Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization.

Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients' vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3-6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6-8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.

Size-Tailored Design of Highly Monodisperse Lipid Nanocapsules for Drug Delivery.

The empirical development of nanocarriers has unfortunately led to high attrition rates in clinical trials. This underpins the importance of the rational design of nanomedicines to achieve efficient disease-driven therapies. Since particle size certainly influences in vivo behaviour, rational disease-driven colloid design can only be achieved by determining the parameters that accurately control their size distribution. To this end, we have thoroughly revisited the parameters that drive the phase-inversion temperature nanoemulsification method to obtain kinetically stable and monodisperse lipid nanocapsules. Notably, we have evidenced that the major parameter driving nanocapsule formation is the oily phase/surfactant ratio and consequently, we have established a linear univariate mathematical model that predicts the particle size distribution for various oily phase-surfactant combinations (R² > 0 99). Furthermore, we have observed that the difference between the HLB values of the surfactants and the triglycerides utilized as oily phase correlates with the steepness of the slope of the linear mathematical model. This model will bring the implementation of size-tailored lipid drug carriers determined by pathophysiological features a step closer. Importantly, this model pioneeringly fits all data available in the literature on size distribution of colloids prepared by low-energy methods and that were originally evaluated following other parameters. Moreover, the nanocapsules have been obtained following a single-step process, with the ensuing potential for a future scale-up in an energetically-efficient manner. These findings will eventually enable nanomedicines to be obtained "on-demand" to meet disease-driven criteria in terms of particle size and will also increase their chances of success.

Ranibizumab Plus Panretinal Photocoagulation versus Panretinal Photocoagulation Alone for High-Risk Proliferative Diabetic Retinopathy (PROTEUS Study).

PURPOSE: Comparison of the efficacy of ranibizumab (RBZ) 0.5 mg intravitreal injections plus panretinal photocoagulation (PRP) versus PRP alone in the regression of the neovascularization (NV) area in subjects with high-risk proliferative diabetic retinopathy (HR-PDR) over a 12-month period. DESIGN: Prospective, randomized, multicenter, open-label, phase II/III study. PARTICIPANTS: Eighty-seven participants (aged ≥18 years) with type 1/2 diabetes and HR-PDR (mean age, 55.2 years; 37% were female). METHODS: Participants were randomized (1:1) to receive RBZ+PRP (n = 41) or PRP monotherapy (n = 46). The RBZ+PRP group received 3 monthly RBZ injections along with standard PRP. The PRP monotherapy group received standard PRP between day 1 and month 2; thereafter, re-treatments in both groups were at the investigators' discretion. MAIN OUTCOME MEASURES: The primary outcome was regression of NV total, on the disc (NVD) plus elsewhere (NVE), defined as any decrease in the area of NV from the baseline to month 12. Secondary outcomes included best-corrected visual acuity (BCVA) changes from baseline to month 12, time to complete NV regression, recurrence of NV, macular retinal thickness changes from baseline to month 12, need for treatment for diabetic macular edema, need for vitrectomy because of occurrence of vitreous hemorrhage, tractional retinal detachment or other complications of DR, and adverse events (AEs) related to treatments. RESULTS: Seventy-seven participants (88.5%) completed the study. Overall baseline demographics were similar for both groups, except for age. At month 12, 92.7% of participants in the RBZ+PRP group presented NV total reduction versus 70.5% of the PRP monotherapy participants (P = 0.009). The number of participants with NVD and NVE reductions was higher with RBZ+PRP (93.3% and 91.4%, respectively) versus PRP (68.8% and 73.7%, respectively), significant only for NVE (P = 0.048). Complete NV total regression was observed in 43.9% in the RBZ+PRP group versus 25.0% in the PRP monotherapy group (P = 0.066). At month 12, the mean BCVA was 75.2 letters (20/32) in the RBZ+PRP group versus 69.2 letters (20/40) in the PRP monotherapy group (P = 0.104). In the RBZ+PRP group, the mean number of PRP treatments over month 12 was 3.5±1.3, whereas in the PRP monotherapy group, it was 4.6±1.5 (P = 0.001). No deaths or unexpected AEs were reported. CONCLUSIONS: Treatment with RBZ+PRP was more effective than PRP monotherapy for NV regression in HR-PDR participants over 12 months.

Retinal findings in membranoproliferative glomerulonephritis.

PURPOSE: To assess the evolution of retinal findings in patients with membranoproliferative glomerulonephritis (MPGN) by funduscopy, intravenous fluorescein angiography and optical coherence tomography. OBSERVATIONS: Three women and one man were followed for a period of 1.5-37 years. Four patients (8 eyes) had drusen detected at first fundus exam at age 24, 29, 50 and 55. Three patients (6 eyes) had diffuse thickening of Bruch's membrane, and two patients (3 eyes) had detachment of the retinal pigment epithelium with serous retinal detachment. Drusen tended to widen over a period of 10-year follow-up in one case. CONCLUSIONS AND IMPORTANCE: Drusen remain the ocular stigmata for MPGN occuring at an early age. The retinal disease is progressive with gradual thickening of Bruch's membrane and occurrence of retinal pigment epithelium detachment.

