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.     

Combination therapy in exudative age-related macular degeneration: visual outcomes following combined treatment with photodynamic therapy and intravitreal bevacizumab

Objective: To measure visual outcomes following combined treatment with photodynamic therapy (PDT) and intra-vitreal bevacizumab for exudative age-related macular degeneration (AMD).Design: Single-centre, retrospective cohort analysis.Participants: One hundred and seventy-four eyes in 174 patients, representing a consecutive series of all patients with at least 6 months’ follow-up after combined treatment with PDT and bevacizumab for exudative AMD.Methods: Each patient was treated with PDT, followed by intravitreal injection of bevacizumab approximately 30 minutes later. The patients were then followed at 8-12-week intervals. The primary outcome of the study was the mean change in visual acuity (VA) from baseline.Results: One hundred seventy-four eyes in 174 patients completed at least 6 months’ follow-up, with a mean duration of 10 months. The mean number of treatments was 3.0 for bevacizumab and 1.4 for PDT. After stabilization, the mean treatment-free interval was 193 days, and 52% of the patients did not require postinduction retreatment. Mean VA improved from baseline at 2,4, and 6 months of follow-up (p < 0.05). In the subgroup analysis, treatment-naïve patients had more favorable visual outcomes (p < 0.05).Conclusions: The combination of PDT and intravitreal bevacizumab is an effective therapy for preserving VA in patients with exudative AMD.     

Outcome of intravitreal bevacizumab for idiopathic choroidal neovascularization in a Chinese population

Objective: To assess the long-term visual and anatomical outcomes and safety of intravitreal injection of bevacizumab for idiopathic choroidal neovascularization (ICNV) in Chinese patients.Design: Retrospective interventional case series.Participants: Seventy-seven eyes of 77 patients with ICNV.Methods: Patients were given intravitreal injection of bevacizumab (1.25 mg/0.05 mL) for ICNV between March 2006 and May 2008. Main outcome measures were changes in best-corrected visual acuity (BCVA), central foveal thickness, which was measured by optical coherence tomography, and fluorescein angiography findings.Results: Mean follow-up was 14.3 (SD 2.4, range 10∼20) months. Mean BCVA improved from 0.66 (SD 0.36) logMAR at baseline to 0.25 (SD 0.28) logMAR at final follow-up (p < 0.001). Sixty-one patients (79%) gained BCVA of ≥2 Snellen lines, and 1 eye (1%) lost BCVA of ≥2 Snellen lines. Mean central foveal thickness decreased from 365 (SD 124) μm at baseline to 211 (SD 94) μm at final visit (p < 0.001). Sixty-two eyes (81%) needed reinjection. Both BCVA improvement and the change in central foveal thickness between the 1 — time injection group and the multi-injections group were not statistically significant (p = 0.45 and p = 0.19, respectively). No significant ocular or systemic adverse effects were observed.Conclusions: The long-term results suggest an encouraging efficacy and safety of intravitreal bevacizumab for ICNV in Chinese patients.     

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.     

Clinical,anatomical, and electrophysiological assessments of the central retina following intravitreal bevacizumab for macular edema secondary to retinal vein occlusion

The purpose of this study is to evaluate the long-term visual, anatomical and electrophysiological outcomes of repeated intravitreal injections of bevacizumab for macular edema due to retinal vein occlusion (RVO) and investigate any possible toxic effects on the central fovea. This is a prospective, noncomparative, interventional case series. Thirty-three eyes of 33 patients with macular edema secondary to RVO were treated with 1.25 mg/0.05 ml intravitreal bevacizumab. Nine patients had nonischemic central retinal vein occlusion (CRVO) and 24 patients had branch retinal vein occlusion (BRVO). The main outcome measures were best-corrected visual acuity, central retinal thickness (CRT), and multifocal electroretinography (mfERG) responses changes at baseline, 1 month after the third injection and at the end of the 2-year long follow-up period. Patients with CRVO had mean best-corrected Snellen visual acuity of 0.10 at baseline, which improved significantly to 0.31 after 2 years (P = 0. 028).The mean CRT at presentation was 756.28 μm and reduced significantly to 439.14 μm after 2 years (P = 0.05). Patients with BRVO had mean best-corrected Snellen visual acuity of 0.19 at baseline, which improved significantly to 0.40 after 2 years (P < 0.001). The mean CRT at presentation was 681.04 μm and reduced significantly to 369.81 μm after 2 years (P < 0.001). Mean mfERG responses within central 10° (ring1, ring2) showed statistically significant differences on P1 parameters in terms of response density and implicit time after 2 years in both CRVO and BRVO patients. Repeated intravitreal bevacizumab injections for macular edema due to either CRVO or BRVO resulted in long-term improvement of visual acuity, a reduction in CRT and statistically significant changes in the mfERG responses with nondemonstrable toxic effects on the central fovea.     

