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254 Indian Journal of Ophthalmology Vol. 64 No. 3

3. Walton OB 4th, Garoon RB, Weng CY, Gross J, Young AK, Camero KA,
et al. Evaluation of Automated Teleretinal Screening Program for
Diabetic Retinopathy. JAMA Ophthalmol 2016;134:204‑9.
4. Rico‑Sergado L, Pérez‑Canales JL, Pérez‑Santonja JJ. Effect of
visual impairment on teleretinal imaging for diabetic retinopathy
screening. Ophthalmic Surg Lasers Imaging Retina 2016;47:42‑8.
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DOI:
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Cite this article as: Hajra A, Bandyopadhyay D. Screening for diabetic

retinopathy: New methods to come. Indian J Ophthalmol 2016;64:253-4.

Paralytic ileus after bilateral

intravitreal injection of bevacizumab
Sir,
There are few reports of systemic adverse events associated
with intravitreal injection of bevacizumab (IVB). Rare
systemic events include formed visual hallucinations,[1] erectile
dysfunction,[2] and acute decrease in kidney function.[3] We
recently experienced a case of paralytic ileus after bilateral IVB,
thus herein report the case.
A 47‑year‑old male patient was screened for diabetic
retinopathy. He was admitted to the department of internal
medicine with uncontrolled Type 2 diabetes mellitus. The blood
sugar test was 496 mg/dL and hemoglobin A1c was 13.6%. At the
initial ophthalmic examination, his corrected visual acuity was
20/40 in the right eye and 20/30 in the left eye. The intraocular Figure 1: Erect abdominal X-ray showing excess air and niveau in
pressure was 18 mmHg in the right eye and 19 mmHg in the the intestine
left eye. Slit lamp examination revealed no abnormal findings
in anterior segment while the funduscopic examination showed
microaneurysms and dot hemorrhages in four quadrants.
Fluorescein angiography revealed the neovascularization with
leakage of dye in both eyes. The IVB (1.25 mg/0.05 mL) was
done in both eyes in the same day with patient’s request of
prompt treatment. Panretinal photocoagulation was scheduled
in both eyes after 2 days; however, the laser photocoagulation
could not be done because of patient’s severe abdominal pain
with vomiting and abdominal distension.
An erect abdominal X‑ray demonstrated excess air and
niveau in the intestine [Fig. 1]. A computed tomography sagittal
scan revealed prominent dilated and air‑filled images of the
intestinal wall, without apparent lesions [Fig. 2]. Paralytic ileus
was diagnosed. Paralytic ileus had improved after conservative
treatment with ileus tubing, without surgery.
In our case, the patient had no history of gastrointestinal
disorder. Matsuyama et al. reported that the plasma vascular Figure 2: Computed tomography sagittal scan showing prominent
endothelial growth factor (VEGF) level decreased markedly as dilated and air-filled images of the intestinal wall without apparent lesions
early as 1 day after IVB in patients with diabetic retinopathy.[4]
Thus, it is possible that systemic side effects can develop after plasma VEGF resulted in the decreased production of nitric
IVB as well as after intravenous bevacizumab. Decreased oxide,[5] a known vasodilator. Therefore, decreased VEGF
[Downloaded free from http://www.ijo.in on Sunday, May 27, 2018, IP: 182.1.195.34]
March 2016 Letters to the Editor
production can cause vasoconstriction and reduce the supply
of gastrointestinal blood flow. Moreover, the patient received
bilateral IVB, which might cause the higher plasma VEGF level
than in the case of unilateral IVB.
In conclusion, we report on a patient with paralytic
ileus after bilateral IVB. In spite of very low incidences, the
physicians should aware of the gastrointestinal disorders such
as paralytic ileus following bilateral IVB.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Young Gyun Kim, Seung Jun Lee1, Sang Beom Han1,
Moosang Kim1
Department of Ophthalmology, School of Medicine, Kyung Hee
University Hospital at Gangdong, Kyung Hee University, Seoul,
1
Department of Ophthalmology, School of Medicine, Kangwon
National University, Chuncheon, South Korea
Correspondence to: Prof. Moosang Kim,
Kangwon National University Hospital, 156 Baengnyeong‑ro,
Chuncheon, Gangwon 200‑722, South Korea.
