SAFETY AND EFFICACY OF INTRAVITREAL BEVACIZUMAB (AVASTIN) FOR THE MANAGEMENT OF BRANCH AND HEMIRETINAL VEIN OCCLUSION

Hemi-retinal vein occlusion: Characterizing a rare retinal vasculopathy

PURPOSE

To characterize hemi-retinal vein occlusion (HRVO) in patients presenting to a multi-tier ophthalmology hospital network.

METHODS

This retrospective, hospital-based study analyzed 2,834,616 new patients between August 2010 and June 2021. Patients with a clinical diagnosis of HRVO in at least one eye were included as cases. Data were collected using an electronic medical record system. Data were compared to the findings noted in branch RVO (BRVO) and central RVO (CRVO) patients.

RESULTS

HRVO constituted 0.9% ( n = 191) of all the retinal vein occlusions (RVOs), with the mean age being 60.55 ± 10.14 years. Most patients were male (125, 65.45%) with unilateral (92.67%) affliction. Majority presented during the sixth (31.41%) or seventh (32.46%) decade of life. Most patients reported mild (37.07%) or moderate (27.32%) visual impairment, with vision < 20/200 being less common in HRVO (25.8%) and BRVO (17.2%) compared to CRVO (44.1%) ( P < 0.00001). Glaucoma was diagnosed and treated in 49 (23.90%) eyes, which was much higher than CRVO (11.45%) and BRVO (5.04%) ( P < 0.001), though neovascular glaucoma was much less than CRVO (2.9% vs. 9.2%) ( P = 0.0037). On follow-up, HRVO eyes (12.2%) had lesser vision loss compared to CRVO eyes (13.7%) (this difference does not look very significant to me), though BRVO had the least (9.1%) vision loss.

CONCLUSION

HRVO is a rare RVO, presenting more in males. It causes less-severe visual impairment compared to CRVO. Large majority of patients with HRVO do not have identifiable systemic risk factors other than age. Preexisting glaucoma was more associated with HRVO compared to other RVOs.

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.

Real-Life Efficacy of Bevacizumab Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion according to Pro Re Nata or Treat-and-Extend Regimen in Eyes with or without Epiretinal Membrane

Purpose. To present real-life data of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO) treated with bevacizumab (BVZ); determine the possible influence of epiretinal membrane (ERM) on treatment efficacy; and compare treatment outcomes in a treat-and-extend regimen (TER) versus pro re nata (PRN). Methods. We carried out a retrospective analysis of 58 eyes (56 patients) with new-onset CRVO treated only with intravitreal bevacizumab according to TER or PRN. Outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and 12 months after the first treatment, number of visits and injections, and presence of ERM confirmed by optical coherence tomography in the first 6 months. Results. At 12 months, the mean number of injections was 6.3 across all eyes, with significantly more injections given in TER ( $p<0.001$ ). Mean CRT improved from 627 μm to 359 μm ( $p<0.001$ ) in all eyes, with improvement noted in TER ( $p<0.001$ ), PRN ( $p<0.001$ ), ERM ( $p=0.003$ ), and non-ERM ( $p<0.001$ ) subgroups. The mean BCVA gain was +13.6 letters, and the mean BCVA improved from 0.81 to 0.54 LogMAR ( $p<0.001$ ) in all eyes. BCVA improvement from baseline was significant in TER ( $p<0.001$ ) and non-ERM ( $p<0.001$ ) but not in PRN ( $p=0.08$ ) or ERM ( $p=0.2$ ) subgroups. Seven eyes, all receiving PRN treatment, developed neovascularization. Conclusions. Intravitreal bevacizumab according to either PRN or TER resolved edema and stabilized vision in the first 12 months, with TER yielding significant visual improvement and avoiding neovascular complications. ERM had no influence on bevacizumab efficacy in reducing ME in CRVO during 12 months of treatment.

Hemi-central retinal vein occlusion as a rare manifestation of the hypercoagulable state in COVID-19

To date, COVID-19 has no definite effective targeted therapy, and management is primarily supportive. Central retinal vein occlusion (CRVO) is frequently caused by systemic risk factors posing hypercoagulable states. In April 2020, a female patient with a history of hypertension, diabetes mellitus and chronic kidney disease presented with 2 days of loose, watery stools, nasal congestion and severe lethargy. The patient denied dyspnoea or fever. A week after the initial symptoms, the patient reported decreased vision from the left eye. Dilated funduscopy and fluorescein angiography suggested hemi-CRVO. The patient refused intravitreal antivascular endothelial growth factor agents because of non-severe visual loss. Testing was positive for COVID-19 IgG antibodies; reverse transcription PCR was not available. Vision improved within 3 weeks of presentation. We recommend that clinicians keep a high suspicion for acute onset of thrombotic events in patients with COVID-19 and thrombotic predisposing risk factors.

