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McAllister IL, Smithies LA, Chen FK, Mackey DA, Sanfilippo PG. Benefits of a Laser Chorioretinal Anastomosis Plus Ranibizumab vs Ranibizumab Alone for Central Retinal Vein Occlusion: 4-Year Results. Am J Ophthalmol 2023; 252:101-110. [PMID: 37030494 DOI: 10.1016/j.ajo.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE To evaluate what clinical gains can be achieved over conventional treatment with ranibizumab alone for central retinal vein occlusion (CRVO) when causal pathology is additionally addressed successfully with a laser-induced chorio-retinal anastomosis (L-CRA). DESIGN Two-year extension of prospective, randomized controlled clinical trial. METHODS A total of 58 patients with macular edema secondary to CRVO were randomized 1:1 to receive either an L-CRA (n = 29) or sham procedure (n = 29) at baseline and then monthly intravitreal ranibizumab 0.5 mg. Outcomes (best corrected visual acuity [BCVA], central subfield thickness [CST], injection requirements) were monitored in the monthly pro re nata (PRN) ranibizumab phase from months 7 to 48. RESULTS Injection requirements for patients with a functioning L-CRA (24 of 29) during the monthly PRN period from 7 to 24 months were a mean (95% CI) of 2.18 (1.57, 2.78) injections compared to 7.07 (6.08, 8.06) (P < .0001) for control (ranibizumab alone). These decreased further over the next 2 years to 0.29 (0.14, 0.61) compared to 2.20 (1.68, 2.88) (P < .001) for the third year and 0.25 (0.11, 0.56) and 1.84 (1.34, 2.54) for the fourth year (P < .001). Mean BCVA was statistically different at all follow-up time points from month 7 through month 48 for the group with the functioning L-CRA compared to the control monotherapy group. This improved to 14.06 letters at month 48 (P = .009). There was no difference in CST between any of the groups over the 48 months of follow-up. CONCLUSION For CRVO patients, addressing causal pathology in addition to conventional therapy improves BCVA and reduces injection requirements.
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Affiliation(s)
- Ian L McAllister
- From the Centre for Ophthalmology and Visual Science (I.L.M., L.A.S., F.K.C., D.A.M., P.G.S.), Lions Eye Institute, University of Western Australia, Perth, Australia.
| | - Lynne A Smithies
- From the Centre for Ophthalmology and Visual Science (I.L.M., L.A.S., F.K.C., D.A.M., P.G.S.), Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Fred K Chen
- From the Centre for Ophthalmology and Visual Science (I.L.M., L.A.S., F.K.C., D.A.M., P.G.S.), Lions Eye Institute, University of Western Australia, Perth, Australia
| | - David A Mackey
- From the Centre for Ophthalmology and Visual Science (I.L.M., L.A.S., F.K.C., D.A.M., P.G.S.), Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Paul G Sanfilippo
- From the Centre for Ophthalmology and Visual Science (I.L.M., L.A.S., F.K.C., D.A.M., P.G.S.), Lions Eye Institute, University of Western Australia, Perth, Australia; Centre for Eye Research Australia (P.G.S.), University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Wang Y, Wang S, Wang S, Ding M, Zhang M, Tang J, Deng A. Chorioretinal venous anastomosis for non-ischemic retinal vein occlusion. FRONTIERS IN OPHTHALMOLOGY 2022; 2:869843. [PMID: 38983556 PMCID: PMC11182135 DOI: 10.3389/fopht.2022.869843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 07/04/2022] [Indexed: 07/11/2024]
Abstract
Retinal vein occlusion (RVO) refers to the occlusion of the central retinal vein or primary and secondary branches caused by multiple factors. Clinical treatments for it include intravitreal or systemic vasodilator application, local usage of steroids and NSAID (non-steroidal anti-inflammatory drugs), thrombolysis, hemodilution, retinal laser photocoagulation, vitrectomy with vascular sheath incision, chorioretinal venous anastomosis (CRVA), and so on. At present, most treatments are aimed at RVO complications, while chorioretinal vein anastomosis can fundamentally reflux retinal vein blood through the choroid by venous vascular remodeling. Reports on the treatment of retinal vein occlusion by chorioretinal anastomosis are numerous in various countries. As a treatment means, CRVA can drain the venous blood, skipping the thrombosis spot, thus partially relieving anatomical vascular occlusion to achieve a therapeutic purpose. In this study, CRVA is evaluated from the aspects of indications, implementation process, postoperative effect evaluation, complications, and combination with anti-VEGF treatment. Based on the development of laser technology and vitrectomy, we hope to further review this treatment and provide a new reference for the clinical treatment of RVO.
