Grid laser photocoagulation for macular oedema due to branch retinal vein occlusion in the age of bevacizumab? Results of a prospective study with crossover design.

BACKGROUND AND AIM: To investigate the long term effectiveness of grid laser photocoagulation (GLP) versus intravitreal bevacizumab (BEV) in macular oedema (MO) secondary to branch retinal vein occlusion (BRVO), and to evaluate the treatment courses after treatments were switched. METHODS: In this prospective interventional consecutive case series, previously untreated eyes with perfused MO were enclosed over a period of 16 months for BEV and for 29 months for GLP. The follow-up period was 1 year. Patients with persistent MO after 12 months of BEV were offered GLP and vice versa, and were followed-up for another 12 months. RESULTS: Both BEV (23 eyes) and GLP (21 eyes) caused a significant (p<0.05) reduction in central retinal thickness (CRT) at 12 months although this was delayed with GLP. However, BEV revealed a significantly better best corrected visual acuity (BCVA) compared with GLP (0.2 vs 0.5 logMAR; p<0.04). Switching therapy for non-responders revealed a reduced CRT at another 12 months, although this was not significant. CONCLUSIONS: Functionally and anatomically, BEV appears to be more effective than GLP for the therapy of MO due to BRVO. BCVA is significantly better after 1 year and the anatomical response of the MO is faster. Furthermore, non-responders with persistent MO despite BEV or GLP treatment might benefit from switching therapy.

Predictive factors for functional improvement after intravitreal bevacizumab therapy for macular edema due to branch retinal vein occlusion.

BACKGROUND: To identify predictive factors for improvement of visual acuity and central retinal thickness by intravitreal bevacizumab for the treatment of macular edema (ME) due to branch retinal vein occlusion (BRVO). METHODS: Two hundred and five eyes from 204 patients with ME secondary to BRVO were retrospectively included at six sites. All eyes received intravitreal bevacizumab therapy (1.25 mg/0.05 ml). The mean follow-up was 36.8 ± 12.7 weeks (range, 18 to 54 weeks). Measurement of ETDRS best-corrected visual acuity (BCVA, in all eyes) and optical coherence tomography (OCT, in 87% of eyes) were performed at baseline and at follow-up examinations every 12 weeks. Using fluorescein angiography, the perfusion status of the macula at baseline could be assessed in 84% of the eyes. The main outcome measures were changes in BCVA and central retinal thickness (CRT). For analysis of predictive factors, the results at 24 weeks were used. RESULTS: The median BCVA was 0.6 LogMAR at baseline and improved to 0.4 LogMAR at 24 and 48 weeks. This visual improvement was associated by a significant reduction in CRT, decreasing from a baseline of 454 µm to 267 µm and 248 µm after 24 and 48 weeks respectively. Eyes with ME and intact (perfused) or interrupted (ischemic) foveal capillary ring showed a 2-line increase of median BCVA [45 eyes (22%) and 128 eyes (62%) respectively]. However, the final median BCVA was significantly worse in eyes with ischemic ME (0.6 versus 0.3 logMAR in perfused ME). Other factors for visual improvement were absence of previous treatments of the ME, age younger than 60 years and low baseline BCVA (≥0.6 logMAR) (2, 3, and 2 median BCVA lines increase respectively). Furthermore, eyes with duration of the ME of less than 12 months responded with a 3-line increase of the median BCVA. Final CRT only showed minor differences between the subgroups. During the entire follow-up, retreatments were performed in 85% of the eyes, with a median number of injections of three (mean 3.2; range, 1 to 10) and a median time-interval between injections of 11.6 weeks (mean 14.6 weeks). CONCLUSIONS: Intravitreal injection of bevacizumab resulted in a significant improvement of BCVA and reduction of ME in BRVO. Baseline BCVA, patient's age, and duration of BRVO were found to be of prognostic relevance for visual improvement. A less favorable outcome of the bevacizumab therapy in eyes with longstanding BRVO would advocate initiation of treatment within 12 months after onset.

Bone spicule pigment formation in retinitis pigmentosa: insights from a mouse model.

