To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis... more To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis (IMP) in the management of patients with persistent central serous chorioretinopathy (CSC). Interventional noncomparative case series. Eleven patients with CSC presenting with persistent subretinal fluid in optical coherence tomography (OCT) four months after presentation and decrease in visual acuity (VA) were submitted to a single IMP session with 2 mg/kg body weight ICG and application of 5.6 W/cm(2) light at 810 nm. A continuous follow-up was provided with best-corrected ETDRS VA assessment, and angiographic and OCT documentation 72 hours before and at 2 days, 1 and 2 weeks, 1, 3, 6, and 12 months after treatment. Pretreatment VA levels ranged from 20/32 - 1 to 20/100 (mean, 20/63 + 2 [logMAR equivalent, 0.460 +/- 0.155]); post treatment levels ranged from 20/25 - 2 to 20/20 (mean, 20/20 - 2 [logMAR equivalent, 0.038 +/- 0.048]). Ten out of eleven patients presented with VA levels of >/=20/25 2 weeks after treatment; the mean logMAR VA change of 0.345 at that time was statistically significant (p < 0.05, Friedman test). OCT disclosed resolution of persistent subretinal fluid in all eyes. No recurrence was observed after 12 months of follow-up. Complications included transient retinal whitening in two patients, and associated occlusion of retinal capillaries in one. Photothrombosis using low-intensity 810 nm light to direct laser energy continuously at the active leakage sites after intravenous ICG infusion induced rapid VA recovery in patients with persistent CSC; accordingly, restoration of the macular architecture was evidenced on OCT, and no recurrence was noted 12 months after IMP.
A tomografia de coerência óptica incorporou-se gradativamente ao contemporâneo arsenal diagnóstic... more A tomografia de coerência óptica incorporou-se gradativamente ao contemporâneo arsenal diagnóstico em Oftalmologia, passando a exercer papel fundamental na inves-tigação e condução de doenças oculares, particularmente na especialidade de Retina e Vítreo. A ...
To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for ... more To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV), the authors evaluated the retinal and choroidal response immediately after treatment with serial optical coherence tomography (OCT) and indocyanine green angiography (ICGA). This study was a prospective, noncomparative case series. PDT was performed on nine eyes of nine consecutive patients who presented with subfoveal CNV due to age-related macular degeneration, and serial evaluation with OCT as well as ICGA was performed at 20-minute intervals for the first 2 hours and then at 1 week, 1 month, and 3 months. In the first 2 hours after PDT, OCT showed an increase in the thickness of the retina in the treatment area due to fluid leakage from the neovascular complex as confirmed by ICGA. At 1 week, marked reduction of intraretinal/subretinal fluid was observed in all patients. Neovascular complex nonperfusion by ICGA was associated with some degree of choroidal hypoperfusion in the treatment area. Return of the foveal contour by OCT was optimal after 1 month of treatment. At 3 months, choroidal reperfusion by ICGA and recurrent intraretinal/subretinal fluid by OCT were observed. Serial OCT and ICGA evaluation after PDT suggests that the initial successful CNV nonperfusion as shown by fluorescein angiography at 1 week occurs by means of selective PDT damage to the lesion and/or reduced choroidal blood flow in the treatment area, thereby decreasing intraretinal/subretinal fluid and facilitating restoration of the retinal architecture.
To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitre... more To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitreal bevacizumab injections for the management of macular edema due to ischemic central or hemicentral retinal vein occlusion (RVO). In this prospective, open-label study, 7 consecutive patients (7 eyes) with macular edema associated with ischemic central or hemicentral RVO were treated with intravitreal injections of 2.0 mg (0.08 mL) of bevacizumab at 12-week intervals. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 after each injection. Clinical evidence of toxicity and complications as well as changes in logarithm of minimum angle of resolution Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) shown by optical coherence tomography (OCT), and dye leakage shown by fluorescein angiography were evaluated. The median age of the 7 patients was 65 years (range, 58-74 years), and the median duration of symptoms before injection was 7 months (range, 2.5-16 months). At baseline, mean BCVA was 1.21 (Snellen equivalent, approximately 20/320) in the affected eye. Mean baseline CMT and TMV were 730.1 microm and 17.1 mm(3), respectively. Fluorescein leakage was observed in the macula and affected retinal quadrants in all seven eyes. Six patients completed the 25-week follow-up examination with reinjections performed at weeks 12 and 24. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. At the last follow-up, mean BCVA in the affected eye was 0.68 (Snellen equivalent, 20/100(+1). No patient had a decrease in BCVA. Mean CMT and TMV at the 25-week follow-up were 260.3 microm and 9.0 mm(3), respectively; fluorescein leakage within the macula and affected retinal quadrants as compared with baseline was markedly reduced in all patients. Coupled with fluorescein angiographic findings, OCT data suggest a trend of macular edema recurrence between 6 weeks and 12 weeks after injection. Intravitreal bevacizumab injections of 2.0 mg at 12-week intervals were well tolerated and were associated with short-term BCVA stabilization or improvement and favorable macular changes in all patients with ischemic RVO and associated macular edema.
