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Bode C, Kranz H, Siepmann F, Siepmann J. In-situ forming PLGA implants for intraocular dexamethasone delivery. Int J Pharm 2018; 548:337-348. [PMID: 29981408 DOI: 10.1016/j.ijpharm.2018.07.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 11/15/2022]
Abstract
Different types of in-situ forming implants based on poly(lactic-co-glycolic acid) (PLGA) and N-methyl-pyrrolidone (NMP) were prepared for controlled ocular delivery of dexamethasone. The impact of the volume of the release medium, initial drug content, polymer molecular weight and PLGA concentration on the resulting drug release kinetics were studied and explained based on a thorough physico-chemical characterization of the systems. This included for instance the monitoring of dynamic changes in the implants' wet and dry mass, morphology, PLGA polymer molecular weight, pH of the surrounding bulk fluid and water/NMP contents upon exposure to phosphate buffer pH 7.4. Importantly, the systems can be expected to be rather robust with respect to variations in the vitreous humor volumes encountered in vivo. Interestingly, limited drug solubility effects within the implants as well as in the surrounding aqueous medium play an important role for the control of drug release at a drug loading of only 7.5%. Furthermore, the polymer molecular weight and PLGA concentration in the liquid formulations are decisive for how the polymer precipitates during solvent exchange and for the swelling behavior of the systems. These features determine the resulting inner system structure and the conditions for mass transport. Consequently, they affect the degradation and drug release of the in-situ formed implants.
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Affiliation(s)
- C Bode
- Univ. Lille, Inserm, CHU Lille, U1008, 59000 Lille, France
| | - H Kranz
- Bayer AG, Muellerstraße 178, 13353 Berlin, Germany
| | - F Siepmann
- Univ. Lille, Inserm, CHU Lille, U1008, 59000 Lille, France
| | - J Siepmann
- Univ. Lille, Inserm, CHU Lille, U1008, 59000 Lille, France.
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152
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Rosenfeld PJ, Windsor MA, Feuer WJ, Sun SJ, Frick KD, Swanson EA, Huang D. Estimating Medicare and Patient Savings From the Use of Bevacizumab for the Treatment of Exudative Age-related Macular Degeneration. Am J Ophthalmol 2018; 191:135-139. [PMID: 29655642 DOI: 10.1016/j.ajo.2018.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/30/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The Medicare cost savings from the use of bevacizumab in the United States for the treatment of exudative age-related macular degeneration (AMD) were estimated by replacing the use of bevacizumab with ranibizumab and aflibercept. DESIGN Retrospective trend study. METHODS Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology (CPT) codes for intravitreal injections (67028) and treatment-specific J-codes (J0178, J2778, J9035, J3490, and J3590) for inhibitors of vascular endothelial growth factor. These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 to 2015. The 2008 claims were acquired from the 100% fee-for-service (FFS) Part B Medicare Claims File. RESULTS The use of bevacizumab from 2008 to 2015 resulted in an estimated savings of $17.3 billion, which corresponded to a $13.8 billion savings to Medicare and a $3.5 billion savings to patients. This amount underestimated the actual cost savings to Medicare providers, since approximately 30% of Medicare-eligible recipients received care within Medicare Advantage plans and were not included in this analysis. CONCLUSIONS The cost savings from the use of bevacizumab from 2008 to 2015 for Medicare fee-for-service patients undergoing treatment for exudative AMD was estimated at $17.3 billion. Additional savings over the $17.3 billion would have accrued from the use of bevacizumab if diagnostic categories such as diabetic macular edema and retinal vein occlusion were included in this study.
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153
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Past and prognosis of anti-VEGF therapy for wet age-related macular degeneration—the future has begun. Graefes Arch Clin Exp Ophthalmol 2018; 256:1553-1555. [DOI: 10.1007/s00417-018-4005-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/02/2018] [Indexed: 01/24/2023] Open
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Haga A, Kawaji T, Ideta R, Inomata Y, Tanihara H. Treat-and-extend versus every-other-month regimens with aflibercept in age-related macular degeneration. Acta Ophthalmol 2018; 96:e393-e398. [PMID: 29220114 DOI: 10.1111/aos.13607] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/22/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the 1-year outcomes of treat-and-extend (TAE) and every-other-month (2M) regimens with intravitreal aflibercept in Japanese wet age-related macular degeneration (AMD) patients. METHODS Prospective, multicenter, randomized clinical trial. The primary outcome measure was the proportion of eyes in which the best-corrected visual acuity (BCVA) was maintained at week 52 [with a loss of <0.3 logarithm of minimum angular of resolution (logMAR) units]. The secondary outcome measures were the mean change from baseline in the central retinal thickness (CRT) and the number of injections. RESULTS Forty-one patients were enrolled. The mean changes in the BCVA from baseline in the TAE and 2M were -0.32 ± 0.27 and -0.26 ± 0.30 logMAR units (p = 0.46). The TAE group was noninferior to the 2M group in BCVA maintenance. The mean CRT changes from baseline in the TAE and 2M were -161 ± 133 and -157 ± 90 μm (p = 0.73). The mean number of injections in the TAE and 2M were 7.5 ± 1.2 (range, 7-12) and 8.0 ± 0.0 (p < 0.0001). CONCLUSION Treat-and-extend (TAE) regimen with aflibercept improved the BCVA and CRT to the same extent as 2M regimen, with a reduced number of injections.
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Affiliation(s)
- Akira Haga
- Department of Ophthalmology; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
| | - Takahiro Kawaji
- Department of Ophthalmology; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
- Sato Eye and Internal Medicine Clinic; Kumamoto Japan
| | | | - Yasuya Inomata
- Department of Ophthalmology; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
| | - Hidenobu Tanihara
- Department of Ophthalmology; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
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155
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Wai KM, Singh RP. Treat and Extend Dosing Regimen with Anti-vascular Endothelial Growth Factor Agents for Neovascular Age-related Macular Degeneration. ACTA ACUST UNITED AC 2018. [DOI: 10.25259/ajoct-2-2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Anti-vascular endothelial growth factor (anti-VEGF) agents are the mainstay of therapy for treatment of neovascular age-related macular degeneration (nvAMD), one of the leading causes of blindness in the developed world. There have been a variety of different treatment regimens that have been examined for the administration of anti-VEGF therapies, including continuous fixed dosing, pro re nata administration, and treat and extend (TAE) protocols. There is no clear consensus on which dosing regimen optimizes visual and anatomical outcomes while accounting for factors such as cost and patient burden. Based on recent surveys in 2014 and 2017 by the American Society of Retina Specialists (ASRS), the majority of ophthalmology providers are utilizing TAE protocol for anti-VEGF dosing for the management of nvAMD. Although there are a number of clinical trials that have examined TAE dosing, the ALTAIR study is the first, large, prospective randomized controlled trial to compare two different TAE protocols utilizing the anti-VEGF agent aflibercept for nvAMD. The ALTAIR study, in conjunction with other previous clinical trials, suggests that TAE protocol with aflibercept is an effective anti-VEGF dosing regimen for patients with nvAMD as it produces good visual gains and minimizes cost and burden for the patient.
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156
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Nikkhah H, Karimi S, Ahmadieh H, Azarmina M, Abrishami M, Ahoor H, Alizadeh Y, Behboudi H, Daftarian N, Dehghan MH, Entezari M, Farrahi F, Ghanbari H, Falavarjani KG, Javadi MA, Karkhaneh R, Moradian S, Manaviat MR, Mehryar M, Nourinia R, Parvaresh MM, Ramezani A, Haghi AR, Riazi-Esfahani M, Soheilian M, Shahsavari M, Shahriari HA, Rajavi Z, Safi S, Shirvani A, Rahmani S, Sabbaghi H, Pakbin M, Kheiri B, Ziaei H. Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline. J Ophthalmic Vis Res 2018; 13:158-169. [PMID: 29719645 PMCID: PMC5905310 DOI: 10.4103/jovr.jovr_50_18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 12/17/2017] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy. METHODS Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations. RESULTS All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases. CONCLUSION The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients.
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Affiliation(s)
- Homayoun Nikkhah
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Karimi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Azarmina
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Abrishami
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Ahoor
- Department of Ophthalmology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yousef Alizadeh
- Department of Ophthalmology, Guilan University of Medical Sciences, Rasht, Iran
| | - Hasan Behboudi
- Department of Ophthalmology, Guilan University of Medical Sciences, Rasht, Iran
| | - Narsis Daftarian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Dehghan
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Entezari
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fereydoun Farrahi
- Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | | | - Mohammad Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Karkhaneh
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Siamak Moradian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Reza Manaviat
- Department of Ophthalmology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Morsal Mehryar
- Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Parvaresh
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Ramezani
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Riazi-Esfahani
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Soheilian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Shahsavari
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein-Ali Shahriari
- Department of Ophthalmology, Al-Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Zhale Rajavi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sare Safi
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Standardization and CPG Development Office, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran
| | - Saeed Rahmani
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Optometry, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamideh Sabbaghi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Optometry, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojgan Pakbin
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahareh Kheiri
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Ziaei
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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157
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Arslan J, Baird PN. Changing vision: a review of pharmacogenetic studies for treatment response in age-related macular degeneration patients. Pharmacogenomics 2018; 19:435-461. [DOI: 10.2217/pgs-2017-0183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Nonresponsiveness to age-related macular degeneration (AMD) treatments has become a growing concern in ophthalmology. Disparity among publications that have assessed pharmacogenetic (PGx) connections between AMD disease genes and treatments has delayed the implementation of PGx testing in AMD. We assessed all AMD PGx publications to identify the degree of agreement for publications within similar ethnic cohorts and worldwide, and the causes for differences in study outcomes. There are no accepted genotype–phenotype correlations, either within similar ethnic cohorts or worldwide. The diversity of measured outcomes, treatment protocols and statistical methods used may be causing this discrepancy. A universally accepted treatment protocol and the creation of agreed response group classification may bridge the gap between AMD PGx publications.
