Adjunctive Intravitreal Bevacizumab Injection
at the End of Sutureless 23 G Vitrectomy for
Diabetic Vitreous Hemorrhage
Zagazig University, 3 Ahmed Orabi st., Zagazig, Sharkia, Egypt
Ayman Lotfy, MD, Zagazig University, 3 Ahmed Orabi st., Zagazig, Sharkia, Egypt, Tel no: 00201022204510; E-mail:
Received: 02 November, 2016; Accepted: 17 November, 2016; Published: 27 November, 2016
Lotfy A (2016) Adjunctive Intravitreal Bevacizumab Injection at the End of Sutureless 23 G Vitrectomy for Diabetic Vitreous
Hemorrhage. Int J Open Access Ophthal 1(1): 3. DOI: 10.15226/2474-9249/1/1/00113
This study aims to evaluate the safety and efficacy of intravitreal
bevacizumab (IVB) at the end of vitrectomy in prevention of
rebleeding in patients with diabetic vitreous hemorrhage.
Methods: This is a retrospective interventional study comprised
of 30 eyes from 30 patients who underwent 23 G pars plana
vitrectomy for diabetic vitreous hemorrhage (VH). IVB (1.25 mg/0.05
ml) was injected at the end of vitrectomy. Main outcome measure was
the postoperative VH and reoperation 1 and 3 months of follow-up.
Other outcome measures were Best-Corrected Visual Acuity (BCVA)
and Intraocular Pressure (IOP).
Results: Early rebleeding within one month postoperatively
occurred in 3.3%. The rate of early rebleeding was significantly
reduced (p=0.002). Late VH after 1 month occurred in 6.6%. BCVA
at 1 and 3 ms postoperative significantly improved (p < 0.01). There
was no significant increase in the rate of reoperation (p=0.27).
Conclusion: Adjunctive IVB injection at the end of vitrectomy
for diabetic vitreous hemorrhage is safe and effective in reduction of
Keywords: Vitrectomy; Diabetic retinopathy; Bevacizumab
The recurrent postoperative hemorrhage is considered one
of the commonest postoperative complications for the pars
plana vitrectomy for proliferative diabetic retinopathy and
advanced diabetic eye disease. The recurrent postoperative
rebleeding incidence ranges from 29 to 75%. Early rebleeding
after pars plana vitrectomy may be caused by the remaining
peripheral blood clots or the fibrovascular tissue ruminants.
Anterior fibrovascular proliferation and the sclerotomies
neovascularization are considered to be the sources of late
hemorrhage . Intravitreal Bevacizumab (IVB) decreases
macular edema in diabetic retinopathy [2-5]. IVB injection
reduced the neovascularization and bleeding in [6-9]. The IVB
injection has been showed to be an effective adjunctive before
vitrectomy for proliferative diabetic retinopathy [7-11]. The aim
of this work is to evaluate the safety and efficacy of IVB injection
at the end of vitrectomy for diabetic vitreous hemorrhage.
Materials and methods
This retrospective case series trial included 30 eyes of
30 patients suffered from diabetic vitreous hemorrhage with
or without Tractional Retinal Detachment (TRD). This work
was performed according to the declaration of Helsinki. All
patients signed informed consent, particularly, the off-label use
of the drug and its risks. The inclusion criterion was persistent
vitreous hemorrhage for more than one month. The exclusion
criteria were previous ocular surgery other than cataract
surgery, previous bevacizumab injection, neovascular glaucoma
and combined tractional-rhegmatogenous retinal detachment.
