Ranibizumab for the treatment of macular edema associated with perfused central retinal vein occlusions

Factors Associated with Pain Level in Patients Receiving Intravitreal Injection

Purpose:

To identify the factors associated with the pain level in patients receiving intravitreal injection.

Methods:

A total of 120 patients were prospectively evaluated, and 104 were included in the study. Patients were asked to rate their pain intensity from 0 to 10 on the visual analog scale. Factors that were possibly associated with pain level were evaluated using a sociodemographic data form, state anxiety inventory, and the hospital anxiety and depression scale.

Results:

Of the participants, 54 (51.9%) were female, and 50 (48.1%) were male, with a mean age of 65 ± 9.01 years. There was a positive correlation between pain level and state anxiety scores (r = 0.30; P < 0.001) and a negative correlation between hospital anxiety score (r = −0.23; P = 0.02) and hospital depression score (r = −0.27; P = 0.01). The correlation between pain score and education level was significantly higher in primary and secondary school graduates (P < 0.01). Smokers were observed to have higher pain scores (6.50 ± 2.21 in smokers and 4.87 ± 2.50 in nonsmokers; P = 0.01). Among diagnostic groups, pain scores were found to be significantly lower in the diabetic retinopathy (DR) group (6.82 ± 1.99 in age-related macular degeneration, 5.94 ± 2.27 in retinal vein occlusion, and 3.58 ± 1.97 in DR; P < 0.001). When pain scores were evaluated according to the drug injected, the group receiving bevacizumab injection was observed to have higher pain scores (7.32 ± 1.81 in bevacizumab, 4.00 ± 2.08 in aflibercept, and 3.92 ± 1.96 in ranibizumab; P < 0.001). Based on the multiple regression analysis, the state anxiety score, hospital anxiety score, hospital depression score, and smoking status were observed not to be significant predictors. The level of education, diagnosis, and active substance were found to have a statistically significant effect on pain perception.

Conclusion:

In this study, pain levels have been found to be high in smokers, those with a low educational level, individuals receiving bevacizumab for intravitreal injection, and those having a higher level of state anxiety, whereas patients with DR have lower pain scores.

A Multicenter, Retrospective Study (RE-ENACT 2) on Razumab™ (World's First Biosimilar Ranibizumab) in Retinal Vein Occlusion

Purpose

The REal life assessmENt of safety And effeCTiveness of Razumab 2 (RE-ENACT 2) study evaluated the long-term effectiveness of biosimilar ranibizumab. We present the subgroup analysis of patients with retinal vein occlusion (RVO).

Methods

Data of patients who received pro re nata (PRN) biosimilar ranibizumab (November 2015 to December 2018, 17 centers) were analyzed. Endpoints were change from baseline in best corrected visual acuity (BCVA, Snellen’s/logMAR), central subfield thickness (CSFT), intraocular pressure (IOP), and proportions of patients having intraretinal fluid (IRF) and subretinal fluid (SRF) at weeks 4, 8, 12, 16, 20, 24, 30, 36, and 48.

Results

Of 101 patients, 48.51% were men, and the majority (79.21%) were treatment naïve and had received 3 (range 1–5) injections (53.5%). Significant improvements (P < 0.05) were observed from baseline to all timepoints for BCVA [baseline, 0.89 ± 0.06 (n = 94); week 48, 0.41 ± 0.08 (n = 14)] and CSFT [baseline, 527.58 ± 19.9 (n = 85); week 48, 307.47 ± 16.4 (n = 15)]. Changes in IOP (mmHg) were non-significant [baseline, 15.38 ± 0.4 (n = 94); week 48, 13.94 ± 0.6 (n = 16); P = 0.5575). Proportions of patients having IRF [baseline, 71.3% (n = 84) vs week 48, 0% (n = 15)] and SRF [baseline, 52.5% (n = 83) vs week 48, 0% (n = 15)] were decreased. Similar results for BCVA, CSFT, IOP, IRF, and SRF were observed for BRVO and CRVO subgroups. There were no new safety concerns.

Conclusions

Biosimilar ranibizumab demonstrated improvements in visual acuity and disease outcomes up to 48 weeks in patients with RVO without any new safety concerns.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00277-3) contains supplementary material, which is available to authorized users.

Novel Liposome Aggregate Platform (LAP) system for sustained retention of drugs in the posterior ocular segment following intravitreal injection

A novel Liposome Aggregate Platform (LAP) system for prolonged retention of drugs in the posterior eye segment after intravitreal injection (IVT) was developed and evaluated. Calcein, FITC-dextran-4000 (FD4) and Flurbiprofen (FLB), were encapsulated in negatively charged liposomes, and mixed with protamine to produce the LAP. The lipid/protamine ratio was fixed, in order to have a convenient aggregation rate permitting IVT injection and also a sustained release of liposome-entrapped molecules (in vitro) from LAP. In vitro release studies confirmed the potential of LAP system consisted of HPC/DPPG/Chol liposomes and protamine (at 1:1 w/w to lipid), to delay calcein, FD4 and FLB release, compared to free liposomes. In vivo studies demonstrated increased vitreous retention of liposomes and LAP for all molecules, compared to the corresponding solutions; however the retention of FD4 is similar for non-aggregated liposomes and LAP, and calcein retention is only slightly increased by LAP compared to liposomes. The later result may be connected with the visible ocular inflammation caused by both dyes; interestingly inflammation was moderately reduced when dyes were entrapped in liposomes and even more when in LAP. No visible inflammation was demonstrated for FLB, and the LAP system significantly increased the retention of FLB in the ocular tissues (compared to non-aggregated liposomes). Taking into account the capability of the novel LAP system to decrease inflammatory reactions towards calcein and FD4, and prolong the retention of FLB in ocular tissues, it is concluded that such systems, after further optimization, may be considered as promising effective and safe approaches for treatment of posterior segment ocular pathologies.

RETINAL MICROVASCULATURE AND VISUAL ACUITY AFTER INTRAVITREAL AFLIBERCEPT IN EYES WITH CENTRAL RETINAL VEIN OCCLUSION: An Optical Coherence Tomography Angiography Study

PURPOSE

To investigate vascular perfusion and foveal avascular zone area in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) after intravitreal aflibercept therapy in central retinal vein occlusion eyes and their association with best-corrected visual acuity.

METHODS

Thirty-five subjects with central retinal vein occlusion and macular edema were evaluated. After macular edema resolution following intravitreal aflibercept, subjects underwent optical coherence tomography angiography to measure SCP and DCP perfusion and the foveal avascular zone within a 3 × 3-mm area. Correlations between best-corrected visual acuity and optical coherence tomography angiography measurements were examined.

