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 Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 61-63  

Tremendous result of bevacizumab in malignant hypertensive retinopathy


Department of Surgery, Division of Ophthalmology, Security Forces Hospital, Riyadh, Saudi Arabia

Date of Web Publication23-Jan-2015

Correspondence Address:
Ali M Al-Halafi
Department of Surgery, Division of Ophthalmology, Security Forces Hospital, P.O Box 3643, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.149872

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   Abstract 

Signs of hypertensive retinopathy are common and are correlated with elevated blood pressure. Patients who have swelling of both optic discs and very high blood pressure (i.e., malignant retinopathy) need urgent antihypertensive treatment. A patient was reported with malignant hypertensive retinopathy who recovered promptly following single intravitreal bevacizumab injection. Intravitreal bevacizumab (1.25 mg/0.05 mL) was injected in two eyes of a patient having malignant hypertensive retinopathy with optic disc edema, macular edema, and retinal exudates. A complete ophthalmic examination, including the best-corrected visual acuity (BCVA), central macular thickness on optical coherence tomography (OCT), and fluorescein angiography (FAG), was performed before and after the treatments. Two eyes in a patient received a single intravitreal injection of bevacizumab had improvement of macular edema on OCT at 1 month and decreased fluorescein leakage on FAG 3 months after the treatment, which led to improvements in the BCVA both eyes. The results suggest that intravitreal bevacizumab injections might be a useful and safe adjunctive treatment of malignant hypertensive retinopathy, in addition to proper medical management of malignant hypertension.

Keywords: Bevacizumab (avastin), hypertensive retinopathy, optic disc edema


How to cite this article:
Al-Halafi AM. Tremendous result of bevacizumab in malignant hypertensive retinopathy. Oman J Ophthalmol 2015;8:61-3

How to cite this URL:
Al-Halafi AM. Tremendous result of bevacizumab in malignant hypertensive retinopathy. Oman J Ophthalmol [serial online] 2015 [cited 2019 Nov 17];8:61-3. Available from: http://www.ojoonline.org/text.asp?2015/8/1/61/149872


   Introduction Top


Hypertensive retinopathy was first described by Gunn in the 19 th century in a series of patients with hypertension and renal disease. [1] Hypertensive retinopathy is characterized by the presence of retinal vascular signs in patients with elevated blood pressure. It is well known that the retinal circulation shares anatomical, physiological, and embryologic features with the cerebral circulation. An autopsy study of patients with stroke showed a close similarity between retinal and cerebral arteriolar findings which indicates an evidence of the association between the risk of stroke and hypertensive retinopathy. [2] There are infrequent data regarding the association of hypertensive retinopathy and the risk of coronary heart disease. [3] According to the Joint National Committee (JNC) criteria, the presence of retinopathy may be an indication for starting antihypertensive treatment, even in patients with stage 1 hypertension (blood pressure, 140-159/90-99 mm Hg) who have no other proof of target-organ damage. [4] The evidence in support of the JNC guidelines on retinal findings in hypertension is based on earlier studies that may not have a direct connection to current clinical practice. [1],[5],[6],[7]

Bevacizumab (avastin), an antibody against vascular endothelial growth factor (VEGF) (anti-VEGF), has been injected intravitreally in various retinal diseases that have increased vascular permeability and edema. [8] Researchers using preclinical models have shown that anti-VEGF agents such as bevacizumab may work by causing several changes in blood vessels. Next to interfering with vessel growth and neovascularization, they help a regression of existing microvessels and stimulate "normalization" of surviving mature vasculature, stabilize the vessel, and prevent leakage. [9]

This study reports a patient with malignant hypertensive retinopathy who presented with visual impairment and severe exudative retinal changes, but recovered quickly following a single intravitreal bevacizumab injection.


