Flare levels after intravitreal injection of ranibizumab, aflibercept, or triamcinolone acetonide for diabetic macular edema

Flare levels after intravitreal injection of brolucizumab for diabetic macular edema

PURPOSE

This study aimed to evaluate anterior flare intensity (AFI) after intravitreal injection of brolucizumab (IVBr) in patients with diabetic macular edema (DME), and to identify the factors associated with the change of AFI after IVBr.

METHODS

This prospective multicenter study was conducted at five sites in Japan for patients with DME who underwent a single IVBr. AFI and central retinal thickness (CRT) were measured using a laser flare meter and spectral-domain optical coherence tomography, respectively, at weeks 0 and 6.

RESULTS

Sixty-five patients (phakia, 37 eyes; pseudophakia, 28 eyes) were enrolled. Six weeks after IVBr, CRT and best-corrected visual acuity significantly improved (p < 0.0001). AFI (p = 0.0003) and age (p = 0.0054) were significantly higher in patients with pseudophakic eyes than those with phakic eyes. The AFI of the phakic eyes decreased after IVBr (p = 0.043). As the AFI before injection is higher (p = 0.0363) and the age is lower (p = 0.0016), the AFI decreases after IVBr. There was a significant positive correlation between the rates of change in CRT and AFI (p = 0.024).

CONCLUSION

After IVBr, AFI decreases in phakic eyes but not in pseudophakic eyes. The age, AFI and CRT before injection and changes of CRT are involved in the change in AFI after IVBr.

Laser flare photometry in eyes receiving brolucizumab intravitreal injections for age related macular degeneration

PURPOSE

To measure aqueous flare levels in treatment naïve eyes suffering from wet age- related macular degeneration (wAMD) treated with intravitreal brolucizumab.

METHODS

Patients with treatment naïve wAMD in one eye were prospectively enrolled. Flare levels were measured with laser flare photometry at baseline, 1 day and 1 month after each of the 3 monthly injections during the loading phase.

RESULTS

Twenty-two eyes from 22 patients aged 76.7 ± 6.0 years were enrolled. Flare values were 10.6 ± 3.7 photons/msec at baseline and 12.6 ± 5.8 photons/msec at the last follow up visit, 1 month after the third injection (p = 0.289, repeated measures ANOVA). The mean change in flare after the first injection was 4.2 ± 3.6. photons/msec, 6.6 ± 8.9 photons/msec after the 2nd and 8.6 ± 20.8 photons/msec after the 3rd injection (p = 0.640, repeated measures ANOVA). No patient had clinical signs of intraocular inflammation.

CONCLUSIONS

Eyes receiving brolucizumab injections for wAMD showed similar flare at baseline, during and 1 month after completion of three-monthly intravitreal injections. There was no evidence of subclinical inflammation during the loading phase of brolucizumab based on laser flare photometry measurements.

Intravitreal steroids compared to anti-vascular endothelial growth factor treatment for diabetic macular edema: a meta-analysis

TOPIC

Diabetic macular edema (DME) can be treated with either intravitreal anti-VEGF injections or intravitreal corticosteroid injections.

CLINICAL RELEVANCE

We provide an updated meta-analysis of the comparative efficacy and safety of intravitreal steroids and anti-VEGF agents for DME.

METHODS

A systematic search was performed on Ovid MEDLINE, Embase, and Cochrane Controlled Register of Trials from January 2005 to November 2021. Inclusion criteria included published randomized clinical trial data comparing the efficacy and safety of intravitreal steroids versus anti-VEGF agents for DME. Nonrandomized, noncomparative, and non-English studies were excluded.

RESULTS

Fourteen randomized clinical trials reporting on 827 eyes were included. Between these 2 treatments, our analysis revealed no significant difference in best-corrected visual acuity (BCVA) outcomes at 3 months (P = 0.11), 6 months (P = 0.21), 12 months (P = 0.24), and final follow-up (P = 0.91). Retinal thickness was significantly lower with steroid treatment at 3 months (P = 0.04), 6 months (P < 0.00001), and final follow-up (weighted mean difference = 39.99 μm; 95% confidence interval [CI] = 14.58,65.41; P = 0.002); however, there was no significant difference at 12 months (P = 0.18). Intravitreal anti-VEGF agents were associated with a lower incidence of intraocular pressure-related adverse events (risk ratio = 0.13; 95% CI = 0.05, 0.34; P < 0.00001). There was no significant difference between comparators for other adverse events, including cataract-related adverse events (P = 0.22).

