[Abnormal retinal artery perfusion and optical coherence tomography angiography]. / Trouble de la perfusion artérielle rétinienne et tomographie en cohérence optique-angiographie.

INTRODUCTION: To analyze optical coherence tomography angiography (OCT-A) findings in patients with impaired retinal artery perfusion secondary to occlusion of the central retinal artery or its branches, cilioretinal artery occlusion or retinal vein occlusion (RVO). METHODS: In this retrospective observational study of patients with impaired retinal artery perfusion, we recorded the results of clinical examination and multimodal imaging, including fluorescein angiography, spectral-domain (SD)-OCT, and OCT-A (Optovue) of the central 10 degrees with measurement of vascular density. RESULTS: The files of 10 patients were analyzed (5 men, mean age: 63 years), including 3 retinal artery occlusions, 4 cilioretinal artery occlusions, isolated or combined with central retinal vein occlusion (CRVO), and 3 RVO with an arterial component. SD-OCT showed hyper-reflectivity of the inner nuclear layer consistent with paracentral acute middle maculopathy (PAMM) in the acute stage (8 eyes) resulting in retinal atrophy as early as the following month. OCT-A revealed capillary dropout in all patients with various degrees, the deep capillary plexus seemed to be more involved than the superficial plexus. A fern-like pattern was observed on en-face OCT in 4 eyes, outlining venular contours. Vascular density was significantly diminished (whole en-face density in the deep capillary plexus: 50.39 vs. 56.21 in the control group, P=0.001). On fluorescein angiography, reperfusion was observed in half of the eyes. CONCLUSION: OCT-A can be very useful in patients with a transitory arterial occlusion by revealing involvement of the superficial and deep capillary plexus. It may enable a retrospective diagnosis in the case of reperfusion.

[Comparison of early management of central retinal vein occlusion with ranibizumab versus hemodilution]. / Comparaison de la prise en charge précoce des occlusions de la veine centrale de la rétine par ranibizumab et/ou hémodilution.

PURPOSE: This study was designed to evaluate and compare the efficacy of early treatment of CRVO with either hemodilution by erythrocytopheresis or intravitreal (IVT) ranibizumab, or both. MATERIAL AND METHODS: A multicentric prospective randomized study including patients with CRVO for less than 1 month was designed. Patients were randomized into 3 treatment groups: hemodilution (HD group), 3 monthly intravitreal injections of ranibizumab followed by PRN treatment (IVT group), or combined treatment (IVT+HD group). A monthly evaluation during a 6-month follow-up included best-corrected visual acuity (BCVA) and macular thickness measurements with OCT. Fluorescein angiography was performed at baseline, month 2 and month 6. Local and systemic tolerability of the different treatments were also compared. RESULTS: Forty-four CRVO patients were included between February 2010 and June 2013: 20 in the IVT group, 13 in the HD group and 11 in the HD+IVT group. The mean duration of CRVO at baseline was 10 days and 16 days at the time of treatment without any significant difference between groups. Retinal ischemia was present at baseline in 40% of eyes in each group. After a 6-month follow-up, no difference between the 3 groups was observed in BCVA (10.5 ETDRS letters, 14.6 and 14.1 in the IVT group, HD group and IVT+HD group respectively, P=0.726) or in macular thickness (398 µ, 440 µ and 379 µ respectively, P=0.465). The time until treatment from CRVO onset, ranging from 1 to 35 days, was not correlated to final outcomes. No significant difference in the mean number of IVT (3.2 in the IVT+HD group vs 3.7 in the IVT group) was observed at 6 months. CONCLUSION: No difference in BCVA nor in macular thickness was seen at M6 between the study groups. The duration of CRVO at the time of the initiation of the treatment was not correlated to better visual outcomes. Therefore, etiologic treatment with HD can still be proposed as a first-line treatment in young patients, which allows delaying or avoiding the IVT treatment and its potential side effects. Anti-VEGF IVT still remains an effective option in every case and can be started one month after the beginning of the CRVO.

