Photodynamic therapy with verteporfin for retinal angiomatous proliferation

PURPOSE

The aim of this study was to evaluate the results of photodynamic therapy (PDT), using verteporfin, for subfoveal neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) with pigment epithelial detachment (PED) and/or choroidal neovascularization (CNV).

METHODS

In this non-comparative, consecutive, interventional, case series, the data on 21 eyes (19 with stage 2 and two with stage 3 RAP) of 20 patients were reviewed. Serous PED occupied more than 50% of the lesion in 19 eyes. PDT was performed as per TAP protocol. Biomicroscopy and fluorescein and indocyanine-green angiography were performed to evaluate anatomical results and need for retreatment. Changes from baseline in best-corrected visual acuity (BCVA), and complications, were assessed.

RESULTS

A mean of 3.5+/-0.9 treatments was performed. After 13.7+/-2.2 months, mean BCVA decreased from 20/80 to 20/174 (P=0.0063). In six eyes (28.6%) BCVA remained stable, whereas in 15 eyes (71.5%) it decreased. Occlusion of RAP and flattening of PED was observed in three (14.2%) eyes, conversion to disciform lesion in one (4.7%), and persistence of PED in 11 eyes (52.3%). One eye (4.7%) evolved to haemorrhagic PED, and one (4.7%) toward stage 3 RAP. A tear in the retinal pigment epithelium (RPE) was observed in four eyes (19%). Eleven (52.3%) showed progression of leakage, six moderate leakage (28.6%), and three (14.2%) absence of leakage.

CONCLUSIONS

Timely PDT with verteporfin in the early stages in eyes with smaller lesions has the potential for a beneficial effect on vision, whereas it might worsen the natural course of larger lesions, with most eyes undergoing enlargement, disciform transformation or RPE tear.

[Eruptive pseudoangiomatosis in infant and newborns]

INTRODUCTION

Eruptive pseudoangiomatosis was first described in children in the form of an acute non-pruritic macular or papular rash that fades on application of a glass test and resolves within several days. Viral aetiology is suspected but has never been demonstrated to date.

OBSERVATIONS

We discuss seven cases of infants presenting this disease: 5 boys and 2 girls aged 8 days to 16 months. The rash presented typical clinical features in all cases and affected the face and limbs in 6 of the 7 subjects. In one child, involvement of the face and back was observed with sparing of the limbs. The rash occurred after an episode of rhinolaryngeal infection in 3 cases and after gastrointestinal infection in 1 case. Spontaneous resolution was seen within 3 to 10 days in 6 patients although a longer course lasting over 9 months was observed in one infant. In another patient, the rash appeared after surgery for mesoblastic nephroma. In one child, a similar rash was seen in both parents. Screening for infectious agents was negative for the two children from whom samples were obtained.

DISCUSSION

This series of paediatric cases of eruptive pseudoangiomatosis is characterised by the very young age of one of the children, coexistence of the condition with a renal tumour in another child, the familial nature of the rash in a third child and unusually long disease duration in the final child. However, this series did not allow identification of the causative infectious agent or agents. Probably, as with other syndromes such as Giannotti-Crosti syndrome or "gloves and socks" syndrome, eruptive pseudoangiomatosis forms a clinical picture common to a non-specific viral infection.

Successful wireless capsule endoscopy for a 2.5-year-old child: obscure gastrointestinal bleeding from mixed, juvenile, capillary hemangioma-angiomatosis of the jejunum

The lesion responsible for obscure gastrointestinal bleeding in the pediatric population may not be determined with standard primary endoscopic methods. Wireless capsule endoscopy, now a first-line modality for evaluation of the small bowel in the adult population, is a tool that may be useful among children. We report a case of a 2.5-year-old girl who presented with melenic stools. Upper and lower endoscopy, Meckel scans, and mesenteric angiography yielded negative results. Wireless capsule endoscopy identified numerous abnormal, dilated, blood vessels in the proximal jejunum, with associated fresh blood. The patient underwent surgical exploration, with resection of the affected portion of the jejunum. Pathologically, the dilated blood vessels were consistent with mixed, juvenile, capillary hemangioma-angiomatosis of developmental or congenital origin. The patient fared well postoperatively, with no additional bleeding in 9 months of follow-up monitoring. This case report highlights the use of capsule endoscopy in the diagnosis and successful treatment of gastrointestinal bleeding in a young infant. This is the youngest reported patient treated with the use of wireless capsule endoscopy in the pediatric population.

