Photodynamic Therapy in Retinal Angiomatous Proliferation Stage I

The potential key role of choroidal non-perfusion and rod degeneration in the pathogenesis of macular neovascularization type 3

Macular neovascularization type 3 (MNV3) is a multifactorial disease with distinct epidemiological, clinical, pathomorphological and topographical characteristics. This review of the literature discusses the latest experimental and clinical outcomes that could explain the pathogenesis of retinal neovascularization. Although patients with MNV3 are usually older than those with MNV1 or 2, their lesions do not coexist with, precede, or follow other types in the same eye. The regional distribution of MNV3 lesions is characterized as confined to the parafoveal macula without any involvement of the rod-free foveal area. Focal outer retinal atrophy and choroidal non-perfusion are the main structural features that occur prior to the development of retinal neovascularization. Also, histological and experimental studies of MNV3 and other non-neovascular age-related macular degeneration diseases complicated with MNV3-like lesions strongly suggest rod degeneration contributes to the pathogenesis. Therefore, the retinal neovascularization in MNV3 has a different pathogenesis from the choroidal neovascularization in MNV1 and 2 and emerging evidence indicates that choroidal non-prefusion and rod degeneration play a key role in the pathogenesis of MNV3. Accordingly, we suggest a sequence of pathological events that start with choroidal non-perfusion due to advanced age followed by hypoxia of the outer retina at the parafoveal area. This induces a remarkable degeneration of rods that triggers the growth of retinal neovascularization due to the imbalance of the angiogenic factors in the outer retina.

Intravitreal Anti-Vascular Endothelial Growth Factor Drugs for Retinal Angiomatous Proliferation in Real-Life Practice

PURPOSE

To describe the outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) in the treatment of retinal angiomatous proliferation (RAP) in real-life practice in 7 Italian centers under the Progetto Luce initiative.

METHODS

Clinical data of 95 eyes of 95 patients affected by RAP, regularly followed up and treated with either intravitreal ranibizumab or bevacizumab over 12 months, were examined. After a loading phase of 3 consecutive injections, retreatments were administered following a pro-re-nata regimen on the basis of the persistence or the recurrence of subretinal/intraretinal fluid on optical coherence tomography, or leakage on fluorescein angiography.

RESULTS

Overall, the mean best corrected visual acuity changed from 0.66 to 0.53 LogMAR (P: 0.0003); 36.8% of eyes gained at least 3 ETDRS lines, whereas 13.7% lost >3 lines at the end of the follow-up. Mean central retinal thickness improved from 384 μm at baseline to 262 μm at the 12-month examination (P < 0.001). A serous pigment epithelium detachment (PED) was identified in 68.4% of eyes at baseline, and it was still detectable in 30.5% at the end of follow-up. The mean number of injections was 4.4 over the follow-up. A significantly greater proportion of eyes showed PED resolution in the subgroup treated with ranibizumab (P < 0.001).

CONCLUSIONS

Intravitreal anti-VEGF treatment in routine clinical practice allows a significant improvement in visual function in patients affected by RAP. A limited number of anti-VEGF injections are generally required in most cases.

[Intravitreal ranibizumab for the treatment of retinal angiomatous proliferation]

BACKGROUND

Retinal angiomatous proliferations (RAP) are a subgroup of exsudative or "wet" age-related macular degeneration (wAMD) with devastating reduction of visual acuity in later stages. Intravitreal ranibizumab provides good therapy, but is considered to be less effective than in other choroidal neovascularizations (CNV).

OBJECTIVE

We investigated the efficacy of ranibizumab in late-stage III RAP with retinochoroidal anastomosis compared to the outcome of other CNV lesions.

MATERIALS AND METHODS

The data of all patients with wAMD treated with ranibizumab were retrospectively analyzed. Patients were divided into groups depending on the lesion type into RAP (identified and selected clinically, proven by fluorescein angiography) and CNV lesions (identified by fluorescein angiography only) named occult, minimally and predominantly classic groups. The best-corrected visual acuity (BCVA) was obtained before (at the timepoint "diagnosis"), during (1st, 2nd, and 3rd injection), and after upload ("1st control").

RESULTS

Before first injection, visual acuity decreased in all groups (0.73 to 0.78 logMAR for all CNV, 0.95 to 1.02 logMAR for RAP). During upload there was no further decline in visual acuity but no improvement as well up to the 1st control visit in the RAP group (1.02 to 1.03 logMAR), but a statistically significant increase in all other groups (0.78 to 0.67 logMAR).

