Randomized Trial of Monthly Versus As-Needed Intravitreal Ranibizumab for Radiation Retinopathy-Related Macular Edema: 1-Year Outcomes

PURPOSE

To assess efficacy of intravitreal ranibizumab injections and targeted panretinal photocoagulation (TRP) for radiation retinopathy-related macular edema.

DESIGN

Phase IIb, prospective, randomized clinical trial.

METHODS

Setting: Multicenter.

SUBJECTS

Forty eyes in 40 treatment-naïve patients with radiation-induced macular edema and a resulting decrease in visual acuity ranging between 20/25 and 20/400 (Snellen equivalent).

INTERVENTION

Patients either received intravitreal 0.5 mg ranibizumab monthly, monthly ranibizumab with TRP, or 3 monthly ranibizumab (loading doses) followed by as-needed (PRN) injections and TRP. After week 52, all subjects entered a treat-and-extend protocol for ranibizumab. MainOutcomeMeasures: Mean Early Treatment Diabetic Maculopathy Study (ETDRS) BCVA change from baseline.

RESULTS

Mean patient age was 57 years (range, 22-80 years), ETDRS BCVA was 56.7 letters (20/74 Snellen equivalent), and central macular thickness (CMT) was 423 μm (range, 183-826 μm). Thirty-seven patients completed the month 12 visit (92.5%), at which time the change in mean BCVA was +4.0 letters, -1.9 letters, and +0.9 letters in the monthly, monthly plus laser, and PRN plus laser cohorts, respectively. There was a significant difference in mean BCVA at 1 year among all 3 cohorts (P < .001), as well as between cohorts in pairwise comparisons, with the most significant gains in the monthly group. A total of 82.5% of the patients retained visual acuity of 20/200 or better, and 20.0% improved 10 or more ETDRS letters.

CONCLUSIONS

Ranibizumab may improve vision and anatomy in patients with radiation retinopathy-related macular edema and prevent vision loss through 48 weeks of therapy. Monthly injections were more effective than as-needed approach, and the addition of TRP yielded no therapeutic benefits.

Anti-vascular endothelial growth factor for macular oedema secondary to branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is one of the most commonly occurring retinal vascular abnormalities. The most common cause of visual loss in people with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss. Limitations to this treatment exist, however, and newer modalities may have equal or improved efficacy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has recently been used successfully to treat MO resulting from a variety of causes.

OBJECTIVES

To investigate the efficacy and gather evidence from randomised controlled trials (RCTs) on the potential harms of anti-vascular endothelial growth factor (VEGF) agents for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); MEDLINE Ovid; Embase Ovid; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. The date of the last search was 12 June 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating BRVO. Eligible trials had to have at least six months' follow-up where anti-VEGF treatment was compared with another treatment, no treatment, or placebo. We excluded trials where combination treatments (anti-VEGF plus other treatments) were used; and trials that investigated the dose and duration of treatment without a comparison group (other treatment/no treatment/sham).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data using standard methodological procedures expected by Cochrane. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and 12 months of follow-up. The secondary outcomes were the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean visual acuity (VA) change at six and 12 months, as well as the change in central retinal thickness (CRT) on optical coherence tomography from baseline at six and 12 months. We also collected data on adverse events and quality of life (QoL).

MAIN RESULTS

We found eight RCTs of 1631 participants that met the inclusion criteria after independent and duplicate review of the search results. These studies took place in Europe, North America, Eastern Mediterranean region and East Asia. Included participants were adults aged 18 or over with VA of 20/40 or worse. Studies varied by duration of disease but permitted previously treated eyes as long as there was sufficient treatment-free interval. All anti-VEGF agents (bevacizumab, ranibizumab and aflibercept) and steroids (triamcinolone and dexamethasone) were included. Overall, we judged the studies to be at moderate or unclear risk of bias. Four of the eight studies did not mask participants or outcome assessors, or both. One trial compared anti-VEGF to sham. At six months, eyes receiving anti-VEGF were significantly more likely to have a gain of 15 or more ETDRS letters (risk ratio (RR) 1.72, 95% confidence interval (CI) 1.19 to 2.49; 283 participants; moderate-certainty evidence). Mean VA was better in the anti-VEGF group at six months compared with control (mean difference (MD) 7.50 letters, 95% CI 5.29 to 9.71; 282 participants; moderate-certainty evidence). Anti-VEGF also proved more effective at reducing CRT at six months (MD -57.50 microns, 95% CI -108.63 to -6.37; 281 participants; lower CRT is better; moderate-certainty evidence). There was only very low-certainty evidence on adverse effects. There were no reports of endophthalmitis. Mean change in QoL (measured using the National Eye Institute Visual Functioning Questionnaire VFQ-25) was better in people treated with anti-VEGF compared with people treated with sham (MD 7.6 higher score, 95% CI 4.3 to 10.9; 281 participants; moderate-certainty evidence). Three RCTs compared anti-VEGF with macular laser (total participants = 473). The proportion of eyes gaining 15 or more letters was greater in the anti-VEGF group at six months (RR 2.09, 95% CI 1.44 to 3.05; 2 studies, 201 participants; moderate-certainty evidence). Mean VA in the anti-VEGF groups was better than the laser groups at six months (MD 9.63 letters, 95% CI 7.23 to 12.03; 3 studies, 473 participants; moderate-certainty evidence). There was a greater reduction in CRT in the anti-VEGF group compared with the laser group at six months (MD -147.47 microns, 95% CI -200.19 to -94.75; 2 studies, 201 participants; moderate-certainty evidence). There was only very low-certainty evidence on adverse events. There were no reports of endophthalmitis. QoL outcomes were not reported. Four studies compared anti-VEGF with intravitreal steroid (875 participants). The proportion of eyes gaining 15 or more ETDRS letters was greater in the anti-VEGF group at six months (RR 1.67, 95% CI 1.33 to 2.10; 2 studies, 330 participants; high-certainty evidence) and 12 months (RR 1.76, 95% CI 1.36 to 2.28; 1 study, 307 participants; high-certainty evidence). Mean VA was better in the anti-VEGF group at six months (MD 8.22 letters, 95% CI 5.69 to 10.76; 2 studies, 330 participants; high-certainty evidence) and 12 months (MD 9.15 letters, 95% CI 6.32 to 11.97; 2 studies, 343 participants; high-certainty evidence). Mean CRT also showed a greater reduction in the anti-VEGF arm at 12 months compared with intravitreal steroid (MD -26.92 microns, 95% CI -65.88 to 12.04; 2 studies, 343 participants; moderate-certainty evidence). People receiving anti-VEGF showed a greater improvement in QoL at 12 months compared to those receiving steroid (MD 3.10, 95% CI 0.22 to 5.98; 1 study, 307 participants; moderate-certainty evidence). Moderate-certainty evidence suggested increased risk of cataract and raised IOP with steroids. There was only very low-certainty evidence on APTC events. No cases of endophthalmitis were observed.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that treatment of MO secondary to BRVO with anti-VEGF improves visual and anatomical outcomes at six and 12 months.

