One-year outcome after intravitreal ranibizumab for large, serous pigment epithelial detachment secondary to age-related macular degeneration

Impact of Anti-Vascular Endothelial Growth Factor Treatment on Neovascular Age-Related Macular Degeneration with and without Retinal Pigment Epithelial Detachment: A Real-World Study

BACKGROUND/OBJECTIVES

This study evaluates the impact of anti-vascular endothelial growth factor (anti-VEGF) treatment on neovascular age-related macular degeneration (nAMD) with and without pigment epithelial detachment (PED) over a one-year period.

METHODS

Conducted at a tertiary referral center in Taiwan, this retrospective analysis included 88 eyes treated with intravitreal aflibercept injections. Patients were categorized into four groups based on the presence or absence of PED at baseline and 12 months post-treatment.

RESULTS

Significant reductions in central macular thickness (CMT) and PED height were observed, although no statistical difference was found in best-corrected visual acuity (BCVA). The presence or type of PED did not negatively impact visual outcomes. Among nAMD patients with persistent PED throughout the first year of anti-VEGF treatment, linear regression analysis showed that mixed-type PED revealed poor final BCVA compared to those with serous PED. The analysis also identified older age and poorer initial BCVA as predictors of less favorable visual outcomes.

CONCLUSIONS

This study highlights the effectiveness of anti-VEGF therapy in real-world settings and offers insights into factors influencing visual outcomes for nAMD patients with PED.

Age-Related Macular Degeneration: An Exponentially Emerging Imminent Threat of Visual Impairment and Irreversible Blindness

Age-related macular degeneration (AMD) is a significant cause of blindness globally. With the exponential rise in the aging population, AMD is the third leading cause of visual impairment worldwide. Neovascular AMD (nAMD; Wet AMD) and geographical atrophy (GA, late-stage dry AMD) are the advanced AMD accountable for substantial cases of visual deterioration among the elderly. Our review of the literature depicted that notable risk factors include cigarette smoking, nutritional elements, cardiovascular disorders, and genetic markers, including genes regulating complement, lipid, and angiogenic pathways. Some studies have suggested a relative decline in the proportion of AMD cases in the last two decades attributable to novel diagnostic and therapeutic modalities. Accurate diagnosis is the result of a combination of clinical examination and imaging techniques, including retinal photography, angiography, and optical coherence tomography. The incorporation of dietary antioxidant supplements, explicitly lutein, slows the progression of the disease in advanced stages. The induction of vascular endothelial growth factor (VEGF) inhibitors in the treatment of neovascular AMD, often combined with other modalities, has shown an immensely favorable prognosis. Research to integrate gene therapy and regenerative techniques using stem cells is underway to further mitigate AMD-associated morbidity. It is imperative to establish screening and therapeutic guidelines for AMD to curtail the future social and financial burden and improve the diminishing quality of life among the elderly.

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

Influence of pigment epithelial detachment on visual acuity in neovascular age-related macular degeneration

Pigment epithelial detachment (PED), the anatomical separation of the retinal pigment epithelium from the Bruch membrane, is common in many chorioretinal diseases, including neovascular age-related macular degeneration. PED is present in about 30% to 80% of neovascular age-related macular degeneration patients based on the CATT, EXCITE, and VIEW studies. The influence of PED on visual acuity is controversial as a result of inconsistent results reported by various studies. With advances in imaging technologies, it is possible to evaluate not only the presence or absence of PED, but also detailed quantitative parameters, such as height, width, greatest linear diameter, area, volume, and reflectivity within the PED. We performed a comprehensive literature review to evaluate the relationship of PED with visual acuity. In summary, the presence or persistence of a PED may still be compatible with relatively good visual acuity. There is no strong evidence that the presence of a PED or aspects of its morphology has a significant impact on visual acuity. The presence of a PED may be predictive of the need for more regular treatment. More well-designed studies with standardized PED definitions and classifications are needed to evaluate the relationship between PED and visual acuity.

