Luis Arias

Intravitreal bevacizumab (Avastin) for choroidal neovascularisation secondary to pathological myopia: 6-month results

Background: To determine the efficacy and safety of intravitreal Avastin (bevacizumab) in the treatment of choroidal neovascularisation (CNV) secondary to pathological myopia (PM). Methods: This paper reports on a consecutive prospective study of patients with CNV secondary to PM who were treated with intravitreal bevacizumab (1.25 mg/0.05 ml). 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 fluorescein angiography. Results: There were 17 eyes of 17 patients, and the mean age was 55.4 (SD 10.0) years. At the 6-month follow-up, the mean visual acuity improved by 8.4 letters (p = 0.04). Forty-one per cent of patients increased at least one line, and 17% increased more than six lines. There were no cases of moderate vision loss (⩾3 lines) or severe vision loss (⩾6 lines). The mean OCT foveal thickness decreased by 79.6 μm (p = 0.002). Favourable outcomes were obtained in all subgroups. Patients received an average of one injection. As a complication, there was a tear of the retinal pigment epithelium. No other ocular or systemic side effects were observed. Conclusion: In our study, intravitreal bevacizumab appeared to be safe and efficacious in eyes with CNV secondary to PM.

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.

Photodynamic therapy for chronic central serous chorioretinopathy.

Purpose:  This study aimed to evaluate the efficacy of photodynamic therapy (PDT) in treating chronic central serous chorioretinopathy (CSC).

Intravitreal anti-VEGF therapy for choroidal neovascularisation secondary to pathological myopia: 4-year outcome

Objective To report the visual outcome after 4-year follow-up in a series of highly myopic eyes with choroidal neovascularisation (CNV) treated with antivascular endothelial growth factor (anti-VEGF) drugs. Methods A retrospective, non-randomised, multicentre, consecutive, interventional case series study was performed. 92 highly myopic eyes with subfoveal CNV were treated with intravitreal injection (IVI) of anti-VEGF. The initial protocol (1 vs 3 injections) was dictated by surgeons’ preferences and followed by an as-needed monthly regime. Best-corrected visual acuity (BCVA) was evaluated at baseline and then monthly. The primary aim was to analyse BCVA changes. The effect of age, spherical equivalent (SE) and treating drug were evaluated as secondary objectives. Results The mean age of the patients was 57 years (SD 14, range 30–93). The mean number of letters read was 46.1 (SD 16.8, range 5–70) at baseline, 55.5 (SD 18.6, range 10–85) at 12 months, 50.1 (SD 20.1, range 5–82) at 24 months, 54.2 (SD 21.9, range 2–85) at 36 months and 53.1 (SD 22.5, range 1–83) at 48 months (p=0.000, initial vs 12, 24 and 36 months; p=0.01 initial vs 48 months; Student t test for paired data). The mean total number of IVI was 4.9 (SD 5.4, range 1–29). SE and treating drug had no influence on the final visual outcome and number of injections required. Conclusions Intravitreal bevacizumab and ranibizumab are effective therapies and show similar clinical effects in highly myopic CNV. Visual acuity gain is maintained at 4-year follow-up.

Twelve-month outcome after one intravitreal injection of bevacizumab to treat myopic choroidal neovascularization.

Purpose: To report the changes during a 1-year follow-up in visual acuity and macular thickness in a series of highly myopic eyes with choroidal neovascularization treated with bevacizumab. Methods: Retrospective and multicenter study including 107 highly myopic eyes from 107 patients (mean age, 55 years) with subfoveal or juxtafoveal choroidal neovascularization. All cases were treated by one intravitreous injection of 1.25 mg bevacizumab. Best-corrected visual acuity and macular thickness with the optical coherence tomography were evaluated at baseline and then monthly during 1 year. Results: Logarithm of the minimum angle of resolution best-corrected visual acuity at baseline averaged 0.72 (standard deviation [SD], 0.43) versus 0.53 (SD, 0.41) at 1 year after treatment (P < 0.001). Logarithm of the minimum angle of resolution best-corrected visual acuity was 0.30 or better in 49 of 107 eyes (45%) at 1 year. Thirty-three eyes (30%) gained at least 3 Early Treatment Diabetic Retinopathy Study lines (15 letters) during the follow-up. In 43 eyes (40%), reinjections were necessary because signs of choroidal neovascularization activity were still evident. The mean number of reinjections was 0.8 (SD, 1.3). Best-corrected visual acuity improvement was better in the younger group (younger than 50 years). No adverse reactions were reported. Conclusion: One intravitreal bevacizumab injection seems to be an effective therapeutic approach to treat choroidal neovascularization in highly myopic eyes. Careful monitoring is necessary to assess the need for reinjections.

