Intravitreal Use Research Articles

Intravitreal bevacizumab (Avastin) vs. ranibizumab (Lucentis) for the treatment of age-related macular degeneration: a systematic review

We conducted a systematic review to evaluate whether the existing evidence justifies the intravitreal use of bevacizumab in comparison to ranibizumab in age-related macular degeneration. Compared with photodynamic therapy, bevacizumab shows a relative improvement in visual acuity that is of similar size as in the comparison of ranibizumab with photodynamic therapy (relative improvement from 30 to 35%). However, this finding is based on one randomized controlled trial including less than 50 patients treated with bevacizumab. Also, nothing is known about long-term (>12 months) improvements in visual acuity and optimal treatment intervals for bevacizumab.Regarding safety, the published literature indicates that ocular and systemic adverse effects are less frequent under bevacizumab than ranibizumab treatment. But the validity of this finding is strongly limited by inadequate reporting, an unsystematic evaluation of adverse effects and short follow-up times in studies evaluating bevacizumab. Given the lack of controlled data, the widespread off-label use of bevacizumab is not justified in clinical practice. On the other hand, a major challenge in the management of patients who require repeated antivascular endothelial growth factor injections is the high cost of ranibizumab. This dilemma underlines the need for head-to-head studies comparing both vascular endothelial growth factor antibodies, or, at least, well conducted randomized controlled trials evaluating intravitreal bevacizumab.

Intravitreal bevacizumab vs triamcinolone acetonide for macular oedema due to central retinal vein occlusion

Intravitreal bevacizumab vs triamcinolone acetonide for macular oedema due to central retinal vein occlusion

Pegaptanib sodium for acute retinal necrosis‐induced macular oedema

35-year-old immunocompromisedwoman with umbilical cordblood transplantation for adult lym-phoma presented with a 2-week his-tory of redness and blurred vision inboth eyes following initial herpes zos-ter encephalitis. Examination revealedvitritis, retinal whitening (Fig. 1), vas-culitis and optic nerve head oedema.Best-corrected visual acuity (BCVA)was 20⁄40 right eye (OD) and 20⁄60left eye (OS). Optical coherencetomography (OCT) showed no cystoidmacular oedema (CMO).Polymerase chain reaction testing ofthe aqueous fluid revealed varicellazoster virus and the patient was diag-nosed with bilateral acute retinalnecrosis (ARN).The retinitis was controlled withoral valacyclovir and intravitrealfoscarnet (2.4 mg) every 3 days,followed 10 days later by pars-planavitrectomy and endolaser in both eyes.BCVA improved to 20⁄25 OD and20⁄20 OS with no signs of ocularinflammation.One month later, the clinical coursewas complicated by severe CMO inthe right eye with a central fovealthickness of 410 lm and a BCVA of20⁄60, with no signs of ocular inflam-mation.After discussion of periocularand⁄or intravitreal use of steroids, thepatient refused to have this treatmentbecause of his family history of glau-coma and the increased potential riskof cataract formation. After a lengthydiscussion of the potential risks andbenefits of off-label intravitreal bev-acizumab or intravitreal pegaptanibsodium use, the patient requestedintravitreal pegaptanib sodium.An intravitreal injection of pegap-tanib sodium (Macugen; Eyetech⁄Pfizer, New York, NY, USA) wasadministered in the right eye withoutcomplication. Two weeks after injec-tion, OCT demonstrated a markedimprovement of the macular oedema,with a central foveal thickness of 197lm and a BCVA of 20⁄25 in theright eye (Fig. 2). Three months aftertreatment, there was no ocularinflammation and the OCT revealedno CMO.Acute retinal necrosis (ARN) syn-drome is a distinct infectious retinitiscaused by members of the herpes virusfamily that can impair vision. Itoccurs mostly in adult patients,especially those severely immunocom-promised, in association with a reacti-vation of a herpes virus infection (Lauet al. 2007).Active vasculitis is characterized byvascular sheathing and perivascularintraretinal haemorrhages. Vesselobstruction affects the central retinalartery more often than the vein and isa contributing factor to severe visionloss (Chang & Young 2007). Retinalischaemia is the major trigger ofvascular endothelial growth factor(VEGF) over-expression; it can leadto chronic inflammation and thedevelopment of retinal neovasculari-zation (Nishijima et al. 2007).Active inflammation secondary toARN progresses despite antiviraltreatment. High-dose systemic cortico-steroid therapy improves intraocularinflammation and improves vitreousopacity (Chang & Young 2007).However, some patients have CMOthat is resistant or non-responsive tosteroids.Bevacizumab is an anti-VEGFmonoclonal antibody that blocksall VEGF isoforms. Intravitrealbevacizumab has been used success-fully for the treatment of uveitic-resistant CMO (Cordero Coma et al.2007) with short-term improvementin BCVA and decreased OCT retinalthickness in a considerable propor-tion of patients. However, VEGF-Ais a survival factor for retinal neu-rons and a critical neuroprotectantduring the adaptative response toischaemic injury (Nishijima et al.2007).Pegaptanib sodium is a selectiveRNA aptamer that inhibits VEGF-165, the VEGF isoform primarilyresponsible for pathological ocularneovascularization and vascular per-meability, while sparing the physiolog-ical isoform VEGF-121. Retrospectivedata suggest that pegaptanib may pro-vide therapeutic benefit for patientswith diabetic macular oedema, prolif-erative diabetic retinopathy and reti-nal vein occlusion (Ng & Adamis2006).

