Intravitreal Bevacizumab Injection Research Articles

Trends in Anti-Vascular Endothelial Growth Factor Original Medicare Part B Claims in the United States, 2014–2019

ABSTRACT Purpose To characterize trends in use of and expenditure for the intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents aflibercept, ranibizumab, and bevacizumab among the population enrolled in Original Medicare from 2014 to 2019. Methods The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to extract Medicare Part B fee-for-service outpatient injection claims data submitted by ophthalmologists. Multivariable linear regression models were used to evaluate the association between reimbursement, ophthalmologist availability, and agent administration rate. Results Between 2014 and 2019, 17,588,995 intravitreal injection claims were filed by 4218 US ophthalmologists. Medicare costs for anti-VEGF injections increased from 2.51 B USD in 2014 to 4.02 B USD in 2019. Increased state-level ophthalmologist availability and incremental increases in average reimbursement amounts were found to be significantly associated with a 6.8-fold variation in 2019 overall anti-VEGF injection rates across states. Conclusions Medicare injection rates and costs for anti-VEGF injections have both increased between 2014 and 2019, largely driven by increased aflibercept use. There is a significant association between ophthalmologist availability and anti-VEGF injection rate on the state level, suggesting access to care may contribute to the observed state-level disparities in intravitreal injection rates. Further characterization of factors contributing to the state-level variation in injection rates of individual anti-VEGF agents may help inform interventions promoting equitable access to and use of these drugs.

Unilateral Retinopathy in a Preterm Infant With 4q Duplication: Description and Management.

A 33-5/7, 1570 g dichorionic diamniotic twin presented with cryptorchidism, failed hearing examination (both ears), poor feeding, profound hypoglycemia, coagulopathy, conjugated hyper-bilirubinemia, hydronephrosis, and hypotension. Microarray sent with results of whole genome SNP microgray analysis detected an interstitial duplication of the chromosomal segment 4q35 1q35.2. On this basis, telemedicine screening was performed to evaluate for ocular abnormalities in association with abnormal gene testing. Unilateral advanced retinopathy was noted affecting the right eye, with mature vascularization in the left eye. This infant was managed in concordance with retinopathy of prematurity guidelines, despite not making screening criteria. Off-label intravitreal bevacizumab injection (0.625 mg in 0.025 mL) resulted in full vascular maturation assessed by fluorescein angiography 6 months later. This represents the first description and management of retinopathy in 4q duplication syndrome. [Ophthalmic Surg Lasers Imaging Retina 2024;55:228-230.].

Calcified Sclero-Choroidal Choristomas in Mosaic RASopathies: A Description of a New Imaging Sign

PurposeTo evaluate the imaging and clinical features of unusual calcified lesions seen in the fundus of mosaic RASopathy patients. DesignSingle-center retrospective observational study. SubjectsTen eyes with calcified fundus lesions in 7 mosaic RASopathy patients. MethodsThe lesions were evaluated with fundus photography, oral fundus fluorescein angiography, B-scan ultrasonography, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) scan where available. Main Outcome MeasuresThe imaging characteristics of calcified fundus lesions were assessed. ResultsWe found seven patients with mosaic RASopathies, 5 males and 2 females (3 with Linear Sebaceous Nevus Syndrome, 3 with Oculoectodermal Syndrome, and 1 with Encephalocraniocutaneous Lipomatosis) with molecular confirmation in 5 cases, all 5 having KRAS-pathogenic variants. Calcified fundus lesions were identified in 10 eyes (bilateral in 3 patients), appearing as slightly elevated, creamy-yellow lesions around or adjacent to the optic nerve, extending supero-nasally; all but two of these lesions involved both the choroid and sclera, with two of them only involving the sclera at the time of examination. One case developed a choroidal neovascular membrane (CNV) necessitating intravitreal bevacizumab injections. All 7 patients had B-scan ultrasonography and the lesion appeared as a hyperechogenic area with an acoustic shadow posteriorly despite reduced gain. Five patients had MRI, and where fundus lesions were present, there was a focal defect in the sclero-choroidal layer. Four patients had a CT scan and all four showed calcifications affecting both the posteromedial sclero-choroid and adjacent medial rectus muscle. Two of these patients had normal eye movements, one had a unilateral fixed adducted eye and a vestigial fibrous medial rectus muscle seen in imaging and intraoperatively, and the fourth had marked exotropia with a right gaze deficit affecting both eyes. ConclusionsWe propose that the lesions seen in this cohort are calcified sclero-choroidal choristomas (CaSCCs) and should be suspected in mosaic RASopathies when creamy-yellow lesions are seen in the fundus. If identified, the possibility of choroidal neovascularization should be considered during follow-up. In all cases where a CT scan was performed, a novel sign of sclero-muscular calcification involving the medial rectus muscle was seen.

