Efficacy of Bevacizumab Compared to Mitomycin C Modulated Trabeculectomy in Primary Open Angle Glaucoma: A One-Year Prospective Randomized Controlled Study

Long-Term Outcomes of Trabeculectomy with Collagen Matrix Implant as a Bevacizumab Depot

PURPOSE

To report the long-term outcomes of trabeculectomy with collagen implant as bevacizumab depot in eyes with uncontrolled glaucoma.

METHOD

In this retrospective non-comparative interventional study, medical records of patients (age ≥18 years) who underwent trabeculectomy with Ologen implant as bevacizumab depot for uncontrolled glaucoma with ≥ 2 years follow-up were reviewed. The underlying etiology, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and number of anti-glaucoma medications (AGM) were recorded at baseline. Postoperatively, BCVA, IOP, AGMs, complications, and re-surgery were noted on day 1, 1-week, 1-, 3-, 6- months, 1-, 2-, 3-, 4-, 5-years and at final follow-up after 24 months. The main outcomes measured were IOP, number of AGM, and cumulative probability of overall success after 2 years.

RESULTS

Forty-three eyes of 43 patients with a mean age of 54.79 ± 17.27 years were included. The mean follow-up was 62.9 ± 27.42 (24-108) months. The mean pre-operative IOP was 29.23 ± 10.09 mmHg with an average of 4.3 ± 1.2 AGM. The mean IOP and number of AGM were significantly reduced in all follow-up visits (p < .0001) following surgery. The complete success was 48.8% and 48.5% at 2-year and 5-year respectively. The cumulative probability of overall success was 95%, 85%, 80%, and 71% at 2-5-, 7-, and 9-years respectively. A total of 24 complications were noted in 15 eyes in early postoperative days, and all were managed conservatively. The failure was noticed in 6 (17.2%) eyes at 5-year study visits.

CONCLUSION

The use of ologen implant as a drug depot for bevacizumab in trabeculectomy was safe and had a good long-term outcome.

Topical Administration of Bevacizumab to Facilitate the Functional Filtering Bleb After Trabeculectomy in the Rabbit

Purpose: To evaluate the effects of bevacizumab in 3 different application methods, subconjunctival injection (SCI), hyaluronic acid retardant (HAR), and eye drop (ED), on attenuating scar formation in the filtering bleb. Methods: Trabeculectomy (TRAB) was performed on New Zealand rabbits. TRAB rabbits were intervened with bevacizumab SCI, HAR, ED, or mitomycin C, respectively. Intraocular pressure (IOP) of 1, 7, 14, and 28 days after TRAB was recorded, and the bleb survival rate was analyzed. Bleb height, area, and vascularization were evaluated using anterior segment optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) at 7, 14 and 28 days after surgery. A histopathology examination of the bleb tissue was performed. The expression levels of vascular endothelial growth factor (VEGF)-A, interleukin (IL)-1α, tumor necrosis factor-alpha (TNF-α), transforming growth factor-β1 (TGF-β1), and α-smooth muscle actin (α-SMA) were measured by Western blot. Results: Bevacizumab significantly reduced postoperative IOP and increased the survival of the filtering bleb, especially in the ED group. Less vascularization was shown in the SCI, HAR, and ED groups. Histopathological results showed the fewest levels of scarring and fibrosis in the ED group. The local VEGF-A, IL-1α, and TNF-α expression levels after bevacizumab ED were decreased, combined with suppression of TGF-β1 and α-SMA. Conclusions: Postoperative use of bevacizumab EDs was an effective application method for improving surgical outcomes after TRAB in rabbits. It might be effective in preventing scarring of the filtering bleb by antivascularization and anti-inflammation.

Novel Therapies for the Prevention of Fibrosis in Glaucoma Filtration Surgery

Conjunctival fibrosis remains the major impediment to the success of glaucoma filtration surgery. Anti-metabolites remain the gold standard for mitigating post-surgical fibrosis, but they are associated with high complication rates and surgical failure rates. Establishing a more targeted approach to attenuate conjunctival fibrosis may revolutionize the surgical approach to glaucoma. A new strategy is needed to prevent progressive tissue remodeling and formation of a fibrotic scar, subsequently increasing surgical success and reducing the prevalence of glaucoma-related vision loss. Advancements in our understanding of molecular signaling and biomechanical cues in the conjunctival tissue architecture are broadening the horizon for new therapies and biomaterials for the mitigation of fibrosis. This review aims to highlight the strategies and current state of promising future approaches for targeting fibrosis in glaucoma filtration surgery.

Assessing safety and success after using bevacizumab, 5-fluorouracil or placebo in primary trabeculectomy. A Prospective Randomized placebo controlled 1-Year Follow-up Study

PURPOSE

The aim of this study was to determine whether glaucoma patients after trabeculectomy could benefit more from subconjunctival injections of bevacizumab than 5-FU or placebo.

