- Email: [email protected]
Recurrent Bullous Retinal Detachments From Photodynamic Therapy for Idiopathic Polypoidal Choroidal Vasculopathy
Foundation, Creighton University, Omaha, Nebraska, Texas Tech University Health Sciences Center, Lubbock, Texas, Pfizer, Inc, New York, New York, Merck and Co, Inc, Whitehouse Station, New Jersey, Pharmacia Hellas, Athens, Greece, and Novartis Hellas, Athens, Greece. The authors indicate no financial conflict of interest. Involved in design and conduct of the study (F.T., A.L.C., A.H., M.R.W.); Involved in collection, management, analysis, and interpretation of the data (F.T., A.L.C., A.H., E.A., F.Y., A.K., T.P., L.M., M.R.W.); and involved in preparation, review, or approval of the manuscript (F.T., A.L.C., A.H., E.A., F.Y., A.K., T.P., L.M., M.R.W.). REFERENCES
1. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology 1992;99:993–943. 2. Mitchell P, Smith W, Attebo K, Wang JJ. Prevalence of age-related maculopathy in Australia: the Blue Mountains Eye Study. Ophthalmology 1995;102:1450 –1460. 3. Vingerling JR, Dielemans I, Hofman A, et al. The prevalence of age-related maculopathy in the Rotterdam Study. Ophthalmology 1995;102:205–210. 4. Augood CA, Vingerling JR, de Jong PT, et al. Prevalence of age-related maculopathy in older Europeans: the European Eye Study (EUREYE). Arch Ophthalmol 2006;124:529 – 535. 5. Topouzis F, Coleman AL, Harris A, et al. Association of blood pressure status with the optic disc structure in non-glaucoma subjects: the Thessaloniki Eye Study. Am J Ophthalmol 2006; 142:60 – 67. 6. Bird AC, Bressler NM, Bressler SB, et al. An international classification and grading system for age-related maculopathy and age-related macular degeneration: the International ARM Epidemiological Study Group. Surv Ophthalmol 1995;39: 367–374. 7. Varma R, Fraser-Bell S, Tan S, Klein R, Azen SP. Prevalence of age-related macular degeneration in Latinos: the Los Angeles Latino Eye Study. Ophthalmology 2004;111: 1288 –1297.
Recurrent Bullous Retinal Detachments From Photodynamic Therapy for Idiopathic Polypoidal Choroidal Vasculopathy Manvi Prakash, MD, and Dennis P. Han, MD To report the recurrent bullous retinal detachments as complications of photodynamic therapy (PDT) for idiopathic polypoidal choroidal vasculopathy (IPCV). DESIGN: Interventional case report. PURPOSE:
Accepted for publication Jun 21, 2006. From the The Eye Institute, Medical College of Wisconsin, Milwaukee, Wisconsin. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York (Medical College of Wisconsin, Milwaukee, Wisconsin). Inquiries to Dennis P. Han, MD, Eye Institute, Medical College of Wisconsin, 925 North 87th St, Milwaukee, WI 53226-4812; e-mail: [email protected]
VOL. 142, NO. 6
METHODS: A pseudophakic 84-year-old-woman had IPCV and decreased vision. Angiography demonstrated macular leakage. PDT with verteporfin was applied. Two days later, visual acuity decreased from 20/50 to 20/400. Examination revealed extensive inferior subretinal fluid, which mimicked a pseudophakic rhegmatogenous retinal detachment. A scleral buckle was placed; no retinal breaks were identified. RESULTS: Vision and fluid resolved over three weeks. Four months later, examination revealed decreased vision and persistent leakage. Two days after repeat PDT, bullous exudative macular detachment recurred. Detachment resolved over two weeks; visual acuity returned to 20/50. CONCLUSION: IPCV that is treated with PDT may be complicated by iatrogenic bullous exudative retinal detachments that resemble rhegmatogenous detachments. Modified treatment parameters may reduce the risk of recurrence. The natural history likely includes spontaneous resolution and visual recovery. (Am J Ophthalmol 2006;142:1079 –1081. © 2006 by Elsevier Inc. All rights reserved.)