Injeção intravítrea de bevacizumab e gás C3F8 para tratamento da hemorragia submacular secundária a degeneração macular relacionada à idade: relato de casos

The purpose of this case series is to describe if the intravitreal use of bevacizumab and perfluoropropane gas (C3F8) would be beneficial to the displacement of subretinal hemorrhage in patients with age-related macular degeneration (AMD). A retrospective study of 5 eyes that received concurrent intravitreal injection of bevacizumab and C3F8 was performed. The results were graded according to blood displacement under the fovea, best final visual acuity and intraoperative complications. At the initial presentation, mean age of patients was 72.6 +/- 8.9 years-old and duration of symptoms was 13 +/- 9.7 days. From the 5 patients, 3 (60%) were male and 2 (40%) female. The success of submacular hemorrhage full displacement was achieved in 4 patients. The mean preoperative visual acuity (VA) was 1.12 +/- 0.34 logMAR and the mean postoperative VA was 0.92 +/- 0.4 logMAR. No cases of retinal detachment, endophthalmitis, vitreous hemorrhage, uveitis, cataracts and increased intraocular pressure were noted during the follow-up period. Intravitreal bevacizumab and C3F8 injection, associated to prone position can be a valuable therapeutic option for eyes with neovascular age-related macular degeneration and subretinal hemorrhage to the blood displacement out of the foveal area.

Progressive indocyanine green toxicity.

To report a case of progressive indocyanine green (ICG) toxicity that occurred after pars plana vitrectomy for an epiretinal membrane. The patient underwent pars plana vitrectomy for an epiretinal membrane. After fluid--air exchange, ICG was spread only on the macular area, and air-fluid exchange was performed immediately. The epiretinal membrane was removed with serrated forceps. Although the preoperative visual acuity was 0.6, it was 0.2 in the first postoperative month, and fundus fluorescein angiography revealed retinal pigment epithelium atrophy in the macula that matched the area of ICG application. Visual acuity in the fourth postoperative month was 0.1, and there was optic atrophy. During the sixth postoperative month, visual acuity was hand movements, and there were multiple retinal holes in the macula and sclerosis of the arteries. This study demonstrates that intravitreal use of ICG might have toxic effects on the retina. Unnecessary use of ICG should be avoided, and care must be taken when using intravitreal ICG.

INFLIXIMAB STABILITY AFTER RECONSTITUTION, DILUTION, AND STORAGE UNDER REFRIGERATION

The purpose of this study was to investigate the stability of reconstituted infliximab solutions and determine whether infliximab is suitable for compounding for potential intravitreal use. Infliximab was reconstituted, and the solution was aliquoted and stored refrigerated. On each day of testing, an aliquot was serially diluted to concentrations ranging from 50,000 pg/mL to 69 pg/mL. Each dilution was assayed by microsphere immunoassay daily for 5 days and weekly for a total of 6 weeks. The outcome measure was median fluorescence intensity measured by dual laser flow analysis of fluorochrome-labeled secondary antibodies to infliximab bound to tumor necrosis factor-alpha-coated microspheres. There was an increasing median fluorescence intensity for increasing infliximab concentration in a sigmoidal dose-response curve with a variable slope that was equivalent for each time point. Each respective concentration of infliximab showed nearly equivalent median fluorescence intensity for every time point over the 6-week period. The authors found that the immunoreactivity of 2 different concentrations of infliximab stored at 4 degrees C over a 6-week period remained stable. Infliximab is suitable for compounding and could be a cost-effective intravitreal medication for use in clinical practice if further study supports its safety and efficacy.