Comparison of intravitreal preservative-free triamcinolone versus posterior sub-tenon triamcinolone acetonide injection for bevacizumab-resistant diabetic macular edema

BackgroundTriamcinolone acetonide (TA) is administered as an intravitreal or posterior sub-Tenon’s capsule injection, as treatment for diabetic macular edema (DME). The intravitreal use of TA is limited because commercially available triamcinolone acetonide contains benzyl alcohol, a neurotoxic preservative. Few studies have compared effects of preservative-free intravitreal TA (IVTA) and posterior sub-Tenon capsule TA (STTA) injections for DME. Thus, herein, we compared the effectiveness of preservative-free IVTA and STTA for treatment of bevacizumab-resistant DME.MethodsIn this retrospective cohort study, bevacizumab-resistant DME was defined as a lack of response to at least three consecutive intravitreal bevacizumab (IVB) injections. Changes in mean central macula thickness (CMT), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) between IVTA and STTA groups were compared at baseline and at 1, 2, and 3 months after treatment.ResultsForty eyes from 40 patients were included in this study. In the IVTA group, the mean CMT improved significantly from 400.2 ± 144.42 μm at baseline to 288.35 ± 151.74 μm at 3 months after treatment (p = 0.01). Similarly, in the STTA group, the mean CMT improved significantly from 446.65 ± 120.74 μm at baseline to 382.9 ± 113.58 μm at 3 months after treatment (p = 0.009). The mean BCVA of the IVTA group also showed improvement, decreasing from 0.75 ± 0.55 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.625 ± 0.50 logMAR at 3 months after treatment (p = 0.089). Similarly, the mean BCVA of the STTA group improved, from 0.6 ± 0.36 logMAR at baseline to 0.54 ± 0.35 logMAR at 3 months after treatment (p = 0.094).ConclusionGiven that IVTA and STTA demonstrated statistically equivalent anatomical and functional effects in patients with bevacizumab-resistant DME, the less invasive STTA may be considered the preferred treatment approach for the management of bevacizumab-resistant DME.Trial registrationRetrospectively registered.

Incidence of acute endophthalmitis after intravitreal bevacizumab injection in a tertiary hospital

Aims: To investigate the incidence of acute endophthalmitis after intravitreal bevacizumab injections. Methods: Patients who received treatment with intravitreal bevacizumab (1.25 mg/0.05 ml) injections for various indications between November 2020 and March 2022 were included in this retrospective study. The patients were followed up for 4 weeks after the injection in terms of acute endophthalmitis symptoms and signs. Results: Acute endophthalmitis developed in 1 patient after 4593 intravitreal bevacizumab injections were administered to 1427 eyes of 1026 patients, and the incidence was found to be 0.0217%. The patient who developed acute endophthalmitis underwent pars plana vitrectomy and after 3 months, a significant improvement in visual acuity was observed. Conclusion: Development of endophthalmitis postoperatively was found to be moderately low after intravitreal bevacizumab injection. It was concluded that following asepsis rules and optimal bevacizumab preparation conditions could further reduce this.

