Review Article

Intravitreal Methotrexate

Fatemeh Abdi1, MD; S. Saeed Mohammadi2, MD; Khalil Ghasemi Falavarjani1,3, MD

1Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
2Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran

3Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran

ORCID:
Khalil Ghasemi Falavarjani https://orcid.org/0000-0001-5221-1844

Fatemeh Abdi https://orcid.org/0000-0002-0280-2969

Abstract

Intravitreal methotrexate (MTX) has been proven to be an effective treatment for
various intraocular diseases. In this article, a comprehensive review was performed
on intravitreal applications of methotrexate. Different aspects of the administration of
intravitreal MTX for various clinical conditions such as intraocular tumors, proliferative
vitreoretinopathy, diabetic retinopathy, age-related macular degeneration, and uveitis
were reviewed and the adverse effects of intravitreal injection of MTX were discussed.
The most common indications are intraocular lymphoma and uveitis. Other applications
remain challenging and more studies are needed to establish the role of intravitreal MTX
in the management of ocular diseases.

Keywords: Inflammation; Intraocular Tumor; Intravitreal Injection; Methotrexate; Proliferative
Vitreretinopathy; Uveitis

J Ophthalmic Vis Res 2021; 16 (4): 657–669

INTRODUCTION

Methotrexate (MTX), a Food and Drug
Administration (FDA)-approved folic acid
antagonist, inhibits DNA synthesis, repair, and
subsequently cellular proliferation. MTX (formerly
known as amethopterin) and its analog aminopterin
were developed in 1947.[1, 2] Structural similarities
of these drugs to folic acid and their ability

Correspondence to:

Khalil Ghasemi Falavarjani, MD. Eye Research Center,
Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran,
Iran.
E-mail: drghasemi@yahoo.com
Postal code: 1445613131
Received: 04-02-2021 Accepted: 17-08-2021

Access this article online

Website: https://knepublishing.com/index.php/JOVR

DOI: 10.18502/jovr.v16i4.9756

to inhibit folate-dependent enzymes made them
good choices for the treatment of cancers.[3–5]

MTX reduces the synthesis of polyamines by
inhibition of dihydrofolate reductase (DHFR),
an enzyme that catalyzes the reduction of
dihydrofolate which results in decreased
production of ammonia and hydrogen peroxide
and lessens subsequent injury. MTX also increases
the release of adenine nucleotides into the
extracellular space which are converted to
adenosine by cell-surface enzymes and exerts
its inhibitory effects on nearly all inflammatory
cells.[5] Inhibiting the reduction of dihydrobiopterin
to tetrahydrobiopterin by MTX results in the

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How to cite this article: Abdi F, Mohammadi SS, Falavarjani KG. Intravitreal
Methotrexate. J Ophthalmic Vis Res 2021;16:657–669.

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Intravitreal Methotrexate; Abdi et al

production of reactive oxygen species. Increased
reactive oxygen species activate Jun N-terminal
kinase which leads to activation of apoptosis and
induction of cell cycle arrest.[6] MTX modulates
expression of lincRNA-p21, a long non-coding
RNA, that regulates the p53-mediated apoptotic
response without affecting the regulation of the
cell cycle.[4, 7] Activation of signal transducer and
activator of transcription proteins by receptor-
associated Janus kinases (JAK-STAT signaling
pathway) is also inhibited by MTX which leads
to decrease in the production of inflammatory
signals.[8] MTX also has modulatory effects on the
T-cells, monocytes, and fibroblast-like synoviocytes
functions.[9–11]

MTX is one of the best choices in the treatment
of systemic immune-mediated diseases such
as rheumatoid arthritis (RA), psoriasis, juvenile
idiopathic arthritis (JIA), multiple sclerosis
(MS), systemic lupus erythematosus (SLE), and
inflammatory bowel diseases (IBD). It is also useful
for the prevention of graft rejection and treatment
of malignant disorders due to its anti-inflammatory
and immunomodulatory activities.[2, 12] Recently,
promising results have been shown for the
application of MTX in ophthalmic diseases. The
effect of systemic MTX in the treatment of anterior,
intermediate, posterior, and pan-uveitis, ocular
mucous membrane pemphigoid, and scleritis
has already been shown.[13] However, intravitreal
injection of MTX has been recently investigated
widely as an approach to increase the drug
availability to intraocular tissues and to decrease
the systemic adverse effects. In this article, we
reviewed the current evidence on the application
of intravitreal MTX.

METHODS

A PubMed and Scopus search was performed
in October 2020 using each of the following
keywords: “Methotrexate”, “MTX”, “Eye”, “Ocular”,
“intravitreal MTX”, “intraocular MTX”, “intravitreal
Methotrexate”, “intraocular Methotrexate” in
different combinations. All article types including
original articles, reviews, and case reports that
described the ocular applications of MTX were
identified. No limitation for the time of publication
was applied. Abstracts only and non-English
articles were excluded. All selected articles were
reviewed thoroughly by the authors and relevant

articles describing the application of intravitreal
MTX were discussed.

RESULTS

Overall, 1066 articles were identified. From these,
146 articles described the use of intravitreal MTX.
Intravitreal MTX was injected for intraocular tumors,
uveitis, complex retinal detachment, diabetic
retinopathy, age-related macular degeneration
(AMD), and other indications.

Preclinical Studies

Ericson et al[14] investigated the safety profile
of intravitreal MTX in rabbits. They injected 0.3
ml of 2.5–30 mg/ml concentration of MTX into
the vitreous cavity of rabbits and showed that
these concentrations would result in a flare
in the anterior chamber, precipitation in the
vitreous, and clouding of the lens. However, these
concentrations are highly above routine intravitreal
dose of MTX and side effects are much more
likely with these concentrations. Ozkan et al[15]
evaluated the ultrastructural changes of retina
induced by intravitreal MTX. Early changes were
retinal edema, vacuolization, and disintegration of
mitochondria of the retinal cells and long-term
changes were edema in the photoreceptors and
inner nuclear and ganglionic cell layers, three
days and one month after four weekly injections
of 800 µg intravitreal MTX. They showed that
high dose intravitreal MTX results in significant
ultrastructural changes in the rabbit retina in
varying severities. In another study, Aly and
Ebrahim[16] assessed the effect of MTX toxicity
on electroretinogram (ERG) and retinal caspase-3
activity which has an executive role in apoptosis
of pigment epithelial cell, outer nuclear layer cell,
and ganglion cells[17] after injection of a single
dose of 800 µg MTX. They showed that intravitreal
injection of MTX leads to a significant reduction
in a- and b-waves with an increase in caspase-
3 activity. Hara and colleagues[18] evaluated the
effect of intravitreal MTX on embryonic stem cell
differentiation and teratogenicity. They integrated
embryonic stem cells into the retinas of adult mice
and showed that injection of a single dose of
intravitreal MTX four weeks after transplantation
could increase neuronal differentiation, decrease
expression of teratogenic markers, and reduce

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the proliferative activity of transplanted cells
compared with non-treated retina. Palakurthi and
colleagues[19] evaluated the safety of MTX-loaded-
biodegradable microneedle implants which were
made using solving cast method. Implants were
inserted into deep lamellar scleral pockets of both
eyes of three rabbits. Animals were sacrificed
and enucleated four weeks after implantation.
Enucleated eyes were studied histopathologically
for any evidence of inflammation or toxicity related
to implant or embedded drug. No evidence of drug
toxicity or inflammation and infection was seen
around the implantation site and they showed that
MTX-containing sustained release implant could be
nontoxic and well tolerated by rabbit eyes.

Sunalp et al[20] investigated the effect of
intravitreal MTX on the experimental model
of proliferative vitreoretinopathy (PVR). They
showed that intravitreal injection of 250,000
homologous dermal fibroblasts into the rabbit
vitreous with 10 nmol and 1 µmol concentration of
MTX resulted in 71% and 83% retinal detachment,
respectively, which was not lower than control
cases. They proposed that as MTX inhibits DHFR,
it is only effective on the fraction of cells that are
at the S phase of the cell cycle and therefore
active proliferation.[21] This might explain the
ineffectiveness of intravitreal injection of MTX
in the reduction of PVR and subsequent retinal
detachment.

