Treatment of neovascular age-related macular degeneration with a variable ranibizumab dosing regimen and one-time reduced-fluence photodynamic therapy: the TORPEDO trial at 2 years

Review of Fibrosis in Neovascular Age-Related Macular Degeneration

PURPOSE

To report the diagnosis and definitions, epidemiology, risk factors, and visual outcomes of fibrosis in neovascular age-related macular degeneration (nAMD).

DESIGN

Systematic review and meta-analysis.

METHODS

The review was performed using the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Observational studies and randomized controlled trials were included.

RESULTS

Identification of fibrosis is challenging. Optical coherence tomography angiography and polarization-sensitive optical coherence tomography represent novel options in multimodal imaging. The prevalence of fibrosis at baseline, 12, 24, and 60 months was 13%, 32%, 36%, and 56%, respectively. Approximately 60% of the fibrosis burden in nAMD at 5 years was present in the first year of treatment. Fibrosis development was highest in the first 12 months and slowed down over time. The risk factors of fibrosis included classic choroidal neovascularization (CNV), intra-retinal fluid, hemorrhage, hyperreflective material, CNV lesion size, and retinal thickness. Sub-retinal fluid and pigment epithelial detachment may be protective. Treatment-associated factors included disease activity and time to diagnosis. At baseline, the best corrected visual acuity in eyes with fibrosis was poorer than in eyes without fibrosis (-18.50 letters); this difference became larger at 12 months despite treatment (-26.86 letters).

CONCLUSIONS

There is a need to identify effective treatment strategies for fibrosis and to closely monitor at-risk patients. More studies involving multimodal imaging are required to clarify the definitions and grading criteria for fibrosis.

Microvascular abnormalities and long-term efficacy after stereotactic radiotherapy under continued intravitreal anti-VEGF treatment for neovascular AMD

Background

For treatment of neovascular age-related macular degeneration (nAMD), multiple intravitreal injections of drugs targeting vascular endothelial growth factors (VEGF) result in a high burden for patients and healthcare systems. Low-energy stereotactic radiotherapy (SRT) might reduce the anti-VEGF need. This study evaluated the long-term efficacy and safety of adjunct SRT to anti-VEGF injections in a treat-and-extend regimen in nAMD.

Methods

50 consecutive patients were followed 3 years after single-session SRT, a safety analysis including standardised study imaging, and a reading centre based image analysis was performed after 2 years.

Results

After increase from baseline (4.24±0.66 weeks) to 12 months (7.52±3.05 weeks, p<0.001), mean recurrence-free anti-VEGF treatment interval remained stable at 24 (7.40±3.17, p=0.746) and 36 months (6.89±3.00, p=0.175). Mean visual acuity change was −5.8±15.9 and −11.0±20.1 letters at 24 and 36 months, respectively. 36% of eyes showed microvascular abnormalities (MVAs) on colour fundus photography and/or fluoresceine angiography most frequently located in parafoveal inferior and nasal regions.

Conclusion

In real life, low-energy SRT was associated with a reduced anti-VEGF injection frequency through year 3. However, due to an observed visual acuity reduction and remarkable number of MVAs, a close follow-up of these patients is recommended. The real-life use, optimal treatment schedule and dose should be rediscussed critically.

Efficacy of ranibizumab combined with photodynamic therapy on wet age-related macular degeneration

Efficacy and safety of intravitreal ranibizumab (IVR) combined with photodynamic therapy (PDT) in treating wet age-related macular degeneration (wAMD) were studied. A total of 130 eyes were collected from 130 wAMD patients treated in Affiliated to Qingdao University Yuhuangding Hospital of Yantai, of which 65 were given IVR combined with PDT (combination therapy group) and the remaining 65 were treated with simple IVR (ranibizumab group). The differences in best corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure, choroidal neovascularization (CNV) leakage, levels of serum vascular endothelial growth factor (VEGF) and transforming growth factor-β1 (TGF-β1) as well as complication rate were compared before and after treatment between the two groups. At 1, 3, 6 and 12 months after treatment, combination therapy group had remarkably better BCVA and notably smaller CMT than ranibizumab group. Fundus fluorescein angiography (FFA) showed that the area of macular degeneration was reduced markedly after treatment in both groups, and the area in combination therapy group was evidently smaller than that in ranibizumab group at 1, 3 and 6 months after treatment. At 3 months after treatment, the levels of serum VEGF and TGF-β1 declined obviously in the two groups compared with those before treatment. The IVR combined with PDT can effectively improve the visual acuity, decrease CMT and prominently reduce the area of macular degeneration of wAMD patients, and its therapeutic effects are long-standing and tolerable for the patients, so it is worthy of clinical popularization.

