光动力疗法治疗卵黄样黄斑营养不良并发脉络膜新生血管临床观察

目的 观察光动力疗法(PDT)治疗卵黄样黄斑营养不良(VMD)并发脉络膜新生血管(CNV)的临床疗效.方法 回顾性分析行PDT治疗的7例VMD并发CNV患者7只眼的临床资料.患者中男性4例,女性3例.年龄20～54岁.治疗前后行最佳矫正视力(BCVA)、裂隙灯显微镜、眼底彩色照相、荧光素眼底血管造影(FFA)、吲哚青绿血管造影(ICGA)、频域光相干断层扫描(SD-OCT)以及眼电图( EOG)、视网膜电图(ERG)等检查.患眼BCVA数指/眼前～0.6；光感受器内外节(IS/OS)界面下积液,视网膜水肿,平均中央视网膜厚度(506.00±30.71) μm.PDT治疗按照标准常规操作完成.治疗后随访2～11个月,平均随访时间6.3个月.观察BCVA及CNV变化以及与治疗相关的副作用.结果 末次随访时,患眼BCVA 0.12～1.0,均有不同程度提高；FFA及ICGA检查显示,CNV萎缩变小,渗漏减轻；SDOCT检查见神经视网膜水肿减轻或消退,平均中央视网膜厚度下降为(401.00±52.22) μm,IS/OS界面与视网膜色素上皮间光反射暗区消失,黄斑恢复基本正常形态；未见与治疗相关的局部及全身副作用发生.结论 PDT能有效治疗VMD并发的CNV,稳定或提高患者视力.     

Karl Lisch,MD: Remembered July 24, 1907 - February 5, 1999

Purpose: To report a novel VMD2 gene mutation in a Japanese family with Best disease and the clinical phenotype of the patients. Patients and methods: Mutational analysis for VMD2 was performed by direct sequencing in two members of a Japanese family with Best disease. Clinical examination included visual acuity, electro-oculography (EOG), and fundus examination. Results: A T990C mutation of the VMD2 gene was found in the 20-year-old boy and his 47-year-old mother. The boy had bilateral vitelliform cyst-like lesions in both eyes and showed a pathological Arden ratio of 1.0 on EOG. The mother had a normal fundus appearance with an Arden ratio of 1.0 on EOG. Conclusion: A novel disease-causing mutation in the VMD2 gene (T990C) was found in Japanese patients with Best disease.     

Ocular haemodynamic changes after single treatment with photodynamic therapy assessed with non‐invasive techniques

Purpose: To investigate in patients with neovascular age‐related macular degeneration (ARMD) the changes in ocular perfusion caused by single treatment with photodynamic therapy (PDT) by different non‐invasive methods; to evaluate correlations between relative changes of ocular haemodynamic parameters after PDT among each other and compared to morphological parameters; and to assess this in relation to early changes of visual acuity. Methods: Study population: 17 consecutive patients with subfoveal choroidal neovascularization (CNV) caused by ARMD scheduled for PDT without previous PDT treatment (four patients with predominantly classic CNV and 13 patients with occult CNV). Observation procedures: best‐corrected visual acuity (before PDT, 6 and 8 weeks after PDT), fundus photography, fluorescein angiography, haemodynamic measurements with laser Doppler flowmetry (LDF), laser interferometry and ocular blood flow (OBF) tonometry (baseline and 1, 2, 6 and 8 weeks after treatment). Main outcome measures: choroidal blood flow (CHBF), fundus pulsation amplitude (FPA), pulsatile ocular blood flow (POBF), visual acuity. Changes smaller than 20% were considered clinically irrelevant. Results: Ocular haemodynamic parameters did not change significantly in the follow‐up period. Changes of haemodynamic parameters showed no correlation to treatment spot, morphological changes or visual acuity. Changes of visual acuity were comparable to results of earlier studies. Conclusion: Single treatment with PDT did not modify ocular blood flow parameters above 20% as assessed with different non‐invasive methods.     

