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   Table of Contents      
BRIEF REPORTS
Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 61-63

RPE Atrophy following Photodynamic Therapy in Type 2A Idiopathic Parafoveal Telangiectasis


Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India

Date of Submission17-Dec-2002
Date of Acceptance21-Dec-2003

Correspondence Address:
Mahesh P Shanmugam
Sankara Nethralaya, 18,College Road, Chennai - 600 006,Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.15289

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  Abstract 

We report a case of Type 2A idiopathic parafoveal telangiectasis treated by Photodynamic Therapy (PDT), resulting in retinal pigment epithelial (RPE) atrophy corresponding to the size of the laser spot used. This raises a doubt regarding the safety of photodynamic therapy in CNVM secondary to type 2A parafoveal telangiectasis.

Keywords: Parafoveal telangiectasis, PDT, RPE atrophy


How to cite this article:
Shanmugam MP, Agarwal M. RPE Atrophy following Photodynamic Therapy in Type 2A Idiopathic Parafoveal Telangiectasis. Indian J Ophthalmol 2005;53:61-3

How to cite this URL:
Shanmugam MP, Agarwal M. RPE Atrophy following Photodynamic Therapy in Type 2A Idiopathic Parafoveal Telangiectasis. Indian J Ophthalmol [serial online] 2005 [cited 2020 Nov 30];53:61-3. Available from: https://www.ijo.in/text.asp?2005/53/1/61/15289

Extrafoveal choroidal neovascular membranes (CNVM) complicating parafoveal telangiectasis (PFT) can be treated with laser photocoagulation. Recently photodynamic therapy has been used to treat subfoveal CNVM secondary to PFT.[1] Choroidal neovascular membranes complicating PFT may be particularly suitable for treatment with Photodynamic Therapy (PDT), as they are usually ′classic′ in nature.


  Case report Top


A 50-year-old male reported to us with a 6-month history of diminution and distortion of central vision both for distance and near in the left eye. The best corrected visual acuity in right eye was 6/6, N6 and fundus examination was suggestive of Type 2A parafoveal telangiectasis. The best corrected visual acuity in the left eye was 6/9+1, N10 and the fundus examination showed a subfoveal neovascular membrane with subretinal fluid, exudates and haemorrhage along with telangiectatic and right angled parafoveal vessels partially obscured by subretinal haemorrhage [Figure - 1]. Fundus fluorescein angiography of the right eye showed parafoveal telangiectatic vessels and the left eye showed a classic subfoveal CNVM with early hyperflourescence and leakage in the late phase [Figure - 2]. Considering the location of the CNVM and the good visual acuity of the left eye, PDT was suggested as a treatment modality for the patient. After obtaining the patient′s consent PDT was performed in the left eye, as outlined by the TAP Study report # 1.[2] The greatest linear diameter (GLD) of the CNVM was 3.62 mm and the laser spot diameter (LSD) used was 4.62 mm.

Three months following PDT in the left eye, the visual acuity in the right eye was 6/6, N6 and in the left eye was 6/12-2, N12. Fundus examination of the right eye showed no change and the left eye showed partially scarred CNVM with partly absorbed subretinal haemorrhage, persistent exudates and minimal subretinal fluid, along with evidence of RPE alterations [Figure - 3]. Fundus fluorescein angiography of the left eye showed persistence of activity at the nasal edge of the CNVM and a well circumscribed area of multiple window defects corresponding to the area of the laser spot used during the PDT [Figure - 4]. The patient was advised a second sitting of PDT, which he refused.

Five months later he had a best corrected visual acuity of 6/6, N6 in his right eye and 6/18+1, N18 vision in his left eye. Fundus examination of the left eye showed parafoveal telangiectatic vessels with a well circumscribed subretinal glial nodule just involving the fovea with decreased subretinal exudates and haemorrhage, minimal subretinal fluid with a high water mark, along with a well circumscribed area of retinal pigment epithelium atrophy exactly corresponding to the size of the laser spot used.