To evaluate the effect of intravitreal bevacizumab on area of fluorescein leakage from active new... more To evaluate the effect of intravitreal bevacizumab on area of fluorescein leakage from active new vessels (NVs) and on best-corrected visual acuity in patients with actively leaking NV associated with diabetic retinopathy unresponsive to panretinal photocoagulation. A prospective open-label study of diabetic patients with actively leaking NV refractory to panretinal photocoagulation and best-corrected visual acuity worse than 20/40. Ophthalmic evaluation, including fluorescein angiography, was performed at baseline and at Weeks 1, 6, 12, 24, and 48 after intravitreal bevacizumab (1.5 mg/0.06 mL) injection. After Week 12, patients could receive additional intravitreal bevacizumab injections pro re nata, per the discretion of the treating ophthalmologist. Main outcome measures include change from baseline (at each study visit) in total area of fluorescein leakage from active NV and change from baseline in best-corrected visual acuity. Fifteen consecutive patients were included, and 12 completed the study. Mean ± SEM fluorescein leakage was 27.7 ± 6.2 mm at baseline and was significantly lower at all visits post injection; at Week 6, no leakage was observed (P = 0.0001). The mean ± SEM logarithm of minimum angle of resolution best-corrected visual acuity improved from 0.90 ± 0.11 at baseline to 0.70 ± 0.12 at Week 48 (P = 0.0449). Throughout the 48-week study period, patients received a mean of 2.16 injections. With 1-year follow-up, treatment with intravitreal bevacizumab was associated with reduced fluorescein leakage from persistent NV and improved visual acuity in patients with diabetic retinopathy unresponsive to panretinal photocoagulation.
Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading ca... more Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading cause of definitive visual impairment and legal blindness in the elderly. During the past decade, advances in ophthalmic imaging systems have enabled the recognition of presumed new distinct choroidal neovascular lesions that share some unique clinical and angiographic peculiarities as well as better comprehension of the pathophysiologic mechanisms related to such entities. Amongst presumed newer exudative maculopathies, polypoidal choroidal vasculopathy, which has been described as a distinct choroidal abnormality characterized by inner choroidal vascular network of vessels ending in polyp-like structures only identified on indocyanine green angiography and mostly affecting African-American and Asian descendents, has gained special interest from the ophthalmic community particularly because of its growing recognition among patients with clinical appearance of neovascular age-related macular degeneration. Thus far, however, the exact nature of the vascular structure of the polypoidal choroidal vasculopathy lesion remains unclear and data from recent studies have conflicted with the initial concept of a benign exudative maculopathy with long-term preservation of good vision. All together, such factors make difficult the establishment of an appropriate treatment, if any, for the entity. Herein, by using a modified technique of conventional indocyanine green angiography, we demonstrate new information about the morphologic characteristics, and to some extent the blood flow dynamics perfusion, of the polypoidal choroidal vasculopathy lesion. Our results suggest that the PCV lesion should be considered a variety of choroidal neovascularization rather than a distinct clinical entity, characterized by one single large neovascular complex presenting well-defined arterial neovascular vessels arising from one major "ingrowth site" and draining vessels that present aneurysm-like dilations corresponding to the polyp-like structures typically described for the entity. Finally, the visual acuity and angiographic findings observed after selective ingrowth site photothrombosis corroborate the existence of one major "ingrowth site" for the PCV neovascular complex and point toward a new treatment paradigm for this variety of choroidal neovascularization.
Over the 15 years since the original description, optical coherence tomography (OCT) has become o... more Over the 15 years since the original description, optical coherence tomography (OCT) has become one of the key diagnostic technologies in the ophthalmic subspecialty areas of retinal diseases and glaucoma. The reason for the widespread adoption of this technology originates from at least two properties of the OCT results: on the one hand, the results are accessible to the non-specialist where microscopic retinal abnormalities are grossly and easily noticeable; on the other hand, results are reproducible and exceedingly quantitative in the hands of the specialist. However, as in any other imaging technique in ophthalmology, some artifacts are expected to occur. Understanding of the basic principles of image acquisition and data processing as well as recognition of OCT limitations are crucial issues to using this equipment with cleverness. Herein, we took a brief look in the past of OCT and have explained the key basic physical principles of this imaging technology. In addition, each of the several steps encompassing a third generation OCT evaluation of retinal tissues has been addressed in details. A comprehensive explanation about next generation OCT systems has also been provided and, to conclude, we have commented on the future directions of this exceptional technique.
To evaluate the safety of three dose regimens of intravitreal bevacizumab (Avastin; Genentech, In... more To evaluate the safety of three dose regimens of intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) for the management of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). This was a prospective, nonrandomized open-label study of 45 patients with AMD and subfoveal CNV. A standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 (+/-1) after a single intravitreous injection (1.0, 1.5, or 2.0 mg) of bevacizumab. Main outcomes measures include clinical evidence of toxicity and complications. Changes in best corrected visual acuity (BCVA) and lesion characteristics-macular morphology were also evaluated. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. Mean BCVA improved from baseline throughout the study (P < 0.001; ANOVA with Geisser-Greenhouse correction). Compared with baseline, BCVA was improved at week 1 (P = 0.001), week 6 (P < 0.001), and week 12 (P = 0.001; Dunnett test). At week 12, the lesion area and CNV area were stable or decreased in 79.1% (34/43) and in 74.4% (32/43) of patients, respectively, with no deterioration of macular architecture observed in 83.7% (36/43). A dose-related change in BCVA (in Early Treatment Diabetic Retinopathy Study [ETDRS] lines) was observed at week 12 (1.0 mg [+0.3 line]; 1.5 mg [+0.6 line]; and 2.0 mg [+1.0 line]; P = 0.02; nonparametric test for ordered groups). A single intravitreal bevacizumab injection was well tolerated and, except for minor transient local adverse events, no other adverse events were observed. In the short-term, treatment was associated with vision stabilization or improvement and no unfavorable neovascular lesion-macular changes in most patients.
