Aflibercept, ranibizumab and bevacizumab upcoming biosimilars: a general overview

Anti-vascular endothelial growth factors currently are the first-line treatment option for neovascular age-related macular degeneration (nAMD) and other retinal vascular disorders, and their clinical use is associated with high financial burden. Biosimilars are a type of biological product highly similar to referral biologic drugs; they are increasing competition among biologics and have the potential to reduce the overall expenditures on biologics. In this comprehensive literature review, the current investigational biosimilars acting on retinal diseases are discussed. The authors review the results of clinical studies and highlight ongoing trials. Several biosimilar candidates are under evaluation and the pipeline will rapidly change in the future, as soon as each patent expires. Clinicians have to know these new therapeutic agents, which might come in the mainstream clinical practice as a more cost-efficient option.

Razumab -- the role of biosimilars for the treatment of retinal diseases

Biologics targeting vascular endothelial growth factor (anti-VEGF) are the mainstay treatment of many vascular retinal pathologies. To date, Razumab is the only approved biosimilar for ophthalmic use. Razumab showed no differences compared to the innovator ranibizumab, in terms of VEGF binding activity nor in inhibition of VEGF-induced proliferation. Clinical and preclinical studies have shown a favorable efficacy and safety profile of Razumab. Nonetheless, even if clinical equivalence is expected, randomized controlled clinical trials are needed to directly compare Razumab with the innovator ranibizumab in different retinal diseases.

Retinal Pigment Epithelial Tear following Intravitreal Injection of Bevacizumab (Avastin)

Purpose

To report one case of retinal pigment epithelium tear following intravitreal bevacizumab injection for neovascular age-related macular degeneration.

Methods

A 59-year-old patient presented with occult choroidal neovascularization associated with a serous pigment epithelial detachment secondary to age-related macular degeneration. The patient was treated with an intravitreal injection of bevacizumab.

Results

The patient developed a retinal pigment epithelium tear 60 days following the intravitreal injection.

Conclusions

This report describes the development of retinal pigment epithelium tear after intravitreal bevacizumab injection. Future studies should be performed to evaluate which subtypes of lesions are most susceptible to this potential devastating visual complication.

Choroidal Hemangioma Treated with Photodynamic Therapy Using Verteporfin: Report of a Case

Purpose

To report the results of treatment of circumscribed choroidal hemangioma with a single application of photodynamic therapy (PDT) with verteporfin according to the Treatment of Age-related Macular Degeneration with Photodynamic Therapy study.

Methods

A 44-year-old man with unilateral decreased vision and macular subretinal fluid secondary to a circumscribed choroidal hemangioma diagnosed by fluorescein and indocyanine green angiography and ultrasonography underwent PDT with verteporfin therapy.

Results

One year after PDT, subretinal fluid was absent and visual acuity improved.

Conclusions

The results obtained in this case are in keeping with previously reported results; however, future randomized studies are necessary to evaluate and standardize different infusion times in order to obtain maximum efficacy of treatment.

Intravitreal Triamcinolone Acetonide as Primary Treatment for Diffuse Diabetic Macular Edema: A Prospective Noncomparative Interventional Case Series

Purpose

To evaluate the efficacy and safety of one intravitreal injection of 25 mg of triamcinolone acetonide as primary treatment for diffuse diabetic macular edema.

Methods

Intravitreal triamcinolone acetonide injection was performed in 30 eyes with previously untreated diabetic macular edema. The main outcome measures were logMAR visual acuity (VA) and central macular thickness (CMT) at 1, 3, and 6 months. A secondary outcome was intraocular pressure progression.

