The effect of intravitreal bevacizumab in the treatment of Coats disease in children. Retina. 2010;30:617-622. [PMID: 19996822 DOI: 10.1097/iae.0b013e3181c2e0b7]

Coats' Disease: A Comprehensive Review of Its Pathophysiology, Diagnosis, and Advances in Treatment

BACKGROUND AND PURPOSE

Coats' disease, first described by George Coats in 1908, is a rare ocular disorder primarily affecting young males, often unilaterally. It is characterized by retinal telangiectasia, aneurysms, and exudation, which, in severe cases, can lead to blindness, painful red eye, or ocular atrophy, particularly with early childhood onset. Over the last century, advancements have been made in understanding its natural history, morphology, incidence, and clinical manifestations, showing a male predominance without significant ethnic disparities. This review aims to provide a comprehensive overview of Coats' disease, focusing on its pathogenesis, clinical presentation, diagnostic methods, and management strategies.

METHODS

The pathogenesis of Coats' Disease is multifactorial, involving inflammatory, vascular, and potentially genetic components. Early theories suggested inflammation as the primary cause, but modern research highlights the role of vascular endothelial growth factor (VEGF), where ischemic retinal areas elevate VEGF levels, promoting angiogenesis and impairing the blood-retinal barrier. Clinically, the disease is asymptomatic in early stages but progresses to symptoms like reduced visual acuity, strabismus, and leukocoria, typically within the first decade of life. Diagnostic methods include fundus fluorescein angiography, optical coherence tomography (OCT), and OCT angiography (OCTA), with recent studies identifying reduced blood flow density in capillary networks. Management ranges from intravitreal anti-VEGF agents and steroids to surgical options like pars plana vitrectomy and transscleral drainage, with additional techniques such as laser photocoagulation and cryotherapy proving effective in advanced stages.

CONCLUSION

The prognosis of Coats' Disease heavily depends on the stage of disease at presentation. Early detection and intervention can preserve vision, but advanced stages often result in poor outcomes. Factors such as younger age at presentation, advanced stage, and severe manifestations are associated with more aggressive progression and poorer prognosis. This review highlights the importance of early diagnosis and a multifaceted management approach, emphasizing the need for further research into its pathophysiology and innovative treatment strategies to improve patient outcomes.

Efficacy and Safety of Anti-Vascular Endothelial Growth Factor Drugs for Coats' Disease Treatment: A Systematic Review

Purpose: The efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) treatment for Coats' disease remains controversial. This study was designed to evaluate the efficacy and safety of anti-VEGF treatment for Coats' disease. Methods: PubMed, Embase, The Cochrane Library, Clinical Trials, CNKI, and WanFang databases were systematically searched for clinical efficacy and safety studies on anti-VEGF treatment for Coats' disease through June 2021. Study selection, data extraction, and quality assessment were independently performed by 2 reviewers. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal tools and GRADE-CERQual. Results: A total of 1,501 articles were retrieved and reviewed, of which 24 case series involving 378 patients (range: 3-67 patients each with 3-71 eyes) were included in the analysis. No randomized controlled trials, case-controlled studies, or cohort studies were available for analysis. Most patients were male (60.0%-92.9%), aged 1.35-42.3 years, with a median follow-up time ranging from 3 to 63 months. Among the 24 case series, 22 reported changes in the visual acuity (VA) after anti-VEGF treatment and 21 reported safety outcomes. The results showed that VA improved in 73 patients (37.63%), was stable in 89 (45.87%), and worsening VA was observed in 12 cases (6.19%). The most common adverse event was fibrotic changes (n = 35). Systemic complications were not observed. Conclusions: The results of this study indicate that anti-VEGF drugs provide an effective and relatively safe treatment strategy for Coats' disease. However, conducting well-designed, prospective, randomized clinical trials are necessary to confirm our findings.

Fovea-threatening and fovea-involving peripheral Coats disease: effects of posture and intervention

BACKGROUND

We believe that our experience with patients presenting with Coats disease and macular sparing should be shared with our colleagues. We would like to show the effect of posture and prompt intervention in cases with fovea-threatening and/or fovea-involving peripheral Coats disease (FTPCD). This association has been poorly debated in our specialty and literature. We call the attention for the unexpexted scenario of observing the lost of the fovea during some types of traditional and prompt interventional treatments of these cases with previous 20/20 vision (something that we have been studying and observing for many years). In order to publish our best representative cases, we have chosen 8 Brazilian patients (age range, 7-62 years; 5 male) with FTPCD. All patients underwent multimodal imaging and different treatments (observation, sleep-posture repositioning, laser, intraocular steroids, and/or anti-vascular endothelial growth factor therapy). All patients, initially, informed to adopt a sleeping lateral-down position, favoring exudation shifting to the fovea pre-treatment. Most promptly-treated patients in this way (n = 4), developed subretinal fluid and exudates in the macula and some had irreversible central visual loss (n = 3). Patients with recent fovea-involving exudation who changed postural sleep position (to protect the foveal area) before and during treatment fared better, with some preserved central vision and an intact fovea (n = 5). The fundus status was correlated with the gravitational effects of posture before and after treatment. Despite prepared as an observational/interventional study, with a small number of cases, the most difficult part is documenting the sleep position of these patients and its influence in the outcomes as there is not good way to prove how well or poorly the positioning occurred in our cases. Finally, we also intended to call the attention to the fact that Coats disease must be studied in all its clinical stage variants and not only seen as a potential blinding and incurable ocular disease.

CASE PRESENTATION

This study is a retrospective and/or interventional analysis of eight cases with a less severe clinical variant of classic Coats disease that we refer to as fovea-threatening and fovea-involving peripheral Coats disease (FTPCD). All cases were unilateral with no systemic disease or family history of Coats disease. The bilateral anterior segment and intraocular pressure were normal in all patients. The characteristics of all patients are shown in the Table.

CONCLUSION

The funduscopic features of FTPCD are fundamental to disease understanding and optimal management. Habitual posturing may affect the fundus morphologic features of retinal exudation as observed in all current patients with exudative peripheral Coats disease. When sleep habitual posture is not observed in patients with FTPCD, the effects of prompt invasive treatments can cause rapid visual loss because of foveal subretinal pooling of exudates post-treatment. Initial vigilant adjusting of the habitual sleep posture for several patients with FTPCD, before the indication of traditional invasive treatments (laser and/or pharmacologic medications) can result in improved vision and fundoscopic morphologic features.

Treatment of Advanced Coats' Disease With Combination Therapy of Laser Photocoagulation, Intravitreal Ranibizumab, and Sub-Tenon Methylprednisolone Acetate

PURPOSE

To investigate the efficacy of combination therapy with laser photocoagulation, intravitreal ranibizumab, and sub-Tenon methylprednisolone acetate in patients presenting with advanced Coats' disease.

