Treatment of subfoveal choroidal neovascularization associated with multifocal choroiditis and panuveitis with photodynamic therapy

Punctate inner choroidopathy: A review of the current diagnostic and therapeutic approaches

Punctate inner choroidopathy (PIC) is an uncommon idiopathic inflammatory condition characterized by multifocal chorioretinopathy that primarily affects young adults, with a predilection for myopic females. Clinically, it manifests as small, yellowish-white lesions in the inner choroid and outer retina, often associated with inflammatory changes. Accurate diagnosis remains a challenge due to its resemblance to other posterior uveitic entities, necessitating an astute clinical eye and advanced imaging techniques for differentiation. Multimodal imaging plays a crucial role by offering valuable insights, as it enables the visualization of various abnormalities related to uveitis. The pathogenesis of PIC is still a subject of debate, with a complex interplay of genetic, immunological, and environmental factors proposed. Managing PIC presents multiple challenges for clinicians. Firstly, variable disease severity within and among patients requires diverse treatments, from observation to aggressive immunosuppression and/or anti-VEGF therapy. Secondly, treatment must distinguish between primary causes of vision loss. New or worsening PIC lesions suggest active inflammation, while new neovascular membranes may indicate secondary neovascular processes. Thirdly, deciding on maintenance therapy is complex, balancing PIC prognosis variability against immunosuppression risks. Some patients have long periods of inactivity and remission, while others face sudden, vision-threatening episodes during quiescent phases. Through a systematic review of the literature, this paper sheds light on the current understanding of PIC, its challenges, and the prospects for future research. By synthesizing existing knowledge, it aims to aid clinicians in accurate diagnosis and guide treatment decisions for improved visual outcomes in individuals affected by PIC.

[White dot syndromes : Principles, diagnostics, and treatment]

The white dot syndromes include a group of diseases which are characterized by multiple yellowish-white foci in the outer retina, retinal pigment epithelium, and choroid. For clinicians and researchers alike they present significant diagnostic and therapeutic challenges. White dot syndromes include primary inflammatory choriocapillaropathies, such as acute posterior multifocal placoid pigment epitheliopathy (APMPPE)/acute multifocal ischemic choriocapillaropathy (AMIC), multiple evanescent white dot syndrome (MEWDS)/acute idiopathic blind spot enlargement (AIBSE), multifocal choroiditis (MFC), punctate inner choroidopathy (PIC), serpiginous choroiditis (SC), acute zonal occult outer retinopathy (AZOOR), and acute macular neuroretinopathy (AMN). Among the primary stromal choroiditis is birdshot retinochoroidopathy (BSRC); however, the pathogenesis of these disorders is largely unknown. Immunological reactions to previous viral infections with a genetic disposition seem to be a common denominator.

An efficacy analysis of anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to multifocal choroiditis and comparison with wet age-related macular degeneration

OBJECTIVE

To evaluate the effect of anti-vascular endothelial growth factor (VEGF) on juxtafoveal choroidal neovascularization (CNV) secondary to multifocal choroiditis (MFC) and wet age-related macular degeneration (AMD).

METHODS

In this retrospective, comparative study, 20 unique eyes with CNV were divided into two groups: 10 patients affected by MFC and 10 patients diagnosed with wet AMD. They all received local intravitreal (IVT) injections of ranibizumab, with 6 months of follow-up. Retreatment injections were performed based on findings suggestive of active neovascularization.

RESULTS

Significant improvements were observed in the juxtafoveal CNV lesions, and average central macular thickness decreased in both groups following the anti-VEGF therapy (P<0.05). The average number of injections used in MFC patients was 1.6, while three injections on average were used in wet AMD patients (Z=-2.844, P=0.009). Best-corrected visual acuity was significantly improved in MFC patients after anti-VEGF therapy (P<0.05), and there was no significant difference in wet AMD patients between before anti-VEGF therapy and 6 months later (P>0.05).

CONCLUSIONS

IVT ranibizumab resulted in good clinical outcomes for juxtafoveal CNV secondary to MFC and wet AMD, but the average number of injections used in MFC was fewer than that used in wet AMD over a 6-month observation period. Compared with the wet AMD group, visual acuity was obviously improved in the MFC group at 6 months.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Punctate inner choroidopathy: A review

Punctate inner choroidopathy (PIC), an idiopathic inflammatory multifocal chorioretinopathy that predominantly affects young myopic women, appears to be relatively rare, but there are limited data to support accurate estimates of prevalence, and it is likely that the condition is underdiagnosed. The etiological relationship between PIC and other conditions within the "white dot syndromes" group remains uncertain. We, like others, would suggest that PIC and multifocal choroiditis with panuveitis represent a single disease process that is modified by host factors (including host immunoregulation) to cause the range of clinical phenotypes seen. The impact of PIC on the patient is highly variable, with outcome ranging from complete spontaneous recovery to bilateral severe sight loss. Detection and monitoring have been greatly facilitated by modern scanning techniques, especially optical coherence tomography and autofluorescence imaging and may be enhanced by coregistration of sequential images to detect change over time. Depending on the course of disease and nature of complications, appropriate treatment may range from observation to systemic immunosuppression and antiangiogenic therapies. PIC is a challenging condition where treatment has to be tailored to the patient's individual circumstances, the extent of disease, and the risk of progression.

