Intravitreal bevacizumab in the treatment of vasoproliferative retinal tumours

Ocular Complications of Intermediate Uveitis

Intermediate uveitis (IU) in an intraocular inflammation that predominantly affects the vitreous. It typically manifests as chronic low-grade inflammation, mainly affecting children and young adults. Uncontrolled chronic intraocular inflammation carries a high risk of visual loss. IU, despite being a low-grade inflammation, is among the sight-threatening conditions owing to its intrinsically-associated vision-robbing ocular complications. It can cause early and late-onset ocular complications affecting the anterior and posterior segments of the eye. 40-60% of the patients who suffer from IU will develop at least one ocular complication during the disease course. Prompt management and long-term monitoring are vital for the early detection of ocular complications and timely intervention. Proactive screening programs are essential in children because of the occult nature of IU in the pediatric age group and the high prevalence of complications at the initial visit. This review provides a comprehensive panorama of anterior segment complications, namely, band keratopathy, corneal endotheliopathy, posterior synechiae, and cataract as well as of posterior segment complications including macular edema, retinoschisis, retinal detachment, vitreous hemorrhage, vasoproliferative tumor, optic neuritis, and papillitis, in addition to glaucoma and hypotony.

[Morphological features of vasoproliferative tumor of the retina]

Vasoproliferative retinal tumor (VPT) is a term proposed by ophthalmologists in relation to the totality of manifestations of an intraocular volumetric process with involvement of the inner lining of the eye, an integral part of which is the active growth of blood vessels. The available literature data on the morphology of this process are very contradictory and ambiguous. The article presents two clinical cases of vasoproliferative retinal tumor with own illustration of morphological studies.

CLINICOPATHOLOGICAL ANALYSIS OF SECONDARY RETINAL VASOPROLIFERATIVE TUMOR/REACTIVE RETINAL ASTROCYTIC TUMOR SUCCESSFULLY TREATED BY ENDORESECTION

PURPOSE

To report the clinicopathological findings of retinal vasoproliferative tumor/reactive retinal astrocytic tumor (VPT/RRAT) with retinal vasculitis, treated by tumor resection.

METHODS

A retrospective single case report.

PATIENT

A 29-year-old Japanese woman was referred with cystoid macular edema and retinal vasculitis in the right eye. Best-corrected visual acuity was 0.9. Results of fundus examination, optical coherence tomography, and fluorescein angiography demonstrated VPT/RRATs in the temporal retina surrounded by a subretinal exudate, serous retinal detachment and macular edema, and retinal vasculitis. Despite 3 months of oral prednisolone treatment, a full-thickness macular hole developed. Pars plana vitrectomy and endoresection of the VPT/RRATs were performed. Pathologic and immunohistochemical analyses with anti-CD34 antibody, antiglial fibrillary acidic protein antibody, anti-Ki67 antibody, and anti-vascular endothelial growth factor antibody were performed on the excised tissue. Inflammation was evaluated by immunohistological staining with leukocyte common antigen (LCA), anti-CD3 antibody, and anti-CD20 antibody.

RESULTS

After surgery, the macular hole closed, best-corrected visual acuity improved to 1.2, retinal vasculitis was ameliorated, and retinal exudate disappeared. There was no recurrence of VPT/RRAT or retinal vasculitis. Pathologic examination showed that antiglial fibrillary acidic protein and anti-vascular endothelial growth factor were widely expressed, irrespective of the distribution of blood vessels. Ki67-positive proliferating cells were detected in the perivascular area. Leukocyte common antigen-positive leukocytes and CD3-positive T cells were detected throughout the samples, whereas CD20-positive B cells were rarely detected.

CONCLUSION

Endoresection of VPT/RRAT could be a good treatment option for secondary VPT/RRAT accompanied by retinal vasculitis. Pathologic findings revealed for the first time that inflammatory cells infiltrate the tissue in secondary VPT/RRAT.

SURGICAL OUTCOMES OF PARS PLANA VITRECTOMY FOR INTRAOCULAR COMPLICATIONS RELATED TO VASOPROLIFERATIVE TUMOR OF THE RETINA

PURPOSE

To investigate the safety and efficacy of vitrectomy pars plana vitrectomy in managing intraocular complications relating to vasoproliferative tumors of the retina (VPL).

METHODS

Retrospective study. 17 patients with VPL who underwent vitrectomy at Sheffield Teaching Hospital NHS Trust from 2005 to 2020 were included. Patient demographics, clinical characteristics, intraoperative data, and surgical outcomes were collected and evaluated.

