Transpupillary Thermotherapy for CNVM

and Choroidal Hemangioma

Chung May YangNTUH

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 Thermotherapy

lComplication

– RPE tear

– Subretinal hemorrhage

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

11811Total

011Myopia

11710ARMD

WSI

Transpupillary Thermotherapy

12Mixed

755Occult

334Classic

WSI

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

TTT for TTT for Choroidal HemangiomaChoroidal Hemangioma

SummaryTransient SRF increase after

suprathreshold treatmentTumor flattening down gradually