Vision Loss in Younger Patients: A Review of Choroidal Neovascularization

Efficacy and safety of intravitreal injections of conbercept for the treatment of idiopathic choroidal neovascularization

BACKGROUND

To determine the efficacy and safety of intravitreally injected conbercept, a vascular endothelial growth factor receptor fusion protein, for the treatment of idiopathic choroidal neovascularization (ICNV).

METHODS

This retrospective study analyzed outcomes in 40 patients (40 eyes) with ICNV who received intravitreal injections of conbercept 0.5 mg (0.05 ml) and were followed up for at least 12 months. All patients underwent full ophthalmic examinations, including best-corrected vision acuity (BCVA), intraocular pressure (IOP), slit-lamp examination, color fundus photography, optical coherence tomography angiography, multifocal electroretinogram, and fundus fluorescence angiography, if necessary, at baseline and after 1, 3, 6, and 12 months. BCVA, macular central retinal thickness (CRT), IOP, CNV blood flow area, thickness of the CNV-pigment epithelial detachment complex, thickness of the retinal nerve fiber layer (RNFL), and the first positive peak (P1) amplitude density in ring 1 before and after treatment were compared.

RESULTS

Mean baseline BCVA (logMAR), CRT, CNV blood flow area, and CNV-pigment epithelial detachment complex thickness were significantly lower 1, 3, 6, and 12 months after than before conbercept treatment (P < 0.05 each). IOP and baseline RNFL thickness were unaffected by conbercept treatment. P1 amplitude density was significantly higher 1, 3, 6, and 12 months after than before conbercept treatment (P < 0.05 each). None of the 40 eyes showed obvious ocular adverse reactions, such as endophthalmitis, glaucoma, cataract progression, and retinal detachment, and none of the patients experienced systemic adverse events, such as cardiovascular and cerebrovascular accidents.

CONCLUSIONS

Intravitreal injection of conbercept is beneficial to eyes with ICNV, inducing the recovery of macular structure and function and improving BCVA, while not damaging the neuroretina. Intravitreal conbercept is safe and effective for the treatment of ICNV.

BILATERAL PERIPAPILLARY CHOROIDAL NEOVASCULARIZATION IN AN OTHERWISE HEALTHY TEENAGER TREATED WITH ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS

PURPOSE

This case report describes the presentation, diagnostic reasoning, and successful management of a 14-year-old teenage boy found to have bilateral peripapillary choroidal neovascularization.

METHODS

This is a case of a teenage boy with an unremarkable ocular and systemic history presenting with decreased visual acuity, macular edema, and bilateral peripapillary choroidal neovascularization.

RESULTS

After intravitreal antivascular endothelial growth factor injections, the patient's visual acuity improved. Imaging further revealed that the initially present macular edema, subretinal fluid, and peripapillary choroidal neovascularizations markedly improved after treatment.

CONCLUSION

Peripapillary choroidal neovascularizations are often not trivial to diagnose. As this report illustrates, work-up with different modalities is extremely valuable, and antivascular endothelial growth factor injections may help decrease exudation and improve visual outcomes.

Real-World Treatment Intensity and Patterns in Patients With Myopic Choroidal Neovascularization: Common Data Model in Ophthalmology

BACKGROUND

A paucity of data addressing real-world treatment of myopic choroidal neovascularization (mCNV) in the era of anti-vascular endothelial growth factor (VEGF) drugs led us to investigate real-world treatment intensity and treatment patterns in patients with mCNV.

METHODS

This is a retrospective, observational study using the Observational Medical Outcomes Partnership-Common Data Model database of treatment-naïve patients with mCNV over the 18-year study period (2003-2020). Outcomes were treatment intensity (time trends of total/average number of prescriptions, mean number of prescriptions in the first year and the second year after initiating treatment, proportion of patients with no treatment in the second year) and treatment patterns (subsequent patterns of treatment according to the initial treatment).

RESULTS

Our final cohort included 94 patients with at-least 1-year observation period. Overall, 96.8% of patients received anti-VEGF drugs as first-line treatment, with most of injections from bevacizumab. The number of anti-VEGF injections in each calendar year showed an increasing trend over time; however, there was a drop in the mean number of injections in the second year compared to the first year from 2.09 to 0.47. About 77% of patients did not receive any treatment in their second year of treatment regardless of drugs. Most of patients (86.2%) followed non-switching monotherapy only and bevacizumab was the most popular choice either in the first-line (68.1%) or in the second-line (53.8%) of treatment. Aflibercept was increasingly used as the first-line treatment for patients with mCNV.

