Foveal atrophy and macular hole formation following intravitreal ranibizumab with/without photodynamic therapy for choroidal neovascularization secondary to age-related macular degeneration

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Full-Thickness Macular Hole Caused by Acute Subretinal Hemorrhage From Wet Age-Related Macular Degeneration

Purpose: To present a case of full-thickness macular hole (MH) that developed in association with acute subretinal hemorrhage from wet age-related macular degeneration (AMD). Methods: A retrospective observational review of a single case was performed. Results: An 84-year-old man with wet AMD presented with central vision loss and floaters and was noted to have a subretinal hemorrhage and an associated MH, which subsequently progressed to MH-associated macular detachment. The patient had a pars plana vitrectomy with internal limiting membrane peeling, gas tamponade, and prone positioning, resulting in closure of the MH and improvement in visual acuity. Conclusions: A full-thickness MH developed as a result of foveal dehiscence from an acute hemorrhage caused by choroidal neovascularization in wet AMD.

SURGICAL OUTCOMES OF PARS PLANA VITRECTOMY FOR INTRAOCULAR COMPLICATIONS RELATED TO VASOPROLIFERATIVE TUMOR OF THE RETINA

PURPOSE

To investigate the safety and efficacy of vitrectomy pars plana vitrectomy in managing intraocular complications relating to vasoproliferative tumors of the retina (VPL).

METHODS

Retrospective study. 17 patients with VPL who underwent vitrectomy at Sheffield Teaching Hospital NHS Trust from 2005 to 2020 were included. Patient demographics, clinical characteristics, intraoperative data, and surgical outcomes were collected and evaluated.

RESULTS

The mean age was 52 years. Indications for pars plana vitrectomy included epiretinal membrane (n = 7), vitreous hemorrhage (n = 5), retinal detachment (n = 3), diagnostic (n = 1), and others (n = 1). After pars plana vitrectomy, 14/17 (82.4%) have stabilized vision and 3/17 (17.6%) deteriorated. Subgroup analysis of epiretinal membrane peel had good outcomes with 6/7 (85.7%) noticing improvement or stabilization of symptoms and mean logarithm of minimal angle of resolution visual acuity improved from 0.719 [6/30] ± 0.267 [6/12] to 0.476 [6/19] ± 0.271 [6/12]. Patients undergoing surgery for vitreous hemorrhage also had good outcomes with resolution (and no recurrence) of the hemorrhage in 3/5 (60%) and 5/5 (100%) with one or more surgeries, respectively. Outcomes for retinal detachment surgery were logarithm of minimal angle of resolution 2.126 [HM] ± 0.301 [6/12] preoperatively and 1.185 [6/95] ± 0.522 [6/19] postoperatively, with one recurrence of retinal detachment. In the epiretinal membrane group, three patients had adjunctive treatment for VPL intraoperatively and four patients had none, and no difference found between the two groups in outcome or complications. Tumor with thickness of ≥2 mm exhibited inferior visual outcomes compared with <2 mm ( P < 0.05).

CONCLUSION

This is one of the largest data sets in looking at outcomes of vitrectomy for complications of VPL. Pars plana vitrectomy is effective and safe in managing VPL-related intraocular complications with good outcomes and a low rate of complications, especially for patients with epiretinal membrane and vitreous hemorrhage.

INCREASING EVIDENCE FOR THE SAFETY OF FOVEA-INVOLVING HALF-DOSE PHOTODYNAMIC THERAPY FOR CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

A retrospective study was performed with data from the prospective randomized controlled trials, PLACE and SPECTRA, assessing the risk of foveal atrophy and the likelihood of structural and functional improvement on optical coherence tomography, after foveal half-dose photodynamic therapy in chronic central serous chorioretinopathy.

METHODS

A total of 57 chronic central serous chorioretinopathy patients received a single half-dose photodynamic therapy with a treatment spot that included the fovea. Optical coherence tomography scans and fundus autofluorescence images were analyzed for structural improvement and possible atrophy development, at baseline and at several visits after treatment. Main outcome measures were integrity of the external limiting membrane and ellipsoid zone on optical coherence tomography and hypoautofluorescence on fundus autofluorescence.

