SINGLE INJECTION RESPONSE TO ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS IN PATIENTS WITH WET AGE-RELATED MACULAR DEGENERATION: Incidence and Characteristics

PURPOSE

To determine the incidence of complete resolution of choroidal neovascular membrane-associated exudation with a single antivascular endothelial growth factor injection in treatment-naive wet age-related macular degeneration patients and its associated characteristics.

METHODS

Retrospective, observational study of naive wet age-related macular degeneration patients who received antivascular endothelial growth factor therapy with ranibizumab/aflibercept and demonstrated complete resolution of retinal exudation with a single injection. Complete resolution was defined as the total disappearance of the intraretinal fluid, cysts, and subretinal fluid and a return of retinal thickness to <250 μm on spectral-domain optical coherence tomography. All relevant data were collected. Follow-up was scheduled on Days 1, 7, and 30 postoperatively and then monthly, with at least 9 visits mandatory per year if the macula remained fluid free. Appropriate statistical analyses were performed.

RESULTS

Sixty-three patients (29 men; mean age 67.25 ± 4.40 years) were identified. The mean baseline and final-corrected distance visual acuity was 20/160 and 20/45, respectively. Patients completed a mean of 10.9 follow-up visits per year. Smaller choroidal neovascular membranes (<200 μm), early presentation, better presenting corrected distance visual acuity, subfoveal choroidal neovascular membranes, absence of blood/fibrosis, and use of aflibercept (2 mg) favored resolution with one injection.

CONCLUSION

A subset (13.76%; 63/458, 95% confidence intervals: 10.73-17.25) of patients with treatment-naive wet age-related macular degeneration demonstrates resolution of choroidal neovascular membrane-associated exudation with a single antivascular endothelial growth factor injection, sustained over 2 years or more. This can lower therapy costs, treatments, office visits, and the potential risk of geographic atrophy.

EIGHTEEN-MONTH RESULTS OF INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR ON VISION AND MICROCIRCULATION IN RADIATION MACULOPATHY

PURPOSE

To evaluate 18 months' results of a strict anti-vascular endothelial growth factor protocol for radiation maculopathy following proton therapy in choroidal melanoma.

METHODS

Retrospective, comparative, nonrandomized study of 74 radiation maculopathy patients presenting macular lipid deposits, hemorrhages, microaneurysms, cystoid edema, nerve layer infarction, telangiectasia, or capillary nonperfusion. The study group included 52 consecutive patients injected with intravitreal anti-vascular endothelial growth factors (bevacizumab/ranibizumab: 46/6) every two months for the first and every 3 months for the second year, with minimum 12 months' follow-up. The control group consisted of 22 patients having declined this treatment. Best-corrected visual acuity, spectral domain-optical coherence tomography and optical coherence tomography angiography were recorded at baseline, 6, 12, and 18 months. The foveal avascular zone and capillary density were measured at the superficial capillary plexus.

RESULTS

Radiation maculopathy was diagnosed at 2 years (1.5-3.5) after proton therapy. Best-corrected visual acuity at baseline, 12 and 18 months improved in the study group from 0.45, 0.3 to 0.2 logarithm of the minimum angle of resolution, but decreased in the control group from 0.5, 0.9 to 1.0 logarithm of the minimum angle of resolution respectively (P < 0.001 at 12 months). Simultaneously, foveal avascular zone enlargement was less in the study (from 0.377, 0.665 to 0.744 mm2) than control group (from 0.436, 1.463 to 2.638 mm2) (P = 0.05 at 12 months). CMT (280 and 276 µm) and capillary density (37% and 38%, at baseline, respectively) did not evolve significantly different.

CONCLUSION

Intravitreal anti-vascular endothelial growth factors, every 2 months for the first and every 3 months for the second year, slow down, over up to 18 months, vision loss and anatomical degradation in radiation maculopathy following proton therapy for choroidal melanoma.

EFFICACY AND SAFETY OF INTRAVITREAL AFLIBERCEPT USING A TREAT-AND-EXTEND REGIMEN FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: The ARIES Study: A Randomized Clinical Trial

BACKGROUND/PURPOSE

Treating neovascular age-related macular degeneration with intravitreal aflibercept treat-and-extend (T&E) can reduce treatment burden. ARIES assessed whether intravitreal aflibercept early-start T&E was noninferior to late-start T&E.

METHODS

A randomized, open-label, Phase 3b/4 study that included treatment-naïve patients aged ≥50 years with the best-corrected visual acuity 73-25 Early Treatment Diabetic Retinopathy Study letters and active choroidal neovascularization secondary to AMD. Patients received 2 mg intravitreal aflibercept at Week (W) 0, W4, W8, and W16. At W16, patients were randomized 1:1 to early-start (2W interval adjustments) or late-start T&E (8W intervals until W48 then 2W interval adjustments). Primary endpoint: the best-corrected visual acuity change from randomization to W104.