Anti-Vascular Endothelial Growth Factor Activity in the Bevacizumab and Triamcinolone Acetonide Combination for Intravitreal Use

To find out if the combination for intravitreal use of the antibody bevacizumab (AvastinTM; Genentech, Inc., San Francisco, CA) and triamcinolone acetonide (TA) (Kenacort; Bristol-Myers Squibb, Anagni, Italy) could affect over time the anti -vascular endothelial growth factor (VEGF) activity of bevacizumab. Two different combined preparations were obtained, drawing up together 1.25 mg/0.05 mL of bevacizumab and 2 mg/0.05 mL (B+TA(2mg)) or 4 mg/0.05 mL (B+TA(4mg)) of TA into insulin syringes with 29-G needle. Control preparations were obtained with bevacizumab and an injectable solution (B). The syringes were stored refrigerated at 4 degrees C. The bevacizumab concentration was measured, through its binding to VEGF-165 isoform, at 48 hours and at 1 week. No preparations showed statistically significant changes in bevacizumab concentration with time (p=0.74 for B+T(2mg), p=0.92 for B+T(4mg), p=0.57 for B). The B+TA(2mg) preparations showed a larger percentage of degradation of bevacizumab than the B+TA(4mg) preparations (28.4% versus 17.6% at 48 hours; 26.4% versus 18% at 1 week). The B control preparations showed the lowest drug degradation: 9.6% at 48 hours and 14.8% at 1 week. After storage at 4 degrees C for 48 hours and 1 week, the combined preparations showed a larger reduction in bevacizumab concentration than the control preparations. No significant change was observed with the length of storage. The preparations obtained mixing 4 mg/0.05 mL of TA and 1.25 mg/0.05 mL of bevacizumab maintained the highest anti-VEGF activity over time.

Safety evaluation of intravitreal use of a beta2‐agonist in rabbit eyes

Abstract Purpose There is no known information on the use and safety of a long‐acting beta‐agonist, such as Clenbuterol when administered by intravitreal injection. Therefore, it is appropriate to perform this intravitreal injection in an animal model prior to start with a human experiment. The aim is to investigate the safety of an intravitreal injection of the beta2‐agonist Clenbuterol in rabbit eyes. This study is in preparation of using of this molecule in human eyes. That trial will be a monocentric, academic (investigator driven) trial to investigate the safety and efficacy of an intravitreal beta2‐agonist in patients with persistent subfoveal fluid after retinal detachment surgery. Approval of the ethics committee for the human trial has already been obtained, pending a re‐evaluation after the results of the animal study will be known. Methods 5 rabbits will receive an injection of 0.1 ml solution containing 0.08µg Clenbuterol in one eye and an injection of 0.1ml NaCl 0.9% in the other eye. Since the volume of an adult rabbit eye is only one third of an adult human eye, the achieved concentration with be three time the concentration suggested for use in a human eye.

Intravitreal bevacizumab vs triamcinolone acetonide for macular oedema due to central retinal vein occlusion

To compare the effect of intravitreal bevacizumab vs intravitreal triamcinolone for the treatment of non-ischaemic central retinal vein occlusion (CRVO). The comparative nonrandomized retrospective clinical interventional study included 72 patients with non-ischaemic CRVO, divided into a bevacizumab group of 30 patients (1.25 mg bevacizumab) and a triamcinolone group of 42 patients (4.0 mg triamcinolone). All patients were consecutively included. At baseline, both study groups did not vary significantly in visual acuity, macular thickness, and duration of symptoms (191+/-300 days vs 222+/-256 days). The minimal follow-up was 3 months (mean: 7.8+/-4.3 months; range: 3-12 months). During follow-up, 1.3+/-0.4 re-injections of the triamcinolone group (range:1-2 injections) and 2.7+/-1.8 re-injections of bevacizumab (range:1-6 injections) were administered. In both study groups, the mean visual acuity increased significantly (P<0.001) from baseline during follow-up. The differences in gain in visual acuity were not statistically significant (P>0.40) between both study groups at any time during follow-up. The mean macular thickness decreased significantly (P<0.001) in both study groups, with the reduction being significantly (P=0.006) more pronounced in the triamcinolone group. Intraocular pressure increased significantly (P<0.001) in the triamcinolone group. In long-standing non-ischaemic CRVO, intravitreal bevacizumab and intravitreal triamcinolone are both associated with a comparable gain in visual acuity. The reduction in macular oedema was more marked in the triamcinolone group. In view of the potential complications of intravitreal triamcinolone in terms of intraocular pressure rise and cataractogenesis, bevacizumab may be preferred compared with triamcinolone for intravitreal use in non-ischaemic CRVO.

