Tractional Retinal Detachment following Intravitreal Bevacizumab Avastin in patients with Severe Proliferative Diabetic Retinopathy

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Slide 1 :

Tractional Retinal Detachment following Intravitreal Bevacizumab (Avastin®) in patients with Severe Proliferative Diabetic Retinopathy J. Fernando Arevalo, MD FACS Clínica Oftalmológica Centro Caracas Caracas, Venezuela

Slide 2 :

TRD & Bevacizumab in PDR Co-authors Rafael A. Garcia-Amaris, MD Mauricio Maia, MD Harry W. Flynn Jr., MD Mario Saravia, MD Robert L. Avery, MD Lihteh Wu, MD Michel Eid Farah, MD Dante J. Pieramici, MD Maria H. Berrocal, MD Juan G. Sanchez, MD

Slide 3 :

TRD & Bevacizumab in PDR Centers Clinica Oftalmológica Centro Caracas Caracas, Venezuela The Universidade Federal de São Paulo - Instituto da Visão São Paulo, Brazil The Retina and Vitreous Service, Bascom Palmer Eye Institute Miami, FL, USA The Hospital Universitario Austral, Buenos Aires, Argentina California Retina Consultants and Research Foundation Santa Barbara, California, USA Instituto de Cirugia Ocular, San Jose, Costa Rica The University of Puerto Rico, San Juan, Puerto Rico

Slide 4 :

Drs. Avery and Pieramici are consultants for GenentechThe other authors have no proprietary or financial interest in any products or techniques described in this presentationThis presentation includes the off-label use of Bevacizumab (Avastin®)

Slide 5 :

TRD & Bevacizumab in PDR Objective To report the development or progression of TRD following IVT bevacizumab as an adjuvant to vitrectomy for the management of severe PDR

Slide 6 :

TRD & Bevacizumab in PDR Methods Retrospective multicenter study of eyes with TRD who had undergone IVT bevacizumab (1.25 mg) before vitrectomy for the management of PDR 11 eyes (patients) out of 211 IVT injections (5.2%) that developed or had progression of TRD were identified Mean age was 39.5 years (range: 22-62) 54.5% were male

Slide 7 :

TRD & Bevacizumab in PDR Methods All patients had had a PRP at least 2 months before bevacizumab All eyes had PDR refractory to PRP 9 patients had DM 1 with more than 15.5 years from diagnosis (range:14-30) 2 patients had DM type 2 within 1 year from diagnosis All patients had uncontrolled DM (HbA1c mean = 10.6%)

Slide 8 :

TRD & Bevacizumab in PDR Inclusion Criteria Inclusion criteria for the use of IVT bevacizumab before vitrectomy for the management of PDR included TRD, persistent vitreous hemorrhage, and incomplete regression even after extensive PRP

Slide 9 :

TRD & Bevacizumab in PDR Methods All cases were treated with a dose of 1.25 mg

Slide 10 :

TRD & Bevacizumab in PDR Results Time from injection to TRD had a mean of 13 days (range: 3-31) 11 eyes (patients) out of 211 IVT injections (5.2%) that developed or had progression of TRD were identified One patient developed a retinal break as a result of the increased traction Combined total TRD - RRD was apparent 3 weeks after IVT bevacizumab

Slide 11 :

TRD & Bevacizumab in PDR Results 8 eyes underwent vitrectomy Performed within 10 days after TRD 2 patients refused or were unable to undergo surgery 1 patient surgery was not recommended

Slide 12 :

TRD & Bevacizumab in PDR BCVA Results Baseline Mean BCVA was LogMAR = 0.8 (range: 0.3-1.6) TRD development or progression Mean BCVA was LogMAR = 2.2 (range: 1.0 to 2.6) After vitrectomy Final mean BCVA was LogMAR = 0.9 (range: 0.2 to 2.0) p = 0.002

Slide 13 :

TRD & Bevacizumab in PDRFinal BCVA Analysis by Sub-groups Final BCVA after vitrectomy: 8 (100%) eyes improved = 2 ETDRS lines when compared to TRD BCVA Final BCVA after vitrectomy vs baseline: 4 (50%) eyes improved, 2 (25%) eyes remained stable, and 2 (25%) eyes lost = 2 ETDRS lines when compared to baseline BCVA

Slide 14 :

TRD & Bevacizumab in PDR Selected Case

Slide 15 :

Case 1. A 22-y.o woman Poorly controlled DM type 1 since age 6 Bilateral PDR PRP in her RE BCVA was 20/200

Slide 16 :

Case 1. 1.25 mg IVT Bevacizumab and PDR 4 days later sudden visual loss (CF) Dense VH and partial TRD Post-Vitrectomy BCVA = 20/50

Slide 17 :

TRD & Bevacizumab in PDR Discussion Development or progression of TRD in PDR following IVT bevacizumab could have happened by natural history or rapid NV involution with accelerated fibrosis and posterior hyaloidal contraction as a response to decreased levels of VEGF The short time between the injection and TRD (mean: 13 days) suggest a cause-effect relationship

Slide 18 :

TRD & Bevacizumab in PDR Discussion In cases at risk for progression of TRD that might involve the central macular region, timely surgery should be anticipated Avery et al. have reported that diabetic eyes may be very sensitive to IVT bevacizumab Use of lower doses is prudent in eyes with pre-existing significant traction

Slide 19 :

TRD & Bevacizumab in PDR Advantages IVT bevacizumab reduced risk of intraoperative bleeding facilitating the removal of fibrovascular membranes Better visibility less likely to create an iatrogenic retinal break Chances of postoperative complications such as rebleeding or fibrinoid syndrome may be decreased

Slide 20 :

TRD & Bevacizumab in PDR Discussion All these advantages may allow us to save more eyes utilizing preoperative IVT bevacizumab regardless of increased traction on some severe PDR cases

Slide 21 :

TRD & Bevacizumab in PDR Summary TRD in PDR may occur or progress after IVT bevacizumab used as an adjuvant to vitrectomy Most patients had poorly controlled DM associated with elevated HbA1c, insulin administration, PDR refractory to PRP, and longer time between IVT bevacizumab and vitrectomy

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