Management of uveitis-related choroidal neovascularization: from the pathogenesis to the therapy

Inflammatory choroidal neovascularization is a severe but uncommon complication of uveitis, more frequent in posterior uveitis such as punctate inner choroidopathy, multifocal choroiditis, serpiginous choroiditis, and Vogt-Koyanagi-Harada syndrome. Its pathogenesis is supposed to be similar to the wet age related macular degeneration: hypoxia, release of vascular endothelial growth factor, stromal cell derived factor 1-alpha, and other mediators seem to be involved in the uveitis-related choroidal neovascularization. A review on the factors implicated so far in the pathogenesis of inflammatory choroidal neovascularization was performed. Also we reported the success rate of single studies concerning the therapies of choroidal neovascularization secondary to uveitis during the last decade: photodynamic therapy, intravitreal bevacizumab, and intravitreal ranibizumab, besides steroidal and immunosuppressive therapy. Hereby a standardization of the therapeutic approach is proposed.

Current and investigational pharmacotherapeutic approaches for modulating retinal angiogenesis

Retinal vascular development is a carefully orchestrated developmental process during which retinal and choroidal vasculature form to provide a dual vascular supply to the neurosensory retina and retinal pigment epithelium. The most common causes of vision loss in children and adults involve at least in part perturbation of the normal vascular physiology or development. Vascular endothelial growth factor has emerged as a key molecular regulator of retinal vascular development as well as retinal and choroidal neovascularization, which underlie the pathophysiology of many retinal diseases. Over the past decade, the advent of injectable pharmacotherapeutic agents into the vitreous cavity of the eye has revolutionized our management of neovascular age-related macular degeneration and other retinal diseases and has, for the first time, offered an opportunity to improve vision rather than just slow the progression of disease processes. The transient duration of these agents, however, requires chronic treatment with repeated intraocular injections and significant treatment burden for patients and the healthcare system. Novel treatments modulating retinal angiogenesis offer the promise of improved efficacy, decreased treatment burden and improved cost-effectiveness.

Gender differences in birdshot chorioretinopathy and the white dot syndromes: do they exist?

Inflammatory conditions that affect the posterior pole are diverse. Specifically, birdshot chorioretinopathy and the white dot syndromes present with multiple white dots in the fundus. These diseases appear to affect similar age groups but there is question as to whether or not a difference exists between the genders. This review summarizes the current studies on birdshot chorioretinopathy and the white dot syndromes as they are related to gender, exploring the differences, if any, which may exist between prevalence, clinical presentation, and treatment response for these diseases. Though the specific etiology of these diseases remains unclear, future treatments may be guided as to how these diseases affect the sexes differently.

Peripheral multifocal chorioretinitis: complications, prognosis and relation with sarcoidosis

PURPOSE

To investigate the prognosis and complications in patients with peripheral multifocal chorioretinitis (PMC). PMC is a posterior or panuveitis characterized by chronic bilateral vitritis and punched-out lesions in the peripheral retina which occurs commonly in elderly white women and is associated with sarcoidosis. Prognosis and complications are largely unknown.

METHODS

A structured literature search in PubMed, Embase and Cochrane was performed to identify relevant articles. Articles were screened, and the remaining articles were critically appraised based on relevance and validity.

RESULTS

The search yielded 267 articles. Eight relevant articles were retrieved. All studies reported on moderate visual impairment. Macular oedema occurred in 60% of the patients with PMC (range, 0-71%), glaucoma in 27% (range, 25-43%) and an epiretinal membrane in 21% (range, 0-28%). In total, 47% had proven or presumed sarcoidosis. Treatment usually comprised topical corticosteroids, periocular steroid injections and systemic corticosteroids regularly in combination with methotrexate.

CONCLUSION

The prognosis of patients with PMC is characterized by a rather poor visual outcome and the relatively high prevalence of complications. PMC is strongly associated with sarcoidosis. Solid proof for the treatment efficacy of PMC is lacking.

Effects of intravitreal bevacizumab on inflammatory choroidal neovascular membrane

purpose. To test the efficacy of intravitreal bevacizumab (IB) in the treatment of inflammatory choroidal neovascularization (CNV). 
Methods. A prospective interventional study on patients with subfoveal CNV secondary to posterior/diffuse uveitis treated with 1.5 mg/0.05 mL of IB. Eight eyes of 8 patients, with mean follow-up of 19.25±6 months, were included. The measurements adopted were 1) changes in best-corrected visual acuity (BCVA), 2) reduction in CNV size, and 3) changes in central foveolar thickness (CFT) measured by optical coherence tomography. 
Results. The mean number of intravitreal injections was 3.75±1.38. After IB treatment, the mean BCVA improved significantly, from 0.27±0.10 before treatment to 0.5±0.29 after treatment (p<0.05). The CFT also responded well to IB, with 402.75±114.11 µm preoperatively, and after treatment 300.5±90.98 µm (p<0.01). Notably, all patients showed a reduction in the size of the CNV and BCVA remained stable or improved in 7 eyes (87.5%). No episode of active intraocular inflammation was observed and patients continued to receive their systemic steroid or immunosuppressive therapy.
Conclusions. Intravitreal bevacizumab may be an additional strategy in inflammatory CNV of eyes with controlled uveitis.