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Affiliation(s)
- Janan Arslan
- Department of Surgery (Ophthalmology), Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye & Ear Hospital, East Melbourne, Victoria, 3002, Australia
| | - Paul N Baird
- Department of Surgery (Ophthalmology), Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye & Ear Hospital, East Melbourne, Victoria, 3002, Australia
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158
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Munk MR, Arendt P, Yu S, Ceklic L, Huf W, Ebneter A, Wolf S, Zinkernagel MS. The Impact of the Vitreomacular Interface in Neovascular Age-Related Macular Degeneration in a Treat-and-Extend Regimen with Exit Strategy. ACTA ACUST UNITED AC 2018; 2:288-294. [DOI: 10.1016/j.oret.2017.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022]
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159
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Ciulla TA, Huang F, Westby K, Williams DF, Zaveri S, Patel SC. Real-world Outcomes of Anti-Vascular Endothelial Growth Factor Therapy in Neovascular Age-Related Macular Degeneration in the United States. Ophthalmol Retina 2018; 2:645-653. [PMID: 31047372 DOI: 10.1016/j.oret.2018.01.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 11/29/2017] [Accepted: 01/11/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Real-world visual outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD) have been reported in cohorts outside of the United States. This study sought to assess the relationship between presenting visual acuity (VA) and visual outcomes, as well as the potential impact of loss to follow-up, in real-world anti-VEGF-treated nAMD patients from the United States. DESIGN Retrospective study of aggregated, longitudinal electronic medical records obtained from a geographically diverse sample of US retina specialists and included in the Vestrum Health Retina Database. PARTICIPANTS Inclusion criteria were a diagnosis of nAMD, no previous treatment, and ≥3 monthly anti-VEGF injections in the first 4 months from diagnosis in patients diagnosed between January 2011 and July 2013. METHODS To model loss to follow-up, mutually exclusive cohorts of nAMD patients with loss to follow-up after specific time points of 6 and 12 months (i.e., no follow-up beyond) were compared with a separate cohort of patients who completed 24 months of follow-up ending prior to July 2015 (n = 2213). MAIN OUTCOME MEASURE VA outcomes were assessed on each cohort as a whole, with additional stratification by baseline VA. RESULTS The 6-, 12-, and 24-month cohorts received means of 5.4, 7.3, and 12.1 injections and showed no change, no change, and a mean change of +3.1 letters from baseline (95% confidence interval 1.8-4.4 letters, P < 0.01), respectively. When stratified by baseline VA, nearly all groups lose VA at their respective follow-up periods, except for those with baseline VA of 20/200 or worse. CONCLUSIONS Real-world nAMD patients in the United States receive fewer anti-VEGF injections and experience worse visual outcomes compared with patients in randomized clinical trials, consistent with non-US studies. Patients with better VA at presentation tend to be particularly vulnerable to vision loss. Compared with other patients, those ultimately lost to follow-up have worse visual outcomes at, or prior to, their final visit, suggesting that loss to follow-up may lead to overestimation of visual outcomes in clinical studies of nAMD.
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Affiliation(s)
| | | | | | - David F Williams
- VitreoRetinal Surgery, PA, Minneapolis, Minnesota; Vestrum Health, Naperville, Illinois
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160
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Adrean SD, Chaili S, Grant S, Pirouz A. Recurrence Rate of Choroidal Neovascularization in Neovascular Age-Related Macular Degeneration Managed with a Treat–Extend–Stop Protocol. ACTA ACUST UNITED AC 2018; 2:225-230. [DOI: 10.1016/j.oret.2017.07.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/09/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022]
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161
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Ashraf M, Souka A, Adelman RA. Age-related macular degeneration: using morphological predictors to modify current treatment protocols. Acta Ophthalmol 2018; 96:120-133. [PMID: 29130626 DOI: 10.1111/aos.13565] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/19/2017] [Indexed: 01/09/2023]
Abstract
To assess predictors of treatment response in neovascular age-related macular degeneration (AMD) in an attempt to develop a patient-centric treatment algorithm. We conducted a systematic search using PubMed, EMBASE and Web of Science for prognostic indicators/predictive factors with the key words: 'age related macular degeneration', 'neovascular AMD', 'choroidal neovascular membrane (CNV)', 'anti-vascular endothelial growth factor (anti-VEGF)', 'aflibercept', 'ranibizumab', 'bevacizumab', 'randomized clinical trials', 'post-hoc', 'prognostic', 'predictive', 'response' 'injection frequency, 'treat and extend (TAE), 'pro re nata (PRN)', 'bi-monthly' and 'quarterly'. We only included studies that had an adequate period of follow-up (>1 year), a single predefined treatment regimen with a predetermined re-injection criteria, an adequate number of patients, specific morphological [optical coherence tomography (OCT)] criteria that predicted final visual outcomes and injection frequency and did not include switching from one drug to the other. We were able to identify seven prospective studies and 16 retrospective studies meeting our inclusion criteria. There are several morphological and demographic prognostic indicators that can predict response to therapy in wet AMD. Smaller CNV size, subretinal fluid (SRF), retinal angiomatous proliferation (RAP) and response to therapy at 12 weeks (visual, angiographic or OCT) can all predict good visual outcomes in patients receiving anti-VEGF therapy. Patients with larger CNV, older age, pigment epithelial detachment (PED), intraretinal cysts (IRC) and vitreomacular adhesion (VMA) achieved less visual gains. Patients having VMA/VMT required more intensive treatment with increased treatment frequency. Patients with both posterior vitreous detachment (PVD) and SRF require infrequent injections. Patients with PED are prone to recurrences of fluid activity with a reduction in visual acuity (VA). A regimen that involves less intensive therapy and extended follow-up intervals (4 weekly) can be suggested for patients who show adequate visual response and have both SRF and PVD at baseline. In addition, patients with poor prognostic indicators such as IRC, VMA, large CNV size, older age and poor response at 12 weeks should be extended very cautiously with the possibility of fixed monthly/bimonthly (every 2 months) treatments if they fail to achieve dryness. Patients with PED at baseline should receive monthly/bimonthly injections of anti-VEGF therapy or can be extended very cautiously (two weekly intervals) using a TAE protocol.
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Affiliation(s)
- Mohammed Ashraf
- Ophthalmology Department; Faculty of Medicine; Alexandria University; Alexandria Egypt
| | - Ahmed Souka
- Ophthalmology Department; Faculty of Medicine; Alexandria University; Alexandria Egypt
| | - Ron A. Adelman
- Department of Ophthalmology and Visual Studies; Yale Medical School; European Vitreo-retinal Society (EVRS); New Haven Connecticut USA
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162
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Conti FF, Silva FQ, Srivastava SK, Ehlers JP, Schachat AP, Singh RP. 36-Month Evaluation of Intravitreous Aflibercept Injection for Wet Age-Related Macular Degeneration in Patients Previously Treated With Ranibizumab or Bevacizumab. Ophthalmic Surg Lasers Imaging Retina 2018; 49:179-185. [PMID: 29554385 DOI: 10.3928/23258160-20180221-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/03/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE In the ASSESS study, patients with neovascular age-related macular degeneration transitioned from other anti-vascular endothelial growth factor therapies to intravitreous aflibercept (Eylea; Regeneron, Tarrytown, NY) injections (IAI). The purpose was to determine the 36-month outcomes following the change from a fixed 24-month IAI dosing regimen to a routine clinical practice regimen. PATIENTS AND METHODS Patients were treated with a fixed bimonthly regimen for the first 2 years. In the third year, patients were managed according to routine clinical practice. RESULTS A total of 18 patients completed the 36 months and were considered for statistical analyses. At 36 months, a nonsignificant decrease of -37.8 μm in central subfield thickness and a nonsignificant gain of 5.8 letters from baseline were observed. CONCLUSION Despite the significant visual and anatomical gains observed in the 2 years of fixed-dosing IAI, there was gradual decline in these improvements when patients were transitioned to a variable regimen. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:179-185.].
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Switching between ranibizumab and aflibercept for the treatment of neovascular age-related macular degeneration. Surv Ophthalmol 2018; 63:638-645. [PMID: 29476754 DOI: 10.1016/j.survophthal.2018.02.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/22/2022]
Abstract
The introduction of antivascular endothelial growth factor agents such as ranibizumab and aflibercept has revolutionized the management of neovascular age-related macular degeneration. A number of randomized clinical trials have shown that ranibizumab and aflibercept produce similar efficacy and safety outcomes. Most of the switching studies published to date show that efficacy benefits are uncontrolled, retrospective trials with limitations in terms of their selection, monitoring, numbers, and assessment criteria. Based on the published literature to date, we propose arguments for and against switching antivascular endothelial growth factor agents, provide our own perspective on this topic, and suggest a focus for future research.
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164
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Cebeci Z, Yilmaz YC, Kir N. Real-life experience of ranibizumab therapy for neovascular age-related macular degeneration from Turkey. Int J Ophthalmol 2018; 11:267-273. [PMID: 29487818 PMCID: PMC5824083 DOI: 10.18240/ijo.2018.02.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/31/2017] [Indexed: 11/23/2022] Open
Abstract
AIM To report the real-life experience and clinical results of intravitreal ranibizumab injections to neovascular age-related macular degeneration (nAMD) in a single institution in Turkey. METHODS A total of 101 eyes of 89 patients with nAMD treated with intravitreal ranibizumab injection, followed up for at least 24mo between 2009 and June 2014, which were evaluated retrospectively. A pro re nata (PRN) treatment protocol was performed after the patients had received three, monthly loading injections. Best corrected visual acuity (BCVA) and central macular thickness measurements were evaluated at baseline and 3, 6, 12, 18, and 24mo. Number of injections and visits were also recorded. RESULTS Of the 89 patients, 34 (38.2%) were male and 55 (61.8%) were female and the mean age was 74.0±9.5 (52-91)y. The mean follow-up period was 24.82±4.4 (24-29)mo. Mean number of visits was 8.4±1.12 (7-12) in the first year and 6.6±1.33 (4-12) in the second year. The mean number of injections was 5.8±1.6 (3-10) and 4.2±2.2 (0-9) in the first and second year, respectively. The mean BCVA was 59±15.8 letters at baseline by the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The mean BCVA at 3, 12, and 24mo was 70.3±15.9, 67.9±14.3 and 67.3±16.9 letters, respectively. Improvement in visual acuity for each of the visits from baseline was found to be statistically significant (P<0.01). Visual acuity in 9 eyes at month 3, 7 eyes at month 12, and 13 eyes at month 24 did not change. The mean central macular thickness (CMT) was 437.99±164.78 µm at baseline. The mean CMT was 348.05±138.47 µm, 349.27±139.79 µm, and 344.13±146.30 µm at months 3, 12, and 24, respectively. The decrease in CMT for each of the visits from baseline was found to be statistically significant (P<0.01). CONCLUSION Anatomical and functional achievement are obtained in our study, but the mean number of injections and visits are found to be lower than the findings reported in randomized controlled clinical trials in the literature. However, the mean number of injections and visits in our study are compatible with the findings reported in real-life experience studies in the literature.
