Radiation Macular Edema after Ru-106 Plaque Brachytherapy for Choroidal Melanoma Resolved by an Intravitreal Dexamethasone 0.7-mg Implant

Purpose

To report the effective treatment of radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma with a dexamethasone 0.7-mg (Ozurdex^®) intravitreal implant.

Methods

An interventional case report with optical coherence tomography (OCT) scans.

Results

A 65-year-old Caucasian woman was suffering from radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma on her left eye. She had undergone one intravitreal injection of 0.5 mg bevacizumab (Avastin^®, Genentech/Roche) in the following months without functional or anatomical improvement. Seven months after the development of radiation macular edema, she received a single intravitreal injection of dexamethasone 0.7 mg (Ozurdex). Four weeks following the injection, her best-corrected visual acuity improved from 0.3 to 0.5. Radiation macular edema resolved with a reduction of central retinal thickness from 498 μm before Ozurdex injection to 224 μm after Ozurdex injection, as measured by OCT scan.

Conclusion

Dexamethasone 0.7 mg (Ozurdex) has proven to be an effective treatment option in retinal vein occlusion and noninfectious uveitis. It can also be considered as off-label treatment in radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma.Key Words: Choroidal melanoma, Ru-106 plaque, Macular edema, Dexamethasone 0.7 mg, Ozurdex^®     

Improvement of visual acuity based on optical coherence tomography patterns following intravitreal bevacizumab treatment in patients with diabetic macular edema

AIM:To report the visual outcome based on various patterns of optical coherence tomography (OCT) morphology in diabetic macular edema (DME), following treatment with anti-VEGF intravitreal bevacizumab (IVB) injection.METHODS:Sixty-seven consecutive subjects with centre involving DME underwent intravitreal injection of Bevacizumab (1.25 mg/0.05 mL) in this retrospective, comparative, non randomized study. The DME was classified into one of four categories:focal, diffuse, focal cystoid and neurosensory detachment based on OCT. Best corrected visual acuity (BCVA), macular appearance, and OCT findings were used to decide whether the subject should have a repeat injection of intravitreal bevacizumab. Outcome measures were a change in mean BCVA (Snellen converted to logMAR) and central macular thickness (CMT) in each group during the six month follow-up period.RESULTS:The mean BCVA improved to logMAR 0.23 at final follow-up from a baseline of 0.32 logMAR (P=0.040) in the focal group, logMAR 0.80 at final follow-up from a baseline of 0.82 logMAR (P=0.838) in the diffuse group, worsened to logMAR 0.53 at final follow-up from a baseline of 0.43 logMAR (P=0.276) in the focal cystoid group, and improved to logMAR 0.79 at final follow-up from a baseline of 0.93 logMAR (P=0.490) in the neurosensory detachment group. The mean CMT before treatment were 298.8±25.03 μm in the focal group, 310.8±40.6 μm in the diffuse group, 397.15±31.05 μm in the focal cystoid group and 401.03±75.1 μm in the neurosensory detachment group. A mean of 2.05 (range:1-5) injections in the focal group, 1.32 (range:1-2) in the diffuse group, 2.6 (range:1-6) in the focal cystoid group and 2.6 (range:1-6) in the neurosensory detachment group were performed during the six month follow-up period. Following intravitreal bevacizumab treatment, vision improved, remained unchanged or worsened in 11, 7 and 2 subjects in focal group; 11, 9 and 8 in diffuse group; 0, 2 and 4 in focal cystoid group and 5, 5 and 3 subjects respectively in neurosensory detachment group.CONCLUSION:OCT morpholgy patterns in DME may predict the effects of intravitreal bevacizumab treatment, and patients with focal DME are most likely to benefit from the improvent of visual acuity from this treatment.     

Intravitreal bevacizumab (Avastin) versus triamcinolone (Volon A) for treatment of diabetic macular edema: one-year results

Purpose

The objective was to compare retinal morphology and function following intravitreal injections of bevacizumab (Avastin) or triamcinolone (Volon A) in patients with early diabetic macular edema (DME).

