Vincenzo Isola

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization secondary to pathologic myopia: long-term study.

Purpose: To assess the safety and effectiveness of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM). Methods: Sixty-two patients (62 eyes) with PM underwent PDT according to the guidelines of the Verteporfin in Photodynamic Therapy Study. Clinical evaluations performed at all study visits included measurement of best-corrected Snellen visual acuity, slit-lamp biomicroscopy, and fundus fluorescein angiography. Patients were followed up at 1 month and 3 months after treatment and thereafter at 3-month intervals. Results: The final visual acuity of the study patients, after a median follow-up of 31 months, improved by ≥1 Snellen lines in 8 patients (13%), deteriorated in 20 (32%), and remained stable in 34 (55%). The baseline visual acuity was similar in the various study groups. The final mean visual acuity in group A (55 years of age or younger) was 20/80 and significantly (P = 0.006) better than that (20/138) in group B (older than 55 years of age). The mean final visual acuity in eyes with higher refractive error at baseline (greater than −17 diopters) was significantly better (P = 0.014) than that in eyes with lower refractive error (−6 to −10 diopters). CNV size did not affect visual outcomes. Conclusion: PDT preserves vision in patients with CNV associated with PM. Younger patients and eyes with higher refractive error appear more likely to benefit from PDT with verteporfin.

Autofluorescence imaging of cystoid macular edema in diabetic retinopathy.

Aim: Our purpose was to assess fundus autofluorescence (FAF) images in patients with diabetic retinopathy and cystoid macular edema (CME) and their correlation with fluorescein angiography (FA) and optical coherence tomography (OCT) findings. Methods: Sixty-eight eyes of 34 consecutive patients with diabetic retinopathy were examined with autofluorescence imaging using a confocal scanning laser ophthalmoscope, FA and OCT. The eyes were divided into 2 groups, group 1 with CME and group 2 without. Results: In the 44 eyes of group 1 (65% of the series), we identified 3 patterns of FAF: (1) multicystic increased FA (57%), (2) a single cyst of increased FAF (16%), (3) combined single- and multicystic increased FAF (27%). FA and OCT gave a positive correlation between cystic increased FAF and CME (r = 0.95; p = 0.001). Visual acuity loss was not correlated with the size of the cystic area (p = 0.83), but it was related to significant macular thickening (p = 0.007). Conclusions: Confocal scanning laser ophthalmoscopy can selectively visualize autofluorescent, multilobulated spaces in eyes with diabetic CME. Even if OCT remains preferable for evaluating macular thickening and cysts, FAF might be another useful easy test to rapidly distinguish this entity noninvasively and with no risk.

Photodynamic Therapy With Verteporfin For Choroidal Neovascularization Associated With Retinal Pigment Epithelial Detachment In Age-related Macular Degeneration

Purpose: To assess the effectiveness of photodynamic therapy (PDT) with verteporfin for choroidal neovascularization (CNV) associated with retinal pigment epithelium detachment (PED) in age-related macular degeneration. Methods: Thirty eyes of 26 patients with CNV and PED were treated with PDT. The eyes were divided in two groups based on CNV location in relation to PED; group 1 included 13 eyes with CNV within PED, and group 2 included 17 eyes with CNV at the edge of PED. The median follow-up was 16 months. Results: Patients received a mean ± SD of 2.83 ± 1.26 treatments (range, 1–6 treatments). In the whole cohort, the mean preoperative visual acuity changed from 20/144 (0.86 ± 0.42 logarithm of minimal angle of resolution [logMAR]) to 20/182 (0.96 ± 0.51 logMAR; P = 0.39) at month 18. Five eyes (16%) gained a mean of 1.5 Snellen lines from baseline. Twelve eyes (40%) lost a mean of 1.7 Snellen lines of visual acuity. Vision in 13 eyes (44%) remained stable. In group 1, the mean visual acuity at month 12 was 20/303 (1.18 ± 0.51 logMAR) and significantly (P = 0.015) worse than that, 20/110 (0.74 ± 0.42 logMAR), in group 2. Conclusion: PDT can improve or stabilize visual function in 60% of eyes with vascularized PED. CNV at the edge of PED appears to respond more favorably to PDT. Appropriate patient selection and prompt treatment are essential to obtain the best outcomes after verteporfin therapy.