BACKGROUND: Bone spicule pigments (BSP) are a hallmark of retinitis pigmentosa (RP). In this study, we examined the process of BSP formation in the rhodopsin knockout (rho (-/-)) mouse, a murine model for human RP. METHODS: In rho (-/-) mice from 2 to 16 months of age, representing the range from early to late stages of degeneration, retinal sections and whole mounts were examined morphologically by light and electron microscopy. The results were compared to scanning laser ophthalmoscopy of BSP degeneration in human RP. RESULTS: After the loss of all photoreceptor cells in rho-/- mice, the outer retina successively degenerated, leading to approximation and finally a direct contact of inner retinal vessels and the retinal pigment epithelium (RPE). We could show that it was the event of proximity of retinal vessel and RPE that triggered migration of RPE cells along the contacting vessels towards the inner retina. Ultrastructurally, these mislocalized RPE cells partially sealed the vessels by tight junction linkage and deposited extracellular matrix perivascularly. Also, the vascular endothelium developed fenestrations similar to the RPE-choroid interface. In whole mounts, the pigmented cell clusters outlining retinal capillaries correlated well with BSPs in human RP. The structure of the inner retina remained well preserved, even in late stages. CONCLUSIONS: The Rho (-/-) mouse is the first animal model that depicts all major pathological changes, even in the late stages of RP. Using the rho (-/-) mouse model we were able to analyze the complete dynamic process of BSP formation. Therefore we conclude that: (1) In rho (-/-) retinas, BSPs only form in areas devoid of photoreceptors; (2) Direct contact between inner retinal vessels and RPE appears to be a major trigger for migration of RPE cells; (3) The distribution of the RPE cells in BSPs reflects the vascular network at the time of formation. The similarity of the disease process between mouse and human and the possibility to study all consecutive steps of the course of the disease makes the rho (-/-) mouse valuable for further insights in the dynamics of BSP formation in human RP.

One-year results after intravitreal bevacizumab therapy for macular edema secondary to branch retinal vein occlusion.

BACKGROUND: To investigate the long-term effectiveness of intravitreal bevacizumab treatment in eyes with perfused macular edema due to branch retinal vein occlusion (BRVO). METHODS: In this prospective interventional case series, 23 consecutive, previously untreated eyes with perfused macular edema were treated with intravitreal bevacizumab (1.25 mg) injections and followed for 1 year. The main outcome measures were visual acuity (VA) and central retinal thickness (CRT). In addition, VA data were adapted to the non-logarithmic VA charts used in the previously published grid laser photocoagulation BRVO Study. RESULTS: The median VA gained 3.0 lines from baseline at 48 weeks. This was accompanied by a significant decrease of 39% of the median CRT. The mean number of re-injections was 1.6 during the first 6 months of follow-up and only 0.8 during the subsequent 6 months. In 65% of the cases, adapted VA data showed a gain of 1 or more lines and no eye lost more than 1 line. CONCLUSIONS: Repetitive intravitreal bevacizumab injections result in a significant long-term improvement of VA and CRT. The number of re-injections necessary to maintain this effect declined over time. However, the treatment seems to be only slightly better than grid laser photocoagulation.

The distribution, release kinetics, and biocompatibility of triamcinolone injected and dispersed in silicone oil.

PURPOSE: Triamcinolone acetonide (TA) has been proposed as an adjuvant to pars plana vitrectomy with silicone oil for the surgical treatment of proliferative vitreoretinopathy and proliferative diabetic retinopathy. However, to date no data about the distribution and pharmacokinetics of lipophilic TA injected into silicone oil have been reported. METHODS: An artificial vitreous space chamber was filled with silicone oil. TA was either injected or dispersed into silicone oil. TA release using a continuous flow model was measured spectrophotometrically. To determine the antiproliferative or cytotoxic effect of the released TA, monolayer cultures of retinal pigment epithelial cells (ARPE19) and retinal ganglion cells (RGC5) were used. Bromodeoxyuridine incorporation, MTT assay, and scanning electron microscopy were performed. RESULTS: Injected TA sank slowly through the silicone oil and started to sediment below the silicone oil bubble shortly after injection. After the simulated intravitreal injection, no TA could be retrieved from the silicone oil bubble. In contrast, when a suspension of silicone oil and TA was prepared before injection, stable noncytotoxic amounts of TA (25 microg/mL) could be retrieved for up to 90 days. After mere injection (without previous suspension in silicone oil), the sedimented TA crystals showed a pronounced cytotoxic effect. CONCLUSIONS: Intravitreally injected TA does not mix with silicone oil. TA crystals that sediment at the lower border of a silicone oil bubble may be harmful to retinal cells. A suspension of TA in silicone oil may exhibit safer extended release over several days.