RESULTS

After intravitreal aflibercept therapy, mean retinal vascular area was 3.41 ± 0.74 mm in the SCP and 3.25 ± 0.91 mm in the DCP. Foveal avascular zone area was 1.03 ± 1.04 mm in the SCP and 1.78 ± 1.73 mm in the DCP. Improved best-corrected visual acuity was significantly associated with better SCP and DCP perfusion (both P < 0.001) and with smaller SCP and DCP foveal avascular zone areas (both P < 0.001). Additionally, SCP and DCP perfusion were negatively correlated with macular edema before treatment (P < 0.05) and ischemia (determined via pretreatment fluorescein angiography, P < 0.05), and positively correlated with photoreceptor integrity (P < 0.001).

CONCLUSION

Patients with better retinal perfusion and less retinal ischemia are associated with better visual outcomes after aflibercept in eyes with central retinal vein occlusion.

Effect of funding source on reporting bias in studies of intravitreal anti-vascular endothelial growth factor therapy for retinal vein occlusion

PURPOSE

To examine the relationship between industry funding and outcome reporting bias in high-quality studies investigating the use of intravitreal anti-vascular endothelial growth factor (VEGF) agents for patients with macular oedema secondary to branch or central retinal vein occlusion (RVO).

METHODS

This systematic review in PubMed and Ovid MEDLINE examined all randomized clinical trials and meta-analyses published in journals with impact factor of ≥2 that investigated effectiveness of intravitreal anti-VEGF therapy in patients with RVO. The main outcome measure was correspondence between statistical outcome and abstract conclusion wording.

RESULTS

Forty-five studies met inclusion criteria; 38 (84%) showed correspondence between outcome and abstract conclusion without difference between industry-funded and nonindustry-funded publications (p = 0.39) or between publications in journals with impact factor ≥3 versus <3 (p = 0.96).

CONCLUSION

In high-quality studies of intravitreal anti-VEGF therapy for RVO, neither industry funding nor journal impact factor affected the rate of outcome reporting bias.

Which quadrant is less painful for intravitreal injection? A prospective study

PURPOSE

To evaluate the relationship between injection site and pain severity following intravitreal injection of bevacizumab (IVB).

DESIGN

Prospective, randomized, four-armed, clinical trial.

METHODS

The present study was a prospective, randomized, four-armed clinical trial, which included 1004 eyes from 1004 patients. Patients receiving IVB were randomly assigned into four groups: superotemporal (ST); superonasal (SN); inferotemporal (IT); and inferonasal (IN) injections. The visual analog scale (VAS) was used to assess pain. Primary study variables were the relationship between pain severity and injection site, number of previous injections, age, sex, and indication for injection. Secondary variables included best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes 1 month post IVB.

RESULTS

Overall mean pain score was 2.86 ± 2.2. Indications for injection were diabetic macular edema (84.1%), neovascular age-related macular degeneration (7.7%), and macular edema secondary to retinal vein occlusion (8.2%). The mean VAS scores in the SN, IN, ST, and IT groups were 1.5 ± 1.7, 3 ± 2.3, 4 ± 2, and 3 ± 2.1, respectively. Pain severity was significantly correlated with injection site (p < 0.001) and sex (p < 0.001); females showed higher pain scores. A negative correlation existed between pain score and number of previous injections (p = 0.03). Pain severity was not associated with age (p = 0.659), lens status (p = 0.478), vitreous reflux (p = 0.648), or indication for injection (p = 0.390). No significant complications were observed.

CONCLUSIONS

ST quadrant was the most painful and SN quadrant was the least painful sites for IVB. Pain severity score was significantly associated with injection site, number of injections, and sex.

Effect of intravitreal ranibizumab on serous retinal detachment in branch retinal vein occlusion

Purpose

The aim of this study was to evaluate the effect of initial intravitreal ranibizumab injection on visual acuity (VA) and central macular thickness (CMT) for the treatment of macular edema (ME) with and without serous retinal detachment (SRD) secondary to branch retinal vein occlusion (BRVO).

Materials and methods

Fifty-two BRVO eyes, treated with intravitreal ranibizumab injection for ME with and without SRD, were retrospectively reviewed. Patients were divided into two groups according to spectral domain optical coherence tomography (SD-OCT). The efficacy of intravitreal ranibizumab injection at first month was assessed by analyzing the change in best-corrected VA and reduction in CMT with SD-OCT.

Results

There were 21 patients with SRD and 31 patients with only CME (no-SRD). CMT was significantly greater in the SRD group than in the CME group (451±62.2 µm vs 383.5±37.2 µm, respectively, P<0.05). After initial intravitreal ranibizumab injection, mean VA improved from 0.87±0.26 logarithm of the minimum angle of resolution (LogMAR) to 0.54±0.27 LogMAR (P<0.01) and CMT decreased from 451±62.2 µm to 379.3±58.6 µm (P<0.001) in the SRD group. In the no-SRD group, mean VA improved from 0.69±0.25 LogMAR to 0.44±0.25 LogMAR (P<0.001) and the CMT decreased from 383.5±37.2 µm to 337.7±39.4 µm (P<0.001) at the first month visit. Eyes with SRD revealed better anatomic results and greater reduction of CMT after intravitreal ranibizumab injection (P<0.01).

Conclusion

VA and CMT can be improved by intravitreal ranibizumab injection in BRVO patients with and without SRD. However, more marked improvement in macular morphology was achieved in patients with SRD than those without SRD.

Short-term efficacy of intravitreal triamcinolone acetonide for macular edema secondary to retinal vein occlusion that is refractory to intravitreal bevacizumab

AIMS

To evaluate the 1-month efficacy of intravitreal triamcinolone acetonide (TA) in treating macular edema secondary to retinal vein occlusion (RVO) that was refractory to intravitreal bevacizumab.

MATERIALS AND METHODS

This retrospective, observational study included 23 eyes from 23 patients with macular edema secondary to RVO. Macular edema that did not respond to two or more consecutive intravitreal bevacizumab injections was treated with intravitreal TA. Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared before and one month after TA injection.

RESULTS

Fifteen eyes were diagnosed with central RVO, and eight eyes were diagnosed with branch RVO. All patients were previously treated with 2.4 ± 0.6 intravitreal bevacizumab injections. The TA injection was performed, on average, 5.8 ± 1.4 weeks after the last bevacizumab injection. The CFT before TA injection was 516.6 ± 112.4 μm and significantly decreased to 402.3 ± 159.7 μm after TA therapy (P < 0.001). The logarithm of the minimal angle of resolution BCVA was 0.72 ± 0.34 before TA therapy and was not significantly improved by the treatment (0.67 ± 0.35, P = 0.119), despite a decrease in CFT. However, seven eyes (30.4%) had a BCVA gain of one or more lines.

CONCLUSIONS

Intravitreal TA therapy was beneficial in some patients with macular edema secondary to RVO that was refractory to intravitreal bevacizumab therapy. This study suggests that intravitreal TA should be considered as a treatment option for refractory macular edema.

