Ocular Immunology and Inflammation
ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20
Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report Do Yeh Yoon MD & Se Joon Woo MD, PhD To cite this article: Do Yeh Yoon MD & Se Joon Woo MD, PhD (2016): Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report, Ocular Immunology and Inflammation, DOI: 10.1080/09273948.2016.1239744 To link to this article: http://dx.doi.org/10.1080/09273948.2016.1239744
Published online: 24 Oct 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioii20 Download by: ["Queen's University Libraries, Kingston"]
Date: 03 November 2016, At: 10:38
Ocular Immunology & Inflammation, 2016; 00(00): 1–3 © Taylor & Francis Group, LLC ISSN: 0927-3948 print / 1744-5078 online DOI: 10.1080/09273948.2016.1239744
LETTER TO THE EDITOR
Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report Do Yeh Yoon, 1
MD
1,2
and Se Joon Woo,
MD, PhD
2
Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea, and 2Seoul National University Hospital, Seoul, South Korea
ABSTRACT Purpose: To report a case of a choroidal neovascularization (CNV) secondary to ocular toxocariasis treated with intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. Methods: A 66-year-old woman presented with decreased vision (20/40) and metamorphopsia in the right eye. Fundus examination revealed inferotemporal retinal whitish lesion and subretinal hemorrhage in the right eye. Results: She was diagnosed with ocular toxocariasis based on the clinical features and positive serological antitoxocara antibody test result. Ophthalmic examination revealed classic CNV formation adjacent to a retinal granuloma. She was treated with intravitreal ranibizumab and bevacizumab injections combined with oral albendazole. Her vision decreased to 20/100 following CNV recurrence. However, after additional bevacizumab treatment, the CNV became inactive and her vision recovered to 20/40. Conclusions: CNV can be combined with retinal granuloma due to ocular toxocariasis. Repeated intravitreal injections of anti-VEGF agents can be efficacious for regressing toxocariasis-associated CNV and improving vision. Keywords: Ocular toxocariasis, choroidal neovascularization, granuloma, bevacizumab, ranibizumab
was successfully treated with intravitreal administration of anti-VEGF agents. Herein, we report the clinical features and course of this extremely rare case. To our knowledge, this is the first reported case of toxocariasisassociated CNV treated with intravitreal administration of anti-VEFG agent. A healthy 64-year-old woman with no ophthalmic history presented with a 2-month history of metamorphopsia associated with blurred vision. On her first visit, her bestcorrected visual acuities (BCVAs) in the right and left eyes were 20/40 and 20/25, respectively. On slit-lamp examination, both anterior chambers showed clear, colorless aqueous humor and no inflammatory reaction. Dilated fundus examination of the right eye revealed a subretinal whitish mass with adjacent subretinal hemorrhage (Figure 1A and B). Left eye examination revealed normal findings. She had a history of ingestion of raw cow liver. The result of the serologic examination using enzymelinked immunosorbent assay (Bordier-Affinity Products,
CASE REPORT Ocular toxocariasis (OT) is a globally prevalent illness caused by infestation of the parasite Toxocara canis or T. cati larvae, which is the most ubiquitous gastrointestinal helminth in dogs and cats.1 Larvae that migrate to the eye cause OT. OT occurs primarily in children, commonly contracting the infection from dirt and soil while playing and because of poor hygiene.2 Our group reported about 100 cases of adult OT that were probably contracted through oral ingestion of raw meat.3 Many clinical factors affect the vision of patients with OT, such as retinal granuloma (posterior pole or peripheral retina), retinal nerve fiber layer defect, epiretinal membrane, vitreous opacity, retinal detachment, and macular edema.3 One of our patients showed a CNV occurring adjacent to a posterior pole granuloma associated with OT and
Received 18 March 2016; revised 31 July 2016; accepted 19 September 2016; published online 21 October 2016. Correspondence: Se Joon Woo, Seoul National University Bundang Hospital, #300, Gumi-dong, Bundang-gu, Seongnam, Gyeoggi-do 463–707, South Korea. E-mail: [email protected]
1
2
D. Y. Yoon and S. J. Woo
FIGURE 1. Fundus photography (A, B, D, and E), fundus fluorescein angiography (C), and optical coherence tomography images of the affected right eye (a–e, horizontal section shown in B, D, and E). Clinical course of choroidal neovascularization (arrowhead), granuloma (arrow), and subretinal fibrosis can be seen (A–C: before treatment, D: 7 months after the first bevacizumab injection, E: 11 months after the second bevacizumab injection).
