Macular Degeneration: Puliafito CA

Moshfeghi AA, Puliafito CA. · Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA. · Expert Opin Investig Drugs. · Pubmed #15926872 No free full text.

Abstract: This article reviews pegaptanib sodium, a compound developed by Eyetech Pharmaceuticals Inc. and Pfizer Inc., for the treatment of neovascular age-related macular degeneration (AMD). Traditional treatment approaches to neovascular AMD have included destructive therapies such as thermal laser photocoagulation and photodynamic therapy; the use of pegaptanib sodium heralds a new treatment approach that is a non-destructive therapy based on the inhibition of vascular endothelial growth factor activity in the eye. This diminishes the neovascular drive in the pathologically hyperpermeable state of the diseased eye. Pegaptanib sodium is one of the first therapeutics belonging to the class of compounds known as aptamers. The chemistry, mechanism of action, pharmacokinetics and rationale for the clinical use of the drug are reviewed. The article highlights and summarises the results of the multi-centre, randomised, sham-controlled clinical trials with pegaptanib sodium to treat subfoveal choroidal neovascularisation in AMD. In addition, the safety profile is reviewed.

Fung AE, Lalwani GA, Rosenfeld PJ, Dubovy SR, Michels S, Feuer WJ, Puliafito CA, Davis JL, Flynn HW, Esquiabro M. · Pacific Eye Associates, California Pacific Medical Center, San Francisco, California, USA. · Am J Ophthalmol. · Pubmed #17386270 No free full text.

Abstract: PURPOSE: To evaluate an optical coherence tomography (OCT)-guided, variable-dosing regimen with intravitreal ranibizumab for the treatment of patients with neovascular age-related macular degeneration (AMD). DESIGN: Open-label, prospective, single-center, nonrandomized, investigator-sponsored clinical study. METHODS: In this two-year study, neovascular AMD patients with subfoveal choroidal neovascularization (CNV) (n = 40) and a central retinal thickness of at least 300 microm as measured by OCT were enrolled to receive three consecutive monthly intravitreal injections of ranibizumab (0.5 mg). Thereafter, retreatment with ranibizumab was performed if one of the following changes was observed between visits: a loss of five letters in conjunction with fluid in the macula as detected by OCT, an increase in OCT central retinal thickness of at least 100 microm, new-onset classic CNV, new macular hemorrhage, or persistent macular fluid detected by OCT at least one month after the previous injection of ranibizumab. RESULTS: At month 12, the mean visual acuity improved by 9.3 letters (P < .001) and the mean OCT central retinal thickness decreased by 178 microm (P < .001). Visual acuity improved 15 or more letters in 35% of patients. These visual acuity and OCT outcomes were achieved with an average of 5.6 injections over 12 months. After a fluid-free macula was achieved, the mean injection-free interval was 4.5 months before another reinjection was necessary. CONCLUSION: This OCT-guided, variable-dosing regimen with ranibizumab resulted in visual acuity outcomes similar to the Phase III clinical studies, but required fewer intravitreal injections. OCT appears useful for determining when retreatment with ranibizumab is necessary.

Moshfeghi AA, Rosenfeld PJ, Puliafito CA, Michels S, Marcus EN, Lenchus JD, Venkatraman AS. · Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. · Ophthalmology. · Pubmed #17027972 No free full text.

