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Reactive macular edema and acute visual loss after photodynamic therapy on the same day of fluorescein angiography.
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MedLine Citation:
PMID:  21897625     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Reactive macular edema can occur following photodynamic therapy (PDT) in patients who have undergone fluorescein angiography (FA) on the same day. It might be better not to perform PDT on the same day of FA to avoid side effects. The safety interval between FA and PDT should be at least 24 hours, considering fluorescein retention in the body.
Authors:
Chun-Ju Lin; Jiunn-Feng Hwang; San-Ni Chen
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Oman journal of ophthalmology     Volume:  4     ISSN:  0974-7842     ISO Abbreviation:  Oman J Ophthalmol     Publication Date:  2011 May 
Date Detail:
Created Date:  2011-09-07     Completed Date:  2011-11-10     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101519430     Medline TA:  Oman J Ophthalmol     Country:  India    
Other Details:
Languages:  eng     Pagination:  84-6     Citation Subset:  -    
Affiliation:
Department of Ophthalmology, Changhua Christian Hospital, Taichung, Taiwan.
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Full Text
Journal Information
Journal ID (nlm-ta): Oman J Ophthalmol
Journal ID (publisher-id): OJO
ISSN: 0974-620X
ISSN: 0974-7842
Publisher: Medknow Publications, India
Article Information
© 2011 Chun-Ju L, et al.
open-access:
Print publication date: Season: May-Aug Year: 2011
Volume: 4 Issue: 2
First Page: 84 Last Page: 86
ID: 3160076
PubMed Id: 21897625
Publisher Id: OJO-4-84
DOI: 10.4103/0974-620X.83660

Reactive macular edema and acute visual loss after photodynamic therapy on the same day of fluorescein angiography
Chun-Ju Lin123
Jiunn-Feng Hwang13
San-Ni Chen13
1Department of Ophthalmology, Changhua Christian Hospital, Taichung, Taiwan
2Department of Optometry, Chung Hwa University of Medical Technology, Taichung, Taiwan
3School of Medicine, Chung Shan Medical University, Taichung, Taiwan
Correspondence: Correspondence: Dr. San-Ni Chen, Department of Ophthalmology, 135 Nanxiao St., Changhua city 500, Taiwan. E-mail: 108562@cch.org.tw

Introduction

Verteporfin is the first light-activated drug that has been shown in large, randomized clinical trials to reduce the risk of visual loss compared with no treatment in choroidal neovascularization (CNV). The 2005 update in guidelines for using verteporfin in photodynamic therapy (PDT) for CNV due to age-related macular degeneration (AMD) only indicates that the therapy should be initiated ideally within 1 week of the initial fluorescein angiography (FA). No mention has been made about the shortest safe interval between FA and PDT. We report a 65-year-old male patient of reactive macular edema which occurred following PDT performed on the same day of FA.


Case Report

A 65-year-old male complained of blurred vision OS. Best-corrected visual acuity (BCVA) was 1.0 OD and 0.5 OS. FA revealed predominantly classic CNV due to AMD OS. Optical coherent tomography (OCT) showed macular edema and intraretinal fluid OS.

After seven intravitreal bevacizumab injections and one ranibizumab injection, BCVA remained 0.5, but CNV persisted. OCT showed retinal pigment epithelium (RPE) detachment and intraretinal fluid [Figure 1]. Repeat FA was performed. Verteporfin (6 mg/m2 of body surface area) was administered via intravenous infusion of 30 ml over 10 minutes. Fifteen minutes after the start of the infusion, a laser light at 689 nm delivered 50 J/cm2 at an intensity of 600 mW/cm2 (total 127 mW) over 83 seconds, using a spot size with a diameter of 5000 mm. Intravitreal 1.25 mg bevacizumab injection was also administered on the same day after 1 hour of PDT as per the patient's request.

The whole procedure went on smoothly; however, blurred vision and central scotoma were noted soon after PDT. Vision dropped from 0.5 to hand movement. OCT showed profound macular edema [Figure 2]. Posterior subtenon triamcinolone was given. BCVA improved to 0.05 one day later. After 1 week, BCVA improved to 0.1. Indocyanine green angiography (ICGA) revealed focal hypofluorescence compatible with the irradiated area [Figure 3]. Acetylsalicylic acid (100 mg) one tablet daily was prescribed. After 1 month, BCVA recovered to 0.7. After 2 months, BCVA remained 0.7 and FA showed no CNV. OCT revealed no more macular edema [Figure 4].


Discussion

Verteporfin is the first light-activated drug that has been shown in large, randomized clinical trials to reduce the risk of losing ≥3 lines of visual acuity or losing ≥6 lines of visual acuity compared with no treatment in patients with CNV. Laser irradiation is performed with laser light at 689 nm using a Coherent Opal Photoactivator.

Sodium fluorescein is a hydrocarbon that responds to light energy between 465 and 490 nm and fluoresces at a wavelength of 520–530 nm. The excitation wavelength is blue; the resultant fluorescence is green-yellow. The peak emission is at 520–530 nm, but the wavelength can be up to 700 nm. Fluorescein is eliminated by the liver and kidneys within 24 hours, although traces may be found in the body for up to a week after injection.