Mapping From Visual Acuity to EQ-5D, EQ-5D With Vision Bolt-On, and VFQ-UI in Patients With Macular Edema in the LEAVO Trial

OBJECTIVES

Mappings to convert clinical measures to preference-based measures of health such as the EQ-5D-3L are sometimes required in cost-utility analyses. We developed mappings to convert best-corrected visual acuity (BCVA) to the EQ-5D-3L, the EQ-5D-3L with a vision bolt-on (EQ-5D V), and the Visual Functioning Questionnaire-Utility Index (VFQ-UI) in patients with macular edema caused by central retinal vein occlusion.

METHODS

We used data from Lucentis, Eylea, Avastin in vein occlusion (LEAVO), which is a phase-3 randomized controlled trial comparing ranibizumab, aflibercept, and bevacizumab in 463 patients with observations at 6 time points. We estimated adjusted limited dependent variable mixture models consisting of 1 to 4 distributions (components) using BCVA in each eye, age, and sex to predict utility within the components and BCVA as a determinant of component membership. We compared model fit using mean error, mean absolute error, root mean square error, Akaike information criteria, Bayesian information criteria, and visual inspection of mean predicted and observed utilities and cumulative distribution functions.

RESULTS

Mean utility scores were 0.82 for the EQ-5D-3L, 0.79 for the EQ-5D V, and 0.88 for the VFQ-UI. The best-fitting models for the EQ-5D and EQ-5D V had 2 components (with means of approximately 0.44 and 0.85), and the best-fitting model for VFQ-UI had 3 components (with means of approximately 0.95, 0.74, and 0.90).

CONCLUSIONS

Models with multiple components better predict utility than those with single components. This article provides a valuable addition to the literature, in which previous mappings in visual acuity have been limited to linear regressions, resulting in unfounded assumptions about the distribution of the dependent variable.

Effectiveness and safety of ranibizumab 0.5 mg in treatment-naïve patients with diabetic macular edema: Results from the real-world global LUMINOUS study

PURPOSE

To assess the one-year effectiveness and safety of ranibizumab 0.5 mg in treatment- naïve patients with diabetic macular edema (DME) enrolled in the real-world LUMINOUS study.

PATIENTS AND METHODS

A 5-year, prospective, observational, open-label, global study which recruited 30,138 patients across all approved indications. Consenting patients (≥18 years) who were treatment-naïve or previously treated with ranibizumab or other ocular treatments were treated as per the local ranibizumab label. Here, we present the change in visual acuity (VA) (Early Treatment Diabetic Retinopathy Study letter score; primary treated eye) at Year 1, as well as the change in VA based on injection frequencies (≤4 and ≥5), treatment exposure, and the overall adverse events (AEs) and serious AEs (SAEs) in treatment-naïve DME patients.

RESULTS

Of the 4,710 DME patients enrolled in the study, 1,063 were treatment-naïve. At baseline, mean age was 64.5 years, 54.7% were male, and 69.2% were white. At 1 year, mean VA letter score improved by +3.5 (n = 502) from a baseline of 57.7 with a mean of 4.5 injections. Presented by injection frequencies ≤4 and ≥5, VA letter score gains were 0.5 (n = 264) and 6.9 (n = 238) from baseline letter scores of 56.6 and 59.0, respectively. Over 5 years, the incidence of ocular/non-ocular AEs and SAEs was 7.2%/10.1% and 0.3%/5.8%, respectively. No endophthalmitis cases were reported.

CONCLUSIONS

The LUMINOUS study included patients with DME with more diverse baseline characteristics than those in randomized clinical trials. The 1-year data showed improvement in VA with low number of injections in treatment- naïve patients with DME. Greater VA gains were observed in patients who received ≥5 injections. No new safety findings were identified. LUMINOUS confirms the effectiveness and safety of ranibizumab for the treatment of patients with DME in a real-world clinical practice.

Effectiveness of treat-and-extend versus pro re nata regimens in the treatment of Neovascular Age Macular Degeneration: A Real World Comparison

PURPOSE

Evaluate and compare the visual and morphological results of Pro re nata (PRN) and treat-and-extend (T&E) treatment regimens at 3 years in real world clinical practice.

METHODS

Retrospective study of patients with neovascular age macular degeneration (AMD) treated with anti-VEGF with 3 years of continuous follow-up and no previous anti-VEGF treatment. Best corrected visual acuity (BCVA), central foveal thickness (CFT) and number of intravitreal injections outcomes were tested for statistical differences between the two groups at baseline and during follow-up.

