Intraocular bevacizumab for macular edema due to CRVO. A multifocal-ERG and OCT study

Real-Life Efficacy of Bevacizumab Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion according to Pro Re Nata or Treat-and-Extend Regimen in Eyes with or without Epiretinal Membrane

Purpose. To present real-life data of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO) treated with bevacizumab (BVZ); determine the possible influence of epiretinal membrane (ERM) on treatment efficacy; and compare treatment outcomes in a treat-and-extend regimen (TER) versus pro re nata (PRN). Methods. We carried out a retrospective analysis of 58 eyes (56 patients) with new-onset CRVO treated only with intravitreal bevacizumab according to TER or PRN. Outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and 12 months after the first treatment, number of visits and injections, and presence of ERM confirmed by optical coherence tomography in the first 6 months. Results. At 12 months, the mean number of injections was 6.3 across all eyes, with significantly more injections given in TER ( $p<0.001$ ). Mean CRT improved from 627 μm to 359 μm ( $p<0.001$ ) in all eyes, with improvement noted in TER ( $p<0.001$ ), PRN ( $p<0.001$ ), ERM ( $p=0.003$ ), and non-ERM ( $p<0.001$ ) subgroups. The mean BCVA gain was +13.6 letters, and the mean BCVA improved from 0.81 to 0.54 LogMAR ( $p<0.001$ ) in all eyes. BCVA improvement from baseline was significant in TER ( $p<0.001$ ) and non-ERM ( $p<0.001$ ) but not in PRN ( $p=0.08$ ) or ERM ( $p=0.2$ ) subgroups. Seven eyes, all receiving PRN treatment, developed neovascularization. Conclusions. Intravitreal bevacizumab according to either PRN or TER resolved edema and stabilized vision in the first 12 months, with TER yielding significant visual improvement and avoiding neovascular complications. ERM had no influence on bevacizumab efficacy in reducing ME in CRVO during 12 months of treatment.

Changes of focal macular and full-field electroretinograms after intravitreal aflibercept in patients with central retinal vein occlusion

PURPOSE

To evaluate the physiology of the macular and whole retina after intravitreal aflibercept (IVAs) injections in patients with macular edema associated with a central retinal vein occlusion (CRVO) by electroretinography (ERG).

METHODS

We studied 20 eyes of 20 patients with non-ischemic CRVO (72.0 ± 9.2 years). All patients were treated with monthly injections of IVA for the initial 3 months and then treated by the treat-and-extend (TAE) regimen for 12 months. The best-corrected visual acuity (BCVA), optical coherence tomographic images, focal macular ERGs (fmERGs), and full-field ERGs recorded before and after the treatment were compared. The fmERGs were elicited by a 15° white stimulus spot centered on the fovea. The full-field ERGs were recorded by a protocol recommended by International Society for Clinical Electrophysiology of Vision. The amplitudes and implicit times determined before and after the IVA were compared.

RESULTS

The foveal thickness was significantly reduced accompanied by improvement of the BCVA after the treatments, and the improvements were maintained for at least 12 months. The amplitudes and implicit times of the fmERGs improved continuously for the 12 months. On the other hand, the reduced amplitudes of the full-field ERG, summed oscillatory potentials, and the photopic negative responses remained unchanged for the 12-month period. However, the implicit times of the maximum and cone responses were significantly shortened after the IVA.

CONCLUSIONS

IVA injections by the TAE regimen led to a continuous improvement of the macular function in patients with ME associated with a CRVO. However, the function of the whole retina changed differently than the macula after the treatment.

Quantitative physiological measurements to evaluate the response of antivascular endothelial growth factor treatment in patients with neovascular diseases

Antivascular endothelial growth factor (VEGF) treatment is still used intravitreally worldwide for various neovascular diseases, despite other available, approved treatments. We performed a systematic search of the literature focused on visual physiology studies. We used the online biomedical search engine PubMed and searched key words including “M-chart,” “Preferential Hyperacuity Perimetry,” “microperimetry,” (MP) “electroretinography,” and “contrast sensitivity” to estimate treatment efficacy of anti-VEGF treatments in a quantitative manner. Many studies were identified which used a variety of methodologies, disease entities, injected agents, and patient populations, making it difficult to obtain a direct comparison of their results. However, favorable functional outcomes achieved using current quantitative methods would lend further confidence to the effectiveness of a treat-and-extend protocol using intravitreal anti-VEGF for the management of patients with neovascular diseases. Despite anti-VEGF's wide use, a well-designed longitudinal multicenter study to systematically evaluate and compare different physiological methods or parameters in patients with neovascular diseases is still lacking, though it would benefit therapeutic decisions.

Therapeutic effect of dexamethasone implant in retinal vein occlusions resistant to anti-VEGF therapy

Purpose

To test the efficacy of the intravitreal dexamethasone (DEX) implant in patients with retinal vein occlusions (RVOs) who have failed multiple anti-vascular endothelial growth factor (anti-VEGF) treatments.

