Quarterly Anti-Vascular Endothelial Growth Factor Dosing for Neovascular Age-Related Macular Degeneration: Real-World Clinical Outcomes

BACKGROUND AND OBJECTIVE

Characterize eyes managed with quarterly intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

Treatment-naïve nAMD eyes managed predominately using a treat-and-extend approach that received five or more consecutive quarterly injections from 2005 to 2017.

RESULTS

One hundred fifty eyes were retrospectively identified. During quarterly dosing, a mean of 9.8 injections were given over a mean of 29 months. Ninety-one eyes (61%) had no exudative disease recurrence during quarterly dosing. Thirty-three eyes (22%) experienced exudative activity recurrence, with a mean cumulative yearly recurrence rate of 12% and a mean 6-letter loss of visual acuity (VA). Twenty-four eyes (16%) stopped quarterly treatments; nine (38%) of these subsequently experienced exudative activity recurrence with a mean 8-letter VA loss.

CONCLUSION

In this real-world analysis of nAMD managed with quarterly dosing over a mean of more than 2 years' follow-up, 22% experienced disease recurrence during quarterly dosing, and 38% of eyes that stopped quarterly dosing experienced subsequent exudative disease recurrence. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e250-e256.].

PHOTOCOAGULATION VERSUS RANIBIZUMAB FOR PROLIFERATIVE DIABETIC RETINOPATHY: Should Baseline Characteristics Affect Choice of Treatment?

PURPOSE

Among eyes with proliferative diabetic retinopathy, identify whether baseline characteristics impact the benefit of ranibizumab over panretinal photocoagulation (PRP) in DRCR.net Protocol S.

METHODS

Participants had proliferative diabetic retinopathy, visual acuity of 20/320 or better, and no previous PRP. Eyes were randomized to PRP or intravitreous 0.5-mg ranibizumab.

RESULTS

Ranibizumab was superior to PRP for change in visual acuity and development of vision-impairing central-involved diabetic macular edema over 2 years (P < 0.001). Among 25 characteristics, there were none in which participants assigned to PRP had superior outcomes relative to ranibizumab-assigned participants. The relative benefit of ranibizumab over PRP for change in visual acuity seemed greater in participants with higher mean arterial pressure (P = 0.03), without previous focal/grid laser (P = 0.03), with neovascularization of the disk and elsewhere on clinical examination (P = 0.04), and with more advanced proliferative diabetic retinopathy on photographs (P = 0.02). For development of vision-impairing central-involved diabetic macular edema, the relative benefit of ranibizumab over PRP seemed greater among nonwhite participants (P = 0.01) and those with higher mean arterial pressure (P = 0.01).

CONCLUSION

There were no characteristics identified in which outcomes were superior with PRP compared with ranibizumab. These exploratory analyses provide additional support that ranibizumab may be a reasonable alternative to PRP for proliferative diabetic retinopathy over a 2-year period.

Efficacy and Safety of Ranibizumab in Asian Patients with Branch Retinal Vein Occlusion: Results from the Randomized BLOSSOM Study

PURPOSE

To assess the efficacy and safety profile of intravitreal ranibizumab 0.5 mg in Asian patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO).

DESIGN

A 12-month, phase III, double-masked study.

PARTICIPANTS

A total of 283 patients with BRVO.

METHODS

Patients aged ≥18 years were randomized (2:1) to receive ranibizumab 0.5 mg or sham. The ranibizumab group received a minimum of 3 monthly intravitreal injections until stable maximal visual acuity (VA) was achieved followed by an individualized VA stabilization criteria-driven pro re nata (PRN) regimen. Patients in the sham group received sham injections up to month 5 and could receive ranibizumab 0.5 mg PRN from month 6.

MAIN OUTCOME MEASURES

Mean average change in best-corrected VA (BCVA) from baseline to month 1 through month 6 and safety up to month 12.

RESULTS

At baseline, patients' mean (standard deviation [SD]) BCVA and central subfield thickness (CSFT) were 57.4 (11.7) letters and 525 (193.4) μm, respectively. Compared with sham, ranibizumab treatment resulted in superior VA gains. The least squares (LS) mean average change in BCVA from baseline to month 1 to month 6 in ranibizumab and sham groups was +12.5 and +5.0 letters, respectively (LS mean difference between ranibizumab vs. sham: +7.5 letters [95% confidence interval, 5.5-9.5], 1-sided P < 0.001). The LS mean change from baseline at month 12 in the ranibizumab versus sham groups in BCVA was +16.4 (14.9-17.8) versus +11.4 (9.3-13.5) letters and in CSFT was -280.0 (-291.6 to -268.4) versus -269.7 (-286.2 to -253.1) μm. The mean (SD) number of injections over 12 months was 7.0 (2.55) in the ranibizumab group and 3.6 (1.60) in the sham with ranibizumab group. No new safety findings were reported.

CONCLUSIONS

In Asian patients with BRVO, individualized PRN ranibizumab treatment was statistically superior to sham at month 6 and led to early visual gains that were maintained up to 12 months. Results from the sham group indicate the importance of early treatment in achieving optimal visual outcomes in BRVO. The safety of ranibizumab in this study was consistent with the well-established safety profile of ranibizumab.

