Laser and anti-vascular endothelial growth factor treatment for drusenoid pigment epithelial detachment in age-related macular degeneration.

This study aims to report the 12 months results of efficacy and safety of laser photocoagulation and anti-vascular endothelial growth factor (VEGF) injections for drusenoid pigment epithelial detachment (dPED). In this prospective study, patients with treatment naïve bilateral intermediate age-related macular degeneration, featuring dPED, with visual acuity ≤ 83 letters were enrolled. The study group received PASCAL laser (532 nm) along the periphery of the dPED, and the fellow eye served as a control group. To prevent complications of choroidal neovascularization, intravitreal anti-VEGF injections to laser treated eye were performed on a 3-month interval up to 1 year. Primary outcomes-drusen area, PED height-and secondary outcomes-best-corrected visual acuity (BCVA), contrast sensitivity, degree of metamorphopsia, NEI-VFQ 25, and fundus autofluorescence-were analyzed. Among 21 patients, a total of 20 patients satisfied the 12 months follow-up. Drusen area and PED height decreased significantly in the laser group, while no significant change appeared in the control group (74.1% vs. - 3.5%, P < 0.001; 76.6% vs. 0.1%, P < 0.001). Mean BCVA improved 4.6 letters in the laser group (vs. 1.1 letters in the control group, P = 0.019). As for safety, one study eye developed retinal pigment epithelial tear, and one control eye developed retinal angiomatous proliferation. Low energy laser photocoagulation and anti-VEGF injection in eyes with dPED showed some improvement in visual acuity. dPED regressed without developing center involving GA in the study eye, but a longer term follow-up is necessary to reveal the efficacy and safety of these treatments. The 2-year results of this study will be followed to reveal long term efficacy and safety of the treatment for dPED.

Results of external beam radiotherapy for diffuse choroidal hemangiomas in Sturge-Weber syndrome.

PURPOSE: The Sturge-Weber Syndrome (SWS) is a phacomatosis which include facial nevus flammeus, glaucoma, diffuse choroidal hemangioma, and leptomeningeal hemangiomatosis. External beam radiotherapy (EBRT) using photons was used to treat retinal detachment. We investigate the anatomical and functional results in a long-term basis. METHODS: Retrospective review of SWS patients treated by EBRT (20 Gy in 10 fractions) for an exudative diffuse choroidal hemangioma. Visual acuity, B-scan tumor thickness, size of retinal detachment, intra-ocular pressure, and hypotonic treatment were collected before EBRT, 1 year after, and at the latest news. RESULTS: Twenty-five patients (26 eyes) were treated between 2001 and 2014. Retinal detachment including the macula was found among twenty-six eyes before treatment. The average follow-up time was 47 months. The mean tumor thickness was initially 4.5 mm, 2.8 mm at first year, and 2.7 mm at the last visit. The retina was reattached at the last visit for all eyes except two. The visual acuity was stable or better for 20 eyes (p = 0.02). Four patients developed mild cataract during the follow-up. CONCLUSION: EBRT using 20 Gy in 10 fractions is efficient, decreases tumor thickness, reattaches the retina, and stabilizes visual acuity. In the long term, retinal reattachment allows ocular conservation by preventing phthisis bulbi.

Intraocular beta-radiation for proliferative vitreo-retinopathy.

Proliferative vitreoretinopathy (PVR) is the most common cause of failure in retinal detachment surgery. PVR is a result of an enhanced healing process. Various surgical and pharmacological methods have failed to provide a definite solution to the problem. Radiation has since long been shown to be effective in similar situations like keloids, pterygia, and post trabeculectomy. Externally delivered radiation has also been tried in PVR, but with limited success. We propose that treatment with intraocularly delivered beta-radiation is a viable method to try and reduce the incidence of PVR after retinal detachment. This can improve the safety of the treatment, reduce potential side effects to surrounding tissues and help achieve a targeted treatment. However, the treatment was limited by the absence of a practical method for intraocular delivery of radiation. This is now possible, as we now have a method which has been shown to be safe in the CABERNET trial. If this can be proved, then it will be an important step towards treating PVR and hence reducing blindness after retinal detachment.

