Management of Intravitreal Anti-VEGF Therapy in Left Eye with Prior Retinal Surgery
Yes, restart intravitreal anti-VEGF injections in the left eye (OS) now that the B-scan confirms no retinal detachment, and continue routine monitoring of the stable right eye (OD).
Rationale for Restarting Anti-VEGF Therapy
The decision to restart intravitreal injections (IVE) in the left eye is appropriate based on the following considerations:
Safety confirmation: The B-scan showing no retinal detachment in the left eye provides critical safety clearance to proceed with intravitreal injections, as the absence of retinal detachment eliminates the primary contraindication to anti-VEGF therapy in eyes with prior retinal surgery 1.
Treatment resumption protocol: When anti-VEGF therapy has been withheld and the underlying pathology (likely macular edema or neovascularization based on the clinical context) persists or recurs, treatment should be resumed 1.
Prior surgical history consideration: While the patient has had retinal surgery (possibly twice), this does not preclude anti-VEGF therapy once structural stability is confirmed. The B-scan serves as your safety net here 2.
Treatment Protocol Moving Forward
Initial treatment phase:
Resume monthly (every 4 weeks) intravitreal anti-VEGF injections in the left eye until disease stability is achieved 1, 2.
Disease stability is defined as stable or improved visual acuity with reduction in retinal thickening on OCT (>10% reduction in central subfield thickness) 2.
Typically requires at least 3-4 consecutive monthly injections to re-establish disease control 2.
Monitoring requirements:
Perform OCT at each visit (approximately every 4 weeks initially) to assess treatment response and guide re-injection decisions 1.
Monitor for signs of recurrent macular edema, including intraretinal or subretinal fluid on OCT 1, 2.
Patient should be instructed to report any new symptoms including decreased vision, metamorphopsia, or scotoma promptly 1.
Follow-up Interval Adjustment
After achieving stability:
Once the left eye demonstrates treatment success (resolution of edema or vision reaching optimal level), follow-up intervals can be extended 1.
If edema does not recur or worsen at consecutive visits, the follow-up interval can be doubled (from 4 weeks to 8 weeks, then to 16 weeks) 1.
Typical injection frequency decreases over time: 6-8 injections in year one, 2-3 in year two, 1-2 in year three, and 0-1 in years four and five 1.
Right Eye Management
For the stable right eye:
Continue routine monitoring with OCT at regular intervals (every 3-6 months depending on underlying pathology) 1.
The stable OCT finding suggests no active disease requiring immediate intervention 1.
Patient should perform self-monitoring (Amsler grid) and report any new symptoms immediately 1.
Critical Safety Considerations and Pitfalls
Common pitfalls to avoid:
Incomplete history: The unclear surgical history is a significant concern. Before proceeding, attempt to obtain operative reports from the prior retinal surgeon to understand what procedures were performed and why 3.
Tractional complications: In eyes with prior retinal surgery and potential fibrovascular proliferation, anti-VEGF therapy can rarely precipitate tractional retinal detachment through the "crunch phenomenon" (rapid regression of neovascularization with concurrent fibrosis causing increased traction) 4. This risk is mitigated by the B-scan showing no current detachment, but warrants close monitoring.
Macular hole risk: In highly myopic eyes or eyes with vitreomacular traction, anti-VEGF therapy carries a small risk of macular hole formation 5. Careful OCT evaluation for vitreoretinal interface abnormalities is essential before each injection.
Inadequate treatment intensity: Failure to maintain monthly injections during the re-initiation phase may result in suboptimal outcomes and permanent photoreceptor damage 2, 3.
Monitoring for complications:
At each visit, perform careful biomicroscopic examination to detect early signs of retinal traction or new breaks 1.
If persistent retinal thickening occurs despite 24 weeks of anti-VEGF therapy, consider adding focal/grid laser treatment 1, 3.
Patients should be counseled about endophthalmitis symptoms and instructed to seek immediate care if they develop pain, redness, or vision loss after injection 1, 3.
Documentation Recommendations
Given the incomplete history, document the following at each visit:
Current visual acuity and OCT central subfield thickness to establish baseline for treatment response 1, 2.
Detailed fundus examination findings, particularly noting any epiretinal membranes, vitreoretinal traction, or areas of prior retinopexy 3.
Treatment response at each visit to guide interval extension decisions 1, 2.