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Treatment of Inflammatory Choroidal Neovascular Membranes

  • Piergiorgio Neri
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Abstract

Choroidal neovascularization (CNV) represents a severe sight-threatening occurrence in patient with inflammation of the uveal tract. CNV might can be secondary to both infectious and noninfectious uveitis.

After an appropriate assessment of the uveal inflammation by fluorescein angiography (FA), indocyanine green angiography (ICGA) and optical coherence tomography (OCT) and OCT angiography, a prompt and effective therapeutic strategy has to be planned.

Infectious uveitis complicated by CNV has to treated by targeting the infectious disease itself primarily and by associating therapies directly targeting the neovascular process, such as the intravitreal anti-Vascular Endothelial Growth Factor (VEGF) agents. In specific cases, an adjuvant therapy by steroids might appropriate.

The treatment strategy for CNV secondary to noninfectious uveitis should aim primarily the control of the inflammation control. The association of steroids with immunosuppressive agents is most appropriate therapy for inflammatory CNV. Anti-VEGF agents are commonly associated with systemic therapy.

Although there is no comparative study between immunosuppressive agents, mycophenolate mofetil seems to offer a promising profile for the long term control of non-infectious inflammatory CNV.

Although a series of publications reported different treatment strategies for inflammatory neovascularization, there is no guideline available till now.

Keywords

Inflammatory choroidal neovascularization Uveitis Immunosuppression Steroids Anti VEGF 