Management of retinal vasoproliferative tumor associated with ROP by plaque brachytherapy.

The authors report a secondary exudative vasoproliferative tumor of the retina associated with retinopathy of prematurity, managed by plaque radiotherapy. A 15-year-old girl with a history of mild, stable retinopathy of prematurity in both eyes noted progressively reduced visual acuity to hand motions in the left eye. Examination disclosed a vasoproliferative tumor of 10-mm base and 3.5-mm thickness with near total (macula-off) exudative retinal detachment. She was treated with iodine-125 plaque radiotherapy, giving apex dose of 40 Gy over 4 days. The tumor regressed to 1.9 mm and retinal detachment resolved 8 months following therapy. Epiretinal membrane with significant macular pucker and edema later developed and was managed with pars plana vitrectomy and membrane peeling. Visual acuity was counting fingers due to photoreceptor loss. Retinopathy of prematurity is a rare cause of vasoproliferative tumor. Iodine-125 plaque radiotherapy can lead to tumor regression and reattachment of the retina in such cases.

Gamma knife radiosurgery for choroidal hemangioma.

PURPOSE: Patients with choroidal hemangioma (CH), a benign ocular hamartoma, frequently presents with visual disturbance as a result of exudative retinal detachment (RD), which originates in subretinal fluid accumulation. We report our experience using the Leksell Gamma Knife in the management of symptomatic CH. METHODS AND MATERIALS: Seven patients with symptomatic CH (circumscribed form in 3 patients and diffuse form in 4) were treated with the Leksell Gamma Knife at our institution during a 7-year period. All patients presented with exudative RD involving the macula that resulted in severe visual deterioration. The prescription dose to the target margin was 10 Gy in all cases. The mean tumor volume receiving the prescription dose was 536 mm3 (range, 151-1,057). The clinical data were analyzed in a retrospective fashion after a mean follow-up of 34.4 months (range, 9-76). RESULTS: The resolution of exudative RD was achieved within 6 months, and the visual acuity of the affected eye had improved at the latest follow-up examination (p=.018) in all patients. No recurrence of exudative RD occurred. Thinning of the CHs was observed in most patients; however, symptomatic radiation toxicity had not developed in any of the patients. CONCLUSION: Symptomatic CHs can be safely and effectively managed with Gamma Knife radiosurgery using a marginal dose of 10 Gy.

Retinopexia pneumática e fotocooagulacão a laser para tratamento de descolamento secundário à fosseta de disco óptico: relato de caso / Pneumatic retinopexy and laser photocoagulation for treatment of optic disc pit detachment: case report

Os autores relatam o caso de um paciente com fosseta congênita de disco óptico associado a descolamento seroso macular, tratado com sucesso por meio de fotocoagulacão com laser de argônio na borda temporal da fosseta, seguido de injecão intravítrea de 0,3 ml de C3F8 (100 por cento). O paciente foi seguido por 12 meses. A resolucão do descolamento foi acompanhada de melhora da acuidade visual, bem como o retorno da fóvea a sua configuracão normal, comprovada através da tomografia de coerência óptica.

Palladium 103 (103Pd) plaque radiation therapy for circumscribed choroidal hemangioma with retinal detachment.

OBJECTIVE: To describe clinical experience with palladium 103 ((103)Pd) ophthalmic plaque radiotherapy for choroidal hemangioma. METHODS: One course of (103)Pd ophthalmic plaque radiotherapy was used in each of 5 patients with circumscribed choroidal hemangioma who had progressive loss of vision due to subretinal exudation. A mean apex dose of 2900 cGy (2900 rad) was delivered. Functional tests of outcome included best-corrected visual acuity. Anatomic results included changes in tumor height and subretinal fluid documented by ophthalmoscopy, fluorescein angiography, and ultrasonography. RESULTS: All patients had complete resolution of subretinal fluid with reattachment of the retina. All tumors decreased in height (mean, 50%) after treatment. Three patients (60%) demonstrated improvement in visual acuity at the last follow-up, and in 1 patient vision remained stable with resolution of metamorphopsia. Twenty-four months after treatment, 1 patient whose visual acuity had recovered from 20/160 to 20/32 had a loss of vision to 20/160 because of radiation maculopathy. For all patients, a mean visual acuity improvement of 2 lines was documented (95% confidence interval, 0.23-0.88). Mean follow-up was 18.6 months (range, 6-29 months). CONCLUSIONS: A single (103)Pd plaque radiation treatment was effective in decreasing tumor height, eliminating subretinal fluid, and improving visual acuity in patients with symptomatic circumscribed choroidal hemangiomas.