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Affiliation(s)
- Yucheng Wang
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
| | - Shaolong Wang
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
| | - Shiwu Wang
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
| | - Min Ding
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Min Zhang
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
| | - Jiannan Tang
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
| | - Aijun Deng
- Eye Center of Affiliated Hospital of Weifang Medical University, Weifang, China
- Weifang Medical University, Weifang, China
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McAllister IL, Smithies LA, Chen FK, Mackey DA, Sanfilippo PG. Functional benefits of a chorioretinal anastomosis at 2 years in eyes with a central retinal vein occlusion treated with ranibizumab compared with ranibizumab monotherapy. BMJ Open Ophthalmol 2021; 6:e000728. [PMID: 33768164 PMCID: PMC7942268 DOI: 10.1136/bmjophth-2021-000728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 12/01/2022] Open
Abstract
Objective To evaluate the functional benefits (best corrected visual acuity (BCVA), central subfield thickness, injection loads, central venous pressure (CVP)) of a laser-induced chorioretinal anastomosis (L-CRA) in patients with central retinal vein occlusion (CRVO) treated with ranibizumab compared with ranibizumab monotherapy. Methods and Analysis This is a post-hoc analysis of the 2-year randomised ranibizumab plus L-CRA for CRVO trial. Twenty-four patients (82.5%) developed a functioning or successful L-CRA; outcome effects were monitored in the monthly as-needed ranibizumab phase from months 7 to 24 and compared with the ranibizumab monotherapy group (n=29). Results From months 7 to 24, the mean (95% CI) injection load for the functioning L-CRA group was 2.18 (1.57 to 2.78) compared with 7.07 (6.08 to 8.06) for the control group (p<0.0001). The mean BCVA was averaged across all timepoints between the control and functioning L-CRA groups (average difference=11.46 (3.16 to 19.75) letters, p=0.01). At 2 years, there was an 82.5% reduction in the odds of high CVP (greater or equal to central retinal artery diastolic pressure) for those with a successful L-CRA compared with controls (p<0.0001). Conclusion For patients with CRVO, adding L-CRA as a causal-based treatment to conventional therapy reduced CVP and injection loads and offered improved BCVA. Trial registration number ACTRN12612000004864.
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Affiliation(s)
- Ian L McAllister
- Lions Eye Institute (Centre for Ophthalmology and Visual Science), University of Western Australia, Perth, Western Australia, Australia
| | - Lynne A Smithies
- Lions Eye Institute (Centre for Ophthalmology and Visual Science), University of Western Australia, Perth, Western Australia, Australia
| | - Fred K Chen
- Lions Eye Institute (Centre for Ophthalmology and Visual Science), University of Western Australia, Perth, Western Australia, Australia.,Ophthalmology Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David A Mackey
- Lions Eye Institute (Centre for Ophthalmology and Visual Science), University of Western Australia, Perth, Western Australia, Australia
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McAllister IL. Chorioretinal Anastomosis for Central Retinal Vein Occlusion: A Review of Its Development, Technique, Complications, and Role in Management. Asia Pac J Ophthalmol (Phila) 2020; 9:239-249. [PMID: 32501894 PMCID: PMC7299219 DOI: 10.1097/apo.0000000000000286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/23/2020] [Indexed: 11/25/2022] Open
Abstract
Treatments for central retinal vein occlusion (CRVO) have improved dramatically with the advent of intravitreal agents aimed at blocking the effects of the dominant hypoxia-induced upreglulated cytokine, which is vascular endothelial growth factor (VEGF). This cytokine breaks down the capillary endothelial barriers and is a major component of the macular edema in this condition. These treatments although impressive only address some of the sequelae of CRVO and have no effect on the underlying cause which is an obstruction to venous outflow leading to retinal blood flow stagnation and an elevation of the retinal central venous pressure (CVP). The creation of a laser-induced chorioretinal anastomosis (L-CRA) between the obstructed high pressure retinal venous circulation and the unobstructed low pressure choroidal venous circulation is a means addressing the causal pathology. The L-CRA will help lower the elevated CVP, which has been up until now an unaddressed component of the macular edema in this condition.This article reviews the preclinical and clinical development of the L-CRA and the results of the studies into its effect on the natural history of CRVO. It now can be used in combination with existing anti-VEGF treatments with the intravitreal agents addressing the component of the CRVO-induced macular edema due to the cytokine dysregulation, and the L-CRA addressing the component due to the elevated CVP and retinal venous stagnation. Improvements in laser technology have led to higher success rates in L-CRA creation and potential complications are now minimized and better controlled. The combination of L-CRA with intravitreal anti-VEGF agents offers the potential of a permanent cure with a significant reduction in the burden of therapy and improved visual outcomes in this condition.