Neovascular age-related macular degeneration: intraocular inflammatory cytokines in the poor responder to ranibizumab treatment

Purpose

To determine the levels of interleukin (IL)-6, vascular endothelial growth factor-A, platelet-derived growth factor, placental growth factor (PLGF), and other cytokines in the aqueous fluid of patients with neovascular age-related macular degeneration who respond poorly to ranibizumab.

Patients and methods

This is an observational, prospective study. Thirty-two eyes from 30 patients were included in the study: 11 patients who responded poorly to ranibizumab and were switched to aflibercept (AF group), 8 patients who received ranibizumab and photodynamic therapy (PDT group), and 13 patients who responded to ranibizumab (control group). Aqueous fluid samples were collected for analysis of cytokine levels at baseline and after 1, 2, and 3 months of treatment. The effect of treatment on cytokine levels was compared between the study groups and between different time points using a linear mixed-effect regression model.

Results

In the AF group, there was an increase in vascular endothelial growth factor-C, IL-7, and angiopoeitin-2 levels (P=0.01) and a decrease in intercellular adhesion molecule and IL-17 levels (P=0.01) between baseline and 3 months. After adjustment for age, sex, race, and type of lesion at baseline, the PLGF level was higher (P=0.02) and the IL-7 level was lower (P=0.04) in the ranibizumab non-responder group than in the ranibizumab responder group.

Conclusion

Switching from ranibizumab to aflibercept did not reduce intraocular levels of angiogenesis cytokines, but resulted in improvement of central subfield thickness. PLGF levels were higher in poor responders to ranibizumab. The response of lesions to medication might be related to the stage of choroidal neovascularization.

Trial registration

www.ClinicalTrial.gov (NCT02218177c).

Long-term outcomes of combination photodynamic therapy with ranibizumab or bevacizumab for treatment of wet age-related macular degeneration

Aim:

To evaluate and compare the efficacy of combination of ranibizumab or bevacizumab with photodynamic therapy (PDT) in treating choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD) on long-term follow-up.

Materials and Methods:

Of 42 eyes, 18 were treated with bevacizumab (Group A) and 24 with ranibizumab (Group B) in combination with verteporfin PDT. Treatment was initiated after informed consent. Complete ophthalmic examination including optical coherence tomography (OCT) was performed at presentation, 1 month, 3 months, and subsequent follow-up visits. OCT measures used were lesion thickness (LT) of the CNV, retinal thickness above the lesion (RT), and central macular thickness (CMT). Mean follow-up period was 33 months (median 18, range 1-84). Additional treatment on follow-up was left at treating surgeon's discretion.

Results:

Visual acuity improved significantly from baseline by 0.3 LogMAR in Group A and 0.26 LogMAR in Group B. LT decreased significantly from 1^st month onward and remained significant at all the subsequent visits, in both the groups. CMT and RT showed a decreasing trend in both the groups. No difference was seen in visual acuity (VA), LT, CMT, and RT between Group A and Group B at any of the visits. The mean number of additional anti-vascular endothelial growth factor injections given postcombination therapy were 1.5 (median 1, range 0-7) injections per eye.

Conclusions:

PDT in combination with either ranibizumab or bevacizumab was equally effective in preventing vision loss in eyes with wet-Age-related macular degeneration (ARMD). Such combination also reduces the economic burden of the treatment.

CHANGES IN VISUAL ACUITY IN PATIENTS WITH WET AGE-RELATED MACULAR DEGENERATION TREATED WITH INTRAVITREAL RANIBIZUMAB IN DAILY CLINICAL PRACTICE: The TWIN Study

PURPOSE

The real-life LUMIERE study on patients with wet age-related macular degeneration treated with intravitreal ranibizumab in 2006 to 2009 showed that failure to follow recommendations was associated with lower efficacy than had been observed in the development phase. The TWIN Study reviewed the situation in 2010 to 2011.