Five-Year Real-World Outcomes of Occult and Classic Choroidal Neovascularization: Data From the Fight Retinal Blindness! Project

PURPOSE

To compare 5-year real-world outcomes of eyes with classic and occult choroidal neovascularization (CNV) treated with anti-vascular endothelial growth factor (anti-VEGF) injections.

DESIGN

Retrospective analysis from a prospectively designed observational database.

METHODS

Treatment-naïve eyes diagnosed with occult or minimally or predominantly classic CNV that commenced anti-VEGF treatment between January 2007 and December 2012 were identified from a registry of neovascular age-related macular degeneration (nAMD) treatment outcomes. Baseline characteristics, visual acuity (VA) at 5 years, change in VA, time to first inactivation, number of injections, and proportion of visits graded with active nAMD over the 5 years were compared between the 3 groups.

RESULTS

A total of 1929 eyes from 1730 subjects (1196 occult, 289 minimally classic, and 444 predominantly classic CNV) were analyzed. Baseline VA (mean [standard deviation]) was higher in occult CNVs (56.9 [17.4] letters) than in minimally (52.9 [19.7] letters) and predominantly (49.1 [19.9] letters) classic CNVs (P = .003 and P < .0001, respectively). VA change was similar across the groups. At 5 years eyes with occult CNVs still had better VA than other CNVs. Age, lesion size, and baseline VA, but not CNV type, significantly affected final VA in the multivariate model. Predominantly classic CNVs became inactive sooner and were overall less active than other CNV types. The number of injections received was similar across the groups.

CONCLUSIONS

Eyes with occult CNVs had overall a better VA than other CNVs. The difference in final VA was not significant after adjusting for baseline VA. Five-year outcomes and treatment patterns were not affected by the lesion type.

Intravitreal Ranibizumab With Panretinal Photocoagulation Followed by Trabeculectomy Versus Visco-Trabeculotomy in Management of Neovascular Glaucoma

PURPOSE

The aim of the current study was to compare visco-trabeculotomy (VT) with standard trabeculectomy with mitomycin C (Trab-MMC) in the treatment of quiescent neovascular glaucoma (NVG).

METHODS

The study was conducted on 51 eyes of 51 patients presenting with NVG and treated at an Ophthalmic Center in Egypt between March 2014 and April 2017. All study eyes were subjected to a standard protocol of intravitreal injection of ranibizumab followed by panretinal photocoagulation. Eyes were then randomized to either VT or Trab-MMC. Study eyes were followed up for at least 18 months. Success was defined as an intraocular pressure of ≤21 mm Hg and without vision-threatening complications. Complications were noted.

RESULTS

The mean ± SD (range, median) age of the study patients was 54.1 ± 6.4 (40-67, 54.5) and 52.4 ± 8.8 (38-66, 53) years in the VT (26 eyes) and Trab-MMC (25 eyes) groups, respectively (P = 0.45). The mean ± SD (range, median) intraocular pressure (IOP) of the study eyes was 45.19 ± 2.97 (39-52, 45.5) and 45.64 ± 3.56 (3-53, 45) mm Hg on maximal medical therapy in the VT and Trab-MMC groups, respectively (P = 0.61). At 18 months' follow-up, the mean ± SD (range, median) IOP of the study eyes was 18.19 ± 2.0 (16-23, 17) and 19.92 ± 2.6 (18-26, 19) mm Hg in the VT and Trab-MMC groups, respectively (P = 0.004). There was no difference in postoperative antiglaucoma medication between the 2 groups (P = 0.62). Complications included hyphema and Descemet split in the VT group and an IOP spike in the Trab-MMC group. Success rates were 84.6% and 80% in the VT and Trab-MMC groups, respectively (P = 0.726).

CONCLUSIONS

Both VT and Trab-MMC groups are effective in reducing the IOP in cases of NVG after control of neovascularization with anti-vascular endothelial growth factor and pan retinal photocoagulation.

One- and two-year visual outcomes from the Moorfields age-related macular degeneration database: a retrospective cohort study and an open science resource

OBJECTIVES

To analyse treatment outcomes and share clinical data from a large, single-centre, well-curated database (8174 eyes/6664 patients with 120 756 single entries) of patients with neovascular age-related macular degeneration (AMD) treated with anti-vascular endothelial growth factor (VEGF). By making our depersonalised raw data openly available, we aim to stimulate further research in AMD, as well as set a precedent for future work in this area.

SETTING

Retrospective, comparative, non-randomised electronic medical record (EMR) database cohort study of the UK Moorfields AMD database with data extracted between 2008 and 2018.

PARTICIPANTS

Including one eye per patient, 3357 eyes/patients (61% female). Extraction criteria were ≥1 ranibizumab or aflibercept injection, entry of 'AMD' in the diagnosis field of the EMR and a minimum of 1 year of follow-up. Exclusion criteria were unknown date of first injection and treatment outside of routine clinical care at Moorfields before the first recorded injection in the database.

MAIN OUTCOME MEASURES

Primary outcome measure was change in VA at 1 and 2 years from baseline as measured in Early Treatment Diabetic Retinopathy Study letters. Secondary outcomes were the number of injections and predictive factors for VA gain.

RESULTS

Mean VA gain at 1 year and 2 years were +5.5 (95% CI 5.0 to 6.0) and +4.9 (95% CI 4.2 to 5.6) letters, respectively. Fifty-four per cent of eyes gained ≥5 letters at 2 years, 63% had stable VA (±≤14 letters), 44% of eyes maintained good VA (≥70 letters). Patients received a mean of 7.7 (95% CI 7.6 to 7.8) injections during year 1 and 13.0 (95% CI 12.8 to 13.2) injections over 2 years. Younger age, lower baseline VA and more injections were associated with higher VA gain at 2 years.

