A 65-year-old woman was referred to the retina clinic of tertiary referral center with decreased vision of 3 days duration in her right eye. She had no remarkable past medical or family history. Her best corrected visual acuity was 0.15 in the right eye and 1.0 in the left. IOP was 19 mmHg in both eyes. There was no afferent pupillary defect of right or left pupils. On slit-lamp examination, sclera and conjunctiva showed no injection, and there was no corneal edema in either eye. AC was relatively shallow (3 corneal thicknesses centrally, 1/4 corneal thicknesses peripherally) in both eyes, and no inflammation was observed in either eye. Lenses showed mild nuclear cataract in both eyes. A gonioscopy exam demonstrated a narrow angle of over 180° in both eyes. The refractive error was +1.00 diopter sphere in each eye. Dilated fundus exam revealed extensive flame-shaped hemorrhage along the superotemporal vein and macular edema in the right eye (Fig. 1). The optic nerve head appeared normal with no evidence of glaucomatous excavation and a cup-to-disc ratio of 0.5 in both eyes. The remaining fundus examination was unremarkable in the left eye.
Optical coherence tomography (OCT) depicted intraretinal multiple cystic spaces and subretinal fluid (SRF) around fovea in the right eye (Fig. 1). Central retinal thickness (CRT) was 677 μm in the right eye. Fluorescein angiography of the right eye revealed a delayed filling time of the involved superior retinal vein.
Intravitreal bevacizumab (1.25 mg/0.05 mL) was injected into the right eye using a 30 gauge needle. The injection site was pressed for 10 s with a cotton-tipped applicator to prevent bevacizumab reflux. One month after this injection, the cystoid macular edema had almost regressed and CRT was 256 μm. Visual acuity of the right eye had increased to 0.5. To resolve the remaining edema and SRF, second intravitreal bevacizumab injection was administered to the right eye, and 1 month after this second injection, macular edema and SRF had regressed, CRT was 236 μm, and visual acuity was 0.6.
Five months after the second bevacizumab injection, macular edema recurred and OCT showed intraretinal multiple cystic spaces with a CRT of 479 μm. Visual acuity was 0.5 in right eye. We immediately injected an intravitreal bevacizumab a third time into the right eye. All injections were performed by one retinal specialist using the same method. After injetion, notable complications were not observed, and the patient did not complain any symptoms at that time. Gross visual acuity was routinely checked after injection and she was able to count fingers.
The next day, the patient presented to our emergency department complaining of persistent ocular pain. The patient now mentioned that this pain had started after the intravitreal injection. She also complained of headache, nausea, and vomiting. At this presentation, visual acuity was 0.08 in the right eye and 0.9 in the left. The left pupil was normal but the right pupil was fixed and mid-dilated (6 mm). A slit-lamp exam revealed diffuse epithelial edema of cornea in the right eye. AC depth was similar to that observed at her first visit (3 corneal thicknesses centrally, 1/4 corneal thicknesses peripherally) in both eyes (Fig. 2). IOP was 56 mmHg in the right eye and 15 mmHg in the left. A diagnosis of acute angle-closure glaucoma was made and she was immediately treated with 300 ml of 20% mannitol intravenously. One hour after mannitolization, IOPs in right and left eyes were 14 and 16 mmHg, respectively, and epithelial edema of the right eye had decreased. Finally, a glaucoma specialist performed laser iridotomy (LI) to the right eye. After 3 days, prophylactic LI to the left eye was performed to prevent the potential risk of AAC.
One month after LI, IOPs in right and left eyes were 13 and 15 mmHg, respectively, and iridotomy sites were patent in both eyes. Visual acuity was 0.7 in the right eye and 1.0 in the left. Automated visual field testing was performed using the Humphrey 750i (Carl Zeiss Meditec, Dublin, California, USA) with the 24–2 Swedish interactive threshold algorithm (SITA) standard program and no glaucomatous visual field defect was evident in either eye. On dilated fundus examination, the optic nerve showed no glaucomatous change in either eye. Previous macular edema and flame-shaped hemorrhage had almost disappeared in the right eye, and OCT revealed normal peripapillary retinal nerve fiber layer thickness in both eyes and no macular edema in the right eye. Ocular biometry was performed using IOL master (Carl Zeiss Meditec, Dublin, California, USA). In right and left eyes, AC depths were 2.42 and 2.12 mm, respectively, and axial lengths were 22.64 and 22.50 mm, respectively.