Photodynamic therapy of subfoveal choroidal neovascularization in high myopia in a clinical setting: visual outcome in relation to age at treatment

Treatment of myopic choroidal neovascularization with intravitreal ranibizumab injections: the role of age

PURPOSE

The aim of this study was to explore the role of age as a prognostic factor for the outcome of myopic choroidal neovascularization (CNV) treatment with intravitreal ranibizumab injections.

METHODS

A retrospective review of charts of patients treated with intravitreal injections of ranibizumab for the treatment of myopic CNV was done. Patients with other ophthalmic disease were excluded. Patients were followed for at least 2 years. The correlation between age and the change in visual acuity and the number of injections during treatment was investigated.

RESULTS

Age of the patients was significantly correlated with the number of injections that the patients received (Pearson's r=0.585, P=0.005). Also, it was significantly correlated with improvement in corrected distance visual acuity, defined as the difference between final and initial LogMAR corrected distance visual acuity (Pearson's r=0.614, P=0.003).

CONCLUSION

Age significantly affects the visual outcome of myopic CNV treatment with ranibizumab. Younger patients in our study needed fewer intravitreal injections and achieved a more significant improvement in vision.

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.

Comparison of foveal-sparing with foveal-involving photodynamic therapy for myopic choroidal neovascularization

PURPOSE

To evaluate the visual outcomes of choroidal neovascularization (CNV) secondary to pathological myopia in eyes treated with photodynamic therapy (PDT), and to determine the effect of lesion location and foveal involvement on visual prognosis.

METHODS

Interventional case series of 24 consecutive patients with myopic CNV treated with PDT. The main outcome measure was final LogMAR visual acuity (VA).

RESULTS

Of 24 eyes, the CNV lesion was subfoveal in 11 and extrafoveal in 13. Overall, the mean LogMAR VA at 24 months was 0.72. Extrafoveal CNV lesions achieved significantly better final VA compared with subfoveal CNV (LogMAR 0.45 vs 1.05, P=0.012). Eyes with extrafoveal CNV lesions were subdivided into foveal-sparing PDT (where the PDT laser spot did not involve the foveal center) and foveal-involved PDT (where the PDT laser covered the fovea). At all time points, the group with foveal-sparing PDT had significantly better VA compared with the foveal-involved group. The final LogMAR VA for the foveal-sparing PDT group was 0.26 compared with 1.00 for the foveal-involved PDT group (P=0.003). At 24 months, 77.8% of foveal-sparing PDT cases achieved VA of ≥ 20/40, compared with 25% of foveal-involved PDT cases and 9.1% of subfoveal CNV lesions (P=0.006).

CONCLUSION

For patients with myopic CNV, foveal-sparing PDT results in significantly better long-term visual outcomes compared with those with foveal-involved PDT. Foveal-sparing PDT may be of value for treatment of myopic CNV patients who are not suitable for treatment with anti-vascular endothelial growth factor injections.

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.

Predictive factors for visual outcome to intravitreal bevacizumab in young Chinese patients with myopic choroidal neovascularization

PURPOSE

To report the anatomical and functional outcomes of intravitreal bevacizumab in both young and old Chinese patients with myopic choroidal neovascularization.

METHODS

Consecutive series of 56 eyes (52 patients) with myopic choroidal neovascularization treated exclusively with intravitreal bevacizumab were reviewed retrospectively. Data from clinical examination, fundus photography, fluorescein angiography, and optical coherence tomography were collected.

RESULTS

Vision significantly improved after intravitreal bevacizumab in this patient series (P < 0.0001), with an average of 2.2 injections. Higher myopia was positively correlated to a worse outcome (r = -0.3, P = 0.036). Stratifying by age, the correlation between spherical equivalent and final outcome showed statistical significance (r = -0.44, P = 0.027) only in younger patients. In younger patients, both spherical equivalent (P = 0.036) and initial visual acuity (P = 0.004) were predictive factors for visual outcome after adjusting for age, spherical equivalent, and number of injections, whereas in older patients, only initial visual acuity (P < 0.0001) was predictive of visual outcome after similar adjustments.

CONCLUSION

Younger patients do not have a better outcome when compared with older patients. Initial visual acuity, regardless of age, plays a more significant role. Both initial visual acuity and spherical equivalent are predictive factors for final visual acuity in young Chinese patients.

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).

Intravitreal injection of 2.5 mg bevacizumab for treatment of myopic choroidal neovascularization in treatment-naive cases: a 2-year follow-up

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of intravitreal bevacizumab in treatment-naive patients with choroidal neovascularization (CNV) secondary to pathologic myopia over a 2-year interval.

METHODS

Patients diagnosed with myopic CNV who had not received previous treatment were given intravitreal injections of bevacizumab (2.5 mg/0.1 mL). All patients were retrospectively evaluated using best-corrected visual acuity (BCVA) and central macular thickness (CMT) measured with optical coherence tomography (OCT).

