A long-term follow-up study of laser coagulation of neovascular membranes in angioid streaks

Angioid Streaks Remain a Challenge in Diagnosis, Management, and Treatment

Aim: Angioid streaks (ASs) are a rare retinal condition and compromise visual acuity when complicated with choroidal neovascularization (CNV). They represent crack-like dehiscences at the level of the Bruch's membrane. This objective narrative review aims to provide an overview of pathophysiology, current treatment modalities, and future perspectives on this condition. Materials and Methods: A literature search was performed using "PubMed", "Web of Science", "Scopus", "ScienceDirect", "Google Scholar", "medRxiv", and "bioRxiv." Results: ASs may be idiopathic, but they are also associated with systemic conditions, such as pseudoxanthoma elasticum, hereditary hemoglobinopathies, or Paget's disease. Currently, the main treatment is the use of anti-vascular endothelial growth factors (anti-VEGF) to treat secondary CNV, which is the major complication observed in this condition. If CNV is detected and treated promptly, patients with ASs have a good chance of maintaining functional vision. Other treatment modalities have been tried but have shown limited benefit and, therefore, have not managed to be more widely accepted. Conclusion: In summary, although there is no definitive cure yet, the use of anti-VEGF treatment for secondary CNV has provided the opportunity to maintain functional vision in individuals with AS, provided that CNV is detected and treated early.

To laser or not?

A 64-year-old male patient presented to the clinic with diminished vision in his right eye for the past 2 years. Examination revealed a best-corrected visual acuity (BCVA) of counting fingers at 1 m with a scarred choroidal neovascular membrane (CNVM) in the right eye while the left eye had a BCVA of 20/20 with a small peripapillary subretinal hemorrhage along with angioid streaks in both eyes. Multimodal imaging revealed the presence of a CNVM in the left eye which was treated with focal thermal laser. Regression was noted on optical coherence tomography angiography at 1 month post-laser, but at 3-month follow-up, exacerbation of the CNVM was observed. Subsequently, four intravitreal ziv-aflibercept injections were given, and scarring of CNVM was noted on OCT. Thermal laser in the background of angioid streaks has worsened the breaks in the Bruch's membrane leading to worsening of the CNVM.

Photodynamic Therapy with Verteporfin of Choroidal Neovascularization in Angioid Streaks: Conventional versus Early Retreatment

PURPOSE

To evaluate the effectiveness of conventional photodynamic therapy with verteporfin (PDT) in a series of patients with macular choroidal neovascularization (CNV) due to angioid streaks and to compare it to the effectiveness of early PDT retreatment.

METHODS

This is a retrospective study of 24 eyes (22 consecutive patients) with subfoveal or juxtafoveal CNV secondary to angioid streaks treated with PDT from September 2000 through February 2003 and that completed at least the first year of follow-up. Until August 2001, retreatments were performed according to the conventional protocol for PDT every 3 months (Group 1, consisting of 11 eyes of 9 patients). After August 2001 (13 more eyes of 13 new patients), retreatments were performed earlier (every 8 weeks) when indicated (Group 2). The follow-up time ranged from 30 to 42 months and from 12 to 30 months in Groups 1 and 2.

RESULTS

At the end of the follow-up, final best-corrected visual acuity decreased in 21 (87.5%), stabilized in 2 (8.3%), and improved in 1 (4.2%) of the total 24 eyes. In all, 19 of the 24 eyes (79.2%) had a final best-corrected visual acuity equal to or less than 20/400. There were not any statistically significant differences in final visual acuity between the two groups.

CONCLUSIONS

In this large series of patients with macular CNV secondary to angioid streaks, the functional and the anatomic results of PDT were not satisfactory, even when retreatments were performed earlier than the conventional time of 3 months.

Treatment of choroidal neovascularization due to angioid streaks: a comprehensive review

PURPOSE

To evaluate different therapies for choroidal neovascularization (CNV) due to angioid streaks (AS).

