Intravitreal bevacizumab for macular edema secondary to central retinal vein occlusion may induce resolution of macular edema. However, the possibility of a rebound macular edema thicker than at the initial presentation after intravitreal bevacizumab injections has been reported. A case of dramatic deterioration of central retinal vein condition with hemorrhagic macular infarction 3 weeks after intravitreal injection of bevacizumab is presented.
Hemorrhagic Macular Infarction After Intravitreal Bevacizumab for Central Retinal Vein Occlusion
From the Dipartimento di Oftalmologia ed Otorinolaringoiatria, Università di Bari, Bari, Italy.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Claudio Furino, Dipartimento di Oftalmologia ed Otorinolaringoiatria – Università di Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy.
Accepted: June 08, 2009
Posted Online: March 09, 2010
Bevacizumab (Avastin, Genentech Inc., San Francisco, CA) is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF) approved in 2004 by the Food and Drug Administration for intravenous use in metastatic colorectal cancer and since 2007 by Italian National Health Care System for intravitreal injection for choroidal neovascularization secondary to age related macular degeneration or neovascular glaucoma.
Intravitreal bevacizumab has also been injected as a treatment for macular edema secondary to central retinal vein occlusion (CRVO).1–6 In these uncontrolled case series it appeared to have a positive effect in reducing cystoid macular edema and improving vision. In this report, we present a case of dramatic deterioration of retinal pathology of one patient affected by CRVO 3 weeks after intravitreal injection of bevacizumab.
A 70-year-old Caucasian man with diagnosis of CRVO and macular edema in left pseudophakic eye was scheduled for intravitreal injection of bevacizumab. Diagnosis of CRVO was made 3 months before treatment. Best-corrected visual acuity (BCVA) was 20/100 and intraocular pressure (IOP) was 15 mm Hg. Retinal fundus presented numerous intraretinal hemorrhages in all 4 quadrants and in posterior pole, macular edema and dilatation of retinal veins, as revealed by red free fundus photograph and fluorescein angiography (Figs. 1A and 1B). After obtaining signed informed consent, the patient received an intravitreal injection of 0.05 mL (1.25 mg) of bevacizumab in a sterile fashion, and prophylactic topical antibiotics were given for 2 days after injection. No intraoperative and early postoperative complications were observed. Three weeks later, BCVA decreased to 20/320, IOP was 15 mm Hg, and retinal fundus presented a dramatic deterioration of the pathology with an increased number of hemorrhages, increased macular edema and hemorrhagic star-shaped macular infarction as demonstrated by red free photograph and fluorescein angiography (Figs. 2A and 2B).
Figure 1. Baseline. Best-Corrected Visual Acuity of 20/100. Red Free Photograph (A) and Fluorescein Angiography (B) Haemorrhages in 4 Quadrants and Posterior Pole, Macular Edema, and Vein Congestion.
Figure 2. Three Weeks After Intravitreal Bevacizumab Injection. Best-Corrected Visual Acuity of 20/320. Red Free Photograph (A) and Fluorescein Angiography (B) a Dramatic Deterioration of Retinal Condition with Haemorrhagic Macular Infarction.
There are several reports of intravitreal bevacizumab for macular edema secondary to CRVO showing resolution of macular edema both clinically and on fluorescein angiography with one or more injections.1–6 These published reports have also demonstrated that intravitreal bevacizumab is well-tolerated and has a favorable safety profile even if there is the possibility of a rebound macular edema, more pronounced than at the initial presentation, after intravitreal bevacizumab injections for venous occlusive disease.7
In our case the intravitreal bevacizumab injection seems to have deteriorated the occlusive retinal condition as a recrudescence of CRVO has been induced. Perhaps the effect itself of bevacizumab stimulated a second episode of CRVO in the same way as in tumor-bearing animals study in which it has been demonstrated that antiangiogenic therapy increased tumor blood flow and oxygen delivery at least during the first weeks of therapy.8
This case suggest a potential limitation in using relatively short-acting VEGF antagonists in retinal vascular disease of a chronic nature. Until the short-and long-term safety of injection of these agents is established, we recommend caution in using this treatment strategy for CRVO.
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