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C. I. Bourne, W. Deegan; Evaluation of Central Retinal Artery Occlusion (CRAO) After Intravitreal Injection: Comparison of Pegaptanib, Bevacizumab, and Ranibizumab. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5564.
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To evaluate the incidence of CRAO after intravitreal injection (IVT) with pegaptanib, bevacizumab, and ranibizumab. Determine if co-morbities and social risk factors contributed to the occurrence of CRAO.
This retrospective chart review included 67 patients from a large retinal group over 12 months, June 2006 - May 2007. Patients received a total of 287 IVT. Diagnosis of CRAO was made by dilated fundus examination. All patients diagnosed with CRAO underwent immediate intraocular paracentesis.
Of the 67 patients, 41 were females and 26 were males. Age ranged from 35 to 102 years. Ranibzumab was given to 223 of 287 (77.7%), bevacizumab to 60 of 287 (20.9%), and pegaptanib to 4 of 287 (13.9%). Sixty three patients (94.3%) were receiving treatment for neovascular membranes (NVM) secondary to age related macular degeneration (AMD) and 4 patients (5.97%) for NVM secondary to presumed ocular histoplasmosis. Co-morbities of this cohort in included hypertension (HTN) (64.2%), cardiac arrthymia/disease (23.9%), diabetes mellitus (5.97%). Social and ocular history included 11.9% using tobacco, 47.76% with pseudophakia, and 7.46% with glaucoma. CRAO occurred in a total of 6 patients; one patient having reoccurrence of CRAO. Overall, incidence was 2.44%. All of the cases of CRAO occurred in the ranibzumab group, with incidence of 3.14%, equal distribution of gender, and mean age of 82.6 years. All of the ranibzumab group were receiving treatment for NVM secondary to AMD. The 6 patients with CRAO received a total of 31 injections, an average of 5.17 IVT per person in comparison with the overall cohort average of 4.28 injections per person. In the CRAO group, 2 of the 6 (33%) had pseudophakia and 1 of 6 (16.7%) had glaucoma. Five of the 6 patients (83.33%) had HTN, 4 of 6 (66.7%) reported cardiac arrthymia/disease, and 1 of 6 (33%) used tobacco. All had intraocular pressures <21 mmHg prior to IVT. All patients had recovery of vision to +/-1 line of visual acuity prior to IVT.
Patients treated with anti-VEGF IVT can develop ocular side-effects such as CRAO. It is prudent to treat visual symptoms immediately for preservation of visual function. To date, CRAO has not been listed as a major side effect of IVT anti-VEGF treatment. Our early results suggest that underlying vasculopathy may be a contributing factor. Further research should be conducted to aid ophthalmologists in identifying high-risk patients to better understand side effects of different anti-VEGF treatments.
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