Faculty Bibliography

PURPOSE: To evaluate clinical safety and efficacy of the angiostatic agent anecortave acetate for treatment of subfoveal choroidal neovascularization secondary to AMD. METHODS: 128 patients were randomized to placebo treatment or one of three anecortave acetate doses. Study medication was administered as a posterior juxtascleral injection onto the posterior scleral surface. Best-corrected logMAR vision was obtained at baseline and follow-up visits. Fluorescein angiograms were evaluated for eligibility before enrollment and posttreatment. RESULTS: Six months after a single treatment, visual acuity (mean change from baseline logMAR values) was significantly better (P = 0.003) after anecortave acetate 15 mg than placebo. More patients treated with anecortave acetate 15 mg than placebo maintained vision (88% versus 70%, P = 0.080), especially those with predominantly classic lesions (92% versus 65%, P = 0.021). Anecortave acetate 15 mg inhibited lesion growth significantly better than placebo (P = 0.001). Trends favoring the other doses over placebo were observed for vision preservation and lesion inhibition, but statistical significance was not achieved. The Independent Safety Committee overseeing this study identified no clinically relevant treatment-related changes. CONCLUSION: Anecortave acetate 15 mg is safe and effective for preserving or improving vision and for inhibiting lesion growth in patients with subfoveal AMD

PURPOSE: To describe the optical coherence tomography (OCT) and fluorescein angiography findings in the macula of eyes with chronic central serous chorioretinopathy (CSC) and reduced central vision. METHODS: Using OCT, clinical examination, and fluorescein and indocyanine green (ICG) angiography, the authors examined eight eyes of seven patients with CSC, an attached macula, and reduced central vision of 20/200 or worse. All had a history of chronic CSC with resolution of the subretinal fluid in the macular area and poor vision. RESULTS: Patient ages ranged from 55 to 82 years (mean, 66 years). All eight eyes had some parafoveal, patchy RPE atrophy with corresponding transmission hyperfluorescence (window defect) on fluorescein angiography. Five eyes also had a window defect in the foveal area. With OCT, the foveal area revealed variable areas of cystoid change and atrophy in seven of the eight eyes. In four of these eyes, the cystoid changes were not seen on clinical examination or fluorescein angiography. The seven eyes with cystoid changes imaged with OCT had no intraretinal leakage of fluorescein in the foveal region. The authors categorized these eyes as having cystoid macular degeneration (CMD). One other eye had foveal thinning or atrophy without cystoid changes. CONCLUSIONS: Intraretinal cystoid spaces without intraretinal leakage, or CMD, was a common finding in eyes with chronic CSC and reduced central vision after resolution of subretinal fluid. OCT was useful to establish the presence of CMD and foveal atrophy, even when these changes were not clearly evident on clinical examination or fluorescein angiography. Chronic foveal detachment and antecedent intraretinal leakage were proposed to be the mechanisms for the development of the changes. CMD in conjunction with foveal atrophy was an important clinical finding to account for the poor visual outcome in patients with CSC

OBJECTIVE: To describe peripapillary detachment in pathologic myopia (PDPM), a newly recognized fundus lesion. DESIGN: Retrospective medical record review. METHODS: We evaluated a series of myopic eyes that had a yellow-orange elevation of the retina and retinal pigment epithelium at the inferior border of the myopic conus. RESULTS: Twenty eyes of 15 patients were identified during a 17-year period to have characteristic findings of PDPM. The mean age of the patients was 58 years. They were followed up for an average of 6 years. The mean spherical equivalent correction was -11.00 diopters (D) (range, -6.00 to -16.00 D). The mean axial length was 27.4 mm (range, 25.3-28.9 mm). In each case, ophthalmic coherence tomographic examination showed a localized detachment of the retinal pigment epithelium and retina corresponding to the PDPM lesion. During the follow-up period, the lesion remained stable in all cases except for 1. No apparent negative effect on visual function was noted. CONCLUSIONS: Peripapillary detachment in pathologic myopia is an asymptomatic, yellow-orange peripapillary detachment of the retinal pigment epithelium and retina in pathologic myopia. Recognition of this lesion is important to distinguish it from other fundus pathologic conditions, such as tumors or choroidal neovascularization, which require further investigation and treatment

This paper demonstrates the clinical application of a multiplanar imaging system, which simultaneously acquires en-face (C-scan) OCT and corresponding confocal ophthalmoscopic images along with cross-sectional (B-scan) OCT at cursor designated locations on the confocal image. Advantages of the simultaneous OCT/confocal acquisition as well as the challenges of interpreting the C-scan OCT images are discussed. Variations in tissue inclination with respect to th coherence wave surface alters the sampling of structures within the depth in the retina, producing novel slice orientations which are often challenging to interpret. We evaluate for the first time the utility of C-scan OCT for a variety of pathologies including exudative ARMD, macular hole, central serous retinopathy, diabetic retinopathy, polypoidal choroidal vasculopathy and macular pucker. Several remarkable observations of new aspects of clinical anatomy were noted. The versatility of selective capture of C-scan OCT images and B-scan OCT images at precise points on the confocal image affords the clinician a more complete and interactive tool for 3D imaging of retinal pathology