I
DIOPATHIC POLYPOIDAL CHOROIDAL VASCULOPATHY
(IPCV) involves abnormal choroidal vascular nets with terminal dilatations.1 These are visible ophthalmoscopically as reddish-orange nodules below retinal pigment epithelium (RPE) and angiographically as polypoidal lesions. The lesions can cause recurrent serosanguineous RPE and neurosensory retinal detachments. Associated vision loss may be severe and permanent if the overlying RPE and retina are damaged.2 Currently, no consensus on the treatment of IPCV exists; however, photodynamic therapy (PDT) with verteporfin has had promising results.3 The following case report describes an unusual complication of recurrent, bullous retinal detachments within two days of two separate PDT treatments in a single eye of one patient. This indicates a causative role of PDT and a predictability component on repeated treatment. A 84-year-old woman with IPCV (Figure 1) with decreased visual acuity (VA) of 20/50 in her pseudophakic left eye was evaluated. Fluorescein angiography (FA) demonstrated macular leakage hyperfluorescence. PDT with verteporfin was applied with 689 nm laser, 6.3 mm spot diameter, and 600 mW/cm2 that was begun 15 minutes after verteporfin injection initiation at standard labeled dose (6 mg/m2). Two days after treatment, the patient returned with painless vision loss in the treated eye; VA measured 20/ 400. Examination revealed bullous retinal elevation from the 4 through 8 o’clock meridians. It extended anteriorly to the ora-serrata throughout its extent and posteriorly to the posterior pole, which caused a shallow
BRIEF REPORTS
1079
FIGURE 1. Indocyanine green angiography of the left eye of an 84-year-old woman that was obtained six years before the onset of recurrent bullous retinal detachments from photodynamic therapy (PDT) shows polypoidal vascular structures (arrowheads) and an interconnecting vascular network (arrow) with late leakage that was consistent with idiopathic polypoidal choroidal vasculopathy (IPCV).
FIGURE 2. Fluorescein angiogram of left eye just before second photodynamic therapy (PDT) treatment for idiopathic polypoidal choroidal vasculopathy (IPCV) shows persistent macular hyperfluorescence with late leakage. This angiogram was obtained after complete resolution of bullous inferior retinal detachment that had occurred after the first PDT treatment. Visual acuity was 20/60.
macular detachment. This mimicked a pseudophakic, bullous, rhegmatogenous retinal detachment. A scleral buckle procedure was performed empirically; however, no breaks were identified before or during the operation. The subretinal fluid resolved by postoperative day 22; VA returned to 20/50. Four months later, her vision decreased to 20/60. FA demonstrated persistent macular leakage, as seen before initial treatment (Figure 2). PDT was repeated with same treatment parameters. Two days after treatment, she again experienced painless vision loss to 20/200 in the treated eye. Examination demonstrated recurrent exudative macular and inferior retinal detachment with shifting subretinal fluid and scleral buckle in original position. FA showed hypofluorescence in the PDT-treated area (Figure 3). The 1080
AMERICAN JOURNAL
patient was observed, and the detachment resolved spontaneously over 14 days. By three months, VA had returned to 20/50. We are unaware of previous reports of acute recurrent exudative retinal detachments that mimic rhegmatogenous detachments after PDT for IPCV. Exudative detachments after PDT have been reported in two patients with age-related macular degeneration and subfoveal occult neovascular membranes.4 Both patients were observed; the subretinal fluid resolved within three months, and vision returned to pretreatment levels. Other investigators have documented that PDT increases vascular endothelial growth factor expression in the choriocapillary endothelial layer only within the treated choroidal vessels.5 Up-regulation of this potent activator of vascular permeOF
OPHTHALMOLOGY
DECEMBER 2006
Age-related Macular Degeneration Is Associated With an Increased Risk of Hip Fractures in the Medicare Database Eleftherios Anastasopoulos, MD, Fei Yu, PhD, and Anne L. Coleman, MD, PhD PURPOSE: To explore the relationship between age-related
FIGURE 3. Fluorescein angiogram of left eye, arteriovenous phase, after second photodynamic therapy (PDT) treatment was given for idiopathic polypoidal choroidal vasculopathy (IPCV), shows marked macular hypofluorescence that surrounds localized hyperfluorescence in the PDT–treated area. A co-existing recurrent inferior bullous retinal detachment from the PDT treatment was present, which simulated the clinical course after the first PDT treatment. Visual acuity was 20/200 but returned to 20/50 over three months.
