Intravitreal bevacizumab (Avastin) for retinal angiomatous proliferation

OBJECTIVE: To evaluate the short-term visual acuity and anatomic responses after intravitreal bevacizumab (Avastin, Genentech) treatment in patients with retinal angiomatous proliferation (RAP). METHODS: The authors conducted a retrospective review of consecutive patients with newly diagnosed or recurrent RAP treated with intravitreal bevacizumab (1.25 mg) during a 3-month period. Complete ocular examination was performed at baseline and follow-up visits. Interval data were analyzed statistically at 1 and 3 months follow-up. RESULTS: Twenty-three eyes of 23 patients underwent intravitreal bevacizumab treatment. The mean age of patients was 81.1 years, median baseline visual acuity of treated eyes was 20/80 (range 20/25-20/800), and mean baseline central macular thickness was 335 mum (optical coherence tomography was available for 22 eyes). Nine eyes had retinal pigment epithelial detachments (PEDs) at baseline. At 1-month follow-up, the median acuity improved to 20/60 (range 20/30-20/400) (P < 0.001), mean central macular thickness decreased to 202 microm (P < 0.001), and PED was present in only 2 eyes (P = 0.016). Seven of 23 eyes at 1 month (30.4%) had improved visual acuity, defined as halving of the visual angle, and no eyes had worse acuity, defined as doubling of the visual angle. Of the 17 eyes available for 3-month follow-up, 5 eyes (29.4%) had better visual acuity, 1 eye (5.9%) had worse acuity, and the remaining 11 (64.7%) had the same acuity. The median visual acuity at month 3 was 20/60 (range 20/25-20/400). There were no thromboembolic phenomena, endophthalmitis cases, retinal detachments, or any other adverse events. CONCLUSION: Treatment of RAP with intravitreal bevacizumab during this retrospective review resulted in a significant decrease in macular thickness and improvement or stabilization of visual acuity. Further long-term investigation is warranted given the promising short-term results.     

Intravitreal bevacizumab for the treatment of retinal angiomatous proliferation

PURPOSE: To verify the potential efficacy of intravitreal bevacizumab (IVB) injections for the treatment of retinal angiomatous proliferation (RAP). DESIGN: Retrospective interventional case series. METHODS: Four consecutive patients affected by RAP at different stages and refractory to photodynamic therapy (PDT). All patients underwent a complete ophthalmic examination including best-corrected visual acuity (BCVA), fluorescein and indocyanine green angiographies, and optical coherence tomography (OCT) at baseline, and after one, three, six, nine, and 12 months. All patients received IVB injections (1.25 mg/0.05 ml). RESULTS: The best functional response has been achieved in patients with RAP at stages 1 and 2; whereas in stage 3, a detectable recovery of visual acuity was not observed. This improvement was stable over the follow-up period with a concomitant reduction of macular thickness. CONCLUSIONS: The use of IVB in patients affected by RAP seems to exert morphologic benefits at all RAP stages that does not always correspond a functional improvement.     

Intravitreal injection of bevacizumab (Avastin) for retinal angiomatous proliferation

CLINICAL CASE: An 81-year-old man presented with stage 2 retinal angiomatous proliferation (RAP) as identified by fluorescein angiography and optical coherence tomography (OCT), and was shown to have a visual acuity (VA) of 20/40. One week after an intravitreal injection of bevacizumab (1.25 mg) the VA improved to 20/25, and the OCT showed a reduction of both intraretinal edema and pigment epithelium detachment. Three months after the injection, no ocular complications were observed, VA was 20/20 and the OCT showed an almost normal macular contour. DISCUSSION: Intravitreal injection of bevacizumab may provide another treatment option for patients with RAP.     

