Sir,
I read with great interest the article “Dramatic response to intravitreal bevacizumab in hypertensive retinopathy” by Padhy and Kumar.[1] The authors have attributed rapid resolution of intra-retinal and sub-retinal fluid at macula in both eyes following intravitreal injection of bevacizumab only in the right eye. Systemic absorption of intravitreal bevacizumab had been cited as a reason for improvement in fellow eye.
Although data on the use of bevacizumab in malignant hypertension is relatively sparse, reports on fellow eye effect of unilateral intravitreal bevacizumab in diabetic macular edema (DME) are controversial. Velez-Mentoya et al.[2] failed to identify a contralateral eye effect in a prospective study involving 23 patients. Hanhart et al.[3] have shown bilateral response after unilateral injection; however, the average reduction in central subfield macular thickness (CST) was more in injected eye and a significant proportion received multiple injections. In the index case, complete resolution of intra- and sub-retinal fluid following a single intravitreal injection can be due to systemic control of hypertension as evidenced by blood pressure (BP) at presentation and BP after 1 month. Moreover, concurrent use of systemic steroids to treat primary renal disease can also reduce blood retinal barrier breakdown and help in resolution of macular fluid.
It would be interesting to know from the authors, the magnitude of reduction in CST of injected and fellow eye and to see for any differential response between the two eyes. Symmetrical reduction in both eyes may point more toward better systemic control rather than effect of bevacizumab. Injecting bevacizumab is also known to cause dysregulation of BP especially in severe hypertensive patients.[4] Hence, using bevacizumab as a primary modality in a treatment naïve malignant hypertensive retinopathy warrants caution.
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References
- 1.Padhy S, Kumar V. Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy. Indian J Ophthalmol. 2018;66:1494–5. doi: 10.4103/ijo.IJO_214_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Velez-Montoya R, Fromow-Guerra J, Burgos O, Landers MB, Morales-Catón V, Quiroz-Mercado H. The effect of unilateral intravitreal bevacizumab (avastin), in the treatment of diffuse bilateral diabetic macular edema: A pilot study. Retina. 2009;29:20–6. doi: 10.1097/IAE.0b013e318186c64e. [DOI] [PubMed] [Google Scholar]
- 3.Hanhart J, Tiosano L, Averbukh E, Banin E, Hemo I, Chowers I. Fellow eye effect of unilateral intravitreal bevacizumab injection in eyes with diabetic macular edema. Eye. 2014;28:646–53. doi: 10.1038/eye.2014.94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rasier R, Artunay O, Yuzbasioglu E, Sengul A, Bahcecioglu H. The effect of intravitreal bevacizumab (avastin) administration on systemic hypertension. Eye. 2009;23:1714–8. doi: 10.1038/eye.2008.360. [DOI] [PubMed] [Google Scholar]