Combined photodynamic therapy and intravitreal triamcinolone acetonide for the treatment of myopic subfoveal choroidal neovascularization

A systematic review of clinical practice guidelines for myopic macular degeneration

Background

Methods

Results

Conclusions

DEXAMETHASONE INTRAVITREAL IMPLANT FOR CHOROIDAL NEOVASCULARIZATION DURING PREGNANCY

PURPOSE

To describe the management of active choroidal neovascularization (CNV) during pregnancy with the use of a dexamethasone intravitreal implant (DXI) (Ozurdex).

METHODS

Case series of active CNV treated with DXI with at least 12-month follow-up retrospectively analyzed at 2 high-volume referral centers in France. Medical records and multimodal macular imaging were evaluated.

RESULTS

Three eyes of 3 patients (age 30.0 ± 3.6 years) were included. One case of idiopathic CNV and two cases of CNV secondary to multifocal choroiditis were analyzed. Mean follow-up was 20.6 ± 4.0 months (range, 16-23 months). The DXI was given at second trimester of established pregnancy in all cases. Mean central retinal thickness decreased from 359 ± 53 μm to 301 ± 17 μm 1 month after DXI and remained stable up to 12 months of follow-up. Visual improvement in all cases was observed (mean 10 letters; range, 5-30 letters) 1 month after DXI and remained stable/increased up to 12-month follow-up (mean 22 letters; range, 10-30 letters). All patients had an uneventful prenatal course and delivered a healthy full-term infant.

CONCLUSION

In the authors' experience, a single DXI revealed safe and effective in CNV treatment during pregnancy.

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.

Prognostic factors of eyes with naïve subfoveal myopic choroidal neovascularization after intravitreal bevacizumab

PURPOSE

To determine the efficacy of 1 intravitreal bevacizumab injection followed by pro re nata (1 + PRN) injection in cases of subfoveal myopic choroidal neovascularization (CNV) and to identify CNV-recurrence-related prognostic factors.

DESIGN

Retrospective observational case series.

METHODS

In total, 103 eyes of 89 consecutive naive patients who had subfoveal myopic CNV and had been followed-up for at least 2 years were included. Of those eyes, 24 had recurrences. The remaining eyes were stable after the initial treatment.

RESULTS

The average patient age was 51.1 ± 15.2 years. The average follow-up duration was 44.1 ± 12.7 months. At baseline and at the 1-year, 2-year, and final visits, the average best corrected visual acuities (BCVAs) were 0.57 ± 0.45, 0.38 ± 0.51, 0.40 ± 0.52, and 0.41 ± 0.41 logMAR, respectively. The recurrence rate during follow-up was 23.3%. The BCVA improved by 0.2 logMAR after 2.7 injections in the eyes without recurrence but by only 0.08 logMAR after 6.9 injections in the eyes with recurrence. In univariate analysis, recurrence was associated with older age, more myopic refraction, thinner choroid, larger CNV lesions, and subfoveal hemorrhage at baseline. In multivariate analysis, only baseline CNV lesion size associated significantly with CNV recurrence (P = 0.002). Recurrence, baseline BCVA, choroidal thickness, and CNV size associated significantly with final BCVA (P = 0.026, <0.0001, 0.007, and 0.002, respectively). Baseline choroidal thickness, CNV size, age, and presence of lacquer cracks associated significantly with injection number (P < 0.0001, <0.0001, 0.026, and 0.035, respectively).

CONCLUSIONS

1 + PRN intravitreal bevacizumab monotherapy effectively stabilized subfoveal myopic CNV. The CNV size, the baseline BCVA, and the choroidal thickness were the main prognostic factors of subfoveal myopic CNV after 1 + PRN injection of bevacizumab.

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.

Combined therapy: photodynamic therapy and bevacizumab to treat myopic neovascular membranes. One-year follow-up

PURPOSE

The purpose of this study was to evaluate whether combined customized photodynamic therapy (PDT) and bevacizumab in myopic choroidal neovascularization can improve vision and whether it is possible to decrease the frequency and number of intravitreal antiangiogenic injections.

METHODS

A prospective, consecutive, noncomparative, interventional case series of 36 patients with myopic choroidal neovascularization, treated with an initial dose of PDT and intravitreal bevacizumab 48 hours to 60 hours afterward. Retreatments were carried out as required with monthly bevacizumab and PDT every 3 months if there were relapses. Follow-up lasted 1 year in all cases.

RESULTS

The mean best-corrected visual acuity increased from 44 letters before the initial treatment to 59.5 letters at the 12-month follow-up (P < 0.01). Compared with initial vision, 94.5% of the eyes had the same or better vision and 5.5% lost fewer than 6 lines of vision. The mean number of PDT treatments was 1.1 per patient, and the mean number of bevacizumab injections was 1.5 per patient. Only 1 initial treatment with PDT + bevacizumab was necessary in 28 cases (77.8%).

