By Fred Gebhart
SAN FRANCISCO -- October 27, 2009 -- Intravitreal bevacizumab shows advantages for patients with neovascular glaucoma that are refractory to conventional treatment, researchers stated here at the 2009 Joint Meeting of the American Academy of Ophthalmology and Pan-American Association of Ophthalmology (AAO-PAAO).
Patients showed no improvement in visual acuity as a result of treatment, but had significant pain relief and had safer, more predictable surgical results compared with control eyes.
"We had people coming back a week after bevacizumab saying they had not had a full night's sleep in years until this treatment," said Alexander Spratt, Glaucoma Research Unit, Moorfields Eye Hospital, London, United Kingdom, on October 25. "Bevacizumab also helped them get through surgery. This is an important finding, especially since the conventional alternatives are no good."
Panretinal photocoagulation (PRP) has long been the treatment of choice to reduce ischaemia and to prevent the formation of new vessels or induce the regression of existing vessels. Increasing pressure can cause severe pain that interferes with sleep and other normal activities, Dr. Spratt noted. Eyes in which PRP is not effective account for a large percentage of eviscerations and enucleations.
For the study, Dr. Spratt and colleagues injected 50 consecutive eyes with a single intravitreal injection of bevacizumab 1.25 mg and 5% topical povidone-iodine in the conjunctival fornix. Additional injections were given only as clinically indicated. Follow-up visits were scheduled at 1 week, then 1, 3, and 6 months.
Patients who were able to distinguish hand motion or better were given surgical glaucoma drainage. Patients who were unable to distinguish hand motion but had light perception were given cyclodiode laser treatment.
Of the 50 eyes, 27 had tube surgery, 12 had cyclodiode laser treatment, and 11 needed no further treatment following bevacizumab injection. Subjective pain scores were significantly lower 1 week following injection, Dr. Spratt said, and the improvement continued to the end of follow-up at 6 months.
Intraocular pressure was also reduced significantly, from a mean of 38.2 mm Hg before bevacizumab injection to 29 mm Hg at 1 week and 21.9 mm Hg at 6 months.
In addition, the number of glaucoma medications was reduced from 3.7 before injection to 1.4 at 6 months.
Dr. Spratt said the most important criticism of the study was the lack of randomised control. He agreed that a randomised controlled trial would be beneficial, but said it would probably never be conducted.
"We think it is unethical to randomise in this condition," he explained. "When the untreated eyes end up in the dustbin, how do you randomise ethically? What we know now is that if you catch patients early with open angles, bevacizumab can prevent progression, keep that angle open, and avoid PRP."
[Presentation title: Intravitreal Bevacizumab for Neovascular Glaucoma Refractory to Conventional Treatment: A 6-Month Prospective Case Series. Abstract PO122]
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