The Effect of Intravitreal Bevacizumab Injection before Trabeculectomy in Patients with Neovascular Glaucoma

You Hyun Lee; Rebecca Kim; Sung Dong Chang

doi:10.3341/jkos.2015.56.6.917

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Lee, Kim, and Chang: The Effect of Intravitreal Bevacizumab Injection before Trabeculectomy in Patients with Neovascular Glaucoma

Original Article

J Korean Ophthalmol Soc 2015;56(6):917-924.

Published online: 7 September 2015

DOI: https://doi.org/10.3341/jkos.2015.56.6.917

The Effect of Intravitreal Bevacizumab Injection before Trabeculectomy in Patients with Neovascular Glaucoma

You Hyun Lee, MD, Rebecca Kim, MD, Sung Dong Chang, MD, PhD

Department of Ophthalmology, Keimyung University School of Medicine, Daegu, Korea

Address reprint requests to Sung Dong Chang, MD, PhD Department of Ophthalmology, Keimyung University Dongsan Medical Center, #56 Dalseong-ro, Jung-gu, Daegu 700-712, Korea, Tel: 82-53-250-7708, Fax: 82-53-250-7705 E-mail: changsd@dsmc.or.kr

Received 28 November 20144 January 2015 Accepted 6 May 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the efficacy of preoperative intravitreal bevacizumab injection (IVBI) and prognostic factors of surgical success in neovascular glaucoma patients, who underwent trabeculectomy.

Methods

A total of 58 patients (58 eyes) diagnosed with neovascular glaucoma who underwent trabeculectomy between 2003 and 2013 were enrolled in this retrospective study. Trabeculectomy with mitomycin C was performed between 2003 and 2006 and additional preoperative IVBI with the above mentioned technique was performed between 2007 and 2013. To evaluate the efficacy of preoperative IVBI, the patients were divided into the preoperative IVBI group and control group. Best corrected visual acuity (BCVA) and intraocular pressure (IOP) were measured from preoperative to postoperative 12 months. To evaluate the prognostic factors related to surgical success, the following was investigated: age, lens status, preoperative IVBI, time interval between preoperative IVBI and trabeculectomy, previous vitrectomy and, postoperative complications.

Results

Trabeculectomy with mitomycin C only was performed in 26 eyes and additional preoperative IVBI was performed in 32 eyes. Surgical success was 81.3% in the IVBI group and 57.7% in the control group at postoperative 6 months (p = 0.012), and 78.1% in the IVBI group and 50.0% in the control group at postoperative 12 months (p = 0.021). Statistically significant IOP reduction effect was observed in the IVBI group (p = 0.048), and reduced anti-glaucoma eye drop usage was observed in the IVBI group (0.4) compared with 0.8 in the control group (p = 0.040). Postoperative hyphema (hazard ratio [HR] = 2.872, p = 0.044) and preoperative IVBI (HR = 0.280, p = 0.030) were considered risk factors for surgical failure in univariate analysis, however, only preoperative IVBI was statistically significant in multivariate analysis (p = 0.046).

Conclusions

In neovascular glaucoma patients, preoperative IVBI before trabeculectomy is a good prognostic factor of surgical success and shows benefit in lowering the IOP and reducing anti-glaucoma eye drop usage at postoperative 1 year.

Keywords: Bevacizumab, Hyphema, Neovascular glaucoma, Trabeculectomy

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Figure 1.

Cumulative probability of the surgical success of the preoperative intravitreal bevacizumab injection (IVBI) group and the control group after trabeculectomy for neovascular glaucoma by Kaplan-Meier Survival Analysis.

Figure 2.

Mean best corrected visual acuity (BCVA, log MAR) changes in the preoperative intravitreal bevacizumab injection (IVBI) group and the control group after trabeculectomy for neovascular glaucoma. PreOP = preoperation. ^*Statistically significant changes compared to preoperative BCVA in IVBI group; ^†Statistically significant changes compared to preoperative BCVA in control group.

Figure 3.

Mean intraocular pressure (IOP) changes in the pre-operative intravitreal bevacizumab injection (IVBI) group and the control group after trabeculectomy for neovascular glaucoma. PreOP = preoperation. ^*Statistically significant changes compared to preoperative IOP in IVBI group. ^†Statistically significant changes compared to preoperative IOP in control group.

Table 1.