RESULTS

Twenty-six eyes of 26 patients aged 15-81 years (mean, 42.6 years) were enrolled. OCT images demonstrated that the mean CMT±standard deviation (SD) significantly changed from 270±47 μm at baseline to 228±35, 218±35, 212±25, 210±29, and 209±30 μm in the 1st, 3rd, 6th, 12th, and 24th post-treatment months, respectively (P<0.001 for all). The BCVA in logarithm of the minimum angle of resolution±SD significantly changed from 0.75±0.43 at baseline to 0.57±0.44, 0.42±0.44, 0.39±0.47, 0.41±0.44, and 0.42±0.41 in the 1st, 3rd, 6th, 12th, and 24th post-treatment months, respectively (P<0.001 for all). The mean number of injections was 1.69 (range, 1-4) within the 24-month period. The follow-up period ranged from 24 to 35 months (mean, 28 months). No other ocular or systemic adverse effects were observed.

CONCLUSIONS

Although the present study lacked a control group, the results in this small series of patients over the 2-year follow-up period indicate that intravitreal injection of 2.5 mg bevacizumab is effective and safe in patients with myopic CNV.

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.

Effects of photodynamic therapy using hematoporphyrin monomethyl ether on experimental choroidal neovascularization

Hematoporphyrin monomethyl ether (HMME) is a novel and promising second-generation porphyrin-related photosensitizer for photodynamic therapy (PDT). To study the effects of HMME PDT on choroidal neovascularization (CNV) in rats, the PDT was performed 20 min after HMME bolus injection, which was investigated prior to the PDT by fluorescence microscopy with laser-induced CNV, and delivered at an irradiance of 400, 600 and 1000 mW cm(-2) corresponding to a fluence of 36, 54, 90 J cm(-2) in PDT plan I (15 mg kg(-1) HMME). In PDT plan II (30 mg kg(-1) HMME), the laser had a constant irradiance of 600 mW cm(-2), which was delivered for 60, 90 or 150 s, to also achieve total energy doses of 36, 54 or 90 J cm(-2). CNV closure rates assessed by fluorescein angiography and histologic damage to treated areas of choroid and retina varied as a function of the dose of HMME and of the activating light energy fluence. Endothelial cell labeled by platelet/endothelial cell adhesion molecule-1 presented treated CNV lesions that were significantly reduced in size (P < 0.01). It can be concluded that PDT using HMME can effectively occlude CNV. HMME is a potentially useful photosensitizer for the reduction in CNV size of irradiated areas.

Photodynamic therapy for choroidal neovascularization in young adult patients

We report our experience with photodynamic therapy (PDT) in the treatment of choroidal neovascularization (CNV) in young adult patients. This was a retrospective study of young adults with CNV treated with PDT. Data collected included age, diagnosis, type and size of CNV, number of treatments, visual outcome, and side effects. Ten patients (11 eyes) were included in the study (mean age 27.2 +/- 13.3 years). Etiologies included multifocal choroiditis (3 eyes), idiopathic CNV (5 eyes), central serous chorioretinopathy (1 eye), and toxoplasma (2 eye). The mean number of treatments was 2 +/- 0.7 and the mean follow-up time was 13.1 +/- 9.5 months. Initial visual acuity (VA) ranged from 20/25 to 20/1,200 (mean logMAR 0.6 +/- 0.5), and improved to 20/20 to 20/250 (mean logMAR 0.46 +/- 0.4) (P = 0.51). Of the four eyes that received additional treatment with oral steroids, one of which also received intravitreal bevacizumab (Avastin) injections, all had visual acuity improvement of 2 or more lines, while only two of seven eyes that received PDT alone showed such improvement. PDT can improve visual outcome in a subgroup of young patients with subfoveal CNV especially when supplemented with oral steroid and bevacizumab injections.

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.

Efficacy of intravitreal bevacizumab (Avastin) therapy for early and advanced neovascular age-related macular degeneration

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab therapy for early and advanced neovascular age-related macular degeneration (ARMD).

METHODS

A consecutive series of eyes with neovascular ARMD treated with monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml) as long as there was evidence of activity on fluorescein angiography (FA) and optical coherence tomography (OCT) was included and observed for 6 months. For further analysis they were assigned to either an early (untreated/newly diagnosed) or an advanced (predominantly fibrotic/pre-treated) ARMD group. We examined distance visual acuity (VA) with Early Treatment Diabetic Retinopathy Study (ETDRS) charts and central retinal thickness with OCT, as well as lesion size and safety aspects.

RESULTS

Forty-four patients (44 eyes) were enrolled (21 early lesions, 23 advanced lesions). Mean VA changed from 0.74 logMAR at baseline to 0.68 logMAR at month 6 (P = 0.01). Improvement in VA was statistically significant only in eyes with early lesions (n = 21) from month 1 (P = 0.015) up to month 6 (P = 0.03). The changes in central retinal thickness (CRT) (P < 0.001) and total lesion size (P < 0.001) were significant in both groups (early and advanced) at all time-points during follow-up. No significant ocular or systemic adverse effects were observed.

