Pro Re Nata Intravitreal Bevacizumab for the Treatment of Idiopathic Choroidal Neovascular Membrane

Purpose: To study the efficacy of intravitreal bevacizumab on a pro re nata basis for treatment of idiopathic choroidal neovascular membrane. Material and methods: Thirty-seven eyes of 37 patients presenting with idiopathic choroidal neovascular membrane were included in the study. Intravitreal bevacizumab (1.25?mg/0.05?ml) was given on a pro re nata basis from the base line. Results: Twenty-one (58.3%) patients were male and 15 (41.7%) were female aged 13–49 years. Idiopathic choroidal neovascular membrane showed a classic leak on fluorescein angiogram in all the eyes. Subfoveal location (25; 67.6%) was the commonest site of involvement. Mean number of intravitreal bevacizumab injections required to achieve resolution was 2.81?±?1.4. At final follow-up, 31 (83.8%) eyes had maintained or improved vision (Group A) and six (16.2%) eyes had worsening of vision (Group B). There was no significant difference in mean age, gender, and mean number of injections between groups A and B. Conclusion: Intravitreal bevacizumab on a pro re nata basis is effective in the treatment of idiopathic choroidal neovascular membrane. A larger controlled study would be required to formulate an accurate injection protocol.     

Intravitreal Bevacizumab for Treatment of Bilateral Candida Chorioretinitis Complicated with Choroidal Neovascularization

ABSTRACT

Purpose: The purpose of this report is to describe a case of bilateral Candida chorioretinitis complicated with choroidal neovascularization (CNV) and effectively treated with combined intravitreal bevacizumab and amphotericin B.

Results: An 83-year-old patient was diagnosed with Candida chorioretinitis in both eyes. Optical coherence tomography and fluorescein angiography revealed CNV. Treatment using combined intravitreal bevacizumab and amphotericin B was initiated followed by a 4-weekly regimen of bevacizumab, eventually resulting in the regression of the subretinal fluid and intraretinal edema.

Conclusion: Our study supports the combined use of intravitreal bevacizumab and amphotericin B in the management of CNV in Candida chorioretinitis.     

Aflibercept Treatment for Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy Refractory to Anti-vascular Endothelial Growth Factor

Purpose

To report the results of switching treatment to vascular endothelial growth factor (VEGF) Trap-Eye (aflibercept) in neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to anti-VEGF (ranibizumab and bevacizumab).

Methods

This is a retrospective study involving 32 eyes from 29 patients; 18 were cases of neovascular AMD and 14 were cases of PCV. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) of spectral-domain optical coherence tomography were evaluated.

Results

BCVA and CMT improved from 0.58 to 0.55 (p = 0.005) and from 404 to 321 µm (p < 0.001), respectively, after switching to aflibercept. The 14 eyes that received 6 or more aflibercept injections remained stable at 0.81 to 0.81 and 321 to 327 µm (p = 1.0, 0.29), respectively, after 3 aflibercept injections. The 10 eyes that received 3 or more bevacizumab injections after 3 or more aflibercept injections worsened, from 0.44 to 0.47 and from 332 to 346 µm (p = 0.06, 0.05), respectively. The results showed similar improvement of BCVA and CMT in neovascular AMD and PCV.

Conclusions

Aflibercept seems to be effective for improvement and maintenance of BCVA and CMT for neovascular AMD and PCV refractory to anti-VEGF. Switching from aflibercept back to bevacizumab treatment may not be a proper strategy.     

