Intravitreal bevacizumab (Avastin) and panretinal photocoagulation in the treatment of high-risk proliferative diabetic retinopathy

Abstract

Purpose: To report the short-term efficacy and safety of intravitreal bevacizumab (Avastin) injection with panretinal laser photocoagulation (PRP) in patients with high-risk proliferative diabetic retinopathy (PDR) according to the Early Treatment Diabetic Retinopathy Study criteria.

Methods: A prospective, interventional case series study was conducted in 17 patients (20 eyes) with high-risk PDR, who were treated with intravitreal bevacizumab (2.5 mg) followed by PRP when the peripheral vitreous became clear or 2 weeks after injection. Patients underwent complete ophthalmic evaluation, including Snellen visual acuity and fluorescein angiography at baseline, 1, 3, and 6 months after bevacizumab injection. Main outcome measures included the serial changes in visual acuity, vitreous clear-up time, and neovascularization on the disc (NVD) regression time.

Results: All patients had obvious reduction in angiographic leakage and involution of retinal neovascularization (NV) at the 1- and 3-month follow-up. The mean follow-up time was 7.5 months. The vitreous hemorrhage (VH) showed a partial resolution as early as 1 week, and complete regression at 3 months. The mean vitreous clear-up time after intravitreal Avastin was 8.5±2.2 weeks. The mean time interval from intravitreal Avastin to NVD regression was 10.8±3.4 weeks. Mean logarithm of the minimum angle resolution visual acuity improved from 1.03 at baseline to 0.36 at 1-month, 0.38 at 3-month, and 0.48 at the 6-month follow-up (P<0.01). Three eyes (18%) required vitrectomy surgery during follow-up. The indication for vitrectomy was dense, persistent VH in 2 eyes, and focal tractional retinal detachment (TRD) in 1 eye. Recurrent retinal NV with minor preretinal hemorrhage was observed in 6 eyes (30%) 3 months after the first injection, and resolved after repeated bevacizumab injections. Patients received an average of 1.4 injections (range: 1-2). Seven eyes (35%) underwent 2 injections. One eye (5%) had ocular complication of PDR progression to TRD. No systemic adverse events were observed following injections.

Conclusions: Short-term results suggest combined intravitreal bevacizumab and PRP achieved rapid clearance of VH, regression of retinal NV, and visual improvement in the treatment of high-risk PDR. Long-term study is warranted to assess the long-term efficacy and safety.

FIG. 1.

Mean best-corrected visual acuity [logarithm of the minimum angle resolution (logMAR)] changes in eyes with proliferative diabetic retinopathy (n=17) at baseline and different time points after intravitreal bevacizumab injections (*P<0.01 at each time points).

FIG. 2.

A 51-year-old female presented with moderate (1/2 disc area) neovascularization elsewhere (NVE) and vitreous hemorrhage (VH) in the left eye, and fluorescein angiography (FA) showed large regions of NVE leakage compatible with the diagnosis of high-risk proliferative diabetic retinopathy. She received the first intravitreal injection of bevacizumab at baseline. After 1 month, VH remarkably cleared, and visual acuity improved from counting fingers (CF) at baseline to 20/40. Three months after bevacizumab injection, VH completely cleared up and FA disclosed no more fluorescein leakage from NVE. After 6 months, NVE completely regressed with fibrous tissue left. Color images available online at www.liebertpub.com/jop

FIG. 3.

A 50-year-old male presented with severe neovascularization on the disc (NVD), compatible with the diagnosis of high-risk proliferative diabetic retinopathy. FA showed profuse NVD leakage and a large area of capillary dropout. He received the first intravitreal injection of bevacizumab at baseline. After 3 months, NVD completely regressed without any fluorescein leakage. However, reperfused NVD with preretinal hemorrhage occurred in the 6-month follow-up, thus, he received repeated intravitreal bevacizumab injection. NVD regressed again at the 9-month follow-up, and visual acuity improved from 20/50 at baseline to 20/25. Color images available online at www.liebertpub.com/jop