Review: coats disease: the 2001 LuEsther T. Mertz lecture

MACULAR HOLE IN A YOUNG PATIENT AFFECTED BY FAMILIAL EXUDATIVE VITREORETINOPATHY

PURPOSE

To report a case of familial exudative vitreoretinopathy in which genetic testing was used to confirm the diagnosis with a new mutation identified in FZD4 gene.

METHODS

A 28-year-old girl was addressed to our clinic for surgical management of a macular hole possibly associated with Coats disease. Multimodal imaging was performed including fundus photography, fundus autofluorescence, optical coherence tomography, fluorescein, and indocyanine green angiography.

RESULTS

On examination, visual acuity was light perception secondary to previous retinal detachment and 20/32, respectively, in her right and left eye. Clinical and imaging evaluations showed findings suggestive for familial exudative vitreoretinopathy. Spectral domain optical coherence tomography study of the macula showed a macular pucker with lamellar macular hole and a conservative approach was preferred. After 18 months of observation, the patient underwent surgery secondary to the onset of a full thickness macular hole. After 24 months, the patient's vision was 20/32. Genetic testing was used to confirm the diagnosis demonstrating 2 new mutations in FZD4 gene.

CONCLUSION

Our case emphasizes the importance of a prompt recognition of familial exudative vitreoretinopathy disease also using gene testing and a close follow-up to prevent and manage possible complications.

Early onset coats' disease initially treated as unilateral ROP at 39 weeks postmenstrual age: a case report

Background

This is the youngest case of Coats’ disease, in terms of postmenstrual age (PMA), to be reported in the literature. This case highlights the remarkable variations in the clinical manifestations and the very early onset of Coats’ disease. This case is unusual in both the age of onset and atypical clinical features, which resemble retinopathy of prematurity (ROP).

Case presentation

We report a case of a preterm boy born at 31 5/7 weeks gestational age who presented with atypical Coats’ disease and was initially diagnosed as having ROP of only one eye at 39 weeks PMA. After initial laser treatment, severe exudative retinal detachment (ERD) occurred after initial laser treatment for ROP. Fundus fluorescein angiography (FFA) showed telangiectasia and anastomosis of peripheral retinal vessels and nonperfusion areas, and the diagnosis of Coats’ disease was thus established. A series of intravitreal injections of ranibizumab (IVR) and laser ablations were performed to resolve the exudation and to ablate the abnormal vessels. At the last visit, the retinopathy was under control, and useful vision was preserved.

Conclusions

Coats’ disease resembling stage 3 ROP can be detected before the expected date of childbirth. Therefore, asymmetric ROP should be differentiated from Coats’ disease.

Coats' disease of adult-onset in 48 eyes

Background:

Coats’ disease diagnosed in adulthood is an idiopathic, retinal exudative vascular disease without an inciting factor and has retinal features different from the childhood disease.

Aim:

To describe clinical features, treatment, and outcomes of eyes with Coats’ disease first diagnosed in patients 35 years or older.

Materials and Methods:

Retrospective chart review of patients first diagnosed with Coats’ disease at the age of 35 years or more at a tertiary eye care center between January 1995 and 2012. Eyes with retinal exudation or Coats’-like response from secondary causes were excluded.

Results:

Forty-five of 646 patients (7%) diagnosed with Coats’ disease had adult-onset disease. Mean age at presentation was 47 years. Systemic hypertension was the most common (22%) systemic association and decreased vision the predominant presenting feature (83%). Localized (<6 clock h) presentation (74%) was unique to adults as against diffuse involvement (69%) in children (P < 0.001). Eyes were treated with laser photocoagulation 29 (60%), cryotherapy (4%), or both (2%) with surgical intervention in three (6%) eyes. Following treatment eight (35%) eyes improved, 11 (48%) eyes were stable while four (12%) eyes worsened due to complications.

Conclusion:

Adult-onset Coats’ disease has less extensive involvement, more benign natural course, and a more favorable treatment outcome as against the childhood-onset disease. The bilateral presentation emphasizes the need for regular follow-up to detect possible future involvement of the fellow eye.

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.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Monitoring Coats' Disease

. OCTA and OCT, in combination with FA, are useful in Coats' disease diagnostics and treatment monitoring. As noninvasive methods, OCT and OCTA may be performed more often than FA, which enable precise monitoring of the disease and making decisions as to its further treatment.

Ultra-wide field imaging in the diagnosis and management of adult-onset Coats' disease

BACKGROUND

The conventional fundus imaging covers up to 60 degrees of retina only. Although various montaging techniques can significantly increase the area that can be imaged, it is still difficult to image and document the peripheral retina. The purpose of this study is to describe the use of ultra-wide field imaging in the diagnosis and management of adult-onset Coats' disease.

METHODS

This is a retrospective case series of three patients diagnosed with adult-onset Coats' disease that were treated at the retina clinic of our institute. The case records, conventional and ultra-wide field fluorescein angiograms and optical coherence tomography scans were reviewed.

RESULTS

The ultra-wide field pseudo-colour photographs and fluorescein angiograms were able to provide clinically useful information over and above that provided by conventional imaging. In all three patients, ultra-wide field angiography showed the temporal avascular periphery. In addition, it revealed retinal neovascularisation, peripheral vascular leakage and documented peripheral telangiectasia in selected patients.

