Irmela Mantel

Incidence of presumed endophthalmitis after intravitreal injection performed in the operating room: a retrospective multicenter study.

Purpose: To evaluate the incidence of presumed endophthalmitis (EO) after intravitreal injection (IVI) of anti–vascular endothelial growth factor agents performed in the operating room. Methods: Retrospective study at 2 Swiss eye hospitals between 2004 and 2012. Hospital records were used to identify patients treated with an IVI of an anti–vascular endothelial growth factor agent between 2004 and 2012 and those treated for EO, defined as any intraocular inflammation treated with intravitreal antibiotics. All IVIs were performed using standard sterile technique in a Swiss Class 1 operating room. No patient received preinjection topical antibiotics. Postinjection topical antibiotics were used only in one hospital. Results: A total of 40,011 IVIs were performed at the 2 centers during the study period. Of the IVIs, ranibizumab was injected in 36,398 (91%), bevacizumab in 3,518 (9%), aflibercept in 89 (0.2%), and pegaptanib in 6 (<0.1%). Three cases of post-IVI presumed EO occurred, yielding a combined incidence of 0.0075% per injection (95% confidence interval: 0.0026–0.0220%) or 1 case per 13,337 IVIs. Two of the three cases of EO occurred in patients using post-IVI antibiotics. All three cases followed ranibizumab injection and were culture negative by anterior chamber tap or vitreous biopsy. Conclusion: The risk of EO after IVI performed under the sterile conditions of the operating room was very low.

Genotype-phenotype correlation of age-related macular degeneration: influence of complement factor H polymorphism

Background/aims: Complement factor H (CFH) Y402H polymorphism shows a strong association with age-related macular degeneration (AMD). Although the phenotypic concordance of AMD has been shown in sibling/twin studies, little is known about the genotype–phenotype association. In this study, we investigated whether CFH Y402H is associated with early phenotypic features. Methods: Statistical analysis was performed on 420 patients with AMD with complete clinical and genetic data (graded colour fundus photographs, according to the International Classification and Grading System for AMD and successful testing for CFH Y402H). Results: In this Swiss population, an OR of 2.95 was confirmed for AMD in the presence of at least one risk C allele and OR of 9.05 for the CC homozygotes, corrected for age and sex. No difference was found between the AMD stages. Patients homozygous for the risk allele showed significant association with peripheral drusen (p = 0.028) and for central drusen location (p = 0.049). No trend was found for other drusen criteria (size, total surface, location nasal to disc) and for pigmentary changes. Conclusions: The CFH Y402H polymorphism showed a genotype–phenotype association for some drusen features. Additional genetic factors are likely to influence drusen phenotype.

Factors Influencing the Treatment Response of Pigment Epithelium Detachment in Age-Related Macular Degeneration

PURPOSE To study the effect of various baseline factors, particularly the type of drug (ranibizumab vs aflibercept), on the functional and anatomic response of treatment-naïve pigment epithelial detachment (PED) associated with neovascular age-related macular degeneration (neovascular AMD), after 3 intravitreal injections. DESIGN Retrospective consecutive case series. METHODS This study included 102 patients (n = 115 eyes) with treatment-naïve neovascular AMD and PED (>150 μm), who were treated with either ranibizumab (n = 68 eyes) or aflibercept (n = 47 eyes). A multivariate analysis using stepwise linear regression was performed in order to assess factors influencing visual acuity improvement, as well as treatment response of PED height after 3 monthly injections. RESULTS Multivariate analysis revealed that better visual improvement was associated with lower best-corrected visual acuity (BCVA) at baseline (P = .001), presence of subretinal fluid (P = .001), and retinal angiomatous proliferation (P = .001); PED reduction was associated with higher PED at baseline (P = .001), predominantly serous PED (P = .003), and the use of aflibercept (P = .022). Drug type was not associated with change in BCVA at 3 months. CONCLUSION Eyes with neovascular AMD and PED showed significant functional and anatomic response after 3 monthly intravitreal anti-VEGF injections. The functional response depended on baseline BCVA, presence of subretinal fluid, and retinal angiomatous proliferation, while anatomic response was influenced by baseline PED height, degree of vascularization, and drug type. Drug type was not associated with change in BCVA, but had a weak effect on anatomic response.

Retinal pigment epithelium tears after intravitreal injection of ranibizumab for predominantly classic neovascular membranes secondary to age-related macular degeneration.

