Macular Degeneration: Farah ME

Furlani BA, Meyer CH, Rodrigues EB, Maia M, Farah ME, Penha FM, Holz FG. · Federal University of Sao Paulo, Vision Institute, Department of Ophthalmology, Sao Paulo, Brazil. · Expert Opin Emerg Drugs. · Pubmed #17979601 No free full text.

Abstract: Diabetic macular edema (DME) is the most frequent cause of severe vision impairment in patients with non-proliferative diabetic retinopathy. Even though patients should achieve optimal glycemic control, normalization of blood pressure and serum lipids, as well as improvement of cardiac and renal status, these measures alone will not prevent every patient from developing visual loss caused by DME. The goal of local treatment for DME is vision improvement, usually achieved after reducing leakage on fluorescein angiography (FA) and retinal thickness on optical coherence tomography (OCT). Laser photocoagulation is still the standard treatment for clinically significant DME. However, laser photocoagulation rarely provides major visual improvement, especially in patients with diffuse DME. Thus, a therapeutic intervention that restores visual acuity impaired by DME more often remains a significant unmet medical need. This review aims to present the most important emerging drug technologies for therapy of DME at present, including corticosteroids, vascular endothelial growth factor inhibitors, protein kinase C inhibitors, small interfering RNA, hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors and non-hormonal anti-inflammatory agents. Recent progress in this field suggests that local management of DME may change rapidly in the near future. Novel emerging drugs should enable better anatomical and functional outcomes for therapy of this sight-threatening disease.

Costa RA, Navajas EV, Farah ME, Calucci D, Cardillo JA, Scott IU. · UDAT-Retina Diagnostic and Treatment Division, Hospital de Olhos Araraquara, Rua Itália 1905, Apto 74, Araraquara, SP 14801-350, Brazil. · Prog Retin Eye Res. · Pubmed #16005406 No free full text.

Abstract: Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading cause of definitive visual impairment and legal blindness in the elderly. During the past decade, advances in ophthalmic imaging systems have enabled the recognition of presumed new distinct choroidal neovascular lesions that share some unique clinical and angiographic peculiarities as well as better comprehension of the pathophysiologic mechanisms related to such entities. Amongst presumed newer exudative maculopathies, polypoidal choroidal vasculopathy, which has been described as a distinct choroidal abnormality characterized by inner choroidal vascular network of vessels ending in polyp-like structures only identified on indocyanine green angiography and mostly affecting African-American and Asian descendents, has gained special interest from the ophthalmic community particularly because of its growing recognition among patients with clinical appearance of neovascular age-related macular degeneration. Thus far, however, the exact nature of the vascular structure of the polypoidal choroidal vasculopathy lesion remains unclear and data from recent studies have conflicted with the initial concept of a benign exudative maculopathy with long-term preservation of good vision. All together, such factors make difficult the establishment of an appropriate treatment, if any, for the entity. Herein, by using a modified technique of conventional indocyanine green angiography, we demonstrate new information about the morphologic characteristics, and to some extent the blood flow dynamics perfusion, of the polypoidal choroidal vasculopathy lesion. Our results suggest that the PCV lesion should be considered a variety of choroidal neovascularization rather than a distinct clinical entity, characterized by one single large neovascular complex presenting well-defined arterial neovascular vessels arising from one major "ingrowth site" and draining vessels that present aneurysm-like dilations corresponding to the polyp-like structures typically described for the entity. Finally, the visual acuity and angiographic findings observed after selective ingrowth site photothrombosis corroborate the existence of one major "ingrowth site" for the PCV neovascular complex and point toward a new treatment paradigm for this variety of choroidal neovascularization.

Avila MP, Farah ME, Santos A, Kapran Z, Duprat JP, Woodward BW, Nau J. · Centro de Referência em Oftalmologia, Universidade Federal de Goiás, Goiânia, Brazil. · Retina. · Pubmed #19202425 No free full text.

Abstract: PURPOSE: The purpose of this study was to evaluate the short-term safety and feasibility of intraocular, epiretinal delivery of beta radiation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration for 12 months. A 3-year follow-up period is planned to assess the long-term safety of the procedure. METHODS: In this nonrandomized, multicenter feasibility study, 34 treatment-naïve patients with predominantly classic, minimally classic, or occult lesions due to subfoveal choroidal neovascularization secondary to age-related macular degeneration received a single treatment with either 15 Gray (Gy) (8 patients) or 24 Gy (26 patients) beta radiation (strontium-90) using a novel intraocular delivery device. Adverse events and safety endpoints were observed and recorded. Visual acuity was measured preoperatively and postoperatively using standard Early Treatment Diabetic Retinopathy Study vision charts. RESULTS: Twelve months after treatment, no adverse events associated with exposure to radiation were observed. All patients in both 15 Gy (n = 4) and 24 Gy cohorts (n = 17) who met inclusion criteria and were treated according to protocol lost fewer than three lines of vision. Fifty percent (2/4) of the 15 Gy-treated patients and 76% (13/17) of the 24 Gy-treated patients improved or maintained their visual acuity at 12 months. In the 24 Gy group, 29% (5/17) gained three lines or more in visual acuity. The mean change in visual acuity observed at month 12 was +10.3 letters in the 24 Gy study cohort and -1.0 letters in the 15 Gy cohort. CONCLUSION: The short-term safety and efficacy of intraocular, epiretinal delivery of beta radiation for the treatment of subfoveal choroidal neovascularization was promising in this small study group and should be studied in a larger cohort of patients.