CONCLUSION

Ultra-wide field imaging provides information that can help in the diagnosis and management of adult-onset Coat's disease. This may lead to better visual outcomes in Coats' disease.

CLINICAL CHARACTERISTICS AND TREATMENT OUTCOMES OF COATS DISEASE IN A SAUDI ARABIAN POPULATION

PURPOSE

To present the clinical aspects and treatment outcomes of Coats disease in Saudi Arabia.

METHODS

A retrospective chart review was performed of 92 patients (97 eyes) diagnosed with Coats disease at King Khalid Eye Specialist Hospital from 1983 to 2010.

RESULTS

The most common presenting complaint was decreased visual acuity followed by strabismus and then leukocoria. Snellen visual acuity was 20/20 to 20/50 in 9 eyes (9%), 20/50 to 20/160 in 11 eyes (11%), 20/200-counting fingers in 29 eyes (30%), and hand motion to no light perception in 24 eyes (25%). Telangiectasia was located in the preequatorial area in 71 eyes (73%) and most commonly involved the temporal retina in 67 eyes (69%). In eyes with clear view to the fundus, quadrant involvement by telangiectasia had the following distribution: 1) quadrant (n = 36, 37%); 2) quadrants (n = 26, 27%); 3) quadrants (n = 8, 8%); and 4 quadrants (n = 15, 15%). Total retinal detachment was present at presentation in 28 eyes (29%) and neovascular glaucoma in 8 (8%). Based on the Shields classification, the eyes were Stage 1 (n = 1, 1%), Stage 2A (n = 7, 7%), Stage 2B (n = 23, 24%), Stage 3A1 (n = 26, 27%), Stage 3A2 (n = 12, 12%), Stage 3B (n = 16, 17%), Stage 4 (n = 11, 11%), and Stage 5 (n = 5, 1%). Stage 3A was the most commonly presented stage (39%). Primary management included cryotherapy (19%), laser photocoagulation (64%), intravitreal agents (9%), and surgical drainage (4%). Combination treatment was performed in 29% of eyes. Thirteen eyes (13%) were enucleated because of clinical suspicion of retinoblastoma or the presence of glaucoma. Factors that were associated with a poor visual outcome of 20/200 or worse included age less than 10 years (relative risk: 1.27), Stages 3 and 4 disease (relative risk: 1.40), presence of subretinal fluid in all 4 quadrants including the fovea (relative risk: 14.25), and initial visual acuity of 20/200 (relative risk: 6.72) or worse (P < 0.005 for all factors).

CONCLUSION

Although rare, Coats disease is usually advanced at presentation and has a poor visual prognosis in the Saudi population, like in other populations. The findings of this study give validity and applicability to the Shields staging scheme, which we recommend using in clinical practice.

Subretinal Fluid Drainage and Vitrectomy Are Helpful in Diagnosing and Treating Eyes with Advanced Coats' Disease

Severe forms of Coats' disease are often associated with total retinal detachment, and a differential diagnosis from retinoblastoma is critically important. In such eyes, laser- and/or cryoablation is often ineffective or sometimes impossible to perform. We report a case of advanced Coats' disease in which a rapid pathological examination of subretinal fluid was effective for the diagnosis, and external subretinal drainage combined with vitrectomy was effective in preserving the eye.

Haploinsufficiency of RCBTB1 is associated with Coats disease and familial exudative vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) belongs to a group of genetically and clinically heterogeneous disorders in retinal vascular development. To date, in approximately 50% of patients with FEVR, pathogenic mutations have been detected in FZD4, LRP5, TSPAN12, NDP and ZNF408. In this study, we identified two heterozygous frameshift mutations in RCBTB1 from three Taiwanese cases through exome sequencing. In patient-derived lymphoblastoid cell lines (LCLs), the protein level of RCBTB1 is approximately half that of unaffected control LCLs, which is indicative of a haploinsufficiency mechanism. By employing transient transfection and reporter assays for the transcriptional activity of β-catenin, we demonstrated that RCBTB1 participates in the Norrin/FZD4 signaling pathway and that knockdown of RCBTB1 by shRNA significantly reduced nuclear accumulation of β-catenin under Norrin and Wnt3a treatments. Furthermore, transgenic fli1:EGFP zebrafish with rcbtb1 knockdown exhibited anomalies in intersegmental and intraocular vessels. These results strongly support that reduced RCBTB1 expression may lead to defects in angiogenesis through the Norrin-dependent Wnt pathway, and that RCBTB1 is a putative genetic cause of vitreoretinopathies.

Pearls and pitfalls in diagnosis and management of coats disease

PURPOSE

To review current literature on Coats disease and provide a structured framework for differentiating challenging clinical features in Coats disease patients.

METHODS

We critically reappraise historical and current literature and present clinical methods for developing a thorough differential diagnosis and management strategy for Coats disease.

RESULTS

Coats disease is a sporadic, usually unilateral condition typically occurring in young males. When untreated, this disorder can lead to total exudative retinal detachment and secondary glaucoma.

CONCLUSIONS

Anti-VEGF agents are currently a treatment option in combination with ablative therapy of telangiectatic vessels. Anti-VEGF agents appear particularly useful for patients with extensive areas of exudative retinal detachment, and are an effective treatment option for total retinal detachment.