RESULTS

Two-hundred seventy-one patients were randomized. The mean (SD) best-corrected visual acuity at baseline was 60.2 (12.1; early-T&E) and 61.3 (10.8; late-T&E) letters. The mean (SD) best-corrected visual acuity change (W16-104) was -2.1 (11.4) versus -0.4 (8.4) letters (early-T&E vs. late-T&E; least-squares mean difference: -2.0; 95% confidence interval: -4.75 to 0.71; P = 0.0162 for noninferior); +4.3 (13.4) versus +7.9 (11.9) letters (W0-104). The mean (SD) number of injections was 12.0 (2.3) versus 13.0 (1.8). From baseline to W104, 93.4% and 96.2% maintained best-corrected visual acuity; the mean (SD) central retinal thickness change was -161.6 (135.6) µm and -158.6 (125.1) µm. The last injection interval (W104) was ≥12W for 47.2% and 51.9% of patients.

CONCLUSION

Outcomes were similar between patients with neovascular age-related macular degeneration treated with an intravitreal aflibercept early-T&E or late-T&E regimen after initial dosing, with one injection difference over 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02581891 https://clinicaltrials.gov/ct2/show/NCT02581891. Supplemental Digital Contents (files 1 http://links.lww.com/IAE/B419).

INTRAVITREAL RANIBIZUMAB TREATMENT FOR ADVANCED FAMILIAL EXUDATIVE VITREORETINOPATHY WITH HIGH VASCULAR ACTIVITY

PURPOSE

To determine the efficacy of intravitreal ranibizumab (IVR) treatment for advanced familial exudative vitreoretinopathy with high vascular activity.

METHODS

The retrospective interventional case series included 28 eyes (20 patients) that had IVR in combination or not with other treatment, for Stage 3 to 5 familial exudative vitreoretinopathy with active fibrovascular proliferation and prominent subretinal exudation. Outcome measures were fundus features after treatment, associated clinical variables, and genetic mutations.

RESULTS

The age of patients at the first IVR ranged from 0.2 to 36 months. An average of 1.3 IVR injections per eye were given. Familial exudative vitreoretinopathy regressed in 16 (57%) eyes and progressed in 12 eyes (43%) after IVR. Laser and/or vitrectomy was performed on 13 eyes. The retina was reattached in 22 eyes (78%) after 24 to 58 months follow-up. Clinical variables associated with progression after IVR were preexisting fibrovascular proliferation over one quadrant and persistent vascular activity after the initial injection (P < 0.05). Familial exudative vitreoretinopathy-causative genetic mutations in 11 patients were related to variable response to IVR treatment.

CONCLUSION

Intravitreal ranibizumab treatment may effectively regress advanced familial exudative vitreoretinopathy with high vascular activity in selected cases. Different treatment outcomes may be relevant to variable presentation and genetic heterogeneity of familial exudative vitreoretinopathy.

Evolving Treatment Patterns and Outcomes of Neovascular Age-Related Macular Degeneration Over a Decade

PURPOSE

Management of neovascular age-related macular degeneration (nAMD) has evolved over the last decade with several treatment regimens and medications. This study describes the treatment patterns and visual outcomes over 10 years in a large cohort of patients.

DESIGN

Retrospective analysis of electronic health records from 27 National Health Service secondary care healthcare providers in the UK.

PARTICIPANTS

Treatment-naïve patients receiving at least 3 intravitreal anti-vascular endothelial growth factor (VEGF) injections for nAMD in their first 6 months of follow-up were included. Patients with missing data for age or gender and those aged less than 55 years were excluded.

METHODS

Eyes with at least 3 years of follow-up were grouped by years of treatment initiation, and 3-year outcomes were compared between the groups. Data were generated during routine clinical care between September 2008 and December 2018.

MAIN OUTCOME MEASURES

Visual acuity (VA), number of injections, and number of visits.

RESULTS

A total of 15 810 eyes of 13 705 patients receiving 195 104 injections were included. Visual acuity improved from baseline during the first year, but decreased thereafter, resulting in loss of visual gains. This trend remained consistent throughout the past decade. Although an increasing proportion of eyes remained in the driving standard, this was driven by better presenting VA over the decade. The number of injections decreased substantially between the first and subsequent years, from a mean of 6.25 in year 1 to 3 in year 2 and 2.5 in year 3, without improvement over the decade. In a multivariable regression analysis, final VA improved by 0.24 letters for each year since 2008, and younger age and baseline VA were significantly associated with VA at 3 years.

CONCLUSIONS

Our findings show that despite improvement in functional VA over the years, primarily driven by improving baseline VA, patients continue to lose vision after the first year of treatment, with only marginal change over the past decade. The data suggest these results may be related to suboptimal treatment patterns, which have not improved over the years. Rethinking treatment strategies may be warranted, possibly on a national level or through the introduction of longer-acting therapies.

BRAIN HEALTH ASSESSMENT IN MACULAR DEGENERATION PATIENTS UNDERGOING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS (THE BHAM STUDY): An Interim Analysis

PURPOSE

After intravitreal injection, anti-vascular endothelial growth factor (VEGF) agents are found in the systemic circulation and can suppress systemic VEGF levels. Neuronal health and cognitive function in the central nervous system have been associated with normal physiological levels of VEGF expression. We wished to determine whether there was an association between cumulative anti-VEGF exposure and cognitive function.

METHODS

One hundred and seventy-five patients aged 65 to 85 with vision of at least 20/50 or better in one eye and a diagnosis of age-related macular degeneration took an iPad-based brain health assessment to determine their risk of mild cognitive impairment. The result for each patient was compared with the total number of anti-VEGF injections per individual patient. Patients were then stratified into groups with 0 injections (control), 1 to 9 injections, 10 to 20 injections, or greater than 20 injections.

