Acute Vision Loss after Intravitreal Injection of Bevacizumab (Avastin) Associated with Ocular Ischemic Syndrome

Abstract

Aim: To report a patient with diabetic rubeosis who suffered from acute retinal ischemic change and stroke after intravitreal injection of bevacizumab. Methods: A 55-year-old man had diabetes with unilateral rubeosis and macular edema. Three days after receiving intravitreal injection of bevacizumab (1.25 mg in 0.1 ml), he developed acute vision loss and change of consciousness. A complete ocular examination, fluorescein angiography, carotid artery Doppler sonography and brain magnetic resonance imaging were performed. Results: Best corrected visual acuity before injection was 6/60 in the left eye. He had underlying left carotid artery stenosis combined with bilateral preproliferative diabetic retinopathy. Three days after intravitreal injection of bevacizumab, acute ocular ischemic syndrome occurred. He also suffered from acute stroke, and brain magnetic resonance angiography showed total left internal carotid artery occlusion. The final visual acuity was no light perception in the left eye and 3/6 in the right eye. Conclusions: Patients receiving intravitreal injections of bevacizumab should be evaluated for potential systemic risk factors such as carotid insufficiency, coagulopathy and poorly controlled diabetes mellitus. Acute ocular ischemic change may be associated with intravitreal injection of bevacizumab in patients with vascular compromised diabetic retinopathy and/or underlying stenosis of the carotid artery.

Adverse events and complications associated with intravitreal injection of anti-VEGF agents: a review of literature

“…51 Rare ocular and systemic side effects There are few reports of ocular and systemic adverse events associated with intravitreal anti-VEGF agents. Rare ocular adverse events include anterior ischemic optic neuropathy after bevacizumab injection, 52,53 retinal venous occlusions after bevacizumab injection, 54 retinal artery occlusions, 55 hemorrhagic macular infarction, 56 development or exacerbation of ocular ischemic syndrome, 57 and sixth nerve palsy following bevacizumab injection. 58 Rare systemic events include formed visual hallucinations, 59 erectile dysfunction, 60 and acute decrease in kidney function.…”

Post-Treatment Change in the Localization of Recurrent or Persistent Macular Edema Secondary to Branch Retinal Vein Occlusion

“…When patients with a past medical history of vascular obstruction such as cerebral infarction selected medical therapy, we recommended intravitreal injections of triamcinolone rather than intravitreal injections of bevacizumab because of the adverse effect of bevacizumab [8,9]. Funduscopic examinations and OCT were performed before treatment, 1 week after treatment, and every 4 weeks after treatment.…”

Pharmacovigilance in Intraocular Antiangiogenic Therapy

“…Von Hanno et al [32] presented two cases of retinal artery occlusion after intravitreal injection of bevacizumab (Avastin) and ranibizumab (Lucentis) respectively and concluded that the therapeutic principle may be associated with an increased risk of retinal arterial occlusions. Increased risk of ocular blood flow disturbancies was noted specifically in case of bevacizumab injections-retinal venous occlusions [33] , anterior ischemic optic neuropathy [34,35] development or exacerbation of ocular ischemic syndrome [36] , decrease in retrobulbar blood flow [37] . Leung et al [38] presented a series of three patients of the nearly 200 patients with CRVO who suffered apparent macular infarction within weeks of intravitreal administration of bevacizumab.…”