Multimodal Imaging of Microvascular Abnormalities in Retinal Vein Occlusion

The technologies of ocular imaging modalities such as optical coherence tomography (OCT) and OCT angiography (OCTA) have progressed remarkably. Of these in vivo imaging modalities, recently advanced OCT technology provides high-resolution images, e.g., histologic imaging, enabling anatomical analysis of each retinal layer, including the photoreceptor layers. Recently developed OCTA also visualizes the vascular networks three-dimensionally, which provides better understanding of the retinal deep capillary layer. In addition, ex vivo analysis using autologous aqueous or vitreous humor shows that inflammatory cytokine levels including vascular endothelial growth factor (VEGF) are elevated and correlated with the severity of macular edema (ME) in eyes with retinal vein occlusion (RVO). Furthermore, a combination of multiple modalities enables deeper understanding of the pathology. Regarding therapy, intravitreal injection of anti-VEGF drugs provides rapid resolution of ME and much better visual improvements than conventional treatments in eyes with RVO. Thus, the technologies of examination and treatment for managing eyes with RVO have progressed rapidly. In this paper, we review the multimodal imaging and therapeutic strategies for eyes with RVO with the hope that it provides better understanding of the pathology and leads to the development of new therapies.

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.

Lessons Learned From Avastin and OCT-The Great, the Good, the Bad, and the Ugly: The LXXV Edward Jackson Memorial Lecture

PURPOSE

To describe the synergistic benefits and cost savings from the use of optical coherence tomography (OCT) and vascular endothelial growth factor (VEGF) inhibitors, particularly intravitreal bevacizumab, in the treatment of exudative age-related macular degeneration (AMD).

DESIGN

Retrospective literature review and personal perspective.

METHODS

Retrospective literature review and personal perspective.

RESULTS

The introduction of the first clinically useful OCT instrument coincided with early-phase clinical trials of a drug that would become known as ranibizumab. OCT provided a noninvasive imaging strategy that unambiguously showed the macular fluid associated with exudative AMD and the ability of anti-VEGF therapy to resolve this fluid with concomitant visual acuity improvement. Clinicians came to embrace the use of OCT imaging as the basis for dosing with anti-VEGF drugs, rather than the fixed-interval dosing that was the standard in clinical trials and recommended by industry after approval. But, before ranibizumab was approved for the treatment of exudative AMD, intravenous bevacizumab was approved to treat cancer. Both drugs shared a common molecular lineage, and this led to a clinical trial using intravenous bevacizumab for the treatment of exudative AMD. Intravenous bevacizumab resulted in visual acuity and OCT improvements similar to ranibizumab, and this observation soon led to the intravitreal use of bevacizumab in 2005. Fortuitously, both ranibizumab and bevacizumab were packaged at similar molar concentrations, so similar volumes of both drugs when injected into an eye would result in similar anti-VEGF activity. With ranibizumab not yet commercially available, intravitreal bevacizumab rapidly became adopted worldwide for the treatment of VEGF-driven ocular diseases. Despite numerous attempts by industry and anonymous sources to discredit and prevent its use, bevacizumab spread globally owing to its availability; its low treatment cost, which was $5.50 per 1 mg in the United States; the evidence of efficacy based on OCT imaging and vision improvement; and its perceived safety. In the United States alone, the use of OCT-guided therapy and the use of bevacizumab for the treatment of exudative AMD has saved Medicare over $40 billion since 2008.

CONCLUSIONS

The rapid adoption of OCT-guided therapy and the use of intravitreal bevacizumab by the global retinal community has prevented blindness from exudative and neovascular ocular diseases worldwide while saving healthcare providers and patients billions of dollars.

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.

