Intravitreal pegabtanib sodium in choroidal neovascularization secondary to angioid streaks

Editor, Angioid streaks are irregular, greyish lines that surround the optic disc and extend radially outwards. They are associated with different disorders, the most frequent being pseudoxanthoma elasticum or Grönblad−Strandberg syndrome. In a large proportion of cases, they are associated with choroidal neovascularization (CNV). The treatment most frequently employed for CNV is photodynamic therapy (PDT). However, the current use of antiangiogenic agents for CNV secondary to age-related macular degeneration (AMD) opens a new avenue to treatment for patients affected by CNV secondary to other disorders. Texeira et al. (2006) reported a case of CNV-associated angioid streaks treated with bevacizumab with very good results. We report a case of subfoveal CNV-associated angioid streaks treated with intravitreal pegabtanib sodium. A 41-year-old man presented with a sudden decrease in visual acuity (VA) in the left eye. His best corrected VA was 45 letters (ETDRS). In direct ophthalmoscopy, angioid streaks were observed in both eyes and a lesion suspected of being a neovascular membrane was seen in the foveal area of the left eye (LE). Fluorescein angiography (FA) showed an occult CNV in the LE. Optical coherence tomography (OCT) showed evidence of pigment epithelial detachment (PED) and intraretinal oedema (Fig. 1). Treatment was started with intravitreal injections of sodium pegabtanib (Macugen® 0.3 mg/0.5 ml; ) at regular intervals, with 6 weeks between injections. Four injections of pegabtanib were administered. After 36 weeks, BCVA in the LE was 79 letters. No leakage was seen on FA. Examination by OCT showed a dramatic improvement in the PED and complete disappearance of the intraretinal oedema. No systemic or ocular side-effects were reported. Up figures: fluorescein angiography (FA) and optical coherence tomography (OCT) before treatment; Down figures: FA and OCT post treatment. The most frequent cause of vision loss in patients with angioid streaks is CNV, which occurs in 86% of cases. Photodynamic therapy with verteporfin (Visudyne®) had been the most broadly applied treatment for this type of CNV until the new antiangiogenic therapies emerged. Various authors have found differing results with PDT (Arias et al. 2006; Browning et al. 2002; Karacorlu et al. 2002), but some of the series reported were affected by significant limitations (Arias et al. 2006; Browning et al. 2002; Karacorlu et al. 2002). Antiangiogenic agents are a new therapy for AMD and depend on their inhibitory effect on vascular endothelial growth factor (VEGF). Pegabtanib avoids significant visual loss in patients affected with AMD (Chakravarthy et al. 2006). In addition, bevacizumab and ranibizumab have appeared as alternatives. Texeira et al. (2006) reported a case of CNV associated-angioid streaks treated with two injections of bevacizumab (Avastin®), in which a dramatic visual recovery was seen, along with lack of leakage in OCT and FA. The fundamental difference between this case and the one we present concerns the type of CNV. Texeira et al. (2006) described a classical neovascular membrane; by contrast, our case involved a neovascular membrane of the occult type, which is less frequently associated with angioid streaks. Another difference concerns the number of injections: our case required four injections, whereas Texeira et al. (2006) administered two. Best corrected VA at the end of treatment was very good in both cases. Further research is required, involving detailed studies with extended follow-up to determine the efficacy and safety of intravitreal sodium pegabtanib (Macugen®; pfizer) in the treatment of CNV associated with angioid streaks.