Intravitreal ranibizumab for choroidal neovascularization related to traumatic Bruch's membrane rupture

Optical coherence tomography angiography for the detection of macular neovascularization-comparison of en face versus cross-sectional view

PURPOSE

To evaluate sensitivity and specificity of swept source-optical coherence tomography angiography (SS-OCTA) en face images versus cross-sectional OCTA versus a combination of both for the detection of macular neovascularization (MNV).

DESIGN

Prospective cohort study.

PARTICIPANTS

Consecutive patients with various chorioretinal diseases and subretinal hyperreflective material (SHRM) and/or pigment epithelial detachment (PED) on OCT possibly corresponding to MNV in at least one eye.

METHODS

102 eyes of 63 patients with fluorescein angiography (FA), OCT and SS-OCTA performed on the same day were included. FA images, the outer retina to choriocapillaris (ORCC) OCTA en face slab, a manually modified en face slab ('custom slab'), cross-sectional OCTA and a combination of OCTA en face and cross-section were evaluated for presence of MNV.

MAIN OUTCOME MEASURES

Sensitivity and specificity for MNV detection, as well as the concordance was calculated using FA as the reference.

RESULTS

OCTA en face imaging alone yielded a sensitivity of 46.3% (automated)/78.1% (custom) and specificity of 93.4% (automated)/88.5% (custom) for MNV detection. Cross-sectional OCTA (combination with en face) resulted in a sensitivity of 85.4% (82.9%) and specificity of 82.0% (85.3%). Concordance to FA was moderate for automated en face OCTA (κ = 0.43), and substantial for custom en face OCTA (κ = 0.67), cross-sectional OCTA (κ = 0.66) and the combination (κ = 0.68).

CONCLUSION

Segmentation errors result in decreased sensitivity for MNV detection on automatically generated OCTA en face images. Cross-sectional OCTA allows detection of MNV without manual modification of segmentation lines and should be used for evaluation of MNV on OCTA.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS IN A CASE OF CHOROIDAL NEOVASCULARIZATION SECONDARY TO TRAUMATIC CHOROIDAL RUPTURE

BACKGROUND/PURPOSE

To document by optical coherence tomography angiography, the onset of a choroidal neovascularization (CNV) secondary to traumatic choroidal rupture and describe its changes after an intravitreal injection of bevacizumab.

METHODS

Case report.

RESULTS

A 20-year-old woman presented referring vision loss after a blunt ocular trauma in her left eye. The patient underwent a complete ophthalmic examination. Best-corrected visual acuity was 20/200. Fundus examination, fluorescein angiography, indocyanine green angiography, and optical coherence tomography displayed a choroidal rupture with no evidence of CNV. Optical coherence tomography angiography showed the choroidal rupture as a line of choriocapillaris rarefaction because of the mechanical damage. Six months later, best-corrected visual acuity decreased to 20/300; optical coherence tomography angiography displayed the growth of a CNV, characterized by a tangled vascular network. After one intravitreal injection of bevacizumab, optical coherence tomography angiography documented a contraction of the CNV.

CONCLUSION

Optical coherence tomography angiography is a useful imaging technique for the diagnosis and follow-up of patients with choroidal ruptures. Anti-vascular endothelial growth factor agents represent an effective therapy for the treatment of CNVs secondary to this affection.

RANIBIZUMAB 0.5 MG TREATMENT IN ADOLESCENTS WITH CHOROIDAL NEOVASCULARIZATION: SUBGROUP ANALYSIS DATA FROM THE MINERVA STUDY

PURPOSE

To evaluate the efficacy and safety of ranibizumab 0.5 mg in adolescent patients with any choroidal neovascularization etiology enrolled in the 12-month MINERVA study.

METHODS

In the open-label, non-randomized study arm, ranibizumab 0.5 mg was administered to five adolescents (aged 13-17 years). The findings were assessed descriptively as individual case reports at Month 12. Best-corrected visual acuity changes, central subfield thickness, treatment exposure, and safety were described over 12 months.

RESULTS

Baseline choroidal neovascularization etiologies of the study eye included choroidal neovascularization secondary to Best disease (n = 2), idiopathic chorioretinopathy (n = 2), and optic disk drusen (n = 1). At Months 2, 6, and 12, the observed mean best-corrected visual acuity changes in the study eye from baseline were +9.2, +16.6, and +16.6 letters, respectively, and the observed mean central subfield thickness change from baseline was -31.4, -87.6, and -116.4 μm, respectively. Adolescent patients received a mean of three (range, 2-5) ranibizumab injections in the study eye. No adverse events or serious adverse events related to ranibizumab were reported.

