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Ando T, Kubota M, Yasukawa T, Miyase T, Ishiguro K, Esaki Y, Kato A, Kokuzawa S, Hirano Y, Sakaguchi H. Macular hole with retinal pigment epithelium tear after anti-VEGF therapy in an eye with neovascular age-related macular degeneration. Am J Ophthalmol Case Rep 2024; 36:102126. [PMID: 39149619 PMCID: PMC11324838 DOI: 10.1016/j.ajoc.2024.102126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 06/26/2024] [Accepted: 07/12/2024] [Indexed: 08/17/2024] Open
Abstract
Purpose To report a case of a full-thickness macular hole (FTMH) associated with a retinal pigment epithelium (RPE) tear after anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nvAMD), which was successfully closed by vitreous surgery. Observations A 73-year-old man with nvAMD in the right eye received an intravitreal aflibercept injection due to enlarged pigment epithelial detachment. However, 2 days after the third injection, the patient experienced a sudden decline in vision. An FTMH with a tear in the underlying RPE was detected. The FTMH was closed using vitrectomy combined with the inverted internal limiting membrane (ILM) flap technique. Conclusions and Importance Our case highlights a rare complication of both an FTMH and an RPE tear after anti-VEGF therapy. Vitrectomy, with the inverted ILM flap technique, proved effective in closing the FTMH despite the complexity of the case.
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Affiliation(s)
- Tomoko Ando
- Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Masaomi Kubota
- Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Taishi Miyase
- Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Kiyona Ishiguro
- Department of Ophthalmology, Ogaki Tokushukai Hospital, Ogaki, Gifu, Japan
| | - Yuya Esaki
- Department of Ophthalmology, Ogaki Tokushukai Hospital, Ogaki, Gifu, Japan
| | - Aki Kato
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Satoko Kokuzawa
- Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Yoshio Hirano
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hirokazu Sakaguchi
- Department of Ophthalmology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
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Li C, Lu Y, Song Z, Liu Y. A real-world data analysis of ocular adverse events linked to anti-VEGF drugs: a WHO-VigiAccess study. Front Pharmacol 2024; 15:1398783. [PMID: 39139633 PMCID: PMC11319140 DOI: 10.3389/fphar.2024.1398783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 07/15/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction Vascular endothelial growth factor (VEGF) is key to wet age-related macular degeneration (wAMD). Anti-VEGF drugs are the main treatment in clinics. This study assessed ocular adverse events (AE) from anti-VEGF drugs in VigiAccess, WHO's database, and compared adverse drug reaction (ADR) profiles of four drugs to aid personalized treatment choices for optimal benefit and safety. Methods The design was a descriptive retrospective study. We observed four anti-VEGF drugs commonly used in the clinical treatment of wAMD, and their ADR reports came from WHO-VigiAccess. The collected data included the age group, gender, and regional data, as well as the data of disease systems and symptoms caused by ADR recorded in the annual ADR reports and reports received by the WHO. We observed the overall characteristics of the ADR reports of these drugs, then explored the distribution of 27 SOCs of these drugs. Subsequently, we compared the most common ocular ADRs of the drugs. Finally, we compared the commonalities and differences of ocular ADRs related to the drugs. Results Overall, 57,779 AE associated with the four anti-VEGF drugs were reported. The results showed that the number of females experiencing ADRs (67.83%) was significantly higher than males (32.17%), the age group with the highest reported incidence was over 75 years old. More than half of the ADR reports came from the Americas (50.86%). The five most common types of AE were: eye disorders (43.56%), general disorders and administration site conditions (34.47%), injury poisoning and procedural complications (13.36%), infections and infestations (11.61%), nervous system disorders (9.99%). Compared with the other three inhibitors, brolucizumab had a significantly higher rate of ocular ADR reports. The most common ocular ADRs of these four anti-VEGF drugs were mostly related to visual impairment, vision blurred, and blindness. However, there is still a disparity of ADRs between different drugs. Conclusion The presence of ocular AEs when using anti-VEGF drugs to treat wAMD in clinical practice should attract clinical attention. Clinicians should use these expensive drugs more rationally based on the characteristics of ADRs and develop personalized treatment plans for patients.
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Affiliation(s)
- Chen Li
- Department of Ophthalmology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Shi H, Guo N, Zhao Z, Duan J. ASSOCIATION BETWEEN RETINAL PIGMENT EPITHELIUM TEAR AND ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY: A Systematic Review and Meta-Analysis. Retina 2024; 44:179-188. [PMID: 37824816 DOI: 10.1097/iae.0000000000003922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
PURPOSE To identify the prevalence of retinal pigment epithelium tear (RPET) after anti-vascular endothelial growth factor (VEGF) therapy and determine the efficacy of continued anti-VEGF therapy in patients with RPET. METHODS All relevant clinical trials and observational studies in several online databases were screened. The main outcomes were the incidence of RPET after anti-VEGF therapy and changes in visual acuity for patients with RPET treated with continued anti-VEGF. RESULTS The pooled incidence of RPET after anti-VEGF therapy from 24 studies with 17,354 patients was 1.9% (95% CI: 1.3-2.7). Most new RPET cases were concentrated in the first month at baseline or after the first injection during anti-VEGF therapy and gradually decreased by the subsequent month or injection. 13 studies with 157 patients reported that for patients who received anti-VEGF therapy after RPET, their pooled best-corrected visual acuity improved, but did not reach a significant level (standardized mean differences 0.34; 95% CI: -0.03 to 0.71). CONCLUSION The incidence of RPET after anti-VEGF therapy is low. The intravitreal anti-VEGF injection may accelerate this process. For patients with RPET, maintenance of anti-VEGF therapy ensures visual acuity stability.
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Affiliation(s)
- Hekai Shi
- Department of Ophthalmology, The Second Hospital of Hebei Medical University, Shijiazhuang, China; and
| | - Nuojin Guo
- Hebei Medical University, Shijiazhuang, China
| | - Zeming Zhao
- Hebei Medical University, Shijiazhuang, China
| | - Jialiang Duan
- Department of Ophthalmology, The Second Hospital of Hebei Medical University, Shijiazhuang, China; and
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Takemoto M, Kitamura Y, Kakisu M, Shimizu D, Baba T. Retinal Pigment Epithelial Tears after Ex-PRESS Filtration Surgery in a Glaucoma Patient with a History of Ischemic Optic Neuropathy. Case Rep Ophthalmol Med 2023; 2023:6645156. [PMID: 37920746 PMCID: PMC10620019 DOI: 10.1155/2023/6645156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
Background To describe a case of retinal pigment epithelial tears (RPE tears) and serous retinal detachment (SRD) after Ex-PRESS filtration surgery for primary open-angle glaucoma (POAG) combined with ischemic optic neuropathy. Case Presentation. This case report involved a 69-year-old woman who underwent Ex-PRESS filtration surgery for right POAG. She had a history of systemic arteriosclerotic disease and subacute progressive visual field loss due to suspected ischemic optic neuropathy in her right eye. The right preoperative visual acuity was 0.7, and intraocular pressure (IOP) was 19 mmHg with maximum glaucoma eye drops. RPE detachment was not observed in the fundus. On day 9 after surgery, the IOP was 6 mmHg, and mild choroidal detachment was observed. On day 13, although IOP remained almost unchanged at 7 mmHg, bullous SRD was observed in the inferior retina, including the macula, and RPE tears were observed along the superior arcade vessel. While subretinal fluid gradually decreased with increasing IOP, tractional retinal folds persisted along the superior arcade, accompanied by macular degeneration. Conclusion We experienced a case of RPE tears after Ex-PRESS filtration surgery. In addition to choroidal detachment in the setting of hypotony, a pathologic condition causing structural fragility of the RPE layer may contribute to the development of RPE tears.
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Affiliation(s)
- Mamiko Takemoto
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Japan
- Department of Ophthalmology, International University of Health and Welfare Narita Hospital, Japan
| | - Yuta Kitamura
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Japan
| | - Masato Kakisu
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Japan
- Department of Ophthalmology, Japanese Red Cross Narita Hospital, Japan
| | - Daisuke Shimizu
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Japan
| | - Takayuki Baba
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Japan
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Ranjan R, Manayath G, Khanna A, Venkatapathy N. Healing pattern of subfoveal retinal pigment epithelium rip and aperture in central serous chorioretinopathy. Oman J Ophthalmol 2023; 16:170-174. [PMID: 37007249 PMCID: PMC10062083 DOI: 10.4103/ojo.ojo_331_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 10/25/2022] [Accepted: 12/02/2022] [Indexed: 02/23/2023] Open
Abstract
This report describes a rare case of spontaneous Grade-4 retinal pigment epithelium (RPE) rip of serous pigment epithelial detachment (PED) in central serous chorioretinopathy (CSC) and RPE aperture in the fellow eye, with favorable long-term outcomes. A 38-year-old man presented with defective vision (20/30) in the left eye (LE) due to bullous CSC associated with a large extramacular RPE rip located temporally and inferior exudative retinal detachment. Optical coherence tomography (OCT) confirmed a subfoveal serous PED with RPE aperture, subretinal fluid (SRF) and fibrinous exudation, and a large extramacular RPE rip temporally. The right eye (RE) had an asymptomatic large serous PED. The LE was treated with low-fluence photodynamic therapy, which resulted in the closure of RPE aperture and complete resolution of PED and SRF. Six-month later, the patient presented with sudden defective vision (20/120) in the RE secondary to a large fovea-involving (Grade-4) RPE rip with SRF as confirmed on OCT. Fluorescein angiography showed two extrafoveal active point leaks, which were treated with focal photocoagulation. He was also started on oral eplerenone. On subsequent serial follow-ups over 1 year, OCT showed SRF resolution and patchy reorganization of the subfoveal RPE-photoreceptor complex with good visual outcome (20/30).
