E-mail: docrishi@yahoo.co.in Manuscript received: 07.11.08; Revision accepted: 29.08.09 Combination photodynamic therapy and bevacizumab for choroidal neovascularization associated wit
Trang 162 Indian Journal of Ophthalmology Vol 59 No 1
References
1 Grabow HB Early results with foldable toric IOL implantation
Eur J Implant Refract Surg 1994;6:177–8
2 Novis C Astigmatism and toric intraocular lenses Curr Opin
Ophthalmol 2000;11:47–50
3 Bauer NJ, de Vries NE, Webers CA, Hendrikse F, Nuijts RM Astigmatism management in cataract surgery with the AcrySof toric intraocular lens J Cataract Refract Surg 2008;34:1483-8
Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18,
College Road, Chennai - 600 006, Tamil Nadu, India
Correspondence to: Dr Pukhraj Rishi, Shri Bhagwan Mahavir
Vitreoretinal Services, Sankara Nethralaya, 18, College Road, Chennai
- 600 006, Tamil Nadu, India E-mail: docrishi@yahoo.co.in
Manuscript received: 07.11.08; Revision accepted: 29.08.09
Combination photodynamic therapy
and bevacizumab for choroidal
neovascularization associated with
toxoplasmosis
Pukhraj Rishi, Anusha Venkataraman, Ekta Rishi
A 14-year-old girl presenting with visual loss in both eyes
was diagnosed to have healed toxoplasma retinochoroiditis in
the right eye with active choroidal neovascularization (CNV)
secondary to toxoplasmosis in the left She underwent combination
photodynamic therapy (PDT) and intravitreal bevacizumab as
primary treatment PDT was performed as per the ‘Treatment
of Age-related Macular Degeneration by Photodynamic therapy’
study protocol and was followed by intravitreal bevacizumab
after 2 days CNV regressed at 8 weeks of follow-up and remained
stable at 8 months of follow-up The initial visual acuity improved
from 20/120 to 20/30 Combination therapy with PDT and
intravitreal bevacizumab appears to be effective in the treatment
of CNV secondary to toxoplasma retinochoroiditis
Key words: Bevacizumab, choroidal neovascularization,
photodynamic therapy, toxoplasmosis
Indian J Ophthalmol: 2011;59:62-64
DOI: 10.4103/0301-4738.73728 PMID: 21157079
Ocular toxoplasmosis is an important cause of choroidal
neovascularization (CNV) in the pediatric age group.[1] The
development of CNV adjacent to retinochoroidal scars is a
well-known late complication contributing to loss of useful
vision due to foveal involvement Treatment modalities for
CNV secondary to toxoplasma retinochoroiditis include
laser photocoagulation, submacular surgery, photodynamic
therapy (PDT) and anti-vascular endothelial growth factor
(VEGF) agents.[1] We report a case of CNV secondary to ocular
toxoplasmosis treated with a combination of verteporfin–PDT
and intravitreal bevacizumab Combination therapy for CNV
secondary to toxoplasmosis has not been reported in the past
Case Report
A 14-year-old girl presented with a 1-year history of deterioration of vision in both eyes There were no significant ocular problems in the past Medical and family history and systemic examination were unremarkable On ocular examination, her best corrected visual acuity (BCVA) at presentation was CF 1 mt, N36 in the right eye and 20/120, N18 in the left eye Biomicroscopic examination did not show any evidence of intra-ocular inflammation and the anterior segment was unremarkable in both eyes Fundus evaluation
of the right eye showed the presence of a punched-out pigmented lesion with well-demarcated borders at the macula that was suggestive of a healed toxoplasma lesion [Fig 1A] Clinical findings were confirmed on fluorescein angiography [Fig 1B] and Optical coherence tomography [Fig 1C] Left eye examination not only showed a punched-out pigmented lesion
at the macula but also a choroidal neovascular membrane with adjacent subretinal fluid and hemorrhage just medial to the pigmented scar [Fig 2A]
The clinical findings were confirmed on fundus fluorescein angiography (FFA) and optical coherence tomography (OCT) The FFA of the left eye revealed an active subfoveal classic choroidal neovascular membrane with profuse leakage Blocked choroidal fluorescence due to the overlying hemorrhage was also noted [Fig 2B] OCT revealed subfoveal choroidal neovascular membrane (CNVM) and subretinal fluid adjacent to a subretinal scar [Fig 2C] The routine hemogram, kidney function tests and liver function tests were within the normal range Mantoux test was negative and chest X-ray was normal The anti-toxoplasma IgM titer was negative; IgG titer was however equivocal A diagnosis of healed toxoplasma retinochoroiditis in the right eye and subfoveal CNVM secondary to toxoplasma retinochoroiditis in the left eye was arrived at The nature of the disease and treatment options were explained The patient underwent verteporfin–PDT as per the ‘Treatment of Age-related Macular Degeneration by Photodynamic therapy’ protocol.[2] This was followed by an intravitreal injection of bevacizumab (1.25 mg/0.05 ml) after
