A Multicenter, Cross-Sectional Study of the Incidence of Major Macular Diseases That Cause Visual Impairment and Require Therapeutic Intervention in Greece: The ADVICE Study

Purpose

This multicenter, epidemiological, cross-sectional study aimed to estimate the annual cumulative incidence of major macular diseases that cause visual impairment and require therapeutic intervention in the routine care of Greece.

Methods

The study was carried out between December 2012 and May 2015 in 20 ophthalmology clinics. Over a one-year recruitment period per study site, all treatment naïve adult patients newly diagnosed with wet age-related macular degeneration, visual impairment due to diabetic macular edema or macular edema secondary to retinal vein occlusion requiring therapeutic management and who had not been diagnosed or treated for the same disease in the past were enrolled after providing informed consent. Study data were collected during the single study visit.

Results

A total of 1532 incident cases were enrolled. The estimated annual cumulative incidence of wet age-related macular degeneration, diabetic macular edema and macular edema secondary to retinal vein occlusion requiring therapeutic management was 0.82 [95% confidence interval (CI): 0.76, 0.88; n=723], 0.63 (95% CI: 0.58, 0.69; n=559), and 0.29 (95% CI: 0.25, 0.32; n=250) per 10,000 cases, respectively.

Conclusion

The study provides estimates of the incidence of major macular diseases causing visual impairment and requiring treatment in outpatient hospital settings in Greece, indicating a considerable socioeconomic burden to the healthcare system.

Photodynamic Therapy with Verteporfin of Choroidal Neovascularization in Angioid Streaks: Conventional versus Early Retreatment

PURPOSE

To evaluate the effectiveness of conventional photodynamic therapy with verteporfin (PDT) in a series of patients with macular choroidal neovascularization (CNV) due to angioid streaks and to compare it to the effectiveness of early PDT retreatment.

METHODS

This is a retrospective study of 24 eyes (22 consecutive patients) with subfoveal or juxtafoveal CNV secondary to angioid streaks treated with PDT from September 2000 through February 2003 and that completed at least the first year of follow-up. Until August 2001, retreatments were performed according to the conventional protocol for PDT every 3 months (Group 1, consisting of 11 eyes of 9 patients). After August 2001 (13 more eyes of 13 new patients), retreatments were performed earlier (every 8 weeks) when indicated (Group 2). The follow-up time ranged from 30 to 42 months and from 12 to 30 months in Groups 1 and 2.

RESULTS

At the end of the follow-up, final best-corrected visual acuity decreased in 21 (87.5%), stabilized in 2 (8.3%), and improved in 1 (4.2%) of the total 24 eyes. In all, 19 of the 24 eyes (79.2%) had a final best-corrected visual acuity equal to or less than 20/400. There were not any statistically significant differences in final visual acuity between the two groups.

CONCLUSIONS

In this large series of patients with macular CNV secondary to angioid streaks, the functional and the anatomic results of PDT were not satisfactory, even when retreatments were performed earlier than the conventional time of 3 months.

Lacquer Crack Formation after Photodynamic Therapy

PURPOSE

To report the occurrence of a lacquer crack after photodynamic therapy (PDT) of choroidal neovascularization (CNV) in a patient with pathologic myopia.

METHODS

PDT was performed with verteporfin, which was activated by a diode laser light at 690 nm.

RESULTS

The left eye of a 42-year-old woman was treated with PDT because of juxtafoveal CNV caused by pathologic myopia. No lacquer crack was present in the macula on either fluorescein or indocyanine green angiography before treatment. The CNV subsided after treatment. However, a large lacquer crack underlying a subretinal hemorrhage was formatted in the macula of the treated eye soon after PDT.

CONCLUSIONS

Although the chorioretinal damage produced by PDT is minimal, it is enough to create, directly or indirectly, the basis for the formation of a lacquer crack in an eye with pathologic myopia.

Photodynamic Therapy in Retinal Angiomatous Proliferation Stage I

PURPOSE

To report a case of photodynamic therapy (PDT) treatment in an 85-year-old patient with retinal angiomatous proliferation (RAP) stage I.

METHODS

According to Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy study guidelines, two sessions of PDT with verteporfin were performed, which was activated by a diode laser light at 690 nm.