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Foster WJ, Berg BW, Luminais SN, Hadayer A, Schaal S. Computational Modeling of Ophthalmic Procedures: Computational Modeling of Ophthalmic Procedures. Am J Ophthalmol 2022; 241:87-107. [PMID: 35358485 PMCID: PMC9444883 DOI: 10.1016/j.ajo.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/16/2022] [Accepted: 03/17/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To explore how finite-element calculations can continue to contribute to diverse problems in ophthalmology and vision science, we describe our recent work on modeling the force on the peripheral retina in intravitreal injections and how that force increases with shorter, smaller gauge needles. We also present a calculation that determines the location and stress on a retinal pigment epithelial detachment during an intravitreal injection, the possibility that stress induced by the injection can lead to a tear of the retinal pigment epithelium. BACKGROUND Advanced computational models can provide a critical insight into the underlying physics in many surgical procedures, which may not be intuitive. METHODS The simulations were implemented using COMSOL Multiphysics. We compared the monkey retinal adhesive force of 18 Pa with the results of this study to quantify the maximum retinal stress that occurs during intravitreal injections. CONCLUSIONS Currently used 30-gauge needles produce stress on the retina during intravitreal injections that is only slightly below the limit that can create retinal tears. As retina specialists attempt to use smaller needles, the risk of complications may increase. In addition, we find that during an intravitreal injection, the stress on the retina in a pigment epithelial detachment occurs at the edge of the detachment (found clinically), and the stress is sufficient to tear the retina. These findings may guide physicians in future clinical research. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- William J Foster
- From the Department of Bioengineering (W.J.F.), Lewes Katz School of Medicine (B.W.B., S.N.L.), Temple University, Philadelphia, Pennsylvania, USA; Altasciences, Montréal, Québec, Canada (W.J.F.).
| | - Brian W Berg
- From the Department of Bioengineering (W.J.F.), Lewes Katz School of Medicine (B.W.B., S.N.L.), Temple University, Philadelphia, Pennsylvania, USA
| | - Steven N Luminais
- From the Department of Bioengineering (W.J.F.), Lewes Katz School of Medicine (B.W.B., S.N.L.), Temple University, Philadelphia, Pennsylvania, USA
| | - Amir Hadayer
- Department of Ophthalmology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (A.H.)
| | - Shlomit Schaal
- Department of Ophthalmology, University of Massachusetts Medical School, Worcester, Massachusetts, USA (S.S.)
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Yoshida M, Hosoda Y, Akimoto M. Coughing-induced retinal pigment epithelial tear after trabeculectomy combined with pars plana vitrectomy. Am J Ophthalmol Case Rep 2022; 27:101663. [PMID: 35865660 PMCID: PMC9294478 DOI: 10.1016/j.ajoc.2022.101663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose Observations Conclusions and importance
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Affiliation(s)
| | | | - Masayuki Akimoto
- Corresponding author. Department of Ophthalmology Japanese Red Cross Osaka Hospital, 5-30 Fudegasaki-cho Tennoji-ku, Osaka, 543-8555, Japan.
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Multimodal Imaging Characteristics and Functional Correlates in Rip Healing. Retina 2022; 42:1844-1851. [DOI: 10.1097/iae.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Blue-light fundus autofluorescence imaging of pigment epithelial detachments. Eye (Lond) 2022; 37:1191-1201. [PMID: 35581370 PMCID: PMC10102186 DOI: 10.1038/s41433-022-02076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/18/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Pigment epithelial detachments (PEDs) occur in association with various chorioretinal diseases. With respect to the broad clinical spectrum of PEDs we describe fundus autofluorescence (FAF) characteristics of PEDs. METHODS Ninety-three eyes of 66 patients (mean age 71.9 ± 11.1) with uni- or bilateral PED ( ≥ 350 µm) were included in a retrospective cross-sectional study. PEDs were secondary to age-related macular degeneration (n = 79), central serous chorioretinopathy (n = 7), polypoidal choroidal vasculopathy (n = 2), pattern dystrophy (n = 3) or idiopathic PED (n = 2). FAF images were recorded using confocal scanning laser ophthalmoscopy (488 nm excitation wavelength, detection of emission >500 nm). Diagnosis of PED was confirmed using spectral-domain optical coherence tomography. A qualitative FAF grading system was established, and grading was performed by two independent readers. RESULTS PEDs showed highly variable characteristics on FAF imaging. FAF within the area of PED was found to be irregular/granular (n = 59, 63.4%), increased (n = 28, 30.1%), decreased (n = 3, 3.2 %), or normal (n = 3, 3.2%). Accompanying FAF changes included condensation of macular pigment (n = 67, 72.0%), focally increased FAF at the PED apex (n = 14, 15.1%) or elsewhere (n = 52, 55.9%), focally decreased FAF (n = 23, 24.7%), a cartwheel-like pattern (n = 10, 10.8%), a doughnut sign (n = 6, 6.5%), and a halo of decreased FAF encircling the PED (completely n = 20, 21.5% or incompletely n = 20, 21.5%). CONCLUSIONS PEDs show a variety of abnormal patterns on FAF imaging. These changes in FAF signals may be secondary to morphological and metabolic alterations within corresponding retinal layers and do not necessarily correspond with the underlying PED subtype or a specific pathology.
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Venkatesh R, Agrawal R, Thomas S, Reddy NG, Gupta A, Yadav NK, Chhablani J. Sequential retinal pigment epithelium tears following intravitreal Ranibizumab injections for age-related macular degeneration. Eur J Ophthalmol 2022; 33:NP100-NP104. [PMID: 35388732 DOI: 10.1177/11206721221093025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report a case of sequential retinal pigment epithelium (RPE) tears following intravitreal Ranibizumab injections for neovascular age-related macular degeneration (AMD). METHODS Retrospective, observational case. CASE DESCRIPTION A 75-year-old hypertensive male was diagnosed with active neovascular AMD and pre-existing RPE tear in the left eye. His presenting best-corrected visual acuity was counting finger @ 1 metre, <N36 in the right eye and 6/9, N8 in the left eye respectively. The right eye fundus had a scarred choroidal neovascular membrane (CNV) with extensive hard exudates. The left eye fundus showed active CNV, subretinal fluid and haemorrhage and a large RPE tear inferior to the fovea with rolled up margins. Following treatment with intravitreal Ranibizumab injection (Accentrix®, Alcon, 0.5 mg/0.05 ml) at monthly intervals, patient developed two extra RPE tears following each injection adjacent to the existing RPE tear. At the final follow-up visit, his CNV had regressed and visual acuity was maintained at 6/6, N6. No additional RPE tears were noted. CONCLUSION Pathogenesis of sequential RPE tears remains unclear. There is a need to look out for new RPE tears which can affect vision in a patient with neovascular AMD following CNV treatment.
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Affiliation(s)
- Ramesh Venkatesh
- Dept. of Retina and Vitreous, 80219Narayana Nethralaya, Bangalore, India
| | - Rohit Agrawal
- Dept. of Retina and Vitreous, 80219Narayana Nethralaya, Bangalore, India
| | - Sherina Thomas
- Dept. of Retina and Vitreous, 80219Narayana Nethralaya, Bangalore, India
| | | | - Aditi Gupta
- Dept. of Retina and Vitreous, 80219Narayana Nethralaya, Bangalore, India
| | - Naresh Kumar Yadav
- Dept. of Retina and Vitreous, 80219Narayana Nethralaya, Bangalore, India
| | - Jay Chhablani
- University of Pittsburgh School of Medicine, Medical Retina and Vitreoretinal Surgery, Pittsburg, PA, United States
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Giralt-Peret L, Rodríguez-Urzay A, Pérez-Fernández S, Martínez-Alday N, Fonollosa-Calduch A. Real-life results in treating neovascular age-related macular degeneration with anti-VEGF therapy. Analysis of 122 patients from a single centre. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:191-197. [PMID: 35523465 DOI: 10.1016/j.oftale.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/09/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The prognosis of age-related macular degeneration (AMD) has improved significantly since the advent of antiangiogenic treatments. However, several «real life» studies have shown lower number of injections and a markedly worse visual prognosis than pivotal clinical trials. OBJECTIVE To assess the effectiveness and safety of the treatment of neovascular AMD and analyse clinical factors related to the functional and structural prognosis in routine clinical practice. MATERIAL AND METHODS Retrospective, observational, single-centre study that included 143 eyes of 122 patients diagnosed with neovascular AMD between the years 2015 and 2016, who received treatment with antiangiogenic drugs and were followed up for two or more years. RESULTS Visual acuity improved in 45% of patients after two years of treatment. The mean decrease in central macular thickness was 85 μm (p < 0.001) and the mean number of injections was 13. Retinal pigment epithelium rupture was present in 3.5%. Ranibizumab was the drug most used as a first option, although 79 patients (55.2%) required a change in treatment, most being switched to aflibercept. A greater number of visits (p < 0.001) and a lower number of injections (p < 0.01) were predictors of worse structural outcome. The number of visits was associated with better visual acuity (p < 0.001). CONCLUSIONS The treatment has demonstrated its efficacy by improving visual acuity and central macular thickness. However, the number of injections performed has generally been higher than in other real-life studies.
