Inflammatory choroidal neovascular membrane in posterior uveitis-pathogenesis and treatment

Idiopathic multifocal choroiditis and punctate inner choroidopathy: an evaluation in pregnancy

Purpose

To evaluate the clinical course of idiopathic multifocal choroiditis (MFC) and punctate inner choroidopathy (PIC) and the efficacy and safety of treatment options during pregnancy.

Methods

Patients with MFC or PIC and a pregnancy in 2011–2019 from two academic centres were enrolled. For the most recent pregnancy, data on best‐corrected visual acuity (BCVA) before and after pregnancy, relapse rate in pregnancy and postpartum period and obstetric, maternal and neonatal outcomes were collected. Treatment regimens consisted of a wait‐and‐see regime and an immunosuppressive treatment regime with systemic corticosteroids and/or azathioprine, both combined with intravitreal antivascular endothelial growth factor injections when indicated.

Results

Sixteen women (26 affected eyes) were included. Median Snellen BCVA was 20/19 before pregnancy and 20/18 after delivery. In seven pregnancies a wait‐and‐see regime and in nine pregnancies an immunosuppressive treatment regime was carried out. Fourteen intravitreal anti‐VEGF injections were given in six pregnancies. The relapse rate during pregnancy was 44% and in the postpartum period 31%. Maternal/obstetrical and fetal complications occurred in 31% and 13% of the pregnancies, respectively. Fifteen healthy children were born and one pregnancy ended in a stillbirth in a patient with a complicated obstetrical history. One patient treated with azathioprine developed intrahepatic cholestasis of pregnancy (ICP).

Conclusions

Among women with MFC and PIC BCVA remained stable during pregnancy despite a relapse rate of 44% in pregnancy. No major maternal, obstetric and fetal complications occurred in pregnant patients treated with systemic corticosteroids, azathioprine or intravitreal anti‐VEGF injections, though one patient developed ICP while treated with azathioprine.

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.

Pediatric choroidal neovascularization: Etiology and treatment outcomes with anti-vascular endothelial growth factors

PURPOSE

To describe the etiology and treatment outcomes of choroidal neovascularization (CNV) in a pediatric population with intravitreal anti-vascular endothelial growth factors (VEGF).

METHODS

Retrospective single center interventional case series. A total of 26 eyes of 23 consecutive pediatric patients with CNV of various etiologies were treated with intravitreal injection of anti-VEGF agents.

RESULTS

There were 15 males (65.2%) and eight females (34.8%), diagnosed with CNV during the study period. The mean age at presentation with CNV was 11.7 ± 3.3 years, (range 4-16 years) and the mean follow was 28.1 ± 18 months, (range 8-72 months). Inflammatory CNV was the most common etiology. The mean best corrected visual acuity (BCVA) and mean central macular thickness (CMT) at presentation, were logMAR 0.8 ± 0.3 and 367.6 ± 134.8 µm respectively. At the final visit, CNV in all eyes remained regressed with significant improvement in mean BCVA to logMAR 0.4 ± 0.4 (p < 0.0001) and mean CMT to 242.5 ± 82.4 µm (p < 0.0001). A mean of two intravitreal injections per eye was required for CNV regression.

CONCLUSION

Intravitreal anti-VEGF therapy for pediatric CNV is an effective treatment in majority of affected eyes.

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.].

The efficacy of adalimumab in treating patients with central multifocal choroiditis

PURPOSE

To evaluate the efficacy of adalimumab in patients with central multifocal choroiditis (cMFC) refractory to conventional corticosteroid-sparing immunomodulatory agents (IMT).

METHODS

Medical records were reviewed from all patients with cMFC and treated with adalimumab with follow-up of at least 12 months. The study focused on the 12 months prior to and after the start of adalimumab. The imaging results were independently evaluated by two ophthalmologists. The main outcomes were the number of patients without a relapse of disease activity in 12 months after the start of adalimumab and the ability to stop the systemic corticosteroids to evaluate the corticosteroid-sparing effect.

