Comparison of visual outcomes of polypoidal choroidal vasculopathy and typical neovascular age-related macular degeneration-up to 10 years of follow-up

PURPOSE

To investigate long-term visual outcomes of patients with polypoidal choroidal vasculopathy (PCV) and typical neovascular age-related macular degeneration (nAMD) in the real-world setting.

METHODS

Retrospective, multicenter, noninterventional consecutive cohort study. Two hundred eighty-five eyes of 261 patients with PCV and 902 eyes of 877 patients with typical nAMD, who could be followed up 1 year or longer from 2005 to 2018, were included. Mean changes in best-corrected visual acuity (BCVA) from baseline in the PCV and the typical nAMD groups were compared.

RESULTS

Mean follow-up period of total patients was 4.3 ± 2.8 (1-10) years. Baseline BCVA was better in the PCV group than that in the typical nAMD group (0.59 ± 0.52 versus 0.79 ± 0.63 logMAR, p < 0.001). The mean changes in BCVA from baseline in the PCV and nAMD group were +2.1 and -0.1 letters at 1 year, -0.2 and -3.7 letters at 3 years, -3.9 and -10.5 letters at 5 years and - 8.7 and - 12.1 letters at 7 years, respectively. Before 2006, the initial BCVA was sustained for approximately 1 year in eyes with PCV and for less than half year in eyes with typical nAMD. However, after 2007, when anti-VEGF agents were available, the initial BCVA was sustained for 4 years in eyes with PCV, while it was sustained for 1 year in eyes with typical nAMD.

CONCLUSION

In the real-world, long-term BCVA deteriorated in both PCV and typical nAMD groups, but the PCV group showed better visual outcomes than the typical nAMD group.

TREATMENT DEFERRAL DURING COVID-19 LOCKDOWN: Functional and Anatomical Impact on Patients With Neovascular Age-Related Macular Degeneration

PURPOSE

To investigate the visual and anatomical impact of intravitreal injection treatment deferral because of the COVID-19 lockdown on patients affected by neovascular age-related macular degeneration.

METHODS

We retrospectively reviewed 314 patients (394 eyes) who were scheduled to receive the impact of intravitreal injections during the Swiss lockdown. We compared patients who continued to receive scheduled impact of intravitreal treatment without clinical consultation (Group Continue ‟C"; n = 215) and patients for whom the impact of intravitreal treatment was completely deferred (Group Stop, ‟S"; n = 179). Functional and anatomical parameters were collected at four time points before and after the lockdown.

RESULTS

In Group C, the visual acuity at baseline and after the lockdown did not differ significantly. In Group S, the visual acuity deteriorated significantly compared with baseline and then improved slightly after the resumption of treatment, but it did not recover to baseline values. The mean central subfield thickness remained stable in Group C, whereas it increased in Group S and then returned to prelockdown values after the resumption of treatment.

CONCLUSION

An "injection-only" approach was effective in managing patients with neovascular age-related macular degeneration during the pandemic lockdown, whereas patients who deferred their scheduled treatment showed partially irreversible deterioration of visual function. We recommend treatment continuation in patients with neovascular age-related macular degeneration during a lockdown.

IMPACT OF FLUID COMPARTMENTS ON FUNCTIONAL OUTCOMES FOR PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Systematic Literature Review

PURPOSE

Understanding the impact of fluid in different retinal compartments is critical to developing treatment paradigms that optimize visual acuity and reduce treatment burden in neovascular age-related macular degeneration. This systematic review aimed to determine the impact of persistent/new subretinal fluid, intraretinal fluid, and subretinal pigment epithelial fluid on visual acuity over 1 year of treatment.

METHODS

Publication eligibility and data extraction were conducted according to Cochrane methods: 27 of the 1,797 screened records were eligible.

RESULTS

Intraretinal fluid negatively affected visual acuity at baseline and throughout treatment, with foveal intraretinal fluid associated with lower visual acuity than extrafoveal intraretinal fluid. Some studies found that subretinal fluid (particularly subfoveal) was associated with higher visual acuity at Year 1 and longer term, and others suggested subretinal fluid did not affect visual acuity at Years 1 and 2. Data on the effects of subretinal pigment epithelial fluid were scarce, and consensus was not reached. Few studies reported numbers of injections associated with fluid status.

CONCLUSION

To optimally manage neovascular age-related macular degeneration, clinicians should understand the impact of fluid compartments on visual acuity. After initial treatment, antivascular endothelial growth factor regimens that tolerate stable subretinal fluid (if visual acuity is stable/improved) but not intraretinal fluid may enable patients to achieve their best possible visual acuity. Confirmatory studies are required to validate these findings.

KSI-301: an investigational anti-VEGF biopolymer conjugate for retinal diseases

INTRODUCTION

KSI-301 is an intravitreal anti-vascular endothelial growth factor (VEGF) agent in clinical trials for the treatment of neovascular age-related macular degeneration (nAMD), diabetic retinopathy, diabetic macular edema (DME), and retinal vein occlusion (RVO). Its antibody-biopolymer conjugate structure is designed to decrease clearance from the eye and increase the duration of the effect.