To investigate the automatic delineation of the outer limits of the macular neural retina, by usi... more To investigate the automatic delineation of the outer limits of the macular neural retina, by using the optical coherence tomography (OCT)-3 built-in software, and to determine its influence in assessing retinal thickness in the normal macula. Retrospective analysis of the OCT3 data at a tertiary-care referral center was performed to study the automatic delineation of the outer neural retina boundary generated by the OCT built-in software. In parallel, a cross-sectional study was designed to compare retinal thickness measurements obtained at specific macular regions of nine normal eyes by the automatic measurement tool with those obtained using a manual-caliper-assisted technique. OCT data from 121 eyes were evaluated. Two parallel, linear highly reflective layers (HRL) were visible at the level of the outer retinal boundary in normal macular regions. Disappearance of the inner and maintenance of the outer HRL was noted in the presence of eye conditions affecting the external retinal layers. The automated software delineation for the outer retinal border was primarily guided by the presence of the inner HRL, whereas the correlation of the OCT findings with the expected clinical and angiographic features on eyes presenting specific macular conditions pointed toward a deeper retinal pigment epithelium-retina interface occurring at the level of the outer HRL. There was a statistically significant difference between the retinal thickness in specific normal macular regions obtained by the automatic measurement tool and the caliper-assisted technique in which the outer retinal border delineation was based on the outer HRL (P = 0.008, Wilcoxon signed rank test). Incorrect delineation of the outer neural retina boundary is occurring with the automated retinal thickness measurement tool of the OCT3 software. At specific regions of the normal macula, retinal thicknesses were significantly underestimated due to such misalignment.
Graefe's Archive for Clinical and Experimental Ophthalmology, 2007
A novel alternative for combined treatment using verteporfin photodynamic therapy (PDT) has emerg... more A novel alternative for combined treatment using verteporfin photodynamic therapy (PDT) has emerged as preliminary safety and efficacy data of the intravitreal use of the anti-angiogenic bevacizumab became available. In the current study we investigate the feasibility of intravitreal bevacizumab combined with verteporfin PDT for the treatment of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). A single-centre, prospective, open-label study of 11 patients with documented CNV progression after PDT treatment who underwent combined PDT and intravitreal injection of 1.5 mg of bevacizumab was undertaken. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 2, 12 and 24. Clinical evidence of complications and changes in logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and in fluorescein leakage from CNV were evaluated. The mean (+/-SD) age of the 11 patients was 74 (+/-5) years. Seven eyes had been treated with one previous PDT session and four eyes had two previous PDT sessions. The mean baseline logMAR ETDRS BCVA was 1.031 (Snellen equivalent, 20/200(-2)). At follow-up weeks 1, 2, 12 and 24, the mean logMAR ETDRS BCVA (Snellen equivalent) was 0.944 (20/160(-2)), 0.924 (20/160(-1)), 0.882 (20/160(+1)), and 0.933 (20/160(-2)), respectively. The change in BCVA from baseline was significant at each study follow-up interval (P < or = 0.001); at 12 and 24 weeks, the mean change in BCVA from baseline was an improvement of 1.49 and of 0.98 ETDRS line, respectively. Fluorescein leakage from CNV was absent in all eyes at week 12. One additional treatment session was required in seven (63.6%) eyes at week 24 due to recurrent fluorescein leakage from CNV ("minimum" [<50% of the leaking area noted at baseline], n = 4; and "moderate" [>50% of the leaking area noted at baseline], n = 3). No progression of the neovascular lesion was observed at week 24. No safety issues were identified throughout the period of the study. The overall changes in vision and fluorescein leakage from CNV throughout the study suggest that a possible synergistic effect may arise from the combination of intravitreal bevacizumab with verteporfin PDT for the treatment of neovascular AMD.
Graefe's Archive for Clinical and Experimental Ophthalmology, 2007
To describe the clinical, angiographic, and optical coherence tomography findings of a patient wi... more To describe the clinical, angiographic, and optical coherence tomography findings of a patient with subretinal neovascularization (SRN) in idiopathic juxtafoveolar retinal telangiectasis (IJRT) treated with intravitreal bevacizumab injection. In the setting of a tertiary referral center, a patient with bilateral acquired IJRT, complicated with juxtafoveal SRN in one eye, was treated with a single intravitreal injection of 1.5 mg of bevacizumab and then prospectively followed for 24 weeks. Vision improved from 20/40(-1) to 20/20(-2) by 24 weeks of follow-up. Fluorescein angiography demonstrated the absence of leakage from a previously active SRN. Optical coherence tomography revealed gradual neovascular lesion contraction and the resolution of subretinal fluid over the 24-week follow-up period. No obvious adverse events were noted. In the short-term, intravitreal bevacizumab treatment resulted in partial restoration of the macular architecture and vision improvement by means of neovascular lesion regression and the resolution of associated serohemorrhagic complications.
... hyperfluorescence, have been described in patients with acute mani-festation of the disease, ... more ... hyperfluorescence, have been described in patients with acute mani-festation of the disease, which may persist during remission [4145]. ... Psychophysical stress The association between psychophysical stress and the mani-festation of CSC is very well documented [99102]. ...
