perfusion in the temporal periphery ofeach eye. No adverse events wereobserved in 4 weeks of follow-uppost-injection.

To our knowledge, and accordingto a search of MEDLINE, this is thefirst report of retinal neovasculariza-tion regression associated with intravi-treal bevacizumab injection. Ourresults in a single patient with a4-week follow-up are provocativeand require additional investigation.Further studies should include adose-escalation strategy so that adose–response curve can be estab-lished. If studies demonstrate thatintravitreal bevacizumab is safely andreliably associated with retinal neovas-cularization regression, intravitrealbevacizumab may be a useful adjunctto laser photocoagulation in the man-agement of proliferative retinopathy,and may (as in the case reportedherein) permit some patients to avoidpars plana vitrectomy.

ReferencesAvery RL (2006): Regression of retinal and

iris neovascularization after intravitreal

bevacizumab (Avastin) treatment. Retina

26: 352–354.

Michels S, Rosenfeld PJ, Puliafito CA, Mar-

cus EN & Venkatraman AS (2005):

Systemic bevacizumab (Avastin) therapy

for neovascular age-related macular degen-

eration: 12-week results of an uncontrolled

open-label clinical study. Ophthalmology

112: 1035–1047.

Nguyen QD, Shah S, Tatlipinar S, Do DV,

Anden EV & Campochiaro PA (2005):

Bevacizumab suppresses choroidal neovas-

cularization caused by pathological myo-

pia. Br J Ophthalmol 89: 1368–1370.

Rosenfeld PJ, Fung AE & Puliafito CA

(2005b): Optical coherence tomography

findings after an intravitreal injection

of bevacizumab (Avastin�) for macular

oedema from central retinal vein occlusion.

Ophthalmic Surg Lasers Imaging 36: 336–

339.

Rosenfeld PJ, Moshfeghi AA & Puliafito CA

(2005a): Optical coherence tomography

findings after an intravitreal injection of

bevacizumab (Avastin�) for neovascular

age-related macular degeneration. Ophthal-

mic Surg Lasers Imaging 36: 331–335.

Correspondence:

Rodrigo Jorge MD, PhD

Department of Ophthalmology

School of Medicine of Ribeirao Preto

University of Sao Paulo

Avenue Bandeirantes 3900

Sao Paulo 14049-900

Brazil

Tel: + 55 16 3602 2423

Fax: + 55 16 3602 2860

Email: rjorge@fmrp.usp.br

Choroidal

neovascularization treated

with intravitreal injection

of bevacizumab (Avastin)

in angioid streaks

Anderson Teixeira, Nilva Moraes, MichelEid Farah and Pedro Paulo Bonomo

Department of Ophthalmology, FederalUniversity of Sao Paulo (UNIFESP),

Sao Paulo, Brazil

doi: 10.1111/j.1600-0420.2006.00762.x

Editor,

A ngioid streaks are irregular,radiating, jagged, tapering lines

that extend from the peripapillaryarea into the peripheral fundus thatmay occur in isolation or as the ocu-lar manifestation of a systemic dis-ease. Linear breaks or dehiscence in athickened, calcified and abnormallybrittle Bruch’s membrane can be asso-ciated with choroidal neovasculariza-tion (CNV) and poor vision. Severaltreatments have been attempted withlimited success and high rates ofrecurrence (Costa et al. 2003; Shaikhet al. 2003; Aras et al. 2004). Wereport a case of subfoveal CNV dueto angioid streaks treated with intravi-treal bevacizumab 1.25 mg.

A 23-year-old man with angioidstreaks was referred for subfovealCNV in his right eye (OD). He hadsuffered visual loss in the left eye (OS)after minor trauma. Best correctedvisual acuity (BCVA) was countingfingers at 2 m OD and 20 ⁄ 400 OS.Fundus examination revealed peripap-illary angioid streaks in both eyes, agrey subfoveal lesion with subretinalhaemorrhage and subsensory fluid ODand a large pigmented macular scarOS. Fluorescein angiography (FA)revealed a subfoveal classic CNVassociated with leakage and peripapil-lary hyperfluorescence correspondingto the angioid streaks OD and a stain-ing of disciform scarring with no act-ive leakage in the macula OS. Opticalcoherence tomography (OCT) showedneurosensory serous detachment andtype 2 CNV OD (Figs 1 and 3A). Thepatient was counselled as to the prog-nosis of his condition and treatmentoptions. Photodynamic therapy was

(C)

(A) (B)

(D)

Fig. 1. Retinal neovascularization in the (A) right and (B) left eyes before treatment.

