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Mácula 2012 y 2013

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Avances en el diagnóstico y tratamiento de la patología macular en el año 2012 y 2013.

Avances en el diagnóstico y tratamiento de la patología macular en el año 2012 y 2013.

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  • 1. LO MEJOR DEL AÑO EN MÁCULA 1º PARTE
  • 2. DMAE
  • 3. DMAE EXUDATIVA Nueva clasificación de la DMAE  Conceptos tomográficos nuevos en la DMAE  Microestructura foveal y Pronóstico visual  Neurotubulización y Pseudoquistes retinianos  Grosor coroideo   Tratamiento Flexibilidad a la hora de tratar con lucentis  Nuevos antiVEFG: VEFG TRAP-EYE  MNV refractarias opciones: Metrotexate… RT 
  • 4. NUEVA CLASIFICACIÓN DE LAS DMAE  TIPO 1 BAJO EL EPR Freund KB, Zweifel SA, Engelbert M. Do we need a new classification for choroidal neovascularization in age-related macular degeneration? Retina. 2010; 30: 1333-49.
  • 5.  TIPO 2 EN EL EPR Freund KB, Zweifel SA, Engelbert M. Do we need a new classification for choroidal neovascularization in age-related macular degeneration? Retina. 2010; 30: 1333-49.
  • 6.  TIPO 3 EN LA RETINA
  • 7. OCT Y DMAE Pérdida de IS/OS  Grosor coroideo  Pseudoquistes  ORT  Depósitos subretinianos 
  • 8. GROSOR COROIDEO EN AMD Normal PCV 15μm Exudativa
  • 9. GROSOR COROIDEO Y DMAE SECA Seca
  • 10. SECUELAS DEL PRONTO STUDY (AM J OPHTHALMOL. 2009 JUL) Estudio Prospective Optical Coherence Tomography (OCT) Imaging of Patients with Neovascular Age-Related Macular Degeneration (AMD) Treated with intraOcular Ranibizumab (PrONTO) A study comparing two protocols of treatment with intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration. Arias L, Caminal JM, Casas L, Masuet C, Badia MB, Rubio M, Pujol O, Arruga J. Br J Ophthalmol. 2008 Dec;92(12):1636-41 Efficacy and Safety of Monthly versus Quarterly Ranibizumab Treatment in Neovascular Age-related Macular Degeneration: The EXCITE Study. Schmidt-Erfurth U, Eldem B, Guymer R, Korobelnik JF, Schlingemann RO, Axer-Siegel R, Wiedemann P, Simader C, Gekkieva M, Weichselberger A; EXCITE Study Group. Ophthalmology. 2011 May;118(5):831-9 ONE-YEAR RESULTS OF A FLEXIBLE REGIMEN WITH RANIBIZUMAB THERAPY IN MACULAR DEGENERATION: Relationship with the Number of Injections. Arias L, Roman I, Masuet-Aumatell C, Rubio MJ, Caminal JM, Catala J, Pujol O. Retina. 2011 Apr 14 Bevacizumab for neovascular age related macular degeneration (ABC Trial): multicentre randomised double masked study. Tufail A, Patel PJ, Egan C, Hykin P, da Cruz L, Gregor Z, Dowler J, Majid MA, Bailey C, Mohamed Q, Johnston R, Bunce C, Xing W; ABC Trial Investigators. BMJ. 2010 Jun 9;340:c2459.
  • 11. BEVACIZUMAB VS RANIBIZUMAB      1208 pacientes (no inferioridad = 5letras)  Administración mensual  Administración «as needed» = Ganancia visual 8 y 8.5 letras a 1 año = Mortalidad, IAM, ACV (p>0.20) Complicaciones sistémicas A 24.1% vs. L 19.0% Grupo mayor ↓CST Ranibizumab mensual (p=0.03) Continued global use of intravitreal bevacizumab is an effective, low-cost alternative to ranibizumab CATT Research Group, Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011 May 19;364(20):1897-908.
  • 12. NUEVOS ANTI-VEFG  KH902 (fase 1)  VEFG TRAP-EYE o aflibercept (fase 3) Bloquea el PIGF VEFGR1 VEFGR2 Más afines que ranibizumab Bloquea todas las isoformas del VEFG-A Bloquea todas las isoformas del VEFG-A VEFG-B VEFG-C Ambos diseñados sobre estructura de IgG Zhang M, Zhang J, Yan M et al. A phase 1 study of KH902, a vascular endothelial growth factor receptor decoy, for exudative age-related macular degeneration. Ophthalmology. 2011; 118: 672-8.
