Soon Hyun Kim

Aflibercept Treatment for Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy Refractory to Anti-vascular Endothelial Growth Factor.

Purpose To report the results of switching treatment to vascular endothelial growth factor (VEGF) Trap-Eye (aflibercept) in neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to anti-VEGF (ranibizumab and bevacizumab). Methods This is a retrospective study involving 32 eyes from 29 patients; 18 were cases of neovascular AMD and 14 were cases of PCV. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) of spectral-domain optical coherence tomography were evaluated. Results BCVA and CMT improved from 0.58 to 0.55 (p = 0.005) and from 404 to 321 µm (p < 0.001), respectively, after switching to aflibercept. The 14 eyes that received 6 or more aflibercept injections remained stable at 0.81 to 0.81 and 321 to 327 µm (p = 1.0, 0.29), respectively, after 3 aflibercept injections. The 10 eyes that received 3 or more bevacizumab injections after 3 or more aflibercept injections worsened, from 0.44 to 0.47 and from 332 to 346 µm (p = 0.06, 0.05), respectively. The results showed similar improvement of BCVA and CMT in neovascular AMD and PCV. Conclusions Aflibercept seems to be effective for improvement and maintenance of BCVA and CMT for neovascular AMD and PCV refractory to anti-VEGF. Switching from aflibercept back to bevacizumab treatment may not be a proper strategy.

EPIRETINAL MEMBRANE FORMATION AFTER INTRAVITREAL AUTOLOGOUS STEM CELL IMPLANTATION IN A RETINITIS PIGMENTOSA PATIENT.

Methods: A retrospective case report of a retinitis pigmentosa patient who underwent vitrectomy for epiretinal membrane after intravitreal autologous stem cell implantation. Results: A 71-year-old female RP patient came to our clinic for ophthalmic evaluation after intravitreal autologous stem cell injection. Four months ago, she underwent intravitreal autologous stem cell injection for both eyes at another hospital. New thick epiretinal membrane (ERM) with extensive macular pucker was found on her left eye. She underwent pars plana vitrectomy and membranectomy. After biopsy, many CD34-positive stem cells were detected in ERM specimen. Conclusion: This is the first report of ERM formation following intravitreal autologous stem cells injection. CD34-positive stem cells were detected in a human eye at 4 months after injection. Further studies are needed to determine how stem cells caused ERM and how long they would stay in the eye.

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase, Anti-vascular Endothelial Growth Factor and Gas

Purpose To evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas. Methods This study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed. Results The mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied. Conclusions A triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.

Sterile Inflammation after Intravitreal Injection of Aflibercept in a Korean Population

Purpose To report the frequency and clinical features of sterile inflammation after intravitreal aflibercept injection in a Korean population. Methods A single-center, retrospective study was performed in patients who received intravitreal aflibercept from July 2013 through January 2015. Results A total of four cases of post-injection sterile inflammation were identified from 723 aflibercept injections in 233 patients. Patients presented 1 to 13 days after intravitreal aflibercept injection (mean, 5 days). The mean baseline visual acuity was 20 / 60, which decreased to 20 / 112 at diagnosis but ultimately recovered to 20 / 60. Three cases had inflammatory cells in the anterior chamber (mean, 2.25+; range, 0 to 4+), and all cases had vitritis (mean, 3+; range, 2+ to 4+). No patients had pain. Only one patient underwent anterior chamber sampling (culture negative) and injection of antibiotics. Three of four patients were treated with a topical steroid, and all experienced improvement in their symptoms and signs of inflammation. Conclusions The overall incidence of sterile inflammation after intravitreal aflibercept injection in a Korean population was 4 of 723 injections (0.55%), or 4 of 233 patients (1.79%). Sterile inflammation after intravitreal aflibercept injection typically presents without pain, and the visual outcomes are generally favorable.

Subretinal tenecteplase injection in a submacular hemorrhage from polypoidal choroidal vasculopathy: a case report.

PURPOSE The purpose of this report was to describe a case with a thick submacular hemorrhage (SMH) resulting from polypoidal choroidal vasculopathy that was successfully treated with a subretinal tenecteplase injection. METHODS A retrospective case report. RESULTS A 63-year-old man with acute SMH secondary to polypoidal choroidal vasculopathy underwent a partial posterior vitrectomy, a subretinal tenecteplase (100 μg/0.1 mL) injection with air/fluid exchange, and an intravitreal injection of bevacizumab (2.5 mg/0.1 mL). His preoperative corrected visual acuity was 20/30, but the SMH threatened the fovea. The SMH was displaced inferiorly and absorbed completely at 1 month postoperative. His visual acuity decreased to 20/40 1 week postoperative but recovered to 20/20 2 months after surgery. The electroretinogram showed no distinct elongation of implicit time and slightly decreased amplitude of a-wave and b-wave at 3 months postoperative; optical coherence tomography presented disruption of the inner segment/outer segment line at the onset of SMH but recovered completely at 3 months postoperative. CONCLUSION Subretinal tenecteplase was found to have sufficient hemolytic function and no retinal toxicity and could represent a feasible treatment option for the management of SMH.

