Macular infarction after transpupillary thermotherapy for subfoveal choroidal neovascularization in age-related macular degeneration

PURPOSE: To report the complication of macular infarction after transpupillary thermotherapy (TTT) for the treatment of subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD). DESIGN: Interventional case reports. METHODS: Among 107 consecutive patients with subfoveal CNV due to AMD, a 73-year-old woman with recurrent subfoveal classic choroidal neovascularization and a 76-year-old man with subfoveal occult choroidal neovascularization with adjacent areas of geographic retinal pigment epithelium atrophy noted a severe decrease in visual acuity and photopsias within hours of undergoing TTT. RESULTS: Both patients had marked whitening of the macula clinically and closure of the perifoveal capillaries on fluorescein angiography. Immediately after treatment their visual acuity decreased from 20/200 to 6/200 and from 20/400 to 2/200, respectively. Several months later, all exudation had resolved and their visual acuity had stabilized at 20/100 and 20/200, respectively. CONCLUSIONS: Macular infarction is a rare complication that occurred in two of 107 patients undergoing TTT for subfoveal CNV due to AMD. The presence of geographic retinal pigment epithelium atrophy or a previous laser treatment scar in the macular region may predispose patients to this complication.     

Comparison of photodynamic therapy and transpupillary thermotherapy for subfoveal choroidal neovascularization due to age-related macular degeneration

BACKGROUND: The purpose of this study was to compare photodynamic therapy (PDT) against subthreshold transpupillary thermotherapy (TTT) with a diode laser for subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD). METHODS: Patients with subfoveal choroidal neovascularization secondary to AMD were offered PDT as an initial intervention. If they declined PDT, then TTT was offered. RESULTS: We evaluated and followed 115 consecutive patients for an average of 1 year. The primary outcome measure was visual acuity, but the interventions were also compared on the basis of lesion size and angiographically determined lesion activity. Baseline comparisons between the 2 treatment groups showed significant differences in pretreatment visual acuity, lesion size, and lesion composition. Univariate analysis of outcomes demonstrated equivalence between the treatment groups in final lesion size, angiographic activity, and visual acuity. Multivariate analysis also demonstrated equivalence between the treatment groups in final visual acuity while controlling for age, pretreatment visual acuity, and lesion category. Predominantly classic lesions were associated with poorer visual outcomes. INTERPRETATION: The PDT and TTT groups were equivalent in terms of all outcome parameters evaluated.     

Low power vs standard power transpupillary thermotherapy in patients with age-related macular degeneration and subfoveal choroidal neovascularization ineligible for photodynamic therapy

AIM: To assess the effect of standard power vs low power transpupillary thermotherapy (TTT) in patients with active subfoveal choroidal neovascularization secondary to age-related macular degeneration ineligible for photodynamic therapy (PDT) by original treatment of age-related macular degeneration with photodynamic therapy (TAP) study group recommendations. METHODS: Retrospective review of 79 patients with active predominantly occult subfoveal choroidal neovascularization or predominantly classic subfoveal choroidal neovascularization but Snellen visual acuity <20/200. All patients were treated with TTT administered via a Mainster wide field fundus contact lens with a retinal power/diameter coefficient of 248 mW/mm in the standard power (n=27) and 181 mW/mm in the low power group (n=52). The primary outcome was stabilization (<1 Snellen line change) or improvement (two or more Snellen lines) in visual acuity. Clinical and fluorescein angiographic resolution of overlying exudation was documented. RESULTS: At 24 month follow-up, 17 patients (63%) in the standard power and 36 patients (69%) in the low power group achieved stable or improved vision. Improved vision (mean three lines) was observed in 22% of the standard power and 23% of the low power group. Overlying exudation was reduced clinically with minimal or no leakage on fluorescein angiogram in 85% of standard power and 90% of low power group. Subgroup analysis in the low power group demonstrated a visual benefit in patients with subfoveal lesions, which had any classic component. CONCLUSIONS: Low power TTT is as effective as standard power in stabilizing or improving vision and reducing overlying exudation in patients with active subfoveal choroidal neovascularization ineligible for PDT.     

