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Effects of Topical and Subconjunctival Bevacizumab in High-Risk Corneal Transplant Survival

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Effects of Topical and Subconjunctival Bevacizumab in High-Risk Corneal Transplant Survival Effects of Topical and Subconjunctival Bevacizumab in High-Risk Corneal Transplant Survival The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Dastjerdi, Mohammad H., Daniel R. Saban, Andre Okanobo, Nambi Nallasamy, Zahra Sadrai, Sunil K. Chauhan, Amir R. Hajrasouliha, and Reza Dana. 2010. “Effects of Topical and Subconjunctival Bevacizumab in High-Risk Corneal Transplant Survival.” Investigative Opthalmology & Visual Science 51 (5) (May 1): 2411. doi:10.1167/iovs.09-3745. Published Version doi:10.1167/iovs.09-3745 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:34787803 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Cornea Effects of Topical and Subconjunctival Bevacizumab in High-Risk Corneal Transplant Survival Mohammad H. Dastjerdi,1,2,3,4 Daniel R. Saban,1,2,4 Andre Okanobo,1,2,3 Nambi Nallasamy,1,2 Zahra Sadrai,1,2 Sunil K. Chauhan,1,2 Amir R. Hajrasouliha,1,2 and Reza Dana1,2,3 PURPOSE. To investigate whether corneal graft survival could be rejection in high-risk corneal transplantation. (Invest Ophthal- improved by topical or subconjunctival bevacizumab in a mu- mol Vis Sci. 2010;51:2411–2417) DOI:10.1167/iovs.09-3745 rine model of vascularized high-risk corneal transplantation. METHODS. Before corneal transplantation, intrastromal sutures llograft rejection is a leading cause of corneal graft failure were placed for 2 weeks in the corneas of BALB/c mice, Aand thus a leading indication for repeat penetrating kera- inducing intense angiogenesis. Allogeneic corneal transplanta- toplasty.1 Indeed, repeat grafting as a result of previous failure tion was performed using C57BL/6 donor mice. Topical bev- has become the second leading indication for corneal trans- acizumab (2.5%) was delivered 3 times a day for 3 weeks in one plantation, as reported.2 It has been known for many decades treatment group, and 0.02 mL (0.5 mg) bevacizumab was that the presence of preexisting blood vessels is a strong risk injected subconjunctivally at days 0, 4, 8, and 15 after trans- factor for corneal graft immune rejection.3–5 Grafting into plantation in the other treatment group. The control group vascularized corneal beds, or so-called high-risk corneal trans- received no treatment. Grafts were examined twice a week for plantations, leads to a rate of immune rejection of greater than 8 weeks by slit-lamp microscopy and were photographed once 50%, even with a strict regimen of topical and systemic immu- a week by slit-lamp digital camera and scored for opacity. For nosuppressive drugs.6 In fact, stratification of risk factors for assessment of corneal neovascularization (NV), a quantitative immunologic rejection in penetrating keratoplasty has identi- method was used to measure three primary metrics including fied recipient vascularization as a critical proximal cause for neovascular area, vessel caliber, and neovessel invasion area. earlier and more fulminant rejection episodes.4,5,7,8 Targeting angiogenesis to modulate immune responses after RESULTS. Both topical and subconjunctival bevacizumab treat- corneal transplantation has been the core area of interest for ment reduced neovascular area and vessel caliber; however, 9–13 the regression of corneal NV was more profound when treated many investigators. Why the relative immunologic quies- cence of the eye, which is a central facet of its immunoprivi- subconjunctivally. The mean percentage reduction of neovas- leged state, is disturbed in patients with corneal neovascular- cular area was 55% (P Ͻ 0.05) by week 8 in the subconjunc- ization (NV) is not fully understood.14 However, experimental tival treatment group and 33% (P ϭ 0.15) in the topical group. evidence strongly suggests that molecular factors such as the Only subconjunctival bevacizumab treatment resulted in signif- Ͻ local immunosuppressive cytokine milieu (transforming icant regression of neovessel invasion area (P 0.05). All growth factor-␤, ␣-melanocyte-stimulating hormone) and func- corneal transplants in both the control and the topical groups tional attributes (anterior chamber-associated immune devia- were rejected by 4 weeks after transplantation. However, in tion), which play a critical role in maintaining the physiologic the subconjunctival treatment group, 33% of corneal grafts quiescence in the anterior segment, are subverted in the pres- survived (P Ͻ 0.01). ence of corneal NV.14 In addition to blood vessels in vascular- CONCLUSIONS. Subconjunctival bevacizumab may offer an ad- ized high-risk corneas, lymphatic neovessels can