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Affiliation(s)
- Zafer Cebeci
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
| | - Yusuf Cem Yilmaz
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
| | - Nur Kir
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
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Wykoff CC, Clark WL, Nielsen JS, Brill JV, Greene LS, Heggen CL. Optimizing Anti-VEGF Treatment Outcomes for Patients with Neovascular Age-Related Macular Degeneration. J Manag Care Spec Pharm 2018; 24:S3-S15. [PMID: 29383980 PMCID: PMC10408401 DOI: 10.18553/jmcp.2018.24.2-a.s3] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The introduction of anti-vascular endothelial growth factor (anti-VEGF) drugs to ophthalmology has revolutionized the treatment of neovascular age-related macular degeneration (nAMD). Despite this significant progress, gaps and challenges persist in the diagnosis of nAMD, initiation of treatment, and management of frequent intravitreal injections. Thus, nAMD remains a leading cause of blindness in the United States. OBJECTIVE To present current knowledge, evidence, and expert perspectives on anti-VEGF therapies in nAMD to support managed care professionals and providers in decision making and collaborative strategies to overcome barriers to optimize anti-VEGF treatment outcomes among nAMD patients. SUMMARY Three anti-VEGF therapies currently form the mainstay of treatment for nAMD, including 2 therapies approved by the FDA for treatment of nAMD (aflibercept and ranibizumab) and 1 therapy approved by the FDA for oncology indications and used off-label for treatment of nAMD (bevacizumab). In clinical trials, each of the 3 agents maintained visual acuity (VA) in approximately 90% or more of nAMD patients over 2 years. However, in long-term and real-world settings, significant gaps and challenges in diagnosis, treatment, and management pose barriers to achieving optimal outcomes for patients with nAMD. Many considerations, including individual patient characteristics, on-label versus off-label treatment, repackaging, and financial considerations, add to the complexity of nAMD decision making and management. Many factors may contribute to additional challenges leading to suboptimal long-term outcomes among nAMD patients, such as delays in diagnosis and/or treatment approval and initiation, individual patient response to different anti-VEGF therapies, lapses in physician regimentation of anti-VEGF injection and monitoring, and inadequate patient adherence to treatment and monitoring. These latter factors highlight the considerable logistical, emotional, and financial burdens of long-term, frequent intravitreal injections and the vital importance of personalized approaches to anti-VEGF treatment decision making and management for patients with nAMD. To address these challenges and reduce the number of yearly injections, studies have examined alternative dosing regimens, including extended fixed intervals, as needed, and treat-and-extend strategies in specific nAMD patient populations. New clinical evidence and insights into expert clinical practice discussed in this article can support managed care professionals in the key role they play in addressing challenges in nAMD treatment and management and optimizing patient outcomes through appropriate management of anti-VEGF treatment. DISCLOSURES PRIME Education is an independent medical education company and has been an accredited provider of continuing education for 23 years. There is no fee for this activity as it is sponsored by PRIME through an educational grant from Regeneron. All authors contributed to the writing and reviewing of the article. Wykoff reports consultancies/research grants from Alcon Laboratories, Genentech/Roche, Clearside, and Iconic Therapeutics; consultancies/honoraria, research grants, and speaker fees from Allergan and Regeneron; research grants from Allegro, Apellis, Aura, NEI, NIH, Novartis, OHR Pharmaceuticals, Ophthotech, pSivida, Roche, Santen, SciFluor, Tyrogenex; and consultancies for Alimera Sciences, Alnylam Pharmaceuticals, Bayer, DORC, ONL Therapeutics, Thrombogenics, and Valeant. Clark reports advisory board work, consultancies, research grants, and speaker fees from Genentech/Roche and Regeneron and consultancy for Bayer. Brill reports consultancies for Aries Pharma, Avella, BaroNova, Braeburn Pharmaceuticals, Cardinal Health, Endogastric Solutions, GeneNews, Halt Medical, Lumendi, Medtronic, Monteris Medical, Natera, Phosphorus, Rebiotix, Seno Medical, UCB, Vermillion, Echosens, and HAP Innovations. Brill is a shareholder in EndoChoice, GeneNews, SonarMD, and SynerZ and reports advisory board work with Nestle Health Sciences, Indivior Pharmaceuticals, Eli Lilly, Blue Earth Diagnostics, Bayer, and AstraZeneca. Nielson reports advisory board work/consultancy and research grants for Genentech/Roche; advisory board work and research grants from Regeneron; and research grants from Alcon and Ophthotech.
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Subfoveal choroidal thickness predicts macular atrophy in age-related macular degeneration: results from the TREX-AMD trial. Graefes Arch Clin Exp Ophthalmol 2018; 256:511-518. [PMID: 29374796 DOI: 10.1007/s00417-017-3888-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/13/2017] [Accepted: 12/20/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Our purpose was to evaluate the relationship between subfoveal choroidal thickness (SCT) and development of macular atrophy (MA) in eyes with age-related macular degeneration (AMD). METHODS This was a prospective, multicenter study. Sixty participants (120 eyes) in the TREX-AMD trial (NCT01648292) with treatment-naïve neovascular AMD (NVAMD) in at least one eye were included. SCT was measured by certified reading center graders at baseline using spectral domain optical coherence tomography (SDOCT). The baseline SCT was correlated with the presence of MA at baseline and development of incident MA by month 18. Generalized estimating equations were used to account for information from both eyes. RESULTS Baseline SCT in eyes with MA was statistically significantly less than in those without MA in both the dry AMD (DAMD) (P = 0.04) and NVAMD (P = 0.01) groups. Comparison of baseline SCT between MA developers and non-MA developers revealed a statistically significant difference (P = 0.03). Receiver operating characteristic curve (ROC) analysis showed the cut-off threshold of SCT for predicting the development of MA in cases without MA at baseline was 124 μm (AUC = 0.772; Sensitivity = 0.923; Specificity = 0.5). Among eyes without MA at baseline, those with baseline SCT ≤124 μm were 4.3 times more likely to develop MA (Odds ratio: 4.3, 95% confidence interval: 1.6-12, P = 0.005) than those with baseline SCT >124 μm. CONCLUSIONS Eyes with AMD and MA had less SCT than those without MA. Eyes with less baseline SCT also appear to be at higher risk to develop MA within 18 months.
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TWO YEAR OUTCOMES OF “TREAT AND EXTEND” INTRAVITREAL THERAPY USING AFLIBERCEPT PREFERENTIALLY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2018; 38:20-28. [DOI: 10.1097/iae.0000000000001496] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fayzrakhmanov RR. [Anti-VEGF dosing regimen for neovascular age-related macular degeneration treatment]. Vestn Oftalmol 2018; 134:107-115. [PMID: 30721208 DOI: 10.17116/oftalma2018134061107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
antivasoproliferative therapy is a revolutionary option in the therapy of Neovascular Age-related Macular Degeneration (nAMD). In addition to the problem of choosing an anti-VEGF drug, it is equally important to choose the mode of its intravitreal administration. The basic dosing regimen is fixed monthly intravitreal injections. The effectiveness of monthly intravitreal injections has been demonstrated in randomized clinical trials; however, this regimen is associated with heavy workload on the healthcare system and patients. This fact leads to the constant search of the optimal administration mode for anti-VEGF drugs, which would reduce the number of injections by increasing the interval between them. VIEW1 and VIEW2 randomized clinical trials showed that the optimal dosing regimen for aflibercept is 1 injection every other month after 3 initial monthly doses, and that it reduces the burden of treatment. The Pro Re Nata (PRN) and Observe-and-Plan (O&P) regimens also reduce the number of injections, but the antivasoproliferative effect of the therapy with these regimens may be decreased. In addition, when using the PRN regimen, patients need regular monitoring visits and examinations between injections. The basis of another Treat and Extend (T&E) regimen is the principle of achieving the maximum possible interval between injections while preserving the achieved anatomical and functional results of the treatment. The individualized approach implemented in T&E results in pronounced functional improvements avoiding negative effect onits efficiency. However, the rapid, steady and unpredictable course of nAMD imposes certain restrictions on its implementation of T&E in clinical practice, especially in the first year of treatment. Therefore, when choosing the optimal regimen for anti-VEGF therapy, in addition to the criteria for the duration and mechanism of action of the corresponding anti-VEGF drug, the individual characteristics of the course of the disease should also be considered.
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Affiliation(s)
- R R Fayzrakhmanov
- National Medical and Surgical Center named after N.I. Pirogov, 70 Nizhnyaya Pervomayskaya St., Moscow, Russian Federation, 105203
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Windsor MA, Sun SJ, Frick KD, Swanson EA, Rosenfeld PJ, Huang D. Estimating Public and Patient Savings From Basic Research-A Study of Optical Coherence Tomography in Managing Antiangiogenic Therapy. Am J Ophthalmol 2018; 185:115-122. [PMID: 29224686 DOI: 10.1016/j.ajo.2017.09.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE To compare patient and Medicare savings from the use of optical coherence tomography (OCT) in guiding therapy for neovascular age-related macular degeneration (nvAMD) to the research investments made in developing OCT by the National Institutes of Health (NIH) and the National Science Foundation (NSF). DESIGN Observational cohort study. METHODS Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology codes on intravitreal injections (67028), retinal OCT imaging (92134), and anti-vascular endothelial growth factor (anti-VEGF) treatment-specific J-codes (J0178, J2778, J9035, J3490, and J3590). These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 to 2015; 2008 claims were acquired from the 100% FFS Part B Medicare Claims File. OCT research costs were determined by searching for grants awarded by NIH and NSF from inception to 2015. All costs and savings were discounted by 3% annually and adjusted for inflation to 2015 dollars. RESULTS From 2008 to 2015, the United States government and nvAMD patients have accrued an estimated savings of $9.0 billion and $2.2 billion, respectively, from the use of OCT to guide personalized anti-VEGF treatment. The $9.0 billion represents a 21-fold return on government investment into developing the technology through NIH and NSF grants. CONCLUSIONS Although an overall cost-benefit ratio of government-sponsored research is difficult to estimate because the benefit may be diffuse and delayed, the investment in OCT over 2 decades has been recouped many times over in just a few years through better personalized therapy.
