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Editors Selection IGR 12-1

Surgical Treatment: Bevacizumab and/or 5 FU

Comment by Peng Tee Khaw & Ashkan Khalili on:

25100 Combined treatment with bevacizumab and 5-fluorouracil attenuates the postoperative scarring response after experimental glaucoma filtration surgery, How A; Chua JL; Charlton A et al., Investigative Ophthalmology and Visual Science, 2010; 51: 928-932

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The use of anti-VEGF antibodies such as bevacizumab has stimulated a lot of interest recently in ophthalmology. More recently, attention has been turned to post-operative scarring which is an extremely important problem in many situations, but particularly after glaucoma surgery. This was stimulated by the finding that systemic bevacizumab increases the rate of wound dehiscence in colon rectal and anastomosis. There is now evidence both in models of glaucoma surgery and also clinically that bevacizumab may be useful, but nonetheless the clinical experience suggests that bevacizumab are not much stronger than 5-Fluorouracil injections. Therefore, stronger agents are still required. In this study, Wong et al. (490) have used a well established model of glaucoma filtration surgery to examine the effects of using both bevacizumab and 5-Fluorouracil alone and then in combination. What they have found using a variety of outcomes including histology expression, MRHA expression of collagen 1 and fibronectin and also clinical masked grading of the bleb is that the combination of 5-Fluorouracil and bevacizumab is superior to 5-Fluorouracil or bevacizumab alone.

Combinations of agents which are readily available for clinical use might be more effectively used for would healing modulation

What the study does not show is the exact mechanism of action of bevacizumab and 5-Fluorouracil combined. Although the authors have shown a decrease in collagen and fibronectin, this could be partially mediated by some of the effects of the carrier trehalose or IgG itself on the fibroblasts and other cells which may in turn give rise to other effects in humans. Also the precise role of vascularity and angiogenesis is uncertain. However, these elements are a standard part of the current clinical injection so are an intrinsic part of the effect. Their findings are important as they suggest that combinations of agents which are readily available for clinical use might be more effectively used together, and if translated into the clinical setting would increase our armamentarium available to prevent scarring and improve surgical success rate after glaucoma surgery. What is clearly needed now is an appropriate clinical study to confirm whether or not this is the case in a clinical setting. This is an important study to lead the way forward to suggesting how new available combinations of existing drugs potentially help us increase the success of glaucoma filtration surgery.

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