Anti-VEGF treatment helps diabetic patient

A 76-year-old white female presented for her periodic diabetic eye examination at UAB Eye Care in July 2014. She admitted to blurry vision in her left eye for approximately one week. Her significant medical history included diabetes of at least 15 years duration for which she was treated with Humalog (insulin lispro, Lilly), Lantus (insulin glargine, Sanofi), and metformin.

She quoted her most recent A1C as 8.2 percent. In addition, she was treated with hydrochlorothiazide for systemic hypertension of unknown duration. Blood pressure was not assessed at this visit. She has never smoked and was appropriately oriented with respect to time, place, person, mood, and affect. Body mass index (BMI) was greater than 30.

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Best-corrected visual acuity was 20/25 OD and 20/400 OS with minimal refractive correction. She was pseudophakic in each eye with a clear capsule in the right and S/P capsulotomy in the left. 

Presence of the pre-retinal hemorrhage is consistent with her history of diabetes despite the absence of apparent diabetic changes within the visible portion of the posterior pole. There is macular swelling, which accompanies the juxtapapillary pre-retinal hemorrhage. 

Anti-VEGF treatment

She had a consult with a retina specialist that day and was administered Avastin (bevacizumab, Genentech) via intravitreal injection and was scheduled for follow-up in one month. At the four-month follow-up visit, best-corrected visual acuity OS improved to 20/40, and the pre-retinal hemorrhage resolved almost completely (see Figure 2). Fortunately, she is free of other diabetic retinal complications. 

Among the lessons from this case are the significant disparity in visual acuity between the two eyes with apparently minimal patient awareness as well as the significant hemorrhagic response secondary to minimal attendant diabetic fundus changes. There was no evidence of proliferative retinopathy throughout either fundus.

With resolution of the hemorrhage and a brighter exposure, asteroid bodies become evident in the left eye. The family of anti-VEGF agents, of which Avastin is a member is intended to restore the integrity of the circulatory system.

Since the introduction of Lucentis (ranimizubab, Genentech) with FDA approval in June 2006 for the treatment of neovascular age-related macular degeneration (AMD), many additional applications have been reported. In the intervening years (2010 and 2012, respectively), the FDA granted approval for Lucentis to treat macular edema following retinal vein occlusion (central [CRVO] and branch [BRVO]) as well as diabetic macular edema.

The intermediate history of safety and efficacy of the anti-VEGF agents makes the future bright for this and other neovascular complications.