Acta Ophthalmol. 2010: 88: 736–741

Intravitreal ranibizumab in the treatment of choroidal neovascularization associated with idiopathic central serous chorioretinopathy

Purpose We evaluate the functional and anatomic outcome after intravitreal ranibizumab treatment in patients with choroidal neovascularization (CNV) related to chronic central serous chorioretinopathy (CSC). Methods This is a small case series of 5 eyes with CNV associated with chronic CSC treated with intravitreal injection of 0.5 mg ranibizumab in the Jules Gonin University Eye Hospital from July 2007 to July 2009. Baseline and monthly follow-up visits included best-corrected visual acuity (BCVA), fundus examination, and optical coherence tomography (OCT). Fluorescein and indocyanine green angiography (ICG) were performed at baseline and repeated at least every 6 months. Results We studied 5 eyes of 4 patients with a mean age of 66 years. Mean follow-up was 21 months (SD 1.9). The mean number of intravitreal injections administered for each patient was 10(SD4.6). The mean initial BCVA was 0.23 (decimal equivalent) (logMAR 0.64, SD 0.13). At the last follow-up, mean BCVA was 0.44 decimal equivalent (logMAR 0.36, SD 0.31). Mean central macular thickness (CMT) measured with OCT was 330 μm (SD 43) at baseline and decreased at the final follow-up to 243 μm (SD 44). Persistent intraretinal or subretinal fluid on OCT and/or multifocal areas of increased choroidal permeability on ICG angiographies were present in all patients at the last follow-up visit. Conclusions Intravitreal ranibizumab appeared to be an effective treatment of CNV related to chronic CSC. However, residual intraretinal or subretinal fluid and increased choroidal permeability persisted. Prospective controlled studies are warranted to evaluate the long-term safety and efficacy of intravitreal ranibizumab.

Early Clinical Experience with Ranibizumab for Occult and Minimally Classic Neovascular Membranes in Age-Related Macular Degeneration

Background: In large randomized multicenter trials, ranibizumab has shown its therapeutic efficacy for exudative age-related macular degeneration (AMD). The aim of this paper is to report the real-life clinical experience with this treatment for occult and minimally classic membranes without pigment epithelium detachment. Methods: We conducted a retrospective chart review of 37 patients with occult and minimally classic neovascular membranes in AMD, without pigment epithelium detachment. Results: The mean visual improvement of 2 lines at 3, 6 and 9 months corresponds well with the results of the large trials. A mean number of 5 reinjections was reached by month 8. It may potentially exceed the mean 5.5 injections of the PrONTO study (prospective optical coherence tomography imaging of patients with neovascular AMD treated with intraocular ranibizumab). At months 6–8 recurrence was frequently observed. Conclusion: The early experience of ranibizumab in clinical practice brings similarly good results as the large-scale trials. However, interrupting the treatment too early may be a disadvantage.

Peripheral Exudative Hemorrhagic Chorioretinopathy: A Clinical, Angiographic, and Histologic Study

PURPOSE To describe the clinical and angiographic characteristics of peripheral exudative hemorrhagic chorioretinopathy, an uncommon chorioretinal mass lesion, important for its differential diagnosis to choroidal melanoma, but only rarely described in the literature. DESIGN Retrospective, institutional chart review. METHODS Institutional chart review of 45 patients (56 eyes) diagnosed with peripheral exudative hemorrhagic chorioretinopathy to describe the clinical findings and those obtained by fluorescein angiography (FA) and indocyanine green angiography (ICGA), in addition to a review of the histologic findings of an enucleated eye. RESULTS Peripheral exudative hemorrhagic chorioretinopathy typically was characterized by increased age of the patient (mean, 77 years; range, 60 to 91 years), female preponderance (69%), frequent pigment epithelium detachment, temporal equatorial location, and a highly hemorrhagic and exudative presentation, sometimes extending to the macula. Bilateral involvement (24%) was associated with multiples lesions in the same eye (P < .001) and with nasal extension (P < .001). A neovascular origin was suspected on FA, but was more evident on ICGA. Histologic examination of the enucleated eye did not reveal a neovascular network. CONCLUSIONS Peripheral exudative hemorrhagic chorioretinopathy is a characteristic peripheral degenerative disorder, frequently with benign outcome, although it can be vision threatening because of hemorrhage or exudation. Clinical features are helpful for its diagnosis. FA and ICGA contribute valuable evidence to the hypothesis of a neovascular origin, but further histologic studies are needed to prove this hypothesis.

Resolution of foveal detachment in dome-shaped macula after treatment by spironolactone: report of two cases and mini-review of the literature.

Dome-shaped macula (DSM) was recently described in myopic patients as a convex protrusion of the macula within a posterior pole staphyloma. The pathogenesis of DSM and the development of associated serous foveal detachment (SFD) remain unclear. The obstruction of choroidal outflow and compressive changes of choroidal capillaries have been proposed as causative factors. In this paper, we report two cases of patients with chronic SFD associated with DSM treated with oral spironolactone. After treatment, there was a complete resolution of SFD in both patients. To the best of our knowledge, this is the first report of successful treatment of SFD in DSM by a mineralocorticoid receptor antagonist.