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Affiliation(s)
- L Giralt-Peret
- Servicio de Oftalmología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain; Facultad de Medicina de la Universidad del País Vasco (UPV/EHU), Leioa, Vizcaya, Spain; Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain.
| | - A Rodríguez-Urzay
- Facultad de Medicina de la Universidad del País Vasco (UPV/EHU), Leioa, Vizcaya, Spain
| | - S Pérez-Fernández
- Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain
| | - N Martínez-Alday
- Servicio de Oftalmología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain; Facultad de Medicina de la Universidad del País Vasco (UPV/EHU), Leioa, Vizcaya, Spain
| | - A Fonollosa-Calduch
- Servicio de Oftalmología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain; Facultad de Medicina de la Universidad del País Vasco (UPV/EHU), Leioa, Vizcaya, Spain; Biocruces Bizkaia Health Research Institute, Barakaldo, Vizcaya, Spain
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Bridge arch-shaped subretinal fluid in neovascular age-related macular degeneration - evolution and outcomes. Retina 2022; 42:1012-1019. [PMID: 35152246 DOI: 10.1097/iae.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To study factors leading to bridge arch-shaped subretinal fluid (SRF) on optical coherence tomography (OCT) in wet age-related macular degeneration and evaluate its anatomical and functional outcomes. METHODS In this single-center, retrospective study, patients with bridge arch-shaped SRF and choroidal neovascular membrane (CNVM) were included. RESULTS We identified 623 eyes in 431 patients with chronic CNVM and 24 (4%) eyes in 21 patients showed bridge arch-shaped SRF. Mean age of patients was 69.19 ± 12.0 years. Type 1 CNVM was noted in 79% cases before development of bridge arch-shaped SRF. Mean ETDRS letters visual acuity was 53.93 ± 32.19. Time interval to develop bridge arch-shaped SRF was 21.9 ± 30.63 months. Mean number of intravitreal anti-VEGF injections given before developing bridge arch-shaped SRF was 6.5 ± 7.09. During development of bridge arch-shaped SRF, visual acuity reduced by -20.57 ± 31.13 letters (p=0.033) and fibrotic type 2 CNVM (n=18, 75%) was noted. RPE tear was noted in 8 (33%) eyes. At final visit, further reduction in visual acuity of -7.136 ± 13.73 ETDRS letters (p=0.011) after developing bridge arch-shaped SRF was seen. Mean number of injections given after developing bridge arch shaped SRF was 4.76 ± 3.76. CONCLUSION Bridge arch-shaped SRF is an uncommon finding seen in eyes with type 2 chronic CNVMs. Presence of RPE breach and tear and non-aggressive treatment regimen with intravitreal anti-VEGF injections could be responsible for its pathogenesis. It is a marker of fibrotic enlargement, leading to poor visual outcomes despite showing favourable therapeutic response.
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Modern trends in diagnostics and prediction of results of anti-vascular endothelial growth factor therapy of pigment epithelial detachment in neovascular agerelated macular degeneration using deep machine learning method (literature review). ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.6-1.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Detachment of the pigment epithelium is the separation of the basement membrane of the retinal pigment epithelium from the inner collagen layer of Bruch’s membrane, which occurs in 80 % of cases in patients with neovascular age-related macular degeneration. The outcome of anti-VEGF therapy for pigment epithelial detachment may be adherence of the pigment epithelium, the formation of pigment epithelium tear, or preservation of the detachment. The pigment epithelium tear of 3–4th degrees can lead to a sharp decrease in visual acuity.Most retrospective studies confi rm the absence of a proven correlation between anatomical and functional outcomes in the treatment of pigment epithelial detachment in cases of maintaining the integrity of the pigment epithelium monolayer, and therefore the main attention of researchers is focused on studying the morphological features of pigment epithelial detachment during therapy with angiogenesis inhibitors. Modern technologies of spectral optical coherence tomography make it possible to evaluate detailed quantitative parameters of pigment epithelium detachment, such as height, width, maximum linear diameter, area, volume and refl ectivity within the detachment.Groups of Russian and foreign authors identify various biomarkers recorded on optical coherence tomography images. Dynamic registration of such biomarkers expands the ability of clinicians to predict morphological changes in pigment epithelial detachment during anti-VEGF therapy, as well as to optimize treatment regimens to prevent complications in the form of pigment epithelium tear leading to a decrease in visual acuity.Modern methods of deep machine learning and the use of neural networks allow achieving higher accuracy in diff erentiating the types of retinal fluids and automating the quantitative determination of fl uid under the pigment epithelium. These technologies allow achieving a high level of compliance with manual expert assessment and increasing the accuracy and speed of predicting morphological results of treatment of pigment epithelium detachments.
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Saito M, Iida T, Saito K, Kano M, Itagaki K, Maruko I, Sekiryu T. Long-term characteristics of exudative age-related macular degeneration in Japanese patients. PLoS One 2021; 16:e0261320. [PMID: 34905560 PMCID: PMC8670714 DOI: 10.1371/journal.pone.0261320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/30/2021] [Indexed: 01/12/2023] Open
Abstract
Purpose The present study aimed to evaluate the clinical characteristics of exudative age-related macular degeneration (AMD) in Japanese patients over a 10-year period and to compare the past our report. Methods We retrospectively reviewed 1,600 treatment-naïve patients (1,777 eyes) with exudative AMD. The 10 years were divided into 2-year phases I to V. Results Of the 1,600 patients, 720 (45.0%), 733 (45.8%), 98 (6.1%), and 49 (3.1%) were diagnosed with typical AMD, polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation, and combined subtypes, respectively. The prevalence of PCV decreased from 54.7% in phase I to 46.0% at phase V. Of the 1,777 eyes, the mean baseline logarithm of the minimum angle of resolution best-corrected visual acuities (BCVAs) in phases I, II, III, IV, and V were 0.70, 0.66, 0.55, 0.50, and 0.48, respectively. Phases III, IV, and V had significantly (P = 0.0012, P<0.0001, P<0.0001, respectively) better baseline VAs compared with phase I. The mean lesion sizes in phases I, II, III, IV, and V were 8.6, 6.7, 5.3, 5.7, and 5.7 Macular Photocoagulation Study disc areas, respectively. The sizes were significantly (P<0.0001 for all comparisons) smaller in phases III, IV, and V compared with phase I. Conclusions Although the prevalence of PCV decreased from 54.7% in phase I to 46.0% at phase V, PCV has nevertheless been highly prevalent in Japanese patients with AMD compared with Caucasian patients. The annual better baseline VAs and smaller lesion sizes over time might be related to development of treatment and better concerns about AMD.
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Affiliation(s)
- Masaaki Saito
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Ophthalmology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- * E-mail:
| | - Tomohiro Iida
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Ophthalmology, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Kuniharu Saito
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mariko Kano
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Ophthalmology, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Kanako Itagaki
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Ichiro Maruko
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Ophthalmology, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Tetsuju Sekiryu
- Department of Ophthalmology, Fukushima Medical University School of Medicine, Fukushima, Japan
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15
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Barth T, Reiners M, Zeman F, Greslechner R, Helbig H, Gamulescu MA. [Anti-VEGF-therapy of fibrovascular and serous-vascularized pigment epithelial detachment in neovascular AMD : A retrospective five-year-analysis]. Ophthalmologe 2021; 118:1255-1263. [PMID: 33320292 PMCID: PMC8648623 DOI: 10.1007/s00347-020-01297-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neovascular age-related macular degeneration (nAMD) is the most frequent cause of pigment epithelial detachment (PED). In the clinical routine the treatment of fibrovascular PED (fPED) and serous vascularized PED (svPED) with intravitreal vascular endothelial growth factor (VEGF) inhibitors has a restricted prognosis. OBJECTIVE There are limited data on the long-term outcome of PED under anti-VEGF therapy. Therefore, this study recorded the course of treated PEDs in nAMD eyes over a period of 5 years. METHODS All eyes with fPED or svPED that underwent anti-VEGF medication between 2006 and 2015 were retrospectively analyzed regarding the clinical course and the morphology seen on optical coherence tomography (OCT). The inclusion criteria were the detection of a PED on OCT, the angiographic verification of nAMD, a documented clinical history over 5 years and a good image quality. RESULTS A total of 23 eyes from 22 patients met the inclusion criteria. After 5 years a significant deterioration of visual acuity (VA) was seen in all eyes (p = 0.007) and in the subgroup of cases with fPED (p = 0.045). In the eyes with svPED the decline of VA was not significant (p = 0.097). In the collective study group a statistically significant reduction of PED height (p = 0.006) and an increase of PED diameter was measured (p = 0.002). In the subgroup analysis the decrease of PED height and increase of PED diameter were significant for cases with svPED (p = 0.004, p = 0.013, respectively) but were not statistically significant for fPED eyes (height: p = 0.616; diameter: p = 0.097). In 17 (74%) eyes fibrosis or atrophy were seen on the final assessment of OCT images. DISCUSSION After 5 years of anti-VEGF therapy for nAMD-associated PED the VA declined in half of the eyes and the OCT showed an unfavorable morphology in 3/4 of the cases. The average number of visits and injections was distinctly lower than in clinical trials and other real-life analyses. In summary, we observed an undertreatment with a worse functional and anatomical outcome in our clinical routine compared to other studies.
