Choroidal Neovascularization Associated with Punctate Inner Choroidopathy: Combination of Intravitreal Anti-VEGF and Systemic Immunosuppressive Therapy

Purpose

Choroidal neovascularization (CNV) associated with punctate inner choroidopathy (PIC) is a rare clinical entity, yet still a challenge for medical treatment. A case of a young myopic woman developing CNV secondary to unilateral PIC is presented. Clinical morphology, diagnostic procedure and follow-up are reported.

Case Report

A 29-year-old woman presented with multiple yellowish dots at the posterior pole. No other signs of inflammation could be seen. Angiography with fluorescein yielded hyperfluorescent signals in the affected areas with a diffuse leak, and SD-OCT showed a slightly elevated retinal pigment epithelial layer, consistent with the diagnosis of PIC. Additionally a classic CNV was observed.

Results

Anti-inflammatory therapy with local prednisolone acetate eye drops in combination with intravitreal injection of anti-vascular endothelial growth factor (VEGF, bevacizumab) yielded an increased best-corrected visual acuity. As CNV reappeared, systemic medication with prednisone and azathioprine in combination with two further intravitreal injections of anti-VEGF stabilized CNV and increased visual acuity again.

Conclusion

Combined therapy of immunosuppression with intravitreal anti-VEGF injections can be considered as therapeutic strategy in the management of recurrent CNV associated with PIC.Key Words: Punctate inner choroidopathy, Choroidal neovascularization, Intravitreal anti-VEGF therapy, Choroiditis     

Long-term outcome of intravitreal anti-vascular endothelial growth factor therapy with bevacizumab or ranibizumab as primary treatment for subfoveal myopic choroidal neovascularization

Purpose

To evaluate the long-term efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy as primary treatment for subfoveal myopic choroidal neovascularization (CNV).

Methods

In all, 37 treatment-naïve eyes of 37 patients with subfoveal myopic CNV who received intravitreal bevacizumab (n=22) or ranibizumab (n=15) injections with at least 2 years of follow-up were reviewed. All eyes received initial three loading doses of anti-VEGF at monthly intervals and retreatment was performed in persistent or recurrent CNV. Multivariate regression analyses were performed to determine the prognostic factors for visual outcome.

Results

The mean age was 57.3 years and the mean refractive error was −11.7 D. For all eyes, the mean logMAR best-corrected visual acuity improved from 0.86 (20/145) at baseline to 0.48 (20/60) at 2 years (P<0.001). The mean visual improvement for the bevacizumab and ranibizumab groups at 2 years was 2.8 and 5.1 lines, respectively (P=0.073). There was no significant difference in the proportion of eyes having visual gain of three or more lines or visual loss of three or more lines between the two groups. The mean number of injections was 3.8 for both bevacizumab and ranibizumab groups. Multivariate analyses showed that eyes with higher myopic refractive error were less likely to have visual gain after treatment (P=0.043), while size of CNV was negatively correlated with mean change in vision (P=0.046).

Conclusions

Intravitreal anti-VEGF therapy resulted in long-term visual improvement in myopic CNV. The treatment efficacy in terms of visual gain and number of retreatment appeared to be similar between bevacizumab and ranibizumab.     

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.     

Factors affecting visual outcome of myopic choroidal neovascularization treated with verteporfin photodynamic therapy

AIM: To evaluate the visual outcomes of choroidal neovascularization (CNV) secondary to pathological myopia and the impact of novel risk factors affecting the final visual outcome.METHODS:Interventional case series of 18 consecutive patients with pathological myopia treated with photodynamic therapy (PDT). Inclusion criteria were spherical equivalent -6D or worse or features of pathological myopia on retinal examination. The main outcome measure was final best-corrected visual acuity (BCVA).RESULTS:Of 18 eyes, 13 (72.2%) avoided moderate visual loss (≥3 lines of LogMAR BCVA) and 5 eyes (27.8%) improved by at least 1 line after 1 year. Patients with LogMAR BCVA ≤0.3 (Snellen equivalent 20/40) at one year were younger than those with BCVA >0.3 (mean age 39.0 vs 61.6 years, P=0.001). A higher proportion of eyes with greatest linear dimension (GLD) of ≤1000µm avoided moderate visual loss (100% vs 50%, P=0.026). Among patients who were treated within 2 weeks of visual symptoms, 88.9% avoided the loss of 3 or more lines compared to 55.6% for those who presented later. The mean improvement in LogMAR BCVA of those with GLD ≤1000µm was +0.12 compared to a loss of 0.55 LogMAR units for those with GLD >1000µm (P=0.02). Visual outcomes were not associated with gender or refractive error.CONCLUSION: Good visual outcome in myopic CNV is associated with younger age, smaller lesion size and earlier initiation of treatment. These factors are relevant for ophthalmologists considering treatment options for myopic CNV.     

