Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER study year 2

Current knowledge and trends in age-related macular degeneration: today's and future treatments

PURPOSE

To address the most dynamic and current issues concerning today's treatment options and promising research efforts regarding treatment for age-related macular degeneration. This review is aimed to serve as a practical reference for more in-depth reviews on the subject.

METHODS

An online review of the database PubMed and Ovid were performed, searching for the key words age-related macular degeneration, AMD, VEGF, treatment, PDT, steroids, bevacizumab, ranibizumab, VEGF-trap, radiation, combined therapy, as well as their compound phrases. The search was limited to articles published since 1985. All returned articles were carefully screened, and their references were manually reviewed for additional relevant data. The web page www.clinicaltrials.gov was also accessed in search of relevant research trials.

RESULTS

A total of 363 articles were reviewed, including 64 additional articles extracted from the references. At the end, only 160 references were included in this review.

CONCLUSION

Treatment for age-related macular degeneration is a very dynamic research field. While current treatments are mainly aimed at blocking vascular endothelial growth factor, future treatments seek to prevent vision loss because of scarring. Promising efforts have been made to address the dry form of the disease, which has lacked effective treatment.

[Long-term treatment with intravitreal ranibizumab for exudative age-related macular degeneration]

INTRODUCTION

The results of intravitreal ranibizumab treatment for exsudative age-related macular degeneration have been favourable until this time.

AIM

To evaluate the two-year functional and anatomic results of intravitreal ranibizumab treatment.

METHOD

46 patients (age: 75 ± 9.1 years) were included in a prospective single center study. Treatment regimen was the following: monthly 0.5 mg ranibizumab was administered in the first 3 months, and later as required (pro re nata). The change of best corrected visual acuity and central retinal thickness was followed.

RESULTS

The visus change at the end of the follow-up time was not statistically significant compared to baseline (p = 0.760) and the at the end of the first year (p = 0.154). Central retinal thickness decreased significantly compared to baseline (p = 0.000001), but the change was not statistically significant compared to the end of the first year (p = 0.875).

CONCLUSIONS

Patients with neovascular macular degeneration treated with intravitreal ranibizumab using pro re nata regimen have stable visus for long term, and the exsudation could be reduced efficiently.

Efficacy of treatment with ranibizumab in patients with wet age-related macular degeneration in routine clinical care: data from the COMPASS health services research

Background

To assess healthcare processes during treatment of neovascular age-related macular degeneration (AMD) in patients under real-life conditions and evaluate efficacy of monthly visual acuity (VA) assessment in a pro re nata treatment regime.

Methods

A multicentre, prospective, non-interventional study based in Germany included neovascular AMD patients treated with intravitreal ranibizumab. Patients completed a 3-month loading phase with monthly intravitreal injections of 0.5 mg ranibizumab, followed by a 12-month maintenance phase during which investigators documented VA, additional injections, metamorphopsias, routine ophthalmological examinations and adverse events at monthly follow-up visits. Efficacy analysis included change from baseline in best-corrected VA (BCVA) based on descriptive statistics.

Results

A total of 2,232 patients were enrolled throughout Germany and 1,729 patients (mean age 77.8 years, 63.2 % women) comprised the efficacy population with a complete set of data. In the clinical setting recorded in our study, only a minority of patients underwent optical coherence tomography during the maintenance phase (71 of 1,729 patients). Patients received a mean total of 4.5 injections; three injections during upload phase and 1.5 additional injections during maintenance phase. Over half of the patients (51.4 %) did not receive additional injections. Mean decimal BCVA increased during the upload phase, (from LogMAR mean of 0.201 at baseline to 0.219 at Month 4) but displayed a decline over time (0.192 at Month 15).

Conclusion

Ranibizumab treatment in a real-life setting demonstrated efficacy in neovascular AMD patients, as shown by initial gains in BCVA. However, maintenance and improvement of these gains during the maintenance phase in a clinical routine setting remained below those expected compared with MARINA, ANCHOR and CATT trials, most likely due to a low number of retreatments, and the high number of patients with a poor response in regard to improvements of VA who were not investigated in these studies.

Trial registration number

This phase IV non-interventional health services research study was conducted under the Novartis internal registration code, CRFB002ADE10.

Trophic factors in the pathogenesis and therapy for retinal degenerative diseases

Trophic factors are endogenously secreted proteins that act in an autocrine and/or paracrine fashion to affect vital cellular processes such as proliferation, differentiation, and regeneration, thereby maintaining overall cell homeostasis. In the eye, the major contributors of these molecules are the retinal pigment epithelial (RPE) and Müller cells. The primary paracrine targets of these secreted proteins include the photoreceptors and choriocapillaris. Retinal degenerative diseases such as age-related macular degeneration and retinitis pigmentosa are characterized by aberrant function and/or eventual death of RPE cells, photoreceptors, choriocapillaris, and other retinal cells. We discuss results of in vitro and in vivo animal studies in which candidate trophic factors, either singly or in combination, were used in an attempt to ameliorate photoreceptor and/or retinal degeneration. We also examine current trophic factor therapies as they relate to the treatment of retinal degenerative diseases in clinical studies.

Ranibizumab: a review of its use in the treatment of neovascular age-related macular degeneration

Ranibizumab (Lucentis(®)), an inhibitor of all vascular endothelial growth factor (VEGF) A isoforms, is approved for the intravitreal treatment of neovascular age-related macular degeneration (AMD). In pivotal trials, monthly injections of ranibizumab were superior to verteporfin photodynamic therapy in the treatment of predominantly classic choroidal neovascularization (CNV) due to neovascular AMD (ANCHOR) and sham in the treatment of minimally classic or occult CNV due to neovascular AMD (MARINA). Monthly or less frequent injections of ranibizumab are generally well tolerated and associated with low rates of ocular and systemic serious adverse events (SAEs). Less frequent dosing has been evaluated with the aim of reducing the burden, risk and cost of monthly injections. In the landmark CATT trial, monthly monitoring and retreatment as-needed with ranibizumab was equivalent to monthly treatment in terms of the vision gain at 1 year, but reduced the number of injections (and the related cost) by approximately one-half. In head-to-head comparisons, aflibercept administered bimonthly was noninferior to ranibizumab administered monthly (VIEW 1 and 2), bevacizumab administered monthly was equivalent to ranibizumab administered monthly (CATT), and bevacizumab administered as-needed was equivalent to ranibizumab administered as-needed (CATT). Bevacizumab is widely used (off-label) for economic reasons; while it was less costly than ranibizumab, it was associated with more systemic SAEs. Notwithstanding the availability of other similarly effective anti-VEGF therapies that are approved (aflibercept) or unapproved (bevacizumab), ranibizumab continues to set the standard as regards the totality of evidence from randomized clinical trials demonstrating its efficacy and tolerability (particularly that of the monthly regimen) in the treatment of neovascular AMD.

