Tock Han Lim

EVEREST study: efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with symptomatic macular polypoidal choroidal vasculopathy.

Purpose: To assess the effects of verteporfin photodynamic therapy (PDT) combined with ranibizumab or alone versus ranibizumab monotherapy in patients with symptomatic macular polypoidal choroidal vasculopathy. Methods: In this multicenter, double-masked, primarily indocyanine green angiography–guided trial, 61 Asian patients were randomized to verteporfin PDT (standard fluence), ranibizumab 0.5 mg, or the combination. Patients were administered with verteporfin PDT/placebo and initiated with three consecutive monthly ranibizumab/sham injections starting Day 1, and re-treated (Months 3–5) as per predefined criteria. The primary endpoint was the proportion of patients with indocyanine green angiography–assessed complete regression of polyps at Month 6. Secondary endpoints included mean change in best-corrected visual acuity at Month 6 and safety. Results: At Month 6, verteporfin combined with ranibizumab or alone was superior to ranibizumab monotherapy in achieving complete polyp regression (77.8% and 71.4% vs. 28.6%; P < 0.01); mean change ± standard deviation in best-corrected visual acuity (letters) was 10.9 ± 10.9 (verteporfin PDT + ranibizumab), 7.5 ± 10.6 (verteporfin PDT), and 9.2 ± 12.4 (ranibizumab). There were no new safety findings with either drug used alone or in combination. Conclusion: Verteporfin PDT combined with ranibizumab 0.5 mg or alone was superior to ranibizumab monotherapy in achieving complete regression of polyps in this 6-month study in patients with symptomatic macular polypoidal choroidal vasculopathy. All treatments were well tolerated over 6 months.

Polypoidal choroidal vasculopathy: evidence-based guidelines for clinical diagnosis and treatment.

Background: Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy affecting vision, with clinical features distinct from neovascular age-related macular degeneration. Currently, no evidence-based guidelines exist for its diagnosis and treatment. Methods: A panel of experts analyzed a systematic literature search on PCV together with results of the EVEREST trial, the only published randomized controlled clinical trial in PCV. At a subsequent Roundtable meeting, recommendations for the management of PCV were agreed based on this analysis and their own expert opinion. Results: Diagnosis of PCV should be based on early-phase nodular hyperfluorescence from choroidal vasculature visualized using indocyanine green angiography. Recommended initial treatment of juxtafoveal and subfoveal PCV is either indocyanine green angiography-guided verteporfin photodynamic therapy or verteporfin photodynamic therapy plus 3 × 0.5 mg ranibizumab intravitreal injections 1 month apart. If there is incomplete regression of polyps by indocyanine green angiography, eyes should be retreated with verteporfin photodynamic therapy monotherapy or verteporfin photodynamic therapy plus ranibizumab. If there is complete regression of polyps by indocyanine green angiography, but there is leakage on fluorescein angiography and other clinical or anatomical signs of disease activity, eyes should be retreated with ranibizumab. Conclusion: Practical guidance on the clinical management of PCV is proposed based on expert evaluation of current evidence.

Ophthalmic complications of dengue.

A case series suggests that the spectrum of complications in dengue infection is widening.

Subjective visual experience during phacoemulsification and intraocular lens implantation using retrobulbar anesthesia

