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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 15

Use of the dexamethasone implant as an adjunct in the treatment of Coats disease in a pediatric patient


1 Instituto de Oftalmología y Glaucoma Vásquez, Quito, Retina Division, Ecuador
2 Pediatric Ophthalmology and Strabismus Department, Centro Medico Axxis, Quito, Ecuador
3 General Ophthalmology, Centro Médico Vista Integral, Quito, Ecuador

Date of Submission08-Dec-2021
Date of Acceptance05-Jan-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Salcedo Hugo Ricardo
Jardines del Batán, Edificio Semirabad, Quito
Ecuador
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_125_21

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  Abstract 


To report the use of intravitreal dexamethasone implant and its short-term efficacy in a pediatric patient with Coats' disease. A 7-year-old patient was referred to the clinic because of decreased visual acuity in the right eye of 10-month duration. Best-corrected visual acuity was 20/400. Funduscopic examination showed evidence of Stage 2B Coats' disease. The patient underwent treatment with laser photocoagulation, intravitreal injection of bevacizumab, and intravitreal injection of dexamethasone implant. During the 10-month follow-up, there was no evidence of side effects. Anatomical resolution was evident on funduscopic examination and macular optical coherence tomography, with best-corrected visual acuity being 20/60. Intravitreal dexamethasone implant was effective during the 10-month follow-up; providing improvement in visual acuity without any side effects.

Keywords: Coats' disease, intravitreal dexamethasone implant, Ozurdex


How to cite this article:
Ricardo SH, Fitha M V, Mariana LE. Use of the dexamethasone implant as an adjunct in the treatment of Coats disease in a pediatric patient. Pan Am J Ophthalmol 2022;4:15

How to cite this URL:
Ricardo SH, Fitha M V, Mariana LE. Use of the dexamethasone implant as an adjunct in the treatment of Coats disease in a pediatric patient. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 May 25];4:15. Available from: https://www.thepajo.org/text.asp?2022/4/1/15/340385




  Introduction Top


Coats´ disease is defined as a unilateral idiopathic telangiectatic neovascular disease with intraretinal and/or subretinal exudation.[1] The pathogenesis of the disease includes the breakdown of the blood–retinal barrier. The weakening of the retinal vessel walls leads to an exudative retinal detachment.[2]

The inflammatory component underlying the disease,[3] with corticosteroids, can be considered as they reduce intraocular inflammation, in addition to their anti-VEGF properties.[4]

We present a case in which intravitreal injection of the dexamethasone implant was combined with laser photocoagulation and intravitreal injection of bevacizumab to treat a pediatric patient with Stage 2B Coats´ disease.


  Case Report Top


A7-year-old patient was referred to the clinic because of decreased visual acuity in the right eye of 10-month duration. The patient's guardian does not refer any prior use of corrective lenses. Best-corrected visual acuity was 20/400 in both eyes. The manifest refraction was −4.40 + 3.00 × 105 for the right eye and −5.00 + 2.00 × 105 in the left eye without improvement. Anterior segment was unremarkable. Intraocular pressures were 12 mmHg in both eyes. Funduscopic examination of the right eye showed evidence of avascular peripheral temporal retina, peripheral telangiectasias, and important foveal and extrafoveal exudates [Figure 1]a. Funduscopic examination of the left eye was unremarkable. Macular optical coherence tomography (OCT) of the right eye demonstrated abundant intraretinal hard exudates [Figure 2]a. Based on the clinical findings, we classified Coats' disease as Stage 2B.
Figure 1: (a) Fundus photo with important foveal and extrafoveal exudates, (b) 10-month follow--up with marked reduction of macular exudates

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Figure 2: (a) Macular optical coherence tomography with thick hyperreflective layer corresponding to hard exudates, (b) 10-month follow-up with reduction of macular exudates

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Alternate eye patching was prescribed with continuous use of corrective lenses. Prior informed consent, the patient underwent general anesthesia for laser photocoagulation, intravitreal injection of bevacizumab (2.5 mg/0.1 mL), and intravitreal injection of dexamethasone implant (Ozurdex).

