Prognostic factors influencing visual outcome of photodynamic therapy for subfoveal choroidal neovascularization in pathologic myopia

Myopic maculopathy: Current status and proposal for a new classification and grading system (ATN)

Myopia is a highly frequent ocular disorder worldwide and pathologic myopia is the 4th most common cause of irreversible blindness in developed countries. Pathologic myopia is especially common in East Asian countries. Ocular alterations associated with pathologic myopia, especially those involving the macular area-defined as myopic maculopathy-are the leading causes of vision loss in patients with pathologic myopia. High myopia is defined as the presence of a highly negative refractive error (>-6 to -8 diopters) in the context of eye elongation (26-26.5 mm). Although the terms high myopia and pathologic myopia are often used interchangeably, they do not refer to the same eye disease. The two key factors driving the development of pathologic myopia are: 1) elongation of the axial length and 2) posterior staphyloma. The presence of posterior staphyloma, which is the most common finding in patients with pathologic myopia, is the key differentiating factor between high and pathologic myopia. The occurrence of staphyloma will, in most cases, eventually lead to other conditions such as atrophic, traction, or neovascular maculopathy. Posterior staphyloma is for instance, responsible for the differences between a myopic macular hole (MH)-with and without retinal detachment-and idiopathic MH. Posterior staphyloma typically induces retinal layer splitting, leading to foveoschisis in myopic MH, an important differentiating factor between myopic and emmetropic MH. Myopic maculopathy is a highly complex disease and current classification systems do not fully account for the numerous changes that occur in the macula of these patients. Therefore, a more comprehensive classification system is needed, for several important reasons. First, to more precisely define the disease stage to improve follow-up by enabling clinicians to more accurately monitor changes over time, which is essential given the progressive nature of this condition. Second, unification of the currently-available classification systems would establish standardized classification criteria that could be used to compare the findings from international multicentric studies. Finally, a more comprehensive classification system could help to improve our understanding of the genetic origins of this disease, which is clearly relevant given the interchangeable-but erroneous-use of the terms high and pathologic myopia in genetic research.

Photodynamic Therapy for Choroidal Neovascularization in Patients with Multifocal Choroiditis and Panuveitis

Purpose

To evaluate the visual benefit of photodynamic therapy (PDT) with verteporfin in patients with choroidal neovascularization (CNV) secondary to multifocal choroiditis and panuveitis over a longer follow-up period.

Methods

A total of 14 eyes of 12 patients (mean age 34 years) with a classic subfoveal CNV (13/14) or juxtafoveal CNV (1/14) were treated with PDT Visual outcome was assessed by best-corrected visual acuity (VA). Morphologic characteristics of CNVs such as localization, size, and activity were monitored by fluorescein angiography.

Results

Patients were followed for 3 to 45 months (mean 23 months). During this period, one to six PDTs (mean 2.4) were performed. At the time of the first PDT no acute inflammation was seen in the affected eyes. Improved or stabilized visual function (VA loss ≤ 2 lines in the Early Treatment Diabetic Retinopathy Study chart) was observed in 71.4% of the eyes. A total of 78% of the eyes showed an inactive scar in the area of CNV after PDT. Treatment failure after PDT occurred due to uninfluenced CNV growth. No further complications were observed.

Conclusions

PDT in subfoveal or juxtafoveal classic CNV secondary to multifocal choroiditis and panuveitis stabilized or improved VA in the majority of patients over a longer follow-up period. No risk factor for failed VA rehabilitation could be defined.

The role of anti-VEGF agents in myopic choroidal neovascularization: Current standards and future outlook

INTRODUCTION

The global prevalence of pathologic myopia is 0.9-3.1%, and visual impairment is found in 0.1-0.5% of European and 0.2-1.4% of Asian studies. Myopic choroidal neovascularization (mCNV) affects 5.2-11.3% of pathologic myopia patients and is a leading cause of vision impairment in the working-age population. Characteristic morphological changes and visual-acuity decrease are diagnostic features. Vascular-Endothelial-Growth-Factor (VEGF) has been identified as a trigger for pathologic neovascularization in these highly myopic patients.

AREAS COVERED

We cover the epidemiology, pathology and diagnostic aspects of mCNV. The history of therapeutic interventions is described, followed by an overview of current standard-of-care (SOC)-blocking VEGF using bevacizumab (off-label), ranibizumab or aflibercept and improving vision up to 13.5-14.4 letters. Despite good efficacy, an unmet medical need remains. We summarize ongoing and future developments of new drugs to treat or potentially cure mCNV.

EXPERT OPINION

mCNV is a major global health concern. Early detection and treatment is key for a satisfying outcome. The current SOC, VEGF inhibitors, affords good therapeutic efficacy and reasonable disease stabilization with few intravitreal treatments per year. However, the long-term prognosis is still unsatisfactory, and side-effects like chorioretinal atrophy development are of concern. Therefore, efforts should be intensified to develop more effective therapies.

Effect of Factor XIII-A G185T Polymorphism on Visual Prognosis after Photodynamic Therapy for Neovascular Macular Degeneration

