Reducing the incidence of early postoperative vitreous haemorrhage by preoperative intravitreal bevacizumab in vitrectomy for diabetic tractional retinal detachment

Abstract

ABSTRACT.Purpose: This study aimed to evaluate whether preoperative intravitreal injection of bevacizumab reduces early postoperative vitreous haemorrhage (VH) in vitrectomy for diabetic tractional retinal detachment. Methods: We conducted a retrospective chart review of a consecutive, interventional case series. This included 29 eyes (27 patients) in the bevacizumab group and 40 eyes (37 patients) in the non-bevacizumab group. For statistical analysis, each patient was assigned to one of four groups according to the haemostatic modalities used (group 1, none; group 2, only long-acting gas; group 3, only preoperative intravitreal bevacizumab; group 4, both long-acting gas and preoperative intravitreal bevacizumab). The primary outcome measure was the incidence of early postoperative VH. The secondary outcome measure was visual acuity (VA) at 1 month. Results: The incidence of early postoperative VH was highest in group 1 (63%), followed by group 2 (21%), group 3 (20%) and group 4 (5%). Group 3 showed the best visual recovery in the first month. All eyes in group 3 reached VA ‡ 1 ⁄ 100 at 1 month after the operation, compared with 44%, 29% and 42% in groups 1, 2 and 4, respectively. Conclusions: Preoperative intravitreal injection of bevacizumab may be useful for reducing early postoperative VH in vitrectomy for diabetic tractional retinal detachment. Eyes receiving preoperative intravitreal bevacizumab without the use of long-acting gas achieved the best visual recovery at 1 month after the operation.

Antiangiogenic drugs and advanced proliferative diabetic retinopathy

“…The occurrence of postoperative vitreous hemorrhage tends to be less frequent with the adjuvant use of bevacizumab (18)(19)(22)(23) , although this result was not observed in other studies (21,24,28) . Postoperative vitreous hemorrhage can also be combated with gas buffering, which proved to be as effective as preoperative bevacizumab in a study by Yeung et al (23) , although in that study the best results were obtained with the preoperative use of bevacizumab in combination with gas at the end of vitrectomy. Yang et al (28) suggested that, although the frequency of postoperative vitreous hemorrhage did not differ between groups treated or not with adjuvant bevacizumab in their study, the use of the antiangiogenic drug allowed a more rapid vitreous clearing during the postoperative period.…”

“…While some studies have reported a statistically significant postoperative gain of visual acuity in patients previously treated with bevacizumab (18)(19)(22)(23)29) , others did not observe this benefit (20)(21)24,28) . The occurrence of postoperative vitreous hemorrhage tends to be less frequent with the adjuvant use of bevacizumab (18)(19)(22)(23) , although this result was not observed in other studies (21,24,28) . Postoperative vitreous hemorrhage can also be combated with gas buffering, which proved to be as effective as preoperative bevacizumab in a study by Yeung et al (23) , although in that study the best results were obtained with the preoperative use of bevacizumab in combination with gas at the end of vitrectomy.…”

“…This time is considered to be safe in order to avoid complications of increased fibrosis and vitreoretinal traction, with regression of active neovessels and reduction of high VEGF levels characteristic of PDR having been observed (33) . The preoperative use of bevacizumab proved to be favorable regarding technical aspects of the execution of pars plana vitrectomy, reducing surgical time and material exchange and facilitating the removal of fibrovascular membranes, in addition to reducing intraoperative hemorrhage and the need to use endodiathermy (3,20,(22)(23)25,27,(29)(30) . The improvement of the surgical technique for vitrectomy was probably due to the induction of neovascular regression and the reduction of vascular caliber (3,(6)(7)22,25,30) , with the consequent facilitation of the intraoperative manipulation of fibrovascular proliferations.…”

“…The reduction of vascular caliber after bevacizumab administration may result in lower intraoperative hemorrhage due to less damage to the vascular structures, with a consequent reduction of postoperative hemorrhage (22)(23) . Although preoperative bevacizumab is eliminated from the vitreous with vitrectomy, its action may be prolonged by tissue penetration, since the presence of the drug in the choroid and inner retina one day after intravitreal administration has been demonstrated, continuing to be detectable 14 days after its use (34) .…”

“…Bevacizumab has been used preoperatively as an adjuvant in vitrectomy in patients with TRD, vitreal hemorrhage, mixed TRD, active fibrovascular proliferation (FVP) (3,(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) , and neovascular glaucoma (31) (Table 1). Also, a pilot study of bevacizumab injected immediately after vitrectomy for vitreous hemorrhage was conducted (32) .…”