Deng et al[22] investigated the antimicrobial
property of intravitreal MTX. They established
a rabbit model of endophthalmitis induced by
Staphylococcus epidermidis and assessed the
effect of intravitreal injection of dexamethasone
and MTX by grading the degree of vitreous haze
and pathologic evaluation of ocular structures.
The dexamethasone group had the most and the
MTX group had the least intraocular inflammation
and vitritis. Live bacteria were only isolated
from the dexamethasone group and not in the
MTX group. Pathologic evaluation revealed severe
ocular destruction in the dexamethasone group
and intact structures in the MTX group. They
suggested that intravitreal MTX can reduce the risk
of the development of bacterial endophthalmitis
and associated ocular destruction compared with
intravitreal dexamethasone.

Abbaszadeh Hasiri and colleagues[23] evaluated
the effect of intravitreal administration of MTX with
two different doses for the treatment of endotoxin-
induced uveitis (EIU) in the rabbit. They showed

that mean histopathological inflammation intensity
scores in both groups of intravitreal MTX (400 µg vs
800 µg) were significantly higher than the control
group and intravitreal MTX did not have significant
anti-inflammatory effects on EIU in rabbits.

Clinical Studies

MTX has been used to treat various ocular
conditions. This part summarizes the clinical
studies in which the intravitreal injection of MTX
have been performed.

Intraocular tumors

(i) Retinoblastoma
Retinoblastoma is the most common intraocular

tumor in children.[24] It was nearly 100% fatal
about a century ago; however, therapeutic
advances have led to a >90% survival rate.[25]
Primarily enucleation was the method of choice for
the treatment of retinoblastoma. Nowadays, this
method is only reserved for unsalvageable eyes.[26]
The most prevalent drugs used for chemoreduction
are vincristine, etoposide, and carboplatin followed
by transpupillary thermotherapy, cryotherapy, and
brachytherapy which cures >90% of group
A–C and about 50% of group D and E eyes
with retinoblastoma.[27] Kivela et al reported
intravitreal MTX monotherapy for the management
of intraocular relapse of retinoblastoma after
chemoreduction in six eyes.[28] They used an
established protocol that was developed for
primary intraocular lymphoma.[29] Induction phase
consisted of weekly intravitreal injections of
400 µg MTX for two months; consolidation
and maintenance injections followed every
two and four weeks for two and eight months,
respectively.[28] Objective response to intravitreal
MTX alone occurred in five of six eyes.[28] Their
results are consistent with previous in vitro
studies which showed that about one-third of
retinoblastomas are sensitive to MTX.[28, 30]

(ii) Intraocular lymphoma
Primary CNS lymphomas (PCNSL), characterized

by an aggressive clinical course and poor outcome,
are extranodal lymphomas arising exclusively
inside the central nervous system and about
25% of these patients will develop vitreoretinal
involvement.[31] In the past three decades, the
mean survival rate of PCNSL patients was

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significantly improved from 19.1% to 30.1% due
to developments in chemotherapeutic agents.[32]
However, treatment protocols for intraocular
lymphoma have not been fully validated and the
need for low toxicity regimens that maintain high
efficacy is undeniable.

Intraocular lymphomas are divided into four
major groups, vitreoretinal lymphomas which
are mostly high-grade B-cell lymphoma, primary
choroidal lymphomas which are mainly low-
grade B-cell lymphomas, secondary uveal
lymphomas, and primary iridial lymphomas.[33]
Primary vitreoretinal lymphoma (PVRL), a great
masquerader, is the most common and aggressive
form of intraocular lymphoma and is usually
associated with PCNSL. The characteristic
feature of intraocular involvement of PCNSL
is the presence of vitreous cells, especially
in clumps which could be a masquerader
of chronic nonresponsive uveitis.[34] Several
methods have been proposed for the treatment of
intraocular involvement of PCNSL. Orbital radiation
in combination with systemic chemotherapy
with MTX was used and showed effectiveness;
however, several studies reported ocular side
effects such as cataract formation, dry eye and
persistent corneal epithelial defects, radiation
retinopathy, and optic neuropathy after orbital
irradiation.[35–37] In recent years, intravitreal MTX
has been used more widely for the treatment of
vitreoretinal involvement of PCNSL and has been
found to be effective in induction of remission
with acceptable morbidity.[38–40] Fishburne
and colleagues[38] developed a protocol for
the treatment of intraocular lymphoma by the
intravitreal injection of 400 µg MTX. Intravitreal
injection of 400 µg of MTX was performed twice
weekly until the vitreous was clinically cleared
of malignant cells, then weekly for one month,
followed by monthly injections for one year.
Seven eyes were treated based on this protocol
which resulted in remission without any serious
ocular adverse effects. Frenkel et al[29] described
their 10-year experience in treating vitreoretinal
involvement of PCNSL by intravitreal injections of
MTX. Their treatment protocol included injection
of 400 µg MTX intravitreally twice weekly for four
weeks, once weekly for eight weeks, and then
once monthly for nine months. They reported their
experience with 44 eyes of 26 patients. Sixteen
patients were previously diagnosed with CNS
or systemic lymphoma, and six were primarily

diagnosed as chronic nonresponsive uveitis.
Seventeen eyes completed the treatment protocol
and 95% of the eyes were cleared from malignant
cells and retinal infiltrates with a maximum of 13
injections (mean injections of 6.4). Those eyes
which had poor initial visual acuity showed little
improvement; however, those who had higher
visual acuity showed more improvement in vision.
Corneal epitheliopathy was the most common
side effect that occurred in all patients. It appeared
after the third injection and resolved when intervals
between injections increased. Since there was no
intraocular recurrence and no significant side
effect, they proposed their protocol as a good first-
line treatment option for intraocular lymphoma. Ma
et al[41] evaluated the outcomes of 19 patients with
intraocular lymphoma who were treated with a
combined intravenous high-dose MTX (6–8 g/m2)
and intravitreal MTX (400 µg). They reported that
the patients with concurrent CNS involvement had
worse therapeutic outcomes compared to those
with isolated primary intraocular lymphoma who
remained disease-free after salvage treatment. In
another study, Smith and colleagues[39] evaluated
the effect of intravitreal MTX in the management of
PCNSL involving the eye. All 26 eyes of 16 patients
were cleared of malignant cells after a maximum
of 12 MTX injections. Three patients experienced
recurrence who were treated with another course
of intravitreal MTX. The most common side effect
in the study was the progression of preexisting
cataracts, followed by corneal epitheliopathy,
maculopathy, and vitreous hemorrhage.

(iii) Systemic lymphoma
Lymphoid proliferations can affect the

intraocular structures in various ways. Involvement
of ocular tissues by systemic lymphoma is rare and
could masquerade benign ocular lesions.[42] Lee
Ong et al presented a patient with systemic chronic
lymphocytic lymphoma and secondary anterior
uveitis and hypopyon which was confirmed by
anterior chamber tap and vitreous biopsy. As
intravitreal triamcinolone in association with
intrathecal MTX failed to improve the patient’s
vision, intravitreal MTX (400 µg) was injected
weekly. Following the first injection, the patient’s
vision improved and the second injection resulted
in the resolution of the hypopyon.[43] Iris and
ciliary body involvement are extremely rare in
acute lymphoblastic leukemia (ALL). Mello and
colleagues reported a patient with unilateral
infiltration of iris and ciliary body by ALL which

