1
|
Bachmeier I, Armendariz BG, Yu S, Jäger RJ, Ebneter A, Glittenberg C, Pauleikhoff D, Sadda SR, Chakravarthy U, Fauser S. Fibrosis in neovascular age-related macular degeneration: A review of definitions based on clinical imaging. Surv Ophthalmol 2023; 68:835-848. [PMID: 37023894 DOI: 10.1016/j.survophthal.2023.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
Despite the success of antiangiogenic therapy in controlling exudation in neovascular age-related macular degeneration (nAMD), the involvement of the outer retina in fibrosis results in gradual vision loss over time. The development of drugs that prevent or ameliorate fibrosis in nAMD requires that it is accurately detected and quantified with reliable endpoints and identification of robust biomarkers. Achievement of such an aim is currently challenging due to the lack of a consensus definition of fibrosis in nAMD. As a first step towards the establishment of a clear definition of fibrosis, we provide an extensive overview of the imaging modalities and criteria used to characterize fibrosis in nAMD. We observed variety in the selection of individual and combinations of imaging modalities, and criteria for detection. We also observed heterogeneity in classification systems and severity scales for fibrosis. The most commonly used imaging modalities were color fundus photography, fluorescein angiography and optical coherence tomography (OCT). A multimodal approach was frequently utilized. Our review suggests that OCT offers a more detailed, objective and sensitive characterization than color fundus photography/fluorescein angiography. Thus, we recommend it as a primary modality for fibrosis evaluation. This review provides a basis for future discussions to reach a consensus definition using standardized terms based on a detailed characterization of fibrosis, its presence and evolution, and taking into consideration impact on visual function. Achieving this goal is of paramount importance for the development of antifibrotic therapies.
Collapse
Affiliation(s)
- Isabel Bachmeier
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland.
| | - Beatriz G Armendariz
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Siqing Yu
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Ralf J Jäger
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Andreas Ebneter
- Department of Ophthalmology, Cantonal Hospital St. Gallen, University of Bern, Switzerland
| | - Carl Glittenberg
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | | | - SriniVas R Sadda
- Doheny Eye Institute, University of California-Los Angeles, Pasadena, 91103 CA, USA
| | - Usha Chakravarthy
- Queens University of Belfast, Institute of Clinical Science Block A, Belfast, UK
| | - Sascha Fauser
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| |
Collapse
|
2
|
Guo J, Qiu X, Tang W, Xu G, Moyers MF, Ren W, Xing Y, Gao J, Sun J, Lu J, Kong L, Liu W. One-Year Efficacy and Safety of Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: A Pilot Study. Ophthalmol Ther 2021; 11:187-199. [PMID: 34773572 PMCID: PMC8770763 DOI: 10.1007/s40123-021-00409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction To investigate the efficacy and safety of proton-beam irradiation (PBI) combined with intravitreal conbercept (IVC) injection for refractory or recurrent polypoidal choroidal vasculopathy (PCV). Methods A prospective interventional clinical trial included 12 patients with refractory PCV (defined as persistent exudation or fluid after six consecutive injections at monthly intervals and/or photodynamic therapy) or recurrent PCV (defined as new exudative signs after six monthly injections and/or photodynamic therapy) treated between January 2019 and September 2020. Every patient underwent single PBI (14 GyE) with concomitant IVC (0.5 mg) within 1 week and further doses of IVC were administered pro re nata. Results By the 12-month follow-up, the subretinal fluid was completely absorbed in 9 eyes (81.8%). The angiographic regression and closure rates of the polyps were 60% (12/20) and 90% (18/20), respectively. The mean number of IVC injections was 3.1 ± 1.37. The mean BCVA improved by 20 letters (P = 0.006). The mean central macular thickness (CMT) decreased from 476.50 ± 123.63 μm to 317.70 ± 89.34 μm (P = 0.004). The areas of branching vascular networks and polyps decreased by 37.2% and 72.3%, respectively. Radiation retinopathy was observed in five eyes, but no systemic adverse events were observed. Conclusion PBI combined with IVC appears to promote polyp regression and closure, reduce CMT, and improve BCVA, with a favorable safety profile, after 12 months. Therefore, PBI may be a useful adjuvant therapy for patients with refractory or recurrent PCV. Trial Registration Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: Prospective Phase II Clinical Study (ChiCTR2000038987).