Polypoidal choroidal vasculopathy seems to be a distinct clinical entity that should be differentiated from other types of CNV associated with AMD and other known choroidal degenerative, inflammatory, and ischemic disorders. The principle abnormality seen in PCV, notably the branching vascular network and polypoidal structures at the borders of the lesion, seem to be unique to the disorder. In patients with serosanguineous detachment of the pigment epithelium, particularly in those with increased risk factors such as African American or Asian race, ICG should be performed to evaluate the choroidal vascular abnormality to establish a more definitive diagnosis. If the characteristic vascular lesion of PCV is seen, a conservative approach to management should be taken unless there is a persistent or progressive exudative change that threatens the central macula. In that event, there may be a rationale for photo-coagulation treatment of leaking aneurysmal or polypoidal components within the vascular lesion, but not the entire vascular complex. Photodynamic therapy seems to be a promising therapeutic modality, but randomized clinical trials are needed to establish the efficacy and safety of the PDT treatment in the management of these patients

Although these preliminary results on the use of antiangiogenesis drugs for the treatment of neovascular AMD appear promising, double-masked, placebo-controlled, multicenter clinical trials are needed to demonstrate the therapeutic efficacy of such treatments. For example, the first antiangiogenesis drug tested in AMD, interferon alpha-2a, raised great enthusiasm. Indeed, interferon alpha-2a had been shown to be antiangiogenic in animal and in vitro models. It proved to be ineffective, however, in halting the progression of neovascular AMD in a double-masked, placebo-controlled clinical trial [28]. Another antivasogenesis drug tested in a phase 3 clinical trial is thalidomide [67]. Although the enrollment of patients is finished, the results are not yet known

PURPOSE: To clarify the frequency and nature of ICG angiographic 'hot spots' seen in patients with neovascular age-related macular degeneration (ARMD). METHODS: A consecutive series of newly diagnosed patients with neovascular ARMD and fluorescein angiographic evidence of occult choroidal neovascularization (occult CNV) was imaged with ICG angiography. Eyes with ICG angiographic 'hot spots' were identified and further classified. A hot spot was defined as any area of abnormal hyperfluorescence, in the mid to late stages of ICG angiography, measuring less than 1 disk area in size. RESULTS: From a total of 190 patients (220 eyes) with neovascular ARMD, 30 patients and 34 eyes (16%) with hot spots were identified. Hot spots were noted to be of three distinct patterns: polypoidal choroidal neovascularization (polypoidal CNV) in 21 of 34 eyes, or 62%; retinal angiomatous proliferation (RAP) in 11 of 34 eyes, or 30%; and focal occult CNV in 2 of 34 eyes, or 8%. CONCLUSIONS: A focal area of intense hyperfluorescence or so-called hot spot seen on ICG angiography in neovascular ARMD is due to one of three possible forms of neovascularization: most frequently polypoidal CNV, less commonly RAP, and infrequently nonspecific, focal occult CNV. Since neovascular ARMD may be caused by different types of neovascularization, each with distinct clinical manifestations, natural course, visual prognosis, and response to treatment, it is important to identify the precise nature of hot spots to establish an accurate diagnosis and, when appropriate, a specific form of management

PURPOSE: To study the effects of photodynamic therapy (PDT) using verteporfin on the treatment of patients with subfoveal choroidal neovascularization (CNV) secondary to multifocal choroiditis and panuveitis (MCP), an uncommon disorder with no proven forms of therapy. METHODS: A retrospective chart review of seven consecutive patients with subfoveal CNV secondary to MCP treated with PDT using verteporfin was performed. RESULTS: The mean age of the 7 patients (all myopic women) was 41.4 years. A mean of 1.86 treatments was performed, and the mean follow-up time was 10 months. Four of the seven patients were treated unsuccessfully with corticosteroids before referral for PDT. The mean improvement of visual acuity was 0.86 line; 3 patients (42.8%) had an improvement in visual acuity representing at least a halving of their visual angle, while the other 4 patients remained stable. There were no treatment-related side effects. CONCLUSIONS: Although the follow-up time and the number of patients in this study were limited, the use of PDT was associated with stabilization or improvement of visual acuity in patients with subfoveal CNV secondary to MCP. Further study of this treatment modality is indicated

PURPOSE: To study the effects of photodynamic therapy using verteporfin in the treatment of patients with subfoveal polypoidal choroidal vasculopathy (PCV). METHODS: A retrospective chart review of 16 consecutive patients with subfoveal PCV treated with photodynamic therapy using verteporfin was performed. RESULTS: The mean age of the patients involved was 70.5 years. The mean follow-up time was 12 months. The visual acuity improved in 9 (56.3 %), remained the same in 5 (31.3 %), and decreased in 2 (12.5 %). The mean change in visual acuity was an improvement of 2.38 lines, a difference that was highly significant ( = 0.004). The change in visual acuity was negatively correlated with increasing age. The final visual acuity was positively correlated with initial acuity and negatively correlated with age. These results were confirmed by multiple linear regression. No patient had any lasting complication from the treatment. CONCLUSIONS: Subfoveal PCV has no proven method of treatment. Although the follow-up time and the number of patients in this pilot study were limited, the encouraging results and lack of complications suggest that further study is indicated