CONCLUSION

Intravitreal bevacizumab was tolerated well by our patients and we did not identify any apparent short-term safety concerns. We observed stabilization in VA overall, with significant improvement in the early lesion group.

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 for choroidal neovascularization attributable to pathological myopia: one-year results

PURPOSE

To assess the potential effect of intravitreal bevacizumab (IVB) (Avastin) on retinal function and anatomic recovery in eyes with choroidal neovascularization attributable to pathological myopia (mCNV).

DESIGN

Retrospective case series.

METHODS

setting: Institutional. patient population: Sixty-three eyes of 63 patients were treated with IVB for mCNV. intervention procedure: 1 mg of bevacizumab was injected into the vitreous via the pars plana. IVB was repeated after two to three months if there was fluorescein leakage in fluorescein angiogram (FA), apparent subretinal fluid in optical coherence tomography (OCT) persisted, or both. main outcome measurement: Best-corrected visual acuity (BCVA) and CNV size measured on FA.

RESULTS

IVB was performed one to six times during the first 12 months (mean, 2.4 +/- 1.4 times). The size of the mCNV decreased and the BCVA improved significantly (P < .01 for both comparisons). The BCVA improved more than three lines in 25 eyes (40%), worsened more than three lines in three eyes (5%), and was unchanged in 35 (56%) eyes 12 months after. Fluorescein leakage from the mCNV ceased in 30 eyes (48%), diminished in 28 (44%), and was unchanged in five (8%) eyes. Stepwise analysis showed that the number of IVB (P < .01), macular atrophy associated with mCNV (P < .05), and myopic atrophy (P < .05) were significant predictive factors for BCVA at 12 months.

CONCLUSIONS

Although the current study lacked a control group, IVB seems to be an effective treatment for mCNV after a long-term. The absence of chorioretinal atrophy and that of recurrence and persistency of mCNV are positive predictive factors.

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.

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.

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.

Combined photodynamic therapy and intravitreal triamcinolone for the treatment of myopic choroidal neovascularization in a 13-year-old girl

BACKGROUND

Combination photodynamic therapy with verteporfin (PDT) and intravitreal triamcinolone acetonide (IVT) is currently being investigated as a treatment for choroidal neovascularization (CNV) due to age-related macular degeneration. However, PDT with triamcinolone has never previously been described in the treatment of CNV secondary to pathologic myopia, or in a young person. We describe the case of a young girl treated with combination PDT and IVT for a myopic subfoveal CNV membrane.

METHODS

This study was an interventional case report. The medical chart of a 13-year-old child treated with combination PDT with IVT was reviewed for changes in visual acuity on the ETDRS chart, CNV leakage on fluorescein angiography, and adverse events reported.

RESULTS

ETDRS visual acuity improved from 20/80-2 to 20/25 in the right eye over 7 months following two treatments of a myopic CNV lesion with combination PDT and IVT. Following treatment, an inactive scar with no further leakage was visible on fluorescein angiography. An increase in intraocular pressure was associated with the second IVT treatment, and successfully treated with topical therapy.

CONCLUSIONS

Combination PDT with IVT may be considered under appropriate circumstances to treat children with CNV.

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.

Differences in reading performance of patients with Drusen maculopathy and subretinal fibrosis after CNV

PURPOSE

To evaluate differences in reading performance and contrast sensitivity on patients with drusen maculopathy and subretinal fibrosis after CNV (choroidal neovascularisation).

METHODS

136 patients (60 with drusen (D), 76 with fibrosis (F)) were studied. Patients were classified according to type of maculopathy and best-corrected visual acuity into groups D1 and F1 (LogMAR 0.2-0.4), groups D2 and F2 (LogMAR>0.4-0.7), and group F3 (LogMAR>0.7-1.3). Reading acuity (in LogRAD) and speed were examined with the Radner Reading charts and compared to the reading speed measured with the long paragraphs of the Zuercher Reading Test. Contrast sensitivity was measured with Pelli-Robson charts.

RESULTS

The patients' distance visual acuity was comparable between the drusen and fibrotic CNV groups (D1 versus F1, D2 versus F2). The reading acuity of the corresponding groups D1 and F1 was also comparable, but F2 patients showed a statistically lower reading acuity than D2 patients (P=0.03). All reading speed measurements of the groups F1 and F2 were significantly worse than those of the corresponding groups D1 and D2 (P-values: 0.0005-0.02). The correlation of reading speed between the Radner and Zuercher texts was very high (r=0.73-0.94). The contrast sensitivity was significantly lower in all groups compared with group D1 (P<0.001), but comparable for groups F1, F2, and F3.

CONCLUSIONS

Despite comparable results in distance visual acuity, patients with subretinal fibrosis after CNV had a greater reduction in reading ability than the patients with drusen. The distance visual acuity measurements alone, therefore, underestimate the real-life conditions and impact of AMD.