Suppression of melanoma-associated neoangiogenesis by bevacizumab.

BACKGROUND: Bevacizumab, a potent antibody against the vascular endothelial growth factor (VEGF), has been shown to be effective for treatment of colorectal cancer. Recently, high effectiveness of bevacizumab in combination with paclitaxel has been reported in a single metastatic melanoma case. To our knowledge, we demonstrate for the first time the antiangiogenetic effect of bevacizumab in a patient with a vitreous melanoma metastasis. OBSERVATIONS: A 68-year-old man with a vitreous melanoma metastasis of the left eye was treated with a revitrectomy combined with intravitreal bevacizumab application because of iris neovascularization and progressive epiretinal tumor plaques. Four days after the treatment, the melanoma-associated neovascularization completely disappeared, but it recurred after 6 weeks. Although repetitive administration of local bevacizumab produced the same antiangiogenetic effect, progression of the epiretinal tumor plaques could not be stopped with the local bevacizumab treatment. CONCLUSIONS: Intraocular administration of the anti-VEGF drug bevacizumab causes immediate and complete regression of melanoma-associated angiogenesis. The rationale for the therapeutic strategy in our patient was an elevated level of VEGF in the vitreous cavity. Because we could not demonstrate a direct antiproliferative effect of bevacizumab on melanoma metastasis, bevacizumab seems most promising if evaluated in combination with antiproliferative agents.

Epiretinal deposit of triamcinolone acetonide at the posterior pole after intravitreal injection.

The authors investigated possible toxic side effects of epiretinal triamcinolone acetonide deposits at the posterior pole after an intravitreal injection in both a vitrectomized and a non-vitrectomized eye. The vitrectomized eye developed massive epiretinal triamcinolone acetonide deposits at the posterior pole that were less pronounced in the non-vitrectomized eye. After resolution of the deposits, no morphologic signs of retinal toxicity were apparent. Mild scattered visual field defects did not correlate with the localization of the triamcinolone acetonide deposits. However, because recent in vitro studies indicate potential cytotoxicity, patients should be instructed to keep their heads in an upright position after intravitreal triamcinolone acetonide injection to avoid deposits at the posterior pole.

Different biocompatibility of crystalline triamcinolone deposits on retinal cells in vitro and in vivo.

Epiretinal deposits of triamcinolone acetonide (TA) can be detrimental to retinal cells in vitro as several laboratory studies have shown. This contrasts with the good clinical experience of intravitreal TA use. We investigated the effect of TA crystals on retinal cells concerning the critical dose range, a potential cell recovery, the drug-tissue interaction and what protective biological factors could explain the discrepancy between in vivo and in vitro results. A human retinal pigment epithelium cell line (ARPE19) and transformed rat retinal ganglion cells (RGC5) were used. Purified TA crystals were either added directly on top of the cell cultures or on top of membrane filter inserts, basement membrane sheets or porcine vitreous with the cells growing underneath. To determine the number of live versus dead cells fluorescent stains were used. Proliferation and viability were measured using the MTT assay and the mean inhibitory dose (ID(50)) calculated with or without a filter. Cell recovery was measured after transient TA exposure (0.01-1 mg/ml) compared to continuous exposure after 7 days. To exclude a mere mechanical effect of epicellular deposits the TA crystals were replaced by glass pearls in a serum-free medium and the MTT toxicity assay was performed after 24 h. Without direct contact of TA crystals with the cells only a moderate decrease of mitochondrial activity was observed that fully recovered after transient exposure and showed a clinically safe ID(50) of 7.7 mg/ml. In contrast, direct exposure to even minute crystalline deposits for 7 days caused a rapid progressive and irreversible cell death being significant far below clinically used concentrations (ID(50) 0.058 mg/ml). Direct exposure to glass pearls did not show any loss of viability. Both basement membrane sheets and vitreous reliably prevented direct cytotoxicity to underlying retinal ganglion cells. Our findings suggest that irreversible TA cytotoxicity in a cell culture setting occurs earlier than previously assumed in the presence of even minute epicellular deposits. But in most clinical situations epiretinal TA deposits seem not to be harmful to ocular cells as protective biological factors may prevent close apposition of TA crystals to susceptible retinal cells. However, in eyes that have undergone vitrectomy with ILM peeling epimacular deposits could be critical.