经瞳孔温热疗法治疗湿性年龄相关性黄斑变性的参数研究

目的评价三种不同参数的经瞳孔温热疗法(transpupillarythermotherapy,TTT)治疗湿性年龄相关性黄斑变性(age-relatedmaculardegeneration,ARMD)的疗效。方法2002年4月～2005年1月在我科确诊为ARMD渗出型患者24例32眼,男性17例25眼,女性7例7眼,年龄47～84岁(平均67.96岁)。其中17位患者(隐匿性CNV9眼、典型性及典型性为主型10眼)接受TTT治疗,按采取的能量参数分为100%能量组(7眼)、80%能量组(5眼)、70%能量组(7眼),其余7例13眼不接受任何治疗手段的患者作为无治疗组列为观察对象。术后对眼底改变、视力、眼底血管造影复查,随访6～37个月(平均21.65个月)观察疗效并进行统计分析。结果至末次复查时所有接受TTT治疗的19只患眼的出血、水肿、渗出消失、病灶斑痕化。100%能量组,80%能量组以及70%能量组视力提高的患眼比例相比较,均无统计学显著差异(分别为p=0.523,p=1.000,p=1.000)。治疗组(包括100%能量组,80%能量组以及70%能量组)与无治疗组视力下降的患眼比例相比较,有统计学显著差异(p=0.002)。治疗组与无治疗组视力提高的患眼比例相比较,无统计学显著差异(p=0.361)。结论TTT对隐匿型和经典型CNV均有稳定患眼视力的作用。目前选择该研究中80%能量组的参数,可以在安全性和有效性上得到进一步完善,仍有待更多病例的证实。     

Pulsatile ocular blood flow of choroidal neovascularization in asymmetric age-related macular degeneration after transpupillary thermotherapy

PURPOSE: A previous study has shown that the pulsatile ocular blood flow (POBF) in eyes with asymmetric age-related macular degeneration (AMD) differs. Whereas eyes with drusen have higher POBF than contralateral eyes with disciform scarring, the POBF of eyes with drusen is lower relative to contralateral eyes with choroidal neovascularization (CNV). This study was designed to assess whether the POBF of eyes with CNV changes after transpupillary thermotherapy (TTT), using the contralateral eyes with drusen or scarring without TTT as controls. METHODS: In total, 26 patients with CNV in one eye and drusen or scarring in the other were enrolled in this prospective case series. Eyes with CNV were treated with TTT. POBF was measured monthly in both eyes of each subject. RESULTS: Before TTT, the POBF of eyes with CNV was 1179+/-317 microl/min. After TTT, the POBF of CNV eyes had decreased at 1 month (1015+/-273 microl/min, P=0.002) and 2 months (945+/-398 microl/min, P=0.011) of follow-up, but had rebounded at 3 months (P=0.441) and 6 months (P=0.084). CONCLUSIONS: These findings suggest that TTT decreases the pulsatile choroidal blood flow in eyes with CNV in patients with asymmetric AMD and the effects persist for 2 months. POBF may be used as a modality to monitor the therapeutic effects of CNV in asymmetric exudative AMD.     

Vision‐related function after low‐dose transpupillary thermotherapy versus photodynamic therapy for neovascular age‐related macular degeneration

