Macular thickness mapping in exudative age-related macular degeneration

PURPOSE: To report the feasibility of retinal thickness mapping for evaluating thickness differences in retinal areas with and without leakage shown by fluorescein angiography for patients who have age-related macular degeneration with choroidal neovascularization. METHODS: A custom-built version of the retinal thickness analyzer was used for thickness mapping. Retinal thickness was defined as the separation between vitreoretinal and pigment epithelium-choroid interfaces. Imaging was performed in 1 eye of 10 patients with the clinical diagnoses of age-related macular degeneration and choroidal neovascularization. Patients either had never undergone photodynamic therapy at the time of measurement (untreated) or had received one or more photodynamic therapy treatments (treated). Average retinal thicknesses in selected areas with and without the presence of leakage shown by fluorescein angiography were calculated and compared statistically. RESULTS: Retinal thickness (mean +/- SD) in areas with leakage (315 +/- 54 microm) was significantly greater than that in areas without leakage (280 +/- 28 microm) (P = 0.03). In untreated patients, areas with leakage (345 +/- 45 microm) were significantly thicker than areas without leakage (289 +/- 23 microm) (P = 0.02). In treated patients, retinal thickness in areas with leakage (271 +/- 33 microm) and without leakage (267 +/- 34 microm) was similar. CONCLUSION: Retinal thickness mapping may prove to be useful as an adjunct to fluorescein angiography to monitor choroidal neovascularization and its treatment.     

Utility values in Japanese patients with exudative age-related macular degeneration

Purpose  

To investigate the utility values associated with visual loss due to age-related macular degeneration (AMD) in Japanese patients.     

Clinical characteristics of exudative age-related macular degeneration in Japanese patients

PURPOSE: To clarify the clinical characteristics of exudative age-related macular degeneration (AMD) in Japanese patients. DESIGN: Retrospective, observational, consecutive case series. METHODS: Two hundred and eighty-nine patients with neovascular AMD were examined. RESULTS: The authors classified the patients into three subtypes of neovascular AMD: polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP), and typical AMD. One hundred and fifty-eight patients (54.7%) were diagnosed with PCV and 102 patients (35.3%) with typical AMD. RAP was observed in 13 patients (4.5%). In 16 patients (5.5%), one eye had PCV and the other eye had typical AMD. Most patients with PCV and typical AMD had unilateral disease (81.6% and 94.1%, respectively) with a male preponderance (77.8% and 71.6%, respectively). Nine of 13 patients with RAP were female (69.2%). Patients with RAP were older (mean, 80.3 years for men and 75.3 years for women) than patients with other subtypes. Serous and hemorrhagic pigment epithelial detachment developed in 69 patients (43.7%) with PCV, 22 patients (21.6%) with typical AMD, and nine patients (69.2%) with RAP. In the patients with unilateral disease in each subtype, large drusen in the unaffected eye were seen in 24.0% with PCV, 30.2% with typical AMD, and 77.8% with RAP. CONCLUSIONS: Neovascular AMD in Japanese patients has different demographic features compared with that in White patients. In Japanese patients, there is a preponderance of PCV, male gender, unilaterality, and absence of drusen in the second eye, with the exception of RAP.     

Intravitreal triamcinolone acetonide for exudative age-related macular degeneration among Japanese patients

AIM: To study the results of intravitreal triamcinolone acetonide (TA) for exudative age-related macular degeneration (AMD) among Japanese patients. METHODS: 13 eyes of 12 Japanese patients (9 males and 3 females) with subfoveal choroidal neovascularization (CNV) of exudative AMD received intravitreal TA (8 mg). Visual acuity, size of CNV and serous retinal detachment, and complications related to treatment were evaluated for 6 months or longer. RESULTS: Postoperative maximum visual acuity significantly improved (p < 0.05). Postoperative eyes had a greater probability of a reduced size of CNV and/or retinal detachment compared to preoperative eyes. Seven eyes showed increased intraocular pressure (21 mm Hg or over), which was controlled well by medication. Cataract development and advancement were observed in 90% of phakic eyes. No other serious complications were found. CONCLUSIONS: Intravitreal TA might be an effective treatment for subfoveal CNV of exudative AMD among Japanese as well as Caucasian patients for a comparatively short period.     

