Apart from its established role in Age related maculopathy, Ani-Vegf have other usage too. Presently clinical study reports are coming in showing encouraging results.

1. Anti-VEGF “Other” uses 39th Annual All Gujarat Ophthalmology confSaturday 24th Sept 2011 Sep 24, 2011 11.45 am to 1.15 pm Hall C Dr. AnandSudhalkar Vadodara 9/23/2011 1

2. VEGF Generation: attempt at repair Hypoxia Trauma Neovascularization Increased permeability Tissue regeneration, fibrosis 9/23/2011 2

3. The Research: Hypoxia & VEGF VEGF secreted in 24 hours Peaked in 7 days Decreased by 21 days Returned to basal levels by 90 days after correction of hypoxia Ref: Vascular endothelial growth factor expression and angiogenesis induced by chronic cerebral hypoperfusion in rat brain. Hai J, Li ST, Lin Q, Pan QG, Gao F, Ding MX. Neurosurgery. 2003 Oct;53(4):963-70; discussion 970-2. 9/23/2011 3

4. The Research: TRAUMA & VEGF Starts within 4 hrs post injury Max from 8hrs to 1 day post trauma. Ref: Neuroscience. 2003;122(4):853-67. Early neutrophilic expression of vascular endothelial growth factor after traumatic brain injury. Chodobski A, Chung I, Koźniewska E, Ivanenko T, Chang W, Harrington JF, Duncan JA, Szmydynger-Chodobska J. 9/23/2011 4

5. Anti VEGF, Properties STOP New vessels formation Anti Inflammatory Anti Tissue Growth and healing Applications Pterigium Keratoplasty Trabeculectomy Granuloma 9/23/2011 5

7. The Dosage Injection: 1.25mg (0.05cc) Topical: 25mg (1cc from inj) make upto 4cc i.e. 6.25mg per cc 1cc = 20 drops 0.3125mg per drop 1.25mg per 4 drops 9/23/2011 7

8. How long? 21 days to max one month Decreased corneal NV was noted in 7 of 10 eyes, usually within 1 month of treatment. Adverse effects generally appeared during the second month of treatment. The Effect of Topical Bevacizumab onCorneal Neovascularization ( Over a period of three months) Sang Woo Kim, MD,1 Byung Jin Ha, MD,1 EungKweon Kim, MD, PhD,1,2 HungwonTchah, MD,3Tae-im Kim, MD1,2doi:10.1016/j.ophtha.2008.02.013 9/23/2011 8

9. Is it Safe? Safety Profile of Topical VEGF Neutralization at the Cornea Bock F, Onderka J, Rummelt C, Dietrich T, Bachmann B, Kruse FE, ...Department of Ophthalmology, University of Erlangen-Nürnberg, Erlangen, Germany. 2009 May;50(5):2095-102. Epub 2009 Jan 17. 9/23/2011 9

10. Conclusion Topical neutralization of VEGF-A at the corneal surface does not have significant side effects on normal corneal epithelial wound healing, normal corneal integrity, or normal nerve fiber density. Therefore, anti-VEGF eyedrops seem to be a relatively safe option to treat corneal neovascularization. 9/23/2011 10

11. Pterigium: Role of VEGF Decreased Pigment Epithelium-Derived Factor and Increased Vascular Endothelial Growth Factor Levels in Pterygia Jin, Ji MD; Guan, Ming PhD; Sima, Jing MD; Gao, Guoquan MD, PhD; Zhang, Mei MD; Liu, Zhuguo MD; Fant, James B.S.; Ma, Jian-xing MD, PhD Cornea: July 2003 - Volume 22 - Issue 5 - pp 473-477 Basic Investigation Basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) 9/23/2011 11

12. Pterigium 9/23/2011 12

13. Surgery: Excision with Hinged graft Corneal dissection Subconj tissue removal Hinged Conj Graft 9/23/2011 13

14. From Day 4, Topical Bevacizumab started 9/23/2011 14

15. Day 14th 9/23/2011 15

16. Injection route for Pterigium 9/23/2011 16

17. Treatment of inflamed pterygia (Before surgery) or residual pterygial bed (after surgery) A M MansourBr. J. Ophthalmol. 2009;93;864-865doi:10.1136/bjo.2008.155291 9/23/2011 17

