Sevinç ŞAHİN ATİK, FİLİZ AFRASHİ, Cezmi AKKIN

Oftalmolojide fotodinamik tedavi

Amaç: Yaşa Bağlı Makula Dejeneresansı (YBMD) sonucu gelişen koroid neovaskülarizasyonlarının farklı tiplerinde, verteporfin kullanılarak yapılan fotodinamik tedavinin (FDT) sonuçlarını değerlendirmektir. Gereç ve Yöntem: Ege Üniversitesi Tıp Fakültesi Göz Hastalıkları Anabilim Dalı’nda YBMD'ye bağlı koroid neovaskülarizasyonlarında FDT uygulanmış 40 hastanın 42 gözü çalışma kapsamına alındı. Olguların tedavi öncesi ve sonrası görme keskinlikleri, kontrast duyarlılıkları ve floresein anjiografideki (FA) lezyon özellikleri kaydedildi. FDT uygulanmış hastaların 7. gün, 6. hafta, 12. hafta ve sonrasında ise bir sorun izlenmediği takdirde 1 yıl süre ile 3 ayda bir olan kontrolleri değerlendirildi. Hastaların 3 ay arayla çekilen FA görüntülerinde lezyonun sızdırma özelliklerine göre tedavinin başarısı değerlendirildi. Bulgular: Çalışmaya alınan 28 erkek, 12 kadın hastanın yaş ortalaması 64.50±12.00 yıldı. Lezyonların 18'i (%43) saf klasik, 4'ü (%9) minimal klasik, 15'i (%36) predominant klasik, 5'i ise okkült idi. Bu lezyonlardan 31'i (%74) subfoveal, 11'i (%26) ise juxtafoveal; 18'i (%43) iyi sınırlı, 28'i (%67) ise kötü sınırlıydı. Lezyon türleri açısından predominant klasik grupta başarı oranı daha yüksek bulundu, ancak bu fark anlamlı değildi (p=0.062). Subfoveal yerleşimli 31 gözden 30'unda başarı sağlanırken (%97), juxtafoveal yerleşimli 11 gözün 8'inde (%73) başarı sağlanmıştı (p=0.049). Tedavi öncesi lezyon çapı, görme keskinliği, kontrast duyarlılık ve uygulanan FDT sayısı açısından başarılı ve başarısız grup arasında anlamlı fark yoktu. Başarılı grupta son muayenede saptanan görme keskinliği düzeyi belirgin olarak yüksekti (p=0.015). Kontrast duyarlılıkta tedavi sonrasında istatistiksel olarak anlamlı düzelme saptandı (p=0.028). Sonuç: FDT, YBMD'ye bağlı gelişen özellikle subfoveal koroid neovaskülarizasyonlarında görme kaybı r sk n azaltmaktadır. Ancak son yıllarda yaygın kullanılan vasküler endotelyal büyüme faktörü inhibitörlerinin başarılı sonuçları nedeniyle FDT'nin YBMD tedavisinde sınırlı bir kullanımı mevcuttur.

Photodynamic therapy in ophthalmology

Aim: To evaluate the results of photodynamic therapy (PDT) using verteporfin in different types of choroidal neovascularization resulting from age-related macular degeneration (AMD). Materials and Methods: Forty-two eyes of 40 patients were included in the study. Visual acuity, contrast sensitivity and lesion characteristics in fluorescein angiography (FA) of the cases were recorded before and after PDT. The patients were evaluated at the 7th day, 6th week, 12th week, and afterwards, if no problem was observed, every 3 months in a year. We evaluated the success or failure rates of the treatment. Results: Mean age of the patients was 64.50±12.00 years. Eighteen of the lesions (43%) were pureclassical, 4 (9%) minimally-classical, 15 (36%) predominant-classical and 5 occult. Of these lesions, 31 (74%) were subfoveal and 11 (26%) juxtafoveal; 18 (43%) well-defined, and 28 (67%) poorly-defined. When examined in terms of lesion types, success rate was higher in predominant-classical group, but this difference was not statistically significant (p=0.062). Success was achieved in 30 of 31 eyes with subfoveal lesions (97%) and in 8 of 11 (73%) eyes with juxtafoveal lesions (p=0.049). The visual acuity level determined at the last visit in the successful group was significantly higher than that of the unsuccessful group (p=0.015). Statistically significant improvement in contrast sensitivity was achieved after treatment (p=0.028). Conclusion: PDT reliably reduces the risk of visual loss in subfoveal choroidal neovascularization due to AMD. However, the use of PDT in the treatment of AMD is limited because of the higher success of recently used vascular endothelial growth factor (VEGF) inhibitors.

