Photodynamic therapy for subfoveal choroidal neovascularisation in Vogt-Koyanagi-Harada disease

Long-Term Analysis of Clinical Features and Treatment Outcomes of Inflammatory Choroidal Neovascularization

PURPOSE

To investigate the long-term clinical features and treatment outcomes of patients with inflammatory choroidal neovascularization (CNV) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF).

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Sixty-five eyes of 65 patients with inflammatory CNV treated with anti-VEGF injections and followed up at least 12 months were included. Retrospective chart review was conducted at a single tertiary referral center.

RESULTS

Study participants were followed up for 60.6 ± 42.8 (range, 16-160) months. Mean age was 33.4 ± 10.8 years, and mean refractive error was -3.94 ± 1.35 D in spherical equivalent. Final best-corrected visual acuity (BCVA) was 0.21 ± 0.20 logMAR after treatment. Patients were treated with bevacizumab (76.9%), ranibizumab (4.6%), aflibercept (3.1%), and drug combinations (15.4%). Systemic corticosteroid or immunosuppressant use was not correlated with visual outcome, required number of anti-VEGF injections, and recurrence. Commonly occurring optical coherence tomography (OCT) features included ellipsoid zone disruption, choroidal hypertransmission, retinal pigment epithelium atrophy or absence (RPEA), intraretinal hyperreflective foci (HRF), choroidal vessel engorgement, focal choroidal excavation, and irregular vascular loops (on OCT angiography). RPEA after treatment (β = 0.238, P = .036) and BCVA (β = 0.267, P = .029) showed significant correlation with final BCVA. A total of 28 patients (43.1%) experienced recurrence; intraretinal HRF after treatment was the single risk factor for recurrence (odds ratio = 2.712, P = .031).

CONCLUSIONS

Inflammatory CNV recurrence showed higher rates over time after anti-VEGF treatment than previously reported, even though the overall visual outcome was good. Baseline BCVA and RPEA after treatment are significant predictors for visual outcome. Intraretinal HRF after anti-VEGF treatment suggests the potential risk of recurrence.

A Case of Pneumatic Displacement with Gas Tamponade Performed for Macular Subretinal Hemorrhage Complicating Vogt-Koyanagi-Harada Disease

We experienced a case of subretinal hemorrhage (SRH) from choroidal neovascularization (CNV) complicating Vogt-Koyanagi-Harada disease (VKH) that underwent pneumatic displacement of hematoma by intravitreal gas injection. A 76-year-old male revealed VKH relapses and optical coherence tomography showed irregular retinal pigment epithelium in his right eye and serous retinal detachment and retinal pigment epithelial detachment in his left eye. Fluorescein angiography of the left eye showed hyperfluorescence possibly attributable to CNV. One month later, SRH occurred in the left eye, yet it was spontaneously absorbed. However, approximately 1 year later, the SRH recurred in the left eye affecting a wide area, including the macular region, and his visual acuity (VA) decreased to 0.06. When pneumatic displacement of the hematoma by intravitreal gas injection was performed, the SRH was inferiorly displaced, and his VA improved to 0.4. Pneumatic displacement with gas tamponade was effective for treating a case of SRH caused by persistent CNV complicating VKH.

Inflammatory Choroidal Neovascular Membranes in Patients With Noninfectious Uveitis: The Place of Intravitreal Anti-VEGF Therapy

Inflammatory choroidal neovascularization (iCNV) is an infrequent but an important cause of visual morbidity in patients with non-infectious uveitis and mostly occurs in intermediate or posterior uveitis. Punctate inner choroiditis, Vogt-Koyanagi-Harada disease and multifocal choroiditis are among the leading causes of uveitis entities resulting in iCNVs. The diagnosis and management of iCNVs still remain a challenge. Use of multimodal imaging techniques such as fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT) and OCT-angiography may be necessary for the diagnosis of iCNVs. The treatment algorithm is not straightforward for iCNV. While control of the active inflammation with steroids and/or immunosuppressive agents is a key to success, various adjunctive treatment modalities such as thermal laser photocoagulation, photodynamic therapy and surgical membrane removal were also co-administered previously. Nowadays, vascular endothelial growth factor (VEGF) inhibitors have become the most commonly administered adjunctive treatment option as they provide better anatomical and functional outcome and the recurrence rate of CNV is relatively low. We hereby reviewed important clinical studies and case series on anti-VEGF administration in iCNVs and briefly overviewed their results.

