Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study

PURPOSE

To report on macular hole repair in macular telangiectasia type 2 (MacTel2).

DESIGN

Global, multicenter, retrospective case series.

PARTICIPANTS

Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH).

METHODS

Standardized data collection sheet distributed to all surgeons.

MAIN OUTCOME MEASURES

Anatomic closure and visual outcomes of MTMH.

RESULTS

Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 μm (range, 34-573 μm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 μm (range, 97-697 μm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 μm (range, 132-687 μm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%.

CONCLUSIONS

Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Lifting the White Walker's curse-Management of Coats' disease

Background

Coats' disease, described by George Coats in the early 1900s, is an idiopathic unilateral retinal vascular abnormality with exudation occurring in young males. It is characterized by retinal telangiectasia with intraretinal or subretinal exudation. Coats' disease is mostly diagnosed in the first to the second decade of life, with a common presentation of leukocoria. Younger patients have a more severe presentation and are associated with poor visual prognosis. Management of Coats' disease varies from observation, cryotherapy with anti-VEGFs (Vascular Endothelial Growth Factor), and surgery to enucleation. The mode of treatment depends on the age of presentation, the severity of the disease, and the stage of the disease. Through this video, we describe the clinical features, pathology, and surgical management of a 2-year-old child with grade 3B of Coats' disease.

Purpose

To demonstrate successful surgical management of grade 3B of Coats' disease in a 2-year-old boy.

Synopsis

Coats' disease mostly presents with a diagnostic dilemma due to its varied presentation. Early detection and treatment are the keys to salvaging the eye as well as the vision, hence, avoiding dreadful complications such as neovascular glaucoma or phthisis bulbi. We demonstrate successful surgical management of a child who presented with grade 3B of Coats' disease.

Highlights

Through this video, we aim to describe the clinical features, pathology, and surgical management of a 2-year-old child with grade 3B of Coats' disease. Combination of external drainage with vitrectomy, challenges faced, and the importance of visual rehabilitation postoperatively.

Video Link

https://youtu.be/0obpVTOkKKs.

Neglected Coats Disease

Coats disease is a rare, non-hereditary retinal vascular abnormality that typically presents in the first two decades of life and is characterized by idiopathic retinal telangiectasia with progressive exudation. The authors describe a patient with Coats disease in which the family neglected treatment, demonstrating the natural course of this disease. [J Pediatr Ophthalmol Strabismus. 2020;57:e82-e85.].

Adult Coats' Disease, Dubin-Johnson Syndrome, and the Search for Targeted Therapies

Coats' disease is nonhereditary retinal vascular disorder characterized by telangiectatic retinal vessels with prominent aneurysmal changes and exudation. A conclusive etiology has not yet been determined. In this retrospective case report and literature review, a 64-year-old male with Dubin-Johnson syndrome presented with unilateral retinal vascular changes and exudation consistent with a diagnosis of adult Coats' disease. The authors conclude that patients with Dubin-Johnson syndrome carry mutations in a multidrug resistance associated protein (MRP). MRPs are also expressed in the retina, retinal pigment epithelium, and vascular endothelium, where they export toxins and metabolites, and may serve as a therapeutic target. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:318-321.].

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.

Surgical Management of Coats Disease

Coats disease is a sporadic, chronic retinal vascular disorder with telangiectatic and aneurysmal retinal vessels, with retinal exudation and retinal detachment in severe cases. Various treatment modalities have been used, including laser therapy, cryotherapy, anti‒vascular endothelial growth factor (VEGF) therapy, and surgery. Anti-VEGF therapy seems to be effective in reducing exudative changes and is often combined with other treatment modalities. For severe cases with exudative retinal detachment, external drainage of subretinal fluid with or without vitrectomy is commonly performed, combined with laser therapy and/or cryotherapy. Relatively good anatomical outcomes have been reported; however, postoperative functional results, particularly in young patients and/or severe cases, seem to be limited.

