Efficacy and Safety of Ranibizumab in Asian Patients with Branch Retinal Vein Occlusion: Results from the Randomized BLOSSOM Study

Comparing ranibizumab, dexamethasone implant, and combined therapy for macular edema secondary to branch retinal vein occlusion: a clinical trial

BACKGROUND

Macular edema (ME) is a common complication following branch retinal vein occlusion (BRVO) and is also the main reason for visual impairment. This study aimed to compare the efficacy and safety of intravitreal ranibizumab (IVR) or dexamethasone implant (IDI) monotherapy, as well as the combination of IVR and IDI injections, in patients with ME secondary to branch retinal vein occlusion (BRVO).

METHODS

This multicenter, prospective, and comparative study included 292 patients with unilateral ME involvement (total of 292 eyes) secondary to BRVO. The patients were randomly assigned to three groups and followed up for 12 months. Patients in group 1 (n = 96) were treated with 3-dose loading IVR injections followed by a pro re nata (PRN) regimen. Patients in group 2 (n = 98) received IVR combined with IDI injection, followed by IVR PRN regimen. Patients in group 3 (n = 98) were treated with IDI injection, followed by repeated IDI injection based on clinical necessity. Best corrected visual acuity (BCVA), central retinal thickness (CRT), complications, and frequency of injections were recorded and compared between the three groups.

RESULTS

At baseline, the three groups did not differ in age, gender, duration of ME, BCVA, IOP, and CRT (P > 0.05). Mean number of total injections per eye within 12 months were 7.1 ± 2.3 (range 4-9) in group 1, 3.7 ± 1.5 (range 2-6) in group 2, and 1.8 ± 0.4 (range 1-3) in group 3. There was a statistical difference in the number of injections between group 1 and group 2 (P = 0.037). Eyes in group 3 received fewer injections than those in group 2, but the difference was not statistically significant (P = 0.052). BCVA improvement and CRT reduction were achieved in all groups and there was no significant difference between the three groups at the end of the 12th month. However, IOP elevation and cataract progression were more frequent in group 3, especially in those patients who received repeated IDI injections.

CONCLUSION

Three therapeutic regimens had comparable efficacy in treating ME secondary to BRVO. Combination therapy had an advantage in maintaining good effect with fewer re-injections and complications.

TRIAL REGISTRATION INFORMATION

The study complied with the principles of the Declaration of Helsinki and was approved by Xi'an Aier Ancient City Eye Hospital, Xi'an Aier Eye Hospital, and Xianyang Aier Eye Hospital ethics committees (2022SF-367).

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.

Antivascular endothelial growth factor for macular oedema secondary to retinal vein occlusion: a systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of antivascular endothelial growth factor (anti-VEGF) agents in treating macular oedema due to retinal vein occlusion (RVO-ME).

Methods

Studies of randomised controlled trials were searched in PubMed, EMBASE, Cochrane databases and ClinicalTrials.gov registry. RevMan V.5.4 software and GRADE were used to synthesise the data and validate the evidence, respectively.

Results

Seventeen studies were included in this meta-analysis. The anti-VEGF agents showed significant better mean best-corrected visual acuity (BCVA) improvement, more patients with ≧15 Early Treatment in Diabetic Retinopathy Study (ETDRS) letters gained and fewer patients with ≧15 ETDRS letters lost, more effectiveness at reducing central retinal thickness (CRT) and improving the quality of life than sham and steroids both at 6 and 12 months. Compared with laser, the anti-VEGF agents showed significant BCVA improvement and more effectiveness at CRT both at 6 and 12 months. The proportion of eyes gaining ≧15 ETDRS letters was greater in the anti-VEGF group at 6 months. The anti-VEGF and other three groups reported similar levels of non-ocular serious adverse events (SAEs). The incidence of eye pain was significantly higher in the anti-VEGF group than in the sham group. There was a significant increase in the incidence of ocular AEs and conjunctival haemorrhage in the anti-VEGF group compared with the laser group. The incidence of elevated intraocular pressure and cataract was significantly higher in the steroid group than in the anti-VEGF group.

Conclusions

This meta-analysis suggested that treatment of ME secondary to RVO with anti-VEGF improves visual and anatomical outcomes compared with other treatments. Thus, anti-VEGF treatment is the first choice for treating patients with ME secondary to RVO.

Estimating ranibizumab injection numbers and visual acuity at 12 months based on 2-month data on branch retinal vein occlusion treatment

Anti-vascular endothelial growth factor treatment for macular edema secondary to branch retinal vein occlusion generally provides good visual acuity (VA) improvement but may require repeated injections for years. To reduce the number of patients who suffer from avoidable VA loss caused by treatment drop-out, providing prospects of the correlation between expected vision improvement and required number of injections at the early stages of treatment may be helpful. In this post hoc analysis of the phase IV, randomized, open-label ZIPANGU study, we investigated the correlation between the data from Month 2 and Month 12 in terms of VA and required ranibizumab injection numbers. Fifty-nine patients were evaluated (ranibizumab monotherapy, 29; combination therapy, 30). In the monotherapy group, patients who received 1 and 3 injections by Month 2 received a mean total of 2.8 and 8.3 injections during the year, respectively. Data from the combination group were similar. The correlation coefficients for VA scores at Months 2 and 12 were 0.60 and 0.51 for the monotherapy and combination groups, respectively (both p < 0.01). Based on VA and injection numbers at Month 2 of treatment, physicians could provide rough prospects on patients’ expected final VA and required number of injections.