CONCLUSION

Anti-VEGF drugs have become the treatment of choice and second-line treatment for mCNV over the past decade. Anti-VEGF drugs are effective for the treatment of mCNV as the non-switching monotherapy is the main treatment regimen in most cases and the number of treatments decreases significantly in the second year of treatment.

The clinical relevance of the adhesion G protein-coupled receptor F5 for human diseases and cancers

Among the numerous adhesion G protein-coupled receptors (GPCRs), adhesion G protein-coupled estrogen receptor F5 (ADGRF5) contains unique domains in the long N-terminal tail which can determine cell-cell and cell-matrix interaction as well as cell adhesion. Nevertheless, the biology of ADGRF5 is complex and still poorly explored. Accumulating evidence suggests that the ADGRF5 activity is fundamental in health and disease. For instance, ADGRF5 is essential in the proper function of lungs and kidney as well as the endocrine system, and its signification in vascularization and tumorigenesis has been demonstrated. The most recent studies have provided findings about the diagnostic potential of ADGRF5 in osteoporosis and cancers, and ongoing studies suggest other diseases as well. Here, we elaborate on the current state of knowledge about the ADGRF5 in the physiology and pathophysiology of human diseases and highlight its high potential as a novel target in various therapeutic areas.

Simultaneous bilateral inflammatory choroidal neovascularization in a case of healed serpiginous-like choroiditis

Objective

Inflammatory choroidal neovascularization (i-CNV) is an infrequent but sight-threatening complication of posterior uveitis. Although it can occur in a wide range of infectious and non-infectious uveitides, presence of simultaneous bilateral i-CNV is rare. In this report, we present a unique case of bilateral simultaneous i-CNV in a young patient of healed tubercular serpiginous-like choroiditis.

Method

A 20-year-old male presented with recent worsening of vision in the right eye for one month. Fundus examination revealed bilateral multifocal healed choroiditis lesions with right eye tiny subfoveal hemorrhage raising the suspicion of an underlying choroidal neovascularization. Fundus fluorescein angiography and optical coherence tomography confirmed presence of choroidal neovascular membrane in both eyes.

Result

Resolution of activity was noted in both eyes after bilateral sequential intravitreal bevacizumab injections.

Conclusion

Inflammatory choroidal neovascularization may be seen in patients with healed tubercular serpiginous-like choroiditis, after a long period of quiescence. Simultaneous bilateral presentation is rare but possible, requiring mandatory multimodal imaging of both eyes under high index of suspicion. Early institution of anti-vascular endothelial growth factor may salvage optimum vision in such a scenario.

Assessment of intravitreal anti-VEGF drugs and dexamethasone for retinal diseases in real world setting: A multi-centre prospective study from Southern Italy

Describe drug utilisation and clinical outcomes of intravitreal anti-VEGF drug and dexamethasone use in the real-world setting in Southern Italy using data from multi-centre study of retinal disease. Clinical data of retinal disease patients treated with anti-VEGF drugs and dexamethasone implant in 6 out-patient ophthalmology centres from Southern Italy were collected by means of an electronic case report form. Patients receiving at least one intravitreal injection/implant of the study drugs were followed for up to two years and described in terms of demographics and clinical characteristics. Drug utilisation patterns were described. A sign-rank test was used to compare clinical data on visual acuity and other ophthalmic parameters from baseline at different follow-up times for each indication. Data from 1327 patients was collected. Most patients were diagnosed with age-related macular degeneration (AMD) (660, 49.7%), followed by diabetic macular oedema (423, 31.9%), retinal vein occlusion (164, 12.3%), and myopic choroidal neovascularization (80, 6.0%). Patients were followed for a median of 10.3 months (interquartile range: 3.6 - 24.7 months). Mean patient age was 69.7 (±10.9) years and 54.2% were males. Ranibizumab (55.4%) and aflibercept (27.5%) were the most commonly used drugs. Baseline visual acuity significantly improved by about 0.05 to 0.1 logMAR at all follow-up times for AMD and RVO but less consistently for the other diseases. Intravitreal ranibizumab use accounted for half of all treatment for retinal diseases in a Southern Italian out-patient setting. Patients treated with anti-VEGF drugs for AMD and RVO in Southern Italy experienced significant improvement in VA.