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Silva R, Berta A, Larsen M, Macfadden W, Feller C, Monés J. Treat-and-Extend versus Monthly Regimen in Neovascular Age-Related Macular Degeneration. Ophthalmology 2018; 125:57-65. [DOI: 10.1016/j.ophtha.2017.07.014] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/28/2017] [Accepted: 07/14/2017] [Indexed: 10/18/2022] Open
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Garweg JG, Niderprim SA, Russ HM, Pfister IB. Comparison of Strategies of Treatment with Ranibizumab in Newly-Diagnosed Cases of Neovascular Age-Related Macular Degeneration. J Ocul Pharmacol Ther 2017; 33:773-778. [DOI: 10.1089/jop.2017.0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Justus G. Garweg
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Sophie A. Niderprim
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Hanna Maria Russ
- University of Bern, Bern, Switzerland
- Clinic for Radiology and Nuclear Medicine, University Hospital Lübeck, Lübeck, Germany
- Department of Interventional Radiology, Lübeck, Germany
| | - Isabel B. Pfister
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
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172
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Berg K, Roald AB, Navaratnam J, Bragadóttir R. An 8-year follow-up of anti-vascular endothelial growth factor treatment with a treat-and-extend modality for neovascular age-related macular degeneration. Acta Ophthalmol 2017; 95:796-802. [PMID: 28926190 DOI: 10.1111/aos.13522] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 06/01/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE To investigate long-term visual results of treatment with anti-vascular endothelial growth factor (VEGF) agents for neovascular age-related macular degeneration (nAMD) following a treat-and-extend regimen. METHODS Retrospective review of 155 patients who initiated treatment with bevacizumab for nAMD in one eye. At the final 8-year visit, 40 patients (26%) remained for follow-up. Mean change in best-corrected visual acuity (BCVA) was calculated compared to baseline values. RESULTS Mean BCVA improved significantly from baseline during the first year of treatment, with -0.11 logMAR units equivalent to 6.1 approximate Early Treatment Diabetic Retinopathy Study (approxETDRS) letters (p = <0.001). Mean BCVA was still significantly improved after 4 years of treatment for the entire group of patients and after 6 years of treatment for the subgroup of 40 patients who remained at the final 8-year visit. Thereafter, BCVA gradually declined and at 8 years, there was a mean change of 0.05 logMAR units equivalent to 2.1 approxETDRS letters below baseline (p = 0.530). Mean number of injections during the first year was 6.1 ± 2.8 and during year 8 was 5.4 ± 3.5. At 5 years, fundus autofluorescence showed some degree of macular atrophy in all eyes. At the final 8-year visit, 87.5% of the eyes had stable neovascular lesions with no fluid on optical coherence tomography (OCT). CONCLUSION In an everyday clinical setting, treatment of nAMD patients with a treat-and-extend modality provided improvement and stability of vision for several years. After 8 years of follow-up, there was a decline in visual acuity (VA) that could be explained by macular atrophic development.
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Affiliation(s)
- Karina Berg
- Department of Ophthalmology; Oslo University Hospital; Oslo Norway
| | - Anca B. Roald
- Department of Ophthalmology; Oslo University Hospital; Oslo Norway
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Sasaki M, Kato Y, Fujinami K, Hirakata T, Tsunoda K, Watanabe K, Akiyama K, Noda T. Advanced quantitative analysis of the sub-retinal pigment epithelial space in recurrent neovascular age-related macular degeneration. PLoS One 2017; 12:e0186955. [PMID: 29095879 PMCID: PMC5667874 DOI: 10.1371/journal.pone.0186955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022] Open
Abstract
To quantitatively evaluate changes in the sub-retinal pigment epithelial (RPE) space and determine the association with recurrent neovascular age-related macular degeneration (AMD). Twenty-two eyes treated with intravitreal aflibercept for treatment-naïve neovascular AMD were studied retrospectively. The sub-RPE area, volume, and central retinal thickness (CRT) were evaluated 1 and 2 months after the loading phase using spectral-domain optical coherence tomography. Recurrence was defined as newly detected neovascular activity during the 6 months after the loading phase. In eyes with recurrent AMD, the sub-RPE area increased significantly (P = 0.036) from 1 to 2 months after the loading phase and the sub-RPE volume increased marginally (P = 0.06). Subgroup analysis showed significant (P = 0.008 and P = 0.016, respectively) increases in the sub-RPE area and volume in typical AMD. In eyes with no recurrence, no significant changes occurred in the two parameters. No significant CRT changes occurred in eyes with or without a recurrence. A quantitative analysis demonstrated an increased likelihood of the sub-RPE space shortly after the loading phase in eyes with recurrent AMD; no changes occurred in eyes without a recurrence. These early changes in the sub-RPE space could indicate disease activity and are valuable for predicting recurrences of neovascular AMD.
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Affiliation(s)
- Mariko Sasaki
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
- Department of Ophthalmology, Tachikawa Hospital, Tokyo, Japan
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Yu Kato
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
- Department of Ophthalmology, Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kaoru Fujinami
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
- Genetics, UCL Institute of Ophthalmology, London, United Kingdom
| | - Toshiaki Hirakata
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
| | - Kazushige Tsunoda
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
| | - Ken Watanabe
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
| | - Kunihiko Akiyama
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
| | - Toru Noda
- Department of Ophthalmology, National Institute of Sensory Organs, National Tokyo Medical Center, Tokyo, Japan
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Müller S, Ehlken C, Bauer-Steinhusen U, Lechtenfeld W, Hasanbasic Z, Agostini H, Wilke T. Treatment of age-related neovascular macular degeneration: the patient's perspective. Graefes Arch Clin Exp Ophthalmol 2017; 255:2237-2246. [PMID: 28776095 PMCID: PMC5640748 DOI: 10.1007/s00417-017-3739-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 06/12/2017] [Accepted: 07/03/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess patients' views and expectations with regard to neovascular age-related macular degeneration (nAMD) and intravitreal anti-VEGF therapy (IVT). METHODS We conducted a multicenter, non-interventional, prospective cohort study including nAMD patients treated with IVT in Germany. Patients with at least one IVT before study enrollment and aged ≥50 years were included. Three telephone interviews were conducted during a 12-month observational period. Here, patient's beliefs/expectations with regard to the nAMD disease and the IVT treatment were discussed. Only patients who completed all three phone interviews were included in the analyses. We used a two-step cluster analysis to identify patient clusters regarding specific patient attitudes towards nAMD and its treatment. RESULTS Three hundred and thirty-two patients completed all interviews (mean age of 76.4 ± 7.2 years, 59.0% women). Out of these, 57.8% acknowledged that they needed general assistance in daily life, while 77.4% stated being able to attend general medical appointments on their own. However, 64.7% needed a driver or an accompanying person to attend their IVT appointments. In addition, 3.9% of the patients were afraid of IVT side effects. Also, 87.3% and 43.1% of the patients could name their disease or the anti-VEGF drug administered, respectively. More than three-quarters of the patients (83.1%) were aware of possible consequences of nAMD by stating vision loss or blindness, but only 16.6% knew that nAMD is a chronic disease. Generally, patients were optimistic: 70.2%, 5.1% and 13.0% of them expected stable visual acuity (VA), a significant improvement or expected worsening of VA in the next year, respectively. Almost two thirds of patients who provided their therapy expectations (47.0%) anticipated fewer injections/discontinuation of IVT. We identified five patient clusters differing significantly from each other with regard to four variables: being afraid of IVT, nAMD disease awareness, optimism with regard to effectiveness of IVT, and nAMD disease and treatment knowledge. CONCLUSIONS Only a minority of patients is aware of the chronic nature of nAMD. To motivate patients to accept a life-long IVT treatment, physicians and caregivers must know that there exist different patient types with significant differences in communication needs.
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Affiliation(s)
- S Müller
- IPAM - Institute for Pharmacoeconomics and Medication Logistics, University of Wismar, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - C Ehlken
- Department of Ophthalmology, Universitäts-Klinikum Schleswig-Holstein, Campus Kiel, Germany
| | - U Bauer-Steinhusen
- Bayer Vital GmbH, Medical Affairs, Kaiser-Wilhelm-Allee 70, 51373, Leverkusen, Germany
| | - W Lechtenfeld
- PRO RETINA Deutschland e.V, Vaalser Str. 108, 52074, Aachen, Germany
| | - Z Hasanbasic
- Bayer Vital GmbH, Medical Affairs, Kaiser-Wilhelm-Allee 70, 51373, Leverkusen, Germany
| | - H Agostini
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Killianstraße 5, 79106, Freiburg, Germany
| | - T Wilke
- IPAM - Institute for Pharmacoeconomics and Medication Logistics, University of Wismar, Alter Holzhafen 19, 23966, Wismar, Germany
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Cui J, Sun D, Lu H, Dai R, Xing L, Dong H, Wang L, Wei D, Jiang B, Jiao Y, Jablonski MM, Charles S, Gu W, Chen H. Comparison of effectiveness and safety between conbercept and ranibizumab for treatment of neovascular age-related macular degeneration. A retrospective case-controlled non-inferiority multiple center study. Eye (Lond) 2017; 32:391-399. [PMID: 28937147 PMCID: PMC5805597 DOI: 10.1038/eye.2017.187] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/26/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose To compare the efficacy and safety of conbercept and ranibizumab when administered according to a treat-and-extend (TREX) protocol for the treatment of neovascular age-related macular degeneration (AMD) in China. Patients and methods Between May 2014 and May 2015, 180 patients were treated in a 1 : 1 ratio using conbercept or ranibizumab from four hospitals. Patients received either conbercept 0.5 mg or ranibizumab 0.5 mg intravitreal injections. Follow-up time was 1 year and treated based on a TREX approach. Main outcomes and measures include best-corrected visual acuity (BCVA), using Early Treatment Diabetic Retinopathy Study (ETDRS); number of injections; central retinal thickness (CRT); and leakage of choroidal neovascularization before and after the treatment was analyzed by fluorescein fundus angiography and indocyanine green angiography. Results The 1-year visit was completed by 168 (93.3%) of patients. Mean BCVA was equivalent between two cohorts, and were improved by 12.7±7.770 and 12.3±7.269 letters in the conbercept and ranibizumab cohorts, respectively (P=0.624). There was no significant difference in measured CRT, with a mean decrease of 191.5 μm for conbercept and 187.8 μm for ranibizumab (P=0.773). There was a statistically significant difference (P=0.001) between the drugs regarding the number of treatments: 7.4 for conbercept and 8.7 for ranibizumab. The difference in the distribution of injection intervals was statistically significant between two groups (P=0.011). During the study, there were no cases of endophthalmitis or intraocular inflammation. Conclusion Both drugs had equivalent effects in visual and anatomic gains at 1 year when administered. In the conbercept group, longer treatment intervals were achieved with more patients.
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Affiliation(s)
- J Cui
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China.,Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - D Sun
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, PR China
| | - H Lu
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - R Dai
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, PR China
| | - L Xing
- Department of Ophthalmology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihaer, Heilongjiang, PR China
| | - H Dong
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - L Wang
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - D Wei
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - B Jiang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, PR China
| | - Y Jiao
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M M Jablonski
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - S Charles
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA.,Charles Retina Institute, Germantown, TN, USA
| | - W Gu
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA.,Research Service, Veterans Affairs Medical Center, Memphis TN, USA
| | - H Chen
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
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[Smart eye data : Development of a foundation for medical research using Smart Data applications]. Ophthalmologe 2017; 113:469-77. [PMID: 27222127 DOI: 10.1007/s00347-016-0272-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Smart Data means intelligent data accumulation and the evaluation of large data sets. This is particularly important in ophthalmology as more and more data are being created. Increasing knowledge and personalized therapies are expected by combining clinical data from electronic health records (EHR) with measurement data. OBJECTIVE In this study we investigated the possibilities to consolidate data from measurement devices and clinical data in a data warehouse (DW). MATERIAL AND METHODS An EHR was adjusted to the needs of ophthalmology and the contents of referral letters were extracted. The data were imported into a DW overnight. Measuring devices were connected to the EHR by an HL7 standard interface and the use of a picture archiving and communications system (PACS). Data were exported from the review software using a self-developed software. For data analysis the software was modified to the specific requirements of ophthalmology. RESULTS In the EHR 12 graphical user interfaces were created and the data from 32,234 referral letters were extracted. A total of 23 diagnostic devices could be linked to the PACS and 85,114 optical coherence tomography (OCT) scans, 19,098 measurements from IOLMaster as well as 5,425 pentacam examinations were imported into the DW including over 300,000 patients. Data discovery software was modified providing filtering methods. CONCLUSION By building a DW a foundation for clinical and epidemiological studies could be implemented. In the future, decision support systems and strategies for personalized therapies can be based on such a database.
