Graefes Arch Clin Exp Ophthalmol (2007) 245:1873–1875 DOI 10.1007/s00417-007-0637-y
CASE REPORT
Intravitreal bevacizumab as initial treatment for choroidal neovascularization associated with presumed ocular histoplasmosis syndrome Alfredo Adán & Manuel Navarro & Ricardo P. Casaroli-Marano & Santiago Ortiz & Juan José Molina
Received: 12 February 2007 / Revised: 30 April 2007 / Accepted: 7 May 2007 / Published online: 5 September 2007 # Springer-Verlag 2007
Abstract Purpose To report a case of juxtafoveal choroidal neovascularization in a patient with presumed ocular histoplasmosis syndrome (POHS) who was treated with intravitreal injection of bevacizumab (Avastin) as initial treatment. Methods A 23-year-old woman with POHS presented with sudden dimness of vision and metamorphopsia in the right eye. The patient was examined with ophthalmoscopy, fluorescein angiography, and optical coherence tomography (OCT). Results Fundus examination, fluorescein angiography, and OCT of the right eye revealed a juxtafoveal choroidal neovascularization. Intravitreal injection of bevacizumab was performed with a postoperative improvement of visual acuity and resolution of the distortion. Conclusions This case report describes a case of juxtafoveal choroidal neovascularization associated with POHS that responded remarkably well to intravitreal injection of bevacizumab. Keywords Bevacizumab . Intravitreal . Choroidal neovascularization . Ocular histoplasmosis
A. Adán (*) : M. Navarro : R. P. Casaroli-Marano : S. Ortiz : J. J. Molina Department of Ophthalmology, Hospital Clinic de Barcelona, Universidad de Barcelona, Calle Villarroel 170, 08036 Barcelona, Spain e-mail:
[email protected]
A. Adán Instituto de Microcirugía Ocular, Barcelona, Spain
Presumed ocular histoplasmosis syndrome (POHS) is characterised by small, round, mid peripheral chorioretinal lesions and peripapillary atrophy. Choroidal neovascularization (CNV) in POHS patients is a well-documented complication secondary to inflammation, which leads to visual disturbance, metamorphopsia, and loss of visual acuity [1]. Without treatment, the visual prognosis in these cases is poor. We report in a patient the efficacy of initial treatment with intravitreal injection of bevacizumab (Avastin) for CNV associated to POHS. A 23-year-old woman presented with metamorphopsia and sudden loss of visual acuity to 20/200 in her right eye. Ophthalmoscopy revealed multiple peripheral chorioretinal lesions, atrophy around the optic nerve, and a juxtafoveal subretinal membrane with foveal haemorrhage and serous detachment around the lesion (Fig. 1a,b). Fluorescein angiography revealed an classic juxtafoveal subretinal membrane.The ocular findings were consistent with CNV associated with PHOS. Horizontal optical coherence tomography (OCT) scan showed a hyper-reflective lesion related to CNV complex with serous foveal detachment (Fig. 1c). Visual acuity and ophthalmoscopy of the left eye were unremarkable. An intravitreal off-label bevacizumab injection was recommended. The patient was fully informed about the experimental nature of the treatment and signed an informed consent. An intravitreal dose of 1.25 mg of bevacizumab was injected. On postinjection day 7, OCT showed extensive reduction of CNV and visual acuity improved to 20/60 with a decrease of retinal haemorrhage and a tendency toward fibrosis on NVC. The patient was examined at 3 months and showed complete resolution of the serous detachment and the foveal haemorrhage (Fig. 2a,b). Visual acuity at 8 and 12 months was 20/30.
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Graefes Arch Clin Exp Ophthalmol (2007) 245:1873–1875
CNV due to inflammatory causes has been well investigated, and vascular endothelial growth factor (VEGF) has been confirmed to contribute to CNV development and progression [5]. In consequence, intravitreal anti-VEGF therapy could have a potential role in their treatment. Bevacizumab (Avastin) has a anti-VEGF effect and might penetrate the full retinal thickness [6]. In the clinical case described here only one injection of bevacizumab was required to treat CNV. The onset of improvement within 1 week of bevacizumab injection and the complete remission within 3 months suggest that the bevacizumab may have contributed towards the favourable outcome. We could not find any reference using MEDLINE to intravitreal injections of bevacizumab into POHS with CNV. While a randomized controlled trial with a large number of patients with inflammatory CNV is needed to prove the effectiveness, safety, and effective duration of this therapy, our case report suggests that intravitreal injection of bevacizumab seems to be useful for treatment of this disease.
Fig. 1 Pretreatment of the right eye. a Fundus photograph shows choroidal neovascularization with serous detachment and foveal haemorrhage. b Multiple chorioretinal lesions were seen at the periphery. c Optic coherence tomography shows foveal subretinal fluid. The CNV complex is also identifiable in OCT scan (arrow)
Options available for managing CNV associated with POHS include laser photocoagulation, photodynamic therapy, local and systemic corticosteroids, and surgical removal or macular displacement surgery; although, all have potential limitations and a high rate of recurrence [2–4].
Fig. 2 The right eye at 3 months. a The fundus photograph shows fibrosis of CNV. b OCT shows foveal reattachment
Graefes Arch Clin Exp Ophthalmol (2007) 245:1873–1875
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