RESULTS

The group of patients with more than 20 injections had a higher likelihood of mild cognitive impairment compared with the control group, with statistically significant worse mean Z-scores (P = 0.04).

CONCLUSION

Our study is the first to associate worsening cognitive health with higher cumulative anti-VEGF injections. This study was not designed to show a causal link, but does suggest that additional investigation is warranted.

INTRAOCULAR JARISCH-HERXHEIMER REACTION IN LEMIERRE SYNDROME

PURPOSE

To report an intraocular Jarisch-Herxheimer reaction induced by Lemierre syndrome antibiotherapy.

METHODS

Case report.

RESULTS

A 43-year-old-man presented with an acute onset of bilateral blurred vision few days after intravenous antibiotic administration for Lemierre syndrome. Best-corrected visual acuity was 20/32 in both eyes. Examination revealed bilateral cystoid macular edema and peripheral retinal vasculitis, persisting despite Lemierre syndrome recovery with antibiotics. Intravitreal injection of ranibizumab 0.5 mg (0.05 mL) was performed in both eyes. After 1 month, cystoid macular edema and retinal vasculitis were totally resolved, and best-corrected visual acuity increased to 20/20 in both eyes. The paradoxical worsening of the patient's best-corrected visual acuity after initiating antibiotherapy evokes a Jarisch-Herxheimer reaction. The result of this single intravitreal injection of ranibizumab was sustained; best-corrected visual acuity remained unchanged (20/20 in both eyes), and no recurrence of cystoid macular edema or retinal vasculitis was found after 4-year follow-up.

CONCLUSION

To the best of our knowledge, this is the first reported case of an isolated intraocular Jarisch-Herxheimer reaction induced by Lemierre syndrome antibiotherapy and successfully treated with a single intravitreal injection of ranibizumab.

SYSTEMIC MEDICATION USE AND THE INCIDENCE AND GROWTH OF GEOGRAPHIC ATROPHY IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENTS TRIALS

PURPOSE

To determine associations of systemic medications with the incidence and growth of geographic atrophy (GA) in participants of the comparison of age-related macular degeneration treatments trials.

METHODS

Participants of comparison of age-related macular degeneration treatments trials with new untreated choroidal neovascularization in the study eye (one study eye per participant) were randomized to receive treatment with bevacizumab or ranibizumab. Participants were released from clinical trial treatment at 2 years and examined at approximately 5 years. Color fundus photographs and fluorescein angiograms taken at baseline, Years 1, 2, and 5 were assessed for the presence and size of GA by two masked graders. Participants were interviewed about systemic medication use at baseline. Systemic medications previously reported to be associated with age-related macular degeneration were evaluated for associations with GA incidence in study eye using univariable and multivariable Cox models and for association with the GA growth using linear mixed effects models.

RESULTS

In multivariable analysis of 1,011 study eyes without baseline GA, systemic medications, including cholinesterase inhibitors, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers, diuretics, aspirin, steroids, statins, hormone replacement therapy, antacids, and drugs targeting G protein-coupled receptors, were not associated with GA incidence in the study eye (all adjusted hazard ratios ≤1.86, P ≥ 0.18). In multivariable analysis of 214 study eyes with longitudinal GA size measurements, calcium channel blockers were associated with a higher GA growth rate (0.40 vs. 0.30 mm/year, P = 0.02).

CONCLUSION

None of the systemic medications analyzed were associated with GA incidence. However, calcium channel blockers were associated with a higher growth rate of GA in the study eye.

ASSOCIATION BETWEEN ANATOMICAL AND CLINICAL OUTCOMES OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR

PURPOSE

Assess the relationship between subretinal fluid (SRFL), intraretinal fluid, and visual outcomes of neovascular age-related degeneration in routine clinical practice.

METHODS

Treatment-naive eyes enrolled in the Fight Retinal Blindness! registry after January 2017 were identified. Lesion activity was graded at each visit as inactive, active not SRFL only (A-NSRFL only), or active SRFL only (A-SRFL only). Eyes were grouped based on initial activity as follows: 1) initially A-NSRFL only or 2) initially A-SRFL only, and their predominant activity status over 12 months was as follows: 1) mostly inactive, 2) mostly A-NSRFL only, or 3) mostly A-SRFL only.

RESULTS

Seven hundred and three eyes were eligible for analysis. Initially A-NSRFL only had a similar adjusted mean 12-month visual acuity change to initially A-SRFL eyes (5.7 vs. 6.9 letters; P = 0.165), but their final visual acuity was worse (62.5 vs. 67.5 letters at 12 months; P = 0.003). The adjusted mean 12-month visual acuity change between the predominant activity groups was significantly different (P = 0.005), with mostly inactive (7.6 letters) and mostly A-SRFL only (7.5 letters) eyes gaining more than mostly A-NSRFL only eyes (3.6 letters).

CONCLUSION

Eyes with SRFL only had similar outcomes at 1 year to eyes that were mostly inactive. Intraretinal fluid was associated with worse visual outcomes, highlighting the importance of distinguishing between intraretinal fluid and SRFL when managing neovascular age-related degeneration.

