OSLI Retina

February 2017

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■ C A S E R E P O R T ■ February 2017 · Vol. 48, No. 2 167 Significant Bilateral Response in Diabetic Macular Edema After Single Unilateral Intravitreal Aflibercept Injection Ehsan Rahimy, MD; Omondi Nyong'o, MD; Theodore Leng, MD ABSTRACT: A 61-year-old patient with bilateral, treatment-naïve, diffuse diabetic macular edema (DME) that had been progressing during the previ- ous 12 months received a single intravitreal injec- tion of aflibercept (Eylea; Regeneron, Tarrytown, NY) to the left eye. At 2-week follow-up, noticeable bilateral improvement of the DME was observed by spectral-domain optical coherence tomography im- aging with commensurate improvement of visual acuity to 20/30 bilaterally. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:167-169.] INTRODUCTION Intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors are known to result in systemic distribution of medication, which may im- pact circulating VEGF levels. 1,2 Previous reports have observed a treatment effect in the fellow untreated eye of patients after receiving anti-VEGF therapy for retinovascular disease. 3,4 Most of this literature sur- rounds the use of bevacizumab (Avastin; Genentech, South San Francisco, CA) and ranibizumab (Lucen- tis; Genentech, South San Francisco, CA); however, to date, there are limited data regarding the fellow eye effects after aflibercept (Eylea; Regeneron, Tarrytown, NY) therapy. 3-5 Here, we report a case of dramatic im- provement of diabetic macular edema (DME) in both the treated and untreated fellow eye after a single in- travitreal aflibercept injection. CASE REPORT A 61-year-old female with bilateral treatment-naïve diffuse DME and associated severe nonproliferative diabetic retinopathy (hemoglobin A1c persistently > 11%) had repeatedly refused therapeutic interven- tion during 1 year of follow-up (Figure 1). After ex- periencing a progressive decline in vision to 20/80 in both eyes, she consented to a trial of intravitreal anti- VEGF therapy starting with only her left eye. The pre- injection central retinal thickness (CRT) was 599 µm and 721 µm in the right and left eyes, respectively. Two weeks after the initial aflibercept injection in her left eye, a marked bilateral reduction of DME was measured (CRT right eye: 395 µm; CRT left eye: 341 µm) with associated visual improvement to 20/30 bi- laterally (Figure 2). Notably, the patient did not start any new medications or undergo any modification to her diabetes regimen during this period. Additional- ly, her blood pressure remained relatively unchanged during this 1-year interval (mean systolic pressure: 143.9 mm Hg ± 15.2 mm Hg, diastolic pressure: 77.9 mm Hg ± 15.2 mm Hg over nine recorded visits to her primary care physician). DISCUSSION The mechanism of contralateral response after in- travitreal anti-VEGF therapy remains controversial. Hypothetically, such an effect is secondary to escape of medication into the systemic circulation. Condi- tions where significant breakdown of the blood-ret- inal barrier is present, such as diabetic retinopathy, From the Department of Ophthalmology, Palo Alto Medical Foundation, Palo Alto, CA (ER, ON); and Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA (TL). Originally submitted August 3, 2016. Revision received August 3, 2016. Ac- cepted for publication November 2, 2016. The authors report no relevant financial disclosures. Address correspondence to Ehsan Rahimy, MD, Department of Ophthal- mology, Palo Alto Medical Foundation, 795 El Camino, Real Palo Alto, CA 94301; email: erahimy@gmail.com. doi: 10.3928/23258160-20170130-11

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