Current Eye Research
ISSN: 0271-3683 (Print) 1460-2202 (Online) Journal homepage: http://www.tandfonline.com/loi/icey20
Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage Gokcen Gokce, Ali Hakan Durukan, Gokhan Ozge, Tarkan Mumcuoglu, Talay Koylu & Cem Ozgonul To cite this article: Gokcen Gokce, Ali Hakan Durukan, Gokhan Ozge, Tarkan Mumcuoglu, Talay Koylu & Cem Ozgonul (2015): Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage, Current Eye Research To link to this article: http://dx.doi.org/10.3109/02713683.2015.1029135
Published online: 05 May 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icey20 Download by: [Chinese University of Hong Kong]
Date: 12 November 2015, At: 19:05
Current Eye Research, Early Online, 1–2, 2015 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2015.1029135
LETTER TO THE EDITOR
Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage
Downloaded by [Chinese University of Hong Kong] at 19:05 12 November 2015
Gokcen Gokce1, Ali Hakan Durukan2, Gokhan Ozge2, Tarkan Mumcuoglu2, Talay Koylu3 and Cem Ozgonul4 1
Department of Ophthalmology, Kayseri Military Hospital, Kayseri, Turkey, 2Department of Ophthalmology, Gulhane Military Medical Academy, Ankara, Turkey, 3Department of Ophthalmology, Tatvan Military Hospital, Bitlis, Turkey, and 4Department of Ophthalmology, Van Military Hospital, Van, Turkey
We were very interested in the study of Zhao et al.,1 which described bevacizumab treatment for acute branch retinal vein occlusion (BRVO) accompanied by subretinal hemorrhage. While we agree as to the beneficial effects of bevacizumab, we have several significant concerns about the study. Ischemia has always been a subject of debate with regard to treatment and prognosis of BRVO. Not only does ischemia dramatically alter treatment responses, but also strongly correlates with severity of macular edema and loss of visual acuity.2 Sensory retinal elevation and/or subretinal hemorrhage are associated with capillary nonperfusion. Moreover, the clinical course of BRVO can be influenced by the extent of retinal and peripheral ischemia.3 Therefore, prognoses vary according to the severity of ischemia, particularly when the ischemia extends to the fovea.4 In the Zhao et al. study, it is difficult to understand how the reported initial visual acuities of patients with foveal subretinal hemorrhage could be higher – although not statistically so – than those of patients with no subretinal hemorrhage. Nevertheless, final visual acuities were reported as being poorer in their subretinal hemorrhage group of patients. Also, their data indicated that any degree of macular or peripheral ischemia could be present in either group.
Significantly, no fluorescein angiography (FA) data evaluating retinal perfusion status were presented in this study. Although it may be difficult, on initial presentation, to assess the macular region’s vascular perfusion status by FA, their reported (mean) duration of symptoms preceding initial examination was of sufficient length to have performed baseline FA. After all, the authors noted that following the acute phase of the BRVO, FA was performed in order to detect areas of capillary non-perfusion. Thus, it was clearly understood from the article that FA was performed at least once for each patient during the 6-month-follow-up period. In any case, this information should probably have been eliminated from, or at least de-emphasized in, the manuscript. Regarding follow-up times, the authors provided no clear information, but merely mentioned that the minimum follow-up period was 6 months. Results at a specified final visit rather than those from the earlier 6-month visit should have been the main focus for treatment efficacy. Another area of concern is that ischemic areas were treated by grid laser photocoagulation (LP) 1 week after bevacizumab treatment. Since grid LP is acknowledged as being an effective treatment for macular edema-induced BRVO, but is of limited value
Received 12 December 2014; revised 20 January 2015; accepted 5 March 2015; published online 4 May 2015 Correspondence: Gokcen Gokce, MD, Department of Ophthalmology, Kayseri Military Hospital, Kayseri, Turkey. Tel:+905054927620. E-mail: [email protected]