The 2005 update in guidelines for using verteporfin in PDT for CNV due to AMD and other causes only indicates that the therapy should be initiated ideally within 1 week of the initial FA on which the clinical decision to treat is based.[1] The shortest safe interval between FA and PDT has not been mentioned.

In our case, reactive macular edema developed soon after PDT given on the same day of FA. Vision deteriorated from 0.5 to hand movement. ICGA revealed focal non-perfusion compatible with the irradiated area. Fortunately, BCVA recovered to 0.7 under conservative treatment after 1 month.

Transient choroidal ischemia after PDT with verteporfin in AMD has been observed previously in human and animal studies.[24] Acute visual decreases after PDT for AMD have been documented; choroidal hypoperfusion was one of the reasons.[3, 4] However, visual recovery in some patients was observed.[4] Choroidal infarction following PDT with verteporfin has been reported.[5, 6] There were nine patients with age ranging from 75 to 93 years. Five of the nine patients were treated with combination PDT and intravitreal triamcinolone. Our patient is relatively younger (65 years) and was treated with combination PDT and intravitreal bevacizumab. It is unknown whether therapy combining PDT with intravitreal triamcinolone or older age alters the response of the choroid because there have been no pathological studies of such eyes. All nine patients had poor visual outcomes. Conversely, our patient's vision improved after 1 month.

Schmidt-Erfurth et al. found that there was no apparent correlation between FA findings and final visual acuity. Because the incidence of hypofluorescence in eyes that did not have a post-treatment visual acuity decrease was not documented, it was not possible to establish a relationship between the hypofluorescence and unfavorable vision outcomes.[7] They also proposed that hypoperfusion might actually help to reduce recanalization of CNV and permit neuronal recovery by decreasing exposure to oxygen and oxidative radicals. Just like our case, though focal non-perfusion was well demonstrated by ICGA, his vision recovered to 0.7 after 1 month.

Reactive macular edema soon after PDT on the same day of FA has not reported in the literature. The possible mechanism is not well understood. We propose there might be drug interaction between sodium fluorescein and verteporfin, which reduced the selectivity of verteporfin and caused higher photosensitization to 689 nm laser light. Adjacent structures such as photoreceptors, RPE and choroid were more damaged in the course of PDT. Compromised RPE pumping function, damaged photoreceptors and choroidal non-perfusion resulted in profuse macular edema and acute visual loss.

According to our experience, reactive macular edema can occur following PDT in patients who have undergone FA on the same day. It might be better not to perform PDT on the same day as that of FA to avoid unwanted immediate side effects such as reactive macular edema and acute visual loss. The safety interval between FA and PDT should be at least 24 hours to 1 week, considering the possible fluorescein retention in the body. Further studies are necessary to clarify this issue.


Notes

Source of Support: Nil

Conflict of Interest: None declared.

References
1. Verteporfin Roundtable Participants. Guidelines for using verteporfin (Visudyne) in photodynamic therapy for choroidal neovascularization due to age-related macular degeneration and other causes: UpdateRetinaYear: 2005251193415689800
2. Costa RA,Farah ME,Cardillo JA,Calucci D,Williams GA. Immediate indocyanine green angiography and optical coherence tomography evaluation after photodynamic therapy for subfoveal choroidal neovascularizationRetinaYear: 2003231596512707593
3. Michels S,Schmidt-Erfurth U. Sequence of early vascular events after photodynamic therapyInvest Ophthalmol Vis SciYear: 20034421475412714655
4. Recchia FM,Greenbaum S,Recchia CA,Ruby AJ,Alldredge CD,Hassan TS. Self-reported acute decrease in visual acuity after photodynamic therapy for age-related macular degenerationRetinaYear: 2006261042817151492
5. Klais CM,Ober MD,Freund KB,Ginsburg LH,Luckie A,Mauget-Faÿsse M,et al. Choroidal infarction following photodynamic therapy with verteporfinArch OphthalmolYear: 200512311495316087856
6. Lo Giudice G,De Belvis V,Piermarocchi S,Galan A,Prosdocimo G. Acute visual loss and chorioretinal infarction after photodynamic therapy combined with intravitreal triamcinoloneEur J OphthalmolYear: 200818652518609494
7. Schmidt-Erfurth U,Kiss C,Sacu S. The role of choroidal hypoperfusion associated with photodynamic therapy in neovascular age-related macular degeneration and the consequences for combination strategiesProg Retin Eye ResYear: 2009281455419272333

Figures

[Figure ID: F1]
Figure 1 

Optical coherent tomography showing retinal pigment epithelium detachment and intraretinal fluid before photodynamic therapy



[Figure ID: F2]
Figure 2 

One day after photodynamic therapy, optical coherent tomography showed profound macular edema



[Figure ID: F3]
Figure 3 

After 1 week, Indocyanine green angiography revealed focal hypofluorescence compatible with the irradiated area



[Figure ID: F4]
Figure 4 

After 2 months, Optical coherent tomography revealed no more macular edema



Article Categories:
  • Case Report

Keywords: Fluorescein angiography, macular edema, photodynamic therapy, verteporfin.

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