Purpose: To investigate the subjective visual experience of patients during phacoemulsification and intraocular lens (IOL) implantation using retrobulbar anesthesia. Setting: Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Methods: Seventy cataract patients who had routine phacoemulsification and posterior chamber IOL implantation under retrobulbar anesthesia were interviewed on the day of their surgery regarding their visual experience in the operated eye during surgery. Results: Thirty‐nine men (55.7%) and 31 women (44.3%) were included in the study. Their mean age was 65.1 years (range 37 to 87 years). Preoperative best corrected visual acuity ranged from 6/12 to counting fingers. Sixty eyes (85.7%) had no ocular pathology other than cataract. Eleven patients (15.7%) reported no light perception during the surgery. The rest reported they could see light (59 patients, 84.3%), 1 or more colors (39 patients, 55.7%), flashes (35 patients, 50.0%), movements (34 patients, 48.6%), instruments (12 patients, 17.1%), and the surgeons fingers or hands (11 patients, 15.7%). The colors seen included red (23 patients, 32.9%), blue (17 patients, 24.3%), yellow (12 patients, 17.1%), green (7 patients, 10.0%), and orange (1 patient, 1.4%). Eight patients (11.4%) saw a spectrum of colors similar to a rainbow. Thirty‐one patients (44.3%) reported that the brightness of light changed during surgery. Five patients (7.1%) found their visual experience frightening. Patients who reported seeing colors (P = .048, Fisher exact test) and flashes of light (P = .027, Fisher exact test) were more likely to find the experience frightening. There was no statistically significant correlation between those who found the experience frightening and patient sex or age, length of surgery, or history of cataract surgery in the fellow eye. Conclusions: Many patients having phacoemulsification and IOL implantation under retrobulbar anesthesia experienced a variety of visual sensations that were frightening in a small proportion of cases.

A novel classification of the vascular patterns of polypoidal choroidal vasculopathy and its relation to clinical outcomes.

Purpose To propose a novel classification system for polypoidal choroidal vasculopathy (PCV), and compare the clinical outcomes among PCV subtypes. Methods Consecutive treatment-naive patients with symptomatic PCV were managed over 5 years. PCV subtypes were classified based on indocyanine green angiography (ICGA) and fluorescein angiography (FA) characteristics. Results Among 107 patients, 3 PCV subtypes were seen: Type A (interconnecting channels on ICGA) –22.4%; Type B (branching vascular network with no leakage) –24.3%; Type C (branching vascular network with late leakage on FA) –53.3%. The proportion of patients with best-corrected visual acuity (BCVA) ≥20/40 was highest in Type A, intermediate in Type B and lowest in Type C at all time points (80% vs 66.7% vs 7.7% at 5 years, p<0.001). The highest rate of moderate visual loss (loss of ≥3 lines) occurred in Type C PCV (57.7% vs 0% for Types B and A at 5 years, p<0.001). Risk factors for poor visual outcomes were PCV subtype (OR 53.7, p<0.001 for Type C and OR 13.7, p=0.023 for Type B compared to Type A) and age (OR 1.06, 95% CI 1.002 to 1.125, p=0.044). Conclusions The PCV subtype seen on initial presentation affects the long-term visual outcomes over a 5-year period.

EVEREST study report 2: imaging and grading protocol, and baseline characteristics of a randomised controlled trial of polypoidal choroidal vasculopathy

Purpose To describe the imaging standards, grading protocol and baseline characteristics of polypoidal choroidal vasculopathy (PCV) from the EVEREST study. Methods In a prospective, multicentre study, confocal scanning laser ophthalmoscope indocyanine green angiography (ICGA) was performed using a standardised imaging protocol. All images were graded using standardised, calibrated equipment by fellowship-trained ophthalmologists at the Central Reading Center. Results Sixty-one patients with PCV were included in the study. ICGA characteristics included: nodular appearance stereoscopically (56 eyes, 91.8%), hypofluorescent halo (42, 68.9%), abnormal vascular network (54, 88.5%) and pulsation of the polyps (4, 6.6%). Colour fundus photography revealed orange subretinal nodules (34, 55.7%) and massive submacular haemorrhage (8, 13.1%). The mean area of the PCV lesion was 3.11 mm2 (range, 0.2–10.7 mm2). The vascular channels filled within 7.3–32.0 s (mean: 17.9 s) while the mean filling time for polyps was 21.9 s (range, 7.3–40.4 s). Patients with massive submacular haemorrhage were less likely to have abnormal vascular channels seen on ICGA (28.6% vs 83.3% for those without massive haemorrhage, p=0.001). Conclusions The imaging and grading protocols and baseline characteristics of a multicentre, randomised controlled trial of PCV are described in detail, and may serve as reference for future randomised, controlled trials on PCV. Clinical trial number This work was supported by Novartis Pharma AG, Basel, Switzerland grant number NCT00674323 (clinicaltrials.gov).