RESULTS

A total of 240 eyes were included in the study, 170 in the PRN group and 70 in the T&E group. At 12 months, mean BCVA (ETDRS letters) gain from baseline was at its highest point in the T&E group (+6.38±13.32; p=0.25). In the PRN group, BCVA peaked at 3 months and slowly decreased until end of follow-up. With both regimens, from baseline, CFT continued to decrease until the second year (PRN -138.81 [-846.7 to +162.77] and T&E -81 [-604 to +100] μm, p=0.06). After that, T&E group maintained this tendency, reaching the lowest CFT value at 36 months, whereas PRN group showed an increased in CFT values (PRN -104 [-807.7 to +297] μm and T&E -103 [-575 to +244], μm p=0.63). Patients treated with T&E regimen received a significantly higher number of injections (PRN 16.3±7.6 vs T&E 23.9 ±9.4, p<0.01).

CONCLUSION

Our results demonstrated a trend towards for T&E to achieve higher marks in BCVA, peaking at 12 months, and lower CFT thickness at the end of three years. Despite the higher number of injections performed in the T&E group the mean BCVA reverts to baseline values at 3 years.

A systematic review and meta-analysis to compare the efficacy of conbercept with ranibizumab in patients with macular edema secondary to retinal vein occlusion

BACKGROUND

The objective of this review and meta-analysis is to investigate the efficacy of conbercept and ranibizumab, combined with or without laser photocoagulation, in patients with macular edema secondary to retinal vein occlusion (RVO-ME).

METHODS

Several databases have been used to identify relevant publications. After screening, a meta-analysis was conducted to compare conbercept and ranibizumab with the support of RevMan 5.3 (Cochrane Library Software, Oxford, UK).

RESULTS

In this study, 9 randomized controlled trials and 6 retrospective trials were included with a total of 1180 patients. No significant difference was found in best corrected visual acuity (BCVA) or central macular thickness (CMT) in the baseline parameters [BCVA (weighted mean difference (WMD): -0.01; 95% confidence interval CI: -0.03 to 0.01; P = .17), CMT (WMD: 20.14; 95% CI: -26.70 to 66.97; P = .40). No significant differences were found in the improvements of BCVA and adverse events (AEs) between the 2 groups after injection of loading dosage [the 1st month BCVA (WMD: -0.01; 95% CI: -0.04 to 0.02; P = .54),the 3rd month BCVA (WMD: -0.02; 95% CI: --0.05 to 0.01; P = .23), the 6th month BCVA (WMD: -0.02; 95% CI: -0.05 to 0.01; P = .27), AEs (odds ratio: 0.84; 95% CI: 0.38 to 1.84; P = .66)]. However, there were significant differences between conbercept and ranibizumab treatment in terms of CMT [1st month CMT (WMD: -11.70; 95% CI: -19.71 to -3.68; P < .01), 3rd month CMT (WMD: -10.08; 95% CI: -15.62 to -4.53; P < .01), 6th month CMT (WMD: -15.83; 95% CI: -22.88 to -8.78; P < .01)] and the number of injections (WMD, -0.36; 95% CI: -0.68 to -0.04; P = .03).

CONCLUSION

The current pooled evidence suggested that both therapies of intravitreal conbercept and intravitreal ranibizumab with or without laser photocoagulation are effective in vision function in RVO-ME patients, and confirmed that conbercept has advantages over ranibizumab in terms of CMT and the number of injections for treating RVO-ME. In addition, conbercept has the statistically same visual gains and safety as ranibizumab in RVO-ME patients. Longer-term follow-up surveys on the safety and effectiveness of these 2 treatment regimens are required.

Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management.

OBJECTIVES

To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for trial selection, data extraction, and analysis.

MAIN RESULTS

We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 μm in the monthly injection group; the MD compared with standard PRN was 21 μm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 μm (95% CI 37 to -81 μm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 μm in the monthly group; the MD with the extended-fixed group was 8 μm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results.

AUTHORS' CONCLUSIONS

We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.

Clinical features, management and outcomes of patients with sterile endophthalmitis associated with intravitreal injection of antivascular endothelial growth factor

PURPOSE

Analyze clinical features, management and outcomes of patients with sterile endophthalmitis associated with intravitreal antivascular endothelial growth factor.

METHODS

Observational retrospective case series of patients with sterile endophthalmitis following anti-VEGF intravitreal injections. Clinical data of patients treated with intravitreal anti-VEGFs during one year have been revised. Those who have presented an episode of sterile endophthalmitis are analyzed and their causality and management are studied.

RESULTS

Seven patients have had a sterile endophthalmitis onset within 4days after intravitreal injection (aflibercept n=5 and ranibizumab n=2). These patients have some active neovascular condition: age related macular degeneration (n=4), myopic choroidal neovascularization (n=1) or macular edema: diabetic macular edema (n=1), branch retinal vein occlusion (n=1). Shared signs and symptoms included painless vision loss, anterior chamber and vitreous cell and lack of hypopyon. In all patients, visual acuity returned to within one line of baseline acuity.

CONCLUSION

Differentiating cases of sterile from infectious endophthalmitis may be challenging. It is crucial to differentiate both entities as a good diagnosis determines the visual prognosis. We should be aware of minimal inflammation after repeated intravitreal injections in order to establish the adequate treatment.

Outcome of treatment for neovascular age-related macular degeneration by practice-based ophthalmologists compared with a macula clinic

PURPOSE

The aim of this study was to compare neovascular age-related macular degeneration (nAMD) treatment outcomes between ophthalmological practices and a specialized macula clinic.

METHODS

In this case series, we included 347 treatment-naïve eyes with nAMD (332 patients). All patients received intravitreal anti-VEGF treatment using ranibizumab or aflibercept at the discretion of the treating physician using a treat-and-extend protocol either by one of 28 practice-based ophthalmologists (group 1; n = 215 eyes) or at a macula clinic (group 2; n = 132 eyes) over 24 months.

