Intravitreal bevacizumab in recurrent diabetic vitreous haemorrhage after vitrectomy

Abstract

Editor, R ecurrent vitreous haemorrhage (VH) is the most frequent complication of vitrectomy to treat proliferative diabetic retinopathy (PDR), affecting up to 75% of cases (Schachat et al. 1983). Several questions on the subject remain unanswered, such as how long we should wait before performing a new surgery, whether the patient needs to be positioned and which other therapies could be used. The most frequently used treatment for this condition is to repeat vitrectomy if adequate time and positioning have failed, with an average number of 2.3 vitrectomies (Cooper et al. 2004). Bevacizumab is a recombinant monoclonal antibody directed against vascular endothelial growth factor (VEGF) for cancer therapy that has been used to treat PDR (Spaide & Fisher 2006) among other vascular retinal diseases. In order to avoid repeated vitrectomies, we have performed intravitreal injection of bevacizumab (IVB) to treat recurrent post-vitrectomy diabetic VH. Four eyes from four patients with recurrent VH after vitrectomy to treat PDR were treated by monthly IVB injections of 1.25 mg bevacizumab. All these patients had undergone pars plana vitrectomy with detachment of posterior hyaloid and removal of vitreoretinal adherences. Panretinal photocoagulation had been performed during surgery in all cases. Following vitrectomy, the patients had presented two or more cases of recurrent VH that had not cleared after two further vitrectomies and more than 2 months of follow-up. Retina was attached, as confirmed by B-scan prior to IVB injection. The patients are described in Table 1. Treatment was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki, and data gathering was performed after obtaining written informed consent. Patients were informed about the off-label situation of this therapy. Best-corrected visual acuity (BCVA) was determined at 4 months using standard Early Treatment Diabetic Retinopathy Study (ETDRS) charts (Lighthouse, New York, USA) by certified optometrists. VH density was graded as previously described (Kuppermann et al. 2005). BCVA, indirect funduscopy and ultrasound B-scan were performed at the first visit and then monthly during follow-up. The patients were asked about the appearance of adverse events. All the cases had a grade 3 VH with BCVA hand motion at baseline. No changes in VH could be observed after one single IVB injection. VH cleared completely after two IVB injections in cases 2 and 3, reaching BCVA 20 ⁄400 and 20 ⁄ 125 respectively. VH density was grade 2 after two injections in cases 1 and 4; VH cleared completely after three IVB injections, with final BCVA 20 ⁄ 32 and 20 ⁄ 400 respectively (Table 1). Two patients presented rubeosis iridis, which disappeared after treatment by IVB. No changes in intraocular pressure, inflammatory reaction or other adverse events were observed. Recurrent VH has been attributed to persistence of vitreoretinal neovascularization (Sawa et al. 1998). IVB may induce temporary regression of retinal neovascularization and cessation of bleeding, which may allow spontaneous resorption and clearance of VH. IVB is a less invasive therapeutic alternative in cases of postvitrectomy recurrent VH that does not imply the need for further surgery. In view of the good results achieved (complete clearance in all cases), we may consider IVB as a therapeutic alternative for these patients. Randomized, controlled prospective studies including other possible therapeutic possibilities will probably establish the optimal treatment for these cases.