Predicting the visual acuity for retinal vein occlusion after ranibizumab therapy with an original ranking for macular microstructure

The study investigated predictive factors for best-corrected visual acuity (BCVA) after ranibizumab treatment in patients with macular edema (ME) associated with retinal vein occlusion (RVO) with an original ranking for the impairment of macular microstructure. In this retrospective study, 31 eyes of 31 patients with RVO received 3 monthly consecutive ranibizumab injections and another 3 months of follow-up. An original method was applied to rank the impairment of the external limiting membrane (ELM) and the ellipsoid zone (previously called the photoreceptor inner and outer segment junction, IS/OS) integrity on the baseline optical coherence tomography (OCT) images. Univariate and multivariate linear regression analyses were performed to assess the association between the baseline factors and post-treatment BCVA. ELM integrity and baseline BCVA were shown to be independent factors in the prediction of post-treatment BCVA. Comparison of post-treatment BCVA between original ELM ranks after adjusting for the baseline BCVA revealed the ELM integrity beneath the center of the fovea was important to post-treatment BCVA. ELM integrity in particular beneath the center of the fovea and baseline BCVA may be more useful than other factors in the prediction of visual function in patients with ME secondary to RVO after ranibizumab injections.

Update on the Use of Anti-VEGF Intravitreal Therapies for Retinal Vein Occlusions

The use of anti-vascular endothelial growth factor (VEGF) therapy in ophthalmology has profoundly changed our management and treatment of conditions such as cystoid macular edema, diabetic macular edema, choroidal neovascularization, and other proliferative retinopathies. Although initially used for the treatment of choroidal neovascularization in neovascular age-related macular degeneration, their application has spread rapidly for other indications as their outcomes have often outperformed previously existing treatments. Retinal vein occlusion (RVO) continues to be one of the leading causes of vision loss secondary to macular edema, in addition to macular ischemia and neovascularization in more severe cases. Before the availability of anti-VEGF therapy, the use of macular grid laser and panretinal photocoagulation was the mainstay of treatment of macular edema and neovascularization, respectively, in patients with RVOs. Two landmarks studies established the guidelines of these treatments for nearly a quarter century. Since the availability of anti-VEGF agents, there has been a paradigm shift in the treatment of RVO. Most importantly, there has also been a significant improvement in visual outcomes in these patients. The goal of this article is to provide a review of the pertinent clinical studies that have investigated the use of anti-VEGF in patients with retinal vein occlusions.

Efficacy of intravitreal bevacizumab for macular edema following branch retinal vein occlusion stratified by baseline visual acuity

PURPOSE

To compare the clinical features and bevacizumab efficacy for macular edema (ME) following branch retinal vein occlusion (BRVO) stratified by baseline visual acuity.

METHODS

This retrospective study included a total 117 eyes from 117 consecutive patients with ME following BRVO, who received PRN intravitreal bevacizumab injection and were followed for more than 6 months. The eyes were categorized into three groups according to baseline best-corrected visual acuity (BCVA) (group A, BCVA <20/200; group B, BCVA ≥20/200 and ≤20/40; group C, BCVA >20/40). Baseline demographics, clinical features, BCVA, and central retinal thickness (CRT) at 1, 3, 6, and 12 months after injection and the number of injections were compared.

RESULTS

Groups A-C included 11, 83, and 23 eyes, respectively. The mean baseline CRT was thickest in group A (810.1, 580.8, and 473.5 μm in groups A-C, respectively; p < 0.001) and the percentage of eyes with macular ischemia increased in the worst BCVA group (45.5, 25.0, and 4.3 % in groups A-C, respectively; p = 0.005). The mean BCVA and CRT improved at 1, 3, 6, and 12 months after treatment compared to baseline values in all groups (all, p < 0.001). The number of injections for 6 months was greater in the worst BCVA group (3.2, 2.3, and 1.9 injections in groups A-C, respectively; p = 0.009).

CONCLUSION

In ME following BRVO, baseline visual acuity correlates with macular ischemia and baseline CRT. Intravitreal bevacizumab treatment results in significant anatomical and functional improvement regardless of baseline visual acuity.

Spectral domain optical coherence tomographic analysis of healthy retina in branch retinal vein occlusion and its response to antiangiogenic therapy

PURPOSE

To propose a model that measures the effect of intravitreal bevacizumab (IVB) on relatively healthy retina. The purpose is to analyze the remote effect of a branch retinal vein occlusion in the healthy retina, to determine the response it may have to IVB, and to determine if IVB has an atrophic effect on the healthy retina.

METHODS

Retrospective, longitudinal comparative analysis of patients with branch retinal vein occlusion treated with IVB. Eyes were divided into experimental (branch retinal vein occlusion eye) and control (contralateral eye) groups. Each eye was analyzed for thickness and area. Thickness measurements were performed for total retinal thickness, inner retina thickness, and outer retina thickness. Area was measured for photoreceptors, choroid, and total retina.

