Long-term effects of ranibizumab treatment delay in neovascular age-related macular degeneration

Background

Intravitreal injections of ranibizumab are the standard of care for neovascular age-related macular degeneration (AMD). In clinical trials, comparable efficacy has been shown for either monthly injections or as needed injections upon monthly controls. Unlike in trial settings, treatment in clinical routine is often delayed by complex approval procedures of health insurance and limited short-term surgical capacities.

Methods

Eighty-nine patients with neovascular AMD were followed for 12 months. Early treatment diabetic retinopathy study (ETDRS) visual acuity (VA), Radner reading VA and spectral domain optical coherence tomography were performed monthly, with additional fluorescein angiography if needed. After an initial loading phase of three consecutive monthly intravitreal injections with ranibizumab, re-injections were performed when recurrent activity of choroidal neovascularization (CNV) was detected.

Results

After an initial increase to a value of +5.0?±?11.87 ETDRS letters from baseline, VA constantly decreased over 12 months to a value of ?0.66?±?16.82 ETDRS letters below baseline. Central retinal thickness (CRT) decreased from a value of 438.1?±?191.4 μm at baseline to a value of 289.9?±?138.6 μm after initial therapy and stabilized at a value of 322.4?±?199.5 μm. Loss of VA during latency between indication to treat and treatment was significantly greater than re-gain of VA after re-initiation of therapy (?2.2?±?5.0 versus 0.4?±?7.4 letters; p?=?0.046).

Conclusions

Latency between indication to treat and treatment is responsible for irreversible VA deterioration. A successful PRN treatment regimen for neovascular AMD requires immediate access to therapy after indication.     

Response to anti-VEGF therapy in patients with subretinal fluid and pigment epithelial detachment on spectral-domain optical coherence tomography

Purpose

To analyse the long-term functional and morphological response of a specific choroidal neovascular membrane (CNV) phenotype to anti-vascular endothelial growth factor (VEGF) therapy.

Methods

Data from 30 eyes of 30 consecutive patients with subretinal fluid (SRF) and fibrovascular pigment epithelial detachment (PED) due to CNV on spectral-domain optical coherence tomography (SDOCT) with a follow-up of at least 20 months were retrospectively collected. Main outcome measures included change in visual acuity, quantitative and qualitative parameters on SDOCT [photoreceptor layer, outer nuclear layer (ONL), choroid, PED, SRF] and on fluorescein angiography (CNV activity). Subjects were divided into responders and non-responders based on morphological and functional aspects.

Results

An average number of 20.23?±?9.9 anti-VEGF injections were administered during a mean follow-up of 40.25?±?13.5 months. Fourteen eyes were categorized as morphological non-responders, 12 as functional non-responders and eight as complete non-responders. Complete non-responders were significantly younger than complete responders (68.5?±?4.5 vs 74.3?±?6.8 years; p?<?0.05) and presented thinner baseline ONL values (68.43?±?15.2 vs103.5?±?32.8 μm; p?<?0.05). Intermediate or large drusen as typical features for age-related macular degeneration (AMD) were less frequently present in complete non-responders; however, this was not statistically significant (62.5 % vs 91.7 %; p?=?0.25).

Conclusions

Our preliminary findings indicate that eyes with the specific SDOCT phenotype with isolated fibrovascular PED and SRF frequently demonstrate non-response to anti-VEGF therapy, and the underlying disease mechanism may be different from AMD. Larger prospective trials are required to validate those results, and to develop strategies to improve the morphological as well as functional outcome.     

A prospective, randomised, multicenter trial for surgical treatment of central retinal vein occlusion: results of the Radial Optic Neurotomy for Central Vein Occlusion (ROVO) study group

Background

To compare the surgical outcomes and evaluate the effectiveness of two treatments for central retinal vein occlusion (CRVO), radial optic neurotomy (RON) and intravitreal triamcinolone (IVT), in comparison to natural history.

Methods

A prospective, placebo-controlled, randomised and multi-center study. Patients with CRVO were treated in three groups — with either RON, a single intravitreal injection of 4 mg triamcinolone acetonide, or a placebo treatment. The main outcome measures were change of VA (visual acuity) and proportion of eyes with a significant improvement (defined as?>3 lines logMAR scale) of VA from baseline to month 12.

