Intravitreal Aflibercept for Macular Edema Following Branch Retinal Vein Occlusion: 52-Week Results of the VIBRANT Study

[Aflibercept in a real-world setting: the AURIGA study : 24-month results of the German cohort of treatment-naïve patients with macular edema following retinal vein occlusion receiving intravitreal aflibercept]

BACKGROUND

AURIGA is the largest prospective real-world study to evaluate intravitreal aflibercept 2 mg (IVT-AFL) treatment of macular edema (ME) secondary to retinal vein occlusion (RVO) and diabetic macular edema. Here we present the 24-month data from the German cohort of treatment-naïve patients with ME due to RVO.

METHODS

Treatment-naïve patients with ME secondary to RVO were treated with IVT-AFL 2 mg in the routine clinical practice. The primary endpoint was mean change in visual acuity (VA, early treatment diabetic retinopathy, ETDRS, letters) at month 12 compared to baseline. Analyses were descriptive.

RESULTS

Analysis included 130 patients with RVO (n = 61, 46.9% with central RVO, n = 69, 53.1% with branch RVO). The mean (± SD) time the RVO patients remained in the study was 18.4 ± 7.4 months. The mean VA gain (95% confidence interval) in the overall cohort was +10.9 (7.5-14.2) letters at month 12 and +9.7 (6.1-13.3) at month 24 (baseline VA 56.5 ± 18.9 letters). At 24 months, 67% of RVO patients gained ≥5 letters and 40% gained ≥15 letters. The mean number of injections was 4.4 ± 1.3 up to month 6, 6.2 ± 2.7 up to month 12 and 8.2 ± 4.5 up to month 24. The mean central retinal thickness (CRT) reduction was -206µm (-252 to -160µm) at 12 months and -219µm (-263 to -175µm) at 24 months (baseline CRT 507 ± 177 µm). The safety profile was consistent with that of previous studies.

DISCUSSION

In the German AURIGA cohort of treatment-naïve patients with ME secondary to RVO, IVT-AFL 2 mg treatment in clinical practice resulted in rapid and clinically relevant VA gains and a reduction in CRT. These results were largely maintained over 24 months despite the low injection frequency from month 6.

Fatty Acid-Binding Protein 4-Mediated Regulation Is Pivotally Involved in Retinal Pathophysiology: A Review

Fatty acid-binding proteins (FABPs), a family of lipid chaperone molecules that are involved in intracellular lipid transportation to specific cellular compartments, stimulate lipid-associated responses such as biological signaling, membrane synthesis, transcriptional regulation, and lipid synthesis. Previous studies have shown that FABP4, a member of this family of proteins that are expressed in adipocytes and macrophages, plays pivotal roles in the pathogenesis of various cardiovascular and metabolic diseases, including diabetes mellitus (DM) and hypertension (HT). Since significant increases in the serum levels of FABP4 were detected in those patients, FABP4 has been identified as a crucial biomarker for these systemic diseases. In addition, in the field of ophthalmology, our group found that intraocular levels of FABP4 (ioFABP4) and free fatty acids (ioFFA) were substantially elevated in patients with retinal vascular diseases (RVDs) including proliferative diabetic retinopathy (PDR) and retinal vein occlusion (RVO), for which DM and HT are also recognized as significant risk factors. Recent studies have also revealed that ioFABP4 plays important roles in both retinal physiology and pathogenesis, and the results of these studies have suggested potential molecular targets for retinal diseases that might lead to future new therapeutic strategies.

Retinal Vein Occlusion-Background Knowledge and Foreground Knowledge Prospects-A Review

Thrombosis of retinal veins is one of the most common retinal vascular diseases that may lead to vascular blindness. The latest epidemiological data leave no illusions that the burden on the healthcare system, as impacted by patients with this diagnosis, will increase worldwide. This obliges scientists to search for new therapeutic and diagnostic options. In the 21st century, there has been tremendous progress in retinal imaging techniques, which has facilitated a better understanding of the mechanisms related to the development of retinal vein occlusion (RVO) and its complications, and consequently has enabled the introduction of new treatment methods. Moreover, artificial intelligence (AI) is likely to assist in selecting the best treatment option for patients in the near future. The aim of this comprehensive review is to re-evaluate the old but still relevant data on the RVO and confront them with new studies. The paper will provide a detailed overview of diagnosis, current treatment, prevention, and future therapeutic possibilities regarding RVO, as well as clarifying the mechanism of macular edema in this disease entity.

Disparities in Retinal Vein Occlusion Presentation and Initiation of Anti-VEGF Therapy: An Academy IRIS® Registry Analysis

OBJECTIVE

Investigate disparities in retinal vein occlusion (RVO) presentation and initiation of anti-VEGF treatment.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients in the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry database (2015-2021) with branch or central RVO and macular edema (ME).

METHODS

The association of demographic characteristics and presenting visual acuity (VA) with anti-VEGF treatment initiation were quantified using multivariable logistic regression.

MAIN OUTCOME MEASURES

Treatment with ≥ 1 anti-VEGF injection within 12 months after RVO diagnosis.

RESULTS

A total of 304 558 eligible patients with RVO and ME were identified. Age at presentation varied by race, ethnicity, sex, and RVO type (all P values < 0.001). Within the first year after RVO presentation, 192 602 (63.2%) patients received ≥ 1 anti-VEGF injection. In a multivariable regression model adjusting for relevant covariates, female (vs. male) patients had lower odds of receiving injections (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.93-0.96; P < 0.0001) as did Black/African American (vs. White) patients (OR, 0.90; 95% CI, 0.88-0.92; P < 0.0001) and Asian (vs. White) patients (OR, 0.95; 95% CI, 0.91-0.99; P = 0.02), whereas older patients (vs. patients aged < 51 years) had higher odds (61-70 years: OR, 1.20; 95% CI, 1.16-1.24; 71-80 years: OR, 1.20; 95% CI, 1.16-1.24; > 80 years: OR, 1.15; 95% CI, 1.11-1.18; all P values < 0.0001). Hispanic (vs. non-Hispanic) patients had a small increased odds of treatment initiation (OR, 1.08; 95% CI, 1.04-1.11; P < 0.0001). Results were similar in the subset of 226 143 patients with VA data. In this subset, patients with presenting VA < 20/40 to 20/200 were most frequently treated in the first year after diagnosis (∼ 70%) and patients with light perception/no light perception (LP-NLP) vision or VA of 20/20 or better were treated least frequently (36.9% and 41.9%, respectively).

CONCLUSIONS

In this large national clinical registry, 37% of RVO patients with ME had no anti-VEGF treatment documented in the first year after diagnosis. Black/African American, Asian, and female patients and patients with VA of LP-NLP were least likely to receive treatment. Awareness of this undertreatment and these disparities highlight the need for initiatives to ensure all RVO patients receive timely anti-VEGF injections for optimized visual outcomes.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

RETINAL VEIN OCCLUSIONS BEFORE AND DURING THE COVID-19 PANDEMIC: Visual Outcomes and Treatment Patterns in a Country with no Mandatory Lockdown

PURPOSE

To investigate the incidence, treatment patterns, and visual outcomes in patients with branch retinal vein occlusion (RVO) and central RVO before and during the COVID-19 pandemic in a country with no mandatory lockdown.

METHODS

This retrospective study included 788 patients presenting with a RVO during the years 2019 to 2022 at St. Erik Eye Hospital. The control group and study groups consisted of patients presenting before and during the pandemic, respectively.

RESULTS

The incidence of diagnosed RVO cases decreased from 281 patients before the pandemic to 236 patients during the first year of the pandemic ( P < 0.05). In patients with branch RVO at the end of follow-up, the best-corrected visual acuity improved 10.3 letters (95% confidence intervals [CI] 7.6-12.9) in the control group compared with 14.3 letters (95% CI 12.6-16.0) in the study groups ( P < 0.05). In patients with central RVO, the best-corrected visual acuity improved 6.3 letters (95% CI 2.7-10.0) in the control group compared with 8.6 letters (95% CI 5.7-11.4) in the study groups (p = NS). Overall, the number of intravitreal anti-vascular endothelial growth factor injections increased from 7.0 (95% CI 6.6-7.3) in the control group to 7.6 (95% CI 7.4-7.8) in the study groups ( P < 0.05).

CONCLUSION

Good visual and anatomical outcomes were sustained, and the number of intravitreal anti-vascular endothelial growth factor injections increased significantly in patients with RVO during the COVID-19 pandemic.

Retinal arterial and vein occlusion: is surgery ever indicated?

PURPOSE OF REVIEW

To highlight the recent progression in surgical treatments for central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO).

RECENT FINDINGS

Anti-VEGF treatment, accepted as a primary treatment for CRVO, is unable to effectively treat all types of the diseases. Regarding CRAO, there are not any accepted therapies available. There have however been recent innovations in surgery, such as utilizing robotics-assisted tools in cannulation procedures for central retinal artery occlusion, or micro-cystotomy for refractory macular edema resulting from ischemic CRVO.

SUMMARY

Refractory macular edema due to CRVO can be treated with aspiration of the fluid found inside the large cysts often seen in edema. The success rate of micro-cystotomy has been reported at 78% in eyes with refractory macular edema. Recent studies have shown that cannulation with tissue plasminogen activator (tPA) is effective for eyes with CRAO due to thrombus.Recent cannulation or micro-cystotomy procedures can be enhanced with the use of robotic tools which allow us to perform this difficult procedure more easily. Newly developed technology, and consequent developments in surgical procedures, will allow us to deal with unmet needs for retinal vessel occlusive diseases.