CONCLUSION

This study benchmarks high quality EMR study results of real life AMD treatment and promotes open science in clinical AMD research by making the underlying data publicly available.

Randomized Trial of Treat and Extend Ranibizumab With and Without Navigated Laser Versus Monthly Dosing for Diabetic Macular Edema: TREX-DME 2-Year Outcomes

PURPOSE

To prospectively evaluate a treat and extend algorithm of ranibizumab with and without navigated laser to monthly dosing for center-involving diabetic macular edema.

DESIGN

This was a multicenter, randomized, clinical trial.

METHODS

One hundred fifty eyes were randomized into 3 cohorts: monthly (n = 30), treat and extend without laser photocoagulation (TREX; n = 60), and treat and extend with angiography-guided laser photocoagulation (GILA; n = 60). Monthly cohort eyes received ranibizumab 0.3 mg every 4 weeks. TREX and GILA cohort eyes received 4 monthly injections of ranibizumab 0.3 mg followed by a treat and extend dosing strategy. GILA cohort eyes also received navigated focal laser at month 1 and again every 3 months as needed. The primary outcomes included the mean change in best-corrected visual acuity and central retinal thickness and the number of injections from baseline to 2 years.

RESULTS

At 2 years, mean best-corrected visual acuity and central retinal thickness improved by 7.5, 9.6, and 9.0 letters (P = .75) and 139, 140, and 175 μm (P = .09), in the monthly, TREX, and GILA cohorts, respectively. The mean number of injections was significantly reduced in both the TREX (18.9) and GILA (17.5) cohorts compared with the monthly cohort (24.7, P < .001). Between the TREX and GILA cohorts, there was no significant difference in the mean treatment interval, mean maximal treatment interval, or percentage of eyes extended to 12 weeks. The total 2-year incidence of Anti-Platelet Trialists' Collaboration events was 6.7%.

CONCLUSION

The treat and extend algorithm of ranibizumab in the TREX-DME trial resulted in significantly fewer injections and yielded visual and anatomic gains comparable to monthly dosing at 2 years.

Anti-vascular endothelial growth factor treatment for retinal conditions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the comparative effectiveness and safety of intravitreal bevacizumab, ranibizumab and aflibercept for patients with choroidal neovascular age-related macular degeneration (cn-AMD), diabetic macular oedema (DMO), macular oedema due to retinal vein occlusion (RVO-MO) and myopic choroidal neovascularisation (m-CNV).

DESIGN

Systematic review and random-effects meta-analysis.

METHODS

Multiple databases were searched from inception to 17 August 2017. Eligible head-to-head randomised controlled trials (RCTs) comparing the (anti-VEGF) drugs in adult patients aged ≥18 years with the retinal conditions of interest. Two reviewers independently screened studies, extracted data and assessed risk of bias.

RESULTS

19 RCTs involving 7459 patients with cn-AMD (n=12), DMO (n=3), RVO-MO (n=2) and m-CNV (n=2) were included. Vision gain was not significantly different in patients with cn-AMD, DMO, RVO-MO and m-CNV treated with bevacizumab versus ranibizumab. Similarly, vision gain was not significantly different between cn-AMD patients treated with aflibercept versus ranibizumab. Patients with DMO treated with aflibercept experienced significantly higher vision gain at 12 months than patients receiving ranibizumab or bevacizumab; however, this difference was not significant at 24 months. Rates of systemic serious harms were similar across anti-VEGF agents. Posthoc analyses revealed that an as-needed treatment regimen (6-9 injections per year) was associated with a mortality increase of 1.8% (risk ratio: 2.0 [1.2 to 3.5], 2 RCTs, 1795 patients) compared with monthly treatment in cn-AMD patients.

CONCLUSIONS

Intravitreal bevacizumab was a reasonable alternative to ranibizumab and aflibercept in patients with cn-AMD, DMO, RVO-MO and m-CNV. The only exception was for patients with DME and low visual acuity (<69 early treatment diabetic retinopathy study [ETDRS] letters), where treatment with aflibercept was associated with significantly higher vision gain (≥15 ETDRS letters) than bevacizumab or ranibizumab at 12 months; but the significant effects were not maintained at 24 months. The choice of anti-VEGF drugs may depend on the specific retinal condition, baseline visual acuity and treatment regimen.

PROSPERO REGISTRATION NUMBER

CRD42015022041.

Five-year treatment outcomes following intravitreal ranibizumab injections for neovascular age-related macular degeneration in Japanese patients

PURPOSE

To assess the real-world 5-year treatment outcomes of ranibizumab therapy in Japanese patients with neovascular age-related macular degeneration (AMD).

METHODS

This was a retrospective, observational, and open-label effectiveness study that included 295 eyes. The participants were patients with treatment-naïve neovascular AMD who received intravitreal ranibizumab (IVR) monthly injection at least three times as the loading phase, followed by further injections as needed (pro re nata (PRN)) and follow-up assessments for 5 years. Outcomes were determined at least 5 years after the first ranibizumab injection.