RESULTS

Twelve patients (18 eyes) were included. In 8/12 (67%) patients no relapse of disease activity was observed in the 12 months after the start of adalimumab. In 9/12 patients the systemic corticosteroid treatment could be stopped and in an additional 2 patients tapered to ≤7,5mg daily. In the 12 months before the start of adalimumab, the patients experienced a median of 3 (range 2-4) relapses of disease activity. Nine patients experienced relapses while treated with a combination of systemic corticosteroids (mean dose 13,6 mg; range 5-25 mg) and IMT. Moreover, 3 patients treated with IMT, experienced relapses after tapering and stopping the systemic corticosteroids. In all eyes (n = 5) with CNV before the start of adalimumab, the intravitreal anti-VEGF injections could be stopped after the start of adalimumab.

CONCLUSIONS

AND IMPORTANCE: Adalimumab may be effective in patients with cMFC refractory to IMT and may be considered as a treatment option in patients with cMFC.

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.

Inflammatory choroidal neovascularization associated with immunoglobulin G4-related disease: a case report

Background

Immunoglobulin G4-related disease is a recently recognized condition with pathologic features that are consistent across a wide range of organ systems. Orbital manifestations of this disease entity typically involve the lacrimal gland and lacrimal duct, extraocular muscles, orbital soft tissue, and sclera. Here, the authors report the first known case of inflammatory choroidal neovascular membrane associated with immunoglobulin G4-related disease and offer suggestions for clinical management of this enigmatic condition.

Case presentation

A 38-year-old Caucasian man with a history of recurrent tonsillitis presented with blurry vision in his left eye of 1-week duration and was diagnosed as having inflammatory choroidal neovascular membrane. An infectious workup was negative, but his serum immunoglobulin G4 level was elevated at 248 mg/dL (reference 4–86), and a subsequent tonsillectomy for a repeat episode of tonsillitis revealed increased immunoglobulin G4 staining on histopathology, thus confirming the diagnosis of immunoglobulin G4-related disease. The inflammatory choroidal neovascular membrane was treated with intravitreal bevacizumab injections and orally administered prednisone resulting in improved visual acuity and choroidal neovascular membrane regression. He later received rituximab infusions for immunoglobulin G4-related disease.

Conclusions

We report a case of choroidal neovascularization associated with immunoglobulin G4-related disease, a chronic inflammatory condition whose ophthalmic manifestations typically include dacryoadenitis, orbital myositis, or scleritis. This is the first reported instance of inflammatory choroidal neovascular membrane associated with immunoglobulin G4-related disease. Early detection of this disease is important to avoid organ damage and potential complications, so clinicians should maintain an index of suspicion for this condition when inflammatory choroidal neovascular membrane is observed.

Inflammatory Choroidal Neovascular Membranes in Patients With Noninfectious Uveitis: The Place of Intravitreal Anti-VEGF Therapy

Inflammatory choroidal neovascularization (iCNV) is an infrequent but an important cause of visual morbidity in patients with non-infectious uveitis and mostly occurs in intermediate or posterior uveitis. Punctate inner choroiditis, Vogt-Koyanagi-Harada disease and multifocal choroiditis are among the leading causes of uveitis entities resulting in iCNVs. The diagnosis and management of iCNVs still remain a challenge. Use of multimodal imaging techniques such as fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT) and OCT-angiography may be necessary for the diagnosis of iCNVs. The treatment algorithm is not straightforward for iCNV. While control of the active inflammation with steroids and/or immunosuppressive agents is a key to success, various adjunctive treatment modalities such as thermal laser photocoagulation, photodynamic therapy and surgical membrane removal were also co-administered previously. Nowadays, vascular endothelial growth factor (VEGF) inhibitors have become the most commonly administered adjunctive treatment option as they provide better anatomical and functional outcome and the recurrence rate of CNV is relatively low. We hereby reviewed important clinical studies and case series on anti-VEGF administration in iCNVs and briefly overviewed their results.