Arevalo JF, Fromow-Guerra J, Quiroz-Mercado H, Sanchez JG, Wu L, Maia M, Berrocal MH, Solis-Vivanco A, Farah ME, Anonymous00408. · Retina and Vitreous Service, Clinica Oftalmológica Centro Caracas, Caracas, Venezuela. · Ophthalmology. · Pubmed #17398322 No free full text.

Abstract: PURPOSE: To report the 6-month anatomic and best-corrected visual acuity (BCVA) response after primary intravitreal bevacizumab (Avastin) in patients with diabetic macular edema (DME). DESIGN: Interventional retrospective multicenter study at 6 centers from 6 countries of patients with DME. PARTICIPANTS: We reviewed the clinical records of 88 consecutive patients (110 eyes) with DME. Seventy-eight eyes of 64 consecutive patients with a minimum follow-up of 6 months and mean age of 59.7+/-9.3 years were included in this analysis. INTERVENTION: Patients were treated with at least one intravitreal injection of 1.25 mg or 2.5 mg of bevacizumab and underwent Early Treatment Diabetic Retinopathy Study (ETDRS) BCVA testing, ophthalmoscopic examination, optical coherence tomography (OCT), and fluorescein angiography (FA) at baseline and follow-up visits. Repeated-measures analysis of variance was used to compare mean values. MAIN OUTCOME MEASURES: Changes in BCVA, OCT, and FA. RESULTS: Mean follow-up was 6.31+/-0.81 months (range, 6-9). Sixteen (20.5%) eyes needed a second injection at a mean of 13.8 weeks (range, 4-28), and 6 eyes needed a third injection (7.7%) at a mean of 11.5 weeks (range, 5-20). The mean baseline BCVA was 0.87 (logarithm of the minimum angle of resolution), and the final mean BCVA was 0.6, a difference that was statistically significant (P<0.0001). Final BCVA analysis by subgroups demonstrated that 32 (41.1%) eyes remained stable, 43 (55.1%) improved > or =2 ETDRS lines of BCVA, and 3 (3.8%) decreased > or =2 ETDRS lines of BCVA. Mean central macular thickness at baseline by OCT was 387.0+/-182.8 mum and decreased to a mean of 275.7+/-108.3 at end of follow-up (P<0.0001). No ocular or systemic adverse events were observed. CONCLUSIONS: Primary intravitreal bevacizumab at doses of 1.25 to 2.5 mg seem to provide stability or improvement in VA, OCT, and FA in DME at 6 months. Follow-up is still short to make any specific treatment recommendations; however, the results appear promising. Evaluation in a multicenter randomized controlled clinical trial with longer follow-up is needed.

Cardillo JA, Melo LA, Costa RA, Skaf M, Belfort R, Souza-Filho AA, Farah ME, Kuppermann BD. · Hospital de Olhos de Araraquara, Araraquara, São Paulo, Brazil. · Ophthalmology. · Pubmed #16019075 No free full text.

Abstract: PURPOSE: To compare the safety and efficacy of intravitreal versus posterior Sub-Tenon's capsule injection of triamcinolone acetonide for diffuse diabetic macular edema. DESIGN: Prospective, double-masked, randomized controlled trial. PARTICIPANTS: Twelve patients (24 eyes) with bilateral diffuse diabetic macular edema. INTERVENTION: One eye of each patient was randomly assigned to receive a single 4-mg triamcinolone acetonide intravitreal injection and the fellow eye to receive a 40-mg triamcinolone acetonide posterior Sub-Tenon's capsule injection. MAIN OUTCOME MEASURES: Changes in visual acuity and central macular thickness obtained using optical coherence tomography were measured during a 6-month follow-up. Potential treatment complications were monitored, including increases in intraocular pressure (IOP) and cataract progression. RESULTS: Both intravitreal and Sub-Tenon's capsule injections of triamcinolone acetonide resulted in significant but transient improvements in central macular thickness. The mean (+/-standard deviation [SD]) central macular thickness in eyes with intravitreal injection was significantly thinner than in the Sub-Tenon's capsule-injected eyes at 1 month (226.8+/-41.7 microm and 431.5+/-165.8 microm, respectively; P = 0.002) and 3 months (242.3 +/- 93.9 microm and 364.7+/-78.2 microm, respectively; P = 0.005) after triamcinolone acetonide injection. The mean visual acuity (logarithm of the minimum angle of resolution) in the intravitreally injected eyes was significantly better than in the Sub-Tenon's capsule-injected eyes at 3 months post injection (0.832+/-0.293 and 1.107+/-0.339, respectively; P = 0.004). Intraocular pressure did not show any significant difference between the 2 forms of triamcinolone acetonide delivery at any follow-up visit, and no eyes had IOPs >25 mmHg. CONCLUSIONS: The findings from our study neither advocate nor support the use of corticosteroids for the treatment of diabetic macular edema, but do imply that both intravitreal and Sub-Tenon's capsule injections of triamcinolone acetonide may be equally tolerated, with short-term performance clearly favoring the intravitreal (4 mg) more than the SBT capsule (40 mg) route for the anatomic and functional aspects of improvement tested in this investigation.