To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis... more To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis (IMP) in the management of patients with persistent central serous chorioretinopathy (CSC). Interventional noncomparative case series. Eleven patients with CSC presenting with persistent subretinal fluid in optical coherence tomography (OCT) four months after presentation and decrease in visual acuity (VA) were submitted to a single IMP session with 2 mg/kg body weight ICG and application of 5.6 W/cm(2) light at 810 nm. A continuous follow-up was provided with best-corrected ETDRS VA assessment, and angiographic and OCT documentation 72 hours before and at 2 days, 1 and 2 weeks, 1, 3, 6, and 12 months after treatment. Pretreatment VA levels ranged from 20/32 - 1 to 20/100 (mean, 20/63 + 2 [logMAR equivalent, 0.460 +/- 0.155]); post treatment levels ranged from 20/25 - 2 to 20/20 (mean, 20/20 - 2 [logMAR equivalent, 0.038 +/- 0.048]). Ten out of eleven patients presented with VA levels of >/=20/25 2 weeks after treatment; the mean logMAR VA change of 0.345 at that time was statistically significant (p < 0.05, Friedman test). OCT disclosed resolution of persistent subretinal fluid in all eyes. No recurrence was observed after 12 months of follow-up. Complications included transient retinal whitening in two patients, and associated occlusion of retinal capillaries in one. Photothrombosis using low-intensity 810 nm light to direct laser energy continuously at the active leakage sites after intravenous ICG infusion induced rapid VA recovery in patients with persistent CSC; accordingly, restoration of the macular architecture was evidenced on OCT, and no recurrence was noted 12 months after IMP.
A doença hipertensiva específica da gestação (DHEG) é uma das principais causas de morbidade e mo... more A doença hipertensiva específica da gestação (DHEG) é uma das principais causas de morbidade e mortalidade materna 1 . Ela pode se manifestar de forma pura, sem antecedentes de hipertensão crônica, ou sobreposta a uma doença hipertensiva subjacente. Geralmente acomete ...
... Arnaldo Furman Bordon1 Akioshi Oshima2 Tércio Alves Guia3 Daniela Calucci4 Juliana Maria Ferr... more ... Arnaldo Furman Bordon1 Akioshi Oshima2 Tércio Alves Guia3 Daniela Calucci4 Juliana Maria Ferraz Sallum5 Michel Eid Farah6 ... Tomografia de coerência óptica O aparelho utilizado foi a OCT 1 (Zeiss-Humphrey), utili-zando-se o protocolo de aquisição das imagens de seis ...
To describe the morphologic features of calcified and decalcified choroidal osteomas using multim... more To describe the morphologic features of calcified and decalcified choroidal osteomas using multimodal imaging and correlate these findings with a previous histopathologic study. Retrospective observational case series. Three patients with choroidal osteoma underwent complete ophthalmologic examination, fundus photography, and multimodal fundus imaging, including Fourier-domain optical coherence tomography (FD-OCT) and blue-light fundus autofluorescence (bAF). FD-OCT imaging of calcified tumors revealed a distinctive latticework pattern of reflectivity resembling the spongy bone structure seen histopathologically. On bAF the fluorescence was relatively well preserved overlying calcified tumors. In decalcified areas 2 patterns of reflectivity were identified: the first consisted of areas of relative hyperreflectivity with a lamellar appearance while the second was characterized by heterogeneous, hyperreflective, mound-like irregular areas associated with some posterior optical shadowing. Decalcified tumor areas had reduced overall fluorescence on bAF. FD-OCT demonstrated different reflectivity patterns in both calcified and decalcified portions of the choroidal osteoma, which may correspond to different stages of tumor evolution. A distinctive latticework pattern of reflectivity similar to spongy bone was seen in calcified tumors. These observations improve our knowledge of the in vivo structure of choroidal osteomas and may have implications for the diagnosis and management of this tumor.
To evaluate the visual and angiographic effects as well as optical coherence tomography findings ... more To evaluate the visual and angiographic effects as well as optical coherence tomography findings after a new technique of ingrowth site treatment of subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia with the use of indocyanine green (ICG)-mediated photothrombosis. Interventional, noncomparative case series. In the setting of a tertiary referral center, patients with pathologic myopia in whom fluorescein and conventional ICG angiography demonstrated distinct CNV vessels supplying the subfoveal neovascular complex were submitted to focal ingrowth site treatment using a new therapeutic modality termed ICG-mediated photothrombosis. Prospective evaluation including visual acuity assessment, fluorescein and ICG angiography, and optical coherence tomography (OCT) evaluation was performed at weeks 1, 12, 24, and 48 after treatment. Six consecutive patients (six eyes) had treatment using a single session of ICG-mediated photothrombosis at the CNV ingrowth site. Obliteration of the entire neovascular complex was achieved immediately after treatment in all patients. At last follow-up, visual acuity improvement of 1 or more Early Treatment Diabetic Retinopathy Study lines was observed in five of six patients, and fluorescein angiography showed an absence (four eyes) or minimal leakage (two eyes) from CNV. Indocyanine green angiography demonstrated selective obliteration of the neovascular complex. Accordingly, reduction of retinal edema was observed in the OCT evaluation in all patients. There was no significant complication related to the procedure. The use of lower irradiances of 810- nm continuous light application and intravenous ICG infusion for neovascular ingrowth site photothrombosis induced selective CNV hypoperfusion, as demonstrated by fluorescein and ICG angiography in patients with pathologic myopia. These findings were either consistent with the visual acuity improvement observed in five of six patients or with the partial restoration of the retinal architecture seen in OCT evaluation 12 months after treatment.
