Treatment and monitoring of choroidal neovascular membrane associated with optic disc drusen in paediatric patients
Author: Yun Lin Ang (United Kingdom)
Co-authors: Komala Vadivelu, Yevukai Jaya, Sanil Shah
Choroidal neovascular membrane (CNVM) is a rare but recognised complication seen with optic disc drusen (ODD). There is limited literature regarding treatment and monitoring of CNVM associated with ODD in paediatric patients. We report two cases of CNVM associated with ODD in paediatric patients seen in our department.
Department of Ophthalmology, Darlington Memorial Hospital, Darlington, United Kingdom
Retrospective review of the medical records of two clinical cases
15-year-old boy diagnosed with bilateral ODD with secondary CNVM in his left eye only. There was associated peripapillary leakage and haemorrhage without foveal involvement. Fluorescein angiography showed two CNVM and a small peripapillary haemorrhage in his left eye. Initial BCVA was 6/6 in right eye; 6/9 in left eye. Amsler grid monitoring, BCVA and macula remained stable over 34 weeks of follow-up without treatment. Second case is a girl with Down’s syndrome, left eye convergence excess esotropia and high hypermetropia. Diagnosed at age 13 with extrafoveal CNVM associated with ODD in left eye. Initial BCVA was 6/9 in right eye; 6/15 in left eye. Two years later, as left eye BCVA was 6/24 and she developed new collection of juxtafoveal intraretinal fluid, one intravitreal bevacizumab injection was given to left eye under general anaesthesia (GA). As she only showed modest response to this, one intravitreal aflibercept injection was given 8 weeks later. This reduced the intraretinal fluid considerably, leaving few parafoveal cysts. It was difficult to assess BCVA subjectively due to her Down’s syndrome so we also monitored her regularly with OCT macula. Further anti-VEGF treatment was offered but her parents deliberated over this due to concerns with GA risks.
Amsler grid can be a useful way for patients to self-monitor and seek help if they notice any changes but may not be suitable for patients with learning disabilities. Intravitreal anti-VEGF (Eylea in our experience) can be effective in treating CNVM associated with ODD. It was difficult to assess the BCVA in the second case due to her comorbidity. Nonetheless, her BCVA was assessed by the same, highly experienced orthoptist at every visit to ensure accuracy of her BCVA measurements. The aim of giving intravitreal anti-VEGF is to reduce the risks of long-term damage to the retinal pigment epithelium from persistent macular oedema caused by CNVM associated with ODD. We also had to balance the benefits of giving intravitreal anti-VEGF treatment against the risks of general anaesthesia in the second case. Parents or guardian of the paediatric patient need to be involved in the decision-making process.
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