RESULTS

The mean age was 52 years. Indications for pars plana vitrectomy included epiretinal membrane (n = 7), vitreous hemorrhage (n = 5), retinal detachment (n = 3), diagnostic (n = 1), and others (n = 1). After pars plana vitrectomy, 14/17 (82.4%) have stabilized vision and 3/17 (17.6%) deteriorated. Subgroup analysis of epiretinal membrane peel had good outcomes with 6/7 (85.7%) noticing improvement or stabilization of symptoms and mean logarithm of minimal angle of resolution visual acuity improved from 0.719 [6/30] ± 0.267 [6/12] to 0.476 [6/19] ± 0.271 [6/12]. Patients undergoing surgery for vitreous hemorrhage also had good outcomes with resolution (and no recurrence) of the hemorrhage in 3/5 (60%) and 5/5 (100%) with one or more surgeries, respectively. Outcomes for retinal detachment surgery were logarithm of minimal angle of resolution 2.126 [HM] ± 0.301 [6/12] preoperatively and 1.185 [6/95] ± 0.522 [6/19] postoperatively, with one recurrence of retinal detachment. In the epiretinal membrane group, three patients had adjunctive treatment for VPL intraoperatively and four patients had none, and no difference found between the two groups in outcome or complications. Tumor with thickness of ≥2 mm exhibited inferior visual outcomes compared with <2 mm ( P < 0.05).

CONCLUSION

This is one of the largest data sets in looking at outcomes of vitrectomy for complications of VPL. Pars plana vitrectomy is effective and safe in managing VPL-related intraocular complications with good outcomes and a low rate of complications, especially for patients with epiretinal membrane and vitreous hemorrhage.

Multimodal imaging of reactive retinal astrocytic vasoproliferative tumour in a case of systemic tuberculosis

A man in his 20s presented with diminished vision in the left eye. He had a history of Pott's spine and had been diagnosed elsewhere as having left eye tubercular granuloma in the retina. He was started on anti-tubercular therapy and high-dose oral steroids. He presented to us 1 month later. Presently fundus examination revealed a yellow to whitish mass temporal to disc with diffuse hard exudates throughout the retina. Swept-source optical coherence tomography (SSOCT) revealed a hyper-reflective mass involving the retina. SSOCT angiography and fundus fluorescein angiography revealed vascularity within the lesion. We made a diagnosis of a secondary reactive retinal astrocytic vasoproliferative tumour (VPT) and hence tapered the steroids and given intravitreal bevacizumab injection. At 6 weeks follow-up after intravitreal bevacizumab, there was some amount of resolution of hard exudates along with reduction of the vascular pattern of the lesion. The peripapillary location and development of a VPT following resolution of a presumed tubercular granuloma is rare.

Bilateral astrocytic hamartoma with vasoproliferative tumour in retinitis pigmentosa

We report a rare case of a 32-year-old Indian male who presented to the retina outpatient department with a history of sudden worsening of vision in the left eye. There was a background history of poor vision and deficient night vision since childhood. At the first presentation, the best corrected visual acuity was 6/36 and 6/60 in the right and left eye, respectively. Ocular examination revealed waxy pale disc, bone spicule pigmentation, attenuated vessels and epiretinal membrane in the right eye in keeping with retinitis pigmentosa. An astrocytic harmatoma was also present in the right eye. Vitreous haemorrhage in the left eye precluded a view of the fundus. He subsequently had a left pars plana vitrectomy, and intravitreal bevacizumab on account of non-resolving vitreous haemorrhage and a vasoproliferative tumour and astrocytic hamartoma were noticed intraoperatively. He had a good immediate post-operative outcome post-left vitrectomy but subsequently developed left neovascular glaucoma 2 years after. Neovascular glaucoma may be a sequela of vasoproliferative tumour; hence, regular follow-up and monitoring are essential in these patients.

Monoclonal antibodies in diabetic retinopathy

INTRODUCTION

Diabetic retinopathy (DR), as one of the main complications of diabetes, is among the leading causes of blindness and visual impairment worldwide.

