Comparison of the Effect of Unilateral Intravitreal Bevacizumab and Ranibizumab Injection on Diabetic Macular Edema of the Fellow Eye

Factors affecting prognosis and need for anti-vascular endothelial growth factor injections in wet age-related macular degeneration

PURPOSE

To understand factors affecting visual prognosis and the number of intravitreal antivascular endothelial growth factor (anti-VEGF) injections needed to stabilize wet age-related macular degeneration (AMD).

METHODS

In this retrospective cohort, 119 treatment-naïve wet AMD patients were followed for two years. In patients with bilateral disease, the eye with worse best-corrected visual acuity (BCVA) or that received more intravitreal injections was recruited as the study eye. In all visits, BCVA was recorded, ophthalmological examination was performed including macular optical coherence tomography imaging. Twenty health status/lifestyle questions were asked to the patients via phone as potential risk factors. All patients received 3 loading doses of intravitreal bevacizumab injections and received repeat injections of aflibercept or ranibizumab when the eye had a new, active neovascular lesion.

RESULTS

Patients who took regular micronutrition had similar visual outcome and injection numbers compared to the ones who did not. Patients with bilateral disease needed less intravitreal injections compared to unilateral AMD patients (p = 0.016) and women on hormone replacement therapy (HRT) required less injections compared to the women who were not (p = 0.024). Female patients had a mean gain of 2.7 letters while male patients lost 3.8 letters (p = 0.038). Wet AMD started at an earlier age in smokers (p = 0.002). Patients with a better education level presented earlier with better BCVA (p = 0.037).

CONCLUSION

HRT and anti-VEGF injections to the fellow eye improved the prognosis of wet AMD, while male patients had slightly worse prognosis. Estrogen's protective effects and potential contribution in wet AMD needs further attention. Retrospectively registered: 2020/0622.

Changes in the uninjected contralateral eye after intravitreal brolucizumab for exudative age-related macular degeneration

PURPOSE

Herein we describe the change in the amount of macular oedema in one eye after contralateral intravitreal brolucizumab injections in a patient with neovascular age-related macular degeneration (nAMD).

CASE REPORT

A patient with bilateral nAMD underwent intravitreal bevacizumab injections in both eyes with little improvement in the best-corrected visual acuity (BCVA) and central macular exudation. The treatment was switched to aflibercept, but there was incomplete drying of the macula in both eyes. After uneventful cataract extraction, the central macular thickness (CMT) increased markedly in the operated left eye (LE), which was unresponsive to subtenon triamcinolone and further intravitreal aflibercept. Cataract surgery was also performed in the right eye (RE) combined with an intravitreal sustained-release dexamethasone implant. Nevertheless, the CMT increased. Intravitreal brolucizumab injections were performed in the RE with almost complete disappearance of the oedema in the treated eye. Concurrently, the contralateral uninjected eye showed a remarkable decrease in CMT. Five months after the first brolucizumab injection, the macular exudation increased again in both eyes. A second brolucizumab injection was performed in the RE only, and was followed by a prompt reduction in CMT in both the injected RE and uninjected LE.

CONCLUSIONS

Although contralateral retinal changes have been described for many other vascular endothelial growth factor inhibitors, there is little evidence for brolucizumab. We describe a repeated dose- and time-related effect on the uninjected eye in a case of nAMD.

80 Years of vision: preventing blindness from retinopathy of prematurity

Retinopathy of prematurity (ROP) is one of the leading yet preventable causes of childhood blindness worldwide. The purpose of this review is to provide a practical template for observational and treatment methods in order to reduce the overall incidence of any ROP and to improve both short-term and long-term outcomes once Type 1 ROP (treatable ROP) develops.

Influence of unilateral intravitreal bevacizumab injection on the incidence of symptomatic choroidal neovascularization in the fellow eye in patients with neovascular age-related macular degeneration (Review)

Neovascular age-related macular degeneration (neovascular ARMD) represents only 10% of ARMD cases but is responsible, if untreated, for quick and severe central vision loss due to major macular changes. The presence of choroidal neovascularization (CNV) in one eye is associated with an approximately 10% risk of CNV development in the fellow eye each year. Intravitreal anti-VEGF therapy has quickly evolved as the standard treatment in neovascular ARMD in the last decade due to significant anatomical and functional improvements, especially in the early stages. In many reports an improvement in the untreated fellow eye was mentioned and systemic exposure was soon confirmed for all anti-VEGF agents after unilateral intravitreal injection. In particular, bevacizumab intravitreal injection is followed by a consistent reduction of serum VEGF levels and the drug was shown to have the longest serum half-life raising important debates about its safety. Once bevacizumab was detected in the fellow eye of an animal model after unilateral injection, the possible influence on fellow eye conversion rate into neovascular ARMD was questioned. Although comparative studies have not found statistically significant differences between drugs regarding the incidence of symptomatic CNV in the fellow eye during treatment, we observed, on a retrospective 36-month evaluation, a reduced incidence of symptomatic CNV in the fellow eye that might be explained by the consistent systemic exposure of bevacizumab.

The fellow eye effect of unilateral intravitreal conbercept injections in eyes with diabetic macular edema

AIMS

To investigate whether intravitreal conbercept injection affects contralateral untreated eyes in bilateral diabetic macular edema (DME) patients.