Mechanism of Hypoxia Inducible Factor-1α (HIF-1α) in Choroidal Neovascularization in Macular Lutea of High Myopia

To explore the changes in the expression of hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) in the process of choroidal neovascularization (CNV) in the macular area of cases with form deprivation myopia (FDM), in this study, 36 healthy mice were selected as research subjects for analysis. Specifically, they were randomly divided into test group (n = 18) and control group (n = 18). The right eye of the test group mice underwent form deprivation for 6 weeks to induce FDM, also known as FDM group. Five mice were randomly selected from FDM group and control group at 6 time points (before photocoagulation, at 7 d, 14 d, 21 d, 28 d, and 35 d after photocoagulation), respectively, for fluorescein angiography and hematoxylin-eosin staining (HE) staining to observe differences in the retina. It was found that the retina of Control group mice was well-structured with clear stratification, while that of the test group mice was severely damaged with a disordered structure, manifested as edema and swelling and damaged Bruch membrane and retinal pigment epithelium (RPE) layer. Furthermore, macrophages and RPE cells were observed in the photocoagulation area, and there was a high-fluorescence area with a blurred margin in the fundus, indicating the formation of new blood vessels. The immunohistochemical experiment revealed that within three weeks after the surgery, HIF-1α was highly expressed in the test group, and the expression level was obviously higher than the Control group. The real-time quantitative polymerase chain reaction (PCR) results showed that the expression level of VEGF and HIF-α in the test group was obviously higher than the Control group within three weeks after the surgery. The Western blot experiment was performed 1 week after the surgery, and it was noted that the expression level of VEGF and HIF-1α were higher in the test group versus the Control group. In summary, HIF-1α is instrumental in ocular CNV, which is also associated with VEGF.

Choroidal Neovascularization in Pediatric Patients: Analysis of Etiologic Factors, Clinical Characteristics and Treatment Outcomes

Background and Objectives: Choroidal neovascularization (CNV) is a common pathologic lesion that occurs in various chorioretinopathy, but very limited published data have reported in pediatric patients. This study aimed to investigate the etiologic factors, clinical features, and treatment outcomes of choroidal neovascularization (CNV) in children.

Methods: In this study, 33 eyes in 30 patients aged 18 years or younger with CNV were included. Comprehensive ophthalmic examination was performed in all the patients. The demographic profiles, laterality, visual acuity, optical coherence tomographic findings, fundus fluorescein angiographic findings, and the underlying pathology were analyzed. The types, locations, treatment outcomes, and recurrences of CNV were noted.

Results: The average age was 11.2 ± 4.6 (range, 1–18) years. Most CNVs affecting children were classic and type 2. The most common etiologic factors of CNV in pediatric patients were congenital/developing abnormalities (9/30, 30.0%) and inflammatory retinochoroidopathy (9/30, 30.0%), followed by idiopathic CNV (8/30, 26.7%). Subtype analysis showed that the etiologic factor was inflammatory retinochoroidopathy in children 12 years or older, whereas congenital/developing abnormalities were present in children younger than 12 years. Eyes with active CNVs required a mean of 1.40 ± 0.58 injections. No recurrence was observed during follow-up.

Conclusions: The etiologic factors of CNV in young Chinese patients were diverse, with congenital/developing abnormalities, inflammatory retinochoroidopathy and idiopathic CNV being the 3 most common ones. Eyes with active CNVs had good responses to antivascular endothelial growth factor treatment with low recurrence.

Optical coherence tomography in the diagnosis of choroidal neovascularization in children

AIM: Report cases of choroidal neovascularization (CNV) in children and describe structural and hemodynamic changes in retina associated with this pathology detected by Optical Coherence Tomography (OCT) and OCT-angiography (OCTA). MATERIALS AND METHODS: 6 children (4 girls, 2 boys) aged from 7 to 17 years with CNV associated with pathological myopia, post-traumatic choroid rupture and optic disc abnormalities were examined. The activity of neovascular complexes was evaluated by ophthalmoscopy, OCT, and OCTA. The maximum follow-up period was 4 years. RESULTS: 7 cases of CNV were detected. One child had a two-way process. Myopic and posttraumatic membranes were localized sub- and juxtafoveally and were the membranes of type 2. In children with optic disc anomalies of the 1 type membrane and mixed (1st and 2nd) type was located extrafoveally. The decrease in visual acuity was determined by the localization of membranes, the severity of edema, and the severity of dystrophic changes in the retina. On OCT, subretinal fluid and hyperreflective material corresponding to hemorrhages were visualized in the projection of active membranes. OCTA revealed a network of small capillaries with a large number of loops and anastomoses. Intravitreal angiogenesis inhibitors injections were performed in 5 cases. A persistent effect after a single injection was observed in 2 cases. The return of membrane activity in 3 cases allowed us to justify the repeated administration of angiogenesis inhibitors. Along with a decrease in the activity of CNV, progressive dystrophic changes in the pigment epithelium around the membrane were detected. CONCLUSIONS: High sensitivity of OCT was demonstrated for early detection of structural and hemodynamic retinal disorders, determining the activity of neovascular complexes, predicting outcomes of the disease, and evaluating the effectiveness of therapeutic measures. The progression of dystrophic changes in the retinal pigment epithelium in response to therapy with angiogenesis inhibitors requires long-term monitoring of children and determining the optimal strategy for treating CNV in children.

