Bevacizumab compared with macular laser grid photocoagulation for cystoid macular edema in branch retinal vein occlusion. Retina. 2009;29:511-515. [PMID: 19174717 DOI: 10.1097/iae.0b013e318195ca65]

Update on Retinal Vein Occlusion

Retinal vein occlusion represents the second leading cause of retinal vascular disorders, with a uniform sex distribution worldwide. A thorough evaluation of cardiovascular risk factors is required to correct possible comorbidities. The diagnosis and management of retinal vein occlusion have changed tremendously in the last 30 years, but the assessment of retinal ischemia at baseline and during follow-up examinations remains crucial. New imaging techniques have shed light on the pathophysiology of the disease and laser treatment, once the only therapeutic option, is now only one of the possible approaches with antivascular endothelial growth factors and steroid injections being preferred in most cases. Nowadays long-term outcomes are better than those achievable 20 years ago and yet, many new therapeutic options are under development, including new intravitreal drugs and gene therapy. Despite this, some cases still develop sight-threatening complications deserving a more aggressive (sometimes surgical) approach. The purpose of this comprehensive review is to reappraise some old but still valid concepts and to integrate them with new research and clinical data. The work will provide an overview of the disease's pathophysiology, natural history, and clinical features along with a detailed discussion on the advantages of multimodal imaging and of the different treatment strategies with the aim of providing retina specialists with the most updated knowledge in the field.

Acetazolamide and bevacizumab combination therapy versus bevacizumab monotherapy in macular edema secondary to retinal vein occlusion

PURPOSE

To determine and compare the efficacy of intravitreal bevacizumab (IVB) and oral acetazolamide (OA) combination therapy versus IVB monotherapy in patients with macular edema secondary to retinal vein occlusion (RVO).

METHODS

This randomized clinical trial included 54 eyes of 52 patients with RVO central macular thickness (CMT) of more than 300μm, and best corrected visual acuity (BCVA) between 20/400 and 20/40. Eligible patients were randomly assigned to two groups: (I) IVB and OA (250mg twice daily) combination therapy or (II) IVB monotherapy. Ocular injections were repeated monthly for up to three months; BCVA and CMT were measured monthly.

RESULTS

Both regimens resulted in significant reduction in CMT (534±150μm to 352±90μm in the IVB+OA group, P<0.001; and 580±175μm to 362±90μm in the IVB group, P<0.001); neither showed superiority in this regard. Likewise, BCVA showed significant improvement in both groups (0.87±0.56 to 0.53±0.28 LogMAR in the IVB+OA group, P=0.001; and 0.85±0.62 to 0.46±0.4 LogMAR in the IVB group, P<0.001), with no intergroup difference.

CONCLUSION

Addition of oral acetazolamide to IVB in eyes with macular edema secondary to RVO may not result in additional short-term benefits regarding functional and anatomical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05290948, registered on March 22, 2022. https://clinicaltrials.gov/ct2/show/NCT05290948.

Combination intravitreal anti-vascular endothelial growth factor inhibitors and macular laser photocoagulation relative to intravitreal injection monotherapy in macular oedema secondary to retinal vein occlusion: a meta-analysis of randomized controlled trials

BACKGROUND/OBJECTIVES

This meta-analysis investigates the efficacy and safety of intravitreal anti-VEGF injections (IVI) compared to combination laser photocoagulation and IVI (LPC-IVI) in treating macular oedema secondary to retinal vein occlusion (RVO).

SUBJECTS/METHODS

A literature search of MEDLINE, EMBASE and Cochrane CENTRAL was conducted from inception until March 2021. Randomized controlled trials that reported relevant efficacy and/or safety parameters following LPC-IVI relative to IVI were included. Meta-analysis was conducted with a random effects model. The primary outcome was best-corrected visual acuity (BCVA), while secondary outcomes were central macular thickness (CMT), central retinal thickness (CRT), central subfield thickness (CST), number of IVIs received, and incidence of adverse events.

RESULTS

A total of 10 studies were included, for which 362 eyes were randomized to LPC-IVI and 365 to IVI. In comparing macular laser photocoagulation with IVI (MLP-IVI) in BRVO patients, no significant differences were seen in final BCVA (p = 0.78) or change in BCVA (p = 0.09) after treatment. Similarly, no significant differences were seen in final CMT (p = 0.54), change in CMT (p = 0.33), final CRT (p = 0.90), change in CRT (p = 0.97), or number of injections required (p = 0.78). The same results were seen in subgroup analyses for macular laser without peripheral laser in BRVO and CRVO patients. Consistent results were observed when considering peripheral LPC-IVI to IVI in BRVO and CRVO.

CONCLUSIONS

No significant differences were seen between combination MLP-IVI or peripheral LPC-IVI relative to IVI monotherapy for final BCVA or OCT parameters in macular oedema secondary to RVO.

Anti-Vascular Endothelial Growth Factor Treatment Patterns and Outcomes in Retinal Vein Occlusion in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To characterize treatment patterns for retinal vein occlusion (RVO)-related macular edema (ME) in routine clinical practice and its impact on long-term best-corrected visual acuity (BCVA) and central subfield thickness (CST).

PATIENTS AND METHODS

Retrospective study of 365 eyes with branch RVO (BRVO) or central/hemi-RVO (CRVO/HRVO)-related ME between 2003 and 2020. Regression analysis identified factors associated with maintenance injection interval (MII). Subgroup analysis compared outcomes between different MIIs.

RESULTS

51.3% of BRVO patients received injections ≤q8 weeks, 26.4% received injections q8-12 weeks, and 22.3% received injections >q12 weeks. 45.2% of CRVO/HRVO patients received injections ≤q8 weeks, 32.1% received injections q8-12 weeks, and 22.6% received injections >q12 weeks. Age, diabetes, and baseline CST were found to predict MII. There was no significant difference in BCVA and CST at baseline, 12, or 24 months in all MII groups in BRVO and CRVO/HRVO.

CONCLUSION

There exists a significant heterogeneity in anti-VEGF treatment frequency for RVO-associated ME in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina 2022;53:626-633.].

Antivascular endothelial growth factor for macular oedema secondary to retinal vein occlusion: a systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of antivascular endothelial growth factor (anti-VEGF) agents in treating macular oedema due to retinal vein occlusion (RVO-ME).

Methods

Studies of randomised controlled trials were searched in PubMed, EMBASE, Cochrane databases and ClinicalTrials.gov registry. RevMan V.5.4 software and GRADE were used to synthesise the data and validate the evidence, respectively.

Results

Seventeen studies were included in this meta-analysis. The anti-VEGF agents showed significant better mean best-corrected visual acuity (BCVA) improvement, more patients with ≧15 Early Treatment in Diabetic Retinopathy Study (ETDRS) letters gained and fewer patients with ≧15 ETDRS letters lost, more effectiveness at reducing central retinal thickness (CRT) and improving the quality of life than sham and steroids both at 6 and 12 months. Compared with laser, the anti-VEGF agents showed significant BCVA improvement and more effectiveness at CRT both at 6 and 12 months. The proportion of eyes gaining ≧15 ETDRS letters was greater in the anti-VEGF group at 6 months. The anti-VEGF and other three groups reported similar levels of non-ocular serious adverse events (SAEs). The incidence of eye pain was significantly higher in the anti-VEGF group than in the sham group. There was a significant increase in the incidence of ocular AEs and conjunctival haemorrhage in the anti-VEGF group compared with the laser group. The incidence of elevated intraocular pressure and cataract was significantly higher in the steroid group than in the anti-VEGF group.

Conclusions

This meta-analysis suggested that treatment of ME secondary to RVO with anti-VEGF improves visual and anatomical outcomes compared with other treatments. Thus, anti-VEGF treatment is the first choice for treating patients with ME secondary to RVO.

ASSOCIATIONS WITH RECURRENCE OF MACULAR EDEMA IN BRANCH RETINAL VEIN OCCLUSION AFTER THE DISCONTINUATION OF ANTI VASCULAR ENDOTHELIAL GROWTH FACTOR

PURPOSE

To identify factors predicting the recurrence of macular edema after the discontinuation of intravitreal antivascular endothelial growth factor injection in patients with branch retinal vein occlusion.

METHODS

This retrospective study included only subjects who had discontinued injections at 3 months after the final bevacizumab injection due to fully resolved macular edema. Fifty-two eyes meeting the criteria were included in the study and divided into two groups (recurrence and no recurrence). Clinical features and measurements of retinal thickness at the time of the diagnosis and when the decision to stop injections was made (stopping point) were analyzed.