Results

Ninety patients were included. Due to insufficient data, seven were excluded. Forty-seven percent (n?=?18) of patients treated with RON showed an increase in VA, in comparison to 10 % (n?=?2) of placebo-treated patients, and 20 % (n?=?5) of patients treated with IVT. Significantly more patients showed an improvement in VA following RON than in the placebo group (p?=?0.009). Significantly more patients showed an improvement in VA following RON than in the IVT group (p?=?0.034). No significant difference was found when directly comparing improvement in VA following IVT and placebo (p?=?0.667) treatment.Significantly (p?=?0.007) more patients in the placebo group (35 %, n?=?7) showed a deterioration (defined as?>?3 lines LogMAR scale) in VA than patients in the RON group (8 %, n?=?3).

Conclusion

Our study showed that following treatment with RON, patients with CRVO display a significantly better long-term VA than untreated patients and patients treated with a single dose of IVT.     

Treat-and-extend therapy using intravitreal aflibercept for neovascular age-related macular degeneration: 2-year real-world practice data from Slovenia

Background

To assess visual outcomes over 24?months in patients with neovascular age-related macular degeneration (nAMD) who initiated intravitreal aflibercept therapy under a treat-and-extend (TE) regimen in real-world settings.

Methods

In this retrospective, observational, multicentre study in Slovenia, medical records of all treatment-naïve patients with nAMD who started intravitreal aflibercept therapy between October 2013 and April 2015 were reviewed. The primary outcome measure was change in mean visual acuity (VA) from baseline to 24?months in patients who received the TE regimen for 2?years, assessed by standardised Early Treatment Diabetic Retinopathy Study charts and calculated as least-squares means. Other outcome measures included the numbers of injections and visits at 12?months and 24?months.

Results

The primary analysis included 115 eyes of 105 patients who received TE treatment for 2?years (Group A). The mean VA improved from 57.9?±?14.9 letters at baseline to 64.6?±?15.8 letters (+?6.5 letters, p?<?0.0001) at 12?months and 64.8?±?15.6 letters (+?7.0 letters, p?<?0.0001) at 24?months. The mean number of injections per eye was 8.4?±?1.9 and the mean number of visits was 8.8?±?1.7 at 12?months; these numbers decreased to 6.1?±?2.0 and 6.4?±?1.9, respectively, at 24?months. The additional analysis included 33 eyes of 33 patients who received TE treatment in Year 1, followed by pro re nata treatment in Year 2 (Group B). Compared with Group A whose vision improvement was maintained at 24?months, the VA gain in Group B eyes seen at 12?months (change in mean VA vs baseline: +?6.9 letters, p?=?0.0008) was no longer present at 24?months (change in mean VA vs baseline: +?1.2 letters, p?=?0.5733).

Conclusions

Using the TE regimen in clinical practice, intravitreal aflibercept significantly improved visual outcomes in treatment-naïve patients with nAMD, which were maintained over time. TE therapy with intravitreal aflibercept is a rational long-term strategy that can produce favourable outcomes in clinical practice.

     

Three intravitreal bevacizumab versus two intravitreal triamcinolone injections in recent-onset branch retinal vein occlusion

Purpose

To evaluate the effects of repeated intravitreal injections of bevacizumab (IVB) versus triamcinolone acetonide (IVT) in the treatment of acute branch retinal vein occlusion (BRVO).

Methods

In this randomized clinical trial, 86 eyes with recent-onset (less than 12?weeks) BRVO were included. Participants were randomly assigned to two treatment groups: (1) IVB group (43 eyes), patients who received three monthly injections of 1.25?mg of IVB, and (2) IVT group (43 eyes), patients who received two injections of 2?mg IVT 2?months apart. Patients were examined at 1, 2, 3, 4, and 6?months after enrollment. Main outcome measure was change in best-corrected visual acuity (BCVA) at 6?months. Secondary outcome measures were central macular thickness (CMT) and intraocular pressure (IOP) changes at month 6.

