Rescue therapy with intravitreal aflibercept for choroidal neovascularization secondary to choroidal osteoma non-responder to intravitreal bevacizumab and ranibizumab

Choroidal neovascularization in 111 eyes of children and adolescents

PURPOSE

To describe the clinical features, management, and outcomes of choroidal neovascularization (CNV) in children less than 18 years of age.

METHODS

This was a retrospective, case control study of 111 eyes of 96 patients. CNV was clinically diagnosed in all patients. Eyes were classified as those that were observed (Controls; Group 1) or those that had treatment (Cases; Group 2). CNV was categorized as regressed, persistent, or recurrent in order to evaluate the anatomical outcomes.

RESULTS

Of 96 patients, 68(71%) were male. Mean presenting age was 11.4 ± 3.4 years (median = 11 years, range = 1-17 years). CNV was bilateral in 15(16%) patients. Of 111 eyes, 38 eyes had treatment (Cases) and 73 eyes did not (Natural history group or Controls). Subfoveal CNV was seen in majority of cases (59%). Most common etiology was post-inflammatory (38%), followed by trauma (16%). Eyes were classified as those that were observed (controls; Group 1) or those that had treatment (cases; Group 2). In group 1, spontaneous regression of CNV was seen in 26(36%) eyes and there was no recurrence in this group. In group 2 following treatment, 25(66%) of 38 eyes achieved complete regression at mean 4.9 months and was persistent in 5 eyes. CNV recurrence was seen in 10 eyes with the mean time to first recurrence being 9 months. At presentation, mean best-corrected visual acuity (BCVA) of eyes with subfoveal CNV was logMAR 0.99 that improved to logMAR 0.63 with treatment. Mean follow-up was 17 months.

CONCLUSION

CNV results in significant visual decline in children; most commonly of post-inflammatory etiology. Treatment achieves high regression rates, albeit with limited visual improvement.

Post-hoc analysis of single nucleotide polymorphism profile for eyes with vascularized pigment epithelial detachment due to ARMD

INTRODUCTION

This post-hoc case-control study compares single nucleotide polymorphism (SNP) profile of eyes with vascularized pigment epithelial detachment (vPED) due to age-related macular degeneration (ARMD) with: (1) Control-1 eyes (no ARMD and AREDS Severity Scale 0); and (2) Control-2 eyes (drusen or AREDS Severity Scale 2). SNP profile of High Responders (HR) was also compared with Low Responders (LR) to ranibizumab.

METHODS

Blood samples from 40 patients with vPED treated with ranibizumab were sent for SNP-specific genotype analysis for comparison of variant allele frequencies of 23 SNPs associated with ARMD (VAF) to VAF in 184 Control-1 eyes, and VAF in 85 Control-2 eyes. VAF of HR-50 (⩾50% decrease in PED height) and VAF of HR-75 (⩾75% decrease in PED height) were also compared with VAF of LR.

RESULTS

These SNPs were more frequent in vPED than Control-1 eyes: APOE rs4420638 (A/G), HTRA1 rs104904924 (G/T), VEGF rs943080 (T/C), CFH rs1061170 (T/C), CFH rs2274700 (C/T), CFH rs10737680 (A/C), CFH rs10801555 (G/A). These SNPs were more frequent in vPED than Control-2 eyes: APOE rs4420638 (A/G), CFI rs4698775 (G/T), COL15A1/TGFBR1 rs334353 (T/G). FRK rs3812111 (T/A) was more frequent in HR-50 and HR-75 eyes compared with LR.

CONCLUSION

Seven SNPs were more frequent in vPED eyes than non-ARMD eyes, and three SNPs were more frequent in vPED eyes than drusen eyes. Adjusting for multiplicity, only CFH rs2274700 (C/T) was significant for first comparison, and only COL15A1/TGFBR1 rs334353 (T/G) was significant for second comparison. APOE rs4420638 (A/G) was the single SNP more frequently linked to vPED eyes for both comparisons. FRK rs3812111 (T/A) was consistently associated with high responders.

The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema

BACKGROUND

Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy.

METHODS

The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed.

RESULTS

Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease.

CONCLUSION

Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

Choroidal neovascularization due to choroidal osteoma treated with anti-vascular endothelial growth factor therapy: An optical coherence tomography angiography study

PURPOSE

To evaluate the response to anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to choroidal osteoma using optical coherence tomography angiography.

METHODS

This retrospective study included four eyes of four females with choroidal osteoma complicated by choroidal neovascularization, treated with ranibizumab. All patients underwent full ophthalmologic examination, including ocular ultrasound, retinography, fluorescein angiography, spectral-domain or swept-source optical coherence tomography, and optical coherence tomography angiography. These images were analyzed to measure choroidal osteoma and to study choroidal neovascularization changes after intravitreal anti-vascular endothelial growth factor.