Optical coherence tomography angiography in uveitis

Before the introduction of optical coherence tomography angiography (OCTA) in the early 2000s, dye-based angiography was considered the “gold standard” for the diagnosis and monitoring of ocular inflammation. OCTA is a novel technique, which demonstrates capillary networks based on the amount of light returned from moving blood cells, providing further information on pathophysiological changes in uveitis.

The aim of this review is to describe the basic principles of OCTA and its application to ocular inflammatory disorders. It particularly emphasizes on its contribution not only in the diagnosis and management of the disease but also in the identification of possible complications, comparing it with fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA). Although the advent of OCTA has remarkably enhanced the assessment of uveitic entities, we highlight the need for further investigation in order to better understand its application to these conditions.

Outcomes of Intravitreal Bevacizumab in Choroidal Neovascularization in Vogt-Koyanagi-Harada Disease- A Prospective Study

Purpose: To assess the effectiveness of intravitreal (IV) bevacizumab and the need for systemic immunosuppressive therapy (IMT) in choroidal neovascularization (CNV) in Vogt-Koyanagi-Harada disease (VKHD).Methods: CNV treatment consisted of three monthly IV bevacizumab injections as a loading dose; if intra/subretinal fluid (IRF) persisted, further injections were proceeded besides increment in systemic IMT. Outcome analyses at 3, 6, and 12 months were visual acuity, central foveal thickness, macular volume, IRF, and addition of IMT.Results: Seven eyes of six patients were included. Five patients (five eyes) completed a 12-month follow-up and received 12 IV bevacizumab injections. At the 12-month follow-up, visual acuity improved in four out of five eyes (p = .0568); all eyes had decreased macular volume (p = .0431) but they still had persistent IRF; and all cases needed IMT introduction/increment.Conclusion: Intravitreal bevacizumab in association with systemic IMT was effective for CNV in VKHD. Active CNV may indicate disease of inadequate clinical control.

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

Background and aim

There is still no established treatment regimen for eyes with inflammatory choroidal neovascularisation (iCNV) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections. This study compared the 24-month outcomes of two treatment regimens of anti-VEGF injections in eyes with iCNV.

Methods

Eyes with iCNV treated with anti-VEGF injections were divided into two groups: eyes treated with a loading phase of 3 monthly injections and then re-treated as needed (LOADING group) and eyes treated as needed from the beginning (PRN group). Visual acuity (VA), number of injections and iCNV recurrences at 24 months were compared between the groups.

Results

Eighty-two eyes were included, 42 in the LOADING and 40 in the PRN group. Baseline VA (mean(SD)) was 57.3 (15.8) letters in the LOADING vs 60.7 (15.6) letters in the PRN group (p=0.32). The VA (mean (95% CI)) increased at 3 months (+14.8 (10.6 to 18.9) and +11.2 (6.4 to 16) letters in the LOADING and PRN group, respectively) and remained significantly higher than baseline over the entire follow-up in both groups (all p<0.001). At 24 months, there was no difference in VA between the LOADING and PRN group (72.3 (14.0) vs 74.7 (11.3) letters, p=0.36) but the LOADING group received significantly more injections (median (Q1–Q3)) than the PRN (4.5 (3–7) vs 2.5 (2–3.2), p<0.0001). The iCNV recurrences were similar in both groups.

Conclusions

iCNV responded well to anti-VEGF with significant and sustained VA improvement. The loading phase did not confer any advantage in terms of outcomes. PRN regimen from the beginning was as effective as more intensive treatment.

Neovessel as first manifestation of relapse of associated multifocal choroiditis and MEWDS

Purpose

To report a case of multifocal choroiditis (MC) that has relapsed as choroidal neovascularization in the contralateral eye followed by a mixed aspect of multiple evanescent white dot syndrome (MEWDS) and MC.

Methods

Retrospective case report and literature review. The clinical findings were documented by fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography (OCT-A).

Results

The authors describe the case of a 39-year-old woman with prior ocular history of presumed MEWDS in her left eye, which developed into MC 7 years later in the same eye and 11 years later in the right eye, starting as choroidal neovascularization and developing into MEWDS. OCT-A showed neovessel in a supposedly active MC area outside the macular region in right and left eyes. OCT showed increased choroidal thickness in both eyes and a choroidal neovascularization in the right eye, treated using anti- VEGF therapy.