The 12- and 24-Month Effects of Intravitreal Ranibizumab, Aflibercept and Bevacizumab on Intraocular Pressure: A Network Meta-Analysis

TOPIC

To investigate the effect of anti-vascular endothelial growth factor (VEGF) intravitreal injections on intraocular pressure (IOP) 12- and 24-months after initiation.

CLINICAL RELEVANCE

It is unclear whether serial anti-VEGF injections result in sustained increases in IOP.

METHODS

Randomized control trials (RCTs) comparing anti-VEGF agents to each other or to a control for the treatment of neovascular age-related macular degeneration, retinal vein occlusions or diabetic macular edema were included. Pairwise meta-analysis and Bayesian network meta-analysis were performed examining the proportion of patients at 12- and 24-months whose IOP: a) increased ≥5mmHg from baseline on consecutive visits, b) increased ≥10mmHg from baseline at any visit, c) was ≥21mmHg on consecutive visits, d) was ≥25mmHg at any visit, e) was ≥30mmHg at any visit, f) prompted initiation of IOP lowering medications and g) increased as per the clinicians' discretion. Certainty of evidence was informed by Cochrane Collaboration's Risk of Bias Tool and GRADE (Grading of Recommendations Assessments, Development and Evaluations) guidelines.

RESULTS

26 RCTs of 12,522 eyes were included. Aflibercept (2.0mg), bevacizumab (1.25mg), ranibizumab (0.3mg and 0.5mg) and non-injection controls were analyzed. 83 of 84 network estimates for comparisons between anti-VEGF agents demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates than bevacizumab of IOP measurements ≥30mmHg at 12-months (low certainty of evidence). 53 of 56 network estimates for comparisons between anti-VEGF agents and controls demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates of consecutive IOP increases ≥ 5mmHg at 24-months (low certainty of evidence) and higher rates of IOP increases as per the clinicians' discretion at 12 and 24 months (low and very low certainty of evidence respectively). The 95% credible intervals in all comparisons without statistically significant effects did not rule out important clinical effects. The certainty of evidence in these comparisons is limited by imprecision.

CONCLUSION

Evidence from our network meta-analysis does not show any clear difference between anti-VEGF agents and controls when examining IOP increases 12- and 24-months after treatment initiation. Imprecision precludes definitive conclusions with the available data.

Treat-and-extend regimens of anti-vascular endothelial growth factor therapy for retinal vein occlusions: a systematic review and meta-analysis

OBJECTIVE

To investigate treat-and-extend (T&E) regimens of anti-vascular endothelial growth factor (anti-VEGF) therapy for the treatment of macular oedema secondary to retinal vein occlusions (RVOs).

METHODS

Ovid MEDLINE, Ovid EMBASE and CENTRAL were searched on 25 February 2021. Randomized controlled trials, cohort studies, case-control studies and case series were included. The primary outcome was the change in Early Treatment Diabetic Retinopathy Score (ETDRS) letters from baseline. Conversions from Snellen to ETDRS letters were performed utilizing a published protocol. Secondary outcomes included improvement in retinal thickness from baseline, number of anti-VEGF injections and frequency of adverse events. Outcomes were examined at 12 and 24 months. Certainty of evidence was assessed utilizing GRADE (Grading of Recommendations Assessments, Development and Evaluations) guidelines.

RESULTS

Seven hundred eighty-six eyes from 16 studies were included. Meta-analysis demonstrated a mean improvement of 15.7 (95% CI: 13.3-18.0) ETDRS letters at 12 months. Central retinal thickness improved 269.7 μm (95% CI: 233.64-305.90) at 12 months. Injections were performed 8.1 (95% CI: 7.4-8.7) and 13.1 (95% CI: 9.4-16.8) times at 12 and 24 months respectively. Adverse events were infrequent across all studies. Grading of Recommendations Assessments, Development and Evaluations (GRADE) certainty of evidence was very low across all outcomes.

CONCLUSIONS

The results support the viability of T&E regimens for the treatment of macular oedema secondary to RVOs.

Cost-effectiveness analysis of ranibizumab for retinal vein occlusion patients in China from the societal perspective

BACKGROUND

Clinical trials in China have demonstrated that ranibizumab can improve the clinical outcomes of branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). However, no economic evaluation of ranibizumab has been conducted among Chinese patient population.

METHODS

To provide insights into the economic profile of ranibizumab among Chinese RVO population, a Markov state-transition model was used to predict the outcomes of ranibizumab comparing to laser photocoagulation and observational-only care from the societal perspective. This model simulated changes in patient visuality, quality-adjusted of life years (QALY), medical costs, and direct non-medical costs of individuals with visual impairment due to BRVO or CRVO in lifetime. The base-case analysis used an annual discount rate of 5% for costs and benefits following the China Guidelines for Pharmacoeconomic Evaluations. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model.

