Photodynamic therapy in the treatment of persistent central serous chorioretinopathy: a two-year follow-up.

BACKGROUND: The aim of this study was to assess during a follow-up period of two years the efficacy and safety of photodynamic therapy (PDT) in central serous chorioretinopathy (CSC) showing no spontaneous resolution four months after the onset of the symptoms. PATIENTS AND METHODS: We present a prospective interventional non-comparative case series. The diagnosis of CSC was confirmed by fluorescein angiography (FA), and optical coherence tomography (OCT) in 46 eyes of 42 consecutive patients. PDT was performed according to the protocol used for treating choroidal neovascularization in age-related macular degeneration. The primary end point was to assess the anatomic re-attachment of the retina. The secondary end point was to record the visual function. A paired t-test and a linear regression and correlation test were used for the statistics. RESULTS: The leakage in FA and the detachment of the neurosensory retina in OCT were no longer present in 42 eyes six weeks after PDT and in the remaining four eyes three months after PDT. At the end of the follow-up, the best-corrected visual acuity measured with an ETDRS chart improved in 36 eyes, and remained stable in 10 eyes (mean improvement, 10.2 letters; p < 0.001). Two cases of recurrence were diagnosed. No treatment-related complications were noticed. CONCLUSIONS: PDT could be an effective and durable option for treating patients with persistent CSC.

[Photodynamic therapy in "Secondary Sick RPE Syndrome" after repeated intravitreal injections of VEGF inhibitors in patients with wet age-related macular degeneration]. / Fotodynamische Therapie bei "Secondary Sick RPE Syndrome" nach wiederholten intravitrealen Injektionen von VEGF-Inhibitoren bei Patienten mit feuchter altersabhängiger Makuladegeneration.

BACKGROUND: After repeated injections of VEGF inhibitors for wet AMD some patients show therapy-resistant isolated subretinal fluid (here named secondary sick RPE syndrome). The efficacy of photodynamic therapy was examined in these cases. PATIENTS AND METHODS: A group of in total 18 patients with wet AMD (14 eyes with occult and 4 with minimal classic CNV) showed therapy-resistant isolated subretinal fluid after repeated intravitreal injections of VEGF inhibitors (bevacizumab or ranibizumab). These eyes were treated with photodynamic therapy with verteporfin. After PDT the need for further intravitreal injections of VEGF inhibitors and visual acuity was examined. RESULTS: After a mean number of 7.1 injections of VEGF inhibitors (bevacizumab or ranibizumab), in 14 patients one PDT, in 4 patients two PDT were performed. Twelve of 18 patients showed complete resorption of subretinal fluid and needed no further intravitreal injections during a mean of 11.6 months (4 - 26) after PDT. Six patients needed a mean of 4.3 additional injections. Twelve of 18 patients showed stable visual acuity (± 5 letters ETDRS), 6 improved more than 5 letters while none of them showed visual loss. CONCLUSIONS: In patients with wet AMD and isolated subretinal fluid after repeated injections of bevacizumab or ranibizumab photodynamic therapy could be an option to reduce the number of further injections and to stabilise visual acuity.

The treatment of choroidal neovascularizations in age-related macular degeneration using either Avastin or Lucentis.

BACKGROUND: Either Avastin or Lucentis was used in our clinic to treat choroidal neovascularizations in age-related macular degeneration. The number of injections necessary for drying the macular findings was especially assessed. PATIENTS AND METHODS: From April 2006 to August 2008 324 eyes were treated with Avastin, and from January 2007 to August 2008 348 eyes were treated with Lucentis. The intravitreal injections with Avastin (1.25 mg in 0.05 mL) were performed every six weeks, and with Lucentis (0.05 mg in 0.05 mL) every four weeks until the macular findings were considered to be dry. Fluorescein angiography and optical coherence tomography were used for the diagnosis and for the checks which were carried out every twelve weeks. The visual acuity was measured with an ETDRS chart. RESULTS: The treatment with Avastin is completed in 319 eyes with an average improvement of the visual acuity of 5.1 letters after 3.3 injections, and with Lucentis in 226 eyes with an average improvement of the visual acuity of 6.4 letters after 3.4 injections (p = 0.24; one way ANOVA). CONCLUSION: Both of the drugs allow the drying of the macular findings in the great majority of the cases after a short time and lead to a quite similar improvement of the visual acuity. A definitive stabilization of the disease after stopping the treatment is not foreseeable.

