January - February 2011 Letters to Editor 73

Correspondence to: Dr. Vishal Sharma, 308 SRD Hostel, UCMS & GTB Hospital, Delhi, India. E-mail: [email protected]

References 1. Murthy SR, Prabhakaran VC. Phrynoderma and night blindness. Indian J Ophthalmol 2010;58:175-6. 2. Di Stefani A, Orlandi A, Chimenti S, Bianchi L. Phrynoderma: A cutaneous sign of an inadequate diet. CMAJ 2007;177:855-6.

DOI: 10.4103/0301-4738.73704 PMID: 21157085

Visual acuity and Figure 1: Hperpigmented knuckles findings 3 ½ years after the first intravitreal injection of bevacizumab (Avastin) in aggressive posterior retinopathy of prematurity

Dear Editor, We reported the first case of intravitreal injection of bevacizumab (Avastin, Genentech, San Francisco, CA, USA) in aggressive posterior retinopathy of prematurity (APROP) in 2007.[1] Now we report visual acuity and electroretinography (ERG) findings of the same case, 3 ½ years after the initial injection. A male born at 31 weeks of gestation and having a birth weight of 1170 g was diagnosed to have APROP. Immediate laser was done with almost 3,000 spots in each . One week after laser, both developed anterior segment ischemia which was more severe in the left eye (LE). After taking an Figure 2: Toad-like skin over trunk informed consent from the parents 0.03 ml bevacizumab (0.75 mg) was given intravitreally in LE. Right eye (RE) was managed conservatively. The features of anterior segment 279–996 pg/mL). Folate levels were also reduced to 2 ng/mL ischemia disappeared dramatically in LE after a single injection (normal range: 5.4–18.0 ng/mL). Bone marrow examination was of bevacizumab, and at 10-month follow-up, fundus of both consistent with the diagnosis of megaloblastic anemia. Liver eyes showed regressed retinopathy of prematurity (ROP) functions revealed slightly elevated serum bilirubin (3.2 mg/dL) with peripheral laser scars [Fig. 1]. Both eyes also developed with normal enzymes and serum albumin. The patient was put lamellar cataracts which was more in LE.[1] The cataract in LE on replacement with cobalamin, folic acid and vitamin A. The progressed further and retinoscopy increased to −21 diopters anemia and the skin lesions resolved over 6 months of follow-up. (D) in both the axes. The RE retinoscopy was −1.5 D. The axial We present this case for two reasons. First, the case length was 21.2 mm in LE and 18.7 mm in RE. demonstrates coexistence of phrynoderma and decreased with primary posterior , anterior , and nocturnal vision. Also, the coexistence of features of vitamin posterior chamber intraocular lens implantation was done in A, folate and B12 deficiency existed in this case. It is important LE. One month postsurgery his visual acuity was 20/180 in because of coexistence of both water and fat soluble vitamin RE and 20/360 in LE on Teller’s acuity chart. He was advised deficiency. It may be noted that current belief is that multiple occlusion of RE for 6 h/day for 4 months. At 3 ½ year follow-up, [2] nutrient deficiencies coexist to result in phrynoderma. It best corrected visual acuity was 20/30 in RE and only 20/500 in is therefore of importance that patients with phrynoderma LE on Snellen acuity chart. There was no development delay be evaluated not just for vitamin A deficiency but also for seen in this child, and clinically the central nervous system, deficiency of vitamins B, C and E. pulmonary, gastrointestinal, and renal systems were normal. Electro retinography (ERG) was done under general anesthesia. Vishal Sharma, Mukul P Agarwal, Subhash Giri It showed subnormal and nearly extinguished B-wave in Department of Medicine, University College of Medical Sciences both eyes indicating extensive damage to rods and bipolar (University of Delhi) & GTB Hospital, Delhi, India cells. The oscillatory potential response was present in both 74 Indian Journal of Vol. 59 No. 1

Figure 1: Retcam pictures showing regressed retinopathy of prematurity (ROP) in both eyes with peripheral laser scars extending till zone 1. Bevacizumab was given in left eye

the visual acuity was poor, compared to the other eye. This poor visual acuity could be a side effect of bevacizumab or may be due to amblyopia. Our report suggests that intravitreal bevacizumab does not have an adverse effect on the ERG but could have on the final visual acuity. Thus, we urge caution in using it in premature babies till formal controlled studies with long-term follow-up are conducted to determine its potential safety in ROP.

Parag K Shah, Rodney J Morris, V Narendran, Kalpana N Department of Pediatric and Ocular Oncology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore – 641 014, Tamilnadu, India Correspondence to: Dr. Parag K. Shah, Department of Pediatric Retina and Ocular Oncology, Aravind Eye Hospital, Avinashi Road, Coimbatore- 641 014, Tamil Nadu, India. Figure 2: Ganzfeld session summary of both eyes showing symmetrical E-mail: [email protected] subnormal electroretinography (ERG) waves References eyes, indicating near-normal vascularity. The cone response 1. Shah PK, Narendran V, Tawansy KA, Raghuram A, Narendran K. was noted as better than the rod response as indicated by Intravitreal bevacizumab (Avastin) for post laser anterior segment the subnormal flicker ERG cone response. All the responses, ischemia in aggressive posterior retinopathy of prematurity. Ind although poor, were symmetrical in both eyes [Fig. 2]. J Ophthalmol 2007;55:75-6. 2. Fulton AB, Hansen RM, Petersen RA, Vanderveen DK. The rod ERG changes are seen in ROP irrespective of laser treatment. photoreceptors in retinopathy of prematurity. Arch Ophthalmol Postlaser treatment, both rods[2] and cones get affected, 2001;119:499-505. although rods are affected more than cones.[3] More severe the 3. Fulton AB, Hansen RM, Moskowitz. The cone electroretinogram ROP, more involved are the photoreceptors.[3] Since our case in retinopathy of prematurity. Invest Ophthalmol Vis Sci had a severe form of APROP and extensively lasered, the ERG 2008;49:814-9. was expected to be subnormal. Although bevacizumab was given in LE, the ERG waves were comparable to RE. However DOI: 10.4103/0301-4738.73707 PMID: 21157086 Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.