To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis... more To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis (IMP) in the management of patients with persistent central serous chorioretinopathy (CSC). Interventional noncomparative case series. Eleven patients with CSC presenting with persistent subretinal fluid in optical coherence tomography (OCT) four months after presentation and decrease in visual acuity (VA) were submitted to a single IMP session with 2 mg/kg body weight ICG and application of 5.6 W/cm(2) light at 810 nm. A continuous follow-up was provided with best-corrected ETDRS VA assessment, and angiographic and OCT documentation 72 hours before and at 2 days, 1 and 2 weeks, 1, 3, 6, and 12 months after treatment. Pretreatment VA levels ranged from 20/32 - 1 to 20/100 (mean, 20/63 + 2 [logMAR equivalent, 0.460 +/- 0.155]); post treatment levels ranged from 20/25 - 2 to 20/20 (mean, 20/20 - 2 [logMAR equivalent, 0.038 +/- 0.048]). Ten out of eleven patients presented with VA levels of >/=20/25 2 weeks after treatment; the mean logMAR VA change of 0.345 at that time was statistically significant (p < 0.05, Friedman test). OCT disclosed resolution of persistent subretinal fluid in all eyes. No recurrence was observed after 12 months of follow-up. Complications included transient retinal whitening in two patients, and associated occlusion of retinal capillaries in one. Photothrombosis using low-intensity 810 nm light to direct laser energy continuously at the active leakage sites after intravenous ICG infusion induced rapid VA recovery in patients with persistent CSC; accordingly, restoration of the macular architecture was evidenced on OCT, and no recurrence was noted 12 months after IMP.
A tomografia de coerência óptica incorporou-se gradativamente ao contemporâneo arsenal diagnóstic... more A tomografia de coerência óptica incorporou-se gradativamente ao contemporâneo arsenal diagnóstico em Oftalmologia, passando a exercer papel fundamental na inves-tigação e condução de doenças oculares, particularmente na especialidade de Retina e Vítreo. A ...
To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for ... more To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV), the authors evaluated the retinal and choroidal response immediately after treatment with serial optical coherence tomography (OCT) and indocyanine green angiography (ICGA). This study was a prospective, noncomparative case series. PDT was performed on nine eyes of nine consecutive patients who presented with subfoveal CNV due to age-related macular degeneration, and serial evaluation with OCT as well as ICGA was performed at 20-minute intervals for the first 2 hours and then at 1 week, 1 month, and 3 months. In the first 2 hours after PDT, OCT showed an increase in the thickness of the retina in the treatment area due to fluid leakage from the neovascular complex as confirmed by ICGA. At 1 week, marked reduction of intraretinal/subretinal fluid was observed in all patients. Neovascular complex nonperfusion by ICGA was associated with some degree of choroidal hypoperfusion in the treatment area. Return of the foveal contour by OCT was optimal after 1 month of treatment. At 3 months, choroidal reperfusion by ICGA and recurrent intraretinal/subretinal fluid by OCT were observed. Serial OCT and ICGA evaluation after PDT suggests that the initial successful CNV nonperfusion as shown by fluorescein angiography at 1 week occurs by means of selective PDT damage to the lesion and/or reduced choroidal blood flow in the treatment area, thereby decreasing intraretinal/subretinal fluid and facilitating restoration of the retinal architecture.
To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitre... more To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitreal bevacizumab injections for the management of macular edema due to ischemic central or hemicentral retinal vein occlusion (RVO). In this prospective, open-label study, 7 consecutive patients (7 eyes) with macular edema associated with ischemic central or hemicentral RVO were treated with intravitreal injections of 2.0 mg (0.08 mL) of bevacizumab at 12-week intervals. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 after each injection. Clinical evidence of toxicity and complications as well as changes in logarithm of minimum angle of resolution Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) shown by optical coherence tomography (OCT), and dye leakage shown by fluorescein angiography were evaluated. The median age of the 7 patients was 65 years (range, 58-74 years), and the median duration of symptoms before injection was 7 months (range, 2.5-16 months). At baseline, mean BCVA was 1.21 (Snellen equivalent, approximately 20/320) in the affected eye. Mean baseline CMT and TMV were 730.1 microm and 17.1 mm(3), respectively. Fluorescein leakage was observed in the macula and affected retinal quadrants in all seven eyes. Six patients completed the 25-week follow-up examination with reinjections performed at weeks 12 and 24. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. At the last follow-up, mean BCVA in the affected eye was 0.68 (Snellen equivalent, 20/100(+1). No patient had a decrease in BCVA. Mean CMT and TMV at the 25-week follow-up were 260.3 microm and 9.0 mm(3), respectively; fluorescein leakage within the macula and affected retinal quadrants as compared with baseline was markedly reduced in all patients. Coupled with fluorescein angiographic findings, OCT data suggest a trend of macular edema recurrence between 6 weeks and 12 weeks after injection. Intravitreal bevacizumab injections of 2.0 mg at 12-week intervals were well tolerated and were associated with short-term BCVA stabilization or improvement and favorable macular changes in all patients with ischemic RVO and associated macular edema.
