1
|
Cai R, Zhang L, Chi H. Recent development of polymer nanomicelles in the treatment of eye diseases. Front Bioeng Biotechnol 2023; 11:1246974. [PMID: 37600322 PMCID: PMC10436511 DOI: 10.3389/fbioe.2023.1246974] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023] Open
Abstract
The eye, being one of the most intricate organs in the human body, hosts numerous anatomical barriers and clearance mechanisms. This highlights the importance of devising a secure and efficacious ocular medication delivery system. Over the past several decades, advancements have been made in the development of a nano-delivery platform based on polymeric micelles. These advancements encompass diverse innovations such as poloxamer, chitosan, hydrogel-encapsulated micelles, and contact lenses embedded with micelles. Such technological evolutions allow for sustained medication retention and facilitate enhanced permeation within the eye, thereby standing as the avant-garde in ocular medication technology. This review provides a comprehensive consolidation of ocular medications predicated on polymer nanomicelles from 2014 to 2023. Additionally, it explores the challenges they pose in clinical applications, a discussion intended to aid the design of future clinical research concerning ocular medication delivery formulations.
Collapse
Affiliation(s)
- Ruijun Cai
- Department of Pharmacy, The People’s Hospital of Jiuquan, Jiuquan, Gansu, China
| | - Ling Zhang
- Department of Pharmacy, The People’s Hospital of Jiuquan, Jiuquan, Gansu, China
| | - Hao Chi
- Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| |
Collapse
|
2
|
Daka Q, Špegel N, Atanasovska Velkovska M, Steblovnik T, Kolko M, Neziri B, Cvenkel B. Exploring the Relationship between Anti-VEGF Therapy and Glaucoma: Implications for Management Strategies. J Clin Med 2023; 12:4674. [PMID: 37510790 PMCID: PMC10380425 DOI: 10.3390/jcm12144674] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
A short-term increase in intraocular pressure (IOP) is a common side effect after intravitreal anti-VEGF therapy, but a sustained increase in IOP with the development of secondary glaucoma has also been reported in some studies after repeated intravitreal anti-VEGF injections. The aim of this review is to present and discuss the possible pathophysiological mechanisms and factors contributing to a sustained rise in IOP, as well as treatment strategies for patients at risk. Close monitoring and adjustable IOP-lowering treatment are recommended for high-risk patients, including those with glaucoma, angle-closure anomalies, ocular hypertension or family history of glaucoma; patients receiving a high number of injections or at shorter intervals; and patients with capsulotomy. Strategies are needed to identify patients at risk in a timely manner and to prevent sustained elevation of IOP.
Collapse
Affiliation(s)
- Qëndresë Daka
- Department of Pathophysiology, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
- Eye Clinic, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
- Department of Ophthalmology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Nina Špegel
- Department of Ophthalmology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | | | - Tjaša Steblovnik
- Department of Ophthalmology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Miriam Kolko
- Department of Drug Design and Pharmacology, University of Copenhagen, 2100 Copenhagen, Denmark
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
| | - Burim Neziri
- Department of Pathophysiology, Medical Faculty, University of Prishtina, 10000 Prishtina, Kosovo
| | - Barbara Cvenkel
- Department of Ophthalmology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| |
Collapse
|
3
|
Bae SS, Koenigstein D, Weaver T, Merkur A, Albiani D, Pakzad-Vaezi K, Kirker A. Incidence of ocular hypertension after anti-VEGF injections: examining the effect of drug filtration and silicone-free syringes. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:66-72. [PMID: 34331870 DOI: 10.1016/j.jcjo.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the difference in incidence of ocular hypertension (OHT) following the introduction of filtered anti-vascular endothelial growth factor (anti-VEGF) medication in silicone-free syringes. DESIGN Retrospective cohort study. METHODS A retrospective review of consecutive treatment-naive patients receiving intravitreal anti-VEGF injections in a group practice was performed. Data from the cohort receiving nonfiltered anti-VEGF in insulin syringes (IS group) was collected from June 2015. Data from the cohort receiving filtered anti-VEGF in silicone-free syringes (SFS group) was collected from June 2019. Follow up data were collected at 1 year. Exclusion criteria included prior anti-VEGF treatment, known glaucoma or diagnosis of glaucoma suspect before anti-VEGF treatment, neovascular glaucoma, steroid use, or vitrectomy during follow-up. Primary outcome was the cumulative incidence of intraocular pressure (IOP) > 21 mmHg and IOP ≥ 30 mm Hg at any follow-up visit. The use of IOP lowering therapy was also recorded. RESULTS The mean age (71 ± 13 years), mean number of injections (9.6 ± 2.7), and median follow-up time (392 ± 57 days) were similar between groups. The incidence of IOP ≥ 21 mm Hg was 34% (34/100) in the IS group and 15% (15/100) in the SFS group (p = 0.025). The incidence of IOP ≥ 30 mm Hg was 8% (8/100) in the IS group and 0% (0/100) in the SFS group (p =0.004). The incidence of IOP-lowering therapy was 13% in the IS group and 0% in the SFS group (p =0.0002). CONCLUSION The incidence of OHT and treatment with IOP-lowering therapy significantly decreased after the introduction of filtered anti-VEGF medication and silicone-free syringes.
Collapse
Affiliation(s)
- Steven S Bae
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Dvir Koenigstein
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Travers Weaver
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Merkur
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - David Albiani
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Kaivon Pakzad-Vaezi
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Kirker
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC..
| |
Collapse
|
4
|
Dingerkus VLS, Somfai GM, Kinzl S, Orgül SI, Becker MD, Heussen FM. Incidence of severe rise in intraocular pressure after intravitreous injection of aflibercept with prefilled syringes. Sci Rep 2022; 12:18136. [PMID: 36307473 PMCID: PMC9616868 DOI: 10.1038/s41598-022-23039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/25/2022] [Indexed: 12/30/2022] Open
Abstract
Our aim was to analyze the intraocular pressure (IOP) changes following different intravitreous injection (IVI) procedures with or without prefilled syringes (PFS) and to elaborate their possible causes. Clinical study and laboratory assessment. 173 eyes of 141 patients. The IOP was prospectively measured pre- and postoperatively in three groups of patients receiving IVI either with ranibizumab (RP), aflibercept PFS (AP) or aflibercept vials (AV). The AP emptying volume (EV) was assessed using 40 aflibercept PFS vials: the plunger was aligned precisely (normal volume, NV) or right below the indication line (high volume, HV) and the drug was ejected with (wP) or without forced pressure (nP). Primary outcome was post-treatment IOP with type of IVI and pre-treatment IOP as fixed factors. Secondary outcome was identification of possibly confounding factors (age, sex, pathology, presence of pseudophakia, spherical error, and number of injections) and IOP > 30 mmHg post-treatment. An IOP rise above 30 mmHg was observed in 8/38 (22%), 16/51 (31%) and 35/86 (41%) cases in the RP, AV and AP groups, respectively (p = 0.129). Pre-treatment IOP was the only predictive variable for IOP rise (p < 0.001). The EV values in the NVnP, NVwP, HVnP and HVwP groups were 56.06 ± 10.32, 70.69 ± 4.56, 74.22 ± 7.41 and 81.63 ± 3.67 µl, respectively (p < 0.001). We observed a marked, although not significantly higher incidence of IOP elevations with the aflibercept PFS. One possible reason may be the error-proneness of administering the correct volume with the AP. Caution should be taken when using the aflibercept PFS in order to prevent potential optic nerve damage in cases with marked elevation in IOP.