Triple therapy for neovascular age-related macular degeneration (verteporfin photodynamic therapy, intravitreal dexamethasone, and intravitreal bevacizumab)

Objective: Age-related macular degeneration is a multifactorial disease involving inflammation, neovascularization, and vascular leakage. As a result, a rationale exists for investigating combination treatments that target the different pathological processes involved in this disease. We propose triple therapy consisting of verteporfin photodynamic therapy (PDT), intravitreal bevacizumab, and intravitreal dexamethasone.Design: Retrospective chart review.Participants: Thirty-two eyes of 30 patients were included. None of the patients demonstrated concurrent eye pathology, and none ofthe patients had received previous treatment for their choroidal neovascularization.Methods: One cycle of triple therapy consisted of reduced-fluence PDT (300 mW/cm2 for 83 seconds to deliver 25 J/cm2) followed immediately by an 800 mg (0.08 mL) intravitreal dexamethasone (IVD) injection. At 1 and 7 weeks after PDT and IVD, patients received a 1.25 mg (0.05 mL) bevacizumab injection. At 13 weeks after PDT and IVD, each patient had a repeat optical coherence tomography and fluorescein angiography to assess choroidal neovas-cularization activity. Patients were followed for 12 months.Results: The mean number of treatment cycles was 1.4. The mean number of bevacizumab injections was 2.8. Visual acuity improved from 0.74 (SD 0.33) logMAR (20/100) to 0.53 (SD 0.32) logMAR (20/70) (p > 0.005). Foveal thickness decreased from 328 (SD 116) mm to 216 (SD 85) μm (p > 0.001). Ninety-four percent of patients lost fewer than 3 lines, 31% gained more than 3 lines, and 6% lost more than 3 lines.Conclusions: By combining agents with complementary mechanisms of action, triple therapy could maintain visual acuity and macular anatomy while allowing a reduction in the number of anti-vascular endothelial growth factor injections required.     

Incidence and characteristics of acute intraocular inflammation after intravitreal injection of bevacizumab: a retrospective cohort study

Objective: To determine the incidence and characteristics of acute intraocular inflammation after intravitreal bevacizumab injections from a tertiary care retinal practice.Design: Retrospective cohort study.Participants: A consecutive series of patients who had received bevacizumab injections performed by a single surgeon.Methods: We reviewed the records of all patients with severe anterior chamber inflammation and (or) vitritis after bevacizumab injections.Results: A total of 693 bevacizumab injections were performed on 193 eyes of 173 patients between June 2006 and March 2008. There were a total of 9 cases of acute intraocular inflammation for an incidence of 1.30% (95% CI: 0.69%-2.47%). All patients had a worse visual acuity at the end of follow-up than on injection day. The mean loss of vision was 6.1 lines of Snellen visual acuity; one patient developed inflammation-induced glaucoma which required surgical intervention.Conclusions: Intravitreal injection of bevacizumab is associated with a low but significant risk of acute intraocular inflammation and may result in significant visual loss.     

