Submacular surgery for subfoveal choroidal neovascular membranes in patients with presumed ocular histoplasmosis

MANAGEMENT OF NEOVASCULAR OCULAR HISTOPLASMOSIS: Past and Present

PURPOSE

To review the wide variety of treatment modalities available for choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome.

METHODS

A literature search was performed to review the multitude of studies conducted to investigate the efficacy and safety of treatment modalities available for choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome.

RESULTS

Each treatment modality is reviewed, with the studies summarized and presented to support or refute the method of treatment. Two case reports are presented to demonstrate the treatment regimens.

CONCLUSION

This is a comprehensive review of the treatment modalities available to address choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome. Investigators will continue to strive toward higher efficacy and safety with future innovations in the field.

Photodynamic Therapy for Choroidal Neovascularization in Patients with Multifocal Choroiditis and Panuveitis

Purpose

To evaluate the visual benefit of photodynamic therapy (PDT) with verteporfin in patients with choroidal neovascularization (CNV) secondary to multifocal choroiditis and panuveitis over a longer follow-up period.

Methods

A total of 14 eyes of 12 patients (mean age 34 years) with a classic subfoveal CNV (13/14) or juxtafoveal CNV (1/14) were treated with PDT Visual outcome was assessed by best-corrected visual acuity (VA). Morphologic characteristics of CNVs such as localization, size, and activity were monitored by fluorescein angiography.

Results

Patients were followed for 3 to 45 months (mean 23 months). During this period, one to six PDTs (mean 2.4) were performed. At the time of the first PDT no acute inflammation was seen in the affected eyes. Improved or stabilized visual function (VA loss ≤ 2 lines in the Early Treatment Diabetic Retinopathy Study chart) was observed in 71.4% of the eyes. A total of 78% of the eyes showed an inactive scar in the area of CNV after PDT. Treatment failure after PDT occurred due to uninfluenced CNV growth. No further complications were observed.

Conclusions

PDT in subfoveal or juxtafoveal classic CNV secondary to multifocal choroiditis and panuveitis stabilized or improved VA in the majority of patients over a longer follow-up period. No risk factor for failed VA rehabilitation could be defined.

Treatment of CNV secondary to presumed ocular histoplasmosis with intravitreal aflibercept 2.0 mg injection

OBJECTIVE

To assess the efficacy and safety of intravitreal aflibercept injection in the treatment of CNV secondary to presumed ocular histoplasmosis syndrome (POHS).

PURPOSE

To assess safety of intravitreal aflibercept for the treatment of CNV secondary to presumed ocular histoplasmosis syndrome.

METHODS

Masked, open-label, prospective study. Five subjects will receive 2.0 mg aflibercept injection every 8 weeks with 3 initial monthly doses over a 12 month period.

RESULTS

No adverse systemic or ocular were reported. At month six, the mean visual acuity improved by 7.8 ETDRS letters, mean central subfoveal thickness decreased by 38.8 microns and mean OCT volume decreased by 0.076 mm3 . At month twelve, the mean visual acuity improved by 12.4 ETDRS letters, mean central subfoveal thickness decreased by 34.6 microns and mean OCT volume decreased by 0.576 mm3.

CONCLUSION

The use of intravitreal 2.0 mg aflibercept injection for the treatment of CNV secondary to presumed ocular histoplasmosis syndrome yielded no systemic or ocular adverse events and produced improvement in visual acuity and reduction of OCT thickness and volume.

The Chinese medicine formula HB01 reduces choroidal neovascularization by regulating the expression of vascular endothelial growth factor

BACKGROUND

Choroidal neovascularization (CNV) remains the leading cause of newly acquired blindness in the developed world. Currently anti-vascular endothelial growth factor (VEGF) therapies are broadly used to treat neovascular ocular disorders. Here we demonstrate the effect of a traditional Chinese medicine formula, HB01, on CNV.

METHODS

A rat model of laser-induced CNV was used to investigate the effect of HB01 in vivo. The CNV lesions in the eye were evaluated using fundus fluorescein angiography and visualized/quantified using confocal microscopy. Expression of VEGF in the choroidal and retinal tissues was measured using quantitative real-time PCR and immunohistochemistry.

RESULTS

We demonstrated that a traditional Chinese Medicine formula, named HB01, significantly reduced neovascularization in a rat CNV model. The effect of HB01 on CNV was comparable to the intravitreal injection of bevacizumab (Avastin). Our results also suggested that HB01 may reduce CNV partially through inhibiting the expression of VEGF.

CONCLUSIONS

These data support HB01 as an alternative therapy for ocular neovascular disorders.

Inflammatory choroidal neovascular membrane in posterior uveitis-pathogenesis and treatment

Choroidal neovascular membrane (CNVM) formation is a well-documented sight-threatening complication of posterior segment intraocular inflammation (PSII). The aim of this article is to review the basic and clinical science literature on the pathogenesis of CNVM formation in PSII and to present results of a case series. We searched the literature using the mesh terms- inflammation, CNVM, age-related macular degeneration, immunosuppression, photodynamic therapy, steroids, vascular endothelial growth factors and posterior uveitis. Additionally, we evaluated the visual outcome of and clinical response to our standard treatment protocol involving a combination treatment for young patients with inflammatory CNVM. The development of CNVM in PSII is promulgated by infiltrating myeloid cells as well as choroidal and retinal myeloid cell activation, subsequent vascular endothelial growth factors, cytokine and chemokine production and complement activation acting in consort to mediate angiogenic responses. No clear standard of care currently exists for the treatment of inflammatory CNVM and various combinations have been tried. Using our combination treatment, visual acuity improved in four, stabilized in one and worsened in four patients. Though significant advances have occurred in the understanding of the pathogenesis and management of this condition, optimizing therapeutic regimens will require further well-constructed prospective cohort series.