A new small-incision technique for injector implantation of transsclerally sutured foldable lenses.

A new, minimally invasive technique for clear cornea implantation of one-piece acrylic posterior chamber lenses for transscleral suture fixation in aphakic eyes without capsular support is described. Based on the techniques of modern small-incision cataract surgery, implantation was performed through a self-sealing, 2.75-mm temporal clear cornea incision using the injector technique. This was possible by modifying the insertion of the lens into the cartridge and introducing a new suturing technique of the lens. Suturing of the leading haptic end was performed while the lens was still securely stored inside the cartridge. The trailing haptic was tied after implantation. By using a self-sealing tunnel incision and injector technique, significant fluid egress and consecutive transient hypotony may be minimized throughout the procedure and early visual rehabilitation achieved.

Influence of different purification techniques on triamcinolone yield and particle size spectrum.

BACKGROUND: To systematically investigate the common purification techniques for commercially available triamcinolone acetonide preparations and the influence of different filter parameters on final yield, reproducibility and particle size spectrum. METHODS: Two non-filter techniques using either sedimentation or centrifugation, and two different filter techniques were tested. Filters with different characteristics were investigated with the pore size ranging from 0.1 to 5.0 microm, and the filter diameter ranging from 4 to 30 mm. Only sterile standard syringe filters with low adsorptive characteristics (hydrophilic cellulose filter membranes) for pharmaceutical use were employed. For quantification, triamcinolone acetonide was dissolved in 60% methanol and measured spectrophotometrically at 239 nm. The crystal size spectrum was determined using a particle size analyzer that combines electronic pulse area analysis and resistance measurement. RESULTS: Depending on the purification technique used the resulting triamcinolone doses differed significantly. While the centrifugation method achieved purification without relevant loss, the sedimentation method yielded only 28.7% compared to the original commercial suspension, and in addition, the predictability was low (range 8.1-17.2 mg). With filter techniques high and consistent doses with a good reproducibility were achieved, but results were highly dependent on the filter characteristics. The final triamcinolone amount inversely correlated with the filter diameter due to a uniform loss of crystalline particles. In contrast, enlarging the pore size caused a substantial shift in the particle size spectrum due to a selective loss of small crystalline particles. CONCLUSIONS: The most common purification techniques vary notably in regard to final triamcinolone doses, reproducibility and particle size spectrum. The appropriate choice of the filter parameters seems to be more important than assumed, as pore size and filter diameter substantially influence both the final TA doses and the particle size of the TA crystals.

A case of cutaneous melanoma metastatic to the vitreous cavity: possible pathomechanism and review of the literature.

BACKGROUND: Isolated vitreous metastases are extremely rare and the pathogenesis of metastasis is still unclear. Here we present the detailed description of the disease progression in a 68-year-old patient with vitreous seeding of a metastatic cutaneous melanoma beginning at a very early stage. METHODS: Interventional case report and review of the literature. RESULTS: The initial retrohyaloidal metastatic lesion was identified adjacent to a small epiretinal hemorrhage. As the disease progressed golden brown spherules appeared in the posterior vitreous emanating from the area of the lesion. Further progression led to a dense metastatic infiltration of the entire vitreous cavity and a decline of the visual acuity to 20/1200. Diagnostic and therapeutic pars plana vitrectomy was performed to confirm the diagnosis and preserve the eye and useful vision. CONCLUSIONS: For the first time the formation of vitreous metastases derived from cutaneous melanoma was carefully studied beginning at a very early stage. This made it possible to analyze the rare mechanism of vitreous metastasis, which has not been conclusively known till now. The features of metastatic cutaneous melanoma to the vitreous are discussed in context of a review of the literature that resulted from the study of 17 patients with 22 affected eyes.

