A 25-year-old male patient with sickle cell (SC) genotype presented with a 3 month history of progressive loss of vision in the left eye. The visual acuity on presentation was 6/5 right eye and counting fingers on the temporal field, left eye. In the right eye he had sea fans, black sunburst lesions, schisis cavities, and salmon patch haemorrhages. In the left eye he had relatively organised vitreous haemorrhage with poor visualisation of details. However, with indirect ophthalmoscopy it was possible to discern areas of haemorrhage spanning 360° associated with neovascularisation, some black sunburst and schisis cavities.
The patient was counselled on the nature of the problem and advised that a fluorescein angiogram would be necessary to confirm the extent of the lesions. Treatment options of laser, cryotherapy and intracameral bevacizumab were discussed. The patient needed to be appraised of the off licence nature of bevacizumab. Because of the dense haemorrhage in the left eye, it was decided that bevacizumab would be administered following which laser therapy may be applied only to the right eye.
The fluorescein angiogram confirmed leaking areas of sea fan neovascularisation in the right eye (), both nasally and temporally, with distal avascularised zones. It was not possible to get clear pictures in the left eye due to the haemorrhage.
Right eye before the injection of bevacizumab. Temporal sea fan neovascularisation with areas of haemorrhage, and nasal neovascular tufts on arteriovenous anastomosis (top) with corresponding areas of leakage of fluorescein (below).
Bevacizumab, 1.25 mg, was administered into both eyes by atraumatic trans-scleral pars plana injection 3.5 mm temporally behind the limbus. The following day, the eyes were inspected. There was no fresh haemorrhage in either eye, either anteriorly or posteriorly. The old vitreous haemorrhage in the left eye remained unchanged.
On day 5, a crescentic hyphaema was noticed in the left eye while there was no change in the sea fan formations in the right eye. Slit lamp examination of the left eye showed that the anterior chamber was densely packed with blood cells, contiguous with the cells in the vitreous cavity. The intraocular pressure was 12 mm Hg in both eyes.
Bed rest and double padding of the eyes were ordered. This did not result in any significant change. By day 12 there was about a 30% hyphaema, with red cells in the anterior segment. A paracentesis was carried out the following day with no recurrence of hyphaema. However, the vitreous haemorrhage remained unchanged.
By the 26th day following bevacizumab injection, an examination of the right eye showed a fibrotic regression of the sea fan and haemorrhage. There was still no change in the vitreous haemorrhage in the left eye.
A repeat fluorescein angiogram was carried out on the 27th day after bevacizumab injection.
This confirmed that there was no more leakage of the sea fan neovascular lesions, both temporally and nasally (). It was considered unnecessary to apply laser therapy to the avascular zone of the eye.
Same right eye 3 weeks after injection of bevacizumab. Temporal sea fan and haemorrhage has resolved into a white fibrotic strand, and there is an absence of leakage both nasally and temporally.