Macular degenerations represent leading causes of central blindness or low vision in developed countries. Most of these severe visual disabilities are due to age-related macular degeneration (AMD) and pathologic myopia (PM), both of which are frequently complicated by subfoveal choroidal neovascularization (CNV). Photodynamic therapy with verteporfin (PDT-V) is still employed for CNV treatment in selected cases or in combined regimen. In Caucasian patients, the common polymorphism G185T of factor XIII-A gene (FXIII-A-G185T; rs5985) has been described as predictor of poor angiographic CNV responsiveness to PDT-V. Nevertheless, the prognostic implications of this pharmacogenetic determinant on long-term visual outcome after a PDT-V regimen have not been evaluated. We retrospectively selected Caucasian patients presenting with treatment-naive CNV and receiving standardized PDT-V protocol for two years. The study population included patients affected by subfoveal CNV secondary to AMD or PM. We assessed the correlations between the polymorphic allele T of FXIII-A-G185T and: (1) total number of photodynamic treatments; and (2) change in visual acuity from baseline to the end of the follow-up period. Considering a total study population of 412 patients with neovascular AMD or PM, the carriers of 185 T-allele of FXIII-A (GT or TT genotype) received a higher number of photodynamic treatments than patients without it (GG wild-type genotype) (p < 0.01; mean number of PDT-V: 5.51 vs. 3.76, respectively). Moreover, patients with 185 T-allele of FXIII-A had a more marked worsening of visual acuity at 24 months than those with the GG-185 wild genotype (p < 0.01; mean difference in logMAR visual acuity: 0.22 vs. 0.08, respectively). The present findings show that the G185T polymorphism of the FXIII-A gene is associated with significant differences in the long-term therapeutic outcomes of patients treated with standardized PDT-V protocol. The comprehensive appraisal of both anti-thrombophilic effects due to FXIII-A G185T variant and photo-thrombotic action of PDT-V toward CNV provides several clues about the rationale of this intriguing pharmacogenetic correlation. Further investigations are warranted to outline the appropriate paradigm for guiding PDT-V utilization in the course of the combined therapeutic protocol for neovascular macular degeneration.

Management of Choroidal Neovascularization Secondary to Pathological Myopia: The Era of Changes

Choroidal neovascularization (CNV) secondary to pathological myopia is an important cause of significant visual impairment in young adults. High myopia is particularly prevalent in Asian population. New scientific contributions have been made to the understanding of high myopia and myopic CNV. Treatment for myopic CNV has previously relied on photodynamic therapy, laser photocoagulation, and submacular surgery. The treatment outcomes from these modalities are, however, controversial. The introduction of antiangiogenic agents including bevacizumab and ranibizumab has brought the treatment of myopic CNV into a new era. The purpose of this review was to provide an overview of the natural history of myopic CNV, the prognostic factors, and the various treatment options including laser photocoagulation and photodynamic therapy, with particular attention on antiangiogenic agents.

Choroidal neovascularization in pathological myopia

Myopic choroidal neovascularization (CNV) is one of the leading causes of visual impairment worldwide. The clinical and socioeconomic impact of myopic CNV in Asian countries is particularly significant due to rising trend in the prevalence and severity of pathological myopia. The exact pathogenesis of myopic CNV remains unclear and there is paucity of information with respect to incidence and risk factors for myopic CNV from prospective studies. Furthermore, there are no recognized measures that may prevent or delay the development of CNV in eyes with pathological myopia. Advances have been made in the diagnosis and characterization of myopic CNV over the years. Until recently, treatment modalities for myopic CNV were limited to thermal laser photocoagulation and photodynamic therapy with verteporfin, both these modalities primarily aim at prevention of further visual loss. In the last 5 years, inhibitors of vascular endothelial growth factor (VEGF) have been used successfully and may improve vision to some extent. Nevertheless, the long-term safety and efficacy of anti-VEGF agents remains unknown. Furthermore, the risk of developing chorioretinal atrophy remains the key factor in determining the final visual outcome. This review article summarizes the current literature on myopic CNV, highlighting new evolving diagnostic and treatment modalities, prognostic factors influencing visual outcome, and areas of future research.

Anti-vascular endothelial growth factor for myopic choroidal neovascularization

Myopic choroidal neovascularization (CNV) is a vision-threatening complication in the eyes with pathological myopia, which is particularly prevalent among young and middle-aged Asians globally. To date, the verteporfin in photodynamic therapy study is the only randomized-controlled study in treatment of subfoveal myopic CNV. However, its long-term benefit is controversial. Recently, intravitreal injections of anti-vascular endothelial growth factors have shown promising results. In the absence of randomized-controlled trial comparing the efficacy of anti-vascular endothelial growth factors with photodynamic therapy and placebo, the purpose of this article is to review the current studies on functional and anatomical outcomes in both subfoveal and juxtafoveal myopic CNV. Furthermore, the influences of various doses and frequencies, as well as age and previous photodynamic therapy treatment on its effect are described.

Intravitreal bevacizumab therapy on an as-per-needed basis in subfoveal choroidal neovascularization secondary to pathological myopia: 2-year outcomes of a prospective case series

PURPOSE

To evaluate the effects of intravitreal bevacizumab in the treatment of subfoveal choroidal neovascularization (CNV) related to pathological myopia.

METHODS

Thirty eyes with treatment-naive CNV were included. Best-corrected visual acuity on Early Treatment Diabetic Retinopathy Study chart, optical coherence tomography (OCT), and fluorescein angiography assessment was performed at baseline and thereafter monthly for more than 24 months. Intravitreal bevacizumab on an as-per-needed basis was administered if either persistent intraretinal/subretinal fluid was detected on OCT or the presence of leakage was noted on fluorescein angiography. Primary outcome measures included the change in mean best-corrected visual acuity and the proportion of eyes improving by three lines or greater. Secondary outcome measures included the change in mean central macular thickness on OCT. The proportion of eyes with resolution of intraretinal/subretinal fluid on OCT and leakage on fluorescein angiography over the follow-up was also noted.

RESULTS

Mean best-corrected visual acuity improved from 54.8 ± 14.8 (Early Treatment Diabetic Retinopathy Study letters ± SD) to 59.03 ± 17.0 at 3 months, subsequently stabilizing to 58.63 ± 18.52 at 12 months and 59.25 ± 20 at 24 months. A statistically significant difference was detected only at the 1-month examination. Best-corrected visual acuity at 24 months showed a 3-line improvement in 36.6% of cases and at least a 1-line increment in 43.3% of cases. Mean central macular thickness showed no significant reduction from baseline (216.8 ± 86 µm) up to the end of 24 months (205 ± 77.8 µm). At the last visit, a complete CNV closure was obtained in 93% of cases while intraretinal/subretinal fluid was detected on OCT in 13% of cases. The mean number of intravitreal bevacizumab injections was 4.73 (range, 1-10) at the end of 12 months and 5.9 (range, 1-13) at the end of the 24 months.

