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      Low-Power Transpupillary Thermotherapy Combined with Intravitreal Triamcinolone Acetonide for Subfoveal Choroidal Neovascularization

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          Abstract

          Purpose: To examine transpupillary thermotherapy combined with intravitreal triamcinolone for treatment of subfoveal choroidal neovascularization. Methods: The clinical interventional, noncomparative, case series study included 14 patients (14 eyes) with choroidal neovascularization (age-related macular degeneration, n = 11; high myopia, n = 2; unknown reason, n = 1), who underwent transpupillary thermotherapy (75–150 mW, 60 s, 500–3,000 µm), followed by an intravitreal triamcinolone injection (10 mg). Follow-up was at least 6 months. Results: Visual acuity increased by 3 lines in 3 (21%) eyes at 3 months, and in 3 (21%) eyes at 6 months of follow-up. None of the patients experienced a visual acuity loss of 3 or more lines. At the 6-month follow-up, mean visual acuity was improved by 1.36 ± 1.16 lines. Retreatment by transpupillary thermotherapy was performed for 3 (21%) eyes at 3 months, and for 1 (7%) eye at 6 months of follow-up. Conclusions: Transpupillary thermotherapy combined with intravitreal triamcinolone may be a therapeutic option for choroidal neovascularization particularly if other treatment modalities are not available.

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          Influence of photodynamic therapy on expression of vascular endothelial growth factor (VEGF), VEGF receptor 3, and pigment epithelium-derived factor.

          Ursula Schmidt-Erfurth, Stephan Michels, Claus Cursiefen … (2003)
          To evaluate the impact of photodynamic therapy (PDT) on expression and distribution of vascular endothelial growth factor (VEGF), VEGF receptor (VEGFR)-3, and pigment epithelium-derived factor (PEDF). Eyes of patients scheduled for enucleation due to untreatable malignancy served as study eyes (n = 4), age-matched donor eyes were used as the control (n = 4). PDT using verteporfin with the recommended standard parameters was applied to intact areas of the perimacular region. Lesions were classified by ophthalmoscopy, fluorescein angiography (FA), and indocyanine green angiography (ICGA), as well as light and electron microscopic (LM/EM) histology. Immunolabeling using specific antibodies against VEGF, VEGFR-3, and PEDF was performed in PDT-treated areas, untreated collateral areas in study eyes, and untreated areas of control eyes. Specimens were fixed in 4% paraformaldehyde and 1% glutaraldehyde and embedded in paraffin. Four-micrometer-thick sections were stained using the peroxidase-labeled streptavidin-biotin method. All PDT-treated areas demonstrated characteristic choroidal hypofluorescence by FA and ICGA. LM/EM histology revealed selective damage of choriocapillary endothelial cells. VEGF was expressed in the endothelial layer of choriocapillaries and focally within larger choroidal vessels in treated areas, but not in untreated areas. Sites with positive VEGF labeling also demonstrated upregulation of VEGFR-3. PEDF expression was localized to retinas in all eyes; however, PEDF staining of choroidal endothelial cells was specific for treated areas of study eyes. PDT using verteporfin induces a reproducible angiogenic response in elderly human eyes. VEGF, VEGFR-3, and PEDF expression is enhanced after PDT. Choroidal endothelial cells appear to be the primary site of angiogenic stimulation.
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            Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration.

            M Ip, C Puliafito, J Düker … (1999)
            To evaluate the efficacy of transpupillary thermotherapy for the treatment of occult subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration. A retrospective, noncomparative case series. Sixteen eyes of 15 consecutive patients who presented with occult subfoveal choroidal neovascularization secondary to age-related macular degeneration. After informed consent was obtained, 16 eyes of 15 patients were treated with transpupillary thermotherapy. All patients underwent pretreatment fluorescein angiography and were deemed untreatable by the Macular Photocoagulation Study standard. Transpupillary thermotherapy was delivered using a diode laser at 810 nm. A variable spot size of 1.2 mm, 2.0 mm, or 3.0 mm was used depending on the size of CNV. The diode laser was delivered through a contact lens, and treatment was initiated in one spot for 60 seconds' duration at a power range between 360 and 1000 mW. The end point was an area of no visible color change to a light-gray appearance. In all eyes, outcome was assessed by Snellen chart visual acuity and clinical examination. In 10 of 16 eyes, preoperative and postoperative fluorescein angiography and optical coherence tomography were available. In the remaining 6 of 16 eyes, exudation was measured by postoperative clinical examination alone. Three eyes (19%) showed a two-or-more-line improvement in visual acuity over a period of 6 to 25 months. Mean follow-up was 13 months. Visual acuity remained stable (no change or one-line improvement) in nine treated eyes (56%). The remaining four eyes (25%) showed a decline (equal to one-line worsening or greater) in visual acuity. Fifteen eyes (94%) demonstrated decreased exudation on fluorescein angiography, optical coherence tomography, and/or clinical examination. Transpupillary thermotherapy shows no deleterious side effects in treating occult subfoveal choroidal neovascularization. A randomized, prospective study is necessary to evaluate treatment efficacy.
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              Verteporfin therapy combined with intravitreal triamcinolone in all types of choroidal neovascularization due to age-related macular degeneration.