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resulted in decreased vision and pseudohypopyon
and iris irregularity. Anterior chamber reaction, iris,
and ciliary body involvement was resolved after
eight intravitreal MTX injections and the patient’s
visual acuity improved. Although the patient
developed MTX-associated keratopathy, it was
treated with frequent lubrication.[44] Intraocular
involvement of mycosis fungoides (cutaneous
T-cell lymphoma) is an uncommon phenomenon.
Reddy et al presented a case of mycosis fungoides
with anterior chamber involvement, mutton fat
keratic precipitate (KPs), and exudative retinal
detachment which resulted in decreased vision. It
was confirmed by vitreous biopsy and intravitreal
MTX (400 µg) was administered weekly for
one month and then every two weeks. This
regimen resulted in the resolution of exudative
retinal detachment and infiltrations. To prevent
recurrence, the patient continued to receive
monthly injection of intravitreal MTX.[45] Ryan
and coworkers reported a patient with systemic
large B-cell lymphoma which presented with
decreased vision and retinal pigment epithelial
changes, as well as a yellow–white infiltrative
macular lesion with adjacent retinal whitening
and hemorrhage in the right and left eyes,
respectively. Diagnostic vitrectomy confirmed the
presence of large lymphoma cells with associated
reactive lymphocytes. Although, PET scan, lumbar
puncture, and bone marrow biopsy showed no
evidence of malignancy, the patient received one
treatment of intrathecal MTX (12 mg) at the time
of the lumbar puncture in association with two
treatment sessions of combination of intravitreal
MTX (400 µg) and rituximab (1 mg) in her left eye
at monthly intervals. Twenty-six months following
initiation of the treatment, the patient showed no
evidence of recurrence.[46] Mantle cell lymphoma
has poor long-term survival and is almost
considered incurable.[47] This aggressive non-
Hodgkin lymphoma rarely involves the eye. Singer
and colleagues reported a patient with mantle cell
lymphoma who presented with decreased vision
and bilateral optic disc swelling in the course of the
disease. Resolution of optic disc swelling initiated
in the temporal disk margin after intravitreal
MTX injections with regression of the infiltrative
process.[48] In another study, Zhang et al reported
a patient with metastatic large B-cell lymphoma
which presented as recurrent iridocyclitis with
mutton-fat KPs, hypopyon, and decreased vision
in both eyes. Aqueous humor tap confirmed the

diagnosis and the patient was planned to receive
25 intravitreal injections of 400 µg MTX which was
administrated twice a week for four weeks; once
a week for eight weeks; and then monthly for a
total of nine months. In the course of treatment,
patient received systemic high dose of MTX due
to cutaneous relapse of lymphoma. Hypopyon
was completely disappeared and only few cells
were visible in the anterior vitreous cavity after the
sixth injection. However, the patient experienced
severe corneal toxicity; therefore, subsequent
injections were cancelled. Epitheliopathy was
treated with carboxymethyl cellulose sodium drops
and patient’s vision improved.[49] Wickremasinghe
and colleagues also reported two patients with
systemic T-cell lymphoma which presented with
fibrinous exudate in the anterior chamber and
thickened and nodular iris. The first patient
received one dose of intravitreal injection of MTX
(400 µg) and responded well to therapy; five days
after injection, the patient’s vision improved, and
uveitis and fibrinous exudate were resolved. The
other case received three doses of intravitreal
injection of MTX every six weeks and showed
rapid improvement.[50]

Uveitis

Uveitis, intra-ocular inflammation of various
causes, leads to irreversible visual loss if not
treated properly.[51] Treatments of infectious uveitis
are mainly aimed at the pathogens; however,
in noninfectious uveitis, corticosteroids are the
main regimen to decrease inflammation.[52]
Local injections might be preferable in specific
conditions, such as those patients without a
concomitant systemic disease, those who are
unable to take systemic therapy, or those who
have very asymmetric ocular disease. Also, uveitic
CME is one of the indications of local therapy. Local
therapy leads to a high concentration of the drug at
the site of disease activity and decreases the risk
of systemic toxicity.[53] Hardwig and colleagues[54]
evaluated the safety of intravitreal MTX for
improvement of ocular diseases such as uveitis
and advanced proliferative diabetic retinopathy
(PDR), epithelial downgrowth, and idiopathic
fibrovascular proliferation. Patients were treated
with a single dose of 400 µg intravitreal MTX.
Seven of nine uveitis eyes showed improvement
in visual acuity, one remained stable, and one
patient had decreased visual acuity which seemed

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to be due to the advanced preexisting pathology
and natural history of the disease rather than the
treatment intervention. In another retrospective
case series, Taylor and colleagues[55] showed
that a single injection of 400 µg intravitreal
MTX in patients with unilateral noninfectious
intermediate, posterior, or panuveitis and/or CME
could lead to improvement of ocular inflammation,
visual acuity, CME, and reduction of systemic
immunosuppressive therapy. Five of the fifteen
patients experienced uveitic flare after a median
of four months. Four patients who achieved a
partial improvement of CME after injection of
intravitreal MTX showed no further improvement
following IVTA injection. In a larger multicenter
interventional case series, Taylor et al[56] confirmed
the result of the previous study. They showed
that intravitreal injection of 400 µg MTX could
effectively improve visual acuity and/or reduce
CME in 30 of 38 eyes. In some patients, it also
reduced the need for systemic immunosuppressive
drugs. In another study, Khalil and coworkers,[57]
evaluated the efficacy of intravitreal MTX in
controlling posterior segment involvement of
Behcet’s disease (BD) in comparison to retrobulbar
triamcinolone acetonide (TA). They showed that
improvement of anterior chamber reaction and
vitreous inflammation was similar between the
two groups; however, relapses were noted less in
patients who received intravitreal injection of 400
µg MTX. They suggested that intravitreal MTX has
a promising result and may ensure better control
of the inflammatory reaction and longer remission
in comparison to retrobulbar TA in BD patients. In a
similar study by Bae et al,[58] the effect of intravitreal
MTX in the treatment of refractory retinal vasculitis
due to BD was evaluated. Intravitreal injection of
400 µg MTX was given monthly until visual acuity
and intraocular inflammation were stable. Patients
experienced significant improvement in visual
acuity, decrease in fluorescein leakage, and levels
of aqueous humor’s interleukin (IL)-6 and IL-8, four
weeks after intravitreal MTX without any significant
change in IOP. As the increase in levels of IL-6 and
IL-8 is associated with refractory retinal vasculitis
in BD, intravitreal MTX could be effective in these
patients.

Serpiginous choroiditis is defined as chronic,
progressive, and recurrent inflammation of the
choroid that leads to loss of choriocapillaris
and atrophy of RPE and photoreceptors.[59]
In some patients, there is an association with

underlying mycobacterium tuberculosis infection
and hypersensitivity to its components.[60] This
condition usually responds well to antitubercular
therapy and systemic corticosteroids; however,
inflammatory damage may limit visual outcomes
and continuation of antibiotics with the addition of
immunomodulatory drugs such as MTX may result
in disease quiescence.[61] Tsui et al[62] reported a
patient with serpiginous-like choroiditis (SC), from
a TB-endemic area and positive QuantiFERON
assay which was refractory to anti-tuberculosis
regimen and systemic corticosteroids. Within
six weeks of starting anti-TB medication, the
patient started receiving azathioprine 150 mg
daily. Despite receiving antibiotics, prednisolone,
and azathioprine, steady SC extension was seen.
Therefore, intravitreal MTX was injected and
subcutaneous MTX was prescribed. Following
the second intravitreal injection of MTX, the
progression of the lesion stopped and borders
of the lesion started to contract. The lesion
remained quiescent 24 months after treatment.
In another study, Sahin et al[63] investigated
the antiproliferative and anti-inflammatory effect
of intravitreal MTX on suppressing intraocular
inflammation in two patients with presumed
tuberculosis-related uveitis. Both patients
received 400 mg of intravitreal MTX at the
eighth week of anti-tuberculous therapy and
showed improvement of visual acuity, suppression
of intraocular inflammation, and resolution
of CME. No recurrence was observed eight
months after cessation of the anti-tuberculous
regimen. Chin et al[64] reported a patient who
had latent extrapulmonary tuberculosis with
choroidal granulomas (tuberculomas) that had
been treated with antitubercular therapy one year
earlier. Systemic prednisolone provided visual
improvement; however, avascular necrosis of
the hip complicated the therapy. As cessation
of systemic corticosteroid led to worsening of
visual symptoms in this patient, diagnostic pars
plana vitrectomy (PPV) in addition to intravitreal
injection of MTX (400 µg) was performed. Visual
acuity improved after surgery and an intravitreal
dexamethasone implant was inserted one week
later which resulted in sustained resolution of
choroidal infiltration.