METHODS

Studies were identified by a systematic literature search and were included in the analysis based on predefined criteria. Primary outcome measure was change in best-corrected visual acuity (BCVA).

RESULTS

Fifty-four relevant studies were identified and included mostly uncontrolled case series. No randomized controlled trials were available. Treatment with vascular endothelial growth factor inhibitors improved or stabilized BCVA in all case series. Photodynamic therapy slowed down disease progression with stabilization or decrease of BCVA. Individual BCVA and follow-up data for each treated eye were reported in >160 cases for both treatments, vascular endothelial growth factor inhibitors and photodynamic therapy. In a pooled analysis of those studies, the difference of mean change in BCVA between both treatment groups was estimated as approximately 6 lines (0.59 logMAR [95% confidence interval, 0.38-0.8; P < 0.0001]). A better baseline BCVA was associated with a better BCVA outcome (P < 0.0001). Laser photocoagulation yielded comparable results as photodynamic therapy but application was mostly restricted to extrafoveal lesions, was complicated by frequent recurrences, and led to more retinal damage with subsequent absolute scotomas. Combination therapies seem to be not superior to monotherapy.

CONCLUSION

Intravitreal vascular endothelial growth factor inhibitors are currently the most effective treatment of CNV due to angioid streaks.

Long-term follow-up of choroidal neovascularization secondary to angioid streaks: case series and literature review

Background

The purpose of this paper is to report the clinical course of choroidal neovascularization (CNV) secondary to angioid streaks and the outcomes in response to different treatment modalities.

Methods

This was a case series of two consecutive patients (four eyes) with CNV secondary to angioid streaks. Visual acuity, ophthalmological examination, color photographs, fluorescein angiography, and optical coherence tomography were used to assess the outcomes of treatment.

Results

Two eyes were treated with photodynamic therapy for subfoveal choroidal neovascular membrane, one eye underwent thermal laser photocoagulation for extrafoveal CNV followed by intravitreal bevacizumab for subfoveal CNV, and one eye underwent intravitreal bevacizumab for subfoveal CNV. The follow-up period was 4–6 years. The final visual acuities of all eyes were 20/300 or worse with large submacular fibrosis.

Conclusion

CNV secondary to angioid streaks in these two patients had a poor prognosis despite undergoing different types of treatment. Poor outcome was likely related to frequent recurrence and newly developed CNV, which remained a clinical concern in these cases.

Management of CNV in angioid streaks by intravitreal use of specific anti-VEGF165 Aptamer (pegaptanib sodium): long-term results

PURPOSE

To investigate the effectiveness of intravitreal pegaptanib sodium injection in patients with choroidal neovascularization (CNV) secondary to angioid streaks.

METHODS

Five eyes of four patients with angioid streaks with CNV underwent uneventful intravitreal injection of pegaptanib sodium (0.3 mg/90 µL). Patients were followed up with Snellen visual acuity testing, optical coherence tomography, and fundus fluorescein angiography.

RESULTS

The median follow-up time was 18 months (range: 15 to 24 months). Visual acuity improved in two eyes, and stabilized in three out of five eyes. At final examination, CNV regressed with resolution of subretinal fluid in all but one patient with bilateral CNV from angioid streaks.

CONCLUSION

Intravitreal pegaptanib sodium for CNV associated with angioid streaks led to inactivation of most of the CNV lesions, stabilizing or improving visual acuity in all eyes.

Pseudoxanthoma elasticum, ocular manifestations, complications and treatment

Pseudoxanthoma elasticum (PXE), also known as Groenblad syndrome, is an inherited disorder characterised by mineralisation and fragmentation of elastic fibres in a number of organs including the skin, eyes and arterial blood vessels. The clinical manifestations of PXE centre on three major organ systems: skin, cardiovascular system and the eyes. This review focuses on the ocular manifestations of pseudoxanthoma elasticum, namely, peau d'orange, angioid streaks and choroidal neovascularisation, the clinical course of patients, the diagnostic approaches and current therapeutic strategies, such as laser photocoagulation whether transpupillary thermotherapy or photodynamic therapy, macular translocation surgery and anti-vascular endothelial growth factor treatment.

