Bevacizumab, a humanised monoclonal antibody to vascular endothelial growth factor, has been given as an intravitreal injection for age-related macular degeneration,1 macular oedema due to retinal vein occlusion,2, 3 and diabetic macular oedema.4 Here, we present a case of macular oedema secondary to retinal macroaneurysm, which resolved with intravitreal Bevacizumab.

Case report

A 42-year-old female presented with diminution of vision in her right eye for 1-month duration. The patient was a known hypertensive and diabetic.

The best corrected visual acuity (BCVA) was 20/400 OD and 20/20 OS. Anterior segment examination was normal bilaterally. The intraocular pressure was 18 mmHg bilaterally. Ophthalmoscopic examination revealed mild nonproliferative diabetic retinopathy in both eyes and intraretinal haemorrhages along the superotemporal arcade with severe macular oedema and lipid exudation involving the fovea in the right eye (Figure 1b). Based on fluorescein angiography a diagnosis of retinal arteriolar macroaneurysm was made (Figure 1a). The central macular thickness (CMT) measured on optical coherence tomography (OCT) was 607 μ OD and 179 μ OS.

Figure 1
figure 1

(a) Fluorescein angiogram showing hypofluorescence from blockage due to retinal haemorrhages and a hyperfluorescent retinal macroaneurysm with leakage of dye in late phase. (b) Fundus photograph showing retinal macroaneurysm along superotemporal retinal arteriole associated with retinal hemorrhages, lipid exudation and macular edema (left). Post bevacizumab injection fundus picture showing resolved retinal hemorrhages and decrease in lipid exudation and macular edema (right). (c) Retinal thickness measured by optical coherence tomography at baseline (607 μ; left), after 4 weeks (271 μ; middle), and after 6 weeks (173 μ; right).

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The patient's blood pressure was controlled on oral medication. Fasting blood sugar was 5 mmol/l on oral hypoglycaemic. Lipid profile was within normal limits.

After a written consent was signed by the patient, an off-label intravitreal bevacizumab injection (1.25 mg) was given in the right eye. At 4 weeks, BCVA improved to 20/100, retinal haemorrhages resolved and exudation also reduced (Figure 1b). The CMT decreased to 271 μ, although some macular oedema persisted. Intravitreal bevacizumab was repeated and within 2 weeks, there was complete resolution of macular oedema, with CMT of 173 μ and BCVA of 20/50 (Figure 1c).

Comment

Retinal macroaneurysm are localised dilatations of retinal arterioles. Hypertensive women in the sixth or seventh decade have a predilection. The most common clinical symptom is decline in central visual acuity due to retinal oedema, exudation or haemorrhage.5 Direct laser photocoagulation of the macroaneurysm may be considered if the lipid exudates coming from it threaten the fovea. Treatment when haemorrhage is present is fraught with difficulties.

The present case would not have benefited from laser photocoagulation due to the severity of macular oedema and presence of retinal haemorrhages. Although spontaneous resolution is known occur, in the present case, bevacizumab might not only have hastened the decrease in retinal thickness but also provided superior visual outcome. Intravitreal bevacizumab is also well tolerated and no adverse effects were observed. The results observed in this case are provocative and require additional investigation.