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

Efficacy and Safety of Anti-Vascular Endothelial Growth Factor Drugs for Coats' Disease Treatment: A Systematic Review

Purpose: The efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) treatment for Coats' disease remains controversial. This study was designed to evaluate the efficacy and safety of anti-VEGF treatment for Coats' disease. Methods: PubMed, Embase, The Cochrane Library, Clinical Trials, CNKI, and WanFang databases were systematically searched for clinical efficacy and safety studies on anti-VEGF treatment for Coats' disease through June 2021. Study selection, data extraction, and quality assessment were independently performed by 2 reviewers. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal tools and GRADE-CERQual. Results: A total of 1,501 articles were retrieved and reviewed, of which 24 case series involving 378 patients (range: 3-67 patients each with 3-71 eyes) were included in the analysis. No randomized controlled trials, case-controlled studies, or cohort studies were available for analysis. Most patients were male (60.0%-92.9%), aged 1.35-42.3 years, with a median follow-up time ranging from 3 to 63 months. Among the 24 case series, 22 reported changes in the visual acuity (VA) after anti-VEGF treatment and 21 reported safety outcomes. The results showed that VA improved in 73 patients (37.63%), was stable in 89 (45.87%), and worsening VA was observed in 12 cases (6.19%). The most common adverse event was fibrotic changes (n = 35). Systemic complications were not observed. Conclusions: The results of this study indicate that anti-VEGF drugs provide an effective and relatively safe treatment strategy for Coats' disease. However, conducting well-designed, prospective, randomized clinical trials are necessary to confirm our findings.

Adult-onset Coats' disease

Coats disease is an idiopathic retinal vasculopathy characterized by telangiectasia and aneurysm of retinal vessels along with intra and subretinal exudation and fluid. While Coats disease is classically described in young male population, there is an adult variant of Coats disease presenting in adulthood. Adult onset Coats disease have a similar presentation but a slower progression, localised lipid deposition, both peripheral and juxta-macular involvement. In this review article, we have attempted to describe in detail the characteristic clinical features, pathogenesis, investigation modalities and treatment in adult-onset Coats disease.

Clinical manifestation, course and treatment results of Coats disease in children

Purpose: to analyze the clinical manifestations, course, and results of treatment of Coats disease in children. Materials and methods. We performed a retrospective analysis of medical records of 59 patients with Coats retinitis (83 % were boys) who had been comprehensively examined and treated between 2018 and 2021. After the diagnosis was verified, the children were hospitalized for treatment. Retinal laser coagulation was performed on 61 eyes, angiogenesis inhibitors were administered on 1 eye, and 5 eyes received microsurgical interventions. Results. At the time of disease detection, the children’s age varied from 1 to 16 years. In 97 % of cases, the process was unilateral. An improvement of the anatomical condition and the eye-preserving effect were achieved in 87 %. Visual acuity could only be increased in 19 eyes (31.1 %), all with the initial or the advanced stages of Coats retinitis. Proceeding from our experience, the analysis of polymorphism of clinical manifestations, functional prognosis and differentiated approach to treatment depending on the prevailing clinical symptoms, we suggest a new variant of clinical classification of Coats retinitis. Conclusion. In order to ensure a timely diagnosis of the disease, a very thorough examination of patients in the first decade of life is required. Only an early diagnosis and timely treatment can help achieve not only an eye-preserving effect but also functional results.

Treatment of Advanced Coats' Disease With Combination Therapy of Laser Photocoagulation, Intravitreal Ranibizumab, and Sub-Tenon Methylprednisolone Acetate

PURPOSE

To investigate the efficacy of combination therapy with laser photocoagulation, intravitreal ranibizumab, and sub-Tenon methylprednisolone acetate in patients presenting with advanced Coats' disease.

METHODS

This was a retrospective analysis of 16 patients who underwent laser photocoagulation combined with intravitreal ranibizumab and sub-Tenon methylprednisolone acetate between 2008 and 2017. The primary outcome was anatomic success and the secondary outcomes were globe preservation and final visual acuity.

RESULTS

The average age at surgery was 5.12 ± 2.7 years (range: 3 to 10 years). The mean follow-up time was 45.43 ± 29.01 months (range: 12 to 108 months). Of the 16 patients (16 eyes) reviewed, 6 patients had stage 3A and 10 patients had stage 3B Coats' disease. The mean number of applications was 10 (range: 4 to 18). Globe preservation was achieved in all patients. Final visual acuity outcomes were satisfactory: 20/20 to 20/50 in 2 patients, 20/60 to 20/100 in 1 patient, and 20/200 or worse in 13 patients.

CONCLUSIONS

Intravitreal ranibizumab used in combination with laser photocoagulation and sub-Tenon methylprednisolone acetate could be an effective treatment option for patients with advanced Coats' disease. The combined therapy achieved anatomical success, globe preservation, and reasonable visual acuity outcomes. [J Pediatr Ophthalmol Strabismus. 2022;59(3):187-191.].

Coats' disease: trends and long-term treatment outcomes in a tertiary referral centre

Background:

The long-term treatment outcomes in Coat’s disease – particularly in the era of newer pharmacotherapies such as anti-vascular endothelial growth factor (VEGF) agents and depot steroids – are poorly understood.

Aim:

To describe the clinical features and treatment outcomes of 148 eyes with Coats’ disease assessed in a referral centre over 30 years.

Materials and methods:

We conducted a retrospective chart review of patients diagnosed with Coats’ disease between 1 June 1987 and 31 July 2017. The demographic, clinical and treatment data were collected and long-term functional and anatomical outcomes were analysed based on the treatment either with conventional therapy (cryo/laser) or along with adjuvants like intravitreal steroids or anti-VEGFs.

Results:

The mean age at presentation was 15.22 years (median 11). Familial exudative vitreoretinopathy was the most common referral diagnosis, 76/148 (51.5%), followed by Coats’ disease, 37/148 (25%), and retinoblastoma, 35/148 (23.6%). Stage 3B was most common at presentation (31.8%), followed by 2B (22.3%) and 2A (16.9%). A total of 107 patients were treated either with conventional therapy or in combination with adjuvants. The mean follow-up period was 24.95 months. The visual acuity improved from baseline logMAR 2.17 (Snellen-20/2958) to logMAR 1.88 (Snellen-20/1517) at final follow-up (p = 0.004). The improvement in visual acuity was better when the presenting BCVA was <1 logMAR (Snellen 20/200), p = 0.004. No statistically significant change in BCVA was noted between conventional and adjuvant groups, p = 0.5. However, the final anatomical outcome was good in 78/99 (78.8%) in the conventional group and 45/49 (91.8%) in the adjuvant group, respectively (p = 0.046).

Conclusion:

In this series of patients with Coats’ disease over three decades, the use of intravitreal steroids or anti-VEGFs as adjuvants resulted in better anatomical outcomes. A better baseline visual acuity, lower stage of the disease, and older age at presentation were found to be the factors leading to favourable visual outcomes.

Summary

In the current series of 148 eyes with Coats’ disease, adjuvant treatment with intravitreal steroids or anti-VEGFs resulted in better outcomes as compared with conventional cryotherapy or laser photocoagulation alone. Patients with Coats’ disease who had presented with better visual acuity at baseline, lower stage of the disease and older age had better final visual outcomes.