Results

Mean BCVA improved significantly up to 6?months in both groups from 0.68?±?0.25 to 0.31?±?0.21 logMAR (logarithm of minimum angle of resolution) in the IVB group, and from 0.67?±?0.29 to 0.46?±?0.31 logMAR in the IVT group (P?P?=?0.013) and 6 (P?P?=?0.031) at final visit. Dividing the cases into ischemic and non-ischemic types, a significant difference was noted only in the ischemic cases regarding BCVA improvement and CMT reduction in favor of the IVB group. Mean IOP rise was significantly higher in the IVT group at all visits.

Conclusions

Both 3-times-monthly IVB injections and 2-times IVT injections with a 2-month interval could be effective for improving BCVA and CMT in cases with recent-onset BRVO up to 6?months. However, considering the better visual and anatomic outcomes after IVB injections and the potential complications of IVT injections, we would recommend prescheduled repeated IVB injections for such cases. The favorable responses were more pronounced in the ischemic types of BRVO in this trial; nevertheless, this should be confirmed in larger studies.     

Vascularized retinal pigment epithelial detachment in age-related macular degeneration: treatment and RPE tear incidence

Background

To review vascularized-pigment epithelial detachment (V-PED) treatment visual outcome, and to assess acute retinal pigment epithelium (RPE) tear incidence.

Methods

One hundred and thirty-two eyes of 125 consecutive patients with age-related macular degeneration and V-PED were included. Ninety-four eyes (71.2%) were associated with choroidal new vessels (CNV), 38 (28.8%) with retinal angiomatous proliferation (RAP). Patients, treated over a 10-year period with the time-current therapy, received: verteporfin photodynamic therapy (PDT) (group 1, 38 eyes), combined intravitreal triamcinolone acetonide (IVTA) and PDT (group 2, 44 eyes) or intravitreal anti-VEGF injection (bevacizumab or ranibizumab) (group 3, 50 eyes).

Results

Mean follow-up was 20.5?months. At month 12, all eyes treated with PDT or with IVTA and PDT showed a mean significant severe visual decrease. Eyes with CNV lost ?0.67 and ?0.37 logMAR (p?p?p?p?=?0.01 respectively). RPE tear occurred in 14 eyes (36.8%) and in six eyes (13.6%) in groups 1 and 2 respectively. Eyes treated with anti-VEGF therapy showed slight mean visual acuity decrease at month 12. Those with CNV had a mean baseline best-corrected visual acuity (BCVA) of 0.36 ±?0.24 logMAR, final of 0.44 ±?0.30 logMAR (?0.08 logMAR, n.s.). In eyes with RAP, mean baseline BCVA was 0.58 ±?0.39 logMAR, final was 0.78 ±?0.47 logMAR (?0.20 logMAR, n.s.). RPE tear occurred in 14 eyes (36.8%). Patients with either V-PED with CNV or a better baseline BCVA showed greater risk of acute RPE tear (p?=?0.01 and p?=?0.003 respectively).

Conclusions

Effective treatment for vascularized PED is still lacking. Until now, only stabilization of the disease has been achieved using anti-VEGF therapy, but the risk of RPE tear can further hamper our expectations. Baseline characteristics are helpful for prognosis, but patients must be informed of the uncertain response. New therapeutic strategies are needed.     

Relationship between retinal morphological findings and visual function in age-related macular degeneration

Background

We aimed to study the retinal morphological findings associated with exudative age-related macular degeneration (AMD) and their association with visual prognosis.

Methods

We retrospectively reviewed the medical records of 96 consecutive patients (96 eyes) with exudative AMD. Retinal structural changes were examined using optical coherence tomography (OCT).

Results

Initial OCT examination showed cystoid macular edema in 18 eyes (18.8%), fibrin exudate in 56 eyes (58.3%), and hyperreflective foci within the neurosensory retina in 78 eyes (81.3%). Upon initial examination, an external limiting membrane (ELM) line was detected under the fovea in 64 eyes (66.7%). Using Pearson’s correlation analyses, final visual acuity (VA) was correlated with initial VA (r?=?0.61, p?r?=?0.34, p?r?=?0.41, p?r?=?0.40, p?r?=?0.55, p?r?=?0.48, p?r?=?0.23, p?=?0.054), and detection of a foveal ELM line (r?=?0.36, p?=?0.008).