METHODS

Retrospective, descriptive purely observational study of data acquired after 12 months of treatment with intravitreal ranibizumab.

RESULTS

In 881 patients (68% women, mean age, 79 years) treated by 21 ophthalmologists, the mean gain in visual acuity was +4.3 ± 15.4 letters (up from 3.2 ± 14.8 in 2006-2009; NS). Significant improvements were documented in the mean interval between diagnosis and treatment initiation (down from 12.6 ± 26.4-7.7 ± 10.9 days; P < 0.001), and in the percentage of patients who received a full course of induction treatment (56.6 vs. 39.6%; P < 0.001). After induction, hardly any patients were monitored every month as recommended, although retreatment was more assiduous (5.6 ± 2.3 vs. 5.1 ± 2.1 injections; P < 0.001).

CONCLUSION

Despite improvements in key parameters, the effectiveness of intravitreal ranibizumab is still compromised by poor compliance with the guidelines, especially the frequency of postinduction monitoring that is now the most important determinant of successful treatment.

Visual acuity at presentation in the second eye versus first eye in patients with exudative age-related macular degeneration

PURPOSE

To assess the difference in best-corrected visual acuity (BCVA) at presentation between the first and second eye in patients with bilateral neovascular age-related macular degeneration (AMD).

METHODS

We reviewed the charts of all patients who had a clinical examination for neovascular AMD at the University Eye Clinic of Creteil in January 2013. We retrospectively analyzed demographic and clinical data for 264 patients.

RESULTS

In the fellow eye, choroidal neovascularization (CNV) developed in 75/264 patients (28.4%) with a time interval between the 2 events of 30.3 months (range 6-145). Data were available on 65 patients: 14/65 (21.5%) were asymptomatic, 24/65 (36.9%) had BCVA >20/40, whereas at the time of CNV diagnosis in the first eye, no patient was asymptomatic (p<0.0001), and 11/65 (16.9%) eyes had BCVA >20/40 (p<0.0001). The mean BCVA of the first affected eye was 0.68 (± 0.41) logarithm of minimum angle of resolution (logMAR) and the mean BCVA for the second eye was 0.36 (± 0.29) logMAR (p<0.0001).

CONCLUSIONS

The BCVA at the time of diagnosis of CNV was higher in the second eye than in the first affected eye. This was possibly due to several factors including systematic bilateral examination in follow-up of unilateral exudative AMD that allowed detection of 20% of cases.

Predictors of 1-year visual outcome in OCT analysis comparing ranibizumab monotherapy versus combination therapy with PDT in exsudative age-related macular degeneration

AIM

The aim of this study was to find predictive factors of 1-year visual outcome, analyzing novel optical coherence tomography (OCT) biomarkers in exsudative age-related macular degeneration (choroidal neovascularization (CNV)) in two groups of different treatment modalities.

METHODS

In all, 34 consecutive patients with new-onset CNV were randomized 1:1 to receive either ranibizumab monotherapy or ranibizumab combined with photodynamic therapy (PDT) with verteporfin. After three initial injections with ranibizumab, re-treatment was performed according to an as-needed scheme; PDT was performed once at baseline. Best-corrected visual acuity (BCVA) and OCT parameters like central macular volume (CMV), central macular thickness (or central retinal thickness (CRT)), subretinal and intraretinal fluid, fibrovascular lesion thickness, or inner segment/outer segment (IS/OS) junction were analyzed.

RESULTS

After 12 months, a visual gain of 6.1 letters was found in the monotherapy group, whereas patients in the combination therapy group lost - 4.8 letters from baseline to the 12-month visit. CMV and CRT decreased considerably between baseline and month 2-3 in both groups, with a following slight increase until month 12. Additional application of PDT had negative effect to 12-month BCVA, whereas higher baseline BCVA and integrity of the IS/OS junction at month 12 had positive effect to 12-month BCVA.

CONCLUSIONS

Better baseline BCVA and the integrity of IS/OS junction at 12-month visit were the most important predictive factors for final BCVA. Combination therapy caused worse final BCVA and a higher degree of IS/OS disruption.

