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Inflammatory Choroidal Neovascular Membrane (CNVM) is a well documented sight threatening complication of ocular inflammation.
Inactive uveitis Hypoxia surrounding scar + Breach Bruch Membrane Predominantly VEGF
Angiogenesis
CNVM
1) Observation 2) Laser Photocoagulation 3) Local and Systemic steroids 4) Photodynamic therapy( PDT 5) Transpupillary thermotherapy(TTT)
6) Anti VEGF ( bevacizumab and ranibizumab) 8) Surgical removal 7) Combination therapy 9) Intravitreal injection triamcinolone
To postulate treatment strategy for inflammatory CNVM in active and inactive uveitis.
Exclusion criteria
CNVM due to other causes were judiciously excluded (ARMD, myopia,
Subfoveal-CNVM beneath fovea Juxta-foveal- CNVM within 200 of centre of fovea Extra-foveal- CNVM > 200 from centre of fovea. Peripappilary CNVM within 1 DD of ONH.
Size
Large - > 3.5 DD
37 eyes (32 patients). Mean Age 34 years Mean follow up of 29 month Laterality
15 (47%) 17 (53%)
Male Female
14(38%)
10 (27%) 5 (14%)
57%
100%
Inactive Active
MFC TOXO
SC
PU
VKH
Inflammation stimulated angiogenesis in active uveitis ( panuveitis) has propensity for peripapillary region
41% 32%
No. of eyes
12% 9% 3% 3%
44%
29%
26%
Improvement
Stabilization
Deterioration
Mean visual acuity demonstrated improvement from initial visual acuity of (logmar = 0.643 0.385) to final visual acuity of (logmar = 0.574 0.442).
0.7
-42.4%
0.6
128.7%
0.5 Mean Values (Decimal)
40%
0.4
8.8%
23.2%
0.3
0.2
0.1
Multifocal choroiditis
MFC
Serpiginous choroiditis
SC
Toxoplasma
TOXO
Panuveitis
PU
VKH VKH
0.45
17.5%
0.4 0.35 0.3 0.25 0.2 0.15 0.1
38.2%
0.05
0
56.7%
6
40.1%
4
-1.8%
3
-45.2%
Avastin A
PDT PDT
Initial Visual Acuity
TTT
TTT
SSNO + IMN
Treatment
Remarks
100%
Bevacizumab + 3/6 SS
PDT + SS
50%
5/5
100%
TTT + SS
1/2
50%
Remarks
Bevacizumab
71 %
6 1 1
6 1 1
Ranibizumab
PDT+Bevacizu mab
1
1
1
1
100 %
100 %
No of eyes 37
Diseases Uveitis
Treatments studied
MFC, SC, PU, Bevacizumab, PDT, TTT, Toxo, VKH SS Ranimizumab, PHC, (Active Vs Inactive) Combi PIC, POHS PDT
16
1.5(2.5)
Strength of our study Kramar et al 10 1(2) MFC, POHS, Toxo, Bevacizumab 1 .Active uveitis Vs healed uveitis (2004) PIC, PU 2.Longer follow-up(10 eyes >5 years) Perentes et al 12 1.5(3) MFC, Sarcoid, SS, PDT, TTT different uveitic entities. (2010) 3.Varied treatment modalities Toxo, VKH 4.Largest size from singleBevacizumab centre . vs pdt Parodi et al 27 1 (1) sample MFC
(2010) Rouvas et al (2011) 15 1.5 (2.5) MFC, SC, PIC Toxo, Ranibizumab only
Characterization.
Prognostication.
-
Inactive uveitis - Better progosis Active uveitis - Relatively poor prognosis Recurrence and reactivation more common. PDT related side-effects more common.
Treatment strategy..
Stringent control of inflammation throughout the course of disease.
Especially when Timely initiation and judicious extension ofdose CNVM on low targeted Rx (Anti VEGF + / PDT) maintenance RX
Long term + frequent F/U follow up until complete scarring of cnvm is achieved and beyond ..
Thank You
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Bevacizumab vs Photodynamic Therapyfor Choroidal Neovascularizationin Multifocal Choroiditis Maurizio Battaglia Parodi, MD; Pierluigi Iacono, MD; Dimitrios Stelyos Kontadakis, MD; Arch Ophthalmol. 2010;128(9):1100-1103Ilaria Zucchiatti, MD; Maria Lucia Cascavilla, MD; Francesco Bandello, MD
bevacizumab for choroida neovascularization related to nflammatory diseases michal kramer, md,* ruth axer-siegel, md,* tareq jaouni, md, ehud reich, md,* itzhak hemo, md, ethan priel, fops, edward averbukh, md, rita ehrlich, md,*itay chowers, md, dov weinberger, md,* radgonde amer, mdretina 30:938944, 2010
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Intravitreal ranibizumab for the treatment of inflammatory choroidal neovascularizationalexander rouvas, md, phd,* petros petrou, md,* maria douvali, md,* amalia ntouraki, md,* ioannis vergados, md, phd,* ilias georgalas, md, phd, nikolaos markomichelakis, md, phdretina 31:871879, 2011
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ocular photodynamic therapywith verteporfin for choroidal neovascularization secondary to ocular histoplasmosis syndrome m.a. busquets,* g.k. shah,* j. wickens, d. callanan, k.j. blinder,* d. burgess,* m.g. grand,* n.m. holekamp,* i. boniuk,* d.p. joseph,*m.a. thomas,* e. fish, j. bakal, h. hollands, s. sharmaretina 23:299 306, 2003
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long-term visual outcomes of intravitreal bevacizumab in inflammatory ocular neovascularization ahmad m. mansour, j. fernando arevalo, fockeziemssen, abla mehio-sibai,friederike mackensen, alfredo adan, wai-man chan, thomas ness, alay s. banker,david dodwell, thi ha chau tran, christine fardeau, phuc lehoang,padmamalini mahendradas, maria berrocal, zuheir tabbarah, nicholas hrisomalos,frank hrisomalos, khalil al-salem, and rainer guthoffam j ophthalmol 2009;148:310316 subretinal neovascular membranes complicating uveitis: frequency,treatments, and visual outcome yannis perentes ab; van t. tran a; michel sickenberg c; carl p. herbort ab a inflammatory eye diseases, la source eye center, lausanne, and university of lausanne, lausanne,switzerland b university of lausanne, lausanne, switzerland c ouchy angiography and laser center,lausanne, switzerlandocular immunology and inflammation, 13:219224, 2005
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chan wm, lai ty, lau tt, lee vy, liu dt, lam ds. combined photodynamic therapy and intravitreal triamcinolone for choroidal neovascularization secondary to punctuate inner choroidopathy or of idiopathic origin: one-year results ofa prospective series. retina2008;28:7180.
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