AREAS COVERED

This article briefly discusses the impact and mechanisms of nAMD, DME, and RVO and evaluates currently approved anti-VEGF therapies. It progresses to examine a new agent, KSI-301 and the results from numerous clinical trials in these disease areas.

EXPERT OPINION

Despite varied results in the phase 2b/3 study for nAMD, there is potential for KSI-301 to serve as a durable therapy for VEGF-mediated retinal disorders. Ongoing phase 3 trials for nAMD, DME, and RVO will provide additional evidence on its efficacy, duration, and safety profiles.

One-year outcome of neovascular age-related macular degeneration patients followed-up using different optical coherence tomography modalities

PURPOSE

The aim of this study is to compare the one year outcome of neovascular age-related macular degeneration (nAMD) patients treated by a PRN regimen of Anti-vascular endothelial growth factor (VEGF) intravitreal injections (IVTs), using optical coherence tomography B-scan (OCT-B) or OCT Angiography (OCT-A) imaging modalities during follow-up.

METHODS

Patients older than 50 years with nAMD currently treated by PRN regimen of Anti-VEGF IVTs were recruited from Rothschild Foundation Hospital - Paris and Centre Ophtalmologique Maison Rouge - Strasbourg and followed-up for a year. Patients were randomized in two groups: one group was followed by OCT-B while the other was followed by OCT-A.

RESULTS

Thirty-three patients were followed by OCT-A and 31 patients were followed by OCT-B. Twenty-nine patients in the OCT-A group and 27 patients in the OCT-B group attended the last visit. No statistically significant difference was found between the two groups at 1 year concerning: improvement or stabilization of the best corrected distance visual acuity (BCVA) (p > 0.9), exudative signs (p > 0.9), number of injections (p = 0.8) and the delay until the first reinjection was performed (p = 0.5).

CONCLUSION

The use of OCT-A or OCT-B as imaging modalities in nAMD treated by a PRN regimen of Anti-VEGF IVTs seem to be comparable at one year.

Delivery of nVEGFi using AAV8 for the treatment of neovascular age-related macular degeneration

Inhibition of vascular endothelial growth factor (VEGF) is the standard therapy for neovascular age-related macular degeneration (nAMD). However, anti-VEGF agents used in the clinic require repeated injections, causing adverse effects. Gene therapy could provide sustained anti-VEGF levels after a single injection, thereby drastically decreasing the treatment burden and improving visual outcomes. In this study, we developed a novel VEGF Trap, nVEGFi, containing domains 1 and 2 of VEGFR1 and domain 3 of VEGFR2 fused to the Fc portion of human IgG. The nVEGFi had a higher expression level than aflibercept under the same expression cassettes of adeno-associated virus (AAV)8 in vitro and in vivo. nVEGFi was found to be noninferior to aflibercept in binding and blocking VEGF in vitro. AAV8-mediated expression of nVEGFi was maintained for at least 12 weeks by subretinal delivery in C57BL/6J mice. In a mouse laser-induced choroidal neovascularization (CNV) model, 4 × 10⁸ genome copies of AAV8-nVEGFi exhibited a significantly increased reduction in the CNV area compared with AAV8-aflibercept (78.1% vs. 63.9%, p < 0.05), while causing no structural or functional changes to the retina. In conclusion, this preclinical study showed that subretinal injection of AAV8-nVEGFi was long lasting, well tolerated, and effective for nAMD treatment, supporting future translation to the clinic.

Optimal patient adherence and long-term treatment outcomes of neovascular age-related macular degeneration in real-life

PURPOSE

To report on long-term real-life outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy in neovascular age-related macular degeneration (nAMD) with optimal patient adherence.

METHODS

For this retrospective monocenter study, we identified 3217 eyes of 2793 patients that received a minimum of three intravitreal anti-VEGF injections for nAMD therapy between 2006 and 2014 at the University Eye Hospital Munich. From those, we included eyes with treatment-naïve nAMD, follow-up (FU) of ≥60 months and continuous adherence during FU. Primary measures were corrected visual acuity (VA), number of injections and visits as well as treatment regimen.

RESULTS

We included 161 eyes of 125 patients with a mean FU of 8.0 ± 2.3 years. Mean VA at baseline was 60.1 letters (Snellen equivalent, 20/63). After the third year, mean VA declined constantly by 2-3 letters per year. After 5 and 8 years, 26.1% and 42.1% had lost at least 3 lines from baseline. Mean cumulative number of injections was 5.3 after the first year, and 23.9, 38.1, 48.5 after 5, 8, and 10 years. 'Treat and extent' regimen with higher injection frequency correlated with better function. At time of last FU, 69.8% of eyes were under active treatment. Eyes with ≥70 letters at baseline correlated with better VA at the end of FU.

CONCLUSIONS

Despite optimal patient adherence, visual function declined progressively in real-life nAMD therapy over long-term. The highest impact on treatment success is given by an early treatment start with individual but intensive anti-VEGF therapy.

