External beam radiotherapy for subretinal neovascularization in age-related macular degeneration: is this treatment efficient?

Verteporfin photodynamic therapy for the treatment of persistent subfoveal choroidal neovascularization after external beam radiotherapy: one-year results

PURPOSE

To determine the safety and efficacy of verteporfin photodynamic therapy (PDT) for the treatment of persistent choroidal neovascularization (CNV) previously treated with external beam radiotherapy (EBRT).

DESIGN

Retrospective case series.

METHODS

Verteporfin PDT was performed on 14 eyes of 13 patients with symptomatic leakage from CNV previously treated by EBRT. Principal outcome measures were: comparison of visual acuity at 12 months post-PDT with baseline and the recording of any ocular or systemic adverse events.

RESULTS

At baseline, the mean logMAR (+/-SD) VA was 0.81 +/- 0.33, whereas at the 12-month point it was 0.89 +/- 0.43 (P = .326). At the 12-month examination 10 eyes had lost less than 3 lines of VA, and 8 eyes had lost less than 1.5 lines. During this time, there were 2.1 PDT treatment sessions per eye on average (range = 1 to 4). There were no ocular or systemic adverse events recorded.

CONCLUSIONS

This short-term study shows that verteporfin PDT is safe after EBRT and may be of benefit for recalcitrant CNV.

Results of radiotherapy of subfoveal neovascularization with 16 and 20 Gy

PURPOSE

In a nonrandomized, prospective study the efficacy of radiotherapy with 16 and 20 Gray (Gy) for subfoveal neovascularization in age-related macular degeneration (ARMD) was analysed.

MATERIAL AND METHODS

From 1996 to 1998, 63 eyes were irradiated with 16 Gy and 38 eyes with 20 Gy for exudative ARMD. A total of 12 eyes had classic ARMD, 89 eyes occult ARMD, median baseline visual acuity (VA) was 6/30 (range: 3/60-6/9.5), median age was 78 years. Risk factors (type of ARMD, baseline VA) were evenly distributed in both groups. Median follow-up was 1.3 years (range: 4 months-4.7 years). VA of +/-1 line or better and unchanged size and activity of the membrane in fluorescein angiography were defined as stable. Actuarial methods were used.

RESULTS

Median loss of VA was -3 lines (range: -14 to +5), neovascularization remained unchanged or decreased in size and activity in 35 eyes. At 18 months, the probability of stabilized VA was 0.4 (95% confidence interval (CI): 0.3-0.5), at 24 months 0.3 (95% CI: 0.2-0.4). Radiation dose, type of ARMD or baseline VA had no significant impact on outcome of VA and membrane size and activity (P>0.05). Side effects were mild and transient increased tearing.

CONCLUSION

In this study, the results after radiotherapy were comparable to the natural course of the disease. An impact of radiation dose (16 vs 20 Gy) on stabilizing visual acuity and subfoveal neovascularization could not be shown. The results of studies on dose escalation using very small fields and high radiation doses should be awaited.

Current and Future Treatment Options for Nonexudative and Exudative Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in the industrialised world. Although relatively simple to diagnose through direct visualisation augmented with rapid sequence fluorescein angiography, treatment has presented a far greater challenge because the true aetiology of AMD is largely unknown. Within the past decade, researchers have introduced many new, potentially promising treatment and prevention options in an attempt to minimise the damage imparted from AMD. They capitalise on many of the theoretical and known factors contributing to AMD progression. A high-dose of an orally administered combination of the antioxidants ascorbic acid (vitamin C), tocopherol (vitamin E) and beta-carotene, in addition to copper and zinc, is the only widely accepted preventive therapy. Thermal laser photocoagulation and verteporfin photodynamic therapy are the only standard treatment options available based on large scale, randomised, prospective, placebo-controlled trials; however, efficacy is limited and only a minority of patients who present with AMD are eligible for these treatments. Many other preventive and treatment options are in all phases of clinical studies and expected to change the entire approach to AMD management in the near future. For example, alternative antioxidants, drusen ablation, apheresis and HMG-CoA reductase inhibitors have shown promise in some studies by preventing or slowing the progression of certain forms of AMD. In addition, alternative photodynamic therapies, low-intensity laser, antiangiogenic medications, radiation treatment and surgery have demonstrated the ability, albeit to differing degrees, to inhibit or possibly even reverse the severe vision loss often associated with AMD characterised by choroidal neovascularisation.

Ionizing radiation modulates the exposure of the HUIV26 cryptic epitope within collagen type IV during angiogenesis

PURPOSE

The majority of the research on the biologic effects of ionizing radiation has focused on the impact of radiation on cells in terms of gene expression, DNA damage, and cytotoxicity. In comparison, little information is available concerning the direct effects of radiation on the extracellular microenvironment, specifically the extracellular matrix and its main component, collagen. We have developed a series of monoclonal antibodies that bind to cryptic epitopes of collagen Type IV that are differentially exposed during matrix remodeling and are key mediators of angiogenesis. We have hypothesized that ionizing radiation might affect the process of angiogenesis through a direct effect on the extracellular matrix and specifically on collagen Type IV.

METHODS AND MATERIALS

Angiogenesis was induced in a chick chorioallantoic membrane (CAM) model; 24 h later, a single-dose treatment with ionizing radiation (0.5, 5, and 20 cGy) was administered. Angiogenesis was assessed, and the exposure of two cryptic regulatory epitopes within collagen Type IV (HUI77 and HUIV26) was studied in vitro by solid-phase ELISA and in vivo by immunofluorescence staining.

RESULTS

A dose-dependent reduction of angiogenesis with maximum inhibition (85%-90%) occurring at 20 cGy was demonstrated in the CAM model. Exposure of the cryptic HUIV26 site, an angiogenesis control element, was inhibited both in vitro and in vivo by the same radiation dose, whereas little if any change was observed for the HUI77 cryptic epitope.

CONCLUSIONS

A dose-dependent alteration of the functional exposure of the HUIV26 cryptic epitope is induced by radiation in vitro and in the CAM model in vivo. This radiation-induced change in protein structure and function may contribute to the inhibitory effects of ionizing radiation on new blood vessel growth and warrants further studies in other models.