Ranibizumab treatment for neovascular age-related macular degeneration: from randomized trials to clinical practice.

BACKGROUND: Although randomized clinical trials (ANCHOR and MARINA) have shown excellent results of ranibizumab treatment in patients with neovascular age-related macular degeneration (AMD), it is unclear whether such an outcome is achievable in daily practice. We evaluated the results of ranibizumab treatment for neovascular AMD in clinical practice in Australia. METHODS: A retrospective chart review of patients in four practices injected with ranibizumab in 2006 for AMD. Patients who had been diagnosed with subfoveal choroidal neovascular membrane in the preceding 6 months and had completed at least 6 months follow-up were enrolled. No standard treatment protocols were required. The main outcome measure was visual acuity (VA) at 6 and 12 months. RESULTS: A total of 158 patients fulfilled the entry criteria. The mean baseline VA (decimal) was 0.35+/-0.21 (Snellen equivalent 6/17). At 6 months, the mean VA improved to 0.46+/-0.27 (6/13) and remained stable until month 12 (0.48+/-0.30). The improvement in VA between baseline and months 6 and 12 was statistically significant (P<0.0001). Both the mean and the median number of injections were four in the first 6 months and nine at 12 months. VA results were comparable with those of the ANCHOR and MARINA trials, and were achieved with a lower number of injections (P<0.0001). CONCLUSION: VA results achieved in daily clinical practice using ranibizumab for neovascular AMD are similar to large prospective randomized trials.

Vitrectomy with short term postoperative tamponade using perfluorocarbon liquid for giant retinal tears.

AIM: To determine the efficacy and safety of perfluorocarbon liquid as a short term postoperative tamponade in patients with retinal detachment from giant retinal tears. METHOD: A retrospective consecutive case series of patients with retinal detachment from giant retinal tears who underwent vitrectomy using perfluorocarbon liquid as a short term postoperative internal tamponade. The perfluorocarbon liquid was removed 5-14 days (mean 7.5 days) later and replaced by gas or silicone oil. Scleral buckling was performed in some cases with proliferative vitreoretinopathy. The crystalline lens was removed if there was interference with the surgical view or if it was subluxated. The success rate of retinal reattachment, visual outcome, and postoperative complications were assessed. RESULTS: A total of 62 eyes of 61 patients with a follow up of 8-69 months (mean 24.5 months) were included. All retinas were attached intraoperatively. 14 eyes (22.6%) developed re-detachment and additional operations were performed in 13 eyes. At final visit, 58 eyes (93.5%) had retinas that remained attached with visual acuity 6/12 or better in 27 eyes (46.5%). The visual acuity improved in 34 eyes (54.8%) with 28 eyes (45.2%) improving at least two Snellen lines, it was unchanged in 20 eyes (32.3%), and was worse in eight eyes (12.9%). Three patients developed glaucoma that was controlled medically. There was no retained perfluorocarbon liquid in any eyes. CONCLUSION: Perfluorocarbon liquid appears safe and effective to use as a short term postoperative tamponade in management of retinal detachment from giant retinal tears.

Retinal detachment associated with subthreshold retinopathy of prematurity.

PURPOSE: To report a series of infants who progressed from mild retinopathy of prematurity (ROP) to severe ROP with retinal detachment without demonstrating detectable threshold disease. METHODS: Between January 1993 and August 1998, seven infants at Oregon Health Sciences University, followed in accordance with the Cryotherapy for Retinopathy of Prematurity Study (CRYO-ROP) protocol, progressed to retinal detachment despite documentation that threshold had not been reached. This outlying subset of patients was analyzed and compared to the cohort in the CRYO-ROP study. RESULTS: Six of 7 patients were male, 6 (86%) patients had symmetric disease, and all patients were born outside the study hospital. Mean birth-weight was 877 g and mean gestational age was 26 weeks. Mean postconceptual age at the time of retinal detachment was 41 weeks. Because of bilateral detachment in 3 patients, the total number of study eyes is 10. Failure to achieve threshold resulted from insufficient clock hours or insufficient stage in 2 eyes and lack of plus in 8 eyes. Zone I disease was present in 1 eye. CONCLUSION: Rarely, despite adhering to ROP examination protocol, the retina may detach without demonstrating antecedent threshold disease. Very low birthweight is a factor that may lead to a less predictable course. This study found a lack of plus disease results in failure to reach threshold more often than the occurrence of insufficient clock hours of stage 3 disease. Further study is needed to determine if selected cases of subthreshold ROP may benefit from ablative therapy.