Vitrectomy with subretinal tissue plasminogen activator and intravitreal injection of bevacizumab in the treatment of submacular haemorrhage secondary to wet AMD – case series

Vitrectomy with subretinal tissue plasminogen activator and intravitreal injection of bevacizumab in the treatment of submacular haemorrhage secondary to wet AMD – case series

Long-term outcomes of visual motor integration and motor development children with retinopathy of prematurity.

Premature infants have a risk of neurodevelopmental deficits. Little is known, however, about how retinopathy of prematurity (ROP) affects visual motor integration (VMI), which is necessary for both fine motor skills and further school abilities. Due to the systemic escape of bevacizumab in the treatment of ROP, concerns regarding the long-term neurodevelopmental effect of the drug have arisen. The aim is to evaluate VMI and motor development long-term outcomes after intravitreal bevacizumab (IVB) injection and laser treatment for ROP. Two groups of premature children were included: Bevacizumab group - 16 premature children who received IVB treatment and laser group - 23 premature children who underwent laser photocoagulation treatment in this single center cross-sectional study. At 2-6 years of age, VMI (Beery-Buktenica Developmental Test), motor development (Peabody Developmental Motor Scales-2), visual acuity, and refractive status were assessed. The incidence of abnormal visual function was significantly higher in bevacizumab group than in laser group (p = 0.022). The incidence of abnormal VMI skill was significantly higher in bevacizumab group than in laser group (p = 0.024). Incidences of abnormal gross, fine, and total motor skills were significantly higher in bevacizumab group compared to laser group (p < 0.05). Premature children who received bevacizumab for ROP demonstrated significantly lower VMI and motor development features than those with laser treatment at preschool age. Although our results suggest the relevance of bevacizumab injection in impaired VMI and motor development outcomes, general level of sickness rather than treatment might be the cause of delayed motor development.

Real-life neovascular AMD treatment considering reimbursement in Turkiye: One-year comparison of switching to intravitreal ranibizumab or aflibercept after treatment failure with three loading intravitreal bevacizumab injections.

To compare one-year anatomical and functional results of switching to an on-label intravitreal anti-vascular endothelial growth factor (anti-VEGF) agent (intravitreal ranibizumab [IVR] or aflibercept [IVA]) after treatment failure with three loading doses of off-label intravitreal bevacizumab (IVB), which is mandatory in the treatment of neovascular age-related macular degeneration (nAMD) to get reimbursement from Social Security Institution in Turkiye. This comparative, real-life, retrospective cohort study included treatment-naïve nAMD patients treated starting with three loading doses of IVB, switched to three loading doses of IVR and IVA due to treatment failure after IVB loading, and followed up one year with a treat-and-extend (T&E) protocol with 2-week extension/shortening intervals. The primary outcomes were changes in best-corrected visual acuity (BCVA; logMAR) and central macular thickness (CMT, µm) one year after the switch, and the secondary outcomes were maximum treatment intervals, number of injections, and disease activity rates. The mean age (72.9±8.2 and 72.2±6.7, p=0.677) and gender (60.0% and 47.4% females, p=0.398) were similar among the IVR (35 eyes/patients) and IVA (38 eyes/patients) groups. The median BCVA and CMT were significantly improved during the study period (p<0.001) with no significant intergroup differences. The ratio of 4-, 6-, 8-, 10-, and 12-week maximum treatment intervals were 28.6%, 17.1%, 14.3%, 8.6%, and 31.4% in the IVR, and 13.2%, 15.8%, 21.1%, 15.8%, and 34.2% in the IVA group (p=0.492). The median (IQR) number of injections in the IVA group (8 [7-9]) was significantly lower than the IVR group (9 [8-12]) during the one-year T&E period (p=0.026). The disease activity rates were 34.3% and 26.4% one month (p=0.610) and 37.1% and 21.1% one year (p=0.195) after the switch in IVR and IVA groups. This real-life comparison study indicates that, after the treatment failure with three loading doses of IVB, switching to either on-label anti-VEGF agent can be regarded as comparable considering functional and anatomical results. However, although maximum treatment intervals were not significantly different, fewer injections were required with aflibercept during the one-year T&E follow-up period.