   Case Report Top


A 32-year-old woman was referred because of blurred vision in both eyes for 1 week. She had been taking medication to treat hypertension for 2 years with poor control of blood pressure. Her best-corrected visual acuity was counting fingers 5 feet both eyes. The anterior segment examination of both eyes was unremarkable. Fundoscopic examination showed bilateral optic disc swelling, peripapillary retinal edema involving the macula and peripapillary flame-shaped hemorrhages with multiple hard exudates more with the right eye [Figure 1]a. Fluorescein angiography (FAG) showed extensive fluorescein leakage from the optic disc and diffuse capillary leakage along the vascular arcades in both eyes [Figure 2]a. Optical coherence tomography (OCT) revealed bilateral marked macular edema and neurosensory detachment [Figure 3]a. Her blood pressure was 160/100 mm Hg. Cardiology, nephrology, and neurology consultations were obtained and showed renal impairment. This patient was treated with single intravitreal injections of bevacizumab (1.25 mg/0.05 mL) in both eyes. One month after the treatment, visual acuity was 20/400 and 20/100 in her right and left eyes, respectively, and the bilateral optic disc edema and macular edema had resolved [Figure 1]b and [Figure 3]b. Three months after the treatment, much of the hard exudates surrounding the fovea bilaterally were absorbed on fundus examination [Figure 1]c]. FAG showed minimal leakage from the optic discs bilaterally with macular area of nonperfusion of the right eye which might explain decreased right eye vision [Figure 2]b. Although she showed resolution of the bilateral macular edema, atrophic thinning of the fovea in both eyes was detected on OCT [Figure 3]c.
Figure 1: Fundus findings before and after intravitreal bevacizumab injection. At presentation, optic discs welling, macular edema, and peripapillary flame-shaped hemorrhages and hard exudates were present in both eyes (a). One month after intravitreal bevacizumab injection, the bilateral optic disc swelling and hard exudates were decreased (b). Three months (c). after the treatment, the optic disc swelling, macular edema and hard exudates decreased both eyes

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Figure 2: Fluorescein angiography findings before and after intravitreal bevacizumab injection. At presentation, profuse fluorescein leakage from the optic disc and diffuse leakage from the capillaries along the vascular arcades were present in both eyes (a). One month after intravitreal bevacizumab injection, decreased leakage from the optic discs and the retinal vessels (b). Three months after the treatment, minimal fluorescein leakage occurred from the optic disc both eyes with macular area of nonperfusion of the right eye (c)

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Figure 3: Optical coherence tomography findings before and after intravitreal bevacizumab injection. At presentation, macular edema and subfoveal neurosensory detachments were noted both eyes. The central macular thickness (CMT) was 392 mm in the right eye and 874 mm in the left eye (a). One month after the treatment, CMT decreased to 193 mm in the right eye and 194 mm in the left eye (b). The CMT reduced to 144 mm in right eye and 193 mm in left eye with atrophic thinning of the fovea 3 months after the (c)

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   Discussion Top


The retinal circulation suffers a series of pathophysiological changes in reply to elevated blood pressure. [10] The retinal signs are generalized and focal arteriolar narrowing, arteriovenous nicking, flame-shaped and blot-shaped retinal hemorrhages, cotton-wool spots, and swelling of the optic disc some experimental studies [11],[12] and clinical trials [13],[14] have demonstrated that clinical findings of hypertensive retinopathy regress with the control of blood pressure, although spontaneous resolution of these findings in the presence of high blood pressure has also been reported. [15] It is unclear whether antihypertensive medications that are expected to have direct useful result on the microvascular structure (e.g., angiotensin-converting enzyme inhibitors) would decrease the injury of retinopathy beyond the reduction effected by lowered blood pressure. According to Chen et al., [16] 11 of 14 patients with malignant hypertensive retinopathy had an acceptable visual prognosis when the blood pressure was controlled, whereas three patients, who had longer durations of high blood pressure and other retinal comorbidities, such as central artery occlusion and anterior ischemic optic neuropathy still, had bad vision. Salman [17] did not find a significant relation between severity of hypertension and degree of drop in initial visual acuity or extent of retinopathy. However, Browning et al. [18] who found that the worst visual prognosis was associated with the highest presented blood pressure, the worst visual acuity at presentation, and the longest duration of symptoms. The use of intravitreal anti-VEGF therapy has expanded tremendously in recent years, and intravitreal anti-VEGF agents are now used to handle complications of various diseases of the posterior segment. [7] In an exudative stage of hypertensive retinopathy, in which there is a disruption of the blood retinal barrier, necrosis of the smooth muscles and endothelial cells, exudation of blood and lipids, and retinal ischemia. These changes are manifested in the retina as microaneurysms, hemorrhages, hard exudates, and cotton-wool spots. Swelling of the optic disc may occur at this time and usually indicates severely elevated blood pressure (i.e., malignant hypertension). [19],[20]

The intravitreal injection of anti-VEGF agents can accelerate the resolution of macular edema with exudative retinal detachment and improve the visual outcome.

In the current case, intravitreal bevacizumab injection in a patient with exudative stage of malignant hypertensive retinopathy resulted in rapid resolution of the macular edema and optic disc edema. Kim et al. [21] reported same results in two cases. This result and previous results suggest that intravitreal bevacizumab injection might be recommended as effective therapeutic modality for treating exudative stage of hypertensive retinopathy, in addition to lowering blood pressure.