Methods

A randomized exploratory study of ten patients with branch RVO or central RVO who received at least two previous anti-VEGF treatments and had persistent or unresponsive cystoid macular edema. Treatment with the DEX implant was either every 4 months or pro re nata (PRN) depending on their group assignment for 1 year. Multifocal electroretinography and microperimetry were the primary end points, with high-resolution optical coherence tomography and best-corrected visual acuity as the secondary end points.

Results

All patients in both the every 4 month and PRN cohorts who completed the study received the three maximal injections of DEX; therefore, the data from both cohorts were combined and reported as a case series. On average, the multifocal electroretinography amplitude increased significantly from 5.11±0.66 to 24.19±5.30 nV/deg2 at 12 months (P<0.005), mean macular sensitivity increased from 7.67±2.10 to 8.01±1.98 dB at 4 months (P=0.32), best-corrected visual acuity increased significantly from 51.0±5.1 to 55.4±5.1 early treatment of diabetic retinopathy study letters at 2 months (P<0.05), and central retinal thickness decreased from 427.6±39.5 to 367.1±37.8 μm at 4 months (P<0.05). Intraocular pressure increased significantly in one patient, with that patient requiring an additional glaucoma medication for management. Additionally, cataract progression increased significantly (P<0.05) in this patient population and partially limited analysis of other end points.

Conclusion

DEX should be considered as a treatment option in patients with RVOs who have failed anti-VEGF therapy, as the results of this study demonstrated an improvement in retinal morphology and macular function. Cataract progression did occur following multiple consecutive injections; however, steroid-induced glaucoma was not a limiting factor.

Comparison of the effects of intravitreal bevacizumab and triamcinolone acetonide in the treatment of macular edema secondary to central retinal vein occlusion

AIM

To compare the effects of intravitrealbevacizumab (IVB) and intravitreal triamcinolone acetonide (IVT) in the treatment of macular edema (ME) secondary to central retinal vein occlusion (CRVO).

MATERIALS AND METHODS

There were 20 patients treated with IVB (1.25 mg/0.05 mL) and 16 treated with IVT (4 mg/0.1 mL). The two groups were compared with regard to best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography (OCT), slit-lamp biomicroscopy and fundus fluorescein angiography results, intraocular pressure (IOP), numbers of injections, and adverse events.

RESULTS

The mean follow-up times in the IVB and IVT groups were 17.45±8.1 months (range: 8-33 months) and 19.94±10.59 months (range: 6-40 months), respectively (P = 0.431). Visual acuity increased and CMT decreased significantly within both groups, but no differences were observed between the groups (P = 0.718). The percentages of patients with increased IOP and iatrogenic cataracts were significantly higher in the IVT group than in the IVB group.

CONCLUSIONS

Treatment with IVB and IVT both resulted in significant improvement in visual acuity and a decrease in CMT in patients with ME secondary to non-ischemic CRVO, with no difference between the two treatments. The incidence of adverse events, however, was significantly greater in the IVT group than in the IVB group. IVB may be preferred over IVT for the treatment of ME in patients with non-ischemic CRVO.

Morphological and electrophysiological outcome in prospective intravitreal bevacizumab treatment of macular edema secondary to central retinal vein occlusion

PURPOSE

To evaluate intravitreal bevacizumab (IVB) treatment in patients with central retinal vein occlusion (CRVO) by spectral domain optical coherence tomography (OCT) and electroretinography (ERG).

METHODS

Twenty-two CRVO patients were treated with IVB injections and followed for 1 year. Morphological effect of treatment was observed with fluorescent angiography and OCT. Functional effect was followed with best corrected visual acuity (BCVA) and ERG: combined rod-cone response of the standard full-field ERG (dark adapted 3.0 ERG), photopic negative response (PhNR), and pattern ERG (PERG).

RESULTS

Best corrected visual acuity (BCVA) improved by 18.2 letters after 6 months (p ≤ 0.001) and additional 4.7 letters by the 12th month (p ≤ 0.001). The central retinal thickness of 829.8 ± 256.7 μm decreased to 398.8 ± 230 μm (p ≤ 0.001) after 6 months and to 303.7 ± 128.9 μm during the following 6 months (p ≤ 0.001). The total macular volume (14.4 ± 4.2 mm(3)) decreased to 9.6 ± 3.2 mm(3) and 8.5 ± 2.0 mm(3) after 6 months and 1 year of treatment, respectively (p ≤ 0.001). Electrophysiological measures improved significantly after 6 months and 1 year of treatment: the a-wave implicit time of dark adapted 3.0 ERG from 25.6 ± 2.3 to 24.1 ± 2.1 and 24.1 ± 2.0 ms (p ≤ 0.01); the PhNR from -5.9 ± 6.6 to -9.4 ± 6.1 and -10.4 ± 4.6 µV (p ≤ 0.05); the PERG P50 amplitude from 0.2 ± 0.3 to 0.9 ± 0.6 and 1.1 ± 0.6 µV (p ≤ 0.001); and N95 amplitude from 0.4 ± 0.6 to 1.2 ± 0.9 and 1.6 ± 0.9 µV (p ≤ 0.001).

CONCLUSIONS

Intravitreal bevacizumab (IVB) treatment of macular edema due to CRVO improved standard morphological measures and the electrophysiological function of outer and inner retinal layers, which was most evident in central retina.

