Combined Intracorneal and Subconjunctival Bevacizumab Injections for Recurrent Visual Loss and Intraocular Hemorrhage from Vascularized Fibrous Downgrowth
This 44-year-old housewife sustained ocular injuries 23 years ago after a motor vehicle accident and was operated bilaterally. Visual acuity was since lost in the right eye and the left eye was maintained on ocular hypotensive drops. Two weeks before presentation, she had fallen from a ladder and had sustained extensive corneoscleral laceration of the left eye with uveal prolapse and total hyphema. The laceration was sutured in an outside hospital.\nVisual acuity on presentation was light perception with through-and-through vertical corneal wound, dense hyphema and large inferior conjunctival bleb. Intraocular pressure was 5 mm Hg. B-scan ultrasonography revealed total retinal detachment. The corneoscleral wound was resutured because it was gaping. A scleral buckle was placed at 360°. There was profuse continuous bleeding from the iris and ciliary body area throughout surgery despite pars plana cleanout of the anterior segment (lens remnant, vitreous and blood clot). During posterior vitrectomy, a one-disc diameter macular hole was suspected. Silicone oil fill of the vitreous cavity was followed by endolaser of an extensive inferior giant retinal tear. Postoperatively, the patient had multiple sessions of laser retinopexy to seal a localized inferior retinal detachment. A large retrocorneal membrane was evident 6 weeks postoperatively over the temporal cornea (fig. ). Postoperative best spectacle-corrected visual acuity was 6/60. A rise in intraocular pressure was again controlled by topical β-blocker. She had 5 recurrent episodes of visual loss to the level of hand motion from intraocular bleeding (interface hemorrhage, hyphema and anterior vitreous hemorrhage) (fig. ). Visual loss used to resolve 1 week after subconjunctival (0.1 ml; 2.5 mg) and intracorneal (0.05 ml; 1.25 mg) bevacizumab (after formal consent). The rationale was the vascular nature of the fibrovascular membrane with feeder vessels consisting of several branches of limbal and corneal stromal neovascularization (fig. ). The injections were done in a sterile fashion using a speculum and a 30-gauge needle. The intrastromal (corneal) and subconjunctival injections were aimed at the site of the feeder vessels (fig. ). We avoided intracameral injections because of the concomitant presence of glaucoma and intravitreal silicone oil. The patient was instructed to have monthly injections. When she was late for follow-up, intraocular bleeding would occur. The patient was followed for 40 months after presentation with a final vision of 6/120. She received a total of 21 injections over a period of 2.5 years with a total of 5 episodes of vitreous hemorrhage.\nWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.