CONCLUSION

Combined personalized PDT + bevacizumab therapy makes it possible to obtain visual results similar to those obtained in monotherapy studies but with fewer intravitreal injections. It appears to be an interesting option for this type of patient.

Bevacizumab for choroidal neovascularization secondary to pathologic myopia: Is there a decline of the treatment efficacy after 2 years?

BACKGROUND

The Verteporfin in Photodynamic Therapy (VIP) Study failed to prove a statistically significant benefit for myopic choroidal neovascularization (CNV) at the end of the second year. Therefore, we wanted to evaluate whether the early effects seen under anti-VEGF treatment can be maintained over longer follow-up intervals.

METHODS

This consecutive case series included all patients at the Centre for Ophthalmology, Tuebingen, with a 2-year follow-up after treatment with 1.25 mg of bevacizumab alone or in combination with photodynamic therapy. Twenty-one eyes from 19 patients were analyzed in the retrospective evaluation of best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

Mean logMAR BCVA improved from 0.64 at baseline to 0.55 after 1 year (p = 0.32) and remained 0.55 at 2 years (p = 0.23). A subgroup analysis showed that mean logMAR BCVA in the monotherapy group improved from 0.7 to 0.5 at 2 years (n = 11, p = 0.06). In the combined therapy group, mean logMAR BCVA changed from 0.55 to 0.59 at 2 years (n = 10, p = 0.69). Mean CFT decreased significantly in both groups by 168 microm (p < 0.001) and 76 microm (p < 0.05) in the monotherapy and in the combined groups, respectively. No complications or adverse effects were observed.

CONCLUSION

Although the limitations of the study design have to be acknowledged and carefully discussed, we found no obvious superiority of a combined treatment for myopic CNV, at least in terms of the functional outcome and the injection frequency. The results indicate that bevacizumab might be beneficial in the treatment of patients with CNV secondary to pathologic myopia.

Intravitreal bevacizumab vs sub-tenon triamcinolone acetonide for choroidal neovascularization attributable to pathologic myopia

PURPOSE

To compare the visual outcomes of intravitreal bevacizumab (Avastin; Genentech Inc, South San Franciso, California, USA) and sub-Tenon triamcinolone acetonide (TA) for choroidal neovascularization attributable to pathologic myopia (mCNV).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Fifty-four consecutive eyes of 53 patients with mCNV treated with either sub-Tenon TA or intravitreal bevacizumab in an institutional setting were included. Twenty eyes were treated with sub-Tenon TA and 34 eyes were treated with intravitreal bevacizumab. The main outcome measures included best-corrected visual acuity (BCVA) 12 months after the initial injection and logarithm of the minimum angle of resolution gain from baseline compared with analysis of covariance (ANCOVA).

RESULTS

At 12 months, the BCVA improved by 1.9 lines in the intravitreal bevacizumab group and worsened by 0.3 lines in the sub-Tenon TA group. Thus, the intravitreal bevacizumab group had significantly greater visual improvement than the sub-Tenon TA group (P < .01). Statistical analysis (ANCOVA) revealed that age (P = .01), pretreatment BCVA (P < .01), and the treatment choice (intravitreal bevacizumab or sub-Tenon TA; P < .01) correlated significantly with the BCVA and the BCVA gain at 12 months. The refractive error was of borderline significance (P = .06).

CONCLUSIONS

Although this study is limited because of its retrospective nature, intravitreal bevacizumab seems to result in a more favorable visual outcome than sub-Tenon TA in the treatment of mCNV. Patient age, the BCVA before treatment, and the refractive error must be considered to initiate the treatment.

Two years follow-up outcome of verteporfin therapy for subfoveal choroidal neovascularization in pathologic myopia in Indian eyes

CONTEXT

In India, refractive errors are a major cause of treatable blindness. Population surveys in southern India have shown prevalence of high myopia to be 4.32-4.54%. Photodynamic therapy (PDT) for choroidal neovascularization (CNV) caused by pathologic myopia is beneficial.

AIMS

To report the 24 months outcome of PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes.

SETTINGS AND DESIGN

Prospective case series.

MATERIALS AND METHODS

Review of prospectively collected data of Indian patients with pathologic myopia and subfoveal CNV treated with verteporfin therapy between 2001 and 2005 using standard regimen for PDT.

STATISTICAL ANALYSIS USED

Wilcoxon signed rank test was used to see the difference in the mean letter acuity at intervals compared to baseline. Kaplan Meier Survival analysis was done to estimate the success rate of verteporfin therapy for CNV caused by pathologic myopia.

RESULTS

Fifteen patients (15 eyes) treated with standard fluence PDT and who had completed 24 months follow-up were analyzed. The mean spherical equivalent was -13.36 +/- 5.88 diopter. Five out of 15 eyes in six months, three out of 15 eyes at 12 months and four eyes out of 15 at 24 months had improved vision by > 10 letters. The mean number of treatment session was 2.2 in two years.

CONCLUSIONS

PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes is effective.

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