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BRIEF COMMUNICATION
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 77-79

Intravitreal ranibizumab for postlaser anterior segment ischemia in retinopathy of prematurity


Radhatri Nethralaya, Chennai, Tamil Nadu, India

Date of Submission03-May-2021
Date of Decision10-Jun-2021
Date of Acceptance11-Jun-2021
Date of Web Publication18-Jul-2022

Correspondence Address:
Vasumathy Vedantham
Radhatri Nethralaya, 12, Hindi Prachar Sabha Street, T. Nagar, Chennai - 600 017, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_68_21

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  Abstract 


This case report documents the successful management of anterior segment ischemia, a very rare complication following laser in retinopathy of prematurity (ROP), by intravitreal injection of Ranibizumab, an anti-vascular endothelial growth factor agent. This is the first report as per MEDLINE search on the use and efficacy of bilateral intravitreal injection of Ranibizumab in anterior segment ischemia postlaser in ROP.

Keywords: Anterior segment ischemia, prematurity, ranibizumab, retinopathy, vascular endothelial growth factor


How to cite this article:
Vedantham V. Intravitreal ranibizumab for postlaser anterior segment ischemia in retinopathy of prematurity. J Clin Ophthalmol Res 2022;10:77-9

How to cite this URL:
Vedantham V. Intravitreal ranibizumab for postlaser anterior segment ischemia in retinopathy of prematurity. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 Aug 19];10:77-9. Available from: https://www.jcor.in/text.asp?2022/10/2/77/351296



This is a case report of successful management of a rare case of bilateral anterior segment ischemia postlaser in retinopathy of prematurity (ROP) with intravitreal injection of Ranibizumab (first report as per MEDLINE search).


  Case Report Top


A 760 g birth weight, 26 weeks gestational age baby was lasered for bilateral Zone II Stage 2 ROP with plus disease, at 34 weeks postconceptional age (PCA). The baby had a stormy neonatal course, punctuated by severe anemia, and had received 7 transfusions (3 fresh frozen plasma and 4 packed red cells). The baby was ventilated for the 1st week of life and received 8 l/min of oxygen which was gradually tapered, after weaning the baby off the ventilator over the next 2 weeks. The baby did not have prominent tunica vasculosa lentis (TVL) at the time of laser which was done in the neonatal intensive care unit (NICU) in a confluent manner with gray-white burns with diode-pumped double frequency Nd: YAG laser (Power: 90–110 Mw, 200 ms duration, 2005 and 2002 spots in the right and left eyes, respectively), administered by a laser indirect ophthalmoscope. Gentle scleral depression was employed along with a 20 diopter (D) condensing lens and the entire avascular retina from the ridge to the ora serrata was ablated in a single sitting. The procedure itself was uneventful and no corneal clouding, hyphema, or apneic episodes were encountered. Post laser the baby was put on tobramycin dexamethasone eye drops 6 times/day, in both eyes.

Review at 1 week post laser revealed bilateral white corneas, conjunctival edema and gross hypotony, hyphema, and neovascularization of the iris at the pupillary collarette with no view of the fundi [Figure 1]a and [Figure 1]b. A provisional diagnosis of anterior segment ischemia was made and the baby was put on the intensive hourly application of topical prednisolone eye drops, once a day application of homatropine eye drops and hypertonic saline eye drops four times daily, with nasolacrimal occlusion. Systemic steroids which are tried in adults with anterior segment ischemia were considered risky in the infant. A day later, the picture continued to be status quo [Figure 1]c and [Figure 1]d. The prospect of the anterior segment ischemia, worsening of ROP, and risk of bilateral phthisis was worrying. Based on previous reports mentioning the success of intravitreal bevacizumab, an anti-vascular endothelial growth factor (anti-VEGF) in anterior segment ischemia following laser in ROP, the parents were counseled regarding the same. [1],[2] Ranibizumab, an antibody fragment with less systemic half-life than bevacizumab was thought to be a safer option in the baby whose C-reactive protein levels continued to rise. Moreover, Ranibizumab had recently been approved for use in ROP after the RAINBOW trial.[3]
Figure 1: (a) Anterior segment photograph of the right eye 1 week after laser showing hazy cornea, conjunctival edema. (b) Anterior Segment photograph of the left eye 1 week after laser showing hazy cornea, conjunctival edema and hyphema (represented by the black arrow). (c) Anterior Segment photograph of the right eye 1 day after topical steroids showing hazy cornea, conjunctival edema, [status quo as in Figure 1a]. (d) Anterior Segment photograph of the left eye 1 day after topical steroids showing hazy cornea, conjunctival edema, [status quo as in Figure 1b].