RESULTS

At the stopping point, the no recurrence group showed a thinner parafoveal inner retina, better best-corrected visual acuity, and lower incidence of ellipsoid zone disruption in multivariate logistic regression analysis (all P < 0.05). Similarly, parafoveal inner retinal thinning of more than 30 µm, when compared with the corresponding region of the fellow eye or the unaffected region of the affected eye, was significantly related to less recurrence of macular edema.

CONCLUSION

Thinning of the parafoveal inner retina as well as better vision and intact outer retinal layers are associated with a lack of recurrence of macular edema. These findings suggest that inner retinal atrophy after branch retinal vein occlusion may result in a reduction in oxygen demand in the affected retinal tissue and less production of vascular endothelial growth factor.

Photocoagulation for retinal vein occlusion

The role of photocoagulation in retinal vein occlusion (RVO) has been studied since 1974. The most serious complications of central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) are: (i) visual deterioration, most commonly due to macular edema, and (ii) the development of ocular neovascularization (NV), particularly neovascular glaucoma (NVG), with hazardous consequences for vision and even the eye itself. Before discussing the role of photocoagulation in the management of NV and macular edema in RVO, it is crucial to gain a basic scientific understanding of the following relevant issues: classification of RVO, ocular NV in RVO, and the natural history of macular edema and visual outcome of RVO. These topics are discussed. In CRVO, ocular NV is a complication of ischemic CRVO but not of nonischemic CRVO. Photocoagulation has been advocated to prevent and/or treat the development of ocular NV and NVG. Since NVG is the most dreaded, intractable and blinding complication of ischemic CRVO, the role of photocoagulation and its management are discussed. Findings of three randomized, prospective clinical trials dealing with photocoagulation in ischemic CRVO are discussed. The role of photocoagulation in the management of ocular NV and macular edema in BRVO, and three randomized, prospective clinical trials dealing with those are discussed. Recent advent of intravitreal anti-VEGF and corticosteroid therapies has drastically changed the role of photocoagulation in the management of macular edema and NV in CRVO and BRVO. This is discussed in detail.

Bevacizumab induces oxidative cytotoxicity and apoptosis via TRPM2 channel activation in retinal pigment epithelial cells: Protective role of glutathione

PURPOSE

Bevacizumab (BEV) is a blocker of circulating VEGF A generation. However, BEV has adverse apoptotic and cytotoxic effects via upregulation of mitochondrial reactive oxygen species (ROS) and TRPM2 activation, and downregulation of cytosolic glutathione (GSH) in neuronal cells. We investigated the possible protective effects of GSH treatment on BEV-induced oxidant and apoptotic adverse actions in the TRPM2 expressing adult retinal pigment epithelial-19 (ARPE-19) and SH-SY5Y neuronal cells.

MATERIAL AND METHODS

The ARPE-19 and SH-SY5Y cells were divided into five main groups: Control, GSH (10 mM for 2 h), BEV (0.25 mg/ml for 24 h), BEV+GSH, and BEV+TRPM2 channel blockers (ACA or 2-APB). In the SH-SY5Y cells, the Ca²⁺ analyses (Fluo-3) were performed only, although Fluo-3 and the remaining analyses were performed in the ARPE-19 cells.

RESULTS

The levels of apoptosis, cell death, mitochondrial ROS, lipid peroxidation, caspase-3, caspase-9, ADP-ribose-induced TRPM2 current density, cytosolic-free Zn²⁺, and Ca²⁺ were increased by BEV, although their levels were diminished by the treatments of GSH and TRPM2 blockers. The BEV-induced decreases of cell viability, GSH levels, and glutathione peroxidase activities were increased by the treatment of GSH. BEV-induced increase of TRPM2 expression was decreased by the treatment of GSH, although BEV-induced decrease of VEGF A expression was further decreased by the treatment of GSH.

CONCLUSION

Our data confirmed that BEV-induced mitochondrial ROS and apoptosis in the human retinal epithelial cells were modulated by GSH and TRPM2 inhibition. The treatment of GSH may be considered as a therapeutic approach to BEV-induced ARPE-19 cell injury.

Analysis of intravitreal bevacizumab treatment for macular oedema due to retinal vein occlusion

PURPOSE

Our aim was to analyse the clinical effect of intravitreal bevacizumab treatment for macular oedema due to central/branch retinal vein occlusion (CRVO/BRVO). The end points were final best-corrected visual acuity (BCVA), BCVA improvement, final central 1-mm macular subfield thickness (CST) and change in CST.

METHODS

Our study included 34 CRVO and 25 BRVO patients. Patients received intravitreal bevacizumab (IVB) treatment at our department. Our control group consisted of 50 CRVO and 30 BRVO patients, who had not received this treatment because their disease developed before the anti-VEGF treatment became available. For statistical analysis, two-sample t-test, Pearson's correlation, and ANOVA were used. The level of significance was defined at p < 0.05.

RESULTS

With the two-sample t-test we found significant improvement of BCVA in the IVB-treated group (CRVO: 0.171 ± 0.270, p1 = 3.25×10-4; BRVO: 0.215 ± 0.282, p2 = 5.52×10-4). The difference in BCVA improvement was also significant compared to the control group (CRVO: p1 = 3.46×10-4; BRVO: p2 = 0.003). Significant decrease was observed in the CST in the treated group (CRVO: -345.114 ± 280.577, p1 = 6.94×10-9; BRVO: -151.875 ± 174.341, p2 = 1.67×10-4). In case of BRVO patients the final BCVA was significantly better in the treated group (0.617 ± 0.334) compared to the control group (0.406 ± 0.357), p = 0.016.

CONCLUSION

IVB treatment results in significantly better final visual acuity and leads to significantly increased BCVA improvement compared to patients with RVO-induced macular oedema receiving no treatment.

Anti-vascular endothelial growth factor for macular oedema secondary to branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is one of the most commonly occurring retinal vascular abnormalities. The most common cause of visual loss in people with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss. Limitations to this treatment exist, however, and newer modalities may have equal or improved efficacy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has recently been used successfully to treat MO resulting from a variety of causes.

OBJECTIVES

To investigate the efficacy and gather evidence from randomised controlled trials (RCTs) on the potential harms of anti-vascular endothelial growth factor (VEGF) agents for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); MEDLINE Ovid; Embase Ovid; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. The date of the last search was 12 June 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating BRVO. Eligible trials had to have at least six months' follow-up where anti-VEGF treatment was compared with another treatment, no treatment, or placebo. We excluded trials where combination treatments (anti-VEGF plus other treatments) were used; and trials that investigated the dose and duration of treatment without a comparison group (other treatment/no treatment/sham).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data using standard methodological procedures expected by Cochrane. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and 12 months of follow-up. The secondary outcomes were the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean visual acuity (VA) change at six and 12 months, as well as the change in central retinal thickness (CRT) on optical coherence tomography from baseline at six and 12 months. We also collected data on adverse events and quality of life (QoL).

