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PubMed1997

[Acute glaucoma caused by massive subretinal hemorrhage in age-related macular degeneration and disordered thrombocyte function].

BACKGROUND: Hemorrhages from subretinal neovascularizations in age-related macular degeneration are not uncommon, but usually limited to the posterior pole. A therapy-resistant angle closure glaucoma following displacement of the lens-iris diaphragm due to massive choroidal and subretinal hemorrhages has rarely been reported. CASE REPORT: A 72-year-old female patient was first seen in September 1993 because of decreased vision in the right eye. An age related macular degeneration with an extended untreatable neovascularisation membrane was diagnosed. One year later sudden pain attacks were initiated by secondary angle closure glaucoma, caused by a massive choroidal and subretinal bleeding. At first the IOP could be regulated by drug therapy, however, recurring hemorrhages led to continuously elevated IOP. The reason for the recurrent massive hemorrhages was found to be a disorder of the platelet function. Since the IOP (50-80 mm Hg) could not be controlled any further, we decided to perform a sclerotomy in an attempt to drain the blood. Within one day another bleeding occurred and again led to an increase in IOP. Finally, the patient agreed to have the eye enucleated. CONCLUSION: In case of massive hemorrhages in age related macular degeneration a haematological systemic disorder must be included in the diagnostic considerations. If the intraocular pressure can not be lowered neither medically nor surgically, enucleation can not be avoided.

Acetaminophen↗
PubMed1998

Significance of isolated neovascular tufts ("popcorn") in retinopathy of prematurity.

BACKGROUND: The significance of isolated neovascular tufts ("popcorn") occurring in association with stage 2 retinopathy of prematurity (ROP) has not been studied. METHODS: We retrospectively reviewed the clinical courses and outcomes of all patients with zone II, stage 2 ROP with popcorn examined over the past 3 years at one institution. Eyes with zone I disease, plus disease, or stage 3 at the initial appearance of popcorn were excluded. The study group was compared with a control group of patients of similar birth weight and gestational age with zone II, stage 2 ROP without popcorn. RESULTS: Popcorn first appeared at a mean age of 36.4 (+/- 2.2) weeks after conception in 26 patients. Of these, 17 patients (65%) progressed to stage 3, 10 (38%) had plus disease, 6 (23%) reached threshold, and 9 (35%) required laser treatment. Of 19 control patients, 4 (21%) progressed to stage 3, 1 (5%) had plus disease, 1 (5%) reached threshold, and 1 (5%) required laser treatment. The popcorn group had a significantly higher incidence of progression to stage 3 (p < 0.005), plus disease (p < 0.025), and laser treatment (p < 0.025). All eyes of both groups had complete regression of disease. CONCLUSIONS: The presence of popcorn significantly increases the risk that an eye with zone II, stage 2 ROP will progress to stage 3, develop plus disease, and require laser treatment. Patients with popcorn and coexistent mild vascular dilation or tortuosity insufficient for plus disease are at particularly high risk for disease progression.

Disease Progression↗
PubMed2005

Ocular conditions associated with peripapillary subretinal neovascularization, their relative frequencies, and associated outcomes.

OBJECTIVE: To determine frequency and outcomes of conditions with peripapillary subretinal neovascular membranes (PSRNVMs). DESIGN: Retrospective observational case series. PARTICIPANTS: All patients from a private community-based retina practice diagnosed with a PSRNVM. METHODS: Review of clinical charts, photographs, and fluorescein angiograms of 115 eyes of 96 patients, accrued over 18 years. MAIN OUTCOME MEASURES: Demographics, visual acuity (VA), laterality, neovascular membrane type and recurrence status over treatment course, and associated ocular conditions. RESULTS: Prevalences of reported associations were 52 (45.2%), age-related maculopathy (ARM); 45 (39.1%), idiopathic; 5 (4.3%), multifocal choroiditis; 3 (2.6%), angioid streaks; 2 (1.7%), histoplasmosis; 2 (1.7%), choroidal osteoma; 1 (0.9%), optic disc drusen; and 1 (0.9%), congenital disc anomaly. Newly recognized associations include pattern dystrophy (3 [2.6%]) and peripapillary pseudopodal pigment epithelial and choroidal atrophy (1 [0.9%]). Second-eye involvement was observed in 19.8% of patients over a median follow-up of 2 years. Median initial VAs were 20/40 for ARM-associated eyes and 20/30 for idiopathic eyes (P = 0.0230). Median final VAs were 20/70 for ARM-associated eyes and 20/32 for idiopathic eyes (P = 0.0261). The VA changes in the ARM-associated and idiopathic groups did not differ significantly (P = 0.1453). Recurrence of PSRNVMs after laser ablation was seen in 14 of 73 eyes (19.2%). A case of a PSRNVM as a cause of pseudopapilledema leading to unnecessary neurological imaging is reported. CONCLUSIONS: Close inspection of fellow eyes at the time of first eye diagnosis and regular follow-up afterward are indicated, given the high rate of eventual bilateral involvement regardless of associated condition. Laser ablation of PSRNVMs with broad treatment margins reduces recurrence rates relative to earlier series. The differential diagnosis of disc edema should include PSRNVMs. Pattern dystrophy can be associated with PSRNVMs.