Efficacy of single bevacizumab injection as adjuvant therapy to laser photocoagulation in macular edema secondary to branch retinal vein occlusion

Background

Macular grid laser photocoagulation remains the standard treatment for macular edema secondary to branch retinal vein occlusion (BRVO). One possible strategy for treating macular edema is to inhibit VEGF activity by competitive binding of VEGF with an anti-VEGF antibody, suggesting the therapy option with bevacizumab. However, multiple injections of anti-VEGF may lead to complications and high cost.

Purpose

The aim of this study was to evaluate the improvement in visual acuity and central macular thickness after combination therapy of laser photocoagulation with single intravitreal bevacizumab injection in macular edema secondary to BRVO.

Methods

Nineteen patients with macular edema secondary to BRVO were assigned to either the group of nine patients in combination therapy of laser photocoagulation with intravitreal bevacizumab or the group of ten patients in the laser photocoagulation therapy. Complete ophthalmologic examinations were performed just before the therapy and at 1 month following the therapy. Changes in visual acuity were tested with the logarithm of minimum angle of resolution (logMAR), and central macular thickness was measured by optical coherence tomography (OCT).

Results

Combination therapy of laser photocoagulation and single intravitreal bevacizumab injection resulted in a significantly better visual acuity compared to laser photocoagulation therapy (0.35 versus 0.13 logMAR; P=0.041) and reduced macular thickness by 120.33 µm versus 71.50 µm (P=0.277), although this difference was not significant.

Conclusion

Laser photocoagulation combined with a single intravitreal bevacizumab has a substantial effect on increasing visual acuity in macular edema secondary to BRVO.

Analysis of Potential Ischemic Effect of Intravitreal Bevacizumab on Unaffected Retina in Treatment-Naïve Macular Edema Due to Branch Retinal Vein Occlusion: A Prospective, Interventional Case-Series

Background

To study potential ischemic effects of intravitreal Bevacizumab (IVB) on unaffected retina in treatment-naive eyes with macular edema secondary to branch retinal vein occlusion (BRVO) and contralateral eyes secondary to systemic absorption.

Methods and Findings

Prospective, interventional series included 27 treatment-naive eyes with BRVO and macular edema. Exclusion criteria: Eyes with diabetic retinopathy, glaucoma, vasculitides, papilledema or systemic neurologic condition. Subjects underwent complete ophthalmological examination including fluoroscein angiography (FA), optical coherence tomography (OCT) and multifocal electroretinogram (mf-ERG). All subjects received single 1.25 mg/0.05ml IVB injection. Two observers measured all parameters; inter-observer agreements were expressed as kappa values. Paired t-test was used to compare values at baseline and follow-up. The statistical analysis was done using SPSS for Windows, Version 14.0. (Chicago, SPSS Inc.) Presenting mean CFT (central foveal thickness) was 499.5(+/-229.7) μm, mean BCVA (best corrected visual acuity) was 0.64(+/-0.41) logMAR. At last follow-up, mean CFT was 267.9(+/-159.3) μm (P<0.001), 95% CI [127.18, 422.32]; mean BCVA was 0.28(+/-0.24) logMAR. Respectively, mean N1 and P1 amplitudes of mfERG in 'unaffected quadrant' at presentation were -6.10(+/-4.00) nV/deg² and 17.17(+/-11.54)nV/deg²; and -5.33(+/-1.30)nV/deg² and 15.29(+/-4.69)nV/deg² at final follow-up (P = 0.631 and 0.197, respectively), (95% CIs [-0.93, 1.42] and [-4.22, 1.08] respectively). In fundus quadrant of fellow eyes corresponding to unaffected quadrant in treated eyes, mean N1 and P1 amplitudes at presentation were -5.39(+/-1.56)nV/deg² and 15.89(+/-3.89)nV/deg²; and -5.39(+/-1.90)nV/deg² and 15.9(+/-5.52)nV/deg² (P = 0.380 and 0.208), (95% CIs [-0.57, 1.28] and [-4.1, 1.1]) at last follow-up, respectively. Limitations: This study analysed the effects with a single injection of bevacizumab. However, whether ischemic adverse effects will emerge with repeated IVB injections as a consequence of cumulative dosing needs further investigation. The setting of our study being a tertiary care centre, the numbers of fresh BRVO cases without prior intervention were limited. Thus, the limitations of our study include a small sample size with a small follow-up period. No major ocular/systemic adverse event was observed in the study period.

Conclusion

No evidence of progressive ischaemia attributable to single bevacizumab treatment was observed in this study. However, a larger prospective study involving subjects with cumulative dosing of bevacizumab and a longer follow-up could provide a better understanding of the potential ischaemic effects of bevacizumab or other anti-VEGF agents.

Choroidal thickness measurements with optical coherence tomography in branch retinal vein occlusion

AIM

To evaluate central macular thickness (CMT) and mean choroidal thickness (MCT) in eyes with branch retinal vein occlusion (BRVO), before and after ranibizumab treatment using spectral domain-optical coherence tomography (SD-OCT).

METHODS

Forty-two patients with unilateral BRVO and macular edema were included in this study. There were 25 men and 17 women. Using SD-OCT, choroidal thickness was measured at 500 µm intervals up to 1500 µm temporal and nasal to the fovea. MCT was calculated based on the average of the 7 locations. All the eyes with BRVO were treated with intravitreal ranibizumab (0.5 mg/0.05 mL). Comparisons between the BRVO and fellow eyes were analyzed using Mann-Whitney U test. Pre-injection and post-injection measurements were analyzed using Wilcoxon test and repeated measure analysis.

RESULTS

At baseline, there was a significant difference between the BRVO and fellow eyes in MCT [BRVO eyes 245 (165-330) µm, fellow eyes 229 (157-327) µm] and CMT [BRVO eyes 463 (266-899) µm, fellow eyes 235 (148-378) µm (P=0.041, 0.0001, respectively)]. Following treatment, CMT [295 (141-558) µm] and MCT [229 (157-329) µm] decreased significantly compared to the baseline measurements (P=0.001, 0.006, respectively). Also BCVA (logMAR) improved significantly (P=0.0001) in the BRVO eyes following treatment. After treatment CMT [BRVO eyes 295 (141-558) µm, fellow eyes 234 (157-351) µm] and MCT [BRVO eyes 229 (157-329) µm, fellow eyes 233 (162-286) µm] values did not reveal any significant difference in BRVO eyes and fellow eyes (P=0.051, 0.824, respectively).

CONCLUSION

In eyes with BRVO, CMT and MCT values are greater than the fellow eyes, and decrease significantly following ranibizumab injection.

Predictors of short-term outcomes related to central subfield foveal thickness after intravitreal bevacizumab for macular edema due to central retinal vein occlusion

AIM

To investigate the predictive factors for short-term effects of intravitreal bevacizumab injections on central subfield foveal thickness (CSFT) in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO).

