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: Normal O.U. IOP N l 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 of leakage from CNVMs. OCT demonstrated resolution of the subretinal or intraretinal fluid. Vi i Vision improvement was correlated with OCT i t l t d ith 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 segment. Both patients were given a single dose of 1.25 mg t B th ti t i i l d f 1 25 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 over 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 6/60 or better b � Poor results and worsening of VA with most eyes undergoing enlargement and disciform transformation undergoing enlargement and disciform transformation of 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 Thank you k