Vitrectomy and external drainage of subretinal fluid containing high concentration of vascular endothelial growth factor for advanced coats disease

This study investigated the surgical outcomes of Coats disease and the role of external drainage (XD) of subretinal fluid (SRF). The study is a multicenter retrospective interventional case series of 26 consecutive eyes of 26 patients who underwent surgeries for advanced Coats disease with retinal detachment. Main outcomes measured were: 1) comparison of complete SRF resolution with or without XD, and 2) variables that were associated with functional postoperative best-corrected visual acuity (BCVA) defined as BCVA of 0.1 or better, 3) intraocular vascular endothelial growth factor (VEGF) levels. Complete SRF resolution was achieved in all 14 eyes in which XD had been performed and in 75% of 12 eyes in which XD had not been performed (P = .03). Multivariable logistic regression analysis revealed that initial BCVA was the only variable associated with functional postoperative BCVA (odds ratio 3.24, 95% CI 0.93–11.33; P = .04). Markedly elevated VEGF levels were noted in the SRF compared with those in the vitreous humor (49,760 ± 52,990 vs. 707 ± 611 pg/mL, P = .03). XD seems to provide better anatomical success than without XD in the treatment of advanced Coats disease as XD could effectively eliminate substantial amount of VEGF in the SRF.

Clinical features and prognostic factors in 71 eyes over 20 years from patients with Coats' disease in Korea

This retrospective study assesses the clinical features, treatment strategies, and long-term outcomes of patients with Coats’ disease in Korea. Multimodal imaging and medical records of consecutive patients treated between July 2000 and April 2020 at two tertiary centers were evaluated based on onset age (adult vs. childhood [< 18 years]). Factors associated with final visual acuity (VA) and risk of treatment failure were assessed. A total of 71 eyes of 67 patients were included, with subgrouping by onset age showing 45% childhood and 55% adult cases. Overall, Stage 2 disease was most common at presentation (76%), though childhood cases had more Stage 3b (22% vs. 3%, P = 0.02) and greater clock hours of retinal telangiectasia (7 vs. 5, P = 0.005). First-line treatment included laser (25%), combined laser/anti-VEGF (23%), cryotherapy (20%), surgery (16%), and anti-VEGF only (9%). Cryotherapy was associated with a higher risk for secondary interventions (OR 11.8, P < 0.001), required in 56% overall. Despite a 3-line VA decrease in 34% overall, adult cases had superior final VA (P = 0.037). Multivariable regression showed that the number of anti-VEGF injections performed during the initial treatment period was associated with a 9.4 letter improvement in vision (P = 0.041). We observed a higher proportion of adult-onset Coats’ disease than previously reported in other non-Asian populations. An aggressive treatment with the addition of anti-VEGF may yield the most favorable long-term visual outcomes.

Experience with Intravitreal Ranibizumab as an Adjunct to Ablation Therapy in Eyes with Exudative Coats' Disease

Background

Coats’ disease is a rare entity with retinal vascular telangiectasia that can progress to exudative retinal detachment, neovascular glaucoma, and a blind painful eye requiring enucleation. Despite recent therapeutic advances decreasing the need for enucleation, no consensus exists about the optimum management of exudative Coats’ disease. The use of intravitreal anti-vascular endothelial growth factor agents as an adjunct to ablation therapy has been shown to achieve favorable outcomes, but some reports suggest an increased incidence of vitreoretinal (VR) fibrosis and tractional retinal detachment (TRD).

Methods

We retrospectively reviewed records of patients presenting with exudative Coats’ disease (stages 2 and 3) from April 2016 till November 2020. Extracted data included clinical and radiological assessment, stage (Shields’ classification), interventions, and follow-up.

Results

Sixteen eyes were included in the final analysis, of which 4 (25%) were stage 2 and 12 (75%) were stage 3. All eyes underwent intravitreal ranibizumab injection combined with ablation therapy, 14 (87.5%) underwent cryotherapy, 4 (25%) underwent laser ablation, 3 (18.75%) underwent external subretinal fluid drainage, and 3 (18.75%) underwent buckle or vitrectomy surgery. After a median follow-up of 16 months, 11 eyes (68.75%) had complete resolution, 4 (25%) had incomplete resolution, and only one (6.25%) progressed but did not require enucleation. Three eyes (18.75%) developed VR fibrosis, but none progressed to TRD.

Conclusion

Combining intravitreal ranibizumab injection with ablation therapy is effective in managing exudative Coats’ disease. External drainage should be preserved for when ablation therapy is not feasible. Future prospective trials with pre-defined outcomes are required.

Optical Coherence Tomography Angiography Findings After Intravitreal Ranibizumab in Patients With Coats Disease

The aim of this retrospective study was to describe the vascular features in eyes with Coats disease, using optical coherence tomography angiography (OCTA), at baseline and after 3 monthly intravitreal injections of ranibizumab. Fifteen eyes of 15 consecutive patients affected by Coats' disease were recruited in this study. All patients underwent the best-corrected visual acuity (BCVA) evaluation, fundus examination, fluorescein angiography (FA), indocyanine green angiography (ICGA), multicolor imaging, structural Spectral Domain (SD)-OCT and OCTA at baseline and 1 month after the third monthly ranibizumab injection (loading phase). Fifteen patients completed the study, of whom nine were males and six females. Mean age was 20.4 ± 2 years. BCVA was 0.46 ± 0.11 logMar and 0.47 ± 0.12 logMar at baseline and after treatment, respectively (p = 0.164). SD-OCT revealed no significant decrease in central macular thickness (486.33 μm ± 93.37 at baseline vs. 483.4 μm ± 80.97 after treatment; p = 0.915). The subretinal exudates persisted in macular region after intravitreal injections. OCTA showed a general vascular rarefaction in superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillary (CC) that did not change after loading phase. This study showed no functional and vascular improvement following 3 monthly ranibizumab injections. OCTA, non-invasive technique, could be useful during follow up of these patients and provide a better understand of pathogenesis of this disorder.

Three-year follow-up of Coats disease treated with conbercept and 532-nm laser photocoagulation

BACKGROUND

Coats disease is an idiopathic exudative outer retinopathy caused by abnormal retinal vascular development.

AIM

To evaluate the long-term outcomes of intravitreal conbercept injection with laser photocoagulation as a treatment for Coats disease in adults.

METHODS

This retrospective case series study included patients diagnosed with Coats disease and treated with intravitreal conbercept injection and 532-nm laser photocoagulation at the Ophthalmology Department of Shenzhen People’s Hospital between January 2016 and January 2017. Best-corrected visual acuity (BCVA) measurements, noncontact tonometry, ophthalmoscopy, fundus photography, fundus fluorescein angiography and optical coherence tomography were performed before treatment and at 1 wk, 1 mo, 3 mo, 6 mo, 9 mo, 12 mo, 24 mo and 36 mo after therapy. Best-corrected visual acuity was measured using the early treatment of diabetic retinopathy study chart.

RESULTS

The study included eight eyes of 8 patients (7 men) aged 36.10 ± 6.65 years. The average BCVA of the affected eye before treatment was 51.17 ± 15.15 letters (range, 28–70 letters), and the average central macular thickness was 303.30 ± 107.87 µm (range, 221–673 µm). Four eyes were injected once, three were injected twice, and one was injected three times. Average follow-up duration was 37.33 ± 2.26 mo. Average BCVA of the affected eye was 51.17 ± 15.15 letters before treatment and was increased by 13.50 ± 3.20, 16.25 ± 7.73, 18.25 ± 8.96, 18.03 ± 5.27, 18.63 ± 3.35, 19.75 ± 6.96, 18.05 ± 5.36 and 17.88 ± 3.45 letters at 1 wk, 1 mo, 3 mo, 6 mo, 9 mo, 12 mo, 24 mo and 36 mo after treatment, respectively (P < 0.01). The patients showed varying degrees of subretinal fluid resorption after treatment. None of the patients had serious complications such as increased intraocular pressure, development/progression of cataracts, endophthalmitis or retinal detachment.

