Silvia Peter

Ocular photodynamic therapy--standard applications and new indications (part 1). Review of the literature and personal experience.

Ocular photodynamic therapy (PDT) was introduced as a novel treatment for neovascular forms of age-related macular degeneration and choroidal neovascularization (CNV) secondary to pathologic myopia in the mid/end 1990s. The current treatment recommendations are based on the results of two large, prospective, multicenter, randomized clinical trials (Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy Studies) and thousands of patients have been treated worldwide over the last years. Meanwhile, PDT has been performed in several other ocular pathologies with some remarkable results, however, with most reports being case reports and small case series without statistical significance. These extended applications include CNV secondary to choroiditis and retinochoroiditis, angioid streaks, central serous chorioretinopathy, retinal angiomatous proliferation, parafoveal telangiectasia or CNV associated with macular dystrophy and idiopathic CNV, as well as diseases without CNV, such as choroidal hemangioma, retinal hamartoma, choroidal melanoma, chronic central serous chorioretinopathy, angiomatous lesions secondary to systemic diseases, rubeosis iridis or neovascular glaucoma. To date, with the introduction of anti-VEGF therapy, the role of PDT will certainly change. However, it is reasonable to believe that it will maintain an important role in combination therapy due to its unique properties of selective vascular targeting. Therefore, it is essential for the ophthalmologist to be familiar with the extended applications and their modifications of treatment parameters. This review will summarize the standard and experimental applications of PDT based on our own results and the literature.

Ocular Photodynamic Therapy – Standard Applications and New Indications (Part 2)

Photodynamic therapy (PDT) has become a well-established treatment for vascular forms of age-related macular degeneration (AMD). The implementation of evidence-based medicine principles into the treatment regimen of AMD seems to be immensly important, since AMD continues to be the most frequent cause of blindness among patients older than 65 years in industrialized countries. Numerous randomized prospective studies demonstrated high levels of evidence for the efficacy of various treatment approaches such as laser photocoagulation, PDT, subretinal surgery or novel anti-angiogenic drugs [Arch Ophthalmol 2006;124:597–599]. The high evidence shown by these studies supported the rationale to use PDT also in additional, less frequent, vasoproliferative diseases. Although these ‘case series’ and ‘individual case control studies’ have a low level of evidence, they give us important information for treatment decisions in these rare conditions. The goal of this survey is to review the current literature regarding PDT in vasoproliferative and exudative ocular diseases outside AMD. Many studies modified the treatment parameters of PDT to address the specific pathology of the underlying disease. Table 1 summarizes the diseases and treatment parameters that are described in this part 2, the entire table of this review is included in part 1 (www.karger.com/doi/10.1159/ 000101922).

Autofluorescence and Angiographic Findings of Retinal Astrocytic Hamartomas in Tuberous Sclerosis

Objective: To describe fundus autofluorescence (AF), fluorescein angiography (FA) and indocyanine green angiography (ICGA) in different types of retinal astrocytic hamartomas in tuberous sclerosis (Morbus Bourneville-Pringle). Methods: Two eyes with 8 lesions, i.e. type 1 (n = 7) and type 3 (n = 1), were examined. AF pictures were taken prior to injection, FA and ICGA images were obtained in the early and the late phase. To achieve additional cases, a systematic literature review with exten- sive Internet and library search was performed. Results: Strong AF was seen in type 2 and type 3 retinal astrocytic hamartomas, whereas type 1 lesions blocked the physiologic fundus AF. Fluorescence angiography of all types of lesions revealed hypofluorescence in early frames and hyperfluorescence originating from leakage in late frames. ICGA showed a subtle blockade in type 1, a total blockade in type 2 and in the central part and a partial blockade in the peripheral part in type 3 lesions. Conclusions: Retinal astrocytic hamartomas in tuberous sclerosis can be easily detected by angiography, especially type 1 lesions which are difficult to visualize by funduscopy. Early- and late-phase fluorescein angiography and ICGA are helpful to differentiate the three lesion types.