CONCLUSIONS

Overall, intravitreal steroid treatment for DME was associated with no significant differences in BCVA, a significantly lower retinal thickness, and a higher risk of intraocular pressure-related events. The certainty of evidence ranged from low to moderate and the analysis was limited by heterogeneity. Our results reinforce the importance of a continual reevaluation of the role of intravitreal steroids in DME management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Glycemic Control after Initiation of Anti-VEGF Treatment for Diabetic Macular Edema

Diabetic macular edema (DME) induces visual disturbance, and intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs are the accepted first-line treatment. We investigate its impact on glycemic control after starting VEGF treatment for DME on the basis of a questionnaire and changes in hemoglobin A1c (HbA1c). We conducted a retrospective multicenter study analyzing 112 patients with DME who underwent anti-VEGF therapy and their changes in HbA1c over two years. Central retinal thickness and visual acuity significantly improved at three months and throughout the period after initiating therapy (p < 0.0001); a significant change in HbA1c was not found. A total of 59.8% of patients became more active in glycemic control through exercise and diet therapy after initiating therapy, resulting in a significantly lower HbA1c at 6 (p = 0.0047), 12 (p = 0.0003), and 18 (p = 0.0117) months compared to patients who did not. HbA1c was significantly lower after 18 months in patients who stated that anti-VEGF drugs were expensive (p = 0.0354). The initiation of anti-VEGF therapy for DME affects HbA1c levels in relation to more aggressive glycemic control.

Efficacy and Safety of Intravitreal Injection of Triamcinolone Acetonide and Conbercept for Intraocular Lens after Cataract Surgery

Objective

To investigate the effect of intravitreal injection of triamcinolone acetonide and conbercept on the efficacy and safety of diabetic macular edema (DME) after cataract intraocular lens (IOL) surgery.

Methods

A total of 350 patients with cataract complicated with diabetic macular edema in our hospital from January 2017 to July 2021 were randomly divided into conbercept group and triamcinolone acetonide group. Patients in the conbercept group were given intravitreal injection of conbercept during IOL surgery, and patients in the triamcinolone acetonide group were given injection of triamcinolone acetonide during surgery.

Results

Three months after treatment, the best-corrected visual acuity of the two groups was significantly higher than before, the corrected visual acuity of the conbercept group was more significant than the triamcinolone acetonide group, and the intraocular pressure of the triamcinolone acetonide group was higher than the conbercept group. The foveal thickness and macular volume were significantly reduced in both groups, and was reduced more in the conbercept group than in the triamcinolone acetonide group. The contents of VEGF, SDF-1, and IL-6 in both groups were significantly decreased, and the decrease was more significant in the conbercept group than in the triamcinolone acetonide group. The patients with elevated intraocular pressure, headache and vomiting, orbital swelling pain, eye swelling pain, and eye pain in the triamcinolone acetonide group were significantly higher than those in the conbercept group (P < 0.05).

Conclusions

Conbercept and triamcinolone acetonide has a good therapeutic effect on DME in pseudophakic eyes after cataract IOL surgery, which can reduce the degree of macular edema and improve the visual function. However, the therapeutic effect of injection therapy with conbercept is safe, the prognosis is better, and the complication rate is low.

Clinical Comparative Study of Intravitreal Injection of Triamcinolone Acetonide and Aflibercept in the Treatment of Diabetic Retinopathy Cystoid Macular Edema

Objective To compare the curative effect of intravitreal injection of triamcinolone acetonide and aflibercept on diabetic retinopathy (DR) cystoid macular edema. Methods A total of 102 patients with DR cystoid macular edema admitted to the hospital were enrolled between July 2018 and July 2021. According to random number table method, they were divided into the control group (intravitreal injection of triamcinolone acetonide) and the observation group (intravitreal injection of aflibercept), 51 cases in each group. All were followed up for half a year. The clinical curative effect, visual acuity, central subfield macular thickness (CSMT), macular volume, scores of quality of life, and levels of cytokines in aqueous humor (vascular endothelial growth factor (VEGF), monocyte chemoattractant protein-1 (MCP-1), human angiopoietin-like protein 4 (ANGPTL4)] at different time points (before and at 6 months after surgery) were compared between the two groups. The times of drugs injection and occurrence of adverse reactions in both groups were statistically analyzed. Results The total effective rate in observation group was higher than that in the control group (96.08% vs 82.35%) (P < 0.05). After 6 months of treatment, visual acuity was improved, and CSMT and macular volume were decreased in both groups. Also, the above changes were more significant in the observation group than those in the control group (P < 0.05). After 6 months of treatment, levels of cytokines in aqueous humor were decreased in both groups. The levels of VEGF, MCP-1, and ANGPTL4 in observation group were lower than those in the control group (P < 0.05). After 6 months of treatment, quality of life scores in observation group were higher than those in the control group (P < 0.05). In the follow-up period, average times of drugs injection in the observation group were more than those in the control group, and the incidence of adverse reactions was lower than that in control group (5.88% vs 21.57%) (P < 0.05). Conclusion The curative effect of intravitreal injection of both triamcinolone acetonide and aflibercept is good on DR cystoid macular edema. The curative effect of aflibercept is better, which can improve visual acuity and quality of life, and regulate cytokines in aqueous humor, with high safety. However, aflibercept has a high price, and further research is needed to determine whether its price can be matched with clinical benefits. In clinic, medication plan should be selected according to the actual situation.