CONCLUSION

Intravitreal injection of conbercept combined with 532-nm laser photocoagulation may be a feasible treatment for Coats disease in adult patients.

Treatment of Intraretinal Cystic Spaces Associated With Gyrate Atrophy of the Choroid and Retina With Intravitreal Bevacizumab

PURPOSE

To evaluate the use of intravitreal bevacizumab injections for the treatment of intraretinal cystic spaces associated with gyrate atrophy of the choroid and retina.

METHODS

Retrospective chart review of 5 eyes of 3 patients with intraretinal cystic spaces associated with gyrate atrophy and treated with intravitreal bevacizumab injections was performed. Information obtained included history, examination findings, optical coherence tomography (OCT), OCT angiography, fluorescein angiography, and microperimetric findings before and after the injections.

RESULTS

The mean age of patients was 11 ± 4.6 years. All patients received three monthly bevacizumab injections. The mean corrected distance visual acuity was 0.27 ± 0.10 at baseline and improved to 0.36 ± 0.12 after the injections (P = .015). The mean central macular thickness was 569 ± 127 µm at baseline and improved to 422 ± 123 µm after the injections (P = .067). Microperimetry and OCT angiography performed in 1 patient before and after the three injections showed improved macular sensitivity and vascular density measurements following the injections.

CONCLUSIONS

Intravitreal bevacizumab is safe and effective in the treatment of intraretinal cystic spaces associated with gyrate atrophy. [J Pediatr Ophthalmol Strabismus. 2020;57(6):400-406.].

Advanced Coats' disease treated with intravitreal brolucizumab combined with laser photocoagulation

Purpose

To report the first use the intravitreal anti-VEGF brolucizumab for the treatment of macular exudates and edema in a patient with Coats’ disease.

Observations

A 9-year-old boy was referred with a decrease in vision in the right eye. Visual acuity was 20/400 OD on presentation, and examination was remarkable for peripheral telangiectasias, exudates, microaneurysms, macular edema, and an inferior exudative retinal detachment. A diagnosis of Stage 3A2 Coats’ disease was made, and the patient was treated with intravitreal bevacizumab as well as peripheral diode laser. However, on follow up, there was persistence of subretinal fluid accompanied by a decrease in visual acuity. The patient was then treated with intravitreal brolucizumab. Post injection visual and anatomical improvements were significant with complete resolution of macular edema within two weeks. Throughout the 5 months of follow up, there has been no re-accumulation of fluid and no further required therapy.

Conclusions and Importance

Intravitreal brolucizumab was effective for the treatment of retinal edema and exudates in Coats’ disease.

•

Intravitreal brolucizumab may be used in select pediatric patients with positive outcomes.

•

Patients with Coats' disease may benefit from the efficacy of intravitreal brolucizumab.

•

Intravitreal brolucizumab combined with laser photocoagulation can be effective for advanced Coats disease.

Two-year results of intravitreal injections of aflibercept in Coats' Disease; a case report

PURPOSE

To report long term results of treatment with intravitreal injections of aflibercept in a newly diagnosed case of Coats' disease.

CASE REPORT

An 18-year-old man presented to the Retina Clinic of our Hospital complaining of blurred vision in the right eye (OD) for the past 3 months. His past medical and ocular history were unremarkable. Best corrected visual acuity (BCVA) was 20/200 OD and 20/20 in the left eye. Fundoscopy in OD revealed extensive macular edema with a circinate ring of hard exudates in the posterior pole temporally to the macula. Optical coherence tomography (OCT) demonstrated macular edema with subretinal fluid. Peripheral telangiectasias and light bulb aneurysms in the inferior temporal arcade, as well as in the nasal far periphery were found in OD in fluorescein angiography (FA), confirming the diagnosis of stage 2B Coats' disease. The left eye was normal. The original therapeutic strategy proposed was anti-VEGF injections in OD followed by laser photocoagulation. However, the patient did not consent to laser treatment and was treated with aflibercept monotherapy with 8 monthly intravitreal injections of aflibercept followed by 6 injections every 2 months for a total of 14 injections over a period of 2 years. The BCVA in OD improved to 20/25 while OCT imaging revealed significant decrease in retinal thickness with resolution of macular edema and FA demonstrated prominent regression of aneurysms and leakage.

CONCLUSION

To our knowledge this is the first case treated with aflibercept monotherapy, suggesting the significant role of vascular endothelial growth factor (VEGF) in vascular permeability in Coats' and supporting the rationale that anti-VEGFs are a valuable therapeutic option for Coats' disease.

Aqueous humour cytokines profiles in eyes with Coats disease and the association with the severity of the disease

Background

To investigate aqueous humour (AH) cytokine profiles in eyes with Coats disease and analyze the association between cytokine concentrations and the severity of the disease.

Methods

The study included 36 patients (36 eyes) with Coats disease and 15 control patients (15 eyes) with congenital cataract. AH samples were obtained preoperatively and the concentrations of 22 different cytokines were measured through Cytometric Bead Array technology. Clinical characteristics of Coats disease, including the extent of retinal exudation and exudative retinal detachment (ERD), were recorded for analysis.

Results

The concentrations of 8 cytokines (VEGF, IL-6, IL-8, MCP-1, MIP-1α, IP-10, VCAM-1 and ICAM-1) were significantly higher in the Coats disease group than in the control group (all P < 0.002). Except for VCAM-1 and ICAM-1, the concentration of the other cytokines listed above showed a significant increase from stage 2 to stage 3 (all P < 0.05). Meanwhile, the concentrations of VEGF, IL-8, MCP-1 and MIP-1α showed a significant and positive association with the extent of retinal exudation and ERD (all r > 0.4, P < 0.05). Among these, IL-8 showed a strong association with the extent of retinal exudation and ERD (all r > 0.7, P < 0.001). The concentrations of IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-10, IL-12, Fractalkine, RANTES, G-CSF and GM-CSF were very low in both groups.

Conclusions

Various cytokines in the AH, including elevated VEGF, IL-6, IL-8, MCP-1, MIP-1α, IP-10, VCAM-1 and ICAM-1, may be involved in the pathogenesis and progression of Coats disease. Increasing severity of Coats disease is significantly associated with the AH concentrations of VEGF, IL-8, MCP-1 and MIP-1α. Further clinical treatment aimed to reduce vascular leakage and antagonize neovascularization and inflammation may be useful in preventing the progression of Coats disease.

Late re-activation of Coats disease

Purpose

Observation

Conclusion

Vitrectomy for a secondary epiretinal membrane following treatment of adult-onset Coats' disease

Purpose

To report a case of adult-onset Coats’ disease that had worsening of macular edema and progressive macular traction following cryotherapy and repeated intravitreal bevacizumab injections due to formation of a secondary epiretinal membrane which only improved following pars plana vitrectomy and membrane peeling.