Intravitreal bevacizumab versus ranibizumab for the treatment of retinal angiomatous proliferation

Purpose: To evaluate the effects of intravitreal bevacizumab and ranibizumab treatments in retinal angiomatous proliferation (RAP). Methods: Fifty patients affected by RAP were randomly assigned either to intravitreal bevacizumab injection (IVBI) or intravitreal ranibizumab injection (IVRI). After a loading phase including three consecutive monthly injections, the retreatment was administered in cases of persistent RAP. The primary outcome measures were the mean changes in BCVA between the two treatment groups, and the proportion of eyes gaining 1 and 3 lines at the end of the follow‐up. Secondary outcomes included central macular thickness (CMT) changes and progression to more advanced stages of RAP. Results: Fifty patients affected by stage 1 and 2 RAP were recruited. Twenty‐six and 24 patients received IVBI and IVRI, respectively. At the baseline, mean best corrected visual acuity (BCVA) values were 0.59 ± 0.21 (LogMAR ± SD, approximately corresponding to 20/80 Snellen Equivalent‐SE) in IVBI group and 0.66 ± 0.33 (approximately 20/90 SE) in IVRI group with no statistical difference. At 12‐month examination, both groups showed a statistically significant improvement in the BCVA, with a final mean value of 0.43 ± 0.24 (approximately 20/54 SE) in IVBI group and 0.50 ± 0.32 (approximately 20/63 SE) in the IVRI group. A BCVA gain of 1 and 3 lines was registered in 20 and 8 eyes, respectively, in the IVBI group. Similarly, 17 and 7 eyes showed an improvement of 1 or 3 lines, respectively, in the IVRI group. The CMT reduced significantly from baseline to 12‐month examination in both groups. A lower proportion of eyes with complete pigment epithelium detachment resolution was noted in the IVBI group than in the IVRI group (40% versus 90%). Conclusions: Our study shows that both IVBI and IVRI are equally effective in improving the BCVA over a 1‐year follow‐up in eyes affected by stage 1 and 2 RAP.     

Intravitreal bevacizumab (avastin) in central retinal vein occlusion

PURPOSE: To describe the effects of intravitreal bevacizumab in eyes with macular edema resulting from central retinal vein occlusions (CRVO). METHODS: Retrospective consecutive case series of patients diagnosed with macular edema from CRVO who received intravitreal bevacizumab. RESULTS: Thirty eyes of 29 patients with an average age of 72 years (range, 54-87 years) had intravitreal bevacizumab injections. Mean follow-up was 18.1 weeks. Initial mean visual acuity was 20/394. At the 1- and 2-month follow-up, mean visual acuity improved to 20/237 (n = 26, P = 0.04) and 20/187 (n = 21, P = 0.008), respectively. At the 3- and 4-month follow-up, visual acuity improved from 20/228 to 20/157 (n = 15, P = 0.05) and from 20/313 to 20/213 (n = 11, P = 0.03), respectively. No significant changes in visual acuity were found after 4 months though the number of patients in this group was small. Duration of treatment effect following an injection appears to be limited to 2 months for most patients. No ocular or systemic adverse reactions were noted. CONCLUSIONS: The visual benefits of intravitreal bevacizumab for macular edema due to CRVO are apparent early but are not sustained without repeated injections. Larger clinical studies with long-term follow-up will be necessary to better elicit the best regimen for this therapy.     

Intravitreal ranibizumab treatment of retinal angiomatous proliferation

Purpose: To determine the efficacy of intravitreal injections of ranibizumab in the treatment of retinal angiomatous proliferation (RAP) in neovascular age‐related macular degeneration. Methods: Retrospective, consecutive case series of 26 eyes (26 patients) treated with intravitreal injections of 0.5 mg ranibizumab for RAP. Patients received intravitreal injections at monthly intervals during upload phase for a 3‐month period. Results: Mean visual acuity before treatment was 0.75 ± 0.38logMAR (mean ± SD, n = 26). In the upload phase, mean visual acuity improved 4 weeks after the initial injection to 0.6 ± 0.37logMAR (n = 26) and to 0.53 ± 0.34logMAR (n = 26) 4 weeks after the third monthly intravitreal injection of ranibizumab. The mean optical coherence tomography (OCT) central foveal thickness reduced from 345 ± 55 μm at baseline to 215 ± 87 μm at 3 months. In the maintenance phase, mean visual acuity after 6 months was 0.66 ± 0.38logMAR (n = 12) and 0.7 ± 0.37logMAR after 9 months (n = 6). The mean OCT central foveal thickness was 259 ± 59 μm (n = 13) at 6 months and 280 ± 127 μm (n = 6) at nine‐month follow‐up. Conclusion: Intravitreal ranibizumab resulted in an improvement of visual acuity 4 weeks after the first injection but was more pronounced after 3 months. A reduction in leakage and OCT central foveal thickness was seen 3 months after the commencement of treatment.     

