SHORT-TERM INTRAOCULAR PRESSURE TRENDS AFTER INTRAVITREAL INJECTION OF BEVACIZUMAB (AVASTIN) D. Anthony Mazzulla, MD, Seenu M. Hariprasad, MD, Rama D. Jager, MD, MBA, William F. Mieler, MD
Purpose: To report the changes in intraocular pressure (IOP) after intravitreal injection of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA). Design: Retrospective chart review. Methods: After the charts of 29 patients who underwent 51 consecutive intravitreal injections of bevacizumab were reviewed, analysis of the short-term effect of bevacizumab injections on IOP was performed. Results: Mean baseline IOP ⫾ SD was 15.1 ⫾ 2.35 mm Hg (range, 10 –22 mm Hg). Mean postinjection IOP ⫾ SD was 20.1 ⫾ 4.70 mm Hg (range, 16 –31 mm Hg). Mean change in IOP from baseline to ⬇30 minutes after bevacizumab injection was 5.0 mm Hg (P ⫽ 0.0027). Mean IOP ⫾ SD at the first follow-up visit, which occurred ⬇25 days (range, 5– 43 days) after injection, was 14.7 ⫾ 2.93 mm Hg (range, 10 –20 mm Hg). Conclusions: Intravitreal injection of bevacizumab seems to be safe from an IOP standpoint in the short term. IOP monitoring immediately after injection may not be necessary. RETINAL CASES & BRIEF REPORTS 2:234 –235, 2008
From the Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois.
lyze IOP changes immediately after injection as well as at the first follow-up visit to assess the frequency of concerning IOP elevation to help determine the necessity for short-term monitoring and treatment.
T
he number of intravitreal injections has increased significantly over the past several years as new agents, such as bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA), have become available. Clinicians routinely check intraocular pressure (IOP) after intravitreal injections to monitor for potentially dangerous elevations that may require treatment. To our knowledge, there has been no study of the short-term IOP trends after intravitreal injection of bevacizumab. The purpose of this study was to ana-
Methods Approval from the Institutional Review Board of the University of Chicago (Chicago, IL) was obtained before initiating this study. We performed a retrospective review of the charts of 29 patients who received 51 intravitreal injections of bevacizumab (1.25 mg/0.05 mL) at the University of Chicago Retina Clinic. Analysis included determination of the presence of glaucoma, preinjection IOP, IOP 20 minutes to 30 minutes after injection, and IOP at the first follow-up visit. All IOP measurements were performed by Goldmann applanation tonometry. We excluded one patient with acute neovascular glaucoma who required intravitreal in-
Supported by an unrestricted grant from the Research to Prevent Blindness, Inc. (New York, NY). The authors have no financial conflict of interest in relation to this report. Reprint request: Seenu M. Hariprasad, MD, Department of Ophthalmology and Visual Science, University of Chicago, 5841 South Maryland, MC 2114, Chicago, IL 60637; e-mail: [email protected]
234
SHORT-TERM IOP TRENDS AFTER INTRAVITREAL INJECTION OF BEVACIZUMAB
jection of bevacizumab. Statistical analysis was performed using paired Student’s t-test. Results Mean preinjection IOP ⫾ SD was 15.1 ⫾ 2.35 mm Hg (range, 10 –22 mm Hg). Mean postinjection IOP ⫾ SD was 20.1 ⫾ 4.70 mm Hg (range, 16 –31 mm Hg). This difference was statistically significant (P ⫽ 0.0027). Mean IOP ⫾ SD at the first follow-up visit, which occurred an average of 25 days (range, 5– 43 days) after injection, was 14.7 ⫾ 2.93 mm Hg (range, 10 –20 mm Hg). The difference between preinjection IOP and IOP at the first follow-up visit was not statistically significant (P ⫽ 0.36). No eye in this series had IOP elevation severe enough to require pharmacologic or surgical treatment. Discussion Our results indicate that intravitreal injection of bevacizumab is safe from an IOP standpoint. Although patients have a modest increase in IOP immediately after intravitreal injection of bevacizumab, IOP returns to baseline levels by the first follow-up visit. None of the patients in our review had an IOP elevation severe enough to warrant treatment. Anterior chamber paracentesis to reduce IOP should be avoided after