Viral retinitis is a rare ocular infection that
usually results in high rates of visual impairment.
While acute retinal necrosis (ARN) occurs in
immunocompetent patients, progressive outer

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retinal necrosis (PORN) and cytomegalovirus (CMV)
retinitis usually happen in immunocompromised
patients.[65] The human herpesvirus family includes
herpes simplex virus, varicella-zoster virus (VZV),
Epstein-Barr virus (EBV), and CMV. CMV infection
is the leading viral cause of visual impairment
in immunocompromised patients, especially
those who had undergone organ transplants.
Huang et al[66] reported a patient who had
acute myeloid leukemia (AML) and developed
bilateral CMV retinitis with bilateral CME, and
optic disc swelling in the right eye six months
following bone marrow transplantation. Four
weekly injections of intravitreal MTX (400 µg)
were performed in the right eye which was
more severely affected in combination with oral
valganciclovir. Visual acuity improved, optic
disc swelling was resolved, and macular edema
was subsided in the MTX-injected eye one
month after injection. However, the non-injected
eye showed no sign of resolution of macular
edema. No recurrence of macular edema was
observed in the right eye during the next eight
months of follow-up. Mashima and colleagues[67]
presented a patient with interstitial pneumonia
and chronic pyelonephritis who had been on
methylprednisolone for 20 years. The patient
developed vitreous opacity and extensive
necrotizing retinitis with retinal hemorrhage
sparing the posterior pole. Polymerase chain
reaction (PCR) of the vitreous sample was positive
for EBV but negative for HSV, VZV, and CMV.
The patient was unresponsive to intravenous
ganciclovir and intravenous acyclovir, therefore,
intravitreal MTX (400 µg) was tried for the patient.
Three days after intravitreal injection of MTX, the
white–yellowish lesion in the ocular fundus was
regressed. In line with regression of the lesion,
copy numbers of EBV-DNA in aqueous humor
were also decreased.

Proliferative vitreoretinopathy (PVR)

PVR is defined as the growth of fibroglial tissue on
both sides of the detached retina and posterior
hyaloid face.[68] It may be presented as low as the
presence of cellular debris in the vitreous cavity
to the presence of full-thickness retinal folds.[69]
PVR occurs in 5–10% of cases of rhegmatogenous
retinal detachments (RRD) and is the main cause of
surgical failure after the repair of RRD.[70] Several
studies have shown the role of inflammation

in the pathogenesis of PVR and reported the
effectiveness of corticosteroids on inhibiting
the development of PVR.[71, 72] Denstedt and
colleagues,[73] reported a case of a needle
penetrating injury of the globe which resulted in
retinal detachment and progressive post-traumatic
PVR. The patient underwent multiple vitrectomies
in association with multiple intravitreal injections
of 200 μg MTX every two to three weeks. The
patient’s best-corrected visual acuity (BCVA) was
20/40 and the retinal periphery was flat with
stable fibrosis in the last follow-up, 15 months
after the initial treatment. Benner et al[74] treated
five eyes with severe PVR and recurrent retinal
detachment using relaxing retinectomy, extended
perfluorocarbon liquid tamponade for four weeks,
and a series of intravitreal MTX injections (100–
200 μg) every two weeks. Injections started
within one week after re-detachment surgery.
Patients were followed for 11–27 months and
interestingly, all patients remained attached
and four eyes recovered to ambulatory vision
(>20/200) with normal intraocular pressure (IOP).
This study showed that multiple intravitreal MTX
injections could be beneficial for treating complex
retinal detachment associated with PVR. Ghasemi
Falavarjani et al[75] evaluated the role of intra-
silicone oil (SO) injection of MTX at the end
of vitrectomy surgery for RRD with associated
PVR. They injected 250 µg MTX into the silicone
oil at the end of the surgery in 22 eyes of 22
patients with RRD associated with grade C PVR
and compared the rate of retinal detachment with
22 eyes of 22 control patients. They showed
that the rate of re-detachment was lower among
the MTX group, although the difference was not
statistically significant. Nourinia and coworkers[76]
evaluated the effect of repeated intra-silicone oil
injections of MTX on the outcomes of surgery for
RRD associated with grade C PVR. At the end
of the vitrectomy and intraocular injection of SO,
and at the 3rd and 6th week after the surgery, the
patient received 250 μg of intravitreal MTX. Eleven
eyes were treated and followed for about nine
months; the retina of all treated eyes remained
attached and BCVA was significantly improved at
the last follow-up visit. They stated that repeated
intra-silicone injection of MTX could be a promising
adjunctive procedure for the treatment of RRDs
complicated by PVR. Sadaka et al[77] evaluated the
effect of intravitreal MTX infusion during PPV for
retinal detachment in patients with high risk for

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Intravitreal Methotrexate; Abdi et al

the development of PVR (severe recurrent PVR
with tractional retinal detachment [TRD] and/or a
history of severe ocular inflammation). A mixture
of 500 mL balanced saline solution with added 40
mg of MTX was used as an infusion bottle during
the surgery of 29 eligible patients. They believed
that this solution yields intraocular MTX levels
equivalent to that used in intraocular lymphoma
(400 μg intravitreal injection).[54, 78] Six months
after the treatment, 83% of the patients had
stable or improved BCVA and 90% of the retinas
remained attached. Therefore, they suggested
that intravitreal infusion of MTX during the surgery
could be beneficial for those eyes which are at
high risk for PVR development due to a history
of prior PVR or intraocular inflammation. There is
also an ongoing phase 3 clinical trial regarding
the effectiveness of intravitreal MTX on the
rate of re-detachment due to PVR that requires
surgery. During Gain Understanding Against
Retinal Detachment (GUARD) trial, patients with
recurrent retinal detachment due to PVR with
star folds in at least three cumulative clock hours
documented on retinal imaging, or for retinal
detachment associated with open globe injury
are enrolled. At the end of the vitrectomy or on
first postoperative day, and then weekly for eight
weeks, followed by every-other-week treatment
through the 16th postoperative week, patients
receive ADX-2191 (intravitreal MTX 0.8%, Aldeyra
therapeutics) injections.[79]

Proliferative diabetic retinopathy

Ghasemi Falavarjani et al[80] evaluated the effect
of intra-silicone oil injection of MTX at the end
of vitrectomy for advanced PDR and assessed
the rate of retinal re-detachment associated with
fibrovascular proliferation or PVR. They injected
250 µg MTX intravitreally into 19 eyes with
severe diabetic tractional macular detachment or
combined tractional or rhegmatogenous retinal
detachment and compared the outcomes with 19
eyes of a control group. Retinal re-detachment
with fibrovascular proliferation or PVR occurred
in seven eyes (36.8%) in the MTX group and
eight eyes in the control group which was not
statistically significant. Therefore, they showed
that intra-silicone injection of MTX at the end of
vitrectomy for retinal detachment associated with
severe PDR did not reduce the risk of postoperative
retinal detachment due to fibrous or fibrovascular

proliferation. In another study, Hardwig et al[54]
reported five patients with PDR associated with
TRD or CME. Three patients received 200 µg
and two were treated with a total of 400 µg of
intravitreal MTX. Two patients with PDR and TRD
experienced decreased vision, two patients with
PDR and TRD/DME showed increase in vision, and
one patient with PDR and TRD experienced no
change in visual acuity.