Intravitreal Anti-vascular Endothelial Growth Factor for Newly Diagnosed Symptomatic Polypoidal Choroidal Vasculopathy with Extrafoveal Polyps

PurposeTo evaluate the 12-month outcome of anti-vascular endothelial growth factor (VEGF) treatment for extrafoveal polypoidal choroidal vasculopathy (PCV).MethodsThis retrospective observational study included 32 eyes of 32 patients newly diagnosed with extrafoveal PCV (polyps located more than 500 µm from the center of the fovea). Patients were treated with intravitreal ranibizumab, bevacizumab, or both. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at diagnosis and at 12 months were compared. Eyes were divided into two groups according to the presence of submacular hemorrhage. The BCVA in each group was compared at baseline and at 12 months.ResultsDuring the 12-month study period, patients received an average of 4.0 ± 1.1 anti-VEGF injections. The BCVA at baseline, three-month post-diagnosis, and 12-month post-diagnosis was 0.59 ± 0.40, 0.34 ± 0.38, and 0.38 ± 0.38, respectively. The BCVA at 12 months was significantly better than the baseline value (p = 0.002). The CFT at baseline, three-month, and 12-month post-diagnosis was 477.1 ± 194.2 µm, 214.5 ± 108.8 µm, and 229.8 ± 106.1 µm, respectively. The CFT at 12 months was significantly lower than the baseline value (p < 0.001). A significant improvement in BCVA was noted in eyes with and without submacular hemorrhage (n = 13, p = 0.032 and n = 19, p = 0.007, respectively).ConclusionsAnti-VEGF therapy was beneficial in extrafoveal PCV, regardless of the presence of submacular hemorrhage.     

Variation in Visual Outcome to Anti-Vascular Endothelial Growth Factors in Choroidal Neovascular Membrane Developing in Eyes with Previously Untreated Versus Focal Laser-Treated Central Serous Chorioretinopathy

Purpose: To report the visual outcome in choroidal neovascular membrane developing (CNVM) in eyes with central serous chorioretinopathy (CSCR) with our without prior focal laser. Methods: A retrospective case series of eyes with CNVM secondary to CSCR treated with intravitreal anti-VEGF. Results: Ten eyes of nine patients of CNVM with CSCR who underwent intravitreal anti-VEGF injections were analyzed. Five eyes had CNVM without prior laser photocoagulation, and five eyes developed CNVM after laser photocoagulation for CSCR. Intravitreal injection bevacizumab was given in five eyes and ranibizumab in five eyes. The lasered group had significantly shorter duration of the disease, fewer injections given, and better visual acuity at final follow-up (P <0.05). None had any recurrences of either CSCR or CNVM until the last follow-up. Conclusion: CNVM in CSCR with prior history of focal laser had better outcome than that developed de novo, without prior history of laser.     

Clinical Profile of Patients with Tubercular Subretinal Abscess in a Tertiary Eye Care Center in Southern India

Purpose: To retrospectively analyze clinical features, laboratory investigations, treatment and visual outcomes in patients with tubercular subretinal abscess.

Methods: A total of 12 eyes of 12 patients receiving a diagnosis of subretinal abscess, between 2004 and 2014, were included for this retrospective study.

Results: The mean age of the presentation was 29.75 ± 16.72 years (range: 14–62 years) and seven (58.3%) were male. The most common anterior segment presentation was anterior uveitis (75%). The mean BCVA at presentation was 1.62 (in logMAR). A tuberculin skin test was positive in seven patients (58.3%) and five patients had a history of pulmonary tuberculosis. Polymerase chain reaction for the Mycobacterium tuberculosis genome was positive in 6 of 11 eyes from aqueous aspirate (54%) and 4 of 7 eyes from vitreous aspirates (57.14%). All patients were started on systemic steroids and an anti-tubercular regimen. The mean duration of follow-up was 134.28 days. The mean BCVA at final presentation was 1.19 (in logMAR). Chorioretinal scar was the most common finding after resolution.

Conclusions: Subretinal abscess is a rare manifestation of ocular tuberculosis. A high degree of suspicion and timely management of the condition can prevent loss of vision.     

Surgical choroidal neovascular membrane removal in the era of anti-vascular endothelial growth factor agents

Intravitreal anti-vascular endothelial growth factor (VEGF) agents have obtained acceptance as the mainstay in the management strategy of subfoveal choroidal neovascular membranes (CNVM) due to varying etiologies. Few drawbacks include need for repeated intravitreal injections, with its adjunct risks, and the lack of a predefined treatment end point, which can cause doubts and uncertainty in the mind of the patient. Furthermore, it remains a significant financial burden for the patient.Herein we report our data of three patients who were reluctant for further re-injections of anti-VEGF agents and were therefore offered surgical removal of the CNVM by submacular surgery as an alternative treatment plan.     