CONCLUSION

Ranibizumab 0.5 mg treatment was beneficial in improving visual acuity and stabilizing or reducing central subfield thickness in five adolescents with differing choroidal neovascularization etiologies requiring infrequent injection. No new safety findings were observed over 12 months.

MORPHOLOGICAL AND FUNCTIONAL CHARACTERISTICS AT THE ONSET OF EXUDATIVE CONVERSION IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To characterize retinal morphology differences among different types of choroidal neovascularization and visual function changes at the onset of exudative age-related macular degeneration.

METHODS

In a post hoc analysis of a prospective clinical study, 1,097 fellow eyes from subjects with choroidal neovascularization in the study eye enrolled in the HARBOR trial were evaluated. The onset of exudation was diagnosed on monthly optical coherence tomography by two masked graders. At conversion as well as 1 month earlier, pigment epithelial detachment, intraretinal cystoid fluid, subretinal fluid, subretinal hyperreflective material, as well as ellipsoid zone and external limiting membrane loss were quantitatively analyzed. Hyperreflective foci, retinal pigment epithelial defects, haze and vitreoretinal interface status were evaluated qualitatively. Main outcome measures included visual acuity and rates of morphologic features at conversion and 1 month earlier.

RESULTS

New-onset exudation was detected in 92 eyes. One month before conversion, hyperreflective foci, pigment epithelial detachment, retinal pigment epithelial defects, and haze were present in the majority of eyes. At the onset of exudation, the volumes of intraretinal cystoid fluid, subretinal fluid, subretinal hyperreflective material and pigment epithelial detachment, and the areas of external limiting membrane and ellipsoid zone loss significantly increased. The mean vision loss was -2.2 letters. Pathognomonic patterns of the different choroidal neovascularization types were already apparent 1 month before conversion.

CONCLUSION

Characteristic choroidal neovascularization-associated morphological changes are preceding disease conversion, while vision loss at the onset of exudation is minimal. Individual lesion types are related to specific changes in optical coherence tomography morphology already before the time of conversion. Our findings may help to elucidate the pathophysiology of neovascular age-related macular degeneration and support the diagnosis of imminent disease conversion.

Indirect choroidal neovascularization secondary to a posterior-segment intraocular foreign body - case report

Background

We reported a rare case of indirect choroidal neovascularization (CNV) secondary to a posterior-segment intraocular foreign body (IOFB) that was not located in the area of direct injury but in the fovea. After intravitreal injections (IVIs) of aflibercept, the choroidal neovascularization (CNV) lesion disappeared and vision improved.

Case presentation

A 26-year-old male patient suffered from a fast-shot metallic IOFB in his right eye. He underwent primary corneal repair, pars plana vitrectomy, IOFB removal and an IVI of antibiotics in the right eye. Two weeks later, cataract surgery was performed on the right eye for traumatic cataract after an episode of acute phacolytic glaucoma. The best-corrected visual acuity (BCVA) of the right eye improved to 20/20 5 months after the first surgery. However, the vision of the right eye worsened suddenly with metamorphopsia 1 year after the first surgery. Color fundus images showed a whitish lesion with faint retinal hemorrhage and surrounding sensory elevation. Fluorescein angiography (FA) revealed a lesion with early- and late-phase severe leakage. Optical coherence tomography (OCT) demonstrated a CNV lesion with surrounding subretinal fluid. The patient received an IVI of aflibercept every 8 weeks for 3 times. Finally, the BCVA of the right eye improved to 20/25.

Conclusions

For rare cases of fovea-spared injury by a metallic IOFB, it is still necessary to pay close attention to the foveal microstructure to avoid possible CNV formation. Treatment with IVIs of anti-VEGF, aflibercept, as early as possible could provide good visual outcomes.

Comparison of Automated versus Manually Modified OCT Angiography En Face Slabs for Detection of Choroidal Neovascularization

PURPOSE

To evaluate the sensitivity and specificity for the detection of choroidal neovascularization (CNV) using automatically generated versus manually modified swept-source OCT angiography (SS-OCTA) en face images.

DESIGN

Prospective cohort study.