The treatment of choroidal neovascularisation with intravitreal injections of bevacizumab (Avastin).

BACKGROUND: Although bevacizumab (Avastin) has only been approved for the treatment of colorectal carcinoma, many reports have shown that its intravitreal administration against choroidal neovascularisation (CNV) leads to a stabilisation or even a regression of the pathological neovessels, and thus to a positive evolution of visual acuity. PATIENTS AND METHODS: From April 2006 to July 2007, the CNV of different aetiologies were treated with intravitreal injections of bevacizumab (1.25 mg in 0.05 mL) in 300 patients with an average age of 75, 78 years. Fluorescein angiography and optical coherence tomography were used for the diagnosis and for the checks which were carried out every twelve weeks. The intravitreal injections were performed every six weeks until the macular findings were considered to be dry. The visual acuity was checked using an ETDRS chart. RESULTS: In all the groups considered the visual acuity was stabilised or improved on an average with + 4.44 ETDRS letters after 3.04 injections. During the follow-up six cardiovascular diseases were diagnosed and in one case a patient died. No ocular complications were reported after 1036 injections. CONCLUSIONS: The results clearly show that the intravitreal injections of bevacizumab are effective, safe and cost-effective. However, further randomised studies are needed to confirm the duration of the effect, as well as the good ocular and systemic tolerability of the drug.

Photodynamic therapy in the treatment of chronic central serous chorioretinopathy.

BACKGROUND: Central serous chorioretinopathy (CSC) is usually a benign disorder which resolves spontaneously, and requires no treatment. Nevertheless, in cases of chronic or recurrent detachment of the neurosensory retina a durable decrease of the visual acuity may be measured due to lesion of the photoreceptors. To avoid this evolution we performed a pilot study to assess the effect of photodynamic therapy (PDT) in patients with CSC without clinical normalization 6 months after the begin of the symptoms. PATIENTS AND METHODS: We report on 14 eyes in 13 patients presenting a chronic CSC without leaking point accessible for focal laser photocoagulation. The diagnosis was confirmed by fluorescein angiography (FA), and optical coherence tomography (OCT). PDT with verteporfin was performed according to the protocol used for treating choroidal neovascularization in age-related macular degeneration. RESULTS: One month after PDT, leakage on FA and detachment of the neurosensory retina on OCT had disappeared, and visual acuity had improved in all patients. CONCLUSIONS: The mechanism of action of PDT in chronic CSC is still hypothetical. PDT should decrease the passage of fluid towards the retina by affecting the choroidal blood flow, and allow a better resorption of the subretinal fluid. PDT could be an alternative to treat patients with chronic CSC.

Simultaneous fluorescein and indocyanine green angiography for exudative macular degeneration.

BACKGROUND: The present study investigates how often a simultaneous fluorescein and indocyanine green (ICG) angiography had therapeutic consequences and if it is useful as a clinical routine diagnostic tool. PATIENTS AND METHODS: 502 consecutive simultaneous angiographies in eyes with exudative macular degeneration were retrospectively studied. RESULTS: A classic extra- or juxtafoveolar choroidal neovascularisation (CNV) was found in 3.5 % of the eyes. A subfoveal predominantly classic CNV was present in 19 % of the angiographies. ICG angiography showed a vascular network in 3 % of the eyes with occult CNV in fluorescein angiography. A neovascularisation supplied by retinal vessels (retinal angiomatous proliferation) was found in 9 % and a polypoidal choroidal vasculopathy (PCV) in 6 %. Other plaques or hot spots were visible in 4 %. In 11 eyes with progressive exudation from PCV and threatening of the fovea, laser treatment was successfully performed. CONCLUSIONS: Combined angiography identifies treatable PCV. Advantages of a combined procedure (easier logistics, no missing of treatable cases) and arguments for a two step procedure with ICG angiography only in selected cases (lower costs, lower rate of adverse reactions) must be weighed against each other.

[Observations of choroid pulsation]. / Beobachtungen zur Aderhautpulsation.