[Treatment of age-related macular degeneration: Expert opinion and therapeutic algorithm]. / Traitement de la dégénérescence maculaire liée à l'âge : avis d'experts et algorithme thérapeutique.

UNLABELLED: Intravitreal injections (IVT) of aflibercept are indicated in France for the treatment of neovascular age-related macular degeneration (AMD). An induction phase consisting of 3 monthly IVTs followed by follow-up visits and IVTs every other month during the first year is recommended. However, it may be necessary to adjust this schedule for some patients who might benefit from a more tailored approach, namely a follow-up visit immediately after the induction phase. The goal was to develop a treatment algorithm that would reflect current clinical experience and the opinions of experts on neovascular AMD. METHODS: A group of retinologists took positions on therapeutic questions regarding management of AMD using a nominal group technique (NGT). The results were combined to create a treatment algorithm. RESULTS: Seventy-nine percent of experts considered that the approved schedule was efficacious when fluid was completely resorbed after the induction phase. Ninety-four percent of experts recommended, after a successful induction phase, a monthly follow-up visit for 3 to 6 months in order to determine the rhythm of recurrence for each patient. Ninety-six percent of experts recommended that persistent fluid after the induction phase, even if visual acuity is improved satisfactorily, should be a criterion for systematic retreatment. CONCLUSION: The proposed algorithm (expert opinion) after the first year of use of aflibercept in France captures the complexity of the clinical cases that exist in daily practice and the necessity for regular follow-ups.

Pegaptanib sodium for occult choroidal neovascularization in neovascular age-related macular degeneration: a prospective case series.

PURPOSE: To assess the effects of pegaptanib in the treatment of subfoveal occult choroidal neovascularisation (CNV) associated with neovascular age-related macular degeneration (NV-AMD) in a compassionate use program in France. METHODS: Pegaptanib was authorized for patients with CNV-associated visual impairment and in whom usual care (thermal laser photocoagulation or photodynamic therapy with verteporfin) was not appropriate. Patients with occult CNV lesions received intravitreous pegaptanib (0.3 mg every 6 weeks) and were followed with repeated fluorescein angiography, scanning laser ophthalmoscopy-infracyanine green angiography, and ocular coherence tomography through 52 weeks. RESULTS: Of 56 patients (predominantly occult, N=22; purely occult, N=8; occult with chorioretinal anastomosis, N=12; occult with pigment epithelial detachment, N=14), 30% had earlier treatment. All received eight pegaptanib injections. At week 52, 79% were responders (lost <15 letters of visual acuity), 43% gained >or=0 letters, and 9% gained >or=15 letters. The best functional results were obtained in the predominantly and pure occult subgroups (responders, 86 and 75%; gained >or=0 letters, 50 and 50%). Maximum visual outcomes that correlated with morphologic improvements on each diagnostic imaging tool were seen after at least three injections. No significant ocular or systemic adverse events occurred. CONCLUSION: Treatment with pegaptanib was associated with objective functional improvements that can be correlated with objective clinical improvements on routine diagnostic imaging tools in patients with occult NV-AMD. Optimum treatment results appear after at least 4 months of therapy in the majority of cases.

[Spectral Domain OCT in age-related macular degeneration: preliminary results with Spectralis HRA-OCT]. / Tomographie par cohérence optique de type Spectral Domain dans la dégénérescence maculaire liée à l'âge. Premiers résultats avec Spectralis HRA-OCT.

