Trans-Tenon's retrobulbar triamcinolone infusion for myopic choroidal neovascularization

Vision Preservation in Eyes of Polypoidal Choroidal Vasculopathy with Low-Dose Intravitreal Triamcinolone Acetonide

PURPOSE

To evaluate the efficacy and adverse effects of using low-dose intravitreal triamcinolone acetonide (IVTA) to preserve vision in polypoidal choroidal vasculopathy (PCV) eyes.

METHODS

This retrospective chart review study examined 8 eyes of 7 PCV patients, for whom verteporfin photodynamic therapy (vPDT) or antivascular endothelial growth factor (VEGF) therapy was not affordable/available and also with intolerable risk because of underlying cardiovascular and/or cerebrovascular ischemia. Low-dose IVTA (1 mg/0.025 mL) monotherapy was administered and repeated every 4 weeks if intraretinal edema or subretinal fluid persisted.

RESULTS

The median follow-up time was 26.4 months. Three eyes (3/8) maintained their initial best-corrected visual acuity and 4 eyes (4/8) exhibited improvement, whereas 1 eye (1/8) sustained some loss. The mean injection number per month was 0.7 for the first 6 months, after which it decreased to 0.4. In regard to adverse effects, intraocular pressure (IOP) of more than 21 mmHg was noted as persisting for a few weeks in 4 eyes and that of more than 30 mmHg was noted once in 1 eye. The increased IOP was adequately controlled by using IOP-lowering agents. Two initially phakic eyes each underwent cataract surgery in the 12th and 14th months after treatment.

CONCLUSIONS

Low-dose IVTA therapy may be valuable for preserving the vision of PCV patients, while vPDT or anti-VEGF is not affordable/available or of those with underlying diseases for whom anti-VEGF therapy is with intolerable risk.

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

PURPOSE

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

DESIGN

Retrospective observational case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Repeated triamcinolone acetonide injection in the treatment of upper-lid retraction in patients with thyroid-associated ophthalmopathy

OBJECTIVE

To evaluate the efficacy and safety of repeated subconjunctival injections of triamcinolone in the treatment of upper-lid retraction with thyroid-associated ophthalmopathy.

DESIGN

Interventional controlled retrospective clinical study.

PARTICIPANTS

We studied 23 eyes in 15 patients as the nontreatment control group and 35 eyes in 21 patients as the treatment group.

METHODS

In the treatment group, triamcinolone acetonide was subconjunctivally injected into each lid as 4 doses of 20 mg at 1-month intervals. After the treatment, the eyes were divided into 2 groups, response and nonresponse, based on the improvement in margin reflex distance. The eyes of the nontreatment group received no medicine. The eyes were examined regularly.

RESULTS

The rate of spontaneous improvement in the nontreatment group was 17.4%. The mean rate of effectiveness was 68.6%. The improvement of upper-lid retraction was 2.31 mm (0 to 7 mm). The margin reflex distance was significantly smaller at 1 month after the initiation of treatment. Mean lid retraction time before treatment was 4.58 months in the response group versus 9.91 months in the nonresponse group. In the eyes presenting upper-lid retraction up to 6 months before treatment was initiated, the response rate was 83.3%. The response rate was only 36.4% when lid retraction developed more than 6 months before the procedure. The muscle thickness of the levator/superior rectus complex was significantly reduced after treatment in the response group (5.13 ± 0.85 mm at last follow-up vs. 5.69 ± 0.93 mm at baseline).

CONCLUSIONS

Repeated subconjunctival injection of triamcinolone is an effective and safe treatment for upper-lid retraction due to thyroid-associated ophthalmopathy.

Choroidal neovascularization in pathological myopia

Myopic choroidal neovascularization (CNV) is one of the leading causes of visual impairment worldwide. The clinical and socioeconomic impact of myopic CNV in Asian countries is particularly significant due to rising trend in the prevalence and severity of pathological myopia. The exact pathogenesis of myopic CNV remains unclear and there is paucity of information with respect to incidence and risk factors for myopic CNV from prospective studies. Furthermore, there are no recognized measures that may prevent or delay the development of CNV in eyes with pathological myopia. Advances have been made in the diagnosis and characterization of myopic CNV over the years. Until recently, treatment modalities for myopic CNV were limited to thermal laser photocoagulation and photodynamic therapy with verteporfin, both these modalities primarily aim at prevention of further visual loss. In the last 5 years, inhibitors of vascular endothelial growth factor (VEGF) have been used successfully and may improve vision to some extent. Nevertheless, the long-term safety and efficacy of anti-VEGF agents remains unknown. Furthermore, the risk of developing chorioretinal atrophy remains the key factor in determining the final visual outcome. This review article summarizes the current literature on myopic CNV, highlighting new evolving diagnostic and treatment modalities, prognostic factors influencing visual outcome, and areas of future research.