Intravitreal ranibizumab for the treatment of choroidal neovascularisation secondary to angioid streaks

Aims

To assess the medium to long-term efficacy and safety of intravitreal ranibizumab for the treatment of choroidal neovascularisation (CNV) secondary to angioid streaks (AS).

Methods

A total of 12 eyes of nine patients treated with intravitreal ranibizumab (0.5 mg in 0.05 ml) for CNV secondary to AS were retrospectively identified. Efficacy of treatment was determined by changes in best-corrected LogMAR visual acuity (BCVA) and optical coherence tomography. Changes with respect to baseline BCVA were defined as improved or reduced with a gain or loss of more than 10 letters, respectively, or stable if remaining within 10 letters.

Results

Over a mean follow-up of 21.75 months (range: 1–54), patients received mean 5.75 (range: 2–15) intravitreal ranibizumab injections per affected eye. BCVA improved in three eyes (25%), stabilised in eight eyes (66.67%), and deteriorated in one eye (8.33%). There was no significant change in central retinal thickness (CRT) over the follow-up period (P=0.1072). No drug-related systemic side effects were recorded.

Conclusion

The long-term treatment of CNV secondary to AS with intravitreal ranibizumab showed a stabilisation in CRT and an improvement or stabilisation of BCVA. The absence of systemic side effects was reassuring. Further long-term prospective studies are required to validate these findings.     

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

Aims

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

Methods

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24–78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least −6 dioptres.Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

Results

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

Conclusions

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.     

Spectral-domain OCT in anti-VEGF treatment of myopic choroidal neovascularization

Purpose

To evaluate changes in macular morphology due to myopic choroidal neovascularization (CNV), using spectral-domain optical coherence tomography (SD-OCT).

Methods

In all, 22 eyes with recent-onset untreated CNV underwent 1 intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), followed by a pro-re-nata regimen. SD-OCT was performed at baseline (before first administration of anti-VEGF treatment) and month 1, and 2; macular morphologic changes and outer retina characteristics (SD-OCT findings) associated with CNV activity were evaluated. Sensitivity and specificity were calculated for SD-OCT findings using fluorescein angiography (FA) as standard reference.

Results

Mean central retinal thickness (CRT) showed no significant reduction from baseline (284±98 μm) to month 1 (257±74 μm) and month 2 (263±72 μm). A hyper-reflective lesion with fuzzy borders (fuzzy area), and ‘absent or altered'' IS/OS junction were the only SD-OCT findings associated with CNV activity (P<0.0001). Both these SD-OCT findings showed good sensitivity and specificity (95.1 and 96.0% (95% CI: 0.87–0.89), respectively, for the fuzzy area; 87.9 and 66.7% (95% CI: 0.65–0.87), respectively, for ‘absent or altered'' IS/OS junction) when compared with FA leakage (standard reference).

Conclusions

Outer retina characteristics (ie, hyper-reflective lesion with fuzzy borders, and ‘absent or altered'' IS/OS junction) appear more meaningful than CRT in the evaluation of myopic CNV activity. These SD-OCT findings show overall good sensitivity and specificity when compared with FA leakage (standard reference), and could be considered as an alternative diagnostic tool to FA for myopic CNV monitoring.     

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.     

Summary of prognostic factors for choroidal neovascularization due to pathological myopia treated by intravitreal bevacizumab injection

Aim

This systematic review assesses the prognostic factors for intravitreal bevacizumab injection (IVB) in the treatment of choroidal neovascularization (CNV) due to pathological myopia.

