Management of choroidal neovascularization in uveitis

Intravitreal Antivascular Endothelial Growth Factor Treatment for Inflammatory Choroidal Neovascularization in Noninfectious Uveitis

PURPOSE

To compare visual outcome and recurrence rates of eyes with noninfectious inflammatory choroidal neovascularization (CNV) treated with or without anti-vascular endothelial growth factor (VEGF) injections and immunosuppression.

DESIGN

Retrospective, nonrandomized clinical study.

METHODS

Participants: Patients with CNV secondary to noninfectious inflammatory causes who attended uveitis clinics at Moorfields Eye Hospital between January 2000 and April 2016. Data were gathered from the clinical notes of all subjects examined in clinic.

MAIN OUTCOME MEASURES

change in best-corrected visual acuity (BCVA), mean time to CNV recurrence, moderate vision loss (≤20/50), and severe vision loss (≤20/200).

RESULTS

A total of 166 patients (204 eyes) with noninfectious inflammatory CNV were included in this study with a median follow-up of 6.9 years (interquartile range: 2.9-11.7; 1652 eye-years). The mean BCVA at the time of CNV diagnosis was 0.38 ± 0.05 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent 20/47) in the eyes that received the first-line anti-VEGF treatment and 0.44 ± 0.03 logMAR (Snellen equivalent 20/55) in the eyes on other treatment modalities (P = .39). Eyes treated first with anti-VEGF (n = 55) received the mean of 4.35 ± 0.53 injections and showed a statistically significant improvement in vision at all time points (P < .001) except for a 5-year visit (P = .25). The rest of the eyes demonstrated no significant change in vision throughout follow-up (all P > .05). At the final visit, the mean BCVA was 0.26 ± 0.11 logMAR (Snellen equivalent 20/36) in the former and 0.35 ± 0.06 logMAR (Snellen equivalent 20/44) in the latter. The mean time to CNV recurrence was 186 ± 15.1 months, and the risk was significantly reduced by treatment with oral corticosteroids (adjusted hazard ratio = 0.32, confidence interval: 0.17-0.59, P < .001) or anti-VEGF injections (adjusted hazard ratio = 0.31, confidence interval: 0.18-0.52, P < .001).

CONCLUSIONS

Eyes that developed inflammatory CNV were at risk of vision loss. Those receiving early anti-VEGF injections achieved a better visual outcome and had a reduced risk of CNV recurrence. Oral corticosteroids also had an effect that reduces the risk of recurrence in eyes previously treated.

Diagnostic Challenges in Inflammatory Choroidal Neovascular Membranes

PURPOSE

To describe the clinical presentations of inflammatory choroidal neovascular membranes (CNVMs) and factors leading to their delayed diagnosis.

METHODS

Retrospective analysis of chart records and digital images of 60 patients (73 eyes) with inflammatory CNVM (January 1998 to December 2013) to obtain demographic and clinical details, particularly the time of the first documentation of inflammatory CNVM by the uveitis specialist, time of its actual appearance on digital images, and the earliest clinical indicators of a CNVM.

RESULTS

In total, 14 (19.2%) eyes had a delayed diagnosis of inflammatory CNVMs, of which five developed significant visual loss. The earliest clinical indicators of CNVM that were overlooked initially due to their subtle appearance, included a tiny subretinal hemorrhage (five eyes), peripapillary halo/fluid/scar (eight eyes), and a subfoveal scar (one eye). The causes of uveitis in these eyes included Vogt-Koyanagi-Harada disease (five eyes, 35.7%), tubercular uveitis (five eyes, 35.7%), idiopathic (three eyes, 21.4%), and sympathetic ophthalmia (one eye, 7.1%). Presence of significant background fundus scarring, sunset glow fundus, visually significant cataract, poorly dilating pupil, media haze due to vitritis, cystoid macular edema, and multiple chorioretinal scars in these eyes probably predisposed to delayed detection of an underlying CNVM.

CONCLUSIONS

A high index of suspicion and comparison of serial fundus photographs to identify the earliest clues of inflammatory CNVMs are important to prevent diagnostic delays and poorer outcomes.

Risk of choroidal neovascularization among the uveitides

PURPOSE

To evaluate the risk, risk factors, and visual impact of choroidal neovascularization (CNV) in uveitis cases.

DESIGN

Retrospective cohort study.

METHODS

Standardized medical record review at 5 tertiary centers.