Collapse
Affiliation(s)
- Jingli Guo
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Xianxin Qiu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Wenyi Tang
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Gezhi Xu
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Michael. F. Moyers
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Wei Ren
- Department of Radiation Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Ying Xing
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jin Gao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Jiayao Sun
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Jiade Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Lin Kong
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Wei Liu
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| |
Collapse
|
3
|
Yan H, Sun W, Mruthyunjaya P, Beadle B, Yu W, Kanwal B, MacDonald CA, Liu W. Dosimetry modeling of focused kV x‐ray radiotherapy for wet age‐related macular degeneration. Med Phys 2020; 47:5123-5134. [DOI: 10.1002/mp.14404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Huagang Yan
- School of Biomedical Engineering Capital Medical University Beijing100069 China
| | - Weiyuan Sun
- Department of Physics University at AlbanySUNY Albany NY12222 USA
| | - Prithvi Mruthyunjaya
- Department of Ophthalmology Stanford University School of Medicine Stanford CA94305 USA
| | - Beth Beadle
- Department of Radiation Oncology Stanford University School of Medicine Stanford CA94305 USA
| | - Weihong Yu
- Department of Ophthalmology Key Laboratory of Ocular Fundus Diseases Peking Union Medical College HospitalChinese Academy of Medical Sciences Beijing100730 China
| | - Bushra Kanwal
- Center for High Energy Physics University of the Punjab Lahore Pakistan
| | | | - Wu Liu
- Department of Radiation Oncology Stanford University School of Medicine Stanford CA94305 USA
| |
Collapse
|
4
|
Mukkamala LK, Mishra K, Daftari I, Moshiri A, Park SS. Phase I/II randomized study of proton beam with anti-VEGF for exudative age-related macular degeneration: long-term results. Eye (Lond) 2020; 34:2271-2279. [PMID: 32055016 DOI: 10.1038/s41433-020-0807-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/09/2019] [Accepted: 10/28/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/OBJECTIVE To determine if treatment of exudative age-related macular degeneration (eAMD) using proton beam therapy (PBT) combined with intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is safe and effective long term. SUBJECT/METHODS Thirty eyes with newly diagnosed eAMD were enrolled in a phase I/II prospective, sham-controlled double-masked university study. Eyes were randomized 1:1:1-24 GyE, 16 GyE or sham radiation, and treated with three initial monthly intravitreal ranibizumab or bevacizumab. Subsequent anti-VEGF reinjection was based on monthly optical coherence tomography and examination for 2 years and standard of care thereafter. RESULTS A total of 23 eyes completed 2-year study follow-up, of which 16 maintained monthly follow-up. Mean best-correct visual acuity (BCVA) at 2 years was similar among treatment groups (p > 0.05). The 24 GyE group required fewer anti-VEGF injections when compared with the sham group at 2 years (4.67 ± 1.9 vs 9.67 ± 3.5; p = 0.017). Extended follow-up (mean 4 years) available in 22 eyes showed persistent reduced need for anti-VEGF therapy among eyes treated with 24 GyE compared with sham radiation (2.0 ± 1.6 vs 4.84 ± 2.4 per year, p = 0.008). New and increasing geographic atrophy (GA), noted in some eyes in all treatment groups, resulted in decreased mean BCVA from baseline for the 24 GyE group on extended follow-up (p = 0.009). Possible mild radiation retinopathy noted in 15% of eyes was not visually significant. CONCLUSIONS Initial treatment combining PBT (24 GyE) with intravitreal anti-VEGF therapy appears to decrease the need for anti-VEGF reinjection in eyes with newly diagnosed eAMD. Radiation retinopathy risk was low and does not appear visually significant. Long-term vision was limited by GA development especially in the 24 GyE group.
Collapse
Affiliation(s)
- Lekha K Mukkamala
- Vitreoretinal Service, Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, CA, USA
| | - Kavita Mishra
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Inder Daftari
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Ala Moshiri
- Vitreoretinal Service, Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, CA, USA
| | - Susanna S Park
- Vitreoretinal Service, Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, CA, USA.
| |
Collapse
|
5
|
Osmanovic S, Moisseiev E, Mishra KK, Daftari I, Moshiri A, Morse L, Park SS. Phase I/II Randomized Study of Proton Beam with Anti-Vascular Endothelial Growth Factor for Exudative Age-Related Macular Degeneration: One-Year Results. Ophthalmol Retina 2016; 1:217-226. [PMID: 31047424 DOI: 10.1016/j.oret.2016.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of proton beam therapy (PBT) as an adjunct to intravitreal anti-vascular endothelial growth factor (VEGF) for the treatment of exudative age-related macular degeneration. DESIGN Phase I/II, interventional, prospective, randomized, sham-controlled double-blinded study. PARTICIPANTS Eyes with newly diagnosed exudative age-related macular degeneration with vision between 20/40 and 20/400 were included. Exclusion criteria included diabetes or other ocular comorbidities affecting vision. METHODS Eyes were randomized to receive either 16 GyE, 24 GyE, or sham PBT. All eyes had 3 monthly intravitreal anti-VEGF treatments, followed by monthly visits with treatments as needed. MAIN OUTCOME MEASURES Mean change in best-corrected visual acuity (BCVA), mean number of anti-VEGF injections, proportion of eyes with >15 letters BCVA decrease, proportion of eyes developing radiation retinopathy or papillopathy, proportion of eyes with cataract progression, and mean changes central retinal thickness on OCT and lesion size on angiography at 1 year. RESULTS Of 30 enrolled eyes, 22 completed follow-up monthly for 12 months for analysis. The BCVA improved by a mean of 8 letters (0.48±0.36 logarithm of the minimum angle of resolution) overall from baseline. Overall, central retinal thickness decreased from 340±155 to 246±48 (P = 0.008) at 12 months. The mean change in BCVA and central retinal thickness was not different among the 3 study groups. The mean number of anti-VEGF injections at 12 months was 6.13 for sham irradiation arm, 5.52 in the 16 GyE arm, and 3.83 for the 24 GyE arm (P = 0.004 between sham and 24 GyE). No eye had severe visual loss, radiation retinopathy, or papillopathy. CONCLUSIONS No safety issue was noted associated with combining 16 GyE or 24 GyE PBT with intravitreal anti-VEGF therapy in eyes with exudative age-related macular degeneration. Overall improvements in BCVA and imaging parameters were not affected by the addition of PBT, but the number of anti-VEGF treatments needed was significantly lower with the addition of 24 GyE PBT.