RESULTS

Baseline characteristics of the patients in the two groups, including age, initial BCVA (group 1 58.2 ± 18.5, group 2 60.8 ± 16.1 ETDRS letters; p = 0.32), and baseline CRT, were comparable. By end of the observation period, both groups presented similar BCVA (group 1 67.4 ± 19.3, group 2 66.8 ± 17.2 letters; p = 0.51), visual gains (group 1 7.8 ± 16.9, group 2 5.8 ± 14.4 letters; p = 0.11), CRT values (group 1 259.6 ± 80.5, group 2 277.4 ± 87.1 μm; p = 0.10), and number of injections (group 1 13.0 ± 4.5, group 2 11.6 ± 4.1 injections; p = 0.09), as well as portion of eyes with stable disease (absence of any intraretinal fluid and absence or stability of subretinal fluid and pigment epithelial detachment: group 1 78% (n = 128), group 2 75% (n = 95); p = 0.63). However, there was a significant difference regarding the number of examinations (group 1 12.8 ± 5.0, group 2 9.7 ± 3.1 visits; p = 0.0005).

CONCLUSIONS

nAMD treatment delivered by practice-based ophthalmologists is reasonable regarding functional outcomes and reduces the indirect treatment burden, which is partially outweighed by significantly more clinical examinations in ophthalmological practices.

Long-Term Vision Outcomes in Patients With DME and a Limited Early Visual Response to Ranibizumab in RIDE and RISE

BACKGROUND AND OBJECTIVE

To compare early and long-term visual responses to ranibizumab in patients with diabetic macular edema.

PATIENTS AND METHODS

Retrospective analysis of RIDE (NCT00473382) and RISE (NCT00473330). Vision outcomes over 36 months were compared between limited early gainers (gained ≤ 5 Early Treatment Diabetic Retinopathy Study [ETDRS] letters), early 1-line gainers (gained 6 to 9 ETDRS letters), and early 2-or-more-line gainers (gained ≥ 10 ETDRS letters) at Month 3.

RESULTS

Among 235 ranibizumab-treated patients, 42.6%, 20.0%, and 37.4% were limited early gainers, early 1-line gainers, and early 2-or-more-line gainers, respectively. At Month 36, 71.3% of limited early gainers achieved 6 to 9 and 10 or more ETDRS letter gains. Mean ETDRS letter scores at Month 36 were comparable between limited early gainers (67.8), early 1-line gainers (73.4), and early 2-or-more-line gainers (71.6).

CONCLUSION

Clinically meaningful vision outcomes were achieved with long-term ranibizumab treatment, irrespective of early visual acuity response. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:210-218.].

Effect of Lingqi Huangban granule plus intravitreal ranibizumab on macular edema induced by retinal vein occlusion: a randomized controlled clinical trial

OBJECTIVE

To investigate the effect of Lingqi Huangban granule (LQHB) plus intravitreal ranibizumab in the treatment of macular edema (ME) induced by retinal vein occlusion (RVO).

METHODS

A prospective, randomized controlled study was conducted. A total of 60 subjects with RVO induced ME were randomized into control group (CG) (30 eyes) and LQHB group (LQHBG) (30 eyes). CG patients underwent intravitreal ranibizumab (IVR) injections. LQHBG patients were treated with oral LQHB combined with IVR injections. In order to reduce the financial burden of the injections, we used one injection and pro re nata (PRN) regimen for both groups. The best-corrected visual acuity (BCVA), central macular thickness (CMT), and mean number of injections were evaluated at the beginning of treatment and 3, 6, 9 and 12 months afterward. All the subjects were followed up for 1 year.

RESULTS

At the beginning of treatment, there were no statistically significant differences between the two groups in terms of the general condition of patients (P > 0.05). At 3, 6, 9 and 12 months after treatment, however, the BCVA scores improved and the CMT measurements decreased in all patients (P < 0.05), with the improvement of LQHBG significantly greater than that of CG (P < 0.05). The mean numbers of ranibizumab injections were 1.8 ± 0.3 in LQHBG and 2.3 ± 0.6 in CG, respectively (P < 0.05). No adverse events were reported in both groups.

CONCLUSION

LQHB plus intravitreal ranibizumab could be a much more effective and economic treatment for stabilizing and improving vision with fewer intravitreal injections in the treatment of RVO induced ME. This integrative therapy appears to be a promising option for this type of patient.

Diabetic macular edema with neuroretinal detachment: OCT and OCT-angiography biomarkers of treatment response to anti-VEGF and steroids

PURPOSE

To assess and compare early changes in neuroinflammatory and vascular parameters in diabetic macular edema (DME) with subfoveal neuroretinal detachment (SND) after treatment with intravitreal dexamethasone (DEX-I) and ranibizumab (IVR).

METHODS

Thirty-three eyes (33 patients) with treatment naïve DME with SND were retrospectively evaluated at baseline and 2 months after DEX-I (15 eyes) and 1 month after 3 monthly IVR injections (18 eyes). Inclusion criteria were: complete eye examination, good quality OCT and OCT-A images. OCT parameters included: central macular thickness (CMT); number of hyper-reflective retinal spots (HRS) in inner, outer (IR, OR) and full retina; choroidal thickness (CT), extent of disorganization of inner retinal layers (DRIL), outer retina integrity (OR). On OCT-A: foveal avascular zone (FAZ) parameters in the superficial capillary plexus (SCP); cysts area and perfusion density (PD) in SCP and deep capillary plexus (DCP) and flow voids (FV) in choriocapillaris. FAZ was analyzed using ImageJ, perfusion parameters and FV using MATLAB.