METHODS

In this retrospective study, 15 patients (30 eyes) with type 2 diabetes were followed after bilateral DME diagnosis in the Department of Ophthalmology, Peking Union Medical College Hospital from 2015 to 2018. Patients underwent examinations including best corrected visual acuity (BCVA), slit-lamp microscopy, indirect ophthalmoscope, color fundus photography, fundus fluorescein angiography, optical coherence tomography, and glycated hemoglobin (HbA1c). Each patient received conbercept (0.5 mg) intravitreally in the severe eye. Nonparametric Wilcoxon signed-rank tests and Pearson's correlation coefficient were used to assess changes in BCVA and central retinal thickness (CRT) and relations between BCVA changes in treated and untreated eyes, respectively.

RESULTS

The mean follow-up time was 10.60 ± 2.29 months, and the mean injection number of 15 treated eyes was 9.13 ± 0.68. HbA1c remained below 10% during treatment with no significant changes between the initial and final visits (7.81 ± 1.17 vs 7.62 ± 1.19%) (P = 0.576). In untreated eyes, CRT significantly decreased from the initial to final visits (368.93 ± 125.45 vs 306.27 ± 89.70 μm) (P = 0.028). In untreated eyes, BCVA showed no significant difference between the initial and final visits (0.38 ± 0.30 vs 0.40 ± 0.30 logMAR) (P = 0.937), but BCVA changes in treated and untreated eyes were positively correlated (r = 0.527, P = 0.044).

CONCLUSIONS

Intravitreal conbercept injection results in decreased CRT and increased BCVA in untreated eyes, which is consistent with the changes in treated eyes for patients with bilateral DME.

A review on vasohibin and ocular neovascularization

Ischemic and neovascular disease is one of the most difficult ocular diseases to deal with nowadays. Redundancy, poor visual acuity and decreased life quality are bothering patients and ophthalmologists for decades. After vascular endothelial growth factor (VEGF) was found to be a primary factor in promoting retinal angiogenesis, intravitreal injection of anti-VEGF drugs has been the first-line treatment. Whereas, some patients are refractory to this therapy and problems of economic burden, local complications and adverse effects promote researches into other possible targets. The vasohibin (VASH) family is a newly-investigated factor in modulating ocular angiogenesis. The family includes VASH1 and VASH2, which show opposite effects of inhibiting and accelerating angiogenesis respectively. Positive results have been reported in cellular and animal experiments. With further researches, it can be a promising future target of treating ocular neovascular diseases.

Incidence of New Choroidal Neovascularization in Fellow Eyes of Patients With Age-Related Macular Degeneration Treated With Intravitreal Aflibercept or Ranibizumab

Importance

Incidence of conversion to neovascular age-related macular degeneration (nAMD) in untreated fellow eyes of patients who are treated for nAMD in 1 eye with anti-vascular endothelial growth factor agents provides important prognostic information to clinically manage patients.

Objective

To investigate the association of treatment assignment (intravitreal aflibercept vs ranibizumab) and baseline characteristics with fellow eye conversion to nAMD in the VEGF (Vascular Endothelial Growth Factor) Trap-Eye: Investigation of Efficacy and Safety in Wet AMD (VIEW) studies.

Design, Setting, and Participants

This post hoc analysis of the VIEW 1 and VIEW 2 studies (randomized, double-masked, active-controlled, multicenter, 96-week, phase 3 trials comparing the efficacy and safety of intravitreal aflibercept in 2457 patients with treatment-naive eyes with nAMD) analyzed a subgroup of participants treated for nAMD in 1 eye who had untreated fellow eyes without neovascularization at baseline. All participants in the VIEW studies were included in 1 of 4 groups: ranibizumab, 0.5 mg, every 4 weeks; aflibercept, 2 mg, every 4 weeks; aflibercept, 0.5 mg, every 4 weeks; or aflibercept, 2 mg, every 8 weeks after 3 injections at 4-week intervals. Data collection in the VIEW studies occurred from July 2007 to August 2011; the data analysis presented in this report took place from April 2016 to November 2018.

Interventions

Patients received no treatment in the fellow eyes unless after conversion to nAMD, when any treatment approved by heath authorities was given per the investigators' discretion.

Main Outcomes and Measures

Incidence of conversion to nAMD in patients with untreated fellow eyes that had not had clinical signs of neovascularization at baseline.

Results

A total of 1561 participants were included in this analysis. At 96 weeks, 375 patients (24.0%) experienced cases of conversion to neovascular disease in the fellow eye, including 107 of the 399 individuals who received ranibizumab, 0.5 mg, every 4 weeks; 93 of the 387 individuals who received aflibercept, 2 mg, every 4 weeks; 84 of the 387 individuals who received aflibercept, 0.5 mg, every 4 weeks; and 91 of the 388 individuals who received aflibercept, 2 mg, every 8 weeks after 3 doses at 4-week intervals. The rates were 18.1, 16.2, 14.7, and 16.0 per 100 patient-years at risk at week 96, respectively. On multivariate analysis, fellow eye conversion was associated with increasing patient age (per 10 years) at baseline (hazard ratio [HR], 1.20 [95% CI, 1.05-1.36]), female sex (HR, 1.32 [95% CI, 1.06-1.63]), intraretinal fluid in the study eye at baseline (HR, 1.28 [95% CI, 1.02-1.61]), and increasing choroidal neovascularization lesion size (per 10 mm2) in the study eye at baseline (HR, 1.29 [95% CI, 1.06-1.57]). Rates of fellow eye conversion were similar with either of the treatments.