PURPOSE: Optical coherence tomography (OCT) imaging has become extremely valuable in demonstrating the presence of neurosensory or retinal pigment epithelial elevation or detachment associated with occult choroidal newvessels. This imaging method has recently been improved using the Fourier Transform and is called Spectral Domain-OCT or SD-OCT. The preliminary results using this imaging technique can now be used to analyze the advantages of the technique's sensitivity and acquisition speed. MATERIAL: and methods: A consecutive series of 100 AMD patients was examined prospectively and followed with the Spectralis HRA-OCT device (Heidelberg Engineering, Heidelberg, Germany). Each patient underwent a complete ophthalmologic examination, including biomicroscopy, fluorescein and ICG angiographies, and OCT examinations. RESULTS: Different clinical forms of early AMD and advanced ARMD, either atrophic or exudative, can benefit from this new examination. The various changes were registered, mainly at the level of the outer nuclear layer, the outer limiting membrane, and the interface between the inner and outer segments. Intra- or subretinal fluid accumulation and the variations in retinal thickness were precisely analyzed and compared during follow-up using the Tomography Laser Tracking System. CONCLUSION: The Tomography Laser Tracking System can efficiently evaluate the results of treatment, correlated with the angiographic and functional data, providing great assistance in diagnosis and indications for treatment and retreatment. Quantitative measurements can be taken, not only in the lesion area, but also of their volume (especially for drusen), which may become useful in detecting complications in high-risk patients.

[Clinical case of management with intravitreal injection of Ranibizumab (Lucentis) on AMD predominant occult CNV: 6-month follow-up with FA, ICG-A, and OCT]. / Traitement par injection intra-vitréenne de Ranibizumab (Lucentis) pour des néovaisseaux choroïdiens occultes prédominants liés à la DMLA: étude et suivi par imagerie en fluorescéine, infracyanine et OCT pendant 6 mois.

INTRODUCTION: Controlled clinical trial results of occult choroidal neovascularization (CNV) management in age-related macular degeneration (AMD) using intravitreal injections of Ranibizumab have shown significant improvement in vision for the treated group. CASE REPORT: The first clinical case of minimally classic CNV is reported here with the results at 6 months, not only with changes in visual acuity but also with complete imaging at each follow-up with fluorescein angiography, infracyanine angiography using the scanning laser ophthalmoscope (SLO) and with OCT examination. After the second injection, the patient experienced improvement in vision and complete regression of all symptoms to date (5 months after the first injection), showing very favorable progression during the entire follow-up. CONCLUSION: This clinical case shows extremely favorable progression of the minimally classic lesion resulting from the first two injections of Lucentis. The situation is now stabilized in terms of function and morphology, as shown by the fluorescein and infracyanine SLO angiography and OCT examination.

[Optical coherence tomography and ARMD]. / Tomographie par cohérence optique et DMLA.

Optical coherent tomography examination (OCT) is a new medical diagnostic imaging modality analogous to ultrasound B-mode imaging, able to perform anteroposterior cross-sectional imaging of interior tissues and is useful in clinical practice in ARMD. The combination of fluorescein and ICG angiography imaging with OCT imaging will bring additional information for all clinical forms of ARMD. Many patterns and images are easy to identify, including serous retinal detachment, diffuse or cystoid retinal edema, serous or fibrovascular retinal pigment epithelium detachment with or without retinal pigment epithelium (RPE) tears and fibrosis. Other symptoms are more difficult to detect and to analyze and will need to be combined with other imaging techniques: the presence of choroidal new vessels and their localisation related to the center of the fovea and the RPE; the association of different lesions (hemorrhages, exudation, fibrosis, anastomosis and PE detachment) and recognition of less frequent lesions such as polypoidal choroidal vasculopathy. During follow-up, choroidal new vessels may be shown with different modalities. OCT examination could detect and localize these lesions, helping to determine the best management strategy. OCT examination appears to be particularly useful for both detection of persistent fluid and reabsorption and reattachment of the retina.

[Monitoring the patient after treatment: angiographic aspects of recurrence and indications for retreatment]. / La surveillance du patient après traitement. Aspects angiographiques des récidives et indications des retraitements.

