Alexandra E. Hoeh

Intravitreal bevacizumab for treatment of chronic central serous chorioretinopathy

Purpose To evaluate the short-term safety and efficacy of intravitreal bevacizumab for the treatment of intraretinal or subretinal fluid accumulation secondary to chronic central serous chorioretinopathy (CSC). Methods Twelve patients were treated with intravitreal injections of 2.5 mg bevacizumab at 6-to 8-week intervals until intraretinal or subretinal fluid resolved. Observation procedures were Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), ophthalmic examination, and optical coherence tomography (OCT), performed at 6- to 8-week intervals. Fluorescein angiography was performed at baseline visit and thereafter depending on clinical and OCT findings. Multivariate analysis of variance with repeated measures was used to calculate a statistical significance of change in BCVA and mean central retinal thickness, which were the main outcome measures. SAS statistical software was used for analyses. Results Patients received 2±1 intravitreal injections of bevacizumab on average during a follow-up of 24±14 weeks. Mean BCVA increased by 2±2 lines; the change in BCVA (log-MAR) was significant (p<0.02). Mean central retinal thickness decreased significantly over follow-up (p<0.05), with 6 patients (50%) showing complete resolution of subretinal fluid. Conclusions Anatomic and functional improvement following intravitreal bevacizumab injections suggest that vascular endothelial growth factor (VEGF) may be involved in fluid leakage in patients with chronic CSC. The results suggest a possible role for anti-VEGF agents in the treatment of chronic CSC. Further evaluation of intravitreal bevacizumab for chronic CSC in controlled randomized studies is warranted.

Intravitreal Bevacizumab In Vascular Pigment Epithelium Detachment As A Result Of Subfoveal Occult Choroidal Neovascularization In Age-related Macular Degeneration

Purpose: The purpose of this study was to evaluate the effect of intravitreally administered bevacizumab on untreated vascularized pigment epithelium detachment (PED) in sub- or juxtafoveal occult choroidal neovascularization as a result of age-related macular degeneration. Methods: In this retrospective study, 28 untreated eyes of 26 patients (4 men, 22 women; mean age, 74.6 ± 7.2 years) with PED and sub- or juxtafoveal occult choroidal neovascularization as a result of age-related macular degeneration and additional intra- and/or subretinal fluid were treated with intravitreal injections of 1.25 mg bevacizumab. Baseline and follow-up visits included best-corrected visual acuity, complete ophthalmic examination, and Stratus optical coherence tomography. Fluorescein angiography was performed at baseline. Reinjections were performed if intra- and/or subretinal fluid persisted or recurred or PED increased. Results: Patients received 3.2 ± 1.8 injections (follow-up 37.9 ± 18.3 weeks). Mean maximum PED height showed a tendency to decrease (372 ± 150.5 μm to 290.3 ± 189 μm; P = 0.094). In 14 eyes (53.8%), PED height was reduced at last visit, including complete flattening in 1 eye. Mean visual acuity remained stable (0.58 ± 0.30 logarithm of the minimum angle of resolution to 0.58 ± 0.37 logarithm of the minimum angle of resolution; P = 0.905). Pigment epithelium detachment response to treatment did not correlate with baseline PED height or visual acuity at baseline or at the last visit. One patient sustained a retinal pigment epithelium rip, and another patient sustained an extensive subretinal hemorrhage. Conclusion: During bevacizumab therapy, mean PED height decreases in 50% of patients. No predictive factors for the response of PED to bevacizumab treatment could be identified. Treatment of PED with bevacizumab might result in a long-term functional benefit compared with the natural course.

