Ugo Introini

Outcome of choroidal neovascularization in angioid streaks after photodynamic therapy.

Purpose: To evaluate the visual and anatomic outcomes of photodynamic therapy for choroidal neovascularization (CNV) in patients with angioid streaks. Methods: The authors retrospectively evaluated 40 consecutive patients (48 eyes) with visual acuity of 20/200 or greater who were treated at 6 referral centers for CNV associated with angioid streaks. Main outcome measures were visual acuity, greatest linear diameter of the lesion, and, in patients with nonsubfoveal CNV, distance from the foveola. Results: Of 34 eyes with subfoveal CNV, 21 were followed up for at least 12 months (range, 5–33 months). Median visual acuity was 20/50 at baseline and 20/120 at the final examination. The 12-month estimate of the percentage of eyes with vision loss of fewer than 3 lines was 68% (95% confidence interval, 50%–85%) by using survival analysis, whereas eyes with no increase in the greatest linear diameter were 45% (95% confidence interval, 27%–62%). Fourteen eyes had extrafoveal (n = 11) or juxtafoveal (n = 3) CNV, 12 of which were followed up for at least 10 months (range, 4–36 months). Visual acuity was 20/40 or greater in all eyes with extrafoveal lesions at baseline and in 5 of 12 eyes at the last examination, when 3 cases of CNV had become subfoveal. At baseline, visual acuity was low in two eyes with juxtafoveal CNV and nearly normal in the third. It remained substantially stable at the end of follow-up (range, 10–36 months), when two lesions were subfoveal. Conclusions: Most of our patients had good baseline visual function and, thus, were at high risk for losing vision because of the poor prognosis of CNV in angioid streaks. Because most had no or limited vision loss after 1 year, the authors suggest that photodynamic therapy can be used to try to limit or delay visual damage caused by this aggressive disease.

Spectral-domain OCT in anti-VEGF treatment of myopic choroidal neovascularization.

PurposeTo evaluate changes in macular morphology due to myopic choroidal neovascularization (CNV), using spectral-domain optical coherence tomography (SD-OCT).MethodsIn all, 22 eyes with recent-onset untreated CNV underwent 1 intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), followed by a pro-re-nata regimen. SD-OCT was performed at baseline (before first administration of anti-VEGF treatment) and month 1, and 2; macular morphologic changes and outer retina characteristics (SD-OCT findings) associated with CNV activity were evaluated. Sensitivity and specificity were calculated for SD-OCT findings using fluorescein angiography (FA) as standard reference.ResultsMean central retinal thickness (CRT) showed no significant reduction from baseline (284±98 μm) to month 1 (257±74 μm) and month 2 (263±72 μm). A hyper-reflective lesion with fuzzy borders (fuzzy area), and ‘absent or altered’ IS/OS junction were the only SD-OCT findings associated with CNV activity (P<0.0001). Both these SD-OCT findings showed good sensitivity and specificity (95.1 and 96.0% (95% CI: 0.87–0.89), respectively, for the fuzzy area; 87.9 and 66.7% (95% CI: 0.65–0.87), respectively, for ‘absent or altered’ IS/OS junction) when compared with FA leakage (standard reference).ConclusionsOuter retina characteristics (ie, hyper-reflective lesion with fuzzy borders, and ‘absent or altered’ IS/OS junction) appear more meaningful than CRT in the evaluation of myopic CNV activity. These SD-OCT findings show overall good sensitivity and specificity when compared with FA leakage (standard reference), and could be considered as an alternative diagnostic tool to FA for myopic CNV monitoring.

ICGA-GUIDED LASER PHOTOCOAGULATION OF OCCULT CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION

Purpose: To evaluate the efficacy of indocyanine green angiography (ICGA)‐guided laser photocoagulation in eyes with fluorescein angiographic evidence of occult choroidal neovascularization (O‐CNV) in patients with age‐related macular degeneration (ARMD) with or without pigment epithelium detachment (PED). Methods: Eighty eyes of 79 consecutive patients with O‐CNV underwent laser treatment of a clearly outlined extrafoveal ICGA hyperfluorescent area, presumed to be focal CNV. Four types of presumed CNV were treated: Group 1 (20 eyes), CNV beneath the PED; Group 2 (23 eyes), CNV at the margin of the PED; Group 3 (10 eyes), parapapillary CNV and PED; and Group 4 (27 eyes), macular CNV without PED. Median follow‐up was 17.5 months (range, 6‐24 months). Results: After 1 year, 15% of the eyes in Group 1, 30% in Group 2, 100% in Group 3, and 52% in Group 4 had obliteration of the presumed CNV. After 1 year, visual acuity was stable or improved in 18% of Group 1, in 37.5% of Group 2, in 100% of Group 3, and in 73% of Group 4. The remaining eyes worsened. Conclusions: Indocyanine green angiography‐guided laser treatment may improve or stabilize visual acuity in some eyes with O‐CNV. The best outcome is seen in eyes with presumed parapapillary CNV, probably made up of choroidal telangiectases in many cases. The type and location of the presumed CNV influence prognosis after laser treatment considerably. A randomized, controlled clinical study appears necessary to investigate the efficacy of ICGA‐guided laser treatment in different types of presumed CNV. The inclusion criteria for further trials need to be defined with precision, as data from patients with different choroidal vascular abnormalities have been pooled until now.