BACKGROUND: While performing indocyanine-green (ICG) videoangiograms with the Rodenstock scanning laser ophthalmoscope (SLO), we got more and more aware of visible choroidal pulsation mainly during the inflow of ICG into the eye. We wanted to learn more about the frequency and the different forms of this phenomenon. MATERIAL AND METHODS: We examined 187 consecutive ICG angiographies retrospectively, which were performed with a Rodenstock SLO and stored by videotape. Most patients suffered from age-related macular degeneration and had a mean age of about 70 years. We defined 4 groups of different pulsatile dye inflow in the choroid, namely (group 1) the diffuse form, involving the whole macular region; (group 2) the local form, involving an area smaller than the fovea. In group 3 (mixed form) we found the pulsatile inflow diffuse initially, later on remained a local pulsation. In group 4 (special form) we noticed a localized pulsation of a longer duration (10-15 seconds) and of a special type, namely back and forth movements of dye in one or a few choroidal veins. In addition, we examined the presence of pulsation in the central retinal vein. RESULTS: In 173 of 187 angiograms we could examine the choroidal inflow in the macular region. We found in 94 of these 173 angiograms (or in 54%) choroidal pulsation. 84% of all cases were in group 1, 2 and 3. This probably physiological pulsation occurred mostly in the first few seconds after the inflow of the dye. After about 5 seconds it was normally not visible any more. In our group 4 we collected 16 out of 94 angiograms (or 17%). We could not find a correlation between the presence of a pulsation in the central vein and in the choroid. CONCLUSIONS: Choroidal pulsatile inflow of ICG is a frequent (most probably physiological) phenomenon. The localized pulsation found in several older patients with back and forth movements of dye in one or a few veins may be abnormal; it reflects phasic pressure changes in choroidal veins of low flow. We do not know yet if this phenomenon is of any diagnostic value. However, more studies of these interesting dynamic processes seem to be warranted.

[Simultaneous digital indocyanine green and fluorescein angiography]. / Simultane digitale Indocyaningrün- und Fluoreszeinangiographie.

BACKGROUND: The simultaneous recording of indocyanine green and fluorescein angiography is since more than twenty years possible. The real-time digital recording of angiograms is about since 10 years possible. Because of the poor temporal resolution due to technical limitations, both of the above methods were only seldom used routinely. Graphics workstations can digitize and store multiple video sources real-time with full video framerate. Comparing to conventional videoangiography, the quality can be improved significantly. MATERIALS AND METHODS: Simultaneous ICG and Fluorescein (SIF) angiography images of a two-channel Scanning Laser Ophthalmoscope were digitized and stored real-time at a rate of 28-50 images/sec using a graphics workstation. The digitized image sequence could be replayed as a motion picture and/or single images of the recorded sequence could be analyzed separately. RESULTS: The simultaneous digital recording of angiograms is easier, than using two video tape recorders. It was possible to enhance the quality of the stored images using standard digital image processing procedures. Morphological measurements and densitometry were done with software developed for the UNIX workstation, or with personal computers using standard software packages. CONCLUSION: Simultaneous digital ICG and fluorescein angiography has several advantages over conventional video-angiographies: the image quality is better, data retrieval is easier, it is easier to perform than conventional video angiography, image can be accessed through a computer network, it is easy to perform morphological and densitometrical measurements, etc.

[Digital internet-based ophthalmologic image databank]. / Digitale Internet-basierte ophthalmologische Bilddatenbank.

OBJECTIVE: To manage an ophthalmological image database easily and rationally. MATERIALS AND METHODS: Fundus, macro and simultaneously recorded Fluorescein and ICG angiography images were digitized and archived using personal computers and UNIX workstations. Image data were written to CD-recordables. The CD-s with image information were stored in a jukebox-server. On demand image information was converted to dynamic hypertext markup language (html) with a WWW-server. Information stored on the servers could be observed with browser programs running on client computers connected to local area network. The communication with ophthalmologist working outside our hospital was realized by electronic mail. RESULTS: Different platforms (PC, Mac, workstations, etc.) and operating systems (Windows 3.x, 95, NT, MacOS, UNIX, etc.) can be used as clients. The communication with the system is accomplished by standard internet programs (Internet Explorer, Netscape Navigator, etc.). Thanks to the intuitive graphical user interface, no special computer knowledge is required to retrieve the stored data. CONCLUSION: Our digital image database has many advantages over a conventional image archive: it is round the clock available, images can be stored and copied without loss of quality, digital images can be easily integrated in other applications, it can be used without special computer knowledge, it is expandable and compatible with all contemporary computer platforms.

[Simultaneous ICG- and fluorescein-angiography for fundus examination]. / Simultane ICG- und Fluoreszeinangiographie in der Fundusdiagnostik.

