Photodynamic therapy for extrafoveal choroidal neovascularization associated with choroidal nevus

Treatment response to intravitreal bevacizumab in small pigmented choroidal lesions with subretinal fluid

Background

To describe the effects of intravitreal bevacizumab injection (IVB) and/or transpupillary thermotherapy (TTT) in the treatment of small pigmented choroidal lesions with subfoveal fluid (SFF), and to investigate prognostic value of the therapeutic response in future tumor growth.

Methods

Retrospective chart review of 19 patients, who were diagnosed with choroidal neovascularization (CNV)-free small pigmented choroidal lesions and treated with IVB and/or TTT, was performed.

Results

Complete resolution of SFF was achieved in two eyes (2/14; 14.3%) after IVB, and in three eyes (3/4; 75%) after TTT. Best corrected visual acuity was improved in two eyes (2/9; 22%) after IVB, and in three eyes (3/4; 75%) after TTT. Among five patients who underwent TTT after IVB, four patients (4/5; 80%) demonstrated additional advantage. All IVBs could not reduce tumor sizes. Rather, tumor growth was detected in seven out of 14 eyes (7/14; 50%) that underwent IVB. None of the patients who underwent TTT showed tumor growth. The lack of treatment response to IVB was suggestive of malignancy, as most small pigmented lesions that had no response to IVB showed tumor growth (86%, p = 0.010).

Conclusion

IVB was not effective in reducing tumor size and subfoveal fluid in small pigmented choroidal lesions. Therapeutic response to IVB can be used as an indicator between melanoma and nevus in small pigmented choroidal lesion.

Treatment of vascular activity secondary to atypical choroidal nevus using intravitreal bevacizumab

Objective

To report the optical coherence tomography (OCT) findings of 27 eyes treated with intravitreal bevacizumab for intraretinal and subretinal vascular activity associated with atypical choroidal nevi.

Methods

This was an Internal Review Board-approved retrospective review of 27 eyes of 27 patients with choroidal nevus treated for secondary vascular activity with intravitreal injections of bevacizumab, performed by a single surgeon (TGM) at the Bascom Palmer Eye Institute. All patients were rigorously evaluated before the procedure and followed thereafter with ophthalmic examinations, refractive analysis, fundus photos, optical coherence tomography (OCT), and ocular echography. Patient demographics, tumor characteristics, dates of bevacizumab injections, and spectral-domain (SD)-OCT findings at each injection were recorded. Macular edema was graded as per SD-OCT findings for the initial and final visit.

Results

The mean age was 66.6 years (range, 40–86 years), with ten males and 17 females. Mean, median, and range baseline best corrected visual acuity (BCVA) were 20/53, 20/40, and 20/20–4/200, respectively. After a mean follow up of 29 months, the final BCVA mean, median, and range were 20/50, 20/40, and 20/20–20/400, respectively. The final BCVA ranged from 20/20 to 20/25 in nine eyes, while only six eyes had an initial BCVA within the same range. All patients demonstrated OCT findings of vascular activity suggestive of choroidal neovascularization (CNV). Initial SD-OCT findings included intraretinal cysts in eleven eyes, intraretinal fluid in six eyes, subretinal fluid in 14 eyes, pigment epithelial detachment in six eyes, epiretinal membrane in five eyes, and subretinal neovascularization in 14 eyes. On fundus photos, four eyes presented retinal hemorrhage. A mean of eight (range of 1–31) intravitreal bevacizumab (1.25 mg/0.05 cc) injections were given in all cases. A total of 37% (10/27) of eyes had complete or partial regression of vascular activity. The mean initial OCT classification for macular edema was 3 and a mean grade of 3 was maintained at the final follow-up OCT. All 27 choroidal nevi remained stable, and there were no adverse effects from the bevacizumab injections.

Conclusion

To our knowledge, this is the largest published case series of eyes treated with intravitreal bevacizumab for vascular activity associated with choroidal nevus. Intravitreal bevacizumab seems to be effective in the treatment of CNV secondary to choroidal nevus, and OCT can be a useful tool in the follow up of these patients, to assess the regression of CNV and to monitor macular edema.

[Outcome of photodynamic therapy for subretinal neovascularization secondary to choroidal nevi]

INTRODUCTION

Choroidal nevi are the most common benign intraocular tumors. However, the occurrence of subretinal neovascularization secondary to choroidal nevus is very rare. Our goal was to assess the efficacy and the safety of photodynamic therapy (PDT) for treatment of subretinal neovascularization related to choroidal nevi.

PATIENTS AND METHOD

We conducted a retrospective study including subretinal neovascularization secondary to choroidal nevi treated by PDT from 1999 to 2005. PDT was performed according to the standard protocols used for treating neovascularization due to age-related macular degeneration (ARMD). Post-PDT follow-up was also done according to the guidelines used in ARMD. Moreover, tumors were followed up every 3 months.

RESULTS

Six subretinal neovascularizations secondary to choroidal nevi were included in our study. All nevi were localized in the posterior choroids. The median diameter of tumors was 3mm and their thickness was less than 2mm in all cases. Subretinal neovascularizations were classic in five cases. The last case was a small vascularized pigment epithelium detachment. Locations were subfoveal in two cases, juxtafoveal in three cases, and extrafoveal in one case. In half the cases, the size of subretinal neovascularization was 1-disk-diameter or less. A mean of 3.3 sessions of PDT were necessary to obtain the stabilization of subretinal neovascularization on both fluorescein angiography and OCT. The average follow-up period was 35 months with no patients lost to follow-up. Visual outcomes were extremely variable. Large or subfoveal neovascularization but also a history of atrophic ARMD were related to worse functional results. No growth of the nevi was observed.

CONCLUSIONS

Subretinal neovascularization is reassuring from the oncologist's point of view because it is considered a relative indicator of benignity of the nevus. However, it often marks a definitive turning point in visual function. PDT appears to be a safe and effective procedure for the treatment subretinal neovascularization secondary to choroidal nevus, with results similar to those observed in ARMD.