Baseline characteristics of trabeculectomy patients in neovascular glaucoma

Characteristics	Numbers (%)
Gender
Male	38 (65.5)
Female	20 (34.5)
Age (years)
>50	24 (41.4)
≤50	34 (58.6)
Prior surgery
Pseudophakic eyes	37 (63.8)
Vitrectomized eyes	19 (32.8)
Previous PRP
Yes	58 (100)
No	0 (0)
Predisposing diagnoses
Proliferative diabetic retinopathy	49 (84.5)
Retinal vascular occlusion	6 (10.3)
Ocular ischemic syndrome	3 (5.2)
Previous IVBI
Yes	32 (55.2)
No	26 (44.8)

PRP = panretinal photocoagulation; IVBI = intravitreal bevacizumab injection.

Table 2.

Baseline characteristics of IVBI and control group

	IVBI group	Control group	p-value
Age (years)	56.53 ± 11.86	52.73 ± 11.27	0.472
DM (n, %)	28 (87.5)	25 (96.2)	0.367
Eye (OD/OS)	13/19	14/12	0.428
Preoperative IOP (mm Hg)	37.12 ± 10.58	38.15 ± 14.05	0.667
Preoperative BCVA (log MAR)	1.42 ± 0.63	1.47 ± 0.50	0.868
Previous vitrectomy (n, %)	9 (28.1)	10 (38.5)	0.574
Lens status (n, %)			1.000
Phakic	12 (37.5)	9 (34.6)
Pseudophakic	20 (62.5)	17 (65.4)
Predisposing diagnosis (n, %)			0.211
Proliferative diabetic retinopathy	25 (78.1)	24 (92.3)
Retinal vascular occlusion	4 (12.5)	2 (7.7)
Ocular ischemic syndrome	3 (9.4)	0 (0)

Values are presented as mean ± SD unless otherwise indicated.

IVBI = intravitreal bevacizumab injection; DM = diabetes mellitus; OD = oculus dexter; OS = oculus sinister IOP = intraocular pressure; BCVA = best corrected visual acuity.

Table 3.

Complications of the IVBI group and the control group

	IVBI group (n, %)	Control group (n, %)	p-value
Hyphema	5 (15.6)	9 (34.6)	0.085
Choroidal detachment	13 (40.6)	8 (30.8)	0.250

IVBI = intravitreal bevacizumab injection.

Table 4.

Multivariate Cox proportional hazard regression model for hyphema in neovascular glaucoma

	Hazard ratio (95% CI)	p-value
Eye (OD/OS)	0.513 (0.135-1.940)	0.325
Sex (M/F)	1.017 (0.241-4.298)	0.982
Preoperative IVBI	0.374 (0.097-1.439)	0.153
Preoperative IOP	1.049 (0.989-1.112)	0.111

CI = confidence interval; OD = oculus dexter; OS = oculus sinister IVBI = intravitreal bevacizumab injection; IOP = intraocular pressure.

Table 5.

Regression of neovascularization of iris period and postoperative anti-glaucoma eye drop usage in the IVBI group and the control group

	IVBI group	Control group	p-value
Regression of NVI period (days)	15.53 ± 12.66	46.42 ± 49.75	0.000
Numbers of anti-glaucoma eye drop usage	0.4 ± 0.8	0.8 ± 1.1	0.040

Values are presented as mean ± SD.

IVBI = intravitreal bevacizumab injection; NVI = neovascularization of iris.

Table 6.

Univariate Cox proportional hazard regression model for surgical failure of trabeculecomy in neovascular glaucoma

	Hazard ratio (95% CI)	p-value
Age (>50 years)	0.892 (0.376-2.145)	0.266
Sex (M/F)	1.444 (0.468-4.454)	0.570
Preoperative IVBI	0.280 (0.090-0.873)	0.030
Regression of NVI period (≥2 weeks)	1.957 (0.587-6.516)	0.385
Lens status (Pseudophakia)	1.238 (0.578-4.228)	0.563
Vitrectomized eyes	1.636 (0.525-5.099)	0.557
Postoperative hyphema	2.872 (0.809-10.192)	0.044
Trabeculectomy done after regression of NVI in preoperative IVBI patients	0.731 (0.579-0.923)	0.296
Interval period between preoperative IVBI and trabeculectomy (≥2 weeks)	0.233 (0.024-2.252)	0.372

CI = confidence interval; IVBI = intravitreal bevacizumab injection; NVI = neovascularization of iris.

Table 7.

Multivariate Cox proportional hazard regression model for surgical failure of trabeculecomy in neovascular glaucoma

	Hazard ratio (95% CI)	p-value
Age (>50 years)	0.972 (0.352-2.472)	0.266
Preoperative IVBI	0.295 (0.087-0.983)	0.046
Vitrectomized eyes	1.326 (0.384-4.579)	0.655
Postoperative hyphema	2.646 (0.809-10.303)	0.161

CI = confidence interval; IVBI = intravitreal bevacizumab injection.

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