18. The Injection DOSE subconjunctival Ranibizumab -Lucentis (0.1 ml or 1 mg) 9/23/2011 18

19. Inflamed Pterygia One week after subconjunctival ranibizumab (0.1 ml or 1 mg), the pterygium bed appears flattened with attenuation of conjunctival vessels. This appearance was unchanged 13 months after the injection. Pterygium bed of the left eye displays elevated fibrovascular mass with a high count of microvessels. Figure 9/23/2011 19

20. Residual Pterygium ( Post Excision) The residual pterygium of the right eye was markedly injected following excision of the advancing edge of the pterygium at the end of phacoemulsification. Note the high count of conjunctivalmicrovessels. One week after subconjunctivalbevacizumab (0.1 ml or 2.5 mg), the injection disappeared in the residual pterygium bed. 9/23/2011 20

21. Post Keratoplasty Corneal Vascularization 9/23/2011 21

22. Topical Avastin in Keratoplasty Sang Woo Kim, MD,1 Byung Jin Ha, MD,1 EungKweon Kim, MD, PhD,1,2 HungwonTchah, MD,3 Tae-im Kim, MD1,2 Ophthalmology 2008;115: e33–e38 © 2008 by the American Academy of Ophthalmology. 9/23/2011 22

23. Design: Prospective, nonrandomized, masked observational case series.Participants: Ten eyes of 7 patients with corneal NV. Methods: Patients received topical bevacizumab (1.25%) twice daily. Ophthalmic evaluations included visual acuity, slit-lamp examination, and tonometry. Main Outcome Measures: Corneal NV and changes in ophthalmic evaluations. Results: Decreased corneal NV was noted in 7 of 10 eyes, usually within 1 month of treatment. Epitheliopathy (epithelial defect, epithelial erosion) was observed in 6 of 10 eyes, 1 resulting in corneal thinning. Adverse effects generally appeared during the second month of treatment. Conclusions: Topical application of bevacizumab was effective in reducing corneal NV within the first month. However, by the second month there was an increased risk of adverse effects. Ophthalmology 2008;115: 9/23/2011 23

24. A B A. Before topical bevacizumab treatment. Note the corneal NV over the donor host junction in the right eye after penetrating keratoplasty. B, One month after topical bevacizumab treatment. Note the delayed progression of corneal NV. 9/23/2011 24

25. Trabeculectomy 9/23/2011 25

26. Surgical Procedure Fornix based conj flap Triangular Scleral flap Lamellar corneal dissection Enter Ac Punch Closure 9/23/2011 26

27. Anti VEGF: Desired Effect Reduce bleb congestion and fibrosis Work as an adjuvant? 9/23/2011 27

28. Topical Avastin started on Trab BlebPost op day 3 9/23/2011 28

29. Post op day 19 9/23/2011 29

30. Post Op day 40, Topical drops stopped 9/23/2011 30

31. Post Op day 110th 9/23/2011 31

32. Intracameral VEGF after trab OSN SuperSite September 17, 2011 Intracameral anti-VEGF injection associated with success in trabeculectomy cases, study of 141 cases IngeborgStalmans VIENNA, Austria — More glaucoma patients achieved target IOP without medication or postoperative surgical interventions when receiving bevacizumab than a placebo group, a prospective study found. "A single intracameral inj. of bevacizumab at the end of trabeculectomy was associated with increased absolute success rates and reduced need for postoperative interventions," IngeborgStalmans, MD, PhD, In the study, absolute success was defined as "meeting the target IOP without IOP-lowering medication or postoperative surgical interventions," which excluded massage and suture adjustments. 9/23/2011 32

33. The study found that 83% of all patients in the bevacizumab group achieved absolute success 9/23/2011 33

34. Does Adding Bevacizumab Therapy in Glaucoma Surgery Improve the Success of Needle Bleb Revisions? (Avastin) This study is ongoing, but not recruiting participants. First Received on February 26, 2009. Last Updated on August 4, 2011 History of Changes 9/23/2011 34