Recent advances in the management of neovascular glaucoma

The development of anti-vascular endothelial growth factor (VEGF) molecules has expanded the range of available treatment options for many ocular diseases, including neovascular glaucoma (NVG). A number of studies have explored the use of anti-VEGF agents as stand-alone or adjunctive treatment for NVG. Although no large, prospective, randomized trials have been performed to date, the growing body of knowledge suggests that anti-VEGF agents are effective at reversing iris and angle neovascularization and lowering intraocular pressure in patients with NVG. Response to a single injection is typically temporary; therefore, laser or incisional surgery is still necessary in most cases. Future research is needed to determine the optimal agent, dose, route of administration, and timing of treatment either as monotherapy or coupled with other medical and/or surgical interventions.

Real-world variability in ranibizumab treatment and associated clinical, quality of life, and safety outcomes over 24 months in patients with neovascular age-related macular degeneration: the HELIOS study

INTRODUCTION

The aim of this study was to examine ranibizumab treatment patterns in "real-world" practice and clinical settings, as well as to assess quality of life outcomes over a 24-month period.

MATERIALS AND METHODS

This was a prospective, observational, multicenter, open-label study of 0.5 mg of ranibizumab administered intravitreally. Patients were followed over 24 ± 3 months with intermediate data points at 6 ± 2 months and 12 ± 2 months, and a limited data point at 2.5 ± 1 month that coincided with the end of the loading phase. Outcomes included visual acuity (Early Treatment Diabetic Retinopathy Study), visual function (National Eye Institute Visual Function Questionnaire-25 [NEI VFQ-25]), quality of life (Health Utilities Index Mark III [HUI3]), and safety.

RESULTS

A total of 267 patients with wet age-related macular degeneration (mean ± standard deviation [SD] age = 78.5 ± 7.3 years; 62.4% were female; 34.5% with dual eye involvement; 74.9% were treatment-naïve) were treated (309 eyes were treated). The mean ± SD Early Treatment Diabetic Retinopathy Study score at baseline was 56.3 ± 14.3 letters. The mean ± SD number of injections over 24 months was 7.6 ± 4.1, including 2.5 ± 0.7 and 5.9 ± 3.6 during the loading and maintenance phases, respectively, with corresponding treatment intervals of 4.8 ± 1.4 weeks and 11.5 ± 9.5 weeks, respectively. Improvements in visual acuity over baseline were reached at 2.5 months and maintained at 6 months (both P < 0.0001). The mean visual acuity increase over baseline at 12 months was not significant (P = 0.08); the decline over baseline at 24 months statistically significant (P = 0.02). Overall, 94.3% of patients showed stable or improved disease at 6 months and 81.5% of patients showed stable or improved disease at 24 months. At 6 months, improvements over baseline were significant for VFQ-25 (P = 0.03) and HUI3 (P = 0.02), but not at 12 months and 24 months. Improvements in VFQ-25 and HUI3 were maintained at 24 months in 38% and 34% of patients, respectively. In total 78 serious adverse events were reported in 40 patients and 77 nonserious adverse events in 34 patients. Nine serious adverse events and nine nonserious adverse events in 14 patients were suspected to be related to ranibizumab treatment.

CONCLUSION

The "real-world" clinical effectiveness of ranibizumab was evidenced by the initial improvements over baseline in visual acuity and quality of life, as well as the maintenance of these outcomes at baseline levels at 24 months, and this was observed under variable treatment conditions. The findings underscore the need for individualized treatment with regular monitoring to achieve optimal vision and quality of life outcomes.

Predictors of visual response to intravitreal bevacizumab for treatment of neovascular age-related macular degeneration

Purpose. To identify the predictors of visual response to the bevacizumab treatment of neovascular age-related macular degeneration (AMD). Design. A cohort study within the Neovascular AMD Treatment Trial Using Bevacizumab (NATTB). Methods. This was a multicenter trial including 144 participants from the NATTB study. Visual outcomes measured by change in visual acuity (VA) score, proportion gaining ≥15 letters, and change in central retinal thickness (CRT) were compared among groups according to the baseline, demographic, and ocular characteristics and genotypes. Results. Mean change in the VA score was 9.2 ± 2.3 SD letters with a total of 46 participants (31.9%) gaining ≥15 letters. Change in median CRT was −81.5 μm. Younger age, lower baseline VA score, shorter duration of neovascular AMD, and TT genotype in rs10490924 were significantly associated with greater VA score improvement (P = 0.028, P < 0.001, P = 0.02, and P = 0.039, resp.). Lower baseline VA score and TT genotype in rs10490924 were significantly associated with a higher likelihood of gaining ≥15 letters (P = 0.028, and P = 0.021, resp.). Conclusions. Baseline VA and genotype of rs10490924 were both important predictors for visual response to bevacizumab at 6 months. This trial is registered with the Registration no. NCT01306591.

