Intravitreal Bevacizumab for Neovascular Glaucoma A Randomized Controlled Trial Shahin Yazdani, MD,* Kamran Hendi, MD,w Mohammad Pakravan, MD,* Manijeh Mahdavi, MD,w and Mehdi Yaseri, MSczy Purpose: To determine the effect of intravitreal bevacizumab (IVB) on neovascular glaucoma (NVG) in terms of iris neovasculariza- tion (NVI), intraocular pressure (IOP), and visual acuity. Methods: This randomized controlled trial included 26 eyes of 26 patients with NVG. All eyes received conventional treatment for NVG and were randomly allocated to three 2.5 mg IVB injections at 4-week intervals or a sham procedure (subconjunctival normal saline) at similar time intervals and in the same setting. Results: Overall, 14 eyes of 14 patients received IVB and 12 eyes of 12 subjects were allocated to the sham procedure and followed for a mean period of 5.9 ± 1.4 months. The IVB group demonstrated significant reduction in IOP from a baseline value of 33.4 ±14.5 mm Hg to 21.8 ± 13.7 mm Hg (P = 0.007), 25.1 ± 20 mm Hg (P = 0.058), and 23.9 ± 18.7 mm Hg (P = 0.047) at 1, 3, and 6 months after intervention, respectively. NVI was also significantly reduced from a mean baseline value of 347 ± 48 degrees to 206 ± 185 degrees (P = 0.01), 180 ± 187 degrees (P = 0.004), and 180 ± 180 degrees (P = 0.004) at 1, 3, and 6 months after intervention. In contrast, IOP and NVI remained unchanged or increased insignificantly at all follow-up intervals in the control group. No significant change in visual acuity was observed within the study groups at any time interval. The study groups were comparable in terms of require- ment for additional interventions such as panretinal photocoagula- tion and cyclodestructive procedures. Conclusions: Intravitreal injections of bevacizumab seem to reduce NVI and IOP in NVG and may be considered as an adjunct to more definitive surgical procedures for NVG. Key Words: neovascular glaucoma, intravitreal bevacizumab, iris neovascularization, intraocular pressure (J Glaucoma 2009;18:632–637) N eovascular glaucoma (NVG) is a form of secondary glaucoma in which abnormal fibrovascular tissue grows on the iris and drainage angle structures including the trabecular meshwork. Contraction of this tissue leads to progressive angle closure and intraocular pressure (IOP) elevation eventually leading to a glaucoma that is poorly responsive to conventional treatment and has poor visual prognosis. 1 Ischemic retinal disorders are the most pre- valent conditions leading to NVG, however, other condi- tions such as inflammation, retinal detachment, tumors, and irradiation may also result in NVG. 2 Currently, management of this condition is directed toward the underlying disease process, mostly by some form of retinal ablation to reduce the neovascular stimuli, and IOP reduction by means of medical and surgical therapy. 1,2 It is now evident that several mediators are involved in pathologic neovascularization, the most important and well studied of which is the vascular endothelial growth factor type A (VEGF-A). Regarding the pivotal role of VEGF-A in ocular neovascularization, inhibition of this mediator seems to have a strong biologic basis for treatment of NVG. 1,3 Antagonists of VEGF-A have recently gained widespread popularity for different ocular conditions associated with a neovascular component. We have previously described 2 patients who received intravitreal bevacizumab (IVB) for treatment of NVG. 4 A number of other reports have also demonstrated the somewhat dramatic therapeutic effect of this agent for this particular indication. 5–9 Randomized clinical trials on anti-VEGF agents are currently scarce in the ophthalmic literature and to the best of our knowledge, the present study is the first randomized clinical trial on IVB for NVG. PATIENTS AND METHODS Eligibility Criteria This randomized clinical trial was conducted at a tertiary referral eye center. Consecutive patients with NVG were screened and evaluated for eligibility. Exclusion criteria included monocular subjects, lack of light percep- tion, best-corrected visual acuity (BCVA) better than 20/200, presence of infectious ocular disease, uncontrolled systemic hypertension, history of thromboembolic disor- ders, pregnancy or lactation, renal failure, and any severe systemic disease. One eye of each subject was considered for enrollment. Baseline Evaluation Eligible subjects underwent a complete ophthalmo- logic examination including refraction and determination of BCVA, slitlamp examination, Goldmann applanation tono- metry, gonioscopy, and dilated funduscopy. Digital slitlamp photography was performed before intervention and repeated 1 and 2 weeks and 1, 3, and 6 months after intervention. Randomization Permuted block randomization was used to assign one eye of each patient to the study groups. The allocation of each patient was printed inside a sealed enveloped and only Copyright r 2009 by Lippincott Williams & Wilkins DOI:10.1097/IJG.0b013e3181997211 Received for publication November 28, 2007; accepted December 8, 2008. From the *Department of Ophthalmology and Ophthalmic Research Center; wLabbafinejad Medical Center; zOphthalmic Research Center, Shahid Beheshti University, M.C.; and ySchool of Public Health and Public Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran. The authors have no financial or proprietary interest in any material or method mentioned in this report. Reprints: Shahin Yazdani, MD, Ophthalmic Research Center, Labba- finejad Medical Center, Boostan 9 Street, Pasdaran Avenue, Tehran 16666, Iran (e-mail: shahinyazdani@sbmu.ac.ir; shahinyazdani@ yahoo.com). ORIGINAL STUDY 632 | www.glaucomajournal.com J Glaucoma  Volume 18, Number 8, October–November 2009