              Albert J. Augustin, Ursula Schmidt-Erfurth (2005)
              To evaluate the efficacy and safety of photodynamic therapy with verteporfin combined with intravitreal triamcinolone in choroidal neovascularization secondary to age-related macular degeneration (AMD). Prospective, noncomparative, interventional case series. One hundred eighty-four patients undergoing treatment for neovascular AMD at one retinal referral center. One hundred eighty-four eyes of 184 consecutive patients (63.6% female, 36.4% male) with a mean age of 76.5 years and a follow-up of a median of 38.8 weeks (range, 12-103) were included in a case series. One hundred forty-eight (80.4%) patients had subfoveal choroidal neovascularization, 19 patients (10.3%) had juxtafoveal choroidal neovascularization, and 17 patients (9.2%) had extrafoveal choroidal neovascularization. Verteporfin photodynamic therapy was performed using the recommended standard procedure. A solution containing 25 mg of triamcinolone was injected intravitreally 16 hours after photodynamic therapy in 184 patients. The combined therapy procedure was repeated at the 3-month follow-up visits whenever persistent choroidal neovascularization leakage was documented angiographically. Mean change in best-refracted visual acuity (VA) between baseline and the last visit, and number of treatments necessary to achieve absence of leakage. Visual acuity improved in the majority of patients (baseline VA, mean 20/125) by a mean increase of 1.22 Snellen lines and 1.43 lines using laser interferometry (P<0.01). The mean number of required treatments was 1.21. Twenty-three eyes (12.5%) required 2 treatments, 6 eyes (3.26%) required 3 treatments, and 1 eye (0.5%) required 4 treatments. The combination treatment including laser and intravitreal steroid administration was well tolerated. Forty-six patients (25%) required glaucoma therapy due to a transient steroid-induced intraocular pressure (IOP) increase. Twelve patients (6.5%) were on topical medication for preexisting glaucoma. Two patients (1%) whose IOP increase could not be controlled with topical therapy required surgery. Verteporfin photodynamic therapy combined with intravitreal triamcinolone may improve the outcome of standard verteporfin photodynamic therapy in the treatment of choroidal neovascularization secondary to AMD. A significant improvement in VA was observed in a majority of treated patients and was maintained during the maximum follow-up. In addition, retreatment rates were lower than anticipated.
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                Author and article information

                Journal
                Journal ID (publisher-id): ORE
                Journal ID (nlm-ta): Ophthalmic Res
                Journal ID (doi): 10.1159/issn.0030-3747
                Title: Ophthalmic Research
                Publisher: S. Karger AG
                ISSN (Print): 0030-3747
                ISSN (Electronic): 1423-0259
                Publication date Subscription-year: 2007
                Publication date (Print): August 2007
                Publication date (Electronic): 29 June 2007
                Volume: 39
                Issue: 4
                Pages: 241-242
                Affiliations
                aBeijing Institute of Ophthalmology, Department of Ophthalmology and Eye Hospital, Tongren Hospital, Capital University of Medical Science, Beijing, China; bDepartment of Ophthalmology, Faculty of Clinical Medicine Mannheim, University of Heidelberg, Mannheim, Germany
                Article
                Publisher ID: 104833 Other ID: Ophthalmic Res 2007;39:241–242
                DOI: 10.1159/000104833
                PubMed ID: 17622745
                SO-VID: 7ab0fc4c-6509-4001-bbba-01ce0f4ce485
                Copyright © © 2007 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 17 October 2006
                Date accepted : 05 February 2007
                Page count
                References: 7, Pages: 2
                Categories
                Subject: Short Communication

                ScienceOpen disciplines: Vision sciences,Ophthalmology & Optometry,Pathology
                Keywords: Myopic macular degeneration,Transpupillary thermotherapy,Choroidal neovascularization,Age-related macular degeneration,Intravitreal steroids,Visual impairment,Low vision
                Data availability:
                ScienceOpen disciplines: Vision sciences, Ophthalmology & Optometry, Pathology
                Keywords: Myopic macular degeneration, Transpupillary thermotherapy, Choroidal neovascularization, Age-related macular degeneration, Intravitreal steroids, Visual impairment, Low vision

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