Large-spot subthreshold transpupillary thermotherapy for chronic serous macular detachment.

PURPOSE: To report the effect of subthreshold transpupillary thermotherapy (TTT) in treating serous detachment of the neurosensory retina secondary to chronic central serous chorioretinopathy (CCSC). METHODS: Seven eyes from five patients with CCSC, persistent serous detachment of the neurosensory retina and a clinical course of between 12 and 60 months were treated. All eyes received large-spot TTT guided by indocyanine green angiography (ICGA). Subthreshold TTT was performed using an 810 nm diode laser with a spot size of 3.0 mm (power was set at 350 mW). Treatment was applied for 60 seconds to the areas of choroidal hyperfluorescence on ICGA. RESULTS: The mean number of TTT sessions was 1.4 ± 0.5. All eyes were followed up for at least 6 months (mean 9.6 ± 3.2 standard deviation; range 6-12 months). The mean logarithm of the minimum angle of resolution best-corrected visual acuity was significantly better compared with baseline. All TTT-treated eyes had stable or improved vision (P < 0.001). Mean optical coherence tomography (OCT) central foveal thickness was significantly lower in all patients (P < 0.001) compared with pretreatment OCT, with a reduction in subretinal fluid and resolution of serous detachment associated with anatomical fovea restoration. No patient had any treatment-related side effects. CONCLUSION: Modified subthreshold TTT appears to have a beneficial effect in treating patients with CCSC and persistent neurosensory detachment. The encouraging results and lack of visually significant complications suggest that further investigation is warranted.

Single-session photodynamic therapy combined with intravitreal bevacizumab for retinal angiomatous proliferation.

PURPOSE: To evaluate the efficacy of single-session photodynamic therapy (PDT) combined with intravitreal bevacizumab (IVB) in the treatment of retinal angiomatous proliferation (RAP) in age-related macular degeneration. METHODS: In this pilot study, eight patients with RAP underwent indocyanine green angiography (ICGA)-guided single-session verteporfin PDT followed by intravitreal bevacizumab (1.25 mg) within a 0-day +/- 1-day interval. All patients were naïve to treatment. Best-corrected visual acuity (BCVA), fluorescein angiography, ICGA, and optical coherence tomography (OCT) were performed at baseline and at each follow-up visit. All patients received three consecutive monthly IVB injections; thereafter, retreatment with bevacizumab was performed in the case of worsening BCVA or a deterioration of angiographic or OCT findings. RESULTS: All patients had 9 months of follow-up. Complete resolution of angiographic leakage was achieved in all eyes at 9 months. A significant improvement in the mean BCVA was observed at 1 month, 3 months, 6 months, and 9 months after combined treatment (P = 0.004). Visual acuity improved in 62.5% and was stable in 37.5% of cases. No patients had a decrease in BCVA of three or more lines during follow-up. Mean central macular thickness was significantly reduced in all patients (P < 0.0001) as controlled at 1-month, 3-month, 6-month, and 9-month intervals from initial treatment. The mean number of injections for the 9 months were 3.2 +/- 0.4. No ocular complications or systemic events developed. CONCLUSION: Sequenced combined treatment with single-session PDT and IVB injections may be useful in treating RAP, reducing or eliminating retinal edema, and improving or stabilizing visual acuity. Further investigations are warranted to outline the appropriate treatment paradigm for combination therapy.

Long-term choroidal vascular changes after iodine brachytherapy versus transpupillary thermotherapy for choroidal melanoma.

PURPOSE: To compare long-term choroidal vascular changes after iodine-125 brachytherapy (IBT) versus transpupillary thermotherapy (TTT) used as primary treatment of small choroidal melanoma. METHODS: Ninety-five small choroidal melanomas were randomized: 49 eyes with TTT and 46 eyes with IBT alone. Fluorescein and indocyanine green angiography (ICGA) were performed at 3-month intervals during the first year, and every 6 months thereafter. RESULTS: Mean follow-up was 56.2 months (range, 24-118 months; SD, 22.6). Tumor regressed in 45 (92%) TTT-treated vs 45 (98%) IBT-treated eyes (p=0.397). Four TTT-treated and one IBT-treated tumor recurred. Occlusion of choriocapillaris was present in all TTT and IBT cases. Closure of medium and large choroidal vessels was observed in 17 (35%) TTT-treated vs 44 (96%) IBT-treated eyes (p<0.001). Choroidal vascular remodeling was detected in 20 (41%) TTT-treated and 16 (35%) IBT-treated eyes (p=0.693). Retinochoroidal anastomosis was present in 4 of the 37 (11%) TTT-treated eyes with patency of medium and large choroidal vessels, but never observed in the IBT-treated eyes, and was associated with tumor recurrence. Among IBT-treated eyes, segments of choroidal vascular wall ICG staining and choroidal aneurysmal changes were detected in 30 (65%) and 7 (15%), respectively. These changes were never detected in TTT-treated cases (p<0.0001 and p=0.015, respectively). CONCLUSIONS: The pattern of tumor choroidal vascular changes following IBT and TTT differs. TTT is less effective in closing all tumor vasculature. The role of long-term choroidal vascular remodeling observed after these two treatments needs longer follow-up.

Long-term outcome of transpupillary thermotherapy as primary treatment of selected choroidal melanoma.