Comparative toxicity of 4 commonly used intravitreal corticosteroids on rat retina

Objective: To investigate the effects of 4 commonly used steroids (dexamethasone, triamcinolone, betamethasone, and methylprednisolone) on 50 retinas of 25 adult pigmented rats. Study Design: Experimental animal study. Participants: Twenty-five pigmented Long-Evans male rats. Methods: Each steroid drug with 2 different doses (0.025 mL and 0.050 mL) was injected into the vitreous of each eye of 5 rats. The low drug dose was injected into the right eye and the high dose was injected into the left eye. Ten eyes of 5 randomly selected rats were used as a control group and intravitreal saline was injected into these eyes. Oxidative damage and intrinsic antioxidative capacity were determined by measuring retinal malondialdehyde (MDA) and glutathione (GSH) levels, respectively. Results: No statistically meaningful difference was observed in retinal GSH and MDA measurements in the lowand high-dose triamcinolone (1 and 2 mg), low-dose betamethasone (0.075 mg), and low-dose dexamethasone (0.1 mg) groups, compared with the control group. Both doses of methylprednisolone (1.6 mg and 3.2 mg), high-dose betamethasone (0.15 mg), and high-dose dexamethasone (0.2 mg) markedly altered retinal GSH and MDA levels. Conclusions: The results of our study show that the toxicity of triamcinolone is not evident even in high doses. It may be used safely. We also suggest that intravitreal use of low doses of betamethasone and dexamethasone is safer than higher doses of these drugs and both doses of methylprednisolone.

TACHYPHYLAXIS AFTER INTRAVITREAL BEVACIZUMAB FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION

To describe tachyphylaxis to intravitreal bevacizumab (IVB) in patients with exudative age-related macular degeneration (AMD). We retrospectively reviewed the records of 59 consecutive patients treated with IVB at the National Eye Institute over a 14-month period and identified cases demonstrating loss of treatment efficacy as revealed by spectral domain optical coherence tomography. We defined tachyphylaxis as a loss of therapeutic response to IVB 28 +/- 7 days after administration in an eye that had previously demonstrated a therapeutic response in the same time interval. Five patients (six eyes) were identified as developing tachyphylaxis after repeated treatment with IVB. High-dose IVB (2.50 mg) did not restore therapeutic response in these patients. Bilateral tachyphylaxis to IVB was seen after an episode of unilateral postinjection anterior uveitis. After the first treatment of IVB, the median time taken to develop tachyphylaxis was 100 weeks (range: 31-128 weeks), and the median number of IVB treatments to the development of tachyphylaxis was 8 treatments (range: 5-10 treatments). Tachyphylaxis can occur after long-term intravitreal use of bevacizumab in patients with AMD. The precise mechanism of tachyphylaxis is unclear, but both local and/or systemic factors may be involved.

Current trends of intravitreal steroid use in retinal diseases

The aim of this article is to provide a current update on the use of intravitreal steroids as a treatment option for a variety of retinal diseases and to review the current literature in regard to their properties, safety, and adverse effects.

Skin rash associated with intravitreal bevacizumab in a patient with macular choroidal neovascularization

The purpose of this observational case report is to describe a case of skin rash after intravitreal use of bevacizumab. A 50-year-old man with choroidal neovascularization in the right eye due to age-related macular degeneration was treated with three intravitreal injections of bevacizumab. Twelve days after the first injection, the patient developed a maculopapular rash on his forehead and on both temporal regions around his eyes. The rash disappeared eight days after treatment with topical corticosteroids. A skin rash with the same distribution reappeared 14 days after the second and 10 days after the third injection. Similarly, it disappeared five and seven days after the use of the same treatment. The follow-up period was 15 months after the third injection. During the follow-up period the rash did not reappear. This case report may initiate further investigation of similar cases to support this observation, as there are a lack of reports of skin rash after intravitreal administration of bevacizumab.

