Bevacizumab for macular edema in central retinal vein occlusion: a prospective, randomized, double-masked clinical study

[Retinal vein occlusion: Therapy of retinal vein occlusion]

Treatment of retinal vein occlusion can be systemic or local. Therapeutic strategies include improved blood supply, treatment of the vision-reducing macular edema by intravitreal injection of inhibitors of vascular endothelial growth factors (VEGF) or corticosteroids and laser photocoagulation for neovascular complications. As long as head-to-head studies comparing steroids and VEGF inhibitors have not been published, none of the available intravitreally injected substances can be given priority. Well-known side effects of intravitreal steroids are cataract formation and ocular hypertension whereas VEGF inhibitors need to be frequently injected. Although therapy for retinal vein occlusion is protracted, initial long-term data indicate that treatment can be terminated in at least half of the patients . Finally, a treatment recommendation according to the current state of data is presented.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Therapies for macular edema associated with central retinal vein occlusion: a report by the American Academy of Ophthalmology

PURPOSE

To review the available evidence regarding the safety and efficacy of therapies for the treatment of macular edema (ME) associated with central retinal vein occlusion (CRVO).

METHODS

A literature search of the PubMed database was last conducted in March 2014 with no date restrictions but limited to articles published in English. A literature search of the Cochrane Library was also conducted in March 2014 with no date restrictions and without a language limitation. The combined searches yielded 108 citations, of which 20 were deemed clinically relevant for the Ophthalmic Technology Assessment Committee Retina/Vitreous panel to review in full text. Three additional studies were also identified for panel review. The level of evidence of these selected studies was reviewed by the panel methodologist.

RESULTS

There were 7 citations representing 4 clinical trials that provided level I evidence supporting the use of anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME associated with CRVO, including intravitreal ranibizumab (2), aflibercept (3), and bevacizumab (2). There were 3 citations representing 2 studies with level I evidence for intravitreal corticosteroid injection with dexamethasone intravitreal implant (2 citations) or triamcinolone (1 citation), although cataract and glaucoma were observed in these studies. Level I evidence is available on the limited benefit of macular grid-pattern laser photocoagulation (1 citation). Eight other citations reviewed were rated as level II, and 4 citations were rated as level III. Long-term efficacy results (≥2 years of follow-up) are limited to intravitreal ranibizumab at this time, and few studies have evaluated combination therapy with anti-VEGF and corticosteroid versus monotherapy of either class of drug.

CONCLUSIONS

Level I evidence indicates that intravitreal anti-VEGF pharmacotherapy is safe and effective over 2 years for ME associated with CRVO and that delay in treatment is associated with worse visual outcomes. In addition, level I evidence demonstrates short-term efficacy of intravitreal corticosteroid but also an association with a higher frequency of adverse events.

Intravitreal ranibizumab versus isovolemic hemodilution in the treatment of macular edema secondary to central retinal vein occlusion: twelve-month results of a prospective, randomized, multicenter trial

PURPOSE

This is a prospective, randomized, multicenter, investigator-initiated trial to evaluate the 12-month effectiveness of isovolemic hemodilution (IH) with prompt versus deferred intravitreal injections (IVI) of ranibizumab 0.5 mg for the treatment of macular edema secondary to early central retinal vein occlusion (CRVO).

METHODS

Eyes with macular edema due to CRVO having occurred not more than 8 weeks previously received either monthly ranibizumab IVI in combination with IH (group I, n = 28) or IH alone (group II, n = 30). From month 2 to 12, the patients in both groups could be treated with monthly intravitreal ranibizumab. The main outcome variables were gain of visual acuity and the course of central retinal thickness as measured with optical coherence tomography.

RESULTS

At 12 months, eyes in group I on average gained +28.1 (±19.3) letters compared to +25.2 (±20.9) letters in group II (p = 0.326). This result was achieved with significantly fewer injections in group II. Additionally, 30% of the eyes in group II did not need ranibizumab IVI during the 12 months of the trial.

CONCLUSION

Ranibizumab IVI in addition to IH proved to be highly effective in increasing visual acuity and reducing macular edema secondary to CRVO. Initial IH in early CRVO may be a first treatment option in patients anxious about IVI.

Efficacy and visual prognostic factors of intravitreal bevacizumab as needed for macular edema secondary to central retinal vein occlusion

PURPOSE

Our aim was to investigate the efficacy and prognostic factors of intraocular injections of bevacizumab as needed in patients with macular edema secondary to central retinal vein occlusion (CRVO).

METHODS

This is a retrospective study including 28 eyes of 27 consecutive patients with macular edema due to CRVO and followed for at least 6 months. The mean age of the patients was 66.3 years. The patients underwent an intravitreal injection of bevacizumab (1.25 mg) at the initial visit. Retreatments were performed when macular edema was persistent or worsened (as-needed regimen). The primary outcome measure was the mean change in best-corrected visual acuity (BCVA). The change in central retinal thickness (CRT) was evaluated as the secondary outcome. Finally, the factors useful for predicting BCVA outcome were determined.