Lucron Elitech, Benelux, the Netherlands) was positive for Toxocara IgG antibody (titer, 2.396; reference range: 0– 0.904). The serum IgE level was elevated to 428.7 U/mL (reference range: 0–100 U/mL). To distinguish OT granuloma from tuberculosis granuloma, we performed fluorescein angiography (FAG) and it did not show the classical “ring of fire” appearance that is a characteristic of tuberculosis granuloma. Additionally, spectral domain optical
tomography (SD-OCT) was also performed and it did not reveal the “contact” sign (an area of localized adhesion between the choriocapillaris–RPE layer and overlying the neurosensory retina) that is typically shown in the TB granuloma. In addition, the granuloma in our case was placed mainly on the RPE and it was not a choroidal granuloma suggestive of TB. Systemic investigations including CBC and erythrocyte sedimentation rate were within normal range, and chest X-ray also showed as normal. Additional tests such as immunoglobulin gamma release assay (IGRA) might be helpful for differential diagnosis. However, in Korean elderly people aged ≥60 years, the seroprevalence of IGRA is approximately 60%,4 thus IGRA had little diagnostic aid in this case. For OT, oral albendazole 400 mg once a day for 2 weeks was prescribed. SD-OCT revealed active CNV with subretinal fluid in the right eye (Figure 1a–c). FAG revealed fluorescein leakage from the CNV (Figure 1C). Two intravitreal injections of ranibizumab and one intravitreal injection of bevacizumab were performed at intervals of 1 month. After treatment, the CNV regressed to a fibrotic scar and the subretinal fluid disappeared. At 7 months after the treatment, the CNV recurred and her BCVAs in the right was 20/100 (Figure 1D and 1d). FAG revealed leakage from the membrane, and a secondary intravitreal injection of bevacizumab was done. After 1 month, the recurring CNV slightly diminished but still persisted. Thus, she received an additional intravitreal injection of bevacizumab. Her BCVA in the right eye improved to 20/40. However, metamorphopsia showed no improvement. At 11 months after the treatment, inactive CNV with focal choroidal excavation was observed on OCT (Figure 1E and 1e). This is the first reported case of CNV combined with retinal granuloma from OT that was successfully treated with intravitreal injections of anti-VEGF agents. OT can cause defects on retinal nerve fiber layer, epiretinal membrane, vitreous opacity, macular edema, macular hole, retinal detachment, and retinal granuloma.5 These comorbid conditions can lead to permanent retinal damage and visual loss in eyes with OT. Macular granuloma itself can lead to severe visual loss because it damages the retina and photoreceptors.5 Inflammatory injury to the retinal pigment epithelium, Bruch’s membrane, and choriocapillaris caused by granulomas involving the outer retina might induce breakdown of blood–retinal barrier, enhances the inflammatory response, and induces angiogenesis. Granuloma itself might induce traction to the outer retina and RPE that leads to CNV, or migrated larvae might directly disrupt Bruch’s membrane. Without treatment, CNV adjacent to a granuloma may change into a fibrotic scar that mimics an enlarged granuloma. Thus, in the past, the occurrence of CNV secondary to a granuloma could be neglected, losing the chance of treatment. In this case, early treatment with intravitreal injections of anti-VEFG agents prevented macular involvement and visual field defects. Any granuloma observed around the macula should be Ocular Immunology & Inflammation
CNV Secondary to Ocular Toxocariasis monitored regularly, and treatment must be performed as soon as CNV is confirmed. This case demonstrates that intravitreal injections of anti-VEGF agents for CNV combined with granuloma may suppress CNV and preserve vision in patients with OT. Therefore, patients with a history of OT should undergo follow-up examinations regularly and prompt treatment with intravitreal injections of anti-VEGF agents if any signs of macular involvement, especially CNV features, are observed.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
© 2016 Taylor & Francis Group, LLC
3
REFERENCES 1. Despommier D. Toxocariasis: clinical aspects, epidemiology, medical ecology, and molecular aspects. Clin Microbiol Rev. 2003;16:265–272. 2. Woodhall D, Starr MC, Montgomery SP, et al. Ocular toxocariasis: epidemiologic, anatomic, and therapeutic variations based on a survey of ophthalmic subspecialists. Ophthalmology. 2012;119:1211–1217. 3. Ahn SJ, Woo SJ, Jin Y, et al. Clinical features and course of ocular toxocariasis in adults. PLoS Negl Trop Dis. 2014;8: e2938. 4. Ahn SJ, Kim KE, Woo SJ, et al. The usefulness of interferon-gamma release assay for diagnosis of tuberculosisrelated uveitis in Korea. Korean J Ophthalmol. 2014;28:226–233. 5. Ahn SJ, Ryoo NK, Woo SJ. Ocular toxocariasis: clinical features, diagnosis, treatment, and prevention. Asia Pac Allergy. 2014;4:134–141.
ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20
Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report Do Yeh Yoon MD & Se Joon Woo MD, PhD To cite this article: Do Yeh Yoon MD & Se Joon Woo MD, PhD (2016): Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report, Ocular Immunology and Inflammation, DOI: 10.1080/09273948.2016.1239744 To link to this article: http://dx.doi.org/10.1080/09273948.2016.1239744
Published online: 24 Oct 2016.
Submit your article to this journal
Article views: 10
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioii20 Download by: ["Queen's University Libraries, Kingston"]
Date: 03 November 2016, At: 10:38
Ocular Immunology & Inflammation, 2016; 00(00): 1–3 © Taylor & Francis Group, LLC ISSN: 0927-3948 print / 1744-5078 online DOI: 10.1080/09273948.2016.1239744
LETTER TO THE EDITOR
Intravitreal Administration of Ranibizumab and Bevacizumab for Choroidal Neovascularization Secondary to Ocular Toxocariasis: A Case Report Do Yeh Yoon, 1
MD
1,2
and Se Joon Woo,
MD, PhD
2
Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea, and 2Seoul National University Hospital, Seoul, South Korea
ABSTRACT Purpose: To report a case of a choroidal neovascularization (CNV) secondary to ocular toxocariasis treated with intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. Methods: A 66-year-old woman presented with decreased vision (20/40) and metamorphopsia in the right eye. Fundus examination revealed inferotemporal retinal whitish lesion and subretinal hemorrhage in the right eye. Results: She was diagnosed with ocular toxocariasis based on the clinical features and positive serological antitoxocara antibody test result. Ophthalmic examination revealed classic CNV formation adjacent to a retinal granuloma. She was treated with intravitreal ranibizumab and bevacizumab injections combined with oral albendazole. Her vision decreased to 20/100 following CNV recurrence. However, after additional bevacizumab treatment, the CNV became inactive and her vision recovered to 20/40. Conclusions: CNV can be combined with retinal granuloma due to ocular toxocariasis. Repeated intravitreal injections of anti-VEGF agents can be efficacious for regressing toxocariasis-associated CNV and improving vision. Keywords: Ocular toxocariasis, choroidal neovascularization, granuloma, bevacizumab, ranibizumab
was successfully treated with intravitreal administration of anti-VEGF agents. Herein, we report the clinical features and course of this extremely rare case. To our knowledge, this is the first reported case of toxocariasisassociated CNV treated with intravitreal administration of anti-VEFG agent. A healthy 64-year-old woman with no ophthalmic history presented with a 2-month history of metamorphopsia associated with blurred vision. On her first visit, her bestcorrected visual acuities (BCVAs) in the right and left eyes were 20/40 and 20/25, respectively. On slit-lamp examination, both anterior chambers showed clear, colorless aqueous humor and no inflammatory reaction. Dilated fundus examination of the right eye revealed a subretinal whitish mass with adjacent subretinal hemorrhage (Figure 1A and B). Left eye examination revealed normal findings. She had a history of ingestion of raw cow liver. The result of the serologic examination using enzymelinked immunosorbent assay (Bordier-Affinity Products,
CASE REPORT Ocular toxocariasis (OT) is a globally prevalent illness caused by infestation of the parasite Toxocara canis or T. cati larvae, which is the most ubiquitous gastrointestinal helminth in dogs and cats.1 Larvae that migrate to the eye cause OT. OT occurs primarily in children, commonly contracting the infection from dirt and soil while playing and because of poor hygiene.2 Our group reported about 100 cases of adult OT that were probably contracted through oral ingestion of raw meat.3 Many clinical factors affect the vision of patients with OT, such as retinal granuloma (posterior pole or peripheral retina), retinal nerve fiber layer defect, epiretinal membrane, vitreous opacity, retinal detachment, and macular edema.3 One of our patients showed a CNV occurring adjacent to a posterior pole granuloma associated with OT and
Received 18 March 2016; revised 31 July 2016; accepted 19 September 2016; published online 21 October 2016. Correspondence: Se Joon Woo, Seoul National University Bundang Hospital, #300, Gumi-dong, Bundang-gu, Seongnam, Gyeoggi-do 463–707, South Korea. E-mail: [email protected]
1
2
D. Y. Yoon and S. J. Woo
FIGURE 1. Fundus photography (A, B, D, and E), fundus fluorescein angiography (C), and optical coherence tomography images of the affected right eye (a–e, horizontal section shown in B, D, and E). Clinical course of choroidal neovascularization (arrowhead), granuloma (arrow), and subretinal fibrosis can be seen (A–C: before treatment, D: 7 months after the first bevacizumab injection, E: 11 months after the second bevacizumab injection).
