Targeted Multimodality Treatment to Eliminate the Need for Enucleation in Advanced Coats Disease

Purpose: To examine the trends and outcomes in the management of Coats disease and evaluate the effects of a staged therapeutic approach using transpupillary laser vascular ablation, intravitreal (IVT) bevacizumab, and adjunct as-needed posterior sub-Tenon triamcinolone acetonide (used only in cases with a persistent active exudation) on globe retention, anatomic status, and visual acuity (VA). Methods: An evaluation was performed from 2005 to 2023. Previous case series published in the literature were reviewed. In total, the case series comprised 68 patients who were evaluated and treated. In addition, a retrospective consecutive chart review was performed of novel cases of children with advanced Coats disease (stage 3 and 4) who were treated with targeted laser ablation coupled with IVT bevacizumab injection and supplemented with as-needed posterior sub-Tenon triamcinolone acetonide. Results: All patients had total resolution of the retinal detachment, and no patient had evidence of neovascular glaucoma after treatment. At 24 months, 11 (42%) of 26 eyes had better than 20/50 visual acuity (VA), 10 (39%) of 26 eyes had better than 20/400 VA, and 5 (19%) of 26 eyes had better than 5/200 VA. No eye required enucleation or developed endophthalmitis or inflammation after therapy with IVT bevacizumab. In addition, no case required incisional surgery. Conclusions: Treatment trends for advanced Coats disease have evolved, leading to enhanced patient outcomes and improved quality of life. Combined treatment with IVT bevacizumab, transpupillary laser vascular ablation, and as-needed posterior sub-Tenon triamcinolone acetonide results in improved anatomic outcomes.