Jorge Arruga

A study comparing two protocols of treatment with intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration

Aims: The aim of this study was to compare two treatment options for choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD): (1) bevacizumab administered once a month for 3 months and thereafter as needed (loading dose (LD)); and (2) bevacizumab administered as needed, after the first injection (pro re nata (as needed) (PRN)). Methods: Fifty consecutive patients were enrolled in this prospective study. The first 25 patients were included in the LD group and the last 25 patients in the PRN group. In both groups, the need for re-treatment was based on the presence of persistent or recurrent macular oedema, subretinal fluid or pigment epithelial detachment on optical coherence tomography scans. Results: At the 6-month follow-up, mean visual acuity improved by 13.7 letters (p<0.001) in the LD group and 4.6 in the PRN group (p<0.001). Thirty-six per cent of patients in the LD group compared with 12% in the PRN group gained 15 or more letters (p = 0.04). Mean foveal thickness decreased by 91.3 µm (p<0.001) in the LD group and 48.2 µm in the PRN group (p<0.001). No ocular or systemic side effects were observed. Conclusion: Patients with CNV secondary to AMD treated with a LD protocol had better results than patients treated with a PRN protocol with intravitreal bevacizumab.

Preoperative study of the inner segment/outer segment junction of photoreceptors by spectral-domain optical coherence tomography as a prognostic factor in patients with epiretinal membranes

Objective To demonstrate whether the preoperative integrity of the inner segment/outer segment (IS/OS) junction of photoreceptors studied by spectral-domain optical coherence tomography (SD-OCT) is a prognostic factor in epiretinal membrane surgery. Methods We retrospectively studied patients with an idiopathic epiretinal membrane who underwent a 23-gauge vitrectomy to remove this membrane. Best-corrected visual acuity (BCVA) and SD-OCT scans were examined before and 6 months after the surgery. We studied the retinal microstructure, especially the IS/OS junction of the photoreceptors, and evaluated the intergroup differences between patients with an intact layer and those with an irregular or disrupted layer. We applied both the Wilcoxon and Mann–Whitney tests for statistical analysis. Results In total, 51 eyes from 51 enrolled patients were examined in this study. The postoperative BCVA was significantly better for eyes that had an intact IS/OS junction than for eyes that had an irregular or disrupted IS/OS junction, as preoperatively observed with SD-OCT scans (P < 0.001). We also observed an important association between disrupted IS/OS junctions and the presence of cystic macular edema (P < 0.01). Conclusion The presence of an intact IS/OS junction on the preoperative SD-OCT scan was an important predictor of better visual recovery after epiretinal membrane surgery.

Retinal pigment epithelial tears after intravitreal bevacizumab injection for predominantly classic choroidal neovascularization.

Purpose To detect retinal pigment epithelium (RPE) tears in predominantly classic choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) treated with intravitreal bevacizumab injections. Methods Forty consecutive patients with predominantly classic CNV secondary to AMD were treated with 1.25 mg of intravitreal bevacizumab. Patients were evaluated with visual acuity (VA) measured with Early Treatment Diabetic Retinopathy Study charts, optical coherence tomography, and fluorescein angiography. Results Three patients developed a RPE tear after the first injection. The first patient had been treated with verteporfin therapy and VA remained unchanged. In the other two cases the CNV was naïve and VA improved since the foveal center was not involved by the tear and macular edema was reduced. Conclusions RPE tears can occur following intravitreal bevacizumab injections in patients with predominantly classic CNV although VA is not always affected.

En face mode of swept-source optical coherence tomography in circumscribed choroidal haemangioma

