Intravitreal injections of bevacizumab (Avastin; Genentech, San Francisco) could serve as a beneficial off-label use in treating choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). According to a 3-month study, there are no apparent short-term safety concerns in eyes treated with intravitreal bevacizumab injection, and >30% of the eyes showed increased visual acuity and a significant decrease in macular thickness.1,2

The change in visual acuity and retinal thickness suggests that bevacizumab may penetrate the retina and to some extent the retinal pigment epithelium. The only other medication known to cause a mean increase in visual acuity lasting at least 3 months among this patient set is ranibizumab (Lucentis; Genentech, San Francisco), the antibody fragment designed to bind vascular endothelium growth factor.

In a retrospective study of 266 eyes in 266 patients, bevacizumab was offered to patients who had done poorly with other treatment methods. As research continued, we also began to offer intravitreal bevacizumab to patients with large occult or minimally classic lesions. Before treatment, each patient underwent best-corrected distance visual acuity measurement with a Snellen chart and ophthalmologic examination including slit-lamp biomicroscopy. During treatment, patients received injections of 1.25 mg/0.05 mL bevacizumab, with the thought that they would be given three injections over a 3-month span. Patients were then examined at 1 week, 1 month after the first injection, and monthly thereafter.

BASELINE CHARACTERISTICS

The mean age of patients was 80.3 ± 7.5 years, and the mean visual acuity was 20/184. Of the 266 patients, 175 (69.7%) who were previously treated, 139 (55.4%) had prior photodynamic therapy (PDT) with or without concomitant triamcinolone, 53 (21.1%) had previous pegaptanib (Macugen; OSI Eyetech/Pfizer, New York, NY) treatment, and 43 (17.1%) had other treatments (eg, open-label anecortave acetate, thermal laser and intravitreal triamcinolone with concomitant PDT). Baseline optical coherence tomography (OCT) was performed for 214 patients; the mean central foveal thickness ± standard deviation was 340 ±206 µm, and cystoid macular edema was present in 47.8% of the patients.

At the 1-month follow-up, the mean visual acuity was 20/131 (P < .001), and 67 (33.5%) of the patients had improvement in visual acuity as defined by a halving of the visual angle. Thirteen patients had worse visual acuity, but the OCT results showed that the mean central macular thickness was significantly less than baseline findings in 80% of patients. Data for the 2-month follow-up were available for 222 eyes, and showed that the mean visual acuity had improved from the baseline findings to 20/122. In this follow-up, approximately 31% had better visual acuity, while 8% had worse visual acuity. The 3-month follow-up of 141 eyes showed that 38.3% of patients had improved visual acuity while only 4.7% (n = 10) had worse vision.

During all of these treatments, no endophthalmitis, increased intraocular pressure, retinal tears or retinal detachment occurred in any patient. There was also a curiously low rate of intraocular inflammation. Patients previously treated with pegaptanib, PDT and other therapy had significant improvements in mean visual acuity and in mean central macular thickness at all three follow-ups. The patients previously treated with other therapy had the same change in visual acuity as those treated primarily with bevacizumab (P = .81 at 1 month, P = .72 at 2 months, P = .84 at 3 months.)

NEED FOR FURTHER STUDY

Most of the changes seen in this study were noted by the 1-month follow-up and continued throughout the study. Interestingly, it seems that there is no significant correlation between the change in macular thickness and a change in visual acuity.

The short-term results of this study are promising and show the need for further investigation. The relatively low cost of bevacizumab should be considered during this development — especially as a potential treatment in less-wealthy countries that are battling blindness.

Richard F. Spaide, MD, is in practice at the Vitreous-Retina-Macula Consultants of New York in New York City. He may be reached at Rickspaide@yahoo.com.

1. Spaide RF, Laud K, Fine HF, et al. Intravitreal bevacizumab treatment of choroidal neovascularization secondary to age-related macular degeneration. Retina. 2006; 26;383-390.
2. Spaide RF, Laud K, Fine H, et al. Inntravitreal bevacizumab treatment of choroidal neovascularization secondary to age-related macular degeneration. Presented at The Cannes Retina Festival 24th Annual Meeting. of the ASRS & 6th Annual Meeting of the EVRS. Sept. 9-13, 2006. Cannes, France.