INTRAVITREAL RANIBIZUMAB FOR CHOROIDAL NEOVASCULARIZATION SECONDARY TO CHOROIDAL NEVUS Benjamin Guigui, MD,*† Eric H. Souied, MD, PhD,† Salomon Yves Cohen, MD*
Purpose: To describe a patient treated with ranibizumab for juxtafoveal choroidal neovascularization secondary to choroidal nevus. Methods: A 71-year-old man presented with juxtafoveal choroidal neovascularization secondary to choroidal nevus. Choroidal neovascularization was initially treated with a single intravitreal injection of ranibizumab. Results: The treatment was successful and best-corrected visual acuity improved from 20/50 to 20/25 and remained stable during 7 months. A recurrence was observed 9 months after initial treatment. Conclusion: Ranibizumab seems to be an effective treatment for choroidal neovascularization secondary to choroidal nevus. However, late recurrence may occur. RETINAL CASES & BRIEF REPORTS 3:412– 414, 2009
From the *Centre Ophtalmologique d’Imagerie et de Laser, Paris, France; and †University Eye Clinic, Creteil, France.
apy with verteporfin has been used with variable outcomes.4,5 To our knowledge, antivascular endothelial growth factor antibodies have not been used for treating CNV secondary to choroidal nevus. Ranibizumab (Lucentis, Genentech, Inc., South San Francisco, CA) is a recombinant humanized, monoclonal antibody antigen-binding fragment (Fab) that neutralizes all biologically active forms of vascular endothelial growth factor, effectively used in the treatment of neovascular age-related macular degeneration.6,7 We report a patient with CNV secondary to choroidal nevus, who underwent treatment with intravitreal ranibizumab.
C
horoidal nevi are the most common benign intraocular tumors.1 They frequently appear as either a round or oval, flat, or minimally elevated brown-to-gray lesion with well-defined margins located primarily at the posterior pole. Secondary changes in the surrounding retina and retinal pigment epithelium consist of the development of drusen, orange pigment, and retinal pigment epithelium detachment. Occasionally, choroidal nevi may be complicated by choroidal neovascularization (CNV)2 and it could result in visual loss. When the location is extrafoveal, CNV can be treated with laser photocoagulation.2,3 Juxta- or subfoveal CNV secondary to choroidal nevi is a rare finding in which photodynamic ther-
Case Report A 71-year-old man presented for decreased vision and metamorphopsia in his right eye. He had no medical history. His bestcorrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Right eye fundus examination revealed a two disk diameter, slightly elevated, pigmented mass located at the posterior pole, corresponding to a macular nevus. There were drusen overlying the nevus. Fluorescein angiography showed a hyperfluorescence on the early phases with leakage on the late phases corresponding to a juxtafoveal classic CNV (Figure 1). Treatment options were discussed with the patient. After obtaining written informed consent, one injection of 0.05 mL/0.5 mg ranibizumab
The authors have no financial support or financial conflict of interest. Reprint requests: Salomon Yves Cohen, MD, Centre Ophtalmologique d’Imagerie et de Laser, Paris 75015, France; e-mail: [email protected]
412
RANIBIZUMAB FOR CNV IN CHOROIDAL NEVUS
413
Fig. 1. Color photograph (a) and fluorescein angiography (b) of the right eye of a 71year-old man showing a choroidal nevus complicated by a juxtafoveal classic choroidal neovascularization. Some hard and intermediate soft drusen were present.
was administered without complications. One month later, bestcorrected visual acuity improved to 20/32, fundus examination and fluorescein angiography revealed the CNV closure (Figure 2a). Optical coherence tomography showed absence of macular fluid. Two months later, best-corrected visual acuity improved to 20/25. No retreatment was needed. At the 7-month visit, optical coherence tomography and fundus photographies did not show any sign of recurrence. However, 9 months after the initial treatment, a recurrence of the CNV was observed (Figure 2b), and a second intravitreal injection of ranibizumab was performed.