RESULTS

The left eye was treated with PDT because of RAP stage I. Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease. In particular, the lesion evolved towards stage III, being initially in stage I, with the final result of development of retinal pigment epithelial (RPE) tear after the second session of PDT treatment. CONCLUSIONS; Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease, with the final result of RPE tear after the second session of PDT treatment.

Diffuse Retinal Pigment Epitheliopathy: Treatment with Laser Photocoagulation

PURPOSE

To evaluate the effectiveness of laser treatment in eyes with diffuse retinal pigment epitheliopathy (DRPE).

METHODS

The authors retrospectively reviewed the medical records of 56 consecutive patients (78 eyes) with DRPE. All eyes were treated with digital fluorescein angiography guided argon green laser photocoagulation, direct on the focal retinal pigment epithelium (RPE) leaks and in a grid pattern to the RPE decompensation areas. A processed digital red-free fundus image including all the important traces on it was used as a guide to the laser treatment. The follow-up period ranged from 6 months to 7 years.

RESULTS

At the end of the follow-up time, 70 (89.7%) eyes showed anatomic improvement with complete or partial resolution of the macular exudative lesions. Visual acuity of less than 20/40 was noted in 60 eyes (76.9%) preoperatively compared with 46 eyes (59.0%) finally (p=0.0252). The visual acuity was improved in 19 eyes (24.4%), stabilized in 51 (65.4%), and reduced in only 8 eyes (10.2%).

CONCLUSIONS

In this series of patients with DRPE, the results of laser treatment were uniformly satisfactory producing a gradual resolution of the macular exudative lesions and an improvement or stabilization of the visual acuity.

Changing from bevacizumab to ranibizumab in age-related macular degeneration. Is it safe?

Objective:

To report our experiences in changing from intravitreal bevacizumab to ranibizumab in age-related macular degeneration (AMD).

Design:

Retrospective case series.

Participants and methods:

We retrospectively reviewed the records of 34 patients (36 eyes) who were treated with monthly injections of intravitreal bevacizumab for six months and then switched to monthly injections of ranibizumab for 12 months. Best-corrected visual acuity measurements (BCVA), contact lens biomicroscopy, optical coherence tomography (OCT), and fluorescein angiography were performed at the baseline examination and then monthly. Chi-square test was used for statistical analysis.

Results:

Following bevacizumab treatment, retinal thickness decreased (P = 0.033) while BCVA improved (P = 0.040). Changing from bevacizumab to ranibizumab resulted in a transient decrease in BCVA (P = 0.045) and an increase in retinal thickness (P = 0.042). In addition, three eyes presented with a large subretinal hemorrhage. However, final retinal thickness was better than the initial thickness and the value following the bevacizumab course. No major ocular or systemic side effects were noted.

Conclusions:

Ranibizumab was clinically effective in the long term but the change of treatment from bevacizumab to a half-size molecule with less half-life in the vitreous such as ranibizumab contributed to a transient “instability” in the eye which may have triggered the large subretinal hemorrhage. There is insufficient experience reported in the literature in switching from one agent to another. A prospective study with controls is necessary to determine whether it is safe to change from one medication to another.

A case of polypoidal choroidal vasculopathy. Periphery is equally important for such patients

Background

To report a case of peripheral polypoidal choroidal vasculopathy (PCV) which was treated successfully.

Methods

Interventional case report. Best-corrected visual acuity measurements (BCVA), slit-lamp examination, fundus biomicroscopy, fluorescein angiography (FFA), and indocyanine green angiography (ICGA) were performed at baseline examination and during the follow-up period. The patient underwent ICGA-guided argon laser to treat the active polyps.

Results

An 82-year-old Caucasian man presented complaining of sudden deterioration of peripheral vision in his left eye (LE). His previous ocular history was associated with advanced age-related macular degeneration (AMD) involving both eyes (BE). Fundus examination revealed macular scars in BE and a large hemorrhagic pigment epithelial detachment (PED) temporal to the macula in the LE. ICGA revealed active polyps at the margins of the PED. The patient underwent ICGA-guided argon laser to treat the active polyps. Six months post-laser, the patient regained his peripheral vision with resolution of the hemorrhagic PED and remains stable until now, one year after treatment.

Conclusions

Appropriate treatment and regular follow-up is important in patients with PCV and peripheral lesions even if central vision is lost.

