Five-year outcomes after intravitreal bevacizumab of treatment-naive eyes with macular edema secondary to CRVO in routine clinical practice: Results of the Pan-American Collaborative Retina Study (PACORES) group.

PURPOSE: The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice. METHODS: We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years. RESULTS: At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p < 0.0001). At 5 years, 48 (47%) eyes had a gain of ≥ 3 lines, 41 (40.2%) eyes remained within 3 lines and 13 (12.7%) eyes had a loss of ≥ 3 lines of BCVA. The CMT improved from 740 ± 243 to 322 ± 179 µm (p < 0.0001). At 5 years, 59 (57.8%) eyes had a completely dry SD-OCT. Patients received a total of 10.6 ± 6.1 (range 6-27) injections. Baseline BCVA (p < 0.0001) and the duration of symptoms prior to initial anti-VEGF injection (p = 0.0274) were the only predictive factors for BCVA at 5 years. CONCLUSIONS: After 5 years with an average of 10.6 injections, there was a mean gain of 0.22 logMAR. In addition, more eyes achieved a BCVA of ≥ 20/40, gained ≥ 3 lines and less patients had a BCVA ≤ 20/200. Eyes with a better baseline BCVA and a shorter duration of symptoms were more likely to achieve better BCVA at 5 years.

Retinal pigment epithelial tears.

A retinal pigment epithelial (RPE) tear is a well-known complication of retinal pigment epithelial detachments (PED) and may cause a significant visual impairment. The most common cause is a vascularized PED in patients with exudative age-related macular degeneration (AMD). The development of diagnostic imaging techniques brings us closer to the etiology and pathophysiological mechanisms of this entity, offering us new strategies for treatment and follow-up. The advent of intravitreal antiangiogenic treatment (anti-VEGF) has led to an increase in the number of reported cases of RPE tears, which are an important vision-limiting factor during treatment. However, RPE tears may occur spontaneously or as a consequence of thermal laser treatment, photodynamic therapy or anti-VEGF therapy. It is accepted that the mechanism of RPE tears is multifactorial. The optimization of the functional outcome of this complication has been described with continuous treatment with antiangiogenic drugs. The goal of the present review is to evaluate the incidence, risk factors and treatment of RPE tears.

Vitreous levels of placental growth factor correlate with activity of proliferative diabetic retinopathy and are not influenced by bevacizumab treatment.

PurposePlacental growth factor (PlGF) is a member of the VEGF family that plays an important role in experimental models of diabetic retinopathy and retinal neovascularization. We aimed to investigate whether vitreous levels of PlGF correlated with proliferative diabetic retinopathy (PDR) status, VEGF levels, and bevacizumab treatment. We also analysed PDR membranes to confirm the presence of the PlGF receptor, FLT1, in endothelial cells.MethodsThis was a case-control study: undiluted vitreous fluid samples were obtained from 28 active PDR patients without preoperative bevacizumab treatment, 21 active PDR patients with preoperative bevacizumab treatment, 18 inactive PDR patients, and 21 control patients. PlGF and VEGF levels in samples were determined by enzyme-linked immunosorbent assay. Immunohistochemistry for FLT1 was performed on human PDR membranes.ResultsCompared to control, vitreous PlGF levels were higher in both active PDR without bevacizumab (P<0.0001) and with bevacizumab (P<0.0001). There was no significant difference in PlGF between active PDR patients without and with bevacizumab (P=0.56). Compared to active PDR, PlGF levels were significantly reduced in inactive PDR (P=0.004). PlGF levels were highly correlated with VEGF levels in active PDR. VEGFR1 was expressed in endothelial cells in human PDR membranes.ConclusionThe strong correlation of PlGF levels with PDR disease status and expression of FLT1 in human PDR membranes suggest that PlGF has a pathogenic role in proliferative diabetic retinopathy. Therapeutic targeting of PlGF with agents like aflibercept may be beneficial.

Intravitreal bevacizumab for choroidal neovascularisation in serpiginous choroiditis.