A Nonrandomized, Open-Label, Multicenter, Phase 4 Pilot Study on the Effect and Safety of ILUVIEN® in Chronic Diabetic Macular Edema Patients Considered Insufficiently Responsive to Available Therapies (RESPOND).

PURPOSE: The aim of this study was to assess the effectiveness and safety of ILUVIEN® in patients with chronic diabetic macular edema (DME) who were insufficiently responsive to prior therapies. METHODS: This is a prospective, nonrandomized, multicenter, open-label, phase 4 pilot study assessing the effectiveness and safety of ILUVIEN® involving 12 patients insufficiently responsive to available therapies. Assessments were performed at screening, baseline, week 1, and months 1, 3, 6, 9, and 12. Demographics, medical/ophthalmic history, prior laser, anti-VEGF, and steroid treatments, and lab tests were recorded at screening. A complete ophthalmic examination and SD-OCT were performed at screening and at all follow-up visits. RESULTS: The patients showed improvements in best-corrected visual acuity (+3.7 letters), with greater improvement among pseudophakic patients (+6.8 letters) compared with phakic patients (-2.5 letters) 12 months after ILUVIEN®. The mean central subfield thickness decrease from baseline to month 12 was statistically significant, with a rapid reduction in the first week. Regarding safety, only 2 patients showed an intraocular pressure (IOP) increase over 25 mm Hg during the study, and the rise in IOP was well managed with eye drops only. CONCLUSIONS: This prospective and pilot study suggests that ILUVIEN® is safe and may be considered effective for chronic DME patients insufficiently responsive to other available therapies as it showed a rapid and sustained improvement of macular edema obtained after treatment with ILUVIEN®.

Pachychoroid neovasculopathy in a male patient: a case report.

Pachychoroid neovasculopathy is a form of type 1 (subretinal pigment epithelium) neovascularization characterized by the involvement of dilated choroidal vessels in areas of increased choroidal thickness. This disease was originally described in three white female patients. Here we report the multimodal evaluation of a clinical case of PN in a white male patient.

Pachychoroid neovasculopathy in a male patient: a case report / Espessamento de coroide com neovascularização em paciente do sexo masculino: relato de um caso

ABSTRACT Pachychoroid neovasculopathy is a form of type 1 (subretinal pigment epithelium) neovascularization characterized by the involvement of dilated choroidal vessels in areas of increased choroidal thickness. This disease was originally described in three white female patients. Here we report the multimodal evaluation of a clinical case of PN in a white male patient.

RESUMO O espessamento de coroide com neovascularização é uma forma neovascularização de coroide tipo 1 (sub-epitélio pigmentar retiniano), que ocorre sobre áreas de aumento da espessura da coroide e vasos coroidianos dilatados. Esta doença foi relatada em três pacientes brancas do sexo feminino. Descrevemos um caso clínico da doença com avaliação multimodal em um paciente do sexo masculino.

Drusenoid retinal pigment epithelium detachments / Descolamento do epitélio pigmentar da retina tipo drusenóide

The authors make a review of drusenoid retinal pigment epithelium detachments(DPDs), a form of retinal pigment epithelium detachment(PED) that evolves from confluent and large soft drusen.Drusenoidretinal pigment epithelial detachments are a recognized element of the "dry" AMD. Until now, no treatment is indicated in drusenoid PEDs. The authors describe the clinical characteristics of drusenoid retinal pigment epithelium detachments (DPEDs) and make a review of the DPEDs related in the international literature. We related in this revision paper the multimodal advanced image exams in two cases of dusenoid retinal pigment epithelium detachments (DPEDs) and the general characteristics of thisfinding associated with Dry Macular degeneration.Upon examination of the ocular fundusDPEDs emerge as well-circumscribed yellow or yellow–white elevations of the RPE that are usually found within the macula.They may show scalloped borders and a slightly irregular surface. When visualized using fluorescein angiography (FA),DPEDs are typically described as faint hyper-fluorescent in the early phase followed by a slow increase in fluorescence throughout the transit stage of the study without late leakage. With optical coherence tomography (OCT), drusenoid PEDs usually show a smooth contour of the detached hyperreflective RPE band that may have an undulating appearance.Drusenoid PEDs encompass far above the ground possibility type of "dry" AMD that develops in relationship with large confluent soft drusen.At this point no treatment is utilized in drusenoid retinal pigment epithelium detachment(DPEDs).

Os autores fazem uma revisão do descolamento do epitélio pigmentar tipo drusenoide e apresentam dois casos desta patologiaassociada à degeneração macular relacionadaà idade descrevendo seus achados em avançados exames com imagem da retina.Neste artigo de revisão da literatura sobre os achados característicos dodescolamento do epitélio pigmentar tipodrusenoide e sua evolução descrevemos os achados de dois casosassociados à degeneração macular relacionada à idade, forma seca, utilizando exames como SD-OCT, fundusautofluorescencia e angiografia com indocianinaverde, além de retinografiacolorida e fluoresceínica. Odescolamento do epitélio pigmentar tipo druside evolui á partir de drussas moles confluentes presentes na degeneração macular relacionada à idade e é também associado a outras doenças retinianas. Até este momento não há tratamento para esta forma da doença.