CONCLUSION

Intravitreal bevacizumab injection for myopic subfoveal CNV administered on an as-per-needed basis over 24 months of follow-up achieved stabilization of vision with >90% CNV closure rate.

Outcome of photodynamic therapy in choroidal neovascularization due to pathologic myopia and related factors

To evaluate the outcome of photodynamic therapy (PDT) and the factors influencing its outcome in patients with subfoveal choroidal neovascularization (CNV) due to pathologic myopia. Twenty-three eyes of 21 consecutive patients who received PDT for subfoveal CNV due to pathologic myopia and who were followed for >12 months were included in the study. The relationship between the factors that might affect the treatment outcome were evaluated. Mean age was 48.7 ± 16.0 years (23-74 years). Mean follow-up was 23.2 ± 7.7 months (15-41 months). Mean logMAR visual acuity was 0.85 ± 0.24 before treatment, 0.89 ± 0.37 at 12 months, and 0.92 ± 0.46 at the final visit. Mean logMAR visual acuity did not change significantly at 12 months or at the final visit (P = 0.47 and 0.36, respectively). The baseline visual acuity strongly correlated with the final visual acuity (P = 0.001). Age showed an inverse correlation with change in logMAR visual acuity at 12 months (P = 0.01). PDT prevented significant visual loss in eyes with subfoveal CNV due to pathologic myopia. Better initial visual acuity resulted in better final visual acuity. Younger age was correlated with better treatment outcome at 12 months.

Photodynamic therapy in highly myopic eyes with choroidal neovascularization: 5 years of follow-up

PURPOSE

To evaluate the long-term safety and efficacy of photodynamic therapy in the treatment of choroidal neovascularization associated with pathologic myopia.

METHODS

Five-year retrospective study of 43 consecutive eyes of 36 patients with juxtafoveal or subfoveal choroidal neovascularization and pathologic myopia treated with photodynamic therapy.

RESULTS

Mean best-corrected visual acuity changed from 20/125 +1 letter (0.78 logarithm of the minimum angle of resolution) at baseline to 20/100 (0.70 logarithm of the minimum angle of resolution) at 5 years (P = 0.122). Final best-corrected visual acuity improved in 53.5% of the eyes, remained stable in 11.6%, and decreased in 34.9%. A visual acuity gain of ≥3 lines occurred in 32.6% of the eyes, and a visual acuity decrease of ≥3 lines was registered in 20.9% of the cases at 5 years. Only patient's age and initial visual acuity showed to have a significant predictive value for the final visual acuity outcome (P = 0.024 and P = 0.002, respectively).

CONCLUSION

Photodynamic therapy with verteporfin may increase the chance of stabilizing and improving vision in patients with choroidal neovascularization from pathologic myopia at 5 years. Better results were found in younger patients (<55 years).

Vascular endothelial growth factor in the aqueous humour in eyes with myopic choroidal neovascularization

PURPOSE

To determine the concentration of vascular endothelial growth factor (VEGF) in the aqueous humour of eyes with myopic choroidal neovascularization (mCNV).

METHODS

Aqueous humour samples were obtained from 21 eyes of 21 patients with mCNV and from 21 eyes of 21 patients with cataract without CNV or other ocular or systemic diseases (control group). The VEGF concentration in the aqueous humour was measured using an enzyme-linked immunosorbent assay.

RESULTS

The VEGF concentrations in the aqueous humour of eyes with mCNV ranged from < 20.6 to 200 pg/ml (median 35 pg/ml). The concentrations in the control group ranged from 26 to 218 pg/ml (median 100 pg/ml). The difference between the two VEGF concentrations in the aqueous humour was significant (p < 0.001, Mann--Whitney rank sum test).

CONCLUSION

The VEGF concentration in the aqueous humour of patients with mCNV is lower than in normal controls. VEGF might localize in or around the CNV in eyes with mCNV.

Prognostic factors for visual outcomes 2-years after intravitreal bevacizumab for myopic choroidal neovascularization

PURPOSE

To determine the pre-treatment ocular factors significantly associated with the visual outcome 24 months after intravitreal bevacizumab (IVB) for myopic choroidal neovascularization (mCNV).

METHODS

A total of 23 eyes of 23 patients with mCNV were treated with IVB followed by as needed therapy. The efficacy of IVB was evaluated by the best-corrected visual acuity (BCVA) at 24 months after the initial treatment. Forward stepwise multiple linear regression analyses were performed to evaluate the influence of pre-treatment factors on the BCVA and the improvement of the BCVA at 24 months.

RESULTS

The mean pre-IVB BCVA was 0.74 ± 0.30 logarithm of the minimum angle of resolution (logMAR) units, and it improved to 0.43 ± 0.31 logMAR units after 1 month (P < 0.001, paired t-test). The improvement was maintained at 24 months (0.46 ± 0.40, P < 0.005). The mean number of IVB performed during the 24 months was 1.35 ± 0.71. Forward stepwise regression analysis showed that the pre-IVB CNV size (standardized β = 0.52, P < 0.01) and BCVA (standardized β = -0.44, P < 0.05) significantly affected the visual acuity change after 24 months. The CNV size was the only factor that significantly affected the BCVA after 24 months (standardized β=0.56, P < 0.01).

CONCLUSIONS

IVB with as needed therapy for mCNV led to a rapid and sustained visual improvement. Smaller CNV size was a significant prognostic factor that predicts better visual acuity. Patients with lower pre-treatment BCVA had better visual recovery than those with better pre-treatment BCVA, however, this may be due to a ceiling/floor effect.