Purpose To describe the findings in circumscribed choroidal haemangioma (CCH) using en face swept-source optical coherence tomography (SS-OCT). Methods En face images were obtained employing DRI-1 Atlantis OCT (Topcon, Tokyo, Japan), using a three-dimensional volumetric scan of 12×9 mm. Images were obtained from the retinal pigment epithelium to 1000 μm in depth of the tumour. Results Twenty-two eyes from 22 patients with the clinical diagnosis of CCH were included. In 20 eyes (90.9%), a characteristic pattern was visualised in the en face image across the vascular tumour. A multilobular pattern, similar to a honeycomb, with hyporeflective, confluent, oval or round areas corresponding with the lumen of the tumour vascular spaces, and hyper-reflective zones, which may represent the vessels walls and connective tissue of the tumour. Ten eyes (45.4%) showed a hyper-reflective halo surrounding the tumour. Seventeen tumours (77.2%) showed small diameter vessels at the inner zone and larger vessels in the outer area. Twelve patients (54.5%) had previously received treatment (photodynamic therapy, transpupillary thermotherapy, dexamethasone intravitreal implant or brachytherapy with ruthenium-106). No differences were found between treated and untreated patients in any of the measured parameters. Conclusions En face SS-OCT is a rapid, non-invasive, high-resolution, technology, which allows a complementary study to cross-sectional scans in CCH. A characteristic multilobular pattern, with a hyper-reflective halo surrounding the tumour, was found in en face SS-OCT images. No morphological differences were found between naïve patients and patients who received previous treatment.

INTRAVITREAL DEXAMETHASONE IMPLANT FOR RADIATION MACULOPATHY SECONDARY TO PLAQUE BRACHYTHERAPY IN CHOROIDAL MELANOMA.

Purpose: To evaluate the efficacy of intravitreal dexamethasone implant 0.7 mg (Ozurdex) in radiation maculopathy secondary to plaque brachytherapy in choroidal melanoma. Methods: Twelve eyes diagnosed of radiation maculopathy secondary to plaque brachytherapy and treated with intravitreal dexamethasone implant were included. Visual acuity, foveal thickness using spectral domain optical coherence tomography, and grade of macular edema, using Horgan classification, were evaluated. Results: Mean age was 65.5 ± 28 years (range, 40–82 years). Mean follow-up was 8.2 ± 7.8 months (range, 2–28 months). Mean visual acuity before treatment was, in logarithm of the minimum angle of resolution scale, 1 ± 0.58 (range, 0.4–2) and mean final visual acuity 0.8 ± 0.58 (range, 0.2–2), showing a nonsignificant trend to improvement (P = 0.091; Wilcoxons test). Foveal thickness before treatment was 416 ± 263 &mgr;m (range, 222–725 &mgr;m) and final foveal thickness 254 ± 170 &mgr;m (range, 145–750), showing a significant decrease (P = 0.016; Wilcoxons test). Referring to Horgan classification, a significant reduction in grades before and after treatment was demonstrated (P = 0.007; Wilcoxons test). Conclusion: Ozurdex is a useful treatment for radiation maculopathy associated to plaque brachytherapy for uveal melanoma, with a significant decrease in foveal thickness and a significant improvement in Horgan classification. This anatomical improvement was correlated with a moderate improvement in visual acuity.

Intravitreal Ranibizumab for Choroidal Neovascularization Secondary to Pathological Myopia: 12-Month Follow-Up

Purpose: To evaluate the efficacy and safety of intravitreal ranibizumab in the treatment of choroidal neovascularization (CNV) due to pathological myopia (PM). Methods: This retrospective case series studied outcomes in patients with CNV secondary to PM who were treated with intravitreal ranibizumab. Patients underwent complete ophthalmic evaluation, which included best-corrected visual acuity testing measured with Early Treatment Diabetic Retinopathy Study charts, optical coherence tomography (OCT) and baseline fluorescein angiography (FA). Indications for retreatment included the persistence of subretinal fluid on OCT as well as hemorrhages and new CNV on FA. Patients were followed for a minimum of 12 months. Results: We treated 29 eyes in 29 patients; the mean age was 56.8 years. Thirteen eyes were naïve, while 16 had been previously treated with photodynamic therapy or intravitreal bevacizumab. The mean initial visual acuity was 44.8 letters; at the 12-month follow-up, it was 53.7 letters. The mean OCT foveal thickness decreased by 35.3 µm. Patients received an average of 1.38 injections. Statistically significant differences were observed both in visual acuity and in central foveal thickness. All subgroups had favorable outcomes. None of the patients developed injection-induced complications or drug-related side effects. Conclusion: Intravitreal injection of ranibizumab appears to be safe and efficacious in patients with CNV secondary to PM followed over a 12-month period.