At 1-month follow-up, the patient improved visual acuity to 20/70 with correction, intraocular pressures were maintained at 12 mmHg with reduction of macular exudates.

Due to the global pandemic and traveling restrictions, the patient could not return for follow-up evaluations, but was being controlled by the local ophthalmologist. Findings were unremarkable during this period.

The patient was re-evaluated at 10-month posttreatment with best-corrected visual acuity of 20/60, intraocular pressure of 11 mmHg, and a clear lens. Funduscopic examination of the right eye demonstrated a significant reduction of macular exudates [Figure 1]b which correlates with the macular OCT findings [Figure 2]b.


  Discussion Top


The main goal of treatment in patients with Coats' disease is to eradicate all abnormal vasculature alongside areas of nonperfusion allowing resolution of intraretinal and subretinal exudation to preserve vision.[5] Historically, the main treatments included repetitive laser photocoagulation in nonperfusion areas, cryotherapy in retinal telangiectasias, and surgical intervention for retinal detachment.[6]

New treatment options have drastically changed to preserve visual acuity in our patients. The dexamethasone intravitreal implant (0.7 mg DEX Implant, Ozurdex; Allergan, Inc., Irvine, Calif.) is a biodegradable injectable implant that provides a sustained release of the pharmacological agent into the vitreous cavity. It consists of two distinct pharmacokinetic phases; an early high dexamethasone concentration peaking at 2 months after administration, followed by a low concentration sustained release up to 6 months.[7]

Although rare (a reported incidence of 0.09%–0.87%), intravitreal injections may be associated with numerous complications that require immediate treatment. The two most common complications related to intravitreal steroid injections are raised intraocular pressure and the development of cataracts.[8]

We believe the dexamethasone implant has a role in the therapeutic options for our pediatric patients; but we have to balance risk/benefits of said treatment (less frequent injections, financial burden, use of general anesthesia, etc.) versus the possible side effects (ocular hypertension and cataract formation) and be prepared to manage them.


  Conclusions Top


This case report exemplifies the use of dexamethasone intravitreal implant as a treatment option for pediatric patients with Coats' disease; demonstrating a resolution of the pathological changes without reporting side effects during the 10 month follow-up.

Patient consent

Consent was obtained from the patient before the study and publication of the case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sen M, Shields CL, Honavar SG, Shields JA. Coats disease: An overview of classification, management and outcomes. Indian J Ophthalmol 2019;67:763-71.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Martínez-Castillo S, Gallego-Pinazo R, Dolz-Marco R, Marín-Lambíes C, Díaz-Llopis M. Adult coats' disease successfully managed with the dexamethasone intravitreal implant (ozurdex®) combined with retinal photocoagulation. Case Rep Ophthalmol 2012;3:123-7.  Back to cited text no. 2
    
3.
Lim WK, Nussenblatt RB, Chan CC. Immunopathologic features of inflammatory coats disease. Arch Ophthalmol 2005;123:279-81.  Back to cited text no. 3
    
4.
Villegas VM, Gold AS, Berrocal AM, Murray TG. Advanced Coats' disease treated with intravitreal bevacizumab combined with laser vascular ablation. Clin Ophthalmol 2014;8:973-6.  Back to cited text no. 4
    
5.
Saatci AO, Doruk HC, Yaman A. Intravitreal dexamethasone implant (ozurdex) in coats' disease. Case Rep Ophthalmol 2013;4:122-8.  Back to cited text no. 5
    
6.
Adeniran JF, Duff SM, Mimouni M, Lambert N, Ramasubramanian A. Treatment of Coats' disease: An analysis of pooled results. Int J Ophthalmol 2019;12:668-74.  Back to cited text no. 6
    
7.
Lei S, Lam WC. Efficacy and safety of dexamethasone intravitreal implant for refractory macular edema in children. Can J Ophthalmol 2015;50:236-41.  Back to cited text no. 7
    
8.
Fung AT, Tran T, Lim LL, Samarawickrama C, Arnold J, Gillies M, et al. Local delivery of corticosteroids in clinical ophthalmology: A review. Clin Exp Ophthalmol 2020;48:366-401.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 1], [Figure 2]



 

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