Faculty Bibliography

PURPOSE: To determine the incidence of endophthalmitis following intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents. DESIGN: A retrospective interventional case series. METHODS: A total of 10,254 intravitreal anti-VEGF injections (406 pegaptanib, 3,501 bevacizumab, and 6,347 ranibizumab) were performed from January 5, 2005 to October 18, 2007. The number of the injections was determined from the injection log books and billing records. The injections were performed as an office based procedure with use of povidone-iodine as a part of preinjection preparation. Preinjection antibiotics, eye drape, or surgical attire were not used. The main outcome measures were the incidence of suspected and proven endophthalmitis. RESULTS: There were three cases of suspected endophthalmitis, one case following bevacizumab injection and two cases following ranibizumab injection. There was no case of culture-proven endophthalmitis. All three patients regained their preinjection visual acuity. The incidence of suspected endophthalmitis was 0.029% (95% confidence interval, 0.006% to 0.085%). There was no difference in the incidence of endophthalmitis between ranibizumab and bevacizumab injections (P = .6). CONCLUSIONS: Although there is no consensus regarding the intravitreal injection procedure technique, the incidence of suspected endophthalmitis was very low in a large series of injected patients in a community setting and the incidence compares favorably with that reported in clinical trials where much more extensive preinjection preparation was mandated. We found no difference in the endophthalmitis risk of patients receiving bevacizumab as compared with ranibizumab

BACKGROUND: Bevacizumab, a humanized monoclonal antibody to vascular endothelial growth factor (VEGF), has been given via intravitreal injection as an off-label therapy for both neovascular age-related macular degeneration and for macular edema secondary to retinal vascular disease. The authors describe three patients with macular edema secondary to retinal venous occlusion whose edema initially responded to intravitreal bevacizumab but subsequently recurred in excess of that observed before treatment. METHODS: This is a retrospective case series of three patients with macular edema secondary to retinal vein occlusion treated with intravitreal bevacizumab. RESULTS: In all three patients, the rebound retinal edema observed was more pronounced than that present before treatment. CONCLUSION: These cases suggest a potential limitation of using relatively short-acting VEGF antagonists in retinal vascular disease of a chronic nature. Frequent repeated injections may be required to prevent a rebound effect with no clearly defined endpoint. Until the long-term safety of multiple injections of these agents is established, the authors recommend caution in using this treatment strategy

OBJECTIVE: To evaluate the short-term visual acuity and anatomic responses after intravitreal bevacizumab (Avastin, Genentech) treatment in patients with retinal angiomatous proliferation (RAP). METHODS: The authors conducted a retrospective review of consecutive patients with newly diagnosed or recurrent RAP treated with intravitreal bevacizumab (1.25 mg) during a 3-month period. Complete ocular examination was performed at baseline and follow-up visits. Interval data were analyzed statistically at 1 and 3 months follow-up. RESULTS: Twenty-three eyes of 23 patients underwent intravitreal bevacizumab treatment. The mean age of patients was 81.1 years, median baseline visual acuity of treated eyes was 20/80 (range 20/25-20/800), and mean baseline central macular thickness was 335 mum (optical coherence tomography was available for 22 eyes). Nine eyes had retinal pigment epithelial detachments (PEDs) at baseline. At 1-month follow-up, the median acuity improved to 20/60 (range 20/30-20/400) (P < 0.001), mean central macular thickness decreased to 202 microm (P < 0.001), and PED was present in only 2 eyes (P = 0.016). Seven of 23 eyes at 1 month (30.4%) had improved visual acuity, defined as halving of the visual angle, and no eyes had worse acuity, defined as doubling of the visual angle. Of the 17 eyes available for 3-month follow-up, 5 eyes (29.4%) had better visual acuity, 1 eye (5.9%) had worse acuity, and the remaining 11 (64.7%) had the same acuity. The median visual acuity at month 3 was 20/60 (range 20/25-20/400). There were no thromboembolic phenomena, endophthalmitis cases, retinal detachments, or any other adverse events. CONCLUSION: Treatment of RAP with intravitreal bevacizumab during this retrospective review resulted in a significant decrease in macular thickness and improvement or stabilization of visual acuity. Further long-term investigation is warranted given the promising short-term results

