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First Author: C.Utine TURKEY
Co Author(s): M. Altunsoy F. Ciftci
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Presentation of a case with corneal neovascularisation secondary to vernal keratoconjunctivitis that was managed with subconjunctival anti-vascular endothelial growth factor (anti-VEGF) injections
Yeditepe University, Department of Ophthalmology, Istanbul, Turkey
A 21 years old male patient was admitted to our hospital with the complaint of decreased vision and redness in the left eye. He had been treated with topical steroid and cyclosporine A drops since his childhood with the diagnosis of vernal keratoconjunctivitis. He was on chronic topical steroid therapy, absence of which significantly increased ocular hyperemia and discomfort according to his own statements. However, he suffered from reluctant red eyes and loss of vision mainly in the left eye during the last few months. His examination revealed best corrected visual aucity of 0.8 in the right eye with +1.00D. Left eye had an uncorrected visual acuity of 0.5 and vision did not improve with refractive correction. Biomicroscopic examination revealed chronic inflammatory conjunctival changes including tarsal subconjunctival fibrosis and some follicular reaction at the fornices. No symblaphora or fornix fore-shortening were observed. The eyelids, eyelashes and meibomian gland orifices were also normal. In the right eye the cornea was clear with only some ghost vessels at the limbal area inferiorly. Left eye had vascularised corneal leucoma that approached the optical axis from the inferior and nasal quadrants. Subconjunctival bevacizumab injection was planned for the left eye.
After a total of 3 subconjunctival injections of 12.5 mg (0.5 ml) of 400 mg/16 ml bevacizumab solution (Altuzan, Genentech, Roche) each one month apart, corneal neovascularisation in the left eye decreased significantly, along with a considerable decrease in intrastromal exudation and opacity. The remaining vessels were essentially ghost vessels. Patient experienced a relief of symptoms of the disease. The visual acuity remained the same but we could perform a refractive correction of +2.25(-3.00@160) that improved visual quality as stated by the patient. Patient remained on artificial tear eye drops only, between the subsequent injections. In the first week of March 2013, patient returned with an increase in redness of both eyes. Biomicroscopic examination revealed almost stable cornea findings with gradually decreasing corneal opacity but a minor increase in the diameters of the corneal ghost vessels in the left eye and seasonal flare-up of conjunctival inflammatory findings with diffuse conjunctival hyperemia in both eyes. Patient was put on fluoromethalone 0.1% eye drop bid OU (Efemoline, Thea Pharma) and bevacizumab eye drop bid OS (10 mg/ml, prepared from Altuzan, Genentech, Roche) for 2 weeks and the inflammatory attack was controlled.
Subconjunctival anti-VEGF injection is a recently popularized treatment modality for the regression of corneal neovascularization due to different underlying diseases. Even though there is an inflammatory process in vernal keratoconjunctivitis, subconjunctival anti-VEGF injection should be considered as a valid option for corneal neovascularization threatening the optical axis and vision. This treatment not only decreases corneal vessel ingrowth and protects corneal clarity, but also can potentialy spare the patients from chronic steroid use and its associated adverse effects.