Photodynamic Therapy and Intravitreal Bevacizumab with Versus without Triamcinolone for Neovascular Age-related Macular Degeneration; a Randomized Clinical Trial

PURPOSE

To compare the outcomes of photodynamic therapy (PDT) combined with intravitreal bevacizumab (IVB) with versus without intravitreal triamcinolone (IVT) in neovascular age-related macular degeneration (AMD).

METHODS

Eighty-four eyes with active CNV secondary to AMD with no prior treatment were enrolled and followed for 1-year. Eligible eyes were randomly assigned to either PDT/IVB or PDT/IVB/IVT. The main outcome measure was change in best-corrected visual acuity (BCVA).

RESULTS

Mean patient age was 71 ± 9 years. BCVA changes from baseline were statistically significant in both study arms at all follow-up intervals, however no significant difference was observed between the two groups regarding BCVA changes at week 12 (95% CI:-0.11-0.12 LogMAR) and other time points (all P > 0.6). Mixed model analysis revealed a significant effect from age (P < 0.001), pigment epithelial detachment (P = 0.009) and baseline BCVA (P < 0.001) on visual improvement. Significant central macular thickness (CMT) reduction occurred at all-time points as compared to baseline in both groups which was comparable between the study arms. There was no significant difference between the study arms in terms of retreatment rate (P = 0.1) and survival to the first repeat IVB injection (P = 0.065).

CONCLUSION

Additional low-dose IVT to a PDT/IVB regimen for neovascular AMD provided no beneficial effects in terms BCVA or CMT, yet demonstrated a trend toward extending the injection-free period.

Systemic thromboembolic adverse events in patients treated with intravitreal anti-VEGF drugs for neovascular age-related macular degeneration: an overview

INTRODUCTION

Anti-VEGF therapy improved the quality of life for millions of patients suffering from wet age-related macular degeneration (wet-AMD); unfortunately, this therapy involves multiple injections over many years. The administration of anti-VEGF can overcome the blood-retinal barrier with agents entering the systemic circulation and causing a significant decrease in VEGF serum concentration. Although circulating VEGF protects the integrity and patency of vessels, prolonged anti-VEGF treatment has the potential to increase the risk of thromboembolic events.

AREAS COVERED

In this review, we discuss the safety data from recent trials involving available anti-VEGF drugs.

EXPERT OPINION

During the 2 years of follow-up in the relevant clinical trials, the rates of serious adverse events such as stroke, heart attack and death were similar for patients treated with different anti-VEGF drugs. Moreover the arterial thrombotic risk appears sufficiently low when compared with the natural incidence of arterial thrombotic events in this category of elderly patients and acceptably balanced against the advantage of improved vision. Since the use of these drugs is likely to become increasingly widespread and prolonged, it is desirable that the scientific community improves the pharmacovigilance program on all anti-VEGF drugs, expanding knowledge with studies that compares head to head all four compounds belonging to anti-VEGF armamentarium.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Ranibizumab monotherapy versus combination of Ranibizumab with photodynamic therapy with neovascular age-related macular degeneration

PURPOSE

Modern therapy of neovascular age-related macular degeneration consists in intravitreal injections of inhibitors of the vascular endothelial growth factor. An increasing number of these injections is required not only in monthly but also in as-needed treatment regimen. In this study, it should be examined whether an additional administered photodynamic therapy (PDT) can considerably reduce the number of injection.

METHODS

In this prospective, randomized study carried out in three large hospitals of Vienna eyes with neovascular age-related macula degeneration were included. Patients were randomized to either Ranibizumab monotherapy or combined standard fluence PDT and Ranibizumab therapy. All patients received a loading dose of three intravitreal Ranibizumab injections and were thereafter treated in an as-needed regimen based on distance acuity and retinal thickness values. In the combined treatment group, PDT was administered 1 day after the first Ranibizumab injection.

RESULTS

Fifty-one patients were randomized, 44 were finally included (four screening failures and three withdrawals). Twenty-four patients were assigned to the monotherapy and 20 patients to the combined treatment group. Fewer injections were required in the combined treatment group (4.7 versus 6.3). Overall the patients lost 0.5 letters; in the combined treatment group, the patients lost mean 7.1 letters; in the monotherapy group, they gained mean 5.1 letters. Retinal thickness decreased significantly in both groups.