Intravitreal ranibizumab for choroidal neovascularization in angioid streaks

PURPOSE

To analyze retrospectively the efficacy of intravitreal ranibizumab injections for the management of choroidal neovascularization (CNV) in patients with angioid streaks.

DESIGN

Nonrandomized, double-center, retrospective, interventional case series.

METHODS

A consecutive series of patients affected with CNV associated with angioid streaks were treated with intravitreal ranibizumab injections (0.5 mg/0.05 mL). Best-corrected visual acuity, fundus photography results, optical coherence tomography (OCT) results, and fluorescein angiography results were examined before and after treatment. The primary end point was the percentage of eyes with stable or improved visual acuity at the end of follow-up. Secondary end points were the percentage of eyes with stable or decreased macular thickness on optical coherence tomography and the percentage of eyes with persistent leakage on fluorescein angiography at the last follow-up examination.

RESULTS

Thirty-five eyes of 27 patients were treated with repeated intravitreal ranibizumab injections (mean, 5.7 injections; range, 2 to 14 injections) for a mean of 24.1 months (range, 6 to 37 months). At the end of follow-up, visual acuity was stabilized or improved in 30 (85.7%) of 35 eyes. Macular thickness had stabilized or decreased in 18 (51.5%) of 35 eyes. At the last follow-up examination, on fluorescein angiography, no further leakage was observed in 23 (65.7%) of 35 eyes.

CONCLUSIONS

In this large series of angioid streaks-associated CNV, ranibizumab injections allowed stabilization of visual acuity. Ranibizumab seems to be a safe therapeutic option in CNV associated with angioid streaks.

Long-term results of intravitreal bevacizumab injection for choroidal neovascularization secondary to angioid streaks

PURPOSE

To investigate the long-term efficacy of intravitreal injections of bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) for choroidal neovascularization (CNV) secondary to angioid streaks.

DESIGN

Observational case series.

METHODS

Fifteen eyes of 13 patients (5 men, 8 women; mean age, 59 years; range, 54 to 70 years) treated with 1-mg intravitreal bevacizumab injections were included. The minimum follow-up after the first injection was 12 months. Eyes that had undergone previous treatments were excluded. The best-corrected visual acuity (BCVA) was measured. Optical coherence tomography and fluorescein angiography images were examined before and after treatment.

RESULTS

The mean follow-up was 19 months (range, 12 to 24 months). The mean number of injections for primary CNV was 4.5 (range, 1 to 9). The mean preoperative BCVA (decimal equivalent) was 0.39 (range, 0.08 to 1.5) and 0.47 (range, 0.06 to 1.2) at the final visit (P = .355). The BCVA improved by 2 lines of logarithm of the minimum angle of resolution visual acuity at the final visit in 5 eyes (33%), was unchanged in 8 eyes (54%), and decreased in 2 eyes (13%). The final fluorescein angiography examination showed no leakage in 10 eyes (67%), minimal leakage in 2 eyes (13%), and persistent or recurrent leakage in 3 eyes (20%). Five eyes (33%) had a recurrence 4 to 7 months (mean, 5.1 months) after the last bevacizumab injection. New CNV lesions developed in different areas in 3 eyes (20%) 6 to 14 months after the last bevacizumab injection for primary CNV.

CONCLUSIONS

An intravitreal injection of bevacizumab seems to maintain visual acuity. However, CNV frequently recurred or new CNV developed during the long follow-up.