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."

Complex genetics of familial exudative vitreoretinopathy and related pediatric retinal detachments

Familial exudative vitreoretinopathy (FEVR) is a hereditary vitreoretinal disorder that can cause various types of retinal detachments. The abnormalities in eyes with FEVR are caused by poor vascularization in the peripheral retina. The genetics of FEVR is highly heterogeneous, and mutations in the genes for Wnt signaling and a transcription factor have been reported to be responsible for FEVR. These factors have been shown to be the regulators of the pathophysiological pathways of retinal vascular development. Studies conducted to identify the causative genes of FEVR have uncovered a diverse and complex relationship between FEVR and other diseases; for example, Norrie disease, a Mendelian-inherited disease; retinopathy of prematurity, a multifactorial genetic disease; and Coats disease, a nongenetic disease, associated with pediatric retinal detachments.

Intraoperative fluorescein angiography-guided treatment in children with early Coats' disease

PURPOSE

To review the anatomic and visual outcomes of a series of children diagnosed with Coats' disease and treated on the basis of intraoperative fluorescein angiography (FA) findings.

DESIGN

Retrospective case series.

PARTICIPANTS

Twenty-five children 2 to 15 years of age diagnosed with early Coats' disease and treated after intraoperative FA.

METHODS

Retrospective review of patients who underwent treatment for stage 2 Coats' disease in a tertiary center in the United Kingdom between 2007 and 2012. The children underwent treatment to the telangiectatic vessels and associated areas of retinal nonperfusion identified on intraoperative FA performed with a wide-angle retinal camera (RetCam II).

MAIN OUTCOME MEASURES

Anatomic and structural assessment of the retina after treatment, visual acuity (VA), and complications related to treatment.

RESULTS

Twenty children with Coats' disease who underwent intraoperative RetCam FA and retinal ablative treatment and who had more than 3 months of follow-up were identified from clinical records. All had unilateral disease. Six eyes were classified as stage 2a, and 14 eyes were classified as stage 2b. The median duration of follow-up was 21 months (mean, 26 months). Fifteen eyes needed 1 treatment to stabilize the disease, and 5 eyes needed a second treatment. None of the patients demonstrated progression of the disease to a more severe stage. Twelve eyes had a final VA of 0.4 logarithm of the minimum angle of resolution (logMAR) or better, 6 patients had VA between 0.4 and 1.0 logMAR, and 2 patients had VA worse than 1.0 logMAR.

CONCLUSIONS

The treatment of retinal telangiectasia and areas of retinal nonperfusion identified by wide-angle intraoperative FA in children with stage 2 Coats' disease led to good anatomic outcome, with preservation of VA in most cases.

Coats-like retinopathy in a Young Indian Rhesus Macaque (Macaca mulatta)

A 1-year-old male Indian rhesus macaque presented with a bilateral blindness. Ocular examination, gross and histopathological evaluation, and immunohistochemistry were performed. The major findings were retinal telangiectasia, accumulation of exudate in the intraretinal and subretinal space, and retinal detachment. Coat-like retinopathy was diagnosed, and it has not been previously reported in veterinary medicine.

Coats disease in a patient with Fanconi anemia: a case report

PURPOSE

To describe the diagnosis and management of Coats disease in a patient with Fanconi anemia.

METHODS

Case report.

RESULTS

A 12-year-old girl with Fanconi anemia developed Coats disease. Retinal vasculature anomalies are present in both diseases; however, differential diagnosis in this case could be based on the presence of telangiectasias, which are typical of Coats disease, and the absence of perivascular sheathing, usually described in the uncommon retinal manifestations of Fanconi anemia. The stage 4 Coats disease was managed with intravitreal bevacizumab injections and later pars plana vitrectomy with silicone oil tamponade surgery, which prevented enucleation despite visual loss.

CONCLUSIONS

Patients with Fanconi anemia can have retinal vasculature anomalies that are not necessarily related to this systemic anomaly. In this case, the retinal alterations were related to advanced Coats disease stage, which was successfully treated, and enucleation of the affected eye was not necessary.

Optical coherence tomography in pediatric ophthalmology: current roles and future directions

The application of existing optical coherence tomography (OCT) technology to the pediatric population is limited in both the design specification of the device and its hardware. However, the potential of OCT in the pediatric population has not been fully realized. The authors review the literature, highlighting the currently available spectral-domain OCT technology and summarizing the reported normal pediatric OCT parameters for retinal nerve fiber layer and macular thickness. They also review the pediatric ophthalmological conditions in which OCT has been used and discuss advancements in OCT design and their potential applications to the pediatric population. The use of OCT in pediatric populations is likely to increase greatly in the coming years, aiding clinical decision-making and providing new insights into pediatric disease pathophysiology.

Peripheral retinal nonperfusion in fellow eyes in coats disease

PURPOSE

To measure peripheral nonperfusion and describe bilateral vascular abnormalities in patients with Coats disease, emphasizing subtle findings in the contralateral eyes of patients diagnosed with unilateral disease.

METHODS

Clinical records, including retina drawings and fluorescein angiography images obtained under anesthesia, were retrospectively reviewed from consecutive pediatric patients with Coats disease. The main outcome measure was disk diameters of peripheral nonperfusion and proportion of Coats disease patients with bilateral findings.