ability may increase subretinal fluid. This may help explain the transient shifting subretinal fluid that was noted in our patient after successive PDT treatments. Patients with IPCV who experience a bullous exudative detachment after PDT treatment may be at risk for subsequent episodes with transient and severe visual loss. In such cases, modification of initial treatment parameters may be appropriate. The natural history of PDT-associated exudative detachments likely includes spontaneous resolution and return of vision. REFERENCES
1. Yannuzzi LA, Sorenson J, Spaide RF, Lipson B. Idiopathic polypoidal choroidal vasculopathy (IPCV). Retina 1990;10: 1– 8. 2. Moorthy RS, Lyon AT, Rabb MF, Spaide RF, Yannuzzi LA, Jampol LM. Idiopathic polypoidal choroidal vasculopathy of the macula. Ophthalmology 1998;105:1380 –1385. 3. Spaide RF, Donsoff I, Lam DL, et al. Treatment of polypoidal choroidal vasculopathy with photodynamic therapy. Retina 2002;22:529 –535. 4. Holz ER, Linares L, Mieler WF, Weinberg DV. Exudative complications after photodynamic therapy. Arch Ophthalmol 2003;121:1649 –1652. 5. Schmidt-Erfurth U, Schlotzer-Schrehard U, Cursiefen C, Michels S, Beckendorf A, Naumann GO. Influence of photodynamic therapy on expression of vascular endothelial growth factor (VEGF), VEGF receptor 3, and pigment epitheliumderived factor. Invest Ophthalmol Vis Sci 2003;44:4473– 4480.
VOL. 142, NO. 6
macular degeneration (AMD) and incident hip fractures in the Medicare population. DESIGN: Prospective cohort study. METHODS: With a 5% random sample of Medicare beneficiaries in 1995, 8596 cases were coded with exudative AMD; 26,942 cases were coded with atrophic AMD, and 1,013,748 cases were coded without AMD. The Medicare claims from 1996 to 1999 were evaluated for hip fracture codes. The relationship between AMD and incident hip fractures was analyzed with multiple logistic regression models, with adjustment for baseline, ocular, and systemic covariates. RESULTS: In adjusted analyses, the risk of hip fractures was similar in cases that were coded with exudative AMD (odds ratio, 1.03; 95% confidence interval (CI), 0.95, 1.12) compared with cases with no AMD but was significantly higher in cases that were coded with atrophic AMD (odds ratio, 1.11; 95% CI, 1.06, 1.16). CONCLUSION: Medicare patients with a code for atrophic AMD had an 11% greater risk of hip fractures than did patients without a code for AMD over a fouryear follow-up period. (Am J Ophthalmol 2006;142: 1081–1083. © 2006 by Elsevier Inc. All rights reserved.)