Observations

A 35-year-old male presented with diminution of vision in his left eye and was found to have localized telangiectatic retinal vessels and aneurysmal dilatations with massive exudation and cystoid macular edema. He was diagnosed as adult-onset Coats’ disease and treated with cryotherapy and a concomitant intravitreal injection of 2.5 mg bevacizumab followed by 3 monthly intravitreal injections of 2.5 mg bevacizumab and a single injection of 4 mg triamcinolone acetonide. Partial obliteration of the telangiectatic vessels and aneurysmal dilatations with improvement in surrounding lipid and fluid exudate was achieved, however, this was associated with progressive worsening of macular edema and macular traction due to formation of an epiretinal membrane which only improved following vitrectomy and membrane peeling. Effect of therapy at each stage was evaluated using visual acuity testing, fundus examination, fundus fluorescein angiography, and optical coherence tomography.

Conclusion and Importance

A secondary epiretinal membrane can develop following treatment of adult-onset Coats’ disease and cause traction especially when combining cryotherapy with bevacizumab injections. Vitrectomy in such cases with membrane peeling may result in improvement of anatomical and functional outcomes.

Associations of cytokine concentrations in aqueous humour with retinal vascular abnormalities and exudation in Coats' disease

PURPOSE

To investigate the associations of cytokine concentrations in aqueous humour with the severity of retinal vascular abnormalities, exudation and fibrosis in patients with Coats' disease.

METHODS

Aqueous humour samples were collected in 23 paediatric patients (23 eyes) with Coats' disease and six age-matched control patients (six eyes) with congenital cataract in this cross-sectional, case-control study. Through Cytometric Bead Array technology, six angiogenic, inflammatory and fibrotic cytokines were measured for their concentrations in aqueous humour. Ophthalmologic characteristics including retinal vessel abnormalities, exudation and fibrosis of Coats' disease were also clinically evaluated for analysis.

RESULTS

The aqueous levels of vascular endothelial growth factor (VEGF) (p = 0.006) and monocyte chemoattractant protein-1 (MCP-1) (p < 0.001) were significantly higher in the Coats' disease group than in the control group. The concentrations of angiogenin were peaked in eyes with first-grade vessels tortuosity (p < 0.001), and also positively correlated with the severity of retinal capillary abnormalities (r = 0.910, p < 0.001). The concentrations of MCP-1 (r = 0.966, p < 0.001) and VEGF (r = 0. 765, p = 0.002) were significantly correlated with the extent of retinal exudation. The aqueous humour transforming growth factor-β (TGFβ) concentrations were higher in eyes with retinal fibrosis than in non-fibrotic eyes with Coats' disease (p = 0.004).

CONCLUSION

In Coats' disease, angiogenin may act as a potential biomarker for retinal vascular abnormalities. The concentrations of VEGF and MCP-1 may positively correlate with the severity of retinal exudation.

Treatment of Coats' disease: an analysis of pooled results

AIM

To elucidate the association of treatment modality to vitreoretinal fibrosis and traction retinal detachment (TRD) in Coats' disease.

METHODS

A PubMed search for Coats' disease with included studies describing eyes with clinical features and treatment course of Coats' disease. Binary logistic regression with fibrosis at presentation and treatment type as independent variables was performed to determine predictors of TRD historically (since 1921) and in the anti-vascular endothelial growth factor (VEGF) era (since 2007). Odds ratios (OR) with 95% confidence intervals (CI) reported.

RESULTS

Of 175 articles described 1183 eyes. Vitreoretinal fibrosis increased from presentation (5.4%) to follow-up (15.5%) and TRD increased from 0.44% to 3.9% at follow up. Laser was protective against vitreoretinal fibrosis (OR 0.6, 95%CI 0.4-0.9) but TRD was borderline (OR 0.6, 95%CI 0.3-1.1). Cryotherapy showed a higher association with TRD (OR 1.9, 95%CI 1.0-3.7) than with vitreoretinal fibrosis (OR 0.8, 95%CI 0.5-1.2). Similarly, intravitreal anti-VEGF alone was not associated with fibrosis (OR 1.1, 95%CI 0.6-1.8) nor TRD (OR 1.1, 95%CI 0.5-2.6) but the combination of laser and anti-VEGF therapy was protective [Fibrosis: 0.1 (0.03, 0.35); TRD: 0.05 (0.01, 0.23)] compared to anti-VEGF plus cryotherapy (P<0.001). Disease stage ≤2B or ≥3A was not associated with TRD.

CONCLUSION

Vitreoretinal fibrosis and TRD increase after treatment in Coats' disease. The combination of anti-VEGF agents and cryotherapy may lead to higher risk for TRD. Presence of pre-treatment fibrosis is the highest risk factor for post-treatment worsening of vitreoretinal fibrosis and TRD.

Recent advances in the diagnosis and treatment of Coats' disease

PURPOSE

To review and summarize the recent progress in the diagnosis and treatment of Coats' disease.

METHODS

Literature was collected from Web of Science, Medline and Pubmed, through searching of these keywords: "Coats' disease", "diagnosis" and "treatment".

RESULTS

Coats' disease is characterized by idiopathic leaky retinal vascular telangiectasia and microvascular abnormalities often accompanied by intraretinal or subretinal exudation and retinal detachment. Neovascular glaucoma and phthisis bulbi often occur in advanced cases. Coats' disease has significant diversity in terms of its clinical presentation and morphology. Anti-VEGF therapy combined with laser photocoagulation for early Coats' disease and anti-VEGF therapy combined with minimally invasive vitrectomy for advanced Coats' disease can achieve good efficacy.

CONCLUSION

Early diagnosis and timely treatment based on clinical stage are critical to retaining the patient's visual function. Patients should be aware that close long-term follow-up is necessary.

The use of bevacizumab in pediatric retinal and choroidal disease: A review

The use of intravitreal bevacizumab in pediatric retinal and uveitic disease has become more widespread over the past decade. This article serves to outline the rationale underlying the use of intravitreal bevacizumab, and which disease entities it should be appropriately thought of as a primary or solo therapy, as opposed to an adjuvant one. Also presented is the relevant literature regarding each of these retinopathies.

Surgical Management of Coats Disease

Coats disease is a sporadic, chronic retinal vascular disorder with telangiectatic and aneurysmal retinal vessels, with retinal exudation and retinal detachment in severe cases. Various treatment modalities have been used, including laser therapy, cryotherapy, anti‒vascular endothelial growth factor (VEGF) therapy, and surgery. Anti-VEGF therapy seems to be effective in reducing exudative changes and is often combined with other treatment modalities. For severe cases with exudative retinal detachment, external drainage of subretinal fluid with or without vitrectomy is commonly performed, combined with laser therapy and/or cryotherapy. Relatively good anatomical outcomes have been reported; however, postoperative functional results, particularly in young patients and/or severe cases, seem to be limited.

Anti-VEGF for ROP and Pediatric Retinal Diseases

Vascular endothelial growth factor (VEGF) is an important mediator of the pathological neovascularization and vascular permeability of the eye. The increasing use of intravitreal therapies targeting VEGF has revolutionized the treatment of pediatric vitreoretinal diseases. In retinopathy of prematurity (ROP), the role of VEGF in pathogenesis has been well recognized and the use of anti-VEGF treatment in phase 2 ROP has demonstrated promising results, particularly in severe cases of posterior disease. This has made VEGF an established target in the treatment of pediatric retinal diseases known to have abnormal vascular activity. However, questions remain about late systemic and neurodevelopmental effects after anti-VEGF therapy for children because intravitreal injection of anti-VEGF may result in systemic circulation of anti-VEGF agent and a corresponding suppression of systemic VEGF. We do not currently know whether the short-term suppression of systemic VEGF affects long-term neurodevelopmental outcomes because VEGF is a vital supporting factor during neurodevelopment. This review article focuses on the evidence for the use of anti-VEGF treatment in certain pediatric ocular diseases, including ROP, Coats disease, and retinoblastoma. More extensive and prospective studies are warranted to further elucidate the role of anti-VEGF therapy in these diseases and illustrate how we can optimally use these agents in pediatric patients.