[Punctate inner choroidopathy - Improvement in vision after anti-VEGF and photodynamic therapy. An 18-month follow-up control]

Punctate inner choroidopathy (PIC) is a rare disease which seems to have an inflammatory origin. Treatment is symptom-oriented and the development of choroidal neovascularization (CNV). If CNV is present the trend is towards the use of anti-VEGF (vascular endothelial growth factor) therapy. Oral therapy with steroids should be initially attempted.

Verteporfin PDT for non-standard indications--a review of current literature

BACKGROUND

Verteporfin photodynamic therapy (PDT) is approved for the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD), as well as for subfoveal CNV due to pathologic myopia and ocular histoplasmosis syndrome. Verteporfin PDT addresses the underlying pathology of ocular vascular disorders through its angio-occlusive mechanism of action, which reduces both visual acuity loss and the underlying leakage associated with lesions. Verteporfin PDT has also been associated with encouraging treatment outcomes in case studies involving patients with choroidal vascular disorders such as polypoidal choroidal vasculopathy, central serous chorioretinopathy, choroidal haemangioma, angioid streaks, and inflammatory CNV, i.e. conditions currently considered as non-standard indications of verteporfin PDT. In many studies, outcomes were better than expected based on the natural courses of each of these conditions. Although the anti-vascular endothelial growth factor (VEGF) therapies, ranibizumab and pegaptanib, have been approved for CNV due to AMD, their role in these other choroidal vascular disorders remains to be established. We summarize current literature that has documented the use of verteporfin PDT in these conditions.

CONCLUSIONS

The complex pathogenesis of CNV provides a rationale for investigating combination approaches comprising verteporfin PDT and anti-VEGF therapies. Randomized controlled studies are warranted to confirm the preliminary results of verteporfin PDT as a monotherapy or in combination with anti-VEGF therapies in the treatment of a variety of choroidal vascular conditions.

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.

Photodynamic Therapy for Subfoveal and Juxtafoveal Choroidal Neovascularization Associated with Punctate Inner Choroidopathy

PURPOSE

To evaluate the treatment of subfoveal and juxtafoveal choroidal neovascularization (CNV) using verteporfin photodynamic therapy (vPDT) in patients affected by punctate inner choroidopathy (PIC).

METHODS

A chart review of 8 patients with CNV associated with PIC treated with vPDT was done.

RESULTS

The 8 patients (8 eyes) included 4 men and 4 women with a mean age of 30.9 years. Six of them presented juxtafoveal CNVs, and two had subfoveal CNVs, at presentation. Mean follow-up time was 22.7 months. The VA improved in five eyes, and three eyes declined. One patient developed a new CNV a few days after vPDT, and one had multiple CNVs at presentation. Two of the 3 patients with longer follow-up period presented late recurrences.

CONCLUSIONS

vPDT is a beneficial resource in stabilizing and also improving VA in PIC patients affected with subfoveal and juxtafoveal CNV, although one third of the patients retain poor visual acuity.

Bevacizumab (avastin) and ranibizumab (lucentis) for choroidal neovascularization in multifocal choroiditis

BACKGROUND

Multifocal choroiditis (MFC) is an inflammatory condition, occasionally associated with choroidal neovascularization (CNV). Bevacizumab (Avastin) and ranibizumab (Lucentis) are therapies that target vascular endothelial growth factor. Bevacizumab and ranibizumab have been used successfully to treat CNV in age-related and myopic macular degeneration.

PURPOSE

: To describe the treatment of MFC-associated CNV with intravitreal bevacizumab and/or ranibizumab.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Six eyes of five patients with MFC-associated CNV were treated with intravitreal bevacizumab and/or ranibizumab.

MAIN OUTCOME MEASURES

Visual acuity at 1, 3, and 6 months after the initial injection.

RESULTS

Previous therapies (number of eyes treated) included sub-Tenon's corticosteroids (2), intravitreal corticosteroids (1), photodynamic therapy (1), and thermal laser (1). The mean number (range) of antivascular endothelial growth factor injections per eye was 2.3 (1-6). The mean duration (range) of follow-up per patient was 41.5 (25-69) weeks. Five of six eyes improved to 20/30 acuity or better at 6 months. One eye suffered a subfoveal rip of the retinal pigment epithelium with 20/400 acuity. There was a qualitative decrease in clinical and angiographic evidence of CNV.

CONCLUSIONS

Bevacizumab and ranibizumab were effective at improving visual acuity over 6 months in a small series of patients with MFC-associated CNV. Tears of the retinal pigment epithelium may occur after intravitreal antivascular endothelial growth factor therapy in MFC-associated CNV.