Outcomes of Intravitreal Bevacizumab in Choroidal Neovascularization in Vogt-Koyanagi-Harada Disease- A Prospective Study

Purpose: To assess the effectiveness of intravitreal (IV) bevacizumab and the need for systemic immunosuppressive therapy (IMT) in choroidal neovascularization (CNV) in Vogt-Koyanagi-Harada disease (VKHD).Methods: CNV treatment consisted of three monthly IV bevacizumab injections as a loading dose; if intra/subretinal fluid (IRF) persisted, further injections were proceeded besides increment in systemic IMT. Outcome analyses at 3, 6, and 12 months were visual acuity, central foveal thickness, macular volume, IRF, and addition of IMT.Results: Seven eyes of six patients were included. Five patients (five eyes) completed a 12-month follow-up and received 12 IV bevacizumab injections. At the 12-month follow-up, visual acuity improved in four out of five eyes (p = .0568); all eyes had decreased macular volume (p = .0431) but they still had persistent IRF; and all cases needed IMT introduction/increment.Conclusion: Intravitreal bevacizumab in association with systemic IMT was effective for CNV in VKHD. Active CNV may indicate disease of inadequate clinical control.

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.

Vogt-Koyanagi-Harada disease: review of a rare autoimmune disease targeting antigens of melanocytes

Vogt-Koyanagi-Harada disease (VKHD) is a rare granulomatous inflammatory disease that affects pigmented structures, such as eye, inner ear, meninges, skin and hair. This disease is mainly a Th1 lymphocyte mediated aggression to melanocytes after a viral trigger in the presence of HLA-DRB1*0405 allele. The absence of ocular trauma or previous intraocular surgery sets VKHD appart from sympathetic ophthalmia, its main differential diagnosis. The disease has an acute onset of bilateral blurred vision with hyperemia preceded by flu-like symptoms. The acute uveitic stage is characterized by a diffuse choroiditis with serous retinal detachment and optic disc hyperemia and edema. Fluorescein angiography in this phase demonstrates multiple early hyperfluorescent points. After the acute uveitic stage, ocular and integumentary system pigmentary changes may appear. Ocular findings may be accompanied by lymphocytic meningitis, hearing impairment and/or tinnitus in a variable proportion of patients. Prompt diagnosis followed by early, aggressive and long-term treatment with high-dose corticosteroids is most often ensued by good visual outcomes. However, some patients may experience chronic uveal inflammation with functional eye deterioration. The current review discusses the general features of VKHD, including epidemiology, classification into categories, differential diagnosis and current therapeutic approaches.

Vogt-Koyanagi-Harada disease: Novel insights into pathophysiology, diagnosis and treatment

Vogt-Koyanagi-Harada (VKH) disease is one of the major vision-threatening diseases in certain populations, such as Asians, native Americans, Hispanics and Middle Easterners. It is characterized by bilateral uveitis that is frequently associated with neurological (meningeal), auditory, and integumentary manifestations. Although the etiology and pathogenesis of VKH disease need to be further elucidated, it is widely accepted that the clinical manifestations are caused by an autoimmune response directed against melanin associated antigens in the target organs, i.e. the eye, inner ear, meninges and skin. In the past decades, accumulating evidence has shown that genetic factors, including VKH disease specific risk factors (HLA-DR4) and general risk factors for immune mediated diseases (IL-23R), dysfunction of immune responses, including the innate and adaptive immune system and environmental triggering factors are all involved in the development of VKH disease. Clinically, the criteria of diagnosis for VKH disease have been further improved by the employment of novel imaging techniques for the eye. For the treatment, early and adequate corticosteroids are still the mainstream regime for the disease. However, immunosuppressive and biological agents have shown benefit for the treatment of VKH disease, especially for those patients not responding to corticosteroids. This review is focused on our current knowledge of VKH disease, especially for the diagnosis, pathogenesis (genetic factors and immune mechanisms), ancillary tests and treatment. A better understanding of the role of microbiome composition, genetic basis and ongoing immune processes along with the development of novel biomarkers and objective quantitative assays to monitor intraocular inflammation are needed to improve current management of VKH patients.

Clinical Characteristics of Inflammatory Choroidal Neovascularization in a Chinese Population

PURPOSE

To describe demographic features and clinical and imaging characteristics of inflammatory choroidal neovascularization (CNV) in a Chinese population.