Conclusions

In eyes with exudative AMD, final VA was most correlated with initial VA. In addition, the initial integrity of the foveal outer retina was partially correlated with the visual prognosis. The initial ELM condition was associated with good final VA, while the initial presence of hyperreflective foci in the foveal neurosensory retina was associated with poor final VA.     

Bimonthly injections of ranibizumab for age-related macular degeneration

Purpose

To evaluate the efficacy of bimonthly intravitreal injections of ranibizumab for age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) in a pilot study.

Methods

This study was a prospective, interventional case series. Thirty eyes of 30 patients received prospectively at least three bimonthly intravitreal injections of ranibizumab (0.5 mg/0.05 ml) without loading doses. The best-corrected visual acuity (BCVA) and the central retinal subfield thickness (CRST) were measured before and monthly after the injections.

Results

Twenty-eight patients received the three planned injections; one patient refused the third injection, one patient did not receive the third injection because blood pressure was raised, and one patient received a rescue injection at month 5 because of increased retinal thickness. The mean logarithm of the minimum angle of resolution (logMAR) BCVA was 0.44?±?0.37 before treatment and significantly improved to 0.25?±?0.34 at month 6 (p?p?p?=?0.005). The mean CRST was 360?±?110.8 μm before treatment and decreased significantly to 249?±?57.0 μm at month 12 (p?=?0.025).

Conclusions

Bimonthly injections of ranibizumab may be effective for treating AMD and PCV.     

Short-term Results of a Single Intravitreal Bevacizumab (Avastin) Injection versus a Single Intravitreal Triamcinolone Acetonide (Kenacort) Injection for the Management of Refractory Noninfectious Uveitic Cystoid Macular Edema

Purpose: To report the short-term results of a single intravitreal injection of bevacizumab (IVB) versus a single intravitreal injection of triamcinolone acetonide (IVT) to treat refractory noninfectious uveitic cystoid macular edema (CME).

Methods: Twenty-eight consecutive patients (36 eyes) were retrospectively included. Patients received either 2.5?mg of IVB (16 eyes) or 4?mg of IVT (20 eyes).

Results: In the IVT group, baseline best-corrected visual acuity (BCVA) was logMAR 1.1?±?0.2, and improved to 0.7?±?0.3 (p?<?.001) at 6 months. In the IVB group, baseline BCVA was logMAR of 1.2?±?0.4 and improved to 0.8?±?0.4 at 6 months (p?=?.031). At 6 months, central macular thickness (CMT) in the IVT group improved from 454.8?±?238.9?μm to 296?±?134.4?μm (p?<?.0001).

Conclusion: A single IVT injection improves BCVA and reduces CMT more effectively than IVB in refractory noninfectious uveitic CME at 6 months.     

Long-term follow-up of OCT-guided bevacizumab treatment of macular edema due to retinal vein occlusion

Background

To evaluate the long-term outcome of an OCT-guided reinjection scheme for bevacizumab treatment of macular edema (ME) due to retinal vein occlusion.

Methods

Patients with persistent ME (>250 μm) due to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) received intravitreal bevacizumab 2.5 mg/0.1 ml. Visual acuity (ETDRS), ophthalmic examination and OCT were performed at baseline and at 6- to 8-week intervals. Reinjections were only performed if OCT showed persistent or recurrent ME.

Results

Sixty-one patients with a minimum follow-up of 25 weeks were included in this analysis. Mean follow-up was 60?±?29 wks. In CRVO patients, central retinal thickness (CRT) decreased from 748?±?265 µm to 372?±?224 µm (p?<?0.001) and visual acuity (VA) improved by 1.9?±?3.2 lines. In BRVO patients, mean CRT decreased from 601?±?206 µm to 386?±?178 µm (p?<?0.001) and VA improved by 1.8?±?2.6 lines. Thirty-three percent of CRVO and 15% of BRVO patients did not show a ME recurrence for ≥25 wks at last visit. Thirty-seven percent of CRVO and 50% of BRVO patients suffered recurrences of ME within the last 25 wks, whereas 30% of CRVO and 35% of BRVO patients did not achieve a complete resolution of ME at any follow-up visit after receiving a minimum of three injections. CRVO patients with dry interval of ≥25 weeks at last visit were significantly younger, had a thinner CRT at baseline and more often had a complete resolution of ME after the first injection. In CRVO and BRVO, final VA was correlated significantly with initial VA, patients’ age and final CRT. Change of VA was correlated with change of CRT in BRVO.