To evaluate the effect of intravitreal bevacizumab on area of fluorescein leakage from active new... more To evaluate the effect of intravitreal bevacizumab on area of fluorescein leakage from active new vessels (NVs) and on best-corrected visual acuity in patients with actively leaking NV associated with diabetic retinopathy unresponsive to panretinal photocoagulation. A prospective open-label study of diabetic patients with actively leaking NV refractory to panretinal photocoagulation and best-corrected visual acuity worse than 20/40. Ophthalmic evaluation, including fluorescein angiography, was performed at baseline and at Weeks 1, 6, 12, 24, and 48 after intravitreal bevacizumab (1.5 mg/0.06 mL) injection. After Week 12, patients could receive additional intravitreal bevacizumab injections pro re nata, per the discretion of the treating ophthalmologist. Main outcome measures include change from baseline (at each study visit) in total area of fluorescein leakage from active NV and change from baseline in best-corrected visual acuity. Fifteen consecutive patients were included, and 12 completed the study. Mean ± SEM fluorescein leakage was 27.7 ± 6.2 mm at baseline and was significantly lower at all visits post injection; at Week 6, no leakage was observed (P = 0.0001). The mean ± SEM logarithm of minimum angle of resolution best-corrected visual acuity improved from 0.90 ± 0.11 at baseline to 0.70 ± 0.12 at Week 48 (P = 0.0449). Throughout the 48-week study period, patients received a mean of 2.16 injections. With 1-year follow-up, treatment with intravitreal bevacizumab was associated with reduced fluorescein leakage from persistent NV and improved visual acuity in patients with diabetic retinopathy unresponsive to panretinal photocoagulation.
Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading ca... more Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading cause of definitive visual impairment and legal blindness in the elderly. During the past decade, advances in ophthalmic imaging systems have enabled the recognition of presumed new distinct choroidal neovascular lesions that share some unique clinical and angiographic peculiarities as well as better comprehension of the pathophysiologic mechanisms related to such entities. Amongst presumed newer exudative maculopathies, polypoidal choroidal vasculopathy, which has been described as a distinct choroidal abnormality characterized by inner choroidal vascular network of vessels ending in polyp-like structures only identified on indocyanine green angiography and mostly affecting African-American and Asian descendents, has gained special interest from the ophthalmic community particularly because of its growing recognition among patients with clinical appearance of neovascular age-related macular degeneration. Thus far, however, the exact nature of the vascular structure of the polypoidal choroidal vasculopathy lesion remains unclear and data from recent studies have conflicted with the initial concept of a benign exudative maculopathy with long-term preservation of good vision. All together, such factors make difficult the establishment of an appropriate treatment, if any, for the entity. Herein, by using a modified technique of conventional indocyanine green angiography, we demonstrate new information about the morphologic characteristics, and to some extent the blood flow dynamics perfusion, of the polypoidal choroidal vasculopathy lesion. Our results suggest that the PCV lesion should be considered a variety of choroidal neovascularization rather than a distinct clinical entity, characterized by one single large neovascular complex presenting well-defined arterial neovascular vessels arising from one major "ingrowth site" and draining vessels that present aneurysm-like dilations corresponding to the polyp-like structures typically described for the entity. Finally, the visual acuity and angiographic findings observed after selective ingrowth site photothrombosis corroborate the existence of one major "ingrowth site" for the PCV neovascular complex and point toward a new treatment paradigm for this variety of choroidal neovascularization.
Over the 15 years since the original description, optical coherence tomography (OCT) has become o... more Over the 15 years since the original description, optical coherence tomography (OCT) has become one of the key diagnostic technologies in the ophthalmic subspecialty areas of retinal diseases and glaucoma. The reason for the widespread adoption of this technology originates from at least two properties of the OCT results: on the one hand, the results are accessible to the non-specialist where microscopic retinal abnormalities are grossly and easily noticeable; on the other hand, results are reproducible and exceedingly quantitative in the hands of the specialist. However, as in any other imaging technique in ophthalmology, some artifacts are expected to occur. Understanding of the basic principles of image acquisition and data processing as well as recognition of OCT limitations are crucial issues to using this equipment with cleverness. Herein, we took a brief look in the past of OCT and have explained the key basic physical principles of this imaging technology. In addition, each of the several steps encompassing a third generation OCT evaluation of retinal tissues has been addressed in details. A comprehensive explanation about next generation OCT systems has also been provided and, to conclude, we have commented on the future directions of this exceptional technique.
To evaluate the safety of three dose regimens of intravitreal bevacizumab (Avastin; Genentech, In... more To evaluate the safety of three dose regimens of intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) for the management of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). This was a prospective, nonrandomized open-label study of 45 patients with AMD and subfoveal CNV. A standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 (+/-1) after a single intravitreous injection (1.0, 1.5, or 2.0 mg) of bevacizumab. Main outcomes measures include clinical evidence of toxicity and complications. Changes in best corrected visual acuity (BCVA) and lesion characteristics-macular morphology were also evaluated. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. Mean BCVA improved from baseline throughout the study (P < 0.001; ANOVA with Geisser-Greenhouse correction). Compared with baseline, BCVA was improved at week 1 (P = 0.001), week 6 (P < 0.001), and week 12 (P = 0.001; Dunnett test). At week 12, the lesion area and CNV area were stable or decreased in 79.1% (34/43) and in 74.4% (32/43) of patients, respectively, with no deterioration of macular architecture observed in 83.7% (36/43). A dose-related change in BCVA (in Early Treatment Diabetic Retinopathy Study [ETDRS] lines) was observed at week 12 (1.0 mg [+0.3 line]; 1.5 mg [+0.6 line]; and 2.0 mg [+1.0 line]; P = 0.02; nonparametric test for ordered groups). A single intravitreal bevacizumab injection was well tolerated and, except for minor transient local adverse events, no other adverse events were observed. In the short-term, treatment was associated with vision stabilization or improvement and no unfavorable neovascular lesion-macular changes in most patients.
