A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6

Approved pharmacotherapy for macular edema secondary to branch retinal vein occlusion: A review of randomized controlled trials in dexamethasone implants, ranibizumab, and aflibercept

There are three approved pharmacotherapies for treating macular edema secondary to branch retinal vein occlusion (BRVO), including corticosteroids (dexamethasone implants) and anti-vascular endothelial growth factor (VEGF) (ranibizumab and aflibercept). They all show superior ability to improve vision and reduce macular thickness, comparing with sham injections or macular grid laser treatment. There is no severe ocular or systemic adverse reaction reported in studies associated with anti-VEGF for macular edema after BRVO. Intraocular pressure elevation and cataract aggravation should be addressed after intravitreal dexamethasone implants. Single intravitreal dexamethasone implant had effective duration as long as four to six months. Intravitreal anti-VEGF requires six monthly injections as loading doses, and then PRN regimen needed according to functional and anatomical changes. Ozurdex and ranibizumab reduce not only macular edema, but also the probability of retinal ischemia and neovascularization in patient s with BRVO. Prompt treatment with these agents can lead to a better outcome.

[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.

Safety and Efficacy of Intravitreal Preservative-Free Triamcinolone Acetonide (Triesence) for Macular Edema

PURPOSE

To evaluate the efficacy and safety of preservative-free triamcinolone acetonide (Triesence) for the treatment of macular edema.

METHODS

A retrospective study was conducted on patients who attended a tertiary retinal clinic from June 2009 to July 2012 with macular edema due to various causes. Patients who received at least 1 intravitreal Triesence injection and completed 6 months of follow-up were recruited. Data, including best-corrected Snellen visual acuity, central macular thickness (CMT), intraocular pressure (IOP), and adverse events (AEs), were collected at baseline, week 1, month 1, month 3, and month 6 after initiation of treatment. Snellen visual acuity was converted to visual acuity score (VAS) for statistical analysis using paired t-tests and linear regression.

RESULTS

One hundred two eyes from 102 patients were included in the study. Mean VAS was significantly improved at all follow-up time points compared to baseline (P≤0.002), with highest mean gain at month 1 (6.1±8.9 letters). Mean CMT decreased significantly at all follow-up points compared to baseline (P≤0.0005), with the greatest reduction at week 1 (146.6±109.4 μm). A total of 22 AEs were observed, and IOP elevation was the most common AE related to Triesence treatment (17/22, 77.3%). No sterile or infectious endophthalmitis was observed.

CONCLUSION

Intravitreal Triesence improves visual acuity and reduces macular thickness in eyes with macular edema from various causes. Treatment-associated IOP elevation was manageable with antiglaucoma medications. There were no serious vision-threatening complications associated with intravitreal Triesence therapy during the study period.

[Ocular hypertension after intravitreal steroid injections: Clinical update as of 2015]

Intravitreal injections are a therapeutic delivery method best suited to the treatment of retinal diseases. Recent years have been marked by the use of anti-VEGF agents as well as the arrival of sustained-release corticosteroid implants in France, replacing triamcinolone acetonide. A common complication of IVT steroids is secondary ocular hypertension (OHT) resulting from increased outflow resistance. This article summarizes current understanding. OHT induced by topical steroids has been described for 60 years. Intravitreal use also shows a temporary effect if the exposure is short, dose dependence, and varying incidence depending on the drug used. Sustained release formulations and discontinuing treatment have reduced the risk of induced OHT. Risk factors that induce OHT must be clearly identified prior to an injection. Most cases of OHT can be controlled medically, although differences exist between different drugs. In cases where it cannot be controlled, removal of the implant, selective laser trabeculoplasty, and filtration surgery can be discussed.

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.

Efficacy and Safety of Dexamethasone Intravitreal Implant for Treatment of Refractory Macular Edema Secondary to Retinal Vein Occlusion in Taiwan

PURPOSE

To evaluate the long-term efficacy and safety of slow-release dexamethasone intravitreal implant (DEX implant) in patients with refractory macular edema (ME) secondary to retinal vein occlusion (RVO) in Taiwan.

METHODS

We conducted a retrospective chart review of patients with a diagnosis of ME secondary to RVO who received the DEX implant at Kaohsiung Veterans General Hospital from October 2010 to February 2014.

RESULTS

A total of 28 patients with an average age of 60.7 ± 11.1 years were examined. Of these patients, 17 were diagnosed with branch RVO (BRVO) and 11 were diagnosed with central RVO (CRVO). The mean maximal change in vision from the baseline after the final injection was an improvement of 1.7 ± 2.8 lines (equivalent to 8.5 ETDRS letters; p<0.0001). The response to the first injection was similar across both BRVO and CRVO groups, but patients with BRVO showed a more favorable response than those with CRVO after the second injection. The response in patients who had refractory ME after at least 3 previous interventions was similar to the whole group. Three patients (10.7%) had elevated intraocular pressure (IOP) that was well controlled by IOP-lowering medications. None of these patients required laser or glaucoma surgery. Five patients (17.9%) exhibited cataract progression during the observation period.

CONCLUSION

The DEX implant is an effective and safe treatment for ME, secondary to RVO, including refractory ME.

Early results of dexamethasone implant, ranibizumab, and triamcinolone in macular edema due to branch retinal vein occlusion

PURPOSE

To compare the short-term results of the efficacy and safety of dexamethasone intravitreal implant (DEX), ranibizumab (RAN), and intravitreal triamcinolone acetonide (IVTA) in macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

One eye each of 32 patients who were treated with intravitreal injections for macular edema secondary to BRVO was studied. This retrospective study included 3 groups. The patients received DEX in group 1 (n = 11), RAN in group 2 (n = 11), and IVTA in group 3 (n = 10). Data were collected before and after the injections at the first and third months. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were analyzed statistically.

RESULTS

The median duration of the follow-up was 3.0 months in overall groups. The BCVA increased significantly in all groups (p = 0.018, p = 0.034, p = 0.014, respectively). The CMT increased significantly in groups 1 and 3 (p = 0.02, p&lt;0.001, respectively), but not in group 2 (p = 0.14). The IOP increased significantly in groups 1 and 3 (p = 0.05, p&lt;0.001, respectively). Antiglaucomatous treatment was required only in group 3. Cataract developed in 2 patients (20%) in group 3 and surgery was required.

CONCLUSIONS

Although RAN was the safest among the 3 agents, DEX and IVTA reduced CMT more than RAN, while significant improvement was achieved in BCVA in all groups. All 3 agents can be effectively used in the treatment of macular edema due to BRVO.

Comparative efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion: a network meta-analysis

OBJECTIVE

To compare the efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Randomised controlled trials (RCTs) evaluating the efficacy and safety of approved treatments for macular oedema secondary to BRVO were identified from an updated systematic review.

SETTING

A Bayesian network meta-analysis of RCTs of treatments for macular oedema secondary to BRVO.

INTERVENTIONS

Ranibizumab 0.5 mg pro re nata, aflibercept 2 mg monthly (2q4), dexamethasone 0.7 mg implant, laser photocoagulation, ranibizumab+laser, or sham intervention. Bevacizumab and triamcinolone were excluded.

