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• W2086421826 abstract "Editor, Over the past few years, several agents treating VEGF (Vascular Endothelial Growth Factor) have become available for patients with neovascular ocular diseases associated with increased vascular permeability. Bevacizumab is a recombinant humanized monoclonal antibody that inhibits the biological activity of all VEGF-A isoforms (Gunther & Altaweel 2009). It has been reported to treat choroidal and retinal neovascularization including wet age-related macular degeneration, diabetic macular oedema and proliferative diabetic retinopathy (Gunther & Altaweel 2009). Topical neutralization of VEGF-A at the corneal surface does not have significant side-effects on normal corneal epithelial wound healing, normal corneal integrity or normal nerve fibre density. Therefore, anti-VEGF eye drops seem to be a relatively safe option to treat corneal neovascularization (Bock et al. 2007). Moreover, subconjunctival injections of bevacizumab play a role in the inhibition of corneal neovascularization, and it may provide an additional strategy in improving success of corneal grafts (Bock et al. 2007), but it also has a similar power when it is administered topically in patients with ocular surface inflammatory diseases (Yoeruek et al. 2008). Short-term use of topical bevacizumab may be effective to prevent recurrence in a patient with impending recurrent pterygium (Bock et al. 2007). Intracameral bevacizumab may cause rapid regression of the iris and angle neovascularization, which may slow or even halt the progression of PAS (Peripheral Anterior Synechiae) process with IOP (Intraocular Pressure) control, so it may be a helpful adjunct for the surgical treatment of neovascular glaucoma with IOP control (Bock et al. 2007). Subconjunctival bevacizumab-augmented trabeculectomy reduces bleb vascularity improving the outcome of glaucoma filtration surgery (Coote et al. 2008; Grewal et al. 2008). As we know that healing process of the wound is known to be the major cause of bleb failure after trabeculectomy, possibly topical bevacizumab could be used postoperatively to retard wound healing following trabeculectomy thus enhancing its effect. A 75-year-old male patient with a 6 years history of normal tension glaucoma, IOP between 17–22 mmHg in the RE (Right Eye) and 14–18 mmHg in the LE (Left Eye) on dorzolamid two times daily and latanoprost once a day in both eyes was referred to our department. Humphrey visual field showed progressive, large superior arcuate scotomas in both eyes with MD (Mean Deviation)−14.7 dB RE and −16.7 dB LE and with PSD (Pattern Standard Deviation) 11.5 dB RE and 11.7 dB LE. Best corrected visual acuity (BCVA) was counting fingers (CF) from 0.5 m in the RE and CF to 2 m in the LE, central corneal thickness (CCT) 520 μm (RE) and 505 μm (LE) and cup/disc ratio of 0.8–0.85 (RE) and 0.9–0.95 (LE). Gonioscopy revealed wide open angle with trabeculum, scleral spur and half of ciliary body line visible in both eyes. He was scheduled for left eye trabeculectomy with the adjunctive use of mitomycin-C in July 2008. The same procedure was performed in the right eye 4 months later in November 2008. History of LE: first day after surgery, filtration bleb was diffused, elevated with 6 mmHg IOP with deep and clear anterior chamber. He started mydriatic drops – 1% Atropinie sulphate two times/day – combined with a topical antibiotic–corticosteroid cover – Dexamytrex (dexamethasone/gentamycin sulphate) five times/day. On the second postoperative day, the patient’s IOP was 17 mmHg with flat and injected bleb, one of three releasable sutures was removed, and digital massage of the bleb was performed decreasing IOP to 10 mmHg. At the first check up, IOP was 20 mmHg, and bleb was flat and even more congested than a week before. The two remaining releasable sutures were removed with a subsequent lowering left eye IOP to 10 mmHg. He received prednisolone drops five times/day instead of topical antibiotic–corticosteroid cover. Flattening and injection of the bleb was observed simultaneously with the increase in IOP to the level of 20 mmHg. The bleb was difficult to massage. Laser suture lysis was performed to increase filtration, but the bleb remained flat and injected. Prednisolone drops were continued seven times/day in an attempt to diminish the bleb vascularity. Unfortunately, it was refractory to topical treatment. (Fig. 1). (A) LE – flat and injected bleb before bevacizumab instillation 14 days after trabeculectomy, (B) LE – 10 days after topical administration of bevacizumab, (C) LE – 2.5 months after topical