Conclusions

Patients with retinal vein occlusion benefit from treatment with bevacizumab. Favourable long-term results without necessity of further injections were achieved in 33% and 15% of CRVO and BRVO patients respectively. The remaining patients needed repeated injections to treat ME recurrences. However, one third of the CRVO/BRVO patients did not improve in VA, and further injections might be discontinued in these patients.     

Visual outcomes following cataract surgery in age-related macular degeneration patients

ObjectiveTo evaluate visual acuity (VA) outcomes, prognostic factors, and changes in disease severity in patients with age-related macular degeneration (AMD) undergoing cataract surgery.DesignRetrospective cohort studyParticipantsPatients with AMD or healthy control patients who underwent cataract surgery between 2012 and 2017.MethodsEyes were categorized into 3 AMD groups—intermediate AMD (iAMD), fovea-involving geographic atrophy (GA), neovascular AMD (nAMD)—and 3 preoperative VA-matched control groups (iAMDc), fovea-involving geographic atrophy control (GAc), neovaascular AMD control (nAMDc).ResultsWe compared 216 iAMD, 35 GA, and 184 nAMD eyes with 130, 31, and 129 controls. At postoperative month 12 (POM12), VA increased significantly in iAMD and nAMD (+10.1 ± 14.5 and +9.7 ± 18.9 letters, p < 0.001), but not in GA (p = 0.68). All control groups showed significant VA gains (iAMDc: +17.1 ± 9.7, GAc: +30 ± 12.9, and nAMDc: +26.4 ± 15.6 letters, p < 0.001). For AMD groups, POM12 VA and gain in VA were significantly lower than that of controls (p < 0.01), and better preoperative VA predicted smaller VA gains (p ≤ 0.007). Longer duration of AMD in iAMD, ellipsoid zone disruption in nAMD, and lower central subfield thickness in GA were associated with poorer VA outcomes (p < 0.05). Development of nAMD occurred in 8 iAMD eyes and was associated with longer duration of disease (p = 0.001). For nAMD eyes, injection frequency did not vary between the 12-month pre- and postoperative periods (p = 0.051).ConclusionsCataract surgery improves VA for patients with iAMD and nAMD, albeit not to the level of those without retinal pathology. Preoperative VA, AMD duration, and optical coherence tomography parameters may be important prognostic factors for cataract surgery in patients with AMD.     

Efficacy of intravitreal aflibercept in Japanese patients with exudative age-related macular degeneration

Purpose

To clarify the efficacy of aflibercept for treating exudative age-related macular degeneration (AMD).

Methods

We prospectively studied 47 eyes with AMD. Forty-seven patients (mean age 72.2 years) received three consecutive monthly intravitreal aflibercept injections followed by an injection every 2 months until 12 months. The primary outcome was the 12-month visual results compared with baseline; the secondary outcomes were the prevalence of geography atrophy (GA), a dry macula at month 12, and anatomic changes on optical coherence tomography.

Results

The mean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) in 27 eyes with typical AMD and 20 eyes with polypoidal choroidal vasculopathy (PCV) significantly (p < 0.0001, p < 0.05, respectively) improved from 0.60 to 0.32 at baseline to 0.29 and 0.21 at month 12. At month 12, 22 (81.5 %) eyes with typical AMD and 17 (85 %) eyes with PCV had dry macula. The subfoveal choroidal thicknesses in typical AMD and PCV decreased significantly (p < 0.0001 for both comparisons) from 241 ± 118 and 294 ± 76 μ at baseline to 198 ± 104 and 244 ± 84 μ at month 12. Progressing or new GA was seen in three eyes with typical AMD and one eye with PCV; the mean change in the BCVA was significantly (p = 0.0026) worse at month 12. No other complications developed.

Conclusion

Intravitreal aflibercept significantly improved VA and anatomic changes in typical AMD and PCV over 12 months. Development of GA might be a risk for declining VA.

     

Long-term outcome of primary versus secondary intraocular lens implantation after simultaneous removal of bilateral congenital cataract

Background

Long-term outcomes of intraocular lens (IOL) implantation for congenital cataract in children under 2 years old are still undetermined.

