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| CASE REPORT |
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| Year : 2023 | Volume
: 22
| Issue : 3 | Page : 395-398 |
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Outcome of peripapillary polypoidal choroidal vasculopathy treatment using combination therapy intravitreal ranibizumab and thermal retinal laser photocoagulation
Ogugua Ndubuisi Okonkwo1, Toyin Akanbi2, Tolulope Odubela3, Martha-Mary Udoh4
1 Department of Ophthalmology, Eye Foundation Hospital, Lagos; Department of Ophthalmology, Eye Foundation Hospital, Abuja, Nigeria
2 Department of Ophthalmology, Eye Foundation Hospital, Abuja, Nigeria
3 Department of Ophthalmology, Eye Foundation Hospital, Lagos, Nigeria
4 Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
| Date of Submission | 19-Apr-2022 |
| Date of Decision | 19-Aug-2022 |
| Date of Acceptance | 03-Nov-2022 |
| Date of Web Publication | 12-Apr-2023 |
Correspondence Address:
Ogugua Ndubuisi Okonkwo
Eye Foundation Retina Institute and Eye Foundation Hospital, 27 Isaac John Street, GRA Ikeja, Lagos
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/aam.aam_68_22
 Abstract | | |
We present the case of a middle-aged female Nigerian diagnosed to have right eye peripapillary polypoidal choroidal vasculopathy (PCV). At presentation, her right eye Snellen visual acuity was 6/24+ (unaided) and 6/12 (aided) and the left eye was 6/9 (unaided) and 6/6 (aided). Fundus fluorescein angiography showed a hyperfluorescent peripapillary subretinal lesion associated with subretinal fluid demonstrated on spectral-domain optical coherence tomography. The PCV lesion was successfully treated using a combination of 3 monthly doses of intravitreal ranibizumab initially, followed by one session of focal thermal retinal laser photocoagulation. Her clinical state has remained stable after 5 years of follow-up, requiring no further treatment. This case demonstrates the effectiveness of combination therapy and can be a strategy for treating this PCV type. Successful treatment using this approach will reduce the burden of intravitreal anti-vascular endothelial growth factor, e.g., ranibizumab injections.
Résumé
Nous présentons le cas d'une Nigériane d'âge moyen diagnostiquée comme ayant une vasculopathie choroïdienne polypoïdale (VPC) péripapillaire de l'œil droit. Lors de la présentation, son œil droit Snellen avait une acuité visuelle de 6/24+ (sans aide) et de 6/12 (aidé) et l'œil gauche était de 6/9 (sans aide) et 6/6 (aidé). L'angiographie à la fluorescéine du fond d'œil a montré une lésion sous-rétinienne péripapillaire hyperfluorescente associée au liquide sous-rétinien démontrée par tomographie par cohérence optique dans le domaine spectral. La lésion VPC a été traitée avec succès en utilisant une combinaison de 3 doses mensuelles de ranibizumab intravitréen initialement, suivie d'une séance de photocoagulation laser thermique rétinienne focale. Son état clinique est resté stable après 5 ans de suivi, ne nécessitant aucun traitement supplémentaire. Ce cas démontre l'efficacité de la thérapie combinée et peut être une stratégie pour traiter ce type de VPC. Un traitement efficace utilisant cette approche réduira le fardeau du facteur de croissance endothélial antivasculaire intravitréen, par exemple les injections de ranibizumab.
Mots-clés: Facteur de croissance endothéliale antivasculaire, thérapie combinée, vasculopathie choroïdienne polypoïdale, ranibizumab, laser rétinien Photocoagulation
| Abstract in French | | |
Résumé
Nous présentons le cas d'une Nigériane d'âge moyen diagnostiquée comme ayant une vasculopathie choroïdienne polypoïdale (VPC) péripapillaire de l'œil droit. Lors de la présentation, son œil droit Snellen avait une acuité visuelle de 6/24+ (sans aide) et de 6/12 (aidé) et l'œil gauche était de 6/9 (sans aide) et 6/6 (aidé). L'angiographie à la fluorescéine du fond d'œil a montré une lésion sous-rétinienne péripapillaire hyperfluorescente associée au liquide sous-rétinien démontrée par tomographie par cohérence optique dans le domaine spectral. La lésion VPC a été traitée avec succès en utilisant une combinaison de 3 doses mensuelles de ranibizumab intravitréen initialement, suivie d'une séance de photocoagulation laser thermique rétinienne focale. Son état clinique est resté stable après 5 ans de suivi, ne nécessitant aucun traitement supplémentaire. Ce cas démontre l'efficacité de la thérapie combinée et peut être une stratégie pour traiter ce type de VPC. Un traitement efficace utilisant cette approche réduira le fardeau du facteur de croissance endothélial antivasculaire intravitréen, par exemple les injections de ranibizumab.
