Intravitreal bevacizumab for occult choroidal neovascularization with pigment epithelium detachment in age‐related macular degeneration

Abstract

Editor, Occult choroidal neovascularization (CNV) with pigment epithelium detachment (PED) in age-related macular degeneration (AMD) is generally associated with poor visual prognosis. Most physicians agree that further treatment modalities are required to treat these lesions, although photodynamic therapy with verteporfin should be avoided for the risk of retinal pigment epithelium tears (Axer-Siegel et al. 2004). Intravitreal bevacizumab is safe and effective in the treatment of exudative AMD in the short-term. Its results have been characterized by improvement in visual acuity (VA), decreased retinal thickness by optical coherence tomography (OCT) and no significant ocular or systemic side-effects (Rosenfeld et al. 2005; Avery et al. 2006). A 58-year-old man was referred for evaluation of progressive visual loss in the right eye (OD) of 30 days' duration. Visual acuity was 20/80. Funduscopy revealed PED in the juxtafoveal inferotemporal macula surrounded by hard exudates and inferior subretinal haemorrhage. Scattered drusen were seen in the posterior pole in both eyes. Fluorescein angiography showed early hyperfluorescence and pooling under the pigment epithelium in the inferotemporal macula, blocked choroidal fluorescence inferior to it, and stippled fluorescence and late leakage in the superior and nasal macular regions (Fig. 1). Optical coherence tomography disclosed inferotemporal PED and mild thickening of the overlying neurosensory retina (Fig. 2). The potential risks and benefits, as well as the off-label use of the drug, were discussed with the patient, after which 1.25 mg (0.05 ml) bevacizumab was injected intravitreally in an outpatient setting as previously described (Avery et al. 2006). One month later, VA was unchanged and partial resolution of the PED was noted on OCT images. Intravitreal bevacizumab was then re-injected OD. Seven days after the procedure, VA was 20/50. Fluorescein angiography showed late staining in the macular region and OCT depicted abnormal hyperreflectivity and thickening at the level of the retinal pigment epithelium−choriocapillaris band, consistent with early fibrosis (Fig. 3). Six weeks later, the picture was unchanged. Initial presentation. (A) Red-free photography of the right eye (OD) revealing pigment epithelium detachment in the juxtafoveal inferotemporal macula surrounded by hard exudates and inferior subretinal haemorrhage, as well as scattered drusen. (B) Late-phase fluorescein angiography frame OD showing pooling of the dye under the pigment epithelium in the inferotemporal macula, inferior blocked choroidal fluorescence, as well as stippled fluorescence and late leakage in the superior and nasal macular region. Initial presentation. (A) Horizontal cross-sectional image by optical coherence tomography (OCT). (B) Vertical cross-sectional image by OCT. An inferotemporal PED with mild thickening of the overlying neurosensory retina was noted. Visual acuity was 20/80. Seven days after the second intravitreal bevacizumab injection. (A) Horizontal cross-sectional image by optical coherence tomography (OCT). (B) Vertical cross-sectional image by OCT. Abnormal hyperreflectivity and thickening at the level of the retinal pigment epithelium−choriocapillaris band was seen in the subfoveal region, consistent with early fibrosis. Visual acuity was 20/50. Intravitreal bevacizumab injection was associated with both visual and anatomic improvement, as revealed by the lack of angiographic leakage, as well as tomographic resolution of the PED. Two intravitreal injections of the drug administered 1 month apart led to rapid and successful control of the disease. Thus, intravitreal bevacizumab may be beneficial to patients with occult CNV and PED in AMD and should be investigated further.