Therapeutic Effects of Laser Photocoagulation and/or Vitrectomy in Eales' Disease

Retinal laser photocoagulation in management of eales' disease

Eales’ disease is an idiopathic occlusive inflammatory vasculopathy resulting in peripheral retinal ischemia, neovascularization, recurrent hemophthalmos, and proliferative tissue formation. It is often complicated by tractional retinal detachment, secondary glaucoma, and central retinal vein occlusion. The management of patients with Eales’ disease includes mainly glucocorticosteroid therapy, the use of angiogenesis inhibitors, vitreoretinal surgery and laser photocoagulation. The clinical case reported demonstrates the potential of retinal laser photocoagulation for treatment of the Eales’ disease in the ischemic and proliferative stages. The results of retinal laser photocoagulation used as monotherapy demonstrate the clinical and functional indices improvement: enhanced visual acuity, stabilized central retinal sensitivity value, restored clarity to the ocular media, regression of neovascularization and macular edema in the patient’s eye being in the proliferative (3b) stage, and the process stabilization in the eye being in the ischemic (2a) stage of the disease.

Pediatric Eales Disease: An Indian Tertiary Eye Center Experience

PURPOSE

To report the clinical profiles, etiologies, treatment modalities, and outcomes for Eales disease in patients younger than age 16 years in India.

METHODS

Retrospective review of medical records of patients with Eales disease who had a minimum 5-year follow-up period.

RESULTS

A total of 25 eyes of 13 patients were included. Of these 13 patients, 12 (94%) had bilateral Eales disease and 11 (84.6%) were men. Mean patient age was 14.1 years (range: 11 to 16 years). Diminution of vision (36%) was the most common presenting complaint, followed by both diminutions of vision and floaters (32%). Sclerosed vessels were seen in all eyes, and 21 (84%) eyes had active periphlebitis at presentation. Neovascularization elsewhere was seen in 20 (80%) eyes and neovascularization of the optic disc was seen in 1 (4%) eye. Veno-venous shunts were found in 12 (48%) eyes, and 18 (72%) eyes had vitreous hemorrhage. All eyes received photocoagulation; 84.6% of patients received oral steroids, with 7.7% of patients treated with azathioprine and 38.4% treated with anti-tubercular therapy. Vitrectomy was performed in 36% of eyes for non-clearing vitreous hemorrhage and tractional retinal detachment. Vision improved in 7 (28%) eyes, was stable in 12 (48%) eyes, and worsened in 6 (24%) eyes. Recurrence of the disease more than five times during the 5-year follow-up period occurred in 20% of patients.

CONCLUSIONS

Recurrent vasculitis and vitreous hemorrhage in children should raise the suspicion of pediatric Eales disease. [J Pediatr Ophthalmol Strabismus. 2018;55(4):270-274.].

Clinical Outcome of Retinal Vasculitis and Predictors for Prognosis of Ischemic Retinal Vasculitis

PURPOSE

To determine factors affecting the visual outcome in eyes with retinal vasculitis and the rate of neovascularization relapse in ischemic vasculitis.

DESIGN

Retrospective cohort study.

METHODS

We reviewed 1169 uveitis patients from Moorfields Eye Hospital, London, UK. Retinal vasculitis was observed in 236 eyes (121 ischemic, 115 nonischemic) that were compared with a control group (1022 eyes) with no retinal vasculitis. Ultra-widefield fluorescein angiography images were obtained in 63 eyes with ischemic vasculitis to quantify area of nonperfusion measured as ischemic index.

RESULTS

The risk of vision loss was significantly more in the retinal vasculitis compared with the non-vasculitis group (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.24-2.25, P = .001). Retinal vasculitis had twice the risk of macular edema compared to the non-vasculitis group. Macular ischemia increased the risk of vision loss in vasculitis eyes by 4.4 times. The use of systemic prednisolone in eyes with vasculitis was associated with a reduced risk of vision loss (HR 0.36, 95% CI 0.15-0.82, P = .01). Laser photocoagulation was administered in 75 eyes (62.0%), out of which 29 (38.1%) had new vessel relapse and required additional laser treatment. The median ischemic index was 25.8% (interquartile range 10.2%-46%). Ischemia involving ≥2 quadrants was associated with increased risk of new vessel formation (HR 2.7, 95% CI 1.3-5.5, P = .003).

CONCLUSIONS

Retinal vasculitis is associated with an increased risk of vision loss, mainly secondary to macular ischemia, and has a higher risk of macular edema compared to eyes with no vasculitis. Ischemia involving ≥2 quadrants is a risk factor for new vessel formation.

The use of a vascular endothelial growth factor inhibitor (ranibizumab) in macular edema due to eales disease

PURPOSE

To report the results of intravitreal use of ranibizumab in a patient with macular edema due to Eales disease.

METHOD

This was an open-label, Phase 1, 6-month study of the safety and efficacy of intravitreally administered ranibizumab in patients with macular edema due to Eales disease. A single patient was eligible for the study during the 2 years of recruitment. She received 3 monthly intravitreal injections of 0.5 mg of ranibizumab for 3 months. At each of her monthly visits during the 6-month study, she was evaluated with a full ocular examination and optical coherence tomography imaging of the macula. Primary outcome measure was change in optical coherence tomography central subfield thickness at 6 months.