Association of electroretinogram and morphological findings in central retinal vein occlusion with macular edema

The objective of this study was to evaluate the relations among electroretinogram (ERG) parameters (cone a-wave, cone b-wave, and 30 Hz flicker), retinal thickness, and retinal volume in 16 patients with central retinal vein occlusion and macular edema. The amplitude and implicit time of the ERG parameters were extracted from the ERG traces. Retinal thickness and volume were measured by optical coherence tomography in nine macular subfields. Then the correlations among ERG parameters and morphological parameters were analyzed. The cone b-wave and 30 Hz flicker implicit time were correlated with retinal thickness and volume in seven out of nine subfields, excluding the temporal subfields. In addition, the amplitude of the cone b-wave was correlated with retinal thickness and volume in the nasal inner and nasal outer subfields. These findings suggest that retinal thickness and volume may be associated with outer and inner retinal function in central retinal vein occlusion patients.

Macular edema in the era of spectral-domain optical coherence tomography

The development of spectral-domain optical coherence tomography (OCT) allows for the highest commercially available resolution of in vivo retinal anatomic details to date. The ability to see the macula with ever increasing detail is dramatically improving our understanding of the pathogenesis of retinal disease. However, the only prospective study that partially evaluated spectral-domain OCT versus time-domain OCT failed to show any clinical benefit of increased OCT resolution. Clinical outcomes, eg, best-corrected visual acuity, central macular thickness and number of injections, with “newer” OCT technologies remain an unproven advantage.

Meta-analysis of the effect of intravitreal bevacizumab versus intravitreal triamcinolone acetonide in central retinal vein occlusion

PURPOSE

To further evaluate the effect of intravitreal bevacizumab (IVB) for the treatment of central retinal vein occlusion (CRVO) by meta-analysis.

METHODS

Pertinent publications were identified through PubMed, EMBASE, and the Cochrane Controlled Trials Register up to January 30, 2013. Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) were extracted at 4, 12, and 24 weeks after treatment, and a meta-analysis was carried out to compare results between groups receiving IVB and intravitreal triamcinolone acetonide (IVTA).

RESULTS

One randomized controlled trial and 4 comparative studies were identified and included. All of the funnel plots, the Egger's method and Begg method did not show publication bias. Our meta-analysis revealed that BCVA and CMT at 4, 12, and 24 weeks after treatment did not vary significantly between the IVB groups and IVTA groups (BCVA: at 4 weeks, P=0.27; at 12 weeks, P=0.51; at 24 weeks, P=0.64; CMT at 4 weeks, P=0.88; at 12 weeks, P=0.57; at 24 weeks, P=0.64). However, the rate of intraocular pressure rise after intravitreal injection varied significantly between the IVB groups and IVTA groups (P<0.001).

CONCLUSIONS

Our results showed a similar improvement in BCVA and CMT among CRVO patients was obtained after intravitreal injections of both IVB, or IVTA, while the rate of IOP rise was significantly higher in the latter.

Prospective study of peripheral panretinal photocoagulation of areas of nonperfusion in central retinal vein occlusion

PURPOSE

To investigate the effect that panretinal photocoagulation to peripheral areas of retinal vascular nonperfusion has on the visual acuity and injection frequency of ranibizumab in eyes with previous central retinal vein occlusion.

METHODS

Patients enrolled in a prospective study of ranibizumab for central retinal vein occlusion were imaged with wide-field angiography using the Optos P200 system. Laser photocoagulation was carried out and the extent of laser photocoagulation was evaluated with repeat wide-field angiography. Injection of ranibizumab was based on an as needed strategy throughout the study. The injection frequency in the 6 months before laser was compared with a 6-month period starting 2 months after the laser photocoagulation. The visual acuity was measured by Early Treatment Diabetic Retinopathy Study protocol refraction at both the end of the 6-month follow-up period and at the time of laser photocoagulation.

RESULTS

There were 10 patients treated in this study with a mean number of 1,757 spots of laser photocoagulation in the peripheral retina. The injection frequency in the 6-month lead-in period was 3.4 and in the 6-month follow-up period was 3.1, a difference that was not significant (P = 0.26). The visual acuity at the time of laser photocoagulation was 54.2 letters (approximate Snellen equivalent of 20/80) and at the end of the observation period was 51.4 letters, a difference that was not significant (P = 0.33).

CONCLUSION

In this small study, laser photocoagulation to peripheral areas of nonperfusion as visualized by wide-field angiography did not result in either decreased injection frequency or improved visual acuity in eyes with central retinal vein occlusion treated with ranibizumab.

Extrafoveal changes following intravitreal bevacizumab injections for macular edema secondary to branch retinal vein occlusion: an mfERG and OCT study

PURPOSE

To evaluate the functional and structural changes of extrafoveal macula after intravitreal bevacizumab (IVB) injection in patients with macular edema due to branch retinal vein occlusion (BRVO) using multifocal electroretinogram (mfERG) and optical coherence tomography (OCT).