RESULTS

Among 15,137 uveitic eyes (8868 patients), CNV was rare in the cases of anterior or intermediate uveitis. Among the 4041 eyes (2307 patients) with posterior uveitis or panuveitis, 81 (2.0%) had CNV at presentation. Risk factors included posterior uveitis in general and specific uveitis syndromes affecting the outer retina-retinal pigment epithelium-choroid interface. Among the 2364 eyes (1357 patients) with posterior uveitis or panuveitis and free of CNV at the time of cohort entry, the cumulative 2-year incidence of CNV was 2.7% (95% confidence interval [CI], 1.8% to 3.5%). Risk factors for incident CNV included currently active inflammation (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.26 to 3.60), preretinal neovascularization (aHR, 3.19; 95% CI, 1.30 to 7.80), and prior diagnosis of CNV in the contralateral eye (aHR, 5.79; 95% CI, 2.77 to 12.09). Among specific syndromes, the incidence was greater in Vogt-Koyanagi-Harada syndrome (aHR, 3.37; 95% CI, 1.52 to 7.46) and punctate inner choroiditis (aHR, 8.67; 95% CI, 2.83 to 26.54). Incident CNV was associated with a 2-line loss of visual acuity (+0.19 logarithm of the minimal angle of resolution units; 95% CI, 0.079 to 0.29) from the preceding visit.

CONCLUSIONS

CNV is an uncommon complication of uveitis associated with visual impairment that occurs more commonly in forms affecting the outer retina-retinal pigment epithelium-choroid interface, during periods of inflammatory activity, in association with preretinal neovascularization, and in second eyes of patients with unilateral CNV. Because CNV is treatable, a systematic approach to early detection in high-risk patients may be appropriate.

Peripapillary choroidal neovascularization in pars planitis

BACKGROUND

Choroidal neovascularization (CNV) is a rare complication of intermediate uveitis. Risk factors are not well-characterized. Here, we describe a case of peripapillary CNV in a patient with intermediate uveitis and explore the pathophysiology and treatment of this condition. This study is a case report and review of the literature.

RESULTS

A 15-year-old boy with intermediate uveitis - suppressed for the preceding year on immunosuppressive therapy and low-dose corticosteroids - and chronic disc swelling presented with unilateral metamorphopsia, peripapillary subretinal hemorrhage, and subretinal fluid. Fluorescein angiogram confirmed the presence of an active choroidal neovascular membrane. Treatment with intravitreal bevacizumab 1.25 mg every 4 weeks for 4 months resulted in resolution of subretinal fluid, subretinal hemorrhage, and regression of the CNV. The patient's intermediate uveitis remained inactive throughout this time.

CONCLUSION

Review of the existing literature and pathophysiologic consideration suggests that chronic disc edema may be a risk factor for this condition. Peripapillary CNV in the context of intermediate uveitis appears to respond well to VEGF-inhibitor therapy.

Effects of intravitreal bevacizumab on inflammatory choroidal neovascular membrane

purpose. To test the efficacy of intravitreal bevacizumab (IB) in the treatment of inflammatory choroidal neovascularization (CNV). 
Methods. A prospective interventional study on patients with subfoveal CNV secondary to posterior/diffuse uveitis treated with 1.5 mg/0.05 mL of IB. Eight eyes of 8 patients, with mean follow-up of 19.25±6 months, were included. The measurements adopted were 1) changes in best-corrected visual acuity (BCVA), 2) reduction in CNV size, and 3) changes in central foveolar thickness (CFT) measured by optical coherence tomography. 
Results. The mean number of intravitreal injections was 3.75±1.38. After IB treatment, the mean BCVA improved significantly, from 0.27±0.10 before treatment to 0.5±0.29 after treatment (p<0.05). The CFT also responded well to IB, with 402.75±114.11 µm preoperatively, and after treatment 300.5±90.98 µm (p<0.01). Notably, all patients showed a reduction in the size of the CNV and BCVA remained stable or improved in 7 eyes (87.5%). No episode of active intraocular inflammation was observed and patients continued to receive their systemic steroid or immunosuppressive therapy.
Conclusions. Intravitreal bevacizumab may be an additional strategy in inflammatory CNV of eyes with controlled uveitis.

Inflammatory choroidal neovascular membrane in posterior uveitis-pathogenesis and treatment

Choroidal neovascular membrane (CNVM) formation is a well-documented sight-threatening complication of posterior segment intraocular inflammation (PSII). The aim of this article is to review the basic and clinical science literature on the pathogenesis of CNVM formation in PSII and to present results of a case series. We searched the literature using the mesh terms- inflammation, CNVM, age-related macular degeneration, immunosuppression, photodynamic therapy, steroids, vascular endothelial growth factors and posterior uveitis. Additionally, we evaluated the visual outcome of and clinical response to our standard treatment protocol involving a combination treatment for young patients with inflammatory CNVM. The development of CNVM in PSII is promulgated by infiltrating myeloid cells as well as choroidal and retinal myeloid cell activation, subsequent vascular endothelial growth factors, cytokine and chemokine production and complement activation acting in consort to mediate angiogenic responses. No clear standard of care currently exists for the treatment of inflammatory CNVM and various combinations have been tried. Using our combination treatment, visual acuity improved in four, stabilized in one and worsened in four patients. Though significant advances have occurred in the understanding of the pathogenesis and management of this condition, optimizing therapeutic regimens will require further well-constructed prospective cohort series.