ORIGINAL ARTICLE  
Outcomes of Intravitreal Bevacizumab for Macular  
Edema Secondary to Branch Retinal Vein Occlusion  
Nasir Ahmad Chaudhry1, Sarmad Zahoor2, Usama Iqbal3, Muhammad Owais Sharif4  
Muhammad Sharjeel5, Asima Rafique6  
Departments of Ophthalmology, 1-2Eye Unit 2 Mayo Hospital, Lahore. 3DHQ Teaching Hospital, Gujranwala.  
4,6Eye Unit 3 Mayo Hospital, Lahore. 5Gomal Medical College, DI Khan – KPK  
ABSTRACT  
Purpose: To determine the functional and anatomical outcome of intravitreal Bevacizumab in patients with  
macular edema secondary to branch retinal vein occlusion.  
Study Design: Quasi Experimental study.  
Place and Duration of Study: Institute of Ophthalmology, King Edward Medical University/Mayo hospital  
Lahore, from February 2016 to December 2018.  
Material and Methods: Forty eyes of 40 patients with macular edema on OCT (macular thickness > 300 µm)  
secondary to BRVO were included in the study. All the patients suffering from other types of macular edema  
caused by diabetes, epi-retinal membrane (ERM), surgery involving posterior segment, vitreoretinal traction and  
history of intravitreal VEGF or steroids were excluded from the study. Intravitreal Bevacizumab was given when  
macular thickness was > 300 µm or Visual acuity was < 6/12. Follow-up was at 1st, 3rd, 6th and 12th month.  
Results: The mean age of the patients was 52.12 ± 5.63 years. Male to female ratio was 1.5:1. Infero-temporal  
venous arcade was the most common site of BRVO (55%) followed by supero-temporal (35%) and macular  
BRVO (10%). Baseline visual acuity was 6/12 or better in 17.5% of the patients at presentation. This proportion  
increased to 27.5%, 40%, 52.5% and 67.5% at 1, 3, 6 and 12 months respectively. Macular thickness measured  
at presentation was 540 ± 120 μm. Macular thickness gradually reduced on follow-up. At one month mean  
macular thickness was 430 ± 90 μm. It was less than 300 μm after 6 months.  
Conclusion: Intravitreal bevacizumab results in improved functional and anatomical outcomes in cases of  
macular edema secondary to BRVO.  
Key Words: Bevacizumab, retinal vein occlusion, branch retinal vein occlusion, vascular endothelial growth  
factor, macular edema.  
How to Cite this Article: Chaudhry NA, Zahoor S, Iqbal U, Sharif MO, Sharjeel M, Rafique A. Outcomes of  
Intravitreal Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion. Pak J Ophthalmol.  
2020; 36 (3): 231-235.  
Doi: 10.36351/pjo.v36i3.998  
vein occlusion (BRVO) is the most common disease  
INTRODUCTION  
Among the vascular diseases of retina, branch retinal  
after diabetic retinopathy1,2. Several factors have been  
associated with pathogenesis of BRVO. These include  
hypertension, diabetes mellitus, age, open angle  
Correspondence to: Usama Iqbal  
DHQ Teaching Hospital, Gujranwala  
Email: usamaiqqbal@gmail.com  
glaucoma, hyperlipidemia, alcohol and increased  
alpha2 globulin3-5. The possible mechanism of its  
progress is occlusion of vein leading to stasis of blood.  
This is turn leads to wide spread retinal hemorrhages  
along the distribution of involved branch retinal vein.  
Received: February 4, 2020  
Revised: May 4, 2020  
Accepted: May 4, 2020  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 231-235  
231  
Nasir Ahmad Chaudhry, et al  
Resulting hypoxia leads to production of vascular  
endothelial growth factor (VEGF). VEGF causes  
proliferation of abnormal new vessels, which are leaky  
and have increased permeability. This ultimately leads  
to swelling of the macula, termed as macular edema6.  
Applying inclusion and exclusion criteria, 40 eyes  
of 40 patients with a diagnosis of macular edema due  
to BRVO were included. Participants of the study were  
informed about the details of study and an institutional  
permission of ethical board was taken. All the  
participants were examined by a single observer in  
order to reduce bias. Complete examination of anterior  
and posterior segment was done. Visual acuity was  
recorded using Snellen’s visual acuity chart. OCT  
macula was done to measure macular thickness.  
