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A 32-year-old woman presented with loss of stereopsis and blurred vision in the right eye of 1 month's duration. A documented gradual loss of best corrected visual acuity (BCVA) in the right eye had occurred during this period, from 0.9 at onset to 0.16 at presentation in our institution. Best corrected VA in the left eye was 1.0 and refraction was − 5.0 dioptres in both eyes. The right eye demonstrated a serous detachment of the entire macula and extensive subretinal haemorrhage from a peripapillary choroidal neovascularization (PCNV), the apparent origin of which was an area of peripapillary atrophy (Fig. 1). The left fundus was normal except for a small temporal sector of peripapillary atrophy. Photocoagulation and photodynamic therapy were deferred because the PCNV was poorly delineated in angiography and partially obscured by haemorrhage. The patient received a 1-week course of prednisolone 1 mg/kg, after which the serous detachment and the subretinal haemorrhage were seen to have increased. Subjectively, vision had deteriorated further, although objectively BCVA in the right eye remained at 0.16. We advised the patient that the prognosis for spontaneous visual recovery was poor and that the likely prospect with photocoagulation only was visual stabilization. Because of her critical professional need for stereopsis, the patient was offered and accepted open-label treatment using 1 mg (0.04 ml) intravitreal bevacizumab (Avastin; Roche, Copenhagen, Denmark). The intravitreal injection was given via the pars plana after preparation of the eye with 5% povidone/iodine, topical antibiotics and topical anaesthesia. The study protocol conformed with Danish law and adhered to the tenets of the Declaration of Helsinki. The patient was followed weekly for 3 months, during which complete resolution of the serous detachment, near-complete resorption of the subretinal haemorrhage and recovery of BCVA to 1.0 in the right eye were noted (1, 2). No adverse effects were seen other than subconjunctival haemorrhage immediately after injection. (A) Colour and (B) red-free greyscale fundus photography, and (C) late-phase fluorescein angiography of the right eye of a woman aged 32 years with subretinal peripapillary choroidal neovascularization. Baseline pictures (top row) show the eye after 1 week of systemic prednisolone therapy; subretinal serous fluid, haemorrhage and a leaking neovascular membrane are seen. Three weeks after intravitreal injection of bevacizumab (second row), a definite reduction in fluid, haemorrhage and leakage is seen. At 8 weeks (third row) the fluid has disappeared, the blood has been almost completely resorbed, and the neovascular membrane has ceased to leak, although it continues to stain. At 12 weeks (fourth row) the blood has completely disappeared and the size of the neovascular membrane is decreased. (A) Horizontal and (B) vertical transfoveal optical coherence tomography scans of the right eye of the subject, before intravitreal bevacizumab injection and at 3, 8, and 12 weeks after injection (top, second, third and fourth row respectively). Before injection, serous subretinal fluid and an indistinguishable mixture of haematoma and new vessels are seen to involve the entire macula. After injection of bevacizumab, a gradual and steady process of resolution is seen; at 12 weeks the most prominent finding is an elevated mound of retinal pigment epithelium with internal hyperreflectivity at the apparent site of origin of the neovascular membrane. Peripapillary choroidal neovascularization can lead to loss of central vision if blood, exudate or new vessels extend under the fovea. The condition may be associated with age-related macular degeneration (AMD), multifocal choroiditis, angioid streaks, histoplasmosis scars, choroidal osteoma, optic disc drusen, congenital disc anomalies, pattern dystrophy, and peripapillary pseudopodal pigment epithelial and choroidal atrophy. About half of the cases show no obvious primary underlying condition and may be categorized as idiopathic (Browning Nguyen et al. 2005; Rosenfeld et al. 2005). The natural history of PCNV is poorly described, whereas the course after photocoagulation treatment has been documented in an uncontrolled case series, where the average non-AMD patient was found to experience stabilization of baseline VA but a high frequency of PCNV recurrence without further treatment (Browning & Fraser 2005). Spontaneous involution of PCNV leakage can occur, but in our case the onset of improvement within 1 week of bevacizumab injection and the near-complete remission within 3 months suggest that the bevacizumab may have contributed towards the favourable outcome. This study was supported by a Patient-oriented Diabetes Research Career Award to Dr Larsen from the Juvenile Diabetes Research Foundation (grant no. 8-2002-130) and by the Velux Foundation.
Soliman et al. (Thu,) studied this question.