Ocular Immunology & Inflammation, 17, 221–223, 2009 C Informa Healthcare USA, Inc. Copyright ISSN: 0927-3948 print / 1744-5078 online DOI: 10.1080/09273940902731023
Combined Intravitreal Bevacizumab and Triamcinolone Acetonide Injection for Idiopathic Neuroretinitis ¨ ¨ Mehmet C ¸ akır, MD, Osman C ¸ ekic¸, MD, PhD, Ercument Bozkurt, MD, Gokhan Pekel, Ahmet T. Yazıcı, MD, ¨ and Omer F. Yılmaz, MD Beyo˘glu Eye Training and Research Hospital, Istanbul, Turkey
ABSTRACT Purpose: To present a case with idiopathic neuroretinitis that was treated with combined intravitreal bevacizumab and triamcinolone. Design: Case report. Methods: Interventional case report. Results: A 31-year-old man presented with a visual acuity of 3/10 and afferent pupillary defect in the right eye. Ophthalmologic examination disclosed papillitis and macular edema. Neurology consultation with cranial computerized tomography scan revealed no abnormality. The patient was injected with bevacizumab and triamcinolone intravitreally. One week later, the vision increased to 10/10, macular edema disappeared. One month later, optic disc edema disappeared. Conclusions: Intravitreal injection of bevacizumab and triamcinolone effectively treated idiopathic neuroretinitis. Keywords: bevacizumab; idiopathic neuroretinitis; intravitreal injection; triamcinolone acetonide; vascular endothelial growth factor
Neuroretinitis is as a disorder characterized by optic disc edema accompanied by macular exudates. Although most cases are thought to be the result of a nonspecific viral infection or other immune-mediated process, various infectious agents have been implicated, including syphilis, Lyme disease, toxoplasmosis, and cat-scratch disease.1 Noninfectious factors like sarcoidosis and inflammatory bowel syndrome may also play role in the etiology.1,2 Physical findings of recent onset neuroretinitis include optic disc swelling and peripapillary exudative retinal detachment, followed by vitreous cells and macular or peripapillary hard exudates.1
Received 1 October 2008; Accepted 7 January 2009. Presented at the 3rd Mediterranean Retina Meeting, Istanbul, Turkey, 2008. Address correspondence to Mehmet C ¸ akir, MD, Beyoglu Eye Training and Research Hospital, Istanbul, Turkey. E-mail:
[email protected]
We here report a case of idiopathic neuroretinitis that was treated with combined intravitreal bevacizumab– triamcinolone.
CASE REPORT A 31-year-old man presented with worsening of vision of the right eye for the last 10 days. Visual acuity was 3/10 and afferent pupillary defect was positive in the affected eye. Intraocular pressure was 16 mmHg. Anterior segment findings were nonspecific. Ophthalmologic examination disclosed papillitis and macular edema (Figure 1A). Fluorescein angiography confirmed the clinical findings (Figure 2A). Central macular thickness was 613 µm on optical coherence tomography (Figure 3A). Neurology consultation with cranial computerized tomography scan revealed no abnormality. General medical history and physical examination reports were normal. Laboratory tests, including complete 221
M. C ¸ akır et al.
Figure 1. Pretreatment (A) and post-treatment (B) fundus photos.
Figure 2. Pretreatment (A) and post-treatment (B) fundus fluorescein pictures.
blood count, erythrocyte sedimentation rate, blood cultures, and serological tests for syphilis, Lyme disease, toxoplasmosis, toxocariasis, and cat-scratch disease, showed no abnormality. Three days after presentation, the patient was injected with 1.25 mg bevacizumab and 2 mg triamcinolone acetonide intravitreally. One week later, vision increased to 10/10 and macular edema disappeared, but papillitis persisted. One month later, optic disc edema disappeared (Figures 1B, 2B, and 3B). At 6 months, transient intraocular hypertension (34 mmHg) was detected. It was controlled with topical glaucoma agents. At 8 months, visual acuity was 10/10, intraocular pressure was 16 mmHg, and retina was normal.
DISCUSSION There are a lot of possible causative agents and conditions for the development of neuroretinitis, but nearly 222
Figure 3. Pretreatment (A) and post-treatment (B) optical coherence tomography images.
Triamcinolone and Bevacizumab for Neuroretinitis
one-half remain idiopathic. Many of the candidate etiologies are treatable conditions, and accurate diagnosis can result in visual rehabilitation. Since we could not find a definitive etiologic factor, our treatment option was focused on the direct treatment of the papillitis and macular edema with intravitreal bevacizumab– triamcinolone combination. Recent research has revealed that anti-vascular endothelial growth factor medications may have a critical role in treatment of macular edema. There are reliable results indicating an increase of visual acuity and a decrease of retinal thickness after intravitreal bevacizumab injection.3,4 The anti-inflammatory effect of bevacizumab is unclear for neuroretinitis, but anti edematous effect of bevacizumab for radiation optic neuropathy has been documented.5 Intravitreal injection of triamcinolone is safe and effective for the management of macular edema associated with uveitis and some other retinal vascular conditions. The anti-inflammatory effect of triamcinolone is well known.6 In our case, we wanted to get benefit from the additive effect of combination treatment for macular edema and strong antiinflammatory effect of triamcinolone for papillitis. The effect of the treatment was quick: visual acuity reached to 10/10 in a week. No recurrence of neuroretinitis was encountered. The only postinjection complication was transient intraocular
hypertension that was responsive to topical glaucoma agents. In conclusion, combined intravitreal bevacizumab and triamcinolone effectively treated idiopathic neuroretinitis. It is also important to make all the investigations to reveal the etiology of neuroretinitis, as specific forms of neuroretinitis require specific treatment according to the etiology. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES [1] Dreyer RF, Hopen G, Gass JD, Smith JL. Leber’s idiopathic stellate neuroretinitis. Arch Ophthalmol. 1984;102:1140–1145. [2] Sedwick LA, Klingele TG, Burde RM, Behrens MM. Optic neuritis and inflammatory bowel disease. J Clin Neuroophthalmol. 1984;4:3–6. [3] Funatsu H, Yamashita H, Ikeda T, Nakanishi Y, Kitano S, Hori S. Angiotensin II and vascular endothelial growth factor in the vitreous fluid of patients with diabetic macular edema and other retinal disorders. Am J Ophthalmol. 2002;133:537–543. [4] Haritoglou C, Kook D, Neubauer A, et al. Intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. Retina 2006;26:999–1005. [5] Finger PT. Anti-VEGF bevacizumab (Avastin) for radiation optic neuropathy. Am J Ophthalmol. 2007;143:335–338. [6] Young S, Larkin G, Branley M, et al. Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Experiment Ophthalmol. 2001;29:2–6.
223