Effect of intravitreal injections due to neovascular age-related macular degeneration on retinal nerve fiber layer thickness and minimum rim width: a cross sectional study

PURPOSE

The present study tested the hypothesis that repeated anti-VEGF injections are associated with reduced retinal nerve fiber layer (RNFL) and minimum rim width (MRW) of the optic nerve head.

PATIENTS AND METHODS

Sixty-six patients with a history of intravitreal injections due to neovascular age-related macular degeneration were included. RNFL and MRW were measured using optical coherence tomography (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany).

RESULTS

Mean global RNFL was 90.62 μm and both RNFL as well as MRW significantly decreased with advanced age (p = 0.005 and p = 0.019, respectively). Correlating for the number of injections, no significant impact on RNFL was found globally (p = 0.642) or in any of the sectors. In contrast, however, global MRW was significantly reduced with increasing numbers of intravitreal injections (p = 0.012). The same holds true when adjusted for the confounding factor age (RNFL p = 0.566 and MRW p = 0.023).

CONCLUSION

Our study shows that repeated intravitreal injections due to choroidal neovascularization seem to have a deleterious effect on MRW but not on RNFL. This suggests that MRW is a more sensitive marker than RNFL for evaluating the effect of frequent intravitreal injections on the optic nerve head since it seems to be the first structure affected.

Three-Year Outcomes of VEGF Inhibitors in Naive Branch Retinal Vein Occlusion: Fight Retinal Blindness!

PURPOSE

To evaluate the 3-year outcomes of VEGF inhibitors in the treatment of cystoid macular edema due to branch retinal vein occlusion (BRVO) in an international multicenter cohort of eyes.

DESIGN

Multicenter, international, BRVO database study.

SUBJECTS

Seven hundred forty-seven patients (760 eyes) undergoing intravitreal therapy for BRVO for 3 years in a multicenter international setting.

METHODS

Demographics, visual acuity (VA) in logarithm of the minimum angle of resolution letters, central subfield thickness (CST), treatments, number of injections, and visits data was collected using a validated web-based tool.

MAIN OUTCOME MEASURES

Visual acuity gain at 3 years in logarithm of the minimum angle of resolution letters. Secondary outcome measures included anatomical results, treatment pattern, and percentage of completers. A subgroup analysis by study drug was conducted for clinical outcomes.

RESULTS

Mean adjusted VA change was +11 letters (95% confidence interval 9-13), mean adjusted change in CST was -176 μm (-193, -159). Median number of injections/visits was 16 of 24 at 3 years of follow-up. Most eyes received VEGF inhibitors exclusively (89%, n = 677) and as a monotherapy in 71% (n = 538). Few eyes were switched to steroids (11%, n = 83). Suspensions in treatment >180 days occurred in 26% of study eyes. Aflibercept showed greater CST reductions (-147 vs. -128 vs. -114 μm; P < 0.001) and significantly lower switching rates (14% vs. 38% vs. 33%; P < 0.001) compared with ranibizumab and bevacizumab, respectively.

CONCLUSIONS

This international study of 3-year BRVO outcomes after starting treatment with VEGF inhibitors found adequate visual and anatomical results in routine clinical care. Visual outcomes were similar among the different initiating VEGF inhibitors, although eyes starting with aflibercept had better anatomical outcomes and a lower switching rate.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Foveal Thickness Fluctuations in Anti-VEGF Treatment for Central Retinal Vein Occlusion

Purpose

The aim of this study was to examine the effects of foveal thickness (FT) fluctuation (FTF) on 2-year visual and morphological outcomes of eyes with central retinal vein occlusion (CRVO) undergoing anti-VEGF treatment for recurrent macular edema (ME) based on a pro re nata regimen.

Design

Retrospective, observational case series.

Participants

We analyzed 141 treatment-naive patients (141 eyes) with CRVO-ME at a multicenter retinal practice.

Methods

We assessed FT using OCT at each study visit. Patients were divided into groups 0, 1, 2, and 3 according to increasing FTF.

Main Outcome Measures

We evaluated the logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA), the length of the foveal ellipsoid zone (EZ) band defect measured using OCT, and the association of FTF with VA and EZ band defect length.

Results

The mean baseline logMAR BCVA and FT were 0.65 ± 0.52 (Snellen equivalent range: 20/20-20/2000) and 661.1 ± 257.4 μm, respectively. The mean number of anti-VEGF injections administered was 5.6 ± 3.6. At the final examination, the mean logMAR BCVA and FT values were significantly improved relative to the baseline values (both P < 0.01). During the observation, BCVA longitudinally improved in Groups 0 and 1, remained unchanged in Group 2, and worsened in Group 3. Likewise, the length of the foveal EZ band defect did not increase in Group 0; however, it gradually increased in Groups 1, 2, and 3. Foveal thickness fluctuation was significantly and positively associated with the logMAR BCVA and length of the foveal EZ band defect at the final examination (P < 0.01). The final logMAR BCVA of patients developing neovascular complications was 1.27 ± 0.72 (Snellen equivalent range: 20/50-counting fingers), which was significantly poorer than that of patients without complications (P < 0.001). There was no significant difference in the neovascular complication rate among the FTF groups (P = 0.106, Fisher exact test).

Conclusions

In eyes receiving anti-VEGF treatment for CRVO-ME, FTF can longitudinally impair the visual acuity and foveal photoreceptor status during the observation period, thus influencing the final outcomes. However, neovascular complications, which would also lead to a poor visual prognosis, may not be associated with FTF.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Branch retinal vein occlusion treated with anti-VEGF: to switch or not to switch?

OBJECTIVE

To evaluate visual outcomes after switching from bevacizumab to ranibizumab or aflibercept in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

DESIGN

A retrospective, multi-center, observational study.

PARTICIPANTS

Patients diagnosed with BRVO and were treated with at least 3 bevacizumab injections, before anti VEGF switch.

METHODS

The follow-up period was 36 months, and the primary study outcomes assessed changes in best corrected visual acuity (BCVA) after anti VEGF switch.

RESULTS

A total of 263 eyes of 263 patients with a mean age of 71.5 ± 11.2 years of which 50% were of male gender met the inclusion criteria. Of them, 175 eyes did not undergo switch, whereas 88 eyes underwent anti-VEGF switch. There was not a significant difference in mean age (p = 0.634) and gender (p = 0.269) between the groups. Baseline BCVA of the no-switch group was 0.47 ± 0.43 logMAR (20/59 Snellen) versus 0.6 ± 0.49 logMAR (20/79 Snellen) (p = 0.031) in the switch group, and at 36-months it was 0.41 ± 0.39 (20/51 Snellen) logMAR versus 0.54 ± 0.49 logMAR (20/69 Snellen) (p = 0.035), respectively. The difference between the rate of change in BCVA per year was insignificant between groups (p = 0.414). In multivariate analysis, baseline BCVA was the single significant predictor for switch (beta 0.137, p = 0.035). Patients with more than one anti-VEGF switch suffer from decrease in BCVA.

CONCLUSIONS

Worse baseline BCVA is a significant predictor for anti-VEGF switch execution, though the switch has no significant impact on the change in BCVA over time. Multiple anti-VEGF switch is not recommended.

Real-World Management of Macular Edema Secondary to Retinal Vein Occlusion with Intravitreal Aflibercept: 24-month Results from the AURIGA Observational Study

INTRODUCTION

AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema or macular edema secondary to retinal vein occlusion (RVO) in routine clinical practice. Here, we report the 24-month outcomes in the RVO cohort from France, Germany, Italy, and Taiwan.

METHODS

AURIGA (NCT03161912) was a prospective observational study. Eligible patients with RVO were enrolled for whom the decision to treat with IVT-AFL had already been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month (M) 12. All statistical analyses were descriptive.

RESULTS

In 554 treatment-naïve and 65 previously treated patients with RVO, the respective mean (95% confidence interval) change in VA from baseline was + 12.5 (10.8, 14.3) and + 7.9 (3.3, 12.6) letters by M12 and + 11.4 (9.4, 13.3) and + 4.4 (- 0.6, 9.5) letters by M24 (baseline mean ± standard deviation: 51.0 ± 21.9 and 51.9 ± 20.4 letters); 44.0% of treatment-naïve and 27.9% of previously treated patients reported ≥ 15-letter gains by M24. By M24, the mean change in central retinal thickness from baseline was - 247 (- 267, - 227) µm in treatment-naïve patients and - 147 (- 192, - 102) µm in previously treated patients. From baseline to M6, M12, and M24, treatment-naïve patients received a total of 4.0 ± 1.3, 5.5 ± 2.5, and 6.9 ± 4.2 injections, respectively, and previously treated patients received 3.8 ± 1.5, 5.0 ± 2.2, and 6.3 ± 3.7 injections, respectively. The safety profile of IVT-AFL was consistent with that of previous studies.

CONCLUSIONS

In AURIGA, patients with RVO experienced clinically relevant functional and anatomic improvements following IVT-AFL treatment in routine clinical practice. These improvements were largely maintained in treatment-naïve patients over the 24-month study despite the decreasing treatment frequency, suggesting long-term durability of IVT-AFL treatment outcomes. Infographic available for this article.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017). INFOGRAPHIC.

Treatment outcomes for maculopathy secondary to retinal vein occlusion in Afghanistan

OBJECTIVES

The objective of this study was to investigate the efficacy of intravitreal antivascular endothelial growth factor (VEGF) therapy in the treatment of macular edema secondary to retinal vein occlusion (RVO) in Afghanistan.

METHODS

A retrospective analysis was conducted of all RVO cases that underwent intravitreal ant-VEGF injection at the two leading hospitals in Kabul. The main outcome measures were visual acuity and central retinal thickness as determined by optical coherence tomography. Information was also collected on the distance traveled by each patient and the frequency of injections.

