LAMELLAR MACULAR HOLE AFTER RANIBIZUMAB IN A PATIENT WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AND VITREOMACULAR ADHESION Vinod Kumar, MS, DNB, MNAMS, FRCS (Glasg) Jai Shankar, MS, FRCS, FRCOphth

Purpose: To report a case of formation of lamellar macular hole after ranibizumab in a patient with neovascular age-related macular degeneration and vitreomacular adhesion. Methods: A 76-year-old man with neovascular age-related macular degeneration and vitreomacular adhesion was studied by biomicroscopy, fluorescein angiography, and optical coherence tomography and was treated with intravitreal ranibizumab. Results: The neovascular membrane regressed and the patient developed lamellar macular hole when seen 1 month after the ranibizumab injection. Conclusion: Persistent vitreomacular traction along with the decrease in retinal edema after intravitreal ranibizumab could have contributed to the formation of lamellar macular hole. Thus, in cases with retinal edema and vitreomacular adhesion, this event after anti– vascular endothelial growth factor therapy should be considered, especially if vision does not improve despite resolution of edema. RETINAL CASES & BRIEF REPORTS 6:109–110, 2012

From the Department of Ophthalmology, Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom.

Case Report A 76-year-old man presented with a 2-week history of distortion of vision in his right eye. The best-corrected visual acuity was 6/60 in the right eye and 6/6 in the left eye. Anterior segment examination was unremarkable in both the eyes. Fundus examination revealed a choroidal neovascular membrane in the right eye and drusen in the left eye. Fluorescein angiography confirmed the presence of a large subfoveal classic choroidal neovascular membrane in the right eye (Figure 1A). Optical coherence tomography showed the presence of choroidal neovascular membrane along with vitreomacular adhesion in the foveal area (Figure 1B). The central retinal thickness measured 414 mm. After discussing with the patient regarding the visual prognosis, a written informed consent was obtained. Ranibizumab (0.5 mg in 0.05 mL) was administered intravitreally under standard sterile conditions. At 1-month follow-up, best-corrected visual acuity in the affected eye remained unchanged at preinjection level of 6/60. Optical coherence tomography revealed marked reduction in intraretinal fluid along with the formation of a lamellar MH. The central retinal thickness was reduced to 253 mm. The posterior vitreous face was still attached to the edge of MH (Figure 1C). The patient underwent two more injections of intravitreal ranibizumab with no subsequent recurrence of fluid accumulation or further complications. The vision remained stable at 6/60 till the end of follow-up.

B

oth vitreomacular adhesion and traction have been suspected to play a crucial role in the pathogenesis of different forms of age-related macular degeneration.1,2 They have also been suspected as one of the causes of poor response to anti–vascular endothelial growth factor drug treatment.3 We hereby report the formation of lamellar macular hole (MH) after a single injection of intravitreal ranibizumab in a patient with neovascular age-related macular degeneration with vitreomacular adhesion. To the best of our knowledge, this has not been reported previously in literature.

The authors have no financial interest or conflicts of interest. Reprint requests: Vinod Kumar, 9/2, Punjabi Bagh Extension, New Delhi 110026, India; e-mail: [email protected]

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Discussion It is difficult to speculate the cause of formation of MH. Grigoropoulos et al4 described a case of fullthickness MH after intravitreal injection of ranibizumab in a patient with retinal pigment epithelium detachment and tear and postulated that intravitreal ranibizumab may create focal sites of tractional forces on the retinal surface. Also, changes in the vitreous subsequent to the injection could be a possible factor in inducing posterior vitreous detachment and hence MH. In our case, vitreomacular adhesion was present before therapy was instituted. Decrease in retinal thickness after intravitreal ranibizumab along with the persistent vitreomacular adhesion in a thinner retina could have contributed to the formation of lamellar MH. The formation of lamellar MH may have resulted in the lack of improvement in the visual acuity despite reduction in retinal thickness after treatment with ranibizumab. Thus, in cases with retinal edema (because of neovascular age-related macular degeneration or any other cause) and vitreomacular adhesion, this possibility after anti–vascular endothelial growth factor therapy, though rare, must be kept in mind, especially if vision does not improve despite resolution of edema. Key words: choroidal neovascular membrane, lamellar, macular hole, ranibizumab.

References

Fig. 1. A. Fluorescein angiography of the right eye shows a large classic subfoveal choroidal neovascular membrane. B. Optical coherence tomography shows the presence of vitreomacular adhesion in addition to the choroidal neovascular membrane. C. Optical coherence tomography scan 1 month after the first injection of ranibizumab shows resolution of fluid and development of lamellar MH with persistent attachment of vitreous to its edge.

1. Krebs I, Brannath W, Glittenberg C, Zeiler F, Sebag J, Binder S. Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration? Am J Ophthalmol 2007;144:741–746. 2. Schulze S, Hoerle S, Mennel S, Kroll P. Vitreomacular traction and exudative age-related macular degeneration. Acta Ophthalmol 2008;86:470–481. 3. Mojana F, Cheng L, Bartsch DU, et al. The role of abnormal vitreomacular adhesion in age-related macular degeneration: spectral optical coherence tomography and surgical results. Am J Ophthalmol 2008;146:218–227. 4. Grigoropoulos V, Emfietzoglou J, Nikolaidis P, Theodossiadis G, Theodossiadis P. Full-thickness macular hole after intravitreal injection of ranibizumab in a patient with retinal pigment epithelium detachment and tear. Eur J Ophthalmol 2010;20: 469–472.

Lamellar macular hole after ranibizumab in a patient with neovascular age-related macular degeneration and vitreomacular adhesion.

To report a case of formation of lamellar macular hole after ranibizumab in a patient with neovascular age-related macular degeneration and vitreomacu...
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