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Corneal fine needle diathermy with adjuvant bevacizumab to treat corneal
neovascularization in children
Asim Ali, MD, FRCSC, Uri Elbaz, MD, Carl Shen, BMSc, Kamiar Mireskandari, MBChB, FRCSEd, FRCOphth, PhD.
Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
The authors have no financial interest to disclose
To report the outcomes of corneal fine needle
diathermy (FND) with adjuvant intrastromal and subconjunctival bevacizumab injection for corneal neovascularization (CN) in children.
PURPOSE
The medical records of all children who had undergone
FND with adjuvant bevacizumab injection were reviewed retrospectively.
Treatment efficacy was evaluated by changes in visual acuity, regression of CN and clearing of lipid deposits with the aid of slit lamp colour images that were taken prior to surgical intervention and at last follow-up visit.
Postoperative complications were recorded and served to assess the safety of the procedure.
METHODS
The needle tip from a stainless steel needle detached from a 10-0
monofilament nylon suture was inserted intrastromally approximately 1mm from the limbus to the level of corneal new vessels.
Unipolar diathermy was then lightly tapped against the needle and served to heat the needle in its corneal track to a degree where blanching of the vessels was noticeable with minimal stromal collagen shrinkage.
An attempt was made to cannulate the vessels or at least disrupt their integrity to further enhance the thermal effect.
This was repeated as needed to disrupt all of the blood vessels.
Once cauterization was complete, bevacizumab 25 mg/ml was injected into the deep stroma (up to 2.5mg in 0.1ml per each corneal quadrant involved) in proximity to the vessels until whitening around the vessels was visible and the remainder into the subconjunctival space adjacent to areas of CN.
SURGICAL TECHNIQUE
Nine eyes of 9 patients were included in this study.
The mean patient age was 8.4 ± 4.2 years (4-15 years) and the mean follow-up time was 18.7 ± 12.2 months (5 – 35 months).
Following treatment, 8 out of 9 eyes treated (88.9%) had complete CN resolution with subsequent resolution of corneal edema within 1 month of treatment.
They all maintained corneas devoid of vessels throughout a mean follow-up of 17.0 ± 11.9 months (5 – 35 months) from surgery.
RESULTS
FND – fine needle diathermy, CN – corneal neovascularization; CDVA – corrected distance visual acuity; HSK – herpes simplex keratitis; BKC – blepharokeratoconjunctivitis; DALK – deep anterior lamellar keratoplasty; NA – not applicable. Patient # 4 who had concomitant FND, bevacizumab injections and DALK was excluded from CDVA analysis.
Patient demographics, preoperative findings and postoperative outcomes following fine needle diathermy combined with subconjunctival and corneal intrastromal bevacizumab injections.
#
Age (y)
Eye
Sex
Follow-up (m)
Preoperative
diagnosis
Previous FND
Additional surgery
Preoperative
CN / Lipid
regression
Preop
CDVA
logMAR
Postop
CDVA
logMAR)
CN duration (m)
prior to
treatment
CN Characterisics
Lipid deposits
1 15 OS F 31
Corneal anesthesia post brain
tumor resection
Yes x1
Concomitant tarsorrhaph
y and Consecutive
corneal neurotizatio
n
37Singl
e stem
Yes
Complete /
Complete
0.2 0.2
2 7 OS M 13 HSK No Noneunknown
Double
stem
Yes
Complete /
Complete
0.3 0
3 9 OS F 32
Corneal anesthesia exposure
keratopathy post brain
tumor resection
Yes x 2
Concomitant Tarsorrhaph
y13
Double
stemNo
Partial / NA
1 1
Patient demographics, preoperative findings and postoperative outcomes following fine needle diathermy combined with subconjunctival and corneal intrastromal bevacizumab injections – continued table from previous slide.
#
Age (y)
Eye
Sex
Follow-up (m)
Preoperative
diagnosis
Previous FND
only
Additional surgery
Preoperative
CN / Lipid regression
Preop CDVA logMAR
Postop
CDVA logMAR
CN duration (m)
CN Characterisics
Lipid deposits
4 5 OD F 10
Suture tract
infection with CN
No
Concomitant repeat DALK
(post DALK for HSK)
24Single stem
Yes
Complete / NA
(removed with DALK)
NA NA
5 15 OD M 26 HSKYes x
2No 32
Double
stem
Yes
Complete / Complete
0.8 0.5
6 5 OS F 11 BKC NoPrevious DALK
for corneal scar
3Doubl
e stem
NoComplete /
NA0.4 0.1
7 4 OD F 35
Suture tract
infection with
corneal melt and
CN
No
Previous dermoid excision
with lamellar keratoplasty
11Single stem
NoComplete /
NA0.9 0.9
8 6 OS M 5
Idiopathic Corneal
anesthesi
a
NoConcomitant tarsorrhaphy
1Single stem
NoComplete/
NA0.8 0.6
9 10 OD F 5 HSK No No 1Doubl
e stem
Yes
Complete/Partial
0.9 0.7
A
A’
B
B’ C’810µ 370µ 490µ
C
Corneal neovascularization resolution phases. Slit lamp photography (upper row) with time-matched Visante OCT (Carl Zeiss, Germany) images (lower row). A. Preoperative images showing neovascularization pattern, sectorial corneal haze (A) and localized stromal edema (A’). B. Clinical phase II. Three months post-surgery, a complete resolution of CN with more prominent lipid deposition. OCT (B’) shows significant decrease in corneal edema with more stromal hyperreflectivity corresponding to the increase in lipid deposition. C. Clinical phase III. Thirteen months post-surgery. No recurrence of CN, mild localized scar and completely resolved lipid deposits. OCT image (C’) shows reorganization of stroma with thickened posterior lamella (slowly resuming normal stromal thickness), less anterior hyperreflectivity and epithelial thickening compensating for the mild stromal loss.
A B
C D E
Pre and post-operative images of patient # 9. A. Preoperative image. Nasal corneal neovascularization in patient with a history of herpes simplex keratitis showing 2 vessel stems crossing the corneal center with lipid deposits (white arrow) and mild temporal edema (slit view). B. Ten days post combined treatment. Cessation of blood flow and discontinuation of blood vessels tract is demonstrated. C, D, E. Three and a half months post combined treatment. Accentuation of lipid deposition (C), resolved temporal edema with minimal thinning (D, slit view) and complete CN resolution, quiet conjunctiva and moderate residual scarring (E).
A B
Immediate and late post-operative images of patient # 5. A. Intracorneal hemorrhage one day following surgery. B. Twenty-six months after combined treatment. Complete CN resolution with moderate residual scarring.
We selected the longer lasting stromal injection as our favoured technique in these children aiming for a one-time treatment under general anesthesia.
This was done immediately after FND treatment in order to saturate the corneal stroma and enhance bevacizumab’s duration of effect.
DISCUSSION
Of note, 2 of our patients with complete resolution of CN
following combined treatment previously had multiple CN recurrences when FND alone was utilized.
In these patients, once bevacizumab was given by intrastromal and subconjunctival injection following FND, we did not observe CN recurrence even after extended follow up beyond 2 years.
This demonstrates the additive effect of the intrastromal bevacizumab injection specifically in children where CN likely behaves more aggressively than in adults and therefore presents with higher recurrence rates after FND alone.
DISCUSSION
we show that corneal FND with adjuvant
intrastromal and subconjunctival bevacizumab injection is an effective method to treat corneal vascularization in the pediatric population.
We believe this technique simplifies the post-operative drop regimen by avoiding the need for prolonged bevacizumab or steroid drops or repeat anaesthesia for repeated subconjunctival injections in children.
CONCLUSIONS