RESULTS

One hundred and twenty-five eyes of 121 patients (86 males) with RVO were identified as having undergone treatment, with a mean age of 53.1 years (range 20-80). The only agent used was bevacizumab. The mean central retinal thickness reduced from 624.2 ± 24.9 μm at the baseline to 257.8 ± 5.7 μm following treatment (P < 0.001). There was a small increase in visual acuity from 1.33 LogMAR at the baseline to 1.13 LogMAR following the most recent injection (P = 0.03, paired t-test). The mean distance traveled by patients was 173.9 km (range 2-447 km).

CONCLUSION

Despite the challenges of health-care provision in Afghanistan, this review shows that the use of intravitreal bevacizumab has provided an effective treatment for macular edema after RVO.

Anti-vascular endothelial growth factor dosing frequency and visual outcomes in macular oedema following branch retinal vein occlusion

OBJECTIVES

To determine the relationship between treatment frequency with intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents and visual acuity (VA) outcomes in eyes with macular oedema (MO) secondary to branch retinal vein occlusion (BRVO) in US clinical practice.

METHODS

Study eyes that initiated anti-VEGF injections between January 2012 and May 2016 were followed for ≥1 year in a retrospective analysis of medical records (Vestrum Health database). Eyes were analysed in 2 cohorts by treatment duration (years 1 and 2) and then in 2 subcohorts by injection frequency (≤6 or ≥7 injections/year).

RESULTS

Among 3099 eyes with MO secondary to BRVO, 1197 (38.6%) received ≤6 injections (mean injections, 4.6; baseline mean VA, 53 letters) and 1902 (61.4%) received ≥7 injections through 1 year (mean injections, 8.8; baseline mean VA, 52 letters). At year 1, mean VA gain from baseline was 10.4 versus 13.9 letters in eyes receiving ≤6 versus ≥7 injections (p < 0.001). At year 2, mean VA in eyes receiving ≤6 (n = 42) versus ≥7 injections (n = 227) was 64 versus 68 letters, respectively (p = 0.19). Mean VA change between the start and end of year 2 in eyes receiving ≥7 injections in year 1 and ≤6 in year 2 differed significantly from that of eyes receiving ≥7 injections in both years (-3.0 vs 0.7 letters, respectively; p < 0.001).

CONCLUSIONS

In routine clinical practice, more frequent dosing with anti-VEGF agents was associated with greater visual benefits in eyes with MO secondary to BRVO.

Alteration of perivascular reflectivity on optical coherence tomography of branched retinal vein obstruction

This study aimed to evaluate perivascular reflectivity in patients with branched retinal vascular obstruction (BRVO) using en-face optical coherence tomography (OCT). The study retrospectively analyzed 45 patients with recurrent BRVO, 30 with indolent BRVO, and 45 age- and sex-matched controls. Using a 3.0 × 3.0-mm deep capillary plexus slab on macular scans, OCT angiography (OCTA) and structural en-face OCT scans were divided into four quadrants. Obstructive quadrants of OCTA scans were binarized using a threshold value of mean + 2 standard deviation. The selected area of high signal strength (HSS) was applied to the structural en-face OCT scans, and the corrected mean perivascular reflectivity was calculated as the mean reflectivity on the HSS area/overall en-face OCT mean reflectivity. The same procedure was performed in the quadrants of the matched controls. Regression analysis was conducted on several factors possibly associated with corrected perivascular reflectivity. The perivascular reflectivity in the obstructive BRVO quadrant was significantly higher than in the indolent BRVO and control quadrants (P = 0.009, P = 0.003). Both univariate and multivariate regression analyses showed a significant correlation between the average number of intravitreal injections (anti-vascular endothelial growth factor or dexamethasone implant) per year and refractive errors and image binarization threshold and perivascular reflectivity (P = 0.011, 0.013, < 0.001/univariate; 0.007, 0.041, 0.005/multivariate, respectively). En-face OCT scans of the deep capillary plexus slab revealed higher perivascular reflectivity in recurrent BRVO eyes than in indolent BRVO and control eyes. The results also indicate a remarkable correlation between perivascular reflectivity and the average number of intravitreal injections, suggesting a link to recurrence rates.

Cardiovascular morbidity and all-cause mortality in patients with retinal vein occlusion: a Danish nationwide cohort study

BACKGROUND/AIMS

Associations between retinal vein occlusion (RVO) and subsequent cardiovascular disease (CVD) or mortality have not been evaluated in a recent cohort, after novel therapeutic options have increased referrals for treatment of the condition. We aimed to evaluate overall and subtype-stratified risk of CVD and all-cause mortality following RVO and assess any alterations after the introduction of angiostatic therapy in Denmark in 2011.

METHODS

This nationwide, registry-based cohort study from 1998 to 2018 evaluated 4 194 781 individuals. Hazard ratios (HRs) were reported for RVO as an overall measure and subclassified as branch and central RVO.

RESULTS

Patients with RVO (n=15 665) were median 71.8 years old at the time of exposure and 50.7% were women. RVO associated with incident CVD (adjusted HR 1.13, 95% CI 1.09 to 1.17) but not mortality (adjusted HR 1.00, 95% CI 0.97 to 1.03). Almost similar risks of CVD were found for patients with branch and central RVO (adjusted HRs 1.14, 95% CI 1.03 to 1.25, and 1.12, 95% CI 1.00 to 1.25, respectively), but only patients with central RVO exhibited increased mortality (adjusted HR 1.12, 95% CI 1.04 to 1.21). Risk of CVD, especially non-ischaemic, was higher for patients diagnosed after 2011 (adjusted HRs 1.24, 95% CI 1.15 to 1.33 vs 1.06, 95% CI 1.01 to 1.12).

CONCLUSION

In a cohort of the Danish population aged 40 years or more, patients with RVO had a 13% increased risk of incident CVD compared with unexposed individuals. Risk of CVD was increased after 2011, when intravitreal angiostatic treatment was introduced and referral practices altered.

BALATON and COMINO: Phase III Randomized Clinical Trials of Faricimab for Retinal Vein Occlusion: Study Design and Rationale

Purpose

Dual inhibition of angiopoietin-2 and VEGF-A with faricimab (Vabysmo) offers excellent visual acuity gains with strong durability in patients with diabetic macular edema (ME) and neovascular age-related macular degeneration. The phase III BALATON/COMINO (NCT04740905/NCT04740931) trials will investigate the efficacy, safety, and durability of faricimab in patients with ME due to retinal vein occlusion (RVO).

Design

Two identically designed global, randomized, double-masked, active comparator-controlled studies.

Participants

Anti-VEGF treatment-naive patients with branch, central, or hemiretinal RVO.

Methods

Patients were randomized to 6 monthly injections of faricimab 6.0 mg or aflibercept 2.0 mg. From weeks 24 to 72, all patients received faricimab 6.0 mg administered in up to 16-week intervals using an automated treatment algorithm to generate a treat-and-extend-based personalized treatment interval dosing regimen. Personalized treatment interval adjustments were based on changes in central subfield thickness (CST) and best-corrected visual acuity (BCVA).

Main Outcome Measures

Primary end point was noninferiority of faricimab versus aflibercept in mean change from baseline in BCVA (week 24; noninferiority margin: 4 letters). Secondary end points (weeks 0-24) were mean change from baseline in BCVA, CST, and National Eye Institute Visual Function Questionnaire 25 composite score; proportion of patients gaining or avoiding loss of ≥ 15/≥ 10/≥ 5/> 0 letters. Secondary end points (weeks 24-72) were treatment durability (week 68); continuation of weeks 0 to 24 end points. Ocular/nonocular adverse events will be assessed.

Results

In total, 1282 patients across 22 countries were enrolled (BALATON, 553 patients, 149 centers; COMINO, 729 patients, 193 centers).

Conclusions

Using a novel automated interval algorithm, BALATON/COMINO will evaluate the efficacy and safety of faricimab for ME secondary to RVO and provide key insights into how to personalize treatment.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Intravitreal Anti-Vascular Endothelial Growth Factor Therapies for Retinal Disorders

Vascular endothelial growth factors (VEGFs) are key mediator of retinal and choroidal neovascularization as well as retinal vascular leakage leading to macular edema. As such, VEGF plays an important role in mediating visually significant complications associated with common retinal disorders such as diabetic retinopathy, retinal vein occlusion, and age-related macular degeneration. Various drugs that inhibit vascular endothelial growth factors (anti-VEGF therapies) have been developed to minimize vision loss associated with these disorders. These drugs are injected into the vitreous cavity in a clinic setting at regular intervals. This article provides an overview of the various anti-VEGF drugs used in ophthalmology and the common retinal conditions that benefit from this therapy.

Foveal Eversion is Associated with High Persistence of Macular Edema and Visual Acuity Deterioration in Retinal Vein Occlusion

INTRODUCTION

Foveal eversion (FE) is a recently described optical coherence tomography (OCT) finding associated with negative outcome in diabetic macular edema. The main goal of the present study was to investigate the role of the FE metric in the diagnostic workup of retinal vein occlusion (RVO).

METHODS

This study was a retrospective, observational case series. We included 168 eyes (168 patients) affected by central RVO (CRVO) and 116 eyes (116 patients) affected by branch (RVO). We collected clinical and imaging data from CRVO and BRVO eyes affected by macular edema with a minimum follow-up of 12 months. On structural OCT, we classified FE as pattern 1a, characterized by thick vertical intraretinal columns, pattern 1b, presenting thin vertical intraretinal lines, and pattern 2, showing no signs of vertical lines in the context of the cystoid macular edema. For statistical purposes, we considered data collected at baseline, after 1 year and at the last follow-up.