PARTICIPANTS

Consecutive patients with various chorioretinal diseases and subretinal hyperreflective material (SHRM) or pigment epithelial detachments (PEDs) on OCT possibly corresponding to CNV in at least 1 eye.

METHODS

A total of 102 eyes of 63 patients were included in this study. Fluorescein angiography (FA) and SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec, Dublin, CA) were performed at the same day. OCTA en face images were generated using the "retina," "avascular," "choriocapillaris," and "outer retina to choriocapillaris (ORCC)" slabs automatically provided by the software. In addition, a custom slab was created by manual modification of the automatically provided boundary "retinal pigment epithelium fit" positioned at the level of Bruch's membrane and anterior to any SHRM or PED to ensure that a possible CNV was captured in its entirety. Two graders independently evaluated OCTA en face images for the presence of CNV masked to all other images of the patient.

MAIN OUTCOME MEASURES

Sensitivity and specificity for detection of CNV using FA as the reference.

RESULTS

In 40% of cases (41/102), a CNV was detected on FA. Automatically provided OCTA en face slabs revealed the highest sensitivity for the "ORCC" slab (46.3%), followed by the "retina" slab (22.0%), "avascular" slab (17.1%), and "choriocapillaris" slab (14.6%). Specificity ranged between 93.4% for "ORCC" and 100% for the "retina" and "avascular" slabs. Sensitivity could be increased to 78.1% using the custom slab with a specificity of 88.5%. Concordance between FA and OCTA en face slabs was moderate for the "ORCC" slab (κ = 0.43; range, 0.41-0.60) and substantial for the custom slab (κ = 0.67; range, 0.61-0.80).

CONCLUSIONS

Segmentation artifacts and incomplete coverage of CNV on SS-OCTA en face images may impede identification of CNV. Manual modification of the position of automatically generated segmentation lines anterior and posterior to any suspected CNV (SHRM or PED) increases the sensitivity of CNV detection compared with automatically generated slabs.

Intravitreal anti-VEGF treatment for choroidal neovascularization secondary to traumatic choroidal rupture

Background

So far only single cases with short follow-up have been reported on the use of intravitreal anti-VEGF for traumatic choroidal neovascularizations (CNV). This paper reports a large case series of patients with CNV secondary to choroidal rupture after ocular trauma receiving intravitreal anti-VEGF (vascular endothelial growth factor) injections.

Methods

Fifty-four patients with unilateral choroidal rupture after ocular trauma diagnosed between 2000 and 2016 were retrospectively evaluated. Eleven patients with CNV secondary to choroidal rupture were identified. Five eyes with traumatic secondary CNV were treated with anti-VEGF and were systematically analysed. The other 4 patients with inactive CNV underwent watchful observation.

Results

Four men and one woman with a mean age of 29 years (SD 12.4; range 19–45) had intravitreal anti-VEGF therapy for traumatic CNV. Another 4 patients with a mean age of 37 years (SD 6.6; range 31–46) presented with inactive CNV and did not receive specific treatment. In all 9 cases the mean interval between the ocular trauma and the diagnosis of CNV was 5.7 months (SD 4.75; range 2–12). In the treatment group per eye 4.2 injections (SD 3.2; range 1–8) were given on average. Four eyes were treated with bevacizumab and one eye with ranibizumab. Regression of CNV was noted in all eyes. In 4 eyes visual acuity (VA) improved, one eye kept stable visual acuity.

Conclusions

Here, we present the up to now largest case series of traumatic CNV membranes treated with anti-VEGF injections with a mean follow-up period of 5 years. Intravitreal anti-VEGF therapy seems to be safe and effective for secondary CNV after choroidal rupture. Compared to exudative age-related macular degeneration fewer injections are needed to control the disease.

Trial registration

Retrospective registration with local ethics committee on 21 March 2019. Trial registration number is 19-1368-104.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IMAGING OF CHOROIDAL NEOVASCULARIZATION SECONDARY TO CHOROIDAL RUPTURE TREATED BY INTRAVITREAL RANIBIZUMAB

PURPOSE

To describe optical coherence tomography angiography findings at baseline and during the follow-up of choroidal neovascularization secondary to choroidal rupture (CR) in a patient with kidney transplant treated by a single intravitreal injection of ranibizumab.