Methods

The literature searches were performed in Ovid Medline, EMBASE and CENTRAL. Relevant studies with prognostic data on best corrected vision acuity (BCVA) after intravitreal bevacizumab injection were included for review. Two reviewers participated in the data retrieval and independently assessed each included study.

Results

A total 252 articles were retrieved, including 16 studies containing the most updated and complete data on prognostic factors for neovascularization due to pathological myopia treated by intravitreal bevacizumab injection. A great number of quantitative, clinical, and treatment-related factors were determined to have a positive influence on vision outcome after intravitreal bevacizumab.

Conclusion

A lower rate of development of chorioretinal atrophy, smaller pretreatment CNV size, and younger age were indentified as the most consistently significant prognostic factors affecting the efficacy of IVB in eyes of myopic CNV and were associated with improved BCVA. A worse BCVA after IVB in eyes with myopic CNV probably was associated with subfoveal CNV, lower baseline BCVA, longer duration of CNV, incomplete regression of CNV, subretinal hemorrhage, and previous PDT treatment. No apparent association were observed between the refraction error, axial length, lens status and change in BCVA after IVB. We indentified significant prognostic factors in this systematic review study that might allow for the selection of patients with myopic CNV which are most likely to benefit from IVB.     

Prognostic factors for visual outcomes 2-years after intravitreal bevacizumab for myopic choroidal neovascularization

Purpose

To determine the pre-treatment ocular factors significantly associated with the visual outcome 24 months after intravitreal bevacizumab (IVB) for myopic choroidal neovascularization (mCNV).

Methods

A total of 23 eyes of 23 patients with mCNV were treated with IVB followed by as needed therapy. The efficacy of IVB was evaluated by the best-corrected visual acuity (BCVA) at 24 months after the initial treatment. Forward stepwise multiple linear regression analyses were performed to evaluate the influence of pre-treatment factors on the BCVA and the improvement of the BCVA at 24 months.

Results

The mean pre-IVB BCVA was 0.74±0.30 logarithm of the minimum angle of resolution (logMAR) units, and it improved to 0.43±0.31 logMAR units after 1 month (P<0.001, paired t-test). The improvement was maintained at 24 months (0.46±0.40, P<0.005). The mean number of IVB performed during the 24 months was 1.35±0.71. Forward stepwise regression analysis showed that the pre-IVB CNV size (standardized β=0.52, P<0.01) and BCVA (standardized β=−0.44, P<0.05) significantly affected the visual acuity change after 24 months. The CNV size was the only factor that significantly affected the BCVA after 24 months (standardized β=0.56, P<0.01).

Conclusions

IVB with as needed therapy for mCNV led to a rapid and sustained visual improvement. Smaller CNV size was a significant prognostic factor that predicts better visual acuity. Patients with lower pre-treatment BCVA had better visual recovery than those with better pre-treatment BCVA, however, this may be due to a ceiling/floor effect.     

Low-fluence photodynamic therapy combinations in the treatment of exudative age-related macular degeneration

AIM: To compare the efficacy of low-fluence photodynamic therapy (PDT) combinations in the treatment of age-related macular degeneration (AMD). METHODS: Forty-five previously untreated eyes of 45 patients with exudative AMD whose best-corrected visual acuity (BCVA) was ≥0.3 (Snellen) were enrolled. 15 patients in Group I underwent low-fluence PDT (25J/cm2-300mW/cm2-83sec) and intravitreal pegaptanib combination, 15 patients in Group II underwent PDT (50J/cm2-600mW/cm2-83sec) and intravitreal pegaptanib combination while, 15 patients in Group III underwent intravitreal pegaptanib monotherapy. Complete ophthalmologic examinations were performed in pre and post treatment visits, and the results were statistically analised. A clinical activity score (CAS) was calculated by using changes in lesion size, amount of hemorrhage, staining pattern in FA and OCT measurement of intra/subretinal fluid. ≤ 3 logMAR lines of decrease in BCVA and decrease in CAS were considered as successful treatment. RESULTS: The mean age of 19 female (42.2%) and 26 male (57.8%) patients was 72.82±8.02 years. Mean follow-up was 13.93±5.87 months. Lesion type was occult in 28 eyes (62.2%). Treatment success rates according to BCVA assessments were 86.7%, 80%, 60% and mean BCVA decrease were 0.3, 1.0, 2.2 logMAR lines in Group I, II and III, respectively (P>0.05). According to the changes in central macular thickness and CAS, no difference was found among the study groups (P=0.850 and P=0.811, respectively). Patients treated with combination regimens had lower intravitreal injection frequencies (P=0.015). CONCLUSION: Combination regimen with intravitreal pegaptanib and low-fluence PDT seems to be safe and effective in stabilizing the clinical activity and BCVA in exudative AMD.     

