Faculty Bibliography

OBJECTIVE:To investigate the safety and efficacy of intravitreal ranibizumab treatment combined with verteporfin photodynamic therapy (PDT) in patients with predominantly classic choroidal neovascularization secondary to age-related macular degeneration. METHODS:In this 2-year, phase I/II, multicenter, randomized, single-masked, controlled study, patients received monthly ranibizumab (0.5 mg) (n = 106) or sham (n = 56) injections. The PDT was performed 7 days before initial ranibizumab or sham treatment and then quarterly as needed. MAIN OUTCOMES MEASURES/METHODS:Proportion of patients losing fewer than 15 letters from baseline visual acuity at 12 months (primary efficacy outcome) and the incidence and severity of adverse events. RESULTS:At 12 months, 90.5% of the ranibizumab-treated patients and 67.9% of the control patients had lost fewer than 15 letters (P<.001). The most frequent ranibizumab-associated serious ocular adverse events were intraocular inflammation (11.4%) and endophthalmitis (1.9%; 4.8% if including presumed cases). On average, patients with serious inflammation had better visual acuity outcomes at 12 months than did controls. Key serious nonocular adverse events included myocardial infarctions in the PDT-alone group (3.6%) and cerebrovascular accidents in the ranibizumab-treated group (3.8%). CONCLUSION/APPLICATION TO CLINICAL PRACTICE: Ranibizumab + PDT was more efficacious than PDT alone for treating neovascular age-related macular degeneration. Although ranibizumab treatment increased the risk of serious intraocular inflammation, affected patients, on average, still experienced visual acuity benefit.

OBJECTIVE:To assess safety of repeated intravitreal injections of ranibizumab in treating neovascular age-related macular degeneration (AMD), and to assess changes in visual acuity (VA) and AMD lesion characteristics. DESIGN/METHODS:Multicenter, controlled, open-label, clinical trial. PARTICIPANTS/METHODS:Sixty-four patients with subfoveal predominantly or minimally classic AMD-related choroidal neovascularization. METHODS:In part 1, subjects were randomized to monthly intravitreal ranibizumab for 3 months (4 injections of 0.3 mg or 1 injection of 0.3 mg followed by 3 injections of 0.5 mg; n = 53) or usual care (UC; n = 11). In part 2, subjects could continue their regimen for 3 additional months or cross over to the alternative treatment. MAIN OUTCOME MEASURES/METHODS:Adverse events (AEs), intraocular pressure (IOP), VA, and lesion characteristics assessed by fluorescein angiography and fundus photography. RESULTS:Of the 64 randomized subjects, 62 completed the 6-month study. Twenty of 25 subjects (80%) randomized to 0.3 mg, and 22 of 28 subjects (79%) randomized to 0.5-mg ranibizumab in part 1 continued on that treatment in part 2; 9 of 11 (82%) subjects randomized to UC in part 1 crossed over to ranibizumab treatment in part 2. The most common AEs with ranibizumab were reversible inflammation and minor injection-site hemorrhages. Serious AEs were iridocyclitis, endophthalmitis, and central retinal vein occlusion (1 subject each). Postinjection, IOP increased transiently in 22.6% of ranibizumab-treated eyes in parts 1 and 2. After 4 ranibizumab injections (day 98), mean (+/- standard deviation) VA had increased 9.4+/-13.3 and 9.1+/-17.2 letters in the 0.3- and 0.5-mg groups, respectively, but had decreased 5.1+/-9.6 letters with UC. In part 2 (day 210), VA increased from baseline 12.8+/-14.7 and 15.0+/-14.2 letters in subjects continuing on 0.3 and 0.5 mg, respectively. Visual acuity improved from baseline > or =15 letters in 26% (day 98) and 45% (day 210) of subjects initially randomized to and continuing on ranibizumab, respectively, and areas of leakage and subretinal fluid decreased. No UC subject had a > or =15-letter improvement at day 98. CONCLUSIONS:Repeated intravitreal injections of ranibizumab had a good safety profile and were associated with improved VA and decreased leakage from choroidal neovascularization in subjects with neovascular AMD.

We demonstrate the clinical application of a multiplanar imaging system that simultaneously acquires en face (C-scan) optical coherence tomography (OCT) and the corresponding confocal ophthalmoscopic images, along with cross-sectional (B-scan) OCT at specifiable locations on the confocal image. The advantages of the simultaneous OCT and confocal acquisition as well as the challenges of interpreting the C-scan OCT images are discussed. Variations in tissue inclination with respect to the coherence wave surface alter the sampling of structures within the depth of the retina, producing novel slice orientations that are often challenging to interpret. We have evaluated for the first time the utility of C-scan OCT for a variety of pathologies, including melanocytoma, diabetic retinopathy, choroidal neovascular membrane, and macular pucker. Several remarkable new aspects of clinical anatomy were revealed using this new technique. 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 3-D imaging of retinal pathology

Using an advanced prototype of en-face OCT/cSLO instrument, an extensive array of clinic pathologies were studied including macular degeneration, central serous retinopathy (CSR), macular hole, macular pucker, cystoid macular edema (CME), diabetic maculopathy, and macular trauma. We report observation of reoccurring patterns in the en-face OCT images which could be identified with different diseases. Uniquely specific and reoccurring patterns could be characterized for macular hole ('chrysanthemum flower'), CME ('Swiss cheese wheel'), macular pucker ('star'), CSR ('target') and RPE detachment ('ring of light'). Other entities such as polypoidal choroidopathy and diabetic edema residues had easily recognizable features but were variable enough to defy specific descriptive comparison. To facilitate the interpretation of the en-face OCT images, a three dimensional interactive simulation was designed which allows the demonstration of characteristic features and artifacts encountered in the acquisition of transverse images

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

PURPOSE: To describe focal obstruction of drainage tubes by kinking at the scleral entry site after pars plana insertion. METHODS: Case study. RESULTS: Three eyes of three patients underwent uncomplicated placement of a Baerveldt implant into the vitreous cavity at the time of pars plana vitrectomy. Intraocular pressure remained increased after the procedure without evidence of flow. Surgical exploration and modification of the tube placement resulted in immediate intraocular pressure reduction. Compression of the tube at the scleral entry site was confirmed intraoperatively in all eyes by ultrasound biomicroscopy. CONCLUSION: Kinking of the tube at its scleral entry site should be recognized as a possible cause of increased intraocular pressure without bleb formation after pars plana insertion of a glaucoma drainage implant

PURPOSE: To evaluate the utility of ultrasound biomicroscopy in imaging cyclitic membranes. METHODS: Patients with hypotony and suspected or known cyclitic membrane underwent ultrasound biomicroscopic examination. Histopathology of cyclitic membrane was correlated with ultrasound biomicroscopy in three cases. RESULTS: Six eyes of six patients were enrolled. Mean patient age was 62.2 +/- 18.4 (SD) years. The mean intraocular pressure in the affected eye was 4.3 +/- 3.4 mmHg. Three eyes were pseudophakic and three eyes were aphakic. All eyes had undergone two or more previous intraocular surgeries. Ultrasound biomicroscopy imaged the cyclitic membrane in all six eyes. Histopathology revealed fibroproliferative cyclitic membranes with associated inflammatory cells. CONCLUSION: Ultrasound biomicroscopy is useful in detecting the presence of those cyclitic membranes that may not be identified on clinical examination