Long-term efficacy and complications of intravitreal anti-vascular endothelial growth factor agents combined with ablative therapies in juvenile Coats disease: a five year follow-up study

PURPOSE

To evaluate the long-term safety and efficacy of adjuvant intravitreal anti-VEGF therapy in juvenile Coats disease.

METHODS

This retrospective, observational study included a total of 62 eyes in 62 pediatric patients with juvenile Coats disease treated with intravitreal anti-VEGF agents followed for a mean of 67.08 months (ranged from 60 to 93 months). All affected eyes were managed initially with one session of ablative treatment plus adjuvant intravitreal anti-VEGF agent (0.5 mg/0.05 ml ranibizumab or conbercept). Ablative treatment was repeated if telangiectatic retinal vessels were not completely regressed or recurred. Anti-VEGF therapy was repeated if subretinal fluid or macular edema still existed. Treatments above were repeated every 2 to 3 months. We reviewed clinical and photographic records of patients including the demographics, clinical characteristics and interventions.

RESULTS

At final visit, all 62 affected eyes had partially or completely disease resolution; none progressed to advanced stage namely neovascular glaucoma or phthisis bulbi, respectively. No ocular or systemic side effects related to intravitreal injections were observed during follow-up. In terms of 42 affected eyes that could cooperate with visual examination, best corrected visual acuity improved in 14 (14/42, 33.3%) eyes, stabled in 25 (25/42, 59.5%) eyes, and worsened in 3 (3/42, 7.1%) eyes. In the field of complications, 22 (22/62, 35.5%) eyes developed cataracts; 33 (33/62, 53.2%) eyes developed vitreoretinal fibrosis, of whom 14 (14/33, 42.4%) eyes in the subgroup of stage 3B developed progressive TRD; 40 (40/62, 64.5%) eyes developed subretinal fibrosis. Multivariate regression analysis showed increased clinical stage may be associated with the development of vitreo- and subretinal fibrosis (adjusted odds ratio:16.77,17.59; 95% CI:4.50-62.53, 3.98-77.86, respectively, all P < 0.001).

CONCLUSION

Adjuvant intravitreal ranibizumab or conbercept combined with ablative therapies may be a long-term safe and effective treatment for juvenile Coats disease.

Efficacy and Safety of Anti-Vascular Endothelial Growth Factor Drugs for Coats' Disease Treatment: A Systematic Review

Purpose: The efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) treatment for Coats' disease remains controversial. This study was designed to evaluate the efficacy and safety of anti-VEGF treatment for Coats' disease. Methods: PubMed, Embase, The Cochrane Library, Clinical Trials, CNKI, and WanFang databases were systematically searched for clinical efficacy and safety studies on anti-VEGF treatment for Coats' disease through June 2021. Study selection, data extraction, and quality assessment were independently performed by 2 reviewers. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal tools and GRADE-CERQual. Results: A total of 1,501 articles were retrieved and reviewed, of which 24 case series involving 378 patients (range: 3-67 patients each with 3-71 eyes) were included in the analysis. No randomized controlled trials, case-controlled studies, or cohort studies were available for analysis. Most patients were male (60.0%-92.9%), aged 1.35-42.3 years, with a median follow-up time ranging from 3 to 63 months. Among the 24 case series, 22 reported changes in the visual acuity (VA) after anti-VEGF treatment and 21 reported safety outcomes. The results showed that VA improved in 73 patients (37.63%), was stable in 89 (45.87%), and worsening VA was observed in 12 cases (6.19%). The most common adverse event was fibrotic changes (n = 35). Systemic complications were not observed. Conclusions: The results of this study indicate that anti-VEGF drugs provide an effective and relatively safe treatment strategy for Coats' disease. However, conducting well-designed, prospective, randomized clinical trials are necessary to confirm our findings.