Efficacy and safety of one intravitreal injection of bevacizumab in diabetic macular oedema

To assess the efficacy, duration of effect and safety of one intravitreal injection of bevacizumab in diabetic macular oedema (DMO). Bevacizumab (1 mg/0.04 ml) was injected intravitreally into eyes with DMO (29 with and nine without previous treatments). Best corrected visual acuity (BCVA), intraocular pressure and central retinal thickness (CRT) were measured; slit-lamp examination, macular biomicroscopy, optical coherence tomography and fluorescein angiography were performed before and at 2-4, 8 and 12 weeks post-injection. Best corrected VA and CRT were analysed in both groups. In the non-pretreated group, mean BCVA improved from 0.76 +/- 0.33 (baseline) to 0.57 +/- 0.30 and 0.54 +/- 0.27 at 2-4 weeks and 8 weeks post-injection, respectively (p = 0.02, p = 0.014, paired t-test). Mean CRT decreased from 632.4 +/- 196.0 microm (baseline) to 392.3 +/- 113.6 microm and 370.4 +/- 141.7 microm at the same time-points, respectively (p = 0.01, p = 0.01). There was no difference in BCVA or CRT at 12 weeks. In the pretreated group, mean BCVA improved from 0.62 +/- 0.30 (baseline) to 0.53 +/- 0.33 at 2-4 weeks post-injection (p = 0.01), and mean CRT decreased from 583.9 +/- 180.7 microm (baseline) to 404.1 +/- 197.9 microm at 2-4 weeks post-injection (p < 0.001). Mean BCVA was unchanged at 8 weeks and 12 weeks post-injection, although mean CRT remained lower at 8 weeks (p = 0.004). No ocular or systemic side-effects developed during follow-up. One intravitreal injection of bevacizumab for DMO seems to be effective and safe in both eyes that have been treated previously and eyes that have not. The therapeutic effect is temporary and repeat treatment may be needed.

Intravitreal bevacizumab for vitreous hemorrhage

Abstract Purpose Vitreous hemorrage is one of the major complications of ischemic retinopathies such as diabetic retinopathy. Our purpose was to describe the clinical outcome of patients who underwent a less invasive intervention than vitrectomy for therapy of persisting vitreous hemorrage Methods Our clinical interventional case series study included 10 patients (n=11 eyes) who presented with vitreous hemorrage due to proliferative diabetic retinopathy (n=10 eyes)or ischemic retinal vein occlusions (n=1). The hemorrage had persisted for at least 3 months. Mean age was 62,1+/‐14,5 years (median 58.4 years; range 45.8‐90.8 years) and mean visual acuity was 1,65+/‐0.97 logMAR. The mean intraocular pressure was 14.6+/‐3.6 mm Hg. All eyes received an intravitreal injection of 1.25 mg bevacizumab, which was repeated in 2 eyes (17%). All patients were fully informed about the experimental character of the treatment and signed an informed consent. Results At the end of follow‐up at 3.9+/‐2.3 months (range 1‐6 months) after the first injection, the vitreous hemorrage had cleared without any further intervention in all but 1 (9%) eye. Visual acuity improved significantly (p=0.02) from 1.65+/‐0.97 logMAR to 0.98+/‐0.67 logMAR. The intraocular pressure remained in the normal range (mean 14.6+/‐3.5 mm Hg) with no significant difference to the baseline values (p=0.94). We did not observe any sign of intraocular inflammation or other changes that could be regardesd as side‐effects of the intravitreal injecion. 4 (36%) eyes underwent panretinal laser coagulation after clearing of the vitreous hemorrage. Conclusion The present study may suggest to extend the intravitreal use of bevacizumab to persisting vitreous hemorrage due to ischemic retinopathies.

