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Intravitreal Bevacizumab in Aggressive Posterior Retinopathy of Prematurity

António Travassos, MDSusana Teixeira, MD

Pinto Ferreira, MDIsaura Regadas, MD

Ana Sofia Travassos, MDFlorindo Esteves Esperancinha, MD

Isabel Prieto, MDGraça Pires, MD

Robert van Velze, AOA. Valido, MD

Maria do Céu Machado, MD

Abstract. The anatomic response to intravitreal be-vacizumab injection in three patients with aggressive, posterior retinopathy of prematurity is described. In all cases, the worse eye was treated with a single intravit-real injection of 0.75 mg of bevacizumab as monother-apy or complementary to laser therapy. In 24 hours, all injected eyes showed regression of the tunica vasculosa lentis and iris vessel engorgement and disappearance of iris rigidity. In addition, plus disease and retinal pro-liferation began to regress. None of the eyes required additional treatment. Follow-up of up to 10 months

showed good anatomic outcomes and no evidence of local or systemic adverse events. [Ophthalmic Surg Lasers Imaging 2007;38:233-237.]

INTRODUCTIONRetinopathy of prematurity is a proliferative vas-

cular retinal disease that affects premature infants.1,2 Although prospective studies have proved the positive effect of ablative retinal treatment in retinopathy of prematurity,2-4 30.8% of infants with stage 3, zone 1 retinopathy of prematurity had unfavorable visual out-come, even when treated early.5

Oxygen-induced retinopathy models showed an association of elevated intraocular levels of vascular en-dothelial growth factor (VEGF) with pathologic retinal neovascularization.6-12 Further, VEGF mRNA was ex-pressed in the avascular zone of the human infant eye with threshold retinopathy of prematurity.13 Published data revealed elevated subretinal fluid VEGF levels in human eyes with advanced retinopathy of prematu-rity.14 Anti-VEGF treatment could become a valuable strategy to control retinopathy of prematurity.15,16

Intravitreal injection of bevacizumab, an anti-VEGF antibody, has been used to treat ocular neovas-cular disease with good results17-21 and no apparent toxicity.22,23 We decided to offer off-label, intravitreal injection of bevacizumab to infants with progressive retinopathy of prematurity as salvage treatment.

CASE REPORTSThree premature infants were treated with a single

injection of intravitreal bevacizumab in the worse eye as a salvage treatment for aggressive posterior progres-sive retinopathy of prematurity. In each case, the off-la-bel use of bevacizumab was approved by the neonatol-ogy team and the Ethics Committee. The parents were fully informed about potential local and systemic risks and complications and signed an informed consent.

Case 1 was born at a gestational age of 25 weeks + 2 days and a birth weight of 510 g. Case 2 was born

From the Pediatric Retina Department (ST, FEE, IP, GP), Ophthalmology Service, Hospital Fernando Fonseca, Lisbon; the Surgical Center of Coimbra (AT, IR, AST, RV), Coimbra; the Ophthalmology Department (PF), Centro Hospitalar de Lisboa, Zona Central, Hospital de S. José, Lisbon; Alfredo da Costa Maternity (AV), Lisbon; and the High Commissary for Portuguese Health (MCM), Lisbon, Portugal.

Accepted for publication February 26, 2007.Presented at the World ROP Meeting, Vilnius, Lithuania, September 14-

16, 2006. Abstract number 015.The authors thank Drs. Stephan Michels and Rike Michels for their support.Address correspondence to Susana Teixeira, MD, Pediatric Retina Depart-

ment at the Service of Ophthalmology, Hospital Fernando Fonseca, R. João de Freitas Branco nº 21, 6º D, 1500-714 Lisboa, Portugal. E-mail: susanateixeira.oft@gmail.com.

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at a gestational age of 25 weeks + 3 days and a birth weight of 650 g. At a post-menstrual age of 35 weeks, screening revealed bilateral, high-risk posterior zone 2 prethreshold retinopathy of prematurity. Laser treat-ment was performed in the left eyes of both infants, resulting in slow regression of retinopathy of prematu-rity with disappearance of the disease without an unfa-vorable retinal outcome at week 4 after laser treatment. Anterior segment involvement made laser treatment in the right eyes of both infants impossible. Therefore, in-travitreal bevacizumab was injected in the right eyes

according to the protocol without early apparent com-plications.

Case 3 was born at a gestational age of 23 weeks + 4 days and a birth weight of 649 g. At a post-menstrual age of 33 weeks, screening revealed bilateral, high-risk zone 1 prethreshold retinopathy of prematurity. Laser treatment in both eyes was complicated by anterior segment involvement, especially in the left eye. Two weeks later, as the disease progressed, a supplemental laser treatment was done bilaterally. Retinopathy of prematurity in the right eye regressed, but the left eye showed further progression at a post-menstrual age of 37 weeks. Intravitreal injection of bevacizumab was then performed in the left eye without complications.

The injections for all cases were performed in the operating room under sterile conditions. The infants were sedated, and anesthetic and betadine drops were used. To lower the intraocular pressure, gentle mas-sage with a depressor was performed before the in-jection. A 30-gauge needle was used to intravitreally inject 0.75 mg of bevacizumab (0.03 mL of commer-cially available Avastin [Genentech, Inc., San Francis-co, CA]) at the inferior temporal quadrant, 1.5 mm from the limbus.

Intraocular pressure and arterial blood pressure were checked 1 and 2 hours after treatment. Prophylac-tic topical antibiotics were given for 3 days. The infants were examined at days 1, 3, and 6, as well as weekly during the first 2 months and monthly thereafter.

