Corneal neovascularization can be a difficult problem to treat. The authors describe a patient with lipid keratopathy secondary to corneal neovascularization treated with photodynamic therapy. Six months following treatment the neovascularization has not returned and the lipid keratopathy has not increased in size. No significant side effects from the treatment occurred. Photodynamic therapy with Verteporfin was a useful treatment modality in this case of corneal neovascularization with associated lipid keratopathy.
Photodynamic Therapy with Verteporfin for Corneal Neovascularisation
From the Lions Eye Institute, Centre for Ophthalmology and Visual Science, Perth, Western Australia, Australia.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Reece C. Hall, Wellington Eye Centre, Level 4, 148 Cuba Street, Wellington, New Zealand.
Accepted: August 19, 2009
Posted Online: March 09, 2010
Corneal neovascularization following keratitis can be a problem affecting vision that is difficult to treat and many different treatment modalities have been tried over the years.1 We report a case of corneal neovascularization with lipid keratopathy secondary to Herpes simplex virus (HSV) keratitis where the neovascularization was treated with photodynamic therapy (PDT) and the lipid keratopathy stabilized.
A 37-year-old woman developed a right corneal ulcer in January 2000 secondary to HSV keratitis. Four months later, stromal neovascularization was noted and after 5 months a lipid infiltrate was beginning to develop. The treatment included topical steroids and Acyclovir. Visual acuity was 6/6-2 in May 2001.
She represented in August 2005 with a concern of decreased vision and increasing size of the corneal lipid keratopathy. Her vision was 6/9 and the lipid keratopathy measured 2.5 mm in diameter at the 5-o’clock position of her cornea. This increased to 3.3 mm diameter by November 2006 and argon laser of the corneal vessels during fluorescein infusion was attempted twice with no effect. PDT was arranged for April 2008 when the vision was 6/12 and the lipid keratopathy was 3.8 mm in diameter. Figs. 1A to C shows the appearance at pretreatment.
Figure 1. Pre-Treatment (A) Magnification x5 (B) Magnification x8 (C) Magnification x16.
Lipid formulated Verteporfin was prepared at a dose of 6 mg/m2. The patient was 1.6 m2, therefore 4.8 mL of Verteporfin with 25.2 mL of 5% dextrose in water was infused intravenously over 10 minutes. A 689 nm non-thermal laser was started 15 minutes from the start of infusion for 250 seconds with a 5 mm spot size at a power intensity of 600 mW/cm2. The 5 mm spot size covered all of the corneal neovascularization from the limbus but did not cover the peripheral margin of lipid keratopathy in the cornea center. A total light dose of 150 J/cm2 was given. The treatment of 150 J/cm2 is three times higher than used in the treatment of choroidal neovascularization.
Post laser, the patient was treated with topical Prednisolone, Acyclovir, and oral Valacyclovir 500 mg bd. At week one Figs. 2A to C shows occlusion of some of the smaller vessels and bleeding within the lipid keratopathy. Visual acuity was 6/24. At week two stellate like keratic precipitates (KP) were noted on the endothelium surface but no cells in the anterior chamber. Visual acuity was 6/12. At month one, Figs. 3A to C shows occlusion of all vessels and resolution of the bleeding within the lipid keratopathy. The KP were present with no cells noted in the anterior chamber. Visual acuity was 6/12. At month two the KP had disappeared and the treatment was tapered over the next month. Visual acuity was 6/9. At month six Figs. 4A to C shows total occlusion of the vessels with no re-growth. Visual acuity was 6/6.
Figure 2. Week 1 (A) Magnification x5 (B) Magnification x8 (C) Magnification x16.
Figure 3. Month 1 (A) Magnification x5 (B) Magnification x8 (C) Magnification x16.
Figure 4. Month 6 (A) Magnification x5 (B) Magnification x8 (C) Magnification x16.
Traditionally, PDT with Vertoporfin was used in the treatment of choroidal neovascularization associated with age-related neovascularization. PDT has been reported in animal and human eyes for corneal neovascularization.1 A recent report found a 77.8% decrease in corneal neovascularization and complete vascular occlusion in 50.0%.2 Recurrence occurred in 11.1% of cases.2 Visual acuity improved in 44.4% and did not change in 50.0%.2 There is minimal damage to adjacent tissue,3,4 but stromal haze can occur in 5.6% of cases.2 In this case, we observed stellate KP that have not been previously reported. It is possible to repeat treatments and treating before penetrating keratoplasty may reduce allograft rejection.2 The negatives are PDT is costly, and associated side effects such as visual disturbance, photosensitivity, injection site reaction, and back pain occur.5 Treatment achieved occlusion of corneal blood vessels, stabilization of the lipid keratopathy and improvement of vision. Penetrating keratoplasty is not planned at this stage due to her good visual acuity. Photodynamic therapy with Verteporfin was a useful modality in this case of corneal neovascularization with associated lipid keratopathy limited to 6 months follow-up.
- Chang JH, Gabison EE, Kato T, Azir DT. Corneal neovascularisation. Curr Opin Ophthalmol. 2001;12:242–249. doi:10.1097/00055735-200108000-00002 [CrossRef]
- Yoon KC, You IC, Kang IS, et al. Photodynamic therapy with Verteporfin for corneal neovascularisation. Am J Ophthalmol. 2007;144:390–395. doi:10.1016/j.ajo.2007.05.028 [CrossRef]
- Fossarello M, Peiretti E, Zucca I, Serra A. Photodynamic therapy of corneal neovascularisation with Verteporfin. Cornea. 2003;22: 485–488. doi:10.1097/00003226-200307000-00018 [CrossRef]
- Brookes BJ, Ambati BK, Marcus DM, Ratanasit A. Photodyamic therapy for corneal neovascularisation and lipid degeneration. Br J Ophthalmol. 2004;88:840. doi:10.1136/bjo.2003.035071 [CrossRef]
- Treatment of age-related macular degeneration with Photodynamic therapy (TAP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularisation in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trial-TAP report. Arch Ophthalmol. 1999;117:1329–1345.