Maribel Fernández

Intravitreal Triamcinolone for the Treatment of Diabetic Macular Edema

Diabetic macular edema is one of the leading causes of visual loss in first world countries and the first cause in diabetic retinopathy. The Early Treatment Diabetic Retinopathy Study showed a significant benefit in using focal laser photocoagulation for the treatment of macular edema, more specifically defined as clinically significant macular edema. Nevertheless, progressive visual loss is found in the 26% of patients with diabetic macular edema treated with photocoagulation. The failure of laser treatment and the destructive nature of the therapy has forced researchers to pursue new alternatives including vitrectomy with or without internal limiting membrane peels, the use of proteinkinase C inhibitors, intravitreal injections of antibodies that inhibit the vascular endothelial growth factor, somatostatin analog, or the intravitreal injection with corticosteroids. Triamcinolone acetonide is glucocoticosteroid with antiangiogenic and antiedematous properties. Publications evaluating the safety and efficacy of intravitreal injection of triamcinolone in the treatment of diabetic macular edema show varying outcomes with respect to the increases of visual acuity and decreases in foveal thickness. Despite this, intravitreal triamcinolone is a treatment that has evolved quickly and is considered increasingly useful.

Successful treatment of retinal angiomatous proliferation by photodynamic therapy.

Purpose. The purpose of this study is to describe a patient with retinal angiomatous proliferation (RAP) treated successfully by photodynamic therapy. Methods. A 74-year-old white woman was referred to our clinic for evaluation as a result of progressive decrease of vision in the right eye. Visual acuity was 20/100 in the affected right eye. The findings of fluorescein and indocyanine green angiography were consistent with a diagnosis of RAP, and cystoid macular edema was also revealed by optical coherence tomography (OCT). Photodynamic therapy (PDT) was carried out because of visual deterioration and localization of the RAP. Results. The RAP was treated with PDT, and an improvement in visual acuity to 20/60 was noted 4 months after treatment and 20/40 after 6 months. The resolution of the lesion was confirmed by fluorescein angiography, indocyanine green angiography, and OCT. Conclusions. Photodynamic therapy can be effective for the treatment of RAP when it is associated with visual acuity decrease and is located near the fovea.

Intravitreal Triamcinolone in Diabetic Retinopathy

Diabetic macular edema is an important cause of visual loss in the developed world and may frequently lead to irreversible changes in visual acuity. The Early Treatment Diabetic Retinopathy Study showed a significant benefit in using focal laser photocoagulation for the treatment of macular edema, more specifically defined as clinically significant macular edema. However, some cases of diabetic macular edema are refractory to laser therapy and do not have a good prognosis with such treatment. Triamcinolone acetonide is glucocoticosteroid with antiangiogenic and antiedematous properties. Recently, some promising results, respect to the increases of visual acuity and decreases in foveal thickness, have been shown in different studies for the treatment of refractory diabetic macular edema with intravitreal triamcinolone acetonide.

A 1-year retrospective review of ranibizumab for naive nonsubfoveal choroidal neovascularization secondary to age-related macular degeneration.

Purpose: To assess efficacy and safety in the treatment of nonsubfoveal choroidal neovascularization secondary to age-related macular degeneration with intravitreal ranibizumab. Methods: Retrospective, multicentric, noncomparative, interventional case series. We included patients with naïve extrafoveal and juxtafoveal choroidal neovascularization treated with intravitreal ranibizumab and a follow-up of 1 year. Patients were evaluated using visual acuity testing with Snellen charts, fluorescein angiography, and optical coherence tomography scans. Results: There were 15 patients with a mean age of 72.4 years (SD, 7.2). There were 11 juxtafoveal lesions (73.3%) and 4 extrafoveal lesions (26.6%). Eight lesions were predominantly classic (53.3%), 6 lesions were occult (40%), and 1 lesion was minimally classic (6.6%). The mean visual acuity improved from 20/60 (mean logarithm of the minimum angle of resolution = 0.47) at baseline to 20/40 (mean logarithm of the minimum angle of resolution = 0.34) at the 1-year follow-up visit (P = 0.03). The mean foveal thickness improved from 312 &mgr;m to 262 &mgr;m (P = 0.01), and the mean lesion size (disk areas) improved from 1.9 to 1.1 (P = 0.01). No cases progressed to a subfoveal location. The mean number of injections was 3.8. As complications, we had an endophthalmitis and a macular hole. Conclusion: In our study, intravitreal ranibizumab showed efficacy for the treatment of nonsubfoveal choroidal neovascularization secondary to age-related macular degeneration mainly in terms of preventing subfoveal progression.