Prophylactic Ranibizumab to Prevent Neovascular Age-Related Macular Degeneration in Vulnerable Fellow Eyes: A Randomized Clinical Trial

PURPOSE

To determine whether prophylactic ranibizumab prevents the development of neovascular age-related macular degeneration (nAMD) in eyes with intermediate AMD for patients with pre-existing nAMD in their contralateral eye.

DESIGN

Multicenter randomized clinical trial.

PARTICIPANTS

Adults aged 50 and older with intermediate AMD (multiple intermediate drusen [≥ 63 μm and <125 μm] or ≥1 large drusen [≥125 μm] and pigmentary changes) in the study eye and nAMD in the contralateral eye.

INTERVENTION

Intravitreal ranibizumab injection (0.5 mg) every 3 months for 24 months or sham injection.

MAIN OUTCOME MEASURES

Conversion to nAMD over 24 months (primary). Change in best-corrected visual acuity from baseline to 24 months (secondary).

RESULTS

Among 108 enrolled participants (54 [50%] in each group), all except two were non-Hispanic Whites, 61 participants (56%) were female, and the mean age was 78 years. The mean baseline visual acuity was 77.7 letters (Snellen equivalent 20/32). The rate of conversion to nAMD over 24 months was 7 of 54 eyes (13%) in both groups (ranibizumab vs. sham hazard ratio=0.91 [95% CI, 0.32-2.59], P=.86). At 24 months, the cumulative incidence of nAMD adjusted for loss to follow-up was 14% (95% CI, 4%-23%) in the ranibizumab group and 15% (95% CI, 4%-25%) in the sham group. At 24 months, the mean change in visual acuity from baseline was -2.1 letters (standard deviation, 5.4) with ranibizumab and -1.4 letters (standard deviation, 7.7) with sham (adjusted difference=-0.8 [95% CI, -3.7 to 2.2], P=.63). The proportion of eyes that lost at least 10 letters of visual acuity from baseline at 24 months was 2 of 39 (5%) with ranibizumab and 4 of 40 (10%) with sham. There were no serious ocular adverse events in either group.

CONCLUSIONS

Quarterly dosing of 0.5 mg ranibizumab in eyes with intermediate AMD did not reduce the incidence of nAMD as compared to sham injections; however, the study was likely underpowered given the 95% confidence interval, and a clinically meaningful effect cannot be excluded. There also was no effect on visual acuity at 24 months. Other strategies to reduce neovascular conversion in these vulnerable eyes are needed.

Efficacy and Safety of Anti-Vascular Endothelial Growth Factor Monotherapies for Neovascular Age-Related Macular Degeneration: A Mixed Treatment Comparison

Background: We aimed to evaluate the comparative efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) monotherapy to identify its utilization and prioritization in patients with neovascular age-related macular degeneration (nAMD). Methods: Eligible studies included randomized controlled trials comparing the recommended anti-VEGF agents (ranibizumab, bevacizumab, aflibercept, brolucizumab, and conbercept) under various therapeutic regimens. Outcomes of interest included the mean change in best-corrected visual acuity (BCVA), serious adverse events, the proportion of patients who gained ≥15 letters or lost <15 letters in BCVA, the mean change in central retinal thickness, and the number of injections within 12 months. Results: Twenty-seven trials including 10,484 participants and eighteen treatments were identified in the network meta-analysis. The aflibercept 2 mg bimonthly, ranibizumab 0.5 mg T&E, and brolucizumab 6 mg q12w/q8w regimens had better visual efficacy. Brolucizumab had absolute superiority in anatomical outcomes and a relative advantage of safety, as well as good performance of aflibercept 2 mg T&E. The proactive regimens had slightly better efficacy but a slightly increased number of injections versus the reactive regimen. Bevacizumab had a statistically non-significant trend toward a lower degree of efficacy and safety. Conclusion: The visual efficacy of four individual anti-VEGF drugs is comparable. Several statistically significant differences were observed considering special anti-VEGF regimens, suggesting that brolucizumab 6 mg q12w/q8w, aflibercept 2 mg bimonthly or T&E, and ranibizumab 0.5 mg T&E are the ideal anti-VEGF regimens for nAMD patients. In the current landscape, based on the premise of equivalent efficacy and safety, the optimal choice of anti-VEGF monotherapies seems mandatory to obtain maximal benefit.

Differentially Regulated Apolipoproteins and Lipid Profiles as Novel Biomarkers for Polypoidal Choroidal Vasculopathy and Neovascular Age-Related Macular Degeneration

Lipid dyshomeostasis has been implicated in the pathogenesis of various retinal and choroidal vascular diseases. This study aims to investigate whether apolipoprotein (apo) mediated differential regulation of lipid metabolism contributes to the phenotypes of polypoidal choroidal vasculopathy (PCV) and neovascular age-related macular degeneration (nAMD). This study involved 148 subjects including 53 patients with PCV, 44 patients with nAMD, and 51 age-, sex-matched subjects with normal fundus controls. Routine blood biochemistry profile was evaluated. Apolipoproteins was estimated by Luminex technology. After controlling for age, gender, body mass index, duration of hypertension and type 2 diabetes mellitus, apoB/non-high density lipoprotein cholesterol (HDL-C) (p=0.015) was an independent risk factor for nAMD, apoB was an independent risk factor for PCV(p=0.011), compared with control. Low-density lipoprotein cholesterol (LDL-C) was significantly higher in patients with PCV when compared with nAMD (p=0.037). Furthermore, apoB/non-HDL, LDL-C, triglycerides and were significantly correlated with the pathogenesis of subgroups of PCV and nAMD. We concluded that lipid profiles and apos are differential regulated in PCV, nAMD and their subtypes, indicating different pathogenicity contributed to the different phenotypes of PCV and nAMD. Non-pachy PCV shares pathological similarities with nAMD, which is highly correlated with age-related atherosclerosis.

