Adjunctive Intravitreal Anti-vascular Endothelial Growth Factor and Moxifloxacin Therapy in Management of Intraocular Tubercular Granulomas.

ABSTRACT

PURPOSE: To report pre and post treatment levels of VEGF-A in the aqueous humour of patients with intraocular tubercular granulomas and study the effect of a combined intravitreal anti-VEGF bevacizumab and moxifloxacin therapy on their regression. METHODS: Aqueous samples of 10 consecutive patients with intraocular tubercular granulomas obtained before and after initiating treatment were subjected to ELISA for analysing intraocular VEGF-A levels. Intravitreal injections of bevacizumab and moxifloxacin were given weekly till complete regression of these granulomas. All patients received the usual four-drug ATT and oral corticosteroids. RESULTS: Mean baseline VEGF-A level was 1004.27±411.40 pg/ml (401.32-1688.95) that reduced significantly to 27.62±46.86 pg/ml (6.9-131.83) at the last injection. Meannumber of intravitreal injections was 3.1 (2-4). We found significant correlation of decreasing levels of aqueous VEGF-A with the clinical regression of these tubercular granulomas. CONCLUSIONS: Intraocular TB granulomas have high levels of VEGF-A. Weekly intravitreal injections of anti-VEGF bevacizumab with moxifloxacin as an adjunct to the standard care may cause prompt regression of tubercular granulomas. ABBREVIATIONS TB Tuberculosis; IOTB Intraocular tuberculosis; VEGF Vascular endothelial growth factor; RD Retinal detachment; Mtb Mycobacterium tuberculosis; ATT Antitubercular therapy; AMD Age-related macular degeneration; SRF Subretinal fluid; ELISA Enzyme immunosorbent assay; PCR Polymerase chain reaction; ONH Optic nerve head; MDR-TB Multidrug-resistant tuberculosis; pg/ml picogram/milliliter; ESR Erythrocyte sedimentation rate; CECT Contrast enhanced computed tomography; DNA Deoxyribonucleic acid; RNA Ribonucleic acid; BSL Biosafety level; BCVA Best corrected visual acuity; HM Hand movements; KP Keratic precipitates; PSC Posterior subcapsular cataract; PS Posterior synechiae; CRA Chorio-retinal atrophy; IVMP Intravenous methyl prednisolone; OCT Optical coherence tomography; RPE Retinal pigment epithelium; FFA Fundus fluorescein angiography; ICG Indocyanine angiography; RAP Retinal arterial proliferans.