Birdshot retinochoroidopathy and subretinal new vessels

Intravitreal ranibizumab for choroidal neovascularization in a patient with angioid streaks and multiple evanescent white dots

BACKGROUND

To report a patient with angioid streaks (ASs) and coincident multiple evanescent white dot syndrome (MEWDS) who developed choroidal neovascularization (CNV).

CASE PRESENTATION

A 20-year-old woman presented with reduced vision (20/100) in her left eye (LE). Based on a complete ophthalmologic examination the patient was diagnosed with ASs and coincident MEWDS. Two weeks later best-corrected visual acuity (BCVA) improved up to 20/25 and the MEWDS findings almost disappeared. Two months later BCVA dropped again (20/100) due to the development of CNV which was treated by a single intravitreal injection of ranibizumab (0.5 mg/0.05 mL). One month after this BCVA improved up to 20/40, and there was regression of the CNV. There was no need for retreatment at the last follow-up visit, 1 year after the ranibizumab injection, when the patient showed further recovery of BCVA up to 20/25.

CONCLUSIONS

In this case of ASs, MEWDS completely resolved after 2 weeks, but 2 months later CNV developed. A single intravitreal injection of ranibizumab had a long-lasting effect. Larger series are necessary to clarify the pathogenesis of CNV in such cases and the role of intravitreal ranibizumab.

Choroidal Neovascularization Associated With Birdshot Chorioretinopathy

BACKGROUND AND OBJECTIVE

Patients with birdshot chorioretinopathy (BCR) may develop visual compromise due to choroidal neovascularization (CNV), and few series address management strategies in the anti-vascular endothelial growth factor (VEGF) era. The purpose of this study was to describe the clinical outcomes of combination anti-VEGF and immunosuppressive therapy for CNV associated with BCR.

PATIENTS AND METHODS

Retrospective, interventional case series. Patients with BCR from two tertiary uveitis and retina practices were reviewed. Patients with CNV in association with BCR were identified and reviewed in detail. Clinical features, treatments utilized (ie, anti-VEGF injections, immunosuppressive therapy), and functional and structural outcomes over long-term follow-up were recorded. Outcomes measured included Snellen visual acuity, spectral-domain optical coherence tomography macular thickness during treatment, number and type of anti-VEGF injections, the need for initiation or escalation of immunosuppression, and incidence of CNV in macula-involved versus macula-sparing BCR.

RESULTS

Four of 36 BCR patients were diagnosed with choroidal neovascularization (11%). Identification of CNV in all patients prompted treatment with intravitreal anti-VEGF injections and an increase or initiation of local or systemic immunosuppression. Mean Snellen visual acuity improved from 20/60 to 20/30 at final follow-up (P = .02). Mean central subfield thickness improved from 443 μ to 254 μ (P = .04). CNV in association with BCR occurred at a rate of 0.11 events per patient-year (95% CI, 0.02-0.31) in macula-involved BCR versus zero events/patient-year in macula-spared BCR (95% CI, 0-0.058; P = .009).

CONCLUSION

Anti-VEGF therapy was effective for the treatment of CNV in BCR patients. A combination of systemic or local immunosuppression and anti-VEGF therapy may be useful in the management of CNV associated with BCR. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:450-457.].

Visual Acuity in Birdshot Retinochoroidopathy Evaluation

PURPOSE

To determine the statistical correlation between visual acuity (VA) and various quantitative parameters relevant to birdshot retinochoroidopathy (BRC) evaluation.

DESIGN

Hospital-based retrospective observational study.

METHODS

setting: Institutional.

STUDY POPULATION

Consecutive HLA29+ BRC patients were included between May and August 2013 at a single tertiary center (Pitié-Salpétrière Hospital, Paris).

OBSERVATION PROCEDURES

Demographic data and quantitative parameters relevant to BRC at baseline were collected: VA, degree of anterior and posterior inflammatory reaction, foveal thickness measured by optical coherence tomography (OCT), Arden ratio, and electrooculography (EOG) light peak.

MAIN OUTCOME MEASURES

Correlation between VA and the other parameters of the ipsilateral and fellow eye was performed using Spearman rank correlation coefficients.

RESULTS

Fifty-five patients were included. Mean VA was 6/9.5 in the right eye (OD) and 6/12 in the left eye (OS). Mean foveal thickness was 240 μm OD (range: 112-606) and 251 μm OS (range: 85-662). Mean Arden ratio was 159% OD and 160% OS. EOG light peak was 714 mV OD (range: 316-1379) and 746 mV OS (range: 272-1652). VA of a given eye was moderately correlated with VA of the contralateral eye (r = 0.4). On the contrary, all other parameters showed a strong correlation between both eyes (all r > 0.7, P < .01). Overall, none of the studied parameters was correlated with its VA (all r < 0.5).

