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Anterior Segment Ischemia with Rubeosis Iridis After A ANTERIOR SEGMENT ISCHEMIA WITH RUBEOSIS IRIDIS AFTER A CIRCULAR BUCKLING OPERATION TREATED SUCCESSFULLY WITH AN INTRAVITREAL BEVACIZUMAB INJECTION: A CASE REPORT AND REVIEW OF THE LITERATURE JANSSENS K, ZEYEN T, VAN CALSTER J ABSTRACT ly detection of rubeosis iridis. This report demon- strates the rapid resolution of rubeosis iridis on iris Purpose: To report a case of anterior segment ischemia fluorescein angiography after a second intravitreal in- (ASI) with rubeosis iridis after circular buckling sur- jection of bevacizumab. How long this regression will gery in a highly-myopic patient which was success- persist is unknown and repeated injections of fully treated with a second intravitreal bevacizumab bevacizumab may be necessary if rubeosis re- injection. appears. Methods: Case report and review of the literature. KEYWORDS Discussion: ASI is a rare but potentially serious com- plication of posterior segment surgery. Finally it leads Anterior segment ischemia (ASI); rubeosis iridis; to neovascular glaucoma as a result of rubeosis iri- neovascular glaucoma (NVG); circular buckling dis. An encircling band can compromise anterior seg- surgery; intravitreal bevacizumab (IVB); iris ment circulation in different ways: by manipulation fluorescein angiography. or disinsertion of the recti muscles, by occlusion of the vortex veins through compression or by changes in the blood supply of iris and ciliary body. This pa- tient developed rubeosis iridis secondary to ASI. There was a remarkable regression of rubeosis iridis one month after a second intravitreal bevacizumab in- jection. Other case reports of bevacizumab use in neovascular glaucoma have shown clinical improve- ments of these patients, with intraocular pressure control and reduction of the neovascularization process. Conclusion: We describe a highly-myopic patient who developed ASI with rubeosis iridis after a cir- cular buckling operation. Slit-lamp examination and gonioscopy can show very little rubeosis iridis and can be misleading. Iris fluorescein angiography is the most sensitive technique for evaluation of iris vessel abnormalities and is of considerable value in the ear- zzzzzz Submitted: July 04, 2011 Accepted: Aug 08, 2011 Bull. Soc. belge Ophtalmol., 319, 5-9, 2012. 5 INTRODUCTION We describe a highly-myopic patient who developed rubeosis iridis and NVG after a circular Anterior segment ischemia (ASI) is a rare but buckling operation and strabismus surgery. This potentially serious complication of posterior case demonstrates a remarkable and rapid re- segment surgery. Finally it leads to neovascu- gression of rubeosis iridis after a second intra- lar glaucoma (NVG) as a result of rubeosis iri- vitreal bevacizumab injection, confirmed by an dis. The studies of Tanaka et al. (1) and Tawara iris fluorescein angiography. et al. (2) concluded that ASI, even without retinal ischemia, can cause neovascularization of the CASE HISTORY iris in rabbits. Tanaka et al. also reported that ASI causes an elevated aqueous vascular en- This 57-year-old myopic woman had a retinal dothelial growth factor (VEGF) in accordance detachment of the left eye in 1997. She un- with the ischemic severity (1). derwent a vitrectomy with encircling band, sil- icone oil tamponnade and endolaser photoco- ASI after posterior segment surgery is not usu- agulation in the left eye. The silicone oil (tam- ally found in young, healthy patients (3-6). Pre- ponnade) was removed 5 months later but she disposing factors are detachment of the recti developed a secondary glaucoma in 1998 due muscles, arterial and venous compression by to residual oil emulsification. The IOP was un- the explant or encircling band and the use of der control with topical therapy. In 1998 she diathermy (7). Underlying systemic conditions underwent cataract surgery of the left eye with such as generalized atherosclerosis, dysthy- a postoperative visual acuity of 20/100. In 2003 roid ophthalmopathy and hematologic disor- a bilateral recession (4.5 mm) of the external ders including anemia, increased hypercoagu- rectus muscle was performed for a decompen- lability or sickle cell disease/trait can increase sated exophoria. In 2009 the IOP was not any the risk for ASI (8). more under control medically and a Baerveldt Inhibiting the angiogenesis process by block- tube was implanted in the anterior chamber of ing VEGF is a promising strategy for the treat- the left eye. Six months later there was a good ment of anterior segment neovascularization IOP control, but rubeosis iridis was observed and NVG (9). Bevacizumab is a full-length hu- at gonioscopy. Fundus fluorescein angiography manized monoclonal antibody against vascu- was performed and did not reveal retinal is- lar endothelial growth