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Nichani PAH, Popovic MM, Dhoot AS, Pathak A, Muni RH, Kertes PJ. Treat-and-extend dosing of intravitreal anti-VEGF agents in neovascular age-related macular degeneration: a meta-analysis. Eye (Lond) 2023; 37:2855-2863. [PMID: 36859600 PMCID: PMC10517126 DOI: 10.1038/s41433-023-02439-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/04/2022] [Accepted: 02/01/2023] [Indexed: 03/03/2023] Open
Abstract
Intravitreal injections of antiangiogenic agents are pivotal in treating neovascular age-related macular degeneration (nAMD). The comparative efficacy and safety of treat-and-extend (T&E) versus bimonthly, monthly, and pro re nata (PRN) dosing remains unclear. A systematic review and meta-analysis of English-language RCTs reporting on efficacy and/or safety outcomes of dosing regimens of anti-VEGF agents in nAMD was performed. Best-corrected visual acuity (BCVA, ETDRS letters) at last follow-up represented the primary endpoint, while central subfield thickness (CSFT, μm), injection burden, and ocular adverse events were secondary endpoints. A random effects meta-analysis was performed, and 95% confidence intervals were calculated. Across six RCTs, 781 T&E-, 663 monthly-, 130 PRN-, and 123 bimonthly treated eyes were included. Mean changes in BCVA and CSFT at last follow-up were similar between T&E versus monthly (WMD, -0.62 letters; 95% CI, -2.12 to 0.87; P = 0.41; WMD, 5.30 microns; 95% CI, -10.67 to 21.26; P = 0.52, respectively), bimonthly (WMD, 1.68 letters; 95% CI, -3.55 to 6.91; P = 0.53; WMD, -18.91 microns; 95% CI, -46.41 to 8.60; P = 0.18, respectively), and PRN (BCVA WMD, 1.08 letters; 95% CI, -2.95 to 5.11; P = 0.60) regimens. T&E was associated with a reduced injection burden versus monthly (WMD, -4.52 injections; 95% CI, -6.66 to 2.39; P < 0.001) but higher injection burden versus PRN (WMD, 1.81 injections; 95% CI, 1.12 to 2.51; P < 0.001) dosing. There was no significant difference in safety outcomes amongst comparators. There was no significant difference in efficacy and safety between T&E, bimonthly, monthly, and PRN dosing. T&E resulted in fewer injections versus monthly and fewer clinic visits versus PRN.
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Affiliation(s)
- Prem A H Nichani
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Marko M Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Arjan S Dhoot
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Biomedical Engineering, Faculty of Applied Science and Engineering, University of Toronto, Toronto, ON, Canada
| | - Ananya Pathak
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Rajeev H Muni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Ophthalmology, St. Michael's Hospital/Unity Health Toronto, Toronto, ON, Canada
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Peter J Kertes
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
- John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Jiménez-Santos M, Saenz-Francés F, Calvo-González C, Fernández-Vigo JI, Donate-Lopez J, López-Guajardo L. Subfoveal choroidal thickness as a potential predictor of treatment response after intravitreal ranibizumab injections for polypoidal choroidal vasculopathy. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:82-89. [PMID: 34678176 DOI: 10.1016/j.jcjo.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/03/2021] [Accepted: 09/17/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the impact of subfoveal choroidal thickness (SFCT) and other clinical biomarkers in intravitreal anti-vascular endothelial growth factor response in treatment-naive Caucasian patients diagnosed with polypoidal choroidal vasculopathy (PCV/AT1). DESIGN Cross-sectional study. PARTICIPANTS Treatment-naive patients diagnosed with PCV/AT1 recruited in a single centre from January 2013 to December 2020. METHODS Eligibility was determined in treatment-naive PCV patients who received a loading dose of 3 injections of 0.5 mg ranibizumab. A diagnosis of PCV/AT1 was made based on the diagnostic criteria in the efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with sumptomatic macular polypoidal choroidal vasculopathy study. Choroidal thickness was manually measured by enhanced depth imaging technology in Spectralis spectral domain optical coherence tomography. RESULTS Eighty-three eyes of 83 patients were included in this study, 47 patients diagnosed with PCV/AT1 with a good response to 3 intravitreal injections of ranibizumab and 36 with a poor response. The receiver operating characteristic curve of treatment effect against the SFCT revealed that the area under the curve was 0.85 (range, 0.74-0.96). Based on the Youden index, the optimal SFCT cut-off point for predicting a poor response to anti-vascular endothelial growth factor is 257 µm. In the multivariate analysis, the SFCT remained statistically significant (odds ratio 1.02 [range, 1.01-1.04]; P = 0.008). The combined effect of treatment effect against clinical biomarkers produced an area under the curve of 0.90 (range, 0.82-0.98). CONCLUSION SFCT is a risk factor for a poor response to the 3 loading injections of ranibizumab in treatment-naive PCV/AT1 Caucasian patients. A cut-off point of 257 µm could be a valuable parameter for defining the population at risk for an inadequate response to ranibizumab.
