Combined intravitreal bevacizumab and triamcinolone injection in a child with Coats disease

doi:10.1016/j.jaapos.2008.01.009

Journal of American Association for Pediatric Ophthalmology and Strabismus

Volume 12, Issue 3, June 2008, Pages 309-311

https://doi.org/10.1016/j.jaapos.2008.01.009 Get rights and content

We report a child with Coats disease who demonstrated a rapid response to intravitreal bevacizumab and triamcinolone injection. A 14-year-old boy presented with stage 3A Coats disease unresponsive to initial argon laser treatment and was injected with intravitreal bevacizumab and triamcinolone acetonide. Following intravitreal injection, a superior bullous exudative retinal detachment and subfoveal serous fluid collection dramatically improved. Additional argon laser photocoagulation resulted in complete regression of telangiectatic vessels as well as decrease in macular exudation. Visual acuity improved from 20/400 to 20/125 after treatment, and the boy remained stable 6 months after injection.

Section snippets

Case Report

A 14-year-old boy presented with visual acuities of 20/400 in the right eye and 20/20 in the left eye. A right exotropia of 10^Δ was present. Intraocular pressures were 15 mm Hg bilaterally. Biomiscroscopic evaluation disclosed a small posterior subcapsular opacity in the right eye and normal findings in the left eye. Dilated fundus examination of the right eye revealed submacular exudation, retinal telangiectasias, and intraretinal hemorrhage at the temporal midperiphery, with a superior

Discussion

Photocoagulation and/or cryopexy are the recommended initial treatment modalities in eyes with stage 3A Coats disease.² Usually the combination of cryotherapy and laser works well in combination with the drainage of subretinal fluid externally if the retina is highly elevated.⁴ Our patient responded well to intravitreal injection of bevacizumab and triamcinolone after no response to initial laser treatment. Although the contributory effect of the triamcinolone in this patient cannot be

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There are more references available in the full text version of this article.

Cited by (53)