bevacizumab injection. This procedure is associated with complications such as lens damage, patient discomfort, and a theoretical risk of increased infection. Our study further suggests that measuring IOP 30 minutes after intravitreal injection may not be necessary. Given the need for frequent repeated injections, shorter office visits may lead to greater acceptability of treatment by patients and improved compliance. Our study included six patients with existing openangle glaucoma. All cases were reported as adequately controlled at the most recent glaucoma evaluation. None of these patients had an IOP elevation severe enough to warrant treatment. We did exclude one patient with acute neovascular glaucoma from our study. We thought that the great reduction in IOP secondary to regression of anterior segment neovas-
235
cularization by the first follow-up visit would have skewed the data. We did not exclusively study patients with severe glaucoma (i.e., neovascular glaucoma, synechial closure, severe uncontrolled open-angle glaucoma, etc). We recommend further study of these patients before discontinuing IOP monitoring. Recently, bevacizumab has shown promise in many studies in treating choroidal neovascularization secondary to various disorders, including age-related macular degeneration.1,2 There was no evidence of sustained elevation of IOP in these previously reported studies. Looking at other intravitreally administered medications, it is well established that intravitreal injection of triamcinolone acetonide can cause a marked increase in IOP several weeks after injection.3 However, Lee et al4 found no significant IOP changes in the short term. Hariprasad et al5 reviewed shortterm IOP trends after pegaptanib injection. Similar to our review, they found a modest elevation in IOP immediately after injection that returned to baseline at the first follow-up visit. In conclusion, intravitreal injection of bevacizumab seems to be safe from an IOP standpoint in the short term. Key words: bevacizumab, intraocular pressure, intravitreal injection. References 1.
2.
3.
4.
5.
Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmic Surg Lasers Imaging 2005;36:331–335. Spaide RF, Laud K, Fine HF, et al. Intravitreal bevacizumab treatment of choroidal neovascularization secondary to agerelated macular degeneration. Retina 2006;26:383–390. Jonas JB, Degenring RF, Kreissig I, et al. Intraocular pressure elevation after intravitreal triamcinolone acetonide injection. Ophthalmology 2005;112:593–598. Lee EW, Hariprasad SM, Mieler WF, et al. Short-term intraocular pressure trends after intravitreal triamcinolone injection. Am J Ophthalmol 2007;143:365–367. Epub September 28, 2006. Hariprasad SM, Shah GK, Blinder KJ. Short-term intraocular pressure trends following intravitreal pegaptanib (Macugen) injection. Am J Ophthalmol 2006;141:200–201.
Purpose: To report the changes in intraocular pressure (IOP) after intravitreal injection of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA). Design: Retrospective chart review. Methods: After the charts of 29 patients who underwent 51 consecutive intravitreal injections of bevacizumab were reviewed, analysis of the short-term effect of bevacizumab injections on IOP was performed. Results: Mean baseline IOP ⫾ SD was 15.1 ⫾ 2.35 mm Hg (range, 10 –22 mm Hg). Mean postinjection IOP ⫾ SD was 20.1 ⫾ 4.70 mm Hg (range, 16 –31 mm Hg). Mean change in IOP from baseline to ⬇30 minutes after bevacizumab injection was 5.0 mm Hg (P ⫽ 0.0027). Mean IOP ⫾ SD at the first follow-up visit, which occurred ⬇25 days (range, 5– 43 days) after injection, was 14.7 ⫾ 2.93 mm Hg (range, 10 –20 mm Hg). Conclusions: Intravitreal injection of bevacizumab seems to be safe from an IOP standpoint in the short term. IOP monitoring immediately after injection may not be necessary. RETINAL CASES & BRIEF REPORTS 2:234 –235, 2008
From the Department of Ophthalmology and Visual Science, University of Chicago, Chicago, Illinois.
lyze IOP changes immediately after injection as well as at the first follow-up visit to assess the frequency of concerning IOP elevation to help determine the necessity for short-term monitoring and treatment.