Conclusions and Relevance

In this secondary analysis of randomized clinical trial data, patients with active nAMD in 1 eye appeared to have a high risk for fellow eye conversion. Such patients should be monitored closely.

Bilateral Multiple Serous Retinal Detachments Following Bone Marrow Transplantation

Purpose:

To describe a case of bilateral multiple serous retinal detachments (SRD) following bone marrow transplantation (BMT), which showed bilateral response to a single unilateral intravitreal bevacizumab injection.

Case Report:

A 37-year-old man with acute myelogenous leukemia who had received bone marrow transplantation four months prior was referred to our clinic with the chief complaint of gradually decreasing vision in both eyes for three months. During the funduscopic examination, multiple serous retinal detachments (SRD) were observed bilaterally, and he was diagnosed with multiple foci of central serous chorioretinopathy (CSCR). He was advised to discontinue the steroid dosage, which did not make significant improvement, and he was treated with intravitreal bevacizumab injection in the more severely affected eye. One month later, significant improvement was noticed in both eyes.

Conclusion:

Serous retinal detachment is a rare complication following BMT. Significant bilateral improvement after single unilateral intravitreal bevacizumab injection shows not only the possible role of increased level of vascular endothelial growth factor (VEGF) in this case, but also the systemic diffusion of the drug and effect on the contralateral eye following unilateral injection.

Risk of Systemic Adverse Events Associated with Intravitreal Anti-VEGF Therapy for Diabetic Macular Edema in Routine Clinical Practice

PURPOSE

Intravitreal anti-vascular endothelial growth factor (VEGF) pharmacotherapy has become standard of care for the management of diabetic macular edema (DME). The systemic safety profile of this treatment in routine clinical practice remains incompletely understood. We used a large claims database to investigate the risk of systemic serious adverse events (SAEs) in patients receiving anti-VEGF for DME compared with controls treated with macular laser photocoagulation or intravitreal corticosteroid.

DESIGN

Retrospective cohort study.

PARTICIPANTS

By using a large U.S. insurance database, we identified privately insured and Medicare Advantage patients aged ≥18 years treated with anti-VEGF for DME between January 1, 2006, and December 31, 2015, along with control patients receiving macular laser or corticosteroid. We included patients with 1 year of medical coverage before initial DME treatment.

METHODS

We assessed associations between treatment modalities and predefined systemic outcomes using Cox proportional hazards regression. We performed 2 separate comparisons, one between anti-VEGF and macular laser and one between anti-VEGF and corticosteroid. We used inverse propensity score weighting for the first comparison to account for treatment selection bias. For the second, we used 2:1 propensity score matching on demographics, year, and baseline comorbidities because of the smaller number of corticosteroid-treated patients.

MAIN OUTCOME MEASURES

Risk of cerebrovascular disease, myocardial infarction, major bleeding, and all-cause hospitalization occurring within 6 months of initial DME treatment as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

A total of 23 348 patients receiving treatment for DME met inclusion criteria; 13 365 received macular laser, 9219 received intravitreal anti-VEGF, and 764 received intravitreal corticosteroid as initial treatment. Anti-VEGF pharmacotherapy was not associated with an increased hazard of cerebrovascular disease (HR, 0.96; 95% CI, 0.65-1.41; P = 0.83), major bleeding (HR, 1.23; 95% CI, 0.76-1.99; P = 0.41), or myocardial infarction (HR, 1.03; 95% CI, 0.73-1.44; P = 0.88) when compared with macular laser for DME; however, there was an increased hazard of post-treatment all-cause hospital admission (HR, 1.17; 95% CI, 1.05-1.30; P = 0.01). The rates of all primary systemic SAE outcomes were similar after treatment with anti-VEGF versus corticosteroid (P > 0.05 for all).

CONCLUSIONS

We identified no increased risk of cerebrovascular disease, myocardial infarction, or major bleeding within 6 months after intravitreal anti-VEGF pharmacotherapy for the treatment of DME in routine clinical practice. A potential difference in all-cause hospitalization may merit further investigation.

Mortality after a cerebrovascular event in age-related macular degeneration patients treated with bevacizumab ocular injections

PURPOSE

To analyse the mortality associated with intravitreal injections of bevacizumab for age-related macular degeneration (AMD) in patients previously diagnosed with stroke or transient ischaemic attack (TIA).

METHODS

We reviewed bevacizumab-treated AMD patients with a diagnosis of stroke or TIA prior to their first bevacizumab injection (n = 948). Those patients, naïve to any anti-vascular endothelial growth factor (anti-VEGF) at the time of stroke/TIA, were then compared to age- and gender-matched patients who had a stroke/TIA at the same time and had never been exposed to anti-VEGF. Survival analysis was performed using adjusted Cox regression. The main outcome measure was survival. Adjusted variables were age, smoking, alcohol abuse, hypertension, diabetes mellitus, obesity, ischaemic heart disease, congestive heart failure and liver cancer.