Adult↗
PubMed2002

A new health technology: where is the consensus on a clinically worthwhile benefit?

AIM: New therapies are often introduced into the NHS prior to full evaluation, leading to inequities in provision. Uncertainty exists regarding the value of photodynamic therapy in the treatment of neovascular age-related macular degeneration. We ascertained the availability of this treatment and the information used to inform clinical policy. METHODS: A postal survey of all clinical directors/lead consultants in the UK sought data on which (if any) patients were referred or treated with PDT by their unit, the sources of evidence informing clinical policy and the threshold of clinical benefit at which respondents would support the use of PDT. RESULTS: 123/152 questionnaires were returned. 42% of units make some provision for PDT on the NHS, including routine provision by 9%. 14.5% of units offer the option of care in the private sector, whilst 26.5% treated or referred no patients. The threshold at which respondents considered introduction of PDT would be justifiable varied widely. Respondents cited local literature review, advice from clinicians, guidance from the Royal College and information from the pharmaceutical industry as most influential in determining current policy. However, the National Institute for Clinical Excellence (NICE) and the Cochrane Library were anticipated as playing a greater role in shaping future practice. CONCLUSIONS: Substantial variation exists in the availability of PDT. Advocates of PDT may interpret our data as an indication of the NHS failing to provide an effective therapy equitably, whilst others may deduce that patients are receiving an under-evaluated treatment in routine clinical practice. The differing thresholds at which clinicians believe treatment would be justified may further exacerbate variations and the priority given to PDT.

Attitude of Health Personnel↗
PubMed1995

[Low dosage radiotherapy of subfoveal neovascularization in age-related macular degeneration. Preliminary results].

AIM OF THE STUDY: The aim of this study is to test the effect of low dose radiation on the subfoveal neovascular membranes (SNVM) and to analyse visual acuity in age-related macular degeneration. METHODS AND PATIENTS: From November 1993 through to August 1994, 10 patients, on the one hand, were given a dose of 5 Gy followed by controls 6 weeks and 6 months later. On the other hand, 21 patients were treated with a dose of 8 Gy and were subjected to controls 6 weeks later. Before the radiotherapy and during the control sessions, all patients were required to be measured for different parameters of visual acuity and to receive a simultaneous fluorescein and indocyanine green angiography. The radiotherapy was done by a linear accelerator 6 MeV and through a lateral port 3 x 4 cm in half beam technic. RESULTS: In the 5 Gy group, no changes in the parameters for visual acuity were noted in most cases after 6 months. In 9 of the cases, the membranes had increased in size and in 1 case, they had remained unchanged. In the 8 Gy group, no changes in the visual acuity or in the membrane size were diagnosed. Of all the patients treated, only one refused the angiography control. DISCUSSION AND CONCLUSIONS: Given the low dose used and the period of observation, the visual acuity of all patients remained stable. The size of the membranes increased in most cases for those 5 Gy patients and in this respect, no changes at all were noted in the 8 Gy patients. In order to better evaluate the potential of radiotherapy, this study must be pursued and coupled with further studies analysing the effect of different doses on patients.

Aged↗
PubMed1998

External beam radiation in patients suffering from exudative age-related macular degeneration. A matched-pairs study and 1-year clinical follow-up.