Intravitreal bevacizumab for uveitic choroidal neovascularization

PURPOSE

To report 5 cases of inflammatory choroidal neovascularization (CNV) that were treated with intravitreal bevacizumab.

METHODS

Six eyes of 5 patients with uveitic CNV were treated with 2.5 mg/0.1 mL of intravitreal bevacizumab. Main outcome measures were the changes in BCVA and reduction in the size of the CNV.

RESULTS

The mean follow-up time was 15.3 months. The mean intravitreal injections administered were 2.7. All patients showed a reduction in the size of the CNV with improvement in BCVA in 60% of cases at the last follow-up.

CONCLUSION

Intravitreal bevacizumab may provide an additional strategy in the management of inflammatory CNV.

Intravitreal bevacizumab as initial treatment for choroidal neovascularization associated with presumed ocular histoplasmosis syndrome

PURPOSE

To report a case of juxtafoveal choroidal neovascularization in a patient with presumed ocular histoplasmosis syndrome (POHS) who was treated with intravitreal injection of bevacizumab (Avastin) as initial treatment.

METHODS

A 23-year-old woman with POHS presented with sudden dimness of vision and metamorphopsia in the right eye. The patient was examined with ophthalmoscopy, fluorescein angiography, and optical coherence tomography (OCT).

RESULTS

Fundus examination, fluorescein angiography, and OCT of the right eye revealed a juxtafoveal choroidal neovascularization. Intravitreal injection of bevacizumab was performed with a postoperative improvement of visual acuity and resolution of the distortion.

CONCLUSIONS

This case report describes a case of juxtafoveal choroidal neovascularization associated with POHS that responded remarkably well to intravitreal injection of bevacizumab.

Two-year results of surgical removal of choroidal neovascular membranes related to non-age-related macular degeneration

PURPOSE

To present the 2-year outcomes of surgical removal of non-age-related macular degeneration (AMD)-related choroidal neovascular membranes and to evaluate any association between visual outcome and baseline clinical factors.

METHODS

Retrospective consecutive case series. All patients who had surgery for non-AMD-related choroidal neovascularisation (CNV) between November 1997 and March 2003 under the care of a single surgeon (WA) were included in the study. Baseline data including patient age, duration of subfoveal CNV, preoperative visual acuity (VA), lesion size, lesion components and aetiology were collected. The primary outcome was VA change with secondary outcomes retinal detachment, operative peripheral retinal break formation, CNV recurrence and cataract.

RESULTS

A total of 52 eyes were included in the study. The aetiology of CNV was: punctate inner choridopathy 21 (40%); idiopathic 8 (15%); pathologic myopia 6 (12%); ocular histoplasmosis syndrome 1 (2%); and other 16 (31%). The mean age of patients was 41(range 14-72) years. 24-month follow-up was available for 41 (80%) eyes. The mean logMAR equivalent baseline acuity was 1.1 and mean lesion size 1.2 disc areas. An improvement in VA >1 Snellen line was noted in 26 (63%) eyes, whereas 10 (24%) eyes remained the same (within 1 line) and 5 (12%) lost >1 line of acuity. Improvement in VA was associated with worse baseline VA (84% for eyes with VA <or=6/36 vs 31% for those with VA>6/36, p=0.001). No evidence of association between 2-year visual outcome and any other baseline factor under study was observed. Peripheral retinal breaks were noted in 5 (10%) eyes at the time of surgery, and 3 (5.8%) eyes developed postoperative retinal detachments. Persistent/recurrent CNV was noted in 17 (33%) eyes. The median time to presentation of CNV in these eyes was 27 (range 2-172) weeks. Five eyes underwent cataract surgery during the follow-up period. The mean age of these patients was significantly higher than the mean age of those who did not require cataract surgery (57 vs 37 years, p=0.014).

CONCLUSIONS

Surgical excision of non-AMD-related CNV resulted in improvement of VA in the majority of eyes. Worse presenting acuity was associated with better visual improvements.

Adult retinal pigment epithelial transplantation in exudative age-related macular degeneration

PURPOSE

To improve visual function by retinal pigment epithelial (RPE) cell transplantation and systemic immunosuppression at the time of surgical removal of subfoveal choroidal neovascularization in exudative age-related macular degeneration (AMD).

DESIGN

An interventional case series of RPE transplantation in exudative AMD.

METHODS

Twelve patients (one eye only) underwent subfoveal membranectomy with transplantation of a sheet of adult human allogeneic RPE cells at a single institution and were followed for one year. Eligibility criteria included age >60, best-corrected acuity < or =20/63 and subfoveal neovascularization < or =9 disk areas on preoperative fluorescein angiography. All patients were started on triple immunosuppression postoperatively. The primary outcome measure was best-corrected vision, with contrast sensitivity and reading speed as secondary outcome measures.

RESULTS

The best-corrected visual acuity (P = .085), contrast sensitivity (P = .204), and the reading speed (P = .077) did not change significantly at one year compared with preoperative values. Transplants showed no signs of rejection in patients who were able to continue the immunosuppressants for six months. Postoperative surgical complications included cataract progression requiring surgery (three of eight phakic eyes), retinal detachment (three eyes), intraoperative retinal breaks (two eyes), and macular pucker (two eyes). None of the patients developed cystoid macular edema on postoperative fluorescein angiography or postoperative inflammation.

CONCLUSIONS

A sheet of adult human allogeneic RPE can be transplanted into the subretinal space in AMD patients at the time of subfoveal membranectomy. Systemic immune suppression appeared to prevent rejection of the transplanted tissue, but did not lead to an improvement in visual function.

Photodynamic therapy for inflammatory choroidal neovascularisation unresponsive to immunosuppression

AIM

To report on visual and angiographic outcomes of a consecutive series of patients with inflammatory choroidal neovascular membranes (CNV) unresponsive to systemic immunosuppression treated with photodynamic therapy (PDT).