Intravitreal injection of bevacizumab 1.25mg /0.05ml  
was given in operation theatre taking aseptic measures.  
Decision of second injection was based on macular  
thickness on OCT (> 300 μm) and visual acuity  
(< 6/12). Patients were followed up at 1 month, 3  
months, 6 months and after 12 months. On each  
follow-up, visual acuity was measured with Snellen  
chart and OCT macula was done. Collected data was  
analyzed using SPSS 20.  
Macular edema (ME) occurs due to accumulation  
of extracellular fluid within the retina because of break  
down in blood retinal barrier7. Fluid accumulates  
primarily in the outer plexiform and inner nuclear  
layers8,9.  
There have been several therapeutic modalities for  
the treatment of macular edema secondary to BRVO,  
which include both interventional and pharmacological  
therapies. The earliest of all interventional procedures  
was  
laser  
photocoagulation10-11  
.
Among  
pharmacological therapies, people have been using  
topical non-steroidal anti-inflammatory drugs, oral  
acetazolamide, corticosteroids, sub-tenon steroid and  
intravitreal injections to treat macular edema12.  
Intravitreal dexamethasone was initially used to reduce  
inflammatory cytokines in addition to stabilizing  
RESULTS  
vascular  
membranes13.  
Later,  
intra-vitreal  
Mean age of the patients was 52.12 ± 5.63 years.  
Hypertension was found in 60% (24 patients) patients,  
Ischemic heart disease in 10% (4 patients), Diabetes in  
15% (6 patients), Cerebrovascular accidents were  
found to be in 2.5% of the patients, while  
hematological disorders were present in 7.5% (3  
patients). All these factors were compared with  
outcome using chi-square test. It was found that none  
of them was associated with outcome (p-value was  
more than 0.05). This showed that outcome of macular  
edema was independent of these factors.  
triamcinolone was used14. Latest modality is anti-  
VEGF treatment that inhibits growth of new vessels  
offering a better era of treatment of macular edema in  
BRVO15. These anti-VEGF includes Aflibercept,  
Ranibizumab16, Bevacizumab17 and Pegaptanib18.  
Bevacizumab is used off label but is the most  
commonly used due to its low cost19.  
The purpose of our study was to see the  
improvement in visual acuity (as per Snellen chart)  
and anatomy of macula (macular thickness on OCT)  
after the use of intravitreal anti- vascular endothelial  
growth factor (Anti-VEGF).  
At presentation VA of 6/9 to 6/12 was found in 7  
patients, 6/18 – 6/24 in 12 patients, 6/36 – 6/60 in 14  
MATERIAL AND METHODS  
Table1: Number of injections per patient.  
Single arm, single centre, open-label, prospective  
Quasi-experimental study was conducted at the  
Institute of Ophthalmology, King Edward Medical  
University/Mayo hospital Lahore. Patients with  
macular edema secondary to BRVO were diagnosed  
on fundus examination and confirmed on OCT  
(macular thickness > 300 μm). Treatment regimen was  
on as needed basis. All the patients suffering from  
other diseases leading to macular edema like diabetic  
retinopathy, epi-retinal membrane (ERM), any history  
of surgery involving posterior segment, vitreoretinal  
traction and any history of intravitreal VEGF or  
steroids were excluded from the study.  
No. of Patients  
No of Injections Given  
Percentage  
5%  
2
5
1
2
12.5%  
15%  
6
3
12  
15  
40  
4
30%  
5 – 7  
37.5%  
100%  
patients and Counting finger or worse in 7 patients.  
Number of patients presenting with supero-temporal  
232  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 231-235  
Outcomes of Intravitreal Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion  
BRVO were 14. Twenty-four patients had infero-  
± 120 that reduced to 430 ± 90 at 1 month, 360 ± 110  
at 3 months, 270 ± 60 at 6 months and 210 ± 40 at 1  
year. (Table 4, Figure 1).  
temporal BRVO while 4 had macular BRVO. Visual  
acuity improved to 6/6 in 60% cases, 6/9 – 6/12 in  
7.5% cases, 6/18 – 6/24 in 20% cases and 6/36 – 6/60  
in 12.8% cases in 12 months. Further details of  
improvement in visual acuity are shown in table 2.  