Collapse
Affiliation(s)
- Vita Louisa Sophie Dingerkus
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland
| | - Gabor Mark Somfai
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland
| | - Stephan Kinzl
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland
| | - Selim Ismet Orgül
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland
| | - Matthias Dieter Becker
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland ,grid.7700.00000 0001 2190 4373Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany
| | - Florian Moritz Heussen
- Werner H. Spross Foundation for the Advancement of Research and Teaching in Ophthalmology, Zurich, Switzerland ,Department of Ophthalmology, City Hospital Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Faculty of Medicine, University of Zurich, Zurich, Switzerland ,Department of Ophthalmology and Center for Clinical Research and Quality Assurance, Stadtspital Zürich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
| |
Collapse
|
5
|
Sarkar A, Jayesh Sodha S, Junnuthula V, Kolimi P, Dyawanapelly S. Novel and investigational therapies for wet and dry age-related macular degeneration. Drug Discov Today 2022; 27:2322-2332. [PMID: 35460893 DOI: 10.1016/j.drudis.2022.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/13/2022] [Accepted: 04/13/2022] [Indexed: 12/13/2022]
Abstract
Age-related macular degeneration (AMD) is a macular degenerative eye disease, the major cause of irreversible loss of central vision. In this review, we highlight current progress and future perspectives of novel and investigational therapeutic strategies in the drug pipeline, including anti-vascular endothelial growth factor (VEGF) agents, bispecific antibodies, biosimilars, small molecules, gene therapy, and long-acting drug delivery strategies for both dry and wet AMD. We anticipate that biologics with dual functionalities and combined therapies with long-acting capabilities will lead the wet AMD pipeline. Sustained-release platforms also show potential. However, significant breakthroughs are yet to be made for dry AMD. The personalized approach might be well suited in the scenario of diverse genetic variations in both conditions. Teaser: AMD is the leading cause of global blindness in the developed world. This article highlights investigational therapeutics, such as antibodies, Bi-specifics, small molecules, biosimilars, gene therapy and long-acting strategies (Port Delivery System), for this condition.
Collapse
Affiliation(s)
- Aira Sarkar
- Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Srushti Jayesh Sodha
- Department of Pharmaceutical Sciences, University of the Sciences, Philadelphia, PA 19104, USA
| | | | - Praveen Kolimi
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, The University of Mississippi, Oxford, MS 38677, USA
| | - Sathish Dyawanapelly
- Department of Pharmaceutical Science and Technology, Institute of Chemical Technology, Mumbai, 400019, India.
| |
Collapse
|
6
|
Effects of the Presence of Pseudoexfoliation on Intraocular Pressure and Retinal Nerve Fiber Layer Thickness in Patients with Macular Degeneration Receiving Intravitreal Ranibizumab. Clin Pract 2022; 12:78-83. [PMID: 35200261 PMCID: PMC8870721 DOI: 10.3390/clinpract12010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/11/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
Abstract
Aims: In the present study, we aimed to compare the effect of intravitreal ranibizumab (IVR) treatment on intraocular pressure (IOP) and retinal nerve fiber layer (RNFL) thickness in patients with age-related macular degeneration (AMD) with and without pseudoexfoliation (PEX). Materials and Methods: A total of 24 patients, 12 with PEX (12 eyes) and 12 without PEX (12 eyes), receiving IVR treatment for neovascular AMD between June 2017 and June 2019, were included in the study. Exclusion criteria were composed of the history of glaucoma, uveitis, intravitreal steroid administration, pars plana vitrectomy surgery, and less than three IVR injections. Such criteria as age, gender, follow-up times, number of injections administered, IOP, and RNFL thickness before the first injection and one month after the last injection were also recorded. Results: Age, gender, follow-up time, and the number of injections were similar in groups with and without PEX (p > 0.05). While mean post-treatment IOP values were not significantly higher in the PEX group (14.50 ± 3.06 vs. 12.91 ± 1.83 mmHg, p = 0.065), the values were significant for the non-PEX group (13.25 ± 2.76 vs. 11.83 ± 2.69 mmHg, p = 0.01), and these values were within normal IOP limits. Additionally, RNFL thickness was significantly thinner after treatment in both groups (91.41 ± 7.14 vs. 94.00 ± 6.76 in those with PEX; 95.58 ± 5.91 vs. 97.66 ± 6.89 in those without PEX; p < 0.05). The decrease in RNFL thickness in the PEX group was 2.58 ± 1.62 µ and in the non-PEX group was 2.08 ± 1.98 µ. However, there was no statistically significant difference between the two groups in terms of RNFL thinning (p = 0.505). Discussion: Ranibizumab may reduce RNFL thickness in patients with PEX. Longer-term studies including larger populations are necessary for understanding IOP and RNFL changes after anti-vascular endothelial growth factor (anti-VEGF) injection.
Collapse
|
7
|
Erichev VP, Tarasenkov AO, Andreeva YS. [Ocular hypertension after intravitreal injections]. Vestn Oftalmol 2022; 138:234-239. [PMID: 36287161 DOI: 10.17116/oftalma2022138052234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) for the treatment of age-related macular degeneration with choroidal neovascularization have become much more popular nowadays. Anti-VEGF therapy is generally well-tolerated; however, one of its possible side effects is ocular hypertension - elevation of intraocular pressure (IOP) above the accepted norm, but without structural and functional changes in the retina and optic nerve common for glaucoma. The average duration of IOP elevation is 30 to 60 minutes, but it can increase when the patient has primary open-angle glaucoma (POAG). There is currently no uniform understanding of the pathogenesis of elevated IOP after IVI, as well as the effect of IOP fluctuations on the functional prognosis and the condition of the ocular tunics. This review considers the main causes and mechanisms of IOP elevation after IVI, analyzes recent publications on the consequences of ocular hypertension for the neurosensory part of the retina and the optic nerve, and examines the conditions for transition of IOP fluctuations into clinically significant ocular hypertension or POAG.