Photodynamic therapy outcomes in a case of macular choroidal neovascularization secondary to Candida endophthalmitis

PURPOSE: To evaluate the effects on visual function and choroidal neovascularization (CNV) progression in a case of subretinal CNV due to Candida endophthalmitis treated with a combination of photodynamic therapy (PDT) and drugs. METHODS: A 28-year-old one-eyed woman with CNV in the right eye came to our observation. The CNV developed as a consequence of Candida endophthalmitis. The CNV was treated with six PDT treatments with verteporfin in association with systemic steroid therapy with prednisone (100 mg/day to reduce) and fluconazole (800 mg/day to reduce). Visual acuity (VA) was assessed in pre-PDT conditions and after six PDT treatments (24 months of follow-up). RESULTS: Pre-PDT VA was 20/125; after 24 months of follow-up, six PDT re-treatments, and pharmacologic therapy, VA was stabilized at 20/100. CONCLUSIONS: In our case, associated PDT and drug therapies were safe and useful to maintain VA and to arrest CNV progression in the foveal region after 2 years of follow-up.     

Photodynamic therapy for unilateral idiopathic peripapillary choroidal neovascularization in a child

A 10-year-old girl presented with visual loss in her right eye. Best-corrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Dilated funduscopic examination revealed a yellowish elevated lesion near the optic disc with macular edema and hemorrhage on the inferotemporal vascular arcade in the right eye. Fluorescein angiography showed a hyperfluorescent lesion consistent with choroidal neovascularization (CNV) and optical coherence tomography (OCT) showed a peripapillary lesion with subretinal fluid elevating the neurosensory retina in the macular area. With a diagnosis of unilateral idiopathic peripapillary CNV, the patient underwent photodynamic therapy (PDT) with verteporfin. At the four month follow-up, visual acuity increased to 20/25 and OCT showed peripapillary scar formation and total resolution of the subretinal fluid. At the one year follow-up, visual acuity and fundus were stable without recurrence of the lesion. PDT for peripapillary CNV in children has not previously been reported. Although it seems to be a favorable treatment option for peripapillary lesions, there is a lack of knowledge about long-term follow-up in pediatric cases.     

Combined intravitreal anti‐vascular endothelial growth factor (Avastin®) and photodynamic therapy to treat retinal juxtapapillary capillary haemangioma

Objective: Retinal capillary haemangioma complications are characterized by progressive exudation with consecutive intraretinal and subretinal leakage. A successful therapy without side‐effects has not been found. We report a case of retinal juxtapapillary capillary haemangioma causing consecutive leakage with macular involvement. The tumour was treated with a combination of anti‐vascular endothelial growth factor (VEGF) and photodynamic therapy (PDT) and was followed for 1 year. Methods: A 44‐year‐old woman with retinal juxtapapillary capillary haemangioma in the right eye experienced a decrease of visual acuity from 20/20 to 20/60 because of a severe leakage from the tumour involving the macula with lipid depositions. Two sessions of PDT (sparing the part of the haemangioma located within the optic disc) and five injections of bevacizumab were applied in a period of 5 months. Visual acuity, visual field testing, retinal thickness measurements, fundus photography and fluorescein angiography were performed to evaluate the treatment effect. Results: One year after the last injection, visual acuity increased to 20/40. All lipid exudates at the posterior pole resolved. Retinal thickness decreased from 490 to 150 μm with the restoration of normal central macular architecture. Leakage in fluorescence angiography reduced significantly, but hyperfluorescence of the tumour was still evident. Visual field testing and angiography did not show any treatment‐related vaso‐occlusive side‐effects. Conclusion: In this single case, the combination of anti‐VEGF and PDT appeared to be an effective strategy for the treatment of retinal juxtapapillary capillary haemangioma without side‐effects. Further studies with a greater number of eyes and adequate follow‐up are necessary to support these first clinical results.     

The development of recurrent choroidal neovascularization in a patient with choroidal coloboma

We report a case of recurrent choroidal neovascularization (CNV) in an eye with chorioretinal coloboma. A 36-year-old woman presented complaining of decreased visual acuity (VA) in her left eye. Best corrected visual acuity (BCVA) was 20/200 and iris coloboma was observed. Funduscopy and fluorescein angiography (FA) showed CNV in the superior extrafoveal region with chorioretinal coloboma reaching just inferior to the optic disc. No other cause for CNV was observed except for the chorioretinal coloboma. BCVA improved to 20/30 after laser photocoagulation. She revisited our clinic for deteriorating VA (20/400) in the same eye 3 years after treatment. Funduscopy and FA demonstrated recurrent CNV with subfoveal hemorrhage. Photodynamic therapy (PDT) was followed by three consecutive intravitreal bevacizumab injections (IVB) for the subfoveally-located CNV. However, the CNV persisted with the appearance of a fresh subretinal hemorrhage. Additional PDT was combined with IVB on the same day 6 months after the initial PDT. The CNV regressed 3 months after treatment and has not recurred as of 8 months after the last treatment. The patient's BCVA improved to 20/60. This case suggests that PDT combined with IVB can be an alternative treatment for the management of recurrent CNV after laser photocoagulation in eyes with chorioretinal coloboma.     

