Complete Visual Recovery After Erythropoietin (EPO) IVT Realized 48 Hours Post Central Ischemic Retinal  Venous Occlusion: A Full Documented Case Report


ABSTRACT

We report here the case of a 59-year-old male patient with a stabilized hemochromatosis, victim of Ischemic Central Retinal Venous Occlusion (ICRVO) involvement of the right eye. The ischemic nature and absence of stasis have challenged the anti-VEGF treatment. A treatment associating Aspirin and ocular hypotoniser was only instituted. The importance of the functional deficit, with a reduced acuity to fingers count and the prognosis following fluorescein angiography (less than 1% recovers an acuity ≥20/100; Hayreh SS and All 2011), We decided to propose an Off Label treatment with an IVT of erythropoietin (EPO). The informed consent of the patient was obtained on the existence of several animal and human studies on safety and efficacy after use of EPO in IVT up to 2000 IU / eye on similar pathologies (NOIA: Modarres M and All 2011). These various studies confirms the endogenous retinal production of EPO and the presence of EPO retinal receptors (EPO / R), as well as neuroprotective and anti- apoptotic effect of exogenous EPO. Exogenous EPO being able to induce a Low regulation of HIF-1alpha protein mRNA productions, VEGF-A, Endogenous EPO, VHL and caspase 3.

Materials & Methods:

48 hours after the accident, an IVT injection of 900 IU of 0.05 cc of EPO supplemented with 0.02 cc of anti-VEGF was realised at 3.5 mm of the limbus, after hypotonizing ocular massage and local preparation including operative field, ciliary protection, blepharostat, iodine cutanéo-conjunctival disinfection and local anesthesia by oxybuprocain drops. An analytical fluo-angiographic / Video-Fluoangiography, ICG angiography and OCT comparison before and about one month after IVT is performed, including one Visual field for the latter.

Results:

Total recovery of the visual function with return to a normal visual acuity 20/20 was obtained in the week following the IVT, with a strong photophobia. Angiographic comparisons revealed the Disappearance of the hypofluorescence pattern in “leaf of fern” observed in Autofluorescence, as well as those of major perfusion delays. The OCT comparisons showed decreased ischemic edema with discrete local temporal thinning, found in the layer of the ganglion cells, with corresponding local sequellar impairment of the visual field .

Discussion:

What we call venous occlusion, in fact is often enough, only one rheological normal flow disturbance by viscology disorder with a dynamic and direct vascular endothelial involvement. A part of the regulation of intravascular blood flow is dependent of the endothelial physiology and secretions of endothelin, prostaglandin PG12 or of nitric oxide (NO-eNOS) related to the shear stress from the blood flow. The action’s mode of EPO could act at this level by restoring endothelial control of this homeodynamic.

Conclusion:

EPO appears to be effective as a treatment upon acute Ischemic CRVO. A non-randomized study, enlarged to a large number of patients nevertheless remains necessary to decide. With difficulties, concerning the unpredictable, accidental nature of these cases and the time Implementation of treatment.

Literature:

  1. Modarres M, Falavarjani KG, Nazari H, Sanjari MS, Aghamohammadi F, Homaii M, Samiy N. Intravitreal erythropoietin injection for the treatment of non-arteritic anterior ischaemic optic neuropathy.Br J Ophthalmol. 2011 Jul;95(7):992-5. doi: 10.1136/bjo.2010.191627. Epub 2010 Dec 3.
  2. Hayreh SS, Podhajsky PA, Zimmerman B Natural History of Visual Outcome in Central Retinal Vein Occlusion.Ophthalmology. 2011 January ; 118(1): 119–133.e2. doi:10.1016/j.ophtha.2010.04.019.


CONTACT DETAILS

 

 

Richard Luscan
Garches, France
Email: r.luscan@wanadoo.fr