Author: Marco Mazzola (Italy)
Co-authors: Mariella Scalfati, Antonio Cantatore, Giulia Caminiti, Mattia Passilongo, Federica Romanelli
Purpose
To describe the long-term follow-up of a patient with exudative perifoveal vascular anomalous complex (ePVAC) successfully treated with subthreshold focal laser photocoagulation.
Setting/Venue
Multizone Unit of Ophthalmology of the Autonomous Province of Trento, Trento, Italy.
Methods
Case report. Full ophthalmic examination (best corrected visual acuity (BCVA) and intraocular pressure (IOP) measurement, slit lamp (SLE) and fundus examination) and multimodal imaging were performed at baseline and over a 29-month follow-up period. Spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), near infrared (NIR) and blue autofluorescence (BAF) images were obtained with Spectralis HRA OCT (Heidelberg Engineering, Heidelberg, Germany). Nine spots of subthreshold focal laser photocoagulation (90 mW, 50 μm, 200 ms, using lens with no amplification factor) were performed in one laser session 10 months after diagnosis.
Results
A 79 year-old woman was referred to our Retina Service for evaluation of macular hemorrhages in the right eye (RE). The patient was in good general health with no significant medical or ophthalmological history. BCVA was 20/50 in the RE and 20/40 in the left eye (LE). SLE showed a corticonuclear cataract in both eyes (OU). IOP was 14 mmHg OU. Fundus examination showed an isolated perifoveal aneurysmal lesion accompanied by small hemorrhages in the RE and a small drusen in the LE. SD-OCT revealed cystoid macular edema secondary to a round hyperreflective lesion with hyporeflective lumen in the RE. FA demonstrated a well-defined hyperfluorescent lesion with late pooling of the dye in the intraretinal cystoid spaces in the RE. As the patient was asymptomatic, the lesion was initially followed. Cataract surgery was performed and BCVA improved to 20/32. However, fluid progressively increased and therefore subthreshold focal laser was performed 10 months after diagnosis. One month after focal laser, the intraretinal fluid almost completely reabsorbed. 8 months after focal laser the edema completely disappeared, PVAC lesion shrank and was no more visible on FA. 19 months after focal laser, BCVA remained stable at 20/32 with no recurrence of intraretinal fluid.
Conlusions
First reported in 2011 by Querques et al., perifoveal exudative vascular anomalous complex (PEVAC) has been described as isolated large perifoveal aneurysm, in the absence of retinal vascular or inflammatory diseases. Sacconi et al. recently described the pre-exudative stage of PEVAC and proposed to change the original acronym for the exudative lesion from PEVAC to ePVAC. The pathogenesis of this disease remains unclear, and ePVAC lesions appear to be unresponsive to intravitreal anti-VEGF and corticosteroid treatment. Focal thermal laser photocoagulation, which is an effective treatment for macular edema associated with microaneurysms in other contexts, was also effective for the larger PVAC aneurysmal lesion in our case. Our goal was to heat and coagulate the content and the wall of the aneurysmal lesion and induce a post thermal injury remodelling, with occlusion of the aneurysm, extended control of the exudation and as minimal perilesional injury as possible. After a single session of subthreshold laser, the core of the perifoveal aneurysm lesion shrank, with BCVA stabilization and sustained (>19 months) resolution of the intraretinal exudation. However, further studies are needed to better understand the nature of this clinical entity and to confirm the use of this laser technique as first therapeutic option.
Financial Disclosure
Authors have no financial conflicts of interest to disclose.
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