NEWS BRIEFS ARVO 2006
Initial Focal Pulsed Laser Treatment Effective
for RAP Associated With PED
of Retinal Angiomatous Proliferation Lesions Associated With Pigment Epithelial
Detachment With Focal Pulsed Laser
RP, ALBANO M, GILMER WL. THE RETINA GROUP OF WASHINGTON
In a retrospective chart review of consecutive patients, Murphy and colleagues evaluated
focal pulsed laser treatment as the primary therapy for inner retinal angiomatous
proliferation (RAP) lesions associated with retinal pigment epithelial detachment
(PED). Lesions were defined by video indocyanine green angiography (ICG–A)
and fluorescein angiography (FA).
Investigators reviewed charts of patients with at least 6
months of follow-up who had RAP lesions associated with PED. Eyes with any choroidal
neovascularization (CNV) were excluded. After ICG-A identification and lesion
localization, eyes were treated with confluent pulsed 532-nm laser applications
using spot sizes of
75 μm to 200 μm. The treatment endpoint was identified
as mild inner retinal graying over the RAP lesion.
The study looked at 46 eyes of 41 patients. Of the 41 patients,
85.4% were women, and all five bilateral eyes were in women. The mean age of the
study cohort was 80.4 years of age, ranging from 63 to 91 years. The mean baseline
visual acuity was 44.3 ETDRS letters or 20/130 on the Snellen chart.
On FA, 67.4% had a pattern of PED only; 26.1% had PED with an
occult leakage pattern; and 6.5% had PED with other patterns that mimicked CNV.
On ICG-A, the inner retinal lesions were well defined and small, ranging in size
from 100 μm to 400 μm.
FINDINGS AT 3, 6, 12 MONTHS
After treatment, with 80.4% follow-up, there was a mean de-crease
compared to baseline of –0.8 ETDRS letters at 3 months, –4.4
ETDRS letters at 6 months and –8.7 ETDRS letters at 12 months. Most eyes had
At 6 months, the proportion of eyes with stable or improved vision
was 79.6%; and at 12 months 67.7% had stable or improved vision. At 6 months, 29
out of 46 (63%) RAP lesions were closed; and at 12 months, 29 out of 37 (78.4%)
were closed. At 6 months, 20 out of 46 (43.5%) of PEDs had resolved; and at 12 months,
27 out of 37 PEDs (73%) had resolved. Another 6 out of 37 (16.2%) progressed to
fibrovascular scars with no PED.
For RAP associated with PED, investigators found early ICG-A identification
and initial focal pulsed laser treatment was a safe, effective treatment for this
type of retinal neovascularization. (Note that in this series, RAP could not be
diagnosed by FA alone.) Investigators saw little initial adverse treatment effect,
with sustained visual benefit for 1 year.
Closing the RAP lesion can be associated with PED resolution,
suggesting that leakage from RAP may induce them. These findings suggest that treatment
failure may be associated with progression to CNV. Further follow-up to determine
long-term visual outcome is warranted.
Study Shows Ties Between Wet AMD and Other
Between Neovascular Age-related Macular Degeneration and Incident Myocardial Infarction
SCOTT IU, MO J, KLEIN R, ET AL.
Neovascular age-related macular degeneration (AMD) is associated with hypertension,
diabetes and a history of myocardial infarction (MI), independent of age, sex and
race. This finding comes from a retrospective study of Medicare beneficiaries facilitated
by researchers at Penn State University College of Medicine; University of Wisconsin-Madison;
and Pfizer Inc.
analysis also revealed the presence of neovascular AMD is associated with a higher
risk of incident MI, independent of demographic factors and comorbidity. The report
indicates if these findings are confirmed by other studies with the ability to control
for smoking and other lifestyle factors, it may be possible to identify shared common
antecedents of AMD and incident MI.
In an effort to investigate the association between neovascular
AMD and the development of MI among elderly Americans, researchers reviewed a 5%
sample of Medicare beneficiaries and their medical reimbursement claims from 2000
to 2003. A total of 1,519,806 beneficiaries from this sample formed a cohort of
subjects who were 65 years of age or older during the 2-year baseline period encompassing
2000 and 2001. The researchers extracted baseline demographic information from the
Medicare data, based on relevant ICD-9 codes on at least one claim's "Claim
Principal Diagnosis Code" field during this period. Baseline conditions were defined
as neovascular AMD, MI, hypertension and diabetes.
After excluding 73,409 prospective subjects with a history of
MI at baseline, the team used 2002 and 2003 claims data to identify incident MI
cases, which numbered 56,541, among 1,446,397 subjects without a history of MI at
At baseline, the mean age of this cohort was 76, and it included
60% women and 88% Caucasians. Of this cohort, 11% of the Medicare beneficiaries
had been diagnosed with AMD; 19% of that subgroup had the neovascular form of AMD.
Among people with neovascular AMD, baseline age-, sex- and race-adjusted
prevalence of hypertension, diabetes and MI were 73%, 28% and 4.7%, respectively.
This was in contrast to 65%, 25% and 4.5% among people without neovascular AMD.
After adjusting for age, sex, race, hypertension and diabetes,
the 2-year incident odds ratios (and 95% confidence intervals) of MI associated
with neovascular AMD were:
1.10 (1.00, 1.21) for subjects aged 65 to 69
1.11 (1.04, 1.19) for subjects aged 70 to 74
1.17 (1.11, 1.23) for subjects aged 75 to 79
1.23 (1.18, 1.27) for subjects aged 80 or above.