H
IP FRACTURES AMONG ELDERLY PATIENTS REPRESENT
an important public health issue.1 Visual impairment has been recognized in the literature as a well-documented risk factor for falls and fall-related hip fractures in elderly patients.2 However, only a limited number of studies have examined the association between hip fractures and specific eye disorders.3–5 Specifically, regarding age-related macular degeneration (AMD), only one previous study included patients with AMD in its analysis and featured only one hip fracture among 62 patients with AMD.4 The present study explored the association of the two forms of
Accepted for publication Jun 21, 2006. From the Center for Eye Epidemiology, Jules Stein Eye Institute, University of California at Los Angeles, School of Medicine, Los Angeles, California. Supported by the Center for Eye Epidemiology, Jules Stein Eye Institute, University of California at Los Angeles; by an unrestricted educational grant from Pfizer/Eyetech Inc; and by an unrestricted educational grant from Research to Prevent Blindness, New York, New York. Inquiries to Anne L. Coleman, MD, PhD, Center for Eye Epidemiology, Jules Stein Eye Institute, 100 Stein Plaza, Suite 2–118, Los Angeles, CA 90095; e-mail: [email protected]
BRIEF REPORTS
1081
1. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology 1992;99:993–943. 2. Mitchell P, Smith W, Attebo K, Wang JJ. Prevalence of age-related maculopathy in Australia: the Blue Mountains Eye Study. Ophthalmology 1995;102:1450 –1460. 3. Vingerling JR, Dielemans I, Hofman A, et al. The prevalence of age-related maculopathy in the Rotterdam Study. Ophthalmology 1995;102:205–210. 4. Augood CA, Vingerling JR, de Jong PT, et al. Prevalence of age-related maculopathy in older Europeans: the European Eye Study (EUREYE). Arch Ophthalmol 2006;124:529 – 535. 5. Topouzis F, Coleman AL, Harris A, et al. Association of blood pressure status with the optic disc structure in non-glaucoma subjects: the Thessaloniki Eye Study. Am J Ophthalmol 2006; 142:60 – 67. 6. Bird AC, Bressler NM, Bressler SB, et al. An international classification and grading system for age-related maculopathy and age-related macular degeneration: the International ARM Epidemiological Study Group. Surv Ophthalmol 1995;39: 367–374. 7. Varma R, Fraser-Bell S, Tan S, Klein R, Azen SP. Prevalence of age-related macular degeneration in Latinos: the Los Angeles Latino Eye Study. Ophthalmology 2004;111: 1288 –1297.
Recurrent Bullous Retinal Detachments From Photodynamic Therapy for Idiopathic Polypoidal Choroidal Vasculopathy Manvi Prakash, MD, and Dennis P. Han, MD To report the recurrent bullous retinal detachments as complications of photodynamic therapy (PDT) for idiopathic polypoidal choroidal vasculopathy (IPCV). DESIGN: Interventional case report. PURPOSE:
Accepted for publication Jun 21, 2006. From the The Eye Institute, Medical College of Wisconsin, Milwaukee, Wisconsin. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York (Medical College of Wisconsin, Milwaukee, Wisconsin). Inquiries to Dennis P. Han, MD, Eye Institute, Medical College of Wisconsin, 925 North 87th St, Milwaukee, WI 53226-4812; e-mail: [email protected]
VOL. 142, NO. 6
METHODS: A pseudophakic 84-year-old-woman had IPCV and decreased vision. Angiography demonstrated macular leakage. PDT with verteporfin was applied. Two days later, visual acuity decreased from 20/50 to 20/400. Examination revealed extensive inferior subretinal fluid, which mimicked a pseudophakic rhegmatogenous retinal detachment. A scleral buckle was placed; no retinal breaks were identified. RESULTS: Vision and fluid resolved over three weeks. Four months later, examination revealed decreased vision and persistent leakage. Two days after repeat PDT, bullous exudative macular detachment recurred. Detachment resolved over two weeks; visual acuity returned to 20/50. CONCLUSION: IPCV that is treated with PDT may be complicated by iatrogenic bullous exudative retinal detachments that resemble rhegmatogenous detachments. Modified treatment parameters may reduce the risk of recurrence. The natural history likely includes spontaneous resolution and visual recovery. (Am J Ophthalmol 2006;142:1079 –1081. © 2006 by Elsevier Inc. All rights reserved.)