玻璃体内注射康柏西普治疗湿性年龄相关性黄斑变性的临床观察

目的 观察玻璃体内注射康柏西普治疗湿性年龄相关性黄斑变性(age-related macular degeneration,AMD)的临床疗效及安全性.方法 回顾性临床研究.选择2014年3月至2016年3月在我院确诊为湿性AMD患者60例(60眼),给予玻璃体内注射康柏西普0.5 mg,随访6～12(8.5±2.4)个月.对比分析患者注射前和注射后1、2、3、6个月及末次随访的ETDRS视力、黄斑中心凹视网膜厚度(central macular thickness,CMT)及脉络膜新生血管(choroidal neovascularization,CNV)病灶渗漏变化情况.结果 康柏西普注射次数为1 ～5(2.80±0.89)次.首次注射后1、2、3、6个月及末次随访时,ETDRS视力较治疗前分别提高(14.76±5.89)、(19.88±7.13)、(24.75±6.74)、(23.94±6.15)、(22.89±8.53)个字母,差异均有统计学意义(均为P＜0.05);CMT较治疗前分别降低(70.19±60.56) μm、(82.07±57.97) μm、(95.40±87.92)μm、(97.57±46.68) μm、(107.46±56.82) μm,差异均有统计学意义(均为P＜0.05).首次注射前CNV渗漏面积为(12.32±5.67) mm2,与首次注射后3、6个月的CNV渗漏面积比较,差异有统计学意义(均为P＜0.05).注射后仅有4例出现球结膜下点片状出血,3例患者出现轻度眼压升高,均在治疗后1周复查恢复正常.随访期间未见眼部及全身严重不良反应发生.结论 玻璃体内注射康柏西普治疗湿性AMD可提高患眼视力,降低CMT,封闭CNV渗漏,无与治疗相关的严重副反应发生.     

孔源性视网膜脱离视网膜下液和前房液中VEGF及PDGF含量测定

目的研究血管内皮生长因子(vascular endothelialgrowth factor,VEGF)和血小板源性生长因子(platelet-derivedgrowthfactor,PDGF)在视网膜下液(subretinal fluid,SRF)和前房液(anterior chamber fluid,ACF)中的含量,并观察其对增生性玻璃体视网膜病变(proliferative vitreo-retinopathy,PVR)形成的影响。方法用ELISA测定63例孔源性视网膜脱离患者SRF和ACF的VEGF和PDGF的含量。结果孔源性视网膜脱离患者SRF和ACF中含有VEGF和PDGF;其含量随患者眼部病情的加重而增加;VEGF和PDGF含量在SRF中成相关关系,在ACF中亦成相关关系;同一患者的VEGF在SRF和ACF中成相关关系,PDGF亦是。结论VEGF和PDGF在PVR的发生发展过程中起了一定的作用,且VEGF和PDGF具有协同效应。     

Three Variants of or near VEGF-A Gene are Not Associated with Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy in a Han Chinese Population

Purpose: To investigate whether three previously identified variants for age-related macular degeneration (AMD), the single nucleotide polymorphism (SNP) variants of or near the vascular endothelial growth factor A gene (VEGFA), were associated with neovascular AMD or polypoidal choroidal vasculopathy (PCV) in a Han Chinese cohort.

Methods: This was a case-control study comprising 251 PCV patients, 157 neovascular AMD patients, and 204 control participants in a Han Chinese population. The rs833069, rs943080 and rs4711751 SNP were genotyped using the Multiplex SNaPshot system. Genotypes and allele frequencies of patients and controls were evaluated for the SNPs using PLINK software.

Results: None of the allelic or genotypic effects of these three variants was significantly associated with PCV, neovascular AMD or combined both patient categories.

