Author: Raisa Vanessa Pineda Oliveros (Spain)
Co-authors: Alvaro Casado Blanco, Mireia Molina Perez, Beatriz Framiñán Aparicio, Adoración Alonso Santamaria
Purpose
To explain the outcomes of a combined therapy with an intravitreal antiangiogenic agent that blocks placental growth factor (PlGF) along with VEGF and laser photocoagulation in a young patient with poor response to monotherapy with focal laser.
Setting/Venue
Retina service, Department of Ophthalmology at Hospital Universitario de Salamanca (A public hospital located in Spain at the service of a 300.000 – 350.000 population).
Methods
The history, ocular and laboratory findings, management strategies, and treatment response of the patient were documented. Multimodal imaging monitorization and evaluation was performed over a 3-year follow-up. Bibliographic research and analysis of related cases.
Results
33-year-old male without systemic diseases was referred to our department with a 1-month history of visual acuity (VA) drop in the left eye. He had been first assessed, and unsuccessfully treated with 577 nm laser at another center. His VA was 1.0 in the right eye (OD) and 0.4 in the left eye (OS). Slit-lamp examination was normal in both eyes. Fundus examination of the OS revealed multiple micro and macro aneurysms, telangiectasias, lipid exudation and macular edema. Optical Coherence Tomography (OCT) of the macula showed severe cystic edema and subretinal fluid. Fluorescein angiography disclosed aneurysmal lesions and telangiectasias in the paracentral area with hypofluorescent blockage due to exudation and ischemic areas. Laboratory studies were negative. These findings were consistent with MacTel1. The patient underwent treatment with monthly Ranibizumab injections and 532 nm laser photocoagulation of ischemic areas with inconstant results and recurrences. Given the lack of response, we switched to monthly Aflibercept, blocking both VEGF and PIGF, which has been described in literature to better address this pathology, achieving a better control of the disease with excellent anatomic and clinical outcomes. On OCT angiography (OCT-A), macular superficial and deep capillary plexus were not affected during the follow up.
Conlusions
Multimodal imaging is crucial to rule out vascular, hematological diseases and other idiopathic entities and to monitor laser treatment. Laser photocoagulation remains the standard treatment for MacTel1 to control ischemia, exudation and improve visual acuity. Anti-VEGF are short acting agents, temporally increasing visual acuity and decreasing central retinal thickness. Combining both therapies contributes to a long-term clinical stabilization. 577 nm laser photocoagulation may not be sufficient to control macular edema in MacTel1, and 532 nm laser may yield better results in a single session pattern, without decreasing macular vascular capillary density in OCT-A. A better response in MacTel1 disorders may be obtained using anti-VEGF drugs that neutralizes both VEGF-A and PlGF.
Financial Disclosure
The authors declare no conflicts of interest.
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