Results

Visual acuity results for 30 eyes that had a follow-up of at least 6 months are presented. Twenty of them were followed up to 10.1 ±2.38 months. Preoperatively, VA was 0.54±0.27. At 1, 3, and 6 months follow-up, VA was 0.44±0.29 (p=0.001), 0.43±0.28 (p=0.001), and 0.45±0.29 (p=0.006), respectively. Preoperatively, CMT was 417.3±143.5 μm. At 1, 3, and 6 months follow-up, CMT was 277.3 +74.0 μm (p<0.0001), 279.6±94.4 μm (p<0.0001), and 297.07±114.87 μm (p=0.002), respectively. For the 20 eyes with a follow-up of 10.1±2.38 months, VA was 0.5±0.25 and 0.50±0.32 at baseline and at the last follow-up visit, respectively (p>0.05). Preoperatively, intraocular pressue (IOP) was 15.13±1.48 mmHg. IOP was 18.26±2.71 mmHg, 20.07±4.27 mmHg, and 20.4±6.18 mmHg, at 1, 3, and 6 months, respectively (p<0.0001). Four eyes underwent uncomplicated filtrating surgery for intractable glaucoma.

Conclusions

Intravitreal triamcinolone as primary treatment effectively increases VA and reduces CMT due to diffuse diabetic macular edema. Longer follow-up and randomized clinical trial are war ranted. Safety results highlight the need to further study the relationship between triamcinolone and intraocular pressure.

Multiple Bilateral Choroidal Metastatic Tumors from a Small-Cell Neuroendocrine Carcinoma of Unknown Primary Site

PURPOSE

To report one case of multiple and bilateral choroidal tumors from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary.

METHODS

The case of a 30-years-old white female who developed multiple and bilateral choroidal tumors from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary is presented.

RESULTS

The patient had a disseminated disease and died 6 months after. The oncologic work-up, including physical examination, laboratory and radiographic study, fails to identify the primary site.

CONCLUSIONS

Intraocular involvement from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary has not yet reported. We describe this case together with a review of the literature.

Comparison of views on the need for continuing education on oral cancer between general dentists and oral medicine experts: A Delphi survey

Objectives:

The role of dental professionals in screening for oral cancer has been limited. The purpose of this study was to investigate and compare the educational priorities of oral medicine specialists, general dental practitioners, and doctors of dental surgery with regards to the diagnosis and management of oral cancers and potential malignant disorders.

Study Design:

This was a longitudinal survey.

Materials and Methods:

A Delphi survey was directed to a panel of 25 oral medicine specialists asking them to identify the major difficulties in diagnosing and managing patients with oral cancer or suspected malignancy. In a second phase, two groups of generalists were asked to express their ratings on the issues identified by experts.

Results:

The response rate of the experts to the survey was 84%, while only 44% of the generalists participated. Although the three groups agreed on most of the issues, there were significant differences of opinions on 10 of the items proposed by specialists (P < 0.05 from the Kruskal–Wallis test), which were observed mainly between experts and general dental practitioners (P < 0.017 from the Mann–Whitney U test). The opinion of the participants about future investments in the field of education resulted in similar results (P > 0.05 from the Chi-square test), with the specialists ranking highest on mandatory annual thematic courses, while the generalists prioritizing more interactive and extensive pre-graduation courses on oral cancer detection.

Conclusion:

This study confirms a clear need to improve the educational foundation on oral cancer by a didactic process starting with pre-graduation courses that should involve National Health Care Services, National Dental Associations, and academia.

Soft tissue conditions and marginal bone levels of implants with a laser-microtextured collar: a 5-year, retrospective, controlled study

AIM

To compare clinical and radiographic outcomes of implants with a Laser-Lok®-microtextured collar to implants with a resorbable blast textured (RBT) collar after a 5-year follow-up period.

MATERIALS AND METHODS

Thirty-four implants with a Laser-Lok®-microtextured collar (test group [TG]) and 31 implants with an RBT collar (control group [CG]) were placed in 45 non-smoking, periodontally healthy patients. The full-mouth plaque score, full-mouth bleeding score, number of sites with plaque, and the number of sites with bleeding on probing (BOP) were recorded at baseline, and at 1-, 2-, 3-, 4-, and 5-year follow-up. Probing depth (PD) and mucosal recession were assessed at baseline and after the 5-year follow-up period. The radiographic marginal bone loss (MBL) was calculated by subtracting the bone level at the time of crown insertion from the bone level at the 5-year follow-up.

