Funduscopy-guided fluorescein angiography-free focal laser photocoagulation for central serous chorioretinopathy

Purpose: To identify and correlate hypopigmented spots on fundoscopy with the leakage points on fluorescein angiography (FA) in patients with central serous chorioretinopathy (CSCR) to provide criteria for FA?free focal laser photocoagulation (FLP). Methods: Fifty consecutive patients of acute CSCR were evaluated between March and October 2019 confirming the inclusion and exclusion criteria. Colocalization of leakage points with discrete hypopigmented spots on clinical fundoscopy was evaluated using FA. Positive predictive value (PPV) was calculated to identify the status of association between these to formulate criteria for FA?free FLP of CSCR patients in future. Results: Out of the 50 eyes, 38 (76%) had a discrete hypopigmented spot on fundoscopy which coincided with the leakage point on FA. The PPV of finding a leakage point at the area of discrete hypopigmented spot is 95%. Colocalization with a pigment epithelial detachment was found in 25 (65.7%) of these 38 eyes. Retinal pigment epithelial irregularities were found associated in all of these 38 eyes. Subretinal homogenously hyperreflective material was found in 8 (21.05%) of 38 eyes. optical coherence tomography following FLP of leakage point in all cases showed complete resolution of CSCR in 47 (94%) eyes. Conclusion: This study demonstrates that hypopigmented spots on clinical fundus examination in CSCR patients, when present, coincide with the leakage point of FA. This may aid to undergo FA?free FLP treatment in CSCR patients

Effect and safety of aflibercept in the treatment of polypoidal choroidal vasculopathy with ranibizumab-resistant serous pigment epithelial detachment / 中华实验眼科杂志

Objective:To evaluate the effectiveness and safety of intravitreal injection of different doses of aflibercept for polypoidal choroidal vasculopathy (PCV) with serous pigment epithelial detachment (PED) resistant to ranibizumab.Methods:A non-randomized controlled clinical study was conducted.Seventy-three eyes of 73 patients with PCV and serous PED resistant to ranibizumab were enrolled at the First Affiliated Hospital of Zhengzhou University from January 2019 to December 2020.All patients were treated by intravitreal injection of 2 mg or 4 mg aflibercept according to patients' willingness.2 mg aflibercept or 4 mg aflibercept was intravitreally injected monthly for three consecutive months following pro re nata (PRN) regimen in 2 mg aflibercept group (38 eyes) and 4 mg aflibercept group (35 eyes), respectively.PED height and central macular thickness (CMT) were measured by optical coherence tomography, and the best corrected visual acuity (BCVA) was examined with a visual acuity chart and converted to logarithm of the minimum angle of resolution (LogMAR) unit before injection and 1 month, 2, 3, 6 months from the first injection.Intraocular pressure and treatment-related adverse events were recorded.This study adhered to the Declaration of Helsinki and was approved by an Ethics Committee of The First Affiliated Hospital of Zhengzhou University (No.2021-KY-1252).Written informed consent was obtained from each patient prior to entering study cohort.Results:Thirty-three patients (86.84%) in 2 mg aflibercept group and 30 patients (85.71%) in 4 mg aflibercept group finished the treatment and follow-up, respectively. The PED, BCVA and CMT before treatment and at the end of follow-up were (379.24±95.50) and (280.09±120.50)μm, 0.68±0.27 and 0.51±0.19, (393.96±100.81) and (291.70±44.09)μm in 2 mg aflibercept group, respectively, showing statistically significant differences (all at P<0.05).The PED, BCVA and CMT before treatment and at the end of follow-up were (393.07±93.76) and (278.63±145.07)μm, 0.66±0.31 and 0.48±0.22, (377.43±79.61) and (284.67±84.88)μm in 4 mg aflibercept group, respectively, with statistically significant differences (all at P<0.05).The CMT value in 4 mg aflibercept group was significantly lower than that in the 2 mg aflibercept group in one month after injection ( P<0.05).No severe ocular and systemic adverse events were found during the follow-up, such as retinal detachment, endophthalmitis, cataract, and persistent high intraocular pressure. Conclusions:Both 2 mg and 4 mg aflibercept can effectively treat ranibizumab-resistant PCV with serous PED, and improve the anatomical structure of retina and BCVA.4 mg aflibercept can accelerate the recovery of PED and CMT.