Predominantly hemorrhagic choroidal neovascular lesion from exsudative age-related macular degeneration treated with intravitreal ranibizumab therapy / Lesão neovascular predominantemente hemorrágica da degeneração macular relacionada à idade, tratada com ranibizumab intravítrea

The authors relate a predominantly hemorrhagic choroidal neovascular lesion from neovascular. Age-related macular degeneration patient case treated with intravitreal ranibizumab therapy. Monthly ranibizumab (six intravitreal injections) displayed a promising response but this limited report is insufficient to guarantee the indication for all predominantly hemorrhagic choroidal neovascular lesion from neovascular age-related macular degeneration. Further studies will be necessary for complete validation of our results for all predominantly hemorrhagic choroidal neovascular lesions from CNV due to AMD...

Os autores apresentam um caso de paciente com lesão neovascular predominantemente hemorrágica com degeneração macular relacionada à idade, tratada mensalmente com injenções intravítrea com ranibizumab. Discutem sua evolução, que apesar da boa resposta terapêutica, necessita de maiores estudos para confirmação de seus resultados...

Intravitreal ranibizumab and bevacizumab therapy for choroidal neovascularization in age-related macular degeneration with extensive pre-existing geographic atrophy.

PURPOSE: To report the response of choroidal neovascularization to intravitreal ranibizumab or bevacizumab treatment in the setting of age-related macular degeneration with extensive pre-existing geographic atrophy of the retinal pigment epithelium. METHODS: This is a retrospective case series of 11 eyes in ten consecutive patients retrieved from a photographic database. The patients were treated with ranibizumab or bevacizumab for neovascular age-related macular degeneration with pre-existing geographic atrophy. Patients were included if they had geographic atrophy at or adjacent to the foveal center of at least 1 disc area in size that was present before the development of choroidal neovascularization. The best corrected visual acuity and optical coherence tomography analysis of the central macular thickness were recorded for each visit. Serial injections of ranibizumab or bevacizumab were administered until there was complete resolution of subretinal fluid on optical coherence tomography. Data over the entire follow-up period were analyzed for overall visual and optical coherence tomography changes. RESULTS: The patients received an average of 7 ± 3 intravitreal injections over the treatment period. Seven of 11 eyes had reduced retinal thickening on optical coherence tomography. On average, the central macular thickness was reduced by 72 ± 115 µm. Six of these 7 eyes had improvement of one or more lines of vision and one had no change. The average acuity change for all patients was -0.04 ± 0.46 logMAR units, which corresponded to a gain of 0.2 ± 4.4 lines of Snellen acuity. The treatment resulted in a good anatomic response with resolution of the subretinal fluid and overall stable visual acuity. CONCLUSIONS: The results of this case series suggest that the use of an intravitreal anti-vascular endothelial growth factor (VEGF) agent (ranibizumab or bevacizumab) for choroidal neovascularization in age-related macular degeneration with pre-existing geographic atrophy is effective. Our results are not as striking as published results from large-scale trials of anti-vascular endothelial growth factor therapy for subfoveal choroidal neovascularization, presumably due to the limitation in the baseline visual acuity caused by the underlying geographic atrophy. The favorable anatomic response with the resolution of subretinal fluid and stable acuity were consistent with other ranibizumab and bevacizumab studies.

Age-related macular degeneration with choroidal neovascularization in the setting of pre-existing geographic atrophy and ranibizumab treatment. Analysis of a case series and revision paper / Avaliação da resposta da injeção intravítrea de ranibizumab em pacientes com neovascularização de coróide da degeneração macular relacionada à idade com atrofia geográfica extensa pré-existente e revisão da literatura

PURPOSE: To report the response of choroidal neovascularization (CNV) to intravitreal ranibizumab treatment in the setting of age-related macular degeneration (AMD) with extensive pre-existing geographic atrophy (GA) and a revision paper. METHODS: This is a revision paper and a retrospective case series of 10 eyes in nine consecutive patients from a photographic database. The patients were actively treated with ranibizumab for neovascular AMD with extensive pre-existing GA. Patients were included if they had GA at or adjacent to the foveal center that was present before the development of CNV. The best corrected visual acuity and optical coherence tomography (OCT) analysis of the central macular thickness were recorded for each visit. Serial injections of ranibizumab were administered until there was resolution of any subretinal fluid clinically or on OCT. Data over the entire follow-up period were analyzed for overall visual and OCT changes. All patients had been followed for at least 2 years since diagnosis. RESULTS: The patients received an average of 6 ± 3 intravitreal injections over the treatment period. Eight eyes had reduced retinal thickening on OCT. On average, the central macular thickness was reduced by 94 ± 101 µm. Eight eyes had improvement of one or more lines of vision, where as one eye had dramatic vision loss and one had no change. The average treatment outcome for all patients was -0.07 ± 4.25 logMAR units, which corresponded to a gain of 0.6 ± 4.4 lines of Snellen acuity. The treatment resulted in a good anatomic response with the disappearance of the subretinal fluid, improved visual acuity, and stabilized final visual results. CONCLUSION: The results of this case series suggest that the use of an intravitreal anti-vascular endothelial growth factor (VEGF) agent (ranibizumab) for CNV in AMD with extensive pre-existing GA is effective. Our results are not as striking as published results from large-scale trials of anti-VEGF therapy for subfoveal CNV, presumably due to the limitation in the baseline visual acuity caused by the underlying GA. The good anatomic response with the disappearance of the subretinal fluid, improved visual acuity, and stabilized final visual results were consistent with other ranibizumab studies.