MAIN RESULTS

We found eight RCTs of 1631 participants that met the inclusion criteria after independent and duplicate review of the search results. These studies took place in Europe, North America, Eastern Mediterranean region and East Asia. Included participants were adults aged 18 or over with VA of 20/40 or worse. Studies varied by duration of disease but permitted previously treated eyes as long as there was sufficient treatment-free interval. All anti-VEGF agents (bevacizumab, ranibizumab and aflibercept) and steroids (triamcinolone and dexamethasone) were included. Overall, we judged the studies to be at moderate or unclear risk of bias. Four of the eight studies did not mask participants or outcome assessors, or both. One trial compared anti-VEGF to sham. At six months, eyes receiving anti-VEGF were significantly more likely to have a gain of 15 or more ETDRS letters (risk ratio (RR) 1.72, 95% confidence interval (CI) 1.19 to 2.49; 283 participants; moderate-certainty evidence). Mean VA was better in the anti-VEGF group at six months compared with control (mean difference (MD) 7.50 letters, 95% CI 5.29 to 9.71; 282 participants; moderate-certainty evidence). Anti-VEGF also proved more effective at reducing CRT at six months (MD -57.50 microns, 95% CI -108.63 to -6.37; 281 participants; lower CRT is better; moderate-certainty evidence). There was only very low-certainty evidence on adverse effects. There were no reports of endophthalmitis. Mean change in QoL (measured using the National Eye Institute Visual Functioning Questionnaire VFQ-25) was better in people treated with anti-VEGF compared with people treated with sham (MD 7.6 higher score, 95% CI 4.3 to 10.9; 281 participants; moderate-certainty evidence). Three RCTs compared anti-VEGF with macular laser (total participants = 473). The proportion of eyes gaining 15 or more letters was greater in the anti-VEGF group at six months (RR 2.09, 95% CI 1.44 to 3.05; 2 studies, 201 participants; moderate-certainty evidence). Mean VA in the anti-VEGF groups was better than the laser groups at six months (MD 9.63 letters, 95% CI 7.23 to 12.03; 3 studies, 473 participants; moderate-certainty evidence). There was a greater reduction in CRT in the anti-VEGF group compared with the laser group at six months (MD -147.47 microns, 95% CI -200.19 to -94.75; 2 studies, 201 participants; moderate-certainty evidence). There was only very low-certainty evidence on adverse events. There were no reports of endophthalmitis. QoL outcomes were not reported. Four studies compared anti-VEGF with intravitreal steroid (875 participants). The proportion of eyes gaining 15 or more ETDRS letters was greater in the anti-VEGF group at six months (RR 1.67, 95% CI 1.33 to 2.10; 2 studies, 330 participants; high-certainty evidence) and 12 months (RR 1.76, 95% CI 1.36 to 2.28; 1 study, 307 participants; high-certainty evidence). Mean VA was better in the anti-VEGF group at six months (MD 8.22 letters, 95% CI 5.69 to 10.76; 2 studies, 330 participants; high-certainty evidence) and 12 months (MD 9.15 letters, 95% CI 6.32 to 11.97; 2 studies, 343 participants; high-certainty evidence). Mean CRT also showed a greater reduction in the anti-VEGF arm at 12 months compared with intravitreal steroid (MD -26.92 microns, 95% CI -65.88 to 12.04; 2 studies, 343 participants; moderate-certainty evidence). People receiving anti-VEGF showed a greater improvement in QoL at 12 months compared to those receiving steroid (MD 3.10, 95% CI 0.22 to 5.98; 1 study, 307 participants; moderate-certainty evidence). Moderate-certainty evidence suggested increased risk of cataract and raised IOP with steroids. There was only very low-certainty evidence on APTC events. No cases of endophthalmitis were observed.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that treatment of MO secondary to BRVO with anti-VEGF improves visual and anatomical outcomes at six and 12 months.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Is there still a role of macular laser treatment in branch retinal vein occlusion in the era of intravitreal injections?

We aimed to evaluate whether macular laser still has a role in the treatment of macular oedema (MO) caused by branch retinal vein occlusion (BRVO) and provide an overview of recent studies on commonly available treatment options. A literature search was last conducted in PubMed on 26 February 2019, limited to human randomized controlled trials published in English since 2008. Seventeen articles addressing 13 trials were included in this assessment. In trials evaluating intravitreal corticosteroid and macular laser, triamcinolone was non-inferior to laser in regard to visual acuity (VA) and central retinal thickness (CRT) outcomes. Combination treatment of dexamethasone and laser resulted in better VA and lower CRT after 6 months. In trials evaluating vascular endothelial growth factor (VEGF) inhibitors versus macular laser treatment, or sham and rescue laser, better VA and CRT of VEGF inhibition treatment was consistently reported. Results of combination treatment versus VEGF inhibition monotherapy were inconsistent, with four of six studies reporting comparable outcomes and injection burden. Study comparison was affected by considerable differences in study design and inadequate reporting of laser protocol and rescue laser. Studies evaluating angiostatic treatment as monotherapy largely report the use of rescue laser, indicating that some patients would benefit from supplemental laser treatment even in the era of intravitreal therapy. Thus, we suggest further studies on optimal design of combination therapy prioritizing longer follow-up time to sufficiently evaluate the delayed effect of laser.

Intravitreal Medications for Retinal Vein Occlusion: Systematic Review and Meta-analysis

Purpose

To evaluate the outcomes of different intravitreal injections for the treatment of retinal vein occlusion including central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).

Methods

PubMed, Cochrane, the metaRegister of ControlledTrials, and ClinicalTrials were searched for intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and steroids with relevant keywords and date limitation of 2009-2018. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were visual acuity (VA) and central macular thickness (CMT).

Results

Out of 681 studies, 36 articles (including 21 reporting CRVO and 15 dealing with BRVO) were selected for systematic review. All five intravitreal drugs including triamcinolone, dexamethasone, ranibizumab, bevacizumab, and aflibercept showed improvement of CMT and VA as compared to placebo or laser treatment. Six randomized controlled trials were selected for meta-analysis in RVO patients. The pooled mean difference of visual improvement between sham and ranibizumab was 12.7 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (95%CI: 11.00 to 13.2), and the pooled mean difference in CMT reduction was 221μm (95%CI: 153 to 284); both changes were significantly in favor of ranibizumab. The pooled mean difference of visual improvement between bevacizumab and triamcinolone was 5.3 ETDRS letters in favor of bevacizumab (95%CI: 16 μm to 17.5 μm). Triamcinolone led to 68.1 μm greater CMT reduction than bevacizumab (95%CI: 58 μm to 76 μm). However, none of these differences were statistically significant.

Conclusion

Treatment with anti-VEGF agents in RVO is superior to observation. No significant difference was seen between the eyes treated with bevacizumab or triamcinolone based on these results.

Anti-vascular endothelial growth factor treatment for retinal conditions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the comparative effectiveness and safety of intravitreal bevacizumab, ranibizumab and aflibercept for patients with choroidal neovascular age-related macular degeneration (cn-AMD), diabetic macular oedema (DMO), macular oedema due to retinal vein occlusion (RVO-MO) and myopic choroidal neovascularisation (m-CNV).

DESIGN

Systematic review and random-effects meta-analysis.

METHODS

Multiple databases were searched from inception to 17 August 2017. Eligible head-to-head randomised controlled trials (RCTs) comparing the (anti-VEGF) drugs in adult patients aged ≥18 years with the retinal conditions of interest. Two reviewers independently screened studies, extracted data and assessed risk of bias.

RESULTS

19 RCTs involving 7459 patients with cn-AMD (n=12), DMO (n=3), RVO-MO (n=2) and m-CNV (n=2) were included. Vision gain was not significantly different in patients with cn-AMD, DMO, RVO-MO and m-CNV treated with bevacizumab versus ranibizumab. Similarly, vision gain was not significantly different between cn-AMD patients treated with aflibercept versus ranibizumab. Patients with DMO treated with aflibercept experienced significantly higher vision gain at 12 months than patients receiving ranibizumab or bevacizumab; however, this difference was not significant at 24 months. Rates of systemic serious harms were similar across anti-VEGF agents. Posthoc analyses revealed that an as-needed treatment regimen (6-9 injections per year) was associated with a mortality increase of 1.8% (risk ratio: 2.0 [1.2 to 3.5], 2 RCTs, 1795 patients) compared with monthly treatment in cn-AMD patients.

CONCLUSIONS

Intravitreal bevacizumab was a reasonable alternative to ranibizumab and aflibercept in patients with cn-AMD, DMO, RVO-MO and m-CNV. The only exception was for patients with DME and low visual acuity (<69 early treatment diabetic retinopathy study [ETDRS] letters), where treatment with aflibercept was associated with significantly higher vision gain (≥15 ETDRS letters) than bevacizumab or ranibizumab at 12 months; but the significant effects were not maintained at 24 months. The choice of anti-VEGF drugs may depend on the specific retinal condition, baseline visual acuity and treatment regimen.

PROSPERO REGISTRATION NUMBER

CRD42015022041.

Long-term outcomes of intravitreous bevacizumab or tissue plasminogen activator or vitrectomy for macular edema due to branch retinal vein occlusion

Purpose

The purpose of this study was to determine the long-term outcomes of intravitreal bevacizumab (IVB) or intravitreal tissue plasminogen activator (tPA) or vitrectomy for macular edema associated with a branch retinal vein occlusion (BRVO).

Methods

This was a retrospective, interventional case series. Forty-one patients received a single 1.25 mg of IVB injection and followed by pro re nata protocol, 71 patients received a single intravitreal tPA, and 116 patients underwent phacovitrectomy with intraocular lens implantation.

Results

The baseline characteristics and follow-up periods were not significantly different among the three groups. The mean follow-up period was 55.5 months with a range of 12-160 months. Sixteen patients (39.0%) in the IVB group, 24 patients (33.8%) in the tPA group, and two patients (1.7%) in the vitrectomy group underwent additional surgeries during the follow-up period. The best-corrected visual acuity (BCVA) significantly improved in all groups at 1 year after the initial treatment (all, P<0.0001) and at the final visit (all, P<0.0001). The differences in the BCVA between the three groups were not significant at all times after the initial treatment.