Intravitreal ranibizumab for choroidal neovascularization with large submacular hemorrhage in age-related macular degeneration.

Purpose: To evaluate the effects of intravitreal ranibizumab injections in the treatment of choroidal neovascularization with large submacular hemorrhage secondary to age-related macular degeneration. Methods: Prospective interventional case series. Patients presenting occult choroidal neovascularization with flat large submacular hemorrhage >50% of the entire lesion were considered. The protocol required 3 monthly consecutive injections, followed by repeat injections over the 12-month follow-up on the basis of optical coherence tomography parameters and angiographic features. Results: Twenty-three patients were enrolled in the study and prospectively followed up. Mean best-corrected visual acuity and mean central macular thickness at the baseline were 0.82 ± 0.22 (logarithm of the minimum angle of resolution ± standard deviation) and 342 ± 56 µm, respectively. At 12-month examination, mean visual acuity improved significantly to 0.68 ± 0.41 (P = 0.04), and mean central macular thickness decreased to 236 ± 26 µm (P < 0.0001). A progressive resolution of macular bleeding was registered in 22 of 23 patients. No side effect or complication was registered. Conclusion: Intravitreal ranibizumab can be considered a beneficial approach for the management of choroidal neovascularization with flat large submacular hemorrhage secondary to age-related macular degeneration.

Intravitreal bevacizumab for nonsubfoveal choroidal neovascularization associated with angioid streaks.

PURPOSE To evaluate the effects of intravitreal bevacizumab injections in the treatment of nonsubfoveal choroidal neovascularization (CNV) associated with angioid streaks. DESIGN Nonrandomized, interventional, prospective case series. METHODS Fifteen patients (15 eyes) affected by juxtafoveal or extrafoveal CNV secondary to angioid streaks were enrolled in the study. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement on Early Treatment Diabetic Retinopathy Study (ETDRS) chart, optical coherence tomography (OCT), and fluorescein angiography (FA). The protocol treatment included a first injection, followed by repeated injections over a 12-month follow-up period on the basis of the detection of new hemorrhage on biomicroscopic examination, any type of fluid on OCT, or presence of leakage on FA. PRIMARY OUTCOME MEASURES Mean changes in BCVA and proportion of eyes gaining at least 10 letters (2 ETDRS lines) at the end of the follow-up. SECONDARY OUTCOMES Mean changes of central macular thickness (CMT) and extension to the fovea. RESULTS Mean BCVA did not change throughout the follow-up period, being 0.2 ± 0.2 logMAR at baseline and 0.2 ± 0.3 logMAR at the 12-month examination. A functional improvement of at least 2 ETDRS lines was achieved by 5 eyes (33%), with 3 eyes (20%) gaining 3 lines. Mean CMT at baseline was 215 ± 13 μm and 225 ± 85 μm at the 12-month examination. Two eyes (13.3%) showed CNV extension to the fovea. CONCLUSIONS Intravitreal bevacizumab injection can be a beneficial approach for the management of nonsubfoveal CNV secondary to angioid streaks over a 1-year follow-up.