Macular atrophy after combined intravitreal triamcinolone and photodynamic therapy to treat choroidal neovascularization

AIM: To report the appearance of choriocapillaris atrophy after combined high dose intravitreal triamcinolone acetonide (TA) and photodynamic therapy (PDT) to treat choroidal neovascularization (CNV) associated with age related macular degeneration (AMD). METHODS: The present study was retrospective about non-randomized interventional case series. Fifty-one consecutive eyes with subfoveal (all types) CNV associated with AMD were treated by PDT and intravitreal (19.4±2.1)mg per 0.1mL TA at the Alicante Institute of Ophthalmology. The appearance of macular choriocapillaris and retinal pigment epithelium (RPE) atrophy was considered at two years follow-up. Thirty consecutive eyes treated by PDT alone, matched for age, sex, and type and size of CNV were considered as control group. RESULTS: Twenty-one of 47 eyes in the study group (45%) and 7 of 30 eyes in the control group (23%) developed macular RPE and choriocapillaris atrophy in the treated area at month 24 (P=0.04, Chi-square test). The greatest diameter of the atrophic areas averaged (5044±1666)μm in the study group vs (4345±1550)μm in the control group. Mean final best corrected visual acuity (logarithm of minimal angle of resolution) was (0.87±0.33) in the cases with RPE atrophy vs (0.66±0.26) in the cases with no RPE atrophy in the study group (P=0.11, Mann-Whitney U test). CONCLUSION: The association of high doses of intravitreal TA and PDT may increase the risk for RPE and choriocapillaris atrophy.     

The analysis of lacquer crack in the assessment of myopic choroidal neovascularization

Objective

The aim of this study was to clarify the characteristic findings in myopic choroidal neovascularization (CNV) and the relationship with lacquer crack (LC).

Methods

In all, 66 consecutive myopic CNV patients treated with photodynamic therapy and/or intravitreal anti-vascular endothelial growth factor injection in one eye were reviewed. Data from fluorescein angiography (FA) and indocyanine green angiography (ICGA), obtained simultaneously using the Heidelberg retina angiograph 2 (HRA2), were analyzed.

Results

LCs were associated with a relatively large extent (≥3000 μm) of peripapillary choroidal atrophy and a dark rim, the proliferation of retinal pigment epithelial cells surrounding the neovascular membrane was accompanied by a small extent. Myopic CNV usually developed in the LC area surrounded by tiny crack fragments. In all, 35 patients with LCs received FA and ICGA at least twice during follow-up. LC progression was observed in nine (25.7%) treated eyes and six (23.1%) non-CNV fellow eyes. Crack fragments progressed in three distinct forms such as elongation, branching, or bridging pattern. Newly diagnosed myopic CNV was reported in 18 treated eyes and 3 fellow eyes. Progression of LCs and development of CNV occurred simultaneously in eight eyes. By multivariate Cox''s regression, a statistically significant association was observed between recurrence of myopic CNV and the absence of a dark rim on ICGA.

Conclusions

The HRA2 instrument affords detailed high-resolution images of FA and ICGA. Notably, recurrence of myopic CNV developed in areas surrounded by new small crack fragments and LCs are considered to be important in the development of myopic CNV.     

Anti-VEGF-refractory Exudative Age-related Macular Degeneration: Differential Response According to Features on Optical Coherence Tomography

Purpose

To describe optical coherence tomography (OCT) characteristics of neovascular age-related macular degeneration (AMD) patients refractory to intravitreal anti-vascular endothelial growth factor (VEGF) injections (ranibizumab, bevacizumab) and their responses to alternative anti-VEGF agents or photodynamic therapy (PDT).

Methods

A retrospective review of 267 neovascular AMD patients treated with intravitreal anti-VEGF injections.