PURPOSE: To evaluate the short-term outcomes after intravitreal ranibizumab (Lucentis; Genentech, Inc., South San Francisco, CA) injection in patients with neovascular age-related macular degeneration. METHODS: A review of data for consecutive patients who received intravitreal ranibizumab injection was conducted. The main outcome measures were mean visual acuity and central macular thickness at 3 months compared with those at baseline. Response to ranibizumab therapy was evaluated with particular attention to prior treatment with bevacizumab (Avastin; Genentech, Inc.). RESULTS: Mean baseline visual acuity of 231 eyes of 231 patients was 20/152, and 189 patients (81.8%) had undergone prior treatment, with 153 (65.4%) having received intravitreal bevacizumab. Mean visual acuity at 3 months, available for 203 patients (88%), was 20/126 (P = 0.004). Mean visual acuity for 98 patients treated with bevacizumab within 3 months before ranibizumab injection was 20/100 at baseline and 20/98 at 3 months (P = 0.35). Mean baseline central macular thickness was 278 microm for all patients and improved to 211 microm at 3 months (P < 0.001). Macular thickness decrease was noted irrespective of previous bevacizumab therapy. CONCLUSION: Ranibizumab therapy was associated with significant improvements in mean visual acuity and central macular thickness for the group of all patients. Patients who had received bevacizumab treatment within 3 months before initiating ranibizumab treatment had stability of, but no improvement in, visual acuity

PURPOSE: To determine the results of intravitreal bevacizumab injections for the management of choroidal neovascularization (CNV) in patients with pseudoxanthoma elasticum (PXE)-associated angioid streaks. METHODS: A consecutive series of patients with PXE and CNV were managed with intravitreal bevacizumab injection (1.25 mg per 0.05 cc). The main outcome measures were visual acuity and greatest lesion height as measured by optical coherence tomography (OCT). RESULTS: Nine eyes of nine consecutive patients received intravitreal bevacizumab (1.25 mg/0.05 mL) injections. The mean follow-up time was 6 months, during which eyes received an average of 1.8 injections. The baseline visual acuity was a mean of 20/368 and improved to 20/289 at the last visit (P = 0.056). Visual acuity either improved or stabilized in all 9 eyes (100%). Serial OCT measurements in 8 eyes showed a mean of 353 microm at baseline, which decreased to 201 mum at the last visit (P = 0.012). No complications were noted. CONCLUSIONS: These short-term results support the use of intravitreal bevacizumab for the management of CNV in patients with PXE. Continued experience with intravitreal bevacizumab in this population will help establish its longer-term efficacy and better define the potential need for serial injections to maintain these results

We retrospectively evaluated the effectiveness of intravitreal triamcinolone in treating 19 eyes with macular edema related to branch retinal vein occlusion (BRVO). Eyes with nonischemic BRVO respond more favorably than those with ischemic BRVO. A single injection of intravitreal triamcinolone led to elevated intraocular pressure in 3 of 19 eyes (16%). Half of phakic eyes had progression of cataract. Retreatment may be necessary.

AIM: To review the outcomes of eyes with neovascular age-related macular degeneration (AMD) treated with photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide injection. MATERIALS AND METHODS: We retrospectively reviewed the outcomes of consecutive eyes with neovascular AMD that received an intravitreal triamcinolone injection within 1 week of their first PDT and had at least 6 months of follow-up. Eyes were retreated with PDT at 3-month intervals if angiographic leakage was present. RESULTS: Twenty-six eyes from 24 patients were identified. The mean visual acuity at baseline was 20/118 (median 20/112). The mean visual acuity decreased to 20/138 at 9 months (P = 0.24, n = 15) and to 20/174 at 12 months (P = 0.23, n = 8). The change in visual acuity from baseline was not statistically significant at any time point. The mean central foveal thickness by OCT measured 342 microm at baseline and decreased to 296 microm at 12 months (P = 0.31). Sixty-two per cent of eyes required no additional PDT at 12 months. Nineteen per cent of 26 eyes had a rise in intraocular pressure that was controlled with topical medication alone. CONCLUSION: Photodynamic therapy with verteporfin combined with intravitreal triamcinolone injection in the treatment of neovascular AMD may be superior to PDT alone by decreasing visual loss and reducing the number or retreatments

