Acute angle closure attack after an intravitreal bevacizumab injection for branch retinal vein occlusion: a case report

Abstract

BackgroundIntravitreal injection is widely used to treat retinal vein occlusion, and acute angle closure (AAC) is an exceptional complication of intravitreal injection. The authors report a case of AAC that occurred immediately after administering intravitreal bevacizumab to treat branch retinal vein occlusion (BRVO).Case presentationA 65-year-old woman was referred to the retina clinic of a tertiary referral center for the treatment of macular edema secondary to BRVO. On slit lamp examination, anterior chamber (AC) depth was shallow (3 corneal thicknesses centrally, 1/4 corneal thicknesses peripherally) in both eyes. Intraocular pressure (IOP) was 19 mmHg in both eyes, and refractive error was +1.00 diopter sphere in both eyes. A gonioscopy exam demonstrated narrow angle of over 180° in both eyes. To treat the macular edema, bevacizumab was injected into her right eye intravitreally. After two bevacizumab injections, the macular edema regressed but recurred 5 months later, and thus, a third injection was performed. The next day, she visited our emergency department complaining of persistent ocular pain in her right eye. The right pupil had dilated to 6 mm diameter and was fixed. Slit lamp exam revealed diffuse corneal edema in her right eye, which had an IOP of 56 mmHg. After administration of intravenous mannitol, the IOP fell to 14 mmHg and the corneal edema disappeared. Subsequently, a glaucoma specialist performed laser iridotomy on the right eye.ConclusionsAlthough AAC is a rare complication of intravitreal injection, it can occur in a patient with risk factors such as hyperopic eye or narrow angle.

A Case of Refractory Acute Angle Closure Glaucoma after an Intravitreal Bevacizumab Injection

“…In most cases, intraocular pressure (IOP) elevation after an intravitreal injection appears as a transient IOP spike due to volume effects in the closed intravitreal cavity. However, IOP elevation due to morphological changes in the anterior chamber (AC) angle has been rarely reported [ 3 , 4 ]. We report a case of acute angle closure (AAC) refractory to mannitol and laser iridotomy that occurred after intravitreal bevacizumab (IVB) injection in an eye for treatment of central retinal vein occlusion.…”

“…Jeong et al [ 3 ] and Semoun et al [ 4 ] previously reported AAC after IVB. In these cases, the eyes were hyperopic and showed shallow AC at baseline, accounting for the risk of AAC.…”

Anterior chamber paracentesis during intravitreal injections in observational trials: effectiveness and safety and effects

“…When this happens, in many cases AC paracentesis is necessary to avoid permanent damage to the optic nerve. Persistent IOP increase may be present in some eyes and may cause acute angle closure attack [4].…”

“…There is some controversy about the clinical management of IOP increase in the post-intravitreal injection period [4]: while some reports showed a rapid IOP spike [5] and speculated that this might cause damage to the optic nerve, other authors believe this is negligible as IOP usually returns to normal within 15–30 min [6]. Nevertheless, there are patients with considerable IOP spikes of more than 80 mmHg post intravitreal injection that might be asymptomatic and therefore undetected after the injection or at the next day clinical check-up [7], which might result in serious and irreversible damage to the optic nerve and should have been treated immediately.…”

Predictors of elevated intraocular pressure after intravitreal injection of anti-vascular endothelial growth factor: a prospective observational study

“…Intravitreal injection (IVI) of anti-vascular endothelial growth factor (anti-VEGF) is widely used for the treatment of various retinal pathologies such as neovascular age-related macular degeneration, 1,2 diabetic macular edema, 3 and retinal venous occlusion. 4 Although IVI is a safe procedure, complications have been reported, including acute angle closure 5 and…”