METHODS

This was a retrospective analysis of 16 patients who underwent laser photocoagulation combined with intravitreal ranibizumab and sub-Tenon methylprednisolone acetate between 2008 and 2017. The primary outcome was anatomic success and the secondary outcomes were globe preservation and final visual acuity.

RESULTS

The average age at surgery was 5.12 ± 2.7 years (range: 3 to 10 years). The mean follow-up time was 45.43 ± 29.01 months (range: 12 to 108 months). Of the 16 patients (16 eyes) reviewed, 6 patients had stage 3A and 10 patients had stage 3B Coats' disease. The mean number of applications was 10 (range: 4 to 18). Globe preservation was achieved in all patients. Final visual acuity outcomes were satisfactory: 20/20 to 20/50 in 2 patients, 20/60 to 20/100 in 1 patient, and 20/200 or worse in 13 patients.

CONCLUSIONS

Intravitreal ranibizumab used in combination with laser photocoagulation and sub-Tenon methylprednisolone acetate could be an effective treatment option for patients with advanced Coats' disease. The combined therapy achieved anatomical success, globe preservation, and reasonable visual acuity outcomes. [J Pediatr Ophthalmol Strabismus. 2022;59(3):187-191.].

Coats Disease in 9 Patients: A Hispanic Case Series

BACKGROUND/AIM

To describe demographic and clinical characteristics, treatment, and visual prognosis of Coats disease in Hispanic patients.

METHODS

A retrospective chart review was performed on nine patients (ten eyes) diagnosed with Coats disease in our two clinical centrers from 2004 - 2017.

RESULTS

Mean age at diagnosis was 5.5 years (range 1 - 12 years) and mean follow-up time was 48 months (range 9 - 108 months). Eight patients (89%) were male and had unilateral disease and one (11%) female patient had bilateral disease. In 40% of the cases, patients were asymptomatic. Visual acuity at first presentation was worse than hand motion in 60% of the eyes. Half of the eyes (5/10 eyes, 50%) had exudative retinal detachment (≥ stage IIIA). Vascular ablation with cryotherapy combined with retinal photocoagulation was the most frequent therapeutic approach (40%). Despite anatomical success at 6 months in 100% of the treated eyes, visual outcome at 1 year of treatment was poor (worse than 20/200) in 70% of the cases.

CONCLUSIONS

In our case series, patients were mostly asymptomatic on presentation, with severe stages of Coats disease. Even with anatomical success after surgical treatment in all treated cases, long-term visual prognosis remained very limited.

Coats' disease: trends and long-term treatment outcomes in a tertiary referral centre

Background:

The long-term treatment outcomes in Coat’s disease – particularly in the era of newer pharmacotherapies such as anti-vascular endothelial growth factor (VEGF) agents and depot steroids – are poorly understood.

Aim:

To describe the clinical features and treatment outcomes of 148 eyes with Coats’ disease assessed in a referral centre over 30 years.

Materials and methods:

We conducted a retrospective chart review of patients diagnosed with Coats’ disease between 1 June 1987 and 31 July 2017. The demographic, clinical and treatment data were collected and long-term functional and anatomical outcomes were analysed based on the treatment either with conventional therapy (cryo/laser) or along with adjuvants like intravitreal steroids or anti-VEGFs.

Results:

The mean age at presentation was 15.22 years (median 11). Familial exudative vitreoretinopathy was the most common referral diagnosis, 76/148 (51.5%), followed by Coats’ disease, 37/148 (25%), and retinoblastoma, 35/148 (23.6%). Stage 3B was most common at presentation (31.8%), followed by 2B (22.3%) and 2A (16.9%). A total of 107 patients were treated either with conventional therapy or in combination with adjuvants. The mean follow-up period was 24.95 months. The visual acuity improved from baseline logMAR 2.17 (Snellen-20/2958) to logMAR 1.88 (Snellen-20/1517) at final follow-up (p = 0.004). The improvement in visual acuity was better when the presenting BCVA was <1 logMAR (Snellen 20/200), p = 0.004. No statistically significant change in BCVA was noted between conventional and adjuvant groups, p = 0.5. However, the final anatomical outcome was good in 78/99 (78.8%) in the conventional group and 45/49 (91.8%) in the adjuvant group, respectively (p = 0.046).

Conclusion:

In this series of patients with Coats’ disease over three decades, the use of intravitreal steroids or anti-VEGFs as adjuvants resulted in better anatomical outcomes. A better baseline visual acuity, lower stage of the disease, and older age at presentation were found to be the factors leading to favourable visual outcomes.

Summary

In the current series of 148 eyes with Coats’ disease, adjuvant treatment with intravitreal steroids or anti-VEGFs resulted in better outcomes as compared with conventional cryotherapy or laser photocoagulation alone. Patients with Coats’ disease who had presented with better visual acuity at baseline, lower stage of the disease and older age had better final visual outcomes.

Vitrectomy and external drainage of subretinal fluid containing high concentration of vascular endothelial growth factor for advanced coats disease

This study investigated the surgical outcomes of Coats disease and the role of external drainage (XD) of subretinal fluid (SRF). The study is a multicenter retrospective interventional case series of 26 consecutive eyes of 26 patients who underwent surgeries for advanced Coats disease with retinal detachment. Main outcomes measured were: 1) comparison of complete SRF resolution with or without XD, and 2) variables that were associated with functional postoperative best-corrected visual acuity (BCVA) defined as BCVA of 0.1 or better, 3) intraocular vascular endothelial growth factor (VEGF) levels. Complete SRF resolution was achieved in all 14 eyes in which XD had been performed and in 75% of 12 eyes in which XD had not been performed (P = .03). Multivariable logistic regression analysis revealed that initial BCVA was the only variable associated with functional postoperative BCVA (odds ratio 3.24, 95% CI 0.93–11.33; P = .04). Markedly elevated VEGF levels were noted in the SRF compared with those in the vitreous humor (49,760 ± 52,990 vs. 707 ± 611 pg/mL, P = .03). XD seems to provide better anatomical success than without XD in the treatment of advanced Coats disease as XD could effectively eliminate substantial amount of VEGF in the SRF.