PURPOSE: To report the short term anatomic and visual acuity response after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with macular edema due to central retinal vein occlusion (CRVO). METHODS: The authors conducted a retrospective study of patients with macular edema due to CRVO who were treated with at least one intravitreal injection of bevacizumab 1.25 mg in 0.05 mL. Patients underwent Snellen visual acuity testing, optical coherence tomography (OCT) imaging, and ophthalmoscopic examination at baseline and follow-up visits. RESULTS: There were 16 eyes of 15 consecutive patients with a mean age of 76.1 years (SD 9.8 years). Intravitreal triamcinolone had been previously administered to 9 patients, but all of these patients either had no improvement or had excessive intraocular pressure caused by the triamcinolone. The patients received a mean of 2.8 injections of bevacizumab per eye. No adverse events were observed, including endophthalmitis, clinically evident inflammation, increased intraocular pressure, retinal tears, retinal detachment, or thromboembolic events in any patient. The mean central macular thickness at baseline was 887 microm and decreased to a mean of 372 microm at month 1 (P < 0.001). The mean baseline acuity was 20/600 (logMAR = 1.48) and the mean acuity at month 1 was 20/200 (logMAR = 1.05), a difference that was highly significant (P = 0.001). At last follow-up, a mean of 3 months after the first injection, the mean visual acuity was 20/138 (logMAR = 0.84), which was significantly better than baseline (P < 0.001). Visual acuity improvement, defined as a halving of the visual angle, was seen in 14 of the 16 eyes. CONCLUSION: Initial treatment results of patients with macular edema secondary to CRVO did not reveal any short-term safety concerns. Intravitreal bevacizumab resulted in a significant decrease in macular edema and improvement in visual acuity. The number of patients in this pilot study was limited and the follow-up is too short to make any specific treatment recommendations, but the favorable short-term results suggest further study is needed

PURPOSE: To describe the short-term anatomical and visual acuity responses after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: We conducted a retrospective study of patients with CNV secondary to AMD who were treated with intravitreal injection of bevacizumab (1.25 mg) during a 3-month period. Patients underwent best-corrected Snellen visual acuity testing, optical coherence tomography, and ophthalmoscopic examination at baseline and follow-up visits. RESULTS: There were 266 consecutive eyes of 266 patients who received injections, and follow-up information was available for 251 (94.4%). The mean age of the patients was 80.3 years, the mean baseline visual acuity was 20/184, and 175 (69.7%) had inadequate response to alternate methods of treatment. At the 1-month follow-up (data available for 244 patients), the mean visual acuity was 20/137 (P < 0.001 as compared with baseline), and 74 (30.3%) of patients had improvement in visual acuity as defined by a halving of the visual angle. At the 2-month follow-up (data available for 222 patients), the mean visual acuity was 20/122 (P < 0.001), and 78 (31.1%) of patients had visual improvement. At the 3-month follow-up (data available for 141 patients), the mean visual acuity was 20/109 (P < 0.001), and 54 (38.3%) of patients had visual acuity improvement. The mean central macular thickness at baseline was 340 mum and decreased to a mean of 247 microm at month 1 (P < 0.001) and 213 microm at month 3 (P < 0.001). At 1 month, two patients had mild vitritis, as did one patient at 2 months, who had a history of recurrent uveitis. No endophthalmitis, increased intraocular pressure, retinal tear, or retinal detachment occurred. The risk for thromboembolic disorders did not seem to be different than reported previously in studies concerning macular degeneration. CONCLUSION: There were no apparent short-term safety concerns for intravitreal bevacizumab injection for CNV. Treated eyes had a significant decrease in macular thickness and improvement in visual acuity. The follow-up was too short to make any specific treatment recommendations, but the favorable short-term results suggest further study is needed