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Affiliation(s)
- T Barth
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - M Reiners
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - F Zeman
- Zentrum für klinische Studien, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - R Greslechner
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - H Helbig
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - M-A Gamulescu
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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16
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Clinical associations and prognostic implications of repair tissue proliferation in eyes with retinal pigment epithelium tears. Retina 2021; 42:519-528. [PMID: 34743132 DOI: 10.1097/iae.0000000000003332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate demographic and clinical factors influencing the longitudinal changes of retinal pigment epithelium (RPE) dehiscence area after RPE tears, including the presence of RPE tear-associated repair proliferation (TARP), and identify factors associated with TARP development over follow-up. METHODS Retrospective, single-center, observational cohort study of patients with a history of macular neovascularization and RPE tear. The area of RPE dehiscence was measured on repeated short-wavelength fundus autofluorescence imaging. Associations between potential covariates and RPE dehiscence areas were tested with multivariable linear mixed models. Associations between TARP development and clinical variables were investigated with Cox regression models. Factors associated with visual acuity changing rates were explored with linear mixed models. RESULTS Thirty-seven eyes of 36 patients were included in this study and followed for a median time of 18 months. TARP was identified in 27 eyes (73%). The median time for TARP detection was 112 days; none of the investigated factors was significantly associated with TARP occurrence. The presence of TARP (β estimate: -0.042 mm2/month, p=0.001) and female gender (β estimate: -0.035 mm2/month, p=0.006) were associated with slower rates of RPE dehiscence enlargement over time. Faster rates of visual improvement were seen in eyes with TARP compared with those without TARP (β = -0.010 LogMAR/month if TARP was present, p=0.008). CONCLUSION RPE tear repair with TARP and female gender were associated with slower RPE degeneration after RPE tears. The presence of TARP was associated better visual prognosis. Additional research on factors promoting TARP development may have therapeutic and prognostic implications.
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17
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Foss A, Rotsos T, Empeslidis T, Chong V. The Development of Macular Atrophy in Patients with Wet Age-Related Macular Degeneration Receiving Anti-VEGF Treatment. Ophthalmologica 2021; 245:204-217. [PMID: 34695835 DOI: 10.1159/000520171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022]
Abstract
Age-related macular degeneration (AMD) is a leading cause of blindness. Late AMD can be classified into exudative (commonly known as wet AMD [wAMD]) or dry AMD, both of which may progress to macular atrophy (MA). MA causes irreversible vision loss and currently has no approved pharmacological treatment. The standard of care for wAMD is treatment with anti-vascular endothelial growth factors (VEGF). However, recent evidence suggests that anti-VEGF treatment may play a role in the development of MA. Therefore, it is important to identify risk factors for the development of MA in patients with wAMD. For example, excessive blockade of VEGF through intense use of anti-VEGF agents may accelerate the development of MA. Patients with type III macular neovascularisation (retinal angiomatous proliferation) have a particularly high risk of MA. These patients are characterised as having a pre-existing thin choroid (age-related choroidopathy), suggesting that the choroidal circulation is unable to respond to increased VEGF expression. Evidence suggests that subretinal fluid (possibly indicative of residual VEGF activity) may play a protective role. Patients receiving anti-VEGF agents must be assessed for overall risk of MA and there is an unmet medical need to prevent the development of MA without undertreating wAMD.
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Affiliation(s)
- Alexander Foss
- University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Tryfon Rotsos
- Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theo Empeslidis
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
| | - Victor Chong
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
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18
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Barresi C, Borrelli E, Fantaguzzi F, Grosso D, Sacconi R, Bandello F, Querques G. Complications Associated with Worse Visual Outcomes in Patients with Exudative Neovascular Age-Related Macular Degeneration. Ophthalmologica 2021; 244:512-522. [PMID: 34517374 DOI: 10.1159/000519518] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neovascular age-related macular degeneration (AMD) represents a leading cause of vision loss in older subjects. The introduction of anti-vascular endothelial growth factor therapy has enormously improved the visual prognosis in these patients. SUMMARY However, severe complications may still occur in this disease and their development may significantly affect short- and long-term visual outcomes. Key Messages: In this article, we provided a review of these complications, highlighting their distinctive signs or symptoms and focusing on the current evidence of treatment. To place the complications related to neovascular AMD in a proper context, this review deals with core components essential for proper comprehension of neovascular AMD that includes pathogenesis, clinical signs, and basic principles of treatment.
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Affiliation(s)
- Costanza Barresi
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Borrelli
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Fantaguzzi
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Grosso
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Riccardo Sacconi
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Querques
- Vita-Salute San Raffaele University Milan, Milan, Italy.,IRCCS San Raffaele Scientific Institute, Milan, Italy
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19
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VEGF Mediates Retinal Müller Cell Viability and Neuroprotection through BDNF in Diabetes. Biomolecules 2021; 11:biom11050712. [PMID: 34068807 PMCID: PMC8150851 DOI: 10.3390/biom11050712] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
To investigate the mechanism of vascular endothelial growth factor (VEGF) and brain-derived neurotrophic factor (BDNF) in Müller cell (MC) viability and neuroprotection in diabetic retinopathy (DR), we examined the role of VEGF in MC viability and BDNF production, and the effect of BDNF on MC viability under diabetic conditions. Mouse primary MCs and cells of a rat MC line, rMC1, were used in investigating MC viability and BDNF production under diabetic conditions. VEGF-stimulated BDNF production was confirmed in mice. The mechanism of BDNF-mediated MC viability was examined using siRNA knockdown. Under diabetic conditions, recombinant VEGF (rVEGF) stimulated MC viability and BDNF production in a dose-dependent manner. rBDNF also supported MC viability in a dose-dependent manner. Targeting BDNF receptor tropomyosin receptor kinase B (TRK-B) with siRNA knockdown substantially downregulated the activated (phosphorylated) form of serine/threonine-specific protein kinase (AKT) and extracellular signal-regulated kinase (ERK), classical survival and proliferation mediators. Finally, the loss of MC viability in TrkB siRNA transfected cells under diabetic conditions was rescued by rBDNF. Our results provide direct evidence that VEGF is a positive regulator for BDNF production in diabetes for the first time. This information is essential for developing BDNF-mediated neuroprotection in DR and hypoxic retinal diseases, and for improving anti-VEGF treatment for these blood-retina barrier disorders, in which VEGF is a major therapeutic target for vascular abnormalities.
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20
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Molina-Pallete R, Andreu-Fenoll M, Gallego-Pinazo R, Dolz-Marco R. ATYPICAL HEALING IN A CASE WITH RETINAL PIGMENT EPITHELIUM APERTURES. Retin Cases Brief Rep 2021; 15:294-298. [PMID: 30015776 DOI: 10.1097/icb.0000000000000789] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To analyze the multimodal imaging features in a case showing resolution of retinal pigment epithelium (RPE) apertures in association with an avascular pigment epithelium detachment secondary to nonneovascular age-related macular degeneration. METHODS Report of a case diagnosed with aperture of the RPE with multimodal imaging long-term follow-up. Color fundus photography, fundus autofluorescence, eye-tracked spectral domain optical coherence tomography (OCT), and OCT angiography findings are discussed. RESULTS A 71-year-old man diagnosed with nonneovascular age-related macular degeneration presented with three different areas of RPE aperture in his right eye. At baseline, best-corrected visual acuity was 20/100 in his right eye. Dilated fundus examination showed three round areas of RPE atrophy, and fundus autofluorescence demonstrated marked hypoautofluorescence in the corresponding areas. The OCT scans showed discontinuities of the RPE band with no evidence of RPE tear. The OCT angiography showed no evidence of abnormal blood flow within the sub-RPE space. Over time, fundus autofluorescence and eye-tracked spectral domain OCT scans demonstrated spontaneous resolution of two of the RPE defects and reduction of the size of the third one, with complete flattening of the pigment epithelium detachment. CONCLUSION Distinction between RPE tears and apertures is important due to their different etiopathogenic mechanism and prognosis. To the best of our knowledge, this is the first report of a case of complete closure of an RPE aperture. The mechanism of the observed RPE closure remains unknown, and further studies are warranted to better understand the mechanisms of RPE restoration and remodeling.
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Affiliation(s)
| | - Maria Andreu-Fenoll
- Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain
- Unit of Macula, Health Research Institute, University and Polytechnic Hospital La Fe, Valencia, Spain ; and
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21
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Mitchell P, Rodríguez FJ, Joussen AM, Koh A, Eter N, Wong DT, Korobelnik JF, Okada AA. MANAGEMENT OF RETINAL PIGMENT EPITHELIUM TEAR DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY. Retina 2021; 41:671-678. [PMID: 33346626 PMCID: PMC7989608 DOI: 10.1097/iae.0000000000003083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This article aims to review current evidence on the development, diagnosis, and management of retinal pigment epithelium (RPE) tear during anti-vascular endothelial growth factor (VEGF) therapy. METHODS Literature searches were performed using MEDLINE/PubMed databases (cut-off date: August 2019). RESULTS Three key recommendations were made based on existing literature and clinical experience: 1) Multimodal imaging with color fundus photography, optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence imaging, optical coherence tomography-angiography, and/or fluorescein angiography are recommended to diagnose RPE tear and assess risk factors. Retinal pigment epithelium tears can be graded by size and foveal involvement. 2) Patients at high risk of developing RPE tear should be monitored after each anti-VEGF injection. If risk factors worsen, it is not yet definitively known whether anti-VEGF administration should be more frequent, or alternatively stopped in such patients. Prospective research into high-risk characteristics is needed. 3) After RPE tear develops, anti-VEGF treatment should be continued in patients with active disease (as indicated by presence of intraretinal or subretinal fluid), although cessation of therapy should be considered in eyes with multilobular tears. CONCLUSION Although evidence to support the assumption that anti-VEGF treatment contributes to development of RPE tear is not definitive, some data suggest this link.