RESULTS

BCVA increased equally after both treatments (13.0 ± 10.0 ETDRS letters, p < 0.0001). There was a similar decrease (p < 0.05) in: height of SND, cysts area at SCP, central and mean CT, increase in FAZ perimeter and OR integrity, after both treatments. A greater decrease in DEX-I versus IVR group was found in: CMT (- 38.7% vs. - 22.2%, p = 0.012), HRS number in IR (- 29.2% vs. - 14.0%, p = 0.05) and full retina (- 24.7% vs. - 8.0%, p = 0.03), DRIL extension (- 62.0% vs. - 24%, p = 0.008), cysts area at DCP (- 68.7% vs. - 26.1%, p = 0.03), FAZ-CI (- 19.1% vs. - 8.3%, p = 0.02), PD at DCP (- 27.5%  vs. + 4.9%, p = 0.02). FV did not change.

CONCLUSIONS

More pronounced changes in specific inflammatory parameters in the inner retina are documented after steroid versus anti-VEGF treatment. These include reduction in HRS number, DRIL extension, CMT, cysts area at DCP. These data may help in further study of noninvasive imaging biomarkers for better evaluation of treatment response.

Five-year outcomes of photodynamic therapy combined with intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy

We report 5-year visual and anatomical outcomes after combination therapy of photodynamic therapy (PDT) and intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy (PCV) and predictive factors for visual outcomes at 5-year and time to recurrence. Medical charts were retrospectively reviewed for 43 consecutive eyes with PCV treated with combination therapy of PDT and intravitreal injection of ranibizumab(n = 13) or aflibercept(n = 30) and completed 5-year follow-up. The variants of ARMS2 A69S and CFH I62V were genotyped using TaqMan assay. Best corrected visual acuity (BCVA) significantly improved at 5-year (P = 0.01) with 20% reduction of subfoveal choroidal thickness irrespective of presence or absence of recurrence. Visual improvement was associated with baseline shorter greatest linear dimension (GLD) (P = 1.0×10-4). Mean time to recurrence was 28.6±23.1 months (95% CI: 21.5-35.7, Median:18.0) and time to recurrence was associated with G allele (protective allele) of ARMS2 A69S and GLD (P = 4.0×10-4 and 1.0×10-2, respectively). Multiple regression analysis revealed that time to recurrence extended by 15.5 months when the G allele of ARMS2 A69S increased by one allele (TT: 15.7±17.0, TG: 30.8±23.5, GG: 41.1±22.6 months). The combination therapy resulted in a favorable visual outcome for PCV during 5-year follow-up.

Changes in Ocular Blood Flow after Ranibizumab Intravitreal Injection for Diabetic Macular Edema Measured Using Laser Speckle Flowgraphy

PURPOSE

To evaluate the effects of intravitreal ranibizumab (IVR) treatment on the blood flow of the optic nerve head (ONH) and of retinal vessels of the peripapillary region of eyes with diabetic macular edema (DME) assessed using laser speckle flowgraphy (LSFG).

METHODS

Forty eyes of 30 patients treated with IVR for DME were included in this prospective clinical study. Mean blur rate (MBR) and relative flow volume (RFV) of the ONH and of a superior retinal artery and an inferior retinal vein of the peripapillary region were measured using LSFG at baseline, 2 weeks (T1), and 1 month (T2) after IVR injection. In addition, best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were measured in all cases.

RESULTS

The BCVA improved and CRT decreased significantly during the follow-up period (p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA, p < 0.010). MBR-related parameters of the ONH such as MBR of all area (MA), MBR of vascular area (MV), and MBR of tissue area (MT) decreased significantly at 2 weeks after IVR compared to baseline values (MA.

CONCLUSION

IVR injection leads to a reduction of ocular blood flow both in the ONH and in the retinal peripapillary vessels associated with peripapillary vessel constriction. The reduction of CRT and related improvement of vision may be related to the changes in ocular blood flow.

MACULAR ATROPHY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Pilot Post Hoc Analysis of Patients With Pigment Epithelial Detachments

PURPOSE

To determine optical coherence tomography signs associated with macular atrophy (MA) in eyes with neovascular age-related macular degeneration and pigment epithelial detachments treated with vascular endothelial growth factor inhibitors.

METHODS

Optical coherence tomography scans from a subgroup of the pigment epithelial detachment cohort of the HARBOR study were analyzed for MA. Two groups were formed based on MA presence/absence at Month 24. Then, optical coherence tomography scans from each baseline visit were graded with standard reading center grading parameters including ellipsoid zone disruption, intraretinal cysts, subretinal fluid, and MA or nascent MA in the study and fellow eyes.

RESULTS

Twenty-eight eyes from 28 patients were included in the analysis. Fourteen eyes had optical coherence tomography-based MA at Month 24 and 14 did not. Macular atrophy at Month 24 was significantly associated with 1) MA/nascent MA at baseline (P = 0.0136), 2) intraretinal cysts at baseline (P = 0.0048), and 3) collapse of pigment epithelial detachments in the study eye (P = 0.0025). Macular atrophy was not associated with ellipsoid zone disruption or subretinal fluid in the study eye at baseline.

CONCLUSION

This study suggests that some optical coherence tomography findings in eyes of patients with neovascular age-related macular degeneration were present before the start of anti-vascular endothelial growth factor therapy and may predict the development of MA.

A case of late-onset larynx angioedema after ranibizumab intravitreal injection: Ranibizumab-related angioedema

This case report describes an unusual case of late-onset larynx angioedema after ranibizumab intravitreal injection. A 72-year-old female patient presented to our clinic for decreased vision; right eye (RE) fundoscopy and optical coherence tomography (OCT) revealed mild chorioretinal atrophy and choroidal neovascularization with subretinal fluid. A ranibizumab injection was planned in the RE, with standard pretreatment with daily oral administration of betamethasone, cetirizine, and ranitidine because her medical history revealed two adverse drug reactions (ADRs) to contrast media (CM). Despite the premedication, 2 h after injection, the patient referred throat closing sensation and dyspnea that resolved within few hours by betamethasone 4 mg intramuscular injection, without further reoccurrence. In occasion of the second intravitreal injection, video rhinofibrolaryngoscopy revealed subglottic edema that resolved within few hours by betamethasone 4 mg intramuscular injection. This report suggests that, even in cases of intravitreal injection, patients with history of allergy, despite the anti-allergic treatment, should be hospitalized to detect late onset of such a life-threatening complication.