Conclusion

This case corroborates the proximity of some inflammatory diseases such as MC and MEWDS. OCT-A has opened new horizons for the better understanding of some retinal diseases by providing more thorough and promising morphological analyses using enhanced tools.

Polypoidal Choroidal Vasculopathy Complicating Retinal Laser in Quiescent Uveitis

A 58-year-old Afro-Caribbean gentleman with a diagnosis of quiescent systemic lupus erythematosus- (SLE-) related occlusive retinal vasculitis was previously treated with sector pan-retinal photocoagulation in his right eye to control temporal retinal neovascularization. At routine review he was found to have a focal area of subretinal fluid in the temporal macula sparing an ischaemic fovea. Fundus fluorescein angiography and indocyanine green angiography confirmed a branching vascular network (BVN) and terminal polys (i.e., polypoidal choroidal vasculopathy (PCV)). Interestingly, the BVN arose within an old laser scar. To our knowledge this is the first report of PCV in uveitis in an Afro-Caribbean patient and of the lesions arising within a laser scar.

Anatomical and functional outcomes of pars plana vitrectomy for inflammatory epiretinal membrane surgery in healed toxoplasmosis infection

Epiretinal membrane over macula secondary to toxoplasmosis compromises vision. We describe the outcome of pars plana vitrectomy and epiretinal membrane removal after adequate treatment of acute infection. The average age of all four male patients was 36 years (range 20–60 years). Following surgery there was an average three or more lines visual acuity improvement, restoration of foveal contour with reduction in central macular thickness. One patient developed choroidal neovascular membrane postsurgery and was effectively treated with intravitreal bevacizumab. Surgery for ERM secondary to healed toxoplasmosis infection has good anatomical outcome and reasonable visual improvement, when the surgery is done in a quiet eye.

An update on inflammatory choroidal neovascularization: epidemiology, multimodal imaging, and management

Inflammatory choroidal neovascular membranes are challenging to diagnose and manage. A number of uveitic entities may be complicated by the development of choroidal neovascularization leading to a decrease in central visual acuity. In conditions such as punctate inner choroidopathy, development of choroidal neovascularization is extremely common and must be suspected in all cases. On the other hand, in patients with conditions such as serpiginous choroiditis, and multifocal choroiditis, it may be difficult to differentiate between inflammatory choroiditis lesions and choroidal neovascularization. Multimodal imaging analysis, including the recently introduced technology of optical coherence tomography angiography, greatly aid in the diagnosis and management of inflammatory choroidal neovascularization. Management of these neovascular membranes consists of anti-vascular growth factor agents, with or without concomitant anti-inflammatory and/or corticosteroid therapy.

INFLAMMATORY CHOROIDAL NEOVASCULAR MEMBRANE: Long-Term Visual and Anatomical Outcomes After Intravitreal Anti-vascular Endothelial Growth Factor Therapy

PURPOSE

To assess the long-term visual and anatomical outcomes after intravitreal anti-vascular endothelial growth factor therapy for inflammatory choroidal neovascular membrane (CNVM).

METHODS

Retrospective case series of 15 consecutive cases of newly diagnosed inflammatory CNVM who were treated with intravitreal bevacizumab or ranibizumab injections.

RESULTS

The study included 8 women and 7 men with mean age at presentation with CNVM of 40.53 ± 17.46 years (range, 11-70 years), and mean follow-up duration after anti-vascular endothelial growth factor therapy was 20.53 ± 14.53 months (range, 6-48 months). All eyes had classic CNVM confirmed by fluorescein angiography, most commonly located in the peripapillary area (8 eyes, 53.3%), followed by juxtafoveal (4 eyes, 26.7%), and subfoveal location (3 eyes, 20%). All CNVMs showed complete resolution with mean 2.6 ± 1.2 injections per eye. Preinjection mean best-corrected visual acuity of logarithm of minimum angle of resolution 0.79 ± 0.76 (approximate Snellen equivalent 20/123) and mean central macular thickness of 435.9 ± 190.2 μm improved significantly to mean best-corrected visual acuity of logarithm of minimum angle of resolution 0.46 ± 0.43 (approximate Snellen equivalent 20/58) and mean central macular thickness of 262.13 ± 108.70 μm (P value 0.02 and <0.0001, respectively) at the final visit. Recurrence was seen in 26.7% eyes (4/15), all of which regressed with single injection. Only complication noted was subretinal fibrosis in one eye (6.7%).

