Intravitreal ranibizumab for type 3 choroidal neovascularization complicating adult onset foveomacular vitelliform dystrophy

Novel IMPG2 variant causing adult macular vitelliform dystrophy: A case report

INTRODUCTION

Adult-onset vitelliform macular dystrophy (AVMD) is an inherited maculopathy characterized by metamorphopsias and decrease in visual acuity occurring between the fourth and the sixth decade. It is characterized by an 'egg yolk' macular lesion eventually evolving towards foveal atrophy and fibrosis. It is usually an autosomal dominant inherited disorder with variable penetrance, mainly related to variants in BEST1, PRPH2, IMPG1, and IMPG2 genes.

CASE DESCRIPTION

A 47-year-old woman complaining of "wavy" vision was referred to our clinic. Her past medical history and reported family history did not reveal any ocular disease. Complete ophthalmological evaluation was performed. Funduscopic examination and multimodal imaging revealed a round vitelliform lesion in both eyes, leading to a diagnosis of AVMD. Genetic analysis revealed a novel, likely pathogenetic, heterozygous c.478G > T (p.Glu160Ter), (NM_016247) variant in the IMPG2 gene.

DISCUSSION

Our patient exhibits a novel pathogenetic variant in a gene associated with AVMD. Heterozygous variants in the IMPG2 gene have been reported in multiple individuals with vitelliform macular dystrophy, with an autosomal dominant mode of inheritance. Genetic screening is essential to characterize patients, to predict vision loss in patients with a positive family history and to characterize eligible patients for new potential emerging therapies. Genotype-phenotype correlation studies are needed to have a clearer picture of pathogenetic mechanisms. Our study characterizes the phenotype related to a novel IMPG2 pathogenic variant through multimodal imaging.

Lack of Response to Intravitreal Ranibizumab Treatment in Adult Onset Foveomacular Vitelliform Dystrophy Complicated with Choroidal Neovascularization: A Case Report

Adult-onset foveomacular vitelliform dystrophy (AOFVD) is a rare disease characterized by accumulation of yellowish deposits in the macula. Rarely, it may be complicated by choroidal neovascularization (CNV). Cases with CNV may be confused with occult CNV in age-related macular degeneration. In our case, we will present the visual and anatomical results of a patient with AOVF-related CNV, in which we administered 3 doses of intravitreal ranibizumab (IVR). A 59-year-old female patient, who attended our clinic with the complaint of decreased vision in both eyes, was diagnosed with AOVF-related CNV in both eyes and was treated with 3 doses of IVR for 3 months. Despite the improvement in visual and anatomical functions 1 month after the first dose, vision decreased, and anatomical functions regressed to the pre-injection state in continued injections. IVR therapy is not an appropriate treatment option in the treatment of AOVF-associated CNV.

Macular neovascularization in inherited retinal diseases: A review

Inherited retinal diseases (IRDs) are the most common cause of blindness in working-age adults. Macular neovascularization (MNV) may be a presenting feature or occurs as a late-stage complication in several IRDs. We performed an extensive literature review on MNV associated with IRDs. MNV is a well-known complication of Sorsby fundus dystrophy and pseudoxanthoma elasticum. Those with late-onset Stargardt disease may masquerade as exudative age-related macular degeneration (AMD) when MNV is the presenting feature. Peripherinopathies may develop MNV that responds well to a short course of anti-vascular endothelial growth factor (anti-VEGF) therapy, while bestrophinopathies tend to develop MNV in the early stages of the disease without vision loss. Enhanced S-cone syndrome manifests type 3 MNV that typically regresses into a subfoveal fibrotic nodule. MNV is only a rare complication in choroideraemia and rod-cone dystrophies. Most IRD-related MNVs exhibit a favorable visual prognosis requiring less intensive regimens of anti-vascular endothelial growth factor therapy compared to age-related macular degeneration. We discuss the role of key imaging modalities in the diagnosis of MNV across a wide spectrum of IRDs and highlight the gaps in our knowledge with respect to the natural history and prognosis to pave the way for future directions of research.

Clinical Features, Prognosis, and Long-Term Response to Ranibizumab of Macular CNVs in Pattern Dystrophies Spectrum: A Pilot Study

Introduction

To analyze the morphological and functional features of choroidal neovascularizations (CNVs) in eyes affected by pattern dystrophies (PD), evaluating their long-term response to intravitreal ranibizumab, and comparing them with CNVs in age-related macular degeneration (AMD). The mean goal is to identify possible disease biomarkers and to evaluate the long-term prognosis of CNVs in PD.

Materials and Methods

A retrospective study of 42 patients with naïve CNV (26 PD and 16 AMD), for a total of 47 eyes (29 eyes in the PD group and 18 eyes in the AMD group). Each patient received a loading dose of ranibizumab (one monthly for three months) followed by pro re nata (PRN) reinjection protocol for a period of at least three years. Morphological OCT parameters (CRT, central retinal thickness; SRF, subretinal fluid; IRF, intraretinal fluid; SHRM, subretinal hyperreflective material; HRF, hyperreflective foci; HCD, hyperreflective crystalline deposits; cCT, central choroidal thickness; slCT, sublesional choroidal thickness; EZd, ellipsoid zone disruption; and best corrected visual acuity (BCVA in logMAR scale)) were reported at baseline and last follow-up.

