Inflammatory Choroidal Neovascular Membranes in Patients With Noninfectious Uveitis: The Place of Intravitreal Anti-VEGF Therapy

Abstract

Inflammatory choroidal neovascularization (iCNV) is an infrequent but an important cause of visual morbidity in patients with non-infectious uveitis and mostly occurs in intermediate or posterior uveitis. Punctate inner choroiditis, Vogt-Koyanagi-Harada disease and multifocal choroiditis are among the leading causes of uveitis entities resulting in iCNVs. The diagnosis and management of iCNVs still remain a challenge. Use of multimodal imaging techniques such as fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT) and OCT-angiography may be necessary for the diagnosis of iCNVs. The treatment algorithm is not straightforward for iCNV. While control of the active inflammation with steroids and/or immunosuppressive agents is a key to success, various adjunctive treatment modalities such as thermal laser photocoagulation, photodynamic therapy and surgical membrane removal were also co-administered previously. Nowadays, vascular endothelial growth factor (VEGF) inhibitors have become the most commonly administered adjunctive treatment option as they provide better anatomical and functional outcome and the recurrence rate of CNV is relatively low. We hereby reviewed important clinical studies and case series on anti-VEGF administration in iCNVs and briefly overviewed their results.

Keywords: Aflibercept; Bevacizumab; Inflammatory Choroidal Neovascularization; Intravitreal Injection; Ranibizumab; Vascular Endothelial Growth Factor Inhibitors.

Figure 1

Images of a 64-year-old man with peripapillary healed multifocal choroiditis (MFC) scars and inflammatory choroidal neovascularization (iCNV). Right eye, color fundus picture showing peripapillary hard exudates and dot hemorrhages (A). Early venous phase of fluorescein angiogram showing a hypofluorescent lesion complex at the peripapillary area and multiple subtle hypofluorescent scattered dots (B) Late venous phase of fluorescein angiogram with profuse peripapillary hyperfluorescence (C), Early indocyanine green angiogram revealing peripapillary hypocyanesence of the lesion complex (D) and later frames showing peripapillary hypercyanesent lesion with a faintly seen dark halo suggestive of a ''polyp'' (yellow arrow) together with peripapillary hypocyanescent dots representing the old scars (E). Optical coherence tomography (OCT) showing subretinal fluid with sharp pigment epithelial detachment corresponding to the polyp (F). One month following thermal laser photocoagulation and anti-VEGF treatment, color fundus picture (G) and OCT (H) show some clinical improvement

Figure 2

A 74-year-old male with bilateral old serpiginous like choroiditis scars and left active inflammatory choroidal neovascularization (iCNV) and a right disciform scar. Color fundus picture of the right (A) and left eyes (B) showing widespread healed choroiditis areas together with the scattered pigmentary changes. The right eye had a macular fibrotic scar (black arrow) and the left eye had a small grayish membrane (red arrow) with retinal hemorrhage. Late-phase fluorescein angiogram of the right (C) and left eyes (D) shows fluorescein blockage resulting from the widespread chorioretinal atrophic areas and pigment clumping. There was a hyperfluorescent foveal lesion with diffuse leakage (green arrow) corresponding to iCNV and a hypofluorescent area corresponding to hemorrhage (yellow arrow). OCT section shows a hyperreflective foveal scar in the right eye (E) and fluid accumulation with hyperreflective material in the subretinal space in the left eye (F). He was treated with four ranibizumab injections within one year. The iCNV healed with a scar formation and few residual persistent intraretinal cysts (G, H)

Figure 3

A 17-year-old girl with bilateral intermediate uveitis and right inflammatory choroidal neovascularization (iCNV). Color fundus picture (A) showing a subfoveal yellow-orange-colored lesion corresponding to pigment epithelial detachment (black arrow). Fundus angiogram (B, C) revealing ill-defined iCNV, disc staining and peripheral vascular leakage (black arrows). Optical coherence tomography angiography image of the superficial slab showing normal appearance (D), but deep (E), outer retina (F) and choriocapillaris (G) slabs revealing poorly circumscribed vascular complex with motion artifacts (yellow arrows). Optical coherence tomography (OCT) image (H) illustrating CNV and pigment epithelial detachment with pitchfork sign (red arrow). Four weeks after intravitreal injection of ranibizumab, color fundus photograph (I) and OCT image (J) showing partial regression of iCNV and resolution of subretinal fluid (red arrows)