South Asian diabetic macular oedema treated with ranibizumab (ADMOR)-real-life experience

Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data

The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.

Evaluating initial responses to brolucizumab in patients undergoing conventional anti-VEGF therapy for diabetic macular edema: a retrospective, single-center, observational study

Our retrospective, single-center, observational study aimed to evaluate the initial responses to intravitreal injection of brolucizumab (IVBr) in patients undergoing anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME). In total, 23 eyes of 20 patients with DME treated with at least one intravitreal injection of ranibizumab or aflibercept within one year and then switched to IVBr were included. Best corrected visual acuity (BCVA), central macular thickness (CMT), and macular volume (MV) on optical coherence tomography images were evaluated just before the most recent conventional anti-VEGF (ranibizumab/aflibercept) injection therapy (V1), one month after the most recent traditional anti-VEGF therapy (V2), just before the first IVBr (V3), and one month after the first IVBr (V4). BCVA, CMT, MV, and presence of intraocular inflammation (IOI) were evaluated at each visit. Anterior chamber flare values were also examined at V3 and V4. BCVA showed significant improvement at V2 (0.30 ± 0.23) than V1 (0.39 ± 0.29) and at V4 (0.34 ± 0.26) than V3 (0.48 ± 0.34) (P = 0.002, P < 0.001). However, no significant difference was observed between V2 and V4 (P = 0.257). CMT was significantly thinner at V2 (346.8 ± 90.2 µm) than V1 (495.5 ± 123.8 µm), and at V4 (322.2 ± 95.7 µm) than V3 (536.5 ± 166.0 µm) (P < 0.001, P < 0.001), but no significant difference was observed between V2 and V4 (P = 0.140). MV was significantly smaller at V2 (11.6 ± 2.0 mm³) than V1 (12.6 ± 1.9 mm³) and at V4 (11.2 ± 2.0 mm³) than V3 (12.6 ± 2.0 mm³) (P < 0.001, P < 0.001), and even significantly smaller at V4 than V2 (P = 0.009). No patient had IOI. No significant changes were observed in anterior chamber flare values between V3 and V4 (25.6 ± 14.6 vs. 24.0 ± 11.5 photon count/ms; P = 0.543). Both CMT and MV significantly reduced without any adverse events one month after switching from conventional anti-VEGF to IVBr therapy for DME, including IOI. MV was significantly lower for IVBr than anti-VEGF therapy after one month of treatment. Therefore, brolucizumab may be a viable treatment option for DME patients considering switching from conventional anti-VEGF agents for various reasons, such as poor response or inability to extend dosing intervals.

Factors affecting central macular thickness of diabetic macular oedema patients after an induction treatment of intravitreal ranibizumab

OBJECTIVE

Intravitreal ranibizumab is one of the anti-vascular endothelial growth factors used for the treatment of diabetic macular oedema, not always successfully. We aimed to identify the factors affecting the changes of central macular thickness after induction treatment with intravitreal ranibizumab, to predict the treatment effect and facilitate early treatment decisions.

METHODS

Cross-sectional study involving a retrospective record review of diabetic macular oedema patients who received an induction treatment of three monthly 0.5 mg intravitreal ranibizumab injections between 2016 and 2019. Central macular thickness was measured at baseline and 3 months post-treatment. Linear regression was applied to identify the factors associated with the changes of central macular thickness.

RESULTS

A total of 153 diabetic macular oedema patients were involved in this study. Their mean age was 57.5 ± 7.7 years, 54.9% were female. The mean change of central macular thickness from baseline to 3 months after completed induction treatment of intravitreal ranibizumab was 155.5 ± 137.8 μm. Factors significantly associated with changes of central macular thickness were baseline central macular thickness [b = 0.73; 95% (CI): 0.63, 0.84; p = <0.001] and presence of subretinal fluid [b = 35.43; 95% CI: 3.70, 67.16; p = 0.029].

CONCLUSION

Thicker baseline central macular thickness and presence of subretinal fluid were the factors significantly associated with greater changes of central macular thickness in diabetic macular oedema patients after receiving three injections of intravitreal ranibizumab.