Collapse
Affiliation(s)
- V P Erichev
- Research Institute of Eye Diseases, Moscow, Russia
| | | | | |
Collapse
|
8
|
Nanji K, Sarohia GS, Kennedy K, Ceyhan T, McKechknie T, Phillips M, Devji T, Thabane L, Kaiser P, Sarraf D, Garg SJ, Sivaprasad S, Wykoff CC, Bakri S, Sheidow T, Bhandari M, Chaudhary V. The 12- and 24-Month Effects of Intravitreal Ranibizumab, Aflibercept and Bevacizumab on Intraocular Pressure: A Network Meta-Analysis. Ophthalmology 2021; 129:498-508. [PMID: 34871637 DOI: 10.1016/j.ophtha.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/09/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
Abstract
TOPIC To investigate the effect of anti-vascular endothelial growth factor (VEGF) intravitreal injections on intraocular pressure (IOP) 12- and 24-months after initiation. CLINICAL RELEVANCE It is unclear whether serial anti-VEGF injections result in sustained increases in IOP. METHODS Randomized control trials (RCTs) comparing anti-VEGF agents to each other or to a control for the treatment of neovascular age-related macular degeneration, retinal vein occlusions or diabetic macular edema were included. Pairwise meta-analysis and Bayesian network meta-analysis were performed examining the proportion of patients at 12- and 24-months whose IOP: a) increased ≥5mmHg from baseline on consecutive visits, b) increased ≥10mmHg from baseline at any visit, c) was ≥21mmHg on consecutive visits, d) was ≥25mmHg at any visit, e) was ≥30mmHg at any visit, f) prompted initiation of IOP lowering medications and g) increased as per the clinicians' discretion. Certainty of evidence was informed by Cochrane Collaboration's Risk of Bias Tool and GRADE (Grading of Recommendations Assessments, Development and Evaluations) guidelines. RESULTS 26 RCTs of 12,522 eyes were included. Aflibercept (2.0mg), bevacizumab (1.25mg), ranibizumab (0.3mg and 0.5mg) and non-injection controls were analyzed. 83 of 84 network estimates for comparisons between anti-VEGF agents demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates than bevacizumab of IOP measurements ≥30mmHg at 12-months (low certainty of evidence). 53 of 56 network estimates for comparisons between anti-VEGF agents and controls demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates of consecutive IOP increases ≥ 5mmHg at 24-months (low certainty of evidence) and higher rates of IOP increases as per the clinicians' discretion at 12 and 24 months (low and very low certainty of evidence respectively). The 95% credible intervals in all comparisons without statistically significant effects did not rule out important clinical effects. The certainty of evidence in these comparisons is limited by imprecision. CONCLUSION Evidence from our network meta-analysis does not show any clear difference between anti-VEGF agents and controls when examining IOP increases 12- and 24-months after treatment initiation. Imprecision precludes definitive conclusions with the available data.
Collapse
Affiliation(s)
- Keean Nanji
- McMaster University, Department of Surgery, Division of Ophthalmology, 2757 King Street East, Hamilton, Ontario, Canada
| | - Gurkaran S Sarohia
- University of Alberta, Department of Ophthalmology and Visual Sciences, 2319 Active Treatment Centre, 10240 Kingsway Avenue NW, Edmonton, Alberta, Canada T5H 3V8
| | - Kevin Kennedy
- McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Tiandra Ceyhan
- Queen's University, Department of Ophthalmology, 166 Brock Street, Kingston, Ontario, Canada
| | - Tyler McKechknie
- McMaster University, Department of Surgery, Division of General Surgery, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Mark Phillips
- McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Tahira Devji
- University of Toronto, Temerty Faculty of Medicine, 1 King's College Circle, Toronto, Ontario, Canada
| | - Lehana Thabane
- McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Peter Kaiser
- Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland OH, USA
| | - David Sarraf
- Retinal Disorders and Ophthalmic Genetics, Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sunir J Garg
- The Retina Service of Wills Eye Hospital, Philadelphia, PA, USA
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | - Charles C Wykoff
- Retina Consultants of Texas, Houston, Texas, Blanton Eye Institute, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Sophie Bakri
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tom Sheidow
- University of Western Ontario, Department of Ophthalmology, Ivey Eye Institute, 268 Grosvenor Street, London, Ontario, Canada
| | - Mohit Bhandari
- McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, Ontario, Canada; McMaster University, Department of Surgery, Division of Orthopedic Surgery, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Varun Chaudhary
- McMaster University, Department of Surgery, Division of Ophthalmology, 2757 King Street East, Hamilton, Ontario, Canada; McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, Ontario, Canada.
| |
Collapse
|
9
|
Levin AM, Chaya CJ, Kahook MY, Wirostko BM. Intraocular Pressure Elevation Following Intravitreal Anti-VEGF Injections: Short- and Long-term Considerations. J Glaucoma 2021; 30:1019-1026. [PMID: 34086610 PMCID: PMC8635259 DOI: 10.1097/ijg.0000000000001894] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
Published studies agree that transient intraocular pressure (IOP) spikes are common after intravitreal injections of anti-vascular endothelial growth factor agents. Currently, there is no standard of care guiding if and when to prevent these IOP spikes. Furthermore, there are challenges in determining the impact of postinjection IOP elevation on the health of the retinal ganglion cells, particularly given the often-existing comorbidities of retinal and glaucoma pathology. This review highlights the current literature regarding both acute and chronic postinjection IOP elevations and discusses management of postinjection IOP elevation, especially in patients at high risk for glaucomatous damage.
Collapse
Affiliation(s)
- Ariana M. Levin
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Craig J. Chaya
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Malik Y. Kahook
- Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO
| | - Barbara M. Wirostko
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
10
|
Sarkar A, Junnuthula V, Dyawanapelly S. Ocular Therapeutics and Molecular Delivery Strategies for Neovascular Age-Related Macular Degeneration (nAMD). Int J Mol Sci 2021; 22:10594. [PMID: 34638935 PMCID: PMC8508687 DOI: 10.3390/ijms221910594] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 12/12/2022] Open
Abstract
Age-related macular degeneration (AMD) is the leading cause of vision loss in geriatric population. Intravitreal (IVT) injections are popular clinical option. Biologics and small molecules offer efficacy but relatively shorter half-life after intravitreal injections. To address these challenges, numerous technologies and therapies are under development. Most of these strategies aim to reduce the frequency of injections, thereby increasing patient compliance and reducing patient-associated burden. Unlike IVT frequent injections, molecular therapies such as cell therapy and gene therapy offer restoration ability hence gained a lot of traction. The recent approval of ocular gene therapy for inherited disease offers new hope in this direction. However, until such breakthrough therapies are available to the majority of patients, antibody therapeutics will be on the shelf, continuing to provide therapeutic benefits. The present review aims to highlight the status of pre-clinical and clinical studies of neovascular AMD treatment modalities including Anti-VEGF therapy, upcoming bispecific antibodies, small molecules, port delivery systems, photodynamic therapy, radiation therapy, gene therapy, cell therapy, and combination therapies.