RESULTS

Eighteen eyes of 9 patients. For thickness analysis, 1,050 scans were studied, and 126 measurements were performed on 42 scans for area analysis. No difference was observed for thickness, except for inner retina thickness. No difference was observed for area. No difference was observed when analyzing a cumulative exposure to IVB.

CONCLUSION

There is no evidence to suggest an atrophic effect caused by IVB when analyzing thickness or area in this experiment. This model could be used to analyze the long-term safety of IVB in larger studies.

Bevacizumab treatment for acute branch retinal vein occlusion accompanied by subretinal hemorrhage

PURPOSE

The purpose of this study was to compare the efficacy of intravitreal bevacizumab (IVB) in the treatment of acute (<3 months [mo]. duration) macular edema (ME), with or without subretinal hemorrhage (SRH), resulting from branch retinal vein occlusion (BRVO).

MATERIALS AND METHODS

We conducted a retrospective review of 33 consecutive patients (n = 33 eyes) with ME caused by acute BRVO. All patients received an injection of IVB at baseline examination. All patients were followed monthly, with administration of additional IVB injections if there was persistent or recurrent ME. Specific patterns of ME were investigated using spectral-domain optical coherence tomography (SD-OCT).

RESULTS

SD-OCT revealed serous retinal detachments in the fovea of 15 eyes, 10 of which had accompanying foveal SRH. Based on initial detection of foveal SRH, patients were divided into SRH-negative (n = 23 eyes) or SRH-positive (n = 10 eyes) groups. Initial best-corrected visual acuity (BCVA) did not differ between the two groups. In the SRH-negative group, both BCVA and central macular thickness (CMT) improved significantly after IVB injections (mean, 2.3 injections) at the 6-mo. follow-up examination. In the SRH-positive group, there was no significant improvement in BCVA after IVB injections (mean, 2.0 injections), although there was a significant decrease in CMT. The final BCVA of the SRH-positive group was significantly poorer than that of the SRH-negative group (p = 0.001).

CONCLUSION

The presence of foveal SRH may be a negative predictor of IVB treatment outcomes for BRVO patients with ME.

Intravitreal bevacizumab alone or combined with macular laser photocoagulation for recurrent or persistent macular edema secondary to branch retinal vein occlusion

Background. To evaluate the efficacy of intravitreal bevacizumab (IVB) injection with or without macular laser photocoagulation (MLP) for recurrent or persistent macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods. Thirty-four eyes underwent IVB injection for ME secondary to BRVO as a primary treatment. Twenty of the 34 eyes experienced recurrent or persistent ME after the first IVB. Nine of the 20 eyes (Group 1) were retreated with IVB combined with MLP. The remaining 11 eyes (Group 2) were retreated with IVB alone. Results. In Group 1, the postoperative best corrected visual acuity (BCVA) improved compared with the preoperative value at all follow-up visits, although no statistically significant improvement was observed at 6 months. In contrast, BCVA significantly improved from 0.53 to 0.40 at 6 months (P < 0.05) in Group 2. Conclusion. Combined therapy tended to have a smaller effect on visual acuity compared with IVB monotherapy.

Comparison of intravitreal ranibizumab and bevacizumab for the treatment of macular edema secondary to retinal vein occlusion

AIM

To compare the efficacy of ranibizumab and bevacizumab for macular edema due to retinal vein occlusion (RVO).

METHODS

A retrospective study was conducted at a single academic institution. Eighty-one patients naïve to anti-VEGF therapy with RVO and macular edema were identified. Twenty-six eyes were treated with ranibizumab, 33 eyes with bevacizumab, and 22 eyes with bevacizumab then switched to ranibizumab (crossover). The main outcome was change in visual acuity at 3 months, 6 months, and final visit.

RESULTS

The mean visual acuity improved from 20/80 to 20/40 in the ranibizumab (R) group and from 20/125 to 20/60 in the bevacizumab (B) group (P=0.66). The mean change in central subfield thickness (CST) was -186 and -212µm, respectively (P=0.69). Mean time between injections was 94±21.1d in the R group and 103.8±10.5d in the B group (P=0.78). In the crossover group, mean initial visual acuity was 20/125, reached 20/60 at crossover, and remained 20/60 at conclusion (P=0.91).

