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Hemorrhage in patients who have received transpupillary thermotherapy for subfoveal choroidal neovascularization
PHOTOGALLERY OF CLINICAL OPHTHALMOLOGY
Hemorrhage in patients who have received transpupillary thermotherapy for subfoveal choroidal neovascularization Kevin Greuloch, MD; Wico W. Lai, MD; Jose S. Pulido, MD, MS, MBA
C
horoidal neovascularization (CNV) that develops as a result of age-related macular degeneration (AMD) is a major cause of severe and irreversible vision loss in the Western world. Recently, transpupillary thermotherapy (TIT), in which a diode laser delivers infrared light in the form of heat to the retina, has been used to treat occult subfoveal CNV. 1- 3 It was found to be effective, with no or minimal side effects reported in these case series. In this paper we describe hemorrhages that developed during and after TTT. CASE REPORTS
Case I A 59-year-old white man presented with group II juxtafoveal telangiectasia in the left eye. His visual acuity was counting fingers at 2 ft in the left eye and 20125 in the right eye. Fundus exam with pupillary dilation revealed an area of subretinal fluid and blood about 2 disc diameters in width in the left eye (Fig. 1). Fluorescein angiography showed early hyperfluorescence corresponding to occult CNV and mild leakage of dye in the later phases; the area of hyperfluorescence was surrounded by blocked fluorescence that was secondary to the subretinal blood (Fig. 2).
Fig. I-Case I: Subretinal blood in fovea of left eye.
TIT was recommended and applied to the CNV with the following laser settings: spot size, 3 mm; dura-
From the Illinois Eye and Ear Infirmary and the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Ill. Originally received June 24, 2002 Accepted for publication Jan. 15, 2003 Reprint requests to: Dr. Wico Lai, Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, 1905 W Taylor St., Chicago IL 60612, USA; fax (312) 996-2913; [email protected] This article has been peer-reviewed. Can J Ophthalmol 2003;38:308-3 11
308
Fig. 2-Case I: Fluorescein angiogram, showing area of hyperfluorescence corresponding to occult choroidal neovascularization (CNV); fluorescence is blocked in surrounding area because of subretinal blood.
Hemorrhage in TIT for subfoveal CNV-Greuloch et al
Hemorrhage in TIT for subfoveal CNV-Greuloch et al tion, 60 s; power, 1000 mW. During the procedure the amount of subretinal blood increased. No photography was done immediately after the operation, but fundus photographs were taken 6 weeks later and demonstrated the increased amount of blood superior to the CNV, which had since evolved into a subretinal scar (Fig. 3). The patient's vision in this eye remained at counting fingers at 2 ft, with a central scotoma.
Case 2 A 79-year-old white man with a history of AMD presented with a I-month history of decreased vision in the right eye. His visual acuity was 20/200 in the right eye and 20/400 in the left eye. Fundus exam with pupillary dilation revealed a fibrovascular pigment epithelium detachment (PED) from the foveola to the inferior juxtafovea in the right eye; pigment clumping was also noted under the fovea. The left fundus had optociliary shunt vessels, macular edema and panretinal photocoagulation scars that were consistent with an old central retinal vein occlusion. Fluorescein angiography of the right eye revealed early, intense juxtafoveal hyperfluorescence and stippled subfoveal hyperfluorescence with dye leakage in the late phases. A diagnosis of occult subfoveal CNV was made. After discussion, the patient elected observation of the CNV. Five weeks later the visual acuity in the right eye dropped to counting fingers at 1 ft. A new, large subretinal hemorrhage had developed temporal to the previously noted PED (Fig. 4). Fluorescein angiography
Fig. 3-Case I: Increased amount of subretinal blood (arrow) superior to disciform scar after transpupillary thermotherapy (TTT).
Fig. 4-Case 2: Fibrovascular pigment epithelium detachment (PED) in fovea and adjacent subretinal hemorrhage in right eye.
showed occult CNV and adjacent blockage of fluorescence corresponding to the subretinal blood (Fig. 5). In light of the large, ill-defined occult CNV and extensive adjacent subretinal blood, TTT was recommended and performed, at the following laser settings: spot size, 3 mm; duration, 60 s; power, 900 mW. One month afterwards, the area of subretinal blood had increased (Fig. 6). Mild vitreous hemorrhage was also noted. Two months after TTT, a large disciform scar was seen; the patient's vision was counting fingers at 6 in.
Fig. 5-Case 2: Fluorescein angiogram, showing occult CNV and adjacent blockage of fluorescence corresponding to subretinal blood.
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J OPHTHALMOL-YOL. 38. NO.4. 2003
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Hemorrhage in TIT for subfoveal CNV-Greuloch et al
Fig. 6--Case 2: One month after Tn, area of subretinal blood has increased.
