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A. B. Richards, E. B. Suhler, J. R. Smith, C. J. Flaxel; Intravitreal VEGF Blockade for CNV Related to Multifocal Choroiditis and Panuveitis Previously Treated With Fluocinolone Acetonide Intravitreal Implants: A Case Series. Invest. Ophthalmol. Vis. Sci. 2008;49(13):4736.
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Multifocal choroiditis and panuveitis (MFC) is an inflammatory disease of the posterior segment that leads to choroidal neovascularization (CNV) in 32-46% of patients, often in a subfoveal, juxtafoveal, or peripapillary location. In contrast to noninflammatory CNV, immunosuppression is often the primary mode of treatment for these lesions. We present a case series of 3 eyes of 3 patients with MFC treated with fluocinolone acetonide (FA) intravitreal implants who developed CNV, which was successfully treated with intravitreal bevacizumab or ranibizumab.
All patients had been diagnosed with bilateral MFC for a range of 26 months to 9 years. Each patient had received multiple treatments, including intravitreal triamcinolone, prednisone, mycophenolate mofetil, methotrexate, tacrolimus, cyclosporine A, or infliximab prior to FA implant to control their intraocular inflammation. All patients had secondary glaucoma and cataract development from the corticosteroids, two pre-implant and one post-implant. The ages of the patients at time of FA implant were 25 (Case 1), 41 (Case 2), and 53 (Case 3) years. The duration from implantation to the first anti-VEGF injection ranged from 6 to 7 months. Case 1 and 2 received bevacizumab. Case 3 received ranibizumab, as he had suffered an inflammatory reaction to intravitreal bevacizumab prior to FA implant.
The pre-injection visual acuities (VA) were -0.54, -0.54, -0.48 logMAR (mean -0.52). The post-injection VAs were -0.88, -0.50, -0.54 logMAR (mean -0.64). The pre-injection central retinal thicknesses (CMT) measured by Stratus OCT 3 were 798 µm, 215 µm, and 417 µm (mean 477 µm). The post-injection CMTs were 220 µm, 200 µm, and 241 µm (mean 220 µm). The retinal edema and subretinal fluid resolved in each case. There was no significant change in inflammation pre- and post-injection. Advancing cataracts were a significant factor in cases with worsening visual acuity post-injection. The total number of anti-VEGF injections until resolution of retinal edema and subretinal fluid associated with the CNV was 6 injections for Case 1 and 1 injection for Cases 2 and 3 with followup of 24, 25, and 8 months, respectively.
Anti-VEGF therapy was successful in treating persistent CNV in patients with MFC following insertion of FA implants with well-controlled inflammation. Anti-VEGF therapy should be considered in treating active CNV in eyes with quiescent inflammatory disease.
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