RESULTS

The mean follow-up was 40 ± 25 months for CRVO eyes and 36 ± 24 months for BRVO eyes. We found FE in 64 of 168 CRVO eyes (38%) and in 25 of 116 BRVO eyes (22%). Most of the eyes developed FE during the follow-up. For CRVO eyes, we found 6 eyes (9%) with pattern 1a, 17 eyes (26%) with pattern 1b and 41 eyes (65%) with pattern 2. Of those BRVO eyes with FE, we found 8 eyes (32%) with pattern 1a + 1b and 17 eyes (68%) with pattern 2. In both CRVO and BRVO the presence of FE was significantly associated with higher persistence of macular edema and worse outcome, with FE pattern 2 representing the most severe condition. Remarkably, FE patterns 1a and 1b were characterized by BCVA stability over the follow-up, whereas FE pattern 2 showed significant bestcorrected visual acuity (BCVA) worsening at the end of the follow-up.

CONCLUSIONS

FE can be considered a negative prognostic biomarker in RVO, associated with higher persistence of macular edema and worse visual outcome. Müller cell impairment might represent the pathogenic mechanism leading to the loss of macular structural support and impairment of fluid homeostasis.

Benefit of intravitreal injections in patients with sub-threshold baseline visual acuity: a retrospective single-centre study

PURPOSE

To investigate the lower visual acuity threshold for recommending intravitreal injection therapy (IVI). The lower limit of 1.3 logMAR best-corrected visual acuity (BCVA) was adopted in 2006 and has been maintained since then.

METHODS

In this retrospective study, data from patients with a logMAR BCVA ≤ 1.3 and 24 months follow-up were analysed. We included patients with neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), or retinal vein occlusion (RVO).

RESULTS

The data from 164 patients (nAMD: 107; DME: 15; RVO: 42) were analysed. We observed a significant improvement at all time intervals (0 to 6, 6 to 12, 12 to 18, and 18 to 24 months after initiating IVI) compared to baseline. Across all indications, median BCVA improved from 1.4 to 1.0 within the first 6 months and remained stable within 24 months. Patients received a median of 5 and 10 injections within 6 and 24 months, respectively. Median foveal retinal thickness was 594.5 μm at baseline and dropped to 244.5 μm, 235.5 µm, 183 µm, and 180 µm during the four consecutive time intervals.

CONCLUSION

Patients with nAMD, DME, and RVO with poor baseline BCVA may also benefit from intravitreal therapy with VEGF-inhibitors. In the present study, we observed functional and morphological improvement over 2 years irrespective of the underlying macular disease. Those patients should not be excluded from therapy.

Novel pharmaceuticals for the management of retinal vein occlusion and linked disorders

INTRODUCTION

Retinal vein occlusion (RVO) is the second leading cause of blindness from retinal vascular disease behind diabetic retinopathy. Anti-vascular endothelial growth factor (VEGF) and glucocorticoid therapy are the cornerstones of pharmaceutical treatment for RVO. There is considerable interest in developing new pharmaceuticals in and out of these two classes to reduce costs, lower injection burden, and treat the occlusion itself, rather than the complications.

AREAS COVERED

In this review, we discuss novel pharmaceuticals for the treatment of RVO outside of current standard of care. We performed a comprehensive literature search encompassing pharmaceuticals that have recently been approved or have shown promising results in early clinical trials or animal models.

EXPERT OPINION

Anti-VEGF therapy remains the most efficacious treatment for RVO with a very favorable side effect profile. New biosimilars reduce costs while maintaining efficacy. Novel glucocorticoids may be a useful therapy in patients for whom anti-VEGF therapy has failed, or as an adjunct. Pharmaceuticals in other drug classes, particularly those with neuroprotective or regenerative properties, as well as those geared toward treating the occlusion itself, represent exciting options for early RVO therapy, but are likely years away from clinical relevance.

Association between retinal vein occlusion and early-stage hypertension: A propensity score analysis using a large claims database

BACKGROUNDS/OBJECTIVES

The threshold of hypertension was lowered from systolic blood pressure (SBP)/diastolic blood pressure (DBP) 140/90 mmHg to 130/80 mmHg by the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline. Thus, we investigated the association between retinal vein occlusion (RVO) occurrence and early-stage hypertension.

SUBJECTS/METHODS

This retrospective cohort study used the JMDC Claims Database (JMDC Inc., Tokyo, Japan) between 2005 and 2020. Individuals undergoing health checkups who had data on BP and did not take antihypertensive medications were included. They were classified into four BP groups: normal BP (SBP < 120 mmHg and DBP < 80 mmHg), elevated BP (SBP 120-129 mmHg and DBP < 80 mmHg), stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg), and stage 2 hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). Date of RVO occurrence was defined as the first date of diagnosis. We estimated adjusted hazard ratios for RVO and central RVO using weighted Cox regression to adjust for potential confounders.

RESULTS

A total of 2,703,264 individuals were eligible. During a mean follow-up of 1,091 days, 3,526 RVO and 828 central RVO events occurred. The adjusted hazard ratios (95% confidence intervals) were 1.37 (1.19-1.57), 1.95 (1.75-2.18), and 3.33 (2.95-3.76) for RVO and 1.44 (1.07-1.93), 2.17 (1.72-2.73), and 3.76 (2.91-4.86) for central RVO in the elevated BP, stage 1 hypertension, and stage 2 hypertension groups, respectively, compared with the normal BP group.

CONCLUSIONS

Even individuals with early-stage hypertension showed higher risks for RVO and central RVO than individuals with normal BP.

Improving blood flow in occluded veins to reduce anti-vascular endothelial growth factor injections for branch retinal vein occlusion

Purpose

To assess the relationship between improving blood flow via arteriovenous (AV) sheathotomy without vitrectomy and the total number of anti-vascular endothelial growth factor injections (VEGF) required to treat branch retinal vein occlusion (BRVO).

Methods

In this prospective, clinical case series, 16 eyes of 16 patients at the Toho University Sakura Medical Center with best-corrected visual acuity (BCVA) of 20/40 or worse due to macular edema associated with BRVO were analyzed for 12 months. AV sheathotomy was performed without vitrectomy for all cases. On the second day after surgery, anti-VEGF was injected into the operated eye. During the 12-month follow-up after surgery, pro re nata injections were administered when changes in foveal exudation and BCVA were evident. The blood flow of the occluded vein was assessed before and after AV sheathotomy during the operation using laser speckle flowgraphy. The total number of anti-VEGF injections, central retinal thickness (CRT), and BCVA 12 months after surgery were examined.

Results

The changes in CRT and BCVA from baseline to month 12 were statistically significant (P < 0.01). No additional anti-VEGF injections were required for nine of 16 eyes (56.3%) during the 12 months. The total number of anti-VEGF injections for 12 months correlated with the change rate of blood flow in an occluded vein before and after AV sheathotomy (r = -2.816, P = 0.022).

Conclusions and Importance

Improved blood flow in occluded vein may reduce the need for anti-VEGF injections in BRVO.

Binocular metamorphopsia in patients with branch retinal vein occlusion: a multi-center study

PURPOSE

The pathology of branch retinal vein occlusion (BRVO), a retinal circulatory disease, is related to monocular metamorphopsia-related vision impairment of the affected eyes, but the association of binocular metamorphopsia in such patients is unclear. This study aimed to examine the frequency of binocular metamorphopsia and its association with the clinical characteristics of patients with BRVO.

METHODS

A total of 87 patients who were treated for BRVO-associated macular edema (ME) were included in this study. At baseline and 1 and 3 months after the initiation of anti-vascular endothelial growth factor (VEGF) treatment, we quantified metamorphopsia in the affected eyes and binocular metamorphopsia using the M-CHARTS^® diagnostic tool.

RESULTS

At baseline, 53 and 7 patients had metamorphopsia in the affected eyes and binocular metamorphopsia, respectively. Although the visual acuity improved significantly after the initiation of anti-VEGF treatment, the mean M-CHARTS score in the affected eyes did not change from the baseline score. At 3 months, 9 patients showed binocular metamorphopsia; it was significantly associated with metamorphopsia in the affected eyes with a 95% confidence interval of 0.021-0.122 (β = 0.306, p = 0.006).

CONCLUSION

Metamorphopsia in the affected eyes can cause binocular metamorphopsia in patients with BRVO-ME.

Management of macular oedema due to retinal vein occlusion: An evidence-based systematic review and meta-analysis

BACKGROUND

Central retinal vein occlusion and branch retinal vein occlusion are common causes of visual loss due to associated macular oedema. The aim of this review was to assess the effectiveness of interventions improving vision and treating macular oedema in central retinal vein occlusion and branch retinal vein occlusion.

METHODS

Medical search engines and clinical trial registries were systematically searched. Randomised clinical trials with ≥90 eyes and real-world outcome studies with ≥100 eyes each with ≥6 months follow-up were included.

RESULTS

There were 11 randomised controlled trials evaluating treatments for central retinal vein occlusion which met the inclusion criteria and 10 for branch retinal vein occlusion. There were 10 real world outcome studies of central retinal vein occlusion and 5 real world outcome studies of branch retinal vein occlusion. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were change in visual acuity at 6-, 12-, 24- and 36 months by treatment.

CONCLUSIONS

Intravitreal anti-vascular endothelial derived growth factor is recommended as first line treatment over intravitreal corticosteroid due to its effectiveness and lower rate of ocular adverse events. Best outcomes are achieved when intravitreal treatment is started early. Macular laser may have an adjunctive role in branch retina vein occlusion but not central retinal vein occlusion.