Intravitreal aflibercept for neovascular age-related macular degeneration

Neovascular age-related macular degeneration (AMD) is the leading cause of legal blindness in patients over the age of 50 in the western world. Intravitreally administered anti-VEGF drugs have been developed to halt neovascular growth in AMD. Randomized trials have demonstrated the excellent safety profile and significant benefit of anti-VEGF therapy in maintaining vision. Aflibercept (Eylea(®); Regeneron, NY, USA) is a soluble decoy receptor against VEGF that offers greater potency and binding affinity than other anti-VEGF drugs. Having received US FDA approval for neovascular AMD in November 2011, aflibercept given every 8 weeks after a loading dose was 'clinically equivalent' and statistically noninferior to the current FDA-approved therapy ranibizumab (Lucentis(®); Genentech, CA, USA), given every 4 weeks. This article discusses the clinical background of AMD, development of aflibercept, results of the clinical trials and the future role of aflibercept in ocular neovascular diseases.

Ranibizumab as adjuvant in the treatment of rubeosis iridis and neovascular glaucoma--results from a prospective interventional case series

BACKGROUND

To evaluate the capability of adjuvant intraocular ranibizumab (Lucentis) injections in the treatment of rubeosis and intraocular pressure in patients with rubeosis and neovascular glaucoma.

METHODS

Ten eyes with rubeosis (R) and ten eyes with neovascular glaucoma (NVG) received Lucentis injections (ranibizumab 0.5 mg/0.05 ml) in this prospective, monocenter, 12-months, interventional case series. The primary efficacy outcome measure was the change of degree of iris rubeosis as documented by iris fluorescein angiography measured after 12 months. Secondary outcomes were intraocular pressure (IOP), best-corrected visual acuity (BCVA, logMAR), numbers of additional interventions or antiglaucoma medications administered after injection, the gonioscopic status of the anterior chamber angle, and central retinal thickness.

RESULTS

In the R group, 3.6 injections and in the NVG group 2.3 injections of Lucentis were administered. Additional treatments were photocoagulation (n = 19), cyclodestructive procedures (n = 9), cryopexy (n = 3), and vitrectomy (n = 1). The mean stage of rubeosis was 3.4 ± 0.7 in the R group and 3.6 ± 0.8 in the NVG group at baseline. At month 12, the rubeosis was almost resolved in the R group (0.1 ± 0.3, p < 0.001), and decreased significantly in the NVG group (0.7 ± 1.1, p < 0.001). In the NVG subgroup, mean IOP was 41.4 ± 13.4 mmHg at baseline, which decreased rapidly (18.2 ± 12.3, day-14, p = 0.005) and stabilized during the follow-up (15.6 ± 2.0 mmHg, p < 0.05). BCVA improved significantly in both groups (p < 0.05, at month 12).

CONCLUSIONS

Injection of 0.5 mg ranibizumab appears to be beneficial as an adjuvant treatment in neovascular glaucoma and rubeosis due to its anti-angiogenic properties and its ability to prevent establishment or progression of anterior chamber angle obstruction. Conventional therapeutic procedures addressing the retinal ischemia are still required in a stage-wise treatment approach.

Safety of ranibizumab in routine clinical practice: 1-year retrospective pooled analysis of four European neovascular AMD registries within the LUMINOUS programme

Purpose

Evaluation of 1-year safety profile of intravitreal ranibizumab 0.5 mg in neovascular age-related macular degeneration (NV-AMD) within routine clinical practice.

Methods

The LUMINOUS programme comprises a prospective observational study assessing ranibizumab ‘real-world’ safety and clinical effectiveness across licensed indications worldwide and an annual retrospective pooled safety analysis from completed NV-AMD ranibizumab registries. 1-year data from four European registries are available. This retrospective pooled safety analysis assessed 1-year incidence rates for safety events of particular interest (key ocular or systemic events possibly related to the injection procedure or vascular endothelial growth factor inhibition) together with treatment exposure. Patients were treated according to local protocols within the ranibizumab licence.

Results

Data of 4444 patients from registries in Germany (n=3470), the Netherlands (n=243), Belgium (n=260) and Sweden (n=471) were retrospectively pooled. Between 70.4% and 84.4% of enrolled patients completed 1 year of follow-up. Most frequent overall ocular events of particular interest were retinal pigment epithelial tears (27 patients; <1%) and intraocular pressure-related events (12 patients; <0.3%). Most frequent non-ocular event of particular interest was stroke (19 patients; 0.4%); annual incidence of stroke was low across all registries (0.0–0.5%).

Conclusions

Ranibizumab demonstrated favourable 1-year safety profile for NV-AMD in this routine clinical practice sample, consistent with previous reported trial data. Additional data from a larger patient population are needed to better describe the long-term safety profile of ranibizumab in routine clinical practice and further evaluate risk for infrequent but serious events in ‘real-life’ settings. The 5-year LUMINOUS prospective observational study will address this need.

Antiangiogenic therapy for ischemic retinopathies

Neovascularization is a common pathological process in various retinal vascular disorders including diabetic retinopathy (DR), age-related macular degeneration (AMD) and retinal vein occlusion (RVO). The development of neovascular vessels may lead to complications such as vitreous hemorrhage, fibrovascular tissue formation, and traction retinal detachments. Ultimately, irreversible vision loss may result. Various proangiogenic factors are involved in these complex processes. Different antiangiogenic drugs have been formulated in an attempt treat these vascular disorders. One factor that plays a major role in the development of retinal neovascularization is vascular endothelial growth factor (VEGF). Anti-VEGF agents are currently FDA approved for the treatment of AMD and RVO. They are also extensively used as an off-label treatment for diabetic macular edema (DME), proliferative DR, and neovascular glaucoma. However, at this time, the long-term safety of chronic VEGF inhibition has not been extensively evaluated. A large and rapidly expanding body of research on angiogenesis is being conducted at multiple centers across the globe to determine the exact contributions and interactions among a variety of angiogenic factors in an effort to determine the therapeutic potential of antiangiogenic agent in the treatment of a variety of retinal diseases.

Short-term outcomes of aflibercept for neovascular age-related macular degeneration in eyes previously treated with other vascular endothelial growth factor inhibitors

PURPOSE

To report results of aflibercept therapy in eyes with neovascular age-related macular degeneration previously treated with bevacizumab, ranibizumab, or both.

