Sir,

We describe a case of a patient who developed a multifocal choroiditis complicated with a choroidal neovascular (CNV) membrane, and propose an intravitreal methotrexate therapy as a treatment option that can improve vision and eliminate all inflammatory signs.

Case report

A healthy 25-year-old woman presented with evidence of a multifocal choroiditis (MFC) complicated with a choroidal neovascular (CNV) membrane in the left eye (OS) for 2 weeks. Best-corrected visual acuity was 20/20 in both eyes. The anterior segment was quiet. Some yellowish-gray lesions were also present in the right eye.

Fluorescein angiography (FA) showed early hypofluorescence and late hyperfluorescence due to staining at the level of the lesions. Acute lesions on indocyanine green (ICG) angiography were hypofluorescent. Both revealed a CNV membrane in the OS. (Figures 1 and 2).

Figure 1
figure 1

FA before any treatment.

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Figure 2
figure 2

ICG angiography before any treatment.

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Sarcoidosis, tuberculosis, and presumed ocular histoplasmosis syndrome were excluded. Blood analysis excluded other infectious and inflammatory causes.

The patient received three intravitreal (IVT) injections of ranibizumab in the OS spaced 1 month apart. The CNV membrane disappeared, but 2 months later it reappeared and vision decreased to 20/80. Three additional injections were administered whereby vision stabilized at 20/63. FA was repeated. No leakage was present. However, the ICG showed small hypofluorescent spots within 3 DD of the lesion that suggested inflammatory activity in the choroid. (Figure 3).

Figure 3
figure 3

ICG angiography before MTX injection.

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We performed an IVT injection of 400 μg methotrexate (MTX) in 0.1 ml. Vision improved to 20/25 over 3 months. The vision remained stable with no flare up for over 20 months.

Comment

CNV occurs in up to one third of patients with MFC. Numerous therapies have been proposed, including thermal laser, subretinal surgery, PDT, local and systemic corticosteroids, anti-VEGF therapy, and immunosuppressive agents.1

IVT MTX, used as chemotherapy, is effective in inducing a clinical remission of intraocular tumor in primary central nervous system lymphoma.2 MTX has also been used in unilateral intermediate or posterior uveitis, and cystoid macular edema.3 Its anti-inflammatory effect is well known, but it can also decrease VEGF.4 For instance, Byun et al5 used topical and subconjunctival MTX for corneal neovascularization with good results. We achieved improved vision and no CNV membrane recurrence by administering IVT MTX. The absence of recurrence can be due to MTX’s dual mechanism of action: anti-inflammatory and anti-angiogenic. MTX should be considered as a treatment option for CNV membrane especially in cases with an inflammatory etiology.