Photodynamic therapy for choroidal metastasis from lung adenocarcinoma

To study the relationship between intraretinal optical coherence tomography (OCT) and fluorescein angiography (FA) findings in eyes with diabetic macular oedema (DMO). We carried out a retrospective observational case series. Thirty eyes with previously untreated DMO underwent FA and OCT. The same ETDRS template was overlaid on the FA images in order to compare OCT and FA. Transfoveal linear high-resolution OCT scans (at the 0- and 90-degree meridians) and FA pictures were compared according to the ETDRS rings. Six distinct patterns of intraretinal changes in OCT correlated with changes in FA: (a) focal angiographic leakage did not correspond to any obvious intraretinal abnormality in OCT in four eyes; (b) localized thickening of the outer nuclear layer in OCT corresponded to focal leaking microaneurysm (focal oedema) in FA in 11 eyes; (c) diffuse thickening of the outer nuclear layer in OCT corresponded to diffuse angiographic leakage in 21 eyes; (d) cystoid expansion of the outer nuclear layer was found in seven eyes with a petaloid angiographic pattern of leakage; (e) cystoid expansion of the inner nuclear layer was found in relation to honeycomb angiographic oedema in five eyes, and (f) serous detachment of the fovea in OCT did not correspond to any distinct finding in FA in four eyes. Intraretinal abnormalities found in OCT correlate systemically with changes in FA. Very early DMO morphological changes may be seen better with FA than with OCT. Serous detachment of the fovea is seen in OCT, but not in FA. The combination of OCT and FA is useful in facilitating understanding of the pathophysiological changes that occur in DMO.

Purpose: We present a case of choroidal metastatic tumors achieving a best corrected visual acuity of 20/20 after intravitreal injection of bevacizumab (Avastin) and focal laser photocoagulation.Method: Interventional case report.Results: A 68 y/o male has been diagnosed with pulmonary adenocarcinoma (T4N1M0) in December 2006, and had received surgical intervention, radiotherapy and chemotherapy. He visited our outpatient department in December 2009 and presented with blurred vision in his right eye. His best corrected visual acuity was 20/40. Fundus examination revealed multiple subretinal masses, light orange in color, superotemporal and inferonasal to the fovea, in the right eye. Optical coherence tomography scan showed marked subretinal fluid of the macula. A diagnosis of choroidal metastasis secondary to lung cancer was made. After discovering choroidal metastatic lesions, two sessions of intravitreal injection of bevacizumab and three sessions of focal laser photocoagulation were performed. After three months follow-up, his best corrected visual acuity regained 20/20. Scarring and flattening of choroidal lesions were noted on color fundus photography. Multiple hyperfluorescent spots without leakage were showed on fluorescein angiography. Regression of macular edema and serous detachment were evident on optical coherence tomography scan.Conclusion: For the patient with choroidal metastases who wants to preserve good visual acuity and better quality of remained life, intravitreal injection of bevacizumab plus focal laser photocoagulation may be considered. Longer follow-up period is needed for evaluation of efficacy and effectiveness of such treatment.

Central Serous Chorioretinopathy (CSCR) is a significant cause of vision impairment worldwide, with Photodynamic Therapy (PDT) emerging as a promising treatment strategy. The capability to precisely segment fluid regions in Optical Coherence Tomography (OCT) scans and predict the response to PDT treatment can substantially augment patient outcomes. This paper introduces a novel deep learning (DL) methodology for automated 3D segmentation of fluid regions in OCT scans, followed by a subsequent PDT response analysis for CSCR patients. Our approach utilizes the rich 3D contextual information from OCT scans to train a model that accurately delineates fluid regions. This model not only substantially reduces the time and effort required for segmentation but also offers a standardized technique, fostering further large-scale research studies. Additionally, by incorporating pre- and post-treatment OCT scans, our model is capable of predicting PDT response, hence enabling the formulation of personalized treatment strategies and optimized patient management. To validate our approach, we employed a robust dataset comprising 2,769 OCT scans (124 3D volumes), and the results obtained were significantly satisfactory, outperforming the current state-of-the-art methods. This research signifies an important milestone in the integration of DL advancements with practical clinical applications, propelling us a step closer towards improved management of CSCR. Furthermore, the methodologies and systems developed can be adapted and extrapolated to tackle similar challenges in the diagnosis and treatment of other retinal pathologies, favoring more comprehensive and personalized patient care.

