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

Background

• Vascular Endothelial Growth Factor (VEGF)

- Mediator cytokine

of pathological angiogenesis

- Key transcriptional regulator

of hypoxic responses

Angiogenesis in pterygiumAngiogenesis 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

Bevacizumab (Avastin®)• Humanized recombinant Ab : binds all isoforms of VEGF

Purpose• To evaluate the effects of

the subconjunctival injection

of Bevacizumab (Avastin®)

in recurrent pterygium.

• 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

Materials and Methods

Method of subconjunctival Method of subconjunctival BevacizumabBevacizumab injectioninjection

• Bevacizumab (Avastin®) - Refrigerated before use

- No more than 14 days

1. Topical anesthesia

2. 5% povidone/iodine and topical antibiotics

3. 0.2cc (5.0mg) of Avastin® injected subconjuntivally with tuberculin syringe(30G)

4. Topical antibiotics & steroid

The level of conjunctival injection

Level 1 - Reached the rock-bottom after injection.

Level 2 - Level between 1~3.

Level 3 - Similar level before injection.

Level 4 - Increase of conjunctival injection

compared to the degree before

Bevacizumab injection.

• Wilcoxon signed ranks test

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

Demography

Patients No. 20

Sex (M / F) 6/14

Age (years) 53.45 ± 18.32(38~72)

Follow-up period (weeks) 17.10±8.22

(Mean ± SD)

Clinical Results

Before treatment 1 week after treatment

Progressive change in the level of conjunctival injection

* Wilcoxon signed ranks test

Pre-injection level

B. 2 weeks after

D. 5 months afterC. 2 months after

A. Pre-injection

Changes in degree of conjunctival injection

B. 2 weeks after

D. 5 months afterC. 2 months after

A. Pre-injection

B. 2 weeks after

D. 5 months afterC. 2 months after

A. Pre-injection

B. 2 weeks after

D. 5 months afterC. 2 months after

A. Pre-injection

Pre-injection 2 weeks after

0.04mm

0.04mm

Pre-injection

0.03mm

0.02mm

2 weeks after

Ant. segment photographs and ICG angiopgaphy

The change of conjunctival vessel thickness of recurrent pterygium

* Paired T-test

Complications

• Subconjunctival hemorrhage - 4 cases

resolved within 1 week

• Rebound conjunctival injection - 2 cases

improved after reinjection

• Other ocular & systemic complication - none

A. before injection

C. 2 months after

B. 2 weeks after

D. after reinjection

Rebound conjunctival injection Case-1

A. before injection

C. 2 months after

B. 2 weeks after

D. after reinjection

Rebound conjunctival injection Case-2

Conclusions1. After injection, Conjunctival injection was

decreased than before injection.

2. The maximum effect of subconjunctival injection of pterygium lasted less than 1 month.

3. In ICG, the thickness of conjunctival blood vessels decreased(30.14%).

The subconjunctival injection of Bevacizumab

0.2cc was effective for recurrent pterygium

4. Additional research

- timing of additional injection

- the long term effect on the progress of

recurrent pterygium.

Rebound phenomenon

Matsumoto Y et al. Rebound macular edema following bevacizumab therapy

for retinal venous occlusive disease.Retina 2007;27:426-31

Inhibition of the VEGF pathway by Bevacizumab → Upregulate VEGF receptors → An increase in VEGF receptors → the endothelial cells more sensitive to the VEGF

The EndThank you for your attention