Intravitreal bevacizumab and aqueous shunting surgery for neovascular glaucoma: safety and efficacy

Objective: To study the safety and efficacy of intravitreal injection of bevacizumab followed by aqueous shunting tube surgery for the management of neovascular glaucoma (NVG).Study Design: A prospective, non-randomized study with a historical control group.Participants: Twenty eyes of 20 patients with intractable NVG were treated with intravitreal injection of bevacizumab followed by aqueous shunting surgery (IVB group). A historical group of 10 NVG eyes treated with panretinal photocoagulation followed by aqueous shunting surgery without bevacizumab injection was used for comparison (PRP group).Methods: Injection of bevacizumab (1.25 mg/0.05 mL) was performed under topical anesthesia. An Ahmed valve was implanted in all cases after 1-2 weeks. In the IVB group, 10 eyes received postoperative panretinal photocoagulation (subgroup IA), and 10 eyes were followed without further photocoagulation (subgroup IB). Minimum follow-up was I year or when failure was diagnosed.Results: Mean preoperative intraocular pressure (IOP) was 46.5 mm Hg in the IVB group and 49.2 mm Hg in the PRP group (p = 0.5). After bevacizumab injection, iris neovessels regressed markedly. The final IOP after aqueous shunting tube surgery was 18.8 mm Hg in the IVB group and 15.9 mm Hg in the PRP group (p = 0.2). Postsurgical complications were comparable between the groups. The success rate was 85% and 70% in the 2 groups, respectively. Two eyes were considered failures, and 3 required repeated bevacizumab injections in subgroup IB as compared with I in subgroup IA.Conclusion: Intravitreal bevacizumab is a useful preparatory step to safely and effectively implant an aqueous shunting tube in NVG. Panretinal photocoagulation after bevacizumab injection promotes the success rate of aqueous shunt surgery by permanent ablation of the ischemic retina.     

Intravitreal bevacizumab for iris neovascularization following proton beam irradiation for choroidal melanoma

Objective: To evaluate the safety and efficacy of intravitreal injections of bevacizumab as an eye-sparing treatment for iris neovascularization (NVI) following proton beam irradiation for choroidal melanoma.Design: Retrospective interventional case series.Participants: Four patients who received intravitreal bevacizumab for NVI following proton beam irradiation for choroidal melanoma were identified in the Department of Ophthalmology archives at the University of British Columbia. Methods: Clinical details were reviewed. Long-term follow-up of more than 2 years was detailed for each case.Results: All 4 patients responded to a single injection of bevacizumab with regression of NVI. Neovascular glaucoma (NVG) was evident in 3 cases, 2 of which had stable intraocular pressure following treatment. NVI recurred following a single injection in all patients after an interval ranging from 1 month to 12 months. A longer period of regression was seen in patients with fewer systemic neovascular risk factors and earlier treatment.Conclusions: Regression of NVI following proton beam irradiation for choroidal melanoma was seen in all treated patients. Repeated treatments may be required to maintain regression of new vessels. This treatment modality may be a useful eye-sparing adjunct in the prevention and treatment of NVG following proton beam irradiation.     

Testing toxicity of multiple intravitreal injections of bevacizumab in rabbit eyes

Objective: To evaluate the potential toxicity of repeated intravitreal injections of bevacizumab in rabbit eyes.Design: Randomized, placebo-controlled experimental animal study.Participants: Fourteen chinchilla rabbits; 12 assigned to the experimental group and 2 assigned to the normal control group.Methods: Three sequential, biweekly, intravitreal injections of bevacizumab in doses of 2.5 mg/0.1 mL or 5.0 mg/0.2 mL were performed on each rabbit. Evaluations included intraocular pressure (IOP), aqueous flare, B-scan ultrasound, fundus photography, ultrasound biomicroscopy, electroretinography (ERG), and visually evoked potentials (VEPs) performed at baseline and during the follow-up period. The eyes were enucleated at 1 week and 4 weeks after the last intravitreal injection, and underwent light and electron microscopic evaluations, as well as testing for apoptotic activity.Results: After intravitreal injections, no changes were found by regular clinical observation and IOP tests. There was no significant difference in the anterior chamber inflammatory activity evaluated by the laserflare meter. No evidence of retinal toxicity was seen after intravitreal bevacizumab at doses of 2.5 and 5.0 mg by either ERG or flash VEPs. Electron microscopy did show the presence of inflammatory cells and some ultrastructural changes in the photo-receptor cells in the 5.0 mg experimental group 1 week after the third injection. Mild to moderate apoptosis of photoreceptors was detected in the 5.0 mg group at the same time.Conclusions: The biweekly, multiple intravitreal injections of bevacizumab did not result in evidence of toxicity in regular clinical and functional observations at both 2.5 mg and 5.0 mg doses. The 5.0 mg dose may induce transient inflammation, ultrastructural abnormalities, and apoptosis.     