Clinical features and prognostic factors in 71 eyes over 20 years from patients with Coats' disease in Korea

This retrospective study assesses the clinical features, treatment strategies, and long-term outcomes of patients with Coats’ disease in Korea. Multimodal imaging and medical records of consecutive patients treated between July 2000 and April 2020 at two tertiary centers were evaluated based on onset age (adult vs. childhood [< 18 years]). Factors associated with final visual acuity (VA) and risk of treatment failure were assessed. A total of 71 eyes of 67 patients were included, with subgrouping by onset age showing 45% childhood and 55% adult cases. Overall, Stage 2 disease was most common at presentation (76%), though childhood cases had more Stage 3b (22% vs. 3%, P = 0.02) and greater clock hours of retinal telangiectasia (7 vs. 5, P = 0.005). First-line treatment included laser (25%), combined laser/anti-VEGF (23%), cryotherapy (20%), surgery (16%), and anti-VEGF only (9%). Cryotherapy was associated with a higher risk for secondary interventions (OR 11.8, P < 0.001), required in 56% overall. Despite a 3-line VA decrease in 34% overall, adult cases had superior final VA (P = 0.037). Multivariable regression showed that the number of anti-VEGF injections performed during the initial treatment period was associated with a 9.4 letter improvement in vision (P = 0.041). We observed a higher proportion of adult-onset Coats’ disease than previously reported in other non-Asian populations. An aggressive treatment with the addition of anti-VEGF may yield the most favorable long-term visual outcomes.

External Drainage Alone Versus External Drainage With Vitrectomy in Advanced Coats Disease

PURPOSE

To evaluate the efficacy of transscleral drainage of subretinal fluid (TDSRF) with and without pars plana vitrectomy (PPV), which are performed as an adjunct to ablative therapies in advanced Coats disease.

DESIGN

Retrospective, comparative case series.

PATIENT POPULATION

A total of 31 eyes from 31 consecutive patients with advanced Coats disease at an average age of 47.8 ± 34.2 (2-156) months at the time of the surgery, who underwent TDSRF alone or in combination with PPV.

METHODS

Main outcome measurements were LogMAR visual acuity values, anterior and posterior segment findings, need for further surgery, laser photocoagulation, and anti-vascular endothelial growth factor (anti-VEGF) treatment. Anatomical success was defined as the maintenance of retinal reattachment without any further surgery during follow-up.

RESULTS

Sixteen patients underwent TDSRF alone, and 15 patients underwent combined TDSRF and PPV. Mean follow-up time was 34.8 ± 32.9 months (6-128). Anatomical success rate of combined TDSRF and PPV was higher than that of TDSRF alone (93.8% vs 75%, respectively). The incidence of epiretinal membrane formation, number of laser photocoagulation procedures, and anti-VEGF treatments were statistically significantly higher in the group that underwent TDSRF alone than in those who had combined TDSRF and PPV in the long term. There was an improvement in vision in only 4 eyes (12.9%) (all >3 years old at presentation) during the follow-up.

CONCLUSIONS

Combined TDSRF and PPV appears to be more effective in controlling the disease than TDSRF alone, as an adjunct to ablative procedures for the treatment of advanced Coats disease. The need for additional treatment is much less with the addition of PPV.

Three-year follow-up of Coats disease treated with conbercept and 532-nm laser photocoagulation

BACKGROUND

Coats disease is an idiopathic exudative outer retinopathy caused by abnormal retinal vascular development.

AIM

To evaluate the long-term outcomes of intravitreal conbercept injection with laser photocoagulation as a treatment for Coats disease in adults.

METHODS

This retrospective case series study included patients diagnosed with Coats disease and treated with intravitreal conbercept injection and 532-nm laser photocoagulation at the Ophthalmology Department of Shenzhen People’s Hospital between January 2016 and January 2017. Best-corrected visual acuity (BCVA) measurements, noncontact tonometry, ophthalmoscopy, fundus photography, fundus fluorescein angiography and optical coherence tomography were performed before treatment and at 1 wk, 1 mo, 3 mo, 6 mo, 9 mo, 12 mo, 24 mo and 36 mo after therapy. Best-corrected visual acuity was measured using the early treatment of diabetic retinopathy study chart.

RESULTS

The study included eight eyes of 8 patients (7 men) aged 36.10 ± 6.65 years. The average BCVA of the affected eye before treatment was 51.17 ± 15.15 letters (range, 28–70 letters), and the average central macular thickness was 303.30 ± 107.87 µm (range, 221–673 µm). Four eyes were injected once, three were injected twice, and one was injected three times. Average follow-up duration was 37.33 ± 2.26 mo. Average BCVA of the affected eye was 51.17 ± 15.15 letters before treatment and was increased by 13.50 ± 3.20, 16.25 ± 7.73, 18.25 ± 8.96, 18.03 ± 5.27, 18.63 ± 3.35, 19.75 ± 6.96, 18.05 ± 5.36 and 17.88 ± 3.45 letters at 1 wk, 1 mo, 3 mo, 6 mo, 9 mo, 12 mo, 24 mo and 36 mo after treatment, respectively (P < 0.01). The patients showed varying degrees of subretinal fluid resorption after treatment. None of the patients had serious complications such as increased intraocular pressure, development/progression of cataracts, endophthalmitis or retinal detachment.

CONCLUSION

Intravitreal injection of conbercept combined with 532-nm laser photocoagulation may be a feasible treatment for Coats disease in adult patients.

Predictors of enucleation in Coats disease: analysis of 259 eyes of 259 patients at a single center

PURPOSE

To evaluate the effects of clinical features associated with enucleation in eyes with Coats disease.

METHODS

The medical records of all patients with Coats disease at the Ocular Oncology, Wills Eye Hospital from November 1, 1973, to July 31, 2018, were reviewed retrospectively. The clinical features pertaining to need for ultimate enucleation and time to enucleation were compared.

RESULTS

The records of 351 eyes were reviewed, of which 259 had follow-up at our center and 32 (12%) were managed with enucleation. Reasons for enucleation included neovascular glaucoma (n = 24 [75%]), possible tumor (6 [19%]), and phthisis bulbi (2 [6%]). Compared to nonenucleated eyes, enucleated eyes had more extensive clock hour involvement of telangiectasia (P < 0.001), light bulb aneurysms (P < 0.001), exudation (P < 0.001), and subretinal fluid (P < 0.001). On adjusted analysis by binomial logistic regression, variables predictive of enucleation included presence of iris neovascularization (P = 0.01), ultrasonographic retinal detachment (P = 0.004), open-funnel retinal detachment (P = 0.04), closed-funnel retinal detachment (P = 0.01), ultrasonographic elevation of subretinal fluid by millimeters (P = 0.001), and angiographic extent of light bulb aneurysms by clock hours (P = 0.02). By Kaplan-Meier analysis of 4-year cumulative risk of enucleation, risk factors for enucleation included presence of iris neovascularization (hazard ratio [HR] 31.0; P < 0.001), ultrasonographic retinal detachment (HR 56.2; P < 0.001), open-funnel retinal detachment (HR 2.7; P = 0.01), and closed-funnel retinal detachment (HR 4.5; P < 0.001).