BACKGROUND: The aim of this prospective study was to ascertain whether external beam irradiation is effective in patients with subretinal neovascularization (SRN) due to age-related macular degeneration (AMD). METHODS: All patients had subfoveal SRN due to AMD as verified by fluoresceinangiography. Two hundred and eighty-seven patient-eyes were treated by external beam irradiation (total dose of 16 Gy in 2-Gy fractions, 5 times a week) from January 1996. The analysis was restricted to those 73 patients with a minimum follow-up of 11 months. Eighteen patients with subfoveal SRN who refused treatment served as control group (CG). 18 patients of the treatment group (TG) were matched for visual acuity, refraction and extent of SRN. The statistical analysis was performed with the unpaired t-test. RESULTS: The mean age of the CG was 73.9 years (range 66.9-81.3 years) and of the TG 75.6 years (range: 65.7-80.6 years). The median follow-up was 13.5 months (range 11.9-18.4 months) in the CG and 12.9 months (range 11-13.9 months) in the TG. The initial visual acuity (VA) was 20/80 in both groups. After 7 months the follow-up revealed median VA of 20/400 in the CG and 20/160 in the TG (P=0.0335). The final median VA was 20/400 in both groups, with a range from 20/40 to 20/1000 in the CG and from 20/63 to 20/500 in the TG (P=0.2433). The SRN doubled in size during this time in both groups. CONCLUSION: These results suggest that external beam irradiation applied in 2-Gy fractions 5 times a week slows down the visual loss in exudative AMD for a short time. Nevertheless, the patients' reading vision could not be saved in the long term.

Aged↗
PubMed1996

[Observations of different presentations of choroid neovascularization in indocyanine green angiography].

The interpretation of choroidal neovascular membranes (CNV) in indocyanine green angiography (ICG-A) is difficult. It is not known whether demarcated hyperfluorescence in the ICG-A reliably reflects the true morphology and the total extent of a CNV. Therefore, in this retrospective study, the patterns of fluorescein and ICG angiograms were evaluated and compared in both occult and well-defined CNV. In 153 out of a total of 168 cases with CNV, age-related macular degeneration (AMD) was the underlying disease. CNV was occult in 114 and well-defined in 39 cases. The angiographic examinations with both dyes were performed with a modified fundus camera combined with a digital imaging system. In the group of AMD patients with occult or ill-defined CNV. 42 cases (36.8%) showed a defined membrane in the ICG stain. The filling patterns of ICG were extremely variable. In the group of AMD patients with classic CNV, ICG-A showed evidence of staining in the early and late phase in 14/39 cases (36%), exclusively in the early phase in 5/39 (13%) cases and only in the late phase in 17/39 cases (44%). Surprisingly, three well-defined membranes in fluorescein angiography (FLA) were not seen in any phase of the ICG-A. Compared with FLA, the 17 CNVs with demarcation only in the late phase of the ICG-A were seen to be larger in 8 and smaller in 9 cases while all CNVs seen in the early phase, or in both early and late phase, were of identical size with the early fluorescein staining. The pattern of ICG staining of CNV is complex. The single finding of a demarcated hyperfluorescence in the late phase of ICG-A should be interpreted with utmost caution, particularly in regard to planning laser therapy.

Aged↗
PubMed1996

[Low dosage radiotherapy of subfoveal neovascularizations in age related macular degeneration. Results after 6 weeks and 6 months].

AIM OF THE STUDY: The aim of this pilot study is to test the effect of low dose radiation on classic and occult subfoveal neovascular membranes (SNVM) in age-related macular degeneration. METHODS AND PATIENTS: From November 1993 through to May 1995 the macula of the affected eye was irradiated with 5 Gy for 12 patients and with 8 Gy for 34 patients. The radiotherapy was done ambulatorily by a linear accelerator 6 MeV during 4 consecutive days with daily 1.25 Gy and 2 Gy respectively. A "half beam technic" was used to protect the lens. Before the treatment, 6 weeks and 6 months later different parameters of the visual acuity were measured and a simultaneous Fluo- and ICG-angiography was done. RESULTS: In the 5 Gy group, all the planned controls were done for 11 patients. 9 membranes were classic and 2 occult. After 6 months the vision in the distance remained the same in 7 cases, was better in 2 cases and worse in 2 cases. The size of the membrane increased in 10 cases and remained unchanged in 1 case. In the 8 Gy group, all the planned controls were done for 29 patients. 12 membranes were classic and 17 occult. The vision in the distance remained the same in 17 cases, was better in 4 cases and worse in 8 cases. The size of the membrane increased in 12 cases and there was no change in 17 cases. DISCUSSION AND CONCLUSION: Exact comparisons between the 5 Gy and 8 Gy group are not possible because of the different composition of these groups. In no case were we able to note a reduction of the size of the membrane. Concerning the visual acuity, our results are better than the spontaneous evolutions described in the literature. Meanwhile, affirmations about possible stabilisation of the visual acuity are too early. A further study which is being done in our hospital may possibly bring new information.

