PTERYGIUM AND TOPICAL BEVACIZUMAB: A 2 YEAR FOLLOW UP

DR. ADITYA SUDHALKAR,M.S.DR. ANAND SUDHALKAR,M.S.

The authors have no financial interest in this presentation

INTRODUCTION

Pterygium: Subconjunctival elastotic degeneration; Can be a cosmetic blemish and/or interfere with vision Excision is the primary treatment modality; recurrence is

often a problem Numerous adjuvants suggested for preventing recurrence,

including:

• Mitomycin C, 5 FU, triamcinolone

• Irradiation**

• Conjunctival autografts Their efficacy however, is variable Bevacizumab has been suggested as an off label use**Effect of subconjunctival bevacizumab on primary pterygiumTeng

CC, Patel NN, Jacobson L. Cornea. 2009 May;28(4):468-70*Topical bevacizumab for corneal limbal neovascularisation to prevent impending recurrence of pterygiumWu PC, Kuo HK, Tai MH, Shin SJ.Cornea. 2009 Jan;28(1):103-4**Strahlenther Onkol. 2009 Dec;185(12):808-14 Vastradis et al.*Med Hypotheses. 2007;69(4):925-7. Bevacizumab as a potential novel adjunct in the management of pterygia

PURPOSE:

To determine the efficacy and safety of topical bevacizumab in flurbiprofen as an adjunct to conjunctival autograft in prevention of recurrence of primary pterygium

METHODS:

STUDY DESIGN: Prospective Case Series

PATIENTS: 17 consecutive patients of primary pterygium, with :

• No associated systemic or ocular disorder

• No known predisposition to hypersensitivity reactions

TREATMENT: Primary pterygium excision with conjunctival autograft; single surgeon, standardised technique.

POST OPERATIVE REGIMEN(FOR 4 WEEKS-q.i.d.):

• Antibiotic steroid *eye drops

• Bevacizumab(0.3mg/drop), topically with punctal occlusion-5 minutes

• Flurbiprofen eye drops

• Preservative free artificial tears

FOLLOW UPS : Post operative days 1, 7, 30, 90, 180, years 1 and 2.

OUTCOME MEASURES:

Recurrence of pterygium

Safety of bevacizumab eye drops administered topically

RESULTS:

MEAN AGE: 43.12+/-3.24years(range-35 to 49 years)

GENDER DISTRIBUTION: Males: 10; Females 7

TOPICAL REGIMEN WELL TOLERATED

NO RECURRENCE TILL THE END OF THE FOLLOW -UP PERIOD

• Seven patients complained of foreign body sensation; treated with lubricants

• 2 had dellen formation, resolved with artificial tears

• 1 had hyperemia of the autograft, resolved with flurbiprofen

ILLUSTRATIVE CASE:

POST OPERATIVE: AT END OF TWO YEARS

PRE -OPERATIVE

DISCUSSION:

Recurrence of pterygium entails further procedures on a patient; excision can leave a scar

Antimetabolites, irradiation not without side effects

Bevacizumab in an off label use has been shown to be effective in prevention of recurrence*

Subconjunctival bevacizumab in immediate post operative period might not prevent neovascularisation which usually occurs later

Multiple subconjunctival* injections potentially hazardous and painful;*Ann Ophthalmol (Skokie). 2010;42 Spec No:28-30. Multiple subconjunctival injections for advanced primary

pterygium*Cornea. 2011 Feb;30(2):127-9 Fallah et al. Intralesional bevacizumab in decreasing pterygium size.

DISCUSSION:

Administration of topical therapy(bevacizumab+flurbiprofen) with punctal occlusion did not produce ocular/systemic side effects

Topical therapy gives a prolonged dose of bevacizumab to the autograft

None of the patients showed a recurrence till the end of follow up period

Steroids not a confounding factor as they have not shown to significantly alter recurrence rates*~*Cornea. 2010 Feb;29(2):141-5, Comparison of recurrence rates….Kandavel et al

~Ann Ophthalmol. 1985 Jan;17(1):92-5. Pterygium: clinical classification and management in Virgin Islands. Anduze et al.~East Afr Med J. 1992 Sep;69(9):490-3. Post-operative management of pterygium in Jos, Nigeria--comparison of antibiotics, steroids and opticrom

REFERENCES:

Pterygium. Etiology, clinical aspects and novel adjuvant therapies].Heindl LM, Cursiefen C.Ophthalmologe. 2010 Jun;107(6):517-20, 522-4

Safety and efficacy of intraoperative 5-fluorouracil infiltration in pterygium treatment].

Vlezi VG, et al. Arq Bras Oftalmol. 2009 Mar-Apr;72(2):169-73.

Comparative Study of Different β-Radiation Doses for Preventing Pterygium Recurrence.

Yamada T et al. Int J Radiat Oncol Biol Phys. 2010 Oct

Results of treatment with topical mitomycin C 0.02% following excision of primary pterygium. Rachmiel R et al.Br J Ophthalmol. 1995 Mar;79(3):233-6

Postoperative subconjunctival corticosteroid injection to prevent pterygium recurrence.

Paris Fdos et al.Cornea. 2008 May;27(4):406-10

Dev Ophthalmol. 2010;46:133-9. Scholl et al. Anti vascular growth factors in anterior segment disease

Cornea. 2009 May;28(4):468-70. Teng et al. Effect of subconjunctival bevacizumab on primary pterygium

LIMITATIONS:

Small sample size

No control group

Further studies will be required

CONCLUSION

Topical Bevacizumab appears to be safe and effective in preventing pterygium recurrence.