Twenty-four-month outcomes of inflammatory choroidal neovascularisation treated with intravitreal anti-vascular endothelial growth factors: a comparison between two treatment regimens

Differential diagnosis of myopic choroidal neovascularization (mCNV): insights from multimodal imaging and treatment implications

PURPOSE

The aim of this article is to conduct a comprehensive systematic review about the current understandings and differential diagnosis of myopic choroidal neovascularization (mCNV) and other several similar diseases, describing their multimodal imaging analysis, prognostic implications, and current types of management.

METHODS

This systematic review was performed based on a search on the PubMed database of relevant papers regarding mCNV and other entities discussed in the paper, according to our current knowledge.

RESULTS

Through the integration of a multimodal imaging approach, especially optical coherence tomography (OCT), along with accurate demographic and clinical assessment, it becomes possible to effectively differentiate mCNV from similar yet heterogeneous entities. These conditions include macular hemorrhage due to new lacquer crack (LC) formation, inflammatory diseases such as punctate inner choroidopathy (PIC)/multifocal choroidits (MFC) and epiphenomenon multiple evanescent white dot syndrome (Epi-MEWDS), neovascular age-related macular degeneration (nAMD), idiopathic CNV (ICNV), dome-shaped macula (DSM) with subretinal fluid, retinal pigment epithelium (RPE) humps, angioid streaks (AS), choroidal rupture (CR), and choroidal osteoma (CO). Each one of these entities will be described and discussed in this article.

CONCLUSION

Myopic choroidal neovascularization is a common retinal condition, especially among young individuals. Accurate diagnosis and differentiation from similar conditions are crucial for effective treatment. Multimodal imaging, particularly OCT, plays a crucial role in precise assessment. Future research should focus on defining biomarkers and distinguishing features to facilitate prompt treatment.

Immunomodulatory Treatment Versus Systemic Steroids in Inflammatory Choroidal Neovascularization Secondary to Idiopathic Multifocal Choroiditis

PURPOSE

To evaluate the influence of immunomodulatory therapy (IMT) on visual and treatment outcomes of inflammatory choroidal neovascularization (iCNV) in patients affected by multifocal choroiditis (MFC), and to compare them to patients treated with steroids as needed.

DESIGN

Multicenter retrospective matched cohort study.

METHODS

Patients affected by MFC with iCNV were divided into a IMT group and a "steroids as needed" group and matched according to the time between diagnosis and beginning of systemic treatment. Visual acuity (VA), number of anti-vascular endothelial growth factor (VEGF) intravitreal injections, and number of iCNV reactivations during 2 years of follow-up after treatment initiation were compared between the 2 groups.

RESULTS

A total of 66 eyes of 58 patients were included, equally divided into the 2 groups. Patients in the IMT group had a lower relative risk (RR) of iCNV reactivation (0.64, P = .04) and of anti-VEGF intravitreal injection retreatment (0.59, P = .02). Relapses of MFC-related inflammation were independently associated with a higher RRs of iCNV reactivation (1.22, P = .003). Final VA was higher in the IMT compared to the steroids as needed group (mean [SD], 69.1 [15.1] vs 77.1 [8.9] letters, P = .01), and IMT was associated with greater VA gains over time (+2.5 letters per year, P = .04).

CONCLUSIONS

IMT was associated with better visual and treatment outcomes in MFC complicated by iCNV compared to steroids as needed. The better outcomes of the IMT group and the association between MFC-related inflammation and iCNV reactivations highlight the need for tighter control of inflammation to prevent iCNV relapses and visual loss.

[Intermediate and Posterior Uveitis - Classification, diagnostics, complications, and therapeutic algorithms]

Intermediate and posterior uveitis describes a broad variety of different types of intraocular inflammation. Before starting treatment of intermediate or posterior uveitis, a differentiation between infectious or non-infectious uveitis must always be made. Pathognomonic symptoms do not exist, visual loss and vitreous floaters are the most common symptoms. The indication for therapy is influenced by the anatomical localization, the degree of inflammation, an association, complications and the activity of the inflammation. In addition to clinical ophthalmological standard examination, angiography and OCT are the most important investigations to classify and assess the course of inflammation. Macular edema is the most common complication of intermediate or posterior uveitis and should be treated at first onset, recurrence, or worsening. Oral, intravenous, or intravitreal corticosteroids are usually the primary therapy for intermediate or posterior uveitis. Systemic immunosuppression is indicated after steroid failure in non-infectious uveitis.

