Vision-related function after low-dose transpupillary thermotherapy versus photodynamic therapy for neovascular age-related macular degeneration

PURPOSE

To compare the effects of low-dose transpupillary thermotherapy (TTT) and verteporfin photodynamic therapy (PDT) on patient-reported visual function using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) in patients with occult neovascular age-related macular degeneration (AMD).

METHODS

Patients were randomized to receive either low-dose TTT (and sham PDT) (n = 52) or PDT (and sham TTT) (n = 46). Patients were followed for 12 months with retreatment according to clinical assessment. The clinical outcome of this study has been recently reported. The NEI VFQ-25 questionnaire was administered at baseline and at 12 months.

RESULTS

Forty-two patients (80.1%) in the TTT group and 37 patients (80.0%) in the PDT group completed the questionnaire at the 12-month follow-up. The mean change in the NEI VFQ-25 composite score was +1.2 for the TTT group (p > 0.05) and +0.7 for PDT group (p > 0.05). None of the subscale categories showed significant changes between treatment groups at 12 months. Subgroup analysis showed that NEI VFQ-25 scores were lower in patients treated in their better-seeing eye.

CONCLUSION

In this randomized study on patients with occult neovascular AMD, low-dose TTT and PDT appeared to be equally potent at stabilizing patient-reported visual function. However, the study was underpowered for this conclusion to be made firmly. Also, given the impressive results obtained with ranibizumab for all types of neovascular AMD, neither PDT nor low-dose TTT should be considered as first-line treatments.

Contrast sensitivity after intravitreal antivascular endothelial growth factor therapy for myopic choroidal neovascularization

BACKGROUND

To evaluate contrast sensitivity (CS) using Pelli-Robson charts after intravitreal ranibizumab (IVR) (Lucentis, Novartis, Basel, Switzerland) or bevacizumab (IVB) (Avastin, Genentech, South San Francisco, California, USA) in eyes with myopic choroidal neovascularization (mCNV).

METHODS

A retrospective review was performed of 17 consecutive patients treated with IVR (n = 10; 0.5 mg) or IVB (n = 7; 1.25 mg) for mCNV from July, 2006 with follow-ups through September, 2009. Re-treatment was performed at monthly or longer intervals if there was fluorescein leakage in fluorescein angiogram (FAG) and or apparent subretinal fluid in optical coherence tomography (OCT) persisted.

RESULTS

CS improved by a mean of one letter at 1 month (n = 17; p = 0.32), four letters at 3 months (n = 17; p = 0.02), four letters at 6 months (n = 15; p = 0.01), five letters at 9 months (n = 14; p = 0.04) and six letters at 12 months (n = 13; p = 0.03). The mean number of IVR/IVB was 1.6/1.6, 2.6/2.3, 3.1/3.2, 4.1/4.2 and 4.5/4.6 at 1 month, 3 months, 6 months, 9 months, and 12 months, respectively.

CONCLUSIONS

Improvements in Pelli-Robson CS scores were observed during the first year after IVR/IVB in eyes with mCNV.

Time-course and characteristic morphology of retinal changes following combination of verteporfin therapy and intravitreal triamcinolone in neovascular age-related macular degeneration

PURPOSE

To identify characteristic morphological changes of the retina over time and the association with visual function after combined photodynamic therapy (PDT) and intravitreal triamcinolone (IVTA).

METHODS

In this retrospective study, 40 patients (40 eyes) were treated with PDT and same-day IVTA. Optical coherence tomography (OCT), fluorescein angiography (FA) and evaluation of distance visual acuity (VA) were performed. The anatomical changes within intra- and subretinal compartments and their detailed analysis and grading were the main outcome measures.

RESULTS

Intraretinal fluid (IRF) and subretinal fluid (SRF) by OCT decreased until 3 months (p < 0.01). At month 3, intraretinal cystoid spaces (ICS) had resolved or decreased in 84% of eyes, SRF in 58% and pigment epithelial detachment (PED) in 50%. Mean best-corrected VA (BCVA) improved significantly at month 1 (p < 0.01). Mean central retinal thickness (CRT) increased from 334 microm at baseline to 439 microm at day 1 (p = 0.03) before decreasing to 286 microm at day 7 (p = 0.06), 233 microm at month 1 (p = 0.001) and 255 microm at month 3 (p = 0.001).

CONCLUSION

Combined verteporfin/IVTA therapy induces distinct time-related effects on the retina within the different intra- and subretinal compartments.

Effects of vitrectomy on age-related macular degeneration

PURPOSE

To determine whether vitrectomy alters the long-term progression of age-related macular degeneration (AMD).

DESIGN

Retrospective case-control study.

PARTICIPANTS

Forty-four eyes of 22 patients with AMD who underwent vitrectomy in 1 eye were included in the study. The progression of AMD at follow-up in the 22 eyes that underwent vitrectomy was compared with the 22 fellow, nonvitrectomized eyes.

METHODS

The charts and photographs of subjects with Age-Related Eye Disease Study category 3 AMD in both eyes who previously underwent vitrectomy surgery for an epiretinal membrane or macular hole were reviewed. Subjects were excluded if they had had a vitrectomy in both eyes, had <2 years of follow-up, had previous choroidal neovascularization (CNV), retinal detachment, diabetic retinopathy, angioid streaks, high myopia, vascular occlusions, or extensive macular scarring in either eye, or insufficient hospital records or photographs to determine the extent of AMD. Clinical notes throughout the follow-up interval were reviewed. Two vitreoretinal specialists independently graded pre- and postvitrectomy fundus photographs of all eyes in a masked fashion.

MAIN OUTCOME MEASURES

The development or progression of geographic atrophy of the retinal pigment epithelium and the development of CNV.

RESULTS

Twenty-two patients were included. The average follow up interval was 5.5 years (range, 2-15). Choroidal neovascularization developed in 5 control eyes and in 2 vitrectomized eyes, and atrophy developed in 7 control and 4 vitrectomized eyes. The difference between vitrectomized eyes and fellow eyes for the combined end points of RPE geographic atrophy or CNV was significant (P = 0.02).

