Intravitreal methotrexate for recurrent epiretinal membrane re-proliferation
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BACKGROUND: Epiretinal membranes are a common disease that can either be idiopathic, meaning no cause can be detected this is usually caused by aging, or secondary which is caused by injury disease or surgery. Despite current treatment methods, there are still persistence of this disease in some rare cases. Methotrexate although traditionally used to treat cancer and rheumatoid arthritis has been being explored as a treatment option in the field of ophthalmology for use against proliferative and migrating cellular diseases coupled with inflammation. Methotrexate has been reported in a few ocular diseases to reduce or stop cell migration and proliferation due to this finding a case study was conducted with this recurrent ERM patient to test its effectiveness against this disease. PURPOSE: To investigate a potential new treatment method for recurrent epiretinal membranes. After a visually significant epiretinal membrane develops there would be an epiretinal membrane (ERM) peel performed. Traditionally if there is recurrence of epiretinal membranes post ERM peeling the patient will be treated with an internal limiting membrane (ILM) peel. For most cases, this will resolve the issue. In the rare instances where an ILM peel doesn’t resolve recurrence, like in this case, we sought to test whether a series of methotrexate injections could help prevent ERM re-proliferation. CASE REPORT: Reporting on a case of a 65-year-old woman with a recurrent recalcitrant epiretinal membrane. This membrane was treated with a pars plana vitrectomy and ERM peeling. The membrane grew back and was met with an ILM peel in hopes of resolution. With continuing recurrence, the patient was treated with another ERM and ILM peel and 12 weekly intravitreal methotrexate (MTX) injections. METHODS: A patient with persistent recurrent epiretinal membranes underwent three surgeries in an attempt to cure the ERM. At every clinical visit, best corrected distance visual acuity was assessed with a Snellen Vision Test and the retina was imaged using optical coherence tomography. Measurements were taken using the machines built in analysis technology to measure retinal thickness and retinal volume at each visit. These were graphed alongside visual acuity to determine complimenting trends. RESULTS: At the first visit the patient began treatment at a visual acuity of 20/200 and a central macular thickness of 676. Seven months after the final methotrexate injection the patient was at a visual acuity of 20/80 and a central macular thickness of 328. The overall results were that visual acuity and central macular thickness significantly improved without ERM recurrence at seven months after treatment. CONCLUSION: When an ERM is significantly impacting the patient’s visual acuity surgery is usually performed in the form of an ERM peel or ILM peel. Although treatment of recurrent epiretinal membranes is well maintained by these procedures there are a small percentage of cases where recurrence is still found post ILM surgery. This case represents the first documented use of MTX to treat recurrent ERM and it suggests great potential for its use in otherwise treatment resistant cases. More research is required to better understand the true potential of this treatment option as well as associated risks.
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