METHODS

This was a retrospective study in 60 eyes treated with intravitreal bevacizumab injections for ME due to CRVO. Follow-up was three months. The Early Treatment Diabetic Retinopathy Study (ETDRS) score and CSFT measured by spectral-domain optical coherence tomography (SD-OCT) were used to observe the changes in best-corrected visual acuity (BCVA). Baseline BCVA, CSFT, age, CRVO duration and the presence of cystoid macular edema (CME) or subretinal fluid (SRF) were analyzed as potential predictive factors of the effects of intravitreal bevacizumab injections.

RESULTS

BCVA improved from 0.9 logMAR at baseline to 0.6 logMAR at 3mo, which was associated with a significant reduction in CSFT from 721 µm to 392 µm 3mo after injection. About 50% of CME cases and more than 90% of SRF cases responded to treatment with a complete resolution at 3mo. Age (P=0.036) and low baseline CSFT (P=0.037) were associated with a good 3-month prognosis. Patients >60 years old achieved better CME resolution (P=0.031) and lower CSFT at 3mo (305 µm vs 474 µm, P=0.003).

CONCLUSION

Intravitreal bevacizumab significantly improved visual acuity and CSFT in patients with CRVO after 3mo. Older age and lower baseline CSFT were good predictors of short-term CSFT outcomes. The retinal thickness response to bevacizumab might depend on the resolution of CME rather than SRF.

Impact of Intravitreal Ranibizumab on Vessel Functionality in Patients With Retinal Vein Occlusion

PURPOSE

To investigate the short-term effects of intravitreal ranibizumab on retinal vessel functionality in patients with retinal vein occlusion (RVO).

DESIGN

Prospective, interventional case series.

METHODS

We enrolled 11 eyes of 11 consecutive treatment-naïve patients with macular edema secondary to RVO. All patients underwent a complete ophthalmic evaluation, including optical coherence tomography and dynamic and static retinal vessel analysis, using the Dynamic Vessel Analyzer (Imedos, Jena, Germany) before (baseline) and 1 week and 1 month after administration of intravitreal ranibizumab. Investigations of RVO patients were compared to 11 eyes of age- and sex-matched control subjects.

RESULTS

In RVO patients, dynamic analysis showed a significant increase of mean venous dilation from +2.46% ± 1.03% at baseline to +3.96% ± 1.3% at 1 week (P = .001). At 1 week mean maximum venous and arterial dilations did not differ from those of control subjects. Static analysis showed a mean overall significant decrease of central retinal artery equivalent and central retinal vein equivalent from baseline to 1 week (from 174.8 ± 22.5 measurement units [MU] to 167.2 ± 26.7 MU [P = .04], and from 228.4 ± 20.7 MU to 217.3 ± 22.8 [P = .0002]). Mean central retinal artery equivalent in healthy control subjects was 175.9 ± 10.45 MU, not significantly different from baseline, week 1, and month 1 of RVO eyes. Conversely, mean central retinal vein equivalent was 195.5 ± 9.91 MU in healthy control subjects, significantly different from baseline, week 1, and month 1 of RVO eyes.

CONCLUSIONS

Using the Dynamic Vessel Analyzer in patients with RVO, we found that intravitreal ranibizumab increased vein dilation (dynamic analysis) and had a vasoconstrictive effect on both arteries and veins (static analysis).

Assessment of patient pain experience during intravitreal 27-gauge bevacizumab and 30-gauge ranibizumab injection

PURPOSE

To compare pain scores of patients during intravitreal 27-gauge bevacizumab and 30-gauge ranibizumab injection procedures.

METHODS

Seventy eyes of 70 patients who had not previously undergone intravitreal anti-vascular endothelial growth factor therapy were included in this study. Thirty-five patients received ranibizumab and 35 patients received bevacizumab. The diagnoses of the patients were: 27 age related macular degeneration, 15 diabetic macular edema, 9 diabetic vitreous hemorrhage, 6 central retinal vein occlusion, 11 branch retinal vein occlusion and 2 central serous chorioretinopathy. Bevacizumab (1.25 mg/0.05 mL) was injected into the vitreous cavity using a 27-gauge needle, and ranibizumab (0.5 mg/0.05 mL) was injected with 30-gauge needle. Patients were asked just after the injection to rate their perceived pain during the injection using the visual analogue scale (VAS) of 0 (no pain) to 10 (unbearable/worst pain). The average of these scores was used as the primary outcome.

RESULTS

The VAS pain scores in the ranibizumab and bevacizumab groups were 1.06 ± 0.91 (range, 0 to 3) and 1.94 ± 1.55 (range, 0 to 7), respectively, a significant difference (p = 0.005). Patients <65 and ≥65 years of age in both the ranibizumab and bevacizumab groups were then compared. For patients <65, there was a significant difference in the average VAS pain scores between groups (p = 0.003). However, for patients ≥65 years, there was not a significant difference in the average VAS pain scores between groups (p = 0.238). Female and male patients in both ranibizumab and bevacizumab groups were also compared. For female patients, there was a significant difference in the average VAS pain scores between groups (p = 0.016), although not for male patients (p = 0.078).

CONCLUSIONS

Thirty-gauge intravitreal injection is more comfortable than 27-gauge injection. Injection of bevacizumab with 30-gauge needle syringes may be more tolerable for patients.

[Management of macular edema secondary to retinal vein occlusion]

BACKGROUND

In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO.

METHODS

A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article.

RESULTS

The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters.

DISCUSSION

Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

Strategy for the management of macular edema in retinal vein occlusion: the European VitreoRetinal Society macular edema study

Objective. To compare the efficacy of different therapies in the treatment of macular edema associated with retinal vein occlusion (RVO). Design. This is a nonrandomized, multicenter collaborative study. Participants. 86 retina specialists from 29 countries provided clinical information, including choice of treatment and outcome, on 2,603 patients with macular edema including 738 cases of RVO. Methods. Reported data included the type and number of treatments performed, visual acuities, and other clinical and diagnostic findings. Main Outcome Measures. The mean increase in visual acuity and mean number of treatments performed. Results. 358 cases of central retinal vein occlusion (CRVO) and 380 cases of branch retinal vein occlusion (BRVO) were included in this investigation. Taking all RVO cases together, pars plana vitrectomy with internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than other therapies. Those treated with intravitreal antivascular endothelial growth factor (anti-VEGF) injection alone showed the second greatest improvement in vision. Dexamethasone intravitreal implant alone and intravitreal triamcinolone alone both resulted in modest visual gains. Conclusions. In the treatment of macular edema in RVO, vitrectomy with ILM peeling may achieve visual improvement and may be a good option for certain cases. Anti-VEGF injection is the most effective of the nonsurgical treatments.

