Another Proliferative Diabetic Retinopathy? A Case Report of Retinal Cavernous Haemangioma Treated with Intravitreal Bevacizumab, Initially Labelled as Persistent Proliferative Diabetic Retinopathy

doi:10.4236/ojoph.2012.21002

Paper Menu >>

Journal Menu >>

Open Journal of Ophthalmology, 2012, 2, 5-7

http://dx.doi.org/10.4236/ojoph.2012.21002 Published Online February 2012 (http://www.SciRP.org/journal/ojoph) 5

Another Proliferative Diabetic Retinopathy? A Case

Report of Retinal Cavernous Haemangioma Treated

with Intravitreal Bevacizumab, Initially Labelled as

Persistent Proliferative Diabetic Retinopathy

Myrto Tsagkataki1*, Ahmad Khalil1, Ahmed Kamal1

1Ophthalmology Department, Aintree University Hospitals, Liverpool, United Kingdom.

Email: *[email protected]

Received November 19th, 2011; revised December 24th, 2011; accepted January 25th, 2012.

ABSTRACT

We present a case of Retinal Cavernous Haemangioma treated with Intravitreal Bevacizumab, which was initially la-

belled as persistent proliferative diabetic retinopathy with multiple episodes of v itreous haemorrhage. These lesions can

be confused with new retinal vessels in diabetics and if correctly diagnosed unnecessary photocoagulation can be

avoided. Our patient received a course of three intravitreal Bevacizumab injections (1.25 mg/0.05 ml) in order to stop

the leakage from the retinal cavernous haemangioma lesions and prevent another episode of vitreous haemorrhage. No

intraoperative or postoperative complications were seen. Twenty-two months following treatment there was no recur-

rence of vitreous haemorrhage.

Keywords: Retinal Cavernous Haemangioma; Intravitreal Bevacizumab; Persistent Proliferative Diabetic Retinopathy;

Vitreous Haemorrhage

1. Introduction

We would like to report a case of Retinal Cavernous

Haemangioma treated with Intravitreal Bevacizumab,

which was initially diagnosed as persistent proliferative

diabetic retinopathy with multiple episodes of vitreous

haemorrhage.

2. Case

A 59 year-old insulin dependent diabetic male was re-

ferred from another ophthalmic unit with a diagnosis of

persistent retinal neovascularisation in the left eye, de-

spite repeat sessions of laser photocoagulation. He had a

history of multiple mild to moderate self-limiting vitre-

ous haemorrhages in the past which settled without any

surgical intervention. Previous medical history apart

from diabetes mellitus was insignificant. On examination

Best-Corrected Visual Acuity (BCVA) was logMAR

0.00 OD and 0.18 OS. Anterior segment examination

was unremarkable. Fundus exa mination showed a cluster

of abnormal vessels in the juxtapapillary region of the

temporal retina (Figure 1(a)). Fluorescein Angiography

(FFA) showed saccular lesions with slow filling in the

early phase and late hyperfluorescence with typical fluid

levels within the saccules (Figure 1(b)).Optical Coher-

ence Tomography (OCT) showed a bunch of “gr a pe-l i ke” ,

nodular retinal lesions proliferating to the posterior hya-

loid space (Figure 1(c)). The working diagnosis was

Retinal Cavernous Haemangioma. MRI brain and orbit

was then performed which didn’t show any abnormalities.

A decision was made to treat the patient with a view to

shrink these lesions and prevent a recurrence of vitreous

haemorrhage. The patient received monthly intravitreal

injections of Bevacizumab (1.25 mg/0.05 ml) for three

months. At the last follow up, 22 months following treat-

ment, BCVA remained logMAR 0.18 OS. The lesions

showed demonstrable decrease in dimensions and no

leakage on FFA (Figures 2). During that period the pa-

tient develop no further episodes of vitreous haemor-

rhage.

3. Discussion

Cavernous haemangiomas of the retina are believed to be

rare congenital vascular hamartomas and may present

commonly as an incidental finding or rarely as a cause of

vitreous haemorrhage [1]. Histologically, these vascular

alformations have normal endothelial cells and support- m

*Corresponding a uthor.