Patients and methods

The study was planned as a randomized, prospective, interventional clinical trial. A total of 30 diabetic patients with treatment-naïve, clinically significant macular edema were included in this study and randomized to two equal groups. One group initially received three injections of 2.5 mg bevacizumab in monthly intervals. The second group received a single injection of 8 mg triamcinolone, followed by two sham interventions. Functional and anatomic results were evaluated monthly using ETDRS vision charts and spectral-domain optical coherence tomography. According to the study protocol, retreatment after 3 months was dependent on functional and anatomic outcome in a PRN regimen.

Results

Baseline best corrected visual acuity (BCVA) was 0.30 logMAR and central retinal subfield thickness (CSRT) was 505 μm in the bevacizumab group and 0.32 logMAR and 490 μm CSRT in the triamcinolone group. After 3 months, BCVA improved to 0.23 logMAR (bevacizumab) and 358 μm CRST and 0.26 logMAR (triamcinolone) and 308 μm CSRT. After 12 months, BCVA further recovered in the bevacizumab group (0.18 logMAR) but slightly decreased in the triamcinolone group (0.36 logMAR).

Conclusion

Intravitreal bevacizumab and triamcinolone are both equally effective in reducing CSRT in early DME. After 6 months, rehabilitation of vision was comparable in both treatment arms, whereas at the final follow-up at month 12, BCVA was superior in the bevacizumab than in the triamcinolone sample. This may be related to cataract development following steroid treatment, as well as to substance-specific mechanisms within the angiogenic versus the inflammatory cascade.     

Visual and anatomical outcomes following intravitreal aflibercept in eyes with recalcitrant neovascular age-related macular degeneration: 12-month results

Purpose

To describe the efficacy of intravitreal aflibercept on 12-month visual and anatomical outcomes in patients with neovascular age-related macular degeneration (AMD) recalcitrant to prior monthly intravitreal bevacizumab or ranibizumab.

Methods

Non-comparative case series of 21 eyes of 21 AMD patients with evidence of persistent exudation (intraretinal fluid/cysts, or subretinal fluid (SRF), or both) on spectral domain OCT despite ≥6 prior intravitreal 0.5 mg ranibizumab or 1.25 mg bevacizumab (mean 29.8±17.1 injections) over 31.6±17.4 months who were transitioned to aflibercept.

Results

At baseline, best-corrected visual acuity (BCVA) was 0.42±0.28 logarithm of minimum-angle of resolution (logMAR), central foveal thickness (CFT) was 329.38±102.67 μm and macular volume (MV) was 7.71±1.32 mm³. After 12 months of aflibercept (mean 10.2±1.2 injections), BCVA was 0.40±0.28 logMAR (P=0.5), CFT decreased to 292.71±91.35 μm (P=0.038) and MV improved to 7.33±1.27 mm³ (P=0.003). In a subset of 15 eyes with a persistent fibrovascular or serous pigment epithelial detachment (PED), mean baseline PED greatest basal diameter (GBD) was 2350.9±1067.6 μm and mean maximal height (MH) was 288.7±175.9 μm. At 12 months, GBD improved to 1896.3±782.3 μm (P=0.028), while MH decreased to 248.27±146.2 μm (P=0.002).

Conclusion

In patients with recalcitrant AMD, aflibercept led to anatomic improvement at 12 months, reduction in proportion of eyes with SRF and reduction in PED, while preserving visual acuity.     

Dexamethasone implant in diabetic macular edema in real-life situations

Purpose

To report outcome of eyes with recalcitrant and naive eyes with diabetic macular edema (DME) treated with intravitreal dexamethasone implants (Ozurdex) injection.

Methods

Retrospective multicenter data analysis of eyes with DME treated with Ozurdex implant and with minimum follow-up of at least one year after the first implant. Data collected included demographic details, history of presenting illness, past treatment history, clinical examination details including visual acuity at presentation, and follow-up with imaging and treatment details. Paired sample t-test was used to measure mean differences between pre- and post-implant values obtained at baseline and last follow-up.