RESULTS

An implant survival rate of 94% and of 90% was reported for the TG and the CG, respectively. No statistical differences were found between the study groups for presence of plaque (10.1% vs. 25%) or for number of sites with BOP (10.3% vs. 23%). The differences between both study groups were statistically significant for mean MBL (0.81 ± 0.24 vs. 2.02 ± 0.32 mm), mean PD (2.32 ± 0.44 vs. 4.25 ± 0.87 mm), and mean mucosal recession (0.16 ± 0.3 vs. 0.22 ± 0.3 mm).

CONCLUSIONS

Within the limitations of this study, results suggest that the laser-microtextured implant collar surface may provide more favorable conditions for the attachment of hard and soft tissues, and reduce the level of MBL.

Intravitreal triamcinolone acetonide as primary treatment for diffuse diabetic macular edema: a prospective noncomparative interventional case series

PURPOSE

To evaluate the efficacy and safety of one intravitreal injection of 25 mg of triamcinolone acetonide as primary treatment for diffuse diabetic macular edema.

METHODS

Intravitreal triamcinolone acetonide injection was performed in 30 eyes with previously untreated diabetic macular edema. The main outcome measures were logMAR visual acuity (VA) and central macular thickness (CMT) at 1, 3, and 6 months. A secondary outcome was intraocular pressure progression.

RESULTS

Visual acuity results for 30 eyes that had a follow-up of at least 6 months are presented. Twenty of them were followed up to 10.1+/-2.38 months. Preoperatively, VA was 0.54+/-0.27. At 1, 3, and 6 months follow-up, VA was 0.44+/-0.29 (p=0.001), 0.43+/-0.28 (p=0.001), and 0.45+/-0.29 (p=0.006), respectively. Preoperatively, CMT was 417.3+/-143.5 microm. At 1, 3, and 6 months follow-up, CMT was 277.3 +74.0 microm (p<0.0001), 279.6+/-94.4 microm (p<0.0001), and 297.07+/-114.87 microm (p=0.002), respectively. For the 20 eyes with a follow-up of 10.1+/-2.38 months, VA was 0.5+/-0.25 and 0.50+/-0.32 at baseline and at the last follow-up visit, respectively (p>0.05). Preoperatively, intraocular pressure (IOP) was 15.13+/-1.48 mmHg. IOP was 18.26+/-2.71 mmHg, 20.07+/-4.27 mmHg, and 20.4+/-6.18 mmHg, at 1, 3, and 6 months, respectively (p<0.0001). Four eyes underwent uncomplicated filtrating surgery for intractable glaucoma.

CONCLUSIONS

Intravitreal triamcinolone as primary treatment effectively increases VA and reduces CMT due to diffuse diabetic macular edema. Longer follow-up and randomized clinical trial are warranted. Safety results highlight the need to further study the relationship between triamcinolone and intraocular pressure.

Branch retinal artery occlusion combined with branch retinal vein occlusion in a patient with hepatitis C treated with interferon and ribavirin

PURPOSE

To report a case of a combined branch retinal artery and vein occlusion in a patient with hepatitis C treated with interferon and ribavirin.

METHODS

A 29-year-old man with a 1-week history of sudden visual field defect and decrease of central visual acuity was examined.

RESULTS

Ophthalmoscopy and fluorescein angiography demonstrated an ischemic whitening of the inferior hemi-retina involving part of the macular region, numerous intraretinal hemorrhages, and a significant delay in arterial and vein filling of the dye.

CONCLUSIONS

The findings of a retinopathy associated with interferon and ribavirin treatment of hepatitis C are important. The symptomatic permanent visual field defect and decrease of central visual acuity developing following a branch retinal artery and vein occlusion event emphasizes the need for careful and regular ocular monitoring of patients receiving interferon for hepatitis C.