Conclusions: No association was found to support the role for the rs833069, rs943080 and rs4711751 variants of or near VEGFA gene in susceptibility to either PCV or neovascular AMD in Han Chinese population. Further replication is necessary to validate these results.     

OCTA在脉络膜新生血管治疗效果评估中的作用

目的：采用光学相干断层扫描血管成像（OCTA）技术观察抗血管内皮生长因子（VEGF）治疗后脉络膜新生血管（CNV）的形态变化，并探讨OCTA在诊断该类疾病以及在判断预后方面的优势。方法：回顾性系列病例研究。收集2017年7月至2018年4月在青岛眼科医院就诊的CNV患者17例（17眼）。所有患者常规进行最佳矫正视力（BCVA）、频域相干光断层扫描（SD-OCT）以及OCTA等检查，对患眼行玻璃体腔注射抗VEGF药物（雷珠单抗或康博西普）0.05 ml，治疗后每个月随访1次，采用OCTA观察CNV在治疗前后的变化情况。采用配对t检验比较治疗前后BCVA和SD-OCT显示的黄斑中心凹视网膜厚度（CMT）的变化。结果：所有患者治疗前BCVA（LogMAR）为0.69±0.35，治疗后改善到0.49±0.38，差异有统计学意义（t=3.541，P=0.003）。CMT由治疗前的（363±66）μm下降到了治疗后的（302±66）μm，差异有统计学意义（t=4.227，P=0.001）。OCTA显示，抗VEGF治疗后所有患者CNV密度呈不同程度降低；部分患者CNV基本消失，神经上皮层脱离与水肿减轻甚至消失；部分患者虽仍存在粗大的异常血管，但神经上皮层脱离与水肿已完全消失。1例患者虽神经上皮层水肿消失，但仍存在边缘血管吻合，随访3个月复发。结论：OCTA能够清晰显示抗VEGF治疗后CNV的形态变化，可作为临床上CNV的诊断以及治疗效果评估的可靠工具。     

Intravitreal ranibizumab for the treatment of choroidal neovascularization secondary to ocular toxoplasmosis

The purpose of the study was to report a case of choroidal neovascularization (CNV) secondary to ocular toxoplasmosis in an 18-year-old female patient. She was treated with a single intravitreal injection of ranibizumab. The CNV resolved as confirmed by fluorescein angiography and optical coherence tomography (OCT). The visual acuity improved to 20/30, which was maintained till the last follow-up visit at two years, without requisition of a repeat injection.     

血清和视网膜下液中氨基酸和VEGF表达水平与孔源性视网膜脱离程度的关系

目的：分析血清和视网膜下液中氨基酸和血管内皮生长因子（vascular endothelial growth factor ,VEGF）表达水平与研究孔源性视网膜脱离程度关系。方法：选取本院诊断治疗的孔源性视网膜脱离患者48例52眼,根据视网膜脱落范围分＜1／2象限组,1／2～3／4象限组和＞3／4象限组,选取同期在我院健康体检者55例55眼作为对照组,比较孔源性视网膜脱离患者与对照组的血清中氨基酸和VEGF水平的差异。比较孔源性视网膜脱离患者不同脱离程度视网膜下液中氨基酸以及VEGF水平的差异。视网膜下液中 VEGF 水平与氨基酸的相关分析。结果：孔源性视网膜脱离患者血清中色氨酸28．59±4.46 mg／L、苯丙氨酸8．95±2．55 mg／L、蛋氨酸8．15±2.17 mg／L、缬氨酸28．62±5．29 mg／L、组氨酸18．96±1.85 mg／L以及血管内皮生长因子589．92±185．34μg／L高于对照组,且差异有统计学意义（P＜0．05）;孔源性视网膜脱离患者脱离程度＞3／4象限者视网膜下液的苯丙氨酸9.85±1．21 mg／L、组氨酸20．63±2．07、血管内皮生长因子718．69±283．34μg／L高于＜1／2象限者和1／2～3／4象限者,且差异具有统计学意义（P＜0．05）。孔源性视网膜脱离患者视网膜下液 VEGF 与苯丙氨酸呈正相关（ r＝0.542,P＜0．001）,与组氨酸呈正相关（ r＝0．782, P＜0.001）。结论：孔源性视网膜脱离患者的视网膜下液中氨基酸和VEGF的表达高于正常对照组,且随脱离程度的增加而上升。     

