Visual Outcome after Intravitreal Anti-VEGF Therapy for Macular Neovascularisation Secondary to Sorsby's Fundus Dystrophy: A Systematic Review

The aim of this paper is to summarise our own and to review published experience regarding the long-term outcome of intravitreal treatment for macular neovascularisation (MNV) secondary to Sorsby's fundus dystrophy (SFD). A systematic literature search using the MeSH terms [Sorsby] and [anti-vascular endothelial growth factor (VEGF)] was conducted in NCBI/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ScienceDirect, Google Scholar and ClinicalTrials.gov to identify publications reporting anti-VEGF treatment outcomes in SFD. Treatment outcomes were extracted for this meta-analysis from 14 publications and an own patient reporting a total of 31 cases with a mean follow-up (FU) of 54 months. Both eyes were affected in ten (32.3%) instances. Heterogenous reporting limited the comparability of the outcomes. All papers in common, however, reported satisfied to excellent responses to anti-VEGF therapy if patients were diagnosed and treated immediately after onset of symptoms. Of 20 eyes, for which visual acuity was reported before and after treatment, five worsened and seven improved by more than 1 line, whereas eight eyes maintained their function by end of the follow up, and 11 eyes (55%) maintained a driving vision (Snellen VA ≥ 0.5). Of six eyes with a VA < 0.5, VA improved in one to VA ≥ 0.5, whereas of 14 eyes with an initial VA ≥ 0.5, this dropped to <0.5 despite therapy. In MNV secondary to SFD, the delay between first symptoms and access to anti-VEGF treatment determines subretinal scar formation and thereby, functional prognosis. If treated early, this is generally favourable under regular controls and a consequent anti-VEGF treatment of MNV activity.

Gene, Cell and Antibody-Based Therapies for the Treatment of Age-Related Macular Degeneration

Here we discuss antibody, cell and gene-based therapies that are currently available and under investigation for both wet and dry age-related macular degeneration (AMD). We initially discuss ocular anatomy, AMD modelling as well as the underlying pathophysiology of AMD. The antibody-based trials which have revolutionised the management of wet AMD are reviewed. The latest concepts in antibody therapy for wet AMD such as the port delivery systems, bispecific antibodies, designed ankyrin repeat protein (DARPINs) and brolucizumab are explored. Furthermore, the antibody-based trials targeting the complement pathway to reduce progression of geographic atrophy (GA) in dry AMD are discussed. Stem cell therapy and gene therapy are novel treatment modalities with no established clinical use in wet or dry AMD. Here, we discuss their efficacy so far in clinical trials. Their benefits and risk in the treatment of both wet and dry AMD are evaluated.

Bevacizumab as a treatment option for choroidal neovascularisation due to large optic nerve drusen in a 14-year-old girl

Purpose: To report the effects of a single intravitreous injection of bevacizumab for the treatment of secondary choroideal neovascularisation due to large optic disc drusen.

Methods: A 14-year-old female patient with painless loss of vision in one eye presented with unusually large optic disc drusen and juxtapapillary choroidal neovascularisation with subretinal hemorrhage. She was treated with a single intravitreous injection of bevacizumab.

Results: Visual acuity increased from 20/100 to 20/25 within 4 weeks after injection and remained at this level during the 12-month follow-up period.

Conclusions: Bevacizumab is a possible primary treatment option for secondary choroidal neovascularisation due to large optic disc drusen in children as an alternative to other more invasive or complex procedures.

[Anti-VEGF therapy in the treatment of neovascularization secondary to angioid streaks (a case report)]

The article presents a clinical case of using anti-VEGF therapy in the treatment of retinal neovascularization consequent to angioid streaks (AS). Angioid streaks are linear breaks or divergences in an abnormally brittle or calcified Bruch's membrane. The development of choroidal neovascularization (CNV) due to AS is one of the most serious complications of the disease and the main cause of visual impairment, especially in active middle-aged patients. Currently, determination of the morphology and activity of CNV is done using multimodal macular imaging methods such as optical coherence tomography of the retina (OCT), optical coherence tomography angiography (OCT-A), fluorescin angiography (FA), indocyanine green angiography (ICGA) and autofluorescence. With the discovery of anti-VEGF therapy, it became possible to improve and stabilize functional results in this group of patients.