Collapse
Affiliation(s)
- Senad Osmanovic
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Elad Moisseiev
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Kavita K Mishra
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Inder Daftari
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ala Moshiri
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Lawrence Morse
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Susanna S Park
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California.
| |
Collapse
|
6
|
Rice SR, Katz MSJ, Mehta MP. Context for Protons as Adjunctive Therapy in Neovascular Age-Related Macular Degeneration: A Review. Int J Part Ther 2016; 2:555-569. [PMID: 31772967 PMCID: PMC6871634 DOI: 10.14338/ijpt-15-00019.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/04/2015] [Indexed: 11/21/2022] Open
Abstract
In the last few years we have witnessed increasing availability of proton therapy in the United States and worldwide. As a result, proton therapy is considered as either a primary or adjunctive approach for numerous indications where conventional radiation therapy shows promise but is accompanied by toxicities. Age-related macular degeneration (AMD) remains the leading cause of adult blindness in industrialized nations, and third worldwide, following cataract and glaucoma. Current standard therapy is intravitreal injection of anti-vascular endothelial growth factor agents. While this treatment shows improvement and stabilization in visual acuity for 40% of patients, 60% still experience disease progression. These injections are costly, necessitate repeated office visits, and carry the risk of endophthalmitis. The pathophysiology underlying neovascular AMD (nAMD) underscores the need to simultaneously target multiple pathways to retain useful vision. Radiation can be antiangiogenic, anti-inflammatory, and antiproliferative. Early photon therapy clinical trials were heterogeneous, and a Cochrane review of data demonstrated usefulness in treatment of nAMD but recommended further studies. Advantages of proton therapy over photon therapy include the ability to deliver a focal dose to the target while minimizing dose to normal structures, which is enhanced by unique treatment planning software that uses fluorescein angiography to verify target location and allows conformation of dose to the irregular shape and thickness characteristic of choroidal neovascular membranes, the pathognomonic finding in nAMD. Preliminary data suggest a potential role for proton therapy in the treatment of nAMD. In this article we review previous treatments for AMD, including those with both photon and proton radiation, and recommend future directions for clinical investigations to evaluate the role of proton therapy as an adjunct to antiangiogenic therapy, the current standard of care in this challenging setting.
Collapse
Affiliation(s)
- Stephanie R. Rice
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Minesh P. Mehta
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Ophthalmology, National Retina Institute, Towson, MD, USA
| |
Collapse
|
7
|
Zur D, Loewenstein A, Barak A. One-year results from clinical practice of epimacular strontium-90 brachytherapy for the treatment of subfoveal choroidal neovascularization secondary to AMD. Ophthalmic Surg Lasers Imaging Retina 2015; 46:338-43. [PMID: 25856820 DOI: 10.3928/23258160-20150323-07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 10/22/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate clinical feasibility, safety, and efficacy of epiretinal strontium-90 brachytherapy in subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) in eyes unresponsive to repeated anti-VEGF injections. PATIENTS AND METHODS A retrospective, single-center study on patients treated with strontium-90 brachytherapy for CNV secondary to neovascular AMD. Patients underwent pars plana vitrectomy with a single 24 Gy dose brachytherapy. They were re-treated with anti-VEGF injections on an as-needed basis if subretinal or intraretinal fluid was detected on optical coherence tomography imaging. RESULTS Twenty-two patients were treated, and 20 completed 12 months of follow-up. Ten patients maintained stable vision, eight gained vision, and two lost more than three Snellen lines. The mean best corrected visual acuity change from baseline was -8 ± 5.7 letters. A mean of 5.5 ± 4.4 anti-VEGF injections were administered throughout 12 months. CONCLUSION Epimacular brachytherapy is feasible in clinical practice. While some patients benefit from the treatment and need significantly fewer as-needed injections, others appear not to react to irradiation treatment after 1 year of follow-up. Larger numbers of patients are needed to evaluate therapeutic efficacy and to determine which patients can benefit from combined radiation and anti-VEGF therapy.
Collapse
|
8
|
Chen L, Kim IK, Lane AM, Gauthier D, Munzenrider JE, Gragoudas ES, Miller JW. Proton beam irradiation for non-AMD CNV: 2-year results of a randomised clinical trial. Br J Ophthalmol 2014; 98:1212-7. [DOI: 10.1136/bjophthalmol-2013-304761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
9
|
Balaiya S, Murthy RK, Malyapa R, Grover S, Chalam KV. Differential sensitivity of choroidal endothelial, retinal ganglion, and retinal pigment epithelial cells in vitro to proton radiation. Am J Ophthalmol 2013; 156:444-453.e2. [PMID: 23769193 DOI: 10.1016/j.ajo.2013.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 04/26/2013] [Accepted: 04/30/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the differential sensitivity of choroidal endothelial, retinal pigment epithelial, and retinal ganglion cells to escalating doses of proton beam radiation and to establish a safe dose range for the management of choroidal neovascularization associated with age-related macular degeneration (AMD). DESIGN Laboratory investigation. METHODS Proliferating simian choroidal endothelial cells (RF/6A), differentiated rat retinal ganglion cells (RGC-5), and serum-starved human retinal pigment epithelial cells (ARPE-19) were exposed to 2, 4, 8, and 12 cobalt gray equivalent of proton beam radiation and cell viability was quantified on day 9. Reactive oxygen species levels were analyzed. RESULTS Significant decline of choroidal endothelial cell viability was noted as dose escalated from 4 to 8 cobalt gray equivalent with maximum effect observed at 12 cobalt gray equivalent. RGC-5 and ARPE-19 cell count decreased to 95% and 62.7% at 8 cobalt gray equivalent, respectively. Sub-analysis between 4 and 8 cobalt gray equivalent radiation revealed significant decrease in choroidal endothelial cell viability (43.1% at 7 cobalt gray equivalent and 32.3% at 8 cobalt gray equivalent of radiation). Correspondingly, RGC-5 and ARPE-19 cells did not show decrease in cell count or viability. Reactive oxygen species levels significantly increased in radiation-treated choroidal endothelial cells (8.3%-11.9%). CONCLUSIONS At 6-8 cobalt gray equivalent proton beam radiation, retinal ganglion and retinal pigment epithelial cells are preserved while choroidal endothelial cells are completely inhibited. This dosage offers optimum therapeutic safety window for treatment using proton beam radiation for exudative AMD.