Bilateral choroidal neovascularization in birdshot retinochoroidopathy treated with intravitreal injections of triamcinolone and bevacizumab

PURPOSE

To describe a patient with birdshot retinochoroidopathy (BRC) with bilateral choroidal neovascularization (CNV) who was treated with intravitreal injection of bevacizumab and antiinflammatory medications.

METHOD

Interventional case report.

PATIENT

A 35-year-old woman with bilateral CNV associated with BRC.

RESULTS

The patient was treated with intravitreal injection of triamcinolone, photodynamic therapy, and intravitreal injection of bevacizumab in one eye, while the fellow eye was treated with intravitreal injection of triamcinolone. Immunosuppressive therapy was performed in the course of the treatment. Not only did the neovascularization respond, but the birdshot lesions vanished as well.

DISCUSSION

BRC can have secondary CNV that, as in the current case, responds favorably to treatment. We serendipitously observed regression of the choroidal inflammatory lesions with intravitreal injection of triamcinolone.

[White dot syndrome]

The white dot syndromes comprise a group of diseases with a suspected immunological background, which show no systemic manifestations. The characteristic inflammatory changes of the choroid and the retinal pigment epithelium are typically yellow-white foci beneath the retina. Diseases belonging to the white dot syndromes which will be discussed in this article are acute multifocal placoid pigment epitheliopathy (AMPPE), multiple evanescent white dot syndrome (MEWDS), birdshot retinochoroidopathy (BSRC), multifocal choroiditis with panuveitis (MFC/MCP), punctuate inner choroidopathy (PIC), acute zonal occult outer retinopathy (AZOOR) and serpiginous choroiditis, Neither the trigger mechanism nor the pathogenetic development is known with certainty for any of these diseases. Immunological reactions to previous viral infections coupled with a genetic predisposition seem to be a common denominator. Transitions between the individual diseases have also been described.

Ocular photodynamic therapy--standard applications and new indications (part 1). Review of the literature and personal experience

Ocular photodynamic therapy (PDT) was introduced as a novel treatment for neovascular forms of age-related macular degeneration and choroidal neovascularization (CNV) secondary to pathologic myopia in the mid/end 1990s. The current treatment recommendations are based on the results of two large, prospective, multicenter, randomized clinical trials (Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy Studies) and thousands of patients have been treated worldwide over the last years. Meanwhile, PDT has been performed in several other ocular pathologies with some remarkable results, however, with most reports being case reports and small case series without statistical significance. These extended applications include CNV secondary to choroiditis and retinochoroiditis, angioid streaks, central serous chorioretinopathy, retinal angiomatous proliferation, parafoveal telangiectasia or CNV associated with macular dystrophy and idiopathic CNV, as well as diseases without CNV, such as choroidal hemangioma, retinal hamartoma, choroidal melanoma, chronic central serous chorioretinopathy, angiomatous lesions secondary to systemic diseases, rubeosis iridis or neovascular glaucoma. To date, with the introduction of anti-VEGF therapy, the role of PDT will certainly change. However, it is reasonable to believe that it will maintain an important role in combination therapy due to its unique properties of selective vascular targeting. Therefore, it is essential for the ophthalmologist to be familiar with the extended applications and their modifications of treatment parameters. This review will summarize the standard and experimental applications of PDT based on our own results and the literature.

Intravitreal bevacizumab (avastin) for choroidal neovascularization secondary to central serous chorioretinopathy, secondary to punctate inner choroidopathy, or of idiopathic origin

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab in the treatment of idiopathic choroidal neovascularization (CNV) and CNV secondary to central serous chorioretinopathy (CSC) or punctate inner choroidopathy (PIC).

DESIGN

Prospective, nonrandomized, interventional case series.

METHODS

In an institutional clinical practice, 15 patients were recruited; nine had idiopathic CNV, two had CNV secondary to CSC, and four had CNV attributable to PIC. Patients received three monthly 1.25-mg intravitreal bevacizumab injections for three months. Patients were followed for six months, and the best-corrected visual acuity (BCVA), fluorescein angiography (FA) findings, and optical coherence tomography (OCT) central foveal thickness (CFT) were assessed.

RESULTS

At baseline, the mean logMAR BCVA was 0.48 (Snellen equivalent = 20/60). The mean logMAR BCVA improved significantly to 0.25 (Snellen equivalent = 20/36) and 0.17 (Snellen equivalent = 20/30) at one and six months, respectively (both P = .001). The mean OCT CFT reduced from 306 microm at baseline to 201 microm at six months (P < .001). All eyes (100%) had visual improvement of 1 line or more at six months, and 11 (73.3%) improved by 2 or more lines. FA showed absence of CNV leakage, the angiographic end point, at three months, and no recurrence was observed at six months in all eyes. No systemic or ocular adverse events were encountered.

CONCLUSIONS

Intravitreal bevacizumab injections resulted in visual and anatomic improvements in eyes with idiopathic CNV and CNV attributable to CSC or PIC. Further studies are warranted to assess the long-term safety and the regimen for optimal efficacy of intravitreal bevacizumab.