Mots clés: Facteur de croissance endothéliale antivasculaire, thérapie combinée, vasculopathie choroïdienne polypoïdale, ranibizumab, laser rétinien Photocoagulation
Keywords: Anti-vascular endothelial growth factor, combination therapy, polypoidal choroidal vasculopathy, ranibizumab, retinal laser photocoagulation
How to cite this article:
Okonkwo ON, Akanbi T, Odubela T, Udoh MM. Outcome of peripapillary polypoidal choroidal vasculopathy treatment using combination therapy intravitreal ranibizumab and thermal retinal laser photocoagulation. Ann Afr Med 2023;22:395-8 |
How to cite this URL:
Okonkwo ON, Akanbi T, Odubela T, Udoh MM. Outcome of peripapillary polypoidal choroidal vasculopathy treatment using combination therapy intravitreal ranibizumab and thermal retinal laser photocoagulation. Ann Afr Med [serial online] 2023 [cited 2023 Sep 28];22:395-8. Available from: https://www.annalsafrmed.org/text.asp?2023/22/3/395/374134 |
Key Lesson
This case highlights the effectiveness and significant cost savings achieved when using combination therapy, intravitreal anti-VEGF, and focal thermal laser to treat symptomatic peripapillary PCV. This treatment may be equally effective for other localized extramacular PCV lesions.
| Introduction | |  |
Polypoidal choroidal vasculopathy (PCV) is a disease characterized by an abnormal vascular network of choroidal vessels, presenting with subretinal polypoidal vascular lesions associated with recurrent serous or hemorrhagic neurosensory retinal detachment and or retinal pigment epithelial detachment.[1] PCV usually presents as a colorful (red-orange) lesion located in the peripapillary or perimacular region. It occurs in middle-aged Africans (between 50 and 65 years), with a female preponderance.[2],[3],[4],[5] Studies among Asians show a male preponderance of PCV.[3] PCV affects persons of African and Asian descent more than Caucasians.[1],[3],[6] Risk factors such as systemic hypertension, hyperlipidemia, thrombocytopenia, and increased plasma viscosity have been associated with PCV. PCV can cause significant loss of vision because of recurrent hemorrhage and exudation into the macula, with associated macular scarring.[7]
PCV lesion is generally treated with verteporfin photodynamic therapy (vPDT), the gold standard for treatment, either singly or in combination with anti-vascular endothelial growth factor (VEGF).[8],[9] The cost of PDT and the unavailability of both the verteporfin dye and laser machine for cold laser delivery are significant challenges in developing countries. Intravitreal anti-VEGF is effective for the treatment of PCV.[10] However, the obvious drawback of its use is the need for frequent monthly dosing of intravitreal therapy, as discontinuation of treatment can be associated with disease recurrence. This situation has led to an ever-increasing burden of intravitreal injections and monitoring of the response to treatment. Combining anti-VEGF and conventional retinal laser (thermal retinal laser photocoagulation) is a cost-effective strategy. It can be used to induce long-term resolution of PCV, reduce the anti-VEGF injection burden, and the need for frequent clinic monitoring.[11]
| Case Report | | |
A 57-year-old female Nigerian presented with a 9-month history of reduced vision in the right eye and a 10-year history of systemic hypertension, controlled with oral hypotensive. On ocular examination, visual acuity was 6/24 and 6/9 (unaided) in the right and left eyes, respectively, and 6/12 and 6/6 (aided) in the right and left eyes, respectively. Right eye fundus examination revealed a peripapillary, ill-defined, oval, raised lesion of about one disc diameter, temporal to the disc, [Figure 1]a, left eye fundus examination was normal, [Figure 1]b. There were no drusen or retinal hemorrhages in both eyes and no findings to suggest a diagnosis of age-related macular degeneration. Fundus fluorescein angiography (FFA) showed a well-defined hyperfluorescent subretinal lesion in the right eye superotemporal, peripapillary region, suggestive of a classic type neovascular complex, [Figure 1]c. The left eye FFA was normal, [Figure 1]d. Spectral-domain optical coherence tomography of the right eye showed serous neurosensory retinal detachment with underlying subretinal fluid (SRF) in the macula and perimacula area; the left eye was normal, pFigure 2]. The central foveal thickness was 475 μ. She was diagnosed to have a right eye active peripapillary PCV. Indocyanine green angiography was unavailable for confirmatory evaluation of the lesion. | Figure 1: (a and b) Fundus photographs of right and left eyes, respectively. Notice the peripapillary, circular, raised lesion superotemporal to the optic disc; also, there is a prominent circular reflex around the entire macular in the right eye (a). (b) Normal appearing left eye. (c and d) the fluorescein angiograms of the right and left eyes, respectively. Notice the hyperfluorescent lesion, with well-defined borders in the superotemporal peripapillary area. (d) Normal appearing left eye. (e) Right eye fundus photograph, showing the thermal laser-induced pigmented chorioretinal scar in the previous hyper fluorescence area