Subretinal pigment epithelium fibrotic tissue morphological changes after a single anti-vascular endothelial growth factor injection in age-related macular degeneration

Aims

To demonstrate and evaluate the morphological changes of multilayered fibrovascular pigment epithelial detachment (PED) to a single anti-vascular endothelial growth factor (VEGF) injection in age-related macular degeneration (AMD).

Methods

We retrospectively analysed the morphological changes of 30 eyes with exudative AMD showing fibrotic multilayered PED, between two consecutive visits. All patients had one anti-VEGF intravitreal injection at the first visit. We quantitatively analysed the different compartments within the PED and their morphological response.

Results

The mean follow-up time interval between the first and the second visit was 32.46±4.64 days. We defined three optical coherence tomography zones within the PED: a subretinal pigment epithelium inhomogeneous hyporeflective space (layer 1), a hyper-reflective band beneath layer 1 (layer 2), and a hyporeflective space between the Bruch’s membrane and layer 2 (layer 3). The mean height of layer 1 was 142±44.63 and 99.30±39.79 µm at visits 1 and 2, respectively. The mean thickness of layer 2 was 101.42±46.66 and 82.76±35.24 µm at visits 1 and 2, respectively. The mean height of layer 3 was 35.77±32.77 and 5.66±8.68 µm at visits 1 and 2, respectively (p=0.009). The mean height change for layer 1 was statistically significantly higher than for layer 2 (p=0.0002).

Conclusions

Fibrovascular PED was compartmented into three layers with different reflectivities that morphologically responded differently to a single anti-VEGF injection. Layer 2 had a statistically significantly lower response compared with layer 1, suggesting the hypothesis of a fibrotic component in layer 2.

Treatment of large avascular retinal pigment epithelium detachments in age-related macular degeneration with aflibercept, photodynamic therapy, and triamcinolone acetonide

Purpose

To evaluate the use of aflibercept, triamcinolone acetonide, and photodynamic therapy (PDT) in the treatment of avascular pigment epithelium detachments (aPEDs).

Patients and methods

Patients with treatment-naïve aPEDs ≥1,500 µm in diameter were randomized to treatment or observation. Treatment consisted of 6 monthly intravitreal injections of aflibercept. If the aPED persisted, the patients were treated with half-fluence PDT in combination with intravitreal triamcinolone acetonide and aflibercept. The primary outcome was change of best-corrected visual acuity (BCVA) after 24 months of follow-up. Secondary outcomes were changes in pigment epithelium volume, height and diameter, central retinal thickness, and number of patients developing choroidal neovascularization or geographic atrophy (GA).

Results

Treatment and inclusion of patients were stopped after an interim analysis of 6-month data because 75% of the aPEDs were in different stages of GA. Nine patients with aPED were included in the study, of these one patient was excluded because of bilateral central serous chorioretinopathy. The remaining eight had drusenoid aPEDs. After 24 months of follow-up, estimated means of BCVA decreased by 4.2 and 20.8 letters in the treatment and observation group, respectively. This decrease over time was not significantly different between groups (P=0.140, 95% CI −5.3, 38.6). Estimated means of PED volume, height, diameter, and central retinal thickness were not significantly different between groups. Choroidal neovascularization and retinal pigment epithelium tear developed in one patient in the treatment group. One patient in the treatment group and two patients in the observation group progressed to complete retinal pigment epithelium and outer retinal atrophy. A decrease in PED volume was associated with the development of complete retinal pigment epithelium and outer retinal atrophy (P=0.029).

Conclusion

This small trial indicates that multitargeted, primarily antiangiogenic therapy does not favorably alter the natural course of drusenoid aPEDs.

Clinical response of pigment epithelial detachment associated with neovascular age-related macular degeneration in switching treatment from Ranibizumab to Aflibercept

Background

To study the clinical outcomes of pigment epithelial detachment (PED) associated with neovascular age-related macular degeneration (nAMD) in patients switched from Ranibizumab to Aflibercept.