Occult inflammation detected by autofluorescence May Be the cause of idiopathic choroidal neovascularization

Purpose

To describe retinal pigment epithelium (RPE) disease detected by fundus autofluorescence (FAF) imaging in eyes with idiopathic choroidal neovascularization (ICNV).

Methods

A retrospective review of patients seen during a 14-month period with the diagnosis of ICNV was performed to identify patients with RPE disease, defined as hypo or hyperautofluorescent lesions on FAF. The presence of ICNV was confirmed by clinical history, ophthalmoscopic examination, fluorescein angiography (FA), and spectral domain-optical coherence tomography (SD-OCT). The clinical diagnosis of an underlying inflammatory condition was based on the FAF appearance of multiple punched-out hyper or hypoautofluorescent spots in the retinal fundus.

Results

The mean age was 27 years (range, 21-33 years). Best-corrected visual acuity ranged from 20/25 to 20/200 with a median visual acuity of 20/80. Ten eyes of 8 patients presented RPE abnormalities on FAF. Of the 10 study eyes, ICNV was observed in 8 eyes. ICNV appeared as a type 2 neovascular membrane at the macular area on FA, and SD-OCT revealed neurosensory detachment in all study eyes. FAF demonstrated abnormalities of the RPE that were not appreciated on clinical examination or by other imaging modalities.

Conclusions

FAF may reveal an underlying inflammatory condition in patients diagnosed as ICNV, modifying the diagnosis and management.

DEXAMETHASONE INTRAVITREAL IMPLANT FOR CHOROIDAL NEOVASCULARIZATION DURING PREGNANCY

PURPOSE

To describe the management of active choroidal neovascularization (CNV) during pregnancy with the use of a dexamethasone intravitreal implant (DXI) (Ozurdex).

METHODS

Case series of active CNV treated with DXI with at least 12-month follow-up retrospectively analyzed at 2 high-volume referral centers in France. Medical records and multimodal macular imaging were evaluated.

RESULTS

Three eyes of 3 patients (age 30.0 ± 3.6 years) were included. One case of idiopathic CNV and two cases of CNV secondary to multifocal choroiditis were analyzed. Mean follow-up was 20.6 ± 4.0 months (range, 16-23 months). The DXI was given at second trimester of established pregnancy in all cases. Mean central retinal thickness decreased from 359 ± 53 μm to 301 ± 17 μm 1 month after DXI and remained stable up to 12 months of follow-up. Visual improvement in all cases was observed (mean 10 letters; range, 5-30 letters) 1 month after DXI and remained stable/increased up to 12-month follow-up (mean 22 letters; range, 10-30 letters). All patients had an uneventful prenatal course and delivered a healthy full-term infant.

CONCLUSION

In the authors' experience, a single DXI revealed safe and effective in CNV treatment during pregnancy.

Vision-related quality of life in patients treated for myopic choroidal neovascularization: A post hoc analysis of the OLIMPIC study

PURPOSE

To investigate vision-related quality of life in patients referred to the Italian Retina Services for intravitreal ranibizumab treatment for choroidal neovascularization due to pathologic myopia.

DESIGN

Post hoc analysis of a multicenter, interventional phase IIIb study (OLIMPIC).

METHODS

Patients with either previously untreated (naïve) or treated choroidal neovascularization due to pathologic myopia were enrolled. Vision-related quality of life was measured using the Italian version of the Impact of Vision Impairment Questionnaire with scores from 0 (no impact) to 5 (severe impact). Burden of illness data were collected regarding income, and personal and public resource use.

RESULTS

In the 200 included subjects, mean best-corrected visual acuity in the better eye was 68.3 Early Treatment Diabetic Retinopathy Study letters (standard deviation: 15.2) compared with 42.5 Early Treatment Diabetic Retinopathy Study letters (standard deviation: 23.3) in the worse eye. The proportion of better eyes affected by choroidal neovascularization was 147/200 (73.5%). In multivariable analyses, lower better eye, but not worse eye, best-corrected visual acuity was associated with lower vision-related quality of life (per 10 fewer letters, beta: + 0.17, p < 0.001). An annual income below 20,000 euros was also associated with lower vision-related quality of life (beta: + 0.38; standard error: 0.13, p = 0.004). Moreover, in univariate analyses, increasing income level was linearly associated with better presenting best-corrected visual acuity in the better eye (p < 0.003), with a difference of 15 Early Treatment Diabetic Retinopathy Study letters for patient income <20,000 euros compared with >70,000 euros.