Collapse
Affiliation(s)
- Aira Sarkar
- Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
| | | | - Sathish Dyawanapelly
- Department of Pharmaceutical Sciences & Technology, Institute of Chemical Technology, Nathalal Parekh Marg, Mumbai 400019, India
| |
Collapse
|
11
|
Keshet Y, Gal-Or O, Schaap Fogler M, Mimouni K, Ben Ishai M, Weinberger D, Dotan A. Aflibercept clearance through the drainage system in a rat model. Int J Retina Vitreous 2021; 7:53. [PMID: 34496977 PMCID: PMC8427964 DOI: 10.1186/s40942-021-00322-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Background As intravitreal anti-VEGF injections became the mainstay of treatment for many retinal diseases, the cause of a secondary sustained elevated intraocular pressure is still unclear. The aim of our study was to study the clearance of Aflibercept from the anterior chamber angle, in a rat model, to test if an aggregation exists. Methods Choroidal neovascular lesions (CNV) were induced in the right eye of 12 brown Norway rats, using indirect laser ophthalmoscope. Intravitreal Aflibercept injection (0.12 mg/3 µl) was performed 3 days after CNV induction. Rats were euthanized at predetermine time intervals of 3, 6, 24 and 48 h post injection, with immediate enucleation for histological analysis with H&E and immunofluorescence staining. Aflibercept molecules were stained with red fluorescence thanks to the formation of the immune complex Aflibercept-Rabbit anti human IgG-Anti rabbit antibodies-Cy3. Results Immediately after the injection, a strong fluorescence signal was detected, indicating the presence of Aflibercept in the iridocorneal angle. At 3- and 6-h interval a strong signal of Aflibercept was still seen. Six hours post injection, the signal was highly concentrated in Schlemm’s canal. In the 2 eyes harvested 24 h post Aflibercept injection, red fluorescence signal intensity was decreased in one eye, occupying mainly intra scleral venous plexuses, and absent in the other eye. At 48 h there was no fluorescence signal, confirming complete clearance of Aflibercept. Conclusions In our rat model, a complete clearance of Aflibercept from the anterior chamber angle, was seen 48 h after the injection. This finding refutes the theory of possible connection between IOP elevation and mechanical obstruction. Evacuation time of Aflibercept through the angle is of the same magnitude as that of Bevacizumab in the same rat model.
Collapse
Affiliation(s)
- Yariv Keshet
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Orly Gal-Or
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Schaap Fogler
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karin Mimouni
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meydan Ben Ishai
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dov Weinberger
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Dotan
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
12
|
Schargus M, Kopp KT, Helbig C, Frings A, Winter G. Comparison of Syringes With Intravitreal Anti-VEGF Drugs: Particle Burden and Protein Aggregates in Brolucizumab, Aflibercept and Bevacizumab. Transl Vis Sci Technol 2021; 10:21. [PMID: 34406342 PMCID: PMC8375009 DOI: 10.1167/tvst.10.9.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/08/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose In a benchwork particle counting analytical evaluation, the number and type of particles in intravitreal injection formulations of three different agents against vascular endothelial growth factor were investigated. Methods Commercially available ready-to-use aflibercept and brolucizumab glass syringes, vials containing bevacizumab (off-label use in ophthalmology), and repackaged ready-to-use plastic syringes containing bevacizumab were tested without filtration. Total visible, subvisible, and nanoparticles numbers and size distributions were quantified using light obscuration, flow imaging, resonant mass measurement (RMM), tunable resistive pulse sensing, and dynamic light scattering. Results Repackaged bevacizumab showed overall low particle numbers, aflibercept showed high numbers of micrometer sized particles but low nanoparticle numbers, brolucizumab showed low to moderate numbers of micrometer sized particles but high nanoparticle numbers. RMM measurements identified particles in the nanometer range as either proteinaceous or silicon oil; the nature of the other particles was not further evaluated. Conclusions Repackaged bevacizumab shows no inferior particle quality compared to ready-to-use products. It is relevant to study nanoparticle load of the products as the micrometer-sized particle numbers do not in all cases correlate to nanoparticle counts. Particularly for the high concentration product Beovu (brolucizumab), high nanoparticle numbers were found despite low numbers of micrometer sized particles. Silicone oil droplets did not account for high particle numbers as the measured numbers were low. Translational Relevance Different side effects are registered in different frequencies with different intravitreal anti-VEGF-drugs and syringes, which are applied by injection by small 30G needles through the sclera directly to the intravitreal cavity. The study of nanoparticles and silicone oil droplets may be able to contribute to narrowing down the causes.
Collapse
Affiliation(s)
- Marc Schargus
- Department of Ophthalmology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Ophthalmology, Asklepios Hospital Nord-Heidberg, Hamburg, Germany
| | - Katharina Tatjana Kopp
- Department of Pharmacy, Pharmaceutical Technology and Biopharmaceutics, Ludwig-Maximilians-University Munich, Germany
| | | | - Andreas Frings
- Department of Ophthalmology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gerhard Winter
- Department of Pharmacy, Pharmaceutical Technology and Biopharmaceutics, Ludwig-Maximilians-University Munich, Germany
| |
Collapse
|
13
|
Iyer PG, Albini TA. Drug-related adverse effects of antivascular endothelial growth factor agents. Curr Opin Ophthalmol 2021; 32:191-197. [PMID: 33770015 DOI: 10.1097/icu.0000000000000757] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antivascular endothelial growth factor (VEGF) agents have provided historic therapeutic breakthroughs in the treatment of retinal disease. New anti-VEGF agents are emerging for the treatment of retinal vascular diseases. Both systemic and ocular adverse effect need to be understood in managing patients. This review aims to highlight the adverse effects seen with routine use of bevacizumab, ranibizumab and aflibercept, as well as with new medications such as brolucizumab and abicipar. RECENT FINDINGS We review the recent findings of intraocular inflammation (IOI) of brolucizumab and abicipar in the context of the efficacy and safety reported with the routine anti-VEGF agents. Specifically, brolucizumab has been reported to cause occlusive retinal vasculitis in the setting of IOI, which has not been seen in other anti-VEGF medications. In addition, abicipar appears to cause IOI at a higher rate of patients than other anti-VEGF agents have previously. SUMMARY Newer anti-VEGF agents pose a significant risk of adverse events not seen with routine anti-VEGF agents.