Efficacy of this treatment was found significant  
functionally by applying paired sample t-test. P-value  
was less than 0.005. This proves the functional  
outcome of intravitreal bevacizumab (Table 3). The  
mean central retinal thickness at presentation was 540  
DISCUSSION  
Our study demonstrates the safety and beneficial  
outcomes of bevacizumab in terms of improvement in  
visual acuity (VA) and decrease in macular thickness,  
in patients with macular edema secondary to BRVO.  
In this prospective study baseline visual acuity was  
6/12 or better in 17.5% of the patients. After 1 month,  
27.5% of the patients had VA of 6/12 or better. Trend  
towards further improvement in VA was seen on  
successive follow-ups. The BERVOLT study showed  
significant improvement in visual acuity and decrease  
in Central Macular Thickness with no adverse events  
with intravitreal Bevacizumab in macular edema due  
to BRVO20. In a local, single center study done by  
Azhar et al, baseline macular thickness was 358 ± 36  
µm. At one month, 2 months and 3 months macular  
thickness reduced to 326 ± 34 µm, 295 ± 34 µm and  
252 ± 12 µm respectively. The macular thickness was  
below 300 µm, as early as 2 months after intravitreal  
bevacizumab. In this study regimen was three  
consecutive injection of bevacizumab at one monthly  
interval21. In our study higher baseline macular  
thickness was noted and macular thickness was below  
300 µm after approximately 6 month follow up. This is  
in accordance with a study done by Kondo M., et al22.  
They showed that macular thickness decreased  
significantly from 523 to 305 µm during the 12-month  
follow-up period. Maximum number of intravitreal  
bevacizumab injections given to a single patient were  
0724. In our study 95% of the patients required more  
than one injection of bevacizumab.  
Table 2: Functional Improvement after injection.  
No of Patients Improved after Therapy  
Visual  
After 1  
Month  
0
11  
16  
After 3  
Months  
After 6  
Months  
After 12  
Months  
Acuity  
6/6  
1
16  
14  
9
6
21  
9
24  
3
8
6/9 to 6/12  
6/18 to 6/24  
6/36 to 6/60  
13  
4
5
Table 3: Statistical significance of visual improvement.  
Variables  
p-value  
0.000  
0.000  
0.000  
0.000  
VA at Presentation and VA at 12 months  
VA at presentation & VA at 1 month  
VA at 3 Months & VA at 6 months  
VA at 6 Months & VA at 12 months  
Table 4: Anatomical improvement after injection.  
Central Macular Thickness  
Duration (Follow-up)  
(μm)  
540 ± 120  
430 ± 90  
360 ± 110  
270 ± 60  
210 ± 40  
Basal thickness at presentation  
1 Month  
3 Month  
6 Month  
12 Month  
This study is limited to single center. Prospective  
multi center trials are needed to highlight the safety  
and effectiveness of this treatment modality.  
600  
540  
Macular Thickness  
500  
430  
360  
400  
CONCLUSION  
270  
Intravitreal bevacizumab is a safe treatment modality.  
It can be used for treatment of macular edema  
secondary to BRVO. It results in improvement in  
visual acuity and also helps in the return of macular  
thickness over time to normal.  
300  
210  
230  
200  
100  
0
Presentation  
1 Month  
3 Months  
6 Months  
1 Year  
Ethical Approval  
Graph 1: Macular thickness at different times after injection.  
The study was approved by the Institutional review  
board/Ethical review board.  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 231-235  
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Nasir Ahmad Chaudhry, et al  
Oedema: The Role of Soluble Mediators. Br J  
Ophthalmol. 2000; 84: 542-545.  
Conflict of Interest  
Authors declared no conflict of interest.  
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Authors’ Designation and Contribution  
Nasir Ahmad Chaudhry; Professor: Supervisor of this  
project, study design, final manuscript review.  
Sarmad Zahoor; Medical Officer: Data Collection and  
analysis, Statistical work.  
Usama Iqbal; Post Graduate Resident: Manuscript  
writing and final review  
Muhammad Owais Sharif; Senior Registrar: Data  
Collection, Article review.  
Muhammad Sharjeel; Assistant Professor: Data  
collection and compiling, final review, Discussion  
writing.  
Group.  
Randomized,  
sham-controlled  
trial  
Asima Rafique; Post Graduate Resident: Data  
Collection, Manuscript writing, final review  
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