METHODS

The clinical course, conventional multimodal imaging findings including ultra-widefield fundus color photography and fundus autofluorescence (Optos California, Marlborough, MA), spectral-domain optical coherence tomography (SD-OCT Spectralis; Heidelberg Engineering, Heidelberg, Germany), fluorescein angiography (FA; Heidelberg Engineering, Heidelberg, Germany), indocyanine green angiography ,and optical coherence tomography angiography (Plex-Elite, Carl Zeiss Meditec, Inc, Dublin, CA) findings at baseline and during the follow-up of a patient with choroidal neovascularization secondary to CR.

RESULTS

A 19-year-old young man with a history of blunt trauma presented with acute visual decline of the right eye. He had a systemic history of kidney transplant. His best-corrected visual acuity was 20/200 in the right eye and 20/20 in the left eye at baseline. Funduscopic examination and ultra-widefield fundus autofluorescence imaging revealed a double vertical macular lesion corresponding to a CR in the right eye. Spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography revealed active Type 2 choroidal neovascularization secondary to the CR. Optical coherence tomography angiography showed a high-flow neovascular network consistent with conventional multimodal imaging. One month after intravitreal injection of ranibizumab, bestcorrected visual acuity was 20/100, optical coherence tomography angiography showed a contraction and remodeling of the neovascular flow, and exudative signs disappeared on multimodal imaging. No side effect was detected.

CONCLUSION

Optical coherence tomography angiography is able to detect choroidal neovascularization secondary to CR at baseline and during the follow-up after a single intravitreal injection of ranibizumab. Ranibizumab was effective in the treatment of this sight-threatening lesion in a patient with a history of kidney transplant.

Intravitreal Bevacizumab for Traumatic Choroidal Rupture

PURPOSE

To report a case of visual loss associated with traumatic choroidal rupture after blunt ocular trauma that was successfully treated with an early intravitreal bevacizumab injection despite the absence of choroidal neovascularization (CNV).

CASE REPORT

A 14-year-old boy presented with visual disturbance in his left eye after sustaining an ocular contusion 4 weeks earlier. The best-corrected visual acuity (BCVA) in the left eye was 20/50. Funduscopic examination revealed macular choroidal rupture accompanied by subretinal hemorrhage. Optical coherence tomography (OCT) showed accumulation of subretinal fluid around a disrupted retinal pigment epithelium/Bruch membrane complex extending into the juxtafoveolar area, but there was no active leakage suggestive of CNV on fluorescein angiography. Intravitreal bevacizumab (1.25 mg) injection was performed to treat persistent serous retinal detachment at macula causing visual loss. There was a reduction of subretinal fluid and concomitant improvement of BCVA to 20/30 within 1 week after intravitreal bevacizumab injection. The BCVA recovered to 20/25 in the left eye after 4 weeks, and only a minimal amount of residual fluid remained according to OCT. Complete resolution of subretinal fluid was observed by OCT at the 6-week follow-up examination, and BCVA improved to 20/20. Good visual acuity (20/20) and stable macula were maintained in the left eye at 1 year of follow-up without recurrence of subretinal fluid accumulation or hemorrhage and CNV. There were no ocular or systemic complications associated with intravitreal bevacizumab injection.

CONCLUSIONS

Early intravitreal bevacizumab injection could be an effective treatment option for patients with vision loss associated with traumatic choroidal rupture and subretinal fluid within the posterior pole before development of CNV.

Intravitreal bevacizumab for extrafoveal choroidal neovascularization after ocular trauma

PURPOSE

To describe two cases of extrafoveal choroidal neovascularization (CNV) after ocular trauma successfully treated with intravitreal bevacizumab injection.

METHODS

A 41-year-old man presented for progressive visual impairment in the left eye (LE). The patient had a positive history for pseudoxanthoma elasticum and suffered a blunt trauma in the LE 1 year before. Best-corrected visual acuity (BCVA) in the affected eye was 20/100. Fundus examination of the LE revealed angioid streaks and a choroidal rupture with retinal hemorrhages. Fluorescein angiography (FA) revealed an extrafoveal CNV and optical coherence tomography (OCT) findings demonstrated the presence of intraretinal fluid extending to the fovea. The second patient was a 61-year-old man complaining of blurred vision in the LE. Fundus examination of the LE revealed retinal pigment epithelium (RPE) changes, while FA showed the presence of an extrafoveal CNV close to the area of RPE attenuation. Intraretinal fluid extending to the fovea was detectable on OCT examination. An intravitreal injection of bevacizumab was proposed in both cases.