Intravitreal triamcinolone in the treatment of serous pigment epithelial detachment and occult choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To report two cases of occult choroidal neovascularization (CNV) and serous pigment epithelial detachment (PED) treated with intravitreal triamcinolone (IVT) injections.

METHODS

Interventional case reports.

RESULTS

Both patients showed an increase in visual acuity and a complete flattening of the PED at 10 months (Case 1) and 4 months (Case 2) after IVT injections. No complications or adverse effects are reported.

CONCLUSIONS

Future studies should be designed to investigate if IVT can effectively influence the clinical and functional outcome of eyes with serous PED and occult CNV secondary to age-related macular degeneration, for which at the moment no treatment has been shown to be effective.

Morphologic variations in bacteria under stress conditions: near-field optical studies

The morphologic and structural variations suffered by cells of a population of Pseudomonas aeruginosa ATCC 27853 under stress conditions were investigated by using scanning near-field optical microscopy. The analysis of the images, supported by microbiological data, showed that the bacteria evolved from the initial distribution of rod-shaped cells of standard size to a population with structural and morphologic modifications. The detection of variations in the optical reflectivity over a subwavelength scale (< or = 100 nm), combined with the concurrently acquired topographical signal, allowed the visualisation of rod-shaped bacteria going towards a lytic process and entire "U"-shaped cells. In the latter cells, which derived from a morphology refolding of rod bacteria, cellular matter seemed to rearrange itself to attain a coccoid stress resistant form, responsible for the residual viability of the population.

Pleomorphic adenocarcinoma of the ciliary epithelium: a clinicopathological, immunohistochemical, ultrastructural, DNA-ploidy and comparative genomic hybridization analysis of an unusual case

PURPOSE

To describe detailed phenotypic and genotypic analysis of a pleomorphic adenocarcinoma of the ciliary epithelium (CE).

CASE REPORT

An 86-year-old white woman developed an enlarging mass protruding from her previously eviscerated left eye 2 months postoperatively. Based on light and ultrastructural microscopy, the final diagnosis was a pleomorphic adenocarcinoma of the ciliary epithelium (CE).

DISCUSSION

Cell proliferation indices confirmed the unusually rapid growth rate of this tumor; the peridiploid DNA content might explain the relatively low incidence of distant metastases. An imbalance of the chromosome 6 was also found by Comparative Genomic Hybridization (CGH).

Solitary fibrous tumor of the inguinal region: a clinicopathological, light-microscopic, immunohistochemical, electron microscopic and flow-cytometric DNA study

Solitary fibrous tumors (SFTs) are rare neoplasms with a probable mesenchymal origin that were first reported in the pleura but can occur in different sites. We report a case of SFT arising in the inguinal region of a 55-year-old woman. The patient presented with a mass in the left groin; she underwent wide excision of the lesion which was well-circumscribed and without evidence of adjacent soft tissue involvement. The histological, immunohistochemical and electron microscopic criteria for SFT were found. She had an uneventful recovery and she is alive without evidence of disease five years after operation. To our knowledge, this neoplasm has never been reported in this location.

Marker gene transfer and oncolysis of human Y79 retinoblastoma cells mediated by herpes simplex virus mutants

Three different herpes simplex virus (HSV) mutants, designated hrR3, MGH-1 and R3616, were used to infect Y79 retinoblastoma cells grown in suspension. Two parameters were assayed: (a) vector-mediated gene expression, measured by histochemical staining of a transferred LacZ transgene, and (b) virus-mediated oncolysis, determined by the inability of infected cells to exclude trypan blue dye. The tested HSV mutants were found to infect cells grown in suspension at a relatively low multiplicity of infection (MOI = 0.01) and were capable of transferring the LacZ gene as early as 2 days after infection. Furthermore, differences in oncolytic activity were observed amongst the tested viruses: MGH-1 and R3616 exhibited 50% cell kill at a MOI of 0.1 over a period of 6 days, whereas hrR3-mediated oncolysis appeared less efficient. These studies provide a rationale for further exploitation of oncolytic herpes viruses as a potential treatment of intraocular tumors.

