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A. Toor, D. Chruscicki, A. Macedo, R. L. Lieberman, R. M. Fischer; Intravitreal Bevacizumab as an Adjunct to Ovine Hyaluronidase (Vitrase®) in the Long-Term Management of Vitreous Hemorrhage. Invest. Ophthalmol. Vis. Sci. 2007;48(13):265.
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Intravitreal ovine hyaluronidase (Vitrase®) is a novel therapy believed to expedite the resorption of vitreous hemorrhage by causing the dissolution of collagen and hyaluronic complexes in vitreous humor. Bevacizumab (Avastin, Genentech), a monoclonal antibody that targets vascular endothelial growth factor (VEGF), has been shown to cause regression of retinal neovascularization . We present a long-term follow up of patients with vitreous hemorrhage treated with a combination of intravitreal hyaluronidase followed by intravitreal bevacizumab.
A retrospective chart review was done of patients with established VH secondary to proliferative diabetic retinopathy (PDR) or retinal vein occlusion, who were then treated with a single intravitreal injection of Vitrase® (55 IU/0.05ml), followed by intravitreal bevacizumab (1.25mg/0.05ml). Data collected included patient demographics, best corrected visual acuity (BCVA) with VH, at 2wks, 1mth, 2mths, 3mths, 4mths, 5mths and 6mths post-injection, treatment with panretinal photocoagulation (PRP) post-injection and fluorescein angiogram (FA) results.
10 eyes from 9 patients (5M, 4F), age 52+8.4yrs, were included. Initial BCVA ranged from 20/60 to LP. After Vitrase® injection, 5 eyes had a ≥3 line gain in BVCA, 1 had <3 line gain, and 4 eyes showed no change in BCVA. Intravitreal bevacizumab was injected in all eyes at a median 8wks post-Vitrase for persistent VH, inability to place sufficient PRP, or for vitreous rebleeds due to persistent retinal neovascularization. In eyes with a ≥3 line gain in BVCA post-Vitrase® (n=5), retinal neovascularization regressed on FA, vision improved further by ≥3 lines and 680+211 additional PRP burns were placed post-bevacizumab. In eyes with <3 line gain in BCVA post-Vitrase® (n=5), bevacizumab injection did not improve vision or clear VH further in 4 out of 5 eyes. Poor response to Vitrase®/bevacizumab was associated with vision worse than CF on presentation.
Intravitreal bevacizumab can be a useful adjunct in improving vision, facilitating placement of PRP and promoting regression of neovascularization in VH when there is an initial response to Vitrase®. In eyes with VH that fails to clear post-Vitrase®, adjunctive bevacizumab is unlikely to improve visual outcome. A larger prospective protocol is required to confirm the findings of this pilot study.
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