CONCLUSION

Both ranibizumab and bevacizumab are effective for the treatment of RVO and appear to have similar visual and anatomic outcomes. Changing treatments from bevacizumab to ranibizumab did not result in further gains in visual acuity.

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).

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 common occurring retinal vascular abnormalities. The pathogenesis of BRVO is thought to involve both retinal vein compression and damage to the vessel wall, possibly leading to thrombus formation at sites where retinal arterioles cross retinal veins. The most common cause of visual loss in patients with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss and improve visual acuity (VA) in up to two thirds of individuals with MO secondary to BRVO, however, limitations to this treatment exist and newer modalities have suggested equal or improved efficacy. Recently, antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has been used successfully to treat MO resulting from a variety of causes. As elevated intraocular levels of VEGF have been demonstrated in patients with retinal vein occlusions there is a strong basis for the hypothesis that anti-VEGF agents may be beneficial in the treatment of vascular leakage and MO.

OBJECTIVES

To investigate the efficacy and safety of intravitreal anti-VEGF agents for preserving or improving vision in the treatment of MO secondary to BRVO.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2012), EMBASE (January 1980 to August 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2012, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 August 2012 and the clinical trials registers on 10 September 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTS of at least six months duration 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. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity (BCVA) of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and at 12 months of follow-up. The secondary outcomes we report are the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean VA change at six months and any additional follow-up intervals as well as the change in central retinal thickness on optical coherence tomography (OCT) from baseline and final reported follow-up, the number and type of complications, the number of additional interventions administered and any adverse outcomes. Where available, the cost benefit and quality of life data reported in the primary studies is presented.

MAIN RESULTS

We found one RCT and one quasi-RCT that met the inclusion criteria after independent and duplicate review of the search results. The studies used different anti-VEGF agents and different study groups which were not directly comparable.One multi-centre RCT (BRAVO) conducted in the USA randomised 397 individuals and compared monthly intravitreal ranibizumab (0.3 mg and 0.5 mg) injections with sham injection. The study only included individuals with non-ischaemic BRVO. Although repeated injections of ranibizumab appeared to have a favourable effect on the primary outcome, approximately 50% of the ranibizumab 0.3 mg group and 45% of the ranibizumab 0.5 mg group received rescue laser treatment which may have an important effect on the primary outcome. In addition, during the six-month observation period 93.5% of individuals in the sham group received intravitreal ranibizumab (0.5 mg). This cross-over design limits the ability to compare the long-term impact of ranibizumab versus a pure control group.The second trial was a small study (n = 30) from Italy with limitations in study design that reported a benefit of as-required intravitreal bevacizumab (1.25 mg) over laser photocoagulation in MO secondary to BRVO. We present the evidence from these trials and other interventional case series.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that repeated treatment of non-ischaemic MO secondary to BRVO with the anti-VEGF agent ranibizumab may improve clinical and visual outcomes at six and 12 months. However, the frequency of re-treatment has not yet been determined and the impact of prior or combined treatment with laser photocoagulation on the primary outcome is unclear. Results from ongoing studies should assess not only treatment efficacy but also, the number of injections needed for maintenance and long-term safety and the effect of any prior treatment.

Changes in the foveal microstructure after intravitreal bevacizumab application in patients with retinal vascular disease

PURPOSE

To investigate changes in the area of the foveal avascular zone (FAZ) in patients with retinal vascular disease.

PATIENTS AND METHODS

This retrospective, consecutive study examined 53 eyes of 53 patients with macular edema due to branch retinal vein occlusion in 25 patients (47.2%) and nonproliferative diabetic retinopathy in 28 patients (52.8%). The macular edema was treated with an intravitreal injection of 0.05 mL equal to 1.25 mg bevacizumab. Before and 6-8 weeks after the injection, best corrected visual acuity, slit lamp biomicroscopy of the anterior segment and fundus, optical coherence tomography, and fluorescein angiography were conducted. The FAZ was manually circumscribed on early-phase angiography images and the area of the FAZ was measured.

RESULTS

The preoperative overall mean FAZ area was 0.327 ± 0.126 mm(2) (median 0.310 mm(2)). At the control consultation, the overall mean area was significantly larger (0.422 ± 0.259 mm(2); median 0.380 mm(2); P < 0.001). In the nonproliferative diabetic retinopathy subpopulation, the mean area was 0.361 ± 0.129 mm(2) (median 0.330 mm(2)) before bevacizumab application and 0.434 mm(2) at the follow-up visit (mean increase 0.071 mm(2)/19.7%). In the branch retinal vein occlusion group, the baseline FAZ area was 0.290 ± 0.115 mm(2) and 0.407 ± 0.350 mm(2) at follow-up (median 0.330 mm(2); mean increase 0.117 mm(2)/40.3%). No cases of severe operation-associated complications were observed.