Malignant melanoma of soft tissues (clear cell sarcoma) of the foot. Is MRI able to perform a specific diagnosis? Report of one case and review of the radiological literature

The magnetic resonance (MR) findings in malignant melanoma of soft tissues, also called clear cell sarcoma of tendons and aponeuroses, have been described as a focal abnormality with a specific MR pattern of increased signal intensity (relative to normal muscle) on T1 weighted sequences and variably decreased signal intensity on T2 weighted sequences (relative to surrounding fat). We have reported here a case of malignant melanoma of soft tissues of the foot, studied with ultrasonography (US) and MR, in which MR showed T1-hypointensity, T2-hyperintensity and marked gadolinium uptake. We have described the relationship between the intracytoplasmic melanin amount of and these atypical MR findings.

Detection of tenascin-C in surgically excised choroidal neovascular membranes

BACKGROUND

Increase of tenascin-C (TN-C) expression has been found in pathologic tissues in which angiogenesis occurs. The aim of this study was to investigate TN-C expression in human choroidal neovascularization (CNV).

METHODS

Ten choroidal neovascular membranes were surgically removed from 10 patients with age-related macular degeneration (n=6) and multifocal choroiditis (n=4). All membranes underwent immunohistochemical evaluation using monoclonal antibodies against TN-C and factor VIII.

RESULTS

All membranes were positive for TN-C, which was abundantly and diffusely expressed in the extracellular matrix.

CONCLUSIONS

Our results support the concept that TN-C has a role in cell proliferation and neovascularization in humans. TN-C, as a marker of angiogenesis, may provide novel rationales for the development of pharmacologic therapies for neovascular disorders, particularly CNV.

Follicular large-cell lymphoma of the orbit: a clinicopathologic, immunohistochemical and molecular genetic description of one case

BACKGROUND

Follicular large cell lymphoma of the orbit is a very rare and aggressive lymphoproliferative disease of the ocular adnexa. In this study we analyzed the clinicopathologic characteristics of one patient, including the immunoglobulin gene rearrangement assay by means of polymerase chain reaction.

CASE REPORT

A 71-year-old female underwent an incisional biopsy in the superior nasal quadrant of the left orbit following the occurrence of bilateral eyelid edema and ptosis. Histology and immunohistochemistry revealed a follicular large cell lymphoma of the orbit. Computerized tomography aimed at staging the disease revealed a supraclavicular lymphoadenopathy approximately 0.5 cm in diameter. Bone marrow biopsy was negative for lymphoma. The patient was classified as stage IV. She underwent a 10-week cycle of polychemotherapy (VP16, adriamycin, cyclophosphamide, vincristine, prednisone, bleomycin). Ten months after therapy, disease recurred at the cervical lymph nodes and the patient underwent a radiotherapy cycle of 4320 cGy with disease remission. At the time of writing, the patient presents a left axillary adenopathy on computerized tomography followup.

CONCLUSION

Ophthalmologists should be aware of possible rare occurrences of follicular large cell lymphomas of the orbit. In this case the clinical outcome is always more aggressive than the more common MALT-type lymphoma, which usually exhibits benign behavior.

Morphological, physiological, and biochemical changes in rhodopsin knockout mice

Mutations in rod opsin, the visual pigment protein of rod photoreceptors, account for approximately 15% of all inherited human retinal degenerations. However, the physiological and molecular events underlying the disease process are not well understood. One approach to this question has been to study transgenic mice expressing opsin genes containing defined mutations. A caveat of this approach is that even the overexpression of normal opsin leads to photoreceptor cell degeneration. To overcome the problem, we have reduced or eliminated endogenous rod opsin content by targeted gene disruption. Retinas in mice lacking both opsin alleles initially developed normally, except that rod outer segments failed to form. Within months of birth, photoreceptor cells degenerated completely. Retinas from mice with a single copy of the opsin gene developed normally, and rods elaborated outer segments of normal size but with half the normal complement of rhodopsin. Photoreceptor cells in these retinas also degenerated but did so over a much slower time course. Physiological and biochemical experiments showed that rods from mice with a single opsin gene were approximately 50% less sensitive to light, had accelerated flash-response kinetics, and contained approximately 50% more phosducin than wild-type controls.