CONCLUSION

Italian patients with myopic choroidal neovascularization and a low income presented with lower better-eye best-corrected visual acuity and lower vision-related quality of life compared with those with a higher income. Future research should investigate disease awareness and candidacy issues that may influence the quality of life of patients.

Novel devices for studying acute and chronic mechanical stress in retinal pigment epithelial cells

Choroidal neovascularization (CNV) is a major cause of blindness in patients with age-related macular degeneration (AMD). Overexpression of vascular endothelial growth factor (VEGF), a potent angiogenic protein, by retinal pigment epithelial (RPE) cells is a key stimulator of CNV. Mechanical stress occurs during different stages of AMD and is a possible inducer of VEGF expression in RPE cells. However, robust and realistic approaches to studying acute and chronic mechanical stress under various AMD stages do not exist. The majority of previous work has studied cyclic stretching of RPE cells grown on flexible substrates, but an ideal model must be able to mimic localized and continuous stretching of the RPE as would occur in AMD in vivo. To bridge this gap, we developed two in vitro devices to model chronic and acute mechanical stress on RPE cells during different stages of AMD. In one device, high levels of continuous mechanical stress were applied to focal regions of the RPE monolayer by stretching the underlying silicon substrate to study the role of chronic mechanical stimulation. In the second device, RPE cells were grown on porous plastic substrates and acute stress was studied by stretching small areas. Using these devices, we studied the effect of mechanical stress on VEGF expression in RPE cells. Our results suggest that mechanical stress in RPE cells induces VEGF expression and promotes in vitro angiogenesis. These results confirm the hypothesis that mechanical stress is involved in the initiation and progression of CNV.

An update on inflammatory choroidal neovascularization: epidemiology, multimodal imaging, and management

Inflammatory choroidal neovascular membranes are challenging to diagnose and manage. A number of uveitic entities may be complicated by the development of choroidal neovascularization leading to a decrease in central visual acuity. In conditions such as punctate inner choroidopathy, development of choroidal neovascularization is extremely common and must be suspected in all cases. On the other hand, in patients with conditions such as serpiginous choroiditis, and multifocal choroiditis, it may be difficult to differentiate between inflammatory choroiditis lesions and choroidal neovascularization. Multimodal imaging analysis, including the recently introduced technology of optical coherence tomography angiography, greatly aid in the diagnosis and management of inflammatory choroidal neovascularization. Management of these neovascular membranes consists of anti-vascular growth factor agents, with or without concomitant anti-inflammatory and/or corticosteroid therapy.

An efficacy analysis of anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to multifocal choroiditis and comparison with wet age-related macular degeneration

OBJECTIVE

To evaluate the effect of anti-vascular endothelial growth factor (VEGF) on juxtafoveal choroidal neovascularization (CNV) secondary to multifocal choroiditis (MFC) and wet age-related macular degeneration (AMD).

METHODS

In this retrospective, comparative study, 20 unique eyes with CNV were divided into two groups: 10 patients affected by MFC and 10 patients diagnosed with wet AMD. They all received local intravitreal (IVT) injections of ranibizumab, with 6 months of follow-up. Retreatment injections were performed based on findings suggestive of active neovascularization.

RESULTS

Significant improvements were observed in the juxtafoveal CNV lesions, and average central macular thickness decreased in both groups following the anti-VEGF therapy (P<0.05). The average number of injections used in MFC patients was 1.6, while three injections on average were used in wet AMD patients (Z=-2.844, P=0.009). Best-corrected visual acuity was significantly improved in MFC patients after anti-VEGF therapy (P<0.05), and there was no significant difference in wet AMD patients between before anti-VEGF therapy and 6 months later (P>0.05).

CONCLUSIONS

IVT ranibizumab resulted in good clinical outcomes for juxtafoveal CNV secondary to MFC and wet AMD, but the average number of injections used in MFC was fewer than that used in wet AMD over a 6-month observation period. Compared with the wet AMD group, visual acuity was obviously improved in the MFC group at 6 months.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF CHOROIDAL NEOVASCULARIZATION IN FOUR INHERITED RETINAL DYSTROPHIES

PURPOSE

To demonstrate the clinical utility of optical coherence tomography (OCT) angiography (OCT-A) in inherited retinal dystrophies complicated by choroidal neovascularization (CNV).

METHODS

Optical coherence tomography angiography and structural OCT were performed using a 70-kHz spectral domain OCT system using the split-spectrum amplitude-decorrelation angiography algorithm. Semiautomated image processing software was used to segment and measure the CNV.