RESULTS

In the first patient, treatment with one intravitreal bevacizumab injection was successful in contrasting CNV activity, as OCT findings showed a resolution of intraretinal fluid accumulation. BCVA remained unchanged (20/100) over the 12-month follow-up period, most probably due to permanent alteration of the photoreceptors. In the second case, BCVA improved from 20/40 to 20/20 with complete resolution of leakage on FA and fluid on OCT 1 month after a single intravitreal injection of bevacizumab. Visual function remained stable over the 14-month follow-up.

CONCLUSIONS

Our results indicate that intravitreal bevacizumab is effective in the management of extrafoveal CNV secondary to ocular trauma.

Intravitreal bevacizumab as a primary treatment for idiopathic choroidal neovascularization

PURPOSE

To report long-term outcomes of the use of intravitreal bevacizumab in subjects with idiopathic choroidal neovascularization (ICNV).

MATERIALS AND METHODS

Six consecutive subjects with ICNV were included in this prospective study. All subjects received 1.25 mg intravitreal bevacizumab at diagnosis. A decrease in best corrected visual acuity (BCVA), presence of increased retinal edema or hemorrhage, increased retinal thickness on optical coherence tomography (OCT) or increased leakage documented by fluorescein angiography prompted further injections of bevacizumab.

RESULTS

The study cohort was comprised of 3 males and 3 females with a mean age of 31.17 years. Mean follow-up was 13.8 months (range, 8 months to 20 months). Following intravitreal bevacizumab injection, vision improved in 3 subjects, remained stable in 3 subjects and no patient lost visual acuity. The mean BCVA improved to logMAR 0.20 at final follow-up from baseline at 0.950 logMAR (P=0.031). The mean central macular thickness and central foveal thickness at the last postoperative visits were reduced from pre-treatment levels of 374.33 ± 146.52 and 347.16 ± 213.97 to 251.20±35.36 and 215.33 ± 43.94 μm, respectively. (P = 0.99 and P = 0.16, respectively). Four subjects required repeat treatments. The total number of repeat treatments was 4. Two subjects required no repeat injections, 3 subjects had 1 retreatment and one subject required 2 additional treatments. The injections were well tolerated by all the subjects, with no ocular or systemic adverse events.

CONCLUSION

Intravitreal injection of 1.25 mg bevacizumab in patients with ICNV is effective in improving and stabilizing vision. Additional studies, particularly determination of optimal protocol for timing of re-injection are required to assess long-term effects.

Intravitreal bevacizumab for posttraumatic choroidal neovascularization in a child

Choroidal neovascularization, an uncommon occurrence in children, may complicate up to 20% of cases of closed-globe blunt trauma with Bruch's membrane rupture. Visual outcome in untreated eyes is usually poor, and there is no consensus on the management of this complication. Treatment options include observation, surgical removal of the membrane, photocoagulation, or photodynamic therapy. Antivascular endothelial growth factor therapy has recently been proposed in sporadic adult cases. We report a case of post-traumatic choroidal neovascularization in a boy that has was successfully treated with intravitreal bevacizumab.

Choroidal neovascularization in a patient with blunt trauma-caused traumatic retinopathy without choroidal rupture

PURPOSE

To report a case of choroidal neovascularization (CNV) following blunt trauma without choroidal rupture, with past history of central serous chorioretinopathy (CSC).

METHODS

A 43-year-old man with a nonperforating injury caused by a baseball that hit his right eye exhibited traumatic retinopathy. The damage was localized to the outer layer of the retina at the macula and there was no choroidal rupture. Five years prior to the accident, the patient suffered from a CSC attack with retinal pigment epithelium detachment. Two weeks after the blunt trauma, fundus examination revealed CNV extending into the subfoveal space, which led to an abrupt development of retinal hemorrhage and serous retinal detachment at the macula. Intravitreal injection of bevacizumab led to the resolution of retinal detachment 15 days later, with complete absorption of retinal hemorrhage 41 days later. Fluorescein angiography performed 2 months later revealed hyperfluorescent points with no leakage.

CONCLUSION

CNV following blunt trauma in this case occurred in traumatic retinopathy, with the damage localized in the outer layer of the retina. This suggests that the retinal pigment epithelium-Bruch's membrane complex developed susceptibility to anteroposterior forces, which is subsequent to the spontaneous healing of CSC. Bevacizumab treatment also reduced exudation from CNV.