35. Conclude Topical/ injectableBevasizumab is effective in reducing vascularity post operatively in Pterigium and Trabeculectomies. The effect is long lasting even after stopping the topical drops after one month. There were no surface healing problems during one month treatment. 9/23/2011 35

36. Thank You 9/23/2011 36

38. Weon Sun Lee2 and

40. Corresponding author: Man Soo Kim, Department of Ophthalmology, Seoul St. Mary's Hospital, 505 Ban-po Dong, Seocho-Ku, Seoul 137-040, Korea; mskim@catholic.ac.kr. The bevacizumab group was treated with 5% bevacizumab and antibiotic 0.5% levofloxacin eye drops four times daily and the control group with antibiotic eye drops only 9/23/2011 37

41. Safety Profile of Topical VEGF Neutralization at the Cornea From the Department of Ophthalmology, University of Erlangen-Nürnberg, Erlangen, Germany. 9/23/2011 38

42. 9/23/2011 39

43. Expression of Vascular Endothelial Growth Factor and Inducible Nitric Oxide Synthase in PterygiaLee, Do-Hyung M.D., Ph.D.; Cho, Hye Jin B.S.; Kim, Jong-Tak B.S.; Choi, Jun Sub B.S.; Joo, Choun-Ki M.D., Ph.D.Cornea: October 2001 - Volume 20 - Issue 7 - pp 738-742Basic Investigation VEGF and NO may play an important role in the development of pterygium and to identify VEGF and NO in the epithelium of pterygium. We hypothesize that environmental stress, such as ultraviolet irradiation and local inflammation stimulate the elaboration of NO and VEGF, resulting in the conjunctival fibrovascular ingrowth characteristic of pterygium. 9/23/2011 40

44. Decreased Pigment Epithelium-Derived Factor and Increased Vascular Endothelial Growth Factor Levels in PterygiaJin, Ji MD; Guan, Ming PhD; Sima, Jing MD; Gao, Guoquan MD, PhD; Zhang, Mei MD; Liu, Zhuguo MD; Fant, James B.S.; Ma, Jian-xing MD, PhDCornea: July 2003 - Volume 22 - Issue 5 - pp 473-477Basic Investigation Pterygia exhibit significantly lower PEDF but higher VEGF levels than those in normal corneas and conjunctivae. The decreased PEDF level in pterygia may play a role in the formation and progression of pterygia. 9/23/2011 41

45. The Effect of Topical Bevacizumab onCorneal NeovascularizationSang Woo Kim, MD,1 Byung Jin Ha, MD,1 Eung Kweon Kim, MD, PhD,1,2 Hungwon Tchah, MD,3Tae-im Kim, MD1,2Ophthalmology 2008;115:e33–e38 © 2008 Topical application of bevacizumab was effective in reducing corneal NV within the first month. (12.5mg bevacizumab with 1 mL normal saline However, by the second month there was an increased risk of adverse effects. 9/23/2011 42

46. Figure 3. The effect of topical bevacizumab in cases 6 and 7. Case 6 (A, B). A, Before topical bevacizumab treatment. Note that more than half of the cornea is covered with diffuse superficial and deep corneal neovascularization (NV). B, At 3 months after treatment. Note no significant changes. Case 7 (C, D). C, Before topical bevacizumab treatment. Vessels from the conjunctiva crossed from the limbus towards the cornea 1 month after pterygiumresection. D, One month after topical bevacizumab treatment. Note no significant vascular change, but reduced corneal opacification. 9/23/2011 43