The efficacy of conbercept or ranibizumab intravitreal injection combined with laser therapy for Coats' disease

PURPOSE

The current treatment approaches for Coats' disease by intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents (ranibizumab or conbercept) combined with laser therapy were evaluated for the efficacy during the treatment.

METHODS

The medical records of 28 patients diagnosed with Coats' disease followed by the treatment with intravitreal injection of anti-VEGF agents and laser therapies at Tianjin Medical University Eye Hospital and Hebei Eye Hospital during July 2012 and October 2017 were reviewed retrospectively. Clinical outcomes were recorded with a minimum follow-up of 6 months. The patients were divided into ranibizumab- and conbercept-treated groups, as well as based on age: pediatric and adult groups.

RESULT

Twenty-eight patients were involved in this study. The average number of the injections was 2.82 ± 0.98. Laser photocoagulation was conducted in all patients, and the average number of lasers was 2.63 ± 0.74. The average follow-up period was 24.29 ± 9.85 months. Fourteen patients (50%) were stable, 12 (43%) patients were improved, and 2 patients (7%) showed recurred subretinal fluid and exudation. The final best corrected visual acuity (BCVA) increased markedly after intravitreal injection of ranibizumab or conbercept combined with laser therapy (p = 0.029, p = 0.009, respectively). The number of injections and lasers between conbercept and ranibizumab groups did not vary significantly (p = 0.160, p = 0.573, respectively). Nine patients (60%) in the ranibizumab-treated group and five (38%) in the conbercept-treated group reached a stable phase, and five (33%) and seven (54%) patients got the vision improved after treated with ranibizumab or conbercept, respectively. In pediatric and adult groups, the initial and final BCVA differed significantly (p = 0.03, p = 0.008, respectively). However, the injection number was remarkably different (p = 0.02), while the laser numbers did not have any markedly difference (p = 0.38).

CONCLUSION

Intravitreal injection of ranibizumab or conbercept combined with laser therapy is an effective therapeutic option in Coats' disease. Moreover, the intravitreal injection of ranibizumab or conbercept had no significant adverse effects and appeared to offer visual improvement in Coats' disease.

EFFICACY OF INTRAVITREAL AFLIBERCEPT IN MACULAR TELANGIECTASIA TYPE 1 IS LINKED TO THE OCULAR ANGIOGENIC PROFILE

PURPOSE

To evaluate intravitreal aflibercept in macular telangiectasia Type 1 (MacTel 1) patients and measure their ocular angiogenic profile.

METHODS

Eight subjects with MacTel 1 refractory to bevacizumab, ranibizumab, or laser therapy and switched to aflibercept were included. Best-corrected visual acuity, central macular thickness, and cystic areas quantified on optical coherence tomography B-scans were assessed during 12 months. Perifoveal capillary densities were measured on optical coherence tomography angiography. Aqueous humor was sampled from six patients and eight control subjects undergoing cataract extraction. Growth factors were quantified using a multiarray immunoassay.

RESULTS

Over 12 months, patients received 6.6 ± 1.4 (range, 5-8) intravitreal aflibercept injections. Twelve months after switching to aflibercept, best-corrected visual acuity increased by ≥5 letters in 5 of 8 patients, compared with preaflibercept levels. Mean best-corrected visual acuity improved from 79.6 (∼20/50) to 88.0 (∼20/35) Early Treatment Diabetic Retinopathy Study letters (P = 0.042), and central macular thickness decreased from 434 ± 98 μm to 293 ± 59 μm (P = 0.014). Compared with control subjects, the profile of angiogenic factors in MacTel 1 eyes revealed no difference in vascular endothelial growth factor-A levels but significantly higher levels of placental growth factor (P = 0.029), soluble vascular endothelial growth factor receptor-1 (sFlt-1; P = 0.013), vascular endothelial growth factor-D (P = 0.050), and Tie-2 (P = 0.019). Placental growth factor levels inversely correlated with both superficial and deep capillary plexus densities on optical coherence tomography angiography (P = 0.03).

CONCLUSION

The clinical response to aflibercept coupled to the angiogenic profile of MacTel 1 eyes support the implication of the placental growth factor/Flt-1 pathway in MacTel 1.

Long-Term Outcomes of Total Exudative Retinal Detachments in Stage 3B Coats Disease

PURPOSE

To evaluate the long-term outcomes of treatment of total exudative retinal detachments (ERDs) secondary to Coats disease (stage 3B) and the role of vitrectomy.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

A total of 16 eyes in 16 patients undergoing treatment for total ERDs secondary to Coats disease with at least 5 years of follow-up.

METHODS

We reviewed the records of patients with stage 3B Coats disease. The interventions, including the timing of vitrectomy if used, and clinical course were recorded.

MAIN OUTCOME MEASURES

The primary outcome measures were visual acuity at the most recent appointment, whether there was progression to neovascular glaucoma (NVG) or phthisis bulbi, and need for enucleation.

RESULTS

All patients received ablative treatment (photocoagulation or cryotherapy), with 8 having scleral buckling (SB) and 6 having external drainage of subretinal fluid (XD). Of the 12 patients who had pars plana vitrectomy (PPV), 8 had early PPV (EV) in the first year after presenting, and 4 of 8 in the expectant management group had late PPV (late vitrectomy) at a mean of 4.3 years post-presentation for treatment of significant traction retinal detachment (TRD). The other 4 patients of 8 in the expectant management group did not require vitrectomy. Mean follow-up overall was 9 1/2 years. At the date of last follow-up, 50% had no light perception or light perception vision, which was consistent across the subgroups that underwent EV (4/8), late vitrectomy (2/4), or no PPV (2/4). A total of 4 of 16 patients had progression to NVG or phthisis, 1 of whom required enucleation.

CONCLUSIONS

In this retrospective series of patients with Stage 3B Coats disease, ablative therapy with a combination of PPV, XD, or SB was effective in preventing progression to NVG or phthisis in the majority of patients, thus preserving the globe. Half of the patients (4/8) in this series who did not undergo PPV in the early vitrectomy group developed late-onset TRD, suggesting a possible role for early prophylactic vitrectomy with possible SB and XD; however, this is balanced by the other half (4/8) in the expectant management group who did not require any vitrectomy.

INTRAVITREAL RANIBIZUMAB AS AN ADJUNCTIVE TREATMENT FOR COATS DISEASE (6-YEAR FOLLOW-UP)

PURPOSE

To evaluate the effectiveness of intravitreal ranibizumab in combination with laser photocoagulation in the management of Coats disease.

METHOD

Six intravitreal injections of 0.5 mg (0.05 mL) ranibizumab were performed, each 4 weeks apart. Correspondence to therapy was evaluated using visual acuity measurements and optical coherence tomography images. Six months after the initiation of treatment, laser photocoagulation was applied on the telangiectasias and on the surrounding ischemic areas, followed by a single intravitreal ranibizumab injection. Three months later, laser photocoagulation was repeated in purpose to prevent recurrence.