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Affiliation(s)
- Paul Mitchell
- Department of Ophthalmology, Centre for Vision Research, Westmead Institute for Medical Research, the University of Sydney, Sydney, Australia
| | - Francisco J. Rodríguez
- Fundación Oftalmologica Nacional, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | | | - Adrian Koh
- Eye and Retina Surgeons, Camden Medical Centre, Singapore
| | - Nicole Eter
- Department of Ophthalmology, University of Münster Medical Center, Münster, Germany
| | - David T. Wong
- Unity Health Toronto, St. Michael's Hospital, University of Toronto, Canada
| | - Jean-François Korobelnik
- Service d'ophtalmologie, CHU Bordeaux, Bordeaux, France
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team LEHA, UMR 1219, Bordeaux, France; and
| | - Annabelle A. Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
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22
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THE OCCURRENCE, CHARACTERISTICS, MANAGEMENT, AND PROGNOSIS OF RETINAL PIGMENT EPITHELIUM TEARS IN PATIENTS WITH POLYPOIDAL CHOROIDAL VASCULOPATHY: A Retrospective Study of 397 Patients. Retina 2021; 40:477-489. [PMID: 30475788 DOI: 10.1097/iae.0000000000002389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate retinal pigment epithelium (RPE) tears in patients with polypoidal choroidal vasculopathy. METHOD A retrospective review of polypoidal choroidal vasculopathy cases with confirmed RPE tears was conducted. Patients' comprehensive clinical data were collected and analyzed. The treatment strategy was a loading dose of one intravitreal antivascular endothelial growth factor injection, combined with additional injections if exudative activities or visual deterioration were detected. RESULTS Among 397 polypoidal choroidal vasculopathy patients, 33 patients with RPE tears (8.3%) were included. 42.4% of them happened spontaneously. Pigment epithelial detachment (PED) occurred more frequently in RPE tear patients and most of them had serous vascularized or hemorrhagic PED. The height and greatest linear diameter of PED, and the subfoveal choroidal thickness of these cases were significantly larger, whereas the central foveal thickness was significantly smaller. Most of the RPE tears occurred at the edge of the PED. After our treatment strategy, patients' best-corrected visual acuity improved significantly from 2.13 ± 1.24 (median 20/52) to 1.32 ± 1.31 (median 20/166). Large subretinal hemorrhage may increase the risk of the formation of subretinal fibrosis (P < 0.05). CONCLUSION Retinal pigment epithelium tears in polypoidal choroidal vasculopathy are associated with high subRPE hydrostatic pressure, produced by a large PED or hemorrhage. After our intervention strategy, this condition may not necessarily result in poor prognosis.
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23
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Romano F, Parrulli S, Battaglia Parodi M, Lupidi M, Cereda M, Staurenghi G, Invernizzi A. Optical coherence tomography features of the repair tissue following RPE tear and their correlation with visual outcomes. Sci Rep 2021; 11:5962. [PMID: 33727575 PMCID: PMC7966766 DOI: 10.1038/s41598-021-85270-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/15/2021] [Indexed: 11/26/2022] Open
Abstract
To assess the optical coherence tomography (OCT) features of the repair tissue after retinal pigment epithelial (RPE) tear in neovascular age-related macular degeneration. Retrospective, observational study. Medical and imaging records of patients that developed tears after starting anti-VEGF treatment and with at least 12 months of follow-up were reviewed. OCT reflectivity of the RPE-subretinal hyperreflective tissue (SHT) complex was measured at 6, 12 and 18 months (when available). Reflectivity of the adjacent unaffected RPE-Bruch’s membrane was taken as internal reference. Other variables: grade and rip occurrence (early/late); number of intravitreal injections; type of macular neovascularization; sub-macular hemorrhage (SMH) at onset. Forty-nine eyes (age: 76.1 ± 7.0 years; VA: 0.54 ± 0.27 LogMAR) were included. Thirty-eight eyes had OCT signs of healing during the follow-up, with 21 showing SMH at baseline. Final VA positively correlated with the number of injections and negatively correlated with the RPE-SHT reflectivity and the presence of SMH (p < 0.001). Reflectivity of the RPE-SHT complex was positively associated with time and SMH at baseline (p < 0.05). In our study, most eyes showed signs of tissue repair after RPE tear. The reflectivity of repair tissue, the SMH presence and the number of anti-VEGF injections appeared to be major predictors of visual outcomes.
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Affiliation(s)
- Francesco Romano
- Eye Clinic, Department of Biomedical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy. .,Eye Clinic, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
| | - Salvatore Parrulli
- Eye Clinic, Department of Biomedical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Maurizio Battaglia Parodi
- Department of Ophthalmology, Scientific Institute San Raffaele, Vita-Salute University, Milan, Italy
| | - Marco Lupidi
- Department of Surgical and Biomedical Sciences, Section of Ophthalmology, University of Perugia, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Matteo Cereda
- Eye Clinic, Department of Biomedical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Giovanni Staurenghi
- Eye Clinic, Department of Biomedical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Alessandro Invernizzi
- Eye Clinic, Department of Biomedical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy.,Faculty of Health and Medicine, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
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24
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Lei C, Hua R, Duan J, Zhang M. Retinal pigment epithelium aperture in acute central serous chorioretinopathy: Another novel possible pathological mechanism. Eur J Ophthalmol 2021; 32:NP103-NP108. [PMID: 33719657 DOI: 10.1177/11206721211002444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To present retinal pigment epithelium (RPE) aperture related to an avascular pigment epithelium detachment (PED) secondary to acute central serous chorioretinopathy (CSC). METHODS Case report. RESULTS A 47-year-old man diagnosed as acute CSC presented with RPE aperture in the superonasal area of the macula in his left eye during follow-up. At 2-week follow-up, his decimal best-corrected visual acuity (BCVA) was improved from 0.08 to 0.6 and subretinal fluid was partially absorbed. However, the near-infrared reflectance demonstrated a round mild hyperreflective lesion on the superonasal area of the macula. On spectral-domain optical coherence tomography (SD-OCT), RPE band of the round lesion discontinued but RPE fractured edges without shrinkage and curling. Fundus autofluorescence (FAF) showed RPE aperture appeared as round hypoautofluorescence and hyperautofluorescence outlined its borderline. OCT angiography demonstrated that no evidence of neovascularization within the sub-RPE space. En Face OCT confirmed that the RPE aperture developed at the edge of the PED lesion. At 8-month follow-up, his decimal BCVA was improved to 1.0 and SD-OCT demonstrated spontaneous resolution of subretinal fluid and restoration of RPE structure, with complete flattening of PED. However, FAF revealed hypoautofluorescence mingled with slight hyperautofluorescence within the lesion. CONCLUSIONS To the best of our knowledge, this is the first report of an RPE aperture secondary to acute CSC. Our case indicated another novel possible pathological mechanism that in the relatively healthy RPE, increased hydrostatic pressure simply itself could contribute to RPE aperture.
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Affiliation(s)
- Chunyan Lei
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Hua
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China.,Department of Ophthalmology, First Hospital of China Medical University, Shenyang, China
| | - Jianan Duan
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Meixia Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
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25
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Vilares-Morgado R, Madeira C, Falcão M, Godinho G, Ribeiro M, Beato J, Pedrosa AC, Brandão E, Falcão-Reis F, Carneiro Â. Predicting retinal pigment epithelium remodelling and its functional impact. Graefes Arch Clin Exp Ophthalmol 2021; 259:2583-2595. [PMID: 33651204 DOI: 10.1007/s00417-021-05129-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 02/05/2021] [Accepted: 02/15/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To identify predictive factors for RPE tear remodelling and its correlation with functional and morphological outcomes. METHODS Retrospective longitudinal study of patients with retinal pigment epithelium (RPE) tears secondary to age-related macular degeneration (AMD). Imaging was performed using spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF). RPE layer integrity in the RPE-denuded area was examined with SD-OCT, and variation in the RPE-denuded homogeneous hypofluorescent area was examined with FAF over time for each case (eye). Patients were divided in two groups, according to the presence (Rem) or absence (No Rem) of evidence of RPE tear remodelling. Data were collected at three different time points: at baseline (at diagnosis of exudative AMD), at RPE tear diagnosis, and at the last available follow-up. Using SD-OCT, the following parameters were evaluated: type of CNV, type of PED and its dimensions, presence of subretinal (SRF) or intraretinal (IRF) fluid, central retinal thickness (CRT), presence and location of hyperreflective dots, and dimension and location of RPE tear. RESULTS This study included 32 eyes from 31 patients (19 female and 12 male), with RPE tears secondary to AMD. RPE remodelling after tear development was evident in 17 (53.1%) eyes after 7 [1-59] months. Anatomical recovery was associated with a younger age at RPE tear diagnosis (73 ± 7 vs. 81 ± 7 years old, p=0.01), smaller and narrower retinal pigment epithelial detachment (PED) at tear diagnosis (height 369 vs. 602 μm, p=0.02; width 2379 vs. 3378 μm, p=0.04), and the presence of SRF at tear diagnosis (94% vs. 53%, p=0.02). After adjusting for other covariates, a younger age at RPE tear diagnosis maintained significant association with RPE tear remodelling. RPE tear remodelling did not correlate with a better visual outcome at last follow-up (43 ± 22.8 vs. 34 ± 23.8 ETDRS letters, p=0.30). Final VA was directly proportional to VA at tear diagnosis (r= 0.654; p<0.001) and correlated negatively with PED width at tear diagnosis (r = -0.388; p=0.03). CONCLUSION RPE remodelling was evident in half of our sample and was associated with a younger age, smaller and narrower PED at RPE tear diagnosis, and presence of SRF also at tear diagnosis. Nevertheless, this structural recovery did not result in a better functional outcome.