DESIGN

Retrospective, interventional, noncomparative, consecutive case series.

METHODS

Ninety-six eyes from 85 patients with neovascular age-related macular degeneration who previously had received bevacizumab, ranibizumab, or both were treated with aflibercept monthly for 3 months followed by a fourth injection within 2 months. Outcomes were determined 4 ± 1 months after the first aflibercept dose and included: proportion of patients gaining or losing 2 lines or more of best-corrected visual acuity, proportion remaining within a gain or loss of 1 line, mean change in logarithm of the minimal angle of resolution visual acuity, mean change in central foveal thickness, mean change in macular cube volume, and qualitative anatomic response as assessed by spectral-domain optical coherence tomography.

RESULTS

At baseline, 82 (85%) eyes had signs of active exudation despite a mean of 17 previous anti-vascular endothelial growth factor injections. At final visit, 82 (85%) remained stable within a gain or loss of 1 line, 7 (7%) gained 2 lines or more, and 7 (7%) lost 2 lines or more of best-corrected visual acuity. Mean logarithm of the minimal angle of resolution visual acuity showed minimal change 0.02 (range, -0.46 to 0.70; P = .14). Mean central foveal thickness decreased -18 μm (range, -242 to 198 μm; P = .06). Mean macular volume decreased -0.27 mm(3) (95% confidence interval, -0.4 to -0.1 mm(3); P = .004). On qualitative analysis, 4 (5%) eyes had complete resolution of exudative fluid, 40 (49%) showed partial resolution, 26 (32%) remained unchanged, and 12 (14%) showed worsened exudative fluid.

CONCLUSIONS

Aflibercept seems to be an effective alternative for neovascular age-related macular degeneration patients previously treated with bevacizumab, ranibizumab, or both at 4 months of follow-up. Most treated eyes demonstrated stable visual acuity and anatomic improvements by spectral-domain optical coherence tomography.

Neovascular age-related macular degeneration: individualizing therapy in the era of anti-angiogenic treatments

The treatment of neovascular age-related macular degeneration (AMD) had been revolutionized by the use of anti-vascular endothelial growth factor (VEGF) drugs: bevacizumab and ranibizumab. With the introduction of a third anti-VEGF drug, aflibercept, ophthalmologists have several options to choose from, as well as various treatment regimens they can follow. In this Interview, Jeffrey S. Heier, MD, of Ophthalmic Consultants of Boston, Massachusetts, discusses his approaches to managing the treatment of patients with AMD and providing them with individualized care.

Ocular and systemic safety of bevacizumab and ranibizumab in patients with neovascular age-related macular degeneration

PURPOSE OF REVIEW

This study reviews differences in both ocular and systemic safety between intravitreal bevacizumab and ranibizumab in the setting of neovascular age-related macular degeneration.

RECENT FINDINGS

Serious adverse events associated with either bevacizumab or ranibizumab injections are generally rare. However, acute intraocular inflammation (AII) tends to occur more frequently following bevacizumab injection. Systemic absorption of bevacizumab is greater than with ranibizumab, and many studies have shown an increased risk of systemic adverse events in patients receiving bevacizumab compared with those receiving ranibizumab.

SUMMARY

Although rare, adverse events with off-label use of bevacizumab are more common than with ranibizumab. Continued study into long-term safety of the two agents is warranted.

Three-year visual outcome and injection frequency of intravitreal ranibizumab therapy for neovascular age-related macular degeneration

BACKGROUND

To assess the 3-year visual outcome and injection frequency for patients on ranibizumab for neovascular age-related macular degeneration (NV-AMD).

METHODS

Retrospective case-note review of 174 treatment-naïve eyes of 156 patients with NV-AMD with 3-year follow-up was done at specific time points closest to 12, 24 and 36 months.

RESULTS

The median baseline visual acuity (VA) of 50 Early Treatment Diabetic Retinopathy Study letters (mean 48.2 ± 16.9) improved significantly to 55 (mean 51.2 ± 18.7) by the end of 12 months (p = 0.04). At 24 months, the median letter score remained unchanged at 55 (mean 50.4 ± 20.8; p = 0.14 as compared to baseline) and at 36 months, the median VA was 54 letters (mean 49.1 ± 21.7; p = 0.34 compared to baseline). The mean numbers of injections were 4.8 ± 2.2 at 1 year, 7.8 ± 4.2 at 2 years (2.9 in the second year) and 10.2 ± 6.2 at the end of the third year (2.4 in the third year).

CONCLUSION

Our study demonstrates the efficacy of a variable dosing regimen of ranibizumab for the treatment of NV-AMD. The mean gain in VA is inversely proportional to the baseline VA and did not correlate with the number of injections.

Anatomical measures as predictors of visual outcomes in ranibizumab-treated eyes with neovascular age-related macular degeneration

PURPOSE

To investigate if anatomical characteristics of eyes undergoing ranibizumab therapy were predictive of best-corrected visual acuity (BCVA) outcomes over 2 years.

METHODS

Post hoc analyses of patients with age-related macular degeneration from PIER studies, defined by fundus fluorescein angiography, quantitative optical coherence tomography (OCT), and qualitative OCT, were performed to determine if associations with BCVA outcomes could be found.

RESULTS

Ranibizumab-treated subgroups defined by baseline fundus fluorescein angiography lesion size and composition did not differ in BCVA outcomes at month 24 (P = 0.13-1.0). Inactivity on fundus fluorescein angiography at month 3 was associated with a 12-letter gain by month 12 (P < 0.01), whereas inactivity on month 3 qualitative OCT was not (P > 0.05). Qualitative OCT inactivity at month 5 and separately at month 8 was associated with greater BCVA gains by month 24 (7.1 and 9.5 letters, respectively; P ≤ 0.045) versus eyes with OCT activity.

CONCLUSION

When assessed separately, eyes with qualitative OCT (Months 5 and 8) or fundus fluorescein angiography (months 3 and 5) inactivity maintained vision gain from baseline at month 24, while those with leakage not only lost initial vision gains achieved by intraocular ranibizumab but also had net vision losses from baseline at month 24. The PIER infrequent dosing regimen likely exaggerated and accelerated the deleterious effects of retinal fluid on BCVA, and it is not known whether these findings are applicable to treatment regimens that use more frequent monitoring and dosing of ranibizumab.