Pseudoxanthoma elasticum: genetics, clinical manifestations and therapeutic approaches

Pseudoxanthoma elasticum (PXE) is an inherited disorder that is associated with accumulation of mineralized and fragmented elastic fibers in the skin, vascular walls, and Bruch's membrane in the eye. Clinically, patients exhibit characteristic lesions of the posterior segment of the eye including peau d'orange, angioid streaks, and choroidal neovascularisations, of the skin including soft, ivory-colored papules in a reticular pattern that predominantly affect the neck and large flexor surfaces, and of the cardiovascular system with peripheral and coronary arterial occlusive disease as well as gastrointestinal bleedings. There is yet no definitive therapy. Recent studies suggest that PXE is inherited almost exclusively as an autosomal recessive trait. Its prevalence has been estimated to be 1:25,000-100,000. Very recently, the ABCC6 gene on chromosome 16p13.1 was found to be associated with the disease. Mutations within ABCC6 cause reduced or absent transmembraneous transport that leads to accumulation of extracellular material. Presumably, this mechanism causes calcification of elastic fibers. Despite the characteristic clinical features, the variability in phenotypic expressions, and the low prevalence may be responsible for the disease being underdiagnosed. This review compiles and summarizes current knowledge of PXE pathogenesis and clinical findings. Furthermore, different therapeutic strategies to treat retinal manifestations are discussed, including thermal laser coagulation, photodynamic therapy, and intravitreal injections of drugs inhibiting vascular endothelial growth factor.

Photodynamic therapy with verteporfin for choroidal neovascularization in patients with angioid streaks

Purpose

To evaluate the functional and anatomic outcomes of photodynamic therapy (PDT) for choroidal neovascularization (CNV) in patients with angioid streaks.

Methods

The authors retrospectively evaluated 6 consecutive patients (6 eyes) with CNV secondary to angioid streaks. All patients were treated with standard PDT with verteporfin protocol. Standardized protocol refraction, visual acuity testing, ophthalmologic examination, color photographs, fluorescein angiograms and indocyanin angiograms were used to evaluate the results of PDT with verteporfin. Main outcome measures were visual acuity and CNV size.

Results

Their mean age was 61.3±5.50 years (range, 53-68 years). Follow-up time ranged from 12 to 38 months with mean of 20.5±10.91 months. The mean visual acuity at baseline was 20/100 (range 20/25-20/500), and the mean visual acuity at the last examination was 20/320(range 20/125-counting finger). The mean greatest linear dimension (GLD) at baseline was 2400±766.81 µm, and the mean GLD at the last examination was 3483±444.59 µm.

Conclusions

PDT for CNV associated with angioid streaks seemed to slow down but not prevent the progression of the disease and associated visual loss.

INTRAVITREAL BEVACIZUMAB FOR THE MANAGEMENT OF CHOROIDAL NEOVASCULARIZATION IN PSEUDOXANTHOMA ELASTICUM

PURPOSE

To determine the results of intravitreal bevacizumab injections for the management of choroidal neovascularization (CNV) in patients with pseudoxanthoma elasticum (PXE)-associated angioid streaks.

METHODS

A consecutive series of patients with PXE and CNV were managed with intravitreal bevacizumab injection (1.25 mg per 0.05 cc). The main outcome measures were visual acuity and greatest lesion height as measured by optical coherence tomography (OCT).

RESULTS

Nine eyes of nine consecutive patients received intravitreal bevacizumab (1.25 mg/0.05 mL) injections. The mean follow-up time was 6 months, during which eyes received an average of 1.8 injections. The baseline visual acuity was a mean of 20/368 and improved to 20/289 at the last visit (P = 0.056). Visual acuity either improved or stabilized in all 9 eyes (100%). Serial OCT measurements in 8 eyes showed a mean of 353 microm at baseline, which decreased to 201 mum at the last visit (P = 0.012). No complications were noted.

CONCLUSIONS

These short-term results support the use of intravitreal bevacizumab for the management of CNV in patients with PXE. Continued experience with intravitreal bevacizumab in this population will help establish its longer-term efficacy and better define the potential need for serial injections to maintain these results.

Photodynamic Therapy Using Verteporfin for Choroidal Neovascularization Associated with Angioid Streaks – Long-Term Effects

AIM

To investigate the safety and efficacy of photodynamic therapy with verteporfin (PDT) in patients with choroidal neovascularization associated with angioid streaks (CNVAS).