A Novel Approach to Subretinal Fluid Drainage in Coats'-Related Exudative Retinal Detachment

Laser is effective at treating exudative retinal detachment (ERD) in Coats' disease. However, with severe ERD, the retina may be in contact with the lens. In such cases, laser can result in cataract formation. This case report of two patients treated at an academic medical center for Coats'-related ERD describes a technique of minimally invasive subretinal fluid drainage to create space between the lens and retina to avoid cataract. Transconjunctival unguarded needle drainage allowed for complete treatment of telangiectatic vessels and resulted in favorable anatomical outcomes in the patients. Transconjunctival unguarded needle drainage is a useful technique for treating severe, Coats'-related ERD, when a bullously detached retina is in contact with the lens. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:407-409.].

INTRAVITREAL RANIBIZUMAB INJECTION AND RETINAL LASER PHOTOCOAGULATION TREATMENT FOR ADULT-ONSET COATS DISEASE

PURPOSE

To describe the evolution of a case of adult-onset Coats disease and the results of treatment with intravitreal ranibizumab and laser photocoagulation.

METHODS

Observational case report.

CASE REPORT

A 17-year-old girl presented with vision loss in her right eye (20/50) showing aneurysmatic and abnormal telangiectatic vessels associated with profuse lipid exudation and serous retinal detachment within the temporal posterior pole. The diagnosis of Coats disease was established and therapy with intravitreal injections of ranibizumab and photocoagulation was initiated achieving control of the exudative manifestations leading to restoration of visual acuity (20/20).

CONCLUSION

Treatment with antiangiogenic agents before laser photocoagulation may be useful for treatment of adult-onset Coats disease.

Resolution of Foveal Lipid Deposition in Adult-Onset Coats Disease With Combined Focal Laser Photocoagulation and Anti-VEGF Therapy

A major cause of poor visual prognosis in Coats disease is the formation of fibrovascular changes following dense foveal lipid deposition. The authors document the multimodal imaging findings of a 38-year-old woman and a 23-year-old man with adult-onset Coats disease who presented with macular edema and foveal lipid accumulation. Thermal laser targeting individual capillary macroaneurysms combined with intravitreal anti-vascular endothelial growth factor (VEGF) therapy was performed. Although there was a subsequent increase in foveal lipid immediately following the resolution of macular edema, these lipids largely resolved, leaving behind no evidence macular neovascular fibrosis. This report highlights the potential protective effect of combination therapy with thermal laser and intravitreal anti-VEGF therapy for macular exudation associated with Coats disease. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:396-399.].

Refractory adult Coats disease treated with dexamethasone intravitreal implant: A case report

INTRODUCTION

Coats disease is a sporadic, retinal vascular abnormality, causing blindness. Several interventional methods, including laser photocoagulation, have been proposed; however, the use of intravitreal dexamethasone in refractory Coats disease is not well described.

PATIENT CONCERNS

A 38-year-old man presented with a painless reduction in visual acuity in his right eye, commencing 15 days prior to initial assessment.

DIAGNOSIS

Clinical manifestations and multimodal imaging indicated Coats disease.

INTERVENTIONS

Retinal laser photocoagulation was performed in the nonperfused areas, 15 months later, the exudative retinal detachment, and macular edema remained, the patient was then treated with an intravitreal slow-release dexamethasone implant.

OUTCOMES

The exudative retinal detachment and macular edema had resolved, and the BCVA had also improved.

CONCLUSION

Dexamethasone intravitreal implantation was effective in treating refractory Coats disease.

Optical Coherence Tomography Angiography in Monitoring Proliferative Macular Telangiectasia Type 2 Treatment Response

BACKGROUND AND OBJECTIVE

Difficulty exists in the follow-up of proliferative macular telangiectasia type 2 (MacTel 2) cases after anti-vascular endothelial growth factor (VEGF) treatment due to staining in fluorescein angiography (FA) and alteration in retinal layers by optical coherence tomography (OCT). Herein, the authors report three cases in which OCT angiography (OCTA) could resolve this issue.