RESULTS

Age and gender distribution of bevacizumab-treated patients and controls were similar (mean age: 83.4 versus 83.7 years, p = 0.3; 51.7% males versus 52.5% males, p = 0.7). The adjusted mortality in patients who received bevacizumab within 3 months after stroke/TIA was significantly different than in patients non-exposed to bevacizumab (OR = 6.92, 95%, CI 1.88-25.43, p < 0.01). Within 6 months after stroke/TIA, the difference in adjusted mortality showed a strong trend (OR = 2.00, 95%, CI 0.96-4.16, p = 0.064). Within 12 months, it was insignificant (OR = 1.30, 95%, CI 0.75-2.26, p = 0.348).

CONCLUSION

We found increased mortality within three months after a cerebrovascular event in patients treated with bevacizumab for AMD compared to patients for whom there was no record of a prescription to any anti-VEGF agent.

Role of combined phacoemulsification and intravitreal injection of bevacizumab in prevention of postoperative macular edema in non-proliferative diabetic retinopathy

Purpose

To evaluate the role of combined phacoemulsification and intravitreal injection of bevacizumab in prevention of postoperative diabetic macular edema (DME) in patients with no diabetic retinopathy or non-proliferative diabetic retinopathy (NPDR) and without macular edema.

Methods

In a prospective randomized clinical trial, 71 eyes from 71 diabetic patients with no diabetic retinopathy or mild NPDR and with central macular thickness (CMT) of less than 300 μm were enrolled and were randomized into two groups: combined phacoemulsification and intravitreal bevacizumab injection group and only phacoemulsification group. Our primary outcome measures included best corrected visual acuity (BCVA), CMT, and total macular volume (TMV) before and after (1 month and 3 months) the cataract surgery.

Results

The two groups did not show any significant difference in terms of baseline BCVA, age, CMT, stage of diabetic retinopathy. While the bevacizumab group showed lower CMT one month after the surgery compared to control group (267.3 ± 31.8 and 293.6 ± 53.7, respectively, P = 0.019), this difference did not remain significant 3 months after surgery (264.5 ± 21.9 and 291.4 ± 79.8, P = 0.089). The TMV and BCVA in the two groups showed no significant difference one month or 3 months after surgery. Considering our definition of post-cataract surgery diabetic macular edema (PME) in this study [CMT >300 μm using spectral domain optical coherence tomography (SD-OCT)], there was no significant difference between the incidence of PME at 1 month and at 3 months after surgery.

Conclusions

Although the intravitreal injection of bevacizumab during phacoemulsification would result in decreased macular thickness in patients with no diabetic retinopathy or NPDR and without macular edema in the early postoperative period, this effect would no longer persistent at 3 months. In addition, the BCVA and TMV showed no significant difference between the two groups at any time during follow-up period.

POOLED ESTIMATES OF INCIDENCE OF ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS WITH AND WITHOUT TOPICAL ANTIBIOTIC PROPHYLAXIS

PURPOSE

To assess the effect of topical antibiotic prophylaxis on postoperative endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.

METHODS

A systematic literature search was performed from inception to March 2016 using PubMed, Medline, Web of Science, Embase, and the Cochrane Library, to identify articles that reported cases of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. We used a pooled analysis to estimate the incidence of cases of endophthalmitis who developed after injections performed with and without topical antibiotic prophylaxis. We used regression analysis to explore the effects of study characteristics on heterogeneity.

RESULTS

From our search of electronic databases, we identified and screened 4,561 unique records. We judged 60 articles to have reported findings for cohorts of patients who met our inclusion criteria, (12 arms of randomized clinical trials, 11 prospective cohort studies, and 37 retrospective cohort studies), which included 244 cases of endophthalmitis and 639,391 intravitreal injections of anti-vascular endothelial growth factor agents. The final pooled estimate endophthalmitis proportions were 9/10,000 (95% confidence interval, 7/10,000-12/10,000) in the antibiotic-treated group and 3/10,000 (95% confidence interval, 2/10,000-5/10,000) in the untreated group. The estimated incidence of endophthalmitis with topical antibiotic prophylaxis was approximated three times the incidence without prophylaxis. Random effects regression showed that none of the study characteristics significantly affected the effect size in either group.

CONCLUSION

Topical antibiotic after intravitreal injection of anti-vascular endothelial growth factor agents is associated with a higher risk of endophthalmitis.

Mortality associated with bevacizumab intravitreal injections in age-related macular degeneration patients after acute myocardial infarct: a retrospective population-based survival analysis

BACKGROUND

Intraocular injections of antivascular endothelial growth factor (VEGF) agents are currently the main therapy in age-related macular degeneration (AMD). The safety of bevacizumab, an anti-VEGF compound frequently delivered off label, is debated, particularly for high-group risks. We aim to analyze the mortality associated with intravitreal injections of bevacizumab for AMD in patients previously diagnosed with acute myocardial infarct (MI).