CONCLUSIONS

Clinical features that predict risk of and time to enucleation in eyes with Coats disease include iris neovascularization, ultrasonographic presence and millimeter-elevation of retinal detachment, and angiographic extent of light bulb aneurysms.

Late re-activation of Coats disease

Purpose

Observation

Conclusion

Coats Disease: Clinical Features and Outcomes by Age Category in 351 Cases

PURPOSE

To investigate features and outcomes of Coats disease by patient age.

METHODS

Patients with Coats disease from 1973 to 2018 were evaluated based on age category at presentation (3 years or younger vs older than 3 to 10 years vs older than 10 years).

RESULTS

There were 351 eyes of 351 patients with Coats disease diagnosed (2 vs 6 vs 27 years, P < .001). The youngest age group had more referral diagnoses of retinoblastoma (29% vs 15% vs 0%, P < .001), worse presenting visual acuity (< 20/200: 80% vs 67% vs 31%, P < .001), more advanced Coats disease stage (stage 3B: 65% vs 38% vs 10%, P < .001), and greater clock-hour extent of telangiectasia (7 vs 5 vs 4, P < .001), light bulb aneurysms (7 vs 4 vs 3, P < .001), exudation (10 vs 7 vs 5, P < .001), and subretinal fluid (10 vs 7 vs 4, P < .001). The oldest patients received a greater total number of treatments (3.3 vs 3.1 vs 4.4, P = .04), with more argon laser photocoagulation (37% vs 52% vs 73%, P < .001) and intravitreal anti-vascular endothelial growth factor (6% vs 9% vs 23%, P < .002) and less cryotherapy (74% vs 84% vs 58%, P < .001). At mean follow-up (70 vs 65 vs 38 months, P = .02), the youngest patients had poorer visual acuity outcome (< 20/200: 83% vs 64% vs 39%, P < .001), had less disease resolution (43% vs 65% vs 62%, P = .01), and were more likely to ultimately require enucleation (22% vs 10% vs 6%, P = .01).

CONCLUSIONS

Younger patients (3 years or younger) with Coats disease present with worse visual acuity and more advanced disease stage, and are more likely to require ultimate enucleation. [J Pediatr Ophthalmol Strabismus. 2019;56(5):288-296.].

Coats disease: An overview of classification, management and outcomes

Coats disease is an idiopathic retinal vascular disorder with retinal telangiectasia with intraretinal and/or subretinal exudation without appreciable retinal or vitreal traction. The condition is sporadic with no associated systemic abnormalities. Unilateral involvement in young males is the typical presentation with most cases being diagnosed in the first and second decade of life. Younger the patient, more severe is the presentation and poorer the visual outcome. The management varies with the stage of the disease. Over the years, we have shifted from enucleation to a more conservative approach for the treatment of Coats disease with laser photocoagulation, cryotherapy and surgery for retinal detachment achieving good outcomes. The anti-VEGF agents have come into the scene as important form of adjuvant treatment along with the traditional management options. This article describes the clinical features, underlying pathology, classification and staging, the complications and the management of Coats disease and gives an overview of the changing trends in treatment and outcomes spanning across five decades.

Recent advances in the diagnosis and treatment of Coats' disease

PURPOSE

To review and summarize the recent progress in the diagnosis and treatment of Coats' disease.

METHODS

Literature was collected from Web of Science, Medline and Pubmed, through searching of these keywords: "Coats' disease", "diagnosis" and "treatment".

RESULTS

Coats' disease is characterized by idiopathic leaky retinal vascular telangiectasia and microvascular abnormalities often accompanied by intraretinal or subretinal exudation and retinal detachment. Neovascular glaucoma and phthisis bulbi often occur in advanced cases. Coats' disease has significant diversity in terms of its clinical presentation and morphology. Anti-VEGF therapy combined with laser photocoagulation for early Coats' disease and anti-VEGF therapy combined with minimally invasive vitrectomy for advanced Coats' disease can achieve good efficacy.

CONCLUSION

Early diagnosis and timely treatment based on clinical stage are critical to retaining the patient's visual function. Patients should be aware that close long-term follow-up is necessary.

The use of bevacizumab in pediatric retinal and choroidal disease: A review

The use of intravitreal bevacizumab in pediatric retinal and uveitic disease has become more widespread over the past decade. This article serves to outline the rationale underlying the use of intravitreal bevacizumab, and which disease entities it should be appropriately thought of as a primary or solo therapy, as opposed to an adjuvant one. Also presented is the relevant literature regarding each of these retinopathies.

Application of subthreshold laser therapy in retinal diseases: a review

Introduction

Laser photocoagulation has been a valuable tool in the ophthalmologist's armamentarium for decades. Conventional laser photocoagulation relies on visible retinal burns as a treatment endpoint, which is thought to result in photocoagulative necrosis of retinal tissue. Recent studies have suggested that using subthreshold (ST) laser, which does not cause detectable damage to the retina may also have therapeutic effects in a variety of retinal diseases. Areas covered: We review the proposed biological mechanisms mediating the therapeutic effects of subthreshold laser on the retina, followed by the evidence for ST laser efficacy in retinal diseases such as diabetic macular edema, central serous chorioretinopathy, age-related macular degeneration, and retinal vein occlusion.

Expert Commentary

Multiple clinical studies demonstrate that subthreshold laser does not cause structural damage to the retina based on multimodal imaging. Evidence suggests that there is a therapeutic effect on decreasing diabetic macular edema and subretinal fluid in chronic central serous retinopathy; however, the effect may be relatively modest and is not as efficacious as first line treatments for these diseases. Given the repeatability and lack of damage to the retina by this treatment, subthreshold laser deserves further study to determine its place in the retina specialist's armamentarium.

Retinal detachments in the pediatric population

In this review, we present a concise summary of the more commonly seen types of retinal detachments (RDs) that one can encounter in pediatric patients. A spectrum of diseases from rhegmatogenous RD in Stickler syndrome, Marfan syndrome, and choroidal coloboma to exudative RD in Coats disease, to tractional RD in persistent fetal vasculature, and combined RDs in familial exudative vitreoretinopathy are described with the management pearls for each.