T
he number of intravitreal injections has increased significantly over the past several years as new agents, such as bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA), have become available. Clinicians routinely check intraocular pressure (IOP) after intravitreal injections to monitor for potentially dangerous elevations that may require treatment. To our knowledge, there has been no study of the short-term IOP trends after intravitreal injection of bevacizumab. The purpose of this study was to ana-
Methods Approval from the Institutional Review Board of the University of Chicago (Chicago, IL) was obtained before initiating this study. We performed a retrospective review of the charts of 29 patients who received 51 intravitreal injections of bevacizumab (1.25 mg/0.05 mL) at the University of Chicago Retina Clinic. Analysis included determination of the presence of glaucoma, preinjection IOP, IOP 20 minutes to 30 minutes after injection, and IOP at the first follow-up visit. All IOP measurements were performed by Goldmann applanation tonometry. We excluded one patient with acute neovascular glaucoma who required intravitreal in-
Supported by an unrestricted grant from the Research to Prevent Blindness, Inc. (New York, NY). The authors have no financial conflict of interest in relation to this report. Reprint request: Seenu M. Hariprasad, MD, Department of Ophthalmology and Visual Science, University of Chicago, 5841 South Maryland, MC 2114, Chicago, IL 60637; e-mail: [email protected]
234
SHORT-TERM IOP TRENDS AFTER INTRAVITREAL INJECTION OF BEVACIZUMAB
jection of bevacizumab. Statistical analysis was performed using paired Student’s t-test. Results Mean preinjection IOP ⫾ SD was 15.1 ⫾ 2.35 mm Hg (range, 10 –22 mm Hg). Mean postinjection IOP ⫾ SD was 20.1 ⫾ 4.70 mm Hg (range, 16 –31 mm Hg). This difference was statistically significant (P ⫽ 0.0027). Mean IOP ⫾ SD at the first follow-up visit, which occurred an average of 25 days (range, 5– 43 days) after injection, was 14.7 ⫾ 2.93 mm Hg (range, 10 –20 mm Hg). The difference between preinjection IOP and IOP at the first follow-up visit was not statistically significant (P ⫽ 0.36). No eye in this series had IOP elevation severe enough to require pharmacologic or surgical treatment. Discussion Our results indicate that intravitreal injection of bevacizumab is safe from an IOP standpoint. Although patients have a modest increase in IOP immediately after intravitreal injection of bevacizumab, IOP returns to baseline levels by the first follow-up visit. None of the patients in our review had an IOP elevation severe enough to warrant treatment. Anterior chamber paracentesis to reduce IOP should be avoided after bevacizumab injection. This procedure is associated with complications such as lens damage, patient discomfort, and a theoretical risk of increased infection. Our study further suggests that measuring IOP 30 minutes after intravitreal injection may not be necessary. Given the need for frequent repeated injections, shorter office visits may lead to greater acceptability of treatment by patients and improved compliance. Our study included six patients with existing openangle glaucoma. All cases were reported as adequately controlled at the most recent glaucoma evaluation. None of these patients had an IOP elevation severe enough to warrant treatment. We did exclude one patient with acute neovascular glaucoma from our study. We thought that the great reduction in IOP secondary to regression of anterior segment neovas-
235
cularization by the first follow-up visit would have skewed the data. We did not exclusively study patients with severe glaucoma (i.e., neovascular glaucoma, synechial closure, severe uncontrolled open-angle glaucoma, etc). We recommend further study of these patients before discontinuing IOP monitoring. Recently, bevacizumab has shown promise in many studies in treating choroidal neovascularization secondary to various disorders, including age-related macular degeneration.1,2 There was no evidence of sustained elevation of IOP in these previously reported studies. Looking at other intravitreally administered medications, it is well established that intravitreal injection of triamcinolone acetonide can cause a marked increase in IOP several weeks after injection.3 However, Lee et al4 found no significant IOP changes in the short term. Hariprasad et al5 reviewed shortterm IOP trends after pegaptanib injection. Similar to our review, they found a modest elevation in IOP immediately after injection that returned to baseline at the first follow-up visit. In conclusion, intravitreal injection of bevacizumab seems to be safe from an IOP standpoint in the short term. Key words: bevacizumab, intraocular pressure, intravitreal injection. References 1.
2.
3.
4.
5.
Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (Avastin) for neovascular age-related macular degeneration. Ophthalmic Surg Lasers Imaging 2005;36:331–335. Spaide RF, Laud K, Fine HF, et al. Intravitreal bevacizumab treatment of choroidal neovascularization secondary to agerelated macular degeneration. Retina 2006;26:383–390. Jonas JB, Degenring RF, Kreissig I, et al. Intraocular pressure elevation after intravitreal triamcinolone acetonide injection. Ophthalmology 2005;112:593–598. Lee EW, Hariprasad SM, Mieler WF, et al. Short-term intraocular pressure trends after intravitreal triamcinolone injection. Am J Ophthalmol 2007;143:365–367. Epub September 28, 2006. Hariprasad SM, Shah GK, Blinder KJ. Short-term intraocular pressure trends following intravitreal pegaptanib (Macugen) injection. Am J Ophthalmol 2006;141:200–201.