Figure 1.Case1.(Left)Anteriorsegmentinvolvementoftherighteyeonthedayofthetreatment,presentingapersistenceoftunicavasculosalentis,engorgementofirisvessels,andirisrigidity.(Right)Allsignsofanteriorsegmentinvolvementdisappeared24hoursaftertheintravitrealinjectionofbevacizumab.

Figure 2.Case1.Whiteavascularremnantsofproliferativemem-braneintherighteye3weeksafterintravitrealinjectionofbeva-cizumab.

Case RepoRt 235

RESULTSIn cases 1 and 2, the right eyes experienced an al-

most complete regression of the tunica vasculosa lentis, iris vessel engorgement, and iris rigidity 24 hours after intravitreal bevacizumab injection (Fig. 1). In addition, the extent of plus disease decreased and the extraretinal neovascularization had a gray appearance. Neovascu-larization regressed further within 1 week and showed only remnants of fibrous tissue after 3 weeks (Fig. 2). At 6 months following injection, physiologic retinal vessels had developed up to peripheral zone 2, leaving zone 3 avascular.

In case 3, the tunica vasculosa lentis had almost regressed and there was no iris rigidity in the left eye within 24 hours of the injection (Fig. 3). In addition, plus disease and the retinal proliferation began to re-gress (Fig. 4). Complete regression took 15 days in the injected (left) eye compared to 30 days in the eye that received only laser treatment (right eye).

Throughout the follow-up, retinopathy of prema-turity did not recur in any of the eyes, no more treat-ment was necessary, and no evidence for local or sys-temic adverse events was found (Fig. 5).

Figure 3.Case3.(Left)Anteriorsegmentinvolvementofthelefteyeon thedayof intravitreal injectionofbevacizumab,present-ingapersistenceoftunicavasculosalentis,engorgementof irisvessels,andirisrigidity.(Right)Allsignsofanteriorsegmentin-volvementdisappeared24hoursaftertheintravitrealinjectionofbevacizumab.

Figure 4.Case3.Progressionofretinopathyofprematurity(lefttop)andextensiveperipheralneovascularization(leftbottom)ofthe left eye on the day of intravitreal injection of bevacizumab.Twenty-four hours later, plus disease had regressed (right top)andtheextraretinalproliferationhadagrayappearance(rightbot-tom).

Figure 5.Case3.Posteriorpoleandperipheralretinaofthelefteye5monthsfollowingintravitrealinjectionofbevacizumab.

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DISCUSSIONIt is well known that VEGF, a hypoxia-induced

cytokine, plays an important role in the normal de-velopment of retinal vasculature, in involution of the hyaloid vascular system, and in retinopathy of prema-turity.6-12,24-26 In phase 1 or the ischemic phase of reti-nopathy of prematurity, VEGF is down-regulated by hyperoxia leading to vessel occlusion via apoptosis of endothelial cells. In phase 2 or the proliferative phase of retinopathy of prematurity, retinal ischemia induces increased levels of VEGF leading to retinal neovascu-larization.24-26 In addition, high levels of VEGF may not only limit regression of hyaloid vasculature but may also lead to persistence of the tunica vasculosa len-tis, iris vessel engorgement, and iris rigidity. This ante-rior segment involvement reflects proliferative activity of the retinal vasculature and is a prognostic factor in retinopathy of prematurity screening.26,27 The regres-sion of the anterior segment involvement within 24 hours following intravitreal bevacizumab injection may reflect the strong dependence of the described anterior retinopathy of prematurity findings on VEGF.

VEGF is not the only cytokine involved in an-giogenesis or vasculogenesis, but it is probably the most relevant.24 Similar to the oxygen-induced reti-nopathy model, human infant eyes with retinopathy of prematurity show up-regulated intraocular levels of VEGF.13,14 Up to now, approved therapies indirectly af-fected VEGF by destruction of the ischemic peripheral retina. Anti-VEGF drugs offer the major advantage of limiting tissue destruction by directly blocking the me-diator VEGF. However, it appears that optimal timing and dosing of anti-VEGF drugs is most important to obtain the most favorable outcomes.

Bevacizumab, a humanized recombinant antibody that binds all isoforms of VEGF-A, is a relatively large molecule (approximately 150 kD). The molecule size might limit bevacizumab reaching the systemic circula-tion following intravitreal injection and is likely to have a longer intravitreal half-life time. Binding all isoforms could potentially be a disadvantage because physiologic vascular development could be suppressed.26,28 The fol-low-up of the two infants who received bevacizumab monotherapy (cases 1 and 2) showed that normal vascular development was “frozen” within the first 3 months following injection. Thereafter, normal retinal vasculature progressed along the avascular retina up to zone 3, which remained avascular. This finding could

also indicate that the currently used dose was slightly too high and that a lower dose of bevacizumab might be advantageous.

We have to be most careful when treating prema-ture infants with an invasive procedure that potentially can have local complications or systemic side effects. Although there is currently no evidence for an in-creased risk of systemic adverse events in adult humans who received intravitreal bevacizumab,23 the risk profile might be different in a developing infant. However, we also have to keep in mind the devastating outcomes in eyes with progressive retinopathy of prematurity that are refractory to or not suitable for the current stan-dard of care, which can lead to blindness. The pros and cons must be evaluated and both parents and specialists should be involved in the decision-making process.

Preliminary results with intravitreal injection of bevacizumab may suggest it as an alternative therapy in the management of aggressive retinopathy of prematu-rity, and we anticipate the need for controlled studies to further examine this.

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