METHODS

The medical records of six consecutive patients with inflammatory CNVs that failed to respond to systemic immunosuppression and that later underwent PDT were retrospectively reviewed. Patient demographics, visual acuity, and fluorescein angiographic findings were evaluated.

RESULTS

There were five females and one male with a mean age of 40.8 years (range 35-58 years). Four patients had clinical features consistent with punctate inner choroidopathy and two with presumed ocular histoplasmosis. In all cases clinical signs of CNV activity, including subretinal fluid, subretinal blood, hard exudates, and/or recent decrease in visual acuity were present prior to PDT. All patients had been treated with high dose systemic immunosuppressants, which failed to induce regression of the CNV and/or to improve vision. The CNVs were subfoveal in five patients and juxtafoveal in one; all were classified as predominantly classic. Following PDT an improvement in vision occurred in all cases (median improvement of 18 letters, range 3-42 letters). At last follow up, signs of decreased activity in the CNV were detected in all cases. Patients were followed for a median of 10 months (range 9-20 months).

CONCLUSION

PDT appears to be a useful option in the management of patients with inflammatory CNVs unresponsive to immunosuppressive therapies.

Photodynamic therapy for juxtafoveal choroidal neovascularization due to ocular histoplasmosis syndrome

PURPOSE

To report the use of photodynamic therapy with verteporfin in patients with juxtafoveal choroidal neovascularization (CNV) for ocular histoplasmosis syndrome (OHS).

METHODS

Retrospective review. Data regarding the following variables were extracted from patient charts: demographic characteristics, previous surgeries, angiographic features, number and time of treatments, follow-up time, and change in visual acuity.

RESULTS

This study sample consisted of 23 eyes of 23 consecutive patients who were treated with photodynamic therapy for the management of juxtafoveal CNV. When post-treatment visual acuity (mean logMAR acuity=0.321) was compared to baseline acuity (mean logMAR visual acuity=3.89) vision improved by more than three Snellen lines in 30% of eyes, remained the same (+/-2 Snellen lines) in 52% of eyes, and worsened (greater than a two-line loss in visual acuity) in 18% of eyes. Although this series was uncontrolled, the patients had a trend toward a therapeutic benefit when compared to published natural history of similar cases (OR=0.292, P value=0.071 when compared to data from the Macular Photocoagulation Study for treatment of juxtafoveal lesions).

CONCLUSION

Photodynamic therapy with verteporfin may be beneficial in patients with juxtafoveal CNV secondary to OHS in terms of both visual stabilization and improvement.

Photodynamic therapy of subfoveal and juxtafoveal choroidal neovascularization in ocular histoplasmosis syndrome: a retrospective case series

PURPOSE

To evaluate the safety and effect on visual acuity of photodynamic therapy (PDT) with verteporfin in patients with subfoveal and juxtafoveal choroidal neovascular membranes from ocular histoplasmosis syndrome (OHS).

METHODS

Retrospective case series. The visual outcome of 11 patients with subfoveal (n = 6) and juxtafoveal (n = 5) choroidal neovascularization treated with PDT was reviewed. At 1 to 3 months of follow-up, retreatment with PDT was performed if angiography showed leakage.

RESULTS

Within the subfoveal group, 3 patients (50%) had improved vision (two or more lines better than initial vision), 2 patients (33.3%) had no change in vision (within 1 line), and 1 (16.7%) lost four lines of vision. At last follow-up, 3 patients (50%) had vision between 20/20 and 20/40 compared with only 1 patient (16.6%) at the initial visit. Mean follow-up was 13.7 months. Within the juxtafoveal group, 3 patients (60%) had improved vision, 1 patient (20%) had no change in vision, and 1 patient (20%) lost nine lines of vision. At last follow-up, 3 of 5 patients (60%) had vision between 20/20 and 20/40 compared with 2 patients (40%) at the initial visit. Mean follow-up was 10.2 months. No significant adverse effects were reported.

CONCLUSION

PDT is a safe and promising option for patients with OHS with choroidal neovascularization that is subfoveal or juxtafoveal.

Visual prognosis in patients with traumatic choroidal rupture

BACKGROUND

There is a paucity of work in the literature examining the long-term visual prognosis of patients with choroidal ruptures. We performed a study to get a better assessment of long-term visual recovery in these patients as well as to identify prognostic indicators.

METHODS

We reviewed the charts of 32 patients who experienced traumatic choroidal rupture following blunt ocular trauma. All charts contained International Classification of Diseases code 363.63 (choroidal rupture). For inclusion in the study, the chart had to contain detailed drawings or photographic evidence that could confirm the presence and location (foveal, juxtafoveal or extrafoveal) of the choroidal rupture. In addition, demographic data and visual acuity on follow-up examinations had to be present. The mechanism and location of the injury, initial and final visual acuity, associated ocular findings and length of follow-up were recorded.

RESULTS

Of the 32 eyes 31 had indirect choroidal ruptures and I had a direct rupture. The mean final visual acuity values in the foveal, juxtafoveal and extrafoveal subgroups were 20/68, 20/35 and 20/60 respectively after a mean duration of follow-up of 4.5, 3.5 and 4.4 years respectively. There was no statistically significant difference in mean final visual acuity or mean length of follow-up between the three groups. The eight patients with multiple choroidal ruptures had a mean final vision of 20/31 after a mean follow-up period of 3.8 years. The 24 patients with a single choroidal rupture achieved a mean final vision of 20/47 over a mean duration of follow-up of 4.1 years. There was no difference in final vision or in length of follow-up between the two groups. The six patients under 15 years of age attained a mean final vision of 20/34 over a mean follow-up period of 4.5 years, whereas the adult group achieved a mean final vision of 20/44 over a mean follow-up period of 3.8 years. Again, there was no difference in final vision or in length of follow-up between the two groups.

