SUBFOVEAL CHOROIDAL NEOVASCULAR MEMBRANE IN THE SECOND TRIMESTER Wayne E. Fung, MD
Purpose: To report the experience of treating a woman who presented with a subfoveal neovascular membrane during the fifth month of her second pregnancy. Methods: Case report. Results: The visual acuity of the eye 1 month after 1 intravitreal injection of bevacizumab was 20/30 after the birth of her daughter. Conclusion: A woman presented with a subfoveal choroidal neovascular membrane during the fifth month of her second pregnancy. The decision was made to withhold anti– vascular endothelial growth factor therapy until after delivery. RETINAL CASES & BRIEF REPORTS 5:270–272, 2011
stable at 20/50, the membrane slowly shrunk, and the amount of exudation gradually decreased. Two months after the birth of her child, a fluorescein angiogram was obtained showing mild exudation in the late frames (Figure 3). In an attempt to stop this exudation, she received an intravitreal injection of Avastin (Genetech, Inc., South San Francisco, CA), 1.25 mgm, 2 and 1.5 months after delivery while she was still breast feeding. This was her only injection, and 1 month after the injection, her visual acuity was 20/30. On a subsequent visit, 18 months after the injection, her visual acuity was the same, and the status of her macula was nearly normal (Figures 4 and 5).
From the California Pacific Medical Center, San Francisco, California.
Case Report A 41-year-old Chinese woman complained of decreased central vision on her right eye for 1 month. Physical examination revealed that the best-corrected vision of her right eye was 20/50 while that of her left eye was 20/20. Her ophthalmic history revealed her correction to be the following: 25.25 w/+0.75@90 in each eye. Her ophthalmic history was noncontributory except for myopia. Her medical history was significant in that she was 5 months pregnant with her second child. All aspects of her ophthalmic examination were normal except for Hruby lens examination of her right posterior pole. Here, there was a serous detachment of the macula approximately 2 disk diameters. Directly beneath the fovea, a 0.25–disk diameter pinkish neovascular membrane was present (Figure 1). An optical coherence tomography (OCT) was obtained (Figure 2), and this demonstrated the presence of the subfoveal CNVM. She was not treated with any medication but followed on a monthly basis with determination of best-corrected visual acuity, dilated Hruby lens/slit-lamp examinations, and OCT images for the remainder of her pregnancy. During this time, her acuity remained
Discussion The development of a subfoveal neovascular membrane during pregnancy without predisposing risk factors is not common. Her eyes were myopic, near the ‘‘high myope’’ range, and both had a myopic conus but no Fuchs spot. Presumed histoplasmosis spots and punctate inner choriditis have been associated with CNVMs developing during pregnancy, but our patient did not show any signs suggesting the presence of either.1,2 During pregnancy, vascular endothelial growth factor and placental development hormone, both vasculogenic hormones, circulate in the mother’s blood.3 Hence, the development of an idiopathic neovascular membrane in the absence of weak zones in Bruch membrane could happen. An additional differential diagnosis would be idiopathic central serous choroidopathy. This
Presented at the Fluorescein Conference of the Retina Society; Scottsdale, Arizona; September 25, 2008. The author has no proprietary interest in any of the treatment instruments or drugs. Reprint requests: Wayne E. Fung, MD, 2100 Webster Street, Ste. 214, San Francisco, CA 94115-2375; e-mail: [email protected]
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SUBFOVEAL CNVM IN THE SECOND TRIMESTER
Fig. 1. Color image of right macula on the first visit during the fourth month of gestation. Note the serous detachment of the macula, the subfoveal neovascular membrane, and the absence of white subretinal fibrosis. Also note the absence of punctate innerchoroidal lesions. Bestcorrected visual acuity was 20/50.
271
Fig. 3. Late phase of a fluorescein angiogram obtained 2 months after delivery. Note the continued mild leakage. The only bevacizumab injection was given 1 month after this angiogram.
condition occurs usually in the third trimester, and on physical examination, the zone of serous detachment frequently shows white subretinal fibrosis.4,5 In this case, the visual symptoms began at the end of the first trimester, and the physical examination did not show any subretinal fibrosis (Figure 1). In addition, the initial OCT demonstrated the subfoveal CNVM (Figure 2). Performing a fluorescein angiogram early in pregnancy has been reported. It was obtained in a woman who did not know that she was pregnant as well as intentionally later in her pregnancy.6 In general, sodium fluorescein is not considered a teratogenic substance, but in this instance, one was not obtained when she was initially seen because the OCT image made the diagnosis.