Discussion Choroidal neovascularization is a rare complication of choroidal nevus. Juxta- and subfoveal CNV complicating choroidal nevi have been previously treated by photodynamic therapy. The first report showed closure of the CNV with final best-corrected visual acuity of 20/25 after a single photodynamic therapy session.4 However, a series of five patients, two cases
Fig. 2. Follow-up at 1 month (a) and 9 months (b). One month after intravitreal injection of ranibizumab, fluorescein angiography showed complete closure of the choroidal neovascularization (a). No additional treatment was performed. A recurrence was observed 9 months later (b) and led to a second injection.
with subfoveal CNV and three with juxtafoveal CNV, showed more variable outcomes. Best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of photodynamic therapy sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six.5 We report the case of a 71-year-old man in which we performed intravitreal ranibizumab injection. In this patient, one intravitreal ranibizumab stopped the neovascular process during 7 months with significant improvement of bestcorrected visual acuity. Ranibizumab seems to be an effective treatment for CNV secondary to choroidal nevus. However, long-term follow-up is needed because of the risk of recurrence of the CNV. Further studies and additional data are needed to establish the visual benefit of ranibizumab for CNV secondary to choroidal nevi.
RETINAL CASES & BRIEF REPORTSℜ
414
Key words: choroidal neovascularization, choroidal nevus, ranibizumab. References 1. 2.
3.
Shields JA, Shields CL. Intraocular Tumors: A Text and Atlas. Philadelphia: Saunders; 1992:85–100. Callanan DG, Lewis ML, Byrne SF, Gass JD. Choroidal neovascularization associated with choroidal nevi. Arch Ophthalmol 1993;111:789 –794. Waltman DD, Gitter KA, Yannuzzi L, Schatz H. Choroidal neovascularization associated with choroidal nevi. Am J Ophthalmol 1978;85:704 –710.
4.
5.
6.
7.
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2009
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VOLUME 3
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NUMBER 4
Stanescu D, Wattenberg S, Cohen SY. Photodynamic therapy for choroidal neovascularization secondary to choroidal nevus. Am J Ophthalmol 2003;136:575–576. Parodi MB, Boscia F, Piermarocchi S, Ferrari TM, Furino C, Sborgia C. Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus. Retina 2005;25:438 – 442. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006;355:1419 –1431. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006;355:1432–1444.
Purpose: To describe a patient treated with ranibizumab for juxtafoveal choroidal neovascularization secondary to choroidal nevus. Methods: A 71-year-old man presented with juxtafoveal choroidal neovascularization secondary to choroidal nevus. Choroidal neovascularization was initially treated with a single intravitreal injection of ranibizumab. Results: The treatment was successful and best-corrected visual acuity improved from 20/50 to 20/25 and remained stable during 7 months. A recurrence was observed 9 months after initial treatment. Conclusion: Ranibizumab seems to be an effective treatment for choroidal neovascularization secondary to choroidal nevus. However, late recurrence may occur. RETINAL CASES & BRIEF REPORTS 3:412– 414, 2009
From the *Centre Ophtalmologique d’Imagerie et de Laser, Paris, France; and †University Eye Clinic, Creteil, France.
apy with verteporfin has been used with variable outcomes.4,5 To our knowledge, antivascular endothelial growth factor antibodies have not been used for treating CNV secondary to choroidal nevus. Ranibizumab (Lucentis, Genentech, Inc., South San Francisco, CA) is a recombinant humanized, monoclonal antibody antigen-binding fragment (Fab) that neutralizes all biologically active forms of vascular endothelial growth factor, effectively used in the treatment of neovascular age-related macular degeneration.6,7 We report a patient with CNV secondary to choroidal nevus, who underwent treatment with intravitreal ranibizumab.