CONCLUSION

The results confirm the safety of intravitreal bevacizumab injection in patients with macular edema due to nonproliferative diabetic retinopathy and branch retinal vein occlusion. The enlargement of the FAZ could be equivalent to an increase in retinal ischemia. These results may be transient; a potential vascular risk, however, when applying antivascular endothelial growth factor therapy in eyes with preexistent vascular disease must be considered.

Unilateral branch retinal arterial occlusion following administration of bevacizumab for branch retinal vein occlusion

Intravitreal bevacizumab has been adopted as a well-established treatment modality for the treatment of macular edema associated with branch retinal vein occlusion. It is considered a safe and efficacious option for improving visual acuity. We present an interesting case of unilateral superotemporal branch retinal vein occlusion in a 55-year-old man who received two doses of intravitreal bevacizumab one month apart. Laboratory tests including complete hypercoagulability and thrombotic work-up were completed but the patient successively developed branch retinal artery occlusion. We reviewed cases in literature and combined possible etiologies. We report a previously unpublished case of retinal artery occlusion following the use of intravitreal bevacizumab. Several studies have shown evidence of systemic thromboembolic events after the use of intravenous and systemic bevacizumab; however, to the best of our knowledge, no case has been reported of retinal artery occlusion immediately after administration of intravitreal bevacizumab.

Combined intravitreal bevacizumab and grid laser photocoagulation for macular edema secondary to branch retinal vein occlusion

PURPOSE

To evaluate long-term efficacy of intravitreal bevacizumab (IVB) versus combined IVB and macular grid laser photocoagulation for the treatment of macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

In this prospective study, 18 eyes were randomized into 2 groups according to treatment: Group 1 (9 eyes) underwent IVB at baseline, at month 1, and at month 2; Group 2 (9 eyes) underwent same IVB protocol combined with macular grid laser photocoagulation. Macular edema and visual acuity represented the endpoints of the study. IVB reinjections were performed in both groups if recurrent macular edema was diagnosed. Spectral domain optical coherence tomography examination as well as visual acuity examination were performed during follow-up. Statistical evaluation was performed for a matched-pair analysis.

RESULTS

In Group 1, median baseline central retinal thickness (CRT) decreased from 420 µm (95% confidence interval 355.6-484.4) to 323 µm (261.44-384.56) at month 12 (p=0.06); median baseline BCVA improved from 0.7 logMAR (0.54-0.86) to 0.4 logMAR (0.29-0.51) at month 12 (p<0.01). In Group 2, baseline CRT decreased from 386 µm (353.91-418.09) to 238 µm (200.58-275.42) at month 12 (p<0.01); median BCVA improved from 0.6 logMAR (0.45-0.75) to 0.2 logMAR (0.12-0.28) at month 12 (p<0.01). A statistically significant difference (p=0.03) was found regarding the median number of injections (Group 1: 4±1.1; Group 2: 3±0.4).

CONCLUSIONS

Both treatment modalities appeared effective to control BRVO-induced macular edema. In the combined-treatment Group, we observed a lower number of reinjections during follow-up, suggesting the efficacy of grid laser photocoagulation to reduce the number of intravitreal injections and maintain short- and long-term results of the therapy.

Three treatments for macular edema because of branch retinal vein occlusion: intravitreous bevacizumab or tissue plasminogen activator, and vitrectomy

PURPOSE

To evaluate the effectiveness of intravitreous bevacizumab (Avastin), intravitreous tissue plasminogen activator, and vitrectomy for the macular edema secondary to branch retinal vein occlusion.

METHODS

Retrospective, interventional case series. We studied 228 eyes of 228 patients. Forty-one eyes received 1.25 mg of intravitreous bevacizumab, 71 eyes received tissue plasminogen activator, and 116 eyes underwent vitrectomy. A reinjection of 1.25 mg of bevacizumab was based on the morphologic and functional findings. The main outcome measures were the best-corrected visual acuity and optical coherence tomography-determined foveal thickness.

