The therapeutic effects of intravitreal bevacizumab in a patient with recalcitrant idiopathic polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy: An update on current management and review of literature

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), commonly seen in the Asian population. It is dissimilar in epidemiology, genetic heterogeneity, pathogenesis, natural history, and response to treatment in comparison to nAMD. Confocal scanning laser ophthalmoscopy-based simultaneous fluorescein angiography and indocyanine green angiography, spectral-domain optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography have improved the ability to detect PCV, understand its pathology, and monitor treatment response. A plethora of literature has discussed the efficacy of photodynamic therapy, anti-vascular endothelial growth factor (VEGF) monotherapy, and combination of both, but only a few studies with higher level of evidence and limited follow-up duration are available. This review discusses the understanding of PCV with respect to epidemiology, pathogenesis, clinical features, natural history, imaging techniques, and various treatment options. Recent clinical trials (EVEREST-II and PLANET study) have emphasized that either anti-VEGF monotherapy or combination treatment is equally capable to strike a balance between polyp regression and stabilization of visual acuity. The recurrent nature of the disease, the development of macular atrophy, and the long-term poor visual prognosis despite treatment are concerns that open avenues for further research.

Batch-related sterile endophthalmitis following intravitreal injection of bevacizumab

Background:

To report a series of patients with sterile endophthalmitis after intravitreal bevacizumab (IVB) injection from 2 different batches of bevacizumab.

Materials and Methods:

Records of 11 eyes with severe inflammation after IVB injections from two different batches (7 eyes from one and 4 from the other) on two separate days were evaluated. Fifteen eyes of 15 patients in one day were treated with one batch and 18 eyes of 17 patients were treated another day using another batch injected for different retinal diseases. Each batch was opened on the day of injection. We used commercially available bevacizumab (100 mg/4 ml) kept at 4°C. Severe cases with hypopyon were admitted to the ward and underwent anterior chamber and vitreous tap for direct smear and culture.

Results:

Pain, redness and decreased vision began after 11-17 days. All had anterior chamber and vitreous reactions and 5 had hypopyon. Antibiotics and corticosteroids were initiated immediately, but the antibiotics were discontinued after negative culture results. Visual acuity returned to pre-injection levels in 10 eyes after 1 month and only in one eye pars plana vitrectomy was performed. Mean VA at the time of presentation with inflammation (1.76 ± 0.78 logMAR) decreased significantly (P =0.008) compared to the initial mean corrected VA (1.18 ± 0.55 logMAR); however, final mean corrected VA (1.02 ± 0.48 logMAR) improved in comparison with the baseline but not to a significant level (P =0.159).

Conclusions:

We report a cluster of sterile endophthalmitis following intravitreal injection of bevacizumab from the same batch of bevacizumab that has a favorable prognosis.

Photodynamic therapy of bullous central serous chorioretinopathy with subretinal exudate and a tear of the retinal pigment epithelium

PURPOSE

To report a case of bullous central serous chorioretinopathy associated with subretinal exudates and a tear of the retinal pigment epithelium imaged using spectral domain optical coherence tomography and treated successfully with reduced fluence verteporfin photodynamic therapy.

PATIENTS

Observational case report.

METHODS

Patient with central serous chorioretinopathy and associated subretinal exudates was imaged using spectral domain optical coherence tomography and managed using photodynamic therapy.

RESULTS

The patient was treated unsuccessfully with intravitreal bevacizumab and ranibizumab followed by successful treatment with reduced fluence photodynamic therapy. Spectral domain optical coherence tomography imaging of the lesion identified the subretinal exudates and a retinal pigment epithelium tear before treatment.

CONCLUSION

In this case of severe bullous central serous chorioretinopathy, spectral domain optical coherence tomography identified a tear of the retinal pigment epithelium not previously identified using clinical exam or time domain optical coherence tomography. The lesion was successfully treated using reduced fluence photodynamic therapy after intravitreal antivascular endothelial growth factor drugs had no effect.