NOVEL CASE OF CLOSTRIDIUM PERFRINGENS ENDOPHTHALMITIS AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTION

INTRODUCTION

Endophthalmitis after anti-vascular endothelial growth factor injection is a rare complication but may lead to rapid destruction of structures within the eye. Infection with Clostridium perfringens has not previously been reported in this context.

CASE REPORT

A 90-year-old woman presented with endophthalmitis of the right eye, 2 days after an intravitreal injection of ranibizumab. Initial examination showed a high intraocular pressure, refractive to topical treatment, reduced vision, and a hypopyon. Gram stain showed a Gram-positive bacillus, which was identified as C. perfringens. Despite the use of intravitreal and intravenous antibiotics, the patient went on to develop cornea-scleral melt of the right eye. She required an evisceration on the fifth day after ranibizumab.

CONCLUSION

This case describes a unique and virulent pathogen leading to globe loss after an anti-vascular endothelial growth factor injection. C. perfringens, naturally living in feces or soil, is more commonly associated with dirty traumatic open-globe injuries. However, it is an important pathogen to consider when there is rapid destruction of eye structures associated with endophthalmitis. Based on a root cause analysis of this case, our department has introduced patient information leaflets on hand hygiene to educate patients having intraocular injections.

Classification of Strokes in Patients Receiving Intravitreal Anti-Vascular Endothelial Growth Factor

BACKGROUND AND OBJECTIVE

The purpose of this study was to identify the differences in the types of strokes seen in patients receiving intravitreal anti-vascular endothelial growth factor (VEGF) compared with normal control populations.

PATIENTS AND METHODS

We performed a retrospective consecutive review of all patients receiving intravitreal anti-VEGF injections in Olmsted County, Minnesota, from January 1, 2004, to December 31, 2013, for exudative age-related macular degeneration (AMD), diabetic macular edema (DME), proliferative diabetic retinopathy (PDR), or retinal vein occlusion (RVO). A 2-year follow-up period was required for study inclusion. Three age- and sex-matched cohorts were identified.

RESULTS

A total of 2,541 patients were examined. There were 690 patients identified during the study period as receiving an intravitreal injection for AMD, DME, PDR, or RVO. Of these patients, 38 (5.8%) suffered a stroke after starting intravitreal injection therapy. Of these strokes, 27 (71.1%) were ischemic, six (15.8%) were embolic, and five (13.2%) were hemorrhagic. There were no differences in the types of strokes identified among the patients receiving intravitreal injections between the case cohort and the control cohorts (P > .05 for all).

CONCLUSION

The authors' data suggest there is no predilection to the development of ischemic infarcts or hemorrhagic strokes in those patients receiving intravitreal anti-VEGF compared with control populations. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e140-e157.].

Advances in the treatment of diabetic retinopathy

As the diabetes epidemic in the United States continues to worsen, so too does the prevalence of diabetic retinopathy (DR). DR is divided broadly into nonproliferative and proliferative stages, with or without vision-threatening macular edema. Progression to proliferative DR is associated with vision loss that is often irreparable, and a rapid decline in health-related quality of life. Vascular endothelial growth factor (VEGF)-A is upregulated in the diabetic eye, and has been identified as a key driver of DR pathogenesis. With this perspective, we review the published phase III clinical trial data of anti-VEGF therapies approved for the treatment of DR in the United States. Using the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale, in which an improvement of ≥2 steps is considered clinically significant, approximately one-third of patients with DR and macular edema experience this level of improvement after 1 year of treatment with either ranibizumab or aflibercept. The rates of clinically significant DR improvement with ranibizumab could be twice that in the subgroup of patients with moderately severe or severe nonproliferative DR and macular edema. These clinical trial data indicate that intraocular inhibition of VEGF is a rational approach for the management of DR.

Comparison of anatomical and visual outcomes following different anti-vascular endothelial growth factor treatments in subretinal neovascular membrane secondary to type 2 proliferative macular telangiectasia

PURPOSE

To evaluate central macular thickness (CMT), subfoveal choroidal thickness (SFCT), and visual outcomes following different intravitreal anti-vascular endothelial growth factor (VEGF) treatments in eyes with subretinal neovascular membrane (SRNVM) due to type 2 proliferative macular telangiectasia (Mac Tel 2).

MATERIALS AND METHODS

A total of 38 eyes of 34 patients who underwent intravitreal aflibercept (IVA), intravitreal ranibizumab (IVR), or intravitreal bevacizumab (IVB) injections secondary to SRNVM due to type 2 proliferative MacTel were retrospectively reviewed. The CMT, central macular volume (CMV), best corrected visual acuity (BCVA), and SFCT were evaluated at baseline and at 2 weeks, at 1 month, and at final visits following treatment. Spectral-domain optical coherence tomography and enhanced depth optical coherence tomography were used for the analysis.

RESULTS

The mean age of the patients was 58.34 ± 12.48 years (range, 27-79 years). The mean follow-up time was 15.97 ± 6.79 months (range 5-32 months). The mean BCVA showed a statistically significant increase in each group (< 0.001). There was no statistically significant difference in BCVA changes between groups in follow-up periods. There was a significant decrease in CMT following IVA (326.4 ± 168.03 μm to 236 ± 58.33 μm) and IVB (383.71 ± 156.79 μm to 343.85 ± 146.25 μm) (p < 0.001, p = 0.004, respectively) whereas no significant decrease in CMT was observed following IVR (374.57 ± 124.28 μm to 339.71 ± 126.10 μm) (p = 0.65) between baseline and final visit. The SFCT significantly decreased following both IVB and IVR treatments (p = 0.009, p = 0.03, respectively).

