Anti-VEGF Usage in Trabeculectomy
Current evidence does not support the routine use of anti-VEGF agents (bevacizumab or ranibizumab) as adjunctive therapy in trabeculectomy, as they provide no additional benefit over standard mitomycin C (MMC) treatment and may result in inferior outcomes. 1
Evidence Quality and Recommendations
The highest quality systematic review evidence demonstrates that:
Combination of bevacizumab (1.25 mg/mL) with standard antimetabolite concentrations showed no additional benefit or harm compared to antimetabolite alone in primary trabeculectomy 1
Low quality evidence is insufficient to refute or support anti-VEGF subconjunctival injection for control of intraocular pressure (IOP) at 12 months follow-up 1
When compared directly to MMC, anti-VEGF agents demonstrated inferior outcomes: mean IOP was 1.86 mm Hg higher (95% CI 0.15 to 3.57) in anti-VEGF groups versus MMC groups at 12 months 2
Comparative Outcomes: Anti-VEGF vs MMC
Complete Surgical Success
Bevacizumab 2.5 mg showed lower complete success rates (RR 0.71,95% CI 0.46 to 1.08) compared to MMC, with anticipated success between 37.2% and 87.4% versus approximately 81% for MMC 2
No evidence of difference in qualified success rates (RR 1.00,95% CI 0.87 to 1.14) 2
IOP Control
Ranibizumab demonstrated significantly higher IOP at 1 month (p = 0.002) compared to MMC 3
Mean IOP at 12 months was consistently higher in anti-VEGF treated eyes across multiple studies 2
Surgical Failure Rates
More patients in ranibizumab groups required additional glaucoma surgery during follow-up periods 3
Three of 12 ranibizumab patients (25%) required tube shunt surgery within one year versus minimal failures in MMC groups 3
Postoperative Adjunctive Use
When anti-VEGF is used postoperatively as an adjunct to 5-fluorouracil (5-FU):
Bevacizumab injection reduced the number of required 5-FU injections by 2.4 injections (mean 4.0 ± 2.8 vs 6.4 ± 3.3, p ≤ 0.005) 4
No significant difference in final IOP reduction, bleb morphology, or medication requirements was detected between groups receiving bevacizumab plus 5-FU versus 5-FU alone 4
No reduction in vascularization or corkscrew vessels at final follow-up when comparing bevacizumab-augmented treatment to 5-FU alone 4
Ologen Implant Combinations
A retrospective study comparing trabeculectomy with MMC alone versus MMC with Ologen implant and bevacizumab showed:
Highest success rate (77.5%) achieved with MMC alone without Ologen or bevacizumab 5
Success rates decreased to 63.6% with Ologen plus bevacizumab depot and 57.1% with Ologen plus intracameral bevacizumab (p = 0.34) 5
No significant differences in complications, subsequent interventions, or postoperative medication requirements between groups 5
Clinical Implications and Pitfalls
Common Pitfalls to Avoid
Do not substitute anti-VEGF agents for MMC in primary trabeculectomy, as this results in inferior IOP control and higher failure rates 2, 3
Avoid using anti-VEGF as primary adjunctive therapy based on theoretical benefits of angiogenesis inhibition, as clinical outcomes do not support this approach 1, 2
Do not expect reduced bleb vascularity from anti-VEGF treatment, as bleb extent was significantly less with ranibizumab at 6 months (p = 0.006) 3
When Anti-VEGF Might Be Considered
Only as a postoperative adjunct to reduce 5-FU injection burden in patients requiring extensive postoperative wound modulation, though this provides no IOP benefit 4
Not recommended for routine use given lack of demonstrated superiority and potential for worse outcomes 1, 2
Current Standard of Care
Mitomycin C remains the gold standard adjunctive agent for trabeculectomy, with no evidence supporting replacement or augmentation with anti-VEGF agents 2, 5, 3. The theoretical benefits of VEGF inhibition on angiogenesis and fibrosis have not translated into clinically meaningful improvements in surgical outcomes or patient morbidity 1, 2.