RESULTS

Twenty-two of 32 patients with Coats disease had bilateral abnormal peripheral vasculature. In Group 1 (classic Coats disease: presumed unilateral, ocular only disease), 15 of 24 patients had peripheral nonperfusion >2 disk diameters in their contralateral eyes, 5 with telangiectasis and/or microaneurysms. Seven of 8 patients in Group 2 (Coats-like disease: systemic and/or clinically bilateral disease) had bilateral vascular anomalies.

CONCLUSION

Bilateral vascular abnormalities are more common in Coats disease than previously reported. This observation supports a systemic and/or genetic association with Coats disease. Patients with Coats disease should have careful evaluation of the periphery of the less affected eye, preferably with fluorescein angiography, to identify vascular changes not visible clinically. Both eyes warrant surveillance over the lifetime of the patient for potential progression to exudative disease that would warrant treatment.

Coats disease in a 3-week-old boy

Coats disease is a rare, idiopathic retinal vasculopathy that predominantly affects males in the first decade of life. We report the case of a 3-week-old boy who presented with atypical rapidly progressing disease suggestive of Coats exudative vasculopathy. The eye developed retinal fibrosis and phthisis bulbi within 4 weeks. Retinoblastoma could not be ruled out, although histopathology after enucleation revealed no retinoblastoma. To our knowledge, this is the youngest case of Coats disease to be reported in the literature. This case highlights the wide variation in the clinical presentation of Coats disease and the difficulty in differentiating it from diffuse infiltrative retinoblastoma.

Pars plana vitrectomy for treatment of advanced Coats' disease--presentation of a modified surgical technique and long-term follow-up

BACKGROUND

To present a modified surgical technique in the treatment of retinal detachment secondary to advanced Coats' disease in children, and report on long-term anatomical and functional outcome.

METHODS

We analysed an interventional case series of 13 patients (13 eyes) with advanced Coats' disease characterised by retinal detachment in addition to massive subretinal exudates and vascular malformation. The presented patients underwent pars plana vitrectomy (PPV), including a modified technique of exocryotherapy applied after fluid-air exchange in order to achieve complete treatment of the vascular changes, to reduce associated side-effects, and to avoid retinectomy and silicone oil tamponade.

RESULTS

Within a median follow-up period of 37 months (range: 18-66 months), no enucleation was necessary. Four eyes (31 %) did not need any further therapy, and in nine eyes (69 %) additional treatments were performed. Six patients (46 %) required revisional surgery with silicone oil tamponade. In ten eyes (77 %), the pathologic vessels and exudates finally regressed and the retina reattached. Visual acuity (VA) could be stabilized in the majority of patients: in three eyes (27 %) VA improved, in four eyes (36 %) VA remained stable, in four eyes (36 %) visual acuity (VA) deteriorated, and in two eyes VA could not be evaluated.

CONCLUSIONS

The presented modified technique allows for sufficient cryotherapy of vascular malformations, even in the presence of massive exudation, in a subset of patients with advanced Coats' disease, and thus may reduce surgery-related complications and improve the rehabilitation process of these young patients.

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.

Intravitreal ranibizumab in the management of stage 2B Coats disease in a young adult Malay man

This paper describes a rare case of Coats disease with late presentation in a young adult. The condition improved with a combination of focal photocoagulation, cryotherapy and intravitreal ranibizumab.

Coats syndrome in facioscapulohumeral dystrophy type 1: frequency and D4Z4 contraction size

OBJECTIVE

To investigate the frequency of Coats syndrome and its association with D4Z4 contraction size in patients with facioscapulohumeral muscular dystrophy type 1 (FSHD1).

METHODS

We searched a North American FSHD registry and the University of Rochester (UR) FSHD research database, reviewed the literature, and sent surveys to 14 FSHD referral centers in the United States and overseas to identify patients with genetically confirmed FSHD1 with a diagnosis of Coats syndrome.

RESULTS

Out of 357 genetically confirmed patients in a North American FSHD registry and 51 patients in the UR database, 3 patients had a self-reported history of Coats disease (0.8%; 95% confidence interval 0.2%-2.2%). In total, we identified 14 patients with FSHD with known genetic contraction size and Coats syndrome confirmed by ophthalmologic examination: 10 from our survey and 4 from the literature. The median age at diagnosis of Coats syndrome was 10 years (interquartile range 14 years). The median D4Z4 fragment size was 13 kilobases (kb) (interquartile range 1 kb). One patient was mosaic (55% 11 kb, and 45% 78 kb).

CONCLUSIONS

Coats syndrome is a rare extramuscular complication of FSHD1 associated with large D4Z4 contractions. Closer surveillance for retinal complications is warranted in patients with D4Z4 fragments ≤15 kb.

Transscleral diode photocoagulation of large retinal and choroidal vascular lesions

BACKGROUND

Transscleral retinal photocoagulation with a diode laser is used in glaucoma refractory to medical and surgical treatment. Our main research question was how the technique performed in large vascular lesions associated with hemangiomas of the retina and choroid.