Conclusion

The three groups led to similar long-term good visual outcomes. However, additional surgeries were performed in more than 30% of patients in the IVB and tPA groups.

Effect of funding source on reporting bias in studies of intravitreal anti-vascular endothelial growth factor therapy for retinal vein occlusion

PURPOSE

To examine the relationship between industry funding and outcome reporting bias in high-quality studies investigating the use of intravitreal anti-vascular endothelial growth factor (VEGF) agents for patients with macular oedema secondary to branch or central retinal vein occlusion (RVO).

METHODS

This systematic review in PubMed and Ovid MEDLINE examined all randomized clinical trials and meta-analyses published in journals with impact factor of ≥2 that investigated effectiveness of intravitreal anti-VEGF therapy in patients with RVO. The main outcome measure was correspondence between statistical outcome and abstract conclusion wording.

RESULTS

Forty-five studies met inclusion criteria; 38 (84%) showed correspondence between outcome and abstract conclusion without difference between industry-funded and nonindustry-funded publications (p = 0.39) or between publications in journals with impact factor ≥3 versus <3 (p = 0.96).

CONCLUSION

In high-quality studies of intravitreal anti-VEGF therapy for RVO, neither industry funding nor journal impact factor affected the rate of outcome reporting bias.

Combination of Grid Laser Photocoagulation and a Single Intravitreal Ranibizumab as an Efficient and Cost-Effective Treatment Option for Macular Edema Secondary to Branch Retinal Vein Occlusion

Our prospective comparative study of 60 patients aimed to compare the efficacy and feasibility of a single injection ranibizumab versus a single grid laser photocoagulation and versus a combined treatment in macular edema secondary to branch retinal vein occlusion in Asian population. Patients were randomized 1:1:1 (n = 20/group) into grid laser (LAS), the ranibizumab (RAN), and the combination (COM) group. Outcomes were measured as best-corrected visual acuity (BCVA) and central macular thickness (CMT). There were significant differences in mean BCVA between the three groups at 1 week and 1 month (p < 0.05) and in mean CMT at 1 week and 1, 3, 6, and 12 months (p < 0.05). Overall, best results were observed in the combination group. However, the RAN and COM groups achieved very similar results. At 12 months, the CMT in all three groups was decreased compared with baseline (p < 0.05). Our results allow to conclude that the effect of early treatment with a single injection of intravitreal ranibizumab (cost reduction) and the stabilizing effect of grid laser photocoagulation is indeed an effective, feasible, and safe regiment for macular edema secondary to BRVO in Chinese patients, allowing to obviate the need for repeated intravitreal injections and thus reduce the adverse events, therapy duration, patients' malcompliance, and adverse events. A single ranibizumab therapy however is a comparable alternative.

The use of bevacizumab and ranibizumab for branch retinal vein occlusion in medicare beneficiaries

Purpose

To describe the frequency and variation of intravitreal bevacizumab and ranibizumab use for branch retinal vein occlusion (BVO) in the United States (US).

Methods

We obtained a 5% random sample of Medicare beneficiaries from the Medicare Denominator and Physician/Supplier Part B claims files from 2010 to 2013 and identified all beneficiaries with an ICD-9-CM code for branch retinal vein occlusion (BVO, 362.36). Patient age, gender, race, state of residence and Charlson Comorbidity Index (CCI) scores were collected. Healthcare Common Procedure Coding System (HSCPS) codes for bevacizumab (J3590, J9035, and J3490) and for ranibizumab (J2778) were used to identify the mode of treatment for each patient. Patients who met the following criteria were excluded from this study: (1) under 65 years of age; (2) residence outside of the 50 United States or the District of Columbia; (3) no Part-B coverage or with HMO coverage that was not processed by Centers for Medicare & Medicaid Services (CMS); (4) concomitant diagnosis of diabetic edema (ICD-9: 362.07) or central retinal vein occlusion (ICD-9: 362.35); and (5) received both or none of the above two treatments. Geographic variation was examined by comparing injection frequencies across the nine US census divisions using Chi-squared analysis.

Results

During 2010–2013, a majority of the 3944 BVO patients who met the inclusion criteria received bevacizumab compared to ranibizumab (76.7% vs 23.3%). Most patients were aged 75–79 (22.0%) or 80–84 (22.0%), female (61.5%), white (88.3%), and had a CCI score of 1–2 (39.8%). The frequencies of bevacizumab and ranibizumab injections for BVO varied significantly between the US census divisions (p < 0.0001). The highest frequencies of bevacizumab use were in the Mountain (90.6%) and Pacific (82.7%) divisions while the highest frequencies of ranibizumab use were in the West North Central (37.9%) and Mid Atlantic (32.7%) divisions.

Conclusions and Importance

A majority of Medicare beneficiaries with BVO received bevacizumab compared to ranibizumab from 2010 to 2013, with significant geographic variation in the use of the two anti-VEGF agents. Future research into factors driving geographic variation in the use of these agents may help direct cost-effective strategies for the management of BVO.

Retinal Vein Occlusion Review

Retinal vein occlusions are a very common condition with great importance in ophthalmology clinical practice. This article reviews the salient epidemiology, risk factors, clinical features, and treatments related to retinal vein occlusions.

Comparison between anti-VEGF therapy and corticosteroid or laser therapy for macular oedema secondary to retinal vein occlusion: A meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Therapeutic effects of anti-VEGF agents, corticosteroids and laser therapy have been previously examined for treating macular oedema secondary to branch and central retinal vein occlusion (BRVO and CRVO). However, anti-VEGF efficacy has not been previously compared to corticosteroid or laser therapy efficacy. We performed a meta-analysis to compare these treatments.

METHODS

Pertinent publications were identified through comprehensive literature searches. Therapeutic effects were estimated using best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP). The Review Manager (version 5.3.5) was used to perform searches.

RESULTS AND DISCUSSION

Eleven randomized, controlled trials that included 1045 RVO patients were identified. For eyes with BRVO, anti-VEGF therapy improved BCVA significantly more than corticosteroid/laser therapy at 3 (P=.0002), 6 (P<.00001) and 12 months (P<.00001). For eyes with CRVO, this difference was only significant at 6 months (P=.002). The same was true when efficacy was examined using CRT at 3 and 6 months (BRVO: both P<.00001, CRVO 6 months: P=.02). Long-term efficacy of anti-VEGF agents was limited in eyes with BRVO and CRVO. Improvements in BCVA were similar at 1 and 3 months (P=.74), but BCVA decreased between 3 and 6 months (P=.03). In contrast, BCVA progressively decreased 1 and 6 months following corticosteroid/laser therapy (both P<.00001). Lastly, eyes that had been treated with anti-VEGF agents had significantly lower IOP changes than eyes treated with corticosteroids/laser 3 and 6 months after initiating therapy (both P<.00001).

WHAT IS NEW AND CONCLUSION

Anti-VEGF agents improve BCVA and reduce CRT more effectively and longer than corticosteroid/laser in eyes with RVO. Anti-VEGF agents also have a lower risk of elevating IOP. Additionally, anti-VEGF agents are more effective for treating BRVO than CRVO.

Therapies for Macular Edema Associated with Branch Retinal Vein Occlusion: A Report by the American Academy of Ophthalmology

PURPOSE

To evaluate the available evidence on the ocular safety and efficacy of current therapeutic alternatives for the management of macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

METHODS

Literature searches were last conducted on January 31, 2017, in PubMed with no date restrictions and limited to articles published in English, and in the Cochrane Database without language limitations. The searches yielded 321 citations, of which 109 were reviewed in full text and 27 were deemed appropriate for inclusion in this assessment. The panel methodologist assigned ratings to the selected studies according to the level of evidence.

RESULTS

Level I evidence was identified in 10 articles that addressed anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME, including intravitreal bevacizumab (5), aflibercept (2), and ranibizumab (4). Level I evidence was identified in 6 studies that examined intravitreal corticosteroids, including triamcinolone (4) and the dexamethasone implant (2). Level I evidence also was available for the role of macular grid laser photocoagulation (7) and scatter peripheral laser surgery (1). The inclusion of level II and level III studies was limited given the preponderance of level I studies. The number of studies on combination therapy is limited.