CONCLUSIONS

In this pilot study, we did not detect that vitrectomy increased the progression of AMD. In fact, it was associated with a reduced progression to geographic atrophy or CNV. Additional studies are needed to confirm or refute this association.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Photodynamic therapy for choroidal neovascularization in young adult patients

We report our experience with photodynamic therapy (PDT) in the treatment of choroidal neovascularization (CNV) in young adult patients. This was a retrospective study of young adults with CNV treated with PDT. Data collected included age, diagnosis, type and size of CNV, number of treatments, visual outcome, and side effects. Ten patients (11 eyes) were included in the study (mean age 27.2 +/- 13.3 years). Etiologies included multifocal choroiditis (3 eyes), idiopathic CNV (5 eyes), central serous chorioretinopathy (1 eye), and toxoplasma (2 eye). The mean number of treatments was 2 +/- 0.7 and the mean follow-up time was 13.1 +/- 9.5 months. Initial visual acuity (VA) ranged from 20/25 to 20/1,200 (mean logMAR 0.6 +/- 0.5), and improved to 20/20 to 20/250 (mean logMAR 0.46 +/- 0.4) (P = 0.51). Of the four eyes that received additional treatment with oral steroids, one of which also received intravitreal bevacizumab (Avastin) injections, all had visual acuity improvement of 2 or more lines, while only two of seven eyes that received PDT alone showed such improvement. PDT can improve visual outcome in a subgroup of young patients with subfoveal CNV especially when supplemented with oral steroid and bevacizumab injections.

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

PURPOSE

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

DESIGN

An open-label, interventional case series.

METHODS

SETTING

Multi-institutional.

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration in treatment-naive patients

PURPOSE

To report the effects of intravitreal bevacizumab (Avastin) in treatment-naive patients with exudative age-related macular degeneration (ARMD) assessed by visual acuity (VA), optical coherence tomography (OCT) and contrast sensitivity.

METHODS

 A prospective, uncontrolled, pilot study of 26 eyes of 26 patients, all previously treatment-naive to photodynamic therapy, argon laser or anti-vascular endothelial growth factor (VEGF), were treated with one or more intravitreal injections of 1.25 mg bevacizumab. Of the 26 patients, 15 (57.7%) had occult choroidal neovascularization (CNV), 6 (23.1%) had predominantly classic CNV and 5 (19.2%) had minimally classic CNV. Ophthalmic outcome measures included changes in standardized Early Treatment Diabetic Research Study (ETDRS) VA, contrast sensitivity and OCT. The patients were examined at baseline and 1 week, 6 weeks, 3 months and 6 months after the first injection. Re-treatment was given on an 'as needed' basis.

RESULTS

 Twenty-four eyes of 24 patients completed 6 months of follow-up. Two patients chose to discontinue the study. Mean ETDRS VA score improved from 55 letters at baseline to 60 letters at 1 week (P < 0.01) and to 61 letters at 6 weeks (P < 0.01). No significant improvement in VA from baseline was found after 3 and 6 months. Patients with pigment epithelial detachment (PED) had a significantly worse outcome in VA at 6 months. Contrast sensitivity improved from baseline to 3 or 6 months, but this improvement was not statistically significant. Mean macular thickness decreased significantly from baseline to all follow-up examinations (P < 0.01).

CONCLUSION

 Mean ETDRS VA improved significantly after 1 and 6 weeks; thereafter, it remained stable throughout the study period. Macular thickness improved significantly at all time points. The results indicate that 1.25 mg intravitreal bevacizumab is associated with functional as well as morphological improvement among treatment-naive ARMD patients.

Prophylactic laser treatment of soft drusen maculopathy: a prospective, randomized Nordic study

PURPOSE

This study aimed to investigate whether mild laser treatment of soft drusen maculopathy might reduce the incidence of choroidal neovascularization (CNV) and/or significantly reduce loss of visual acuity compared with outcomes in a control group.

METHODS

 A total of 135 patients (mean age 70.4 years) were randomized into a treatment group of 67 subjects and a control group of 68 subjects. The treatment group was subdivided into a group of 54 subjects with bilateral soft drusen and a group of 13 subjects with unilateral soft drusen in the study eye and advanced AMD in the fellow eye. The control group was subdivided into a bilateral group of 54 subjects and a unilateral group of 14 subjects. Sub-threshold or barely visible laser spots were scattered on and between drusen in the posterior pole. Inclusion of patients was stopped prematurely as other studies did not show any benefit from the treatment. Mean follow-up time was 3.7 years.

RESULTS

More CNVs developed in the treated group (4/54 eyes in the bilateral group, 3/13 eyes in the unilateral group; 7/67 eyes in total) than in the control group (3/54 eyes in the bilateral group, 2/14 eyes in the unilateral group; 5/68 eyes in total) but these differences were not statistically significant for either the bilateral or unilateral groups (p = 0.20-0.32). No CNV developed in the bilateral treated group before 4 years of follow-up. Visual acuity was significantly reduced from baseline to the last follow-up in all groups (p < 0.0001-0.02) except the unilateral control group (p = 0.08), but there were no significant differences between the treated and control groups for either the bilateral or unilateral groups (p = 0.17-0.97).

CONCLUSIONS

 Mild prophylactic laser treatment of soft drusen maculopathy was neither beneficial nor harmful and cannot be recommended.

Introduction: Understanding the role of angiogenesis and antiangiogenic agents in age-related macular degeneration

Inhibition of angiogenesis is critical in the prevention and treatment of neovascular age-related macular degeneration (AMD). Pathologic states such as hypoxia, ischemia, or inflammation may tip the balance of proangiogenic and antiangiogenic factors in favor of the formation of new blood vessels. Vascular endothelial growth factor (VEGF) is pivotal in ocular angiogenesis because it is highly selective for endothelial cells, hypoxia drives its synthesis, it diffuses to its target, and it affects multiple components of angiogenesis such as endothelial cell proliferation, survival, and migration. Basic and clinical research implicates VEGF in the pathogenesis of choroidal neovascularization (CNV), although other candidate factors involved with regulation of angiogenesis exist. Intravitreal drugs that block VEGF have revolutionized the care of patients with neovascular AMD, decreasing growth and leakage from choroidal neovascular lesions and preventing moderate and severe vision loss associated with this process.

Long-term results of intravitreal bevacizumab injection for choroidal neovascularization secondary to angioid streaks

PURPOSE

To investigate the long-term efficacy of intravitreal injections of bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) for choroidal neovascularization (CNV) secondary to angioid streaks.

DESIGN

Observational case series.

METHODS

Fifteen eyes of 13 patients (5 men, 8 women; mean age, 59 years; range, 54 to 70 years) treated with 1-mg intravitreal bevacizumab injections were included. The minimum follow-up after the first injection was 12 months. Eyes that had undergone previous treatments were excluded. The best-corrected visual acuity (BCVA) was measured. Optical coherence tomography and fluorescein angiography images were examined before and after treatment.

