Pediatric Refractive Surgery by L587rDN


									Michael A. Morris, MD
 PGY-3 Ophthalmology Resident
   Scott & White Eye Institute
           Temple, TX

 Authors   have no financial interests.
 To evaluate the effectiveness of
  combination treatment with corneal
  photodynamic therapy (PDT) using
  verteporfin and subconjunctival
  bevacizumab for deep stromal corneal
  neovascularization as primary treatment or
  in preparation for therapeutic penetrating
 The above therapy is an off-label use of
  PDT with verteporfin and bevacizumab.
 Retrospective case series performed at
  Scott & White Eye Institute from 2009-
 Six eyes of 6 patients with deep corneal
  neovascularization were treated with
  corneal PDT with verteporfin (total light
  dose=150 J/cm2) and subconjunctival
  bevacizumab (2.5 mg/0.1 ml).
 Blood flow through the deep stromal
  vessels was evaluated by slit lamp
  examination (SLE) and corneal fluorescein
  angiography (FA).
 Examination was performed before
  treatment and at 1 week, 1 month, and
  3 months after treatment.
 Repeat combination treatment was applied
  after the 1-month visit if reperfusion of the
  deep stromal vessels was observed either
  by SLE or corneal FA.

 Patients (eyes)       6 eyes out of 6 patients
  Age (years)         65 ± 22 (Range 43-87)
                        66% Female (n=4)
                         33% Male (n=2)
 Pre-op BCVA       20/188 (Range = 20/30 - 5/200)

3 month BCVA       20/62 (Range = 20/30 – 20/100)

 Post-tx IOP                   0 cases
 Absence of blood flow in the deep stromal
  vessels was observed on SLE and corneal
  FA in all patients (N=6 eyes) treated with
  corneal PDT and subconjunctival
  bevacizumab at the 1-week follow-up
 In addition, all patients (5 of 6) evaluated at
  the 1-month follow-up examination showed
  persistent absence of blood flow on slit
  lamp evaluation and/or corneal FA.
Red-free (Pre-treatment)             Early phase (Pre-treatment)

                            1:11.0                                 8:07.6
Mid-phase (Pre-treatment)            Late phase (Pre-treatment)
Red-free (1 month post-treatment)     Early phase (1 month post-treatment)

                             1:45.7                               7:36.2
Mid-phase (1 month post-treatment)    Late phase (1 month post-treatment)
 At 3 months, 4/6 patients (66%) were noted to
  have early revascularization requiring
  retreatment and 2/6 (33%) had no
  revascularization at 3 months post-treatment.
 Recurrences were much less prominent, and
  easily treated with a second treatment.
 One patient underwent PKP after the 3-month
  follow-up appointment.
 Of the 2 patients without revascularization at 3
  mos, 1 patient had revascularization at 6 mos
  requiring retreatment.

                                 A                                       B
Figure 1 PK host cornea 1 month s/p PDT and subconjunctival
 bevacizumab treatment. A, Erythrocytic debris in the stromal vessels
 (arrow) and stroma (asterisk) appears red when stained with Masson-
 trichrome. B, Fibrin in the stromal vessels appears blue when stained
 with Phosphotungstic acid hematoxylin (PTAH).
 No serious adverse events were observed.
 All patients had mild corneal intrastromal and
  subconjunctival hemorrhage at the 1-week
  post-treatment visit which resolved by the
  1-month post-tx visit.
 No cases of elevated IOP throughout the
  duration of post-tx follow-up.
 The combination of corneal PDT with
  verteporfin and subconjunctival injection
  of bevacizumab appears to be effective
  in closing deep stromal blood vessels as
  observed by SLE and corneal FA.
 Further study is required to examine the
  long-term effectiveness of this
  combination therapy to treat corneal
  neovascularization either as primary
  treatment or in patients anticipating
  corneal transplantation.
    Special thanks to Dr. Samuel Fulcher and Dr. Robert Rosa, Jr. at the Scott & White
    Eye Institute for allowing me to join them in this research project.
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