Aged↗
PubMedDate not supplied

Subretinal neovascular membranes complicating uveitis: frequency, treatments, and visual outcome.

PURPOSE: Retrospective evaluation in a uveitic population of subretinal neovascular membranes (SRNMs), their occurrence, visual impact, and outcome in differently treated subgroups of patients. METHODS: Medical records of patients were reviewed and cases with SRNM (n = 12) identified. Intraocular inflammation was classified according to vitreous examination records as high (2+ cells), low (1/2+ to 1+ cells), or inactive (0 cells). Visual outcome was considered to be +VA (same or gain of one or more Snellen lines) or -VA (loss of Snellen lines). In nine cases, treatment consisted of the oral administration of high doses of corticosteroids (CST) for one month, tapered down in favorable situations (+VA or SRNM angiographic regression) or maintained at half the dose in unfavorable situations (-VA or SRNM angiographic progression) while additional laser therapies, including photodynamic therapy (PDT), transpupillary thermotherapy (TTT), or argon laser therapy (CLT)), were performed in some of the cases. The above treatment scheme was not applied in three cases (pre-PDT period; undiagnosed underlying uveitis treated without CST). RESULTS: Twelve out of 648 patients (1.9%) with uveitis developed SRNM. The mean visual impact was 4.5 Snellen lines and mean follow-up time was 19.5 months. Two patients with high intraocular inflammation had a favorable visual outcome with CST alone. Eight patients with low intraocular inflammation had a favorable visual outcome with CST alone in three cases, with additional laser therapy in four cases (PDT in 3 cases and TTT in 1 case), and exclusively with PDT in one case (undiagnosed uveitis). Two patients with no intraocular inflammation had unfavorable visual outcome with CST alone (no PDT/TTT available). CONCLUSION: SRNMs occurred as a rare complication of uveitis. Their visual outcome was relatively favorable. Although high doses of CST seem to be the first step in the management of SRNMs, alternative laser treatments should be considered early, especially in cases of absence or low intraocular inflammation.

Adolescent↗
PubMed2005

Photodynamic therapy for neovascular age-related macular degeneration.

BACKGROUND: In neovascular age-related macular degeneration (AMD) new vessels grow under the retina distorting vision and leading to scarring. This is exacerbated if the blood vessels leak. Photodynamic therapy (PDT) has been investigated as a way to treat the neovascular membranes without affecting the retina. OBJECTIVES: The aim of this review was to examine the effects of PDT in the treatment of neovascular AMD. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which includes the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 1, 2005), MEDLINE (1966 to January 2005), EMBASE (1980 to January 2005). We used the Science Citation Index to search for reports that cited relevant studies. We contacted experts in the field and searched the reference lists of relevant studies. SELECTION CRITERIA: We included randomised trials of PDT in people with choroidal neovascularisation due to AMD. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data. Relative risks were combined using a fixed-effect model after testing for heterogeneity. MAIN RESULTS: Two published trials were identified that randomised 948 participants to verteporfin therapy compared to 5% dextrose in water. Both trials were performed by the same investigators using largely the same clinical centres and funded by manufacturers of verteporfin. Outcome data were available at 12 and 24 months after the first treatment. Participants received on average five treatments over two years. The relative risk of losing three or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.77 (95% confidence interval 0.69 to 0.87). The relative risk of losing six or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.62 (95% confidence interval 0.50 to 0.76). The results at 12 months were similar to those at 24 months. The most serious adverse outcome, acute (within 7 days of treatment) severe visual acuity decrease, occurs in about one in 50 patients. AUTHORS' CONCLUSIONS: Photodynamic therapy in people with choroidal neovascularisation due to AMD is probably effective in preventing visual loss though there is doubt about the size of the effect. Outcomes and potential adverse effects of this treatment should be monitored closely. Further independent trials of verteporfin are required to establish that the effects seen in this study are consistent and to examine important issues not yet addressed, particularly relating to quality of life and cost.

Glucose↗
PubMed1997

Interval between onset of mild nonproliferative and proliferative retinopathy in type I diabetes.