Efficacy and safety of anti-vascular endothelial growth factor (VEGF) therapy with intravitreal ranibizumab (Lucentis) for naive retinal vein occlusion: 1-year follow-up

Purpose To evaluate the efficacy and safety of intravitreal ranibizumab (Lucentis) in patients with treatment-naive retinal vein occlusion. Design Prospective, consecutive, non-comparative, interventional case series. Participants Seventeen eyes of 17 consecutive patients with naive retinal vein occlusion. Methods Consecutive patients were recruited and received, on demand, intravitreal 0.5 mg of ranibizumab; nine had central retinal vein occlusion (CRVO) and eight had branch retinal vein occlusion (BRVO). Pre- and postoperative clinical evaluation included measurement of best corrected visual acuity (BCVA) for distance, and near vision (MNREAD time, reading fluency), contrast sensitivity, colour fundus photography, fluorescein angiography and optical coherence tomography (OCT). All subjects were followed for a minimum of 12 months. Main outcome measures Change in BCVA, contrast sensitivity, angiographic leakage, OCT central macular thickness (CMT), number of treatments. Results Patients with CRVO had mean pre-treatment BCVA of 20/240 (1.08±0.25 logarithm of the minimum angle of resolution (logMAR)) and final BCVA of 20/46 (0.36±0.16 logMAR), with significant improvement at 1 year of follow-up (p<0.0001). At 12 months mean BCVA improved to 36.7 letters, with a gain of 6.4 lines, and OCT showed that the mean CMT was 271 μm, with a mean reduction of 360 μm (p<0.0001) from baseline (mean 631 μm). Patients with BRVO had mean pre-treatment BCVA of 20/126 (0.80±0.29 logMAR) and final BCVA of 20/50 (0.41±0.23 logMAR) (p<0.0001). The mean OCT CMT was 278 μm, with a mean reduction of 275 μm (p<0.0001) from baseline (mean 553 μm). Contrast sensitivity, MNREAD time and reading fluency improved significantly in the treated eyes. No ocular or systemic side effects were observed. Eyes with CRVO received an average of 3.0 injections (range 2–4) and those with BRVO 3.6 (range 3–4). Conclusions Intravitreal ranibizumab for the management of naive CRVO or BRVO can favourably modify the course of the occlusion, indicating that short- and long-term blockade of vascular endothelial growth factor (VEGF)-A may restore the integrity of the inner blood–retinal barrier, reduce CMT and significantly improve visual function, with a good safety profile. Further prospective long-term studies are warranted to confirm the efficacy, safety and optimal treatment regimen for intravitreal ranibizumab.

Autofluorescence in adult-onset foveomacular vitelliform dystrophy

Purpose: To describe fundus autofluorescence (FAF) characteristics of adult-onset foveomacular vitelliform dystrophy (AOFVD) and to perform a comparative evaluation of FAF patterns and functional response. Methods: Fifteen patients with AOFVD and 10 healthy volunteers underwent complete ophthalmic examination, including visual acuity determination (Early Treatment Diabetic Retinopathy Study charts), blue-light autofluorescence (BL-AF) analysis, near-infrared autofluorescence (NIR-AF) analysis, and microperimetry. Results: Three different patterns of BL-AF (normal, focal, and patchy) and two of NIR-AF (focal and patchy) were identified in AOFVD. Abnormal BL-AF and NIR-AF patterns were detectable in 86% and 100% of cases, respectively. Patchy BL-AF and NIR-AF patterns are associated with the worst functional outcomes. Conclusions: AOFVD can be associated with different FAF patterns. A functional correlate with visual acuity and retinal sensitivity, measured by means of microperimetry, can be found.

Branch retinal vein occlusion and exudative retinal detachment: Pathogenetical aspects

Exudative retinal detachment (ERD) is an uncommon complication of branch retinal vein occlusion (BRVO). The ERD pathogenesis has been mainly related to the haemodynamic overload and to an impairment in the function of the retinal pigment epithelium. Data relative to 98 cases of BRVO without ERD were compared with the correspondent data of 10 cases of BRVO with ERD. Venous leakage showed a substantial equivalency between the two groups, while evaluation of retinal venous collaterals demonstrated a lower amount in the BRVO cases with ERD, with a statistically significant difference. Moreover, considering the various ERD localizations, we suggest that the ERD pathogenesis is mainly ascribable to the scant development of retinal venous collaterals but that an important role may also be played by the retinal pigment epithelium impairment consequent to the retinal ischaemia.

Intravitreal Ranibizumab Injection for Nonarteritic Ischemic Optic Neuropathy

PURPOSE The aim of this study was to evaluate the functional and morphological outcomes of intravitreal ranibizumab injection (IVR) in the treatment of nonarteritic ischemic optic neuropathy (NAION). METHODS Three patients with NAION of 1–2 days onset underwent IVR. A complete ophthalmologic examination was performed at baseline (before IVR) and at 1 day, 1 week, 1 month, 6 months, and 1 year following IVR. RESULTS In all patients, we found an early resolution of optic disk swelling, as soon as 1 week after IVR; however, such a morphological improvement was not accompanied by a corresponding functional (visual acuity and perimetric) improvement. The first treated patient presented a good visual acuity and a relative central visual field defect at baseline, and at the 12-month follow-up, we found an overall functional stabilization, with no further visual acuity and visual field deterioration. The second and third treated patients presented a lower visual acuity and an absolute center-involving visual field defect at baseline. In these patients, despite early papillary edema resolution, late optic nerve atrophy occurred, and visual acuity and visual field did not improve at the 12-month follow-up. CONCLUSION The results from our study suggest that even if IVR is effective in reducing optic nerve swelling in NAION patients, no functional improvement may be observed. Further studies are necessary to definitively establish the efficacy and safety of IVR in the treatment of NAION.