Functional recovery after intravitreal bevacizumab treatments for idiopathic choroidal neovascularization in young adults

PURPOSE

To evaluate the morphology and functional recovery of the retina after treatment of idiopathic choroidal neovascularization using intravitreal injections of bevacizumab in young adults.

METHODS

For this interventional case series, 20 eyes of 19 patients with idiopathic choroidal neovascularization were treated with multiple intravitreal injections of bevacizumab. Changes in best-corrected visual acuity before the treatment and at follow-up visits were recorded. Structural changes were evaluated using optical coherence tomography and functional changes were assessed using microperimetry.

RESULTS

Twenty eyes were followed for 12 months after their first injection. The eyes underwent an average of 3.95 injections. All eyes had a stable or an improved vision. The mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.43 to 0.06 (Wilcoxon signed-ranks test, P < 0.005). Improvement in macular function was detected as early as 1 month after the treatment and lasted for at least 6 months. Microperimetry demonstrated that mean retinal sensitivities within the central 10° field (10.29 ± 5.12 dB) at baseline improved to 13.98 ± 3.96 dB at the last visit. Dense scotomas were found in 13 of the 20 eyes at baseline and 5 of the 20 eyes at the last visit. Stable fixation (6 of 20 at baseline) was found in 17 of the 20 eyes at the last visit. Twelve of the 14 eyes with either a predominantly eccentric or poor central fixation at baseline established central fixation at 12 months. No serious local or systemic complications were encountered.

CONCLUSION

In young adults with idiopathic choroidal neovascularization, an improvement in visual acuity and macular function was detected after intravitreal injections of bevacizumab.

Reduced-fluence photodynamic therapy combined with intravitreal bevacizumab for polypoidal choroidal vasculopathy

PURPOSE

To evaluate the efficacy and safety of reduced-fluence photodynamic therapy (PDT) combined with bevacizumab for polypoidal choroidal vasculopathy (PCV).

DESIGN

Prospective, noncomparative, interventional case series.

METHODS

Sixteen treatment-naïve patients with polypoidal choroidal vasculopathy were treated with reduced-fluence PDT combined with bevacizumab. All patients were followed up monthly for 12 months with measurements of best-corrected visual acuity (BCVA) and central foveal thickness by optical coherence tomography. Indocyanine green angiography and fluorescein angiography were performed every 3 months. Patients were re-treated with reduced-fluence PDT combined with bevacizumab or with sole injection of bevacizumab when indicated.

RESULTS

The mean logMAR BCVA showed significant improvement from 0.76 at baseline to 0.46 at 12 months (P = .002). At 12 months, the BCVA improved in 9 eyes (56.3%) by 3 lines or more, was stable in 6 eyes (37.5%), and decreased in 1 eye (6.3%) because of recurrence of polyps. During the study period, 3 patients (18.8%) had recurrence of polyps and 2 patients (12.5%) had persistent polyps. Mean episodes of reduced-fluence PDT and mean injections of intravitreal bevacizumab over 12 months were 1.44 and 2.44, respectively. Although 3 patients had mild choroidal nonperfusion-1 eye after 1 session of PDT and 2 eyes after 2 sessions-no severe complications, including endophthalmitis, uveitis, or subretinal hemorrhage, developed.

CONCLUSION

Reduced-fluence PDT combined with bevacizumab for PCV seemed to be effective for improving vision and reducing complications. Further study to optimize the light dose of PDT in combination therapy is needed in order to achieve better treatment outcomes for PCV.

Combination therapy with focal laser photocoagulation and intravitreal ranibizumab for polypoidal choroidal vasculopathy: a case series

PURPOSE

The study aim is to describe the clinical outcomes of patients with polypoidal choroidal vasculopathy (PCV) treated with focal argon laser photocoagulation and ranibizumab combination therapy.

METHODS

This study is a retrospective case series of 6 patients (6 eyes) diagnosed with PCV who received combination therapy with argon laser photocoagulation and ranibizumab and have at least 12 months follow-up. Argon laser photocoagulation was applied directly to the polypoidal lesions as identified on indocyanine green angiography and followed by a course of intravitreal ranibizumab injections. The primary outcome measures were the mean change in logMAR visual acuity and the mean change in central macular thickness (CMT) at final follow-up.