METHODS

In a national database, we identified bevacizumab-treated AMD patients with a diagnosis of MI prior to their first bevacizumab injection, delivered between September 2008 and October 2014 (n = 2100). We then generated sub-groups of patients treated within 3 months (n = 11), 6 months (n = 24), 12 months (n = 52), and 24 months (n = 124) after MI. Those patients were compared to age- and gender-matched members that had a MI at the same time and had never been exposed to anti-VEGF. Survival analysis was performed using propensity score-adjusted Cox regression.

RESULTS

Bevacizumab-treated patients were slightly and insignificantly older than controls (mean age 83.25 vs 83.19 year, P = .75). Gender distribution was similar. In a Cox regression adjusted with propensity score, the following differences in mortality were found: within 3 months between MI and initiation of bevacizumab treatment, OR = 6.22 (95% C.I 1.08-35.97, P < .05); within 6 months, OR = 2.37 (95% C.I 0.93-6.02, P = .071); within 12 months, OR = 3.00 (95% C.I 1.44-6.28, P < .01); within 24 months after MI, OR = 2.24 (95% C.I 1.35-3.70, P < .01); and MI any time prior to first bevacizumab injection, OR = 1.71 (95% C.I 1.53-1.92, P < .001).

CONCLUSIONS

We report increased mortality associated with the use of intravitreal bevacizumab in AMD patients after MI, compared to age- and gender-matched post-MI patients with no exposure to any anti-VEGF agent. Caution should be taken while offering bevacizumab to AMD patients after MI.

Evaluation of effect of bevacizumab on central subfield macular thickness in the injected and contralateral (untreated) eye of patients with bilateral diabetic macular oedema

Purpose

Antivascular endothelial growth factor (anti-VEGFs)—bevacizumab is routinely utilised for the treatment of diabetic macular oedema (DME). We plan to evaluate the impact of bevacizumab on the central subfield macular thickness (CSMT) of the treated and untreated eye.

Methods

A sequential group of patients with bilateral DME who were treated with unilateral bevacizumab injection were assessed preinjection and postinjection by Spectral Domain-Optical Coherence Tomography (SD-OCT) by CSMT.

Results

Thirty-one patients, 20 male and 11 female, were evaluated. Seven patients had type 1 diabetes mellitus and 24 had type 2 diabetes mellitus. In regard to the duration of disease, 23 patients had diabetes for more than 10 years, seven patients had the condition for 5–10 years and one patient for more than 5 years. Mean age of the patients was 60.48 years (SD±7.13) with the range of 46–72 years. Mean follow-up was 28 days (range 26–35 days). The eyes which received intravitreal injection had median CSMT of 473.2 µm(range 321–566 µm). The CSMT of the contralateral eye had median of 347.6 µm (range 357–437 µm). A median reduction of −132 µm (range 93–156 µm) could be observed in the treated eye and −18 µm (range 15–22) in the untreated eye after treatment. Our study also found that eyes with greater CSMT, when injected with bevacizumab, produced higher responses in the contralateral eye (R² 0.538, P<0.05).

Conclusions

Patients with bilateral DME treated with bevacizumab in one eye produced a bilateral response. Eyes with greater CSMT due to DME elicited higher levels of response in the untreated eye.

Norrin treatment improves ganglion cell survival in an oxygen-induced retinopathy model of retinal ischemia

Treatment of a mouse model of oxygen-induced retinopathy (OIR) with recombinant human Norrin (Norrie Disease Protein, gene: NDP) accelerates regrowth of the microvasculature into central ischemic regions of the neural retina, which are generated after treatment with 75% oxygen. While this reduces the average duration and severity of ischemia overall, we do not know if this accelerated recovery of the microvasculature results in any significant survival of retinal ganglion cells (RGCs). The purpose of this study was to investigate ganglion cell survival with and without the intravitreal injection of Norrin in the murine model of oxygen induced retinopathy (OIR), using two strains of mice: C57BL/6J and Thy1-YFP mice. Intravitreal injections of Norrin or vehicle were done after five days of exposure to 75% oxygen from ages P7 to P12. The C57BL/J mice were followed by Spectral-Domain Optical Coherence Tomography (SD-OCT), and the average nerve fiber layer (NFL) and inner-plexiform layer (IPL) thicknesses were measured at twenty-four locations per retina at P42. Additionally, some C57BL/J retinas were flat mounted and immunostained for the RGC marker, Brn3a, to compare the population density of surviving retinal ganglion cells. Using homozygous Thy1-YFP mice, single intrinsically fluorescent RGCs were imaged in live animals with a Micron-III imaging system at ages P21, 28 and P42. The relative percentage of YFP-fluorescent RGCs with dendritic arbors were compared. At age P42, the NFL was thicker in Norrin-injected OIR eyes, 14.4 μm, compared to Vehicle-injected OIR eyes, 13.3 μm (p = 0.01). In the superior retina, the average thickness of the IPL was greater in Norrin-injected OIR eyes, 37.7 μm, compared to Vehicle-injected OIR eyes, 34.6 μm (p = 0.04). Retinas from Norrin injected OIR mice had significantly more surviving RGCs (p = 0.03) than vehicle-injected mice. Based upon NFL thickness and counts of RGCs, we conclude that Norrin treatment, early in the ischemic phase, increased the relative population density of surviving RGCs in the central retinas of OIR mice.