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Affiliation(s)
| | | | | | | | - Juan Donate-Lopez
- Department of Ophthalmology, Hospital Clinico San Carlos, Madrid 28040, Spain
| | - Lorenzo López-Guajardo
- Department of Ophthalmology, Hospital Clinico San Carlos, Madrid 28040, Spain; Department of Ophthalmology, Faculty of Medicine, Autonomous University of Madrid, Madrid 28029, Spain
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Wong DT, Berger AR, Bourgault S, Chen J, Colleaux K, Cruess AF, Dookeran RI, Gauthier D, Hurley B, Kapusta MA, Kertes PJ, Qian CX, Samad A, Sheidow T, Whelan JH. Imaging Biomarkers and Their Impact on Therapeutic Decision-Making in the Management of Neovascular Age-Related Macular Degeneration. Ophthalmologica 2021; 244:265-280. [PMID: 33823520 DOI: 10.1159/000516108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 03/09/2021] [Indexed: 11/19/2022]
Abstract
These recommendations, produced by a group of Canadian retina experts, have been developed to assist both retina specialists and general ophthalmologists in the management of vision-threatening neovascular age-related macular degeneration (nAMD). The recommendations are based on published evidence as well as collective experience and expertise in routine clinical practice. We provide an update on practice principles for optimal patient care, focusing on identified imaging biomarkers, in particular retinal fluid, as well as current and emerging therapeutic approaches. Algorithms for delivering high-quality care and improving long-term patient outcomes are provided, with an emphasis on timely and appropriate treatment to preserve and maintain vision. In the context of nAMD, increasing macular fluid or leakage on fluorescein angiography (FA) may indicate disease activity regardless of its location. Early elimination of intraretinal fluid (IRF) is of particular relevance as it is a prognostic indicator of worse visual outcomes. Robust referral pathways for second opinion and peer-to-peer consultations must be in place for cases not responding to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy.
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Affiliation(s)
- David T Wong
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alan R Berger
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Serge Bourgault
- Department of Ophthalmology, Université Laval, Québec, Québec, Canada
| | - John Chen
- Department of Ophthalmology, McGill University, Montréal, Québec, Canada
| | - Kevin Colleaux
- Department of Ophthalmology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Alan F Cruess
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ravi I Dookeran
- Department of Ophthalmology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Danny Gauthier
- Department of Ophthalmology, Université de Montréal, Montréal, Québec, Canada
| | - Bernard Hurley
- Department of Ophthalmology, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael A Kapusta
- Department of Ophthalmology, McGill University, Montréal, Québec, Canada
| | - Peter J Kertes
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia X Qian
- Department of Ophthalmology, Université de Montréal, Montréal, Québec, Canada
| | - Arif Samad
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Thomas Sheidow
- Department of Ophthalmology, Western University, London, Ontario, Canada
| | - James H Whelan
- Faculty of Medicine, Memorial University, St. John's, Newfoundland, Canada
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