Collapse
Affiliation(s)
- Prashanth G Iyer
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | |
Collapse
|
14
|
Sustained Elevation of Intraocular Pressure After Administration of Intravitreal Anti-Vascular Endothelial Growth Factor Agents in Patients With and Without Pseudoexfoliation Syndrome. J Glaucoma 2020; 29:981-988. [DOI: 10.1097/ijg.0000000000001600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Effects of Intravitreal Anti-VEGF Therapy on Glaucoma-like Progression in Susceptible Eyes. J Glaucoma 2020; 28:1035-1040. [PMID: 31633617 DOI: 10.1097/ijg.0000000000001382] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PRéCIS:: Intravitreal anti-vascular endothelial growth factor (VEGF) injections may accelerate glaucomatous change in patients with preexisting glaucoma or ocular hypertension (OHT). The safety of long-term injections in this specific population may be reflected in the need for additional glaucoma interventions. PURPOSE The purpose of this study was to investigate whether repeated anti-VEGF injections accelerate structural and functional glaucomatous change in eyes with preexisting glaucoma or OHT. MATERIALS AND METHODS This is a retrospective, observational study of injected and noninjected fellow eyes. A total of 28 patients with preexisting glaucoma or OHT, who received ≥6 unilateral anti-VEGF injections for concurrent neovascular retinal disease, were selected for chart review. Primary outcome measures were rate of visual field loss in dB/year, rate of change in retinal nerve fiber layer (RNFL) thickness in microns/year, and need for additional glaucoma medications, surgery, or laser. RESULTS The number of eyes requiring additional glaucoma surgery or laser was 8 of 28 (28.6%) for the injected group and 2 of 28 (7.1%) for the noninjected group. A significantly greater proportion of injected eyes required invasive glaucoma intervention (P=0.034). Average rate of decline in mean deviation and change in pattern standard deviation were both significantly greater in injected eyes (P=0.029; P=0.019). Estimated mean rate of global retinal nerve fiber layer change was -4.27 µm/y for the injected group and -1.17 µm/y for the noninjected group and was significant only for injected eyes (P=0.014). Only the superior quadrant exhibited thinning that was significantly different between groups (P=0.030). CONCLUSIONS Intravitreal injections were associated with accelerated functional and structural glaucoma-like change in susceptible eyes. Clinicians should assess the need for glaucoma medications or other interventions over the course of anti-VEGF therapy.
Collapse
|
16
|
Schargus M, Frings A. Issues with Intravitreal Administration of Anti-VEGF Drugs. Clin Ophthalmol 2020; 14:897-904. [PMID: 32256047 PMCID: PMC7101474 DOI: 10.2147/opth.s207978] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 03/10/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To provide an update of summary of risk factors and side effects of long-term use and contamination of intravitreal anti-VEGF injections. Methods We reviewed relevant publications of the topic of contamination of anti-VEGF injections and long-term side effects due to this reason. Results Due to the long-term use of anti-VEGF drugs and the higher number of injections worldwide, various studies have shown side effects in recent years, ranging from increased intraocular pressure to visual disturbing silicone oil vesicles in the vitreous cavity. Several studies have demonstrated that both the drug and the processing, storage, environmental factors and the material and design of the syringes have a decisive influence on these side effects. Conclusion The risks of deposits from syringes in the eye can be significantly reduced by various optimizations in transport, storage and syringe and cannula selection.
Collapse
Affiliation(s)
- Marc Schargus
- Department of Ophthalmology, Heinrich Heine University, Duesseldorf, Germany.,Department of Ophthalmology, Asklepios Hospital Nord-Heidberg, Hamburg, Germany
| | - Andreas Frings
- Department of Ophthalmology, Heinrich Heine University, Duesseldorf, Germany.,Augenarztpraxis Dr. Frings, Nuremberg, Germany
| |
Collapse
|
17
|
Wingard JB, Delzell DA, Houlihan NV, Lin J, Gieser JP. Incidence of Glaucoma or Ocular Hypertension After Repeated Anti-Vascular Endothelial Growth Factor Injections for Macular Degeneration. Clin Ophthalmol 2019; 13:2563-2572. [PMID: 31920279 PMCID: PMC6935302 DOI: 10.2147/opth.s232548] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose To estimate the risk of glaucoma or sustained ocular hypertension (OHT) related to anti-vascular endothelial growth factor (VEGF) injections for age-related macular degeneration (AMD). Design Retrospective chart review. Subjects Patients who received unilateral anti-VEGF injections for AMD at the Wheaton Eye Clinic (IL). Methods Chart analysis was performed on 1095 patients, without prior glaucoma or OHT, who received unilateral anti-VEGF injections for AMD from 2005 to 2012, with data collected through 2013. Data collection included demographics, lens status, date and medication type of each injection, and the date of diagnosis of glaucoma or OHT by a treating glaucoma specialist, which was the main outcome measure. Rare events logistic regression was performed to determine the risk of disease development based on sex, lens status, and injection frequency. Results Unilateral glaucoma or sustained OHT developed in 42 patients over the course of follow-up, with 40 events in the injected eye only, 2 in the contralateral eye only. Statistical modeling predicted elevated risk for onset of glaucomatous disease with a higher maximum frequency of injections (p < 0.0001, odds ratio [OR] 2.18 for each additional injection over the most injection-intense 6 months for a given subject) and with phakic lens status (p = 0.0009, OR 0.33 for pseudophakia). Conclusion Our results show a significant risk for glaucoma or OHT development in patients undergoing repeated treatments with intravitreal anti-VEGF injections for AMD, establishing the first reliable connection between disease development and a period of high-frequency injections. In addition, we show a significantly increased risk of disease development in phakic patients, which we believe points to a mechanical explanation for this type of secondary glaucoma.
