Subfoveal nodule in Coats' disease

Subfoveal Nodule Affecting Visual Prognosis in Coats Disease

PURPOSE

To investigate the characteristics of subfoveal nodules in Korean patients with Coats disease and their association with visual outcomes.

METHODS

A retrospective analysis was conducted within the medical records of patients with stage 2B or 3A1 Coats disease, including clinical features, imaging, presence of either a subfoveal nodule or macular fibrosis, and visual outcome.

RESULTS

Twelve patients were present with stage 2B or 3A1 Coats disease, and nine patients (75%) presented with subfoveal nodule. Between the group without subfoveal nodule and the group with subfoveal nodule, there were no significant differences in age (mean, 14.0 ± 1.7 years vs. 27.7 ± 21.8 years; p = 0.482), sex (all men), stage of the disease (stage 2B: three patients vs. eight patients, p > 0.999; stage 3A1: none vs. one patient, p > 0.999), extension of retinal exudation (mean, 7.7 hours vs. 4.1 hours; p = 0.209) and peripheral telangiectasia (mean, 3.7 hours vs. 4.2 hours; p = 0.727), and follow-up duration (mean, 65.0 months vs. 46.1 months; p = 0.600). There were significantly more patients with severe visual loss (≤20 / 200) among the patients with subfoveal nodule (none vs. seven patients, p = 0.045), and the cause for severe visual loss was macular fibrosis in all cases. Macular fibrosis developed significantly more frequently in the patients with subfoveal nodule (none vs. seven = patients, p = 0.045).

CONCLUSIONS

This study is the first study covering the analysis of subfoveal nodules in Korean patients with Coats disease. The existence of a subfoveal nodule at the initial diagnosis serves as an indicator predicting the development of macular fibrosis and a less favorable visual outcome in the patients with Coats disease. A multicenter study with a larger patient pool and further studies toward the therapeutic approach for the subfoveal nodule and macular fibrosis are needed.

Macular fibrosis in Coats' disease demonstrated by Optical Coherence Tomography Angiography - new data toward pathophysiology

PURPOSE

To analyze if Segmented Swept-Source Optical Coherence Tomography Angiography (SS OCT-A) can provide additional information on morphology and pathophysiology of macular fibrosis in Coats' patients.

METHODS

A consecutive case series of three male patients (5, 7 and 15 years old), with Coats' disease-related macular fibrosis (stage 2b-2 patients, 3b-1 patient). SS OCT-A 3×3 mm macular scans of affected eyes were performed.

RESULTS

In all three cases the inner portion of macular fibrosis displayed a dense network of vessels, continuing into deeper layers. This structure was similar to that observed in retinal angiomatous proliferations (RAP). There was associated loss of the foveal avascular zone. In one case we observed evolution of the lesion.

CONCLUSION

SS-OCT imaging of macular fibrosis in Coats' disease reveals a distinct intralesional vascular structure with elements resembling RAP, probably developing as a secondary process.

Adult Coats Disease Presenting as Subfoveal Nodule

A 21-year-old female presented with decreased vision in the right eye. Best corrected visual acuity was 6/60 in the right eye and 6/6 in the left eye. Funduscopy of the right eye revealed a subfoveal nodule with surrounding exudates and temporal peripheral retinal vessel telangiectasia with exudation. The patient underwent retinal laser in the areas of telangiectatic vessels and capillary non-perfusion as seen on fundus fluorescein angiography. It was combined with an intravitreal injection of bevacizumab which was repeated twice at monthly intervals. The macular lesion and peripheral vessels along with subretinal exudates showed resolution during the course of treatment. However, the patient was lost to follow-up and returned 5 months later when examination revealed increased macular fibrosis. In the literature, the reported presentation of subfoveal nodule in Coats disease is during the first decade. It progresses to macular fibrosis within a few months. This case illustrates that subfoveal nodule before macular fibrosis in Coats disease may present later, even up to the third decade.

SUBFOVEAL NODULE IN COATS' DISEASE: Toward an Updated Classification Predicting Visual Prognosis

Among 40 Coats' disease patients presenting foveal exudation without foveal detachment (Stages 2B-3A1, median follow-up: 4.7 years), 21 eyes (52.5%) developed a subfoveal nodule. These eyes were significantly associated with macular fibrosis progression (P < 0.0001, mean onset time: 11.0 ± 2.6 months) and worse visual outcome (P = 0.01). These observations suggested an updated classification.

To determine the prevalence, clinical characteristics and nature of subfoveal nodules in Coats' disease and the associated impact on the long-term visual outcome.