Surgical Management of Coats Disease

Coats disease is a sporadic, chronic retinal vascular disorder with telangiectatic and aneurysmal retinal vessels, with retinal exudation and retinal detachment in severe cases. Various treatment modalities have been used, including laser therapy, cryotherapy, anti‒vascular endothelial growth factor (VEGF) therapy, and surgery. Anti-VEGF therapy seems to be effective in reducing exudative changes and is often combined with other treatment modalities. For severe cases with exudative retinal detachment, external drainage of subretinal fluid with or without vitrectomy is commonly performed, combined with laser therapy and/or cryotherapy. Relatively good anatomical outcomes have been reported; however, postoperative functional results, particularly in young patients and/or severe cases, seem to be limited.

Anti-VEGF for ROP and Pediatric Retinal Diseases

Vascular endothelial growth factor (VEGF) is an important mediator of the pathological neovascularization and vascular permeability of the eye. The increasing use of intravitreal therapies targeting VEGF has revolutionized the treatment of pediatric vitreoretinal diseases. In retinopathy of prematurity (ROP), the role of VEGF in pathogenesis has been well recognized and the use of anti-VEGF treatment in phase 2 ROP has demonstrated promising results, particularly in severe cases of posterior disease. This has made VEGF an established target in the treatment of pediatric retinal diseases known to have abnormal vascular activity. However, questions remain about late systemic and neurodevelopmental effects after anti-VEGF therapy for children because intravitreal injection of anti-VEGF may result in systemic circulation of anti-VEGF agent and a corresponding suppression of systemic VEGF. We do not currently know whether the short-term suppression of systemic VEGF affects long-term neurodevelopmental outcomes because VEGF is a vital supporting factor during neurodevelopment. This review article focuses on the evidence for the use of anti-VEGF treatment in certain pediatric ocular diseases, including ROP, Coats disease, and retinoblastoma. More extensive and prospective studies are warranted to further elucidate the role of anti-VEGF therapy in these diseases and illustrate how we can optimally use these agents in pediatric patients.

LONG-TERM ANATOMICAL AND FUNCTIONAL OUTCOMES FOLLOWING VITRECTOMY FOR ADVANCED COATS DISEASE

PURPOSE

To assess the long-term anatomical and functional results of vitreoretinal surgery in patients with advanced Coats disease.

METHODS

Retrospective analysis of 23 patients who underwent 23-gauge pars plana vitrectomy combined with transscleral cryotherapy, laser photocoagulation, and intraocular tamponade between 2005 and 2014 and had a follow-up of at least 1 year. The primary outcomes were mean visual acuity and anatomical success.

RESULTS

The average age at the time of surgery was 8.7 ± 1.3 years (range, 2-18 years). The mean follow-up period was 55.2 ± 31 months (range, 12-120 months). In 16 eyes (70%), further treatment was not necessary. In the remaining 7 patients (30%), revision surgery with silicone oil tamponade was required. In 20 eyes (87%), the retina was reattached. At the final visit, 8 eyes (35%) had improved mean Snellen visual acuity from 20/1,000 at initial presentation to 20/160, 3 eyes (13%) showed stabilization, and 6 eyes (26%) had decline in visual acuity. No enucleation was necessary, and no progression to neovascular glaucoma was observed.

CONCLUSION

Pars plana vitrectomy combined with cryotherapy, laser photocoagulation, and intraocular tamponade could be an effective treatment option for advanced Coats disease. Despite surgery, disease-related complications remained high, but the main aim of management in these young patients is functional and anatomical stability.

Coats' Disease-Related Macular Edema Treated with Combined Aflibercept and Laser Photocoagulation

Purpose

To describe the clinical response of refractory macular edema associated with Coats' disease following treatment with aflibercept and laser photocoagulation.

Methods

Case report.

Results

A 17-year-old female presented with decreased vision of the left eye. Ophthalmic exam demonstrated intraretinal hemorrhages and exudation with associated edema centrally. Angiographic evaluation revealed central leaking microaneurysms and peripheral capillary dropout. These findings and a systemic work-up that yielded an incidental Factor V Leiden mutation lead to a diagnosis of Coats' disease. Initial treatment consisted of laser photocoagulation and intravitreal bevacizumab but with poor response. Switching to intravitreal aflibercept resulted in resolution of the refractory macular edema and improvement of visual acuity to 20/25 in the left eye.

Conclusion

We describe a case of refractory macular edema which responded more favorably to intravitreal aflibercept compared with bevacizumab when combined with laser photocoagulation in a patient with Coats' disease.

Paediatric retinal detachment: a review

Paediatric retinal detachment (PRD) is an uncommon and challenging disease; it differs from adult detachments in etiology, anatomical characteristics, management and prognosis. PRDs can be particularly challenging, even for the most expert paediatric surgeons due to the higher prevalence of total retinal detachments, late diagnosis and bilateral involvement with respect to those which occur in adulthood. Moreover, the anatomical success, when achieved, is frequently not related to a functional recover. Postsurgical adverse events, refractive errors and amblyopia may additionally undermine the final outcome. Up to date there are few reviews regarding the approach of retinal detachment in children, mainly dealing with rhegmatogenous retinal detachment. In this review, rhegmatogenous, retinopathy of prematurity-related and Coats'-related PRDs were considered. The available literature from the last decades were reviewed and summarized. Epidemiology, etiology and clinical presentation, together with therapeutic approaches and outcomes have been reviewed and discussed.

Comparison of Visual Outcomes in Coats' Disease: A 20-Year Experience

PURPOSE

To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice.

DESIGN

Single-center retrospective cohort study.

PARTICIPANTS

Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015.

METHODS

Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015).

MAIN OUTCOME MEASURES

Visual acuity (VA).

RESULTS

Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P = 0.03), but remained stable for decade 2 eyes (P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P < 0.001).

CONCLUSIONS

The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

577-NM YELLOW LASER PHOTOCOAGULATION FOR COATS DISEASE

PURPOSE

To describe the outcomes of children with Coats disease treated with 577-nm yellow laser indirect ophthalmoscopy.

METHODS

A retrospective consecutive case series of pediatric patients with Coats disease treated at a single institution between 2011 and 2014. Laser indirect ophthalmoscopy was performed under anesthesia. Full treatment was defined as complete ablation of all visible telangiectasias and resolution of subretinal fluid. No patients were treated with cryotherapy or bevacizumab.

RESULTS

Seventeen eyes of 16 patients were consecutively treated. At the time of diagnosis, the eye was classified as Stage 1 (telangiectasias only) in 1 case, Stage 2A (extra-foveal exudation) in 2 cases, Stage 2B (fovea-involving exudation) in 6 cases, Stage 3A1 (extra-foveal exudative retinal detachment) in 2 cases, Stage 3A2 (subtotal foveal-involving detachment) in 1 case, and Stage 3B (total exudative retinal detachment) in 5 cases. The mean age at initial treatment was 71.2 months. Mean length of follow-up was 20.8 months (median 18.5 months, range 3.7-37.3 months). Patients underwent an average of 2.5 laser treatments. Sixteen of 17 eyes achieved full treatment (94.1%) with a mean time-to-full-treatment of 11.2 months. One eye developed glaucoma and end-stage disease.

