One-year outcome of bevacizumab therapy for chronic macular edema in central and branch retinal vein occlusions in real-world clinical practice in the UK.

BACKGROUND: The purpose of this study was to investigate the 12-month outcome of macular edema secondary to both chronic and new central and branch retinal vein occlusions treated with intravitreal bevacizumab in the real-life clinical setting in the UK. METHODS: Retrospective case notes analysis of consecutive patients with retinal vein occlusions treated with bevacizumab in 2010 to 2012. Outcome measures were visual acuity (measured with Snellen, converted into logMAR [logarithm of the minimum angle of resolution] for statistical calculation) and central retinal thickness at baseline, 4 weeks post-loading phase, and at 1 year. RESULTS: There were 56 and 100 patients with central and branch retinal vein occlusions, respectively, of whom 62% had chronic edema and received prior therapies and another 32% required additional laser treatments post-baseline bevacizumab. Baseline median visual acuity was 0.78 (interquartile range [IQR] 0.48-1.22) in the central group and 0.6 (IQR 0.3-0.78) in the branch group. In both groups, visual improvement was statistically significant from baseline compared to post-loading (P<0.001 and P=0.03, respectively), but was not significant by month 12 (P=0.058 and P=0.166, respectively); 30% improved by at least three lines and 44% improved by at least one line by month 12. Baseline median central retinal thickness was 449 µm (IQR 388-553) in the central group and 441 µm (IQR 357-501) in the branch group. However, the mean reduction in thickness was statistically significant at post-loading (P<0.001) and at the 12-month time point (P<0.001) for both groups. The average number of injections in 1 year was 4.2 in the central group and 3.3 in the branch group. CONCLUSION: Our large real-world cohort results indicate that bevacizumab introduced to patients with either new or chronic edema due to retinal vein occlusion can result in resolution of edema and stabilization of vision in the first year.

Effect of initial retinal thickness on outcome of intravitreal bevacizumab therapy for diabetic macular edema.

PURPOSE: To investigate whether eyes with diabetic macular edema (DME) and central retinal thickness (CRT) >400 µm had better visual and anatomical outcomes compared to eyes with a CRT <400 µm when treated with intravitreal bevacizumab in a real-world setting. PATIENTS AND METHODS: Patients undergoing intravitreal bevacizumab therapy for DME were identified from the departmental database of a tertiary referral unit. Following the initial injection, a retreatment was performed for any persistent macular edema, unless there had been no previous response to repeated doses. Recorded parameters included visual acuity, CRT on optical coherence tomography (spectral domain optical coherence tomography [SD-OCT]), and SD-OCT characteristics. Comparisons were made between data at baseline and 12 months after the first injection, and differences were tested for statistical significance using the Student's t-test. RESULTS: In all, 175 eyes of 142 patients were analyzed. Patients in group 2 (CRT >400 µm) had significantly more injections than group 1 (CRT <400 µm) (4.0 versus 3.3; P=0.003). Both groups had similar numbers of eyes with preexisting epiretinal membrane and/or vitreomacular traction at baseline. The reduction in CRT was significantly greater in group 2 when compared to group 1 (P<0.0001). In terms of visual gain between baseline and month 12, each gained significantly by a mean of 0.12 logarithm of the minimum angle of resolution units (P=0.0001), but there was no difference between groups 1 and 2 (P=0.99). CONCLUSION: These results do not support a 400 µm baseline CRT cut-off for treating DME with bevacizumab, in contrast to published data on ranibizumab. Our results also indicate that patients with a thicker CRT require more bevacizumab injections, making treatment less cost-effective for these patients. Our results could be used by practitioners to support the use of bevacizumab in DME without applying a CRT cut-off.

Clinical course and visual outcome in patients with diabetes mellitus and uveitis.

PURPOSE: We report the clinical course and visual outcome of patients with diabetes mellitus (DM) who subsequently developed uveitis from any cause. METHODS: Longitudinal, retrospective case note review. RESULTS: A total of 36 patients (M/F: 18/18, 58 eyes) were included, Of the 36 patients, 35 had Type 2 DM and one had Type 1 DM. Mean age of onset of DM was 49 years and uveitis 55 years. The uveitis was bilateral in 22 (61%) patients. There were 19 patients with anterior uveitis, 12 with panuveitis and 5 with intermediate uveitis. Mean follow up was 4.4 years (range 1-18). Mean number of uveitis recurrences was 3 (range 1-7). Causes of vision of 6/18 or worse appeared related to the uveitis in 9 eyes and diabetes in 4 eyes. Cataract occurred in 22 eyes, glaucoma in 17 eyes, and cystoid macular oedema in 10 eyes. Diabetic retinopathy was detected in 38 (65.5%) eyes (29 non-proliferative including 6 with clinically significant macular oedema, and 9 proliferative). Progression of diabetic retinopathy to proliferative stage occurred in 7 eyes of 4 patients over a mean duration of 4.4 years. In 10 patients with active uveitis the mean HbA1c was 80 mmol/mol [9.5%], (range 49-137 [6.6-14.7]), and 67 mmol/mol [8.3%] (range 46-105 [6.4-11.8]) when the uveitis was quiescent, p = 0.01. Better glycaemic control was required in 10 patients during episodes of uveitis. CONCLUSIONS: Patients with DM who develop uveitis may have a high complication rate, reduced vision and poor glycaemic control. Checking blood glucose during episodes of uveitis is important.