Six-Week Outcomes after Pegaptanib

The objective of the study was to analyze optical coherence tomography (OCT) scan differences between patients with predominantly classic subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) treated with only photodynamic therapy (PDT) and patients treated with PDT combined with intravitreal triamcinolone acetonide (IVTA). In this prospective study, 61 patients were randomized to receive PDT (n = 30) or PDT combined with IVTA (n = 31). They were evaluated every 3 months with a refraction protocol for best-corrected visual acuity (VA) measured with Early Treatment Diabetic Retinopathy Study (ETDRS) charts, fluorescein angiography (FA), and OCT. When measuring foveal thickness on OCT scans, neuroretinal foveal thickness (NFT) was differentiated from outer high reflectivity band thickness (OHRBT). The main outcome measures were mean change in OCT measurements and correlation of VA and angiographic area of the lesion with OCT measurements. At the 12-month follow-up, the mean change in NFT was not significantly reduced (P = 0.9), but the mean change in OHRBT was significantly lower (P = 0.004) in the group of patients who received combined therapy. There was no correlation between final VA and NFT in either patient group (P = 0.2). The final VA was significantly worse in eyes with a thicker OHRBT (P = 0.04) in the group of patients treated with only PDT. There was no correlation between angiographic area and NFT and OHRBT in either patient group (P > 0.3). There was a statistically significant difference between the pre-treatment angiographic area of the lesion and VA at the 12-month follow-up in the combined therapy group (P = 0.01), and more eyes treated with only PDT presented with intraretinal fluid at the last follow-up (P = 0.01). Combined PDT+IVTA therapy was more effective than PDT alone at reducing OHRBT. This OCT measurement seems to be have a greater effect on VA than NFT.

PurposeTo analyze the individual value and the contribution of color fundus photography (CFP) and optical coherence tomography (OCT) in the screening of age-related macular degeneration (AMD) of an unselected population.MethodsCFP and OCT images of 15957 eyes of 8069 subjects older than 55 years, obtained during a population-based screening for AMD using a single diagnostic non-mydriatic imaging device, were analyzed by a blinded examiner. The two techniques were preliminary evaluated considering the dichotomous parameter "gradable/ungradable", then gradable images were classified. CFP were graded according to the standardized classification of AMD lesions. OCT images were also categorized considering the presence of signs of early/intermediate AMD, late AMD, or other retinal diseases. Another blinded operator re-graded 1978 randomly selected images (for both CFP and OCT), to assess test reproducibility.ResultsOf the 15957 eyes, 8356 CFP (52.4%) and 15594 (97.7%) OCT scans were gradable. Moreover, most of the eyes with ungradable CFP (7339, 96.6%) were gradable at OCT. AMD signs were revealed in 7.4% of gradable CFP and in 10.4% of gradable OCT images. Moreover, at OCT, AMD signs were found in 1110 (6.9%) eyes whose CFP were ungradable or without AMD (847 and 263 eyes, respectively). The inter-operator agreement was good for the gradable versus ungradable parameter, and optimal for the AMD grading parameter of CFP. The agreement was optimal for all OCT parameters.ConclusionsOCT provided gradable images in almost all examined eyes, compared to limited CFP efficiency. Moreover, OCT images allowed to detect more AMD eyes compared to gradable photos. OCT imaging appears to significantly improve the power of AMD screening in a general, unselected population, compared to CFP alone.

Aims:To compare the relative efficacy of photodynamic therapy (PDT), PDT associated with intravitreal triamcinolone (PDT–IT) and PDT associated with periocular triamcinolone (PDT–PT) for treatment of retinal angiomatous proliferation (RAP) stage...

Objective To study the effect of Transpupillary thermotherapy (TTT) on choroidal metastases. Methods Nine cases were enrolled in the study, male 2 and female 7 cases. Bilateral eyes were affected in 3 cases. The age of cases was 37-60yrs with averaged at 44.6 yrs. The visual acuity was ≤0.05 in 1 eye,0.06-0.2 in 2 eyes, 0.3-1.0 in 9 eyes. The metastatic tumor showed as a yellow-white flat lesions with retinal detachment in different extent on their surfaces. The number of the lesions was single in 2 eyes, 2 in 3 eyes, ≥3 in 7 eyes. The location of the lesions was at the posterior pole in 4 eyes, at the macular and its surrounding in 6eyes, around the disc in 2 eyes. The primary tumor was located at the lung and bronchus in 5 cases, at the breast in 3 cases, at the large intestine in 1 case. Indirect ophthalmoscope, fundus fluorescein angiography (FFA), ultrasound (A, B) and optical coherence tomography (OCT) were used for exam. Treatment was delivered via slit lamp using an 810 nm diode laser (Iridex) with 250 to 1000 mw, with average 510 mw; the spot size was 2.0-3.0mm, duration ranged from 60 s to 120 s. The lesions just turned into pale-white appearance after treatment. The number of laser spot was 2-6 with average 3.7 spots. The session for management was 1-6 with average 2.9. The interval between 2 sessions was 1-3 months. The lesion just underlying the fovea was combined with photodynamic therapy (visudyne) in 1 case. Results The lesions turned into a flat scar with pigmentation and fluid absorption after treatment. The visual acuity was improved in 2 cases, unchanged in 4 cases, declined in 6 cases. The visual decline was caused by the lesion underneath the fovea and secondary macular lesions. The fellow-up was 1-32 months with average 9.6 months. Conclusions TTT is rational for choroidal metastatic lesions and has definite effect with low cost. It is worth doing in the future. Early discovering and managing the lesions helped to protect the visual acuity of the patients. Key words: Transpupillary thermotherapy; Choroidal metastasis; Photodynamic therapy