Laser-induced choroidal neovascularization: A case report and some reflection on animal models for age-related macular degeneration

RATIONALE

Laser induced maculopathy includes retinal photoreceptor disruption, macular hole, macular hemorrhage, and rarely choroidal neovascularization (CNV). Here we report a case of laser induced CNV that was treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and resulted in visual improvement and CNV resolution during 1-year follow up. In addition, the case of laser induced CNV treated with intravitreal anti-VEGF injections are reviewed for the first time in literature.

PATIENT CONCERNS

A 7-year-old boy presented to our department with blurred vision in his right eye for 2 months. The symptom immediately happened after the boy staring at the laser beam for a few seconds. Examination of ocular fundus with slit lamp showed yellowish lesion in macula in his right eye.

DIAGNOSES

CNV was confirmed by fundus examinations, including color fundus photograph, spectral domain optical coherence tomography, fluorescein angiography, and spectral domain optical coherence tomography angiography.

INTERVENTIONS

After the diagnosis of laser induced CNV, intravitreal ranibizumab (LUCENTIS, NOVARTIS) injection was performed.

OUTCOMES

After 1 injection of intravitreal ranibizumab, the best corrected visual acuity improved from 20/50 to 30/50 and CNV gradually regressed during 1-year follow up.

LESSONS

For young patients with laser induced CNV, intravitreal anti-VEGF injections may be helpful in visual improvement and CNV regression. Moreover, age seems to be a significant factor thus we propose that old animals may be more appropriate for laser induced CNV animal models of age-related macular degeneration.

Two different treatment regimens of ranibizumab 0.5 mg for neovascular age-related macular degeneration with or without polypoidal choroidal vasculopathy in Chinese patients: results from the Phase IV, randomized, DRAGON study

PURPOSE

To evaluate the efficacy and safety of monthly and pro re nata (PRN, guided by visual acuity stabilization and disease activity criteria) ranibizumab regimens in Chinese patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV).

METHODS

This double-masked study randomized nAMD patients (1:1) to ranibizumab monthly from baseline to Month (M) 11 to a PRN regimen from M12 to M23 (monthly group, n = 167) versus ranibizumab three monthly doses followed by a PRN regimen up to M23 (PRN group, n = 166). Subgroups were assessed based on the presence/absence of PCV (indicated by indocyanine green angiography).

RESULTS

Of 334 randomized patients, 41.7% had PCV at baseline. Mean average best-corrected visual acuity (BCVA) change from M3 to M4 through M12 was 3.3 letters with monthly and 1.7 letters with PRN (mean difference: 1.6; 95% CI: -2.95, -0.20, primary end-point). Mean change in BCVA from baseline (monthly/PRN, 53.8/53.7) to M12 and M24 was 12.3 and 11.3 letters in monthly and 9.6 and 9.3 letters in PRN group. Corresponding values for patients with PCV/without PCV were 12.7/12.1 letters (M12) and 12.3/10.6 letters (M24) in monthly and 9.4/9.4 letters (M12) and 9.7/8.7 letters (M24) in PRN groups. The mean number of injections was 11.4 (monthly) and 8.2 (PRN) from Day 1 to M11 and 4.8 (monthly) and 5.0 (PRN) from M12 to M23. No new safety findings were reported.

CONCLUSIONS

The study results support the use of either ranibizumab monthly or PRN regimens in Chinese patients with nAMD, regardless of presence of PCV.

Visual Acuity Variability: Comparing Discrepancies between Snellen and ETDRS Measurements among Subjects Entering Prospective Trials

PURPOSE

To compare the variability between Snellen visual acuity (VA) and Early Treatment Diabetic Retinopathy (ETDRS) best-corrected VA (BCVA) measurements.

DESIGN

Retrospective chart review.

PARTICIPANTS

Eyes from subjects entering 12 prospective retinal trials in a large, urban retina practice.

METHODS

Eyes were included if a Snellen VA measurement was performed at the visit preceding trial screening and VA was better than counting fingers. Snellen VA and ETDRS BCVA were then converted to logarithm of the minimum angle of resolution (logMAR) units, and the variability between measurements was calculated.

MAIN OUTCOME MEASURES

Outcome measures include VA variability among disease states, absolute VA, and central subfield thickness (CST).

RESULTS

A total of 773 eyes of 413 subjects were identified with a mean of 27.2 days (median, 19; 95% confidence interval [CI], 25.1-29.3) between measurements. Mean Snellen and ETDRS measurements were 0.40 (20/50) and 0.27 logMAR (20/40), respectively. Overall, mean ETDRS BCVA was 6.1 letters better than Snellen VA (median, 5.8; 95% CI, 5.3-7.0; P < 0.05); 76.6% of eyes had improved ETDRS. Restricting the number of days between measurements did not result in any meaningful differences from this directionality. Among eyes with worse VA, variation was more pronounced than among eyes with better VA; eyes 20/25 or better were a mean +1.9 letters better on ETDRS testing (P < 0.05) and eyes 20/160 or worse were a mean +12.6 letters better on ETDRS testing (P < 0.05). Subgroup analyses by disease state found statistically significantly better vision measurements with the ETDRS protocol compared with Snellen in 4 of the 5 disease states studied. Although lens status did not affect the extent of discrepancy between ETDRS and Snellen measurements, amount of retinal edema (CST) did: increased CST correlated with increased variability.