Results

A total of 79 eyes (62 subjects) were included. Sixty-four eyes had been previously treated; 15 eyes were naive. Among the previously treated eyes, mean interval between first Ozurdex injection and any previous treatment was 7.69±8.2 months. In naive eyes, the visual acuity improved from baseline 0.58±0.25 to 0.44±0.33 logMAR at last follow-up (P=0.05). In eyes that had been previously treated, the improvement was from 0.65±0.34 at baseline to 0.48±0.35 logMAR (P=0.01). Mean treatment-free interval was 6.5±4.5 months. Nine eyes were steroid responder with controlled intraocular pressure (IOP), none showed any spike in IOP during the follow-up period.

Conclusions

Ozurdex implant could be a good alternative for recalcitrant as well as naive eyes with DME. The visual gain after initial implant injection was fairly maintained, with additional treatment usually after 6 months in naive eyes. Ozurdex appeared safe even in steroid responders with good control of IOP with antiglaucoma medications.     

Cystoid Macular Edema after Complicated Cataract Surgery Resolved by an Intravitreal Dexamethasone 0.7-mg Implant

Purpose

To report the effective treatment of cystoid macular edema (CME) following complicated cataract surgery (resulting in Irvine-Gass syndrome) with a dexamethasone 0.7-mg (Ozurdex^®) intravitreal implant.

Methods

An interventional case report with optical coherence tomography (OCT) scans.

Results

An 83-year-old Caucasian woman was suffering from CME following complicated cataract surgery on her left eye. She had undergone 3 intravitreal injections of dexamethasone 0.4 mg in the 3 months following the surgery without any improvement of visual function. Seven months after the cataract surgery, she received a single intravitreal injection of dexamethasone 0.7 mg (Ozurdex). Four weeks following the injection, her best-corrected visual acuity improved from 0.3 to 0.8. CME resolved with a reduction of central retinal thickness from 393 μm pre-Ozurdex injection to 212 μm post-Ozurdex injection, as measured by OCT scan.

Conclusion

Dexamethasone 0.7 mg (Ozurdex) has proven to be an effective treatment option in retinal vein occlusion and non-infectious uveitis. It can also be considered as off-label treatment in Irvine-Gass syndrome.Key Words: Cystoid macular edema, Irvine-Gass syndrome, Dexamethasone 0.7 mg, Ozurdex^®     

Short-term efficacy of intravitreal triamcinolone acetonide for macular edema secondary to retinal vein occlusion that is refractory to intravitreal bevacizumab

Aims:

To evaluate the 1-month efficacy of intravitreal triamcinolone acetonide (TA) in treating macular edema secondary to retinal vein occlusion (RVO) that was refractory to intravitreal bevacizumab.

Materials and Methods:

This retrospective, observational study included 23 eyes from 23 patients with macular edema secondary to RVO. Macular edema that did not respond to two or more consecutive intravitreal bevacizumab injections was treated with intravitreal TA. Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared before and one month after TA injection.

Results:

Fifteen eyes were diagnosed with central RVO, and eight eyes were diagnosed with branch RVO. All patients were previously treated with 2.4 ± 0.6 intravitreal bevacizumab injections. The TA injection was performed, on average, 5.8 ± 1.4 weeks after the last bevacizumab injection. The CFT before TA injection was 516.6 ± 112.4 μm and significantly decreased to 402.3 ± 159.7 μm after TA therapy (P < 0.001). The logarithm of the minimal angle of resolution BCVA was 0.72 ± 0.34 before TA therapy and was not significantly improved by the treatment (0.67 ± 0.35, P = 0.119), despite a decrease in CFT. However, seven eyes (30.4%) had a BCVA gain of one or more lines.

Conclusions:

Intravitreal TA therapy was beneficial in some patients with macular edema secondary to RVO that was refractory to intravitreal bevacizumab therapy. This study suggests that intravitreal TA should be considered as a treatment option for refractory macular edema.     