Comparison of the efficacy of Conbercept and Ranibizumab for nARMD with fibrovascular pigment epithelial detachment / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To compare the efficacy of conbercept and ranibizumab on neovascular age-related macular degeneration(nARMD)of type 1 macular neovascularization(MNV)with fibrovascular pigment epithelial detachment(fPED).<p>METHODS: Retrospective clinical study. From January 2019 to December 2020, 48 patients(48 eyes)of nARMD type 1 MNV patients with fPED diagnosed in our hospital were included and divided into conbercept group with 26 patients(26 eyes)and ranibizumab group with 22 patients(22 eyes)according to the drugs they received. All patients received treatment of 3+PRN. Followed up for 12mo, the best corrected visual acuity(BCVA)of the two groups was observed, and optical coherence tomography(OCT)was used to measure the macula foveal thickness(CFT)and the regression degree(height, area, volume)of retinal pigment epithelial detachment(PED).<p>RESULTS: There was no significant difference between two groups in BCVA, CFT and PED height, area and volume before treatment(<i>P</i> >0.05). The PED height of the two groups was significantly improved at 3, 6 and 12mo after the first intravitreal injection treatment compared with those before treatment(<i>P</i><0.05). But the PED area and volume were not significantly improved(<i>P</i>>0.05). There was no significant improvement in BCVA between the two groups after treatment compared with those before treatment(<i>P</i>>0.05). The CFT of the conbercept group was significantly improved at 3, 6 and 12mo after treatment compared with those before treatment(<i>P</i><0.05), and the ranibizumab group improved significantly only 3mo after treatment(<i>P</i><0.05). There were no significant differences in BCVA, CFT, and PED height, area and volume between the two groups at 3, 6 and 12mo after treatment(<i>P</i> >0.05).<p>CONCLUSION: The conbercept and ranibizumab have good effects on type 1 MNV with fPED in nARMD, which can reduce the PED height and CFT, and stabilize the visual acuity, PED area and volume. However, conbercept can achieve longer reduction of macular edema.

Lateral elongation of flat irregular pigment epithelial detachment: A novel optical coherence tomography biomarker in polypoidal choroidal vasculopathy

Purpose: To explore novel Optical Coherence Tomography (OCT) biomarkers and precursor lesions in Polypoidal Choroidal Vasculopathy (PCV). Methods: This retrospective cohort study included 76 treatment na飗e fellow eyes of PCV. Focus was given to analyse the various morphological changes in the clinically unaffected fellow retina during the follow-up period. Results: 11 fellow eyes (14.47%) developed disease activity in the form of Sub Retinal Fluid (SRF) or Intra Retinal Fluid (IRF) within a mean follow-up of 17 months. All 11 eyes (100%) showed the presence of flat irregular pigment epithelial detachment (FIPED) and a peculiar property of lateral elongation of FIPED during disease activity. A positive correlation with the disease progression was found for the same (P < 0.0001). The mean horizontal dimension of the flat irregular PED at the enrolment was 1984 � 376u and the mean expansion of FIPED at SRF formation was 461 � 152u. ICG taken at the time of disease activity in the fellow eye revealed branching vascular network (BVN) in 9 (81.8%) eyes, polyps in 7 (63.6%) eyes, a combination of both in 5 (45.4%) eyes. Type one BVN with interconnecting channels showed faster disease progression than type two BVN. Eye tracking ICG illustrated that BVN corresponded to the FIPED in OCT and polypoidal lesions developed at the end of expanding FIPED. Conclusion: Flat irregular pigment epithelial detachment with its characteristic property of lateral elongation may be considered as a precursor lesion for PCV and as a novel OCT biomarker for the disease activity. Fellow eyes with FIPED need close monitoring to identify development of disease activity at the earliest.