Cystic meningioangiomatosis

A case of cerebral meningioangiomatosis with rare cyst formation is reported. A 14-year-old boy without any stigmata of neurofibromatosis type 2 presented intractable complex partial and generalized seizures since the age of 12 years. Neuroradiological studies showed an abnormal cystic mass with calcification in the left frontal lobe of the cerebrum. The tumor was located in the leptomeninges and cerebral cortex. The patient underwent surgical treatment because medical treatment with phenytoin and sodium valproate was not sufficient to control the seizures. An intraoperative electrocorticogram revealed that epileptic foci were recorded from the cortex, which was adjacent to the lesion. Histopathology showed specific features of meningioangiomatosis with meningioma-like nodules. The patient did not have any seizures with anticonvulsants after surgery. It is important to distinguish meningioangiomatosis from other possible cortical lesions and epileptic foci should be carefully considered before resection, because it is a benign and surgically manageable cause of seizures.

Primary Left Ventricular Angiomatosis First Description of a Rare Vascular Tumor in the Left Heart

A 24 year-old male who presented with palpitations and presyncopal attacks had monomorphic ventricular tachycardia and a well-defined huge mass within the inferoposterior wall of the left ventricle proved by transthoracic echocardiography. The mass was completely resected and shown to be proliferative angiomatosis by histopathologic examination. This is the first reported case of primary left ventricular angiomatosis in the literature.

Treatment of Retinal Angiomatous Proliferation in Age-Related Macular Degeneration

OBJECTIVE

To report the management of retinal angiomatous proliferation (RAP), a recently described intraretinal neovascular lesion occurring in age-related macular degeneration.

METHODS

This was a retrospective review of consecutive patients with age-related macular degeneration who underwent treatment of RAP from January 1, 2000, through January 31, 2003. Inclusion criteria were age 55 years or older, signs of age-related macular degeneration, and diagnosis of RAP based on dynamic indocyanine green angiography. Baseline angiograms were reviewed and RAP was classified into the following 3 stages: stage 1, intraretinal neovascularization, early stage; stage 2, subretinal neovascularization, middle stage; and stage 3, choroidal neovascularization, late stage. Treatment and concomitant treatment results were assessed separately for each RAP stage. The clinical data were statistically analyzed (chi2 test and analysis of variance) for 2 main outcome measures--complete obliteration of the lesion and final visual acuity.

RESULTS

Eighty-one patients (99 eyes) with 104 RAPs were identified. Forty-two lesions were at stage 1, 42 at stage 2, and 20 at stage 3. The following 5 treatments were performed: direct laser photocoagulation of the vascular lesion, laser photocoagulation of the feeder retinal arteriole, scatter "gridlike" laser photocoagulation, photodynamic therapy, and transpupillary thermotherapy. Complete obliteration of RAP was achieved in about 24 (57.1%) of the stage 1 lesions (direct laser photocoagulation of the vascular lesion, 73% success rate; photodynamic therapy, 45%), 11 (26.2%) of the stage 2 lesions (scatter gridlike laser photocoagulation, 38% success rate; direct laser photocoagulation of the vascular lesion, 17%), and only 3 (15.0%) of stage 3 lesions (P = .001). Predictive factors with a significant effect on final visual acuity were initial visual acuity (P = .003) and early lesion stage (P = .04). Best final visual acuity was 0.41 (mean, direct laser photocoagulation of the vascular lesion in stage 1) and 0.39 (mean, photodynamic therapy in stage 1), with a mean decrease of 2.5 and 3 lines from baseline, respectively.

CONCLUSIONS

Treatment of RAP remains difficult. Early detection of the lesion and subsequent direct conventional laser photocoagulation seems to be associated with better anatomical and functional outcome. Once the vascular complex is well established, anatomical closure is rarely achieved. Further study is warranted to assess the long-term efficacy and the need for re-treatment.