Purpose: To compare the effects of low‐dose transpupillary thermotherapy (TTT) and verteporfin photodynamic therapy (PDT) on patient‐reported visual function using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ‐25) in patients with occult neovascular age‐related macular degeneration (AMD). Methods: Patients were randomized to receive either low‐dose TTT (and sham PDT) (n = 52) or PDT (and sham TTT) (n = 46). Patients were followed for 12 months with retreatment according to clinical assessment. The clinical outcome of this study has been recently reported. The NEI VFQ‐25 questionnaire was administered at baseline and at 12 months. Results: Forty‐two patients (80.1%) in the TTT group and 37 patients (80.0%) in the PDT group completed the questionnaire at the 12‐month follow‐up. The mean change in the NEI VFQ‐25 composite score was +1.2 for the TTT group (p > 0.05) and +0.7 for PDT group (p > 0.05). None of the subscale categories showed significant changes between treatment groups at 12 months. Subgroup analysis showed that NEI VFQ‐25 scores were lower in patients treated in their better‐seeing eye. Conclusion: In this randomized study on patients with occult neovascular AMD, low‐dose TTT and PDT appeared to be equally potent at stabilizing patient‐reported visual function. However, the study was underpowered for this conclusion to be made firmly. Also, given the impressive results obtained with ranibizumab for all types of neovascular AMD, neither PDT nor low‐dose TTT should be considered as first‐line treatments.     

Socioeconomic status and clinical features of patients undergoing photodynamic therapy or transpupillary thermotherapy for subfoveal choroidal neovascularization due to age-related macular degeneration

BACKGROUND: The purpose of this study was to compare baseline clinical and socioeconomic features of patients undergoing self-funded photodynamic therapy (PDT) or government-funded subthreshold transpupillary thermotherapy (TTT) with a diode laser for subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD). METHODS: Between July 2000 and August 2001, 115 patients with subfoveal choroidal neovascularization secondary to AMD were offered PDT as an initial intervention. If individuals believed that they could not afford or did not want PDT, then TTT was offered. In masked fashion, leakage pattern and lesion size were determined retrospectively from pretreatment angiograms. Baseline visual acuity was determined with autorefraction and subsequent Snellen testing. The mean income of each treatment group was estimated from the average sex-specific income for each subject's postal code, based on the 1996 Canadian census data. The average education level for each subject's postal code was also determined. RESULTS: The patients who were not willing to pay for PDT had significantly worse macular disease before treatment (larger lesions and poorer visual acuity) and a significantly lower mean income than the patients who were willing to pay for PDT. INTERPRETATION: The severity of exudative choroidal neovascularization appears to be associated with lower socioeconomic status.     

Intravitreal triamcinolone with photodynamic therapy for subfoveal choroidal neovascularisation in age related macular degeneration

AIMS: To report the effects of intravitreal triamcinolone acetonide (iTAAC) injections as an adjunctive treatment to photodynamic therapy (PDT) with verteporfin for new subfoveal choroidal neovascularisation (CNV) in age related macular degeneration (AMD). METHODS: We retrospectively reviewed the records of all AMD patients who had iTAAC within 6 weeks of their first PDT and had a follow up of one year or longer. The proportion of eyes after one year follow up that lost or gained >or=15 and >or=30 ETDRS letters, baseline and one year lesion greatest linear dimension (GLD), number of PDTs, and side effects were assessed. RESULTS: Fourteen patients were evaluated. Eleven received one initial combined treatment and three received an additional combined treatment after 6 months. Median follow up was 18 months (range 12 to 25 months). Overall, 7% gained >or=30 letters, 50% maintained stable vision, 14% lost 15-29 letters, and 29% lost >or=30 letters. Overall, mean GLD increased from 2580 (SD 1088) microm to 3946 (SD 1503) micro m (p = 0.01). The mean number of PDTs during the first year was 2.57. Side effects were mild intraocular pressure elevation in 28.5% and cataract progression in 50% of phakic eyes. CONCLUSIONS: iTAAC with PDT in AMD was found to be relatively safe and had reasonable results for lesions with some classic component.     