2 days
At 8 weeks follow-up, the CNV showed regression with
no evidence of subretinal fluid or hemorrhage on clinical examination or OCT The BCVA improved to 20/30, N6 and the fundus remained stable up to the eighth month of
follow-up [Fig 3] No adverse ocular or systemic event related to the treatment procedure was encountered
Discussion
The natural history of CNV secondary to toxoplasmosis reveals
a poor visual prognosis.[3-5] The CNV originates adjacent to the retinochoroidal scars and leads to central visual loss due
Trang 2January - February 2011 Brief Communications 63
to foveal involvement The different treatment modalities
described for CNV secondary to toxoplasmosis in children
include laser photocoagulation, submacular surgery, PDT
and anti-VEGF agents.[1] Laser photocoagulation is no longer
preferred as it results in a permanent scotoma Uemura et al.[6]
assessed the efficacy of surgical removal of membranes in a
series of 14 children with subfoveal CNV of which one was
secondary to toxoplasmosis The initial visual acuity of 20/100
in this patient improved to a final visual acuity of 20/20 at 27
months follow-up The favorable outcome is attributed to the
solitary subretinal site of ingrowth that is easily amenable to
surgery.[7] However, surgery can have its own complications
and does not prevent recurrences
The use of verteporfin–PDT, although initially used for the treatment of age-related macular degeneration and myopic CNV, has now been extended beyond these indications to inflammatory and infectious etiologies Mauget Faysse et al.[8] have found verteporfin–PDT to be efficacious for subfoveal CNV associated with toxoplasma retinochoroiditis In their study of eight patients, the mean visual acuity improved from 20/225 to 20/123 during a mean follow-up period of 25 months Ben Yahia et al.[9] recently reported the resolution
of two CNVMs secondary to toxoplasma retinochoroiditis following administration of a single intravitreal injection of bevacizumab as primary treatment or as rescue treatment following unsuccessful PDT
Figure 3: At 8 months of follow-up, color fundus photograph (A) reveals a regressed choroidal neovascular membrane Optical coherence
tomography reveals (B) a high reflective subfoveal scar
Figure 1: At presentation, right eye color fundus photograph (A) reveals a punched-out pigmented lesion with well-demarcated borders at the
macula suggestive of a healed toxoplasma scar Fluorescein angiography (B) reveals staining of the retinal scar Optical coherence tomography reveals retinal atrophy corresponding to the lesion (C)
Figure 2: At presentation, left eye color fundus photograph (A) reveals a pigmented lesion at the macula along with a choroidal neovascular
membrane, adjacent subretinal hemorrhage and fluid medial to the pigmented scar Fluorescein angiography (B, C) reveals an active, subfoveal classic choroidal neovascular membrane with profuse leakage Blocked choroidal fluorescence due to the overlying hemorrhage is also noted Optical coherence tomography reveals subfoveal choroidal neovascular membrane and subretinal fluid adjacent to a subretinal scar
Trang 364 Indian Journal of Ophthalmology Vol 59 No 1 There is however no report of any patient with CNV
secondary to toxoplasmosis who has been managed with
combination PDT and intravitreal bevacizumab as a primary
treatment The combined regime is postulated to have a
beneficial synergistic effect that could reduce the need for
repeated injections Combination therapy using PDT and
bevacizumab as the first-line management in such cases could
be a viable option.[10] Larger studies with longer follow-up may
reveal that visual outcome with combination therapy could be
better than PDT alone
References
1 Sivaprasad S, Moore AT Choroidal neovascularisation in children
Br J Ophthalmol 2008;92:451-4
2 Treatment of Age related macular degeneration with photodynamic
therapy (TAP) study group: Photodynamic therapy of subfoveal
CNV in ARMD with verteporfin; One year results of 2 Randomized
