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R. Horn, P. S. Bernstein; Treatment of Coats Reaction and Cystoid Macular Edema in a Retinitis Pigmentosa Patient. Invest. Ophthalmol. Vis. Sci. 2009;50(13):985.
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To report the successful use of verteporfin photodynamic therapy (PDT) combined with triamcinolone acetonide after an unsuccessful trial of intravitreal bevacizumab in treating cystoid macular edema (CME) and Coats-type retinitis pigmentosa (RP).
Observational case report; A 15 year old female received a series of two intravitreal bevacizumab injections for CME associated with Coats-type RP without effect. Subsequent treatment with verteporfin PDT to the peripheral Coats lesion along with intravitreal triamcinolone was successful.
Initial treatment was started with intravitreal bevacizumab in the right eye. A series of two bevacizumab injections was performed without improvement of macular edema on OCT or resolution of the Coats lesion. At this time, standard-dose verteporfin PDT was performed to the Coats lesion along with an injection of intravitreal triamcinolone acetonide. There was a prompt response to this intervention with OCT showing a reduction in central foveal thickness to 165 microns, a decrease of 428 microns, and fibrosis of the peripheral Coats lesion. Intravitreal triamcinolone was then performed to the left eye with a resolution of edema from 546 microns to 188 microns, six weeks later. Visual acuity stabilized at 20/50 OD and 20/60 OS with the patient noting a significant subjective improvement in visual function.
There are no reported cases of Coats-type RP being treated with anti-angiogenic agents. Theoretically, bevacizumab has the potential to treat both the Coats reaction as well as the CME due to its anti-permeability and anti-angiogenic actions. Based on this facts, a trial of intravitreal bevacizumab was initiated in this patient who had both macular edema and peripheral Coats-reaction. This treatment was found to be ineffective for treatment of CME or the Coats response in our patient, and we next tried verteporfin PDT in combination with intravitreal triamcinolone. This approach proved very effective. The CME resolved for many months and the regressed peripheral Coats lesion has been stable for over a year. There is very little published experience regarding successful treatment of CME in RP with anti-VEGF agents. Our experience in this case report confirmed reported unsuccessful results of anti-VEGF therapy for CME in RP. Although other approaches such as direct laser photocoagulation to the Coats lesion and oral or topical carbonic anhydrase inhibitors for CME may have also been successful for the management of this patient, the combination of verteporfin photodynamic therapy and intravitreal triamcinolone appears to be a safe and effective means to treat RP with Coats reaction and CME.
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