High Dose Intravitreal Bevacizumab for Refractory Pigment Epithelial Detachment in Age-related Macular Degeneration

Purpose Intravitreal anti-vascular endothelial growth factor (anti-VEGF) is the first choice of treatment for age-related macular degeneration. However, quite a few eyes treated using conventional dose anti-VEGF (CDAV) have persistent pigment epithelial detachment (PED) on optical coherence tomography. This study investigated the efficacy and safety of high dose anti-VEGF (HDAV) for refractory PED. Methods In this retrospective study, 31 eyes of neovascular age-related macular degeneration patients with persistent PED findings despite six or more intravitreal injections of CDAV (bevacizumab 1.25 mg or ranibizumab 2.5 mg) were analyzed. Changes in visual outcome, central foveal thickness, and PED height were compared before and after HDAV (bevacizumab 5.0 mg) for these refractory PED cases. Results The mean age of patients was 67.7 years. The number of CDAV injections was 12.1. The number of HDAV injections was 3.39. Best-corrected visual acuity in logarithm of the minimum angle of resolution before and after HDAV was 0.49 and 0.41 (p < 0.001), respectively. Central foveal thickness before and after HDAV was 330.06 and 311.10 µm (p = 0.125), respectively. PED height before and after HDAV was 230.28 and 204.07 µm (p = 0.014), respectively. There were no serious adverse reactions in all the eyes. Conclusions Increasing the dose of bevacizumab in refractory PED may be a possible treatment option.

Macular Edema after Gabapentin

Dear Editor, Gabapentin is an anticonvulsant and has been used to manage neuropathic pain. It was originally developed as an antiepileptic agent; however, it is now recommended as a drug of choice for the treatment of neuropathic pain. There is strong evidence that gabapentin is also effective in diabetic neuropathy and postherpetic neuralgia [1]. To the best of our knowledge, macular edema after use of gabapentin has not been reported to date. Therefore, we report a case of macular edema after gabapentin. A 71-year-old man presented with a 1 day history of visual disturbance and metamorphosis in both eyes. The patient had taken oral gabapentin (Neurontin; Pfizer, New York, NY, USA) and oral methylprednisolone (Methylon; Alvogen, Seoul, Korea) for 8 days for treatment of postherpetic neuralgia. He had no other significant medical history, except hypertension controlled by oral medication. Best-corrected visual acuity (Snellen) was 0.4 (right eye) and 0.2 (left eye), and the intraocular pressure was 9 mmHg (right eye), 11 mmHg (left eye), as determined by non-contact tonometry. Both eyes had moderate cataract. Ophthalmic examination of the anterior segments revealed no other abnormal findings. Dilated fundus examination and spectral domain optical coherence tomography revealed macular edema and serous retinal detachment of macula in both eyes (Fig. 1A-1D). Fluorescence angiography revealed fluorescein dye pooling on the macula and multiple leakages in both eyes (Fig. 1E and 1F). The patient was advised to discontinue gabapentin, and the use of the drug was stopped. Fig. 1 At the initial visit, macular edema and serous detachment on both eyes were observed by fundus photo (A, right eye [OD]; B, left eye [OS]) and spectral domain optical coherence tomography (C, OD; D, OS). On fluorescence angiography, fluorescein dye pooling ... Four weeks after the initial visit, best corrected visual acuity improved to 0.9 (both eye). Fundus exam and spectral domain optical coherence tomography revealed markedly improved macular edema and serous detachment in both eyes (Fig. 1G-1J). Gabapentin is an amino acid initially designed as a cyclic gamma-aminobutyric acid analogue with action as a gamma-aminobutyric acid agonist [2]. It also acts on different brain receptors by an as-yet unknown mechanism. Common adverse effects of gabapentin include dizziness, fatigue, drowsiness, sexual dysfunction, weight gain, and peripheral edema [3]. Uncommonly, gabapentin causes blurred vision and diplopia [4]. Steinhoff et al. [5] reported that this drug has been linked with abnormal color perception and reduced contrast sensitivity due to an unknown mechanism. Gabapentin could also cause abnormal finding of visual evoked potentials and pattern electroretinogram [2]. It was suggested that toxic effects on the neuro-transmitter function of the optic nerve might be responsible. Macular edema on optical coherence tomography after gabapentin has not hitherto been described. Using fluorescence angiography, the present patient was observed to suffer multiple chorioretinitis. Thus, it is possible that the macular edema was due to chorioretinitis. Herpetic infection can also induce chorioretinitis. However, the macular edema in the presented case was spontaneously improved after cessation of gabapentin and steroid, suggesting that chorioretinitis is not a sufficient explanation. Because the precise action mechanism of gabapentin is not known, it is difficult to deduce the mechanism of macular edema after the use of gabapentin. Further studies about the mechanism and frequency of macular edema after gabapentin are required. In summary, we report macular edema occurring in a male patient receiving gabapentin therapy for postherpetic neuralgia treatment. The macular edema improved after discontinuing the use of the drug. If vision loss after the use of gabapentin occurs, it is prudent to identify macular edema. Gabapentin should be considered one of the potential causes of macular edema.