INTRAVITREAL BEVACIZUMAB IN THE MANAGEMENT OF POSTTRAUMATIC CHOROIDAL NEOVASCULAR MEMBRANE Pukhraj Rishi, MS, Daraius Shroff, MS, Ekta Rishi, MS
Purpose: To report the therapeutic response in the treatment of juxtafoveal choroidal neovascular membrane (CNVM) secondary to traumatic choroidal rupture with intravitreal bevacizumab. Methods: A 20-year-old man presented with distortion of central vision following blunt trauma and was found to have juxtafoveal, classic CNVM associated with a choroidal rupture. The patient underwent intravitreal bevacizumab (1.25 mg/0.05 mL) and was periodically followed up. Results: Four weeks post injection, best-corrected visual acuity improved to 20/20. Optical coherence tomography revealed regression of CNVM and resolution of subretinal fluid. The anatomic and functional status of the treated eye was maintained at 6 months follow-up. No treatment-related ocular or systemic adverse effects were noted. Conclusion: Bevacizumab appears to be safe and effective in the treatment of CNVM secondary to choroidal rupture. RETINAL CASES & BRIEF REPORTS 2:236 –238, 2008
From Sankara Nethralaya, Chennai, India.
dus examination of right eye revealed the presence of choroidal rupture just temporal to the fovea along with subretinal hemorrhage (Figure 1A). Fundus fluorescence angiography (FFA) revealed an area of hyperfluorescence temporal to the fovea which increased in size and intensity with time and was suggestive of a juxtafoveal, classic CNVM. (Figure 1B). Optical coherence tomography (OCT) confirmed the presence of choroidal rupture with subfoveal hemorrhage and early CNVM (Figure 1C). After informed consent, the patient was administered intravitreal bevacizumab (1.25 mg/0.05 mL) in the affected eye. Four weeks post injection, the BCVA improved to 20/20. OCT revealed regression of CNVM and resolution of subretinal fluid. The anatomic and functional status of the treated eye was maintained at 6 months follow-up (Figure 2, A–C). No ocular or systemic adverse effects particularly related to intravitreal injection of bevacizumab were noted.
C
horoidal neovascularization with serous retinal detachment has been described as a cause of late visual loss in patients with traumatic choroidal rupture.1 Various treatment modalities described for post traumatic choroidal neovascular membrane (CNVM) include laser photocoagulation, photodynamic therapy (PDT), and submacular surgery.2– 4 This report describes an impressive therapeutic response in the treatment of a juxtafoveal CNVM secondary to traumatic choroidal rupture, with intravitreal bevacizumab injection (1.25 mg/0.05 mL). Case Report
Discussion
A 20-year-old man presented with a history of distortion of central vision noticed for 10 days following blunt trauma to the right eye, a few months previously. The best-corrected visual acuity (BCVA) was 20/30 in the right eye and 20/20 in the left eye. Anterior segment evaluation was unremarkable in both eyes. Fun-
Various treatment modalities described for post traumatic CNVMs include laser photocoagulation, photodynamic therapy (PDT), and submacular surgery.2– 4 Extrafoveal membranes have been treated successfully with laser photocoagulation.2 PDT has shown encouraging results in a retrospective review of five
Reprint requests: Pukhraj Rishi, MS, Sankara Nethralaya, 18, College Road, Chennai 600006, India; e-mail: docrishi@yahoo. co.in
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BEVACIZUMAB FOR POSTTRAUMATIC CHOROIDAL NEOVASCULAR MEMBRANE
237
Fig. 1. A, At presentation, right eye shows the presence of choroidal rupture just temporal to the fovea with subretinal hemorrhage and retinal thickening. B, Fundus fluorescence angiography reveals an area of hyperfluorescence temporal to the fovea suggestive of a juxtafoveal, classic choroidal neovascular membrane (CNVM). C, Optical coherence tomography highlights subfoveal hemorrhage and early CNVM temporal to the fovea.