Pharmacogenetics of antiangiogenic and antineovascular therapies of age-related macular degeneration

Age-related macular degeneration (AMD), the most common age-related disease causing irreversible visual loss in industrialized countries, is a complex and multifactorial illness. Researchers have found components of the complement alternative pathway inside drusen and Bruch's membrane of AMD patients, underlying a possible important role of complement factor H in the pathogenesis of AMD. The neovascular (wet) AMD is the most destructive form and it is characterized by invasion of new blood vessels into subretinal spaces with subsequent exudation and bleeding, resulting in scarring of the macular region and loss of the central vision. The hallmark of the neovascular form is the choroidal neovascularization, where VEGF-A has an important role in the pathogenesis of the disease. SNPs of these genes have recently been investigated as potential pharmacogenetic markers of the antiangiogenic and antineovascular therapy of AMD, which includes verteporfin photodynamic therapy and anti-VEGF-A drugs, such as pegaptanib, bevacizumab and ranibizumab. The CFH rs1061170 CT and TT genotypes have been associated with an improvement of visual acuity in bevacizumab or ranibizumab treated patients, whereas patients harboring VEGF-A rs699946 G allele responded better to bevacizumab-based therapy if compared with patients carrying the A allele. In conclusion, the discovery of pharmacogenetic markers for the personalization of the antiangiogenic and/or antineovascular therapy could be, in the future, a key issue in ophthalmology to obtain a personalization of the therapy and to avoid unnecessary costs and adverse drug reactions.

Preferred therapies for neovascular age-related macular degeneration

PURPOSE OF REVIEW

This report reviews the current treatment strategies and the most recent clinical trials in the treatment of neovascular age-related macular degeneration.

RECENT FINDINGS

The functional and anatomic outcomes achieved in the pivotal ranibizumab trials with monthly injections set the standard for comparison. Since then, various modified dosing regimens with the aim of lessening the treatment burden associated with monthly injections have been investigated. Additionally, level I evidence now exists for the noninferiority of bevacizumab, as compared to ranibizumab, in the treatment of neovascular age-related macular degeneration (AMD) through 1 year of follow-up. Aflibercept has emerged as a new anti- vascular endothelial growth factor (VEGF) therapy showing encouraging treatment results at 1 year. Novel treatments combined with anti-VEGF agents such as localized radiation are currently being investigated.

SUMMARY

Anti-VEGF monotherapy remains the preferred therapy for the management of neovascular AMD at the present time. Aflibercept is a new, FDA-approved, effective, anti-VEGF agent available for clinical use. Ongoing clinical trials will help determine the optimal dosing regimens for all of these agents, as well as the long-term efficacy and safety of combination therapy modalities.

Twelve-month efficacy and safety of 0.5 mg or 2.0 mg ranibizumab in patients with subfoveal neovascular age-related macular degeneration

OBJECTIVE

To evaluate the 12-month efficacy and safety of intravitreal ranibizumab 0.5 mg and 2.0 mg administered monthly and on an as-needed (PRN) basis in treatment-naïve patients with subfoveal neovascular age-related macular degeneration (wet AMD).

DESIGN

A 24-month, phase III, randomized, multicenter, double-masked, dose-response study.

PARTICIPANTS

Patients aged ≥ 50 years with subfoveal wet AMD.

METHODS

Patients (n = 1098) were randomized to receive ranibizumab 0.5 mg or 2.0 mg intravitreal injections administered monthly or on a PRN basis after 3 monthly loading doses.

MAIN OUTCOME MEASURES

The primary efficacy end point was the mean change from baseline in best-corrected visual acuity (BCVA) at month 12. Key secondary end points included the mean number of ranibizumab injections, the mean change from baseline in central foveal thickness (CFT) over time, and the proportion of patients who gained ≥ 15 letters of BCVA. Unless otherwise specified, end point analyses were performed using the last-observation-carried-forward method to impute missing data.

RESULTS

At month 12, the mean change from baseline in BCVA for the 4 groups was +10.1 letters (0.5 mg monthly), +8.2 letters (0.5 mg PRN), +9.2 letters (2.0 mg monthly), and +8.6 letters (2.0 mg PRN). The proportion of patients who gained ≥ 15 letters from baseline at month 12 in the 4 groups was 34.5%, 30.2%, 36.1%, and 33.0%, respectively. The mean change from baseline in CFT at month 12 in the 4 groups was -172.0 μm, -161.2 μm, -163.3 μm, and -172.4 μm, respectively. The mean number of injections was 7.7 and 6.9 for the 0.5-mg PRN and 2.0-mg PRN groups, respectively. Ocular and systemic safety profiles were consistent with previous ranibizumab trials in AMD and comparable between groups.

CONCLUSIONS

At month 12, the ranibizumab 2.0 mg monthly group did not meet the prespecified superiority comparison and the ranibizumab 0.5 mg and 2.0 mg PRN groups did not meet the prespecified noninferiority (NI) comparison. However, all treatment groups demonstrated clinically meaningful visual improvement (+8.2 to +10.1 letters) and improved anatomic outcomes, with the PRN groups requiring approximately 4 fewer injections (6.9-7.7) than the monthly groups (11.2-11.3). No new safety events were observed despite a 4-fold dose escalation in the study. The pHase III, double-masked, multicenter, randomized, Active treatment-controlled study of the efficacy and safety of 0.5 mg and 2.0 mg Ranibizumab administered monthly or on an as-needed Basis (PRN) in patients with subfoveal neOvasculaR age-related macular degeneration (HARBOR) study confirmed that ranibizumab 0.5 mg dosed monthly provides optimum results in patients with wet AMD.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Epimacular brachytherapy for neovascular age-related macular degeneration: a randomized, controlled trial (CABERNET)

PURPOSE

To evaluate the safety and efficacy of epimacular brachytherapy (EMBT) for the treatment of neovascular age-related macular degeneration (AMD).

