Author: Fiona Mason (United Kingdom)
Co-authors: Romi Chhabra, Sasa Pockar, Chiara Giuffre, Laura Steeples
Purpose
To describe the use and clinical outcomes of fluocinolone acetonide intravitreal implant (FAc)( 0.19m, 0.2mcg/day; ILUVIEN®, Alimera Sciences, UK ) in punctate inner choroidopathy (PIC). PIC is a rare ocular inflammatory disease that predominantly affects young myopic women. The condition and course are variable and can cause severe bilateral vision loss directly as a result of inflammatory lesions or secondary to choroidal neovascular (CNV). Multimodal imaging has significantly enhanced the detection and monitoring of the condition. There is a lack of evidence for systemic corticosteroid, immunomodulatory therapy (IMT) and local steroid therapy in PIC and treatment can be challenging. Relapses and secondary CNV often necessitate corticosteroid rescue therapy with anti-vascular endothelial growth factor (anti-VEGF) therapy for CNV.
Setting/Venue
Manchester Royal Eye Hospital Uveitis Service.
Methods
We describe the clinical history, treatment course and long-term follow up of two myopic, female Caucasian patients with PIC. Both patients received ILUVIEN therapy (unilateral in one and bilateral in the second) for symptomatic PIC, which was associated with active inflammatory lesions. We present multimodal imaging findings, including swept source and enhanced depth imaging optical coherence tomography (OCT), OCT- angiography (OCTA), fluorescein angiography and ultra-widefield fundus autofluorescence (FAF), from baseline (FAc) implantation and during follow-up.
Results
Both patients had a history of side effects from multiple courses of systemic corticosteroid and IMT and were keen to reduce systemic treatment. Patient A, a 39 year-old female with bilateral PIC and CNV. She received multiple courses of systemic corticosteroid, intravitreal anti-VEGF (x6) and bilateral intravitreal dexamethasone implant (Ozurdex®, Allergan) during her 8-year follow-up. She was on oral prednisolone 10mg daily, mycophenolate mofetil 1.5g orally twice daily and subcutaneous adalimumab 40mg two-weekly. She had refractory disease with four reactivations of new PIC lesions and areas of increased signal of autofluorescence. She underwent bilateral, non-simultaneous ILUVIEN 5-months apart. Patient B, 31 year-old female with unilateral PIC. She had been treated, over a 6-year period, with systemic steroids, mycophenolate mofetil, anti-VEGF (x 4), intravitreal preservative-free triamcinolone (x3) (Triesence®, Alcon) and photodynamic therapy (PDT). She reported temporary control of symptoms (photopsia/shimmering) and demonstrated stability on imaging with intravitreal triamcinolone, but relapsed after the treatment duration ended (around 4-6 months). She was intolerant to systemic steroids/IMT and was keen to continue with local treatment and underwent unilateral ILUVIEN. We present between 6-12 month outcomes for both, demonstrating stability in visual acuity and multimodal imaging, reduced systemic treatment burden and report the patient perspectives.
Conlusions
PIC is a sight-threatening condition and treatment must be personalised to individual patient circumstances, disease severity and course, complications, laterality and risk of progression. Local therapy may be preferred, particularly in women planning pregnancy and if intolerant to systemic therapy. Long-acting intravitreal steroid achieved stability in these patients and permitted a reduction of systemic treatment burden. Further studies to evaluate FAc implants in PIC are necessary.
Financial Disclosure
None
Comments
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