Yale L. Fisher

Intravitreal bevacizumab treatment of choroidal neovascularization secondary to age-related macular degeneration.

Purpose: To describe the short-term anatomical and visual acuity responses after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Methods: We conducted a retrospective study of patients with CNV secondary to AMD who were treated with intravitreal injection of bevacizumab (1.25 mg) during a 3-month period. Patients underwent best-corrected Snellen visual acuity testing, optical coherence tomography, and ophthalmoscopic examination at baseline and follow-up visits. Results: There were 266 consecutive eyes of 266 patients who received injections, and follow-up information was available for 251 (94.4%). The mean age of the patients was 80.3 years, the mean baseline visual acuity was 20/184, and 175 (69.7%) had inadequate response to alternate methods of treatment. At the 1-month follow-up (data available for 244 patients), the mean visual acuity was 20/137 (P < 0.001 as compared with baseline), and 74 (30.3%) of patients had improvement in visual acuity as defined by a halving of the visual angle. At the 2-month follow-up (data available for 222 patients), the mean visual acuity was 20/122 (P < 0.001), and 78 (31.1%) of patients had visual improvement. At the 3-month follow-up (data available for 141 patients), the mean visual acuity was 20/109 (P < 0.001), and 54 (38.3%) of patients had visual acuity improvement. The mean central macular thickness at baseline was 340 &mgr;m and decreased to a mean of 247 &mgr;m at month 1 (P < 0.001) and 213 &mgr;m at month 3 (P < 0.001). At 1 month, two patients had mild vitritis, as did one patient at 2 months, who had a history of recurrent uveitis. No endophthalmitis, increased intraocular pressure, retinal tear, or retinal detachment occurred. The risk for thromboembolic disorders did not seem to be different than reported previously in studies concerning macular degeneration. Conclusion: There were no apparent short-term safety concerns for intravitreal bevacizumab injection for CNV. Treated eyes had a significant decrease in macular thickness and improvement in visual acuity. The follow-up was too short to make any specific treatment recommendations, but the favorable short-term results suggest further study is needed.

Intravitreal bevacizumab (Avastin) treatment of macular edema in central retinal vein occlusion: a short-term study.

Purpose: To report the short term anatomic and visual acuity response after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with macular edema due to central retinal vein occlusion (CRVO). Methods: The authors conducted a retrospective study of patients with macular edema due to CRVO who were treated with at least one intravitreal injection of bevacizumab 1.25 mg in 0.05 mL. Patients underwent Snellen visual acuity testing, optical coherence tomography (OCT) imaging, and ophthalmoscopic examination at baseline and follow-up visits. Results: There were 16 eyes of 15 consecutive patients with a mean age of 76.1 years (SD 9.8 years). Intravitreal triamcinolone had been previously administered to 9 patients, but all of these patients either had no improvement or had excessive intraocular pressure caused by the triamcinolone. The patients received a mean of 2.8 injections of bevacizumab per eye. No adverse events were observed, including endophthalmitis, clinically evident inflammation, increased intraocular pressure, retinal tears, retinal detachment, or thromboembolic events in any patient. The mean central macular thickness at baseline was 887 &mgr;m and decreased to a mean of 372 &mgr;m at month 1 (P < 0.001). The mean baseline acuity was 20/600 (logMAR = 1.48) and the mean acuity at month 1 was 20/200 (logMAR = 1.05), a difference that was highly significant (P = 0.001). At last follow-up, a mean of 3 months after the first injection, the mean visual acuity was 20/138 (logMAR = 0.84), which was significantly better than baseline (P < 0.001). Visual acuity improvement, defined as a halving of the visual angle, was seen in 14 of the 16 eyes. Conclusion: Initial treatment results of patients with macular edema secondary to CRVO did not reveal any short-term safety concerns. Intravitreal bevacizumab resulted in a significant decrease in macular edema and improvement in visual acuity. The number of patients in this pilot study was limited and the follow-up is too short to make any specific treatment recommendations, but the favorable short-term results suggest further study is needed.

Intravitreal bevacizumab (Avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage.

Purpose: To report the short-term anatomic and visual acuity response after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with proliferative diabetic retinopathy complicated by vitreous hemorrhage. Methods: Two patients with vitreous hemorrhage due to proliferative diabetic retinopathy were treated with at least one intravitreal injection of bevacizumab 1.25 mg in 0.05 mL. The patients underwent Snellen visual acuity testing, ophthalmoscopic examination, and fluorescein angiography at baseline and follow-up visits. Results: Both patients had proliferative diabetic retinopathy with vitreous hemorrhage extensive enough to preclude panretinal photocoagulation. Following intravitreal injection of bevacizumab both patients experienced improvement in visual acuity starting within the first week. At 1 month of follow-up one patient had 2 lines of improvement in visual acuity and the other 5 lines. Each patient had regression of retinal neovascularization at 1 month of follow-up. Repeat injection was given to one patient at the 1-month follow-up because of slight leakage from neovascularization on the nerve, and to the other patient at 3 months because the retinal neovascularization showed early signs of reperfusion. The vitreous hemorrhage in each patient showed partial resolution at 1 week and nearly complete regression at 1 month. No adverse events were observed in either patient. Conclusions: Initial treatment results of patients with vitreous hemorrhage and proliferative diabetic retinopathy did not reveal any short-term safety concerns. Intravitreal bevacizumab resulted in marked regression of neovascularization and rapid resolution of vitreous hemorrhage. The favorable short-term results suggest further study is needed in a larger group of patients.

