Intravitreal Bevacizumab (Avastin) for Diabetic Retinopathy: The 2010 GLADAOF Lecture

J Fernando Arevalo, Juan G Sanchez, Andres F Lasave, Lihteh Wu, Mauricio Maia, Sergio Bonafonte, Miguel Brito, Arturo A Alezzandrini, Natalia Restrepo, Maria H Berrocal, Mario Saravia, Michel Eid Farah, Jans Fromow-Guerra, Virgilio Morales-Canton, J Fernando Arevalo, Juan G Sanchez, Andres F Lasave, Lihteh Wu, Mauricio Maia, Sergio Bonafonte, Miguel Brito, Arturo A Alezzandrini, Natalia Restrepo, Maria H Berrocal, Mario Saravia, Michel Eid Farah, Jans Fromow-Guerra, Virgilio Morales-Canton

Abstract

This paper demonstrates multiple benefits of intravitreal bevacizumab (IVB) on diabetic retinopathy (DR) including diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) at 24 months of followup. This is a retrospective multicenter interventional comparative case series of intravitreal injections of 1.25 or 2.5 mg of bevacizumab for DME, PDR without tractional retinal detachment (TRD), and patients who experienced the development or progression of TRD after an intravitreal injection of 1.25 or 2.5 mg of bevacizumab before vitrectomy for the management of PDR. The results indicate that IVB injections may have a beneficial effect on macular thickness and visual acuity (VA) in diffuse DME. Therefore, in the future this new therapy could complement focal/grid laser photocoagulation in DME. In PDR, this new option could be an adjuvant agent to panretina photocoagulation so that more selective therapy may be applied. Finally, TRD in PDR may occur or progress after IVB used as an adjuvant to vitrectomy. Surgery should be performed 4 days after IVB. Most patients had poorly controlled diabetes mellitus associated with elevated HbA1c, insulin administration, PDR refractory to panretinal photocoagulation, and longer time between IVB and vitrectomy.

Figures

Figure 1
Figure 1
Changes in best-corrected visual acuity (BCVA) after intravitreal bevacizumab. BCVA improved at 1 month from 0.90 to 0.76 (logarithm of the minimum angle of resolution), a difference that was statistically significant (P < .001), this level of BCVA was maintained throughout 3-, 6-, 12-, and 24-months. CI: confidence interval (Reprinted with permission from [13]).
Figure 2
Figure 2
Changes in macular thickness with optical coherence tomography (OCT) during followup after intravitreal bevacizumab. The foveal thickness improved after 1 month, mean 1-mm central macular thickness (CMT) measurement decreased from 446.4 μm ± 154.4 μm to 333.75 μm ± 117 μm (P < .001), and this overall improvement continued throughout the 24-month followup. At 3-, 6- 12- and 24-month followup were 344.7 ± 115.3 μm, 321.7 ± 102.7 μm, 303 ± 89.1 μm and, 279.7 ± 80 μm, respectively, which were significantly lower than at 1-month followup (P < .001). CI: confidence interval (Reprinted with permission from Arevalo JF, Sanchez JG, Wu L, Maia M, Alezzandrini AA, Brito M, Bonafonte S, Lujan S, Diaz-Llopis M, Restrepo N, Rodríguez FJ, Udaondo-Mirete P; Pan-American Collaborative Retina Study Group. Primary intravitreal bevacizumab for diffuse diabetic macular edema the Pan-American Collaborative Retina Study Group at 24 months. Ophthalmology 2009; 116:1488-97, 1497.e1. Epub 2009 Jul 9).
Figure 3
Figure 3
Sequential optical coherence tomography (OCT) of a 69-year-old diabetic woman with a 6-months history of lost of vision to counting fingers (CF) in her left eye that had developed diabetic macular edema (DME).
Figure 4
Figure 4
A 53-year-old man had a 2-month history of visual loss to 20/60 in his right eye. We had performed panretinal photocoagulation (PRP) in his right eye 2 years previously. Fundus examination revealed a mild vitreous hemorrhage. (a) Fluorescein leakage from neovascularization of the disc (NVD) at baseline between retinal vessels crossing the optic disc was demonstrated. In addition, fluorescein angiography (FA) showed magnification of retinal neovascularization elsewhere (NVE) in the superonasal retina. (b) At week 1 after intravitreal bevacizumab, total resolution of leakage from NVD and NVE are shown. His visual acuity returned to 20/32 one month later. He needed a reinjection at months 6, 14, and 24 of followup. A PRP was performed at 24 months.
Figure 5
Figure 5
(a)–(c) Color photographs before intravitreal bevacizumab. Severe proliferative diabetic retinopathy with abundant fibrovascular tissue and subhyaloid hemorrhage. The retina is attached and best-corrected visual acuity (BCVA) is 20/80. (d)–(f) Color photographs 10 days after 2.5 mg of intravitreal bevacizumab demonstrating dense fibrous tissue contraction, and tractional retinal detachment with macular involvement. BCVA is hand motions at 2 meters. (g)–(i) Same eye, eight days after vitrectomy. The retina is reattached and best-corrected visual acuity (BCVA) is 20/120 with silicone oil tamponade.

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