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Affiliation(s)
- Rodrigo Vilares-Morgado
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal.
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Carolina Madeira
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
| | - Manuel Falcão
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Gonçalo Godinho
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
| | - Margarida Ribeiro
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Beato
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
| | - Ana Catarina Pedrosa
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
| | - Elisete Brandão
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
| | - Fernando Falcão-Reis
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ângela Carneiro
- Department of Ophthalmology, Centro Hospitalar de São João Hospital, Avenida Prof. Hernâni Monteiro, 4202 - 451, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Voronin GV, Yusef NY, Kazaryan EE, Smirnova TV, Khasyanova MV. [Morphological and functional features of bilateral avascular retinal pigment epithelium detachment (a case report)]. Vestn Oftalmol 2020; 136:235-242. [PMID: 32880145 DOI: 10.17116/oftalma2020136042235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Detachment of the retinal pigment epithelium (RPE) is a manifestation of a number of degenerative, vascular, inflammatory processes in the eye. The most common cause of RPE detachment in older individuals is the neovascular form of age-related macular degeneration (AMD). Only in 10% of cases the detachment is transudative (avascular), characterized by high domed serous RPE detachment. The article presents an analysis of a case of idiopathic bilateral avascular pigment epithelium detachment - clinical, morphological and functional features of the disease, its impact on the visual functions and the quality of life.
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Affiliation(s)
- G V Voronin
- Research Institute of Eye Diseases, Moscow, Russia
| | - N Y Yusef
- Research Institute of Eye Diseases, Moscow, Russia
| | - E E Kazaryan
- Research Institute of Eye Diseases, Moscow, Russia
| | - T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
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Tracing the retina to analyze the integrity and phagocytic capacity of the retinal pigment epithelium. Sci Rep 2020; 10:7273. [PMID: 32350384 PMCID: PMC7190639 DOI: 10.1038/s41598-020-64131-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/09/2020] [Indexed: 12/24/2022] Open
Abstract
We have developed a new technique to study the integrity, morphology and functionality of the retinal neurons and the retinal pigment epithelium (RPE). Young and old control albino (Sprague-Dawley) and pigmented (Piebald Virol Glaxo) rats, and dystrophic albino (P23H-1) and pigmented (Royal College of Surgeons) rats received a single intravitreal injection of 3% Fluorogold (FG) and their retinas were analyzed from 5 minutes to 30 days later. Retinas were imaged in vivo with SD-OCT and ex vivo in flat-mounts and in cross-sections. Fifteen minutes and 24 hours after intravitreal administration of FG retinal neurons and the RPE, but no glial cells, were labeled with FG-filled vesicles. The tracer reached the RPE 15 minutes after FG administration, and this labeling remained up to 30 days. Tracing for 15 minutes or 24 hours did not cause oxidative stress. Intraretinal tracing delineated the pathological retinal remodelling occurring in the dystrophic strains. The RPE of the P23H-1 strain was highly altered in aged animals, while the RPE of the RCS strain, which is unable to phagocytose, did not accumulate the tracer even at young ages when the retinal neural circuit is still preserved. In both dystrophic strains, the RPE cells were pleomorphic and polymegathic.
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The relationship between pigment epithelial detachment and visual outcome in neovascular age-related macular degeneration and polypoidal choroidal vasculopathy. Eye (Lond) 2020; 34:2257-2263. [PMID: 32047280 DOI: 10.1038/s41433-020-0803-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/OBJECTIVES To compare the detailed optical coherence tomography (OCT)-based morphological parameters of pigment epithelial detachment (PED) in eyes presenting with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and to assess whether these PED-associated parameters influence 1-year visual outcomes. SUBJECT/METHODS We analysed images from a prospective observational study of treatment-naive Asian participants with nAMD or PCV. An independent reading centre graded baseline morphological features of PED on spectral-domain OCT, including greatest height, greatest width, greatest volume, morphology (predominantly dome shaped versus peaked), presence of retinal pigment epithelium (RPE) tear and cholesterol bands. The influence of these baseline features on 12 months best corrected visual acuity (BCVA) was evaluated. RESULTS Seventy-eight eyes of 78 participants with PED were studied. In total, 40 (51.3%) participants had nAMD and 38 (48.7%) had PCV. Eyes with PCV, compared with nAMD, had PED of greater height (455.9 µm versus 389.9 µm; P = 0.035) and had higher prevalence of RPE tear (22.9 versus 5.3%; P = 0.041). In the multivariate analysis, only baseline BCVA was significantly associated with month 12 BCVA, but none of the PED-associated OCT parameters at baseline influenced month 12 BCVA. CONCLUSIONS Despite the differences in PED height and prevalence of RPE tear between nAMD and PCV, none of these PED morphological factors on OCT at baseline significantly influenced visual outcome at 12 months.
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Wong DT, Lambrou GN, Loewenstein A, Pearce I, Okada AA. SUSPENDING TREATMENT OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN CASES OF FUTILITY. Retina 2019; 40:1010-1020. [PMID: 31876889 PMCID: PMC7448759 DOI: 10.1097/iae.0000000000002713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide guidance on the management of patients with neovascular age-related macular degeneration and its subtypes who respond poorly to anti-vascular endothelial growth factor (anti-VEGF) therapy, and to identify cases where suspending anti-VEGF treatment may be warranted. METHODS Through a literature review and the combined knowledge and clinical experience of retinal experts, the Steering Committee of the Bayer-sponsored Vision Academy developed an algorithm for determining when to suspend anti-VEGF treatment of neovascular age-related macular degeneration in cases of futility. RESULTS Consideration of factors that may cause suboptimal response to anti-VEGF therapy, such as undertreatment or misdiagnosis of the underlying condition, and factors that may preclude continued treatment, such as injection- or drug-induced complications, is necessary for adjusting treatment protocols in patients who respond poorly to anti-VEGF. If poor response to treatment persists after switching to an alternative anti-VEGF agent and no change in response is observed after withholding treatment for a predetermined period of time ("treatment pause"), anti-VEGF treatment may be considered futile and should be suspended. CONCLUSION This publication introduces an algorithm to guide the management of neovascular age-related macular degeneration in patients showing poor response to anti-VEGF treatment and provides expert guidance for suspending anti-VEGF treatment in cases of futility.
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Affiliation(s)
- David T Wong
- University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | | | - Anat Loewenstein
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ian Pearce
- Royal Liverpool University Hospital, Liverpool, United Kingdom; and
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Sastre-Ibáñez M, Martínez-Rubio C, Molina-Pallete R, Martínez-López-Corell P, Wu L, Arévalo JF, Gallego-Pinazo R. Retinal pigment epithelial tears. J Fr Ophtalmol 2018; 42:63-72. [PMID: 30594420 DOI: 10.1016/j.jfo.2018.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 10/27/2022]
Abstract
A retinal pigment epithelial (RPE) tear is a well-known complication of retinal pigment epithelial detachments (PED) and may cause a significant visual impairment. The most common cause is a vascularized PED in patients with exudative age-related macular degeneration (AMD). The development of diagnostic imaging techniques brings us closer to the etiology and pathophysiological mechanisms of this entity, offering us new strategies for treatment and follow-up. The advent of intravitreal antiangiogenic treatment (anti-VEGF) has led to an increase in the number of reported cases of RPE tears, which are an important vision-limiting factor during treatment. However, RPE tears may occur spontaneously or as a consequence of thermal laser treatment, photodynamic therapy or anti-VEGF therapy. It is accepted that the mechanism of RPE tears is multifactorial. The optimization of the functional outcome of this complication has been described with continuous treatment with antiangiogenic drugs. The goal of the present review is to evaluate the incidence, risk factors and treatment of RPE tears.
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Affiliation(s)
- M Sastre-Ibáñez
- Ophthalmology Department, Clinico San Carlos Hospital of Madrid, Gran Vía del Este, 80, 28031 Madrid, Spain.
| | - C Martínez-Rubio
- Ophthalmology Department, Universitario y Politécnico La Fe Hospital, Valencia, Spain
| | - R Molina-Pallete
- Macula, Vitreous and Retina associates of Costa Rica, San José, Costa Rica
| | | | - L Wu
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J F Arévalo
- Macula Department, Oftalvist Clinic, Valencia, Spain
| | - R Gallego-Pinazo
- Macula Department, Oftalvist Clinic, Valencia, Spain; RETICS RD160008 Ocular Diseases, Prevention, Early Detection, Treatment and Rehabilitation of Ocular Diseases, Carlos III Health Institute, Madrid, Spain
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Clemens CR, Alten F, Heiduschka P, Gamulescu MA, Wolf A, Eter N. Volumetrische Analyse der vaskularisierten Pigmentepithelabhebung bei AMD: Post-hoc-Analyse der RECOVER-Studie. Ophthalmologe 2018; 115:754-760. [DOI: 10.1007/s00347-017-0586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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van Zeeburg EJ, Maaijwee KJ, van Meurs JC. Visual acuity of 20/32, 13.5 years after a retinal pigment epithelium and choroid graft transplantation. Am J Ophthalmol Case Rep 2018; 10:62-64. [PMID: 29780916 PMCID: PMC5956743 DOI: 10.1016/j.ajoc.2018.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 11/28/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose To present the 13.5-year-survival of an autologous retinal pigment epithelium (RPE) and choroid graft transplantation with good visual acuity results. Observations A 72-year old patient presented with a 5-weeks-old visual acuity deterioration to excentric finger counting at half a meter. Fundoscopy showed a fibrotic macular scar, a large subretinal hemorrhage, partly recent, combined with intraretinal fluid, blood, and hard exudates. RPE-choroid graft surgery was performed, and visual acuity improved to 20/32, and maintained up until 13.5 years postoperative. Microperimetry performed at the same time revealed a 3.4 dB sensitivity, with fixation on the graft. During the postoperative years glaucoma developed, an uveitis anterior was treated, and to treat a small Coats' like lesion; one bevacizumab injection was administered. Conclusions and importance A best corrected visual acuity of 20/32 could be achieved and maintained up to 13.5 years after an RPE-choroid graft transplantation, despite an unfavorable preoperative presentation and some early and late complications. This case is a proof of principle that an RPE-choroid graft harvested from the midperiphery can support the macular metabolism up to 13.5 after surgery in a patient with severe exudative AMD. It also represents a rationale for pursuing stem cell derived RPE replacement. Anti-vascular endothelial growth factor injections are nowadays the mainstay of therapy for choroidal neovascularization and/or small hemorrhages and offer good results. Nevertheless, selected patients that cannot benefit from this therapy may profit from an autologous RPE-choroid graft transplantation.
