نوشته‌ها

Journal Club -30-02-1403

Journal Club -23-02-1403

Polypoidal choroidal vasculopathy: evaluation based on 3-dimension reconstruction of OCT angiography

This article presents a clinical case series that aims to describe novel observations of polypoidal choroidal vasculopathy (PCV) using three-dimensional (3D) reconstruction of swept source OCT angiography (SS-OCTA) images.

The study compares these observations with similar images of type I neovascular age-related macular degeneration (nAMD). The study included patients with PCV in either eye, and the images were obtained and reconstructed in 3D using a pre-specified SS-OCTA imaging protocol.

The researchers evaluated three specific features:

the pattern of flow signal within the polypoidal lesions (PLs).

the configuration of the branching neovascular network (BNN), and.

the spatial arrangement of the PLs in relation to the BNN.

The results showed that all PLs exhibited internal vascular architecture in the form of coil-like loops and none exhibited homogenous flow. Small focal nodules were present within this internal vascular architecture in 70% of cases.

The BNN exhibited a hypermature/mature configuration and was associated with thicker choroid compared to typical nAMD type I neovascularization.

The study concludes that proliferating vasculature is present in both the PL and the BNN, and the configuration suggests that the BNN represents a more chronic and inactive lesion than the PL. The findings provide insights into the nature and structure of PCV and its component parts.

The article is available at the following address: [Polypoidal choroidal vasculopathy: evaluation based on 3-dimension reconstruction of OCT angiography – Ophthalmology Retina].

از بین رفتن drusenoid PED به دنبال استفاده از برولیسوزوماب

در مقاله جالبی که در مجله ۲۰۲۳ OSLI چاپ شده است بیمار ۶۸ ساله ای معرفی شده است که به علت ابتلا به Neovascular AMD در چشم راست ( Vascularized PED ) تحت درمان با برولیسوزوماب (سه تزریق ماهانه ) قرار میگیرد. در تصویر بالا تصاویر پیگیری بیمار را پس از ۳ و ۱۲ ماه بعد از تزریق مشاهده میکنید. به خوبی دیده میشود که دروزن بیمار در چشم راست در حال از بین رفتن میباشد و در پیگیری یک سال بعد drusenoid PED بیمار به صورت کامل از بین رفته است. توضیحاتی که نویسندگان مقاله برای توجیه این پدیده ذکر میکنند جالب است که در زیر به آنها اشاره خواهیم کرد :

در بیمار مذکور ، AMD نئوواسکولار به همراه PED بزرگ و دروزن ماکولا وجود داشت که با موفقیت با برولوسیزوماب داخل ویتره درمان شد و این درمان  باعث کاهش قابل توجه ارتفاع PED و به طور قابل توجهی بهبود اندازه دروزن شده و نتیجه بینایی خوبی به همراه داشت.

نکته مهم این است که این کاهش ارتفاع PED و از بین رفتن دروزن در پیگیری ۱ ساله حفظ شد. با توجه به سرعت تحلیل دروزن پس از دوره بارگیری برولوسیزوماب، بعید است که دروزن به طور طبیعی پسرفت کرده باشد. این بیمار برای سال‌ها مکمل  (AREDS) و استاتین با دوز پایین  مصرف می‌کرده است، اما علی‌رغم داشتن دروزن دو طرفه ماکولا، این برطرف شدن دروزن و از بین رفتن drusenoid PED  تنها در چشم  راست بیمار مشاهده شد. این امر برلوسیزوماب را به عنوان علت احتمالی این قضیه مورد حمایت قرار می دهد، اگرچه مکانیسم مسئول نامشخص است.

 

مطالعات موردی از بین رفتن دروزن را به دنبال ویترکتومی به تنهایی و ویترکتومی با ترمیم سوراخ ماکولا گزارش کرده اند که ممکن است به دلیل القای جداشدگی زجاجیه خلفی (PVD)، فعال شدن مسیرهای التهابی یا سایر عوامل مرتبط با جراحی باشد.

در مورد بیمار معرفی شده، یک جداشدگی  در حال تکامل غشای هیالوئید خلفی از شبکیه در چشم راست بیمار وجود دارد ( یعنی PVD بیمار در حال کامل شدن است )، اما در چشم چپ  این قضیه وجود ندارد . PVD ناقص ممکن است به طور مکانیکی توسط تزریق داخل زجاجیه کامل شده  باشد. به این ترتیب، PVD ممکن است یک عامل تحریک کننده یا کمک کننده بالقوه برای تحلیل دروزن در این بیمار باشد.

 

اگرچه تحلیل خود به خودی دروزن غیر معمول نیست و مطالعات مشاهده ای باید در تفسیر علت زمینه ای این پدیده احتیاط کنند اما خود داروی برولیسوزوماب بالقوه ممکن است در تحلیل رشد دروزن نقش مهمی ایفا کند.

پی نوشت : 

تقریباً ۷ درصد از چشم‌های دارای دروزن در طی یک دوره ۲۴ ماهه، رگرسیون خود به خودی را بدون ایجاد AMD پیشرفته نشان میدهند.