RESULTS

The mean number of injections was 1.8 over a period of 6 months. The mean BCVA (logarithm of minimum angle of resolution) was significantly improved at 1 (-0.097), 3 (-0.14), and 6 months (-0.25) after the initial injection (P<0.05, <0.01, and <0.001, respectively). The mean CRT was also improved significantly at 1 (-250.4), 3 (-150.0), and 6 months (-187.2) (P<0.001 each). Earlier treatment and better improvement in BCVA at 1 month after the initial treatment were the prognostic factors significantly associated with better visual outcomes at 6 months (P=0.047 and 0.029, respectively).

CONCLUSION

Intravitreal injection of bevacizumab as needed significantly improved visual acuity and macular edema in CRVO patients. Time before the treatment and early response to the treatment were important factors for the visual outcome.

Pathogenesis, prevention, diagnosis and management of retinal vein occlusion

Retinal vein occlusion (RVO) is the second vascular retinal cause of visual loss and defined by the occlusion of a retinal vein. It is divided into branch retinal vein occlusion or central retinal vein occlusion, depending on the location of occlusion. RVO has severe medical, financial and social implications on the patients. The diagnosis of the disease is easier nowadays with the use of spectral domain optical coherence tomography and fluorescein angiography. The treatment options for RVO have changed dramatically over the past few years with the introduction of the intravitreal injections of dexamethasone (Ozurdex), bevacizumab (Avastin), ranibizumab (Lucentis) and aflibercept (EYLEA), along with the panretinal laser photocoagulation, abandoning former treatment modalities and surgical solution. This manuscript is a review of current literature about RVO with emphasize on the pathophysiology, risk factors and prevention, diagnosis and sub-group categorization and treatments including medical and surgical. Since no official guidelines are available for the treatment of RVO patients, and considering the latest developments in the treatment options, and the variety of follow-up and treatment modalities, this manuscript aims to provide tools and knowledge to guide the physician in treating RVO patients, based on the latest publications from the literature and on several of the patients characteristics.

Three intravitreal bevacizumab versus two intravitreal triamcinolone injections in recent onset central retinal vein occlusion

PURPOSE

To evaluate the effects of repeated intravitreal injections of bevacizumab (IVB) versus triamcinolone acetonide (IVT) in the treatment of acute central retinal vein occlusion (CRVO).

METHODS

In this randomized clinical trial, 86 eyes with recent onset (<12 weeks) CRVO were assigned to two groups: IVB group (43 eyes) that received three monthly injections of 1.25 mg of IVB, and IVT group (43 eyes) that received two injections of 2 mg IVT 2 months apart. Outcomes were best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) changes.

RESULTS

Mean BCVA improved significantly at 6 months in both groups; from 0.87 ± 0.49 to 0.41 ± 0.35 logMAR in IVB group, and from 0.81 ± 0.45 to 0.62 ± 0.48 logMAR in IVT group (p < 0.001). However, between-group differences reach a significant level at months 4 (p = 0.003) and 6 (p < 0.001) in favour of the IVB group. In terms of CMT reduction, the difference between the groups was statistically significant (p = 0.002) at month 6. Significant differences were noted more in the ischaemic cases in favour of the IVB group. Mean IOP rise was significantly higher in the IVT group at all visits.

CONCLUSIONS

Both 3-times monthly IVB injections and 2-times IVT injections could be effective in cases with recent onset CRVO up to 6 months. However, considering the better outcomes after IVB injections and the potential complications of IVT injections, we would recommend prescheduled repeated IVB injections for such cases. The observed favourable responses were more pronounced in the ischaemic types; nevertheless, this should be confirmed in larger studies.

Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents

BACKGROUND AND OBJECTIVE

To investigate the rate of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents, the spectrum of causative organisms, and associated visual acuity outcomes.

PATIENTS AND METHODS

PubMed articles containing the keywords "endophthalmitis" and "intravitreal" between January 2005 and May 2012 were identified and reviewed. Inclusion criteria included article in English, more than 100 intravitreal anti-VEGF injections, and report of adverse events including endophthalmitis after intravitreal injection.

RESULTS

Forty-three articles were analyzed. Endophthalmitis occurred after 197 of 350,535 intravitreal anti-VEGF injections (0.056%). The most common organisms isolated were coagulase-negative Staphylococcus (38.24%) and Streptococcus species (29.41%).

CONCLUSION

The reported rate of endophthalmitis after intravitreal anti-VEGF injection is low. Coagulase-negative Staphylococcus and Streptococcus species were the most frequent causative organisms. Streptococcus species represent the causative organism of endophthalmitis after intravitreal VEGF injections at a higher rate than rates reported in the literature for endophthalmitis following most incisional intraocular surgeries. Among patients with endophthalmitis after intravitreal anti-VEGF injection, endophthalmitis caused by Streptococcus species is associated with poorer visual acuity outcomes than endophthalmitis caused by coagulase-negative Staphylococcus and culture-negative cases.

