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179
Letters to the Editor
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.
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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: 10.4103/ijo.IJO_1642_18
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.
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Cite this article as: Samanta R. Comment on: Dramatic response to intravitreal bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2019;67:178-9.
Response to comment on: Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy
The dramatic anatomical and functional response to intravitreal Bevacizumab in our patient reinforces that this maybe a viable option to avoid irreversible vision loss from macular edema in hypertensive retinopathy. Collaboration with cardiology and nephrology departments for BP control and subsequent monitoring is warranted in such patients.
Sir, We would like to thank the authors for their interest and comments on the article “Dramatic response to intravitreal Bevacizumab in Hypertensive Retinopathy”[1,2] and address their queries as follows: As mentioned by the authors, fellow eye effect of unilateral intravitreal Bevacizumab is controversial and the factors on which it depends are unknown.[3] It is therefore difficult to predict the effect on the fellow eye after unilateral intravitreal Bevacizumab. We noticed a significant reduction of intraretinal and subretinal fluid in both the eyes at 1 week after unilateral intravitreal Bevacizumab injection, while the blood pressure (BP) was still not well controlled. Since the patient was started on oral steroids 1 month back (as per advice of the treating nephrologist) and developed severe hypertensive retinopathy during this period, it is unlikely that systemic steroids would have contributed toward resolution of intraretinal and subretinal fluid. All these factors point toward the effect of intravitreal Bevacizumab on the fellow eye. Nevertheless, it is difficult to exclude the additional effect of hypertension control at 1 month on the resolution of macular edema. The pre‑injection central subfield macular thickness (CST) was 695 microns in OD and 591 microns in OS. At 1‑month post injection, it was 301 microns in OD and 282 microns in OS. We agree with the authors that intravitreal Bevacizumab may cause dysregulation of BP, especially in severely hypertensive patients. [4] However, the rise in BP after intravitreal Bevacizumab is usually mild and is considered to be safe even in hypertensive patients.[5,6] Furthermore, our patient was under close observation in our institution’s nephrology and cardiology departments and due clearance had been obtained prior to the injection.
© 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Srikant Padhi, Vinod Kumar Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to: Dr. Vinod Kumar, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. E‑mail:
[email protected]
References 1. Samanta R. Comment on: Dramatic response to intravitreal bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2019;67:178-9. 2. Padhy S, Kumar V. Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2018;66:1494‑5. 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. 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. 5. Chung YR, Lee K, Cho EH, Lew HM. Blood pressure changes after intravitreal Bevacizumab in patients grouped by ocular pathology. Eye 2010;24,1320‑4. 6. Lee K, Yang H, Lim H, Lew HM. A prospective study of blood pressure and intraocular pressure changes in hypertensive and
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Indian Journal of Ophthalmology
nonhypertensive patients after intravitreal Bevacizumab injection. Retina 2009;29:1409‑17.
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Website: www.ijo.in DOI: 10.4103/ijo.IJO_1739_18 PMID: ***
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Comment on: Dramatic response to intravitreal bevacizumab in hypertensive retinopathy Sir, We read with interest the case report[1] on the resolution of bilateral subfoveal fluid and disc edema due to hypertensive retinopathy (HTNR) after unilateral intravitreal bevacizumab. We want to discuss few points. 1. As one eye did not receive the intravitreal injection, one could consider that eye as the control eye as opposed to the other interventional eye with intravitreal injection. Resolution of the control eye’s subfoveal fluid after 1 month of the intervention may denote a positive effect of the control of blood pressure (BP) or systemic disease and may not solely be related to the contralateral effect of the injection as the authors have proposed. It would be interesting to know if the patient underwent any interventions to control BP including hemodialysis. 2. Typically mean arterial BP (MABP) is calculated as diastolic BP + (systolic BP − diastolic BP)/3. Thus, the calculated MABP of 210/140 mm Hg would be 140 + (210 − 140)/3 = 163.3 mm Hg and not 136 mm Hg. Was MABP measured invasively by an arterial line? 3. As the primary cause of HTNR is hypertension, the adequate control of hypertension is the most important intervention. Without the adequate control of BP, any intervention including intravitreal anti‑vascular endothelial growth factor (VEGF) agents may not be considered. Though bevacizumab has been considered as a “wonder drug,” it carries a rare but devastating risk of blindness due to endophthalmitis.[2] However, in the clinical setting even after control of hypertension, the subfoveal fluid may not resolve and the patient may want earlier visual rehabilitation. Salman[3] used intravitreal bevacizumab in 12 cases of persistent HTNR despite control of hypertension for 1 month and noted stabilization and improvement of vision in all cases. This paper[1] also adds to the evidence[4,5] that anti‑VEGF agents may be helpful in HTNR. The exact role of anti‑VEGF agents in HTNR needs further exploration, but these agents may add to the armamentarium to treat the cases of HTNR with subfoveal fluid which do not resolve despite good systemic control. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Cite this article as: Padhi S, Kumar V. Response to comment on: Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2019;67:179-80. © 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Koushik Tripathy, Arpan Chaudhuri1 Department of Vitreoretina and Uvea, ASG Eye Hospital, Dakshindari Road, VIP Road, Sreebhumi, Near Lake Town, 1 Department of Internal Medicine and Intensive Care, Columbia Asia Hospital, Salt Lake City, Kolkata, West Bengal, India Correspondence to: Dr. Koushik Tripathy, Department of Vitreoretina and Uvea, ASG Eye Hospital, 403/1 Alcove Gloria, Dakshindari Road, VIP Road, Sreebhumi, Near Lake Town, Kolkata ‑ 700 048, West Bengal, India. E‑mail:
[email protected]
References 1. Padhy S, Kumar V. Dramatic response to intravitreal Bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2018;66:1494‑5. 2. Kumar A, Tripathy K, Chawla R. Intraocular use of bevacizumab in India: An issue resolved? Natl Med J India 2017;30:345‑7. 3. Salman AG. Intravitreal bevacizumab in persistent retinopathy secondary to malignant hypertension. Saudi J Ophthalmol 2013;27:25‑9. 4. 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 Off J Assoc Ocul Pharmacol Ther 2012;28:318‑22. 5. Al‑Halafi AM. Tremendous result of bevacizumab in malignant hypertensive retinopathy. Oman J Ophthalmol 2015;8:61‑3.
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Access this article online Quick Response Code:
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Cite this article as: Tripathy K, Chaudhuri A. Comment on: Dramatic response to intravitreal bevacizumab in hypertensive retinopathy. Indian J Ophthalmol 2019;67:180. © 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