Effect Modification by Indication to the Risks of Major Thromboembolic Adverse Events in Patients Receiving Intravitreal Anti-Vascular Endothelial Growth Factor Treatment: A Population-Based Retrospective Cohort Study

BACKGROUND

The association between intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment and the risk of major thromboembolic adverse events (TAEs) remains under debate. This study aimed to examine associated risks of TAEs in patients receiving intravitreal anti-VEGF treatment, and effect modification by different indications.

METHODS

This retrospective cohort study analyzed Taiwan's National Health Insurance Database during 2011-2017 to identify neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) patients newly receiving intravitreal aflibercept or ranibizumab. We followed up patients for 2 years, or until the occurrence of TAEs, including ischemic heart disease, ischemic stroke, transient ischemic attack, deep vein thrombosis, and pulmonary embolism, death, or the end of the study period (i.e., 31 December 2018). We compared the risk of TAEs between patients with aflibercept and ranibizumab using Cox-proportional hazard models. We examined statistical interactions between the anti-VEGF treatment (i.e., ranibizumab and aflibercept) and indications (i.e., nAMD and DME) with regard to the outcome of TAEs.

RESULTS

We included 12,215 nAMD and 7532 DME patients. Among nAMD patients, those receiving aflibercept had lower risk of TAEs (adjusted hazard ratio [HR] 0.85; 95% CI 0.77-0.94) compared with those receiving ranibizumab. However, among DME patients, those receiving aflibercept had no differences in the risk of TAEs (1.14; 0.97-1.35) compared with those receiving ranibizumab. Among patients treated with ranibizumab, the DME group had a higher risk of TAEs than the nAMD group (HR 1.15; 95% CI 1.03-1.28); similar results were observed in patients treated with aflibercept (HR 1.53; 95% CI 1.27-1.85). When DME patients were treated with aflibercept, the risk of TAEs was 31% higher than when nAMD patients were treated with ranibizumab (HR 1.31; 95% CI 1.09-1.56; p < 0.05). The p-value for statistical interaction between the anti-VEGF treatment and indications was 0.0033.

CONCLUSIONS

Patients treated with aflibercept or ranibizumab for different indications may be associated with varying risk of TAEs. The findings provide evidence to support treatment selection, taking indications and TAE risk into consideration.

Triamcinolone as an adjunct to the combination of anti-VEGF for the management of diabetic macular edema

AIM

To assess the efficacy of intravitreal triamcinolone (IVTA) as an adjunct to the combination of anti-vascular endothelial growth factor (VEGF) for the management of diabetic macular edema (DME).

METHODS

A total of 51 patients with visual disabilities causing by DME from two sites were retrospectively collected and assigned to two groups according to the therapeutic method: intravitreal conbercept (IVC) combined with focal laser (24 eyes) and IVC combined with focal laser and IVTA (27 eyes). Best-corrected visual acuity (BCVA), the required number of IVCs, central retinal thickness (CRT), the mean costs of treatment burden and safety were compared over 12mo.

RESULTS

From baseline to month 1 through month 12, IVC combined with focal laser and IVTA improved the mean average change in BCVA superior to IVC combined with focal laser (+5.20 vs +2.71 letters). At month 12, 20.83% of the IVC combined with focal laser and 37.04% of IVC combined with focal laser and IVTA arms gained more than 10 BCVA letters. During the period, the mean CRT decreased significantly in the IVC combined with focal laser and IVTA arm (-245.9 µm) compared to the IVC combined with focal laser arm (-98.45 µm). The average of 6.45 and 1.25 conbercept injections performed in the IVC combined with focal laser and IVC combined with focal laser and IVTA arms, respectively. The mean cost of treatment burden for 12mo was $6247.44±4069.18 in the IVC combined with focal laser arm and $1679.19±542.73 in the IVC combined with focal laser and IVTA arm, with a statistically significant difference. Apart from occasional minor subconjunctival hemorrhage, no other significant ocular adverse events (AEs) were observed in either group during the12-month period.

CONCLUSION

It is effective and cost-effective to treat DME by utilizing triamcinolone as an adjunct to the combination of anti-VEGF.