Intravitreal bevacizumab (avastin) for circumscribed choroidal hemangioma

Circumscribed choroidal hemangiomas are rare ophthalmic entities that cause diminution in vision due to accumulation of subretinal and/or intraretinal fluid in the macular area. Various treatment options ranging from conventional laser to photodynamic therapy have been employed to destroy the tumor and reduce the exudation; however, either the inability to penetrate through the exudative fluid or the collateral retinal damage induced by these treatment modalities make them unsuitable for lesions within the macula. We evaluated the role of intravitreal bevacizumab, a pan-vascular endothelial growth factor (VEGF) inhibitor, in reducing the sub- and intraretinal fluid in three patients with circumscribed choroidal hemangiomas. All the patients had complete resolution of the serous retinal detachment that was maintained till at least 12 months after the first injection. Intravitreal bevacizumab may be used in combination with thermal laser or photodynamic therapy in treating circumscribed choroidal hemangiomas with subretinal fluid.     

Intravitreal bevacizumab (avastin) injection as primary treatment of inflammatory choroidal neovascularization

OBJECTIVE: To assess the effects of intravitreal bevacizumab injection as primary treatment of inflammatory choroidal neovascularization (CNV). METHODS: Data for nine consecutive patients with newly diagnosed inflammatory CNV who were treated with intravitreal bevacizumab (1.25 mg) injection were reviewed retrospectively. Main outcome measures were best-corrected visual acuity, foveal thickness measured by optical coherence tomography (OCT), and complete resolution of CNV. RESULTS: CNV resolved completely in 9 (100%) of 9 affected eyes. At the last examination, visual acuity was improved in 8 eyes (88.8%), stable in 1 (11.2%), and worse in 0. Over a mean follow-up of 7.1 months (range, 6-10 months), 7 eyes received 1 injection, 1 eye developed CNV recurrence and required a second injection, and 1 eye required a third injection. Foveal thickness by OCT decreased significantly (P = 0.049) after treatment. CONCLUSION: In this small case series of eyes with limited follow-up, intravitreal bevacizumab injection for treatment of inflammatory CNV was found to be safe and was associated with favorable visual outcomes for both subfoveal and juxtafoveal or extrafoveal inflammatory CNV.     

Intravitreal bevacizumab (avastin) for central and hemicentral retinal vein occlusions: IBeVO study

PURPOSE: To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitreal bevacizumab injections for the management of macular edema due to ischemic central or hemicentral retinal vein occlusion (RVO). METHODS: In this prospective, open-label study, 7 consecutive patients (7 eyes) with macular edema associated with ischemic central or hemicentral RVO were treated with intravitreal injections of 2.0 mg (0.08 mL) of bevacizumab at 12-week intervals. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 after each injection. Clinical evidence of toxicity and complications as well as changes in logarithm of minimum angle of resolution Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) shown by optical coherence tomography (OCT), and dye leakage shown by fluorescein angiography were evaluated. RESULTS: The median age of the 7 patients was 65 years (range, 58-74 years), and the median duration of symptoms before injection was 7 months (range, 2.5-16 months). At baseline, mean BCVA was 1.21 (Snellen equivalent, approximately 20/320) in the affected eye. Mean baseline CMT and TMV were 730.1 microm and 17.1 mm(3), respectively. Fluorescein leakage was observed in the macula and affected retinal quadrants in all seven eyes. Six patients completed the 25-week follow-up examination with reinjections performed at weeks 12 and 24. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. At the last follow-up, mean BCVA in the affected eye was 0.68 (Snellen equivalent, 20/100(+1). No patient had a decrease in BCVA. Mean CMT and TMV at the 25-week follow-up were 260.3 microm and 9.0 mm(3), respectively; fluorescein leakage within the macula and affected retinal quadrants as compared with baseline was markedly reduced in all patients. Coupled with fluorescein angiographic findings, OCT data suggest a trend of macular edema recurrence between 6 weeks and 12 weeks after injection. CONCLUSIONS: Intravitreal bevacizumab injections of 2.0 mg at 12-week intervals were well tolerated and were associated with short-term BCVA stabilization or improvement and favorable macular changes in all patients with ischemic RVO and associated macular edema.     