patients with CNV secondary to traumatic choroidal rupture. Three of these patients reported an improvement, a single patient showed a decline, while the vision stabilized in one patient.3 RPE alteration after PDT including accentuation of the pigmentary zone surrounding the CNV and progression of the development of RPE atrophic
changes have been reported in pathologic myopia.5 In cases of traumatic CNV too, there is usually type II (pre-RPE) neovascularization with a prominent pigment halo at the site of ingrowth of vessels into the subretinal space. This could lead to similar RPE atrophic changes in this subgroup of patients also. However, intravitreal anti-VEGF injections have
Fig. 2. A, At 6 months follow-up, no retinal thickening is appreciated clinically at the area of choroidal rupture. B, Fundus fluorescence angiography shows staining of choroidal rupture without any active leakage. C, Optical coherence tomography reveals restoration of foveal contour and absence of any subretinal fluid.
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not yet been implicated with RPE atrophy following treatment. Although surgical removal of the CNVM in traumatic choroidal rupture has been reported with excellent visual results, the surgery itself has its own potential for complications with no extra advantage of prevention of CNVM recurrence.4 Bevacizumab is a humanized, full-length antibody that binds all forms of VEGF. It has been described as an off-label treatment modality for CNVM in age-related macular degeneration, neovascular glaucoma, proliferative diabetic retinopathy, and vascular occlusions. Bevacizumab appears to be safe and effective in the treatment of CNVM secondary to choroidal rupture.
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2008
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VOLUME 2
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NUMBER 3
References 1. 2.
3.
4.
5.
Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. St Louis: Mosby; 1987. Fuller B, Gitter KA. Traumatic choroidal rupture with late serous detachment of the macula: report of successful argon laser treatment. Arch Ophthalmol 1973;89:354–355. Mehta HB, Shanmugam MP. Photodynamic therapy of a posttraumatic choroidal neovascular membrane. Ind J Ophthalmol 2005;53:131–132. Gross JG, King LP, de Juan E, Powers T. Subfoveal CNVM removal in patients with traumatic choroidal rupture. Ophthalmology 1996;103:579–585. Parodi MB, Da Pozzo S, Ravalico G. Retinal pigment epithelium changes after photodynamic therapy for choroidal neovascularization in pathological myopia. Acta Ophthalmol Scand 2007;85:50–54.
Purpose: To report the therapeutic response in the treatment of juxtafoveal choroidal neovascular membrane (CNVM) secondary to traumatic choroidal rupture with intravitreal bevacizumab. Methods: A 20-year-old man presented with distortion of central vision following blunt trauma and was found to have juxtafoveal, classic CNVM associated with a choroidal rupture. The patient underwent intravitreal bevacizumab (1.25 mg/0.05 mL) and was periodically followed up. Results: Four weeks post injection, best-corrected visual acuity improved to 20/20. Optical coherence tomography revealed regression of CNVM and resolution of subretinal fluid. The anatomic and functional status of the treated eye was maintained at 6 months follow-up. No treatment-related ocular or systemic adverse effects were noted. Conclusion: Bevacizumab appears to be safe and effective in the treatment of CNVM secondary to choroidal rupture. RETINAL CASES & BRIEF REPORTS 2:236 –238, 2008
From Sankara Nethralaya, Chennai, India.
dus examination of right eye revealed the presence of choroidal rupture just temporal to the fovea along with subretinal hemorrhage (Figure 1A). Fundus fluorescence angiography (FFA) revealed an area of hyperfluorescence temporal to the fovea which increased in size and intensity with time and was suggestive of a juxtafoveal, classic CNVM. (Figure 1B). Optical coherence tomography (OCT) confirmed the presence of choroidal rupture with subfoveal hemorrhage and early CNVM (Figure 1C). After informed consent, the patient was administered intravitreal bevacizumab (1.25 mg/0.05 mL) in the affected eye. Four weeks post injection, the BCVA improved to 20/20. OCT revealed regression of CNVM and resolution of subretinal fluid. The anatomic and functional status of the treated eye was maintained at 6 months follow-up (Figure 2, A–C). No ocular or systemic adverse effects particularly related to intravitreal injection of bevacizumab were noted.