Fig. 8--Case 3: Late-phase fluorescein angiogram, showing stippled hyperfluorescence at superior edge of PED, corresponding to occult subfoveal CNV.
Case 3 A 71-year-old white man with AMD presented with a 7-month history of decreased vision in the right eye. His visual acuity was 20/80 in the right eye and 20/20 in the left eye. Fundus examination with pupillary dilation revealed a fibrovascular PED in the right eye (Fig. 7). Fluorescein angiography showed stippled hyperfluorescence at the superior edge of the PED and leakage of dye in the later phases (Fig. 8), consistent with occult subfoveal CNV. The left eye showed nonexudative AMD and geographic atrophy. TTT was applied to the right eye to treat the CNV, with the following laser settings: spot size, 3 mm;
Fig. 7-Case 3: Fibrovascular PED in right eye.
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duration, 90 s; power, 380 mW. One month afterwards, a large suprachoroidal hemorrhage and a vitreous hemorrhage developed. The intraocular pressure was elevated, at 70 mm Hg. His vision subsequently became no light perception and remained so 8 months after treatment. COMMENTS
TTT delivers heat to the choroid and retinal pigment epithelium. With long exposure and a large retinal spot, low therapeutic retinal irradiance is produced. 4 In the rnid-1990s it was shown to be effective in the treatment of small posterior choroidal melanomas;5 complications of treatment included vascular occlusion, retinal traction, retinal neovascularization, and retinal, choroidal and vitreous hemorrhage. The application of TTT was expanded to occult subfoveal CNV secondary to AMD.I-3 The only complication reported thus far is transient appearance of classic CNV.3 Newsom and colleagues2 noted posttreatment hemorrhage in 2 patients in their series but did not report the timing of onset of the hemorrhage. It is difficult to determine from that report how the patients did or the time course of the hemorrhage and its relation to the treatment. In the patient in our case 1, who had idiopathic juxtafoveal telangiectasia, the amount of subretinal hemorrhage increased during TIT. To our knowledge, this is the first report of such a complication
Hemorrhage in TIT for subfoveal CNV-Greuloch et al during the treatment of CNV with TTT. Although the hemorrhages in cases 2 and 3 may have resulted from the natural course of the disease, another possibility is that TTT was responsible. They were treated when there was little experience with TTT for CNV and with higher powers than are currently reported in the literature. Using lower powers and shorter durations, we have not seen any of these complications. However, a major problem with this technique has been determining the appropriate treatment parameters for each patient. A recent publication by the laser manufacturer6 (not peer-reviewed) reported acute vision loss either during or after TTT, particularly in patients with glaucoma; it was hypothesized that these patients might be predisposed to the thermal effects of the laser by their compromised choroidal vasculature. Since TTT may damage the vascular endothelium without causing photocoagulation, pulsatile blood flow may continue in the compromised vessels after the treatment, with resultant hemorrhage. TTT appears to be a promising alternative for the treatment of occult CNV, and a multicentre trial is under way. However, in addition to the thermal effect on the overlying retina in patients with glaucoma, the possible development of hemorrhage during or after TTT should be considered before treatment. This study was supported by an unrestricted grant from Research to Prevent Blindness Inc., New York, and an
institutional core grant (EY0l792) from the US National Eye Institute, Bethesda, Md. The authors have no financial or proprietary interest in any product or company mentioned in this article. REFERENCES
1. Reichel E, Berrocal AM, Ip M, et al. Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration. Ophthalmology 1999; 106: 1908-14. 2. Newsom RS, McAlister JC. Saeed M, McHugh JD. Transpupillary thermotherapy (TTT) for the treatment of choroidal neovascularization. Br J Ophthalmol 2001 ;85: 173-8. 3. Kaga T, Fonseca RA. Dantas MA, Spaide RF. Transient appearance of classic choroidal neovascularization after trans pupillary thermotherapy for occult choroidal neovascularization. Retina 2001;21:172-3. 4. Mainster MA, Reichel E. Transpupillary thermotherapy for age-related macular degeneration: long pulse photocoagulation, apoptosis, and heat shock proteins. Ophthalmic Surg Lasers 2000;31 :359-73. 5. Shields CL, Shields JA, DePotter P, Kheterpal S. Transpupillary thermotherapy in the management of choroidal melanoma. Ophthalmology 1996;103:1642-50. 6. Iridex Corporation. TTT consideration for patients with glaucoma. Iridex 17T Consumer Update Feb 2002. p. 2.