Effect of intravitreal ranibizumab on the ocular circulation of the untreated fellow eye

Purpose

To evaluate the effects of unilateral intravitreal ranibizumab (IVR) on the ocular circulation of the fellow eyes.

Methods

Fifteen eyes of 15 patients with macular edema (average age 69.6 ± 11.8 years) were studied. Eleven eyes had diabetic macular edema (DME) and four eyes had macular edema associated with a branch retinal vein occlusion. Each eye received 0.5 mg of IVR. The blood circulation on the optic nerve head of the treated and untreated eyes were determined by laser speckle flowgraphy (LSFG, Softcare Co., Ltd) before, 1 day, and 1 week after the IVR. The mean blur rate (MBR) and the relative changes of the MBRs determined as dMBR(%) = 100−(MBR before/MB after) × 100) were evaluated. The central macular thickness (CMT) and the rate of reduction in the thickness (dCMT = 100−(CMT before/CMT after) × 100) were also evaluated.

Results

The mean dMBR was significantly higher in the treated eyes than the untreated eyes at 1 day (−16.4 ± 17.0% vs 2.31 ± 19.3%) and at 1 week (−12.0 ± 14.6% vs 4.50 ± 25.9%) after the IVR (P = 0.02, paired t tests).

Conclusion

These findings indicate that if ranibizumab enters the systemic circulation, the concentration is not high enough to affect the ocular circulation of the fellow eyes.

Reduction of Diabetic Macular Edema in the Untreated Fellow Eye Following Intravitreal Injection of Aflibercept

A 59-year-old patient with bilateral worsening diabetic macular edema received intravitreal injection of aflibercept (Eylea; Regeneron, Tarrytown, NY) to the left eye only. On 1-month follow-up, there was noted bilateral improvement of visual acuity and diabetic macular edema on spectral-domain optical coherence tomography imaging, reflecting bilateral effect of unilateral treatment with aflibercept. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:474-476.].

Considerations for management of patients with diabetic macular edema: Optimizing treatment outcomes and minimizing safety concerns through interdisciplinary collaboration

Diabetes is a growing worldwide epidemic and a leading cause of blindness in working-age people around the world. Diabetic retinopathy (DR) and diabetic macular edema (DME) are common causes of visual impairment in people with diabetes and often indicate the presence of diabetes-associated preclinical micro- and macrovascular complications. As such, patients with DR and DME often display complex, highly comorbid profiles. Several treatments are currently available for the treatment of DME, including anti-vascular endothelial growth factor (VEGF) agents, which are administered via intravitreal injection. While the safety profiles of approved ocular anti-VEGF therapies have been reassuring, the high-risk nature of the DME patient population means that treatment must be carefully considered and a holistic approach to disease management should be taken. This requires multidisciplinary, collaborative care involving all relevant specialties to ensure that patients not only receive prompt treatment for DME but also appropriate consideration is taken of any systemic comorbidities to evaluate and minimize potentially serious safety issues.

Novel pharmacotherapies in diabetic retinopathy: Current status and what's in the horizon?

The blood-retinal barrier (BRB) alteration is the hallmark feature of diabetic retinopathy. Vascular endothelial growth factor (VEGF) is a potent vasopermeability factor that has been implicated in the pathogenesis of BRB alteration. Inflammation also plays a crucial role in this process with involvement of several chemokines and cytokines. Multiple anti-VEGF drugs are widely used as in the treatment of diabetic macular edema (DME) as well as proliferative diabetic retinopathy. Several clinical trials have proved the beneficial effects of these drugs in improvement of vision and prevention of vision loss. However, the response to anti-VEGF drugs in DME is not complete in a significant number of patients. The effect seems transient in this latter group, and many patients do not show complete resolution of fluid. Potential novel therapies targeting molecules beyond VEGF are being developed and examined in clinical trials.

The effect of intravitreal bevacizumab and ranibizumab on macular edema of the contralateral eye: A comparative study of two anti-VEGFs

Purpose:

To compare the effects of bevacizumab and ranibizumab on the visual function and macular thickness in the contralateral (untreated) eye of patients with bilateral diabetic macular edema (DME).

Materials and Methods:

Thirty-nine patients with bilateral DME, who had been treated with both bevacizumab and ranibizumab in the same eye, were considered retrospectively for this study. Recorded outcome measurements included the best-corrected visual acuity (BCVA) assessment with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the central subfield macular thickness (CSMT) measurement of the contralateral, uninjected eye before and at 4 weeks after the injections.

Results:

The median BCVA of the uninjected eye was 50 ETDRS letters and the median CSMT was 459 μm preceding the bevacizumab injection whereas at the control appointment, 4 weeks after the injection, the median BCVA had increased to 52 letters (P = 0.098), and the median CSMT had decreased to 390 μm (P = 0.036). The mean interval between the bevacizumab and ranibizumab treatments was 4.79 ΁ 1.52 months. The measurements of the untreated eye after the ranibizumab treatment showed that the median BCVA decreased from 55 to 52 letters, and the median CSMT increased from 361 μm to 418 μm (P = 0.148 and P = 0.109, respectively).