METHODS

A total of 19 eyes of 19 patients with macular edema due to BRVO received three consecutive IVB injections with a 6-week interval. Spectral domain optical coherence tomography (SD-OCT), mfERG, and fluorescein angiography (FA) were performed at baseline. The macular area was divided into four quadrants (Q1-Q4) based on FA. The mean retinal thickness (MRT) and mfERG parameters in each of the four quadrants were measured at baseline and 4 weeks after the third injection.

RESULTS

The MRT in the four quadrants improved significantly after IVB injections (p < 0.01 for Q1 and Q2, p < 0.05 for Q3 and Q4) compared to baseline. The significant improvements in mfERG responses were seen in Q1 and Q2. In Q1, there were 68 and 56% improvement in N1 and P1 amplitude, respectively (p < 0.01). N1 and P1 amplitude in Q2 increased significantly by 43 and 46%, respectively, compared to baseline (p < 0.05). The MRT and P1 amplitude were significantly correlated at baseline in Q1 and Q2, but no significant correlations were found after three IVB injections.

CONCLUSIONS

The injection of IVB improved functional and structural outcomes in the primarily affected half of the extrafoveal macula effectively. The measurements of structural and functional changes using mfERG and OCT may be appropriate for monitoring the effects of IVB injection in BRVO patients.

Clinical and electrophysiologic outcome in patients with neovascular glaucoma treated with and without bevacizumab

PURPOSE

To investigate the clinical and electrophysiologic effect of a single intravitreal injection of bevacizumab for neovascular glaucoma (NVG) after ischemic central retinal vein occlusion (iCRVO).

METHODS

Nineteen eyes from 19 patients with NVG secondary to iCRVO were randomly allocated to either an intravitreal bevacizumab injection and panretinal photocoagulation (PRP) (10 eyes) or PRP alone (9 eyes). The primary outcome measure was the change in the total retinal function 6 months after treatment, demonstrated by full-field electroretinography (ERG). Secondary outcomes included visual acuity, intraocular pressure (IOP), glaucoma medication, additional IOP-lowering treatment, and the presence of ocular neovascularization before treatment, and 1 week, 2 months, and 6 months after treatment.

RESULTS

The regression of ocular neovascularization in the bevacizumab/PRP group was confirmed 1 week after injection. Patients in both study groups had very poor visual acuity at baseline. This remained unchanged. There was no significant difference in the mean IOP between the groups at any point in time. The a-wave amplitudes of combined rod-cone response were significantly decreased after 6 months in the bevacizumab/PRP group (p=0.028), compared with the baseline values. The a- and b-wave amplitudes of combined rod-cone response and the b-wave amplitudes of the 30-Hz flicker response were also markedly reduced compared with the PRP group (-60%, -43%, -47% vs +23%, -36%, -16%, respectively).

CONCLUSIONS

This study suggests that intravitreal injection of bevacizumab is valuable in the treatment of NVG by hastening the resolution of neovascularization, while the full-field ERG results indicate that bevacizumab may reduce the photoreceptor function in NVG patients.

Early neural and vascular changes in the adolescent type 1 and type 2 diabetic retina

PURPOSE

This cross-sectional study examines the existence and frequency of functional and structural abnormalities in the adolescent Type 1 diabetic retina. We also compare the results with those of adolescents with Type 2 diabetes.

METHODS

Thirty-two adolescents with Type 1 diabetes (5.7 ± 3.6 years; mean duration ± SD), 15 with Type 2 diabetes (2.1 ± 1.3 years), and 26 age-matched control subjects were examined. Multifocal electroretinogram responses from 103 retinal regions were recorded. Optical coherence tomography was used to measure retinal thickness. Vascular diameter around the optic nerve was also assessed.

RESULTS

Nine of the 32 (28%) adolescents with Type 1 diabetes and 6 of the 15 (40%) with Type 2 diabetes had significant multifocal electroretinogram implicit time delays compared with 2 of the 26 controls (8%). Retinal thicknesses in both patient groups were significantly (P ≤ 0.01) thinner than controls. The Type 2 group also showed significant (P ≤ 0.03) retinal venular dilation (235.8 ± 5.9 μm) compared with controls (219.6 ± 4.0 μm).

CONCLUSION

The present study illustrates that subtle but significant functional and structural changes occur very early in Type 1 diabetes. Adolescents with Type 2 diabetes appear to be more affected than those with Type 1 diabetes. Further longitudinal examination of the etiology and progression of these abnormalities is warranted.

Intravitreal bevacizumab (Avastin) in the treatment of macular edema secondary to retinal vein occlusion

Objective

To evaluate efficacy and safety of intravitreal injections of bevacizumab in the treatment of macular edema secondary to retinal vein occlusion (RVO).

Methods

Prospective study, noncomparative, interventional case series. Twelve consecutive patients (12 eyes) with macular edema associated with nonischemic retinal vein occlusion were treated with intravitreal bevacizumab (1.25 mg). All subjects underwent standardized ophthalmic evaluation at baseline and at weeks 1, 4, 12, and 24, consisting of visual acuity (VA) measurement using ETDRS charts, and imaging with ocular coherence tomography evaluating changes in foveal thickness (FT) and macular volume (MV).

