CASE PRESENTATION CASE PRESENTATION Prepared by: Dr. Lina Raffa - - PowerPoint PPT Presentation

CASE PRESENTATION CASE PRESENTATION

Prepared by: Dr. Lina Raffa

Case Report p

14 year old boy known case of Vogt Kayanagi 14 year old boy known case of Vogt Kayanagi

Harada disease diagnosed 2 yrs ago

Following up in the clinic regularly Following up in the clinic regularly Initially was treated with oral and topical

corticosteroids and cycloplegic agents corticosteroids and cycloplegic agents

Cyclosporin 100 mg O.D., Methotrexate 10 mg/week

and Immuran 100 mg OD g

Ramicade (anti TNF) 400 mg IV given 5 months by

May 2008 y

Initial Presentation

VA 20/70 O.D. and 20/100 O.S. VA 20/70 O.D. and 20/100 O.S. A/C +3 cells +2 flare Vitreous +2 cells Vitreous +2 cells Pupils: RRR no RAPD

IOP N l O U

IOP: Normal O.U. EOM: full CVF: Normal O.U.

Fundoscopy: multifocal choroidal lesions,BL exudative RD Fundoscopy: multifocal choroidal lesions,BL exudative RD and intensely congested optic nerve May 2007 y

AS: Posterior synechaie PS: Dalen Fuchs Nodules and RPE alterations PS: Dalen Fuchs Nodules and RPE alterations

7 acute episodes between May 2006 and 2008 7 acute episodes between May 2006 and 2008

Follow-up: VA 20/20 O.U. Follow up: VA 20/20 O.U. Stopped Ramicade for 2 months due to non

availability in the market and presented on July 2008 ava ab y e a e a d p ese ed o Ju y 008

with sudden drop in vision in the left eye

O/E CF O.S.

/

FA(July 2008) ( y )

OCT

Diagnosed as CNVM O.S. Diagnosed as CNVM O.S. Avastin injection (1.25 mg) was given VA improved to 20/100 O S first week post VA improved to 20/100 O.S. first week post

injection

Today VA 20/60 ph 20/40 Today VA 20/60 ph 20/40

Fundus photo p

OCT

Result

We report successful treatment in a 14-year-old We report successful treatment in a 14 year old VKH patient with subfoveal CNVM in the left eye who received a dose of intravitreal bevacizumab (1.25 mg) injection, resulting in rapid regression of the CNVM. Angiogram findings showed resolution

• f leakage from CNVMs. OCT demonstrated

resolution of the subretinal or intraretinal fluid. Vi i i t l t d ith OCT Vision improvement was correlated with OCT changes.

Conclusion

This case illustrates that intravitreal bevacizumab This case illustrates that intravitreal bevacizumab has a possible role in the treatment of the above condition with regression of neovascular membrane g and subsequent visual improvement, although a large prospective study and a longer follow-up is required to reach a conclusive result.

A literature review using MEDLINE failed to A literature review using MEDLINE failed to

reveal any mention of a case of choroidal neovascularization in children with VKH neovascularization in children with VKH treated with intravitreal bevacizumab.

Therapeutic efficacy of intravitreal bevacizumab on posterior uveitis complicated by neovascularization

Purpose: To evaluate the therapeutic effect of intravitreal

p p bevacizumab in patients with uveitis-associated choroidal/retinal neovascularization.

Methods: Two female patients (40 years 15 years) with Methods: Two female patients (40 years, 15 years) with

posterior uveitis, (one presumed ocular sarcoidosis, one lupus) were evaluated for neovascularization of the posterior t B th ti t i i l d f 1 25

• segment. Both patients were given a single dose of 1.25 mg

intravitreal bevacizumab.

Results: Significant anatomical and functional recovery was

evident in both patients within a few weeks.

Conclusion: In selected uveitic patients, bevacizumab may be

an option for managing neovascularization an option for managing neovascularization.

Shree Kurup et al 2008 Acta Ophthalmol

CNVM

Complication of multiple eye diseases,that usually Complication of multiple eye diseases,that usually

results in irreversible vision loss.