RESULTS

In all cases, fluorescein angiography revealed the presence the choroidal neovascularization, as an early hyperfluorescence area increasing during the exam. Optical coherence tomography showed both the choroidal osteoma and choroidal neovascularization and intra- or subretinal fluid as activity sign. In optical coherence tomography angiography, choroidal osteoma vessels were valuable in outer retina and choroidal slabs, and were irregular and did not change after ranibizumab injection; neovascular network correlating with choroidal neovascularization showed a hyperflow tangled vessels in outer retina, decreasing in density after anti-vascular endothelial growth factor therapy.

CONCLUSION

Optical coherence tomography angiography seems to be a useful tool in visualizing and distinguishing vascular networks of choroidal osteoma and of choroidal neovascularization secondary to choroidal osteoma better than fluorescein angiography.

Baseline Predictors of Visual Acuity Outcome in Patients with Wet Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is one of the leading causes of severe vision loss in people over 60 years. Wet AMD (wAMD) causes more severe visual acuity (VA) loss compared with the dry form due to formation of choroidal neovascularization (CNV). Antivascular endothelial growth factor (anti-VEGF) agents such as ranibizumab and aflibercept are now the standard of care treatment for wAMD. Unfortunately, up to a quarter of anti-VEGF-treated wAMD patients might not fully benefit from intravitreal injections and CNV activity may not respond to the treatment and these patients are called anti-VEGF nonresponders. This article aims to discuss the baseline factors associated with VA outcome such as age, initial VA, lesion types, disease duration, optical coherence tomography (OCT) features, fundus autofluorescence findings, and the presence of particular genotype risk alleles in patients with wAMD. Recommendations are provided regarding when to consider discontinuation of therapy because of either success or futility. Understanding the predictive factors associated with VA outcome and treatment frequency response to anti-VEGF therapy may help retina specialists to manage patients' expectations and guide treatment decisions from the beginning of treatment on the basis of “personalized medicine.”

Intravitreal Ziv-Aflibercept: Clinical Effects and Economic Impact

During the past decade, drugs that inhibit the actions of vascular endothelial growth factor (VEGF) have become standard-of-care treatment for a variety of chorioretinal vascular conditions. The off-label, intravitreal use of ziv-aflibercept (Zaltrap) has provided clinicians with an additional cost-effective drug. The commercial preparation of ziv-aflibercept contains the same aflibercept (VEGF-trap) molecule as Eylea but has a much higher osmolarity (1000 mOsm/kg vs 300 mOsm/kg). Initial concerns regarding cytotoxicity and long-term safety of intravitreal ziv-aflibercept have been largely negated after a series of publications failed to identify adverse ocular and systemic side effects. Both treatment-naive and anti-VEGF‒resistant cases of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), retinal vein occlusion (RVO), and choroidal neovascular membrane (CNVM) may respond as well to ziv-aflibercept as to aflibercept. A higher dose of ziv-aflibercept (2 mg in 0.08 mL) does not cause any adverse effects during short-term follow-up period (1 month). Data from various sources suggest that ziv-aflibercept may be as cost effective as bevacizumab, thereby making it an attractive treatment option in low- and middle-income countries. However, problems with off-label use, compounding, and counterfeiting limit its availability in many countries. Data from prospective, randomized, multicenter clinical trials are still required to convince physicians and regulatory bodies of its clinical efficacy and potential as early therapy.

Intravitreal bevacizumab monotherapy for choroidal neovascularisation secondary to choroidal osteoma

PurposeThe purpose of this study is to present the outcomes of a series of patients with choroidal neovascular membrane (choroidal neovascularisation (CNV)) secondary to a choroidal osteoma undergoing anti-VEGF monotherapy.Patients and methodsRetrospective series of patients with choroidal neovascularization secondary to choroidal osteoma. All patients underwent clinical and imaging assessment (fundus photo, B-scan ultrasonography, fluorescein angiography, and optical coherence tomography-where available), and were managed with intravitreal anti-VEGF injections (Bevacizumab). Visual acuity and central retinal thickness were recorded pre treatment and at the end of the follow-up period.ResultsEight patients were included in this study. Of this, 6/8 had predominantly classic or classic and 2/8 patients had minimally classic or occult CNV. Each patient received 3-10 injections of bevacizumab. Median follow-up was 9 months (3-15 months). Visual acuity improved in 5 patients, by 2-6 Snellen lines. CNV completely regressed in 5 cases and partially regressed in 3 cases. Mean CRT reduction was 122 μm (6 to -230 μm).ConclusionIntravitreal bevacizumab can be an effective treatment modality in the management of vision threatening CNV secondary to choroidal osteoma.