OUTCOME MEASURES

Efficacy outcomes were mean change in best corrected visual acuity (Early Treatment Diabetic Retinopathy Study scale) and the percentage of patients gaining ≥ 15 letters. Safety outcome was the percentage of patients with increased intraocular pressure (IOP)/ocular hypertension (OH).

RESULTS

8 RCTs were identified for inclusion with 1743 adult patients. The probability of being the most efficacious treatment at month 6 or 12 based on letters gained was 54% for ranibizumab monotherapy, 30% for aflibercept, 16% for ranibizumab plus laser (adjunctive or prompt), and 0% for dexamethasone implant, laser or sham. The probability of being the most efficacious treatment for patients gaining ≥ 15 letters was 39% for aflibercept, 35% for ranibizumab monotherapy, 24% for ranibizumab plus laser, 2% for dexamethasone implant, and less than 1% for laser or sham. There was no statistical difference between ranibizumab monotherapy and aflibercept for letters gained (+1.4 letters for ranibizumab vs aflibercept with 95% credible interval (CrI) of -5.2 to +8.5 letters) or the OR for gaining ≥ 15 letters: 1.06 (95% CrI 0.16 to 8.94)). Dexamethasone implant was associated with significantly higher IOP/OH than antivascular endothelial growth factor agents (OR 13.1 (95% CrI 1.7 to 116.9)).

CONCLUSIONS

There was no statistically significant difference between ranibizumab and aflibercept.

Macular grid laser photocoagulation for branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is the second most common cause of retinal vascular abnormality after diabetic retinopathy. Persistent macular oedema develops in 60% of eyes with a BRVO. Untreated, only 14% of eyes with chronic macular oedema will have a visual acuity (VA) of 20/40 or better. Macular grid laser photocoagulation is used for chronic non-ischaemic macular oedema following BRVO and has been the mainstay of treatment for over 20 years. New treatments are available and a systematic review is necessary to ensure that the most up-to-date evidence is considered objectively.

OBJECTIVES

To examine the effects of macular grid laser photocoagulation in the treatment of macular oedema following BRVO.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, EMBASE, Web of Science Conference Proceedings Citation Index, the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 August 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing macular grid laser photocoagulation treatment to another treatment, sham treatment or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five studies conducted in Europe and North America. Four separate trials compared grid laser to no treatment, sham treatment, intravitreal bevacizumab and intravitreal triamcinolone. One further trial compared subthreshold to threshold laser. Two of these trials were judged to be at high risk of bias in one or more domains.In one trial of grid laser versus observation, people receiving grid laser were more likely to gain visual acuity (VA) (10 or more ETDRS letters) at 36 months (RR 1.75, 95% confidence interval (CI) 1.08 to 2.84, 78 participants, moderate-quality evidence). The effect of grid laser on loss of VA (10 or more letters) was uncertain as the results were imprecise (RR 0.68, 95% CI 0.23 to 2.04, 78 participants, moderate-quality evidence). On average, people receiving grid laser had better improvement in VA (mean difference (MD) 0.11 logMAR, 95% CI 0.05 to 0.17, high-quality evidence). In a trial of early and delayed grid laser treatment versus sham laser (n = 108, data available for 99 participants), no participant gained or lost VA (15 or more ETDRS letters). At 12 months, there was no evidence for a difference in change in VA (from baseline) between early grid laser and sham laser (MD -0.03 logMAR, 95% confidence interval (CI) -0.07 to 0.01, 68 participants, low-quality evidence) or between delayed grid laser and sham laser (MD 0.00, 95% CI -0.04 to 0.04, 66 participants, low-quality evidence).The relative effects of subthreshold and threshold laser were uncertain. In one trial, the RR for gain of VA (15 or more letters) at 12 months was 1.68 (95% CI 0.57 to 4.95, 36 participants, moderate-quality evidence); the RR for loss of VA (15 or more letters) was 0.56 (95% CI 0.06 to 5.63, moderate-quality evidence); and at 24 months the change in VA from baseline was MD 0.07 (95% CI -0.10 to 0.24, moderate-quality evidence).The relative effects of macular grid laser and intravitreal bevacizumab were uncertain. In one trial, the RR for gain of 15 or more letters at 12 months was 0.67 (95% CI 0.39 to 1.14, 30 participants, low-quality evidence). Loss of 15 or more letters was not reported. Change in VA at 12 months was MD 0.11 logMAR (95% CI -0.36 to 0.14, low-quality evidence).The relative effects of grid laser and 1mg triamcinolone were uncertain at 12 months. RR for gain of VA (15 or more letters) was 1.13 (95% CI 0.75 to 1.71, 1 RCT, 242 participants, moderate-quality evidence); RR for loss of VA (15 or more letters) was 1.20 (95% CI 0.63 to 2.27, moderate-quality evidence); MD for change in VA was -0.03 letters (95% CI -0.12 to 0.06, moderate-quality evidence). Similar results were seen for the comparison with 4mg triamcinolone. Beyond 12 months, the visual outcomes were in favour of grid laser at 24 months and 36 months with people in the macular grid group gaining more VA.Four studies reported on adverse effects. Laser photocoagulation appeared to be well tolerated in the studies. One participant (out of 71) suffered a perforation of Bruch's membrane, but this did not affect visual acuity.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from one RCT supports the use of grid laser photocoagulation to treat macular oedema following BRVO. There was insufficient evidence to support the use of early grid laser or subthreshold laser. There was insufficient evidence to show a benefit of intravitreal triamcinolone or anti-vascular endothelial growth factor (VEGF) over macular grid laser photocoagulation in BRVO. With recent interest in the use of intravitreal anti-VEGF or steroid therapy, assessment of treatment efficacy (change in visual acuity and foveal or central macular thickness using optical coherence tomography (OCT)) and the number of treatments needed for maintenance and long-term safety will be important for future studies.

Highly reflective line in optical coherence tomography images of eyes with macular edema associated with branch retinal vein occlusion

PURPOSE

To determine whether the highly reflective vertical lines seen in spectral-domain optical coherence tomographic (SD OCT) images, which we have termed track lines, after resolution of macular edema associated with branch retinal vein occlusion are related to the integrity of the photoreceptors.

DESIGN

Retrospective, observational, cross-sectional study.

METHODS

We reviewed the medical records of 59 eyes with resolved macular edema associated with branch retinal vein occlusion. The eyes were classified by the presence or absence of the track lines in the SD OCT images after the resolution of macular edema. The correlation between the presence of the track lines and the integrity of the photoreceptors was determined.

RESULTS

Twenty-one of 59 (36%) eyes had track lines in the SD OCT images after a resolution of the macular edema during the follow-up period. At the final visit, 17 (81%) of 21 eyes with the track lines had an interrupted ellipsoid zone at the fovea, whereas 3 eyes (14%) had an intact ellipsoid zone and 1 eye (5%) had an absent ellipsoid zone (P < .0001). The percentage of eyes with a disrupted external limiting membrane at the initial visit was significantly higher in eyes with track lines (90%) than that in eyes without track lines (63%; P = .0324).

