Intravitreous Methotrexate and Rituximab for Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP)

PURPOSE: To investigate the utility of intravitreous methotrexate and rituximab in the treatment of Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP). METHODS: Observational cohort study of five eyes of three patients with BDUMP receiving combination injections of intravitreous methotrexate 400mcg/.05mL and rituximab 1g/.1mL as part of multimodal treatment of BDUMP. Change in central foveal thickness (CFT) and subfoveal fluid (SFF) obtained by optical coherence tomography, and change in logMAR/Snellen vision were compared before and after each injection and over the follow up duration. RESULTS: Five eyes of three male patients with BDUMP received thirty-nine combination injections of intravitreous methotrexate and rituximab. The median follow-up period was 48.2 mos; all eyes exhibited a decrease in CFT and SFF and an improvement in vision at some point from baseline. The median/mean vision increase was 5/3.4 Snellen lines, decrease in CFT was 243/235µm and decrease in SFF was 240/273µm. Over the follow up period, one eye had a gradual decline in vision from 20/40 to 20/150 over 48 mos. Four of the five eyes had marked improvement and sustained vision: from vision ranging 20/50 to 20/150 at baseline to all four improving to 20/25 or 20/20. CONCLUSION: Intravitreous methotrexate and rituximab may be a useful, well-tolerated adjunctive treatment for BDUMP. Improvements in central foveal thickness and subfoveal fluid were noted following injections and over the follow up period. Unlike the often, rapid decline in vision that is expected of this paraneoplastic disease, the eyes in this cohort appeared to have more favorable outcomes.