Effect of Intravitreal Injection of Bevacizumab with Laser Photocoagulation versus Combination of Intravitreal Injection of Bevacizumab with Triamcinolone Acetonide in the Treatment of Diabetic Macular Edema

Background &amp; Objective: Recently there are various treatment modalities for the patients of diabetic macular edema. So, it is very difficult to choose the option. This study was aimed to compare the efficacy of combination of intravitreal injection of bevacizumab with laser photocoagulation versus combination of intravitreal injection of bevacizumab with triamcinolone acetonide in the treatment of DME. Methods &amp; Materials: A prospective observational study was conducted on 50 eyes of fifty patients who were diagnosed with DME at vitreo-retina department of NIO&amp;H. They were divided into 2 groups, Group A (treated with bevacizumab with laser photocoagulation) and Group B (treated with intra-vitreal bevacizumab with triamcinolone acetonide). Follow-up pattern was set after 1 and 3 months of intervention. All the baseline data and outcome data were recorded in a pre-designed data collection sheet and was statistically analyzed by SPSS version 23. Result: Mean baseline BCVA was 0.57±0.29 (SD) Log MAR in group A and 0.70±0.26 (SD) Log MAR in group B (p=0.57). BCVA was 0.40±0.32 (SD) and 0.40±0.37 (SD) in group A and 0.58±0.28 (SD) and 0.45±0.36 (SD) in group B during 1st and 2nd follow-up respectively. Comparison of mean BCVA between two groups at final follow-up was not significant. Improvement of CMT from baseline in every follow up in each group was significant but comparison of mean CMT between two groups at final follow-up was not significant (p=0.64). Though the difference of baseline IOP of both groups are statistically significant, comparison of mean IOP between two groups at final follow-up was not significant (p=0.67). Conclusion: There was significant improvement in mean BCVA and mean CMT within the group in each follow-up. At final follow-up, Combination of intravitreal bevacizumab and triamcinolone acetonide shows better improvement which is non-significant. TAJ 2023; 36: No-2: 179-184

Intravitreal injection of methotrexate in persistent diabetic macular edema: a 6-month study.

Diabetic macular edema (DME) affects approximately 10% of patients with diabetes mellitus. This condition can cause blurred or distorted vision, which significantly affects the quality of life of these patients. We evaluated the therapeutic effects of intravitreal methotrexate (MTX) injections on persistent DME. This prospective interventional case series included patients with confirmed persistent DME that was unresponsive to previous standard treatments. The patients underwent comprehensive eye examinations and macular imaging with optical coherence tomography (OCT). A single intravitreal MTX injection (400 µg MTX in 0.16 mL solution) was administered, followed by patient assessments at 1, 3, and 6 months after injection. Best-corrected distance visual acuity (BCDVA), intraocular pressure (IOP), macular thickness (MT), and central subfield thickness (CST) were measured at baseline and post-injection to evaluate treatment efficacy. We included 33 eyes of 30 patients with a mean (standard deviation [SD], range) age of 62.7 (8.3, 44 to 77) years, of whom 17 (56.7%) were men and 13 (43.3%) were women. All participants had type 2 diabetes mellitus, with a mean (SD, range) duration of 17.0 (6.8, 10 to 31) years. Most participants (n = 27 eyes, 81.8%) had non-proliferative diabetic retinopathy, and six eyes (18.2%) had regressed proliferative diabetic retinopathy. Four eyes (12.1%) had undergone prior macular laser photocoagulation. The mean (SD) number of prior intravitreal bevacizumab injections was 3.4 (0.8), and 29 eyes (87.8%) had received one intravitreal triamcinolone injection. During the study period, a statistically significant difference was observed in CST (P < 0.05); however, no statistically significant differences were observed in BCDVA, MT, or IOP (P > 0.05). Pairwise comparison revealed a significant decrease in CST at 6 months post-injection compared to the baseline value (P < 0.05). During the investigation period, no side effects of MTX, such as macular edema, retinal tears, vitreous hemorrhage, endophthalmitis, or vision loss, were observed. A single intravitreal MTX injection significantly reduced CST in patients with persistent DME, without relevant safety concerns. However, no significant improvement in functional outcomes was observed. Therefore, there is no strong evidence to recommend its use as a treatment for pDME. Further studies, preferably randomized clinical trials with long-term follow-ups, are warranted to assess the long-term efficacy, safety, and potential benefits of intravitreal MTX for the treatment of persistent DME.

