Indocyanine green-mediated photothrombosis with and without intravitreal triamcinolone acetonide for subfoveal choroidal neovascularization in age-related macular degeneration: a pilot study

Surgical implantation of steroids with antiangiogenic characteristics for treating neovascular age-related macular degeneration

BACKGROUND

Neovascular age-related macular degeneration (AMD) is associated with rapid vision loss due to choroidal neovascularization (CNV), leakage, and scarring. Steroids have gained attention in their role for the treatment of neovascular AMD for their antiangiogenic and anti-inflammatory properties.

OBJECTIVES

This review aims to examine effects of steroids with antiangiogenic properties in the treatment of neovascular AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 11), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2012), EMBASE (January 1980 to November 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to November 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 November 2012.

SELECTION CRITERIA

We included randomized controlled clinical trials of intra- and peri-ocular antiangiogenic steroids in people diagnosed with neovascular AMD.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts and full-text articles, assessed risk of bias in the included trials, and extracted data. We did not conduct a meta-analysis.

MAIN RESULTS

We included three trials after screening a total of 1503 abstracts and 21 full-text articles. The three trials included a total of 809 participants. One trial compared different doses of acetonide anecortave acetate with placebo, a second trial compared triamcinolone acetonide versus placebo, and the third trial compared anecortave acetate against photodynamic therapy (PDT). We did not conduct a meta-analysis owing to heterogeneity of interventions and comparisons. The risk ratio for loss of 3 or more lines of vision at 12 months follow-up was 0.8 (95% confidence interval (CI) 0.45 to 1.45) with 3 mg anecortave acetate, 0.45 (95% CI = 0.21 to 0.97) with 15 mg anecortave acetate, 0.91 (0.52 to 1.58) with 30 mg anecortave acetate, 0.97 (95% CI 0.74 to 1.26) with triamcinolone acetonide, all compared to placebo and 1.08 (95% CI 0.91 to 1.29) with anecortave acetate compared with PDT.

AUTHORS' CONCLUSIONS

Based on the included trials, we found no evidence that antiangiogenic steroids prevent visual loss in patients with neovascular AMD. With the emergence of anti-vascular endothelial growth factor modalities, based on evidence summarized in this review, it is unclear what role steroids have in treating patients with neovascular AMD.

Vasoproliferative retinal tumor treated with indocyanine green-mediated photothrombosis

PURPOSE

To assess the efficacy of indocyanine green-mediated photothrombosis (ICGMP) in the treatment of large vascular lesions, and in particular of a 6-mm large, actively exudating vasoproliferative retinal tumor (VPRT).

METHODS

Thirty minutes after the administration of a loading dose of 1 mg/kg of intravenous ICG multiple, confluent, 2 mm wide, infrared 810 nm diode laser spots were applied on the surface of the tumor. Duration of each spot was 60 seconds, and the power chosen was 400 mW. A subTenon injection of 40 mg triamcinolone suspension was administered immediately after treatment.

RESULTS

No change in tumor aspect was observed after treatment. ICG late images were taken, showing no perfusion of the lesion. Two weeks after treatment the lesion was remarkably reduced in volume, but residual perfusion on ICG was observed. A second treatment with three laser spots on the diffusion site under the same modalities was performed. After the second treatment a complete obliteration of the lesion could be observed. In the original tumor site patchy retinal pigment epithelium atrophy and hyperplasia appeared. A diffuse, gradual, complete resolution of the exudates is now apparent at the fundus. Vision has slightly improved to 20/100. Follow-up has reached 2 years.

CONCLUSION

In the presented case ICGMP achieved complete obliteration of a large VPRT. To our knowledge, this is the first VPRT successfully treated with ICGMP, and the largest retinal vascular lesion treated with laser technique reported in the literature. ICGMP is less invasive than cryotherapy and less expensive than recently proposed photodynamic therapy. It may deserve further study in the treatment of selected retinal vascular tumors.

Surgical implantation of steroids with antiangiogenic characteristics for treating neovascular age-related macular degeneration

BACKGROUND

Neovascular age-related macular degeneration (AMD) is associated with rapid vision loss due to choroidal neovascularization (CNV), leakage, and scarring. Steroids have gained attention in their role for the treatment of neovascular AMD for their antiangiogenic and anti-inflammatory properties.

OBJECTIVES

This review aims to examine effects of steroids with antiangiogenic properties in the treatment of neovascular AMD.

SEARCH STRATEGY

We searched for trials in CENTRAL, MEDLINE, EMBASE, and LILACS on 2 October 2006.

SELECTION CRITERIA

We included randomised controlled clinical trials of intra- and peri-ocular steroids in people diagnosed with neovascular AMD.

DATA COLLECTION AND ANALYSIS

Review authors extracted the data and assessed trial quality independently. We did not pool data since the included studies evaluated difference comparisons.