OBJECTIVE: To describe the interval between first appearance of mild nonproliferative diabetic retinopathy (NPDR) and first appearance of neovascularization (NV) in type I diabetes. SETTING: A longitudinal study of 269 patients followed up annually. PARTICIPANTS: Participants had insulin-dependent diabetes and were free of proliferative diabetic retinopathy in both eyes at the baseline visit. MAIN OUTCOME MEASURE: Stereoscopic color fundus photographs of each eye at each study visit, graded for features of retinopathy. RESULTS: Among the 305 eyes for which the duration of diabetes at the first appearance of mild NPDR could be determined, NV developed in 28 by the end of the study. Survival analysis showed that the later the onset of mild NPDR was, the shorter the time from onset of mild NPDR to onset of NV (relative hazard for each additional year to onset of mild NPDR, 1.22; 95% confidence interval, 1.10-1.35). Adjustment for systolic and diastolic blood pressure, proteinuria, and glycosylated hemoglobin (Hgb A10) levels did not change the relative hazard estimate for onset of mild NPDR. Higher levels of Hgb A10 were associated with a shorter time from onset of mild NPDR to onset of NV (relative hazard, 1.26; 95% confidence interval, 1.05-1.51 [after adjusting for time at onset of mild NPDR]), as were higher levels of diastolic blood pressure, although not significantly (relative hazard for 10-mm Hg increase in diastolic blood pressure, 1.52; 95% confidence interval, 0.82-2.83 [adjusting for onset of mild NPDR, Hgb A10 level, systolic blood pressure, and proteinuria]). Neither proteinuria nor systolic blood pressure had an effect on time from onset of mild NPDR to onset of NV, after adjustment for time at onset of mild NPDR, Hgb A10 level, and diastolic blood pressure. CONCLUSION: Later onset of mild NPDR is not necessarily associated with delayed development of NV in patients with type I diabetes. Caution must therefore be used in assessing the value of interventions that delay the onset of mild NPDR without evidence of delayed onset of NV.

Adolescent↗
PubMed2004

CD4-CD8 and CD28 expression in T cells infiltrating the vitreous fluid in patients with proliferative diabetic retinopathy: a flow cytometric analysis.

OBJECTIVES: To investigate CD4-CD8 and CD28 expression in T cells infiltrating the vitreous fluid in patients with proliferative diabetic retinopathy and to evaluate the relationship between the infiltrating T cells and both the activity of proliferative diabetic retinopathy and the clinical outcome. METHODS: Both vitreous and peripheral blood samples were obtained simultaneously from 20 consecutive diabetic patients and analyzed by flow cytometry. Three diabetic patients were excluded because there were no viable cells in the vitreous fluid. Six nondiabetic patients requiring vitrectomy were also studied. RESULTS: T lymphocytes were detected in all 6 diabetic patients with vitreous hemorrhage and in 6 (55%) of the 11 diabetic patients without vitreous hemorrhage, but in none of the nondiabetic patients. The percentages of T cells (CD3+), TCD4+ (CD3+ CD4+), and TCD8+ (CD3+ CD8+) subsets, as well as the expression of CD28, were similar in the vitreous fluid and in the peripheral blood in patients with vitreous hemorrhage. However, in patients without vitreous hemorrhage, the percentage of CD4+ CD28-T cells in the vitreous fluid was significantly higher than in the peripheral blood (33.34% [20.75%-100.00%] vs 8.45% [2.43%-56.59%]; P =.02). In addition, all of these patients showed quiescent retinopathy and their outcome was better than that of patients with vitreous hemorrhage and patients in whom intravitreous T cells were undetectable. CONCLUSION: T cells infiltrating the vitreous of diabetic patients without vitreous hemorrhage not only show a different pattern than in the peripheral blood but also seem to improve the prognosis of proliferative diabetic retinopathy. CLINICAL RELEVANCE: Our results provide further understanding of events involved in the autoimmune response in diabetic retinopathy and may aid in the research for new treatment approaches.

CD28 Antigens↗
PubMed1991

Central serous chorioretinopathy and white subretinal exudation during pregnancy.

Six otherwise healthy pregnant women had development of idiopathic central serous chorioretinopathy in one or both eyes. All had one or more focal areas of white subretinal exudate, which probably was fibrinous in type. In some patients, this was misinterpreted as subretinal neovascularization or retinitis. Symptoms developed in most patients in the third trimester and following delivery, there was spontaneous resolution of retinal detachment and return of visual acuity to 20/20 or better. In a randomly selected group of 50 patients with idiopathic central serous retinopathy unassociated with pregnancy, subretinal white exudation occurred in only six (17%) of 42 men and in zero (0%) of eight women. The cause for the higher prevalence of this exudate in pregnant women is unknown.

Adult↗