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Editors Selection IGR 8-4

Surgery: Bevacizumab in avascular blebs

Comment by Tina Wong on:

22406 Vascular changes after intra-bleb injection of bevacizumab, Coote MA; Ruddle JB; Qin Q et al., Journal of Glaucoma, 2008; 17: 517-518

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Increased vascularity at the bleb site after trabeculectomy surgery is one of the principal markers used to guide anti-fibrosis treatment after glaucoma surgery.

Coote et al. (1712) describes the longitudinal changes in conjunctival vascularity following a single subconjunctival injection of bevacizumab following cataract surgery in a glaucoma patient who had a pre-existing functioning filtering bleb. The patient developed a visually significant cataract three months after trabeculectomy surgery. This is a common scenario that we often encounter in the clinic. The result of a consecutive operation can often be associated with greater post-operative conjunctival inflammation thereby increasing the risk of bleb failure. The authors demonstrate that the administration of bevacizumab (in the one case) at the right time after surgery, can effectively reduce conjunctival vascularity with no evident signs of toxicity at six months. The results are encouraging. Post-operative inhibition of vasculoproliferative scarring of the bleb has up to now mostly relied on the administration of 5-FU subconjunctival injections, which is far from ideal when given repeatedly. Now there appears to be a newcomer in the horizon. However, despite the encouraging reports many questions remain unanswered. Firstly, the optimum dosing has to be determined for this therapeutic role, as well as the safety profile for repeated injections. Secondly, apart from its well-established anti-angiogenic property, we need to determine whether bevacizumab possesses any direct anti-fibrotic effect on fibroblasts. Reduction of vascularity alone is unlikely to be a sufficiently effective inhibitor of the scarring response in the long term. The exact role for bevacizumab in the management of scarring after trabeculectomy remains to be described.

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