METHODS

A nonrandomized, prospective clinical investigation of 12 patients with CNVAS was performed. PDT was based on the criteria concerning the treatment of age-related macular degeneration.

RESULTS

The mean follow-up was 41.75 months (range 24-60). The mean number of (re)treatments was 3.3 (range 2-7). Visual acuity improved by at least 1 line in 42%, was stable within +/-2 lines in 33%, decreased by at least 1 line in 58% and by >3 lines in 25% of the patients. The mean visual acuity was 0.30 (range 0.2-0.5) prior to and 0.17 (range 0.03-0.6) after the final PDT. The mean visual acuity of the contralateral eye was 0.1. 75% of contralateral eyes and 25% of the treated eyes had a final visual acuity of < or =0.1 (20/200). At the final follow-up, a significant enlargement of the lesion size was noted in 92% of the cases.

CONCLUSION

Using the current (re)treatment criteria, PDT does not appear to limit the growth of CNVAS. Compared to the aggressive natural course and to the limited treatment options, PDT may at least in part help to stabilize macular function over a limited period of time.

Long-term results of photodynamic therapy for the treatment of choroidal neovascularization secondary to angioid streaks

PURPOSE

To evaluate the anatomic-functional results and complications associated with the use of photodynamic therapy (PDT) with verteporfin in the treatment of choroidal neovascularization (CNV) secondary to angioid streaks (AS).

METHODS

The authors retrospectively evaluated 10 consecutive patients (10 eyes) with CNV secondary to AS. All patients were treated with standard PDT with verteporfin protocol. The primary outcome to evaluate was the proportion of cases that lost < 3 lines of visual acuity (VA) measured on ETDRS charts. Secondary outcomes were changes in the greatest linear dimension (GLD) and in the area of the lesion. Seven previously examined patients were used as a control group.

RESULTS

The mean duration of follow-up was 18 months (SD 9.2, range 6-36 months). In nine cases CNV was subfoveal and in one case, juxtafoveal. Mean VA was 20/126 at baseline (range 20/40-20/320) and 20/500 at the final examination (range 20/64-20/800). Three patients (30%) lost< 3 lines of VA. Four patients (40%) lost > or =6 lines of VA. The mean line change was -4.9 lines. The mean GLD went from 2861 microm at baseline (SD 1086.6, range 1350-4300 microm) to 4452 microm at last visit (SD 2564.2, range 1260-9450 microm). The mean area of the lesion was 3.78 mm(2) at baseline (SD 1.9, range 1.0-5.7 mm(2)) and 12.1 mm(2) at the final examination (SD 15.1, range 0.8-50.6 mm(2)). One patient developed a subfoveal rip of the retinal pigment epithelium. In the control group, the mean duration of follow-up was 15 months (SD 2.4, range 12-18 months). At baseline, the mean VA was 20/160 (range 20/100-20/320) and the mean GLD was 2685 microm (SD 676.8, range 1800-3500 microm). At the last examination, mean VA was 20/640 (range: 20/400-20/800) and mean GLD was 5528 microm (SD 2106.90, range 3500-8000 microm).

CONCLUSION

PDT with verteporfin does not seem to be a good treatment for stabilization of VA and lesion size in CNV secondary to AS, although the overall results seem to be slightly better in the group of patients treated with PDT than in the control group.

Verteporfin photodynamic therapy of choroidal neovascularization in angioid streaks: one-year results of a prospective case series

PURPOSE

To report the 12-month results on the use of verteporfin photodynamic therapy (PDT) in the treatment of choroidal neovascularization (CNV) secondary to angioid streaks.

STUDY DESIGN

Five-center prospective case series.

METHODS

Patients with CNV secondary to angioid streaks who were treated with PDT were recruited and followed up at 3-month intervals for 12 months, with the addition of visits at 1.5 and 4.5 months if deemed appropriate by the investigator. Best-corrected visual acuity (BCVA) was measured at each visit after full refraction or with their current distance spectacles using Early Treatment Diabetic Retinopathy Study logarithm of the minimum angle of resolution charts. Stereoscopic fundus fluorescein angiography was used to determine baseline lesion characteristics and location.