RESULTS

In the sixth month, no improvement in visual acuity was recorded, as thick circinate hard exudates still remained in the submacular space. Nevertheless, retinal detachment had completely subsided, and fluorescein angiography showed a significant decrease of leakage from the telangiectatic vessels. At the 12-month follow-up visit, an impressive improvement was recorded, with total absorption of the submacular exudate and visual acuity being 20/30. At the 20-month follow-up visit, his visual acuity was 20/20 and the retina was flat with no signs of macular edema or exudates. At the 6-year follow-up visit, the patient was absolutely stable.

DISCUSSION

Elevated vascular endothelial growth factor levels have been demonstrated in Coats disease. Anti-vascular endothelial growth factor agents assist to the decrease of vascular permeability of the capillary endothelial cells, thus increasing the efficiency of laser application.

Coats' Disease-Related Macular Edema Treated with Combined Aflibercept and Laser Photocoagulation

Purpose

To describe the clinical response of refractory macular edema associated with Coats' disease following treatment with aflibercept and laser photocoagulation.

Methods

Case report.

Results

A 17-year-old female presented with decreased vision of the left eye. Ophthalmic exam demonstrated intraretinal hemorrhages and exudation with associated edema centrally. Angiographic evaluation revealed central leaking microaneurysms and peripheral capillary dropout. These findings and a systemic work-up that yielded an incidental Factor V Leiden mutation lead to a diagnosis of Coats' disease. Initial treatment consisted of laser photocoagulation and intravitreal bevacizumab but with poor response. Switching to intravitreal aflibercept resulted in resolution of the refractory macular edema and improvement of visual acuity to 20/25 in the left eye.

Conclusion

We describe a case of refractory macular edema which responded more favorably to intravitreal aflibercept compared with bevacizumab when combined with laser photocoagulation in a patient with Coats' disease.

Differences in aqueous concentrations of cytokines in paediatric and adult patients with Coats' disease

PURPOSE

To investigate the differential aqueous concentrations of vascular endothelia growth factor (VEGF) and inflammatory cytokines in paediatric and adult patients with Coats' disease.

METHODS

A total of 20 eyes of 20 patients with Coats' disease, 12 eyes of 12 paediatric patients, and eight eyes of eight adult patients, six patients (six eyes) with congenital cataract as the paediatric control group and 10 patients (10 eyes) with senile cataract as the adult control group were examined. Aqueous humour samples were assessed for interleukin-6, -8, -1β (IL-6, IL-8, IL-1β, respectively), basic fibroblast growth factor, monocyte chemo-attractant protein 1, tumour necrosis factor alpha and VEGF by multiplex bead assay.

RESULTS

Significantly, higher concentrations of VEGF, IL-6 and IL-1β were found in the paediatric patients with Coats' disease (p = 0.001, p = 0.004 and p = 0.006). Concentration of VEGF in the paediatric patients with Stage 3B of Coats' disease was significantly higher than that of Stage 3A (p = 0.010). In the adult patients with Coats' disease, the aqueous levels of IL-6 and IL-1β were significantly higher than that of the controls (p = 0.012, and p = 0.005). The concentration of IL-6 was significantly linearly associated with the extent of exudative retinal detachment (p = 0.003, R = 0.892).

CONCLUSIONS

Increasing severity of Coats' disease is significantly associated with intraocular VEGF concentration in the paediatric patients. And IL-6 may be involved with the inflammatory process in the adult patients with Coats' disease.

The effects of a treatment combination of anti-VEGF injections, laser coagulation and cryotherapy on patients with type 3 Coat's disease

Background

To examined the curative effect of vitreous injection with ranibizumab,laser coagulation and cryotherapy in treating stage 3 Coats’ disease with exudative retinal detachment.

Methods

Seventeen patients with stage 3 Coats’ disease were enrolled in the study. All eyes were treated with vitreous injection of ranibizumab as initial treatment, and subsequent treatment depended on the absorption of subretinal fluid, Including cryotherapy and laser photocoagulation. Repeat treatment for the two treatment intervals occurred in ≥1 month. The mean follow-up time was 24.12 ± 5.99 months. The main data evaluation and outcome measurements included the patient’s vision, intraocular pressure(IOP), optical coherence tomography (OCT), slit lamp examination, indirect ophthalmoscopy, color Doppler imaging (CDI) and color fundus image analysis. The following variables were compared between groups: abnormal vascular changes, subretinal fluid and exudate absorption, retinal reattachment and complications. The final follow-up results were used to determine the effectiveness of treatment.

Results

Of the 17 patients included, 88.24% were male and 11.76% were female. Visual acuity was less than 0.02 in 12 eyes before surgery and 8 eyes after surgery. Visual acuity improved in 7 eyes, accounting for 41.18% of cases, and remained unchanged in 7 eyes, accounting for 41.18% of cases. Three patients were too young to undergo the operation, accounting for 17.65% of cases. The best vision was 0.1. Patients were treated 1 to 5 times for an average of 2.82 ± 0.95 times each. There was no statistically significant difference (t = 1.580, p = 0.135) between the preoperative and postoperative intraocular pressures. However, there was a statistically significant difference between the preoperative and postoperative retinal detachment height (2- related samples Wilcoxon signed rank test with z = 3.517, p = 0.000). The results further showed that all patients had different degrees of subretinal fluid absorption, and some of the new blood vessels subsided. All patients were successfully treated with laser and cryosurgery. No ocular or systemic complications were observed during follow-up.

Conclusions

Intravitreal ranibizumab (IVR), laser coagulation and cryotherapy were effective in the treatment of Coats’ disease with exudative retinal detachment.

Trial registration number

We retrospectively registered our study, The trial registration number (TRN) is ChiCTR-ONC-17011161 and date of registration is April 16, 2017.

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.

Severe Glomerular Endothelial Injury Associated with a Short D4Z4 Repeat on Chromosome 4q35

The short D4Z4 repeat on chromosome 4q35 is a confirmatory genetic cause of facioscapulohumeral muscular dystrophy (FSHD), which presents with no renal complications. We herein report a five-year-old girl previously diagnosed with Coat's-like retinopathy, deafness, and mental retardation, who was found to have early-onset, severe FSHD. Despite the absence of muscle weakness, a Southern blot analysis showed a short D4Z4 repeat on chromosome 4q35. She presented with steroid-resistant nephrotic syndrome, and her renal histopathological findings were severe glomerular endothelial injury, which is a new complication associated with this genetic abnormality. Screening of renal complications may be necessary for FSHD patients. This patient requires close follow-up for her muscle symptoms.

Coats' disease with macular oedema responsive to aflibercept and argon laser

CLINICAL CASE

A 14 year-old boy with Coats' disease in his right eye, presented with a visual acuity (VA) of 0.1, micro-aneurysms, exudates, a macular oedema of 959 microns, and peripheral telangiectasias. After 12 months follow-up with 6 ranibizumab injections and 3 sessions of argon laser photocoagulation, the macular oedema remained and VA was 0.2. Following 4 aflibercept injections and another 2 laser sessions, he had a good foveal slope and a VA of 0.5, with no recurrences in the last 12 months.