Key words: transpupiJlary thermotherapy, choroidal neovascularization, fibrovascular pigment epithelium detachment, hemorrhage
CAN
J OPHTHALMOL-VOL. 38, NO.4, 2003
3I I
Hemorrhage in patients who have received transpupillary thermotherapy for subfoveal choroidal neovascularization Kevin Greuloch, MD; Wico W. Lai, MD; Jose S. Pulido, MD, MS, MBA
C
horoidal neovascularization (CNV) that develops as a result of age-related macular degeneration (AMD) is a major cause of severe and irreversible vision loss in the Western world. Recently, transpupillary thermotherapy (TIT), in which a diode laser delivers infrared light in the form of heat to the retina, has been used to treat occult subfoveal CNV. 1- 3 It was found to be effective, with no or minimal side effects reported in these case series. In this paper we describe hemorrhages that developed during and after TTT. CASE REPORTS
Case I A 59-year-old white man presented with group II juxtafoveal telangiectasia in the left eye. His visual acuity was counting fingers at 2 ft in the left eye and 20125 in the right eye. Fundus exam with pupillary dilation revealed an area of subretinal fluid and blood about 2 disc diameters in width in the left eye (Fig. 1). Fluorescein angiography showed early hyperfluorescence corresponding to occult CNV and mild leakage of dye in the later phases; the area of hyperfluorescence was surrounded by blocked fluorescence that was secondary to the subretinal blood (Fig. 2).
Fig. I-Case I: Subretinal blood in fovea of left eye.
TIT was recommended and applied to the CNV with the following laser settings: spot size, 3 mm; dura-
From the Illinois Eye and Ear Infirmary and the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Ill. Originally received June 24, 2002 Accepted for publication Jan. 15, 2003 Reprint requests to: Dr. Wico Lai, Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, 1905 W Taylor St., Chicago IL 60612, USA; fax (312) 996-2913; [email protected] This article has been peer-reviewed. Can J Ophthalmol 2003;38:308-3 11
308
Fig. 2-Case I: Fluorescein angiogram, showing area of hyperfluorescence corresponding to occult choroidal neovascularization (CNV); fluorescence is blocked in surrounding area because of subretinal blood.
Hemorrhage in TIT for subfoveal CNV-Greuloch et al
Hemorrhage in TIT for subfoveal CNV-Greuloch et al tion, 60 s; power, 1000 mW. During the procedure the amount of subretinal blood increased. No photography was done immediately after the operation, but fundus photographs were taken 6 weeks later and demonstrated the increased amount of blood superior to the CNV, which had since evolved into a subretinal scar (Fig. 3). The patient's vision in this eye remained at counting fingers at 2 ft, with a central scotoma.
Case 2 A 79-year-old white man with a history of AMD presented with a I-month history of decreased vision in the right eye. His visual acuity was 20/200 in the right eye and 20/400 in the left eye. Fundus exam with pupillary dilation revealed a fibrovascular pigment epithelium detachment (PED) from the foveola to the inferior juxtafovea in the right eye; pigment clumping was also noted under the fovea. The left fundus had optociliary shunt vessels, macular edema and panretinal photocoagulation scars that were consistent with an old central retinal vein occlusion. Fluorescein angiography of the right eye revealed early, intense juxtafoveal hyperfluorescence and stippled subfoveal hyperfluorescence with dye leakage in the late phases. A diagnosis of occult subfoveal CNV was made. After discussion, the patient elected observation of the CNV. Five weeks later the visual acuity in the right eye dropped to counting fingers at 1 ft. A new, large subretinal hemorrhage had developed temporal to the previously noted PED (Fig. 4). Fluorescein angiography
Fig. 3-Case I: Increased amount of subretinal blood (arrow) superior to disciform scar after transpupillary thermotherapy (TTT).
Fig. 4-Case 2: Fibrovascular pigment epithelium detachment (PED) in fovea and adjacent subretinal hemorrhage in right eye.
showed occult CNV and adjacent blockage of fluorescence corresponding to the subretinal blood (Fig. 5). In light of the large, ill-defined occult CNV and extensive adjacent subretinal blood, TTT was recommended and performed, at the following laser settings: spot size, 3 mm; duration, 60 s; power, 900 mW. One month afterwards, the area of subretinal blood had increased (Fig. 6). Mild vitreous hemorrhage was also noted. Two months after TTT, a large disciform scar was seen; the patient's vision was counting fingers at 6 in.
Fig. 5-Case 2: Fluorescein angiogram, showing occult CNV and adjacent blockage of fluorescence corresponding to subretinal blood.
CAN
J OPHTHALMOL-YOL. 38. NO.4. 2003
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Hemorrhage in TIT for subfoveal CNV-Greuloch et al
Fig. 6--Case 2: One month after Tn, area of subretinal blood has increased.