Drug treatment of macular oedema secondary to central retinal vein occlusion: a network meta-analysis

OBJECTIVE

To indirectly compare aflibercept, bevacizumab, dexamethasone, ranibizumab and triamcinolone for treatment of macular oedema secondary to central retinal vein occlusion using a network meta-analysis (NMA).

DESIGN NMA DATA SOURCES

The following databases were searched from January 2005 to March 2013: MEDLINE, MEDLINE In-process, EMBASE; CDSR, DARE, HTA, NHSEED, CENTRAL; Science Citation Index and Conference Proceedings Citation Index-Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Only randomised controlled trials assessing patients with macular oedema secondary to central retinal vein occlusion were included. Studies had to report either proportions of patients gaining ≥3 lines, losing ≥3 lines, or the mean change in best corrected visual acuity. Two authors screened titles and abstracts, extracted data and undertook risk of bias assessment. Bayesian NMA was used to compare the different interventions.

RESULTS

Seven studies, assessing five drugs, were judged to be sufficiently comparable for inclusion in the NMA. For the proportions of patients gaining ≥3 lines, triamcinolone 4 mg, ranibizumab 0.5 mg, bevacizumab 1.25 mg and aflibercept 2 mg had a higher probability of being more effective than sham and dexamethasone. A smaller proportion of patients treated with triamcinolone 4 mg, ranibizumab 0.5 mg or aflibercept 2 mg lost ≥3 lines of vision compared to those treated with sham. Patients treated with triamcinolone 4 mg, ranibizumab 0.5 mg, bevacizumab 1.25 mg and aflibercept 2 mg had a higher probability of improvement in the mean best corrected visual acuity compared to those treated with sham injections.

CONCLUSIONS

We found no evidence of differences between ranibizumab, aflibercept, bevacizumab and triamcinolone for improving vision. The antivascular endothelial growth factors (VEGFs) are likely to be favoured because they are not associated with steroid-induced cataract formation. Aflibercept may be preferred by clinicians because it might require fewer injections.

SYSTEMATIC REVIEW REGISTRATION

Not registered.

The safety of intravitreal bevacizumab monotherapy in adult ophthalmic conditions: systematic review

OBJECTIVES

To assess the safety of intravitreal bevacizumab (IVB) as a monotherapy and to evaluate the relationship between quality of treatment and adverse events.

DATA SOURCES

Cochrane Library, Ovid MEDLINE, MEDLINE in-process, Ovid EMBASE and Toxicology Literature Online (TOXLINE) from January 2009 to May 2012. Studies included in an earlier systematic review were also assessed for inclusion.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Randomised controlled trials (RCTs), controlled trials or observational studies including ≥10 participants reporting adverse events data following IVB monotherapy as a primary treatment in patients (aged 18 years or more) with any eye condition were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study selection was undertaken independently by a minimum of two reviewers using pre-defined criteria. Data abstraction and quality assessment were performed by one reviewer, and then checked by a second reviewer. Study quality was assessed for only RCTs in accordance to the Cochrane Risk of Bias Tool. Additional items relating to safety data were also assessed. Results were tabulated or meta-analysed as appropriate.

RESULTS

22 RCTs and 67 observational studies were included. Only two RCTs reported valid safety data. Rates of serious adverse events following treatment were low. There was insufficient data to explore the relationship between the incidence of adverse events and quality of IVB injection.

LIMITATIONS

A majority of relevant existing studies were characterised by small sample sizes, unclear diagnostic criteria and reporting of safety outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Available evidence demonstrates low rates of serious local and systemic adverse events following treatment. However, the role of IVB quality in the incidence of adverse events remains unclear. Robust evidence is needed to examine the relationship between the incidence of adverse events and variables such as injection techniques, pre-existing risk factors (eg, immunosuppression, cross-contamination) and quality of IVB treatment.

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

BACKGROUND

Central retinal vein occlusion (CRVO) is a relatively common retinal vascular disorder in which macular oedema may develop, with a consequent reduction in visual acuity. Until recently there has been no treatment of proven benefit, but growing evidence supports the use of anti-vascular endothelial growth factor (anti-VEGF) agents.

OBJECTIVES

To investigate the effectiveness and safety of anti-VEGF therapies for the treatment of macular oedema secondary to CRVO.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 10), Ovid MEDLINE (January 1950 to October 2013), EMBASE (January 1980 to October 2013), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to October 2013), OpenGrey, OpenSIGLE (January 1950 to October 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and Web of Science Conference Proceedings Citation Index-Science (CPCI-S). There were no language or date restrictions in the electronic search for trials. The electronic databases and clinical trials registers were last searched on 29th October 2013.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared intravitreal anti-VEGF agents of any dose or duration to sham injection or no treatment. We focused on studies that included individuals of any age or gender and a minimum of six months follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The primary outcome was the proportion of participants with a gain in best-corrected visual acuity (BCVA) from baseline of greater than or equal to 15 letters (3 lines) on the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Secondary outcomes included the proportion of participants with a loss of 15 letters or more of BCVA, the mean change from baseline BCVA, the mean change in central retinal thickness (CRT), the number and type of complications or adverse outcomes, and the number of additional interventions administered. Where available, we also presented quality of life and economic data.