INTERPRETATION

Traumatic choroidal rupture involving the fovea has been thought to have a poor visual prognosis. Our findings show that eyes with foveal choroidal ruptures may regain good central vision over longer follow-up. Furthermore, multiple choroidal ruptures do not necessarily predict a poor visual outcome. Children with choroidal ruptures attained good final visual outcomes.

Verteporfin : a review of its use in the management of subfoveal choroidal neovascularisation

Verteporfin (Visudyne) therapy (photodynamic therapy with intravenous liposomal verteporfin) is the first treatment to effectively prevent the loss of visual acuity in patients with subfoveal choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD), pathological myopia or presumed ocular histoplasmosis syndrome (POHS). In adult patients with classic subfoveal CNV or occult with no classic subfoveal CNV secondary to AMD, or subfoveal CNV secondary to pathological myopia or POHS, verteporfin therapy slows or prevents loss of visual acuity. In well designed clinical trials, verteporfin therapy was superior to placebo in patients with subfoveal classic-containing CNV and occult with no classic CNV secondary to AMD at 12 and/or 24 months (Treatment of Age-related macular degeneration with Photodynamic therapy [TAP] Investigation and Verteporfin In Photodynamic therapy [VIP-AMD] trial) and in patients with pathological myopia at 12 months (Verteporfin In Photodynamic therapy [VIP-PM] trial). Limited data suggest that verteporfin therapy also prevents loss of visual acuity in patients with subfoveal CNV secondary to POHS. Verteporfin therapy was generally well tolerated in clinical trials; most adverse events were mild to moderate in intensity and transient. The most frequently reported verteporfin therapy-related adverse events (incidence >2%) were visual disturbance, injection-site reactions, photosensitivity reactions and infusion-related back pain. Approximately 5% of patients with occult with no classic subfoveal CNV secondary to AMD reported severe vision decrease within 7 days of treatment in clinical trials; 3 months later, several patients had recovered some of this loss.

CONCLUSION

Photodynamic therapy with verteporfin, the first photosensitiser approved for the treatment of subfoveal CNV, is a well tolerated treatment that stabilises or slows visual acuity loss in adult patients with predominantly classic or occult with no classic subfoveal CNV secondary to AMD, and subfoveal CNV secondary to pathological myopia or POHS. Thus, verteporfin therapy provides a valuable option for the management of these patients for whom treatment options are few, and should be considered as a first-line therapy in these difficult-to-manage conditions.

Ocular photodynamic therapy with verteporfin for choroidal neovascularization secondary to ocular histoplasmosis syndrome

PURPOSE

To evaluate the use of ocular photodynamic therapy (OPT) with verteporfin in patients with choroidal neovascularization (CNV) from ocular histoplasmosis syndrome (OHS) and to compare these results with those for a natural history group.

METHODS

A retrospective chart review was performed to identify cases of CNV secondary to OHS treated with OPT. Complete data were available for 38 of 41 eligible eyes. Data regarding the following variables were abstracted from the patient charts: demographic characteristics, previous surgery, angiographic features, number and timing of treatments with OPT, follow-up time, and visual acuity. The visual acuity results of eyes receiving photodynamic therapy were compared with those for a natural history cohort.

RESULTS

On average, OHS patients who received treatment developed 0.88 line of visual improvement. Visual acuity improved or stayed the same in 69% (22 of 32) of eyes, improved by > or = 2 lines in 44% (14 of 32), and improved by > or = 4 lines in 22% (7 of 32). Patients who received OPT were 2.07 times more likely to have improved or constant vision than were those in the natural history group as described in one retrospective series (odds ratio = 2.07; 95% confidence interval, 0.78-5.56; P = 0.162). Thirty-eight percent (12 of 32) of eyes had undergone submacular surgery for CNV before any OPT.

CONCLUSIONS

Ocular photodynamic therapy with verteporfin may be beneficial in patients with CNV secondary to OHS, even in the setting of previous submacular surgery.

Immunotherapy for choroidal neovascularization in a laser-induced mouse model simulating exudative (wet) macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness after age 55 in the industrialized world. Severe loss of central vision frequently occurs with the exudative (wet) form of AMD, as a result of the formation of a pathological choroidal neovasculature (CNV) that damages the macular region of the retina. We tested the effect of an immunotherapy procedure, which had been shown to destroy the pathological neovasculature in solid tumors, on the formation of laser-induced CNV in a mouse model simulating exudative AMD in humans. The procedure involves administering an Icon molecule that binds with high affinity and specificity to tissue factor (TF), resulting in the activation of a potent cytolytic immune response against cells expressing TF. The Icon binds selectively to TF on the vascular endothelium of a CNV in the mouse and pig models and also on the CNV of patients with exudative AMD. Here we show that the Icon dramatically reduces the frequency of CNV formation in the mouse model. After laser treatment to induce CNV formation, the mice were injected either with an adenoviral vector encoding the Icon, resulting in synthesis of the Icon by vector-infected mouse cells, or with the Icon protein. The route of injection was i.v. or intraocular. The efficacy of the Icon in preventing formation of laser-induced CNV depends on binding selectively to the CNV. Because the Icon binds selectively to the CNV in exudative AMD as well as to laser-induced CNV, the Icon might also be efficacious for treating patients with exudative AMD.

Photodynamic therapy of subfoveal choroidal neovascularization with verteporfin in the ocular histoplasmosis syndrome: one-year results of an uncontrolled, prospective case series

OBJECTIVE

To evaluate the safety and effect on visual acuity of photodynamic therapy with verteporfin (Visudyne, Novartis AG) in patients with subfoveal choroidal neovascularization (CNV) secondary to the ocular histoplasmosis syndrome (OHS).

DESIGN

Open-label, three-center, noncomparative prospective case series.

PARTICIPANTS

OHS patients with subfoveal CNV lesions no larger than 5400 micro m in greatest linear dimension (GLD) with classic or occult CNV extending under the geometric center of the foveal avascular zone and best-corrected visual acuity letter score of 73 to 34 (approximate Snellen equivalent 20/40-20/200).