factor type A. Case re- chemia. A carotid echography was done, but ports of bevacizumab use in NVG or anterior showed no significant stenosis. segment neovascularization have shown clini- cal improvements of these patients, with in- In December 2009 she presented at our clinic traocular pressure (IOP) control (10-13) and re- with a red and painful left eye. On examina- duction of the neovascularization process (14- tion the visual acuity was counting fingers and 15). the IOP was 45 mmHg. Slit-lamp biomicros- copy showed a hyphema, rubeosis iridis and a well- formed anterior chamber. In- direct fundoscopy was not possible, but echography showed no retinal detach- ment. The diagnosis of neovascular glaucoma was set and she was treated with oral and topical IOP lower- ing drugs. One day later the IOP was reduced to Fig. 1: Iris fluorescein angiography showed pathologic vessels in all quadrants of 12 mmHg. Transscleral re- the iris showing leakage within seconds. Biomicroscopy showed very little rubeosis tinal cryocoagulation of the iridis. The angiographic picture was taken after 28 seconds. 4 retinal quadrants was per- 6 gest that the anterior cili- ary arterial system supplies 70% to 80% of the anteri- or segment blood supply (16). Just posterior to the muscle insertions, the an- terior ciliary arteries devi- ate from the muscle belly and penetrate the sclera to anastomose with the long posterior ciliary arteries. The Fig. 2: These pictures were taken one month after a second IVB injection. Iris fluo- venous drainage of the an- rescein angiography revealed only regular radial iris vessels and minimal leakage in terior segment takes place the superotemporal quadrant. Biomicroscopy showed no rubeosis iridis. The an- through the 4-6 vortex giographic picture was taken after 37 seconds. veins. Damage to the vortex veins, the anterior ciliary ar- formed three days later and an intravitreal be- teries and the long posterior ciliary arteries are vacizumab (IVB) injection was also given. On the most important factors in the development examination two months later the visual acu- of ASI. There are various ways in which the vas- ity was 25/100 and the IOP 14 mmHg. Slit- cularization can be endangered. lamp biomicroscopy showed very little rubeo- sis iridis (Figure 1, right). Iris fluorescein an- After strabismus surgery, the incidence of an- giography at that time revealed pathologic ves- terior segment ischemia is approximately 1 case sels in all quadrants of the iris showing leak- per 13,000 procedures (8). It is sometimes age within seconds (Figure 1, left). One month necessary to detach one or more of the recti after a second IVB injection, only regular radi- muscles and this will cause the anterior ciliary al iris vessels and minimal leakage in the su- arteries to drop out. The vertical recti muscles perotemporal quadrant were seen (Figure 2, are most dangerous in this connection because left). there are no compensating long posterior cili- ary arteries there. Patients who have under- DISCUSSION gone two-muscle vertical rectus manipulation, operations involving three or more extraocular We present a patient with anterior segment is- muscles or strabismus surgery following encir- chemia (ASI) after a circular buckling opera- cling buckling surgery are more likely to expe- tion and strabismus surgery. The anterior seg- rience significant anterior segment ischemia. ment is vascularized by the long posterior cil- iary arteries and short anterior ciliary arteries. An encircling band or explant can compromise Two long posterior ciliary arteries arise from the anterior segment circulation in various ways ophthalmic artery and course toward the ante- (8). First by manipulation or disinsertion of the rior segment within the sclera along the hori- recti muscles. In the past, scleral buckle appli- zontal meridians. The vessels supply approxi- cation often included disinsertion of one or more mately 30% of the blood flow to the anterior recti muscles. Even with contemporary surgi- segment (8). The anterior ciliary arteries, which cal techniques, ischemia can also arise from oc- arise from the muscular branches of the oph- clusion of the vortex veins through compres- thalmic artery, lie within the recti muscles. There sion. Finally, scleral buckling can cause chang- are two anterior ciliary arteries per muscle, the es in the arterial circulation. In an experimen- sole exception being the lateral rectus, which tal model using albino rabbits, an encircling carries only one. The one anterior ciliary artery band decreased perfusion of the iris and cili- to the lateral muscle is also unique in that it ary body (17). often arises from the lacrimal artery. These ar- teries supply the remainder of the arterial flow Panretinal photocoagulation (PRP) can cause to the
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