Unilateral Decompression Retinopathy After Laser Iridotomy in a Patient with Bilateral Acute Angle-Closure Glaucoma

Acute angle closure glaucoma is an ocular pathology characterized by a severe increase of intraocular pressure (IOP) that requires the realization of a peripheral Nd:YAG laser iridotomy as a treatment. Several complications have been described after a peripheral laser iridotomy such as hyphema, endothelial corneal damage, intraocular pressure spikes or cataract. Furthermore, retinal and subhyaloid haemorraghes have been observed after the treatment. This uncommon finding has been named decompression retinopathy. The case of an unilateral decompression retinopathy in a 67-year-old woman after the resolution of a bilateral episode of acute angle closure glaucoma was presented.

Relative survival of patients with uveal melanoma managed in a single center.

To assess the 5-year relative survival of patients diagnosed with uveal melanoma (UM) in a single center. UM patients were recruited from 1995 to 2004 (N=155) and were followed until December 2008. Relative survival (RS) methods were used to assess excess mortality. An RS regression model was fitted by sex, age, tumor origin, treatment, and tumor size to estimate the excess hazard rate (EHR) of death from UM. The overall 5-year RS was 90%, lower in women (84.6%) than in men (100%), lower in patients older than 60 years (88.8%) compared with those younger than or of 60 years of age (94.8%). Large tumors (80.8%) showed lower RS than medium (95.1%) and small ones (98.3%). Enucleated patients (80.5%) had lower RS compared with those who received brachytherapy (93.6%) and other treatments (94.7%). A significant EHR was found for women (EHR: 3.65), patients older than 60 years (EHR: 2.25), large-sized melanoma (EHR: 2.45), and during the third (EHR: 5.37) and fourth year (EHR: 3.01) of follow-up. This is the first Spanish study in a single center reporting RS among UM patients, taking into account clinical characteristics. Prognostic factors that explained RS among UM patients were sex, age, tumor size, and the year of follow-up. We also found a peak of excess mortality from the third until the fourth year after diagnosis, which warrants strict follow-up of these patients during this time interval.

Sequential bilateral retinal artery occlusion

An 86 year old woman experienced a sequential bilateral loss of vision over a period of less than 24 hours. Clinical findings and complementary studies suggested a bilateral atherogenic embolic event. Initially, she presented a superior branch retinal artery occlusion in her right eye followed by a central retinal artery occlusion with cilioretinal artery sparing in her left eye. Some conservative maneuvers performed did not improve visual acuity in the left eye. Supra-aortic Doppler ultrasonography revealed mild right internal carotid artery stenosis and moderate left internal carotid artery stenosis with a small, smooth, and homogeneous plaque. The transthoracic echocardiography showed a severe calcification of the mitral valve with a mild-moderate rim of stenosis. Central retinal artery occlusion and branch retinal artery occlusion are characterized by painless monocular loss of vision. Clinical approach and management attempt to treat the acute event, find the source of the vascular occlusion, and prevent further vascular events from occurring. Giant cell arteritis is a potentially treatable cause of central retinal artery occlusion and should be excluded in every single patient over 50 years old.

Noonan syndrome with bilateral acute angle‐closure

about 40% of the patients with mild or moderate NTG. Furthermore, the most vulnerable area in the macular map was the arcuate area in the temporal and inferior region (Fig. 2). These findings for regional distribution and abnormal grid point frequency in the mGCL + IPL are consistent with previous reports on vulnerable areas of the mRNFL in OAG patients, as well as with HFA findings on macular visual field damage in NTG. Thinning of the mGCL + IPL represents in situ damage caused by glaucoma, and thickness measurements are highly consistent with the results of visual field testing. We thus believe that this new information on mGCL + IPL regional damage should improve comparative investigations of visual field damage. Our finding that the distal area of the inferior arcuate region had a higher vulnerability to macular damage may be explained by the susceptibility to peripheral lesions of the lamina cribrosa. In conclusion, we found regional vulnerabilities to glaucomatous damage in OCT macular maps of NTG patients. This information may help improve the management of NTG, the major type of glaucoma in Asia.