Results

The median age was 66 years (± 4.16), and the median duration of symptoms was 4 months (± 1.81). There were six cases of inferior branch vein occlusion and six cases of superior branch retinal vein occlusion. Mean VA improved from 1.32 ± 0.24 (logMAR values) at baseline to 0.8 ± 0.15 (p = 0.0003) at the 6-month follow-up. The macular edema responded promptly, and a trend to restoration of normal macular anatomy was observed at by the seventh day. Mean FT improved from 615.50 ± 116.29 microns to 420 ± 72.53 microns (p = 0.001), and the mean MV improved from 19.81 ± 2.31mm3 to 9.23 ± 1.38 (p = 0.0001) at the 6-month follow-up.

Vitreal levels of erythropoietin are increased in patients with retinal vein occlusion and correlate with vitreal VEGF and the extent of macular edema

PURPOSE

This study compares vitreal levels of erythropoietin (EPO) in patients with retinal vein occlusion (RVO) with control subjects. In addition, it investigates different RVO disease parameters (time of vein occlusion, patient age, vitreal vascular endothelial growth factor (VEGF) levels, and extent of central macular edema) for possible correlations with vitreal EPO levels.

METHODS

Serum and vitreal EPO were measured from 6 patients with branch retinal vein occlusion, 6 patients with central retinal vein occlusion, and 12 control subjects (10 macular puckers and 2 macular holes).

RESULTS

Serum EPO levels (9.8 ± 4.9 mU/mL) did not differ between the RVO and control groups and were significantly lower than vitreal EPO levels in all groups. Vitreal EPO was elevated both in branch RVO (91 ± 59 mU/mL) and central RVO (182 ± 70 mU/mL) compared with controls (35 ± 24 mU/mL). Increased vitreal EPO correlated with higher vitreal VEGF (r = 0.64, P = 0.0008) and more pronounced central macular edema (r = 0.66, P = 0.001).

CONCLUSION

The results from this study indicate that EPO is locally expressed in the retina and that it is upregulated together with VEGF in RVO eyes. Because of its role both in neuroprotection and angiogenesis, ocular EPO might represent an interesting target to investigate in patients with RVO, especially in light of the current anti-VEGF treatments.

Anti-vascular endothelial growth factor for macular edema secondary to central retinal vein occlusion

BACKGROUND

Central retinal vein occlusion (CRVO) is a common retinal vascular disorder in which macular edema (ME) may develop, with a consequent reduction in visual acuity. The visual prognosis in CRVO-ME is poor in a substantial proportion of patients, especially those with the ischemic subtype, and until recently there has been no treatment of proven benefit. Macular grid laser treatment is ineffective, and whilst a few recent randomized controlled trials (RCTs) suggest short-term gains in visual acuity with intravitreal steroids for patients with non-ischemic CRVO-ME, there is no established treatment for ischemic CRVO-ME. Anti-vascular endothelial growth factor (anti-VEGF) agents have been used to treat ME resulting from a variety of causes and may represent a treatment option for CRVO-ME.

OBJECTIVES

To investigate the effectiveness and safety of intravitreal anti-VEGF agents in the treatment of CRVO-ME.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 8), MEDLINE (January 1950 to August 2010), EMBASE (January 1980 to August 2010), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2010), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to August 2010), OpenSIGLE (January 1950 to August 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 10 August 2010.

SELECTION CRITERIA

We considered RCTs that compared intravitreal anti-VEGF agents of any dose or duration to sham injection or no treatment. We focused on studies that included individuals of any age or gender with unilateral or bilateral disease and a minimum of six months follow up. Secondarily, we considered non-randomized studies with the same criteria, but did not conduct a separate electronic search for these.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We found two RCTs that met the inclusion criteria after independent and duplicate review of the search results. These RCTs utilized different anti-VEGF agents which cannot be assumed to be directly comparable. We, therefore, performed no meta-analysis. Evidence from these trials and from other non-randomized case series is summarized in this review.

AUTHORS' CONCLUSIONS

Ranibizumab and pegaptanib sodium have shown promise in the short-term treatment of non-ischemic CRVO-ME. However, effectiveness and safety data from larger RCTs with follow up beyond six months are not yet available. There are no RCT data on anti-VEGF agents in ischemic CRVO-ME. The use of anti-VEGF agents to treat this condition therefore remains experimental.

Early Avastin management in acute retinal vein occlusion

PURPOSE

To evaluate the safety, functional and anatomical effects of intravitreal Avastin (bevacizumab) in treatment of recent retinal venous occlusion.

DESIGN

Prospective interventional series non-comparative study.

SETTING

Department of Ophthalmology, Faculty of Medicine, El-Minia University, Egypt.

METHODS

The study included 30 eyes of 30 patients with recent retinal venous occlusion of less than 3 months duration 12 eyes (40%) of patients with central retinal vein occlusion (CRVO) and 18 eyes (60%) with branch retinal vein occlusion (BRVO) were injected with intravitreal bevacizumab 1.25 mg (0.05 ml) of commercially available bevacizumab [Avastin; Genentech, Inc., San Francisco, CA] at a concentration of 25 mg/ml as a primary treatment. The mean number of injections was 2.7 (range, 1-6 injections) 6-8 weeks intervals and follow-up for 12 months (range, 9-13 months). Patients underwent visual acuity testing (VA) as functional assessment. Anatomically, optical coherence tomography (OCT) is used for measurement of central retinal thickness (CRT) to detect macular edema (ME), fundus photography and fluorescein angiography (FA) to detect venous tortuosity, optic disc edema and surface wrinkling rather than ME. All finding at baseline and each follow-up visit were reported.