CONCLUSIONS

The ETDRS protocol BCVA measurement resulted in significantly better scores when compared with Snellen VA measurements. This difference was more pronounced among eyes with worse VA. Additionally, specific retinal disease states and anatomic variables such as extent of retinal edema (CST) may have a meaningful impact on the anticipated variability between ETDRS and Snellen VA measurement.

CONSEQUENCES OF LAPSES IN TREATMENT WITH VASCULAR ENDOTHELIAL GROWTH FACTOR INHIBITORS IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN ROUTINE CLINICAL PRACTICE

PURPOSE

Evaluating outcomes in patients receiving intravitreal antivascular endothelial growth factor (VEGF) inhibitors for neovascular age-related macular degeneration whom experience a lapse in treatment.

METHODS

A retrospective chart review evaluating 3,304 patients ≥18 years who experienced treatment lapses ≥3 months compared with control counterparts. Demographic information, macular thickness as measured by central subfield thickness, and visual acuity were collected at baseline, the first postlapse appointment, and at 3, 6, and 12 months after the lapse for the study group.

RESULTS

Lapse (n = 241) and control patients (n = 241) had similar baseline visual acuity and central subfield thickness (Early Treatment Diabetic Retinopathy Study: 58.9 ± 20.2 [20/63] vs. 59.2 ± 20.1 [20/63]; central subfield thickness: 252.4 ± 63.2 µm vs. 259.8 ± 66.2 µm, P = 0.21). Analysis revealed that lapse patients experienced a significant increase in central subfield thickness after lapse when compared with controls (279.4 ± 86.9 µm vs. 253.7 ± 65.9 µm, P < 0.01), which normalized on resumption of treatment (259.1 ± 79 µm vs. 246.8 ± 57.6 µm, P = 0.06). Study patients also experienced loss in the visual acuity after lapse when compared with controls (52.9 ± 23.6 Early Treatment Diabetic Retinopathy Study [20/100] vs. 59.9 ± 20.8 [20/63] Early Treatment Diabetic Retinopathy Study, P < 0.01) that did not recover through 12 months of follow-up.

CONCLUSION

Patients with neovascular age-related macular degeneration who have lapses in care are at risk for poorer outcomes. Although macular thickness normalizes on resumption of treatment, their decline in the visual acuity does not recover.

RANIBIZUMAB WITH OR WITHOUT VERTEPORFIN PHOTODYNAMIC THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY: Predictors of Visual and Anatomical Response in the EVEREST II Study

PURPOSE

To evaluate the demographic and imaging factors at baseline and Month 3 (M3) that predict visual or anatomical responses at Month 12 (M12) in the EVEREST-II study for polypoidal choroidal vasculopathy.

METHODS

Post-hoc analysis of 322 participants in the EVEREST-II study. Patient factors, best-corrected visual acuity (BCVA), treatment, and imaging parameters at baseline and M3 were evaluated with respect to outcomes at M12 using univariate and multivariable analysis.

RESULTS

Younger age (P < 0.001) and lower baseline BCVA (P < 0.001) were associated with higher BCVA gains at M12. Smaller baseline polypoidal lesion area was associated with higher BCVA gains at M12 only in the ranibizumab monotherapy arm (P = 0.008). Central subfield thickness at M3, area of branching vascular network at M3, BCVA at M3, and age were associated with change in BCVA from M3 at M12. Higher odds of fluid-free retina at M12 were associated with lower baseline central subfield thickness (P = 0.006), treatment with combination therapy (baseline and M3 models; P < 0.001), and absence of subretinal fluid at M3 (P < 0.001).

CONCLUSION

Several imaging parameters at baseline and M3 can predict treatment outcome. The interaction between treatment arm and total polypoidal lesion area suggests this feature may assist selecting between initial ranibizumab monotherapy or combination therapy.

ASSOCIATION OF SERUM VASOGENIC AND PROINFLAMMATORY FACTORS WITH CLINICAL RESPONSE TO ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR FOR DIABETIC MACULAR EDEMA

PURPOSE

To study the role of serum biomarkers as prognostic factors for qualitative and quantitative response to anti-vascular endothelial growth factor injections for diabetic macular edema (DME).

METHODS

Sixty-seven eyes with DME were treated with intravitreal bevacizumab during a 12-month follow-up period. All cases underwent a baseline workup consisting of 12 inflammatory, metabolic and prothrombotic factors. The following outcomes were evaluated at 3-month intervals until 1 year of follow-up: visual acuity, central subfield thickness (CST), macular volume (MV), % of change from baseline in CST, occurrence of a CST change < 10%, a CST change >20%, and a CST <330 µm, achieving an improvement ≥2 lines of visual acuity, achieving visual acuity ≥20/40.

RESULTS

A significant improvement in CST and visual acuity was seen from third month onwards. Twenty-eight (48.1%) cases were classified as "early responders," 24 (35.8%) as "late responders", and 15 (22.4%) as "poor responders." Serum vascular endothelial growth factor-A levels were significantly lower in "poor responders" (P = 0.006). C-reactive protein (hsCRP) was associated with a limited anatomic response (<10% CST change) (P = 0.002, OR = 1.845, cutoff value of hsCRP = 1.84 mg/L). hsCRP was also negatively associated with obtaining a final CST <330 µm (P = 0.04, r2 = 0.112, OR = 0.643). Baseline visual acuity was significantly associated with 12th month visual acuity (P < 0.001, r2 = 0.602) and also with an improvement ≥2 visual acuity lines (P = 0.009, OR = 20.54).