Comparative Treatment Study on Macular Edema Secondary to Branch Retinal Vein Occlusion by Intravitreal Ranibizumab with and without Selective Retina Therapy

The purpose of this study was to compare the safety and efficacy of selective retina therapy (SRT) combined with the intravitreal injection of ranibizumab (IVR) in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). This trial was a 12-month single-center, randomized, single-masked prospective study. Eligible patients were randomized (1:1) to IVR and SRT (IVR + SRT group), or IVR and sham SRT (IVR + sham group). After the initial IVR, all participants received ME resolution criteria-driven pro re nata treatment. SRT or sham SRT was always applied one day after IVR. The primary outcome measure of this study was the mean change in central macular thickness (CMT) from baseline, and the secondary outcome measures were the mean change in visual acuity from baseline and the number of IVR treatments at a 52-week follow-up. Thirteen patients were in the IVR + SRT group, and 11 were in the IVR + sham group. Compared to the baseline, mean CMT and BCVA improved significantly after 52 weeks in both groups, with no significant difference between the two groups. The mean number of IVR was 2.85 ± 1.52 in the IVR + SRT group and 4.73 ± 2.33 in the IVR + sham group at the 52-week follow-up, with a significant difference between the two groups (p < 0.05). IVR combined with SRT may significantly decrease the number of IVR treatments while maintaining the visual and anatomical improvement effect of IVR monotherapy.

Update on Retinal Vein Occlusion

Retinal vein occlusion represents the second leading cause of retinal vascular disorders, with a uniform sex distribution worldwide. A thorough evaluation of cardiovascular risk factors is required to correct possible comorbidities. The diagnosis and management of retinal vein occlusion have changed tremendously in the last 30 years, but the assessment of retinal ischemia at baseline and during follow-up examinations remains crucial. New imaging techniques have shed light on the pathophysiology of the disease and laser treatment, once the only therapeutic option, is now only one of the possible approaches with antivascular endothelial growth factors and steroid injections being preferred in most cases. Nowadays long-term outcomes are better than those achievable 20 years ago and yet, many new therapeutic options are under development, including new intravitreal drugs and gene therapy. Despite this, some cases still develop sight-threatening complications deserving a more aggressive (sometimes surgical) approach. The purpose of this comprehensive review is to reappraise some old but still valid concepts and to integrate them with new research and clinical data. The work will provide an overview of the disease's pathophysiology, natural history, and clinical features along with a detailed discussion on the advantages of multimodal imaging and of the different treatment strategies with the aim of providing retina specialists with the most updated knowledge in the field.

Acetazolamide and bevacizumab combination therapy versus bevacizumab monotherapy in macular edema secondary to retinal vein occlusion

PURPOSE

To determine and compare the efficacy of intravitreal bevacizumab (IVB) and oral acetazolamide (OA) combination therapy versus IVB monotherapy in patients with macular edema secondary to retinal vein occlusion (RVO).

METHODS

This randomized clinical trial included 54 eyes of 52 patients with RVO central macular thickness (CMT) of more than 300μm, and best corrected visual acuity (BCVA) between 20/400 and 20/40. Eligible patients were randomly assigned to two groups: (I) IVB and OA (250mg twice daily) combination therapy or (II) IVB monotherapy. Ocular injections were repeated monthly for up to three months; BCVA and CMT were measured monthly.

RESULTS

Both regimens resulted in significant reduction in CMT (534±150μm to 352±90μm in the IVB+OA group, P<0.001; and 580±175μm to 362±90μm in the IVB group, P<0.001); neither showed superiority in this regard. Likewise, BCVA showed significant improvement in both groups (0.87±0.56 to 0.53±0.28 LogMAR in the IVB+OA group, P=0.001; and 0.85±0.62 to 0.46±0.4 LogMAR in the IVB group, P<0.001), with no intergroup difference.

CONCLUSION

Addition of oral acetazolamide to IVB in eyes with macular edema secondary to RVO may not result in additional short-term benefits regarding functional and anatomical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05290948, registered on March 22, 2022. https://clinicaltrials.gov/ct2/show/NCT05290948.

Reported Rates of Intraocular Inflammation with Intravitreal Aflibercept Administered via Pre-Filled Syringe or from Vials in Clinical Practice Between 2012 and 2022

Purpose

To determine the reported rates of intraocular inflammation (IOI) in patients treated with intravitreal aflibercept (IVT-AFL) 2 mg in routine clinical practice (ie, outside interventional studies), across all indications and within all countries (excluding the United States), with access to either the vial presentation or pre-filled syringe (PFS).

Patients and methods

A search was conducted using the Bayer EYLEA^® Global Safety Pharmacovigilance Database for reported cases of IOI and IVT-AFL use between October 2012 and March 31, 2022.

Results

With more than 10 years of post-marketing experience with the IVT-AFL vial presentation (>25 million sold units), and over 2 years of experience with the PFS of IVT-AFL (>6.7 million sold units) the rate of any IOI, including endophthalmitis, outside the United States was 0.3 events per 10,000 units for the PFS and 1.2 events per 10,000 units for the vial presentation. The event rates specifically for endophthalmitis were 0.1 per 10,000 units for the IVT-AFL PFS and 0.6 per 10,000 units for the IVT-AFL vial presentation.

Conclusion

In patients with retinal diseases treated in routine clinical practice with IVT-AFL either from a vial or the PFS, medically important adverse events of IOI, and in particular, endophthalmitis, are infrequently reported events. Numerically, reported rates of IOI and endophthalmitis are low for the vial presentation and even lower for the PFS.

Vision-related quality of life and subscale items following intravitreal ranibizumab injections for central retinal vein occlusion

PURPOSE

To evaluate the vision-related quality of life (VR-QOL) before and after intravitreal ranibizumab injections (IVR) for central retinal vein occlusion (CRVO) and to investigate subscale items of VR-QOL in detail.

STUDY DESIGN

A multicenter, open-label, prospective and comparative study.

METHODS

Twenty-three patients with treatment naïve CRVO and 22 age-matched normal controls were included. VR-QOL was assessed by 25-Item Visual Function Questionnaire (VFQ-25) before and up to 12 months post-treatment. The VFQ-25 composite score and 12 subscales were compared between CRVO patients and normal controls.

RESULTS

The VFQ-25 composite scores of CRVO patients showed significant improvement throughout the treatment period compared with baseline. The VFQ-25 composite scores both before and after treatment for CRVO were significantly lower than in normal controls. The subscale items, including general health, general vision, near activities, social functioning, mental health, role difficulties, dependency, and peripheral vision in CRVO, were significantly lower than in the normal controls even after treatment.

CONCLUSION

Vision-related QOL was low in patients with CRVO before treatment and improved with IVR. In spite of the improvements, several subscale items remained lower than in normal controls following treatment. Attention should be paid to the patients with CRVO and their decreased visual, social and psychological QOL.

Recent trends in anti-vascular endothelial growth factor intravitreal injections: a large claims database study in Japan

PURPOSE

To clarify recent trends in the use of intravitreal injections of anti-vascular endothelial growth factor (VEGF) in Japan.

STUDY DESIGN

Retrospective cohort study.

METHODS

We used the DeSC database, a large-scale claims database for Japan, for entries between April 2014 and March 2021. We counted the number of anti-VEGF drug injections (aflibercept, ranibizumab, brolucizumab, and pegaptanib) administered every year, calculated the sex- and age-adjusted injection rates, and stratified these rates according to sex, age categories, anti-VEGF drugs, and diagnoses. We also calculated the number of injections administered within one year after the first injection according to the diagnoses.

RESULTS

In total, 164,451 cases of anti-VEGF injections were identified. The sex- and age-adjusted rates of anti-VEGF injections per 1000 person-years increased from 7.9 in 2014 to 16.1 in 2020. Men were approximately twice as likely to receive anti-VEGF injections than women. The 70-79, 80-89, and ≥90 age categories had the highest rates, accounting for approximately 80%. Neovascular age-related macular degeneration had the highest rate, accounting for 60-70% over the study period. Aflibercept was the most commonly used drug, accounting for approximately 80% over the study period. The average number of injections within one year after the first injection was 4.4 for neovascular age-related macular degeneration, 2.7 for branch retinal vein occlusion, 3.1 for central retinal vein occlusion, and 3.5 for diabetic macular edema in 2020.

CONCLUSION

These findings can be used as a benchmark for the clinical practice of anti-VEGF therapy.

Visual Acuity in Patients Requiring Intravitreal Injections: Short-Term and Long-Term Effects of Delay in Care

Purpose: To assess the short-term and long-term effects of a delay in care on visual acuity (VA) in patients requiring intravitreal injections. Methods: This retrospective cohort study comprised patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO) receiving intravitreal injections. The visual and anatomic outcomes at the next completed visit and at the 1-year follow-up were studied. Results: Of 1172 patients, 38% had a delay in care (mean 5.7 weeks). Compared with baseline, these patients lost VA (Early Treatment Diabetic Retinopathy Study letters) (mean −2.13 ± 0.49 SE) in the short-term ( P = .0003) and had a thicker central subfield. Patients with no delay in care had a net VA gain (0.97 ± 0.39) ( P = .0067). There was no difference in VA between 1 year and the baseline in either group. Long term, patients with nAMD in both groups had VA loss (no delay in care: −1.76 ± 0.60; delayed care: −2.44 ± 0.78) ( P = .0005 and P = .0114, respectively). Patients with DME and no delay in care maintained gains in vision (4.68 ± 1.86) but those with delayed care did not (1.72 ± 2.24) ( P = .0202 and P = .3756, respectively). In both groups, patients with RVO had no significant difference in vision from baseline. Conclusions: In patients requiring intravitreal injections, a delay in care of 5.7 weeks affected vision outcomes in the short term but not the long term.

Long-term real-world outcomes in retinal vein occlusions: How close are we to the trials?

Purpose

To assess and analyze the visual outcomes of patients with retinal vein occlusions in a real-world setting with a long-term follow-up of more than 5 years.