RESULTS

The subfoveal external limiting membrane was graded as continuous in 21 of 57 of patients (36.8%) at baseline, and the subfoveal ellipsoid zone was graded as continuous in 5 of 57 patients (8.8%) at first visit, which improved to 50 of 51 (98.0%) and 32 out of 51 (62.7%) at the final visit at 2 years, respectively (both P < 0.001). Hypoautofluorescent changes on fundus autofluorescence were present in 25 of 55 patients (45.5%) at baseline and in 23 of 51 patients (45.1%) at the final visit ( P = 0.480).

CONCLUSION

In patients with chronic central serous chorioretinopathy who received a single, foveal, half-dose photodynamic therapy, a significant improvement in structure and function was seen at the final follow-up. None of the patients developed foveal atrophy.

FULL-THICKNESS MACULAR HOLE IN AGE-RELATED MACULAR DEGENERATION PATIENTS WITH TWO DISTINCT ENTITIES: A Multicenter Study

PURPOSE

To describe optical coherence tomography characteristics of full-thickness macular holes (FTMHs) in age-related macular degeneration patients.

METHODS

A multicenter, retrospective, observational case series of patients diagnosed with age-related macular degeneration and FTMHs seen between January 1, 2009, and January 3, 2020. Clinical charts and spectral-domain optical coherence tomography images were reviewed. Optical coherence tomography findings included FTMH-inverted trapezoid or hourglass appearance, central macular thickness (CMT), complete retinal pigment epithelium and complete retinal outer retinal atrophy, and presence of pigment epithelium detachment and epiretinal membrane. The mean outcome was the morphologic and functional characterization of different subtypes of FTMHs.

RESULTS

A total of 86 eyes of 85 consecutive patients, with mean age of 80.31 ± 8.06 and mean best-corrected visual acuity of 1.17 ± 0.58 logarithm of the minimal angle of resolution. Two different subtypes of FTMHs were identified: tractional and degenerative. Fifty (58%) degenerative FTMHs characterized with inverted trapezoid appearance and 36 (42%) tractional FTMHs characterized with hourglass appearance. Degenerative FTMHs presented with 66% of CMT < 240 µm, 14% of CMT > 320, and 70% of complete retinal outer retinal atrophy, in comparison with 41% of CMT < 240 µm, 42.9% of CMT > 320%, and 20% of complete retinal outer retinal atrophy in the tractional FTMH group (P = 0.002, 0.003, <0.001, respectively). The presence of epiretinal membrane and pigment epithelium detachment where significantly higher in tractional FTMHs (P = 0.02, 0.03, respectively).

CONCLUSION

Degenerative and tractional FTMHs may be two distinct clinical entities. Discerning degenerative from tractional FTMHs is possible by using optical coherence tomography features including shape of the FTMHs, CMT, internal-external ratio of FTMHs, and presence of complete retinal outer retinal atrophy, pigment epithelium detachment, and epiretinal membrane.

ATYPICAL MACULAR HOLES

PURPOSE

To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs).

METHODS

A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded.

RESULTS

Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is.

CONCLUSION

With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

Macular hole retinal detachment after intravitreal Conbercept injection for the treatment of choroidal neovascularization secondary to degenerative myopia: a case report

BACKGROUND

We report a case of macular hole (MH) formation and retinal detachment after intravitreal conbercept injection for the treatment of choroidal neovascularization (CNV) secondary to degenerative myopia.

CASE PRESENTATION

A 60-year-old woman presented with blurred vision in her left eye was diagnosed as CNV secondary to degenerative myopia. Intravitreal injection of conbercept, an anti -vascular endothelial growth factor (VEGF) agent, was uneventfully performed in the left eye. Unfortunately, a full thickness MH and retinal detachment was found three weeks postoperatively by ophthalmoscopy and spectral-domain optical coherence tomography. Vitrectomy, internal limiting membrane peeling and silicone oil tamponade were then performed, and macular retina was reattached soon after surgery. However, MH still kept open during three months' follow-up.

CONCLUSION

MH is a quite rare complication of intravitreal anti- VEGF agent injection, tangential contraction secondary to CNV shrinkage and regression caused by anti-VEGF agent is proposed to be the major pathogenesis of MH formation.

Photodynamic Therapy-Induced Macular Hole

A 72-year-old female with neovascular macular degeneration refractory to anti-vascular endothelial growth factor injections underwent photodynamic therapy and subsequently developed a macular hole (MH) associated with vitreomacular traction. After a period of observation, the MH enlarged. Pars plana vitrectomy was performed, and the MH was closed successfully. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:270-272.].