CONCLUSION

In BRC, visual acuity alone does not seem to fully reflect the disease severity in terms of clinical or ancillary quantitative findings at baseline.

Birdshot Chorioretinopathy

Birdshot chorioretinopathy is a well-known, yet poorly understood, form of posterior uveitis, characterized by multiple, distinctive, hypopigmented choroidal lesions, and strongly associated with human leukocyte antigen (HLA)-A29. We reviewed all English language publications regarding birdshot chorioretinopathy and performed analyses of combined patient data taken from these articles. The mean age at presentation was 53 years, with a slight female predominance (54.1%). At least 95.7% of reported patients have been HLA-A29-positive. Blurring of vision and floaters are the most prevalent presenting complaints, even in patients with visual acuity of 20/20 or better in both eyes. Birdshot chorioretinopathy is a slowly progressive disease with profound dysfunction of vision that may not be reflected in Snellen visual acuity. Two or more lines of Snellen visual acuity were lost in approximately 20% of eyes over a median follow-up of 3.5 years; macular edema was the most common cause of reduced visual acuity. Overall, patients had a slow decline in visual acuity, despite the fact that nearly all were treated with anti-inflammatory therapies. Final visual acuity in the better eye was 20/40 or better in 75.1% of patients and 20/200 or worse in 9.8% of patients. Oral corticosteroids and cyclosporine were the most commonly used medications. Using a regression model, patients in the literature that have been treated with cyclosporine alone had better final visual acuity than patients treated with oral corticosteroids alone. Further study is needed to determine the optimal methods for treating and monitoring patients with birdshot chorioretinopathy.

Subretinal neovascular membranes complicating uveitis: frequency, treatments, and visual outcome

PURPOSE

Retrospective evaluation in a uveitic population of subretinal neovascular membranes (SRNMs), their occurrence, visual impact, and outcome in differently treated subgroups of patients.

METHODS

Medical records of patients were reviewed and cases with SRNM (n = 12) identified. Intraocular inflammation was classified according to vitreous examination records as high (2+ cells), low (1/2+ to 1+ cells), or inactive (0 cells). Visual outcome was considered to be +VA (same or gain of one or more Snellen lines) or -VA (loss of Snellen lines). In nine cases, treatment consisted of the oral administration of high doses of corticosteroids (CST) for one month, tapered down in favorable situations (+VA or SRNM angiographic regression) or maintained at half the dose in unfavorable situations (-VA or SRNM angiographic progression) while additional laser therapies, including photodynamic therapy (PDT), transpupillary thermotherapy (TTT), or argon laser therapy (CLT)), were performed in some of the cases. The above treatment scheme was not applied in three cases (pre-PDT period; undiagnosed underlying uveitis treated without CST).

RESULTS

Twelve out of 648 patients (1.9%) with uveitis developed SRNM. The mean visual impact was 4.5 Snellen lines and mean follow-up time was 19.5 months. Two patients with high intraocular inflammation had a favorable visual outcome with CST alone. Eight patients with low intraocular inflammation had a favorable visual outcome with CST alone in three cases, with additional laser therapy in four cases (PDT in 3 cases and TTT in 1 case), and exclusively with PDT in one case (undiagnosed uveitis). Two patients with no intraocular inflammation had unfavorable visual outcome with CST alone (no PDT/TTT available).

CONCLUSION

SRNMs occurred as a rare complication of uveitis. Their visual outcome was relatively favorable. Although high doses of CST seem to be the first step in the management of SRNMs, alternative laser treatments should be considered early, especially in cases of absence or low intraocular inflammation.

Electroretinographic monitoring in birdshot chorioretinopathy

PURPOSE

To evaluate electroretinography (ERG) during long-term follow-up in birdshot chorioretinopathy (BCR).

DESIGN

Retrospective, comparative interventional case series.

METHODS

SETTING

University subspecialty clinic.

PATIENT POPULATION

Twenty-three HLA-A29-positive patients with BCR and 40 normal control subjects. INTERVENTION PROCEDURE: Patients were monitored with ERG approximately annually. Treatment was according to best medical judgment. main outcome measures: Baseline ERG values, vision, and ERG values during observed and treated intervals.