Long-term results of photodynamic therapy for choroidal neovascularization in Japanese patients with pathologic myopia

OBJECTIVE

To determine the results of photodynamic therapy (PDT) in highly myopic eyes with choroidal neovascularization (CNV).

DESIGN

Open-label, consecutive, interventional case series.

METHODS

Forty-eight eyes of 46 consecutive Japanese patients with a myopic CNV were studied. The eyes were treated with PDT and were followed up from 1 to 4 years. The best-corrected visual acuities (BCVAs) at the baseline and after the PDT were compared. Multivariate regression analyses were used to determine the factors that were significantly associated with the BCVA at 3 or 4 years.

RESULTS

The mean follow-up period was 3.2 years. Sixty-nine percent of the patients obtained angiographic closure by a single PDT treatment, and the average number of PDT treatments was 1.4. Chorioretinal atrophy developed in 61% of the eyes at 3 years and in 70% of the eyes at 4 years. The BCVA did not change significantly after the PDT. Multivariate regression analyses showed that the BCVA at 3 years was significantly correlated with the baseline BCVA and area of chorioretinal atrophy. Analyses of the 20 patients at 4 years or more showed that in 5 of 7 (71.4%) patients with juxtafoveal CNV, chorioretinal atrophy did not develop and that all had BCVA of 0.5 or better. However, in 12 of the 13 patients with a subfoveal CNV, chorioretinal atrophy developed at 4 years, and 10 of these patients had BCVA of 0.1 or worse.

CONCLUSIONS

In highly myopic patients, 69% obtained angiographic closure by a single PDT treatment, and recurrence was rare. These findings indicate that PDT is still a good option for treating CNVs in highly myopic patients.

[Intravitreal ranibizumab for choroidal neovascularization secondary to pathological myopia: 12-month results]

PURPOSE

To evaluate the efficacy and safety of intravitreal ranibizumab (Lucentis) in the first-line treatment of choroidal neovascularization (CNV) secondary to pathological myopia.

METHODS

Consecutive series of patients with primary subfoveal CNV secondary to pathological myopia treated with intravitreal ranibizumab 0.5mg (0.05ml) were included prospectively in this study. Best-corrected visual acuity, fundus examination, fluorescein angiography, optical coherence tomography, and the presence of metamorphopsia were assessed at baseline and then monthly. Indications for retreatment were persistent leakage from CNV shown on FA and/or evidence of CNV activity on OCT.

RESULTS

Eight eyes of seven patients were followed from November 2007 to April 2009. The mean age was 61 years. None of these eyes had been treated previously with photodynamic therapy or direct photocoagulation. The mean spherical equivalent refractive error was -10.75 (range: -7.75 to -15.75). Follow-up was 12 months or more for all patients except one (3 months). The mean number of intravitreal injections administered for each patient was 1.5 (range: 1-4). Six eyes received one ranibizumab injection, one eye received two, and one eye received four. Four eyes demonstrated a gain in visual acuity, three eyes stabilization, and one eye vision loss. No injection complications or drug-related side effects were noted during the follow-up period.

CONCLUSIONS

In this small series of eyes with limited follow-up, intravitreal ranibizumab was a safe and effective treatment for CNV secondary to pathological myopia, resulting in functional and anatomic improvements.

Two-year visual results for older Asian women treated with photodynamic therapy or bevacizumab for myopic choroidal neovascularization

PURPOSE

To compare the long-term visual and anatomic outcome of treatment with photodynamic therapy (PDT) or intravitreal bevacizumab (IVB; Avastin; Genentech Inc, South San Francisco, California, USA) for choroidal neovascularization attributable to pathologic myopia (mCNV).

DESIGN

An open-label, interventional case series.

METHODS

SETTING

Multi-institutional.

PATIENTS

Thirty-one eyes of Japanese women who received either PDT or IVB for mCNV. Inclusion criteria were age 50 years or older, greatest linear dimension (GLD) 1200 to 3000 microm, and baseline best-corrected visual acuity (BCVA) 20/200 to 20/40. INTERVENTION PROCEDURES: Patients received either PDT or IVB (1 mg/40 microL) throughout the study, with re-treatment when necessary.

MAIN OUTCOME MEASURES

BCVA and visual gain/loss at 3, 6, 12, 18, and 24 months after the initial treatment.

RESULTS

Age, BCVA, location of CNV, refractive error, and symptom duration at baseline did not differ significantly between groups. BCVA was significantly improved at 3 to 12 months (P < .05); however, the significance was lost at 18 and 24 months in the IVB group. The PDT group showed no significant improvement within the first year, and vision slowly worsened after 12 months, becoming significantly worse at 18 and 24 months compared to baseline (P< .01). BCVA was significantly higher in the IVB group at 6 months (P< .05), and 12 months or further (P < .01). Visual gain was significantly greater in the IVB group at 6, 12, 18, and 24 months (P < .05 for 6, 18, and 24 months and P < .01 for 12 months).

CONCLUSIONS

These findings indicate that the effects of PDT and IVB have a different time course, and that IVB provides a significantly better BCVA than PDT for mCNV over the long-term.

Low-fluence-rate photodynamic therapy to treat subfoveal choroidal neovascularization in pathological myopia. A study of efficacy and safety

BACKGROUND

To evaluate the efficacy and safety of low-fluence-rate photodynamic therapy (LFPDT) to treat choroidal neovascularisation (CNV) secondary to pathological myopia (PM).

METHODS

Twenty-five eyes with CNV in PM underwent LFPDT, with a standard dose of verteporfin and timing but adopting fluence and irradiance rates reduced to 25 mJ/cm2 and 300 mW/cm2, respectively. Best corrected visual acuity (BCVA) was measured and biomicroscopy and fluorescein angiography (FA) were evaluated. Particular attention was paid to choroidal hypoperfusion, and to changes (depigmentation/atrophy) at the RPE level in areas exposed to laser light.