Quality of vision: A consensus building initiative for a new ophthalmologic concept

Purpose Many studies have addressed the quantification of visual acuity, and the conventional method of measuring it has so far demonstrated serious limitations. Vision testing requires new methods that can more precisely express the quality of vision as perceived by the patient. Methods This study employed the Delphi method of consensus building. Concepts associated with quality of vision (QoV) were identified by a board of experts and proposed to participating specialists in two subsequent questionnaires. Upon receipt of the completed questionnaires, the replies were classified to determine the building blocks of a consensus. Results By analyzing the replies to the two questionnaires, the authors determined the key elements of QoV on which a consensus was found among the respondents. Conclusions A consensus was reached on the opinion that the quantification of visual acuity by traditional means is inadequate for investigating QoV. Although visual acuity is still a basic element for testing, the experts believe that contrast sensitivity, reading speed, and microperimetry are additional parameters necessary for quantifying QoV. The use of a psychometric questionnaire on visual function could allow a better interpretation of visual impairment.

Spectral domain OCT versus time domain OCT in the evaluation of macular features related to wet age-related macular degeneration.

Background The aim of this study was to compare the agreement between spectral domain optical coherence tomography (SD OCT) and time domain stratus OCT (TD OCT) in evaluating macular morphology alterations in wet age-related macular degeneration (AMD). Methods This retrospective study was performed on 77 eyes of 77 patients with primary or recurring subfoveal choroidal neovascularization secondary to AMD. All patients underwent OCT examination using Zeiss Stratus OCT 3 (Carl Zeiss Meditec Inc, Dublin, CA) and Opko OTI Spectral SLO/OCT (Ophthalmic Technologies Inc, Toronto, Canada). In all radial line scans, the presence of intraretinal edema (IRE), serous pigment epithelium detachment (sPED), neurosensory serous retinal detachment (NSRD), epiretinal membrane (EM), inner limiting membrane thickening (ILMT), and hard exudates (HE) were evaluated. The degree of matching was quantified by Kappa measure of agreement. Results The percentage distribution of TD OCT findings versus SD OCT findings was: IRE 36.3% versus 77.9%, sPED 57.1% versus 85.7%, NSRD 38.9% versus 53.2%, EM 10.5% versus 26.3%, ILMT 3.8% versus 32.4%, and HE 6.4% versus 54.5%. The agreement was as follows: sPED: kappa value 0.15; NSRD: kappa value 0.61; IRE: kappa value 0.18; EM: kappa value 0.41; ILMT: kappa value 0.02; HE: kappa value 0.06. Conclusion The agreement in the evaluation of macular lesions between the two techniques is poor and depends on the lesion considered. SD OCT allows better detection of the alterations typically related to choroidal neovascularization such as IRE, PED, ILM thickening, and HE. Consequently its use should be strongly considered in patients with wet AMD.

Accelerated ischemic vascular retinopathy after intravitreally injected bevacizumab for central retinal vein occlusion in elderly patients

Background: Ischemic changes in the retinal circulation are an uncommon but severe adverse vascular reaction to intravitreal bevacizumab (Avastin®, Genentech, San Francisco, CA, USA/Roche, Basel, Switzerland) for central retinal vein occlusion (CRVO). In the two cases reported here, ischemic changes in the retina vasculature following intravitreal bevacizumab for CRVO were observed with the aim of describing the clinical and angiographic features of these changes. Methods: Two elderly patients with recent-onset CRVO received one off-label intravitreal injection of bevacizumab 0.05 mL/1.25 mg. Results: In Case 1, the patient’s pre-treatment visual acuity was 20/400. At 3 weeks post injection, the patient could count fingers at a distance of 1 ft (30 cm) and fluorescein angiography showed reduction in intraretinal hemorrhages and areas of retinal non-perfusion. However, at 6 weeks these were markedly increased compared with those seen in the photograph taken 3 weeks after treatment. In Case 2, the patient’s pre-treatment visual acuity was 20/200. At 1 month post injection, vision had decreased to 20/400 and fluorescein angiography showed severe macular ischemia with a remarkable capillary dropout throughout the macula. Conclusion: Ischemic retinal injury may be an uncommon but severe adverse vascular reaction to intravitreal bevacizumab for CRVO. Although progression of retinal ischemia in CRVO could be observed shortly after intravitreal bevacizumab, whether this is a drug- or procedure-related effect or part of the natural history of the condition remains uncertain.