The aim of this study was to report the development or progression of tractional retinal detachment (TRD) after the injection of intravitreal bevacizumab (Avastin) used as an adjuvant to vitrectomy ...for the management of severe proliferative diabetic retinopathy (PDR).
The clinical charts of patients who experienced the development or progression of TRD after an intravitreal injection of 1.25 mg bevacizumab before vitrectomy for the management of PDR were reviewed.
Eleven eyes (patients) out of 211 intravitreal injections (5.2%) that developed or had progression of TRD were identified. All eyes had PDR refractory to panretinal photocoagulation (PRP). Nine patients had type 1 diabetes mellitus (DM), and two patients had type 2 DM. Patients had a mean age of 39.5 years (range 22-62 years). In the current study, all patients used insulin administration and had poor glycaemic control (mean HbA(1c) 10.6%). Time from injection to TRD was a mean of 13 days (range 3-31 days). Mean best correct visual acuity (BCVA) at TRD development or progression was logarithm of the minimal angle of resolution (LogMAR) 2.2 (range 1.0-2.6) (mean Snellen equivalent hand motions; range 20/200 to light perception), a statistically significant worsening compared with baseline BCVA (p<0.0001). Eight eyes underwent vitrectomy and three patients refused or were unable to undergo surgery. The final mean BCVA after surgery was LogMAR 0.9 (range 0.2-2.0) (mean Snellen equivalent 20/160; range 20/32 to counting fingers), a statistically significant improvement compared with TRD BCVA (p = 0.002).
TRD may occur or progress shortly following administration of intravitreal bevacizumab in patients with severe PDR.
With the identification of vascular endothelial growth factor (VEGF) and the confirmation of its pathophysiologic link to retinal and choroidal angiogenesis, numerous agents have been designed to ...inhibit its activity. It is noteworthy that anatomic and visual benefits have been associated with the use of anti-VEGF agents such as pegaptanib (Macugen) and to a greater extent, ranibizumab (Lucentis) and bevacizumab (Avastin), particularly in the management of neovascular age-related macular degeneration (AMD). Clinical trials and case series have confirmed the utility of these agents. However, shortcomings of the current drugs such as short half-life, intraocular dosing, limited effectiveness in some patients, and potential systemic side effects continue to drive the development of new agents. In this article, we review current anti-VEGF therapies and discuss future developments.
To determine the baseline predictors of visual acuity (VA) outcomes 1 year after treatment with ranibizumab or bevacizumab for neovascular age-related macular degeneration (AMD).
Cohort study within ...the Comparison of Age-related Macular Degeneration Treatments Trials (CATT).
A total of 1105 participants with neovascular AMD, baseline VA 20/25 to 20/320, and VA measured at 1 year.
Participants were randomly assigned to ranibizumab or bevacizumab on a monthly or as-needed schedule. Masked readers evaluated fundus morphology and features on optical coherence tomography (OCT). Visual acuity was measured using electronic VA testing. Independent predictors were identified using regression techniques.
The VA score, VA score change from baseline, and ≥3-line gain at 1 year.
At 1 year, the mean VA score was 68 letters, mean improvement from baseline was 7 letters, and 28% of participants gained ≥3 lines. Older age, larger area of choroidal neovascularization (CNV), and elevation of retinal pigment epithelium (RPE) were associated with worse VA (all P<0.005), less gain in VA (all P<0.02), and a lower proportion gaining ≥3 lines (all P<0.04). Better baseline VA was associated with better VA at 1 year, less gain in VA, and a lower proportion gaining ≥3 lines (all P<0.0001). Predominantly or minimally classic lesions were associated with worse VA than occult lesions (66 vs. 69 letters; P=0.0003). Retinal angiomatous proliferans (RAP) lesions were associated with more gain in VA (10 vs. 7 letters; P=0.03) and a higher proportion gaining ≥3 lines (odds ratio, 1.9; 95% confidence interval, 1.2-3.1). Geographic atrophy (GA) was associated with worse VA (64 vs. 68 letters; P=0.02). Eyes with total foveal thickness in the second quartile (325-425 μm) had the best VA (P=0.01) and were most likely to gain ≥3 lines (P=0.004). Predictors did not vary by treatment group.