RESULTS

The mean follow-up was 19 months (range, 12 to 24 months). The mean number of injections for primary CNV was 4.5 (range, 1 to 9). The mean preoperative BCVA (decimal equivalent) was 0.39 (range, 0.08 to 1.5) and 0.47 (range, 0.06 to 1.2) at the final visit (P = .355). The BCVA improved by 2 lines of logarithm of the minimum angle of resolution visual acuity at the final visit in 5 eyes (33%), was unchanged in 8 eyes (54%), and decreased in 2 eyes (13%). The final fluorescein angiography examination showed no leakage in 10 eyes (67%), minimal leakage in 2 eyes (13%), and persistent or recurrent leakage in 3 eyes (20%). Five eyes (33%) had a recurrence 4 to 7 months (mean, 5.1 months) after the last bevacizumab injection. New CNV lesions developed in different areas in 3 eyes (20%) 6 to 14 months after the last bevacizumab injection for primary CNV.

CONCLUSIONS

An intravitreal injection of bevacizumab seems to maintain visual acuity. However, CNV frequently recurred or new CNV developed during the long follow-up.

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

PURPOSE

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

DESIGN

Retrospective, comparative, interventional case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Change in area of geographic atrophy in the Age-Related Eye Disease Study: AREDS report number 26

OBJECTIVE

To characterize progression of geographic atrophy (GA) associated with age-related macular degeneration in AREDS as measured by digitized fundus photographs.

METHODS

Fundus photographs from 181 of 4757 AREDS participants with a GA area of at least 0.5 disc areas at baseline or from participants who developed bilateral GA during follow-up were scanned, digitized, and evaluated longitudinally. Geographic atrophy area was determined using planimetry. Rates of progression from noncentral to central GA and of vision loss following development of central GA included the entire AREDS cohort.

RESULTS

Median initial lesion size was 4.3 mm(2). Average change in digital area of GA from baseline was 2.03 mm(2) (standard error of the mean, 0.24 mm(2)) at 1 year, 3.78 mm(2) (0.24 mm(2)) at 2 years, 5.93 mm(2) (0.34 mm(2)) at 3 years, and 1.78 mm(2) (0.086 mm(2)) per year overall. Median time to developing central GA after any GA diagnosis was 2.5 years (95% confidence interval, 2.0-3.0). Average visual acuity decreased by 3.7 letters at first documentation of central GA, and by 22 letters at year 5.

CONCLUSIONS

Growth of GA area can be reliably measured using standard fundus photographs that are digitized and subsequently graded at a reading center. Development of GA is associated with subsequent further growth of GA, development of central GA, and loss in central vision.

Efficacy of intravitreal bevacizumab (Avastin) therapy for early and advanced neovascular age-related macular degeneration

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab therapy for early and advanced neovascular age-related macular degeneration (ARMD).

METHODS

A consecutive series of eyes with neovascular ARMD treated with monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml) as long as there was evidence of activity on fluorescein angiography (FA) and optical coherence tomography (OCT) was included and observed for 6 months. For further analysis they were assigned to either an early (untreated/newly diagnosed) or an advanced (predominantly fibrotic/pre-treated) ARMD group. We examined distance visual acuity (VA) with Early Treatment Diabetic Retinopathy Study (ETDRS) charts and central retinal thickness with OCT, as well as lesion size and safety aspects.

RESULTS

Forty-four patients (44 eyes) were enrolled (21 early lesions, 23 advanced lesions). Mean VA changed from 0.74 logMAR at baseline to 0.68 logMAR at month 6 (P = 0.01). Improvement in VA was statistically significant only in eyes with early lesions (n = 21) from month 1 (P = 0.015) up to month 6 (P = 0.03). The changes in central retinal thickness (CRT) (P < 0.001) and total lesion size (P < 0.001) were significant in both groups (early and advanced) at all time-points during follow-up. No significant ocular or systemic adverse effects were observed.

CONCLUSION

Intravitreal bevacizumab was tolerated well by our patients and we did not identify any apparent short-term safety concerns. We observed stabilization in VA overall, with significant improvement in the early lesion group.

Ocular haemodynamic changes after single treatment with photodynamic therapy assessed with non-invasive techniques

PURPOSE

To investigate in patients with neovascular age-related macular degeneration (ARMD) the changes in ocular perfusion caused by single treatment with photodynamic therapy (PDT) by different non-invasive methods; to evaluate correlations between relative changes of ocular haemodynamic parameters after PDT among each other and compared to morphological parameters; and to assess this in relation to early changes of visual acuity.

METHODS

STUDY POPULATION

17 consecutive patients with subfoveal choroidal neovascularization (CNV) caused by ARMD scheduled for PDT without previous PDT treatment (four patients with predominantly classic CNV and 13 patients with occult CNV).

OBSERVATION PROCEDURES

best-corrected visual acuity (before PDT, 6 and 8 weeks after PDT), fundus photography, fluorescein angiography, haemodynamic measurements with laser Doppler flowmetry (LDF), laser interferometry and ocular blood flow (OBF) tonometry (baseline and 1, 2, 6 and 8 weeks after treatment).

MAIN OUTCOME MEASURES

choroidal blood flow (CHBF), fundus pulsation amplitude (FPA), pulsatile ocular blood flow (POBF), visual acuity. Changes smaller than 20% were considered clinically irrelevant.

RESULTS

Ocular haemodynamic parameters did not change significantly in the follow-up period. Changes of haemodynamic parameters showed no correlation to treatment spot, morphological changes or visual acuity. Changes of visual acuity were comparable to results of earlier studies.

CONCLUSION

Single treatment with PDT did not modify ocular blood flow parameters above 20% as assessed with different non-invasive methods.

Visual acuity and its decrease in classic neovascular age-related macular degeneration

PURPOSE

To identify factors affecting visual acuity and its decrease in eyes with subfoveal choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD).

METHODS

Distance visual acuity was recorded at screening and up to five follow-up visits during the first year of a randomized, double-blind, placebo-controlled trial of oral prinomastat. Subjects had AMD in both eyes and neovascular AMD in at least one eye. Analysis employed a generalized linear mixed model.

RESULTS

Of 158 eligible subjects (age 56-90), 125 (79.1%) received prinomastat. Visual acuity was independently affected by relative acuity of the fellow eye, whether the study eye had been the first or second to develop CNV, age, current smoking, leakage area, and prior photocoagulation. Decrease in visual acuity score, unaffected by prinomastat, was less steep in eyes that had been second to develop CNV. Such eyes had a comparable time since CNV onset to other study eyes.