Ocular-central nervous system lymphoma mimicking posterior scleritis with exudative retinal detachment.

OBJECTIVE: We describe an unusual ocular presentation of ocular-central nervous system lymphoma in a young patient. DESIGN: Interventional case report and literature review. METHODS: A previously well 24-year-old white woman presented with left eye pain and reduced vision. Episcleral injection, globe tenderness, an afferent pupil defect, and exudative retinal detachment were present. Computed tomographic scan of the head and orbits demonstrated scleral thickening, retinal detachment, and no other abnormality. A provisional diagnosis of posterior scleritis with exudative retinal detachment was made. Investigation for underlying connective tissue diseases was negative. There was an initial prompt response to corticosteroid therapy. The patient's symptoms and signs then recurred, and a left third cranial nerve palsy developed. Systemic investigations including lumbar puncture ultimately led to the diagnosis of primary T-cell central nervous system (CNS) lymphoma. Serologic tests for human immunodeficiency virus were negative. MAIN OUTCOME MEASURES AND RESULTS: The patient underwent orbital and cranial irradiation and intrathecal and systemic chemotherapy. Despite an initial response to treatment, she returned with a recurrence of the lymphoma in the anterior segment of the left eye. Her systemic disease progressed rapidly, and she died shortly thereafter. CONCLUSIONS: This patient's young age and initial presentation mimicking posterior scleritis with unilateral exudative retinal detachment, without evidence of vitreous involvement, are highly unusual for ocular involvement in primary CNS lymphoma. A review of the literature highlights the atypical nature of this presentation.

Exudative macular degeneration and intravitreal triamcinolone: 18 month follow up.

PURPOSE: To evaluate the safety and efficacy of intravitreal triamcinolone after 18 months of follow up in patients with age-related macular degeneration and subfoveal or juxtafoveal choroidal neovascularization considered unsuitable for laser photocoagulation. METHODS: Thirty eyes of 28 patients, referred from general eye clinics as well as the private clinic of one of the authors to a hospital-based retinal out-patient clinic, were treated with an intravitreal injection of triamcinolone (4 mg). The primary outcome measure was the proportion of eyes with loss of six or more lines on a Bailey-Lovie Chart. The incidence of adverse events associated with treatment was also observed. RESULTS: Of the 20 eyes with initial visual acuity (VA) of 6/60 or better, the vision was maintained (+/-1 Bailey-Lovie lines) in 11 eyes (55%), while six eyes (30%) suffered severe visual loss (six or more lines). The VA improved by five to six lines in three of 10 eyes with initial vision of 3/60 or worse. Three of four eyes receiving a second injection suffered either progressive cataract or elevated intra-ocular pressure (IOP) requiring cataract surgery and/or filtering surgery. One of 26 eyes (3%) receiving a single injection showed progression of cataract and elevation of IOP within 6 weeks of treatment and required anti-glaucoma medication for 6 weeks. Progression of nuclear sclerosis 8-12 months after treatment was observed in six of 26 eyes (23%) receiving a single injection. CONCLUSIONS: The results of the present study suggest that a single intravitreal injection of 4 mg triamcinolone is reasonably well tolerated by the human eye. The rate of development of severe visual loss was less than reported for historical controls. Because the results are preliminary and uncontrolled, the treatment should not be used routinely until its benefit to patients is established by a prospective, randomized controlled study.

External argon laser choroidotomy for subretinal fluid drainage.

PURPOSE: To evaluate the efficacy and safety of external argon laser choroidotomy for drainage of subretinal fluid (SRF) during scleral buckling procedures for the repair of rhegmatogenous retinal detachments. METHODS: Fifty eyes of 50 consecutive patients presenting to a hospital-based retinal outpatient clinic with rhegmatogenous detachments underwent choroidotomy with argon endolaser for SRF drainage. The laser parameters used were 0.5s duration and 0.8W power. The primary outcome measures were successful drainage of SRF and incidence of complications. The drainage was considered successful if it was sufficient to complete the planned scleral buckling procedure. The extent of subretinal haemorrhage was graded. RESULTS: The mean age of patients was 55 years (range 16-80 years). Successful drainage of SRF was obtained in 47 eyes (94%). The complications observed at the drainage site included subretinal haemorrhage of less than 1 disc diameter in six eyes (12%) and retinal perforation in one eye (2%). CONCLUSION: External argon laser choroidotomy appears to be an effective method of draining SRF in rhegmatogenous retinal detachments.