CONCLUSIONS

Current level I evidence suggests that intravitreal pharmacotherapy with anti-VEGF agents is effective and safe for ME secondary to BRVO. Prolonged delay in treatment is associated with less improvement in visual acuity (VA). Level I evidence also indicates that intravitreal corticosteroids are effective and safe for the management of ME associated with BRVO; however, corticosteroids are associated with increased potential ocular side effects (e.g., elevated intraocular pressure, cataracts). Laser photocoagulation remains a safe and effective therapy, but VA results lag behind the results for anti-VEGF therapies.

Cellular stress response in human Müller cells (MIO-M1) after bevacizumab treatment

Bevacizumab, an anti-vascular endothelial growth factor (VEGF) agent, is widely used in the treatment of retinal vascular diseases. However, due to the essential role Müller cell derived-VEGF plays in the maintenance of retinal neurons and glial cells, cell viability is likely to be affected by VEGF inhibition. We therefore evaluated the effect of bevacizumab-induced VEGF inhibition on Müller cells (MIO-M1) in vitro. MIO-M1 cells were cultured for 12 or 24 h in media containing bevacizumab at 0.25 or 0.5 mg/mL. Controls were cultured in medium only. Cell viability was determined with the trypan blue exclusion test and MTT assay. Caspase-3, beclin-1, glial fibrillary acidic protein (GFAP) and vimentin content were quantified by immunohistochemistry. Gene expression was evaluated by real-time quantitative PCR. Treatment with bevacizumab did not reduce MIO-M1 cell viability, but increased metabolic activity at 24 h (0.5 mg/mL) and induced apoptosis and autophagy, as shown by the increased caspase-3 levels at 12 h (0.25 and 0.5 mg/mL) and the increased beclin levels at 24 h (0.5 mg/mL). Caspase-3 mRNA was upregulated at 12 h and downregulated at 24 h in cells treated with bevacizumab at 0.25 mg/mL. Bevacizumab treatment was also associated with structural protein abnormalities, with decreased GFAP and vimentin content and upregulated GFAP and vimentin mRNA expression. Although bevacizumab did not significantly affect MIO-M1 cell viability, it led to metabolic and molecular changes (apoptosis, autophagy and structural abnormalities) suggestive of significant cellular toxicity.

Intravitreal PRN ranibizumab treatment for macular edemadue to branch retinal vein occlusion

BACKGROUND/AIM

To evaluate the effect of intravitreal pro re nata (PRN) ranibizumab treatment from the start on the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) in macular edema (ME) due to branch retinal vein occlusion (BRVO).

MATERIALS AND METHODS

Patients with ME secondary to BRVO, who were treated on a PRN basis after a single intravitreal ranibizumab injection, were retrospectively evaluated. The main outcome measures were changes in BCVA and CRT as measured by optical coherence tomography.

RESULTS

The number of injections over 6 months was 2.43 ± 1.16. The mean BCVA of the patients was 0.84 ± 0.10 logMAR at baseline and 0.41 ± 0.06 at the 6th month (P < 0.001). Mean BCVA of the ischemic BRVO group was 1.06 ± 0.68 logMAR at baseline and 0.44 ± 0.30 logMAR at the 6th month (P < 0.05). Similarly, the mean BCVA of the nonischemic BRVO group was 0.77 ± 0.53 logMAR at baseline and 0.41 ± 0.36 logMAR at the 6th month (P < 0.05). Between groups, there was no significant difference in mean BCVA at any examination.

CONCLUSION

Intravitreal ranibizumab is a safe and effective treatment option for ME due to ischemic and nonischemic BRVO using PRN from the start.

Risk factors of recurrence of macular oedema associated with branch retinal vein occlusion after intravitreal bevacizumab injection

BACKGROUND/AIMS

To identify risk factors of recurrence of macular oedema in branch retinal vein occlusion (BRVO) after intravitreal bevacizumab (IVB) injection.

METHODS

The records of 63 patients who underwent IVB injection for macular oedema secondary to BRVO with at least 6 months of follow-up were reviewed. Patients were evaluated at baseline with fluorescein angiography (FA), optical coherence tomography (OCT) and ultra-wide-field fundus photography (WFP). During follow-up, OCT and WFP were repeated. The area of retinal haemorrhage, central retinal thickness (CRT), area (mm²) of capillary non-perfusion within the 1 mm (NPA1), 1-3 mm and 6 mm zones of the ETDRS circle, foveal capillary filling time, degree (°) of foveal capillary network destruction and FA pattern were analysed.

RESULTS

Macular oedema recurred in 41 of 63 (65.1%) eyes after initial IVB injection. A binary logistic regression model showed that NPA1 (OR=434.97; 95% CI=5.52 to 34262.12, p=0.006) and initial CRT (OR=1.004; 95% CI=1.000 to 1.008, p=0.015) were significantly associated with the recurrence of macular oedema. Receiver operating characteristic curve analysis identified an NPA1 of 0.36 mm² (AUC: 0.735, sensitivity: 70.7%; specificity: 63.6%) and an initial CRT of 570 µm (AUC: 0.745, sensitivity: 63.4%; specificity: 77.3%) as cut-off values for predicting recurrence of macular oedema.

CONCLUSIONS

Patients with BRVO with non-perfusion of more than half of the 1 mm zone of the ETDRS circle or with an initial CRT >570 µm should be closely monitored for macular oedema recurrence within 6 months of IVB injection.

Effects of two different doses of intravitreal bevacizumab on subfoveal choroidal thickness and retinal vessel diameter in branch retinal vein occlusion

AIM

To investigate the effects of two different doses of intravitreal bevacizumab on subfoveal choroidal thickness (SFChT) and retinal vessel diameter in patients with branch retinal vein occlusion.

METHODS

An interventional, restrospective study of 41 eyes of 41 patients who had completed 12mo of follow-up, divided into group 1 (1.25 mg of bevacizumab, 21 eyes of 21 patients) and group 2 (2.5 mg of bevacizumab, 20 eyes of 21 patients). Complete ophthalmic examination, fluorescein angiography, enhanced depth imaging optical coherence tomography and measurement of retinal vessel diameter with IVAN software were performed at baseline and follow-up.

RESULTS

The SFChT changed from 279.1 (165-431) µm at baseline to 277.0 (149-413) µm at 12mo in group 1 (P=0.086), and from 301.4 (212-483) µm to 300.3 (199-514) µm in group 2 (P=0.076). The central retinal arteriolar equivalent (CRAE) changed from 128.8±11.2 µm at baseline to 134.5±8.4 µm at 12mo in group 1, and from 134.6±9.0 µm to 131.4±12.7 µm in group 2 (P=0.767). The central retinal venular equivalent (CRVE) changed from 204.1±24.4 µm at baseline to 196.3±28.2 µm at 12mo in group 1, and from 205.8±16.3 µm to 194.8±18.2 µm in group 2 (P=0.019). The mean central macular thickness (P<0.05) and average best-corrected visual acuity (BCVA; P<0.05) improved in both groups.

CONCLUSION

Changes in the SFChT are not statistically significant and not different according to the doses of bevacizumab. The CRAE did not show significant change, however, the CRVE showed significant decrease regardless of the dose.

Comparison of the Efficacy of Intravitreal Aflibercept and Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion

Fifty-two eyes of 52 patients with treatment-naïve macular edema associated with perfused branch retinal vein occlusion were retrospectively reviewed. Twenty-seven cases received PRN intravitreal bevacizumab, and 25 cases were treated by PRN intravitreal aflibercept with monthly follow-ups for 12 months. Both aflibercept and bevacizumab were effective in reduction of macular thickness and improvement of visual acuity for the participants. Both antivascular endothelial growth factor agents had similar efficacy and duration of treatment for these eyes with macular edema secondary to branch retinal vein occlusion during a 12-month period. No serious systemic or ocular adverse events were reported.

Update in the Management of Macular Edema Following Retinal Vein Occlusions

Retinal vein occlusion (RVO) is a common retinal vascular disease classified according to the anatomical location of the occlusion in central (CRVO) or branch (BRVO) retinal vein occlusion. RVO is an important cause of visual loss worldwide and frequently results in visual impairment and ocular complications. Major causes of vision loss in BRVO and CRVO include macular edema (ME), capillary non-perfusion, and neovascularization, causing glaucoma, vitreous hemorrhage and/or tractional retinal detachment.[1-4] Macular edema is the leading cause of decreased central visual acuity in RVO.[5] Recently, there was a paradigm shift in the treatment of ME due to RVO with the advent of new pharmacotherapy treatment strategies and combination therapies. This paper reviews the current thinking and discusses the evidence behind the emerging treatment options for ME following RVO, including laser photocoagulation, intravitreal anti-vascular endothelial growth factor (VEGF), intravitreal corticosteroid-based pharmacotherapies, and surgical management.