Retinal angiomatous proliferation with chorioretinal anastomosis in childhood Coats disease: a reappraisal of macular fibrosis using multimodal imaging

PURPOSE

To describe the structural characteristics of retinal angiomatous proliferation and chorioretinal anastomosis in childhood Coats disease and redefine the previously described macular fibrosis.

METHODS

Prospective observational case series of consecutive patients with Coats disease examined over a 1-year study period. Multimodal imaging, including color fundus photography, wide-field fluorescein angiography, and spectral domain optical coherence tomography, was used to identify the features of macular retinal angiomatous proliferation and chorioretinal anastomosis.

RESULTS

Retinal angiomatous proliferation and chorioretinal anastomosis were present in 5 of 21 patients with Coats disease (24%). The lesions appeared as well demarcated, nodular retinal pigment epithelial detachments surrounded by exudate, with retinal vessels continuous with the underlying choroidal neovascularization.

CONCLUSION

Retinal angiomatous proliferation and chorioretinal anastomoses are features observed in a number of children (24% in the present series) with Coats disease and macular involvement. This lesion represents a distinct macular variant of Coats disease that underlies at least a proportion (all in the present series) of the previously described "macular fibrosis" and "subretinal mounds."

Macular fibrosis in Coats disease

PURPOSE

The purpose of this study was to describe the angiographic features and visual impact of macular fibrosis in patients with Coats disease.

METHODS

This is a single institution retrospective case series. Charts of patients diagnosed with Coats disease between 1973 and 2007 were reviewed. Data collected included patient demographics, treatment method, initial and final logarithm of the minimum angle of resolution visual acuity, photographic findings, angiographic characteristics, and anatomical outcome.

RESULTS

Forty-seven patients were identified with adequate imaging and posttreatment follow-up. Average age at presentation was 38 years (4-82 years). Average follow-up was 4.9 years (0-17 years). Macular fibrosis was identified in 11 patients (23%). At presentation, the average logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.67; patients with macular fibrosis, 1.14; and patients without macular fibrosis, 0.50 (P = 0.01, 2-tailed Student's t-test). The average posttreatment logarithm of the minimum angle of resolution visual acuity was as follows: all patients, 0.78; patients with macular fibrosis, 0.97; and patients without macular fibrosis, 0.70 (P = 0.26). Macular fibrosis was associated with a pigmented spot at the point of apparent intraretinal vascular anastamosis. Fluorescein angiography showed leakage consistent with neovascularization that appeared to be intraretinal.

CONCLUSION

Macular fibrosis is a common finding in Coats disease, occurring in 23% of our patients. It may be a result of intraretinal neovascularization and is associated with a worse vision outcome.

RetCam II Fluorescein Angiography to Guide Treatment and Diagnosis of Coats Disease

Coats disease is a well-described clinical condition featuring peripheral leakage from telangiectatic vasculature, resulting in exudative retinal detachments and exudative deposits. It often affects pediatric patients, requiring examinations and treatments to be performed under anesthesia. It can be difficult to distinguish from retinoblastoma. The RetCam II is a wide-field fundus imaging system that can also obtain intraoperative fluorescein angiography. The case of a 5-year-old girl diagnosed with Coats disease is presented. She presented with an exudative detachment, a submacular nodule, and peripheral telangiectasis. An examination under anesthesia, including angiography, was performed. The angiograph revealed characteristic aneurysms as well as extensive areas of telangiectasis and ischemia not readily visible on examination. The angiogram allowed more diagnostic certainty and guided a more complete treatment than otherwise possible. We propose that fluorescein angiography with the RetCam II system can be a useful tool when examining and treating pediatric patients with Coats disease.

Vitreoretinal surgery in advanced coats disease

PURPOSE

To report the outcomes of vitreoretinal surgery for a patient with total retinal detachment and a subretinal nodule associated with Coats disease (CD).

METHODS

A 20-year-old woman stage 3B CD underwent vitreoretinal surgery with triamcinolone acetonide-assisted pars plana vitrectomy, limited retinotomy, removal of the subretinal nodule and membrane, endolaser photocoagulation, and silicone oil tamponade. The surgical outcomes were observed.

RESULTS

Retinal attachment was achieved after vitreoretinal surgery, removal of the subretinal membrane, and endoresection of the subretinal fibrous nodule. No intraoperative or postoperative complications occurred due to the surgical technique. The retina remained attached during the postoperative follow-up period of 6 months.

CONCLUSION

Vitreoretinal surgery is an effective surgical technique that provides successful reattachment of the retina and enables endoresection of the subretinal fibrous nodule in eyes with advanced CD. It also prevents the devastating intraocular complications leading to enucleation.