RESULTS

Four participants were enrolled to study the following inherited retinal dystrophies complicated by CNV: choroideremia, EFEMP1-related retinopathy, Best vitelliform dystrophy, and adult-onset vitelliform dystrophy. Interpretation of fluorescein angiography was difficult because of abnormal retinal architecture but suggested the presence of CNV. Structural OCT revealed subretinal or subretinal pigment epithelium fibrovascular tissue, within which flow signal was observed on OCT-A. The CNV morphology varied from dense capillary networks in active lesions to asymptomatic large caliber loops. Baseline CNV vessel areas ranged from 0.07 mm to 0.98 mm. After treatment with intravitreal bevacizumab, the CNV in choroideremia decreased in the vessel area then rebounded, whereas the one in EFEMP1-related retinopathy remained largely unchanged.

CONCLUSION

Optical coherence tomography angiography enables morphologic characterization and quantification of CNV in patients with retinal dystrophies despite distorted retinal architecture, can assess response to treatment, and may facilitate differentiation between active and regressed lesions.

Ranibizumab versus bevacizumab for the treatment of idiopathic choroidal neovascularization: 2-Year results

PURPOSE

To compare the efficacy and safety of bevacizumab vs ranibizumab for the treatment of idiopathic choroidal neovascularization (ICNV).

METHODS

This retrospective study included 60 eyes of 60 patients with ICNV who underwent intravitreal injection of bevacizumab (1.25 mg/0.05 mL, n = 30 eyes) or ranibizumab (0.5 mg/0.05 mL, n = 30 eyes). Multiple treatments were based on complete ophthalmologic investigation including slit-lamp biomicroscopy, fundus examination, fundus fluorescein angiography (FFA), optical coherence tomography (OCT), and best-corrected visual acuity (BCVA). The BCVA, central retinal thickness (CRT), intraocular pressure (IOP), FFA results, and complications were compared between the 2 groups during the 2-year follow-up.

RESULTS

Visual acuity was significantly better at 1, 3, 6, 12, and 24 months after treatment (p&lt;0.01), with no significant difference in visual acuity between the bevacizumab and ranibizumab groups. In both groups of patients, the CRT after treatment was significantly less than before. At 12 and 24 months, the CRT in the ranibizumab group was significantly less than in the bevacizumab group (p&lt;0.05). The FFA examination showed that CNV was reduced after intravitreal injection of either drug, with no significant difference in IOP between the 2 groups. No ophthalmologic or systemic complications occurred.

CONCLUSIONS

Bevacizumab and ranibizumab are effective and safe in the treatment of ICNV, with similar effects in improving visual acuity and reducing retinal edema. The long-term efficacy of ranibizumab is superior to bevacizumab in reducing CRT.

Clinical characteristics and antivascular endothelial growth factor effect of choroidal neovascularization in younger patients in Taiwan

Background/Purpose:

The purpose of this study is to share experiences diagnosing and treating choroidal neovascularization (CNV) in young patients (age ≤ 50 years) at our hospital.

Methods:

The study reviewed retrospective data of patients (≤ 50 years old) with CNV who received antivascular endothelial growth factor treatment (anti-VEGF) between January 2007 and August 2012 at Shin Kong Wu Ho-Su Memorial Hospital. We recorded the total number of injections, types of drugs, preoperative and final best-corrected visual acuity (BCVA), central retinal thickness (CRT) in optical coherence tomography (OCT), and total follow-up times, and then used two-tailed paired t tests to compare mean changes in BCVA and CRT on OCT.

Results:

The study enrolled 59 patients ≤ 50 years of age with CNV diagnosed in 67 eyes. The mean age was 36.9 ± 10.0 years (range, 8–50 years). Twenty-one patients were male and 38 patients were female. Forty-two CNV lesions were subfoveal, 19 were juxtafoveal, and five were extrafoveal. The mean total follow-up time was 18.5 ± 19.9 months (range, 0.5–71 months). Pathologic myopia was the most common cause of CNV in this study (47.8%), followed by punctate inner choroidopathy (17.9%), idiopathic CNV (16.4%), polypoidal choroidal vasculopathy (13.4%), angioid streaks (3.0%), and choroidal rupture (1.5%). After anti-VEGF treatment, the mean BCVA improved from 0.69 ± 0.61 to 0.42 ± 0.59 (p < 0.05). CRT decreased from 257.5 ± 48.2 to 210.3 ± 35.7 (p < 0.05). The mean number of injections was 1.9 ± 1.6 (range, 1–9).

Conclusion:

In this study we found that pathologic myopia, punctate inner choroidopathy, and idiopathic and polypoidal choroidal vasculopathy comprised the four most common causes of CNV in patients ≤ 50 years of age in Taiwan. We also revealed that anti-VEGF treatment is highly effective in the treatment of CNV in this age group.