PURPOSE: To evaluate prospectively, on a long-term range, the clinical outcomes of transpupillary thermotherapy (TTT) as primary treatment of selected choroidal melanoma. METHODS: Seventy-seven eyes of 77 patients affected by small posterior choroidal melanoma were treated with TTT as a sole treatment, using an infrared diode laser at 810 nm according to a standard procedure. Follow-up was longer than 36 months. RESULTS: Seventeen tumours (22%) were parapapillary (PP) and 60 tumours (78%) were non-parapapillary (NPP) in location. Mean follow-up was 55.2 ± 17.9 months in PP tumours and 44.3 ± 23.7 months in NPP tumours. Thirteen (76%) PP tumours and 55 (92%) NPP tumours regressed (P > 0.05). Nine tumours recurred: seven were retreated using Iodine-125 brachytherapy and two were enucleated (both parapapillary). Four patients (5%) developed liver metastasis and died during follow-up. Tumour thickness was found to be predictive of recurrence (odds ratio: 4.3). Complications were found in 20 eyes (26%): macular pucker in 11 (14%), macular oedema in three (4%), retinal vein occlusion in six (8%), vitreous and subretinal haemorrhage in two (3%) and neovascular glaucoma in three (4%). PP tumours had more local complications (but this was not statistically significant; P > 0.05). Complications appeared more frequently in tumours treated with more than one TTT session (P = 0.01), and time-risk to develop intraocular complications seems longer in the PP group, without reaching statistical significance (P = 0.07). CONCLUSION: TTT may be a clinically effective method for conservative treatment of selected, non-parapapillary, small posterior choroidal melanoma.

Spontaneous resolution of retinal angiomatous proliferation.

PURPOSE: To describe a case of spontaneous resolution of retinal angiomatous proliferation (RAP) in a patient with age-related macular degeneration. METHODS: A 67-year-old woman complained about progressive visual loss in the right eye. Visual acuity was 20/50 in the right eye and 20/20 in the left eye. Detailed ophthalmoscopic examination, fluorescein angiography, indocyanine green angiography, and optical coherence tomography of the right eye were performed. RESULTS: Fundus examination of the right eye revealed a small extrafoveal hemorrhage with a few hard exudates around a serous retinal elevation. Fluorescein angiography showed late-phase staining with an area of hyperfluorescence interpreted as occult neovascularization. The middle-phase indocyanine green angiograms showed a focal "hot spot" with late intraretinal leakage. Optical coherence tomography performed through the hot spot shown by indocyanine green angiography demonstrated a localized area of increased intraretinal reflectivity and subfoveal optically empty areas corresponding to serous retinal detachment. The patient was diagnosed with stage II RAP. Treatment was recommended, but the patient was lost to follow-up. Five months later, the patient returned to our department with visual acuity of 20/30 in the involved eye. Spontaneous resolution of the angiographic leakage shown by both fluorescein angiography and indocyanine green angiography and restoration of the normal retinal layers by optical coherence tomography were observed. CONCLUSIONS: To our knowledge, this is the first known case in which angiographic and optical coherence tomography findings depicted the spontaneous regression of RAP.

Acute bilateral vitreo-retinal hemorrhages following oxygen-ozone therapy for lumbar disk herniation.

PURPOSE: To describe a case of acute bilateral intraocular hemorrhages occurring after injection of oxygen-ozone (O(2)O(3)) mixture. DESIGN: Observational case report. METHODS: A 45-year-old woman complained about acute bilateral visual loss after intradiscal and periganglionic injection of gas mixture (O(2)O(3)) for lumbar disk herniation. Detailed ophthalmologic examination; magnetic resonance imaging (MRI) of brain and spinal cord; and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser membranotomy in the left eye was performed. RESULTS: Ophthalmoscopy revealed a premacular hemorrhage involving the left macula. In the right eye multiple, flat, retinal hemorrhages around the optic disk and the posterior pole were observed. The MRI scan for intracranial hemorrhage was unremarkable. Drainage of the left premacular hemorrhage by pulsed Nd:YAG laser was obtained a few weeks later. CONCLUSIONS: Retinal hemorrhages seem to be an uncommon but significant complication of intradiscal O(2)O(3) infiltration, and we suggest that it should be carefully considered when recommending this procedure.

Choroidal vascular changes after transpupillary thermotherapy for choroidal melanoma.

OBJECTIVE: To evaluate choroidal vascular alterations after transpupillary thermotherapy used as the sole treatment for choroidal melanoma. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Forty-five eyes of 45 patients affected by malignant choroidal melanoma treated with transpupillary thermotherapy alone with more than 1 year of follow-up. INTERVENTION: Transpupillary thermotherapy was performed through a panfunduscopic contact lens using an 810-nm diode laser. MAIN OUTCOME MEASURES: Dynamic/static fluorescein and indocyanine green angiography were performed at scheduled intervals (24 hours, at 3-month intervals during the first year, and every 6 months thereafter) after transpupillary thermotherapy. Visual acuity, clinical evaluation, fundus photographs, and ultrasonographic examination were also performed. RESULTS: The mean follow-up was 30.5 months (range, 12-54 months). Changes in the choroidal circulation were always confined within the treatment margins (except in one case) and characterized by occlusion of choriocapillaris (100%), patent medium and/or large choroidal vessels (76%), retinochoroidal anastomosis (11%), and progressive choroidal vascular remodeling (42%). Forty-one cases (91%) showed persistent clinical regression, and four cases (9%) recurred; recurrent cases showed retinochoroidal anastomosis. CONCLUSIONS: Transpupillary thermotherapy is suggested as a new single therapeutic modality in the treatment of selected choroidal melanomas, but more precise eligibility criteria and longer follow-up are mandatory. Patent choroidal circulation, choroidal vascular remodeling, and anastomosis after transpupillary thermotherapy might be helpful to detect recurrent tumors.