Successful management of rubella retinopathy–related subretinal neovascular membrane with intravitreal ranibizumab: A case report

Amrita Dey; Bristi Majumdar; Ahana Sen; Sukanya Gorhe; Manpreet Chugh; Kumar Saurabh; Rupak Roy

doi:10.4103/ijo.IJO_1728_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 402-404

Successful management of rubella retinopathy–related subretinal neovascular membrane with intravitreal ranibizumab: A case report

Amrita Dey¹, Bristi Majumdar¹, Ahana Sen¹, Sukanya Gorhe¹, Manpreet Chugh¹, Kumar Saurabh², Rupak Roy¹
¹ Department of Vitreo Retina, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
² Department of Vitreo Retina, Nethralayam Superspeciality Eye Hospital, Kolkata, West Bengal, India

Date of Submission	15-Jul-2022
Date of Acceptance	20-Mar-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Rupak Roy
Aditya Birla Sankara Nethralaya, 147, Mukundapur, E.M. Bypass, Kolkata - 700 099, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1728_22

Abstract

A seven-year-old boy with a known case of bilateral rubella retinopathy presented to us as part of his annual follow-up. Best-corrected visual acuity (BCVA) at presentation was 20/80 in the right eye and 20/600 in the left eye. On dilated fundoscopy, the right eye showed the presence of subretinal neovascular membrane (SRNVM), subretinal fluid, and classical salt-and-pepper retinopathy, all of which was documented by imaging. The left eye was poorly dilating and showed a pale disc. The right eye was treated with two doses of intravitreal ranibizumab at an interval of two months. Post-treatment examination showed resolution of SRNVM accompanied by scarring and significant improvement in BCVA.

Keywords: Intravitreal ranibizumab, rubella retinopathy, subretinal neovascular membrane

How to cite this article:
Dey A, Majumdar B, Sen A, Gorhe S, Chugh M, Saurabh K, Roy R. Successful management of rubella retinopathy–related subretinal neovascular membrane with intravitreal ranibizumab: A case report. Indian J Ophthalmol Case Rep 2023;3:402-4

How to cite this URL:
Dey A, Majumdar B, Sen A, Gorhe S, Chugh M, Saurabh K, Roy R. Successful management of rubella retinopathy–related subretinal neovascular membrane with intravitreal ranibizumab: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:402-4. Available from: https://www.ijoreports.in/text.asp?2023/3/2/402/374903

Congenital rubella syndrome (CRS) is one of the most devastating congenital viral infections caused by the rubella virus. First-trimester infection in a pregnant woman leads to the most common presentation of sensorineural hearing loss, heart defect, and ocular involvement.^[1] Ocular manifestations are microphthalmos, congenital cataract, salt-and-pepper appearance of the fundus, and glaucoma.^[2] Ocular finding of pigmentary retinopathy is present in 50% of cases. Salt-and-pepper retinopathy of the retina is the most common ocular manifestation of congenital rubella. The intensity of the pigmentation increases over a number of years. As a rare complication, salt and pepper retinopathy can lead to subretinal neovascularization, which eventually may lead to disciform maculopathy.^[3]

Subretinal neovascular membrane (SRNVM) secondary to rubella retinopathy (RR) is extremely rare. There are prior reports of RR associated with SRNVM, but very few studies have reported on its treatment response. Battaglia et al.^[4] reported a case of bilateral CNV secondary to RR and late development of large choroidal excavation (LCE) following treatment with PDT. Wang et al.^[5] also report treatment of subfoveal neovascularization secondary to rubella with photodynamic therapy using verteporfin. D'souza et al.^[6] assessed the long-term visual and anatomical outcomes after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for inflammatory choroidal neovascular membrane (CNVM) and concluded that anti-VEGF therapy seemed to be a very effective treatment modality that resulted in significant visual improvement and foveal flattening.

Treatment response of pediatric RR-related SRNVM to intravitreal ranibizumab has not yet been reported in literature.

Here, we report a rare case of a SRNVM secondary to congenital RR in a child who was treated with intravitreal anti-VEGF (injection ranibizumab) and its response to the same.

Case Report

A seven-year-old male and known case of CRS and bilateral RR presented to us as part of his annual follow-up. Best-corrected visual acuity (BCVA) was 20/80 in the right and 20/600 in the left eye. Anterior segment of the right eye was normal. Left eye was poorly dilating and aphakic. Intraocular pressure was within normal limits in both eyes.