METHODOLOGY/CLINICAL FINDINGS

Patient charts were retrieved from the hospital files for patients who underwent the procedure and were followed for at least 24 months. Five patients (6 eyes) fit the criteria. Cases included Von Hippel's disease (2 eyes), Coats' disease (1 eye) and choroidal hemangioma (3 cases). Transscleral diode laser treatment was performed under retrobulbar and topical anesthesia with a retinopexy probe (IRIS DioPexy, IRIS Medical Instruments, Mountain View, CA) applied transsclerally under indirect ophthalmoscope visualization. We found an improvement in best-corrected visual acuity at 24 months postoperatively.

CONCLUSIONS/SIGNIFICANCE

Transscleral photocoagulation may have a clinical application in these diseases as an alternate to the high cost of photodynamic therapy with photosensitizing agents.

Primitive retinal vascular abnormalities: tumors and telangiectasias

Primitive retinal vascular abnormalities are benign conditions of the retinal circulation that comprise vascular tumors and telangiectasias. The principal vascular tumors of the retina include retinal capillary hemangioma, cavernous hemangioma of the retina, racemose hemangiomatosis of the retina and retinal vasoproliferative tumor, while primary retinal telangiectasias include Coats' disease, Leber's miliary aneurysms and idiopathic juxtafoveal telangiectasias. In most cases, these alterations result in significant visual impairment due to exudation determined by the structural abnormalities of the retinal vasculature. The aim of this review is to assess the different clinical and diagnostic features of the single pathological entities and to discuss the available treatment modalities including the onset of intravitreal antivascular endothelial growth factor therapy.

Increased nitric oxide and vascular endothelial growth factor levels in the aqueous humor of patients with coats' disease

PURPOSE

To determine the aqueous humor levels of nitric oxide (NO) and vascular endothelial growth factor (VEGF) in the eyes of patients with Coats' disease and study the correlation between these levels.

METHODS

Samples of aqueous humor were obtained from 7 patients with Coats' disease and 15 age-matched patients with congenital cataracts as controls. Nitrite and nitrate (NOx), the stable end products of NO, were detected by the Griess reaction, and VEGF levels were assessed by enzyme-linked immunosorbent assay.

RESULTS

The aqueous humor NOx and VEGF levels were elevated in the eyes of patients with Coats' disease compared with those of controls (P=0.001 and P<0.001, respectively). The median NOx level was 55.2 μM (range, 23.0-75.3 μM) in the Coats' disease group and 18.8 μM (range, 8.7-36.2 μM) in the control group. The median VEGF level was 731.7 pg/mL (range, 288.3-1364.3 pg/mL) in the Coats' disease group and 33.3 pg/mL (range, 9.0-96.8 pg/mL) in the control group. No correlation was observed between the aqueous humor concentrations of NOx and VEGF.

CONCLUSIONS

NOx and VEGF are increased but not related in the aqueous humor samples of patients with Coats' disease. NO and VEGF may play roles in the pathogenesis of Coats' disease. Further studies are needed to clearly elucidate the relationship among VEGF, NO, and other cytokines in Coats' disease.

Diffuse retinal capillary leakage in coats disease

PURPOSE

Coats disease is a rare condition characterized by retinal vascular telangiectasia, aneurysms, and leakage from these abnormal blood vessels. We report the phenomenon and treatment of Coats disease with diffuse hyperpermeability from angiographically normal retinal capillaries.

METHODS

This case series describes two patients with Coats disease, diagnosed based on fundus photography and fluorescein angiography. The first patient was treated with intravitreal bevacizumab and limited laser photocoagulation. The second patient was treated only with limited photocoagulation.

RESULTS

The diffuse exudation from normal retinal capillaries resolved with treatment of the focal primary vascular Coats lesions.

CONCLUSION

Vasculopathies such as Coats disease may produce diffuse hyperpermeability of otherwise normal capillaries in the fundus. Limiting treatment only to the primary Coats lesions is a minimally invasive strategy that preserves normal capillaries.

Over 10 years follow-up of Coats' disease in adulthood

Coats’ disease diagnosed in adulthood is rare; therefore, the treatment options and longer clinical course are not well established. We report on two cases of adult onset Coats’ disease, which have been observed for more than 10 years after conventional treatment. In the first case, a 76-year-old man with 9 years of diabetic retinopathy noticed a visual field defect in his left eye. Yellowish subretinal exudation with serous retinal detachment in his superior peripheral retina, and telangiectatic vessels with fluorescein leakage, numerous microaneurysms, and areas of capillary nonperfusion observed in a fluorescein angiography indicated adult Coats’ disease, and retinal photocoagulation was applied. Within 1 year, subretinal exudation was regressed and visual acuity was improved from 20/50 to 20/20, and was maintained for the next 11 years. In the second case, a 71-year-old man presented with decreased vision in his right eye. The fundus of his right eye showed multiple telangiectasic vessels and subretinal exudates extended to the fovea, which is diagnosed as adult Coats’ disease. Despite retinal photocoagulation, an increase of exudation and an enlargement of retinal detachment was observed within 1 month, and subsequently, additional treatment of cryotherapy was performed. Two months after these therapies, the exudation was regressed without retinal detachment, and visual acuity was improved to 20/200 which was maintained for the next 10 years. Even with adult Coats’ disease, conventional therapies of retinal photocoagulation and cryotherapy are effective and are the initial choice for improving or maintaining visual function.