Methods

Retrospective analysis of 56 patients having retinal vein occlusions from a tertiary eye center, with a mean follow-up of 7 years was performed. Primary outcome measures were mean change in best-corrected visual acuity (BCVA) from baseline at 6 months, 1 year, 2 years, 3 years, and final visit (≥5 years), proportion of patients having BCVA better than 20/40 and worse than 20/200, and mean number of injections. Secondary outcome measures were change in central macular thickness (CMT), development of subsequent retinal vein occlusion (RVO) in same eye or the other eye, and development of neovascular complications.

Results

The mean change in letter score was + 11.84 in branch RVO (BRVO), +7.14 in non-ischemic central RVO (CRVO), and -9.5 in ischemic CRVO at 1 year, which changed to + 8.57, -5 and - 24, respectively, at the end of follow-up. CMT had improved from 506 ± 98.8 μm, 576.44 ± 149 μm, and 618 ± 178.27 μm, respectively, at baseline to 267 ± 94 μm, 345.20 ± 122.61 μm, and 265.50 ± 107.75 μm, respectively, in BRVO, non-ischemic, and ischemic hemi RVO (HRVO)/CRVO groups. The total mean number of injections given in BRVO, non-ischemic CRVO, and ischemic CRVO groups were 4.6, 6.6, and 4.1, respectively. None of the patients with BRVO developed neovascular glaucoma (NVG). Non-ischemic to ischemic HRVO/CRVO conversion was noted in 4/11 eyes at a mean duration of 12.6 months. NVG was noted in 7/9 eyes (77.8%) in initial ischemic CRVO/HRVO group and 3/4 (75%) converted eyes.

Conclusion

Patients with BRVO have good visual outcomes with anti-VEGF, while in CRVO results may vary considerably owing to patient compliance and treatment burden on long-term follow-up in a real-world setting.

Anti-Vascular Endothelial Growth Factor Treatment Patterns and Outcomes in Retinal Vein Occlusion in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To characterize treatment patterns for retinal vein occlusion (RVO)-related macular edema (ME) in routine clinical practice and its impact on long-term best-corrected visual acuity (BCVA) and central subfield thickness (CST).

PATIENTS AND METHODS

Retrospective study of 365 eyes with branch RVO (BRVO) or central/hemi-RVO (CRVO/HRVO)-related ME between 2003 and 2020. Regression analysis identified factors associated with maintenance injection interval (MII). Subgroup analysis compared outcomes between different MIIs.

RESULTS

51.3% of BRVO patients received injections ≤q8 weeks, 26.4% received injections q8-12 weeks, and 22.3% received injections >q12 weeks. 45.2% of CRVO/HRVO patients received injections ≤q8 weeks, 32.1% received injections q8-12 weeks, and 22.6% received injections >q12 weeks. Age, diabetes, and baseline CST were found to predict MII. There was no significant difference in BCVA and CST at baseline, 12, or 24 months in all MII groups in BRVO and CRVO/HRVO.

CONCLUSION

There exists a significant heterogeneity in anti-VEGF treatment frequency for RVO-associated ME in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina 2022;53:626-633.].

Navigated laser and aflibercept versus aflibercept monotherapy in treatment-naïve branch retinal vein occlusion: A 12-month randomized trial

PURPOSE

Angiostatic agents have proven effective in the treatment of macular oedema in patients with branch retinal vein occlusion (BRVO). However, treatment is inconvenient and expensive, and novel treatment regimens are warranted. We aimed to evaluate if combination treatment of navigated central retinal laser and aflibercept lowered the treatment burden in these patients.

METHODS

Treatment-naïve patients with BRVO and macular oedema were included at two centres and randomized 1:1 to three monthly injections of 2.0 mg aflibercept with (Group A) or without (Group B) navigated central laser, followed by aflibercept as needed from month 4 through 12. Re-treatment need was evaluated, and secondary endpoints included functional and anatomical outcomes and safety evaluated by retinal microperimetry.

RESULTS

We evaluated 41 eyes of 41 patients with a mean age of 69.6 years. Baseline median best-corrected visual acuity (BCVA) was 70.0 letters, and median central retinal thickness (CRT) was 502 μm with no difference between Groups A (n = 21) and B (n = 20). Percentage of patients needing re-treatment after month three was 71% and 80% (p = 0.72). At month 12, groups did not differ in number of injections after loading (1 versus 2, p = 0.43), change in BCVA (+12.8 versus +15.1 letters, p = 0.48), CRT (-195 versus -181 μm, p = 0.82), or retinal sensitivity (+3.3 versus +4.1 dB, p = 0.67).

CONCLUSION

In treatment-naïve BRVO patients, addition of navigated central laser to aflibercept did not lower treatment burden or affect functional or anatomical outcomes. A low number of intravitreal injections were needed for successful outcome in both treatment arms.

Risk Factors and Treatment Strategy for Retinal Vascular Occlusive Diseases

Retinal occlusive diseases are common diseases that can lead to visual impairment. Retinal artery occlusion and retinal vein occlusion are included in the clinical entity, but they have quite different pathophysiologies. Retinal artery occlusion is an emergent eye disorder. Retinal artery occlusion is mainly caused by thromboembolism, which frequently occurs in conjunction with life-threatening stroke and cardiovascular diseases. Therefore, prompt examinations and interventions for systemic vascular diseases are often necessary for these patients. Retinal vein occlusion is characterized by retinal hemorrhage and ischemia, which may impair visual function via several complications such as macular edema, macular ischemia, vitreous hemorrhage, and neovascular glaucoma. Even though anti-vascular endothelial growth factor therapy is the current established first-line of treatment for retinal vein occlusion, several clinical studies have been performed to identify better treatment protocols and new therapeutic options. In this review, we summarize the current findings and advances in knowledge regarding retinal occlusive diseases, particularly focusing on recent studies, in order to provide an update for a better understanding of its pathogenesis.

Intravitreal Dexamethasone Implant Has Better Retinal Perfusion than Anti-Vascular Endothelial Growth Factor Treatment for Macular Edema Secondary to Retinal Vein Occlusion: A Five-Year Real-World Study

PURPOSE

The purpose of the study was to investigate the long-term effect of intravitreal dexamethasone (DEX) implant and anti-vascular endothelial growth factor (VEGF) injection on macular edema (ME) secondary to retinal vein occlusion (RVO) in a real-world setting.

METHODS

The medical records of RVO-ME cases, with intravitreal injections and followed up for at least 5 years, were retrospectively reviewed. Changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) were primary outcomes. Images of fluorescence angiography and swept-source optical coherence tomography angiography were analyzed. Foveal avascular zone (FAZ) metrics and perfusion density at the last visit were also compared between the two treatments.

RESULTS

A total of 16 patients were recruited, 8 in the anti-VEGF group and 8 in the DEX group. At the 5th year, the BCVA and the CMT in the DEX group were not different from those in the anti-VEGF group (0.69 ± 0.36 LogMAR vs. 0.57 ± 0.30 LogMAR, p = 0.574; 183.25 ± 97.31 µm vs. 195.38 ± 40.92 µm, p = 0.442). Compared with the anti-VEGF group, the DEX group had higher FAZ circularity index (0.57 ± 0.14 vs. 0.68 ± 0.14, p = 0.130) and higher retinal perfusion density (0.45 ± 0.02 vs. 0.39 ± 0.03, p = 0.001), especially in the deep capillary plexus.

CONCLUSION

DEX implant and anti-VEGF injection had comparative long-term effects on RVO-ME. Compared with the anti-VEGF treatment, the DEX treatment had advantages in maintaining retinal perfusion in patients with RVO.

Efficacy of single-dose intravitreal dexamethasone implantation for retinal vein occlusion patients with refractory macular edema: A systematic review and meta-analysis

Purpose: To assess the functional and anatomical consequences of single-dose dexamethasone (DEX) implants for the treatment of refractory macular edema (ME) secondary to retinal vein occlusion (RVO) after anti-vascular endothelial growth factor agents.

Methods: A literature search of studies on switching therapy to DEX implants from anti-VEGF agents in refractory RVO patients was performed with five electronic databases (PubMed, Embase, Web of Science, MEDLINE, and Cochrane Library) prior to January 2022. The main outcomes included best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes at different follow-up endpoints from baseline. All analyses were performed using Stata version 15.0.

Results: The final analysis included four eligible studies with a total of 99 patients. After single-dose DEX implant application, BCVA improved significantly at 2, 3, and 6 months with an average gain of −0.23 logarithm of the minimum angle of resolution (logMAR) (p = 0.004), −0.20 logMAR (p = 0.027), and -0.09 logMAR (p = 0.021), respectively. Mean CMT reduction was also significant from baseline to 2 months (-241.89 μm, p &lt; 0.001), 3 months (−222.61 μm, p &lt; 0.001), and 6 months (−90.49 μm, p &lt; 0.001). No serious adverse events were observed in any of the included studies.

Conclusion: This meta-analysis showed that RVO patients with refractory ME could benefit significantly from switching therapy to DEX implantation, with efficacy lasting 6 months after a single-dose application. Intravitreal DEX implantation is a safe and effective option for refractory cases.

Similarities and differences in systemic risk factors for retinal artery occlusion and retinal vein occlusion: A nationwide case-control study

BACKGROUND

To investigate the relationship between risk factors for retinal artery occlusion (RAO) and retinal vein occlusion (RVO) and thereby identify similarities and differences between the two types of retinal vascular occlusions.

METHODS

In this case-control study, 5708 patients with RAO were included and matched with three patients with RVO each. The patients with RVO were matched on sex and age at index date. All patients, personal information, diagnoses, and prescriptions were obtained from the Danish nationwide registries. Adjusted conditional logistic regression was used to investigate the association of RAO and RVO with the included risk factors.