To investigate the automatic delineation of the outer limits of the macular neural retina, by usi... more To investigate the automatic delineation of the outer limits of the macular neural retina, by using the optical coherence tomography (OCT)-3 built-in software, and to determine its influence in assessing retinal thickness in the normal macula. Retrospective analysis of the OCT3 data at a tertiary-care referral center was performed to study the automatic delineation of the outer neural retina boundary generated by the OCT built-in software. In parallel, a cross-sectional study was designed to compare retinal thickness measurements obtained at specific macular regions of nine normal eyes by the automatic measurement tool with those obtained using a manual-caliper-assisted technique. OCT data from 121 eyes were evaluated. Two parallel, linear highly reflective layers (HRL) were visible at the level of the outer retinal boundary in normal macular regions. Disappearance of the inner and maintenance of the outer HRL was noted in the presence of eye conditions affecting the external retinal layers. The automated software delineation for the outer retinal border was primarily guided by the presence of the inner HRL, whereas the correlation of the OCT findings with the expected clinical and angiographic features on eyes presenting specific macular conditions pointed toward a deeper retinal pigment epithelium-retina interface occurring at the level of the outer HRL. There was a statistically significant difference between the retinal thickness in specific normal macular regions obtained by the automatic measurement tool and the caliper-assisted technique in which the outer retinal border delineation was based on the outer HRL (P = 0.008, Wilcoxon signed rank test). Incorrect delineation of the outer neural retina boundary is occurring with the automated retinal thickness measurement tool of the OCT3 software. At specific regions of the normal macula, retinal thicknesses were significantly underestimated due to such misalignment.
Graefe's Archive for Clinical and Experimental Ophthalmology, 2007
A novel alternative for combined treatment using verteporfin photodynamic therapy (PDT) has emerg... more A novel alternative for combined treatment using verteporfin photodynamic therapy (PDT) has emerged as preliminary safety and efficacy data of the intravitreal use of the anti-angiogenic bevacizumab became available. In the current study we investigate the feasibility of intravitreal bevacizumab combined with verteporfin PDT for the treatment of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). A single-centre, prospective, open-label study of 11 patients with documented CNV progression after PDT treatment who underwent combined PDT and intravitreal injection of 1.5 mg of bevacizumab was undertaken. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 2, 12 and 24. Clinical evidence of complications and changes in logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and in fluorescein leakage from CNV were evaluated. The mean (+/-SD) age of the 11 patients was 74 (+/-5) years. Seven eyes had been treated with one previous PDT session and four eyes had two previous PDT sessions. The mean baseline logMAR ETDRS BCVA was 1.031 (Snellen equivalent, 20/200(-2)). At follow-up weeks 1, 2, 12 and 24, the mean logMAR ETDRS BCVA (Snellen equivalent) was 0.944 (20/160(-2)), 0.924 (20/160(-1)), 0.882 (20/160(+1)), and 0.933 (20/160(-2)), respectively. The change in BCVA from baseline was significant at each study follow-up interval (P < or = 0.001); at 12 and 24 weeks, the mean change in BCVA from baseline was an improvement of 1.49 and of 0.98 ETDRS line, respectively. Fluorescein leakage from CNV was absent in all eyes at week 12. One additional treatment session was required in seven (63.6%) eyes at week 24 due to recurrent fluorescein leakage from CNV ("minimum" [<50% of the leaking area noted at baseline], n = 4; and "moderate" [>50% of the leaking area noted at baseline], n = 3). No progression of the neovascular lesion was observed at week 24. No safety issues were identified throughout the period of the study. The overall changes in vision and fluorescein leakage from CNV throughout the study suggest that a possible synergistic effect may arise from the combination of intravitreal bevacizumab with verteporfin PDT for the treatment of neovascular AMD.
Graefe's Archive for Clinical and Experimental Ophthalmology, 2007
To describe the clinical, angiographic, and optical coherence tomography findings of a patient wi... more To describe the clinical, angiographic, and optical coherence tomography findings of a patient with subretinal neovascularization (SRN) in idiopathic juxtafoveolar retinal telangiectasis (IJRT) treated with intravitreal bevacizumab injection. In the setting of a tertiary referral center, a patient with bilateral acquired IJRT, complicated with juxtafoveal SRN in one eye, was treated with a single intravitreal injection of 1.5 mg of bevacizumab and then prospectively followed for 24 weeks. Vision improved from 20/40(-1) to 20/20(-2) by 24 weeks of follow-up. Fluorescein angiography demonstrated the absence of leakage from a previously active SRN. Optical coherence tomography revealed gradual neovascular lesion contraction and the resolution of subretinal fluid over the 24-week follow-up period. No obvious adverse events were noted. In the short-term, intravitreal bevacizumab treatment resulted in partial restoration of the macular architecture and vision improvement by means of neovascular lesion regression and the resolution of associated serohemorrhagic complications.
... hyperfluorescence, have been described in patients with acute mani-festation of the disease, ... more ... hyperfluorescence, have been described in patients with acute mani-festation of the disease, which may persist during remission [4145]. ... Psychophysical stress The association between psychophysical stress and the mani-festation of CSC is very well documented [99102]. ...
