To report a case of branch retinal vein occlusion (BRVO) in which rapid formation of macular pucker was observed after an intravitreal ranibizumab (IVR) injection.
A 66-year-old patient was referred to our department for the treatment of macular edema (ME) secondary to BRVO in the left eye. On the initial visit, widespread retinal hemorrhage was observed around the superior temporal vascular arcade, and the decimal best-corrected visual acuity (BCVA) was 0.7 (Snellen equivalent 20/29) in the left eye. Optical coherence tomography demonstrated a thin epiretinal membrane (ERM) accompanied by diffuse retinal thickening. A 0.5 mg IVR injection was administered for the treatment of ME and prompt resolution of retinal hemorrhage. Fourteen days after IVR administration, the ERM had progressed remarkably into a macular pucker and had spread from the superior macula to the equator, accompanied by partial tractional retinal detachment. We performed pars plana vitrectomy combined with encircling scleral buckling. Three months after the surgery, the decimal BCVA was 0.4 (Snellen equivalent 20/50), the retina was attached, and no recurrence of ME or proliferation was observed.
Conclusions and Importance
IVR for BRVO may cause rapid formation of macular pucker in the eye, especially in the presence of pre-existing ERM. Careful observation of patients with BRVO is essential after administration of anti-VEGF agents, especially in eyes with pre-existing ERM.
Retinal vein occlusion (RVO) is a retinal vascular disease that can be classified into central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). In both diseases, elevated levels of intraocular vascular endothelial growth factor (VEGF) are known to contribute to macular edema (ME), which is the main cause for reduced vision. In a clinical trial of ranibizumab (Lucentis, Genentech, Inc., South San Francisco, CA) for treating ME following CRVO, the aforementioned anti-VEGF agent not only reduced ME and improved visual acuity, but also led to early resolution of retinal hemorrhages. However, a variety of side effects of intravitreal anti-VEGF agents have been reported. Herein, we report a case of BRVO treated with an intravitreal ranibizumab (IVR) injection, followed by a rapid formation of macular pucker and tractional retinal detachment (TRD).
A 66-year-old man was referred to the University of the Ryukyus Hospital for treatment of ME secondary to BRVO in the left eye. He had systemic hypertension, for which he was being treated with oral hypertensive medication. The decimal best-corrected visual acuity (BCVA) was 0.9 (Snellen equivalent 20/22) in the right eye and 0.7 (Snellen equivalent 20/29) in the left eye. Slit-lamp examination revealed bilateral mild cataract; otherwise, his anterior segment was normal. Widespread retinal hemorrhage was seen around the superior temporal vascular arcade ( Fig. 1 ). On optical coherence tomography (OCT), a thin epiretinal membrane (ERM) was observed extending superiorly from the fovea and accompanied with diffuse retinal thickening. Based on these findings, we diagnosed the patient as BRVO with ERM.
Accordingly, 0.5mg IVR injection was administered for the treatment of ME and prompt resolution of retinal hemorrhage. Fourteen days after IVR administration, the patient returned to our hospital with symptoms of sudden vision deterioration in the left eye. By then, the retinal hemorrhage had decreased; however, the ERM had progressed remarkably into a macular pucker, causing severe retinal folds ( Fig. 2 ). The decimal BCVA had also decreased to 0.2 (Snellen equivalent 20/100). The macular pucker had spread from the superior macula towards the equator, accompanied by partial TRD. OCT showed a thick proliferative membrane on the retina, causing prominent retinal folds and traction.