Investigar os resultados da injeção intravítrea de Ranibizumab em pacientes com neovascularização de coróide da degeneração macular relacionada a idade, com atrofia geográfica extensa, pré-existente e revisão da literatura. MÉTODOS: Este é um artigo de revisão e também um estudo retrospectivo de 9 pacientes, 10 olhos com neovascularização de coróide da degeneração macular relacionada à idade, com atrofia geográfica extensa, pré-existente. Os pacientes incluídos apresentaram atrofia geográfica, envolvendo a fóvea ou adjacente, antes do desenvolvimento da neovascularização de coróide. A melhor correção visual e o exame de tomografia de coerência óptica (OCT) com analise da espessura macular foram registrados em cada visita. As injeções de ranibizumab intravítrea foram feitas até a resolução do líquido sub-retiniano pelo OCT e clinicamente. Todos os pacientes tinham seguimento de 6 meses do diagnostico a 2 anos, com média de 16 meses. RESULTADOS: 10 olhos de 9 pacientes incluídos receberam uma média de 6 ± 3 injeções intravítreas de ranibizumab, sendo que 8 apresentaram redução do espessamento macular pelo OCT. A mácula teve o espessamento reduzido entre 94 ± 101 microns, 8 olhos tiveram melhora de 1 ou mais linhas de visão, um olho teve acentuada diminuição da visão.e um outro não teve alteração. A media do resultado do tratamento em logMAR era -0,07 ± 4.25 correlacionando um ganho de visão na tabela de Snellen entre 0,6 ± 4.4linhas de visão. CONCLUSÃO: Estes resultados sugerem que o uso do Ranibizumab intravítreo para neovascularização de coróide da degeneração macular relacionada à idade em extensa atrofia geográfica pré-existente é efetivo. Existem, entretanto, dificuldades na avaliação da acuidade visual destes pacientes em virtude da extensa Atrofia Geográfica que apresentavam e sobre esta ainda as complicações da neovascularização de coróide, se comparados a casos em que a neovascularização de coróide não ocorre em atrofia geográfica pré-existente.

Intravitreal ranibizumab and bevacizumab therapy for choroidal neovascularization in age-related macular degeneration with extensive pre-existing geographic atrophy / Avaliação da resposta da injeção intravítrea de ranibizumab e bevacizumab em pacientes com neovascularização de coroide da degeneração macular relacionada à idade com atrofia geográfica extensa pré-existente

PURPOSE: To report the response of choroidal neovascularization to intravitreal ranibizumab or bevacizumab treatment in the setting of age-related macular degeneration with extensive pre-existing geographic atrophy of the retinal pigment epithelium. METHODS: This is a retrospective case series of 11 eyes in ten consecutive patients retrieved from a photographic database. The patients were treated with ranibizumab or bevacizumab for neovascular age-related macular degeneration with pre-existing geographic atrophy. Patients were included if they had geographic atrophy at or adjacent to the foveal center of at least 1 disc area in size that was present before the development of choroidal neovascularization. The best corrected visual acuity and optical coherence tomography analysis of the central macular thickness were recorded for each visit. Serial injections of ranibizumab or bevacizumab were administered until there was complete resolution of subretinal fluid on optical coherence tomography. Data over the entire follow-up period were analyzed for overall visual and optical coherence tomography changes. RESULTS: The patients received an average of 7 ± 3 intravitreal injections over the treatment period. Seven of 11 eyes had reduced retinal thickening on optical coherence tomography. On average, the central macular thickness was reduced by 72 ± 115 µm. Six of these 7 eyes had improvement of one or more lines of vision and one had no change. The average acuity change for all patients was -0.04 ± 0.46 logMAR units, which corresponded to a gain of 0.2 ± 4.4 lines of Snellen acuity. The treatment resulted in a good anatomic response with resolution of the subretinal fluid and overall stable visual acuity. CONCLUSIONS: The results of this case series suggest that the use of an intravitreal anti-vascular endothelial growth factor (VEGF) agent (ranibizumab or bevacizumab) for choroidal neovascularization in age-related macular degeneration with pre-existing geographic atrophy is effective. Our results are not as striking as published results from large-scale trials of anti-vascular endothelial growth factor therapy for subfoveal choroidal neovascularization, presumably due to the limitation in the baseline visual acuity caused by the underlying geographic atrophy. The favorable anatomic response with the resolution of subretinal fluid and stable acuity were consistent with other ranibizumab and bevacizumab studies.