DISCUSSION

Treatment with aflibercept and argon laser was effective in our patient with stage 2B Coats' disease and macular oedema unresponsive to ranibizumab.

iTRAQ-Based Proteomics Investigation of Aqueous Humor from Patients with Coats' Disease

Background

Coats' disease is an uncommon form of retinal telangiectasis, and the identification of novel proteins that contribute to the development of Coats' disease is useful for improving treatment efficacy. Proteomic techniques have been used to study many eye diseases; however, few studies have used proteomics to study the development of Coats' disease.

Methods

Isobaric tagging for relative and absolute protein quantification (iTRAQ) was employed to screen differentially expressed proteins (DEPs) in the aqueous humor (AH) between stage 3A patients (n = 8), stage 3B patients (n = 14), stage 4 patients (n = 2) and control patients (n = 20). Differentially co-expressed proteins (DCPs) were present in all three stages of Coats' disease and were considered disease-specific proteins. These proteins were further analyzed using Gene Ontology (GO) functional annotations.

Results

A total of 819 proteins were identified in the AH, 222 of which were significantly differentially expressed (fold change > 2 and P < 0.05) in the samples from at least one stage of Coats' disease. Of the DEPs, 46 were found among all three stages of Coats' disease and the controls; therefore, they were considered Coats' disease-specific proteins (DCPs). A GO classification analysis indicated that the DCPs were closely related to structural molecule activity, cell adhesion molecule binding and receptor binding. Western blotting confirmed the expression levels of haptoglobin and apolipoprotein C-I were significantly up-regulated in Coats’ disease.

Conclusions

The 46 Coats' disease-specific proteins may provide additional insights into the mechanism of Coats' disease and represent potential biomarkers for identifying individuals with Coats' disease.

Successful use of intravitreal ranibizumab injection and combined treatment in the management of Coats' disease

PURPOSE

To observe the efficacy of intravitreal ranibizumab (IVR) combined with another ablative therapy, such as laser photocoagulation, for Coats' disease.

METHODS

Patients younger than 16 years of age who were diagnosed with Coats' disease were included in this study. They were treated with IVR (0.5 mg, monthly in the first 3 months) as an initial treatment, which was combined with another ablative therapy, such as laser photocoagulation or cryotherapy, as needed. The main data evaluation and outcome measurements included best-corrected visual acuity (BCVA) before and after treatment, fundus photography, optical coherence tomography (OCT), the number of treatment sessions, and ocular and systemic side-effects during follow-up.

RESULTS

Seventeen patients were included in this study; the average age was 7.9 ± 3.8 years, and the average follow-up time was 9.7 ± 3.3 months. The mean number of IVR treatments was 3.9 ± 1.0. Sixteen patients (94.1%) needed another treatment. Eleven patients (64.7%) were stable at the final follow-up. The BCVA at the last follow-up was significantly improved compared to baseline (p < 0.001). Telangiectasia regression was found in all patients. Partial and total retinal attached was found in 14 patients (82.4%), and exudate resolution was found in eight patients (47.1%). There were no severe ocular or systemic side-effects during the follow-up period.

CONCLUSION

Intravitreal ranibizumab combined with other ablative therapies as an initial treatment is an effective and safe treatment approach for Coats' disease that may improve the visual acuity and reduce the subretinal fluid, exudates and telangiectasia.

Intravitreal bevacizumab injections combined with laser photocoagulation for adult-onset Coats' disease

PURPOSE

To evaluate the efficacy of intravitreal bevacizumab injections combined with laser photocoagulation in the treatment of adult-onset Coats' disease.

METHODS

Thirteen eyes of 13 patients suffering from adult-onset Coats' disease were retrospectively included and analyzed. All patients were treated at baseline using intravitreal bevacizumab injections combined with laser photocoagulation. Follow-up treatment was performed as necessary.

RESULTS

The mean age of the subjects was 40.3 years, and the mean follow-up period was 24.8 months. The mean number of bevacizumab injections was 2.69, and the mean number of laser treatment sessions was 1.68. The mean baseline best-corrected visual acuity (BCVA) was 0.72 logarithm of the minimum angle of resolution (logMAR; 20/104 Snellen equivalent), while the mean BCVA at the final visit was 0.68 logMAR (20/95; P = 0.548). In three patients (23.0 %), BCVA had improved by more than 3 lines, and seven patients (54.0 %) showed stable BCVA (changes within 2 lines of visual acuity) after treatment. The mean central foveal thickness improved significantly, from 473 μm at baseline to 288 μm at the final visit (P = 0.023). Final BCVA was significantly correlated with a baseline BCVA (P < 0.001; ρ = 0.882). The final BCVA of patients who had subfoveal hard exudates at baseline was significantly worse than that of patients without such exudates (P = 0.005).

CONCLUSIONS

Intravitreal bevacizumab injection combined with laser photocoagulation may be an effective treatment option for adult-onset Coats' disease. Both poor initial BCVA and the occurrence of subfoveal hard exudates at baseline were associated with poor prognosis and poor therapeutic response.

Long-term follow-up of intravitreal bevacizumab for the treatment of pediatric retinal and choroidal diseases

PURPOSE

To describe the long-term outcomes of intravitreal bevacizumab (IVB) for the treatment of pediatric retinal and choroidal diseases.

METHODS

This was a multicenter, retrospective, consecutive case series of patients <18 years of age treated with IVB from 2005 to 2013. Primary outcome measures included visual acuity and central macular thickness at 12 months' follow-up.

RESULTS

A total of 95 eyes of 90 patients (average age, 8.7 years [range, 0.33-17 years]) were included, in which 352 injections (average, 3.7/eye) were administered for choroidal neovascular membrane (CNVM, n = 35), Coats disease (n = 35), familial exudative vitreoretinopathy (FEVR, n = 13), cystoid macular edema (CME, n = 6), and other (n = 6). Mean follow-up was 679 ± 581 days. IVB was used as monotherapy in 27 eyes and as part of combination therapy in 68. Mean Snellen equivalent visual acuity improved from 20/224 at baseline to 20/120 at 6 months (P = 0.034) and 20/108 at 12 months (P = 0.005). Mean central macular thickness improved from 426 μm to 349 μm at 6 months (P = 0.025) and 340 μm at 12 months (P = 0.002). Statistically significant visual acuity gains at 12 months were achieved in patients with CNVM (P = 0.009) but not in eyes with CME (P = 0.06), Coats disease (P = 0.15), or FEVR (P = 0.93). Adverse effects included ocular hypertension in 8 eyes and worsening tractional retinal detachment in 3 eyes.

CONCLUSIONS

Patients receiving IVB as part of the treatment for pediatric retinal and choroidal diseases experienced significant visual acuity gains and reductions in central macular thickness. IVB was generally well tolerated, although safety concerns persist.

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."

ranibizumab in the management of advanced Coats disease Stages 3B and 4: long-term outcomes

BACKGROUND

Laser photocoagulation and cryotherapy to completely destroy telangiectatic vessels and ischemic retina in Coats disease is barely applicable in advanced cases with total retinal detachment, and globe survival is notoriously poor in Stages 3B and 4. Anti-vascular endothelial growth factor intravitreal injections may offer new prospects for these patients.

METHODS

This study is a retrospective review of all consecutive patients with Coats disease treated with neoadjuvant or adjuvant intravitreal ranibizumab plus conventional and amblyopia treatment as appropriate.