Results

At baseline, no significant differences were found between the two groups, except for choroidal thickness parameters that were significantly greater in the PD group (p = 0.009). Longitudinal PD analysis demonstrated reduction in BCVA (p = 0.009), decrease in CRT (p = 0.046), resolution of SRF in 61.6% of cases (p = 0.004) and SHRM in 30% (p = 0.034), and choroidal thinning both centrally (p = 0.004) and sublesional (p = 0.011) compared to baseline. At 3 years, the PD group received significantly more injections than the AMD (p = 0.011) and showed significantly thicker choroid (p = 0.033) and more frequent HRF (p = 0.006). Regarding the PD group, we found a negative correlation between age and choroidal thicknesses at baseline and at 3 years (p < 0.05); significant positive correlations were found between baseline BCVA and at 3 years (p < 0.001), BCVA at 3 years and IRF (p = 0.003) and SHRM at 3 years (p = 0.003); CRT baseline and CRT 3 years (p = 0.017); HCD at 3 years was associated with greater CRT (p = 0.04) and IRF at 3 years (p = 0.019).

Conclusions

Early and long-term morphofunctional features of CNVs in PD and in AMD are overlapping. CNVs in PD have poorer long-term response to ranibizumab and higher choroidal thickness suggesting different pathogenetic and evolutionary mechanisms.

Geographic atrophy in patients receiving anti-vascular endothelial growth factor for neovascular age-related macular degeneration

PURPOSE

To examine factors associated with the apparent growth of geographic atrophy (GA) in a consecutive series of eyes with treatment-naive neovascular age-related macular degeneration receiving intravitreal anti-vascular endothelial growth factor therapy on a treat-and-extend regimen.

METHODS

This was a retrospective cohort study. Two independent graders identified areas of GA using near-infrared reflectance imaging and spectral domain optical coherence tomography (SD-OCT). Neovascular lesion subtypes were classified based on fluorescein angiography (FA) as occult choroidal neovascularization, classic choroidal neovascularization, retinal angiomatous proliferation, or mixed choroidal neovascularization, and by the anatomical classification system which utilizes FA and SD-OCT as Types 1 (sub-retinal pigment epithelium), 2 (subretinal), 3 (intraretinal), or mixed neovascularization.

RESULTS

Ninety-one patients (94 eyes) fit the inclusion criteria, of which 52 eyes (55.3%) experienced apparent GA growth. The odds of developing apparent GA were significantly lower in Type 1 neovascularization compared to the other lesion types (P < 0.001). Using both FA and SD-OCT to classify neovascular age-related macular degeneration significantly improves the goodness of fit in the correlation between apparent GA growth and baseline neovascular lesion type (P < 0.001).

CONCLUSION

Treatment-naive neovascular age-related macular degeneration eyes with Type 1 neovascularization at baseline were less likely to develop GA than eyes with other types. The correlation between apparent GA growth and subtype of neovascularization is stronger when lesions are classified with an anatomic grading that utilizes both FA and SD-OCT.

The incidence of neovascular subtypes in newly diagnosed neovascular age-related macular degeneration

PURPOSE

To determine the frequency of neovascularization subtypes as determined by fluorescein angiography (FA) alone vs FA and optical coherence tomography (OCT) grading in age-related macular degeneration (AMD).

DESIGN

Retrospective cohort.

METHODS

participants: Newly diagnosed neovascular AMD patients who initiated intravitreal anti-vascular endothelial growth factor therapy by 1 physician from October 1, 2005 to December 1, 2012. interventions: Two independent graders classified the baseline lesions using FA alone and FA+OCT. main outcome measures: Analysis of the frequency of lesion subtypes by FA alone or FA+OCT and agreement between both classification systems was performed.

RESULTS

A total of 232 patients (266 eyes) fit the inclusion criteria. Mean age was 86.3 years; 67.7% of eyes (180/266) were from female patients, and 95.5% (254/266) were from white patients. The distribution using FA alone was 49.6% (132/266), 12.0% (32/266), 28.6% (76/266), and 9.8% (26/266) among occult, classic, retinal angiomatous proliferation, and mixed choroidal neovascularization, respectively. With FA+OCT, 39.9% (106/266), 9.0% (24/266), 34.2% (91/266), and 16.9% (45/266) were type 1 (sub-retinal pigment epithelium), type 2 (subretinal), type 3 (intraretinal), and mixed neovascularization (NV), respectively. The κ statistic was 0.65 (standard error ±0.37, P < .001) between the 2 classification systems, representing good agreement.

CONCLUSION

With both FA-alone and FA+OCT grading, we found a higher incidence of type 3 NV in eyes with newly diagnosed neovascular AMD than that reported in prior studies. The κ statistic between the 2 classification systems showed "good" agreement. The discrepancies are likely attributable to the identification of a higher frequency of type 3 and mixed NV and a lower frequency of type 1 NV with the aid of OCT.