Fig. 8--Case 3: Late-phase fluorescein angiogram, showing stippled hyperfluorescence at superior edge of PED, corresponding to occult subfoveal CNV.
Case 3 A 71-year-old white man with AMD presented with a 7-month history of decreased vision in the right eye. His visual acuity was 20/80 in the right eye and 20/20 in the left eye. Fundus examination with pupillary dilation revealed a fibrovascular PED in the right eye (Fig. 7). Fluorescein angiography showed stippled hyperfluorescence at the superior edge of the PED and leakage of dye in the later phases (Fig. 8), consistent with occult subfoveal CNV. The left eye showed nonexudative AMD and geographic atrophy. TTT was applied to the right eye to treat the CNV, with the following laser settings: spot size, 3 mm;
Fig. 7-Case 3: Fibrovascular PED in right eye.
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J OPHTHALMOL-YOL. 38, NO.4, 2003
duration, 90 s; power, 380 mW. One month afterwards, a large suprachoroidal hemorrhage and a vitreous hemorrhage developed. The intraocular pressure was elevated, at 70 mm Hg. His vision subsequently became no light perception and remained so 8 months after treatment. COMMENTS
TTT delivers heat to the choroid and retinal pigment epithelium. With long exposure and a large retinal spot, low therapeutic retinal irradiance is produced. 4 In the rnid-1990s it was shown to be effective in the treatment of small posterior choroidal melanomas;5 complications of treatment included vascular occlusion, retinal traction, retinal neovascularization, and retinal, choroidal and vitreous hemorrhage. The application of TTT was expanded to occult subfoveal CNV secondary to AMD.I-3 The only complication reported thus far is transient appearance of classic CNV.3 Newsom and colleagues2 noted posttreatment hemorrhage in 2 patients in their series but did not report the timing of onset of the hemorrhage. It is difficult to determine from that report how the patients did or the time course of the hemorrhage and its relation to the treatment. In the patient in our case 1, who had idiopathic juxtafoveal telangiectasia, the amount of subretinal hemorrhage increased during TIT. To our knowledge, this is the first report of such a complication
Hemorrhage in TIT for subfoveal CNV-Greuloch et al during the treatment of CNV with TTT. Although the hemorrhages in cases 2 and 3 may have resulted from the natural course of the disease, another possibility is that TTT was responsible. They were treated when there was little experience with TTT for CNV and with higher powers than are currently reported in the literature. Using lower powers and shorter durations, we have not seen any of these complications. However, a major problem with this technique has been determining the appropriate treatment parameters for each patient. A recent publication by the laser manufacturer6 (not peer-reviewed) reported acute vision loss either during or after TTT, particularly in patients with glaucoma; it was hypothesized that these patients might be predisposed to the thermal effects of the laser by their compromised choroidal vasculature. Since TTT may damage the vascular endothelium without causing photocoagulation, pulsatile blood flow may continue in the compromised vessels after the treatment, with resultant hemorrhage. TTT appears to be a promising alternative for the treatment of occult CNV, and a multicentre trial is under way. However, in addition to the thermal effect on the overlying retina in patients with glaucoma, the possible development of hemorrhage during or after TTT should be considered before treatment. This study was supported by an unrestricted grant from Research to Prevent Blindness Inc., New York, and an
institutional core grant (EY0l792) from the US National Eye Institute, Bethesda, Md. The authors have no financial or proprietary interest in any product or company mentioned in this article. REFERENCES
1. Reichel E, Berrocal AM, Ip M, et al. Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration. Ophthalmology 1999; 106: 1908-14. 2. Newsom RS, McAlister JC. Saeed M, McHugh JD. Transpupillary thermotherapy (TTT) for the treatment of choroidal neovascularization. Br J Ophthalmol 2001 ;85: 173-8. 3. Kaga T, Fonseca RA. Dantas MA, Spaide RF. Transient appearance of classic choroidal neovascularization after trans pupillary thermotherapy for occult choroidal neovascularization. Retina 2001;21:172-3. 4. Mainster MA, Reichel E. Transpupillary thermotherapy for age-related macular degeneration: long pulse photocoagulation, apoptosis, and heat shock proteins. Ophthalmic Surg Lasers 2000;31 :359-73. 5. Shields CL, Shields JA, DePotter P, Kheterpal S. Transpupillary thermotherapy in the management of choroidal melanoma. Ophthalmology 1996;103:1642-50. 6. Iridex Corporation. TTT consideration for patients with glaucoma. Iridex 17T Consumer Update Feb 2002. p. 2.
Key words: transpupiJlary thermotherapy, choroidal neovascularization, fibrovascular pigment epithelium detachment, hemorrhage
CAN
J OPHTHALMOL-VOL. 38, NO.4, 2003
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