CORRESPONDENCE

Intravitreal Bevacizumab forSymptomatic Retinal ArterialMacroaneurysm

EDITOR:

I OFFER THE FOLLOWING OBSERVATIONS REGARDING THE

recent study by Cho and associates.1 Intravitreal bevacizumabfor exudative complications of retinal artery macroaneurysmwas first reported in 2009.2 Since then, there have beenseveral reports indicating benefit from intravitreal bavacizu-mab for both hemorrhagic and exudative complications ofretinal artery macroaneurysm.1,3 However, there seems tobe little benefit or rationale for such therapy for subfovealhemorrhage from ruptured retinal artery macroaneurysm.Hemorrhage from retinal artery macroaneurysm, unlikeexudation, which is a continuous process that can bedemonstrated by leakage on fluorescein angiography, isgenerally a one-time event that commonly leads to fibrosisand occlusion of retinal artery macroaneurysm. Visual lossusually results from atrophy of retinal pigment epitheliumowing to well-established toxicity of subfoveal blood.4 Bothpatients in the present study (Patients 10 and 12) whopresented with subfoveal bleed suffered further loss of vision>_0.3 logMAR because of retinal pigment epithelial atrophy.Bevacizumab-induced clearing of blood in 4 weeks, asopposed to 8 weeks natural history as reported by the authors,might still be too slow to prevent irreversible damage to pho-toreceptors.4 Thus, early evacuation of subfoveal blood offersthe best chance for improvement in vision in such eyes. Sincethe initial report of tissue plasminogen activator–assistedevacuation of submacular blood from ruptured retinal arterymacroaneurysm,5 excellent visual outcomes have beenreported with this approach by others. Each of the 9 eyesachieved significant improvement in vision with tissueplasminogen-assisted removal of blood without any lasertreatment to the retinal artery macroaneurysm.6

KAMAL KISHORE

Peoria, Illinois

CONFLICT OF INTEREST DISCLOSURES: THE AUTHOR HAScompleted and submitted the ICMJE Form for Disclosure of PotentialConflicts of Interest and none were reported.

REFERENCES

1. Cho HJ, Rhee TK, Kim HS, et al. Intravitreal bevacizumab forsymptomatic retinal arterial macroaneurysm. Am J Ophthalmol2013;155(5):898–904.

260 � 2014 BY ELSEVIER INC.

2. Chanana B, Azad RV. Intravitreal bevacizumab for macularedema secondary to retinal macroaneurysm. Eye (Lond)2009;23(2):493–494.

3. Javey G, Moshfeghi AN, Moshfeghi AA. Management ofruptured retinal arterial macroaneurysm with intravitrealbevacizumab. Ophthalmic Surg Lasers Imaging 2010;41(4):1–5.

4. Glatt H, Machemer R. Experimental subretinal hemorrhage inrabbits. Am J Ophthalmol 1982;94(6):762–773.

5. Peyman GA, Nelson NC Jr, Alturki W, et al. Tissue plasmin-ogen activating factor assisted removal of subretinal hemor-rhage. Ophthalmic Surg 1991;22(10):575–582.

6. Humayun M, Lewis H, Flynn HW Jr, Sternberg P Jr,Blumenkranz MS. Management of submacular hemorrhageassociated with retinal arterial macroaneurysms.Am J Ophthal-mol 1998;126(3):358–361.

REPLY

WE APPRECIATE DR KISHORE’S INTEREST IN OUR RECENTLY

published manuscript.1 He questioned the use of bevacizu-mab (1.25 mg/0.05 mL; Avastin; Genentech Inc, SanFrancisco, California, USA) for the treatment of subfovealhemorrhage secondary to retinal arterial macroaneurysmand stated that it has limited benefits. We agree that beva-cizumab monotherapy could be insufficient for submacularhemorrhage treatment. He noted that in our study, 2(Patients 10 and 12) out of 4 patients with submacularhemorrhage showed poor visual outcomes after bevaci-zuamb injections. However, there were also patients withgood visual outcomes in spite of submacular hemorrhageafter treatment. In our study, in 2 patients (Patients 14and 19) with submacular hemorrhage, the visual acuityincreased by more than 0.3 logarithm of the minimal angleof resolution (logMAR) after treatment.1 To date, the pre-cise treatment effects or anti–vascular endothelial growthfactor mechanisms for submacular hemorrhage have notyet been clearly elucidated. Various factors, includingsymptom duration, submacular hemorrhage size, or subfo-veal hemorrhage thickness, could be associated with theefficacy of bevacizumab injection for the submacular hem-orrhage. The factors associated with a good visual outcomeafter bevacizumab injection for patients with submacularhemorrhage require further investigation.Dr Kishore mentioned that recombinant tissue plasmin-

ogen activator (rTPA) may be effective in retinal arterialmacroaneurysm treatment. However, the minimum safeconcentration and retinal toxicity of rTPA is still contro-versial.2 Moreover, some reports suggest that cases withsubmacular hemorrhage secondary to retinal arterial macro-aneurysm have an increased risk of dense vitreous hemor-rhage after intravitreal rTPA injection.3 Furthermore, if

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