CONCLUSION

Increased high-sensitivity C-reactive protein was associated with limited anatomic response to anti-vascular endothelial growth factor treatment and persistent DME. Poor responders had significantly lower values of serum vascular endothelial growth factor-A, suggesting an alternative pathogenic pathway for persisting DME.

The laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion: A protocol for systematic review and meta-analysis

BACKGROUND

At present, laser is regarded as an effective treatment for macular edema secondary to branch retinal vein occlusion. With the breakthrough of anti-vascular endothelial growth factor drugs in ophthalmology clinical research, the intravitreal injection of ranibizumab is widely applied, but both methods have their limitations, so some clinical studies have combined and applied them together. However, the clinical results are inconsistent and controversial, and there is no relevant system evaluation for the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion now.

OBJECTIVE

Meta analysis is used to analyze and evaluate the effectiveness and safety of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion.

METHOD

CNKI, VIP, WANFANG, China Biology Medicine disc, Web of Science, PubMed, Embase, Cochrane Library have used random controlled clinical trial of laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion from the establishment of the database to October 2020. Two researchers conducted independent screening, quality assessment and data extraction for the literatures, and used RevMan5.3 to conduct Meta analysis for the included literatures.

RESULT

The research has evaluated the effectiveness and safety of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion through the aspects of the best corrected visual acuity 6 months after operation, macular center thickness and the incidence of adverse reactions such as elevated intraocular pressure, endophthalmitis, vitreous hemorrhage and cataract.

CONCLUSION

Laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion has good effect, and the research has provided reliable evidence for the use of clinical treatment of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion.

BETA-PERIPAPILLARY ATROPHY AND GEOGRAPHIC ATROPHY IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENTS TRIALS

PURPOSE

To determine associations between beta-peripapillary atrophy (B-PPA) and incidence and growth of geographic atrophy (GA) in eyes treated with anti-vascular endothelial growth factor agents in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

METHODS

We included 245 cases with incident GA and 245 controls matched by baseline demographics and characteristics associated with development of GA in the CATT. Baseline color images were graded for the type of B-PPA, defined as presence of hypopigmentation with visible choroidal vessels and sclera that is adjacent to the optic disk. Beta-peripapillary atrophy was further classified as scleral ring, sclera, sclera/choroidal blood vessels, or combination. Areas of each type of B-PPA and the circumferential extent of B-PPA were measured.

RESULTS

Beta-peripapillary atrophy was present in 58% of eyes developing GA and in 52% without GA (P = 0.17). The greater circumferential extent of sclera/choroidal blood vessels B-PPA in relation to the optic disk was associated with incident GA (P = 0.02) and the GA size at first observation (P = 0.047). Beta-peripapillary atrophy was not associated with GA growth rates (P>0.05). Patients without B-PPA had a higher number of GA-associated risk alleles of ARMS2 (P = 0.0003) and HTRA1 (P = 0.001).

CONCLUSION

The extent of sclera/choroidal blood vessel B-PPA was associated with the GA incidence and size but not with the growth rate in eyes treated for neovascular age-related macular degeneration. Beta-peripapillary atrophy and GA may share some common pathophysiologic pathways unrelated to the GA-associated risk alleles evaluated.

Ranibizumab treatment patterns in prior ranibizumab-treated neovascular age-related macular degeneration patients: Real-world outcomes from the LUMINOUS study

Purpose

To evaluate the effectiveness, safety, and treatment patterns of ranibizumab 0.5 mg in prior ranibizumab-treated patients with neovascular age-related macular degeneration (nAMD) enrolled in the LUMINOUS^™ study.

Patients and methods

LUMINOUS, a 5-year, prospective, multicenter, observational study, recruited 30,138 adult patients (treatment-naïve or prior ranibizumab-treated or other ocular treatments) across all approved indications for ranibizumab. Patients were treated as per local ranibizumab label of participating countries. Here we report the mean change in visual acuity (VA) at Year 1, treatment exposure, overall incidence of ocular, non-ocular adverse events (AEs) and serious AEs (SAEs) in prior ranibizumab-treated nAMD patients (n = 16,167).

Results

At baseline, the mean (standard deviation [SD]) age of patients was 78.4 (9.0) years, 59.0% were female, and 80.0% were Caucasian. At Year 1 (n = 10,168), the mean (SD) VA change was −1.6 (12.6) letters (baseline VA: 58.3 [19.0] letters) with a mean (SD) of 4.7 (3.1) ranibizumab injections. Stratified by duration of prior ranibizumab treatment of <1 (n = 4,112), 1 to <2 (n = 2,095), 2 to <3 (n = 1,506), 3 to <4 (n = 1,123), 4 to <5 (n = 689), and ≥5 (n = 256) years, the mean (SD) VA change at Year 1 were −1.2 (13.5), −2.0 (12.3), −2.0 (11.3), −1.9 (11.8), −2.5 (10.9), and 0.0 (11.2) letters, respectively. Mean (SD) VA change in patients who received ≤6 and >6 injections over 1 year was −1.8 (13.8) and +0.5 (12.5) letters, respectively. The rate of ocular/non-ocular AEs and SAEs across all prior ranibizumab-treated patients over 5 years were 13.29%/23.02% and 0.84%/13.66%, respectively.