Intravitreal ranibizumab as primary treatment for neovascular membrane associated with idiopathic juxtafoveal retinal telangiectasia

Dear Editor, Proliferative idiopathic juxtafoveal retinal telangiectasia (PIJRT) is characterized by bilateral ectatic lesions of the perifoveal capillaries associated with subretinal neovascularization (SRNV) [1], and has a poor natural history. [2] It has been hypothesized that vascular endothelial growth factor-A (VEGF-A) might play an important role in the pathogenesis of PIJRT. [3] Ranibizumab (Lucentis®, Genentech, South San Francisco, CA, USA) neutralizes all active forms of VEGF-A, and has been found to be effective in the treatment of exudative age-related macular degeneration. However, as far as we are aware, this is the first case to report efficacy of ranibizumab as monotherapy in the treatment of PIJT. A 56-year-old woman was admitted to our hospital with progressive visual loss over 1 week in her right eye. Bestcorrected visual acuity (BCVA) at presentation was 0.2 (decimal equivalent). Fluorescein angiography (FFA) showed dilated, ectatic capillaries involving the temporal juxtafoveolar retina, with late exudation in both eyes and evidence of active SRNV in the right eye (Fig. 1). Optical coherence tomography (OCT) (Carl Zeiss Meditec, Inc.) of both eyes revealed increased thickness of the temporal parafoveal retina and foveal cystoid spaces. In the right eye, OCT revealed a hyper-reflective lesion at inner retinal layers on the temporal juxtafoveal retina corresponding to the SRNV (Fig. 2). Following informed written consent, ranibizumab (0.5 mg) was administered intravitreally. The patient was followed monthly with OCT and FFA. Reinjection criteria were evidence of SRNVactivity on FFA. One month after treatment, BCVA improved to 0.32 (decimal equivalent), and central macular thickness (CMT) on OCT decreased. Exudation from both the SRNV and the ectatic vessels was decreased but still persistent on FFA. Two more injections at monthly intervals were administered in order to obtain complete regression of the neovascular complex. At 4-month follow-up and after three injections at monthly intervals, FFA revealed no activity of the SRNV. BCVA improved to 0.5 (decimal equivalent). FFA showed regression of the neovascular complex with absence of exudation and, additionally, marked regression of the ectatic dilatation of the parafoveal vessels (Fig. 1). At 6-month follow-up, 2 months after the third injection, BCVA decreased to 0.4 (decimal equivalent). OCT demonstrated cystoid foveal cysts, and FFA showed leakage from the ectatic vessels but no signs of SRNV activity (Figs. 1 and 2). Patient was not re-treated, and BCVA, FFA and OCT findings remained stable until the last follow-up at 8 months. PIJT has been reported to have a poor natural history, with 80% of cases ending with a final visual acuity of 0.1 decimal equivalent or worse [2]. Several treatment modalities have been assessed [4, 5], with poor results in most of the cases. Recently, several studies have shown favorable functional and anatomic results using the off-label anti-VEGF–A drug bevacizumab in the treatment of PIJT [3, 6, 7]. In 2008, Rishi et al. reported a case of PIJT that underwent primary treatment with a combination of photodynamic therapy (PDT) and intravitreal ranibizumab that demonstrated functional improvement [8]. Graefes Arch Clin Exp Ophthalmol (2009) 247:1567–1569 DOI 10.1007/s00417-009-1117-3

Retinal angiomatous proliferation treated with a combination of intravitreal triamcinolone acetonide and photodynamic therapy with verteporfin

Purpose Retinal angiomatous proliferation (RAP) is a particularly aggressive form of exudative age-related macular degeneration. Response to laser photocoagulation or to photodynamic therapy (PDT) alone is often disappointing. The purpose of this study was to determine whether intravitreal triamcinolone acetonide (TA) injections followed by PDT in eyes with early stage RAP may be effective. Methods Prospective uncontrolled study, enrolling 11 patients (11 eyes) with stage 2 RAP, treated with intravitreal TA injection followed by PDT. Patients with large pigment epithelium detachment, RAP stage 3, or pre-existing glaucoma and known steroid responders were excluded. All patients underwent a complete ophthalmic examination including fluorescein and indocyanine green (ICG) angiography and optical coherence tomography (OCT-3) at baseline and at 1, 3, 6, and 12 months. Informed consent was obtained from all patients. Results Mean follow-up was 14.9 months (range 6–21 months). Mean age was 82 years. In four patients a small pigment epithelium detachment was found on tomography. Initial visual acuity (VA) ranged from 0.1 to 0.6 on the Snellen scale. After calculating the logarithmic values the authors found an initial mean VA of logMAR 0.61, which improved by 1.5, 0.9, and 0.9 log lines after 3, 6, and 12 months, respectively. Although the VA gain from baseline tended to decrease with time, only 2 patients (18%) had an actual loss of acuity (≥3 lines). Retreatment was required in 5 eyes. Conclusions In this prospective pilot study examining the use of intravitreal TA followed by PDT with verteporfin in eyes with stage 2 RAP, without a large pigment epithelium detachment, the authors found a potential benefit in terms of stabilization or even improvement of vision.