Predictors of short-term outcomes related to central subfield foveal thickness after intravitreal bevacizumab for macular edema due to central retinal vein occlusion

AIM: To investigate the predictive factors for short-term effects of intravitreal bevacizumab injections on central subfield foveal thickness (CSFT) in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO). METHODS: This was a retrospective study in 60 eyes treated with intravitreal bevacizumab injections for ME due to CRVO. Follow-up was three months. The Early Treatment Diabetic Retinopathy Study (ETDRS) score and CSFT measured by spectral-domain optical coherence tomography (SD-OCT) were used to observe the changes in best-corrected visual acuity (BCVA). Baseline BCVA, CSFT, age, CRVO duration and the presence of cystoid macular edema (CME) or subretinal fluid (SRF) were analyzed as potential predictive factors of the effects of intravitreal bevacizumab injections. RESULTS: BCVA improved from 0.9 logMAR at baseline to 0.6 logMAR at 3mo, which was associated with a significant reduction in CSFT from 721 µm to 392 μm 3mo after injection. About 50% of CME cases and more than 90% of SRF cases responded to treatment with a complete resolution at 3mo. Age (P=0.036) and low baseline CSFT (P=0.037) were associated with a good 3-month prognosis. Patients >60 years old achieved better CME resolution (P=0.031) and lower CSFT at 3mo (305 μm vs 474 μm, P=0.003). CONCLUSION: Intravitreal bevacizumab significantly improved visual acuity and CSFT in patients with CRVO after 3mo. Older age and lower baseline CSFT were good predictors of short-term CSFT outcomes. The retinal thickness response to bevacizumab might depend on the resolution of CME rather than SRF.     

Evaluation of pain during intravitreal Ozurdex injections vs intravitreal bevacizumab injections

Purpose

The purpose was to evaluate the pain associated with intravitreal Ozurdex injections, and to compare it with that associated with intravitreal bevacizumab injections.

Methods

The study included 57 eyes of 57 patients who received an intravitreal Ozurdex injection at our institution. Pain was measured by the visual analog scale (VAS). Additional parameters recorded included age, sex, indication for the injection, number of previous Ozurdex injections in the study eye, presence of diabetes mellitus, and lens status. Data were compared with a 2 : 1 sex- and age-matched control group of 114 patients who received intravitreal bevacizumab injections.

Results

Indications for injection included diabetic macular edema (40.4%) and macular edema secondary to central and branch retinal vein occlusion (28% and 31.6%, respectively). Pain scores on the VAS ranged from 0 to 90, with a mean of 20.8±20.3. There was no significant difference in pain between Ozurdex and bevacizumab injections. Pseudophakia was correlated with increased pain in Ozurdex injections.

Conclusions

This is the first series evaluating the pain associated with intravitreal Ozurdex injections. Despite a larger needle gauge and tunneled injection technique, intravitreal injection of Ozurdex is not associated with increased pain compared with bevacizumab. This finding may be a potential advantage for Ozurdex, and may serve to improve patient compliance with future long-term treatment protocols.     

Lack of positive effect of intravitreal bevacizumab in central serous chorioretinopathy: meta-analysis and review

Purpose

To review and evaluate the effects of intravitreal bevacizumab injection (IVB) in centralserous chorioretinopathy (CSC) by meta-analysis.

Patients and methods

Clinical controlled studies that evaluated the effect of IVB in CSC were identified through systematic searches of Embase, PubMed, and the Cochrane Central Register of Controlled Trials. Data on the best-corrected visual acuity (BCVA) in logMAR and central macular thickness (CMT) in μm at baseline and 6 months after IVB were extracted and compared with those treated by simple observation.

Results

Four clinical controlled studies were included in the meta-analysis. The IVB injection group achieved better BCVA at a follow-up of 6 months. However, the analysis showed that there were no significant differences of BCVA at 6 months after injection between IVB group and the observation group (−0.02 logMAR, 95% CI −0.14 to 0.11, P=0.80). The analysis of the reduction in CMT revealed that the difference between groups was not statistically significant (−8.37 μm, 95% CI −97.26 to 80.52, P=0.85). No report assessed severe complications or side effects of IVB in patients with CSC.