OBJECTIVES: Dynamic phototherapy with intravenous injection of Verteporfin (Visudyne) is a relatively recent therapeutic concept based on a photochemical reaction. Its statistically significant efficacy has been demonstrated in treating choroidal newvessels and age-related macular degeneration. This occlusion is often temporary, thus requiring repeated treatments in persistent cases and/or recurrences. Angiographic monitoring of the patient, over the short or medium term and then later over the long term, will identify these cases. METHODS: The indications for retreatment are based on very close follow-up with fluorescein angiographic results, and the persistence or reappearance of leakage should be analyzed and clearly distinguished from staining phenomena. Leakage is an essential element and the main diagnostic criterion of recurrence. Associated criteria could be envisaged based on follow-up angiographic examinations at different stages of progression: early, at 4 or 6 weeks (often a good indicator of progression), or at 3 months, currently indispensable. RESULTS: With a relatively stable lesion with no progression or extension, the angiographic examination will make it possible to decide whether a treatment is needed: either retreatment if there is leakage or no treatment if the lesion is fibrous. To assist in therapeutic decisions, a number of arguments must be gathered based on fluorescein angiography but also on indocyanine green angiography (ICG), which will analyze neovascularization, and optical coherence tomography (OCT) examination, which will bring out the presence or absence of fluid at the lesion, as well as functional signs of visual acuity. In difficult cases, the angiographic examination will determine the source of the major decreases in acuity that can be caused by hemorrhages, breaks (which are not necessarily absolute contraindications for retreatment), or acute choroidal ischemia. CONCLUSIONS: Fluorescein and IGC angiographic follow-up and OCT examinations will screen and analyze persistence or reperfusion of choroidal neovessels as well as the extension or reappearance of lesions and, on the other hand, the presence or absence of fibrotic staining phenomena and scarring. The changes in central visual acuity and different functional signs are indicators of patient management and therapeutic indications.

[Feeder vessel treatment of choroidal neovascularization in age-related macular degeneration]. / Traitement des vaisseaux nourriciers de la néovascularisation choroïdienne rétrofovéale dans la DMLA.

INTRODUCTION: To report on the results of feeder vessel treatment for choroidal neovascularization in age-related macular degeneration (AMD). MATERIAL AND METHODS: Retrospective study of 40 patients presenting subfoveal classic choroidal neovascularization (CCNV) and/or occult choroidal neovascularization (OCNV) with or without fibrovascular pigment epithelium detachment (PED), based on fluorescein angiography (FA) and indocyanine green angiography (ICG). Visual acuity was measured using Snellen lines and/or ETDRS. The feeder vessels were visualized with high-speed ICG angiography (confocal scanning laser ophthalmoscope, Heidelberg HRA, Heidelberg, Germany). Feeder vessels were identified as very thin vessels with early filling and rapid emptying. Feeder vessel closure was achieved by laser photocoagulation treatment with either minipulse infrared laser therapy (810 nm), microburst, or yellow laser (568 nm). Post-treatment high-speed ICG angiography follow-up was recommended to the patient immediately or the day after the treatment. The number of treatments and location of the feeder vessels in relation to the macula as well as FA, ICG, and visual acuity results were assessed. If necessary, other treatment techniques such as photodynamic therapy (PDT) or transpupillary thermotherapy (TTT) were offered to the patient when leakage was still present. RESULTS: The patients were followed for an average of 6.2 months (2-9 months). Twenty-six women and 14 men (mean age, 72 years; range, 51-95) were included. Eight patients demonstrated classic neovascularization, 32 presented occult neovascularization, including 17 cases of vascularized PED and 15 retrofoveal plaques. The average number of treatments was 1.8 (range, 1-4 treatments). Location of feeder vessels were as follows: nine superior-macular, 18 inferior-macular, six nasal-macular and 11 temporal-macular. Visual acuity improved two lines or more in nine patients (22.5%), decreased 2 lines or less in five patients (12.5%) and was stable in 26 patients (65%). After feeder vessel treatment, seven patients showed improvement of the anatomical aspect of the AMD lesions, with a reduction in leakage. Except for one subretinal hemorrhage, no complications after feeder vessel treatment were observed. CONCLUSION: Feeder vessel treatment is a technique requiring high-speed ICG angiography to detect the feeder vessels located at a distance from the subfoveal OCNV, CCNV, and PED. Although the final visual acuity result was for the most part stabilization, the technique appeared to be safe and reproducible. In patients who were not eligible for other therapies such as PED, feeder vessel treatment seemed to be a reasonable alternative.