RESULTS

RAO was stronger associated with arterial hypertension, heart failure, ischemic heart disease, peripheral artery disease, and stroke than RVO, with effect measures ranging from 1.10 to 2.21. RVO was associated with cataract and glaucoma with effect measures of 0.80 (95% CI 0.73-0.87) and 0.65 (95% CI 0.56-0.76), respectively.

CONCLUSION

Differences in the level of associations with the included risk factors suggests differences in the pathophysiologies of the two diseases. The main pathophysiology associated with RAO was atherosclerosis, whereas the main pathophysiology associated with RVO was changes in the pressure gradients of the eyes.

Suprachoroidal delivery enables targeting, localization and durability of small molecule suspensions

Drug delivery to the suprachoroidal space (SCS®) has become a clinical reality after the 2021 FDA approval of CLS-TA, a triamcinolone acetonide injectable suspension for suprachoroidal use (XIPERE®), administered via a microneedle-based device, the SCS Microinjector®. Suprachoroidal (SC) delivery facilitates targeting, compartmentalization, and durability of small molecule suspensions, thereby potentially addressing some of the efficacy, safety, and treatment burden limitations of current retinal therapies. Herein, the design features of the SCS Microinjector are reviewed, along with the biomechanics of SC drug delivery. Also presented are preclinical evaluations of SC small molecule suspensions from 4 different therapeutic classes (plasma kallikrein inhibitor, receptor tyrosine kinase inhibitor, corticosteroid, complement factor D inhibitor), highlighting their potential for durability, targeted compartmentalization, and acceptable safety profiles following microinjector-based SC delivery. The clinical evaluations of the safety, tolerability and efficacy of SC delivered triamcinolone further supports potential of SC small molecule suspensions as a clinically viable strategy for the treatment of chorioretinal diseases. Also highlighted are current limitations, key pharmacological considerations, and future opportunities to optimize the SC microinjector platform for safe, effective, and potentially long-acting drug delivery for the treatment of chorioretinal disorders.

Longer-Term Anti-VEGF Therapy Outcomes in Neovascular Age-Related Macular Degeneration, Diabetic Macular Edema, and Vein Occlusion-Related Macular Edema: Clinical Outcomes in 130 247 Eyes

PURPOSE

The clinical practice visual acuity (VA) outcomes of anti-VEGF therapy for up to 5 years were assessed in patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), branch retinal vein occlusion-related macular edema (BRVO-ME), and central retinal vein occlusion-related macular edema (CRVO-ME).

DESIGN

A retrospective analysis was performed using the Vestrum Health Retina Database.

PARTICIPANTS

Treatment-naive patients with nAMD, DME, BRVO-ME, or CRVO-ME who received anti-VEGF injections between 2014 and 2019 and had follow-up data for ≥12 months.

METHODS

Data on age, sex, the number of anti-VEGF treatments, and VA were analyzed.

MAIN OUTCOME MEASURES

Mean VA change up to 3 years (BRVO-ME and CRVO-ME) and 5 years (nAMD and DME).

RESULTS

At 1, 3, and 5 years, in 67 666, 21 305, and 5208 eyes with nAMD, after a mean of 7.6, 19.5, and 32 injections, there was a mean change of +3.1, -0.2, and -2.2 letters, respectively. At 1, 3, and 5 years, in 40 832, 7728, and 1192 eyes with DME, after a mean of 6.2, 15.4, and 26.0 injections, there was a mean change of +4.7, +3.3, and +3.1 letters, respectively. At 1 and 3 years, in 12 451 and 3027 eyes with BRVO-ME, after a mean of 7.1 and 18.2 injections, there was a mean change of +9.5 and +7.7 letters, respectively. At 1 and 3 years, in 9298 and 2264 eyes with CRVO-ME, after a mean of 7.3 and 18.8 injections, there was a mean change of +8.3 and +6.0 letters, respectively (P < 0.01 for all VA changes of > 1 letter). In all 4 conditions, the mean VA increased with the mean number of anti-VEGF injections, eyes with a baseline VA of 20/40 or better tended to lose VA, and eyes with progressively worse baseline VA experienced a progressively greater VA gain at 3 years.

CONCLUSIONS

In practice, patients with nAMD, DME, BRVO-ME, and CRVO-ME showed limited visual outcomes, with patients with nAMD tending to lose VA at 3 and 5 years. Across all 4 disorders, the mean change in VA correlated with treatment intensity at 1, 3, and 5 years. Patients with better baseline VA are more vulnerable to vision loss.

Time course of changes in vision-related quality of life following intravitreal ranibizumab treatment for branch retinal vein occlusion

To evaluate the vision-related quality of life (VR-QOL) treated by intravitreal ranibizumab (IVR) in patients with branch retinal vein occlusion (BRVO) and to assess subscale items of the VR-QOL. This was prospective, multicenter, open-label, observational study including 38 patients with unilateral BRVO who underwent IVR treatment and 28 age-matched healthy subjects. VR-QOL using the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) and best-corrected visual acuity (BCVA) were examined before and at 3, 6, and 12 months after treatment. The VFQ-25 composite score and BCVA significantly improved from 3 to 12 months after IVR treatment (P < 0.05), such that there was no significant difference between the BRVO and control groups at 12 months. All subscales of the VFQ-25, except “general health”, significantly improved after treatment, while “near vision” and “mental health” were worse than those in healthy subjects (P < 0.05). Patients with superior BRVO had a lower “near vision” score than healthy subjects after treatment (P < 0.05). BCVA in the treated eye and fellow eye had no significant relationship with the VFQ-25 composite score before and after treatment. The VR-QOL of patients with BRVO improved with IVR treatment and was comparable to that of healthy subjects after 12 months. Superior BRVO particularly affected near vision for a low level.

Association between Retinal Vein Occlusion and Life's Simple 7 Cardiovascular Health Metrics: A Large Claims Database Study

PURPOSE

Cardiovascular diseases and retinal vein occlusion (RVO) have many risk factors in common. We aimed to investigate the associations between RVO occurrence and each of the cardiovascular health (CVH) metrics known as Life's Simple 7, which are indicators of an unhealthy lifestyle.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Individuals in the JMDC Claims Database (JMDC Inc) who underwent health checkups between 2005 and 2020.

METHODS

We set the following exposures: (1) each component of the CVH metrics (body mass index, blood pressure [BP], fasting blood glucose, total cholesterol, smoking, dietary habits, and physical activity) and (2) the number of nonideal CVH metrics (nonideal CVH score, ranging from 0 [healthiest] to 7 [unhealthiest]). The study outcomes were RVO and central RVO (CRVO) occurrence, which were identified on the first date of diagnosis. We performed Cox regression analyses, with covariates including age, sex, and glaucoma.

MAIN OUTCOME MEASURES

The hazard ratios for RVO and CRVO occurrence for (1) each component of the CVH metrics and (2) the nonideal CVH score.

RESULTS

We included 2 093 536 individuals. During a mean follow-up period of 1070 ± 884 days, there were 3265 RVO and 789 CRVO events. An increased risk of RVO occurrence was most strongly associated with a nonideal BP (hazard ratio [HR], 2.25; 95% confidence interval [CI], 2.06-2.46), followed by a nonideal body mass index (HR, 1.31; 95% CI, 1.21-1.41). Individuals with nonimprovement in BP within 1 year showed a higher risk of RVO occurrence than those with improvement (HR, 2.07; 95% CI, 1.70-2.52). The adjusted HRs of the groups with nonideal CVH scores of 6 to 7, 5, 4, 3, 2, and 1 were 3.76 (2.66-5.30), 2.87 (2.06-4.00), 2.57 (1.85-3.57), 2.22 (1.60-3.08), 1.79 (1.29-2.48), and 1.39 (0.99-1.95), respectively, compared with the group with a score of 0. Similar results were observed for CRVO.

CONCLUSIONS

The strongest risk factor for RVO was nonideal BP, followed by nonideal body mass index. There was a dose-dependent positive association between a nonideal CVH score and RVO occurrence. These findings are important with respect to the identification of individuals at higher risk of RVO.

Month 60 Outcomes After Treatment Initiation With Anti-Vascular Endothelial Growth Factor Therapy for Macular Edema Due to Central Retinal or Hemiretinal Vein Occlusion

PURPOSE

To investigate 5-year outcomes in eyes initially treated with aflibercept or bevacizumab for macular edema due to central retinal or hemiretinal vein occlusion.

METHODS

Long-term follow-up (LTF) after a randomized clinical trial from 64 centers in the United States. Participants were followed up to 60 months and treated at investigator discretion after completing the 12-month treatment protocol. Main outcomes were visual acuity letter score (VALS) and central subfield thickness (CST) on optical coherence tomography.

RESULTS

Seventy-five percent (248/330) of eligible participants completed at least 1 visit between months 24 and 60, and 45% completed the month 60 visit. Among participants completing month 60, overall mean VALS improvement over baseline was 13.5 (95% CI: 9.6, 17.5), less than the mean improvement of 20.6 (95% CI: 18.7, 22.4) observed at month 12, with no significant differences between originally assigned study groups. Further, 66% (99/150) had at least 1 treatment between months 48 and 60 with a mean (SD) of 3.41 (3.69) treatments over this period. Mean CST was 671 μm at baseline and 261 μm (95% CI: 241.2, 280.9) at month 60.

CONCLUSIONS

Although VALS improved substantially when patients were treated per protocol through month 12, improvement lessened when treatment was at investigator discretion and fewer treatments were received although VALS remained markedly improved over baseline through year 5. Most patients continued to receive treatment in year 5. This suggests that continued monitoring and, if warranted, treatment with anti-VEGF therapy benefits patients with macular edema associated with central retinal or hemiretinal vein occlusion. Publication of this article is sponsored by the American Ophthalmological Society.