CONCLUSIONS

The presence of highly reflective vertical lines in the SD OCT image is associated with a disrupted external limiting membrane before the resolution of macular edema and is associated with an interruption of the ellipsoid zone after resolution of macular edema. Thus, the vertical lines are useful markers of damage to the photoreceptors.

Two or more dexamethasone intravitreal implants as monotherapy or in combination therapy for macular edema in retinal vein occlusion: subgroup analysis of a retrospective chart review study

Background

Dexamethasone intravitreal implant (DEX implant) is a sustained-release biodegradable implant approved for treatment of macular edema associated with retinal vein occlusion (RVO). The safety and efficacy of treatment of RVO-associated macular edema with sequential DEX implants in clinical practice was evaluated in patients who received DEX implant as monotherapy compared with patients who received DEX implant in combination with other RVO treatments.

Methods

A multicenter, retrospective, open-label chart review study (one study eye/patient) evaluated use of DEX implant and outcomes in 289 patients with branch or central RVO who received at least 2 DEX implant treatments in the study eye. Data were collected from the time of the first implant (baseline) to 3–6 months after the last implant. Subgroup analysis evaluated outcomes in patients receiving only DEX implant during the study versus patients receiving DEX implant plus adjunctive RVO treatments. Endpoints included best-corrected visual acuity (BCVA) and central retinal thickness (CRT) change from baseline.

Results

DEX implant was used as monotherapy in 84 (29.1%) patients and in combination with other therapy in 205 (70.9%) patients. Mean number of DEX implant treatments received was 3.1 in the monotherapy group and 3.3 in the combination therapy group (P = 0.344). Mean time between implants was longer in the combination therapy group (177 vs. 151 days, P < 0.001). Mean change from baseline BCVA after the first through sixth DEX implants ranged from +0.6 to +3.4 lines in the monotherapy group and +1.3 to +2.8 lines in the combination therapy group. Mean decrease from baseline CRT ranged from 165 to 230 μm in the monotherapy group and 136 to 175 μm in the combination therapy group. Increased intraocular pressure was more common in the combination therapy group.

Conclusions

Treatment of RVO-associated macular edema with at least 2 sequential DEX implants was safe and effective both when used alone and when combined with other RVO treatments. Improvements in BCVA and CRT were generally similar in the monotherapy and combined therapy groups.

Trial registration

ClinicalTrials.gov NCT01411696.

Baseline predictors of visual acuity and retinal thickness in patients with retinal vein occlusion

This study investigated the baseline predictors of best corrected visual acuity (BCVA) and central retinal thickness (CRT) at 6 months in patients with treatment-naïve branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). This multicenter, interventional case series included 208 BRVO and 123 CRVO patients with follow-up period of 6 months or more. Outcome measures of BCVA (logMAR) included absolute change from baseline and a gain or loss of ≥ 0.3 from baseline. Outcome measures of CRT included absolute change from baseline and a measurement of ≤ 250 µm or ≥ 400 µm at 6 months. Univariate and multiple regression analyses were done to find baseline predictors. For BRVO, younger age, worse baseline BCVA, and shorter duration of symptom were associated with more gain in BCVA. For CRVO, worse baseline BCVA was associated with more gain in BCVA. For CRT outcomes, higher baseline CRT predicted greater decrease at 6 months in both BRVO and CRVO. Younger age and better baseline BCVA were associated with an increased likelihood of measurement of a ≤ 250 µm outcome for BRVO and CRVO, respectively. For CRVO, smoking was associated with greater decrease from baseline and decreased likelihood of measurement of a CRT ≥ 400 µm at 6 months. In conclusion, several baseline factors including age, symptom duration, and baseline BCVA and CRT are associated with BCVA and CRT outcomes at 6 months, which may help to predict disease course for RVO patients.

Intravitreal triamcinolone acetonide in the treatment of ophthalmic inflammatory diseases with macular edema: a meta-analysis study

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) that compared the effects of treatment with intravitreal injections of triamcinolone acetonide (TA) with the standard of care for ocular inflammatory diseases.

METHODS

Medline database was searched for causes of macular edema terms in association with intravitreal triamcinolone. The primary outcome of interest included changes in best corrected visual acuity (BCVA) and central macular thickness (CMT). Pooled summary estimates for primary outcomes were calculated as weighted mean differences (WMD) either on a fixed- or random-effect model.

RESULTS

A total of 8 studies were included for quantitative analysis. Treatment with intravitreal TA showed improvement in BCVA compared with standard of care at 1 month (WMD, -0.09; 95% confidence interval [CI], -0.17 to -0.02), at 4 months (WMD, -0.09; 95% CI, -0.15 to -0.03), at 6 months (WMD, -0.13; 95% CI, -0.21 to -0.05), and in CMT at 1 month (WMD, -88.14; 95% CI, -105.86 to -70.43). Increased intraocular pressure (IOP) among patients treated with intravitreal TA was found at 4 months (WMD, 2.83; 95% CI, 1.96 to 3.70), persisting also at 12 months (WMD, 3.78; 95% CI, 2.97 to 4.59), compared with those receiving the standard of care. All outcomes are mostly equivalent at further follow-up times.

CONCLUSIONS

Intravitreal injections of TA may offer certain advantages over the standard of care for ocular inflammatory diseases, especially in the early stage of follow-up. However, it is necessary to take into account risks and benefits of TA treatment for ocular inflammatory diseases due to possible ocular hypertension elicited, in general, by intravitreal injection of corticosteroids.

Retinal tears and rhegmatogenous retinal detachment after intravitreal injections: its prevalence and case reports

PURPOSE

To report the prevalence of postoperative retinal tear or rhegmatogenous retinal detachment secondary to intravitreal injections.

METHODS

Surgical and medical records of patients who received intravitreal injections at the practice of a single retina specialist from January 2004 to May 2013 and who were followed for at least 6 months were investigated retrospectively.

RESULTS

During the study period, a total of 3,907 intravitreal injections were performed in 1,049 eyes of 784 patients (416 males [47%]). The mean number of injections per eye was 3.72 ± 3.43 (range, 1-22). The mean age of the participants was 67.03 ± 13.56 (range, 5-94 years). The mean follow-up time was 31.98 ± 22.86 months (range, 6-144 months). Retinal break or rhegmatogenous retinal detachment occurred in 3 injections of 3 eyes, yielding an overall prevalence of 0.077% per injection and 0.29% per eye.

CONCLUSIONS

Retinal tear and rhegmatogenous detachment are rare complications of intravitreal injection. Precautions should be taken especially in patients having predisposing conditions, such as high myopia, or any other vitreoretinal disorders.

Comparison of intravitreal bevacizumab and dexamethasone implant for the treatment of macula oedema associated with branch retinal vein occlusion

BACKGROUND/AIMS

To compare the functional and anatomical outcomes of intravitreal bevacizumab (IVB) with those of dexamethasone implant injection (IVD) for macular oedema associated with branch retinal vein occlusion (BRVO).