A rapid review of evidence relating to service use, experiences, and support needs of adults from minority ethnic communities along the eyecare pathway in the United Kingdom

Background

There is growing awareness of the health inequalities experienced by minority ethnic communities, who make up an increasing proportion of the United Kingdom (UK) population and have been found to be at increased risk of visual impairment (V.I.). V.I. impacts on a wide range of life domains including employment, social functioning and activities of daily living. Considering existing health inequalities, the increased risk of V.I. and its wide-ranging impact, it is important to understand the experiences of adults from minority ethnic communities living with V.I. in the UK.

Methods

A rapid evidence review of academic and gray literature published since 2005 and in English was performed. A search of AMED, CINAHL Plus and MEDLINE via EBSCOhost identified 969 articles. Articles were included in the review if they reported findings relating to the UK-context, to adults from minority ethnic communities living with V.I., and to experiences of V.I. and the eyecare pathway.

Results

A total of 11 academic articles and 4 charity reports presented findings relating to perceptions of V.I. and eye disease (n = 3), access to services and service use (n = 5), impact of interventions (n = 7), the wider impact of V.I. (n = 2), and registration status (n = 1). Much of the literature focused on primary eyecare resulting in a comprehensive list of barriers and recommendations to increase eye tests. Less research addressed experiences and use of services further along the eyecare pathway although use of services may be low. Overall, the research on the experiences of adults with V.I. from minority ethnic communities in the UK remains anecdotal, outdated or unavailable. There are substantial gaps in the evidence relating to the wider impact of V.I., the impact of perceptions of V.I., and the use of services beyond primary eyecare.

Conclusions

This review summarizes our current knowledge of the experiences of adults from minority ethnic communities living with V.I. in the UK and highlights substantial gaps in the evidence. The findings provide practical implications for practitioners and researchers committed to addressing health inequalities in the field of eyecare in the UK.

Three year outcomes of intravitreal ranibizumab and aflibercept treatment of patients with diabetic macular edema: A comparative study

Background

Diabetic macular edema (DME) is the most common cause of visual deterioration in patients with diabetes mellitus. Various treatment options have been used for DME, including intravitreal injection of steroids and anti-vascular endothelial growth factors.

Objectives

To evaluate and compare the functional and anatomical outcomes of intravitreal ranibizumab (IVR) and intravitreal aflibercept (IVA) treatments in patients with DME.

Design

Retrospective study.

Methods

Four hundred three eyes of 235 naïve patients who underwent IVR or IVA treatment for DME followed up to 36 months included in the study. Best corrected visual acuity (BCVA) and central macular thickness (CMT) were measured at baseline, year 1, 2 and 3. Primary endpoint of the study was the change in BCVA and CMT each year from baseline and requirement of additional treatment (laser/steroid injection).

Results

There were 198 eyes in IVR group and 205 eyes in IVA group. The changes in mean BCVA were 0.09 ± 0.32 versus 0.17 ± 0.41 Logarithm of the minimum angle of resolution (logMAR) (p = 0.042) at year 1, 0.09 ± 0.37 versus 0.12 ± 0.45 logMAR (p = 0.512) at year 2 and 0.13 ± 0.36 versus 0.15 ± 0.48 logMAR (p = 0.824) at year 3 in IVA and IVR groups, respectively. The baseline mean BCVA were lower (p = 0.004) in IVA group. The mean total number of injections was 7.93 ± 3.38 versus 7.42 ± 3.05 (p = 0.112).

Conclusion

At year 1, change in mean BCVA was statistically significantly higher in IVA group; however this difference did not persist at years 2 and 3. Although the mean total number of injections was similar between groups, the requirement for adjuvant steroid treatment was significantly higher in ranibizumab group, which may affect the number of visits and treatment costs. Both ranibizumab and aflibercept treatments achieved a good long-term visual and anatomical response in DME patients.