RESULTS

The base-case incremental cost-effectiveness ratio (ICER) comparing ranibizumab to laser photocoagulation was ¥65,008/QALY among BRVO patients and was ¥65,815/QALY among CRVO patients, respectively. Comparing to the 2019 gross domestic product (GDP) per capita of ¥71,000, both two ICERs were far below the cost-effective threshold at three times of GDP per capita (¥213,000). The deterministic and probabilistic sensitivity analyses demonstrated the base-case results were robust in most of the simulation scenarios.

CONCLUSION

The current Markov model demonstrated that ranibizumab may be cost-effective compared with laser photocoagulation to treat BRVO and cost-effective compared to observation-only care to treat CRVO in China from the societal perspective.

Cardiovascular Adverse Events With Intravitreal Anti-Vascular Endothelial Growth Factor Drugs: A Systematic Review and Meta-analysis of Randomized Clinical Trials

IMPORTANCE

Systemic safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) is a matter of debate and regular updates are necessary.

OBJECTIVE

To evaluate systemic adverse events (SAEs) associated with intravitreal anti-VEGF drugs compared with non-anti-VEGF treatments in patients with ocular diseases.

DATA SOURCES

Electronic searches were conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases from inception to July 7, 2020.

STUDY SELECTION

Randomized clinical trials conducted in adults with retinal diseases who received intravitreal anti-VEGF drugs.

DATA EXTRACTION AND SYNTHESIS

Studies and treatment characteristics and outcome data were extracted and analyzed, and study quality was evaluated.

MAIN OUTCOMES AND MEASURES

Main outcomes were major cardiovascular events (MACEs) and total mortality. Secondary outcomes included nonocular hemorrhage, components of MACEs, other cardiovascular outcomes, serious SAEs, and all SAEs.

RESULTS

A total of 74 randomized clinical trials were analyzed: 32 trials (43%) included 14 190 patients with age-related macular degeneration (AMD), 24 (32%) included 5424 patients with diabetic retinopathy (diabetic macular edema or proliferative diabetic retinopathy), 17 trials (23%) included 3757 patients with retinal vein occlusion, and 1 trial (1%) included 122 patients with myopic choroidal neovascularization. Anti-VEGF drug administration did not increase MACEs compared with control agents (odds ratio [OR], 1.16; 95% CI, 0.85-1.58) or total mortality (OR, 1.27; 95% CI, 0.82-1.96). There was an interaction (subgroup difference, P = .04) in mortality risk depending on the underlying disease with an increase (OR, 1.80; 95% CI, 1.03-3.16; P = .04) in the risk of death in patients with diabetic retinopathy; however, no increase was observed in patients with AMD or retinal vein occlusion. Administration of anti-VEGF drugs increased the risk of nonocular hemorrhage (OR, 1.46; 95% CI, 1.01-2.10), mainly in patients with AMD.

CONCLUSIONS AND RELEVANCE

Intravitreal anti-VEGF was not associated with an increase in MACEs in the trials examined herein. Increased mortality in patients with diabetes and nonocular hemorrhages, especially in those with AMD, could represent a safety signal, but the evidence was not strong. However, continued surveillance of SAEs remains warranted.

The randomized ZIPANGU trial of ranibizumab and adjunct laser for macular edema following branch retinal vein occlusion in treatment-naïve patients

The ZIPANGU study assessed the efficacy and safety of ranibizumab as a one loading dose + pro re nata (one + PRN) regimen with/without focal/grid laser among treatment-naïve patients suffering from macular edema (ME) following branch retinal vein occlusion (BRVO). ZIPANGU was a phase IV, prospective, randomized, open-label, active-controlled, 12-month, two-arm, multicenter study. Treatment-naïve patients with visual impairment (19–73 letters) caused by ME, defined as central subfield thickness (CSFT) > 300 µm, due to BRVO were randomly assigned to ranibizumab monotherapy (n = 29) or combination therapy (ranibizumab + focal/grid short-pulse laser, n = 30). The primary endpoint was the number of ranibizumab injections. Secondary endpoints were mean changes in best-corrected visual acuity (BCVA) and CSFT, and safety. There were no statistically significant differences in the mean number of ranibizumab injections between monotherapy (4.3 injections) vs. combination (4.1 injections) therapy, or in CSFT. BCVA improvement in the monotherapy arm (22.0 letters) was better than the combination therapy arm (15.0 letters) (p = 0.035). Overall, both regimens appeared to be safe and well tolerated. One + PRN ranibizumab is safe and efficacious in treatment-naïve patients with ME secondary to BRVO. A conjunctive laser treatment did not lead to better functional outcomes or fewer ranibizumab injections.

Use of Anti-VEGF Drugs in Retinal Vein Occlusions

Retinal vein occlusion (RVO) is one of the most prevalent causes of visual loss in the Western World. Its pathogenesis is still not completely known. Chronic macular edema and ischemia compromise the functional and anatomical status of the retina. Antivascular endothelial growth factor (anti-VEGF) injections have demonstrated better results than other previous options, including observation or laser therapy. This narrative review aims to analyze the current aspects related to these drugs.