OBJETIVO: Avaliação dos resultados da injeção intravítrea de ranibizumab e bevacizumab em pacientes com neovascularização de coróide da degeneração macular relacionada a idade, com atrofia geográfica extensa, pré-existente. MÉTODOS: Este é um estudo retrospectivo de 10 pacientes, 11 olhos com neovascularização de coroide da degeneração macular relacionada à idade, com atrofia geográfica extensa, pré-existente. Os pacientes incluídos apresentaram atrofia geográfica, envolvendo a fóvea ou adjacência, antes do desenvolvimento da neovascularização de coroide. A melhor correção visual e o exame de tomografia de coerência óptica com análise da espessura macular foram registrados em cada visita. As injeções de ranibizumab e bevacizumab intravítrea foram feitas até a resolução do líquido sub-retiniano pela tomografia de coerência óptica e clinicamente. Todos os pacientes tinham seguimento de 6 meses do diagnóstico a 2 anos, com média de 16 meses. RESULTADOS: Onze olhos de 10 pacientes incluídos receberam uma média de 7 ± 3 injeções intravítreas de ranibizumab e bevacizumab, sendo que 7 apresentaram redução do espessamento macular pelo tomografia de coerência óptica. A mácula teve o espessamento reduzido entre 72 ± 115 µm, 6 olhos tiveram melhora de 1 ou mais linhas de visão, um olho teve acentuada diminuição da visão e um outro não teve alteração. A média do resultado do tratamento em logMAR era -0,04 ± 0,46 correlacionando um ganho de visão na tabela de Snellen entre 0,2 ± 4,4 linhas de visão. CONCLUSÕES: Estes resultados sugerem que o uso do ranibizumab e bevacizumab intravítrea para neovascularização de coroide da degeneração macular relacionada à idade em extensa atrofia geográfica pré-existente é eficaz. Há, entretanto dificuldades na avaliação da acuidade visual destes pacientes em virtude da extensa atrofia geográfica que apresentavam e sobre esta ainda a neovascularização de coroide, se comparados a casos em que a neovascularização de coroide não ocorre em atrofia geográfica pré-existente.

Long term follow-up of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome): case report.

PURPOSE: To report a 16-year long-term follow-up of a patient with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome). A 21-year old male was seen in 1994 with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome), first in the left eye, and later in the right eye. He was treated with retinal photocoagulation in areas of retinal ischemia and oral steroids, followed by sequential annual fundus examination and photography for 16 years. Vision improved to 20/25 in both eyes after retinal ischemic areas photocoagulation and oral steroids, and his vision has been maintained for 16 years. Photocoagulation of retinal ischemia and oral steroids are effective for the treatment of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome).

Long term follow-up of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome): case report / Síndrome de vasculite retiniana hemorrágica multifocal aguda (síndrome de Blumenkranz) com seguimento a longo prazo: relato de caso

PURPOSE: To report a 16-year long-term follow-up of a patient with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome). A 21-year old male was seen in 1994 with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome), first in the left eye, and later in the right eye. He was treated with retinal photocoagulation in areas of retinal ischemia and oral steroids, followed by sequential annual fundus examination and photography for 16 years. Vision improved to 20/25 in both eyes after retinal ischemic areas photocoagulation and oral steroids, and his vision has been maintained for 16 years. Photocoagulation of retinal ischemia and oral steroids are effective for the treatment of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome).

Relato de caso com acompanhamento por 16 anos de um paciente com a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz). Um paciente de 21 anos de idade foi diagnosticado em 1994 com a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz), primeiro no olho esquerdo e depois no olho direito. Foi tratado com fotocoagulação retiniana nas áreas retinianas isquêmicas e corticosteroide oral e seguido por exames complementares da retina por 16 anos. A visão melhorou para 20/25 em ambos os olhos após a fotocoagulação retiniana nas áreas isquêmicas da retina e corticosteroide oral permanecendo assim até o momento por 16 anos. A fotocoagulação retiniana nas áreas isquêmicas e o uso de corticosteróide oral são tratamentos efetivos para a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz).

Tratamento da degeneração macular relacionada à idade com neovascularização de coróide extrafoveal: análise de uma série de casos e revisão de literatura / Treatment of nonsubfoveal choroidal neovascularization in age-related macular degeneration: analysis of a cases series and revision paper

