Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

BACKGROUND: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. OBJECTIVE: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. METHODS: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. RESULTS: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. CONCLUSIONS: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

A novel function of p53: a gatekeeper of retinal detachment.

Proliferative vitreoretinopathy (PVR) is a blinding disease associated with rhegmatogenous retinal detachment, for which there is no satisfactory treatment. Surgery helps in many cases, but, to our knowledge, there are no pharmacological approaches to reduce PVR risk. We report that suppressing expression of p53 was a required event in two assays of PVR (namely, platelet-derived growth factor receptor α-mediated contraction of cells in a collagen gel and retinal detachment in an animal model of PVR). Furthermore, preventing the decline in the level of p53 with agents such as Nutlin-3 protected from retinal detachment, which is the most vision-compromising component of PVR. Finally, Nutlin-3 may be effective in the clinical setting because it prevented human PVR vitreous-induced contraction of cells isolated from a patient PVR membrane. These studies identify Nutlin-3 as a potential PVR prophylaxis.

Pharmacologic vitreolysis.

It is now well recognized that vitreous plays an important role in the pathogenesis of various retinal disorders. In many instances it can be addressed with pars plana vitrectomy, although this approach, like any surgery, has its limitations. The search for alternatives or adjunct to surgery has led to the development of pharmacologic vitreolysis. The use of intravitreal agents to alter the vitreous in order to reduce or eliminate its role in disease seems promising. The purpose of this article is to summarize the present knowledge on pharmacologic vitreolysis. A review of the different agents used and of ongoing trials will be presented. Also, current understanding of vitreous structure and its interaction with the retina will be discussed.

Pigment dispersion and recurrent hyphema associated with in-the-bag lens implantation.

We present the case of a patient who experienced recurrent episodes of blurry vision and eye pain after uneventful cataract extraction and in-the-bag intraocular lens (IOL) implantation. Examination revealed a microhyphema and signs of pigment dispersion. Iris transillumination was seen overlying areas where the IOL optic was not covered by the anterior capsule. Anterior segment optical coherence tomography confirmed iris indentation by the IOL optic, which was alleviated by performing laser peripheral iridotomy. This case shows that IOLs in the capsular bag can erode the posterior surface of the iris and that an adequately sized capsulorhexis should be performed to ensure anterior capsule coverage. Laser peripheral iridotomy should be considered when significant posterior iris bowing is observed.

Intravitreal bevacizumab for the treatment of choroidal neovascularization associated with pathological myopia.

BACKGROUND: The recent discovery of vascular endothelial growth factor and its role in the pathogenesis of ocular neovascularization has led to the development of new pharmacological agents that could block its action. This study was carried out to investigate the effect of intravitreal injections of bevacizumab on choroidal neovascularization (CNV) associated with pathological myopia. METHODS: We retrospectively reviewed the charts of all patients who had CNV secondary to pathological myopia and who had been treated with intravitreally administered bevacizumab between November 2005 and April 2007 at Notre-Dame Hospital in Montréal, Québec. Data on best-corrected visual acuity (BCVA), previous treatments, number of injections, fundus photography, and fluorescein angiography were collected. RESULTS: Ten eyes from 9 patients were followed for a mean period of 9.7 (range 2.5-14) months. At baseline the mean (SD) logMAR BCVA was 0.62 (0.25) (Snellen equivalent 6/24). The mean number of injections per eye was 2.6 (range 1-5). At the end of the study the mean (SD) logMAR BCVA had significantly improved to 0.26 (0.16) (Snellen equivalent 6/10.5; p < 0.001). Vision improved by a mean of 3.9 (range 0-7) lines on the Snellen visual acuity chart. Leakage from the CNV on fluorescein angiography had resolved in 7 of the 10 eyes and was reduced in the 3 other eyes. No drug-related side effects or complications were observed during the follow-up period. INTERPRETATION: Intravitreal injection of bevacizumab appears to be a safe and effective treatment alternative for CNV associated with pathological myopia.