Drivers of and Barriers to Adherence to Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema Treatment Management Plans: A Multi-National Qualitative Study

PURPOSE

Neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) patients treated with intravitreally injected anti-vascular endothelial growth factor (anti-VEGF) monotherapies achieve lower vision improvements compared with patients in clinical trials. This qualitative research study aimed to better understand the real-world anti-VEGF treatment experience from nAMD and DME patients', caregivers', and retina specialists' perspectives.

METHODS

One-time, semi-structured, individual interviews were conducted with adult patients with nAMD or DME treated with anti-VEGF injections for ≥12 months, their caregivers, and experienced retina specialists. Interview transcripts were analyzed qualitatively using a thematic analysis approach.

RESULTS

A total of 49 nAMD and 46 DME patients, 47 nAMD and 33 DME caregivers, and 62 retina specialists were interviewed in the USA, Canada, France, Germany, Italy and Spain. Most (79%) patients and caregivers reported disruptions to their routine on the day before, the day of, or the day after anti-VEGF injection. Seven nAMD patients (14%) and 14 DME patients (30%) reported having missed an injection visit. The most frequently reported driver for adherence for patients was the doctor-patient relationship (n=66, 70%), whereas for caregivers, it was the ease of booking an appointment (n=25, 32%). Retina specialists reported patient education on the treatment (n=28, 45%) as the most important driver. Treatment barriers could be grouped into four categories: tolerability, clinical factors, logistical parameters and human factors. The most frequently reported barrier to adherence for patients and caregivers was related to side effects (pain/discomfort/irritation: n=63, 67% of patients; n=52, 66% of caregivers), whereas for retina specialists it was logistical parameters (travel logistics: n=44, 71%).

CONCLUSION

This study highlights the importance of the doctor-patient relationship and patient education as key drivers, and treatment tolerability and logistics as key barriers to treatment adherence. Improved doctor-patient relationship/communication and patient education together with new therapies offering convenience, long-acting effectiveness, and better tolerability may improve treatment adherence.

[Potential pitfalls of anti-VEGF therapy of neovascular age-related macular degeneration]

When administering anti-VEGF therapy for neovascular age-related macular degeneration (nAMD), it is necessary to take into account the fact that treatment outcomes - in addition to factors associated with the disease itself - may be affected by progressive concomitant conditions (for example, macular atrophy) and possible adverse events (AEs). The latter can be divided into two large groups: non-inflammatory and inflammatory. Intraocular inflammation (IOI) is a rare but potentially dangerous AE of anti-VEGF therapy, which can include endophthalmitis, early sterile inflammation and retinal vasculitis. Raising awareness about inflammatory AEs is becoming even more important due to the sheer number of intravitreal injections performed, as well as the frequency of cases of IOI when using new anti-VEGF drugs. The new anti-VEGF drug Brolucizumab is associated with the development of retinal vasculitis, which is considered a type III and IV hypersensitivity reaction (involving cellular and humoral immune responses, respectively). The article presents an overview of publications on the mechanisms, clinical manifestations, differentiation, and methods of treatment of various types of IOI.

Brolucizumab for persistent macular fluid in neovascular age-related macular degeneration after prior anti-VEGF treatments

Background

Some patients with neovascular age-related macular degeneration (nAMD) have persistent intraretinal/subretinal fluid (IRF/SRF) despite being treated with anti-VEGF agents. There is limited data on efficacy of switching to intravitreal brolucizumab (IVBr) in these patients.

Purpose

To determine anatomic and visual outcomes of eyes with nAMD treated with for persistent IRF/SRF.

Methods

Retrospective series of eyes with nAMD treated initially with aflibercept (IVA, n = 48) and bevacizumab (IVBe, n = 10), then switched to IVBr for persistent IRF/SRF.

Results

In the IVA-IVBr group, a mean of 42 days after one IVBr, mean logMAR changed from 0.50 to 0.49 (p = 0.73) and mean CSFT changed from 340 to 305 µm (p < 0.001); 31% of eyes had no fluid, 42% had persistent but reduced fluid, 25% had stable fluid, and 2% had increased fluid. For a subgroup of 25 eyes that completed a series of 3 IVBr, mean logMAR changed from 0.44 to 0.40 (p = 0.35) and mean CSFT changed from 325 to 277 µm (p = 0.001); 24% of eyes had no fluid at last follow-up, a mean of 54 days after last IVBr. In the IVBe-IVBr group, a mean of 44 days after one IVBr, mean logMAR changed from 0.46 to 0.40 (p = 0.114) and mean CSFT from 401 to 325 µm (p = 0.009); 30% of eyes had no fluid and 70% had persistent but reduced fluid. For a subgroup of four eyes that completed a series of three IVBr, mean logMAR changed from 0.33 to 0.35 (p = 0.391) and mean CSFT improved from 375 to 275 µm (p = 0.001); 50% of eyes had no fluid at last follow-up, a mean of 65 days after last IVBr.