RESULTS

The mean age of all patients was 65.3 years ± 8.5 (range, 55-82 years), 20 males and 10 females patients. The mean baseline VA was 20/240 (log MAR 1.08 ± 0.52) and improved to 20/60 (log MAR 0.48 ± 0.32) with statistically significance difference change (P < 0.001). The mean baseline CRT was 455 μm ± 126 (range, 386-510), decreased to 356 μm ± 118 (range, 296-416) after 1 month with statistically significance difference change (P < 0.02) and to 402 μm ± 170 (range, 338-468) after 6 months (P < 0.067) and to 250 μm ± 48 (range, 200-298) at last follow-up with statistically significance difference change from the baseline (P < 0.001). There were great proportional decrease in venous tortuosity, optic disc edema and surface wrinkling after 1 month of injection. Neither systemic nor intraocular adverse events were reported.

CONCLUSIONS

Intravitreal Avastin (IVA) is safe well tolerated, effectively improve VA, fundus picture and stabilize anterior segment neo-vascular activity in patients with recent retinal venous occlusion.

Bevacizumab in central retinal vein occlusion: a retrospective analysis after 2 years of treatment

PURPOSE

Bevacizumab (Avastin) was first used clinically in 2005. Reports on the treatment of more than 600 patients with central retinal vein occlusion (CRVO) have been published to date. However, there are limited data on the long-term effects of bevacizumab in patients with CRVO.

METHODS

We retrospectively re-evaluated 10 patients with CRVO who were initially part of one of the first published case series on the short-term effects of bevacizumab. The patients were invited for a follow-up visit 2 years after their initial bevacizumab injection. Study endpoints were changes in visual acuity (VA) and central macular edema (CME) compared to 1) baseline values and 2) short-term values after the initial injection.

RESULTS

Short-term VA gain had been 2.9 lines 3 weeks after the first bevacizumab injection. Two years later, mean VA gain vs baseline was 1.6 lines. Low baseline VA and good response to the first injection correlated positively with higher long-term VA gains (Pearson correlation of r = 0.50 and r = 0.66). There was no correlation for injection number, occlusion time, or CME changes with long-term VA gain.

CONCLUSIONS

The initial short-term VA gain after bevacizumab treatment was not always maintained over a 2-year period despite repeated injections. Patients with low baseline VA and good response to the first injection seemed to benefit most from repeated bevacizumab injections.

Transitions of multifocal electroretinography in patients with age-related macular degeneration after combination therapy with photodynamic therapy and intravitreal bevacizumab

To compare the differences in color Doppler imaging (CDI) and pattern visual evoked potential (P-VEP) examinations between normal tension glaucoma (NTG) and hypertension primary open angle glaucoma (HTG) patients, and investigate the relation between flow velocities measured by CDI and P-VEP examination in NTG and HTG patients. Sixty NTG patients, 66 HTG patients and 44 control subjects underwent CDI evaluation of the ophthalmic artery (OA), short posterior ciliary artery (SPCA) and central retinal arteries (CRA). The peak systolic velocities (PSV) and end-diastolic velocities (EDV) and resistive index (RI) of all retrobulbar vessels were measured. The latency and amplitude of P100 in P-VEP were recorded from the three groups. The differences of CDI and P-VEP parameters among NTG group, HTG group and control group were compared by one-way analysis of variance. The correlations between CDI parameters and visual field indices, P-VEP and visual field indices, P-VEP and CDI parameters in NTG and HTG patients were evaluated by Pearson's correlation analysis. NTG and HTG patients had the lower EDV and higher RI in the OA, CRA and SPCA comparing with that of control subjects. NTG and HTG patients also had lower PSV in OA and CRA comparing with that of control subjects. There was no significant difference in the blood flow velocities and RI of all retrobulbar vessels between NTG and HTG patients. The latency of P100 in VEP delayed and the amplitude of P100 decreased in the NTG and HTG patients comparing with that of the control group. There was no significant difference in the latency and amplitude of P100 between the NTG and HTG patients. The RI of OA and SPCA were negatively correlated with the mean deviation (MD) values in the NTG and HTG patients. The RI of OA was positively correlated with the PSD value in the NTG and HTG patients. The MD values in the NTG and HTG patients were negatively correlated with the latency time of P100. The RI of OA was positively correlated with the latency time of P100 in NTG and HTG patients. The RI of OA was negatively correlated with the amplitude of P100 in HTG patients. No significant difference was found in the parameters of CDI and P-VEP between NTG and HTG patients. The certain parameters of CDI were correlated with P-VEP parameters in NTG and HTG patients.