Oliver McFarlane syndrome and choroidal neovascularisation: a case report

BACKGROUND

Oliver McFarlane syndrome (OMS) is a rare autosomal recessive disorder characterised by pigmentary chorioretinal atrophy with no previous reports of choroidal neovascularisation (CNV).

MATERIAL AND METHODS

We describe the history, findings of clinical examination, retinal imaging and electrodiagnostic studies, and the treatment of a patient with CNV secondary to OMS.

CASE DESCRIPTION

CNV secondary to OMS was diagnosed in a ten-year-old white female who presented with reduced visual acuity and a macular haemorrhage in her right eye. CNV was confirmed on optical coherence tomography. She was initially treated with a single injection of intravitreal bevacizumab and 2 years later with an injection of intravitreal ranibizumab for a recurrence. Although macular scarring secondary to the CNV was observed, her vision has stabilised and she continues to be closely monitored.

CONCLUSION

We report the first case of CNV secondary to OMS and its successful treatment with intravitreal anti-vascular endothelial growth factor injections.

Comparison of different morphologies of choroidal neovascularization evaluated by ocular coherence tomography angiography in age-related macular degeneration

IMPORTANCE

The clinical implications of different morphologies of choroidal neovascularization (CNV), as evaluated by ocular coherence tomography angiography (OCTA) in neovascular age-related macular degeneration (nAMD), are lacking.

BACKGROUND

To describe the morphology of CNV in nAMD using OCTA, and to compare the visual prognosis and other structural OCT biomarkers between different morphologic patterns.

DESIGN

Retrospective cohort study.

PARTICIPANTS

One hundred and forty eyes with nAMD treated with anti-vascular endothelial growth factor (VEGF).

METHODS

Patients were examined using OCTA prior to and at 3, 6 and 12 months after receiving anti-VEGF therapy.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) and morphologic retinal features.

RESULTS

Organized CNV was identified in 110/140 eyes (78.6%) using OCTA. These CNV complexes could be divided into three OCTA patterns: the 'medusa' pattern (n = 41), characterized by branching vessels radiating in all directions; the 'seafan' pattern (n = 43), characterized by branching vessels radiating to one side of the lesion; and the 'tangled' pattern (n = 26), characterized by globular entwined vessels without a main trunk. At baseline, the eyes with the tangled pattern were from younger patients (P = .031) with better BCVA (P = .007). There were also fewer intraretinal cysts (P = .021), less fibrovascular pigment epithelial detachment (P = .009), and more pachychoroid (P = .007) in eyes with the tangled pattern on OCT. At 12 months post-treatment, patients with the tangled CNV pattern also showed greater visual improvement than patients with the other two patterns (P = .049).

CONCLUSIONS AND RELEVANCE

Using OCTA, distinct morphologies of CNV in nAMD patients were identified. These different patterns might be useful predictors for the prognosis of nAMD patients after anti-VEGF therapy.

Influence of pigment epithelial detachment on visual acuity in neovascular age-related macular degeneration

Pigment epithelial detachment (PED), the anatomical separation of the retinal pigment epithelium from the Bruch membrane, is common in many chorioretinal diseases, including neovascular age-related macular degeneration. PED is present in about 30% to 80% of neovascular age-related macular degeneration patients based on the CATT, EXCITE, and VIEW studies. The influence of PED on visual acuity is controversial as a result of inconsistent results reported by various studies. With advances in imaging technologies, it is possible to evaluate not only the presence or absence of PED, but also detailed quantitative parameters, such as height, width, greatest linear diameter, area, volume, and reflectivity within the PED. We performed a comprehensive literature review to evaluate the relationship of PED with visual acuity. In summary, the presence or persistence of a PED may still be compatible with relatively good visual acuity. There is no strong evidence that the presence of a PED or aspects of its morphology has a significant impact on visual acuity. The presence of a PED may be predictive of the need for more regular treatment. More well-designed studies with standardized PED definitions and classifications are needed to evaluate the relationship between PED and visual acuity.

Optical coherence tomography angiography findings in fellow eyes of choroidal neovascularisation associated with central serous chorioretinopathy

AIM

To evaluate the optical coherence tomography angiography (OCTA) features of fellow eyes of patients with unilateral choroidal neovascularisation (CNV) associated with chronic central serous chorioretinopathy (CSCR).