Efficacy and safety of Aflibercept for the treatment of inflammatory choroidal neovascularization: The ALINEA study

PURPOSE

To evaluate mean change in best-corrected visual acuity (BCVA) at 52 weeks in patients with inflammatory choroidal neovascularization (CNV) treated with aflibercept.

METHODS

We conducted a prospective non-comparative open-label trial. Following one mandatory intravitreal injection of aflibercept, patients were treated under a pro re nata (PRN) dosing regimen with monthly visits.

RESULTS

A total of 19 patients were included, but one presented exclusion criteria; 16 patients were followed for the whole 52-week study, and data for the primary endpoint analysis were available for 14. At baseline, mean BCVA and mean central retinal thickness (CRT) were 64.53 (±19.64) letters and 351.79 (±97.77) μm, respectively. At 52 weeks, the mean change in BCVA was +9.50 (±12.90) letters [95%CI = +2.05-+16.95]. One patient had lost more than 15-letters at 24 weeks, and another one at 52 weeks. CRT change was -62.77 (±100.73) μm at 24 weeks and -66.53 (±97.47) μm at 52 weeks. There was a mean number of 3.56 (±3.29) intravitreal injections at 52 weeks (min = 1; max = 12). No serious ocular adverse events related to the treatment were reported.

CONCLUSIONS

Our study shows that aflibercept is clinically effective, both anatomically and functionally in the treatment of inflammatory CNV. Following the first injection, the PRN strategy appears sufficient for treating most choroidal neovessels.

Subretinal Hyperreflective Material (SHRM) as biomarker of activity in Exudative and Non- exudative inflammatory choroidal neovascularization

AIM

To analyze the structural features and therapeutic response in clinical and subclinical inflammatory choroidal neovascularization (i-CNV) detected inside subretinal hyperreflective material (SHRM) using swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography (SS-OCTA).

METHODS

In this prospective interventional study, subjects with quiescent posterior uveitis presenting with SHRM on SS-OCT and CNV network on SS-OCTA were included. Subjects with intraretinal fluid/subretinal fluid (IRF/SRF) received intravitreal antivascular endothelial growth factor (anti-VEGF) injections, while those with no IRF/SRF either received treatment or observation for 6 months until they developed IRF/SRF or decrease in best-corrected visual acuity (BCVA)/metamorphopsia. Serial comparisons included SHRM width and height and intrinsic flow signal on OCTA.

RESULTS

28 eyes of 22 subjects (12 males; mean age: 29.52 ± 12.56 years) were evaluated. Subjects with IRF/SRF at baseline (n = 6 eyes; termed as exudative iCNVs) receiving treatment showed significant improvement in BCVA (p = .017), SHRM width/height and flow signal (p < .05). Among eyes with no IRF/SRF (n = 22; termed as non-exudative iCNVs), 7 received treatment and showed significant improvement in SHRM parameters and BCVA (p < .05). 4/15(26.67%) eyes that received no treatment developed IRF/SRF upon 6-month follow-up.

CONCLUSION

SHRM may act as a useful biomarker to monitor activity and response to therapy in eyes with iCNV.

Sarcoid Uveitis: An Intriguing Challenger

The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.

ROLE OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN DETECTING AND MONITORING INFLAMMATORY CHOROIDAL NEOVASCULARIZATION

PURPOSE

To investigate the utility of optical coherence tomography angiography (OCTA) for the detection of inflammatory choroidal neovascularization (iCNV) and monitoring their response to treatment.

METHODS

A retrospective review of patients with a diagnosis of uveitis and associated iCNV with active exudation was performed. Active iCNV was determined by spectral domain OCT and/or fluorescein angiogram. Spectral domain OCTA outer retina to choriocapillaris slabs was evaluated for the presence of iCNV. Follow-up OCTA images were qualitatively assessed to determine whether regression of iCNV occurred after treatment.