METHODS

Seventy-two patients with centre-involving macular oedema secondary to BRVO were retrospectively enrolled in the study; these patients were treated with either 1.25 mg IVB (44 eyes; mean injections: 2.92±1.38) pro re nata (PRN) by follow-up monthly or 700 µg IVD (28 eyes; mean injections: 1.71±0.47) given at 6-month intervals PRN and were followed for at least 12 months. Main outcome measures were changes in best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

There was no statistically significant difference of mean change of the logarithm of the minimum angle of resolution BCVA between IVB and IVD groups at monthly visits, up to 12 months (all p>0.05); however, there was a trend towards greater BCVA gain in the IVB group than in the IVD group at 6 months (p=0.053). Additionally, 52.6% in the IVB group and 50% in the IVD group gained two or more lines of Snellen visual acuity at 12 months (p=0.85). The mean CFT decreased by 160 µm for the IVB group and by 140.7 µm for the IVD group at 12 months. Both the IVB group and the IVD group achieved statistically similar improvement of CFT at monthly visits, up to 5 months (all p>0.05); however, the CFT began to deteriorate after 5 months in the IVD group, and at 6 months, improvement in the IVB group was significantly greater than that in the IVD group (p=0.007). After a second IVD injection at 6 months, the IVD group showed significant improvement of CFT, and there was no significant difference of CFT change between the IVB and IVD groups until 12 months.

CONCLUSIONS

For macular oedema secondary to BRVO, IVB administered PRN monthly and IVD administered PRN at 6-month intervals, yielded functionally and anatomically comparable outcomes at 12 months.

Changes in retinal blood flow in patients with macular edema secondary to branch retinal vein occlusion before and after intravitreal injection of bevacizumab

PURPOSE

To investigate the effect of intravitreal bevacizumab (IVB) injections for macular edema secondary to acute branch retinal vein occlusion on the retinal microcirculation.

METHODS

The study was a prospective, interventional case series. Central macular thickness using spectral-domain optical coherence tomography and retinal blood flow (RBF) in untreated eyes with macular edema secondary to acute branch retinal vein occlusion in occluded (V1) and opposite venules in affected eyes (V2) and the equivalent venules in contralateral eyes (V3), using laser Doppler velocimetry during follow-up and after IVB injection, were measured.

RESULTS

In 33 eyes with acute branch retinal vein occlusion of <2 months of duration at the first visit, changes in the retinal microcirculation for 1 month was observed; the macular edema improved spontaneously, and the RBF was unchanged in 15 of 33 eyes, and the RBF increased by 23.3% in 18 eyes with persistent macular edema. Twenty-four eyes received an IVB injection (1.25 mg per 0.05 mL). The RBF did not change significantly during follow-up. In 8 of 24 eyes (33%) with improved macular edema 3 months after the treatment, the average RBF values before injection were significantly higher compared with that of eyes with recurrent edema.

CONCLUSION

One IVB injection might have little effect on the retinal microcirculation in patients with macular edema secondary to acute branch retinal vein occlusion at least 3 months after the injection. However, the increased RBF in the occluded venules before injection might be associated with improved macular edema after the IVB injection.

Combination therapy with intravitreal bevacizumab and macular grid and scatter laser photocoagulation in patients with macular edema secondary to branch retinal vein occlusion

PURPOSE

To assess the efficacy of combined intravitreal bevacizumab (IVB) and macular grid and scatter laser photocoagulation in the treatment of macular edema secondary to branch retinal vein occlusion (BRVO) over a 12-month period.

METHODS

A prospective, interventional case series study was conducted in 20 patients. Patients were treated with 3 monthly IVB injections, followed by macular grid laser and scatter laser photocoagulation to nonperfused ischemic retina. Repeated IVB injections were performed on an as-needed basis when patients had recurrent macular edema.

RESULTS

The best-corrected visual acuity of 20/40 or better was achieved in 17 eyes (85%) and a vision gain of 3 lines or more was noted in 12/20 eyes (60%). Mean visual acuity improved from 0.68 logMAR at baseline to 0.28 logMAR at 3 months, 0.26 logMAR at 6 months, and 0.26 logMAR at 12 months (P<0.01). The mean central macular thickness (CMT) was 442 μm at baseline and decreased to 266, 264, 300, and 294 μm at 1, 3, 6, and 12 months' follow-up, respectively (P<0.01). A mild rebound CMT increase was noted at 6 months, which was reduced after bevacizumab reinjection. Ten patients (50%) required repeated IVB injections. Fifteen eyes (75%) have complete edema resolution on optical coherence tomography scan at the 12-month return visit. Overall, patients received an average of 4 injections during the 12-month period. No adverse ocular or systemic events were observed following injections.

CONCLUSIONS

Early IVB injections in combination with subsequent macular grid and scatter laser photocoagulation treatment significantly improved vision and reduced macular edema secondary to BRVO. Further studies are warranted to evaluate the long-term outcomes and safety.

Intracellular delivery of dendrimer triamcinolone acetonide conjugates into microglial and human retinal pigment epithelial cells

Triamcinolone acetonide (TA) is a potent, intermediate-acting, steroid that has anti-inflammatory and anti-angiogenic activity. Intravitreal administration of TA has been used for diabetic macular edema, proliferative diabetic retinopathy and exudative age-related macular degeneration (AMD). However, the hydrophobicity, lack of solubility, and the side effects limit its effectiveness in the treatment of retinal diseases. In this study, we explore a PAMAM dendrimer-TA conjugate (D-TA) as a potential strategy to improve intracellular delivery and efficacy of TA to target cells. The conjugates were prepared with a high drug payload (∼ 21%) and were readily soluble in saline. Compared to free TA, D-TA demonstrated a significantly improved toxicity profile in two important target [microglial and human retinal pigment epithelium (RPE)] cells. The D-TA was ∼ 100-fold more effective than free TA in its anti-inflammatory activity (measured in microglia), and in suppressing VEGF production (in hypoxic RPE cells). Dendrimer-based delivery may improve the efficacy of TA towards both its key targets of inflammation and VEGF production, with significant clinical implications.

Ranibizumab for Branch Retinal Vein Occlusion Associated Macular Edema Study (RABAMES): six-month results of a prospective randomized clinical trial

PURPOSE

To compare standard-of-care grid laser photocoagulation versus intravitreal ranibizumab (IVR) versus a combination of both in the treatment of chronic (>3 months) macular oedema secondary to branch retinal vein occlusion.

METHODS

Prospective, randomized, multicentre clinical trial. Thirty patients with a best-corrected visual acuity (BCVA) between 20/320 and 20/40 were randomized 1:1:1 to receive grid laser or three monthly injections of 0.5 mg IVR or both followed by 3 months of observation.