METHODS

Medical records of patients with chronic CSCR who had undergone OCT angiography of both the eyes were reviewed. Patients with evidence of unilateral CNV detected by conventional imaging (OCT, fluorescein angiography and/or indocyanine green angiography) were included in the study. The OCT and OCTA characteristics of fellow eyes were analysed.

RESULTS

Forty patients (80 eyes-40 fellow eyes) with chronic CSCR with evidence of CNV in one eye were included. Mean age of the patients was 54.9±9.9 years and 82.5 % were males. Twenty-five (62.5%) fellow eyes had flat irregular pigment epithelial detachment on OCT, out of which 21 had internal hyper-reflectivity. A definite vascular network was picked up by OCTA in 9 of these 40 fellow eyes (22.5%) which was not detected on conventional imaging. In addition, two eyes had an ill-defined hyper-reflectivity, which could not be classified as a definite network at that point of time. The networks detected on OCTA in fellow eyes were mostly inactive, suggesting a subclinical neovascularisation.

CONCLUSION

One-fourth of fellow eyes showed vascular network which could not be diagnosed on conventional imaging which highlights the importance of imaging both the eyes of chronic CSCR for early detection of CNV using OCTA. Further longitudinal studies are needed to assess the clinical course of such subclinical vascular networks in CSCR.

Optical coherence tomography angiography in exudative age-related macular degeneration: a predictive model for treatment decisions

Aims

To evaluate on optical coherence tomography angiography (OCT-A), the predictive role of different qualitative findings of choroidal neovascularisations (CNV) in assessing the status of exudative age-related macular degeneration (eAMD) and to develop a potential model to predict the CNV activity.

Methods

Retrospective review of the multimodal imaging records of patients with eAMD obtained during treatment for type 1 or type 2 CNV. The qualitative analysis of CNVs on OCT angiograms assessed the presence or absence of tiny branching vessels, loops, peripheral anastomotic arcades and choriocapillaris hypointense halo. These findings were then correlated with those of structural OCT scans. A score forecast was built and validated.

Results

One hundred and twenty-six eAMD eyes were enrolled in the study. Exudation was observed in 90 eyes (71%) on structural OCT. The qualitative OCT-A analysis revealed: tiny branching vessels in 82.5% of the cases, vascular loops in 81.7%, peripheral anastomotic arcades in 66.7% and choriocapillaris hypointense halo in 54.8%. In the univariate analysis, each OCT-A parameter showed a statistically significant correlation with exudation on structural OCT (p<0.001). The overall analysis demonstrated a sensitivity of 96.7% and a positive predictive value of 87.9%. In the multivariate analysis, a model with four criteria predicted an exudative lesion in 97.6% of cases and one with two criteria (tiny branching vessels and peripheral anastomotic arcades) in 71.2%.

Conclusions

The presence of tiny branching vessels and a peripheral anastomotic arcade appears to predict the lesion activity with a good accuracy and the model based on four criteria enables optimal decisions regarding retreatment in eAMD.

Modifying Choroidal Neovascularization Development with a Nutritional Supplement in Mice

We examined the effect of nutritional supplements (modified Age Related Eye Disease Study (AREDS)-II formulation containing vitamins, minerals, lutein, resveratrol, and omega-3 fatty acids) on choroidal neovascularization (CNV). Supplements were administered alone and combined with intravitreal anti-VEGF in an early-CNV (diode laser-induced) murine model. Sixty mice were evenly divided into group V (oral vehicle, intravitreal saline), group S (oral supplement, intravitreal saline), group V + aVEGF (oral vehicle, intravitreal anti-VEGF), and group S + aVEGF (oral supplement, intravitreal anti-VEGF). Vehicle and nutritional supplements were administered daily for 38 days beginning 10 days before laser. Intravitreal injections were administered 48 h after laser. Fluorescein angiography (FA) and flat-mount CD31 staining evaluated leakage and CNV lesion area. Expression of VEGF, MMP-2 and MMP-9 activity, and NLRP3 were evaluated with RT-PCR, zymography, and western-blot. Leakage, CNV size, VEGF gene and protein expression were lower in groups V + aVEGF, S + aVEGF, and S than in V (all p < 0.05). Additionally, MMP-9 gene expression differed between groups S + aVEGF and V (p < 0.05) and MMP-9 activity was lower in S + aVEGF than in V and S (both p < 0.01). Levels of MMP-2 and NLRP3 were not significantly different between groups. Nutritional supplements either alone or combined with anti-VEGF may mitigate CNV development and inhibit retinal disease involving VEGF overexpression and CNV.