PURPOSE: To assess the effects of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularisation (CNV) secondary to serpiginous choroiditis (SC). DESIGN: Non-randomised, interventional case series. PARTICIPANTS: Seven patients (seven eyes) affected by juxtafoveal CNV (six eyes) and subfoveal CNV (one eye) associated with SC were recruited. METHODS: Each patient underwent an ophthalmological examination, including measurement of best-corrected visual acuity (BCVA), fluorescein angiography (FA) and optical coherence tomography (OCT). After a first IVB injection (1.25 mg), patients were evaluated monthly over a 12-month follow-up. Further re-treatments were performed on the basis of detection of any type of fluid on OCT and/or presence of leakage on FA. The primary outcome considered was the median change in BCVA, as well as the proportion of eyes gaining at least 5 and 10 Early Treatment Diabetic Retinopathy Study (ETDRS) letters at the end of the 12-month follow-up. Secondary outcomes included median changes in central macular thickness (CMT) and number of injections over the planned follow-up. RESULTS: Median BCVA changed from 0.3 to 0.4 LogMAR. A functional improvement of at least 5 and 10 ETDRS letters was obtained in two eyes (28%) and one eye (14%), respectively, at the 12-month examination. Four eyes (57%) had stable BCVA, whereas one eye (14%) experienced a two-line decrease. Median CMT at baseline was 261 µm, decreasing to 196 µm at the 12-month examination. The median number of IVB injections was 1 in 12 months. CONCLUSIONS: IVB can achieve anatomical stabilisation of CNV secondary to SC, avoiding a decline in visual acuity, in almost 90% of cases over a 12-month follow-up.

[Intravitreal triamcinolone combined with grid laser photocoagulation for patients with cystoid macular edema and advanced diabetic retinopathy: pilot study]. / Triamcinolona intravítrea combinada con fotocoagulación láser en rejilla en pacientes con edema macular quístico y retinopatía diabética avanzada: estudio piloto.

BACKGROUND: To determine if primary intravitreal injection of triamcinolone acetonide (TA) plus grid laser photocoagulation (GLP) is effective in treating cystoid diabetic macular edema (DME). METHODS: Prospective comparative non-randomized clinical trial. Fourteen eyes (14 patients) diagnosed with cystoid DME were treated with GLP according to the Early Treatment Diabetic Retinopathy Study (ETDRS) guidelines, plus an intravitreal injection of 4 mg of TA. A matched control group (16 eyes [16 patients]) treated with GLP was selected retrospectively from our medical records. Best-corrected visual acuity (BCVA), and quantitative change in optical coherence tomography (OCT) macular thickness were assessed. RESULTS: Mean follow up was 14.9 months (12 to 19 months). In 3 (21.4%) eyes BCVA increased > 2 ETDRS lines, in 5 (35.7%) eyes BCVA remained the same, and BCVA decreased >2 ETDRS lines in 6 (42.8%) eyes. Central macular thickness, as measured by OCT, decreased a mean of 106.2 µm (30.2%). The difference with the control group was not statistically significant (P = .2). Four (28.5%) eyes developed an increased in intraocular pressure in our study group. CONCLUSIONS: Although all of our patients showed an improvement of cystoid DME by means of OCT and fluorescein angiography, 42.8% (6 eyes) lost 2 or more lines in BCVA with primary intravitreal injection of TA plus GLP. Primary intravitreal injection of TA plus GLP may not be effective for cystoid DME at 12-months.

[Pars plana vitrectomy, phacoemulsification and intraocular lens implantation for the management of cataract and proliferative diabetic retinopathy: comparison of a combined versus two-step surgical approach]. / Vitrectomía pars plana, facoemulsificación e implante de lente intraocular para el manejo de catarata y retinopatía diabética proliferativa: comparación de técnica quirúrgica combinada versus en dos tiempos.

