Intravitreal bevacizumab for extrafoveal choroidal neovascularization secondary to pathologic myopia

Management of coexistent choroidal neovascular membrane and macular hole with serous detachment in a case of pathological myopia: challenges and dilemmas

Coexistent choroidal neovascular membrane and macular hole with serous retinal detachment in pathological myopia is a rare entity and may be quite challenging to manage. We present such a case managed with bevacizumab injection and vitrectomy. Although the retina was attached at the final follow-up, the visual outcome was poor, due to non-closure of hole.

Pharmacotherapy of Myopic Choroidal Neovascularization

BACKGROUND

Myopic choroidal neovascularization (CNV) is a common cause of central visual loss in patients with high myopia, and the most common form of CNV in younger individuals. Pharmacologic therapy is the current mainstay of treatment of these patients.

METHODS

Review of pharmacological treatment options for myopic CNV, which primarily involves intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF) agents.

RESULTS

At this time, anti-VEGF therapy agents are the first-line therapy in these patients. Comparative trials have not identified any major differences in treatment outcomes between aflibercept, bevacizumab, and ranibizumab. Only ranibizumab is approved for this indication in the US. Best visual outcomes are associated with younger age, smaller lesion size, and absence of chorioretinal atrophy.

CONCLUSION

Anti-VEGF therapy is generally very effective in the treatment of myopic CNV.

Management of Myopic Choroidal Neovascularization: Focus on Anti-VEGF Therapy

Myopic choroidal neovascularization (mCNV) is the second most common form of CNV after age-related macular degeneration (AMD). It is a sight-threatening complication of pathologic myopia (PM) and often affects patients in their working years causing significant impact on quality of life. Previous therapies such as photodynamic therapy with verteporfin have shown limited success. Due to the similarities in pathogenesis of mCNV and AMD CNV, anti-vascular endothelial growth factor therapy (anti-VEGF), which has so far been the mainstay of treatment for AMD CNV, has been shown to be effective in the treatment of mCNV and has become the first-line treatment of choice. This article aims to examine briefly the epidemiology and pathophysiology of mCNV, as well as review the evidence for efficacy, safety, and clinical use of anti-VEGF treatment for mCNV.

Anti-VEGF treatment for myopic choroid neovascularization: from molecular characterization to update on clinical application

Choroidal neovascularization (CNV) secondary to pathologic myopia has a very high incidence in global, especially in Asian, populations. It is a common cause of irreversible central vision loss, and severely affects the quality of life in the patients with pathologic myopia. The traditional therapeutic modalities for CNV secondary to pathologic myopia include thermal laser photocoagulation, surgical management, transpupillary thermotherapy, and photodynamic therapy with verteporfin. However, the long-term outcomes of these modalities are disappointing. Recently, intravitreal administration of anti-VEGF biological agents, including bevacizumab, ranibizumab, pegaptanib, aflibercept, and conbercept, has demonstrated promising outcomes for this ocular disease. The anti-VEGF regimens are more effective on improving visual acuity, reducing central fundus thickness and central retina thickness than the traditional modalities. These anti-VEGF agents thus hold the potential to become the first-line medicine for treatment of CNV secondary to pathologic myopia. This review follows the trend of “from bench to bedside”, initially discussing the pathogenesis of myopic CNV, delineating the molecular structures and mechanisms of action of the currently available anti-VEGF drugs, and then systematically comparing the up to date clinical applications as well as the efficacy and safety of the anti-VEGF drugs to the CNV secondary to pathologic myopia.

Intravitreal ranibizumab for naive extrafoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To investigate the effect of intravitreal ranibizumab on extrafoveal choroidal neovascularization secondary to age-related macular degeneration.

METHODS

Eighteen eyes affected by extrafoveal choroidal neovascularization secondary to age-related macular degeneration were prospectively enrolled in this study. After an initial intravitreal ranibizumab, all patients were reevaluated monthly over 12 months of follow-up. Further retreatments were performed on a pro re nata basis, depending on detection of any type of fluid on optical coherence tomography and/or the presence of leakage on fluorescein angiography. Primary outcome measures were mean changes in best-corrected visual acuity and the proportion of eyes gaining at least 15 letters (3 Early Treatment Diabetic Retinopathy Study [ETDRS] lines) at the end of the follow-up. Secondary outcome measures were central macular thickness variations and changes in choroidal neovascularization size.

RESULTS

Mean best-corrected visual acuity presented a significant improvement during the follow-up period, being 0.3 ± 0.2 logMAR at baseline and 0.2 ± 0.2 logMAR at the 12-month examination (P < 0.001). An improvement of at least 3 EDTRS lines was achieved by 6 eyes (33.3%), whereas 6 patients (33.3%) gained 1 to 2 lines. The mean central macular thickness at baseline was 314 ± 87 μm, changing to 268 ± 65 μm at the 12-month examination (P = 0.003). The mean lesion size was 1.4 ± 1.4 mm and remained stable throughout the follow-up, being 1.8 ± 2.9 mm at 12 months (P = 0.64).

CONCLUSION

Intravitreal ranibizumab administered after a pro re nata regimen with monthly evaluation is a beneficial approach for the management of extrafoveal choroidal neovascularization secondary to age-related macular degeneration over 12 months of follow-up. Further studies are warranted to confirm our preliminary results.

Intravitreal bevacizumab for nonsubfoveal choroidal neovascularization associated with angioid streaks

PURPOSE

To evaluate the effects of intravitreal bevacizumab injections in the treatment of nonsubfoveal choroidal neovascularization (CNV) associated with angioid streaks.

DESIGN

Nonrandomized, interventional, prospective case series.

METHODS

Fifteen patients (15 eyes) affected by juxtafoveal or extrafoveal CNV secondary to angioid streaks were enrolled in the study. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement on Early Treatment Diabetic Retinopathy Study (ETDRS) chart, optical coherence tomography (OCT), and fluorescein angiography (FA). The protocol treatment included a first injection, followed by repeated injections over a 12-month follow-up period on the basis of the detection of new hemorrhage on biomicroscopic examination, any type of fluid on OCT, or presence of leakage on FA.

PRIMARY OUTCOME MEASURES

Mean changes in BCVA and proportion of eyes gaining at least 10 letters (2 ETDRS lines) at the end of the follow-up.

SECONDARY OUTCOMES

Mean changes of central macular thickness (CMT) and extension to the fovea.

RESULTS

Mean BCVA did not change throughout the follow-up period, being 0.2 ± 0.2 logMAR at baseline and 0.2 ± 0.3 logMAR at the 12-month examination. A functional improvement of at least 2 ETDRS lines was achieved by 5 eyes (33%), with 3 eyes (20%) gaining 3 lines. Mean CMT at baseline was 215 ± 13 μm and 225 ± 85 μm at the 12-month examination. Two eyes (13.3%) showed CNV extension to the fovea.

CONCLUSIONS

Intravitreal bevacizumab injection can be a beneficial approach for the management of nonsubfoveal CNV secondary to angioid streaks over a 1-year follow-up.

Co-existent choroidal neovascular membrane and macular hole in pathologic myopia: a long follow-up clinical outcome and literature review

Choroidal neovascularization (CNV) is an uncommon complication associated with a macular hole. In this case report of a rare condition, we present a pathologic myopia patient with a co-existent macular hole and choroidal neovascular membrane. The patient was treated with photodynamic therapy for CNV, and then vitreous surgery for the retinal detachment and macular hole. At the end of 4 years follow-up, her visual acuity was improved to 0.1 while the macular hole remained open. Optical coherence tomography is a useful inspection method of the diagnosis of CNV and macular hole.