Results

Twenty patients (7.5%) were refractory to anti-VEGF injections (stationary or increased retinal exudation despite three or more monthly injections). They were grouped into either the extensive intraretinal fluid group (IRF group, 9 patients) or the subretinal fluid only group (SRF group, 11 patients) according to OCT findings. In the IRF group, response rates to subsequent treatment were 0% (0 / 7) for bevacizumab, 50% (3 / 6) for ranibizumab and 50% (3 / 6) for PDT ± anti-VEGF. Three out of four bevacizumab-refractory patients showed response to ranibizumab as a secondary treatment. In the SRF group, response rates were lower with 0% (0 / 7) for bevacizumab, 22.2% (2 / 9) for ranibizumab and 28.6% (2 / 7) for PDT ± anti-VEGF. One out of four bevacizumab-refractory patients responded to ranibizumab. The visual outcome was worse in the IRF group (median 20 / 1,000) than in the SRF group (median 20 / 100).

Conclusions

In anti-VEGF-refractory neovascular AMD, patients with extensive IRF refractory to bevacizumab can be responsive to ranibizumab while patients with SRF may be refractory to both, suggesting a different pathophysiology and intraocular pharmacokinetics.     

Choroidal Neovascularization Regression on Fluorescein Angiography after VEGF Blockade

Background

Intravitreal vascular endothelial growth factor (VEGF) inhibitors stabilize vision in a majority of patients with neovascular age-related macular degeneration (AMD) and can improve vision in almost 40% of patients. However, some individuals who respond to anti-VEGF treatment still lose vision due to the formation of geographic atrophy (GA). While optical coherence tomography is often the primary imaging modality used, fluorescein angiography (FA) can provide useful information on GA development after choroidal neovascularization (CNV) regression.

Methods

A retrospective chart review was conducted to evaluate the changes seen on FA over a 47-month period for 3 patients with neovascular AMD treated with anti-VEGF inhibitors.

Results

All 3 patients were initially noted to have subfoveal CNV due to AMD at baseline; they were followed up monthly and treated on an as needed basis for at least 47 months with intravitreal VEGF inhibitors. All subjects had regression of their CNV lesions after VEGF blockade. Two subjects developed foveal atrophy.

Conclusions

This case series depicts the changes on FA seen over a 4-year period and shows that GA can occur with regression of CNV after treatment with VEGF inhibitors.Key words: Choroidal neovascularization, Fluorescein angiography, Age-related maculopathies     

Intravitreal Anti-vascular Endothelial Growth Factor versus Observation in Acute Central Serous Chorioretinopathy: One-year Results

Purpose

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) compared with observation for treating acute central serous chorioretinopathy (CSC).

Methods

A retrospective study of 36 patients with acute CSC, including 21 patients treated with anti-VEGF (anti-VEGF group) and 15 patients with observation (observation group). Patients in the anti-VEGF group received a single dose of bevacizumab or ranibizumab at baseline. Best-corrected visual acuity (BCVA), central foveal thickness (CFT) and resolution of subretinal fluid (SRF) on optical coherence tomography (OCT) were assessed. The integrity of the foveal inner segment/outer segment (IS/OS) line at 12 months was also analyzed.

Results

Resolution of SRF was achieved in 20 of 21 eyes in the anti-VEGF group and in 12 of 15 eyes in the observation group (p = 0.151). Mean BCVA and CFT were not different between the two groups at 12 months (p > 0.05). The amount of change in BCVA, however, differed significantly between the groups (p = 0.044). Final OCT more frequently detected the foveal IS/OS line in the anti-VEGF group than in the observation group (p = 0.012).

Conclusions

In terms of BCVA, anti-VEGF and observation only had similar therapeutic effects in acute CSC patients. In some patients, however, the rapid resolution of SRF by anti-VEGF might reduce the risk of photoreceptor degeneration and improve long-term visual acuity.     

Blockade of Tumor Necrosis Factor-Alpha: A Role for Adalimumab in Neovascular Age-Related Macular Degeneration Refractory to Anti-Angiogenesis Therapy?