Netzhautablösung im Kindesalter: Differenzialdiagnose und aktuelle Therapieoptionen

The number of retinal detachments in children is very low in comparison to the number of retinal detachments in adults, only 3.2 - 6.6% occur in children. The main predisposing factors are trauma, associated conditions, myopia and retinopathy of prematurity (ROP) i. e., stage 4 and 5 and late stage of ROP. Furthermore, retinal detachment in children can be idiopathic. These eyes are not associated with any identified ocular or systemic comorbidity. Associated conditions include hereditary vitreoretinal disorders (e. g., morbus Stickler, X-linked juvenile retinoschisis, Marfan syndrome, familiär exsudative vitreoretinopathy), malformations (e. g., persistent hyperplastic primary vitreous, coloboma) and retinal detachment following cataract surgery. In a few cases retinal detachment is caused by uveitis and by Coats disease. Delayed presentation and proliferative vitreoretinopathy are a common problem and in most eyes primary pars plana vitrectomy is necessary. It is important to perform consequent postoperative follow-up. The functional and anatomic outcomes of retinal detachment in children are less successful than in adults. Further surgical innovations and aetiology-specific treatment strategies are required to improve the outcome in this group. Recent results show that the intravitreal use of VEGF inhibitors to treat proliferative retinopathy (ROP) in children is effective, but we need further information about safety and side-effects.

Equine special edition of veterinary ophthalmology

It has been just over three years since my textbook Equine Ophthalmology was published. In the preface to this textbook, I mentioned that the field of equine ophthalmology lagged behind in science compared to that in other species. I was also concerned that clinicians practicing equine ophthalmology did not frequently use specific equine evidence-based information, but instead extensively ‘borrowed’ knowledge from ophthalmology of dog, cats, and humans. In fact, I challenged veterinary ophthalmologists to do research and report their findings on equine ophthalmology so that we will advance this discipline. This equine special edition of Veterinary Ophthalmology demonstrates that we are meeting this challenge. However, much more work is needed regarding characterization of specific equine diseases and the development of effective, safe, and practical treatments. I have asked preeminent veterinary immunologists, Drs Connie Deeg and Andy Matthew, to review the immuno-pathogenesis on two of the most common and vision threatening diseases in horses: equine recurrent uveitis and keratitis. Dr Connie Deeg, from Munich, has reviewed her research and theories on the pathogenesis of equine recurrent uveitis. Andy Matthews, from Scotland, has provided a comprehensive review of the ocular surface immunology and how this information pertains to equine ocular surface disease. Additionally, in this special edition, there are reports on innovative diagnostic procedures [fluorescein angiography (JM Molleda et al.) and orbital MRI imaging (K Barnett et al.)]. We have included reports of innovative treatments, including safety of intravitreal triamcinolone (NY Yi et al.) and use of photodynamic therapy for squamous cell carcinoma (E Giuliano et al.). Finally, we have two very interesting and well-described case reports of ocular neoplasms [epibulbar melanoma (R McMullen et al.) and lymphoma (S Germann et al.)]. These articles are a great start, but we need much more research into equine ophthalmology, especially studies that provide information to help in the diagnosis and treatment of equine ocular disease by primary care equine veterinarians. Methods for definitive diagnoses and practical treatment of equine ocular disorders remain elusive, in general. In addition, our understanding of genetic ocular disorders and how to prevent them is also in its infancy. To facilitate and promote equine ophthalmology research, Dr Dennis Brooks and I have organized a group called the International Equine Ophthalmology Consortium (IEOC). The purpose of the IEOC is to advance the science of equine ophthalmology and to improve care of our equine patients. Specifically, the IEOC's goals are to promote the sharing of knowledge by organizing annual international meetings of interested equine ophthalmology clinician scientists; organize controlled multicenter clinical trials/studies among participating institutions and practices; organize and promote sharing of resources to perform multicenter collaborative research projects; develop specific research cores within participating member practices/institutions to attract funding for research and clinical studies from industry, private, and granting organizations (governmental and private); and promote the sharing of case material, innovative treatment, and knowledge between academic institutions and private practices with interest in equine ophthalmology. Recently an AAEP administered list-serve has been created to assist in communications with IEOC. Please see the IEOC website <http://web.mac.com/briangilger/IEOC/Mission.html> or contact me <[email protected]> if you have questions or would like to participate in this group. As an example of the value of such a group, the IEOC participants were recently asked to list their top five ‘problems’ in equine ophthalmology – that is, those diseases needing more research in the coming years. The most frequent disease mentioned was fungal keratitis (67% of responders), equine recurrent uveitis (47%), glaucoma (33%), nonulcerative keratitis (33%), ocular and periocular SCC (20%) and melting corneal ulcers (20%). Although many other diseases were mentioned, study of these six ocular diseases is definitely needed in the near future.

