INTRAVITREAL RANIBIZUMAB FOR THE TREATMENT OF INFLAMMATORY CHOROIDAL NEOVASCULARIZATION

Resolution of vitreomacular traction following intravitreal ranibizumab in cases of ocular toxoplasmosis with choroidal neovascularization

PURPOSE

To present the occurrence of the resolution of vitreomacular traction following intravitreal ranibizumab in two patients with inflammatory choroidal neovascular (CNV) membrane with a background of ocular toxoplasmosis.

METHODS

Interventional case report.

RESULTS

A 21-year-old Caucasian woman and a 52-year-old Caucasian man both presented with vitreomacular traction with coexistent classic CNV membrane and a background of ocular toxoplasmosis. They both received an intravitreal injection of ranibizumab in an effort to control the underlying CNV membrane. A resolution of the vitreomacular traction was observed within 1 week of the intravitreal injection in both cases.

CONCLUSION

To the best of our knowledge, this is the first reported case of vitreomacular traction resolution in two patients with ocular toxoplasmosis following ranibizumab administration. Of course, further studies are needed in order to adequately support this association.

Corticosteroid intravitreal implants vs. ranibizumab for the treatment of vitreoretinal disease

PURPOSE OF REVIEW

Three long-acting corticosteroid implants are now available for the treatment of retinal disease, offering control of macular edema and inflammation for between 6 months and up to 3 years. This review evaluates their efficacy and side-effect profile in comparison with the antivascular endothelial growth factor agent ranibizumab in diabetic macular edema, retinal vein occlusion, pseudophakic macular edema, and uveitis.

RECENT FINDINGS

Trials of ranibizumab in diabetic macular edema have demonstrated excellent efficacy without serious safety concerns to date. Fluocinolone acetonide implants can be considered, but have a high risk of cataract and sequelae from intraocular pressure rise. In retinal vein occlusion, both ranibizumab and Ozurdex have been shown to be effective, although their relative efficacy has not been determined in head-to-head clinical trials. In pseudophakic and uveitic macular edema, steroid implants are probably the first choice therapy, although there is evidence that ranibizumab is effective. For choroidal neovascularization secondary to inflammatory disease, ranibizumab is indicated, whereas Retisert has been shown to reduce the risk of uveitis relapse.

SUMMARY

In diabetic macular edema, ranibizumab has shown greater efficacy with fewer side-effects than steroid implants. Both ranibizumab and steroid implants can be considered in retinal vein occlusion, but trials are awaited to determine their relative efficacy.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

Think global--act local: intravitreal drug delivery systems in chronic noninfectious uveitis

The eye is probably the most attractive site of the body for treatment using locally delivered therapeutic agents. An ideal indication for such an approach is noninfectious posterior uveitis. Since intraocular structures of the posterior segment are difficult to reach and are otherwise accessible only by systemic treatment, current interest is focused on the pros and cons of intravitreal drug delivery. Because of its chronic and recurrent nature, the long-term release of anti-inflammatory agents is a major treatment goal. Intravitreal injections, intravitreal implants and biodegradable devices are the most commonly used and approved approaches to deliver various agents to the vitreous. Because of their broad and potent effects, corticosteroids (CS) have been the first-line candidates for intraocular delivery. An increasing spectrum of CS preparations including nondegradable and biodegradable devices is currently available. Since repeated and long-term applications bear the risk of steroid-related complications such as increased intraocular pressure and cataract, alternative agents are currently being tested. Intravitreal injection of methotrexate, anti-VEGF (vascular endothelial growth factor), anti-TNFα (tumor necrosis factor α) and sirolimus have also been applied in patients with conflicting results. Intravitreal treatment has significantly reduced the incidence of adverse effects compared to systemic application, but due to greater ocular side effects there are still some limitations.

Three-year visual and anatomic results of administrating intravitreal bevacizumab in inflammatory ocular neovascularization

OBJECTIVE

To assess the 3-year visual outcome of intravitreal bevacizumab in inflammatory ocular neovascularization.

DESIGN

Experimental study.

METHODS

Retrospective multicenter consecutive case series in 81 patients with inflammatory ocular neovascularization refractory to standard therapy and treated with intravitreal bevacizumab. The outcome measures included improvement of best corrected visual acuity expressed as logarithm of minimum angle of resolution (logMAR) and paired comparison decrease in central foveal thickness by optical coherence tomography.

RESULTS

Mean best corrected visual acuity improved from baseline 0.699 (6/30 or 20/101) (SD 0.434) to 0.426 (6/16 or 20/53) (SD 0.428) (n = 81; p < 0.001), a gain of 2.7 lines (median 3 injections; 81 eyes; 81 patients). Paired comparisons revealed significant central foveal flattening at 3 years of 97.9 μm (n = 51; p < 0.001). In a subgroup analysis, visual improvement was significant for ocular histoplasmosis (p = 0.026); multifocal choroiditis (p = 0.05); serpiginous choroiditis (p = 0.028); ocular toxoplasmosis (p = 0.042); and punctate inner choroidopathy (p = 0.015). In a subgroup analysis, foveal flattening was significant for ocular histoplasmosis (p = 0.004); multifocal choroiditis (p = 0.007); serpiginous choroiditis (p = 0.011); and punctate inner choroidopathy (p = 0.001). Of the group, 5 eyes developed submacular fibrosis, 1 eye retinal pigment epithelial tear, and 1 eye macular ischemia in the context of vasculitis.

CONCLUSION

At 3 years, intravitreal bevacizumab sustained significant visual improvement of 2.7 lines and significant foveal flattening of 98 μm in a wide variety of inflammatory ocular diseases without major complications after a median of 3 injections.

Five-year visual results of intravitreal bevacizumab in refractory inflammatory ocular neovascularization

Purpose

To assess the 5-year visual outcome of intravitreal bevacizumab in inflammatory ocular neovascularization.

Methods

Retrospective, multicenter, consecutive case series of eight patients with inflammatory ocular neovascularization refractory to standard therapy who were treated with intravitreal bevacizumab and followed for 5 years after first injection. The outcome measures included improvement of best-corrected visual acuity expressed as logarithm of minimum angle of resolution.

Results

Mean best-corrected visual acuity significantly improved from 0.58 at baseline (6/23 or 20/76; standard deviation = 0.32) to 0.20 at final assessment (6/10 or 20/32; standard deviation = 0.25) (n = 8; P = 0.02), a gain of 3.8 lines (median: three injections; eight eyes; eight patients). No ocular or systemic complications from intravitreal bevacizumab were noted.

Conclusion

At 5 years, intravitreal bevacizumab sustained significant visual improvement in ocular neovascularization due to a variety of inflammatory ocular diseases without major complications after a median of three injections.