Transpupillary Thermotherapy for CNVM and Choroidal … · Transpupillary Thermotherapy lNatural History of CNVM – 50%-55% lost at least 3 lines of VA in one year of FU – 45%-50%
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Transpupillary Thermotherapy
lClassic CNVM: well demarcated area by fluorescein angiography
lOccult CNVM: fibrovascular RPED or late phase leakage
Transpupillary Thermotherapy
lNatural History of CNVM
– 50%-55% lost at least 3 lines of VA in one year of FU
– 45%-50% lost at least 6 lines of VA in two years of FU
Transpupollary ThermotherapyTreatment options for CNVM
- Laser photocoagulation direct feeder vessels
- photodynamic theraphy- Surgical removal of CNVM- Macular translocation- Medical treatment
steroid anti-VEGF
- Dietary supplement
Transpupillary Thermotherapy for CNVM
History
lReichel E. et al, 1997 (Presentation)
lReichel E. et al, 1999 (Ophthalmology)
Transpupillary Thermotherapy
lLow irradiance
lLarge Spot size
lLong-pulsed infrared laser
lTarget temperature rise: 10-15°
Transpupillary Thermotherapy
lProposed mechanism
– Vascular thrombosis (Free radical, apoptosis, heat shock protein)
– Thermal inhibition of angiogenesis
– Induction of fibrosis
Transpupillary Thermotheraphy
l Instrument
– Diode laser, 810nm
– Slit lamp
– Area centralis lens, Q lens
Transpupillary Thermotheraphyl Power setting
– Power / diameter = 247mw/mm– Spot size 1.2, 2.0, 3.0mm, 3.85mm, 5.77mm– Power: 800mw 3.0mm
530 2.0mm320 1.2mm955 3.85mm
1430 5.77mm – Duration 1min– Test spots ( ? )
Transpupillary Thermotherapy
lPower adjustment
– Pigmentation– Pseudophakia– Classic vs occult– Fluid, blood – Myopia
Transpupillary Thermotherapy
lPower adjustment
Extensive fluid elevation : 10% increase
Subretinal blood : 5-10% increase
Transpupillary Thermotherapy
lRetreatment– Time : Occult 3 months
Classic 2 months – Indications
No reduction of exudationVA lossActive CNVM
Transpupillary Thermotherapy
lAdvantage
– Uncomplicated procedure
– No immediate scotoma
– No immediate retinal damage
Transpupillary Thermotherapyl Previous studies (improved: same: worsened)
I: 20%, 30%S: 65%, 40%W: 25%, 30%(Reichel et al, Miller-Rivero et al)I: 0%S: 60%W: 40% (Newsom et al)
Transpupillary Thermotherapy
lClinical TrialsTTT 4 CNV– Occult, ARMD– >50year– <2 D.D.– Serous RPED <25%– Classic component <10%
Transpupillary Thermotherapy (TTT)
l Patients and Methodsl CNVM:
inclusion criteriaARMD or myopic degenerationSubfoveal NV confirmed by FAVA < 0.5no previous treatment
l Thorough ophthalmological examinations and FA
Transpupillary Thermtherapy
lPatients and Methods– Treatment Methods
lDiode laser, 810nm (Iris Medical OculrightSLX) through slit lamp
l Test spotslPower: 250-750mwlEnd point: no visible lesionslSingle surgern
Transpupillary Thermotherapy
l Results- ARMD 28 myopia 2- classic 10, occult 17, mixed 3- size 1 ≦1DD
10 > 1DD~4DD19 > 4DD
- age: 36~86 (69.6)- Fu: 1~24M’(8.72)
Transpupillary Thermotherapy
lConclusion– Limited experiences suggest beneficial– Both classic and occult respond to the
treatment– Unpredictable outcome
lFuture direction– Combined with ICG
ScarS2MNDC, 1DDNDL648
Scar=RDW9M’0.03C, 4.5DDNDL699
Scar+ActiveS4M’0.01O, 5-6DD0.02R7610
Size ↑W14M’0.15O, 1DD0.3R7411
Size ↑W3M’0.01C, 4DDNDL8612
Size ↓S12M’0.03C,1DD0.05R7313
Scar I5M0.1O,0.5DD0.05L6514
Scar + EI3M0.05-0.1O,2DD0.04L687
ScarI15M0.053DD0.025R6915
S2M0.04O,1.5DD0.04R746
S3MNDO, 1.5DDNDR765
ScarI16M0.03O,6-7DDNDL714
RecurrentI→W14MNDO, 1.5DD0.05R633
I4.5M0.05-0.1O, 1/5DD0.05R622
Size ↑W15M0.01O=C, 1DD0.05R681
CommentResultFu(M’)Post-VAF’d change
Pre-VAR/LAgeCase No.