Low-dose proton beam therapy for circumscribed choroidal hemangiomas.

OBJECTIVE: To evaluate the efficacy and safety of proton beam therapy for complicated circumscribed choroidal hemangiomas. METHODS: The study was a retrospective nonrandomized investigation. Seventeen consecutive patients, referred to the Institut Gustave-Roussy, Villejuif, France, for circumscribed choroidal hemangioma associated with serous retinal detachment were studied. Each eye received a total dose of 20 cobalt gray equivalents (CGEs) delivered in 15-second fractions of 5 CGEs over 4 days. Functional tests included the initial and final best-corrected visual acuity, slitlamp examination, intraocular pressure, fundus examination, fluorescein angiography, and indocyanine green angiography. Tumor thickness was determined on B-scan ultrasonography. RESULTS: The macula was involved in 7 eyes and the lesion was juxtapapillary in 2 eyes. The mean (SD) tumor thickness was 3.06 (9.0) mm. The mean initial tumor diameter was 6.82 mm (range, 3.2-12.1 mm). The right eye was involved in 7 cases and the left eye in 10 cases. The mean (SD) follow-up period was 52 (58) months (range, 36-90 months). Retinal reattachment was obtained in all cases after a mean period of 2 months (range, 1-12 months; median, 1 month). Tumor regression was obtained in all cases. One recurrence occurred 1 year after the initial treatment in an undertreated area. After re-treatment, however, resolution of the retinal detachment occurred, and flattening of the choroidal lesion was obtained. Final visual acuity improved to 2 Snellen lines or more in 16 eyes (94%), was stable in 1 eye, and attained 20/40 or more in 12 eyes (70.6%). No radiation therapy complications occurred during follow-up. CONCLUSIONS: Proton beam therapy for choroidal hemangiomas seems to be an effective and safe alternative option. A total dose of 20 CGEs delivered in 4 daily 15-second fractions of 5 CGEs seems adequate for local control of both the tumor and serous retinal detachment.

[External beam radiation in treatment of subfoveal vascularized pigment epithelium detachment in age-related macular degeneration. Long-term results of a pilot study]. / Radiothérapie externe dans le traitement des décollements vascularisés rétrofovéolaires de l'épithélium pigmentaire de la DMLA. Résultats à long terme d'une étude pilote.

PURPOSE: The purpose of this study was to contribute to the evaluation of long-term external beam radiation treatment in patients with subfoveal occult choroidal neovessels complicated with pigment epithelium detachment in age-related macular degeneration. MATERIALS AND METHODS: This was a retrospective study of ten patients with a mean age of 75 years and a mean follow-up of 18.7 months. External beam radiation of 14.4 Gy was administered with a daily dose of 1.8 Gy. The efficacy of the treatment was assessed based on visual acuity, the size of the membrane and the persistence or not of neovascular activity. RESULTS: We observed stabilization of visual acuity in 44% of the cases at 6 months but only in 20% at 19 and 30 months. The mean initial visual acuity was measured at 0.2 at presentation and 0.1 at the final evaluation. At the end of the study, 60% of patients attained the level of legal blindness; 90% of patients developed a disciform scar, with persistence of neovascular activity in 27% of the cases. On fluorescein angiography, the size of pigment epithelium detachment increased more than one optic disc diameter in 20% of the cases at 1 year. On the other hand, no radiation complication was observed. DISCUSSION: The visual and anatomical results of our study are similar to the natural progression of occult neovascular membrane. External beam radiation at a dose of 14.4 Gy did not seem to provide a long-term benefit in the treatment of subfoveal occult neovessels associated with pigment epithelium detachment.