CONCLUSION

Fellow eye features independently affect visual acuity and its decrease in eyes with classic neovascular AMD.

Transpupillary thermotherapy of occult CNV with no or minimally classic CNV in age-related macular degeneration

Transpupillary thermotherapy (TTT) has been suggested as a putative treatment for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). This prospective study comprised 66 consecutive patients referred for exudative AMD with predominantly occult subfoveal CNV. Based on fluorescein angiography, there were 38 cases with occult CNV only, and 28 eyes with minimally classic CNV as well. Visual acuity was determined using the logarithmic ETDRS chart. For TTT a diode laser (810nm) with a power of 800 mW or 500-600 mW for a 3.0 mm spot was used (duration 60 sec.). Follow-up included clinical examination with biomicroscopy and fluorescein angiography at 2-3 months and 6 months in all cases. In the entire case material (n = 66), the mean visual acuity was preoperatively 20/125 (47.4 letters) and postoperatively 20/160 (41.8 letters) yielding a decay of 5.6 letters ("one line"). Visual acuity improved in 8 cases (12.1%), deteriorated in 17 (25.8%), and remained stable in 74.2%. In purely occult CNV visual acuity remained stable in 81.6% as compared to 64.3% in occult & minimally classic CNV; the former subgroup lost on the average 3.6 letters, the latter 8.3 letters (close to "two lines") over 6 months. The proportion of eyes losing at least 15 letters was 13.2% in purely occult CNV versus 35.7% in the occult & minimally classic subgroup. In 39 of 66 cases (59.1%) fluorescein leakage regressed to staining only concomitant with absorption of subretinal fluid. Complications associated with deterioration of visual acuity (17 cases) included postoperative hemorrhage, increase of exudation on angiography, and progressive fibrosis. The results indicate that TTT stabilizes visual acuity concomitant with regression of exudation and resorption of subretinal fluid in the majority of cases with predominantly occult CNV Cases with occult CNV only seem to do better than those with minimally classic CNV as well. The safety and complication rate appear to be acceptable. A randomized controlled trial is in progress.

Fixation pattern and macular sensitivity in eyes with subfoveal choroidal neovascularization secondary to age-related macular degeneration. A microperimetry study

PURPOSE

To investigate the effects of subfoveal choroidal neovascularizzation (CNV) secondary to age-related macular degeneration (AMD) on macular functional parameters quantified with an automatic fundus perimeter.

METHODS

118 eyes of 98 consecutive patients with subfoveal CNV secondary to AMD were evaluated. Best corrected visual acuity (ETDRS charts), fundus photography, and fluorescein angiography were performed. Microperimetry (fundus-related perimetry) was used to quantify macular sensitivity and fixation pattern (location and stability).

RESULTS

Of 118 eyes: 26 (21.9%) had central, 18 (15.1%) poor central and 74 (63.0%) eccentric fixation; 31 (26.0%) had stable, 42 (35.6%) relatively unstable and 45 (38.4%) unstable fixation. In 75 eyes (63.4%) a dense central scotoma was found. Angiographic classification of subfoveal CNV (occult versus classic) was not significantly related to fixation pattern (location: P = 0.274; stability: P = 0.385), and presence of dense scotoma (P = 0.41).

CONCLUSION

Microperimetric quantification of macular sensitivity and fixation pattern in eyes with subfoveal CNV secondary to AMD offers new data about the impact of visual impairment in these eyes. Moreover, microperimetry improves the functional evaluation of subfoveal CNV in AMD.

Efficacy of transpupillary thermotherapy (TTT) in the treatment of occult subfoveal choroidal neovascularization in age-related macular degeneration

PURPOSE

To determine the efficacy of transpupillary thermotherapy (TTT) in the treatment of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration (ARMD).

METHODS

We conducted a retrospective review of patients with ARMD treated with TTT from June, 1999 through July, 2000 at a retina referral practice. TTT was delivered through a slit-lamp using a modified diode laser at 810 nm wavelength and a spot size of 3 mm delivered at one location for a minimum of 60 seconds duration. Re-treatment was performed at 2-month intervals if indicated.

RESULTS

81 eyes of 77 patients were included in the study. Vision improved greater than one line Snellen in 18 eyes (22%), vision was stable within one line Snellen in 38 (47%), and worsened greater than one line Snellen in 25 (31%). Patients had a mean follow-up of 9 months. The average number of treatments was 1.37 (range 1 to 4). Pretreatment vision was less than or equal to 20/200 in 54% of eyes.

CONCLUSIONS

Transpupillary thermotherapy may stabilize visual acuity in a majority of patients with occult subfoveal choroidal neovascularization secondary to ARMD. Proof of therapeutic benefit is best determined by a randomized clinical trial that is currently underway (TTT4CNV).

Transpupillary thermotherapy of occult choroidal neovascularization in age-related macular degeneration

PURPOSE

To evaluate the efficacy of transpupillary thermotherapy (TTT) in management of occult subfoveal choroidal neovascularization (CNV) in exudative age-related macular degeneration (AMD).

METHODS

Retrospective chart review of eyes that were treated with TTT and had at least 12 weeks of follow-up. Base-line and final ETDRS visual acuity and fluorescein angiography (FA) were compared.

RESULTS

For the 48 eyes which met inclusion criteria, mean pre-operative visual acuity was 20/128 (range: 20/50-20/500). Average follow-up was 27 weeks (range: 12 weeks-55 weeks). At 3 months after treatment, 12 eyes (25%) improved 2 lines or more, 18 eyes (37.5%) had no change or 1 line of visual improvement, and 18 eyes (37.5%) worsened 1 or more lines. No significant adverse event was noted during treatment. Three eyes developed large submacular hemorrhage within 2 months of treatment. Based on clinical examination and FA, 61% of the eyes appeared to have reduction of subretinal fluid compared to pre-operative evaluations.

CONCLUSION

Visual acuity was stable or improved in 62.5% of eyes in our series and the treatment was well tolerated. Longer follow up and larger number of patients would be required to evaluate the ultimate benefit of TTT in management of occult CNV due to AMD.

Intravitreal bevacizumab for treatment of neovascular age-related macular degeneration: the second year of a prospective study

PURPOSE

To demonstrate the efficacy of intravitreal bevacizumab for treatment of neovascular age-related macular degeneration (AMD).

DESIGN

Prospective, open-label, nonrandomized clinical study.