Ranibizumab in retinal vein occlusion: treatment recommendations by an expert panel

Retinal vein occlusion (RVO) is a common cause of retinal vascular disease, resulting in potentially irreversible loss of vision despite the existence of several therapeutic options. The humanised monoclonal antibody fragment ranibizumab binds to and inhibits vascular endothelial growth factor, a key driver of macular oedema in RVO. In 2010, ranibizumab was approved in the USA for the treatment of macular oedema in RVO and, in 2011, ranibizumab was approved in the European Union for the treatment of visual impairment caused by macular oedema secondary to RVO in branch and central RVO. Ranibizumab provides an additional therapeutic option for this complex disease: an option that was not fully considered during the preparation of current international guidelines. An expert panel was convened to critically evaluate the evidence for treatment with ranibizumab in patients with visual impairment caused by macular oedema secondary to RVO and to develop treatment recommendations, with the aim of assisting physicians to optimise patient treatment.

Intravitreal Bevacizumab in Central Retinal Vein Occlusion: 18-month Results of a Prospective Clinical Trial

Purpose.

To evaluate the long-term visual results in central retinal vein occlusion (CRVO) following repeated intravitreal injections of bevacizumab (IVB).

Methods.

Thirteen patients (aged 34 to 79 years) with a duration of CRVO of 2 weeks to 6 months (mean 2.5 months) had a best-corrected visual acuity (BCVA) 0.05 to 0.4 (mean 0.13) as determined by Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Clinical examination was carried out at baseline and every 6 to 8 weeks. Intravitreal bevacizumab (1.25 mg) was given every 6 weeks during the first 6 months, and after that at the discretion of the attending physician.

Results.

In total, 96 IVB (average 7.4/patient) were given: 50 IVB during the first 6 months, 28 from 6 to 12 months, and 18 from 12 to 18 months. Average BCVA had improved 15 ETDRS letters at 3 months, 24 letters at 6 months, 24 letters at 12 months, and 18 letters at 18 months (p<0.05). Eight patients (62%) had gained >15 ETDRS letters at 12 months, and 7 subjects (54%) >15 ETDRS letters at 18 months. Foveal thickness decreased from 596 μm at baseline to 294 μm at 18 months (p<0.05) and mean IOP from 15.2 mmHg to 15.8 mmHg. No serious adverse events occurred.

Conclusions.

Following repeated IVB, there was a significant gain of BCVA during the follow-up of 18 months. To maintain visual gain, regular ophthalmologic examinations and repeated injections seem to be necessary as long as the disease is active.

Comparison of intravitreal ranibizumab and bevacizumab for the treatment of macular edema secondary to retinal vein occlusion

AIM

To compare the efficacy of ranibizumab and bevacizumab for macular edema due to retinal vein occlusion (RVO).

METHODS

A retrospective study was conducted at a single academic institution. Eighty-one patients naïve to anti-VEGF therapy with RVO and macular edema were identified. Twenty-six eyes were treated with ranibizumab, 33 eyes with bevacizumab, and 22 eyes with bevacizumab then switched to ranibizumab (crossover). The main outcome was change in visual acuity at 3 months, 6 months, and final visit.

RESULTS

The mean visual acuity improved from 20/80 to 20/40 in the ranibizumab (R) group and from 20/125 to 20/60 in the bevacizumab (B) group (P=0.66). The mean change in central subfield thickness (CST) was -186 and -212µm, respectively (P=0.69). Mean time between injections was 94±21.1d in the R group and 103.8±10.5d in the B group (P=0.78). In the crossover group, mean initial visual acuity was 20/125, reached 20/60 at crossover, and remained 20/60 at conclusion (P=0.91).

CONCLUSION

Both ranibizumab and bevacizumab are effective for the treatment of RVO and appear to have similar visual and anatomic outcomes. Changing treatments from bevacizumab to ranibizumab did not result in further gains in visual acuity.

Efficacy and safety of widely used treatments for macular oedema secondary to retinal vein occlusion: a systematic review

Background

Macular oedema secondary to retinal vein occlusion (RVO) can cause vision loss due to blockage of the central retinal vein (CRVO) or a branch retinal vein (BRVO). This systematic review assessed the efficacies of widely used treatments for macular oedema secondary to RVO and the feasibility of conducting indirect comparisons between these therapies.

Methods

A systematic review was undertaken in November 2010, including a literature search for trials in medical databases and relevant websites. Abstracts, conference presentations and unpublished studies were considered. Studies were data-extracted and quality assessed by two independent researchers. Outcome measures included the mean change in best corrected visual acuity (BCVA) from baseline in the study eye and/or number of patients gaining at least 10 letters from baseline to 6 months or the nearest equivalent time point.

Results

Fourteen unique randomized controlled trials (RCTs) were identified. Ranibizumab 0.5 mg produced greater improvements in BCVA at 6 months than sham in BRVO (mean difference 11.0 letters, 95% confidence interval [CI] 7.83, 14.17) and CRVO (mean difference 14.10 letters, 95% CI 10.51, 17.69) in two double-blind sham-controlled RCTs. Pooled data from two double-blind, sham-controlled RCTs showed that improvements in BCVA were also significantly better for dexamethasone intravitreal (IVT) implant 0.7 mg compared with sham in patients with BRVO or CRVO (mean difference 2.5 letters, 95% CI 0.7, 4.3); the difference was significant for BRVO alone, but not CRVO alone. A significantly greater proportion of patients with BRVO gained ≥15 letters with laser therapy vs. no treatment at 36 months in a large prospective RCT (odds ratio 3.16, 95% CI 1.25, 8.00), whereas no difference was observed at 9 months in a smaller study. Three studies reported no benefit for laser therapy in CRVO. No indirect comparisons with ranibizumab were feasible due to differences in study design and baseline characteristics.

Conclusions

Data from RCTs for ranibizumab and dexamethasone IVT demonstrate that both new agents constitute significant improvements over the previously widely accepted standard of care (laser therapy) for the treatment of BRVO and CRVO. However, head-to-head studies are needed to assess the relative efficacies of licensed therapies for RVO.

Late retinal neovascularization after central retinal vein occlusion: a case report and literature review

PURPOSE

To present the case of a 59-year-old man with central retinal vein occlusion with limited retinal ischemia who developed retinal neovascularization over a year after initial presentation.

METHODS

Retrospective case report.

RESULTS

On initial presentation, the patient had counting fingers vision in the affected eye and significant macular edema. After 4 intravitreal ranibizumab injections, his vision improved to 20/30. An intravenous fluorescein angiography performed at presentation and at a 4-month follow-up revealed limited retinal ischemia and no neovascularization. Over a year after his initial presentation, the patient returned with visual symptoms and was found to have subhyaloid hemorrhage and areas of retinal neovascularization.

CONCLUSION

Anterior and posterior segment neovascularization after central retinal vein occlusion has traditionally been thought to occur within a few months of the inciting event. However, the use of antivascular endothelial growth factor agents may alter the angiogenic processes within an eye after central retinal vein occlusion, potentially delaying the onset of neovascularization. This suggests the need for enhanced monitoring in this patient population.

Long-term results of the effect of intravitreal ranibizumab on the retinal arteriolar diameter in patients with neovascular age-related macular degeneration

PURPOSE

To study the effect of intravitreal (IVT) ranibizumab on the retinal arteriolar diameter in patients with neovascular age-related macular degeneration (AMD).

