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BMJ Case Rep. 2010; 2010: bcr10.2009.2398.
Published online 2010 January 13. doi:  10.1136/bcr.10.2009.2398
PMCID: PMC3029625
Copyright 2010 BMJ Publishing Group Ltd
Novel treatment (new drug/intervention; established drug/procedure in new situation)
Intracameral injection of ranibizumab caused regression of iris neovascularisation and clearance of hyphaema in a non-diabetic patient with ischaemic remnant retinal flap in a silicone filled eye
Mae-Lynn Catherine Bastion
Universiti Kebangsaan Malaysia, Ophthalmology, Hospital Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur, 56000, Malaysia
Correspondence to Mae-Lynn Catherine Bastion, maelynnb2003/at/yahoo.com
Abstract
The use of 0.5 mg/0.05 ml of ranibizumab intracamerally, to induce regression of iris neovascularisation in a non-diabetic patient, is reported. A 55-year-old Malay man presented with left eye rubeosis and hyphaema secondary to ischaemic remnant retinal flap in his silicone filled pseudophakic eye. Regression of rubeosis and resolution of hyphaema was noted within 4 days of injection of intracameral ranibizumab, allowing repeat vitrectomy to be performed without much bleeding, thus facilitating removal of his intraocular lens and laser to remaining flap. One month postoperatively he remained comfortable with counting fingers vision similar to the pre-hyphaema period.
Background
The effectiveness and safety of injecting ranibizumab intracamerally, in a rare case of rubeosis secondary to ischaemic anterior retinal flap remnant, is reported. Although the definitive management was surgery to excise the ischaemic anterior retinal flap, the ranibizumab helped to facilitate this by reducing to almost nil the amount of intraoperative bleeding as well as controlling the perioperative inflammation.
A 55-year-old Malay man presented with left eye discomfort and blurring of vision of 2 days’ duration. He first presented with left rhegmatogenous retinal detachment and brunescent cataract 13 months earlier. He had no diabetes mellitus.
He developed proliferative vitreo-retinopathy (PVR) post-primary vitrectomy and required three revision vitrectomies. The last procedure was vitrectomy, inferior retinectomy, laser retinopexy and silicone oil (SO) injection. View of the peripheral retina was significantly hampered by the presence of a small pupil and capsular fibrosis. The intraocular lens (IOL) was left in situ. Postoperatively, his visual acuity was counting fingers (CF) with attached macula and intracameral SO globule. His intraocular pressure (IOP) was consistently below 10 mm Hg. He remained comfortable until this presentation, 7 months later.
On examination, vision was hand motions. There was left rubeosis and hyphaema (fig 1). There was 360° posterior synechiae involving the IOL.
Figure 1
Figure 1
Anterior segment photograph of the patient’s left eye showing hyphaema and iris neovascularisation at presentation.
The patient was commenced on topical steroids and homatropine. On the second day of admission, he developed iris bombe and pupillary block with IOP of 16 mm Hg. Laser peripheral iridotomy was performed.
Informed consent was obtained as to the off-label nature of ranibizumab (Lucentis, Genentech Inc, San Francisco, USA) used. Under aseptic conditions in the operating theatre, a corneal incision was first made at 2 o’clock in the left eye with a 15° blade. This paracentesis allowed egress of some fluid before injection at the 10 o’clock position of 0.5 mg of ranibizumab with an insulin syringe and 27G needle by a right handed surgeon. There was no leak of ranibizumab by this method.
Regression of rubeosis was noted on the first day and hyphaema resolved by day 4 (fig 2). This facilitated removal of the IOL and capsule, with minimal bleeding on day 7. There was no local or systemic injection related complication. Intraoperatively, an anterior remnant retinal flap (RRF) was noted inferiorly. This was retinectomised and/or lasered once SO was removed. The patient remained comfortable with no recurrence of rubeosis 1 month later and a completely attached retina. His visual acuity returned to CF.
Figure 2
Figure 2
Anterior segment photograph of the patient’s left eye showing resolution of the rubeosis and hyphaema 4 days after the injection of 0.05 mg of ranibizumab.
Rubeosis occurs in eyes with history of complex retinal detachments that are injected with SO due to persistent peripheral annular detachments.1 IOLs may become incorporated into anterior PVR membranes. Vascular endothelial growth factor (VEGF) released by ischaemic tissues such as the retina is implicated in the development of rubeosis and was released by ischaemic RRF. Therefore, anti-VEGF agents have a role.
Ranibizumab is a humanised antigen binding fragment designed to inhibit all isoforms and active degradation products of VEGF-A.2 Since its development as an effective treatment for age related macular degeneration, intravitreal ranibizumab has been proposed for various other retinal vascular diseases associated with increased VEGF such as diabetic retinopathy, central retinal vein occlusion, and rubeosis. A number of case series have documented the effectiveness of bevacizumab (Avastin, Genentech Inc, San Francisco, USA), a sister compound to ranibizumab, in causing regression of rubeosis.3,4
Ranibizumab caused regression of rubeosis in a patient with radiation induced neovascular glaucoma and exudative retinal detachment.5 However, to our knowledge, the role of ranibizumab in a non-diabetic patient with rubeosis secondary to RRF has not been documented previously and articles on its role in rubeosis are limited.
Ranibizumab was injected intracamerally as the retinal ischaemia was deemed to be limited to the anterior segment. This technique also avoided needle passage through possible anterior PVR. The concentration of ranibizumab and its diffusibility in silicone oil is uncertain. However, there is a safety issue of intracameral injection of ranibizumab, especially in the context of a silicone filled eye, where the aqueous compartment may be notably reduced depending on the level of oil fill. Bevacizumab is safe when injected intracamerally.3,6
Learning points
  • Ranibizumab has a role in causing rapid regression of rubeosis in cases of RRF in non-diabetic eyes filled with silicone oil.
  • Ranibizumab did not have obvious side effects when injected intracamerally.
  • Ranibizumab has an adjunctive role in reducing intraoperative bleeding in eyes with rubeosis in the setting of RRF and silicone oil that are undergoing vitreo-retinal surgical procedures.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Santosh GH, Mallika G, Ajit BM, et al. Glaucoma after pars planar vitrectomy and silicone oil injection for complicated retinal detachments. Ophthalmology 1999; 106: 169–77. [PubMed]
2. Gaudreault J, Fei D, Beyeret JC, et al. Pharmacokinetics and retinal distribution of ranibizumab, a humanized antibody fragment directed against VEGF-A, following intravitreal administration in rabbits. Retina 2007; 27: 1260. [PubMed]
3. Chalam KV, Gupta SK, Grover S, et al. Intracameral Avastin dramatically resolves iris neovascularisation and reverses neovascular glaucoma. Eur J Ophthalmol 2008; 18:2: 255–62. [PubMed]
4. Costagliola C, Cipollone U, Rinaldi M, et al. Intravitreal bevacizumab (Avastin(R)) injection for neovascular glaucoma: a survey on 23 cases throughout 12-month follow-up. Br J Clin Pharmacol 2008; 66: 667–73. [PubMed]
5. Dunavoelgyi R, Zehetmayer M, Simader C, et al. Rapid improvement of radiation-induced neovascular glaucoma and exudative retinal detachment after a single intravitreal ranibizumab injection. Clin Experiment Ophthalmol 2007; 35: 878–80. [PubMed]
6. Park HY, Kim SJ, Lee HB, et al. Effect of intracameral bevacizumab injection on corneal endothelium in rabbits. Cornea 2008; 27: 1151–5. [PubMed]
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