Topical and Subconjunctival Bevacizumab in Corneal Neovascularization in Keratoplasty Patients

1. Topical and Subconjunctival Bevacizumab in Corneal Neovascularization in Keratoplasty Patients Vladimir Pfeifer, Petra Schollmayer, Špela Štunf, Alenka LavričEye Hospital, University Medical Centre Ljubljana, Slovenia Authors have no financial interest

2. PURPOSE To report the clinical use of topical and subconjunctival bevacizumab (Avastin) in keratoplasty patients with corneal neovascularization (NV). GOAL: improving graft survival METHODS • Aproval of National Medical Ethics Committee • Prospective case series: 9 eyes of 9 patients with corneal transplant and corneal NV, (all patients baseline therapy with topical corticosteroids (0,1% dexamethason or 0,5% loteprednol) • Three patients: subconjunctival bevacizumab 2.5mg/0.1ml single dose. • Five patients: topical bevacizumab 5mg/ml 4 times daily for 1 month. • One patient first received injection, followed by topical bevacizumab, repeated keratoplasty and repeated topical bevacizumab.

3. METHODS • UCVA, BCVA, tonometry, slit-lamp examination and photography • NV graded for: • extent(clock hours of circumference) • centricity(0 = no corneal invasion, 1 = host cornea, 2 = graft periphery, 3 = graft centre) • hyperaemia(1 = low, 2 = moderate, 3 = intense) • Follow up up to 6 months: before therapy, 2 days, 1 week, 1, 3, 6 months

4. Bevacizumab injection Extent (clock hours) Time (days) Bevacizumab injection Bevacizumabinjection Hyperaemia Centricity Time (days) Time (days) RESULTS Subconjunctival bevacizumab • NV regressed in all patients • Partial regrowth in next month,no further regrowth • Adverse effects: • 1 patient: persistent epithelial defectwith stromal thinning • no other adverse effects

5. Subconj.injection Before injection 2 days after injection-beginning NV regression Case 1: subconjunctival bevacizumab Graft failure (PK for chemical injury)

6. 1 week after injection – maximal response 1 week after injection – maximal response Case 1: subconjunctival bevacizumab

7. Topical bevacizumab Extent (clock hours) Time (days) Topical bevacizumab Topical bevacizumab Hyperaemia Centricity Time (days) Time (days) RESULTS Topical bevacizumab • NV partially regressed in 4 out of 5 patients. • (no regression in patient with old nonprogressive NV) • No regrowth • No adverse effects were noted.

8. Before topical therapy 1 month on topical therapy -maximal response 3 month follow up - no NV regrowth Case 2: topical bevacizumab

9. Perforated corneal ulcer, extensive NV After PK, before topical bevacizumab Case 3: topical bevacizumab

10. Case 5: topical bevacizumab 1 week on topical bevacizumab-beginning NV regression 3 months follow up 6 month follow up -no NV regrowth

11. CONCLUSION • Topical and subconjunctival bevacizumab is effective in inhibiting and regressing corneal NV in keratoplasty patients. • The greatest effect was seen in reduction of hyperaemia. • The treatment seemed to have no effect on old nonprogressive corneal NV. • Repeated treatment may be needed in some cases.