Small Case Series: Bevacizumab Did Not Improve Acuity in Behçet's-Related Macular Edema

Behçet’s disease (BD) is a form of vasculitis that affects multiple systems. Its cause is unknown. Ocular disease is typically noted in the first few years after a BD diagnosis. Cystoid macular edema (CME) in BD results in a visual acuity of < 20/60 and leads to permanent or persistent visual loss in 42% of BD patients.

Because vascular endothelial growth factor (VEGF) induces the formation of new blood vessels, experts have assumed this factor is involved in the pathophysiology of BD. Moreover, anti-VEGF agents have improved visual acuity and decreased CME in uveitic eyes. However, until recently, only a single published study had evaluated the use of intravitreal anti-VEGF agents for CME in BD patients.

To explore the effectiveness of intravitreal bevacizumab (IVB, Avastin/Roche) for ME secondary to BD, Fariba Ghassemi, MD, and colleagues from the Farabi Eye Hospital at Tehran University of Medical Sciences (UMS) or from Shahid Beheshti UMS in Tehran, Iran, recently completed a nonrandomized, prospective case series. The series included 15 consecutive patients with bilateral ME from BD who were referred to the Retina Service of Farabi Eye Hospital between January, 2010, and May, 2013.

The mean age of the study patients was 30.6 ± 7.4 years, and 13 were men. Their mean duration of uveitis was 5.1 ± 2.4 years, and ME was present for a mean of 1.1 ± 0.3 years. All study eyes were panuveitic according to Standardization of Uveitis Nomenclature criteria, and none had been treated with intravitreal injections of anti-VEGF agents or corticosteroids previously. All patients received a systemic corticosteroid at a dosage of 0.5 mg/kg/day, adjusted as needed, plus immunosuppressants or immune modulators if needed.

In this series, the investigators injected bevacizumab, 1.25 μg/0.05 mL, into the more severely affected eye of each patient and allowed the less affected contralateral eye to serve as the control. They found no baseline differences in vision, foveal thickness, or cystic changes between the case group and the control group.

Patients were treated with IVB for 6 months as needed, and a single ophthalmologist followed up each patient for at least 6 months. Follow-up consisted of a monthly comprehensive ocular examination and optical coherence tomography (OCT) and quarterly fluorescein angiography. IVB was repeated if central macular thickness (CMT) was >300 μm on the OCT image of the previously injected eye.

Patients received a mean of 3.3 injections of IVB during the study. For the case group, mean vision was 0.6 ± 0.3 LogMAR before injection and 0.50 ± 0.30 LogMAR at study end. This change was not statistically significant (P = 0.85).

During the study, improvement in visual acuity was greater in the case group who received IVB than in the control group who did not. Nevertheless, after adjustment for age, sex, and number of injections, no significant difference in vision was found between the case group and the control group at 6 months (P = 0.74).

Moreover, after similar adjustment, CMT in the case group did not significantly differ from that in the control group at 6 months (P = 0.63). Also, in the case group, mean CMT did not change significantly from baseline to study end: Mean CMT was 375.3 ± 132.1 μm before injection and 401.0 ± 199.9 μm after 6 months (P = 0.65). Although in the case group a statistically nonsignificant improvement in ME occurred during the first 3 months, this improvement did not persist at month 6.

However, eyes that received IVB had significantly more decreases in the thickness of the superior foveal ETDRS subfields on OCT images (P = 0.04 for the perifoveal and P = 0.01 for the parafoveal area). Moreover, a significant reduction in disc leakage was noted on the fluorescein angiograms of the treated eyes (P = 0.058).

In addition, IVB reduced the size of macular cysts as well as vascular leakage in the optic nerve head. The investigators attributed these results to the treatment’s anti-inflammatory effect.

The investigators concluded, “IVB provided a nonsignificant increase in visual acuity and an improvement in macular thickness that was not consistent during the 6-month follow-up period.” However, their positive but nonsignificant findings regarding vision and CMT led them to recommend larger studies that evaluate different doses, types, and frequencies of anti-VEGF agents and that include a longer follow-up period.

A report on the study, “Characteristics of macular edema in Behcet disease after intravitreal bevacizumab injection,” appears in the January-March, 2017, issue of the Journal of Ophthalmic and Vision Research.

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