MAIN RESULTS

We found six RCTs that met the inclusion criteria after independent and duplicate review of the search results. These RCTs included 937 participants and compared outcomes at six months to sham injection for four anti-VEGF agents: aflibercept (VEGF Trap-Eye, Eylea), bevacizumab (Avastin), pegaptanib sodium (Macugen) and ranibizumab (Lucentis). Three trials were conducted in Norway, Sweden and the USA, and three trials were multicentre, one including centres in the USA, Canada, India, Israel, Argentina and Columbia, a second including centres in the USA, Australia, France, Germany, Israel, and Spain, and a third including centres in Austria, France, Germany, Hungary, Italy, Latvia, Australia, Japan, Singapore and South Korea. We performed meta-analysis on three key visual outcomes, using data from up to six trials. High-quality evidence from six trials revealed that participants receiving intravitreal anti-VEGF treatment were 2.71 times more likely to gain at least 15 letters of visual acuity at six months compared to participants treated with sham injections (risk ratio (RR) 2.71; 95% confidence intervals (CI) 2.10 to 3.49). High-quality evidence from five trials suggested anti-VEGF treatment was associated with an 80% lower risk of losing at least 15 letters of visual acuity at six months compared to sham injection (RR 0.20; 95% CI 0.12 to 0.34). Moderate-quality evidence from three trials (481 participants) revealed that the mean reduction from baseline to six months in central retinal thickness was 267.4 µm (95% CI 211.4 µm to 323.4 µm) greater in participants treated with anti-VEGF than in participants treated with sham. The meta-analyses demonstrate that treatment with anti-VEGF is associated with a clinically meaningful gain in vision at six months. One trial demonstrated sustained benefit at 12 months compared to sham. No significant ocular or systemic safety concerns were identified in this time period.

AUTHORS' CONCLUSIONS

Compared to no treatment, repeated intravitreal injection of anti-VEGF agents in eyes with CRVO macular oedema improved visual outcomes at six months. All agents were relatively well tolerated with a low incidence of adverse effects in the short term. Future trials should address the relative efficacy and safety of the anti-VEGF agents and other treatments, including intravitreal corticosteroids, for longer-term outcomes.

The effect of antivascular endothelial growth factor therapy on the development of neovascular glaucoma after central retinal vein occlusion: a retrospective analysis

Purpose. Ischemic central retinal vein occlusion (CRVO) eyes are at high risk of developing neovascular glaucoma (NVG). Our purpose is to investigate the effect of anti-VEGF therapy for macular edema after CRVO on the development of neovascular glaucoma (NVG) in ischemic CRVO eyes. Methods. This is a retrospective case series of 44 eyes from 44 patients with CRVO treated with anti-VEGF therapy for macular edema. The primary outcome was the development of NVG. Results. Of the 44 eyes, 14 eyes had ischemic CRVO, and 30 eyes had nonischemic CRVO. Nonischemic eyes received a mean of 8.4 anti-VEGF doses, over mean follow-up of 24 months. One nonischemic eye (3.3%) developed NVD but not NVG. The 14 ischemic eyes received a mean of 5.6 anti-VEGF doses, with mean follow-up of 23 months. Of these 14 ischemic eyes, two eyes (14%) developed iris neovascularization and 3 eyes (21%) developed posterior neovascularization. Three of these 5 eyes with neovascularization progressed to NVG, at 19.7 months after symptom onset, on average. Conclusion. Anti-VEGF therapy for macular edema may delay, but does not prevent, the development of ocular NV in ischemic CRVO. Significant risk of NVG still exists for ischemic CRVO eyes.

Treatments for macular oedema following central retinal vein occlusion: systematic review

OBJECTIVES

To review systematically the randomised controlled trial (RCT) evidence for treatment of macular oedema due to central retinal vein occlusion (CRVO).

DATA SOURCES

MEDLINE, EMBASE, CDSR, DARE, HTA, NHSEED, CENTRAL and meeting abstracts (January 2005 to March 2013).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

RCTs with at least 12 months of follow-up assessing pharmacological treatments for CRVO were included with no language restrictions.

STUDY APPRAISAL AND SYNTHESIS METHODS

2 authors screened titles and abstracts and conducted data extracted and Cochrane risk of bias assessment. Meta-analysis was not possible due to lack of comparable studies.

RESULTS

8 studies (35 articles, 1714 eyes) were included, assessing aflibercept (n=2), triamcinolone (n=2), bevacizumab (n=1), pegaptanib (n=1), dexamethasone (n=1) and ranibizumab (n=1). In general, bevacizumab, ranibizumab, aflibercept and triamcinolone resulted in clinically significant increases in the proportion of participants with an improvement in visual acuity of ≥15 letters, with 40-60% gaining ≥15 letters on active drugs, compared to 12-28% with sham. Results for pegaptanib and dexamethasone were mixed. Steroids were associated with cataract formation and increased intraocular pressure. No overall increase in adverse events was found with bevacizumab, ranibizumab, aflibercept or pegaptanib compared with control. Quality of life was poorly reported. All studies had a low or unclear risk of bias.