To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis... more To evaluate the potential benefit and complications of indocyanine green-mediated photothrombosis (IMP) in the management of patients with persistent central serous chorioretinopathy (CSC). Interventional noncomparative case series. Eleven patients with CSC presenting with persistent subretinal fluid in optical coherence tomography (OCT) four months after presentation and decrease in visual acuity (VA) were submitted to a single IMP session with 2 mg/kg body weight ICG and application of 5.6 W/cm(2) light at 810 nm. A continuous follow-up was provided with best-corrected ETDRS VA assessment, and angiographic and OCT documentation 72 hours before and at 2 days, 1 and 2 weeks, 1, 3, 6, and 12 months after treatment. Pretreatment VA levels ranged from 20/32 - 1 to 20/100 (mean, 20/63 + 2 [logMAR equivalent, 0.460 +/- 0.155]); post treatment levels ranged from 20/25 - 2 to 20/20 (mean, 20/20 - 2 [logMAR equivalent, 0.038 +/- 0.048]). Ten out of eleven patients presented with VA levels of >/=20/25 2 weeks after treatment; the mean logMAR VA change of 0.345 at that time was statistically significant (p < 0.05, Friedman test). OCT disclosed resolution of persistent subretinal fluid in all eyes. No recurrence was observed after 12 months of follow-up. Complications included transient retinal whitening in two patients, and associated occlusion of retinal capillaries in one. Photothrombosis using low-intensity 810 nm light to direct laser energy continuously at the active leakage sites after intravenous ICG infusion induced rapid VA recovery in patients with persistent CSC; accordingly, restoration of the macular architecture was evidenced on OCT, and no recurrence was noted 12 months after IMP.
A doença hipertensiva específica da gestação (DHEG) é uma das principais causas de morbidade e mo... more A doença hipertensiva específica da gestação (DHEG) é uma das principais causas de morbidade e mortalidade materna 1 . Ela pode se manifestar de forma pura, sem antecedentes de hipertensão crônica, ou sobreposta a uma doença hipertensiva subjacente. Geralmente acomete ...
... Arnaldo Furman Bordon1 Akioshi Oshima2 Tércio Alves Guia3 Daniela Calucci4 Juliana Maria Ferr... more ... Arnaldo Furman Bordon1 Akioshi Oshima2 Tércio Alves Guia3 Daniela Calucci4 Juliana Maria Ferraz Sallum5 Michel Eid Farah6 ... Tomografia de coerência óptica O aparelho utilizado foi a OCT 1 (Zeiss-Humphrey), utili-zando-se o protocolo de aquisição das imagens de seis ...
To describe the morphologic features of calcified and decalcified choroidal osteomas using multim... more To describe the morphologic features of calcified and decalcified choroidal osteomas using multimodal imaging and correlate these findings with a previous histopathologic study. Retrospective observational case series. Three patients with choroidal osteoma underwent complete ophthalmologic examination, fundus photography, and multimodal fundus imaging, including Fourier-domain optical coherence tomography (FD-OCT) and blue-light fundus autofluorescence (bAF). FD-OCT imaging of calcified tumors revealed a distinctive latticework pattern of reflectivity resembling the spongy bone structure seen histopathologically. On bAF the fluorescence was relatively well preserved overlying calcified tumors. In decalcified areas 2 patterns of reflectivity were identified: the first consisted of areas of relative hyperreflectivity with a lamellar appearance while the second was characterized by heterogeneous, hyperreflective, mound-like irregular areas associated with some posterior optical shadowing. Decalcified tumor areas had reduced overall fluorescence on bAF. FD-OCT demonstrated different reflectivity patterns in both calcified and decalcified portions of the choroidal osteoma, which may correspond to different stages of tumor evolution. A distinctive latticework pattern of reflectivity similar to spongy bone was seen in calcified tumors. These observations improve our knowledge of the in vivo structure of choroidal osteomas and may have implications for the diagnosis and management of this tumor.
To evaluate the visual and angiographic effects as well as optical coherence tomography findings ... more To evaluate the visual and angiographic effects as well as optical coherence tomography findings after a new technique of ingrowth site treatment of subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia with the use of indocyanine green (ICG)-mediated photothrombosis. Interventional, noncomparative case series. In the setting of a tertiary referral center, patients with pathologic myopia in whom fluorescein and conventional ICG angiography demonstrated distinct CNV vessels supplying the subfoveal neovascular complex were submitted to focal ingrowth site treatment using a new therapeutic modality termed ICG-mediated photothrombosis. Prospective evaluation including visual acuity assessment, fluorescein and ICG angiography, and optical coherence tomography (OCT) evaluation was performed at weeks 1, 12, 24, and 48 after treatment. Six consecutive patients (six eyes) had treatment using a single session of ICG-mediated photothrombosis at the CNV ingrowth site. Obliteration of the entire neovascular complex was achieved immediately after treatment in all patients. At last follow-up, visual acuity improvement of 1 or more Early Treatment Diabetic Retinopathy Study lines was observed in five of six patients, and fluorescein angiography showed an absence (four eyes) or minimal leakage (two eyes) from CNV. Indocyanine green angiography demonstrated selective obliteration of the neovascular complex. Accordingly, reduction of retinal edema was observed in the OCT evaluation in all patients. There was no significant complication related to the procedure. The use of lower irradiances of 810- nm continuous light application and intravenous ICG infusion for neovascular ingrowth site photothrombosis induced selective CNV hypoperfusion, as demonstrated by fluorescein and ICG angiography in patients with pathologic myopia. These findings were either consistent with the visual acuity improvement observed in five of six patients or with the partial restoration of the retinal architecture seen in OCT evaluation 12 months after treatment.
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