Intravitreal Ganciclovir Maintenance Injection for Cytomegalovirus Retinitis: Efficacy of a Low-Volume, Intermediate-Dose Regimen

OBJECTIVE To report the clinical outcomes of highly active antiretroviral therapy (HAART)-naïve, human immunodeficiency virus (HIV)-positive patients with newly diagnosed cytomegalovirus (CMV) retinitis receiving intravitreal injections of a low-volume intermediate maintenance dose (1.0 mg/0.02 ml) of ganciclovir. DESIGN Nonrandomized, retrospective, interventional series. PARTICIPANTS A consecutive cohort of 34 eyes from 24 HAART-naïve patients with AIDS and diagnosed with CMV retinitis by retinal specialists at the Singapore Communicable Disease Centre. INTERVENTION Patients received a maintenance dose of 1.0 mg/0.02 ml of intravitreal ganciclovir once weekly after standard induction therapy with 2.0 mg/0.04 ml of twice weekly intravitreal ganciclovir. MAIN OUTCOME MEASURES Time to progression, visual acuity, and complications. Progression was observed using photographic documentation. RESULTS The median time to progression was 152 days (mean, 380.1 days, 95% confidence interval, 240.8-519.4). The median follow-up was 95 days (mean, 207.9 days). Three eyes developed rhegmatogenous detachments, but there was no endophthalmitis after 1858 injections. Contralateral involvement of CMV retinitis occurred in 17.6% of the patients. The cost estimate for intravitreal injections over a 6-month period was 11.7% that of sustained-release implants for unilateral treatment and 11.1% that of daily continuous intravenous infusions and oral valganciclovir compared with bilateral treatments. CONCLUSIONS Weekly low-volume, intermediate-dose (1.0 mg/0.02 ml) ganciclovir is an efficacious option in developing countries where newer options of sustained-release implants and oral valganciclovir are unavailable or prohibitively expensive. The regimen maintains a long time to progression, preserving vision while minimizing retinal toxicity complications.

Central serous retinopathy complicating systemic lupus erythematosus: a case series

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with widespread manifestations including the eye. Central serous retinopathy (CSR) has been associated as a complicating event in SLE, although it is uncommon. We present a case series of four female Chinese SLE patients who developed CSR during the course of their systemic disease. All four presented clinically with typical CSR. Angiographic findings did not show evidence of choroidal ischaemia or delayed choroidal filling. Resolution of the serous retinal detachment occurred in all four patients. Recovery of vision was seen in three patients. The clinical outcome was similar to that occurring in the usual male population. Central serous retinopathy as a manifestation of SLE may be caused by various factors. These include SLE‐associated choroidopathy, systemic hypertension, renal disease, retinal pigment epithelial dysfunction and glucocorticoid therapy.

Asian age‐related macular degeneration phenotyping study: rationale, design and protocol of a prospective cohort study

Background:  Current knowledge of the phenotypic characteristics (e.g. clinical features, risk factors, natural history and treatment response) of age‐related macular degeneration (AMD) in Asians remains limited. This report summarizes the rationale and study design of a prospective observational study of Asian neovascular AMD, including polypoidal choroidovasculopathy variant.

Sub-Tenon's Versus Retrobulbar Anesthesia for Cataract Surgery

BACKGROUND AND OBJECTIVE A prospective, randomized, double-blind study was conducted to compare sub-Tenons anesthesia with retrobulbar anesthesia. PATIENTS AND METHODS One hundred six patients undergoing cataract extraction received either sub-Tenons anesthesia (55 patients) or retrobulbar anesthesia (51 patients). The number of injections required, time until adequate akinesia was achieved, degree of pain experienced, and complications of the anesthetic injection were compared. The depth of the akinesia after sub-Tenons injection was graded. RESULTS There was no significant difference between the two study groups with respect to time of onset of adequate akinesia, the need for a second top-up injection, and the effectiveness of the akinesia. The sub-Tenons injection group reported less pain during the anesthetic injection, as well as during the postoperative injection of subconjunctival gentamicin. CONCLUSION Sub-Tenons anesthesia is a safe technique that is comparable to retrobulbar anesthesia.