A Review of Randomized Trials of Approved Pharmaceutical Agents for Macular Edema Secondary to Retinal Vein Occlusion

There are 3 approved pharmaceutical agents for treating macular edema secondary to retinal vein occlusion (RVO): dexamethasone (a corticosteroid) implant and ranibizumab and aflibercept (both antivascular endothelial growth factor agents). All show a superior ability to improve vision and reduce macular thickness in comparison with sham injections or macular grid laser treatment. Prompt treatment with these agents may lead to a better outcome. A review of randomized trials of injected aflibercept or ranibizumab reveals protocol variations. They include "as needed" injections until functional and anatomical changes are achieved, preceded by either 1 injection or 3 to 6 monthly injections as loading doses. Ocular and systemic adverse effects of vascular endothelial growth factor antagonists for macular edema secondary to RVO are rarely severe. The antiedematous response to a single intravitreal dexamethasone implant is maximal 1 to 3 months after the injection. Intraocular pressure elevation and cataract aggravation should be monitored after the use of intravitreal dexamethasone implants. Intravitreal dexamethasone implants and ranibizumab injections reduce not only macular edema, but also the risk of retinal ischemia and neovascularization in patients with RVO.

Efficacy of combined intravitreal bevacizumab and triamcinolone for branch retinal vein occlusion

Purpose:

To evaluate the efficacy of combined treatment with intravitreal bevacizumab (IVB) and triamcinolone acetate (IVT) for patients with macular edema secondary to branch retinal vein occlusion (BRVO).

Materials and Methods:

Retrospective analysis of 20 eyes injected with 1.25 mg IVB and 2 mg IVT for clinically identified BRVO within 8 weeks of onset. All patients lacked concomitant ocular pathology and completed 6 months’ follow-up. Clinical examination including LogMAR visual acuity (VA) and central macular thickness (CMT) by spectralis optical coherence tomography (OCT) was performed preoperatively and at 1, 3 and 6 months post-operatively.

Results:

Mean patient age was 61.3 years with a mean BRVO diagnosis time of 3 weeks at presentation. VA improved from logMAR 1.08 preoperatively to Mean logMAR VA of 0.55 ± 0.17 at 1 month (P < 0.001), 0.56 ± 0.21 at 3 months (P < 0.001), and 0.38 ± 0.1 at 6 months (P < 0.001) Mean CMT improved from 482 ± 107 μm preoperatively to 319 ± 53 μm at 1 month (P < 0.001), 344 ± 89 μm at 3 months (P < 0.001), and 241 ± 29 μm at 6 months (P < 0.001). Mean IOP preoperatively was 16.5 mmHg, 21 mmHg at 1 month, and 15 mmHg at 6 months. Six out of 20 patients (30%) were re-injected with IVB and IVT at 3 months.

Conclusions:

Early combined treatment with IVB and IVT is effective in improving anatomic and functional outcomes in patients with macular edema secondary to BRVO.

Approved pharmacotherapy for macular edema secondary to branch retinal vein occlusion: A review of randomized controlled trials in dexamethasone implants, ranibizumab, and aflibercept

There are three approved pharmacotherapies for treating macular edema secondary to branch retinal vein occlusion (BRVO), including corticosteroids (dexamethasone implants) and anti-vascular endothelial growth factor (VEGF) (ranibizumab and aflibercept). They all show superior ability to improve vision and reduce macular thickness, comparing with sham injections or macular grid laser treatment. There is no severe ocular or systemic adverse reaction reported in studies associated with anti-VEGF for macular edema after BRVO. Intraocular pressure elevation and cataract aggravation should be addressed after intravitreal dexamethasone implants. Single intravitreal dexamethasone implant had effective duration as long as four to six months. Intravitreal anti-VEGF requires six monthly injections as loading doses, and then PRN regimen needed according to functional and anatomical changes. Ozurdex and ranibizumab reduce not only macular edema, but also the probability of retinal ischemia and neovascularization in patient s with BRVO. Prompt treatment with these agents can lead to a better outcome.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Comparative efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion: a network meta-analysis

OBJECTIVE

To compare the efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Randomised controlled trials (RCTs) evaluating the efficacy and safety of approved treatments for macular oedema secondary to BRVO were identified from an updated systematic review.

SETTING

A Bayesian network meta-analysis of RCTs of treatments for macular oedema secondary to BRVO.

INTERVENTIONS

Ranibizumab 0.5 mg pro re nata, aflibercept 2 mg monthly (2q4), dexamethasone 0.7 mg implant, laser photocoagulation, ranibizumab+laser, or sham intervention. Bevacizumab and triamcinolone were excluded.

OUTCOME MEASURES

Efficacy outcomes were mean change in best corrected visual acuity (Early Treatment Diabetic Retinopathy Study scale) and the percentage of patients gaining ≥ 15 letters. Safety outcome was the percentage of patients with increased intraocular pressure (IOP)/ocular hypertension (OH).

RESULTS

8 RCTs were identified for inclusion with 1743 adult patients. The probability of being the most efficacious treatment at month 6 or 12 based on letters gained was 54% for ranibizumab monotherapy, 30% for aflibercept, 16% for ranibizumab plus laser (adjunctive or prompt), and 0% for dexamethasone implant, laser or sham. The probability of being the most efficacious treatment for patients gaining ≥ 15 letters was 39% for aflibercept, 35% for ranibizumab monotherapy, 24% for ranibizumab plus laser, 2% for dexamethasone implant, and less than 1% for laser or sham. There was no statistical difference between ranibizumab monotherapy and aflibercept for letters gained (+1.4 letters for ranibizumab vs aflibercept with 95% credible interval (CrI) of -5.2 to +8.5 letters) or the OR for gaining ≥ 15 letters: 1.06 (95% CrI 0.16 to 8.94)). Dexamethasone implant was associated with significantly higher IOP/OH than antivascular endothelial growth factor agents (OR 13.1 (95% CrI 1.7 to 116.9)).

CONCLUSIONS

There was no statistically significant difference between ranibizumab and aflibercept.

Macular grid laser photocoagulation for branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is the second most common cause of retinal vascular abnormality after diabetic retinopathy. Persistent macular oedema develops in 60% of eyes with a BRVO. Untreated, only 14% of eyes with chronic macular oedema will have a visual acuity (VA) of 20/40 or better. Macular grid laser photocoagulation is used for chronic non-ischaemic macular oedema following BRVO and has been the mainstay of treatment for over 20 years. New treatments are available and a systematic review is necessary to ensure that the most up-to-date evidence is considered objectively.

OBJECTIVES

To examine the effects of macular grid laser photocoagulation in the treatment of macular oedema following BRVO.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, EMBASE, Web of Science Conference Proceedings Citation Index, the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 August 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing macular grid laser photocoagulation treatment to another treatment, sham treatment or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five studies conducted in Europe and North America. Four separate trials compared grid laser to no treatment, sham treatment, intravitreal bevacizumab and intravitreal triamcinolone. One further trial compared subthreshold to threshold laser. Two of these trials were judged to be at high risk of bias in one or more domains.In one trial of grid laser versus observation, people receiving grid laser were more likely to gain visual acuity (VA) (10 or more ETDRS letters) at 36 months (RR 1.75, 95% confidence interval (CI) 1.08 to 2.84, 78 participants, moderate-quality evidence). The effect of grid laser on loss of VA (10 or more letters) was uncertain as the results were imprecise (RR 0.68, 95% CI 0.23 to 2.04, 78 participants, moderate-quality evidence). On average, people receiving grid laser had better improvement in VA (mean difference (MD) 0.11 logMAR, 95% CI 0.05 to 0.17, high-quality evidence). In a trial of early and delayed grid laser treatment versus sham laser (n = 108, data available for 99 participants), no participant gained or lost VA (15 or more ETDRS letters). At 12 months, there was no evidence for a difference in change in VA (from baseline) between early grid laser and sham laser (MD -0.03 logMAR, 95% confidence interval (CI) -0.07 to 0.01, 68 participants, low-quality evidence) or between delayed grid laser and sham laser (MD 0.00, 95% CI -0.04 to 0.04, 66 participants, low-quality evidence).The relative effects of subthreshold and threshold laser were uncertain. In one trial, the RR for gain of VA (15 or more letters) at 12 months was 1.68 (95% CI 0.57 to 4.95, 36 participants, moderate-quality evidence); the RR for loss of VA (15 or more letters) was 0.56 (95% CI 0.06 to 5.63, moderate-quality evidence); and at 24 months the change in VA from baseline was MD 0.07 (95% CI -0.10 to 0.24, moderate-quality evidence).The relative effects of macular grid laser and intravitreal bevacizumab were uncertain. In one trial, the RR for gain of 15 or more letters at 12 months was 0.67 (95% CI 0.39 to 1.14, 30 participants, low-quality evidence). Loss of 15 or more letters was not reported. Change in VA at 12 months was MD 0.11 logMAR (95% CI -0.36 to 0.14, low-quality evidence).The relative effects of grid laser and 1mg triamcinolone were uncertain at 12 months. RR for gain of VA (15 or more letters) was 1.13 (95% CI 0.75 to 1.71, 1 RCT, 242 participants, moderate-quality evidence); RR for loss of VA (15 or more letters) was 1.20 (95% CI 0.63 to 2.27, moderate-quality evidence); MD for change in VA was -0.03 letters (95% CI -0.12 to 0.06, moderate-quality evidence). Similar results were seen for the comparison with 4mg triamcinolone. Beyond 12 months, the visual outcomes were in favour of grid laser at 24 months and 36 months with people in the macular grid group gaining more VA.Four studies reported on adverse effects. Laser photocoagulation appeared to be well tolerated in the studies. One participant (out of 71) suffered a perforation of Bruch's membrane, but this did not affect visual acuity.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from one RCT supports the use of grid laser photocoagulation to treat macular oedema following BRVO. There was insufficient evidence to support the use of early grid laser or subthreshold laser. There was insufficient evidence to show a benefit of intravitreal triamcinolone or anti-vascular endothelial growth factor (VEGF) over macular grid laser photocoagulation in BRVO. With recent interest in the use of intravitreal anti-VEGF or steroid therapy, assessment of treatment efficacy (change in visual acuity and foveal or central macular thickness using optical coherence tomography (OCT)) and the number of treatments needed for maintenance and long-term safety will be important for future studies.

