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 investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement.
Retrospective, noncomparative case ...series.
From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each.
The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25–100 μg in 0.1–0.2 ml) and expansile gas (0.3–0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours).
Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications.
In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4–19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure.
Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.
Pneumatic retinopexy is an operation for reattaching the retina by injecting an expanding gas bubble and using laser and/or cryopexy. The procedure is controversial because the literature reports a ...variable initial success rate, sometimes less than conventional scleral buckling surgery. PR is done in an office setting and may be the most cost-effective means of retinal reattachment.
The goal of this study is to decide which eyes are most successfully treated with pneumatic retinopexy, and which pneumatic technique is most effective.
Three hundred two (302) consecutive retinal detachments treated by one surgeon with pneumatic retinopexy and followed for six months to ten years were reviewed. Risk factors for failure were detected. The cost of treating eyes with pneumatic retinopexy and scleral buckling was compared using Medicare reimbursement rates.
The average single operation success (SOS) rate for all 302 cases was 68%; 95% were ultimately attached with additional surgery. Factors adversely affecting SOS included pseudophakia/aphakia, the extent of the retinal detachment, and the number of retinal breaks. Factors not influencing SOS included the type of retinal break, the presence of lattice degeneration, the type, volume and sequence of gas injection, retinopexy with laser or cryotherapy, and gender. Complete 360 degrees peripheral retinopexy between the insertion of the vitreous base and ora serrata significantly improved SOS. A 97% SOS rate was detected for a subgroup of eyes. This subgroup included phakic eyes with one quadrant of the retina detached, and one retinal break located in the upper two-thirds of the fundus. Treatment included 360 degrees of peripheral retinopexy. Factors positively influencing visual recovery included SOS, better preoperative acuity, macular attachment, duration of macular detachment less than eight days, and younger age. Eighty-six percent of eyes cured with a single operation attained 20/40 or better acuity. The cost of repairing these 302 cases with pneumatic retinopexy, including reoperations, was estimated to be approximately half the cost of repairing a similar group with scleral buckling. With careful patient selection and peripheral 360 degrees retinopexy, the cost of PR may be one quarter the cost of scleral buckling.
Success with PR, as with other surgical procedures, depends upon proper case selection and surgical technique. Ideal case selection and peripheral 360 degrees retinopexy can increase the SOS rate to 97%. Even with reoperations, PR is more cost effective than scleral buckling.
To review our experience with vitrectomy surgery techniques for the treatment of traumatic macular holes and the biomicroscopic and surgical findings.
Retrospective noncomparative, multicenter, case ...series.
Twenty-five patients with traumatic macular hole underwent surgical repair.
Vitrectomy with membrane peeling and gas injection followed by prone positioning for 7 to 14 days.
Postoperative evaluation included visual acuity testing, closure of the macular hole, and ocular complications.
The macular hole was successfully closed in 24 of 25 cases (96%). The visual acuity improved two or more lines in 21 (84%) cases, and 16 (64%) achieved 20/50 or better vision.
Vitrectomy surgery can successfully close macular holes associated with trauma and improve vision.
To investigate whether postoperative face-down positioning is necessary for successful macular hole repair.
Although never proven, face-down positioning is strongly considered an important maneuver ...to achieve macular hole closure. Face-down posturing is inconvenient, and for patients with physical or mental limitations, weeks of face-down positioning may be an impossible task. A gas bubble that completely fills the vitreous cavity will tamponade a macular hole despite head position and may close a macular hole as effectively as a partial gas fill with face-down positioning. If face-down positioning were not necessary, more patients would be eligible to benefit from this surgery.
Thirty-three consecutive eyes in 31 patients aged 65-79 years with Stage II, III, or IV full-thickness macular holes underwent macular hole surgery with a complete 15% C3F8 vitreous fill. Hole duration varied from 1 month to 10 years; in 21% of eyes, (seven of 33) holes had been present for more than 1 year. All phakic eyes (n = 25) had cataract extraction with intraocular lens insertion when macular hole surgery was done. No patients were positioned face down.
The follow-up period was 6-40 months; 73% of the patients have been observed for more than 1 year. Preoperative hole duration did not affect hole closure rate. The success rate after one surgery was 79% (26 of 33 eyes), and with additional vitrectomy surgery, the total success rate was 85% (28 of 33 eyes). Forty-eight percent of eyes attained visual acuity of 20/50. Eighty percent of eyes with preoperative acuity of > 20/100 attained > 20/50 acuity. Significant complications included iris incarceration into the cataract wound during a postoperative fluid-gas exchange (one eye), posterior synechiae (four eyes), intraocular lens capture (two eyes), elevated intraocular pressure (three eyes), and retinal detachment (three eyes). Most of these problems can be avoided or reduced.
This pilot study suggests that successful macular hole closure is possible without face-down positioning. This technique may be an alternative for patients with macular holes in pseudophakic eyes who are unable to assume face-down posturing. Combining cataract surgery with this technique for macular hole repair is reasonable for phakic patients who cannot maintain prone positioning. Major disadvantages of combined surgery include the morbidity of the second procedure and removal of a visually insignificant cataract. This approach should be considered for those patients unable to tolerate face-down positioning.
Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. This study evaluates the ...fluorescein angiographic changes that occur after macular hole surgery.
Sixteen patients with stage III idiopathic macular holes underwent pars plana vitrectomy, removal of the posterior hyaloid, peeling of fine epiretinal sheets along the edges of the holes, and fluid-gas exchange. Preoperative fluorescein angiograms were performed, and best-corrected preoperative visual acuity was 20/200 or less in all eyes.
Postoperatively, the macular hole disappeared in 12 eyes (75%). In all 12 eyes, retinal pigment epithelial swelling was present, with a unique fluorescein angiographic appearance. This pattern slowly resolved over months, with gradual visual improvement but residual retinal pigment epithelial mottling. Systemic and periocular steroids had no significant impact on the process.
The combination of prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula appears to be responsible for this pigmentary pattern. Depending on the severity of the pigment epithelial alteration, this unique pattern may portend a guarded visual prognosis in affected patients undergoing successful macular hole repair.
Optical coherence tomography 3 images and a simple model suggest macular hole formation may be due to a defect in the inner retina with secondary vitreous fluid accumulation into the middle and outer ...retinal tissue.
The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with ...scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.
The current study is a prospective randomized clinical trial to determine the effect of interferon alpha-2a on eyes with subfoveal subretinal neovascularization secondary to age-related macular ...degeneration (AMD).
Twenty eyes of 19 patients with subfoveal neovascularization secondary to AMD were prospectively evaluated. Ten eyes were randomized to subcutaneous interferon alpha-2a (3 million units/m2) every other day for 8 weeks, whereas 10 eyes were randomized to observation alone as controls. Fluorescein angiography, best-corrected visual acuity tests, and macular visual field assessments were performed, and all eyes were followed for a minimum of 6 months.
At the 2-month follow-up visit, the interferon group manifested somewhat slower neovascular growth than controls, but the results were not statistically significant. At the 6-month follow-up visit, there was no difference in visual acuity, average macular sensitivities, or extent of neovascularization. The rate of neovascular progression was significantly related to the extent of previous macular photocoagulation in both groups.
Though the rate of neovascular progression was slowed during the second month of interferon treatment, the effect did not persist once interferon was discontinued. No long-term benefit appeared to be present. Unfortunately, lengthening the time of administration, increasing the dosage, or increasing the frequency of administration would likely give rise to unacceptable side effects.
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