Conclusions:

In contrast to ranibizumab, the intravitreal administration of bevacizumab resulted in a statistically significant decrease in macular thickness in the untreated eye in patients with bilateral DME.

Reactivation of retinopathy of prematurity after ranibizumab treatment

INTRODUCTION

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the developing retina and a significant cause of childhood blindness around the world. Vascular endothelial growth factor (VEGF) plays an important role in the neovascular phase of ROP, and treatment with an anti-VEGF agent is justified in select cases. Bevacizumab is the most commonly used anti-VEGF agent in ROP, but ranibizumab has a shorter half-life with the potential for decreased systemic toxicity. The purpose of this study is to report our experience with anti-VEGF agents for the treatment of ROP.

METHODS

A retrospective chart review was performed on consecutive infants screened for ROP. Infants treated with peripheral retinal ablation, bevacizumab 0.625 mg/0.025 mL, or ranibizumab 0.25 mg/0.025 mL were specifically identified for review of their clinical outcomes. All treated infants had at least 6 months of follow-up with the treating team and were examined until total regression of ROP.

RESULTS

One hundred and forty-two infants were screened over a two-year period. Six infants received anti-VEGF agents, with a mean gestational age of 23.48 weeks and mean birth weight of 620 g. Ten eyes from the six infants received anti-VEGF treatment. All ten eyes demonstrated initial regression of ROP. However, ROP reactivation occurred in 5/6 (83%) eyes treated with ranibizumab, on average 5.9 weeks after treatment; whereas none of the 4 eyes treated with bevacizumab experienced reactivation (P < 0.05). One infant who received a unilateral injection of ranibizumab demonstrated bilateral regression of ROP.

CONCLUSION

The role of anti-VEGF treatment for ROP is still being evaluated. Although the shorter half-life of ranibizumab makes it an attractive option, reactivation of ROP is possible. Physicians and families should be aware of this to follow infants closely for an extended period of time.

Posterior sub-tenon's bevacizumab injection in diabetic macular edema; a pilot study

Purpose

To evaluate the short-term results of sub-tenon’s injection of bevacizumab in patients with clinically significant macular edema (CSME).

Methods

In this prospective non-comparative interventional case series, sub-tenon’s injection of 2.5 mg/0.1 ml bevacizumab was performed for eyes with CSME. Macular thickness and best corrected visual acuity measurements were performed before and one month after injections.

Results

Nineteen eyes of twelve patients with a mean age of 59.8 ± 5.7 years were evaluated. Thirteen eyes (68.4%) had center-involving macular edema. No significant difference was observed between pre- and post-injection central subfield retinal thickness measurements (P = 0.3). Central subfield thickness measurements improved or remained unchanged in 13 eyes (68.4%). Baseline BCVA of 0.48 ± 0.35 LogMAR improved to 0.36 ± 0.26 LogMAR after injection (P = 0.01). Improvement of >2 lines in BCVA was found in 5 eyes (26.3%), and no eye lost >2 lines of BCVA. No complication associated with sub-tenon’s injection was observed.

Conclusion

Sub-tenon’s injection of bevacizumab resulted in significant short-term visual improvement in eyes with CSME. Retinal thickness changes were not significant.

Spectral-Domain OCT Analyses of Macular Changes After Ranibizumab Therapy for Type 1 Retinopathy of Prematurity

PURPOSE

To investigate the clinical and macular spectral-domain optical coherence tomography (SD-OCT) findings after intravitreal ranibizumab treatment for type 1 retinopathy of prematurity (ROP).

METHODS

Eighteen eyes of 10 premature infants with type 1 ROP were retrospectively studied. All eyes were treated with intravitreal ranibizumab as monotherapy. Macular SD-OCT was performed before and after intravitreal ranibizumab therapy using a portable SD-OCT machine; the follow-up images were taken 1 day, 1 week, 1 month, and 2 months after therapy.

RESULTS

Among the 10 infants, there were six males and four females. Mean central foveal thickness before and 2 months after intravitreal ranibizumab was 292.5 ± 61.4 and 171.6 ± 21.7 µm, respectively. Differences were statistically significant (P = .01). Sixteen eyes of eight patients had macular edema before treatment. Two eyes of two patients developed a crack in the outer hyperreflective line on SD-OCT corresponding with retinal pigment epithelium with serous retinal detachment 1 day after treatment. Macular edema regressed in all patients 2 months after intravitreal ranibizumab therapy. Mean follow-up time was 11.4 ± 1.5 months. No recurrence was seen except in both eyes of one patient treated with intravitreal ranibizumab monotherapy.

CONCLUSIONS

Intravitreal ranibizumab injection is effective for the treatment of type 1 ROP as a monotherapy agent; however, macular changes not seen with indirect ophthalmoscope may develop.

Progression to macula-off tractional retinal detachment after a contralateral intraoperative intravitreal bevacizumab injection for proliferative diabetic retinopathy

We report a patient with progression to a macula-off tractional retinal detachment in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection. A 32-year-old diabetic man noted decreased vision in his left eye 1 week following 25 gauge pars plana vitrectomy, gas tamponade, and intraoperative injection of bevacizumab in his right eye. Left eye visual acuity decreased from 20/80 to 20/200, and macula-off tractional retinal detachment was seen on clinical exam and imaging. Progression of tractional retinal detachment associated with proliferative diabetic retinopathy in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection may occur.