CONCLUSIONS

The IVA, IVR, and IVB were found to be effective with regards to anatomical and visual outcomes in proliferative Mac Tel type 2 patients related with SRNVM. Patients receiving both IVA and IVB needed less injections compared to patients who received IVR. Moreover, IVB and IVR lead to significant decrease in SFCT whereas IVA did not show significant effect on SFCT.

Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): an open-label randomised controlled trial

BACKGROUND

Despite increasing worldwide use of anti-vascular endothelial growth factor agents for treatment of retinopathy of prematurity (ROP), there are few data on their ocular efficacy, the appropriate drug and dose, the need for retreatment, and the possibility of long-term systemic effects. We evaluated the efficacy and safety of intravitreal ranibizumab compared with laser therapy in treatment of ROP.

METHODS

This randomised, open-label, superiority multicentre, three-arm, parallel group trial was done in 87 neonatal and ophthalmic centres in 26 countries. We screened infants with birthweight less than 1500 g who met criteria for treatment for retinopathy, and randomised patients equally (1:1:1) to receive a single bilateral intravitreal dose of ranibizumab 0·2 mg or ranibizumab 0·1 mg, or laser therapy. Individuals were stratified by disease zone and geographical region using computer interactive response technology. The primary outcome was survival with no active retinopathy, no unfavourable structural outcomes, or need for a different treatment modality at or before 24 weeks (two-sided α=0·05 for superiority of ranibizumab 0·2 mg against laser therapy). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02375971.

INTERPRETATION

Between Dec 31, 2015, and June 29, 2017, 225 participants (ranibizumab 0·2 mg n=74, ranibizumab 0·1 mg n=77, laser therapy n=74) were randomly assigned. Seven were withdrawn before treatment (n=1, n=1, n=5, respectively) and 17 did not complete follow-up to 24 weeks, including four deaths in each group. 214 infants were assessed for the primary outcome (n=70, n=76, n=68, respectively). Treatment success occurred in 56 (80%) of 70 infants receiving ranibizumab 0·2 mg compared with 57 (75%) of 76 infants receiving ranibizumab 0·1 mg and 45 (66%) of 68 infants after laser therapy. Using a hierarchical testing strategy, compared with laser therapy the odds ratio (OR) of treatment success following ranibizumab 0·2 mg was 2·19 (95% Cl 0·99-4·82, p=0·051), and following ranibizumab 0·1 mg was 1·57 (95% Cl 0·76-3·26); for ranibizumab 0·2 mg compared with 0·1 mg the OR was 1·35 (95% Cl 0·61-2·98). One infant had an unfavourable structural outcome following ranibizumab 0·2 mg, compared with five following ranibizumab 0·1 mg and seven after laser therapy. Death, serious and non-serious systemic adverse events, and ocular adverse events were evenly distributed between the three groups.

FINDINGS

In the treatment of ROP, ranibizumab 0·2 mg might be superior to laser therapy, with fewer unfavourable ocular outcomes than laser therapy and with an acceptable 24-week safety profile.

FUNDING

Novartis.

OCT Angiography Biomarkers for Predicting Visual Outcomes after Ranibizumab Treatment for Diabetic Macular Edema

PURPOSE

To correlate quantitative OCT angiography (OCTA) biomarkers with clinical features and to predict the extent of visual improvement after ranibizumab treatment for diabetic macular edema (DME) with OCTA biomarkers.

DESIGN

Retrospective, longitudinal study in Taiwan.

PARTICIPANTS

Fifty eyes of 50 patients with DME and 22 eyes of 22 healthy persons, with the exception of cataract and refractive error, from 1 hospital.

METHODS

Each eye underwent OCT angiography (RTVue XR Avanti System with AngioVue software version 2017.1; Optovue, Fremont, CA), and 3×3-mm2 en face OCTA images of the superficial layer and the deep layer were obtained at baseline and after 3 monthly injections of ranibizumab in the study group. OCT angiography images also were acquired from the control group.

MAIN OUTCOME MEASURES

Five OCTA biomarkers, including foveal avascular zone (FAZ) area (FAZ-A), FAZ contour irregularity (FAZ-CI), average vessel caliber (AVC), vessel tortuosity (VT), and vessel density (VD), were analyzed comprehensively. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) also were obtained. Student t tests were used to compare the OCTA biomarkers between the study group and the control group. Linear regression models were used to evaluate the correlations between the baseline OCTA biomarkers and the changes of BCVA and CRT after treatment.

RESULTS

Eyes with DME had larger AVC, VT, FAZ-A, and FAZ-CI and lower VD than those in the control group (P < 0.001 for all). After the loading ranibizumab treatment, these OCTA biomarkers improved but did not return to normal levels. Among all biomarkers, higher inner parafoveal VD in the superficial layer at baseline correlated most significantly with visual gain after treatment in the multiple regression model with adjustment for CRT and ellipsoid zone disruption (P < 0.001). To predict visual improvement, outer parafoveal VD in the superficial layer at the baseline showed the largest area under the receiver operating characteristic curve (0.787; P = 0.004). No baseline OCTA biomarkers showed any significant correlation specifically with anatomic improvement.

CONCLUSIONS

For eyes with DME, parafoveal VD in the superficial layer at baseline was an independent predictor for visual improvement after the loading ranibizumab treatment.

SIERRA-AMD: A Retrospective, Real-World Evidence Study of Patients with Neovascular Age-Related Macular Degeneration in the United States

PURPOSE

Characterize real-world baseline visual acuity (VA) and anti-vascular endothelial growth factor (VEGF) treatment patterns in neovascular age-related macular degeneration patients in 2012-2015.

DESIGN

Retrospective, multicenter, noninterventional real-world evidence study.

PARTICIPANTS

A total of 98 821 eyes from 79 885 patients receiving intravitreal anti-VEGF therapy.