METHODS

Fifty-one patients (51 eyes) with subfoveal choroidal neovascularization (CNV) resulting from AMD participated in this study at the American University of Beirut and Hotel Dieu de France Retina Clinics. These patients had already completed 12 months of follow-up. The criteria for reinjection were presence of fluid in the macula, increased central retinal thickness (CRT) of at least 100 microm, loss of at least 5 letters of vision associated with increased fluid in the macula, new classic CNV, or new macular hemorrhage. The main outcome measure was the proportion of eyes losing fewer than 15 letters of vision after 12 months.

RESULTS

Fifty-one patients (51 eyes) completed the additional 12 months. Mean visual acuity improved from 45.7 letters at baseline to 54.3 letters at 24 months (P = .001), and 47 eyes (92.2%) lost fewer than 15 letters. Mean CRT decreased from 327.4 microm at baseline to 246.6 mum at 24 months (P < .001). A mean of 1.5 injections were administered over the course of the second year. No serious ocular or systemic side effects were noted.

CONCLUSIONS

Eyes with neovascular AMD treated with intravitreal bevacizumab over 2 years had significant anatomic and functional improvement compared with baseline. Further studies are necessary to confirm the long-term efficacy and safety of this treatment.

[Electroretinography in the diagnosis and monitoring of treatment for neovascular age-related macular degeneration: Communication 1]

The pathophysiological mechanisms responsible for the development of choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) still remain to be little studied and clinical electrophysiology that has a wide spectrum of objective studies plays a great role in the assessment of regularities of retinal functional changes in this disease. Recording of different types of electroretinograms (ERG) from the ISCEV standards and multifocal ERG is most extensively used to characterize CNV. The review considers the pattern of ERG changes in normal physiological aging and the specific features of suppressed retinal electrogenesis in neovascular ARMD. The diagnostic capacities of different electroretinographic methods, their disadvantages and limits in the evaluation of retinal functions in patients with CNV are compared.

Intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization in age-related macular degeneration

PURPOSE

This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD).

METHODS

Twelve eyes of 12 patients (mean age 76 +/- 6 years) with mean best corrected visual acuity (BCVA) of 20/100 and occult subfoveal CNV at fluorescein angiography (FA), indocyanine-green (ICG) angiography and optical coherence tomography (OCT), showing intra- or subretinal fluid with or without retinal pigment epithelial detachment (PED), underwent multiple intravitreal injections (mean 2.4 +/- 0.7) of 1.25 mg (0.05 ml) bevacizumab. Visual acuity and OCT findings were assessed at the end of follow-up.

RESULTS

After a mean follow-up of 5.7 +/- 2 months, BCVA improved from 20/100 (range 20/50-20/303) to 20/60 (range 20/28-20/200) (p = 0.038). Five eyes (42%) increased BCVA by > or = 3 lines, six eyes (50%) increased BCVA by < 3 lines and one eye (8%) remained stable. Macular thickness decreased from 298 +/- 71 microm to 223 +/- 72 microm (p = 0.017). No ocular or systemic side-effects were observed.

CONCLUSIONS

Short-term results suggest that multiple intravitreal injections of 1.25 mg bevacizumab are well tolerated and associated with significant improvements in BCVA and decreased retinal thickness by OCT in most patients with treatment-naïve occult CNV. Further evaluation of intravitreal bevacizumab for the treatment of occult CNV is warranted.

Photodynamic therapy with intravitreal application of triamcinolone acetonide in age-related macular degeneration: functional results in 54 patients

PURPOSE

This study aimed to investigate the functional results, efficacy and complications after photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide injection (IVTA) in patients with choroidal neovascularization (CNV) caused by age-related macular degeneration (AMD).

METHODS

A retrospective analysis of clinical data for 54 patients with CNV resulting from AMD was carried out. All patients had a follow-up of 12 months. The patients were treated with standardized PDT and IVTA (4 mg) as a first-line treatment or following PDT failure. Visual acuity (VA), greatest linear diameter (GLD) of the CNV and foveal thickness were evaluated.

RESULTS

Mean VA at baseline was 0.8 logMAR (0.4-1.4). After 12 months VA improved (> 2 lines) in 20.4% of patients and stabilized (+/- 2 lines) in 64.8%. There was no statistical significance in VA outcome between patients undergoing first-line treatment and patients with PDT failure; however, fewer PDT treatments were required to stop CNV activity in patients undergoing first-line treatment. At 12 months, a reduction in foveal thickness was seen in 67.7% of patients and a reduction in CNV GLD in 32.7%. Complications occurred in 22% of patients and included a transient rise in intraocular pressure, cataract and sterile hypopyon.

CONCLUSIONS

Our analysis shows that fewer PDT treatments were required to stop CNV activity when triamcinolone was used as first-line treatment. We can thus conclude that PDT combines synergistically with IVTA and the combination may lead to a cost reduction compared with PDT therapy alone. The overall complication rate of 22% is high and must be compared with complication rates caused by new intravitreal anti-VEGF (vascular endothelial growth factor) drugs in combination with PDT.

ACTA-EVER lecture 2007. The retinal pigment epithelium: friend or foe?

The retinal pigment epithelium (RPE) plays an important role in the physiology and pathophysiology of the vertebrate retina. The RPE absorbs fluid from the retinal extracellular space, via a proton-lactate-water co-transport mechanism located in the apical membrane of the epithelium. This mechanism can account for the apparent capability of the RPE to absorb water against an osmotic gradient. RPE cells participate in retinal wound healing. We have created a porcine model of experimental choroidal neovascularization (CNV). In this model, the CNV eventually becomes enveloped by seemingly proliferating RPE cells. By means of 5-bromo-2-deoxyuridine (BrdU) labelling, we studied the proliferation of RPE cells in the porcine eye after experimental posterior pole injury. Surprisingly, we found that only the peripheral RPE cells incorporated the BrdU label, indicating that central injury elicits peripheral RPE proliferation. This might suggest the existence of a peripheral pool of RPE stem cells. RPE cell proliferation plays a role in the pathological wound healing known as proliferative vitreoretinopathy. Antiproliferative agents have been tried to treat this condition but with little success so far. We report on a drug delivery system under development where a prodrug of the antimetabolite 5-fluoro-uracil (5-FU) is suspended in the silicone oil used as a surgical device in the treatment of proliferative vitreoretinopathy (PVR). The theoretical advantage of this approach is that it allows for long contact times between therapeutic, and non-toxic, concentrations of 5-FU and the RPE.

