Intravitreal bevacizumab treatment for retinal neovascularization and vitreous hemorrhage in proliferative diabetic retinopathy

Abstract

Purpose: To report the short term anatomical and visual acuity response after intravitreal injection of bevacizumab in patients with proliferative diabetic retinopathy.

Methods: Ten eyes having proliferative diabetic retinopathy were treated with at least one intravitreal injection of bevacizumab, 1.25 mg in 0.05 mL. Patients underwent complete ophthalmologic evaluation at baseline and follow up visits including Snellen's best corrected visual acuity (BCVA), fundus biomicroscopy and fluorescein angiography. Vitreous hemorrhage precluding laser treatment was present in 6 eyes.

Results: Follow up ranged between 3 and 6 months (mean 4.2 +/- 1.23 months). Improvement of vision was observed after one week with BCVA improved to 0.47 +/- 0.26 compared with baseline BCVA of 0.365 +/- 0.26 (P < 0.05). At last follow up, BCVA was 0.65 +/- 0.33. Seven eyes had better visual acuity. Vitreous hemorrhage cleared completely in 4 eyes while 2 eyes had residual vitreous hemorrhage. Regression of retinal neovascularization was complete in 7 eyes, incomplete in 3 eyes. Regression was observed as early as 2 weeks after first injection. Reperfusion after regression was observed in 2 eyes. Patients received a mean of 1.7 +/- 0.67 injections per eye. No complications were noted in all eyes. Pancryopexy was done in 1 eye and additional laser was done in 2 eyes.

Conclusion: Intravitreal bevacizumab was safe and effective in treatment of proliferative diabetic retinopathy. It can induce effective regression of retinal neovascularization and rapid clearance of vitreous hemorrhage. It can be used as an adjunctive therapy with laser photocoagulation and to enhance absorption of vitreous hemorrhage with subsequent deferral from vitrectomy.

Summary: Ten eyes having proliferative diabetic retinopathy were treated with intravitreal bevacizumab. Following injection, evident regression of retinal neovascularization and rapid clearance of vitreous hemorrhage as well as vision improvement was observed.

Keywords: intravitreal bevacizumab; proliferative diabetic retinopathy; retinal neovascularization; vascular endothelial growth factor; vitreous hemorrhage.

Figure 1

shows improvement of vision following bevacizumab injection which is maintained up to the end of follow up.

Figure 2

This 53 years old patient presented with dense vitreous hemorrhage obscuring fundus details 4 months after having intensive laser therapy. One month after first bevacizumab injection, (A) Fundus details could be partially seen due to starting absorption of the blood and (B) the angiogram showed NVD. C, One month after second bevacizumab injection, the blood was completely absorbed and the angiogram (D) showed complete regression of the NVD.

Figure 3

A 40 years old patient with PDR and vitreous hemorrhage (A). B, The fluorescein angiogram showed evident neovascularization at the disc (NVD) with evident nasal ischemia. C, One month following bevacizumab injection there was near complete absorption of vitreous hemorrhage with a fibrous tuft arising from the optic disk (arrow). The macula looks dry with marks of previous grid. The angiogram (D) showed near complete regression of the neovascularization. E, three months following single injection, the angiogram showed evidence of reperfusion of NVD. F, 2 weeks following re-injection, the angiogram showed again complete regression of the NVD.

Figure 4

This 43 years old patient presented with mild vitreous hemorrhage and preretinal hemorrhage 3 months after complete PRP. A, showed NVDs on the disk and a tuft of neovessels nasal to the disk (arrows). NVE on the upper arcade are not shown in the color photo. He had visual acuity of 0.6. One month after first bevacizumab injection, (B) showed better visualization of the retinal details and regression of NVDs on the disk and (C) the angiogram showed no NVD on the disk with residual leakage from NVE on the upper arcade (arrows) and NVD nasal to the disk. There is upper macular intraretinal leakage (edema).The central macula however was dry. He was given a second injection. Six weeks after 2nd injection, D, angiogram showed residual activity of NVE on the upper arcade and nasal to the disk but no vessels on the disk. After 4 months from 1st injection, re-vitreous hemorrhage was observed. E, angiogram showed reperfusion of NVDs on and nasal to the disk and NVE on the upper arcade. A 3rd injection was given. F&G,4 weeks after injection, angiogram showed disappearance of NVD and NVE. Final visual acuity was 0.9. Cryopexy to the anterior retina was done to stabilize the final outcome.