RESULTS

After a mean follow-up of 13.4+/-2.46 months (range: 12-21), and 1.37+/-0.66 treatments (range: 1-3), BCVA was stable in 29 (91%) eyes. Two (6%) patients gained more than three lines and one (3%) eye lost more than three lines. Mean greatest linear dimension did not change significantly (p=0.08) at the end of follow-up. RPE depigmentation was present in six eyes (18%) and no patient showed RPE atrophy.

CONCLUSIONS

LFPDT is effective and safe for CNV secondary to PM treatment, stabilizing visual acuity and lesion size and determining only mild RPE changes. Further controlled studies are needed to demonstrate the long-term efficacy and safety of this treatment option.

Verteporfin photodynamic therapy for subfoveal choroidal neovascularization in pathologic myopia: a 12-month retrospective review

PURPOSE

To evaluate the visual outcome of patients with subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia treated with verteporfin photodynamic therapy (PDT-V) and to verify the predictive role of visual and angiographic parameters.

METHODS

This is a retrospective, interventional, consecutive case series study of subjects with subfoveal CNV secondary to pathologic myopia. All patients received PDT-V according to VIP guidelines. A complete ophthalmologic evaluation was performed on all patients and included best-corrected visual acuity (BCVA), fundus examination, and fluorescein angiography (FA, IMAGEnet System, Topcon Corp., Japan). CNV size (mm2) was directly measured on the early phase of the angiogram using the software included with the IMAGEnet package. All checks were scheduled at 3-month intervals for a period of 1 year. A review of medical and angiographic records was performed and assessed throughout a 12-month follow-up period.

RESULTS

A total of 62 patients (62 eyes) were examined. Best-corrected visual acuity (BCVA) moderately decreased without reaching a statistically noticeable level throughout the followup; reduction in lesion size reached a significant level at the second checkup. A significant correlation between higher baseline BCVA and better final visual outcome was detected.

CONCLUSIONS

Standardized PDT-V minimizes central vision deterioration in patients with CNV secondary to pathologic myopia. Better BCVA at presentation represents a good predictive sign.

Intravitreal bevacizumab treatment for choroidal neovascularization in pathologic myopia: 12-month results

PURPOSE

To evaluate the short-term efficacy and safety of intravitreal bevacizumab for the treatment of myopic choroidal neovascularization (CNV).

DESIGN

Prospective, nonrandomized, interventional case series.

METHODS

Twenty eyes from 20 patients with CNV secondary to pathologic myopia participated in this prospective nonrandomized interventional case series. All patients were scheduled for three monthly intravitreal bevacizumab 1.25 mg injections. Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), foveal center thickness (FCT) on optical coherence tomography (OCT), and fluorescein angiographic findings were examined before and after treatment. Patients were followed up for 12 months.

RESULTS

The mean BCVA (+/- standard deviation [SD]) at baseline was 24.8 (+/- 11.86) letters (Snellen equivalent: 20/80). At 12 months after treatment, the mean BCVA (+/- SD) improved significantly (P = .000001) to 43 (+/- 12.38) letters (Snellen equivalent: 20/35). At 12 month follow-up, BCVA improved 10 letters or more in 18 (90%) out of 20 treated eyes and improved 15 letters or more in 14 (70%) out of 20 treated eyes. No treated eyes experienced a worsening of BCVA from baseline. The mean FCT (+/- SD) at baseline was 223 (+/- 47.43) microns. At 12 months after treatment, the mean FCT (+/- SD) reduced to 206 (+/- 50.87) microns. This reduction in FCT after treatment was not statistically significant (P = .11). At 12 months follow-up, absence of fluorescein leakage from the CNV was demonstrated in 19 (95%) out of 20 treated eyes and persistent leakage in one eye (5%). None of the 19 eyes that had CNV closure experienced recurrence at 12-month follow-up. No ocular or systemic adverse effects from treatment were encountered.

CONCLUSION

These results of intravitreal bevacizumab in myopic CNV are very promising with no apparent short-term safety concerns. At 12 months, treated eyes had a significant improvement in visual acuity (VA). OCT findings, as well, showed a trend consistent with the beneficial changes observed for VA. Treatment resulted in complete absence of angiographic leakage in 95% of eyes. Further studies will be needed to better determine long-term efficacy and safety.

Photodynamic therapy with verteporfin for choroidal neovascularization of pathologic myopia in Japanese patients: comparison with nontreated controls

PURPOSE

To examine the effects of photodynamic therapy (PDT) with verteporfin on subfoveal or juxtafoveal choroidal neovascularization (CNV) secondary to pathologic myopia in Japanese patients and to compare the visual outcomes of PDT-treated patients with that of age-matched and visual acuity-matched untreated controls.

DESIGN

Prospective, open-label, consecutive, interventional case series.

METHODS

We prospectively followed up 43 eyes of 42 consecutive patients with pathologic myopia (>6 diopters or axial length>26.5 mm) who received PDT for myopic CNV. In addition, the visual outcomes of these patients who were followed up for more than one year were compared with those of age- and initial visual acuity-matched untreated controls.

RESULTS

The average follow-up was 15.0+/-7.0 months. Patients received an average of 1.40+/-0.73 treatments during follow-up, and 30 eyes (69.8%) required only one treatment. The best-corrected visual acuity (BCVA) improved by more than two Snellen lines in seven eyes (16.3%), decreased in six eyes (14.0%), and remained stable in 30 eyes (69.7%). In three eyes with a juxtafoveal CNV, CNV could not be detected ophthalmoscopically or angiographically after PDT. Statistical analysis showed that the PDT-treated patients had significantly better visual acuity at one year after PDT than the age- and initial BCVA-matched untreated controls.

CONCLUSIONS

These results indicate that PDT was beneficial for maintaining vision in Japanese patients with myopic CNV. The visual outcome after PDT was better than the natural course of the disease as determined from untreated controls. The effect on chorioretinal atrophy around CNV should be investigated with a long-term study.