RESULTS

The central macular thickness as measured on optical coherence tomography reduced from 269 μm at baseline to 186 μm at 3 months. This reduction was transient with subsequent increase to 262 μm at the conclusion of the study at 6 months.

CONCLUSION

Ranibizumab use led to transient resolution of macular edema at 3 months; however, this reduction in edema was not sustained.

Role of intravitreal bevacizumab in Eales disease with dense vitreous hemorrhage: a prospective randomized control study

PURPOSE

To investigate the role of intravitreal bevacizumab in Eales disease with dense vitreous hemorrhage.

METHODS

This is a prospective randomized control trial. Twenty eyes of 20 patients with dense vitreous hemorrhage because of Eales disease were randomly distributed in Group 1 (n = 10) and Group 2 (n = 10). Group 1 eyes received intravitreal injection of bevacizumab (1.25 mg/0.05 mL) every 4 weeks, and Group 2 eyes were observed. Patients of both groups were followed-up every 2 weeks. Vitrectomy was performed in case of nonresolving vitreous hemorrhage Grade 2 or more after 3 months of enrollment or immediately if retinal detachment was detected. Intraoperative difficulties while performing surgery and excessive bleeding were noted. The primary outcome measures were reduction in the grade of vitreous hemorrhage and the need for vitrectomy.

RESULTS

Only 1 eye from Group 1 and 2 eyes from Group 2 showed decrease in vitreous hemorrhage to Grade 2 (P = 0.531, 95% confidence interval). But all three eyes required vitrectomy because of persisting poor vision. Postoperative mean vision ± SD in Group 1 was 1.2 ± 0.57 in logarithm of the minimum angle of resolution units, and in Group 2, it was 0.78 ± 0.41 in logarithm of the minimum angle of resolution units (P = 0.086, 95% confidence interval). Three eyes (30%) in Group 1 had tractional retinal detachment after a single bevacizumab injection, while none of the Group 2 eyes had tractional retinal detachment (P = 0.060, 95% confidence interval). Vitrectomy was performed in all three eyes and had poor visual outcome after surgery. No intraoperative difficulties were noted in either group.

CONCLUSION

Our study showed that repeated intravitreal bevacizumab in patients with Eales disease with dense vitreous hemorrhage may not hasten the resolution of vitreous hemorrhage or reduce the need for vitrectomy. Moreover, tractional retinal detachment may be a serious complication of therapy and hence should be closely monitored because it entails a poor visual prognosis.

Eales' disease: the great masquerader

BACKGROUND

Eales' disease, also known as idiopathic retinal periphlebitis, is a diagnosis of exclusion, mainly affecting men in the second through fourth decades of life. Although less common in the United States, Eales' disease is widespread in India and certain areas of the Middle East.

CASE REPORT

A healthy, 42-year-old Filipino man presented with reduced vision in the right eye of 2 days' duration and had recently had a nonrhegmatogenous retinal detachment diagnosed. Clinical findings included angle neovascularization, posterior vitritis, intraretinal hemorrhages, and retinal vascular sheathing in that eye. Systemic evaluation did not disclose an underlying etiology. Eales' disease was diagnosed. Treatment included topical steroids and cycloplegia, along with intravitreal triamcinolone acetonide injection, which yielded an improvement in the vasculitis and vitritis with subsequent visual improvement and stabilization.

CONCLUSION

Eales' disease should be considered as a differential diagnosis in patients with vasculitis and vitritis.

Surgical outcomes for vitrectomy in Eales' disease

AIM

To present and analyse the anatomical and functional outcomes for vitrectomy in Eales' disease.

METHODS

This retrospective case series enrolled 63 patients (71 eyes) who underwent pars plana vitrectomy (PPV) for the complications of Eales' disease. Indications included nonclearing vitreous haemorrhage (VH) with/without epiretinal membranes in 49 (69%) eyes, and retinal detachments (RD) involving/threatening macula in 22 (31%). Additional procedures (scleral buckling; gas/oil tamponade) were performed at surgeon's discretion. Minimum follow-up was 6 months. The primary outcome measures were change in best-corrected visual acuity (BCVA) and posterior segment status.

RESULTS

The mean age of the patients was 29.6 years (range: 15-70 years); 60 were male (95%). Preoperatively, posterior vitreous detachment (PVD) existed in 28 (39.4%) eyes. Forty (56.3%) eyes underwent only PPV; the rest required additional surgical procedures (q.v.). The mean baseline BCVA (1/60) improved to 6/24 postoperatively (P<0.0001). Fifty-four eyes of 50 patients (76%) showed an improvement of > or =2 equivalent Snellen lines; six eyes (four patients) remained stable (+/-1 line); visual acuity worsened in 11 eyes (nine patients). The mean final BCVA was similar in eyes operated for VH and RD (P=0.08); but the magnitude of change from baseline was greater in the VH group (P=0.009). PVD had a borderline association with final BCVA (P=0.056); but did not influence the functional/anatomical improvement. Thirteen eyes required repeat interventions; 11 (15.49%) eyes experienced surgical failure.

CONCLUSIONS

Although surgical outcomes in Eales' disease depend on preoperative PVD/RD to some extent; good results are possible in the presence of incomplete PVD and tractional sequelae.