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First Author: N.Varma INDIA
Co Author(s): S. Abrol
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The purpose of this study was to assess safety and efficacy of bevacizumab in comparison with mitomycin C (MMC) in maintaining intraocular pressure (IOP) lowered by trabeculectomy in patients with refractory primary open-angle glaucoma (POAG) and chronic angle closure glaucoma (CACG)
Kalra Hospital, Kirti Nagar, New Delhi, India
Forty eyes from 32 patients diagnosed as POAG or CACG not responding to maximally tolerable medical therapy and having visually significant cataract underwent combined two site phacotrabeculectomy clear corneal phacoemulsification temporally and trabeculectomy superiorly. One group of 20 eyes received MMC soaked in surgical sponge placed underneath the Tenons capsule for 2 minutes and the other group of 20 eyes received bevacizumab subconjunctivally (1.25mg/0.05 ml) administered adjacent to the bleb immediately after completion of trabeculectomy. Surgical steps of standard clear corneal phacoemulsification and conventional trabeculectomy performed by the same surgeon were same in all eyes. Visual acuity and IOP were recorded at baseline, post-operative days 1, 3, 7, week 4, 8, 12 and 6, 12 and 18 months. Bleb morphology was studied at week 1 and thereafter on all follow-up visits. Any bleb complication during follow-up visits was recorded. Primary outcome measure was IOP control and number of IOP lowering medications used post-operatively. Bleb morphology assessed using Moorfields Bleb Grading System (MBGS) was the secondary outcome measure. Surgical success was defined as IOP <21 mm Hg with or without medication and failure as IOP exceeding these criteria on two successive follow-up visits or progressive glaucomatous changes.
There was no clinical or statistically significant difference in IOP (P>0.05), LogMAR visual acuity (P>0.05) and bleb characteristics in the two groups and all eyes achieved satisfactory IOP control without any antiglaucoma medication at 12 weeks follow-up. 6 eyes (30%) in MMC group and 2 eyes (10%) in bevacizumab group had shallow anterior chamber with hypotony on post-op day 1 that responded well to pressure patching. Digital massage was recommended in 3 eyes (15%) from bevacizumab group to bring IOP to acceptable levels. 2 of these eyes (10%) had an IOP of 24 mm Hg at 6 months that normalized with one antiglaucoma medication each. No progression of glaucomatous optic neuropathy was observed in either group. Morphological characteristics of the filtering blebs in all eyes graded by the MBGS showed no statistically significant difference in the score (P >0.05) at 18 months follow-up. However, bleb leakage at 1 year was observed in 4 eyes (20%) in MMC group that healed with conservative management.
Subconjunctival bevacizumab administration is an effective and safe adjunct regimen in combined two site phacotrabeculectomy in eyes with refractory POAG and CACG associated with visually significant cataract. No adverse complications related to delayed wound healing process were associated with its use. Clinical and surgical outcomes of use of bevacizumab as an adjunct were comparable to MMC in terms of bleb survival and IOP control without any bleb related complications.