A Case of Repeated Intravitreal Dexamethasone Implantation for Treatment of Macular Edema after Scleral Fixation of Intraocular Lens

The purpose of this case was to report a case of repeated dexamethasone intravitreal implant (Ozurdex; Allergan Inc., Irvine, CA, USA) migration into the anterior chamber without any corneal complications in a patient with cystoid macular edema. A 70-year-old male patient had decreased vision due to cystoid macular edema after scleral fixation of a dislocated intraocular lens in his right eye. He had repeated intravitreal bevacizumab injection but macular edema showed little improvement. Macular edema improved after intravitreal dexamethasone implantation but he needed repeated implantation since macular edema recurred as the therapeutic effect of the implant decreased. After the third implantation, 70 days later, the implant was observed in the anterior chamber, and the intraocular pressure (IOP) measured 46 mm Hg, while the cornea remained clear. We decided to have a close follow-up with IOP control since no corneal edema was seen. The implant was completely absorbed after 40 days with clear cornea and another intravitreal dexamethasone implantation was performed owing to increasing macular edema. The implant was seen in the anterior chamber again after 78 days but no corneal edema was seen and IOP was normal. After 1 month the implant was completely absorbed and intravitreal dexamethasone implantation was repeated. Migration of dexamethasone intravitreal implant may happen in a patient with posterior capsular defect but the treatment could be maintained under close observation in absence of corneal complications.

Effects of repeated intravitreal bevacizumab administration on anterior segment parameters and limbal stem cells

Background: Macular edema (ME) is fluid accumulation in the macula caused by vascular leakage. Repeated intravitreal bevacizumab (IVB) injections are extensively used to treat ME of different origins, are well tolerated, and have few side effects. This study evaluated the effects of repeated IVB injections on the anterior segment parameters and limbal stem cells (LSCs) in eyes with ME.&#x0D; Methods: This before–after study involved patients with ME of different causes who underwent repeated IVB injections at the Imam Khomeini Ophthalmology Center in Kermanshah, Iran. Before and after repeated IVB injections, anterior segment parameters were measured using anterior segment optical coherence tomography, and the LSCs were assessed using impression cytology.&#x0D; Results: We enrolled 42 eyes of 42 patients with a mean (standard deviation [SD]) age of 59.6 (7.6) years, of whom 25 (59.5%) were men and 17 (40.5%) were women. The underlying diseases included diabetic ME in 30 eyes (71.4%), central (5 [11.9%]) or branch (3 [7.1%]) retinal vein occlusion, and choroidal neovascularization in 4 eyes (9.5%). The right eye was affected in 22 (52.4%) participants. The mean (SD) number of IVB injections was 4.3 (1.3). After repeated injections, the mean central corneal thickness (CCT) increased, whereas the mean anterior chamber angle (ACA) and anterior chamber depth (ACD) decreased (all P&lt;0.001). Three patients developed LSC deficiency after repeated IVB injections for diabetic ME.&#x0D; Conclusions: We observed a significant increase in the mean CCT and a decrease in the mean ACA and ACD after repeated IVB injections in our series. Three patients developed LSC deficiency after repeated IVB injections for diabetic ME management. The observed effect on LSC may cast doubt on the safety of repeated IVB injections; however, this finding must be verified in multicenter clinical trials with longer follow-up periods and larger study samples.

Anatomical and Functional Outcomes with Prompt versus Delayed Initiation of Anti-VEGF in Exudative Age-Related Macular Degeneration.