RESULTS

Mean change from baseline BCVA at month 6 was +2 letters [laser; 0.04 logMAR, 95% confidence interval (-0.17; 0.25)], +17 letters [IVR; 0.34 (0.19; 0.5)] and +6 letters [combination; 0.12 (0.01; 0.24)] (IVR versus laser p = 0.02 and IVR versus combination p = 0.02). At month 3, mean improvement in central retinal thickness (CRT) was 90.6 μm (laser) (-18.65; 199.8), 379.5 μm (IVR) (204.2; -554.8), and 248 μm (167.2; -328.8) (combination) (IVR versus laser p = 0.005, laser versus combination p = 0.02). During the observation period, CRT improved in laser [37.6 μm (-66.82; 142.0)], but deteriorated in IVR [-142.4 μm (-247.6; -37.16)] and combination [-171.7 μm (-250.4; -92.96)] (laser versus IVR p = 0.01, laser versus combination p = 0.002) indicating recurrent oedema. Less laser retreatments (at 8 weeks) were required in combination group (2/10) than grid group (7/10).

CONCLUSION

Six-month results suggest that ranibizumab may be superior to grid laser in improving visual acuity. Grid combined with IVR neither enhanced functional and morphological improvement of IVR nor did it prevent or prolong recurrence of oedema. In IVR groups, CRT increased slowly after stopping injections, whereas improvement in visual acuity was sustained, indicating that morphological changes occur prior to functional impairment.

Strategy for the management of macular edema in retinal vein occlusion: the European VitreoRetinal Society macular edema study

Objective. To compare the efficacy of different therapies in the treatment of macular edema associated with retinal vein occlusion (RVO). Design. This is a nonrandomized, multicenter collaborative study. Participants. 86 retina specialists from 29 countries provided clinical information, including choice of treatment and outcome, on 2,603 patients with macular edema including 738 cases of RVO. Methods. Reported data included the type and number of treatments performed, visual acuities, and other clinical and diagnostic findings. Main Outcome Measures. The mean increase in visual acuity and mean number of treatments performed. Results. 358 cases of central retinal vein occlusion (CRVO) and 380 cases of branch retinal vein occlusion (BRVO) were included in this investigation. Taking all RVO cases together, pars plana vitrectomy with internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than other therapies. Those treated with intravitreal antivascular endothelial growth factor (anti-VEGF) injection alone showed the second greatest improvement in vision. Dexamethasone intravitreal implant alone and intravitreal triamcinolone alone both resulted in modest visual gains. Conclusions. In the treatment of macular edema in RVO, vitrectomy with ILM peeling may achieve visual improvement and may be a good option for certain cases. Anti-VEGF injection is the most effective of the nonsurgical treatments.

Comparative evaluation between ranibizumab combined with laser and bevacizumab combined with laser versus laser alone for macular oedema secondary to branch retinal vein occlusion

Purpose:

To evaluate the anatomical and functional efficacy of combination therapy of intravitreal ranibizumab with laser or intravitreal bevacizumab with laser treatment compared to only laser treatment for macular edema due to branch retinal vein occlusion (BRVO).

Materials and Methods:

Thirty eyes of 30 patients with BRVO of at least 6 weeks duration were randomized into three groups: Group 1 received a single dose of intravitreal Ranibizumab followed by grid laser treatment, Group 2 received a single dose of intravitreal Bevacizumab followed by grid laser treatment, and Group 3 received grid laser alone. Outcomes at 6 months follow-up were reported. Data were collected on best corrected visual acuity (BCVA), central foveal thickness (CFT), and gain in lines of Snellen acuity.

Results:

At 6 month follow-up, the difference in the mean BCVA and CFT between the three treatment groups was not statistically significant (P > 0.05, all comparisons). Six eyes (60%) in Group 1, four eyes (40%) in Group 2 and two eyes (20%) in Group 3 had a statistically significant gain of ≥3 lines of Snellen acuity (P < 0.05).

Conclusion:

Both ranibizumab and bevacizumab combined with laser photocoagulation, resulted in better outcomes than grid laser treatment.

Indirect comparisons of ranibizumab and dexamethasone in macular oedema secondary to retinal vein occlusion

Background

Two treatments, ranibizumab and dexamethasone implant, for visual impairment due to macular oedema (ME) secondary to retinal vein occlusion (RVO) have recently been studied in clinical trials. There have been no head to head comparisons of the two treatments, and improvement measured as gain in Best Corrected Visual Acuity (BCVA) was reported using different outcomes thresholds between trials. To overcome these limitations, and inform an economic model, we developed a combination of a multinomial model and an indirect Bayesian comparison model for multinomial outcomes.

Methods

Outcomes of change from baseline in BCVA for dexamethasone compatible with those available for ranibizumab, reported by 4 randomised controlled trials, were estimated by fitting a multinomial distribution model to the probability of a patient achieving outcomes in a range of changes from baseline in BCVA (numbers of letters) at month 1. A Bayesian indirect comparison multinomial model was then developed to compare treatments in the Branch RVO (BRVO) and Central RVO (CRVO) populations.

Results

The multinomial model had excellent fit to the observed results. With the Bayesian indirect comparison, the probabilities of achieving ≥20 letters, with 95% credible intervals, at month 1 in patients with BRVO were 0.191 (0.130, 0.261) with ranibizumab and 0.093 (0.027, 0.213) with dexamethasone. In patients with CRVO, probabilities were 0.133 (0.082, 0.195) (ranibizumab) and 0.063 (0.016, 0.153) (dexamethasone). Probabilities of a gain in ≥10 letters in BRVO patients were 0.500 (0.365, 0.650) v 0.459 (0.248, 0.724) and in CRVO patients 0.459 (0.332, 0.602) v 0.498 (0.263, 0.791) for ranibizumab and dexamethasone treatments respectively. The comparisons also favoured ranibizumab at month 6 although changes to therapies after month 3 may have introduced bias.

Conclusion

The newly developed combination of multinomial and indirect Bayesian comparison models indicated a trend for ranibizumab association with a greater percentage of ME patients achieving visual gains than dexamethasone at months 1 and 6 in a common clinical context, although results were not classically significant. The method was a useful tool for comparisons of probability distributions between clinical trials that reported events on different categorical scales and estimates can be used to inform economic models.

Intravitreal ranibizumab for retinal vein occlusion through 1 year in clinical practice

PURPOSE

To evaluate the efficacy and safety of intravitreal ranibizumab for branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) in daily clinical practice.

METHODS

A prospective study enrolling all patients diagnosed with BRVO or CRVO who received intravitreal ranibizumab therapy at our department.

RESULTS

Fifty-seven patients had BRVO and 49 had CRVO. By 12 months, the patients with BRVO improved a mean of 11.6 (P < 0.0001) ETDRS (Early Treatment Diabetic Retinopathy Study) letters, whereas the patients with CRVO improved a mean of 1.8 letters (P = 0.50). The proportion of patients gaining ≥ 15 ETDRS letters was 26.3% for BRVO and 16.7% for CRVO. The proportion of patients losing ≥ 15 ETDRS letters was 0% for BRVO and 8.3% for CRVO. The reduction in foveal center point thickness at 12 months was 248 μm for BRVO (P < 0.0001) and 222 μm for CRVO (P < 0.0001). Functional outcome did not mirror anatomical outcome, and younger patients had better outcome.

CONCLUSION

Our 12-month results of BRVO treated with intravitreal ranibizumab in daily clinical practice are similar to the results of the BRAVO trial that led to the approval of the therapy. However, our results for CRVO failed to reproduce the results of the CRUISE trial.