Changes in Fundus Autofluorescence after Anti-vascular Endothelial Growth Factor According to the Type of Choroidal Neovascularization in Age-related Macular Degeneration

Purpose

To describe the changes of fundus autofluorescence (FAF) in patients with age-related macular degeneration before and after intravitreal injection of anti-vascular endothelial growth factor according to the type of choroidal neovascularization (CNV) and to evaluate the correlation of FAF with spectral domain optical coherence tomography (SD-OCT) parameters and vision.

Methods

This was a retrospective study. Twenty-one treatment-naïve patients with neovascular age-related macular degeneration were included. Study eyes were divided into two groups according to the type of CNV. Fourteen eyes were type 1 CNV and seven eyes were type 2 CNV. All eyes underwent a complete ophthalmologic examination, including an assessment of best-corrected visual acuity, SD-OCT, fluorescein angiography, and FAF imaging, before and 3 months after intravitreal anti-vascular endothelial growth factor injection. Gray scales of FAF image for CNV areas, delineated as in fluorescein angiography, were analyzed using the ImageJ program, which were adjusted by comparison with normal background areas. Correlation of changes in FAF with changes in SD-OCT parameters, including CNV thickness, photoreceptor inner and outer segment junction disruption length, external limiting membrane disruption length, central macular thickness, subretinal fluid, and intraretinal fluid were analyzed.

Results

Eyes with both type 1 and type 2 CNV showed reduced FAF before treatment. The mean gray scales (%) of type 1 and type 2 CNV were 52.20% and 42.55%, respectively. The background values were 106.72 and 96.86. After treatment, the mean gray scales (%) of type 1 CNV and type 2 CNV were changed to 57.61% (p = 0.005) and 57.93% (p = 0.008), respectively. After treatment, CNV thickness, central macular thickness, and inner and outer segment junction disruption length were decreased while FAF increased.

Conclusions

FAF was noted to be reduced in eyes with newly diagnosed wet age-related macular degeneration, but increased after anti-vascular endothelial growth factor therapy regardless of CNV lesion type.     

Complications of Subspecialty Ophthalmic Care: Systemic Complications from the Intravitreal Administration of Agents that Target the Vascular Endothelial Growth Factor Pathway

Abstract

The treatment of neovascular age-related macular degeneration (AMD) and other pathologic ocular conditions that overexpress the vascular endothelial growth factor (VEGF) has been revolutionized in the last decade by the introduction of intravitreal agents that target the VEGF pathway. Since treatment trials are designed primarily to assess the prevention of vision loss caused by ocular conditions, they are inadequate for detecting rare, but potentially serious, systemic side effects. The aim of this article is to present what the ophthalmologist needs to know about systemic complications from anti-VEGF therapy and review the likelihood that these side effects occur in the context of small, but often-repeated, intravitreal doses of these potent biological medications. Preferred practice patterns need to be developed that weigh the ability of these medications to mitigate potentially blinding conditions, while at the same time minimizing the risk of adverse outcomes in specific patient populations that possess multiple and often interrelated medical comorbidities.     

Intravitreal Bevacizumab and Ranibizumab in the Treatment of Acute Central Serous Chorioretihopathy: A Single Center Retrospective Study