METHODS

Ten eyes of 10 patients with previously untreated neovascular AMD were included. All eyes had three monthly IVT injections of ranibizumab and then were retreated as needed, based on visual acuity and optical coherence tomography (OCT) criteria. The diameter of the retinal arterioles was measured in vivo with a retinal vessel analyser (RVA) before the first IVT injection, 7 and 30 days after the first, the second and the third injection, and at month 12 of follow-up.

RESULTS

  A significant vasoconstriction of the retinal arterioles was observed following each one of the first three IVT injections of ranibizumab. Thirty days following the first, second and third injection, there was a mean decrease of 8.4 ± 3.2%, 11.9 ± 4.5% and 18.5 ± 7.2%, respectively, of the retinal arteriolar diameter compared with baseline (p < 0.01). At month 12, the vasoconstriction was still present with a mean decrease of 19.1 ± 8.3% of the retinal arteriolar diameter compared with baseline (p < 0.01). Median number of ranibizumab injections was 4 (range 3-10). There was no correlation between the number of injections and percentage diameter decrease at month 12 (r = -0.54, p > 0.1). There was no significant change in mean arterial pressure (MAP) during the period of follow-up (p > 0.05).

CONCLUSIONS

  These results suggest that IVT ranibizumab induces sustained retinal arteriolar vasoconstriction in eyes with neovascular AMD.

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.

Intravitreal bevacizumab for macular complications from retinal arterial macroaneurysms

PURPOSE

To evaluate the anatomic and functional results of the treatment with intravitreal bevacizumab in complicated retinal arterial macroaneurysm (RAM).

DESIGN

A multicenter interventional, prospective, nonrandomized study.

METHODS

Thirty-eight macroaneurysms of 37 patients with foveal complications were evaluated. All patients underwent a comprehensive ophthalmologic examination, fluorescein angiography (FA), and spectral-domain optical coherence tomography (SD OCT) examination. Each patient underwent 3 monthly injections of bevacizumab 1.25 mg/0.05 mL; 3 follow-up visits were planned at week 2, 6, and 12.

RESULTS

Both best-corrected visual acuity (BCVA), expressed in logarithm of minimal angle of resolution (logMAR), and central retinal thickness (CRT) significantly improved during the follow-up visits (0.57 ± 0.21 vs 0.41 ± 0.15 vs 0.23 ± 0.13 vs 0.09 ± 0.10 and 520.38 ± 191.05 vs 396.24 ± 136.18 vs 283.86 ± 71.87 vs 214.84 ± 26.86, respectively, Friedman test P < .0001 for all variables). At 6 weeks of follow-up, FA showed complete closure of the RAM in 36 of 38 cases (94.7%). Four weeks following the third injection, the macular edema had completely resolved and hard exudates regressed slowly in 100% of patients.

CONCLUSIONS

Intravitreal bevacizumab is an effective therapy for complicated RAM, quickly improving BCVA and CRT. Anti-vascular endothelial growth factor (VEGF) drugs might actively close the involved pathologically permeabilized retinal artery and normalize the vessel wall formation by localized inhibition of VEGF.

Therapeutic potential of intravitreal pharmacotherapy in retinal vein occlusion

Retinal vein occlusion (RVO) is the most common visually disabling disease affecting the retina after diabetic retinopathy. Although the disease entity has long been known, its management is still controversial. Macular edema is the main reason for decreased visual acuity (VA) in this retinal vascular disorder. Recently the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of macular edema through intravitreal injection route. The most widely injected drugs so far have been triamcinolone acetonide (TA) and bevacizumab. The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestions that intravitreal pharmacotherapy by corticosteroids and anti-vascular endothelial growth factors may be useful in the treatment of retinal vein occlusion.

Retinal Vein Occlusions

Retinal vein occlusions (RVOs) are second to diabetic retinopathy in the prevalence as retinal vascular disorder and are characterized by dilatation of the retinal veins with retinal and subretinal hemorrhages, macular edema, hard retinal exudates, retinal ischemia, and consequent atrophy of the retina and optic nerve. They are differentiated into central RVOs and branch RVOs (BRVO), into ischemic versus nonischemic RVOs, and in the case of BRVOs, into intrapapillary BRVOs and extrapapillary BRVOs. Diagnosis is based on ophthalmoscopy, fluorescein angiography, and spectral-domain optical coherence tomography. The latter can display the presence and integrity of the retinal outer limiting membrane and of the inner and outer segments of the photoreceptors as useful information for prognosis and a guide for treatment. Risk factors for RVOs are glaucoma and arterial hypertension. Ischemic RVOs can develop iris neovascularization and secondary angle-closure glaucoma. Formerly, therapy consisted of laser photocoagulation in a "grid" pattern over the leaking area, leading to a reduction of macular edema and, as adverse effect, to focal retinal destruction. Intravitreal medical therapy including steroids and vascular endothelial growth factor inhibitors shows a marked antiedematous effect leading to an at least temporary reduction in foveal edema and correspondingly improves visual function. Intravitreal medical therapy is associated with the disadvantage of a limited duration of its effect and the advantage of not damaging the retina. A preventive therapy to avoid a recurrence of RVO or the development of an RVO in the contralateral eye has not been proven yet.

Management of retinal vascular diseases: a patient-centric approach

Retinal vascular diseases are a leading cause of blindness in the Western world. Advancement in the clinical management of these diseases has been fast-paced, with new treatments becoming available as well as license extensions of existing treatments. Vascular endothelial growth factor (VEGF) has been implicated in certain retinal vascular diseases, including wet age-related macular degeneration (AMD), diabetic macular oedema (DMO), and retinal vein occlusion (RVO). Treatment of wet AMD and visual impairment due to either DMO or macular oedema secondary to RVO with an anti-VEGF on an as needed basis, rather than a fixed schedule, allows an individualised treatment approach; providing treatment when patients are most likely to benefit from it, while minimising the number of unnecessary intravitreal injections. Thus, an individualised treatment regimen reduces the chances of over-treatment and under-treatment, optimising both the risk/benefit profile of the treatment and the efficient use of NHS resource. Streamlining of treatment for patients with wet AMD and visual impairment due to either DMO or macular oedema secondary to RVO, by using one treatment with similar posology across all three diseases, may help to minimise burden of clinic capacity and complexity and hence optimise patient outcomes. Informed treatment decisions and efficient clinic throughput are important for optimal patient outcomes in the fast-changing field of retinal vascular diseases.

Visual Acuity Outcome and Predictive Factors after Bevacizumab for Central Retinal Vein Occlusion

Purpose.

To evaluate the 12-month outcome and predictive factors of visual acuity (VA) changes following bevacizumab therapy for central retinal vein occlusion (CRVO).

Methods.