Conclusion

In nAMD eyes previously treated with IVA and IVBe, switching to IVBr significantly reduced persistent IRF/SRF but did not significantly affect visual outcomes.

Switching to aflibercept versus continuing bevacizumab for treatment-resistant neovascular age-related macular degeneration: a one-year comparative observational study

PURPOSE

To compare outcomes of a treatment algorithm that allows for switching treatment-resistant neovascular age-related macular degeneration (nAMD) eyes to aflibercept with continuing bevacizumab.

METHODS

Retrospective study of nAMD patients who initiated treatment in 2012 (aflibercept unavailable) and 2018 (aflibercept available). Eyes were included in the case of residual macular fluid after a minimum of 4 monthly bevacizumab injections. Only eyes in the 2018 group could then switch to aflibercept.

RESULTS

The study included 40 eyes from 2012 and 88 eyes from 2018. Patient characteristics were similar across the groups at baseline and 4 months. In 2018, 59 eyes (67%) were switched to aflibercept after 4 months. Mean change in BCVA from 4 months to one year was +2.8 letters in 2018 versus -1.7 letters in 2012 (p = 0.043). Mean change in BCVA from baseline to one year was +9.4 letters in 2018 (p < 0.001) and +4.4 letters in 2012 (p = 0.073). Mean change in CRT from 4 months to one year was -36 µm in 2018 versus -23 µm in 2012 (p = 0.373). Mean change in CRT from baseline to one year was -100 µm in 2018 (p < 0.001) and -75 µm in 2012 (p < 0.001). Mean number of injections given in one year was 11.8 in 2018 versus 10.4 in 2012 (p < 0.001). After one year, a majority of eyes in both groups still received treatment at 4-week intervals.

CONCLUSION

The study suggests that the possibility of switching eyes with treatment-resistant nAMD to aflibercept leads to a modest visual benefit compared with continuing first-line bevacizumab therapy.

Role of intraretinal and subretinal fluid on clinical and anatomical outcomes in patients with neovascular age-related macular degeneration treated with bimonthly, treat-and-extend and as-needed ranibizumab in the In-Eye study

PURPOSE

To assess the effect of fluid status at baseline (BL) and at the end of the loading phase (LP) of three different ranibizumab regimens: treat-and-extend (T&E), fixed bimonthly (FBM) injections and pro re nata (PRN), in patients with neovascular age-related macular degeneration (nAMD).

DESIGN

Post hoc analysis of the In-Eye study (phase IV clinical trial).

METHODS

Patients were randomized 1:1:1 to the three study arms and were treated accordingly. The presence and type of fluid, intraretinal fluid (IRF) or subretinal fluid (SRF) and the anatomical and visual outcomes were analysed.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), the mean change from baseline BCVA (BL BCVA), and the proportion of eyes gaining more than 15 letters or losing more than five letters were analysed. Morphological characteristics including the subtype of choroidal neovascular membrane and the development of atrophy and fibrosis were also evaluated.

RESULTS

Patients with SRF at LP had better visual outcomes than patients with IRF. The persistence of SRF did not affect the mean change from BL BCVA among the three treatment regimens. However, in patients with IRF mean change from BL BCVA was significantly lower in the FBM group. The presence of IRF at BL and at the end of the loading phase was associated with the development of fibrosis at the end of the study; this result was contrary to that observed for patients with SRF.

CONCLUSIONS

While SRF is compatible with good visual and anatomical outcomes, IRF leads to worse results in patients with nAMD; our results suggest that patients with IRF have better outcomes when individualized treatment regimens are used (PRN or T&E) in contrast with a FBM regimen.

Short-Term Efficacy and Safety Outcomes of Brolucizumab in the Real-Life Clinical Practice

To report the early efficacy and safety outcomes of treatment with intravitreal injections of brolucizumab (IVT-B) in patients presenting neovascular age-related macular degeneration (nAMD) in a tertiary clinical setting. A retrospective case series of patients that received IVT-B with a minimum of two injections performed and at least 4 weeks of follow-up after last injection. Nineteen eyes of 19 patients were included. The number of IVT-B performed for the whole cohort was 58 injections; the mean number of IVT-B per patient was 3.0 ± 1.0 (range 2–6); the mean follow-up time was 14.4 ± 9.0 weeks. Mean baseline best-corrected visual acuity was 0.4 ± 0.4 logMAR and at the last follow-up was 0.4 ± 0.6 logMAR (p = 0.778). All eyes showed a reduction in retinal thickness, with the central macular thickness being 470 ± 151 μm at baseline and 360 ± 144 μm at the last follow-up (p = 0.001). Intra-retinal fluid was present at baseline in 12 eyes (63%) and in three eyes (16%) at the last follow-up (p = 0.065). Sub-retinal fluid was present at baseline in 17 eyes (89%) and at the last follow-up in three eyes (16%, p = 0.011). Pigment epithelium detachment was apparent in the 16 eyes (84%) at baseline and was still present in 14 eyes (73%, p = 0.811). One adverse event of intraocular inflammation was reported. In conclusion, our short-term experience showed that brolucizumab was highly effective in restoring the anatomy and in stabilizing the visual acuity of eyes with nAMD. Its safety profile should be evaluated carefully and needs further investigations.

