Intravitreal bevacizumab (Avastin) for the treatment of proliferative sickle retinopathy

Dear Editor,

A 32-year-old African-American female with type SC sickle cell disease presented with vitreous hemorrhage in her right eye of 2 weeks′ duration. Her visual acuity was 20/25 in the right eye and 20/20 in the left eye. An active area of sea fan neovascularization was noted in the superotemporal periphery of the right eye. Vitreous hemorrhage emanating from the lesion precluded adequate visualization of the retinal periphery and administration of laser therapy. Over the following week, the patient′s vision decreased to 20/40. She was offered a conservative course of observation until sufficient clarity could be obtained for laser therapy, but she had become severely anxious over perceived loss of vision and had required psychiatric counseling.

After a discussion of the potential risks and benefits of off-label bevacizumab (Avastin) use, the patient signed a comprehensive consent form and underwent pars plana injection of 1.25 mg of bevacizumab. Two weeks later, her visual acuity had returned to 20/25 and the vitreous hemorrhage had near-completely cleared with incipient fibrosis of the neovascular lesion. A month later, her vision was 20/20 and examination demonstrated complete resolution of vitreous hemorrhage with fibrous involution of the neovascular complex. Angiography demonstrated diffuse peripheral capillary ischemia but no areas of active neovascularization. Laser photocoagulation was not performed. She remained without recurrent hemorrhage or neovascularization at last follow-up 6 months postinjection.

The use of anti-vascular endothelial growth factor (anti- VEGF) therapy significantly altered the acute history of proliferative sickle retinopathy in our patient. We might have anticipated the progression of neovascularization or at least the persistence of vitreous hemorrhage without surgical intervention in the form of laser therapy or vitrectomy. Our experience here, and a similar case reported previously, demonstrate that intravitreal bevacizumab can induce rapid regression of neovascularization and resolution of vitreous hemorrhage secondary to proliferative sickle retinopathy.¹ Although we are unable to state whether anti-VEGF therapy changes the long-term history and prognosis of the disease and incidence of future complications, intravitreal bevacizumab injection may have a role in the primary and/or adjunct therapy of neovascular complications of sickle cell retinopathy. Further study on the role of anti-VEGF therapy in proliferative sickle retinopathy is warranted.