A total of 50 eyes from 50 patients with CRVO were consecutively included in this prospective study. Predictive factors were assessed by comparing baseline characteristics of patients classified into 3 groups: those showing a decrease in VA; those displaying a change in Early Treatment Diabetic Retinopathy Study (ETDRS) letter score between 0 and 15; and those in whom an increase in VA ≥15 letters was achieved. Baseline variables considered in the analyses of predictive factors were demographic and clinical characteristics.

Results.

Mean baseline ETDRS letter score was 20±12 and mean macular thickness was 575.1±152.7 µm. Mean final ETDRS letter score improved significantly, reaching 27±20, p=0.04, while mean macular thickness decreased significantly to 391.1±229.6 µm, p<0.001. The predictive factors associated with an increase in VA ≥15 ETDRS letters were younger age (p=0.002), shorter duration of symptoms before treatment initiation (p=0.001), and a higher visual acuity pretreatment (p=0.004). The frequency of ischemic CRVO and low vision at baseline was higher among nonresponsive patients (p=0.005).

Conclusions.

Intravitreal bevacizumab seems to be an effective primary treatment option for macular edema due to CRVO. Its main drawback is that multiple injections are often necessary to maintain visual improvement. Early injections of bevacizumab in young patients in whom VA is relatively preserved leads to a significant improvement in VA. Ischaemic CRVO and poor baseline VA are associated with nonresponse to such therapy.

Intravitreal ranibizumab for macular oedema secondary to retinal vein occlusion: a retrospective study of 34 eyes

PURPOSE

To evaluate the efficacy and the safety of intravitreal ranibizumab injection (Lucentis) in eyes with macular oedema secondary to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO).

METHODS

The files of consecutive patients (34 eyes, 15 CRVO, 19 BRVO) were retrospectively analysed. Intravitreal injections of 0.5 mg ranibizumab were administered; retreatment was based on acuity visual changes and optical coherence tomography findings. Patients received 2-4 injections (mean, 2.1). Mean follow-up was 7 months.

RESULTS

After the first injection, mean best-corrected visual acuity (BCVA) improved from 20/160 to 20/80 and mean central retinal thickness (CRT) decreased significantly from 549 to 301 μm (p < 0.01). For each injection, BCVA improvement was on average nine letters (p < 0.01) and macular oedema reduction was 195 μm CRT (p < 0.01). The decrease in CRT was similar in CRVO and BRVO, but the improvement in BCVA was larger in BRVO. No local or systemic adverse effect was detected. Final visual acuity was correlated to initial visual acuity and to visual acuity measured after the first injection. The change in CRT was correlated to the number of injections and to initial CRT.

CONCLUSION

Intravitreal injections of ranibizumab appeared to be a safe and effective option in the treatment of macular oedema secondary to retinal vein occlusion. Nevertheless, because the natural course has demonstrated a possible improvement in vision in almost one quarter of affected eyes at 3 years, further controlled and prospective studies are necessary to compare this treatment to the natural course with a longer follow-up.

Anti-vascular endothelial growth factor treatment for retinal vein occlusions

Retinal vein occlusion (RVO) encompasses two conditions: central RVO, in which the major outflow vessel of the retina is obstructed, and branch RVO, in which a proximal branch of the central retinal vein is obstructed. In both conditions, there is increased intraluminal and interstitial pressure throughout the retina drained by the obstructed vessels, resulting in reduced arterial perfusion, which is exacerbated by preexistent arterial insufficiency, and in variable amounts of retinal ischemia. Retinal ischemia causes increased production of vascular endothelial growth factor (VEGF), which causes vascular leakage and macular edema. High levels of VEGF also promote retinal hemorrhages and exacerbate capillary nonperfusion. Intraocular injections of a VEGF-binding protein reduce vascular leakage, resulting in improvement in macular edema, accelerate resorption of retinal hemorrhages, and prevent worsening of capillary nonperfusion. The ideal regimen has not been defined, but it appears that monthly injections early in the course control edema and may help to limit disease severity in a large percentage of patients. Over time, treatment should be individualized based upon timing and severity of recurrent edema and/or progression of nonperfusion. The role of adjunctive treatments is yet to be defined, but it is clear that VEGF antagonists provide excellent first-line treatment that has dramatically improved visual outcomes in patients with RVO.

Safety and Efficacy of Ranibizumab in Macular Edema following Retinal Vein Occlusion

Macular edema is the leading cause of visual impairment in patients with retinal vein occlusion. Limited improvements may be obtained with laser photocoagulation or intravitreal triamcinolone. However, according to the data provided by randomized clinical trials, intravitreal injections of ranibizumab (Lucentis; Genentech, South San Francisco, CA) constitute a new effective and safe option for the management of these vision-threatening diseases. The aim of the present review is to summarize the clinical evidence of ranibizumab for macular edema due to retinal vein occlusions.

Rapid resolution of macular edema associated with central retinal vein occlusion using ranibizumab after failure with multiple bevacizumab injections

PURPOSE

To report improvement in cystoid macular edema from central retinal vein occlusion with one injection of ranibizumab after failure with seven injections of bevacizumab.

METHODS

Case report.

RESULTS

A 74-year-old female developed persistent blurred vision for three months. Ocular examination revealed macular edema secondary to nonischemic central retinal vein occlusion. The patient was treated with intravitreal bevacizumab (1.25  mg in 0.05 mL). She received seven injections (every 5-6 weeks). Vision fluctuated between 20/30 and 20/60 with minimal variation in central foveal thickness (449-574 μm). However, weeks after one injection of ranibizumab the patient's vision improved to 20/20 with near resolution of macular edema (CFT = 343 μm).

CONCLUSIONS

Patients with no response to bevacizumab injections can show a rapid and large improvement with ranibizumab. This underscores the important differences between these two medications. Further study is required to determine if these initial effects of ranibizumab can be maintained.

Long-term follow-up of intravitreal bevacizumab in retinal arterial macroaneurysm: a case report

Purpose

To present the long-term effect of intravitreal bevacizumab (Avastin^®) therapy in a patient suffering from retinal arterial macroaneurysm.

Methods

Case report of a 72-year-old female diagnosed with retinal macroaneurysm in the superior temporal artery leading to macular edema. Functional and morphological data at baseline, 4 weeks, 2 months, and 13 months following treatment with two consecutive intravitreal bevacizumab injections are presented.

Results

Best-corrected visual acuity improved from 20/160 at baseline to 20/20 at the 3-months follow-up and remained stable through 13 months of follow-up. Central retinal thickness measured by optical coherence tomography decreased from 364 μm at baseline to 248 μm at the 13-months follow-up. No ocular or systemic side effects were detected.

Conclusions

Intravitreal bevacizumab therapy may lead to resolution of macular edema associated with retinal macroaneurysm and consequently visual improvement. This treatment may promise a long-lasting effect but warrant further investigation in larger series.

