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Original Investigation
March 16, 2017

Association of Repeated Intravitreous Bevacizumab Injections With Risk for Glaucoma Surgery

Author Affiliations
  • 1Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  • 2Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  • 3Child and Family Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
  • 4Pharmaceutical Outcomes Programme, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
JAMA Ophthalmol. Published online March 16, 2017. doi:10.1001/jamaophthalmol.2017.0059
Key Points

Question  Do repeated intravitreous bevacizumab injections increase the risk for glaucoma surgery?

Finding  In this case-control study of 74 patients who underwent glaucoma surgery and 740 control participants, the adjusted rate ratio for glaucoma surgery was higher for patients who received 7 or more intravitreous bevacizumab injections per year than for those who received 3 or fewer intravitreous bevacizumab injections per year.

Meaning  Patients who receive 7 or more intravitreous bevacizumab injections per year have an increased risk of requiring glaucoma surgery.

Abstract

Importance  Intravitreous injections of anti–vascular endothelial growth factor (VEGF) agents are associated with a sustained increase in intraocular pressure. This sustained elevated intraocular pressure could lead to higher rates of glaucoma surgery to lower this pressure.

Objective  To determine the risk of glaucoma surgery following repeated intravitreous bevacizumab injections.

Design, Setting, Participants  This nested, case-control study acquired and analyzed data from large, population-based, linked health databases supported by the British Columbia Ministry of Health in Canada. Study participants included all patients with ophthalmic issues in British Columbia, such as those of the Provincial Retinal Diseases Treatment Program, who had received intravitreous bevacizumab injections for exudative age-related macular degeneration between January 1, 2009, and December 31, 2013. Cases were identified using glaucoma surgical codes for trabeculectomy, complicated trabeculectomy, glaucoma drainage device, and cycloablative procedure. For each case, 10 controls were identified and matched for age, preexisting glaucoma, calendar time, and follow-up time. The number of intravitreous bevacizumab injections received per year—3 or fewer, 4 to 6, or 7 or more—was determined for both cases and controls. Data analysis was performed from February 23, 2016, to November 14, 2016.

Main Outcomes and Measures  Risk of glaucoma surgery compared with the number of intravitreous bevacizumab injections per year in cases and controls. Rate ratios were adjusted for covariates (diabetes mellitus, myocardial infarction, stroke, and verteporfin use).

Results  Seventy-four cases of glaucoma surgery and 740 controls were identified, with a mean (SD) age of 81.3 (8.4) years for cases and 81.4 (7.9) for controls. The case group had more males than the control group (38 [51.4%] vs 272 [36.8%]). The adjusted rate ratio of glaucoma surgery among those who received 7 or more injections per year was 2.48 (95% CI, 1.25-4.93). There was a 10.3% higher number of 7 or more injections among cases compared with controls. The adjusted rate ratio for those who received 4 to 6 injections per year compared with those who received 3 or fewer was 1.65% (95% CI, 0.84-3.23).

Conclusions and Relevance  Findings from this large, pharmacoepidemiologic study suggest that 7 or more intravitreous injections of bevacizumab annually is associated with a higher risk of glaucoma surgery and that 4 to 6 injections per year show a nonstatistically significant rate ratio in the same direction.

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