RESULTS

Median age of patients was 52 years, and 19 patients were untreated at baseline. Eighty-two ERGs were performed. Eighteen patients had more than one ERG; mean follow-up of these patients was 40.2 months +/- 31.2, median 23 months. At baseline, several ERG parameters were statistically reduced compared with control subjects when adjusted for age. The combined rod-cone and cone b/a wave ratios did not differ from control subjects (P = .45 and 0.14). Scotopic rod and combined rod-cone b-wave amplitudes were statistically correlated with baseline vision, as were implicit times for the combined rod-cone a-wave, cone a-wave, and cone flicker b-wave. Median visual acuity was 20/25 and did not change during follow-up. Most ERG parameters showed marked worsening during observed intervals. During treated intervals, the ERG declined at a rate consistent with aging.

CONCLUSIONS

Many ERG parameters in patients with BCR greatly differ from control subjects, correlate with vision, and worsen during observation. Selected patients may show improvement in ERG with treatment. The cone b-wave flicker implicit time was most often associated with clinically important measures such as vision, duration of symptoms, and deviation from normalcy.

Birdshot chorioretinopathy

PURPOSE

To ascertain the clinical features and long-term visual prognosis of birdshot chorioretinopathy (BCR), and to identify patients at risk of visual loss.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Fifty-five consecutive patients with HLA-A29-positive BCR who were identified in ophthalmology departments of the University Medical Center of Utrecht and The Eye Hospital Rotterdam, of whom 37 were observed for at least 5 years.

INTERVENTION

A review of the medical and photographic and/or angiographic records of 55 patients with HLA-A29-positive BCR.

MAIN OUTCOME MEASURES

Numerous variables were compared, including age and gender distribution, onset and course of BCR, ocular manifestations, therapeutic strategies and their outcomes, complications, systemic diseases, visual acuity (VA), and features associated with poor visual outcome.

RESULTS

Loss of VA was gradual; the number of affected eyes with VA less than 20/200 increased from 9 of 108 (8%) at onset to 22 of 73 (30%) at 5 years and 19 of 49 (39%) at 10 years of follow-up. The cause of compromised VA was predominantly macular edema and macular atrophy (42 of 55 [76% of cases]). We found strong associations between the VA at onset and visual outcome after 5 and 10 years (P = 0.005 and P = 0.006, respectively). Mean VA at the 5-year follow-up was significantly lower if macular leakage was observed on angiography (P<0.001). No differences in annual loss of VA were observed between patients treated by standard therapeutic modalities and untreated patients.

CONCLUSION

The visual prognosis of BCR in a spectrum of uveitis is poor, and the recommended therapeutic regimens have had no effect on long-term visual prognosis. New treatment strategies are needed for this blinding disorder.

Birdshot retinochoroiditis: long term follow-up of a chronically progressive disease

PURPOSE

To determine the long-term course of birdshot retinochoroiditis by reviewing patient records from The University of Iowa Hospitals and Clinics.

DESIGN

A descriptive case series.

METHODS

We conducted a retrospective review of 19 patients seen at The University of Iowa for birdshot retinochoroiditis. Inclusion criteria were set before review. Goldmann perimetry isopters were converted to an area measurement in steradians and the I2e and I4e isopters were evaluated at each time point. The visual acuity, electroretinography (ERG), and visual field findings were compared to the clinical appearance of the fundus.

RESULTS

Follow-up ranged from one visit to 220 months. Of the 14 patients who were tested, all were HLA-A29-positive. Seven patients were followed for >or=60 months. Eleven patients were followed for >or=30 months. The initial visual acuity was 20/50 or better in 36 of 38 eyes and 20/60 and 20/80 in the remaining two. Visual acuity was worse than 20/50 in three of 22 eyes followed for more than 30 months. Visual field data demonstrated progressive loss of area for either the I4e or I2e isopters in six of seven patients who were followed for >or=60 months. Multiple ERGs were performed over time on eight of 19 patients; seven of eight patients demonstrated progressive loss of electrophysiologic indices.

CONCLUSION

Retinal function in birdshot retinochoroiditis deteriorated progressively over a period of years despite stable visual acuity. Late in the course of disease, visual acuity may be lost due to chorioretinal atrophy in the posterior pole. Visual acuity alone is not an adequate parameter with which to monitor disease activity and may falsely suggest that a patient is stable or doing well. Intermittent treatment of the inflammatory exacerbations did not prevent progressive visual loss. Other treatment strategies such as prolonged corticosteroid or immunosuppressive treatment should be investigated for patients with birdshot retinochoroiditis.

