Photodynamic therapy for polypoidal choroidal vasculopathy.

The first effective therapy for exudative macular degeneration (AMD) was Photodynamic Therapy (PDT). Diagnosis of the disease was to a large extent by fluorescein angiography (FA). Distinguishing between the leaky choroidal neovessels (CNV) associated with exudative AMD, and the polypoidal structures associated with Polypoidal Choroidal Vasculopathy (PCV) is not always easy using FA alone. The switch to Indocyanine Green angiography helped to pinpoint PCV, and thus to study the efficacy of photodynamic therapy of this particular form of retinal disease, which is more frequently encountered among pigmented individuals. The results appear to be quite promising, and in the year following treatment only a small fraction of the patients had to be retreated. Alternatively, treating PCV with repeated intravitreal VEGF blocking agents was not as successful as it was in the treatment of wet AMD. However, combining PDT-induced angio-occlusion of the polypoidal lesions with anti-vascular endothelial growth factor therapy was shown to be quite effective, and the combination of PDT with an anti-angiogenic agent as well as a steroid, in a triple therapy, was recently also shown to be a quite promising option. In the present article we review the data on PDT of PCV, including combination therapies and alternative treatments. We also report on similarities and differences between AMD and PCV.

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.

[Dependence of the efficiency of low-intensity laser therapy in involution chorioretinal dystrophy on a used wavelength]. / Zavisimost' effektivnosti nizkointensivnoi lazernoi terapii involiutsionnoi tsentral'noi khorioretinal'noi distrofii ot primeniaemoi dliny volny.

Seventy-five patients (75 eyes) with central involution chorioretinal dystrophy (non-exudative type at the progression stage) were followed up. All of them received low-intensity laser therapy. Irradiation of 890 nm, 644 nm and 500 nm was used in groups 1, 2 and 3, respectively. The study purpose was to compare the efficiency of wavelengths. Visual acuity and retinal sensitivity were determined. The results were evaluated immediately after treatment and in 3 months. The maximal improvement in visual acuity and retinal sensitivity was in those who received 890 nm laser therapy; 500 nm irradiation--a less pronounced effect and 640 nm--the lowest one. We attribute such distribution of efficiency to a proliferation type of each irradiation range in the macular zone.

Intraocular involvement in multifocal fibrosclerosis.

OBJECTIVE: To report the clinical and histopathologic findings of intraocular involvement in a patient with multifocal fibrosclerosis and the response of the patient's choroidal masses to external beam radiotherapy. DESIGN: Case report with clinicopathologic correlation of enucleated eyes. METHODS: The patient was studied by clinical observation, contact B- and A-scan ultrasonography, orbital magnetic resonance imaging, fluorescein angiography, indocyanine green angiography, choroidal biopsy, and gross and histopathologic examination of the enucleated eyes. Tissue obtained at an earlier laparotomy was also reviewed. External beam radiotherapy was used when high-dose corticosteroid and low-dose methotrexate therapy failed to decrease the size of the choroidal masses or improve the patient's vision. MAIN OUTCOME MEASURES: Changes in the clinical and ultrasonographic size of the choroidal masses, the clinical appearance of these masses, and the patient's visual acuity in response to external beam radiotherapy were monitored premortem. Histopathologic findings in the enucleated eyes were compared with the changes in previous abdominal and choroidal biopsy specimens and with tissue alterations reported in multifocal fibrosclerosis. RESULTS: Biopsy of the choroidal mass revealed a fibrosclerosing process similar to that found in the abdomen. The patient received external beam radiotherapy with disappearance of the masses. Fibrosclerosing changes similar to those seen in the abdomen were observed replacing the choroid in the enucleated eyes. CONCLUSIONS: Multifocal fibrosclerosis may involve the choroid with histopathologic changes similar to those that have been described in other locations in the body. External beam radiotherapy may be an effective treatment for intraocular involvement by multifocal fibrosclerosis.

Choroidal neovascular membranes: treatment with reirradiation.