METHODS

A retrospective case review of patients with CNV secondary to uveitis from 2002 to 2013.

RESULTS

A total of 125 patients (150 eyes, 166 CNVs; bifocal CNVs in 16 eyes), 64% of whom were women, were reviewed. The mean age was 35.86 years. The proportions of patients with punctate inner choroidopathy (PIC), multifocal choroiditis (MFC), and Vogt-Koyanagi-Harada (VKH) were 50.4, 22.4, and 8%. All of the cases were classic CNV in fluorocein angiography and type 2 CNV in OCT. The proportion of subfoveal lesions in active CNV (30.09%) was less than that in inactive CNV (60.38%).

CONCLUSIONS

PIC, MFC, and VKH were the three primary specific types of uveitis with inflammatory CNV in this study. Inflammatory CNV tended to break though the retinal pigment epithelium and beneath the neurosensory retina. Moreover, inflammatory CNV was usually nonsubfoveal when it occurred.

Management of uveitis-related choroidal neovascularization: from the pathogenesis to the therapy

Inflammatory choroidal neovascularization is a severe but uncommon complication of uveitis, more frequent in posterior uveitis such as punctate inner choroidopathy, multifocal choroiditis, serpiginous choroiditis, and Vogt-Koyanagi-Harada syndrome. Its pathogenesis is supposed to be similar to the wet age related macular degeneration: hypoxia, release of vascular endothelial growth factor, stromal cell derived factor 1-alpha, and other mediators seem to be involved in the uveitis-related choroidal neovascularization. A review on the factors implicated so far in the pathogenesis of inflammatory choroidal neovascularization was performed. Also we reported the success rate of single studies concerning the therapies of choroidal neovascularization secondary to uveitis during the last decade: photodynamic therapy, intravitreal bevacizumab, and intravitreal ranibizumab, besides steroidal and immunosuppressive therapy. Hereby a standardization of the therapeutic approach is proposed.

Choroidal neovascularization in 36 eyes of children and adolescents

PURPOSE

To describe the clinical features and outcomes among eyes with choroidal neovascularization (CNV) in children and adolescents.

METHODS

A total of 36 eyes of 27 patients <18 years of age diagnosed with CNV between January 1978 and December 2008 were retrospectively reviewed. CNV was clinically diagnosed in all patients and its presence was confirmed by fundus fluorescein angiography (FFA). A total of 19 eyes underwent treatment. Anatomical outcome was evaluated as regressed/persistent/recurrent CNV. Snellen's values for best corrected visual acuity (BCVA) were converted to logMAR for statistical calculations.

RESULTS

Of the 27 patients, 17 (63%) were male. Nine (33.3%) of the 27 patients had bilateral CNV. At presentation, CNV was active in 22 (61.1%) eyes and regressed in 14 (28.9%) eyes. All active CNV cases were 'classic' type, with the majority (80.5%) being subfoveal. The mean greatest linear dimension (GLD) was 3.16 ± 1.94 mm (range, 0.9-10.15). The most common cause (41.7%) was post-inflammatory. The mean duration to regression in treated eyes was 103.53 days (15 eyes). Recurrence was noted in three (8.3%) eyes. The mean duration to first recurrence was 260 days (range, 90-390), and the mean follow-up duration was 779.53 ± 988.00 days.

CONCLUSION

CNV remains a cause of significant visual decline in children and adolescents. Male predominance, post-inflammatory etiology, bilateral affection, and subfoveal location are noteworthy, with a high regression rate in response to treatment. Re-treatment is required in a limited number of cases.

Short-term efficacy of intravitreal dobesilate in central serous chorioretinopathy

PURPOSE

To report the anatomic and functional outcome of intravitreal dobesilate to treat recurrent central serous chorioretinopathy (CSC).

METHODS

This is an interventional case report in which dobesilate was intravitreally injected in a case of recurrent CSC. Main measures included fundoscopy, Snellen visual acuity (VA) testing, fluorescein angiography and optical coherence tomography (OCT).

RESULTS

We present anatomical and functional evidences, obtained as early as eleven days after the treatment, of the efficacy of intravitreal dobesilate, in the treatment of chronic CSC condition. The effect after intravitreal dobesilate injection for CSC might be related to the normalization of retinal architecture.