Diabetic macular edema (DME)

Inflammation plays an important role in the
pathogenesis of DME. Intraocular inflammatory
mediators increase in the course of the disease.[81]
Several studies have shown that intravitreal
injection of corticosteroids results in improvement
of DME mainly through suppressing the
inflammatory mediators.[81–83] However, glaucoma
and cataract formation are major drawbacks in
intravitreal corticosteroid injections.[83] Intravitreal
MTX has been investigated as an anti-inflammatory
agent in the treatment of persistent DME. In a
prospective interventional case series, intravitreal
MTX (400 µg) was injected in 18 eyes of 16
patients with persistent center-involving DME
unresponsive to at least three consecutive
intravitreal bevacizumab (IVB) injections or two
consecutive bevacizumab injections plus macular
photocoagulation. Intravitreal injection of MTX
resulted in statistically significant anatomical and
visual improvement.[84]

In another study, the efficacy of IVB combined
with intravitreal MTX (IVM) in the treatment of DME
was investigated. Thirty-six eyes of 18 patients were
randomly allocated into the two groups to receive
three monthly injections of IVB (1.25 mg) plus IVM
(400 µg) or IVB alone. In contrast to the previous
study, no significant therapeutic effects for IVB
combined with IVM compared to IVB alone were
seen over a three-month follow-up.[85]

Age-related macular degeneration

Although vascular endothelial growth factor (VEGF)
is the main mediator in neovascular AMD, other
inflammatory mediators play a significant role in
its pathogenesis. An increase in reactive oxygen
species which can cause cellular damage, caspase
activation inducing cell death, complement
activation, breakdown of Bruch’s membrane

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Intravitreal Methotrexate; Abdi et al

and retinal pigment epithelium (RPE) by matrix
metalloproteinases, and production of cytokines
are the major inflammatory reasons for neovascular
activity in AMD.[86] Therefore, interrupting the
angiogenesis cascade by inhibiting inflammatory
agents may prove effective in the treatment of
neovascular AMD. Kurup et al[87] treated two
patients who were refractive to conventional anti-
VEGF therapy. They injected 400 µg intravitreal
MTX and at the two-week follow-up visit, visual
acuity improved, and perifoveal subretinal fluid
and leakage were decreased. As safety indices
are unknown, they proposed that this treatment
should be used for selected patients who are
refractory to traditional treatments. Soheilian and
coworkers[88] assessed the effect of combined
intravitreal MTX and bevacizumab on choroidal
neovascularization in AMD. They injected 400 µg
of MTX combined with 1.25 mg of bevacizumab.
The mean visual acuity improved and the mean
central macular thickness (CMT) decreased. They
suggested that the addition of intravitreal MTX
to bevacizumab is safe and may enhance the
therapeutic effect of bevacizumab for regression
of neovascular complex. They proposed that MTX
may also decrease the development of fibrous
component and scar formation based on OCT and
fundus images.

Epithelial downgrowth

Epithelial downgrowth, characterized by
intraocular migration of epithelial cells, can lead
to endothelial decompensation, angle-closure
glaucoma, intractable pain, and TRD.[89] Several
methods such as membrane peeling, argon laser,
excision of affected intraocular structures, and
fluorouracil injection have been reported for
treatment of this condition;[90] however, more
than half of these patients are unresponsive to
treatment.[89] Lambert et al[91] reported the use of
multiple intravitreal injection of MTX for treatment
of a patient with recurrent epithelial downgrowth.
The patient was followed for 14 months after his
last injection and neither recurrence nor any side
effect was seen. In another study, a patient who
was suffering from epithelial downgrowth due to
previous radial keratotomy and trabeculectomy
was treated successfully with the injection of 400
µg intravitreal MTX every two weeks for six doses.
Epithelial downgrowth was successfully resolved
and no remnant of the epithelial downgrowth

was visible.[92] Hardwig reported a patient with
idiopathic fibrovascular proliferation for whom
intravitreal injection of 200 µg MTX was done. The
patient experienced four lines increase in visual
acuity three months after the treatment.[54]

MTX Toxicity

Corneal epitheliopathy as the most common
adverse effect of intravitreal injection of MTX
is believed to be due to the local spillage of
MTX into the subconjunctival space resulting in
damage to the limbal stem cells which causes a
transient limbal stem cell deficiency, and therefore
corneal haze and epithelial breakdown.[93] In
some studies, all patients develop some form
of keratopathy, ranging from diffuse punctate
keratopathy to severe epitheliopathy, which
usually appears after the third injection. These
patients usually respond well to short courses of
topical lubricants, topical steroids, and increasing
the interval between injections. Topical folinic acid
0.003% and systemic folic acid 1 mg once daily
could be effective in those who were unresponsive
to lubrication.[29, 39, 93] Zhou et al attempted to
reduce the incidence of keratopathy caused
by intravitreal MTX. They divided patients into
two groups. Group A received intravitreal MTX
at a dosage of 400 μg twice a week for the
first four weeks, weekly for the following eight
weeks, and then monthly for the last nine months.
Patients in group B were started on the treatment
protocol described above and switched directly
to monthly injection for nine months when ocular
remission was achieved. They showed that with
a reduced injection frequency, the incidence of
keratopathy could be lowered by about 60%
without ocular recurrence during follow-up.[94]
In another study, Sahay et al reported a patient
with diffuse large B-cell lymphoma and ocular
involvement which was treated with weekly
injections of intravitreal MTX in both eyes. The
patient developed severe photophobia, tearing,
and a decrease in vision due to severe limbitis
with annular corneal epitheliopathy and corneal
haze. Further injections were discontinued and the
patient received topical lubricants, cyclosporine,
loteprednol, folinic acid, and systemic folic acid
which resulted in complete resolution at two-
week follow-up.[95] Ghasemi Falavarjani and
colleagues evaluated the effect of intravitreal
MTX injection (400 µg) on corneal endothelial

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Intravitreal Methotrexate; Abdi et al

cells in eyes with persistent DME. They assessed
corneal endothelial cell features using specular
microscopy. After six months of follow-up, they
showed that intravitreal injection of 400 µg MTX
had no significant effect on corneal endothelial cell
measurements.[96] They did not observe clinically
significant keratopathy in their series. Progression
of preexisting cataract is also noted as a side
effect of intravitreal MTX injection, however, the
majority of evaluated patients were vitrectomized
that predisposed the eyes to the progression
of cataract.[39] Band keratopathy and iris and
anterior chamber angle neovascularization with
subsequent neovascular glaucoma were also
reported as a rare complications of intravitreal
injection of MTX.[29] Choudhury et al reported two
patients, one having idiopathic retinal vasculitis
and the other having pars planitis in association
with CME who received intravitreal injection
of MTX. Following intravitreal injections, both
patients experienced pain and a decrease in vision
within 24 hr of receiving intravitreal MTX injection.
Vitreous samples and cultures of used and unused
vials of MTX from the same batch grew Ralstonia
pickettii. Patients received intravitreal injection
of vancomycin, amikacin, and dexamethasone
with the diagnosis of acute endophthalmitis which
resulted in visual recovery. This outbreak was
caused by drug contamination at the compounding
pharmacy.[97] Hardwig and colleagues showed that
intravitreal MTX is safe for non-PCNSL indications,
as there was only one case among 16 treated
patients who developed corticosteroid-responsive
sterile endophthalmitis.[54] In another study,
Hardwig et al evaluated the visual results of
intra-silicone injection of MTX at the time of or
after the surgery for retinal detachment. They
suggested that cumulative dosages of MTX
ranging from 200 µg to 1200 µg is safe as there
were no adverse effects observed following single
injection or serial injections.[98] Maculopathy,
vitreous hemorrhage, and optic atrophy were
also reported as rare complications of intravitreal
MTX.[39]

DISCUSSION

Intravitreal MTX has been used in several
ophthalmic conditions such as intraocular
tumors, DME, AMD, PVR, uveitis, and epithelial
downgrowth, showing promising results in many
of these conditions. While the treatment is highly

effective in intraocular lymphoma and uveitis, the
efficacy in other diseases remains to be confirmed.