A degeneração macular relacionada à idade (DMRI) é uma doença degenerativa da área central da retina freqüentemente associada à perda visual central, em pessoas acima de 55 anos de ambos os sexos, sendo a mais importante causa de cegueira irreversível em adultos nos países desenvolvidos e a terceira causa de cegueira no mundo. OBJETIVO: Avaliar a eficácia da injeção intravítrea de Ranibizumab (anti-VEGF) no tratamento da neovascularização de coróide não subfoveal, podendo ser extrafoveal ou justafoveal, causada pela degeneração macular relacionada à idade exsudativa e revisão da literatura. MÉTODOS: Foi realizado um estudo descritivo e transversal com avaliação de quinze pacientes com neovascularização de coróide extrafoveal ou justafoveal causada por degeneração macular relacionada à idade. Os pacientes foram tratados com uma injeção intravítrea, por mês, no mínimo por três meses consecutivos, de Ranibizumab na dose de 0,5mg, no olho com neovascularização de coróide. Os mesmos foram examinados com um mês de intervalo entre as aplicações das injeções e acompanhados com exames complementares. RESULTADOS: Os resultados da análise dos quinze pacientes que foram incluídos nesta série de casos mostraram que onze (73,3 por cento) pacientes apresentavam neovascularização de coróide extrafoveal e quatro (26,6 por cento) justafoveal. Oito (53,3 por cento) apresentavam a forma oculta e sete (46,6 por cento) tinham lesões clássicas. A média de injeções realizadas foi de 3,67, sendo o menor número de injeções 3 e o maior 6 injeções. Oito (53,3 por cento) pacientes apresentaram resolução do quadro exsudativo neovascular com o máximo de três injeções e apenas um (6,67 por cento) paciente necessitou de seis injeções para resolução do seu quadro. A acuidade visual máxima alcançada foi de 20/30, e ocorreu em cinco (33,3 por cento) pacientes. A média de acuidade visual no momento do diagnóstico foi de 0,44logMAR e a média final de 0,27logMAR Na avaliação final dos pacientes após os seis meses de estudo, a média de linha de visão ganha foi de 1,87 linha de acuidade visual pela tabela de Snellen, sendo que todos os 15 pacientes ganharam uma ou mais linhas de visão. CONCLUSÃO: No tratamento dos pacientes com degeneração macular relacionada à idade e neovascularização de coróide extrafoveal a injeção de Ranibizumab mostrou-se eficaz, podendo ser a opção como indicação inicial de tratamento nestes casos.

Age-related macular degeneration is a major cause of central vision loss and is the leading cause of blindness for people aged over 60 years. PURPOSE: To investigate the efficacy of intravitreal injection of Ranibizumab (anti-VEGF) in the treatment of choroidal neovascularization nonsubfoveal, extra-foveal or juxta-foveal, caused by age-related macular degeneration and revision paper. METHODS: The study design was descriptive and transverse.15 patients with nonsubfoveal choroidal neovascularization caused by age-related macular degeneration, were treated with intravitreal injection of Ranibzumab per month, at least for three consecutive months. Patients were examined at one month interval between the injections and evaluated using visual acuity testing with Snellen charts, fluorescein angiography, and optical coherence tomography scans. RESULTS: There were 11extra-foveal lesions (73.3 percent) and 4 juxta-foveal lesions (26.6 percent). Seven lesions were predominantly classic (46.6 percent) and eight lesions were occult (53,3 percent). The mean number of injections performed was 3.67 and the lowest number of injections 3 and 6 larger injections. Eight (53.3 percent) patients had complete resolution of the exudative neovascular condition with a maximum of three injections and only one (6.67 percent) patient required six injections to resolution his condition. The best visual acuity achieved was 20/30, and occurred in five (33.3 percent) patients. The mean visual acuity at diagnosis was 0.44 logMAR and 0.27 logMAR final average. In the final evaluation of patients after six months of study, the average line of sight gains were 1.87 line of visual acuity by Snellen chart. All 15 patients gained one or more lines of vision. CONCLUSION: In the treatment of patients with nonsubfoveal choroidal neovascularization in age-related macular degeneration, injection of Ranibizumab was effective and could be an option as an indication of initial treatment in these cases.

Polypoidal choroidal vasculopathy causing cystoid macular edema and the response to Ranibizumb intravitreal treatment / Vasculopatia coroidiana polipoidal causando edema macular cistóide e a resposta ao tratamento com Ranibizumab

PURPOSE: To report a polypoidal vascular choroidopathy clinical case causing cystoid macular edema and the response to Ranibizumab intravitreal treatment. METHODS: A 62-year old caucasian woman was referred by her comprehensive ophthalmologist for retinal avaliation. On presentation best corrected visual acuity was 20/100 in the left eye and 20/20 in right eye.Anterior segment examination was unremarkable in both eyes. Clinical examination and FA on the left eye demonstrated numerous small drusen and a cystoid macular edema due leakage from any polips in justapapilar region and from polips in the superior arcade vascular region and subretinal fluid and cystic change in the OCT.The right eye had FA normal. The patient refused to submitt a ICGV angiography. The patient was treated by intravitreal ranibizumab injections in the left eye every 4 weeks, 3 injections ,three months. RESULTS: The patient showed resolution both of cystic change and subretinal fluid in the OCT, and the visual acuity in the six months follow-up improved to 20/25. The patient was followed by 18 months at this time and the visual acuity remained stable 20/25. CONCLUSION: We reported a patient case of cystoid macular edema from a polypoidal choroidal vaculopathy that responded well to ranibizumab intravitreal injection as monotheraphy with disappearance of the initial subretinal fluid and cystic change in OCT follow-up and stop the polips.

