Choroidal neovascularization treated with intravitreal injection of bevacizumab (Avastin) in angioid streaks

Abstract

Editor, Angioid streaks are irregular, radiating, jagged, tapering lines that extend from the peripapillary area into the peripheral fundus that may occur in isolation or as the ocular manifestation of a systemic disease. Linear breaks or dehiscence in a thickened, calcified and abnormally brittle Bruch's membrane can be associated with choroidal neovascularization (CNV) and poor vision. Several treatments have been attempted with limited success and high rates of recurrence (Costa et al. 2003; Shaikh et al. 2003; Aras et al. 2004). We report a case of subfoveal CNV due to angioid streaks treated with intravitreal bevacizumab 1.25 mg. A 23-year-old man with angioid streaks was referred for subfoveal CNV in his right eye (OD). He had suffered visual loss in the left eye (OS) after minor trauma. Best corrected visual acuity (BCVA) was counting fingers at 2 m OD and 20/400 OS. Fundus examination revealed peripapillary angioid streaks in both eyes, a grey subfoveal lesion with subretinal haemorrhage and subsensory fluid OD and a large pigmented macular scar OS. Fluorescein angiography (FA) revealed a subfoveal classic CNV associated with leakage and peripapillary hyperfluorescence corresponding to the angioid streaks OD and a staining of disciform scarring with no active leakage in the macula OS. Optical coherence tomography (OCT) showed neurosensory serous detachment and type 2 CNV OD (1, 3). The patient was counselled as to the prognosis of his condition and treatment options. Photodynamic therapy was offered but not accepted and an intravitreal injection of bevacizumab 1.25 mg was administered. (A) Early and (B) late-phase fluorescein angiography images at baseline. Optical coherence tomography scans at 6-mm at (A) baseline and (B) 18 weeks post-injection. After 7 weeks, VA was 20/40 and some residual leakage was seen at the lesion margin on FA. The subject underwent a second injection. After 12 weeks VA was 20/30, fundus examination showed no subsensory fluid, and OCT and FA revealed no leakage (2, 3). (A) Early and (B) late-phase fluorescein angiography images at 18 weeks after treatment Choroidal neovascularization occurs in 70–86% of patients with angioid streaks and more than half have vision of 20/200 or worse after the age of 50 years. It has been suggested that laser photocoagulation might resolve CNV and help to stabilize VA or slow down visual loss, given the very high frequency of recurrence (Lim et al. 1993). Other therapies such as photodynamic therapy, Indocyanine green-mediated photothrombosis (IMP) and transpupillary thermotherapy have recently been proposed as alternative treatments for CNV associated with age-related macular degeneration (AMD) and others types of CNV but they do not appear to change the course of the disease and the visual prognosis is poor (Lim et al. 1993; Costa et al. 2003; Shaikh et al. 2003; Aras et al. 2004). This is the first case report of intravitreal injection of bevacizumab in a patient with subfoveal CNV with angioid streaks. Our patient demonstrated a significant improvement at 18 weeks, with VA of 20/30. There was no evidence of inflammation by either OCT or FA at this time-point. Vascular endothelial growth factor (VEGF) has been implicated as the major angiogenic stimulus responsible for neovascularization in AMD. Bevacizumab has shown promising results in off-label intravenous injections administered as salvage treatment (Rosenfeld et al. 2005). A formal prospective study is necessary to determine the safety and efficacy of intravitreal bevacizumab in the treatment of CNV.