RESULTS

Thirteen eyes of 12 patients were included. The etiologies of uveitis include punctate inner choroidopathy (n = 4), multifocal choroiditis (n = 2), presumed sarcoid uveitis (n = 2), tuberculous choroiditis (n = 1), birdshot chorioretinopathy (n = 1), syphilitic uveitis (n = 1), serpiginous choroiditis (n = 1), and idiopathic panuveitis (n = 1). Inflammatory choroidal neovascularization was detected on en face OCTA in 10 of 13 eyes (76.9%). After iCNV treatment, en face OCTA demonstrated complete regression of iCNV in 5 of 10 eyes (50%), partial regression in 2 of 10 eyes (20%), and no regression in 3 of 10 eyes (30%).

CONCLUSIONS

Optical coherence tomography angiography is an effective modality for detecting iCNV and could provide detailed visualization regarding location, morphologic structure, and flow of the iCNV and its response to therapy.

Review for Diagnostics of the Year: Inflammatory Choroidal Neovascularization – Imaging Update

Inflammatory choroidal neovascularization (iCNV) is a rare complication of uveitis but is a major cause of vision compromise in affected patients. Fluorescein angiography (FA) has been the gold standard for diagnosis. However, it is an invasive modality and when used alone, it might be difficult to distinguish iCNV from inflammatory lesions. Optical coherence tomography (OCT) is a noninvasive and rapid imaging modality that can provide additional features to diagnose iCNV. OCT angiography (OCTA) uses intrinsic motion contrast to visualize flow and is useful to distinguish iCNV from inflammatory lesions. However, its role in evaluating iCNV activity and treatment response is still unclear and more studies are required to reach consensus. In conclusion, the use of data from multimodal imaging is necessary to identify and promptly treat iCNV, thus preserving patient vision.

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.

Long-Term Analysis of Clinical Features and Treatment Outcomes of Inflammatory Choroidal Neovascularization

PURPOSE

To investigate the long-term clinical features and treatment outcomes of patients with inflammatory choroidal neovascularization (CNV) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF).

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Sixty-five eyes of 65 patients with inflammatory CNV treated with anti-VEGF injections and followed up at least 12 months were included. Retrospective chart review was conducted at a single tertiary referral center.

RESULTS

Study participants were followed up for 60.6 ± 42.8 (range, 16-160) months. Mean age was 33.4 ± 10.8 years, and mean refractive error was -3.94 ± 1.35 D in spherical equivalent. Final best-corrected visual acuity (BCVA) was 0.21 ± 0.20 logMAR after treatment. Patients were treated with bevacizumab (76.9%), ranibizumab (4.6%), aflibercept (3.1%), and drug combinations (15.4%). Systemic corticosteroid or immunosuppressant use was not correlated with visual outcome, required number of anti-VEGF injections, and recurrence. Commonly occurring optical coherence tomography (OCT) features included ellipsoid zone disruption, choroidal hypertransmission, retinal pigment epithelium atrophy or absence (RPEA), intraretinal hyperreflective foci (HRF), choroidal vessel engorgement, focal choroidal excavation, and irregular vascular loops (on OCT angiography). RPEA after treatment (β = 0.238, P = .036) and BCVA (β = 0.267, P = .029) showed significant correlation with final BCVA. A total of 28 patients (43.1%) experienced recurrence; intraretinal HRF after treatment was the single risk factor for recurrence (odds ratio = 2.712, P = .031).

CONCLUSIONS

Inflammatory CNV recurrence showed higher rates over time after anti-VEGF treatment than previously reported, even though the overall visual outcome was good. Baseline BCVA and RPEA after treatment are significant predictors for visual outcome. Intraretinal HRF after anti-VEGF treatment suggests the potential risk of recurrence.

Results of Intravitreal Anti-Vascular Endothelial Growth Factor Therapy in Inflammatory Choroidal Neovascularization

Purpose:

To report the visual outcomes of intravitreal (IVT) anti-vascular endothelial growth factor (anti-VEGF) in inflammatory choroidal neovascularization (iCNV).

