The Effects of the Subconjunctival Injection of Bevacizumab (Avastin

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The Effects of the Subconjunctival Injection of
Bevacizumab (Avastin) in Recurrrent Pterygium

• Cheil Eye Hospital
• Young Jeung Park, MD
• Jong Wook Lee, MD
• Kyoo Won Lee, MD

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Background

• Vascular Endothelial Growth Factor (VEGF)
• - Mediator cytokine
• of pathological angiogenesis
• - Key transcriptional regulator
• of hypoxic responses

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Angiogenesis in pterygium

• Angiogenic stimulators?, inhibitors?
• the formation and progression of pterygium
• Abundant expression of VEGF
• in pterygium tissue
• Application of anti-VEGF therapy
• Inducing regression of blood vessels in
  pterygium

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Bevacizumab (Avastin)

• Humanized recombinant Ab
• binds all isoforms of VEGF

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Purpose

• To evaluate the effects of
• the subconjunctival injection
• of Bevacizumab (Avastin)
• in recurrent pterygium.

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Materials and Methods

• From December 2006 to May 2007
• 20 eyes with recurrent pterygium
• Bevacizumab subconjunctival injection (0.2cc)
• Folllowed up at 1st week, 2nd week, 4th week, and
  every month thereafter.
• Evaluation
• - Clinical results (degree of conjunctival
  injection)
• - ICG angiography
• at pre-injection and at 2 weeks
  post-injection)
  
• - Ocular and systemic complications

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Method of subconjunctival Bevacizumab injection

• Bevacizumab (Avastin)
• - Refrigerated before use
• - No more than 14 days
• Topical anesthesia
• 5 povidone/iodine and topical antibiotics
• 0.2cc (5.0mg) of Avastin injected
  subconjuntivally with tuberculin syringe(30G)
• Topical antibiotics steroid

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The level of conjunctival injection

• Level 1 - Reached the rock-bottom after
  injection.
• Level 2 - Level between 13.
• Level 3 - Similar level before injection.
• Level 4 - Increase of conjunctival injection
• compared to the degree before
• Bevacizumab injection.
• Wilcoxon signed ranks test

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Vessel thickness

• ICG ant. segment angiography
• with HRA II
• - 10 eyes
• - Before and 2 weeks after the subconjunctival
  injection
• - Measured 5 vessels thickness per eye
• - Larger than 0.01mm
• (possible to measure the thickness)
• Paired t-test

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Demography
(Mean SD)
Patients No. 20
Sex (M / F) 6/14
Age (years) 53.45 18.32(3872)
Follow-up period (weeks) 17.108.22
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Clinical Results
Before treatment
1 week after treatment
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Progressive change in the level of conjunctival
injection
Wilcoxon signed ranks test
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Changes in degree of conjunctival injection
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B. 2 weeks after
A. Pre-injection
D. 5 months after
C. 2 months after
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Ant. segment photographs and ICG angiopgaphy
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The change of conjunctival vessel thickness of
recurrent pterygium
Paired T-test
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Complications

• Subconjunctival hemorrhage - 4 cases
• ? resolved within 1 week
• Rebound conjunctival injection - 2 cases
• ? improved after reinjection
• Other ocular systemic complication - none

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Rebound conjunctival injection Case-1
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Rebound conjunctival injection Case-2
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Conclusions

• After injection, Conjunctival injection was
  decreased than before injection.
• 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

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• Additional research
• - timing of additional injection
• - the long term effect on the progress of
• recurrent pterygium.

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Rebound phenomenon

• Matsumoto Y et al.
• Rebound macular edema following bevacizumab
  therapy for retinal venous occlusive disease.
• Retina 200727426-31
• Inhibition of the VEGF pathway by Bevacizumab
• ? Upregulate VEGF receptors
• ? An increase in VEGF receptors
• ? the endothelial cells more sensitive to
  the VEGF

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The End
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