Efficacy of Subconjunctival Bevacizumab Injection in Primary and Recurrent Pterygia Olivia L. Lee, MD Michael R. Banitt, MD Justin Anderson, MD Carolyn Shih, MD David C. Ritterband, MD New York Eye and Ear Infirmary ASCRS-ASOA 2008 Symposium & Congress April 4-9, 2008 No Relevant Financial Relationships with Commercial Interests

Background Fibroangiogenic growth factors have been identified in pathologic specimens of pterygia VEGF is a potent angiogenic factor and has been shown to be highly expressed in vascular endothelium, epithelial and stromal cells of pterygium tissue compared to normal conjunctiva Bevacizumab, a humanized monoclonal antibody to VEGF, has become a common treatment option for neovascular age-related macular degeneration and neovascular glaucoma

Purpose To report the efficacy of subconjunctival bevacizumab injection in regression of vascularity of recurrent pterygia. To report the safety of subconjunctival bevacizumab injection in recurrent pterygia

Methods This IRB approved prospective pilot study included 11 eyes of 11 patients Inclusion criteria: over the age of 18 with recurrent fibrovascular growth onto limbus and/or cornea following pterygium excision without regression on topical steroid treatment for at least 2 weeks Single injections of subconjunctival bevacizumab 1.25mg/0.05ml given into the body of the pterygium adjacent to the limbus Slit lamp photos taken prior to and 2 and 4 weeks following injection Pterygia were evaluated photographically by two independent, masked cornea specialists and graded on a 0 to 10 scale of increasing vascularity

Progressive Change in Pterygium Vascularity Scores Results Progressive Change in Pterygium Vascularity Scores Bevacizumab group p value Baseline 4.6 +/- 2.13 Baseline to week 2 3.5+/- 2.28 (improvement) 0.006 Baseline to week 4 5.1 +/- 2.53 (exacerbation) 0.236 Statistically significant improvement in vascularity scores noted 2 weeks following injection of Bevacizumab. No statistically significant change in vascularity scores between baseline and 4 weeks following injection. No relevant adverse side effects observed in this series.

Results Two weeks following bevacizumab injection, 63.6% were graded as having less vascularity By 4 weeks, only 28.6% had a vascularity score lower than their pre-injection level

Recurrent pterygium in a 43 yo M who received bevacizumab injection Before injection 2 weeks after injection 4 weeks after injection

60 yo F with early recurrent pterygial tissue below conjunctival autograft Before injection 2 weeks after injection 4 weeks after injection

Conclusions While this pilot study did not show any lasting effect of bevacizumab on vascularity of recurrent pterygia, it is one of the first to report the use of subconjunctival injection for this indication. Single injections of bevacizumab at a concentration of 1.25mg/0.05ml result in improvement in vascularity noted at two weeks following injection. However, this effect is transient as there is no statistically significant change from baseline noted by 4 weeks. It is likely that the dose and/or frequency of bevacizumab used in this study is not adequate to show a permanent improvement in vascularity of recurrent pterygia. Further investigation is required to determine whether subconjunctival injection(s) of bevacizumab is of clinical value in the treatment of recurrent pterygium, either in alone or in conjunction with established modes of therapy.

Acknowledgments Evelyn Icasiano, MD Jayrag Patel, MD Robert Massini