Macular Degeneration: Mittra RA

Mittra RA, Singerman LJ. · VitreoRetinal Surgery, Minneapolis, Minnesota, USA. · Optom Vis Sci. · Pubmed #11999147 No free full text.

Abstract: Choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) can cause rapid and severe central vision loss in many older people. Until recently, the only treatment proven beneficial was thermal laser photocoagulation, which was applicable to only a small subset of patients. Furthermore, the thermal laser damaged the retina overlying the CNV, which is especially problematic for lesions involving the foveal center. Photodynamic therapy is a new treatment consisting of intravenous infusion of a drug that is then activated by a low-energy laser, causing damage to CNV. Photodynamic therapy with verteporfin (Visudyne, Novartis AG) has been shown to reduce the risk of moderate and severe vision loss in patients with predominantly classic subfoveal CNV secondary to AMD. With the advent of verteporfin therapy, eye care providers will play an increasingly important role in managing patients with AMD, especially in the early detection and rapid referral of appropriate cases.

Dhalla MS, Shah GK, Blinder KJ, Ryan EH, Mittra RA, Tewari A. · Barnes Retina Institute, St Louis, MO, USA. · Retina. · Pubmed #17151484 No free full text.

Abstract: PURPOSE: To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: This is a retrospective series of 24 eyes with juxtafoveal or subfoveal CNV secondary to AMD. Patients were treated with PDT with verteporfin and 1.25 mg of intravitreal bevacizumab. All patients were naive to treatment and had either treatment within a 14-day interval. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and retreatment rate. RESULTS: At the 7-month follow-up, 20 (83%) of 24 patients had stabilization of visual acuity. Sixteen eyes (67%) had improvement in visual acuity. Mean improvement in visual acuity (n = 24) was 2.04 Snellen lines. Fifteen eyes (63%) required only a single combined treatment for CNV resolution. There were no complications, including endophthalmitis, uveitis, and ocular hypertension. CONCLUSION: The results of this study suggest that combined treatment of PDT with verteporfin and intravitreal bevacizumab may be useful in treating neovascular AMD by reducing retreatment rates and improving visual acuity. Further investigation with large, controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Kim JE, Pollack JS, Miller DG, Mittra RA, Spaide RF, Anonymous00322. · Medical College of Wisconsin, Milwaukee, USA. · Retina. · Pubmed #18463518 No free full text.

Abstract: PURPOSE:: To determine safety and efficacy of intravitreal triamcinolone acetonide (IVTA) for refractory clinically significant diabetic macular edema (DME). DESIGN:: Prospective, randomized, dose-escalation pilot study comparing single injection of 2 mg versus 4 mg doses of IVTA. METHODS:: Inclusion criteria included clinically significant DME persisting >/=3 months after maximal laser treatment and visual acuity </=20/40. Best-corrected ETDRS vision, intraocular pressure, presence of DME, and fluorescein angiography (FA) were evaluated at 3 months and 6 months after injection. RESULTS:: Mean change in visual acuity at 3 months compared to baseline was 7.1 letters (P = 0.01) in the 2 mg group and 12.5 letters in the 4 mg group (P < 0.0001). However, there was not a significant difference in visual improvement between the 2 mg and 4 mg dose groups (P = 0.11). Vision improved >15 letters at 3 months in 23% (3/13) of 2 mg group and in 33% (5/15) of 4 mg group (P = 0.69), and 0% (0/11) and 21% (3/14) at 6 months, respectively (P = 0.23). Visual improvement was more likely in cystoid-type DME than diffuse DME. Intraocular pressure rise of >/=10 mmHg occurred in 19% (3/16) of 2 mg group and 41% (7/17) of 4 mg group. CONCLUSIONS:: Both doses of IVTA were well tolerated and had significant positive effects on refractory DME for short term. There were consistent trends throughout the study that suggest that a 4 mg IVTA may be more effective than a 2 mg dose. The benefit of IVTA was greater for cystoid-type DME.

Smith BT, Dhalla MS, Shah GK, Blinder KJ, Ryan EH, Mittra RA. · Barnes Retina Institute, St. Louis, Missouri, USA. · Retina. · Pubmed #18463509 No free full text.

Abstract: PURPOSE: To report the outcome for eyes treated with intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy (PDT) for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). STUDY DESIGN AND PARTICIPANTS: Interventional, consecutive, retrospective case series including 40 eyes of 40 patients with newly diagnosed juxtafoveal or subfoveal CNV secondary to AMD. METHODS: The charts of patients treated with a 1.25-mg intravitreal injection of bevacizumab followed by PDT within a 2-week period were reviewed. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and need for retreatment. RESULTS: Thirty-three (83%) of 40 eyes had stabilization of visual acuity. Mean improvement in visual acuity was 1.73 lines. Twenty-six eyes (65%) required only a single intravitreal injection of bevacizumab combined with PDT. Of the 23 eyes with 12 months of follow-up, 17 (74%) had stabilization of visual acuity, while 9 (40%) had improvement in visual acuity (mean, 1.22 Snellen lines). Eleven eyes (48%) required only a single combined treatment for CNV resolution at the 12-month follow-up. Fifteen (88%) of 17 eyes with only 6 months of follow-up required only a single combined treatment. There were no complications such as endophthalmitis, uveitis, or ocular hypertension. CONCLUSION: These findings suggest that eyes treated with both intravitreal injection of bevacizumab and PDT require none to a minimal number of re-treatments to have stabilization of vision, even at 12 months of follow-up. Further investigation with large controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Mittra RA. · VitreoRetinal Surgery, P.A., Edina, USA. · Minn Med. · Pubmed #12797657 No free full text.

Abstract: The estimated increase in life expectancy of the U.S. population will result in a greater incidence of age-related macular degeneration (AMD) in the next few decades. Exudative AMD, which is characterized by choroidal neovascularization, carries a high risk of severe central vision loss and can compromise an individual's independence and quality of life. The increasing burden of AMD has created an acute need for more effective treatments. Results from a recent large-scale study have shown that supplementation with antioxidants and zinc reduces the risk of progression of dry to exudative AMD. Standard thermal laser photocoagulation can reduce the risk of central vision loss in exudative AMD in a limited number of patients. The recent advent of photodynamic laser therapy has increased the number of patients with exudative AMD who can benefit from treatment. This paper summarizes the clinical presentation of AMD and reviews treatments that are currently available, as well as treatments in development.