Effect of Anti-VEGF Therapy on the Disease Progression of Neovascular Age-Related Macular Degeneration: A Systematic Review and Model-Based Meta-Analysis

Anti–vascular endothelial growth factor (VEGF) therapy is used to slow the disease progression of neovascular age‐related macular degeneration. Due to the treatment burden of frequent intravitreal injections, anti‐VEGFs are often used on treat and extend protocols rather than the labeled frequency. The current goal of anti‐VEGF drug development is to minimize treatment burden by reducing the number of intravitreal injections. The purpose of this systemic review and model‐based meta‐analysis (MBMA) was to (1) perform modeling to describe the disease progression of neovascular age‐related macular degeneration in the absence of treatment, as well as in the presence of abicipar, aflibercept, brolucizumab, or ranibizumab intervention; (2) and to simulate virtual head‐to‐head comparisons among the drugs with an extended dose schedule of once every 12 weeks (Q12). Data sources were PubMed, internal Allergan data, www.clinicaltrials.gov, and www.clinicaltrialsregister.eu. Eligibility assessment was performed by 2 independent review authors. Randomized, controlled trials that had at least 1 arm with an anti‐VEGF (aflibercept, abicipar, bevacizumab, brolucizumab, pegaptanib, or ranibizumab), a control arm of placebo or anti‐VEGF, a treatment duration of at least 4 months, reported best‐corrected visual acuity data, and at least 20 patients were included. A total of 22 trials, consisting of 55 arms, from across 9500+ subjects and 500+ best‐corrected visual acuity observations were used to develop the model. Consistent with reported data, results from the model showed that abicipar Q12 underperformed ranibizumab (every 4 weeks), aflibercept (every 4 weeks), and brolucizumab (every 8 weeks/Q12) labeled dosing schedules. However, when all drugs were virtually tested using the extended schedule, abicipar outperformed ranibizumab and aflibercept and produced a similar week 52 change from baseline as brolucizumab. Predicted week 52 changes from baseline were 5.92 ± 1.02, 3.04 ± 1.61, 6.61 ± 0.284, and 3.02 ± 2.35 best‐corrected visual acuity letters for abicipar, aflibercept, brolucizumab, and ranibizumab, respectively, using the Q12 schedule. Results demonstrate the feasibility of Q12 dosing with clinically meaningful letter gains for abicipar and brolucizumab. The model developed under this MBMA has utility for exploring different regimens for existing or novel anti‐VEGF agents.

[The significance of choroidal neovascularization type in predicting the effectiveness of antiangiogenic therapy]

Neovascular age-related macular degeneration (nAMD) is one of the causes of irreversible visual acuity loss. Intravitreal injections of anti-vascular endothelium growth factor (anti-VEGF agents) have been proved to be an effective treatment of nAMD. Among the topical problems of this type of treatment is the possibility for predicting the response of different types of choroidal neovascularization (CNV) to the anti-VEGF therapy. This article discusses the differences in the dynamics of morphological and functional parameters of various types of neovascular membranes in the process of anti-VEGF therapy.

Inflammatory Factors of Macular Atrophy in Eyes With Neovascular Age-Related Macular Degeneration Treated With Aflibercept

Background

Neovascular age-related macular degeneration (nAMD) is a leading cause of blindness in older people. Low-grade inflammation is well-known as one of the pathogenic mechanisms in nAMD. Anti-vascular endothelial growth factor (VEGF) therapy is the first-line treatment for nAMD, although macula atrophy (MA) developed under anti-VEGF therapy causes irreversible visual function impairment and is recognized as a serious disorder. Here, we show specific expression patterns of aqueous humor (AH) cytokines in nAMD eyes developing MA under intravitreal injection of aflibercept (IVA) as an anti-VEGF antibody and present predictive cytokines as biomarkers for the incidence of MA in nAMD eyes under IVA treatment.

Methods

Twenty-eight nAMD patients received three consecutive monthly IVA, followed by a pro re nata regimen for 2 years. AH specimens were collected before first IVA (pre-IVA) and before third IVA (post-IVA). AH cytokine levels, visual acuity (VA), and central retinal thickness (CRT) were measured.