玻璃体腔注射Ranibizumab联合经瞳孔温热疗法治疗年龄相关性黄斑变性

目的：观察玻璃体腔注射Ranibizumab联合经瞳孔温热疗法( TTT)治疗渗出型年龄相关性黄斑变性的临床疗效及安全性。方法：选取来我院就诊并通过病史、临床症状及眼底血管照影(FFA/ICGA)和光学相干断层扫描(OCT)等辅助检查确诊的渗出型年龄相关性黄斑变性的患者160例(160眼),随机分为联合组和对照组,联合组给予单次行玻璃体腔注射Ranibizumab,7d后行TTT治疗,对照组仅行TTT治疗,随访1a,分别于治疗后1wk;1,6mo;1a,观察患者的最佳矫正视力、散瞳后眼底的变化及眼底血管照影( FFA/ICGA)及OCT的检查。
　　结果：观察期末,联合组最佳矫正视力提高34例(42.50%),对照组最佳矫正视力提高16例(20.00%),差异具有统计学意义(P<0.05)。治疗后1wk;1,6mo;1a联合组和对照组的荧光渗透有效率分别为(88.75%,62.50%);(91.25%,65.00%);(86.25%,61.25%);(78.75%,51.25%)。治疗后1 wk;1,6 mo;1 a联合组和对照组黄斑中心厚度分别为：(347.43±36.96)μm 和(423.58±29.03)μm;(287.78±34.16)μm和(387.14±32.98)μm;(301.75±37.21)μm和(415.40±31.38)μm;(326.17±27.39)μm 和(436.44±35.49)μm,两组相比,差异具有统计学意义(P<0.05)。结论：玻璃体腔注射Ranibizumab联合经瞳孔温热疗法治疗渗出型年龄相关性黄斑变性,能够使患者的视力得到改善,病灶渗漏停止或减轻,促进黄斑区出血、水肿及渗出的吸收,安全、疗效可靠,是一种有效的临床治疗方法。     

Long term results after transpupillary thermotherapy in eyes with occult choroidal neovascularisation associated with age related macular degeneration: a prospective trial

AIM: To evaluate long term results after transpupillary thermotherapy (TTT) in eyes with exudative age related macular degeneration. METHODS: In a prospective clinical study eyes with occult or predominantly occult choroidal neovascularisation and no pretreatment were scheduled to have a TTT with a power of 630 mW. Visual acuity for far and near distances as well as contrast sensitivity were evaluated 6, 12, and 24 months postoperatively and statistically analysed. RESULTS: 47 eyes fulfilled the inclusion criteria. Overall, 70% of the patients showed an improved (14%) or had unchanged (56%) ETDRS vision after 24 months. Reading vision was stabilised (51%) or better (5%) in 56% of the eyes at this time. However, the increasing number of eyes with severe deterioration resulted in a significant decrease of both parameters over time (p = 0.0002 and p = 0.0003, respectively). Contrast sensitivity could be maintained (70%) or improved (9%) in 79%. Statistical analyses indicated a trend but no significant decrease over time (p = 0.056). CONCLUSION: Although in the majority of patients far and near distance acuity could be stabilised on average a significant decrease over time after TTT was observed. Statistical comparison of months 12 and 24 showed no further deterioration.     

Using optical coherence tomography to monitor photodynamic therapy in age related macular degeneration

PURPOSE: To evaluate the role of optical coherence tomography (OCT) in determining choroidal neovascularization (CNV) activity before and after photodynamic therapy (PDT) in patients with age-related macular degeneration (ARMD). DESIGN: Prospective observational case series. METHODS: SETTING: Institutional study. patient population: Fifty-three patients (62 eyes) with ARMD. OBSERVATION PROCEDURE: Prospective observational case study. MAIN OUTCOME MEASURES: Presence or absence of leakage on fluorescein angiography, presence of intraretinal or sub-retinal fluid on OCT, and macular and choroidal neovascular complex thickness on OCT. RESULTS: The macular thickness decreased significantly after PDT (P = .001). However, no significant changes in CNV thickness were measured after PDT (P = .567). Once the diagnosis of ARMD was established before treatment, OCT had a sensitivity of 96.77% for detecting CNV activity. After treatment, OCT had a good sensitivity (95.65%) and a moderate specificity (59.01%) in determining CNV activity, which resulted in a diagnostic efficiency (proportion of correct results) of 82.95%. CONCLUSIONS: OCT appears to be useful for indicating CNV activity. Therefore, it may serve as a complementary technique for deciding the need for PDT and re-treatment in patients with ARMD.     