LIMITATIONS

All studies evaluated a relatively short primary follow-up (1 year or less). Most had an unmasked extension phase. There was no head-to-head evidence. The majority of participants included had non-ischaemic CRVO.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Bevacizumab, ranibizumab, aflibercept and triamcinolone appear to be effective in treating macular oedema secondary to CRVO. Long-term data on effectiveness and safety are needed. Head-to-head trials and research to identify 'responders' is needed to help clinicians make the right choices for their patients. Research aimed to improve sight in people with ischaemic CRVO is required.

Antivascular endothelial growth factors in the treatment of macular oedema secondary to central retinal vein occlusion: a meta-analysis

BACKGROUND

Macular oedema secondary to central retinal vein occlusion is a major cause of vision loss. Intraocuclar anti-vascular endothelial growth factor injection is a promising treatment but lacks clinical evidence of its safety and efficacy.

DESIGN

Meta-analysis.

PARTICIPANTS

Patients from previously reported randomized, controlled trials comparing intravitreal anti-vascular endothelial growth factor versus sham injections.

METHODS

A comprehensive search in MEDLINE, CENTRAL, and EMBASE was conducted for reports published by April 2013. A meta-analysis of the retrieved data was conducted in RevMan 5.2 software.

MAIN OUTCOME MEASURES

Primary outcome measures were changes in best-corrected visual acuity and central retinal thickness from baseline. Secondary outcome measures were the proportion of eyes changing 15 or more letters on the Early Treatment in Diabetic Retinopathy Study chart, the proportion with neovascularization and changes in the 25-item Visual Function Questionnaire. Severe adverse events were summarized to assess safety.

RESULTS

Six trials involving a total of 940 eyes were included in the meta-analysis. The mean difference in 6-month changes in best-corrected visual acuity and central retinal thickness for the anti-vascular endothelial growth factor group were 15.2 Early Treatment Diabetic Retinopathy Study letters (P < 0.00001) and -242.2 μm (P < 0.00001), respectively. Severe adverse event incidence was similar between the groups.

CONCLUSIONS

Intravitreal anti-vascular endothelial growth factor injections were safe and effective for macular oedema secondary to central retinal vein occlusion. The efficacy was rapid and robust. Further trials are needed to determine the detailed indications and therapeutic regimens of anti-vascular endothelial growth factor treatments.

Late retinal neovascularization after central retinal vein occlusion: a case report and literature review

PURPOSE

To present the case of a 59-year-old man with central retinal vein occlusion with limited retinal ischemia who developed retinal neovascularization over a year after initial presentation.

METHODS

Retrospective case report.

RESULTS

On initial presentation, the patient had counting fingers vision in the affected eye and significant macular edema. After 4 intravitreal ranibizumab injections, his vision improved to 20/30. An intravenous fluorescein angiography performed at presentation and at a 4-month follow-up revealed limited retinal ischemia and no neovascularization. Over a year after his initial presentation, the patient returned with visual symptoms and was found to have subhyaloid hemorrhage and areas of retinal neovascularization.

CONCLUSION

Anterior and posterior segment neovascularization after central retinal vein occlusion has traditionally been thought to occur within a few months of the inciting event. However, the use of antivascular endothelial growth factor agents may alter the angiogenic processes within an eye after central retinal vein occlusion, potentially delaying the onset of neovascularization. This suggests the need for enhanced monitoring in this patient population.

A meta-analysis of anti-vascular endothelial growth factor remedy for macular edema secondary to central retinal vein occlusion

Background

Central retinal vein occlusion (CRVO) associates with severe vision outcome and no proven beneficial treatment. Our meta-analysis intended to appraise the efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) agents in macular edema (ME) following CRVO.

Methods

Data were collected and analyzed by Review Manager 5.2.1. We employed a random-effects model to eliminate between-study heterogeneity. N_fs (called fail-safe number) was calculated to evaluate the publication bias.

Results

We included 5 trials consisting 323 cases and 281 controls. Primary outcomes showed that overall comparison of anti-VEGF agents with placebo control yielded a 374% and 136% increased tendency for a gain of 15 letters or more on Early Treatment Diabetic Retinopathy Study (ETDRS) chart (95% confidence interval [95% CI]: 2.43–9.23; P<0.00001; I² = 59%, 95% CI: 1.60–3.49; P<0.0001; I² = 0%, respectively) at 6 and 12 months. Secondary outcomes showed that a 90% and 77% decreased risk at 6 and 12 months for a loss of 15 letters or more. The overall mean difference showed a statistically significance in best-corrected visual acuity (BCVA) on each time point. However, changes of central retinal thickness (CRT) lost significance at 12 months after 6-month as-needed treatment. The incidence of adverse events (AEs) had no statistical difference between anti-VEGF and placebo groups. Subgroup analyses indicated that patients receiving Aflibercept got the highest tendency to gain 15 letters or more (OR = 9.78; 95% CI: 4.43–21.56; P<0.00001). Age controlled analysis suggested a weaken tendency of BCVA improvement in age over 50 (MD = 12.26; 95% CI: 7.55–16.98; P<0.00001). Subgroup analysis by clinical classification showed a strengthen difference of BCVA changes at 6 months in ischemic type (MD = 19.65 letters, 95% CI: 13.15 to 26.14 letters, P<0.00001).