Photodynamic therapy of idiopathic subfoveal choroidal neovascularization in Taiwanese patients: a 2-year follow-up

AIMS

To study the efficacy of verteporfin photodynamic therapy (VPDT) retrospectively in the treatment of idiopathic subfoveal choroidal neovascularization (ICNV) in an Asian population in correlation with number of treatments and age at treatment. This is the first report to compare the efficacy between single and multiple treatments.

METHODS

VPDT was administered according to protocol to 45 eyes in 45 patients aged 18-55 years diagnosed with active subfoveal ICNV between September 2003 and December 2005. In total 28 patients received a single VPDT treatment and the remaining 17 received multiple treatments. Collected measurements of visual acuity (VA) were plotted on a time-course model, and later dichotomized by age (18-45 vs 46-55 years).

RESULTS

The 28 patients receiving a single VPDT treatment showed significant improvement in VA at 3-month follow-up. The 17 patients, who did not show improvement after the first treatment, received multiple VPDT treatments. Those patients showed an even clearer trend in VA improvement although significance was detected only at the 24th month. All patients showed a significant improvement in mean VA of 0.46 logMAR (P<0.01 compared to baseline) by the end of the 24-month observation period, although VPDT treatment for subfoveal ICNV appears to stabilize vision more rapidly in younger patients.

CONCLUSIONS

ICNV patients who did not benefit from single VPDT treatments could receive multiple treatments, and showed a more significant improvement in visual acuity. These results are the first of their kind in ICNV treatment.

Intravitreal Bevacizumab (Avastin) for Myopic Choroidal Neovascularization

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab in the treatment of choroidal neovascularization (CNV) secondary to pathologic myopia (PM).

DESIGN

Prospective, consecutive, nonrandomized, interventional case series.

PARTICIPANTS

Twenty-two eyes of 22 patients with CNV secondary to PM.

METHODS

Consecutive patients with subfoveal or juxtafoveal CNV secondary to PM were recruited prospectively to receive an initial course of 3 monthly intravitreal injections of bevacizumab. Three additional monthly injections were performed in eyes with persistent CNV leakage after 3 months. Patients were followed up for 6 months, and the best-corrected visual acuity (BCVA), changes in fluorescein angiography, and optical coherence tomography (OCT) results were assessed.

MAIN OUTCOME MEASURES

Changes in BCVA, angiographic closure, and OCT central foveal thickness (CFT) at the 6-month follow-up.

RESULTS

The mean+/-standard deviation (SD) spherical equivalent refractive error of the 22 eyes was -10.3+/-3.7 D (range, -6.0D to -18.0D). All patients completed follow-up at 6 months. Twenty (90.9%) eyes had angiographic closure after 3 monthly injections of intravitreal bevacizumab, and 2 (9.1%) eyes required further treatment up to 6 months. The mean+/-SD logarithm of the minimum angle of resolution (logMAR) BCVA at baseline was 0.60+/-0.18 (Snellen equivalent, 20/80). At 1 and 6 months, the mean+/-SD logMAR BCVA improved significantly to 0.43 (Snellen equivalent, 20/53; P = 0.003) and 0.35 (Snellen equivalent, 20/45; P<0.001), respectively. The mean lines of improvements at 1 and 6 month compared with baseline were 1.7 and 2.6 lines, respectively. Fifteen (68.2%) eyes had an improvement of 2 or more lines at 6 months. The OCT results also showed significant reduction in CFT after treatment. No ocular or systemic complications were noted after intravitreal injections.

CONCLUSIONS

The 6-month outcomes suggest intravitreal bevacizumab to be a promising treatment method for CNV secondary to PM, resulting in both visual and anatomic improvements. Treatment resulted in complete absence of angiographic leakage in 90.9% of eyes at 3 months. Further studies to evaluate the safety, efficacy, and optimal treatment regimen are justified.

Photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularization in pathologic myopia: a long-term follow-up study

PURPOSE

To assess the effect of verteporfin photodynamic therapy (PDT) in juxtafoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM).

DESIGN

Prospective, open-label, consecutive, interventional case series.

METHODS

We prospectively followed a series of 48 consecutive patients (49 eyes) with pathologic myopia (> or = 6 diopters) who received verteporfin PDT for juxtafoveal CNV. This population was divided into two groups based on age (group A < or = 55 years old, group B >55 years old), in three subgroups based on CNV lesion size, and in three categories based on refractive error at baseline.

RESULTS

The median follow-up was 32 months (range, 12 to 56 months). Visual acuity (VA) improved by 1 or more Snellen lines in 18 eyes (37%), decreased in 12 eyes (24%), and remained stable in 19 eyes (39%). The median number of lines gained was 2.15, while the median number of lines lost was 2.4. The final mean VA in group A (mean age, 43.9 years) was 20/50 (logMAR 0.41, standard deviation [SD] 0.3) and significantly better (P = .01) than the 20/105 (logMAR 0.72, SD 0.5) in group B (mean age, 67.8 years). Neither CNV size nor refractive error magnitude influenced visual outcomes.

CONCLUSION

Verteporfin PDT is a promising treatment modality resulting in stable or improved vision in 76% of the myopic eyes with juxtafoveal CNV. Younger patients appear to respond more favorably to treatment.

Combined photodynamic therapy and intravitreal triamcinolone injection for the treatment of choroidal neovascularisation secondary to pathological myopia: a pilot study

Intravitreous triamcinolone associated with PDT should preferably be used among elderly patients who usually show lower visual acuity and a poorer response to PDT, or among patients with recurrent or greater CNVs

Photodynamic therapy vs limited macular translocation in the management of subfoveal choroidal neovascularization in pathologic myopia: a two-year study

PURPOSE

To compare the results of limited macular translocation and photodynamic therapy (PDT) in subfoveal choroidal neovascularization (CNV) attributable to pathologic myopia with a 24-month follow-up.

DESIGN

Retrospective analysis of nonrandomized interventional clinical study.