Can Novel Treatment of Age-Related Macular Degeneration Be Developed by Better Understanding of Sorsby's Fundus Dystrophy

Sorsby’s Fundus Dystrophy (SFD) is a rare autosomal dominant maculopathy that shares many clinical features with Age-Related Macular Degeneration (AMD). It is caused by a mutation in a single gene, TIMP-3, which accumulates in Bruch’s membrane (BM). BM thickening and TIMP-3 accumulation can also be found in AMD. From our understanding of the pathophysiology of SFD we hypothesize that BM thickening could be responsible for making the elastic layer vulnerable to invasion by choriocapillaris, thereby leading to choroidal neovascularization in some cases of AMD, whilst in others it could deprive the retinal pigment epithelium of its blood supply, thereby causing geographic atrophy.

Is it necessary to use three mandatory loading doses when commencing therapy for neovascular age-related macular degeneration using bevacizumab? (BeMOc Trial)

PURPOSE

To determine whether a Pro Re Nata (PRN) regimen with three initial mandatory loading doses results in better functional and anatomical outcome compared with a PRN regimen without initial loading when using intravitreal bevacizumab in patients with minimal classic or occult choroidal neovascularisation secondary to age-related macular degeneration.

METHODS

Patients were randomised (1 : 1) to Loading (LD group) or No Loading (NLD group) and treated with open label intravitreal bevacizumab. In the LD group, patients received two mandatory doses after the baseline dose before entering the PRN phase and in the NLD group, patients did not receive mandatory doses after the baseline dose. Six-weekly evaluations were performed up to week 54 and retreatment was done based on OCT criteria. Visual stability and reduction in central retinal thickness were compared between groups.

RESULTS

49 patients were in the NLD group and 50 patients were in the LD group. At the 12-month end point, 84% of the patients in the LD group achieved visual stability (<15 letter loss) compared with 67% of the patients in the NLD group (P<0.05). The mean reduction in central macular thickness was 105.35 μm in the LD group and 81.45 μm in the NLD group (P>0.05). There was no significant difference in scores of VFQ-25 questionnaire testing between the two groups and no serious ocular or systemic side effects were observed.

CONCLUSION

The results supported our hypothesis that a loading dose leads to slightly better visual stability in terms of proportions of patients experiencing moderate visual loss, but did not support the hypothesised difference in anatomical outcome.

Effect of ranibizumab on serous and vascular pigment epithelial detachments associated with exudative age-related macular degeneration

Purpose

To report the effect of intravitreal ranibizumab therapy for serous and vascular pigment epithelial detachments (PED) associated with choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD).

Methods

In a prospective study, best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) data were collected for 62 eyes of 62 patients, with serous or vascular PED associated with CNV secondary to AMD. Intravitreal ranibizumab 0.5 mg was administered with a loading phase of three consecutive monthly injections, followed by monthly review with further treatment, as indicated according to the retreatment criteria of the PrONTO study. The change in visual acuity and PED height from baseline to month 12 after the first injection was determined.

Results

Sixty-one eyes of 61 patients (one of the patients developed retinal pigment epithelial tear and was excluded from the study) were assessed at the 12-month follow-up examination. There were two types of PED, including vascular PED in 32 patients (Group A) and serous PED (Group B) in 29 patients. The mean improvement of mean BCVA from baseline to 12 months was 0.09 logMAR (Logarithm of the Minimum Angle of Resolution) in Group A and 0.13 logMAR in Group B. Both groups showed significant improvement of the mean BCVA 12 months after the first injection compared with the baseline value (P < 0.05). In relation to the PED height, the mean decrease of mean PED height from baseline to 12 months was 135 μm in Group A and 180 μm in Group B. Both groups showed significant reduction of the PED height during the follow-up period (P < 0.01). The PED anatomical response to ranibizumab was not correlated with the BCVA improvement in any of the groups. Apart from one patient who developed pigment epithelial tear no other complications were documented.