AREAS COVERED

Current clinical therapies include photocoagulation, vitrectomy, and anti-vascular endothelial growth factor (VEGF) therapies. Bevacizumab and ranibizumab are two monoclonal antibodies (mAbs) inhibiting angiogenesis. Intravitreal ranibizumab and bevacizumab can decrease the rate of blindness and retinal thickness, and improve visual acuity whether as monotherapy or combined with other treatments. They can increase the efficacy of other treatments and decrease their adverse events. Although administered intravitreally, they also might enter the circulation and cause systemic effects. This study is aimed to review our current knowledge about mAbs, bevacizumab and ranibizumab, in DR including superiorities, challenges, and limitations. Meanwhile, we tried to shed light on new ideas to overcome these limitations. Our latest search was done in April 2021 mainly through PubMed and Google Scholar. Relevant clinical studies were imported.

EXPERT OPINION

Future direction includes detection of more therapeutic targets considering other components of DR pathophysiology and shared pathogenesis of DR and neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, the treat-and-extend regimen, and new ways of drug delivery and other routes of ocular drug administration.

Retinal vasoproliferative tumor regression after intravitreal aflibercept

Retinal vasoproliferative tumors (RVPTs) are rare benign retinal lesions typically located in the inferotemporal peripheral retina. Several treatment options exist for the management of RVPTs, but no consensus has been proposed. There are only a few reports on the use of anti-vascular endothelial growth factor with bevacizumab to treat exudative or neovascular retinal changes secondary to RVPTs. This report describes a 68-year-old female with a history of systemic hypertension that presented with a 2-week history of gradual loss of visual acuity in the right eye. Fundoscopic examination showed a RVPTs with atypical location that had a favorable response to two-intravitreal aflibercept injections 1 month apart, with resulting subretinal fluid absorption and tumor regression.

Management of Vasoproliferative Tumors of the Retina with Macular Complications by Pars Plana Vitrectomy Combined with Episcleral Cryotherapy

Objective

To evaluate the efficacy of pars plana vitrectomy (PPV) combined with episcleral cryotherapy in treating vasoproliferative tumors of the retina (VPTR) with macular complications.

Methods

In this retrospective noncomparative interventional case-series analysis, we included 11 eyes of ten patients diagnosed with VPTR. All patients underwent comprehensive ophthalmic examinations and were treated with PPV combined with episcleral cryotherapy. Best-corrected visual acuity (BCVA), tumor activity, retinal morphological structure, and postoperative complications were evaluated.

Results

Macular complications included epimacular membrane (n = 10), macular hole (n = 3), and macular edema (n = 1). Tumors were treated with triple freeze-thaw episcleral cryotherapy during PPV. The mean logarithm of minimal angle of resolution (logMAR) BCVA dropped from 0.62 ± 0.58 to 0.39 ± 0.46. The difference between the mean values of logMAR BCVA before and after treatment was statistically significant (t = 2.48, P=0.033). The tumor activity was controlled effectively in nine cases. Compared with preoperative tumor activity, tumor activity after treatment was significantly lower (P < 0.01). The increase of central retinal thickness and the disruption of retinal layers were associated with macular holes, macular edema, and retinal proliferative membrane. After the treatment, visual acuity improved in 91% of the cases, and 73% had no long-term complications.

Conclusion

PPV combined with episcleral cryotherapy promoted tumor regression, preserved retinal integrity, and improved visual acuity. Thus, the combination of PPV with episcleral cryotherapy can be considered effective and safe for the management of VPTR with macular complications.

Photodynamic Therapy in Ocular Oncology

Over the past two decades, we have witnessed the increasing use of photodynamic therapy (PDT) in the field of ocular oncology. Based on a review of the literature and our own experience, we herein review the role of PDT for the management of intraocular tumors. The discussion includes two main topics. First, we discuss the application of PDT for benign tumors, including circumscribed choroidal hemangioma, choroidal osteoma, retinal astrocytoma, retinal capillary hemangioma (retinal hemangioblastoma), and retinal vasoproliferative tumor. Second, we assess the role of PDT for malignant tumors, including choroidal melanoma and choroidal metastasis.

The Relationship Between Vasoproliferative Tumor and Uveitis in a Multiple Sclerosis Patient: A Case Report and Review of the Literature

Vasoproliferative retinal tumor (VPRT) is a rare, benign lesion with a variable clinical course depending on the individual. Favorable outcomes are obtained with early diagnosis and treatment of patients with VPRT. In this case report, we present a case of concomitant VPRT and multiple sclerosis along with our management of uveitis and secondary glaucoma that presumably developed following cryotherapy for VPRT.

