Effect of intravitreal bevacizumab (Avastin®) in the fellow eye of a patient with bilateral exudative age related macular degeneration

P.K.Agarwal1, S Dudgeon2, S Parks2, D Keating2, W Wykes1

1 Southern General Hospital, Glasgow, United Kingdom
2Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, United Kingdom

Corresponding Author:
Pankaj kumar Agarwal
pankaj_eye@yahoo.com
Phone: 00447931325566
Fax: 00441412113466

Introduction:

Bevacizumab, anti-VEGF, medication approved by the Food and Drug Administration as treatment for metastatic colorectal cancer1. It is widely used ‘off label’ throughout the world for various ocular conditions. Several published case series shows its efficacy in neovascular age related macular degeneration. 2, 3, 4 Short term, self reported results have not shown an increased rate of potential drug-related ocular or systemic events.5 We report a case of bilateral exudative age related macular degeneration treated by intravitreal bevacizumab showing evidence of therapeutic benefit in the fellow non treated eye.
Key Words: Retina, Macula, Degeneration, Avastin, Bevacizumab, Intravitreal, Bilateral

Case Report:

An 84 year old female was referred with rapid deterioration in central vision in both eyes. Her general health was good apart from controlled essential hypertension. On examination her logMAR visual acuity (VA) was 0.9 and 0.8 in the right and left eye (LE) respectively, associated with large central scotomata. Fundus examination showed bilateral hemorrhagic pigment epithelial detachment (PED) which was confirmed by angiography. She was given 1.25 mg in 0.1ml intravitreal Bevacizumab in both eyes. Two months after the initial injections her logMAR VA became stable at 0.7 in both eyes with reduction of edema and hemorrhage at the maculae. The patient herself didn’t notice any significant improvement in her vision or improvement in her central scotomata. A month later her VA dropped down to 0.8 in the right and 1.0 in the left eye. Optical Coherence Tomography confirmed PEDs bilaterally with subretinal fluid surrounding the PEDs. On this occasion she was given the same dose of intravitreal bevacizumab in LE only. On follow up after a month there was a marked reduction in the subretinal fluid and hemorrhage in both maculae with a VA of 0.6 in both eyes and, improvement of 20 letters and 14 letters respectively in the right and left eyes.OCT showed a significant improvement in the depth of the PED in the LE and a virtual resolution of the subretinal fluid surrounding the PED with just a small pocket of SRF present under the fovea. OCT of the RE showed no significant change in macular appearance. In her most recent follow up 2 months after the repeat injection her visual status was unchanged. She was aware of significant improvement of vision in both eyes with a very satisfactory patient related visual outcome. No systemic side effects were noted.

Discussion:

A single intravitreal injection of Avastin gives rise to detectable levels of this agent in the blood stream.4, 5 Some detectable drug is expected in the vitreous in the fellow eye but it is very encouraging to observe its beneficial clinical effect with similar and comparable results to the injected eye. Lack of clinical trials and published literature about Avastin complicates the situation regarding repeat injections and managing bilateral macular degeneration without significant systemic side effects. Prospective studies are needed to determine the effects of this and similar agents in the fellow eye. This case suggests however that it may not be necessary to subject both eyes at once to the risk of intravitreal injection in bilateral wet maculopathy. We are unaware of any reported case indicative of a biologic effect in the fellow eye of anti-VEGF and could find no reference to it in a computerized search in MEDLINE.

References

  1. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 2004; 350:2335-2342.
  2. Rosenfield PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmic Surg Lasers Imaging 2005; 36:331-335.
  3. Avery RL, Pieramici DJ, Rabena MD, Castellarin AA, Nasir MA, Giust MJ. Intravitreal bevacizumab (Avastin) for neovascular age related macular degeneration. Ophthalmology 2006; 113:363-372.
  4. Rich RM, Rosenfeld PJ, Puliafito CA, et al. Short-term safety and efficacy of intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. Retina 2006; 26:495–511.
  5. Fung A E, Rosenfeld P J, Reichel E. The International Intravitreal Bevacizumab Safety Survey: using the internet to assess drug safety worldwide. BJO 2006; 90:1344-1349.

Figure Legends:

Figure 1. Right (right side) and left (left side) fundus and OCT before injection showing Haemorrhage, oedema and subretinal fluid with RPE detachmentLeft fundus after 2nd injection


Figure 2. Right (right side) and left (left side) fundus showing resolution of haemorrhage and decrease in edema and subretinal fluidLeft OCT horizontal after 2nd injection.