Transpupillary thermotherapy for treatment of exudative age-related macular degeneration in Japanese patients

PURPOSE: To report the therapeutic outcome of transpupillary thermotherapy (TTT) for subfoveal choroidal neovascularizarion (CNV) in brown retina using a diode-laser with the setting of lower energy level compared to the previous studies on light-pigmented Caucasian patients. METHODS: A total of 19 subfoveal CNVs in 18 patients were treated with TTT. The power of diode-laser was set 160 mW for 1.2 mm beam, 270 mW for 2.0 mm beam, and 400 mW for 3.0 mm beam, and the laser was delivered for 1 min through a slit-lamp mounted-delivery system. Patients were followed up for a mean of 8.8 months (4-12 months). Visual acuity and the fundus change as judged by funduscopic examination and simultaneous fluorescein and indocyanine green angiography were evaluated. Visual acuity was measured by a Japanese standard Landolt visual acuity chart and converted to logarithm of the minimal angle resolution (log MAR) visual acuity for statistical analysis. Improvement or decline in vision was defined as change of more than 0.2 in log MAR visual acuity. RESULTS: In eyes with minimally classic or occult only CNV, visual acuity improved in two eyes (18%) stabilized in seven eyes (64%) and worsened in two eyes (18%). In eyes with predominantly classic CNV, visual acuity improved in two eyes (25%), stabilized in four eyes (50%) and worsened in two eyes (25%). In all, 15 (84%) eyes of all studied subjects had improvement in exudation. Two (11%) and one (5%) eye(s) were noted to have a significant post-treatment haemorrhage and retinal pigment epithelial tear, respectively. CONCLUSION: In patients with brown retinal colour, the treatment outcome of TTT was comparable to that of light-pigmented Caucasian patients with approximately half the laser power energy. Further randomized control studies are warranted.     

Efficacy of intravitreal aflibercept in Japanese patients with exudative age-related macular degeneration

Purpose

To clarify the efficacy of aflibercept for treating exudative age-related macular degeneration (AMD).

Methods

We prospectively studied 47 eyes with AMD. Forty-seven patients (mean age 72.2 years) received three consecutive monthly intravitreal aflibercept injections followed by an injection every 2 months until 12 months. The primary outcome was the 12-month visual results compared with baseline; the secondary outcomes were the prevalence of geography atrophy (GA), a dry macula at month 12, and anatomic changes on optical coherence tomography.

Results

The mean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) in 27 eyes with typical AMD and 20 eyes with polypoidal choroidal vasculopathy (PCV) significantly (p < 0.0001, p < 0.05, respectively) improved from 0.60 to 0.32 at baseline to 0.29 and 0.21 at month 12. At month 12, 22 (81.5 %) eyes with typical AMD and 17 (85 %) eyes with PCV had dry macula. The subfoveal choroidal thicknesses in typical AMD and PCV decreased significantly (p < 0.0001 for both comparisons) from 241 ± 118 and 294 ± 76 μ at baseline to 198 ± 104 and 244 ± 84 μ at month 12. Progressing or new GA was seen in three eyes with typical AMD and one eye with PCV; the mean change in the BCVA was significantly (p = 0.0026) worse at month 12. No other complications developed.

Conclusion

Intravitreal aflibercept significantly improved VA and anatomic changes in typical AMD and PCV over 12 months. Development of GA might be a risk for declining VA.

     

Development of typical age-related macular degeneration and polypoidal choroidal vasculopathy in fellow eyes of Japanese patients with exudative age-related macular degeneration

PURPOSE: To investigate the development of typical age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) in fellow eyes of Japanese patients with exudative AMD. DESIGN: Retrospective observational consecutive case series. METHODS: Two hundred and sixteen Japanese patients were enrolled in this study from the outpatient clinic of the University of Tokyo Hospital. Ninety-one patients had typical AMD and one hundred and twenty-five patients had PCV. The average follow-up period was 33.6 and 25.1 months for typical AMD and PCV patients. RESULTS: The cumulative incidence of involvement in fellow eyes with overall exudative AMD, including both typical AMD and PCV, was 3.4% in one year, 9.3% in three years, and 11.3% in five years. It was 3.6%, 7.3%, and 11.2% in typical AMD, and 3.2%, 11.1%, and 11.1% in PCV in one, three, and five years, respectively. Before the development of exudative AMD, patients with typical AMD had a variety of funduscopic findings including retinal pigment epithelium (RPE) atrophy, drusen, drusenoid pigment epithelial detachments (PED), and normal macula. PCV patients, on the other hand, had funduscopic findings of RPE atrophy. Inner choroidal vascular abnormality of vascular network and polypoidal formation was observed in several eyes before the clinical manifestation of exudative changes. CONCLUSIONS: Typical AMD and PCV had similar probabilities of involving the fellow eye in unilaterally affected Japanese patients. RPE atrophy was a prevailing finding in fellow eyes of patients who developed PCV. In PCV, choroidal vascular network and polypoidal formation gradually grow before exudative changes.     