Exudative macular degeneration and intravitreal triamcinolone. A pilot study.

PURPOSE: To study the efficacy of the anti-inflammatory agent triamcinolone (Kenacort A-40) in patients with exudative age-related macular degeneration and subfoveal and juxtafoveal choroidal new vessels, considered unsuitable for laser photocoagulation. METHOD: Thirty eyes of 28 patients were treated with intravitreal injection of triamcinolone. The subsequent visual acuity (VA) of treated eyes was compared with published VA outcomes of untreated eyes. Patients were classified into three types according to their responses to treatment. RESULTS: Within two weeks of receiving treatment, exudation decreased and vision improved in the majority of Types I and II patients (87%), the trend continuing in longer term follow-up. The overall VA outcome for treated eyes was significantly better than published VA data for untreated exudative macular lesions. CONCLUSIONS: The preliminary results are encouraging and no serious side effects of a single injection of triamcinolone have been detected in patients followed for up to 18 months. The treatment should, however, continue to be regarded as unproven and only administered in the context of a prospective, case-controlled clinical trial.

Reflexes and the eye.

Reflexes are an essential part of protective and homeostatic function, both in general terms and with specific reference to ocular structures. A wide range of stimuli and responses, with varying degrees of central processing, is involved in such reflexes. The simplest reflexes are monosynaptic, such as the stretch or myotatic reflex. More complex polysynaptic reflexes are involved in many regulatory and protective functions--these include autonomic as well as somatic reflexes. Ocular autonomic reflexes include the oculocardiac, pupillary, accommodative and lacrimatory reflexes. Ocular somatic reflexes include eyelid and extra-ocular muscle reflexes (such as Bell's phenomenon, vestibulo-ocular and optokinetic reflexes). An account of the above reflexes is given in the format of an essay, modified from the FRACO Part I Examination in Physiology. The topic was 'Discuss reflex activities with particular reference to the eye'. The content is based on several of the texts recommended for the Part I Examination, as listed under references.

Treatment of choroidal neovascularisation in age-related macular degeneration with interferon alfa-2a and alfa-2b.

Forty eight eyes of 42 patients with choroidal neovascular membranes and age-related macular degeneration who received three different dose regimens of systemic interferon alfa-2 were studied retrospectively. The response to treatment of 41 eyes of the 37 patients who received at least 4 weeks' treatment was analysed with respect to the change in size of the choroidal neovascular membrane and the visual acuity compared with pretreatment levels. The size of the membrane at the end of the course of treatment had decreased in seven (17%) eyes overall, not changed in 16 (39%), and increased in 18 (44%). At the end of treatment, the visual acuity had improved in seven (17%) eyes, not changed in 27 (66%), and deteriorated in seven (17%). With an average follow up of 10 months after treatment, the visual acuity had deteriorated compared with the pretreatment value in 21 out of 41 (51%) eyes. Vision improved in some fellow eyes with disciform scars. Side effects were common and often severe. The data suggest that one of the major effects of interferon alfa may be to decrease vascular permeability. While further research may identify a place for interferon alfa in the treatment of choroidal neovascularisation, we were unable to demonstrate that the treatment regimens of systemic interferon alfa we used caused a dramatic benefit to patients with exudative age-related macular degeneration.

Superior sagittal sinus thrombosis--an unexpected cause of papilloedema.

Two patients with superior sagittal sinus thrombosis are reported. Papilloedema was an important diagnostic sign in both cases. Magnetic resonance imaging (MRI) provided the diagnosis in each case and proved to be the investigation of choice. Superior sagittal sinus thrombosis should be considered in the differential diagnosis of papilloedema as it is both potentially fatal and probably underdiagnosed.

Iodine-125 irradiation of choroidal melanoma: clinical experience from the Prince of Wales and Sydney Eye Hospitals.