OBJETIVO: Relatar um caso de paciente com Vasculopatia coroidiana polipoidal com edema macular cistóide e a resposta ao tratamento com Ranibizumab intravítrea como monoterapia MÉTODOS: Uma paciente com 62 anos foi referida por seu oftalmologista para avaliação retiniana . Apresentava acuidade visual com correção de 20/100 no olho esquerdo e 20/20 no olho direito. A avaliação do segmento anterior era normal em ambos os olhos. No exame de fundo de olho e retinografia fluoresceínica apresentava numerosas drussas pequenas e edema macular cistóide devido a vazamentos de alguns pólipos vasculares coroidianos na arcada vascular superior e ainda fluido sub-retiniano e alteração cística no OCT . O olho direito apresentava angiografia fluoresceínica da retina e OCT normais.A paciente recusou-se a se submeter a vídeoangiografia com indocianina verde. A paciente foi tratada com injeção intravítrea de Ranibizumab como monoterapia, sendo uma injeção a cada quatro semanas, três injeções em três meses. RESULTADOS: A paciente apresentou resolução da alteração cística e do fluido sub-retiniano, ambos presentes no OCT prévio ao tratamento no olho esquerdo. A acuidade visual melhorou para 20/25 após 6 meses de tratamento. A paciente permanence com acuidade visual estável de 20/25 após 18 meses de acompanhamento. CONCLUSÃO: Reportamos um caso de paciente com edema macular cistóide originada da vasculopatia coroidiana polipoidal que respondeu ao tratamento com Ranibizumab intravítrea, como monoterapia com desaparecimento do fluido sub-retiniano e da alteração cística no OCT tendo cessado o vazamento dos pólipos que eram a causa do edema macular cistóde.

Intravitreal ranibizumab and bevacizumab for the treatment of nonsubfoveal choroidal neovascularization in age-related macular degeneration.

PURPOSE: To investigate the efficacy of vascular endothelial growth factor-specific (VEGF) monoclonal antibodies in the treatment of choroidal neovascularization secondary to age-related macular degeneration (AMD) that does not extend beneath the foveal center (nonsubfoveal CNV). METHODS: The study design was a retrospective chart review of consecutive patients over a two-month period under active treatment with bevacizumab and/or ranibizumab for neovascular AMD. Patients with neovascularization within the macula that did not extend beneath the center of the foveal avascular zone, along with at least one large drusen (>125 micro) or many intermediate size (63-124 micro) drusen were included. Best corrected Snellen visual acuity and optical coherence tomography (OCT) analysis of the central macular thickness was recorded for each visit. Serial injections of bevacizumab and/or ranibizumab were administered until there was resolution of subretinal fluid clinically or by OCT. Data over the entire follow-up period were analyzed for overall visual acuity and OCT changes. All patients had follow-up since diagnosis of at least 6 months (mean=9.6 months). RESULTS: Of the thirteen included patients, eleven had reduction of retinal thickening in the area involved by the CNV. The remaining two patients did not have OCT data available but had no fluid or activity on clinical examination at last follow-up. One patient (8%) lost one line of vision; one (8%) remained stable, and eleven (84%) gained one or more lines of visual acuity. Three patients (23%) gained three or more lines. The average treatment outcome for all patients was a gain of 1.7 +/- 1.3 lines of Snellen acuity. Both therapeutic agents were effective, with an average gain of 1.6 +/- 0.6 lines for patients treated with bevacizumab, 1.5 +/- 1.9 lines gained for patients treated with ranibizumab and 2.5 +/- 0.7 lines gained in the two patients who received both agents over the course of their treatment. CONCLUSIONS: The use of intravitreal anti-VEGF agents for nonsubfoveal CNV in AMD is effective. Our results are comparable to published results from large-scale trials of anti-VEGF therapy for subfoveal CNV. Our data support the idea that bevacizumab or ranibizumab appear to be the treatment of choice for AMD patients with nonsubfoveal CNV.

Intravitreal ranibizumab and bevacizumab for the treatment of nonsubfoveal choroidal neovascularization in age-related macular degeneration / Ranibizumab e bevacizumab intravítreo no tratamento da neovascularização de coróide extrafoveal da degeneração macular relacionada à idade

PURPOSE: To investigate the efficacy of vascular endothelial growth factor-specific (VEGF) monoclonal antibodies in the treatment of choroidal neovascularization secondary to age-related macular degeneration (AMD) that does not extend beneath the foveal center (nonsubfoveal CNV). METHODS: The study design was a retrospective chart review of consecutive patients over a two-month period under active treatment with bevacizumab and/or ranibizumab for neovascular AMD. Patients with neovascularization within the macula that did not extend beneath the center of the foveal avascular zone, along with at least one large drusen (>125 µ) or many intermediate size (63-124 µ) drusen were included. Best corrected Snellen visual acuity and optical coherence tomography (OCT) analysis of the central macular thickness was recorded for each visit. Serial injections of bevacizumab and/or ranibizumab were administered until there was resolution of subretinal fluid clinically or by OCT. Data over the entire follow-up period were analyzed for overall visual acuity and OCT changes. All patients had follow-up since diagnosis of at least 6 months (mean=9.6 months). RESULTS: Of the thirteen included patients, eleven had reduction of retinal thickening in the area involved by the CNV. The remaining two patients did not have OCT data available but had no fluid or activity on clinical examination at last follow-up. One patient (8 percent) lost one line of vision; one (8 percent) remained stable, and eleven (84 percent) gained one or more lines of visual acuity. Three patients (23 percent) gained three or more lines. The average treatment outcome for all patients was a gain of 1.7 ± 1.3 lines of Snellen acuity. Both therapeutic agents were effective, with an average gain of 1.6 ± 0.6 lines for patients treated with bevacizumab, 1.5 ± 1.9 lines gained for patients treated with ranibizumab and 2.5 ± 0.7 lines gained in the two patients who received both agents over the ...