CONCLUSIONS

Intravitreal dobesilate may be an effective treatment option for recurrent CSC.

The use of intravitreal ranibizumab for choroidal neovascularization associated with vogt-koyanagi-harada syndrome

Purpose. To describe the use of intravitreal ranibizumab for choroidal neovascular membrane (CNVM) secondary to Vogt-Koyanagi-Harada (VKH) syndrome. Methods. Interventional case report. Results. A 50-year-old woman presented with conjunctival injection and bilateral eye pain. Vision was 20/400 and 20/80 in the right and left eyes, respectively. Bilateral iritis, vitritis, and choroidal thickening were evident. Exudative retinal detachment was present in the left eye. Corticosteroid treatment improved vision to 20/40 bilaterally. Methotrexate (MTX) was initiated and vision remained stable for 3 months. After a 5-month loss to follow-up, vision in the left eye decreased to finger counting (CF) and a parafoveal CNVM was identified. After 3 intravitreal ranibizumab injections, vision improved to 20/40. Twelve months later, despite inflammation control, vision decrease to CF due to recurrent CNVM. A fourth ranibizumab injection was given. Twenty months later, best-corrected vision was 20/400, and an inactive CNVM was present in the left eye. Conclusion. After initial CNVM regression and visual acuity improvement due to ranibizumab, the CNVM recurred and became refractory to treatment. Despite control of inflammation and neovascularization, VKH chronicity lead to permanent vision loss in our patient. A combinational treatment approach may be required in such patients.

Bevacizumab in inflammatory eye disease

PURPOSE

To report the effect of intravitreal bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) on visual acuity and macular thickness in patients with inflammatory choroidal neovascularization (CNV) or cystoid macular edema (CME).

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

Each eye received 1.25 mg of intravitreal bevacizumab at baseline. Follow-up examinations were scheduled at 1- to 2-month intervals, with additional injections at the discretion of the physician. Comprehensive evaluations, including Snellen best-corrected visual acuity (BVCA) and optical coherence tomography measurements, were performed at each visit. Main outcome measures were BCVA and central subfield thickness (CST), as measured by optical coherence tomography.

RESULTS

Thirty-four eyes of 30 patients with inflammatory CNV (n = 21 eyes of 19 patients; 9 male, 10 female) or CME (n = 13 eyes of 11 patients; 4 male, 7 female) were identified. Median ages were 52 years (range, 7 to 83) and 67 years (range, 17 to 83) for the CNV and CME groups, respectively. The median length of follow-up for CNV eyes was 7 months (range, 1 to 28) while the median follow-up for CME eyes was 13 months (range, 1 to 20). Both groups received a median of two injections (range, 1 to 9 for CNV and 1 to 4 for CME). For eyes with CNV, BCVA improved significantly at follow-up month 1, but was not different from baseline thereafter; CST remained unchanged throughout follow-up. For eyes with CME, neither BCVA nor CST changed significantly over the course of follow-up.

CONCLUSIONS

Bevacizumab appears to stabilize BCVA and CST for eyes with inflammatory CNV or CME.

Long-term visual outcomes of intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the long-term role of bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) in inflammatory ocular neovascularization.

DESIGN

Retrospective multicenter consecutive case series of inflammatory ocular neovascularization.

METHODS

settings: Multicenter institutional and private practices.

STUDY POPULATION

Patients with inflammatory ocular neovascularization in one or both eyes of varying etiologies who failed standard therapy. intervention: Intravitreal injection of bevacizumab.

MAIN OUTCOME MEASURES

Improvement of best-corrected visual acuity (BCVA) expressed as logarithm of minimal angle of resolution (logMAR), and decrease in central foveal thickness as measured by optical coherence tomography at 6, 12, 18, and 24 months of follow-up.

RESULTS

Mean logMAR BCVA (central foveal thickness) following intravitreal bevacizumab was as follows: baseline, 0.65 (6/27 or 20/90) (338 microm; 99 eyes of 96 patients); 6 months, 0.42 (6/16 or 20/53) (239 microm; 2.0 injections; 81 eyes); 12 months, 0.39 (6/15 or 20/49) (241 microm; 2.3 injections; 95 eyes); 18 months, 0.40 (6/15 or 20/50) (261 microm; 3.0 injections; 46 eyes); and 24 months, 0.34 (6/13 or 20/44) (265 microm; 3.6 injections; 27 eyes). Paired comparisons revealed significant visual improvement at 6 months of 2.4 lines (P = .000), at 12 months of 2.5 lines (P = .000), at 18 months of 2.5 lines (P = .001), and at 24 months of 2.2 lines (P = .013). Paired comparisons revealed significant central foveal flattening at 6 months of 78 microm (P = .000), at 12 months of 85 microm (P = .000), at 18 months of 90 microm (P = .003), and at 24 months of 77 microm (P = .022). Three eyes developed submacular fibrosis and 1 eye submacular hemorrhage.