CONCLUSION

For inflammatory CNVM, in addition to immunosuppression in cases with active inflammation, anti-vascular endothelial growth factor therapy seems as a very effective treatment modality resulting in significant visual improvement and foveal flattening. Incidence of major complications is rare, and the recurrence rate seems low.

Re-programming immunosurveillance in persistent non-infectious ocular inflammation

Ocular function depends on a high level of anatomical integrity. This is threatened by inflammation, which alters the local tissue over short and long time-scales. Uveitis due to autoimmune disease, especially when it involves the retina, leads to persistent changes in how the eye interacts with the immune system. The normal pattern of immune surveillance, which for immune privileged tissues is limited, is re-programmed. Many cell types, that are not usually present in the eye, become detectable. There are changes in the tissue homeostasis and integrity. In both human disease and mouse models, in the most extreme cases, immunopathological findings consistent with development of ectopic lymphoid-like structures and disrupted angiogenesis accompany severely impaired eye function. Understanding how the ocular environment is shaped by persistent inflammation is crucial to developing novel approaches to treatment.

Cytokine Signaling Protein 3 Deficiency in Myeloid Cells Promotes Retinal Degeneration and Angiogenesis through Arginase-1 Up-Regulation in Experimental Autoimmune Uveoretinitis

The suppressor of cytokine signaling protein 3 (SOCS3) critically controls immune cell activation, although its role in macrophage polarization and function remains controversial. Using experimental autoimmune uveoretinitis (EAU) as a model, we show that inflammation-mediated retinal degeneration is exaggerated and retinal angiogenesis is accelerated in mice with SOCS3 deficiency in myeloid cells (LysM^Cre/+SOCS3^fl/fl). At the acute stage of EAU, the population of infiltrating neutrophils was increased and the population of macrophages decreased in LysM^Cre/+SOCS3^fl/fl mice compared with that in wild-type (WT) mice. Real-time RT-PCR showed that the expression of tumor necrosis factor-α, IL-1β, interferon-γ, granulocyte-macrophage colony-stimulating factor, and arginase-1 was significantly higher in the LysM^Cre/+SOCS3^fl/fl EAU retina in contrast to the WT EAU retina. The percentage of arginase-1⁺ infiltrating cells was significantly higher in the LysM^Cre/+SOCS3^fl/fl EAU retina than that in the WT EAU retina. In addition, bone marrow-derived macrophages and neutrophils from the LysM^Cre/+SOCS3^fl/fl mice express significantly higher levels of chemokine (C-C motif) ligand 2 and arginase-1 compared with those from WT mice. Inhibition of arginase using an l-arginine analog amino-2-borono-6-hexanoic suppressed inflammation-induced retinal angiogenesis without affecting the severity of inflammation. Our results suggest that SOCS3 critically controls the phenotype and function of macrophages and neutrophils under inflammatory conditions and loss of SOCS3 promotes the angiogenic phenotype of the cells through up-regulation of arginase-1.

Intravitreal aflibercept for choroidal neovascularization associated with chorioretinitis: a pilot study

Purpose

The purpose of this study was to evaluate the potential benefits of intravitreal aflibercept injections for the treatment of choroidal neovascularization (CNV) secondary to chorioretinitis.

Methods

In this uncontrolled, prospective cohort study, 15 eyes of 14 consecutive patients affected by CNV associated with ocular toxoplasmosis were treated with intravitreal aflibercept (2 mg) pro re nata and observed over a 12-month follow-up period. The primary outcome was the change in best-corrected visual acuity (BCVA) from baseline to month 12. Secondary outcomes included change in central retinal thickness (CRT) in the foveal area on optical coherence tomography (OCT) from baseline to month 12, the number of intravitreal aflibercept injections administered, and safety.

