Anti-Vascular Endothelial Growth Factor Injection in Wet Age-Related Macular Degeneration

Introduction. AMD is a macular progressive degeneration that arises at the age of more than 50 years, which is characterized by the presence of drusen which is a deposit of material between the retinal pigment epithelium (RPE) and the Bruch membrane. The prevalence of AMD is 29.2% unilateral and 70.8% bilateral. In unilateral wet AMD, 50% will develop on the other eye in a period of 5 years. Case Presentation. A woman, Mrs. S, 59 years old, civil servant working, located in the city, came to the Polyclinic RSMH on January 21, 2019. Anamnesis (Auto-anamnesis) the main complaint of vision of the left eye blurred since, 2 months ago. Since about two months ago, sufferers complained of vision in the left eye blurred, blurred felt suddenly, darker vision in the middle. Since about two weeks ago, sufferers complained that his left eye vision had become blurred. The view in the middle is covered with black shadows and accompanied by waves. Working diagnosis of macular oculi sinistra ec wet age-related macular degeneration. The treatment is informed consent, Pro injection of anti-VEGF intravitreal oculi sinistra, Pro laboratory check, Pro X-ray of thorax PA, Pro consul of internal medicine. Conclusion. A clinically significant case of macular edema (CSME) has been reported that is treated with intravitreal anti-VEGF combined with focal photon photocoagulation laser. A woman aged 55 years, with complaints of vision both eyes blurred since ± 6 months ago.


Introduction
Age-related Macular Degeneration (AMD) is a major cause of blindness in developing countries, which causes severe central visual impairment in one or both eyes. AMD is a macular progressive degeneration that arises at the age of more than 50 years, which is characterized by the presence of drusen which is a deposit of material between the retinal pigment epithelium (RPE) and the Bruch membrane. The prevalence of AMD is 29.2% unilateral and 70.8% bilateral. In unilateral wet AMD, 50% will develop on the other eye in a period of 5 years. It is estimated that in 2020 around 8 million people in America have AMD because of an increase in the population of old age [1][2][3] AMD is classified into non-neovascular (Dry AMD) and neovascular (Wet AMD). Nonneovascular forms are more common and constitute 90% of AMD cases. The neovascular shape is only found in 10% but 85% causes severe visual impairment. Neovascular AMD is characterized by choroidal neovascularization. Risk factors for AMD are old age, hyperopia, bright iris color, family history, smoking, hypertension, hypercholesterolemia and cardiovascular disease. 1,2,4,5 In the early stages AMD rarely causes complaints. Complaints are only felt when there have been drusen, choroid neovascularization, the presence of fluid and blood that spreads to the central macula or the movement of blood into the vitreous space, which can cause central visual field disturbances and a sharp decrease in vision that can make sufferers lose independence and the ability for daily activities days. 1-3-5 In 1980-2010, the treatment options for AMD were laser photocoagulation and photodynamic therapy. In early 2010 therapies were introduced using anti-angiogenesis which focused on VEGF inhibition. Therefore, the authors are interested in examining the action of anti-VEGF injection as a treatment for vascular type AMD cases. 1,5 Reported cases of wet age-related macular degeneration treated with intravitreal anti vascular endothelial growth factor injection.

Case Report
A woman, Mrs. S, 59 years old, civil servant working, located in the city, came to the Polyclinic RSMH on January 21, 2019 with medical records 761611. Anamnesis (Autoanamnesis) The main complaint of vision of the left eye blurred since, 2 months ago. Since about two months ago, sufferers complained of vision in the left eye blurred, blurred felt suddenly, darker vision in the middle. Sufferers do not complain to see like lightning, and like a curtain. Red eye complaints and no pain. Patients go to a GP clinic and get two kinds of eye drops, but the patient 3 forgets the name of the medicine. Complaints are not-reduced, the patient does not seek treatment again.
Since about two weeks ago, sufferers complained that his left eye vision had become blurred. The view in the middle is covered with black shadows and accompanied by waves.
Sufferers do not complain of vision like seeing lightning, like being covered by a curtain, and like smoking. Patients seek treatment at RSUD and are referred to RSMH.
Past history of disease History of diabetes is denied, history of high blood pressure is denied, history of heart disease is denied, history of hypercholesterolemia (+) since 2 years ago, history of wearing glasses there, reading glasses, history of trauma to the area around the eye previously denied, history of the same disease in family denied, smoking history denied.

Discussion
Age-related macular degeneration (AMD) is a macular progressive degeneration that arises Based on history and examination, the differential diagnosis of this patient is macular edema ec wet age-related macular degeneration, polypoidal choroidal vasculopathy, and diabetic macular edema. Age-related macular degeneration is macular degeneration that occurs in old age, more than 50 years. The prevalence of AMD is 29.2% unilateral and 70.8% bilateral. In unilateral wet AMD, 50% will develop on the other eye in a period of 5 years. [1][2][3] Polypoidal choroidal vasculopathy is a retinal disease involving choroidal blood vessels characterized by the presence of polypoidal aneurysms with or without branching of blood vessel tissue. Usually occurs in middle age. The prevalence of AMD is 10% unilateral and 90% bilateral.
Vision is better than AMD-associated CNV. This patient is classified as old age with poor vision, and the prevalence of unilateral polypoidal choroidal vasculopathy is low, only 10%, so the differential diagnosis of polypoidal choroidal vasculopathy can be ruled out.
Diabetic retinopathy is a progressive disease that damages the integrity of retinal blood vessels. Proliferative diabetic retinopathy is characterized by neovascularization, pre-retina bleeding, and vitreous bleeding. At the first day of follow-up after injection the vision was 5/60, on the seventh day 6/60 was obtained. This shows a good response to the therapy given. According to the guidelines for handling wet AMD in Indonesia issued by PERDAMI anti VEGF, it is given once every month in the first 3 months, after which it is given pro-renata. Patients were given a second anti-VEGF injection in the left eye and had vision improvement being 6/30 on day VII after the second injection. Patients were planned for a third anti VEGF injection in the third month of therapy and continued according to the anti VEGF injection protocol in wet AMD.
The prognosis of quo ad function is dubia ad bonam, because there is improvement in vision after anti-VEGF injection, and there are no contra indications (fluorescent allergies) to continue therapy. The prognosis of quo ad Sanationam dubia ad bonam depends on the patient's compliance with re-control and adopting therapeutic protocols. While the prognosis of quo ad vitam is bonam. [1][2][3]5 Conclussion A clinically significant case of macular edema (CSME) has been reported that is treated with intravitreal anti-VEGF combined with focal photon photocoagulation laser. A woman aged 55 years, with complaints of vision both eyes blurred since ± 6 months ago. When you go to the eye clinic for blood sugar levels when, blood pressure and blood cholesterol levels increase. From the results of fundoscopic examination, thickening of the retina and hard exudates within 500 µm from the central macula in the right and left eye was in accordance with CSME criteria.
The treatment chosen for this patient was intravitreal anti-VEGF (bevacizumab) injection in the right and left eye every month for 3 months. One week later, the focal photocoagulation laser was performed on the right and left eyes. The patient's final vision 1 week after the focal photocoagulation argon laser was performed showed improvement. The initial vision of the right and left eye 3/60 becomes 6/30. Blood pressure, blood sugar levels, and cholesterol at follow-up are always controlled, so they can help reduce the risk of progressive retinopathy, macular edema and decreased vision.