A combination of intravitreal bevacizumab injection with tunable argon yellow laser photocoagulation as a treatment for adult-onset Coats' disease

PURPOSE

The purpose of this study was to investigate the effectiveness of intravitreal bevacizumab injections combined with tunable argon yellow laser photocoagulation as a treatment for adult-onset Coats' disease.

METHODS

We consecutively treated 3 patients suffering from Coats' disease diagnosed in adulthood with a combination of intravitreal bevacizumab injection and tunable argon yellow laser photocoagulation. All patients received an intravitreal injection of 2.5 mg bevacizumab together with various sessions of laser photocoagulation targeting the area of telangiectasia. The patients' best-corrected visual acuities were recorded. Fundus photography, fluorescein angiography (FA), and optical coherence tomography were used to monitor vascular and retinal exudate changes.

RESULTS

Fundus photography and FA of all 3 patients revealed significant regression of the vascular dilatation and the aneurysmal appearance of the telangiectasia areas. Optical coherence tomography also showed a significant subsidence of the macular edema and submacular fluid in all patients. A concomitant improvement in visual acuity was also noted. No treatment-related complications were identified.

CONCLUSIONS

Combining intravitreal bevacizumab and tunable argon yellow laser photocoagulation is an efficient treatment of choice for Coats' disease that has been diagnosed in adulthood.

The management of "coats' response" in a patient with x-linked retinitis pigmentosa-a case report

The management of exudative retinal detachment in Coats disease can be very difficult with variable results. A case is presented of a 12 year old boy who was diagnosed with X-linked retinitis pigmentosa with an associated “Coat's Response”. The patient had a marked reduction in his left visual acuity due to intragel and subhyaloid haemorrhage as well as exudative retinal detachment. This was managed successfully with vitrectomy and endolaser, resulting in clearance of the haemorrhage and flattening of the retina. In our experience endolaser should be considered as viable therapeutic option in the management of this condition.

Effects of green diode laser in the treatment of pediatric Coats disease

PURPOSE

To review the effect of green diode laser ablation therapy on retinal structure and functional outcome in patients with advanced Coats disease.

DESIGN

Retrospective, interventional case series.

METHODS

Fourteen eyes of 13 patients with Coats disease were included in this study. Medical records, Retcam photographs (Clarity Medical Systems, Pleasanton, CA), and fluorescein angiograms were reviewed. All patients initially were treated with green diode laser (532 nm) ablation therapy to areas of the retinal telangiectasis associated with exudation. Main outcome measures included visual acuity, treatment outcome defined as complete resolution of telangiectatic lesions or exudative detachment, and macular status at the end of follow-up.

RESULTS

Before treatment, 1 eye was at stage 2 (telangiectasis and exudation), 12 eyes were at stage 3 (exudative retinal detachment), and 1 eye was at stage 4 (total retinal detachment with glaucoma). Five eyes had highly detached retina of more than 4 mm. Median age at diagnosis was 51 months (range, 0.5 to 153 months). Median follow-up was 39.5 months (range, 15 to 70 months). Median number of green diode laser photocoagulation treatments was 2 (range, 1 to 5). After laser photocoagulation, 13 (93%) of 14 eyes had no active exudation. Functionally, 4 (29%) of 14 eyes had 20/50 or better visual acuity, 3 (21%) of 14 eyes had 20/60 to 20/200 visual acuity, 5 (36%) of 14 eyes had 20/400 to light perception visual acuity, and 2 (14%) of 14 eyes had no light perception visual acuity. No eye was phthisical or enucleated.

CONCLUSIONS

Green diode laser therapy can be an effective treatment for advanced Coats disease, even in the presence of a moderate to severely elevated retinal detachment.

Intravitreal bevacizumab for pediatric exudative retinal diseases

PURPOSE

To detect if intravitreal bevacizumab can reduce retinal exudation, improve visual and anatomical outcomes, and facilitate the treatment in various pediatric exudative retinal diseases.

PATIENTS AND METHODS

Prospective, non-randomized, case series of nine eyes of pediatric exudative retinal diseases less than 18 years old which included six eyes with juvenile diabetic retinopathy, two eyes in children with Coats' disease, and one eye with myopic choroidal neovascular membrane (CNV). All eyes received only intravitreal bevacizumab injection 1.25 mg/0.05 ml as the primary treatment. The need for adjuvant ablative procedures, including laser photocoagulation or cryotherapy, were performed and recorded. The need for supplementary intravitreal bevacizumab injection was recorded. The changes in pre- and post-operative best-corrected visual acuity (BCVA) and central macular thickness (CMT) were recorded. Serial optical coherent tomography (OCT) and fundus flourescein angiography (FFA) were performed to follow treatment efficacy.

RESULTS

The study included 19 eyes of 11 patients with age equal to or less than eighteen years with exudative retinal diseases including type I DM (n = sixteen eyes), Coats' disease (n = 2 eyes), and due to myopic CNV (n = 1 eye). Mean pre-injection log MAR for all was 0.605 ± 0.174 and mean post-injection for all log MAR was 0.284 ± 0.247. While Mean pre-injection log MAR for DR and myopic CNV patients was 0.576 + 0.152 SD and mean post-injection log MAR for DR and myopic CNV patients was 0.229 + 0.189 at one year. Serial OCT measurements showed that mean CMT for all eyes was 355.8 ± 35.3 μm SD at baseline, which was decreased to 222.42 + 26.2 μm SD. The two eyes of Coats' disease needed another two supplementary intravitreal bevacizumab injections. No ocular or systemic complications related to bevacizumab were noted during the entire course of follow-up.