DESIGN

Multicenter, randomized, active-controlled, phase III clinical trial.

PARTICIPANTS

Four hundred ninety-four participants with treatment-naïve neovascular AMD.

METHODS

Participants with classic, minimally classic, and occult lesions were randomized in a 2:1 ratio to EMBT or a ranibizumab monotherapy control arm. The EMBT arm received 2 mandated, monthly loading injections of 0.5 mg ranibizumab. The control arm received 3 mandated, monthly loading injections of ranibizumab then quarterly injections. Both arms also received monthly as needed (pro re nata) retreatment.

MAIN OUTCOME MEASURES

The proportion of participants losing fewer than 15 Early Treatment Diabetic Retinopathy Study (ETDRS) letters from baseline visual acuity (VA) and the proportion gaining more than 15 ETDRS letters from baseline VA.

RESULTS

At 24 months, 77% of the EMBT group and 90% of the control group lost fewer than 15 letters. This difference did not meet the prespecified 10% noninferiority margin. This end point was noninferior using a 20% margin and a 95% confidence interval for the group as a whole and for classic and minimally classic lesions, but not for occult lesions. The EMBT did not meet the superiority end point for the proportion of participants gaining more than 15 letters (16% for the EMBT group vs. 26% for the control group): this difference was statistically significant (favoring controls) for occult lesions, but not for predominantly classic and minimally classic lesions. Mean VA change was -2.5 letters in the EMBT arm and +4.4 letters in the control arm. Participants in the EMBT arm received a mean of 6.2 ranibizumab injections versus 10.4 in the control arm. At least 1 serious adverse event occurred in 54% of the EMBT arm, most commonly postvitrectomy cataract, versus 18% in the control arm. Mild, nonproliferative radiation retinopathy occurred in 3% of the EMBT participants, but no case was vision threatening.

CONCLUSIONS

The 2-year efficacy data do not support the routine use of EMBT for treatment-naïve wet AMD, despite an acceptable safety profile. Further safety review is required.

In-vivo investigation of laser-induced choroidal neovascularization in rat using spectral-domain optical coherence tomography (SD-OCT)

PURPOSE

This study investigated the in-vivo formation process of laser-induced choroidal neovascularization (CNV) in rat using high-resolution spectral-domain optical coherence tomography (SD-OCT), and compared the results to histological methods.

METHODS

Brown Norway rats (n = 60, 6-8 weeks of age) received 532-nm diode laser photocoagulation. SD-OCT and fluorescein angiography (FA) were performed in vivo 2, 5, 7, 14, and 21 days post-laser application. Haematoxylin and eosin (H&E) staining and immunohistochemistry for CD31, phosphorylated vascular endothelial factor receptor 2 (pVEGFR2) were conducted at each time point to observe the CNV in vitro. Choroidal flatmount preparations were observed using a confocal laser scanning microscope (CLSM) and a scanning electron microscope (SEM).

RESULTS

SD-OCT monitored the longitudinal morphological changes of laser-induced CNV. CNV reached its maximal size on day 7, and began a gradual reduction on day 14. FA revealed similar dynamic changes in leakage. CNV thickness, as assessed by SD-OCT, was consistent with H&E-stained sections at each time point. CLSM and SEM revealed the details of the fibrovascular membrane. CD31 and pVEGFR2 expression supported the results of SD-OCT and histology.

CONCLUSIONS

SD-OCT was a convenient and reliable tool for the imaging of the CNV formation process and quantification of the lesion size in vivo.

Adherence to ranibizumab treatment for neovascular age-related macular degeneration in real life

BACKGROUND

To identify factors and problems influencing treatment adherence in patients undergoing anti-VEGF therapy for neovascular age-related macular degeneration (AMD) under real-life conditions.

METHODS

Cross-sectional study was conducted of 95 patients receiving ranibizumab therapy on a pro re nata (PRN) regimen with monthly controls in a tertiary health care clinic. Monthly controls included best corrected visual acuity, slit-lamp examination and spectral-domain optical coherence tomography. Adherence was measured using Kaplan-Meier time-to-discontinuation analysis. Patients were asked to respond to a 16-item questionnaire covering items such as anxiety, subjective benefit, and financial issues of therapy.

RESULTS

Forty-two men and 53 women were included. After a mean follow-up time of 675 days (range 63-1008), adherence was 81.1% (77/95). The mean number of follow-up visits was 19 (3-30), the mean number of intravitreal injections was ten (3-23). Seven patients withdrew from treatment due to subjective dissatisfaction with benefit. Other reasons for loss to follow-up were death in one case, serious general disease in three patients, and treatment options closer to home in five cases. Two patients cancelled further follow-up after treatment cessation due to terminal fibrosis. 62.1% of patients were afraid of a negative examination result, whereas 19.0% were afraid of intravitreal injections. A major problem was travel to and from the hospital (46.3%), with 61.5% of patients requiring escort.

CONCLUSION

Despite necessary monthly visits, patients showed a high adherence to therapy. The major problem was travel to and from the hospital. From the patients' point of view, anxiety of a negative examination result was more pronounced than fear of intraocular injections, which would be an argument for continuous injections rather than for a PRN regimen.

Improvement of retinal function in early age-related macular degeneration after lutein and zeaxanthin supplementation: a randomized, double-masked, placebo-controlled trial

PURPOSE

To examine the effects of lutein and zeaxanthin supplementation on retinal function using multifocal electroretinograms (mfERG) in patients with early age-related macular degeneration (AMD).

DESIGN

Randomized, double-masked, placebo-controlled trial.

METHODS

One hundred eight subjects with early AMD were randomly assigned to receive 10 mg/d lutein (n = 27), 20 mg/d lutein (n = 27), 10 mg/d lutein plus 10 mg/d zeaxanthin (n = 27), or placebo (n = 27) for 48 weeks. Thirty-six age-matched controls without AMD were also enrolled to compare baseline data with early AMD patients. MfERG responses and macular pigment optical densities (MPODs) were recorded and analyzed at baseline and at 24 and 48 weeks.