[The role of phagocytic cells in periodontal disease]

Having described the morphological and functional characteristics of phagocytic cells, the paper underlines that, in addition to the etiological responsibility of bacterial plaque, the main role in the onset and evolution of periodontitis is played by the host's response. Phagocytic response plays a fundamental role in the host's defence reaction and represents the first barrier to the penetration of bacteria into periodontal tissue. In addition to their defensive role, phagocytic cells may also be responsible for damage to periodontal tissue as a collateral effect of their phagocytic function, thus worsening the periodontal lesion.

[Evaluation of the therapeutic efficacy and tolerance of a new thiamine compound (benzoyloxymethylthiamine) in the treatment of postoperative pain symptomatology in odontostomatological surgery]

The therapeutic effectiveness of benzoyloxymethyl-thiamin in controlling post-operative pain in odontostomatological surgery has been examined. The double blind study used a placebo and concerned 100 patients subjected to avulsion of the third molar in dysodontiasis on an out-patient basis. The results point to the effectiveness of benzoyloxymethyl-thiamin in the symptomatic treatment of post-operative pain symptomatology both as regards its duration and intensity; the drug also proved to be very well tolerated and its administration was not accompanied by any unwanted side-effects.

[Burning mouth syndrome]

The burning mouth syndrome is a pathology characterized by burning oral mucoses. The etiological factors can be numerous. The Authors suggest a nosologic classification of this disease.

[Periodontitis associated with systemic diseases with qualitative deficiency of phagocyte function. I. Diabetes mellitus]

Diabetes mellitus is accompanied constantly by functional changes in polymorphonucleated neutrophils and particularly in their chemotactic properties. Their function of impeding the invasion of the organism on the part of aggressive external factors cannot therefore be implemented. These patients are, therefore abnormally susceptible to infection and, with high frequency, also present serious periodontal disease.

[Periodontitis associated with systemic diseases with qualitative deficiency of phagocyte function. II. Down's syndrome]

Numerous systemic syndromes with different aetiopathogenetic and clinical features are constantly accompanied by functional changes in polymorphonucleated neutrophils and, particularly, in their chemotactic properties. The function they perform, namely impeding invasion of the organism by external aggressive factors, cannot therefore be implemented. These patients are thus abnormally susceptible to infections and present a high frequency of serious periodontal disease.

[Periodontitis associated with systemic diseases with qualitative deficiency of phagocyte function. III. Papillon-Lefevre syndrome]

Numerous systemic syndromes with different aetiopathogenetic and clinical features are constantly accompanied by function changes in neutrophil polymorphoanucleates and, particularly, in their chemotactic properties. The function they perform, namely impeding the invasion of the organism on the part of aggressive external factors, cannot therefore be implemented. These patients are thus abnormally susceptible to infections and present severe periodontal disease with high frequency.

[Desquamative gingivitis: etiopathogenetic and clinical assessment]

The aetiopathogenetic, diagnostic, clinical and therapeutic aspects of a particular form of gingival condition given various names in the past but presently defined as "chronic desquamative gingivitis" have been examined. Desquamative gingivitis is an uncommon clinical condition whose aetiology remains uncertain. It has therefore not yet been definitely established wether it is a specific entity or whether, as is confirmed by much clinical evidence and laboratory data, it is merely an oral clinical sign of dermatological type pathologies (pemphigus vulgaris, benign mucosal pemphigoid, bullous pemphigoid, erosive lichen ruber planus, psoriasis).