Ophthalmolgy D epartment Grand Round Case 2

1. OphthalmolgyDepartmentGrand RoundCase2 Mahmood J Showail

2. History 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.

3. On Examination • Vision • 20/20 (OD) • 20/400 (OS) • Pupils RRR (OU) no RAPD • AC • Deep & quite (OU) • Lens & cornea clear (OU) • Vitreous quite (OU)

4. Fundus Examination • Fundus • Normal fundus (OD) • No drusen, retinal pigment epithelial changes, or macular retinal exudates were observed in either fundus

5. OS left eye . subfovealchroidalneovascular membrane with surrounding subretinal haemorrhage

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

9. Laboratory investigations • Serology • CMVIgM –ve • CMV IgG +ve • HSVIgM –ve • HSV IgG +ve • HBsAg • HIV -ve • VDRL • CBC • WBC 7.2 • HB 13.1 • Plt 265 • ESR 20 • CRP normal “<2.29” • ANA -ve

10. Cont. Investigatgions • PPD 15 • Chest x ray normal

11. Differential Diagnosis • Choroidal tumors • Nevi • Melanoma • Hemangioma • Osteoma • Trauma • Choroidal rupture • Laser photocoagulation • Idiopathic • Degenerative conditions • ARMD • Myopia • Angioid streaks • Inflammatory or infectious conditions • Histoplasmosis • Sarcoidosis • Multifocal choroiditis • PIC

12. Diagnosis Idiopathic choroidalneovascular membrane

13. Management • Intravitrealbevacizumab “ 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)

14. Pre -AVASTIN 3 weeks Post –AVASTIN 5 weeks Post –AVASTIN

15. IVFA pre-AVASTIN early and late IVFA 3 weeks post-AVASTIN early and late

16. OCT Pre-AVASTIN OCT 5wks post-AVASTIN

17. We booked her for another AVASTIN injection ..

18. ChoroidalNeovascularization • 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.

19. Pathophysiology • 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

20. Causes Virtually any pathologic process that involves the RPE and damages the Bruch membrane can be complicated by CNV. • Choroidal tumors • Nevi • Melanoma • Hemangioma • Osteoma • Trauma • Choroidal rupture • Laser photocoagulation • Idiopathic • Degenerative conditions • ARMD • Myopia • Angioid streaks • Inflammatory or infectious conditions • Histoplasmosis • Sarcoidosis • Multifocal choroiditis • PIC

21. 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) • Cohen SY, Laroche A, Leguen Y, et al. Etiology of choroidalneovascularization in young patients. Ophthalmology. 1996;103(8):1241-1244. • 2. Ho AC, Yannuzzi LA, Pisicano K, et al. The natural history of idiopathic subfovealchoroidalneovascularization. Ophthalmology. 1995;102(5):782-789.

22. 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 choroidalneovascularization in persons younger than 50 years of age. Ophthalmology. 1998 Oct;105(10):1816-20 .

23. Litereture review ( Idiopathic CNVM) • 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 choriovitrealneovascularization. • Clinical and OCT Features in Spontaneously Progressive Idiopathic ChoriovitrealNeovascularization“Ophthalmic Surgery, Lasers and Imaging Volume 38(2), March/April 2007, p 151-153 “ • * idiopathic subfoveal CNV spontaneously progressed to choriovitrealneovascularization through an intact retina , which resulted in vigorous vitreomacular traction.

24. Litereture review ( AVASTIN use inIdiopathic CNVM) • Currently, there are no published studies evaluating the efficacy or safety of intravitrealbevacizumab for subfoveal ICNV. • As “AVASTIN “has not been studied in a prospective, randomized, clinical trial till now.

25. IntravitrealBevacizumab for SubfovealIdiopathic ChoroidalNeovascularization“Arch Ophthalmol. 2007;125(11):1487-1492 • prospective,noncomparative, interventional case series. • Thirty-two eyes of 32 patients with idiopathic choroidalneovascularization received intravitrealbevacizumab(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.

26. Conclusion • Short-term results suggest that intravitrealbevacizumab is safe and well tolerated in idiopathic choroidalneovascularization. • 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.

27. Thank you