Large subretinal haemorrhage following change from intravitreal bevacizumab to ranibizumab

BACKGROUND

To report 2 cases of large subretinal haemorrhage in 2 patients with age-related macular degeneration when the intravitreal injections were changed from bevacizumab (Avastin) to ranibizumab (Lucentis).

METHODS

Both patients were treated initially with intravitreal bevacizumab 1.25 mg for 4 months (4 injections) and then switched to 0.5 mg ranibizumab which continued for another 6 months. Best-corrected visual acuity measurements, slit-lamp examination, contact lens biomicroscopy, optical coherence tomography and fluorescein angiography were performed at baseline examination and every month.

RESULTS

Both patients showed initial improvement when treated with intravitreal bevacizumab followed by deterioration and development of a large subretinal haemorrhage when changing to intravitreal ranibizumab.

CONCLUSIONS

There is not enough experience switching from one anti-vascular-endothelial-growth-factor agent to another. A prospective study with large series of patients and controls may be necessary in order to determine whether it is safe enough to change from one medication to another.

An unusual optic disc neovascularization in a case of intermediate uveitis associated with multiple sclerosis

PURPOSE

To report a case of intermediate uveitis associated with multiple sclerosis (MS) presenting with a complex of an unusual optic disc neovascularization which was treated successfully.

METHODS

Interventional case report. Best-corrected visual acuity measurements (BCVA), slitlamp examination, fundus biomicroscopy, and fluorescein angiography (FFA) were performed at baseline examination and during the follow-up period. The patient underwent one injection of intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation.

RESULTS

A 28-year-old man presented with decreased vision in the right eye (RE) (BCVA 20/40). Compete examination showed a large new vessels complex on the optic disc of the RE protruding into the vitreous, ischemic vasculitis, and snowbanking inferiorly. Similar findings but less severe were found in the left eye (LE) with mild vitritis. The RE had also mild, diffuse vitreous hemorrhage. All tests were normal including blood tests, Mantoux, and chest X-ray except brain magnetic resonance imaging which showed three demyelinating lesions. Neurologic evaluation was unremarkable for the first year. The clinical appearance was consistent with intermediate uveitis associated with MS. The patient underwent one injection of intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation. After 6 months BCVA increased to 20/20 and the neovascular complex became fibrous in RE. The patient, 2 years after treatment, remains stable.

CONCLUSIONS

Intermediate uveitis may precede the diagnosis of MS. Intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation proved successful in the management of this case.

Photodynamic therapy of choroidal neovascularization with enlargement of the spot size to include the feeding complex

This is a case report of a 83-year-old man with choroidal neovascularization (CNV), due to age-related macular degeneration (AMD) in his right eye. Digital fluorescein (FA) and indocyanine green angiography (ICG) were performed, which disclosed predominantly classic subfoveal CNV and a dilated and tortuous feeding complex. The visual acuity was 20/800. Anti-vascular endothelial growth factor (anti-VEGF) treatment was suggested, however, the patient was not keen to receive an intraocular injection. Modified photodynamic therapy (PDT) with spot size enlarged, to include not only the CNV lesion but the feeding complex as well, was performed. Ten days after one session of PDT, ICG showed absence of leakage from the CNV and complete occlusion of the feeding complex. The visual acuity gradually improved to 20/100 and remained stable during the following 23 months. No evidence of CNV leakage was seen in the FA and ICG during the follow up period. Adjustment of the PDT spot size to include the detectable by ICG feeding complex might be an additional option in order to close the subfoveal CNV and might be considered as an alternative to intravitreal injection of anti-VEGF in selected cases where anti-VEGF treatment is not available.

INTRAVITREAL BEVACIZUMAB COMBINED WITH PHOTODYNAMIC THERAPY FOR THE TREATMENT OF OCCULT CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH SEROUS PIGMENT EPITHELIUM DETACHMENT IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the efficacy of intravitreal injection of bevacizumab combined with photodynamic therapy (PDT) for the treatment of occult choroidal neovascularization (CNV) associated with serous pigment epithelium detachment (s-PED) due to age-related macular degeneration (AMD).