METHODS AND RESULTS

Fifty-one eyes of 51 patients were recruited for primary MMC (0.2mg/ml for 1 min) augmented trabeculectomy. 17 patients were randomly assigned to receive 1.25mg (0.05ml) of bevacizumab augmentation, 21 patients were assigned to receive 0.1ml of 50mg/ml 5-FU and 13 patients were assigned to a control group receiving a normal saline injection as a placebo. Initial recruitment included 58 patients, but seven patients had to be excluded from the study for various reasons. Postoperative follow up of IOP and bleb characteristics was carried out at 1 day, 1 week, 3 weeks, 6 weeks, 6 months and 1 year after surgery. All analyses where carried out by two masked clinicians. IOP reduction was statistically significant (P < 0.05) across all three groups between baseline visit and final 1-year postoperative visit. There was no significant difference of the final average IOP values between the three groups. Bleb evaluation was made using the Moorfields bleb grading system (MBGS) after 1 year follow up. Central bleb area was statistically greater in the Bevacizumab group when compared with the 5-FU group but not with the placebo group. The vascularity of the central bleb was significantly different between the groups with the Bevacizumab group showing the least vascularity. Vascularity of the peripheral bleb was also decreased in the Bevacizumab group when compared with the placebo group but not with the 5-FU group.

CONCLUSION

The 12-month IOP results showed no significant differences between the groups of patients after Bevacizumab, 5-FU or placebo to augment primary MMC enhanced trabeculectomy. However, by the analysis of bleb morphology there was a significant difference in terms of central bleb area and vascularity.

Influence of Mitomycin C on the Therapeutic Success of Stand-Alone Xen45 Gel Stents and Its Combination with Cataract Surgery in Open-Angle Glaucoma Patients

PURPOSE

Minimally invasive glaucoma surgery (MIGS), like Xen45 gel stents, is known as effective therapy in lowering intraocular pressure (IOP); however, fibrotic reactions are a common problem in postoperative management. It was the aim of this study to investigate the therapeutic success of Xen45 gel stents as a stand-alone technique (Xen) and combined with cataract surgery (XenPhaco), and with antimetabolites (mitomycin C, MMC) in open-angle glaucoma patients.

METHODS

Retrospective analysis was performed of 199 eyes of 177 glaucoma patients of the Department of Ophthalmology, University of Erlangen Nürnberg, and from the Erlangen Glaucoma Registry (NCT00494923; ISSN 2191-5008, CS-2011) who underwent implantation of a Xen45 gel stent. Therapeutic success was defined as IOP reduction of ≥ 20% on the same or less anti-glaucomatous medication after 12 months compared to preoperative and without any additional glaucoma-related surgery (except bleb needling). IOP reduction, reduction in local anti-glaucomatous eye drops, and intra- and postoperative complications were monitored.

RESULTS

Stand-alone Xen45 gel stent: therapeutic success was reached in 39% (-MMC) and 55% (+MMC). Failure rate was 61% (-MMC) and 45% (+MMC). XenPhaco: therapeutic success was achieved in 57% (-MMC) and 46% (+MMC). Failure rate was 43% (-MMC) and 54% (+MMC). Data were not different for group and subgroup analyses (p > 0.05).

CONCLUSIONS

The use of MMC seemed to increase the therapeutic success rate after stand-alone Xen45 gel stent implantation and combined with cataract surgery, yet statistical significant was not reached.

The outcome of initial mitomycin C-augmented trabeculectomy with subconjunctival bevacizumab in the management of secondary glaucoma associated with Fuchs heterochromic iridocyclitis

PURPOSE

To investigate the outcome of mitomycin C (MMC)-augmented trabeculectomy with subconjunctival bevacizumab in the management of Fuchs heterochromic iridocyclitis (FHI)-related glaucoma in 1-year follow-up period.

METHODS

This retrospective study included 50 eyes with FHI-related glaucoma those had underwent initial trabeculectomy with MMC (0.2 mg/ml-3 min). Thirty-one of them had single-dose bevacizumab injection (1.25 mg/0.05 ml) into the bleb area just at the end of the surgery, while 19 eyes did not have. The intraocular pressure (IOP) and the mean number of anti-glaucomatous medications were evaluated. The IOP value ≤ 21 mmHg was defined as complete or qualified surgical success in terms of using medical anti-glaucomatous treatment. Bleb height and vascularity were evaluated with Indiana bleb grading system. Paired sample t test, t test, Chi-square and Kolmogorov-Smirnov tests were used for statistical analysis.

RESULTS

The preoperative IOP values of bevacizumab and without bevacizumab groups were 32.8 ± 4.5 mmHg and 32.8 ± 4.5 mmHg, respectively, and they decreased to 17.5 ± 4.6 mmHg and 17 ± 5.2 mmHg at the final visit (p < 0.001 for all values). There were no significant differences in postoperative IOP and the number of medications between the groups at the final visit. In bevacizumab group, complete success was achieved in 100% within the third month but decreased to 22.5% (complete) and 74.1% (qualified) at the first year. In the other group (without bevacizumab group), complete success was achieved in 94.7% within the third month but decreased to 15.8% (complete) and 84.2% (qualified) at the first year.

CONCLUSION

Initial trabeculectomy with MMC and subconjunctival bevacizumab injection was found to have lower rates of complete success with relatively acceptable qualified success rates in the management of FHI-related glaucoma. Subconjunctival bevacizumab was not found to have additional effect to improve the surgical success.