Collapse
Affiliation(s)
- Sankarathi Balaiya
- Department of Ophthalmology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ravi K Murthy
- Department of Ophthalmology, University of Florida College of Medicine, Jacksonville, Florida
| | - Robert Malyapa
- University of Florida Proton Therapy Institute, Jacksonville, Florida
| | - Sandeep Grover
- Department of Ophthalmology, University of Florida College of Medicine, Jacksonville, Florida
| | - Kakarla V Chalam
- Department of Ophthalmology, University of Florida College of Medicine, Jacksonville, Florida.
| |
Collapse
|
10
|
Morales-Canton V, Quiroz-Mercado H, Velez-Montoya R, Zavala-Ayala A, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 16 and 24 Gy low-voltage X-ray irradiation with ranibizumab therapy for neovascular age-related macular degeneration: 12-month outcomes. Am J Ophthalmol 2013; 155:1000-1008.e2. [PMID: 23497847 DOI: 10.1016/j.ajo.2013.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 01/06/2013] [Accepted: 01/08/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the 12-month safety and efficacy outcomes of 16 or 24 Gy radiation using low-voltage x-ray irradiation in conjunction with intravitreal ranibizumab for neovascular age-related macular degeneration (AMD). DESIGN Prospective, phase I, open-label, nonrandomized uncontrolled safety study. METHODS setting: Institutional. study population: Neovascular AMD patients. intervention: One x-ray irradiation treatment at 16 or 24 Gy was administered externally through 3 locations in the inferior pars plana. After 2 initial monthly loading doses of ranibizumab, subsequent ranibizumab was administered according to predetermined criteria. main outcome measures: Visual acuity, number of ranibizumab injections, safety and efficacy metrics at 12 months. RESULTS Forty-seven eyes of 47 patients were enrolled and completed 12 months of follow-up: 16 Gy (n = 28) and 24 Gy (n = 19). There was no evidence of radiation retinopathy, optic neuropathy, or cataract. The mean visual acuity improved in both groups: +8.4 ± 11.9 letters and +7.8 ± 12 letters for 16 and 24 Gy, respectively. In both groups, 100% of subjects lost <15 letters, with 76% and 79% gaining ≥0 letters in the 16 Gy and 24 Gy groups, respectively. Patients received a mean of 1.0 additional injection over 12 months. The mean change in optical coherence tomography central subfield thickness from baseline to month 12 was -107 and -87 μm for the 16 Gy and 24 Gy groups, respectively. CONCLUSION One treatment of 16 or 24 Gy low-voltage x-ray therapy with as-needed ranibizumab appears safe in subjects with neovascular AMD at 12 months. An overall improvement in visual acuity was observed. No radiation-related adverse effects were reported.
Collapse
|
11
|
Kishan AU, Modjtahedi BS, Morse LS, Lee P. Radiation therapy for neovascular age-related macular degeneration. Int J Radiat Oncol Biol Phys 2012; 85:583-97. [PMID: 22975610 DOI: 10.1016/j.ijrobp.2012.07.2352] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 07/15/2012] [Indexed: 12/29/2022]
Abstract
In the enormity of the public health burden imposed by age-related macular degeneration (ARMD), much effort has been directed toward identifying effective and efficient treatments. Currently, anti-vascular endothelial growth factor (VEGF) injections have demonstrated considerably efficacy in treating neovascular ARMD, but patients require frequent treatment to fully benefit. Here, we review the rationale and evidence for radiation therapy of ARMD. The results of early photon external beam radiation therapy are included to provide a framework for the sequential discussion of evidence for the usage of stereotactic radiation therapy, proton therapy, and brachytherapy. The evidence suggests that these 3 modern modalities can provide a dose-dependent benefit in the treatment of ARMD. Most importantly, preliminary data suggest that all 3 can be used in conjunction with anti-VEGF therapeutics, thereby reducing the frequency of anti-VEGF injections required to maintain visual acuity.
Collapse
|
12
|
Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 24-Gy Low-Voltage X-Ray Irradiation With Ranibizumab Therapy for Neovascular AMD: 6-Month Safety and Functional Outcomes. Ophthalmic Surg Lasers Imaging Retina 2012; 43:20-4. [DOI: 10.3928/15428877-20111129-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 10/28/2011] [Indexed: 11/20/2022]
|
13
|
Ten-year follow-up of eyes treated with stereotactic fractionated external beam radiation for neovascular age-related macular degeneration. Retina 2011; 31:1303-15. [PMID: 21499195 DOI: 10.1097/iae.0b013e318203ee46] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the long-term effects of stereotactic fractionated external beam radiation on eyes treated for neovascular age-related macular degeneration. METHODS A retrospective review of all eyes treated with stereotactic fractionated external beam radiation (20-40 Gy, 2-Gy fractions) between 1997 and 2000 was performed to identify eyes with ≥ 2-year follow-up for analysis. A subset was imaged prospectively using a high-resolution Fourier-domain optical coherence tomography. RESULTS Among 94 eyes treated, 33 eyes (32 subjects) had ≥ 2-year follow-up information (mean follow-up, 6.2 years; range, 2-10 years). Final visual acuity ranged from 20/50 to no light perception. Final macular findings included central geographic atrophy (49%), disciform scar (30%), and active choroidal neovascular membrane (9%). Fourier-domain optical coherence tomography images of three eyes with geographic atrophy revealed photoreceptor layer loss within areas of geographic atrophy with intact retinal morphology in areas of radiation exposure outside geographic atrophy. Radiation retinopathy was suspected in 18% and confirmed by fluorescein angiography in 15%, ranging from mild to neovascular glaucoma/phthisis bulbi (2 eyes). Mean time from stereotactic fractionated external beam radiation to development of radiation retinopathy was 5.4 years (range, 1-10 years). CONCLUSION A moderate rate of delayed radiation retinopathy was noted in eyes with neovascular age-related macular degeneration treated with stereotactic fractionated external beam radiation. Geographic atrophy was a common finding.