Intravitreal Aflibercept versus Ranibizumab for Diabetic Macular Edema in a Taiwanese Health Service Setting

Purpose: To compare the visual and anatomical outcomes between intravitreal aflibercept and ranibizumab for diabetic macular edemaMethods: A total of 194 eyes from 194 patients (aflibercept n = 95, ranibizumab n = 99) were retrospectively enrolled in the study. All eyes fulfilled the key criteria including a baseline best-corrected visual acuity (BCVA) between 20 and 70 ETDRS letters, a central subfield thickness (CST) 300 µm or more. Primary outcomes were BCVA and CST at 1, 3, 6, and 12 months. Maintenance of vision was defined as visual loss of less than 5 letters over 6 to 12 months. Predictors for final visual acuity and visual maintenance were analyzed using multivariate regression models.Results: Both agents achieved comparable visual and anatomical outcomes at any time point over the course of follow-up (all p > .05). At 12 months, aflibercept group had higher proportions of visual gains 5, 10 and 15 letters or more (p = .014, p = .011, and p = .034, respectively). The mean number of injections was 5.0 ± 1.9 in ranibizumab group and 4.5 ± 1.9 in aflibercept group (p = .09). Ranibizumab predicted poor maintenance of vision (p = .009), but not the final visual acuity (univariate p = .1). Ranibizumab was more likely to have recurrence of subretinal fluid than aflibercept in 12 months after resolution of subretinal fluid at baseline (p = .016). Both aflibercept and ranibizumab had similar rates of loss to follow-up (p = .47) and occurrence of vitreous hemorrhage (p = .21).Conclusion: While both agents improved vision with resolution of edema, aflibercept maintained vision more effectively with less recurrence of subretinal fluid at 12 months in real-world settings.

Outcomes of a 2-year treat-and-extend regimen with aflibercept for diabetic macular edema

This prospective, open-label, single-arm, non-randomized clinical trial, assessed the efficacy of a 2-year treat-and-extend (T&E) regimen involving intravitreal aflibercept injection (IAI), with the longest treatment interval set to 16 weeks, and adjunct focal/grid laser in diabetic macula edema (DME) patients. We examined 40 eyes (40 adults) with fovea-involving DME from 8 Japanese centers between April 2015 and February 2017. Participants received IAI with an induction period featuring monthly injections and a subsequent T&E period featuring 8–16-week injection interval, adjusted based on optical coherence tomography findings. The primary endpoints were mean changes in the best-corrected visual acuity (BCVA) and central subfield macular thickness (CST) from baseline. Thirty patients (75%) completed the 2-year follow-up. The mean BCVA and CST changed from 60.5 ± 15.6 letters and 499.2 ± 105.6 µm at baseline to 66.6 ± 17.1 letters (P = 0.217) and 315.2 ± 79.0 µm (P < 0.001), respectively, after 2 years. The treatment interval was extended to 12 and 16 weeks in 6.7% and 66.7% of patients, respectively, at the end of 2 years. The T&E aflibercept regimen with the longest treatment interval set to 16 weeks, with adjunct focal/grid laser may be a rational 2-year treatment strategy for DME.

Managing Diabetic Macular Edema in Clinical Practice: Systematic Review and Meta-Analysis of Current Strategies and Treatment Options

Purpose

This meta-analysis aims to summarize 12-month best-corrected visual acuity (BCVA) outcomes in response to anti-vascular endothelial growth factor (VEGF) therapy and dexamethasone implant for the treatment of diabetic macular edema (DME) and to identify factors affecting treatment response using evidence generated from meta-regression.

Methods

A systematic review of electronic databases was conducted to identify randomized controlled trials (RCTs) and real-life/observational studies that reported 12-month changes in BCVA in patients with DME on anti-VEGF or dexamethasone implant treatment in monotherapy. Study factors that were analyzed are baseline patient characteristics, study type, drug employed, number of injections and 12-month change in BCVA. Data were pooled in a random-effects meta-analysis with BCVA change as the main outcome. Meta-regression was conducted to assess the impact of multiple covariates.