RESULTS

Mean logMAR best-corrected visual acuity (BCVA) at baseline was 0.52. The mean BCVA significantly improved after three loading injections; however, it declined gradually. The BCVA at 1 year was significantly better than the baseline BCVA, whereas the 3-year, 4-year, and 5-year BCVA values were significantly lower than the baseline values. The average central foveal thickness improved significantly from 366 ± 125 μm to 268 ± 134 μm (p < 0.0001). Macular atrophy was significantly more likely to occur in cases with classic choroidal neovascularization (CNV) than in cases with other AMD (p = 0.01).

CONCLUSIONS

IVR is well tolerated in eyes with AMD. However, a PRN regimen for AMD may have limited real-world effectiveness for long-term maintenance of improved visual acuity. Macular atrophy may occur more frequently in classic CNV. To maintain good vision, IVR treatment should be started earlier and performed continuously.

Visual Outcomes Following Intravitreal Ranibizumab for Diabetic Macular Edema in a Pro Re Nata Protocol from Baseline: A Real-World Experience

PURPOSE

To investigate long-term outcomes of pro re nata (PRN) treatment protocol of ranibizumab for diabetic macular edema (DME) adopted from the first month of therapy without 3 loading doses.

DESIGN

Retrospective interventional study.

METHODS

We analyzed 180 eyes of 144 patients treated with ranibizumab for DME with a minimum follow-up of 1 year during December 2013 to December 2017. Data of all patients with treatment-naive center-involving DME who received at least 1 intravitreal injection of ranibizumab during the study period were drawn from a locally adapted electronic form for DME. The primary outcome measure was change in best-corrected visual acuity (BCVA) from baseline at 1-year follow-up, with intergroup comparisons in BCVA between eyes receiving 1, 2, and 3 injections in the first 3 months of treatment.

RESULTS

The mean baseline BCVA was 0.47 ± 0.30 logMAR, which improved to 0.38 ± 0.3 logMAR (P = 0.003) at 3 months and stabilized at 0.35 ± 0.27 logMAR at 1 year (P = 0.46 vs BCVA at 3 months) and 0.34 ± 0.26 logMAR at 2 years of follow-up (P = 0.44 vs BCVA at 3 months). At 3 months, 24 eyes (13%) underwent 1 intravitreal injection, 52 eyes (29%) had 2 injections, and the majority (n = 104 eyes, 58%) had 3 injections on a monthly basis. During the first year, the group that received only 1 injection in the first 3 months also required fewer injections and fewer follow-up visits compared with those receiving 2 or 3 injections in the first 3 months.

CONCLUSIONS

One-third of eyes with DME responded well to PRN treatment strategy from the first month without 3 loading doses of ranibizumab. Baseline visual acuity is the best predictor of vision at 1 and 2 years of follow-up.

Five-Year Follow-up of Nonfibrotic Scars in the Comparison of Age-Related Macular Degeneration Treatments Trials

PURPOSE

To describe changes in visual acuity (VA) and macular morphologic features at 5 years in eyes with nonfibrotic scar (NFS) identified at 1 year in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

DESIGN

Prospective cohort study within a randomized clinical trial.

PARTICIPANTS

Participants in CATT.

METHODS

Participants assigned to ranibizumab or bevacizumab and to 1 of 3 dosing regimens were released from the clinical trial protocol after 2 years and recalled at 5 years. Nonfibrotic scar was identified on color images at year 1 as flat, small, well-circumscribed areas of pigmentation with varying degrees of central hypopigmentation without exposure of underlying choroidal vessels at the site of baseline choroidal neovascularization. Follow-up images were assessed for changes in and around NFS.

MAIN OUTCOME MEASURES

Pigmentation changes, VA, development of fibrotic scar (FS), nongeographic atrophy (NGA), geographic atrophy (GA), retinal fluid on OCT, and fluorescein leakage.

RESULTS

Among 474 eyes with images obtained at 1, 2, and 5 years, 39 (8.2%) showed NFS at 1 year with a mean VA of 80 letters (Snellen equivalent, 20/25). Among these eyes, FS developed in 5% at 2 years and 28% at 5 years. Nongeographic atrophy was observed in 34%, 47%, and 65% of eyes at 1, 2, and 5 years, respectively. Geographic atrophy developed in 5% of eyes at 2 years and 21% at 5 years. Among eyes with NFS, FS, or no scar at 1 year, mean VA at 5 years was 73 letters (20/32), 48 letters (20/100), and 62 letters (20/63), respectively. At 5 years, NFS eyes demonstrated less GA, less intraretinal fluid, more subretinal fluid, and less subretinal pigment epithelium fluid (all P < 0.01). Among NFS eyes, mean thickness of the retina, subretinal tissue complex, and total retina did not change across years 1 to 5 (P > 0.50). The proportion of eyes with fluid on OCT also did not change (P = 0.36). Subretinal hyperreflective material disappeared by 5 years in 40% of eyes with NFS.

CONCLUSIONS

These results indicate that, on average, eyes with NFS after anti-VEGF treatment have good VA not only at 1 and 2 years, but also through 5 years.

Current Outcomes of Anti-VEGF Therapy in the Treatment of Macular Edema Secondary to Central Retinal Vein Occlusions: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the current anti-vascular endothelial growth factor (anti-VEGF) treatments for macular edema due to central retinal vein occlusions.