CONCLUSION

A significant reduction of the number of required intravitreal injections could be achieved by the additional PDT treatment, but was accompanied by a worse functional outcome in this group.

Predictors of 1-year visual outcome in neovascular age-related macular degeneration following intravitreal ranibizumab treatment

PURPOSE

To describe predictors of visual outcome in patients treated with intravitreal ranibizumab for choroidal neovascularisation (CNV) in age-related macular degeneration (AMD).

METHODS

Retrospective review of 279 patients with CNV in AMD who fulfilled MARINA/ANCHOR study eligibility criteria and were treated with repeated intravitreal injections of ranibizumab 0.5 mg in routine clinical practice, beginning with three initial injections at 4-week intervals followed by individualized retreatment for the subsequent 9 months. Study parameters included best-corrected visual acuity (BCVA) and morphological characteristics.

RESULTS

  Mean BCVA relative to baseline was +4.7 (p < 0.0001), +4.2 (p < 0.0001)and -0.4 (p > 0.667) Early Treatment Diabetic Retinopathy Study letters after 3, 6 and 12 months, respectively, after a mean of 5.1 injections when the proportion of patients with BCVA ≥ 70 letters had doubled compared with baseline. Predictive factors for BCVA ≤ 35 letters after 12 months were BCVA ≤ 35 letters at baseline and month 3 (p < 0.0001) while BCVA ≥ 70 letters at month 12 was associated with BCVA ≥ 70 letters at baseline and month 3 (p < 0.001) and with total lesion size <4 DA (p = 0.0147).

CONCLUSION

  Under a ranibizumab regimen with substantially fewer injections than with fixed four-weekly injection regimens, BCVA was improved compared with the natural history of neovascular AMD, but did not achieve the visual gain observed in randomized clinical trials using fixed 4-week retreatment. Visual acuity at month 3, after the initial fixed-interval injections, was the strongest predictor of BCVA at month 12.

One-year results of photodynamic therapy combined with intravitreal ranibizumab for exudative age-related macular degeneration

Purpose. To evaluate the effects of photodynamic therapy (PDT) combined with intravitreal injection of ranibizumab (IVR) for exudative age-related macular degeneration (AMD). Methods. Retrospective case series. Thirty eight eyes of 38 patients with exudative AMD underwent combined therapy consisting first of IVR, followed by PDT within a week and the second IVR at 1 month. All patients were followed up for more than 12 months. The best corrected visual acuity (BCVA) and central macular thickness (CMT) were examined. Results. The mean number of IVR and PDT sessions were 2.9 ± 1.3 and 1.1 ± 0.3, respectively. The mean BCVA and CMT were significantly improved to 0.38 logMAR units (P < 0.01) and 240 μm (P < 0.01) at 12 months, respectively. Thirty-six of 38 eyes (94.8%) improved or maintained BCVA at 12 months. Conclusion. PDT combined with IVR for exudative AMD was effective at improving visual acuity and CMT with a low recurrence rate for 12 months.

One-year outcomes using ranibizumab for neovascular age-related macular degeneration: results of a prospective and retrospective observational multicentre study

The Swedish Lucentis Quality Registry is a 12-month, open-label, observational, prospective, and retrospective study of ranibizumab administration for wet AMD. Visual acuity (VA) was measured with Snellen or ETDRS chart in 370 patients (66.8% women; age range 46–93 years). In total, a mean of 4.7 ± 1.6 injections per patient (range 1–10) was given to month 12. Mean VA score was 58.3 ± 12.2 letters before treatment, 63.3 ± 12.5 after 3 injections (Δ4.9 ± 10.1 letters from baseline), and 59.3 ± 16.2 at 12 months (Δ1.0 ± 13.6). VA score from baseline to month 12 was stable in 74.4% of patients, improved by 15 letters/3 lines or more in 14.7%, and decreased by ≥15 letters/3 lines in 10.9% of patients. With a mean of 4.7 ranibizumab injections per patient per year, mean VA was stabilised but not increased. To maintain the initial gain seen after the first three injections, an average of 1.8 ± 1.5 additional injections does not appear to be adequate.