Surgical removal of subfoveal choroidal neovascularization: visual outcome and prognostic value of fluorescein angiography and optical coherence tomography.

PURPOSE: To study the functional results of macular surgery and determine pre-operative features associated with better final visual outcome. METHODS: Forty-two consecutive patients underwent surgical removal of subfoveal choroidal neovascularization (CNV), related to age-related macular degeneration (AMD) in 8 eyes, degenerative myopia in 14 eyes, multifocal choroiditis (MFC) in 10 eyes, idiopathic CNV in 6 eyes and other etiologies in 4 eyes. Mean age was 49 years. Pre-operative visual acuity (VA) was 20/200 or less in 30 eyes (71.4%) and never better than 20/40. Fluorescein angiography was analyzed before and after surgery. Pre-operative optical coherence tomographs (OCT) were studied in a masked fashion. Mean follow-up was 12 months (range 4-48 months). RESULTS: Final VA was 20/200 or less in 25 eyes (60%). According to the CNV etiology, the percentage were 87.5%, 80%, 57.1% and 20% respectively in eyes with AMD, MFC, high myopia, and idiopathic or other diseases. Post-operative VA improved in 21 eyes (50%) but subsequently declined in 7% by the final examination. Patients younger than 50 years had better functional results (p=0.006). Lack of retinal pigment epithelium (RPE) changes on pre-operative angiography was correlated with good visual outcome (p<0.001). The OCT study confirmed some features already described and showed some different CNVpatterns: above and usually separated from the RPE, below and not separated from the RPE, and ungradable. Eyes with the first OCT pattern had the best visual outcome. Main complications included 4 (10%) retinal detachments and 9 (21%) recurrences. OCT was also useful to confirm CNV recurrences post-operatively. CONCLUSIONS: CNV surgical excision results vary depending on the underlying disease, the RPE and choriocapillaris function, and the features observed on pre-operative OCT images.

[Translocation of the macula for retrofoveal choroidal neovascularization in age-related macular degeneration and severe myopia: first results]. / Translocation maculaire dans la néovascularisation choroïdienne rétrofovéolaire dans la DMLA et la myopie forte: premiers résultats.

BACKGROUND: Subfoveal choroidal neovascularization is a main cause of blindness. The new surgical technique of macular translocation conceived by De Juan, with scleral shortening and without a retinotomy, allows to move the fovea away from the neovascular membrane with a low rate of complications. The first results obtained with this technique are presented here, in cases of submacular neovascularization due to age-related macular degeneration (AMD) or degenerative myopia. PATIENTS AND METHODS: The first 10 patients who were operated on with this technique presented with subfoveal neovascularization due to AMD (6 eyes) or myopia (4 eyes). The time period between the beginning of the disease and surgery was less than 3 months. Before and after surgery, a complete examination included fluorescein and ICG angiographies and OCT. RESULTS: Visual acuity improved by 2 lines or more in 6 eyes (60%), was unchanged in 3 eyes (30%) and decreased in 1 eye. The improvement in vision seemed higher in myopia than in ARMD. Conversely, the mean foveal displacement was greater in ARMD than in myopia (1.2 disc diameter and 0.5 respectively). Laser photocoagulation has been performed in all patients after surgery. Main complications were retinal detachment (1 eye) and neovascularization at the site of transretinal injection (1 eye). Mean follow-up was 3 months. COMMENTS: Macular translocation with the technique described by De Juan allowed visual improvement in more than the half of the eyes with subfoveal neovascularization, resulting in a moderate rate of complications. Long term follow-up is necessary to confirm these results.