Costa RA, Scapucin L, Moraes NS, Calucci D, Melo LA, Cardillo JA, Farah ME. · Instituto da Visão--IPEPO, Department of Ophthalmology, Federal University of São Paulo, Brazil. · Curr Eye Res. · Pubmed #12658548 No free full text.

Abstract: PURPOSE: To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis (IMP) in the management of patients with persistent central serous chorioretinopathy (CSC). METHODS: Interventional noncomparative case series. Eleven patients with CSC presenting with persistent subretinal fluid in optical coherence tomography (OCT) four months after presentation and decrease in visual acuity (VA) were submitted to a single IMP session with 2 mg/kg body weight ICG and application of 5.6 W/cm(2) light at 810 nm. A continuous follow-up was provided with best-corrected ETDRS VA assessment, and angiographic and OCT documentation 72 hours before and at 2 days, 1 and 2 weeks, 1, 3, 6, and 12 months after treatment. RESULTS: Pretreatment VA levels ranged from 20/32 - 1 to 20/100 (mean, 20/63 + 2 [logMAR equivalent, 0.460 +/- 0.155]); post treatment levels ranged from 20/25 - 2 to 20/20 (mean, 20/20 - 2 [logMAR equivalent, 0.038 +/- 0.048]). Ten out of eleven patients presented with VA levels of >/=20/25 2 weeks after treatment; the mean logMAR VA change of 0.345 at that time was statistically significant (p < 0.05, Friedman test). OCT disclosed resolution of persistent subretinal fluid in all eyes. No recurrence was observed after 12 months of follow-up. Complications included transient retinal whitening in two patients, and associated occlusion of retinal capillaries in one. CONCLUSIONS: Photothrombosis using low-intensity 810 nm light to direct laser energy continuously at the active leakage sites after intravenous ICG infusion induced rapid VA recovery in patients with persistent CSC; accordingly, restoration of the macular architecture was evidenced on OCT, and no recurrence was noted 12 months after IMP.

Oshima A, Berezovsky A, Salomão SR, Sacai PY, Costa RA, Bordon AF, Farah ME. · Universidade Federal de São Paulo - São Paulo (SP) - Brasil. · Arq Bras Oftalmol. · Pubmed #19347117 links to  free full text

Abstract: PURPOSE: To evaluate macular function by focal electroretinography and fluorescein angiography (FA) in patients with neovascular age-related macular degeneration submitted to verteporfin photodynamic therapy (VPT). METHODS: Prospective study involving 22 patients with age-related macular degeneration and predominantly classic subfoveal neovascular membrane, in non consecutive series, treated with VPT and followed for 12 months. They had their best corrected visual acuity measured by ETDRS chart, changes of lesion measured by fluorescein angiography and cone function assessed by focal electroretinography at baseline and each 3-month follow-up. RESULTS: All 22 patients completed the scheduled follow-up. After a mean of 3.5 sessions of treatment per patient, the mean visual acuity variation was not significant at the end of study. Eleven patients showed variation > or =1 line. 86% of patients achieved stabilization of lesion leakage at the end of the study. Focal electroretinography showed a mean of 194.88 nV in amplitude and 29.19 ms in latency and did not present a significant variation during treatment. CONCLUSIONS: There were no significant differences in focal electroretinography amplitudes and latencies after a 9-month period. Visual acuity did not show important variations during the 12 months. The decrease of lesion size showed a significant difference at 12 months with negative correlation between the amplitude of focal electroretinography and best corrected visual acuity.

Arevalo JF, Sanchez JG, Fromow-Guerra J, Wu L, Berrocal MH, Farah ME, Cardillo J, Rodríguez FJ, Anonymous00014. · Retina and Vitreous Service, Clinica Oftalmológica Centro Caracas, Caracas, Venezuela. · Graefes Arch Clin Exp Ophthalmol. · Pubmed #19189118 No free full text.