PURPOSE: To evaluate re-treatment with an additional course of low-dose irradiation in patients with progressive or recurrent choroidal neovascular membranes (CNVMs). MATERIALS AND METHODS: Ten patients who had received 14 Gy of external-beam radiation therapy in seven fractions for subfoveal CNVMs were found to have recurrent or persistent neovascularization at follow-up. They received an additional 15 Gy of radiation therapy administered in five daily fractions with a standard lens-sparing technique. Before reirradiation, visual acuity ranged from 20/80 to counting fingers. The median time between radiation courses was 6.5 months (range, 2-16 months). After re-treatment, the patients were followed up with angiography and visual field testing. The median follow-up was 18.5 months (range, 12-21 months). RESULTS: Eight of 10 patients (80%) maintained their visual acuity at 1 year and three of seven (43%) at 18 months. Visual acuity was stabilized in five of the 10 patients at their last follow-up. No acute or late side effects of irradiation were noted. CONCLUSION: Additional radiation therapy in selected patients with CNVMs who have failed to benefit from previous irradiation is well tolerated and appears to stabilize the disease process in a substantial proportion of these patients.

Correlation between Octopus perimetry and fluorescein angiography after strontium-90 plaque brachytherapy for subfoveal exudative age related macular degeneration.

AIM: To evaluate the correlation between the central visual field and changes in fluorescein angiography and fundus photography in patients treated with strontium plaque radiotherapy for subfoveal exudative age related macular degeneration (AMD). METHODS: Octopus program 34 automated static perimetry, fluorescein angiography, and colour fundus photography were performed on 19 patients at baseline and at 12 months after strontium-90 plaque therapy. A schematic picture outlining the areas of hyperfluorescent neovascular membranes and subretinal blood was drawn of a projected 30 degrees fundus fluorescein angiogram. This drawing was superimposed on the size adjusted Octopus visual field. The changes in retinal sensitivity were calculated and related to angiographic changes. RESULTS: Three of the 19 patients had a reliability factor (RF) > 15% and were excluded from further analysis. In the remaining 16 patients the mean defect (MD) and loss variance (LV) values remained unchanged in patients showing regression of the choroidal neovascular membrane (CNVM) to irradiation at 12 months. MD was 7.7 (SD 1.7) at baseline and 7.6 (1.9) at 12 months (p = 0.86), and LV was 32.6 (13.9) at baseline and 32.4 (15.7) at 12 months (p = 0.94). However, in patients with progression of the CNVM at 12 months, both the MD and LV increased significantly during the 12 month follow up (MD from 7.3 (2.9) to 13.1 (3.6) (p = 0.05) and LV from 31.0 (22.9) to 71.8 (24.1) (p = 0.017)). When comparing the mean retinal sensitivity in the area of the primary CNVM (including classic, occult, and haemorrhagic components), the results were analogous: in patients with a regression of the CNVM after irradiation the mean sensitivity remained almost unchanged. It was 10.3 (6.4) dB at baseline and 9.4 (7.3) dB at 12 months (p = 0.58). In five out of 11 patients (45%) with regression of the CNVM, the mean retinal sensitivity even improved by 2.0-5.0 dB in the area of the original lesion during follow up. Instead, in patients showing progression of the CNVM at 12 months, there was a significant loss in mean retinal sensitivity--from 9.9 (4.6) dB at baseline to 1.0 (1.1) dB at 12 months (p = 0.019). The mean retinal sensitivity in the area of the irradiated but clinically normal retina during follow up was not significantly altered (21.5 dB at baseline, 19.7 dB at 12 months (p = 0.10)). CONCLUSIONS: Regression of subfoveal choroidal membranes in AMD after focal strontium irradiation is connected with stabilisation or even improvement of retinal sensitivity in central visual field measured by automated perimetry. Strontium plaque irradiation does not change the sensitivity in clinically normal paramacular retina during a 12 month follow up.

Choroidal detachment associated with malignant choroidal tumors.

The association of choroidal detachment with malignant choroidal tumors is not well recognized. The authors' experience with six cases suggests that choroidal detachment may be associated with both metastatic tumors and choroidal melanoma. In two of these cases, the choroidal or retinal detachment was so massive that echography was necessary to detect the underlying tumor. Three patients presented with painful visual loss, and three patients presented with painless visual loss or a visual field defect. In one patient, the correct diagnosis and appropriate treatment of the choroidal metastasis with external radiation relieved the patient's pain and improved visual acuity from 1/200 to 20/35. Metastatic and primary uveal malignant tumors should be added to the list of causes of choroidal detachment and can be excluded only after thorough clinical, and often echographic, examination.