PATIENTS AND METHODS

In this retrospective, observational case series, diagnosis of MacTel 2 was made based on clinical examination, FA, OCT, and OCTA at presentation. Regression of neovessels was monitored by OCT and OCTA.

RESULTS

OCTA could delineate neovessels before treatment in all cases and facilitate differentiation between active and regressed lesions after treatment. Simultaneous OCT images were less easily appreciated due to altered retinal structure secondary to degenerative nature of the disease.

CONCLUSION

OCTA could be the tool of choice to monitor neovascular response to anti-VEGF treatment in proliferative MacTel 2. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:485-491.].

Visual outcomes after treatment in pediatric patients with Coats' disease

OBJECTIVE

To report visual outcomes for children with Coats' disease after treatment.

DESIGN

Retrospective case series.

PARTICIPANTS

Pediatric patients with Coats' disease treated between 2000 and 2018 at a tertiary care pediatric hospital.

METHODS

Review of medical records. The primary outcome was visual acuity at final follow-up. Anatomical outcomes, retreatment, and risk factors for a poor outcome were also assessed.

RESULTS

There were 30 patients with Coats' disease. All cases were unilateral, and 28 (93%) were male. At presentation, 14 (47%) had stage 2 disease (retinal exudates) and 16 (53%) had stage 3 disease (subtotal or total exudative retinal detachment). All patients underwent laser photocoagulation and (or) cryopexy as primary treatment, combined with antivascular endothelial growth factor injection in 7 patients, posterior sclerotomy in 5 patients, and pars plana vitrectomy in 1 patient. Retreatment was required in 16 (53%) patients. After a median follow-up of 3.8 years, visual acuity was 20/50 or better in 6 patients (20%), 20/60 to 20/150 in 3 (10%), 20/200 to counting fingers in 8 (23%), and hand motion or worse in 14 (47%). Greater severity of disease at presentation was significantly associated with a poor visual outcome (p = 0.0001). In terms of complications, 7 (23%) eyes developed cataracts and 2 (7%) progressed to phthisis bulbi, but no patients required enucleation.

CONCLUSIONS

The visual prognosis for children with Coats' disease remains poor, particularly in patients with more severe disease at presentation. The risk of severe complications and enucleation is low after treatment.

[Inefficacy of aflibercept in the treatment of idiopathic macular telangiectasia type 2 without neovascularization]

Idiopathic macular telangectasia type 2 is a rare disease consisting primarily of bilateral macular capillary telangiectasia, alterations of the ellipsoid zone and intraretinal cysts that may appear as cystoid macular edema in the absence of neovascularization. Our goal was to study the efficacy of aflibercept in the treatment of these cysts. Thus, we performed a series of three intravitreal injections of aflibercept in the right eye of a woman with a typical presentation of macular telangectasia type 2 complicated by cystoid macular edema without neovascularization. These injections did not significantly improve the anatomical or functional results. Other studies investigating the efficacy of other anti-VEGF in this disease led mainly to a decrease in macular thickness on OCT after injection, without any functional improvement. The anti-VEGFs therefore appear to be of little value in treating MacTel 2 intraretinal cysts without neovascularization.

Fluorescein Angiography Versus Optical Coherence Tomography Angiography in Macular Telangiectasia Type I Treated With Bevacizumab Therapy

This is a report of microvascular changes seen on fluorescein angiography (FA) and optical coherence tomography angiography (OCTA) in a 47-year-old man with macular telangiectasia Type 1 (MacTel1) after a 7-year bevacizumab (Avastin; Genentech, South San Francisco, CA) treatment course. OCTA allowed for clear visualization of most telangiectasias and aneurysms in the deep capillary plexus, with only few microvascular dilatations in the superficial plexus. In addition, areas of capillary dropout in the superficial and deep vascular plexa located near telangiectasias were documented on OCTA. Serial FA demonstrated reduced number of aneurysms and telangiectasias at the 7-year mark compared to baseline. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:263-266.].