Photodynamic therapy and indocyanine green guided feeder vessel photocoagulation of choroidal neovascularization secondary to choroid rupture after blunt trauma

Purpose: To describe photodynamic therapy (PDT) and additional indocyanine green (ICG) guided feeder vessel photocoagulation as a treatment of choroidal neovascularization (CNV) secondary to choroidal rupture in case of blunt head trauma. Design: Interventional case report. Methods: A 61-year-old woman developed subfoveal CNV originating from a choroid tear 8 years after blunt head trauma. Four sessions of PDT were applied and an additional two consecutive sessions of selective ICG-guided feeder vessel photocoagulation conducted. Results: Transient reduction of leakage and closure of feeder vessels could not prevent further growth of the CNV. Conclusions: PDT reduced leakage temporarily and additional ICG-guided feeder vessel photocoagulation closed treated feeder vessel and CNV. New feeder vessel formation and growth of CNV in case of traumatic choroid rupture could not be treated effectively by these two laser treatment modalities to prevent severe deterioration of visual acuity.

Skew deviation: a precursor to basilar artery thrombosis

The aim of this study was to describe skew deviation and vertical nystagmus as the initial signs for basilar artery thrombosis, a life‐threatening disease. A 51‐year‐old woman complained of vertical diplopia for more than 20 h. A computed tomography of the brain was normal, but subsequently the patient developed additional symptoms including nausea, ventilation problems (dyspnoea) and somnolence. Neuro‐ophthalmological evaluation revealed a skew deviation and a vertical nystagmus. Magnetic resonance imaging allowed the diagnosis of basilar artery occlusion. An emergency intervention with cerebral catheter angiography and local intra‐arterial thrombolysis was performed. Total recanalization of the basilar artery was achieved resulting in a complete neurological recovery, including the skew deviation and nystagmus. This rare case of skew deviation associated with basilar artery occlusion was a diagnostic challenge and highlights adequate differential diagnosis. Skew deviation is an important clinical sign. In this patient it was the key to a correct diagnosis enabling an immediate and successful intervention.

Current treatment indications and treatment options for retinal astrocytic hamartoma

Mit großem Interesse haben wir die Arbeit von Herrn Töteberg-Harms et al. gelesen [1]. In ihrem Artikel präsentieren die Autoren den Fall einer 44-jährigen Patientin, die sich aufgrund von Epiphora und rezidivierender Schwellung im Bereich des Tränensacks vorstellte. Als Zufallsbefund zeigte sich am linken Auge am nasal oberen Gefäßbogen ein leicht erhabener weißlich bis gelblicher Tumor mit einer maulbeerartigen Oberfläche, einem astrozytären Hamartom entsprechend. Die Autoren präsentieren eindrucksvolle Fundusaufnahmen sowie den Ultraschallbefund. Die Verlaufskontrolle betrug 4 Jahre und es konnte in diesem Zeitraum keine Veränderung des Tumors beobachtet werden. Da im Rahmen der neurologischen Untersuchung inklusive MRT kein Anhalt auf systemische Veränderungen aufgedeckt werden konnte, wurde die Diagnose solitäres retinales Astrozytom gestellt. Auf 3 Aussagen der Arbeit möchten wir speziell eingehen: Punkt 1

Accessory optical device for the Heidelberg retina angiograph ( HRA classic ) to perform angiography of the vitreous cavity and the anterior eye segment

The Heidelberg retina angiograph (HRA) classic enables fluorescein angiography (FA) and indocyanine green angiography (ICG-A) of the retina and choroid. The goal of this study was to design an accessory device to adapt the HRA classic for application on structures anterior to the retina. The optical device consisted of a cylindrical two-piece plastic frame holding a magnifying lens commonly used with the indirect ophthalmoscope. A 60-diopters lens was inserted in this frame to enable the angiography of the anterior segment. A less strong lens of 30 diopters was used for the visualization of pathologic findings in the vitreous cavity. We designed an easy-to-use and low-cost device to adapt the HRA classic for angiography of the fundus, vitreous cavity and anterior segment in the same session and without delay. FA and ICG-A images of two patients with rubeosis iridis and of one patient with choroidal melanoma are described.

Ocriplasmin treatment for vitreomacular traction in real life: can the indication spectrum be expanded?