CONCLUSION

Intravitreal bevacizumab led in the long-term to significant mean visual improvement of > or =2.2 lines and significant foveal flattening in a wide variety of inflammatory ocular diseases without major complications.

Vogt-koyanagi-harada syndrome

PURPOSE

Vogt-Koyanagi-Harada syndrome is a bilateral, chronic, diffuse granulomatous panuveitis frequently associated with neurological, auditory, and integumentary manifestations. It is also one of the most common forms of uveitis among pigmented races including Chinese patients.

METHODS

This article reviews the current developments of Vogt-Koyanagi-Harada syndrome, including epidemiology, etiology, clinical features, observational techniques, genetics, treatment, and prognosis.

RESULTS

Increasing reports have been published to describe the clinical features of Vogt-Koyanagi-Harada syndrome in various ethnic populations from different parts of the world. In spite of tremendous progress in laboratory and clinical research, the etiology of Vogt-Koyanagi-Harada syndrome is still not completely known. Numerous studies indicate an autoimmune nature for this disease. A recent study has shown that Th17, a new subset of T cell, plays an important role in the initiation and maintenance of this disease. Early and aggressive systemic corticosteroids are still the mainstay of initial therapy for Vogt-Koyanagi-Harada syndrome. However, nonsteroid immunomodulatory therapy, including cyclosporine, chlorambucil, cyclophosphamide, and azathioprine have brought out encouraging results. Improved visual outcomes in patients with Vogt-Koyanagi-Harada syndrome in recent years have been reported when compared with decades ago, presumably due to the more aggressive use of immunosuppressive agents.

CONCLUSION

Although the prognosis for VKH syndrome was greatly improved, future prospective, controlled, multi-center studies are needed to determine the optimal treatment regime for this disease. The IL17/23 pathway may provide a novel therapeutic target to control inflammation in VKH syndrome.

Intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the role of bevacizumab in inflammatory ocular neovascularization.

DESIGN

Retrospective, multicenter, consecutive case series of inflammatory ocular neovascularization.

METHODS

Patients with inflammatory ocular neovascularization of varying causes for whom standard therapy failed were treated with intravitreal injection of bevacizumab. Main outcome measures included improvement of best-corrected visual acuity (BCVA) expressed in logarithm of minimum angle of resolution units, response of inflammatory ocular neovascularization by funduscopy and angiography, and decrease in central foveal thickness as measured by optical coherence tomography at the three-month follow-up.

RESULTS

At the three-month follow-up, 84 eyes of 79 patients had been treated with a mean of 1.3 injections (range, one to three). Thirty-four eyes showed juxtafoveal choroidal neovascularization (CNV), 34 eyes showed subfoveal CNV, eight eyes showed peripapillary CNV, and 11 eyes showed neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). BCVA improved 2.4 lines from 0.68 (6/28 or 20/94) to 0.44 (6/17 or 20/55) (P < .001). BCVA improved by one to three lines in 34.5% of the eyes, by four to six lines in 16.7% of the eyes, and by more than six lines in 14.2% of the eyes. Function was unchanged in 23.8% of the eyes. BCVA worsened in 10.7% (zero to three lines in 7.1%, more than four lines in 3.6%). Central foveal thickness decreased from baseline 346 to 252 microm (P < .001). For CNV, 32 eyes (43.2%) had complete regression after the injection, 27 (36.5%) had partial regression, five (6.8%) had no response, and 10 eyes (13.5%) were not evaluated by the contributors. For NVD or NVE, seven eyes (63.6%) had complete regression of new vessels and four eyes (36.4%) had partial regression after the injection.

CONCLUSIONS

Intravitreal bevacizumab led to short-term significant visual improvement and regression of inflammatory ocular neovascularization in a wide variety of inflammatory ocular diseases.