Two-year results of surgical removal of choroidal neovascular membranes related to non-age-related macular degeneration

PURPOSE

To present the 2-year outcomes of surgical removal of non-age-related macular degeneration (AMD)-related choroidal neovascular membranes and to evaluate any association between visual outcome and baseline clinical factors.

METHODS

Retrospective consecutive case series. All patients who had surgery for non-AMD-related choroidal neovascularisation (CNV) between November 1997 and March 2003 under the care of a single surgeon (WA) were included in the study. Baseline data including patient age, duration of subfoveal CNV, preoperative visual acuity (VA), lesion size, lesion components and aetiology were collected. The primary outcome was VA change with secondary outcomes retinal detachment, operative peripheral retinal break formation, CNV recurrence and cataract.

RESULTS

A total of 52 eyes were included in the study. The aetiology of CNV was: punctate inner choridopathy 21 (40%); idiopathic 8 (15%); pathologic myopia 6 (12%); ocular histoplasmosis syndrome 1 (2%); and other 16 (31%). The mean age of patients was 41(range 14-72) years. 24-month follow-up was available for 41 (80%) eyes. The mean logMAR equivalent baseline acuity was 1.1 and mean lesion size 1.2 disc areas. An improvement in VA >1 Snellen line was noted in 26 (63%) eyes, whereas 10 (24%) eyes remained the same (within 1 line) and 5 (12%) lost >1 line of acuity. Improvement in VA was associated with worse baseline VA (84% for eyes with VA <or=6/36 vs 31% for those with VA>6/36, p=0.001). No evidence of association between 2-year visual outcome and any other baseline factor under study was observed. Peripheral retinal breaks were noted in 5 (10%) eyes at the time of surgery, and 3 (5.8%) eyes developed postoperative retinal detachments. Persistent/recurrent CNV was noted in 17 (33%) eyes. The median time to presentation of CNV in these eyes was 27 (range 2-172) weeks. Five eyes underwent cataract surgery during the follow-up period. The mean age of these patients was significantly higher than the mean age of those who did not require cataract surgery (57 vs 37 years, p=0.014).

CONCLUSIONS

Surgical excision of non-AMD-related CNV resulted in improvement of VA in the majority of eyes. Worse presenting acuity was associated with better visual improvements.

Photodynamic therapy in subfoveal and juxtafoveal idiopathic and postinflammatory choroidal neovascularization

PURPOSE

To evaluate the efficacy of photodynamic therapy (PDT) in the treatment of idiopathic and inflammatory choroidal neovascularization (CNV).

METHODS

This study represents a non-randomized, multicentre, interventional case series. Sixteen eyes of 16 patients with classic or predominantly classic sub- and juxtafoveal idiopathic CNV and 26 eyes of 24 patients with classic or predominantly classic sub- and juxtafoveal CNV secondary to inflammatory conditions were treated with PDT with verteporfin. Best corrected visual acuity (BCVA) before and after PDT, the number of lines gained or lost and the number of PDT sessions were analysed.

RESULTS

The mean follow-up periods were 20 months (SD 11) and 16 months (SD 9) for the idiopathic and inflammatory groups, respectively. The mean BCVA in idiopathic CNV changed from 0.63 logMAR (SD 0.37) before treatment to 0.82 logMAR (SD 0.43) after treatment (p = 0.16; Student's t-test paired data). The number of treatments performed averaged 2.1 (range 1-4, SD 0.9). The mean BCVA in postinflammatory CNV changed from 0.60 logMAR (SD 0.4) before treatment to 0.57 logMAR (SD 0.6) after treatment (p = 0.79; Student's t-test paired data). The mean number of treatments was 2.6 (range 1-6, SD 1.2).

CONCLUSIONS

Photodynamic therapy with verteporfin may be useful in stabilizing BCVA in patients with sub- and juxtafoveal postinflammatory CNV and subfoveal idiopathic CNV.

Photodynamic therapy for subfoveal choroidal neovascularisation in Vogt-Koyanagi-Harada disease

AIM

To assess the effects of photodynamic therapy (PDT) with verteporfin in the treatment of subfoveal choroidal neovascularisation (CNV) secondary to Vogt-Koyanagi-Harada disease (VKH).

METHODS

Six eyes of six patients with VKH who developed subfoveal CNV underwent standard PDT. Repeated treatments were performed at 3 month intervals for persistent leakage. Charts and angiographic data were analysed retrospectively.

RESULTS

Age of patients ranged between 17 years and 27 years. Five CNV lesions were recent and classic (greatest lesion diameter was 1100-3100 microm). One CNV was chronic and partially scarred. Mean visual acuity (VA) at presentation was 20/200. Five patients had more than 1 year of follow up. In five eyes there was active inflammation and CNV. Of these eyes, the first three required one PDT each. The final CNV scar was smaller/stable with improvement of VA in two eyes. The third developed a larger CNV scar with loss of two lines of VA. Submacular fibrosis developed in all three. In the fourth eye, mild CNV leakage persisted after one PDT but hazy media precluded a second PDT. At 18 months the CNV scar and VA were stable. The fifth case, with mild inflammation, required three PDT. The CNV leakage became minimal, the lesion became smaller, and VA improved significantly. The sixth eye with CNV had no inflammation and needed two PDT sessions to halt the CNV leakage. The final lesion was smaller and vision was stable. There were no PDT related complications in our series.