Results

Mean (standard deviation [SD]) BCVA improved significantly from 0.36 (0.23) at baseline to 0.64 (0.3) at month 12 (P=0.0002). Mean (SD) CRT on OCT showed a reduction from 317 (74) µm at baseline to 254 (43) µm (P=0.0002) at month 12. A mean (SD) of 1.7 (0.5) injections (range, 1–2 injections) were performed during the study period. No cases of endophthalmitis, uveitis, stroke, or retinal detachment were noted. No patient demonstrated an intraocular pressure >20 mmHg at any study visit.

Conclusion

Intravitreal aflibercept showed a positive clinical effect and was well tolerated for the treatment of CNV associated with chorioretinitis. The results could be helpful for selecting a treatment for CNV secondary to chorioretinitis.

Outer Retinal Tubulation: A Case Series

PURPOSE

The advent of spectral domain optical coherence tomography has led to superb imaging capabilities in addition to enhanced visualization of the retinal layers. Such advancements have led to the identification of a variety of new retinal conditions, including outer retinal tubulations (ORTs). ORTs are ovoid hyporeflective spaces located in the outer retina. The pathogenesis is unclear but seems to involve sublethal injury to the photoreceptors leading to a compensatory reorganization of the photoreceptor layer with the neighboring ellipsoid zone resulting in a hyperreflective border surrounding a central lumen. Most ORTs have been linked to wet age-related macular degeneration; however, these peculiar structures are now seen in a myriad of retinal disorders.

CASE REPORTS

Our cases will highlight the wide variety of clinical presentations associated with outer retinal tubulations. The clinical presentations include two cases of wet age-related macular degeneration, a case of presumed ocular histoplasmosis syndrome, a case of central areolar choroidal dystrophy, and a case of pathological myopia.

CONCLUSIONS

By correctly differentiating outer retinal tubulations from other masqueraders, unnecessary referrals and interventions can be minimized. Understanding the various disease entities associated with outer retinal tubulation could give further insight into the mechanism and formation of these structures.

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.].

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.

Phase IIb clinical trial of ranibizumab for the treatment of uveitic and idiopathic choroidal neovascular membranes

AIM

To assess the efficacy of intravitreal ranibizumab for the treatment of new onset inflammatory choroidal neovascularisation (iCNV), including both uveitic and idiopathic CNVs.

METHODS

Single-centre, open-label, non-randomised Phase IIb clinical trial. Patients fulfilling strict entry criteria of new onset iCNV were given monthly intravitreal ranibizumab injections for 3 months. Thereafter, re-treatment was based on evidence of persisting activity. All patients completed trial follow-up. Optical coherence tomography (OCT) and best-corrected visual acuity (BCVA) were performed at every visit. Fluorescein angiography was performed at baseline, months 4 and 12. Descriptive analysis and Wilcoxon non-parametric test were performed for analysis.

RESULTS

15 patients, 10 women with a mean age of 48.8 years (range 24-85 years) were included in the study. The mean number of injections was 4.33 (range 3-7). There was a statistically significant difference in the BCVA at month 4 (p=0.001) and at month 12 (p=0.001) compared with baseline. The mean gain in BCVA at month 4 compared with baseline was 20±15.36 letters (mean±SD), and at month 12 was 21±16.97 letters. There was a statistically significant difference in the mean central subfield thickness (CST) at baseline versus month 4 (p=0.003) and month 12 (p=0.001).

CONCLUSION

Patients gained vision (mean of 21 letters at 12 months) and showed reduced CST. These results support the continued use of ranibizumab in the treatment of iCNV.

TRIAL REGISTRATION NUMBER

2008-007476-19, results.