 

 

Journal Club 16-11-1401

Journal Club 16-11-1401

Weekly Case Presentation 12-7-1401

Weekly Case Presentation 12-7-1401

Management of Neovascular AMD

Journal Club 23-5-2021

Journal Club 23-5-2021

Patients with Neovascular Age-Related Macular Degeneration Requiring Intensive Intravitreal Aflibercept Treatment: An ARIES Post Hoc Analysis

Sebastian Wolf Frank G Holz Edoardo Midena Eric H Souied George Lambrou Tobias Machewitz Helmut Allmeier Paul Mitchell ARIES Study Investigators

Abstract

Introduction: The aim of this post hoc analysis of the ARIES study is to explore the requirement for intravitreal aflibercept (IVT-AFL) treatment intervals of < 8 weeks (w) in patients with neovascular age-related macular degeneration (nAMD), and to assess vision and anatomic outcomes in such patients who require more intensive treatment.

Methods: ARIES was a multicenter, randomized, phase 3b/4 study that investigated the efficacy of two IVT-AFL proactive, individualized, treat-and-extend regimens over 2 years in treatment-naïve patients with nAMD. Patients were determined as injection-intensive if the study investigator identified that a treatment interval of < 8 w was needed and if they had ≥ ۱ interval of < 8 w after three initial monthly doses. Treatment intervals could be extended subsequently if extension criteria were met. This is a post hoc analysis of patients enrolled in ARIES and statistical analysis is descriptive.

Results: Of 269 patients in the combined treatment arms, 23.0% (n = 62) were injection-intensive (Year 1: 13.8% [n = 37]; Year 2: 9.3% [n = 25]). Time from IVT-AFL initiation to injection-intensive determination varied (range, 16-100 w; median: 43.2 w). Mean treatment interval was 8.4 w before and 6.1 w after injection-intensive determination. Overall, 59.7% achieved treatment intervals of ≥ ۸ w following injection-intensive determination. Vision improvements from baseline to Week 104 were smaller for injection-intensive patients than non-injection-intensive patients (mean [SD] best-corrected visual acuity change: + 2.3 [15.6] vs. + 5.9 [12.3] letters). Anatomic outcomes were similar between injection-intensive and non-injection-intensive patients (central retinal thickness change from baseline to Week 104: – 160 [154] vs. – 167 [136] µm).

Conclusions: In ARIES, 23% of treatment-naïve patients with nAMD experienced at least one treatment interval of < 8 w. Injection-intensive patients showed improved vision and anatomic outcomes. For most, treatment intervals could be extended to ≥ ۸ w following injection-intensive determination.

N Engl J Med

  • ۲۰۲۲ Jul 14. Online ahead of print.

Aflibercept Monotherapy or Bevacizumab First for Diabetic Macular Edema

Chirag D Jhaveri Adam R Glassman Frederick L Ferris 3rd Danni Liu Maureen G Maguire John B Allen Carl W Baker David Browning Matthew A Cunningham Scott M Friedman Lee M Jampol Dennis M Marcus Daniel F Martin Carin M Preston Cynthia R Stockdale Jennifer K Sun DRCR Retina Network

Abstract

Background: In eyes with diabetic macular edema, the relative efficacy of administering aflibercept monotherapy as compared with bevacizumab first with a switch to aflibercept if the eye condition does not improve sufficiently (a form of step therapy) is unclear.

Methods: At 54 clinical sites, we randomly assigned eyes in adults who had diabetic macular edema involving the macular center and a visual-acuity letter score of 24 to 69 (on a scale from 0 to 100, with higher scores indicating better visual acuity; Snellen equivalent, 20/320 to 20/50) to receive either 2.0 mg of intravitreous aflibercept or 1.25 mg of intravitreous bevacizumab. The drug was administered at randomization and thereafter according to the prespecified retreatment protocol. Beginning at 12 weeks, eyes in the bevacizumab-first group were switched to aflibercept therapy if protocol-specified criteria were met. The primary outcome was the mean change in visual acuity over the 2-year trial period. Retinal central subfield thickness and visual acuity at 2 years and safety were also assessed.

Results: A total of 312 eyes (in 270 adults) underwent randomization; 158 eyes were assigned to receive aflibercept monotherapy and 154 to receive bevacizumab first. Over the 2-year period, 70% of the eyes in the bevacizumab-first group were switched to aflibercept therapy. The mean improvement in visual acuity was 15.0 letters in the aflibercept-monotherapy group and 14.0 letters in the bevacizumab-first group (adjusted difference, 0.8 letters; 95% confidence interval, -0.9 to 2.5; P = 0.37). At 2 years, the mean changes in visual acuity and retinal central subfield thickness were similar in the two groups. Serious adverse events (in 52% of the patients in the aflibercept-monotherapy group and in 36% of those in the bevacizumab-first group) and hospitalizations for adverse events (in 48% and 32%, respectively) were more common in the aflibercept-monotherapy group.

Conclusions: In this trial of treatment of moderate vision loss due to diabetic macular edema involving the center of the macula, we found no evidence of a significant difference in visual outcomes over a 2-year period between aflibercept monotherapy and treatment with bevacizumab first with a switch to aflibercept in the case of suboptimal response. (Funded by the National Institutes of Health; Protocol AC ClinicalTrials.gov number, NCT03321513.).

Journal Club 13-11-2021

Journal Club 13-11-2021

Updates on AMD

Special Thanks to Dr Amini And Dr Riazi

Practical Points in Management of Patients with CNV

Consecutive CNV in the Fellow Eye

Weekly Case Presentation 26-2-2021