Differential toxic effect of dissolved triamcinolone and its crystalline deposits on cultured human retinal pigment epithelium (ARPE19) cells.

The aim of the study was to evaluate the antiproliferative and cytotoxic properties of triamcinolone acetonide (TA) on human retinal pigment epithelium cells (ARPE19) and the role of epicellular crystalline deposits. Monolayer cultures of ARPE19 cells were used. Purified or unpurified crystalline TA suspension (0.01-1.0 mg/ml) or the vehicle alone (benzyl alcohol, 0.025%-0.00025%), diluted in culture medium, were added to the cells that were either grown on cell culture dishes covered by a protecting membrane filter insert or without a filter. After 1, 3, 5 and 7 days mitochondrial activity was measured using the MTT assay and the morphology assessed microscopically. Cellular proliferative activity was monitored by BrdU-incorporation into cellular DNA. For cytotoxicity assays ARPE19 cells were grown to confluence and then cultured in a serum-deficient medium to ensure a static milieu. Annexin V-FITC and propidium iodide co-staining was performed and analyzed by flow cytometry. Exposure to TA without direct cellular contact showed a moderate antiproliferative activity resulting in a dose-dependent suppression of DNA synthesis (maximum 42.7%), but not a cytotoxic effect. In contrast, adherent deposits of crystalline TA particles on top of the cell layer caused a rapid-progressive and dose-dependent cell death preceded by an early phosphatidylserine externalization to the outer leaflet of the plasma membrane. Within a healthy, confluent cell layer the number of viable cells decreased by 14.2, 20.8 and 68.8%, respectively, after one day of direct exposure. Exposure to the vehicle alone caused only a slight growth inhibitory effect in a proliferating cell layer, but early signs of cell death were detected even at the lowest concentration tested. In conclusion, the effect of the vehicle is less pronounced than formerly assumed, but not negligible, thus indicating a beneficial effect of purification. While non-adherent TA, if purified, appears to be safe in clinically used concentrations, direct physical contact with crystalline particles might cause a local, rapid-progressive cytotoxicity that involves the induction of the apoptotic cascade. Therefore, epiretinal deposits after intravitreal TA administration might be critical in terms of long-term biocompatibility.

The role of Rab27a in the regulation of melanosome distribution within retinal pigment epithelial cells.

Melanosomes within the retinal pigment epithelium (RPE) of mammals have long been thought to exhibit no movement in response to light, unlike fish and amphibian RPE. Here we show that the distribution of melanosomes within the mouse RPE undergoes modest but significant changes with the light cycle. Two hours after light onset, there is a threefold increase in the number of melanosomes in the apical processes that surround adjacent photoreceptors. In skin melanocytes, melanosomes are motile and evenly distributed throughout the cell periphery. This distribution is due to the interaction with the cortical actin cytoskeleton mediated by a tripartite complex of Rab27a, melanophilin, and myosin Va. In ashen (Rab27a null) mice RPE, melanosomes are unable to move beyond the adherens junction axis and do not enter apical processes, suggesting that Rab27a regulates melanosome distribution in the RPE. Unlike skin melanocytes, the effects of Rab27a are mediated through myosin VIIa in the RPE, as evidenced by the similar melanosome distribution phenotype observed in shaker-1 mice, defective in myosin VIIa. Rab27a and myosin VIIa are likely to be required for association with and movement through the apical actin cytoskeleton, which is a prerequisite for entry into the apical processes.

Rapid degradation of dominant-negative Rab27 proteins in vivo precludes their use in transgenic mouse models.