  • 13. VEGF TRAP-EYE 159 pacientes MNV  Mejor resultado 2mg mensual→PRN  Heier JS, Boyer D, Nguyen Q et al. The 1-year Results of CLEAR-IT 2, a Phase 2 Study of Vascular Endothelial Growth Factor Trap-Eye Dosed Asneeded After 12-week Fixed Dosing. Ophthalmology. 2011; 118:1098-106. Supported by Regeneron Pharmaceuticals, Inc. and Bayer HealthCare AG.
  • 14. Myrror study
  • 15. MNV RESISTENTE…  400 μm Metrotexate, 2 semanas: 5/200 20/200 CD CD Intravitreal methotrexate in therapeutically resistant exudative agerelated macular degeneration. Kurup SK, Gee C, Greven CM. Acta Ophthalmol. 2010 Jun;88(4):e145-6.
  • 16. RADIOTERAPIA. EPI-RAD90™ O VIDION OPHTHALMIC SYSTEM INTRAOCULAR EPIRETINAL BRACHYTHERAPY  CABERNET (CNV Secondary to ADM Treated with Beta Radiation Epiretinal Therapy)  MERITAGE: MNV refractarias a lucentis  MERLOT: RT vs. Lucentis  NVI-111: 25% 15Gy cataratas  NVI-068: 55% 24Gy cataratas 4700 euros Neovista Inc
  • 17. DMAE SECA ¿NUEVOS TRATAMIENTOS? FASE 3  Preservar el EPR Idaptan 20® Trimetazidina 35mg  Tandospirona (AL-8309B) Sediel®  NT-501 (CNTF, Neurotech)  AREDS trial   Antiinflamatorios Glatiramer acetato (Copaxone, Teva)  FASE 2  Neuroprotectores     Brimonidina tartrato (Allergan) ACU-44219 (MacuCLEAR) Fenretinide (Sirion) RN6G (Pfizer)  Antiiflamatorios     Eculizumab Fluorocinolone Illuvien Sirolimus Células madre
  • 18. CORIORRETINOPATÍA CENTRAL SEROSA
  • 19. CSC  OCT y CSC Los fotorreceptores  El grosor coroideo  Pronóstico visual  Papel de la autofluorescencia  Nuevos tratamientos         AAS Finasteride Anteriores sin éxito: Fluconazol, betabloqueantes, misoprostol, ansiolíticos AntiVEFG ¿Qué TFD deberíamos elegir? full vs. low-fluence Láser diodo micropulsado (MPD) Terapia selectiva de reitna (SRT)
  • 20. OCT Y CSC IS/OS pronóstico  Elongación de los segmentos externos  Hiperreflectividad c plexiforme  Depósitos a expensas de los segmentos externos  DEPs >60%  Alteraciones capas internas (ONL)  Grosor coroideo 
  • 21. AUTOFLUORESCENCIA Y CSC Fundus autofluorescence of elongated photoreceptor outer segments in central serous chorioretinopathy. Matsumoto H, Kishi S, Sato T, Mukai R. Am J Ophthalmol. 2011 Apr;151(4):617-623. Subretinal dot-like precipitates and yellow material in central serous chorioretinopathy. Maruko I, Iida T, Ojima A, Sekiryu T.Retina. 2010 Nov 3.
  • 22. AUTOFLUOPRESCENCIA PRONÓSTICO Menor AV:  Hipoautofluorescencia  Macular      Confluente Granular Peripapilar Tractos Edad Fundus autofluorescence and visual acuity in central serous chorioretinopathy. Imamura Y, Fujiwara T, Spaide RF. Ophthalmology. 2011 Apr;118(4):700-5.
  • 23. AUTOFLUORESCENCIA PRONÓSTICO Normal CSC aguda CSC resuelta CSC 3m después Photopigments in central serous chorioretinopathy. Ojima A, Iida T, Sekiryu T, Maruko I, Sugano Y. Am J Ophthalmol. 2011 Jun;151(6):940-952.
  • 24. GROSOR COROIDEO Subfoveal choroidal thickness in fellow eyes of patients with central serous chorioretinopathy. Maruko I, Iida T, Sugano Y, Ojima A, Sekiryu T. Retina. 2011 Apr 9. Subfoveal choroidal thickness after treatment of central serous chorioretinopathy. Maruko I, Iida T, Sugano Y, Ojima A, Ogasawara M, Spaide RF. Ophthalmology. 2010 Sep;117(9):1792-9.