Aims

To report a case of wet age-related macular degeneration (wet-AMD) refractory to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy in a patient who showed visual and anatomical improvement and stabilization after starting a subcutaneous treatment course with adalimumab, an anti-tumor necrosis factor-alpha (TNF-α) drug, for concomitant Crohn''s disease.

Methods

Observational case report of a female patient. Ophthalmological evaluation was performed by slit lamp and ophthalmoscopy (posterior pole and anterior segment). Best-corrected visual acuity (BCVA) was determined, and imaging was performed by fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT). Intravitreal therapies used and treatment with anti-TNF-α were recorded.

Results

A 64-year-old woman with wet-AMD was treated with fourteen intravitreal injections of ranibizumab (0.5 mg) for a period of 40 months with intervals of 1–6 months. She initially showed a good visual and anatomical response to periodic anti-VEGF treatment but during check visits, anatomical and functional responses deteriorated. At the 40-month follow-up, the patient had developed Crohn''s disease, and her rheumatologist started treatment with adalimumab (40 mg subcutaneously every 2 weeks). During the 25 months of treatment with adalimumab, the patient did not require any additional intravitreal anti-VEGF treatments because her BCVA, clinical, and OCT findings improved and remained stable.

Conclusions

We described a case of a patient with wet-AMD refractory to anti-VEGF therapy, which clinically benefited from subcutaneous adalimumab therapy. Treatment with subcutaneous anti-TNF-α in combination with anti-VEGF therapy avoids the high cost and risks related to multiple intravitreal anti-VEGF injections with good functional and anatomic outcomes.Key Words: Anti-vascular endothelial growth factor, Tumor necrosis factor-alpha inhibitors, Wet age-related macular degeneration     

Multifocal electroretinogram findings after intravitreal bevacizumab injection in choroidal neovascularization of age-related macular degeneration

Purpose

To evaluate the changes in multifocal electroretinogram (mfERG) and optical coherence tomography (OCT) after intravitreal bevacizumab injection in the treatment of age-related macular degeneration (AMD).

Methods

Twenty-one eyes with choroidal neovascularization secondary to AMD were studied before and after intravitreal bevacizumab injection for best corrected visual acuity (BCVA), OCT, and mfERG.

Results

The BCVA improved, while central macular thickness and total macular volume in OCT decreased after intravitreal bevacizumab injection (p = 0.03, 0.01, and 0.01, respectively). In mfERG, the amplitude of P1, and implicit time of P1 and N1 indicated a statistically significant improvement of retinal response after intravitreal bevacizumab injection.

Conclusions

There is a potential role for mfERG in evaluating the effect on retinal function of intravitreal bevacizumab injection.     

Bilateral Hypertensive Retinopathy Complicated with Retinal Neovascularization: Panretinal Photocoagulation or Intravitreal Anti-VEGF Treatment?

Purpose

To present the case of a patient with bilateral hypertensive retinopathy complicated with retinal neovascularization who received anti-VEGF intravitreal injection in one eye and panretinal photocoagulation (PRP) in the fellow eye.

Methods

A 33-year-old male patient presented with gradual visual loss in both eyes for the last 5 months. At that time, he was examined by an ophthalmologist and occlusive retinopathy due to malignant systematic hypertension was diagnosed. He was put on antihypertensive treatment but no ophthalmic treatment was undertaken. At presentation, 5 months later, best-corrected visual acuity (BCVA) was 0.1 in the right eye (RE) and 0.9 in the left eye (LE). Fundus examination was compatible with hypertensive retinopathy complicated with retinal neovascularization. Fluorescein angiography (FFA) revealed macular ischemia mainly in the RE and large areas of peripheral retinal ischemia and neovascularization with vascular leakage in both eyes. The patient was treated with two anti-VEGF (ranibizumab) injections with 2 months interval in the RE and PRP laser in the LE.

Results

Follow-up examination after 12 months showed mild improvement in BCVA, and FFA documented regression of retinal neovascularization in both eyes.

Conclusion

Hypertensive retinopathy can be rarely complicated with retinal neovascularization. Treatment with PRP can be undertaken. In our case, the use of an intravitreal anti-VEGF agent seemed to halt its progression satisfactorily.Key words: Hypertensive retinopathy, Retinal neovascularization, Panretinal photocoagulation, Anti-VEGF