BACKGROUND: Transgenic mice have proven to be a powerful system to study normal and pathological gene functions. Here we describe an attempt to generate a transgenic mouse model for choroideremia (CHM), a slow-onset X-linked retinal degeneration caused by mutations in the Rab Escort Protein-1 (REP1) gene. REP1 is part of the Rab geranylgeranylation machinery, a modification that is essential for Rab function in membrane traffic. The loss of REP1 in CHM patients may trigger retinal degeneration through its effects on Rab proteins. We have previously reported that Rab27a is the Rab most affected in CHM lymphoblasts and hypothesised that the selective dysfunction of Rab27a (and possibly a few other Rab GTPases) plays an essential role in the retinal degenerative process. RESULTS: To investigate this hypothesis, we generated several lines of dominant-negative, constitutively-active and wild-type Rab27a (and Rab27b) transgenic mice whose expression was driven either by the pigment cell-specific tyrosinase promoter or the ubiquitous beta-actin promoter. High levels of mRNA and protein were observed in transgenic lines expressing wild-type or constitutively active Rab27a and Rab27b. However, only modest levels of transgenic protein were expressed. Pulse-chase experiments suggest that the dominant-negative proteins, but not the constitutively-active or wild type proteins, are rapidly degraded. Consistently, no significant phenotype was observed in our transgenic lines. Coat-colour was normal, indicating normal Rab27a activity. Retinal function as determined by fundoscopy, angiography, electroretinography and histology was also normal. CONCLUSIONS: We suggest that the instability of the dominant-negative mutant Rab27 proteins in vivo precludes the use of this approach to generate mouse models of disease caused by Rab27 GTPases.

A mouse model for Sorsby fundus dystrophy.

PURPOSE: Sorsby fundus dystrophy (SFD) is a rare, late-onset macular dystrophy caused by mutations in the tissue inhibitor of metalloproteinases-3 (TIMP3) gene. The known mutations introduce potentially unpaired cysteine residues in the C terminus of the protein and result in the formation of higher-molecular-weight protein complexes of as yet unknown composition and functional consequences in the pathologic course of SFD. To facilitate in vivo investigation of mutant TIMP3, the authors generated a knock-in mouse carrying a disease-related Ser156Cys mutation in the orthologous murine Timp3 gene. METHODS: Site-directed mutagenesis and homologous recombination in embryonic stem (ES) cells was used to generate mutant ES cells carrying the Timp3(S156C) allele. Chimeric animals were obtained, of which two displayed germline transmission of the mutated allele. Molecular genetic, biochemical, electron microscopic, and electrodiagnostic techniques were used for characterization. RESULTS: At 8 months of age, knock-in mice showed abnormalities in the inner aspect of Bruch's membrane and in the organization of the adjacent basal microvilli of the retinal pigment epithelium (RPE). Changes resembling those in the mutant animals were also present to some extent in normal littermates, but only at an advanced age of 30 months. Long-term electrodiagnostic recordings indicated normal retinal function throughout life. The biochemical characteristics of the mutant protein appear similar in humans and knock-in mice, suggesting common molecular pathways in the two species. The localization of the mutant protein in the eye is normal, although there is evidence of increased Timp3 levels in Bruch's membrane of mutant animals. CONCLUSIONS: The knock-in mice display early features of age-related changes in Bruch's membrane and the RPE that may represent the primary clinical manifestations of SFD. In addition, our immunolabeling studies and biochemical data support a model proposing that site-specific excess rather than absence or deficiency of functional Timp3 may be the primary consequence of the known Timp3 mutations.

Inactivation of the murine X-linked juvenile retinoschisis gene, Rs1h, suggests a role of retinoschisin in retinal cell layer organization and synaptic structure.

Deleterious mutations in RS1 encoding retinoschisin are associated with X-linked juvenile retinoschisis (RS), a common form of macular degeneration in males. The disorder is characterized by a negative electroretinogram pattern and by a splitting of the inner retina. To gain further insight into the function of the retinoschisin protein and its role in the cellular pathology of RS, we have generated knockout mice deficient in Rs1h, the murine ortholog of the human RS1 gene. We show that pathologic changes in hemizygous Rs1h(-/Y) male mice are evenly distributed across the retina, apparently contrasting with the macula-dominated features in human. Similar functional anomalies in human and Rs1h(-/Y) mice, however, suggest that both conditions are a disease of the entire retina affecting the organization of the retinal cell layers as well as structural properties of the retinal synapse.