Study Reveals Rate of 'Real World' Adherence
to Preferred Practice Patterns
of Adherence to Clinical Practice Guidelines in the Treatment of Age-related Macular
KECKLEY PH, RECCHIA FM, ET AL.
Retinal physicians rely on the American Academy of Ophthal-mology's Preferred Practice
Pattern (PPP) recommendations about half of the time in their treatment of patients
with age-related macular degeneration (AMD). These were the findings of a retrospective
study by researchers at the Center for Evidence-Based Medicine at Vanderbilt University
Medical Center in Nashville, Tenn.
TWO KEY QUESTIONS
The PPP guidelines are the most widely accepted set for the treatment
of ophthalmic conditions, but until now, there has been little evaluation of the
'real-world' application of its recommendations for AMD, according to Ahmed and
In response, the Center for Evidence-Based Medicine designed a
study to evaluate adherence to AMD practice guidelines by looking at two questions:
How often is Amsler grid testing performed as part of examinations of patients with
AMD? And how often is antioxidant supplementation recommended for patients at high
risk for development of advanced AMD? According to Dr. Ahmed, these questions were
used because "Amsler grid testing and antioxidant and mineral supplementation are
given different 'strength of evidence' levels in the PPP."
To answer these questions, researchers randomly selected 107 charts
from a retrospective review of all patients diagnosed with AMD seen by three retinal
specialists during 2004. "We randomly selected AMD patients seen from January 2004
through December 2004. From that patient mix, we tracked back individual visits
from January 2000 through October 2005 to determine whether recommended care was
documented or not," Dr. Ahmed said.
The selected visits were reviewed for the following information:
► Diagnosis and severity of AMD by AREDS
► Documentation of Amsler grid testing
► Documentation of the recommended use of
antioxidant and mineral supplementation.
LOW ADHERENCE RATES
Researchers reviewed a total of 317 visits. The overall rate of
Amsler grid testing was 48%, with no significant difference among the retinal specialists.
The overall rate of documented recommended use of antioxidant supplements was 47%.
However, there was a significant statistical difference among
the retinal specialists, with one recommending antioxidant supplements to 77% of
AMD patients, while another recommended them to 54% of AMD patients and the third
recommended them to 20% of AMD patients.
"We found that adherence to both of our benchmarks was similar,"
Dr. Ahmed said. "This may indicate that strength of evidence does not substantially
affect adherence in the treatment of AMD."
Failure to document a verbal recommendation, differences in years
of training or lack of knowledge of treatment guidelines are possible explanations
for the relatively low rates of PPP adherence, according to Dr. Ahmed. "Further
studies are required to see which interventions can improve adherence," he said.
Simple Model Predicts Vitrase Treatment
A Simple Predictor
of Vitrase Efficacy for BCVA Improvement in Diabetic Patients With Severe Vitreous
AR, LANDERS MB, PEARSON RK, ET AL.
Simple Predictor of Vitrase Efficacy for Successful Laser Treatment in Diabetic
Patients With Severe Vitreous Hemorrhage
MB, BHAVSAR AR, PEARSON RK, ET AL.
A relatively simple measurement of vitreous hemorrhage density Total Hemorrhage
Point Score (THPS) 1 month post intravitreal injection of lyophilized ovine
hyaluronidase for injection (Vitrase), can predict treatment success in diabetic
patients, according to two studies.
The predictive model analyses were based on subset analyses of
data from the Phase 3 clinical trials of ovine hyaluronidase. In those trials,
1306 patients were enrolled in two randomized, double-masked, placebo-controlled
international Phase 3 studies. In both studies, subjects with diabetes who were
treated with hyaluronidase had significantly higher success rates than those treated
with saline. The present predictive models are based only on subjects with diabetes.
DETERMINE A TREATMENT PATH
Hyaluronidase treatment for vitreous hemorrhage results in variable
clearance rates. Not all patients treated have clearance, so it is valuable to have
a predictive model indicating early in the treatment course whether a patient has
a significant chance of clearing, according to Abdhish R. Bhavsar, MD, Retina Center,
Minneapolis, Minn., a clinical investigator for both studies.
"If a patient receives a hyaluron-idase injection for vitreous
hemorrhage, and at 1 month post injection, the hemorrhage has cleared only slightly,
we need to decide whether to perform vitrectomy then or to observe the patient for
a longer period," Dr. Bhavsar said. "If a patient has a strong chance of not clearing
by 3 months post injection, then we would consider vitrectomy as early as 1 month
ROBUST CLINICAL TOOL
Using a scale of 0 to 4 to grade vitreous hemorrhage in the Phase
3 clinical trials, the THPS represents the sum of the hemorrhage density scores
in each of the 12 clock hours of the fundus. The predictor is the change in THPS
from baseline to month 1 post injection. Using the Receiver Operating Characteristic
analysis, the THPS predictor is a relatively strong predictor of whether the hemorrhage
will clear sufficiently for successful laser treatment or three-line BCVA improvement.
In one study, THPS helped predict treatment success following
a single intravitreous injection of 55 IU or 75 IU hyaluronidase. At 1 month, THPS
predicted hyaluronidase treatment success (defined as three or more lines of BCVA
gained) at 3 months versus saline injection. At 1 month, THPS also predicted
treatment success with hyaluronidase as measured by completion of panretinal laser
photocoagulation as defined in the clinical trials by 3 months without vitrectomy
when compared to a single injection of saline.
Retinal Physician, Issue: September 2006