PTERYGIUM AND TOPICAL BEVACIZUMAB: A 2 YEAR FOLLOW UP DR. ADITYA SUDHALKAR,M.S. DR. ANAND SUDHALKAR,M.S. The authors have no financial interest in this presentation

INTRODUCTION  Pterygium: Subconjunctival elastotic degeneration;  Can be a cosmetic blemish and/or interfere with vision  Excision is the primary treatment modality; recurrence is often a problem  Numerous adjuvants suggested for preventing recurrence, including: Mitomycin C, 5 FU, triamcinolone Irradiation** Conjunctival autografts  Their efficacy however, is variable  Bevacizumab has been suggested as an off label use* *Effect of subconjunctival bevacizumab on primary pterygiumTeng CC, Patel NN, Jacobson L. Cornea May;28(4): *Topical bevacizumab for corneal limbal neovascularisation to prevent impending recurrence of pterygiumWu PC, Kuo HK, Tai MH, Shin SJ.Cornea Jan;28(1):103-4 **Strahlenther Onkol Dec;185(12): Vastradis et al. *Med Hypotheses. 2007;69(4): Bevacizumab as a potential novel adjunct in the management of pterygia

PURPOSE:  To determine the efficacy and safety of topical bevacizumab in flurbiprofen as an adjunct to conjunctival autograft in prevention of recurrence of primary pterygium

METHODS:  STUDY DESIGN: Prospective Case Series  PATIENTS: 17 consecutive patients of primary pterygium, with : No associated systemic or ocular disorder No known predisposition to hypersensitivity reactions  TREATMENT: Primary pterygium excision with conjunctival autograft; single surgeon, standardised technique.  POST OPERATIVE REGIMEN(FOR 4 WEEKS-q.i.d.): Antibiotic steroid *eye drops Bevacizumab(0.3mg/drop), topically with punctal occlusion-5 minutes Flurbiprofen eye drops Preservative free artificial tears  FOLLOW UPS : Post operative days 1, 7, 30, 90, 180, years 1 and 2.

OUTCOME MEASURES:  Recurrence of pterygium  Safety of bevacizumab eye drops administered topically

RESULTS:  MEAN AGE: /-3.24years(range-35 to 49 years)  GENDER DISTRIBUTION: Males: 10; Females 7  TOPICAL REGIMEN WELL TOLERATED  NO RECURRENCE TILL THE END OF THE FOLLOW -UP PERIOD Seven patients complained of foreign body sensation; treated with lubricants 2 had dellen formation, resolved with artificial tears 1 had hyperemia of the autograft, resolved with flurbiprofen

ILLUSTRATIVE CASE: POST OPERATIVE: AT END OF TWO YEARS PRE -OPERATIVE

DISCUSSION:  Recurrence of pterygium entails further procedures on a patient; excision can leave a scar  Antimetabolites, irradiation not without side effects  Bevacizumab in an off label use has been shown to be effective in prevention of recurrence*  Subconjunctival bevacizumab in immediate post operative period might not prevent neovascularisation which usually occurs later  Multiple subconjunctival* injections potentially hazardous and painful; *Ann Ophthalmol (Skokie). 2010;42 Spec No: Multiple subconjunctival injections for advanced primary pterygium *Cornea Feb;30(2):127-9 Fallah et al. Intralesional bevacizumab in decreasing pterygium size.

DISCUSSION: AAdministration of topical therapy(bevacizumab+flurbiprofen) with punctal occlusion did not produce ocular/systemic side effects TTopical therapy gives a prolonged dose of bevacizumab to the autograft NNone of the patients showed a recurrence till the end of follow up period SSteroids not a confounding factor as they have not shown to significantly alter recurrence rates*~ *Cornea Feb;29(2):141-5, Comparison of recurrence rates….Kandavel et al ~Ann Ophthalmol Jan;17(1):92-5. Pterygium: clinical classification and management in Virgin Islands. Anduze et al. ~East Afr Med J Sep;69(9): Post-operative management of pterygium in Jos, Nigeria--comparison of antibiotics, steroids and opticrom

REFERENCES:  Pterygium. Etiology, clinical aspects and novel adjuvant therapies].Heindl LM, Cursiefen C.Ophthalmologe Jun;107(6):517-20, Pterygium. Etiology, clinical aspects and novel adjuvant therapies].  Safety and efficacy of intraoperative 5-fluorouracil infiltration in pterygium treatment]. Safety and efficacy of intraoperative 5-fluorouracil infiltration in pterygium treatment]. Vlezi VG, et al. Arq Bras Oftalmol Mar-Apr;72(2):  Comparative Study of Different β-Radiation Doses for Preventing Pterygium Recurrence. Comparative Study of Different β-Radiation Doses for Preventing Pterygium Recurrence. Yamada T et al. Int J Radiat Oncol Biol Phys Oct  Results of treatment with topical mitomycin C 0.02% following excision of primary pterygium. Rachmiel R et al.Br J Ophthalmol Mar;79(3):233-6 Results of treatment with topical mitomycin C 0.02% following excision of primary pterygium.  Postoperative subconjunctival corticosteroid injection to prevent pterygium recurrence. Postoperative subconjunctival corticosteroid injection to prevent pterygium recurrence. Paris Fdos et al.Cornea May;27(4):  Dev Ophthalmol. 2010;46: Scholl et al. Anti vascular growth factors in anterior segment disease  Cornea May;28(4): Teng et al. Effect of subconjunctival bevacizumab on primary pterygium

LIMITATIONS:  Small sample size  No control group  Further studies will be required

CONCLUSION  Topical Bevacizumab appears to be safe and effective in preventing pterygium recurrence.