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 of stage 3 Coats' disease by endolaser photocoagulation via a two-port pars plana nonvitrectomy approach

Background

To evaluate the effectiveness of endolaser photocoagulation by a two-port pars plana nonvitrectomy approach for treating Coats’ disease with shallow exudative retinal detachment.

Methods

This study included 24 patients (23 boys with an age range of 2–17 years, and one girl, age 6 years) with stage 3 Coats’ disease (25 eyes) from December 2012 and May 2014 at a single center. All of the 25 eyes were complicated with serous or total retinal detachment and received none-vitrectomized endolaser: two (23- or 25-gauge) incisions were routinely made 3 mm posterior to the corneal limbus and a laser was applied directly on the abnormal blood vessels. Additional treatments included subretinal fluid drainage (five eyes), intravitreal triamcinolone injection (seven eyes), and intravitreal anti-vascular endothelial growth factor (VEGF) injection (17 eyes). Best-corrected visual acuity, intraocular pressure, and fundus and abnormal vascular changes were recorded to determine therapeutic effects.

Results

Twenty-four out of the 25 treated eyes (96 %) had retina reattached. The number of treatment sessions differed case by case (1–5 sessions, average 1.96) and the time to full treatment of retinal reattachment was 4 months in average. One patient (4 %) presented with retinal redetachment. Five (20 %) eyes received further laser treatment with indirect ophthalmoscope and four eyes (16 %) presented with total retinal detachment at their first visits received consecutive treatments. At the end of the follow-up period (mean, 10.08 months), telangiectasias of 24 (96 %) eyes were resolved and no severe complications occurred.

Conclusions

Endolaser photocoagulation by a two-port pars plana nonvitrectomy approach is an effective treatment for advanced Coats’ disease with serous retinal detachment. The long-term safety of the approach needs further investigation.

Coats' disease in Tanzania: first case report and literature review

BACKGROUND

Coats' disease is an exudative retinal detachment with vascular telangiectasis occurring mostly in male children, the age group most affected by retinoblastoma.

OBJECTIVES

Compare the differential diagnoses of Coats' disease Establish recommendation to early disease detection.

MATERIALS AND METHODS

A 3-year-old female child was referred to Muhimbili National Hospital (MNH), Tanzania, in September 2011. She had presented at the peripheral hospital with gradual onset of left eye leukocoria for 1 year and pain for 2 months. B-scan showed a mass in the left eye. A clinical diagnosis of retinoblastoma was made. Left eye enucleation was performed; the patient was referred to MNH, with the enucleated specimen.

RESULTS

Brain and orbits scan revealed no residual tumour. The globe measured 2 x 1.8 cm, the optic nerve stump measured 3 mm. A whitish mass filled the vitreous, with complete retinal detachment. Microscopy showed retinal gliosis, detachment with sub retinal PAS positive exudates, vacuolation and cholesterol clefts. Foreign body giant cells were present; telangiectatic thin-walled blood vessels were identified. Clinico-pathological findings were of stage 4 Coats' disease.

CONCLUSION

Coats' disease is an important differential diagnosis of retinoblastoma. Delay to detect Coats' disease leads to vision loss which necessitates eye enucleation as was in this child.

Management of idiopathic retinal vasoproliferative tumors by slit-lamp laser or endolaser photocoagulation

PURPOSE

To report the efficacy of laser photocoagulation in treating idiopathic (primary) retinal vasoproliferative tumors.

DESIGN

Retrospective noncomparative interventional case series.

PATIENTS AND METHOD

Thirty eyes of 30 patients (22 women and 8 men) with retinal vasoproliferative tumors. Main outcome measures were best-corrected visual acuity (BCVA), presence of retinal hard exudates, retinal detachment (RD), cystoid macular edema (CME), and epiretinal membrane (ERM). Laser photocoagulation was performed at the slit lamp or during pars plana vitrectomy for telangiectasia visible at the retinal vasoproliferative tumors surface.

