Mahmood J Showail

Ophthalmolgy Department

Grand RoundCase 2

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.

History

Vision 20/20 (OD)20/400 (OS)

PupilsRRR (OU) no RAPD

ACDeep & quite (OU)Lens & cornea clear (OU)

Vitreous quite (OU)

On Examination

Fundus Normal fundus (OD)No drusen, retinal pigment epithelial changes, or

macular retinal exudates were observed in either fundus

Fundus Examination

OS

left eye . subfoveal chroidal neovascular membrane with surrounding subretinal

haemorrhage

OCT

OCT of the left eye which showed increase in foveal thickness and subretinal fluid

CBCWBC 7.2HB 13.1Plt 265

ESR 20CRP normal

“<2.29”ANA -ve

Laboratory investigations Serology

CMV IgM –ve CMV IgG +ve HSV IgM –ve HSV IgG +ve

HBsAg HIV -ve VDRL

PPD 15 Chest x ray normal

Cont. Investigatgions

Degenerative conditions ARMD   Myopia   Angioid streaks

Inflammatory or infectious conditions Histoplasmosis   Sarcoidosis   Multifocal choroiditis   PIC

Differential DiagnosisChoroidal tumors

Nevi   Melanoma   Hemangioma   Osteoma

Trauma Choroidal rupture Laser photocoagulation 

Idiopathic

Idiopathic choroidal neovascular membrane

Diagnosis

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 (20/200)5 weeks (20/100)7 weeks (20/100)

Management

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 Pre-

AVASTIN

OCT 5wks post-

AVASTIN

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.

Choroidal Neovascularization

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

Pathophysiology

Degenerative conditions ARMD   Myopia   Angioid streaks

Inflammatory or infectious conditions Histoplasmosis   Sarcoidosis   Multifocal choroiditis   PIC

CausesChoroidal tumors

Nevi   Melanoma   Hemangioma   Osteoma

Trauma Choroidal rupture Laser photocoagulation 

Idiopathic

Virtually any pathologic process that involves the RPE and damages the Bruch membrane can be complicated by CNV.

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.

Litereture review ( Idiopathic CNVM)

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.

Litereture review ( AVASTIN use in Idiopathic CNVM)

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 4-week 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.

Conclusion

Thank you