To investigate the correlation between time from diagnosis of treatment-naïve exudative age-related macular degeneration (AMD) to the introduction of anti-VEGF treatment and anatomical and functional outcomes. Retrospective cohort study. Included were treatment-naïve exudative AMD patients who presented to a single tertiary medical center between 2012 and 2018. All patients were treated within the first 30 days of their diagnosis with three monthly intravitreal injections of bevacizumab. Patients were divided into three groups: group 1 (prompt anti-VEGF) were injected with bevacizumab within ten days, group 2 (intermediate anti-VEGF) within 11-20 days, and group 3 (delayed anti-VEGF) within 21-30 days from diagnosis. Baseline characteristics and clinical outcomes were compared up to two years from treatment. 146 eyes of 146 patients were included. Sixty-eight patients were in the prompt anti-VEGF group, 31 in the intermediate anti-VEGF group, and 47 in the delayed anti-VEGF group. Following the induction phase of three intravitreal bevacizumab injections, the mean central subfield macular thickness (328.0 ± 115.4 µm vs. 364.6 ± 127.2 µm vs. 337.7 ± 150.1 µm, p = 0.432) and the best-corrected visual acuity (0.47 ± 0.38 vs. 0.59 ± 0.48 vs. 0.47 ± 0.44 logMAR units, p = 0.458) were comparable between the prompt, intermediate and delayed anti-VEGF groups. Anatomical and functional outcomes, treatment burden, number of relapses and eyes with second-line anti-VEGF therapy were comparable between the groups at both 1-year and 2-year timepoints. Our real-world evidence data emphasize that even if anti-VEGF induction cannot be initiated promptly within ten days from diagnosis of naïve exudative AMD, the visual and anatomical prognosis of the patients may not worsen if the treatment is started within one month of diagnosis.

Trabeculectomy with concurrent intravitreal bevacizumab in neovascular glaucoma.

To evaluate the clinical efficacy of concurrent intravitreal bevacizumab (IVB) injection with trabeculectomy with mitomycin-C (MMC) in neovascular glaucoma (NVG). Patients with NVG who underwent trabeculectomy with concurrent IVB (group 1) and those who underwent IVB sequentially, followed by trabeculectomy with MMC (group 2) in 1-2 weeks between January 2021 and August 2022, were included in this retrospective hospital-based study. The need for medications for intraocular pressure (IOP) control at 6 months in the two groups was the primary outcome measured and compared between the groups. The association of the need for medications postoperatively with clinical variables was assessed using stepwise multivariate regression statistics. We finally included 40 patients ( n = 12 in group 1, n = 28 in group 2) with no significant differences in presenting age between groups. The IOP at 1 day and 1 week were not significantly different between groups though the IOP at 1, 3, and 6 months. IOP was lower in group 1 eyes with the 6-month IOP, being significantly lower in group 1, P = 0.05. Three eyes in group 1 and 11 eyes in group 2 required anti-glaucoma medications in the postoperative period. Multivariate regression identified preoperative IVB >3 (β =0.7, P < 0.001) and recurrent vitreous hemorrhage (β = 0.7, P = 0.004) as prognostic factors ( R2 = 40.6%) determining the need for anti-glaucoma medication (AGM) postoperatively in both groups. Concurrent IVB with trabeculectomy with mitomycin-C is a feasible alternative in patients with NVG with refractory high-presenting IOP. This may serve to address raised IOP as well as retinal ischemia, thereby improving surgical success rates in the most challenging NVG cases.

ANATOMICAL AND FUNCTIONAL OUTCOMES OF BEVACIZUMAB TREATMENT IN PEDIATRIC AUTOSOMAL RECESSIVE BESTROPHINOPATHY.