Abstract: PURPOSE: To evaluate the safety, efficacy, and durability of bevacizumab for the treatment of subfoveal choroidal neovascularization (CNV) in patients with neovascular age-related macular degeneration (AMD). DESIGN: Open-label, single-center, uncontrolled clinical study. PARTICIPANTS: Age-related macular degeneration patients with subfoveal CNV (n = 18) and best-corrected visual acuity (VA) letter scores of 70 to 20 (approximate Snellen equivalent, 20/40-20/400). METHODS: Patients were treated at baseline with an intravenous infusion of bevacizumab (5 mg/kg) followed by 1 or 2 additional doses given at 2-week intervals. Safety assessments were performed at all visits. Ophthalmologic evaluations included protocol VA measurements, ocular examinations, and optical coherence tomography (OCT) imaging at each visit. Retreatment with bevacizumab was performed if there was evidence of recurrent CNV. MAIN OUTCOME MEASURES: Assessments of safety and changes from baseline in VA scores and OCT measurements were performed through 24 weeks. RESULTS: No serious ocular or systemic adverse events were identified through 24 weeks. The only adverse event identified was a mild elevation of mean systolic and diastolic blood pressure measurements (+11 mmHg, P = 0.004; +8 mmHg, P<0.001) evident by 3 weeks and easily controlled with antihypertensive medications. By 24 weeks, the systolic and diastolic mean blood pressures were at or below baseline measurements. Visual acuity in the study eyes improved within the first 2 weeks, and by 24 weeks, the mean VA letter score increased by 14 letters in the study eyes (P<0.001), and the mean OCT central retinal thickness measurement decreased by 112 microm (P<0.001). By 24 weeks, retreatment was needed for only 6 of the 18 study eyes, and after retreatment, the recurrent leakage was eliminated, with restoration of any lost VA. CONCLUSIONS: Systemic bevacizumab therapy for neovascular AMD was well tolerated and effective for all 18 patients through 24 weeks. By 6 months, most patients did not require any additional treatment beyond the initial 2 or 3 infusions. Despite these impressive results, it is unlikely that systemic bevacizumab will be studied in a large clinical trial because of the potential risks associated with systemic anti-VEGF therapy and the perception that intravitreal therapy is safer.

Michels S, Rosenfeld PJ, Puliafito CA, Marcus EN, Venkatraman AS. · Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida 33136, USA. · Ophthalmology. · Pubmed #15936441 No free full text.

Abstract: PURPOSE: To evaluate the short-term safety of systemic bevacizumab (Avastin, Genentech, Inc., South San Francisco, CA) and its effects on visual acuity (VA) and subfoveal choroidal neovascularization (CNV) in patients with neovascular age-related macular degeneration (AMD). DESIGN: Open-label, single-center, uncontrolled clinical study. PARTICIPANTS: Age-related macular degeneration patients with subfoveal CNV (N = 9) and best-corrected VA letter scores of 70 to 20 (approximate Snellen equivalent, 20/40-20/400). METHODS: Patients were treated at baseline with an infusion of bevacizumab (5 mg/kg), followed by 1 or 2 additional doses given at 2-week intervals. Safety assessments were performed at all visits. Ophthalmologic evaluations included protocol VA measurements and ocular examinations, along with optical coherence tomography (OCT) imaging, fluorescein angiography, and indocyanine green angiography. MAIN OUTCOME MEASUREMENTS: Safety assessments were performed, along with assessments of changes from baseline in VA scores, OCT measurements, and angiographic lesion characteristics. RESULTS: There were no serious ocular or systemic adverse events identified. By 6 weeks, the only adverse event identified was a mild elevation of systolic blood pressure (BP) (+12 mmHg; P = 0.035), and this elevation was controlled by either changing or initiating antihypertensive medication. By 12 weeks, the elevation of systolic BP was no longer significant (P = 0.51). In the study eyes, significant increases in VA were evident within 1 week of treatment, and by 12 weeks, the median and mean VA letter scores increased by 8 letters (P = 0.011) and 12 letters (P = 0.008), respectively. The median and mean central retinal thickness measurements decreased by 157 microm (P = 0.008) and 177 microm (P = 0.001), respectively. In the fellow eyes at 12 weeks, the median and mean VA letter scores increased by 27 letters (P = 0.018) and 16 letters (P = 0.012), and the median and mean central retinal thickness measurements decreased by 59 mum (P = 0.028) and 92 microm (P = 0.06). In all study eyes, angiography revealed a marked reduction or an absence of leakage from CNV. CONCLUSION: Overall, bevacizumab therapy was well tolerated, with an improvement in VA, OCT, and angiographic outcomes. Although these preliminary results are promising, a randomized controlled clinical trial is necessary before concluding that systemic bevacizumab therapy is safe and effective for patients with neovascular AMD.