CONCLUSION

Treatment of late-stage III RAP with ranibizumab is effective. Stabiliziation of visual acuity can be achieved, but-in contrast to other forms of CNV lesions-no further improvement. Therefore, patients with this special form need to be identified and treated as early as possible.

Intravitreal bevacizumab versus ranibizumab for the treatment of retinal angiomatous proliferation

PURPOSE

To evaluate the effects of intravitreal bevacizumab and ranibizumab treatments in retinal angiomatous proliferation (RAP).

METHODS

Fifty patients affected by RAP were randomly assigned either to intravitreal bevacizumab injection (IVBI) or intravitreal ranibizumab injection (IVRI). After a loading phase including three consecutive monthly injections, the retreatment was administered in cases of persistent RAP. The primary outcome measures were the mean changes in BCVA between the two treatment groups, and the proportion of eyes gaining 1 and 3 lines at the end of the follow-up. Secondary outcomes included central macular thickness (CMT) changes and progression to more advanced stages of RAP.

RESULTS

Fifty patients affected by stage 1 and 2 RAP were recruited. Twenty-six and 24 patients received IVBI and IVRI, respectively. At the baseline, mean best corrected visual acuity (BCVA) values were 0.59 ± 0.21 (LogMAR ± SD, approximately corresponding to 20/80 Snellen Equivalent-SE) in IVBI group and 0.66 ± 0.33 (approximately 20/90 SE) in IVRI group with no statistical difference. At 12-month examination, both groups showed a statistically significant improvement in the BCVA, with a final mean value of 0.43 ± 0.24 (approximately 20/54 SE) in IVBI group and 0.50 ± 0.32 (approximately 20/63 SE) in the IVRI group. A BCVA gain of 1 and 3 lines was registered in 20 and 8 eyes, respectively, in the IVBI group. Similarly, 17 and 7 eyes showed an improvement of 1 or 3 lines, respectively, in the IVRI group. The CMT reduced significantly from baseline to 12-month examination in both groups. A lower proportion of eyes with complete pigment epithelium detachment resolution was noted in the IVBI group than in the IVRI group (40% versus 90%).

CONCLUSIONS

Our study shows that both IVBI and IVRI are equally effective in improving the BCVA over a 1-year follow-up in eyes affected by stage 1 and 2 RAP.

Intravitreal ranibizumab treatment of retinal angiomatous proliferation

PURPOSE

To determine the efficacy of intravitreal injections of ranibizumab in the treatment of retinal angiomatous proliferation (RAP) in neovascular age-related macular degeneration.

METHODS

Retrospective, consecutive case series of 26 eyes (26 patients) treated with intravitreal injections of 0.5 mg ranibizumab for RAP. Patients received intravitreal injections at monthly intervals during upload phase for a 3-month period.

RESULTS

  Mean visual acuity before treatment was 0.75 ± 0.38logMAR (mean ± SD, n = 26). In the upload phase, mean visual acuity improved 4 weeks after the initial injection to 0.6 ± 0.37logMAR (n = 26) and to 0.53 ± 0.34logMAR (n = 26) 4 weeks after the third monthly intravitreal injection of ranibizumab. The mean optical coherence tomography (OCT) central foveal thickness reduced from 345 ± 55 μm at baseline to 215 ± 87 μm at 3 months. In the maintenance phase, mean visual acuity after 6 months was 0.66 ± 0.38logMAR (n = 12) and 0.7 ± 0.37logMAR after 9 months (n = 6). The mean OCT central foveal thickness was 259 ± 59 μm (n = 13) at 6 months and 280 ± 127 μm (n = 6) at nine-month follow-up.

CONCLUSION

Intravitreal ranibizumab resulted in an improvement of visual acuity 4 weeks after the first injection but was more pronounced after 3 months. A reduction in leakage and OCT central foveal thickness was seen 3 months after the commencement of treatment.

Long-term visual outcome of pigment epithelial tears in association with anti-VEGF therapy of pigment epithelial detachment in AMD

PURPOSE

Retinal pigment epithelium (RPE) tears may develop as a complication after anti-VEGF (vascular endothelial growth factor) treatment for pigment epithelial detachments (PEDs) in exudative age-related macular degeneration (AMD). This retrospective study analyses best-corrected visual acuity (BCVA) and foveal involvement after RPE tears that are associated with anti-VEGF therapy due to PED in exudative AMD.

