Download Intravitreal Bevacizumab for Subfoveal Idiopathic Choroidal

Mahmood J Showail
11/03/2009
A 17-year-old high school female student presented to
our clinic with history of sudden decrease of vision in
her left eye over one month duration.
 There was no history of pain or redness.
 No significant history of trauma.
 No history of fever, headache or photophobia.
 Vision
 20/20 (OD)
 20/400 (OS)
 Pupils
RRR (OU) no RAPD
 AC
 Deep & quite (OU)
 Lens & cornea clear (OU)
 Vitreous quite (OU)
 Fundus
 Normal fundus (OD)
 No drusen, retinal pigment epithelial changes, or macular
retinal exudates were observed in either fundus
left eye . subfoveal chroidal neovascular membrane
with surrounding subretinal haemorrhage
OCT of the left eye which showed increase in foveal
thickness and subretinal fluid
 ESR 20
 Serology
 CMV IgM –ve
 CMV IgG +ve
 HSV IgM –ve
 HSV IgG +ve
 CRP normal “<2.29”
 HBsAg
 ANA -ve
 HIV
 CBC
 WBC 7.2
 HB
 Plt
13.1
265
 VDRL
-ve
 PPD 15
 Chest x ray
normal
 Degenerative conditions
 ARMD

 Myopia

 Angioid streaks
 Inflammatory or
infectious conditions







 Choroidal tumors
 Nevi

 Melanoma

 Hemangioma

 Osteoma
Sarcoidosis
 Trauma
 Choroidal rupture
 Laser photocoagulation
Multifocal choroiditis
 Idiopathic
Histoplasmosis
PIC
Idiopathic choroidal neovascular membrane
 Intravitreal bevacizumab “ AVASTIN “ 1.25 mg/0.1 ml
was injected into the left eye and she was follwed up in
the clinic and her visual acuity improved (OS)
 3 weeks
 5 weeks
 7 weeks
(20/200)
(20/100)
(20/100)
Pre -AVASTIN
3 weeks Post –AVASTIN
5 weeks Post –AVASTIN
IVFA pre-AVASTIN early and late
IVFA 3 weeks post-AVASTIN early and late
OCT
PreAVASTIN
OCT
5wks
postAVASTIN
 We booked her for another AVASTIN injection ..
 It represent the growth of new blood vessels that
originate from the choroid through a break in the
Bruch membrane into the sub–retinal pigment
epithelium (sub-RPE) or subretinal space.
 Mechanisms of CNV are not understood.
 Recently, a protein derived from the RPE, pigment
epithelium derived factor (PEDF), was found to have
an inhibitory effect on ocular neovascularization.
Another peptide, vascular endothelium growth factor
(VEGF), is a well-known ocular angiogenic factor.
 The balance between antiangiogenic factors (eg,
PEDF) and angiogenic factors (eg, VEGF) is speculated
to determine the growth of CNV
Virtually any pathologic process that involves the RPE and
damages the Bruch membrane can be complicated by CNV.
 Degenerative conditions
 ARMD

 Myopia

 Angioid streaks
 Inflammatory or
infectious conditions







 Choroidal tumors
 Nevi

 Melanoma

 Hemangioma

 Osteoma
Sarcoidosis
 Trauma
 Choroidal rupture
 Laser photocoagulation
Multifocal choroiditis
 Idiopathic
Histoplasmosis
PIC
 In patients age 50 years or younger, CNVs usually
develops secondary to various predisposing conditions
such as pathological myopia, angioid streak, trauma,
or inflammation.(1)
 In a significant number of young patients with CNVs,
no apparent cause can be detected, constituting
idiopathic CNV.(2)
1.
Cohen SY, Laroche A, Leguen Y, et al. Etiology of choroidal neovascularization in
young patients. Ophthalmology. 1996;103(8):1241-1244.
2.
Ho AC, Yannuzzi LA, Pisicano K, et al. The natural history of idiopathic subfoveal
choroidal neovascularization. Ophthalmology. 1995;102(5):782-789.
 Idiopathic CNVs are usually unilateral and their
prognosis are considered to be more favorable than
CNVs due to age-related macular degeneration
(AMD).(1)
1. Lindblom B, Andersson T, et al. The prognosis of idiopathic choroidal
neovascularization in persons younger than 50 years of age. Ophthalmology.
1998 Oct;105(10):1816-20 .
 Idiopathic choriovitreal membrane a case report
“ British journal of Ophthalmology 1992; 76: 567-568”
* idiopathic CNV which spontaneously grew through an intact retina to
produce choriovitreal neovascularization.
 Clinical and OCT Features in Spontaneously Progressive
Idiopathic Choriovitreal Neovascularization “Ophthalmic
Surgery, Lasers and Imaging Volume 38(2), March/April 2007, p 151-153 “
 * idiopathic subfoveal CNV spontaneously progressed to choriovitreal
neovascularization through an intact retina , which resulted in vigorous
vitreomacular traction.
 Currently, there are no published studies evaluating
the efficacy or safety of intravitreal bevacizumab for
subfoveal ICNV.
 As “AVASTIN “ has not been studied in a prospective,
randomized, clinical trial till now.
 Intravitreal Bevacizumab for Subfoveal
Idiopathic Choroidal Neovascularization “Arch
Ophthalmol. 2007;125(11):1487-1492
 prospective,noncomparative, interventional case series.
 Thirty-two eyes of 32 patients with idiopathic choroidal
neovascularization received intravitreal bevacizumab (1.25
mg/0.05 mL)
 Injection was repeated if OCT showed intraretinal edema,
subretinal fluid, and/or pigment epithelial detachment at a 4week interval.
 Patients were followed up for at least 12 weeks.
 Short-term results suggest that intravitreal
bevacizumab is safe and well tolerated in idiopathic
choroidal neovascularization.
 Many patients showed marked improvement in VA
and a decrease in central macular thickness.
 Further evaluation with longer follow-up is needed to
confirm long-term efficacy and safety.
Thank
you