METHODS

Twenty-six patients received verteporfin (6 mg/m(2)) infused IV over 10 minutes. Fifteen minutes after the start of infusion, a laser light at 689 nm delivered 50 J/cm(2) at an intensity of 600 mW/cm(2) over 83 seconds using a spot size with a diameter 1000 micro m larger than the GLD of the lesion. At 3-month follow-up examinations, retreatment with the same regimen was applied if angiography showed fluorescein leakage. Safety assessments were also made.

MAIN OUTCOME MEASURES

Visual function measurements were the changes from baseline in visual acuity and contrast sensitivity scores and the proportion of patients who, based on best-corrected visual acuity scores, (1) gained 7 or more letters, (2) lost 8 or more letters, and (3) lost 15 or more letters.

RESULTS

One patient was omitted from the study at the month 3 examination for not meeting the visual acuity eligibility requirements at baseline. By the month 12 examination, but excluding any retreatment at that visit, patients had received an average of 2.9 treatments of a maximum of 4 possible treatments. The month 12 median improvement from baseline in visual acuity of the remaining 25 patients was 7 letters, and median contrast sensitivity improved by 2 letters. Median visual acuity improvement was also 7 letters when three patients, who failed to meet all photographic eligibility requirements at baseline, were excluded. At the month 12 examination, 14 (56%) patients gained 7 or more letters of visual acuity from baseline, whereas 4 (16%) patients lost 8 or more letters, of which 2 (8%) lost 15 or more letters. No serious systemic or ocular adverse events were reported.

CONCLUSIONS

Median visual acuity improved after verteporfin therapy for at least 1 year in a small uncontrolled prospective case series of patients with subfoveal CNV caused by OHS. Verteporfin therapy seemed to be safe and well tolerated in these patients. Two-year data from this study will provide important, additional information on the safety and effect of verteporfin therapy for the treatment of subfoveal CNV secondary to OHS.

Imaging analysis with optical coherence tomography: relevance for submacular surgery in high myopia and in multifocal choroiditis

PURPOSE

To classify the preoperative and postoperative optical coherence tomography (OCT) findings for subfoveal choroidal neovascularization (CNV) related to high myopia and multifocal choroiditis (MFC) and to correlate these findings with surgical outcome.

METHODS

Ten consecutive patients presenting with subfoveal CNV related to either MFC or degenerative myopia were evaluated. Each patient underwent a biomicroscopic examination, fluorescein and indocyanine green angiographies, as well as OCT before and after surgical removal of CNV. Four different parameters were considered in the analysis of all OCT scans: tissue reflectivity, location of the CNV band, presence or absence of a separation zone, and reflectivity underneath the retinal pigment epithelium (RPE) band.

RESULTS

For all six eyes with MFC, OCT showed a hyperreflective band anterior to the RPE with a separation zone and an optically clear zone underneath the RPE. Visual acuity improved in all six eyes. For the degenerative myopia group (4 eyes), OCT revealed findings similar to those observed for MFC for 1 eye, which had a favorable postoperative outcome. The remaining three myopic eyes with different OCT patterns had poor postoperative outcomes.

CONCLUSION

Optical coherence tomography can provide preoperative clues for submacular surgery. Eyes with CNV located anterior to and separated from the RPE that have an "optically clear zone" underneath are the best candidates for surgical removal. Such a feature was correlated with a good postoperative outcome.

Surgical removal of subfoveal choroidal neovascularization without removal of posterior hyaloid: a consecutive series in younger patients

PURPOSE

Subfoveal choroidal neovascularization (CNV) remains a common and important cause of visual loss. Previous studies have suggested that submacular surgery may improve or maintain visual acuity, particularly in younger patients. The majority of reported cases included removal of the posterior hyaloid during vitrectomy. The authors present a consecutive series of patients age 55 or younger with subfoveal CNV removal without posterior hyaloid removal.

METHODS

Seventeen patients without age-related macular degeneration (ARMD), with subfoveal CNV from choroiditis, presumed ocular histoplasmosis syndrome, myopia, or idiopathic causes, underwent a small retinotomy technique to extract the membranes after vitrectomy without posterior hyaloid removal.

RESULTS

Median improvement in visual acuity was from 20/320 to 20/50. Eleven patients (65%) experienced an improvement of three or more lines of Snellen acuity (average 7.5), 4 (23%) were within two lines of preoperative acuity, and 2 (12%) had decreased acuity, with an average follow-up of 12 months (range 3-31). Choroidal neovascularization recurred in six patients (35%). Postoperative retinal detachment, epiretinal proliferation, or macular hole did not occur.

CONCLUSIONS

In this series of younger patients with subfoveal CNV not from ARMD, visual acuity was improved in the majority after submacular membrane removal. Omission of removal of the posterior hyaloid did not adversely affect outcome.

The Swedish national survey of surgical excision for submacular choroidal neovascularization (CNV)

PURPOSE

To compare the visual outcome after surgical removal of subfoveal choroidal neovascularization (CNV) in patients younger and older than 50 years of age.

METHODS

Patient records from all Swedish centers performing submacular CNV surgery were reviewed and 90 patients treated between 1992-1999 with a follow-up of 6 months or more were included. The results obtained in 49 patients aged 51-89 years (median=72 years) with neovascular disease caused by age-related macular degeneration (AMD) were compared with the outcome of 41 patients aged 6-49 years (median=36 years) with CNV secondary to non-AMD causes. The main outcome measure was the improvement or deterioration in visual acuity (standardized in logMAR units) at 6 months following surgery. Secondary endpoints were recurrent CNV and surgical complications.