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Krivosic V, Philippakis E, Couturier A, Dupas B, Erginay A, Desmettre T, Streho M, Bonnin S, Mane V, Jouvaud S, Gualino V, Durand D, Tadayoni R. [A "fast track" to improve management of neovascular age related macular degeneration]. J Fr Ophtalmol 2017; 40:642-647. [PMID: 28865938 DOI: 10.1016/j.jfo.2017.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/20/2017] [Accepted: 03/06/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the role of a fast track for management of patients with neovascular age- related macular degeneration (nARMD) treated by intravitreal injection of anti-VEGF. PATIENTS The records of 100 patients in the chronic maintenance phase of intravitreal anti-VEGF followed in the fast track and 63 patients followed in the standard protocol for at least 12 months were retrospectively analyzed. METHOD Patients in the fast track underwent visual acuity (VA) testing by ETDRS, optical coherence tomography (OCT) and a physician assessment. The injection was performed the same day whenever possible. The primary endpoint to evaluate patient adherence was the time between the ideal date of visit or injection prescribed by the physician and the actual date of administration. RESULTS The mean time between the ideal date of visit or injection prescribed by the physician and the actual date of administration was 4.1±7.5 days for the patients followed in the fast track and 5.6±18.7 days for the patients followed in the standard protocol. Mean VA remained stable for the patients followed in the fast track: 20/50 (20/800 to 20/20) at baseline vs. 20/50 (20/800 to 20/16) at the conclusion of follow-up. It dropped from 40/50 at baseline to 20/63 at the conclusion of follow-up for the patients followed in the standard protocol. CONCLUSION In the context of a fast track, it was possible to improve the adherence of nARMD patients and maintain their VA gain or stabilization achieved after the induction phase.
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Affiliation(s)
- V Krivosic
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France; Centre ophtalmologique de l'Odéon, 113, boulevard Saint-Germain, 75006 Paris, France.
| | - E Philippakis
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - A Couturier
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - B Dupas
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - A Erginay
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - T Desmettre
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - M Streho
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - S Bonnin
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - V Mane
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - S Jouvaud
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - V Gualino
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - D Durand
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
| | - R Tadayoni
- Service d'ophtalmologie, hôpital Lariboisière, université Paris-Diderot, Sorbonne-Paris-Cité, AP - HP, 2, rue, Ambroise-Paré, 75010 Paris, France
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Inner nuclear layer cystoid spaces are a poor prognostic factor in typical age-related macular degeneration and polypoidal choroidal vasculopathy. Graefes Arch Clin Exp Ophthalmol 2017; 255:2157-2163. [DOI: 10.1007/s00417-017-3776-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/27/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022] Open
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179
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Brown D, Heier JS, Boyer DS, Freund KB, Kaiser P, Kim JE, Sarraf D. Current Best Clinical Practices—Management of Neovascular AMD. ACTA ACUST UNITED AC 2017. [DOI: 10.1177/2474126417725946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The hallmark feature of the wet or neovascular form of age-related macular degeneration is the presence of choroidal (or retinal) neovascularization (CNV). If left untreated, CNV may result in significant central vision loss due to complications including exudation, leakage, and ultimately subretinal fibrosis causing remarkable photoreceptor loss. Although the mechanism of development is not fully understood, the process of neovascularization is driven by the upregulation of angiogenic cytokines, principally vascular endothelial growth factor (VEGF). Inhibition of VEGF with intravitreal anti-VEGF therapy has become the standard of care for macular CNV, helping to prevent legal blindness in millions of affected patients worldwide.
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Affiliation(s)
- David Brown
- Houston Methodist Hospital, Houston, TX, USA
| | | | - David S. Boyer
- Retina-Vitreous Associates Medical Group, Beverly Hills, CA, USA
| | - K. Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, NY, USA
| | - Peter Kaiser
- Cleveland Clinic Cole Eye Institute, Cleveland, OH, USA
| | - Judy E. Kim
- Medical College of Wisconsin, Milwaukee, WI, USA
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Parvin P, Zola M, Dirani A, Ambresin A, Mantel I. Two-year outcome of an observe-and-plan regimen for neovascular age-related macular degeneration treated with Aflibercept. Graefes Arch Clin Exp Ophthalmol 2017; 255:2127-2134. [PMID: 28798980 PMCID: PMC5640735 DOI: 10.1007/s00417-017-3762-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 07/05/2017] [Accepted: 07/24/2017] [Indexed: 11/28/2022] Open
Abstract
Purpose The purpose of our study was to investigate the two-year outcome of Aflibercept treatment for neovascular age-related macular degeneration (nAMD), using the Observe-and-Plan regimen, an individually planned treatment regimen, based on the predictability of an individual’s need for retreatment, aiming to reduce the clinical burden. Methods Our prospective study used the Observe-and-Plan regimen with Aflibercept to treat nAMD: Three loading doses, followed by monthly observation visits until the disease-recurrence interval was determined, which then was shortened by 2 weeks in a treatment plan for the next three injections without intermediate monitoring visits. The subsequent treatment plans were adjusted according to periodically assessed disease activity. The primary outcome measures were visual acuity changes, number of injections, and number of monitoring visits. Results The study included 112 eyes of 102 patients with a mean age of 80.7 years (SD 7.6). Mean visual acuity (VA) improved from 61.8 ETDRS letters (20/60+2) at baseline, by 8.5, 8.0, and 6.2 letters at months 3, 12 and 24, respectively. Mean central retinal thickness was 438um at baseline, and reduced by 152um, 155um, and 150um at months 3, 12 and 24, respectively. The mean number of injections was 8.7 and 6.5 in the first and second year, respectively. The mean number of monitoring visits after baseline was 3.8 and 2.8 during the first and second year, respectively. Conclusions The Observe-and-Plan regimen significantly improved VA, while fewer monitoring visits were needed as compared to other variable dosing regimens, thus reducing the workload for chronic care management of nAMD.
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Affiliation(s)
- Parmis Parvin
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Marta Zola
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Ali Dirani
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Aude Ambresin
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Irmela Mantel
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland.
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181
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Wykoff CC, Ou WC, Croft DE, Payne JF, Brown DM, Clark WL, Abdelfattah NS, Sadda SR. Neovascular age-related macular degeneration management in the third year: final results from the TREX-AMD randomised trial. Br J Ophthalmol 2017; 102:460-464. [PMID: 28779006 DOI: 10.1136/bjophthalmol-2017-310822] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND/AIMS Prospectively evaluate outcomes in the third year of neovascular age-related macular degeneration (AMD) management using ranibizumab with continued treat and extend (TREX) dosing compared with monthly visits with retreatment upon evidence of exudative disease activity (PRN, pro re nata). METHODS Subjects with treatment-naïve neovascular AMD were randomised 1:2 to Monthly or TREX and managed through 2 years. In the third year, subjects randomised to Monthly were managed PRN while subjects randomised to TREX were continued on TREX dosing or transitioned to PRN after achieving an interval of 12 weeks between visits. RESULTS Sixty subjects enrolled and 46 (77%) completed month 36 (M36). Transition from Monthly to PRN was associated with a decline in best corrected visual acuity (BCVA) (+10.5 letters (month 24) to +5.4 (M36, p=0.09)); three (15%) subjects required no dosing during year 3, and 47% (114/243) of possible PRN injections were delivered, yielding a mean of 6.1 injections during year 3. Among the 9 (23%) TREX subjects transitioned to PRN, the need for ongoing anti-vascular endothelial growth factor retreatments was small, with 4 (4%) intravitreal injections being delivered among 106 PRN visits; this subgroup displayed an inferior BCVA trajectory compared with the remainder of subjects. Outcomes among subjects continued on TREX were more favourable, with a mean gain of +5.0 letters at M36. CONCLUSIONS Upon transition to PRN, subjects randomised to monthly dosing experienced a decline in BCVA. Among subjects initially randomised to TREX who transitioned to PRN after achieving a 12-week interval between visits, the overall need for additional treatment was low. TRIAL REGISTRATION NUMBER NCT01748292, Results.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas, USA.,Blanton Eye Institute, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - William C Ou
- Retina Consultants of Houston, Houston, Texas, USA
| | | | - John F Payne
- Palmetto Retina Center, West Columbia, South Carolina, USA
| | - David M Brown
- Retina Consultants of Houston, Houston, Texas, USA.,Blanton Eye Institute, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - W Lloyd Clark
- Palmetto Retina Center, West Columbia, South Carolina, USA
| | - Nizar Saleh Abdelfattah
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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182
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Ou WC, Brown DM, Payne JF, Wykoff CC. Relationship Between Visual Acuity and Retinal Thickness During Anti-Vascular Endothelial Growth Factor Therapy for Retinal Diseases. Am J Ophthalmol 2017; 180:8-17. [PMID: 28549848 DOI: 10.1016/j.ajo.2017.05.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the relationship between best-corrected visual acuity (BCVA) and central retinal thickness (CRT) in eyes receiving ranibizumab for 3 common retinal diseases. DESIGN Retrospective analysis of clinical trial data. METHODS Early Treatment Diabetic Retinopathy Study BCVA and spectral-domain optical coherence tomography-measured CRT of 387 eyes of 345 patients enrolled in 6 prospective clinical trials for management of neovascular age-related macular degeneration (AMD), diabetic macular edema (DME), and retinal vein occlusion (RVO) were evaluated by Pearson correlation and linear regression. RESULTS At baseline, there was a small correlation between BCVA and CRT in pooled AMD trial data (r = -0.24). A medium correlation was identified in pooled DME trial data (r = -0.42). No correlation was found in pooled RVO trial data. At month 12, no correlation was found between changes from baseline in BCVA and CRT in pooled AMD trial data. Medium correlations were identified in both pooled DME (r = -0.45) and pooled RVO (r = -0.35) trial data at month 12. Changes in BCVA and CRT associated with edema recurrence upon transition from monthly to pro re nata (PRN) dosing were correlated in AMD (r = -0.27) and RVO (r = -0.72) trials, but not in DME trial data. CONCLUSION DME demonstrated a convincing relationship between BCVA and CRT. Correlations appear to be more complex in AMD and RVO. At the inflection point between monthly and PRN dosing, when recurrence of edema is anticipated in many patients, CRT appears strongly correlated with loss of BCVA in RVO.