MTX, a steroid-sparing agent, is becoming
more popular and even the first-choice drug
in some conditions that require long-term
immunosuppression.[99] MTX exerts its anti-
inflammatory and immunomodulatory effects
through several mechanisms such as inhibition
of DHFR, increasing level of intracellular and
extracellular adenosine, inhibiting the reduction
of dihydrobiopterin to tetrahydrobiopterin,
modulation of expression of lincRNA- p21, inhibition
of JAK-STAT signaling pathway, and modulation
of functions of T-cells and monocytes.[2] The
mechanism of action of the intravitreal MTX is
believed to be similar to its administration for other
systemic diseases.[2, 100]

Intravitreal MTX is considered safe with the
current doses. The most common side effect is
corneal epitheliopathy after repetitive injections
which is easily treated with frequent lubrication
and increasing the interval between injections.
Few other side effects such as progression
of preexisting cataracts, neovascular glaucoma,
maculopathy, vitreous hemorrhage, and corneal
endotheliopathy are very rare and the Causal
associations are unclear.

Intravitreal MTX is generally well tolerated and
avoids the side effects of systemic administration
of MTX or alternative drugs. Although current
routine clinical applications are limited to some
forms of intraocular tumors and uveitis, the use
of intravitreal MTX needs further investigations
for other clinical applications. Different studies
have shown some promise for intravitreal MTX
in diabetic retinopathy, AMD, and after retinal
detachment surgery; however, larger, randomized,
multi-center clinical trials with long-term follow-ups
are required to clarify the benefits of intravitreal
MTX in different vitreoretinal diseases.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

The authors do not have any conflicts of interest.

REFERENCES

1. Mukherjee S. The emperor of all maladies: a biography of
cancer. Scribner, 2011.

666 JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 16, ISSUE 4, OCTOBER-DECEMBER 2021



Intravitreal Methotrexate; Abdi et al

2. Cronstein BN, Aune TM. Methotrexate and its mechanisms
of action in inflammatory arthritis. Nat Rev Rheumatol
2020;16:145–154.

3. Green JM. Glucarpidase to combat toxic levels of
methotrexate in patients. Ther Clin Risk Manag
2012;8:403–413.

4. Weinblatt ME. Methotrexate in rheumatoid arthritis: a
quarter century of development. Trans Am Clin Climatol
Assoc 2013;124:16–25.

5. Cronstein BN, Sitkovsky M. Adenosine and adenosine
receptors in the pathogenesis and treatment of rheumatic
diseases. Nat Rev Rheumatol 2017;13:41–51.

6. Crabtree MJ, Tatham AL, Hale AB, Alp NJ, Channon
KM. Critical role for tetrahydrobiopterin recycling by
dihydrofolate reductase in regulation of endothelial nitric-
oxide synthase coupling: relative importance of the de
novo biopterin synthesis versus salvage pathways. J Biol
Chem 2009;284:28128–28136.

7. Huarte M, Guttman M, Feldser D, Garber M, Koziol MJ,
Kenzelmann-Broz D, et al. A large intergenic noncoding
RNA induced by p53 mediates global gene repression in
the p53 response. Cell 2010;142:409–419.

8. Malemud CJ. The role of the JAK/STAT signal pathway
in rheumatoid arthritis. Ther Adv Musculoskelet Dis
2018;10:117–127.

9. Spurlock CF, 3rd, Gass HMt, Bryant CJ, Wells BC, Olsen
NJ, Aune TM. Methotrexate-mediated inhibition of nuclear
factor kappaB activation by distinct pathways in T cells and
fibroblast-like synoviocytes. Rheumatology 2015;54:178–
187.

10. Olsen NJ, Spurlock CF, 3rd, Aune TM. Methotrexate
induces production of IL-1 and IL-6 in the monocytic cell
line U937. Arthritis Res Ther 2014;16:R17.

11. Brown PM, Pratt AG, Isaacs JD. Mechanism of action of
methotrexate in rheumatoid arthritis, and the search for
biomarkers. Nat Rev Rheumatol 2016;12:731–742.

12. Chan ES, Cronstein BN. Mechanisms of action of
methotrexate. Bull Hosp Jt Dis 2013;71: S5–S8.

13. Gangaputra S, Newcomb CW, Liesegang TL, Kaçmaz RO,
Jabs DA, Levy-Clarke GA, et al. Methotrexate for ocular
inflammatory diseases. Ophthalmology 2009;116:2188–
2198 e2181.

14. Ericson L, Karlberg B, Rosengren BH. Trials of intravitreal
injections of chemotherapeutic agents in rabbits. Acta
Ophthalmol 1964;42:721–726.

15. Ozkan EB, Ozcan AA, Sekeroglu HT, Kuyucu Y, Ozgun
H, Polat S. Intravitreal injection of methotrexate in an
experimental rabbit model: determination of ultrastructural
changes. Indian J Ophthalmol 2013;61:329–333.

16. Aly E, Ebrahim A. Apoptosis and electroretinogram after
intravitreal injection of methotrexate in an experimental
rabbit model. Gen Physiol Biophys 2016;35:231–236.

17. Tian XM, Zhu Y. Apoptosis of rabbit retinal cell after eyeball
rupture. Asian Pac J Trop Med 2013;6:273–279.

18. Hara A, Niwa M, Kumada M, Aokie H, Kunisadae
T, Oyamaa T, et al. Intraocular injection of folate
antagonist methotrexate induces neuronal differentiation
of embryonic stem cells transplanted in the adult mouse
retina. Brain Res 2006;1085:33–42.

19. Palakurthi NK, Correa ZM, Augsburger JJ, Banerjee RK.
Toxicity of a biodegradable microneedle implant loaded

with methotrexate as a sustained release device in
normal rabbit eye: a pilot study. J Ocul Pharmacol Ther
2011;27:151–156.

20. Sunalp M, Wiedemann P, Sorgente N, Ryan SJ. Effects
of cytotoxic drugs on proliferative vitreoretinopathy in the
rabbit cell injection model. Curr Eye Res 1984;3:619–623.

21. Dorr RT, Fritz WL. Cancer chemotherapy handbook.
Elsevier; 1980.

22. Deng SX, Penland S, Gupta S, Fiscella R, Edward DP,
Tessler HH, et al. Methotrexate reduces the complications
of endophthalmitis resulting from intravitreal injection
compared with dexamethasone in a rabbit model. Invest
Ophthalmol Vis Sci 2006;47:1516–1521.

23. Abbaszadeh Hasiri M, Baghaei Moghaddam E, Khalili MR,
Amini AH, Eghtedari M, Azizzadeh M, et al. Intra-vitreal
injection of methotrexate in experimental endotoxin-
induced uveitis in rabbit. Vet Res Forum 2018;9:315–321.

24. Abramson DH, Schefler AC. Update on retinoblastoma.
Retina 2004;24:828-848.

25. Hurwitz RL, Chevez-Barrios P, Boniuk M, Chintagumpala
M, Hurwitz MY. Retinoblastoma: from bench to bedside.
Expert Rev Mol Med 2003;5:1–14.

26. Shields CL, Shields JA. Diagnosis and management of
retinoblastoma. Cancer Control 2004;11:317–327.

27. Shields CL, Mashayekhi A, Au AK, Czyz C, Leahey
A, Meadows AT, et al. The International Classification
of Retinoblastoma predicts chemoreduction success.
Ophthalmology 2006;113:2276–2280.

28. Kivela T, Eskelin S, Paloheimo M. Intravitreal methotrexate
for retinoblastoma. Ophthalmology 2011;118:1689, 1689
e1681–1686.

29. Frenkel S, Hendler K, Siegal T, Shalom E, Pe’er J.
Intravitreal methotrexate for treating vitreoretinal
lymphoma: 10 years of experience. Br J Ophthalmol
2008;92:383–388.

30. Gorlick RG, Abramson DH, Sowers R, Mazza BA, Dunkel
IJ. Impairments in antifolate transport are common in
retinoblastoma tumor samples. Pediatr Blood Cancer
2008;50:573–576.