RESULTS

The mean (SD) duration of follow-up was 1.09 (0.22) years. At the final follow-up the difference (95% confidence interval [CI]) in logMAR acuity was 0.48 (0.10-0.74) (p=0.01) and the difference (95% CI) in CMT was 207 µm (35-490) (p=0.02) on optical coherence tomography. The mean (SD) number of ranibizumab injections per eye was 4.83 (3.6). The mean (SD) number of laser treatments per eye was 1.16 (0.4).

CONCLUSIONS

In this study, combination therapy with focal argon laser photocoagulation and intravitreal ranibizumab resulted in improved visual acuity and clinical outcomes for patients with PCV for up to 1 year.

Intravitreal bevacizumab alone versus in combination with photodynamic therapy for the treatment of neovascular maculopathy in patients aged 50 years or older: 1-year results of a prospective clinical study

PURPOSE

To compare the outcomes of treatment with intravitreal bevacizumab alone (BEVA group) or in combination with photodynamic therapy (PDT) (COMB group), in patients aged at least 50 years with neovascular maculopathy.

METHODS

Forty-one patients with neovascular age-related macular degeneration (AMD) (n = 31) or polypoidal choroidal vasculopathy (PCV) (n = 10) were randomized to either the BEVA group (n = 18) or the COMB group (n = 23). A total of three intravitreal bevacizumab injections (1.25 mg/0.05 ml) were given at 6-week intervals. In the COMB group, PDT was included near the time of one injection. Patients underwent best-corrected visual acuity (BCVA) measurement and optical coherence tomography (OCT) at every visit. Fluorescein angiography and indocyanine green angiography were repeated every 3 months.

RESULTS

Overall BCVA (p = 0.001) and central foveal thickness (CFT) (p < 0.001) measured by OCT improved significantly at 12 months, and there was no between-group difference in BCVA or CFT between the BEVA and COMB groups. Whereas AMD patients showed significant improvement in BCVA (p = 0.001) and CFT (p = 0.004), PCV patients failed to improve. The effect of bevacizumab alone on neovascular AMD was similar to that of combination therapy, when measured by both BCVA and CFT. The total number of bevacizumab injections was not reduced when PDT was given, either among all patients or in a subgroup of naïve patients (p > 0.05). No serious complication was noted.

CONCLUSION

The results of our 12-month prospective study indicate that intravitreal bevacizumab alone has similar efficacy and safety to bevacizumab plus PDT for treatment of patients with neovascular AMD, even treatment-naïve patients. The addition of PDT did not assist in reducing the required total number of bevacizumab injections.

Treatment of polypoidal choroidal vasculopathy with photodynamic therapy combined with intravitreal injections of ranibizumab

PURPOSE

To evaluate the 1-year efficacy and safety of photodynamic therapy (PDT) combined with intravitreal injections of ranibizumab for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective chart review.

METHODS

We retrospectively reviewed the medical records of 63 consecutive patients (66 eyes) with subfoveal PCV who were treated with PDT combined with intravitreal injections of ranibizumab. Of the 66 eyes, 29 had no history of treatment for PCV, 10 had been treated previously with only intravitreal injections of anti-vascular endothelial growth factor agents, and 27 had been treated previously with PDT. All eyes had a minimal follow-up of 12 months.

RESULTS

The combined therapy reduced substantially the exudative change immediately after initiation of treatment. In treatment-naïve eyes, mean VA before treatment (0.47 ± 0.37 logarithm of the minimal angle of resolution [logMAR]) improved to 0.32 ± 0.30 (P < .01) at 3 months and to 0.29 ± 0.29 (P < .01) at 12 months. Polypoidal lesions were reduced in all eyes and disappeared completely in 79.1% of cases. In eyes treated previously with only anti-vascular endothelial growth factor therapy, some visual improvement was achieved, but in eyes treated previously with PDT, mean visual acuity (0.61 ± 0.45) deteriorated to 0.68 ± 0.52 at 12 months. Of all 66 eyes, 5 showed extensive postoperative subretinal hemorrhage, in 2 of which a vitreous hemorrhage developed, necessitating pars plana vitrectomy.

