Transpupillary Thermotherapy

							     Transpupillary
Thermotherapy for CNVM
     and Choroidal
     Hemangioma

     Chung May Yang
         NTUH
Transpupillary Thermotherapy

l ClassicCNVM: well demarcated
 area by fluorescein angiography

l Occult CNVM: fibrovascular RPED
 or late phase leakage
Transpupillary Thermotherapy
l Natural   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 Thermotherapy
 Treatment 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

l Reichel   E. et al, 1997 (Presentation)

l Reichel   E. et al, 1999 (Ophthalmology
Transpupillary Thermotherapy
  l Low   irradiance

  l Large   Spot size

  l Long-pulsed    infrared laser

  l Target   temperature rise: 10-15°
Transpupillary Thermotherapy
l Proposed   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 Thermotheraph
 l Power   setting
   – Power / diameter = 247mw/mm
   – Spot size 1.2, 2.0, 3.0mm, 3.85mm, 5.77mm
   – Power: 800mw          3.0mm
            530         2.0mm
            320         1.2mm
            955         3.85mm
           1430         5.77mm
   – Duration 1min
   – Test spots ( ? )
Transpupillary Thermotherapy
  l Power   adjustment

    – Pigmentation
    – Pseudophakia
    – Classic vs occult
    – Fluid, blood
    – Myopia
Transpupillary Thermotherapy

l Power   adjustment

   Extensive fluid elevation : 10% increase

   Subretinal blood : 5-10% increase
Transpupillary Thermotherapy

 l Retreatment
   – Time : Occult 3 months
             Classic 2 months
   – Indications
          No reduction of exudation
          VA loss
          Active CNVM
Transpupillary Thermotherapy

 l Advantage


  – Uncomplicated procedure

  – No immediate scotoma

  – No immediate retinal damage
Transpupillary Thermotherapy

 l Complication


  – RPE tear


  – Subretinal hemorrhage
Transpupillary Thermotherapy
l Previousstudies (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 Thermotherap
          Trials
  l Clinical
   TTT 4 CNV
    – Occult, ARMD
    – >50year
    – <2 D.D.
    – Serous RPED <25%
    – Classic component <10%
Transpupillary Thermotherapy
            (TTT)
l Patients   and Methods
l CNVM:
  inclusion criteria
     ARMD or myopic degeneration
     Subfoveal NV confirmed by FA
     VA < 0.5
     no previous treatment
l Thorough ophthalmological examinations
  and FA
Transpupillary Thermtherapy

l Patients and Methods
  – Treatment Methods
     l Diode laser, 810nm (Iris Medical Oculright
       SLX) through slit lamp
     l Test spots

     l Power: 250-750mw

     l End point: no visible lesions

     l Single surgern
Transpupillary Thermotherapy
  l Results
   - ARMD 28           myopia 2
   - classic 10, occult 17, mixed 3
   - size     1 ¡Ø1DD
            10 > 1DD~4DD
            19 > 4DD
   - age: 36~86 (69.6)
   - Fu: 1~24M’(8.72)
Transpupillary Thermotherapy
         I    S    W

 ARMD    10   7    11

 Myopia 1     1    0

 Total   11   8    11
Transpupillary Thermotherapy
            I   S   W

  Classic   4   3   3

  Occult    5   5   7

  Mixed     2       1
Transpupillary Thermotherapy
l Conclusion
  – Limited experiences suggest beneficial
  – Both classic and occult respond to the
    treatment
  – Unpredictable outcome
l Future direction
  – Combined with ICG
 ase   Age   R/L   Pre-VA      F’d     Post-VA    Fu(M’)   Result    Commen
No.                          change

 1     68    R      0.05    O=C, 1DD    0.01       15M      W         Size ↑
 2     62    R      0.05    O, 1/5DD   0.05-0.1   4.5M       I
 3     63    R      0.05    O, 1.5DD     ND        14M     I→ W     Recurren
 4     71    L      ND      O,6-7DD     0.03       16M       I         Scar
 5     76    R      ND      O, 1.5DD     ND        3M        S
 6     74    R      0.04    O,1.5DD     0.04       2M        S
 7     68    L      0.04     O,2DD     0.05-0.1    3M        I       Scar + E
 8     64    L      ND       C, 1DD      ND        2M        S         Scar
 9     69    L      ND      C, 4.5DD    0.03       9M’      W        Scar=RD
10     76    R      0.02    O, 5-6DD    0.01       4M’       S      Scar+Acti
11     74    R      0.3      O, 1DD     0.15      14M’      W         Size ↑
12     86    L      ND       C, 4DD     0.01       3M’      W         Size ↑
13     73    R      0.05     C,1DD      0.03      12M’       S        Size ↓
14     65    L      0.05    O,0.5DD      0.1       5M        I         Scar
15     69    R     0.025      3DD       0.05       15M       I         Scar
 ase   Age   R/L   Pre-VA      F’d     Post-VA   Fu(M’)   Result   Commen
No.                          change

16     65    R      0.03    C, 1/4DD     0.1      10M       I       Scar
17     70    L      0.1     O, 3DD      0.05      5M’      W        Size ↑
18     70    R      0.2     O, 2DD      0.05     18M’      W
19     66    L      ND      C, 2DD       ND      16M’       I
20     75    L      0.05    O=C,2DD      0.5     16M’       I
21     36    R      0.1     C, 2/3DD     0.1     14M’       S

