Myopic degeneration associated with subfoveal choroidal neovascularization (CNV) remains a blinding disease with limited treatment options (Figure 1). When left untreated, more than 95% of affected eyes will experience vision loss of 20/200 or worse.1

Photodynamic therapy (PDT) with verteporfin (Visudyne; Novartis, Basel Switzerland) initially offered some hope for treatment of myopic CNV. At 1 year, 72% of treated eyes versus 44% of placebo-treated eyes lost fewer than eight letters on Early Treatment for Diabetic Retinopathy Study (ETDRS) visual testing. Results at 2 years, however, were less promising, and showed no statistical significance between treated eyes and control groups.2

The introduction and growing popularity of off-label intravitreal bevacizumab use (Avastin; Genentech, San Francisco) as an inexpensive yet apparently effective treatment for CNV secondary to age-related macular degeneration (AMD),3,4 may prove beneficial against other forms of CNV.5

A retrospective review by Izumi Yamamoto, MD, and associates, initially published online in July 2006 in the British Journal of Ophthalmology, supports the short-term efficacy of intravitreal bevacizumab 1.25 mg in treating recent vision loss from myopic CNV.6 In that study, 11 eyes of nine patients were treated with intravitreal bevacizumab. Five eyes were previously treated using PDT with verteporfin, while the remaining six eyes received no prior treatments.

Initial visual acuity measured 20/50 to 20/100 in six eyes, and ≤20/200 in five eyes. A mean follow-up of 153 days showed that visual acuity improved a mean of 3.5 lines (Snellen); with final visual acuity ≥20/40 in seven eyes, 20/50 to 20/100 in one eye, and ≤20/200 in three eyes. Central foveal thickness measured on optical coherence tomography (OCT) was reduced an average of 103 µm. No injection or drug-related side effects were observed.

UPDATE FROM ORIGINAL COHORT
At Retina 2007 held in conjunction with the Hawaiian Eye meeting, our team further validated the initial published findings by Dr. Yamamoto, and presented updated results of the original cohort, which at that point included 15 eyes of 13 patients. Visual acuity improved a mean of 3.1 lines with 11 of 15 eyes achieving a visual acuity of ≥20/50 or better at 9.6 months follow-up. Central foveal thickness on OCT demonstrated an average reduction of 93 µm.

One eye received five injections, one eye received three injections, two eyes received two injections and 11 eyes received one injection. No injection or drug related complications were identified with the longer follow-up period.

The initial report by Dr. Yamamoto and associates, has been corroborated by two additional publications. Hideki Sakaguchi, MD, PhD, and colleagues, published the results of eight eyes treated with intravitreal bevacizumab for myopic CNV.7 Visual acuity improved two or more lines in six eyes and was unchanged in two eyes, with a mean follow-up of 4.4 months. Only three of eight eyes received two injections and the remaining five required one injection. Ketan Laud, MD, and colleagues, found a 1.5 line improvement on four eyes with myopic CNV treated with intravitreal bevacizumab, with a mean follow-up of 7.3 months.

SAFE, EFFECTIVE
The data from these three recently published articles lends credibility to the safety and efficacy of intravitreal bevacizumab in treating CNV not associated with AMD. Further studies are needed to validate the long-term efficacy of bevacizumab in treating myopic CNV. After all, the true test of any treatment is whether its benefit is still realized more than 1 to 2 years after the therapy is initiated.

Given these promising early results, however, intravitreal bevacizumab appears to be a cost effective treatment that shows potential in altering the devastating natural history of myopic CNV.

Elias Reichel, MD, is Vice Chair for Research and Education in the Department of Ophthalmology at the New England Eye Center, Boston. Dr. Reichel discloses that he is a consultant for Genentech. He can be reached at EReichel@tufts-nemc.org.

Adam H. Rogers, MD, is a vitreoretinal specialist at the New England Eye Center. Dr. Rogers discloses that he is also a consultant for Genentech. He can be reached at ARogers1@tufts-nemc.org.

1. Yoshida T, Ohno-Matsui K, Yasuzumi K, et al. Myopic choroidal neovascularization: a 10-year follow-up. Ophthalmology. 2003;110:1297-305.
2. Verteporfin in Photodynamic Therapy (VIP) Study Group. Verteporfin therapy of subfoveal choroidal neovascularization in pathologic myopia: 2-year results of a randomized clinical trial – VIP report no 3. Ophthalmology. 2003;110:667-73.20.
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5. Rosenfeld PJ. Intravitreal Avastin for choroidal neovascularisation in pathological myopia: the controversy continues. Br J Ophthalmol. 2007;91:128-130.
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7. Sakaguchi H, Ikuno Y, Gomi F, et al. Intravitreal injection of bevacizumab for choroidal neovascularisation associated with pathological myopia. Br J Ophthalmol. 2007;91:161-165.
8. Laud K, Spaide RF, Freund KB, et al. Treatment of choroidal neovascularization of pathologic myopia with intravitreal bevacizumab. Retina. 2006;26:960-963.