Distribution of fluorescein sodium and triamcinolone acetonide in the simulated liquefied and vitrectomized Vitreous Model with simulated eye movements
2017, European Journal of Pharmaceutical Sciences
Intravitreal administration is the method of choice for drug delivery to the posterior segment of the eye with special emphasis on the vitreous body and its surrounding retinal vasculature. In order to gain a better understanding of the underlying distribution processes, an in vitro model simulating the vitreous body (Vitreous Model, VM) and a system simulating the impact of movement on the VM (Eye Movement System, EyeMoS) was previously developed. In the study reported here, these systems were modified in regard to a standardized injection procedure, the diversity of simulated eye movements, extended periods of investigation, the opportunity to simulate the state after vitrectomy and in considering the physiological temperature. Fluorescein sodium (FS) and triamcinolone acetonide (TA) were used as (model) drugs to examine the drug distribution within the VM. Vitrectomy was simulated by replacing half the volume of the polyacrylamide gel that was used as vitreous substitute with the clinically used Siluron® 5000 whereas for a simulated liquefaction half the volume of the gel was replaced by buffer. A simulated liquefaction caused a 12-fold faster distribution of FS compared to the simulated juvenile VM, which was most likely caused by convective forces and mass transfer. Also, the injection technique (injection into the gel or into the buffer compartment) influenced the resulting distribution pattern. Without any liquefaction, the previously described initial injection channel occurred with both (model) drugs and, in the case of TA, remained almost unchanged during the investigation period of 72 h. Simulating vitrectomized eyes, TA did not spread uniformly, but either remained in the depot or strongly sedimented within the VM suggesting that a homogenous distribution of a TA suspension is highly unlikely in vitrectomized eyes. High variabilities were observed with ex vivo animal eyes, demonstrating the limited benefit of explanted tissues for such distribution studies. The combination of the modified VM and EyeMoS seems a valuable tool for characterizing intravitreal dosage forms in a reproducible simulation of diversified eye movements and a partially liquefied or vitrectomized vitreous body.
Choroidal neovascularization complicating Best's vitelliform macular dystrophy in a child
2016, Journal Francais d'Ophtalmologie
La maladie de Best est une dystrophie progressive de la macula, débutant soit dans l’enfance ou dans l’adolescence.
Nous rapportons le cas rare d’une dystrophie vitelliforme compliquée d’une néovascularisation choroïdienne chez un enfant de 8 ans avec une baisse progressive bilatérale de l’acuité visuelle. L’examen ophtalmoscopique a révélé des lésions vitelliformes dans les deux centres fovéolaires. L’angiographie à la fluorescéine a confirmé la présence d’une membrane néovasculaire au niveau de son œil gauche. Les examens complémentaires du patient ont confirmé le diagnostic de la maladie de Best associée à une néovascularisation choroïdienne.
Le diagnostic de dystrophie vitelliforme maculaire de Best est souvent de découverte occasionnelle car l’acuité visuelle a tendance à rester stable pendant longtemps. Une détérioration soudaine de la vision peut suggérer des complications, telles que la néovascularisation de la choroïde.
Best's disease is a progressive macular dystrophy, beginning either in childhood or adolescence.
We report a rare case of choroidal neovascularization complicating vitelliform dystrophy in a child of 8 years with bilateral progressive loss of visual acuity. The ophthalmoscopic examination showed vitelliform lesions in both foveas. Fluorescein angiography confirmed a subretinal neovascular membrane in the left eye. Additional testing also confirmed the diagnosis of Best's disease associated with choroidal neovascularization.
Best's vitelliform macular dystrophy is often asymptomatic because visual acuity tends to remain stable for a long time. A sudden loss of vision suggests the occurrence of complications, such as choroidal neovascularization.
An interesting case of coats’ disease
2015, Medical Journal Armed Forces India
Intraoperative fluorescein angiography-guided treatment in children with early coats' disease
2015, Ophthalmology
Citation Excerpt :
Several studies26–30 have reported the off-label use of intravitreal anti-VEGF agents in treating Coats' disease in children either alone or combined with laser or cryotherapy. Cakir et al31 reported a patient with stage 3a Coats' disease treated with combined intravitreal bevacizumab and triamcinolone, with stabilization of the disease. Such treatment may reduce exudation, but there are concerns about the risk of inducing vitreoretinal fibrosis26–28 as well as possible systemic side effects.
To review the anatomic and visual outcomes of a series of children diagnosed with Coats' disease and treated on the basis of intraoperative fluorescein angiography (FA) findings.
Retrospective case series.
Twenty-five children 2 to 15 years of age diagnosed with early Coats' disease and treated after intraoperative FA.
Retrospective review of patients who underwent treatment for stage 2 Coats' disease in a tertiary center in the United Kingdom between 2007 and 2012. The children underwent treatment to the telangiectatic vessels and associated areas of retinal nonperfusion identified on intraoperative FA performed with a wide-angle retinal camera (RetCam II).
Anatomic and structural assessment of the retina after treatment, visual acuity (VA), and complications related to treatment.
Twenty children with Coats' disease who underwent intraoperative RetCam FA and retinal ablative treatment and who had more than 3 months of follow-up were identified from clinical records. All had unilateral disease. Six eyes were classified as stage 2a, and 14 eyes were classified as stage 2b. The median duration of follow-up was 21 months (mean, 26 months). Fifteen eyes needed 1 treatment to stabilize the disease, and 5 eyes needed a second treatment. None of the patients demonstrated progression of the disease to a more severe stage. Twelve eyes had a final VA of 0.4 logarithm of the minimum angle of resolution (logMAR) or better, 6 patients had VA between 0.4 and 1.0 logMAR, and 2 patients had VA worse than 1.0 logMAR.
The treatment of retinal telangiectasia and areas of retinal nonperfusion identified by wide-angle intraoperative FA in children with stage 2 Coats' disease led to good anatomic outcome, with preservation of VA in most cases.
Current management of Coats disease
2014, Survey of Ophthalmology
Citation Excerpt :
We have observed dramatic improvement in macular edema and exudate in patients treated with a single intravitreal bevacizumab administration when combined with laser photocoagulation (Fig. 13) and for persistent macular edema following previous ablative therapy (Fig. 14). Intravitreal corticosteroids such as triamcinolone acetate have met with some degree of success8,15,89 as an adjuvant to ablative therapy for decreasing subretinal fluid and exudate. One series of cases experienced total exudative retinal detachment resolution following intravitreal triamcinolone.42
Since its original description in 1908, Coats disease has been recognized as an idiopathic cause of severe vision loss with a remarkable diversity in clinical presentation and morphology. Key clinical and imaging variables are helpful in differentiating Coats disease from life-threatening malignancies, and proper management revolves around a thorough knowledge of the differential diagnosis. Despite significant advancement in scientific understanding of the disease process and clinical spectrum, the underlying etiology remains obscure, and both primary and secondary forms are recognized. With the development of anti-VEGF therapy, vitreoretinal specialists have a new, effective adjunct to the clinical management of exudates, macular edema, and serous retinal detachment. We highlight the history, diagnostic challenges, evolving clinical spectrum, and current management of Coats disease.
Coats disease
2012, Retina Fifth Edition

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: The authors have no conflicts of interest to disclose.

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Short reportCombined intravitreal bevacizumab and triamcinolone injection in a child with Coats disease

Section snippets

Case Report

Discussion

Am J Ophthalmol

Am J Ophthalmol

Short report
Combined intravitreal bevacizumab and triamcinolone injection in a child with Coats disease