METHODS

In this retrospective study, six patients (six eyes) with subfoveal occult CNV associated with s-PED due to AMD were treated with intravitreal bevacizumab combined with PDT. All patients were treated at baseline with PDT followed by intravitreal bevacizumab 1.25 mg 1 hour later. Afterwards, according to the findings of optical coherence tomography and fluorescein angiography, repeat bevacizumab injections were given, if necessary, monthly for three doses followed by further doses every 3 months. PDT was repeated every 3 months according to the same criteria. Follow-up time was 9 months.

RESULTS

All patients completed their treatment during the first 3 months from baseline. Best-corrected visual acuity (BCVA) improved or remained stable related to the baseline values in all patients at the end of the follow-up time. Mean BCVA improved from 20/67 to 20/42. S-PED and subretinal fluid decreased or disappeared. The mean central 1-mm retinal thickness was reduced from baseline value for the 9-month follow-up period by 128 microm.

CONCLUSION

Intravitreal bevacizumab combined with PDT seems to be a promising treatment with good functional and anatomical results for occult CNV associated with s-PED due to AMD.

Vascular shunt of the optic disc resembling neovascularization in a diabetic patient with optic disc drusen

PURPOSE

To report an insulin-dependent diabetic patient who was referred by the diabetic screening clinic as having proliferative diabetic retinopathy who was found to have bilateral optic disc drusen with optociliary shunt resembling neovascularization on the disc.

METHODS

Complete ocular evaluation including a fluorescein angiography was performed.

RESULTS

Fundus examination showed signs of mild nonproliferative diabetic retinopathy in the right eye and the presence of well-defined optic disc drusen in both eyes with a peculiar vascular abnormality resembling neovascularization on the right disc. The central retinal vein pulsation was normal on digital examination. Autofluorescence confirmed the presence of the optic disc drusen in both eyes. Fluorescein angiography showed no leakage from the optociliary shunt. The vascular abnormality has remained stable for 2 years.

CONCLUSIONS

This case highlights the correlation of optic disc drusen and optociliary shunts which in diabetic patients can be misdiagnosed as neovascularization.

Polypoidal choroidal vasculopathy and exudative age-related macular degeneration in Greek population

PURPOSE

To study the prevalence, the clinical features, and the visual prognosis without treatment of polypoidal choroidal vasculopathy (PCV) in a large series of Greek patients presenting with exudative maculopathy.

METHODS

The medical records, photographs,as well as fluorescein and indocyanine green(ICG) angiograms of a series of 268 consecutive elderly white Greek patients, who were originally diagnosed as having exudative age-related macular degeneration (AMD) were reviewed retrospectively.

RESULTS

In all, 22 of the 268 (8.2%) patients initially suspected of having AMD were ultimately diagnosed with PCV. In 15 of the 22(68.2%) patients with PCV, the polypoidal lesions were located in the peripapillary area. Large soft drusen were present in only two fellow eyes of the 10 (20%) patients with unilateral PCV compared with 120 fellow eyes of the 148 (81.1%) patients with unilateral AMD. At the last examination, 11 of the 22(50%) patients with PCV and 120 of the 246(48.8%) patients with AMD presented a visual acuity of less than 6/60 in at least one eye due to scar formation in the macula.

CONCLUSIONS

PCV is not an infrequent disease in Greece. A measurable number of Greek patients with findings suggestive of exudative AMD will instead have PCV. ICG angiography is important in differentiating between these two clinical entities. In Greeks, polypoidal lesions are predominantly peripapillary and are not usually associated with macular drusen in the fellow eye. PCV and exudative AMD do not differ significantly in terms of their natural course and visual prognosis in Greek patients.

Polypoidal choroidal vasculopathy associated with Doyne's familial choroiditis: treatment with thermal laser

PURPOSE

To report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doyne's familial honeycomb choroiditis (DFHC) and its course after laser treatment.

DESIGN

Interventional case report.

METHODS

Indocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions.

RESULTS

A 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years.

CONCLUSIONS

This is, to our knowledge, the first case of a PCV that occurred secondary to DFHC.

Polypoidal choroidal vasculopathy associated with Doynes familial choroiditis: treatment with thermal laser

PURPOSE

To report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doynes familial honeycomb choroiditis (DFHC) and its course after laser treatment.

DESIGN

Interventional case report.

METHODS

Indocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions.

RESULTS

A 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years.

CONCLUSIONS

This is, to our knowledge, the first case of a PCV that occurred secondary to DFHC. (Eur J Ophthalmol 2004; 14: 264-8).