Conclusions

Meta-analysis failed to verify the positive effect of IVB in CSC based on the epidemiological literature published to date.     

Pretreatment clinical variables associated with the response to intravitreal bevacizumab (Avastin) injection in patients with persistent diabetic macular edema

Background

The purpose of the study is to determine whether the pre-treatment clinical systemic variables and optical coherence tomography (OCT) findings are associated with the subsequent response to the intravitreal bevacizumab (IVB) in eyes with persistent diabetic macular edema (DME).

Design

Prospective, interventional non-comparative case series study.

Methods

38 Patients (45 eyes) with refractory diabetic macular edema; 16 females, 22 males with a mean aged 57.5 year. All patients had persistent DME not responded to other forms of treatments. Complete eye examination; best corrected visual acuity (BCVA) (represented as LOGMAR for adequate statistical analysis), slit-lamp exam, intraocular pressure measurement, stereoscopic biomicroscopy of the macula, and morphologic patterns of diabetic macular edema demonstrated by OCT.All patients had intravitreal injection of 0.05 mL = 1.25 mg bevacizumab (Avastin; Genentech, Inc., San Francisco, CA), and were followed up for 3 months. The pre and post-injection follow-up data were analyzed by Student-t test and Mann–Whitney test for two main outcome measures; visual acuity (LOGMAR) and central foveal thickness (CFT) changes over a period of three months, and the data included demographic factors, type, duration and the control of diabetes mellitus (HbA1C%), grade of diabetic retinopathy, renal function (serum creatinine level), serum cholesterol, blood pressure control and previous treatment by focal laser and/or intravitreal triamcinolone injection.

Results

The LOGMAR and central foveal thickness (CRT) improved in 30/45 eyes (67%) and 32/45 eyes (72%), respectively during a mean follow-up time of three months. The mean LOGMAR visual acuities were 0.64 (SD ± 0.34), 0.61 (SD ± 0.31) and 0.60 (SD ± 0.32) at pre-injection, at 1 month post-injection and at 3 months post-injection, respectively; but this mean increase in vision was statistically not significant (P value = 0.099). The mean foveal thicknesses were 444.95 μm (SD ± 127.36), 394.95 μm (SD ± 138.03) and 378.32 μm (SD ± 112.01) at pre-injection, 1 month post-injection and 3 months post-injection, respectively, this decrease in the foveal thickness was statistically significant (P value <0.001). The pre and post-injections values of the variables for diabetic duration, diabetic control (HbA1c) and OCT pattern of macular edema showed significant statistical correlations (P < 0.05) with LOGMAR only, however the values of the variables for serum creatinine and cholesterol show statistical correlation (P < 0.05) with both LOGMAR and CFT.

Conclusions

Chronicity and inadequate control of diabetes mellitus, nephropathy, hyperlipidemia and presence of vitreomacular attachment (VMA) are factors associated with poor vision progress after intravitreal bevacizumab injection.     

Determination of macular hole size in relation to individual variabilities of fovea morphology

Purpose

To determine the preoperative anatomic factors in macular holes and their correlation to hole closure.

Methods

Forty-six eyes with consecutive unilateral macular hole who had undergone surgery and followed up for at least 6 months were enrolled. Optical coherence tomography images and best-corrected visual acuity (BCVA) within 2 weeks prior to operation and 6 months after surgery were analyzed. The maximal hole dimension, foveal degeneration factors (inner nuclear layer cysts, outer segment (OS) shortening) and the widest foveolar floor size of the fellow eyes were measured. For overcoming preoperative individual variability of foveal morphology, an ‘adjusted'' hole size parameter (the ratio between the hole size and the fellow eye foveolar floor size) was used based on the fact that both eyes were morphologically symmetrical.