Results

Two-year incidence of MA was 21.4%. In nAMD eyes developing MA [MA (+) group], pre-IVA levels of monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein (MIP)-1β, VEGF and post-IVA level of MCP-1 were higher than those in nAMD eyes without MA [MA (−) group]. In hierarchical cluster analysis, pre-IVA MCP-1 and VEGF were grouped into the same subcluster, as were post-IVA MCP-1 and CRT. In principal component analysis, principal component loading (PCL) of pre-IVA interferon-γ-inducible protein 10 (IP-10) was 0.61, but PCL of post-IVA IP-10 decreased to −0.09. In receiver operating characteristic analysis and Kaplan–Meier curves, pre-IVA MCP-1, MIP-1β, and VEGF and post-IVA interleukin-6, MCP-1, and MIP-1β were detected as predictive factors for MA incidence. In 2-year clinical course, changes of VA in groups with high levels of pre-IVA MIP-1β (over 39.9 pg/ml) and VEGF (over 150.4 pg/ml) were comparable to those in MA (+) group.

Conclusion

Substantial loss of IP-10 effects and persistent inflammation contribute to incidence of MA, and screening of AH cytokine levels could be a useful method to predict MA incidence in nAMD eyes under anti-VEGF therapy.

Efficacy and safety of different agents, dosages and strategies of anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration: a network meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy and safety of different agents, dosages and strategies of anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (nAMD) by network meta-analysis.

METHODS

Electronic database searches were conducted on PubMed, Embase and Cochrane Central Register of Controlled Trials up to 1 December 2019 to `identify relevant randomized controlled trials (RCTs). The standardized mean difference (SMD), odds ratios (OR), 95% confidence intervals (CI), the surface under the cumulative ranking curves and the mean ranks of each outcome were estimated by Stata 14.0.

RESULTS

Forty-seven RCTs encompassing 17 872 nAMD patients randomly assigned to 36 regimens of anti-VEGF agents or sham treatment were included. T&E strategy shows top-level effect both in BCVA changes and the percentage of patients with a gain of 3 lines or more of BCVA. When taking the same strategy, there is no significant difference of efficacy among ranibizumab, bevacizumab and aflibercept (p > 0.05); The combination of radiation, topical NSAIDs and photodynamic therapy (PDT) might provide additional benefit in central retinal thickness (CRT) reduction; all these therapeutic regimens of different anti-VEGF agents do not significantly increase the risk of severe ocular or cardiocerebral vascular adverse events (ADEs) compared with sham treatment (p > 0.05).

CONCLUSIONS

T&E strategy showed a satisfactory effect in visual improvement and there is no significant difference in efficacy or safety among ranibizumab, bevacizumab and aflibercept. All the included regimens have an acceptable risk of ADEs.

Conbercept for Treatment of Neovascular Age-Related Macular Degeneration and Visual Impairment due to Diabetic Macular Edema or Pathologic Myopia Choroidal Neovascularization: A Systematic Review and Meta-Analysis

Background: Conbercept is a new anti-vascular endothelial growth factor (VEGF) drug. Here, we systematically conducted the efficacy, safety, compliance, and pharmacoeconomic evaluation of intravitreal conbercept (IVC) compared with other treatments in patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or pathologic myopia choroidal neovascularization (pmCNV). Methods: Databases of PubMed, Embase, Cochrane Library, ClinicalTrials.gov, SinoMed, China National Knowledge Infrastructure, and WanFang Data were systematically searched from the inception to July 27, 2021. Randomized clinical trials and pharmacoeconomic studies comparing IVC with control groups in adults with nAMD, DME, or pmCNV were reviewed and selected. Meta-analyses were performed using the fixed-effects model when pooled data were homogeneous. Heterogeneous data were analyzed using the random-effects model. Primary outcomes included visual improvement rate, mean change in visual acuity or best corrected visual acuity, and pharmacoeconomic outcomes. Additional outcomes were the mean change in fundus examination values, adverse events (AEs), quality-of-life measures, and number of injections. Results: Among 3,591 screened articles, 22 original studies with 1,910 eyes of patients were finally included. For nAMD and DME, IVC was significantly associated with better visual acuity or best corrected visual acuity improvement and fundus quantitative measures than placebo, laser photocoagulation (LP), or intravitreal triamcinolone acetonide (IVT). However, IVC showed non-inferior efficacy to intravitreal ranibizumab (IVR) according to low quality of evidence, and there was lack of trials comparing the priority of IVC to other anti-VEGF regimens. No definitive increased risk of ocular or non-ocular AEs were observed in the study groups. All patients with AEs recovered after symptomatic treatments, and no severe AEs occurred. Patients treated with IVC might have higher quality-of-life scores than those in IVR in nAMD or LP in DME. Additionally, IVC showed cost-utility advantages in nAMD and cost-effectiveness advantages than IVR in pmCNV in China. Conclusion: IVC is well-tolerated and effective for improving vision acuity and quantitative measures in fundus condition in patients with nAMD and DME compared with LP, IVT, and placebo, but gains comparable efficacy to IVR. However, well-designed, large-sample, and long-term evaluation of IVC shall be conducted in additional studies worldwide.