Lacquer Cracks and Perforating Scleral Vessels in Pathologic Myopia: A Possible Causal Relationship

PURPOSE To describe a possible causal association between the position of perforating scleral vessels and the position of lacquer cracks in eyes with pathologic myopia. DESIGN Retrospective case series. METHODS Medical records and multimodal imaging results, including confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography, were reviewed from patients with lacquer cracks secondary to pathologic myopia who presented between 2010 and 2014 to 2 institutions. Main outcome measures were the prevalence of perforating scleral vessels at the site of the lacquer crack, the position of the lacquer crack within the macula, and the relationships between perforating scleral vessels and retinal-choroidal structures. RESULTS A total of 35 eyes of 30 patients with lacquer cracks were included. The average number of lacquer cracks was 1.2 ± 0.5/eye and in 37 out of 45 lacquer cracks (82%) retrobulbar vessels were found to perforate the sclera at the site of the lacquer crack. Lacquer cracks were more prevalent in the central macula (51%) than in the nasal (19%), temporal (14%), inferior (11%), and superior macula (5%) (P = .001). Transverse en face images through the area of lacquer cracks were available for 8 cases and clearly depicted the perforating vessels course through the sclera and its termination in the choroid, directly beneath the lacquer cracks. CONCLUSIONS Perforating scleral vessels are often present beneath the site at which lacquer cracks form in pathologic myopia. We hypothesize that scleral expansion at the location of these perforating vessels may play a role in the formation of lacquer cracks.

Macular hole and intravitreal injection of triamcinolone acetonide for macular edema due to central retinal vein occlusion.

Purpose. To report a case of macular hole progression after intravitreal injection of triamcinolone acetonide (IVTA) for chronic macular edema secondary to nonischemic central retinal vein occlusion (CRVO). Methods. A 33-year-old woman with massive macular edema after CRVO underwent IVTA. Optical coherence tomography (OCT) and fluorescein angiography were performed before and after the procedure. Results. At the 1-week IVTA injection control, the patients best-corrected visual acuity improved from 20/400 to 20/200 and OCT detected a progression of macular hole stage. Conclusions. IVTA steroid injection may provide a significant improvement in macular edema, but injection-related complications may occur such as this uncommon macular reaction resulting in permanent visual loss.

Acute macular neuroretinopathy following intranasal use of cocaine

Editor, O riginally described by Bos & Deutman (1975), acute macular neuroretinopathy (AMN) is a rare condition characterized by paracentral scotomas corresponding to flat, reddish, wedge-shaped intraretinal lesions usually pointing towards the fovea. These lesions are best seen using infrared (IR) reflectance imaging and show typical optical coherence tomography (OCT) findings (Fawzi et al. 2012). We have observed two cases of bilateral AMN following intranasal cocaine insufflations in two young otherwise healthy women. A 24-year-old woman (Case 1) presented 3 days after sudden onset of paracentral scotomata in both eyes at her awakening. Her past medical history was unremarkable and she did not take any medication, including oral contraceptives. The patient admitted to intranasal cocaine use the evening before the onset of symptoms. She was an occasional user and she denied any history of alcohol abuse or other drugs

Natural course of photic maculopathy secondary to uncomplicated cataract surgery

We report on a 36‐year‐old man who developed photic maculopathy in the left eye shortly after uncomplicated cataract surgery. The visual acuity (VA) of the left eye was 6/39 and spectral domain optical coherence tomography (SD‐OCT), performed one week after surgery, revealed a hyporeflective space in the outer retina (a ‘partial‐thickness hole’) at the fovea. Microperimetry showed a relative central scotoma and multifocal electroretinogram (ERG) showed reduced responses within the central 10°. Two months later, VA in the felt eye improved to 6/6 and SD‐OCT showed an almost complete resolution of the ‘partial‐thickness hole’. Microperimetry showed the resolution of the relative scotoma at the fovea and multifocal ERG showed improved responses within the central 10°. SD‐OCT, microperimetry and multifocal ERG are useful tools in the diagnosis and follow‐up of photic maculopathy after uncomplicated cataract surgery. Its natural history may be characterised by resolution of both morphological and functional changes shortly after surgery.

Consensus on the diagnosis, treatment and follow-up of patients with age-related macular degeneration eligible for ranibizumab

Age-related macular degeneration (AMD) is an irreversible pathology that is the principal cause of serious loss of central vision and legal blindness among people over 60 years of age. There are two forms of AMD: the dry, or atrophic form, and the wet, neovascular form. The latter is less frequent but is the cause of approximately 80–90% of cases of serious loss of vision in a short time period. Early diagnosis is therefore essential to permit intervention as promptly as possible. Currently, the most effective therapy for neovascular AMD uses the new class of anti-VEGF drugs, and ranibizumab is today’s ‘gold standard’ for this treatment. The Progetto LUCE (LUCE Project) consists of an advisory board of retinal disease specialists in Lombardy, Italy, whose task is to propose a consensus for the diagnosis, treatment and follow-up of neovascular AMD patients treated with ranibizumab on the basis of a review of the scientific evidence and Italian national health service regulations and the clinical experience of the advisory board members.