METHODS

A total of 37 patients with RPE tears during anti-VEGF therapy (bevacizumab 12, ranibizumab 21 and pegaptanib 4 eyes) for progressive PED in AMD (PED with occult choroidal neovascularization 25 eyes and PED with retinal angiomatous proliferation 12 eyes) were included in this study. We analyzed BCVA and different morphologic aspects by means of appearance on fluorescein angiography and optical coherence tomography. Mean follow-up was 88 weeks.

RESULTS

RPE tears were diagnosed a mean of 56 days after the first injection. BCVA deteriorated after RPE tear and during follow-up significantly (P<0.001), with 53.2% of eyes being legally blind (WHO, world health organization) at 12 months. RPE-free foveal area, foveal wrinkling of the RPE, and fibrotic scar development were significantly associated with worse visual acuity.

DISCUSSION

RPE tears can be observed in 12-15% of treated eyes during anti-VEGF therapy for PED in exudative AMD. Owing to the close time relationship with the therapy, this complication must be taken into consideration. Visual prognosis is associated with a decrease in vision in the long term, often resulting in a severe visual disability. Relevant factors for a negative visual prognosis were the potential foveal involvement of the central RPE and morphologic fibrovascular transformation of the RPE tear.

Treatment of recurrent retinal angiomatous proliferation with intravitreal triamcinolone acetonide followed by photodynamic therapy with verteporfin: A retrospective case series

OBJECTIVE

The aim of this study was to report the effect on tolerability of combined treatment with intravitreal triamcinolone acetonide (IVT) and photodynamic therapy (PDT) with verteporfin in patients with stage II retinal angiomatous proliferation (RAP) who had been treated previously with PDT and presented with recurrent RAP (R-RAP).

METHODS

This was a retrospective case series of patients with R-RAP after PDT (1-5 treatments) treated once with IVT followed 1 month later by PDT. A visual acuity test, fluorescein and indocyanine green angiography, and optical coherence tomography were performed at baseline and at 1, 3, and 6 months.

RESULTS

Five patients (4 men, 1 woman; mean [SD] age, 76.8 [3.9] years) with 6 eyes diagnosed with stage II R-RAP who had previously been treated with PDT and who received an IVT injection and PDT within 1 month were included in the study. Best corrected visual acuity (BCVA) remained stable after IVT in 5 eyes (83%) and deteriorated in 1 eye (17%). After PDT, BCVA remained stable in 2 eyes (33%) and deteriorated in 4 eyes (67%). IVT treatment combined with PDT also reduced fluorescein leakage. Median lesion size increased 24% before PDT and 61% at 6 months after PDT. One eye had intraocular hypertension at 3 months, and 1 eye developed a pigment epithelial tear after PDT.

CONCLUSION

The results were limited by the number of eyes and relatively short follow-up, but in this study, PDT after IVT did not appear to be as effective or well tolerated in 5 patients who had already been treated with PDT and presented with R-RAP.

Spontaneous resolution of retinal angiomatous proliferation

PURPOSE

To describe a case of spontaneous resolution of retinal angiomatous proliferation (RAP) in a patient with age-related macular degeneration.

METHODS

A 67-year-old woman complained about progressive visual loss in the right eye. Visual acuity was 20/50 in the right eye and 20/20 in the left eye. Detailed ophthalmoscopic examination, fluorescein angiography, indocyanine green angiography, and optical coherence tomography of the right eye were performed.

RESULTS

Fundus examination of the right eye revealed a small extrafoveal hemorrhage with a few hard exudates around a serous retinal elevation. Fluorescein angiography showed late-phase staining with an area of hyperfluorescence interpreted as occult neovascularization. The middle-phase indocyanine green angiograms showed a focal "hot spot" with late intraretinal leakage. Optical coherence tomography performed through the hot spot shown by indocyanine green angiography demonstrated a localized area of increased intraretinal reflectivity and subfoveal optically empty areas corresponding to serous retinal detachment. The patient was diagnosed with stage II RAP. Treatment was recommended, but the patient was lost to follow-up. Five months later, the patient returned to our department with visual acuity of 20/30 in the involved eye. Spontaneous resolution of the angiographic leakage shown by both fluorescein angiography and indocyanine green angiography and restoration of the normal retinal layers by optical coherence tomography were observed.

CONCLUSIONS

To our knowledge, this is the first known case in which angiographic and optical coherence tomography findings depicted the spontaneous regression of RAP.

Combined intravitreal bevacizumab and photodynamic therapy for retinal angiomatous proliferation

PURPOSE

To clarify the efficiency of combined therapy with intravitreal bevacizumab injections and photodynamic therapy (PDT) in patients with retinal angiomatous proliferation (RAP).

