age - related macular degeneration ( amd ) is the leading cause of irreversible severe central visual acuity loss in people over 50 years of age in the developed world . anti - angiogenic drugs have become increasingly popular for the treatment of choroidal neovascularization ( cnv ) that occurs in a variety of conditions , such as amd , diabetic retinopathy , retinal venous occlusive disease , high myopia , trauma , and others . current research has focused on anti - vascular endothelial growth factor ( vegf ) drugs , most notably ranibizumab ( lucentis ) , which has been approved by the fda for use in ocular disease . bevacizumab ( avastin ) is a recombinant humanized monoclonal antibody that binds vegf and inhibits its interaction with endothelial receptors . due to its relatively lower cost there are no large - scale , long - term randomized controlled studies on the safety and efficacy of bevacizumab , although several studies have focused on its potential complications and adverse effects . wong et al .   reported a very low rate of ocular adverse effects after intravitreal bevacizumab injection , such as retinal pigment epithelium ( rpe ) tears , retinal ischemia , ocular irritation and cataract progression . other potential adverse effects are very rare , and include retinal tears , retinal detachment , endophthalmitis and intraocular inflammation . macular hole formation after intravitreal injections are very rare and have been described only in a small number of case reports . there is a general consensus that adverse effects after intravitreal injections are more likely caused by the injection rather than by the administered medication . a number of studies have shown that the most common adverse effect related to a bevacizumab injection is the formation of rpe tears which occur in 0.8 - 2.9% of cases and mostly in eyes with neovascular amd and pigment epithelium detachment ( ped ) [ 2 , 3 , 8 ] . it should be noted , however , that such tears have also been reported to occur following photodynamic therapy as well as spontaneously . we present a patient with neovascular amd and ped who developed a full - thickness macular hole after an intravitreal injection of bevacizumab in his right eye . an 86-year - old man was referred to our clinic for treatment of subfoveal cnv and ped in his right eye due to neovascular amd . his left eye had previously suffered from neovascular amd , and its visual acuity was reduced to bare light perception due to large subretinal and choroidal hemorrhages following photodynamic therapy treatment for cnv several years earlier . his right eye had been previously treated 6 times with intravitreal bevacizumab after which there were no untoward sequelae . upon presentation , 1 ) demonstrate early subfoveal hyperfluorescence with staining in the later phases , confirming a still active cnv , retinal pigment elevation , the presence of subretinal fluid and an area of hyper - reflectivity . it is important to note that oct demonstrated the presence of posterior vitreous detachment . after discussing the available treatment options and their potential benefits and side effects , the patient gave his written informed consent to undergo the recommended intravitreal bevacizumab injection ( 1.25 mg/0.05 ml ) . fluorescein angiography demonstrated leakage from the partially fibrotic subfoveal cnv , as well as a round area of hyperfluorescence compatible with a full - thickness macular hole ( fig . oct demonstrated persistence of the ped , a small amount of subfoveal subretinal fluid , and a new grade 4 macular hole ( fig . the possibility of surgical repair of the macular hole was discussed , and the patient chose not to undergo any operation in his only functional eye . we report a patient with neovascular amd and ped who developed a full - thickness macular hole following the 7th intravitreal bevacizumab injection to his right eye . the first described a patient with neovascular amd with subfoveal cnv and vitreomacular traction who developed a stage 2 macular hole . the second described a patient with myopic cnv who developed a retinal detachment with a macular hole . the third described a patient with severe diabetic proliferative retinopathy who developed a retinal detachment with a macular hole . to the best of our knowledge , this is the first description of a macular hole forming subsequent to bevacizumab injection for the treatment of neovascular amd . contraction of the prefoveal vitreous cortex results in focal traction which may cause macular hole formation , as hypothesized by gass . however , as posterior vitreous detachment was demonstrated in the affected eye , tractional forces causing the formation of the macular hole are less likely in this case . the macular hole may be attributed to the pharmacological effect of bevacizumab on the cnv , since it can cause contraction resulting in traction on the retinal surface . alternatively , it is possible that the macular hole was caused by toxicity of bevacizumab on a previously compromised retina . this explanation is least likely as several studies found no toxic effect of bevacizumab on the retina and rpe , even after repeated injections [ 11 , 12 ] . another possible explanation is that the macular hole is the result of progressive retinal and rpe atrophy in a patient with amd . in conclusion , macular holes may be a rare adverse effect of bevacizumab injection , whether mechanical or toxic . patients need to be warned about this potential complication , and it should be included in the differential diagnosis when visual acuity does not improve or if it deteriorates after treatment with bevacizumab .
this report describes formation of a full - thickness macular hole subsequent to an injection of bevacizumab for the treatment of neovascular amd . 
 this complication may be caused by focal tractional forces on the retinal surface due to either vitreous incarceration at the injection site or contraction of the choroidal neovascularization membrane . 
 alternatively , it may be due to a toxic effect of bevacizumab on a previously compromised retina .