S1M’NDO, 1DDNDR8328
W4M’0.05O, 2DD0.2L8029
W3M’0.05O, 1DD0.1R7030
S14M’0.1C, 2/3DD0.1R3621
I8M’0.1C, 1DDNDL6522
S5M’0.1O, 1DD0.1L7823
W3M’0.05C, 1.5DD0.09L8324
W24M’0.01O,4.5DD0.4L6525
I11M’0.01C, 1/5DDNDL5926
I2M’0.1O,>4DD0.05R6627
I16M’0.5O=C,2DD0.05L7520
I16M’NDC, 2DDNDL6619
W18M’0.05O, 2DD0.2R7018
Size ↑W5M’0.05O, 3DD0.1L7017
ScarI10M0.1C, 1/4DD0.03R6516
CommentResultFu(M’)Post-VAF’d change
Pre-VAR/LAgeCase No.
Circumscribed Circumscribed Choroidal Choroidal HemangiomaHemangioma
Benign, middle-aged, posteriorly located
Vision affected by:1. Exudative macular RD2. CME3. Direct macular involvement4. Nerve compression (?)
Management of Management of Choroidal Choroidal HemangiomaHemangioma
Observation PhotocoagulationPlaque radiotherapyExternal beam radiotherapyEnucleation for NVG
Circumscribed Circumscribed Choroidal Choroidal HemangiomaHemangioma
Photocoagulation and light therapyXenon-arcArgonICG-assisted diodeTranspupillary thermotherapyPhotodynamic
Laser for Laser for Choroidal Choroidal HemangiomaHemangioma
Reaccumulation of SRF in 40%Multiple sessions requiredTumor shrinkage unlikelyMacular tumor not applicable
TTT for TTT for Intraocular Intraocular TumorsTumors
Tumor heating using light in the infrared range
Modified diode laser delivery system
TTT for TTT for Intraocular Intraocular TumorsTumors
Used for small to medium sized melanoma
Combined with radiotherapy or laser(Shield, CL and JA, 1998)
TTT for TTT for Choroidal Choroidal TumorsTumors
Histopathological changes after TTT on melanoma- Tumor necrosis up to 3.5mm in depth- Sharp margin - No scleral damage(Journee-de Korver JG, et al 1997)
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
First report — Othmane IS, shields CL and JA, et al 1999
Largest series — Garcia-Arumi J, et al (2000, 8 cases)
decrease of tumor size with disappearance of SRF
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
TechniquesGray to white color change of the
retina near the end of the treatmentTiming of retreatment: no consensus
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
Treatment complicationsRetinal vascular occlusionIntraretinal hemorrhage
(localized perivascular)Transient increase of SRF
(Robertson DM, et al 1999)
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
AdvantageMay induce tumor shrinkage:
minimize recurrent SRFMay treat macular lesions
TTT for TTT for Choroidal Choroidal hemangionmahemangionma
Patients and MethodsFrom Feb. 2000 to Sep. 2000Six consecutive patientsInclusion criteria:
- VA decrease secondary to CH- Macular or jurtapapillary CH- Follow-up period: more than 3 months
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
Ophthalmological evaluationClinical examination— VA, ocular fundusFluorescein angiographyUltrasonography Measurement of tumor size (D.D)
TTT for TTT for Choroidal HemangiomaChoroidal HemangiomaTreatment methods
Diode laserSpot size: 3mmDuration: 60 secPower: 400mw-1200mw
End point: subthreshold for macular lesionsGrade? to ? burn for juxtapapillary lesions
Retreat if tumor size no change after 2-3 months
TTT for TTT for Choroidal HemangiomaChoroidal Hemangioma
Results3M, 3F34-60 years3 macular, 3 juxtapapillaryTumor size: 2.5D.D to 6D.DPre-tx VA HM/50cm to 0.4
TTT for TTT for choroidal choroidal HemangiomaHemangioma
ResultsVA improved: 3VA stable: 1VA decreased: 2Tumor size reduced: 4
SRF3.5 D.DJuxtapapillLF606
SRF3.5 D.DJuxtapapillRM345
CME, SRFTumor
2.5 D.DMacular areaRM344
Tumor, SRF4.5 D.DMacular areaRF523
RPE change,
folds
4 D.DJuxtapapillLM602
Tumor, SRF6 D.DMacular areaRM561
Macular change
Tumor sizeTumor locationR/LsexageCase No
5.5 M’TTT Ï ?0.01 0.056
3 M’TTT Ï ?0.7 0.45
5.5 M’TTT Ï ?0.05 0.154
10 M’TTT Ï ?ND/10cmHM/50cm3
9.5 M’TTT Ï ?0.2 ? 0.05 (?)0.012
8.5 M’TTT Ï?0.050.041
FUTxPost-tx VAPre-tx VACase No
TTT for TTT for Choroidal Choroidal HemangiomaHemangioma
SummaryInitial limited experience
suggests usefulnessNo immediate decrease of vision
after treating macular area
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