METHODS

Retrospective review of 66 consecutive patients: 34 myopic eyes with subfoveal neovascularization treated by PDT and 32 operated on with the translocation technique. Translocation was considered principally when the lesion size was adequate (nasal inferior margin of the membrane less than half a disk diameter away from the center of the fovea) with duration of symptoms of less than four months. Main outcome measure was the postoperative change in visual acuity.

RESULTS

In the translocation group, mean gain in visual acuity was greater than in the PDT group (+2.8 lines and -1.8 line, respectively, P = .001). In the translocation group, 55% of eyes gained 3 lines or more at two years compared with 10% in the PDT group. Sixty percent of eyes in the translocation group vs 40% in the PDT group had an improvement of at least five letters. Mean foveal displacement after translocation was 906 mum; postoperative complications included retinal detachment (three eyes), macular fold (one eye), and transient diplopia (four eyes). In young patients, the postoperative gain was better in both groups. In the translocation group, mean survival time for choroidal neovascularization recurrence was 40 months for patients younger than 40 years and 20 months for older patients.

CONCLUSIONS

Translocation showed better results than PDT at two years. Further studies are required to confirm these findings.

Photodynamic therapy for nonsubfoveal choroidal neovascularization in 100 eyes with pathologic myopia

PURPOSE

To evaluate the visual and anatomic outcome of photodynamic therapy (PDT) in eyes with nonsubfoveal choroidal neovascularization (CNV) associated with pathologic myopia (PM).

DESIGN

Interventional, noncomparative cases series.

METHODS

Ninety-seven patients (100 eyes) who were treated with PDT at three centers and followed up for three to 44 months (mean 16.5 months). Outcome measures were visual acuity, lesion size, and the occurrence of subfoveal invasion.

RESULTS

Median baseline visual acuity was 20/40(-2) and ranged from 20/20 to 20/160(+2). On average, visual acuity was stable throughout follow-up after a modest increase of about 0.5 lines between three and six months. The probability of losing 3 or more lines was 10% to 15% during the second year. Lesion size (median: 710 microns) slightly decreased after the first PDT and tended to increase later, but not to a statistically significant extent compared with baseline. The probability of developing subfoveal CNV stabilized at 10% in the second year. The mean number of PDTs per individual was 2.9 in the first year and 0.6 in the second.

CONCLUSIONS

Visual and anatomic outcomes of PDT, in this large group of patients with nonsubfoveal myopic CNV and good visual acuity, suggest that it may halt the progression of the disease in most cases.

Traitement des néo-vaisseaux choroïdiens rétrofovéolaires du myope fort par photothérapie dynamique : résultats à 1 an et à 2 ans

PURPOSE

To evaluate the visual outcome of photodynamic therapy with verteporfin in patients with subfoveal choroidal neovascularization (CNV) caused by pathologic myopia.

METHODS

Retrospective and noncomparative analysis of 42 patients with CNV secondary to pathologic myopia recruited between September 2001 and 2003, who were treated with a standard regimen of photodynamic therapy with verteporfin.

RESULTS

Forty-two patients were followed up for 12 months; 15 out of 42 completed 24 months of follow-up. Initial visual acuity ranged from 1/10 to 5/10 with a mean of 1.6/10. Twenty-five (56.7%) eyes had stable or improved visual acuity at 12 months with a mean of 2.5/10. In the group of patients who completed 24 months of follow-up, six eyes (39.9%) had stable or improved visual acuity with a mean of 1.6/10 at 1 year and 1.25/10 at 2 years. The average photodynamic therapy treatment required in 1 and 2 years were 1.5 and 2.1, respectively, and they are less than those reported by the Verteporfin in Photodynamic Therapy (VIP) study.

CONCLUSION

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization caused by pathologic myopia maintained a visual benefit at 1 and 2 years.

PHOTODYNAMIC THERAPY WITH VERTEPORFIN FOR SUBFOVEAL CHOROIDAL NEOVASCULARIZATION SECONDARY TO PATHOLOGIC MYOPIA

PURPOSE

To assess the safety and effectiveness of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM).

METHODS

Sixty-two patients (62 eyes) with PM underwent PDT according to the guidelines of the Verteporfin in Photodynamic Therapy Study. Clinical evaluations performed at all study visits included measurement of best-corrected Snellen visual acuity, slit-lamp biomicroscopy, and fundus fluorescein angiography. Patients were followed up at 1 month and 3 months after treatment and thereafter at 3-month intervals.

RESULTS

The final visual acuity of the study patients, after a median follow-up of 31 months, improved by >or=1 Snellen lines in 8 patients (13%), deteriorated in 20 (32%), and remained stable in 34 (55%). The baseline visual acuity was similar in the various study groups. The final mean visual acuity in group A (55 years of age or younger) was 20/80 and significantly (P=0.006) better than that (20/138) in group B (older than 55 years of age). The mean final visual acuity in eyes with higher refractive error at baseline (greater than -17 diopters) was significantly better (P=0.014) than that in eyes with lower refractive error (-6 to -10 diopters). CNV size did not affect visual outcomes.

CONCLUSION

PDT preserves vision in patients with CNV associated with PM. Younger patients and eyes with higher refractive error appear more likely to benefit from PDT with verteporfin.

Indocyanine green angiographic features of myopic subfoveal choroidal neovascularization as a prognostic factor after photodynamic therapy

Purpose

To determine the influence of clinical features and Indocyanine green (ICG) angiographic features on the visual outcome of patients with myopic sub-foveal choroidal neovascularization (CNV) who received photodynamic therapy (PDT).

Methods

Thirty-six consecutive patients (39 eyes) with myopic CNV who were followed up for more than one year after PDT were enrolled in this study. Clinical features included age, gender, refractive error, great linear dimension, and subretinal hemorrhage. ICG features included the lesion size, lacquer cracks, hypofluorescence surrounding the CNV (dark rim), peripapillary atrophy size, and visible prominent choroidal veins under the macula. Linear regression analysis was performed using the change in visual acuity (ΔlogMAR) as the dependent variable and the above factors as independent variables.

