Sir,
Romano et al1 present some interesting data regarding the use of intravitreal bevacizumab (IVB) before diabetic vitrectomy, and its effect on the rate of postoperative vitreous cavity haemorrhage (POVCH). We were interested in the authors’ assertion that the preoperative IVB resulted in a reduction in the rate of late POVCH but not early or persistent POVCH after initial surgery. This is contrary to the findings of Yang et al,2 who found a reduction in the rate of early, but not late haemorrhage, and Yeoh et al,3 who reported a 54% POVCH rate in non-oil-filled eyes in their series using preoperative IVB. Although the study by Romano et al1 was an uncontrolled pilot study, these differences perhaps deserve some explanation.
Romano et al1 attribute the reduction in rate of re-bleeding to the use of the preoperative dose of IVB. We note that IVB was also given at the completion of surgery after fluid–air exchange. Do the authors consider this extra dose of IVB to have had an effect on late re-bleeding?
Although there are conflicting reports, air and other tamponade agents have also been noted to have an effect on POVCH.4 The authors report fluid air exchange: was air exchange used in all cases for its haemostatic effect, or just in selected cases to tamponade retinal breaks? Was gas used? In addition, was the dose of IVB adjusted in any way to allow for the reduced volume of distribution after fluid air exchange? If not, the absence of any toxic effect is important and is of clinical relevance.
Finally, Yeoh et al3 considered that one explanation for their high re-bleed rate was the inadequate intraoperative laser because of apparent inactive retinopathy at the time of vitrectomy secondary to the use of preoperative IVB. Romano et al1 reported using endolaser photocoagulation and further detail regarding this would be useful. For example, Yeh et al5 reported a significant reduction in the late re-bleed rate by the addition of confluent anterior cryotherapy to the peripheral retina, and many surgeons now routinely use endolaser to the anterior retina to reduce late re-bleed rates.
Conflict of interest
The authors declare no conflict of interest.
References
Romano MR, Gibran SK, Marticorena J, Wong D, Heimann H . Can a preoperative bevacizumab injection prevent recurrent postvitrectomy diabetic vitreous haemorrhage? Eye 2008; 28 (Epub ahead of print).
Yang CM, Yeh PT, Yang CH, Chen MS . Bevacizumab pretreatment and long-acting gas infusion on vitreous clear-up after diabetic vitrectomy. Am J Ophthalmol 2008; 146 (2): 211–217.
Yeoh J, Williams C, Allen P, Buttery R, Chiu D, Clark B et al. Avastin as an adjunct to vitrectomy in the management of severe proliferative diabetic retinopathy: a prospective case series. Clin Experiment Ophthalmol 2008; 36 (5): 449–454.
Danielescu C, Irimia A, Robu M . Efficiency of air tamponade in prevention of early recurrence of vitreal haemorrhage in diabetic patients with vitrectomy. Oftalmologia 2006; 50 (2): 62–67.
Yeh PT, Yang CM, Yang CH, Huang JS . Cryotherapy of the anterior retina and sclerotomy sites in diabetic vitrectomy to prevent recurrent vitreous haemorrhage: an ultrasound biomicroscopy study. Ophthalmology 2005; 112: 2095–2102.
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Smith, J., Steel, D. Reply to MR Romano et al. Eye 24, 388 (2010). https://doi.org/10.1038/eye.2009.119
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DOI: https://doi.org/10.1038/eye.2009.119
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