Anti-VEGF Therapy Reduces Inflammation in Diabetic Macular Edema

PURPOSE

Correlations among the aqueous flare value (an indicator of inflammation), several functional-morphologic parameters, and aqueous humor levels of multiple cytokines or inflammatory factors were investigated in patients with diabetic macular edema (DME) receiving intravitreal rani-bizumab injection (IRI).

METHODS

Aqueous humor levels of 12 cytokines, growth factors, or inflammatory factors were measured in 46 DME patients who received IRI. Vascular endothelial growth factor (VEGF), soluble VEGF receptor (sVEGFR), and the other cytokines/inflammatory factors were measured by the suspension array method. In addition, aqueous flare values were measured with a laser flare meter, and central macular thickness (CMT) was examined by optical coherence tomography.

RESULTS

At 1 month after IRI therapy, the aqueous flare value showed a significant decrease compared with before treatment (baseline). Significant correlations were noted between the aqueous flare value and the aqueous humor levels of 6 factors/cytokines, including sVEGFR-1, placental growth factor, monocyte chemoattractant protein 1, soluble intercellular adhesion molecule-1, interleukin (IL)-6, and interferon-inducible 10-kDa protein (IP-10). There was also a significant correlation between the change in aqueous flare value and improvement in CMT 1 month after IRI.

CONCLUSIONS

These findings suggest that IRI reduces subclinical inflammation and that the aqueous flare value is influenced by inflammatory factors/cytokines. In addition, the change in the aqueous flare value may be an indicator of the response of CMT to IRI in patients with DME.

Correlation between anterior chamber flare changes and diabetic macular edema after intravitreal injection of ranibizumab and aflibercept

PURPOSE

To evaluate aqueous flare change patterns following anti-vascular endothelial growth factor therapy for diabetic macular edema (DME) and investigate the relationship between changes in flare values and central macular thickness (CMT).

STUDY DESIGN

Retrospective, interventional case series METHODS: A total of 84 eyes of 62 patients with DME received either intravitreal ranibizumab (IVR; n = 62) or aflibercept (IVA; n = 22). A laser flare photometer (Kowa FM500, Kowa Company, Ltd) was used to measure flare values, and CMT was assessed using optical coherence tomography. Flare values and CMT were measured prior to injection (baseline) and at, 1, 7 and 14 days after injection.

RESULTS

Flare values in the IVR group decreased significantly at day 14 (P = 0.001), whereas the IVA group showed a significant increase in flare values at day 1 (P < 0.001). In the IVA group, the baseline flare values were significantly higher in the CMT reduction group than in the non-CMT reduction group (P = 0.035). There was no correlation between changes in flare values and CMT either in the IVA or IVR group.

CONCLUSIONS

Flare value changes in patients treated with IVR decreased at day 14 post-injection. This may indicate when the most anti-inflammatory effect was obtained. There was no correlation between changes in flare values and CMT either in the IVA or IVR group; nevertheless, our research suggests that the baseline flare value is a predictive factor for the efficacy of IVA in DME.

Flare changes after intravitreal injection of ocriplasmin in symptomatic vitreomacular traction syndrome

PURPOSE

To evaluate the changes in anterior chamber flare after a single intravitreal injection of ocriplasmin (125 μg), in patients with symptomatic vitreomacular traction syndrome (VMT).

STUDY DESIGN

An institutional review board-approved single-center not randomized prospective study.

METHODS

Fifteen eyes of fifteen patients (9 women, 6 men) underwent intravitreal injection with ocriplasmin for symptomatic VMT (width of attachment ≤ 1500 μm). Anterior segment flare was measured with a laser flare meter (Kowa) before intravitreal injection and 1 day, 1 week, 1 month after injection. The changes in flare were analyzed; the resolution of VMT was evaluated with spectral-domain OCT.

RESULTS

The mean anterior chamber flare was 10.5 ± 1.9 photons per millisecond (photons/ms) before the injection. After 1 day it increased to 13.6 ± 2.7 photons/ms (p = 0.027) and after 1 week to 14.4 ± 2.5 photons/ms (p = 0.005); after 1 month it decreased to 12.3 ± 2.3 photons/ms (p = 0.123). At 1 day and 1 week after injection, mean anterior chamber flare of fellow eyes was significantly lower than study eyes, while at 1 month this difference was not significant (12.3 ± 2.3 vs. 10.5 ± 1.8 photons/ms, p = 0.124, for study and fellow eyes). There was no statistically significant difference in the changes in flare between women and men or between phakic (N = 10) and pseudophakic (N = 5) eyes. No eye demonstrated intraretinal damage at any time-point. Also, 9 eyes showed resolution of VMT while 6 eyes demonstrated persistence of VMT.

CONCLUSION

Our study shows that intravitreal injection of ocriplasmin can be a safe and effective approach to treat symptomatic VMT syndrome in selected patients.