Indications for intravitreal bevacizumab in ibadan, sub-saharan Africa

BACKGROUND

Angiogenesis is a contributing factor in some retinal diseases, hence the role of vascular endothelial growth factor (VEGF) as a common pathway in proliferative retinopathies. Bevacizumab has been found to be effective in the treatment of these diseases. The aim of this study was to review all cases of intravitreal bevacizumab given in the retinal unit of the University College Hospital, Ibadan from July, 2010 to June 2012, pointing out the common indications.

METHODS

After obtaining ethical approval from the University College Hospital/University of Ibadan Review Board for the study, all cases of intravitreal injections of bevacizumab recorded in the retinal register during the study period (July 2010 to June 2012) were retrieved. Age, sex, diagnoses and indication for injection were recorded in the data sheet prepared for the study. Results were analyzed using proportions and percentages.

RESULTS

A total of one hundred and thirty four injections of bevacizumab were given in the study period. The most common indication was cystoid macular edema from retinal vein occlusion ([26(19.4%)] followed by wet age related maculopathy [23(17.1%)] and sickle cell retinopathy [(22(16.4)]. Emerging indications included idiopathic polypoidal choroidal vasculopathy [8(6%) and retinal macroaneurism with macular edema [6(4.5%)].

CONCLUSION

Cystoid macular edema from vascular occlusion and wet age related macular degeneration are the major indications for intravitreal bevacizumab injection in Ibadan.

Management of macular edema secondary to branch retinal vein occlusion in an eye with prior vitrectomy and lensectomy

An 82-year-old male with a history of pars plana vitrectomy and lensectomy 6 years before presented with symptomatic macular edema (ME) from superotemporal branch retinal vein occlusion. He was sequentially treated with intravitreal agents, bevacizumab (IVB) 1.25 mg, ranibizumab (RBZ) 0.5, 1.0 and 2 mg, triamcinolone acetonide (IVTA) 1 mg, and aflibercept (IAI) 2 mg. The therapeutic benefit from IVB and RBZ was short-lived – although a decrease in ME and improvement in visual acuity were observed, a completely dry macula was not achieved even after 1 week of treatment with any dose of these agents, including 2.0 mg RBZ. IVTA achieved a dry macula for 7 weeks. IAI yielded a dry macula and improved vision with monthly injections. However, regression of the therapeutic benefit was noted at 5 weeks after the IAI injection. A stronger affinity of IAI to vascular endothelial growth factor (VEGF) compared to other anti-VEGF agents is likely responsible for the observed therapeutic effect for 1 month, making this agent preferable for the management of symptomatic ME in a vitrectomized eye.

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.

Subthreshold grid laser versus intravitreal bevacizumab as second-line therapy for macular edema in branch retinal vein occlusion recurring after conventional grid laser treatment

PURPOSE

To compare the effects of subthreshold grid laser treatment (SGLT) and intravitreal bevacizumab injection (IVBI) for the treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO) recurring after conventional grid laser photocoagulation.

METHODS

Thirty-five eyes were considered in this prospective, randomised, interventional study and treated with micropulse diode laser (SGLT subgroup) or IVBI (IVBI subgroup). SGLT was administered once, whereas IVBI (1.25 mg) was given at baseline and then on a pro re nata regimen according to ME presence on optical coherence tomography (OCT), performed at monthly examinations over a 12-month follow-up. Primary outcome measures were the mean BCVA changes over the follow-up and the decrease in mean central foveal thickness (CFT) on optical coherence tomography (OCT). Secondary outcomes included the proportion of eyes that gained at least 15 letters (approximately three lines) at the 12-month examination.

RESULTS

Eighteen and 17 patients were assigned to SGLT and IVBI subgroups, respectively. At baseline, the subgroups were similar with regard to mean ME duration, BCVA, and CFT. At month 12, mean CFT significantly improved from 484 μm to 271 μm in the IVBI subgroup, whereas it was unchanged in the SGLT subgroup. Mean BCVA changed from 0.92 ± 0.3 (LogMAR) to 0.99 ± 0.2 in the SGLT subgroup; in the IVBI subgroup, mean BCVA showed a statistically significant improvement from 0.94 ± 0.3 to 0.72 ± 0.2. Ten patients in the IVBI subgroup (58 %) and no patient in the SGLT subgroup gained at least three lines.

CONCLUSION

At the 1-year follow-up, IVBI provided a significant functional and anatomical improvement, whereas SGLT failed to demonstrate any beneficial effects. IVBI might be a useful approach in the treatment of recurrent ME secondary to BRVO already treated with conventional grid laser photocoagulation. UMIN registry, number UMIN000005014, URL: http://www.umin.ac.jp/ctr/index.htm.

Long-term outcome after vitrectomy for macular edema with retinal vein occlusion dividing into the occlusion site

Purpose. To investigate the efficacy of treatment for macular edema secondary to retinal vein occlusion (RVO) with vitrectomy. Methods. This retrospective study identified patients with macular edema associated with RVO between January 2004 and April 2006. Inclusion criteria were eyes with (1) preoperative visual acuity (VA) of 20/40 or worse, (2) a central foveal thickness (CFT) greater than 250 μm, and (3) vitrectomy with internal limiting membrane and intravitreal triamcinolone acetonide. Each patient had their RVO classified as a major or macular BRVO or hemispheric RVO (HSRVO). Results. Forty-six eyes with major BRVO, 18 eyes with macular BRVO, and 17 eyes with HSRVO were investigated. VA was significantly improved at 24 months after surgery for each group (P < 0.05). Vision in the macular BRVO group 24 months after surgery was significantly better than that in other groups (P < 0.05). For each group, a concomitant reduction of CFT was noted at every time point when compared to preoperative values (P < 0.001). Conclusions. In macular BRVO, the postoperative vision 24 months after surgery was significantly better than the other groups. These findings suggest that additional and earlier treatments might be more important for patients with major BRVO and HSRVO than for those with macular BRVO.

Intravitreal aflibercept for macular edema following branch retinal vein occlusion: the 24-week results of the VIBRANT study

PURPOSE

To compare the efficacy and safety of intravitreal aflibercept injection (IAI) with macular grid laser photocoagulation for the treatment of macular edema after branch retinal vein occlusion (BRVO).

DESIGN

The VIBRANT study was a double-masked, active-controlled, randomized, phase III trial.

PARTICIPANTS

Treatment-naïve eyes with macular edema after BRVO were included in the study if the occlusion occurred within 12 months and best-corrected visual acuity (BCVA) was between ≤73 and ≥24 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (20/40-20/320 Snellen equivalent).

METHODS

Eyes (1 eye per patient) received either IAI 2 mg every 4 weeks (n=91) from baseline to week 20 or grid laser (n=92) at baseline with a single grid laser rescue treatment, if needed, from weeks 12 through 20.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eyes that gained ≥15 ETDRS letters from baseline BCVA at week 24. Secondary end points included mean change from baseline BCVA and central retinal thickness (CRT) at week 24.