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Affiliation(s)
- Elsbeth J.T. van Zeeburg
- The Rotterdam Eye Hospital, Schiedamse Vest 180, 3011 BH Rotterdam, The Netherlands
- Corresponding author.
| | | | - Jan C. van Meurs
- The Rotterdam Eye Hospital, Schiedamse Vest 180, 3011 BH Rotterdam, The Netherlands
- Erasmus Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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Clemens CR, Wolf A, Alten F, Milojcic C, Heiduschka P, Eter N. Response of vascular pigment epithelium detachment due to age-related macular degeneration to monthly treatment with ranibizumab: the prospective, multicentre RECOVER study. Acta Ophthalmol 2017; 95:683-689. [PMID: 28084038 DOI: 10.1111/aos.13359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 11/07/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To assess the effects of monthly intravitreal ranibizumab injections in patients with vascularized pigment epithelium detachment (vPED) secondary to age-related macular degeneration (AMD). METHODS A total of 40 patients were prospectively observed and treated monthly with 0.5 mg ranibizumab injections (ClinicalTrials.gov Ident. NCT00976222). Inclusion criterion was a treatment-naïve vPED lesion with a minimum height of ≥200 μm. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) were evaluated at all visits. Fluorescein angiography and indocyanine green angiography were performed at baseline and quarterly. Lesions were differentiated between serous vascular PED (svPED, group A, 29 patients) and fibrovascular PED (fPED, group B, 11 patients). Primary outcome was the effectivity of continuous monthly treatment during a 12-month period as measured in change in BCVA. Secondary outcomes were change in PED height and PED greatest linear diameter (GLD). Further secondary outcomes were the presence of subretinal fluid and prognostic markers of an impending retinal pigment epithelium (RPE) tear: PED lesion height and diameter, ratio of choroidal neovascularization (CNV) size to PED size, hyperreflective lines in near-infrared images, microrips and subretinal cleft. RESULTS Mean BCVA was 56.9 ± 11.5 letters (A: 55.4 ± 10.8; B: 59.1 ± 13.4) at baseline and 55.1 ± 15.9 (A: 53.7 ± 17.0; B: 58.9 ± 12.7) at 12-month follow-up. Excluding the RPE tear patients, the svPED group showed an increase in BCVA from 56.1 ± 10.3 at baseline to 62.4 ± 10.2 at 12-month follow-up (p = 0.048). Best-corrected visual acuity in patient who developed a RPE tear was 55.8 ± 12.5 at baseline and 37.1 ± 14.9 at 12-month follow-up. The mean change in PED height was -242.1 μm ± 285.5 (A: -427.3 μm ± 299.7; B: -51.6 μm ± 99.5). The mean decrease in PED GLD was -471.8 μm ± 727.6 (A: -738.9 μm ± 788.2; B: -10.4 μm ± 185.6). In group A, 10 patients developed a RPE tear (25%) after a mean of 3.6 injections. No tear was documented in group B. Lesion height, ratio of CNV size to PED size and presence of hyperreflective lines differed significantly between patients with and without RPE tear development. CONCLUSION Serous vascular PED lesions showed an improvement regarding BCVA and morphologic characteristics unless an RPE tear occurred. In fPED lesions, a functional and morphological stabilization was observed. Monthly ranibizumab injections are an effective treatment regarding the resorption of subretinal fluid in vPED due to AMD. Patients should be screened for the presence of morphologic risk factors for RPE tear development before and during treatment.
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Affiliation(s)
- Christoph R. Clemens
- Department of Ophthalmology; University of Muenster Medical Center; Muenster Germany
| | - Armin Wolf
- Department of Ophthalmology; University of Munich; Munich Germany
| | - Florian Alten
- Department of Ophthalmology; University of Muenster Medical Center; Muenster Germany
| | | | - Peter Heiduschka
- Department of Ophthalmology; University of Muenster Medical Center; Muenster Germany
| | - Nicole Eter
- Department of Ophthalmology; University of Muenster Medical Center; Muenster Germany
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Invernizzi A, Nguyen V, Arnold J, Young S, Barthelmes D, Gillies MC. Early and Late Retinal Pigment Epithelium Tears after Anti-Vascular Endothelial Growth Factor Therapy for Neovascular Age-Related Macular Degeneration. Ophthalmology 2017; 125:237-244. [PMID: 28993010 DOI: 10.1016/j.ophtha.2017.08.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/16/2017] [Accepted: 08/30/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To investigate when retinal pigment epithelium (RPE) tears occur and their associated treatment patterns and long-term visual outcomes in patients with neovascular age-related macular degeneration (nAMD) during anti-vascular endothelial growth factor (VEGF) treatment. DESIGN Case-control analysis from a prospectively designed observational database. PARTICIPANTS Treatment-naïve eyes enrolled in the Fight Retina Blindness! observational study that commenced anti-VEGF treatment for nAMD between January 2006 and January 2017 were identified. Cases were defined as eyes in which an RPE tear developed during treatment. Three control eyes per case were matched for age, baseline visual acuity (VA), lesion size, treatment duration before tearing, and duration of follow-up. METHODS Cases were classified as having early or late tears using a segmented regression model. Baseline characteristics were compared between the 2 groups. Comparisons of VA and injections received between tear eyes and control eyes were performed at baseline, before and immediately after the tear, and then 12 and 24 months later. Visual acuity also was compared among different visits within each group. MAIN OUTCOME MEASURES Visual acuity, time to tear, and injections received. RESULTS Fifty-five cases and 165 matched control eyes were included. The segmented regression estimated a breakpoint for the time to tear at 182 days. We therefore defined eyes as having early tears if they tore before the breakpoint (38/55 eyes [69%]), and as late tears if they tore afterward (17/55 eyes [31%]). Baseline VA was significantly lower in early compared with late tears (53.6 vs. 63.4 letters; P = 0.009). Visual acuity had improved in early tears before the tear (+5.6 letters from baseline; P = 0.01), decreased immediately after the tear (-8.3 letters; P = 0.002), then recovered with no difference compared with control eyes 12 and 24 months later (P > 0.05 for both). Late tear eyes had significantly lower VA than control eyes before tearing (55.5 vs. 66.9 letters; P < 0.001). Visual acuity did not decrease significantly after the tear, but continued to decline compared with control eyes at all end points. Both early and late tear eyes received more injections than control eyes after tearing. CONCLUSIONS Retinal pigment epithelium tears act differently depending on when they occur. Long-term visual outcomes in eyes affected by RPE tearing may be related more to the patient's response to therapy than to the tear itself.
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Affiliation(s)
- Alessandro Invernizzi
- Eye Clinic, Department of Biomedical and Clinical Science "Luigi Sacco," Luigi Sacco Hospital, University of Milan, Milan, Italy; Save Sight Institute, University of Sydney, Sydney, Australia.
| | - Vuong Nguyen
- Save Sight Institute, University of Sydney, Sydney, Australia
| | | | | | - Daniel Barthelmes
- Save Sight Institute, University of Sydney, Sydney, Australia; Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mark C Gillies
- Save Sight Institute, University of Sydney, Sydney, Australia
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Capuano V, Farci R, Miere A, Amoroso F, Bandello F, Souied EH, Querques G. Centrifugal Extension of Retinal Atrophy in Retinal Pigment Epithelium Tears Secondary to Age-Related Macular Degeneration. Ophthalmic Surg Lasers Imaging Retina 2017; 48:705-710. [PMID: 28902330 DOI: 10.3928/23258160-20170829-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 07/19/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVE To investigate the progression of retinal atrophy in patients with retinal pigment epithelium (RPE) tears secondary to neovascular age-related macular degeneration. PATIENTS AND METHODS In this retrospective case series, patients were analyzed at two high-volume referral centers. The extension of the areas without RPE was analyzed yearly from baseline to last examination through fundus autofluorescence (FAF) imaging using Region Finder (Heidelberg Engineering, Heidelberg, Germany). RESULTS Sixteen eyes of 14 patients were included in the study. Mean follow-up was 70.11 months ± 15.5 months. The average area of atrophy was 6.89 mm2 ± 5.4 mm2 at baseline and 9.21 mm2 ± 7.7 mm2 at the last visit (P < .0001). This accounts for a progression of 0.36 mm2 ± 0.46 mm2/year. In all cases, FAF revealed centrifugal extension of retinal atrophy. CONCLUSIONS In this series, the area of retinal atrophy enlarged over time. Atrophy enlargement is characterized by centrifugal extension from the base of the tear. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:705-710.].