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Bilateral intravitreal injections of 0.025 ml of Ranibizumab (Lucentis, Novartis Pharma AG, Basel, Switzerland, and Genentech, Inc, South San Francisco, and CA) were given in the NICU at 35 weeks PCA of the baby and there was striking improvement in corneal clarity from the next day which continued till day 18 after the injection when the corneas became crystal clear. As the corneal clarity improved, the hypotony resolved by day 4 following the injection with hyphema completely resolving in the right eye and retinal details clearer in the left eye [Figure 2]a and [Figure 2]b. One week following the injection, blobs of yellow-white exudate-like material were seen in front of the anterior lens capsule with early cataractous changes in the right eye [Figure 2]c, while the left eye fared better with retinal vessels seen up to the equator. The left eye had a sheet of persistent neovascularization iris (NVI), 11 days after the injection [Figure 2]d and well regressed ROP with laser marks; in the right eye still, there was no view of the retina, with only a faint red glow seen and cataractous lens. By the 18th day after injection, the NVI had completely regressed bilaterally. B scan right eye showed a well-attached retina [Figure 3] and the intraocular pressure as measured with Perkin's hand-held applanation tonometer, was 12 mmHg. The intensive topical steroids were gradually tapered and stopped by 40 days following the injection, wherein the corneas remained clear bilaterally with resolved hyphema and NVI and a total cataractous lens in the right eye [Figure 2]e and [Figure 2]f.
Figure 2: (a) Anterior segment photograph of the right eye 4 days after intravitreal injection of Ranibizumab showing resolved hyphema with improved corneal clarity. (b) Anterior Segment photograph of the left eye 4 days after intravitreal injection of Ranibizumab showing resolved hyphema with improved corneal clarity. (c) Anterior Segment photograph of the right eye 1 week after intravitreal injection of Ranibizumab showing blobs of yellow white exudate like material in front of the anterior lens capsule with early cataractous changes. (d) Anterior Segment photograph of the left eye 11 days after intravitreal injection of Ranibizumab showing sheet of persistent neovascularization of the iris (represented by the black arrow). (e) Anterior Segment photograph of the right eye 40 days after intravitreal injection of Ranibizumab showing total cataract, clear cornea, no hyphema and resolved neovascularization of the iris. (f) Anterior Segment photograph of the left eye 40 days after intravitreal injection of Ranibizumab showing clear cornea, no hyphema and resolved neovascularization of the iris

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Figure 3: B scan (superior transverse) of the right eye showing well attached retina

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The option of lensectomy in the right eye and dangers of amblyopia if unoperated and the risk of phthisis following lensectomy as per previous reports[4],[5],[6] was clearly discussed with the parents, who were not keen on the surgery and they were lost to follow-up after 4 months.


  Discussion Top


Anterior segment ischemia is a rare but severe complication following laser which is usually safe and the gold standard in the management of ROP. [7],[8],[9] It is the most likely diagnosis in this case as the corneas were clear at the end of laser with no iridocorneolenticular burns and no prominent TVL at the time of laser both of which could suggest thermal injury, and absorption of laser by the TVL leading to cataract,[10] respectively. The severe anemia in the baby could have compromised the anterior segment circulation further following the possible thermal injury by laser to the long posterior ciliary vessels leading to bilateral anterior segment ischemia. We suggest sparing of the horizontal meridians while doing laser to reduce the risk.


  Conclusion Top


The immediate resolution of hyphema and hypotony with Ranibizumab suggests the therapeutic efficacy of the anti-VEGF agent in this condition; however, more such cases need to be studied before generalization of this finding. This is the first report as per MEDLINE search on the use and efficacy of bilateral intravitreal injection of Ranibizumab in anterior segment ischemia postlaser in ROP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh SR, Katoch D, Handa S, Kaur S, Moharana B, Dogra M, et al. Safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser photocoagulation for treatment of retinopathy of prematurity. Ind J Ophthalmol 2019;67:860-5.  Back to cited text no. 1
    
2.
Shah PK, Narendran V, Tawansy KA, Raghuram A, Narendran K. Intravitreal bevacizumab (Avastin) for post laser anterior segment ischemia in aggressive posterior retinopathy of prematurity. Ind J Ophthalmol 2007;55:75-6.  Back to cited text no. 2
    
3.
Stahl A, Lepore D, Fielder A, Fleck B, Reynolds JD, Chiang MF, et al. Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): An open-label randomised controlled trial. Lancet 2019;394:1551-9.  Back to cited text no. 3
    
4.
Lambert SR, Capone A Jr., Cingle KA, Drack AV. Cataract and phthisis bulbi after laser photoablation for threshold retinopathy of prematurity. Am J Ophthalmol 2000;129:585-91.  Back to cited text no. 4
    
5.
Kaiser RS, Trese MT. Iris atrophy, cataracts, and hypotony following peripheral ablation for threshold retinopathy of prematurity. Arch Ophthalmol 2001;119:615-7.  Back to cited text no. 5
    
6.
Quan AV, Pineles SL, Tsui I, Velez FG. Phthisis bulbi after lensectomy in retinopathy of prematurity eyes previously treated with laser photocoagulation. Retin Cases Brief Rep 2015;9:67-71.  Back to cited text no. 6
    
7.
Trese MT. Retinopathy of Prematurity. In: Ryan SJ, editor. Retina. 4th ed. Philadelphia: Elsevier-Mosby; 2006. p. 2463-76.  Back to cited text no. 7
    
8.
Gaitan JR, Berrocal AM, Murray TG, Hess D, Johnson RA, Mavrofrides EC. Anterior segment ischemia following laser therapy for threshold retinopathy of prematurity. Retina 2008;28:S55-7.  Back to cited text no. 8
    
9.
Gunay M, Sekeroglu MA, Celik G, Gunay BO, Unlu C, Ovali F. Anterior segment ischemia following diode laser photocoagulation for aggressive posterior retinopathy of prematurity. Graefes Arch Clin Exp Ophthalmol 2015;253:845-8.  Back to cited text no. 9
    
10.
Christiansen SP, Bradford JD. Cataract in infants treated with argon laser photocoagulation for threshold retinopathy of prematurity. Am J Ophthalmol 1995;119:175-80.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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