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).
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.
References
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Lommatzsch A, Radermacher M, Spital G, Pauleikhoff D . Photodynamic therapy of pigment epithelium detachments in AMD (ARVO abstract). Invest Ophthalmol Vis Sci 2002; (Suppl): 439.
Copt RP, Zografos L . Retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularisation caused by age-related macular degeneration (ARVO abstract). Invest Ophthalmol Vis Sci 2002; (Suppl): 440.
Gelisken F, Inhoffen W, Partsch M, Schneider U, Kreissig I . Retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularisation. Am J Ophthalmol 2001; 131: 518–520.
Pece A, Introini U, Bottoni F, Brancato R . Acute retinal pigment epithelial tear after photodynamic therapy. Retina 2001; 21: 661–665.
Dhalla MS, Blinder KJ, Tewari A, Hariprasad SM, Apte RS . Retinal pigment epithelial tear following intravitreal pegaptanib sodium. Am J Ophthalmol 2006; 141 (4): 752–754.
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Mathews, J., Jalil, A., Lavin, M. et al. Retinal pigment epithelial tear following intravitreal injection of bevacizumab (avastin®): optical coherence tomography and fluorescein angiographic findings. Eye 21, 1004–1005 (2007). https://doi.org/10.1038/sj.eye.6702805
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DOI: https://doi.org/10.1038/sj.eye.6702805
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