Identifying systemic safety signals following intravitreal bevacizumab: systematic review of the literature and the Canadian Adverse Drug Reaction Database

Objective: As the off-label use of intravitreal bevacizumab continues for an increasing number of ocular conditions, a systematic review of the literature aimed at detecting temporally associated systemic adverse events was undertaken.Design: Systematic review of the literature and a health regulatory database.Participants: A total of 22 different clinical studies representing 12 699 patientsMethods: A systematic review indexed by Ovid MEDLINE, EMBASE, ISI Web of Science, the Cochrane database (CENTRAL), and the Canadian Adverse Drug Reaction Information System Database was performed. All clinical studies with at least 100 eyes injected with bevacizumab and case reports documenting suspected events were included for review.Results: A total of 22 different clinical studies were reviewed, including an international internet survey, 6 retrospective studies assessing the safety of intravitreal bevacizumab, and 15 clinical trials. The most common adverse systemic event reported in these studies, representing 12 699 patients was an increase in blood pressure (0.46% of patients), followed by cerebrovascular accidents (0.21% of patients), and myocardial infarction (0.19% of patients). The 6 case reports documented suspected events not previously identified and only 1 systemic event from the Health Canada database was retrieved.Conclusions: The systemic events temporally associated with intravitreal bevacizumab are mainly of cardiovascular and neurological origin and can be predicted from an exaggerated pharmacology, although a causal association cannot be established at this time. Health Canada's spontaneous drug reporting system is an underutilized resource and a more active surveillance system such as a patient registry may be better suited to establish the low rates of systemic adverse events following bevacizumab use in ophthalmology.     

Effect of vitreomacular adhesion on antivascular endothelial growth factor therapy for macular edema secondary to branch retinal vein occlusion

Purpose

To investigate the association between vitreomacular adhesion (VMA) and the visual and anatomic outcomes of antivascular endothelial growth factor therapy for macular edema due to branch retinal vein occlusion (BRVO).

Methods

This study included 107 eyes of 107 patients with BRVO who underwent intravitreal injection of 1.25 mg bevacizumab. The presence of VMA was determined with spectral-domain optical coherence tomography (SD-OCT). All eyes underwent best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements using SD-OCT immediately before the injection and at 3, 6, 9, and 12 months after the injection. The main outcome measures were changes in BCVA and CRT from baseline.

Results

The VMA(+) and VMA(?) groups consisted of 47 and 60 eyes, respectively, and patients’ age differed significantly between the groups (P < 0.001). In both groups, BCVA and CRT improved after the injection. The VMA(+) group showed better improvement in BCVA than did the VMA(?) group (P = 0.0150), and the presence of VMA was associated with a greater decrease in CRT after adjusting for age (P = 0.0019).

Conclusions

Presence of VMA may be associated with superior visual and anatomic outcome for intravitreal bevacizumab in the treatment of macular edema due to BRVO.     

Intravitreal bevacizumab for the treatment of choroidal neovascularization associated with pathological myopia

Background: The recent discovery of vascular endothelial growth factor and its role in the pathogenesis of ocular neovascularization has led to the development of new pharmacological agents that could block its action. This study was carried out to investigate the effect of intravitreal injections of bevacizumab on choroidal neovascularization (CNV) associated with pathological myopia.Methods: We retrospectively reviewed the charts of all patients who had CNV secondary to pathological myopia and who had been treated with intravitreally administered bevacizumab between November 2005 and April 2007 at Notre-Dame Hospital in Montréal, Québec. Data on best-corrected visual acuity (BCVA), previous treatments, number of injections, fundus photography, and fluorescein angiography were collected.Results: Ten eyes from 9 patients were followed for a mean period of 9.7 (range 2.5-14) months.At baseline the mean (SD) logMAR BCVA was 0.62 (0.25) (Snellen equivalent 6/24). The mean number of injections per eye was 2.6 (range 1-5). At the end of the study the mean (SD) logMAR BCVA had significantly improved to 0.26 (0.16) (Snellen equivalent 6/10.5; p < 0.001).Vision improved by a mean of 3.9 (range 0-7) lines on the Snellen visual acuity chart. Leakage from the CNV on fluorescein angiography had resolved in 7 of the 10 eyes and was reduced in the 3 other eyes. No drug-related side effects or complications were observed during the follow-up period.Interpretation: Intravitreal injection of bevacizumab appears to be a safe and effective treatment alternative for CNV associated with pathological myopia.     

