Intravitreal Methotrexate


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.


Inflammation, Intraocular Tumor, Intravitreal Injection, Methotrexate, Proliferative Vitreretinopathy, Uveitis

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

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 nitricoxide 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 endotoxininduced 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.

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 laserassisted 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 epsteinbarr 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.

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:

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. Threeyear 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 agerelated 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 stepdown 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.