Venous angiomata: treatment with sclerosant foam

Venous angiomata, or venous malformations, are often present at birth, although they may not be evident until later. They consist of a spongy tangle of veins, and these lesions usually vary in size. Treatment of venous angiomata is often requested for cosmetic reasons, but painful ulcerations, nerve compression, functional disability can command care. This presentation describes management using sclerosant foam as the treating agent. During a 30-month period ending March 2004, 1,321 patients were investigated for venous disorders at the Vein Institute of La Jolla. Fourteen (incidence 1%) were found to have venous angiomata (: nine women). The age range was 15-76 years (mean 30.8 +/- 18.6). Lesions were classified by the Hamburg system and were primarily venous, extratruncular in 12 patients and combined extratruncular and truncular in two patients. Eight patients, three males, had manifestations of lower extremity Klippel-Trenaunay (syndrome; six had only venous angiomas. Only 10 of the 14 patients were treated. All patients were studied by Doppler duplex examination. Selected lesions were chosen for helical computed tomographic studies. Magnetic resonance venography was also used to image the lesions, define the deep circulation, note connections with normal circulation, identify vessels for therapeutic access, and determine infiltration of the lesion into adjacent soft tissue. Foam was produced by the Tessari two syringes one three-way stopcock teclinique, with the air to Polidocanol ratio being 4 or 5 to 1. This was used at 1% or 2% concentration, specific for each patient. The SonoSite 190 plus Duplex Doppler was used for ultrasound guidance, whenever deep access was required and to monitor progress and effects of treatment. A goal was set for each patient before treatment was begun. Ten patients were treated, and four await treatment. The mean number of treatments was 3.6 +/- 2.8 (range 1-10). A primary goal of pain-free healing was set in patients with nonhealing, painful ulceration or symptomatic varicose veins. This was achieved in all treated patients. Cosmetically, all of the patients were improved, and symptomatic patients were relieved of pain. The single complication was formation of a cutaneous ulcer following injection of telangiectasias. Sclerosant foam is a satisfactory tool to use in treating venous angiomata including the Klippel-Trenaunay syndrome. Use of foam sclerotherapy in this experience has proven the technique to be effective, essentially pain-free, and durable in the short term.

Recurrent retinal angiomatous proliferation after surgical ablation

PURPOSE

To report a case of retinal angiomatous proliferation (RAP) treated by ablation of the feeding and draining vessels that recurred by 6 months postoperatively.

DESIGN

Interventional case report.

METHODS

Images from fluorescein angiography, indocyanine green (ICG) angiography, and optical coherence tomography (OCT) were examined before and after ablation.

RESULTS

The hot spot on late-phase ICG, the leakage on fluorescein angiography, the pigment epithelial detachment, and macular edema on OCT decreased postoperatively. However, a large hyperfluorescent lesion was detected on ICG 6 months postoperatively with recurrent cystoid macular edema.

CONCLUSIONS

A new RAP lesion can develop even after the original lesion seemed to resolve after ablation.

Neurokutane Angiomatose

A 54-year-old woman developed epilepsy and gait disorder. The initial CCT showed multiple intracerebral cysts. Histologically these turned out to be cavities from repetitive bleedings out of abnormal vessels in the border region. Regular observation during 7 years showed spontaneous episodes of regression and progression of the cysts. In addition, multiple hemangiomas of the skin were found. The case presented here represents an unusual manifestation of neurocutaneous angiomatosis.

New micro vertical scissors for the surgical ablation of retinal angiomatous proliferation

PURPOSE

To develop new micro vertical scissors for the ablation of retinal angiomatous proliferation (RAP) to minimize possible retinal damage.

DESIGN

Interventional case report.

METHODS

New micro vertical scissors were developed and used for the ablation of RAP vessels.

RESULTS

The length of the inner side of the tip is 180 microm, which is approximately one seventh that of regular vertical scissors. The scissors handled easily and the RAP vessels were ablated with less retinal damage compared with that associated with use of standard vertical scissors. Postoperatively, intraretinal hemorrhage was reduced and hyperfluorescence seen on indocyanine green angiography resolved.

CONCLUSIONS

The new micro vertical scissors developed for the ablation of RAP vessels can be used safely and effectively during this surgical procedure.

Photodynamic therapy for retinal angiomatous proliferations and pigment epithelium detachment

PURPOSE

To evaluate results of photodynamic therapy (PDT) with verteporfin for subfoveal neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) and pigment epithelial detachment (PED).

DESIGN

Interventional case series.

METHODS

Thirteen eyes (11 stage 2 and 2 stage 3 RAP) underwent PDT. Best-corrected visual acuity (BCVA), fluorescein and indocyanine-green angiography were performed to evaluate the outcome.

RESULTS

After 13.5 +/- 2.5 months and 1.7 +/- 0.4 treatments, mean BCVA decreased from 20/73 to 20/174 (P = .04). Occlusion of RAP and flattening of PED was observed in three eyes, and persistence of PED in six. Two eyes deteriorated to disciform lesions, one developed hemorrhagic PED, and one evolved toward stage 3 RAP. Three eyes, with PED exceeding 50% of the entire lesion, developed retinal pigment epithelium tear.

CONCLUSIONS

PDT might prove effective for neovascular ARMD with RAP and small PED, whereas it might cause acute retinal pigment epithelium tear for RAP with PED exceeding 50% of the lesion.

Pseudo-angiomatose éruptive associée à une séroconversion pour les entérovirus

BACKGROUND

Eruptive pseudo-angiomatosis is a benign, acute dermatosis, mostly associated with a viral infection. Skin lesions consist of angioma-like papules, scattered over the skin. Involution is usually spontaneous and swift.

