Sir,

Bevacizumab is a humanised monoclonal antibody against all isoforms of vascular endothelial growth factor1 (VEGF) for the treatment of choroidal neovascularisation.

We report a case with pigment epithelial detachment (PED) that developed a retinal pigment epithelial tear after intravitreal injection of bevacizumab.

This is, to our knowledge, the first report of this finding.

Case report

A 78-year-old fit patient presented with a 3week history of decreased vision and metamorphopsia in her left eye. Best-corrected snellen visual acuity (VA) in this eye was 6/12.

Fundoscopy showed subretinal fluid at the fovea with a large PED adjacent and inferior to it (Figure 1a). These changes were secondary to age-related macular degeneration (AMD). A fundus fluorescein angiogram (FFA) confirmed the presence of a subfoveal, minimally classic, choroidal neovascular membrane (CNVM) with a fibro vascular PED (Figure 1b). Optical coherence tomography (OCT) scans confirmed the findings (Figure 1c). All scans were obtained with the Stratus® OCT scanner (Humphrey-Zeiss Inc., Dublin, CA, USA).

Figure 1
figure 1

(a) Subretinal fluid at the fovea (hollow arrow) with a large PED adjacent and inferior to it (solid arrow). Best-corrected VA was 6/12. (b) FFA 3 min and 16 s frame showed the presence of a subfoveal, minimally classic CNV with leakage and a fibrovascular PED. (c) A 3 mm single line OCT scan showing subretinal fluid (hollow arrow) and the extent of the PED (between solid arrows). (d) Retinal pigment epithelial tear inferior to the fovea after intravitreal injection of bevacizumab (2.5 mg). (Solid arrow indicates inwardly rolled edge of RPE. Hollow arrow indicates area denuded of RPE.) (e) FFA 21 s frame showed window defect corresponding to the area denuded of RPE (solid arrow) and hypofluorescence secondary blockage of choroidal fluorescence due to multilayered RPE (hollow arrow). (f) A 3 mm single line OCT scan showing fovea still apposed onto the RPE (short hollow arrow) and edge of inwardly rolled of RPE (short solid arrow) with resulting optical shadowing (long solid arrow) and increased reflectivity of outer band extent corresponding to the area denuded of RPE (long hollow arrow). VA remained unchanged as a result of the fovea remaining apposed onto the RPE despite the inferior to the fovea macular neuroretina being elevated and perpetuating the distortion of central vision.

Full size image

Photodynamic therapy (PDT) is contraindicated in the presence of a PED,2, 3, 4, 5 and therefore the patient received an intravitreal injection of 2.5 mg of bevacizumab (Avastin) with informed consent. Three weeks later left eye VA and metamorphopsia remained unchanged, although the patient had developed a retinal pigment epithelial tear inferior to the fovea (Figure 1d) and underwent FFA (Figure 1e) and OCT (Figure 1f).

Discussion

There might be the need for a high index of suspicion for retinal pigment epithelium tears in patients who report significant visual deterioration after intravitreal injection of anti-VEGF agents. Though retinal pigment epithelial tear following intravitreal injection of pegaptanib sodium has been reported by Dhalla et al.6

In view of the fact that the natural history of subfoveal minimally classic choroidal neovascularisation associated with or without fibrovascular PED is considered to be poor with respect to visual outcome and PDT results in this subgroup of patients have been unsatisfactory,4 anti-VEGF therapy with bevacizumab was offered to the patient with full-informed consent while vision was still at an acceptable level.

Deterioration of vision did not occur in our patient because the fovea had been spared by the RPE tear and as shown by the OCT scans, it has remained apposed to the RPE (Figure 1f).

This is the first report where a retinal pigment epithelial tear has occurred following an intravitreal injection of bevacizumab. Further studies are required to determine whether specific angiographic subtypes of choroidal neovascularisation are more susceptible to developing retinal pigment epithelium tears after treatment with anti-VEGF agents.