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of our knowledge, the ring‑shaped lesion at fovea could be a differential finding of MRNF among foveal lesions. Cases with regression of MRNF associated with inflammatory diseases and glaucoma were also reported in the literature.[7,8] The regression of widespread MRNF lesions leaving a spared lesion at fovea may mimic our case’s presentation. However, MRNF lesions in our case were stable and no other ocular pathology, which may cause regression was observed during follow‑up.
Conclusion MRNF may present with the ring‑shaped lesion at fovea and should be considered in the differential diagnosis of foveal diseases, which cause visual impairment. To our knowledge, this is the first report of foveal MRNF. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment Marcus Werner Storch, Hans Hoerauf We describe a case of macular hole (MH) closure after intravitreal bevacizumab therapy for an underlying pigment epithelial detachment (PED) due to exudative age‑related macular degeneration (AMD). The 73‑year‑old Caucasian female presented with reduced visual acuity (20/80) of the left eye and metamorphopsia for approximately 6 months. Spectral domain optical coherence tomography revealed a subfoveal PED due to AMD with an associated MH. To treat the exudative component of the pathology, we started intravitreal bevacizumab therapy, Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_818_16
Volume 65 Issue 7
References 1. Straatsma BR, Foos RY, Heckenlively JR, Taylor GN. Myelinated retinal nerve fibers. Am J Ophthalmol 1981;91:25‑38. 2. Kodama T, Hayasaka S, Setogawa T. Myelinated retinal nerve fibers: Prevalence, location and effect on visual acuity. Ophthalmologica 1990;200:77‑83. 3. Kreidl KO, Lin DY, Egbert JE. Myelination of the macula associated with disabling photophobia. Arch Ophthalmol 2003;121:1204‑5. 4. FitzGibbon T, Nestorovski Z. Morphological consequences of myelination in the human retina. Exp Eye Res 1997;65:809‑19. 5. Tarabishy AB, Alexandrou TJ, Traboulsi EI. Syndrome of myelinated retinal nerve fibers, myopia, and amblyopia: A review. Surv Ophthalmol 2007;52:588‑96. 6. Prakalapakorn SG, Buckley EG. Acquired bilateral myelinated retinal nerve fibers after unilateral optic nerve sheath fenestration in a child with idiopathic intracranial hypertension. J Pediatr Ophthalmol Strabismus 2012;16:534‑8. 7. Sowka JW, Nadeau MJ. Regression of myelinated retinal nerve fibers in a glaucomatous eye. Optom Vis Sci 2013;90:e218‑20. 8. Chavis PS, Tabbara KF. Demyelination of retinal myelinated nerve fibers in Behcet’s disease. Doc Ophthalmol 1998;95:157‑64.
consecutively leading to reduction of the height of PED and allowing closure of the MH. Detachment recurred during further follow‑up, but the MH remained closed. MHs and exudative AMD are common diseases, which rarely occur simultaneously. To the best of our knowledge (search via PubMed for “MH,” “PED,” “age‑related macular degeneration”), no other case with the persistent closure of an MH associated with PED during intravitreal antivascular endothelial growth factor therapy and despite recurrent PED has been published to date. Key words: Age‑related macular degeneration, bevacizumab, intravitreal antivascular endothelial growth factor therapy, macular hole, pigment epithelial detachment
We present the case of a 73‑year‑old Caucasian female with macular hole (MH) closure after intravitreal bevacizumab therapy for an underlying pigment epithelial detachment (PED) due to exudative age‑related macular degeneration (AMD). This case represents the first in literature, though there are several case reports on PED or antivascular endothelial growth factor (VEGF) therapy‑associated MHs.[1,2]
Case Report The 73‑year‑old Caucasian female presented with decreased vision and metamorphopsia for 6 months in her left eye. Initial examination revealed best‑corrected visual acuity (BCVA)
PMID: ***
Department of Ophthalmology, University of Göttingen, Göttingen, Germany Correspondence to: Dr. Marcus Werner Storch, Department of Ophthalmology, University of Göttingen, Robert‑Koch‑Street, 40, D‑37075 Göttingen, Germany. E‑mail: marcus.storch@med. uni‑goettingen.de Manuscript received: 31.10.16; Revision accepted: 19.06.17
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact:
[email protected] Cite this article as: Storch MW, Hoerauf H. Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment. Indian J Ophthalmol 2017;65:632-3.
