Table 3.
Therapeutic strategy for ocular complications in PDB based on pathogenic mechanism
| Ocular Complication | Dominant Mechanism | Role of Systemic Therapy (Bis/Denosumab) |
Necessity of Ocular-Specific Therapy | Therapeutic Synergy & Timing |
|---|---|---|---|---|
| Vascular Optic Neuropathy | Vascular “Steal” / Hyperemia | Direct & Primary: Suppresses pagetic hypermetabolism/hypervascularity to reverse ischemia | Adjunct: Corticosteroids may be used acutely to reduce optic nerve edema/inflammation; severe cases may consider vascular embolization | Concurrent/Sequential: Start systemic anti-resorptive urgently; consider short-term steroids for acute presentation |
| Compressive Optic Neuropathy | Bony Stenosis / Mechanical | Foundational/Preventive: Halts progression of hyperostosis; does not reverse existing compression | Necessary & Definitive: Surgical decompression is indicated for progressive or severe compression | Sequential: Optimize systemic control preoperatively to reduce bleeding risk; surgery addresses fixed anatomy |
| Orbital GCT causing Ptosis | Mass Effect | Variable/Adjuvant: Denosumab may induce tumor regression; bisphosphonates control background PDB activity | Necessary & Definitive: Surgical excision is primary treatment for symptomatic mass effect | Combined/Neoadjuvant: Consider denosumab to shrink tumor preoperatively; surgery for definitive removal |
| AS with CNV | Local Neovascularization | Indirect/Supportive: Manages systemic disease but has no direct effect on CNV | Necessary & Primary: Intravitreal anti-VEGF injections are standard care for active CNV | Parallel: Treat systemic disease and ocular CNV independently but concurrently |
| Cataract | Age-related / Multifactorial | No Role | Necessary & Definitive: Cataract surgery when visually significant | Independent: Ocular surgery proceeds based on ophthalmic indication, independent of PDB status if bone is inactive |
Abbreviations: Paget’s disease of bone (PDB), Bisphosphonates (Bps), Giant Cell Tumor (GGT), Angioid Streaks (AS), Choroidal Neovascularization (CNV), Anti-Vascular Endothelial Growth Factor (anti-VEGF)