Management of recurrent inflammatory choroidal neovascular membrane secondary to Vogt-Koyanagi-Harada syndrome, using combined intravitreal injection of bevacizumab and triamcinolone acetate

The purpose of this report is to evaluate the efficacy and safety of combined intravitreal injection of bevacizumab and intravitreal triamcinolone acetonide (IVTA) for recurrent inflammatory choroidal neovascular membrane (CNVM). It was a prospective interventional study of a young female, who was a known case of Vogt-Koyanagi-Harada syndrome. She presented with an inflammatory choroidal neovascualar membrane and signs of panuveitis in the right eye. She underwent a complete ophthalmic examination. She was given intravitreal injection of bevacizumab and IVTA at different sites. There was complete regression of CNVM and ocular inflammation within a week. After six months, she had recurrence of CNVM in the same eye, which was treated similarly. There was a complete resolution of CNVM and ocular inflammation after the combination therapy and systemic steroids, until one year of follow-up. No serious systemic or ocular adverse events were noted. Combination therapy appears to be an effective and safe method in the management of recurrent inflammatory CNVM.

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.

In-vivo investigation of laser-induced choroidal neovascularization in rat using spectral-domain optical coherence tomography (SD-OCT)

PURPOSE

This study investigated the in-vivo formation process of laser-induced choroidal neovascularization (CNV) in rat using high-resolution spectral-domain optical coherence tomography (SD-OCT), and compared the results to histological methods.

METHODS

Brown Norway rats (n = 60, 6-8 weeks of age) received 532-nm diode laser photocoagulation. SD-OCT and fluorescein angiography (FA) were performed in vivo 2, 5, 7, 14, and 21 days post-laser application. Haematoxylin and eosin (H&E) staining and immunohistochemistry for CD31, phosphorylated vascular endothelial factor receptor 2 (pVEGFR2) were conducted at each time point to observe the CNV in vitro. Choroidal flatmount preparations were observed using a confocal laser scanning microscope (CLSM) and a scanning electron microscope (SEM).

RESULTS

SD-OCT monitored the longitudinal morphological changes of laser-induced CNV. CNV reached its maximal size on day 7, and began a gradual reduction on day 14. FA revealed similar dynamic changes in leakage. CNV thickness, as assessed by SD-OCT, was consistent with H&E-stained sections at each time point. CLSM and SEM revealed the details of the fibrovascular membrane. CD31 and pVEGFR2 expression supported the results of SD-OCT and histology.

CONCLUSIONS

SD-OCT was a convenient and reliable tool for the imaging of the CNV formation process and quantification of the lesion size in vivo.

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.

Persistent inflammation subverts thrombospondin-1-induced regulation of retinal angiogenesis and is driven by CCR2 ligation

Neovascular retinal disease is a leading cause of blindness orchestrated by inflammatory responses. Although noninfectious uveoretinitis is mediated by CD4(+) T cells, in the persistent phase of disease, angiogenic responses are observed, along with degeneration of the retina. Full clinical manifestation relies on myeloid-derived cells, which are phenotypically distinct from, but potentially sharing common effector responses to age-related macular degeneration. To interrogate inflammation-mediated angiogenesis, we investigated experimental autoimmune uveoretinitis, an animal model for human uveitis. After the initial acute phase of severe inflammation, the retina sustains a persistent low-grade inflammation with tissue-infiltrating leukocytes for over 4 months. During this persistent phase, angiogenesis is observed as retinal neovascular membranes that arise from inflamed venules and postcapillary venules, increase in size as the disease progresses, and are associated with infiltrating arginase-1(+) macrophages. In the absence of thrombospondin-1, retinal neovascular membranes are markedly increased and are associated with arginase-1(-) CD68(+) macrophages, whereas deletion of the chemokine receptor CCR2 resulted in reduced retinal neovascular membranes in association with a predominant neutrophil infiltrate. CCR2 is important for macrophage recruitment to the retina in experimental autoimmune uveoretinitis and promotes chronicity in the form of a persistent angiogenesis response, which in turn is regulated by constitutive expression of angiogenic inhibitors like thrombospondin-1. This model offers a new platform to dissect the molecular and cellular pathology of inflammation-induced ocular angiogenesis.