Martidis A, Duker JS, Greenberg PB, Rogers AH, Puliafito CA, Reichel E, Baumal C. · Wills Eye Hospital, Philadelphia, Pennsylvania 19107, USA. · Ophthalmology. · Pubmed #11986098 No free full text.

Abstract: PURPOSE: To determine if intravitreal injection of triamcinolone acetonide is safe and effective in treating diabetic macular edema unresponsive to prior laser photocoagulation. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Sixteen eyes with clinically significant diabetic macular edema (CSME) that failed to respond to at least two previous sessions of laser photocoagulation. METHODS: Eyes were diagnosed with CSME and treated with at least two sessions of laser photocoagulation according to Early Treatment Diabetic Retinopathy Study guidelines. At least 6 months after initial laser therapy, the response was measured by clinical examination and optical coherence tomography (OCT). Eyes with a residual central macular thickness of more than 300 microm (normal, 200 microm) and visual loss from baseline were offered intravitreal injection of 4 mg triamcinolone acetonide. The visual and anatomic responses were observed as well as complications related to the injection procedure and corticosteroid medication. MAIN OUTCOME MEASURES: Visual acuity and quantitative change in OCT macular thickening were assessed. Potential complications were monitored, including intraocular pressure response, cataract progression, retinal detachment, vitreous hemorrhage, and endophthalmitis. RESULTS: All patients completed 3 months of follow-up, and 8 of 16 patients (50%) completed 6 or more months of follow-up. Mean improvement in visual acuity measured 2.4, 2.4, and 1.3 Snellen lines at the 1-, 3-, and 6-month follow-up intervals, respectively. The central macular thickness as measured by OCT decreased by 55%, 57.5%, and 38%, respectively, over these same intervals from an initial pretreatment mean of 540.3 microm (+/-96.3 microm). Intraocular pressure exceeded 21 mmHg in 5, 3, and 1 eye(s), respectively, during these intervals. One eye exhibited cataract progression at 6 months. No other complications were noted over a mean follow-up of 6.2 months. Reinjection was performed in 3 of 8 eyes after 6 months because of recurrence of macular edema. CONCLUSIONS: Intravitreal triamcinolone is a promising therapeutic method for diabetic macular edema that fails to respond to conventional laser photocoagulation. Complications do not appear to be prohibitive. Further study is warranted to assess the long-term efficacy and safety, and the need for retreatment.

Reichel E, Berrocal AM, Ip M, Kroll AJ, Desai V, Duker JS, Puliafito CA. · The New England Eye Center, Tufts University Boston, Massachusetts, USA. · Ophthalmology. · Pubmed #10519584 No free full text.

Abstract: OBJECTIVE: To evaluate the efficacy of transpupillary thermotherapy for the treatment of occult subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration. DESIGN: A retrospective, noncomparative case series. PARTICIPANTS: Sixteen eyes of 15 consecutive patients who presented with occult subfoveal choroidal neovascularization secondary to age-related macular degeneration. INTERVENTION: After informed consent was obtained, 16 eyes of 15 patients were treated with transpupillary thermotherapy. All patients underwent pretreatment fluorescein angiography and were deemed untreatable by the Macular Photocoagulation Study standard. Transpupillary thermotherapy was delivered using a diode laser at 810 nm. A variable spot size of 1.2 mm, 2.0 mm, or 3.0 mm was used depending on the size of CNV. The diode laser was delivered through a contact lens, and treatment was initiated in one spot for 60 seconds' duration at a power range between 360 and 1000 mW. The end point was an area of no visible color change to a light-gray appearance. MAIN OUTCOME MEASURES: In all eyes, outcome was assessed by Snellen chart visual acuity and clinical examination. In 10 of 16 eyes, preoperative and postoperative fluorescein angiography and optical coherence tomography were available. In the remaining 6 of 16 eyes, exudation was measured by postoperative clinical examination alone. RESULTS: Three eyes (19%) showed a two-or-more-line improvement in visual acuity over a period of 6 to 25 months. Mean follow-up was 13 months. Visual acuity remained stable (no change or one-line improvement) in nine treated eyes (56%). The remaining four eyes (25%) showed a decline (equal to one-line worsening or greater) in visual acuity. Fifteen eyes (94%) demonstrated decreased exudation on fluorescein angiography, optical coherence tomography, and/or clinical examination. CONCLUSIONS: Transpupillary thermotherapy shows no deleterious side effects in treating occult subfoveal choroidal neovascularization. A randomized, prospective study is necessary to evaluate treatment efficacy.