Changes in wave-front aberrations after rigid gas permeable contact lens fitting in post—laser in situ keratomileusis patients with visual complaints

Objective: To evaluate the effect of rigid gas permeable (RGP) contact lenses in reducing wave-front aberrations in post-laser in situ keratomileusis (LASIK) myopic patients.Design: Cross-sectional study.Participants: Thirty patients with visual complaints after conventional LASIK procedure for correcting myopia.Methods: The 30 patients were fitted with RGP contact lenses. Wave-front measurements were taken before and after RGP contact lens wearing.Results: Compared with bare eye examinations, root mean-square values of higher-order aberrations (HOAs) significantly decreased with RGP contact lens use. Amongthese, spherical aberration decreased from 0.507 (SD 0.304) μm to 0.164 (SD 0.121) μm(t = 7.186, p < 0.001); coma decreased from 0.470 (SD 0.312) μm to 0.165 (SD 0.090) μm (t = 5.566, p < 0.001); secondary coma decreased from 0.079 (SD 0.050) μm to 0.044 (SD 0.027) μm (t = 4.118, p < 0.001); and total HOAs decreased from 0.782 (SD 0.449) μm to 0.307 (SD 0.140) μm (t = 6.710, p < 0.001).Conclusions: Fitting RGP contact lenses effectively decreased HOAs induced by conventional myopic LASIK surgery. Possible reasons may be the elimination of irregularity and dissymmetry on the corneal anteriorsurface, relief of the aspherical extent of the central corneal surface, and enlargement of the effective optical zone.     

Behandlung der Patienten mit einem Venenastverschluss in Abhängigkeit von der Verschlussdauer

Purpose

The aim of this study was to evaluate the effects of intravitreal treatment with bevacizumab (IVB) compared with triamcinolone (IVT) in patients with macular edema due to branch retinal vein occlusion (BRVO) depending on the duration of BRVO.

Methods

A total of 65 BRVO patients were divided into 2 subgroups: group 1 with early treatment (≤?3 months since onset of BRVO) and group 2 with late treatment (>?3 months since onset). For the two groups IVB was injected into 17 eyes as early (IVB1) and into 18 eyes as late (IVB2) treatment. For comparison IVT was injected into 14 eyes as early (IVT1) and into 16 eyes as late (IVT2) treatment. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) were analyzed at baseline, 1, 3 and 6 months after treatment.

Results

In both subgroups a significant improvement of BCVA and CRwas observed. After 6 months, for patients with early treatment, IVB1 showed better results than IVT1 (BCVA: p?=?0.008, CRT: p?=?0.021). In the late treatment no significant differences between IVT2 and IVB2 were found.

Conclusions

Bevacizumab and triamcinolone significantly improved BCVA and CRT in patients with BRVO. The best BCVA was found if bevacizumab was used as early treatment. In the late treatment no significant differences between bevacizumab and triamcinolone were observed.     