Dye-guided retinal laser and internal drainage for optic pit maculopathy

Dear Editor, Optic disc pit (ODP) is considered to be a small colobomatous defect of the optic nerve head, and may be associated with a serous macular detachment. It has been proposed that the defect of the optic disc allows the accumulation of intraretinal fluid coming from the vitreous cavity, constituting a retinoschisis-like separation. Subsequently, there is a passage of the fluid into the subretinal space creating a serous detachment of the macula [3]. Long-term visual prognosis of ODP is poor when serous macular detachment persists [5]. We report a new surgical technique for the treatment of ODP maculopathy. A 14-year-old girl was referred because of decreased visual acuity (VA) in OS (left eye) detected on a routine examination. Her right eye VA was 20/20 and 20/63 in OS. Left eye funduscopy and optical coherence tomography revealed the presence of an ODP and a retinoschisis-like area extending from the disc to the macular area, combined with serous detachment of the macula. After obtaining an informed consent, the patient underwent surgical treatment. Left eye surgery consisted in 25-gauge pars plana vitrectomy, induction of posterior vitreous detachment, and diode endolaser barrier around the temporal edge of the disc as described before [2]. Sulfur hexafluoride was left as endotamponade. After 6 months, VA in OS remained 20/63, with persistent retinoschisis and macular detachment. A reoperation with internal limiting membrane (ILM) peeling was advised. During re-intervention, ILM was stained with brilliant blue under air. We observed that part of the dye pooled in the submacular space, revealing a channel-like connection between the macula and the ODP at the superotemporal margin of the disc. Diode endolaser was selectively applied at this site. After ILM peel and during fluid–air exchange, the tinted fluid was aspirated by placing a silicone-tipped cannula at the ODP. Finally, sulfur hexafluoride was used as endotamponade. Once the gas reabsorbed, we could observe the absence of submacular fluid, and 6 weeks after surgery there was a complete reabsorption of the intraretinal fluid. After 1 year, VA of OS was 20/32. Different surgical treatments have been described for ODP maculopathy, but there is not enough evidence to recommend any specific option for primary treatment or persistence of the macular detachment after an initial intervention. In this case, failure of the first surgery could be in part because of the difficulty of obtaining an effective retinopexy with the endolaser administered under fluid, because of the absence of contact between the retina the retinal pigment epithelium. Within the re-intervention, the use of the dye clearly showed a connection between the ODP and the macular area, despite the previous laser given. We believe that using a dye such as brilliant blue could serve not only to peel the ILM and reduce any tractional component [1], but also to produce a selective laser barrier just at the site of the fluid passage. This will avoid the need The authors declare that there are no competing/conflicts of interest related to any topic of this letter. J. Marticorena (*) : F. Gómez-Ulla :M. Fernández Instituto Tecnológico de Oftalmología, Hospital Nuestra Señora de la Esperanza, Av de las Burgas 2, Santiago de Compostela 15705, Spain e-mail: jmarticorena@gmail.com

Verteporfin Photodynamic Therapy Combined with Intravitreal Ranibizumab for Polypoidal Choroidal Vasculopathy Controversy Concerning Long-Term Followup

Purpose. To show the long-term results of intravitreal ranibizumab combined with photodynamic therapy (PDT) for the treatment of polypoidal choroidal vasculopathy (PCV). Methods. We analyzed the progress of two patients for 36 and 58 months, respectively. We only used PDT for the treatment in the area of the active PCV or “hot spot” evident on the indocyanine green angiography (ICGA). The spot size was chosen so as to cover only the active neovascular lesion. We combined intravitreal ranibizumab with PDT when PCV remained active without visible polyps in ICGA or without a response to PDT. Conclusion. Administration, as required, of verteporfin photodynamic therapy combined with intravitreal ranibizumab is an effective treatment for symptomatic polypoidal choroidal vasculopathy. These data need to be confirmed in large, prospective, and controlled clinical trials which are randomized and carried out over a long period.

Intravitreal injections of anti-VEGF agents and antibiotic prophylaxis for endophthalmitis: A systematic review and meta-analysis

We performed a systematic review and meta-analysis to determine whether the use of local antibiotics is a beneficial prophylactic treatment for endophthalmitis in patients treated with anti-VEGF agents. We searched the MEDLINE and EMBASE databases, and the Cochrane Library over the period January 2007 to December 2016. The search terms used included “Endophthalmitis”, “Antibiotic” and “Intravitreal injection”. Studies in which the patients were treated exclusively with intravitreal injections of anti-VEGF were selected. Eight studies fit the inclusion criteria, which included a total of 276,774 injections; 109,178 (39.45%) were associated with the use of antibiotics and 114,821 (60.55%) were not associated with the use of antibiotics. Our meta-analysis indicated a significant risk for endophthalmitis that was 1.70 times greater with the use of antibiotics than that without antibiotics, with a confidence interval of 1.08 to 2.66 (p = 0.02). A meta-regression indicated that the location (operating rooms versus outpatient clinics) of injection did not have a significant effect on the incidence of endophthalmitis. The prophylactic use of antibiotics when administering anti-VEGF intravitreal injections may contribute to a greater incidence of endophthalmitis. This finding, in addition to reducing costs, would eliminate a treatment that has been shown to be unnecessary and even harmful to patients.