RESULTS

Fifteen eyes were treated with slit-lamp laser. Mean follow-up was 36.5 months (range 7 months to 11 years). Mean BCVA increased from 20/40 to 20/32 at the end of the follow-up. Hard exudates and CME regressed completely in 15 of 15 and 5 of 6 eyes, respectively. Fifteen eyes underwent vitrectomy owing to the presence of ERM (10 eyes), large exudative RD (4 eyes), or vitreous hemorrhage (1 eye). Mean follow-up was 24 months (9 months to 3.5 years). Mean BCVA increased from 20/125 to 20/40 at the end of the follow-up. No vision loss occurred. The retina reattached in all cases. Hard exudates regressed completely in 14 of 15 eyes and decreased significantly in 1. Postoperative complications were rhegmatogenous RD in 2 eyes, successfully reattached after additional surgery.

CONCLUSION

Selective laser photocoagulation of retinal telangiectasia at the retinal vasoproliferative tumors' surface induced the regression of retinal exudation. Slit-lamp laser photocoagulation was sufficient in half of the cases. In more severe conditions, direct endolaser photocoagulation of the telangiectasia was required.

Pars plana vitrectomy for treatment of advanced Coats' disease--presentation of a modified surgical technique and long-term follow-up

BACKGROUND

To present a modified surgical technique in the treatment of retinal detachment secondary to advanced Coats' disease in children, and report on long-term anatomical and functional outcome.

METHODS

We analysed an interventional case series of 13 patients (13 eyes) with advanced Coats' disease characterised by retinal detachment in addition to massive subretinal exudates and vascular malformation. The presented patients underwent pars plana vitrectomy (PPV), including a modified technique of exocryotherapy applied after fluid-air exchange in order to achieve complete treatment of the vascular changes, to reduce associated side-effects, and to avoid retinectomy and silicone oil tamponade.

RESULTS

Within a median follow-up period of 37 months (range: 18-66 months), no enucleation was necessary. Four eyes (31 %) did not need any further therapy, and in nine eyes (69 %) additional treatments were performed. Six patients (46 %) required revisional surgery with silicone oil tamponade. In ten eyes (77 %), the pathologic vessels and exudates finally regressed and the retina reattached. Visual acuity (VA) could be stabilized in the majority of patients: in three eyes (27 %) VA improved, in four eyes (36 %) VA remained stable, in four eyes (36 %) visual acuity (VA) deteriorated, and in two eyes VA could not be evaluated.

CONCLUSIONS

The presented modified technique allows for sufficient cryotherapy of vascular malformations, even in the presence of massive exudation, in a subset of patients with advanced Coats' disease, and thus may reduce surgery-related complications and improve the rehabilitation process of these young patients.

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.

Ultra-widefield imaging for the management of pediatric retinal diseases

PURPOSE

To describe the utility of using ultra-widefield digital fundus photography and ultra-widefield fluorescein angiography (UWFA) in the pediatric patient population to evaluate peripheral retinal pathology and to manage Coats' disease and familial exudative vitreoretinopathy (FEVR).

METHODS

Retrospective review of pediatric retinal patients with FEVR or Coats' disease who underwent ultra-widefield fundus photography and UWFA.

RESULTS

Eight patients were included in this case series. Five patients had the clinical diagnosis of FEVR, and two eyes of two patients with FEVR received UWFA-guided laser photocoagulation. Three patients were diagnosed as having Coats' disease and received UWFA-guided laser photocoagulation.

CONCLUSIONS

Ultra-widefield fundus photography and UWFA can be used successfully as an outpatient procedure in the pediatric patient population without the necessity of examination under anesthesia and can aid the physician in the documentation and evaluation of peripheral retinal pathology. UWFA can also assist in directing laser photocoagulation in the treatment of pediatric retinal diseases.

Idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysm treated with indocyanine green dye-enhanced photocoagulation

This case report presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of idiopathic juxtafoveal retinal telangiectasis and a retinal macroaneurysm. A 35-year-old male with 20/20 vision had been followed for 5 years for a retinal macroaneurysm with retinal telangiectasis outside the macular area. He then presented with a recently decreased vision in his right. He had macular edema with a new area of idiopathic juxtafoveal retinal telangiectasis. After 4 focal argon laser treatments, angiographic closure of the lesions was not obtained and the retinal edema remained. After 3 sessions of ICG-DEP, the lesions were closed and the edema absorbed. The 810 nm infrared laser with ICG-DEP should be considered for the treatment of idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysms. In this case the procedure appears to be safe and well tolerated. It may allow for more direct energy absorption than that of the argon laser to these types of retinal lesions with better tissue closure.

Transscleral diode photocoagulation of large retinal and choroidal vascular lesions

BACKGROUND

Transscleral retinal photocoagulation with a diode laser is used in glaucoma refractory to medical and surgical treatment. Our main research question was how the technique performed in large vascular lesions associated with hemangiomas of the retina and choroid.

METHODOLOGY/CLINICAL FINDINGS

Patient charts were retrieved from the hospital files for patients who underwent the procedure and were followed for at least 24 months. Five patients (6 eyes) fit the criteria. Cases included Von Hippel's disease (2 eyes), Coats' disease (1 eye) and choroidal hemangioma (3 cases). Transscleral diode laser treatment was performed under retrobulbar and topical anesthesia with a retinopexy probe (IRIS DioPexy, IRIS Medical Instruments, Mountain View, CA) applied transsclerally under indirect ophthalmoscope visualization. We found an improvement in best-corrected visual acuity at 24 months postoperatively.

CONCLUSIONS/SIGNIFICANCE

Transscleral photocoagulation may have a clinical application in these diseases as an alternate to the high cost of photodynamic therapy with photosensitizing agents.

[Long-term prognosis of 5 cases with stage 3A Coats disease after vitrectomy]

PURPOSE

The effectiveness of laser photocoagulation and/or cryopexy to the abnormal retinal vessels for the treatment of eyes with Coats disease is reported. However, in Coats cases with serous detachment laser photocoagulation and/or cryopexy is sometimes not enough to coagulate and consecutively scar the abnormal vessels, leading to persistent subretinal fluid and multiple courses of treatment. Therefore, we investigated the long-term prognosis of Stage 3A Coats cases with macular detachment which underwent vitrectomy.

METHODS

Five eyes of 5 cases (all men) with Stage 3A Coats disease, which underwent primary vitrectomy between 1999 and 2009, were investigated retrospectively. The average age at vitrectomy was 13.8 years (range; 6-21 years) and the average preoperative visual acuity in decimal equivalent was 0.1 (range; 0.04-0.5). The average follow-up period after vitrectomy was 83 months (range; 13-137 months). In the vitrectomy, posterior vitreous detachment either occurred or was confirmed. An intentional retinal hole was made and the subretinal fluid was drained through the hole. The abnormal vessels were coagulated by endo-diathermy and/or laser photocoagulation. The vitreous fluid was replaced with long-lasting gas or air. The visual acuity and the findings from the ocular fundus both before and after the vitrectomy were investigated.

RESULTS

The average best-corrected visual acuities in decimal equivalent before, 3 and 12 months after the vitrectomy, and at the final visit were 0.1, 0.2, 0.2, 0.4, respectively. There was a statistically significant (p = 0.007) difference between the 4 time points, and the visual acuities at 12 months after vitrectomy and the final visit were significantly (p < 0.05) better than before the vitrectomy. The macular part of the retina in all 5 cases was attached once the gas in the vitreous cavity had disappeared. The foveal exudation which was observed before the vitrectomy in all 5 cases was completely absorbed after the vitrectomy. The average period from the vitrectomy to the complete absorption of the exudation was 20 months. Subfoveal fibrosis was observed in 4 of the 5 eyes and chorioretinal atrophy occurred in 3.

CONCLUSIONS

Vitrectomy for eyes with Stage 3A Coats disease may be effective for visual prognosis compared to conventional therapy, i.e., laser photocoagulation and cryopexy, by enabling retinal attachment in the early postoperative period and by causing the foveal exudation to disappear.