Methods

Retrospective non-comparative case series. 50 eyes with active nAMD and fovea involving PED of ≥100 μm measured manually using the caliper on the OCT, initially treated with intravitreal Ranibizumab (0.5 mg/0.05 ml) and later switched to Aflibercept (2.0 mg/0.05 ml). The outcome measures of best corrected visual acuity (BCVA), PED height, PED width and number of injections were measured at baseline and at time point of switch, 4 months, 1 year and at last follow up visit post-switch. Three paired t-tests and Pearson’s correlations were calculated to analyze variables at switch and change in variables at 1 year.

Results

After switch to Aflibercept, the improvement of BCVA was 1.84 (p = 0.11), 1.74 (p = 0.21) and 1.16 (p = 0.45) letters, the change in PED height was − 65.6μm (p < 0.001), − 50.64μm (p = 0.007) and − 68.48μm (p < 0.001) and the change in PED width was − 36.6μm (p = 0.514), + 29.7μm (p = 0.922) and + 118.4μm (p = 0.210) at 4 months, 1 year and the last visit respectively. There was a moderate negative correlation between reduction in PED height at 1 year after switch and PED height at the time of switch to Aflibercept (r = − 0.474, p < 0.05).

Conclusion

The improvement in BCVA and change in PED width was not statistically significant however the reduction in PED height was significant after switching treatment to Aflibercept. The change in BCVA at 1 year after switch was not correlated with any of the analyzed anatomical characteristics of PED.

Treatment outcomes of conventional or high-dose ranibizumab for vascularized pigment epithelial detachment based on lesion subtypes

Introduction:

A post hoc study was conducted to compare visual and anatomic outcomes of vascularized serous pigment epithelial detachment (Group 1) with fibrovascular pigment epithelial detachment (Group 2) due to age-related macular degeneration treated with either 0.5 or 2.0 mg ranibizumab injections.

Methods:

A prospective, randomized trial was performed with the following regimens for 12 months: (1) 0.5 mg monthly, (2) 0.5 mg monthly for 4 months followed by pro re nata injections, (3) 2.0 mg monthly, and (4) 2.0 mg monthly for 4 months followed by pro re nata injections. Primary measure was best-corrected standardized vision. Secondary measures included central subfield, thickness surface area A2, greatest linear diameter, heights of pigment epithelial detachment and choroidal neovascularization (CNV), subretinal fluid, cystoid macular edema, and adverse events.

Results:

For 36 eyes (8 in Group 1 and 28 in Group 2), follow-up time was 12 months. There were no differences in baseline features between groups except for pigment epithelial detachment A2 (Group 2 > Group 1). Two-way analysis of variance showed comparable improvements in anatomic and vision outcomes. Three-way analysis of variance also showed similar responses for both lesion subtypes with high-dose treatment. There was a trend toward greater pigment epithelial detachment resolution in Group 1 eyes. There were no differences in retinochoroidal angiomatous proliferation (Type-3 CNV) and cataracts between groups, although greater percentages of eyes in Group 1 developed retinal pigment epithelial tears (25% vs 10.7%).

Conclusion:

There were no differences in vision and anatomic outcomes between lesion subtypes, and similarly, more rapid responses to high-dose than conventional-dose ranibizumab occurred for eyes with both lesion subtypes. More retinal pigment epithelial tears may develop in eyes with vascularized serous pigment epithelial detachment.

Histologic and Optical Coherence Tomographic Correlates in Drusenoid Pigment Epithelium Detachment in Age-Related Macular Degeneration

PURPOSE

Drusenoid pigment epithelium detachment (DPED) is a known precursor to geographic atrophy in age-related macular degeneration (AMD). We sought histologic correlates for spectral-domain (SD) optical coherence tomography (OCT) signatures in DPED and determined the frequency and origin of these OCT signatures in a clinical cohort of DPED eyes.