Using retinal architecture to help characterize multiple sclerosis patients

Objective: We compared retinal nerve fibre layer (RNFL) thickness and visual function in a heterogeneous multiple sclerosis (MS) cohort to determine whether optical coherence tomography (OCT) may complement the existing methods used to characterize MS patients.Design: Cross-sectional cohort study.Participants: One hundred and ninety-three patients with optic neuritis (ON) as a clinically isolated syndrome (CIS) (n = 63), relapsing-remitting MS (RRMS) (n = 108), secondary progressive MS (SPMS) (n = 13), and primary progressive MS (PPMS) (n = 9).Methods: All patients underwent standardized ophthalmic, neurological, and OCT testing at a single academic institution.Results: RNFL values were reduced in PPMS (94.3 μm), RRMS (99.6 μm), and SPMS eyes (84.7 μm) relative to CIS eyes (105.7 μm) (p < 0.0001). RNFL values were lower in eyes with recurrent ON (64.2 μm) relative to eyes affected by a single ON event (86.3 μm) (p < 0.0001). The strongest correlation between RNFL thickness and neurological disability occurred in RRMS patients (r = −0.51, p < 0.0001). RNFL thickness correlated with visual field sensitivity for CIS (r = 0.23, p < 0.01) and RRMS (r = 0.22, p < 0.01) patients. Simple linear regression showed that every 10 μm decrease in RNFL correlated with a 5.8 decibel decrease in visual field sensitivity (adjusted R² = 0.35, p < 0.0001) for RNFL values less than 75 μm.Conclusions: There were robust correlations between RNFL thickness and visual function, particularly in ON eyes. OCT may complement the existing tools used to characterize MS patients, but further studies are needed.     

Intravitreal ganciclovir in the management of non-AIDS-related human cytomegalovirus retinitis

Objective:To report and evaluate intravitreal ganciclovir injections in non-AIDS patients with human cytomegalovirus (HCMV) retinitis. Design: Retrospective chart review.Participants: Two SLE patients and one patient post chemotherapy for a non Hodgkin's lymphoma presented with myelosuppression and persistent cytomegalovirus retinitis despite systemic ganciclovir therapy.Methods: Patients were treated with 100 μL of intravitreal ganciclovir (4 mg/dL), initially given weekly. Systemic anti-CMV medication was stopped, and following quiescence, intravitreal injections were tapered and ultimately stopped based on therapeutic response. Patients were followed periodically for signs of recurrence.Results: Intravitreal ganciclovir was well tolerated and led to remission of the retinitis in 2 patients. One patient had persistent smouldering disease and reached quiescence using an intravitreal ganciclovir implant. Fluorescence-activated cell sorting analysis in one patient showed the presence of low CD4 and CD8 while treated with systemic ganciclovir, which improved with intravitreal treatment. In another, the low ratio was maintained against cytomegalovirus-specific antigens.Conclusions: Intravitreal ganciclovir injections should be considered as a treatment option in selected iatrogenically immunocompromised patients with HCMV retinitis. Responses may vary and will require an adjusted approach to treatment.     

Spectral-domain optical coherence tomography (SD-OCT) patterns and response to intravitreal bevacizumab therapy in macular edema associated with branch retinal vein occlusion

Background

To evaluate the baseline spectral-domain optical coherence tomography (SD-OCT) characteristics of macular edema (ME) due to branch retinal vein occlusion (BRVO) for visual outcome after intravitreal bevacizumab injection.

Methods

Fifty-nine patients treated in one eye with intravitreal bevacizumab for ME due to BRVO were retrospectively reviewed. Stepwise multiple regression analysis was used to evaluate the relative contribution of several variables, including SD-OCT characteristics such as photoreceptor inner segment/outer segment (IS/OS) integrity and external limiting membrane (ELM status), baseline best-corrected visual acuity (BCVA), and baseline central retinal thickness (CRT) with final visual outcome.

Results

Thirty-one patients (52.5 %) had disrupted photoreceptor IS/OS integrity. The mean BCVA improved significantly from 0.50 logMAR (20/63 Snellen equivalent) to 0.10 logMAR (20/25 Snellen equivalent) in the intact photoreceptor group (p?=?0.000, paired t-test). However, the mean BCVA was improved in the disrupted photoreceptor group, from 1.10 logMAR (20/252 Snellen equivalent) to 0.94 logMAR (20/174 Snellen equivalent), which was not statistically significant (p?=?0.177, paired t-test). ELM was disrupted in 23 patients (39.0 %). The mean BCVA improved significantly from 0.63 logMAR (20/85 Snellen equivalent) to 0.26 logMAR (20/36 Snellen equivalent) in the intact ELM group (p?=??0.000, paired t-test), however, not significantly improved in the disrupted ELM group, from 1.09 logMAR (20/246 Snellen equivalent) to 1.01 logMAR (20/205 Snellen equivalent) (p?=??0.563, paired t-test). The strongest individual predictor of final BCVA among patients with ME due to BRVO was the integrity of photoreceptor IS/OS layer on SD OCT (r ²?=?0.514, p?=?0.000, stepwise multiple regression), but the most efficient model was the combination of the photoreceptor IS/OS integrity, ELM status, and baseline BCVA (r ²?=?0.671, p?=?0.000, stepwise multiple regression). The strongest predictor of final BCVA was the status of photoreceptor IS/OS integrity (β?=?0.532, p?=?0.000, stepwise multiple regression), followed by ELM status (β?=?0.325, p?=?0.006, stepwise multiple regression), and the baseline BCVA (β?=?0.238, p?=?0.013, stepwise multiple regression).