Collapse
|
14
|
Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 16-Gy low-voltage x-ray irradiation with ranibizumab therapy for AMD: 6-month safety and functional outcomes. Ophthalmic Surg Lasers Imaging Retina 2011; 42:468-73. [PMID: 21830747 DOI: 10.3928/15428877-20110804-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 06/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To describe the 6-month safety and preliminary efficacy outcomes of the use of 16-Gy radiation with intravitreal ranibizumab for patients with neovascular age-related macular degeneration (AMD). PATIENTS AND METHODS A single treatment of a non-invasive, externally delivered low-voltage 16-Gy x-ray irradiation was administered in one session through three locations in the inferior pars plana. Optical coherence tomography (OCT) and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) examinations were performed at 1 week, 1 month, and monthly thereafter, with quarterly fluorescein angiography (FA). After the two initial ranibizumab injections, subsequent injections were administered according to the following criteria: VA decline of 10 ETDRS letters compared with baseline, increase of 100-μm central foveal thickness on OCT compared with baseline, the development of new submacular hemorrhage, and the development of a new area of classic choroidal neovascularization on FA. RESULTS Twenty-six patients completed a 6-month follow-up. There was no evidence of radiation retinopathy, optic neuropathy, or cataract. The mean baseline ETDRS score was 46.6 letters (range: 5 to 80; standard deviation [SD]: 21.5). At 6 months, the corresponding ETDRS score was 55.6 letters (range: 25 to 80; SD: 18.9) and the mean change in VA was 9.5 ETDRS letters (SD: 10.3). On responder analysis, 96% lost 15 or fewer ETDRS letters, 81% gained 0 or more ETDRS letters, and 50% gained 15 or more ETDRS letters. Patients received a total of 13 ranibizumab injections following two initial injections. At 6 months, patients received an average of 0.5 additional injections following the initial two mandated injections. CONCLUSION A single treatment of externally applied, non-invasive 16-Gy low-voltage x-ray therapy in conjunction with ranibizumab demonstrated an overall improvement of VA in patients with neovascular AMD at 6 months with no radiation-related adverse effects.
Collapse
|
15
|
Steinle N, Barakat M, Moshfeghi D, Kaiser PK. Radiation therapy in the treatment of exudative age-related macular degeneration. EXPERT REVIEW OF OPHTHALMOLOGY 2011. [DOI: 10.1586/eop.11.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
16
|
Silva RA, Moshfeghi AA, Kaiser PK, Singh RP, Moshfeghi DM. Radiation Treatment for Age-Related Macular Degeneration. Semin Ophthalmol 2011; 26:121-30. [DOI: 10.3109/08820538.2011.554486] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
17
|
The effectiveness and safety of proton radiation therapy for indications of the eye : a systematic review. Strahlenther Onkol 2009; 185:211-21. [PMID: 19370423 DOI: 10.1007/s00066-009-1900-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 12/10/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE : Proton radiation has been used for the treatment of uveal melanoma since 1975, but few studies have been conducted to assess its efficacy and safety. This paper aims to systematically review the effects and side effects of proton therapy for any indication of the eye. MATERIAL AND METHODS : A range of databases were searched from inception to 2007. All studies that included at least ten patients and that assessed the efficacy or safety of proton therapy for any indication of the eye were included. RESULTS : The search generated 2,385 references, of which 37 met the inclusion criteria. Five controlled trials, two comparative studies and 30 case series were found, most often reporting on uveal melanoma, choroidal melanoma and age-related macular degeneration (AMD). Methodological quality of these studies was poor. Studies were characterized by large differences in radiation techniques applied within the studies, and by variation in patient characteristics within and between studies. Results for uveal melanoma and choroidal melanoma suggest favorable survival, with, however, significant rates of side effects. Results for choroidal hemangioma and AMD did not reveal beneficial effects from proton radiation. CONCLUSION : There is limited evidence on the effectiveness and safety of proton radiation due to the lack of well-designed and well-reported studies. There is a need to lift evidence on proton therapy to a higher level by performing dose-finding randomized controlled trials (RCTs), comparative studies of proton radiation versus standard given alternatives and prospective case studies enrolling only patients treated with up-to-date techniques, allowing extrapolation of results to similar patient groups.
Collapse
|
18
|
TWELVE-MONTH SAFETY AND VISUAL ACUITY RESULTS FROM A FEASIBILITY STUDY OF INTRAOCULAR, EPIRETINAL RADIATION THERAPY FOR THE TREATMENT OF SUBFOVEAL CNV SECONDARY TO AMD. Retina 2009; 29:157-69. [DOI: 10.1097/iae.0b013e3181985915] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Abstract
Particle beams like protons and heavier ions offer improved dose distributions compared with photon (also called x-ray) beams and thus enable dose escalation within the tumor while sparing normal tissues. Although protons have a biologic effectiveness comparable to photons, ions, because they are heavier than protons, provide a higher biologic effectiveness. Recent technologic developments in the fields of accelerator engineering, treatment planning, beam delivery, and tumor visualization have stimulated the process of transferring particle radiation therapy (RT) from physics laboratories to the clinic. This review describes the physical, biologic, and technologic aspects of particle beam therapy. Clinical trials investigating proton and carbon ion RT will be summarized and discussed in the context of their relevance to recent concepts of treatment with RT.
