Correspondence

Eye (2013) 27, 277–278; doi:10.1038/eye.2012.262; published online 7 December 2012

Intravitreal methotrexate for the treatment of choroidal neovascularization in multifocal choroiditis

A Mateo-Montoya1, E Baglivo2 and M D de Smet1

  1. 1Clinique de Montchoisi, Ophthalmology Service, Retina and Inflammation Unit, Chemin des Allinges 10, Lausanne, Switzerland
  2. 2Geneva University Hospital, Rue Alcide-Jentzer 22, Geneva, Switzerland

Correspondence: A Mateo-Montoya, E-mail: arancha.mateo@gmail.com

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.

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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 2.
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ICG angiography before any treatment.

Full figure and legend (222K)

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 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

ICG angiography before MTX injection.

Full figure and legend (50K)

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

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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.

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Conflict of interest

The authors declare no conflict of interest.

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References

  1. Fine HF, Zhitomirsky I, Freund KB, Barile GR, Shirkey BL, Samson CM et al. Bevacizumab (avastin) and ranibizumab (lucentis) for choroidal neovascularization in multifocal choroiditis. Retina 2009; 29(1): 8–12. | Article | PubMed |
  2. de Smet MD, Vancs VS, Kohler D, Solomon D, Chan CC. Intravitreal chemotherapy for the treatment of recurrent intraocular lymphoma. Br J Ophthalmol 1999; 83(4): 48–51. | Article |
  3. Taylor SR, Habot-Wilner Z, Pacheco P, Lightman SL. Intraocular methotrexate in the treatment of uveitis and uveitic cystoid macular edema. Ophthalmology 2009; 116(4): 797–801. | Article | PubMed |
  4. Park SK, Kim HI, Yang YI, Hur DY. Effects of methotrexate on vascular endothelial growth factor, angiopoietin 1, and angiopoietin 2 in nasal polyps. Am J Rhinol Allergy 2011; 25(4): e129–e132. | Article | PubMed |
  5. Byun YS, Chung SK. The effect of methotrexate on corneal neovascularization in rabbits. Cornea 2011; 30(4): 442–446. | Article | PubMed |