DESIGN

Laboratory imaging and histologic comparison, and retrospective, observational cohort study.

PARTICIPANTS

Four donor eyes with histopathologic diagnosis of AMD (2 with nonneovascular DPED and 2 with neovascular pigment epithelium detachment [PED]) and 49 eyes of 33 clinic patients with nonneovascular DPED more than 2 mm in diameter.

METHODS

Donor eyes underwent multimodal ex vivo imaging, including SD OCT, then processing for high-resolution histologic analysis. All clinic patients underwent SD OCT, near-infrared reflectance, and color photography.

MAIN OUTCOME MEASURES

Histologic correlates for SD OCT signatures in DPED, estimate of coverage by different retinal pigment epithelium (RPE) phenotypes in the DPED surface; frequency and origin of histologically verified SD OCT signatures in a clinical cohort of DPED eyes, and comparisons of histologic features between neovascular PED and DPED resulting from AMD.

RESULTS

Intraretinal and subretinal hyperreflective foci as seen on SD OCT correlated to RPE cells on histologic examination. Hypertransmission of light below the RPE-basal lamina band correlated with dissociated RPE. Subretinal hyperreflective material resulting from acquired vitelliform lesions corresponded to regions of apically expelled RPE organelles. In the clinical cohort, all histologically verified reflectivity signatures were visible and quantifiable. The appearance of intraretinal hyperreflective foci was preceded by thickening of the RPE-basal lamina band. Compared with PEDs associated with neovascular AMD, DPEDs had different crystallization patterns, no lipid-filled cells, and thinner basal laminar deposits.

CONCLUSIONS

Multiple RPE fates in AMD, including intraretinal cells that are highly prognostic for progression, can be followed and quantified reliably using eye-tracked serial SD OCT. This information may be particularly useful for obtaining an accurate timeline of incipient geographic atrophy in clinic populations and for quantifying anatomic end points and response to therapy in AMD clinical trials.

One-year results of aflibercept in vascularized pigment epithelium detachment due to neovascular AMD: a prospective study

PURPOSE

To evaluate individualized intravitreal aflibercept regimens for treatment of neovascular age-related macular degeneration (nAMD)-related pigment epithelial detachment (PED).

METHODS

This prospective, multicenter, nonrandomized study included 32 eyes with nAMD-related PED, treated with ranibizumab for ≥6 months. All patients received intravitreal aflibercept (2 mg/0.05 mL) at baseline (no loading phase) and subsequently treated pro re nata with monthly follow-up for 12 months. Outcome measures included visual acuity, central retinal thickness (CRT), PED height and area, and neovascular network size.

RESULTS

At 12 months, aflibercept improved mean best-corrected visual acuity compared with baseline values (p&gt;0.05); 50% of patients displayed complete resolution of intraretinal and/or subretinal fluid. Compared with baseline, significant decreases were observed for mean CRT and PED height (both p&lt;0.01).

CONCLUSIONS

Aflibercept appears to induce anatomical improvement for at least 12 months after conversion from ranibizumab in patients experiencing nAMD-related PED. Significant reductions in both mean PED height and CRT were observed, although these changes were not necessarily related to significantly improved visual acuity scores. However, larger patient cohorts are required to extend and validate our results, and increased study duration would allow exploration of the potential long-term benefits and challenges of prolonged aflibercept use.

Effectiveness of Intravitreal Injection of Ranibizumab for Neovascular Age-Related Macular Degeneration with Serous Pigment Epithelial Detachment

Background

We sought to observe the effectiveness of intravitreal injection of ranibizumab in treating neovascular age-related macular degeneration (nAMD) with serous pigment epithelial detachment (sPED).

Material/Methods

A retrospective, noncomparative case series was performed. Twenty-3 eyes of 23 patients with sPED secondary to nAMD who had received intravitreal injections of ranibizumab were included in this study. All patients underwent best-corrected visual acuity (BCVA), synchronous fluorescein fundus angiography (FFA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT) examinations. All patients were treated with pro re nata intravitreal injections after 3 loading doses of ranibizumab and were followed up for 12 months. The differences in the BCVAs, maximum PED heights, PED volumes and CFTs of the affected eyes were compared between the baseline and last visit.