CASE-REPORT

We report a case of eruptive pseudo-angiomatosis, which occurred in an immunocompetent 18 year-old adult together with acute gastroenteritis and enterovirus seroconversion.

DISCUSSION

Eruptive pseudo-angiomatosis was described for the first time in 1969 in 4 children and then several pediatric cases were reported. Recently, 9 eruptive pseudo-angiomatosis in adults have been described. Our case had some particularities: it occurred in an immunocompetent adult and the skin lesions were angioma-like.

Retinal angiomatous proliferation: clinical characteristics and treatment options

BACKGROUND

A new form of exudative age-related macular degeneration (ARMD), retinal angiomatous proliferation (RAP), has been described in which neovascularization begins in the deep retina, extends through the subretinal space, and eventually communicates with choroidal neovascularization.

METHODS

Case series.

RESULTS

Common clinical features of RAP include small multiple intra-retinal hemorrhages, intra-retinal edema, vascularized pigment epithelial detachments (PEDs), and retinal choroidal anastomosis (RCA). Fluorescein angiography (FA) reveals ill-defined, occult choroidal neovascularization. Indocyanine green (ICG) angiography is useful in early stages because 'hot spots' can be detected before clinical or FA characteristics are present. Optical coherence tomography (OCT) is useful in illustrating some of the clinical and FA characteristics. The use of photodynamic therapy (POT), combined with intravitreal triamcinolone injection, was successful in stabilizing the RAP lesion in one case discussed in this report.

CONCLUSIONS

Retinal angiomatous proliferation is a newly recognized entity of exudative age-related macular degeneration with its own set of clinical, FA, ICG angiography, and OCT features. Experimental treatments such as the use of PDT combined with intravitreal triamcinolone injection demonstrate potential success with this entity. The biggest hope appears to be anti-angiogenic factors currently in clinical trials for the treatment of exudative ARMD.

Meningioangiomatosis in young dogs: a case series and literature review

Meningioangiomatosis (MA) is a proliferative disorder of the central nervous system (CNS) that has been reported rarely in humans and sporadically in dogs. Meningioangiomatosis may occur in the brainstem or cervical spinal cord of young dogs and can be identified tentatively by magnetic resonance imaging. The histopathologic hallmark of MA is a leptomeningeal plaque that extends along the CNS microvasculature and invades the adjacent neural parenchyma. This case series describes the neurologic signs, clinical progression, diagnostic imaging, and neuropathology of 4 dogs with MA. The 4 dogs with MA are compared and contrasted with 4 previously reported cases in dogs as well as with their human counterpart.

Diffuse abdominal angiomatosis

We present a rare case of diffuse abdominal angiomatosis occurring in a 19-year-old male; particular attention is paid to the MR imaging features of this disease process.

Disappearing calvarium in Gorham disease: MR imaging characteristics with pathologic correlation

Gorham disease is a rare condition characterized by intraosseous neoplastic proliferation of hemangiomatous tissue with progressive, massive osteolysis. We present a pathologically proved case of Gorham disease that involved the left parietal bone in a 23-year-old man. Imaging studies including conventional radiography of the skull, CT, MR imaging, and Technetium-99 m (Tc-99 m) scintigraphy demonstrated a large skull defect without associated soft tissue mass over the left parietal skull. Contrast enhancement and increased isotope uptake along the margin of the defect were shown at gadolinium-enhanced T1-weighted MR imaging and Tc-99 m methylene diphosphate (Tc-99 m MDP) bone scintigraphy. Pathologic study revealed intraosseous angiomatosis at the periphery of the osteolytic skull lesion.

Cystic angiomatosis with splenic involvement: unusual MRI findings

Cystic angiomatosis is a rare disorder with a poor prognosis. We describe a case of a 33-year-old woman who presented with long-standing bone pain, hemolytic anemia, and an enlarged spleen. Radiologically, multiple osseous lesions with a mixed pattern of lytic and sclerotic areas were seen within the shoulders, spine, and pelvis. On CT and MRI of the abdomen, the spleen was markedly enlarged, with internal hyperdense foci on non-contrast CT scan, corresponding to low signal intensity areas on all MR pulse sequences. After administration of contrast, a mottled enhancement pattern throughout the entire spleen was seen both on CT and MRI. Cystic angiomatosis was proven by histological analysis of a biopsy specimen of an involved vertebra and histopathological examination of the spleen after subsequent splenectomy. This is the first report of a patient with disseminated cystic angiomatosis with splenic involvement in which the MRI features differ from the previous reports. Instead of the usual pattern consisting of multiple well-defined cystic lesions, a diffuse involvement replacing the entire spleen, with heterogeneous signal intensities on T2-weighted images and heterogeneous enhancement pattern, was seen in our patient.