After the clinical course, visual acuity, physical examination, and OCT are efficient, accurate, and noninvasive. Research produced evidence that once the placenta is formed, serum vascular endothelial growth factor of a pregnant woman declines in the second and third trimesters.7 Thus, in future cases of this nature, this important fact may be kept in mind, and the situation may be closely observed. Conversely, if the membrane had been more aggressive, what options would there be? Sub-Tenon’s or intravitreal steroid injections would be the only options if one wanted to avoid intravenous drugs and anti–vascular endothelial growth factor therapies. Intravitreal injections of an anti–vascular endothelial growth factor drug during pregnancy has not been reported and should only be considered with caution.8
Fig. 2. Time-domain OCT of right macula on the first visit.
Fig. 4. Spectral-domain OCT of right macula obtained 1 month after the single bevacizumab injection.
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RETINAL CASES & BRIEF REPORTS´ 2011 VOLUME 5 NUMBER 3
endothelial growth factor levels, second trimester, subfoveal. References
Fig. 5. Color image of the right macula 18 months after the bevacizumab injection.
Key words: bevacizumab (Avastin), choroidal neovascular membrane, fluorescein angiogram, optical coherent tomography, pregnancy, serum vascular
1. Sim DA, Sheth HG, Kaines A, Tufail A. Punctate inner choroidopathy-associated choroidal neovascular membranes during pregnancy. Eye 2008;22:725–727. 2. Rhee P, Dev S, Mieler WF. The development of choroidal neovascularization in pregnancy. Retina 1999;19: 520–524. 3. Gass, JDMG. Central serous chorioretinopathy and white subretinal exudates in pregnancy. Arch Ophthalmol 1991;109: 677–681. 4. Sunness JS, Haller J, Fine SL. Central serous chorioretinopathy in pregnancy. Arch Ophthalmol 1993;111:360–364. 5. Wheeler T, Evans PW, Anthony FW, Godfrey KM, Howe DT, Osmond C. Relationship between maternal serum endothelial growth factor concentration in early pregnancy and placental growth. Hum Reprod 1999;14:1619–1623. 6. Halperin LS, Olk RJ, Soubrane G, Coscas G. Safety of fluorescein angiography during pregnancy. Am J Ophthalmol 1990;110:323–325. 7. Lygnos MC, Pappa KI, Papdaki HA, et al. Changes in maternal plasma levels of VEGF, bFGF, TGF-beta 1, ET-1 and sKL during pregnancy, hypertensive pregnancy and gestational diabetes. In vivo 2006;20:157–163. 8. Lin FC, Chen JT, Horng CT. Bevacizumab: a word of caution. Can J Ophthalmol 2007;42:759–760.
Purpose: To report the experience of treating a woman who presented with a subfoveal neovascular membrane during the fifth month of her second pregnancy. Methods: Case report. Results: The visual acuity of the eye 1 month after 1 intravitreal injection of bevacizumab was 20/30 after the birth of her daughter. Conclusion: A woman presented with a subfoveal choroidal neovascular membrane during the fifth month of her second pregnancy. The decision was made to withhold anti– vascular endothelial growth factor therapy until after delivery. RETINAL CASES & BRIEF REPORTS 5:270–272, 2011
stable at 20/50, the membrane slowly shrunk, and the amount of exudation gradually decreased. Two months after the birth of her child, a fluorescein angiogram was obtained showing mild exudation in the late frames (Figure 3). In an attempt to stop this exudation, she received an intravitreal injection of Avastin (Genetech, Inc., South San Francisco, CA), 1.25 mgm, 2 and 1.5 months after delivery while she was still breast feeding. This was her only injection, and 1 month after the injection, her visual acuity was 20/30. On a subsequent visit, 18 months after the injection, her visual acuity was the same, and the status of her macula was nearly normal (Figures 4 and 5).
From the California Pacific Medical Center, San Francisco, California.