References

  1. 1.
    Arnold JJ, Campain A, Barthelmes D, et al. Two-year outcomes of “treat and extend” intravitreal therapy for neovascular age-related macular degeneration. Ophthalmology. 2015;122(6):1212–9.PubMedGoogle Scholar
  2. 2.
    Freund KB, Zweifel SA, Engelbert M. Do we need a new classification for choroidal neovascularization in age-related macular degeneration? Retina. 2010;30(9):1333–49.PubMedGoogle Scholar
  3. 3.
    Wu K, Zhang X, Su Y, et al. Clinical characteristics of inflammatory choroidal neovascularization in a Chinese population. Ocul Immunol Inflamm. 2016;24(3):261–7.PubMedGoogle Scholar
  4. 4.
    Shoughy SS, Jaroudi MO, Tabbara KF. Regression of peripapillary choroidal neovascular membrane in a patient with sarcoidosis after oral steroid therapy. Saudi J Ophthalmol. 2014;28(2):160–2.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Nobrega MJ, et al. Anecortave may help choroidal neovascularization regression in serpiginous choroiditis. Can J Ophthalmol. 2007;42(1):151–2.PubMedGoogle Scholar
  6. 6.
    Mansour AM, Arevalo JF, Fardeau C, et al. Three-year visual and anatomic results of administrating intravitreal bevacizumab in inflammatory ocular neovascularization. Can J Ophthalmol. 2012;47(3):269–74.PubMedGoogle Scholar
  7. 7.
    Gillies MC, Campain A, Walton R, et al. Time to initial clinician-reported inactivation of neovascular age-related macular degeneration treated primarily with ranibizumab. Ophthalmology. 2015;122(3):589–94.e1.PubMedGoogle Scholar
  8. 8.
    Adán A, Mateo C, Navarro R, Bitrian E, Casaroli-Marano RP. Intravitreal bevacizumab (avastin) injection as primary treatment of inflammatory choroidal neovascularization. Retina. 2007;27(9):1180–6.PubMedGoogle Scholar
  9. 9.
    Hohberger B, Rudolph M, Bergua A. Choroidal neovascularization associated with punctate inner choroidopathy: combination of intravitreal anti-VEGF and systemic immunosuppressive therapy. Case Rep Ophthalmol. 2015;6(3):385–9.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Ganesh S, Ahmed A, Biswas J. Analysis of the clinical profile and management of inflammatory choroidal neovascular membranes in uveitic eyes: a study from a tertiary referral center. Ocul Immunol Inflamm. 2019;27:424–34.PubMedGoogle Scholar
  11. 11.
    Arrevola L, Acero MA, Peral MJ. Two-year outcome of aflibercept for the treatment of choroidal neovascularization in punctate inner choroidopathy. Case Rep Ophthalmol. 2019;10(1):24–31.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Kramer M. Photodynamic therapy for inflammatory CNV: do we know enough? Ocul Immunol Inflamm. 2005;13(5):331–3.PubMedGoogle Scholar
  13. 13.
    Mansour AM, Mackensen F, Arevalo JF, Ziemssen F, Mahendradas P, Mehio-Sibai A, Hrisomalos N, Lai TY, Dodwell D, Chan WM, Ness T, Banker AS, Pai SA, Berrocal MH, Tohme R, Heiligenhaus A, Bashshur ZF, Khairallah M, Salem KM, Hrisomalos FN, Wood MH, Heriot W, Adan A, Kumar A, Lim L, Hall A, Becker M. Intravitreal bevacizumab in inflammatory ocular neovascularization. Am J Ophthalmol. 2008;146(3):410–6.PubMedGoogle Scholar
  14. 14.
    Tavallali A, Yannuzzi LA. Idiopathic multifocal choroiditis. J Ophthalmic Vis Res. 2016;11(4):429–32.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Tsaousis KT, Nassr M, Kapoor B, Konidaris VE, Tyradellis S, Empeslidis T. Long-term results of intravitreal bevacizumab and dexamethasone for the treatment of punctate inner choroidopathy associated with choroidal neovascularization: a case series. SAGE Open Med Case Rep. 2018;6:2050313X18772478.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Chen SN, Chen YL, Yang BC. Long-term outcome of punctate inner choroidopathy or multifocal choroiditis with active choroidal neovascularization managed with intravitreal bevacizumab. Ocul Immunol Inflamm. 2019:1–6.  https://doi.org/10.1080/09273948.2019.1588335.
  17. 17.
    Arevalo JF, Adan A, Berrocal MH, Espinoza JV, Maia M, Wu L, Roca JA, Quiroz-Mercado H, Ruiz-Moreno JM, Serrano MA, Pan-American Collaborative Retina Study Group. Intravitreal bevacizumab for inflammatory choroidal neovascularization: results from the Pan-American Collaborative Retina Study Group at 24 months. Retina. 2011;31(2):353–63.PubMedGoogle Scholar
  18. 18.
    Fine HF, Zhitomirsky I, Freund KB, Barile GR, Shirkey BL, Samson CM, Yannuzzi LA. Bevacizumab (avastin) and ranibizumab (lucentis) for choroidal neovascularization in multifocal choroiditis. Retina. 2009;29(1):8–12.PubMedGoogle Scholar
  19. 19.
    Schadlu R, Blinder KJ, Shah GK, Holekamp NM, Thomas MA, Grand MG, Engelbrecht NE, Apte RS, Joseph DP, Prasad AG, Smith BT, Sheybani A. Intravitreal bevacizumab for choroidal neovascularization in ocular histoplasmosis. Am J Ophthalmol. 2008;145(5):875–8.PubMedGoogle Scholar
  20. 20.
    Wu K, Zhang X, Su Y, Ji Y, Zuo C, Li M, Wen F. Clinical characteristics of inflammatory choroidal neovascularization in a Chinese population. Ocul Immunol Inflamm. 2016;24(3):261–7.PubMedGoogle Scholar
  21. 21.
    Lalwani GA, Rosenfeld PJ, Fung AE, et al. A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO study. Am J Ophthalmol. 2009;148(1):43–58.e1.PubMedGoogle Scholar
  22. 22.
    Regillo CD, Brown DM, Abraham P, et al. Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER study year 1. Am J Ophthalmol. 2008;145(2):239–48.e5.PubMedGoogle Scholar
  23. 23.