METHODS

Anonymized patient data routinely collected over 5 years were extracted from 58 United States centers to a central database using an electronic medical records system.

MAIN OUTCOME MEASURES

Baseline VA, VA change from baseline, treatment frequencies, annual anti-VEGF injections, bilateral treatment frequencies, annual total clinic visits, and noninjection clinic visits.

RESULTS

Baseline characteristics were comparable across years. Baseline VAs (Mean±standard deviation [SD] Early Treatment Diabetic Retinopathy Study [ETDRS] letters) were similar for 2012, 2013, and 2014 (53.6±23.3, 53.2±23.4, and 53.1±23.6, respectively), but was lower for 2015 (50.7±24.4). In eyes with 4-year follow-up, VA changes from baseline (ETDRS letters) were least squares means of +1.1 (95% confidence interval [CI], 1.0;1.3), -1.3 (95%CI, -1.5;-1.0), and -3.1 (95%CI, -3.5;-2.7), and -5.2 (95%CI, -6.0;-4.3) for years 1-4. Mean±SD number of injections was 7.5±1.9, 6.7±2.1, 6.6±2.3, and 6.4±2.3 for years 1-4. By year 4, 36.7% of eyes had ≤8-week dosing intervals (q8w) and 21.2% had ≥12-week dosing intervals. Eyes treated q8w increased 40% from Year 1 (32.4%) to Year 4 (45.3%). Baseline bilateral treatment frequency was 6.1%. Of the patients treated bilaterally, 32.0% received the first treatment in the better-seeing eye, and 68.0% received first treatment in an eye with vision the same as or worse than the fellow-eye. This trend was evident across all index years.

CONCLUSIONS

This real-world study describes the treatment burden, initiation and monitoring patterns, and VA outcomes at a scale and timeframe that has not been previously reported. In this cohort, baseline VA was similar for the index years 2012-2014, but lower for 2015. In patients with 4-year follow-up, both VA and injection frequency declined, whereas the proportion of eyes treated more frequently than the recommended q8w interval increased. The reduction in dosing intervals may be a consequence of intensification of treatment due to year-on-year VA loss and disease progression.

Healthcare resource use and costs of diabetic macular oedema for patients with antivascular endothelial growth factor versus a dexamethasone intravitreal implant in Korea: a population-based study

OBJECTIVES

To estimate the costs and healthcare resources of patients with diabetic macular oedema (DME) who received intravitreal antivascular endothelial growth factor (anti-VEGF) agents or a dexamethasone intravitreal implant (DEX-implant) in Korea.

DESIGN

Retrospective cohort study.

SETTING

The Korean National Health Insurance claim data from 1 January 2015 to 30 June 2017 were retrieved from the Health Insurance Review and Assessment Service.

PARTICIPANTS

Adult patients with DME who were diagnosed with diabetic retinopathy or DME and received ranibizumab, aflibercept or a DEX-implant in conjunction with intravitreal injection were included. Patients whose primary diagnoses were age-related macular degeneration or retinal vein occlusion were excluded.

MAIN OUTCOME MEASURES

Healthcare resource utilisation and costs related to DME in the 12-month postindex period.

RESULTS

During the study period, 182 patients and 414 patients were identified in the anti-VEGF and DEX-implant groups, respectively, and there was no significant difference in the demographic characteristics between the two groups. The outpatient eye care-related medical costs were US$3002.33 for the anti-VEGF group vs US$2250.35 for the DEX-implant group (p<0.0001). After adjusting the relevant covariates based on the generalised linear model, the estimated outpatient eye care-related medical costs were 33% higher in the anti-VEGF group than in the DEX-implant group (p<0.0001, 95% CI 22% to 45%). The utilisation pattern of the two groups showed no significant difference except for the number of intravitreal injections, which was higher in the anti-VEGF group (2.69±2.29) than in the DEX-implant group (2.09±1.37, p<0.001).

CONCLUSION

The average annual eye-related medical cost of the DEX-implant group was significantly lower than that of the anti-VEGF group during the study period, which was mainly due to decreased utilisation of eye care-related injections. Further long-term studies are needed.

Repeated intravitreal injections of antivascular endothelial growth factors and risk of intraocular pressure medication use

PURPOSE

To determine the risk of initiating ocular hypertension and glaucoma treatment with repeated injections of antivascular endothelial growth factors (anti-VEGF).

METHODS

A unique, retrospective cohort study was performed using a large national US medical claim database. The study population included patients who had 1 or more injections of an anti-VEGF agent. Exclusion occurred for any previous glaucoma, glaucoma suspect, glaucoma-related procedure, an ocular steroid injection, or not seeing an eye care provider at least once in each year of follow-up. Cohorts were divided into quartiles based on the number of injections performed over the follow-up period. Patients were observed for 2 and 3 years. The main outcome measure was defined as any new prescription for an ocular antihypertensive medication with a concurrent diagnosis of glaucoma, glaucoma suspect, or ocular hypertension. Multivariate logistic regression determined the odds of initiating glaucoma treatment in each injection quartile while controlling for numerous covariates. Sensitivity analysis assessed outcomes that included new medication only as well as a new medication plus diagnosis of glaucoma.

RESULTS

In total, 17,113 and 9992 patients met 2- and 3-year observation end points, respectively. The multivariate odds ratio for initiating glaucoma treatment at 2 years was higher in the highest quartile (OR 1.96, 95% CI 1.39-2.76, p < 0.001) compared with the lowest. The 3-year comparison had similar results with increased odds in the highest quartile (OR 1.51, 95% CI 1.07-2.13, p = 0.006) compared with the lowest. Sensitivity analyses also showed similar results with more injections being associated with initiating treatment (p < 0.053 for all comparisons).

CONCLUSIONS

Repeated anti-VEGF injections are associated with an increased odds of initiating treatment for ocular hypertension and glaucoma.