Objectives: To evaluate and compare the anatomical and functional outcomes of patients with acute central serous chorioretinopathy (CSC) who did not receive any intervention or treatment with intravitreal bevacizumab or ranibizumab. Methods: A single-center retrospective comparative study. Seventy eyes of 70 patients were recruited for the study; 27 patients were only observed without any medication or intervention (observation group), 23 were treated with intravitreal bevacizumab (IVB group), and the remaining 20 were treated with intavitreal ranibizumab (IVR group). The best-corrected visual acuity (BCVA) and central macular thickness (CMT) obtained by spectral-domain optical coherence tomography were compared between the groups. Results: There were no significant differences between the groups with regard to age, sex, and follow-up periods (p>0.05). The mean time from baseline to initial complete resolution of subretinal fluid was 3.52±1.64 months in the observation group, 1.19±0.60 months in the IVB group, and 1.11±0.47 months in the IVR group; the resolution time was significantly longer in the observation group (p<0.001). While the CMT was significantly thicker in the observation group when compared to the IVB and IVR groups in the first month (p=0.001), it was similar between the groups in the third, sixth, and twelfth months (p>0.05). Additionally, pairwise comparisons of the IVB and IVR groups revealed that there were no significant differences between these groups regarding CMT at any follow-up time (p>0.05). Conclusions: Compared with observation alone, neither IVB nor IVR had a positive effect in terms of anatomical and functional outcomes for acute CSC. Although the resolution time of SRF is shorter by using ranibizumab, both the ranibizumab and bevacizumab could be effective in achieving rapid resolution of serous detachment in patients with acute CSC.     

Spectrum of Choroidal Involvement in Presumed Ocular Tuberculosis: Report from a Population with Low Endemic Setting for Tuberculosis

Objective: To describe the clinical spectrum and outcome of patients with presumed tubercular uveitis and choroidal involvement.

Methods: A retrospective case series nested in a cohort study was enrolled at a tertiary referral eye care center in the UK. Failure was defined as recurrence of lesion within 6 months of completion of antitubercular therapy (ATT) or corticosteroid therapy.

Results: Seventy-seven patients with presumed ocular tuberculosis and choroidal involvement were included in the study. Mean age was 45.5 ± 15.7 years, 44 (57.1%) patients were male, and 51 (66.2%) presented with bilateral disease. Choroidal granuloma was the most frequent clinical presentation (n = 27, 35.07%), followed by multifocal choroiditis (n = 24, 31.17%) and serpiginous-like choroiditis (n = 18, 23.38%). Quantiferon Gold in Tube Test (QFT) was positive in 64 (83.11%) patients. Fifty (64.94%) patients received ATT.

Conclusions: Choroidal involvement in presumed ocular tuberculosis can present with a variable spectrum. Treatment failure rates were equivalent between ATT and non-ATT treated groups.     

阿柏西普经玻璃体内注射治疗糖尿病黄斑水肿的临床疗效

目的　探讨阿柏西普经玻璃体内注射治疗糖尿病黄斑水肿的临床疗效。方法　选取2018年6月至7月来我院眼科就诊的糖尿病黄斑水肿患者15例15眼，通过玻璃体内注射阿柏西普进行治疗。注射前和注射后1个月、2个月门诊复查时，分别检查患者最佳矫正视力（best corrected vision acuity，BCVA）和眼压，并行黄斑区光学相干断层成像，记录黄斑中心凹视网膜厚度（central foveal thickness，CFT）等。结果　患者术前BCVA为0.31±0.12；阿柏西普玻璃体内注射术后1个月BCVA为0.44±0.12，和术前相比差异有统计学意义（P=0.009）；术后2个月BCVA为0.53±0.13，和术前相比差异亦有统计学意义（P<0.001）。但术后两组数据之间差异无统计学意义（P=0.132）。黄斑区光学相干断层成像检查显示，术前CFT为（354.30±89.52）μm；阿柏西普玻璃体内注射术后1个月CFT为（233.10±49.54）μm，显著低于术前，差异有统计学意义（P<0.001）；术后2个月CFT为（198.60±41.88）μm，显著低于术前，差异亦有统计学意义（P<0.001）。术后2个月CFT显著低于术后1个月，差异有统计学意义（P=0.038）。术后1个月、2个月间患者眼压以及与术前相比，差异均无统计学意义（均为P>0.05）。结论　经玻璃体内注射阿柏西普可有效减轻糖尿病黄斑水肿病变程度，提高视力。