M. Sartore

Combination of Photodynamic Therapy and Intraocular Triamcinolone for Exudative Age-Related Macular Degeneration and Long-Term Chorioretinal Macular Atrophy

OBJECTIVE To evaluate the long-term effect of intravitreal triamcinolone acetonide (IVT) treatment combined with photodynamic therapy (PDT) vs PDT alone for neovascular age-related macular degeneration. METHODS Prospective randomized study. Eighty-four patients were enrolled to receive PDT (n = 41) or IVT treatment followed by PDT (n = 43) within approximately a 7- to 15-day interval. All patients were naive to treatment. At baseline and each follow-up visit at 3, 6, 12, and 24 months, measurement of best-corrected visual acuity (VA), fluorescein angiography, indocyanine green angiography, and optical coherence tomography were performed. Mean changes in VA and retreatment rate were considered as primary outcome indicators. Analysis of vascular choroidal changes documented by indocyanine green angiography and fundus autofluorescence measurements were also performed. RESULTS Mean VA increased at 1 month of follow-up but decreased progressively by the 24-month point in both groups (P = .74). The retreatment rate was significantly lower (P < .001) in the combined therapy group. Choroidal hypoperfusion/nonperfusion (P < .001) and areas with decreased/absent fundus autofluorescence within the PDT spot area were significantly greater with combined therapy (P < .001). CONCLUSIONS Combination IVT treatment with PDT seemed to be more effective for managing neovascular age-related macular degeneration, but long-term analysis failed to demonstrate functional benefits.

Quality of vision: A consensus building initiative for a new ophthalmologic concept

Purpose Many studies have addressed the quantification of visual acuity, and the conventional method of measuring it has so far demonstrated serious limitations. Vision testing requires new methods that can more precisely express the quality of vision as perceived by the patient. Methods This study employed the Delphi method of consensus building. Concepts associated with quality of vision (QoV) were identified by a board of experts and proposed to participating specialists in two subsequent questionnaires. Upon receipt of the completed questionnaires, the replies were classified to determine the building blocks of a consensus. Results By analyzing the replies to the two questionnaires, the authors determined the key elements of QoV on which a consensus was found among the respondents. Conclusions A consensus was reached on the opinion that the quantification of visual acuity by traditional means is inadequate for investigating QoV. Although visual acuity is still a basic element for testing, the experts believe that contrast sensitivity, reading speed, and microperimetry are additional parameters necessary for quantifying QoV. The use of a psychometric questionnaire on visual function could allow a better interpretation of visual impairment.

Quality of Vision Index: a new method to appraise visual function changes in age-related macular degeneration.

Purpose TO explore the correlation between psychophysical measures of visual function and vision-related quality of life (QOL) in exudative age-related macular degeneration (AMD) and to obtain a new quality of vision index expressed as corrected visual acuity (cVA) that is scaled like visual acuity (VA), but that incorporates the weighted contribution of VA, contrast sensitivity (CS), and reading ability. Methods Visual acuity, CS, and reading ability were measured in 293 patients with AMD in this multicenter prospective study. Vision-related QOL was quantified by the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). The validity of the questionnaire was assessed using Rasch analysis. The relationship between psychophysical tests and NEI-VFQ-25 scores was investigated. A cVA index was developed integrating Rasch-scaled NEI-VFQ-25 score with VA, CS, and reading ability as a tool to be used for evaluating vision-related QOL on the same scale as VA. Results A total of 27.5% of the variability of VFQ score was found to be explained by VA alone in patients with AMD. The proportion of Rasch-scaled QOL estimate variance explained by cVA was 33.2% as compared to 27.5% explained by VA and 24.5% by CS, which was a statistically significant improvement in both cases (p=0.015 and p<0.001, respectively). The correlation of reading ability with vision-related QOL was largely mediated by VA and CS and therefore it was not retained in the vision index. Conclusions Visual acuity is poorly correlated with vision-related QOL in patients with AMD. Even though the new cVA index is a new method which better correlates with vision-related QOL, the major components of the individual perception of vision remain unexplained by common psycho-metric tests.

Is there any relationship between photodynamic therapy for exudative age-related macular degeneration and choroidal neovascolarization recurrence? A rationale for combined treatments.

Purpose Photodynamic therapy (PDT) is the treatment of choice for subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). Interpretation of PDT mechanism of action is not yet fully understood and causes of CNV recurrences are unclear. The authors have conducted a retrospective analysis of fluorescein and indocyanine green angiographies in patients treated with multiple PDT in order to identify risk factors for recurrence. Methods A total of 342 eyes of 342 patients (207 women and 135 men) with ARMD and subfoveal CNV were treated with at least two PDT. Angiographic (fluorescein and indocyanine green) features of recurrences were confronted to pretreatment examinations in all patients. RESULTS. Post-PDT angiographies showed in all eyes a dark circle corresponding to the laser spot even 1 year after treatment. Persistence or progressive regrowth of CNV developed in an area adjacent or corresponding to the original lesion, without any specific relationship with the location of fluorescein and indocyanine green late leakage or with presence of abnormal fluorescence due to pigment abnormalities. At the 3-month angiographic follow-up, 23 patients (6.7%) showed a recurrent CNV resembling shape and dimension of the laser spot used for the PDT treatment. Conclusions The authors failed to identify angiographic signs helpful to predict the risk of CNV persistence or recurrence. PDT leaves minor but persistent changes in the choroidal vasculature within the treatment area. In some cases, the recurrent CNV seems to be related to the laser spot of the PDT.

New Insights Into the Development and Progression of Geographic Atrophy After Full Thickness Autologous Choroidal Graft

Purpose To investigate if the contiguity between native and transplanted retinal pigment epithelium (RPE) represents a protective factor against the progression of atrophy after autologous choroidal graft. In addition, the changes in fundus autofluorescence (FAF) in the contiguous and noncontiguous RPE areas were explored. Methods The first postoperative reliable FAF image was selected and divided into sectors based on the characteristics of the RPE at the edge of the graft. The sectors were categorized into three groups: contiguous RPE, noncontiguous RPE, and not classifiable. The area of RPE atrophy, inside and outside the graft, was measured for each sector at baseline, one, three, and five years of follow-up. The FAF pattern outside the graft was evaluated for every sector at baseline and during the follow-up. Results Nineteen patients met the inclusion criteria and were included in this study. Trend analysis showed that the atrophy progression outside the graft was statistically significant in areas where native and transplanted RPE were noncontiguous (P < 0.0001) yet not so in contiguous areas (P < 0.058). Inside the graft, both groups showed an increase in atrophy over time. In addition, the noncontiguous group developed more severe increased FAF patterns compared with the contiguous group. Conclusions RPE contiguity after autologous choroidal graft seems to be a protective factor against atrophy progression, whereas any area of damaged or absent RPE tends to enlarge over time. This may suggest that the transplantation of an RPE sheet is more likely to be effective than an RPE cell suspension.