CONCLUSION

577-nm yellow wavelength laser indirect ophthalmoscopy is an effective treatment for Coats disease including cases of exudative retinal detachment.

TRANSCLERAL DRAINAGE OF SUBRETINAL FLUID, ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR, AND WIDE-FIELD IMAGING-GUIDED LASER IN COATS EXUDATIVE RETINAL DETACHMENT

PURPOSE

To evaluate the safety and efficacy of combined transscleral drainage of subretinal fluid (SRF) with intravitreal bevacizumab and laser photocoagulation in the management of advanced Coats disease (Stage 3) with exudative retinal detachment.

DESIGN

Retrospective interventional case series.

METHODS

Retrospective case review of eight eyes in eight children with advanced Coats disease manifested as total or subtotal retinal detachment. All eyes initially underwent surgical drainage of exudative SRF followed by intravitreal injection of bevacizumab and laser photocoagulation. Patients were subsequently followed up for up to 60 months.

RESULTS

In all eyes, after SRF drainage and administration of one to two intravitreal injections, SRF was completely eliminated. Patients required up to four sessions of laser photocoagulation. Retinal detachment consequently reduced with all patients showing total retinal reattachment and resolution of the subretinal exudates. At the last follow-up, no patient showed recurrent SRF and no ocular complications related to bevacizumab nor evidence of further disease progression were noted.

CONCLUSION

The authors present a new therapeutic approach that allows for the first time successful treatment of advanced cases of exudative retinal detachment in Coats disease without the need for vitrectomy. Transscleral drainage of SRF accompanied by anti-vascular endothelial growth factor injection and laser photocoagulation appears to be successful in halting progression of advanced Coats disease with exudative detachment and a less invasive approach when compared with conventional management.

Successful use of intravitreal ranibizumab injection and combined treatment in the management of Coats' disease

PURPOSE

To observe the efficacy of intravitreal ranibizumab (IVR) combined with another ablative therapy, such as laser photocoagulation, for Coats' disease.

METHODS

Patients younger than 16 years of age who were diagnosed with Coats' disease were included in this study. They were treated with IVR (0.5 mg, monthly in the first 3 months) as an initial treatment, which was combined with another ablative therapy, such as laser photocoagulation or cryotherapy, as needed. The main data evaluation and outcome measurements included best-corrected visual acuity (BCVA) before and after treatment, fundus photography, optical coherence tomography (OCT), the number of treatment sessions, and ocular and systemic side-effects during follow-up.

RESULTS

Seventeen patients were included in this study; the average age was 7.9 ± 3.8 years, and the average follow-up time was 9.7 ± 3.3 months. The mean number of IVR treatments was 3.9 ± 1.0. Sixteen patients (94.1%) needed another treatment. Eleven patients (64.7%) were stable at the final follow-up. The BCVA at the last follow-up was significantly improved compared to baseline (p < 0.001). Telangiectasia regression was found in all patients. Partial and total retinal attached was found in 14 patients (82.4%), and exudate resolution was found in eight patients (47.1%). There were no severe ocular or systemic side-effects during the follow-up period.

CONCLUSION

Intravitreal ranibizumab combined with other ablative therapies as an initial treatment is an effective and safe treatment approach for Coats' disease that may improve the visual acuity and reduce the subretinal fluid, exudates and telangiectasia.

Intravitreal bevacizumab injections combined with laser photocoagulation for adult-onset Coats' disease

PURPOSE

To evaluate the efficacy of intravitreal bevacizumab injections combined with laser photocoagulation in the treatment of adult-onset Coats' disease.

METHODS

Thirteen eyes of 13 patients suffering from adult-onset Coats' disease were retrospectively included and analyzed. All patients were treated at baseline using intravitreal bevacizumab injections combined with laser photocoagulation. Follow-up treatment was performed as necessary.

RESULTS

The mean age of the subjects was 40.3 years, and the mean follow-up period was 24.8 months. The mean number of bevacizumab injections was 2.69, and the mean number of laser treatment sessions was 1.68. The mean baseline best-corrected visual acuity (BCVA) was 0.72 logarithm of the minimum angle of resolution (logMAR; 20/104 Snellen equivalent), while the mean BCVA at the final visit was 0.68 logMAR (20/95; P = 0.548). In three patients (23.0 %), BCVA had improved by more than 3 lines, and seven patients (54.0 %) showed stable BCVA (changes within 2 lines of visual acuity) after treatment. The mean central foveal thickness improved significantly, from 473 μm at baseline to 288 μm at the final visit (P = 0.023). Final BCVA was significantly correlated with a baseline BCVA (P < 0.001; ρ = 0.882). The final BCVA of patients who had subfoveal hard exudates at baseline was significantly worse than that of patients without such exudates (P = 0.005).

CONCLUSIONS

Intravitreal bevacizumab injection combined with laser photocoagulation may be an effective treatment option for adult-onset Coats' disease. Both poor initial BCVA and the occurrence of subfoveal hard exudates at baseline were associated with poor prognosis and poor therapeutic response.

Long-term follow-up of intravitreal bevacizumab for the treatment of pediatric retinal and choroidal diseases

PURPOSE

To describe the long-term outcomes of intravitreal bevacizumab (IVB) for the treatment of pediatric retinal and choroidal diseases.

METHODS

This was a multicenter, retrospective, consecutive case series of patients <18 years of age treated with IVB from 2005 to 2013. Primary outcome measures included visual acuity and central macular thickness at 12 months' follow-up.

RESULTS

A total of 95 eyes of 90 patients (average age, 8.7 years [range, 0.33-17 years]) were included, in which 352 injections (average, 3.7/eye) were administered for choroidal neovascular membrane (CNVM, n = 35), Coats disease (n = 35), familial exudative vitreoretinopathy (FEVR, n = 13), cystoid macular edema (CME, n = 6), and other (n = 6). Mean follow-up was 679 ± 581 days. IVB was used as monotherapy in 27 eyes and as part of combination therapy in 68. Mean Snellen equivalent visual acuity improved from 20/224 at baseline to 20/120 at 6 months (P = 0.034) and 20/108 at 12 months (P = 0.005). Mean central macular thickness improved from 426 μm to 349 μm at 6 months (P = 0.025) and 340 μm at 12 months (P = 0.002). Statistically significant visual acuity gains at 12 months were achieved in patients with CNVM (P = 0.009) but not in eyes with CME (P = 0.06), Coats disease (P = 0.15), or FEVR (P = 0.93). Adverse effects included ocular hypertension in 8 eyes and worsening tractional retinal detachment in 3 eyes.