Assessment of Artifacts and Reproducibility across Spectral- and Time-Domain Optical Coherence Tomography Devices

Photodynamic Therapy for Choroidal Metastasis in 8 Cases

A 34-year-old gentleman misdiagnosed with ocular tuberculosis was later found to have choroidal metastases from lung adenocarcinoma. This case highlights the importance of multimodal imaging and systemic evaluation in differentiating intraocular malignancies from inflammatory conditions, especially in tuberculosis endemic areas, to ensure timely diagnosis and treatment of the metastatic disease. Case A 34-year-old Asian Indian gentleman presented with progressive vision loss in both eyes for the past 2 months. He was diagnosed elsewhere with bilateral tubercular (TB) choroidal granulomas, started on antitubercular therapy (ATT) and steroids, without any clinical improvement. Laboratory test reports already available with the patient revealed a Mantoux of 10 × 12 mm and left lung consolidation with pleural effusion on computed tomography (CT) chest. At presentation, his visual acuity was 6/12 in the right eye (OD) and 6/60 in the left eye (OS). Fundus examination OU revealed elevated creamy colored choroidal lesions at the posterior pole, choroidal striae, and overlying pigmentary changes [Fig. 1a and b]. In addition, left fundus showed an edematous optic disc. Fundus autofluorescence (FAF) revealed mixed hypo and hyper autofluorescence. Optical coherence tomography (OCT) through the lesions showed choroidal thickening with a lumpy bumpy contour and subretinal fluid [Fig. 1c and d].Figure 1: (a and b) Composite fundus photographs of both eyes reveal large, elevated, creamy-colored lesions at the posterior pole, associated with choroidal folds and areas of altered retinal pigmentation. (c and d) Fundus autofluorescence shows mottled areas of hyper- and hypoautofluorescence. OCT scans through the lesions show diffuse choroidal thickening with a characteristic lumpy-bumpy choroidal contour, presence of subretinal fluid, and scattered hyperreflective fociWhat will you do next? Continue treatment with ATT and oral steroids. Start empirical immunosuppressive therapy. Advise whole body 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to identify primary focus of inflammation/infection and metastasis. Plan a diagnostic vitrectomy and do a choroidal biopsy. Findings and Management PET-CT scan revealed locally advanced FDG avid primary tumor in the left lung upper lobe with multiple metastases to left supraclavicular, mediastinal, and bilateral hilar lymph nodes, right lung, and skeletal system [Fig. 2]. On retrospective questioning, the patient reported intermittent fever, chest pain, dyspnea, and productive cough over the past 3 months, with severe backache and loss of appetite and weight for the past 1 month. He was immediately referred to a pulmonologist. Lung biopsy confirmed stage 4 lung adenocarcinoma. ATT and steroids were stopped, and systemic chemotherapy was initiated.Figure 2: Whole-body FDG PET-CT revealed a primary hypermetabolic lesion in the left lung upper lobe, with FDG avid left supraclavicular and paraaortic lymph nodes, bilateral hilar nodal involvement, right lung metastases, left pleural metastases, and multiple FDG avid sclerotic skeletal metastases involving the sternum, lumbosacral spine, bilateral pelvic bones, and proximal femursDiagnosis Advanced Lung Cancer with Choroidal metastasis. Correct answer C. Advise whole body 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to identify primary focus of inflammation/infection and metastasis. Discussion Intraocular malignancies like choroidal metastases can closely mimic inflammatory conditions such as tubercular granulomas, posing significant diagnostic challenges. Distinguishing between them is critical, particularly in TB-endemic regions. Equivocal or positive Mantoux test and similar radiological chest findings may mislead the diagnosis. Choroidal metastases and tubercular granulomas can present with similar fundus appearances but have distinct OCT and autofluorescence features. On OCT, metastases show a lumpy-bumpy choroidal surface, internal hyperreflective foci, and overlying RPE disruption with subretinal fluid. In contrast, tubercular granulomas appear as smooth, dome-shaped, hypo-reflective choroidal masses with perilesional fluid.[1,2] FAF in metastasis typically shows mottled areas of hyper and hypo AF often described as a “leopard-spot pattern” due to RPE irregularity and damage.[3] A high index of suspicion for metastasis should be kept when imaging reveals bumpy choroidal features, prompting timely systemic evaluation. Multimodal ocular imaging and FDG PET-CT is crucial for early identification and appropriate management of metastatic disease. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