RESULTS

The level of preoperative visual acuity was not significantly different between younger patients with CNV associated with non-AMD and older patients with visual loss due to AMD (p=0.069). However, visual acuity at 6 months after surgery was better (p=0.0042) in younger patients (median improvement=0.19 logMAR) than in older patients (median improvement=0.0 log MAR). Marked visual improvement (>1 log MAR unit) was seen in 29% of non-AMD patients <50 years compared to 0% in the AMD group >50 years.

CONCLUSION

Surgical removal of submacular CNV does not appear to improve visual acuity in patients > 50 years of age. However, it may be beneficial for younger patients where a substantial improvement of visual acuity is seen in a subset of these patients. Further studies are required to assess the long-term outcome.

Presumed ocular histoplasmosis syndrome: update on epidemiology, pathogenesis, and photodynamic, antiangiogenic, and surgical therapies

Presumed ocular histoplasmosis involves the classic triad of discrete atrophic choroidal scars in the macula or midperiphery known as histo spots, peripapillary atrophy, and choroidal neovascularization, which leads to severe loss of central vision. The histo spots from which the choroidal neovascularization develop do not show active inflammation but do represent focal defects in Bruch membrane that could facilitate development of choroidal neovascularization. The macular photocoagulation studies unequivocally show the benefit of photocoagulation compared with observation in reducing the risk of vision loss in patients with presumed ocular histoplasmosis, well defined extrafoveal or juxtafoveal choroidal neovascularization, and choroidal neovascularization in the peripapillary area. However, laser treatment itself causes an absolute scotoma correlating with the site of the laser photocoagulation scar, and subfoveal choroidal neovascularization is not amenable to laser photocoagulation because this would cause a blinding central scotoma. Consequently, other treatments have been sought. The Verteporfin in Ocular Histoplasmosis study evaluated photodynamic therapy for subfoveal choroidal neovascularization caused by presumed ocular histoplasmosis and demonstrated stabilization of the choroidal neovascularization and visual acuity benefit. In addition to photodynamic therapy, antiangiogenic compounds are being developed for choroidal neovascularization caused by age-related macular degeneration, and these agents will likely be of benefit in presumed ocular histoplasmosis associated choroidal neovascularization. Finally, submacular surgery for the removal of subfoveal choroidal neovascularization has promising results. The results of these research efforts will produce more effective therapeutic approaches in the future.

Surgical removal of subfoveal choroidal neovascularization: visual outcome and prognostic value of fluorescein angiography and optical coherence tomography

PURPOSE

To study the functional results of macular surgery and determine pre-operative features associated with better final visual outcome.

METHODS

Forty-two consecutive patients underwent surgical removal of subfoveal choroidal neovascularization (CNV), related to age-related macular degeneration (AMD) in 8 eyes, degenerative myopia in 14 eyes, multifocal choroiditis (MFC) in 10 eyes, idiopathic CNV in 6 eyes and other etiologies in 4 eyes. Mean age was 49 years. Pre-operative visual acuity (VA) was 20/200 or less in 30 eyes (71.4%) and never better than 20/40. Fluorescein angiography was analyzed before and after surgery. Pre-operative optical coherence tomographs (OCT) were studied in a masked fashion. Mean follow-up was 12 months (range 4-48 months).

RESULTS

Final VA was 20/200 or less in 25 eyes (60%). According to the CNV etiology, the percentage were 87.5%, 80%, 57.1% and 20% respectively in eyes with AMD, MFC, high myopia, and idiopathic or other diseases. Post-operative VA improved in 21 eyes (50%) but subsequently declined in 7% by the final examination. Patients younger than 50 years had better functional results (p=0.006). Lack of retinal pigment epithelium (RPE) changes on pre-operative angiography was correlated with good visual outcome (p<0.001). The OCT study confirmed some features already described and showed some different CNVpatterns: above and usually separated from the RPE, below and not separated from the RPE, and ungradable. Eyes with the first OCT pattern had the best visual outcome. Main complications included 4 (10%) retinal detachments and 9 (21%) recurrences. OCT was also useful to confirm CNV recurrences post-operatively.

CONCLUSIONS

CNV surgical excision results vary depending on the underlying disease, the RPE and choriocapillaris function, and the features observed on pre-operative OCT images.

Limited macular translocation for the management of subfoveal retinal pigment epithelial loss after submacular surgery

PURPOSE

To report a case of subfoveal retinal pigment epithelial (retinal pigment epithelium) loss after submacular surgery managed successfully by limited macular translocation.

METHODS

Case report.

RESULTS

A 28-year-old woman presented with a visual acuity of 20/100 caused by subfoveal choroidal neovas-cularization secondary to ocular histoplasmosis syndrome. Submacular resection of the choroidal neovascularization was complicated by inadvertent retinal pigment epithelium loss from beneath the foveal center. She underwent limited macular translocation 5 days after the initial surgery and had successful displacement of the fovea to an area inferior to the retinal pigment epithelium defect. Her visual acuity was 20/60 4 months postoperatively.

CONCLUSION

This report demonstrates the feasibility of using limited macular translocation for the management of eyes with central retinal pigment epithelium defect after submacular surgery and extends the clinical indications for limited macular translocation.

Initial experience of inferior limited macular translocation for subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration

PURPOSE

To report our initial experience of inferior limited macular translocation in patients with subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration.

METHODS

We conducted a retrospective study of 23 eyes of 22 patients with choroidal neovascularization involving the foveal center secondary to pathologic myopia (11 eyes), ocular histoplasmosis syndrome (four eyes), angioid streaks (four eyes), idiopathic neovascularization (three eyes), and multifocal choroiditis (one eye), in which the fovea was moved inferiorly by means of limited macular translocation surgery. The mean preoperative best-corrected visual acuity was 20/150, and in five of 23 eyes (21.7%) the visual acuity was 20/80 or better. The major outcome measures were preoperative and postoperative visual acuity, postoperative foveal displacement, and complications related to the surgery.