Anti-VEGF Agents for Ocular Angiogenesis and Vascular Permeability

We review articles describing intravitreal injection of anti-VEGF drug trials, while discussing the mechanisms of the action of anti-VEGF antibodies, and also evaluating their outcomes. Intraocular injections of anti-VEGF drug are considered to be an effective treatment for macular edema after retinal vein occlusion, however, recurrent/persistent edema is common. The recent reports may lead to a shift in treatment paradigm for DME, from laser photocoagulation, to newer approaches using anti-VEGF drugs. There have been several well-publicized prospective, randomized studies that demonstrated the efficacy of intravitreal injection of anti-VEGF drugs for patients with AMD. Adjuvant bevacizumab for neovascular glaucoma may prevent further PAS formation, and it is likely to open up a therapeutic window for a panretinal photocoagulation and trabeculectomy. Intravitreal injection of bevacizumab (IVB) results in a substantial decrease in bleeding from the retinal vessels or new vessels during a standard vitrectomy. IVB has also been reported to be effective for inducing the regression of new vessels in proliferative diabetic retinopathy. The use of bevacizumab in stage 4 or 5 retinopahty of permaturity (ROP) is to reduce the plus sign to help reduce hemorrhage during the subsequent vitrectomy. Some authors reported cases of resolution of stage 4 A ROP after bevacizumab injection.

Short-term effects of a single intravitreal bevacizumab injection on retinal vessel calibre

PURPOSE

  The aim was to investigate the short-term effects of a single intravitreal bevacizumab injection on the retinal vessel calibre in patients with neovascular age-related macular degeneration and in patients with diabetic macular oedema.

METHODS

  Twelve patients with neovascular age-related macular degeneration and eight patients with diabetic macular oedema were included in the study. All patients received an intravitreal injection of 1.25 mg bevacizumab. Red-free fundus photographs (35°) were acquired with a fundus camera at baseline and one day, one week and one month after the intravitreal injection. Measurements of retinal vessel diameter were made of the supero-temporal retinal venule and arteriole using the software available on the IMAGEnet program.

RESULTS

  Although there appeared to be a trend towards vasoconstriction for the measurements in the diabetic macular oedema group (both for arterioles and venules at day 7) and the age-related macular degeneration group (for venules at day 1 and for arterioles at day 7), it did not reach statistical significance (p > 0.05). Optical coherence tomography revealed a significant decrease in foveal thickness measurements in both groups at the one month visit compared with baseline.

CONCLUSION

  The results suggest that intravitreal injection of bevacizumab might induce retinal vasoconstriction; however, low numbers of subjects might have prevented the difference from reaching statistical significance. Further studies with a larger number of subjects would reveal the effect of intravitreal anti-vascular endothelial growth factor treatment on retinal vessel diameters more clearly.

Evaluation of the incidence of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor

AIMS

To report the incidence of infectious and noninfectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor (VEGF) from a multicenter clinical trial in Japan.

METHODS

A retrospective multicenter review of the data of patients who received intravitreal anti-VEGF injections between January 2007 and March 2011 was undertaken. Cases with the clinical diagnosis of endophthalmitis resulting from intravitreal injection were identified and reviewed.

RESULTS

A total of 5,236 intravitreal anti-VEGF injections (1,209 intravitreal injections of bevacizumab, 3,827 injections of ranibizumab, and 200 injections of pegaptanib sodium) had been administered. Five patients (0.095%), all of whom had received bevacizumab, were diagnosed as having endophthalmitis after the intravitreal injection. All patients visited the institutes for re-examination within 1-2 days after the injection. Among the 5 patients, 2 (0.038%) were culture positive for Streptococcus oralis and Enterococcus faecalis, respectively. The remaining 3 eyes (0.057%) developed presumed noninfectious endophthalmitis.

CONCLUSION

Although endophthalmitis is a rare complication associated with intravitreal injection, in this series intravitreal anti-VEGF injection caused infectious or noninfectious endophthalmitis at a relatively high frequency. Further investigations are needed to consider an appropriate injection protocol for minimizing the incidence rates of endophthalmitis, and to assess the optimal treatment protocol for intravitreal injection-related endophthalmitis although it was difficult to differentiate these two entities.

Ranibizumab: in macular oedema following retinal vein occlusion

Ranibizumab (Lucentis®), a recombinant humanized IgG(1) κ isotype monoclonal antibody fragment, is approved in the US for the treatment of macular oedema following retinal vein occlusion (RVO). It binds to the receptor-binding site of active forms of vascular endothelial growth factor-A, inhibiting its biological activity. In two large, well designed, phase III trials in patients with macular oedema following branch RVO (BRVO) or central RVO (CRVO), monthly intravitreal injections of ranibizumab 0.5 mg were associated with significantly greater improvement from baseline in mean best-corrected visual acuity letter score (measured on the Early Treatment Diabetic Retinopathy Study chart) in the study eye at 6 months (primary endpoint) than sham injections. Moreover, ranibizumab was significantly more effective than sham injections with regard to improvements in central foveal thickness at 6 months, as well as several other visual acuity measures. Ranibizumab was generally well tolerated in patients with macular oedema following CRVO or BRVO. Overall, the most common adverse events with ranibizumab were consistent with the adverse event profile previously reported in patients with age-related macular degeneration.

Retinal vein occlusion and macular edema - critical evaluation of the clinical value of ranibizumab

Retinal vein occlusions (RVOs) constitute the second most common cause of retinal vascular disease after diabetic retinopathy, with a prevalence of between 1% and 2% in persons older than 40 years of age. Despite the existence of numerous potential therapeutic options, none is entirely satisfactory, and many patients with RVO suffer irreversible visual loss. Fortunately however, the recent introduction of antivascular endothelial growth factor (VEGF) agents, such as ranibizumab (Lucentis^®, Genentech, South San Francisco, CA) and bevacizumab (Avastin^®, Genentech), offers a potentially new treatment approach for clinicians managing this disorder. The results of the BRAVO and CRUISE trials have provided the first definitive evidence for the efficacy and safety of ranibizumab in the treatment of RVO. As a result, ranibizumab has recently been approved by the US Food and Drug Administration for the treatment of RVO-associated macular edema. In this review, we provide a critical evaluation of clinical trial data for the safety and efficacy of ranibizumab, and address unresolved issues in the management of this disorder.

Treatment of macular edema due to retinal vein occlusions

Retinal vein occlusion (RVO) is a prevalent retinal vascular disease, second only to diabetic retinopathy. Previously there was no treatment for central retinal vein occlusion (CRVO) and patients were simply observed for the development of severe complications, generally resulting in poor visual outcomes. The only treatment for branch vein occlusion (BRVO) was grid laser photocoagulation, which reduces edema very slowly and provides benefit in some, but not all patients. Within the past year, clinical trials have demonstrated the effects of three new pharmacologic treatments, ranibizumab, triamcinolone acetonide, and dexamethasone implants. The benefit/risk ratio is best for intraocular injections of ranibizumab, making this first-line therapy for most patients with CRVO or BRVO, while intraocular steroids are likely to play adjunctive roles. Standard care for patients with RVO has changed and will continue to evolve as results with other new agents are revealed.