Retinal nerve fiber layer thickness changes in patients with age-related macular degeneration treated with intravitreal ranibizumab

Purpose. To assess the effects of intravitreal ranibizumab therapy on intraocular pressure (IOP) and retinal nerve fiber (RNFL) thickness. Methods. Forty-nine eyes of 49 patients with neovascular age-related macular degeneration (AMD) treated with intravitreal ranibizumab injections and 27 fellow eyes not requiring treatment were followed for 1 year. RNFL thickness, as measured by Fourier domain optical coherence tomography, and IOP were determined pre- and postinjection. Results. After 12 months, the mean number of injections received was 4.8 ± 1.6. The incidence of IOP elevations (>5 mm Hg over baseline) observed at the time of injection was 0.4%. Baseline RNFL thickness was 105.7 ± 12.2 μm in the treatment group compared with 101.8 ± 11.6 μm in the control group (P = 0.176). At the end of follow-up, significant RNFL thinning was noted in the treatment group (100.2 ± 11.0 μm, P < 0.001), whereas no differences were found in the control group (100.5 ± 10.8 μm, P = 0.477). Conclusions. Intravitreal ranibizumab injections used to treat AMD caused a significant change in RNFL thickness after 12 months of follow-up.     

Angiographic findings in patients with exudative age-related macular degeneration

PURPOSE: Exudative age-related macular degeneration (ARMD) is the leading cause for severe visual loss in the elderly. A series of clinical trials has established the efficacy of laser photocoagulation and photodynamic therapy (PDT) in special subgroups of patients with exudative ARMD. We analyzed the fluorescein and indocyanine green angiograms (ICG) of patients with exudative ARMD to characterize the nature of the CNV in order to estimate the percentage of patients amenable for one of the therapies. METHODS: Patients with acute symptoms related to exudative ARMD were recruited for the study. All patients underwent fluorescein and ICG angiography. We analyzed the type of the CNV (classic, occult, or mixed) and location relative to the fovea from the fluorescein angiograms. Additionally, we recorded the presence of a visible capillary network in the early ICG angiograms, as well as hot spots and plaque hyperfluorescence in the late ICG angiographic frames. RESULTS: We included 191 patients aged 53-92 years in the study. The angiograms revealed in 17 (9%) patients classic CNV (12 subfoveal), in 114 (60%) occult CNV, and in 60 (31%) mixed CNV. Of these 19 had a classic component >50%. In the early ICG angiograms a capillary network was visible in 50 eyes with occult CNV. Hot spots were present in 29 eyes and a hyperfluorescent plaque in 54 eyes. CONCLUSION: In total, only 18% of eyes included in our study were eligible for laser photocoagulation or for photodynamic therapy (PDT). These numbers highlight the deficiencies of current treatment modalities for exudative ARMD. For this reason, alternative treatment should be further investigated to offer better treatment to patients with exudative ARMD.     