Conclusions

Overall, regardless of the prior ranibizumab-treatment duration, VA was maintained in these patients at Year 1, and those receiving ≥6 injections showed a trend towards gaining letters. There were no new safety signals. These results may help inform routine clinical practice to appropriately treat nAMD patients with ranibizumab to achieve optimal visual outcomes.

Fluctuations in Macular Thickness in Patients with Retinal Vein Occlusion Treated with Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

To evaluate macular thickness fluctuations in patients with retinal vein occlusions (RVOs) treated with anti-vascular endothelial growth factor (VEGF) agents and to assess whether patients with larger fluctuations have poorer visual outcomes.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Treatment-naive patients with RVO.

METHODS

Central subfield thickness (CST), cube volume (CV), and cube average thickness (CAT) were collected from OCT images obtained at baseline and 3, 6, 9, and 12 months, and standard deviations (SDs) across 12 months were calculated. Mixed-effects regression was performed to examine the relationship between macular thickness SD and 12-month visual acuity (VA). Standard multiple regression was performed to identify predictors of macular thickness SD.

MAIN OUTCOME MEASURES

Standard deviations across 12 months for CST, CV, and CAT and VA at 12 months.

RESULTS

One hundred thirty-four eyes, including 71 with branch RVO (BRVO) and 63 with central RVO (CRVO), were evaluated. Mean baseline and 12-month CST were 488.6 ± 165.0 μm and 334.3 ± 131.9 μm (change, -154.3 ± 210.2 μm; P < 0.001), with CST SD of 114.1 ± 77.0 μm. Baseline and 12-month VA were 52.8 ± 20.9 letters and 65.9 ± 17.3 letters (change, +13.1 ± 20.3 letters; P < 0.001). Central subfield thickness SD was a significant negative predictor of 12-month VA (-5.21 letters/100 μm; 95% confidence interval [CI], -10.21 to -0.22 letters/100 μm; P = 0.041) when adjusting for baseline factors and injections. Baseline CST and number of injections were not predictive (P ≥ 0.101). Stratification by CST SD demonstrated a 10-letter difference in 12-month VA between the first and fourth quartiles. Baseline CST and RVO diagnosis were the only significant predictors of CST SD (CRVO vs. BRVO: +34.64 μm/100 μm [95% CI, 29.33-39.94 μm/100 μm; P < 0.001] and +22.13 μm/100 μm [95% CI, 4.81-39.44 μm/100 μm; P = 0.013]). Associations using CV and CAT were similar.

CONCLUSIONS

Larger macular thickness fluctuations are associated with poorer visual outcomes in patients with RVO treated with anti-VEGF agents. Macular thickness fluctuations, in addition to absolute macular thickness, may be an important prognostic biomarker in these patients.

Comparison of the Effect of Intravitreal Conbercept and Ranibizumab on Aqueous Humor Cytokines in Central Retinal Vein Occlusion-Related Macular Edema

Purpose: To analyze changes in the levels of angiogenic and inflammatory cytokines following the administration of intravitreal conbercept (IVC) or intravitreal ranibizumab (IVR) in patients with macular edema (ME) due to central retinal vein occlusion (CRVO). Methods: This retrospective study was conducted between June 2015 and January 2016 in The First Hospital of China Medical University. We administered 3 consecutive monthly doses of IVC (23 eyes) or IVR (19 eyes) in 42 eyes with CRVO-ME. At each injection, we collected aqueous humor samples and used multiplex bead assays to measure 7 angiogenic and inflammatory cytokines [vascular endothelial growth factor (VEGF), placental growth factor (PlGF), platelet-derived growth factor (PDGF)-AA, monocyte chemoattractant protein (MCP)-1, and interleukins (ILs)-6, 8, and 12]. Results: Visual acuity and ME improved significantly in both groups during the treatment period. Compared with the baseline, all the cytokine concentrations in the aqueous humor samples decreased significantly at 1 and 2 months after the initial dose of IVC or IVR. The improvement of visual acuity and ME and the changes of aqueous humor cytokine levels were similar in both groups. Concentrations of VEGF, PlGF, MCP-1, PDGF-AA, IL-6, IL-8, and IL-12 levels did not show significant intergroup differences after 1 month (P = 0.369, 0.312, 0.185, 0.353, 0.135, 0.487, and 0.337, respectively) and 2 months (P = 0.305, 0.376, 0.230, 0.519, 0.114, 0.960, and 0.830, respectively) of follow-up. Conclusion: IVC and IVR induced comparable improvements in clinical parameters, along with equivalent reductions in the concentrations of angiogenic and inflammatory cytokines in the aqueous humor.

Intravitreal steroids for macular edema in diabetes

BACKGROUND

Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME.

OBJECTIVES

To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020.

SELECTION CRITERIA

We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses.

MAIN RESULTS

We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I² = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I² = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression.

AUTHORS' CONCLUSIONS

Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.

