Lamellar macular hole formation following intravitreal bevacizumab injection for choroidal neovascularization by age-related macular degeneration.

This report describes a lamellar macular hole formation subsequent to intravitreal bevacizumab injection for the treatment of choroidal neovascularization (CNV) by age-related macular degeneration. A 67-year-old woman with bilateral CNV underwent 3 monthly intravitreal bevacizumab injections in her both eyes. One month after the third bilateral injection, vision loss happened. Optical coherence tomography performed for further evaluation that showed reduction of intra- and sub-retinal fluid associated with lamellar macular hole development in both eyes. Although macular hole formation, especially bilateral form, is a rare complication of intravitreal injections, surgeons should consider macular hole development in cases with vision deterioration following intravitreal bevacizumab injection.

Introduction

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness among people over 50-year-old in the developed countries.[1] Anti-vascular endothelial growth factor (VEGF) agents have changed the management and prognosis of exudative form of AMD.[2]

Bevacizumab (Avastin, Genentech, Inc., San Francisco, CA, USA) is a recombinant humanized monoclonal antibody targeting all isoforms of VEGF. Intravitreal bevacizumab injection is an effective option in the treatment of many retinopathies that are associated with VEGF upregulation such as neovascular AMD,[34] proliferative diabetic retinopathy,[56] neovascular glaucoma,[78] retinal vascular occlusions,[910] and retinopathy of prematurity.[11]

The most commonly reported ocular complications of intravitreal bevacizumab injection include endophthalmitis, cataract formation, retinal pigment epithelial (RPE) tears, retinal breaks and retinal detachment.[2] There are few reports of macular hole formation following intravitreal bevacizumab injection.[1213] Here, we report a case of bilateral lamellar macular hole formation after intravitreal bevacizumab injection for the treatment of wet-type AMD.

Case Report

A 67-year-old woman presented to us with bilateral vision loss for 1 year. She had a history of uncomplicated phacoemulsification cataract operation about 4 years ago and 2 monthly intravitreal bevacizumab injections in her both eyes. Best-corrected visual acuity (BCVA) was counting fingers at 5 m in her both eyes. Funduscopic examination revealed a few macular drusen in each eye along with small areas of preretinal hemorrhage and cystoid macular edema. Spectral domain optical coherence tomography (OCT) showed hyperreflective sub-RPE material, intra- and sub-retinal fluid and vitreomacular adhesion [Figure 1a and b]. Fluorescein angiography showed late leakage in the macular area. These findings were compatible with choroidal neovascularization (CNV).

Figure 1

(a and b) Macular optical coherence tomography of the right (a) and left eye (b) before the third bilateral intravitreal bevacizumab injection

The third bilateral intravitreal bevacizumab injection (1.25 mg/0.05 ml) was performed, and the patient was followed up. One month after the third injection, the patient's BCVA deteriorated to counting fingers at 2 meters in both eyes. OCT was performed and revealed lamellar macular hole associated with operculum in both eyes. Furthermore, Postinjection OCT demonstrated reduction of intra- and sub-retinal fluid [Figure 2a and b].

Figure 2

(a and b) Macular optical coherence tomography of the right (a) and left eye (b) 1 month after the third injection

Discussion

We present a patient with neovascular AMD who developed bilateral lamellar macular hole after intravitreal bevacizumab injection in her both eyes. Macular hole formation is a very rare complication of intravitreal injections and has been reported only in a small number of case reports. Moisseiev et al. reported an 86-year-old man underwent intravitreal bevacizumab injection for the treatment of unilateral subfoveal CNV.[13] The patient had a history of previous treatment with 6 times intravitreal bevacizumab injections. One month after the seventh injection, his visual acuity had worsened and OCT demonstrated a full-thickness macular hole. Furthermore, Tufan et al. described a 78-year-old man diagnosed with right eye CNV who was treated with intravitreal bevacizumab injection.[2] One month after the injection, visual acuity reduced and full-thickness macular hole was noticed.

To date, the exact mechanism of lamellar macular hole formation following intravitreal injections remains unclear. Contraction of the prefoveal vitreous cortex following intravitreal injections may result in focal traction which can cause macular hole development.[14] Such tractions may occur secondary to vitreous incarceration at the site of injection.[131415] Alternatively, it is possible that the macular hole develops secondary to posterior vitreous detachment (PVD) following intravitreal injection. Preinjection OCT demonstrated that PVD did not happen in both eyes of our case, and tractional force during PVD may have been caused the macular hole formation.

Conclusion

It seems that lamellar macular hole may develop after intravitreal bevacizumab injection. Consequently, the potential sight-threatening complication should be informed to the patients. Moreover, surgeons should consider macular hole development in cases with vision deterioration following intravitreal bevacizumab injection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.