Conclusion

Ranibizumab is an effective and safe treatment for improving vision in patients with serous and vascular PED, although the anatomical response of the PED to ranibizumab may not correlate directly with the visual outcome.

Rac1 activates HIF-1 in laser induced choroidal neovascularization

AIM

To study the effect of Rac1 on the induction of HIF-1α in choroidal neovascularization (CNV) in mice.

METHODS

One hundred C57BL/6J mice were laser photocoagulated to induce CNV, fifty mice of that were selected randomly for intravitreal injection of Rac1 inhibitor NSC23766 solution (1µL). After laser photocoagulation, fundus fluorescein angiography (FFA) was performed to verify the growth of CNV, Immunohistochemistry and Western blot were used to detect HIF-1α and Rac1 in posterior segment of eye globes.

RESULTS

FFA verified that incidence of CNV was significantly reduced in the eyes with NSC23766 injection comparing with that of eyes without NSC23766 injection (P<0.01). Immunohistochemistry detected that HIF-1α and Rac1 mainly expressing in the new fibrovascular tissue. Western blot showed that HIF-1α and Rac1 was highly increased in tissue explants of retinal pigment epithelium (RPE) and choroid without NSC23766 injection. But for tissue explants of RPE and choroid with NSC23766 injection, both the expression of HIF-1α and Rac1 were inhibited.

CONCLUSION

Rac1 is crucial to activate HIF-1 regulating the growth of CNV, and its inhibition may have potential therapeutic value.

Choroidal neovascularisation and atrophy

There is a lack of knowledge about why and how atrophy spreads over time

Expression of pigment epithelium derived factor and vascular endothelial growth factor in choroidal neovascular membranes and polypoidal choroidal vasculopathy

AIMS

To determine whether pigment epithelium derived factor (PEDF), a protein that inhibits angiogenesis, is expressed in human choroidal neovascular membranes (CNVMs) and in tissues from an eye with polypoidal choroidal vasculopathy (PCV). In addition, to compare the expression of PEDF with that of vascular endothelial growth factor (VEGF), a known stimulator of angiogenesis, in these tissues.

METHODS

CNVMs, associated with age related macular degeneration (AMD), angioid streaks, and PCV, were obtained during surgery. The expression of PEDF and VEGF in the excised subretinal fibrovascular membranes was determined by immunohistochemistry.

RESULTS

PEDF and VEGF were strongly expressed in the vascular endothelial cells and retinal pigment epithelial (RPE) cells in the CNVMs where numerous new vessels were prominent (clinically active CNVMs). On the other hand, immunoreactivity for PEDF and VEGF was weak in the new vessels where fibrosis was prominent (clinically quiescent CNVMs). However, the RPE cells were still positive for PEDF and VEGF. The specimens from the eye with PCV also showed strong expression of PEDF and VEGF in the vascular endothelial cells and the RPE cells.

CONCLUSION

Because PEDF is an inhibitor of ocular angiogenesis and an inhibitor of ocular cell proliferation, our results suggest that PEDF along with VEGF may modulate the formation of subfoveal fibrovascular membranes.

Visual hallucinations and Charles Bonnet syndrome after photodynamic therapy for age related macular degeneration

AIMS

To report on visual hallucinations and Charles Bonnet syndrome (CBS) that may occur in patients with age related macular degeneration (AMD) treated by photodynamic therapy (PDT) with verteporfin for choroidal neovascularisation (CNV).

METHODS

100 consecutive patients were asked to respond to an orally administered questionnaire on visual hallucinations following PDT. Three groups of patients, respectively without visual hallucinations, with unstructured visual hallucinations, and with structured hallucinations-that is, CBS, were compared by ANOVA, Scheffe's test, or the chi(2) test, to establish whether age, sex, or visual acuity, as scored on ETDRS charts, are risk factors for the occurrence of visual hallucinations.