Results

Mean preoperative BCVA (logMAR) was 1.03±0.43 and the mean postoperative BCVA was 0.50±0.38 at 6 months. Preoperative BCVA is significantly associated with postoperative BCVA (P=0.0002). The average hole diameter was 448.9±196.8 μm and the average fellow eye foveolar floor size was 461.3±128.4 μm. There was a correlation between hole diameter and the size of the fellow eye foveolar floor (Pearson''s coefficient=0.608, P<0.0001). The adjusted hole size parameter was 0.979±0.358 (0.761–2.336), which was a strong predictor for both anatomic (P=0.0281) and visual (P=0.0016) outcome.

Conclusion

When determining the extent of preoperative hole size, we have to take into consideration the foveal morphologic variations among individuals. Hole size may be related to the original foveal shape, especially in relation to the centrifugal retraction of the foveal tissues.     

Transitioning to intravitreal aflibercept following a previous treat-and-extend dosing regimen in neovascular age-related macular degeneration: 24-month results

Purpose:

To evaluate frequency of injections, visual and anatomical outcomes of neovascular age-related macular degeneration (nAMD) patients transitioned to intravitreal aflibercept after failure to extend treatment interval beyond 8 weeks with prior intravitreal bevacizumab or ranibizumab.

Methods:

Retrospective review of patients with nAMD switched to aflibercept following ≥6 prior intravitreal ranibizumab or bevacizumab injections at 4–8-week intervals. Three monthly aflibercept injections were given followed by a treat-and-extend dosing regimen.

Results:

Twenty-one eyes of 18 patients who had received a mean of 23.8±18.8 (mean±SD; range 6–62) prior ranibizumab or bevacizumab injections were included. Over a mean follow-up of 24 months after the transition, 9.2±2.9 (range 4–21) aflibercept injections were required. Interval between aflibercept injections increased to 57.3 days (range 35–133 days), as compared with 37±6.1 days (range 29–54 days) with the prior agents (P=0.01). Mean best-corrected visual acuity was preserved (0.42±0.31 vs 0.42±0.23 logMAR; P=0.2). Mean OCT central subfoveal thickness (292.1±83.2 μm to 283.6±78.6 μm; P=0.4) and mean macular volume (7.9±0.95 mm³ to 7.67±0.94 mm³; P=0.16) remained stable.

Conclusion:

Patients requiring treatment more frequently than every 8 weeks with ranibizumab and bevacizumab were transitioned to >8-week treatment interval with aflibercept while maintaining the anatomic and visual gains.     

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

Purpose

To assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema.

Material and methods

This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables.

Results

Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p < 0.01). The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 (p < 0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p > 0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p > 0.05). The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 (p < 0.01).

Conclusions

PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.     

Unilateral amblyopia: Optical coherence tomography findings

Purpose

This study was performed to measure the macular and the retinal nerve fiber layer (RNFL) thicknesses using optical coherence tomography (OCT) in patients with unilateral amblyopia.

Methods

Measurement of the Retinal nerve fiber layer and Macular Retinal Layer thickness for both amblyopic and normal fellow eyes by (OCT) was carried out at king Abdulaziz University Hospital, Riyadh, Saudi Arabia.

Results

Ninety-three patients with unilateral amblyopia between the ages of 5 years and 12 years were included. The macular retinal thickness and the RNFL thickness were measured using OCT. The mean macular retinal thickness was 259.3 μm and 255.6 μm, and the mean RNFL thickness was 112.16 μm and 106 μm, in the amblyopic eye and the normal eye, respectively. OCT assessment of RNFL thickness revealed a significantly thicker RNFL in amblyopic eye (P < 0.0001), but no statistically significant difference was found in macular retinal thickness (P = 0.195).

Conclusion

The amblyopic process may involve the RNFL, but not the macula. However, further evaluation is needed.     

Spectral domain optical coherence tomography changes following intravitreal dexamethasone implant,Ozurdex? in patients with uveitic cystoid macular edema

Purpose:

To correlate the structural and functional changes following intravitreal injection of dexamethasone 0.7 mg (Ozurdex^®) implant in patients with recalcitrant uveitic cystoid macular edema (CME).

