Non-responders to bevacizumab (Avastin) therapy of choroidal neovascular lesions.

AIMS: To determine the characteristics of "non-responders" to intravitreal bevacizumab treatment in choroidal neovascularisation (CNV). METHODS: Forty-three patients with visual loss due to neovascular age-related macular disease (ARMD) (44 eyes) underwent intravitreal injections of 1.25 mg (0.05 ml) bevacizumab and were followed up every 4 weeks for 2, 3 or 6 months. Re-injection was performed when persistent leakage of the CNV was determined by fluorescein angiography and retinal oedema was assessed by optical coherence tomography (OCT). Non-responders were defined as those patients having reduced or stable visual acuity at the last follow-up. RESULTS: 45% of the patients were non-responders. In this group the initial CNV size was significantly larger than in the responders. Initial reading ability was significantly lower in non-responders, but the initial foveal oedema was similar in both groups. Gains in mean visual acuity and reading ability were independent of lesion type. The proportion of non-responders to responders in the different lesion type groups was equally distributed. Only patients with the classic type of CNV seemed to respond better. CONCLUSIONS: In this study initial reasons for non-responders to intravitreal bevacizumab treatment in CNV are given. The efficiency of bevacizumab depends on initial lesion size and initial reading ability, but is independent of the amount of intraretinal and subretinal fluid. There was no general ineffectiveness of bevacizumab with any particular lesion type.

Autologous translocation of the choroid and retinal pigment epithelium in patients with geographic atrophy.

PURPOSE: To evaluate the functional and anatomical outcomes of autologous translocation of peripheral choroid and retinal pigment epithelium (RPE) in patients with geographic atrophy. DESIGN: Prospective nonrandomized study. PARTICIPANTS: Twelve consecutive patients with geographic atrophy secondary to age-related macular degeneration presenting with recent loss of reading vision. METHODS: An autologous peripheral full-thickness graft of RPE, Bruch's membrane, and choroid was positioned under the macula in patients with geographic atrophy. MAIN OUTCOME MEASURES: Functional tests included Early Treatment Diabetic Retinopathy Study distant vision, reading (Radner Test, measured as logarithm of the reading acuity determination [logRAD]), threshold static perimetry, and determination of the point of fixation. Fluorescein and indocyanine green angiography, autofluorescence, and optical coherence tomography served to evaluate the anatomical outcome in a 6-month follow-up (12 months in 7 patients). RESULTS: Preoperative visual acuity (VA) ranged from 20/800 to 20/40 (mean, 0.6+/-0.4 logarithm of the minimum angle of resolution), and reading vision from 1.1 to 0.5 logRAD (mean, 0.8+/-0.2). Three patients were unable to read. Six months after surgery, VA ranged from hand movements to 20/32, with an increase of > or =5 letters in 2 eyes. Two patients without reading ability preoperatively were able to read after surgery. Reading was possible in a total of 8 patients after 6 months (1.3-0.4 logRAD). In 7 patients who were observed for 1 year, VA remained stable (+/-1 line) in 5 eyes and decreased in 2 eyes between 6 months' and 1 year's follow-up. In all eyes but 2, revascularization was visible on indocyanine green angiography as early as 3 weeks after surgery. Autofluorescence of the RPE was independent of revascularization of the graft and persisted throughout follow-up. Four eyes had unstable fixation and/or extrafoveal fixation before surgery. Two of these eyes stabilized during follow-up. Areas overlying atrophic areas demonstrated low threshold sensitivities that persisted after translocation of a free graft with only limited recovery. Revisional surgery due to proliferative vitreoretinopathy was required in 5 eyes. CONCLUSIONS: The translocation of a full-thickness graft usually results in a vascularized and functioning graft in patients with geographic atrophy, although is associated with a high risk of complications and visual loss. Longer follow-up is necessary to learn about the long-term survival and functionality of the graft.

Autologous translocation of the choroid and retinal pigment epithelium in age-related macular degeneration.

PURPOSE: To evaluate the autologous translocation of peripheral choroid and retinal pigment epithelium (RPE) in 45 eyes of 43 patients with age-related macular degeneration (AMD). DESIGN: Prospective nonrandomized study. METHODS: All patients had visual loss due to AMD (n = 5 classic membranes, n = 14 occult, n = 2 mixed, n = 16 pigment epithelial detachment (PED), n = 5 subretinal hemorrhage, n = 3 geographic atrophy). After extraction of the neovascular complex, an autologous peripheral full-thickness explant of RPE, Bruch membrane, and choroid was translocated from the midperiphery to the macula. RESULTS: Preoperative distant visual acuity ranged from 20/800 to 20/40. Reading vision ranged from 1.4 logarithm of reading acuity determination (logRAD) to 0.5 logRAD (0.04 to 0.32 Snellen equivalent). Revision surgery was required in 22 eyes as a result of proliferative vitreoretinopathy (PVR), retinal detachment, macular pucker, or vitreous hemorrhage. In eight patients, the patch was renewed. At six months, distant visual acuity ranged from light perception to 20/50 (increase of 15 letters in four eyes). Reading vision ranged from 1.4 to 0.4 logRAD. Visual outcome was unrelated to the type of AMD. Vascularization of the transplant was visible on indocyanine green (ICG) angiography in 40 of 42 eyes. In most patients, autofluorescence of the pigment epithelium was coincident with revascularization of the graft. Fixation on the patch was positively related to visual acuity. CONCLUSIONS: Autologous translocation of a full-thickness transplant of choroid and RPE usually results in a vascularized and functioning graft. Vascularization was even achieved in patients with geographic atrophy. Fixation stability and microperimetry before the patch translocation may be helpful in selecting patients who will profit from surgery.