Best-Corrected Visual Acuity (BCVA) converted log MAR, slitlamp
biomicroscopy, intraocular pressure (IOP) measurement,
fundus examination by indirect ophthalmoscope, and B-scan
ultrasonograpy were done for all patients. Postoperative
examinations were done at postoperative one week, one month
and three months. The severity of pre- and postoperative
vitreous hemorrhage (VH) was graded such as: mild (retinal
vessels and disc were visible), moderate (retinal vessels or disc
was invisible), and severe (the optic disc was invisible). Early rebleeding was defined as VH occurring within 1 month after the
surgery and late postoperative VH was defined as VH occurring
after 1 month and within 3 months of surgery. All surgeries
were done by a single surgeon. Sclerotomies were made 3.5 mm
posterior to the limbus with a 23G microvitreoretinal blade and
cannula. Infusion cannula was introduced. The infusion pressure
was adjusted to as high as 20 mmHg using the OS3 vitrectomy
system (Oertli, Switzerland). A core vitrectomy was done to
remove the hemorrhage. Fibrovascular tissues were removed
by membrane dissection, segmentation and delamination
techniques. Peripheral vitreous cortex was removed by shaving
under sclera depression. Endolaser photocoagulation was done
up to the ora. SF6 gas was used as a tamponade after fluid gas
exchange. Intravitreal injection of 1.25 mg (0.05 ml) bevacizumab
(Avastin, Genentech, South San Francisco, CA) was done. The
postoperative treatment included 0.3% gatifloxacin eye drops
four times per day for 1 week and 1% prednisolone acetate
eye drops four times per day that was usually tapered off over 4 weeks. Patients were informed to remain face down for one
week. Topical beta blocker and carbonic anhydrase inhibitors
were prescribed when IOP was higher than 22 mmHg.
SPSS software (version 14.0; SSPS Inc., Chicago, IL) was
used for statistical analysis. For all statistical tests, p < 0.05 was
The age of the patients ranged between 34 and 65 years with a
mean of 52.25 ± 8.7 years. Three eyes (10%) showed retinal tears
occurred during posterior manipulations, including membrane
removal. They were managed by endolaser photocoagulation.
Early rebleeding within one month after vitrectomy occurred
in one eye (3.3%). The rate of early rebleeding was significantly
reduced (p =0.002). It was resolved spontaneously within 3
weeks. Late postoperative VH more than 1 month after surgery
occurred in two eyes (6.6%). All of the cases with late VH had
severe VH. One eye resolved spontaneously within 2 weeks.
However, one eye with late VH had a repeated vitrectomy within
one month. No case of NVG or recurrent retinal detachment. The
mean preoperative BCVA was 1.78 ± 0.29 Log MAR (Log MAR
ranged between 1.08 and 3.00), (HM - 0.075). Three eyes (10%)
had BCVA of 0.05. Final best corrected visual acuity showed
improvement in 28 cases (93.3%), no change in two eyes (6.6%).
The mean final best corrected visual acuity reached 0.9 ± 0.4
Log MAR (Log MAR ranged from 0.6 to 3.00) (HM - 0.25). This
improvement of mean BCVA was highly significant (p = 0.001).
Eight eyes (26.6%) reached 0.25. Repeated measures showed
insignificant IOP changes at postoperative one week, one and
three months (p =1.00).
Bevacizumab reduces retinal neovascularization and rebuosis
in diabetic retinopathy [12, 13]. Preoperative bevacizumab
reduced intraoperative bleeding. [12-14] TRD increased in
18% of eyes that injected with bevacizumab one month before
vitrectomy . TRD increased in 5.2% of eyes that injected with
bevacizumab 13 days before vitrectomy . IVB injection failed
to prevent rebleeding as it washed out during vitrectomy [7,
16]. In this work rebleeding could be due to fibrovascular tissue
remnants that bled during the operation. IVB decreases the VEGF,
retinal and disc neovascularization [9, 10, 17, 22]. Bevacizumab
blocked VEGF, nitric oxide and endothelin-1, causing short period
of vasoconstriction which may be similar to vascular regression.
Several studies proved that intravitreal injection of bevacizumab
before vitrectomy reduces the bleeding that may occur during
the operation [8, 14, 15]. On the other hand, one study proved
that bevacizumab injection at the end of vitrectomy didn't reduce
the incidence of the rebleeding in eyes underwent vitrectomy for
the management of proliferative diabetic retinopathy . Late
rebleeding could be due to the shorter bevacizumab half life in
the eye that underwent pars plana viterctomy. The half-life of
bevacizumab is considered shorter in vitrectomized eyes as it
might be washed earlier [19-21]. In other studies, BCVA of the preoperative IVB injection group did not improve in comparison
with the control group [7, 16]. In this trial, postoperative BCVA
showed significant improved from the preoperative BCVA.
This work had several limitations such as; retrospective, not
randomized, limited patients and the possible bias in selection.
Prospective randomized work with large sample size is needed
to prove the adjunctive role of intraoperative bevacizumab in
viterctomy for advanced diabetic eye disease. This work showed
that injection of bevacizumab at the end of pars plana vitrectomy
for diabetic vitreous hemorrhage is a safe and effective adjunctive
tool in reduction of early rebleeding after vitrectomy.
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