RESULTS

The proportion of eyes that gained ≥15 ETDRS letters from baseline at week 24 was 52.7% in the IAI group compared with 26.7% in the laser group (P=0.0003). The mean improvement from baseline BCVA at week 24 was 17.0 ETDRS letters in the IAI group and 6.9 ETDRS letters in the laser group (P<0.0001). The mean reduction in CRT from baseline at week 24 was 280.5 μm in the IAI group and 128.0 μm in the laser group (P<0.0001). Traumatic cataract in an IAI patient was the only ocular serious adverse event (SAE) that occurred. There were no cases of intraocular inflammation or endophthalmitis. The incidence of nonocular SAEs was 8.8% in the IAI group and 9.8% in the laser group. One Anti-Platelet Trialists' Collaboration-defined event of nonfatal stroke (1.1%) and 1 death (1.1%) due to pneumonia occurred during the 24 weeks of the study, both in patients in the laser group.

CONCLUSIONS

Monthly IAI provided significantly greater visual benefit and reduction in CRT at 24 weeks than grid laser photocoagulation in eyes with macular edema after BRVO.

Ranibizumab in retinal vein occlusion: treatment recommendations by an expert panel

Retinal vein occlusion (RVO) is a common cause of retinal vascular disease, resulting in potentially irreversible loss of vision despite the existence of several therapeutic options. The humanised monoclonal antibody fragment ranibizumab binds to and inhibits vascular endothelial growth factor, a key driver of macular oedema in RVO. In 2010, ranibizumab was approved in the USA for the treatment of macular oedema in RVO and, in 2011, ranibizumab was approved in the European Union for the treatment of visual impairment caused by macular oedema secondary to RVO in branch and central RVO. Ranibizumab provides an additional therapeutic option for this complex disease: an option that was not fully considered during the preparation of current international guidelines. An expert panel was convened to critically evaluate the evidence for treatment with ranibizumab in patients with visual impairment caused by macular oedema secondary to RVO and to develop treatment recommendations, with the aim of assisting physicians to optimise patient treatment.

Optical coherence tomographic and visual results at six months after transitioning to aflibercept for patients on prior ranibizumab or bevacizumab treatment for exudative age-related macular degeneration (an American Ophthalmological Society thesis)

PURPOSE

To study optical coherence tomographic (OCT) results and vision at 6 months after transition (post-Tx) from intravitreal bevacizumab and/or ranibizumab to aflibercept for treatment of neovascular age-related macular degeneration (nAMD). The null hypothesis was the lack of improvements in OCT metrics and vision outcome in study eyes at 6 months after transitioning from bevacizumab or ranibizumab to aflibercept.

METHODS

This retrospective study assessed 6 monthly OCT (Cirrus) data after transitioning to aflibercept for eyes on prior Legacy-ranibizumab, Legacy-bevacizumab, or mixed treatment for nAMD. Outcome measures were subretinal fluid (SRF), cystoid macular edema (CME), pigment epithelial detachment (PED) heights and volumes, central 1- and 3-mm subfield, Macular Volume, and best spectacle and pinhole visual acuity (VA). A single masked investigator performed all OCT measurements.

RESULTS

One hundred eighty-nine eyes in 172 patients in Legacy-bevacizumab (95 eyes), Legacy-ranibizumab (84 eyes), or Mixed Group(10 eyes) were switched to aflibercept and followed for 6 months. Significant post-Tx reductions were noted in SRF/CME heights and volumes (all P<.001). Similar findings were noted for PED heights (122.8 μm vs 79.4 μm) and PED volumes (all P<.001). Post-Tx VA was better (20/43 vs 20/51, P<.001). There were no differences between Legacy-bevacizumab and Legacy-ranibizumab groups in OCT and VA changes. Post-Tx VA, SRF/CME, and PED heights and volumes were improved for Nonresponders (suboptimal response to bevacizumab/ranibizumab) (P=.001 to <.001), but not Responders (good responses to same). The only adverse event was a retinal pigment epithelial tear in one eye.

CONCLUSIONS

Significant improvements in vision and OCT metrics developed in Nonresponders but not in Responders. Post-Tx VA and OCT measures were similar for eyes on prior bevacizumab or ranibizumab. Post-Tx adverse events were uncommon.

Steroid differentiation: the safety profile of various steroids on retinal cells in vitro and their implications for clinical use (an American Ophthalmological Society thesis)

PURPOSE

To determine if potentially viable alternatives to the clinical use of intravitreal triamcinolone acetonide should be considered based on a comparative assessment of the in vitro effects of five commercially available corticosteroids. We hypothesized that dexamethasone, betamethasone, methylprednisolone, loteprednol etabonate, and fluocinolone acetonide, at clinically relevant doses, may show different levels of in vitro cytotoxicity to retinal cells.

METHODS

Cultures of human retinal pigment epithelial cells (ARPE-19) and rat embryonal neurosensory precursor retinal cells (R28) were treated with dexamethasone, betamethasone, methylprednisolone, loteprednol, or fluocinolone acetonide. Cell viability as a measure of cell death was determined by trypan blue dye exclusion assay. The mechanical effect of drug crystals was evaluated by solubilizing the steroid formulations. Mitochondrial dehydrogenase and membrane potential were assessed to measure cell damage.

RESULTS

Betamethasone, loteprednol, and methylprednisolone, in commercially available forms, caused significant cytotoxic changes to retinal cells in vitro at clinically relevant doses. This effect was less pronounced with solubilized betamethasone. Dexamethasone at concentrations up to 5 times the clinical dose of free drug injections and 1000 times greater than a drug implant did not cause decreased cell viability. Fluocinolone acetonide at doses 1000 times higher than observed with drug delivery systems showed no cytotoxic effect.

CONCLUSIONS

Betamethasone, loteprednol, and methylprednisolone exhibited cytotoxicity at clinically relevant doses and do not appear to be good therapeutic options for intravitreal use. In comparison, dexamethasone and fluocinolone acetonide, which exhibited fewer cytotoxic effects than other steroids, may be potentially viable alternatives to triamcinolone acetonide for clinical use.

Intravitreal dexamethasone implant in patients with persistent macular edema of variable etiologies

PURPOSE

To examine the effect of an intravitreal dexamethasone drug delivery system (DEX-DDS) in the treatment of persistent cystoid macular edema (CME) of different etiologies.

METHODS

Thirty-seven eyes with persistent CME were treated with DEX-DDS and analyzed for changes in best-corrected visual acuity (BCVA) and optical coherence tomography. Eyes were categorized into three groups: diabetic macular edema (DME, n = 14), vein occlusion (n = 15) and uveitis (n = 7).

RESULTS

The mean follow-up was 22 ± 6.9 weeks. BCVA improved from 0.62 ± 0.38 to 0.35 ± 0.29 logMAR (p < 0.0001). Central macular thickness decreased by 184 ± 246 µm from baseline (p < 0.0001). In eyes where CME resolved and recurred, the average CME-free period was 11 weeks. The uveitis group showed faster CME resolution (2 weeks) and a longer CME-free period (20 weeks). Similar efficacy was shown for repeat DEX-DDS injections. The safety profile was good.