Comparison of the efficiency of anti-VEGF drugs intravitreal injections treatment with or without retinal laser photocoagulation for macular edema secondary to retinal vein occlusion: A systematic review and meta-analysis

Objective: To compare the efficiency of anti-VEGF drugs intravitreal injections(IVI) treatment with or without retinal laser photocoagulation(LPC) for macular edema(ME) secondary to retinal vein occlusion(RVO).

Methods: The randomized controlled trials and retrospective studies including anti-VEGF drug IVI combined with retinal LPC and single IVI in the treatment of macular edema secondary to RVO were collected in PubMed, Medline, Embase, Cochrane Library, and Web of Science. We extracted the main outcome indicators including the best corrected visual acuity (BCVA), central macular thickness(CMT), the number of injections and the progress of retinal non-perfusion areas(NPAs) for systematic evaluation, to observe whether IVI + LPC could be more effective on the prognosis of RVO. We use Review Manager 5.4 statistical software to analyze the data

Results: 527 articles were initially retrieved. We included 20 studies, with a total of 1387 patients who were divided into the combination(IVI + LPC) treatment group and the single IVI group. All the patients completed the ocular examination including BCVA, slit-lamp test, fundus examination and Optical Coherence Tomography(OCT) test before and after each treatment. There was no statistical difference between the combination treatment group and single IVI group on BCVA(WMD = 0.12,95%CI = -3.54–3.78,p = 0.95),CMT(WMD = -4.40,95%CI = -21.33–12.53,p = 0.61) and NPAs(WMD = 0.01,95%CI = -0.28–0.30,p = 0.94).However, the number of IVI was decreased significantly in the combination treatment group in BRVO patients, compared to that in the single IVI group(WMD = -0.69,95%CI = -1.18∼-0.21,p = 0.005).

Conclusion: In the treatment of RVO patients with macular edema, the combination of IVI and retinal LPC neither improves BCVA nor reduces CMT significantly compared with the single IVI treatment. However, the combination treatment can decrease the number of intravitreal injections in patients with BRVO, while it is not observed in CRVO patients.

Wide-field swept-source OCT angiography of the periarterial capillary-free zone before and after anti-VEGF therapy for branch retinal vein occlusion

BACKGROUND

The aim of the study was to investigate the changes in the periarterial capillary-free zone (paCFZ) after anti-vascular endothelial growth factor (VEGF) therapy in patients with branch retinal vein occlusion (BRVO) by wide-field swept-source optical coherence tomography angiography (SS-OCTA) and assess their associations with clinical outcomes.

METHODS

In this retrospective observational study of 54 treatment-naïve BRVO patients with macular edema, we reviewed the findings of 12 × 12 mm² SS-OCTA at baseline, 3, 6, and 12 months after intravitreal ranibizumab injections. The paCFZ and major retinal artery areas were measured on SS-OCTA images. The paCFZ area to artery area (P/A) ratio was calculated.

RESULTS

The paCFZ areas and P/A ratios of first- and second-order arteries were significantly greater in BRVO eyes than in contralateral eyes (all P < 0.01), but there were no differences in the first- and second-order artery areas (P = 0.20 and 0.25, respectively). The paCFZ areas and P/A ratios decreased significantly at 3, 6, and 12 months after anti-VEGF therapy (all P < 0.01). The baseline P/A ratio was significantly correlated with the baseline best-corrected visual acuity (BCVA), central retinal thickness, and their improvements at 3, 6, and 12 months (all P < 0.05). Baseline BCVA and P/A ratios of first- and second-order arteries were independently associated with the final BCVA in multivariate linear regression.

CONCLUSIONS

Wide-field SS-OCTA shows that anti-VEGF therapy can lead to a significant improvement in the paCFZ parameters in BRVO. Smaller baseline P/A ratios on SS-OCTA tend to predict better visual outcomes at 12 months after anti-VEGF therapy.

Correlation between change in central subfield thickness and change in visual acuity in macular edema due to retinal vein occlusion: post hoc analysis of COPERNICUS, GALILEO, and VIBRANT

Purpose

Assess correlation between change in central subfield thickness (CST) and change in best-corrected visual acuity (BCVA) in eyes with macular edema due to retinal vein occlusion (RVO) that received intravitreal aflibercept injections (IAI).

Methods

Post hoc analysis of COPERNICUS and GALILEO trials for CRVO and VIBRANT trial for BRVO with relationships determined using Pearson correlation coefficient.

Results

In COPERNICUS, correlations (r) between change in CST and change in BCVA from baseline at weeks 12, 24, 52, and 100 were −0.36 (95% CI: −0.52, −0.18; P < 0.001), −0.38 (95% CI: −0.53, −0.20; P < 0.001), −0.44 (95% CI: −0.58, −0.27; P < 0.001), and −0.41 (95% CI: −0.56, −0.23; P < 0.001), respectively. CST changes accounted for only 21% of the variance in BCVA changes; every 100-µm decrease in CST was associated with a 2.1-letter increase in BCVA (P = 0.003). Similar findings were noted for GALILEO (r, −0.45 to −0.23) and VIBRANT (r, −0.36 to −0.32) trials.

Conclusion

In eyes treated with IAI for macular edema due to RVO, correlation between change in CST and change in BCVA was weak to moderate. While change in CST may be helpful in determining the need for anti-VEGF therapy, these findings do not support using changes in CST as a surrogate for changes in visual acuity outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-022-05697-4.

Real-world treatment intensities and pathways of macular edema following retinal vein occlusion in Korea from Common Data Model in ophthalmology

Despite many studies, optimal treatment sequences or intervals are still questionable in retinal vein occlusion (RVO) macular edema. The aim of this study was to examine the real-world treatment patterns of RVO macular edema. A retrospective analysis of the Observational Medical Outcomes Partnership Common Data Model, a distributed research network, of four large tertiary referral centers (n = 9,202,032) identified 3286 eligible. We visualized treatment pathways (prescription volume and treatment sequence) with sunburst and Sankey diagrams. We calculated the average number of intravitreal injections per patient in the first and second years to evaluate the treatment intensities. Bevacizumab was the most popular first-line drug (80.9%), followed by triamcinolone (15.1%) and dexamethasone (2.28%). Triamcinolone was the most popular drug (8.88%), followed by dexamethasone (6.08%) in patients who began treatment with anti-vascular endothelial growth factor (VEGF) agents. The average number of all intravitreal injections per person decreased in the second year compared with the first year. The average number of injections per person in the first year increased throughout the study. Bevacizumab was the most popular first-line drug and steroids were considered the most common as second-line drugs in patients first treated with anti-VEGF agents. Intensive treatment patterns may cause an increase in intravitreal injections.

An update on long-acting therapies in chronic sight-threatening eye diseases of the posterior segment: AMD, DMO, RVO, uveitis and glaucoma

In the real-world setting, there is suboptimal compliance with treatments that require frequent administration and assessment visits. This undertreatment frequently has negative consequences in eye disease and carries a real risk to vision. For example, patients with glaucoma risk progression of visual loss even with a small number of missed doses, and patients with neovascular age-related degeneration (nAMD) who fail to attend a bi-monthly clinic appointment to receive an intravitreal anti-vascular endothelial growth factor (VEGF) drug injections may lose the initial vision gains in vision. Protracted regular treatment schedules represent a high burden not only for patients and families, but also healthcare professionals, systems, and ultimately society too. There has been a clear need for longer-acting therapies that reduce the frequency, and therefore the burden, of treatment interventions. Several longer-acting interventions for nAMD, diabetic macular oedema, retinal vein occlusion, uveitis and glaucoma have either been developed or are in late-phase development, some of which employ novel mechanisms of actions, and all of which of promise longer (≥3 month) treatment intervals. This review delivers an overview of anti-VEGF agents with longer durations of action, DARPins, bispecific anti-VEGF/Ang2 therapies, anti-PDGF and anti-integrin therapy, Rho-kinase inhibitors, the Port Delivery System, steroids, gene therapy for retina and uveitis, and for glaucoma, ROCK inhibitors, implants and plugs, and SLT laser and MIGS. The review also refers to the potential of artificial intelligence to tailor treatment efficacy with a resulting reduction in treatment burden.

Association between proteinuria and retinal vein occlusion in individuals with preserved renal function: a retrospective cohort study

PURPOSE

To investigate the association between proteinuria and the incidence of retinal vein occlusion (RVO) in individuals with preserved renal function.

METHODS

We conducted a retrospective cohort study from 2005 to 2020 using the JMDC Claims Database, a large database of health check-ups and administrative claims in Japan. Individuals who underwent annual health check-ups were included. Participants were classified into three groups based on the protein concentration in their urine: negative (≤10 mg/dl), trace (10-30 mg/dl) and positive (≥30 mg/dl). We estimated hazard ratios (HRs) for the development of RVO using Cox regression analyses with adjustment for baseline characteristics by the matching weights calculated from the multiple propensity scores. The cumulative incidence of RVO between the weighted groups was calculated using the Kaplan-Meier estimator.

RESULTS

There were 1 635 212 eligible participants, among whom 2360 developed RVO. The mean follow-up period was 1036 ± 951 days. The adjusted HRs for RVO were 1.10 (95% confidence interval 0.92-1.33) and 1.46 (1.19-1.78) in the groups with trace and positive proteinuria compared with negative proteinuria respectively. The cumulative incidence rates of RVO at 7 years were 0.40%, 0.43% and 0.55% in the groups with negative, trace and positive proteinuria, respectively.

CONCLUSION

Positive proteinuria was independently associated with an increased incidence of RVO in individuals with preserved renal function. Proteinuria may be a novel risk factor for RVO development.