Systemic pharmacokinetics following intravitreal injections of ranibizumab, bevacizumab or aflibercept in patients with neovascular AMD

Background

Data comparing systemic exposure and systemic vascular endothelial growth factor (VEGF) suppression of ranibizumab, bevacizumab and aflibercept following intravitreal injection are lacking.

Methods

Fifty-six patients with wet age-related macular degeneration received intravitreal ranibizumab (0.5 mg), bevacizumab (1.25 mg), or aflibercept (2.0 mg). Serum pharmacokinetics and plasma free VEGF were evaluated after the first and third injections.

Results

Following the first dose, systemic exposure to aflibercept was 5-, 37-, and 9-fold higher than ranibizumab, whereas, bevacizumab was 9-, 310-, and 35-fold higher than ranibizumab, based on geometric mean ratio of peak and trough concentrations and area under the curve, respectively. The third dose showed accumulation of bevacizumab and aflibercept but not ranibizumab. Aflibercept substantially suppressed plasma free VEGF, with mean levels below lower limit of quantitation (10 pg/mL) as early as 3 h postdose until ≥7 days postdose. Mean free (unbound) VEGF levels with ranibizumab were largely unchanged, with mean trough level of 14.4 pg/mL compared with baseline of 17 pg/mL.

Conclusions

There are notable differences in systemic pharmacokinetics and pharmacodynamics among anti-VEGF treatments after intravitreal administration. All three agents rapidly moved into the bloodstream, but ranibizumab very quickly cleared, whereas bevacizumab and aflibercept demonstrated greater systemic exposure and produced a marked reduction in plasma free VEGF.

Trial registration number

NCT02118831.

Fellow eye effect of unilateral intravitreal bevacizumab injection in eyes with diabetic macular edema

AIMS

Anti-vascular endothelial growth factor compounds are routinely used for the treatment of diabetic macular edema (DME). We aim to evaluate for the existence and magnitude of treatment effect on fellow un-injected eyes.

METHODS

A consecutive group of patients with bilateral DME who received unilateral bevacizumab injections was retrospectively evaluated. Data collected included demographics, ophthalmic and systemic findings, and optical coherence tomography (OCT) measurements of macular thickness.

RESULTS

Thirty-five patients were evaluated. Mean follow-up was 245 days (range: 30-800), and the mean number of bevacizumab injections was 3.6 (range: 1-11). At end of follow-up, the mean (SD) OCT central subfield thickness reduced by 72 ± 112 micron in the injected eye (from 469 ± 139 to 397 ± 120 micron; P=0.001), while in the non-injected eye it reduced by 49 ± 75 micron (from 380 ± 130 to 331 ± 106 micron; P<0.001). Sixteen injected eyes (45.7%) showed central subfield thickness reduction of ≥50 micron while 10 (28.6%) non-injected eyes showed such thickness reduction. Improved VA following treatment was detected in 14 (40%) injected eyes and in 15 (43%) non-injected eyes.

CONCLUSIONS

Unilateral bevacizumab injections in patients with bilateral DME are often associated with bilateral response.

SUMMARY STATEMENT

Anti-vascular endothelial growth factor compounds are routinely used for the treatment of diabetic macular edema (DME). In this retrospective study, we show that unilateral bevacizumab injections often result in reduction of the macular thickness in the fellow un-injected eye.

Intravitreal bevacizumab injection in unrecognised early pregnancy

PURPOSE

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age.

PATIENTS AND METHODS

We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women.

RESULTS

All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history.

CONCLUSION

This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

Pharmacokinetics, pharmacodynamics and pre-clinical characteristics of ophthalmic drugs that bind VEGF

Drugs that prevent the binding of VEGF to its trans-membrane cognate receptors have revolutionized the treatment of the most important chorioretinal vascular disorders: exudative age-related macular degeneration, diabetic macular edema, and retinal vein occlusions. Pegaptanib, which binds to VEGF165 and longer isoforms, ranibizumab and bevacizumab, which bind all VEGF-A isoforms, and aflibercept, which binds VEGF-A, VEGF-B, and placental growth factor, all bind VEGF165 with high affinity. The drugs have relatively long half-lives (7 to 10 days) after intravitreal depot injections and clinical durations of action that usually exceed 4 weeks. Plasma VEGF concentrations decrease after intravitreal injections of bevacizumab and aflibercept because their systemic half-lives are extended by their Fc fragments. Extensive in vitro and in vivo testing shows that the drugs prevent VEGF-mediated activation of endothelial cells while exhibiting little evidence of toxicity. Further anti-VEGF drug development is on-going.

What is the evidence for systemic effects of intravitreal anti-VEGF agents, and should we be concerned?

Anti-vascular endothelial growth factor (VEGF) therapy has revolutionised the treatment of retinal disease, and appears to be very safe. Nevertheless, there are several lines of evidence that imply that small doses of these agents could potentially have a systemic effect. The clinical significance of these systemic effects remains unclear, but further study is indicated.