Late-stage metastasis to the choroid from follicular thyroid carcinoma--case report.

BACKGROUND: Metastatic tumors to the choroid represent the most common uveal malignancy in adults. The most common origin of choroidal metastasis is from the breast and lung. Choroidal metastasis from thyroid carcinoma is rare. We report a case of choroidal metastasis that presented 36 years after the patient was initially diagnosed with follicular thyroid carcinoma. CASE REPORT: A 74-year-old Afro-Caribbean woman with nonproliferative diabetic retinopathy presented to the diabetic clinic for a routine 6-month review. A dilated fundus examination found bilateral background diabetic retinopathy and a large metastatic lesion in the periphery of the right eye. Ocular ultrasonography was performed. The patient had undergone partial thyroidectomy for nodular goiter in 1969. Biopsy of skeletal metastases in 1982 confirmed that the primary was follicular thyroid carcinoma. She died 9 months after presentation with choroidal metastasis from progressive metastatic disease. CONCLUSION: Choroidal metastasis may appear in the late stage of a very long period of known thyroid metastatic disease. It can develop fairly rapidly without causing any ocular symptoms.

Clinical features of patients with diabetes mellitus presenting with their first episode of uveitis.

PURPOSE: Little is known about uveitis in patients with diabetes mellitus (DM). The authors studied diabetic patients with their first episode of uveitis. METHODS: Cross-sectional, case note study documenting the uveitis, underlying cause/syndrome, treatment, type of DM and treatment, and any diabetic retinopathy. RESULTS: There were 34 patients (M/F: 17/17, 48 eyes) with their first uveitis episode (33 had type 2 DM). Mean age of onset of DM 49 years and uveitis 56 years. Uveitis was bilateral in 14 (45%), with most having idiopathic anterior uveitis. Visual acuity 6/18-6/60 in 15 eyes, and worse than 6/60 in 11 eyes. There was 3-4+ flare in 16 eyes, 3-4+ anterior chamber cells in 13 eyes. Diabetic retinopathy was seen in 20 (42%) eyes, and mean blood glucose was 13.64 mmol/L in 11 patients. CONCLUSIONS: Diabetic patients presenting with uveitis, whatever the aetiology, may have severe inflammation, reduced vision, and poor glycaemic control.

Indocyanine green angiography in systemic lupus erythematosus-associated uveitis.

PURPOSE: To report indocyanine green (ICG) angiography findings in a patient with systemic lupus erythematosus-associated uveitis. METHODS: Review of the patient's clinical records. RESULTS: ICG angiography revealed dilatation of individual choroidal vessels in the early phase. Furthermore, two types of hypofluorescent areas became visible from the intermediate up to the late phase: the first type was small, round, and better defined, while the second type consisted of larger, ill-defined areas seen around fixation in the right eye and temporal to fixation in the left eye. These hypofluorescent areas were not visible on either clinical examination or fluorescein angiography. CONCLUSIONS: The results of ICG angiography suggest choroidal involvement in patients with systemic lupus erythematosus-associated uveitis.

Bilateral combined retinal and choroidal detachment in antineutrophil cytoplasmic antibody-positive scleritis.

PURPOSE: To describe a rare complication of scleritis in a patient with positive serum antineutrophil cytoplasmic antibodies (ANCA). METHODS: We present a case report of a patient who developed bilateral retinal and choroidal detachment associated with ANCA-positive scleritis. RESULTS: Oral steroids alone were insufficient to maintain sustained remission of ocular inflammation. Clinical relapse of the scleritis was associated with ANCA titres becoming positive again. A combination of cyclophosphamide and steroids was successful in achieving control of the intraocular inflammation over a follow-up period of 18 months. CONCLUSION: Bilateral combined retinal and choroidal detachment is a potentially blinding complication of ANCA-positive scleritis. Monitoring of ANCA titres is useful in the management of the disease.

Bilateral Coats' disease: long-term follow up.

PURPOSE: To report on the long-term follow-up of a female patient with bilateral Coats' disease, who showed marked asymmetry between the two eyes. METHODS: A five year old girl presented in 1978 with leukocoria in a blind right eye. A total exudative retinal detachment and extensive retinal telangiectasiae were noted. In the other eye, there was a localized area of retinal exudation and vascular abnormality in the supero-temporal periphery. Ultrasonography showed no evidence of intraocular tumour in the right eye and a clinical diagnosis of bilateral Coats' disease was made. RESULTS: In 1995, the area or retinal exudation in the left eye increased and laser photocoagulation was applied successfully. To date, no disease recurrences have occurred. CONCLUSION: Although Coats' disease is usually unilateral, bilateral, asymmetrical involvement may occur on rare occasions. Long-term follow-up of the least affected eye is necessary so that late complications can be identified early and treated adequately to prevent visual loss.