1. Two Cases of Subconjunctival Bevacizumab Injection to Prevent Bleb Failure after Trabeculectomy Dongwook Lee, Min Ahn, In-Cheon You, Daegyu Lee Chonbuk National University Medical School, Korea Authors have no financial interests in this presentation

2. Purpose Angiogenesis plays a important role in wound healing process, but it is an unwanted process after trabeculectomy. Bleb failure involves vascularization with fibroblast migration and scarring of the fistula tract. Vascular Endothelial Growth Factor (VEGF) is a unique mitogen specific to vascular endothelial cells and the signal cascade leading to fibroblast migration and proliferation involves dynamic interaction between many cytokines.

3. Purpose Blocking the neovascular signal cascade with anti- VEGF molecules like Bevacizumab may lead to a decrease in fibroblast proliferation by decreasing the supply of mitogenic cytokines such as fibroblast growth factor (FGF) carried in by new vessel formation We analyze the safety and efficacy of Subconjunctival Injection of bevacizumab (Avastin) for preventing bleb failure following trabeculectomy

4. Method The clinical interventional case study included 2 patients with inflammatory glaucoma (Posner-Schlossman syndrome and Bechet’s disease) Limbal based standard trabeculectomy was performed without mitomycin-C treatment. Subconjunctival bevacizumab injections (1.25 ㎎ /0.05 ㎖ ) was given at the end of the surgery adjacent to the bleb raised using a single-use 26 gauge needle and syringe.

5. Method Patients characteristics caseAge/sexDiagnosisPre-operative IOP Pre–operative BCVA * 137/MPosner-schlossman syndrome 40 mmHg0.15 228/MBehcet disease28 mmHg0.1

6. Results Case 1 –A 37 years old male with Posner-Schlossman syndrome on his right eye –Uncontrolled intraocular pressure (around 40mmHg) with the maximum glaucoma medications and steroid (40 mg/day) administration. –Visual field defect (MD, -14dB) and disc cupping –Trabeculectomy with Subconjunctival bevacizumab injections –Post operative 2nd week, additional bevacizumab (1.25 mg/0.05 ㎖ ) injection under a slit lamp because of intense uveitis and increase vascular congestion and vascularization

7. Results Case 2 – a 28 year old male suffering from Bechet’s disease and uveitis in both eyes –about 50% peripheral anterior synechiae of iris through a gonioscopy, and glaucoma-induced changes in optic discs which had a decreased sensitivity of -10 dB in the visual field test –Trabeculectomy with Subconjunctival bevacizumab injections

8. Case 1 patient (1a) Single layer of limbus- based flap and subconjunctival Bevacizumab injection. (1b) Post-operation 1 month photography. Note conjunctival injection and ketatic precipitates on lower half cornea due to iridocyclitis but bleb area shows no vascularization.

9. Case 2 patient (2a) Post-operation 1 day photography. (2b) 3 months after trabeculectomy with subconjunctival Bevacizumab injection. Note the well functioning bleb.

10. Intraocular pressure(IOP) changes following trabeculectomy with subconjunctival Bevacizumab injection.

11. Conclusion The clinical interventional study included 2 patients with secondary glaucoma associated with uveitis Subconjunctival bevacizumab to prevent bleb failure after trabeculectomy show good results No adverse incidents were observed