administration of bevacizumab, (D) LE – 6 months after topical administration of bevacizumab, revealing regression of new vessels. On the 15th day after trabeculectomy, after obtaining the written informed consent, patient was placed on bevacizumab drops (Avastin®; Roche) (5 mg/ml) five times/day for 2 weeks (Koenig et al. 2009). Bevacizumab in this concentration was prepared by solution 25 mg/ml bevacizumab for intravenous injections in 0.9% NaCl in proportion 1:5. Drops were stored in sterile eye drops bottles in the fridge (2–8°C). During the following 7 days, patient noted continuous improvement with reduced irritation and redness. Clinically, regression of smaller blood vessels was noted. After 1 week of bevacizumab administration, there was regression of the bleb vascularity. IOP was 18 mmHg, and bleb was flat but much less injected and easy to massage upon which the pressure decreased to 12 mmHg. Laser suture lysis of second and last left single scleral flap suture was performed decreasing IOP to 6 mmHg. After 2 weeks, the bleb was pale, IOP remained at the same level of 6 mmHg, and drops were discontinued. Reducing doses of prednisolone cover was continued up to 2 months after surgery. Every week, prednisolone was reduced by one drop down to six times/day in 3rd week; five times/day in 4th week; four times/day in 5th week; three times/day in 6th week; two times/day in 7th week; once a day in 8th week. History of RE: on the first postoperative day, filtering bleb was diffuse and elevated with IOP of 10 mmHg. The anterior chamber was deep and clear. Patient started the same postoperative regimen – 1% Atropinie sulphate twice a day – combined with a topical antibiotic–corticosteroid cover – Dexamytrex (dexamethasone/gentamycin sulphate) five times/day. Five days after surgery, his pressure was 14 mmHg with flat and injected bleb. Ten days later, IOP was 4 mmHg, but bleb was small and congested without wound leak. In anticipation of patient’s receptivity to a standard classical postoperative regimen, we placed him additionally on bevacizumab drops five times/day for 4 weeks. Mydriatic drops were continued up to 2 weeks, and topical antibiotic–corticosteroid drops were continued up to 6 weeks in reducing doses. Five times/day in 1st and 2nd week; four times/day in 3rd week; three times/day in 4th week; two times/day in 5th week; once a day in 6th week. During observation period, the size and extent of ocular surface vascularity became smaller, and 2.5 months later, conjunctival vascularity almost completely regressed. (Fig. 2) After four to six months of follow-up (RE/LE, respectively), patient’s postoperative recovery was uneventful, with successful control of IOP at the level of 9–12 mmHg (LE) and 8 mmHg (RE). Topical bevacizumab drops were not associated with any complications, and no recurrence of increased vascularity developed throughout the observation period. (A) RE – flat and injected bleb before bevacizumab instillation 10 days after trabeculectomy, (B) RE – 10 days after topical administration of bevacizumab, (C) RE – 2.5 months after topical administration of bevacizumab, (D) RE – 4 months after topical administration of bevacizumab, revealing regression of bleb vascularity. Bevacizumab appears to have a promising role in the treatment of failing blebs, because it brings rapid resolution of bleb vascularity and control of IOP. Some reports have indicated that neovascularization onset is variable, but in most cases, it occurs within the first 2 weeks after surgery that could be the proper timing to initiate therapy (Coote et al. 2008). Subconjunctival injection of bevacizumab reduces bleb vascularity and may provide an enhancement to standard antifibrosis therapy (Bock et al. 2007). Our observations suggest that topical anti-VEGF therapy is less invasive and thus encouraging option to subconjunctival administration in treating failures of trabeculectomy. We chose topical instead of subconjunctival administration because topical bevacizumab is more convenient (not painful) and may be administered by the patient at home. There are certainly some drawbacks of topical bevacizumab, they include proper drops preparation, storage and compliance. However, further studies are recommended to clarify the long-term safety and efficacy of such therapy. Optimal concentration of bevacizumab drops used for this purpose should also be established." @default.
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• W2086421826 title "Topical bevacizumab is efficacious in the early bleb failure after trabeculectomy" @default.
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