Abstract: BACKGROUND: To report the 12-month anatomic and ETDRS best-corrected visual acuity (BCVA) response after primary intravitreal bevacizumab (Avastin) (1.25 mg or 2.5 mg) in patients with diffuse diabetic macular edema (DDME). In addition, a comparison of the two different doses of intravitreal bevacizumab (IVB) utilized was made. METHODS: We reviewed the clinical records of 82 consecutive patients (101 eyes) with DDME in this interventional retrospective multicenter study. All patients with a minimum follow-up of 12 months (mean 57.6 +/- 8.4 weeks) were included in this analysis. Patients underwent ETDRS best-corrected visual acuity (BCVA) testing, ophthalmoscopic examination, optical coherence tomography (OCT), and fluorescein angiography (FA) at baseline and follow-up visits. RESULTS: The mean age of our patients was 59.7 +/- 9.3 years. The mean number of IVB injections per eye was three (range: one to six injections) at a mean interval of 14.1 +/- 10.5 weeks. In the 1.25 mg group at 1 month BCVA improved from 20/190, logMAR = 0.97 to 20/85, logMAR 0.62, a difference that was statistically significant (p = 0.0001). This improvement was maintained throughout the 3-, 6-, and 12-month follow-up. The mean final BCVA at 12 months was 20/76, logMAR = 0.58 (p < 0.001), a statistically significant difference from baseline BCVA. Similar BCVA changes were observed in the 2.5 mg group. In the 1.25 mg group, the mean central macular thickness (CMT) decreased from 419.1 +/- 201.1 microm at baseline to 295.11 +/- 91.5 microm at 1 month, 302.1 +/- 124.2 microm at 3 months, 313.4.1 +/- 96.3 microm at 6 months, and 268.2 +/- 95.5 microm at 12 months (p < 0.0001). Similar CMT changes were observed in the 2.5 mg group. Adverse events included transient high blood pressure in one patient (1.2%), transient increased intraocular pressure in one eye (1%), and tractional retinal detachment in one eye (1%). CONCLUSIONS: Primary IVB at doses of 1.25 to 2.5 mg seem to provide stability or improvement in BCVA, OCT, and FA in DDME at 12 months. There seems to be no difference in our results between intravitreal bevacizumab at doses of 1.25 mg or 2.5 mg. In addition, our results suggest the need for at least three injections a year to maintain the BCVA results.

Bordon AF, Oshima A, Guia TA, Calucci D, Sallum JM, Farah ME. · Departamento de Oftalmologia da Universidade Federal de São Paulo - São Paulo (SP) - Brasil. · Arq Bras Oftalmol. · Pubmed #19169509 links to  free full text

Abstract: PURPOSE: To identify the optical coherence tomography (OCT) findings in patients with age-related macular degeneration (ARMD) treated with photodynamic therapy (PDT). STUDY DESIGN: Open, non-randomized, interventional case series. METHODS: ARMD patients were submitted to a complete ophthalmological examination, fluorescein angiography, and OCT at baseline (V0), 3, 6, 9 and 12 months (V3, V6, V9 and V12, respectively). PDT was carried out according to the TAP study. Visual acuity (VA) was measured using the logMAR ETDRS chart. The following foveal measurements were performed: foveal intraretinal thickness (FIRT), foveal choriocapillaris - RPE complex thickness (FCC-RPET) and total foveal thickness (TFT). The extrafoveal thicknesses measured were: extrafoveal intraretinal thickness (EFIRT), extrafoveal choriocapillaris - RPE complex thickness (EFCC-RPET) and total extrafoveal thickness (TEFT). Statistical analysis was performed using the block variance analysis test. RESULTS: Twenty-three eyes of 23 patients were enrolled. This study identified nine OCT patterns: 1) thickening of the foveal intraretinal layers; 2) thickening of the extrafoveal intraretinal layers; 3) thickening of the foveal choriocapillaris - RPE complex; 4) thickening of the extrafoveal choriocapillaris - RPE complex; 5) intraretinal fluid; 6) subretinal fluid; 7) subretinal pigment epithelium (RPE) fluid; 8) vitreo-retinal adhesion; 9) foveal depression. At baseline, FIRT and TFT were 398.5 micro and 639.2 micro, respectively. At V12 they were 173.7 micro e 423.9 micro, respectively, and this change was statistical significant (p=0.008 e p=0.003, respectively). The variation of the other foveal and extrafoveal measurements were not statistically significant. Foveal depression was present at baseline in 36.4% of the eyes, whereas at V12 it was present in 78.3%. Subretinal fluid was present in 36.4% of eyes at V0 and in 8.7% at V12. VA at baseline was 0.93 and it V12 was 1.04 (p=0,127). CONCLUSIONS: Visual acuity was stable throughout the study. Foveal depression was reestablished in 78.3% at V12. FIRT and TFT decreased at a statistical significant level, from V0 to V12.