Collapse
Affiliation(s)
| | - Darcie Ap Delzell
- Mathematics and Computer Science Department, Wheaton College, Wheaton, IL, 60187, USA
| | - Nathan V Houlihan
- Mathematics and Computer Science Department, Wheaton College, Wheaton, IL, 60187, USA
| | - Jonathan Lin
- Mathematics and Computer Science Department, Wheaton College, Wheaton, IL, 60187, USA
| | | |
Collapse
|
18
|
Nwanaji-Enwerem JC, Wang W, Nwanaji-Enwerem O, Vokonas P, Baccarelli A, Weisskopf M, Herndon LW, Wiggs JL, Park SK, Schwartz J. Association of Long-term Ambient Black Carbon Exposure and Oxidative Stress Allelic Variants With Intraocular Pressure in Older Men. JAMA Ophthalmol 2019; 137:129-137. [PMID: 30419128 DOI: 10.1001/jamaophthalmol.2018.5313] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Elevated intraocular pressure is a major risk factor for glaucoma, a leading cause of irreversible blindness worldwide. Environmental air pollution has been suggested as a potential contributor to elevated intraocular pressure; however, no studies have demonstrated such an association to date. Objective To investigate the association of long-term ambient black carbon exposure with intraocular pressure in community-dwelling older adults. Design, Setting, and Participants This population-based analysis, conducted from October 18, 2017, through March 22, 2018, used data from the all-male, New England-based Normative Aging Study of the US Department of Veterans Affairs. The analysis included 419 older men with a total of 911 follow-up study visits between January 1, 2000, and December 30, 2011. Intraocular pressure was measured by Goldmann applanation tonometry during the study visits. Validated spatiotemporal models were used to generate 1-year black carbon exposure levels at the addresses of the participants. Main Outcomes and Measures An independently developed genetic score approach was used to calculate allelic risk scores for 3 pathways associated with black carbon toxicity: endothelial function, oxidative stress, and metal processing. The associations among black carbon exposure, allelic risk scores, and intraocular pressure were explored using linear mixed-effects models. Results All 419 participants were men with a mean (SD) age of 75.3 (6.9) years. The mean (SD) 1-year black carbon exposure was 0.51 (0.18) μg/m3, and the mean (SD) intraocular pressure for the left eye was 14.1 (2.8) mm Hg and for the right eye was 14.1 (3.0) mm Hg. Of the 911 visits, 520 (57.1%) had a high endothelial function allelic risk score, 644 (70.7%) had a high metal-processing allelic risk score, and 623 (68.4%) had a high oxidative stress allelic risk score. In fully adjusted linear mixed-effects models, the association of black carbon with intraocular pressure was greater in individuals with a high oxidative stress allelic score (β = 0.36; 95% CI, 0.003-0.73) compared with individuals with a low score (β = -0.35; 95% CI, -0.86 to 0.15). Conclusions and Relevance Ambient black carbon exposure may be a risk factor for increased intraocular pressure in individuals susceptible to other biological oxidative stressors. If additional studies confirm these results, monitoring ambient black carbon exposure and physiological oxidative stress may prevent the development and progression of intraocular pressure-related disease.
Collapse
Affiliation(s)
- Jamaji C Nwanaji-Enwerem
- Department of Environmental Health, Harvard T. H. Chan School of Public Health and MD-PhD Program, Harvard Medical School, Boston, Massachusetts
| | - Weiye Wang
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | | | - Pantel Vokonas
- VA Normative Aging Study, Veterans Affairs Boston Healthcare System, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Andrea Baccarelli
- Department of Environmental Health Sciences, Columbia Mailman School of Public Health, New York, New York
| | - Marc Weisskopf
- Department of Environmental Health and Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Leon W Herndon
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Janey L Wiggs
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
| | - Sung Kyun Park
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor.,Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor
| | - Joel Schwartz
- Department of Environmental Health and Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
19
|
Saria K, Pferzinger M, Radda S, Findl O. IVOM Benchmarking und Optimierung. SPEKTRUM DER AUGENHEILKUNDE 2019. [DOI: 10.1007/s00717-019-00436-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
20
|
Crul M, Zandvliet A, Moes JR, Veenbaas T, Smeets O. Bevacizumab for Intravitreal Injection: Impact of Sub-Visible Particles on the Shelf-Life of Repackaged Bevacizumab. J Ocul Pharmacol Ther 2019; 35:372-375. [DOI: 10.1089/jop.2019.0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mirjam Crul
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anthe Zandvliet
- Department of Clinical Pharmacy, OLVG, Amsterdam, the Netherlands
| | - Jan Reindert Moes
- Department of Clinical Pharmacy, Martini Hospital, Groningen, the Netherlands
| | - Tjitske Veenbaas
- Department of Clinical Pharmacy, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Oscar Smeets
- Laboratorium der Nederlandse Apotheken (LNA), Royal Dutch Pharmacy Association (KNMP), the Hague, the Netherlands
| |
Collapse
|
21
|
The Effect of Anti-Vascular Endothelial Growth Factor Agents on Intraocular Pressure and Glaucoma: A Report by the American Academy of Ophthalmology. Ophthalmology 2018; 126:611-622. [PMID: 30472176 DOI: 10.1016/j.ophtha.2018.11.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the effect of intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents on immediate and long-term intraocular pressure (IOP) elevation and glaucoma. METHODS Literature searches of the PubMed and Cochrane databases, last conducted in April 2018, yielded 253 unique citations. Of these, 41 met the inclusion criteria and were rated according to the strength of evidence. Two articles were rated level I, 17 were rated level II, and 15 were rated level III; an additional 7 were excluded because of poor study design and lack of relevance to the topic under evaluation. RESULTS The studies that reported on short-term IOP elevation (i.e., between 0 and 60 minutes) showed that an immediate increase in IOP is seen in all patients when measured between 0 and 30 minutes of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; 7 studies reported that between 4% and 15% of patients developed sustained elevation of IOP at 9 to 24 months after injection, whereas 6 studies found no long-term change in IOP from 1 to 36 months after injection. Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. CONCLUSIONS Intravitreal injection of anti-VEGF agents results in an immediate and transient increase in IOP. A long-term increase in IOP also may be seen, and further studies are needed to determine at-risk populations. Although there is some suggestion in the literature, there is currently insufficient data to determine the impact of intravitreal anti-VEGF injections on glaucoma progression. Although pretreatment with glaucoma medications, performing anterior chamber paracentesis, or increasing the interval between injections may reduce the impact of transient IOP elevation, the clinical significance and associated risks of these interventions are unknown.
Collapse
|
22
|
Leleu I, Penaud B, Blumen-Ohana E, Rodallec T, Adam R, Laplace O, Akesbi J, Nordmann JP. [Late and sustained intraocular pressure elevation related to intravitreal anti-VEGF injections: Cases requiring filtering surgery (French translation of the article)]. J Fr Ophtalmol 2018; 41:789-801. [PMID: 30348599 DOI: 10.1016/j.jfo.2018.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 10/28/2022]
Abstract
We report cases of delayed, sustained elevated intraocular pressure (IOP) associated with repeated intravitreal anti-VEGF injections (IVI), which ultimately resulted in the need for filtering surgery. Two of the three cases demonstrated severe IOP elevation despite maximal medical treatment following unilateral IVI and required urgent filtering surgery. Optic nerve involvement was severe in all three cases. These intravitreal injections were performed for exudative age-related macular degeneration (AMD), and the patients did not show any sign of glaucoma or ocular hypertension prior to the initiation of treatment. Elevated IOP secondary to intravitreal steroids is a well-known side effect, as is immediate transient IOP elevation associated with anti-VEGF injection. Late, sustained IOP elevation after repeated injections of anti-VEGF, described approximately ten years ago, is often underestimated. Its incidence is estimated between 2.1% and 13% according to studies and increases with the number of IVI (cumulative effect). The pathophysiologic process is becoming increasingly understood, and several risk factors for this chronic IOP elevation have been identified. Most often, it is a moderate IOP elevation for which topical monotherapy is sufficient, or sometimes two, three or four medications or even selective laser trabeculoplasty (SLT). However, filtering surgery may rarely be required. Our findings illustrate a little-described phenomenon: a sudden, severe, late IOP elevation in response to anti-VEGF by an "overflow" effect, requiring urgent filtering surgery.
