Results of flexible ranibizumab treatment in age-related macular degeneration and search for parameters with impact on outcome.

BACKGROUND: The aim of this study was to analyse functional results of flexible ranibizumab treatment in exudative age-related macular degeneration (AMD), and to search for parameters with impact on outcome. METHODS: Analysis of a retrospective institutional case series (104 eyes) with a low-threshold re-treatment algorithm and monthly follow-up for 12 months. RESULTS: Visual acuity (VA) improved at month 3 by +6.7 letters and declined slightly until month 12 to a level of +5.0 letters. On average, eyes received 5.8 injections. A significant loss in VA occurred in the whole group between months 5 and 6 (-2.0 letters), never in the "winner" group (improvement of >5 letters at month 12), between months 5 and 6 (-3.8 letters) in the "stabilizer" group (∆ of ± 5 letters at month 12) and twice, between months 3 and 7 (-7.0 letters) and months 9 and 12 (-6.9 letters), in the "loser" group (loss of >5 letters at month 12). These major functional declines followed moderate but significant increases in average CFT (OCT-central foveal thickness) of 23 to 33 µm. Increased CFT followed periods with a low percentage of treated eyes per month in each group. The amount of regained vision was significantly related to the extent of previous functional loss. The critical limit of short-term VA decline that was associated with the possibility for full VA restoration can approximately be quantified at -4 letters. Restoration of short-term VA deterioration (last month) was significantly better than long-term VA loss (related to the end of loading phase). Restoration of VA loss stratifies mainly into two groups: a group that regained -25 to 25% and one that regained 75 to 125%. A significant correlation was found between the number of injections and functional outcome at month 12 for eyes receiving more than four injections. It was calculated that a mean of 8.4 injections per eye would have been necessary to stabilize vision within the first 12 months. CONCLUSIONS: CFT is a sensitive and early predictor of VA deterioration. Four letters of acute VA loss seems to be a critical limit. VA loss of ≥ 4 letters appears to be associated with incomplete recovery. Eyes with <1 line of gain at the end of the loading phase should be considered for continuation of treatment at months 3 and 4. According to our calculations an average number of 8.4 injections/eye seems to be necessary to maintain stabilization of vision in the first year of treatment.

Combined intravitreal triamcinolone injection and laser photocoagulation in eyes with persistent macular edema after branch retinal vein occlusion.

BACKGROUND: To determine the efficacy of combined intravitreal triamcinolone (TA) injection and laser photocoagulation in persistent macular edema after branch retinal vein occlusion (BRVO). METHODS: Follow-up analysis of a case series of 24 patients with macular edema after BRVO (15 of 24 non-ischaemic, 9 of 24 ischaemic). Patients received an intravitreal injection of 4 mg TA followed by laser photocoagulation within the previously edematous area, applied in one or two sessions. Standardized clinical examinations included best corrected visual acuity testing, anterior and posterior segment biomicroscopy, intraocular pressure, and optical coherence tomography (OCT). Fluorescein angiography was performed before treatment and 3 and 6 months later. RESULTS: Median visual acuity improved significantly from 0.58 logMAR (95%-confidence interval (KI): 0.54-0.75, decimal 0.27) at baseline to 0.41 logMAR (KI: 0.37-0.64, decimal 0.39) at 1 month (p = 0.001), 0.33 logMAR (KI: 0.32-0.62, decimal 0.47) at 3 months (p = 0.002), and 0.41 logMAR (KI: 0.33-0.67, decimal 0.39) at 6 months (p = 0.016). A gain of one or more logarithmic lines was evaluated in 16/24 eyes (67 %) and a gain of 3 lines or more in 8/24 eyes (33 %) at 6 months. Three eyes had lost more than 1 line during the follow-up period. Median change of visual acuity at 6 months was +2.0 lines (KI: 0.2-2.4). Median central foveal thickness (OCT-CFT) was 423 microm (KI: 378-456, n = 24) at baseline and decreased to 270 microm (KI: 249-311, n = 24) at 1 month (p < 0.0001), 265 microm (KI: 254-344, n = 24) at 3 months (p < 0.0001), and 266 microm (KI: 259-365, n = 18) at 6 months (p = 0.001). CONCLUSIONS: Macular edema after BRVO can effectively be treated by a combination of intravitreal TA injection and subsequent laser photocoagulation. During a 6-month follow-up this combination treatment resulted in a significant reduction of central foveal thickness and improvement of visual acuity.

Combined brachytherapy and transpupillary thermotherapy for large choroidal melanoma: tumor regression and early complications.

BACKGROUND: To determine the effectiveness and risk profile of combined ruthenium- (Ru)-106-brachytherapy and transpupillary thermotherapy (TTT) of the tumour apex for the treatment of large choroidal melanoma. METHODS: A consecutive series of 31 large choroidal melanoma treated by Ru-106-brachytherapy and adjuvant TTT was studied. TTT was performed 1 day prior to plaque removal and up to 3 times (mean: 1.8) during follow-up. Evaluation comprised tumour regression, treatment-related adverse events, necessity of additional treatment and visual results. RESULTS: Mean follow-up was 21.6+/-7.8 (10.8-38.3) months. Mean tumour thickness was 6.8+/-1.0 (5.0-8.9) mm prior to treatment. Mean residual tumour thickness at the end of follow-up was 2.5+/-1.0 mm. Relevant adverse treatment effects were exudative maculopathy or macula oedema (22.6%), vitreous haemorrhage (16.1%), optic neuropathy (16.1%) and retinal detachment (9.7%). One tumour recurrence occurred during follow-up, and was treated by enucleation. CONCLUSIONS: The combination of Ru-106-brachytherapy with TTT allows for the treatment of large posterior choroidal melanoma. The rate of treatment-related adverse events appears to be acceptable.