C
horoidal neovascularization with serous retinal detachment has been described as a cause of late visual loss in patients with traumatic choroidal rupture.1 Various treatment modalities described for post traumatic choroidal neovascular membrane (CNVM) include laser photocoagulation, photodynamic therapy (PDT), and submacular surgery.2– 4 This report describes an impressive therapeutic response in the treatment of a juxtafoveal CNVM secondary to traumatic choroidal rupture, with intravitreal bevacizumab injection (1.25 mg/0.05 mL). Case Report
Discussion
A 20-year-old man presented with a history of distortion of central vision noticed for 10 days following blunt trauma to the right eye, a few months previously. The best-corrected visual acuity (BCVA) was 20/30 in the right eye and 20/20 in the left eye. Anterior segment evaluation was unremarkable in both eyes. Fun-
Various treatment modalities described for post traumatic CNVMs include laser photocoagulation, photodynamic therapy (PDT), and submacular surgery.2– 4 Extrafoveal membranes have been treated successfully with laser photocoagulation.2 PDT has shown encouraging results in a retrospective review of five
Reprint requests: Pukhraj Rishi, MS, Sankara Nethralaya, 18, College Road, Chennai 600006, India; e-mail: docrishi@yahoo. co.in
236
BEVACIZUMAB FOR POSTTRAUMATIC CHOROIDAL NEOVASCULAR MEMBRANE
237
Fig. 1. A, At presentation, right eye shows the presence of choroidal rupture just temporal to the fovea with subretinal hemorrhage and retinal thickening. B, Fundus fluorescence angiography reveals an area of hyperfluorescence temporal to the fovea suggestive of a juxtafoveal, classic choroidal neovascular membrane (CNVM). C, Optical coherence tomography highlights subfoveal hemorrhage and early CNVM temporal to the fovea.
patients with CNV secondary to traumatic choroidal rupture. Three of these patients reported an improvement, a single patient showed a decline, while the vision stabilized in one patient.3 RPE alteration after PDT including accentuation of the pigmentary zone surrounding the CNV and progression of the development of RPE atrophic
changes have been reported in pathologic myopia.5 In cases of traumatic CNV too, there is usually type II (pre-RPE) neovascularization with a prominent pigment halo at the site of ingrowth of vessels into the subretinal space. This could lead to similar RPE atrophic changes in this subgroup of patients also. However, intravitreal anti-VEGF injections have
Fig. 2. A, At 6 months follow-up, no retinal thickening is appreciated clinically at the area of choroidal rupture. B, Fundus fluorescence angiography shows staining of choroidal rupture without any active leakage. C, Optical coherence tomography reveals restoration of foveal contour and absence of any subretinal fluid.
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RETINAL CASES & BRIEF REPORTSℜ
not yet been implicated with RPE atrophy following treatment. Although surgical removal of the CNVM in traumatic choroidal rupture has been reported with excellent visual results, the surgery itself has its own potential for complications with no extra advantage of prevention of CNVM recurrence.4 Bevacizumab is a humanized, full-length antibody that binds all forms of VEGF. It has been described as an off-label treatment modality for CNVM in age-related macular degeneration, neovascular glaucoma, proliferative diabetic retinopathy, and vascular occlusions. Bevacizumab appears to be safe and effective in the treatment of CNVM secondary to choroidal rupture.
●
2008
●
VOLUME 2
●
NUMBER 3
References 1. 2.
3.
4.
5.
Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. St Louis: Mosby; 1987. Fuller B, Gitter KA. Traumatic choroidal rupture with late serous detachment of the macula: report of successful argon laser treatment. Arch Ophthalmol 1973;89:354–355. Mehta HB, Shanmugam MP. Photodynamic therapy of a posttraumatic choroidal neovascular membrane. Ind J Ophthalmol 2005;53:131–132. Gross JG, King LP, de Juan E, Powers T. Subfoveal CNVM removal in patients with traumatic choroidal rupture. Ophthalmology 1996;103:579–585. Parodi MB, Da Pozzo S, Ravalico G. Retinal pigment epithelium changes after photodynamic therapy for choroidal neovascularization in pathological myopia. Acta Ophthalmol Scand 2007;85:50–54.