CONCLUSION

Intravitreal bevacizumab appears to be a well-tolerated treatment for pediatric age group with various exudative retinal diseases. It has the potential as an adjuvant therapy for ablative procedures to improve final visual and anatomical outcome.

Coats' disease, Turner syndrome, and von Willebrand disease in a patient with Wildtype Norrie disease pseudoglioma

The authors describe a girl diagnosed as having Coats' disease, Turner syndrome (45X karyotype), and type 1 von Willebrand disease. She tested negative for the Norrie disease pseudoglioma (NDP) gene located on the X-chromosome, which has been suspected of contributing to Coats' disease.

[Retinal involvement and genetic myopathy]

INTRODUCTION

In genetic diseases, association between retinal and muscular involvement is uncommon, quite specific and frequently allows the diagnosis. In this context, three types of retinal involvement have been described: retinitis pigmentosa (RP), pattern retinal dystrophy (PRD) and exudative retinitis resembling Coats disease (CD).

STATE OF THE ART

The association between RP, PRD and muscle weakness is highly evocative of a mitochondrial disorder. Extra ocular muscles may be affected, but limb girdle or distal weakness can also be present in association or not with symptoms and signs of multisystemic involvement. In a large number of patients suffering from facioscapulohumeral muscular dystrophy (FSHD), retinal vessels telangectasia can be found at the fundoscopic examination. This finding, which corresponds to a developmental abnormality of peripheral retinal blood vessels, is not progressive and remains clinically asymptomatic. Nevertheless, a few patients with FSHD can develop an exsudative retinopathy resembling Coats disease with the risk of the major complication, recurrent retinal detachments.

PERSPECTIVES AND CONCLUSIONS

Considering the diagnostic interest and the deleterious consequences that may follow retinal involvement, close collaboration between the neurologist and ophthalmologist is needed in order to establish the diagnosis, detect complications early, and set up appropriate therapies.

[Coats disease]

Coats disease is characterized by idiopathic congenital retinal telangiectasis and exudative retinopathy. Mostly young males are affected. The disease is usually unilateral. Visual prognosis varies from full visual acuity to blindness according to the extent of retinal exudation. Retinoblastoma is a major differential diagnosis particularly in small children but other causes of exudative retinopathy must also be considered. Treatment aims include obliteration of the telangiectasis in order to resolve retinal exudation and achieve reattachment of the retina. Therapeutic options comprise laser coagulation or cryotherapy, drainage of subretinal fluid, buckling surgery and pars plana vitrectomy. In more advanced cases with therapy-resistant secondary glaucoma enucleation may be required. More recently, intravitreal administration of VEGF inhibitors has become an option.

A population-based study of Coats disease in the United Kingdom I: epidemiology and clinical features at diagnosis

AIMS

coats disease is an uncommon form of retinal telangiectasis. Published case series mostly originate from tertiary referrals centres and may provide a skewed view of disease severity. We conducted a prospective population-based study of Coats disease in the United Kingdom to ascertain the incidence and provide a more representative picture.

METHODS

the study was conducted through the British Ophthalmological Surveillance Unit. This first paper reports the features at presentation; gender, mode of presentation, visual acuity, anterior and posterior segment findings, amount of retinal exudation, and disease staging.

RESULTS

a total of 55 eligible cases of Coats disease were identified giving an estimated population incidence of 0.09 per 100.000 of the population. All cases were unilateral and 85% were male. Mean age at presentation was 146 months (median 96 months). The mean age of diagnosis was markedly different with differing mechanisms of presentation. Cases presenting with leucocoria or strabismus presented early whereas subjective visual loss presented much later. A large proportion of eyes (44%) were blind at diagnosis. The great majority of eyes (71%) had 6 or fewer clock hours of retinal exudation. More severe forms/stages of Coats disease were more common in the youngest patients.

CONCLUSIONS

compared with published studies of Coats disease, we have found milder disease severity at presentation. This is most likely because of the population-based nature of our study reflecting the full disease spectrum. A large proportion of eyes with Coats have poor visual acuity and disease severity is worse in younger patients.

A population-based study of Coats disease in the United Kingdom II: investigation, treatment, and outcomes

AIMS

coats disease is an uncommon form of retinal telangiectasia. We conducted a prospective population-based study of Coats disease in the United Kingdom to provide a more balanced picture. This paper reports the investigations and treatments used for Coats disease and their anatomic and visual outcomes.

METHODS

the study was conducted through the British Ophthalmic Surveillance Unit. All ophthalmologists notifying cases of Coats disease were sent a baseline questionnaire and a follow-up questionnaire after 6 months.

RESULTS

in total, 55 baseline and 42 follow-up questionnaires were returned. All cases were unilateral. Ultrasound was performed in 26% of cases, fluorescein angiography in 35%, and examination under anaesthesia in 42% of the cases. Laser photocoagulation was by far the primary treatment modality, used in 92%, with cryotherapy used mainly as a second-line or adjunctive treatment. In more advanced cases with significant retinal detachment, laser photocoagulation combined with pars plana vitrectomy and drainage of sub-retinal fluid can produce anatomic stability and prevent progress to end-stage disease. Intravitreal injections of steroids or VEGF inhibitors are currently of unproven efficacy in Coats disease. Overall, treatment resulted in stabilisation of visual acuity. Anatomic stabilisation or improvement was achieved in virtually all eyes.