Exudative age-related macular degeneration (ARMD) is the leading cause for severe visual loss in the elderly. A series of clinical trials has established the efficacy of laser photocoagulation and photodynamic therapy (PDT) in special subgroups of patients with exudative ARMD. We analyzed the fluorescein and indocyanine green angiograms (ICG) of patients with exudative ARMD to characterize the nature of the CNV in order to estimate the percentage of patients amenable for one of the therapies. Patients with acute symptoms related to exudative ARMD were recruited for the study. All patients underwent fluorescein and ICG angiography. We analyzed the type of the CNV (classic, occult, or mixed) and location relative to the fovea from the fluorescein angiograms. Additionally, we recorded the presence of a visible capillary network in the early ICG angiograms, as well as hot spots and plaque hyperfluorescence in the late ICG angiographic frames. We included 191 patients aged 53-92 years in the study. The angiograms revealed in 17 (9%) patients classic CNV (12 subfoveal), in 114 (60%) occult CNV, and in 60 (31%) mixed CNV. Of these 19 had a classic component >50%. In the early ICG angiograms a capillary network was visible in 50 eyes with occult CNV. Hot spots were present in 29 eyes and a hyperfluorescent plaque in 54 eyes. In total, only 18% of eyes included in our study were eligible for laser photocoagulation or for photodynamic therapy (PDT). These numbers highlight the deficiencies of current treatment modalities for exudative ARMD. For this reason, alternative treatment should be further investigated to offer better treatment to patients with exudative ARMD.

Intravitreal Triamcinolone and PDT

Purpose To define the specific clinical characteristics of uveal metastases from carcinoids and the minimal invasive therapeutic approach.Methods Four consecutive cases of symptomatic uveal metastases from carcinoid tumors were included in this prospective analysis. Each patient underwent full ophthalmological examination, including A‐B scan ultrasonography (US), fluorescein (FA) and indocyanine green angiography (IGA), and optical coherence tomography (OCT) at baseline and during follow‐up. Follow‐up examination was performed at 1 month and every 3 months thereafter.Results Mean follow‐up was 17±6 months. Tree patients were affected by choroidal metastases (75%) whereas one patients by iris metastasis (25%). Choroidal metastases were ipo‐pigmented, mainly located at the posterior pole and characterized by medium internal reflectivity at US, prominent vascular net at ICG and perilesional serous retinal detachment at OCT. Each patient was treated by photodynamic therapy (PDT) with verteporfine as sole focal treatment. Mean PDT sessions were 1.6 (1‐3 sessions). Two patients (50%) showed clinical regression of the treated lesions, whereas in the others two patients (50%) tumor size remained stable during follow‐up. Subretinal fluid resolved in all choroidal lesions. BCVA increased in three patients (75%) and remained unchanged in one patient (25%).Conclusion Uveal metastases from carcinoids are characteristically ipo‐pigmented and highly vascularized. Photodynamic therapy appears to be an effective, safe and well‐tolerated treatment option for the management these metastases.

Choroidal metastasis (CM) are more and more spreading type of eye's neoplasma. The frequency of CM is increasing with prolonging of cancer patients' life. And it makes worse the quality of their life because blindness. Photodynamic therapy (PDT) is very delicate modality, which can be used for this purpose. The aim of this work was to open the possibility and to determine the efficacy of photodynamic therapy (PDT) in the treatment of patients with CM. PDT was performed simultaneously with standard chemotherapy in 8 oncological patients with CM. We used photosensitizer Photosens in doses of 0.3 mg/kg and light doses 150 J/cm² (675 nm). PDT was performed in the some stances. Its are ranged from 7 to 10. Complete tumor regression was achieved in 6 cases. The high retina ablation was developed in one case. And in one case effect was not complete: tumor size reduced from 5 mm to 3 mm of thickness. We didn't notice any recurrence for 6-18 months follow-up. PDT is modality that could to be used in the in the combined treatment of the CM.