Neri_edit_Cardiology_book_temp 25/01/2010 13:56 Page 96
Posterior Segment
Figure 3: Active Punctate Inner Choroidopathy
All of the methods proposed present the results as safe and effective,
Showing Multiple Macular Spots and an Active but it is not clear which one could offer the most advantages. There
Juxta-foveal Choroidal Neovascularisation (arrow)
are no randomised controlled trial data available directly comparing
that Was Treated with Systemic Steroids and
Mycophenolate Mofetil
different techniques. In addition, no trials have been carried out on
CNVs secondary to specific uveitis entities.
The rationale for combined therapy lies in the pathophysiology of the
inflammatory CNV itself. Indeed, the association of medical treatment
with other methods offers control of both the triggering factor of
inflammation and the neovascular process.
Several techniques have been proposed for the management of
CNVs, such as laser photocoagulation,
67
periocular and systemic
steroids,
68
PDT,
69,70
immunesuppression
55
and surgical removal.
71
The
use of systemic steroids should be considered mandatory, as
the inflammatory process is not only loco-regional, but there is also
evidence of involvement of the whole immune system.
72
As reported above, the safety and efficacy of immunosuppression
55
for
the control of new choroidal vessels in uveitis have been described.
The choice of immunosuppressant should be established on the basis
of the characteristics of the drug itself. Some immunosuppressive
drugs, such as cyclosporin A,
73
tacrolimus and sirolimus,
74
are known to
Figure 4: Two Months Later, the Membrane Showed No
produce nephrotoxicity. This nephrotoxicity induces over-expression of
Leakage, Surrounded by an Evident Hypofluorescent
Ring (arrow); The Patient Was on Only Oral
soluble mediators that have an important role in CNV pathogenesis.
75
Mycophenolate Mofetil at that Time
The steroid-sparing drug that is gaining consideration in this area
is mycophenolate mofetil. It is effective in reducing such
biomechanisms,
76
improving arteriolopathy and decreasing the
amount of soluble mediators involved in CNV pathophysiology. For
such reasons, mycophenolate mofetil is a promising drug for the long-
term control of inflammatory CNV
77
(see Figures 3 and 4).
When PDT was introduced, laser treatment changed, limiting argon
laser photocoagulation to extrafoveal neovascular membranes. This
reduced the risk of iatrogenic damage. PDT has been used following
various strategies: some patients have been treated electively with
medical therapy and PDT,
69
while others have received PDT when they
have not achieved control of CNV with other treatments.
70
At this time,
PDT has only a marginal role and the new anti-VEGF drugs have a
prominent position in the management of inflammatory CNV.
78
The same considerations can be made for surgical removal of CNV:
after the introduction of intravitreal anti-VEGF drugs,
78
surgery is
indicated only for extensive peri-papillary membranes,
79
albeit
inflammation in the pathophysiology of idiopathic CNV has been previously this technique was reported to be safe and effective.
71
postulated on the basis of ICGA.
64
It is further supported by the
preceding publications, which have shown CNV as a possible sequela.
4
Although there are no direct comparisons between different
The supposed role of inflammation in idiopathic CNV is important for the treatments, the rationale may suggest medical treatment as the first
treatment strategy. More than in other CNVs, idiopathic CNV should be choice for juxta/sub-foveal CNV. When this fails in controlling the CNV
treated as an inflammatory neovascularisation
65
(see Figures 1 and 2). activity, anti-VEGF intravitreal drugs should be considered, with or
without PDT.
The strategy for the management of non-infectious inflammatory CNV
is changing, albeit the core of the treatment is still based on control Discussion
of the triggering inflammation. The histopathological features, Uveitic CNV is a rare but severe complication of uveitis. In most cases
pathophysiology and preliminary results of some studies suggest a the clinical findings obtained by FA, ICGA and OCT allow clinicians to
relatively unique method for management.
66
accurately determine the characteristics of the CNV.
As there are no guidelines for the management of inflammatory In the case of active inflammation, an infectious disease should be
CNVs, there is no flow-chart that can be followed for their treatment. looked for and a suitable therapy offered when available.
96 EUROPEAN OPHTHALMIC REVIEW
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