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183
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Treat-and-Extend Therapy Using Aflibercept for Neovascular Age-related Macular Degeneration: A Prospective Clinical Trial. Am J Ophthalmol 2017. [PMID: 28624325 DOI: 10.1016/j.ajo.2017.06.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the efficacy and durability of aflibercept used in a treat-and-extend (TAE) regimen for neovascular age-related macular degeneration (NVAMD). DESIGN Multicenter, prospective, open label, noncomparative, interventional study. METHODS Forty eyes of 40 patients with treatment-naïve NVAMD were managed with a TAE regimen of intravitreal aflibercept. The main endpoints were the change in mean and median best-corrected visual acuity from baseline at years 1 and 2. Other endpoints included mean number of annual injections and treatment intervals. RESULTS Thirty-five (87.5%) and 31 patients (77.5%) completed year 1 and year 2, respectively. The mean letter gain was 7.2 (P < .001) and 2.4 (P = .269) letters at 1 and 2 years, respectively, from a mean baseline of 58.9 letters (20/63 Snellen equivalent). The median visual gain was 11.5 and 7.5 letters at 1 and 2 years, respectively, from a median baseline of 59.0 letters (20/63 Snellen equivalent). The mean number of injections was 8.0 and 6.5 during the first and second year, respectively. Twelve-week or longer treatment intervals were used in 35% and 38% of patients during the first- and second-year time points, respectively. CONCLUSION Intravitreal aflibercept TAE therapy led to significant visual improvement in eyes with NVAMD at 1 year, with some loss in the visual gains at the end of year 2 that was not related to loss of exudative control. TAE therapy with aflibercept is a rational strategy to reduce treatments and clinic evaluations over 2 years with satisfactory outcomes.
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184
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Tuuminen R, Uusitalo-Järvinen H, Aaltonen V, Hautala N, Kaipiainen S, Laitamäki N, Ollila M, Rantanen J, Välimäki S, Sipilä R, Laukkala T, Komulainen J, Tommila P, Immonen I, Tuulonen A, Kaarniranta K. The Finnish national guideline for diagnosis, treatment and follow-up of patients with wet age-related macular degeneration. Acta Ophthalmol 2017; 95:1-9. [PMID: 28686003 DOI: 10.1111/aos.13501] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Age-related macular degeneration (AMD) is the main cause of visual impairment in developed countries. Several improvements in the visualization of posterior segment of the eye together with the introduction of intravitreal anti-VEGF treatment have revolutionized the prognosis of the wet form of AMD (wAMD). Increasing incidence of wAMD together with the limited resources of society and of the healthcare system poses challenges for the provision and development of care. In context of these current aspects, we aimed to set evidence-based medical guidelines for diagnosis, treatment and follow-up of patients with wAMD.
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Affiliation(s)
- Raimo Tuuminen
- Department of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Patient Insurance Centre; Helsinki Finland
| | | | - Vesa Aaltonen
- Department of Ophthalmology; Turku University Hospital; Turku Finland
| | - Nina Hautala
- Department of Ophthalmology; Oulu University Hospital; Oulu Finland
- Medical Research Center; University of Oulu; Oulu Finland
| | - Sulevi Kaipiainen
- Department of Ophthalmology; North Karelian Central Hospital; Joensuu Finland
| | - Nina Laitamäki
- Department of Ophthalmology; Kanta-Häme Central Hospital; Hämeenlinna Finland
| | - Marko Ollila
- Department of Ophthalmology; Lapland Central Hospital; Rovaniemi Finland
| | - Jari Rantanen
- Department of Ophthalmology; Satakunta Central Hospital; Pori Finland
| | - Satu Välimäki
- Department of Ophthalmology; Päijät-Häme Central Hospital; Lahti Finland
| | - Raija Sipilä
- The Finnish Medical Society Duodecim; Helsinki Finland
| | | | | | - Petri Tommila
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Ilkka Immonen
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Anja Tuulonen
- Tays Eye Centre; Tampere University Hospital; Tampere Finland
| | - Kai Kaarniranta
- Department of Ophthalmology; Kuopio University Hospital; Kuopio Finland
- Department of Ophthalmology; Institute of Clinical Medicine; University of Eastern Finland; Kuopio Finland
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185
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Lee DH, Kang HG, Lee SC, Kim M. Features of optical coherence tomography predictive of choroidal neovascularisation treatment response in pathological myopia in association with fluorescein angiography. Br J Ophthalmol 2017; 102:238-242. [PMID: 28600301 DOI: 10.1136/bjophthalmol-2017-310244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/03/2017] [Accepted: 05/06/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate the usefulness of several optical coherence tomography (OCT) findings to estimate choroidal neovascularisation (CNV) activity in pathological myopia using fluorescein angiography (FA) as a reference. METHODS This was a single-centre, retrospective study. The medical records of patients with active myopic CNV who received intravitreal bevacizumab treatment were reviewed. Parameters to monitor CNV activity were morphological features of CNV on OCT, such as CNV height, central foveal thickness, intraretinal cysts, subretinal fluid, fuzziness of the CNV border, CNV network area on FA, and haemorrhage or exudation on fundus photo. RESULTS There were 46 patients with active CNV enrolled in this study. After intravitreal bevacizumab treatment, all the previously mentioned parameters of CNV were significantly improved. Using logistic regression analyses with backward elimination, the fuzzy border seen on OCT showed the most significant correlation with improvement of leakage on FA, when compared with other variables such as intraretinal cysts, subretinal fluid or central foveal thickness (R2=0.324, p=0.009). CONCLUSION Our study showed that the fuzziness of the hyper-reflective CNV margin showed the most significant improvement and the strongest correlation with the improvement of CNV leakage on FA after intravitreal bevacizumab injections, suggesting its important role as an OCT parameter for the assessment of myopic CNV activity.
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Affiliation(s)
- Dong Hyun Lee
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Goo Kang
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Chul Lee
- Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Kim
- Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kortüm KU, Müller M, Kern C, Babenko A, Mayer WJ, Kampik A, Kreutzer TC, Priglinger S, Hirneiss C. Using Electronic Health Records to Build an Ophthalmologic Data Warehouse and Visualize Patients' Data. Am J Ophthalmol 2017; 178:84-93. [PMID: 28365240 DOI: 10.1016/j.ajo.2017.03.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 01/09/2023]
Abstract
PURPOSE To develop a near-real-time data warehouse (DW) in an academic ophthalmologic center to gain scientific use of increasing digital data from electronic medical records (EMR) and diagnostic devices. DESIGN Database development. METHODS Specific macular clinic user interfaces within the institutional hospital information system were created. Orders for imaging modalities were sent by an EMR-linked picture-archiving and communications system to the respective devices. All data of 325 767 patients since 2002 were gathered in a DW running on an SQL database. A data discovery tool was developed. An exemplary search for patients with age-related macular degeneration, performed cataract surgery, and at least 10 intravitreal (excluding bevacizumab) injections was conducted. RESULTS Data related to those patients (3 142 204 diagnoses [including diagnoses from other fields of medicine], 720 721 procedures [eg, surgery], and 45 416 intravitreal injections) were stored, including 81 274 optical coherence tomography measurements. A web-based browsing tool was successfully developed for data visualization and filtering data by several linked criteria, for example, minimum number of intravitreal injections of a specific drug and visual acuity interval. The exemplary search identified 450 patients with 516 eyes meeting all criteria. CONCLUSIONS A DW was successfully implemented in an ophthalmologic academic environment to support and facilitate research by using increasing EMR and measurement data. The identification of eligible patients for studies was simplified. In future, software for decision support can be developed based on the DW and its structured data. The improved classification of diseases and semiautomatic validation of data via machine learning are warranted.
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187
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Aflibercept in age-related macular degeneration: evaluating its role as a primary therapeutic option. Eye (Lond) 2017; 31:1523-1536. [PMID: 28548650 DOI: 10.1038/eye.2017.81] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/26/2017] [Indexed: 12/27/2022] Open
Abstract
The recent VIEW studies have demonstrated the non-inferiority of monthly and bi-monthly aflibercept in the management of wet age related macular degeneration (AMD) compared with ranibizumab. However, the current data are limited mainly to fixed dosing regimens with few studies looking at flexible dosing regimens of aflibercept in wet AMD. In addition, recent data from the VIEW 96 week extension has shown that patients being shifted from fixed dosing regimens to PRN have shown a drop in visual acuity and increase in central macular thickness. This is an indication that fixed dosing, a non-sustainable option, is only effective as long as it is continued. Regimens such as treat and extend (TAE) and pro-re nata (PRN) have been studied extensively in ranibizumab and bevacizumab and have shown to be effective options. With the presence of effective, established and less costly drugs such as ranibizumab and bevacizumab, the role of aflibercept as a primary treatment modality has yet to be clearly defined. The current review provides an analysis of the VIEW studies, as well as the extension phases. It also looks at post hoc analysis of predictors of response and outcomes. We have also conducted a search on studies comparing between PRN regimens using aflibercept and other anti-VEGF agents. This review also explores cheaper off label aflibercept; ziv-aflibercept in the treatment of wet AMD. The main purpose of the review is to delineate the role of aflibercept as a primary therapeutic option and if there are any significant advantages that would advocate its use over alternative anti-VEGF drugs. Finally, we propose a treatment algorithm for patients being started on aflibercept during the first year and thereafter.
