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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
CASE REPORT
Year : 2013  |  Volume : 20  |  Issue : 3  |  Page : 256-258  

Successful use of intravitreal bevacizumab and pascal laser photocoagulation in the management of adult Coats' disease


Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, United Kingdom

Date of Web Publication9-Jul-2013

Correspondence Address:
Fahd Quhill
Department of Ophthalmology, Royal Hallamshire Hospital, Glossop Road, Sheffield
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.114805

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   Abstract 

Traditional methods of managing exudative retinal detachment secondary to Coats' disease have been associated with varying degrees of success. We describe a case of a 34 year-old male who presented with a sub-total exudative retinal detachment of the right eye that encroached upon the macula, associated with a vasoproliferative tumor secondary to Coats' disease. The patient under-went successful treatment with two intravitreal injections of bevacizumab (Avastin, Genetech Inc., San Francisco, CA, USA) combined with targeted laser photocoagulation with a 532 nm Pascal laser (Topcon Corp., Tokyo, Japan). The visual acuity improved 5 days after the second intravitreal injection from 6/18 to 6/5, with no residual macular edema and complete regression of the vasoproliferative tumor. The improvement in visual acuity was maintained at 12 months post-treatment. We believe this is the first case report describing the successful use of Pascal laser photocoagulation with intravitreal bevacizumab in the treatment of Coats' disease. Our aim was to defer laser treatment until 'near total' retinal reattachment and regression of the vasoproliferative tumor was achieved. There are, however, reports of vitreous fibrosis in patients with Coats' disease treated with intravitreal bevacizumab. This suggests further long-term follow-up studies are required in patients treated with this approach.

Keywords: Bevacizumab, Coats′ Disease Bevacizumab, Photocoagulation


How to cite this article:
Raoof N, Quhill F. Successful use of intravitreal bevacizumab and pascal laser photocoagulation in the management of adult Coats' disease. Middle East Afr J Ophthalmol 2013;20:256-8

How to cite this URL:
Raoof N, Quhill F. Successful use of intravitreal bevacizumab and pascal laser photocoagulation in the management of adult Coats' disease. Middle East Afr J Ophthalmol [serial online] 2013 [cited 2019 Jun 18];20:256-8. Available from: http://www.meajo.org/text.asp?2013/20/3/256/114805


   Introduction Top


Traditional methods of managing exudative retinal detachment secondary to Coats' disease have been associated with varying degrees of success. We present the first case report describing the successful use of Pascal laser (Topcon Corp., Tokyo, Japan) photocoagulation with intravitreal bevacizumab, in the treatment of Coats' disease, with complete resolution and no signs of disease recurrence at 12 months.


   Case Report Top


A 34 year-old male was referred to our department with rapidly reducing vision in the right eye over a 3-4 week period. He was otherwise medically healthy, with no relevant past ophthalmic history.

At presentation, his visual acuities were 6/18 and 6/5 in the right and left eyes, respectively. The intraocular pressures were 12 mmHg in each eye and slit-lamp examination of the anterior segment was unremarkable. Fundus examination revealed a subtotal temporal exudative retinal detachment of the right eye, with large intraretinal and subretinal exudates, encroaching the macula; with an associated large retinal vasoproliferative tumor affecting the temporal mid-periphery [Figure 1]. The left eye was clinically and angiographically normal.
Figure 1:

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Fluorescein angiography confirmed a profusely leaking temporal vasoproliferative tumor in the right eye with widespread telangiectatic vessels and aneurysmal dilatation of the capillary bed, in addition to diffuse areas of capillary non-perfusion of the right peripheral fundus [Figure 2]. Based on the features of the ophthalmic workup, the patient was diagnosed with vasoproliferative tumor of the retina (VPTR) with exudative retinal detachment secondary to Coats' disease.
Figure 2:

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The patient was treated with two intravitreal Avastin (Genetech Inc., San Francisco, CA, USA) injections (1.25 mg), 4 weeks apart. Five days following the second injection, when he presented for laser treatment, the visual acuity of the right eye had improved to 6/5 unaided with no residual macular edema and complete regression of the VPTR. Panretinal photocoagulation was targeted towards areas of telangiectasia and peripheral ischemia, in addition to direct treatment of the VPTR using a 532 nm Pascal laser photocoagulator. A 3 × 3 square array pattern with pulse duration set at 20 ms and 200 micron spot size was used [Figure 3]. At the last follow-up, 12 months after initial intervention, visual acuity was maintained at 6/5, with no signs of recurrence.
Figure 3:

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   Discussion Top


Sun et al. [1] demonstrated elevated levels of vascular endothelial growth factor (VEGF) in Coats' disease, which rapidly reduced following an injection of pegaptanib sodium. VEGF levels reduced from a pre-treatment level of 908 pg/ml to 167 pg/ml (normal-100 pg/ml), with an improvement in exudation and near complete reattachment of the retina. [1] The authors suggested the vascular changes commonly found in Coats' disease may be secondary to dysregulated VEGF-mediated angiogenesis. [1]

In our case, two bevacizumab injections combined with laser photocoagulation produced significant and permanent reductions in exudation and edema with marked improvement in visual acuity. There has been no recurrence of exudation to date. Our therapeutic rationale for the case was to use an anti-VEGF agent as adjunctive therapy to conventional laser, deferring laser until 'near total' retinal reattachment and regression of the vasoproliferative tumor was achieved. We felt this approach would be preferable as it would enhance subsequent laser uptake and efficacy of treatment, in addition to reducing the total energy of laser delivery. Although complete resolution of the exudative retinal detachment was achieved with two injections of bevacizumab, we felt it was worthwhile to apply laser treatment in order to decrease the chances of disease recurrence.

While there are a handful of other case reports that describe the use of intravitreal bevacizumab in the management of exudative retinal detachment secondary to Coats' disease, either as the sole treatment [2] or as an adjunctive treatment, [3],[4] our case is the first report of the successful use of Pascal laser photocoagulation in conjunction with bevacizumab, using short duration laser burns. However, experience with bevacizumab in Coats' disease remains limited. Ramasubramanian and Shields [5] report the development of vitreous fibrosis in four pediatric patients with exudative retinal detachment secondary to Coats' disease treated with intra-vitreal bevacizumab and warn of inducing vitreoretinal traction with this treatment. Based on this observation, we feel further long term follow-up studies of this therapeutic approach are warranted.

 
   References Top

1.Sun Y, Jain A, Moshfeghi DM. Elevated vascular endothelial growth factor levels in Coats disease: Rapid response to pegaptanib sodium. Graefes Arch Clin Exp Ophthalmol 2007;245:1387-8.  Back to cited text no. 1
    
2.Entezari M, Ramezani A, Safavizadeh L, Bassirnia N. Resolution of macular edema in Coats' disease with intravitreal bevacizumab. Indian J Ophthalmol 2010;58:80-2.  Back to cited text no. 2
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3.Goel N, Kumar V, Seth A, Raina UK, Ghosh B. Role of intravitreal bevacizumab in adult onset Coats' disease. Int Ophthalmol 2011;31:183-90.  Back to cited text no. 3
    
4.Kim J, Park KH, Woo SJ. Combined photodynamic therapy and intravitreal bevacizumab injection for the treatment of adult Coats' disease: A case report. Korean J Ophthalmol 2010;24:374-6.  Back to cited text no. 4
    
5.Ramasubramanian A, Shields CL. Bevacizumab for Coats' disease with exudative retinal detachment and risk of vitreoretinal traction. Br J Ophthalmol 2012;96:356-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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