Treatment of exudative age-related macular degeneration

I PROPHYLACTIC TREATMENT: We followed 75 eyes contralateral to eyes with exudative age-related macular degeneration (AMD), using indocyanine green angiography (IA), for more than one year. Hyperfluorescent areas in the late phase of IA were seen in 19 eyes at the initial examination, and in 25 eyes during follow-up. Exudative AMD developed in 9 of the 25 eyes. Using timetable analysis, we estimated that 11% of these 27 eyes developed AMD within one year and 55% within three years. The hyperfluorescent areas seen on IA appeared to be latent choroidal neovascularization (CNV) under the retinal pigment epithelium. We propose that photocoagulation aimed at hyperfluorescent areas should be considered in such cases. We performed prophylactic laser photocoagulation in 21 eyes, which were then followed up for at least six months. These eyes all had 10 or more serous drusen within 1,500 microns of the fovea and did not show hyperfluorescence, suggesting latent CNV in the late phase of IA. The majority or a small fraction of the serous drusen disappeared in 48% and 18% of the 21 eyes, respectively. CNV appeared adjacent to the laser scar in one eye (5%). Judging from these results, it is important to establish a method of definitively abolishing drusen and preventing the development of CNV. II TREATMENT OF CNV: Of 229 eyes which showed occult CNV in fluorescein angiography (FA), 124 eyes (54%) showed classic CNV outside the fovea on IA. One hundred and two of the 124 eyes (45%) underwent laser photocoagulation. We evaluated indocyanine green guided laser photocoagulation of extrafoveal CNV in 139 eyes. The success rate was 81% at 3 months after laser photocoagulation. This was estimated using timetable analyses to have decreased to 78% at one year and 71% at three years. Eighty percent of successfully treated eyes showed maintained or improved visual acuity. These results did not differ significantly from those obtained with laser photocoagulation based on FA findings. When classic CNV is not detected on FA, IA is indicated and if classic CNV is detected outside the fovea, photocoagulation should be performed aggressively. We compared the histological findings of removed subfoveal CNV with the IA findings prior to removal. IA findings of CNV before removal were divided into four types. Types I and II showed numerous vascular lumina in von Willebrand factor staining. Prominent proliferation in types I and II was demonstrated with Ki-67. Vascular endothelial growth factor (VEGF) showed strong staining in types I, II and III. Therefore, CNV in eyes with types I, II and III, and especially type I, requires urgent treatment. We compared visual outcomes one year after treatment between 52 eyes that underwent removal and 56 eyes that underwent laser photocoagulation of subfoveal CNV. When CNV size was one disc diameter or less, mean visual acuity, the percentage of eyes with improved vision and with a visual acuity of 0.1 or more, was significantly greater in operated eyes than in coagulated eyes. Removal is therefore superior to photocoagulation in subfoveal CNV of one disc diameter or less in size. We evaluated preoperative factors influencing the best corrected visual acuity at least six months after removal of subfoveal CNV in 67 eyes. Factors influencing the best corrected visual acuity were IA findings, feeder vessel ingrowth sites and CNV sizes. Good indications for removal included types I, II and III IA findings, extra foveal location feeder vessel ingrowth sites, and small CNV. III LOW VISION CARE: We performed reading tests using the MN read J chart for 90 eyes with the scar stage of CNV. Reading speed profiles of the 90 eyes were classified into two groups: 48 eyes showing a plateau with a relatively constant reading rate at the maximum level; and 42 eyes showing steadily increasing reading rate without a plateau. Eyes without a plateau had worse visual acuity, worse reading acuity, and slower reading speed. We evaluated newspaper reading performance by comparing conventional versus new methods based on the critical print size of the MN read J chart. Magnification power based on the critical print size were similar to those finally chosen as the best aid by the patients. On the other hand, magnification power was lower when conventional methods were used. The critical print size of the MN Read J chart appears to be valuable for determining low vision aids which facilitate reading by AMD patients.     

Transpupillary thermotherapy in exudative age-related macular degeneration

PURPOSE: Assessment of TTT results in patients with exudative age-related macular degeneration. MATERIAL AND METHODS: The study comprised of 65 patients (73 eyes), in age 50-84 years (average age-75 yrs). The diagnosis of exudative AMD was established on the basis of fundus examination and fluorescein angiography (FA) and in some cases on indocyanine green angiography. The baseline visual acuity (VA) ranged from counting fingers at 50 cm to 0.8. In 31 (42.5%) eyes occult CNV, in 11 (15%) minimally classic CNV and in 31 (42.5%) eyes predominantly classic CNV were observed. Subfoveal CNV was present in 70 (95.9%) eyes and perifoveal in 3 (4.1%). TTT was delivered using a diode laser at 810 nm wavelength, a spot size of 1.2 to 4.5 mm and a duration of 60 seconds for each spot with power settings between 320-800 mW. Follow-up examinations were carried out every 10-12 weeks. In cases with persistent leakage from CNV in late frames of FA a retreatment was performed. The follow-up period ranged from 6 to 28 months (average - 9.8 months). RESULTS: Visual acuity improved in 22 (30.1%) eyes, stabilized in 34 (46.6%) and deteriorated in 17 (23.3%). Fluorescein angiography showed no CNV leakage in 58 (79.5%) eyes. In 56 (71.8%) with regression of leakage in fluorescein angiography improvement or stabilization of visual acuity was detected. Subretinal haemorrhages after TTT were observed in 4 eyes (5.5%). At the end of the follow-up period fibrosis of CNV was detected in 12 eyes (16.4%). CONCLUSIONS: TTT is effective and safe method of treatment of occult and classic CNV in a course of wet AMD. In a majority of cases TTT results in total or partial regression of CNV and stabilization of visual acuity.     