Methods

We retrospectively reviewed all cases of bilateral congenital cataract who had undergone simultaneous bilateral cataract removal with posterior capsulotomy and central anterior vitrectomy between 1990 and 2010. Patients randomly underwent primary IOL implantation or secondary IOL implantation after a period of contact lens wear. The two groups were compared for visual outcome and complications during follow-up.

Results

Cataract removal and primary IOL implantation was performed in 30 eyes (15 patients; nine males, six females) at a mean age of 6.8?±?4.2 months. After 79.31?±?63.4 months, best-corrected visual acuity (BCVA) was 0.53?±?0.36 EDTRS LogMAR. In 36 eyes (18 patients, 11 males, seven females) the lens was removed at a mean age of 5.42?±?2.80 months, and after 32.0?±?6.1 months of contact lens utilization, secondary IOL implantation was performed. After 109.0?±?33.8 months, BCVA was 0.54?±?0.4 ETDRS LogMAR. The association between age at surgery and final visual acuity and the difference between the two groups concerning type of cataract at baseline, BCVA and refractive error at last visit, incidence of posterior capsular opacification, glaucoma, strabismus, and nystagmus during follow-up were not significant (p?>?0.05). Myopic shift was more frequent in eyes undergone primary IOL implantation (p?<?0.001).

Conclusions

Similar visual outcome and complications were observed during long-term follow-up after both primary and secondary IOL implantation following simultaneous bilateral congenital cataract removal with posterior capsulotomy and central anterior vitrectomy.     

Multifocal electroretinography in type 2 idiopathic macular telangiectasia

Background

To characterize the electroretinographic response of the macula by multifocal electroretinography (mfERG) in patients with type 2 idiopathic macular telangiectasia (MacTel).

Methods

A prospective study of mfERG in patients with type 2 MacTel was conducted from April 2009 to November 2009. mfERGs were recorded using a visual evoked response imaging system (MonElec2, Metrovision, Perenchies, France). The International Society for Clinical Electrophysiology of Vision (ISCEV) guidelines were followed. Patients with type 2 MacTel confirmed by fundus fluorescein angiography without subretinal neovascularisation were included. For recording purposes, 61 stimulus hexagonal elements were used. The first-order kernel mfERG responses were analyzed. Individual mfERG responses for the hexagons were grouped into concentric rings centered on the fovea for analysis (< 2, 5–10, 10–15 and >15°). Student’s t-test and Mann–Whitney U test and linear regression analysis was performed with STATA ver 11.1 (StataCorp, College Station , TX, USA).

Results

Twenty eight eyes of 14 patients and 20 eyes of ten normal controls were included in the study. The mean logMAR visual acuity of the patients was 0.51 (Snellen equivalent 20/63). The mean N1 amplitude (nv/deg²) of patients were significantly reduced compared to controls and were as follows: 8.91?±?14.00 vs 43.44?±?9.55 (p?<?0.0001) in less than 2°, 9.24?±?10.47 vs 22.00?±?3.87 (p?<?0.0001) in 5–10°, 8.57?±?10.02 vs 15.24?±?1.89 (p?<?0.0001) in 10–15°, and 7.03?±?6.52 vs 12.47?±?2.62 in?>?15° (p?<?0.001). The mean P1 amplitude (nv/deg²) was also significantly reduced in patients compared to controls and was as follows: 27.66?±?37.44 vs 96.20?±?12.41 (p?<?0.0001) in less than 2°, 22.61?±?19.38 vs 53.78?±?9.79 (p?<?0.0001) in 5–10°, 18.75?±?20.21 vs 35.22?±?4.16 (p?<?0.001) in 10–15°, and 17.10?±?12.54 vs 25.71?±?3.93 (p?<?0.001). The implicit time of N1 and P1 were also delayed significantly in all the rings. The mean central foveal thickness assessed by optical coherence tomography (OCT) scan was 84.78?±?45.12 μm. There was poor correlation between mfERG amplitudes or implicit times with either the visual acuity or OCT central thickness.