Changing paradigms of anti-VEGF in the Indian scenario

Anti-vascular endothelial growth factors (VEGF) agents have revolutionized the treatment of retinal diseases. Use of anti-VEGF agents in the Indian Scenario present some unique challenges considering the absence of compounding pharmacies, poor penetrance of health insurance and limited affordability of the citizens of a developing economy. To study the changing paradigms of anti-VEGF use in the Indian scenario, all articles published by Indian authors, data from web-based surveys amongst Indian vitreo-retinal specialists were reviewed. In the paucity of compounding pharmacies in India, fractionation and injection techniques differ from those of developed countries. Frequent anti-VEGF monotherapy offers the best anatomical and visual results, but economics of scale do not allow the same in the Indian scenario, resulting in PRN dosing and combination of anti-VEGF with laser photocoagulation, being the commonly employed treatment protocols.

Serious adverse events and visual outcomes of rescue therapy using adjunct bevacizumab to laser and surgery for retinopathy of prematurity. The Indian Twin Cities Retinopathy of Prematurity Screening database Report number 5

AIM

To report serious adverse events and long-term outcomes of initial experience with intraocular bevacizumab in retinopathy of prematurity (ROP).

METHODS

Consecutive vascularly active ROP cases treated with bevacizumab, in addition to laser and surgery, were analysed retrospectively from a prospective computerised ROP database. Primary efficacy outcome was regression of new vessels. Secondary outcomes included the anatomic and visual status. Serious systemic and ocular adverse events were documented.

RESULTS

24 ROP eyes in 13 babies, received single intraocular bevacizumab for severe stage 3 plus after failed laser (seven eyes), stage 4A plus (eight eyes), and stage 4B/5 plus (nine eyes). Drug was injected intravitreally in 23 eyes and intracamerally in one eye. New vessels regressed in all eyes. Vision salvage in 14 of 24 eyes and no serious neurodevelopmental abnormalities were noted up to 60 months (mean 30.7 months) follow-up. Complications included macular hole and retinal breaks causing rhegmatogenous retinal detachment (one eye); bilateral, progressive vascular attenuation, perivascular exudation and optic atrophy in one baby, and progression of detachment bilaterally to stage 5 in one baby with missed follow-up. One baby who received intracameral injection developed hepatic dysfunction. One eye of this baby also showed a large choroidal rupture.

CONCLUSIONS

Though intraocular bevacizumab, along with laser and surgery salvaged vision in many otherwise progressive cases of ROP, vigilance and reporting of serious adverse events is essential for future rationalised use of the drug. We report one systemic and four ocular adverse events that require consideration in future use of the drug.

[Clinical course of patients with exudative-haemorrhagic age-related macular degeneration treated with ranibizumab. Eye2Eye study]

OBJECTIVE

To assess the mean best-corrected visual acuity (BCVA) change in patients with exudative-haemorrhagic age-related macular degeneration (EH-ARMD) after 12-month period of treatment with ranibizumab.

METHODS

A retrospective, multicentre and national study of intravitreal administered ranibizumab was conducted on 2 groups of EH-ARMD patients: only one eye affected (group 1) versus second eye affected (group 2), having the first one affected. Eligible subjects were ≥ 50 years old with primary or secondary active subfoveal EH-ARMD-related choroidal neovascularisation (CNV).

RESULTS

A total of 184 patients (91 group 1 and 93 group 2) were included. Mean age (SD) was 75.3 (7.5) years, and 53.6% were women. The BCVA showed a VA improvement at 12 months of 9.3 (18.0) number of letters in group 1 and 5.1 (16.8) number of letters in group 2 (P<.0001 and P=.0042, respectively). No statistical differences between groups were observed. Lesion characteristics in the total population (baseline vs 12-month) were: drusen (69.1% vs 61.1%), macular haemorrhages (59.0% vs 7.3%), lipid exudates (28.1% vs 8.2%), and retinal pigment epithelium detachment (46.8% vs 19.0%). The optical coherence tomography (OCT) in the total population (baseline vs 12-month) showed a reduction in macular oedema (73.6% vs 20.9%), subretinal fluids (71.3% vs 14.7%), and intraretinal cysts (38.5 vs 19.7%), as well as a reduction of the mean foveal thickness 377.4 ± 109.8μm vs 249.1 ± 67.8μm in group 1 and 354.1 ± 123.2μm vs 254.6 ± 67.4μm in group 2, P<.0001, both groups, with no significant differences between groups.