1
Downloaded by [Chinese University of Hong Kong] at 19:05 12 November 2015
2
G. Gokce et al.
for treating capillary non-perfusion areas adjacent to the macula, prophylactic scatter LP should have been performed on the capillary non-perfused areas so as to avoid neovascularization or vitreous hemorrhage. Next, it was not clearly shown which intravitreal treatment, bevacizumab or LP, was more effective for treating BRVO. In general, a combination of two treatments is more effective than a single treatment. There is, thus, the possibility that greater beneficial effects were achieved on the visual acuity of the patients also treated with grid LP. In conclusion, the major prognostic factor for visual outcome in BRVO is the extent of ischemia. The Zhao et al. study would be more reflective of bevacizumab treatment for acute BRVO accompanied by subretinal hemorrhage if data concerning the ischemic status of their patients had been presented.
ACKNOWLEDGMENTS The authors would like to thank Dr. Kathryn Pokorny and Ayse Unal Ersonmez for professional language editing.
DECLARATION OF INTEREST None of the authors have any conflicts of interest to disclose.
REFERENCES 1. Zhao L, Li B, Feng K, Han L, Ma Z, Liu Y. Bevacizumab treatment for acute branch retinal vein occlusion accompanied by subretinal hemorrhage. Curr Eye Res 2014:1–5. [Epub ahead of print]. 2. Gokce G, Sobaci G, Durukan AH, Erdurman FC. The comparison of intravitreal triamcinolone and bevacizumab in patients with macular edema secondary to branch retinal vein occlusion. Clin Ophthalmol 2014;8: 355–362. 3. Singer M, Tan CS, Bell D, Sadda SR. Area of peripheral retinal nonperfusion and treatment response in branch and central retinal vein occlusion. Retina 2014;34: 1736–1742. 4. Parodi MB, Di Stefano G, Ravalico G. Grid laser treatment for exudative retinal detachment secondary to ischemic branch retinal vein occlusion. Retina 2008;28: 97–102.
Current Eye Research
ISSN: 0271-3683 (Print) 1460-2202 (Online) Journal homepage: http://www.tandfonline.com/loi/icey20
Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage Gokcen Gokce, Ali Hakan Durukan, Gokhan Ozge, Tarkan Mumcuoglu, Talay Koylu & Cem Ozgonul To cite this article: Gokcen Gokce, Ali Hakan Durukan, Gokhan Ozge, Tarkan Mumcuoglu, Talay Koylu & Cem Ozgonul (2015): Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage, Current Eye Research To link to this article: http://dx.doi.org/10.3109/02713683.2015.1029135
Published online: 05 May 2015.
Submit your article to this journal
Article views: 40
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icey20 Download by: [Chinese University of Hong Kong]
Date: 12 November 2015, At: 19:05
Current Eye Research, Early Online, 1–2, 2015 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2015.1029135
LETTER TO THE EDITOR
Comment on Bevacizumab Treatment for Acute Branch Retinal Vein Occlusion Accompanied by Subretinal Hemorrhage
Downloaded by [Chinese University of Hong Kong] at 19:05 12 November 2015
Gokcen Gokce1, Ali Hakan Durukan2, Gokhan Ozge2, Tarkan Mumcuoglu2, Talay Koylu3 and Cem Ozgonul4 1
Department of Ophthalmology, Kayseri Military Hospital, Kayseri, Turkey, 2Department of Ophthalmology, Gulhane Military Medical Academy, Ankara, Turkey, 3Department of Ophthalmology, Tatvan Military Hospital, Bitlis, Turkey, and 4Department of Ophthalmology, Van Military Hospital, Van, Turkey
We were very interested in the study of Zhao et al.,1 which described bevacizumab treatment for acute branch retinal vein occlusion (BRVO) accompanied by subretinal hemorrhage. While we agree as to the beneficial effects of bevacizumab, we have several significant concerns about the study. Ischemia has always been a subject of debate with regard to treatment and prognosis of BRVO. Not only does ischemia dramatically alter treatment responses, but also strongly correlates with severity of macular edema and loss of visual acuity.2 Sensory retinal elevation and/or subretinal hemorrhage are associated with capillary nonperfusion. Moreover, the clinical course of BRVO can be influenced by the extent of retinal and peripheral ischemia.3 Therefore, prognoses vary according to the severity of ischemia, particularly when the ischemia extends to the fovea.4 In the Zhao et al. study, it is difficult to understand how the reported initial visual acuities of patients with foveal subretinal hemorrhage could be higher – although not statistically so – than those of patients with no subretinal hemorrhage. Nevertheless, final visual acuities were reported as being poorer in their subretinal hemorrhage group of patients. Also, their data indicated that any degree of macular or peripheral ischemia could be present in either group.