 
   References Top

1.
Gunn RM. Ophthalmoscopic evidence of (1) arterial changes associated with chronic renal diseases and (2) of increased arterial tension. Trans Ophthalmol Soc UK 1892;12:124-5.  Back to cited text no. 1
    
2.
Goto I, Katsuki S, Ikui H, Kimoto K, Mimatsu T. Pathological studies on the intracerebral and retinal arteries in cerebrovascular and noncerebrovascular diseases. Stroke 1975;6:263-9.  Back to cited text no. 2
    
3.
Walsh JB. Hypertensive retinopathy. Description, classification, and prognosis. Ophthalmology 1982;89:1127-31.  Back to cited text no. 3
    
4.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289:2560-72.  Back to cited text no. 4
    
5.
Breslin DJ, Gifford RW Jr, Fairbairn JF 2 nd , Kearns TP. Prognostic importance of ophthalmoscopic findings in essential hypertension. JAMA 1966;195:335-8.  Back to cited text no. 5
    
6.
Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci 1939;197:332-43.  Back to cited text no. 6
    
7.
Nicholson BP, Schachat AP. A review of clinical trials of anti-VEGF agents for diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol 2010;248:915-30.  Back to cited text no. 7
    
8.
Gulati N, Forooghian F, Lieberman R, Jabs DA. Vascular endothelial growth factor inhibition in uveitis: A systematic review. Br J Ophthalmol 2011;95:162-5.  Back to cited text no. 8
    
9.
Ferrara N, Houck KA, Jakeman LB, Winer J, Leung DW. The vascular endothelial growth factor family of polypeptides. J Cell Biochem 1991;47:211-8.  Back to cited text no. 9
    
10.
Tso MO, Jampol LM. Pathophysiology of hypertensive retinopathy. Ophthalmology 1982;89:1132-45.  Back to cited text no. 10
    
11.
Hamada Y, Niisato E, Otori T, Chikugo TA, Ohta Y, Suzuki T, et al. Ocular fundus changes in malignant or precocious stroke-prone spontaneously hypertensive rats after administration of antihypertensive drugs. Clin Exp Pharmacol Physiol Suppl 1995;22:S132-3.  Back to cited text no. 11
    
12.
Morishita R, Higaki J, Nakamura F, Tomita N, Yu H, Nagano M, et al. Regression of hypertension-induced vascular hypertrophy by an ACE inhibitor and calcium antagonist in the spontaneously hypertensive rat. Blood Press Suppl 1992;3:41-7.  Back to cited text no. 12
    
13.
Bock KD. Regression of retinal vascular changes by antihypertensive therapy. Hypertension 1984;6:III158-62.  Back to cited text no. 13
    
14.
Dahlöf B, Stenkula S, Hansson L. Hypertensive retinal vascular changes: Relationship to left ventricular hypertrophy and arteriolar changes before and after treatment. Blood Press 1992;1:35-44.  Back to cited text no. 14
    
15.
Bild DE, Bluemke DA, Burke GL, Detrano R, Diez Roux AV, Folsom AR, et al. Multi-ethnic study of atherosclerosis: Objectives and design. Am J Epidemiol 2002;156:871-81.  Back to cited text no. 15
    
16.
Chen YH, Kuo HK, Kao ML. Malignant hypertensive retinopathy-clinical and fundus manifestations in patients with new onset or acute exacerbation of chronic hypertension. Chang Gung Med J 2003;26:669-77.  Back to cited text no. 16
    
17.
Salman AG. Intravitreal bevacizumab in persistent retinopathy secondary to malignant hypertension. Saudi J Ophthalmol 2013;27:25-9.  Back to cited text no. 17
    
18.
Browning AC, Mengher LS, Gregson RM, Amoaku WM. Visual outcome of malignant hypertension in young people. Arch Dis Child 2001;85:401-3.  Back to cited text no. 18
    
19.
Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.  Back to cited text no. 19
    
20.
DellaCroce JT, Vitale AT. Hypertension and the eye. Curr Opin Ophthalmol 2008;19:493-8.  Back to cited text no. 20
    
21.
Kim EY, Lew HM, Song JH. Effect of intravitreal bevacizumab (Avastin( ® )) therapy in malignant hypertensive retinopathy: A report of two cases. J Ocul Pharmacol Ther 2012;28:318-22.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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