For all treatment groups, older age, better baseline VA, larger CNV area, predominantly or minimally classic lesion, absence of RAP lesion, presence of GA, greater total fovea thickness, and RPE elevation on optical coherence tomography were independently associated with less improvement in VA at 1 year.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Age-related macular degeneration (AMD) is a leading cause of visual impairment in aging populations in industrialized countries. Here we investigated whether the genotype of vascular endothelial ...growth factor A (VEGFA) gene is associated with response to anti-VEGF therapy. 223 eyes with neovascular AMD were treated with intravitreal anti-VEGF therapy. Responders were defined as patients who had an improvement in best corrected visual acuity (BCVA) of at least 5 letters or one line on the EDTRS visual acuity chart along with resolution of intraretinal or subretinal fluid over 12 months. Patients who did not meet the definition of responders were classified as poor-responders. The vision of responders (n = 148) improved while the vision of poor-responders (n = 75) worsened (P<0.001). Responders on average had a decrease in central foveal thickness (CFT), while poor-responders had an increase in CFT (P <0.001). Compared with the responder group, the poor-responder group had a higher frequency of the risk (T) allele (Allelic P = 0.019) and TT genotype (P = 0.002 under a recessive model) for the VEGFA-rs943080 polymorphism. VEGFA expression was 1.8-fold higher in cells with the VEGFA rs943080 TT genotype than in cells with the VEGFA rs943080 CC genotype (P = 0.012). Age, gender, smoking, diabetes mellitus, and hypertension did not play a significant role in treatment response, but BMI was found to be significantly different between responders and poorresponders (P = 0.033). In conclusion, we demonstrated a potential pharmacogenetic relationship between the VEGFA gene and treatment response to anti-VEGF therapy.The studies are registered at ClinicalTrials.gov under the identifiers NCT00474695 (http://clinicaltrials. gov/ct2/show/NCT00474695) and NCT01464723 (http://clinicaltrials.gov/ct2/show/NCT01464723).
To compare the efficacy of ranibizumab 0.5-mg and 2.0-mg intravitreal injections for persistent diabetic macular edema (DME) previously treated with bevacizumab.
In all, 43 patients with residual ...center-involved DME following intravitreal bevacizumab were included in this 12-month prospective, nonrandomized, multicenter study. Enrolled patients received three monthly ranibizumab 0.5-mg injections. At month 3, patients with residual macular edema switched to three monthly injections of ranibizumab 2.0-mg. Assessments included monthly visual acuity and spectral-domain optical coherence tomography.
Mean visual acuity improved by +6.4 letters at month 3 and +8.8 letters at month 6. Mean central subfield thickness (CST) decreased by -113 μm at month 3 and -165 μm at month 6. Before enrollment, 29/43 (67.4%) patients showed <10% CST reduction following monthly bevacizumab treatment. After three monthly ranibizumab 0.5-mg injections, 22/29 (75.9%) patients showed >10% reduction in CST, whereas 6 showed <10% reduction. Of these six, three (50%) showed >10% reduction in CST after switching to three monthly ranibizumab 2.0-mg doses. No serious adverse events were observed to month 6.
Ranibizumab 0.5-mg or 2.0-mg may improve visual and anatomic outcomes in patients with DME who demonstrated minimal or no response to bevacizumab therapy. Moreover, increased dosage of ranibizumab (2.0-mg) may provide additional benefit over ranibizumab 0.5-mg in some patients. However, 2.0-mg ranibizumab is not currently commercially licensed or available.
To develop a classification system for mechanical injuries of the eye.
The Ocular Trauma Classification Group, a committee of 13 ophthalmologists from seven separate institutions, was organized to ...discuss the standardization of ocular trauma classification. To develop the classification system, the group reviewed trauma classification systems in ophthalmology and general medicine and, in detail, reports on the characteristics and outcomes of eye trauma, then established a classification system based on standard terminology and features of eye injuries at initial examination that have demonstrated prognostic significance.
This system classifies both open-globe and closed-globe injuries according to four separate variables: type of injury, based on the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, based on the anteroposterior extent of the injury. This system is designed to be used by ophthalmologists and nonophthalmologists who care for patients or conduct research on ocular injuries. An ocular injury is classified during the initial examination or at the time of the primary surgical intervention and does not require extraordinary testing.
This classification system will categorize ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research studies regarding eye injuries.
The purpose of the study is to evaluate a recent series of patients who presented with open-globe injuries and to compare this series with a previous series collected at the authors' institution to ...determine whether prognostic factors or visual outcomes have changed.
A retrospective review of 290 eyes of consecutive patients who presented to the Wilmer Ophthalmological Institute with open-globe injuries between December 1985 and January 1993 (group B) was compared with a series of 476 eyes with open-globe injury treated and evaluated at this institute between January 1970 and December 1981 (group A). For comparison, the outcomes evaluated included rates of enucleation and final visual acuity.
Several factors identified previously in group A to correlate with visual outcomes also were found to correlate significantly (P < 0.001) with visual outcome in group B, including: (1) type of injury, (2) location and extent of injury, (3) initial visual acuity, (4) presence of an afferent pupillary defect, (5) lenticular involvement, (6) vitreous hemorrhage, and (7) type of intraocular foreign body. Overall visual outcomes differed significantly between the groups (P = 0.02). The incidence of enucleation was lower in group B (24%) than in group A (30%). However, the percentage of patients who achieved ambulatory visual acuity (5/200) or better was similar in both groups (57%, group A versus 55%, group B).