RESULTS

Twenty-two patients were recruited (23 eyes, 16 with subfoveal CNV and 7 with juxtafoveal; all classic no occult). Seventeen patients (77%) had angioid streaks secondary to pseudoxanthoma elasticum. In the subfoveal group, median BCVA at baseline was 49 letters (approximate Snellen equivalent, 20/100) and was 46 at 12 months (approximate Snellen equivalent, 20/125). Twelve of 16 eyes (75%) lost fewer than 8 letters, whereas 14 of 16 eyes (88%) lost fewer than 15 letters. The mean CNV greatest linear dimension (GLD) was 2520 microm at baseline. At 12 months, 7 of 16 eyes with subfoveal CNV at baseline were leaking (GLD = 3220 microm; P = 0.62). The mean number of treatments in the first 12 months was 2.9. In the juxtafoveal group, the median BCVA at baseline was 66 letters (approximate Snellen equivalent, 20/50) and was 51 letters at 12 months (approximate Snellen equivalent, 20/100). Two of 7 eyes (29%) gained 8 or more letters at the 12-month examination, whereas 4 of 7 eyes (57%) lost more than 15 letters. The mean CNV GLD at baseline was 1890 microm. At 12 months, 1 of 7 eyes with juxtafoveal CNV at baseline was leaking. Choroidal neovascularization progressed from juxtafoveal to subfoveal location during the follow-up period in 4 of 7 eyes. The mean number of treatments in the first 12 months was 3.4. No side effects were noted in either patient group.

CONCLUSIONS

This small series suggests that treatment of CNV secondary to angioid streaks with verteporfin PDT seems to limit visual loss in most patients through the first 12 months of follow-up, particularly in those with subfoveal lesions at baseline.

OUTCOME OF CHOROIDAL NEOVASCULARIZATION IN ANGIOID STREAKS AFTER PHOTODYNAMIC THERAPY

PURPOSE

To evaluate the visual and anatomic outcomes of photodynamic therapy for choroidal neovascularization (CNV) in patients with angioid streaks.

METHODS

The authors retrospectively evaluated 40 consecutive patients (48 eyes) with visual acuity of 20/200 or greater who were treated at 6 referral centers for CNV associated with angioid streaks. Main outcome measures were visual acuity, greatest linear diameter of the lesion, and, in patients with nonsubfoveal CNV, distance from the foveola.

RESULTS

Of 34 eyes with subfoveal CNV, 21 were followed up for at least 12 months (range, 5-33 months). Median visual acuity was 20/50 at baseline and 20/120 at the final examination. The 12-month estimate of the percentage of eyes with vision loss of fewer than 3 lines was 68% (95% confidence interval, 50%-85%) by using survival analysis, whereas eyes with no increase in the greatest linear diameter were 45% (95% confidence interval, 27%-62%). Fourteen eyes had extrafoveal (n = 11) or juxtafoveal (n = 3) CNV, 12 of which were followed up for at least 10 months (range, 4-36 months). Visual acuity was 20/40 or greater in all eyes with extrafoveal lesions at baseline and in 5 of 12 eyes at the last examination, when 3 cases of CNV had become subfoveal. At baseline, visual acuity was low in two eyes with juxtafoveal CNV and nearly normal in the third. It remained substantially stable at the end of follow-up (range, 10-36 months), when two lesions were subfoveal.

CONCLUSIONS

Most of our patients had good baseline visual function and, thus, were at high risk for losing vision because of the poor prognosis of CNV in angioid streaks. Because most had no or limited vision loss after 1 year, the authors suggest that photodynamic therapy can be used to try to limit or delay visual damage caused by this aggressive disease.

Selective occlusion of subfoveal choroidal neovascularization in angioid streaks by using a new technique of ingrowth site treatment

PURPOSE

To evaluate the visual and angiographic effects, as well as optical coherence tomography (OCT) findings, after a new treatment-neovascular ingrowth-site photothrombosis-in patients with subfoveal choroidal neovascularization (CNV) secondary to angioid streaks.