METHODS

PubMed, EMBASE, the Cochrane Library were systematically searched for studies between January 2013 and July 2018. Reference lists of published articles were searched and if necessary, authors were contacted to provide additional data. Meta-analysis was performed using Comprehensive Meta-analysis software. The best-corrected visual acuity (BCVA), central foveal thickness (CFT), injection frequency, and adverse events were evaluated.

RESULTS

Seventeen studies involving 1070 eyes were included in the meta-analysis. The mean differences in 12-month changes in BCVA and CFT were 14.4 ETDRS letters (P < 0.001) and -289.2 μm (P < 0.001), respectively. Visual acuity gains were maintained at 24 months (14.2 letters, P < 0.001) and CFT continued to reduce (-327.45 μm, P < 0.001). The incidence of severe adverse events was low and similar across all anti-VEGF therapies. Prospective studies administered a greater number of injections compared with retrospective studies, being 6.6 and 4.4 injections, respectively over 12 months (P < 0.001).

CONCLUSIONS

Intravitreal treatment with anti-VEGF agents demonstrated significant anatomical and functional gains in treating macular edema due to central retinal vein occlusions.

Intravitreal ranibizumab injection at the end of vitrectomy for diabetic vitreous hemorrhage (Observational Study)

To evaluate the outcomes and complications of intravitreal injections of ranibizumab in patients during pars plana vitrectomy for treatment of diabetic vitreous hemorrhage. This retrospective, observational, comparative study included 103 patients (103 eyes) who underwent pars plana vitrectomy for treatment of diabetic vitreous hemorrhage. Sixty-six patients received an intravitreal injection of 0.05 mg (0.05 cc) of ranibizumab at the end of surgery. Main outcome measures were the occurrence of recurrent early vitreous hemorrhage, reoperation, intraocular pressure, best corrected visual acuity. Mean follow-up time was 6 months. The rate of rebleeding in the intravitreal ranibizumab (IVR) group was 6.1% (4 eyes), which is significantly lower than the control group (24.3%, 9 eyes, P < .01). The incidence of postoperative diabetic vitreous hemorrhage (PDVH) was significantly lower in the IVR group than the control group, OR=0.26, 95% CI= (0.06, 0.95). Visual acuity 6 months after operation was better in IVR group (P<.01) There was no difference in mean intraocular pressure between the 2 groups (P=.56). The present clinical study suggests that intravitreal injection of ranibizumab is effective in the prevention of postoperative diabetic vitreous hemorrhage in eyes undergoing pars plana vitrectomy for the treatment of diabetic vitreous hemorrhage.

The Port Delivery System with Ranibizumab for Neovascular Age-Related Macular Degeneration: Results from the Randomized Phase 2 Ladder Clinical Trial

PURPOSE

To evaluate the safety and efficacy of the Port Delivery System with ranibizumab (PDS) for neovascular age-related macular degeneration (nAMD) treatment.

DESIGN

Phase 2, multicenter, randomized, active treatment-controlled clinical trial.

PARTICIPANTS

Patients diagnosed with nAMD within 9 months who had received 2 or more prior anti-vascular endothelial growth factor intravitreal injections and were responsive to treatment.

METHODS

Patients were randomized 3:3:3:2 to receive the PDS filled with ranibizumab 10 mg/ml, 40 mg/ml, 100 mg/ml, or monthly intravitreal ranibizumab 0.5-mg injections.

MAIN OUTCOME MEASURES

Time to first implant refill assessed when the last enrolled patient completed the month 9 visit (primary efficacy end point), improvement in best-corrected visual acuity (BCVA) and central foveal thickness (CFT), and safety.

RESULTS

The primary analysis population was 220 patients, with 58, 62, 59, and 41 patients in the PDS 10-mg/ml, PDS 40-mg/ml, PDS 100-mg/ml, and monthly intravitreal ranibizumab 0.5-mg arms, respectively. Median time to first implant refill was 8.7, 13.0, and 15.0 months in the PDS 10-mg/ml, PDS 40-mg/ml, and PDS 100-mg/ml arms, respectively. At month 9, the adjusted mean BCVA change from baseline was ‒3.2 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, ‒0.5 ETDRS letters, +5.0 ETDRS letters, and +3.9 ETDRS letters in the PDS 10-mg/ml, PDS 40-mg/ml, PDS 100-mg/ml, and monthly intravitreal ranibizumab 0.5-mg arms, respectively. At month 9, the adjusted mean CFT change from baseline was similar in the PDS 100-mg/ml and monthly intravitreal ranibizumab 0.5-mg arms. The optimized PDS implant insertion and refill procedures were generally well tolerated. After surgical procedure optimization, postoperative vitreous hemorrhage rate was 4.5% (7/157; 1 event classified as serious). There was no evidence of implant clogging.

CONCLUSIONS

In the phase 2 Ladder trial, the PDS was generally well tolerated and demonstrated a dose response across multiple end points in patients with nAMD. The PDS 100-mg/ml arm showed visual and anatomic outcomes comparable with monthly intravitreal ranibizumab 0.5-mg injections but with a reduced total number of ranibizumab treatments. The PDS has the potential to reduce treatment burden in nAMD while maintaining vision.