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 | Figure 2: SD-OCT cross-sectional vertical and horizontal line scans of both eyes. Right eye scans showing neurosensory retinal detachment with serous fluid under the macula. SD-OCT: Spectral-domain optical coherence tomography
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She received three consecutive monthly doses of 0.5 mg/0.05 ml ranibizumab (Lucentis). In the 4th month, we followed up her treatment with focal retina laser photocoagulation to the peripapillary neovascular network. Post treatment, unaided visual acuity improved to 6/9. Repeat OCT showed resolution of SRF and restoration of normal foveal contour [Figure 3]. A fundus photograph showed a peripapillary pigmented scar in the area of retinal laser application [Figure 1]e. | Figure 3: Right eye posttreatment SD-OCT showing resolution of subneurosensory retinal fluid and restoration of normal foveomacula anatomy. SD-OCT: Spectral-domain optical coherence tomography
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Summary and chronologically order of treatment
Day of presentation - 09/2016. Intravitreal ranibizumab (IVR) to the right eye – first dose - 09/2016; second dose - 11/2016; third dose - 12/2016. Focal laser photocoagulation (FLP) to the peripapillary neovascular network - 01/2017. She has been monitored from February 2017 to February 2022 (5 years) without recurrence. We obtained consent to report her case and use the FFA and OCT images. Furthermore, ethical approval was obtained from the institutional health research ethics committee for this work to be published.
| Discussion | | |
Our patient was treated with a combination of IVR and FLP, resulting in functional and anatomical recovery as evidenced by restoration of vision and normalized foveal anatomy, [Figure 3]. Several options are available for treating PCV, including intravitreal anti-VEGF injections (e.g., bevacizumab, ranibizumab, and aflibercept), PDT, a combination of these therapies, and FLP.[1],[11] The EVEREST trial concluded that the combined use of intravitreal anti-VEGF injection and vPDT produced a marked reduction in the proliferation of neovascularization and severed growth of feeder vessels.[8],[9] The same study found that combination therapy was superior to ranibizumab monotherapy. However, vPDT is unavailable in several parts of the world. In the case presented, we substituted FLP using a 532 green thermal laser for vPDT. Previous studies used thermal FLP for extrafoveal and extramacular polypoidal lesions.[1] Laser photocoagulation can also be used with intravitreal anti-VEGF injections in extrafoveal PCV with hemorrhage or exudation that extends to the fovea.[11]
IVR was the anti-VEGF used in our patient. Ranibizumab has been investigated and found to be effective in treating PCV, but the cessation of treatment has been linked to recurrent disease. Therefore, long months of treatment are required. Thermal laser treatment induces a photocoagulation effect and causes coagulative necrosis and chorioretinal scarring, including the PCV lesion. Prior use of IVR before FLP increases the effectivity of the laser (by drying the SRF and reducing PCV lesion size, with a consequent reduction in area for laser treatment).
Thermal laser photocoagulation led to the cessation of the need for further IVR in our patient, reducing the total amount of anti-VEGF injections required for treatment. This case suggests that clinicians should individualize PCV treatment since therapeutic choice could depend on the lesion's location. Our patient's lesion was peripapillary and extrafoveal, allowing directed thermal retinal laser photocoagulation to the neovascular complex. Peripapillary PCV is a common clinical presentation;[4] therefore, a retina practitioner should consider a focal retinal laser an effective treatment strategy when PCV is encountered in this location.
| Conclusion | | |
PCV is an infrequent presentation in retinal clinics in Nigeria and probably in sub-Saharan Africa. Effective treatment of a peripapillary PCV can be with available intravitreal anti-VEGF and conventional thermal focal chorioretinal laser photocoagulation. When successful, this treatment offers significant cost savings and reduces the burden of treatment and clinic visits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Authorship statement
All the authors contributed equally to the writing and critical review of this manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 10. | Okoye O, Okonkwo O, Oderinlo O, Hassan K, Ijasan A. Bilateral concomitant intravitreal anti-vascular endothelial growth factor injection: Experience in a Nigerian tertiary private eye care facility. Niger J Clin Pract 2016;19:544-8. [ PUBMED] [Full text] |
| 11. | Gemmy Cheung CM, Yeo I, Li X, Mathur R, Lee SY, Chan CM, et al. Argon laser with and without anti-vascular endothelial growth factor therapy for extrafoveal polypoidal choroidal vasculopathy. Am J Ophthalmol 2013;155:295-304.e1. |
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