DESIGN

Prospective noncomparative small case series.

PARTICIPANTS

Five eyes of 5 patients with angioid streaks in whom fluorescein and conventional indocyanine green (ICG) angiography clearly demonstrated distinct CNV vessels supplying the subfoveal neovascular complex.

INTERVENTION

All five eyes were submitted to ICG-mediated photothrombosis of the neovascular ingrowth site. This novel, laser/dye-mediated technique uses large-spot, lower-intensity 810-nm light for continuous application of laser energy to ICG concentrated in vascular lesions.

MAIN OUTCOME MEASURES

Visual outcome and the results of fluorescein angiography, ICG angiography, and OCT evaluation.

RESULTS

Fluorescein and conventional ICG angiography were sufficient to identify the CNV ingrowth site, which was juxtafoveal in 2 and extrafoveal in 3 of the 5 eyes in this series. Obliteration of the entire neovascular lesion was achieved in all patients within the first hour after ICG-mediated photothrombosis of the CNV ingrowth site. At 1 week, the mean change in best-corrected visual acuity from baseline was +3.2 (+/-1.4) lines. Twelve months after treatment, visual acuity improved by 3 or more lines in all patients, and decreased leakage of fluorescein from the CNV, as well as OCT evidence of reduced or resolved retinal edema, was seen at the last follow-up visit. Major complications, such as immediate severe visual loss and retinal vessel occlusion in the early posttreatment period, were not identified in the 5 patients submitted to the procedure.

CONCLUSIONS

Photothrombosis of the CNV ingrowth site by using lower-intensity light to direct laser energy continuously after IV ICG infusion is a safe and effective technique for rapid induction of CNV hypoperfusion in selected patients and is associated with considerable improvement in visual acuity and partial restoration of the retinal architecture up to 12 months after treatment.

Photodynamic therapy using verteporfin for choroidal neovascularization in angioid streaks

PURPOSE

To evaluate the efficacy of photodynamic therapy with verteporfin in the management of choroidal neovascularization (CNV) associated with angioid streaks.

DESIGN

Retrospective case series.

METHODS

Eleven eyes of nine patients with subfoveal or juxtafoveal CNV due to angioid streaks underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography to evaluate the results of photodynamic therapy with verteporfin. Retreatment of persistent CNV was based on criteria from the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Investigation (TAP) except in one case. Follow-up ranged from 5 to 28 months (mean, 17 months).

RESULTS

Nine of 11 eyes had subfoveal lesions while two eyes had juxtafoveal lesions on initial examination. Conversion from a choroidal neovascular membrane (CNVM) to a fibrous disciform lesion following photodynamic therapy was observed in nine eyes. Enlargement of the CNVM was noted in seven of these eyes by fluorescein angiography at final follow-up. Initial best-corrected visual acuity (BCVA) ranged from 20/25 to counting fingers (CF) (mean, 20/400; median, 20/200). Final BCVA ranged from 20/20 to CF (mean, 20/600; median, 20/400). Seven eyes with subfoveal CNVM had an initial BCVA of at least 20/200 while only three eyes maintained this level or better at last follow-up. In one patient with a juxtafoveal CNVM in one eye, vision decreased from 20/25 to 20/400 with enlargement and fibrosis of the CNVM and subfoveal extension. In the fellow eye a juxtafoveal CNVM was initially treated and then retreated earlier than TAP criteria at 6 weeks. Vision improved to 20/20 and has remained stable 5 months after the initial treatment.

CONCLUSIONS

Verteporfin for choroidal neovascularization-associated with angioid streaks does not appear to significantly alter the course of this disease with most eyes undergoing enlargement and disciform transformation of the neovascular process. However, aggressive management of these patients with biomicroscopic and fluorescein angiographic examination and timely photodynamic therapy with early retreatment when indicated may be beneficial in certain cases.

