Retinal pigment epithelial tear following intravitreal bevacizumab injection for neovascular age‐related macular degeneration

Editor, The principle and potential benefit of inhibiting vascular endothelial growth factor (VEGF) for neovascular age-related macular degeneration (AMD) has been published previously (Gragoudas et al. 2004). Bevacizumab (Avastin; Genentech, Inc., San Francisco, CA, USA) is a humanized monoclonal antibody to VEGF, approved by the US Food and Drug Administration (FDA) for the treatment of colorectal cancer. Recently, the therapeutic effect of intravitreal bevacizumab administration was reported in neovascular AMD (Avery et al. 2006). The effect of intravitreal bevacizumab in such eyes was impressive and has inspired increasing interest in the use of this therapy. We report a case of retinal pigment epithelial (RPE) tear developed after intravitreal bevacizumab treatment in neovascular AMD. A 70-year-old woman presented with diminished vision of 6 weeks' duration OS. Best corrected visual acuity (BCVA) was 20/32 OD and 20/50 OS. Ophthalmoscopy in the left eye revealed subretinal fluid, subretinal haemorrhages and RPE detachment. The right macula was dry. Fluorescein angiography (FA) in the left eye demonstrated subfoveal occult choroidal neovascularization (CNV) type 1 secondary to AMD (Fig. 1). Therapy options for the left eye included photodynamic therapy (PDT) with verteporfin, anti-VEGF therapy, macular surgery or observation. However, the patient's health insurance provider refused to support the options of PDT with verteporfin and pegaptanib financially. The patient was informed in detail about the off-label nature of intravitreal bevacizumab therapy. After obtaining written informed consent, 1.25 mg of bevacizumab (0.5 ml) was injected into the vitreous. One week later, BCVA, ophthalmoscopic and FA findings in the left eye were unchanged. At the 4-week examination, the patient reported no complaints. Best corrected VA was 20/40 OS. Ophthalmoscopic examination disclosed a flat subfoveal RPE detachment and subretinal pigmented lesion outlined with sharp borders inferotemporal to the fovea. Fluorescein angiography revealed evidence of an RPE tear (Fig. 2). (A) Early-phase fluorescein angiography (FA) shows ill-defined hyperfluorescence at the macula. (B) Late-phase FA shows leakage, consistent with subfoveal occult choroidal neovascularization (type 1). (A) Early-phase fluorescein angiography (FA) 4 weeks after intravitreal bevacizumab shows a well demarcated hyperfluorescence inferonasal to the fovea (arrows), corresponding to the RPE tear. (B) Late-phase FA reveals leakage, corresponding to bare choriocapillaris. Note the blocked fluorescence at the nasal and superior edge of the hyperfluorescence caused by the rolled RPE. An RPE tear may develop spontaneously and after different treatment modalities for neovascular AMD (Gass 1984; Gelisken et al. 2001; Dhalla et al. 2006). To our knowledge, this case represents the first description of an RPE tear following intravitreal injection of bevacizumab for neovascular AMD. Good vision in RPE subjects may be only temporary due to the sparing of the fovea from the RPE tear. We do not know the exact mechanism of the RPE tear in the present case. However, rapid resorption of the sub-RPE fluid and contraction of the CNV may have increased the shear forces within the RPE, leading to the dehiscence. Such RPE tears have been reported after treatment with pegaptanib for neovascular AMD (Dhalla et al. 2006). Therefore, the development of an RPE tear may represent a general complication of anti-VEGF treatment. We are unaware of any previous reports of RPE tears after intravitreal bevacizumab therapy for neovascular AMD and found no associated references in a MEDLINE search. Recently published reports on the dramatic improvements brought about by intravitreal bevacizumab in the treatment of neovascular AMD have stirred increasing interest in the use of cost-effective, off-label treatment with bevacizumab. As prospective and controlled studies for intravitreal bevacizumab are still lacking, it is extremely important that data on all complications following this therapy are collected in order to clarify the frequency of complications and to establish a risk/benefit profile in patients with neovascular AMD.