RESULTS

The mean postoperative follow-up period was 32.2 months with a range of 12 months to 69 months. The mean number of intravitreous bevacizumab was 2.8 with a range of 1 to 5. The mean best-corrected visual acuity and foveal thickness significantly improved after all 3 treatments, and the differences in the best-corrected visual acuity between the 3 groups were not significant at 12 months. Fourteen eyes (34%) in the intravitreous bevacizumab group and 21 eyes (30%) in the tissue plasminogen activator group required additional surgeries.

CONCLUSION

The 3 treatments appear to provide similar visual outcomes at 12 months. However, in some eyes treated with intravitreous bevacizumab or tissue plasminogen activator, additional surgeries were required, and a longer follow-up period was required to determine the final outcome.

Treatment of macular edema because of occlusive vasculitis with bevacizumab (avastin): efficacy of three consecutive monthly injections

PURPOSE

To report the efficacy of intravitreal bevacizumab, administered in a series of three monthly injections followed by a period of observation, in the treatment of cystoid macular edema because of occlusive vasculitis.

METHODS

This is a retrospective review of 13 consecutive eyes of 13 patients with cystoid macular edema because of occlusive vasculitis, which had been unresponsive to other medications and were treated with intravitreal bevacizumab (1.25 mg). The evaluation consisted of a complete ophthalmologic examination, including best-corrected visual acuity measurement, ophthalmoscopy, fluorescein angiography, and optical coherence tomography. The eyes received a series of 3 monthly injections followed by a 3-month observation period.

RESULTS

A significant improvement in foveal thickness and visual acuity was obtained after the first injection, which increased after the second and the third injections and was maintained for 1.5 months after the last injection. The 2 parameters returned to the baseline values 3 months after the last treatment. There were no ocular or systemic adverse effects.

CONCLUSION

Intravitreal injection of bevacizumab seems to be well tolerated and is associated with short-term improvement of visual acuity and decreased retinal thickness in patients with cystoid macular edema because of vasculitis that is resistant to conventional therapy.

Recurrence of macular edema associated with branch retinal vein occlusion after intravitreal bevacizumab

PURPOSE

To study the recurrence of macular edema and the probability of retreatment with intravitreal bevacizumab (IVB) of eyes with macular edema associated with branch retinal vein occlusion (BRVO).

METHODS

In this retrospective study of an interventional case series, the temporal profile of visual acuity and retinal thickness after individual IVB, either initial or repeated, was investigated for eyes with acute BRVO associated with symptomatic macular edema.

RESULTS

In a total of 95 IVB treatment sessions conducted on 37 eyes of 37 patients, 25 injections were completed with a follow-up period of 6 months or longer without any additional treatments. Fifty-eight IVB injections were followed by retreatment with IVB after an average interval of 119 days (range 42-308 days) since the preceding IVB injection. The remaining 12 injections were followed either by an insufficient follow-up period of less than 6 months or by laser treatment.

CONCLUSIONS

Although retreatment with IVB because of recurrence of macular edema is common, in this study, the probability of retreatment with IVB was approximately 70% after each individual IVB injection, indicating that 4 injections is maximum for three-quarters of eyes with BRVO macular edema.

Intraocular and serum levels of vascular endothelial growth factor in acute retinal necrosis and ocular toxoplasmosis

PURPOSE

To determine the intraocular and serum vascular endothelial growth factor (VEGF) levels in patients with acute retinal necrosis (ARN) and compare those with VEGF levels found in patients with ocular toxoplasmosis (OT).

METHODS

Paired intraocular fluid and serum samples of 17 patients with ARN and of 16 patients with OT were analyzed by ELISA for VEGF levels, and the clinical records were reviewed.

RESULTS

The mean intraocular VEGF levels in patients with ARN were higher than in patients with OT (P = 0.005), whereas the serum levels did not differ. Intraocular VEGF levels exceeded the serum levels in 8 of 17 patients (47%) with ARN compared with 1 of 16 patients (6%) with OT (P = 0.009). The group with high intraocular VEGF was associated with a more extensive retinitis and lower visual acuity at 3-month follow-up (P < 0.001 and P = 0.031, respectively).

CONCLUSION

Intraocular VEGF levels were elevated in patients with ARN compared with OT patients. Our results suggest strong intraocular VEGF production in ARN, which might be of importance for the treatment of these patients.

Diffuse alveolar haemorrhage may be associated with intravitreal injection of bevacizumab in a patient with systemic risk factors

The authors present a rare case where acute respiratory failure occurred after the intravitreal bevacizumab injection for a branch retinal vein occlusion. Chest CT scan showed ground-glass opacity in the bilateral lung fields. The finding of bronchoalveolar lavage fluid revealed alveolar haemorrhage. Corticosteroid therapy resulted in a rapid improvement of respiratory failure. This report suggests that intravitreal injection of bevacizumab may be associated with diffuse alveolar haemorrhage and acute lung injury.