Results

One-hundred-five heterogeneous study populations (45,032 eyes) were identified and included in the analysis. The use of anti-VEGFs and dexamethasone implant induced an overall increase of +8.13 ETDRS letters in BCVA at 12 months of follow-up. Meta-regression provided evidence that mean BCVA change using anti-VEGFs was not statistically higher for RCTs (p=0.35) compared to observational studies. Dexamethasone implant showed a trend for better results in observational studies over RCTs. Populations following a fixed aflibercept regimen performed better than those following a reactive treatment regimen. Mean BCVA gain was higher in younger populations (p<0.001), with lower baseline BCVA (p<0.0001) and longer diabetes duration (p<0.0001), receiving a higher number of injections (p<0.0001).

Conclusion

Intravitreal therapy with anti-VEGFs or dexamethasone implant produces a significant improvement in BCVA at 12 months in patients with DME. Meta-regression identified the modifiable covariates that can be targeted in order to maximize functional results.

Impact of Intravitreal Ranibizumab Therapy on Vision Outcomes in Diabetic Macular Edema Patients: A Meta-Analysis

PURPOSE

Evaluation of the impact of the injection frequency of ranibizumab on best-corrected visual acuity (BCVA) outcomes in patients with diabetic macular edema (DME).

METHODS

A meta-analysis of randomized controlled trials (RCTs) and real-world studies was performed to quantify the effect of ranibizumab treatment on BCVA and central foveal thickness (CFT) in DME as well as the relationship between the number of injections and the change in BCVA/CFT.

RESULTS

All combined sources (29 RCTs and 11 real-life studies) showed a significant increase in BCVA from baseline following anti-vascular endothelial growth factor (VEGF) treatment (8.2, 9.4, and 10.3 ETDRS letters gained after 12, 24, and 36 months of ranibizumab treatment, respectively). The largest changes in BCVA were observed in RCTs and the smallest in real-life studies at 12 months. A significant relationship was found between the number of injections and change in BCVA at 12 months.

CONCLUSIONS

Inferior vision outcomes were observed in clinical practice compared with RCTs and might be partly attributable to administration of fewer anti-VEGF injections. Physicians should be aware that early and appropriate anti-VEGF treatment regimens are necessary to obtain the results reported in RCTs and help prevent irreversible vision loss in DME patients.

Anti-Vascular Endothelial Growth Factor Treatment for Diabetic Macular Edema in a Real-World Clinical Setting

PURPOSE

To report the long-term outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME) in a real-world clinical setting and to assess the efficacy of subsequent alternative treatments in eyes with suboptimal response to anti-VEGF.

DESIGN

Retrospective interventional case series.

METHODS

The medical records of consecutive eyes with center-involving DME, treated between August 2008 and June 2015 with 3 monthly intravitreal anti-VEGF injections-with or without prompt or deferred laser-followed by pro re nata re-treatment, were reviewed. A subgroup of eyes that were unresponsive to the treatment received subsequent alternative therapeutic options, including switching to another anti-VEGF drug, intravitreal injection of dexamethasone, and vitrectomy.

RESULTS

A total of 170 eyes of 129 patients were included in the study. The mean follow-up (FU) was 45.6 months (SD 18; minimum 12-maximum 81). The change in mean best-corrected visual acuity (BCVA) at 1-year FU was +5 ETDRS letters (P < .0001). Improvement in BCVA was statistically significant up to 5 years. Improvement in central macular thickness (CMT) was statistically significant up to the last FU visit. In eyes with suboptimal response, no significant visual improvement was found by switching to another anti-VEGF (P =.4347). Twenty-four eyes treated with intravitreal dexamethasone and 14 with vitrectomy exhibited a significant reduction in CMT with variable functional responses. In these eyes, better BCVA gain was found in cases with an early change of the treatment strategy.

CONCLUSION

The results support treatment with intravitreal anti-VEGF for DME in real-world clinical settings and suggest that an early change of the therapeutic strategy should be considered for eyes unresponsive to the treatment.

Real-life experience of ranibizumab for diabetic macular edema in Taiwan

PURPOSE

To evaluate the visual and anatomical outcomes of intravitreal ranibizumab for diabetic macular edema (DME) in the healthcare system of Taiwan.