31. Chihara D, Dunleavy K. Primary central nervous system
lymphoma: evolving biologic insights and recent
therapeutic advances. Clin Lymphoma Myeloma Leuk
2020;21:73–79.

32. Shiels MS, Pfeiffer RM, Besson C, Clarke CA, Morton LM,
Nogueira L, et al. Trends in primary central nervous system
lymphoma incidence and survival in the U.S. Br J Haematol
2016;174:417–424.

33. Coupland SE, Damato B. Understanding intraocular
lymphomas. Clin Exp Ophthalmol 2008;36:564–578.

34. Coupland SE, Heimann H, Bechrakis NE. Primary
intraocular lymphoma: a review of the clinical,
histopathological and molecular biological features.
Graefes Arch Clin Exp Ophthalmol 2004;242:901–913.

35. Hoffman PM, McKelvie P, Hall AJ, Stawell RJ, Santamaria
JD. Intraocular lymphoma: a series of 14 patients with
clinicopathological features and treatment outcomes. Eye
2003;17:513–521.

36. Isobe K, Ejima Y, Tokumaru S, Shikama N, Suzuki G,
Takemoto M, et al. Treatment of primary intraocular
lymphoma with radiation therapy: a multi-institutional
survey in Japan. Leuk Lymphoma 2006;47:1800–1805.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 16, ISSUE 4, OCTOBER-DECEMBER 2021 667



Intravitreal Methotrexate; Abdi et al

37. Teckie S, Yahalom J. Primary intraocular lymphoma:
treatment outcomes with ocular radiation therapy alone.
Leuk Lymphoma 2014;55:795–801.

38. Fishburne BC, Wilson DJ, Rosenbaum JT, Neuwelt EA.
Intravitreal methotrexate as an adjunctive treatment of
intraocular lymphoma. Arch Ophthalmol 1997;115:1152–
1156.

39. Smith JR, Rosenbaum JT, Wilson DJ, Doolittle ND, Siegal
T, Neuwelt EA, et al. Role of intravitreal methotrexate
in the management of primary central nervous system
lymphoma with ocular involvement. Ophthalmology
2002;109:1709–1716.

40. Goldberg S, Frenkel S, Blumenthal EZ, Solomon A, Pe’er
J. Intraocular lymphoma. Ophthalmology 2007;114:1236–
1237.

41. Kaur M, Sahu S, Sharma N, Titiyal JS. Femtosecond laser-
assisted cataract surgery in phakic intraocular lens with
cataract. J Refract Surg 2016;32:131–134.

42. Omoti AE, Omoti CE. Ophthalmic manifestations of
lymphoma. Ann Afr Med 2007;6:89–93.

43. Ong YL, White S. Intra-vitreal methotrexate leads to
resolution of intraocular chronic lymphocytic leukaemia. Br
J Haematol 2010;148:181.

44. Mello LGM, de Paula Effgen P, Kiefer K. Intravitreal
methotrexate for iris and ciliary body relapse in acute
lymphoblastic leukemia. J Pediatr Ophthalmol Strabismus
2018;55:e16–e19.

45. Reddy R, Kim SJ. Intraocular T-cell lymphoma due
to mycosis fungoides and response to intravitreal
methotrexate. Ocul Immunol Inflamm 2011;19:234–236.

46. Ryan ME, Shantha JG, Grossniklaus HE, Yeh S. Secondary
vitreoretinal lymphoma masquerading as acute retinal
necrosis. Ophthalmic Surg Lasers Imaging Retina
2015;46:1048–1050.

47. Schieber M, Gordon LI, Karmali R. Current overview and
treatment of mantle cell lymphoma. F1000Res 2018;7:
F1000 Faculty Rev-1136.

48. Singer JR, Nigalye AK, Champion MT, Welch MJ.
Intravitreal methotrexate for mantle cell lymphoma
infiltration of the optic nerves: a case report. Retin Cases
Brief Rep 2018;12:5–9.

49. Zhang P, Tian J, Gao L. Intraocular lymphoma
masquerading as recurrent iridocyclitis: findings based
on in vivo confocal microscopy. Ocul Immunol Inflamm
2018;26:362–364.

50. Wickremasinghe SS, Ojaimi E, Lim L, Stawell R, McKelvie P,
Zamir E. Intravitreal methotrexate as adjunctive, palliative
therapy in intraocular T-cell lymphoma. Ocul Immunol
Inflamm 2010;18:184–186.

51. Rothova A, Suttorp-van Schulten MS, Frits Treffers W,
Kijlstra A. Causes and frequency of blindness in patients
with intraocular inflammatory disease. Br J Ophthalmol
1996;80:332–336.

52. Chen SC, Sheu SJ. Recent advances in managing and
understanding uveitis. F1000Res 2017;6:280.

53. Shah KK, Majumder PD, Biswas J. Intravitreal therapeutic
agents in noninfectious uveitic macular edema. Indian J
Ophthalmol 2018;66:1060–1073.

54. Hardwig PW, Pulido JS, Erie JC, Baratz KH, Buettner
H. Intraocular methotrexate in ocular diseases other
than primary central nervous system lymphoma. Am J
Ophthalmol 2006;142:883–885.

55. Taylor SR, Habot-Wilner Z, Pacheco P, Lightman SL.
Intraocular methotrexate in the treatment of uveitis
and uveitic cystoid macular edema. Ophthalmology
2009;116:797–801.

56. Taylor SR, Banker A, Schlaen A, Couto C, Matthe E, Joshi
L, et al. Intraocular methotrexate can induce extended
remission in some patients in noninfectious uveitis. Retina
2013;33:2149–2154.

57. Khalil HE, El Gendy HA, Youssef HA, Haroun HE, Gheita TA,
Bakir HM. The effectiveness of intraocular methotrexate
in the treatment of posterior uveitis in Behcet’s disease
patients compared to retrobulbar steroids injection. J
Ophthalmol 2016;2016:1678495.

58. Bae JH, Lee SC. Effect of intravitreal methotrexate
and aqueous humor cytokine levels in refractory retinal
vasculitis in Behcet disease. Retina 2012;32:1395–1402.

59. Dutta Majumder P, Biswas J, Gupta A. Enigma
of serpiginous choroiditis. Indian J Ophthalmol
2019;67:325–333.

60. Vasconcelos-Santos DV, Rao PK, Davies JB, Sohn EH,
Rao NA. Clinical features of tuberculous serpiginouslike
choroiditis in contrast to classic serpiginous choroiditis.
Arch Ophthalmol 2010;128:853–858.

61. Gupta V, Bansal R, Gupta A. Continuous progression
of tubercular serpiginous-like choroiditis after
initiating antituberculosis treatment. Am J Ophthalmol
2011;152:857–863 e852.

62. Tsui E, Fern CM, Goldberg NR. Treatment of refractory
tubercular serpiginous-like choroiditis with intravitreal
methotrexate. Retin Cases Brief Rep 2021;15:169–173.

63. Sahin O, Ziaei A. The role of methotrexate in resolving
ocular inflammation after specific therapy for presumed
latent syphilitic uveitis and presumed tuberculosis-related
uveitis. Retina 2014;34:1451–1459.

64. Chin EK, Almeida DR, Mahajan VB. Management
of choroidal granulomas involving the macula in
corticosteroid-intolerant patients. JAMA Ophthalmol
2015;133:1351–1352.

65. Wu XN, Lightman S, Tomkins-Netzer O. Viral retinitis:
diagnosis and management in the era of biologic
immunosuppression: A review. Clin Exp Ophthalmol
2019;47:381–395.

66. Huang EJ, Wang CP, Lai CH, Chen C-C, Kuo C-N.
Rapid regression of cystoid macular edema associated
with cytomegalovirus retinitis in adult acute myeloid
leukemia by intravitreal methotrexate combined with oral
valganciclovir: A case report with comparison of binocular
outcome. Taiwan J Ophthalmol 2016;6:145–149.