Collapse
Affiliation(s)
- I Leleu
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France.
| | - B Penaud
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - E Blumen-Ohana
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - T Rodallec
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - R Adam
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - O Laplace
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - J Akesbi
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - J-P Nordmann
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| |
Collapse
|
23
|
|
24
|
Leleu I, Penaud B, Blumen-Ohana E, Rodallec T, Adam R, Laplace O, Akesbi J, Nordmann JP. Late and sustained intraocular pressure elevation related to intravitreal anti-VEGF injections: Cases requiring filtering surgery. J Fr Ophtalmol 2018; 41:e329-e340. [PMID: 30197188 DOI: 10.1016/j.jfo.2018.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/17/2018] [Accepted: 07/24/2018] [Indexed: 01/13/2023]
Abstract
We report cases of delayed, sustained elevated intraocular pressure (IOP) associated with repeated intravitreal anti-VEGF injections (IVI), which ultimately resulted in the need for filtering surgery. Two of the three cases demonstrated severe IOP elevation despite maximal medical treatment following unilateral IVI and required urgent filtering surgery. Optic nerve involvement was severe in all three cases. These intravitreal injections were performed for exudative age-related macular degeneration (AMD), and the patients did not show any sign of glaucoma or ocular hypertension prior to the initiation of treatment. Elevated IOP secondary to intravitreal steroids is a well-known side effect, as is immediate transient IOP elevation associated with anti-VEGF injection. Late, sustained IOP elevation after repeated injections of anti-VEGF, described approximately ten years ago, is often underestimated. Its incidence is estimated between 2.1 % and 13 % according to studies and increases with the number of IVI (cumulative effect). The pathophysiologic process is becoming increasingly understood, and several risk factors for this chronic IOP elevation have been identified. Most often, it is a moderate IOP elevation for which topical monotherapy is sufficient, or sometimes two, three or four medications or even selective laser trabeculoplasty (SLT). However, filtering surgery may rarely be required. Our findings illustrate a little-described phenomenon: a sudden, severe, late IOP elevation in response to anti-VEGF by an "overflow" effect, requiring urgent filtering surgery.
Collapse
Affiliation(s)
- I Leleu
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France.
| | - B Penaud
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - E Blumen-Ohana
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - T Rodallec
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - R Adam
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - O Laplace
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - J Akesbi
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| | - J-P Nordmann
- Centre hospitalier national d'ophtalmologie des 15-20, 28, rue de Charenton, 75012 Paris, France
| |
Collapse
|
25
|
Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, Schmidt-Erfurth U. 2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations. Ophthalmologica 2018; 239:181-193. [PMID: 29393226 DOI: 10.1159/000486145] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/05/2017] [Indexed: 01/24/2023]
Abstract
Intravitreal injections (IVI) have become the most common intraocular procedure worldwide with increasing numbers every year. The article presents the most up-to-date review on IVI epidemiology and techniques. Unfortunately, important issues related to pre-, peri- and postinjection management lack randomized clinical trials for a final conclusion. Also, a great diversity of approaches exists worldwide. Therefore, expert consensus recommendations on IVI techniques are provided.
Collapse
Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.,Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland
| | - Reinhard Told
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Stefan Sacu
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Francesco Bandello
- Department of Ophthalmology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Elad Moisseiev
- Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Loewenstein
- Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | | |
Collapse
|
26
|
Bracha P, Moore NA, Ciulla TA, WuDunn D, Cantor LB. The acute and chronic effects of intravitreal anti-vascular endothelial growth factor injections on intraocular pressure: A review. Surv Ophthalmol 2017; 63:281-295. [PMID: 28882597 DOI: 10.1016/j.survophthal.2017.08.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 01/18/2023]
Abstract
The acute and chronic effects of repeated intravitreal antivascular endothelial growth factor (VEGF) injections on intraocular pressure have not been fully characterized, and the development of sustained ocular hypertension could adversely affect patients who are at risk of glaucomatous optic neuropathy. As expected, volume-driven, acute ocular hypertension immediately follows intravitreal injection, but this pressure elevation is generally transient and well tolerated. Several medications have been investigated to limit acute ocular hypertension following anti-VEGF therapy, but the benefits of pretreatment are not conclusive. Chronic, sustained ocular hypertension, distinct from the short-term acute ocular hypertension after each injection, has also been associated with repeated intravitreal anti-VEGF injections. Risk factors for chronic ocular hypertension include the total number of injections, a greater frequency of injection, and preexisting glaucoma. Proposed mechanisms for chronic ocular hypertension include microparticle obstruction, toxic or inflammatory effects on trabecular meshwork, as well as alterations in outflow facility by anti-VEGF agents. Although limiting anti-VEGF therapy could minimize the risk of both acute and chronic ocular hypertension, foregoing anti-VEGF therapy risks progression of various macular diseases with resulting permanent central vision loss. While definitive evidence of damage to the retinal nerve fiber layer is lacking, patients receiving repeated injections should be monitored for ocular hypertension and patients in whom sustained ocular hypertension subsequently developed should be periodically monitored for glaucomatous changes with optic nerve optical coherence tomography and static visual fields.
Collapse
Affiliation(s)
- Peter Bracha
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - Nicholas A Moore
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas A Ciulla
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA; Retina Service, Midwest Eye Institute, Indianapolis, Indiana, USA
| | - Darrell WuDunn
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Louis B Cantor
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
27
|
Vo Kim S, Fajnkuchen F, Sarda V, Qu-Knafo L, Bodaghi B, Giocanti-Aurégan A. Sustained intraocular pressure elevation in eyes treated with intravitreal injections of anti-vascular endothelial growth factor for diabetic macular edema in a real-life setting. Graefes Arch Clin Exp Ophthalmol 2017; 255:2165-2171. [PMID: 28831613 DOI: 10.1007/s00417-017-3782-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/04/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the sustained intraocular pressure (IOP) elevation after repeated anti-VEGF intravitreal injections (IVI) in patients with diabetic macular edema (DME). METHODS A retrospective study included 140 eyes without prior glaucoma, treated with at least three anti-VEGF injections for DME between 2012 and 2016. IOP elevation was defined by an increase above baseline IOP by ≥6 mmHg. Baseline IOP was defined as the mean of IOP values before treatment initiation. Three groups were differentiated: group 1 without IOP elevation, groups 2 and 3 with IOP elevation and IOP <21 mmHg (group 2) and ≥21 mmHg (group 3). Rate and several risk factors of IOP elevation were assessed and compared between the three groups. RESULTS IOP elevation occurred in ten eyes (7.1%). IOP was <21 mmHg in six eyes and ≥21 mmHg in four eyes. Statistically significant associations were found between IOP elevation and the number of injections, and HbA1c level. Two patients required local hypotonic treatment. CONCLUSIONS In a real-life setting, we confirmed in eyes with center-involved DME without prior glaucoma or IOP elevation that repeated anti-VEGF IVI may increase the risk of sustained IOP elevation in about 7% of eyes.