Effects of intravitreal anti-vascular endothelial growth factor treatment on retinal vasculature in retinal vein occlusion as determined by ultra wide-field fluorescein angiography

PURPOSE

To investigate both peripheral and central retinal vascular changes after intravitreal anti-vascular endothelial growth factor (VEGF) therapy in the setting of acute retinal vein occlusion (RVO).

METHODS

Two patients with macular edema, one secondary to central RVO (CRVO) and one secondary to branch RVO (BRVO), underwent ultra wide-field (200°) photography and fluorescein angiography before and after a single intravitreal injection of an anti-VEGF agent. The patient with CRVO received an intravitreal injection of ranibizumab (0.5 mg/0.05 mL). The patient with BRVO received an intravitreal injection of bevacizumab (1.25 mg/0.05 mL). The eye with CRVO was reevaluated with ultra wide-field photography and fluorescein angiography at 7 days and 35 days after treatment. The eye with BRVO was reevaluated with ultra wide-field photography and fluorescein angiography at 30 days after treatment. Photographs and fluorescein angiographic results were analyzed for posttreatment changes in arteriovenous transit time, vessel caliber, vessel leakage, peripheral capillary nonperfusion, retinal hemorrhages, and nerve fiber layer infarcts.

RESULTS

In both eyes, there were no changes detected in the arteriovenous transit time or peripheral capillary nonperfusion after anti-VEGF therapy. A reduction in intraretinal hemorrhages and nerve fiber layer infarcts was observed at 7 days and 35 days after treatment in the patient with CRVO and at 30 days after treatment in the patient with BRVO. A decrease in vessel caliber was observed at 7 days after treatment in the patient with CRVO and at 30 days after treatment in the patient with BRVO. In the patient with CRVO, an increase in vessel caliber with a recurrence of vascular leakage was noted at the visit on Day 35.

CONCLUSION

Anti-VEGF therapy in the setting of RVO may initially decrease vessel caliber, retinal hemorrhages, and nerve fiber layer infarcts but does not appear to affect arteriovenous transit time or areas of peripheral capillary nonperfusion after a single treatment. The beneficial effects of anti-VEGF therapy in RVO appear transient, and multiple injections may be required for control of macular edema. Ultra wide-field angiography can be a useful tool in monitoring the treatment of RVO.

Pegaptanib sodium for macular edema secondary to branch retinal vein occlusion

PURPOSE

To assess the efficacy and safety of intravitreous pegaptanib sodium (Macugen; EyeTech Pharmaceuticals/Pfizer Inc, New York, New York, USA) for macular edema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Prospective, randomized, dose-finding study.

METHODS

Twenty subjects from three clinical practices in the United States with BRVO of more than 1 month's and fewer than 6 months' duration; best-corrected visual acuity (BCVA) 70 to 25 Early Treatment Diabetic Retinopathy Study letters inclusive (approximately 20/40 to 20/320 Snellen); and central foveal thickness of 250 microm or more were included. Subjects were randomized 3:1 to intravitreous injections of pegaptanib 0.3 or 1 mg at baseline and at weeks 6 and 12 with subsequent injections at 6-week intervals at investigator discretion until week 48. Principal efficacy outcomes were change from baseline to week 54 in BCVA, center point thickness, central subfield thickness, and macular volume as measured by optical coherence tomography.

RESULTS

Fifteen subjects received pegaptanib 0.3 mg and 5 received pegaptanib 1 mg. Eighteen subjects completed the 54-week follow-up. Results were similar in both the 0.3- and 1-mg groups. Overall improvements from baseline to week 54 occurred in mean BCVA (+14 +/- 13 letters), center point thickness (-205 +/- 195 mum), central subfield thickness (-201 +/- 153 mum), and macular volume (-2.2 +/- 1.6 mm(3)). The response was rapid after the first injection, with a mean BCVA improvement of 11 +/- 7 letters at 1 week from the baseline of 56 +/- 12 letters (approximately 20/80 Snellen). One retinal detachment and no cases of endophthalmitis or traumatic cataract were seen.

CONCLUSIONS

Intravitreous pegaptanib offers a promising alternative as a treatment for macular edema secondary to BRVO.