Estudo do tratamento do edema macular difuso do diabético com triancinolona intravítrea e fotocoagulação

To assess the efficacy of intravitreal use of triamcinolone acetonide combined with laser photocoagulation for the treatment of diffuse diabetic macular edema and to compare it with the separate use of each treatment. After systemic clinical control, thirty patients with diffuse diabetic macular edema were divided into 3 treatment groups: (1) macular grid photocoagulation; (2) intravitreal injection of 4 mg of triamcinolone acetonide; (3) combination of the two previous therapies. Follow-up was scheduled at predetermined intervals of one day, one week and monthly until completion of six months. The following parameters were analyzed: LogMAR best corrected visual acuity, central macular thickness, total macular volume and intraocular pressure. Grid photocoagulation did not significantly reduce the central macular thickness or the total macular volume. On the other hand, this reduction was statistically significant in the other two groups. All groups improved their mean visual acuity, however, the group that received both treatments had a higher percentage of patients that gained 10 or more letters. The simultaneous administration of grid photocoagulation with intravitreal triamcinolone can be considered an option for the treatment of diffuse diabetic macular edema.

Intravitreal bevacizumab for vitreous haemorrhage

Purpose Vitreous hemorrage is one of the major complications of ischemic retinopathies such as diabetic retinopathy. Our purpose was to describe the clinical outcome of patients who underwent a less invasive intervention than vitrectomy for therapy of persisting vitreous hemorrage Methods Our clinical interventional case series study included 10 patients (n=11 eyes) who presented with vitreous hemorrage due to proliferative diabetic retinopathy (n=10 eyes)or ischemic retinal vein occlusions (n=1). The hemorrage had persisted for at least 3 months. Mean age was 62,1+/-14,5 years (median 58.4 years; range 45.8-90.8 years) and mean visual acuity was 1,65+/-0.97 logMAR. The mean intraocular pressure was 14.6+/-3.6 mm Hg. All eyes received an intravitreal injection of 1.25 mg bevacizumab, which was repeated in 2 eyes (17%). All patients were fully informed about the experimental character of the treatment and signed an informed consent. Results At the end of follow-up at 3.9+/-2.3 months (range 1-6 months) after the first injection, the vitreous hemorrage had cleared without any further intervention in all but 1 (9%) eye. Visual acuity improved significantly (p=0.02) from 1.65+/-0.97 logMAR to 0.98+/-0.67 logMAR. The intraocular pressure remained in the normal range (mean 14.6+/-3.5 mm Hg) with no significant difference to the baseline values (p=0.94). We did not observe any sign of intraocular inflammation or other changes that could be regardesd as side-effects of the intravitreal injecion. 4 (36%) eyes underwent panretinal laser coagulation after clearing of the vitreous hemorrage. Conclusion The present study may suggest to extend the intravitreal use of bevacizumab to persisting vitreous hemorrage due to ischemic retinopathies.

Hyperfluorescence of the optic disc with indocyanine green angiography

One-fourth of the patients with exudative age-related macular degeneration (AMD) treated with an autologous retinal pigment epithelium (RPE)-choroid translocation had a hyperfluorescent optic disc with indocyanine green angiography (ICGA). This study aimed to identify whether indocyanine green (ICG)-assisted surgery was related to the hyperfluorescence of the optic disc with ICGA. Retrospective observational case series of 31 AMD patients treated with an RPE-choroid translocation and who had ICGA after surgery. The ICGAs were assessed for hypo/iso/hyperfluorescence of the optic disc and fluorescence was related to the time interval between ICGA and the possible use of intravitreal ICG. The optic disc was hyperfluorescent in six patients, isofluorescent in one, and hypofluorescent in 24 patients. All hyperfluorescent optic discs and 7 of the 24 hypofluorescent optic discs were preceded with ICG-assisted surgery with a time interval of 7+/-3 weeks and 43+/-12 weeks, respectively (P=0.001, Student t-test). The other 17 hypofluorescent discs were not preceded by ICG-assisted surgery and the one isofluorescent optic disc was observed 32 weeks after ICG-assisted surgery. There was a statistically significant correlation between intravitreal ICG use during surgery and a hyperfluorescent optic disc with ICGA in our patient group.