It is characterized by proliferation and growth of It is characterized by proliferation and growth of

choroidal blood vessels through Bruch's membrane into the subpigment epithelial and/or subretinal p g p / space

VEGF has been implicated in the pathogenesis of

CNVM

Types of CNVM yp

Classic: Classic:

early,lacy hyperflourescence with well demarcated margins and late leakage on FA margins and late leakage on FA

Occult:

areas of leakage in the late phase of the areas of leakage in the late phase of the angiogram not corresponding to the classic CNVM discernible in the early phase of the angiogram. discernible in the early phase of the angiogram.

Location

Subfoveal: beneath the center of the FAZ Subfoveal: beneath the center of the FAZ Juxtafoveal:1 to 100 um from the FAZ Extrafoveal :greater than 199 um from the Extrafoveal :greater than 199 um from the

geometric center of the foveal avascular zone

Incidence of CNVM in VKH

Synder and Tessler 5% Synder and Tessler 5% Moorthy and collegues 9% Ober and coworkers 36% Ober and coworkers 36%

Pathophysiology p y gy

Extensive fundus pigmentary derangement Extensive fundus pigmentary derangement Chronic recurrent inflammation

(increased vascular permeability EC matrix (increased vascular permeability,EC matrix breakdown and endothelial budding and vascular proliferation) proliferation)

Recurrence of predominantly anterior segment

inflammation inflammation

Prognosis g

The overall visual prognosis for CNV remains The overall visual prognosis for CNV remains

dismal.

Severe visual loss occurs in over 60% of CNV cases Severe visual loss occurs in over 60% of CNV cases

• ver a five year period.

In general, the currently available therapeutic In general, the currently available therapeutic

modalities are only able to decrease the extent to which vision is lost and are incapable of restoring vision

Differential Diagnoses for pediatric CNVM

Myopic degeneration

y p g

Angiod streaks Trauma Toxoplasmosis,Histoplasmosis Central Serous Chorioretinopathy (CSCR)

p y ( )

Punctate Inner Choroidopathy (PIC) Multifocal Choroiditis (MFC)

( )

Idiopathic CNVM

Treatment

Bevacizumab (avastin) is a monoclonal antibody that

( ) y inhibits VEGF

Rx: colorectal cancer and CNVM in ARMD Serial intravitreal injections every four to six weeks is

however associated with small but significant risks including endophthalmitis, retinal detachment and including endophthalmitis, retinal detachment and cataract.

A literature review using MEDLINE failed to reveal any

mention of a case of choroidal neovascularization in children with VKH treated with intravitreal bevacizumab. bevacizumab.

Avastin side effects

Common: conjunctival hemorrhage, eye pain, Common: conjunctival hemorrhage, eye pain,

floaters, increased IOP , inflammation of the eye

Serious and rare: Endophthalmitis, Uveitis, RD, Serious and rare: Endophthalmitis, Uveitis, RD,

Retinal tear and traumatic cataract.

Argon laser g

Although the risk of severe visual loss is significantly Although the risk of severe visual loss is significantly

reduced (especially for classic lesions >200mmetres from the fovea), the recurrence rate is 50 per cent ), p with this treatment.

Photodynamic therapy y py

Using a non-thermal diode laser (689nm) following Using a non thermal diode laser (689nm) following

intravenous administration of a photo-activated drug (verteporfin).

Current NICE guidelines fund PDT for the treatment of

subfoveal 100 per cent classic CNVM with vision of 6/60 b 6/60 or better

Poor results and worsening of VA with most eyes

undergoing enlargement and disciform transformation undergoing enlargement and disciform transformation

• f the neovascularization process

Submacular surgical removal g

The surgery involves repositioning the macula such The surgery involves repositioning the macula such

that the fovea comes to lie on healthy RPE and choroid away from the visually destructive CNVM. y y

While up to two-thirds of patients may experience

visual improvement, significant complications such as p g p RD may lead to visual loss

Th k Thank you