Case Report A 41-year-old Chinese woman complained of decreased central vision on her right eye for 1 month. Physical examination revealed that the best-corrected vision of her right eye was 20/50 while that of her left eye was 20/20. Her ophthalmic history revealed her correction to be the following: 25.25 w/+0.75@90 in each eye. Her ophthalmic history was noncontributory except for myopia. Her medical history was significant in that she was 5 months pregnant with her second child. All aspects of her ophthalmic examination were normal except for Hruby lens examination of her right posterior pole. Here, there was a serous detachment of the macula approximately 2 disk diameters. Directly beneath the fovea, a 0.25–disk diameter pinkish neovascular membrane was present (Figure 1). An optical coherence tomography (OCT) was obtained (Figure 2), and this demonstrated the presence of the subfoveal CNVM. She was not treated with any medication but followed on a monthly basis with determination of best-corrected visual acuity, dilated Hruby lens/slit-lamp examinations, and OCT images for the remainder of her pregnancy. During this time, her acuity remained
Discussion The development of a subfoveal neovascular membrane during pregnancy without predisposing risk factors is not common. Her eyes were myopic, near the ‘‘high myope’’ range, and both had a myopic conus but no Fuchs spot. Presumed histoplasmosis spots and punctate inner choriditis have been associated with CNVMs developing during pregnancy, but our patient did not show any signs suggesting the presence of either.1,2 During pregnancy, vascular endothelial growth factor and placental development hormone, both vasculogenic hormones, circulate in the mother’s blood.3 Hence, the development of an idiopathic neovascular membrane in the absence of weak zones in Bruch membrane could happen. An additional differential diagnosis would be idiopathic central serous choroidopathy. This
Presented at the Fluorescein Conference of the Retina Society; Scottsdale, Arizona; September 25, 2008. The author has no proprietary interest in any of the treatment instruments or drugs. Reprint requests: Wayne E. Fung, MD, 2100 Webster Street, Ste. 214, San Francisco, CA 94115-2375; e-mail: [email protected]
270
SUBFOVEAL CNVM IN THE SECOND TRIMESTER
Fig. 1. Color image of right macula on the first visit during the fourth month of gestation. Note the serous detachment of the macula, the subfoveal neovascular membrane, and the absence of white subretinal fibrosis. Also note the absence of punctate innerchoroidal lesions. Bestcorrected visual acuity was 20/50.
271
Fig. 3. Late phase of a fluorescein angiogram obtained 2 months after delivery. Note the continued mild leakage. The only bevacizumab injection was given 1 month after this angiogram.
condition occurs usually in the third trimester, and on physical examination, the zone of serous detachment frequently shows white subretinal fibrosis.4,5 In this case, the visual symptoms began at the end of the first trimester, and the physical examination did not show any subretinal fibrosis (Figure 1). In addition, the initial OCT demonstrated the subfoveal CNVM (Figure 2). Performing a fluorescein angiogram early in pregnancy has been reported. It was obtained in a woman who did not know that she was pregnant as well as intentionally later in her pregnancy.6 In general, sodium fluorescein is not considered a teratogenic substance, but in this instance, one was not obtained when she was initially seen because the OCT image made the diagnosis.
After the clinical course, visual acuity, physical examination, and OCT are efficient, accurate, and noninvasive. Research produced evidence that once the placenta is formed, serum vascular endothelial growth factor of a pregnant woman declines in the second and third trimesters.7 Thus, in future cases of this nature, this important fact may be kept in mind, and the situation may be closely observed. Conversely, if the membrane had been more aggressive, what options would there be? Sub-Tenon’s or intravitreal steroid injections would be the only options if one wanted to avoid intravenous drugs and anti–vascular endothelial growth factor therapies. Intravitreal injections of an anti–vascular endothelial growth factor drug during pregnancy has not been reported and should only be considered with caution.8
Fig. 2. Time-domain OCT of right macula on the first visit.
Fig. 4. Spectral-domain OCT of right macula obtained 1 month after the single bevacizumab injection.
272
RETINAL CASES & BRIEF REPORTS´ 2011 VOLUME 5 NUMBER 3
endothelial growth factor levels, second trimester, subfoveal. References
Fig. 5. Color image of the right macula 18 months after the bevacizumab injection.
Key words: bevacizumab (Avastin), choroidal neovascular membrane, fluorescein angiogram, optical coherent tomography, pregnancy, serum vascular
1. Sim DA, Sheth HG, Kaines A, Tufail A. Punctate inner choroidopathy-associated choroidal neovascular membranes during pregnancy. Eye 2008;22:725–727. 2. Rhee P, Dev S, Mieler WF. The development of choroidal neovascularization in pregnancy. Retina 1999;19: 520–524. 3. Gass, JDMG. Central serous chorioretinopathy and white subretinal exudates in pregnancy. Arch Ophthalmol 1991;109: 677–681. 4. Sunness JS, Haller J, Fine SL. Central serous chorioretinopathy in pregnancy. Arch Ophthalmol 1993;111:360–364. 5. Wheeler T, Evans PW, Anthony FW, Godfrey KM, Howe DT, Osmond C. Relationship between maternal serum endothelial growth factor concentration in early pregnancy and placental growth. Hum Reprod 1999;14:1619–1623. 6. Halperin LS, Olk RJ, Soubrane G, Coscas G. Safety of fluorescein angiography during pregnancy. Am J Ophthalmol 1990;110:323–325. 7. Lygnos MC, Pappa KI, Papdaki HA, et al. Changes in maternal plasma levels of VEGF, bFGF, TGF-beta 1, ET-1 and sKL during pregnancy, hypertensive pregnancy and gestational diabetes. In vivo 2006;20:157–163. 8. Lin FC, Chen JT, Horng CT. Bevacizumab: a word of caution. Can J Ophthalmol 2007;42:759–760.