CONCLUSIONS

PDT combined with ranibizumab led to significant visual recovery in treatment-naïve eyes with PCV, but not in eyes with PCV that had demonstrated recurrence after previous PDT. PDT in combination with ranibizumab still has a risk of the postoperative hemorrhagic complications.

[Surgical management of sub-retinal haemorrhage secondary to polypoidal choroidal vasculopathy]

We report the case of a 34-year-old black woman with acute and severe unilateral loss of sight related to idiopathic polypoidal choroidal vasculopathy responsible for a sub macular haemorrhage (1/10 on the Monoyer scale). The patient underwent a pars plana vitrectomy associated with a sub retinal administration of tissue plasminogen activator (100 μg) and a pneumatic displacement by gas (C2F6) with facedown positioning for 5 days. There were no intraoperative complications and the clot was lysed and totally displaced from the macula. There was no recurrence of the disease and the retinal epithelium detachment decreased progressively. The final visual acuity was 7/10. This case report illustrates the capacity and efficacy of this surgical procedure in the management of sub macular haemorrhage related to polypoidal choroidal vasculopathy. It provides effective displacement of the clot, limiting retinal damage induced by sub macular haemorrhage. Furthermore, it allows early treatment of the polypoidal aneurysm by laser or dynamic phototherapy and increases final visual acuity. Randomised studies are expected to determine the indication for this surgical procedure in the management of polypoidal choroidal vasculopathy and the possible association of laser, dynamic phototherapy, or anti-VEGF treatments.

Combined photodynamic therapy and intravitreal bevacizumab for idiopathic polypoidal choroidal vasculopathy: one-year follow-up

OBJECTIVE

To report the efficacy and safety of combined photodynamic therapy (PDT) and intravitreal bevacizumab (IVB) injection in the treatment of idiopathic polypoidal choroidal vasculopathy (IPCV).

MATERIAL AND METHODS

A prospective case series of 10 eyes of 10 consecutive patients affected by IPCV with subfoveal involvement. PDT plus IVB (1.25 mg/0.05 mL) injection two weeks later was performed in all patients. Two adjunctive injections of bevacizumab were scheduled at four and eight weeks after the initial treatment. Best-corrected visual acuity (BCVA), fluorescein and indocyanine green angiographies, and optical coherence tomography were obtained at baseline, and at one, three, six, nine, and 12 months.

RESULTS

The combined treatment led to an improvement of both neurosensory detachment and pigmented epithelial detachment in all eyes, with a decrease of exudation and regression of macular thickness, which remained stable to the end of follow-up. However, BCVA remained stable over the 12 months of follow-up.

CONCLUSION

These findings demonstrate that PDT/IVB combined therapy is able to achieve morphologic stabilization of the IPCV lesion, through a rapid decrease of macular thickness and regression of the size of polypoidal vascular lesion.

Polypoidal choroidal vasculopathy: a review

More than a quarter century has passed since the original description of polypoidal choroidal vasculopathy (PCV) in 1982 as a peculiar hemorrhagic disorder involving the macula characterized by recurrent subretinal pigment epithelial bleeding. In the ensuing years, numerous reports have described the expanded clinical spectrum of this entity. PCV is the principal vascular composition of patients of pigmented races experiencing neovascular maculopathies, particularly African Americans and Asians. This form of neovascularization is now known to occur in white patients with or without concomitant drusen, and the site of involvement has extended from the peripapillary area to the peripheral fundus. Indocyanine green angiography has made detection of these abnormal vascular changes more reliable and definitive. More precise diagnosis has also led to a better understanding of specific clinical features that distinguish PCV from more typical proliferations of abnormal choroidal vessels. We review the nature of PCV, including its genetic basis, demographic features, histopathology, clinical manifestations, natural course, response to treatments, and the histopathological and genetic bases. We emphasize multimodal ophthalmic imaging of these vessels, in particular fluorescein and indocyanine green angiography and optical coherence tomography.