Characterization of the Systemic Findings of Patients Undergoing Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in Routine Clinical Practice

BACKGROUND AND OBJECTIVES

Previous studies have validated that baseline visual acuity (VA) can predict a variance response to anti-vascular endothelial growth factor (VEGF) treatment. However, little is known about the initial systemic presentation of diabetic macular edema (DME) in clinical practice. The aim of this study is to report the baseline systemic findings of patients presenting with DME who received anti-VEGF in clinical practice.

PATIENTS AND METHODS

A retrospective chart review of patients with DME presenting between April 2012 and December 2016 was performed.

RESULTS

Data from 638 patients were retrieved. The average patient age was 63.1 years (±11.6 years), and 53% were male. There were 95.6% type II diabetics with an average HgA1c of 8.1% (range: 5.1% to 14.5%). Insulin use was present in 67%, biguanides in 43%, sulfonylureas in 32.8%, DDP4 inhibitors in 11.8%, thiazolidinediones in 3.9%, and D-phenylalanine derivatives in 0.94%. Hypertension was present in 78.4% of patients, cardiac comorbidities in 29.3%, peripheral vascular disease in 16.5%, and renal insufficiency in 22.6%. Patients were then split into two different cohorts based on VA (ETDRS < 70 and ETDRS ≥ 70), and variables were compared between groups.

CONCLUSION

It was shown that older age, hypertension, elevated creatinine, elevated high-density lipoprotein cholesterol, and decreased biguanide use were positively associated with worse presenting VA. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:16-24.].

Monthly Versus Treat-and-Extend Ranibizumab for Diabetic Macular Edema: A Prospective, Randomized Trial

BACKGROUND AND OBJECTIVE

Compare fixed monthly dosing of ranibizumab to treat-and-extend (T&E) ranibizumab during a period of 24 months for diabetic macular edema (DME) treatment.

PATIENTS AND METHODS

Single-center, randomized, prospective pilot study that included 20 eyes of 20 subjects. Patients' best-corrected visual acuity (BCVA) was less than or equal to 20/40 and central foveal thickness on spectral-domain optical coherence tomography was greater than 325 µm. Intravitreal ranibizumab was dosed monthly or by protocol-specified treat-and-extend. Primary outcome was mean change in mean BCVA. Institutional review board approval was obtained.

RESULTS

At month 24 (M24), there was a mean 8.3-letter gain in the monthly treatment group and an 8.5-letter gain in the T&E group (P = .082; 90% confidence interval). The average change from baseline BCVA was not statistically significantly different at any timepoint. At M24, the median number of injections in the monthly and T&E groups were 22.5 and 18.5, respectively (P = .287).

CONCLUSIONS

Visual acuity with monthly dosing appears equivalent to T&E dosing during the course of 24 months. There was a trend toward a lower injection burden in the T&E arm. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e191-e197.].

Frequency of Bevacizumab and Ranibizumab Injections for Diabetic Macular Edema in Medicare Beneficiaries

BACKGROUND AND OBJECTIVE

To describe the frequency and variation of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) and ranibizumab (Lucentis; Genentech, South San Francisco, CA) use for diabetic macular edema (DME) in the United States.

PATIENTS AND METHODS

The authors obtained a 5% sample of Medicare beneficiaries from the Medicare Part B claims files from 2010 to 2013 and identified beneficiaries with DME using the ICD-9-CM code (362.07). Geographic variation was examined by comparing injection frequencies of bevacizumab and ranibizumab across U.S. census divisions using Chi-squared analysis.

RESULTS

The sample included 5,290 Medicare beneficiaries with DME. Overall, there was greater bevacizumab use (86.4%) compared to ranibizumab use (13.6%). Frequency of bevacizumab use was highest in the Mountain division (92.2%) and lowest in the Mid-Atlantic (76.0%). The total number of bevacizumab and ranibizumab injections for DME varied significantly between U.S. census divisions (P < .0001).

CONCLUSION

Bevacizumab is used more frequently than ranibizumab for the treatment of DME among Medicare beneficiaries, with significant geographic variation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:241-244.].

Longitudinal Quantification of Retinal Nonperfusion in the Macula of Eyes With Retinal Vein Occlusion Receiving Anti-VEGF Therapy: Secondary Analysis of the WAVE Randomized Trial

BACKGROUND AND OBJECTIVE

Longitudinal quantification of retinal nonperfusion (RNP) in eyes with retinal vein occlusion (RVO) undergoing anti-vascular endothelial growth factor therapy.

PATIENTS AND METHODS

Thirty eyes with ischemic RVO were randomized to ranibizumab (Lucentis; Genentech, South San Francisco, CA) (monotherapy) or ranibizumab plus peripheral laser (combination therapy) in a 12-month, prospective trial. RNP on fluorescein angiography was quantified within the macula through 12 months of follow-up.

RESULTS

Baseline mean macular RNP areas were 5.04 mm² and 8.30 mm² in the monotherapy (n = 5) and combination therapy (n = 15) cohorts, respectively. Through month 12, mean macular RNP area increased 0.36 mm² and 0.53 mm² in the monotherapy and combination therapy cohorts, respectively (P = .77). Marked, progressive RNP was observed in three eyes (12%). No areas of reperfusion were detected in any eye.

CONCLUSION

Among ischemic RVO eyes in WAVE, macular RNP was common at baseline and remained stable over time in most eyes, though marked RNP progression occurred in a minority of eyes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:258-264.].