Clinical and histological aspects of CNV formation: studies in an animal model

The purpose of the present thesis was to develop an animal model of CNV in order to study the early formation of CNV and to test the effects of an anti-angiogenic treatment. Porcine eyes were chosen as a substrate for CNV induction, since they are similar to human eyes in terms of both macroscopic and microscopic morphology. However, a major difference is that pigs lack a fovea; instead they have a visual streak, with a relatively stable and high concentration of cones. By surgical perforation of Bruch's membrane we were able to induce formation of CNV membranes. The morphology and cellular composition of these membranes varied with the surgical technique employed. When RPE cells were locally removed at the time of perforation, the resulting CNV was thinner, contained fewer blood vessels and was less prone to leak on fluorescein angiography than when RPE cells were left intact at induction. The neuroretina overlying the perforation site was not damaged by any of the surgical techniques, thus allowing the subsequent retinal damage to be ascribed to the actual process of CNV formation. Using this animal model allowed us to directly map histological findings onto fluorescein angiograms and thereby perform meaningful correlations between histopathologic and photographic features. Such correlations have been hampered in human subjects, since human eyes are not enucleated as a consequence of CNV and are therefore only available for post-mortem studies. In such studies there often is a considerable time-gap between the death of the patient and the latest available fluorescein angiogram, thereby allowing macular pathology to evolve in the interim. Histological examination of the porcine membranes demonstrated that they were composed of RPE cells, glial cells, macrophages, endothelial cells, collagen and smooth muscle fibres, which are the same cellular and fibrillar elements that dominate human CNV membranes. The porcine model was applied to test the effects, in a randomized and masked fashion, of intravitreally injected bevacizumab. Bevacizumab, a pan VEGF A antibody, was found to reduce both the proliferation of endothelial cells in CNV membranes and the propensity to leak in fluorescein angiograms. Immunohistochemically, bevacizumab was detected in the inner limiting membrane, in retinal blood vessels and binding uniformly to the entire CNV membrane without any cellular predisposition. Based on the above findings we believe that the porcine CNV model shows a bearing to human disease and therefore might be used as a tool to obtain improved treatments for this debilitating condition.

Intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the role of bevacizumab in inflammatory ocular neovascularization.

DESIGN

Retrospective, multicenter, consecutive case series of inflammatory ocular neovascularization.

METHODS

Patients with inflammatory ocular neovascularization of varying causes for whom standard therapy failed were treated with intravitreal injection of bevacizumab. Main outcome measures included improvement of best-corrected visual acuity (BCVA) expressed in logarithm of minimum angle of resolution units, response of inflammatory ocular neovascularization by funduscopy and angiography, and decrease in central foveal thickness as measured by optical coherence tomography at the three-month follow-up.

RESULTS

At the three-month follow-up, 84 eyes of 79 patients had been treated with a mean of 1.3 injections (range, one to three). Thirty-four eyes showed juxtafoveal choroidal neovascularization (CNV), 34 eyes showed subfoveal CNV, eight eyes showed peripapillary CNV, and 11 eyes showed neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). BCVA improved 2.4 lines from 0.68 (6/28 or 20/94) to 0.44 (6/17 or 20/55) (P < .001). BCVA improved by one to three lines in 34.5% of the eyes, by four to six lines in 16.7% of the eyes, and by more than six lines in 14.2% of the eyes. Function was unchanged in 23.8% of the eyes. BCVA worsened in 10.7% (zero to three lines in 7.1%, more than four lines in 3.6%). Central foveal thickness decreased from baseline 346 to 252 microm (P < .001). For CNV, 32 eyes (43.2%) had complete regression after the injection, 27 (36.5%) had partial regression, five (6.8%) had no response, and 10 eyes (13.5%) were not evaluated by the contributors. For NVD or NVE, seven eyes (63.6%) had complete regression of new vessels and four eyes (36.4%) had partial regression after the injection.

CONCLUSIONS

Intravitreal bevacizumab led to short-term significant visual improvement and regression of inflammatory ocular neovascularization in a wide variety of inflammatory ocular diseases.

Subretinal surgery and transplantation of autologous pigment epithelial cells in retinal angiomatous proliferation

PURPOSE

The aim of this study was to examine whether the presence of retinal angiomatous proliferation (RAP) is a prognostic factor in subretinal surgery with transplantation of a suspension of autologous retinal pigment epithelial (RPE) cells.

METHODS

Eyes that had been followed for at least 12 months after subretinal surgery were reviewed retrospectively and assigned to group 1 (presence of RAP) or group 2 (lesions without RAP). Main outcome measures were logMAR distance acuity and lesion size at 12 months.

RESULTS

A total of 68 eyes of 68 patients were included; 28 were assigned to group 1 and 40 to group 2. A total of 43% of patients were male and 57% were female. Their mean age was 77.8 years. Mean distance acuity was 1.02 logMAR at baseline and 1.06 logMAR at month 12. Mean lesion size was 27.9 mm(2) at baseline and 29.9 mm2 at month 12. The differences between the groups were not significant.

CONCLUSIONS

The presence of RAP did not significantly influence the outcome after subretinal surgery with transplantation of autologous RPE cells. Other than age, preoperative lesion size and distance acuity were the only predictive factors for postoperative results.

Correlation between CFH Y402H and HTRA1 rs11200638 genotype to typical exudative age-related macular degeneration and polypoidal choroidal vasculopathy phenotype in the Japanese population

BACKGROUND

Typical exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) are two of the major macular diseases found in Asians. Although genomic studies have shown a contribution by CFH and LOC387715/HTRA1 polymorphisms to the development of these two diseases, the correlation of the clinical phenotypes to these genotypes has not been determined in Asian patients.

METHODS

The prevalence of the CFH Y402H and HTRA1 rs11200638 genotypes was determined in 116 patients with typical exudative AMD and in 204 patients with PCV. Potential correlations of these polymorphisms were tested retrospectively and cross-sectionally for bilaterality of the disease, final visual acuity and the greatest linear dimension of the choroidal neovascular (CNV) lesion.

RESULTS

There was no significant difference in the incidence of CFH Y402H (P = 0.598) and HTRA1 rs11200638 (P = 0.290) between eyes with typical exudative AMD and with PCV. There was a significant association between the lesion size and HTRA1 rs11200638. For eyes with typical AMD, the size of the lesion (6363 +/- 2837 microm) was significantly larger in the high-risk homozygous group (AA), than in the low-risk homozygous group (GG) (3866 +/- 1947 microm; P = 0.0003). The same tendency was observed for the size of the lesion in PCV cases (homozygous group: 6347 +/- 2673 microm, non-risk homozygous group: 4405 +/- 2066 microm, P = 1.3 x 10(-5).