The purpose of this study was to report functional and anatomical outcomes of anti-VEGF treatment in eyes with autosomal recessive bestrophinopathy (ARB) presenting in the first decade of life. The study included case series of four eyes from two siblings with compound heterozygous mutations in the BEST1 gene who were treated with eight monthly intravitreal bevacizumab injections. Response to treatment was analyzed using color fundus photography, fundus autofluorescence, optical coherence tomography, OCT angiography, and microperimetry. Patient 1 (male, age 9 years) had visual acuity of 20/20 in the right eye and 20/50 in the left eye. Patient 2 (female, age 10 years) had visual acuity of 20/25 in the right eye and 20/20 in the left eye. All eyes had multifocal subretinal deposition of lipofuscin and subretinal fluid, and three eyes had choroidal neovascularization (CNV). Lipofuscin material reabsorbed in 2 of 4 eyes, the CNV regressed in 3 of 3 eyes, a bacillary detachment resolved in 1 of 1 eye, but the subretinal fluid did not change. Functional improvement in visual acuity was noted, but MP showed scattered areas of reduced retinal sensitivity. No ocular or systemic side effects were detected. Anti-VEGF treatment of choroidal neovascularization in eyes with ARB resulted in anatomical changes that were only clinically significant in the eye with decreased visual acuity. The hyporeflective subretinal material remained unchanged suggesting a nonexudative cause. These findings provide new insights into the management of ARB, especially in pediatric subjects with CNV.

Safety of Suprachoroidal Triamcinolone Acetonide Injection without Cannula Sleeve: A Modified Technique

Purpose: To evaluate safety of a new technique of Suprachoroidal (SC) injection of Triamcinolone Acetonide (TA) without need of cannula sleeve. Study Design: Quasi experimental study. Place and Duration of Study: LRBT Korangi from July 2020 to June 2021. Methods: Fifty eyes of forty two patients with Diabetic Macular Edema not resolved with three consecutive intravitreal injection of Bevacizumab were included. A custom made 30 gauge needle on 1cc insulin syringe without cannula sleeve was used for injection of 0.1 ml (4 mg) Triamcinolone Acetonide. Results: Mean age was 50.8 13.77 years. Mean IOP readings pre injection, after injection at 5 minutes, 30 minutes, 1 hour, 2 hour, 1 week, 1 month and 3 months were 12.76 , 14.8 , 14.5 , 14.6 4.46, 14.7 4.52,14.7 , 12.98 and 12.83 2.62 mm of Hg respectively. Mean BCVA (Log MAR) before injection, 1 month and 3 months after injection were 0.9 ± 0.1, 0.6 ± 0.2 and 0.6 ± 0.2 respectively. Mean CMT values before injection, 1 month and 3 months after injection were 408.4 ± 112.94, 348.67 ± 108.94 and 330.36 ± 105.77 µm respectively. Significant difference was observed between pre-injection IOP and post injection IOP within 2 hours but no significant difference in later readings. BCVA and CMT showed statistically significant improvement. Conclusion: SC injection of TA without cannula sleeve is quite simple and apart from transient increase in IOP immediately after injection no significant adverse effects occur.

A Case of Transient Posterior Capsular Opacity After Intravitreal Bevacizumab Injection

Purpose: We are reporting a case of transient posterior capsular opacity after intravitreal Bevacizumab (Avastin&lt;sup&gt;®&lt;/sup&gt;, Roche Pharma Schweis AG, Zurich, Switzerland) injection in a phakic patient.Case summary: A 34-year-old man visited our clinic with sudden blurred vision in his left eye one day after the intravitreal injection for central serous chorioretinopathy. His visual acuity was 1.0 before the injection and decreased to 0.1 at the presentation. On slit-lamp examination, a snow-flake appearance opacity was noted behind the posterior capsule. No newly appearing lesion was presented on fundus exam, so topical antibiotics and steroid eyedrops were continued. One week after the injection, the visual acuity improved to 1.0 and posterior capsular opacity remained but decreased. Five weeks after the injection, the posterior capsular opacity resolved. Fundus exam revealed improved but persistent subretinal fluid, so he overwent another intravitreal injection. The posterior capsular opacity did not recur for seven months.Conclusions: Iatrogenic lens damage or the turbidity formed by medication can cause a posterior capsular opacity after intravitreal injection. If structural damage is uncertain, close monitoring is needed and ultimately, cataract surgery may be required for chronic crystalline lens opacity.