Intravitreal bevacizumab for retinal capillary haemangioma: longterm results

Editor, V on Hippel)Lindau (VHL) disease is attended by multisystemic manifestations in many cases, but the central nervous system and retina are the most frequent locations of symptoms. Treatment of retinal capillary haemangioma caused by VHL disease can be a challenge and different approaches, such as laser photocoagulation, cryotherapy, photodynamic therapy, transpupillary thermotherapy and radiotherapy, have been tried with variable degrees of success (Garcia-Arumı́ et al. 2000). The VHL gene on chromosome 3, normally expressed in healthy people, is absent in VHL patients. This leads to an increase in the expression of vascular endothelial growth factor (VEGF) (Chan et al. 1999). Systemic anti-VEGF treatment has been reported in single cases, but this can be associated with severe side-effects (von Buelow et al. 2007). The longterm efficacy of intravitreal antiVEGF treatment has not yet been described for this disease. We report the outcome of intravitreal bevacizumab for retinal capillary haemangioma administered over a period of 2 years in a patient naı̈ve to this medication. A 40-year-old woman with VHL disease presented with a new retinal capillary haemangioma in the midperiphery in the left eye. Growth pattern was sessile with associated lipid exudation (Fig. 1A). Thirteen years earlier, a juxtapapillary haemangioma in the same eye had been treated with laser coagulation, resulting in scarred tissue and visual acuity (VA) of 20 ⁄ 400 (Fig. 1B). As a result of this experience, the patient refused further destructive procedures. After detailed discussion, intravitreal bevacizumab was offered as an off-label treatment option. The patient also suffered from several haemangiomas in the kidney, brain and right eye, the last of which had been treated with laser coagulation (VA 20 ⁄ 63). The patient did not receive any systemic treatment for VHL disease. When the patient had provided informed consent, a total of nine injections (administered every 13–14 weeks) of 2.5 mg bevacizumab were given intravitreally in the left eye over a period of 26 months. No adverse events attributable to intravitreal injections were observed and VA remained stable. The retinal capillary haemangioma did not grow significantly, whereas haemangiomas in other locations continued to grow and a new peripheral haemangioma appeared in the right, but not in the left, eye. The lipid exudation resolved almost completely and the feeder vessels did not enlarge (Fig. 1C). The new peripheral haemangioma in the fellow eye was treated with laser coagulation. Therapeutic strategies for retinal haemangiomas associated with VHL disease vary and often lead to unsatisfactory results, especially in centrally located haemangioma (Garcia-Arumı́ et al. 2000). Therefore, the increased intravitreal level of VEGF in VHL patients may represent a new target in effective therapy of retinal capillary haemangioma. In order to avoid an ongoing proliferation of retinal haemangioma caused by high VEGF expression, we administrated the VEGF antibody bevacizumab intravitreally. Injections were given every 13–14 weeks on the basis of our observations in patients with retinal vein occlusions. A dosage of 2.5 mg bevacizumab proved effective in the treatment of macular oedema for an average of 13 weeks. Over a period of > 2 years of treatment, the retinal haemangioma did not grow significantly and lipid exudation resolved completely. Dahr et al. (2007) presented similar results in their patients, but their observation time was only 1 year and this was marked by some adverse events. Here, no side-effects were reported, a finding in line with earlier reports on the safety of intravitreal bevacizumab (Fang et al. 2008). Anti-VEGF treatment reduces the permeability of retinal haemangiomas, which has also been observed after systemic administration of VEGF (A) (B)

Treatment of peripapillary choroidal neovascularization with intravitreal bevacizumab.

Purpose Peripapillary choroidal neovascularization (CNV) is an uncommon condition and often shows a growth tendency towards the fovea during spontaneous progression that threatens visual acuity. Treatment of peripapillary CNV is difficult. The authors report results of intravitreal bevacizumab therapy for peripapillary CNV. Methods Four patients with CNV located in the temporal or superior peripapillary area received intravitreal bevacizumab injections. Ophthalmologic examinations including OCT were performed at baseline and at 6-week intervals. Fluorescein angiography was performed at baseline and depending on clinical and OCT findings. The mean follow-up was 34±20 (22–69) weeks. Results The patients received an average of 3.5±3.1 (1–8) injections. In all patients fluorescein angiography showed inactivation of peripapillary CNV. No further increase in size was observed in any of the patients. The OCT showed a decrease of intraretinal and subretinal fluid. No intraocular or systemic side effects were observed. Conclusions In this series of patients, intravitreal bevacizumab appears to be efficacious. A progression of peripapillary CNV could be prevented in all patients and the lesion was successfully inactivated. Anti-VEGF treatment with bevacizumab represents a promising therapy option for peripapillary CNV.

Light-emitting diode technology in vitreoretinal surgery.

Background: Systems for vitreoretinal illumination during surgery usually consist of an external light source and a light fiber. We introduce a new illumination system for vitreoretinal surgery based on the light-emitting diode technology, with an embedded light source in the handle of the light fiber, making a separate light source unnecessary. Methods: A prototype of a new illumination system for vitreoretinal surgery (ocuLED; Geuder, Heidelberg, Germany) was tested. This system consists of a handle with a built-in light-emitting diode, supported by an external power source. The OcuLED was analyzed in regards to wavelength, maximum radiant power, and maximum irradiance and was compared with three commercially available vitreoretinal illumination systems. Furthermore, the first intraoperative application and handling were evaluated. Results: The ocuLED system works with a cool white or a neutral white light-emitting diode and is powered externally. The wavelength spectrum shows a maximum at 565 nm and a second peak at 455 nm. Compared with other light sources, the proportion of potentially harmful blue light is low. Maximum radiant power and irradiance are in line with xenon and mercury vapor light sources. The intrasurgical light is bright and offers good visibility. The handle of ocuLED is slightly wider than commonly used light fiber handles, which do not affect its use during surgery. Conclusion: Technical progress in light-emitting diode technology allows minimizing the equipment for vitreoretinal illumination. The OcuLED provides bright illumination without an external light source. Wavelength spectrum, maximum radiant power, and irradiance are safe from the risk of phototoxic damage. Intrasurgical handling is identical to conventional light fibers.