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Affiliation(s)
- Ian L McAllister
- Lions Eye Institute, Center for Ophthalmology and Visual Science, University of Western Australia, Western Australia, Australia
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McAllister IL, Smithies LA, Chen FK, Mackey DA, Sanfilippo PG. Two-Year Efficacy of Ranibizumab Plus Laser-Induced Chorioretinal Anastomosis vs Ranibizumab Monotherapy for Central Retinal Vein Occlusion: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 136:1391-1397. [PMID: 30347030 DOI: 10.1001/jamaophthalmol.2018.4973] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Adding a laser-induced chorioretinal anastomosis (L-CRA) to current treatments for central retinal vein occlusion (CRVO) may improve outcomes and lessen therapy burdens. Objective To determine the 2-year efficacy of intravitreal ranibizumab with an L-CRA vs ranibizumab alone for patients with macular edema caused by CRVO. Design, Setting, and Participants In this randomized clinical trial conducted at a single university clinic from March 2012 to June 2015, 58 participants with macular edema caused by CRVO were randomized 1:1 to either an L-CRA or sham procedure at baseline. All participants received monthly intravitreal injections of ranibizumab, 0.5 mg. Data were analyzed from April 2017 to September 2017. Interventions Random assignment to L-CRA plus monthly injections of intravitreal ranibizumab, 0.5 mg, (combination group; n = 29) or to a sham L-CRA procedure plus monthly injections of intravitreal ranibizumab, 0.5 mg, (ranibizumab alone group; n = 29) for 6 months. From month 7 to month 24, participants were evaluated monthly and received an injection of ranibizumab if a loss of 5 or more letters of best-corrected visual acuity (BCVA) on ETDRS chart from previous highest score occurred or if there was evidence of residual macular edema on optical coherence tomography. Main Outcomes and Measures Mean number of injections from month 7 to month 24, change in BCVA, and change in central subfield thickness (CST). Results Of the 58 included participants, 38 (66%) were men, and the mean (SD) age was 68.6 (11.8) years; participants had a mean (SD) BCVA of 57.09 (11.87) ETDRS letters (Snellen equivalent, 20/73) and a mean (SD) CST of 738.36 (175.54) μm. A successful L-CRA was created in 24 of 29 participants (83%) in the combination group. The mean number of injections from month 7 to month 24 was 3.2 (95% CI, 2.5-3.8) in the combination group and 7.1 (95% CI, 6.0-8.0) in the ranibizumab alone group. The ratio of the number of injections in the combination group compared with the ranibizumab alone group was 0.46 (95% CI, 0.36-0.61; P < .001). Mixed-effects regression modeling showed a difference in mean BCVA at 2 years between the combination and ranibizumab alone groups (combination, 70.3 letters [Snellen equivalent, 20/40]; ranibizumab alone, 61.6 letters [Snellen equivalent, 20/60]; difference, 8.8 letters; 95% CI, 0.2-17.3; P = .05). There was also a difference in CST at 2 years between the combination and ranibizumab alone groups (mean CST: combination, 303.6 μm; ranibizumab alone, 394.5 μm; difference, 90.9 μm; 95% CI, 24.3-157.5; P = .01). Four participants (14%) in the combination group required a vitrectomy for early macular traction or vitreous hemorrhage. Conclusions and Relevance For macular edema caused by CRVO, an L-CRA significantly reduced the number of ranibizumab injections required. Trial Registration anzctr.org.au Identifier: ACTRN12612000004864.