Results of vitrectomy for breakthrough vitreous hemorrhage associated with age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

The purpose of this study was to evaluate the results of vitrectomy in patients with vitreous hemorrhage associated with age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).

METHODS

A retrospective review was conducted of consecutive cases of patients undergoing pars plana vitrectomy for nonclearing vitreous hemorrhage associated with neovascular AMD or PCV.

RESULTS

Twenty-four eyes of 23 patients were included. The mean length of time from the onset of vitreous hemorrhage to operation was 4.3 months. Twelve eyes had AMD, and 12 eyes of 11 patients had PCV. Additional treatments for active choroidal neovascularization or PCV were required in 12 eyes during follow-up. The mean visual acuity improved significantly from a logarithm of the minimum angle of resolution of 2.79 +/- 0.85 before operation to 1.61 +/- 0.98 at 2 months after operation (P < 0.001). Visual acuity was >or=20/200 in 9 eyes (37.5%) at 2 months after operation; 1 eye was in the AMD group, and the other eyes were in the PCV group. Improvement was more frequently observed in the PCV group (P = 0.005).

CONCLUSION

In this series, the functional outcomes of vitrectomy for vitreous hemorrhage associated with AMD were inferior to outcomes of the PCV group. Vitrectomy is beneficial for improving visual function in select cases of breakthrough vitreous hemorrhage.

Sterile endophthalmitis after intravitreal injection of bevacizumab obtained from a single batch

PURPOSE

The purpose of this study was to report 14 consecutive cases of endophthalmitis after intravitreal injection of bevacizumab (Avastin; Roche, Basel, Switzerland) obtained from a single batch.

METHODS

One vial of bevacizumab (100 mg/4 mL) was divided into 20 sterile injections and kept at 4 degrees C before use. Bevacizumab (1.25 mg/0.05 mL) was injected intravitreally into 19 eyes of 15 patients to treat macular edema or choroidal neovascularization. All treatments were performed within 1 week of the bevacizumab, which was from a single batch, being aliquotted into the 20 doses.

RESULTS

Of the 19 eyes, 14 showed moderate to severe ocular inflammation immediately after injection. Cultures of aqueous humor and vitreous from 5 eyes were negative for bacteria and fungi. Eyes with moderate inflammation received topical or systemic antibiotics and steroid treatment. Five eyes with severe inflammation underwent pars plana vitrectomy because of dense vitreous opacity. Visual acuity returned to preendophthalmitis levels in 12 eyes but had decreased in 2 eyes at 1 month after the injection.

CONCLUSION

Intravitreal injection of bevacizumab can cause sterile endophthalmitis. Most inflammation occurred within a few days after the intravitreous injection of the bevacizumab, but treatment with antibiotics, steroids, and/or vitrectomy was effective, and the prognosis was good in most cases.

Bevacizumab (Avastin) for the treatment of ocular disease

The use of intravitreal bevacizumab (Avastin) has greatly expanded since its introduction into ophthalmic care 3 years ago. A PubMed search on 1 August 2008 revealed 51 ocular disease processes that have been treated with bevacizumab. The majority of publications consist of case reports or retrospective case series and their number is increasing quickly. It is important to collate the experiences gained to date to properly inform our clinical decision making and improve the design of future clinical trials. Current studies cannot easily be combined in a meta-analysis given the lack of standardized data and the wide variety of disorders studied in small numbers. This paper will describe the attempted uses of intravitreal bevacizumab and its efficacy for each ocular disease in addition to discussing safety. Comments regarding appropriate use of this treatment are based on our current level of knowledge. It is clear that the initial encouraging results described in this paper warrant further study of intravitreal bevacizumab in larger, controlled, randomized trials.

Refractory neovascular age-related macular degeneration secondary to polypoidal choroidal vasculopathy

PURPOSE

To describe a neovascular pattern associated with treatment-refractory neovascular age-related macular degeneration (AMD).

DESIGN

A retrospective observational case series.

METHODS

SETTING

Clinical practice.

PATIENT POPULATION

Twelve eyes of 12 patients with neovascular AMD in which a poor anatomic response to anti-vascular endothelial growth factor (VEGF) therapy was related to polypoidal choroidal vasculopathy (PCV).