DESIGN

Retrospective, observational, consecutive case series.

METHODS

We retrospectively reviewed 11 consecutive eyes with RAP (10 patients; six men, four women) treated with intravitreal bevacizumab injection and PDT. Patients ranged in age from 63 to 89 years old (average, 79 years). No patients had undergone previous treatment, and patients were followed for at least six months. PDT was applied one or two days after the intravitreal bevacizumab (1.25 mg) injection.

RESULTS

The mean best-corrected visual acuity (BCVA) levels at baseline and one, three, and six months after treatment were 0.16, 0.27, 0.31, and 0.29, respectively. A significant improvement in the mean BCVA was observed one, three, and six months after intravitreal bevacizumab injection and PDT (P < .01). The mean improvement in BCVA six months from baseline was 2.64 lines. The BCVA at six months improved in six eyes (54.5%, improved by three lines or more) and was stable in five eyes (45.5%). No patient had a decrease in the BCVA of three or more lines during any six months. The central retinal thickness significantly decreased from 496 +/- 189 microm to 175 +/- 33 microm at six months (P < .001). No patients required retreatment during any six months. No complications such as severe vision loss, endophthalmitis, or systemic events developed.

CONCLUSION

Combined intravitreal bevacizumab and PDT for RAP effectively maintained or improved VA and reduced or eliminated edema in the short-term.

Intravitreal bevacizumab for the treatment of retinal angiomatous proliferation

PURPOSE

To verify the potential efficacy of intravitreal bevacizumab (IVB) injections for the treatment of retinal angiomatous proliferation (RAP).

DESIGN

Retrospective interventional case series.

METHODS

Four consecutive patients affected by RAP at different stages and refractory to photodynamic therapy (PDT). All patients underwent a complete ophthalmic examination including best-corrected visual acuity (BCVA), fluorescein and indocyanine green angiographies, and optical coherence tomography (OCT) at baseline, and after one, three, six, nine, and 12 months. All patients received IVB injections (1.25 mg/0.05 ml).

RESULTS

The best functional response has been achieved in patients with RAP at stages 1 and 2; whereas in stage 3, a detectable recovery of visual acuity was not observed. This improvement was stable over the follow-up period with a concomitant reduction of macular thickness.

CONCLUSIONS

The use of IVB in patients affected by RAP seems to exert morphologic benefits at all RAP stages that does not always correspond a functional improvement.

Retinale Pigmentepithelrisse nach intravitrealem Bevacizumab bei AMD

PURPOSE

Intravitreal injection of the antibody bevacizumab is unofficially becoming more and more the "standard of care" in the treatment of neovascular AMD. After initial concerns about possible systemic adverse events of the drug, intravitreal injection has as yet shown a very good safety profile. Due to the common application of this VEGF inhibitor it is of great importance to report complications that may be related to the use of bevacizumab. In this scope we present a series of patients with predominantly serous detachment of the retinal pigment epithelium (PED), who developed a tear (rip) in the retinal pigment epithelium (RRPE) after intravitreal application of bevacizumab.

METHODS

Our data are based on a prospective, consecutive, interventional case series of 420 patients with neovascular AMD. These patients received at least 1 intravitreal application of 1.25 mg bevacizumab within the period of 1 year. Follow-up examinations were every 4-6 weeks. Visits were documented with best corrected visual acuity according to the ETDRS standard, biomicroscopy of the retina, intraocular pressure measurement, evaluation of central retinal thickness, fluorescein angiography and fundus photography.

RESULTS

Of 420 patients, 74 were classified as having predominantly serous PED. In the further course 13 out of 74 patients developed RRPE. Patients who had an intact subfoveal RPE, gained vision scores of 1.4+/-8.3 ETDRS letters (span width -15 to 14) despite RRPE or had stable Snellen vision of 0.0+/-0.1 logMar. In contrast patients with no subfoveal RPE due to RRPE showed loss of vision of -6.2+/-7.2 ETDRS letters (span width -15 to 1).

CONCLUSION

This case series describes RRPE as a novel complication of intravitreal anti-VEGF therapy with bevacizumab. However, it seems that this complication is limited to the entity of predominantly serous PED. These patients should therefore be informed about the risk of RRPE before initiating anti-VEGF therapy with bevacizumab, although the reverse conclusion to generally exclude patients with PED from anti-VEGF therapy is not justifiable due to therapeutic efficiency and associated gain of vision.