RESULTS

There were significant reductions in N1P1 response densities in ring 1 to ring 3 in early AMD patients compared with the controls (P < .05), whereas neither N1P1 response densities in ring 4 to ring 6 nor P1 peak latencies significantly changed. After 48-week supplementation, the N1P1 response densities showed significant increases in ring 1 for the 20 mg lutein group and for the lutein and zeaxanthin group, and in ring 2 for the 20 mg lutein group. The increases in MPOD related positively to the increases in N1P1 response density in ring 1 and ring 2 for nearly all active treatment groups. N1P1 response densities in ring 3 to ring 6 or P1 peak latencies in all rings did not change significantly in any group.

CONCLUSION

Early functional abnormalities of the central retina in the early AMD patients could be improved by lutein and zeaxanthin supplementation. These improvements may be potentially attributed to the elevations in MPOD.

A safety review and meta-analyses of bevacizumab and ranibizumab: off-label versus goldstandard

BACKGROUND

We set out a systemic review to evaluate whether off-label bevacizumab is as safe as licensed ranibizumab, and whether bevacizumab can be justifiably offered to patients as a treatment for age-related macular degeneration with robust evidence of no differential risk.

METHODS AND FINDINGS

Medline, Embase and the Cochrane Library were searched with no limitations of language and year of publication. We included RCTs with a minimum follow-up of one year which investigated bevacizumab or ranibizumab in direct comparison or against any other control group (indirect comparison). Direct comparison (3 trials, 1333 patients): The one year data show a significantly higher rate of ocular adverse effects (AE) with bevacizumab compared to ranibizumab (RR = 2.8; 95% CI 1.2-6.5). The proportion of patients with serious infections and gastrointestinal disorders was also higher with bevacizumab than with ranibizumab (RR = 1.3; 95% CI 1.0-1.7). Arterial thromboembolic events were equally distributed among the groups. Indirect comparison: Ranibizumab versus any control (5 trials, 4054 patients): The two year results of three landmark trials showed that while absolute rates of serious ocular AE were low (≤ 2.1%), relative harm was significantly raised (RR = 3.1; 95% CI 1.1-8.9). A significant increase in nonocular haemorrhage was also observed with ranibizumab (RR = 1.7; 95% CI 1.1-2.7). Bevacizumab versus any control (3 trials, 244 patients): We were unable to judge the safety profile of bevacizumab due to the poor quality of AE monitoring and reporting in the trials.

CONCLUSIONS

Evidence from head-to-head trials raises concern about an increased risk of ocular and multiple systemic AE with bevacizumab. Therefore, clinicians and patients should continue to carefully weight up the benefits and harms when choosing between the two treatment options. We also emphasize the need for studies that are powered not just for efficacy, but for defined safety outcomes based on the signals detected in this systematic review.

Diabetic angiopathy and angiogenic defects

Diabetes is one of the most serious health problems in the world. A major complication of diabetes is blood vessel disease, termed angiopathy, which is characterized by abnormal angiogenesis. In this review, we focus on angiogenesis abnormalities in diabetic complications and discuss its benefits and drawbacks as a therapeutic target for diabetic vascular complications. Additionally, we discuss glucose metabolism defects that are associated with abnormal angiogenesis in atypical diabetic complications such as cancer.

Effect of intravitreal anti-vascular endothelial growth factor therapy on the risk of arterial thromboembolic events: a meta-analysis

BACKGROUND

Intravitreal anti-vascular endothelial growth factor (VEGF) monoclonal antibodies are used in ocular neovascular diseases. A consensus has emerged that intravenous anti-VEGF can increase the risk of arterial thromboembolic events. However, the role of intravitreal anti-VEGF in arterial thromboembolism is controversial. Therefore, we did a systematic review and meta-analysis to investigate the effects of intravitreal anti-VEGF on the risk of arterial thromboembolic events.

METHODS

Electronic databases were searched to identify relevant randomized clinical trials comparing intravitreal anti-VEGF with controls. Criteria for inclusion in our meta-analysis included a study duration of no less than 12 months, the use of a randomized control group not receiving any intravitreal active agent, and the availability of outcome data for arterial thromboembolic events, myocardial infarction, cerebrovascular accidents, and vascular death. The risk ratios and 95% CIs were calculated using a fixed-effects or random-effects model, depending on the heterogeneity of the included studies.

RESULTS

A total of 4942 patients with a variety of ocular neovascular diseases from 13 randomized controlled trials were identified and included for analysis. There was no significant difference between intravitreal anti-VEGF and control in the risk of all events, with risk ratios of 0.87 (95% CI, 0.64 to 1.19) for arterial thromboembolic events, 0.96 (95% CI, 0.55-1.68) for cerebrovascular accidents, 0.69 (95% CI 0.40-1.21) for myocardial infarctions, and 0.68 (95% CI, 0.37-1.27) for vascular death.

CONCLUSIONS

The strength evidence suggests that the intravitreal use of anti-VEGF antibodies is not associated with an increased risk of arterial thromboembolic events.

Profile of ranibizumab: efficacy and safety for the treatment of wet age-related macular degeneration

Wet age-related macular degeneration (AMD) causes severe vision loss due to the development of choroidal neovascularization (CNV). The critical role of vascular endothelial growth factor in the pathogenesis of CNV is well understood. Ranibizumab plays an inhibitory role with CNV and reduces vascular permeability by binding to vascular endothelial growth factor. Intravitreal ranibizumab reduces the risk of visual acuity (VA) loss and increases the chance of VA gain compared with no treatment or photodynamic therapy for CNV in AMD. Some high-quality research has shown that the optimal timing for ranibizumab treating wet AMD is the first 3 months. It is recommended that ranibizumab is intravitreally injected monthly in the initiation for at least 3 months. Subsequent managing of regimens should be made dependent on the VA change, fundus examination, and image of optical coherence topography. An individualized strategy or combined method with photodynamic therapy is beneficial to the active lesion in the consecutive treatment of ranibizumab for CNV, and may be a good choice in order to decrease injection times. Regarding the safety profile, ranibizumab has been well tolerated in clinical trials. The principal ocular adverse event detected in clinical trials is a low frequency of ocular inflammation. Key serious ocular adverse events occurred in <5% of ranibizumab-treated patients in large-scale clinical trials. It appears unlikely that treatment with ranibizumab increases the risk of vascular events significantly. Less frequent injections on an as-needed schedule, based on monthly monitoring may have the most optimal risk:benefit ratio.

