Short Report
Bilateral response following unilateral intravitreal bevacizumab injection in a child with uveitic cystoid macular edema

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Untreated cystoid macular edema (CME) is a major cause for visual loss in intermediate and posterior forms of uveitis. Conventional treatments for inflammatory CME include steroids, nonsteroidal antiinflammatory agents, and carbonic anhydrase inhibitors; however, not all patients respond, even after quieting of the uveitis. Intravitreal injection of bevacizumab, a monoclonal antibody to vascular endothelial growth factor, has recently been suggested as a short-term treatment for inflammatory CME in adults. Because unilaterally injected bevacizumab can reach the contralateral eye via the systemic circulation there may be a contralateral clinical effect; however, the few reports that evaluate this in adults are conflicting. The purpose of this report is to document bilateral reduction of uveitic CME following unilateral intravitreal bevacizumab injection in an 8-year-old girl.

Section snippets

Case Report

An 8-year-old girl with a 6-year history of insulin-dependent diabetes and a 2-year history of idiopathic bilateral intermediate uveitis complained of gradual bilateral visual deterioration over the preceding several months with no other constitutional symptoms. For almost 2 years she was being treated with oral methotrexate 7.5 mg weekly and supplemental folate 1 mg daily except for the day of oral methotrexate. An extensive medical evaluation to determine a cause for the uveitis was

Discussion

There are few reports of intravitreal bevacizumab use in children1, 2, 3 and none to our knowledge that document a bilateral effect from unilateral injection. We document its use in an 8-year-old child without local or systemic adverse effects. Bilateral reduction of uveitic CME and improvement in visual acuity was observed following unilateral intravitreal injection. Further bilateral reduction in CME was documented following injection of the contralateral eye. The effect of the intravitreal

Literature Search

An English-language PubMed search, without date restrictions, was performed on January 10, 2009, for the terms pediatric and bevacizumab. Relevant references of the identified articles were also reviewed.

References (10)

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    Systemic transfer of anti-vascular endothelial growth factor (VEGF) therapies injected IVT in conditions such as neovascular age-related macular degeneration (AMD) and cystoid macular edema (CME) has been demonstrated. Several publications report a clinical improvement in the contralateral eye after unilateral injection of bevacizumab or ranibizumab for the treatment of AMD or CME.28,29 Hanhart and colleagues30 conducted a retrospective study on 35 patients with bilateral diabetic macular edema to evaluate the effect of unilateral bevacizumab IVT on contralateral noninjected eyes.

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    Slabaugh and associates used topical difluprednate to treat 9 of 26 eyes with ME, with a 78% improvement rate after a mean interval of 4 weeks,2 along with improved vision. One case report described bilateral improvement in central macular thickness and VA 1 week after bevacizumab injection in a single eye.25 The results were maintained to the end of the 16-week follow-up.

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    Bevacizumab was detected in the untreated fellow eye of a rabbit model of neovascular AMD.11 Therapeutic effects after treatment with intravitreal bevacizumab were also noted in the fellow eyes of patients with proliferative diabetic retinopathy,17 AMD,18 type 2 idiopathic macular telangiectasia,19 and uveitic cystoid macular edema,20 supporting the concern that intravitreal anti-VEGF agents may lead to systemic exposure. This may be more significant when there is a breakdown in the blood retinal barrier which accompanies some ocular diseases.21,22

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See editorial on page 329.

Conflict of Interest: None.

Funding: None.

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