Changes in foveal thickness and macular function after transpupillary thermotherapy for age-related macular degeneration

PURPOSE: To evaluate the effect of transpupillary thermotherapy (TTT) on foveal thickness and macular function in eyes with choroidal neovascularization (CNV) associated with age-related macular degeneration. METHODS: Sixteen eyes with occult CNV and 6 eyes with classic CNV were treated with TTT. Optical coherence tomography and focal macular electroretinograms (FMERGs) elicited by a 15-degree stimulus were performed before, 3 months after TTT in 22 eyes and 6 months after TTT in 18 eyes. RESULTS: Before TTT, the fovea in 20 of the 22 eyes with CNV was significantly thicker than that of normal subjects. The foveal thickness was reduced after TTT in 11 of 14 eyes with occult CNV and remained unchanged in 2 eyes. One eye with occult CNV before TTT developed a classic CNV with significant macular edema and increased foveal thickness 3 months after TTT. The amplitudes of the FMERGs were reduced in all eyes before TTT. In eyes with occult CNV, the mean b-wave amplitude increased significantly after TTT (p = 0.0260 at 3 months, p = 0.0142 at 6 months). When the change of foveal thickness was less than 20% after TTT, all eyes with occult CNV had a 30% or more increase in the b-wave amplitude. In eyes with classic CNV, the mean amplitude of the a- and b-waves did not change significantly after TTT. CONCLUSIONS: TTT improves macular function in eyes with occult CNV associated with age-related macular degeneration more when the change of foveal thickness is slight.     

Pulsatile ocular blood flow in asymmetric exudative age related macular degeneration

BACKGROUND/AIMS: Decreased perfusion or increased vascular resistance of the choroidal vessels had been proposed as the vascular pathogenesis for age related macular degeneration (AMD). This study planned to answer the question whether pulsatile ocular blood flow (POBF) was different in patients with asymmetric exudative AMD between eyes with drusen, choroidal neovascularisation (CNV), or disciform scar. METHODS: 37 patients with asymmetric exudative AMD were enrolled in this observational case series study. POBF were measured in both eyes of each subject. Eyes with high myopia, anisometropia, recent laser treatment, and glaucoma were excluded. RESULTS: After adjusting for ocular perfusion pressure, intraocular pressure, and pulse rate, multivariate regression analysis with generalised estimating equation showed POBF was significantly higher in eyes with CNV (1217 (SD 476) microl/min) than the contralateral eyes with drusen (1028 (385) microl/min) (p = 0.024). Eyes with disciform scar had lower POBF than the contralateral eyes with drusen (999 (262) microl/min and 1278 (341) microl/min, respectively, p<0.001). There was no significant correlation between the POBF and the lesion size of the CNV. CONCLUSION: The POBF in eyes with drusen was lower than their fellow eyes with CNV, but higher than their fellow eyes with disciform scar. This finding suggests that haemodynamic differences between fellow eyes in individuals are relevant to the development of CNV and the formation of disciform scar. Further studies on the follow up patients might shed light on the pathogenesis of exudative AMD.     

Transpupillary thermotherapy for choroidal neovascular membrane in age related macular degeneration

PURPOSE: To evaluate the efficacy of transpupillary thermotherapy (TTT) in choroidal neovasularisation (CNVM) secondary to age related macular degeneration (AMD). MATERIAL AND METHODS: Retrospective, non-randomized study of 28 eyes of 28 patients with subfoveal CNVM (classic, occult or mixed) secondary to AMD. RESULTS: Fifteen patients (53.57%) maintained their pre-treatment vision, 2 (7.14%) patients showed improvement of more than 2 lines and 11 (39.28%) patients showed deterioration of vision by >2 lines. Angiographic and clinical regression of CNVM was noted in 19 patients (67.8%) on an average follow up of 15.32 +/- 3.31 months. CONCLUSION: TTT leads to stabilisation of vision in 60% of treated eyes with CNVM due to AMD.     