We examined the records of 53 patients treated for choroidal melanoma between 1985 and 1989. The aim of this study was to assess the safety and short-term results of iodine-125 episcleral plaque therapy. There were 28 males and 25 females, aged 20 to 77 years (median 61 years), treated for single tumours with a median diameter of 9 mm (range 5 to 15 mm) and with a median thickness of 4 mm (range 2 to 10 mm). The plaques containing iodine-125 seeds were chosen according to tumour size: 10 mm (16 patients); 15 mm (36 patients); 20 mm (one patient). All patients are alive at last follow-up (median 1.3 years, range 4 months to 3.3 years). Four patients underwent enucleation for melanoma progression. Thirty patients have developed some type of complication (more than one complication occurred in the same eye in 12 patients): retinitis (19), optic neuropathy (7); cataract (4), rubeosis iridis (2). Overall, visual acuity deteriorated in 32 patients, remained stable in 12 patients and improved in 9 patients. Iodine-125 plaque therapy appears to offer patients good prospects of tumour control and preservation of useful vision.

Solar retinopathy: its significance for the ageing eye and the younger pseudophakic patient.

The sun is the main source of ultraviolet (UV), visible and infrared radiation reaching our atmosphere. The short wavelength components of the sun's spectrum have been shown to have deleterious effects on the retinal photoreceptors. These effects are photochemical and mostly not thermal in nature. Except in early life, most of the ultraviolet (300-400 nm) is effectively filtered out by the lens which in later life also filters out considerable proportions of shorter visible wavelengths to 450 nm. The photochemical effects are mediated by the production of free radicals from the interaction of oxygen, photons and receptor molecules. These radicals attack, among others, polyunsaturated fatty acid components of cell membranes which may eventually degenerate. Protective mechanisms within the receptors and the adjacent pigment epithelium may be overwhelmed in the presence of high retinal irradiances over prolonged periods of time--as may occur in aphakic and pseudophakic eyes. The cone system, with a much slower replacement rate of light-sensitive membranes, is more likely to suffer permanent damage than the rod system, with predictable consequences. The above considerations have special relevance in old patients because of their age-compromised retinas, and in the younger patient who may be rendered aphakic or pseudophakic and faces a prolonged period of exposure to excessive UV irradiation as a consequence. Protection for the retina, whether by sunglasses or UV-absorbing intraocular lenses, as appropriate, is recommended.

Evaluation of nine hundred and sixty-seven consecutive intraocular implants.

We undertook a survey of all intraocular lenses (IOLs) implanted by two surgeons from 1976 up to the end of 1983. Of the 967 implants, 164 were excluded because of lack of adequate follow-up. Of the remaining 803 cases there were 104 anterior chamber lenses, 185 iris-supported lenses, and 514 posterior chamber lenses. The overall final visual acuity was 6/12 or better in 740 cases (92.2%). Of the remaining 63 cases, 32 had pre-existing disease or associated conditions not directly related to the operation. By analysing the results within each major group of IOL we found that the posterior chamber IOLs had the best final visual acuity (94.4% 6/12 or better) and fewer postoperative complications. The major problems with iris-supported IOLs were corneal decompensation and cystoid macular oedema.

Choroidal osteomas.

Two patients with choroidal osteoma, one with bilateral involvement, diagnosed by fluorescein angiography, ultrasonography and CT scanning are presented. The clinical presentation, differential diagnosis and significance are discussed.

Clinical management in the face of the uveal melanoma controversy.

The modalities used to diagnose choroidal melanoma are described. The use of these procedures has reduced the misdiagnosis rate from 20% in the 1960s to less than 5% today. Observation and reinvestigation of small tumours is recommended. Surgery may cause dissemination of tumour emboli, which may be prevented by gentle handling of tissue, use of intravenous mannitol and hypotensive anaesthesia. Measures other than enucleation are available to treat choroidal melanoma, but few tumours meet the criteria for their use.

Systemic factors contributory to retinal vein occlusion.

This study was undertaken in 79 patients with retinal vein occlusion to assess the different systemic mechanisms contributing to the occlusion, namely, intrinsic vessel disease and abnormalities of the blood constituents and blood viscosity. In 55 patients older than 50 years of age, important associations were hypertension, abnormal results on glucose tolerance test, hyperlipidemia, chronic lung disease, and elevated serum IgA levels. In the 24 patients younger than 50 years of age, male incidence was high and important associations were head injuries, hyperlipidemia, and the use of estrogen-containing preparations. Hyperviscosity and cryofibrinogenemia were prominent in both groups. The pathogenesis of retinal venous occlusion is complex involving interaction between the vessel wall and blood constituents.