Hyperviscosity Syndrome-related Retinopathy in a Patient with Waldenström Macroglobulinemia

Purpose: We report a case of retinopathy related to bilateral hyperviscosity syndrome in a patient with Waldenström macroglobulinemia.Case summary: A 77-year-old male presented with reduced visual acuities of both eyes 2 months in duration. Fundus examination revealed extensive flame-shaped retinal hemorrhages and venous congestion. Optical coherence tomography (OCT) evidenced macular edema and OCT angiography (OCTA) indicated damage to the superficial and deep capillary plexi of retina and choriocapillaris and dilated large choroidal vessels. We diagnosed central retinal vein occlusion with macular edema and prescribed intravitreal bevacizumab and posterior subtenon triamcinolone injections, however, the edema did not improve. As retinopathy associated with hematological disease was thus suspected, we referred the patient to our department of hematology and oncology for further assessment. He was diagnosed with Waldenström macroglobulinemia. After initiation of chemotherapy, the retinal hemorrhage in and macular edema of both eyes decreased. After six chemotherapy cycles, the retinal hemorrhages resolved and the macular edema improved in both eyes. OCTA revealed that the choroidal vessel dilation also improved.Conclusions: In elderly patients presenting with central retinal vein occlusions and macular edema of both eyes, it is important to assess whether the retinopathy is associated with a hyperviscosity syndrome linked to a hematological disease.

Complications after proton therapy of choroidal melanoma: A case report

Proton beam therapy is a globe preserving treatment method of choroidal melanoma. It is considered to be less harmful for the tissues around the tumour but the complications such as radiation retinopathy and neuropathy occur according to the dosage of irradiation. The visual outcomes after treatment are variable and dependent on the size of tumour. This article presents a case report of a 44-year-old male with choroidal melanoma in the left eye. Patient was examined in our ophthalmology practice because of photopsia and blurry vision during physical activity. After full ophthalmologic examination, fundus photography, optic coherent tomography, fluoresceine angiography and ultrasonography the diagnosis of malignant melanoma of choroid was set. The patient was referred to a proton center to undergo a proton therapy of choroidal melanoma in the left eye. Follow-up treatment of severe postradiation retinopathy and neuropathy is presented in the article. The patient took intravitreal bevacizumab injections and the panretinal lasercoagulation was performed. After one and half year follow up the melanoma is stable after therapy with no metastases.

Changes in aqueous concentrations of various cytokines after intravitreal bevacizumab injection for chronic central serous chorioretinopathy.

This study aimed to investigate changes in cytokine levels after intravitreal bevacizumab injection in patients with chronic central serous chorioretinopathy (CSC). In a prospective interventional trial, 12 eyes of 12 patients with chronic CSC and 6 eyes of 6 patients who underwent cataract surgery were included as controls. Patients diagnosed as with CSC received a single intravitreal injection of bevacizumab (1.25 mg/0.05 mL). Aqueous humor samples were collected from the patients and controls. Best-corrected visual acuity and foveal thickness were evaluated, and aqueous samples were obtained before and 4 weeks after injection. The aqueous concentrations of interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) were measured using a multiplex bead assay. After injection, the foveal thickness decreased significantly from 328 (210-477) to 283 (168-356) (p = 0.048), but the best-corrected visual acuity was not significantly different (p = 0.066). The aqueous levels of IL-8 increased significantly from 3.3 pg/mL (1.5-8.3) to 4.7 pg ⁄ mL (2.2-11.6) at 4 weeks after the injection (p = 0.046). The aqueous levels of VEGF decreased significantly from 31.4 pg/mL (17.0-53.3) to 15.2 pg/mL (7.7-21.5) (p < 0.01). No significant changes in IL-6, IP-10, MCP-1, and PDGF-AA levels were noted 4 weeks after injection (p = 0.455, p = 0.055, p = 0.076, and p = 0.339, respectively). In this study we found intravitreal bevacizumab injection decreased VEGF and increased IL-8 in the eyes of patients with chronic CSC. This study suggests the possibility that the pathogenesis of CSC may be related to abnormal circulation of the choroidal blood vessels through VEGF and IL-8 cytokine level changes.