MAIN RESULTS

We report the risk of losing three or more lines vision at 12 months - "vision loss". One trial (139 people randomized) reported that a single dose of intravitreal triamcinolone (n = 75) (4 mg) had no significant effect on the risk of vision loss compared to placebo (n = 76). (Risk ratio vision loss 0.97, 95% confidence interval (CI) 0.74 to 1.26). Eyes treated with triamcinolone were more likely to develop cataracts and experience increased intraocular pressure (IOP) compared to untreated eyes. One trial (128 people randomized) reported the effects of anecortave acetate (3 mg (n = 32), 15 mg (n = 33) or 30 mg (n = 33) single dose with retreatment every six months if indicated) compared to placebo (n = 30). Risk ratio vision loss 0.80 (95% CI 0.45 to 1.45) in the 3 mg group, 0.45 (95% CI 0.21 to 0.97) in the 15 mg group and 0.91 (95% CI 0.52 to 1.58) in the 30 mg group. Side effects were similar in all treatment groups with the anecortave group having a slightly higher incidence of foreign body sensation compared to placebo. There was a high loss to follow-up. The final analysis may have been subject to selection bias as participants who were not selected for retreatment, possibly with worsening disease, were excluded. There was also a possibility of type I error due to multiple statistical comparisons. The sample size was estimated on the basis of a single 2-way comparison but three 2-way comparisons were analysed and presented. One trial reported that anecortave acetate (n = 263) (15 mg administered at beginning of study and six months) gave similar results to photodynamic therapy (n = 267) (risk ratio vision loss 1.08, 95% CI 0.91 to 1.29).

AUTHORS' CONCLUSIONS

Overall there is weak evidence as to the benefits and harms of steroids with antiangiogenic properties for treating neovascular AMD with only three published trials of variable quality. Intravitreal triamcinolone injection for neovascular AMD does not appear to prevent severe vision loss and is associated with increased IOP and higher risk of cataract formation. Anecortave acetate 15 mg may have a mild benefit in stabilizing vision, but further better quality evidence is needed. The role of steroids in combination with other treatment modalities is yet to be determined.

Indocyanine-green-mediated photothrombosis (IMP) with intravitreal triamcinolone acetonide for macular edema secondary to group 2A idiopathic parafoveal telangiectasis without choroidal neovascularization: a pilot study

BACKGROUND

The purpose of this study was to determine the feasibility, safety and clinical effect of indocyanine green (ICG)-mediated photothrombosis (IMP) combined with intravitreal triamcinolone acetonide (IVTA) in patients with macular edema secondary to idiopathic parafoveal telangiectasis (IPFT) group 2A without choroidal neovascularization (CNV).

METHODS

Nine eyes of six patients that were treated with IMP immediately followed by IVTA at a dose of 4 mg participated in the study. Patients had a mean follow-up of 23.3 months (range 12-36 months). Patients underwent one or two sessions of IMP combined with IVTA ("study group"). An IVTA-only group of 19 eyes from 14 patients with macular edema secondary to IPFT group 2A that underwent an IVTA 4 mg without IMP ("IVTA-only group") was included for comparison. In addition, a matched control group of 40 eyes from 20 patients selected retrospectively from our medical records with macular edema secondary to IPFT group 2A without any therapy was included ("observation group").

RESULTS

The best-corrected visual acuity (BCVA) remained stable in five eyes (55.5%). Four eyes (44.4%) demonstrated improvement of BCVA (> or = two ETDRS lines), and no eyes experienced worsening of visual acuity (> or = two ETDRS lines). A significant decrease in hyperfluorescence was not seen with fluorescein angiography (FA), however optical coherence tomography (OCT) showed a decrease in the size of inner intraretinal hyporeflective spaces or cystic edema. Two (22.2%) eyes developed an increase in intraocular pressure. However, it was medically controlled with topical anti-glaucoma medications. Cataract developed in five eyes (55.5%). Six of nine eyes (66.6%) required one retreatment during the study period. At the last follow-up (mean 21.1 months, range 12-30 months) in the IVTA-only group, 5 (25.3%) eyes improved BCVA, 11 (57.9%) eyes remained within two lines of baseline BCVA and 3 (15.8%) eyes lost BCVA. In the observation group, with similar follow-up, 87.5% of eyes showed either stabilization or deterioration of BCVA over time.

CONCLUSIONS

Combined IMP and IVTA may provide stability or improvement in BCVA and fundus findings in eyes with macular edema secondary to IPFT group 2A without CNV at a minimum follow-up of 12 months.

Types of choroidal neovascularisation in newly diagnosed exudative age-related macular degeneration

AIM

To describe the types and location of choroidal neovascularisation (CNV) in exudative age-related macular degeneration (AMD), including vascularised pigment epithelial detatchments (PED), and most recently described subtypes, such as retinal choroidal anasmostosis, also termed "retinal angiomatous proliferation" (RAP).

METHODS

Prospective multicentre consecutive descriptive case series. A total of 207 consecutive cases of newly diagnosed exudative AMD undergoing fluorescein angiography (FA) were recruited by 7 French referral hospital-based or private centres. Indocyanine green angiography (ICG) also was performed, when judged necessary by investigators. Types and location of CNV were classified by two independent experts and adjudicated by a third when discordant.

RESULTS

All patients had FA, while ICG was performed in 50% of subjects. A total of 17.6% had classic CNV only, 5.4% and 8.3% had predominantly and minimally classic CNV, respectively. Occult CNV could be classified in occult CNV without PED (32.7%) and occult CNV with PED, ie, vascularised PED (23.9%). RAP was observed in 15.1% of cases, and accounted for 30% of vascularised PED. In 5.8% of the cases there was haemorrhagic AMD and 4.8% had fibrovascular scars. Lesions were mainly subfoveal (80%). Agreement between the centre's ophthalmologist and the final validated expert classification was moderate (kappa = 0.52 for location and 0.59 for type of lesion).

CONCLUSION

This study confirms that newly diagnosed cases of exudative AMD are mainly occult and subfoveal. RAP appeared as a common lesion in patients with newly diagnosed exudative AMD.