Significantly, no fluorescein angiography (FA) data evaluating retinal perfusion status were presented in this study. Although it may be difficult, on initial presentation, to assess the macular region’s vascular perfusion status by FA, their reported (mean) duration of symptoms preceding initial examination was of sufficient length to have performed baseline FA. After all, the authors noted that following the acute phase of the BRVO, FA was performed in order to detect areas of capillary non-perfusion. Thus, it was clearly understood from the article that FA was performed at least once for each patient during the 6-month-follow-up period. In any case, this information should probably have been eliminated from, or at least de-emphasized in, the manuscript. Regarding follow-up times, the authors provided no clear information, but merely mentioned that the minimum follow-up period was 6 months. Results at a specified final visit rather than those from the earlier 6-month visit should have been the main focus for treatment efficacy. Another area of concern is that ischemic areas were treated by grid laser photocoagulation (LP) 1 week after bevacizumab treatment. Since grid LP is acknowledged as being an effective treatment for macular edema-induced BRVO, but is of limited value
Received 12 December 2014; revised 20 January 2015; accepted 5 March 2015; published online 4 May 2015 Correspondence: Gokcen Gokce, MD, Department of Ophthalmology, Kayseri Military Hospital, Kayseri, Turkey. Tel:+905054927620. E-mail: [email protected]
1
Downloaded by [Chinese University of Hong Kong] at 19:05 12 November 2015
2
G. Gokce et al.
for treating capillary non-perfusion areas adjacent to the macula, prophylactic scatter LP should have been performed on the capillary non-perfused areas so as to avoid neovascularization or vitreous hemorrhage. Next, it was not clearly shown which intravitreal treatment, bevacizumab or LP, was more effective for treating BRVO. In general, a combination of two treatments is more effective than a single treatment. There is, thus, the possibility that greater beneficial effects were achieved on the visual acuity of the patients also treated with grid LP. In conclusion, the major prognostic factor for visual outcome in BRVO is the extent of ischemia. The Zhao et al. study would be more reflective of bevacizumab treatment for acute BRVO accompanied by subretinal hemorrhage if data concerning the ischemic status of their patients had been presented.
ACKNOWLEDGMENTS The authors would like to thank Dr. Kathryn Pokorny and Ayse Unal Ersonmez for professional language editing.
DECLARATION OF INTEREST None of the authors have any conflicts of interest to disclose.
REFERENCES 1. Zhao L, Li B, Feng K, Han L, Ma Z, Liu Y. Bevacizumab treatment for acute branch retinal vein occlusion accompanied by subretinal hemorrhage. Curr Eye Res 2014:1–5. [Epub ahead of print]. 2. Gokce G, Sobaci G, Durukan AH, Erdurman FC. The comparison of intravitreal triamcinolone and bevacizumab in patients with macular edema secondary to branch retinal vein occlusion. Clin Ophthalmol 2014;8: 355–362. 3. Singer M, Tan CS, Bell D, Sadda SR. Area of peripheral retinal nonperfusion and treatment response in branch and central retinal vein occlusion. Retina 2014;34: 1736–1742. 4. Parodi MB, Di Stefano G, Ravalico G. Grid laser treatment for exudative retinal detachment secondary to ischemic branch retinal vein occlusion. Retina 2008;28: 97–102.
Current Eye Research
