Angiographic results of retinal-retinal anastomosis and retinal-choroidal anastomosis after treatments in eyes with retinal angiomatous proliferation

Abstract

Background: The purpose of this study was to evaluate the angiographic results of retinal-retinal anastomosis (RRA) and retinal-choroidal anastomosis (RCA) for eyes with retinal angiomatous proliferation (RAP) after treatment with intravitreal bevacizumab injections as monotherapy or intravitreal bevacizumab combined with photodynamic therapy.

Methods: In this interventional, consecutive case series, we retrospectively reviewed five naïve eyes from four patients (mean age 80 years) treated with three consecutive monthly intravitreal bevacizumab (1.25 mg/0.05 mL) injections as initial treatment, and followed up for at least 3 months. In cases with over 3 months of follow-up and having recurrence of RAP or leakage by fluorescein angiography, retreatment was performed with a single intravitreal bevacizumab injection and photodynamic therapy.

Results: Indocyanine green angiography showed RRA in three eyes with subretinal neovascularization and RCA in two eyes with choroidal neovascularization at baseline. At 3 months after baseline (month 3), neither the RRA nor RCA was occluded in any eye on indocyanine green angiography. Retreatment with intravitreal bevacizumab plus photodynamic therapy was performed in three eyes at months 3 (persistent leakage on fluorescein angiography), 6, and 7 (recurrence of RAP lesion), which achieved obvious occlusion of the RRA and RCA. Mean best-corrected visual acuity improved from 0.13 to 0.21 at month 3 (P = 0.066). No complications or systemic adverse events were noted.

Conclusion: Although intravitreal bevacizumab for RAP was effective in improving visual acuity during short-term follow-up, intravitreal bevacizumab could not achieve complete occlusion of RRA and RCA, which could lead to recurrence of a RAP lesion and exudation. Retreatment with intravitreal bevacizumab plus photodynamic therapy ultimately achieved complete occlusion of the RRA and RCA.

Keywords: bevacizumab; photodynamic therapy; ranibizumab; retinal angiomatous proliferation; retinal-choroidal anastomosis; retinal-retinal anastomosis.

Figure 1

A 64-year-old woman was treated with intravitreal bevacizumab for stage 3 retinal angiomatous proliferation (RAP). At baseline, best-corrected visual acuity (BCVA) was 0.1 decimal visual acuity in the left eye. (A) Red-free photograph showing intraretinal and preretinal hemorrhages, drusen, retinal pigment epithelial detachment, and lipid. (B) Fluorescein angiography showing minimal classic choroidal neovascularization and intraretinal edema. (C) Early-phase indocyanine green angiography showing RAP lesions within the retina and beyond as well as retinal-choroidal anastomosis (RCA). (D) Late-phase indocyanine green angiography showing RAP lesions as focal areas of intense hyperfluorescence (hot spots) and staining of fibrin in cystoid spaces. (E) Baseline horizontal optical coherence tomography (OCT) image shows cystoid macular edema and a pigment epithelial detachment. (F) At month 3, after three consecutive monthly intravitreal bevacizumab injections, no hemorrhages, pigment epithelial detachment, or decreased lipid content are visible on a red-free photograph. BCVA improved from 0.1 to 0.2 decimal visual acuity. (G) No leakage or pigment epithelial detachment are seen on fluorescein angiography. (H and I) Indocyanine green angiography shows decreased leakage from RAP lesions, but RCA and neovascular complex remain. (J) OCT showing disappearance of edema and pigment epithelial detachment. No additional treatment was performed. (K) Red-free photograph at month 6 shows recurrence of intraretinal and preretinal hemorrhages, edema, and pigment epithelial detachment. BCVA decreased from 0.2 to 0.1 decimal visual acuity at month 3. (L) Fluorescein angiography shows enlargement of leakage and pigment epithelial detachment. (M) Early-phase indocyanine green angiography shows enlargement of the neovascular complex and thickening of the RCA. (N) No hot spot was seen on late-phase indocyanine green angiography. (O) OCT shows severe edema and expansion of pigment epithelial detachment. We retreated with intravitreal bevacizumab plus photodynamic therapy instead of intravitreal bevacizumab. (P) Three months after intravitreal bevacizumab plus photodynamic therapy (month 9), a red-free photograph shows disappearance of intraretinal and preretinal hemorrhages, edema, and pigment epithelial detachment. (Q and S) Fluorescein and late-phase indocyanine green angiography showing no leakage. (R) Early-phase indocyanine green angiography showing complete disappearance of RCA. (T) Horizontal OCT image shows flattening of the neurosensory retina. BCVA was 0.2 decimal visual acuity.

Figure 2

Magnification of early-phase indocyanine green angiography images from Figure 1 at baseline (A), and months 3 (B), 6 (C), and 9 (D). (A–C) This patient with stage 3 retinal angiomatous proliferation had proliferation within the retina (arrowheads) consisting of a preperfusing (arrows) and a draining (outline arrows) retinal vessel communicating with the area of choroidal neovascularization (outline arrowheads). (B and D) Although retinal-choroidal anastomosis (RCA) persisted after three consecutive monthly intravitreal bevacizumab injections, it finally resolved after combined therapy of intravitreal bevacizumab and photodynamic therapy.