Vitreous hemorrhage as the presenting feature of peripheral exudative hemorrhagic chorioretinopathy in Indian eyes

Five Indian patients presenting with unilateral vitreous hemorrhage (VH) underwent pars plana vitrectomy (PPV) and were found to have lesions suggestive of peripheral exudative hemorrhagic chorioretinopathy (PEHCR). All eyes had extensive sub-retinal hemorrhage; three also showed an elevated mass lesion. The temporal retina anterior to the equator was the most commonly affected site. Exudative manifestations were absent in all. No recurrences occurred over a mean follow-up of 17.5 months. Although PEHCR is reported to be rare in Asians, this series demonstrates that it can present as VH in Indians as well. Unless the macula has irreversible damage, a favorable outcome can be obtained with PPV alone.

Diagnostic performance of confocal scanning laser ophthalmoscope imaging and compared with color fundus camera in retinal pigment epithelial detachment of polypoidal choroidal vasculopathy / 中华眼底病杂志

Objective To observe confocal scanning laser ophthalmoscope (cSLO) based retinal imaging and color fundus camera in pigment epithelial detachment (PED) of polypoidal choroidal vasculopathy (PCV).Methods PED of 30 patients (32 eyes) were recruited from June 2016 to June 2017 in the Beijing Tongren Hospital who were detected in high-definition OCT (HD-OCT) and diagnosed as PCV by FFA and ICGA.There were 16 males (17 eyes) and 14 females (15 eyes);aged from 50-83 years,with the mean age of 66.59 years.The photographs of ocular fundus including color fundus camera,cSLO imaging,HD-OCT,FFA and ICGA were analyzed.Multimodal imaging results were regarded as gold standard.Sensitivity and specificity were calculated in serous and hemorrhagic PED diagnosis using color fundus camera and cSLO imaging.The positive number of PED was used to compare between two modes fundus imaging by using x2 test.Results Twenty serous PED eyes,3 hemorrhagic PED eyes and 9 serous/hemorrhagic PED eyes were determined using multimodal imaging.The sensitivity and specificity of color fundus camera were 45％ and 100％ in detecting serous PED and 100％ and 91％ in detecting hemorrhagic PED.The sensitivity and specificity of cSLO imaging were 83％ and 100％ in detecting serous PED and 50％ and 86％ in detecting hemorrhagic PED.The positive number of serous PED in cSLO imaging was significantly higher than color fundus camera (x2=7.752,P=0.011).The positive number of hemorrhagic PED in cSLO imaging shows no obvious difference compared with color fundus camera (x2=1.164,P=0.419).Conclusion The sensitivity and positive number of detecting serous PED with PCV in cSLO fundus imaging were higher than the color fundus camera technology.

Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection

PURPOSE: To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. METHODS: After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit. RESULTS: The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group. CONCLUSIONS: In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow-up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.

Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection

PURPOSE: To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. METHODS: After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit. RESULTS: The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group. CONCLUSIONS: In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow-up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.

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.

Long-Term Observation of Retinal Pigment Epithelial Tear after Anti-VEGF Treatment for Age-Related Macular Degeneration

PURPOSE: To evaluate the long-term clinical outcomes of retinal pigment epithelium (RPE) tears after intravitreal injection of anti-vascular endothelial growth factor (VEGF) agent for the treatment of neovascular age-related macular degeneration (AMD). METHODS: The authors performed a retrospective chart review of 13 eyes of 13 patients who developed RPE tears after intravitreal anti-VEGF injection between February 2009 and June 2013. We investigated continuation of the treatment after tear, visual acuity, presence of cystoid macular edema, and central macular thickness (CMT) using optical coherence tomography (OCT) before and after treatment and visual outcomes depending on foveal sparing. RESULTS: After RPE tear, 12 of 13 patients continued injection of an anti-VEGF agent. The average number of injections was 6.08 +/- 5.18. Mean visual acuity immediately after tear was 1.65 +/- 0.8 log MAR, and that at the last visit was 1.82 +/- 0.88 log MAR. Nine eyes with macular edema in OCT continued receiving injection, and improvement of macular edema was observed in four eyes at the final visit. The final visual acuity of patients with foveal involvement was 2.17 +/- 0.49 log MAR, which was worse than the 1.51 +/- 1.06 log MAR in patients without foveal involvement, although the difference was not significant (p = 0.295). CONCLUSIONS: When anti-VEGF injections were continued after RPE tear, no improvement in visual acuity was observed, although better anatomical outcomes did result. Patients with foveal involvement had worse visual acuity than patients without foveal involvement, but the difference was not significant.

