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CASE REPORT
Year : 2009  |  Volume : 2  |  Issue : 3  |  Page : 133-136 Table of Contents   

Idiopathic choroidal neovascular membrane in a young female


Department of Ophthalmology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Date of Web Publication28-Oct-2009

Correspondence Address:
Mahmood Jameel Showail
Department of Ophthalmology, King Abdulaziz University Hospital, P.O.BOX 80215 Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.57314

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   Abstract 

A case of idiopathic choroidal neovascular membrane (CNVM) is described in a 17-year-old female patient. On initial examination her vision was counting fingers at one meter in the left eye (OS) and Fluorescein angiography showed a well-defined hyperfluorescent area corresponding to the CNVM. Intravitreal bevacizumab was injected into OS, and at a five-week follow-up visit, visual acuity improved to 20/100 OS. This case is unusual, in that the CNVM developed in a young lady with no significant past medical history and with the absence of a choroidal or retinal pigment epithelial disease process that may be associated with a CNVM.

Keywords: Bevacizumab, choroid, choroidal neovascularization, idiopathic


How to cite this article:
Waheeb SA, Showail MJ. Idiopathic choroidal neovascular membrane in a young female. Oman J Ophthalmol 2009;2:133-6

How to cite this URL:
Waheeb SA, Showail MJ. Idiopathic choroidal neovascular membrane in a young female. Oman J Ophthalmol [serial online] 2009 [cited 2020 Feb 22];2:133-6. Available from: http://www.ojoonline.org/text.asp?2009/2/3/133/57314


   Introduction Top


In patients aged 50 years or younger, choroidal neovascularization (CNV) develops secondary to predisposing conditions that include pathological myopia, angioid streak, trauma or inflammation (e.g. ocular histoplasmosis syndrome). [1] In a significant number of young patients with CNV, no apparent cause can be detected, constituting idiopathic CNV. [2] These membranes are usually unilateral and final visual outcomes are considered to be more favorable than CNV due to age-related macular degeneration (AMD). [3] Only a few reports exist in the literature describing idiopathic CNV in young patients. [4] Several antivascular endothelial growth factor (VEGF) agents are now being administered intravitreally for CNV. The results are promising, and the procedure is considered to be safe and well-tolerated in the management of idiopathic CNV. [5] We report an idiopathic subfoveal CNV in a 17-year-old female with no evidence of any predisposing factor, which responded favorably to intravitreal bevacizumab injection.


   Case Report Top


A 17-year-old high school female student was referred for evaluation of decreasing vision in her left eye (OS). There was no history of pain, redness or photophobia. There was no history of trauma. Past medical history was unremarkable. On examination, her best corrected visual acuity in the right eye (OD) was 20/20 and counting fingers at one meter OS. Her anterior segments were normal in both eyes (OU). On biomicroscopy of the posterior segments, subfoveal choroidal neovascular membrane (CNVM) with subretinal hemorrhage was noted OS [Figure 1]A. Fundus examination OD was unremarkable. No drusen, retinal pigment epithelial changes or macular exudates were observed OU. Fluorescein angiography [Figure 1]C and D showed a well-defined hyperfluorescent area corresponding to the CNVM OS with diffuse leakage on the late phase. Full blood investigations including serology were done to rule out any inflammatory pathology, and were normal. Chest X-ray was normal as well. After obtaining an informed consent, the left eye was anesthetized using topical benoxinate Hydrochloride 0.4%, then Intravitreal bevacizumab (Avastin; Genentech, Inc, South San Francisco,California) was injected into OS supratemporally 3.5 mm posterior to the limbus. At the five-week follow-up visit, visual acuity improved to 20/100 OS with marked reduction of fluid in optical coherence tomography scan (OCT) [Figure 2]B. Repeat fluorescein angiography showed contraction of the membrane and no further leakage in the late phase [Figure 2]C and D. The patient remains under follow-up


   Discussion Top


There are many etiologies of choroidal neovascularization (CNV), all of which are known or thought to occur with a defect in Bruch's membrane. To exclude the possibility of ongoing inflammation, a close biomicroscopic examination and full laboratory investigations were performed. However, there was no evidence of vitreous cells, condensation or vasculitis. There was no evidence of any systemic disease as well.