BACKGROUND: An indocyanine-green (ICG) angiography is rarely used as the only diagnostic procedure. Almost always it is performed additionally to a fluorescein angiography. The use of simultaneous ICG and fluorescein (SIF) angiography therefore makes sense. Several examples for the application of SIF-angiography are presented. MATERIALS AND METHODS: SIF-angiography was performed using a 2-wavelength scanning laser ophthalmoscope (SLO). Images were digitally recorded in real time with a graphics workstation. The following cases will be presented: choroidal neovascularization in age-related macular degeneration, choroidal hemangioma, inflammatory fundus disease (APMPPE) and idiopathic polypoidal choroidal vasculopathy. RESULTS: ICG and fluorescein angiography can be simultaneously recorded with the 2-wavelenghth SLO. The quality of the combined pictures is comparable to single-channel recordings of separate ICG and fluorescein images. We show results of the above mentioned cases. CONCLUSIONS: SIF angiography is time efficient and allows precise comparison and analysis of the transit of both dyes through retinal and choroidal circulation. The topographic relation of pathologic findings in ICG angiograms with the critical retinal vascular landmarks is facilitated.

Indocyanine green versus fluorescein angiography in the differential diagnosis of arteritic and nonarteritic anterior ischemic optic neuropathy.

PURPOSE: We evaluated in a prospective study the usefulness of indocyanine green (ICG) versus fluorescein angiography in the differential diagnosis between arteritic and nonarteritic anterior ischemic optic neuropathy (AION). METHODS: Simultaneous ICG and fluorescein angiography was performed on 22 eyes with AION. Appearance of both dyes in the choroid and in the retina, laminar flow, venous filling, and complete filling of the choroid were measured independently. Massive delayed choroidal filling corresponding to occluded posterior ciliary arteries was especially assessed, as it is almost always diagnostic of arteritic AION. We considered the choroidal filling as massive delayed if it was still incomplete after the venous filling. RESULTS: We diagnosed 5 arteritic AIONs, confirmed by biopsy, and 17 nonarteritic AIONs. In both types of angiography, 3 of 5 patients with arteritic AION showed massive delayed complete choroidal filling times (44.2, 45.8, and 70 seconds), and patients with nonarteritic AION had normal complete choroidal filling times. Dye appearance at the different angiographic times was similar for fluorescein and ICG angiography (P = 0.95-0.96). CONCLUSION: Fluorescein angiography alone is sufficient to reveal massive delayed choroidal filling time in arteritic AION. For our purpose, ICG angiography provides no additional information.

Simultaneous indocyanine green and fluorescein angiography.

PURPOSE: To facilitate the interpretation of the choroidal dye filling sequence, the use of simultaneous indocyanine green (ICG) and fluorescein angiography was evaluated. METHODS: A single-wavelength scanning laser ophthalmoscope (SLO) was modified to a two-wavelength system, permitting the simultaneous recording of ICG and fluorescein angiography. This method has been used in 340 cases. About two thirds of the patients had well-defined or occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). RESULTS: Simultaneous ICG and fluorescein angiography is feasible with a two-wavelength SLO and provides images of good quality. Two corresponding ICG and fluorescein angiography pictures can be presented as one combined red-green picture. CONCLUSION: This method has three advantages: (1) it allows a precise comparison of the transit of both dyes through both circulations, and there are no differences in the injected bolus nor in the actual blood pressure; (2) the important features of the ICG angiograms are fully aligned with the critical retinal vascular landmarks provided by the fluorescein images; and (3) it is very time efficient--with a single injection and one photographic session, immediate results are obtained.

Low dose radiation for subfoveal choroidal neovascularization in age-related macular degeneration. A pilot study: radiotherapy for age-related macular degeneration.

The aim of our pilot study was to test the effect of low dose radiation on classic and occult subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD). The posterior pole of the afflicted eye of 12 patients was irradiated with 5 Gray (Gy), and that of 34 patients with 8 Gy. The radiotherapy was done by a linear accelerator (6 MV X-rays) during 4 consecutive days with daily doses of 1.25 Gy and 2 Gy respectively. At the time of treatment, and 6 weeks, 6 months and 1 year after, a simultaneous fluorescein and ICG angiography of both eyes were carried out, and the distance visual acuity was measured. In none of the cases were we able to note a reduction in the subfoveal membrane's size. With regards to the visual acuity, the evolution was slightly better than the spontaneous courses described in existing literature. Further prospective randomized studies with higher dose radiation are necessary in order to determine the significance of radiotherapy in the treatment of this pathology.