E‑mail: kimmoo‑79@hanmail.net
References
1. Meyer CH, Mennel S, HS, H S, Schmidt JC. Visual hallucinations
after intravitreal injection of bevacizumab in vascular age‑related
macular degeneration. Am J Ophthalmol 2007;143:169‑70.
Adverse drug reactions due to
ophthalmic drugs: Reporting system
in India
Sir,
All new drugs including those for ophthalmic use are approved
by Drugs Controller General (India) of Central Drugs Standard
Control Organization (CDSCO) as per the schedule Y of Drugs
and Cosmetics (D and C) Act 1940 and Rules 1945 thereunder
after reviewing its efficacy and safety in Indian population.
Even after the approval of new drug, as per schedule Y
of the D and C rules, Periodic Safety Update Reports are
required to be submitted to CDSCO every 6 months for the
first 2 years and for the subsequent 2 years to be submitted
annually.[1] Once the drug is introduced in the market, the
responsibility to monitor the adverse drug reactions (ADRs)
in larger population becomes the obligation of all prescribers
as well as the concerned organization. Only a scant amount
of ADRs information is available when a drug is introduced
in the clinical practice because the investigational drug is
exposed in limited subjects and duration. Therefore, there are
possibilities of ADRs to occur when the drug has been used in
larger population for prolonged periods.
Therefore, pharmacovigilance, known as the science and
activity relating to the detection, assessment, understanding
and prevention of adverse effects or any other drug‑related
255
2. Yohendran J, Chauhan D. Erectile dysfunction following intravitreal
bevacizumab. Middle East Afr J Ophthalmol 2010;17:281‑4.
3. Pell2 G, Shweke N, Duong Van Huyen JP, Tricot L, HessaTri S, Fr,
Frricot L, V, et al. Systemic and kidney toxicity of intraocular
administration of vascular endothelial growth factor inhibitors.
Am J Kidney Dis 2011;57:756‑9.
4. Matsuyama K, Ogata N, Matsuoka M, Wada M, Takahashi K,
Nishimura T. Plasma levels of vascular endothelial growth factor
and pigment epithelium‑derived factor before and after intravitreal
injection of bevacizumab. Br J Ophthalmol 2010;94:1215‑8.
5. Hood JD, Meininger CJ, Ziche M, Granger HJ. VEGF upregulates
ecNOS message, protein, and NO production in human endothelial
cells. Am J Physiol 1998;274 (3 Pt 2):H1054‑8.
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Access this article online
Quick Response Code: Website:
www.ijo.in
DOI:
10.4103/0301-4738.181736
PMID:
***
Cite this article as: Kim YG, Lee SJ, Han SB, Kim M. Paralytic ileus
after bilateral intravitreal injection of bevacizumab. Indian J Ophthalmol
2016;64:254-5.
problem, came into existence to monitor ADRs till the life
period of a drug.[2] In India, Ministry of Health and Family
Welfare (MoHFW), Government of India launched a nationwide
Pharmacovigilance Programme of India (PvPI) in the year 2010
to monitor the safety of drugs including for the ophthalmic
use. Indian Pharmacopoeia Commission under the MoHFW
functions as National Coordination Centre (NCC) for PvPI.
NCC identified 150 ADRs monitoring centres (AMCs) across
the country to report ADRs to NCC.[3,4] An ADR is response to
a drug which is noxious and unintended and which occurs at
doses normally used in human for the prophylaxis, diagnosis
or treatment of disease, or for the modification of physiological
function can be reported to AMC‑PvPI. A trained team at AMC
collects manages and assesses the report before submitting to
NCC. A ADRs reporter (healthcare professionals) who is not
a part of AMC can report ADRs with all ophthalmic products
whether known or unknown, serious or nonserious, and
frequent or rare by filling the suspected ADR reporting form
[Fig. 1] and submitted in nearby AMC (available in www.ipc.
gov.in). A helpline (1800 180 3024) also is available to provide
assistance in ADRs reporting.[3] The obtained information is
entered in the database, analyzed, and assessed to identify
new signals. This is also used as main source for identifying
and reducing the risks associated with the ophthalmic drugs.
Submission of ADRs report does not have any legal
implication on the reporter and reporter details are maintained
confidentially.[5] The provided information used to take regulatory