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Show Peripapillary Choroidal Neovascular Membrane in a Teenage Boy: Presenting Feature of Idiopathic Intracranial Hypertension and Resolution With Intravitreal Bevacizumab Michel J. Belliveau, MD, Lin Xing, BSc, David R. P. Almeida, MD, PhD, MBA, Jeffrey S. Gale, MD, FRCSC, Martin W. ten Hove, MEng, MD, FRCSC FIG. 1. There is papilledema in the right (A) and left (B) eyes and a peripapillary choroidal neovascular membrane (arrow) with associated subretinal and intraretinal hemorrhage. Optical coherence tomography prior to treatment shows elevation and thickening of the retina and evidence of subretinal blood (C) extending under the fovea (D). On pretreatment fluorescein angiogram, there is leakage from the peripapillary choroidal neovascular membrane and optic disc in the late phases and blockage of choroidal fluorescence by hemorrhage (E). Department of Ophthalmology (MJB, DRPA, JSG, MWtH) and School of Medicine (LX), Queen's University, Kingston, Ontario, Canada. The authors have no financial, proprietary, or other conflicts of interest to disclose. Address correspondence to Martin ten Hove, MEng, MD, FRCSC, Hotel Dieu Hospital, Department of Ophthalmology, 166 Brock Street, Kingston, ON, Canada, K7L 5G2; E-mail: tenhove@queensu.ca 48 Belliveau et al: J Neuro-Ophthalmol 2013; 33: 48-50 Photo Essay Section Editor: Timothy J. McCulley, MD Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Abstract: Peripapillary choroidal neovascular membrane (ppCNVM) is an infrequent finding in patients with idiopathic intracranial hypertension (IIH). In the pediatric subgroup there is only a single previously reported case. We describe the use of intravitreal bevacizumab for ppCNVM in a teenage boy with IIH. Journal of Neuro-Ophthalmology 2013;33:48-50 doi: 10.1097/WNO.0b013e318281b7b9 © 2013 by North American Neuro-Ophthalmology Society A15-year-old boy with a body mass index of 41 kg/m2 reported a 2-day history of a "black spot" in the center of his right visual field. His visual acuity was 20/200, right eye, and 20/30, left eye. There was no relative afferent pupillary defect but color vision was reduced in the right eye. Ophthalmoscopy revealed bilateral papilledema and subretinal blood temporal to the right optic disc extending beneath the fovea (Fig. 1A-B). Optical coherence tomog-raphy (Fig. 1C-D) and fluorescein angiography (Fig 1E) confirmed the presence of a peripapillary choroidal neovas-cular membrane (ppCNVM). Computed tomography and magnetic resonance imaging of the brain and magnetic res-onance venography were unremarkable. Lumbar puncture opening pressure was 37 cm H2O and cerebrospinal fluid (CSF) composition was normal. Due to a possible sulfa compound allergy, acetazolamide was not prescribed. The patient was counseled on the importance of weight loss, and given an intravitreal injection of 1.25 mg/0.1 mL bevacizu-mab (Avastin; Genentech, South San Francisco, CA). Four weeks later, his vision was 20/40 in the right eye and the papilledema was unchanged. The patient was started on 250 mg of acetazolamide 4 times daily when the allergy history was scrutinized and deemed uncon-vincing. He received a second and third injection of bevacizumab at 4-week intervals with improvement in the appearance of the peripapillary retina (Fig 2A). A month after the third injection, his visual acuity remained 20/40 but fluorescein angiography revealed minimal leakage from the ppCNVM (Fig 2C). The patient was given 3 additional monthly injections of intravitreal bevacizumab and with 7 months of follow-up, the acuity is 20/40 in the right eye, with diminished papilledema and the ppCNVM is inactive. ppCNVM is an infrequent finding in patients with idiopathic intracranial hypertension (IIH), reported to occur in 0.5% of cases (1) and rare in the pediatric pop-ulation (2). There is limited evidence to guide management and proposed treatments include measures to lower intra-cranial pressure and targeted therapy including argon laser photocoagulation, photodynamic therapy, surgical excision, and intravitreal injection of anti-vascular endothelial growth factor (VEGF) compounds (1-4). In IIH, successful resolution of ppCNVM has been reported with lowering of intracranial pressure (2). How-ever, at presentation our patient had subfoveal hemorrhage that called for urgent treatment. The reported allergy to sulfa compounds initially limited our treatment options. We did not feel that a surgical CSF diversion procedure was warranted given the modest level of visual impairment directly attributable to the CNVM. Our patient tolerated FIG. 2. Following 3 injections of bevacizumab, there is regression of the peripapillary choroidal neovascular mem-brane and resorption of the subretinal fluid (A). Optical coherence tomography demonstrates a normal foveal con-tour (B). One month later, there is persistent hyper-fluorescence of the choroidal neovascular membrane and less leakage from the optic disc (C). Belliveau et al: J Neuro-Ophthalmol 2013; 33: 48-50 49 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. the intravitreal injections well with no local adverse reac-tions or known systemic complications although 6 injec-tions were required. This differs from the rapid regression of ppCNVM after a single injection of intravitreal bevaci-zumab in a 30-year-old woman reported by Jamerson et al. (4). Their patient received concomitant oral acetazolamide which may have contributed to the rapid improvement. Sisk et al. (5) have provided the most data on the use of intravitreal bevacizumab in pediatric retinal and choroidal disorders. They showed efficacy and safety in 24 eyes where the goal was reduction of excess retinal fluid and exudation. Five or more injections were used in 5 of the 24 eyes. No ocular or systemic adverse events were reported. Our case report supports the use of anti-VEGF agents for ppCNVM in pediatric patients with IIH. Since our patient was postpubescent, caution should be used in translating our observations to pre-pubescent patients with IIH where disease characteristics may differ. REFERENCES 1. Wendel L, Lee AG, Boldt HC, Kardon RH, Wall M. Subretinal neovascular membrane in idiopathic intracranial hypertension. Am J Ophthalmol. 2006; 141:573-574. 2. Kaeser P, Borruat F. Peripapillary neovascular membrane: a rare cause of acute vision loss in pediatric idiopathic intracranial hypertension. J AAPOS. 2011; 15:83-86. 3. Castellarin AA, Sugino IK, Nasir M, Zarbin MA. Clinicopathological correlation of an excised choroidal neovascular membrane in pseudotumor cerebri. Br J Ophthalmol. 1997; 81:994-1000. 4. Jamerson SC, Arunagiri G, Ellis BD, Leys MJ. Intravitreal bevacizumab for the treatment of choroidal neovascularization secondary to pseudotumor cerebri. Int Ophthalmol. 2009; 29:183-185. 5. Sisk RA, Berrocal AM, Albini TA, Murray TG. Bevacizumab for the treatment of pediatric retinal and choroidal diseases. Ophthalmic Surg Lasers Imaging. 2010; 41:582-592. 50 Belliveau et al: J Neuro-Ophthalmol 2013; 33: 48-50 Photo Essay Copyright © North American Neuro-Ophthalmology Society. 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