ingrow in junctive measure to conventional therapies in preventing graft parallel with hemangiogenesis, facilitating effective access of donor and host antigen-presenting cells and antigenic material to regional lymph nodes, where accelerated sensitization to graft antigens occurs.15,16 Thus, treatment of corneal NV after From the 1Schepens Eye Research Institute, Boston, Massachu- corneal transplantation can potentially limit both the afferent setts; the 2Department of Ophthalmology, Harvard Medical School, 3 (sensitization) and efferent (rejection) arms of alloimmunity Boston, Massachusetts; and the Massachusetts Eye and Ear Infirmary, and, hence, reduce the propensity for immunoinflammatory Boston, Massachusetts. 14 4These authors contributed equally to the work presented here reactions that can jeopardize graft survival. Vascular endothelial growth factor (VEGF) is thought to be and should therefore be regarded as equivalent authors. 17 Presented in part at the Cornea Society/Eye Bank Association of a key mechanistic mediator of NV. The prominent role of America Fall Educational Symposium, November 2008, Atlanta, Geor- VEGF in the pathophysiology of corneal NV has been demon- gia. strated in experimental models of corneal angiogenesis.18 It Supported by National Institutes of Health/National Eye Institute has been shown that VEGF is upregulated in inflamed and Grants K24 EY019098 and RO1 EY12963 and by an Eye Bank Associ- vascularized corneas in humans and in animal models.19 VEGF ation of America Scientific Research Grant. inhibitors, including pegaptanib sodium, ranibizumab, and be- Submitted for publication March 22, 2009; revised June 4 and July vacizumab, are used for the treatment of neovascular age- 25, 2009; accepted September 14, 2009. 20 Disclosure: M.H. Dastjerdi, None; D.R. Saban, None; A. related macular degeneration. Recently, there has been grow- ing interest in using topical and subconjunctival anti-VEGF for Okanobo, None; N. Nallasamy, None; Z. Sadrai, None; S.K. Chau- 21–26 han, None; A.R. Hajrasouliha, None; R. Dana, None the treatment of corneal NV. Our data in a prospective Corresponding author: Reza Dana, Schepens Eye Research Institute, clinical study have demonstrated a significant reduction in the 20 Staniford Street, Boston, MA 02114; [email protected]. severity of corneal NV in response to topical bevacizumab Investigative Ophthalmology & Visual Science, May 2010, Vol. 51, No. 5 Copyright © Association for Research in Vision and Ophthalmology 2411 2412 Dastjerdi et al. IOVS, May 2010, Vol. 51, No. 5 Border of paracentral cornea (marked with A. 1.5 mm trephine) Figure-of-eight suture Limbus FIGURE 1. Preparation of robust high- risk graft beds for orthotopic corneal B. transplantation. (A) Schematic depic- tion of the figure-eight knot used cre- ated with two intrastromal incur- sions, each extending from slightly 1. 2. 3. above the limbus to the circumfer- ence of the paracentral cornea, which was marked with a 1.5-mm trephine. Three of these suture knots were placed in BALB/c mice to stim- ulate robust corneal neovasculariza- tion (B1). After 14 days the sutures were removed (B2), and penetrating corneal transplantation was per- formed using age-matched C57BL/6 donors (B3). therapy in patients with stable corneal NV.27 In an animal mark the central corneas of BALB/c mice. A figure-of-eight suture knot model of high-risk corneal transplantation, it has also been was then placed with two intrastromal incursions approximately 120° shown that intraperitoneal (systemic) injection of a VEGF- apart, and each incursion extended apically from slightly above the neutralizing cytokine trap can improve corneal graft survival.12 limbus to the trephine demarcation (Fig. 1A). Three interrupted figure- These reports suggest that treatment with topical or locally of-eight suture knots were placed using 11-0 nylon sutures (Sharpoint; injected anti-VEGF could offer an adjunctive measure to con- Vanguard, Houston, TX) for 14 days, after which graft beds exhibited ventional therapies (e.g., corticosteroids) to curb the inciting extensive neovascularization. At this time, the sutures were removed, factors of graft rejection in the setting of vascularized high-risk and penetrating corneal transplantation was performed using age- corneal transplantation. Therefore, we sought to evaluate matched C57BL/6 donors. whether corneal graft survival in vascularized high-risk corneal transplantation can be improved by initiating local (topical or Corneal Transplantation subconjunctival) bevacizumab treatment in a murine model. This procedure has been detailed elsewhere.29 Briefly, the central To make a thorough and comprehensive assessment of corneal cornea (2-mm diameter) was excised
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