Intravitreal bevacizumab (avastin) as an adjuvant for the treatment of posterior scleritis

We report a case of posterior scleritis effectively managed with intravitreal bevacizumab. A 71-year-old woman was diagnosed with posterior scleritis. Although she was initially treated with systemic steroids, her clinical presentation deteriorated. She was then treated with a single intravitreal injection of bevacizumab and aqueous humor collection. The aqueous level of vascular endothelial growth factor prior to the intravitreal injection was 880.51 pg/mL, greater than that in the healthy control group (p < 0.001). One month later, the scleritis was completely resolved, and the patient remained stable during six months of follow-up. Intravitreal bevacizumab appears to be an effective adjuvant therapy for patients with posterior scleritis.     

Intravitreal bevacizumab (avastin) for subfoveal neovascular age-related macular degeneration

Objective To report the visual and anatomic outcome of intravitreal bevacizumab (Avastin) injections in the treatment of subfoveal neovascular age-related macular degeneration (AMD). Methods Interventional, consecutive, retrospective case series. Sixty-five eyes of 65 patients with subfoveal neovascular age-related macular degeneration (AMD) received three intravitreal bevacizumab (1.25 mg) injections. Outcome measures included visual acuity (VA), central retinal thickness (CRT), and size of lesion at 24 or more weeks follow-up. Results Thirty-five eyes had prior treatment with photodynamic therapy (PDT). At presentation, VA was 1.12 ± 0.62 logMAR, CRT was 305 ± 115 μm, and greatest linear diameter (GLD) of the lesion was 4,902 ± 1,861 μm. There was no statistically significant difference between previous PDT and naïve eyes in VA, CRT, and GLD at presentation. After three bevacizumab injections, VA, CRT, and GLD significantly improved (P < 0.0001 in all groups). There was no statistically significant difference between CRT and GLD outcomes and subfoveal neovascular membrane type or age. Eyes with better VA at baseline and without previous PDT treatment achieved better final VA (P < 0.0001 and P = 0.045, respectively). A classic membrane type and lower age were somewhat associated with better post-treatment VA. Conclusions Short-term results suggest that intravitreal bevacizumab is well tolerated and associated with improvement in VA, decreased CRT, and decreased lesion size in most patients. The most important predictors of final VA outcomes were baseline VA and no previous PDT treatment. Further evaluation of intravitreal bevacizumab for the treatment of subfoveal neovascular AMD is warranted.     

Intravitreal triamcinolone and laser photocoagulation for retinal angiomatous proliferation

BACKGROUND: Recently, the entity of retinal angiomatous proliferation (RAP) as a subtype of exudative age-related macular degeneration was described, but no treatment options have been established as yet. The only two therapeutic modalities being discussed are surgical lysis of the feeding arteriole and draining venule, and the use of photodynamic therapy combined with intravitreal triamcinolone injection. AIM: To examine focal laser treatment of early extrafoveal intraretinal neovascularisation of RAP. METHODS: Prospective case series. We included 13 consecutive patients with an extrafoveal RAP stage I lesion. All patients underwent a complete ophthalmic examination, including fluorescein angiography and optical coherence tomography (OCT) III before treatment and at 2 weeks, 1, 2 and 4 months afterwards. In cases with marked macular oedema (>350 mum retinal thickening in OCT III, r = 12), intravitreal injection of 4 mg triamcinolone was given before focal laser treatment to reduce the oedema. RESULTS: This case series indicates anatomical improvement or stabilisation in patients with an extrafoveal RAP lesion after treatment. Initial visual acuity ranged from 0.1 to 0.6 on the Snellen chart. By calculating logarithmic values, visual acuity was seen to be improved in five cases (2 to 5 log lines), deteriorated in four cases (-2 to 5 log lines) and stabilised in four cases (-1 to +1 log line change). Exudation on fluorescein angiography was stopped in 11 cases. CONCLUSIONS: This preliminary case series suggests laser photocoagulation combined with prior intravitreal triamcinolone injection as a viable treatment option for RAP stage I. In cases with marked macular oedema, intravitreal triamcinolone injection improved visual acuity. For long-term stabilisation, additional laser treatment is mandatory. These preliminary results warrant a more detailed prospective clinical trial.     