Conclusions

Our results showed that anti-VEGF agents were superior to placebo in CRVO-ME treatment with no statistically significant AEs, especially in younger people and for ischemic type.

The ABCs of RVO: a review of retinal venous occlusion

Retinal vein occlusions are important causes of loss of vision; indeed, they are the second most common retinal vascular disease, following diabetic retinopathy. For this reason alone, primary eye-care providers must be well versed in diagnosis and management. Risk factors, though not universally agreed upon, include but are not limited to advancing age, systemic hypertension, arteriolarsclerosis, diabetes, hyperlipidaemia, blood hyperviscosity, thrombophilia, ocular hypertension and glaucoma. Typically, visual loss is secondary to macular oedema and/or retinal ischaemia. Treatment modalities have included observation, systemic thrombolysis and haemodilution, radial optic neurotomy, chorioretinal anastomosis, vitrectomy, laser photocoagulation and intravitreal injection of anti-inflammatory and, most recently, anti-vascular endothelial growth factors.

Two-year outcomes of intravitreal bevacizumab therapy for macular oedema secondary to branch retinal vein occlusion

Aim

To determine the 2-year outcomes of intravitreal bevacizumab (IVB) injections in eyes with macular oedema (ME) following branch retinal vein occlusion (BRVO).

Methods

Of 105 consecutive eyes (105 treatment-naïve patients) with ME following BRVO, 89 eyes were followed for 2 years after the first injection. During the 2-year follow-up period, patients were examined at least every 3 months and received an IVB injection (1.25 mg/0.05 mL) if they met prespecified retreatment criteria. Rescue grid laser was permitted based on the findings of the Branch Vein Occlusion Study.

Results

The baseline logarithm of the minimum angle of resolution visual acuity (VA) was 0.64±0.24 (mean±SD), which significantly (p=0.001) improved 1 month after the first injection to 0.39±0.22. One year after the first injection, VA improved significantly (p=0.001) to 0.33±0.21 and remained 0.34±0.21 until 2 years after the first injection (p=0.001). The changes in foveal thickness were correlated with those of VA during the 2-year follow-up period with a mean of 3.8±1.5 injections (including the first injection).

Conclusions

This relatively large case series study showed favourable 2-year outcomes using bevacizumab to treat ME following BRVO. Bevacizumab provides substantial long-term benefits in the treatment of ME following BRVO.

Efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review

BACKGROUND

Intravitreal agents have replaced observation in macular edema in central (CRVO) and grid laser photocoagulation in branch retinal vein occlusion (BRVO). We conducted a systematic review to evaluate efficacy and safety outcomes of intravitreal therapies for macular edema in CRVO and BRVO.

METHODS AND FINDINGS

MEDLINE, Embase, and the Cochrane Library were systematically searched for RCTs with no limitations of language and year of publication. 11 RCTs investigating anti-VEGF agents (ranibizumab, bevacizumab, aflibercept) and steroids (triamcinolone, dexamethasone implant) with a minimum follow-up of 1 year were evaluated.

EFFICACY CRVO

Greatest gain in visual acuity after 12 months was observed both under aflibercept 2 mg: +16.2 letters (8.5 injections), and under bevacizumab 1.25 mg: +16.1 letters (8 injections). Ranibizumab 0.5 mg improved vision by +13.9 letters (8.8 injections). Triamcinolone 1 mg and 4 mg stabilized visual acuity at a lower injection frequency (-1.2 letters, 2 injections).

BRVO

Ranibizumab 0.5 mg resulted in a visual acuity gain of +18.3 letters (8.4 injections). The effect of dexamethasone implant was transient after 1.9 implants in both indications.

SAFETY

Serious ocular adverse events were rare, e.g., endophthalmitis occurred in 0.0-0.9%. Major differences were found in an indirect comparison between steroids and anti-VEGF agents for cataract progression (19.8-35.0% vs. 0.9-7.0%) and in required treatment of increased intraocular pressure (7.0-41.0% vs. none). No major differences were identified in systemic adverse events.

CONCLUSIONS

Anti-VEGF agents result in a promising gain of visual acuity, but require a high injection frequency. Dexamethasone implant might be an alternative, but comparison is impaired as the effect is temporary and it has not yet been tested in PRN regimen. The ocular risk profile seems to be favorable for anti-VEGF agents in comparison to steroids. Because comparative data from head-to-head trials are missing currently, clinicians and patients should carefully weigh the benefit-harm ratio.