Intravitreal ranibizumab for the treatment of choroidal neovascularisation secondary to angioid streaks

AIMS

To assess the medium to long-term efficacy and safety of intravitreal ranibizumab for the treatment of choroidal neovascularisation (CNV) secondary to angioid streaks (AS).

METHODS

A total of 12 eyes of nine patients treated with intravitreal ranibizumab (0.5 mg in 0.05 ml) for CNV secondary to AS were retrospectively identified. Efficacy of treatment was determined by changes in best-corrected LogMAR visual acuity (BCVA) and optical coherence tomography. Changes with respect to baseline BCVA were defined as improved or reduced with a gain or loss of more than 10 letters, respectively, or stable if remaining within 10 letters.

RESULTS

Over a mean follow-up of 21.75 months (range: 1-54), patients received mean 5.75 (range: 2-15) intravitreal ranibizumab injections per affected eye. BCVA improved in three eyes (25%), stabilised in eight eyes (66.67%), and deteriorated in one eye (8.33%). There was no significant change in central retinal thickness (CRT) over the follow-up period (P=0.1072). No drug-related systemic side effects were recorded.

CONCLUSION

The long-term treatment of CNV secondary to AS with intravitreal ranibizumab showed a stabilisation in CRT and an improvement or stabilisation of BCVA. The absence of systemic side effects was reassuring. Further long-term prospective studies are required to validate these findings.

Treatment patterns for neovascular age-related macular degeneration: analysis of 284 380 medicare beneficiaries

PURPOSE

To examine trends in the treatment of newly diagnosed neovascular age-related macular degeneration (AMD).

DESIGN

Retrospective cohort study.

METHODS

Among 284 380 Medicare beneficiaries with a new diagnosis between 2006 and 2008, we used the cumulative incidence function to estimate procedure rates and the mean frequency function to estimate the cumulative mean number of intravitreous injections. We used Cox log-binomial regression to estimate predictors of the use of vascular endothelial growth factor (VEGF) antagonists within 1 year after diagnosis. Discontinuation of anti-VEGF therapy was defined by absence of treatment for 12 months. Discontinuation rates were calculated using the Kaplan-Meier method.

RESULTS

The proportion of patients receiving anti-VEGF therapy increased from 60.3% to 72.7%, photodynamic therapy decreased from 12.8% to 5.3%, and thermal laser treatment decreased from 5.5% to 3.2%. Black patients (hazard ratio, 0.77; 95% confidence interval, 0.75-0.79) and patients of other/unknown race (0.83; 0.81-0.84) were less likely than white patients to receive anti-VEGF therapy. Patients with dementia were less likely to receive anti-VEGF therapy (0.88; 0.88-0.89). Among patients who received anti-VEGF therapy, the mean number of injections within 1 year of the first injection was 4.3 per treated eye. Anti-VEGF therapy was discontinued in 53.6% of eyes within 1 year, and in 61.7% of eyes within 18 months.

CONCLUSIONS

Treatment of new neovascular AMD changed significantly between 2006 and 2008, most notably in the increasing use of anti-VEGF therapies. However, few patients treated with anti-VEGF medications received monthly injections, and discontinuation rates were high.

Aflibercept: a Potent Vascular Endothelial Growth Factor Antagonist for Neovascular Age-Related Macular Degeneration and Other Retinal Vascular Diseases

Introduction

In the western hemisphere, age-related macular degeneration (AMD) is the leading cause of visual loss in the elderly. Currently approved therapies for AMD include argon laser, photodynamic therapy, and antivascular endothelial growth factor (VEGF) therapy. The index review discusses aflibercept (VEGF Trap-Eye) in the context of current anti-VEGF therapies for neovascular AMD and other retinal vascular diseases. It highlights important differences between VEGF Trap-Eye and currently used anti-VEGF therapies for neovascular AMD; and discusses the efficacy of these treatments utilizing information from landmark clinical trials.

Methods

A systematic search of literature was conducted on PubMed, Science Direct, and Scopus with no limitations of language or years of publication.

Results

Preclinical studies have shown that VEGF Trap-Eye binds to VEGF-A with a higher affinity than other anti-VEGF molecules; and that it also binds to placental growth factor (PlGF). In clinical trials, VEGF Trap-Eye has been shown to be as effective in the treatment of neovascular AMD as other anti-VEGF therapies and possibly to have a longer duration of drug activity.

Conclusion

VEGF Trap-Eye has enhanced the treatment options currently available for the management of neovascular AMD. The comparable efficacy of VEGF Trap-Eye (to other anti-VEGF agents) coupled with its longer dosing interval may decrease the number of annual office visits for patients with AMD and their caregivers.

Anti-VEGF Treatment Strategies for Wet AMD

Over the past few years, antivascular endothelial growth factor (VEGF) therapy has become a standard treatment for neovascular age-related macular degeneration (AMD). During this time, treatment strategies have evolved from a monthly dosing schedule to individualized regimens. This paper will review the currently available anti-VEGF agents and evidence-based treatment strategies.

New Approach of Anti-VEGF Agents for Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of visual loss in older population. Angiogenesis is an important factor associated with the development of CNV due to AMD. Treatment of CNV with intravitreal anti-VEGF monotherapy is currently the standard of care. However, not all patients respond to monotherapy, and modified anti-VEGF treatment regimen and combination therapy may target reducing treatment frequency or improving visual outcome. This paper reviews the many clinical trials that have been performed utilizing several treatment regimens. While many trials have shown that this variable therapy is justifiable, further study is required to determine correct regimens and dosage.