Gregori NZ, Gaitan J, Rosenfeld PJ, Puliafito CA, Feuer W, Flynn HW, Berrocal AM, Al-Attar L, Dubovy S, Smiddy WE, Schwartz SG, Lee WH, Murray TG. · Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St., Miami, FL 33136, USA. · Retina. · Pubmed #19430392 No free full text.

Abstract: PURPOSE: To evaluate the long-term safety and efficacy of intravitreal bevacizumab injections (Avastin, Genentech Inc., San Francisco, CA) for the treatment of macular edema secondary to central retinal vein occlusions. METHODS: A retrospective review was performed of eyes treated from May 2005 to August 2006 with follow-up through February 2007. The dose of bevacizumab was 1.25 mg (0.05 mL). Retreatment was performed at monthly or longer intervals at the discretion of the treating physician. RESULTS: Fifty-seven eyes received intravitreal bevacizumab at baseline. Visual acuity improved by a mean of 14 letters (N = 53; P < 0.001) at 1 month, 13 letters at 3 months (N = 53; P < 0.001), 9 letters at 6 months (N = 30; P = 0.001), 9 letters at 12 months (N = 17; P = 0.004). The mean optical coherence tomography thickness decreased by 299 microm at 1 month (N = 53; P < 0.001), 144 microm at 3 months, (N = 53; P < 0.001), 127 microm at 6 months (N = 30; P = 0.011), and 276 microm at 12 months (N = 17; P < 0.001). No ocular or systemic adverse events were observed. CONCLUSION: Improvements in visual acuity and optical coherence tomography were observed during the first year following intravitreal bevacizumab for macular edema secondary to central retinal vein occlusions. These retrospective results provide additional evidence to support the perceived safety and efficacy of intravitreal bevacizumab in this disorder.

Lujan BJ, Rosenfeld PJ, Gregori G, Wang F, Knighton RW, Feuer WJ, Puliafito CA. · Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. · Ophthalmic Surg Lasers Imaging. · Pubmed #19320296 No free full text.

Abstract: BACKGROUND AND OBJECTIVE: To compare images of geographic atrophy (GA) obtained using spectral domain optical coherence tomography (SD-OCT) with images obtained using fundus autofluorescence (FAF). PATIENTS AND METHODS: Five eyes from patients with dry AMD were imaged using SD-OCT and FAF, and the size and shape of the GA were compared. RESULTS: GA appears bright on SD-OCT compared with the surrounding areas with an intact retinal pigment epithelium because of increased reflectivity from the underlying choroid. SD-OCT and FAF both identified GA reproducibly, and measurement of the area of GA is comparable between the two methods with a mean difference of 2.7% of the total area. CONCLUSION: SD-OCT can identify and quantitate areas of GA. The size and shape of these areas correlate well to the areas of GA seen on autofluorescence images; however, SD-OCT imaging also provides important cross-sectional anatomic information.

Lujan BJ, Wang F, Gregori G, Rosenfeld PJ, Knighton RW, Puliafito CA, Danis RP, Hubbard LD, Chang RT, Budenz DL, Seider MI, Knight O. · Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. · Ophthalmic Surg Lasers Imaging. · Pubmed #18777875 No free full text.