CONCLUSIONS

Patients receiving IVB as part of the treatment for pediatric retinal and choroidal diseases experienced significant visual acuity gains and reductions in central macular thickness. IVB was generally well tolerated, although safety concerns persist.

Retinal angiomatous proliferation with chorioretinal anastomosis in childhood Coats disease: a reappraisal of macular fibrosis using multimodal imaging

PURPOSE

To describe the structural characteristics of retinal angiomatous proliferation and chorioretinal anastomosis in childhood Coats disease and redefine the previously described macular fibrosis.

METHODS

Prospective observational case series of consecutive patients with Coats disease examined over a 1-year study period. Multimodal imaging, including color fundus photography, wide-field fluorescein angiography, and spectral domain optical coherence tomography, was used to identify the features of macular retinal angiomatous proliferation and chorioretinal anastomosis.

RESULTS

Retinal angiomatous proliferation and chorioretinal anastomosis were present in 5 of 21 patients with Coats disease (24%). The lesions appeared as well demarcated, nodular retinal pigment epithelial detachments surrounded by exudate, with retinal vessels continuous with the underlying choroidal neovascularization.

CONCLUSION

Retinal angiomatous proliferation and chorioretinal anastomoses are features observed in a number of children (24% in the present series) with Coats disease and macular involvement. This lesion represents a distinct macular variant of Coats disease that underlies at least a proportion (all in the present series) of the previously described "macular fibrosis" and "subretinal mounds."

ranibizumab in the management of advanced Coats disease Stages 3B and 4: long-term outcomes

BACKGROUND

Laser photocoagulation and cryotherapy to completely destroy telangiectatic vessels and ischemic retina in Coats disease is barely applicable in advanced cases with total retinal detachment, and globe survival is notoriously poor in Stages 3B and 4. Anti-vascular endothelial growth factor intravitreal injections may offer new prospects for these patients.

METHODS

This study is a retrospective review of all consecutive patients with Coats disease treated with neoadjuvant or adjuvant intravitreal ranibizumab plus conventional and amblyopia treatment as appropriate.

RESULTS

Nine patients (median age, 13 months) presenting Coats Stages 3B and 4 (5 and 4 eyes, respectively) were included. Iris neovascularization resolved within 2 weeks and retinal reapplication within 4 months in all patients. At last follow-up, globe survival was 100% with anatomical success in 8 of the 9 eyes. With a median follow-up of 50 months, fibrotic vitreoretinopathy was developed in 5 of the 9 cases, one leading to tractional retinal detachment and ultimately phthisis bulbi. The remaining 4 of the 9 eyes achieved some vision (range, 0.02-0.063).

CONCLUSION

To the best of the authors' knowledge, this is the largest reported series of late-stage Coats undergoing anti-vascular endothelial growth factor therapy, a homogenous cohort of patients treated with a single agent and with the longest follow-up. This study supports the role of ranibizumab in advanced disease by transient restoration of the hemato-retinal barrier and suppression of neovascularization to facilitate classic treatment. At the last follow-up, the authors report unprecedented anatomical success and functional outcome.

Advanced Coats' disease treated with intravitreal bevacizumab combined with laser vascular ablation

Purpose

To evaluate the impact of intravitreal bevacizumab combined with laser vascular ablation in the management of advanced Coats’ disease presenting with exudative retinal detachment.

Methods

This was a retrospective review of 24 children that presented with exudative retinal detachments associated with advanced Coats’ disease. Mean patient age was 62 months (range 9–160 months). Presenting signs included retinal detachment in 24 children (100%), vascular telangiectasia in 24 children (100%), and retinal ischemia in 24 children (100%). Twenty of 24 children presented with elevated, vascular leakage in the fovea (83%). Two children presented with sub-retinal fibrosis associated with presumed long-standing retinal detachment without evidence of rhegmatogenous retinal detachment. Ten patients exhibited vascular alterations in the periphery of the second eye without clinical evidence of exudation. All 24 children were treated with a large-spot-size diode laser directly to areas of abnormal telangiectatic vasculature. All 24 children received intravitreal bevacizumab injection.

Results

All 24 children had resolution of exudative retinal detachment, ablation of vascular telangiectasia, and anatomic improvement of the retina. No child exhibited progressive retinal detachment and no eye required enucleation. No cases of neovascular glaucoma were seen. Fellow eyes with peripheral vascular alterations showed no progression to exudative vasculopathy during the observation period. Intravitreal bevacizumab injection was not associated with endophthalmitis or systemically-observed complications.

Conclusion

Repetitive intravitreal bevacizumab combined with laser vascular ablation may be utilized effectively for advanced Coats’ disease presenting with exudative retinal detachment.

Vascular endothelial growth factor in Coats' disease

PURPOSE

To examine whether vascular endothelial growth factor (VEGF) as one of the most important intraocular cytokines for angiogenesis and increased vascular permeability is associated with Coats' disease.

METHODS

The clinical interventional study included 28 patients with Coats' disease and seven control patients with congenital cataract. During intraocular surgery, we obtained aqueous humour samples in which the VEGF concentration was measured by double-antibody sandwich enzyme-linked immunosorbent assay (ELISA). Coats' disease was graded into four stages.

RESULTS

The mean aqueous VEGF level was significantly higher in the Coats' study group than in the control group (158±88 versus 97±21 pg/ml; p=0.002). The VEGF concentrations increased significantly (p<0.001) from 91±32 pg/ml in Coats' disease stage 2 to 100±37 pg/ml in stage 3A1, 185±56 pg/ml in stage 3A2 to 256±93 pg/ml in patients with stage 3B. Vascular endothelial growth factor concentrations in Coats' stage 2 and 3A1 did not differ significantly from the values in the control group. Parallel to the association with the stage of the diseases, the VEGF concentrations were significantly (p<0.001) correlated with extent of exudative retinal detachment.

CONCLUSIONS

Increasing severity of Coats' disease is significantly associated with intraocular VEGF concentrations. These results favour the intravitreal application of anti-VEGF drugs as medical therapy of Coats' diseases.

Combined treatment for Coats' disease: retinal laser photocoagulation combined with intravitreal bevacizumab injection was effective in two cases

Background

The exact pathogenetic mechanisms of Coats’ disease remain unknown. In this report, we show two cases of Coats’ disease that achieved a favorable prognosis with the combined treatment of intravitreal bevacizumab (IVB) injection prior to photocoagulation, although both initially resisted photocoagulation therapy.

