Combination treatment with intravitreal injection of ranibizumab and reduced fluence photodynamic therapy for choroidal neovascularization secondary to angioid streaks: preliminary clinical results of 12-month follow-up.
To evaluate combination treatment with intravitreal ranibizumab injection and reduced fluence photodynamic therapy for choroidal neovascularization associated with angioid streaks.
This is an interventional case series of 10 previously untreated eyes of 10 patients with choroidal neovascularization secondary to angioid streaks. All eyes were treated with reduced fluence photodynamic therapy using 25 J/cm, immediately followed by intravitreal ranibizumab injection at baseline, and subsequent injections were performed on an as-needed basis thereafter. Treatment efficacy was assessed based on best-corrected visual acuity and optical coherence tomography findings.
After 12 months of follow-up, the best-corrected visual acuity improved by >2 lines in 6 eyes (60%), remained within 2 lines of baseline in 3 eyes (30%), and decreased by ≥ 3 lines in only 1 eye (10%). The mean central foveal thickness decreased significantly from 332.2 μm at baseline to 235.7 μm at the last follow-up (P < 0.001), as measured by optical coherence tomography.
The preliminary results of this prospective study indicate that combination treatment with intravitreal ranibizumab injection and reduced fluence photodynamic therapy for choroidal neovascularization associated with angioid streaks seems to be effective in reducing or eliminating retinal edema, regression of neovascularization, and improving or stabilizing visual acuity without any complications. Large controlled studies are needed to evaluate the long-term effects of this combination regimen.
"Based on these previous findings in conjunction with the bevacizumab tachyphylaxis and the vitrectomized-pseudophakic condition that was present, we decided to use ranibizumab instead of bevacizumab in all of the subsequent treatments for this patient. Recently, it has been reported that the combination of IVR and reduced-fluence PDT for CNV associated with AS was effective in the regression of CNV and in improving (or stabilizing) the visual acuity [26,27]. Based on the above-mentioned findings, we performed the combined therapy of full-dose PDT and IVR instead of IVR monotherapy. "
[Show abstract][Hide abstract] ABSTRACT: Patients with angioid streaks are prone to developing subretinal hemorrhage after ocular or head injury due to the brittleness of Bruch's membrane. However, there have been no reports of any angioid streak patients in whom choroidal neovascularization occurred after vitrectomy surgery. We report herein a patient with angioid streaks who developed choroidal neovascularization after vitrectomy surgery for epiretinal membrane.
A 76-year-old man presented with distorted vision in his left eye, with a best corrected visual acuity of 1.2 and 0.6 in his right and left eyes, respectively. Fundus examination showed angioid streaks in both eyes and epiretinal membrane only in the left eye. The patient underwent 23-gauge three-port pars plana vitrectomy with removal of the epiretinal membrane combined with cataract surgery. Internal limiting membrane in addition to the epiretinal membrane were successfully peeled and removed, with indocyanine green dye used to visualize the internal limiting membrane. His left best corrected visual acuity improved to 0.8. An elevated lesion with retinal hemorrhage due to probable choroidal neovascularization was found between the fovea and the optic disc in the left eye at 7 weeks after surgery. Since best corrected visual acuity decreased to 0.15 and the hemorrhage expanded, posterior sub-Tenon injection of triamcinolone acetonide was performed. However, no improvement was observed. Even though intravitreal bevacizumab injection was performed a total of five times, his best corrected visual acuity remained at 0.1. Subsequently, we performed a combination treatment of a standard-fluence photodynamic therapy and intravitreal ranibizumab injection, with additional intravitreal ranibizumab injections performed 3 times after this combination treatment. Best corrected visual acuity improved to 0.5 and the size of the choroidal neovascularization markedly regressed at 4 months after the combined treatment.
Development of choroidal neovascularization could possibly occur in elderly patients with angioid streaks after vitrectomy surgery. In such cases, a combination of photodynamic therapy and intravitreal ranibizumab injection may be considered for initial treatment of the choroidal neovascularization.
"This observation has been confirmed in long-term studies with follow-up times exceeding one year, that report recurrent or newly developed CNV in different regions in half of the study cohorts.17,18,27 The use of intravitreal ranibizumab (Lucentis®, Genetech Inc), the antigen-binding fragment of recombinant, humanized monoclonal antibody that neutralizes all active forms of VEGF A, was also used in CNV-related angioid streaks with promising results.32 The largest published retrospective case series investigating the use of ranibizumab in CNV secondary to angioid streaks demonstrated a stabilization of visual acuity over 24 months with a mean of 5.7 injections.27 "
[Show abstract][Hide abstract] ABSTRACT: The purpose of this paper is to report the clinical course of choroidal neovascularization (CNV) secondary to angioid streaks and the outcomes in response to different treatment modalities.
This was a case series of two consecutive patients (four eyes) with CNV secondary to angioid streaks. Visual acuity, ophthalmological examination, color photographs, fluorescein angiography, and optical coherence tomography were used to assess the outcomes of treatment.
Two eyes were treated with photodynamic therapy for subfoveal choroidal neovascular membrane, one eye underwent thermal laser photocoagulation for extrafoveal CNV followed by intravitreal bevacizumab for subfoveal CNV, and one eye underwent intravitreal bevacizumab for subfoveal CNV. The follow-up period was 4-6 years. The final visual acuities of all eyes were 20/300 or worse with large submacular fibrosis.
CNV secondary to angioid streaks in these two patients had a poor prognosis despite undergoing different types of treatment. Poor outcome was likely related to frequent recurrence and newly developed CNV, which remained a clinical concern in these cases.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
To evaluate different therapies for choroidal neovascularization (CNV) due to angioid streaks (AS).
Studies were identified by a systematic literature search and were included in the analysis based on predefined criteria. Primary outcome measure was change in best-corrected visual acuity (BCVA).
Fifty-four relevant studies were identified and included mostly uncontrolled case series. No randomized controlled trials were available. Treatment with vascular endothelial growth factor inhibitors improved or stabilized BCVA in all case series. Photodynamic therapy slowed down disease progression with stabilization or decrease of BCVA. Individual BCVA and follow-up data for each treated eye were reported in >160 cases for both treatments, vascular endothelial growth factor inhibitors and photodynamic therapy. In a pooled analysis of those studies, the difference of mean change in BCVA between both treatment groups was estimated as approximately 6 lines (0.59 logMAR [95% confidence interval, 0.38-0.8; P < 0.0001]). A better baseline BCVA was associated with a better BCVA outcome (P < 0.0001). Laser photocoagulation yielded comparable results as photodynamic therapy but application was mostly restricted to extrafoveal lesions, was complicated by frequent recurrences, and led to more retinal damage with subsequent absolute scotomas. Combination therapies seem to be not superior to monotherapy.
Intravitreal vascular endothelial growth factor inhibitors are currently the most effective treatment of CNV due to angioid streaks.
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