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Tsai AS, Cheung N, Gan AT, Jaffe GJ, Sivaprasad S, Wong TY, Cheung CMG. Retinal angiomatous proliferation. Surv Ophthalmol 2017; 62:462-492. [DOI: 10.1016/j.survophthal.2017.01.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 01/24/2017] [Accepted: 01/27/2017] [Indexed: 01/06/2023]
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INCIDENCE AND CAUSES OF VISION LOSS DURING AFLIBERCEPT TREATMENT FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2017; 37:1320-1328. [DOI: 10.1097/iae.0000000000001370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Retinal pigment epithelium tears: Classification, pathogenesis, predictors, and management. Surv Ophthalmol 2017; 62:493-505. [DOI: 10.1016/j.survophthal.2017.03.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/28/2017] [Accepted: 03/03/2017] [Indexed: 11/21/2022]
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Giannakaki-Zimmermann H, Querques G, Munch IC, Shroff D, Sarraf D, Chen X, Cunha-Souza E, Mrejen S, Capuano V, Rodrigues MW, Gupta C, Ebneter A, Zinkernagel MS, Munk MR. Atypical retinal pigment epithelial defects with retained photoreceptor layers: a so far disregarded finding in age related macular degeneration. BMC Ophthalmol 2017; 17:67. [PMID: 28506260 PMCID: PMC5433076 DOI: 10.1186/s12886-017-0452-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report patients with age-related macular degeneration and atypical central retinal pigment epithelium (RPE) defects not attributable to geographic atrophy (GA) or RPE-tears with overlying preserved photoreceptor layers. METHODS Multimodal imaging case-series evaluating the course of atypical RPE- defects in patients with AMD using Color fundus images, Optical coherence tomography (OCT), OCT-Angiography, fundus autofluorescence (FAF) and fluorescein-angiography (FA). RESULTS Ten patients were identified. Three patients had a prior RPE-rip and were excluded. Seven patients with a mean follow-up period of 47 ± 38 months after the occurrence of the RPE-defect were included (age range 71-87 years). Mean distance Best corrected visual acuity (BCVA) at initial presentation was 0.36 ± 0.29logMAR and at last follow-up visit 0.51 ± 0.43logMAR. Patients presented with clinically apparent GA on funduscopy and FAF, but preserved photoreceptor layers on optical coherence tomography (OCT). On FA there was early hyperfluorescence and late pooling visible. Over time, migration of RPE/drusenoid material right above the Bruch's membrane with concomitant decrease of hypoautofluorescence was detectable in 4 cases. An enlargement of the RPE-defect was apparent in the remaining 3 cases. The majority (n = 4) showed a drusenoid pigment epithelium detachment (PED) preceding the lesion. CONCLUSIONS Beside GA and characteristic RPE-tears, another atypical form of RPE-defect with overlying preserved photoreceptor layers are found in AMD. This so far disregarded subgroup of patients present with reasonable visual function and long-term survival of photoreceptors layers. Repair mechanisms such as ingrowth of RPE/drusenoid material and persistent subretinal fluid (SRF), but also a RPE-independent visual cycle for cone photopigment within the neurosensory retina may contribute to their favorable course.
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Affiliation(s)
- Helena Giannakaki-Zimmermann
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Bern Photographic Reading Center, Inselspital, University Clinic Bern, Bern, Switzerland
| | - Giuseppe Querques
- Department of Ophthalmology, University Vita-Salute, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Ophthalmology, University Paris Est, CHI, Creteil, France
| | - Inger Christine Munch
- Department of Ophthalmology, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - David Sarraf
- Jules Stein Eye Institute, UCLA, Los Angeles, CA, USA.,Greater LA VA Healthcare Center, Los Angeles, CA, USA
| | - Xuejing Chen
- Jules Stein Eye Institute, UCLA, Los Angeles, CA, USA
| | - Eduardo Cunha-Souza
- University of Sao Paulo, Sao Paulo, Brazil.,Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, Brazil
| | - Sarah Mrejen
- Vitreous Retina Macula Consultants of New York, New York, USA
| | - Vittorio Capuano
- Department of Ophthalmology, University Vita-Salute, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | | | - Andreas Ebneter
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin S Zinkernagel
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Bern Photographic Reading Center, Inselspital, University Clinic Bern, Bern, Switzerland
| | - Marion R Munk
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Bern Photographic Reading Center, Inselspital, University Clinic Bern, Bern, Switzerland. .,Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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Treumer F, Wienand S, Purtskhvanidze K, Roider J, Hillenkamp J. The role of pigment epithelial detachment in AMD with submacular hemorrhage treated with vitrectomy and subretinal co-application of rtPA and anti-VEGF. Graefes Arch Clin Exp Ophthalmol 2017; 255:1115-1123. [PMID: 28280989 DOI: 10.1007/s00417-017-3620-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 01/29/2017] [Accepted: 02/08/2017] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess the incidence of pigment epithelial detachment (PED) in age-related macular degeneration (AMD) with submacular hemorrhage (SMH) and its response to treatment with pars plana vitrectomy (ppV), subretinal co-application of recombinant tissue plasminogen activator (rtPA) and anti-VEGF, and an intravitreal gas tamponade. METHODS Consecutive interventional case series of 132 eyes of 129 patients with neovascular AMD with SMH. All eyes underwent ppV with subretinal co-application of rtPA and bevacizumab followed by a gas tamponade. Postoperatively, two additional intravitreal anti-VEGF injections were applied monthly, followed by intravitreal anti-VEGF injections applied PRN thereafter. PEDs and SMHs were evaluated with SD-OCT pre- and postoperatively. RESULTS Preoperatively, 88 of 132 (67%) eyes were examined by OCT, and in 81 of these eyes the RPE could be visualised. A PED was found in 74 (91%) eyes, and no PED was found in five (6%) eyes. Median height of preoperative PED was 503 μm (range 150-1242, n = 65) and reduced to 344 (n = 62) and 306 μm (n = 27) after 3 and 12 months respectively. Two eyes showed a pre-existing rip of the RPE. Postoperatively, a rip was documented in 12 of 128 (9%) eyes. Median height of SMH was 762 μm (range 217-1840), median diameter was 4.3 (1.5-15) disc diameter. A complete displacement of the SMH from the fovea was achieved in 112 of 129 (87%) eyes. Overall, median best-corrected logMAR visual acuity (BCVA) improved significantly from preoperative 1.6 (0.5-2.0, n = 132) to 1.0 (0.2-2.0) 3 (n = 132) and 12 months (n = 74) postoperatively. Excluding eyes with pre-existing macular scars (n = 22), BCVA 3 months postoperatively was 0.8. Height of PED or SMH did not correlate with postoperatively BCVA, while size of SMH showed a mild correlation (rho = 0.25, p = 0.005). CONCLUSION PpV with subretinal co-application of rtPA and bevacizumab and an intravitreal gas tamponade effectively displaces SMH and improves BCVA. Preoperatively, PED is found in the majority of eyes. Height of PED or SMH did not correlate with postoperatively BCVA. Tears of the RPE occur as frequently as in exudative AMD without SMH.
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Affiliation(s)
- F Treumer
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.
| | - S Wienand
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany
| | - K Purtskhvanidze
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany
| | - J Roider
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany
| | - J Hillenkamp
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.,Department of Ophthalmology, University Medical Center Würzburg, Josef-Schneider Str. 11, 97080, Würzburg, Germany
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42
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Clemens CR, Alten F, Heiduschka P, Eter N. OCT-angiography for assessing risk of retinal pigment epithelium tear in patients with vascular retinal pigment epithelium detachment due to AMD. Acta Ophthalmol 2016; 94:e816-e817. [PMID: 27125762 DOI: 10.1111/aos.13052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Christoph R. Clemens
- Department of Ophthalmology; University of Muenster Medical Centre; Muenster Germany
| | - Florian Alten
- Department of Ophthalmology; University of Muenster Medical Centre; Muenster Germany
| | - Peter Heiduschka
- Department of Ophthalmology; University of Muenster Medical Centre; Muenster Germany
| | - Nicole Eter
- Department of Ophthalmology; University of Muenster Medical Centre; Muenster Germany
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Knickelbein JE, Wei M, Nussenblatt RB, Sen HN. Retinal Pigment Epithelium Tear after Immunosuppressive Treatment for Sarcoidosis-related Choroidal Granuloma. Ocul Immunol Inflamm 2016; 25:820-824. [PMID: 27379730 DOI: 10.1080/09273948.2016.1180402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the formation of a retinal pigment epithelial (RPE) tear following immunosuppressive treatment of a large choroidal granuloma in a patient with sarcoidosis-related panuveitis. METHODS A 25-year-old woman presented with bilateral sarcoidosis-related panuveitis and optic disc edema in both eyes with a large choroidal granuloma temporal to the fovea in the left eye. High-dose oral prednisone therapy was given. RESULTS High-dose oral prednisone therapy produced improvement in her panuveitis with reduction in size of the left choroidal granuloma. An RPE tear overlying the flattening choroidal granuloma developed by 3 weeks of treatment. CONCLUSIONS Treatment of choroidal granuloma with rapid reduction in size may result in an RPE tear.
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Affiliation(s)
- Jared E Knickelbein
- a National Eye Institute, National Institutes of Health , Bethesda , Maryland , USA
| | - Maggie Wei
- a National Eye Institute, National Institutes of Health , Bethesda , Maryland , USA
| | - Robert B Nussenblatt
- a National Eye Institute, National Institutes of Health , Bethesda , Maryland , USA
| | - H Nida Sen
- a National Eye Institute, National Institutes of Health , Bethesda , Maryland , USA
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