CONCLUSION

Photodynamic therapy with verteporfin appears to be a safe and viable treatment option for subfoveal CNV secondary to VKH. It offers a chance for stabilisation or even improvement of vision. Further study is warranted.

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.

Photodynamic Therapy for Choroidal Neovascularisation Secondary to Inflammatory Chorioretinal Disease

Introduction: To review the long-term outcome of photodynamic therapy (PDT) with verteporfin for inflammatory chorioretinal disease with subfoveal choroidal neovascularisation (CNV) over a 1-year period. Materials and Methods: Retrospective review of eyes with subfoveal CNV for associated choroiditis that were treated with PDT using verteporfin over a 1-year period. Main outcome measure: visual acuity. Results: Five eyes in 4 patients, with diagnoses including serpiginous choroiditis (2), ocular histoplasmosis syndrome (OHS, 1), and punctate inner choroidopathy (PIC, 2) underwent standard treatment procedure for PDT with verteporfin. Visual acuity, fluorescein angiography and treatment parameters were reviewed. Follow-up ranged from 12 months to 36 months (median, 36 months). Pre-PDT visual acuities ranged from 20/60 to 20/400 (median, 20/200). Post-PDT visual acuities ranged from 20/30 to 20/400 at 1 year (median, 20/300). Visual acuity was stabilised (within 1 line) or improved (greater than 1 line) in 3 eyes at 1 year and 4 of the 5 eyes at last follow-up. Conclusion: PDT for subfoveal CNV may stabilise, but rarely improves, visual acuity in eyes with choroidal neovascularisation secondary to inflammatory chorioretinal disease. Key words: Choroidal neovascularisation, Choroiditis, Photodynamic therapy, Verteporfin

Photodynamic therapy for juxtafoveal choroidal neovascularization associated with multifocal choroiditis

PURPOSE

Evaluation of visual acuity outcome of photodynamic therapy (PDT) with verteporfin for juxtafoveal choroidal neovascularization (CNV) secondary to multifocal choroiditis (MC).

DESIGN

Open-label, prospective, interventional case series.

METHODS

Seven patients (seven eyes) diagnosed with juxtafoveal CNV associated with MC at the Eye Clinic of Trieste were considered. Inclusion criteria were the presence of juxtafoveal CNV no larger than 5400 microm in greatest linear dimension and best-corrected visual acuity (BCVA) (Snellen equivalent) of approximately 20/200 or better. PDT was performed according to the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) study. The primary outcome was the variation in Early Treatment Diabetic Retinopathy Study (ETDRS) charts visual acuity. In particular, the study considered changes of at least eight letters (approximately <1.5 lines of visual acuity loss) at the 12- and 24-month examinations compared with the baseline examination. Secondary outcomes included fluorescein angiographic features such as progression and area of CNV.

RESULTS

At both the 12- and 24-month examinations, three patients (43%) gained at least 1.5 lines of visual acuity, three patients (43%) did not show changes in either direction, whereas visual acuity decreased by 1.5 or more lines from baseline in one patient (14%). The median CNV area was 0.3 mm(2) at baseline and 0.24 mm(2) at the 12- and 24-month controls, respectively.

CONCLUSIONS

The positive results of the present study and the absence of treatment-related side effects suggest that PDT may be considered a safe and viable therapeutic option for juxtafoveal CNV for a 24-month period. Further studies including a greater number of patients are needed to confirm these preliminary results.

Photodynamic Therapy in Young Patients

BACKGROUND AND OBJECTIVE

To present a consecutive case series of patients 50 years or younger who underwent photodynamic therapy (PDT) for choroidal neovascularization (CNV) from etiologies other than age-related macular degeneration.

PATIENTS AND METHODS

Retrospective chart review of 35 consecutive eyes of 34 patients.

RESULTS

Visual acuity remained stable or improved in 20 of 35 eyes. Thirteen eyes with myopic degeneration had pre-treatment and post-treatment mean visual acuities of 20/100 and 20/200, respectively. Eight eyes with idiopathic CNV had an improvement of mean visual acuity from 20/200 to 20/125. Six eyes with ocular histoplasmosis displayed a stable mean visual acuity of 20/50. Of 3 eyes with angioid streaks, visual acuity remained stable in 2 eyes and declined in 1 eye. Five eyes with other etiologies all had improved vision.

CONCLUSION

Although the current literature shows evidence that PDT is beneficial in treating CNV secondary to myopic degeneration, the evidence for etiologies such as idiopathic causes, ocular histoplasmosis, and angioid streaks is optimistic but remains unproven. Our study suggests that PDT may be beneficial in stabilizing and improving vision when treating CNV from these etiologies.