Comparative Study on the Efficacy and Safety of Tumor Resection in Vitrectomy for Retinal Vasoproliferative Tumors

Purpose

To investigate the efficacy and safety of combined vitrectomy with tumor resection in the treatment of retinal vasoproliferative tumors (RVPT).

Methods

Retrospective study. RVPT patients who underwent vitreous surgery at the Eye Hospital of Wenzhou Medical University from January 2011 to July 2017 were included. The main outcomes included treatment type, tumor activity, and best-corrected visual acuity (BCVA).

Results

Altogether, 16 patients with 17 eyes were enrolled with follow-up of no less than 6 months. Eight eyes were in the resection treatment group (Group R) and 9 eyes were in the conservative treatment group (Group C). Female (69%) were more common. The mean age was 50 (49.72 ± 12.92) years. Fifteen patients got unilateral onset and only one patient suffered bilaterally. The common symptoms were decreased visual acuity, floaters, and visual distortion. The preoperative BCVA ranged from hand movement to 20/20, with an average of 0.82 ± 0.75 LogMAR. Patients were all not high myopia, with a mean axial length of 23.27 ± 0.27 mm (21.61 mm to 24.67 mm). Of the retinal diseases, the epiretinal membrane was the most common, followed by vitreous hemorrhage, uveitis, subretinal fluid, and so on. Compared with the baseline BCVA, it improved more at postoperative 6 months and the last visit in Group R than in Group C (P=0.006 and P=0.033). The BCVA-improved 0.2 LogMAR or above in 6 months was 2 eyes in Group C and 7 eyes in Group R. All tumors in Group R were completely resected, whereas three in Group C (33.3%) had definite activity (P=0.008). In all samples, tumors were located on the inner side of the retina and had small vessel wall thickening and hyaline degeneration. The degree of astrocyte proliferation varies widely among different tumors.

Conclusions

RVPT was more likely to occur in nonhigh myopia patients. Epiretinal membrane and vitreous hemorrhage were the main causes for vitreous surgery in RVPT patients. Compared with conservative treatment, surgical resection of the tumor is more beneficial to patients on visual acuity recovery and preventing tumor relapse. It is a safe and effective way to treat RVPT.

Photodynamic Therapy in Ocular Oncology

Although introduced for the treatment of maculopathies, photodynamic therapy (PDT) is now largely used in some eye cancers treatment. The selective tissue damage with PDT is achieved by sequestration of the photosensitizer in the target tissue and focal activation of the photosensitizer by low energy directed light. In this way, it is possible to achieve the destruction of the tumor tissue by safeguarding the surrounding healthy structures. Our study describes the clinical uses and efficacy of photodynamic therapy in ocular oncology.

Macular Burns from Nonmedical Lasers

Laser devices are widely used for medical, military, industrial and entertainment purposes. This extensive and unregulated use of lasers can cause a variety of maculopathies that can result in permanent vision loss. Uncontrolled and inappropriate use of laser instruments should be prevented with strict rules. We strongly emphasize the importance of changing the general misperception that lasers are safe to use for entertainment purposes. In this study we aim to report the clinical features of three patients with a history of maculopathy caused by exposure to laser light in an entertainment venue.

Clinical characters and treatments of retinal vasoproliferative tumors

Retinal vasoproliferative tumors (VPT) are uncommon benign vascular tumors. They mostly occur in healthy patients, but may be associated with other chorioretinal diseases. Here we report four patients with VPT at a referral center from 2006 to 2015. Three patients denied any past history and one had a history of retinal detachment surgery. VPT-related complications included epiretinal membrane (ERM) (n = 2), cystoids macular edema (n = 1), and lamellar hole combined with dense cataract, rigid anterior capsule and vitreous opacity (n = 1). Treatments for VPT and comorbidities included vitrectomy (VT) and membrane peeling with tumor resection (n = 2), a combined treatment of photodynamic therapy (PDT) and intravitreal injection (IVI) of anti-vascular endothelial growth factor (anti-VEGF) (n = 2). Tumor shrinkage was achieved in both patients treated with PDT and IVI of anti-VEGF injection. The other two patients with ERM were successfully treated with VT and tumor resection. Visual acuity improved at least two lines in three patients, and one patient had decreased vision due to cataract formation after VT. Pathology of the resected tumor in one case revealed massive gliosis with positive stain of vascular endothelial cells and glial fibrillary acidic protein stain. Yet the peeled membrane was acellular. Possible beneficial treatments for VPT and comorbidities include PDT combined with IVI of anti-VEGF, or VT and membrane peeling with tumor resection.