Treatment of Macular Telangiectasia Type 2 With Carotenoid Supplements Containing Meso-Zeaxanthin: A Pilot Study

BACKGROUND AND OBJECTIVE

To assess the outcomes of patients with macular telangiectasia type 2 (MacTel 2) in response to lutein (L), meso-zeaxanthin (M), and zeaxanthin (Z) supplements (LMZ3).

PATIENTS AND METHODS

Thirteen patients diagnosed with MacTel 2 were started on lutein 10 mg, meso-zeaxanthin 10 mg, and zeaxanthin 2 mg and were followed-up for a mean period of 15.7 months ± 4.85 months.

RESULTS

Visual acuity improved in three patients (13%), and there was a reduction in the percentage of patients who had worsening vision (25% to 4%; P < .05). Optical coherence tomography changes showed a reduction in the number of cavitations and the largest diameter of the cavitation after the LMZ3 supplements were started. The largest diameter of photoreceptor disruption showed mild improvement in the first 6 months after LMZ3 supplements were started.

CONCLUSION

LMZ3 supplements may stabilize vision and improve the cavitations in patients with MacTel 2. Larger randomized, controlled studies are required to verify these pilot results. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:528-535.].

Successful use of intravitreal ranibizumab injection and combined treatment in the management of Coats' disease

PURPOSE

To observe the efficacy of intravitreal ranibizumab (IVR) combined with another ablative therapy, such as laser photocoagulation, for Coats' disease.

METHODS

Patients younger than 16 years of age who were diagnosed with Coats' disease were included in this study. They were treated with IVR (0.5 mg, monthly in the first 3 months) as an initial treatment, which was combined with another ablative therapy, such as laser photocoagulation or cryotherapy, as needed. The main data evaluation and outcome measurements included best-corrected visual acuity (BCVA) before and after treatment, fundus photography, optical coherence tomography (OCT), the number of treatment sessions, and ocular and systemic side-effects during follow-up.

RESULTS

Seventeen patients were included in this study; the average age was 7.9 ± 3.8 years, and the average follow-up time was 9.7 ± 3.3 months. The mean number of IVR treatments was 3.9 ± 1.0. Sixteen patients (94.1%) needed another treatment. Eleven patients (64.7%) were stable at the final follow-up. The BCVA at the last follow-up was significantly improved compared to baseline (p < 0.001). Telangiectasia regression was found in all patients. Partial and total retinal attached was found in 14 patients (82.4%), and exudate resolution was found in eight patients (47.1%). There were no severe ocular or systemic side-effects during the follow-up period.

CONCLUSION

Intravitreal ranibizumab combined with other ablative therapies as an initial treatment is an effective and safe treatment approach for Coats' disease that may improve the visual acuity and reduce the subretinal fluid, exudates and telangiectasia.

Treatment for Macular Telangiectasia Type 2

Macular telangiectasia (MacTel) type 2 is a bilateral disease of unknown cause with localized retinal degeneration and characteristic changes of the retinal vasculature. Funduscopic findings include reduced retinal transparency, crystalline deposits, ectatic capillaries, blunted venules, retinal pigment plaques, foveal atrophy and neovascular complexes. Leakage of telangiectatic macular capillaries is a characteristic finding on fluorescein angiography, and neurosensory atrophy may be present on optical coherence tomography images. Furthermore, there is a specific depletion of macular pigment in the central retina. Depending on the development of neovascular membranes, a nonproliferative and a proliferative (neovascular) disease stage may be distinguished. To date, there is no evidence for an effective treatment of nonproliferative MacTel type 2. Patients with proliferative MacTel type 2 and hence decreasing visual function may benefit from intravitreal application of vascular endothelial growth factor inhibitors. Early treatment and a small size of the neovascular membrane might be predictive factors for visual function outcome.