Outcomes after combination photodynamic therapy and immunosuppression for inflammatory subfoveal choroidal neovascularisation

AIM

To report the visual and angiographic outcomes after combination photodynamic therapy (PDT) and immunosuppression for inflammatory subfoveal choroidal neovascularisation (CNV).

METHODS

Retrospective review of six consecutive patients, five female and one male, aged 23-40 years with active subfoveal CNV secondary to posterior uveitis. Patients received either intravitreal triamcinolone or systemic immunosuppression (mycophenolate mofetil, tacrolimus) and PDT. Five patients had intravitreal triamcinolone injections and two patients were on systemic immunosuppression; all patients underwent PDT (mean two treatments). Visual acuity was measured on a 2 metre ETDRS chart and fluorescein angiograms were performed at each visit.

RESULTS

Median follow up was 15 months (range 10-31). Vision improved by a median of 13 letters in five patients and remained stable (+/-1 letter) in one patient. Median visual acuity improved from 20/160 at presentation to 20/40 at latest follow up (p=0.03). There was a reduction in clinical exudation and cessation of angiographic leakage in all six patients. All interventions were well tolerated.

CONCLUSION

Combination PDT and immunosuppression may be a useful therapeutic option for young patients with active inflammatory subfoveal CNV.

Subretinal neovascular membranes complicating uveitis: frequency, treatments, and visual outcome

PURPOSE

Retrospective evaluation in a uveitic population of subretinal neovascular membranes (SRNMs), their occurrence, visual impact, and outcome in differently treated subgroups of patients.

METHODS

Medical records of patients were reviewed and cases with SRNM (n = 12) identified. Intraocular inflammation was classified according to vitreous examination records as high (2+ cells), low (1/2+ to 1+ cells), or inactive (0 cells). Visual outcome was considered to be +VA (same or gain of one or more Snellen lines) or -VA (loss of Snellen lines). In nine cases, treatment consisted of the oral administration of high doses of corticosteroids (CST) for one month, tapered down in favorable situations (+VA or SRNM angiographic regression) or maintained at half the dose in unfavorable situations (-VA or SRNM angiographic progression) while additional laser therapies, including photodynamic therapy (PDT), transpupillary thermotherapy (TTT), or argon laser therapy (CLT)), were performed in some of the cases. The above treatment scheme was not applied in three cases (pre-PDT period; undiagnosed underlying uveitis treated without CST).

RESULTS

Twelve out of 648 patients (1.9%) with uveitis developed SRNM. The mean visual impact was 4.5 Snellen lines and mean follow-up time was 19.5 months. Two patients with high intraocular inflammation had a favorable visual outcome with CST alone. Eight patients with low intraocular inflammation had a favorable visual outcome with CST alone in three cases, with additional laser therapy in four cases (PDT in 3 cases and TTT in 1 case), and exclusively with PDT in one case (undiagnosed uveitis). Two patients with no intraocular inflammation had unfavorable visual outcome with CST alone (no PDT/TTT available).

CONCLUSION

SRNMs occurred as a rare complication of uveitis. Their visual outcome was relatively favorable. Although high doses of CST seem to be the first step in the management of SRNMs, alternative laser treatments should be considered early, especially in cases of absence or low intraocular inflammation.

Photodynamic therapy for inflammatory choroidal neovascularisation unresponsive to immunosuppression

AIM

To report on visual and angiographic outcomes of a consecutive series of patients with inflammatory choroidal neovascular membranes (CNV) unresponsive to systemic immunosuppression treated with photodynamic therapy (PDT).

METHODS

The medical records of six consecutive patients with inflammatory CNVs that failed to respond to systemic immunosuppression and that later underwent PDT were retrospectively reviewed. Patient demographics, visual acuity, and fluorescein angiographic findings were evaluated.

RESULTS

There were five females and one male with a mean age of 40.8 years (range 35-58 years). Four patients had clinical features consistent with punctate inner choroidopathy and two with presumed ocular histoplasmosis. In all cases clinical signs of CNV activity, including subretinal fluid, subretinal blood, hard exudates, and/or recent decrease in visual acuity were present prior to PDT. All patients had been treated with high dose systemic immunosuppressants, which failed to induce regression of the CNV and/or to improve vision. The CNVs were subfoveal in five patients and juxtafoveal in one; all were classified as predominantly classic. Following PDT an improvement in vision occurred in all cases (median improvement of 18 letters, range 3-42 letters). At last follow up, signs of decreased activity in the CNV were detected in all cases. Patients were followed for a median of 10 months (range 9-20 months).

CONCLUSION

PDT appears to be a useful option in the management of patients with inflammatory CNVs unresponsive to immunosuppressive therapies.

Severe pigment epithelial alterations in the treatment area following photodynamic therapy for classic choroidal neovascularization in young females

PURPOSE

Although photodynamic therapy (PDT) is an established treatment for choroidal neovascularization (CNV), the mechanisms are still not completely elucidated. Damage to the retinal pigment epithelium (RPE) was observed following uncomplicated PDT in young patients.

DESIGN

Observational case series.

