Bilateral choroidal neovascularization associated with optic nerve head drusen treated by antivascular endothelial growth factor therapy

A Case of Polypoidal Choroidal Vasculopathy Associated With Optic Disc Drusen

We report a case of optic disc drusen (ODD) associated with peripapillary polypoidal choroidal vasculopathy (PCV). A 62-year-old Malay lady presented with both eye ODD and the left eye associated with peripapillary subretinal hemorrhage. Ultrasound B-scan and red-free photography confirmed the optic nerve head drusen findings bilaterally. Optical coherence tomography (OCT) of the left eye showed sharply elevated peripapillary pigment epithelial detachment with subretinal fluid. The presence of peripapillary polyps with branching vascular network in indocyanine green angiography of the left eye further confirmed the diagnosis of PCV and excluded choroidal neovascularization (CNV) secondary to ODD. Subsequently, the patient was treated with a combination of verteporfin photodynamic therapy with three monthly intravitreal ranibizumab injections. Three months after the combined treatment, OCT showed completely resolved subretinal fluid. ODD can cause compression of the subretinal vessels at the optic disc that results in retinal ischemia and release of vascular endothelial growth factor, which may trigger the development of CNV or PCV. The rarity of this combination makes it interesting to study more cases of ODD with PCV. Importantly, a thorough evaluation in distinguishing the PCV from the CNV that mimics it is crucial for early detection and prompt intervention. In this case, indocyanine green angiography (ICGA) is the diagnostic method to differentiate the PCV from CNV secondary to ODD.

Four-Year Outcome of Aflibercept for Peripapillary Choroidal Neovascularization Secondary to Optic Nerve Head Drusen in a Child

Choroidal neovascularization is an optic nerve head drusen complication that can lead to severe vision loss. There is no prior evidence of the efficacy of intravitreal aflibercept in children in such cases. The authors report the case of a boy who was successfully treated with aflibercept with benefits lasting up to 4 years. [J Pediatr Ophthalmol Strabismus. 2020;57:e63-e67.].

Juxtapapillary neovascular membrane associated with optic nerve drusen

CLINICAL CASE

Forteen year old patient presenting progressive decrease in visual acuity of the left eye after 3 months of evolution. On examination he presents bilateral drusen of papilla, associated with juxtapapillary neovascular membrane, which seriously compromises the vision and visual field of the left eye.

RESULT

Treatment with 3 consecutive injections of intravitreal ranibizumab resulted in the inactivation of the neovascular membrane with reabsorption of subretinal fluid and improvement of the best corrected visual acuity of the left eye. After 9 months of follow-up, it was 20/20 and stable.

CONCLUSION

Although optic nerve head drusen are considered benign, neovascular membranes can be a complication. Anti-VEGFs are an effective alternative for treatment.

Optic Coherence Tomography Angiography Findings of Bilateral Choroidal Neovascularization Associated with Optic Disc Drusen Treated with Intravitreal Aflibercept Injection

Purpose

The purpose of this case report is to present the findings of optical coherence tomography angiography (OCTA) of a patient with bilateral choroidal neovascularization (CNV) associated with optic disc drusen (ODD), who was treated with intravitreal aflibercept injection. Case presentation. A 14-year-old girl presented with a complaint of visual loss and metamorphopsia in her both eyes. Best-corrected visual acuity (BCVA) was 20/32 and 20/25, respectively, in the right and left eyes. Intraocular pressure and anterior segment examination were normal. Dilated fundus examination revealed elevated optic discs with blurred margins in both eyes. In addition, slightly elevated yellow lesion extending from optic nerve head to the macula was observed bilaterally. The patient underwent imaging with colour fundus photography, fundus autofluorescence (FAF), fundus fluorescein angiography (FFA), spectral-domain optic coherence tomography (SD-OCT), OCTA, orbital ultrasonography (USG), and computed tomography (CT). In particular, OCTA demonstrated clearly the large circular CNV complex in the right eye and the CNV structure in the left eye containing slightly activated main trunk and minimal vessel loops in the papillomacular region. CNV secondary to bilateral ODD was suspected. Intravitreal aflibercept injections were performed in 3 doses to the right eye and a single dose to the left eye. After the injections, BCVA reached its complete level in both eyes. SD-OCT revealed irregularity of RPE in the temporal region of the optic disc and complete regression of the subretinal fluid. Interestingly, the entire CNV complex including the main trunk completely disappeared in OCTA. CNV complex was not observed in OCTA during 1-year follow-up, and peripapillary and macular vascular density measurements did not show any significant change. BCVA was preserved, and no additional injections were needed.

