Choroidal rupture is a common complication of compressive and contusive injuries of the eye. Gass and others have described the development of Choroidal Neovascular Membrane (CNVM) arising from foci of choroidal rupture from 1 month to 4 years after injury. This usually is a type II (pre-RPE) neovascularisation and often produces a pigment halo at the site of ingrowth of the vessels into the subretinal space.1 Although the natural history of choroidal neovascularisation complicating choroidal rupture is unknown, there is probably a role for laser photocoagulation of an angiographically demonstrable lesion in juxtafoveal and extrafoveal CNVM.2 Gross et al have reported 6/9 or better vision in three patients following surgical excision of posttraumatic subfoveal CNVM.3
Recent randomised clinical trials have demonstrated photodynamic therapy (PDT) with verteporfin to be highly effective in treating CNVM due to age-related macular degeneration (AMD), particularly type II CNVM.4 PDT has also been described to treat CNVM due to myopia, presumed ocular histoplasmosis syndrome and angioid streaks.5 A MEDLINE search failed to reveal any report of PDT being used to treat posttraumatic CNVM. We report the first case of posttraumatic CNVM treated with PDT.
A 45-year-old male presented with a history of distorted central vision of 2 weeks duration noticed following cataract surgery. His past history was significant for diagnosis of choroidal rupture following shuttlecock injury 2 years earlier. The diagnosis of choroidal rupture was made by his referring ophthalmologist. He had had cataract surgery in both the eyes 2 weeks before the presentation. His best-corrected visual acuity (BCVA) with +0.75 DS, was 6/60, N 12 with near vision add of +3.00 DS in the right eye and -3.00 DS 3/60, N 12 with near vision add of +3.00 DS in the left eye. Both eyes were pseudophakic with normal anterior segment. The left eye revealed a well defined, subfoveal CNVM 1 disc diameter in size surrounded by a cuff of subretinal haemorrhage and subretinal fluid [Figure 1a]. Fundus fluorescein angiography (FFA) revealed subfoveal classic CNVM [Figure 1b]. Considering that the affected eye was the better eye of the patient, and the location of the CNVM, we favoured PDT over surgical excision and the same was done as per the TAP study protocol.4 The size of the lesion prior to PDT was 3.28 mm. Informed consent was obtained from the patient prior to treatment.
Three months after treatment, the patient′s BCVA improved to 6/36 (N6 with low vision aids). The CNVM appeared fibrosed with no subretinal fluid or haemorrhage, with absorbing exudates and pigmentation around the fovea [Figure 2a]. FFA revealed staining of the lesion with no leakage [Figure 2b]. At 5 months post- PDT, his BCVA was maintained at 6/36, N6, with inactive CNVM and subretinal scar with a few retinal pigment epithelial alterations.
The patient was reviewed 17 months after treatment with a visual acuity of 3/36, N12. Fundus examination showed cicatricial scar and no extension of the CNVM. The patient had sustained head injury to the left temporal aspect of the head in a road traffic accident since his last visit following which he had developed a left frontoparietal subdural haematoma (drained surgically) and right hemiparesis. Pallor was seen, involving the temporal part of the optic nerve head with right homonymous hemianopia on Humphrey Visual Field SITASTD 30-2 test, causing further decrease in vision.
Though submacular surgery has been described for posttraumatic CNVM, the risks of severe ocular and systemic morbidity associated with it must be recognised. PDT is particularly useful in treating classic CNVM and posttraumatic subfoveal CNVM being classic in nature, PDT may be suited to treat these patients. The obvious disadvantage being, the cost of the treatment and the need for multiple treatment sessions. In our patient regression of CNVM and improvement of BCVA from 3/60 to 6/36 was seen after a single treatment with verteporfin. Larger studies with long term follow-up will be necessary before wider usage of PDT for posttraumatic CNVM can be recommended.
1. Gass JDM Stereoscopic atlas of macular diseases: Diagnosis and treatment. 1987 St Louis CV Mosby
2. Fuller B, Gitter KA. Traumatic choroidal rupture with late serous detachment of the macula: Report of successful argon laser treatment Arch Ophthalmol. 1973;89:354–5
3. Gross JG, King LP, de Juan E, Powers T. Subfoveal CNVM removal in patients with traumatic choroidal rupture Ophthalmol. 1996;103:579–85
4. Bressler NM. Treatment of Age-Related Macular Degeneration with Photodynamic therapy (TAP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: Two-year results of 2 randomized clinical trials-tap report 2 Arch Ophthalmol. 2001;119:198–20
5. Sickenberg M, Scmidt-Erfurth U, Miller JW, Pournas CJ, Zografos L, Piguet B, et al A preliminary study of PDT using verteporfin for CNV in pathologic myopia, ocular histoplasmosis syndrome, angiod streaks, and idiopathic causes Arch Ophthalmol. 2000;118:327–36
Proprietary Interest: None