Results

Twelve months after the first injection, improved visual acuity was observed in 16 of the 23 eyes. 4 eyes exhibited stable visual acuity, and 3 eyes exhibited impaired visual acuity. The mean post-injection logMAR BCVA was 0.58±0.05, which was much better than that at baseline (0.76±0.08; t=1.751, P=0.0869). The mean maximum PED height at baseline was 350.17±35.73μm and it was decreased to 238.87±36.87μm (t=2.192, P=0.0337) at the last visit. The mean PED volume after injection was 0.34±0.1 mm³, which was significantly decreased compared with that at baseline (0.81±0.21 mm³; t=2.021, P=0.0494).The mean CFT decreased, but this difference was not statistically significant (t=1.003, P=0.3211). None of the patients exhibited endophthalmitis, uveitis or RPE tears.

Conclusions

Intravitreal injection of ranibizumab for the treatment of neovascular age-related macular degeneration with serous pigment epithelial detachment safely and effectively improved the patients’ visual acuities and decreased their PED heights volumes.

Alternating Bi-Weekly Intravitreal Ranibizumab and Bevacizumab for Refractory Neovascular Age-Related Macular Degeneration with Pigment Epithelial Detachment. Semin Ophthalmol 2015;32:309-315. [PMID: 26337539 DOI: 10.3109/08820538.2015.1072222]

OBJECTIVE

To describe visual and anatomical outcomes following bi-weekly intravitreal ranibizumab/bevacizumab injections in eyes with refractory neovascular age-related macular degeneration (AMD) and pigment epithelial detachment (PED).

DESIGN

Retrospective, consecutive, interventional case series.

PARTICIPANTS

Eighteen patients diagnosed with neovascular AMD that were refractory to anti-VEGF therapy and received alternating biweekly ranibizumab/bevacizumab injections were included.

METHODS

Patients with neovascular AMD and PED that were refractory to at least 11 monthly ranibizumab or bevacizumab injections were included in this study at a large, single retina practice. Following inclusion, patients received four bi-weekly alternating ranibizumab/bevacizumab intravitreal injections. After completing a course of four bi-weekly injections, patients were treated with variable regimens of intravitreal anti-vascular endothelial growth factor (VEGF) therapy. The primary outcomes of the study included change in visual acuity (VA) and central foveal thickness (CFT) at eight weeks follow-up.

RESULTS

Study eyes had previously received a mean of 22 intravitreal anti-VEGF injections. At enrollment, mean VA was 20/95 and mean CFT was 455 µm. After four bi-weekly anti-VEGF injections, mean VA improved to 20/65 (p < 0.001), and mean CFT decreased to 387 µm (p = 0.029). In patients with PED, there was a mean 27.9% reduction in height (p = 0.046) at eight weeks' follow-up.

CONCLUSIONS

Four injections of bi-weekly alternating ranibizumab/bevacizumab improved visual acuity and reduced macular thickness in a number of patients with refractory neovascular AMD and PED.

Retinal Pigment Epithelium Tear

Retinal pigment epithelium tear is a potentially vision threatening complication of retinal pigment epithelial detachment associated with neovascular age-related macular degeneration. Retinal pigment epithelium tear has been reported to occur spontaneously and after treatment with anti-vascular growth endothelial factor agents. The current study summarizes the presentation, diagnosis, management, and outcomes of retinal pigment epithelium tears.

Clinical findings of acquired vitelliform lesions associated with retinal pigment epithelial detachments

PURPOSE

To study clinical findings associated with acquired vitelliform lesions in retinal pigment epithelial detachments (PEDs).

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

We retrospectively reviewed 32 eyes of 24 patients (22 men, 2 women; age range [mean], 58-85 [73.7] years) with acquired vitelliform lesions.

