Octavio Pujol

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.

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.

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.

Impact of lesion size on photodynamic therapy with verteporfin of predominantly classic lesions in age related macular degeneration.

Aim: To determine if photodynamic therapy (PDT) outcomes are related to lesion size in patients with subfoveal predominantly classic choroidal neovascularisation (CNV) secondary to age related macular degeneration (AMD). Methods: According to greatest linear dimension (GLD) of the entire lesion determined with fluorescein angiography (FA) patients were divided into two groups. In the first group GLD was <3000 μm and in the second one GLD was 3000–5000 μm. All eyes were treated with standard PDT with the verteporfin protocol. The primary outcome was the proportion of eyes in both groups that did not show significant leakage in FA at the end of follow up. Secondary outcomes were changes in GLD and in best corrected visual acuity (BCVA). Results: 64 patients (mean (SD) age, 76.7 (7.7) years; range 58–95 years) were recruited to participate in the study. All participants in the study completed the follow up time (mean 16.6 months). 24 patients (75%) in the group of smaller lesions (n = 32) compared with 15 patients (46.8%) in the group of larger lesions (n = 32) did not show significant leakage in FA at the end of follow up (p = 0.02). A GLD increase >1000 μm was recorded in nine eyes (28.1%) in the group of smaller lesions and in 16 eyes (50%) in the group of larger lesions (p = 0.07). 22 eyes (68.7%) in the group of smaller lesions compared with 19 eyes (59.3%) in the group of larger lesions lost less than three lines of vision (p = 0.06). Relevant side effects related to verteporfin therapy were not recorded, except for four patients (6.2%) with infusion related back pain. Conclusions: These results suggest that lesion size at baseline may be a prognosis factor in PDT in patients with subfoveal predominantly classic CNV secondary to AMD. There are no relevant side effects or safety concerns derived from verteporfin therapy.

One-year results of a flexible regimen with ranibizumab therapy in macular degeneration: relationship with the number of injections.

Purpose: To evaluate the efficacy and safety of a flexible regimen with intravitreal injections of ranibizumab in patients with naive choroidal neovascularization secondary to age-related macular degeneration and to determine whether the final outcome is related to the number of injections. Methods: Prospective, noncomparative, consecutive case series study. We included 90 eyes of 88 patients that were initially treated with 3 consecutive monthly intravitreal injections of ranibizumab, and thereafter, follow-up visits were progressively spread out to a maximum of 8 weeks apart in the absence of visual acuity loss and signs of lesion activity. The primary end points were changes in visual acuity (Early Treatment Diabetic Retinopathy Study letters), foveal thickness measured by spectral-domain optical coherence tomography, and lesion size (LS) measured by fluorescein angiography. Results: The median visual acuity improved from 53 letters at baseline to 60 letters at Month 1 (P < 0.0001), 63 letters at Month 3 (P < 0.0001), and 60 letters at Month 12 (P < 0.0001). A significant reduction was also observed in foveal thickness and LS (P < 0.0001). The mean number of injections was 4.4, and the mean number of visits was 8.0. Treatment consisted of 3 injections for 40% of patients, and 60% of patients received more than 3 injections. No significant association was observed between the visual acuity improvement and the number of injections. No relevant side effects were observed. Conclusion: A flexible regimen with ranibizumab therapy is efficacious and safe in patients with neovascular age-related macular degeneration, reducing both the burden of injections and follow-up visits. The visual acuity improvement was independent of the number of injections.

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.