There are a few published studies on idiopathic CNV (case reports or small case series), which report variable visual results. [4],[5],[6] Different treatment approaches for patients with CNV have been described: thermal laser therapy, ocular photodynamic therapy with verteporfin, transpupillary thermotherapy, submacular surgery and intravitreal injections of antivascular endothelial growth factor (VEGF) agents. [5],[7],[8],[9],[10] As the natural history of Idiopathic CNV is better than that seen in AMD, thermal laser therapy does not appear to be a suitable treatment option because of the risk of immediate central vision diminution. Photodynamic therapy is too expensive and usually needs repeated sessions. Submacular surgeries are associated with a high risk of complications. Transpupillary thermotherapy is outdated and is widely replaced nowadays by anti-VEGF agents. The advantages of anti-VEGF agents are that they are available, easy to be administered and can be repeated as needed. With the introduction of anti-VEGF agents, numerous reports exist regarding their use as an off-label treatment of neovascular AMD. [11]

Several investigators have reported their observations following off-label treatment with bevacizumab in idiopathic CNV. Mandal et al reported results of intravitreal bevacizumab (1.25 mg/0.05 mL) in 32 eyes with idiopathic subfoveal CNV. [5] After 12 weeks follow-up, 19 eyes (59%) had an improvement in BCVA of three or more lines, 11 eyes (34%) remained stable and two eyes (6%) lost three or more lines. Their observations suggest that short-term use of intravitreal bevacizumab is safe and well tolerated in the management of idiopathic CNV.

Bevacizumab injection should be repeated if OCT shows intraretinal edema, subretinal fluid and/or pigment epithelial detachment at a four to six week interval. Although, intravitreal anti-VEGF injections appear to have a low complication rate, possible ocular complications include bacterial endophthalmitis, retinal detachments and uveitis. [12] Systemic side effects following intravitreal bevacizumab injection have been an area of debate. Acute elevation of blood pressure and stroke has been reported. [13] All these have to be made known to the patient and informed consent has to be obtained prior to therapy.

Ongoing studies monitoring ocular and systemic toxicities are vital in establishing the long-term safety profile of the anti-VEGF drugs. In our patient, the CNV regressed, intraretinal fluid was reabsorbed, and visual acuity improved significantly five weeks after VEGF injection and no adverse effect attributable to the drug or procedure were encountered in the follow-up period. However, our patient is under follow-up, and a re-injection would be performed if there is recurrence of edema. Obviously we cannot comment on the efficacy, limitations and long-term side effects of the treatment based on our case where a definite improvement of idiopathic CNV was observed following a single injection of bevacizumab over a five weeks follow-up period. We recommend a multicenter, prospective randomized controlled study to address the issue.

 
   References Top

1.Cohen SY, Laroche A, Leguen Y, Soubrane G, Coscas GJ. Etiology of choroidal neovascularization in young patients. Ophthalmology 1996;103:1241-4.  Back to cited text no. 1      
2.Ho AC, Yannuzzi LA, Pisicano K, DeRosa J. The natural history of idiopathic subfoveal choroidal neovascularization. Ophthalmology 1995;102:782-9.  Back to cited text no. 2      
3.Lindblom B, Andersson T. The prognosis of idiopathic choroidal neovascularization in persons younger than 50 years of age. Ophthalmology 1998;105:1816-20.  Back to cited text no. 3      
4.Cakir M, Cekiη O, Yilmaz OF. Intravitreal bevacizumab for idiopathic choroidal neovascularisation. J AAPOS 2009;13:296-8.  Back to cited text no. 4      
5.Mandal S, Garg S, Venkatesh P, Mithal C, Vohra R, Mehrotra A. Intravitreal bevacizumab for subfoveal idiopathic choroidal neovascularization. Arch Ophthalmol 2007;125:1487-92  Back to cited text no. 5      
6.Sinclair SH, Salmenson BD. Idiopathic choriovitreal membrane: a case report. Br J Ophthalmol 1992;76:567-8.  Back to cited text no. 6      
7.Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration: Updated findings from two clinical trials. Arch Ophthalmol 1993;111:1200-9.  Back to cited text no. 7      
8.Kumar A, Prakash G, Singh RP. Transpupillary thermotherapy for idiopathic subfoveal choroidal neovascularization. Acta Ophthalmol Scand 2004;82:205-8.  Back to cited text no. 8      
9.Spaide RF, Martin ML, Slakter J, Yannuzzi LA, Sorenson J, Guyer DR, et al. Treatment of idiopathic subfoveal choroidal neovascular lesions using photodynamic therapy with verteporfin. Am J Ophthalmol 2002;134:62-8.  Back to cited text no. 9      
10.Thomas MA, Dickinson JD, Melberg NS, Ibanez HE, Dhaliwal RS. Visual results after surgical removal of subfoveal choroidal neovascular membranes. Ophthalmology 1994;101:1384-96.  Back to cited text no. 10      
11.Bashshur ZF, Bazarbachi A, Schakal A, Haddad ZA, El Haibi CP, Noureddin BN. Intravitreal bevacizumab for the management of choroidal neovascularization in age-related macular degeneration. Am J Ophthalmol 2006;142:1-9.  Back to cited text no. 11      
12.Gunther JB, Altaweel MM. Bevacizumab (Avastin) for the treatment of ocular disease. Surv Ophthalmol 2009;54:372-400.  Back to cited text no. 12      
13.Fung AE, Rosenfeld PJ, Reichel E. The International intravitreal bevacizumab safety survey: Using the internet to assess drug safety worldwide. Br J Ophthalmol 2006;90:1344-9.  Back to cited text no. 13      


    Figures

  [Figure 1], [Figure 2]


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