Collapse
Affiliation(s)
- S Vo Kim
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France
| | - F Fajnkuchen
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France.,Centre d'imagerie et de Laser, 11 rue Anoine Bourdelle, Paris, France
| | - V Sarda
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France
| | - L Qu-Knafo
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France
| | - B Bodaghi
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France.,Ophthalmology Department, Pitié-Salpétrière Hospital, APHP, DHU Vision and Handicaps, Paris 6 University, Paris, France
| | - A Giocanti-Aurégan
- Ophthalmology Department, Avicenne Hospital, APHP, DHU Vision and Handicaps, Paris 13 University, 125 rue de Stalingrad, 93000, Bobigny, France.
| |
Collapse
|
28
|
Eadie BD, Etminan M, Carleton BC, Maberley DA, Mikelberg FS. Association of Repeated Intravitreous Bevacizumab Injections With Risk for Glaucoma Surgery. JAMA Ophthalmol 2017; 135:363-368. [PMID: 28301639 DOI: 10.1001/jamaophthalmol.2017.0059] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Intravitreous injections of anti-vascular endothelial growth factor (VEGF) agents are associated with a sustained increase in intraocular pressure. This sustained elevated intraocular pressure could lead to higher rates of glaucoma surgery to lower this pressure. Objective To determine the risk of glaucoma surgery following repeated intravitreous bevacizumab injections. Design, Setting, Participants This nested, case-control study acquired and analyzed data from large, population-based, linked health databases supported by the British Columbia Ministry of Health in Canada. Study participants included all patients with ophthalmic issues in British Columbia, such as those of the Provincial Retinal Diseases Treatment Program, who had received intravitreous bevacizumab injections for exudative age-related macular degeneration between January 1, 2009, and December 31, 2013. Cases were identified using glaucoma surgical codes for trabeculectomy, complicated trabeculectomy, glaucoma drainage device, and cycloablative procedure. For each case, 10 controls were identified and matched for age, preexisting glaucoma, calendar time, and follow-up time. The number of intravitreous bevacizumab injections received per year-3 or fewer, 4 to 6, or 7 or more-was determined for both cases and controls. Data analysis was performed from February 23, 2016, to November 14, 2016. Main Outcomes and Measures Risk of glaucoma surgery compared with the number of intravitreous bevacizumab injections per year in cases and controls. Rate ratios were adjusted for covariates (diabetes mellitus, myocardial infarction, stroke, and verteporfin use). Results Seventy-four cases of glaucoma surgery and 740 controls were identified, with a mean (SD) age of 81.3 (8.4) years for cases and 81.4 (7.9) for controls. The case group had more males than the control group (38 [51.4%] vs 272 [36.8%]). The adjusted rate ratio of glaucoma surgery among those who received 7 or more injections per year was 2.48 (95% CI, 1.25-4.93). There was a 10.3% higher number of 7 or more injections among cases compared with controls. The adjusted rate ratio for those who received 4 to 6 injections per year compared with those who received 3 or fewer was 1.65% (95% CI, 0.84-3.23). Conclusions and Relevance Findings from this large, pharmacoepidemiologic study suggest that 7 or more intravitreous injections of bevacizumab annually is associated with a higher risk of glaucoma surgery and that 4 to 6 injections per year show a nonstatistically significant rate ratio in the same direction.
Collapse
Affiliation(s)
- Brennan D Eadie
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mahyar Etminan
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce C Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada3Child and Family Research Institute, University of British Columbia, Vancouver, British Columbia, Canada4Pharmaceutical Outcomes Programme, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - David A Maberley
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frederick S Mikelberg
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
29
|
Foss AJE, Scott LJ, Rogers CA, Reeves BC, Ghanchi F, Gibson J, Chakravarthy U. Changes in intraocular pressure in study and fellow eyes in the IVAN trial. Br J Ophthalmol 2016; 100:1662-1667. [PMID: 27073205 PMCID: PMC5256412 DOI: 10.1136/bjophthalmol-2015-307595] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 01/31/2016] [Accepted: 02/22/2016] [Indexed: 11/03/2022]
Abstract
PURPOSE To describe changes in intraocular pressure (IOP) in the 'alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN)' trial (registered as ISRCTN92166560). DESIGN Randomised controlled clinical trial with factorial design. PARTICIPANTS Patients (n=610) with treatment naïve neovascular age-related macular degeneration were enrolled and randomly assigned to receive either ranibizumab or bevacizumab and to two regimens, namely monthly (continuous) or as needed (discontinuous) treatment. METHODS At monthly visits, IOP was measured preinjection in both eyes, and postinjection in the study eye. OUTCOME MEASURES The effects of 10 prespecified covariates on preinjection IOP, change in IOP (postinjection minus preinjection) and the difference in preinjection IOP between the two eyes were examined. RESULTS For every month in trial, there was a statistically significant rise in both the preinjection IOP and the change in IOP postinjection during the time in the trial (estimate 0.02 mm Hg, 95% CI 0.01 to 0.03, p<0.001 and 0.03 mm Hg, 95% CI 0.01 to 0.04, p=0.002, respectively). There was also a small but significant increase during the time in trial in the difference in IOP between the two eyes (estimate 0.01 mm Hg, 95% CI 0.005 to 0.02, p<0.001). There were no differences between bevacizumab and ranibizumab for any of the three outcomes (p=0.93, p=0.22 and p=0.87, respectively). CONCLUSIONS Anti-vascular endothelial growth factor agents induce increases in IOP of small and uncertain clinical significance. TRIAL REGISTRATION NUMBER ISRCTN92166560.
Collapse
Affiliation(s)
| | - Lauren J Scott
- School of Clinical Sciences, Clinical Trials Evaluation Unit, University of Bristol, Bristol, UK
| | - Chris A Rogers
- School of Clinical Sciences, Clinical Trials Evaluation Unit, University of Bristol, Bristol, UK
| | - Barney C Reeves
- School of Clinical Sciences, Clinical Trials Evaluation Unit, University of Bristol, Bristol, UK
| | - Faruque Ghanchi
- Department of Ophthalmology, Bradford Royal Infirmary, Bradford, West Yorkshire, UK
| | - Jonathan Gibson
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Usha Chakravarthy
- Centre for Experimental Medicine, Queens University Belfast, Belfast, UK
| | | |
Collapse
|
30
|
Freund KB, Hoang QV, Saroj N, Thompson D. Intraocular Pressure in Patients with Neovascular Age-Related Macular Degeneration Receiving Intravitreal Aflibercept or Ranibizumab. Ophthalmology 2015; 122:1802-10. [DOI: 10.1016/j.ophtha.2015.04.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022] Open
|