METHODS

A total of 39 eyes from 39 patients were retrospectively enrolled in the study. All eyes that fulfilled the key criteria, including a baseline vision between 20 and 70 ETDRS letters and a minimum central macular thickness (CMT) of 300 µm, had at least 3 monthly loading injections of ranibizumab in a year. Macular laser or posterior subtenon injections of triamcinolone acetonide (PSTA) could be performed as supplementary treatments following loading injections. Primary outcomes include best-corrected visual acuity and CMT.

RESULTS

Patients' vision improved from 46.5 ± 15.3 letters at baseline to 51.4 ± 16.6 letters at 12 months (p = 0.031). Mean CMT at baseline was 406 ± 105 µm, which decreased to 329 ± 108 µm (p = 0.002). At 12 months, 44.4% of eyes with total injection number < 5 and 42.9% with injection number ≥ 5 achieved a gain in vision that was 10 letters or more. A total of 5 injections or more did not lead to a better visual gain in comparison with only 3-4 injections (p = 0.71), and both had similar number of supplementary treatments (p = 0.43). Monthly reinjections of ranibizumab resulted in a lower likelihood of visual loss of 10 or 15 letters (p = 0.019 and 0.015, respectively, adjusted for age, baseline vision, severity of diabetic retinopathy and the presence of previous treatments); however, supplementary macular lasers, PSTA or ranibizumab without monthly reinjections did not (all p > 0.05). The average number of injections was 4.3 ± 1.0.

CONCLUSION

Treatment for DME with at least three monthly ranibizumab loading injections, with or without other supplementary treatments, is effective at 12 months thereafter. Two monthly reinjections of ranibizumab, while not significantly increasing vision, may have a role in preventing visual loss.

Treatment Efficacy and Compliance in Patients with Diabetic Macular Edema Treated with Ranibizumab in a Real-Life Setting

Purpose

To assess real-life efficacy of ranibizumab and treatment compliance of patients with vision loss secondary to diabetic macular edema (DME).

Methods

A retrospective study was conducted in DME patients treated with ranibizumab. Patients were monitored every 4 weeks for visual acuity (VA) and central retinal thickness (CRT) by SD-OCT. All patients received a loading dose of 3 monthly injections followed by retreatments on an as-needed basis. The primary endpoint was the change in VA at M12. Patient compliance to the follow-up and the correlation between the injection number and VA were also investigated. Compliance was compared to that of neovascular age-related macular degeneration (nAMD) patients.

Results

Seventy-two eyes of 55 consecutive DME patients were included. At baseline, the mean VA was 56.5 letters and CRT was 470 μm. At M12, the mean VA was 63.4 letters (p < 0.0001), 31.1% of patients had a VA > 70 letters, the mean VA change was +6.9 letters, and the mean CRT was 361.9 μm (p = 0.0001) after a mean number of 5.33 intravitreal injections. In patients who received ≥7 injections, the VA gain and final VA were significantly higher than in patients who received <7 injections. At M12, 25.45% of DME patients were lost to follow-up versus 16.8% of nAMD patients (n = 55).

Discussion/Conclusion

Our study confirms the real-life efficacy of ranibizumab in DME at M12 and the need for a large number of injections to achieve better visual outcomes. We also showed a trend to a lower compliance in diabetic versus nAMD patients.

The real life data of ranibizumab use among the diabetic macular edema patients in Turkey: Documenting the improvement with clinical optimization during three consecutive years

Purpose

To report the 12 month real life outcomes of ranibizumab treated diabetic macular edema (DME) patients.

Methods

Treatment naïve DME patients treated with ranibizumab were included. Patients were divided into three groups according to their hospital admittance years (2013, 2014, and 2015) and were compared in regards to the treatment outcomes.

Results

The mean visual acuity change from baseline to month 12 was not statistically significant in 2013 at month 12. The mean BCVA change from baseline to month 12 was statistically better at month 12 in 2014 and 2015. There was a statistically significant difference among the three groups in regards to both mean visit and injection numbers. The mean visit number in 2013 and 2014 were both lower than 2015. The mean injection number in 2013 was lower than both 2014 and 2015.

Conclusions

It is effortful to obey the strict follow-up criteria of prospective studies in DME patients on a PRN regimen. However, optimizing the clinical processes of patient management may lead to improved clinical outcomes in real life.