Collapse
|
20
|
Zambarakji HJ, Lane AM, Ezra E, Gauthier D, Goitein M, Adams JA, Munzenrider JE, Miller JW, Gragoudas ES. Proton Beam Irradiation for Neovascular Age-Related Macular Degeneration. Ophthalmology 2006; 113:2012-9. [PMID: 16935343 DOI: 10.1016/j.ophtha.2006.05.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Revised: 03/31/2006] [Accepted: 05/26/2006] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate safety and visual outcomes after proton therapy for subfoveal neovascular age-related macular degeneration (AMD). DESIGN Randomized dose-ranging clinical trial. PARTICIPANTS One hundred sixty-six patients with angiographic evidence of classic choroidal neovascularization resulting from AMD and best-corrected visual acuity of 20/320 or better. METHODS Patients were assigned randomly (1:1) to receive 16-cobalt gray equivalent (CGE) or 24-CGE proton radiation in 2 equal fractions. Visual acuity was measured using standardized protocol refraction. Complete ophthalmological examinations, color fundus photography, and fluorescein angiography were performed before and 3, 6, 12, 18, and 24 months after treatment. MAIN OUTCOME MEASURE Proportion of eyes losing 3 or more lines of vision from baseline. Kaplan-Meier statistics were used to compare cumulative rates of vision loss between the 2 treatment groups. RESULTS At 12 months after treatment, 36 eyes (42%) and 27 eyes (35%) lost 3 or more lines of vision in the 16-CGE and 24-CGE groups, respectively. Rates increased to 62% in the 16-CGE group and 53% in the 24-CGE group by 24 months after treatment (P = 0.40). Radiation complications developed in 15.7% of patients receiving 16 CGE and 14.8% of patients receiving 24 CGE. CONCLUSIONS No significant differences in rates of visual loss were found between the 2 dose groups. Proton radiation may be useful as an adjuvant therapy or as an alternative for patients who decline or are not appropriate for approved therapies.
Collapse
Affiliation(s)
- Hadi J Zambarakji
- Retina Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Henderson MA, Valluri S, Lo SS, Witt TC, Worth RM, Danis RP, Timmerman RD. Gamma Knife Radiosurgery in the Treatment of Choroidal Neovascularization (Wet-Type Macular Degeneration). Stereotact Funct Neurosurg 2006; 85:11-7. [PMID: 17077651 DOI: 10.1159/000096634] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We evaluated retrospectively our institutional experience in the treatment of macular degeneration with gamma knife radiosurgery (GKR). Treatment was delivered in a single shot of 12 Gy. Seven patients were treated between March of 1999 and May of 2000. The median duration of follow-up was 2.2 years. The majority of patients maintained stable visual acuity after treatment. Our series indicates that GKR may be useful as a salvage treatment for patients who have failed or are ineligible for other treatments for their macular degeneration. Further studies are needed to better define the role of GKR in the treatment of macular degeneration.
Collapse
Affiliation(s)
- Mark A Henderson
- Department of Radiation Oncology, Indiana University Medical Center, Indianapolis, Ind., USA
| | | | | | | | | | | | | |
Collapse
|
22
|
de Juan E, Fujii GY. Limited Macular Translocation. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
23
|
Kim YH, Kim HS, Yoo JS. Effect of basic fibroblast growth factor-saporin (bFGF-SAP) conjugate on bovine choriocapillary endothelial cells. KOREAN JOURNAL OF OPHTHALMOLOGY 2005; 18:121-31. [PMID: 15635825 DOI: 10.3341/kjo.2004.18.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We evaluated the effect of a basic fibroblast growth factor (bFGF) and saporin conjugate (bFGF-SAP) on proliferation, migration and tubule formation in bovine choriocapillary endothelial cells (BCECs). Cell proliferation and MTS assays were done with 0.01, 0.1, 1, 10, and 100 nM bFGF-SAP, and an equimolar concentration of bFGF and saporin. TUNEL assay was performed to confirm apoptosis. Cells were treated with 1, 10, and 100 nM bFGF-SAP and migration assay and tubule formation assay were done. Results were evaluated with image analysis. All experiments were performed in triplicate and repeated three times. Viable cells (ID50 = 0.62) and cell proliferation by MTS assay (ID50 = 0.75 nM) were inhibited. Saporin caused cytotoxicity and inhibition of proliferation at high concentration. DNA fragmentation was identified by TUNEL assay. Migration and tubule formation were also inhibited. All mechanisms responsible for neovascularization were inhibited, and this could be applied in the management of subretinal choroidal neovascularization (SRN).