OBJETIVO: Investigar a eficácia dos anti-angiogênicos ranibizumab e bevacizumab injetados intravítreo, no tratamento de pacientes com neovascularização de coróide extrafoveal em degeneração macular relacionada à idade. MÉTODOS: Foram avaliados 13 pacientes com neovascularização de coróide extrafoveal em degeneração macular relacionada à idade do Setor de Retina e Vítreo do Departamento de Oftalmologia da Universidade de Iowa, Estados Unidos, que foram tratados por meio de injeção vítrea de ranibizumab e bevacizumab separadamente, em um período de dois anos. Após as injeções iniciais os pacientes foram acompanhados por exames de OCT e as injeções foram repetidas com 4 a 8 semanas dependendo da presença de líquido sub-retiniano e macular. RESULTADOS: Doze pacientes tiveram ganhos de linhas de visão se comparados com a visão antes do tratamento. Onze pacientes tiveram redução do espessamento retiniano na área envolvida pelo CNV e diminuição e resolução do espessamento macular na sua visita final de avaliação. Um paciente (8 por cento) perdeu uma linha de visão se comparado à visão prévia ao tratamento. Pacientes tratados com o ranibizumab tiveram em média 2,5 ± 0,7 ganhos de linhas de visão. Pacientes tratados com bevacizumab tiveram em média 1,6 ± ganhos de linhas de visão. CONCLUSÃO: No tratamento de pacientes com a neovascularização de coróide extrafoveal em degeneração macular relacionada à idade, a injeção vítrea de ranibizumab ou bevacizumab é efetiva e pode ser a opção de escolha.

Remote hypofluorescent dots in recurrent ocular toxoplasmosis on indocyanine green angiography

PURPOSE: To report the findings of indocyanine green angiography performed in patients with recurrent ocular toxoplasmosis. METHODS: Institutional prospective analysis of 23 eyes from 23 immunocompetent patients with recurrent ocular toxoplasmosis aged between 17 and 41 years. These patients underwent a complete ocular examination including indocyanine green angiography. RESULTS: Multiple hypofluorescent spots distant from the recurrent active lesion of retinochoroidal toxoplasmosis were found in 26.08 percent of the patients. We also found multiple hypofluorescent satellite dots in 69.56 percent of the patients. CONCLUSION: These remote dots seen suggest either a more widespread choroidal involvement in this disease and this can represent simply remote collections of inflammatory cells or subclinical infection.

OBJETIVOS: Relatar os achados da angiografia com indocianina verde, realizados em pacientes com recidiva de toxoplasmose ocular. MÉTODOS: Análise institucional e prospectiva de 23 olhos de 23 pacientes, imunocompetentes com idades entre 17 e 41 anos. Estes pacientes foram submetidos a exame oftalmológico de rotina e a angiografia com indocianina verde. RESULTADOS: Foram encontrados múltiplos pontos hipofluorescentes distantes da lesão ativa recidivada da toxoplasmose retino-coroidiana em 26,08 por cento dos casos, chamados por nós de pontos remotos e encontramos também, pontos hipofluorescentes circundando ou próximos da lesão ativa recidivada em 69,56 por cento dos casos. CONCLUSÃO: Os pontos hipofluorescentes distantes da lesão ativa recidivada, chamados de pontos remotos, não descritos previamente na doença, demonstram um maior envolvimento da coróide e podem significar coleções remotas de células inflamatórias ou infecção subclínica.

Ocular histoplasmosis-like syndrome: a report from a nonendemic area.

PURPOSE: To report some cases of ocular histoplasmosis-like syndrome from a nonendemic area. DESIGN: Observational case series. METHODS: This is a prospective study of 16 eyes from 8 immunocompetent patients evaluated between January 2001 to September 2005. Six patients were female and 2 male aged between 20 to 44 years, average 28 years. All patients presented clinical features that resembled ocular histoplasmosis. All patients had a negative antibody test for histoplasmosis and negative medical and laboratory evaluation of toxoplasmosis, syphilis, and tuberculosis. All patients were submitted to a complete ocular examination including fluorescein angiography. One patient was submitted to indocyanine green angiography. RESULTS: Five patients presented the classical triad of clinical features that include peripapillary scarring, histo spots, choroidal neovascularization, one patient presented enlargement of atrophic chorioretina scar, one patient presented multiple retinal pigment epithelial detachment, one, neovascularized retinal pigment epithelial detachment. Another patient presented only histo spots. CONCLUSION: These findings of ocular histoplasmosis-like syndrome in patients with negative antibody serum test from a nonendemic area suggest that other agents could cause these similar fundus findings of ocular histoplasmosis.