Case presentations

Case 1 was a 15-year-old boy with initial visual acuity of 0.4 OD. At the temporal retina, aneurysms and abnormal telangiectatic vessels were observed. Hard exudates and an exudative retinal detachment extended to the fovea. He was diagnosed as having Coats’ disease at stage 3A and we performed laser photocoagulation as an initial approach to treat peripheral aneurysms and telangiectatic vessels. After the treatment, the exudative retinal detachment was eased and visual acuity improved to 1.0; however, recurrence occurred after 5 months. The exudative change was resistant against laser photocoagulation therapy and we therefore added IVB as an adjuvant before photocoagulation. Fourteen days after IVB injection phased laser photocoagulation was given to cover the abnormal capillaries, aneurysms and the leakage area spotted in FA. A good prognosis was obtained with decreased exudation and improved visual acuity.

Case 2 was an 11-year-old boy with decreased visual acuity of 0.15 OS at the initial visit. Hard exudates, retinal edema and serous retinal detachment were seen at the macula and peripheral retina. Fluorescein angiography revealed telangiectatic capillaries at the temporal retina. Our diagnosis was Coats’ disease at stage 3A. Extensive photocoagulation was performed as an initial treatment to the lesion. However, the exudative change was severe and resistant against the photocoagulation treatment. Therefore, we added IVB as an adjuvant before photocoagulation. Exudative change in the retina seemed to be eased 7 days after IVB injection, therefore, phased laser phototherapy was added to cover the abnormal capillaries. After the combination therapy, exudative change was remarkably ameliorated and better visual acuity was achieved.

Conclusion

Bevacizumab is considered an effective adjuvant for Coats’ disease with exudative change resistant to retinal photocoagulation therapy.

Combination treatment of pediatric coats' disease: a bicenter study in Taiwan

PURPOSE

To present the clinical outcome of different combination treatment modalities in pediatric Coats' disease in two Taiwan medical centers.

METHODS

A retrospective review of clinical records was done of pediatric patients with Coats' disease treated at National Taiwan University Hospital and Changhua Christian Hospital. Data regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications were recorded. Changes in vision and retinal status with the different methods of treatment were specifically evaluated.

RESULTS

From 2005 through 2011, 10 eyes of 9 patients were treated under the diagnosis of Coats' disease. The clinical manifestations varied from localized vascular abnormalities with subretinal fluid and hard exudates to extensive detachment with massive exudates and retinal hemorrhage. The main treatment modalities include argon laser photocoagulation, micropulse laser, and cryotherapy. The adjunctive therapies included intravitreal triamcinolone, bevacizumab, and ranibizumab. The mean follow-up was 40.50 ± 20.52 months (range: 14 to 72 months). Best corrected visual acuity at last follow-up was light perception to 1.0 (20/20 Snellen). Anatomic improvement was achieved in 9 eyes (90%). Visual improvement was noted in 7 eyes (70%), visual stabilization in 2 eyes (20%), and visual deterioration in 1 eye (10%). Vitreous fibrosis evolving into tractional retinal detachment occurred in 1 patient receiving cryotherapy combined with intravitreal bevacizumab injections. No enucleation was ultimately necessary.

CONCLUSIONS

Pediatric Coats' disease varies greatly in severity. Carefully selected treatment modalities can improve most eyes with different conditions. Intravitreal anti-vascular endothelial growth factor agents may act as useful adjuncts to improve anatomic and functional outcome. Cryotherapy combined with the intravitreal bevacizumab injection in severe cases of exudative retinal detachment may carry the risk of vitreoretinal traction and tractional retinal detachment.

Current management of Coats disease

Since its original description in 1908, Coats disease has been recognized as an idiopathic cause of severe vision loss with a remarkable diversity in clinical presentation and morphology. Key clinical and imaging variables are helpful in differentiating Coats disease from life-threatening malignancies, and proper management revolves around a thorough knowledge of the differential diagnosis. Despite significant advancement in scientific understanding of the disease process and clinical spectrum, the underlying etiology remains obscure, and both primary and secondary forms are recognized. With the development of anti-VEGF therapy, vitreoretinal specialists have a new, effective adjunct to the clinical management of exudates, macular edema, and serous retinal detachment. We highlight the history, diagnostic challenges, evolving clinical spectrum, and current management of Coats disease.

The effect of intravitreal bevacizumab injection as the initial treatment for Coats' disease

BACKGROUND

In Coats' disease, the most recent development in the treatment has been the intravitreal injection of anti-VEGF agents. The purpose of this article was to evaluate the effect of intravitreal bevacizumab as the initial treatment for Coats' disease in children and adults.

METHODS

The study included 14 pediatric patients and five adult patients with Coats' disease. They were treated with intravitreal bevacizumab (1.25 mg/0.05 ml) as the initial treatment, combined with or without other treatments. The analyses included the evaluation of basic clinical conditions.

RESULTS

In the pediatric group, after a mean of 9.1 months of follow-up, the differences in visual acuity were significant for the comparisons between the baseline examination and the follow-up examinations carried out at weeks 6, 12, and 24 after the baseline (P = 0.006, P = 0.004, P = 0.005 respectively). Vitreoretinal fibrosis was observed in three patients (n = 3, 21.4 %), among whom two showed fibrosis before treatment. All of the pediatric patients showed a resolution of fluid and exudation, and regression of the telangiectasia. In the adult group, after a mean of 10.6 months of follow-up, the differences in visual acuity were not statistically significant (P > 0.05) between the baseline and follow-up examinations. Vitreoretinal fibrosis (n = 2, 40 %) was observed in two patients who both showed fibrosis before treatment. All of the adult patients showed a resolution of fluid and exudation, and regression of the telangiectasia. The differences in the change of BCVA between children and adults were not significant (P > 0.05) during the follow-up examinations.

CONCLUSION

The intravitreal injection of bevacizumab as the initial treatment is associated with a measurable gain in visual acuity in patients with Coats' disease. Resolution of the subretinal fluid and exudation, and regression of the telangiectasia were observed in both pediatric and adult patients. Vitreoretinal fibrosis may be one of the natural courses of Coats' disease, and it remains uncertain whether bevacizumab accelerates the fibrosis phenomenon.

Diagnosis and treatment of coats' disease: a review of the literature

Coats' disease is an idiopathic, ophthalmic condition characterized by retinal telangiectasis, intraretinal and subretinal exudation, which can lead to retinal detachment. It is mostly unilateral, progressive and affects mainly males during childhood, although adult cases have also been described. In this review, we make an update of the literature about Coats' disease, emphasizing on diagnosis and treatment, including the most recent treatment modalities, i.e. anti-vascular endothelial growth factor agents.