Results

At one-year follow-up after PDT, a younger age (p=0.002) and the presence of a dark rim (p=0.002) were significantly correlated with an improvement of visual acuity (decrement in logMAR) after PDT. Other factors had no significant influence on changes in visual acuity.

Conclusions

Younger patients and patients with a dark rim on ICG angiography had a higher chance of visual improvement after PDT in myopic CNV.

Estimation of visual outcome without treatment in patients with subfoveal choroidal neovascularization in pathologic myopia

OBJECTIVE

To clarify prognostic factors of long-term visual outcome without treatment in patients with myopic choroidal neovascularization (CNV) and estimate a regression equation to predict visual acuity at 5 years after CNV onset.

METHODS

Fifty-four eyes of 54 consecutive patients with high myopia and subfoveal CNV who did not receive treatment were identified using clinical records from 1988 to 2004. Photodynamic therapy not approved for myopic CNV in Japan during this period. The association of best-corrected visual acuity (BCVA) at 5 years after CNV onset with patient age, refractive error, axial length, initial BCVA, myopic retinopathy grade, duration of persistent hemorrhage, CNV size at onset, and size of hemorrhage around the CNV was analyzed using Spearman's correlation and multiple linear regression analysis.

RESULTS

BCVA at 5 years after onset was significantly associated with patient age, CNV size, and initial BCVA (P<0.05, Spearman's correlation). The regression equation estimating BCVA at 5 years after CNV onset was based on age and initial BCVA (R2=0.43). When subjects were divided into groups according to age (<40 and >or=40 years), CNV size, axial length and duration of persistent hemorrhage influenced BCVA at 5 years in patients under 40 years; while only initial BCVA was an influence in those at least 40 years old.

CONCLUSIONS

We developed a linear predictive model to estimate BCVA at 5 years after onset of myopic CNV without treatment based on the identified prognostic factors. This information might be important for managing patients with myopic CNV.

Treatment frequency and visual outcome in subfoveal choroidal neovascularization related to pathologic myopia treated with photodynamic therapy

BACKGROUND

The purpose of this study was to examine the influence of treatment frequency on visual acuity of patients with PDT treatment for subfoveal predominantly classic CNV related to pathological myopia.

DESIGN

Retrospective case series.

METHODS

Thirty-seven patients with subfoveal predominantly classic CNV caused by pathologic myopia and treated with PDT were included. All patients received a full ophthalmic examination, including best-corrected visual acuity, slit-lamp biomicroscopy, fundus photography and fluorescein angiography, before first treatment and every 3 months thereafter. Photodynamic therapy was performed according to standard protocol. Main outcome measurements were visual acuity and treatment frequency.

RESULTS

The number of treatments received was 3.35+/-1.83 (average: 1-7). In 12 eyes (32.43%); the BCVA was stable or increased during the entire follow-up period. In eight eyes (21.62%), the BCVA decreased and did not return to the baseline values. A transient loss of visual acuity (over 3-9 months) with subsequent improvement in visual function was found in 68% (17 eyes). A gain of three or more lines compared with lowest BCVA was found in 56% (14 eyes). The number of treatments did not correlate with baseline BCVA, greatest linear dimension of CNV at baseline or with the change of BCVA from baseline. In cases with transient worsening of BCVA, the recovery of visual acuity correlated significantly with the number of treatments (r=-0.522, P<0.05; Spearman rank correlation) received.

CONCLUSION

Visual acuity recovery correlates with the number of PDT re-treatments; in many cases, an improvement in visual function after temporary decrease of BCVA can be observed after re-treatment according to current treatment guidelines. The number of PDT treatments has no negative effect on the visual outcome in subfoveal CNVs caused by pathological myopia.

Choroidal neovascularisation in pathological myopia: an update in management

Choroidal neovascularisation (CNV) secondary to pathological myopia is an important cause of significant visual impairment in young and middle aged adults globally and is particularly prevalent in Asian populations. In the past few years, there have been rapid advancements in the different treatments for myopic CNV. The purpose of this perspective is to give an overview of the natural history of myopic CNV and the various treatment options including laser photocoagulation, photodynamic therapy, sub-macular surgery, and macular translocation surgery. Future directions in the management of myopic CNV are also discussed.

Choroidal neovascularization in pathologic myopia: three-year results after photodynamic therapy

PURPOSE

To examine whether the encouraging functional results one year after photodynamic therapy (PDT) can be maintained up to three years.

DESIGN

Prospective interventional case series.

METHODS

Highly myopic eyes that had been treated with PDT for subfoveal choroidal neovascularization and had been observed at least 36 months were included. Distance acuity (Early Treatment of Diabetic Retinopathy charts), reading acuity (Jaeger charts), 10-degree static threshold perimetry, fluorescein angiography, and optical coherence tomography were performed. The main outcome measures were the differences of the values among the baseline and the month 12 and the month 36 examinations.

RESULTS

Twenty eyes of 18 patients were included: 15 patients were female, and 3 patients were male. The average age was 64 years (range, 36 to 85 years). The mean distance acuity was 43 letters at baseline and 53 letters after 12 months and after 36 months. The mean reading acuity changed from mean J10.8 to mean J8.1 after 12 months and to mean J9.85 after 3 years. The mean defect decreased from mean 13.5 dB at baseline to mean 12.5 dB after 12 months and mean 11.2 dB after 36 months. The maximum retinal thickness decreased from mean 360 mum at baseline to mean 259 mum after one year and mean 238 mum after 36 months.

CONCLUSION

Distance acuity and central visual field showed stabilization after the month 12 examination up to the month 36 examination. The reading acuity decreased between the month 12 and the month 36 examinations, which might be related to an increase of retinal atrophy.