67. Mashima A, Usui Y, Umazume K, Muramatsu D, Goto H.
Successful treatment of necrotizing retinitis with epstein-
barr virus-positive ocular fluid by intravitreal methotrexate
injection. Ocul Immunol Inflamm 2020;28:552–555.

68. Machemer R, Aaberg TM, Freeman HM, Irvine AR, Lean
JS, Michels RM. An updated classification of retinal
detachment with proliferative vitreoretinopathy. Am J
Ophthalmol 1991;112:159–165.

69. Leiderman YI, Miller JW. Proliferative vitreoretinopathy:
pathobiology and therapeutic targets. Semin Ophthalmol
2009;24:62–69.

70. Pastor JC, de la Rua ER, Martin F. Proliferative
vitreoretinopathy: risk factors and pathobiology. Prog
Retin Eye Res 2002;21:127–144.

668 JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 16, ISSUE 4, OCTOBER-DECEMBER 2021



Intravitreal Methotrexate; Abdi et al

71. Rubsamen PE, Cousins SW. Therapeutic effect of
periocular corticosteroids in experimental proliferative
vitreoretinopathy. Retina 1997;17:44–50.

72. Gagliano C, Toro MD, Avitabile T, Stella S, Uva MG.
Intravitreal steroids for the prevention of PVR after surgery
for retinal detachment. Curr Pharm Des 2015;21:4698–
4702.

73. Denstedt J, Schulz DC, Diaconita V, Sheidow T.
Acupuncture resulting in eye penetration and proliferative
vitreoretinopathy – surgical and medical management
with intraocular methotrexate. Am J Ophthalmol Case
Rep 2020;18:100605.

74. Benner JD, Dao D, Butler JW, Hamill KI.
Intravitreal methotrexate for the treatment of
proliferative vitreoretinopathy. BMJ Open Ophthalmol
2019;4:e000293.

75. Falavarjani KG, Hadavandkhani A, Parvaresh MM,
Modarres M, Naseripour M, Alemzadeh SA. Intra-silicone
oil Injection of methotrexate in retinal reattachment
surgery for proliferative vitreoretinopathy. Ocul Immunol
Inflamm 2020;28:513–516.

76. Nourinia R, Borna F, Rahimi A, Bonyadi MHJ, Amizadeh Y,
Daneshtalab A, et al. Repeated injection of methotrexate
into silicone oil-filled eyes for grade C proliferative
vitreoretinopathy: a pilot study. Ophthalmologica
2019;242:113–117.

77. Sadaka A, Sisk RA, Osher JM, Toygar O, Duncan
MK, Riemann CD. Intravitreal methotrexate infusion
for proliferative vitreoretinopathy. Clin Ophthalmol
2016;10:1811–1817.

78. Chan ES, Cronstein BN. Methotrexate–how does it really
work? Nat Rev Rheumatol 2010;6:175–178.

79. NIH. The GUARD trial - part 1: a phase 3
clinical trial for prevention of proliferative
vitreoretinopathy [Internet]. NIH; 2019. Available from:
https://ClinicalTrials.gov/show/NCT04136366.

80. Ghasemi Falavarjani K, Modarres M, Hadavandkhani A,
Moghaddam AK. Intra-silicone oil injection of methotrexate
at the end of vitrectomy for advanced proliferative diabetic
retinopathy. Eye 2015;29:1199–1203.

81. Das A, McGuire PG, Rangasamy S. Diabetic macular
edema: pathophysiology and novel therapeutic targets.
Ophthalmology 2015;122:1375–1394.

82. Rangasamy S, McGuire PG, Das A. Diabetic retinopathy
and inflammation: novel therapeutic targets. Middle East
Afr J Ophthalmol 2012;19:52–59.

83. Diabetic Retinopathy Clinical Research N, Beck RW,
Edwards AR, Aiello LP, Bressler NM, Ferris F, et al. Three-
year follow-up of a randomized trial comparing focal/grid
photocoagulation and intravitreal triamcinolone for
diabetic macular edema. Arch Ophthalmol 2009;127:245–
251.

84. Falavarjani KG, Golabi S, Modarres M. Intravitreal injection
of methotrexate in persistent diabetic macular edema: a 6-
month follow-up study. Graefes Arch Clin Exp Ophthalmol
2016;254:2159–2164.

85. Fazel F, Oliya B, Mirmohammadkhani M, Fazel M,
Yadegarfar G, Pourazizi M. Intravitreal injections of
bevacizumab plus methotrexate versus bevacizumab
alone for the treatment of diabetic macular edema: a

randomized, sham-controlled trial. J Curr Ophthalmol
2020;32:164–169.

86. Bandyopadhyay M, Rohrer B. Matrix metalloproteinase
activity creates pro-angiogenic environment in primary
human retinal pigment epithelial cells exposed to
complement. Invest Ophthalmol Vis Sci 2012;53:1953–
1961.

87. Kurup SK, Gee C, Greven CM. Intravitreal methotrexate
in therapeutically resistant exudative age-related macular
degeneration. Acta Ophthalmol 2010;88:e145–e146.

88. Soheilian M, Movaseghi M, Ramezani A, Peyman GA.
Pilot study of safety and effect of combined intravitreal
bevacizumab and methotrexate for neovascular age-
related macular degeneration. Eur J Ophthalmol
2011;21:77–82.

89. Weiner MJ, Trentacoste J, Pon DM, Albert DM. Epithelial
downgrowth: a 30-year clinicopathological review. Br J
Ophthalmol 1989;73:6–11.

90. Wong RK, Greene DP, Shield DR, Eberhart CG, Huang
JJ, Shayegani A. 5-Fluorouracil for epithelial downgrowth
after Descemet stripping automated endothelial
keratoplasty. Cornea 2013;32:1610–1612.

91. Lambert NG, Wilson DJ, Albert DM, Chamberlain
WD. Intravitreal methotrexate for recurrent epithelial
downgrowth. JAMA Ophthalmol 2019;137:1082–1083.

92. Lee MD, Wu F, Schallhorn JM. Successful treatment
of epithelial ingrowth with intravitreal methotrexate.
Ophthalmology 2019;126:48.

93. Gorovoy I, Prechanond T, Abia M, Afshar AR, Stewart JM.
Toxic corneal epitheliopathy after intravitreal methotrexate
and its treatment with oral folic acid. Cornea 2013;32:1171–
1173.

94. Zhou X, Zhou X, Shi H, Lai J, Wang Q, Li Y, et al. Reduced
frequency of intravitreal methotrexate injection lowers the
risk of keratopathy in vitreoretinal lymphoma patients.
BMC Ophthalmol 2020;20:189.

95. Sahay P, Maharana PK, Temkar S, Chawla R. Corneal
epithelial toxicity with intravitreal methotrexate in a case of
B-cell lymphoma with ocular involvement. BMJ Case Rep
2018;2018: bcr2018226005.

96. Ghasemi Falavarjani K, Golabi S, Hadavandkhani A. Effect
of intravitreal injection of methotrexate on human corneal
endothelial cells. Cornea 2016;35:217–219.

97. Choudhury H, Jindal A, Pathengay A, Flynn HW, Jr. An
outbreak of Ralstonia pickettii endophthalmitis following
intravitreal methotrexate injection. Clin Ophthalmol
2015;9:1117–1120.

98. Hardwig PW, Pulido JS, Bakri SJ. The safety of intraocular
methotrexate in silicone-filled eyes. Retina 2008;28:1082–
1086.

99. Sipkova Z, Insull EA, David J, Turner HE, Keren S, Norris
JH. Early use of steroid-sparing agents in the inactivation
of moderate-to-severe active thyroid eye disease: a step-
down approach. Clin Endocrinol 2018;89:834–839.

100. Mateo-Montoya A, Baglivo E, de Smet MD.
Intravitreal methotrexate for the treatment of choroidal
neovascularization in multifocal choroiditis. Eye
2013;27:277–278.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 16, ISSUE 4, OCTOBER-DECEMBER 2021 669