Characteristics of periconus choroidal neovascularization in pathologic myopia

PURPOSE

To examine the clinical characteristics of periconus choroidal neovascularizations (CNVs) in eyes with pathologic myopia.

DESIGN

Retrospective observational case series.

METHODS

We reviewed the medical records of 260 eyes of 254 patients with a myopic CNV and selected those with a periconus CNV. A periconus CNV was defined as a CNV that is located next to a myopic conus. To differentiate a periconus CNV from a subfoveal CNV that has expanded to the edge of the disc, eyes whose CNV involved the fovea were excluded. The data of the eyes with a subfoveal CNV were used for comparison.

RESULTS

Eleven eyes (4.2%) of 11 patients had a periconus CNV. These CNVs had a triangular or oval shape whose base was directed toward the myopic conus. The eyes with a periconus CNV had a significantly larger myopic conus than eyes with a subfoveal myopic CNV. The degree of myopia and axial length were not significantly associated with the incidence of periconus CNV. In 5 of the 11patients, the periconus CNV had a spontaneous regression without treatment, and none had a recurrence. The other 6 patients received treatment and obtained an angiographic closure after a single treatment. A chorioretinal atrophy (ChRA) developed in 3 eyes, and the ChRA enlarged over the fovea in 2 of these eyes, which led to a significant decrease of vision.

CONCLUSION

A periconus CNV is rare (4.2%) among the eyes with a myopic CNV and is more likely to develop in eyes with a large myopic conus. The absence of a significant association between the degree of myopia and incidence of periconus CNV suggests that the morphologic characteristics of the eye are not the causes of the periconus CNV. Although an angiographic closure can be easily attained with or without the treatment, the later development and progression of ChRA can impair vision.

Two-year visual results for older Asian women treated with photodynamic therapy or bevacizumab for myopic choroidal neovascularization

PURPOSE

To compare the long-term visual and anatomic outcome of treatment with photodynamic therapy (PDT) or intravitreal bevacizumab (IVB; Avastin; Genentech Inc, South San Francisco, California, USA) for choroidal neovascularization attributable to pathologic myopia (mCNV).

DESIGN

An open-label, interventional case series.

METHODS

SETTING

Multi-institutional.

PATIENTS

Thirty-one eyes of Japanese women who received either PDT or IVB for mCNV. Inclusion criteria were age 50 years or older, greatest linear dimension (GLD) 1200 to 3000 microm, and baseline best-corrected visual acuity (BCVA) 20/200 to 20/40. INTERVENTION PROCEDURES: Patients received either PDT or IVB (1 mg/40 microL) throughout the study, with re-treatment when necessary.

MAIN OUTCOME MEASURES

BCVA and visual gain/loss at 3, 6, 12, 18, and 24 months after the initial treatment.

RESULTS

Age, BCVA, location of CNV, refractive error, and symptom duration at baseline did not differ significantly between groups. BCVA was significantly improved at 3 to 12 months (P < .05); however, the significance was lost at 18 and 24 months in the IVB group. The PDT group showed no significant improvement within the first year, and vision slowly worsened after 12 months, becoming significantly worse at 18 and 24 months compared to baseline (P< .01). BCVA was significantly higher in the IVB group at 6 months (P< .05), and 12 months or further (P < .01). Visual gain was significantly greater in the IVB group at 6, 12, 18, and 24 months (P < .05 for 6, 18, and 24 months and P < .01 for 12 months).

CONCLUSIONS

These findings indicate that the effects of PDT and IVB have a different time course, and that IVB provides a significantly better BCVA than PDT for mCNV over the long-term.

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

PURPOSE

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

DESIGN

Retrospective, comparative, interventional case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Marginal crack after intravitreal bevacizumab for myopic choroidal neovascularization

PURPOSE

To report new indocyanine green angiographic (ICGA) findings after intravitreal bevacizumab (IVB) for myopic choroidal neovascularization (mCNV).

CASES REPORT

Three eyes of three patients with mCNV were examined with fluorescein angiography (FA) and ICGA using Heidelberg Retinal Angiograph 2 and the conventional fundus camera before and after IVB. The cessation of angiographic leakage on FA was achieved in all eyes (100%) after IVB, however the hypofluorescent line delineating the margin of the neovascular tissue appeared in ICGA seemingly according to the contraction of mCNV. It was not detected either on FA or ICGA with the conventional camera. This hypofluorescence line enlarged over the time.

CONCLUSION

The contraction-associated hypofluorescence line, namely marginal crack line, indicates the early damage of retinal pigment epithelium and seems to lead to expanding macular chorioretinal atrophy typically seen in mCNV.

Central retinal sensitivity after intravitreal injection of bevacizumab for myopic choroidal neovascularization

PURPOSE

To evaluate retinal sensitivity in the macular area after intravitreal injection of bevacizumab in eyes with myopic choroidal neovascularization (mCNV).