RESULTS

All eyes had acquired vitelliform lesions in the central macula associated with a serous PED at baseline. Of the 32 eyes, 30 (93.8%) were observed for 12 months, 26 (81.3%) for 24 months, and 17 (53.1%) for 36 months. The mean logarithm of the minimal angle of resolution best-corrected visual acuity (BCVA) levels were 0.19 at month 12, 0.28 at month 24, and 0.25 at month 36, none of which differed significantly from baseline. The mean changes in the BCVA were declines of 0.38, 1.29, and 1.21 lines at months 12, 24, and 36, respectively. Of 7 eyes treated with 3 consecutive monthly intravitreal injections of ranibizumab, the serous PEDs remained in all 7 eyes and the mean changes of BCVA were a decline of 2.40 lines 12 months after the first injection and a decline of 3.58 lines at the final visit. In the 24 untreated eyes, the mean change in the BCVA was a decline of 0.25 line at the final visit, which differed significantly (P = .021) compared with that of the treated eyes at the final visit.

CONCLUSION

Intravitreal injections of ranibizumab were ineffective because of the absence of resolution of the PEDs and the declines in VA.

Intravitreal anti-VEGF therapy for vascularized pigment epithelium detachment in age-related macular degeneration

PURPOSE

To assess the efficacy of intravitreal anti-vascular endothelial growth factor (VEGF) treatment of vascularized pigment epithelial detachment (PED) due to age-related macular degeneration (AMD).

METHODS

A total of 26 patients with vascularized PED secondary to AMD were retrospectively analyzed and treated with anti-VEGF intravitreal injections according to a PRN regimen after 3 initial injections. Best-corrected visual acuity (BCVA), optical coherence tomography, and fluorescein angiography were performed at baseline and quarterly.

RESULTS

Mean follow-up ranged from 9 to 26 months (mean 13.5). There was a deterioration in mean BCVA from 0.46 at baseline to 0.79 logMAR at 12 months (p<0.001). The mean PED greatest linear diameter (GLD) increased from 4499 at baseline to 5206 μm at 1-year follow-up (p<0.001). The mean PED maximum height decreased from 669 μm at baseline to 305 μm at 1-year follow-up (p = 0.001). The mean central retinal thickness (CRT) was unchanged (from 277 to 209 μm at 1 year follow-up) (p = 0.099). No effect was seen on the change of VA according to groups of baseline predictors as defined by the medial value: baseline VA, PED height, and CRT (p>0.10).There was a borderline trend (p = 0.064) that GLD affected response to treatment. The mean number of injections was 5.5 (3 to 9). Seven out of 26 (27%) patients developed a retinal pigment epithelium (RPE) tear.

CONCLUSIONS

Intravitreal anti-VEGF therapy, with a PRN regimen, did not prevent visual acuity loss or RPE tear.

Effect of ranibizumab on serous and vascular pigment epithelial detachments associated with exudative age-related macular degeneration

Purpose

To report the effect of intravitreal ranibizumab therapy for serous and vascular pigment epithelial detachments (PED) associated with choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD).

Methods

In a prospective study, best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) data were collected for 62 eyes of 62 patients, with serous or vascular PED associated with CNV secondary to AMD. Intravitreal ranibizumab 0.5 mg was administered with a loading phase of three consecutive monthly injections, followed by monthly review with further treatment, as indicated according to the retreatment criteria of the PrONTO study. The change in visual acuity and PED height from baseline to month 12 after the first injection was determined.