PURPOSE: To report the intra-and postoperative complications and visual acuity outcomes in pars plana vitrectomy (PPV), phacoemulsification and intraocular lens (IOL) implantation in patients with cataract and proliferative diabetic retinopathy (PDR). A comparison of the combined versus two-step surgical approach is given. METHOD: Retrospective uncontrolled interventional clinical trial. Forty-eight eyes of 48 consecutive patients with PDR were included. Twenty-eight (58.3%) eyes with combined surgery and 20 (41.7%) eyes with sequential surgery were analyzed. RESULTS: Postoperative follow-up time was between 6 and 63 months (mean: 18 months). 1) Combined surgery: Preoperative best-corrected visual acuity (BCVA) ranged from 20/200 to hand motions, and postoperative BCVA ranged from 20/30 to hand motions. BCVA improved in 17 eyes (60.7%), while in 7 (25%) eyes there was no change (> or =2 ETDRS lines) in VA, and in 4 (14.3%) eyes BCVA decreased. Postoperative complications included vitreous hemorrhage (VH) in 10 (35.7%) eyes, and fibrinous exudation in 9 (32.1%) eyes. 2) Two-step surgery: Preoperative BCVA ranged from 10/200 to light perception, and from 20/40 to light perception in the postoperative period. Best-corrected visual acuity improved in 15 (75%) eyes, remained the same in 4 (20%) eyes, and decreased in 1 (5%) eye. Postoperative complications included fibrinous exudation in 6 (30%) eyes, and VH in 3 (15%) eyes. CONCLUSION: Combined PPV, phacoemulsification and IOL implantation as well as the two-step procedure are safe and effective for the management of cataract in PDR. Sequential surgery could be advantageous to BCVA outcomes by minimizing postoperative VH, which is significantly more frequent after combined surgery.

Intravitreal bevacizumab (Avastin) for proliferative diabetic retinopathy: 6-months follow-up.

AIMS: To study the effects of intravitreal bevacizumab (Avastin) on retinal neovascularization (RN) in patients with proliferative diabetic retinopathy (PDR). METHODS: Retrospective study of patients with RN due to PDR who were treated with at least one intravitreal injection of 1.25 or 2.5 mg of bevacizumab. 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: Forty-four eyes of 33 patients with PDR and a mean age of 57.2-years (range: 23-82 years) participated in the study. Thirty-three eyes (75%) had previous panretinal photocoagulation (PRP). Twenty-seven eyes (61.4%) showed total regression of RN on fundus examination with absence of fluorescein leakage, 15 eyes (34.1%) demonstrated partial regression of RN on fundus examination and FA. Follow-up had a mean of 28.4 weeks (range from 24 to 40 weeks). BCVA and OCT demonstrated improvement (P<0.0001). Three eyes without previous PRP ('naive' eyes) and with vitreous haemorrhage have avoided vitreo-retinal surgery. One eye (2.2%) had PDR progression to tractional retinal detachment requiring vitrectomy, and one eye (2.2%) had vitreous haemorrhage with increased intraocular pressure (ghost cell glaucoma). No systemic adverse events were observed. CONCLUSIONS: Intravitreal bevacizumab resulted in marked regression of RN in patients with PDR and previous PRP, and rapid resolution of vitreous haemorrhage in three naive eyes. Six-months results of intravitreal bevacizumab at doses of 1.25 or 2.5 mg in patients with PDR do not reveal any safety concerns.

[Photodynamic therapy with verteporfin in choroidal neovascularization after refractive surgery]. / Terapia fotodinámica con verteporfina en neovascularización coroidea después de cirugía refractiva.

PURPOSE: To analyze the results obtained with Photodynamic Therapy (PDT) to treat subfoveal and juxtafoveal Choroidal Neovascularization (CNV) in patients with high myopia corrected by Laser-Assisted in situ Keratomileusis (LASIK) or by implanting a Phakic Intraocular Lens (PIOL). METHODS: We analyzed the results from 14 highly myopic eyes corrected by LASIK (seven cases) or by PIOL implantation (seven cases), which later developed CNV and were treated by PDT with verteporfin. RESULTS: Mean Best Corrected Visual Acuity (BCVA) after refractive surgery was 0.45 SD 0.17 (range, 0.2 to 0.8), with residual spherical equivalent (RSE) -0.5 SD 1.8 D (range, 1 to 5.5 D). After CNV appearance, BCVA was 0.10 SD 0.19 (range, 0.025 to 0.7). CNV was treated in all cases by PDT (mean, 2.0 SD 0.8 treatments). After CNV closure, the mean BCVA improved up to 0.22 SD 0.18 (range, 0.1 to 0.63) (RSE -1.4 SD 1.4 D, range, 0.5 to -4 D). Differences in RSE after refractive surgery and after PDT, and differences between BCVA after CNV appearance and final were not statistically significant (p=0.82 and p=0.06, respectively, Student's t test paired data). CONCLUSION: We consider that PDT is effective in achieving closure of CNV in myopic patients after refractive surgery without inducing changes in spherical equivalent.

Tractional retinal detachment following intravitreal bevacizumab (Avastin) in patients with severe proliferative diabetic retinopathy.

