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

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

Malignant conjunctival T cell lymphoma diagnosed by punch biopsy as a primary manifestation of systemic cancer.

This report documents a case of T cell lymphoma manifesting only with a conjunctival mass. A 67-year-old man underwent a diagnostic punch biopsy, histopathological examination, and immunohistochemical study for a pink-yellow colored mass infiltrating the bulbar conjunctiva in the lower fornix of the eyelid. A biopsy specimen of the conjunctival mass was found histopathologically to be a malignant T cell lymphoma. Systemic involvement was diagnosed within four weeks after the initial diagnosis by computed tomography, showing evidence of extension at the level of the ethmoidal cells, optic nerve, periorbital tissue, and pancreas. T cell lymphoma of the conjunctiva as a primary manifestation of systemic cancer is an uncommon entity. Punch biopsy may be the first diagnostic pathway useful to initiate a search for systemic involvement of a malignant lymphoid tumor of T cell lineage.

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

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

A long-term study of photodynamic therapy with verteporfin for choroidal neovascularization at the edge of chorioretinal atrophy in pathologic myopia.

PURPOSE: To evaluate the effects of verteporfin photodynamic therapy (PDT) on choroidal neovascularization (CNV) at the edge of chorioretinal atrophy in eyes with pathologic myopia. PROCEDURES: Twenty eyes of 20 consecutive patients were treated according to Verteporfin in Photodynamic Therapy criteria. The patients were divided into 3 groups based on CNV location and were followed up with clinical and fluorescein angiographic examinations to evaluate visual acuity (VA) changes and number of treatments. RESULTS: The mean follow-up was 35 months. In group 1 (n = 8; subfoveal CNV), VA declined from 20/73 (0.56 ± 0.26 logMAR) to 20/115 (0.76 ± 0.30 logMAR; p = 0.192). In group 2 (n = 6; juxtafoveal CNV), VA improved from 20/69 (0.54 ± 0.25 logMAR) to 20/46 (0.36 ± 0.16 logMAR; p = 0.176). In group 3 (n = 6; extrafoveal CNV), VA worsened from 20/50 (0.40 ± 0.21 logMAR) to 20/91 (0.66 ± 0.49 logMAR; p = 0.292). CONCLUSIONS: PDT showed inhibitory effects on myopic CNV arising at the edge of chorioretinal atrophy, especially in young adult myopic eyes with juxtafoveal neovascular membranes.

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

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

Intravitreal ranibizumab injection for nonarteritic ischemic optic neuropathy.

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

Verteporfin photodynamic therapy combined with intravitreal triamcinolone for choroidal neovascularization due to angioid streaks.

PURPOSE: To report the visual outcome of photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide (IVTA) for choroidal neovascularization (CNV) secondary to angioid streaks (AS). METHODS: Five eyes of five consecutive patients (mean age 45 +/- 10 years) with CNV secondary to AS were treated by combination of PDT and IVTA. TA (4 mg/0.1 mL) was injected 7 days before PDT. RESULTS: All patients completed the 12-month follow-up. CNV was subfoveal in three cases and extrafoveal in two. Median best-corrected visual acuity (BCVA) was 0.3 LogMAR (70 letters) at baseline (range 1.3-0.1), and 0.5 LogMAR (60 letters) at the final examination (range 1.0-0.1). At 12 months, one patient had severe visual deterioration, with a loss of seven lines of VA; Two patients lost up to three lines. One patient had no change in BCVA and the fifth gained nine lines of VA. Two patients received one further combination of PDT and IVTA after the first combination treatment. All eyes showed the CNV closure at the 12-month follow-up visit. CONCLUSIONS: Combination of PDT and IVTA may reduce the need for retreatment and could be potentially useful for preserving vision in some patients with CNV due to AS.

Autofluorescence imaging of cystoid macular edema in diabetic retinopathy.

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

Autofluorescence in adult-onset foveomacular vitelliform dystrophy.

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

Photodynamic therapy with verteporfin for choroidal neovascularization associated with retinal pigment epithelial detachment in age-related macular degeneration.

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

Photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularization in pathologic myopia: a long-term follow-up study.

PURPOSE: To assess the effect of verteporfin photodynamic therapy (PDT) in juxtafoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM). DESIGN: Prospective, open-label, consecutive, interventional case series. METHODS: We prospectively followed a series of 48 consecutive patients (49 eyes) with pathologic myopia (> or = 6 diopters) who received verteporfin PDT for juxtafoveal CNV. This population was divided into two groups based on age (group A < or = 55 years old, group B >55 years old), in three subgroups based on CNV lesion size, and in three categories based on refractive error at baseline. RESULTS: The median follow-up was 32 months (range, 12 to 56 months). Visual acuity (VA) improved by 1 or more Snellen lines in 18 eyes (37%), decreased in 12 eyes (24%), and remained stable in 19 eyes (39%). The median number of lines gained was 2.15, while the median number of lines lost was 2.4. The final mean VA in group A (mean age, 43.9 years) was 20/50 (logMAR 0.41, standard deviation [SD] 0.3) and significantly better (P = .01) than the 20/105 (logMAR 0.72, SD 0.5) in group B (mean age, 67.8 years). Neither CNV size nor refractive error magnitude influenced visual outcomes. CONCLUSION: Verteporfin PDT is a promising treatment modality resulting in stable or improved vision in 76% of the myopic eyes with juxtafoveal CNV. Younger patients appear to respond more favorably to treatment.

Choroidal ischemia after photodynamic therapy with verteporfin for choroidal neovascularization.

PURPOSE: To report delay in choroidal perfusion suggestive of ischemia after photodynamic therapy (PDT) with verteporfin for choroidal neovascularization (CNV). DESIGN: Observational case series. METHODS: Retrospective review of all patients who developed choroidal ischemia after PDT. RESULTS: This vascular change was found in eight (2.1%) of 373 eyes of patients treated for CNV as a result of age-related macular degeneration (AMD) and in one (0.9%) of 114 eyes treated for pathologic myopia. A decrease of 3 lines of vision was reported to occur one week after treatment in patients with AMD. At the 12-month examination, patients did not exhibit any marked changes in visual acuity. CONCLUSIONS: Choroidal ischemia was an uncommon manifestation owing to the selectivity of verteporfin therapy and the existence of abundant anastomotic vascular connections in the choroid. The low incidence of this vascular event should not preclude counseling PDT in eyes that could benefit greatly from this therapy.

Photodynamic therapy with verteporfin of choroidal malignancy from breast cancer.

PURPOSE: To evaluate the effectiveness of photodynamic therapy (PDT) with verteporfin for treating a submacular choroidal metastasis from breast cancer. DESIGN: Interventional case report. METHODS: Multispot PDT irradiation of tumor surface was performed in a 45-year-old woman who had a choroidal metastasis from breast cancer in the right eye. The response of uveal metastasis to photodynamic action was investigated with the use of fluorescein angiography and optical coherence tomography (OCT). RESULTS: Within four months after photosensitization, the exudative detachment of the macula was resolved, with improvement in the visual acuity following decrease in the tumor vascular permeability and absorption of subretinal fluid. CONCLUSIONS: PDT can effectively destroy a malignant tissue and induce an antitumor activity. PDT as an adjunct to chemotherapy is a possible treatment and might be appropriate for patients who require ocular treatment only.

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

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