Results

Sixty-one eyes of 61 patients (one of the patients developed retinal pigment epithelial tear and was excluded from the study) were assessed at the 12-month follow-up examination. There were two types of PED, including vascular PED in 32 patients (Group A) and serous PED (Group B) in 29 patients. The mean improvement of mean BCVA from baseline to 12 months was 0.09 logMAR (Logarithm of the Minimum Angle of Resolution) in Group A and 0.13 logMAR in Group B. Both groups showed significant improvement of the mean BCVA 12 months after the first injection compared with the baseline value (P < 0.05). In relation to the PED height, the mean decrease of mean PED height from baseline to 12 months was 135 μm in Group A and 180 μm in Group B. Both groups showed significant reduction of the PED height during the follow-up period (P < 0.01). The PED anatomical response to ranibizumab was not correlated with the BCVA improvement in any of the groups. Apart from one patient who developed pigment epithelial tear no other complications were documented.

Conclusion

Ranibizumab is an effective and safe treatment for improving vision in patients with serous and vascular PED, although the anatomical response of the PED to ranibizumab may not correlate directly with the visual outcome.

Therapeutic efficacy of bevacizumab for age-related macular degeneration: what are the implications of CATT for routine management?

CATT (Comparison of Age-related macular degeneration [AMD] Treatment Trials) examined the efficacy of ranibizumab and bevacizumab for the treatment of neovascular AMD. This prospective, randomized, but unblinded trial revealed a significant improvement in vision with both treatments in terms of visual acuity; importantly, patients with juxtafoveal choroidal neovascularization (CNV) and retinal pigment epithelial detachments were not excluded from the study. Monthly treatment with the drugs resulted in similar increases in visual acuity, although angiograms indicated that ranibizumab was superior in terms of reducing retinal fluid and leakage. As the study also differentiated between a fixed regimen and an as-needed (pro re nata [PRN]) dosing regimen, a larger sample size and Bonferroni statistical correction were necessary. The equivalence of the PRN dosing of bevacizumab to the monthly treatment could not be confirmed. Almost all of the frequent deviations from the protocol (referring to retreatment criteria: 25.7-28.5%) resulted in under-treatment. Since this applied to both drugs equally, under-treatment alone could not explain the larger loss of visual acuity observed in the bevacizumab PRN arm. The PRN regimen was generally associated with a larger lesion size after 12 months compared with the fixed treatment regimens. The investigators accepted the drawbacks of an incomplete masking to allow co-payment by Medicare. As assessments of drug trials are often politically motivated, the higher demands of a non-inferiority trial compared with a superiority design must be emphasized. A comparison of the per-protocol and last-observation-carried-forward analysis has not yet been published; ongoing subgroup analysis might highlight the impact of different lesion characteristics. While CATT provided further evidence for the efficacy of bevacizumab treatment, differences in adverse events between the two treatments (e.g. a higher rate of serious adverse events with bevacizumab compared with ranibizumab) were reported; however, these still have to be analysed, with the larger sample sizes of previous ranibizumab studies needing to be taken into account. Preclinical studies imply some differences between the drugs in terms of their adverse event profiles. A possible increased risk of adverse events could not be ruled out by previous clinical case series and CATT because the sample sizes and the follow-up intervals were not adequate. The large discrepancy in the price of bevacizumab versus ranibizumab in the US means a cost-benefit analysis is warranted. A lack of quality-of-life data has prevented calculation of an appropriate bevacizumab price in the context of its performance in the ophthalmological setting. Thus, CATT suggests that a favourable visual acuity might be achieved by very frequent administration of bevacizumab in patients with neovascular AMD. Although there are certain safety caveats, increased focus on subgroup analyses and obtaining longer follow-up data are expected to yield additional information of clinical relevance.

Acute anterior uveitis following intravitreal bevacizumab but not subsequent ranibizumab

Purpose

Previous reports have identified noninfectious uveitis as a potential sequela following both intravitreal bevacizumab and ranibizumab injections. We present two unique cases of acute anterior uveitis following intravitreal bevacizumab that did not occur with subsequent ranibizumab injections.

Methods

Case report.

Conclusion

These cases may reflect differences in the etiology of anterior uveitis following intravitreal bevacizumab and ranibizumab. Given these differences, it may be reasonable to offer ranibizumab to patients who have experienced presumed bevacizumab-induced anterior uveitis.