Characteristic Findings of Optical Coherence Tomography in Retinal Angiomatous Proliferation

PURPOSE: To identify the unique pathologic findings of retinal angiomatous proliferation (RAP) in optical coherence tomography (OCT). METHODS: Retrospectively, 29 eyes of 25 patients with age-related macular degeneration and complicated RAP were analyzed. All 29 eyes had choroidal neovascularization (CNV) in the area of pigment epithelial detachment (PED) or adjacent to it, which was visible with fluorescein angiography or indocyanine green angiography. Cross-sectional images were obtained by OCT scanning through the CNV lesions. RESULTS: Six distinctive findings of OCT included drusen (100%), inner retinal cyst (80%), outer retinal cyst (68%), fibrovascular PED (84%), serous retinal detachment (40%), and PED (68%). CONCLUSIONS: Through analysis of OCT findings, we revealed six different types of lesions distinctive of RAP which may provide helpful diagnostic information for subsequent treatment and predicting the prognosis of RAP.

Time-Lag between Subretinal Fluid and Pigment Epithelial Detachment Reduction after Polypoidal Choroidal Vasculopathy Treatment

PURPOSE: The goal of the present research was to study post-treatment changes in polypoidal choroidal vasculopathy (PCV) shown by optical coherence tomography (OCT). METHODS: The study included 12 patients with naive PCV. Photodynamic therapy and 3 consecutive intravitreal bevacizumab injections at 6-week intervals were given. Best corrected visual acuity, subretinal fluid (SRF), pigment epithelium detachment (PED), central macular thickness (CMT), and total macular volume (TMV) were measured before and after treatment as assessed by Stratus OCT3. RESULTS: After treatment, the SRF height decreased earlier than the PED height. The SRF diameter decreased with statistical significance. However, the PED diameter did not show a statistically significant improvement, persisting at pre-treatment levels. Both CMT and TMV decreased significantly after treatment. CONCLUSIONS: After PCV treatment, SRF and PED stabilized, as shown by OCT. However, the PED treatment response was both delayed and refractory compared to the SRF response. The small change in post-treatment PED diameter may suggest the possibility of PCV recurrence.

Inflammatory pigment epithelial detachment associated with Blastocystis hominis

Objective@#To describe a case of inflammatory pigment epithelial detachment (PED) presumed to be secondary to the amoeba Blastocystis hominis.@*Methods@#This is an interventional case report.@*Results@#A 46-year-old male complained of visual distortion in the left eye for 7 months. Examination revealed the presence of a subretinal cystic lesion on the fovea. Optical coherence tomography demonstrated a PED with a hyperreflective lesion over the detached retinal pigment epithelium (RPE). Work-up included a fecalysis, which revealed the presence of Blastocystis hominis. The patient was treated with oral metronidazole. RPE detachment resolved after treatment with no recurrence in 30 months of follow-up.@*Conclusion@#Intestinal parasitic infection may be associated with retinal disease and should be included in the differential diagnosis of PED when OCT reveals a hyperreflective lesion.

Retinal pigment epithelial detachment post radiation therapy in metastatic ocular infiltration of non-Hodgkin's lymphoma: a case report / 国际眼科杂志(Guoji Yanke Zazhi)

A 32-year-old lady, diagnosed with anaplastic large cell non-Hodgkin's lymphoma of the mediastinum, presented with bilateral floaters and reduced right eye vision 3 years post chemotherapy. Ophthalmic examination revealed bilateral panuveitis with multiple deep seated choroidal lesions in the left eye. Computed tomography scanning of the orbit showed enhancing and bulky optic nerve sheath at the retrobulbar part of both optic nerves. The patient was treated with involved field radiation therapy of the orbit, with cumulative dose of 30Gy. Eight months post radiation therapy, she developed retinal pigment epithelial detachment at the macula and deep chorioretinal degeneration at superotemporal and inferonasal regions of the right fundus. There was evidence of vitreoretinal traction at the margin of chorioretinal degeneration areas, thus barricade lasers were performed in the affected eye. Her visual acuity remains 6/6 in both eyes. Retinal pigment epithelial detachment is a possible complication of radiation therapy in non-Hodgkin's lymphoma with intraocular metastasis. It is essential to alert the managing ophthalmologists about this rare complication.