Comparison of intravitreal bevacizumab and dexamethasone implant for the treatment of macula oedema associated with branch retinal vein occlusion

BACKGROUND/AIMS

To compare the functional and anatomical outcomes of intravitreal bevacizumab (IVB) with those of dexamethasone implant injection (IVD) for macular oedema associated with branch retinal vein occlusion (BRVO).

METHODS

Seventy-two patients with centre-involving macular oedema secondary to BRVO were retrospectively enrolled in the study; these patients were treated with either 1.25 mg IVB (44 eyes; mean injections: 2.92±1.38) pro re nata (PRN) by follow-up monthly or 700 µg IVD (28 eyes; mean injections: 1.71±0.47) given at 6-month intervals PRN and were followed for at least 12 months. Main outcome measures were changes in best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

There was no statistically significant difference of mean change of the logarithm of the minimum angle of resolution BCVA between IVB and IVD groups at monthly visits, up to 12 months (all p>0.05); however, there was a trend towards greater BCVA gain in the IVB group than in the IVD group at 6 months (p=0.053). Additionally, 52.6% in the IVB group and 50% in the IVD group gained two or more lines of Snellen visual acuity at 12 months (p=0.85). The mean CFT decreased by 160 µm for the IVB group and by 140.7 µm for the IVD group at 12 months. Both the IVB group and the IVD group achieved statistically similar improvement of CFT at monthly visits, up to 5 months (all p>0.05); however, the CFT began to deteriorate after 5 months in the IVD group, and at 6 months, improvement in the IVB group was significantly greater than that in the IVD group (p=0.007). After a second IVD injection at 6 months, the IVD group showed significant improvement of CFT, and there was no significant difference of CFT change between the IVB and IVD groups until 12 months.

CONCLUSIONS

For macular oedema secondary to BRVO, IVB administered PRN monthly and IVD administered PRN at 6-month intervals, yielded functionally and anatomically comparable outcomes at 12 months.

Ranibizumab for Branch Retinal Vein Occlusion Associated Macular Edema Study (RABAMES): six-month results of a prospective randomized clinical trial

PURPOSE

To compare standard-of-care grid laser photocoagulation versus intravitreal ranibizumab (IVR) versus a combination of both in the treatment of chronic (>3 months) macular oedema secondary to branch retinal vein occlusion.

METHODS

Prospective, randomized, multicentre clinical trial. Thirty patients with a best-corrected visual acuity (BCVA) between 20/320 and 20/40 were randomized 1:1:1 to receive grid laser or three monthly injections of 0.5 mg IVR or both followed by 3 months of observation.

RESULTS

Mean change from baseline BCVA at month 6 was +2 letters [laser; 0.04 logMAR, 95% confidence interval (-0.17; 0.25)], +17 letters [IVR; 0.34 (0.19; 0.5)] and +6 letters [combination; 0.12 (0.01; 0.24)] (IVR versus laser p = 0.02 and IVR versus combination p = 0.02). At month 3, mean improvement in central retinal thickness (CRT) was 90.6 μm (laser) (-18.65; 199.8), 379.5 μm (IVR) (204.2; -554.8), and 248 μm (167.2; -328.8) (combination) (IVR versus laser p = 0.005, laser versus combination p = 0.02). During the observation period, CRT improved in laser [37.6 μm (-66.82; 142.0)], but deteriorated in IVR [-142.4 μm (-247.6; -37.16)] and combination [-171.7 μm (-250.4; -92.96)] (laser versus IVR p = 0.01, laser versus combination p = 0.002) indicating recurrent oedema. Less laser retreatments (at 8 weeks) were required in combination group (2/10) than grid group (7/10).

CONCLUSION

Six-month results suggest that ranibizumab may be superior to grid laser in improving visual acuity. Grid combined with IVR neither enhanced functional and morphological improvement of IVR nor did it prevent or prolong recurrence of oedema. In IVR groups, CRT increased slowly after stopping injections, whereas improvement in visual acuity was sustained, indicating that morphological changes occur prior to functional impairment.

The influence of anti-VEGF therapy on present day management of macular edema due to BRVO and CRVO: a longitudinal analysis on visual function, injection time interval and complications

The purpose of this study was to evaluate the impact of intravitreal bevacizumab injections on the management and outcome of patients affected by retinal vein occlusions, their effectiveness on morphological and functional parameters, the modalities of long-term management and the need for additional laser treatment due to ischemic retinal evolution. Patients diagnosed with branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) had a comprehensive work-up including complete ophthalmic examination, fluorangiography (FA), optical coherence tomography (OCT), visual field testing (VFT), microperimetry (MP), and laser flare photometry (LFP). In case of BRVO, intraocular bevacizumab injection was performed if significant macular edema/visual deficit was still present 3 months after onset of occlusion and injections were started at presentation in case of CRVO. Post-injection follow-up examination including best corrected visual acuity (BCVA), intraocular pressure (IOP), LFP, OCT, MP, and VFT were performed monthly and recorded at the end of follow-up. Follow-up FA was performed between 12 and 18 months after diagnosis. Injections were repeated in case of recurrence of a significant central macular edema. Patients were subdivided into 2 groups according to number of injections: 1-4 injections or more than 4 injections. The proportion of resolved cases (no recurrence after a minimum follow-up of 12 months) was calculated and correlated with number of injections. In patients needing sustained injections, management modalities were recorded. The proportion of patients having needed laser photocoagulation treatment because of significant ischemic signs was recorded. Fifty-one patients were diagnosed with retinal vein occlusion between 2006 and 2012 at the Centre for Specialized Ophthalmic Care (COS) in Lausanne, Switzerland. Forty-four had enough data and were included in the study. Nine eyes were affected by CRVO and 35 were affected by BRVO. Mean BCVA at presentation was 0.24 ± 0.2 and improved to 0.81 ± 0.38 (p < 0.01) at 48 months. MP improved from 184.9 ± 92 to 362.5 ± 56.2 (p < 0.01) at 42 months follow-up. The number of injections varied from 1 to 25 (mean 5.5 ± 5.43). 31/44 eyes received 1-4 injections (group 1) of which all were recurrence free, with a follow-up of at least 1 years in all. 13/44 eyes received more than 5 injections (group 2) with functional and morphological parameters maintained in 9/13 but only 1/13 patients showed resolution. Rhythm of injection varied from one patient to another but 8/13 patients needing continuous injections had a constant time interval between injections. In 8/44 patients, laser photocoagulation had to be performed due to ischemic complications. The visual outcome using bevacizumab intravitreal injection was exceptionally good and functional parameters such as BCVA, MP, and VFT improved significantly. In about two-thirds of patients, resolution was obtained after 1-4 injections. In one-third of patients, continuous injections were necessary but a constant rhythm for re-injection for each patient could be established allowing to reduce to a minimum follow-up visits. The absence of significant side effects allowed to re-treat apparently without limitation achieving maintained visual function. FA monitoring for the detection of ischemic complications should not be neglected especially in cases where bevacizumab could be discontinued.

