cnvm aios 2013 sje
DESCRIPTION
educationTRANSCRIPT
Dr Shrutika Kankariya DNBDr Suganeswari DO,DNBDr Jyotirmay Biswas MS
Sankara Nethralaya, Chennai
No financial disclosures.
Inflammatory Choroidal Neovascular Membrane (CNVM) is a well documented sight threatening complication of ocular inflammation.
Active uveitis Inactive uveitis
Hypoxia surrounding scar + Breach Bruch Membrane
Inflammation
1) Observation2) Laser Photocoagulation3) Local and Systemic steroids4) Photodynamic therapy( PDT5) Transpupillary
thermotherapy(TTT)
6) Anti VEGF ( bevacizumab and ranibizumab)
8) Surgical removal7) Combination therapy9) Intravitreal injection
triamcinolone
To characterize inflammatory CNVM in various underlying uveitic disease entity
To prognosticate the treatment outcome of inflammatory CNVM in various uveitic diseases
To postulate treatment strategy for inflammatory CNVM in active and inactive uveitis.
Design : Retrospective chart review Period : 1995 to 2011 (16 years) Setting : Tertiary care eye institute Inclusion criteria
Clinically diagnosed inflammatory CNVM ▪ CNVM presenting in eyes with active
uveitis(posterior uveitis and panuveitis) or occuring adjacent to the healed retino-choroiditis lesion.
Confirmation ▪ Optical coherence tomography (OCT) and Fundus
fluorescein angiography (FFA) Follow-up > 1 year with Regular follow-up
Exclusion criteria CNVM due to other causes were judiciously excluded
(ARMD, myopia, angioid streak, idiopathic) Definitions… Location of CNVM
Subfoveal-CNVM beneath fovea
Juxta-foveal- CNVM within 200 µ of centre of fovea
Extra-foveal- CNVM > 200 µ 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
Unilateral – 17 patients. Bilateral- 5 patients.
14(38%)
(toxo)-5(14%)
(PU)-10(27%)
(SC)-6(16%)
- 2(5%)
CNVM was uniformly of classic type in all eyes
57%
100%
66%
100%
100%
MFC
MFC TOXOTOXO
SCSCVKHVKH
PUPU
Inactive
InactiveActive
Active
Juxtafoveal CNVM - 16 eyes (43.3%)
Subfoveal CNVM -11 eyes (29.7%)
Peripapillary CNVM - 10 eyes (27%)
All 10 EYES -ACTIVE UVEITIS
8 eyes - Panuveitis
Inflammation stimulated angiogenesis in active uveitis ( panuveitis) has propensity for peripapillary region
12%
41%
32%
9%
3% 3%No.
of
eyes
SS+ IMN
SS+ IMN
Avasti
n
Avasti
nPDTPDT
TTTTTT
Luce
ntis
Luce
ntisLa
ser
PHCLase
r
PHC
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).
44%
29% 26%
ImprovementImprovement StabilizationStabilization DeteriorationDeterioration
40%40%
128.7%128.7%
8.8%8.8%
-42.4%-42.4%
MFCMFC TOXOTOXOSCSC VKHVKHPUPU
38.2%38.2%17.5%17.5%
Active uveitisActive uveitis
40.1%40.1%
56.7%56.7%
-45.2%-45.2%
-1.8%-1.8%
Avastin SS + IMNTTTTTTPDTPDT
Treatment Regression (eyes)/total (eyes)
% Remarks
Systemic steroids (SS)
4/4 100% Severe inflammation,(>4+), PP cnvm,
Bevacizumab + SS
3/6 50% Inadequate control of underlying inflamation.5.2 injections (Avg-3.2)
PDT + SS 5/5 100% 2 eyes - Regression CNVM didn’t translate into visual gain (RPE atrophy).2 eyes- Delayed stabilization of vision
TTT + SS 1/2 50% Excessive Scarring
Regression (eyes)
Total eyes
% Remarks
Bevacizumab
5 7 71 % 2 eyes – Reactivation (inadequate scarring of CNVM)
PDT 6 6 100 % 1 eye- vision deteriorated (RPE atrophy)
TTT 1 1 100 %
Laser PHC 1 1 100 %
Ranibizumab
1 1 100 %
PDT+Bevacizumab
1 1 100 %
Authors No of eyes
Follow up Mean/max
DiseasesUveitis
Treatments studied
Our study(2013)
37 2.5 (22) MFC, SC, PU, Toxo, VKH(Active Vs Inactive)
Bevacizumab, PDT, TTT, SS Ranimizumab, PHC, Combi
Postelmans et al (2005)
16 1.5(2.5) PIC, POHS PDT
Kramar et al(2004)
10 1(2) MFC, POHS, Toxo, PIC, PU
Bevacizumab
Perentes et al(2010)
12 1.5(3) MFC, Sarcoid, Toxo, VKH
SS, PDT, TTT
Parodi et al(2010)
27 1 (1) MFC Bevacizumab vs pdt
Rouvas et al(2011)
15 1.5 (2.5) MFC, SC, PIC Toxo,
Ranibizumab only
Strength of our study1.Active uveitis Vs healed uveitis
2.Longer follow-up(10 eyes >5 years)3.Varied treatment modalities – different uveitic
entities. 4.Largest sample size from single centre .
Strength of our study1.Active uveitis Vs healed uveitis
2.Longer follow-up(10 eyes >5 years)3.Varied treatment modalities – different uveitic
entities. 4.Largest sample size from single centre .
Characterization….
Active uveitis - Peri-papillary region.
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.
Timely initiation and judicious extension of CNVM targeted Rx (Anti VEGF + / PDT)
Long term + frequent F/U follow up until
complete scarring of cnvm is achieved and beyond ………..
Especially when on low
dose maintenance
RX
Especially when on low
dose maintenance
RX
Good compliance + adequate F/U
Thank You
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