CONCLUSIONS

A common genetic background may exist between typical exudative AMD and PCV patients. Among the patients with these two clinical entities, those with a homozygous HTRA1 rs11200638 risk allele had larger CNV lesions.

Efficacy of intravitreal bevacizumab for polypoidal choroidal vasculopathy

AIMS

The aim of the study was to assess the short-term efficacy of intravitreal injections of bevacizumab for polypoidal choroidal vasculopathy (PCV).

METHODS

Intravitreal bevacizumab (1 mg) was injected into 11 eyes of 11 patients with PCV in this retrospective, interventional case series. The main outcome measure was the change in the polypoidal vessels on indocyanine green angiography (IA) 3 months after injection. The foveal height determined by optical coherence tomography and the best-corrected visual acuity (BCVA) also were evaluated before and after treatment.

RESULTS

At baseline, subretinal fluid was observed in five eyes and a pigment epithelial detachment in eight eyes. The foveal height 1 month after injection decreased significantly (p = 0.023), but at 3 months, no significant decrease was observed, although an additional injection was administrated in five of 11 eyes. The IA at 3 months showed resolution of polyps in one eye but residual or enlarged lesions in the other ten eyes. The BCVA did not improve significantly, although the subjects had relatively good BCVA at baseline (mean 0.45).

CONCLUSION

Intravitreal injection of bevacizumab may reduce the fluid from PCV but seems to be ineffective for diminishing its choroidal vascular changes.

The Natural History and Prognosis of Neovascular Age-Related Macular Degeneration

PURPOSE

To describe the natural history and progression of visual loss in eyes with untreated neovascular age-related macular degeneration (AMD).

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Four thousand three hundred sixty-two untreated neovascular AMD patients from published interventional studies.

METHODS

A systematic review of the literature from 1980 to August 2005 was performed. Studies reporting disease progression outcomes for untreated patients with neovascular AMD were included. Outcome measures were summarized using simple counts and means. Random effects meta-analyses were conducted and tests of heterogeneity were performed where appropriate.

MAIN OUTCOME MEASURES

Changes in visual acuity (VA) loss, development of comorbidities, and fellow eye involvement.

RESULTS

Fifty-three primary studies were included. Nearly half of the studies (28) were randomized clinical trials. The quality of the studies was high, with over 80% providing level I or II evidence. Mean baseline VA among study patients was 0.64 logarithm of the minimum angle of resolution (logMAR) (approximately 20/87 Snellen). The mean VA change in logMAR progressed from 0.1 (1 line lost) at 3 months to 0.3 (2.7 lines lost) after 12 months and 0.4 (4 lines lost) after 24 months. The proportion of patients who developed severe vision loss (>6 lines) from baseline increased from 21.3% at 6 months to 41.9% by 3 years. The proportion of patients with VA worse than logMAR 1.0 (20/200 Snellen) increased from 19.7% at baseline to 75.7% by 3 years. Neovascular AMD developed in the fellow eye in 12.2% of patients by 12 months and in 26.8% by 4 years. Meta-analyses of vision outcome by subtype of neovascular AMD were not possible.

CONCLUSIONS

A doubling of the visual angle of presenting VA may be expected to occur in the year after initial presentation in eyes with untreated neovascular AMD. No conclusions can be drawn as to the differences in rates of disease progression by neovascular AMD subtype. The diversity of reporting formats, paucity of long-term natural history data, and heterogeneity among the reported clinical studies impose limits to the clear understanding of long-term prognosis for visual function in neovascular AMD.

Multifocal electroretinography in patients with exudative amd and intravitreal treatment with pegaptanib sodium

BACKGROUND

To objectively investigate central retinal function in patients with choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) before and after treatment with pegaptanib sodium (PS).

METHODS

Patients with CNV due to exudative AMD received intravitreal injections of 0.3 mg PS every sixth week if angiographic activity was evident. Longitudinal observation included recordings with multifocal electroretinography (mfERG) before the first treatment and before each injection at follow-up intervals.

RESULTS

During the observation period of 30.5 +/- 8 weeks (mean +/- SD) a mean number of 5.3 +/- 1.3 injections were applied. Final mean log(MAR) visual acuity decreased, statistically nonsignificant, from 0.67 +/- 0.3 at baseline to 0.74 +/- 0.16. mfERG recordings in 12 patients after 25 +/- 9 weeks evinced a decrease in response density which was statistically significant in the central 5 degrees . Mean P1-amplitudes of ring 1, 2, and 3 were reduced by 66%, 39% and 30%, respectively. During follow-up, implicit times of the P1 components remained stable within 4% of baseline. In three of four patients with vision loss of 2 lines or more, P1-response amplitudes decreased substantially at least 6 weeks prior vision loss.

CONCLUSION

Treatment with PS resulted in a decrease of central retinal function more obvious in mfERG than in VA longitudinal testing. Good correlations were seen between changes in mean vision and changes in mfERG response density components. As a decline in P1-response amplitudes anteceded vision loss in this study, our results indicate a possible role of mfERG to predict vision loss during intravitreal pharmacotherapy.

Ranibizumab-pegaptanib therapy for idiopathic choroidal neovascularization: report of a case

Idiopathic choroidal neovascularization is a rather uncommon condition in children and young adults. While some cases resolve spontaneously, in this case visual acuity deteriorated from 20/25 to 20/80 in the affected eye of a 20-year-old college student. After weighing numerous treatment options, she was treated with an intravitreal injection of Ranibizumab (Lucentis) which induced an involution of the membrane over one month's time. Vision recovered to 20/20-1. A follow-up injection with Pegaptanib sodium (Macugen) was administered to promote further involution of the membrane. Vision remained stable over the next four months with no recurrence of the membrane.

[Photodynamic visudyne therapy for subretinal neovascularization]

A total of 199 sessions of photodynamic therapy (PDT) with visudine were performed in 119 patients (227 eyes) at the Laser Center, T. I. Yeroshevsky Samara eye diseases hospital. Analysis of the changes occurring in visual function in the presence of the subretinal neovascular membrane developing in age-related macular dystrophy and high complicated myopia showed an increase in visual functions in the first 3-6 months after PDT, which is, in the authors' opinion, associated with the diminution of macular edema and the resolution of hemorrhage. In the subsequent months, visual acuity tended to slightly lower. The late follow-up periods (after 1.5 years) saw visual function stabilization. Visudine PDT for subretinal neovascularization is an effective, safe, technically simple, well-tolerable procedure that makes it possible not only to stabilize, but, in many cases, to improve visual functions. A follow-up of patients for as long as 18 months demonstrated that stable visual functions were retained with a slight tendency for their reduction during continued PDT sessions.