CONCLUSIONS

Intravitreal administration of ranibizumab for a minimum of 12-months significantly improved the BCVA, decreased lesion characteristics, and reduced the initial mean foveal thickness in patients with CNV primary or secondary to EH-ARMD, both in patients with only one eye affected and in patients with a second eye affected, having the first one affected.

Macular hole after intravitreal bevacizumab injection for choroidal neovascularisation

PURPOSE

The aim of this study was to report a patient who developed a full-thickness macular hole following intravitreal bevacizumab injection.

METHODS

A 78-year-old patient diagnosed with choroidal neovascularisation (CNV) was treated with intravitreal bevacizumab injection.

RESULTS

On the first follow-up visit, a decrease in visual acuity was seen and a small full-thickness macular hole with complete resolution of subretinal fluid was observed in optical coherence tomography (OCT). A second intravitreal injection of bevacizumab was performed. At the subsequent visit, a serious loss of visual acuity and limited regression in choroidal neovascularisation was seen. The OCT showed a larger full-thickness macular hole.

CONCLUSIONS

This case demonstrates that intravitreal bevacizumab injection might be responsible for the development of a macular hole. Clinicians should be cautious that a macular hole may be a complication of intravitreal bevacizumab injection.

Lamellar macular hole formation in a patient with diabetic CME treated by intravitreal bevacizumab injections

A 49-year-old woman with a diagnosis of diabetic cystoid macular edema in both eyes presented with the appearance of a macular hole in the left eye 1 month after intravitreal bevacizumab injection. Optical coherence tomography demonstrated a lamellar macular hole in the left eye. Although vitreomacular traction and epiretinal membrane are the possible underlying causes for the development of lamellar macular hole formation in eyes with cystoid macular edema, in this case previous optical coherence tomography scans revealed the complete separation of the posterior hyaloid membrane and the absence of an epiretinal membrane. The exact mechanism involved in the progression of cystoid macular edema to lamellar macular hole and the contribution of the intravitreal bevacizumab injections to this transformation remain unclear.

Low-fluence photodynamic therapy combinations in the treatment of exudative age-related macular degeneration

AIM

To compare the efficacy of low-fluence photodynamic therapy (PDT) combinations in the treatment of age-related macular degeneration (AMD).

METHODS

Forty-five previously untreated eyes of 45 patients with exudative AMD whose best-corrected visual acuity (BCVA) was ≥0.3 (Snellen) were enrolled. 15 patients in Group I underwent low-fluence PDT (25J/cm(2)-300mW/cm(2)-83sec) and intravitreal pegaptanib combination, 15 patients in Group II underwent PDT (50J/cm(2)-600mW/cm(2)-83sec) and intravitreal pegaptanib combination while, 15 patients in Group III underwent intravitreal pegaptanib monotherapy. Complete ophthalmologic examinations were performed in pre and post treatment visits, and the results were statistically analised. A clinical activity score (CAS) was calculated by using changes in lesion size, amount of hemorrhage, staining pattern in FA and OCT measurement of intra/subretinal fluid. ≤ 3 logMAR lines of decrease in BCVA and decrease in CAS were considered as successful treatment.

RESULTS

The mean age of 19 female (42.2%) and 26 male (57.8%) patients was 72.82±8.02 years. Mean follow-up was 13.93±5.87 months. Lesion type was occult in 28 eyes (62.2%). Treatment success rates according to BCVA assessments were 86.7%, 80%, 60% and mean BCVA decrease were 0.3, 1.0, 2.2 logMAR lines in Group I, II and III, respectively (P>0.05). According to the changes in central macular thickness and CAS, no difference was found among the study groups (P=0.850 and P=0.811, respectively). Patients treated with combination regimens had lower intravitreal injection frequencies (P=0.015).

CONCLUSION

Combination regimen with intravitreal pegaptanib and low-fluence PDT seems to be safe and effective in stabilizing the clinical activity and BCVA in exudative AMD.