Systemic bevacizumab for retinal angiomatous proliferation associated with retinal pigment epithelial detachment

PURPOSE: To report the off-label use of systemic bevacizumab in a patient with stage 3 retinal angiomatous proliferation (RAP) associated with a vascularized pigmented epithelium detachment (PED). METHODS: Interventional case report. RESULTS: The patient was treated with systemic bevacizumab after obtaining fully informed consent. At 3 months post-treatment, the authors observed an improvement of one line (seven letters) in visual acuity and total regression of the PED on ocular coherence tomography. No adverse effects were observed. CONCLUSIONS: Systemic bevacizumab therapy appears to be safe and effective in the treatment of RAP associated with PED during this short follow-up period of 3 months. The authors recommend a large trial with long-term follow-up to confirm the promising results and evaluate the occurrence of adverse effects associated with systemic bevacizumab.     

Treatment of idiopathic juxtafoveolar retinal telangiectasis with bevacizumab (avastin)

BACKGROUND: Idiopathic juxtafoveolar retinal telangiectasis presents areas of occult capillary telangiectasis involving the temporal half of the fovea. Its treatment by laser photocoagulation, photodynamic therapy or intravitreal injection of triamcinolone is unsatisfying concerning visual acuity. Recently it has been demonstrated that intravitreal bevacizumab injection could be successful in the treatment of choroidal neovascularisations secondary to ARMD. The principle of this treatment may be successful for the treatment of idiopathic juxtafoveolar retinal telangiectasis as well. PATIENTS AND METHODS: We report about 3 cases treated with three monthly intravitreal injections of bevacizumab. Fluorescein angiographies and OCT measurements of retinal thickness were performed. RESULTS: The mean increase of VA was 2 visual steps. In two cases an increase of 5 and 1 visual steps, respectively, could be determined, in the other case no increase was found. The mean retinal thickness decreased from 300 microns to 287 microns. CONCLUSIONS: According to our results bevacizumab seems to be less suitable for treatment of idiopathic juxtafoveolar retinal telangiectasis because only a small decrease of retinal thickness can be observed.     

Bevacizumab (Avastin) treatment in patients with retinal angiomatous proliferation

Aim To determine the anatomical and functional outcome after injection of bevacizumab (Avastin, Genentech) in eyes with retinal angiomatous proliferation (RAP). Design Prospective interventional case series. Methods Sixteen eyes of 16 consecutive patients with visual loss due to RAP underwent intravitreal injections of 1.25 mg (0.05 ml) bevacizumab. Best corrected visual acuity testing, fluorescein and ICG-angiography as well as OCT imaging were performed at baseline and at each follow-up visit within a 3-month period. Results Mean visual acuity pre-injection was 0.68 ± 0.36 logMAR (n = 16), mean reading ability 0.58 ± 0.26 logRAD (n = 11). Far vision increased significantly by a mean of 1.7 ± 2 lines 4 weeks after the injection (p = 0.004), as did reading (0.6 ± 2.3 lines, p > 0.05). Both remained stable up to 3 months. Central retinal thickness decreased from 367 ± 112 μm (mean±SD) to 272 ± 123 μm 3 months after injection (p = 0.006). Leakage decreased angiographically in 12 eyes (75%) and remained stable in four eyes (25%). Re-injection of bevacizumab within the 3-month follow-up period was performed once in eight eyes, and twice in one eye. No adverse events were observed. Conclusion Intravitreal bevacizumab (Avastin) resulted in a reduction of leakage, intra- and subretinal fluid. An increase in visual acuity was seen already 4 weeks after first injection. However, a complete occlusion of feeder vessels could not be achieved within this 3-month period. Randomized clinical trials would be required to evaluate dose and frequency of injections and possible beneficial effects of combination therapies, as well as the long-term results.     

视网膜血管瘤样增生的诊断与治疗

视网膜血管瘤样增生(retinal angiomatous proliferation,RAP)是湿性老年性黄斑变性(age-related macular degeneration,AMD)隐匿性新生血管的另一种病变形式,起源于黄斑旁视网膜深层毛细血管层,以多发性小灶状视网膜内出血、视网膜色素上皮脱离(pigment epithelial detachment,PED)、视网膜-脉络膜血管吻合(retinal-choroidal anastomosis,RCA)为特点,对视力损害严重。本文对近年来的有关文献进行复习,并就RAP的发病机制、临床分期、诊断特点、治疗及预后进行综述。