Intravitreal dexamethasone implant with retinal photocoagulation for adult-onset Coats' disease

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 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.

Efficacy and Safety Outcomes of Intravitreal Dexamethasone Implant Therapy for the Treatment of Adult Coats' Disease

Purpose

To evaluate the efficacy and safety outcomes of dexamethasone intravitreal implant in patients with Stage 3A Coats' disease.

Methods

A consecutive case series of adult Coats' disease managed with or without intravitreal dexamethasone implant (Ozurdex®, Allergan Inc., Irvine, California, USA) injection was retrospectively evaluated. The medical records of all included patients with a minimum follow-up of 6 months were reviewed. The patients were divided into two groups according to the application of dexamethasone implant as a DEX (+) group and DEX (−) group. Laser photocoagulation, anti-VEGF agents, and vitrectomy were performed if necessary. The primary outcomes included best-corrected visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP) at month 6. Resolution of the exudative retinal detachment (ERD), subretinal fluid (SRF), and vitreous hemorrhage (VH) was also collected.

Results

Ten eyes (10 patients) with Stage 3A Coats' disease were included, and the mean follow-up time was 9.70 ± 4.42 months. The mean age was 44.20 ± 7.42 years, and 80% were male. Six eyes (6 patients) received intravitreal injection of Ozurdex were included in the DEX (+) group, while the other 4 eyes in the DEX (−) group. No significant difference of baseline characteristics including BCVA, CRT, IOP, and follow-up time can be defined between DEX (+) and DEX (−) groups. For the patients in the DEX (+) group, a significant improvement of BCVA was observed from the baseline of 1.28 ± 0.58 to 0.84 ± 0.66 logMAR at month 6 (P=0.03), while the CRT decreased from 970.33 ± 696.49 to 421.00 ± 275.76 μm (P=0.067). For the DEX(−) group, BCVA changed from 0.76 ± 0.74 to 0.96 ± 0.60 logMAR at month 6 (P=0.066), while the CRT from 382.75 ± 17.68 to 412.75 ± 195.53 μm (P=0.525) with no significant difference. IOP was elevated from 13.15 ± 1.74 mmHg at baseline to 18.05 ± 3.57 mmHg at month 6 with a P value of 0.02 for the DEX(+) group and from 14.48 ± 1.70 to 18.83 ± 4.06 mmHg (P=0.076) for the DEX (−) group. After a mean follow-up of 9.70 months, 5/6 (83.3%) eyes in the DEX (+) group and ¼ (25%) eye in the DEX (−) group achieved reattachment of ERD.

Conclusion

Intravitreal dexamethasone implant therapy is effective for adult Stage 3A Coats' disease, which provides a new treatment option for ophthalmologists.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.

Levels of cytokines in the aqueous humor guided treatment of refractory macular edema in adult-onset coats' disease

Background

Two cases with refractory macular edema secondary to adult-onset Coats’ disease underwent unsatisfactory treatment by intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs and retinal photocoagulation.

Case presentation

The authors highlight the guiding effect of the measurement of cytokines in the aqueous humor for the treatment of adult-onset Coats’ disease with refractory macular edema. In the two cases, typical Coats’ disease changes, including telangiectasis, subretinal exudation and macular edema were observed. Initial treatment consisted of intravitreal anti-VEGF drugs and retinal laser photocoagulation; however, the response was poor. Then, the aqueous humor was acquired and the cytokine concentrations were measured (Flow Cytometry Analysis, Beijing Giantmed Medical Diagnostics Lab). When the cytokine levels were tested every time there would be quality control, with a fixed concentration of cytokines samples to detect before the results reported. A low level of VEGF and a high level of inflammatory cytokines were found. Then, treatment was switched to intravitreal injection of dexamethasone implant (Ozurdex®) (Allergan, Inc., Irvine, Calif., USA), which resulted in resolution of the refractory macular edema and improvement of visual acuity in both cases.

Conclusions

For refractory macular edema secondary to adult-onset Coats’ disease, measurement of the levels of VEGF and inflammatory cytokines can help clinic doctors precisely investigate the molecular mechanism of macular edema and thereby find a suitable treatment.

Clinical characteristics and surgical outcome of pediatric and early adulthood retinal detachment

OBJECTIVE

The aim of this study was to evaluate and compare the underlying pathologies, demographic and retinal detachment characteristics in pediatric and early adulthood retinal detachment.

METHODS

Patients with rhegmatogenous, serous, or tractional retinal detachment aged 0-26 years were retrospectively reviewed. The preschool group (n = 4) comprised children aged 0-6 years, the pediatric group (n = 19) comprised children aged 7-16 years, and the early adulthood group (n = 13) aged 17-26 years. Demographic information and retinal detachment characteristics, type of surgery, and intraocular tamponade were analyzed. Postoperatively, the functional outcome, anatomic success, and ocular adverse events were evaluated. Due to the low patient number in the preschool group, statistical analysis was performed for pediatric group and early adulthood group only.

RESULTS

All causes of retinal detachment were present in the pediatric group, but only rhegmatogenous retinal detachment in the early adulthood group. In both groups, the main type of surgical intervention was pars plana vitrectomy (pediatric group: 52%, early adulthood group: 38%; p = 0.36). The type of intraocular tamponade varied statistically significantly between the groups (p = 0.014). Silicone oil was the main intraocular tamponade in the pediatric group (48%), whereas no tamponade (54%) followed by gas tamponade (46%) in the early adulthood group. Final attachment rate was similar in both groups (pediatric group: 89%, early adulthood group: 100%; p = 0.35). Re-detachment occurred significantly sooner in the pediatric group (1.3 ± 0.3 months) than in the early adulthood group (4.3 ± 1.4 months; p = 0.03).

CONCLUSION

In pediatric and early adulthood retinal detachment, pars plana vitrectomy appeared as a successful surgical intervention. Re-attachment rate and re-treatment were similar in both groups with a better functional outcome observed in cases of retinal detachment in early adulthood and poorer results in young children.

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.