Preparation of naringenin/ β-cyclodextrin complex and its more potent alleviative effect on choroidal neovascularization in rats

Choroidal neovascularization (CNV) is characterized by abnormal blood vessels growing from the choroid. Current remedies for CNV have not shown favorable therapeutic efficacy. It is urgent to identify and develop more safe and potent anti-CNV agents via multiple technologies. We previously showed that the natural product naringenin attenuated CNV. However, naringenin has poor water solubility and low bioavailability. Here, we prepared the β-cyclodextrin (β-CD) complex of naringenin and characterized it using infrared spectra and X-ray diffraction analyses. Determination of content and solubility in the complex showed that naringenin accounted for 20.53% in the complex and its solubility was increased by more than 10-fold. Using a laser-induced CNV model in rats we demonstrated that naringenin/β-CD complex more significantly reduced CNV area than naringenin alone in rats. Furthermore, naringenin and its β-CD complex significantly inhibited the mRNA and protein expression of VEGF, COX-2, PI3K, p38MAPK, MMP-2, and MMP-9 in retina and choroid tissues. Naringenin/β-CD complex showed more significant inhibitory effect on VEGF and COX-2 expression than naringenin. These results collectively indicated that naringenin/β-CD complex could be a promising therapeutic option for CNV and that the beneficial effects could be linked to the anti-inflammatory properties of naringenin.

Risk of choroidal neovascularization among the uveitides

PURPOSE

To evaluate the risk, risk factors, and visual impact of choroidal neovascularization (CNV) in uveitis cases.

DESIGN

Retrospective cohort study.

METHODS

Standardized medical record review at 5 tertiary centers.

RESULTS

Among 15,137 uveitic eyes (8868 patients), CNV was rare in the cases of anterior or intermediate uveitis. Among the 4041 eyes (2307 patients) with posterior uveitis or panuveitis, 81 (2.0%) had CNV at presentation. Risk factors included posterior uveitis in general and specific uveitis syndromes affecting the outer retina-retinal pigment epithelium-choroid interface. Among the 2364 eyes (1357 patients) with posterior uveitis or panuveitis and free of CNV at the time of cohort entry, the cumulative 2-year incidence of CNV was 2.7% (95% confidence interval [CI], 1.8% to 3.5%). Risk factors for incident CNV included currently active inflammation (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.26 to 3.60), preretinal neovascularization (aHR, 3.19; 95% CI, 1.30 to 7.80), and prior diagnosis of CNV in the contralateral eye (aHR, 5.79; 95% CI, 2.77 to 12.09). Among specific syndromes, the incidence was greater in Vogt-Koyanagi-Harada syndrome (aHR, 3.37; 95% CI, 1.52 to 7.46) and punctate inner choroiditis (aHR, 8.67; 95% CI, 2.83 to 26.54). Incident CNV was associated with a 2-line loss of visual acuity (+0.19 logarithm of the minimal angle of resolution units; 95% CI, 0.079 to 0.29) from the preceding visit.

CONCLUSIONS

CNV is an uncommon complication of uveitis associated with visual impairment that occurs more commonly in forms affecting the outer retina-retinal pigment epithelium-choroid interface, during periods of inflammatory activity, in association with preretinal neovascularization, and in second eyes of patients with unilateral CNV. Because CNV is treatable, a systematic approach to early detection in high-risk patients may be appropriate.

[Morphological features of myopic choroidal neovascularization: differences to neovascular age-related macular degeneration]

Choroidal neovascularization due to pathological myopia (mCNV) differs in important characteristics from lesions seen in age-related macular degeneration (ARMD). Myopic CNV is associated with typical phenomena, such as lacquer cracks or patchy atrophy drusen or pigment epithelium detachment are rare occurrences. The dimensions of mCNV and the extent of leakage are substantially smaller. The heterogeneous combination of thinning and concomitant staphyloma often complicates the early detection of neovascular lesions. Diagnosis and evaluation of the clinical progress are only possible using the combination of different imaging modalities, e.g. funduscopy, fluorescein angiography (FLA) and spectral domain optical coherence tomography (SD-OCT). Special forms, such as periconal mCNV or dome-shaped variants exhibit a typical progression and response to therapy. In the course of the disease a progressive pigmentation and secondary atrophy occur and later, depigmentation of the mCNV complicates the demarcation of the original mCNV within the zone of atrophy. Extensive information and counselling seem to be mandatory in order to allow a better self-assessment. Sometimes, patients notice the first symptoms of recurrent mCNV activity before confirmation is possible by objective diagnostics.