Prognostic factors identified previously proved valid in this recent series. Visual outcomes have improved at this institution in the last 20 years for patients with severe ocular trauma, although visual potential for these patients is still limited.
To determine the prevalance, associated biometric factors, and rate of disappearance of neonatal retinal hemorrhage.
Cross-sectional and natural history study.
Healthy newborns (n = 149) at an urban ...hospital were examined using indirect ophthalmoscopy within 30 hours of birth. Newborns with retinal hemorrhage were reexamined biweekly until hemorrhage resolved.
Neonatal and maternal biometric factors, and incidence and rate of resolution of retinal hemorrhage.
Intraretinal hemorrhage was present in 34% of newborns and varied from a single dot hemorrhage in one eye to bilateral widespread hemorrhages, occasionally with white centers. The incidence of hemorrhage was higher for vacuum-assisted (75%) than for spontaneous vaginal deliveries (33%) and was least for infants delivered by cesarean section (7%). The mean maternal age was greater for infants with retinal hemorrhage. By 2 weeks after birth, retinal hemorrhage resolved in 86% of eyes, and at 4 weeks no intraretinal hemorrhage was detected, although a single subretinal hemorrhage persisted until 6 weeks after birth.
Intraretinal hemorrhages are common in the immediate postnatal period and resolve by 1 month of age. Retinal hemorrhage in infants older than 1 month should heighten suspicion that the hemorrhage is associated with factors other than birth.
PURPOSE: To review a series of patients with age-related macular degeneration undergoing limited macular translocation for the treatment of subfoveal choroidal neovascularization, to determine ...short-term visual acuity outcomes, to measure amounts of attainable retinal movement, and to identify prognostic factors.
METHODS: A retrospective review was conducted on a consecutive series of patients undergoing inferior limited macular translocation with scleral imbrication for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. The main outcome measures investigated were distance of macular translocation, visual acuity at 3 and 6 months after surgery, change in visual acuity from baseline, and the development of intraoperative and postoperative complications. Univariate and multivariate analyses of a number of potential prognostic factors were undertaken.
RESULTS: Macular translocation was achieved in all 102 eyes (101 patients) included in this study. The range of movement varied from 200 to 2,800 μm with a median movement of 1,200 μm. Nearly 33% of the study group achieved a visual acuity better than 20/100 at 3 months, and 49% achieved this vision at 6 months. At 3 and 6 months, 37% and 48% of the study group, respectively, experienced 2 or more lines of improvement on visual acuity testing, and by 6 months 16% experienced greater than 6 lines of visual improvement. Good baseline vision, achieving the desired amount of macular translocation, a greater amount of macular translocation, and recurrent choroidal neovascularization at baseline were associated with better visual acuities at 3 and 6 months. Poor preoperative vision and the development of complications were associated with worse vision at 3 and 6 months.
CONCLUSIONS: Limited macular translocation is a technically feasible procedure that can lead to significant visual improvement and good visual acuity in some patients presenting with subfoveal choroidal neovascularization associated with age-related macular degeneration. A randomized prospective clinical trial of this surgical technique is warranted.
PURPOSE: To report our initial experience of inferior limited macular translocation in patients with subfoveal choroidal neovascularization resulting from causes other than age-related macular ...degeneration.
METHODS: We conducted a retrospective study of 23 eyes of 22 patients with choroidal neovascularization involving the foveal center secondary to pathologic myopia (11 eyes), ocular histoplasmosis syndrome (four eyes), angioid streaks (four eyes), idiopathic neovascularization (three eyes), and multifocal choroiditis (one eye), in which the fovea was moved inferiorly by means of limited macular translocation surgery. The mean preoperative best-corrected visual acuity was 20/150, and in five of 23 eyes (21.7%) the visual acuity was 20/80 or better. The major outcome measures were preoperative and postoperative visual acuity, postoperative foveal displacement, and complications related to the surgery.
RESULTS: The mean postoperative follow-up was 10.82 months (range, 6 to 18 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in 11 of 23 eyes (47.82%), remained within 1 line in seven of 23 eyes (30.43%), and worsened 2 or more lines of vision in five of 23 eyes (21.74%). The mean postoperative best-corrected visual acuity was 20/100, and in 12 of the 23 eyes (52.17%) the visual acuity achieved was 20/80 or better. Retinal detachment was the most frequent complication and occurred in six eyes (26%).
CONCLUSIONS: Our initial experience with limited macular translocation shows that this treatment modality offers the potential to improve visual function in some eyes with subfoveal choroidal neovascularization secondary to myopia, ocular histoplasmosis syndrome, angioid streaks, idiopathic neovascularization, and multifocal choroiditis. Although longer and more complete follow-up is needed, the results of this initial series warrant further studies to define the precise role of macular translocation in the management of these conditions.
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