Intravitreal infliximab in patients with macular degeneration who are nonresponders to antivascular endothelial growth factor therapy.

Purpose: The purpose of this study was to determine the efficacy and safety of intravitreal infliximab in the treatment of choroidal neovascularization secondary to age-related macular degeneration in patients who are nonresponders to antivascular endothelial growth factor therapy. Methods: Prospective, noncomparative, interventional case series. The primary inclusion criteria for patients consisted of previous treatment with five or more intravitreal injections of bevacizumab and/or ranibizumab, visual loss, angiographic leakage, and intraretinal and/or subretinal fluid on spectral domain optical coherence tomography. At Day 0, a single intravitreal injection of infliximab (2 mg/0.05 mL) was administered. Best-corrected visual acuity testing measured with Early Treatment Diabetic Retinopathy Study charts and spectral domain optical coherence tomography scans were performed on Days 0, 3, 7, 30, 60, and 90. Fluorescein angiography was performed at days 0 and 90. The development of systemic antibodies against infliximab (human antichimeric antibodies) was not sought. Main outcome measures were changes in best-corrected visual acuity, foveal thickness, and lesion size. Results: We included four patients. At Day 90, the best-corrected visual acuity change was −18, +3, +4, and −4 letters, respectively. Intraretinal and/or subretinal fluid on spectral domain optical coherence tomography scans was not significantly reduced in any case. Lesion size was not reduced in any case. Two patients developed intraocular inflammation with high intraocular pressure 3 and 5 weeks after the infliximab injection, respectively. One case was controlled with topical medication, and one case required posterior vitrectomy. Conclusion: Intravitreal infliximab showed no significant visual or anatomical benefit for the treatment of choroidal neovascularization secondary to age-related macular degeneration in patients who were nonresponders to antivascular endothelial growth factor therapy. In addition, half of the cases developed intraocular inflammation.

Update on geographic atrophy in age-related macular degeneration.

Age-related macular degeneration (AMD) is the main cause of legal blindness in older patients in developed countries, and geographic atrophy (GA) represents the advanced form of dry AMD. Although it accounts for one third of the cases of late AMD and is responsible for 20% of the cases of severe visual loss due to the disorder. GA currently lacks effective treatment, whereas antiangiogenic therapies have been shown to be successful in managing choroidal neovascularization, the other form of late AMD. Recent advances in GA epidemiology, etiology, genetics, and imaging techniques have renewed the interest in this entity, which is a cause of progressive visual loss even in treated patients with neovascular AMD. This knowledge has triggered many clinical trials targeting different molecules shown to be associated with the disease, and it is hoped that this research will translate into effective drugs for GA in the near future.

Transconjunctival sutureless vitrectomy with tissue plasminogen activator, gas and intravitreal bevacizumab in the management of predominantly hemorrhagic age-related macular degeneration

Purpose: To determine the efficacy and safety of treating predominantly hemorrhagic age-related macular degeneration (AMD) with transconjunctival sutureless vitrectomy (TSV), tissue plasminogen activator (tPA), sulphur hexafluoride (SF6), and intravitreal bevacizumab. Methods: Retrospective study, consecutive case series. Patients with acute hemorrhagic AMD treated with 25- or 23-gauge TSV, subretinal or intravitreal tPA, fluid-air-SF6 exchange and intravitreal injection of bevacizumab. All operations were performed within the first 5 days after the start of symptoms, which consisted of visual acuity (VA) loss and central scotoma. Results: Fifteen eyes from 15 patients were included. The patients’ mean age was 79.6 years, and the mean follow-up was 11.8 months. Five patients (33%) were receiving oral anticoagulant treatment. At baseline, the mean VA (logMAR values) was 1.5 (20/640 Snellen equivalent). At the last follow-up visit, the mean VA was 1.1 (20/250) (P < 0.0001; paired t-test). The submacular hemorrhage was successfully displaced in all the cases. Complications consisted of three cases of vitreous hemorrhage and a tear or the retinal pigment epithelium. Twelve cases (80%) did not require further treatment during the follow-up period. Conclusion: A surgical approach with 25- or 23-gauge TSV, tPA, SF6 and intravitreal bevacizumab is an efficacious and safe procedure in patients with hemorrhagic AMD. Early treatment is advisable for obtaining the optimal outcome.

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.