    Heier JS, Brown DM, Chong V, et al. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537–48.PubMedGoogle Scholar
  24. 24.
    Wolf S, Balciuniene VJ, Laganovska G, et al. RADIANCE: a randomized controlled study of ranibizumab in patients with choroidal neovascularization secondary to pathologic myopia. Ophthalmology. 2014;121(3):682–92.e2.PubMedGoogle Scholar
  25. 25.
    Spiteri Cornish K, Williams GJ, Gavin MP, Imrie FR. Visual and optical coherence tomography outcomes of intravitreal bevacizumab and ranibizumab in inflammatory choroidal neovascularization secondary to punctate inner choroidopathy. Eur J Ophthalmol. 2011;21(4):440–5.Google Scholar
  26. 26.
    Heier JS, Brown D, Ciulla T, Abraham P, Bankert JM, Chong S, Daniel PE Jr, Kim IK. Ranibizumab for choroidal neovascularization secondary to causes other than age-related macular degeneration: a phase I clinical trial. Ophthalmology. 2011;118(1):111–8.PubMedGoogle Scholar
  27. 27.
    Roy R, Saurabh K, Bansal A, Kumar A, Majumdar AK, Paul SS. Inflammatory choroidal neovascularization in Indian eyes: etiology, clinical features, and outcomes to anti-vascular endothelial growth factor. Indian J Ophthalmol. 2017;65(4):295–300.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Invernizzi A, Pichi F, Symes R, Zagora S, Nguyen V, Erba S, Xhepa A, De Simone L, Cimino L, Gillies MC, McCluskey PJ. Twenty-four month outcomes of inflammatory choroidal neovascularization treated with intravitreal anti vascular endothelial growth factors: a comparison between two treatment regimens. Abstract 3859, ARVO Annual Meeting, Vancouver Convention Centre, Vancouver, BC, Canada.Google Scholar
  29. 29.
    McGarry T, Biniecka M, Veale DJ, Fearon U. Hypoxia, oxidative stress and inflammation. Free Radic Biol Med. 2018;125:15–24.PubMedGoogle Scholar
  30. 30.
    Chen M, Rajapakse D, Fraczek M, Luo C, Forrester JV, Xu H. Retinal pigment epithelial cell multinucleation in the aging eye – a mechanism to repair damage and maintain homoeostasis. Aging Cell. 2016;15(3):436–45.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Balne PK, Agrawal R, Au VB, Lee B, Ghosh A, Sethu S, Agrawal M, Narayanan R, Connolly J. Dataset of plasma and aqueous humor cytokine profiles in patients with exudative age related macular degeneration and polypoidal choroidal vasculopathy. Data Brief. 2018;19:1570–3.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Flaxel CJ, Owens SL, Mulholland B, Schwartz SD, Gregor ZJ. The use of corticosteroids for choroidal neovascularisation in young patients. Eye (Lond). 1998;12(Pt 2):266–72.Google Scholar
  33. 33.
    Martidis A, et al. Corticosteroids as an antiangiogenic agent for histoplasmosis-related subfoveal choroidal neovascularization. J Ocul Pharmacol Ther. 1999;15(5):425–8.PubMedGoogle Scholar
  34. 34.
    Dibas A, Yorio T. Glucocorticoid therapy and ocular hypertension. Eur J Pharmacol. 2016;787:57–71.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Dees C, et al. Immunosuppressive treatment of choroidal neovascularization associated with endogenous posterior uveitis. Arch Ophthalmol. 1998;116(11):1456–61.PubMedGoogle Scholar
  36. 36.
    Nussenblatt RB, et al. The treatment of multifocal choroiditis associated choroidal neovascularization with sirolimus (rapamycin). Acta Ophthalmol Scand. 2007;85(2):230–1.PubMedGoogle Scholar
  37. 37.
    Neri P, Manoni M, Fortuna C, Lettieri M, Mariotti C, Giovannini A. Association of systemic steroids and mycophenolate mofetil as rescue therapy for uveitic choroidal neovascularization unresponsive to the traditional immunosuppressants: interventional case series. Int Ophthalmol. 2010;30(5):583–90.PubMedGoogle Scholar
  38. 38.
    Neri P, Mariotti C, Cimino L, Mercanti L, Giovannini A. Long-term control of cystoid macular oedema in noninfectious uveitis with Mycophenolate mofetil. Int Ophthalmol. 2009;29(3):127–33.PubMedGoogle Scholar
  39. 39.
    Vitale AT, Foster CS. Corticosteroids. In: Vitale AT, Foster CS, editors. Diagnosis and treatment of uveitis. Philadelphia: W.B. Saunders Company; 2002. p. 142–58.Google Scholar
  40. 40.
    Ferrante P, Ramsey A, Bunce C, Lightman S. Clinical trial to compare efficacy and side-effects of injection of posterior sub-Tenon triamcinolone versus orbital floor methylprednisolone in the management of posterior uveitis. Clin Exp Ophthalmol. 2004;32:563–8.PubMedGoogle Scholar
  41. 41.
    Llop SM, Papaliodis GN. Cataract surgery complications in uveitis patients: a review article. Semin Ophthalmol. 2018;33(1):64–9.PubMedGoogle Scholar
  42. 42.
    Neri P, Azuara-Blanco A, Forrester JV. Incidence of glaucoma in patients with uveitis. J Glaucoma. 2004;13(6):461–5.PubMedGoogle Scholar
  43. 43.
    Kilmartin DJ, Forrester JV, Dick AD. Cyclosporine-induced resolution of choroidal neovascularization associated with sympathetic ophthalmia. Arch Ophthalmol. 1998;116(2):249–50.PubMedGoogle Scholar
  44. 44.
    Neri P, Arapi I. Inflammatory choroidal neovascularization: how combined anti‐VEGF and inflammation suppressive therapy is going to become the treatment of choice. Acta Ophthalmologica, 89(s248).Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Piergiorgio Neri
    • 1
  1. 1.The Eye InstituteCleveland Clinic Abu Dhabi/Case Western Reserve UniversityAbu DhabiUAE

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