Comparison of intravitreal bevacizumab and ranibizumab used for myopic choroidal neovascularization: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the effect of intravitreal bevacizumab (IVB) and ranibizumab (IVR) for the treatment of choroidal neovascularization (CNV) secondary to pathologic myopia (PM) by meta-analysis.

METHODS

Pertinent publications of randomized controlled trials (RCTs) were identified through systemic searches of PubMed, EMBASE, Web of science, Cochrane Library, clinicaltrials.gov, CNKI, CQVIP, and Wanfang database. All comparative studies of IVB or IVR as treatment for CNV secondary to pathologic myopia were included. Meta-analysis of these RCTs was performed using Review Manager 5.3 software. The χ test and I values were used to analyze heterogeneity. Measurements included best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

A total of 3 randomized controlled clinical trials involving 158 eyes were included, 81 eyes in IVB group and 77 eyes in IVR group. Compared with baseline, at 1, 3, 6, and 12 months after IVB or IVR treatment, BCVA was significantly increased. Change of BCVA at 1, 3, 6, and 12 months did not vary significantly between IVB and IVR group (1 month: Z = 0.30, 95% CI = -0.08 to 0.11, P = .76; 3 months: Z = 0.36, 95% CI = -0.10 to 0.15, P = .72; 6 months: Z = 0.17, 95% CI = -0.10 to 0.12, P = .86; 12 months: Z = 0.64, 95% CI = -0.15 to 0.08, P = .52).

CONCLUSION

Both IVR and IVB can significantly improve BCVA of eyes with mCNV, but there was no significant difference between the 2 therapies on the treatment of mCNV.

Clinical preferences and trends of anti-vascular endothelial growth factor treatments for diabetic macular edema in Japan

AIMS/INTRODUCTION

To determine the current clinical preferences of anti-vascular endothelial growth factor (VEGF) treatment protocols for diabetic macular edema (DME) in Japan.

MATERIALS AND METHODS

This was a descriptive cross-sectional study. Answers to a questionnaire consisting of 16 questions were obtained from 176 of 278 (63.3%) surveyed ophthalmologists.

RESULTS

The results showed that 81.2% preferred intravitreal injections of anti-VEGF antibodies as the first-line therapy. The most important indicators for beginning anti-VEGF therapy were: the best-corrected visual acuity in 44.3% and the retinal thickness in 30.7%. In the loading phase, 53.4% preferred a single injection, and in the maintenance phase, 75.0% preferred the pro re nata regimen. Financial limitation (85.8%) was reported as the most important difficulty in the treatment. For combination therapy with anti-VEGF treatment, panretinal photocoagulation, focal photocoagulations and a sub-Tenon steroid injection were preferred. The contraindications for anti-VEGF therapy were: prior cerebral infarction (72.7%). Regarding the use of both approved anti-VEGF agents in Japan, ranibizumab and aflibercept, 39.8% doctors used them appropriately.

CONCLUSIONS

Our results present the current clinical preferences of anti-VEGF treatment for DME in Japan. The best-corrected visual acuity and the retinal thickness are important indicators to institute this therapy. The majority of the ophthalmologists use anti-VEGF treatment as first-line therapy and prefer the 1 + pro re nata regimen.

Omega-3 and ranibizumab for age-related macular degeneration: A systematic review protocol

BACKGROUND

Omega-3 and ranibizumab (O3R) has been reported to treat age-related macular degeneration (ARMD) effectively. However, up to the present, no systematic review specifically addressed the efficacy of O3R for the treatment of ARMD. Therefore, in this study, we will propose to assess the efficacy and safety of O3R for the treatment of ARMD.

METHODS

We will search PUMBED, EMBASE, CINAHI, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, Wanfang Data, as well as the gray literature from inception up to the present. We will accept randomized controlled trials for assessing the efficacy and safety of O3R for ARMD. The primary outcomes include change in best corrected visual acuity and central retinal thickness. The secondary outcomes consist of changes in subfoveal choroidal thickness, macular atrophy, retinal average sensitivity, contrast sensitivity, glare disability, and quality of life. In addition, incidence and severity of adverse events will also be evaluated. Cochrane Collaboration tool will be used to assess the risk of bias for each included study. In addition, Grading of Recommendations Assessment, Development, and Evaluation tool will be utilized to assess the overall strength of the evidence. Two authors will independently carry out all procedures and any divergences will be solved through discussion with a third author. If it is possible, we will conduct meta-analysis and subgroup analysis concerning different interventions, risk of bias, and outcome measurements.

RESULTS

In this proposed study, we outline details of the aims and methods of efficacy and safety of O3R for the treatment of ARMD.

CONCLUSION

The findings of this systematic review will summarize current evidence of O3R for the treatment of patients with ARMD.

DISSEMINATION AND ETHICS

The results of the present study are expected to be published by peer-reviewed journals. This is a literature-based study. Thus, ethical approval is unnecessary for this study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019121177.

The Role of Proportional Reflux During Pars Plana Vitrectomy for Tractional Retinal Detachments

BACKGROUND AND OBJECTIVE

To discuss the role of proportional reflux hydrodissection (PRH) during pars plana vitrectomy (PPV) in eyes with diabetic tractional retinal detachment (TRD).

PATIENTS AND METHODS

In this retrospective study, records of patients with diabetic TRD involving the fovea undergoing PPV with the help of PRH between January 2015 to March 2017 were noted. PRH relies on the Constellation system's proportional reflux feature. The mean age, gender, and pre- and postoperative best-corrected visual acuity (BCVA) were noted. Minimum follow-up period of 3 months was ascertained.

