Avastin for vitreous haemorrhage
Recently i have come across patients with PDR with vitreous hmghe mild dispersed who have received Intravitreal avastin as primary treatment. There are also reports in literature about the same. I personally do not give unless patient is to be posted for vitrectomy. AnY thoughts from other senior people regarding their experience?.patient these days come demanding for avastin as treatment for PDR.
feel giving anti VEGF in PDR cases with minimal vitreous haemorrhage should not be a problem with few things in mind
- Fundus is visible to the extent that it is confirmed that there is no TRD or fibrovascular proliferation which may contract with anti VEGF and cause any problem.
- PRP should be augmented as the affect of anti VEGF is transient.
- We should explain to the patient the need of surgery later if haemorrhage does not resolve.
But as per the current guidelines, early vitrectomy is a better option which we should explain to the patient. But can come across such circumstances.
Seniors opinion please
The complications in PDR- Vitreous hge, TRD and macular edema- are all related to VEGF. Of these, only the last is continually modulated by VEGF and a direct response to VEGF suppression can be demonstrated.
The other two have a pathologic process that originates due to VEGF but whose progression is related more to the angio -fibrotic switch. This happens as ratio of VEGF to fibrosis inducing cytokines (mainly CTGF) reverses to cause increasing traction and laying down of fibrous tissue. VEGF in this situation only serves to keep neovascular process alive.
Given this understanding, if decreasing vascularity is the aim (e.g. pre-op in preparation for surgery), VEGF reduction may be employed. For other purposes, anti VEGF treatment is superfluous. The vitreous hemorrhage will resolve regardless (only to recur later), and the TRD will progress (even faster after anti VEGF).
We do not need to change our practice because someone else (for reasons other than science) has.
Do you feel Avastin clears off vit blood?
If fundus is visible to the extent described by you, it may be prudent to wait a couple of weeks and augment PRP.
Even in the abscence of fibrosis, dramatic VEGF suppression as caused by anti-VEGF (and steroid) injections can trigger accelerated fibrosis.
Thanks for bringing up this topic.
I personally have never used antiVEGF for clearing vitreous hemorrhage but as u mentioned its use for the above is rampant.
The question is what is the rationale for its use.
Does the hemorrhage clear because of the antiVEGF or is it the natural course of the hemorrhage to clear?
The use of antivegf before a planned surgery is logical and well proven but its use just to clear hemorrhage seems questionable.
Can it be used when
1) the eye has been well lasered but still hemorrhage exists so as to augment more laser .
2) when the ultrasound shows no evidence of traction.
People who are using it
1) how frequently is the antiVEGF repeated
2) is the antiVEGF advised as the first treatment modality before laser is attempted.
I dont use it. The study quoted also indicates ranibizumab is as good as saline as far as clearing of hemorrhage is concerned. An earlier study by Spaide et al did show improvement in 2 cases. Apparently more articles are available – http://retinatoday.com/pdfs/0412RT_Global_Amaya.pdf
However the recently quoted one compares to saline.
While AVASTIN certainly has no role in clearing up the vitreous hemorrhage, but it may certainly prevent more bleeding. Due to this the existing hemorrhage resolves faster. It is no doubt widely and wildly misused by our colleagues esp the anteriror segment-turned medical retinologists for obvious reasons. While it may prevent more bleeding but that doesnt warrant its indiscriminate use. Cases have to be selected carefully and those who have been under my care from before, about whose prolif retinopathy I know , those who have been lasered by me or those who have had previous vitrectomy are the cases where I use it. But having said that I always follow them closely and prepare them mentally for vitrectomy before injecting.
The only situation I use avastin for vitreous hemorrhage is if the
> patient has a hemorrhage in a previously unlasered eye where the retina
> can be partially seen but laser does not take up sufficiently. If i expect
> the media to clear up, then it will use avastin to tide over the period
> till I can laser the eye.
In my opinion, avastin clears vitreous hemorrhage in an older person, when the vitreous is more liquefied. In these cases i have seen dramatic resolution of hemorrhage.
In younger people the vitreous is thicker and hemorrhage rarely clears. However, avastin reduces neovascularization and would be a useful adjunct to therapy.
Cases with pre-existing traction have shown worsening of traction with avastin. I believe in such cases we give avastin only if surgery is planned.
Respected group members.
As already mentioned. I am adding to it.
Giving only avastin in vitreous hemorrhage leads to rebound vegf and increased chances of re bleed. Even the theory of augmenting pro with avastin is spurious as u need a slow and sustained release of vegf to control PDR which is achieved by prp. Avastin has a half life of around 4 days and its dramatic reduction in vegf and rapid rebound is not responsible for clearing VH