J. Fernando Arevalo, MD FACS Clínica Oftalmológica Centro Caracas Intravitreal Bevacizumab (AvastinTM) for the Management of Refractory Pseudophakic CME: 12-months Follow-Up J. Fernando Arevalo, MD FACS Clínica Oftalmológica Centro Caracas Caracas, Venezuela

Bevacizumab & Refractory Pseudophakic CME Co-authors Mauricio Maia, MD Rafael A. Garcia-Amaris, MD Juan G. Sanchez, MD Jose A. Roca, MD Maria H. Berrocal, MD Lihteh Wu, MD

The authors acknowledge no financial interest This presentation includes the off-label use of Bevacizumab (AvastinTM)

Bevacizumab & Refractory Pseudophakic CME Introduction Incidence: Angiographic CME: up to 20% Clinically significant CME: 0%-13% In most patients, CME resolves spontaneously, with 50% to 75% of patients achieving improved vision within 6 months Some patients suffering permanent visual morbidity

Bevacizumab & Refractory Pseudophakic CME Introduction Studies have demonstrated the usefulness of ITV bevacizumab: CNV secondary to AMD Macular edema secondary to CRVO Pseudophakic CME DME INV, NVG & RN secondary to PDR B C

Bevacizumab & Refractory Pseudophakic CME Objective To determine the 12-months feasibility, safety and clinical effect of IVT bevacizumab in patients with refractory CME after cataract surgery

Bevacizumab & Refractory Pseudophakic CME Methods Interventional retrospective multicenter study of eyes with refractory pseudophakic CME treated with off-label IVT bevacizumab (AvastinTM) 36 eyes of 31 consecutive patients with a minimum follow-up of six months Mean follow-up of 54.3 weeks (range: 24 to 90 weeks) Mean age was 69.5 years (range: 50-87) 64.5% were female

Table 1: Patients’ Demographics Intravitreal Bevacizumab For Refractory Pseudophakic CME No. of eyes/No. of patients 36/31 Age (years) Mean Range 69.5 50-87 Gender Female Male 20 (64.5%) 11 (35.5%) Time Interval from CME symptoms to IVT injection (months) 16.2 3-120 Follow-up (weeks) 54.3 24-90

Bevacizumab & Refractory Pseudophakic CME Methods 21 cases (58.3%) were treated with a dose of 1.25 mg 15 cases (41.7%) were treated with a dose of 2.5 mg

Bevacizumab & Refractory Pseudophakic CME BCVA Results The mean baseline BCVA was logMAR = 0.92 (20/160; range: 2.0 - 0.2) The mean final BCVA was logMAR = 0.55 (20/63;range: 1.3 - 0.0) p < 0.0001

Table 2: BCVA Results Final BCVA Analysis by Sub-groups At 6 months # Eyes Percentage Improved ≥ 2 ETDRS lines of BCVA 25 69.4% Remained stable 11 20.6% Decreased ≥ 2 ETDRS lines of BCVA 0%

Bevacizumab & Refractory Pseudophakic CME OCT Results The baseline mean central macular thickness was 456.2 µm (range: 208-784) The final central macular thickness was 262.9 µm (range: 142-513) p < 0.0001

Bevacizumab & Refractory Pseudophakic CME Reinjections 5 (13.9%) eyes needed a second injection at a mean of 17.4 weeks (range: 6-26) 9 (25%) eyes needed a third injection at a mean of 18.6 weeks (range: 7-45) 5 (13.9%) eyes needed a fourth injection at a mean of 17.5 weeks (range: 11-24) 1 (25%) eye needed a fifth injection at a mean of 14.5 weeks (range: 12-18) The mean interval between injections was 17.6 weeks (range: 6-45 weeks)

Case 1. 2.5 mg Intravitreal Bevacizumab and Refractory Pseudophakic CME A 64-year-old man with refractory pseudophakic CME presented with a VA of 20/160 in his right eye

Before Bevacizumab VA 20/160 1 month later VA 20/63 6 months later VA 20/40 12 months later VA 20/32

Bevacizumab & Refractory Pseudophakic CME Conclusions Bevacizumab modifies the natural history of macular edema by stabilizing the BRB in a rapid and effective form, facilitating fluid reabsorption in the retina and achieving a striking regression of CME with a remarkable decrease of foveal thickness Therefore, complications of chronic CME (serous macular detachment, RPE changes, epiretinal membrane formation, and non-reversible macular changes with permanent visual loss) can be reduced or avoided

Bevacizumab & Refractory Pseudophakic CME Conclusions In the future, this new treatment modality could be established as an alternative treatment for refractory CME after cataract surgery with a rapid reduction in macular edema and improvement in VA with no significant short-term complications Furthermore, bevacizumab may be the only option in patients who are known steroid responders and who are unresponsive to NSAIDs