Effectiveness of anti-vascular endothelial growth factors in neovascular age-related macular degeneration and variables associated with visual acuity outcomes: Results from the EAGLE study

Objective

To assess the overall effectiveness of anti-vascular endothelial growth factor (VEGF) therapy in treatment-naïve patients with neovascular age-related macular degeneration (nAMD) in a clinical practice setting.

Study design

EAGLE was a retrospective, 2-year, cohort observational, multicenter study conducted in Italy that analyzed secondary data of treatment-naïve patients with nAMD. The primary endpoint evaluated the mean annualized number of anti-VEGF injections at Years 1 and 2. The main secondary endpoints analyzed the mean change in visual acuity (VA) from baseline and variables associated with visual outcomes at Years 1 and 2.

Results

Of the 752 patients enrolled, 745 (99.07%) received the first dose of anti-VEGF in 2016. Overall, 429 (57.05%) and 335 (44.5%) patients completed the 1- and 2-year follow-ups, respectively. At baseline, mean (standard deviation, SD) age was 75.6 (8.8) years and the mean (SD) VA was 53.43 (22.8) letters. The mean (SD) number of injections performed over the 2 years was 8.2 (4.1) resulting in a mean (SD) change in VA of 2.45 (19.36) (P = 0.0005) letters at Year 1 and −1.34 (20.85) (P = 0.3984) letters at Year 2. Linear regression models showed that age, baseline VA, number of injections, and early fluid resolution were the variables independently associated with visual outcomes at Years 1 and 2.

Conclusions

The EAGLE study analyzed the routine clinical practice management of patients with nAMD in Italy. The study suggested that visual outcomes in clinical practice may be improved with earlier diagnosis, higher number of injections, and accurate fluid resolution targeting during treatment induction.

The Effect of Topical Bromfenac on Intraretinal and Subretinal Fluid in Neovascular Age-Related Macular Degeneration

Purpose:

To report the effect of topical bromfenac, a non-steroidal anti-inflammatory drug (NSAID), in a case of neovascular age-related macular degeneration (AMD).

Methods:

An 85-year-old woman presented with a complaint of visual acuity reduction in the right eye. Comprehensive ophthalmological examination and retinal imaging were performed.

Results:

Best corrected visual acuity was 2/100. Fundus examination showed reticular pseudodrusen and a small hemorrhage in the fovea. Fluorescein angiography showed an active neovascular membrane. Spectral-domain optical coherence tomography (SD-OCT) confirmed diagnosis and revealed subretinal and intraretinal fluid. The patient refused recommended intravitreal anti-vascular endothelial growth factor treatment and received topical bromfenac 0.09% twice daily. Follow-up with SD-OCT showed subretinal followed by intraretinal fluid reduction at 16 weeks after treatment.

Conclusion:

Short-term reduction of subretinal and intraretinal fluid was observed with topical bromfenac monotherapy in neovascular AMD.

Correction to: Pigment dispersion syndrome and pigmentary glaucoma: a review and update

In the original publication, introduction section under Abstract was published incorrectly. The correct version is given below.

Deep topical anesthesia with ropivacaine-soaked sponge for phacoemulsification

PURPOSE

To assess safety and efficacy of deep topical anesthesia with ropivacaine-soaked sponge compared with topical anesthesia with oxybuprocaine in patients undergoing phacoemulsification.

METHODS

This was a retrospective study where records of patients operated for cataract were evaluated. Patients using a visual analogue scale scored pain during surgery, and the surgeon on a questionnaire recorded ease of operation. Medical records were evaluated for patients who received topical anesthesia with multiple administrations of oxybuprocaine 0.4% or those who received deep topical anesthesia with a polyvinyl acetal sponge impregnated with ropivacaine 0.75% and positioned under the eyelid 30 min before surgery.

RESULTS

A total of one hundred patient records, equally divided in patients receiving deep topical anesthesia or topical anesthesia, were included. The visual analogue scale scores among the groups were statistically significant for a lower pain score in patients who received deep topical anesthesia with ropivacaine-soaked sponges (p = 0.0069). The average surgeon score was significantly higher for the deep topical anesthesia group indicating favorable ease of surgery (p = 0.0341). Six patients had major complications during surgery. No additional anesthesia was necessary to manage the complications in four patients in the deep anesthesia group, whereas propofol was used for the induction and maintenance of anesthesia in two patients in the topical anesthesia group.