Collapse
Affiliation(s)
- Yeong Hoon Kim
- Department of Ophthalmology, St. Paul's Hospital, Catholic University Medical College, Seoul, Korea
| | | | | |
Collapse
|
24
|
Marcus DM, Peskin E, Maguire M, Weissgold D, Alexander J, Fine S, Followill D. The age-related macular degeneration radiotherapy trial (AMDRT): one year results from a pilot study. Am J Ophthalmol 2004; 138:818-28. [PMID: 15531318 DOI: 10.1016/j.ajo.2004.06.081] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the short-term safety and efficacy of treating subfoveal choroidal neovascularization (CNV) with external beam radiation delivered in 5 x 4 Gy fractions among patients having age-related macular degeneration (AMD). DESIGN A multicenter prospective randomized controlled pilot study. METHODS Eighty-eight patients were enrolled through 10 sites and were randomized to radiotherapy (20 Gy delivered in 5 daily fractions of 4 Gy each; 6 MV [N = 41]) or no radiotherapy (sham radiotherapy [N = 22] or observation [N = 25]). Eligibility criteria included visual acuity of at least 20/320 and subfoveal CNV not amenable to treatment. Randomization was stratified by lesion type (new or recurrent CNV) and blood (<50% or >/=50% of the lesion [N = 13]). The primary outcome measure was loss of >/=3 lines of visual acuity. Secondary outcome measures were angiographic response and side effects. RESULTS At baseline, patient and ocular characteristics were similar between treatment groups. At six months, 9 radiated eyes (26%) and 17 eyes not radiated (49%) lost >/=3 lines of visual acuity (P = .04; stratified chi(2) test). At 12 months, 13 radiated eyes (42%) and 9 observed eyes (49%) lost >/=3 visual acuity lines (P = .60). The radiated group demonstrated smaller lesions and less fibrosis than the nonradiated group (P = .05 and .004, respectively) at 12 months. Radiation-induced complications were not observed except for one radiated eye with numerous cotton wool spots and possible radiation retinopathy. CONCLUSIONS External beam radiation at 5 x 4 Gy may have a modest and short-lived (six month) benefit in preserving visual acuity.
Collapse
Affiliation(s)
- Dennis M Marcus
- University of Pennsylvania, Department of Ophthalmology, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | |
Collapse
|
25
|
Marcus DM, Sheils WC, Young JO, McIntosh SB, Johnson MH, Alexander J, Samy CN. Radiotherapy for recurrent choroidal neovascularisation complicating age related macular degeneration. Br J Ophthalmol 2004; 88:114-9. [PMID: 14693787 PMCID: PMC1771925 DOI: 10.1136/bjo.88.1.114] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To report the safety and visual outcome data of external beam irradiation for recurrent choroidal neovascularisation complicating age related macular degeneration. METHODS Eighteen consecutive eyes received external beam irradiation with seven fractions of 2 Gy (total dose 14 Gy). The next 16 consecutive eyes received external beam irradiation with five fractions of 3 Gy (total dose 15 Gy). Main outcome measure was change in visual acuity. Secondary outcome variables were contrast sensitivity and fundus photographic/fluorescein angiographic progression. RESULTS The 3 Gy fraction group lost fewer lines of distance visual acuity at the three and six month follow up. At one year follow up, this difference was not maintained with 2 Gy fraction and 3 Gy fraction eyes. At one year follow up a decrease in visual acuity of three or more lines (moderate visual loss) occurred in 58% of 2 Gy and 42% of 3 Gy fraction eyes (p<0.36). At one year follow up a decrease in visual acuity of six or more lines (severe visual loss) occurred in 41% of 2 Gy eyes and 17% of 3 Gy eyes (p<0.23). At three months follow up, 3 Gy eyes were less likely (0%) than 2 Gy eyes (47%) to show moderate visual loss (p<0.003). However, Kaplan Meier curves estimate a significantly lower rate of severe visual loss in the 3 Gy group (p = 0.02). There were no significant differences in contrast sensitivity loss or fluorescein angiographic stabilisation rates. No evidence of radiation toxicity was observed. CONCLUSION Our results are consistent with trends for a palliative benefit with higher fraction sizes and doses. The radiobiologic differences between low and high fraction size groups in this study are modest and correlate with the modest and short term difference in visual outcomes. These trends support further investigation of radiotherapy using fraction sizes of 4 Gy or higher.
Collapse
Affiliation(s)
- D M Marcus
- Department of Ophthalmology, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA.
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Age-related macular degeneration (AMD) is the leading cause of legal blindness in individuals 50 years and older in the developed world. Choroidal neovascularization (CNV) in exudative AMD is responsible for the majority of severe vision loss. Until recently, laser photocoagulation was the only well-established and widely accepted treatment for CNV. However, it is beneficial only for a small subset of patients, has a high rate of CNV persistence and recurrence and results in iatrogenic, collateral damage to the overlying retina. These issues make it difficult to recommend in the case of subfoveal lesions. Consequently, numerous experimental therapeutic interventions are under investigation with the common objective of destroying the CNV but leaving the foveal neurosensory retina intact. Treatment modalities can be grouped into five major categories: photodynamic therapy; radiotherapy; transpupillary thermotherapy; anti-angiogenic and angiostatic agents; and surgical intervention. The present review aims to explain the rationale behind these new treatments, analyse the evidence for their safety and efficacy, determine their stage of development and indicate in which patients they are potentially useful.