Cost utility of photodynamic therapy for predominantly classic neovascular age related macular degeneration

BACKGROUND/AIM: Age related macular degeneration (AMD) is the leading cause of severe vision impairment and blindness in older people throughout the developed world and currently affects around 420 000 UK citizens. Choroidal neovascularisation (CNV) is treatable with photodynamic therapy (PDT) but is expensive at over pound 1200 per treatment. The aim of this study was to assess the cost utility of PDT for better eye, predominantly classic, subfoveal choroidal neovascular lesions secondary to AMD. METHODS: Cost utility analysis (CUA) was conducted to estimate the cost effectiveness of PDT for scenarios involving reasonable (6/12) and poor (6/60) visual acuity. The models incorporated data from the Treatment of Age-related Macular Degeneration with PDT (TAP) Study and patient based utilities. The incremental CUA was based on decision analytical models, comparing treatment to a placebo comparator. Extensive one way sensitivity analysis of parameters was conducted to determine the robustness of the model. A discount rate of 6% was used for costs and quality adjusted life years (QALY). RESULTS: Model 1: in people with reasonable initial visual acuity, the cost utility of treating applicable neovascular AMD lesions was pound 31 607 per QALY saved, with a sensitivity analysis range from pound 25 285 to pound 37 928. Model 2: in people with poor initial visual acuity, the cost utility was pound 63 214 per QALY saved, with a sensitivity analysis range from pound 54 183 to pound 75 856. CONCLUSIONS: PDT treatment is the only available treatment for some forms of neovascular ("wet") AMD. Under these assumptions, PDT can be considered moderately cost effective for those with reasonable visual acuity but less cost effective for those with initial poor visual acuity. These findings have implications for ophthalmic practice and healthcare planning.     

经瞳孔温热疗法治疗渗出型老年性黄斑变性合并中心凹下脉络膜新生血管

目的 观察经瞳孔温热疗法(TTT)治疗渗出型老年性黄斑变性(AMD)合并中心凹下脉络膜新生血管(CNV)的疗效.方法 回顾分析经TTT治疗的渗出型AMD患者41例44只眼的临床资料.所有患者均经荧光素眼底血管造影(FFA)检查确诊.其中,隐匿性CNV24例26只眼,典型性CNV12例12只眼,微小典型性CNV5例5只眼.采用810 nm半导体激光进行TTT治疗.根据病灶大小选择光斑直径范围1.20～3.00 mm,能量范围160～400 mw,时间60 s.治疗次数1～3次.平均治疗1.48次,治疗后随访3～24个月,平均随访10.80个月.末次随访者40例42只眼.分别以治疗后1、3个月及末次随访时视力、眼底、FFA及光相十断层扫描(OCT)检查结果作为患眼视功能及病灶变化的观察指标,对比观察治疗前后视力改变、眼底出血渗出吸收、CNV闭合情况.结果 末次随访的42只眼中,视力不变或提高者35只眼,占83.34%;视力较治疗前减退者7只眼,占16.67%.OCT检查显示,治疗后1、3个月和末次随访时黄斑区渗液者减少率分别为79.50%、86.40%和88.10%.治疗后3个月,所有患眼黄斑容积较治疗前显著减少,差异有统计学意义(t=1.96,P=0.01);但治疗后1个月和末次随访时黄斑容积较治疗前相比,差异无统计学意义(t=1.17,0.92;P=0.19,0.83).FFA检查显示,末次随访时隐匿性、典型性和微小典型性CNV的闭合率分别为79.16%、46.15%和60.00%.仅6只眼渗漏较治疗前增加.其中,典型性CNV 5只眼,微小典型性CNV1只眼.结论 TTT治疗渗出型AMD合并典型性、隐匿型及微小典型性CNV均有一定效果.