RESULTS

Five patients (5%) described transient structured visual hallucinations, including known or unknown faces and geometric patterns. Fifteen patients (15%) reported photopsias and flashing lights of various colours. These symptoms usually occurred a few days after PDT. There was no significant difference between the group of patients with structured visual hallucinations and the two other groups, with regard to age (p =0.435), sex (p =0.406), or visual acuity (p =0.835).

CONCLUSIONS

Visual hallucinations and CBS appear to be a possible, although unrecognised, side effect of PDT for CNV, which occur just after treatment. These results suggest the need to include the possibility of visual hallucinations in the information given to patients before PDT.

Digital analysis of choroidal neovascularisation in consecutive fluorescein angiograms for use in longitudinal clinical trials

BACKGROUND/AIMS

To document the natural history and to assess the efficacy of interventional therapies in neovascular age related macular degeneration (AMD), an accurate and reproducible method is required for analysis of consecutive fluorescence angiograms. The development and evaluation of an image analysis software for this purpose is described here. It allows for the quantitative analysis of changes in CNV and/or leakage area over time.

METHODS

In digitised angiograms, a mouse driven arrow was used to delineate the CNV border. The ratio of the CNV area to the square of the distance between two vessels was automatically calculated by pixel count to compensate for variation in image sizes at different examination times. These results were directly transferred and stored in a database. To assess reproducibility, CNV areas in 20 patients with occult and 20 patients with classic CNV were determined independently by two readers.

RESULTS

There was only marginal variability between observers with this method: the mean deviation was 0.01 pixels for classic CNV (95% CI -0.17 to +0.15, SD 0.35) and 0.55 pixels for occult CNV (95% CI -1.06 to -0.04, SD 1.14).

CONCLUSIONS

This practical PC based method allows for quantification of angiographic features such as CNV size in early frames and area of leakage in late frames. Limitations include non-readily defined borders in angiograms of poor image quality or indistinct borders of the hyperfluorescent areas of interest. The software is applicable to future clinical trials where the analysis of neovascular complex changes is required, for example, following therapeutic intervention.

Subretinal fibrosis after photodynamic therapy in subfoveal choroidal neovascularisation in highly myopic eyes

AIMS

To analyse the occurrence of subretinal fibrosis (SRF) after photodynamic therapy (PDT) with verteporfin in highly myopic eyes with subfoveal choroidal neovascularisation (CNV).

METHODS

PDT with verteporfin was performed on 33 eyes of 32 highly myopic patients with subfoveal CNV. Patients were followed for 14-24 months and best corrected visual acuity (BCVA) and angiographic and funduscopic findings were recorded.

RESULTS

Two patients (two eyes) were lost to follow up. SRF appeared in 14 of 31 eyes. SRF appeared more frequently in eyes with a spherical equivalent (SE) of less than -10 D, in patients of age equal to or less than 55 years, and when CNVs were larger than 1500 micro m in diameter. SRF appeared more frequently in the group of patients with worse final BCVA.

CONCLUSIONS

The appearance of SRF after treatment is correlated with size of the CNV and SE. The results of this study indicate that highly myopic eyes with CNV treated with PDT do not show a decrease in BCVA, even though they develop SRF. The appearance of SRF after PDT in highly myopic CNV does not always imply a loss of BCVA from baseline, though its presence is more frequent in eyes with lower BCVA.

Patchy atrophy and lacquer cracks predispose to the development of choroidal neovascularisation in pathological myopia

AIMS

To determine the incidence and predisposing findings for choroidal neovascularisation (CNV) in a large series of highly myopic patients.

METHODS

The medical records of 218 consecutive patients (325 eyes) with myopic fundus changes in the macula were reviewed. The incidence of CNV during a follow up of at least 3 years of highly myopic patients and identification of predisposing findings for the development of myopic CNV were examined.

RESULTS

Among 325 highly myopic eyes examined, 33 eyes (10.2%) developed myopic CNV. The incidence was higher (34.8%) among the fellow eyes of patients with pre-existing CNV than among eyes of patients without pre-existing CNV (6.1%). CNV developed in 3.7% with diffuse chorioretinal atrophy, in 20.0% with patchy atrophy, and in 29.4% with lacquer cracks.

CONCLUSION

Approximately one in 10 highly myopic eyes developed myopic CNV in average 130.2 months. Patchy atrophy and lacquer cracks were shown to be important predisposing findings for CNV development.