Abstract: BACKGROUND AND OBJECTIVE: Measurements performed on fundus images using current software are not accurate. Accurate measurements can be obtained only by calibrating a fundus camera using measurements between fixed retinal landmarks, such as the dimensions of the optic nerve, or by relying on a calibrated model eye provided by a reading center. However, calibrated spectral domain OCT (SD-OCT) could offer a convenient alternative method for the calibration of any fundus image. PATIENTS AND METHODS: The ability to measure exact distances on SD-OCT fundus images was tested by measuring the distance between the center of the fovea and the optic nerve. Calibrated SD-OCT scans measuring 6 X 6 X 2 mm centered on the fovea and the optic nerve were analyzed in 50 healthy right eyes. The foveal center was identified using cross-sectional SD-OCT images, and the center of the optic nerve was identified manually. The SD-OCT scans were registered to each other, and the distances between the center of the optic nerve and fovea were calculated. The overlay of these SD-OCT fundus images on photographic fundus images was performed. RESULTS: Any image of the fundus could be calibrated by overlaying the SD-OCT fundus image, and the measurements were consistent with previously defined calibration methods. The mean distance between the center of the fovea and the center of the optic nerve was 4.32 +/-0.32 mm. The line from the center of the optic nerve to the foveal center had a mean declination of 7.67 +/- 3.88 degrees. Mean horizontal displacement and vertical displacement were 4.27 +/- 0.29 mm and 0.58 +/- 0.29 mm, respectively. CONCLUSIONS: The overlay of the SD-OCT fundus image provides a convenient method for calibrating any image of the fundus. This approach should provide a uniform standard when comparing images from different devices and from different reading centers.

Gregori NZ, Rosenfeld PJ, Puliafito CA, Flynn HW, Lee JE, Mavrofrides EC, Smiddy WE, Murray TG, Berrocal AM, Scott IU, Gregori G. · Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. · Retina. · Pubmed #17031288 No free full text.

Abstract: PURPOSE: To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (IVTA) as treatment for macular edema associated with central retinal vein occlusion (CRVO). METHODS: A retrospective review was performed of data for 40 consecutive patients (40 eyes) with CRVO and macular edema treated with IVTA at the Bascom Palmer Eye Institute (Miami, FL). RESULTS: Median duration of symptoms before the first injection was 3 months (range, 1 day to 8 years). Median Snellen visual acuity was 20/400 at baseline (range, 20/60 to light perception; n = 40), 20/300 at 1 month (P = 0.010; n = 37), 20/300 at 3 months (P = 0.007; n = 33), 20/400 at 6 months (P = 0.726; n = 28), and 8/200 at 1 year (P = 0.569; n = 17). Vision improved by > or =3 lines in 21% of eyes at 1 month, 27% at 3 months, 14% at 6 months, and 12% at 1 year. Visual acuity was unchanged from baseline in 71% of eyes at 6 months and 1 year. By 1 year, 50% of eyes received more than one injection (mean = 1.6 injections; range 1-4 injections). Overall, intraocular pressure increased by > or =10 mmHg in 24% of eyes at 1 year. Trabeculectomy was performed on 2 of 12 eyes with preexisting open-angle glaucoma. CONCLUSION: IVTA can substantially improve vision in some patients, but most patients have stable visual acuity compared with baseline at 1 year despite repeated injections.

Rich RM, Rosenfeld PJ, Puliafito CA, Dubovy SR, Davis JL, Flynn HW, Gonzalez S, Feuer WJ, Lin RC, Lalwani GA, Nguyen JK, Kumar G. · Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, FL 33136, USA. · Retina. · Pubmed #16770255 No free full text.

Abstract: PURPOSE: To evaluate the safety and efficacy of intravitreal bevacizumab (Avastin, Genentech Inc.) for the treatment of neovascular age-related macular degeneration (ARMD). METHODS: A retrospective review was performed on consented patients with neovascular ARMD receiving intravitreal bevacizumab therapy. All patients received intravitreal bevacizumab at baseline with additional monthly injections given at the discretion of the treating physician. At each visit, a routine Snellen visual acuity assessment was performed followed by an ophthalmic examination and optical coherence tomography (OCT) imaging. RESULTS: Fifty-three eyes of 50 patients received an intravitreal bevacizumab injection between May and August 2005. Including the month 3 visit, the average number of injections was 2.3 out of a maximum of 4 injections. No serious drug-related ocular or systemic adverse events were identified. Improvements in visual acuity and central retinal thickness measurements were evident by week 1 and continued through month 3. At month 3, the mean visual acuity improved from 20/160 to 20/125 (P < 0.001) and the mean central retinal thickness decreased by 99.6 microm (P < 0.001). CONCLUSION: Off-label intravitreal bevacizumab therapy for neovascular ARMD was well tolerated over 3 months with improvements in visual acuity and OCT central retinal thickness measurements. While the long-term safety and efficacy of intravitreal bevacizumab remain unknown, these short-term results suggest that intravitreal bevacizumab may be the most cost effective therapy for the treatment of neovascular ARMD.