C
horoidal nevi are the most common benign intraocular tumors.1 They frequently appear as either a round or oval, flat, or minimally elevated brown-to-gray lesion with well-defined margins located primarily at the posterior pole. Secondary changes in the surrounding retina and retinal pigment epithelium consist of the development of drusen, orange pigment, and retinal pigment epithelium detachment. Occasionally, choroidal nevi may be complicated by choroidal neovascularization (CNV)2 and it could result in visual loss. When the location is extrafoveal, CNV can be treated with laser photocoagulation.2,3 Juxta- or subfoveal CNV secondary to choroidal nevi is a rare finding in which photodynamic ther-
Case Report A 71-year-old man presented for decreased vision and metamorphopsia in his right eye. He had no medical history. His bestcorrected visual acuity was 20/50 in the right eye and 20/20 in the left eye. Right eye fundus examination revealed a two disk diameter, slightly elevated, pigmented mass located at the posterior pole, corresponding to a macular nevus. There were drusen overlying the nevus. Fluorescein angiography showed a hyperfluorescence on the early phases with leakage on the late phases corresponding to a juxtafoveal classic CNV (Figure 1). Treatment options were discussed with the patient. After obtaining written informed consent, one injection of 0.05 mL/0.5 mg ranibizumab
The authors have no financial support or financial conflict of interest. Reprint requests: Salomon Yves Cohen, MD, Centre Ophtalmologique d’Imagerie et de Laser, Paris 75015, France; e-mail: [email protected]
412
RANIBIZUMAB FOR CNV IN CHOROIDAL NEVUS
413
Fig. 1. Color photograph (a) and fluorescein angiography (b) of the right eye of a 71year-old man showing a choroidal nevus complicated by a juxtafoveal classic choroidal neovascularization. Some hard and intermediate soft drusen were present.
was administered without complications. One month later, bestcorrected visual acuity improved to 20/32, fundus examination and fluorescein angiography revealed the CNV closure (Figure 2a). Optical coherence tomography showed absence of macular fluid. Two months later, best-corrected visual acuity improved to 20/25. No retreatment was needed. At the 7-month visit, optical coherence tomography and fundus photographies did not show any sign of recurrence. However, 9 months after the initial treatment, a recurrence of the CNV was observed (Figure 2b), and a second intravitreal injection of ranibizumab was performed.
Discussion Choroidal neovascularization is a rare complication of choroidal nevus. Juxta- and subfoveal CNV complicating choroidal nevi have been previously treated by photodynamic therapy. The first report showed closure of the CNV with final best-corrected visual acuity of 20/25 after a single photodynamic therapy session.4 However, a series of five patients, two cases
Fig. 2. Follow-up at 1 month (a) and 9 months (b). One month after intravitreal injection of ranibizumab, fluorescein angiography showed complete closure of the choroidal neovascularization (a). No additional treatment was performed. A recurrence was observed 9 months later (b) and led to a second injection.
with subfoveal CNV and three with juxtafoveal CNV, showed more variable outcomes. Best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of photodynamic therapy sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six.5 We report the case of a 71-year-old man in which we performed intravitreal ranibizumab injection. In this patient, one intravitreal ranibizumab stopped the neovascular process during 7 months with significant improvement of bestcorrected visual acuity. Ranibizumab seems to be an effective treatment for CNV secondary to choroidal nevus. However, long-term follow-up is needed because of the risk of recurrence of the CNV. Further studies and additional data are needed to establish the visual benefit of ranibizumab for CNV secondary to choroidal nevi.
RETINAL CASES & BRIEF REPORTSℜ
414
Key words: choroidal neovascularization, choroidal nevus, ranibizumab. References 1. 2.
3.
Shields JA, Shields CL. Intraocular Tumors: A Text and Atlas. Philadelphia: Saunders; 1992:85–100. Callanan DG, Lewis ML, Byrne SF, Gass JD. Choroidal neovascularization associated with choroidal nevi. Arch Ophthalmol 1993;111:789 –794. Waltman DD, Gitter KA, Yannuzzi L, Schatz H. Choroidal neovascularization associated with choroidal nevi. Am J Ophthalmol 1978;85:704 –710.
4.
5.
6.
7.
●
2009
●
VOLUME 3
●
NUMBER 4
Stanescu D, Wattenberg S, Cohen SY. Photodynamic therapy for choroidal neovascularization secondary to choroidal nevus. Am J Ophthalmol 2003;136:575–576. Parodi MB, Boscia F, Piermarocchi S, Ferrari TM, Furino C, Sborgia C. Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus. Retina 2005;25:438 – 442. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006;355:1419 –1431. Brown DM, Kaiser PK, Michels M, et al. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006;355:1432–1444.