A Case of Subretinal Hematoma Secondary to Polypoidal Choroidal Vasculopathy Misunderstood as a Subretinal Mass

PURPOSE: To report a case of subretinal hematoma secondary to polypoidal choroidal vasculopathy (PCV) misunderstood as a subretinal mass. CASE SUMMARY: A 73-year-old man with no specific medical history visited our clinic with decreased vision in the right eye. Slit-lamp examination revealed no specific findings for the anterior segment of the right eye. Upon fundus examination, an elevated macular lesion with some subretinal hemorrhages was observed, and a subretinal mass lesion was found on ultrasonography. After performing fluorescein angiography, indocyanine green angiography, and magnetic resonance imaging, we presumed that this lesion was a subretinal hematoma or ocular tumor and recommended observation. One month later, the subretinal mass had decreased in size. One year later, PCV with large retinal pigment epithelial detachment (RPED) was observed. After the intravitreal bevacizumab injection, RPED and macular edema were improved. CONCLUSIONS: We confirmed PCV with a subretinal hematoma and large RPED which seemed to be a subretinal mass and was difficult to differentiate from ocular tumors.

Preferential Hyperacuity Perimeter in Exudative AMD With Pigment Epithelial Detachment

PURPOSE: To analyze the hyperacuity defects by preferential hyperacuity perimeter (PHP) in exudative age-related macular degeneration (AMD) and correlate them with the properties of pigment epithelial detachment (PED) obtained by optical coherence tomography (OCT). METHODS: Thirty eyes with exudative AMD with choroidal neovascularization (CNV) diagnosed by fluorescein angiography underwent PHP for hyperacuity defect and OCT for PED length and height. We compared hyperacuity defect with the shape of the PED by OCT. RESULTS: 26 eyes with exudative AMD with CNV tested positive for hyperacuity defects. The size of the hyperacuity defect by PHP and the PED length by OCT showed positive correlation (p=0.010). In the 4 eyes that tested negative for hyperacuity defects, the PED was not high although the size was large. CONCLUSIONS: Our results suggest that PHP is a useful method to detect a change of pigment epithelial layer in AMD and the presences of a hyperacuity defect is more sensitive for PED height than size. These results suggest that PHP is useful to detect the state and the activity of CNV lesion.

Combination Treatment for Choroidal Neovascularization Associated With Large Retinal Pigment Epithelial Detachment

PURPOSE: To evaluate the efficacy of the combination therapy of intravitreal bevacizumab injection and photodynamic therapy in neovascular age-related macular degeneration associated with large retinal pigment epithelial detachment. METHODS: A total of 13 eyes were reviewed, with 9 eyes diagnosed with definite choroidal neovascularization (CNV) and 4 eyes diagnosed with CNV or polypoidal choroidal vasculopathy (PCV) becausethe exact type could not be determined. Photodynamic therapy was performed within 1 week after bevacizumab injection according to indocyanine green angiography (ICGA). Additional bevacizumab injections were performed within a 4 to 6 week interval. Additional photodynamic therapy was performed within 4 months. RESULTS: The visual acuity on final examination had improved in 3 eyes (23.1%), was maintained in 7 eyes (53.8%), and decreased in 3 eyes (23.1%). The change of the PED before and after treatment showed regression in 5 eyes (38.5%), recurrence after regression in 2 eyes (15.4%), persistence in 4 eyes (30.8%), and retinal pigment epithelial tear in 2 eyes (15.4%). The maintained or improved visual acuity rate was 66.7% (6/9) and 100% (4/4) in the CNV and CNV or PCV group, respectively. CONCLUSIONS: The combination therapy in neovascular age-related macular degenerationassociated with large retinal pigment epithelial detachment is a viable alternative treatment in the stabilization and improvement of vision. However, further studies with long-term follow up and controlled studies with anti-vascular endothelial growth factor antibody monotherapy are required.