RESULTS

Thirty-three patients were included. Preoperative and postoperative BCVA were 1.80 logMAR units and 1.20 logMAR units, respectively. Fifteen patients also received preoperative intravitreal ranibizumab. Twelve percent needed the help of a second instrument. Thirty-three percent developed intraoperative iatrogenic breaks, and 39.39% needed oil/gas tamponade. All patients had successful reattachments at 3-month follow-up.

CONCLUSIONS

PRH is simple, cost-effective, surgeon-friendly, and highly controlled technique helpful in managing diabetic TRD. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:113-115.].

Analgesic Effect of a Single Drop of Nepafenac 0.3% on Pain Associated with Intravitreal Injections: A Randomized Clinical Trial

PURPOSE

To evaluate the analgesic effect of nepafenac 0.3% in patients undergoing intravitreal injections (IVI) of antivascular endothelial growth factors.

METHODS

This is a single-center, prospective, randomized, blinded, triple-arm, placebo-controlled interventional study. Patients were randomized into 3 Groups. Group 1 (n = 33) received nepafenac 0.1%, Group 2 (n = 32) received nepafenac 0.3%, and Group 3 (n = 31) received placebo 40 min before IVI. Using the short form of the McGill Pain Questionnaire (SF-MPQ), pain intensity was assessed with the visual analog scale (VAS), the Main Component of the SF-MPQ, and the present pain intensity (PPI) scores immediately and 6 h postinjection.

RESULTS

Immediately after IVI, the VAS pain score was statistically significantly lower in patients treated with nepafenac 0.1% and 0.3%, compared with placebo (P < 0.001 and P = 0.001, respectively). The PPI scores were statistically significantly lower when nepafenac 0.1% or 0.3% was instilled compared with placebo (P = 0.01 and P < 0.0001, respectively). The Main Component of the SF-MPQ scores were statistically significantly lower after nepafenac 0.1% and 0.3% administration compared with placebo (P = 0.001 and P < 0.001, respectively). Six hours post-IVI the nepafenac 0.3% demonstrated statistically significantly higher analgesic effect compared with nepafenac 0.1% and placebo as this was indicated by the VAS pain score (P = 0.013 and P < 0.00001, respectively) and by the PPI score (P = 0.01 and P < 0.00001, respectively).

CONCLUSIONS

A single instillation of nepafenac 0.1% or 0.3% before IVI could effectively alleviate the IVI-related pain. The 0.3% formula exerts its analgesic effect more intensively at 6 h after the IVI.

LONG-TERM FOLLOW-UP OF RETINAL PIGMENT EPITHELIUM RESTORATION AFTER A TRIPLE TEAR

PURPOSE

To demonstrate longitudinal multimodal imaging findings in a case of neovascular age-related macular degeneration presenting with multiple retinal pigment epithelium (RPE) tears showing progressive RPE restoration.

METHODS

Observational clinical case report.

RESULTS

A 79-year-old woman diagnosed with neovascular age-related macular degeneration developed 3 consecutive RPE tears in her right eye during the course of treatment with intravitreal anti-vascular endothelial growth factor therapy. The RPE tears initially appeared hypoautofluorescent on fundus autofluorescence. Spectral domain optical coherence tomography showed contractile folds of the RPE with adjacent subretinal fluid and overlying ellipsoid zone disruption. Over an 8-year follow-up period, the RPE defects progressively resolved with a return of patchy fundus autofluorescence. Eye-tracked spectral domain optical coherence tomography showed gradual restoration of the RPE band defects over an enlarging Type 1 neovascular lesion.

CONCLUSION

Some RPE tears may show observable remodeling and restoration over time. These changes may be followed longitudinally with multimodal imaging, including eye-tracked spectral domain optical coherence tomography and fundus autofluorescence.

BRANCH RETINAL VEIN OCCLUSION SECONDARY TO A RETINAL ARTERIOLAR MACROANEURYSM: A NOVEL MECHANISM SUPPORTED BY MULTIMODAL IMAGING

BACKGROUND/PURPOSE

To report a case of a branch retinal vein occlusion secondary to a retinal arteriolar macroaneurysm (RAM).

METHODS

Retrospective case report describing examination findings, treatment outcome and unique multimodal imaging features demonstrated on fluorescein angiography, optical coherence tomography, optical coherence tomography angiography and adaptive optics photography of the retinal vessels and RAM.

RESULTS

A 61-year-old man presented with 20/200 vision in the right eye because of a branch retinal vein occlusion secondary to a RAM. After sector panretinal photocoagulation and a course of 24 intravitreal antivascular endothelial growth factor injections over 4 years, visual acuity improved to 20/25. Fluorescein angiography showed filling of the RAM even after 4 years. Optical coherence tomography angiography demonstrated venous collateral vessels in both the superficial and deep capillary plexuses, and adaptive optics imaging revealed a gap between the RAM wall and occluded vein.

CONCLUSION

Multimodal imaging of this unusual presentation illustrated a novel mechanism of branch retinal vein occlusion in which a primary RAM adjacent to the junction of two retinal veins led to obstruction of venous flow without evidence of direct compression. This supports the theory that perianeurysmal microenvironment changes may be of importance in the pathogenesis of venous occlusion.