I
DIOPATHIC POLYPOIDAL CHOROIDAL VASCULOPATHY
(IPCV) involves abnormal choroidal vascular nets with terminal dilatations.1 These are visible ophthalmoscopically as reddish-orange nodules below retinal pigment epithelium (RPE) and angiographically as polypoidal lesions. The lesions can cause recurrent serosanguineous RPE and neurosensory retinal detachments. Associated vision loss may be severe and permanent if the overlying RPE and retina are damaged.2 Currently, no consensus on the treatment of IPCV exists; however, photodynamic therapy (PDT) with verteporfin has had promising results.3 The following case report describes an unusual complication of recurrent, bullous retinal detachments within two days of two separate PDT treatments in a single eye of one patient. This indicates a causative role of PDT and a predictability component on repeated treatment. A 84-year-old woman with IPCV (Figure 1) with decreased visual acuity (VA) of 20/50 in her pseudophakic left eye was evaluated. Fluorescein angiography (FA) demonstrated macular leakage hyperfluorescence. PDT with verteporfin was applied with 689 nm laser, 6.3 mm spot diameter, and 600 mW/cm2 that was begun 15 minutes after verteporfin injection initiation at standard labeled dose (6 mg/m2). Two days after treatment, the patient returned with painless vision loss in the treated eye; VA measured 20/ 400. Examination revealed bullous retinal elevation from the 4 through 8 o’clock meridians. It extended anteriorly to the ora-serrata throughout its extent and posteriorly to the posterior pole, which caused a shallow
BRIEF REPORTS
1079
FIGURE 1. Indocyanine green angiography of the left eye of an 84-year-old woman that was obtained six years before the onset of recurrent bullous retinal detachments from photodynamic therapy (PDT) shows polypoidal vascular structures (arrowheads) and an interconnecting vascular network (arrow) with late leakage that was consistent with idiopathic polypoidal choroidal vasculopathy (IPCV).
FIGURE 2. Fluorescein angiogram of left eye just before second photodynamic therapy (PDT) treatment for idiopathic polypoidal choroidal vasculopathy (IPCV) shows persistent macular hyperfluorescence with late leakage. This angiogram was obtained after complete resolution of bullous inferior retinal detachment that had occurred after the first PDT treatment. Visual acuity was 20/60.
macular detachment. This mimicked a pseudophakic, bullous, rhegmatogenous retinal detachment. A scleral buckle procedure was performed empirically; however, no breaks were identified before or during the operation. The subretinal fluid resolved by postoperative day 22; VA returned to 20/50. Four months later, her vision decreased to 20/60. FA demonstrated persistent macular leakage, as seen before initial treatment (Figure 2). PDT was repeated with same treatment parameters. Two days after treatment, she again experienced painless vision loss to 20/200 in the treated eye. Examination demonstrated recurrent exudative macular and inferior retinal detachment with shifting subretinal fluid and scleral buckle in original position. FA showed hypofluorescence in the PDT-treated area (Figure 3). The 1080
AMERICAN JOURNAL
patient was observed, and the detachment resolved spontaneously over 14 days. By three months, VA had returned to 20/50. We are unaware of previous reports of acute recurrent exudative retinal detachments that mimic rhegmatogenous detachments after PDT for IPCV. Exudative detachments after PDT have been reported in two patients with age-related macular degeneration and subfoveal occult neovascular membranes.4 Both patients were observed; the subretinal fluid resolved within three months, and vision returned to pretreatment levels. Other investigators have documented that PDT increases vascular endothelial growth factor expression in the choriocapillary endothelial layer only within the treated choroidal vessels.5 Up-regulation of this potent activator of vascular permeOF
OPHTHALMOLOGY
DECEMBER 2006
Age-related Macular Degeneration Is Associated With an Increased Risk of Hip Fractures in the Medicare Database Eleftherios Anastasopoulos, MD, Fei Yu, PhD, and Anne L. Coleman, MD, PhD PURPOSE: To explore the relationship between age-related
FIGURE 3. Fluorescein angiogram of left eye, arteriovenous phase, after second photodynamic therapy (PDT) treatment was given for idiopathic polypoidal choroidal vasculopathy (IPCV), shows marked macular hypofluorescence that surrounds localized hyperfluorescence in the PDT–treated area. A co-existing recurrent inferior bullous retinal detachment from the PDT treatment was present, which simulated the clinical course after the first PDT treatment. Visual acuity was 20/200 but returned to 20/50 over three months.