Conclusion

Our results suggest that baseline SD-OCT characteristics, the status of photoreceptor IS/OS and ELM can be helpful in predicting the final visual outcome after intravitreal bevacizumab injection in these patients.     

Efficacy of combined intravitreal bevacizumab and triamcinolone for branch retinal vein occlusion

Purpose:

To evaluate the efficacy of combined treatment with intravitreal bevacizumab (IVB) and triamcinolone acetate (IVT) for patients with macular edema secondary to branch retinal vein occlusion (BRVO).

Materials and Methods:

Retrospective analysis of 20 eyes injected with 1.25 mg IVB and 2 mg IVT for clinically identified BRVO within 8 weeks of onset. All patients lacked concomitant ocular pathology and completed 6 months’ follow-up. Clinical examination including LogMAR visual acuity (VA) and central macular thickness (CMT) by spectralis optical coherence tomography (OCT) was performed preoperatively and at 1, 3 and 6 months post-operatively.

Results:

Mean patient age was 61.3 years with a mean BRVO diagnosis time of 3 weeks at presentation. VA improved from logMAR 1.08 preoperatively to Mean logMAR VA of 0.55 ± 0.17 at 1 month (P < 0.001), 0.56 ± 0.21 at 3 months (P < 0.001), and 0.38 ± 0.1 at 6 months (P < 0.001) Mean CMT improved from 482 ± 107 μm preoperatively to 319 ± 53 μm at 1 month (P < 0.001), 344 ± 89 μm at 3 months (P < 0.001), and 241 ± 29 μm at 6 months (P < 0.001). Mean IOP preoperatively was 16.5 mmHg, 21 mmHg at 1 month, and 15 mmHg at 6 months. Six out of 20 patients (30%) were re-injected with IVB and IVT at 3 months.

Conclusions:

Early combined treatment with IVB and IVT is effective in improving anatomic and functional outcomes in patients with macular edema secondary to BRVO.     

Recurrence of macular edema in retinal vein occlusions after treatment with intravitreal ranibizumab (Lucentis)

Objective

To evaluate the recurrence of macular edema (ME) in a mixed group of patients with branch (BRVO) and central (CRVO) retinal vein occlusion after early onset treatment with intravitreal injections of ranibizumab.

Design

Nonrandomized, uncontrolled prospective clinical trial.

Participants

Forty patients were enrolled in our study. Twenty-two patients had BRVO and 18 patients had CRVO.

Methods

All patients had a minimum follow-up of 12 months. All patients had fundus fluorescein angiography (FFA) and optical coherence tomography (OCT) at presentation. The time period between RVO occurrences and initial examination and treatment was <1 month. Every patient was treated with 2 consecutive intravitreal injections of ranibizumab (0.5 mg) 1 month apart. Assessment was carried out on a monthly basis and injection was carried out if necessary, based on OCT findings.

Results

Recurrence of ME occurred in 13 patients (13/22, 59%) in the BRVO group, whereas in the CRVO group occurred in all patients (18/18, 100%). Mean time interval of these recurrences from last injection was 2.4 months and 1.2 months for BRVO and CRVO groups, respectively. Mean period of ME reabsorption was 2.5 months for the BRVO group and 3.5 months for the CRVO group.

Conclusions

Recurrent ME occurred in 77.5% of our patients. These recurrences occurred sooner, were more prominent and lasted longer in patients with CRVO.