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188
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Yang Y, Downey L, Mehta H, Mushtaq B, Narendran N, Patel N, Patel PJ, Ayan F, Gibson K, Igwe F, Jeffery P. Resource Use and Real-World Outcomes for Ranibizumab Treat and Extend for Neovascular Age-Related Macular Degeneration in the UK: Interim Results from TERRA. Ophthalmol Ther 2017; 6:175-186. [PMID: 28508241 PMCID: PMC5449310 DOI: 10.1007/s40123-017-0091-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Ranibizumab is an inhibitor of vascular endothelial growth factor-A (anti-VEGF) approved for the treatment of neovascular age-related macular degeneration (nAMD). The treat and extend (T&E) regimen can potentially reduce the burden of clinic visits compared with a pro re nata (PRN) regimen. Retrospective, interim analyses of clinical effectiveness, treatment and resource use patterns were conducted using real-world data in England and Wales from the TERRA study. Methods Two cohorts, those switching from a PRN to a T&E regimen (‘prior PRN’) and those initiating ranibizumab on the T&E regimen as their first anti-VEGF therapy (‘anti-VEGF-naïve’) were enrolled in TERRA. Retrospective clinical assessments were gathered from medical records, while resource use patterns were collected via an operating cost questionnaire completed by each study site. Results At the interim analysis cut-off date (15 November 2016), 11 sites had enrolled 145 patients (prior PRN: n = 110; anti-VEGF-naïve: n = 35). Mean change from baseline (date of first injection) in visual acuity and central subfield retinal thickness to 12 months was +7.6 Early Treatment Diabetic Retinopathy Study letters [95% confidence interval (CI) 2.8, 12.4; p = 0.003; n = 27] and −67.7 μm (95% CI −106.5, −28.9; p = 0.001, n = 29), respectively, in the anti-VEGF-naïve cohort. Most T&E clinics were run as one-stop services (same-day monitoring and injection), whereas 4/10 PRN clinics were run as two-stop services (monitoring and injection on different days). In general, one-stop clinics used less staff resources and were likely to be shorter in duration for healthcare providers than the cumulative time spent for two-stop clinics. Conclusion This is the first real-world observational study conducted in England and Wales demonstrating the effectiveness of the ranibizumab T&E regimen in anti-VEGF-naïve patients. T&E is compatible with one-stop clinic services, which these real-world data suggest to be less resource intensive than two-stop clinic services, possibly providing a dosing regimen beneficial to both patients and resource burden in UK clinical practice. Funding: Novartis Pharmaceuticals UK Limited. Electronic supplementary material The online version of this article (doi:10.1007/s40123-017-0091-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, UK.
- School of Health and Life Sciences, Aston University, Birmingham, UK.
| | | | - Hemal Mehta
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Nishal Patel
- East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Praveen J Patel
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Filis Ayan
- Novartis Pharmaceuticals UK Limited, Surrey, UK
| | - Kara Gibson
- Novartis Pharmaceuticals UK Limited, Surrey, UK
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189
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Rufai SR, Almuhtaseb H, Paul RM, Stuart BL, Kendrick T, Lee H, Lotery AJ. A systematic review to assess the 'treat-and-extend' dosing regimen for neovascular age-related macular degeneration using ranibizumab. Eye (Lond) 2017; 31:1337-1344. [PMID: 28475181 DOI: 10.1038/eye.2017.67] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/12/2017] [Indexed: 12/29/2022] Open
Abstract
Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the developed world. Monthly or as-needed (PRN) dosing strategies of intravitreal ranibizumab have been established as efficacious treatment options for neovascular AMD. More recently, the 'treat-and-extend' dosing regimen (TREX) is being adopted in clinical practice as it represents a patient-centric and economical option, reducing treatment burden by extending injection intervals when possible. However, the efficacy of TREX using ranibizumab monotherapy remains to be defined. Therefore, we performed a systematic review to assess the current evidence for TREX using ranibizumab by searching MEDLINE, Embase and PubMed. Of the 1733 articles identified, nine TREX studies were included in our analysis (n=748 eyes). Average patient age was 79.25 (range: 77.34-82.00; SD: 7.27). Baseline BCVA ranged from 48.5-68.9 ETDRS letters. BCVA improvement was 8.92 letters at 1 year (range: 6.5-11.5; SD: 7.54), as a weighted mean accounting for numbers of study eyes. The weighted mean number of injections at one year was 8.60 (range: 7.3-12.0; SD: 1.73). Previously, the landmark ANCHOR and MARINA trials reported gains of 11.3 and 7.2 letters, respectively, using monthly ranibizumab. Chin-Yee et al reported a gain of 3.5 ETDRS letters with 5.3 (S.D. 0.66) PRN ranibizumab injections as weighted means at 1 year in their recent systematic review. Our analysis suggests that TREX delivers visual outcomes superior to PRN and approaches similar efficacy to monthly injections. Further RCTs are needed to fully evaluate the efficacy and economy of TREX in the long-term.
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Affiliation(s)
- S R Rufai
- Faculty of Medicine, University of Southampton, Southampton, UK.,Southampton Eye Unit, University Hospital Southampton, Southampton, UK
| | - H Almuhtaseb
- Faculty of Medicine, University of Southampton, Southampton, UK.,Southampton Eye Unit, University Hospital Southampton, Southampton, UK
| | - R M Paul
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - B L Stuart
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - T Kendrick
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - H Lee
- Faculty of Medicine, University of Southampton, Southampton, UK.,Southampton Eye Unit, University Hospital Southampton, Southampton, UK
| | - A J Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK.,Southampton Eye Unit, University Hospital Southampton, Southampton, UK
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190
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Lai TYY. An Update on Intravitreal Aflibercept in Treating Macular Diseases. Asia Pac J Ophthalmol (Phila) 2017; 6:225-227. [PMID: 28558181 DOI: 10.22608/apo.2017177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 11/08/2022] Open
Affiliation(s)
- Timothy Y Y Lai
- Hong Kong Eye Hospital, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong
- 2010 Macula & Retina Centre, Kowloon, Hong Kong
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191
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Gemenetzi M, Patel PJ. A Systematic Review of the Treat and Extend Treatment Regimen with Anti-VEGF Agents for Neovascular Age-Related Macular Degeneration. Ophthalmol Ther 2017; 6:79-92. [PMID: 28451952 PMCID: PMC5449306 DOI: 10.1007/s40123-017-0087-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Indexed: 01/05/2023] Open
Abstract
Despite significant progress in retaining vision for neovascular age-related macular degeneration patients in the era of treatment with intravitreal anti-VEGF agents, there is no universally accepted treatment regimen that defines the frequency of treatment needed to achieve the optimal visual outcomes while simultaneously balancing the burden of long-term, frequent and high-cost treatment. Treat and extend has recently and consistently been used by retina specialists to minimise the financial and psychological costs of the need for frequent treatment with anti-VEGF injections. This is a systematic review that presents evidence from clinical trials and the real world on the utilisation of treat and extend with anti-VEGF intravitreal injections in neovascular age-related macular degeneration, and discusses the experience gained thus far from the utilisation of such regimens to preserve vision when treating patients over the long-term.
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Affiliation(s)
- Maria Gemenetzi
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Praveen J Patel
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK.
- UCL Institute of Ophthalmology, London, UK.
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192
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24-month clinical outcomes of a treat-and-extend regimen with ranibizumab for wet age-related macular degeneration in a real life setting. BMC Ophthalmol 2017; 17:58. [PMID: 28449645 PMCID: PMC5408417 DOI: 10.1186/s12886-017-0451-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/22/2017] [Indexed: 11/21/2022] Open
Abstract
Background To evaluate the clinical effectiveness and analyze the outcomes of a treat-and-extend (T&E) treatment regimen with ranibizumab for wet age-related macular degeneration (ARMD) in real life clinical settings over the first 2 years (24 months) of treatment. Methods Retrospective analysis of visual acuity, spectral domain optical coherence tomography (SD-OCT) parameters and treatment burden data of 56 eyes of 54 unselected treatment naive patients diagnosed with exudative ARMD. Monthly injections were offered until no signs of disease activity such as intra-retinal (IRF) or sub-retinal fluid (SRF) were evident on SD-OCT, followed by a gradual extension of the treatment interval by 2 weeks until a maximum of 12 weeks. Results The study met its main objective, demonstrating a mean best-corrected visual acuity gain of 8.3 letters (mean 68.8 ± 11) at month 12 and 5.2 letters (mean 65.7 ± 12.3) at 24 months compared to baseline (mean 60.5 ± 8.9). Anatomical improvement was also documented with a mean reduction of central retinal thickness by 139.7 μm at 24 months (244.9 ± 48.3) compared to baseline (384.6 ± 154.9). Forty-seven eyes (83.9% N = 56) gained vision or preserved baseline vision with 23 eyes (41.1%) gaining 10 letters or more at month 12. Out of the 46 eyes that completed 24 months of treatment and monitoring, 27 (58.7% N = 46) kept a BCVA above baseline with 18 of those (39% N = 46) maintaining a 10-letter gain throughout the 24 months. Six eyes (13% N = 46) lost more than 10 letters by month 24. The mean number of injections was 12.1 ± 2.8 over the 24-month period. Twenty-seven eyes (55.1% N = 56) achieved a treatment interval of 10 weeks or more at month 12, while the respective number at month 24 was 20 eyes (43.4% N = 46) in addition though to four more patients (8.7% N = 46) who were not receiving injections at month 24 since they were placed on a Monitor & Extend regime. Conclusions This is the first UK real-life study of a T&E treatment protocol with ranibizumab for exudative ARMD in a 24-month period and suggests that such a regimen is clinically effective and can achieve favourable outcomes with a significant reduction of the treatment burden compared to monthly PRN.
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193
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Incidence and risk factors of retreatment after three-monthly aflibercept therapy for exudative age-related macular degeneration. Sci Rep 2017; 7:44020. [PMID: 28266609 PMCID: PMC5339812 DOI: 10.1038/srep44020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/02/2017] [Indexed: 11/24/2022] Open
Abstract
Though anti-vascular endothelial growth factor therapy has become the standard treatment for exudative age-related macular degeneration (AMD), retreatment after the initial loading injection is inevitable in most eyes with residual or recurrent exudative changes. In the present study, we studied 140 treatment naïve eyes with typical neovascular AMD (n = 71) or polypoidal choroidal vasculopathy (PCV) (n = 69) and investigated the incidence and risk factors of retreatment after 3-monthly intravitreal aflibercept injection for exudative AMD during the 12-month period. At 12 months, best-corrected visual acuity (BCVA) improved significantly from 0.45 ± 0.39 to 0.26 ± 0.33 (P = 4.1 × 10−11). Multiple regression analysis revealed that better baseline BCVA (P = 3.6 × 10−14) and thicker subfoveal choroidal thickness (P = 0.039) were associated with better BCVA at 12-months. Retreatment was required in 94 out of 140 (67.1%) eyes. Multivariate logistic regression analysis revealed that older age (P = 7.2 × 10−3) and T-allele of ARMS2 A69S (rs10490924) variants (P = 1.9 × 10−3) were associated with retreatment. Cox-regression analysis revealed that older age (P = 1.0 × 10−2) and T-allele of the ARMS2 gene (P = 6.0 × 10−3) were associated with retreatment-free period. The number of retreatment episodes was significantly different among the ARMS2 genotypes (P = 8.1 × 10−4). These findings might be helpful for physicians when considering the optimal treatment regimen for exudative AMD.