Avila MP, Farah ME, Santos A, Duprat JP, Woodward BW, Nau J. · Centro Brasileiro de Cirurgia de Olhos, CEP 74210-010 Goiânia-Goiás, Brazil. · Br J Ophthalmol. · Pubmed #19019935 No free full text.

Abstract: BACKGROUND/AIMS: This study evaluated the short-term safety and feasibility of epiretinal strontium-90 brachytherapy delivered concomitantly with intravitreal bevacizumab for the treatment of subfoveal CNV due to AMD for 12 months. A 3-year follow-up is planned. METHODS: In this prospective, non-randomised, multicentre study, 34 treatment-naïve patients with predominantly classic, minimally classic and occult subfoveal CNV lesions received a single treatment with 24 Gy beta radiation (strontium-90) and two injections of the anti-VEGF antibody bevacizumab. Adverse events were observed. BCVA was measured using standard ETDRS vision charts. RESULTS: Twelve months after treatment, no radiation-associated adverse events were observed. In the intent-to-treat (ITT) population, 91% of patients lost <3 lines (15 ETDRS letters) of vision at 12 months, 68% improved or maintained their BCVA at 12 months, and 38% gained >/=3 lines. The mean change in BCVA observed at month 12 was a gain of 8.9 letters. CONCLUSION: The safety and efficacy of intraocular, epiretinal brachytherapy delivered concomitantly with anti-VEGF therapy for the treatment of subfoveal CNV secondary to AMD were promising in this small study population. Long-term safety will be assessed for 3 years. This regimen is being evaluated in a large, multicentre, phase III study.

Wu L, Martínez-Castellanos MA, Quiroz-Mercado H, Arevalo JF, Berrocal MH, Farah ME, Maia M, Roca JA, Rodriguez FJ, Anonymous00001. · Instituto de Cirugía Ocular, San José, Costa Rica. · Graefes Arch Clin Exp Ophthalmol. · Pubmed #17674014 No free full text.

Abstract: BACKGROUND: Vascular endothelial growth factor (VEGF) plays an important role in many diseases of the posterior pole that are characterized by macular edema and/or intraocular neovascularization. Recently anti-VEGF agents such as ranibizumab and pegaptanib sodium have been shown to be beneficial in the treatment of choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD). However in most parts of the world, both pegaptanib sodium and ranibizumab are not readily available. Bevacizumab, a humanized recombinant monoclonal IgG antibody that binds and inhibits all VEGF isoforms, has been proposed as an alternative treatment option. METHODS: A total of 1,265 consecutive patients were injected with bevacizumab for diseases such as proliferative diabetic retinopathy, diabetic macular edema, retinal vein occlusions, and CNV of several etiologies including ARMD at eight Latin American institutions from 1 September 2005 to 31 January 2006. Of these 1,265, 92 were excluded because they were injected once and lost to follow-up. The remaining 1,173 patients constitute the subjects of this retrospective, multicenter, open label, uncontrolled interventional case series that reports the cumulative systemic and ocular adverse events following intravitreal bevacizumab during 12 months of follow-up. Patients were examined at baseline and then monthly. If the patients were unable to attend the 12-month visit, a telephone interview was conducted to assess for possible systemic complications. RESULTS: A total of 4,303 intravitreal injections of bevacizumab on 1,310 eyes was reported. All 1,173 patients were accounted for at the 12-month visit. Systemic adverse events were reported in 18 (1.5%) patients. These included seven (0.59%) cases of an acute elevation of systemic blood pressure, six (0.5%) cerebrovascular accidents, five (0.4%) myocardial infarctions, two (0.17%) iliac artery aneurysms, two (0.17%) toe amputations and five (0.4%) deaths. Ocular complications included seven (0.16%) bacterial endophthalmitis, seven (0.16%) tractional retinal detachments, four (0.09%) uveitis, and a case (0.02%) each of rhegmatogenous retinal detachment and vitreous hemorrhage. CONCLUSION: Despite the limited follow-up, repeated intravitreal injections of either 1.25 mg or 2.5 mg of bevacizumab appears to be safe and well tolerated during the 1st year.

Aggio FB, Farah ME, de Melo GB, d'Azevedo PA, Pignatari AC, Höfling-Lima AL. · Vision Institute, Federal University of São Paulo, São Paulo, Brazil. · Eye. · Pubmed #17277758 No free full text.

Abstract: PURPOSE: To report two cases of acute endophthalmitis following intravitreal bevacizumab injection. METHODS: Two patients with exudative age-related macular degeneration were treated sequentially with an intravitreal injection of bevacizumab and developed signs of severe but painless infectious endophthalmitis 2 days later. Vitreous samples were obtained, followed by the injection of vancomycin 1 mg/0.1 ml and ceftazidime 2.25 mg/0.1 ml. Pulsed-field gel electrophoresis (PFGE) was used to determine whether the isolated microorganisms were the same. RESULTS: Coagulase-negative staphylococci were identified and isolated from the vitreous specimen of both patients. PFGE revealed different patterns of banding, excluding that interpatient contamination occured. CONCLUSIONS: Infectious endophthalmitis is a potential complication of intravitreal bevacizumab injection.