  Discussion Top


Photodynamic therapy with verteporfin is found to be highly effective for the treatment of classic and occult CNVM secondary to age related macular degeneration,[2],[3] myopia4 and PFT. Treatment of subretinal CNVM in idiopathic PFT by laser photocoagulation and surgery has been generally unsuccessful, with poor post-treatment visual outcome. The CNVM showed partial regression after a session of PDT. However, a large area of diffuse RPE atrophy corresponding to the size of the laser spot appears to have had a deleterious effect on the visual recovery of the patient. The chief advantage of PDT is the selectivity it offers. The RPE atrophy noted by us might indicate that verteporfin may persist in the RPE cells and choriocapillaris even 15 minutes after infusion, leading to the laser-induced damage seen in our patient.

Another reason could be that the TAP and VIP studies were performed on Caucasians in whom the lightly pigmented fundus may not be susceptible to the light-induced damage seen in the Asian Indian eyes. However, we have not seen such RPE atrophy commonly in other Asian Indian patients who have had PDT for age-related macular degeneration.

PFT patients are relatively young with a healthy RPE. A correlation of factors such as the pigmented RPE in a young patient or persistence of verteporfin dye in the healthy RPE cells may have been the cause of this RPE atrophy. Gass et al [5] and Slakter et al,[6] have suggested that the absence of pigment epithelial detachment and the limited size of the neovascular complexes indicates that the retinal rather than the choroidal vasculature is the primary source of the new vessels in PFT, a true retinochoroidal anastomosis could exist and leakage of verteporfin from the abnormal macular vessels may lead to RPE atrophy following PDT in CNVM due to PFT.

A mention of similar post-PDT RPE atrophy changes has been made by Schnurrbusch et al on histopathological examination of an excised CNVM due to age-related macular degeneration,[7] and also following PDT for myopic CNVM,[4] and post inflammatory CNVM secondary to Vogt-Koyanagi-Harada Syndrome.[8]

This signifies the fact that PDT does not spare the RPE completely and that PDT has to be performed with great caution in subfoveal CNVM due to PFT.



 
  References Top

1.
Potter MJ, Szabo SM, Morris AHC. Photodynamic Photodynamic therapy of a subretinal neovascular membrane in type2A idiopathic juxtafoveolar retinal telangiectasis. Am J Ophthalmol 2002;133:149-51.  Back to cited text no. 1
    
2.
Treatment of Age-related Macular Degeneration by Photodynamic therapy (TAP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in age related macular degeneration with verteporfin. Arch Ophthalmol 1999;117:1329-45.  Back to cited text no. 2
    
3.
Verteporfin Therapy of Subfoveal Choroidal Neovascularization in Age-related Macular Degeneration: Two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization: Verteporfin In Photodynamic Therapy Report No. 2. Am J Ophthalmol 2001;131:541-60.  Back to cited text no. 3
    
4.
Photodynamic Therapy of Subfoveal Choroidal Neovascu-larization in Pathologic Myopia with Verteporfin:1-Year Results of a Randomized Clinical Trial-VIP Report No.1. Ophthalmology 2001;108:841-52.   Back to cited text no. 4
    
5.
Gass TDM, Block BA. Idiopathic juxtafoveolar retianl telangiecatsis. Update of classification and follow up study. Ophthalmology 1993;100:1536-46.  Back to cited text no. 5
    
6.
Slakter JS, Yannuzzii LA, Schneider U, Sorenson JA, Ciardella A, Guyer DR et al. Retinal Choroidal Anastomoses and Occult Choroidal Neovascularization in Age-Related Macular Degeneration. Ophthalmology 2000;107:742-54.  Back to cited text no. 6
    
7.
Schnurrbusch UEK, Welt K, Horn LC, Wiededemann P, Wolf S. Histopathological findings of surgically excised choroidal neovascular membranes after photodynamic therapy. Br J Ophthalmol 2001;85:1086-91.  Back to cited text no. 7
    
8.
Farah ME, Costa A, Muccioli C, Guia TA, Belfort R. Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization in Vogt-Koyanagi-Harada syndrome. Am J Ophthalmol 2002;134:137-39.  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


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