AIMS: The aim of this study was to report the development or progression of tractional retinal detachment (TRD) after the injection of intravitreal bevacizumab (Avastin) used as an adjuvant to vitrectomy for the management of severe proliferative diabetic retinopathy (PDR). METHODS: The clinical charts of patients who experienced the development or progression of TRD after an intravitreal injection of 1.25 mg bevacizumab before vitrectomy for the management of PDR were reviewed. RESULTS: Eleven eyes (patients) out of 211 intravitreal injections (5.2%) that developed or had progression of TRD were identified. All eyes had PDR refractory to panretinal photocoagulation (PRP). Nine patients had type 1 diabetes mellitus (DM), and two patients had type 2 DM. Patients had a mean age of 39.5 years (range 22-62 years). In the current study, all patients used insulin administration and had poor glycaemic control (mean HbA(1c) 10.6%). Time from injection to TRD was a mean of 13 days (range 3-31 days). Mean best correct visual acuity (BCVA) at TRD development or progression was logarithm of the minimal angle of resolution (LogMAR) 2.2 (range 1.0-2.6) (mean Snellen equivalent hand motions; range 20/200 to light perception), a statistically significant worsening compared with baseline BCVA (p<0.0001). Eight eyes underwent vitrectomy and three patients refused or were unable to undergo surgery. The final mean BCVA after surgery was LogMAR 0.9 (range 0.2-2.0) (mean Snellen equivalent 20/160; range 20/32 to counting fingers), a statistically significant improvement compared with TRD BCVA (p = 0.002). CONCLUSIONS: TRD may occur or progress shortly following administration of intravitreal bevacizumab in patients with severe PDR.

Optical coherence tomography characteristics of full-thickness traumatic macular holes.

PURPOSE: The objective of this paper is to describe the optical coherence tomography (OCT) characteristics of patients with full-thickness traumatic macular hole (TMH) and to correlate them with biomicroscopy findings. METHODS: Twelve eyes of ten consecutive patients with full-thickness TMH participated in this observational retrospective multicentre study. Patients underwent biomicroscopic fundus examination, colour fundus photography, and OCT. RESULTS: Traumatic macular hole was documented with OCT in five women and five men. Mean (range) time between trauma and macular hole (MH) diagnosis was 8.1 (1-24) months. The shape of TMHs was round in 11 (91.7%) eyes. The posterior vitreous was completely detached in six (50%) eyes, and with an operculum in one (8.3%) eye. The common findings seen on OCT were: (1) full-thickness loss of retinal tissue through the hole with sharp edges, perpendicular to the retinal pigment epithelium in five (41.7%) eyes; (2) TMH with an operculum totally detached from the hole's edge in two (16.7%) eyes; (3) presence of epiretinal membrane around of the hole in three (25%) eyes; and (4) presence of abnormalities of the surrounding retina in all (100%) eyes. The OCT characteristics correlated well with biomicroscopic findings, and these characteristics may be predictive for final visual acuity (VA) in TMHs. Only one of the TMHs closed spontaneously in our series. CONCLUSION: Optical coherence tomography complements biomicroscopy in the evaluation of full-thickness TMHs.

[Decompression retinopathy after intraocular surgery]. / Retinopatía por descompresión después de cirugía intraocular.

OBJECTIVE: To report 10 instances of decompression retinopathy (DCR) developing after intraocular surgery. METHODS: This was a case series of 9 patients (10 eyes). Decompression retinopathy occurred after trabeculectomy (4 eyes), phacomulsification (3 eyes), Ahmed valve placement (1 eye), silicone oil removal (1 eye) and vitrectomy (1 eye). Fundus evaluation and fluorescein angiography were performed in all instances. RESULTS: Superficial, subhyaloidal, and deep retinal hemorrhages were noted in the posterior pole and peripheral retina; some of these had a white center. Nine (90%) of 10 eyes had a previous diagnosis of glaucoma, 6 having primary open-angle glaucoma, 2 neovascular glaucoma and 1 secondary glaucoma associated with intravitreal silicone oil. The patient without glaucoma had a history of cataract surgery and a vitrectomy to close a macular hole. The mean preoperative intraocular pressure (IOP) was 36.6 mm Hg (range: 15 to 58 mm Hg) despite maximal medical therapy in those patients with glaucoma. Fluorescein angiography demonstrated hypofluorescence throughout the study associated with superficial, and deep retinal hemorrhages. On the first post-operative day, visual acuity (VA) decreased more than 2 ETDRS lines in all cases. A pars plana vitrectomy (PPV) was performed in 5 eyes. All patients improved more than 2 ETDRS lines at a mean of 9 months after DCR. CONCLUSIONS: A gradual decrease of IOP pre-operatively and intra-operatively is recommended in order to avoid this complication. Early vitrectomy represents a useful treatment in many cases. A previous history of glaucoma seems to be an important risk factor for the development of DCR.