Rosenfeld PJ, Fung AE, Puliafito CA. · Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Florida, USA. · Ophthalmic Surg Lasers Imaging. · Pubmed #16156153 No free full text.

Abstract: To determine whether bevacizumab could improve visual acuity and optical coherence tomography outcomes in a patient with macular edema from central retinal vein occlusion, an intravitreal injection of bevacizumab (1.0 mg) was given. Prior intravitreal injections of triamcinolone acetonide resulted in vision improvement but worsening cataract and borderline glaucoma. Within 1 week of the bevacizumab injection, visual acuity improved from 20/200 to 20/50 and optical coherence tomography revealed resolution of the cystic maculopathy. The improvements were maintained for at least 4 weeks. Intravitreal injections of bevacizumab may provide another treatment option for patients with macular edema from vein occlusions.

Rosenfeld PJ, Moshfeghi AA, Puliafito CA. · Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Florida, USA. · Ophthalmic Surg Lasers Imaging. · Pubmed #16156152 No free full text.

Abstract: To determine whether intravitreal bevacizumab could improve optical coherence tomography and visual acuity outcomes in a patient with neovascular age-related macular degeneration who was responding poorly to pegaptanib therapy, an intravitreal injection of bevacizumab (1.0 mg) was given. Within 1 week, optical coherence tomography revealed resolution of the subretinal fluid, resulting in a normal-appearing macular contour. The improved macular appearance was maintained for at least 4 weeks, and visual acuity remained stable. No inflammation was observed. An intravitreal injection of bevacizumab may provide an effective, safe, and inexpensive option for patients with age-related macular degeneration who are losing vision secondary to macular neovascularization.

Moshfeghi AA, Scott IU, Flynn HW, Puliafito CA. · Department of Ophthalmology, University of Miami School of Medicine, Bascom Palmer Eye Institute, 900s NW 17th Street, Miami, FL 33136, USA. · Am J Ophthalmol. · Pubmed #15364241 No free full text.

Abstract: PURPOSE: To report pseudohypopyon after intravitreal triamcinolone acetonide injection for cystoid macular edema. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: Records were reviewed of all patients who developed pseudohypopyon after intravitreal triamcinolone acetonide injection at Bascom Palmer Eye Institute between January 1, 2002 and February 1, 2004. RESULTS: A total of 828 intravitreal triamcinolone acetonide injections were administered to 686 patients during the study period. A pseudohypopyon (fine white crystalline opacities in the inferior anterior chamber angle) and suspended white crystalline opacities in the aqueous humor developed after 7 of the 828 injections (0.8%); all pseudohypopyons occurred within 3 days of injection and resolved completely within 2 weeks. None of the 686 patients developed clinically suspected infectious endophthalmitis. CONCLUSIONS: A transient pseudohypopyon may occur in the early postinjection period after intravitreal triamcinolone acetonide injection. Unless progressive intraocular inflammation occurs, close observational management is indicated.

Ip MS, Gottlieb JL, Kahana A, Scott IU, Altaweel MM, Blodi BA, Gangnon RE, Puliafito CA. · Department of Ophthalmology and Visual Science, University of Wisconsin, Madison 53711-1068, USA. · Arch Ophthalmol. · Pubmed #15302652 No free full text.