A 6-year-old boy with Cornelia de Lange syndrome and Coats disease: case report and review of the literature

Cornelia de Lange syndrome (CdLS) can result in multiple congenital abnormalities and numerous ocular findings. We report the case of a 6-year-old boy with history of CdLS who presented with Coats disease. The findings in this case are compared to those found in the two previously reported cases of concomitant CdLS and Coats disease. The low incidence of these two disorders makes it highly unlikely that the connection is random in these 3 cases. The number of patients with both Cornelia de Lange syndrome and Coats disease is likely underestimated due to the difficulty in examining the peripheral retina in this patient population.

SUBRETINAL NEOVASCULARIZATION IN MACULAR TELANGIECTASIA TYPE 2: OPTICAL COHERENCE TOMOGRAPHIC ANGIOGRAPHY AND TREATMENT RESPONSE

PURPOSE

To report the optical coherence tomographic angiography findings and response to treatment in a case of macular telangiectasia Type 2 with subretinal neovascularization.

METHODS

Case report.

RESULTS

A 64-year-old man with macular telangiectasia Type 2 developed subretinal neovascularization, which was imaged on optical coherence tomographic angiography. He was treated with intravitreal aflibercept, and there was a remarkable reduction of flow in the subretinal neovascular network on optical coherence tomographic angiography.

CONCLUSION

Optical coherence tomographic angiography provides detailed information on the retinal microvasculature and subretinal neovascularization in macular telangiectasia Type 2. It can be used to assess response to treatment.

[Intravitreal bevacizumab in the treatment of idiopathic juxtafoveal telangiectasis type I]

CLINICAL CASE

We report a case of a 42 year-old male with a macular edema due to idiopathic juxtafoveal retinal telangiectasis type i, treated with 3 sequential injections of intravitreal bevacizumab (1.25 mg in 0.05 ml). Anatomical improvements were observed after one year of follow up.

DISCUSSION

There is currently no general consensus regarding the treatment of unilateral idiopathic juxtafoveal telangiectasis. The therapeutic options are, grid laser photocoagulation, intravitreal triamcinolone, verteporfin photodynamic therapy, or anti-VEGF. Visual acuity and anatomical improvements were observed in this case after intravitreal bevacizumab. Thus, intravitreal bevacizumab seems to be effective to treat macular edema in idiopathic juxtafoveal telangiectasis type i.

Combination treatment of pediatric coats' disease: a bicenter study in Taiwan

PURPOSE

To present the clinical outcome of different combination treatment modalities in pediatric Coats' disease in two Taiwan medical centers.

METHODS

A retrospective review of clinical records was done of pediatric patients with Coats' disease treated at National Taiwan University Hospital and Changhua Christian Hospital. Data regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications were recorded. Changes in vision and retinal status with the different methods of treatment were specifically evaluated.

RESULTS

From 2005 through 2011, 10 eyes of 9 patients were treated under the diagnosis of Coats' disease. The clinical manifestations varied from localized vascular abnormalities with subretinal fluid and hard exudates to extensive detachment with massive exudates and retinal hemorrhage. The main treatment modalities include argon laser photocoagulation, micropulse laser, and cryotherapy. The adjunctive therapies included intravitreal triamcinolone, bevacizumab, and ranibizumab. The mean follow-up was 40.50 ± 20.52 months (range: 14 to 72 months). Best corrected visual acuity at last follow-up was light perception to 1.0 (20/20 Snellen). Anatomic improvement was achieved in 9 eyes (90%). Visual improvement was noted in 7 eyes (70%), visual stabilization in 2 eyes (20%), and visual deterioration in 1 eye (10%). Vitreous fibrosis evolving into tractional retinal detachment occurred in 1 patient receiving cryotherapy combined with intravitreal bevacizumab injections. No enucleation was ultimately necessary.

CONCLUSIONS

Pediatric Coats' disease varies greatly in severity. Carefully selected treatment modalities can improve most eyes with different conditions. Intravitreal anti-vascular endothelial growth factor agents may act as useful adjuncts to improve anatomic and functional outcome. Cryotherapy combined with the intravitreal bevacizumab injection in severe cases of exudative retinal detachment may carry the risk of vitreoretinal traction and tractional retinal detachment.