Aggio FB, Farah ME, Silva WC, Melo GB. · Vision Institute, Federal University of São Paulo, São Paulo, Brazil. · Graefes Arch Clin Exp Ophthalmol. · Pubmed #17139490 No free full text.

Abstract: BACKGROUND: Photodynamic therapy with verteporfin (PDT) significantly reduces the risk of vision loss in patients with exudative age-related macular degeneration (AMD). Indocyanine green-mediated photothrombosis (IMP) and trans-pupillary thermotherapy (TTT) may also be beneficial for selective cases of exudative AMD. However, a substantial subset of patients responds poorly to these treatments. Intravitreal bevacizumab (IVB) has been recently used in the treatment of exudative AMD, showing both visual and anatomic improvement in the majority of cases. METHODS: This interventional retrospective case series reports the effects of IVB in 17 eyes with subfoveal neovascular AMD that had undergone repeated PDT (combined or not with triamcinolone acetonide) or PDT followed by either IMP or TTT with poor results. The main outcome measures were visual acuity and tomographic signs of intra/subretinal fluid, as well as central retinal thickness. RESULTS: Most patients received a single IVB injection. The mean follow-up was 4.47 months. The mean logMAR visual acuity changed from 1.17 +/- 0.40 to 1.06 +/- 0.44 (P = 0.17). The mean central retinal thickness decreased from 404.05 +/- 245.26 to 280.23 +/- 143.14 microm (P = 0.032). At the end of the study, lack of tomographic signs of intra/ subretinal fluid was noted in four (23.5%) eyes. No ocular or systemic side effects were identified. CONCLUSIONS: Short-term results with IVB for the treatment of exudative AMD have been promising. However, the chronic retinal and pigment epithelium changes frequently present in eyes that underwent multiple previous treatments may limit complete visual recovery. To our knowledge, this is the first report on the use of IVB for this particular group of AMD patients.

Meirelles RL, Aggio FB, Costa RA, Farah ME. · Department of Ophthalmology, Instituto da Visão-IPEPO, Federal University of São Paulo, Rua Botucatu 822, São Paulo, SP 04023-900, Brazil. · Graefes Arch Clin Exp Ophthalmol. · Pubmed #15660280 No free full text.

Abstract: PURPOSE: To report the STRATUS optical coherence tomography (STRATUSOCT) findings in a patient with unilateral coloboma-like excavation of the optic disc without pit but secondary retinoschisis, as well as to discuss the possible involved pathophysiologic mechanisms. METHODS: Observational case report. STRATUSOCT findings in a 66-year-old woman with a coloboma-like excavation of the optic disc without pit but secondary retinoschisis encompassing the macular region, along with evidence of a mild epiretinal membrane superonasal to the disc were evaluated. RESULTS: STRATUSOCT showed signs of a connection between the perineural space and the inner retinal layers on the temporal optic disc border, as well as schisis-like changes extending from the disc to the macula, with cystoid degeneration and two lamellar holes in their nasal portion. CONCLUSION: The use of third generation OCT afforded an enhanced visualization of retinal structures, revealing signs of fluid at several distinct levels, as well as deep and superficial inner breaks apart from the schisis cavity. We are unaware of such previous reports, and could find no reference to them in a computerized search using MEDLINE. In addition, our study supports a common pathomechanism for the development of macular complications in optic pits and colobomas.

Farah ME, Cardillo JA, Luzardo AC, Calucci D, Williams GA, Costa RA. · Department of Ophthalmology, Instituto da Visão-IPEPO, Federal University of São Paulo, School of Medicine, Brazil. · Br J Ophthalmol. · Pubmed #15258024 links to  free full text

Abstract: AIMS: To study the effectiveness of indocyanine green mediated photothrombosis in the management of predominantly classic subfoveal choroidal neovascularisation associated with age related macular degeneration. METHODS: Prospective, non-comparative, interventional case series of nine patients with predominantly classic subfoveal choroidal neovascularisation secondary to age related macular degeneration who declined photocoagulation or verteporfin photodynamic therapy. Patients were submitted to one or more treatments with an intravenous injection of a small volume of high concentration indocyanine green solution followed by low irradiance, large spot 810 nm continuous laser application via a transpupillary approach. Main outcome measures were change in best corrected visual acuity and macular exudative manifestations. RESULTS: After 12 months of follow up, the final best corrected visual acuity was the same (plus or minus two ETDRS lines) in five eyes (55%), improved more than two ETDRS lines in three eyes (33%), and worsened by more than two lines in the remaining eye. The improved vision was probably related to partial or complete restoration of the macular architecture as a result of fluid resolution, whereas the worsened vision was primarily the result of treatment failure in achieving substantial choroidal neovascular occlusion. There were no complications related to the procedure. CONCLUSION: Indocyanine green mediated photothrombosis may be an effective alternative treatment for predominantly classic subfoveal choroidal neovascularisation caused by age related macular degeneration.