The safety of intravitreal bevacizumab monotherapy in adult ophthalmic conditions: systematic review

OBJECTIVES

To assess the safety of intravitreal bevacizumab (IVB) as a monotherapy and to evaluate the relationship between quality of treatment and adverse events.

DATA SOURCES

Cochrane Library, Ovid MEDLINE, MEDLINE in-process, Ovid EMBASE and Toxicology Literature Online (TOXLINE) from January 2009 to May 2012. Studies included in an earlier systematic review were also assessed for inclusion.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Randomised controlled trials (RCTs), controlled trials or observational studies including ≥10 participants reporting adverse events data following IVB monotherapy as a primary treatment in patients (aged 18 years or more) with any eye condition were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study selection was undertaken independently by a minimum of two reviewers using pre-defined criteria. Data abstraction and quality assessment were performed by one reviewer, and then checked by a second reviewer. Study quality was assessed for only RCTs in accordance to the Cochrane Risk of Bias Tool. Additional items relating to safety data were also assessed. Results were tabulated or meta-analysed as appropriate.

RESULTS

22 RCTs and 67 observational studies were included. Only two RCTs reported valid safety data. Rates of serious adverse events following treatment were low. There was insufficient data to explore the relationship between the incidence of adverse events and quality of IVB injection.

LIMITATIONS

A majority of relevant existing studies were characterised by small sample sizes, unclear diagnostic criteria and reporting of safety outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Available evidence demonstrates low rates of serious local and systemic adverse events following treatment. However, the role of IVB quality in the incidence of adverse events remains unclear. Robust evidence is needed to examine the relationship between the incidence of adverse events and variables such as injection techniques, pre-existing risk factors (eg, immunosuppression, cross-contamination) and quality of IVB treatment.

Treat-and-extend intravitreal bevacizumab for branch retinal vein occlusion

BACKGROUND AND OBJECTIVE

To determine the effectiveness and direct medical costs of treat-and-extend (TAE) intravitreal bevacizumab (IVB) for the treatment of branch retinal vein occlusion (BRVO)-associated macular edema (ME).

PATIENTS AND METHODS

Retrospective chart review of 52 consecutive patients diagnosed with BRVO-associated ME treated with IVB using a TAE protocol.

RESULTS

Mean change in logMAR vision was -0.30 (P < .001), and mean change in central macular thickness was -244.0 μm (P < .001). The mean number of injections was 8.2 (95% CI; 7.8 to 8.6). The yearly average direct cost of the TAE regimen was calculated to be $2,580.26 per patient.

CONCLUSION

Treatment of BRVO-associated ME with IVB using a TAE regimen resulted in similar visual outcomes and number of intravitreal injections as did as-needed treatment with 0.5 mg ranibizumab conducted in phase 3 trials but with fewer visits and lower annual medical costs.

Efficacy and safety of widely used treatments for macular oedema secondary to retinal vein occlusion: a systematic review

Background

Macular oedema secondary to retinal vein occlusion (RVO) can cause vision loss due to blockage of the central retinal vein (CRVO) or a branch retinal vein (BRVO). This systematic review assessed the efficacies of widely used treatments for macular oedema secondary to RVO and the feasibility of conducting indirect comparisons between these therapies.

Methods

A systematic review was undertaken in November 2010, including a literature search for trials in medical databases and relevant websites. Abstracts, conference presentations and unpublished studies were considered. Studies were data-extracted and quality assessed by two independent researchers. Outcome measures included the mean change in best corrected visual acuity (BCVA) from baseline in the study eye and/or number of patients gaining at least 10 letters from baseline to 6 months or the nearest equivalent time point.

Results

Fourteen unique randomized controlled trials (RCTs) were identified. Ranibizumab 0.5 mg produced greater improvements in BCVA at 6 months than sham in BRVO (mean difference 11.0 letters, 95% confidence interval [CI] 7.83, 14.17) and CRVO (mean difference 14.10 letters, 95% CI 10.51, 17.69) in two double-blind sham-controlled RCTs. Pooled data from two double-blind, sham-controlled RCTs showed that improvements in BCVA were also significantly better for dexamethasone intravitreal (IVT) implant 0.7 mg compared with sham in patients with BRVO or CRVO (mean difference 2.5 letters, 95% CI 0.7, 4.3); the difference was significant for BRVO alone, but not CRVO alone. A significantly greater proportion of patients with BRVO gained ≥15 letters with laser therapy vs. no treatment at 36 months in a large prospective RCT (odds ratio 3.16, 95% CI 1.25, 8.00), whereas no difference was observed at 9 months in a smaller study. Three studies reported no benefit for laser therapy in CRVO. No indirect comparisons with ranibizumab were feasible due to differences in study design and baseline characteristics.

Conclusions

Data from RCTs for ranibizumab and dexamethasone IVT demonstrate that both new agents constitute significant improvements over the previously widely accepted standard of care (laser therapy) for the treatment of BRVO and CRVO. However, head-to-head studies are needed to assess the relative efficacies of licensed therapies for RVO.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review

BACKGROUND

Intravitreal agents have replaced observation in macular edema in central (CRVO) and grid laser photocoagulation in branch retinal vein occlusion (BRVO). We conducted a systematic review to evaluate efficacy and safety outcomes of intravitreal therapies for macular edema in CRVO and BRVO.

METHODS AND FINDINGS

MEDLINE, Embase, and the Cochrane Library were systematically searched for RCTs with no limitations of language and year of publication. 11 RCTs investigating anti-VEGF agents (ranibizumab, bevacizumab, aflibercept) and steroids (triamcinolone, dexamethasone implant) with a minimum follow-up of 1 year were evaluated.

EFFICACY CRVO

Greatest gain in visual acuity after 12 months was observed both under aflibercept 2 mg: +16.2 letters (8.5 injections), and under bevacizumab 1.25 mg: +16.1 letters (8 injections). Ranibizumab 0.5 mg improved vision by +13.9 letters (8.8 injections). Triamcinolone 1 mg and 4 mg stabilized visual acuity at a lower injection frequency (-1.2 letters, 2 injections).

BRVO

Ranibizumab 0.5 mg resulted in a visual acuity gain of +18.3 letters (8.4 injections). The effect of dexamethasone implant was transient after 1.9 implants in both indications.

SAFETY

Serious ocular adverse events were rare, e.g., endophthalmitis occurred in 0.0-0.9%. Major differences were found in an indirect comparison between steroids and anti-VEGF agents for cataract progression (19.8-35.0% vs. 0.9-7.0%) and in required treatment of increased intraocular pressure (7.0-41.0% vs. none). No major differences were identified in systemic adverse events.

CONCLUSIONS

Anti-VEGF agents result in a promising gain of visual acuity, but require a high injection frequency. Dexamethasone implant might be an alternative, but comparison is impaired as the effect is temporary and it has not yet been tested in PRN regimen. The ocular risk profile seems to be favorable for anti-VEGF agents in comparison to steroids. Because comparative data from head-to-head trials are missing currently, clinicians and patients should carefully weigh the benefit-harm ratio.

Initial dose of three monthly intravitreal injections versus PRN intravitreal injections of bevacizumab for macular edema secondary to branch retinal vein occlusion

Purpose. To compare visual and anatomic outcomes of intravitreal bevacizumab injections administered as needed (PRN group) and initial treatment with 3 monthly injections followed by as-needed injections (3 monthly initial dose group) in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods. This retrospective study included 69 and 26 patients in the PRN and 3 monthly initial dose groups, respectively. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were compared between the 2 groups 6 months after initial injection. Results. At month 6, BCVA change from baseline was −0.27 ± 0.28 (mean ± standard deviation) logMAR in the PRN group and −0.28 ± 0.20 logMAR in the 3 monthly initial dose group. Mean CRT changes were −204 ± 168 in the PRN group and −161 ± 149 μm in the 3 monthly initial dose group at month 6. There were no statistically significant differences in BCVA or CRT changes between groups at any time point. The number of intravitreal injections over 6 months was significantly lower in the PRN group (1.8 ± 0.8 injections) than in the 3 monthly initial dose group (3.4 ± 0.5 injections; P < 0.001). Conclusions. Our results suggest that as-needed intravitreal bevacizumab injections are more tolerable for patients with ME secondary to BRVO.