Neovascular Age-Related Macular Degeneration: Therapeutic Management and New-Upcoming Approaches

Age-related macular degeneration (AMD) constitutes a prevalent, chronic, and progressive retinal degenerative disease of the macula that affects elderly people and cause central vision impairment. Despite therapeutic advances in the management of neovascular AMD, none of the currently used treatments cures the disease or reverses its course. Medical treatment of neovascular AMD experienced a significant advance due to the introduction of vascular endothelial growth factor inhibitors (anti-VEGF), which dramatically changed the prognosis of the disease. However, although anti-VEGF therapy has become the standard treatment for neovascular AMD, many patients do not respond adequately to this therapy or experience a slow loss of efficacy of anti-VEGF agents after repeated administration. Additionally, current treatment with intravitreal anti-VEGF agents is associated with a significant treatment burden for patients, caregivers, and physicians. New approaches have been proposed for treating neovascular AMD. Among them, designed ankyrin repeat proteins (DARPins) seem to be as effective as monthly ranibizumab, but with greater durability, which may enhance patient compliance with needed injections.

Choroidal Neovascular Membrane in a Teenage Girl With Chronic Intracranial Hypertension

The authors describe the case of a 13-year-old girl with choroidal neovascular membrane and a history of benign intracranial hypertension who was successfully treated with a single intravitreal bevacizumab injection administered into the left eye. The visual acuity in the left eye improved to 20/25 at 2 weeks following treatment. The visual acuity was stable (20/20) in the right eye and 20/25 in the left eye with no signs of recurrence over 2 years of follow-up. The current case represents the only one in the literature whereby a teenage girl presented with choroidal neovascular membrane and benign intracranial hypertension. Although this occurrence in males has been previously published, the authors believe that it is important to document the response to treatment because the literature evidence is limited to date. [J Pediatr Ophthalmol. 2020;57:e86-e87.].

Changes in the Systemic Expression of Sirtuin-1 and Oxidative Stress after Intravitreal Anti-Vascular Endothelial Growth Factor in Patients with Retinal Vein Occlusion

OBJECTIVES

Retinal vein occlusions (RVO) are associated with systemic risk factors. However, the ocular occlusive events might also influence a patient's systemic condition. This study tried to investigate serum biomarkers associated with oxidative stress, before and after intravitreal anti-vascular endothelial growth factor (aVEGF) therapy in patients with RVOs.

METHODS

Newly-onset RVO patients were categorized into two groups: comorbid with macular edema requiring aVEGF therapy (treatment group) and no edema (observation group). Age and sex-matched patients (who received cataract surgery) were included as the control group. Intravitreal ranibizumab with a pro-re-nata regimen were administered. Serum samples were collected prior to treatment, at 6 and 12 months after therapy/observation and were collected once before controls who received cataract surgery. mRNA expression of sirtuin-1, its downstream genes, anti-oxidative biomarkers, and proinflammatory cytokines were measured.

RESULTS

There were 32, 26, and 34 patients enrolled in the treatment, observation, and control groups, respectively. The expressions of sirtuin-1 and its downstream genes were significantly lower in patients with RVO compared with the control group. Sirtuin-1 gene expression increased after 1 year of aVEGF therapy in the treatment group but remained unchanged in the observation group. Biomarkers of oxidative stress and proinflammatory cytokines were reduced after 1 year of aVEGF therapy. These biomarkers remained with no changes in the observation group.

CONCLUSIONS

Our study showed that the systemic oxidative stress increased in RVO patients. The aVEGF therapy could alter the gene expression of anti-oxidative proteins and reduce systemic oxidative stress in these patients.

Intravitreal ranibizumab alone or in combination with panretinal photocoagulation for the treatment of proliferative diabetic retinopathy with coexistent macular edema: long-term outcomes of a prospective study

AIMS

To compare intravitreal ranibizumab as monotherapy or in combination with panretinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PDR) and coexistent diabetic macular edema (DME) in a long-term follow-up of 24 months.

METHODS

Participants in this prospective study were 47 patients with PDR and concurrent DME, who were randomized at baseline into two groups: (i) the "ranibizumab alone" group (n = 23), which was treated with at least 3 intravitreal ranibizumab injections as a loading phase, and (ii) the "combination" group (n = 24), which was treated with PRP and at least 3 intravitreal ranibizumab injections. Thereafter, all patients were followed up at a pro re nata (PRN) basis, with regular monthly monitoring for 24 months. At each visit, best corrected visual acuity (BCVA) and spectral domain-optical coherence tomography were performed, while regression of neovascularization was also recorded.

RESULTS

The "combination" group had better control of neovascularization and less events of vitreous hemorrhage than ranibizumab alone through the 2 years. BCVA did not differ significantly between the two groups at months 12 and 24 of the follow-up. The "ranibizumab" alone group presented greater reduction in central retinal thickness at month 12, which did not reach significance at month 24 compared to "combination" group. Greater number of injections was needed in the monotherapy group (mean 14 injections) compared to "combination" group (mean 11 injections) through month 24.

CONCLUSIONS

Both intravitreal ranibizumab alone or in combination with PRP could be used effectively for the treatment of PDR and coexistent DME. Even though there was no difference in BCVA and CRT at the 24-month follow-up between the two groups, the combination group presented greater regression of neovascularization with less injections.