Laser and proton radiation to reduce uveal melanoma-associated exudative retinal detachments.

PURPOSE: To assess whether laser-induced hyperthermia in conjunction with proton irradiation of choroidal melanoma may more rapidly decrease exudative retinal detachments. DESIGN: Case-control study. METHODS: This was a single-center prospective phase 1 study of choroidal melanoma patients with exudative retinal detachments. These tumors did not overhang the optic disc, involve the fovea, or have greater than 40% involvement of the ciliary body. Patients were treated with laser-induced hyperthermia and proton radiation; results were compared with those of similar patients treated at the same institution with only proton radiation. Patients were followed up in an identical manner for loss of subretinal fluid, visual acuity change, and visual field alterations. RESULTS: All 11 patients treated with combined laser and proton therapy had resorption of subretinal fluid with a mean duration of retinal detachment of 193 days, compared with 263 days in the group treated with only proton therapy (P<.04). At 1 year, visual acuity was similar in both groups. CONCLUSIONS: Combined laser-induced hyperthermia and proton radiation may dissipate exudative detachments more rapidly than radiation alone.

Bilateral diffuse choroidal hemangiomas with unilateral facial nevus flammeus in Sturge-Weber syndrome.

PURPOSE: To report bilateral choroidal hemangiomas associated with unilateral facial nevus flammeus in Sturge-Weber syndrome. METHODS: Case report. RESULTS: A 6-year-old male with a left facial nevus flammeus and a history of a left cerebral angioma had been followed 2 years for increasing esotropia. Examination demonstrated bilateral diffuse choroidal hemangiomas with overlying exudative retinal detachments. After bilateral external beam radiotherapy, the retinal detachments resolved and vision improved. CONCLUSION: Patients with Sturge-Weber syndrome and unilateral facial nevus flammeus may harbor bilateral choroidal hemangiomas. Clinical manifestations of the Sturge-Weber syndrome are characteristically unilateral and ipsilateral to the facial nevus flammeus. Bilateral choroidal hemangiomas associated with bilateral facial nevus flammeus are rare. 1,2 We report bilateral diffuse choroidal hemangiomas associated with unilateral facial nevus flammeus in Sturge-Weber syndrome.

[Hemangioma of the choroid with extra-scleral extension]. / Hémangiome de la choroïde avec extension extra-sclérale.

We report a case of atypical circumscribed choroidal hemangioma with retinal detachment in a 41-year-old man referred with the diagnosis of Harada disease. B. Scan ultrasonography showed an hyperechogenic area extended through the sclera. Careful examination of the fundus showed a small peripapillary orange mass and an inferior retinal detachment. Surgical exploration revealed an extrascleral hemangioma. Proton beam irradiation was followed by retinal reattachment within three months. No recurrence has been observed 18 months after treatment.

Long-term results after low dose ocular irradiation for choroidal haemangiomas.

AIM/BACKGROUND: The most common choice of treatment for choroidal haemangiomas (CH) in the past has been the employment of scatter photocoagulation of the surface. This management often requires repetitive treatment or additional invasive management due to massive exudative detachment of the retina. The aim of this retrospective study was to investigate the outcome of the alternative application of low dose external beam irradiation with high energetic photons on these tumours. METHODS: A total absorbed dose of 20 Gy was applied to a total of 51 symptomatic eyes: 36 with a circumscribed CH of the posterior pole and 15 with diffuse CH as part of the Sturge-Weber syndrome. The indication for treatment was an exudative retinal detachment including or threatening the fovea. The mean follow up times in each group were 4.5 and 5.3 years, respectively. Out of a group of 33 patients from whom reliable data could be derived, 17 had symptoms lasting longer than 6 months. RESULTS: In 23 cases (63.8%) with circumscribed CH complete resolution of the subretinal fluid was achieved; the remaining 13 cases (36.2%) showed residual serous detachment distant to the fovea. The visual acuity improved by two or more lines in 14 cases (38.9%), remained stable in 14 cases (38.9%), and decreased in eight cases (22.2%). The functional success was dependent on the lag duration between onset of first subjective symptoms and treatment. The morphological results with diffuse CH were similar to those of the group of circumscribed CH. The visual acuity (VA) at last examination was improved in seven cases (46.6%); in the remaining eight cases, VA was unchanged or had deteriorated. The poor functional outcome in the latter was mainly attributable to secondary glaucoma. CONCLUSION: External beam irradiation is a useful and a low invasive therapeutic option for CH. A successful functional outcome is dependent on the time delay between first onset of symptoms and the beginning of therapy, the formation of subretinal fibrosis, and also on secondary glaucoma in the case of Sturge-Weber syndrome.