Lucron Elitech, Benelux, the Netherlands) was positive for Toxocara IgG antibody (titer, 2.396; reference range: 0– 0.904). The serum IgE level was elevated to 428.7 U/mL (reference range: 0–100 U/mL). To distinguish OT granuloma from tuberculosis granuloma, we performed fluorescein angiography (FAG) and it did not show the classical “ring of fire” appearance that is a characteristic of tuberculosis granuloma. Additionally, spectral domain optical
tomography (SD-OCT) was also performed and it did not reveal the “contact” sign (an area of localized adhesion between the choriocapillaris–RPE layer and overlying the neurosensory retina) that is typically shown in the TB granuloma. In addition, the granuloma in our case was placed mainly on the RPE and it was not a choroidal granuloma suggestive of TB. Systemic investigations including CBC and erythrocyte sedimentation rate were within normal range, and chest X-ray also showed as normal. Additional tests such as immunoglobulin gamma release assay (IGRA) might be helpful for differential diagnosis. However, in Korean elderly people aged ≥60 years, the seroprevalence of IGRA is approximately 60%,4 thus IGRA had little diagnostic aid in this case. For OT, oral albendazole 400 mg once a day for 2 weeks was prescribed. SD-OCT revealed active CNV with subretinal fluid in the right eye (Figure 1a–c). FAG revealed fluorescein leakage from the CNV (Figure 1C). Two intravitreal injections of ranibizumab and one intravitreal injection of bevacizumab were performed at intervals of 1 month. After treatment, the CNV regressed to a fibrotic scar and the subretinal fluid disappeared. At 7 months after the treatment, the CNV recurred and her BCVAs in the right was 20/100 (Figure 1D and 1d). FAG revealed leakage from the membrane, and a secondary intravitreal injection of bevacizumab was done. After 1 month, the recurring CNV slightly diminished but still persisted. Thus, she received an additional intravitreal injection of bevacizumab. Her BCVA in the right eye improved to 20/40. However, metamorphopsia showed no improvement. At 11 months after the treatment, inactive CNV with focal choroidal excavation was observed on OCT (Figure 1E and 1e). This is the first reported case of CNV combined with retinal granuloma from OT that was successfully treated with intravitreal injections of anti-VEGF agents. OT can cause defects on retinal nerve fiber layer, epiretinal membrane, vitreous opacity, macular edema, macular hole, retinal detachment, and retinal granuloma.5 These comorbid conditions can lead to permanent retinal damage and visual loss in eyes with OT. Macular granuloma itself can lead to severe visual loss because it damages the retina and photoreceptors.5 Inflammatory injury to the retinal pigment epithelium, Bruch’s membrane, and choriocapillaris caused by granulomas involving the outer retina might induce breakdown of blood–retinal barrier, enhances the inflammatory response, and induces angiogenesis. Granuloma itself might induce traction to the outer retina and RPE that leads to CNV, or migrated larvae might directly disrupt Bruch’s membrane. Without treatment, CNV adjacent to a granuloma may change into a fibrotic scar that mimics an enlarged granuloma. Thus, in the past, the occurrence of CNV secondary to a granuloma could be neglected, losing the chance of treatment. In this case, early treatment with intravitreal injections of anti-VEFG agents prevented macular involvement and visual field defects. Any granuloma observed around the macula should be Ocular Immunology & Inflammation
CNV Secondary to Ocular Toxocariasis monitored regularly, and treatment must be performed as soon as CNV is confirmed. This case demonstrates that intravitreal injections of anti-VEGF agents for CNV combined with granuloma may suppress CNV and preserve vision in patients with OT. Therefore, patients with a history of OT should undergo follow-up examinations regularly and prompt treatment with intravitreal injections of anti-VEGF agents if any signs of macular involvement, especially CNV features, are observed.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
© 2016 Taylor & Francis Group, LLC
3
REFERENCES 1. Despommier D. Toxocariasis: clinical aspects, epidemiology, medical ecology, and molecular aspects. Clin Microbiol Rev. 2003;16:265–272. 2. Woodhall D, Starr MC, Montgomery SP, et al. Ocular toxocariasis: epidemiologic, anatomic, and therapeutic variations based on a survey of ophthalmic subspecialists. Ophthalmology. 2012;119:1211–1217. 3. Ahn SJ, Woo SJ, Jin Y, et al. Clinical features and course of ocular toxocariasis in adults. PLoS Negl Trop Dis. 2014;8: e2938. 4. Ahn SJ, Kim KE, Woo SJ, et al. The usefulness of interferon-gamma release assay for diagnosis of tuberculosisrelated uveitis in Korea. Korean J Ophthalmol. 2014;28:226–233. 5. Ahn SJ, Ryoo NK, Woo SJ. Ocular toxocariasis: clinical features, diagnosis, treatment, and prevention. Asia Pac Allergy. 2014;4:134–141.
