Sir,

Angioid streaks may be idiopathic or are associated with systemic conditions such as Paget's disease, Pseudoxanthoma elasticum, Ehlers Danlos syndrome, and sickle cell disease. Choroidal neovascularization (CNV) can complicate angioid streaks and lead to severe vision loss.1 Laser photocoagulation for CNV, secondary to angioid streaks, is associated with a high rate of recurrence. We report a case of successful treatment of CNV in a patient with idiopathic angioid streaks with intravitreal bevacizumab (Avastin™)(1.25 mg).

Case report

A 63-year-old Caucasian man presented to the Barnes Retina Institute with complaints of decreased vision in the right eye. His visual acuity was 20/70 in the right eye and 20/25 in the left eye. Fundus examination showed angioid streaks in both eyes, and subfoveal fibrosis and elevation of the retinal pigment epithelium (RPE) with sub-retinal haem in the right eye consistent with CNV (Figure 1a). Fluorescein angiography (FA) showed staining and window defects corresponding to the angioid streaks and mild subfoveal leakage consistent with occult CNV (Figure 1b). There was no identifiable CNV on FA or OCT OS (data not shown). OCT confirmed presence of sub-retinal fluid (SRF) (Figure 1c). After discussion of the therapeutic options, treatment with intravitreal bevacizumab (1.25 mg) was initiated. Following three injections of bevacizumab six weeks apart, vision improved to 20/30 with complete resolution of SRF on OCT and fundus examination (Figure 2). Vision has remained stable for six months after the initiation of the treatment with no additional intervention.

Figure 1
figure 1

Imaging of the left eye: (a) Colour photograph shows angioid streaks and subfoveal CNV; (b) late FA shows mild late leakage underneath the fovea and angioid streaks; (c) OCT shows evidence of sub-retinal fluid.

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Figure 2
figure 2

OCT after three injections of bevacizumab shows resolution of sub-retinal fluid.

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Comment

Intravitreal bevacizumab has been reportedly efficacious in the treatment of CNV, secondary to AMD and myopia.2, 3 Although, there is one reported case of treatment of CNV, secondary to angioid streaks with intravitreal bevacizumab, we have not been able to find additional cases in the English literature.4 We believe that this case illustrates the need for a randomized trial in order to evaluate the efficacy of intravitreal bevacizumab or other anti-vascular endothelial growth factor agents in the treatment of CNV, secondary to angioid streaks.