RESULTS

Nine patients (median age, 13 months) presenting Coats Stages 3B and 4 (5 and 4 eyes, respectively) were included. Iris neovascularization resolved within 2 weeks and retinal reapplication within 4 months in all patients. At last follow-up, globe survival was 100% with anatomical success in 8 of the 9 eyes. With a median follow-up of 50 months, fibrotic vitreoretinopathy was developed in 5 of the 9 cases, one leading to tractional retinal detachment and ultimately phthisis bulbi. The remaining 4 of the 9 eyes achieved some vision (range, 0.02-0.063).

CONCLUSION

To the best of the authors' knowledge, this is the largest reported series of late-stage Coats undergoing anti-vascular endothelial growth factor therapy, a homogenous cohort of patients treated with a single agent and with the longest follow-up. This study supports the role of ranibizumab in advanced disease by transient restoration of the hemato-retinal barrier and suppression of neovascularization to facilitate classic treatment. At the last follow-up, the authors report unprecedented anatomical success and functional outcome.

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.

An unusual case of Coats disease associated with Takayasu arteritis

A 3-year-old Malay boy with strabismus in the left eye was found to have Coats disease in the same eye and underlying Takayasu arteritis. Coats disease is usually idiopathic but can be associated with systemic and ocular conditions. To our knowledge, this is the first reported case of Coats disease associated with Takayasu arteritis.

Advanced Coats' disease treated with intravitreal bevacizumab combined with laser vascular ablation

Purpose

To evaluate the impact of intravitreal bevacizumab combined with laser vascular ablation in the management of advanced Coats’ disease presenting with exudative retinal detachment.

Methods

This was a retrospective review of 24 children that presented with exudative retinal detachments associated with advanced Coats’ disease. Mean patient age was 62 months (range 9–160 months). Presenting signs included retinal detachment in 24 children (100%), vascular telangiectasia in 24 children (100%), and retinal ischemia in 24 children (100%). Twenty of 24 children presented with elevated, vascular leakage in the fovea (83%). Two children presented with sub-retinal fibrosis associated with presumed long-standing retinal detachment without evidence of rhegmatogenous retinal detachment. Ten patients exhibited vascular alterations in the periphery of the second eye without clinical evidence of exudation. All 24 children were treated with a large-spot-size diode laser directly to areas of abnormal telangiectatic vasculature. All 24 children received intravitreal bevacizumab injection.

Results

All 24 children had resolution of exudative retinal detachment, ablation of vascular telangiectasia, and anatomic improvement of the retina. No child exhibited progressive retinal detachment and no eye required enucleation. No cases of neovascular glaucoma were seen. Fellow eyes with peripheral vascular alterations showed no progression to exudative vasculopathy during the observation period. Intravitreal bevacizumab injection was not associated with endophthalmitis or systemically-observed complications.

Conclusion

Repetitive intravitreal bevacizumab combined with laser vascular ablation may be utilized effectively for advanced Coats’ disease presenting with exudative retinal detachment.

Vascular endothelial growth factor in Coats' disease

PURPOSE

To examine whether vascular endothelial growth factor (VEGF) as one of the most important intraocular cytokines for angiogenesis and increased vascular permeability is associated with Coats' disease.

METHODS

The clinical interventional study included 28 patients with Coats' disease and seven control patients with congenital cataract. During intraocular surgery, we obtained aqueous humour samples in which the VEGF concentration was measured by double-antibody sandwich enzyme-linked immunosorbent assay (ELISA). Coats' disease was graded into four stages.

RESULTS

The mean aqueous VEGF level was significantly higher in the Coats' study group than in the control group (158±88 versus 97±21 pg/ml; p=0.002). The VEGF concentrations increased significantly (p<0.001) from 91±32 pg/ml in Coats' disease stage 2 to 100±37 pg/ml in stage 3A1, 185±56 pg/ml in stage 3A2 to 256±93 pg/ml in patients with stage 3B. Vascular endothelial growth factor concentrations in Coats' stage 2 and 3A1 did not differ significantly from the values in the control group. Parallel to the association with the stage of the diseases, the VEGF concentrations were significantly (p<0.001) correlated with extent of exudative retinal detachment.

CONCLUSIONS

Increasing severity of Coats' disease is significantly associated with intraocular VEGF concentrations. These results favour the intravitreal application of anti-VEGF drugs as medical therapy of Coats' diseases.

Combined treatment for Coats' disease: retinal laser photocoagulation combined with intravitreal bevacizumab injection was effective in two cases

Background

The exact pathogenetic mechanisms of Coats’ disease remain unknown. In this report, we show two cases of Coats’ disease that achieved a favorable prognosis with the combined treatment of intravitreal bevacizumab (IVB) injection prior to photocoagulation, although both initially resisted photocoagulation therapy.

Case presentations

Case 1 was a 15-year-old boy with initial visual acuity of 0.4 OD. At the temporal retina, aneurysms and abnormal telangiectatic vessels were observed. Hard exudates and an exudative retinal detachment extended to the fovea. He was diagnosed as having Coats’ disease at stage 3A and we performed laser photocoagulation as an initial approach to treat peripheral aneurysms and telangiectatic vessels. After the treatment, the exudative retinal detachment was eased and visual acuity improved to 1.0; however, recurrence occurred after 5 months. The exudative change was resistant against laser photocoagulation therapy and we therefore added IVB as an adjuvant before photocoagulation. Fourteen days after IVB injection phased laser photocoagulation was given to cover the abnormal capillaries, aneurysms and the leakage area spotted in FA. A good prognosis was obtained with decreased exudation and improved visual acuity.

Case 2 was an 11-year-old boy with decreased visual acuity of 0.15 OS at the initial visit. Hard exudates, retinal edema and serous retinal detachment were seen at the macula and peripheral retina. Fluorescein angiography revealed telangiectatic capillaries at the temporal retina. Our diagnosis was Coats’ disease at stage 3A. Extensive photocoagulation was performed as an initial treatment to the lesion. However, the exudative change was severe and resistant against the photocoagulation treatment. Therefore, we added IVB as an adjuvant before photocoagulation. Exudative change in the retina seemed to be eased 7 days after IVB injection, therefore, phased laser phototherapy was added to cover the abnormal capillaries. After the combination therapy, exudative change was remarkably ameliorated and better visual acuity was achieved.

Conclusion

Bevacizumab is considered an effective adjuvant for Coats’ disease with exudative change resistant to retinal photocoagulation therapy.

Current management of Coats disease

Since its original description in 1908, Coats disease has been recognized as an idiopathic cause of severe vision loss with a remarkable diversity in clinical presentation and morphology. Key clinical and imaging variables are helpful in differentiating Coats disease from life-threatening malignancies, and proper management revolves around a thorough knowledge of the differential diagnosis. Despite significant advancement in scientific understanding of the disease process and clinical spectrum, the underlying etiology remains obscure, and both primary and secondary forms are recognized. With the development of anti-VEGF therapy, vitreoretinal specialists have a new, effective adjunct to the clinical management of exudates, macular edema, and serous retinal detachment. We highlight the history, diagnostic challenges, evolving clinical spectrum, and current management of Coats disease.

Intravitreal dexamethasone implant (ozurdex) in coats' disease

We injected an intravitreal dexamethasone implant in two eyes of 2 pediatric patients with Coats' disease in addition to other treatment modalities, such as intravitreal ranibizumab injection and indirect laser photocoagulation. In both eyes, intraocular pressure moderately rose in a temporary fashion. The dexamethasone implant seems to be a valuable addition to the armamentarium of treatment options for Coats' disease as it necessitates fewer injections than anti-VEGF injections and thereby fewer sessions of general anesthesia in the pediatric population.