Conclusion

mfERG showed significant reduction in amplitudes and implicit times of the waveforms in patients with type 2 MacTel in all the rings, suggesting a more generalized affection of the macula. The maximum reductions were seen in the <2^o rings. Although there was poor correlation between the visual acuity and the amplitudes a of the waveforms, mfERG is a useful investigative modality for functional assessment of macula in type 2 MacTel patients.     

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty

Background

To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty.

Methods

This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse?/Artisan®) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months).

Results

The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0?±?0.46) improved significantly (p?<?0.05) compared to the preoperative CDVA (mean 1.8?±?0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg?±?4.0 was not significantly (p?>?0.05) higher compared to the preoperative IOP 15.6 mmHg?±?5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection.

Conclusions

Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support.     

Rezidivbehandlung der neovaskulären altersbedingten Makuladegeneration mit Ranibizumab nach dem PrONTO-Schema

Background

The goal of this retrospective study was to evaluate the development of visual acuity before and after recurrence treatment of neovascular age-related macular degeneration (AMD) in a university eye clinic with referring ophthalmologists.

Methods

Data from patients with recurrent neovascular AMD who initially had been treated for neovascular AMD and followed by referring ophthalmologists were analyzed. An intravitreal recurrence treatment with ranibizumab using the same PrONTO scheme as used in the “upload” phase followed.

Results

Mean best corrected visual acuity (BCVA) of all 100 patients included in the study was ??0.61?±?0.33 LogMAR before treatment and improved to ??0.36?±?0.24 LogMAR (p?<?0.001) after “upload” therapy. Mean central retinal thickness (CRT) was 291.5?±?85.3 μm before treatment and decreased to 200.1?±?63.7 μm after “upload” therapy (p?<?0.001). At the time of recurrence the mean BCVA was ??0.63?±?0.33 LogMAR and improved significantly to ??0.52?±?0.28 LogMAR (p?<?0.001) after recurrence treatment. At the time of recurrence the mean CRT was 281.2?±?94.4 μm and decreased significantly to 202.7?±?59.9 μm after recurrence treatment (p?<?0.001).

Conclusions

Retreatment criteria according to the PrONTO scheme showed good morphological and functional results in the patients with recurrent neovascular AMD treated but seemed to be defined too broadly for everyday clinical use with an irreversible loss under those conditions in cases of a recurrent episode. Accordingly, the latest recurrence criteria of the DOG/BVA/DOC recommendations should be applied.     

Results of congenital cataract surgery with and without intraocular lens implantation in infants and children

Background

Operations for congenital cataract in children in the past had resulted in aphakia. Improvement in surgical tools and techniques as well as in intraocular lens (IOL) implantation has led to correction of the aphakia by IOL implantation. We report the outcome of cataract surgery with and without IOL on these children in our institution between 1991–2008.

Methods

In this retrospective cohort study, the medical records of all children who underwent surgery for congenital cataract were reviewed. The final study group included 144 children (218 eyes). Postoperative visual acuity (VA) was tested either by Teller Acuity Cards (in preverbal children) or by the Snellen chart. Data on VA status and postoperative complications were retrieved.

Results

Patients with bilateral cataract had better postoperative VA than patients with unilateral cataract (logMAR 0.559?±?0.455 vs. 0.919?±?0.685, respectively, P?<?0.001). Children who underwent IOL implantation had better postoperative VA than those who did not, but the type of surgery had no significant effect after correction for the child’s age at surgery (P?=?0.346). Secondary cataract occurred more frequently in the extra-capsular cataract extraction (ECCE)?+?IOL implantation group than in the ECCE only group (20.6 % vs. 8.3 %, respectively, P?=?0.018).

Conclusions

Patients with bilateral cataract had better postoperative VA compared with those with unilateral cataract. The type of surgery had no effect on final VA, but there was a higher rate of secondary cataract in the ECCE + IOL patients compared to the ECCE only patients.     

Comparison of foveal-sparing with foveal-involving photodynamic therapy for myopic choroidal neovascularization

Purpose

To evaluate the visual outcomes of choroidal neovascularization (CNV) secondary to pathological myopia in eyes treated with photodynamic therapy (PDT), and to determine the effect of lesion location and foveal involvement on visual prognosis.