CONCLUSIONS

Deep topical anesthesia with ropivacaine-soaked sponges performed as well as topical oxybuprocaine regarding safety and efficacy. It provided a lower patient pain score, favorable surgeon satisfaction, and long-lasting anesthesia.

Pigment dispersion syndrome and pigmentary glaucoma: a review and update

INTRODUCTION

Pigment dispersion syndrome (PDS) is a condition where anomalous iridozonular contact leads to pigment dispersion throughout the anterior segment and the released pigment is abnormally deposited on various ocular structures.

CLINICAL PRESENTATION

The clinical presentation of PDS is defined by the presence of pigmented cells on the corneal endothelium, an increase of pigmentation of the trabecular meshwork, and mid-periphery transillumination defects of the iris. This syndrome, more common in myopes, is usually bilateral and can be associated with ocular hypertension or glaucoma. Secondary open-angle pigmentary glaucoma (PG) can develop due to reduction of the outflow of aqueous humour and consequent increase in intraocular pressure leading to glaucomatous optic neuropathy. Diagnosis of PG is commonly between 40 and 50 years of age, occurring more frequently in men. The advent of ultrasound biomicroscopy and anterior segment optical coherence tomography has contributed to enhancing our knowledge on the condition. Typical alterations of the anterior segment are the posterior insertion of the iris and iris concavity. Treatment of PG should be initiated early to hinder disease progression, glaucomatous damage, and vision loss. Management is based on medical therapy, laser iridotomy, selective laser trabeculoplasty, and filtration procedures.

CONCLUSIONS

The differential diagnosis of PDS with other disorders can be challenging and awareness of the condition together with meticulous ophthalmologic examination allows early diagnosis followed by appropriate management strategies. The present review is a comprehensive report on the clinical characteristics, pathogenesis, current management, and status quo of PDS and PG.

Sturge-Weber Syndrome Associated with Monolateral Ocular Melanocytosis, Iris Mammillations, and Diffuse Choroidal Haemangioma

We present the case of a 12-year-old boy with Sturge-Weber syndrome and ocular melanocytosis who presented with bilateral naevus flammeus of the face and hyperpigmentation of the right iris associated with ipsilateral iris mammillations. The patient had glaucoma and a diffuse choroidal haemangioma of the right eye. Optical coherence tomography of the anterior segment confirmed iris hyper-pigmentation and did not show abnormalities of the chamber angle structures. B-scan ultrasonography and enhanced depth imaging optical coherence tomography were performed and showed a marked difference in thickness and reflectance between the right and left choroid. Visual field examinations with perimetry showed early defects in the right eye. Peripapillary optical coherence imaging showed borderline values of retinal nerve fibre layer thickness reduction in the right eye. Sturge-Weber syndrome associated with ocular melanocytosis and iris mammillations is an extremely rare condition. This paper highlights the role of multi-imaging methods in the enhanced evaluation of rare diseases towards choosing the most appropriate management strategies and improving the follow-up of patients over time.

Abnormalities of retinal ganglion cell complex at optical coherence tomography in patients with type 2 diabetes: a sign of diabetic polyneuropathy, not retinopathy

AIMS

To compare optical coherence tomography (OCT)-derived neuro-retinal parameters in patients with type 2 diabetes and non-diabetic controls and to evaluate their correlation with diabetic retinopathy (DR) and polyneuropathy (DPN).

METHODS

One-hundred consecutive patients with type 2 diabetes were examined by spectral-domain (SD) OCT for evaluating ganglion cell complex (GCC) and retinal nerve fibre layer (RNFL) thickness and two new pattern-based quantitative measures of GCC damage, global and focal loss volume (GLV and FLV). Fifty sex- and age-matched non-diabetic subjects served as control.