Bevacizumab for macular edema secondary to retinal vein occlusion: a systematic review and meta-analysis

PURPOSE

To assess the effect and safety of using single intravitreal bevacizumab (IVB) versus intravitreal triamcinolone acetonide (IVTA) and grid laser photocoagulation (GLP), or a combination of IVB and IVTA for treatment of retinal vein occlusion (RVO)-associated macular edema, mainly exploring its effects on visual acuity (VA) and central macular thickness (CMT).

METHODS

Eligible studies were identified via searching databases, including Medline (PubMed), Web of Science, and the Cochrane Library, without status or other limits up to June 2012.

SELECTION CRITERIA

We include randomized clinical control trials comparing 1.25 mg IVB injection with other treatment strategies, including a 4 mg IVTA injection or GLP or a combination of 1.25 mg IVB and 2 mg IVTA injection, for patients with RVO-associated macular edema. Eligible studies should report both VA and CMT outcomes, and with a minimum follow-up of 4 weeks. Results: Two authors assessed the trial quality and extracted data independently.

MAIN RESULTS

Four studies were included in this study. Comparing to IVTA and GLP, IVB was more effective in improving VA at 1 month (weighted mean difference [WMD], -0.07; 95% confidence interval [CI], -0.10 to -0.05; P<0.00001), 3 months (WMD, -0.24; 95% CI, -0.28 to -0.20; P<0.00001), and 6 months during the follow-up (WMD, -0.17; 95% CI, -0.21 to -0.13; P<0.00001) in patients with RVO-associated macular edema. There was no statistical significance in reducing CMT values throughout the periods. Compared with IVB/IVTA combination, VA improvement became statistically significant at 3 months of follow-up (WMD, -0.26; 95% CI, -0.29 to -0.23; P<0.00001), while no statistical significance was found in both VA values at 1 month of follow-up and CMT values throughout the periods. The occurrence of intraocular pressure (IOP) was much lower in IVB groups.

CONCLUSIONS

IVB is effective in treating patients with RVO-associated macular edema; especially if it has distinct effects, of which, VA could be improved to the utmost extent as well as by the earliest of time. IVB is also effective in decreasing CMT, but without any significant advantages over IVTA or GLP. Furthermore, IVB seems to be safer than IVTA in consideration of IOP increase.

Subclinical macular findings in infants screened for retinopathy of prematurity with spectral-domain optical coherence tomography

OBJECTIVE

To evaluate subclinical macular findings in premature patients at risk of retinopathy of prematurity (ROP) with the use of handheld spectral-domain optical coherence tomography (SD-OCT).

DESIGN

Prospective, observational case series.

PARTICIPANTS

Forty-nine prematurely born neonates.

METHODS

Forty-nine infants were imaged using a handheld SD-OCT. Images were acquired in nonsedated infants in the neonatal intensive care unit (NICU). Some patients were followed and reimaged over the course of several weeks. A total of 300 total images were acquired and evaluated for cystoid macular edema (CME) and persistence of inner retinal layers.

MAIN OUTCOME MEASURES

In vivo determination of foveal retinal lamination, image analysis, and clinical observation.

RESULTS

A total of 241 (80%) of the images from 46 patients were usable (defined as having scans passing through the fovea with clearly identifiable retinal layers). Persistence of 1 or more inner retinal layers was seen in 43 of the patients with usable images (93%). Of the patients with at least 1 persistent layer, 17, 4, 8, 12, and 1, had a maximum ROP stage of 0, 1, 2, 3, and 4A, respectively. Cystoid macular edema was seen in 25 of the 46 patients (54%) during 1 or more imaging sessions. Cystoid macular edema was present in 9, 1, 5, 9, and 1 patient with maximum ROP stage of 0, 1, 2, 3, and 4A, respectively.

CONCLUSIONS

Our data suggest there is persistence of inner retinal layers in premature infants regardless of maximal ROP stage. Subclinical CME is seen in premature infants; however, CME does not appear to be correlated with ROP stage. This suggests that there may be other causes for the CME seen in this patient population. Hand-held SD-OCT imaging is a viable technique for evaluating subclinical macular findings in premature infants, although larger datasets are needed from multiple centers to further evaluate the generalizability of these findings.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Inflammation in retinal vein occlusion

Retinal vein occlusion is a common, vision-threatening vascular disorder. The role of inflammation in the pathogenesis and clinical consequences of retinal vein occlusion is a topic of growing interest. It has long been recognized that systemic inflammatory disorders, such as autoimmune disease, are a significant risk factor for this condition. A number of more recent laboratory and clinical studies have begun to elucidate the role inflammation may play in the molecular pathways responsible for the vision-impairing consequences of retinal vein occlusion, such as macular edema. This improved understanding of the role of inflammation in retinal vein occlusion has allowed the development of new treatments for the disorder, with additional therapeutic targets and strategies to be identified as our understanding of the topic increases.

