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. 2021 Dec 6:13:25158414211059256.
doi: 10.1177/25158414211059256. eCollection 2021 Jan-Dec.

Intravitreal bevacizumab prior to vitrectomy for proliferative diabetic retinopathy: a systematic review

Panagiotis Dervenis  1 , Nikolaos Dervenis  2 , David Steel  3 , Teresa Sandinha  2 , Paris Tranos  4 , Panagiotis Vasilakis  5 , Ioannis Liampas  6 , Chrysoula Doxani  7 , Elias Zintzaras  8
Affiliations

Intravitreal bevacizumab prior to vitrectomy for proliferative diabetic retinopathy: a systematic review

Panagiotis Dervenis et al. Ther Adv Ophthalmol. .

Abstract

Background: Diabetic retinopathy is a leading cause of visual loss in the working population. Pars plana vitrectomy has become the mainstream treatment option for severe proliferative diabetic retinopathy (PDR) associated with significant vitreous haemorrhage and/or tractional retinal detachment. Despite the advances in surgical equipment, diabetic vitrectomy remains a challenging operation, requiring advanced microsurgical skills, especially in the presence of tractional retinal detachment. Preoperative intravitreal bevacizumab has been widely employed as an adjuvant to ease surgical difficulty and improve postoperative prognosis.Aims: This study aims to assess the effectiveness of preoperative intravitreal bevacizumab in reducing intraoperative complications and improving postoperative outcomes in patients undergoing vitrectomy for the complications of PDR.

Methods: A literature search was conducted using the PubMed, Cochrane, and ClinicalTrials.gov databases to identify all related studies published before 31/10/2020. Prespecified outcome measures were operation time, intraoperative iatrogenic retinal breaks, best-corrected visual acuity in the last follow-up visit, the presence of any postoperative vitreous haemorrhage and the need to re-operate. Evidence synthesis was performed using Fixed or Random Effects models, depending on the heterogeneity of the included studies. Heterogeneity was assessed using Q-statistic and I2. Additional meta-regression models, subgroup analyses and sensitivity analyses were performed as appropriate.

Results: Thirteen randomized control trials, with a total of 688 eyes were included in this review. Comparison of the intraoperative data showed that bevacizumab reduced operation time (p < 0.001), minimized iatrogenic retinal breaks (p < 0.001), provided better long-term visual acuity outcomes (p = 0.005), and prevented vitreous haemorrhage (p < 0.001) and the need for reoperation (p = 0.001 < 0.05). Findings were strongly corroborated by additional sensitivity and subgroup analyses.

Conclusion: Preoperative administration of bevacizumab is effective in reducing intraoperative complications and improving the postoperative prognosis of diabetic vitrectomy.PROSPERO registration number: CRD42021219280.

Keywords: bevacizumab; diabetic retinopathy; systematic review; vitrectomy.

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Conflict of interest statement

Conflict of interest statement: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Professor David Steel (all unrelated to current work): Alcon – Grant funding, consultancy Roche – Consultancy Bayer – Grant funding Gyroscope – Consultancy Novartis – Consultancy

Figures

Figure 1.
Figure 1.
Risk of Bias assessment of included studies.
Figure 2.
Figure 2.
Overall estimate of preoperative IVB effect on operation time.
Figure 3.
Figure 3.
Overall estimate of the effect of IVB administered less than 5 days preoperatively on operation time.
Figure 4.
Figure 4.
Overall estimate of the effect of IVB administered 5–21 days preoperatively on operation time.
Figure 5.
Figure 5.
Comparison of confidence intervals regarding operation time among primary analysis and subgroup analyses.
Figure 6.
Figure 6.
Overall estimate of preoperative IVB effect on iatrogenic intraoperative retinal breaks occurrence.
Figure 7.
Figure 7.
Overall estimate of preoperative IVB effect on best-corrected visual acuity at the last follow-up visit
Figure 8.
Figure 8.
Sensitivity analysis of the effect of preoperative IVB on best corrected visual acuity for patients undergoing vitrectomy alone.
Figure 9.
Figure 9.
Overall estimate of preoperative IVB effect on postoperative vitreous cavity haemorrhage.
Figure 10.
Figure 10.
Sensitivity analysis of the effect of preoperative IVB on postoperative vitreous cavity haemorrhage for patients undergoing vitrectomy without silicone oil tamponade.
Figure 11.
Figure 11.
Overall estimate of preoperative IVB effect on requirement for revision vitrectomy.
Figure 12.
Figure 12.
Overall estimate of preoperative IVB effect on requirement for revision vitrectomy due to retinal detachment.
Figure 13.
Figure 13.
Overall estimate of preoperative IVB effect on requirement for revision vitrectomy due to postoperative vitreous cavity haemorrhage.
Figure 14.
Figure 14.
Overall estimate of preoperative IVB effect on recurrent retinal traction.
Figure 15.
Figure 15.
Sensitivity analyses of preoperative IVB effect on operation time according to the leave-one-out method.
Figure 16.
Figure 16.
Sensitivity analyses of preoperative IVB effect on iatrogenic intraoperative retinal breaks occurrence according to the leave-one-out method.
Figure 17.
Figure 17.
Sensitivity analyses of preoperative IVB effect on best-corrected visual acuity at the last follow-up visit.
Figure 18.
Figure 18.
Sensitivity analyses of preoperative IVB effect on postoperative vitreous cavity haemorrhage.
Figure 19.
Figure 19.
Sensitivity analyses of preoperative IVB effect on requirement for revision vitrectomy.
Figure 20.
Figure 20.
Sensitivity analysis of the effect of preoperative IVB 1.25 mg/0.05 mL on operation time.
Figure 21.
Figure 21.
Sensitivity analysis of the effect of preoperative IVB 1.25 mg/0.05 mL on iatrogenic intraoperative retinal breaks.
Figure 22.
Figure 22.
Sensitivity analysis of the effect of preoperative IVB 1.25 mg/0.05 mL on best-corrected visual acuity at the last follow-up visit.
Figure 23.
Figure 23.
Sensitivity analysis of the effect of preoperative IVB 1.25 mg/0.05 mL on postoperative vitreous cavity haemorrhage.
Figure 24.
Figure 24.
Sensitivity analysis of the effect of preoperative IVB 1.25 mg/0.05 mL on requirement for revision vitrectomy.
Figure 25.
Figure 25.
Funnel plot assessing publication bias in operation time assessment.
Figure 26.
Figure 26.
Funnel plot assessing publication bias in iatrogenic intraoperative retinal breaks.
Figure 27.
Figure 27.
Funnel plot assessing publication bias in best-corrected visual acuity at the last follow-up visit.
Figure 28.
Figure 28.
Funnel plot assessing publication bias in postoperative vitreous cavity haemorrhage.
Figure 29.
Figure 29.
Funnel plot assessing publication bias in requirement for revision vitrectomy.
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