Treatment of Peripapillary Atrophy with Choroidal Neovascular Membrane
Intravitreal anti-VEGF therapy is the primary treatment for peripapillary choroidal neovascular membranes (CNVM), with bevacizumab, ranibizumab, or aflibercept administered on a pro re nata (PRN) basis, typically requiring 3-5 injections over 12 months to achieve inactivation and visual improvement. 1, 2
Primary Treatment Approach
Anti-VEGF injections represent the established first-line therapy for peripapillary CNVM regardless of underlying etiology, including idiopathic, inflammatory, age-related macular degeneration, or pathologic myopia. 3, 2
The typical treatment regimen involves an average of 4.9 anti-VEGF injections over 12 months using PRN protocol, with monitoring every 6 weeks initially. 2
Visual outcomes are favorable, with significant improvement from baseline 20/70 to 20/40 at 12 months, and successful inactivation of the neovascular membrane in all treated cases. 1, 2
Specific Anti-VEGF Agents
Bevacizumab (1.25 mg), ranibizumab (0.5 mg), or aflibercept are all effective options for peripapillary CNVM. 1, 4
In one series, complete resolution occurred after the initial injection in 55% of cases, with 30% requiring no additional treatment beyond the first injection. 5
The choice between agents can follow standard protocols for other forms of CNVM, as all demonstrate efficacy in this location. 3, 6
Monitoring and Retreatment Criteria
Optical coherence tomography (OCT) is essential for monitoring treatment response, assessing for reduction in intraretinal and subretinal fluid, and determining need for retreatment. 1, 2
Fluorescein angiography should be performed at baseline and repeated based on clinical and OCT findings to confirm inactivation of the membrane. 1, 2
Retreatment is indicated when OCT shows persistent or recurrent fluid, or when fluorescein angiography demonstrates active leakage. 2
Prognostic Factors
Baseline visual acuity and patient age are significant predictors of final visual outcome at 12 months (p=0.04 and p<0.001 respectively). 2
Presence of peripapillary choroidal atrophy is a negative prognostic factor for visual improvement and correlates with worse outcomes. 5
The location near the optic disc does not preclude successful treatment, though anatomical constraints may limit laser-based therapies. 7
Alternative and Adjunctive Therapies
Photodynamic therapy (PDT) with verteporfin is FDA-approved for predominantly classic subfoveal CNV but has significant limitations for peripapillary lesions. 7
The FDA label specifically states that the nasal edge of the PDT treatment spot must be positioned at least 200 microns from the temporal edge of the optic disc, which may result in incomplete treatment of peripapillary CNV. 7
PDT may be considered in pachychoroid-related cases where anti-VEGF response is suboptimal, particularly when ICGA shows hyperfluorescent choroidal changes. 8, 9
In the context of peripapillary pachychoroid syndrome (maximal choroidal thickness near the optic nerve with nasal macular fluid), combination therapy with PDT and anti-VEGF may be beneficial. 8, 9
Special Considerations
Observation alone may be appropriate in select cases, particularly when associated with conditions like idiopathic intracranial hypertension where spontaneous regression with subretinal fibrosis can occur. 4
However, vision-threatening or persistent cases warrant anti-VEGF treatment rather than observation, as this provides safe and effective outcomes. 4
No intraocular or systemic side effects were observed in the reported series of peripapillary CNVM treated with anti-VEGF therapy. 1
Treatment Algorithm
Confirm diagnosis with multimodal imaging including OCT, fluorescein angiography, and consider ICGA to evaluate for pachychoroid features. 2, 10
Initiate anti-VEGF therapy with bevacizumab, ranibizumab, or aflibercept using standard dosing (bevacizumab 1.25 mg, ranibizumab 0.5 mg, or aflibercept 2.0 mg). 1, 4
Monitor at 6-week intervals with OCT and clinical examination, performing fluorescein angiography as needed to assess membrane activity. 1, 2
Retreat on PRN basis when OCT shows fluid or angiography demonstrates active leakage. 2
Consider PDT as adjunctive therapy only if anti-VEGF response is inadequate and pachychoroid features are present on ICGA, ensuring treatment spot maintains required distance from optic disc. 8, 7
Common Pitfalls to Avoid
Do not use PDT as first-line therapy for peripapillary CNVM, as the required 200-micron safety margin from the optic disc limits effective treatment and anti-VEGF therapy demonstrates superior outcomes in this location. 7, 1
Do not assume poor prognosis based on location alone—peripapillary CNVM responds well to anti-VEGF therapy with significant visual improvement possible. 2
Do not overlook underlying pachychoroid disease, as this may influence treatment strategy and suggest benefit from PDT in refractory cases. 8, 9
Avoid aggressive treatment schedules—most cases respond to PRN dosing with an average of 3-5 injections over 12 months. 1, 2