Association between Retinal Thickness Variability and Visual Acuity Outcome during Maintenance Therapy Using Intravitreal Anti-Vascular Endothelial Growth Factor Agents for Neovascular Age-Related Macular Degeneration

Previous studies based on clinical trial data have demonstrated that greater fluctuations in retinal thickness during the course of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD) is associated with poorer visual acuity outcomes. However, it was unclear whether similar findings would be observed in real-world clinical settings. This study aimed to evaluate the association between retinal thickness variability and visual outcomes in eyes receiving anti-VEGF therapy for nAMD using pro re nata treatment regimen. A total of 64 eyes which received intravitreal anti-VEGF therapy (bevacizumab, ranibizumab or aflibercept) for the treatment of nAMD were evaluated. Variability in spectral-domain optical coherence tomography (OCT) central subfield thickness (CST) was calculated from the standard deviation (SD) values of all follow-up visits after three loading doses from month 3 to month 24. Eyes were divided into quartiles based on the OCT CST variability values and the mean best-corrected visual acuity values at 2 years were compared. At baseline, the mean ± SD logMAR visual acuity and CST were 0.59 ± 0.39 and 364 ± 113 µm, respectively. A significant correlation was found between CST variability and visual acuity at 2 years (Spearman's ρ = 0.54, p < 0.0001), indicating that eyes with lower CST variability had better visual acuity at 2 years. Eyes with the least CST variability were associated with the highest mean visual acuity improvement at 2 years (quartile 1: +9.7 letters, quartile 2: +1.1 letters, quartile 3: -2.5 letters, quartile 4: -9.5 letters; p = 0.018). No significant difference in the number of anti-VEGF injections was found between the four CST variability quartile groups (p = 0.21). These findings showed that eyes undergoing anti-VEGF therapy for nAMD with more stable OCT CST variability during the follow-up period were associated with better visual outcomes. Clinicians should consider adopting treatment strategies to reduce CST variability during the treatment course for nAMD.

Decreased gray matter volume and increased white matter volume in patients with neovascular age-related macular degeneration: a voxel-based morphometry study

OBJECTIVE

To measure white and gray matter volume (WMV, GMV) in patients with neovascular age-related macular degeneration (nAMD) using voxel-based morphometry (VBM).

MATERIAL

Eighteen patients (9 men, 9 women) with nAMD and 18 (9 men, 9 women) healthy controls (HCs) aligned were recruited. Functional magnetic resonance imaging (fMRI) and VBM of three-dimensional T1 brain images were analyzed. And we also apply t-tests to look for GMV and WMV differences between groups. Correlation analysis was utilized to probe the connection between observational GMV and WMV values of diverse brain areas and the severity of HADS (hospital anxiety and depression scale). Also, distinctions between nAMD and HCs in GMV can be presented with the help of a ROC (receiver operating characteristic) curve.

RESULTS

Compared with HCs, GMV values were significantly lower in patients with neovascular age-related macular degeneration in the right inferior frontal gyrus, temporal pole of left superior temporal gyrus, left superior temporal gyrus, left middle frontal gyrus, left anterior cingulate and para cingulate gyrus. While WMV was slightly increased in these areas. HADS (hospital anxiety and depression scale) scores portrayed a non-linear correlation with the GMV value of the right inferior frontal gyrus, left middle frontal gyrus, left anterior cingulate and paracingulate gyrus of the nAMD group (r=-0.6629, P=0.0027)(r=-0.9451, P<0.0001)(r=-0.6183, P=0.0062). Moreover, the ROC curve analysis of the mean VBM values for altered brain regions indicated high diagnostic accuracy.

CONCLUSION

These results indicated that patients with nAMD have abnormal GMV and WMV and formed a basis for future research on pathological mechanisms in this disease. Moreover, decreased gray matter volume in particular brain regions might be associated with choroidal neovascularization and abnormal HADS score. It might help to explain the pathological mechanism of anxiety and depression in patients with nAMD.

Topical Triamcinolone Acetonide-Loaded Liposome Formulation Used as an Adjuvant to Intravitreal Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration

Novel strategies have been developed to reduce or avoid intravitreal injections (IVTs) of the antiangiogenic (ranibizumab (RBZ)) and anti-inflammatory (triamcinolone acetonide (TA)) agents used to treat vitreoretinal diseases. One of the strategies includes liposomes. This study evaluated the safety and efficacy of a topical triamcinolone-loaded liposome formulation (TALF) as an adjuvant to intravitreal RBZ therapy in treatment- naïve patients with neovascular age-related macular degeneration (nAMD). Subjects were randomly assigned to the RBZ-TALF or the RBZ-pro re nata (RBZ-PRN) groups. Patients from the RBZ-TALF group were instructed to apply TALF for 12 months after a single dose of RBZ. Patients from the RBZ-PRN group received three monthly RBZ-IVTs. Retreatment with RBZ was considered in the case of nAMD reactivation. Regarding safety, non-ocular abnormalities were observed during TALF therapy. Concerning efficacy, non-significant differences were identified in terms of visual acuity or central foveal thickness when the RBZ-PRN and RBZ-TALF groups were compared. It is worth noting that the average number of RBZ injections was significantly lower in the RBZ-TALF group (2.5 ± 1.4 vs. 6.1 ± 1.3 IVTs; p = 0.0004). Therefore, TALF used as an adjuvant to RBZ reduces the need for RBZ-IVT retreatment with optimal visual and anatomic results.