Sallum JM, Farah ME, Saraiva VS. · Department of Ophthalmology, Federal University of São Paulo, R. Botucatu 822, São Paulo, SP, Brazil 04023-062. · Adv Exp Med Biol. · Pubmed #15180250 No free full text.

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Suzuki CR, Farah ME. · Department of Ophthalmology, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil. · Can J Ophthalmol. · Pubmed #15040617 No free full text.

Abstract: BACKGROUND: Retinal detachment has been reported after laser in situ keratomileusis (LASIK) in myopic eyes. This complication may be related to the risk from myopia before surgery or may be induced by LASIK surgery itself. We performed a study to evaluate retinal peripheral changes after LASIK in patients with high myopia and to correlate symptoms on presentation and vitreoretinal anatomic changes. METHODS: The study was carried out at a university-affiliated hospital in São Paulo between November 1997 and February 1999. Patients scheduled to undergo LASIK were included if their spherical equivalent was greater than 6.00 dioptres. The exclusion criteria were previous retinal treatment and myopic macular degenerations. We performed binocular indirect ophthalmoscopy with scleral indentation and fundus biomicroscopy with Goldmann lens before LASIK and 1, 3 and 6 months after surgery. RESULTS: We examined 198 eyes preoperatively. Of the 198, 50 did not undergo LASIK surgery owing to refractive criteria, and 79 were lost to follow-up. We thus studied 69 eyes. The mean spherical equivalent preoperatively was -8.00 D (standard deviation 1.95 D). Twenty-four eyes had normal retinal periphery preoperatively; all 24 remained without alterations after LASIK. Forty-five eyes had peripheral alterations: 17 (24.6%) had cystic degeneration, 14 (20.3%) had lattice degeneration, 11 (15.9%) had white-without-pressure, 5 (7.2%) had cystic tufts, 3 (4.3%) had pavingstone degeneration, 2 (2.9%) had pigmentary alteration, 1 (1.4%) had holes with free operculum, and 1 (1.4%) had punctiform holes. The only alteration after surgery was almost punctiform holes around the previous cystic tuft 1 month after surgery in one patient. Retinal detachment did not develop in any of the eyes. INTERPRETATION: In this group of patients it appears that LASIK did not lead to progressive peripheral retinal lesions in asymptomatic patients during the period studied.

Andrade RE, Farah ME, Costa RA. · Instituto da Visão-IPEPO, Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil. · Am J Ophthalmol. · Pubmed #14644242 No free full text.

Abstract: PURPOSE: To describe the effects of photodynamic therapy using verteporfin for the treatment of subfoveal choroidal neovascularization (CNV) in Best vitelliform macular dystrophy. DESIGN: Interventional case report. METHODS: A 43-year-old patient with confirmed Best vitelliform macular dystrophy complicated with subfoveal CNV received a single photodynamic therapy session with verteporfin. The patient was prospectively followed with fluorescein angiography and optical coherence tomography. RESULTS: A regression of the neovascular lesion and resolution of the exudative manifestations was observed 3 weeks after treatment; at that time, visual acuity had improved from 20/60 to 20/25. Optical coherence tomography disclosed restoration of normal macular architecture due to fluid resolution and lesion contraction. Up to 2 years from this single treatment, no further change was observed. CONCLUSIONS: Regression of CNV and resolution of subretinal hemorrhage as well as exudative manifestations occurred after photodynamic therapy with verteporfin. Verteporfin therapy may be a viable treatment for subfoveal neovascular lesions in Best vitelliform macular dystrophy.

Saraiva VS, Sallum JM, Farah ME. · Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil. · Ophthalmic Surg Lasers Imaging. · Pubmed #14509465 No free full text.

Abstract: A case of cystoid macular edema related to retinitis pigmentosa treated with intravitreal injection of triamcinolone acetonide is described. A 30-year-old white man with retinitis pigmentosa and progressive visual loss presented with a best-corrected visual acuity of 20/40 in the right eye and 20/80 in the left eye. Examination revealed cystoid macular edema in both eyes. After failure of treatment with oral acetazolamide, intravitreal injection of 0.1 mL of triamcinolone acetonide 0.4% solution was performed in both eyes. In the left eye, macular edema resorbed and visual acuity improved to 20/50. However, 6 months after injection, visual acuity worsened because of recurrence of cystoid macular edema. In the right eye, cystoid macular edema also resorbed, but visual acuity was unchanged. Intravitreal triamcinolone acetonide may be useful for selected cases of cystoid macular edema related to retinitis pigmentosa.