CNV subtype in first eyes predicts severity of ARM in fellow eyes

AIM

To examine the relation between the type of choroidal neovascularisation (CNV) in the first eye and age related maculopathy (ARM) severity in the fellow eye.

METHODS

Colour fundus photographs and fluorescein angiograms from 67 subjects with a clinical diagnosis of CNV in one eye were scrutinised. CNV was classified as wholly classic, predominantly classic, minimally classic, or occult based on the proportion of classic leakage within the lesion. ARM changes in the fellow eye were assigned a severity stage using the system described by the Rotterdam Eye Study. Logistic regression analysis was employed to examine the association between CNV subtype and ARM stage.

RESULTS

Of subjects with classic or predominantly classic CNV in the first eye 78% exhibited least no or early ARM features in the fellow eye. By contrast, 85% of subjects with minimally classic or occult CNV in the first eye exhibited more advanced ARM features in the fellow eye. Kruskall-Wallis one way ANOVA by ranks showed that this was highly significant (p = 0.002). Logistic regression analysis showed that as the proportion of occult CNV increased in the first eye, fellow eyes of subjects in this category were more likely to have been assigned to a higher ARM stage (p = 0.019). The area occupied by the CNV in the first eye also influenced severity of ARM changes in the fellow eye.

CONCLUSION

The type and extent of CNV in the first affected eye has a distinct relation to ARM severity in the fellow eye. Fellow eyes of subjects with minimally classic or occult CNV in the first affected eye show widespread ARM changes suggestive of retinal pigment epithelial dysfunction. These findings suggest that classic CNV may be focal disease while occult CNV is essentially a more widespread retinal pigment epithelial disorder.

Verteporfin photodynamic therapy in highly myopic subfoveal choroidal neovascularisation

AIMS

To analyse the visual and angiographic results of photodynamic therapy (PDT) with verteporfin in highly myopic patients with subfoveal choroidal neovascularisation (CNV).

METHODS

PDT was performed on highly myopic patients with subfoveal CNV. The patient population was divided into two groups according to age at onset of CNV (group 1 aged < or = 55 and group 2 aged >55 years old). Best corrected visual acuity (BCVA) and angiographic findings were considered.

RESULTS

At the end of follow up group 2 had worse BCVA than group 1. 76% of patients in both groups showed a complete closure of CNV at the end of follow up.

CONCLUSION

Visual prognosis of myopic CNV treated by PDT is influenced by age at onset.

Angiographic features after photodynamic therapy for choroidal neovascularisation in age related macular degeneration and pathological myopia

AIM

To describe the angiographic features after photodynamic therapy (PDT) with verteporfin in choroidal neovascularisation (CNV) associated both with age related macular degeneration (AMD) and pathological myopia (PM).

METHODS

36 patients affected by subfoveal CNV in AMD and 25 patients with subfoveal CNV in PM underwent an ophthalmological examination including fluorescein angiography (FA) and indocyanine green angiography (ICGA) using the IMAGEnet System. Post-PDT examinations were performed 7, 30, and 90 days later.

RESULTS

The typical angiographic aspect after PDT for AMD related CNV was a round hypofluorescence visible both on FA and on ICGA, which included both CNV and the surrounding tissues and corresponded to the area exposed to laser light. In PM the CNV appeared hypofluorescent during the early phases and gradually became hyperfluorescent during the late phases on FA, whereas on ICGA it was detectable in its whole extension as a hyperfluorescent lesion since the early phases. Differently from AMD, there was no round hypofluorescence surrounding the CNV on FA or on ICGA. Moreover, five patients in the AMD group showed hot spots on ICGA, which spontaneously disappeared during the follow up. Classic and occult components of the AMD related CNV revealed a different angiographic response to PDT, showing with the latter only a partial closure 1 week after PDT followed by a complete reopening at the first month in 100% of cases.

CONCLUSION

The post-PDT hypofluorescence typical of AMD related CNV, especially visible on FA, might be secondary to a combination of choriocapillary occlusion and masking effect due to swelling of retinal pigment epithelium cells. Hot spots in the AMD affected patients could be interpreted as the expression of a non-thermal choroidal vasculitis secondary to PDT.