Visual Outcomes Associated With Patterns of Macular Edema Resolution in Central Retinal Vein Occlusion Treated With Anti-Vascular Endothelial Growth Factor Therapy: A Post Hoc Analysis of the Lucentis, Eylea, Avastin in Vein Occlusion (LEAVO) Trial

Trends in Anti-Vascular Endothelial Growth Factor Original Medicare Part B Claims in the United States, 2014-2019

PURPOSE

To characterize trends in use of and expenditure for the intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents aflibercept, ranibizumab, and bevacizumab among the population enrolled in Original Medicare from 2014 to 2019.

METHODS

The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to extract Medicare Part B fee-for-service outpatient injection claims data submitted by ophthalmologists. Multivariable linear regression models were used to evaluate the association between reimbursement, ophthalmologist availability, and agent administration rate.

RESULTS

Between 2014 and 2019, 17,588,995 intravitreal injection claims were filed by 4218 US ophthalmologists. Medicare costs for anti-VEGF injections increased from 2.51 B USD in 2014 to 4.02 B USD in 2019. Increased state-level ophthalmologist availability and incremental increases in average reimbursement amounts were found to be significantly associated with a 6.8-fold variation in 2019 overall anti-VEGF injection rates across states.

CONCLUSIONS

Medicare injection rates and costs for anti-VEGF injections have both increased between 2014 and 2019, largely driven by increased aflibercept use. There is a significant association between ophthalmologist availability and anti-VEGF injection rate on the state level, suggesting access to care may contribute to the observed state-level disparities in intravitreal injection rates. Further characterization of factors contributing to the state-level variation in injection rates of individual anti-VEGF agents may help inform interventions promoting equitable access to and use of these drugs.

Rate and associations of inner retinal thinning in eyes with retinal vein occlusion and regressed macular oedema

PURPOSE

To investigate the associations between visual acuity (VA) and structural optical coherence tomography (OCT) features in retinal vein occlusion (RVO) eyes after cystoid macular oedema (CMO) regression and to assess whether inner retinal thinning is progressive.

METHODS

Retrospective observational study of RVO eyes with regressed CMO for at least 6 months. OCT scans at CMO regression were analysed, and features were correlated with VA at that visit. The inner retinal thickness was longitudinally compared between RVO and unaffected fellow eyes (controls) with linear mixed models. The rate of inner retinal thinning was obtained as the interaction term between disease status and time. Associations between inner retinal thinning and clinical characteristics were explored.

RESULTS

Thirty-six RVO eyes were followed for 34.2 ± 21.1 months after CMO regression. The presence of ellipsoid zone disruption (regression estimate[standard error(SE)] = 0.16[0.04] LogMAR vs. intact, p < 0.001) and lower inner retinal thickness (regression estimate[SE] = -0.25[0.12] LogMAR for 100-μm increase, p = 0.01) were associated with worse VA. The inner retinal thickness decreased faster in RVO than controls (rate of retinal thinning -0.27 ± 0.09 μm/month vs. -0.08 ± 0.11 μm/month, p = 0.01). Macular ischaemia was associated with a faster rate of retinal thinning (interaction term macular ischaemia*follow-up time, p = 0.04).

CONCLUSION

Inner retinal and photoreceptors' layers integrity are associated with better visual acuity once CMO resolves. RVO eyes undergo progressive inner retinal thinning after CMO regression, faster in eyes with macular ischaemia.

The Impact of Residual Retinal Fluid Following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema and Macular Edema Secondary to Retinal Vein Occlusion: A Systematic Review

The association between residual retinal fluid and visual acuity for diabetic macular edema (DME) and macular edema (ME) secondary to retinal vein occlusion (RVO) is not well established. We conducted a systematic literature search for peer-reviewed articles reporting on visual acuity stratified by subretinal fluid (SRF), intraretinal fluid (IRF), or any retinal fluid at final follow-up after intravitreal anti-vascular endothelial growth factor therapy injection for treatment of DME or ME secondary to RVO. Two observational studies on ME secondary to RVO and one study for DME found no significant differences between eyes with and without residual retinal fluid for final BCVA. One randomized controlled trial (RCT) found that eyes with residual retinal fluid had significantly worse final best-corrected visual acuity in ME secondary to RVO, whereas another RCT found no significant difference for DME. There is a paucity of evidence examining the impact of residual retinal fluid on visual acuity in DME and ME secondary to RVO. The limited evidence suggests that aggressive fluid resolution is worthwhile. [Ophthalmic Surg Lasers Imaging Retina 2023;54:50-58.].

[Biomarkers in the treatment of retinal vein occlusion]

BACKGROUND

Retinal vein occlusion, subdivided into central retinal and branch retinal vein occlusion, is one of the most frequent vascular diseases of the retina. Biomarkers of optical coherence tomography (OCT), OCT-angiography and (ultra-widefield) fluorescein angiography are of exceptional importance in the initial diagnosis and also in the treatment of complications associated with retinal vascular occlusion, particularly macular edema.

METHODS

A systematic literature review was carried out in PubMed with the keywords central retinal vein occlusion, branch retinal vein occlusion, biomarker, OCT, OCT angiography, ultra-widefield fluorescein angiography with prioritization of the most important aspects.

RESULTS

Relevant biomarkers in OCT include central retinal thickness (CRT), macular fluid, the integrity of the photoreceptor bands (external limiting membrane and ellipsoid zone), disorganization of retinal inner layers (DRIL), hyperreflective foci, choroidal thickness and signs of ischemia, such as a prominent middle limiting membrane (p-MLM), paracentral acute middle maculopathy (PAMM) as well as hyperreflectivity of inner retinal layers (HIRL). The importance of OCT-angiography lies particularly in the assessment of microvascular alterations, especially vessel density in the deep retinal vascular plexus, the foveal avascular zone and of areas with no capillary perfusion. Biomarkers of ultra-widefield angiography, such as peripheral ischemia (ischemic index) and neovascularízation are essential with respect to treatment decisions for retinal laser.

CONCLUSION

A multitude of simple and complex biomarkers currently enable an effective individualized evaluation of treatment and prognosis in retinal vein occlusion. A shift from invasive to noninvasive biomarkers can be observed.