Idiopathic Choroidal Neovascularization (Grand Rounds)

From EyeWiki



Financial Disclosure

  • Dr. Natario Couser states that he has no financial interests or relationships to disclose.

History

  • CC: "blood in the back of my left eye"
  • HPI: 50 y/o male referred from Optometrist for eval. of abnormal changes within macula OS. Pt c/o persistent blurry vision OS x 1 week.
  • Allergies: NKDA
  • Meds(general & ocular): none
  • PMHx/PSHx: chronic back pain
  • POHx: glasses
  • SHx: tobacco-denies, Etoh-none, illicit drugs-none
  • FHx: unremarkable
  • ROS: non-contributory

Physical examination

  • BCVA(CC):
    • 20/20-2
    • 20/30-2
  • CVF: full OU
  • External: wnl OU
  • Motility: intact OU
  • Pupils: 4mm ---> 2mm OU, no RAPD OU

Slit-lamp examination

  • SLE:
    • L/L-wnl OU
    • C/S-wnl OU
    • K-clear OU
    • AC-deep & quiet OU
    • Iris-wnl OU
    • Lens-clear OU
  • Ta: 16 mm Hg OD, 15 mm Hg OS
  • DFE: see pics...

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Differential Diagnosis

  • Idiopathic
  • Central Serous Chorioretinopathy
  • Presumed Ocular Histoplasmosis Syndrome
  • ParafovealTelangectasias
  • Twig BVO
  • Inflammatory/ Granulomatous Dz
  • Pathologic Myopia

Idiopathic juxtafoveal classic Choroidal Neovascularization(CNV)

  • 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
  • In the absence of any other ophthalmoscopic abnormalityor disease known to be associated with CNV


Idiopathic CNV

  • May represent OHS without the punched-out chorioretinal lesions (histo spots)
  • May represent AMD without the characteristic drusen or RPE abnormalities


Krypton laser photocoagulation for idiopathic neovascular lesions: results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990;108:832-837

Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol.

Treatment

  • The Macular Photocoagulation Study(MPS) showed that benefits of laser tx for extrafoveal or juxtafoveal idiopathic CNV are consistent with the results seen in larger samples in the trials studying extrafoveal or juxtafoveal CNV associated with OHS or AMD
  • Photodynamic therapy (PDT) should be considered in cases of idiopathic subfoveal classic CNV


Krypton laser photocoagulation for idiopathic neovascular lesions: results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990;108:832-837

Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989;107 :344-352

Sickenberg M, Schmidt-Erfurth U, Miller JW, et al. A preliminary study of photodynamic therapy using verfeporfin for choroidal neovascularization in pathologic myopia, ocular histoplasmosis syndrome, angiod streaks, and idiopathic causes. Arch Ophthalmol. 2000;118:327-336.

PDT in Idiopathic CNV

  • Prospective, two-center, interventional case series
  • 17 patients aged 50 years or younger with the diagnosis of idiopathic CNV received PDT with verteporfin
  • Proportion of patients with improved (gained 2 lines or more), stable, and dropped (lost 2 lines or more) vision and the mean number of treatments required during the I-year interval were measured
  • Sixteen eyes (94%) had stable or improved vision.
  • Only one patient (6%) had moderate loss of vision
  • Mean number of PDT treatment was 1.8 per eye over the I-year period
  • Patients with smaller lesion size or active vascular CNV on presentation were more likely to have a final BCVA of 20/100 or better
  • No serious local or systemic complications were encountered


Wai-Man Chan MRCP, FRCS et al. Ophthalmology Volume 110, Issue 12, December 2003, Pages 2395-2402

Avastin tx of Idiopathic CNV

  • Prospective, nonrandomized, interventional case series
  • 15 patients were recruited; nine had idiopathic CNV, two had CNV secondary to CSC, and four had CNV attributable to PIC
  • Patients received three monthly 1.25-mg intravitreal bevacizumab injections for three months. Patients were followed for six months, and the best-corrected visual acuity (BCVA), fluorescein angiography (FA) findings, and optical coherence tomography (OCT) central foveal thickness (CFT) were assessed
  • At baseline, the mean Snellen equivalent was 20/60
  • Mean BCVA improved significantly to 20/30 at six months
  • Mean OCT CFT reduced from 306 um at baseline to 201 um at six months
  • All eyes (100%) had visual improvement of 1 line or more at six months, and 11 (73.3%) improved by 2 or more lines
  • FA showed absence of CNV leakage, the angiographic end point, at three months
  • No recurrence was observed at six months in all eyes
  • No systemic or ocular adverse events were encountered


Chan et al. Am J Ophthalmol 2007 Jun; 143(6) :977-983.e1. Intravitreal Bevacizumab (Avastin) for Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy, Secondary to PIC or of idiopathic origin


References

  1. Chan et al. Am J Ophthalmol 2007 Jun; 143(6) :977-983.e1. Intravitreal Bevacizumab (Avastin) for Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy, Secondary to PIC or of idiopathic origin
  2. Krypton laser photocoagulation for idiopathic neovascular lesions: results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990;108:832-837
  3. Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol. 1989;107:344-352
  4. Sickenberg M, Schmidt-Erfurth U, Miller JW, et al. A preliminary study of photodynamic therapy using verfeporfin for choroidal neovascularization in pathologic myopia, ocular histoplasmosis syndrome, angioid streaks, and idiopathic causes. Arch Ophthalmol. 2000;118:327-336
  5. Wai-Man Chan MRCP, FRCS et al. Ophthalmology Volume 110, Issue 12, December 2003, Pages 2395-2402


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