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described. The authors proposed vitreous changes, induced by intravitreal injections as a possible pathomechanism.[9]
Conclusion
a
b
c
Figure 1: Spectral‑domain optical coherence tomography of the left eye at the initial presentation (a) confirmed a full‑thickness macular hole and a partially detached posterior hyaloid on top of a prominent pigment epithelium detachment. Four weeks after, the first bevacizumab injection. (b) Pigment epithelial detachment had resolved, and macular hole was closed. Pigment epithelial detachment recurred, but the macular hole did not reopen during further follow‑up (c)
In the presented case, it is not known whether the MH was already existing before AMD changes occurred. If it had developed after PED, stretching forces may have played a crucial role in the formation of the MH. A rate of 8.6% spontaneous closure in idiopathic MHs is reported by Chew et al.[10] It usually occurs after spontaneous posterior vitreous detachment. In the presented patient, in OCT images the posterior hyaloid remained attached, however, tangential vitreous traction forces may have released during intravitreal drug treatment. Therefore, in this case, the resolution of PED during anti‑VEGF‑therapy seemed to release the mechanical stress allowing approximation of the MH‑edges and closure of the hole. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
References
of 20/80 LE and 20/25 RE. Fundus biomicroscopy showed exudative AMD with subfoveal PED and an associated MH. Spectral domain optical coherence tomography (SD‑OCT) confirmed a full‑thickness MH with attached edges and a partially detached posterior hyaloid on top of the prominent PED [Fig. 1a]. Intravitreal anti‑VEGF‑therapy with three loading doses of monthly bevacizumab (1.25 mg)‑injections was started. Already 4 weeks after, the first injection PED had resolved with an approximation of the MH edges [Fig. 1b], but BCVA decreased to 20/160. Four weeks after, the second injection SD‑OCT findings showed complete closure of the MH and marked visual improvement to 20/50. During further follow‑up, PED recurred, but no reopening of the MH was observed [Fig. 1c]. Continued intravitreal drug therapy with bevacizumab according to Pro Re Nata regimen led to resolution of PED and visual stabilization.
1. Clemens CR, Holz FG, Meyer CH. Macular hole formation in the presence of a pigment epithelial detachment after three consecutive intravitreal antivascular endothelial growth factor injections. J Ocul Pharmacol Ther 2010;26:297‑9.
Discussion
6. Brüggemann A, Hoerauf H. Atypical macular holes. Klin Monbl Augenheilkd 2008;225:281‑5.
MH in the presence of drusen are not rare, and the results of vitreous surgery have been published earlier.[3,4] In contrast to commonly accepted causative factors such as anteroposterior and tangential vitreous traction forces as in idiopathic MH,[5] intraretinal glial pathology seems to be the prominent cause in secondary holes, such as ruptured cysts in vascular macular edema[6] or glial apoptosis on top of confluent soft drusen. The successful surgical treatment of MHs associated with PED was reported by Raiji et al.[7] and Cazabon,[8] but no report exists on closure of a PED‑associated MH by intravitreal anti‑VEGF treatment. However, the formation of MH during intravitreal VEGF treatment in patients with PED[1] and rip[2] is already
7. Raiji VR, Eliott D, Sadda SR. Macular hole overlying pigment epithelial detachment after intravitreal injection with ranibizumab. Retin Cases Brief Rep 2013;7:91‑4.
2. Oshima Y, Apte RS, Nakao S, Yoshida S, Ishibashi T. Full thickness macular hole case after intravitreal aflibercept treatment. BMC Ophthalmol 2015;15:30. 3. Berinstein DM, Hassan TS, Williams GA, Margherio RR, Ruby AJ, Garretson BR. Surgical repair of full‑thickness idiopathic macular holes associated with significant macular drusen. Ophthalmology 2000;107:2233‑9. 4. Chaudhry NA, Flynn HW Jr., Smiddy WE, Thompson JT. Macular hole surgery in the presence of prominent macular drusen. Arch Ophthalmol 2000;118:131‑2. 5. Johnson MW. Posterior vitreous detachment: Evolution and role in macular disease. Retina 2012;32 Suppl 2:S174‑8.
8. Cazabon S. Full‑thickness macular hole formation associated with pigment epithelial detachment: Link or coincidence? Int Ophthalmol 2010;30:739‑42. 9. Geck U, Pustolla N, Baraki H, Atili A, Feltgen N, Hoerauf H. Posterior vitreous detachment following intravitreal drug injection. Graefes Arch Clin Exp Ophthalmol 2013;251:1691‑5. 10. Chew EY, Sperduto RD, Hiller R, Nowroozi L, Seigel D, Yanuzzi LA, et al. Clinical course of macular holes: The Eye Disease Case‑Control Study. Arch Ophthalmol 1999;117:242‑6.