CONCLUSION

laser photocoagulation to telangiectatic retinal vessels is the most commonly used treatment for Coats disease. Other treatments are either adjunctive or of unproven efficacy. A realistic treatment goal is to achieve anatomic stability and avoidance of enucleation for painful end-stage disease. Visual improvement is however unlikely.

Macular fibrosis in Coats disease

PURPOSE

The purpose of this study was to describe the angiographic features and visual impact of macular fibrosis in patients with Coats disease.

METHODS

This is a single institution retrospective case series. Charts of patients diagnosed with Coats disease between 1973 and 2007 were reviewed. Data collected included patient demographics, treatment method, initial and final logarithm of the minimum angle of resolution visual acuity, photographic findings, angiographic characteristics, and anatomical outcome.

RESULTS

Forty-seven patients were identified with adequate imaging and posttreatment follow-up. Average age at presentation was 38 years (4-82 years). Average follow-up was 4.9 years (0-17 years). Macular fibrosis was identified in 11 patients (23%). At presentation, the average logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.67; patients with macular fibrosis, 1.14; and patients without macular fibrosis, 0.50 (P = 0.01, 2-tailed Student's t-test). The average posttreatment logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.78; patients with macular fibrosis, 0.97; and patients without macular fibrosis, 0.70 (P = 0.26). Macular fibrosis was associated with a pigmented spot at the point of apparent intraretinal vascular anastamosis. Fluorescein angiography showed leakage consistent with neovascularization that appeared to be intraretinal.

CONCLUSION

Macular fibrosis is a common finding in Coats disease, occurring in 23% of our patients. It may be a result of intraretinal neovascularization and is associated with a worse vision outcome.

Elevated vascular endothelial growth factor level in Coats' disease and possible therapeutic role of bevacizumab

PURPOSE

To compare intraocular vascular endothelial growth factor (VEGF) level in patients with and without Coats' disease, and to report a case of Coats' disease that responded to intravitreal injection of bevacizumab.

METHODS

Intraocular fluid was obtained from four eyes with Coats' disease (subretinal fluid in three eyes and aqueous in one eye) and from five eyes with rhegmatogenous retinal detachment (subretinal fluid in four eyes and vitreous in one eye). Intraocular VEGF level was compared between these two groups. In one eye with stage 2B Coats' disease, macular edema, visual acuity, and intraocular VEGF level were compared before and after intravitreal injection of bevacizumab.

RESULTS

Mean intraocular VEGF level in eyes with Coats' disease was 2,394.5 pg/ml, compared to 15.3 pg/ml in eyes with rhegmagenous retinal detachment. In the eye with stage 2B Coats' disease, macular edema was reduced after bevacizumab injection, and the visual acuity improved from 0.05 to 0.2. Intraocular VEGF level decreased from 1247 pg/ml to 20.4 pg/ml 1 month after the injection.

CONCLUSION

Coats' disease is associated with increased intraocular VEGF level. Bevacizumab may be a valuable adjunctive treatment for Coats' disease.

Intravitreal anti-vascular endothelial growth factor agents as an adjunct in the management of Coats' disease in children

We describe the role of intravitreal anti-vascular endothelial growth factor (VEGF) agents in Coats' disease in children. In a prospective, interventional, non-randomized case series, three patients (three eyes) aged 16, seven and two years were diagnosed to have Coats' disease. In Case 1 (16 yr/ male) with macular edema, previous laser photocoagulation being unsuccessful, intravitreal pegaptanib sodium (Macugen™) was tried. Case 2 (seven yr/ male) and Case 3 (two yr/ female) were diagnosed to have Stage 4 Coats' and underwent external needle drainage, laser photocoagulation, SF6 gas injection and intravitreal injection of bevacizumab (Avastin™). Reduction of exudation and attached posterior pole (Cases 2 and 3) was seen at a follow-up of six months and two months respectively. Intravitreal anti-VEGF agents may be successfully used as adjunct treatment in select cases of Coats' disease in childhood.

RetCam II Fluorescein Angiography to Guide Treatment and Diagnosis of Coats Disease

Coats disease is a well-described clinical condition featuring peripheral leakage from telangiectatic vasculature, resulting in exudative retinal detachments and exudative deposits. It often affects pediatric patients, requiring examinations and treatments to be performed under anesthesia. It can be difficult to distinguish from retinoblastoma. The RetCam II is a wide-field fundus imaging system that can also obtain intraoperative fluorescein angiography. The case of a 5-year-old girl diagnosed with Coats disease is presented. She presented with an exudative detachment, a submacular nodule, and peripheral telangiectasis. An examination under anesthesia, including angiography, was performed. The angiograph revealed characteristic aneurysms as well as extensive areas of telangiectasis and ischemia not readily visible on examination. The angiogram allowed more diagnostic certainty and guided a more complete treatment than otherwise possible. We propose that fluorescein angiography with the RetCam II system can be a useful tool when examining and treating pediatric patients with Coats disease.