Different treatment modalities for choroidal neovascularization in two eyes of one patient with bilateral type 2A parafoveal telangiectasia

A 60-year-old diabetic man presented with a history of decrease in vision in both eyes since 2 weeks. At presentation, best corrected visual acuity (BCVA) in the right eye (RE) was 20/30 and that in the left eye (LE) was 20/80. The right fundus revealed a grayish reflex, yellowish crystalline deposits and retinal pigment epithelial hyperplasia at the macula. The left fundus showed subretinal fluid and temporal subretinal hemorrhage near a grayish reflex at the macula. A diagnosis in both eyes of idiopathic macular telangiectasia (IMT) type 2A with RE stage 4 and LE stage 5, choroidal neovascularization (CNVM) was made. The patient was treated with photodynamic therapy (PDT) in LE. The visual acuity improved to 20/40 over the next 6 months. At a 4-year follow-up, he developed decreased vision in RE diagnosed as IMT with CNV and was treated with intravitreal ranibizumab. At 6-month follow-up post injection, the vision was 20/40p.     

Photodynamic therapy with intravitreal application of triamcinolone acetonide in age‐related macular degeneration: functional results in 54 patients

Purpose: This study aimed to investigate the functional results, efficacy and complications after photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide injection (IVTA) in patients with choroidal neovascularization (CNV) caused by age‐related macular degeneration (AMD). Methods: A retrospective analysis of clinical data for 54 patients with CNV resulting from AMD was carried out. All patients had a follow‐up of 12 months. The patients were treated with standardized PDT and IVTA (4 mg) as a first‐line treatment or following PDT failure. Visual acuity (VA), greatest linear diameter (GLD) of the CNV and foveal thickness were evaluated. Results: Mean VA at baseline was 0.8 logMAR (0.4–1.4). After 12 months VA improved (> 2 lines) in 20.4% of patients and stabilized (± 2 lines) in 64.8%. There was no statistical significance in VA outcome between patients undergoing first‐line treatment and patients with PDT failure; however, fewer PDT treatments were required to stop CNV activity in patients undergoing first‐line treatment. At 12 months, a reduction in foveal thickness was seen in 67.7% of patients and a reduction in CNV GLD in 32.7%. Complications occurred in 22% of patients and included a transient rise in intraocular pressure, cataract and sterile hypopyon. Conclusions: Our analysis shows that fewer PDT treatments were required to stop CNV activity when triamcinolone was used as first‐line treatment. We can thus conclude that PDT combines synergistically with IVTA and the combination may lead to a cost reduction compared with PDT therapy alone. The overall complication rate of 22% is high and must be compared with complication rates caused by new intravitreal anti‐VEGF (vascular endothelial growth factor) drugs in combination with PDT.     

Time‐course and characteristic morphology of retinal changes following combination of verteporfin therapy and intravitreal triamcinolone in neovascular age‐related macular degeneration

Purpose: To identify characteristic morphological changes of the retina over time and the association with visual function after combined photodynamic therapy (PDT) and intravitreal triamcinolone (IVTA). Methods: In this retrospective study, 40 patients (40 eyes) were treated with PDT and same‐day IVTA. Optical coherence tomography (OCT), fluorescein angiography (FA) and evaluation of distance visual acuity (VA) were performed. The anatomical changes within intra‐ and subretinal compartments and their detailed analysis and grading were the main outcome measures. Results: Intraretinal fluid (IRF) and subretinal fluid (SRF) by OCT decreased until 3 months (p < 0.01). At month 3, intraretinal cystoid spaces (ICS) had resolved or decreased in 84% of eyes, SRF in 58% and pigment epithelial detachment (PED) in 50%. Mean best‐corrected VA (BCVA) improved significantly at month 1 (p < 0.01). Mean central retinal thickness (CRT) increased from 334 μm at baseline to 439 μm at day 1 (p = 0.03) before decreasing to 286 μm at day 7 (p = 0.06), 233 μm at month 1 (p = 0.001) and 255 μm at month 3 (p = 0.001). Conclusion: Combined verteporfin/IVTA therapy induces distinct time‐related effects on the retina within the different intra‐ and subretinal compartments.