RESULTS

The mean postoperative follow-up was 10.82 months (range, 6 to 18 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in 11 of 23 eyes (47.82%), remained within 1 line in seven of 23 eyes (30.43%), and worsened 2 or more lines of vision in five of 23 eyes (21.74%). The mean postoperative best-corrected visual acuity was 20/100, and in 12 of the 23 eyes (52.17%) the visual acuity achieved was 20/80 or better. Retinal detachment was the most frequent complication and occurred in six eyes (26%).

CONCLUSIONS

Our initial experience with limited macular translocation shows that this treatment modality offers the potential to improve visual function in some eyes with subfoveal choroidal neovascularization secondary to myopia, ocular histoplasmosis syndrome, angioid streaks, idiopathic neovascularization, and multifocal choroiditis. Although longer and more complete follow-up is needed, the results of this initial series warrant further studies to define the precise role of macular translocation in the management of these conditions.

Optical coherence tomographic features of idiopathic submacular choroidal neovascularization

PURPOSE

To clarify the morphologic features of idiopathic submacular choroidal neovascularization using optical coherence tomography.

METHODS

Using optical coherence tomography, we prospectively examined 17 consecutive eyes (17 patients; eight men, nine women; mean age +/- SD, 36.0 +/- 9.3 years) with idiopathic submacular choroidal neovascularization. During the follow-up period (mean +/- SD, 7.5 +/- 3.8 months), we repeated optical coherence tomography in 15 eyes; optical coherence tomography was performed only at the initial examination in two eyes that underwent submacular surgery.

RESULTS

Choroidal neovascularization was observed in the subsensory retinal space anterior to the retinal pigment epithelium as a highly or moderately reflective mass, which protruded from the retinal pigment epithelium in 13 of 17 eyes (protruding type). In four eyes, choroidal neovascularization was a highly reflective fusiform mass at the level of the retinal pigment epithelium and choriocapillaris (fusiform type). During the follow-up period, choroidal neovascularization regressed and the protruding mass became a highly reflective fusiform mass in 10 of 11 eyes with the protruding type that underwent repeated examination. In three of the 10 eyes, during 5 to 10 months from initial examination, the choroidal neovascularization was exacerbated and it again protruded into the subsensory retinal space anterior to the retinal pigment epithelium. Four eyes with the fusiform type remained the same throughout the follow-up period. The overlying retina was thickened and had low reflectivity in all 17 eyes at the initial examination. Optical coherence tomography identified subretinal fluid in only 11 of the 13 eyes with protruding type choroidal neovascularization.

CONCLUSIONS

Optical coherence tomography confirmed subsensory retinal location of idiopathic submacular choroidal neovascularization anterior to the retinal pigment epithelium. Protruding choroidal neovascularization transforms to fusiform tissue at the level of the retinal pigment epithelium during the process of regression. Sensory retinal edema was always associated with choroidal neovascularization.

Update on surgical removal of choroidal neovascularization

Surgical management of choroidal neovascularization may offer patients with subretinal membranes another therapeutic option. Current techniques allow extraction of subretinal membranes, but not all patients have favorable clinical outcomes with such an approach. This article reviews the current state of subretinal surgery and attempts to summarize those characteristics that may predict good surgical results. Vitreoretinal surgical techniques for the management of subretinal membranes are reasonably well established. Certain characteristics of choroidal neovascularization have been identified that may suggest favorable surgical outcomes; however, no randomized prospective data are yet available to show the role of these procedures. The National Institutes of Health-sponsored Submacular Surgery Trials are designed to determine whether surgery or observation is better for eyes with subfoveal choroidal neovascularization in presumed ocular histoplasmosis syndrome or age-related macular degeneration and in eyes with age-related macular degeneration-associated hematomas.

Prevention of visual field defects after macular hole surgery

BACKGROUND/AIM

The pathogenesis of visual field loss associated with macular hole surgery is uncertain but a number of explanations have been proposed, the most convincing of which is the effect of peeling of the posterior hyaloid, causing either direct damage to the nerve fibre layer or to its blood supply at the optic nerve head. The purpose of this preliminary prospective study was to determine the incidence of visual field defects following macular hole surgery in cases in which peeling of the posterior hyaloid was confined only to the area of the macula.

METHODS

102 consecutive eyes that had macular hole surgery had preoperative and postoperative visual field examination using a Humphrey's perimeter. A comparison was made between two groups: I, those treated with vitrectomy with complete posterior cortical vitreous peeling; and II, those treated with a vitrectomy with peeling of the posterior hyaloid in the area of the macula but without attempting a complete posterior vitreous detachment. Specifically, no attempt was made to separate the posterior hyaloid from the optic nerve head. Eyes with stage II or III macular holes were operated. Autologous platelet concentrate and non-expansile gas tamponade was used. Patients were postured prone for 1 week.

RESULTS

In group I, 22% of patients were found to have visual field defects. In group II, it was possible to separate the posterior hyaloid from the macula without stripping it from the optic nerve head and in these eyes no pattern of postoperative visual field loss emerged. There were no significant vision threatening complications in this group. The difference in the incidence of visual field loss between group I and group II was significant (p=0.02). The anatomical and visual success rates were comparable between both groups.

CONCLUSION

The results from this preliminary study suggest that the complication of visual field loss after macular surgery may be reduced if peeling of the posterior hyaloid is confined to the area of the macula so that the hyaloid remains attached at the optic nerve head. The postoperative clinical course does not appear to differ from eyes in which a complete posterior vitreous detachment has been effected during surgery.

Treatment of age-related macular degeneration

Age-related macular degeneration (AMD), while rapidly becoming more prevalent due to an aging population, is still poorly understood and treatment modalities are limited. Fortunately, advances are being made in the treatment of AMD that may greatly alter the outcome of this debilitating disease. Treatments for both wet and dry AMD are reviewed.