Decreased leakage from the area of neovascularization in the right eye (C) 1 week and

(D) 4 weeks after treatment with intravitreal bevacizumab.

Acta Ophthalmologica Scandinavica 2006

835

offered but not accepted and anintravitreal injection of bevacizumab1.25 mg was administered.

After 7 weeks, VA was 20 ⁄40 andsome residual leakage was seen at thelesion margin on FA. The subjectunderwent a second injection. After12 weeks VA was 20 ⁄ 30, fundusexamination showed no subsensoryfluid, and OCT and FA revealed noleakage (Figs 2 and 3B).

Choroidal neovascularization occursin 70–86% of patients with angioidstreaks and more than half havevision of 20 ⁄ 200 or worse after theage of 50 years. It has been suggestedthat laser photocoagulation might

resolve CNV and help to stabilize VAor slow down visual loss, given thevery high frequency of recurrence(Lim et al. 1993).

Other therapies such as photo-dynamic therapy, Indocyanine green-mediated photothrombosis (IMP) andtranspupillary thermotherapy haverecently been proposed as alternativetreatments for CNV associated withage-relatedmaculardegeneration(AMD)and others types of CNV but theydo not appear to change the course ofthe disease and the visual prognosisis poor (Lim et al. 1993; Costa et al.2003; Shaikh et al. 2003; Aras et al.2004).

This is the first case report of intra-vitreal injection of bevacizumab in apatient with subfoveal CNV with an-gioid streaks. Our patient demonstra-ted a significant improvement at18 weeks, with VA of 20 ⁄ 30. Therewas no evidence of inflammation byeither OCT or FA at this time-point.

Vascular endothelial growth factor(VEGF) has been implicated as themajor angiogenic stimulus responsiblefor neovascularization in AMD. Bev-acizumab has shown promising resultsin off-label intravenous injectionsadministered as salvage treatment(Rosenfeld et al. 2005).

A formal prospective study is neces-sary to determine the safety and effic-acy of intravitreal bevacizumab in thetreatment of CNV.

ReferencesAras C, Baserer T, Yolar M et al. (2004):

Two cases of choroidal neovasculariza-

tion treated with transpupillary thermo-

therapy in angioid streaks. Retina 24:

801–803.

Costa RA, Calucci D, Cardillo JA & Farah

ME (2003): Selective occlusion of subfoveal

choroidal neovascularization in angioid

streaks by using a new technique of

ingrowth site treatment. Ophthalmology

110: 1192–1203.

Lim JI, Bressler NM, Marsh MJ et al. (1993):

Laser treatment of choroidal neovasculari-

zation in patients with angioid streaks. Am

J Ophthalmol 116: 414–423.

Rosenfeld PJ, Moshfeghi AA & Puliafito CA

(2005): Optical coherence tomography

findings after an intravitreal injection of

bevacizumab (Avastin) for neovascular

age-related macular degeneration. Ophthal-

mic Surg Lasers Imag 36: 331–335.

Shaikh S, Ruby AJ & Williams GA (2003):

Photodynamic therapy using verteporfin

for choroidal neovascularization in angioid

streaks. Am J Ophthalmol 135: 1–6.

Correspondence:

Anderson Teixeira

Rua Conselheiro Brotero 1093 apto 43

Sta Cecilia

Sao Paulo

SP 01232-011

Brazil

Tel: + 55 11 3825 7754

Email: anderson.lbo@uol.com.br

Fig. 1. (A) Early and (B) late-phase fluorescein angiography images at baseline.

Fig. 3. Optical coherence tomography scans at 6-mm at (A) baseline and (B) 18 weeks post-

injection.

Fig. 2. (A) Early and (B) late-phase fluorescein angiography images at 18 weeks after treatment.

Acta Ophthalmologica Scandinavica 2006

836