Retinal function in birdshot retinochoroidopathy

The electroretinograms (ERGs) of 15 patients with birdshot retinochoroidopathy varied from super-normal to non-recordable, depending upon the severity and the stage of the disease. The abnormal ERGs were characterized by a disproportionate decrease of the b-wave amplitude compared with the a-wave amplitude, demonstrating the negative (-) type response. This distinct ERG pattern has not been observed in any other type of uveitis or chorioretinitis, and appears specific to birdshot retinochoroidopathy. ERG findings indicate that in birdshot retinochoroidopathy the neural layers of the retina are more diffusely and severely involved than the receptor-retinal pigment epithelium-choroid complex. In the most advanced stage, the patients becomes night blind with a non-recordable ERG, a situation that is essentially the same as retinitis pigmentosa, except that pigmentation is conspicuously absent in the fundus.

Late developing lesions in birdshot retinochoroidopathy

Birdshot retinochoroidopathy is characterized by depigmented spots radiating from the optic disk in association with mild vitritis, retinal vasculitis, and involvement of the optic nerve head. In two patients, we traced the long-term course of uveitis with vitritis, retinal vasculitis, and papillitis that resulted in the typical cream-colored spots of birdshot retinochoroidopathy after seven and eight years, respectively, of follow-up. These observations suggest that in long-standing inflammation of the retinal vasculature and uveal tract, the HLA-A29 antigen should be assessed, because the development of typical lesions of birdshot retinochoroidopathy may be delayed in some patients.

Birdshot chorioretinopathy: clinical characteristics and evolution

During the period 1980-6 102 patients from 14 European eye clinics were diagnosed as having birdshot chorioretinopathy (BSCR). All were Caucasian, and the series consisted of 47 men and 55 women, with a mean age of 52.5 years. The major findings in this rare disorder concern the ocular fundus. Most marked are the patterned distribution of depigmented spots without hyperpigmentation, radiation from the optic disc in association with vitritis, retinal vasculopathy with frequent cystoid macular oedema, and involvement of the optic nerve head. The distribution and appearance of the lesions suggest that they are related to the major choroidal veins. Complications of the disease were epiretinal membranes, retinal neovascularisation, recurrent vitreous haemorrhage, subretinal neovascular membranes occurring both in the juxtapapillary and macular regions, and optic atrophy. The medical history was not contributary. HLA testing showed very strong disease association with HLA A29 (95.8%). The evidence suggests that it is a single disease entity rather than a group of disorders because of the remarkable similarity in the ophthalmological appearance and the clinical course, combined with the exceptionally high association with HLA A29.

Idiopathic sub-retinal neovascular membranes in the macula (hemorrhagic macular choroidopathy of young adults). Clinical report and effectiveness of laser treatment

Twenty-six patients with idiopathic sub-retinal neovascular membranes (INVMs) located within the posterior pole were examined. Clinical and fluorescein angiographic features of these patients are described. Follow-up ranged from 2 to 96 months (mean 16.5 months). Laser treatment was performed according to the location of the neovascular membrane: 7 out of 9 eyes (77%) increased their final visual acuity or stabilized after Argon blue-green laser photocoagulation (INVMs further than 200 microns from the center of the fovea). Krypton red light laser treatment was performed in 13 eyes with juxta-foveal and sub-foveal INVMs: following treatment 10 eyes (77%) improved by 2 or more Snellen lines or maintained their pre-treatment visual acuity. Because of the fact that the Krypton laser was not yet available, 5 patients were not treated: all of them had sub-foveal (3) or juxta-foveal INVMs (2). The natural history of 4 cases (80%) showed an increase in the final visual acuity in 3 eyes and a steady state in one eye. Pathogenesis and treatment outcome of the disease are finally discussed.

Choroidal neovascularization

Choroidal neovascularization is now considered to be a most important feature in the pathogenesis and treatment of a number of chorioretinal disorders. Since the recognition of its importance, choroidal neovascularization has been described in clinical and pathologic studies of a variety of different ophthalmologic conditions. We have summarized the diseases in which choroidal neovascularization occurs and have reviewed studies on the natural history, clinical findings, and therapy of choroidal neovascularization that provide the basis for the current management of this condition.

Subretinal choroidal neovascularization in birdshot retinochoroidopathy

We studied four eyes of two patients with bilateral birdshot retinochoroidopathy which developed subretinal choroidal neovascular membranes involving the macula. The subretinal choroidal neovascular membranes in our patients developed six months to five years after the onset of the disease. Both patients described decreasing visual acuities at the time when the choroidal neovascular membranes were identified. Adjacent to the classic depigmented areas of birdshot retinochoroidopathy were increased pigmentation, hemorrhage, or fluid indicative of subretinal neovascularization. Fluorescein angiography confirmed the presence and demonstrated the location of these membranes.