Persistent inflammation subverts thrombospondin-1-induced regulation of retinal angiogenesis and is driven by CCR2 ligation

Neovascular retinal disease is a leading cause of blindness orchestrated by inflammatory responses. Although noninfectious uveoretinitis is mediated by CD4(+) T cells, in the persistent phase of disease, angiogenic responses are observed, along with degeneration of the retina. Full clinical manifestation relies on myeloid-derived cells, which are phenotypically distinct from, but potentially sharing common effector responses to age-related macular degeneration. To interrogate inflammation-mediated angiogenesis, we investigated experimental autoimmune uveoretinitis, an animal model for human uveitis. After the initial acute phase of severe inflammation, the retina sustains a persistent low-grade inflammation with tissue-infiltrating leukocytes for over 4 months. During this persistent phase, angiogenesis is observed as retinal neovascular membranes that arise from inflamed venules and postcapillary venules, increase in size as the disease progresses, and are associated with infiltrating arginase-1(+) macrophages. In the absence of thrombospondin-1, retinal neovascular membranes are markedly increased and are associated with arginase-1(-) CD68(+) macrophages, whereas deletion of the chemokine receptor CCR2 resulted in reduced retinal neovascular membranes in association with a predominant neutrophil infiltrate. CCR2 is important for macrophage recruitment to the retina in experimental autoimmune uveoretinitis and promotes chronicity in the form of a persistent angiogenesis response, which in turn is regulated by constitutive expression of angiogenic inhibitors like thrombospondin-1. This model offers a new platform to dissect the molecular and cellular pathology of inflammation-induced ocular angiogenesis.

Relationship between complement membrane attack complex, chemokine (C-C motif) ligand 2 (CCL2) and vascular endothelial growth factor in mouse model of laser-induced choroidal neovascularization

The present study investigated the interactions among the complement membrane attack complex (MAC), CCL2, and VEGF that occur in vivo during the development of choroidal neovascularization (CNV). We first investigated the sequential expression of MAC, CCL2, and VEGF during laser-induced CNV in C57BL/6 mice. Increased MAC deposition was detected at 1 h, CCL2 increased at 3 h, and VEGF was up-regulated at day 3 post-laser treatment. These results suggested that during laser-induced CNV, MAC, CCL2 and VEGF are formed and/or expressed in the following order: MAC → CCL2 → VEGF. To determine the cross-talk between MAC, CCL2, and VEGF during laser-induced CNV, neutralizing antibodies were injected both systemically and locally to block the bioactivity of each molecule. Blocking MAC formation inhibited CCL2 and VEGF expression and also limited CNV formation, whereas neutralization of CCL2 bioactivity did not affect MAC deposition; however, it reduced VEGF expression and CNV formation. When bioactivity of VEGF was blocked, CNV formation was significantly inhibited, but MAC deposition was not affected. Together, our results demonstrate that MAC is an upstream mediator and effect of MAC on the development of laser-induced CNV can be attributed to its direct effect on VEGF as well as its effect on VEGF that is mediated by CCL2. Understanding the interplay between immune mediators is critical to gain insight into the pathogenesis of CNV.

Anti-vascular endothelial growth factor therapy for neovascular ocular diseases other than age-related macular degeneration

PURPOSE OF REVIEW

Anti-vascular endothelial growth factor (anti-VEGF) therapies that arrest choroidal angiogenesis and reduce vascular permeability have revolutionized clinical practices for neovascular eye diseases. This review describes anti-VEGF strategies that are being evaluated in ocular diseases, other than neovascular age-related macular degeneration, in which neovascularization plays a critical role in pathogenesis.

RECENT FINDINGS

Early studies of the anti-VEGF agents, pegaptanib sodium, ranibizumab, bevacizumab, VEGF trap, and bevasiranib in the treatment of various neovascular diseases (e.g., diabetic macular edema, retinal vein occlusion, choroidal neovascularization) have shown promising results. The efficacy and safety of these agents, either alone or combined with standard treatments (e.g., laser photocoagulation), anti-inflammatory agents, or other non-VEGF-based antiangiogenic therapies, is actively investigated. Non-VEGF-driven pathways and growth factors other than VEGF may play important roles in pathogenesis and are included in certain combination therapies with VEGF inhibitors.

SUMMARY

The discovery of VEGF-A's role in the pathogenesis of neovascular ocular disease provided a strong rationale for the development of anti-VEGF-based therapies. There is now ample evidence that anti-VEGF therapies are viable treatment options for these diseases. Nevertheless, large, randomized controlled trials are still awaited to confirm early safety and efficacy findings from small, open-label prospective studies.