Effect of pre-op subconjuntival injection of bevacizumab in pterygium surgery

1
Effect of pre-op subconjuntival injection of
bevacizumab in pterygium surgery

• Young Jeung Park, M.D. Ph.D.
• Jong Wook Lee, M.D.
• Kyoo Won Lee, M.D. Ph.D.
• Financial DisclosureAll authors declares no
  financial interest
• Cheil Eye Hospital , Daegu, Korea

2
Background

• Vascular Endothelial Growth Factor (VEGF)
• - Mediator cytokine of pathological
  angiogenesis
• Angiogenesis in pterygium
• - Angiogenic stimulators?, inhibitors?
• ? the formation and progression of pterygium
• Application of anti-VEGF therapy
• ? Inducing regression of blood vessels in
  pterygium
• ? Pterygial recurrence ?

3
The Effects of the Subconjunctival Injection of
bevacizumab (Avastin) in Recurrent Pterygium
2008 ASCRS poster presentation J. Korean
Ophthalmol Soc. 2008 Dec 49(12)1901-1909

• The maximum effect of subconjunctival injection
  of pterygium lasted less than 1 month.
• In ICG, the thickness of conjunctival blood
  vessels decreased(30.14).
• The subconjunctival injection of bevacizumab
• 0.2cc was effective for recurrent pterygium

4
Purpose

• To evaluate the effects of pre-op
  subconjunctival injection of bevacizumab in
  pterygium surgery.

5
Methods

• Bevacizumab group 25 eyes / Control group 25
  eyes
• Bevacizumab group Bevacizumab subconjunctival
  injection (0.2cc)
• 12 weeks pre-op
• Excision of pterygium and superior
  conjuntivolimbal autograft
• Followed up at 1st week, 2nd week, 4th week, and
  every month thereafter.

Demography
Bevacizumab group Bevacizumab group Control group Control group
Recurrent pterygium Primary pterygium Recurrent pterygium Primary pterygium
N 7 18 7 18
MF 34 117 25 135
Age 52.48.2 53.710.8 51.74.9 55.79.8
Pterygium grade 3 3 3 3
Follow-up period 24.863.80 26.442.36 26.862.04 25.672.59
6
Evaluation

• 1. Grades of vascularity Immunohistochemistr
  y for VEGF of tissues obtained from pterygium
  surgery.
• 2. Degree of edema in conjuntivolimbal
  autograft.
• 3. Ocular and systemic complications.

Pictures of grades of vascularity -
observed for vessel diameter and vessel
density.   - Values per picture (A)1.0,
(B)1.5, (C)2.0, (D)2.5, (E)3.0
The scoring system of graft edema
0 no edema, equal in thickness to normal
conjuntiva 1 mild edema, graft edema
within x1 of the corneal thickness under
slit-lamp exam. 2 moderate edema, between
13 3 severe edema, graft edema above x2
of the corneal thickness under slit-lamp exam.
Fisher exact test
7
Comparison vascularization of pterygium tissue
obtained from pterygium surgery
Bevacizumab group
Control group
Notice the marked decrease in vascularization
grade in group with bevacizumab treatment
compared to the control group.
8
Average vascular grading score
Bevacizumab Control P
N(recurrent/primary) 25(7/18) 25(7/18)
Vascular grading score (meanSD) 1.970.68 2.160.50 0.3188
Immunohistochemistry for VEGF of pterygium
tissue form pterygium surgery
(B) represents stronger stain concentration at
the apical epithelium, indicating denser
concentration of VEGF.
9
Comparison of the graft edema presented at
conjuntivolimbal autograft
The bevacizumab group exhibits more persistent,
and significant graft edema on 2nd month follow
up after surgery
10
Two Cases of persistent post-surgical graft
edema (Bevacizumab group)
(A, B-1) shows severe graft edema 3 months after
surgery. (A, B-2) shows normal connection
between graft vessels and recipient vessels on
ICG anterior segment angiography
Authors hypothesize that the graft edema may be
due to suppression of lymphangiogenesis induced
by bevacizumab.
B-2
11
Complications

• Any pterygial recurrence none
• Other ocular systemic complication none

12
Conclusions

• 1. Vascular grading comparison bevacizumab
  group/control group 1.970.68/2.160.50
• 2. Pre-op bevacizumab injection group presented
  lower VEGF stain .
• ? Subconjunctival injection of bevacizumab on
  pterygium region is effective in reducing the
  vascular thickness and oncurrence of VEGF in the
  histologic pterygium region.
• 3. Persistent auto-graft edema observed at the
  8th week post op compared to the control group.
• ? Bevacizumab inhibit lymphangiogenesis as well
  as
• angiogenesis.
• ? The delay of surgical wound healing must be put
  into
• consideration when using bevacizumab before
• pterygium surgeries.