  • 25. 410 ±92μm 239± 32μm
  • 26. TRATAMIENTOS AAS  Finasteride  Anteriores sin éxito  Anticorticoides: Fluco y ketoconazol y misoprostol  Ansiolíticos y antihipertensivos, betabloqueantes  AntiVEFG  ¿Qué TFD deberíamos elegir? full vs. low-fluence  Láser  Diodo micropulsado (MPD)  Terapia selectiva de retina (SRT) 
  • 27. FINASTERIDE  5mg/día 3m luego observan 3m Finasteride for chronic central serous chorioretinopathy. Forooghian F, Meleth AD, Cukras C, Chew EY, Wong WT, Meyerle CB. Retina. 2011 Jan 26. [Epub ahead of print]
  • 28. ANTIVEFG: BEVACIZUMAB 5,6m± 1,8m  1,25/0.05ml  8/12 agudas  Aqueous humor and plasma levels of vascular endothelial growth factor and interleukin-8 in patients with central serous chorioretinopathy. Lim JW, Kim MU, Shin MC. Retina. 2010; 30:1465-71.
  • 29. AAS  100mg/día 1 mes luego días alternos 5 meses 1 año: 0,77 y 0,76 2 años: 0,8 y 0,6 Low-dose aspirin as treatment for central serous chorioretinopathy. Accavale A, Romanazzi F, Imparato M, Negri A, Morano A, Ferentini F. Clin Ophthalmol. 2010 Aug 9;4:899-903.
  • 30. TFD Guiada por ICG Dosis 6mg/m2 verteporfin láser 689nm  Full fluence: 50J/cm2 83 s  Low fluence: 25J/cm2 83s Comparison of efficacy and safety between half-fluence and full-fluence photodynamic therapy for chronic central serous chorioretinopathy. Shin JY, Woo SJ, Yu HG, Park KH. Retina. 2011 Jan;31(1):119-26. Subfoveal choroidal thickness after treatment of central serous chorioretinopathy. Maruko I, Iida T, Sugano Y, Ojima A, Ogasawara M, Spaide RF. Ophthalmology. 2010 Sep;117(9):1792-9.
  • 31. RETINAL SELECTIVE THERAPY Selective retina therapy for acute central serous chorioretinopathy. Q-switched, doble frecuencia Nd:YLF láser 527 nm Klatt C, Saeger M, Oppermann T, Pörksen E, Treumer F, Hillenkamp J, Repetición de los pulsos 100 Br Ophthalmol. 2011; Fritzer E, Brinkmann R, Birngruber R, Roider J. Hz,J30 pulsos Exposicion 1.7 ms. Spot era de 200 mm . 95:83-8. (Medical Laser Center Lübeck GmbH, Lübeck, Germany).
  • 32. APUNTE SOBRE VITELIFORME DEL ADULTO
  • 33. DRUSAS CUTICULARES? Spectral domain optical coherence tomography in adult-onset vitelliform macular dystrophy with cuticular drusen. Finger RP, Charbel Issa P, Kellner U, Schmitz-Valckenberg S, Fleckenstein M, Scholl HP, Holz FG. Retina. 2010; 30:1455-64.
  • 34. TRATAMIENTO ANTI-VEFG  Mejoría de AV 0.36 ± 0.1 ⇒ 0.56 ± 0.1  No cambios estructurales estadísticos  Lucentis/mes (3) Primary intravitreal ranibizumab for adult-onset foveomacular vitelliform dystrophy. Gallego-Pinazo R, Dolz-Marco R, Pardo-Lopez D, Arevalo JF, Diaz-Llopis M. Graefes Arch Clin Exp Ophthalmol. 2001; 249:455–8
  • 35. TFD Full-fluence 12 m después Photodynamic therapy and vitelliform lesions. Ergun E, Costa D, Slakter J, Yannuzzi LA, Stur M. Retina. 2004 Jun;24(3):399-406.
  • 36. TRANSLOCACIÓN MACULAR 16 pacientes: miopes, CSCR, Best…  Seguimiento 28 meses  AV preop media 20/150  AV post media 20/110  Treatment of non-age-related macular degeneration submacular diseases with macular translocation surgery. Ehlers JP, Maldonado R, Sarin N, Toth CA. Retina. 2011 Apr 9. [Epub ahead of print]
  • 37. Atrofia Pseudohipopion 20/50 PostQX, 20/50
  • 38. TORPEDO         Spielberg L, Leys A. Treatment of neovascular age-related macular degeneration with a variable ranibizumab dosing regimen and one-time reduced-fluence photodynamic therapy: the TORPEDO trial at 2 years. Graefes Arch Clin Exp Ophthalmol. 2010; 248: 943-56. MNV oculta y RAP (25 pacientes) Retreatment was based on the following criteria: (1) presence of subretinal fluid (SRF), intraretinal edema or sub-retinal pigment epithelial fluid, as seen on OCT (2) increase of CMT by >100 mm on OCT (3) signs of active CNV leakage on fluorescein angiography 4) new sub- or intraretinal hemorrhage (5) BCVA decreased of > or =5 letters on the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. If any single criterion for reinjection was fulfilled, retreatment with ranibizumab was administered. Semana 4: Lucentis Lucentis+TFD Semana 8: Lucentis 6 12 18 24