[Retinal vein occlusion: anti-VEGF treatments]

To date, there is no consistently effective proven therapy for patients with macular edema resulting from central retinal vein occlusion. Grid laser treatment only showed visual acuity benefit in branch retinal vein occlusion. Other treatment like intravitreal triamcinolone acetonide demonstrated transient inconsistent benefit with potential complications. As retinal vein occlusion is associated with increased levels of Vascular Endothelial Growth Factor (VEGF), anti-VEGF therapy was proposed to be a promising strategy for retinal vein occlusion. We reviewed the current literature on this topic: case reports, non controlled and non randomized trials. Short term results are encouraging with visual acuity benefit associated with reduction of retinal central thickness but multiple injections seems to be necessary to achieve visual stabilization. Further randomized and controlled clinical trials are necessary to confirm the long term safety and efficacy of bevacizumab in the care of retinal vein occlusion edema treatment.

Evaluation of potential visual acuity in eyes with macular oedema secondary to retinal vein occlusion

PURPOSE

To evaluate the potential visual acuity (VA) of eyes with macular oedema (MO) associated with retinal vein occlusion (RVO).

METHODS

Thirty-one eyes of 31 patients with MO associated with RVO were examined and then treated with an intravitreal injection of bevacizumab. Of these 31 eyes, 22 showed complete resolution of the MO at 1 month after treatment, at which time potential VA was determined; 12 eyes had good function and 10 had poor function at this time. Optical coherence tomography was used to detect the junctions between inner and outer segments of the photoreceptors (IS/OS) as a hallmark of integrity of the outer photoreceptor layer.

RESULTS

In the poor function group, pretreatment VA was significantly worse (P = 0.0106) and pretreatment central macular thickness was significantly greater (P = 0.0121). Preservation of the foveal photoreceptor layer before treatment was associated closely with good visual function after resolution of MO, and IS/OS line beneath the fovea was detected more frequently before treatment in eyes with good function (P = 0.0053).

CONCLUSIONS

In eyes with MO associated with RVO, when the IS/OS line was detected beneath the fovea, they would be expected to have good vision after resolution of the MO.

Bevacizumab (Avastin) for the treatment of ocular disease

The use of intravitreal bevacizumab (Avastin) has greatly expanded since its introduction into ophthalmic care 3 years ago. A PubMed search on 1 August 2008 revealed 51 ocular disease processes that have been treated with bevacizumab. The majority of publications consist of case reports or retrospective case series and their number is increasing quickly. It is important to collate the experiences gained to date to properly inform our clinical decision making and improve the design of future clinical trials. Current studies cannot easily be combined in a meta-analysis given the lack of standardized data and the wide variety of disorders studied in small numbers. This paper will describe the attempted uses of intravitreal bevacizumab and its efficacy for each ocular disease in addition to discussing safety. Comments regarding appropriate use of this treatment are based on our current level of knowledge. It is clear that the initial encouraging results described in this paper warrant further study of intravitreal bevacizumab in larger, controlled, randomized trials.

Off-label use of bevacizumab for the treatment of age-related macular degeneration: what is the evidence?

There is an active and controversial debate about the role of intravitreal bevacizumab versus approved drugs in the treatment of neovascular age-related macular degeneration (AMD). Because bevacizumab was available prior to the launch of ranibizumab, off-label use of the former became widespread and the cancer drug bevacizumab is the most commonly used medication in ophthalmology nowadays. This review considers every publication identified in MEDLINE using the keywords 'bevacizumab' and 'Avastin' between 1 June 2005 and 31 July 2008. The search identified 511 papers that were evaluated. In 33 studies, there was consistent and clear evidence for the efficacy of bevacizumab in neovascular AMD. However, the highest grade studies (three prospective, randomized, controlled trials) did not attain better than grade 2b level of evidence, and objective evaluation of the benefit of bevacizumab relative to representative controls was therefore not possible. Certainly, the available evidence is inferior to that obtained from the approval studies of ranibizumab and this should influence treatment selection and guidance of patients. These considerations indicate that important quality criteria need to be included in future studies to ensure more meaningful conclusions can be drawn. These include clearly defined inclusion criteria, information about the recruitment procedure (including data on withdrawals, excluded patients, concealed treatment allocation, use of intention-to-treat analyses and blinded assessment procedures). Although preclinical studies have almost exclusively found bevacizumab to be safe, the design utilized in clinical case series cannot rule out a possible increase in adverse events, which already show a high spontaneous incidence in elderly AMD patients. The superior evidence level for ranibizumab and the limited safety data for bevacizumab must be taken into consideration when evaluating the costs that a healthcare system is willing to spend. However, the superior grade of evidence for ranibizumab should not be confused with the (still missing) evidence for superior efficacy. The results of ongoing randomized, controlled, comparative trials will provide further data on the efficacy and cost effectiveness of bevacizumab and ranibizumab in the treatment of AMD. In the meantime, patients should be informed about the alternatives, the price differences and the restricted liability issue when off-label use of bevacizumab is offered.

Long-term safety and efficacy of intravitreal bevacizumab (Avastin) for the management of central retinal vein occlusion

PURPOSE

To evaluate the long-term safety and efficacy of intravitreal bevacizumab injections (Avastin, Genentech Inc., San Francisco, CA) for the treatment of macular edema secondary to central retinal vein occlusions.