Purpose To evaluate the efficacy of intravitreal ocriplasmin for the resolution of vitreomacular traction (VMT) with or without a full thickness macular hole (FTMH) in the clinical setting and to assess whether the indication spectrum of this treatment modality can be expanded beyond that of the MIVI-TRUST trials.

[Memantine for optic nerve atrophy in Friedreich's Ataxia].

A 24-year-old patient with Friedreichs ataxia presented with advanced visual loss due to optic nerve atrophy. After interdisciplinary consultation and after obtaining informed consent, an off-label therapy with the N-methyl-D-aspartate (NMDA) antagonist memantine was initiated. In a 1-year follow-up no further loss of the nerve fiber layer could be detected by optical coherence tomography (OCT) and visual acuity remained stable. Despite the limitations of this single and time limited case observational study, memantine should be discussed as an option for treatment of acute optic nerve atrophy in Friedreichs ataxia.ZusammenfassungEin 24-jähriger Patient mit Friedreich-Ataxie stellte sich mit fortgeschrittenem Sehverlust bei Optikusatrophie vor. In interdisziplinärer Absprache und nach informierter Einwilligung wurde eine Off-label-Therapie mit dem N-Methyl-D-Aspartat (NMDA)-Blocker Memantin begonnen. Im 1-jährigen Follow-up konnte mittels optischer Kohärenztomographie kein weiterer Verlust in der Nervenfaserschicht nachgewiesen werden und der Visus blieb stabil. Trotz der Einschränkungen dieser zeitlich limitierten Einzelfallbeobachtung sollte Memantin als Option für die Behandlung der Optikusatrophie bei Friedreich-Ataxie diskutiert werden.AbstractA 24-year-old patient with Friedreich’s ataxia presented with advanced visual loss due to optic nerve atrophy. After interdisciplinary consultation and after obtaining informed consent, an off-label therapy with the N-methyl-D-aspartate (NMDA) antagonist memantine was initiated. In a 1-year follow-up no further loss of the nerve fiber layer could be detected by optical coherence tomography (OCT) and visual acuity remained stable. Despite the limitations of this single and time limited case observational study, memantine should be discussed as an option for treatment of acute optic nerve atrophy in Friedreich’s ataxia.

Memantin bei Optikusatrophie in Friedreich-Ataxie@@@Memantine for optic nerve atrophy in Friedreich’s Ataxia

A 24-year-old patient with Friedreichs ataxia presented with advanced visual loss due to optic nerve atrophy. After interdisciplinary consultation and after obtaining informed consent, an off-label therapy with the N-methyl-D-aspartate (NMDA) antagonist memantine was initiated. In a 1-year follow-up no further loss of the nerve fiber layer could be detected by optical coherence tomography (OCT) and visual acuity remained stable. Despite the limitations of this single and time limited case observational study, memantine should be discussed as an option for treatment of acute optic nerve atrophy in Friedreichs ataxia.ZusammenfassungEin 24-jähriger Patient mit Friedreich-Ataxie stellte sich mit fortgeschrittenem Sehverlust bei Optikusatrophie vor. In interdisziplinärer Absprache und nach informierter Einwilligung wurde eine Off-label-Therapie mit dem N-Methyl-D-Aspartat (NMDA)-Blocker Memantin begonnen. Im 1-jährigen Follow-up konnte mittels optischer Kohärenztomographie kein weiterer Verlust in der Nervenfaserschicht nachgewiesen werden und der Visus blieb stabil. Trotz der Einschränkungen dieser zeitlich limitierten Einzelfallbeobachtung sollte Memantin als Option für die Behandlung der Optikusatrophie bei Friedreich-Ataxie diskutiert werden.AbstractA 24-year-old patient with Friedreich’s ataxia presented with advanced visual loss due to optic nerve atrophy. After interdisciplinary consultation and after obtaining informed consent, an off-label therapy with the N-methyl-D-aspartate (NMDA) antagonist memantine was initiated. In a 1-year follow-up no further loss of the nerve fiber layer could be detected by optical coherence tomography (OCT) and visual acuity remained stable. Despite the limitations of this single and time limited case observational study, memantine should be discussed as an option for treatment of acute optic nerve atrophy in Friedreich’s ataxia.