22     65    L      ND      C, 1DD       0.1      8M’       I

23     78    L      0.1     O, 1DD       0.1      5M’       S
24     83    L      0.09    C, 1.5DD    0.05      3M’      W
25     65    L      0.4     O,4.5DD     0.01     24M’      W
26     59    L      ND      C, 1/5DD    0.01     11M’       I
27     66    R      0.05    O,>4DD       0.1      2M’       I
28     83    R      ND      O, 1DD       ND       1M’       S
29     80    L      0.2     O, 2DD      0.05      4M’      W
30     70    R      0.1     O, 1DD      0.05      3M’      W
Circumscribed Choroidal
     Hemangioma
Benign, middle-aged, posteriorly
 located
Vision affected by:
    1. Exudative macular RD
    2. CME
    3. Direct macular involvement
    4. Nerve compression (?)
Management of Choroidal
     Hemangioma
 Observation
 Photocoagulation
 Plaque radiotherapy
 External beam radiotherapy
 Enucleation for NVG
Circumscribed Choroidal
     Hemangioma
 Photocoagulation and light therapy
  Xenon-arc
  Argon
  ICG-assisted diode
  Transpupillary thermotherapy
  Photodynamic
 Laser for Choroidal
    Hemangioma
Reaccumulation of SRF in 40%
Multiple sessions required
Tumor shrinkage unlikely
Macular tumor not applicable
TTT for Intraocular Tumors

Tumor heating using light in the
 infrared range
Modified diode laser delivery
 system
TTT for Intraocular Tumors

Used for small to medium sized
 melanoma
Combined with radiotherapy or laser
       (Shield, CL and JA, 1998)
TTT for Choroidal Tumors
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 Choroidal
         Hemangioma
First report — Othmane IS, shields CL an
 JA, et al 1999
Largest series — Garcia-Arumi J, et al
                    (2000, 8 cases)
 decrease of tumor size with
    disappearance of SRF
     TTT for Choroidal
       Hemangioma
echniques
Gray to white color change of the
  retina near the end of the treatmen
Timing of retreatment: no consensus
  TTT for Choroidal
    Hemangioma
Treatment complications
    Retinal vascular occlusion
    Intraretinal hemorrhage
       (localized perivascular)
    Transient increase of SRF
       (Robertson DM, et al 1999)
   TTT for Choroidal
     Hemangioma
Advantage
   May induce tumor shrinkage:
      minimize recurrent SRF
   May treat macular lesions
   TTT for Choroidal
    hemangionma
Patients and Methods
 From Feb. 2000 to Sep. 2000
 Six consecutive patients
 Inclusion criteria:
     - VA decrease secondary to CH
     - Macular or jurtapapillary CH
     - Follow-up period: more than 3 months
     TTT for Choroidal
       Hemangioma
Ophthalmological evaluation
 Clinical examination— VA, ocular fundu
 Fluorescein angiography
 Ultrasonography
 Measurement of tumor size (D.D)
TTT for Choroidal Hemangioma
 Treatment methods
   Diode laser
      Spot size: 3mm
      Duration: 60 sec
      Power: 400mw-1200mw
   End point: subthreshold for macular lesions
               Grade? to ? burn for juxtapapillary
               lesions
   Retreat if tumor size no change after 2-3 months
TTT for Choroidal Hemangioma
  Results
   3M, 3F
   34-60 years
   3 macular, 3 juxtapapillary
   Tumor size: 2.5D.D to 6D.D
   Pre-tx VA HM/50cm to 0.4
TTT for choroidal
  Hemangioma
Results
 VA improved: 3
 VA stable: 1
 VA decreased: 2
 Tumor size reduced: 4
ase   age   sex   R/L   Tumor location   Tumor size    Macula
No                                                     change
1     56    M     R      Macular area      6 D.D      Tumor, S

2     60    M     L      Juxtapapill       4 D.D         RPE
                                                       change
                                                        folds
3     52    F     R      Macular area     4.5 D.D     Tumor, S


4     34    M     R      Macular area     2.5 D.D     CME, SR
                                                       Tumor
5     34    M     R      Juxtapapill      3.5 D.D        SRF

6     60    F     L      Juxtapapill      3.5 D.D        SRF
ase
      Pre-tx VA    Post-tx VA        Tx       FU
No
1       0.04          0.05         TTT Ï?    8.5 M

2       0.01      0.2 ? 0.05 (?)   TTT Ï ?   9.5 M

3     HM/50cm       ND/10cm        TTT Ï ?   10 M

4       0.15          0.05         TTT Ï ?   5.5 M

5        0.4           0.7         TTT Ï ?   3 M’

6       0.05          0.01         TTT Ï ?   5.5 M
  TTT for Choroidal
    Hemangioma
Summary
 Initial limited experience
    suggests usefulness
 No immediate decrease of vision
    after treating macular area
TTT for Choroidal Hemangioma

Summary
 Transient SRF increase after
   suprathreshold treatment
 Tumor flattening down gradually