Potential anti-vascular endothelial growth factor therapies for central retinal vein occlusion

Central retinal vein occlusion (CRVO) remains an important cause of visual loss. Impaired venous drainage leads to retinal hypoxia with upregulation and release of vascular endothelial growth factor (VEGF). VEGF increases vascular permeability and leads to the breakdown of the blood-retinal barrier, with the development of macular oedema. Treatment strategies for macular oedema in CRVO currently under evaluation focus on VEGF blockage. Bevacizumab is a humanized monoclonal antibody that blocks VEGF. It has been evaluated in a clinical trial that compared intravitreal injections of bevacizumab 1.25 mg with sham injections every 6 weeks. At the end of a 24-week follow-up period, 60.0% of patients in the bevacizumab group had gained ≥ 15 letters compared with 20.0% in the control group (p=0.003). Aflibercept (previously VEGF Trap-Eye) is a 115  kD decoy receptor fusion protein. Aflibercept is capable of binding both VEGF and placental growth factor (PlGF). By blocking both VEGF and PlGF, aflibercept could be more effective than other anti-VEGF drugs. Two clinical trials have evaluated the efficacy of aflibercept for the treatment of macular oedema in CRVO: COPERNICUS and GALILEO. Both included a similar 6-month phase, during which patients were randomized to receive either an intravitreal injection of aflibercept 2 mg or a sham injection every month. In a second 6-month phase of the GALILEO study, patients in the treatment group were treated on an as needed (PRN) basis with aflibercept, while patients in the placebo group continued with sham injections. In the second 6-month phase in the COPERNICUS study, all patients were treated with aflibercept on a PRN basis. Treatment with aflibercept led to an improvement in visual acuity of ≥ 15 letters in 55.3% (COPERNICUS) and 60.2% of patients (GALILEO). Patients initially in the placebo group and then treated PRN gained only a mean of 3.8 letters, with 30.1% achieving a visual gain of ≥ 15 letters (COPERNICUS). The percentage of patients that improved by ≥ 15 letters was 32.4% for the group receiving sham injections throughout the GALILEO study. In summary, VEGF blockage has been proven to improve visual outcomes in patients with macular oedema due to CRVO. However, an important disadvantage of anti-VEGF drugs is the need for frequent reinjections and even more frequent control visits. Further advances are needed in order to improve quality of life and reduce the burden to healthcare systems.

Therapeutic potential of intravitreal pharmacotherapy in retinal vein occlusion

Retinal vein occlusion (RVO) is the most common visually disabling disease affecting the retina after diabetic retinopathy. Although the disease entity has long been known, its management is still controversial. Macular edema is the main reason for decreased visual acuity (VA) in this retinal vascular disorder. Recently the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of macular edema through intravitreal injection route. The most widely injected drugs so far have been triamcinolone acetonide (TA) and bevacizumab. The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestions that intravitreal pharmacotherapy by corticosteroids and anti-vascular endothelial growth factors may be useful in the treatment of retinal vein occlusion.

Benefit from bevacizumab for macular edema in central retinal vein occlusion: twelve-month results of a prospective, randomized study

PURPOSE

To evaluate the efficacy of intraocular injections with bevacizumab over 12 months in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO).

DESIGN

A prospective study including a randomized 6-month, sham injection-controlled, double-masked clinical trial followed by a 6-month open-label extension.

PARTICIPANTS

Sixty patients with ME secondary to CRVO.

METHODS

At baseline, patients were randomized 1:1 to receive intraocular injections of bevacizumab or sham injections every 6 weeks for 6 months. From month 6, all patients received intraocular injections of bevacizumab every 6 weeks for 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients gaining at least 15 letters at 12 months. Secondary outcome measures included mean change from baseline best-corrected visual acuity (BCVA), change in foveal thickness, and development of neovascular glaucoma.

RESULTS

At the end of follow-up, 18 of 30 patients (60.0%) in the bevacizumab/bevacizumab (bz/bz) group had gained ≥ 15 letters compared with 10 of 30 patients (33.3%) in the sham/bevacizumab (sh/bz) group (P < 0.05). The BCVA improved by 16.0 letters at 12 months in the bz/bz group compared with 4.6 letters in the sh/bz group (P < 0.05). In an unplanned retrospective analysis, patients aged >70 years had a significantly worse outcome when receiving delayed treatment, losing 1.4 letters (95% confidence interval [CI], -9.7 to 8.4) in the sh/bz group compared with a gain of 20.1 letters (95% CI, 13.9-26.3) in the bz/bz group in patients aged <70 years (P < 0.003). The mean decrease in central retinal thickness (CRT) was 435 μm in the bz/bz group compared with 404 μm in the sh/bz group (P = not significant). No patients developed iris rubeosis during the 6-month open-label extension period. There were no events of endophthalmitis, retinal tear, or retinal detachment during the 12-month treatment period. No serious nonocular adverse events were reported.

CONCLUSIONS

Intraocular injections of bevacizumab given every 6 weeks for 12 months improve visual acuity (VA) and reduce ME significantly. Patients receiving delayed treatment have a limited visual improvement.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.