CONCLUSION

DEX-DDS is beneficial in the treatment of persistent CME. In cases of uveitis, CME resolution is rapid, resulting in the longest effect duration, when compared with other CME etiologies.

Baseline characteristics and response to treatment of participants with hemiretinal compared with branch retinal or central retinal vein occlusion in the standard care vs corticosteroid for retinal vein occlusion (SCORE) study: SCORE study report 14

OBJECTIVE

To compare baseline characteristics and treatment response of participants with hemiretinal vein occlusion (HRVO) with those of participants with branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) in the Standard Care vs COrticosteroid for REtinal Vein Occlusion (SCORE) Study.

METHODS

Eyes were randomized to standard care, 1 mg intravitreal triamcinolone acetonide, or 4 mg intravitreal triamcinolone acetonide. Standard care was observation in the SCORE-CRVO trial and grid photocoagulation in the SCORE-BRVO trial. The HRVO eyes were enrolled in the SCORE-BRVO trial. Baseline characteristics, changes in visual acuity and center point thickness, safety outcomes, and number of treatments were compared among HRVO, BRVO, and CRVO participants.

RESULTS

At baseline, HRVO eyes were intermediate between BRVO and CRVO eyes in area of retinal thickening, area of fluorescein leakage, visual acuity, and center point thickness. No differences in visual acuity change from baseline to 1 year were noted between standard care groups for HRVO and BRVO. Within triamcinolone-treated eyes, HRVO eyes did not differ from BRVO eyes in visual acuity change, but HRVO eyes fared better than CRVO eyes. There were no differences in center point thickness change between standard care groups for HRVO and BRVO, nor were there differences across the 3 disease entities for triamcinolone-treated eyes. There were no differences in frequency of protocol treatments and adverse events.

CONCLUSIONS

The HRVO participants were similar to BRVO and CRVO participants regarding most demographic characteristics, with fundus findings intermediate between BRVO and CRVO. In the SCORE Study, HRVO was treated as BRVO; HRVO eyes responded to treatment similarly to BRVO eyes, and there was no difference among the 3 disease entities in frequency of protocol treatments and adverse events.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00105027.

A 6-month, subject-masked, randomized controlled study to assess efficacy of dexamethasone as an adjunct to bevacizumab compared with bevacizumab alone in the treatment of patients with macular edema due to central or branch retinal vein occlusion

Aims

To determine if intravitreal bevacizumab combined with the dexamethasone intravitreal implant 0.7 mg improves visual acuity and macular thickness more than bevacizumab monotherapy in eyes with macular edema due to branch and central retinal vein occlusions.

Methods

Thirty eyes were randomly assigned to receive either combination therapy or bevacizumab monotherapy. All patients received intravitreal bevacizumab at baseline, followed by dexamethasone implants or sham injections 1 week later. Monthly bevacizumab injections were given if the central subfield thickness (CST) was >250 μm, and the combined group received a second implant at month 4 or 5 if CST was >250 μm.

Results

At 6 months, several secondary endpoints were met. Patients receiving combined therapy required fewer bevacizumab reinjections compared to those receiving monotherapy (two versus three; P=0.02), experienced greater mean reductions in CST from randomization (−56 μm versus +45 μm; P=0.01), and were more likely to have resolved all edema (CST <250 μm) (7/11 versus 2/14; P=0.02). The primary endpoint was not met since mean visual acuity changes from baseline were similar in the two groups (P=0.75).

Conclusion

In patients with macular edema due to vein occlusions, bevacizumab with dexamethasone implants produces greater improvements in macular thickness compared to bevacizumab monotherapy, despite fewer bevacizumab injections.

Patient's self-recognition of reduced visual acuity due to recurrence of macular edema and prompt visitation to the hospital in retinal vein occlusion

PURPOSE

To evaluate patients' self-recognition of reduced visual acuity due to recurring macular edema in retinal vein occlusion.

METHODS

A retrospective review of medical records of patients who were diagnosed with recurring macular edema secondary to retinal vein occlusion was performed. The proportion of patients who recognized reduced visual acuity due to the recurrence of macular edema and who visited the hospital before the scheduled follow-up date was determined. Parameters including age, sex, diagnosis, visual acuity before recurrence of macular edema, and extent of visual acuity reduction due to recurrence of macular edema were compared in patients who recognized a reduction in visual acuity and those who did not. The proportion of patients who visited the hospital promptly was also determined.

RESULTS

Forty eyes of 40 patients were included in the analysis. Sixteen and 24 patients were diagnosed with central retinal vein occlusion and branch retinal vein occlusion, respectively. Twenty-one patients (52.5%) recognized reduced visual acuity due to recurring macular edema. These patients were younger (59.2 ± 7.6 vs. 64.8 ± 9.4 years, p = 0.046), had better visual acuity before recurrence of macular edema (0.52 ± 0.48 vs. 1.02 ± 0.46, p = 0.002), and exhibited a greater reduction in visual acuity after recurrence of macular edema (0.34 ± 0.24 vs. 0.14 ± 0.13, p = 0.003). Only four patients visited the hospital before the scheduled follow-up date, and all of these patients lived relatively close to the hospital.

CONCLUSIONS

For prompt treatment of recurring macular edema, more intensive education about the self-estimation of visual acuity is necessary, particularly for elderly patients who have relatively poor visual acuity. In addition, a simple and easy way to identify the recurrence of macular edema at the local clinic should be established for patients who live relatively far from the hospital.

A United Kingdom-based economic evaluation of ranibizumab for patients with retinal vein occlusion (RVO)

OBJECTIVE

This study compares the cost-effectiveness of intravitreal ranibizumab vs observation and/or laser photocoagulation for treatment of macular edema secondary to retinal vein occlusion in a UK-based model.

METHODS

A Markov model was constructed using transition probabilities and frequency of adverse events derived using data from the BRAVO, CRUISE, and HORIZON trials. Outcomes associated with treatments and health states were combined to predict overall health costs and outcomes for cohorts treated with each option.

RESULTS

In branch retinal vein occlusion, ranibizumab produced a gain of 0.518 quality-adjusted life years at an incremental cost of £8141, compared with laser photocoagulation. The incremental cost-effectiveness ratio was £15,710 per quality-adjusted life year, and the incremental cost per month free from blindness was £658. In central retinal vein occlusion, ranibizumab produced a gain of 0.539 quality-adjusted life years at an incremental cost of £9216, compared with observation only. The incremental cost-effectiveness ratio was £17,103, and the incremental cost per month free from blindness was £423.

CONCLUSIONS

These incremental cost-effectiveness ratios are below the £20,000-30,000 range typically accepted as a threshold for cost-effectiveness. This suggests that ranibizumab may be regarded as a cost-effective therapy for patients with macular edema secondary to retinal vein occlusion, relative to grid laser photocoagulation (for BRVO) and observation (for CRVO). Limitations include sparse data for utilities associated with the severity of visual impairment in the WSE in patients with RVO. A lack of direct comparative evidence between ranibizumab and the dexamethasone intravitreal implant for the treatment of BRVO and CRVO and the infeasibility of an indirect comparison due to significant heterogeneity in trial designs prevented the inclusion of this treatment as a comparator in the Markov model.