Materials and Methods:

In a prospective, interventional, nonrandomized study, 30 eyes (27 patients) with uveitic CME received Ozurdex^® implant and were followed-up for 24 weeks at periodic intervals to monitor structural alterations seen on spectral domain optical coherence tomography (SD-OCT). The outcome measures included change in central macular thickness (CMT) and best-corrected visual acuity (BCVA) as well as structural alterations seen on OCT such as change in the height of cystoid spaces (CSs) and sub-foveal serous retinal detachment (SSRD). The integrity of external limiting membrane and inner-outer segment junction was assessed at baseline and follow-up visits.

Results:

Mean age of the patients was 46.09 ± 15.66 years. The mean CMT decreased by 96 μm at 1-day, 231.64 μm at 1-week, 254.21 μm at 4 weeks and 249.14 μm at 12 weeks (P < 0.001) compared with baseline. BCVA improved from a baseline mean of 0.62 LogMAR units to 0.49 on day 1 to 0.31 at 24 weeks (P < 0.001). A decrease in the mean height of CS, that is, 133.28 μm from a baseline of 317.71 μm was noted on the 1^st day (P < 0.001). 4 eyes demonstrated the presence of CS at 4 weeks, 1 eye at 6 weeks and 3 eyes at 12 weeks. At baseline, 16 eyes (53.33%) demonstrated the presence of SSRD. Among these, 11 eyes showed resolution of SSRD on day 1. SSRD resolved in all patients at 4 weeks and was maintained up to 24 weeks.

Conclusions:

Ozurdex^® implant improves the visual outcome of patients with recalcitrant uveitic CME. Reversibility of retinal changes may be possible following treatment with dexamethasone implant. Thus final visual outcome may be independent of pretreatment CMT, the height of CS or SSRD.     

Intravitreal bevacizumab for pediatric exudative retinal diseases

Purpose

To detect if intravitreal bevacizumab can reduce retinal exudation, improve visual and anatomical outcomes, and facilitate the treatment in various pediatric exudative retinal diseases.

Patients and methods

Prospective, non-randomized, case series of nine eyes of pediatric exudative retinal diseases less than 18 years old which included six eyes with juvenile diabetic retinopathy, two eyes in children with Coats’ disease, and one eye with myopic choroidal neovascular membrane (CNV). All eyes received only intravitreal bevacizumab injection 1.25 mg/0.05 ml as the primary treatment. The need for adjuvant ablative procedures, including laser photocoagulation or cryotherapy, were performed and recorded. The need for supplementary intravitreal bevacizumab injection was recorded. The changes in pre- and post-operative best-corrected visual acuity (BCVA) and central macular thickness (CMT) were recorded. Serial optical coherent tomography (OCT) and fundus flourescein angiography (FFA) were performed to follow treatment efficacy.

Results

The study included 19 eyes of 11 patients with age equal to or less than eighteen years with exudative retinal diseases including type I DM (n = sixteen eyes), Coats’ disease (n = 2 eyes), and due to myopic CNV (n = 1 eye). Mean pre-injection log MAR for all was 0.605 ± 0.174 and mean post-injection for all log MAR was 0.284 ± 0.247. While Mean pre-injection log MAR for DR and myopic CNV patients was 0.576 + 0.152 SD and mean post-injection log MAR for DR and myopic CNV patients was 0.229 + 0.189 at one year. Serial OCT measurements showed that mean CMT for all eyes was 355.8 ± 35.3 μm SD at baseline, which was decreased to 222.42 + 26.2 μm SD. The two eyes of Coats’ disease needed another two supplementary intravitreal bevacizumab injections. No ocular or systemic complications related to bevacizumab were noted during the entire course of follow-up.

Conclusion

Intravitreal bevacizumab appears to be a well-tolerated treatment for pediatric age group with various exudative retinal diseases. It has the potential as an adjuvant therapy for ablative procedures to improve final visual and anatomical outcome.     

Posterior sub-tenon’s bevacizumab injection in diabetic macular edema; a pilot study

Purpose

To evaluate the short-term results of sub-tenon’s injection of bevacizumab in patients with clinically significant macular edema (CSME).