Indocyanine green videoangiography of older patients with central serous chorioretinopathy.

Purpose: The authors studied the indocyanine green (ICG) videoangiography findings of central serous chorioretinopathy (CSC) in older adults. Background: Central serous chorioretinopathy in older adults may be confused with the exudative forms of age-related macular degeneration (AMD) because the two entities may have similar ophthalmoscopic and fluorescein angiographic findings. Because of its enhanced ability to image the choroidal circulation, ICG videoangiography has been used to describe certain choroidal vascular abnormalities in young adults with CSC, as well as older patients with choroidal neovascularization (CNV). The ICG videoangiography findings in CSC in older adults is largely unknown. Methods: The authors performed ICG videoangiography on 36 patients aged 50 years or older with CSC to characterize their findings. Results: The ICG videoangiography findings of the patients were consistent, revealing choroidal vascular hyperpermeability manifested by areas of hyperfluorescence that were first seen in the midphase of the angiogram. In the later phases of the angiogram, there were dispersion of the hyperfluorescence and a distinctive silhouetting of the larger choroidal vessels. Conclusions: Older patients with CSC have a unique temporal and topographic pattern of hyperpermeability that can help establish the proper diagnosis.

Central Serous Chorioretinopathy in Younger and Older Adults

PURPOSE The purpose of the study is to investigate the demographic characteristics and clinical findings of central serous chorioretinopathy (CSC). METHODS This study examined a consecutive series of 130 patients with CSC seen over an 18-month period. RESULTS The mean age of the patients when examined was 51 years, and the male-to-female ratio was 2.6:1.0. A total of 62 patients were older than 50 years of age when first examined. Although the patients shared some clinical and angiographic similarities, the older patients had a lower mean visual acuity and were more likely to have diffuse retinal pigment epitheliopathy, bilateral involvement, and secondary choroidal neovascularization than were the younger patients. With ophthalmoscopic and angiographic examination results, it was possible to differentiate CSC in older adults from choroidal neovascularization. CONCLUSION This study expands the clinical concept of CSC. The male-to-female ratio was much lower, and the range of ages of the patients was much greater than in previous studies. Disease manifestations in older adults differed somewhat from those seen in younger adults. In older patients, CSC can be distinguished from other exudative maculopathies, particularly that of choroidal neovascularization secondary to age-related macular degeneration.

Systemic findings associated with central serous chorioretinopathy.

PURPOSE To determine systemic factors associated with central serous chorioretinopathy. METHODS In a retrospective study, 230 consecutive patients with central serous chorioretinopathy examined in a referral setting were compared with a historical gender-matched and age-matched control group of 230 patients with ocular findings who were examined in the same referral setting. RESULTS The median age of the patients was 49.8 years, and of the control subjects, 50.0 years. The male-female ratio for both groups was 2.7:1. Patients with central serous chorioretinopathy were more likely to use psychopharmacologic medications (odds ratio = 2.6; 95% confidence interval = 1.30 to 5.19; P = .0049) and corticosteroids (odds ratio = 3.17; 95% confidence interval = 1.30 to 7.70; P = .0067) and were more likely to have hypertension (odds ratio = 2.25; 95% confidence interval = 1.39 to 3.63; P = .0008) than were the control subjects. CONCLUSIONS This study identified psychopharmacologic medication use, corticosteroid use, and hypertension as factors associated with central serous chorioretinopathy. These findings reinforce the concept that stress and adaptations to stress play a role in this disorder. The findings of possible associations between central serous chorioretinopathy and both hypertension and corticosteroid usage suggest that these modifiable factors may influence morbidity of central serous chorioretinopathy.

Three-Dimensional Evaluation of Vitreomacular Traction and Epiretinal Membrane Using Spectral-Domain Optical Coherence Tomography

PURPOSE To delineate the 3-dimensional (3-D) relationship in vitreomacular traction (VMT) and idiopathic epiretinal membrane (ERM). DESIGN Observational case series. METHODS Forty-eight evaluable eyes of 35 patients with VMT or idiopathic ERM were investigated with spectral-domain (SD) optical coherence tomography (OCT). VMT was defined as focal if the diameter of the vitreous attachment was 1500 microm or less and broad if it was more than 1500 microm. The 3-D OCT representation of vitreomacular interface abnormalities was evaluated. RESULTS Focal VMT was seen in five eyes. Broad VMT was seen in seven eyes. Of these 12 eyes, concurrent ERMs under the detached vitreous were seen in 10 eyes and zones of hyperreflectivity affecting the adjacent detached posterior hyaloid face were seen in 11 eyes. Eyes with focal VMT showed a foveal cavitation, whereas eyes with broad VMT had more widespread cystoid macular edema. Idiopathic ERM was seen in 36 eyes; 30 had complete posterior vitreous detachment (PVD), five had partial PVD associated with attached posterior hyaloid at some peripheral portion of the ERM, and one had no PVD. CONCLUSIONS The SD OCT with 3-D image reconstruction provided unprecedented visualization of VMT and idiopathic ERM. The vitreous attachment to the macula can be subclassified into two subgroups, each having specific induced alterations in retinal anatomy. Most of the eyes with VMT had concurrent ERM, whereas several eyes with idiopathic ERM had attachment of the vitreous to some portion of the ERM, which suggests there is significant overlap between VMT and idiopathic ERM.