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1. Celli, JP, Spring, BQ, Rizvi, I, et al. Imaging and photodynamic therapy: mechanisms, monitoring, and optimization. Chem Rev 2010; 110(5): 2795-838.
2. Dougherty, TJ, Gomer, CJ, Henderson, BW, et al. Photodynamic therapy. J Natl Cancer Inst 1998; 90(12): 889-905.
3. van Straten, D, Mashayekhi, V, de Bruijn, HS, Oliveira, S, and Robinson, DJ. Oncologic Photodynamic Therapy: Basic Principles, Current Clinical Status and Future Directions. Cancers (Basel) 2017; 9(2): 19.
4. Soubrane, G and Bressler, NM. Treatment of subfoveal choroidal neovascularisation in age related macular degeneration: focus on clinical application of verteporfin photodynamic therapy. Br J Ophthalmol 2001; 85(4): 483-95.
5. Bressler, NM. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials-tap report 2. Arch Ophthalmol 2001; 119(2): 198-207.
6. Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization-- verteporfin in photodynamic therapy report 2. Am J Ophthalmol 2001; 131(5): 541-60.
7. Boyer, DS, Schmidt-Erfurth, U, van Lookeren Campagne, M, Henry, EC, and Brittain, C. The Pathophysiology of Geographic Atrophy Secondary to Age-Related Macular Degeneration and the Complement Pathway as a Therapeutic Target. Retina 2017; 37(5): 819-835.
8. Ashraf, M, Souka, A, and Adelman, RA. Age-related macular degeneration: using morphological predictors to modify current treatment protocols. Acta Ophthalmol 2018; 96(2): 120-133.
9. Van Leeuwen, R, Klaver, CC, Vingerling, JR, Hofman, A, and de Jong, PT. Epidemiology of age-related maculopathy: a review. Eur J Epidemiol 2003; 18(9): 845-54.
10. 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(5): 367-74.
11. Yildirim, S, Akkin, C, Oztas, Z, Nalcaci, S, Afrashi, F, and Mentes, J. Direct Treatment Costs of Neovascular Agerelated Macular Degeneration and Comparison of Gained and/or Preserved Vision with Expenditure. Turk J Ophthalmol 2018; 48(1): 27-32.
12. Messmer, KJ and Abel, SR. Verteporfin for age-related macular degeneration. Ann Pharmacother 2001; 35(12): 1593-8.
13. Chakravarthy, U, Soubrane, G, Bandello, F, et al. Evolving European guidance on the medical management of neovascular age related macular degeneration. Br J Ophthalmol 2006; 90(9): 1188-96.
14. Dundar, H, Altinkaynak, H, Kocasarac, C, Hazar, L, Yuksel, K, and Yazici, AT. Intravitreal Ranibizumab Therapy in Wet Type Macular Degeneration. Turk J Ophthalmol 2014; 44(5): 356-360.
15. Karacorlu, M, Karacorlu, S, Burumcek, E, and H., O. A comparison of 6 months results of photodynamic therapy for classic versus classic and occult neovascularization in patient with age-related macular degeneration. T. Oft. Gaz 2002; 32: 832-837.
16. Schmidt-Erfurth, U and Hasan, T. Mechanisms of action of photodynamic therapy with verteporfin for the treatment of age-related macular degeneration. Surv Ophthalmol 2000; 45(3): 195-214.
17. Rubin, GS and Bressler, NM. Effects of verteporfin therapy on contrast on sensitivity: Results From the Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) investigation-TAP report No 4. Retina 2002; 22(5): 536-44.
18. Sharma, S, Brown, GC, Brown, MM, Hollands, H, and Shah, GK. The cost-effectiveness of photodynamic therapy for fellow eyes with subfoveal choroidal neovascularization secondary to age-related macular degeneration. Ophthalmology 2001; 108(11): 2051-9.
19. Arias, L, Ruiz-Moreno, JM, Gomez-Ulla, F, Fernandez, M, and Montero, J. A 1-year retrospective review of ranibizumab for naive nonsubfoveal choroidal neovascularization secondary to age-related macular degeneration. Retina 2009; 29(10): 1444-9.
20. Rosenfeld, PJ, Brown, DM, Heier, JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006; 355(14): 1419-31.
21. Brown, DM, Kaiser, PK, Michels, M, et al. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006; 355(14): 1432-44.
22. Brown, DM, Michels, M, Kaiser, PK, Heier, JS, Sy, JP, and Ianchulev, T. Ranibizumab versus verteporfin photodynamic therapy for neovascular age-related macular degeneration: Two-year results of the ANCHOR study. Ophthalmology 2009; 116(1): 57-65 e5.
23. Larsen, M, Schmidt-Erfurth, U, Lanzetta, P, et al. Verteporfin plus ranibizumab for choroidal neovascularization in age-related macular degeneration: twelve-month MONT BLANC study results. Ophthalmology 2012; 119(5): 992-1000.
24. Kaiser, PK, Boyer, DS, Cruess, AF, Slakter, JS, Pilz, S, and Weisberger, A. Verteporfin plus ranibizumab for choroidal neovascularization in age-related macular degeneration: twelve-month results of the DENALI study. Ophthalmology 2012; 119(5): 1001-10.
25. Tozer, K, Roller, AB, Chong, LP, et al. Combination therapy for neovascular age-related macular degeneration refractory to anti-vascular endothelial growth factor agents. Ophthalmology 2013; 120(10): 2029-34.
26. Newman, DK. Photodynamic therapy: current role in the treatment of chorioretinal conditions. Eye (Lond) 2016; 30(2): 202-10.
27. Van Asten, F, Michels, CTJ, Hoyng, CB, et al. The cost-effectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-A cost-effectiveness analysis from a societal perspective. PLoS One 2018; 13(5): e0197670.