Dilated fundus examination of the right eye revealed a normal optic disk with a classic salt-and-pepper appearance of the retina. A yellowish subretinal lesion with retinal hemorrhages in the macula was also seen. The left eye was poorly dilating and showed a pale disc.

Color fundus photograph of the right eye showed choroidal neovascular membrane as a greyish yellow membrane and subretinal hemorrhage. Diffuse retinal pigment epithelial atrophic patches and changes were noted throughout the retina in both eyes [Figure 1]a. Multicolor image of the right eye showed greyish yellow membrane with interspersed reddish areas of subretinal bleed at the macula, which was suggestive of SRNVM [Figure 1]b. Spectral domain optical coherence tomography structural scan through the macula showed a SRNVM with subretinal fluid [Figure 1]c. Optical coherence tomography angiography showed an active SRNVM [Figure 1]d. Imaging was not possible in the left eye due to poorly dilating pupil.

Figure 1: (a) Color fundus photograph (CFP) of right eye shows CNVM as greyish -yellow membrane (yellow arrow) and subretinal hemorrhage (white arrow). (b) Multicolor (MC) image of right eye shows greyish yellow membrane with interspersed areas of subretinal bleed at the macula, suggestive of of choroidal neovascular membrane and is marked by yellow arrow. (c) Spectral domain optical coherence tomography (SDOCT) structural scan through the macula shows CNVM (yellow arrow) and subretinal fluid (white arrow). (d) Optical coherence tomography Angiography (OCT -A) shows the CNV network (yellow arrow)

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The patient underwent intravitreal injection of ranibizumab in the right eye (two doses at an interval of two months).

Postoperative follow-up after the second dose revealed complete resolution of subretinal fluid along with subretinal hemorrhage. Scarring of the SRNVM was also noted, as documented in spectral domain optical coherence tomography and optical coherence tomography angiography. BCVA after two doses of injection ranibizumab was 20/30 in the right eye and 20/600 in the left eye [Figure 2].

Figure 2: (a) Color fundus photograph of the right eye after injection with anti-vascular endothelial growth factor shows scarred choroidal neovascular membrane (yellow arrow) at the macula. (b) Multicolor image of the right eye shows scarring CNVM (yellow arrow). (c) Spectral domain optical coherence tomography structural scan through the macula shows scarred CNV with resolution of subretinal fluid (yellow arrow). (d) Optical coherence tomography angiography shows regression of the vascular network (yellow arrow)

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Discussion

RR is the most frequent ocular complication in children whose mothers contracted rubella during pregnancy.^[7] Maternal rubella infection in pregnancy may lead to a spectrum of fetal outcomes: an infant may be born normally, with congenital abnormalities, or may be spontaneously aborted.^[8] There is a wide spectrum of ocular findings on CRS. A salt-and-pepper retinopathy is most commonly observed and is seen in 40%–60% of the cases but does not typically have visual consequences unless CNVM develops. Nuclear cataracts may occur in about one-third of all cases and bilateral in 50% of cases.^[8] Microphthalmia, glaucoma, and choroidal neovascularization are the other findings in CRS.^{[2],[3],[7],[8]}

Veloso et al.^[9] reported a spontaneous involution of choroidal neovascularization secondary to RR. There are a few treatment options for CNV described in the literature, such as photodynamic therapy (PDT) and anti-VEGF agents. PDT was found to be an effective treatment option for subfoveal CNV and resulted in involution of the neovascular membrane, resolution of subretinal hemorrhage, and improvement in visual acuity.^[5]

The anti-VEGF treatment is another option for the treatment of CNV. Commonly used anti-VEGF agents are bevacizumab, ranibizumab, and aflibercept. There is only one published report on the management of CNV with anti-VEGF. Kiziltoprak et al.^[10] reported treatment outcomes with intravitreal aflibercept injection. It was reported that after one month of injection, involution of the neovascular membrane and improvement in visual acuity from 20/200 to 20/60 were achieved.^[10]

Conclusion

To the best of our knowledge, our case is the first reported case on the use of intravitreal ranibizumab in SRNVM secondary to pediatric RR in the literature. Intravitreal ranibizumab may be a treatment alternative that provides satisfactory anatomical and functional results and that may lead to a better visual acuity in cases of RR complicated by SRNVM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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