Taku Wakabayashi, MD, PhD
Retina Research Fellow
The Retina Service of Wills Eye Hospital
The final day of ASRS 2021 started off with an exciting Retinal Detachment Symposium moderated by Drs. Christina Weng and Rajeev Muni.
Dr. Alan Franklin from the Diagnostic & Medical Clinic presented the efficacy of postoperative intravitreal methotrexate injections for proliferative vitreoretinopathy (PVR) and diabetic retinopathy, focusing on the reoperation rate and visual outcomes with and without methotrexate injections.
As a background, PVR is the most common cause of rhegmatogenous retinal detachment repair failure with an incidence of 5-10%. Off-label use of methotrexate has been proposed as a promising agent in the treatment of postoperative PVR.
Dr. Franklin retrospectively compared the outcomes between methotrexate-injected eyes (n=27) and non-injected eyes (n=163). The study included not only the PVR patients but also PDR and trauma patients. Intravitreal methotrexate (400 µg) was administered at week 1, 2, 4, 7, and 11, postoperatively.
Dr. Franklin showed that intravitreal methotrexate significantly reduced the reoperation rate and improved vision. He mentioned in the discussion that the overall results are encouraging and intravitreal methotrexate may be indicated not only for PVR but also diabetic eyes and trauma.
Dr. Michelle Abou-Jaoude from Retina Associates of Kentucky presented the outcomes of intravitreal methotrexate for PVR in the perioperative period of retinal detachment repair. Her retrospective chart review included 36 eyes who had intravitreal methotrexate preoperatively (n=3), postoperatively (n=27), and both pre and postoperatively (n=6). The intravitreal methotrexate was injected at the time of PVR diagnosis until PVR stopped advancing. The mean number of injections was 4.3. Overall, 88% (32/36 eyes) had reattachment in patients with known PVR and 58% (21/36 eyes) achieved 20/200 or better vision.
Based on Drs. Franklin and Abou-Jaoude’s presentations, intravitreal methotrexate has a potential to become a treatment option in eyes with complex retinal diseases including PVR. However, it should be noted that the methotrexate is used off-label currently. Therefore, the efficacy, dose, timing, number of injections, and potential adverse effects should be investigated further in a prospective study. Currently, a prospective, randomized clinical trial (GUARD trial) is under way to investigate the efficacy of postoperative intravitreal methotrexate in prevention of redetachment associated with PVR. We all look forward to seeing the results in the near future.