Another Proliferative Diabetic Retinopathy? A Case Report of Retinal Cavernous Haemangioma Treated with

Intravitreal Bevacizumab, Initially Labelled as Persistent Proliferative Diabetic Retinopathy

(a) (b) (c)

Figure 1. (a) Colour photo of left fundus showing “grape like” lesions temporal to the optic disc (arrows); (b) Fluorescein

Angiogram in midphase showing leakage and hyperfluorescent menisci of the juxtapapillary lesions (arrows); (c) OCT

showing retinal nodular lesions proliferating to the posterior hyaloid space (arrow).

(a) (b) (c)

Figure 2. Twenty two months following treatment (a) Colour photo showing decrease in number and size of lesions (arrow);

(b) Fluorescein Angiogram showing no leakage; (c) OCT showing no vascular proliferation to the posterior hyaloid space and

significant shrinkage of lesions (arrow).

ing fibrous septa and therefore have less likelihood of

leakage but may occasionally rupture and cause vitre-

ous haemorrhage. They are often sporadic but familial

bilateral cases have been reported [2]. In some patients,

these tumours have been observed to co exist with intrac-

ranial cavernous haemangioma and angiomatous skin

lesions [3,4]. It has been reported that 5% of the patients

diagnosed with cerebral haemangioma have associated

retinal cavernous haemangiomas [2]. Therefore the oph-

thalmologist plays a critical role in accurate and early

diagnosis. Ophthalmoscopically, retinal cavernous hae-

mangioma appears as a group of blood-filled saccules

within the inner retinal layers. Relevant diagnostic tests

include Fluorescein angiography and Optical coherence

tomography (OCT). Patients may be asymptomatic in

which case no treatment is necessary. However visual

acuity can deteriorate due to accompanying epiretinal

membrane or vitreous haemorrhage where vitrectomy

may be needed [1]. In our patient the decision to treat the

lesions with intravitreal Bevacizumab was taken in view

of the risk of recurrent vitreous haemorrhage, as they

were leaking on FFA. Following the treatment, the size

and number of the retinal lesions reduced and the leakage

disappeared with no recurrence of vitreous haemorrhage

at last follow up.

4. Conclusion

In conclusion, we would like to stress the significance of

identification of these lesions, which can be confused,

with new vessels of diabetic retinopathy and lead to un-

necessary photocoagulation. Furthermore, to the best of

our knowledge this is the first case report where in-

travitreal Bevacizumab has been used for the treatment

of retinal cavernous haemangioma.

REFERENCES

[1] E. Pringle, S. Chen, A. Rubinstein, C. K. Patel and S. Dow-

Another Proliferative Diabetic Retinopathy? A Case Report of Retinal Cavernous Haemangioma Treated with

Intravitreal Bevacizumab, Initially Labelled as Persistent Proliferative Diabetic Retinopathy 7

nes, “Optical Coherence Tomography in Retinal Cavern-

ous Haemangioma may Explain the Mechanism of Vitre-

ous Haemorrhage,” Eye, Vol. 23, 2009, pp. 1242- 1243.

doi:10.1038/eye.2008.156

[2] P. Labauge, V. Krivosic, C. Denier, E. Tounier-Lasserve

and A. Gaudric, “Frequency of Retinal Cavernomas in 60

Patients with Familial Cerebral Cavernomas: A Clinical

and Genetic Study,” Archives of Ophthalmology, Vol.

124, No. 6, 2006, pp. 885-886.

doi:10.1001/archopht.124.6.885

[3] H. Heimann and B. Damato, “Congenital Vascular Mal-

formations of the Retina and Choroid,” Eye, Vol. 24, No.

3, 2010, pp. 459-467. doi:10.1038/eye.2009.310

[4] A. D. Singh, P. A. Rundle and I. Rennie, “Retinal Vascu-

lar Tumors,” Ophthalmology Clinics of North America, Vol.

18, No. 1, 2005, pp. 167-176.

doi:10.1016/j.ohc.2004.07.005