ability may increase subretinal fluid. This may help explain the transient shifting subretinal fluid that was noted in our patient after successive PDT treatments. Patients with IPCV who experience a bullous exudative detachment after PDT treatment may be at risk for subsequent episodes with transient and severe visual loss. In such cases, modification of initial treatment parameters may be appropriate. The natural history of PDT-associated exudative detachments likely includes spontaneous resolution and return of vision. REFERENCES
1. Yannuzzi LA, Sorenson J, Spaide RF, Lipson B. Idiopathic polypoidal choroidal vasculopathy (IPCV). Retina 1990;10: 1– 8. 2. Moorthy RS, Lyon AT, Rabb MF, Spaide RF, Yannuzzi LA, Jampol LM. Idiopathic polypoidal choroidal vasculopathy of the macula. Ophthalmology 1998;105:1380 –1385. 3. Spaide RF, Donsoff I, Lam DL, et al. Treatment of polypoidal choroidal vasculopathy with photodynamic therapy. Retina 2002;22:529 –535. 4. Holz ER, Linares L, Mieler WF, Weinberg DV. Exudative complications after photodynamic therapy. Arch Ophthalmol 2003;121:1649 –1652. 5. Schmidt-Erfurth U, Schlotzer-Schrehard U, Cursiefen C, Michels S, Beckendorf A, Naumann GO. Influence of photodynamic therapy on expression of vascular endothelial growth factor (VEGF), VEGF receptor 3, and pigment epitheliumderived factor. Invest Ophthalmol Vis Sci 2003;44:4473– 4480.
VOL. 142, NO. 6
macular degeneration (AMD) and incident hip fractures in the Medicare population. DESIGN: Prospective cohort study. METHODS: With a 5% random sample of Medicare beneficiaries in 1995, 8596 cases were coded with exudative AMD; 26,942 cases were coded with atrophic AMD, and 1,013,748 cases were coded without AMD. The Medicare claims from 1996 to 1999 were evaluated for hip fracture codes. The relationship between AMD and incident hip fractures was analyzed with multiple logistic regression models, with adjustment for baseline, ocular, and systemic covariates. RESULTS: In adjusted analyses, the risk of hip fractures was similar in cases that were coded with exudative AMD (odds ratio, 1.03; 95% confidence interval (CI), 0.95, 1.12) compared with cases with no AMD but was significantly higher in cases that were coded with atrophic AMD (odds ratio, 1.11; 95% CI, 1.06, 1.16). CONCLUSION: Medicare patients with a code for atrophic AMD had an 11% greater risk of hip fractures than did patients without a code for AMD over a fouryear follow-up period. (Am J Ophthalmol 2006;142: 1081–1083. © 2006 by Elsevier Inc. All rights reserved.)
H
IP FRACTURES AMONG ELDERLY PATIENTS REPRESENT
an important public health issue.1 Visual impairment has been recognized in the literature as a well-documented risk factor for falls and fall-related hip fractures in elderly patients.2 However, only a limited number of studies have examined the association between hip fractures and specific eye disorders.3–5 Specifically, regarding age-related macular degeneration (AMD), only one previous study included patients with AMD in its analysis and featured only one hip fracture among 62 patients with AMD.4 The present study explored the association of the two forms of
Accepted for publication Jun 21, 2006. From the Center for Eye Epidemiology, Jules Stein Eye Institute, University of California at Los Angeles, School of Medicine, Los Angeles, California. Supported by the Center for Eye Epidemiology, Jules Stein Eye Institute, University of California at Los Angeles; by an unrestricted educational grant from Pfizer/Eyetech Inc; and by an unrestricted educational grant from Research to Prevent Blindness, New York, New York. Inquiries to Anne L. Coleman, MD, PhD, Center for Eye Epidemiology, Jules Stein Eye Institute, 100 Stein Plaza, Suite 2–118, Los Angeles, CA 90095; e-mail: [email protected]
BRIEF REPORTS
1081