Methods

Interventional case series of 24 consecutive patients with myopic CNV treated with PDT. The main outcome measure was final LogMAR visual acuity (VA).

Results

Of 24 eyes, the CNV lesion was subfoveal in 11 and extrafoveal in 13. Overall, the mean LogMAR VA at 24 months was 0.72. Extrafoveal CNV lesions achieved significantly better final VA compared with subfoveal CNV (LogMAR 0.45 vs 1.05, P=0.012). Eyes with extrafoveal CNV lesions were subdivided into foveal-sparing PDT (where the PDT laser spot did not involve the foveal center) and foveal-involved PDT (where the PDT laser covered the fovea). At all time points, the group with foveal-sparing PDT had significantly better VA compared with the foveal-involved group. The final LogMAR VA for the foveal-sparing PDT group was 0.26 compared with 1.00 for the foveal-involved PDT group (P=0.003). At 24 months, 77.8% of foveal-sparing PDT cases achieved VA of ≥20/40, compared with 25% of foveal-involved PDT cases and 9.1% of subfoveal CNV lesions (P=0.006).

Conclusion

For patients with myopic CNV, foveal-sparing PDT results in significantly better long-term visual outcomes compared with those with foveal-involved PDT. Foveal-sparing PDT may be of value for treatment of myopic CNV patients who are not suitable for treatment with anti-vascular endothelial growth factor injections.     

Intravitreal bevacizumab (avastin) for subfoveal neovascular age-related macular degeneration

Objective To report the visual and anatomic outcome of intravitreal bevacizumab (Avastin) injections in the treatment of subfoveal neovascular age-related macular degeneration (AMD). Methods Interventional, consecutive, retrospective case series. Sixty-five eyes of 65 patients with subfoveal neovascular age-related macular degeneration (AMD) received three intravitreal bevacizumab (1.25 mg) injections. Outcome measures included visual acuity (VA), central retinal thickness (CRT), and size of lesion at 24 or more weeks follow-up. Results Thirty-five eyes had prior treatment with photodynamic therapy (PDT). At presentation, VA was 1.12 ± 0.62 logMAR, CRT was 305 ± 115 μm, and greatest linear diameter (GLD) of the lesion was 4,902 ± 1,861 μm. There was no statistically significant difference between previous PDT and naïve eyes in VA, CRT, and GLD at presentation. After three bevacizumab injections, VA, CRT, and GLD significantly improved (P < 0.0001 in all groups). There was no statistically significant difference between CRT and GLD outcomes and subfoveal neovascular membrane type or age. Eyes with better VA at baseline and without previous PDT treatment achieved better final VA (P < 0.0001 and P = 0.045, respectively). A classic membrane type and lower age were somewhat associated with better post-treatment VA. Conclusions Short-term results suggest that intravitreal bevacizumab is well tolerated and associated with improvement in VA, decreased CRT, and decreased lesion size in most patients. The most important predictors of final VA outcomes were baseline VA and no previous PDT treatment. Further evaluation of intravitreal bevacizumab for the treatment of subfoveal neovascular AMD is warranted.     

Management of delayed suprachoriodal haemorrhage after intraocular surgery and trauma

Backgroud

To indentify surgical risk factors for delayed suprachoroidal haemorrhage (DSCH) and to report the outcomes of an effective intervention in a consecutive of patients.

Methods

The clinical data of ten patients diagnosed with DSCH in our hospital between July 2007 and December 2012 were extracted from hospital records and analyzed, including ophthalmologic examination, ophthalmologic ultrasonography, surgical procedures, and outcome measures including visual acuity and intraocular pressure.

Results

Ten eyes of ten patients including six men and four women with mean age of 56.6?±?17.67 years, with DSCH, were enrolled. After diagnosis, drainage or/and pars plana vitrectomy were performed for eight patients; another two received conservative treatment. All the patients were followed up for 15.2?±?4.3 months. Intraocular pressure decreased significantly (p?<?0.001); the mean final visual acuity improved significantly after intervention (p?<?0.001).

Conclusions

We emphasized other great risk factors such as intraoperative mitomycin-C use, systemic anticoagulation or thrombolysis, and chronic kidney disease. It seems that earlier surgical intervention after the diagnosis of DSCH will be beneficial to patients by improving their final visual acuity.