Elastic tissue abnormalities resembling pseudoxanthoma elasticum in beta thalassemia and the sickling syndromes

The development of clinical and histopathologic manifestations of a diffuse elastic tissue defect, resembling inherited pseudoxanthoma elasticum (PXE), has been encountered with a notable frequency in patients with beta thalassemia, sickle cell disease, and sickle thalassemia. The PXE-like clinical syndrome, consisting of skin, ocular, and vascular manifestations, has a variable severity in these hemoglobinopathies and it is age-dependent, with a generally late onset, after the second decade of life. The defect is believed to be acquired rather than inherited and related to the consequences of the primary disease. The high prevalence of the findings implicates the elastic tissue injury as one of the main comorbid abnormalities encountered in beta thalassemia and the sickling syndromes. In these patients a number of complications, sometimes serious, has been recognized to be related to ocular and vascular elastic tissue defects. Because several organ systems are involved, each medical specialty should be aware of the phenomenon. This coexistence, on the other hand, introduces a novel pathogenetic aspect of PXE and an important research challenge.

Etiology of choroidal neovascularization in young patients

BACKGROUND

Choroidal neovascularization (CNV) is a common cause of legal blindness in developed countries. In patients younger than 50 years of age, CNV can be due to various causes, but to the authors' knowledge there has been no large epidemiologic study to compare the relative incidence of the various causes of CNV in this younger-aged group.

METHODS

A retrospective study was performed of patients seen over a 30-month period to precisely define the relative incidence of the various etiologies of CNV in patients younger than 50 years of age who had been referred to a tertiary care ophthalmology department in western Europe.

RESULTS

Clinical charts and angiograms of 363 patients were reviewed. The etiology of CNV was high myopia in 225 (62%) patients, pseudo-presumed ocular histoplasmosis syndrome in 42 (12%), angioid streaks in 17 (5%), and miscellaneous hereditary or traumatic or inflammatory disorders in 16 (4%). Choroidal neovascularization could not be related to any etiology in 63 (17%) patients, and was considered to be idiopathic lesions. Choroidal neovascularization was subfoveal in 62% of the patients due to myopia versus 30% to 36% in patients due to other etiologies. Laser photocoagulation was applied in the majority of patients due to all etiologies except myopia.

CONCLUSION

These data provide the relative incidence of the various etiologies of CNV in young patients and emphasize the importance of myopia as an etiology of CNV in such patients. In addition, an apparent preferential localization of CNV to the subfoveal region in myopic eyes precludes its treatment with photocoagulation.

Laser treatment of choroidal neovascularization in patients with angioid streaks

The benefit of laser photocoagulation to choroidal neovascularization secondary to angioid streaks remains controversial. To further expand our knowledge, we reviewed the records of 20 patients (24 eyes) with classic (well-defined) choroidal neovascularization secondary to angioid streaks, who were treated with laser between 1982 and 1991 at the Retinal Vascular Center of the Wilmer Institute. The choroidal neovascularization was extrafoveal in 18 (75%), juxtafoveal in two, subfoveal in three, and indeterminate in one eye. Seventeen of the 24 fellow eyes (71%) had a disciform scar or choroidal neovascularization, or both. Follow-up ranged from three months to nine years (mean, 3.5 years; median, two years). Lines of visual acuity change averaged -2.5 at three, -2.6 at six, -2.4 at 12, and -4.8 lines at 24 months. Choroidal neovascularization persisted in five of 24 eyes and recurred in nine of the remaining 19 eyes at risk. When the fellow eye had choroidal neovascularization, scar, or both, at the time of treatment, the rate of persistence or recurrence was 65% vs 33% if the fellow eye had no choroidal neovascularization, scar, or both. An average of four lines of visual acuity was lost when fellow eyes had choroidal neovascularization, scar, or both, vs one line when the fellow eye had no choroidal neovascularization or scar. Laser photocoagulation of choroidal neovascularization in patients with angioid streaks can result in closure of the choroidal neovascularization and stabilization of visual acuity.