Conclusion

It is possible that OCTA can be used for detailed evaluation of CNV associated with ODD, response to anti-VEGF treatment, and peripapillary and macular vascular density. There is a need for further studies to confirm the changes such as disappearance of CNV in OCTA after injection as we observed in our patient.

Paediatric case of peripapillary choroidal neovascularisation associated with optic disc drusen treated with aflibercept

Peripapillary choroidal neovascularisation (PPCNV) associated with optic disc drusen is a rare complication that can result in severe vision impairment in children. We report the first case of paediatric PPCNV secondary to optic disc drusen successfully treated with intravitreal aflibercept. A 6-year-old girl presented with a one week history of reduced vision in her right eye with best-corrected visual acuity of 20/500. Fundus examination revealed bilateral elevated discs with a peripapillary pigmentary lesion in the right eye. Optical coherence tomography of the right eye showed marked subfoveal fluid. Both B-scan ultrasonography and fundus autofluorescence demonstrated findings consistent with optic disc drusen. Diagnosis of PPCNV was further confirmed on fluorescein fundus angiography. The child received three intravitreal aflibercept injections with complete resolution of the subfoveal fluid. Her visual acuity improved to 20/25 with no recurrence at a 16-month follow-up. No adverse side effects were reported.

Important functional distress in a teenager with optic nerve drusen

We present a case of bilateral optic disc drusen and severe visual field loss in a female patient diagnosed at a very young age.

Optic Nerve Head Drusen: An Update

Optic nerve head drusen are benign acellular calcium concretions that usually form early in life, just anterior to the lamina cribrosa. Improving imaging using optical coherence tomography suggests they are common and may be present in many clinically normal discs. These drusen may change in appearance in early life, but are generally stable in adulthood, and may be associated with visual field defects, anterior ischaemic optic neuropathy, or rarer complications. Based on long-term clinical data and optical coherence tomography, we propose a refined hypothesis as to the cause of optic disc drusen. Here we summarise recent findings and suggest future studies to better understand the forces involved.

Choroidal neovascularisation associated with optic nerve head drusen: Case report and review of literature

A 21-year-old man was seen for follow-up of optic nerve head drusen (ONHD) in the ophthalmology department. Funduscopy revealed the presence of choroidal neovascularisation (CNV) in the papillomacular bundle of his right eye (RE). The patient was successfully treated with two intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF). Peri-papillary choroidal neovascularisation in papillomacular bundle is a rare complication in patients with ONHD. These forms of CNV show a good response to anti-VEGF treatment.

Optic nerve head drusen associated with neovascular membrane in a child: a case report

PURPOSE

To describe the anatomical and functional results of intravitreal antiangiogenic treatment in optic nerve head drusen associated with choroidal neovascularisation.

CASE REPORT

An 8 year-old male patient with a diagnosis of neovascular membrane in the right eye associated with bilateral optic nerve head drusen. Best-corrected visual acuity (BCVA) was by counting fingers in the right eye and improved to 0.4 after antiangiogenic treatment. A complete consolidation of the lesion was observed with no associated complications arising from the treatment.

DISCUSSION/CONCLUSIONS

Antiangiogenic treatment is an effective option, and no side-effects have been observed in treatment of neovascular tissue associated with optic disc drusen in children.

Optic Disc Drusen and Family History of Glaucoma-Results of a Patient-directed Survey

PURPOSE

Prospective evaluation of family history (FH) of glaucoma and FH of optic disc drusen (ODD) in patients with sonographically confirmed ODD.