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Affiliation(s)
- Ian L McAllister
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Ophthalmology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Lynne A Smithies
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Fred K Chen
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Ophthalmology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David A Mackey
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Paul G Sanfilippo
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Chan EW, Eldeeb M, Sun V, Thomas D, Omar A, Kapusta MA, Galic IJ, Chen JC. Disorganization of Retinal Inner Layers and Ellipsoid Zone Disruption Predict Visual Outcomes in Central Retinal Vein Occlusion. Ophthalmol Retina 2019; 3:83-92. [PMID: 30929820 DOI: 10.1016/j.oret.2018.07.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/08/2018] [Accepted: 07/16/2018] [Indexed: 05/24/2023]
Abstract
PURPOSE To assess the associations and predictive value of spectral-domain (SD) OCT inner and outer retinal structural parameters and visual acuity (VA) outcomes in macular edema (ME) secondary to central retinal vein occlusion (CRVO). DESIGN Retrospective, longitudinal cohort study. PARTICIPANTS Eighty-four patients with ME secondary to CRVO receiving pro re nata anti-vascular endothelial growth factor (VEGF) therapy at 3 tertiary-level retina referral centers. METHODS In all participants, VA, demographic and clinical parameters, and SD OCT images from baseline, 3 months, and 12 months were reviewed. Spectral-domain OCT-based morphologic features in the 1500-μm foveal zone were analyzed by masked graders for disorganization of the retinal inner layers (DRIL), ellipsoid zone (EZ) and external limiting membrane disruption, cone outer segment tip (COST) visibility, cysts, subretinal and intraretinal fluid, and epiretinal membranes. MAIN OUTCOME MEASURES Spectral-domain OCT-based retinal structural parameters and VA outcomes. RESULTS In multivariate analyses adjusting for baseline VA, worsening VA over 1 year was associated with 1-year increases in DRIL (point estimate, 0.06 per 100 μm; P < 0.001) and EZ disruption (0.07 per 100 μm; P = 0.023), but decreased COST visibility (-0.09 per 100 μm; P = 0.018). A 3-month increase in DRIL (0.05 per 100 μm; P = 0.003) and EZ disruption (0.10 per 100 μm; P < 0.001) were the only factors predicting VA worsening over 1 year, after controlling for baseline VA. A multivariate model including 3-month evolution in DRIL, EZ disruption, and VA accounted for 86.3% of variability in 1-year VA change. Absolute differences between predicted and actual 1-year VA were within 2 lines in 80.9%. When DRIL increased by 250 μm or more over 3 months, no eyes showed VA improvement of 1 line or more in 1 year. When EZ disruption decreased by 250 μm or more over 3 months, no eyes worsened by 1 line or more over 1 year. CONCLUSIONS Early recovery over 3 months in both DRIL and EZ parameters are key drivers of 1-year VA outcomes. Predictive models incorporating 3-month changes in DRIL and EZ disruption support their usefulness as potential robust determinants of future VA.
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Affiliation(s)
- Errol W Chan
- Department of Ophthalmology, McGill University, Montreal, Canada; Montreal Retina Institute, Montreal, Canada
| | | | - Vincent Sun
- Department of Ophthalmology, McGill University, Montreal, Canada
| | - Doneal Thomas
- CaMos Statistical Analyses Center, McGill University Health Centre Research Institute, Montreal, Canada
| | | | - Michael A Kapusta
- Department of Ophthalmology, McGill University, Montreal, Canada; Eye Health MD, Montreal, Canada
| | - Ivan J Galic
- Department of Ophthalmology, McGill University, Montreal, Canada; Montreal Retina Institute, Montreal, Canada
| | - John C Chen
- Department of Ophthalmology, McGill University, Montreal, Canada; Montreal Retina Institute, Montreal, Canada.
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