A Case of Wegener's Granulomatosis with Retinal Pigment Epithelial Detachment and Subretinal Hemorrhage

PURPOSE: To report a case of very limited Wegener's granulomatosis presenting with inflammation of the anterior segment, orbital pseudotumor, retinal pigment epithelial detachment, and subretinal hemorrhage. METHODS: A 54-year-old man who was treated for pachymeningitis was seen in consultation for painful swelling of the left eye and periorbit, and visual loss of the right eye developed 2 days after admission. He was diagnosed with peripheral keratitis, scleritis, anterior uveitis, and pseudotumor of the left eye, and RPE detachment in the macula of the right eye. He was started on treatment with antibiotics, NSAIDs, and steroids. Twelve days later, he had no response to the treatment and developed otitis media and skin ulcer. A skin biopsy was performed. RESULTS: Histological analysis showed a necrotizing inflammation of the small vessels in the skin lesion. The clinical and radiologic findings and the positive antineutrophil cytoplasmic antibody (ANCA) test were consistent with a diagnosis of Wegener's granulomatosis. Treatment with oral steroids and cyclophosphamide improved the systemic and ocular symptoms dramatically. One year later, he developed choroidal neovascularization and subretinal hemorrhage in the right eye. He was started on oral steroids and cyclophosphamide, with a dramatic improvement in his general health and ocular state.

Photodynamic Therapy of Choroidal Neovasculariation Associated with Large Serous Pigment Epithelial Detachment

PURPOSE: To evaluate the efficacy of photodynamic therapy of choroidal neovascularization (CNV) associated with large serous pigment epithelial detachment (PED) in eyes with age-related macular degeneration. METHODS: The records of nine eyes of nine patients were reviewed. Mean follow-up period was 11.4 months (range, 6 ~ 26 months). The photodynamic therapy was done using a spot size with a diameter larger than the greatest linear dimension of the CNV lesion revealed on indocyanine green angiography (ICGA). RESULTS: In 7 of 9 eyes, the PED persisted with progression of neovascular membrane, and retinal pigment epithelial tear occurred in 3 eyes. In one eye, visual improvement could be achieved with decreased extent of PED until the follow up period of 6 months. In remaining one eye, the caliber of new vessel decreased on ICGA accompanied by improvement of vision and PED after first photodynamic therapy. However, 3 months after second photodynamic therapy, CNV proliferated extensively with resultant visual loss. CONCLUSIONS: The results of our study suggest that photodynamic therapy provide no benefit in the treatment of CNV associated with large serous PED in age-related macular degeneration.

Retinal Angiomatous Proliferation

PURPOSE: To report the cases of retinal angiomatous proliferation (RAP) which has been known to be rare in Asian populations, and to describe the characteristic clinical and angiographic findings of RAP. METHODS: Six eyes of 3 patients were diagnosed as having RAP, and 5 eyes had extensive soft drusen. The first case showed intraretinal neovascularization (RAP stage 1) and subretinal neovascularization with a retinal-retinal anastomosis and an associated serous pigment epithelial detachment (RAP stage 2). The second case showed choroidal neovascularization with a retinal choroidal anastomosis (RAP stage 3) and RAP stage 1. In the third case, RAP stage 2 and severe fibrous scarring, resulting from RAP, could be found. RESULTS: RAP seems to have the tendency for bilateral involvement and extrafoveal location, and a high index of suspicion may be required in the eyes having large serous pigment epithelial detachment accompanied by soft drusen. Fundus findings, such as intraretinal or preretinal hemorrhage, intraretinal reddish nodule, macular edema and indocyanine green angiogram findings of retinal-retinal anastomosis or retinal-choroidal anastomosis, have diagnostic values.