DESIGN

Prospective interventional case series.

METHODS

Twenty-two eyes of 21 patients with mCNV were treated with intravitreal injections of bevacizumab. Microperimetry in the macular area was performed with a Micro Perimeter-1 (Nidek, Vigonza, Italy) before, and at 1 month and 6 months after treatment.

RESULTS

After treatment, visual acuity (VA) and central retinal sensitivity were improved significantly. Mean VA in logarithm of the minimal angle of resolution (logMAR) fashion improved from 0.67 +/- 0.34 to 0.43 +/- 0.33 at 1 month, and to 0.34 +/- 0.26 at 6 months [P < .01, respectively]. Mean retinal sensitivity within the central 10 degree field improved from 4.8 +/- 2.8 decibels (dB) to 6.5 +/- 3.2 dB at 1 month and to 7.4 +/- 4.4 dB at 6 months [P < .01, respectively]. These improvements were more prominent in eyes with juxtafoveal mCNV than in eyes with subfoveal mCNV. With treatment, the mean number of measurement points within the scotomas decreased significantly; the absolute scotoma was reduced substantially in 15 (68%) eyes at 6 months. Unfortunately, the absolute scotoma was significantly enlarged in 1 eye (5%) at 1 month and in 4 eyes (18%) at 6 months. Also at 6 months, chorioretinal atrophy had developed in the macular area in 4 eyes (18%).

CONCLUSIONS

Although intravitreal injection of bevacizumab improved retinal sensitivity in the macular area, some eyes showed enlargement of the scotoma after this treatment.

Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy

PURPOSE

In this study, we aimed to evaluate the efficacy of peribulbar triamcinolone injections to treat inflammatory signs of Graves' ophthalmopathy (GO) in patients with moderate to severe GO and associated optic neuropathy (ON).

METHODS

Twenty-one patients with active GO [clinical activity score (CAS) > or = 4] and systemic thyroid disease under control were enrolled in this prospective pilot study. Peribulbar triamcinolone acetonide was injected in each orbit (42 eyes), in four doses of 20 mg at 2-week intervals. Ophthalmological examination including CAS evaluation, visual field, computerized tomography (CT) scan and digital photography were performed before and after treatment.

RESULTS

Twenty-one patients (11 with moderate disease, 10 with ON) were enrolled in this study and followed for at least 14 months. Initial mean CAS was 6.38 +/- 1.49, which dropped to 1.8 +/- 1.12 after 6 months of treatment (P = 0.01; mean difference of 4.57 +/- 1.56; range 1-8 score points). ON was diagnosed in 10 patients. Of these, 66% improved with peribulbar triamcinolone exclusively. A transitory increase in intraocular pressure in two patients was controlled with topic medication.

CONCLUSION

Peribulbar triamcinolone injections reduce the inflammatory signs of moderate GO, as measured by the CAS, and could also be used as an alternative treatment for ON. Randomized clinical trials are needed to compare the results of triamcinolone peribulbar injections to those of other treatment modalities.

Intravitreal bevacizumab for choroidal neovascularization attributable to pathological myopia: one-year results

PURPOSE

To assess the potential effect of intravitreal bevacizumab (IVB) (Avastin) on retinal function and anatomic recovery in eyes with choroidal neovascularization attributable to pathological myopia (mCNV).

DESIGN

Retrospective case series.

METHODS

setting: Institutional. patient population: Sixty-three eyes of 63 patients were treated with IVB for mCNV. intervention procedure: 1 mg of bevacizumab was injected into the vitreous via the pars plana. IVB was repeated after two to three months if there was fluorescein leakage in fluorescein angiogram (FA), apparent subretinal fluid in optical coherence tomography (OCT) persisted, or both. main outcome measurement: Best-corrected visual acuity (BCVA) and CNV size measured on FA.

RESULTS

IVB was performed one to six times during the first 12 months (mean, 2.4 +/- 1.4 times). The size of the mCNV decreased and the BCVA improved significantly (P < .01 for both comparisons). The BCVA improved more than three lines in 25 eyes (40%), worsened more than three lines in three eyes (5%), and was unchanged in 35 (56%) eyes 12 months after. Fluorescein leakage from the mCNV ceased in 30 eyes (48%), diminished in 28 (44%), and was unchanged in five (8%) eyes. Stepwise analysis showed that the number of IVB (P < .01), macular atrophy associated with mCNV (P < .05), and myopic atrophy (P < .05) were significant predictive factors for BCVA at 12 months.

CONCLUSIONS

Although the current study lacked a control group, IVB seems to be an effective treatment for mCNV after a long-term. The absence of chorioretinal atrophy and that of recurrence and persistency of mCNV are positive predictive factors.