Abstract: OBJECTIVE: To investigate the safety and efficacy of intravitreal triamcinolone acetonide as treatment for macular edema associated with central retinal vein occlusion (CRVO). METHODS: We reviewed the medical records of 13 consecutive patients (13 eyes) with macular edema associated with CRVO who were treated with an injection of intravitreal triamcinolone acetonide (4 mg) at the University of Wisconsin and the Bascom Palmer Eye Institute. Each intravitreal injection was delivered through the pars plana using a 27- or 30-gauge needle. MAIN OUTCOME MEASURES: Change in Snellen visual acuity, clinical appearance of macular edema, measurement of foveal thickening with optical coherence tomography (OCT), and frequency of complications. RESULTS: The median age of the 13 patients was 67 years (interquartile range, 57-77 years), and the median duration of symptoms before injection was 8 months (interquartile range, 4-9 months). Mean baseline visual acuity was 20/500 in the affected eye. Mean visual acuity at the 6-month follow-up examination was 20/180 in the affected eye. All 13 patients completed the 6-month examination. Eyes with nonischemic CRVO (n = 5) demonstrated a significant improvement in visual acuity, whereas eyes with ischemic CRVO (n = 8) demonstrated a nonsignificant visual acuity improvement. No patient had a decrease in visual acuity. Mean baseline foveal thickness as measured by OCT was 590 micro m (retinal thickening = 416 micro m). Mean foveal thickness as measured by OCT at the 1-month follow-up examination in 12 patients was 212 micro m (retinal thickening = 38 micro m). At the 3-month follow-up examination, mean foveal thickness as measured by OCT for 13 patients was 193 micro m (retinal thickening = 19 micro m). Between the 3- and 6-month follow-up examinations, 4 patients developed a recurrence of macular edema. Three of the 4 patients were retreated with a second injection of triamcinolone. Two of these 3 patients experienced an improvement in visual acuity following retreatment. At the 6-month follow-up examination, mean foveal thickness as measured by OCT for 13 patients was 281 micro m (retinal thickening = 107 micro m). No adverse effects such as retinal detachment or endophthalmitis occurred. One patient experienced an increase in intraocular pressure that was controlled with 2 aqueous suppressants. CONCLUSIONS: Intravitreal injection of triamcinolone appears to be a possibly effective treatment in some patients with macular edema associated with CRVO. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO, and retreatment may be necessary in some patients. In this case series, severe complications were not noted.

Rogers AH, Martidis A, Greenberg PB, Puliafito CA. · New England Eye Center, Tufts University School of Medicine, Boston, Massachusetts, USA. · Am J Ophthalmol. · Pubmed #12383814 No free full text.

Abstract: PURPOSE: To develop an optical coherence tomography (OCT) classification system that monitors the response of eyes treated with photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV) from age-related macular degeneration (AMD).DESIGN: Retrospective interventional case series.METHODS: Ninety eyes (88 patients) with AMD and predominantly classic subfoveal CNV treated with PDT using verteporfin were identified by a laser log and retrospectively reviewed. Optical coherence tomography and fluorescein angiography (FA) were performed before treatment and at subsequent follow-up examinations in all eyes. Optical coherence tomography findings were evaluated and compared with corresponding FA.RESULTS: A five-stage OCT classification of eyes treated with PDT was created from the evaluation of 79 total eyes (77 patients). Stage I (two eyes) is recognized within the first week of treatment and demonstrates an acute inflammatory response with increased subretinal fluid. Stage II (28 eyes) represents the restoration of a near-normal fovea contour with diminished subretinal fluid occurring 1 to 4 weeks after treatment. Stage III (79 eyes) occurs between 4 to 12 weeks following treatment and is subdivided into two categories based on the amount of subretinal fibrosis and fluid present. Stage IIIa (15 eyes) contains a greater subretinal fluid to fibrosis ratio indicating an active CNV process. Lesions in stage IIIb (64 eyes) less actively leak and have more prominent fibrosis with minimal intraretinal fluid. Cystoid macular edema defines a stage IV lesion (11 eyes). In stage V lesions (19 eyes) the subretinal fluid resolves with thinning of the retina as well as fibrosis merging with the retinal pigment epithelial layer (RPE).CONCLUSION: Optical coherence tomography appears to be useful in monitoring the retinal changes that occur following PDT of CNV and may assist in understanding the changes observed on angiography.

Martidis A, Duker JS, Puliafito CA. · No affiliation provided · Arch Ophthalmol. · Pubmed #11545651 No free full text.

This publication has no abstract.