RESULTS

RNFL thickness (101.0±10.6 vs. 106.4±10.3 μm, P=0.003) was significantly lower and GLV (6.58±4.98 vs. 4.52±3.10 %, P=0.008) and FLV (1.90±1.97 vs. 0.89±0.84 %, P<0.0001) were significantly higher in diabetic versus control subjects. The OCT parameters did not differ significantly according to DR grade. Conversely, RNFL thickness was lower and GLV and FLV were higher in patients with versus those without DPN, and the extent of changes increased significantly with quartiles of DPN score. At both bivariate and multivariate analysis, OCT parameters, especially FLV, correlated significantly with DPN measures.

CONCLUSIONS

The GCC is significantly affected in patients with type 2 diabetes and SD-OCT might represent a useful tool to detect DPN, but not DR in these individuals.

Intracameral epinephrine without the addition of intracameral lidocaine in the management of tamsulosin associated intraoperative floppy iris syndrome

OBJECTIVE

Intracameral mydriatics using epinephrine associated with lidocaine have been reported as efficacious in reducing intraoperative floppy iris syndrome (IFIS) complications during cataract surgery. The aim of this study was to verify the efficacy of intracameral epinephrine without intracameral lidocaine as prophylaxis against IFIS in patients on tamsulosin.

MATERIALS AND METHODS

This was a retrospective study on the results of cataract surgery in 18 patients on therapy with tamsulosin. Patients had undergone routine phacoemulsification in one eye. Successively, they underwent phacoemulsifcation in the fellow eye using non preserved intracameral epinephrine 1:4000 diluted with BSS. Intraoperative complications during cataract surgery had been documented and IFIS was graded based on iris billowing, miosis or iris prolapse. Follow-up was 3 months.

RESULTS

Thirty-six eyes of 18 patients were included in the evaluation. The incidence of IFIS was significantly higher in the eyes where routine phacoemulsificaton had been performed (100%) with respect to eyes where phacoemulsification was carried out using intracameral epinephrine (33%) (Chi Square test =15.12, p<0.001). In routine phacoemulsification 16 eyes showed iris billowing, 14 eyes had some extent of miosis and 14 eyes had tendency to iris prolapse. In phacoemulsification with the use of intracameral epinephrine 5 eyes showed iris billowing, 4 eyes presented some extent of miosis and 2 eyes had tendency to iris prolapse. There were no serious intraoperative complications.

CONCLUSIONS

Intracameral epinephrine without the addition of lidocaine was efficacious in the management of IFIS in patients on tamsulosin.

Intravitreal injection of dexamethasone implant and ranibizumab in cystoid macular edema in the course of irvine-gass syndrome

PURPOSE

To evaluate the efficacy of 2 dexamethasone intravitreal implants and 1 ranibizumab intravitreal injection after a bilateral postoperative complication of cataract surgery as pseudophakic cystoid macular edema.

PATIENTS AND METHODS

A 70-year-old male patient with systemic hypertension developed a progressive cystoid macular edema (CME) in both eyes starting between 10 and 20 days after cataract surgery. Two intravitreal dexamethasone implants and 1 ranibizumab injection were administered; first in the right eye (RE) and then in the left eye (LE). The patient was checked for 1 whole week and then once a month for 5 months after the injections.

RESULTS

One month after the first dexamethasone implant in his RE, the spectral domain optical coherence tomography (SD-OCT) showed a progressive reduction of the foveal thickness until a complete resolution of the CME occurred, which was associated with an improvement of visual acuity. After 3 months, the SD-OCT showed a relapse of the CME, which was then treated with 1 injection of ranibizumab. One month after this injection, there was a complete resolution of the CME. A new CME in his RE was diagnosed 2 months after the last ranibizumab injection; it was treated with a new dexamethasone implant. A complete resolution of the CME was obtained; a normal foveal profile was still present 5 months after the last injection, and the best-corrected visual acuity was 20/20. His LE developed a CME 40 days after surgery. One intravitreal injection of ranibizumab was first administered in his LE, with a complete resolution of the CME at SD-OCT 2 weeks later. As observed in his RE, 40 days after the ranibizumab injection, there was a relapse of the CME that was treated with 1 intravitreal injection of dexamethasone implant. Five months later, the patient showed a worsening of the CME, but it was completely resolved with a second dexamethasone injection. After 3 months, the foveal thickness was back to normal with a BCVA of 20/20.

