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Editors Selection IGR 16-1

Surgical Treatment: Anti-scarring adjunct therapy

Comment by Malik Kahook on:

54014 Postoperative subconjunctival bevacizumab injection as an adjunct to 5-fluorouracil in the management of scarring after trabeculectomy, Freiberg FJ; Matlach J; Grehn F et al., Clinical Ophthalmology, 2013; 7: 1211-1217

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Ophthalmologists currently modulate the wound-healing cascade after filtration surgery by using agents such as mitomycin-C (MMC) and 5-Fluorouracil (5-FU) as well as both injectable and topical glucocorticoids. MMC has become the most commonly used anti-fibrotic which has resulted in greater intraocular pressure (IOP) lowering efficacy as well as greater risk of hypotony and bleb related adverse events such as infection and dysesthesia. The search for better wound modulation methods to influence surgical success has been ongoing. Vascular Endothelial Growth Factor (VEGF) plays a major role in the healing response and has been explored by several groups as an adjunct for modulating fibrosis after glaucoma filtration surgery. Collagen deposition with scar formation as well as angiogenesis and inflammation are all influenced by VEGF to some degree.

Freiberg and colleagues (Clinical Ophthalmology 2013; 7: 1211-1217) recently published a retrospective case series comparing outcomes after use of subconjunctival 5-FU after trabeculectomy with MMC in two groups. The first group received only 5-FU injections while the second group received a single subconjunctival injection of the anti- VEGF bevacizumab. They reported less 5-FU injections in the group that received the single bevaciuzmab injection. A higher number of 5-FU injections in either group was linked with more complications. Other outcome measures such as IOP and bleb morphology were similar between groups at last follow-up (25 ± 19 months). Notable findings include 14 bleb needle procedures in group 1 (5-FU only) versus only four in group 2 (5FU+bevacizumab) as well as three repeat trabeculectomies in group 1 and none in group 2. It is unclear why there were seven 'resutures of scleral flap' in group 1 versus only one in group 2. This report highlights the need for improved wound modulation techniques after filtration surgery. Limitations of the study include the retrospective design as well as the use of a single subconjunctival injection of bevacizumab that lasts less than one week. It is unclear how longer-lasting intravitreal bevacizumab injections might have influenced the reported findings. The search for the appropriate wound modulation cocktail continues and will require more rigorous prospective data to help guide surgical practice in the future.

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