Methods

In this prospective non-comparative interventional case series, sub-tenon’s injection of 2.5 mg/0.1 ml bevacizumab was performed for eyes with CSME. Macular thickness and best corrected visual acuity measurements were performed before and one month after injections.

Results

Nineteen eyes of twelve patients with a mean age of 59.8 ± 5.7 years were evaluated. Thirteen eyes (68.4%) had center-involving macular edema. No significant difference was observed between pre- and post-injection central subfield retinal thickness measurements (P = 0.3). Central subfield thickness measurements improved or remained unchanged in 13 eyes (68.4%). Baseline BCVA of 0.48 ± 0.35 LogMAR improved to 0.36 ± 0.26 LogMAR after injection (P = 0.01). Improvement of >2 lines in BCVA was found in 5 eyes (26.3%), and no eye lost >2 lines of BCVA. No complication associated with sub-tenon’s injection was observed.

Conclusion

Sub-tenon’s injection of bevacizumab resulted in significant short-term visual improvement in eyes with CSME. Retinal thickness changes were not significant.     

Effect of a single intravitreal bevacizumab injection on different optical coherence tomographic patterns of diabetic macular oedema

Purpose

The aim of this study is to compare the therapeutic effect of a single intravitreal bevacizumab (IVB) injection in eyes with diabetic macular oedema (DMO) of different patterns determined by optical coherence tomography (OCT).

Methods

Medical records of patients who had a single IVB injection for DMO were analysed retrospectively. Eyes with a clinically significant DMO and a central foveal thickness (CFT) of 250 μm or more determined by OCT were included in the analysis. Best-corrected visual acuity (BCVA), CFT and total macular volume values before and after the injection were recorded. Eyes were divided into sponge-like diffuse retinal thickening (DRT), cystoid macular oedema (CMO) and serous retinal detachment (SRD) groups according to the morphology on OCT.

Results

A total of 92 eyes (42 with DRT, 31 with CMO and 19 with SRD) were included in the study. There was no statistically significant variation between three groups regarding the change in BCVA (P=0.695). CMO and SRD groups had greater reductions in their mean CFT, and the amount of reduction showed statistically significant variation between three groups (P=0.048). However, no statistically significant difference was found between groups in terms of percentage of change in CFT (P=0.278).

Conclusion

CMO and SRD subtypes are associated with a greater reduction in the CFT than the DRT subtype. Although the change in BCVA was not significantly different between groups, the DRT group showed markedly better visual improvement in proportion to the decrease in CFT.     

Intravitreal anti-vascular endothelial growth factor monotherapy for large submacular hemorrhage secondary to neovascular age-related macular degeneration

Purpose

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) monotherapy for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

Methods

A total of 49 treatment-naive patients (49 eyes) with large SMH (more than five disc areas (DAs)) secondary to nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly intravitreal anti-VEGF injections, followed by as-needed injections. At the 12-month follow-up, changes in best-corrected visual acuity (BCVA), hemorrhage area, central foveal thickness, and development of vitreous hemorrhage after treatment were evaluated.

Results

The mean SMH area was 13.9±8.8 disk areas (DAs) and mean symptom duration was 7.25±5.9 days at baseline. The mean number of injections was 4.49±1.61. Twelve months after treatment, the mean BCVA significantly improved from 1.14±0.61 logarithm of the minimum angle of resolution (logMAR; 20/276, Snellen equivalent) to 0.82±0.53 logMAR (20/132; P=0.002). Twenty-four eyes (49%) showed improvement of more than three lines of BCVA at 12 months after treatment. Baseline BCVA (odds ratio (OR), 5.119; 95% confidence interval (CI), 1.993–9.545; P=0.004), duration of symptoms (OR, 0.727; 95% CI, 0.332–0.952; P=0.024), hemorrhage area (OR, 0.892; 95% CI, 0.721–0.965; P=0.011), and baseline central foveal thickness (OR, 0.881; 95% CI, 0.722–0.945; P=0.032) were significantly associated with good visual acuity 12 months after treatment.

Conclusions

Intravitreal anti-VEGF monotherapy is a valuable treatment option for large SMH secondary to nAMD.