METHODS

A retrospective review was performed of eyes treated from May 2005 to August 2006 with follow-up through February 2007. The dose of bevacizumab was 1.25 mg (0.05 mL). Retreatment was performed at monthly or longer intervals at the discretion of the treating physician.

RESULTS

Fifty-seven eyes received intravitreal bevacizumab at baseline. Visual acuity improved by a mean of 14 letters (N = 53; P < 0.001) at 1 month, 13 letters at 3 months (N = 53; P < 0.001), 9 letters at 6 months (N = 30; P = 0.001), 9 letters at 12 months (N = 17; P = 0.004). The mean optical coherence tomography thickness decreased by 299 microm at 1 month (N = 53; P < 0.001), 144 microm at 3 months, (N = 53; P < 0.001), 127 microm at 6 months (N = 30; P = 0.011), and 276 microm at 12 months (N = 17; P < 0.001). No ocular or systemic adverse events were observed.

CONCLUSION

Improvements in visual acuity and optical coherence tomography were observed during the first year following intravitreal bevacizumab for macular edema secondary to central retinal vein occlusions. These retrospective results provide additional evidence to support the perceived safety and efficacy of intravitreal bevacizumab in this disorder.

Pattern electroretinographic results after photodynamic therapy alone and photodynamic therapy in combination with intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration

PURPOSE

To evaluate the changes in pattern electroretinography (PERG) 1 month after photodynamic therapy alone and photodynamic therapy in combination with intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

METHODS

This is a prospective series of 45 eyes with subfoveal CNV secondary to AMD. Twenty eyes were treated with photodynamic therapy (PDT) with verteporfin and 1.25 mg of intravitreal bevacizumab, and 25 patients were treated with PDT alone. Visual acuities and serial PERG recordings were performed both before and 1 month after therapy.

RESULTS

Following the 1-month therapy period, visual acuity improved in 56% of patients in the PDT group and 76% of patients in the combination group. No significant ocular or systemic adverse effects were observed in either group. According to the PERG results, the mean P50 amplitude was 1.5 +/- 0.9 microV before PDT and improved to 2.1 +/- 1.1 microV at 1 month after PDT. The mean P50 amplitudes in the combination therapy group before and after therapy were 1.6 +/- 0.8 microV and 2.7 +/- 1.2 microV, respectively, and the difference was statistically significant between the groups.

CONCLUSIONS

In this small series of eyes with limited follow-up, the combined treatment of PDT with verteporfin and intravitreal bevacizumab seems to be associated with improvement in VA and pattern electroretinographic results when compared to those in the PDT group.

Cystoid macular edema

We review the epidemiology, pathophysiology, and etiology of cystoid macular edema (CME). Inflammatory, diabetic, post-cataract, and macular edema due to age-related macular degeneration is described. The role of chronic inflammation and hypoxia and direct macular traction is evaluated in each case according to different views from the literature. The different diagnostic methods for evaluating the edema are described. Special attention is given to fluoroangiography and the most modern methods of macula examination, such as ocular coherence tomography and multifocal electroretinography. Finally, we discuss the treatment of cystoid macular edema in relation to its etiology. In this chapter we briefly refer to the therapeutic value of laser treatment especially in diabetic maculopathy or vitrectomy in some selected cases. Our paper is focused mainly on recent therapeutic treatment with intravitreal injection of triamcinolone acetonide and anti-VEGF factors like bevacizumab (Avastin), ranibizumab (Lucentis), pegaptamid (Macugen), and others. The goal of this paper is to review the current status of this treatment for macular edema due to diabetic maculopathy, central retinal vein occlusion and post-cataract surgery. For this reason the results of recent multicenter clinical trials are quoted, as also our experience on the use of intravitreal injections of anti-VEGF factors and we discuss its value in clinical practice.

Treatment of branch retinal vein occlusion induced macular edema with bevacizumab

BACKGROUND

Branch retinal vein occlusion is a frequent cause of visual loss with currently insufficient treatment options. We evaluate the effect of Bevacizumab (Avastin) treatment in patients with macular edema induced by branch retinal vein occlusion.

METHODS

Retrospective analysis of 32 eyes in 32 patients with fluorescein angiography proven branch retinal vein occlusion, macular edema and Bevacizumab treatment. Outcome measures were best corrected visual acuity in logMAR and central retinal thickness in OCT.

RESULTS

Visual acuity was significantly better 4 to 6 weeks after Bevacizumab treatment compared to visual acuity prior to treatment (before 0.7 +/- 0.3 and after 0.5 +/- 0.3; mean +/- standard deviation; p < 0.01, paired t-test). Gain in visual acuity was accompanied by a significant decrease in retinal thickness (454 +/- 117 to 305 +/- 129 microm, p < 0.01, paired t-test). Follow up (170, 27 - 418 days; median, range) shows that improvement for both visual acuity and retinal thickness last for several months after Bevacizumab use.

CONCLUSION

We present evidence that intravitreal Bevacizumab is an effective and lasting treatment for macular edema after branch retinal vein occlusion.