clinical trials- TAP report Arch Ophthalmol 1999;117:1329-45
3 Atmaca Ls, Simsek T, Batioglu F Clinical features and prognosis in
ocular toxoplasmosis Jpn J Ophthalmol 2004;48:386-91
4 Augsburger JJ, Benson WE Subretinal neovascularisation in
chronic uveitis Albrecht Von Graefes Arch Klin Exp Ophthalmol
1980;215:43-51
5 Goshorn EB, Hoover DL, Eller AW, Friberg TR, Jarrett WH 2nd, Sorr EM Subretinal revascularization in children and adolescents
J Paediatr Ophthalmol Strabismus 1995;32:178-82
6 Uemura A, Thomas MA Visual Outcome after Surgical Removal
of Choroidal Neovascularization in Pediatric Patients Arch Ophthalmol 2000;118:1373-8
7 Melberg NS, Thomas MA, Burgess DB The surgical removal
of subfoveal choroidal neovascularisation Ingrowth as a site of predictor of visual outcome Retina 1996;16:190-5
8 Mauget-Faÿsse M, Mimoun G, Ruiz-Moreno JM,
Quaranta-El Maftouhi M, De Laey JJ, Postelmans L, et al Verteporfin
photodynamic therapy for choroidal neovascularisation associated with toxoplasma retinochoroiditis Retina 2006;26:396-403
9 Ben Yahia S, Herbort CP, Jenzeri S, Hmidi K, Attia S, Messaoud
R, et al Intravitreal bevacizumab (Avastin) as primary and rescue
treatment for choroidal neovascularization secondary to ocular toxoplasmosis International Ophthalmol 2008;28:311-6
10 Dhalla MS, Shah GK, Blinder KJ, Ryan EH Jr, Mittra RA, Tewari A Combined photodynamic therapy with verteporfin and intravitreal bevacizumab for choroidal neovascularization in age related macular degeneration Retina 2006;26:988-93
Department of Ophthalmology and Visual Sciences, The Chinese
University of Hong Kong, Prince of Wales Hospital, Hong Kong Special
Administrative Region, China
Correspondence to: Dr Rita Gangwani, Department of Ophthalmology
and Visual Sciences, Prince of Wales Hospital, Block B, Staff Quarters,
7th Floor, Shatin, NT, Hong Kong SAR E-mail: dr.rita_gangwani@
hotmail.com
Manuscript received: 29.12.08; Revision accepted: 30.01.10
Effectiveness of diode laser
trans-scleral cyclophotocoagulation in
patients following silicone oil-induced
ocular hypertension in Chinese eyes
Rita Gangwani, David T L Liu, Nathan Congdon,
Philip T H Lam, Vincent Y W Lee, Nancy S Y Yuen,
Dennis S C Lam
We evaluated the effectiveness of diode laser trans-scleral
cyclophotocoagulation (TSCPC) on intraocular pressure (IOP)
in nine patients having raised IOP following use of silicone
oil (SO) for retinal detachment (RD) surgery in a retrospective
observational case series Diode laser TSCPC was applied at a
power setting of 1.75 to 2.5 watts, for two sec with a maximum
of 30 applications The patients were followed up for 40 to 312
weeks The mean pre-laser IOP was 32.06 mm Hg (SD 7.32)
The mean post-laser IOP at one month, three months and six
months was 17.89 mm Hg (SD 8.23), 21.89 mm Hg (SD 8.16) and
21.67 mm Hg (SD 7.55) respectively The final IOP (at the last
follow-up) was 19.56 mm Hg (SD 7.85) (P=0.021) Seven of them
had undergone SO removal In our observation, effectiveness of
TSCPC in long-term control of SO-induced ocular hypertension was limited as compared to short-term control of IOP
Key words: Ocular hypertension, pars plana vitrectomy, silicone
oil, trans-scleral cyclophotocoagulation
Indian J Ophthalmol: 2011;59:64-66
DOI: 10.4103/0301-4738.73730 PMID: 21157080
Silicone oil (SO) is an indispensable tool for management
of complicated vitreoretinal (VR) problems like tractional retinal detachment (RD) or proliferative vitreoretinopathy (PVR) However, its usage may be associated with raised intraocular pressure (IOP) or SO-induced glaucoma in 5.9-48% of cases.[1-3] A few reports have shown diode laser trans-scleral cyclophotocoagulation (TSCPC) as an effective tool in controlling IOP in SO-induced glaucoma.[4,5] We intended to look for short-term and long-term IOP control following diode
laser TSCPC in Chinese eyes
Materials and Methods
Clinical records of nine patients who had undergone diode laser TSCPC for control of refractory SO-induced ocular hypertension (OHT) following RD surgery from January
2000 to December 2007 were reviewed Ethics committee approval was obtained Study parameters included primary VR diagnosis and surgery, chamber angle, anterior segment status, pre-laser IOP, post-laser IOP at one, three and six months, final IOP and number of laser sessions required
All patients underwent pars plana vitrectomy (PPV) using three-port technique Postoperative examinations were
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