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Clinical & Medical Case Reports

Case Report Volume 7 issue 1

Single intravitreal injection of etamsylate for the treatment of geographic atrophy associated with submacular hemorrhage

Cuevas Pedro,1 Outeirino Luis,2 Azanza Carlos,2 Angulo-Frutos Javier,3 Cuevas-Bourdier Adrian,4 Gimenez-Gallego Guillermo5

1Universidad Alfonso X el Sabio, Spain
2Departamento de Oftalmolog
3Departamento de Investigaci
4Laboratoire National de Sant
5Departamento de Estructura y Funci

Correspondence: Cuevas Pedro, Facultad de Medicina, Universidad Alfonso X, Madrid

Received: October 23, 2016 | Published: July 5, 2017

Citation: Pedro C, Luis O, Carlos A, et al. Single intravitreal injection of etamsylate for the treatment of geographic atrophy associated with submacular hemorrhage. MOJ Clin Med Case Rep . 2017;7(1):163-164. DOI: 10.15406/mojcr.2017.07.00186

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Abstract

Geographic atrophy of the retinal pigment epithelium is a devastating complication of age-related macular degeneration. We show that a single intravitreal injection of etamsylate reduces geographic atrophy and clears submacular hemorrhage in a patient with dry age-related macular degeneration. This improvement was associated with a significant gain of visual acuity.

Keywords: geographic atrophy, inflammation, submacular hemorrhage, intravitreal etamsylate, fibroblast growth factor

Introduction

Age-related macular degeneration (AMD) is the major worldwide cause of blindness in the elderly. It is characterized by a progressive loss of color and fine vision, reduced contrast, and spatiotemporal sensitivity. The two principal types of AMD are wet or exudative and dry AMD. Wet AMD occurs when blood vessels grow through disturbed Bruch’s membrane and extend from the choroids in a biological process called choroidal neovascularization (CNV). The primary treatment of CNV is anti-vascular endothelial growth factor (VEGF) injections. This therapy has been used to inhibit CNV and protect the retina against leakage. However, the vast majority of AMD patients have the currently untreatable dry or atrophic form of AMD, which is characterized by inflammation-driven degeneration of the retinal pigment epithelium (RPE).1 Geographic atrophy (GA) is an advanced form of dry AMD characterized by the loss of an area of the RPE that grows over time.2 In this case report we show the efficacy of a single intravitreal injection of etamsylate, an anti-inflammatory drug,3 in a patient with GA associated submacular hemorrhage.

Case presentation

This study was performed with patient’s consent after the Ethical Committee approval of our Institution. A 66 years old women presented with hypertension and a three months history of progressive visual loss in her left eye. Ocular examination including Snellen visual acuity (VA) measurements and color fundus photography was performed at baseline and one and three months after treatment. Color fundus photography shows macular edema and features of dry AMD with a submacular hemorrhage that masks a macular GA (Figure 1). GA shows the following characteristics: round or ovoid shape feature, sharp demarcation between relative healthy RPE and visibility of choroidal vessels.

 The patient received an intravitreal injection (150μl) of etamsylate (125mg/ml; Dicynone, Sanofi-Aventis, France) following the International Guidelines for intravitreal injections4 in her left eye. The clearance of submacular hemorrhage was observed after three months of treatment (Figure 1) concomitantly with a significant progressive reduction of GA (70%), suggesting that etamsylate may participate in the regeneration of RPE. Clearance of submacular hemorrhage and reduction of GA was associated with a progressive gain of VA: 0.05 at baseline versus 0.08 and 0.40 after one and three months of treatment, respectively.

Figure 1 Color fundoscopy at baseline, and after one and three months of intravitreal etamsylate administration. A sharp demarcation between regions of retinal pigment epithelium loss and intact retinal pigment epithelium is seen. Within the regions of geographic atrophy (ga), choroidal vessels are seen, sh: submacular hemorrhage.

Discussion

The retinal pigment epithelium (RPE) is a partner of the neural retina and is indispensable for vision in humans. RPE has a wide variety of function, as such nutrient supply, oxidative stress protection, phagocytosis, and secretion of survival signals for retinal cells.5 In addition, RPE has a potential for regeneration.6,7 The sequence of events leading to GA is the progression of large drusen to hyperpigmentation, followed by regression of the drusen, hypopigmentation and ultimately RPE cell death, leading to atrophic area of the retina underlying choroids.8

Opposed to anti-VEFG therapy of exudative AMD, there are not any currently approved treatment for GA. Current clinical trials are investigating remedies for dry GA through multiple approaches, including inflammation, the visual cycle, neuroprotection and cell replacement therapy.9–12 Aetiology of dry AMD suggests that the treatment of inflammation could be a suitable alternative to treat dry AMD.13 Fibroblast growth factor (FGF), in spite of being an angiogenesis promoter,14 is also involved in inflammation processes15–19 and seems to play key roles in neurodegenerative diseases such as AMD.20 It has been shown that etamsylate inhibits several FGF-related activities as such inflammation.21 Etamsylate is a synthetic haemostatic agent that has been used orally and systemically for many years. Furthermore, local delivery seems a better choice in order to reach appropriate therapeutic concentrations of etamsylate in well delimited target organs or tissues, as is the case for dry AMD.

This case report shows that a single intravitreal injection of etamsylate leads to clearance of submacular hemorrhage, resolution of macular edema, reduction of GA and vision improvement that occurs within one month and continues to improve for the next three months. It seems obvious that anti-inflammatory activities of etamsylate3 may, at least in part, contribute to a clinical improvement of GA, which was observed in the present report.

Conclusion

Intravitreal etamsylate injection shows significant improvement of visual acuity over time, associated to submacular hemorrhage clearance and diminution of the geographic atrophy in a patient with dry age-related macular degeneration.

Acknowledgements

None.

Conflict of interest

The author declares no conflict of interest.

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