zografos anti veg fs in ocular oncology

Leonidas ZografosLausanne

Anti-VEGFs in Ocular Oncology

4th Thessaloniki International Vitreo-Retinal Summer School, 16-21. 6.2014, Electra Palace

Intravitreal anti-VEGF in ocular oncology

• Impact in the progression of uveal melanomas• Treatment of choroidal metastasis• Treatment of vascular and pediatric tumors• Treatment on CNV associated to

- choroidal nevi- choroidal osteomas

• Treatment and prevention of irradiation induced complications- Treatment of irradiation induced optic neuropathy- Treatment of retinopathy and maculopathy- Treatment of neovascular glaucoma- Prevention of neovascular glaucoma- Treatment of secondary retinal detachment

Choroidal metastasesAnti-VEGF treatment

N. of publications 10

N. of cases 11

Systemic

chemotherapy 5 / 11 c.

Obs. period 1 – 6 m.

Local tumor control 11 / 11 c.

F. 44 y.Breast cancer + metastasesVis. Ac. 1.0

1 IV Avastin

4.2013 Vis. Ac. 1.0 6.2013 Vis. Ac. 1.0

Treatment of vascular and pediatric tumorsCoat’s deseases

Courtesy F. Munier, MD

Ranibizumab 2 iv inj.

Treatment of vascular and pediatric tumorsCoat’s deseases

Choroidal nevus + CNVLaser treatment

Vis. Ac. 0.3

Choroidal nevus + CNVLaser treatment

Vis. Ac. 1.0

Ac. Vis. 0.5

Naevus + CNV

Période d’obs. 12 mois9 inj. Avastin

Ac. Vis. 0.2 Trithérapie Ac. Vis. 0.3

Observation period 3 years

Distance tumor – optic disc 2.7 mm

Uveal melanoma proton beam radiotherapy

Irradiation inducedOptic Neuropathy

Uveal melanoma proton beam radiotherapy

Obs. period. 2 years / 3 years

Radiation retinopathy

Irradiation induced maculopathy

Radiation retinopathy

External beam radiation Dose 30Gy

Vis. Ac. = 0.3 Avastin 3x

3 months Vis. Ac. = 0.9

Uveal melanomaProton beam radiotherapyIrrad. Dose 60 Gy

Vis. Ac. = 0.001 Bevacizumab 6x

Irradiation induced maculopathy

Obs. period 18 m Vis. Ac. = 0.001

Iris neovascularisationanti-VEGF treatment

Number of cases : 69

Delay proton beam irradiation iris neovascularisation :

0,5 - 6 years (Mean 1,9 year)

Medical treatment glaucoma : 42 c. 61%

Visual acuity < 0,1 –55 cases 80%0,1-0,6 – 14 cases 20%

Iris Ischemia

F.A. Classification ofiris neovascularisation

Vascular tortuosityPresent – 62 cases 90%Absent – 7 cases 10%

F.A. Classification ofiris neovascularisation

Iris ischemiaPresent – 44 cases 64%Absent – 25 cases 36%

Pupillary- 18 c. 26%

Sectorial- 11 c. 16%

F.A. Classification of iris neovascularisation

Tufts- 10 c. 15%

Diffuse- 30 c. 43%

F.A. Classification of iris neovascularisation

F.A. Classification of iris neovascularisationDiffusion of the dye

+ 31 cases 45%

++ 38 cases 55%

Number of treatments- 1 injection 14 c. 20%- 2 injections 25 c. 36%- 3 – 6 inj. 30 c. 44%

Laser coagulation 32 c. 46%

Metastatic death 0 c.

Local recurrence 0 c.

Intraocular pressure< 20 mmHg 53 c. 84%24-52 mmHg 10 c. 16%

Iris neovascularisation Anti-VEGF treatment

Observation period :6 months – 3 years 63 cases

Enucleation 3 c. 4%

Glaucoma tube 3 c. 4%

Regression of tortuosity

43/56 cases 77%

Iris neovascularisation – anti-VEGF treatment

Regression of iris neovascularisation

43/63 cases 68%


Reduction of the diffusion of the dye

42/63 cases 67%


Regression of iris neovascularisation

Pupillary 13/18 c. 72%

Sectorial 5/9 c. 55%

Tufts 6/10 c. 60%

Diffuse 17/26 c. 65%

Final Intraocular Pressure < 21 mmHg

Pupillary 17/18 c. 94%

Sectorial 5/9 c. 56%

Tufts 9/10 c. 90%

Diffuse 20/26 c. 77%

Vascular Remodelling 12/38 c. 32%

9.2007 26 mmHg 1.2008 14 mmHg 3.2009 17 mmHg

Vascular maturation > 2.5 years f. up 4/8 cases

6.2007 24 mmHg 8.2010 14 mmHg

Proton beam irradiationNeovascular glaucomaRisk factors

Age 0.1110

LTD 0.0534

Height 0.0000

Dist. disc 0.0000

Dist. macula 0.4201

Iris invasion 0.6238

Exteriorization 0.5143

Hemorrhage 0.1716

Inflamm. ant. ch. 0.3282

Retinal detach. 0.0000

N. Cases: 554 cRetinal ischemia 115 cEnucleation 23 cNo treatm. Meta. 1 cProton beam 91 c

150° F. Angiography

Retinal ischemia

LTD≤ 15mm 13%16-20mm 26%≥ 21mm 26%

Retinal ischemia

Height

≤ 5mm 9%5,1-8mm 15%≥ 8,1mm 33%

Retinal detachment< 1 quadr.

1 quadr. 10%2 quadr. 21%

> 3 quadr. 52%

Retinal ischemia

Retinal ischemia 91c.[ - ] Anti-VEGF 62c.[ +] Anti-VEGF 29c

Anti-VEGF treatment6 months 1 inj/2 m.

1 inj/3 m.Laser coagulation of ischemic retina

Therapeutic protocol

Lost to follow-up 19 c.Death ~ metastases 1 c.Treat. interrupted 1 c.

Neovascular GlaucomaObs. period 2 years 70 cases

F. 58 years

10.2011 H = 6.2 mm

04.2012 H = 5.4 mmPatient refused further treatment

10.2012 H = 4.8 mm

Proton beam irrad. + Anti-VEGF treatment

[ - ] Anti-VEGF 62c.[ +] Anti-VEGF 29c.

P=0.02

05.2011

11.2011

Proton beam +Anti-VEGF


Initial panoramic 150°fluorescein angiography


Observation period 1 year

Conclusions

Intraocular injection of anti-VEGF drugs in selected cases is a promising therapeutic approche for the treatment of irradiation complications following conservative management of uveal melanomas

zografos anti veg fs in ocular oncology

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