Collapse
Affiliation(s)
- Claire Y Hooper
- Centre for Eye Research Australia, University of Melbourne, Department of Ophthalmology, Melbourne, Victoria, Australia
| | | |
Collapse
|
27
|
Aisenbrey S, Lafaut BA, Reynders S, Szurman P, Grisanti S, Vanden Broecke C, Walter P, Bartz-Schmidt KU. Clinicopathological correlation of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2003; 241:269-76. [PMID: 12719987 DOI: 10.1007/s00417-003-0634-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2002] [Revised: 12/10/2002] [Accepted: 01/08/2003] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To analyze the histopathology of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration. METHODS A retrospective non-case-matched comparative histopathologic study. The histoarchitecture of nine surgically removed subretinal specimens from nine patients that had undergone external beam radiotherapy for exudative age-related macular degeneration was studied. Seven patients had received 20 Gy in 10 fractions and two 15 Gy in 5 fractions with an average time interval between radiotherapy and surgical extraction of 14 months (range 3-28). A consecutive series of classic, mixed and occult choroidal neovascular membranes served as controls. RESULTS Clinical findings. Radiation-associated choroidal neovasculopathy was angiographically suspected in four patients: a coarse net of vessels on fluorescein angiography developing at the border of previously irradiated choroidal neovascularization was observed in three patients; blebs at the margin of a plaque on indocyanine green angiography were observed in two patients. Pathological findings. Diffuse drusen as well as intra-Bruch's fibrovascular tissue was found in all irradiated specimens. In four specimens an edematous vascularized layer was seen between diffuse drusen and normal-appearing intra-Bruch's fibrovascular tissue. This lesion was not found in the control specimens. A particular correlation for the bleb lesion was not recognized. CONCLUSION The appearance of an edematous subretinal pigment epithelial vascularized layer between diffuse drusen and normal-appearing fibrovascular tissue in four of nine irradiated membranes may be secondary to previous irradiation. It may correlate with the unusual exudative manifestations observed after external beam radiotherapy.
Collapse
Affiliation(s)
- S Aisenbrey
- Department of Vitreo-Retinal Surgery, Center of Ophthalmology, University of Cologne, Cologne, Germany
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Ciulla TA, Danis RP, Klein SB, Malinovsky VE, Soni PS, Pratt LM, Pugh NO, Morphis JG, Bloch C, Cameron J. Proton therapy for exudative age-related macular degeneration: a randomized, sham-controlled clinical trial. Am J Ophthalmol 2002; 134:905-6. [PMID: 12470761 DOI: 10.1016/s0002-9394(02)01821-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To examine the effect of proton beam irradiation on subfoveal choroidal neovascular membranes (CNVM) associated with age-related macular degeneration (AMD).Randomized, prospective, sham-controlled, double-masked treatment trial. METHODS Thirty-seven subjects with subfoveal CNVM due to AMD were randomly assigned to 16-Gy proton irradiation delivered in two fractions 24 hours apart or to sham control treatment. Recruitment was halted at 37 subjects for ethical reasons regarding randomization to sham treatment when Food and Drug Administration approval of Visudyne was anticipated. RESULTS Proton irradiation was associated with a trend toward stabilization of visual acuity, but this association did not reach statistical significance. No correlations were found within the fluorescein angiography data, including greatest linear dimension of CNVM total size, area of active leakage, area of associated subretinal hemorrhage, and intensity. CONCLUSIONS With the acceptance of photodynamic therapy, future studies will require more complex design and larger sample size to determine whether radiation can play either a primary or adjunctive role in treating these lesions.
Collapse
Affiliation(s)
- Thomas A Ciulla
- Retina Service, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
Age-related macular degeneration (AMD) is a common macular disease affecting elderly people in the Western world. It is characterised by the appearance of drusen in the macula, accompanied by choroidal neovascularisation (CNV) or geographic atrophy. The disease is more common in Caucasian individuals than in pigmented races. In predominantly Caucasian populations, the age-standardised prevalence of AMD in at least one eye is 7760 cases per million. The age-standardised cumulated 1-year incidence of AMD in at least one eye is 1051 cases per million individuals. AMD is the most important single cause of blindness among Caucasian individuals in developed countries. Blindness resulting from AMD rarely occurs before age 70, and most cases occur after age 80. The age-standardised 1-year incidence of legal blindness resulting from AMD is 212 cases per million. Two-thirds of AMD cases have CNV (exudative cases); the remainder has only geographic atrophy. In cross-sectional population-based studies about 45% of eyes with AMD have visual acuity reduced to 20/200 or worse. This is true both for exudative AMD and pure geographic atrophy. Age and genetic predisposition are known risk factors for AMD. Smoking is probably also a risk factor. Preventive strategies using macular laser photocoagulation are under investigation, but their efficacy in preventing visual loss is as yet unproven. There is no treatment with proven efficacy for geographic atrophy. Optimal treatment for exudative AMD requires a fluorescein angiographic study and a physician capable of interpreting it. For CNV not involving the foveal centre, the only evidence-based treatment is laser photocoagulation. For AMD cases with subfoveal CNV, good visual acuity, and predominantly classic fluorescence pattern on fluorescein angiography, photodynamic therapy with verteporfin is the treatment of choice. Photodynamic therapy is also effective in eyes with pure occult CNV and evidence of recent disease progression. For new subfoveal CNV with poor vision and recurrent CNV, laser photocoagulation can be considered.
Collapse
Affiliation(s)
- Morten la Cour
- Eye Department, National University Hospital (Rigshospitalet), Copenhagen, Denmark.
| | | | | |
Collapse
|
30
|
Kondziolka D, Lunsford LD, Witt TC, Flickinger JC. The future of radiosurgery: radiobiology, technology, and applications. SURGICAL NEUROLOGY 2000; 54:406-14. [PMID: 11240166 DOI: 10.1016/s0090-3019(00)00348-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Kondziolka
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213-2592, USA
| | | | | | | |
Collapse
|
31
|
Chakravarthy U. Radiotherapy for choroidal neovascularisation of age-related macular degeneration: a fresh perspective. Eye (Lond) 2000; 14 ( Pt 2):151-4. [PMID: 10845008 DOI: 10.1038/eye.2000.45] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
|