Evaluation of minimum clinically meaningful changes in scores on the National Eye Institute Visual Function Questionnaire (NEI-VFQ) SST Report Number 19

PURPOSE

To evaluate responsiveness of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) to changes in visual acuity and to provide estimates of minimum clinically meaningful changes in NEI-VFQ scores.

METHODS

Data were combined from three clinical trials of submacular surgery for subfoveal choroidal neovascularization. Patients who completed NEI-VFQ interviews and visual acuity measurements at baseline and 2 years later contributed data for analysis. Data were analyzed using anchor-based (relating 2-year change in NEI-VFQ to 2-year change in visual acuity using correlation and linear regression) and distribution-based (standardized response mean) methods.

RESULTS

Of 1,015 patients enrolled, 828 patients completed NEI-VFQ interviews and had visual acuity measurements at baseline and 2 years later. Median age of patients was 75 years (range 18 to 94); all patients had subfoveal choroidal neovascularization in at least one eye. Median overall NEI-VFQ score at baseline was 69.9 (mean, 66.5). Based on anchor-based methods, a 2-line change in visual acuity of the better-seeing eye translated to a 3.4-point change in the overall NEI-VFQ score and from 2.4-point to 7.0-point changes in most subscale scores. The NEI-VFQ was sensitive to both gains and losses in visual acuity; the standardized response mean for the overall NEI-VFQ score in patients with a 2-line gain was 0.6 and for patients with 2-line loss was -0.3. In the subgroup of patients with a 2-line loss of visual acuity in the better-seeing eye, patients who had overall NEI-VFQ scores at baseline greater than the median (59.8) had an standardized response mean of -0.9 for the overall NEI-VFQ score and patients who had overall NEI-VFQ scores at baseline at or below the median had a standardized response mean of 0.2 for the overall NEI-VFQ score. A 4-point change in the overall NEI-VFQ and a 5-point change in individual subscale scores corresponded to a small clinically meaningful change.

CONCLUSIONS

The NEI-VFQ was responsive to 2-year changes in visual acuity but was less responsive to changes among patients with poorer NEI-VFQ scores at baseline. Based on this analysis, a 4-point change in the overall NEI-VFQ and a 5-point change in individual subscale scores may be considered minimum clinically meaningful within-person changes in NEI-VFQ scores.

The therapeutic effects of intravitreal bevacizumab in a patient with recalcitrant idiopathic polypoidal choroidal vasculopathy

We describe the clinical course of a patient with therapy refractory polypoidal choroidal vasculopathy (PCV) who was treated with intravitreal bevacizumab (IVB). Prior treatments included photodynamic therapy and intravitreal pegaptanib with poor therapeutic response. Within four weeks of follow-up after a single IVB, the visual acuity improved from count fingers to 20/400 coincident to resolution of subretinal fluid. The visual acuity demonstrated sustained improvement and the macula remained without exudation for 12 months post treatment. Intravitreal injection of bevacizumab should be studied as an effective and relatively inexpensive option for patients with active polypoidal choroidal vasculopathy.

Intravitreal bevacizumab in the treatment of neovascular age-related macular degeneration, 6- and 9-month results

PURPOSE

To evaluate 6- and 9-month follow-up data including the effect on vision and anatomic outcome in patients treated with intravitreal bevacizumab for neovascular age-related macular degeneration (AMD).

STUDY DESIGN

Interventional consecutive retrospective case series. Patients received intravitreal bevacizumab for the treatment of neovascular AMD including choroidal neovascular membranes, pigment epithelial detachment, and macular haemorrhage. Ophthalmic evaluation included log MAR or Snellen acuity, ophthalmic examination, optical coherence tomography, and fluorescein angiography. Repeat injections were given in the presence of persistent leakage or retinal oedema. Change in vision and foveal thickness from baseline was evaluated using the paired Student's t-test.

RESULTS

A total of 112 eyes of 111 patients received injections. Median follow-up was 5 months (range: 1-12 months). Mean log MAR vision pre-injection was 0.84+/-0.03 (n=112); at 3 months was 0.69+/-0.05 (P<0.0001, n=84); at 6 months was 0.74+/-0.06 (P<0.05, n=51); and at 9 months was 0.69+/-0.08 (n=29, P=0.09). Thirteen of 17 patients who received only one injection maintained improved or stable vision at 6 months. Mean baseline foveal thickness was 291+/- 9.72 microm (n=56); at 3 months was 282.7+/-28 (P<0.05, n=31); and at 6 months was 249.7+/-10.3 (P<0.05, n=12). One case of endophthalmitis, three submacular haemorrhages, and three retinal pigment epithelial (RPE) tears occurred.

CONCLUSION

Intravitreal bevacizumab is an effective treatment for neovascular AMD, resulting in improved vision and foveal anatomy at 6 months and even up to 9 months. This treatment is well tolerated in the majority of patients but adverse events may include endophthalmitis, RPE tears, and submacular haemorrhage.

Multifocal electroretinography as a predictor of maintenance of vision after photodynamic therapy for neovascular age-related macular degeneration

PURPOSE

To investigate the role of multifocal electroretinography (mfERG) in predicting the outcome of photodynamic therapy (PDT) for neovascular age-related macular degeneration (AMD).

METHODS

Participants underwent refraction protocol VA assessment using the ETDRS logMAR chart at 1 m, Contrast Sensitivity (CS) using the Pelli-Robson chart at 1 m, fundus fluorescein angiography (FA) and mfERGs in response to 19 segments. Response to PDT was binary (1 = the loss of less than 15 letters at 12 months, 0 = the loss of 15 letters or more) and was used as the dependent variable for logistic regression analysis.

RESULTS

Logistic regression modelling identified mfERG central segment amplitude, lesion size on FA, VA and CS as predictors of outcome (P = 0.05, 0.02, 0.01, 0.03). The model is stable and has excellent discriminability.

CONCLUSION

The outcomes of this study are particularly relevant to patients in the UK who are sometimes treated with PDT alone. A larger prospective study would facilitate development of an index to predict outcome of future treatments for AMD.