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194
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Danyliv A, Glanville J, McCool R, Ferreira A, Skelly A, Jacob RP. The Clinical Effectiveness of Ranibizumab Treat and Extend Regimen in nAMD: Systematic Review and Network Meta-Analysis. Adv Ther 2017; 34:611-619. [PMID: 28188433 PMCID: PMC5350194 DOI: 10.1007/s12325-017-0484-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Indexed: 11/25/2022]
Abstract
Introduction Neovascular age-related macular degeneration (nAMD) is a chronic eye condition that causes severe deterioration of vision and ultimately blindness. Two vascular endothelial growth factor inhibitors are approved for nAMD treatment in Europe: ranibizumab and aflibercept. The European license for ranibizumab was updated with an individualized “treat and extend” (T&E) regimen, which involves more proactive treatment based on changes in best corrected visual acuity (BCVA) and/or anatomical outcomes. The aim of this publication is to compare the efficacy of the ranibizumab T&E regimen with other approved dosing regimens for nAMD on the basis of outcomes identified from a systematic review and subsequent NMA. Methods Following a systematic search of publications, to identify relevant studies, a repeated-measures network meta-analysis (NMA) was performed to estimate the relative effectiveness of ranibizumab T&E versus approved dosing regimens of ranibizumab and aflibercept. The analysis focused on licensed treatment regimens for nAMD. We examined mean change from baseline in BCVA on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Results The systematic literature review identified 22,949 records, of which 23 studies were included in the NMA. At 12 months, the ranibizumab T&E dosing regimen vs ranibizumab pro re nata (PRN) was associated with small differences in change in BCVA, between 1.86 letter gain at 12 months and 2.35 letter gain at 24 months. A similar difference was observed in the aflibercept dosing regimen versus ranibizumab T&E ; 1.94 letter gain at 12 months and 3.31 letter gain at 24 months. All doses of ranibizumab and aflibercept showed similar effectiveness, and the differences between treatment options were not significant. Conclusion This study used novel repeated-measures NMA to synthesize efficacy results when treatment effects were reported at multiple follow-up times. This repeated-measures NMA suggests that treating patients with the ranibizumab T&E regimen yields similar effectiveness compared to other approved ranibizumab and aflibercept dosing regimens for nAMD treatment. Funding: Novartis Pharmaceuticals UK Ltd, Surrey, UK. Electronic supplementary material The online version of this article (doi:10.1007/s12325-017-0484-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Julie Glanville
- York Health Economics Consortium, University of York, York, UK
| | - Rachael McCool
- York Health Economics Consortium, University of York, York, UK
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195
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Castro-Navarro V, Cervera-Taulet E, Montero-Hernández J, Navarro-Palop C. Treat-and-extend approach with aflibercept: Effects on different subtypes of age-related choroidal neovascularisation. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2017; 92:112-119. [PMID: 27816486 DOI: 10.1016/j.oftal.2016.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/13/2016] [Accepted: 09/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To describe functional/morphological outcomes of treat-and-extend (TAE) with aflibercept in different subtypes of neovascularizations (CNV) secondary to exudative age-related macular degeneration (AMD). METHODS Retrospective study was conducted on 30 eyes of 30 patients treated with 2 mg-aflibercept according to a TAE protocol. Examinations included best corrected visual acuity (BCVA), number of injections, and visits needed. A quantitative/qualitative analysis was also performed with fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) at baseline, and at 3, 6, and 12 months. RESULTS BCVA significantly improved from 0.61±0.26 logMAR to 0.38±0.34 logMAR. Among the total AMD patients, type 1 CNV was diagnosed in 11 eyes (36%), type 2 CNV in 7 eyes (23%), mixed CNV in 5 eyes (16%), and type 3 CNV or retinal angiomatous proliferation (RAP) in 7 eyes (23%). The final mean number of injections was 7.5±1.65, 8.71±0.76, 7.4±0.89, 7.2±0.7, and number of visits 6.6±2.17, 7.89±1.46, 5.8±1.7, and 7.14±1.57, respectively in type 1, type 2, mixed, and type 3 or RAP. There was no difference between the different subtypes of CNV (P>.05). CONCLUSIONS Aflibercept in TAE is effective for all exudative-AMD subtypes. No significant differences in patient's visual gain, mean number of injections, or number of visits needed were found among the subtypes of CNV.
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Affiliation(s)
- V Castro-Navarro
- Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia. España; Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, España.
| | - E Cervera-Taulet
- Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia. España
| | - J Montero-Hernández
- Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia. España
| | - C Navarro-Palop
- Servicio de Oftalmología, Hospital General Universitario de Valencia, Valencia. España
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196
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Almuhtaseb H, Kanavati S, Rufai SR, Lotery AJ. One-year real-world outcomes in patients receiving fixed-dosing aflibercept for neovascular age-related macular degeneration. Eye (Lond) 2017; 31:878-883. [PMID: 28186507 DOI: 10.1038/eye.2017.6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/10/2017] [Indexed: 01/30/2023] Open
Abstract
PurposeTo investigate 1-year visual and anatomic outcomes of intravitreal aflibercept for neovascular age-related macular degeneration (nAMD) given at a fixed 8-weekly interval.MethodsRetrospective, single-practice data analysis from an electronic medical record system of 255 eyes (223 patients) with treatment-naïve nAMD receiving 8-weekly aflibercept.ResultsMean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) improved from 0.66 at baseline to 0.50 at month 11 (P<0.0001). Mean central retinal thickness (CRT) decreased from 311 μm at baseline to 211 μm at month 11 (P<0.0001). Our mean VA gain of eight ETDRS letters was comparable to the VIEW 1 and VIEW 2 Trials' results at the end of year 1. After loading at month 5, mean BCVA was 0.48 (P<0.0001), and mean CRT was 235 μm. At month 5, 143 eyes (56%) were inactive defined by the absence of macular haemorrhage and intraretinal fluid (IRF) and subretinal fluid (SRF) on optical coherence tomography, and 112 eyes (44%) remained active. At month 11, 136 eyes (53%) were inactive, and 119 eyes (47%) remained active. At month 11, 77% of inactive eyes after loading remained inactive, and 77% of the active eyes after loading remained active. At month 11, mean BCVA of the inactive group was 0.51, and mean BCVA of the active group was 0.48 (P=0.54).ConclusionsAflibercept administered by fixed dosing over 1 year improved VA and macular morphology in treatment-naïve eyes. Active lesions at month 11 do not have worse VA outcomes compared with inactive lesions. The macular status after loading is a reliable indicator of disease activity at the end of year 1.
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Affiliation(s)
- H Almuhtaseb
- Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, Hampshire, UK
| | - S Kanavati
- Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - S R Rufai
- Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, Hampshire, UK
| | - A J Lotery
- Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, Hampshire, UK
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197
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Wykoff CC, Ou WC, Brown DM, Croft DE, Wang R, Payne JF, Clark WL, Abdelfattah NS, Sadda SR. Randomized Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration: 2-Year Results of the TREX-AMD Study. Ophthalmol Retina 2017; 1:314-321. [PMID: 31047517 DOI: 10.1016/j.oret.2016.12.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate a prospective treat-and-extend (TREX) management strategy compared with monthly dosing with intravitreal ranibizumab (Lucentis) in neovascular age-related macular degeneration (AMD). DESIGN Prospective, randomized, multicenter clinical trial. PARTICIPANTS Sixty patients with treatment-naïve neovascular AMD randomized 1:2 to monthly or TREX cohorts. METHODS Patients with Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) of 20/32 to 20/500 (Snellen equivalent) were randomized to receive intravitreal 0.5 mg ranibizumab monthly or, according to a TREX protocol, no less frequently than every 12 weeks. After interval extension, if recurrent exudative disease was identified, this maximum interval between treatments was rechallenged according to a strict prospective protocol. MAIN OUTCOME MEASURE Change in ETDRS BCVA from baseline. RESULTS Sixty patients were enrolled and 50 completed month 24, at which point mean ETDRS BCVA letter gains were similar: 10.5 and 8.7 for the monthly and TREX cohorts, respectively (P = 0.64). At month 24, 4 patients (20%) and 12 patients (30%) in the monthly and TREX cohorts, respectively, gained at least 15 letters (P = 0.41). No monthly cohort patient lost more than 2 letters, whereas 5 TREX cohort patients (13%) lost at least 15 letters. Anatomic improvements were similar between the cohorts. Through month 24, the mean number of injections administered was 25.5 (range, 22-27) and 18.6 (range, 10-25) for the monthly and TREX cohorts, respectively (P < 0.001). Among TREX patients completing month 24, 14 (47%) were at an extension interval of 8 weeks or more, and the mean maximum tolerated extension was 8.5 weeks over the course of 2 years. Of the 26 TREX patients (65%) who demonstrated recurrent exudation upon interval extension, the first maximum extension interval was consistent in most eyes (n = 19 [73%]). CONCLUSIONS The TREX neovascular AMD management protocol used with ranibizumab in the Treat-and-Extend Protocol in Patients with Wet Age-Related Macular Degeneration (TREX-AMD) study resulted in visual and anatomic gains comparable with those obtained with monthly dosing, and most patients randomized to TREX therapy demonstrated a relatively consistent maximum extension interval.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas.
| | | | - David M Brown
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas
| | | | - Rui Wang
- Retina Consultants of Houston, Houston, Texas
| | - John F Payne
- Palmetto Retina Center, West Columbia, South Carolina
| | - W Lloyd Clark
- Palmetto Retina Center, West Columbia, South Carolina
| | - Nizar Saleh Abdelfattah
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
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198
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Abdelfattah NS, Al-Sheikh M, Pitetta S, Mousa A, Sadda SR, Wykoff CC, Wykoff CC, Croft DE, Brown DM, Wang R, Payne JF, Clark L, Abdelfattah NS, Sadda SR, Benz MS, Chen E, Fish RH, Johnson DL, Kim RY, Major JC, O'Malley RE, Schefler AC, Shah AR, Vance SK, Wells JA, Wong TP. Macular Atrophy in Neovascular Age-Related Macular Degeneration with Monthly versus Treat-and-Extend Ranibizumab. Ophthalmology 2017; 124:215-223. [DOI: 10.1016/j.ophtha.2016.10.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/29/2016] [Accepted: 10/03/2016] [Indexed: 01/08/2023] Open
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199
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Dunn EN, Sheth VS, Hariprasad SM. An Overview of the Fovista and Rinucumab Trials and the Fate of Anti-PDGF Medications. Ophthalmic Surg Lasers Imaging Retina 2017; 48:100-104. [DOI: 10.3928/23258160-20170130-02] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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200
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Han JW, Kim JW, Kim CG, Lee DW, Han JI, Lew YJ, Kim JH. Fourteen Anti-vascular Endothelial Growth Factor Injections for Age-related Macular Degeneration: Ending Period and Clinical Outcome. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.9.1042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jae Wook Han
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Jong Woo Kim
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Chul Gu Kim
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Dong Won Lee
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Jung Il Han
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Young Ju Lew
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Jae Hui Kim
- Myung-Gok Eye Resarch Institute, Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
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