Therapeutic options in age-related exudative macular degeneration

The age-related macular disease (AMD) is the most frequent cause for blindness over 65 years in the developed countries. The incidence of this pathology (Framingham study) is: 2% (52-64 old), 11 %(65-74 old), 28%(>75 old). Our paper wants to review the therapeutic armamentarium during the last twenty years for treating Wet AMD--the most serious form of this disease.     

Radiation therapy in exudative age-related macular degeneration

It has been suggested that ionizing radiation at doses relatively safe to the optic nerve and retina exert an inhibitory and occlusive effect on the endothelial proliferation of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). The encouraging results of early studies in preservation or improvement of visual acuity and regression of the CNV gave rise to many clinical trials in different centers. Disparate radiation doses, dose fractions, type and rate of radiation administration have been used to determine the efficacy of radiotherapy in AMD. Conflicting treatment responses have been reported by different centers. Some studies provided evidence of beneficial treatment outcome in AMD, and others could not show any efficacy of ionizing radiation in the visual and morphological evolution of the disease. Data from the literature and our experience indicate that radiotherapy can be effective in regressing the leakage of the CNV in AMD. However, despite treatment visual deterioration continues and new CNV lesions develop. The observation of morphological progression in the disease process might be related to an unfavorable effect of radiation on the pathogenesis of AMD.     

Fundus autofluorescence in exudative age-related macular degeneration

AIM: To evaluate the distribution of fundus autofluorescence in patients with age-related macular degeneration and choroidal neovascularisation (CNV). METHODS: Colour fundus photographs, fundus fluorescein angiograms (FFA) and fundus autofluorescence images were obtained from a group of 40 patients (43 eyes) with age-related macular degeneration and purely classic or occult CNV. Only patients with newly diagnosed CNV and in whom autofluorescence images were obtained within 2 weeks from FFA were included. The distribution of autofluorescence was qualitatively evaluated, and the findings compared with those from colour fundus photographs and FFA. RESULTS: 29 (67%) eyes had classic CNV and 14 (33%) had occult CNV. In 26 (90%) eyes with classic CNV, a low autofluorescence signal was detected at the site of the CNV; in 7 (50%) eyes with occult CNV, multiple foci of low autofluorescence signal were detected. Outside the area affected by the lesion, homogeneous autofluorescence was observed in most of the cases (n = 33, 77%). Similarly, homogeneous autofluorescence was commonly observed in fellow eyes (62%). A pattern of focal increased autofluorescence was rarely seen in eyes with CNV (n = 4, 9%) or in fellow eyes (n = 4, 15%). In 11 of 43 (25%) eyes, areas of increased autofluorescence, other than a pattern of focal increased autofluorescence, were detected. In four patients, autofluorescence images had been obtained before the development of CNV; in none was any increased autofluorescence detected before the formation of CNV. CONCLUSIONS: Distinct patterns of autofluorescence were observed in eyes with pure classic and occult CNV. Increased autofluorescence was rarely seen in eyes with CNV and in fellow eyes, suggesting that increased autofluorescence, and thus, retinal pigment epithelium lipofuscin, may not play an essential part in the formation of CNV.     

渗出性年龄相关性黄斑变性患者的屈光状态

目的 探讨渗出性年龄相关性黄斑变性（AMD）患者与非AMD健康者屈光状态的差异。设计 病例对照研究。 研究对象 筛选并纳入136例渗出性AMD患者具有屈光状态记录的247眼,其中154只患眼作为渗出性AMD组,包括34例双眼渗出性AMD患者的67眼及102例单眼渗出性AMD患者的87眼。选取北京德胜社区非AMD正常受试者中与渗出性AMD患者年龄、性别匹配的136例,纳入具有屈光状态的242眼作为对照组。方法 采用电脑验光后显然验光的方法测量纳入眼的屈光度。远视标准定义为>+0.5 D。比较两组患者的屈光状态。主要指标 屈光状态与屈光度。结果 渗出性AMD组远视72眼（46.7%）,屈光度（四分位数间距）为+0.50（-0.38,+1.25）D。对照组远视74眼（30.6%）,屈光度为+0.13（-1.13,+0.84）D。渗出性AMD组较对照组远视眼比例高（P<0.001）,渗出性AMD组较对照组更倾向于远视（P<0.001）。结论 渗出性AMD患者较非AMD健康者可能更倾向于发生远视,且远视的度数更高。（眼科, 2014, 23： 99-102）