Vitreoretinal surgery for macular hole after laser assisted in situ keratomileusis for the correction of myopia.

UNLABELLED: AMS: To describe the characteristics and surgical outcomes of full thickness macular hole surgery after laser assisted in situ keratomileusis (LASIK) for the correction of myopia. METHODS: 13 patients (14 eyes) who developed a macular hole after bilateral LASIK for the correction of myopia participated in the study. RESULTS: Macular hole formed 1-83 months after LASIK (mean 13 months). 11 out of 13 (84.6%) patients were female. Mean age was 45.5 years old (25-65). All eyes were myopic (range -0.50 to -19.75 dioptres (D); mean -8.4 D). Posterior vitreous detachment (PVD) was not present before and was documented after LASIK on 42.8% of eyes. Most macular hole were unilateral, stage 4 macular hole, had no yellow deposits on the retinal pigment epithelium, had no associated epiretinal membrane, were centric, and had subretinal fluid. The mean diameter of the hole was 385.3 microm (range 200--750 microm). A vitrectomy closed the macular hole on all eyes with an improvement on final best corrected visual acuity (VA) on 13 out of 14 (92.8%) patients. CONCLUSIONS: This study shows that vitreoretinal surgery can be successful in restoring vision for most myopic eyes with a macular hole after LASIK.

High-dose (5000-microg) intravitreal ganciclovir combined with highly active antiretroviral therapy for cytomegalovirus retinitis in HIV-infected patients in Venezuela.

PURPOSE: To describe the use of high doses of intravitreal ganciclovir combined with highly active antiretroviral therapy (HAART) for the treatment of cytomegalovirus (CMV) retinitis in human immunodeficiency virus (HIV)-infected patients. METHODS: Thirteen HIV-infected patients (18 eyes) with active CMV retinitis (83.3% in zone 1 and 38.4% resistant) participated in this prospective interventional case series. Patients were treated with high dose intravitreal ganciclovir (5.0 mg/0.1 mL once a week) in combination with HAART therapy. Intravitreal injections were discontinued once CMV retinitis healed if there was a significant increase in CD4+ count (any increase of > or 50 cells/microL to levels over 100 cells/microL sustained for at least 3 months). Mean follow-up was 15.6 months. Main outcome measures included assessment of visual acuity and retinal inflammation (CMV retinitis activity). A matched historical control group of 20 eyes (15 patients) with CMV retinitis treated with systemic ganciclovir (intravenous [induction] and oral [maintenance]) was included. RESULTS: Complete regression of the retinitis was obtained with high doses of intravitreal ganciclovir in 88.8% of eyes (two patients died during follow-up) at a mean of 4.5 weeks (2 to 8 weeks). Visual acuity improved two or more lines in 61.1% of eyes. No ganciclovir retinal toxicity was identified. Three eyes presented CMV retinitis reactivation at a mean of 25.6 days after their last injection. Complications (33.3%) included retinal detachment (RD; 3 eyes), immune recovery uveitis (IRU; 2 eyes), and endophthalmitis (1 eye). In our control group complete regression of the retinitis was obtained in 100% of eyes at a mean of 4 weeks (3 to 7 weeks). However, 12 eyes (60%) presented with CMV retinitis relapse at a mean of 29 days (21 to 32 days) after initiating oral ganciclovir (maintenance). Complications included RD (7 eyes, 35%) and IRU (3 eyes, 15%). Severe neutropenia occurred in 2 patients (13%). CONCLUSIONS: High doses of intravitreal ganciclovir (5.0 mg) once a week in combination with HAART therapy is effective to control CMV retinitis, and may be discontinued after CMV retinitis has healed if immune reconstitution with a significant increase in CD4+ count has occurred.