CONCLUSION

Treatment with dexamethasone implants (Ozurdex(®)) and ranibizumab injections (Lucentis(®)) induced a progressive reduction of our patient's CME after cataract surgery (Irvine-Gass syndrome) until a complete normal foveal thickness was restored and his visual function was improved despite the order of injections.

Intravitreal bevacizumab in the successful management of choroidal metastases secondary to lung and breast cancer unresponsive to systemic therapy: a case series

PURPOSE

Management of choroidal metastases is commonly with systemic chemotherapy; however, if tumours are refractory to treatment and vision is endangered, local therapy modalities are feasible. A novel option is the use of intravitreal bevacizumab. This report presents three cases of choroidal metastatic tumours secondary to lung and breast cancer treated with intravitreal bevazizumab.

PATIENTS AND METHODS

Three patients with choroidal metastases secondary to lung and breast tumours were treated at the Ophthalmology Unit, University of Rome 'Sapienza', S.Andrea Hospital from January 2009 to August 2012. All patients developed vision loss with diagnosis of chorioidal metastasis during systemic chemotherapy. Off label intravitreal bevacizumab treatment was performed with two 1.25 mg injections in two patients and four injections in one patient at 30-day intervals.

RESULTS

Vision improved, subretinal fluid resolved, and choroidal tumour regression was obtained in all cases. Follow-up was 6, 9, and 12 months and there were no complications related to treatment.

CONCLUSIONS

Intravitreal bevacizumab administration represented an efficacious therapeutic option with rapid effect in the treatment of choroidal metastatic tumours unresponsive to systemic therapy. It can have a role in the management of these tumours by preventing vision loss and improving the quality of life of patients.

Intravitreal Injection of Dexamethasone Implant in Serous Macular Detachment Associated with Waldenström's Disease

Purpose

To evaluate the efficacy of one intravitreal injection of dexamethasone (Ozurdex^®; Allergan, Inc., Irvine, Calif., USA) in serous macular detachment (SMD) of one eye, associated with bilateral central retinal vein occlusion (CRVO) in a patient affected by Waldenström's macroglobulinemia (WM).

Patients and Methods

A female patient, affected by WM, complained of a progressive decrease in visual acuity, mainly in the left eye (LE). SMD in the LE associated with bilateral CRVO was diagnosed. One intravitreal injection of dexamethasone was administered in the LE and the patient was tested 1, 2, and 6 months after the injection.

Results

1, 2, and 6 months after the injection, the spectral domain optical coherence tomography (SD-OCT) showed a progressive slight reduction of foveal thickness that was not related to any improvement of visual function.

Conclusions

Treatment with dexamethasone (Ozurdex) induced a progressive slight reduction of SMD but no improvement of visual acuity, and it is possible that this is related to the condition of hematic hyperviscosity that is present in WM.

Intravitreal ranibizumab and laser photocoagulation in the management of idiopathic juxtafoveolar retinal telangiectasia type 1: a case report

Background

Idiopathic juxtafoveolar retinal telangiectasia (IJRT) type 1 represents an uncommon cause of congenital unilateral visual loss and it typically affects males. Decrease in visual acuity is caused by serous and lipid exudation into the fovea with cystoid macular edema. In some cases, spontaneous resolution may be observed, but when there is a progressive loss of visual acuity, laser photocoagulation is often necessary. This treatment is not always successful and therapy for this condition is still controversial.

Case Presentation

A 57-year-old man referred a 2-month history of blurred and distorted vision in the right eye. Best-corrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Fundus examination showed temporal macular edema, confirmed by optical coherence tomography. Fluorescein angiography showed a localized area of hyperfluorescence probably due to telangiectasia type 1 located below the inferior temporal area of the fovea. A combined therapy of intravitreal ranibizumab injection and laser photocoagulation was performed. Visual acuity improved from 20/50 to 20/32 and the therapy was well tolerated by the patient. After 3 years of follow-up, both visual acuity and fundus examination were stable.

Conclusions

This case suggests that the combined use of ranibizumab and laser photocoagulation may be considered an effective treatment for JRT type 1, leading to an improvement in both visual acuity and macular edema. We believe that intravitreal ranibizumab injection associated with laser photocoagulation should be considered as treatment for IJRT type 1.