caused by stenosis/occlusion of the common/ internal carotid arteries [1, 2]. Generally, a 90 % carotid stenosis reduces the ipsilateral central retinal artery perfusion pressure by approximately 50 % [1, 3–5]. In eyes affected by OIS, patchy or delayed choroidal filling can be demonstrated in 60% of the patients, which is the most specific angiographic sign [1]. Recently, we conducted a retrospective review of the medical records of three patients who were diagnosed with unilateral ocular ischemic syndrome (OIS). In addition to baseline characteristics, subfoveal choroidal thickness at the time of diagnosis was measured using enhanced depth imaging optical coherence tomography (EDI OCT) images by spectral-domain OCT (Spectralis; Heidelberg Engineering, Heidelberg, Germany). Upon analysis, affected eyes with OIS showed thinner subfoveal choroidal thickness than unaffected contralateral eyes in both horizontal and vertical EDI OCT images (Table 1). A representative case is shown in Fig. 1. To our knowledge, subfoveal choroidal thickness has not been fully investigated in patients with OIS. We have demonstrated that subfoveal choroid thinning represents impaired choroidal circulation in patients with OIS, and recommend further prospective studies with larger study populations to elucidate this finding and its clinical application inOIS patients.