Methods:

A retrospective study of 43 eyes of 38 patients with active choroidal neovascularization (CNV) related to ocular inflammatory disease, treated with IVT injections of anti-VEGF (bevacizumab, ranibizumab, or aflibercept), with or without associated systemic anti-inflammatory therapy, at Fattouma Bourguiba University Hospital, Monastir, Tunisia (24 eyes of 23 patients) and at Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (19 eyes of 15 patients) from January 1, 2013, to December 31, 2018.

Results:

The mean age was 35.5 ± 16.4 years. The sex ratio male:female was 0.27. Seventeen eyes (39.5%) of 17 patients (44.7%) had only anti-VEGF injections, and 26 eyes (60.5%) of 21 patients (45.3%) had anti-VEGF injections and associated systemic anti-inflammatory therapy. Bevacizumab was injected in 36 eyes (83.7%), ranibizumab in six eyes (14%), and aflibercept in one eye (2.3%). Mean follow-up was 20.3 ± 19.2 months (range, 6–106 months). Mean visual acuity improved from 0.8 ± 0.37 logMAR (approximate Snellen equivalent 20/125) to 0.51 ± 0.42 logMAR (approximate Snellen equivalent 20/63) (P < 0.001). Mean central macular thickness on optical coherence tomography decreased from 403.7 ± 121.9 to 293.7 ± 82.8 μm (P < 0.001). Mean gain of vision was 2.9 ± 3.1 lines. The mean number of injections was 2.5. Twenty eyes (46.5%) received a single injection. There were no side effects related to the IVT injections of anti-VEGF.

Conclusions:

CNV is a sight-threatening complication of uveitis. IVT anti-VEGF seems to be an effective and safe treatment for iCNV when inflammation is controlled.

Differentiation of Features of Inflammatory Neovascular Membrane Versus Active Posterior Uveitis by SS-OCTA

BACKGROUND AND OBJECTIVE

Neovascularization is a sight-threatening, uncommon complication of posterior uveitis that often goes undetected until persistent clinical findings appear, or in light of treatment failure. This could be attributed to the relative similarity of activity signs in inflammatory neovascular membranes (NVM) and active posterior uveitis. The purpose of the present study is to recognize imaging features that distinguish uveitic neovascularization from active uveitis using swept-source optical coherence tomography angiography (SS-OCTA).

PATIENTS AND METHODS

Cross-sectional study. Patients with posterior uveitis with visual acuity (VA) decrease and at least one of the following findings were assessed by SS-OCTA: retinal thickening, subretinal or intraretinal fluid, and retinal hyperreflective areas. The change of VA and imaging features after treatment with anti-vascular endothelial growth factor (VEGF) therapy were analyzed in cases with inflammatory NVM.

RESULTS

Forty-five eyes of 40 patients were evaluated. Twenty-four eyes (53.3%) showed signs of activity, of which eight (33.3%) presented inflammatory NVM. Imaging features that differentiate inflammatory neovascularization from active posterior uveitis included: vitreous cellularity (P = .003), outer retinal infiltration (P = .08), choroidal thickness (P = .003), posterior shadowing (P = .013), subretinal fluid (P = .04), and neovascular network (P ≤ .001). According to NVM characteristics by OCTA, multiple anastomoses and peripheral arcades were visualized at baseline in 85.7% of cases. Mean pre-operative best-corrected VA of inflammatory NVM was 20/150 (logMAR: 0.88 ± 0.60) with significant improvement to 20/40 (logMAR: 0.32 ± 0.22) after anti-VEGF treatment (P = .027).

CONCLUSIONS

SS-OCTA achieves the distinction of inflammatory NVM from active posterior uveitis through specific imaging features. Inflammatory neovascularization presents a suitable response after anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:129-137.].

Imaging in Tubercular Choroiditis: Current Concepts

PURPOSE

Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is very important to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications.

METHODS

Narrative review.

RESULTS

In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease.

CONCLUSIONS

Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.