The role of submacular surgery in the treatment of choroidal neovascular membranes

The growth of choroidal neovascular membranes (CNVM) beneath the macula can cause significant disturbances of central vision. Conditions such as age-related macular degeneration (AMD) and presumed ocular histoplasmosis syndrome (POHS) are the most common etiologies. The Macular Photocoagulation Study group presented data that clearly showed laser photocoagulation to be beneficial in the treatment of CNVM. Poor visual results and a high rate of recurrence have prompted clinicians to seek out alternative treatments. Experiences with CNVM removal utilizing submacular surgical techniques have shown that central visual function may be restored or preserved in POHS, multifocal choroiditis and idiopathic causes. The Submacular Surgery Trials were designed to investigate whether submacular surgery is more effective in retaining central acuity in patients with subfoveal CNVM, than observation alone. The goal of this paper is to review the role of submacular surgery in the treatment of subfoveal choroidal neovascular membranes.

Choroidal neovascularization in younger patients

Choroidal neovascularization (CNV) is the most common cause of legal blindness in older adults in the United States. The most common cause for CNV in this age group is age-related macular degeneration, a condition manifesting with drusen (particularly soft drusen) and pigmentary alterations in the macular region. CNV can occur in younger people (< 50 years), who usually do not have conspicuous drusen or pigmentary abnormalities. In this age group CNV may occur as a secondary manifestation of many inherited and acquired conditions such as angioid streaks, high myopia, trauma, choroidal tumors, familial macular dystrophies, and inflammatory retinochoroidopathies. Occasionally, CNV in young people has no apparent antecedent cause, and these cases are termed "idiopathic CNV." This review examines the common reasons for CNV in young adults, with reference to some of the older literature as well as to recently published papers.

OCT imaging of choroidal neovascularisation and its role in the determination of patients' eligibility for surgery

AIM

To evaluate the optical coherence tomographic characteristics of choroidal neovascularisation (CNV) in age related macular degeneration (AMD) and in idiopathic and inflammatory CNV. The use of this technique in the selection of patients for surgery is discussed.

METHODS

Ocular coherence tomography (OCT), fluorescein, and indocyanine green angiography were performed in 23 patients affected by AMD complicated by well defined CNV and in 10 patients affected by inflammatory or idiopathic CNV. The neovascular membrane was surgically removed in five age related CNVs, two inflammatory choroidopathies, and two idiopathic CNVs.

RESULTS

In inflammatory and idiopathic CNV, the OCT displayed a neovascularisation on the retinal pigment epithelium (RPE). In three cases the CNV was excised with an improvement of visual acuity equal to or greater than two Snellen lines; in a fourth case, the visual acuity after surgery was unchanged. In the cases of AMD the OCT fell into three different patterns: (A) CNV above the RPE (five cases); (B) focal, irregular thickening of the retinal pigment epithelial band (12 cases); (C) CNV above and below the RPE (six cases). The five pattern A CNV patients underwent the surgical excision of the neovascularisation. In four cases the visual acuity improved by two or more Snellen lines; in the fifth case the visual acuity remained unchanged.

CONCLUSIONS

The authors suggest that the surgical removal of early age related CNV could be performed in those cases where the OCT shows a neovascular membrane on the RPE, as in idiopathic and inflammatory CNVs.

Surgical removal of non-age-related subfoveal choroidal neovascular membranes

PURPOSE

To assess anatomical and visual results following the surgical removal of non-age-related subfoveal choroidal neovascular membranes.

METHODS

A retrospective study was carried out of 31 consecutive patients undergoing vitrectomy, parafoveal retinotomy and removal of subfoveal choroidal neovascular membranes that were either idiopathic or associated with multifocal choroiditis, high myopia, trauma or angioid streaks.

RESULTS

Visual acuity improved or remained the same in 25 eyes (81%) after a mean follow-up of 10.1 months (range 3-37 months). visual acuity improved by more than 2 lines of Snellen acuity in 5 eyes (16%) and decreased by more than 2 lines in 2 eyes (6%). There was no significant association between the final visual outcome and length of symptoms prior to surgery or pre-operative visual acuity. Atrophy of the retinal pigment epithelium and older age were associated with poor outcome. Membranes recurred in 11 eyes (35%), and eyes with subfoveal blood prior to surgery were more likely to have recurrent membranes.

CONCLUSIONS

The results of surgical removal of non-age-related subfoveal neovascular membranes have been encouraging, but further studies of long-term outcome and of the natural history of individual conditions are required.

Surgical excision of subfoveal neovascular membranes

BACKGROUND

Subfoveal choroidal neovascular membranes (CNV) are a cause of significant visual impairment. Laser treatment of such lesions results in visual loss. Surgical excision of CNV may allow stabilisation or improvement of vision. A series of results of surgical excision are presented.

METHODS

The records for 43 eyes of 40 consecutive patients undergoing surgical excision of CNV not associated with age-related macular degeneration (AMD) were reviewed retrospectively. Statistical analyses of the relationship between pre-operative factors and post-operative visual results were made. Improvement or worsening of visual acuity was defined as a change of more than 2 lines of Snellen acuity.

RESULTS

In 79.1% of patients visual acuity was improved or unchanged following surgery, and in 20.9% there was a reduction of Snellen acuity. There was no statistically significant association between visual outcome and age, gender, duration of visual symptoms, cause of CNV, presence of subretinal haemorrhage, elevation of retina by subretinal fluid, prior laser surgery, or the presence of pre-operative or intraoperative subretinal haemorrhage. There was a possible association between the non-use of gas tamponade and an increased chance of reduced vision. Visual loss was more likely in those eyes with good pre-operative visual acuity. Recurrence of CNV was noted in 10 (23%) eyes; repeat surgery was not associated with a worse visual outcome.

CONCLUSIONS

Surgical excision of CNV not related to AMD is a promising technique. More meaningful assessment of visual function in these patients will allow refinement of case selection.