Polypoidal choroidal vasculopathy masquerading as central serous chorioretinopathy

OBJECTIVE To differentiate polypoidal choroidal vasculopathy (PCV) from central serous chorioretinopathy (CSC). DESIGN A retrospective, observational case series. PARTICIPANTS Thirteen patients originally diagnosed with CSC proved to have PCV after more extensive evaluation and follow-up. METHODS A clinical and angiographic review of patients with manifestations of CSC, including macular detachment. MAIN OUTCOME MEASURES Demographic data, funduscopic examination, and fluorescein and indocyanine green (ICG) angiographic findings. RESULTS Thirteen patients initially suspected of having CSC were ultimately diagnosed as having PCV. These eyes had exudative macular detachments secondary to a small caliber, polypoidal choroidal vascular abnormality or so-called polypoidal choroidal neovascularization. The clinical manifestations in the fundus varied. They included multiple, variably sized serous pigment epithelial detachments, neurosensory retinal detachment, lipid deposition, patchy atrophy of the pigment epithelium and indistinct staining from decompensation of the posterior blood-retinal barrier on fluorescein angiography. In reality, the suspected PEDs proved to be polypoidal lesions of PCV when imaged with ICG angiography. CONCLUSIONS The clinical diagnosis of CSC or PCV generally poses little challenge to the experienced retinal specialist. However, in CSC with persistent and/or recurrent exudation, a myriad of retinal pigment epithelial changes may evolve that make it difficult to differentiate these two entities. In such patients, ICG angiography is useful in differentiating CSC from PCV. An accurate clinical diagnosis is important since each of these entities, CSC and PCV, may differ in terms of their risk factors, natural course, and visual prognosis.

External beam radiation therapy for choroidal neovascularization

OBJECTIVE This study aimed to determine the effect of external beam radiation therapy on choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN The study design was a nonrandomized clinical trial with an historic control group. PARTICIPANTS A total of 91 patients were treated with external beam radiation. These patients were compared retrospectively to the 119 patients in a control group. INTERVENTION Patients with subfoveal CNV who did not meet the criteria for laser treatment defined by published reports from the Macular Photocoagulation Study Group or who did not want laser treatment were considered for radiation therapy in a nonrandomized, prospective clinical trial. Additional entry criteria for this prospective study included visual acuity better than or equal to 20/320 on the Early Treatment Diabetic Retinopathy Study chart and a lesion size less than 12 disc areas. The patients were treated with 5 fractions of 200 cGy 6 MV external beam photons. MAIN OUTCOME MEASURES The visual acuity measured at baseline was compared to the visual acuity after 1 year of follow-up. RESULTS The mean baseline visual acuity of the 91 patients entered into the Radiation Study was 20/80. After 1 year, 83 patients (91.2%) completed follow-up, and their mean visual acuity dropped to 20/200. By comparison, the mean baseline visual acuity of the control patients also was 20/80, and after 1 year, the control subjects had a mean visual acuity of 20/125. At 1 year of follow-up, 49.4% of patients treated with radiation and 38.1% of the control subjects lost 3 or more lines of visual acuity (P = 0.16). CONCLUSIONS This study found that external beam radiation using 1000 cGy in 5 fractions, a dose similar to that used in previous studies, was not effective in the treatment of CNV secondary to AMD. These results suggest that patients should not be treated with this dose of external beam radiation for CNV secondary to AMD.

Combined multiplanar optical coherence tomography and confocal scanning ophthalmoscopy

We demonstrate the clinical application of a multiplanar imaging system that simultaneously acquires en face (C-scan) optical coherence tomography (OCT) and the corresponding confocal ophthalmoscopic images, along with cross-sectional (B-scan) OCT at specifiable locations on the confocal image. The advantages of the simultaneous OCT and confocal acquisition as well as the challenges of interpreting the C-scan OCT images are discussed. Variations in tissue inclination with respect to the coherence wave surface alter the sampling of structures within the depth of the retina, producing novel slice orientations that are often challenging to interpret. We have evaluated for the first time the utility of C-scan OCT for a variety of pathologies, including melanocytoma, diabetic retinopathy, choroidal neovascular membrane, and macular pucker. Several remarkable new aspects of clinical anatomy were revealed using this new technique. The versatility of selective capture of C-scan OCT images and B-scan OCT images at precise points on the confocal image affords the clinician a more complete and interactive tool for 3-D imaging of retinal pathology.