[Long-term outcome of radiotherapy of choroid hemangioma]. / Langzeitresultate der Strahlentherapie von Aderhauthämangiomen.

The usual therapeutic approach to circumscribed choroidal hemangiomas of the posterior pole consists of scatter photocoagulation of the tumor surface. This may often require repetitive treatment or additional invasive measures prior to coagulation due to massive exudative detachment of the retina. In this study, external beam irradiation with high-energy photons (total absorbed dose: 20 Gy) was applied to 36 symptomatic patients. The indication for treatment was exudative retinal detachment including or threatening the fovea. The mean duration of follow-up was 4.5 years (4 months to 24 years, median 4 years). In 23 cases (63.8%) complete resolution of the subretinal fluid could be achieved; 13 cases (36.2%) showed residual serous detachment at some distance from the fovea. The visual acuity improved by two or more lines in 14 cases (38.9%), remained stable in 14 cases and decreased in only 8 cases (22.2%). The functional success was dependent on the interval between onset of first subjective symptoms and treatment. External beam irradiation is a successful form of treatment for choroidal hemangiomas.

Radiotherapy treatment of age-related subfoveal neovascular membranes in patients with good vision.

This prospective study investigated whether low-dose ionising radiotherapy preserved vision and caused membrane regression in patients with age-related subfoveal neovascular membranes (SFNVMs) or vascularised pigment epithelial detachments (PEDs) and relatively good initial visual acuities. Twenty-five patients with initial Snellen acuities of 6/24 or better were treated with low-dose external beam radiotherapy. Of the patients with SFNVMs, visual acuities were maintained or improved in 58% at 6 months and 53% at 1 year. Neovascular membrane size was assessed by image analysis and showed some regression in 47% and 41% at 6 and 12 months respectively. These results suggest that patients with SFNVMs and good vision may benefit from radiotherapy, faring better than previous reports of the natural history of this condition. Conversely, patients with vascularised PEDs did not appear to benefit from radiotherapy. Only 17% maintained their vision at 1 year and 33% suffered retinal pigment epithelial tears. The results from patients with SFNVMs and good initial vision, excluding those with vascularised PEDs, are encouraging however, any benefit from this treatment needs to be proven by controlled trials with long follow-up.

Experimental perforating injury with high energy electrons to inhibit intraocular proliferation.

Since 1980, the fibroblast model creating experimental proliferative vitreoretinopathy has been used to evaluate the antiproliferative effect of various drugs. In previous studies radiation therapy was found to reduce effectively intraocular proliferation in this model. We therefore investigated the effect of high energy electrons in a standard perforating injury model creating a traumatic proliferative vitreoretinopathy. In 36 eyes we performed a 8 mm pars plana incision and injected 0.4 ml of 80% fibronectin solution intravitreally. Ten rabbits (20 eyes) received radiation therapy with a Betatron accelerator in a total dosage of 3000 cGy to each eye divided into 10 single fractions starting on the first post-operative day. Maximum concentration of the dose was focused to the posterior vitreous. The other 9 rabbits, 18 eyes, served as control. In our perforating injury model we observed a reduction of retinal detachment rate of 72% in the controls to 55% in the treated group. The effect of radiation therapy with high energy electrons and total dosage of 3000 cGy was not statistically significant in experimental traumatic proliferative vitreoretinopathy.