Costa RA, Farah ME, Cardillo JA, Calucci D, Williams GA. · IPEPO, Instituto da Visão, Department of Ophthalmology, Federal University of São Paulo, Brazil. · Retina. · Pubmed #12707593 No free full text.

Abstract: PURPOSE: To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV), the authors evaluated the retinal and choroidal response immediately after treatment with serial optical coherence tomography (OCT) and indocyanine green angiography (ICGA). METHODS: This study was a prospective, noncomparative case series. PDT was performed on nine eyes of nine consecutive patients who presented with subfoveal CNV due to age-related macular degeneration, and serial evaluation with OCT as well as ICGA was performed at 20-minute intervals for the first 2 hours and then at 1 week, 1 month, and 3 months. RESULTS: In the first 2 hours after PDT, OCT showed an increase in the thickness of the retina in the treatment area due to fluid leakage from the neovascular complex as confirmed by ICGA. At 1 week, marked reduction of intraretinal/subretinal fluid was observed in all patients. Neovascular complex nonperfusion by ICGA was associated with some degree of choroidal hypoperfusion in the treatment area. Return of the foveal contour by OCT was optimal after 1 month of treatment. At 3 months, choroidal reperfusion by ICGA and recurrent intraretinal/subretinal fluid by OCT were observed. CONCLUSIONS: Serial OCT and ICGA evaluation after PDT suggests that the initial successful CNV nonperfusion as shown by fluorescein angiography at 1 week occurs by means of selective PDT damage to the lesion and/or reduced choroidal blood flow in the treatment area, thereby decreasing intraretinal/subretinal fluid and facilitating restoration of the retinal architecture.

Roizenblatt R, Farah ME, Castro J, Cardillo JA, Costa RA, Roizenblatt J. · Retina and Vitreous Department, Federal de São Paulo, EPM/UNIFESP, R Botucatu 822, Vila Clementino, São Paulo 04023-062, Brazil. · Lasers Med Sci. · Pubmed #12627272 No free full text.

Abstract: The aim of this paper is to describe various diode laser modifications and their use in treating choroidal neovascularisation in age-related macular degeneration. Diode lasers are used to treat selected choroidal neovascular membranes. Alterations in microprocessor connectivity, and parameters such as maximum spot size, light delivery time and coupled Joule meter, were made so that ophthalmic surgeons could specify treatment possibilities. A trimodal (photocoagulation, transpupillary thermotherapy and photodynamic therapy) application laser device coupled to a single light source has been developed. The new diode laser modifications were technically successful. Microprocessor connectivity was obtained, larger spot sizes were achieved, light delivery time could be extended and energy parameters were available at the display.

Andrade RE, Farah ME, Cardillo JA, Höfling-Lima AL, Uno F, Costa RA. · Department of Ophthalmology, Paulista School of Medicine, Federal University of São Paulo, Brazil. · Acta Ophthalmol Scand. · Pubmed #11952492 No free full text.

Abstract: A 29-year-old black male with Best's dystrophy presented an elevated choroidal neovascular membrane in the right eye that was diagnosed and followed with fluorescein-indocyanine green angiography and optical coherence tomography. The subretinal neovascularization was successfully treated with argon laser photocoagulation. One month later, the visual acuity improved and an optical coherence tomography confirmed regression of the serous macular detachment. The final clinical picture remained stable for 12 months of follow-up.

Costa RA, Farah ME, Cardillo JA, Belfort R. · Department of Ophthalmology, Federal University of São Paulo, Paulista School of Medicine, São Paulo, Brazil. · Curr Eye Res. · Pubmed #11852428 No free full text.

Abstract: PURPOSE: To report two cases of occult subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) that were successfully treated utilizing large spot, low irradiance 810-nm light and intravenous injection of small-volume, high-concentration indocyanine green (ICG) bolus, termed ICG-mediated photodynamic therapy (i-PDT). METHODS: Case report. Two patients with occult subfoveal CNV (two eyes) due to AMD were treated with i-PDT and were prospectively followed with fluorescein and indocyanine green angiography as well as optical coherence tomography (OCT). RESULTS: Both patients presented a 3-line increase in visual acuity by twelve months of follow-up. A significant regression of the CNV was demonstrated by fluorescein angiography within one week following treatment. OCT revealed diminishing of the subretinal fluid. There were no complications related to the procedure. CONCLUSION: i-PDT induced CNV regression and improved the visual acuity in these particular cases, suggesting a new and promising way to treat neovascular AMD. The partial anatomical restoration associated to the improvement of the visual function observed in both patients suggests that a selective therapeutic effect was achieved. Further studies are required not only to assess the clinical value of this treatment but also to better understand the major mechanism of action involving this novel treatment modality.

Melo GB, Farah ME, Aggio FB. · No affiliation provided · Acta Ophthalmol Scand. · Pubmed #17313405 No free full text.

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