47. VEGF The role of VEGF as a critical factor in the control of the growth of abnormal blood vessels from the choroid directly attacks a central problem in this disease. The profound vascular permeability induced by VEGF is potentially of even greater importance in the treatment of established neovascular ARMD lesions, in which leakage of fluid from new vessels causes visual loss through retinal edema and exudation, subretinal fluid and hemorrhage.[7] Anti-VEGF aptamers are stable small RNA-like molecules that bind exclusively and with high affinity to the 165-kDa isoform of human VEGF [Figure - 1]. Pegaptanib sodium, an oligonucleotide known as an aptamer, binds and inhibits only the extracellular isoforms of VEGF that are at least 165 amino acids in length.[9] Multiple biologically active forms of VEGF-A are generated by both alternative mRNA splicing and posttranslational modification (proteolytic cleavage),[10] and two of these forms (VEGF165 and VEGF121) have been detected in choroidal neovascular lesions. Pegaptanib (Macugen, Pfizer) can only bind and inhibit the larger VEGF165 isoform. 9/23/2011 44

48. Pegaptanib V/S Bevacizumab In contrast to pegaptanib, bevacizumab (Avastin; Genentech, South San Francisco) a full-length, humanized monoclonal antibody against VEGF and ranibizumab (Lucentis; Genentech, South San Francisco, California), a recombinant, humanized, monoclonal antibody antigen-binding fragment (Fab), bind and neutralize all the biologically active forms of VEGF. 9/23/2011 45

49. Bevacizumab The similar VEGF binding properties of bevacizumab and ranibizumab can be explained by their common molecular lineage. Both drugs are proteins that were genetically modified from the same murine monoclonal antibody against VEGF. The two proteins differ in their size and affinity for VEGF. Whereas bevacizumab is a humanized, murine full-length antibody with two binding sites for VEGF, ranibizumab is a humanized, murine antigen-binding fragment (Fab) with only a single affinity-matured binding site for VEGF. [ Bevacizumab is currently approved as an intravenous treatment for metastatic colorectal cancer. There is anecdotal evidence that off-label use intravitreal bevacizumab improves short-term visual outcomes in patients with neovascular ARMD. 9/23/2011 46

50. VEGF-Trap(R1R2) is a fusion protein that combines ligand-binding elements taken from the extracellular domains of VEGFR-1 and VEGFR-2 fused to the Fc portion of IgG. This potent high-affinity VEGF blocker effectively suppresses tumor growth and vascularization in vivo , resulting in almost completely avascular tumors. Subcutaneous injections or a single intravitreous injection of VEGF-Trap(R1R2) strongly suppressed CNV in mice with laser-induced rupture of Bruch's membrane, and subretinal neovascularization in transgenic mice expressing VEGF in photoreceptor cells.[15] 9/23/2011 47

51. RNAi is a double-stranded piece of interference RNA that is taken up by chorioretinal cells, activating a protein that breaks down the antisense mRNA. Destruction of VEGF mRNA prevents the production of VEGF protein. The whole process is catalytic, so the RNAi may be a very potent and efficient blockade of VEGF. RNAi may have a long biologic half-life, indicating a much longer interval between intravitreal injections. Anti-VEGF RNAi for the treatment of CNV is currently being tested in clinical trials.[15] 9/23/2011 48

52. ] 9/23/2011 49

53. . . Design:. Prospective, nonrandomized, masked observational case series 9/23/2011 50

54. Participants: Ten eyes of 7 patients with corneal NV. 9/23/2011 51

55. Intracameral: 141 case The prospective, randomized, placebo-controlled, double-masked study looked at the use of Avastin (bevacizumab, Genentech) for improved outcomes after trabeculectomy, including as an anti-scarring agent following surgery. The study included 141 patients with either primary open-angle glaucoma or normal tension glaucoma. Patients were divided into two groups, with 70 patients receiving bevacizumab and undergoing trabeculectomy and 71 patients receiving a placebo and undergoing trabeculectomy with mytomycin C. Follow-up was 6 months. Bevacizumab 50 µl, 25 mg/mL was injected into the anterior chamber through hydrated paracentesis. The study found that 83% of all patients in the bevacizumab group achieved absolute success, while 59% achieved absolute success in the placebo group. "This was quite a striking difference, which was clearly statistically significant," she said. Disclosure: Dr. Stalmans has no relevant financial disclosures. 9/23/2011 52