Intravitreal bevacizumab for idiopathic choroidalneovascularizationMehmet Cakır, MD, Osman Cekic, MD, PhD, and O. Faruk Yılmaz, MD

An otherwise healthy 8-year-old girl with active juxtapapillary cho-roidal neovascularization was successfully treated with two intravi-treal injections of bevacizumab. Intravitreal bevacizumab was welltolerated, choroidal neovascularization involuted, and subretinaland intraretinal serous fluid resorbed, with improvement in visualacuity from 20/400 to 20/50. The girl has remained stable for 6months after the injections.

The development of choroidal neovascularization(CNV) in children is uncommon. In many casesthe cause is uncertain, although CNV has been

associated with high myopia, inflammation, optic nervehead anomalies, trauma, and retinal dystrophies.1-5 Idio-pathic CNV is usually unilateral.4 Because no clinicaltrials of therapy are available, the decision about the besttreatment option for CNV in children is particularly diffi-cult. We report a case of idiopathic CNV in a childsuccessfully treated with two intravitreal injections ofbevacizumab.

Case Report

An 8-year-old girl was referred to our clinic for gradualdeterioration of visual acuity in the right eye overa year. No systemic disease was reported. Ophthalmo-logic examination revealed best-corrected visual acuityof 20/400 in the right eye and 20/20 in the left eye.Slit-lamp examination was within normal limits, andintraocular pressures were 10 mm Hg bilaterally. Fundu-scopic examination of the right eye demonstrated a juxta-papillary CNV with surrounding subretinal fluidaccumulation. There was no evidence of high myopia,angioid streaks, or chorioretinal lesion (Figure 1A). Theleft fundus was normal.

Infrared and red-free images demonstrated macular stri-ation from retinal edema and a demarcation line of peri-macular fluid accumulation. Fluorescein angiography ofthe right eye showed a classic CNV (Figure 1B). Optical

Author affiliations: Beyoglu Eye Training and Research Hospital, _Istanbul, TurkeySubmitted August 4, 2008.Revision accepted December 16, 2008.Published online March 16, 2009.Reprint requests: Mehmet Cakır, MD, Beyoglu Eye Training and Research Hospital,

_Istanbul, Turkey (email: drmcakir@hotmail.com).J AAPOS 2009;13:296-298.

Copyright � 2009 by the American Association for Pediatric Ophthalmology andStrabismus.

1091-8531/2009/$36.00 1 0doi:10.1016/j.jaapos.2008.12.003

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coherence tomography (OCT) revealed subretinal reflec-tion as well as sub- and intraretinal fluid—consistent witha classic choroidal membrane (Figure 1C). Central macularthickness was 325 mm.

After informed consent was obtained, the patient under-went intravitreal bevacizumab (0.05 cc-1.25 mg/0.05 mL)injection 3.5 mm posterior to the limbus in the right eyeunder general anesthesia. Visual acuity improved to20/50 1 week after the injection. Central macular thicknesswas reduced to 158 mm, and sub- and intraretinal fluid waslargely resorbed, as detected by OCT. After 1 month, thecentral macular thickness increased to 325 mm, and the vi-sual acuity remained at 20/50 in the right eye. A secondbevacizumab injection was administered. Six months fol-lowing the first injection, the patient’s vision has remainedstable at 20/50, with no recurrence of the membrane(Figure 1D). Fluorescein angiography demonstrated latefluorescein staining of the fibrotic CNV, with no signs ofprogression (Figure 1E).

Discussion

To date, different treatment approaches for children withCNV have been described: observation, laser photocoagu-lation, submacular surgery, ocular photodynamic therapywith verteporfin, and intravitreal injections of antivascularendothelial growth factor (VEGF) agents.1-7 Several anti-VEGF agents are now being used intravitreally for CNVin adults. The results in adults are promising, and treat-ment has been associated with few side effects.8,9 Thereare few reports of successful application of intravitrealanti-VEGF in the pediatric age group.5,10

Because of limited patient cooperation and the peripapil-lary localization of CNV in our case, laser photoablation orocular photodynamic therapy options were excluded, anda nonspecific anti-VEGF agent, bevacizumab, was injectedintravitreally. As previously reported, a single injection ofintravitreal bevacizumab and triamcinolone resulted ininvolution of CNV associated with Best disease in an11-year-old girl.5 Although it was not clear which of theagents was responsible for the involution of the CNV inthat patient,5 the use of intravitreal bevacizumab alone re-sulted in regression of CNV in the current case. The de-sired effect was obtained, however, only after twoadministrations of bevacizumab. No adverse effects attrib-utable to the drug or procedure were encountered in thefollow-up period. CNV regressed, intraretinal and subreti-nal fluid reabsorbed, and visual acuity improved beginning1 week after the first injection.

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FIG 1. Color fundus photograph of the patient at presentation (A), and at 6 months (D). Hyperfluorescence of juxtapapillary choroidal neovascula-rization (CNV) in the late phase of angiography (B). Oblique section of optical coherence tomography (OCT) shows retinal elevation associated withlarge amount of sub- and intraretinal fluid that is consistent with an active CNV in the right eye (C). Six months following the first bevacizumabinjection, fluorescein angiography reveals late fluorescein dye staining of the involuted lesion (E). OCT shows contracted CNV (F).

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