PATIENTS AND METHODS

A total of 87 patients with ODD interviewed all their first-degree and second-degree relatives using a detailed questionnaire on whether an ophthalmologist had diagnosed or excluded glaucoma or ocular hypertension (OH). Using a second questionnaire, 62 of these patients also provided information about ODD in their FH. Control groups for FH of glaucoma consisted of 2170 patients with glaucoma or OH evaluated with the same methods and identical questions for FH of glaucoma in a previous study, and of 176 healthy individuals without glaucoma or ODD who were interviewed on family history of glaucoma.

RESULTS

Glaucoma in FH was significantly more frequent in patients with ODD with an incidence of 20.7% compared with healthy controls with an incidence of 2.8%, and half as frequent as in glaucoma patients with an incidence of 40%. ODD in FH were found in 9.7% of patients with ODD.

CONCLUSIONS

As there is a high frequency of family history of glaucoma in patients with ODD, evaluation of FH of ODD and FH of glaucoma is essential in patients with ODD. Glaucoma in FH of ODD patients requires intraocular pressure monitoring and whenever deemed beneficial timely initiation of intraocular pressure-lowering therapy.

Optic disk drusen in children

Optic disk drusen occur in 0.4% of children and consist of acellular intracellular and extracellular deposits that often become calcified over time. They are typically buried early in life and generally become superficial, and therefore visible, later in childhood, at the average age of 12 years. Their main clinical significance lies in the ability of optic disk drusen, particularly when buried, to simulate true optic disk edema. Misdiagnosing drusen as true disk edema may lead to an invasive and unnecessary workup for elevated intracranial pressure. Ancillary testing, including ultrasonography, fluorescein angiography, fundus autofluorescence, and optical coherence tomography, may aid in the correct diagnosis of optic disk drusen. Complications of optic disk drusen in children include visual field defects, hemorrhages, choroidal neovascular membrane, nonarteritic anterior ischemic optic neuropathy, and retinal vascular occlusions. Treatment options for these complications include ocular hypotensive agents for visual field defects and intravitreal anti-vascular endothelial growth factor agents for choroidal neovascular membranes. In most cases, however, children with optic disk drusen can be managed by observation with serial examinations and visual field testing once true optic disk edema has been excluded.

PSEUDO UVEAL MELANOMA CAUSED BY OPTIC DISK DRUSEN WITH JUXTAPAPILLARY CHOROIDAL NEOVASCULAR MEMBRANE

PURPOSE

To describe two cases of choroidal hemorrhage caused by optic disk drusen-induced choroidal neovascularization simulating uveal melanoma.

METHODS

Observational case reports of two patients and brief review of the literature.

RESULTS

Two patients were referred with pigmented juxtapapillary lesions concerning for choroidal melanoma. Multimodal imaging revealed the presence of optic disk drusen with overlying choroidal neovascular membranes and peripapillary choroidal hemorrhage. Both patients were treated with antivascular endothelial growth factor and the lesions resolved.

CONCLUSION

In the setting of diagnostic uncertainty, careful multimodal imaging can assist in distinguishing between malignant choroidal melanoma and a benign simulating lesion. Optic disk drusen with associated neovascularization and hemorrhage should be included in the list of pseudomelanomas.

Peripapillary Choroidal Neovascularization Associated with Optic Nerve Head Drusen Treated with Anti-VEGF Agents

Optic nerve head drusen can be associated with peripapillary choroidal neovascularization, in both the pediatric and adult population. These membranes can involve the macula, causing significant visual loss. Herein, we present a case that required treatment with an anti-VEGF agent. The patient failed to respond to the initial agent, but subsequently responded to a change of agent. Adult patients with macular degeneration involving peripapillary choroidal neovascularization associated with optic nerve head drusen may require individualized treatment plans.

A single injection of intravitreal ranibizumab in the treatment of choroidal neovascularisation secondary to optic nerve head drusen in a child

Optic nerve head drusen are acellular, calcified deposits which may be found in buried or exposed drusen form. Choroidal neovascularisation secondary to optic nerve head drusen is rarely seen in childhood. This case report summarises the clinical and therapeutic outcomes of a 13-year-old girl with unilateral choroidal neovascularisation secondary to optic nerve head drusen. The patient was successfully treated with a single intravitreal ranibizumab injection. After a month from the injection the visual acuity increased dramatically and maintained at the same level during 9 months of follow-up time. There was no complication related to the injection.