Dr. David H. Abramson of Memorial Sloan Kettering Cancer Center has presented groundbreaking findings that challenge the traditional understanding of Coats' disease, revealing both genetic insights and potential treatment implications for this rare eye condition.
At the 2025 New York State Ophthalmological Society (NYSOS) Annual Meeting, Abramson shared results from a pediatric case initially misdiagnosed as retinoblastoma but later confirmed as Coats' disease through detailed imaging. The findings have significant implications for how ophthalmologists understand and approach this challenging condition.
Bilateral Presentation Challenges Conventional Understanding
Perhaps most striking among Abramson's findings is evidence contradicting the long-held belief that Coats' disease is exclusively unilateral. Through peripheral retinal fluorescein angiography—a relatively recent addition to ophthalmological practice—Abramson's team detected subtle abnormalities in the fellow eyes of Coats' disease patients.
"A few years ago, we began doing fluorescein angiograms of the peripheral retina, something we really hadn't done in ophthalmology until relatively recently, and in many, maybe even all of our Coats' patients, we were seeing subtle abnormalities in the fellow eye," Abramson explained to HCPLive.
This discovery suggests that while Coats' disease may present clinically as unilateral, the underlying pathology could be bilateral in many—possibly all—cases. The limited application of fluorescein imaging until recently may explain why this bilateral presentation has gone largely undetected.
Genetic Underpinnings and Telomere Biology
Following this discovery, Abramson's team conducted genetic testing, measuring the patient's telomere length. Previous research has indicated that approximately 10 genes known to influence telomere length are also associated with Coats' disease.
The genetic investigation identified a variation in the LTBP2 gene, previously linked to conditions such as pseudo-exfoliation, open-angle glaucoma, and Marfan syndrome, but not previously associated with Coats' disease. This finding supports Abramson's assertion that "the concept that one gene can cause many diseases is something we are more and more finding is true in ophthalmology."
Treatment Challenges and Combination Approaches
Coats' disease presents significant treatment challenges, particularly in advanced stages. While early-stage, localized disease limited to approximately 90 degrees of the retina can often be managed effectively with laser photocoagulation, more extensive cases typically progress to subretinal exudation, retinal detachment, neovascular glaucoma, and potentially loss of the eye.
Abramson noted that anti-VEGF agents, despite their success in other exudative retinal pathologies, have shown limited and unpredictable effectiveness in Coats' disease. However, the presented case involved a successful outcome using combination therapy with laser and anti-VEGF treatment.
"I've had a suspicion—but I don't really have anything more than a suspicion—that it's the patients who have the telomere biology disorders causing Coats' who are the ones that actually do respond to anti-VEGF agents," Abramson hypothesized.
Surgical Management and Realistic Outcomes
Surgical intervention for total retinal detachment in Coats' disease, while technically straightforward, often proves ineffective due to the viscous nature of chronic subretinal exudate, which Abramson compares to honey. This high failure rate has led many experienced pediatric retinal surgeons to advocate for conservative management in advanced cases.
Importantly, Abramson reframes expectations for successful treatment: "Success here is not determined as getting good vision. Success is keeping the eye and, of course, identifying what [the disease] is."
Existing treatments frequently result in subfoveal, submacular, and subretinal scarring, leading to profound vision impairment—an unfortunate but often unavoidable consequence of intervention.
"Coats' Plus" and Systemic Implications
Abramson's genetic findings further expand understanding of Coats' disease beyond an isolated ocular condition. He describes a broader systemic context, categorized as "Coats' plus," characterized by multi-organ involvement including cardiac, hepatic, pulmonary, dermatologic, neurocognitive, and hematologic manifestations, with potential risks of malignancy and bone marrow failure.
While gene-targeted therapies for Coats' disease do not yet exist, recognizing these systemic associations enables earlier multidisciplinary interventions and more comprehensive patient care.
Future Directions
Abramson emphasizes the importance of evolving beyond outdated clinical paradigms by integrating both modern imaging techniques and genetic diagnostics. This integrated approach promises to improve outcomes and guide long-term management strategies for patients with Coats' disease.
The findings underscore the value of continued research into the genetic foundations of rare eye diseases and highlight how advanced imaging technologies can reveal previously undetected aspects of familiar conditions, potentially leading to more effective treatment approaches in the future.