OBSERVATION PROCEDURE

Slit-lamp biomicroscopy, optical coherence tomography, fluorescein and indocyanine green angiography.

MAIN OUTCOME MEASURES

Snellen visual acuity (VA), anatomic response to therapy including presence or absence of retinal edema, hemorrhage, and lipid exudates.

RESULTS

New or persistent PCV was identified in a cohort of patients demonstrating increasing macular exudation despite regular intravitreal ranibizumab (Lucentis; Genentech Inc, South San Francisco, California, USA) or bevacizumab (Avastin; Genentech Inc) injections for a minimum of 6 months. Treatment with verteporfin photodynamic therapy (PDT), PDT/anti-VEGF combination therapy, or continued anti-VEGF monotherapy resulted in complete resolution of exudation in 9 of 12 patients and partial resolution of exudation in the remaining 3 patients.

CONCLUSION

Treatment-refractory neovascular AMD may harbor vascular abnormalities such as PCV. Modifications in therapeutic protocols may be indicated in order to improve visual and anatomic outcomes in this population.

Association between foveal photoreceptor integrity and visual outcome in neovascular age-related macular degeneration

PURPOSE

To evaluate the correlation between visual outcome and foveal photoreceptor integrity after successful treatment of eyes with neovascular age-related macular degeneration (AMD).

DESIGN

Retrospective chart review.

METHODS

We retrospectively studied the medical records of 51 eyes of 51 patients with neovascular AMD who were treated successfully with photodynamic therapy (PDT). All eyes were followed-up for more than 24 months after the initial treatment. Using spectral-domain optical coherence tomography, the status of the inner segment and outer segment (IS/OS) photoreceptor junction was assessed as a hallmark of the integrity of the foveal photoreceptor layer.

RESULTS

At the final visit, no eyes showed an exudative change. A complete or discontinuous IS/OS line was detected beneath the fovea in 8 (15.7%) and 25 (29.4%) eyes, respectively, whereas 28 (54.9%) had no IS/OS line. Eyes with a continuous or discontinuous IS/OS line beneath the fovea had better final visual acuity (VA) than did eyes without an IS/OS line (P < .001, respectively). Of the 51 eyes, 36 showed polypoidal choroidal vasculopathy (PCV), whereas 15 were diagnosed as having typical AMD without PCV. Visual outcome was significantly better in eyes with PCV (P = .026). Most eyes (13/15; 86.7%) with typical AMD had no IS/OS line at the final visit, whereas only 13 (36.1%) of the 36 eyes with PCV had no IS/OS line beneath the fovea.

CONCLUSIONS

Integrity of the photoreceptor layer beneath the fovea is associated with the final VA in neovascular AMD after successful PDT.

Polypoidal choroidal vasculopathy and treatments

PURPOSE OF REVIEW

This review assesses the current knowledge of the clinical characteristics of polypoidal choroidal vasculopathy and treatments.

RECENT FINDINGS

Polypoidal choroidal vasculopathy is a disease with characteristic choroidal vascular abnormalities. Indocyanine green angiography is essential for diagnosis. The prevalence is higher in Asian people than in Caucasians. Photodynamic therapy is efficacious for treating polypoidal choroidal vasculopathy; 1-year results have shown greater benefit of photodynamic therapy than choroidal neovascularization secondary to age-related macular degeneration. Recurrence, however, seriously affects vision long term during follow-up after photodynamic therapy. The lower efficacy of bevacizumab- a full-length antibody of vascular endothelial growth factor- has been shown for polypoidal choroidal vasculopathy.

SUMMARY

Although the polypoidal choroidal vasculopathy and age-related macular degeneration have been known to share common genetic factors, its clinical characteristics including the different responses to photodynamic therapy suggest that polypoidal choroidal vasculopathy is a separate clinical entity from age-related macular degeneration. The results of photodynamic therapy for polypoidal choroidal vasculopathy are encouraging; however, recurrence may affect vision over time. Therapeutic modalities to inhibit development of the exudative choroidal vasculature of polypoidal choroidal vasculopathy are desirable.