METHODS

Four female patients between the age of 26 and 39 years presented with visual loss because of classic CNV. In two 39 years old females the CNV originated secondary to a small chorioretinal scar, in a 26 and a 36-year-old woman the CNV was of idiopathic cause. All patients received standard PDT according to the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study protocol.

RESULTS

One to three months after an uncomplicated PDT with verteporfin, severe pigment epithelial alterations in the treatment area were observed. The neovascular membranes responded favorably to the treatment and demonstrated fibrosis and resolution of leakage. Ophthalmoscopically and angiographically, atrophy of the retinal pigment epithelium was seen precisely delineating the size of the treatment spot used. Vision declined in two patients from 0.3 to 0.1 and 0.15 to 0.1. The two other patients demonstrated an increase of visual acuity from 0.7 to 0.9 and from 0.4 to 0.9. The retinal pigment epithelium alterations did not resolve during follow-up, but remained unchanged in area and intensity.

CONCLUSIONS

Characteristic retinal pigment epithelium alterations were observed in young female patients with small classic CNV following PDT. Unusual retinal pigment epithelium damage in young female patients without any associated disease might be related to a possible inherent defect in the RPE or to the hormonal status of this specific patient population.

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization associated with multifocal choroiditis

PURPOSE

Evaluation of visual acuity outcomes of photodynamic therapy with verteporfin for subfoveal choroidal neovascularization (CNV) secondary to multifocal choroiditis.

DESIGN

Open-label, prospective, interventional case series.

METHODS

Thirteen patients (13 eyes) diagnosed with subfoveal CNV associated with multifocal choroiditis at the Eye Clinics of Trieste and Udine were considered for the study. Inclusion criteria were the presence of subfoveal CNV no larger than 5,400 microm in greatest linear dimension and best-corrected visual acuity, Snellen equivalent, of approximately 20/400 or better. The primary outcome was the number of eyes that had fewer than 8 letters lost (less than approximately 1.5 lines) at the 12-month examination compared with the baseline examination. Secondary outcomes included fluorescein angiographic features such as progression and CNV size.

RESULTS

Baseline and final best-corrected visual acuity were 0.52 logarithm of the minimal angle of resolution (20/62(-2) Snellen equivalent) and 0.55 logarithm of the minimal angle of resolution (20/62(-2) Snellen equivalent), respectively. By the 12-month visit, one patient (7.7%) had gained at least 1.5 lines, two patients (15.4%) had lost 1.5 or more lines, and no patient lost 3 or more lines of visual acuity, whereas 10 patients (84.6%) showed less than 1.5-line change. Mean CNV area was 0,69 mm(2) and 0.63 mm(2) at baseline and at the 12-month visit, respectively. By the month 12 examination, patients had received an average of 1.7 treatments.

CONCLUSIONS

Photodynamic therapy may be considered a viable therapeutic option for subfoveal CNV associated with multifocal choroiditis at least for a 1-year period. Further studies with longer follow-up are needed to confirm these results.

PHOTODYNAMIC THERAPY AND VITELLIFORM LESIONS

PURPOSE

To investigate the effect of photodynamic therapy (PDT) with verteporfin on patients with vitelliform lesions caused by cuticular drusen or adult-onset foveomacular vitelliform dystrophy (AOFVD).

DESIGN

Observational case series.

PATIENTS AND METHODS

Eight eyes of seven patients from two centers were examined prospectively. Each patient received PDT with verteporfin applied to the vitelliform lesions.

RESULTS

Photodynamic therapy did not significantly affect the median visual acuity outcome (20/50 before PDT and 20/66 after PDT) in all seven treated patients. Of note, however, were four eyes of four patients who experienced a severe decrease in visual acuity after PDT with verteporfin. The temporary relationship of the vision loss to the treatment suggests that this may represent an adverse effect from therapy. The fluorescein angiographic appearance was virtually unchanged in all treated patients, whereas indocyanine green angiography showed typical PDT-associated reduction of choroidal perfusion in the treatment area.

CONCLUSION

Photodynamic therapy does not have a positive influence on the visual outcome in patients with vitelliform lesions and may have a negative impact on vision in some treated patients. It is important for physicians using PDT to exercise caution in distinguishing between choroidal neovascular membranes and vitelliform lesions because the outcome in this latter group may be worse with application of PDT than with the natural course.

The white dot syndromes

PURPOSE

To review the distinctive and shared features of the white dot syndromes, highlighting the clinical findings, diagnostic test results, proposed etiologies, treatments, and prognosis.

DESIGN

Review.

METHODS

Review of the literature.

RESULTS

Common white dot syndromes are reviewed, including acute posterior multifocal placoid pigment epitheliopathy, birdshot chorioretinopathy, diffuse unilateral subacute neuroretinitis, multiple evanescent white dot syndrome, multifocal choroiditis with panuveitis, serpiginous choroiditis, and acute zonal occult outer retinopathy.

CONCLUSIONS

The white dot syndromes are a group of disorders characterized by multiple whitish-yellow inflammatory lesions located at the level of the outer retina, retinal pigment epithelium, and choroid. For clinicians and researchers alike, they present significant diagnostic and therapeutic challenges.