ANTI-VEGF DRUGS AS THE 2009 FIRST-LINE THERAPY FOR CHOROIDAL NEOVASCULARIZATION IN PATHOLOGIC MYOPIA

Recurrence risk of myopic choroidal neovascularisation: a systematic review of current study

INTRODUCTION

The rising prevalence of myopia is a concern in ophthalmology, with myopic choroidal neovascularisation (m-CNV) significantly affecting vision. However, long-term outcomes of m-CNV management have been unsatisfactory, leading to high recurrence rates. These studies aim to identify risk factors for m-CNV recurrence.

METHODS

Comprehensive review followed a pre-registered plan in the International Prospective Register of Systematic Reviews (PROSPERO). The search strategy used various databases including PubMed, Cochrane Library, Embase, Scopus and ScienceDirect using the keywords 'Myopic Choroidal Neovascularization', 'Recurrence' and 'Risk'. Eligible studies were identified and analysed based on predetermined criteria. This study was registered on PROSPERO (CRD4202343461).

RESULTS

The systematic review included three retrospective studies investigating risk factors associated with m-CNV recurrence. These factors are: (1) requiring three or more injections for initial disease control, (2) older age, (3) larger myopic macular neovascularisation, (4) juxtafoveal CNV, (5) larger height of hyper-reflective foci (HRF) and (6) destruction or absence of the ellipsoid zone (EZ) and retinal pigment epithelium (RPE).

CONCLUSION

Risk factors for m-CNV recurrence include a greater number of required injections, older age, large macular CNV, juxtafoveal location, increased HRF height and changes in EZ and RPE structure. Understanding these factors can inform personalised treatment approaches and improve patient outcomes by identifying individuals at higher risk of recurrence and implementing proactive measures to mitigate the impact of m-CNV recurrence and progression. Further investigation is needed to enhance our understanding of the underlying mechanisms and develop innovative therapeutic approaches for effective m-CNV management.

PROSPERO REGISTRATION NUMBER

CRD4202343461.

Real-World Treatment Intensity and Patterns in Patients With Myopic Choroidal Neovascularization: Common Data Model in Ophthalmology

BACKGROUND

A paucity of data addressing real-world treatment of myopic choroidal neovascularization (mCNV) in the era of anti-vascular endothelial growth factor (VEGF) drugs led us to investigate real-world treatment intensity and treatment patterns in patients with mCNV.

METHODS

This is a retrospective, observational study using the Observational Medical Outcomes Partnership-Common Data Model database of treatment-naïve patients with mCNV over the 18-year study period (2003-2020). Outcomes were treatment intensity (time trends of total/average number of prescriptions, mean number of prescriptions in the first year and the second year after initiating treatment, proportion of patients with no treatment in the second year) and treatment patterns (subsequent patterns of treatment according to the initial treatment).

RESULTS

Our final cohort included 94 patients with at-least 1-year observation period. Overall, 96.8% of patients received anti-VEGF drugs as first-line treatment, with most of injections from bevacizumab. The number of anti-VEGF injections in each calendar year showed an increasing trend over time; however, there was a drop in the mean number of injections in the second year compared to the first year from 2.09 to 0.47. About 77% of patients did not receive any treatment in their second year of treatment regardless of drugs. Most of patients (86.2%) followed non-switching monotherapy only and bevacizumab was the most popular choice either in the first-line (68.1%) or in the second-line (53.8%) of treatment. Aflibercept was increasingly used as the first-line treatment for patients with mCNV.

CONCLUSION

Anti-VEGF drugs have become the treatment of choice and second-line treatment for mCNV over the past decade. Anti-VEGF drugs are effective for the treatment of mCNV as the non-switching monotherapy is the main treatment regimen in most cases and the number of treatments decreases significantly in the second year of treatment.

High‑dose aflibercept injection has striking effects on myopic choroidal neovascularization

The aim of the present study was to evaluate the 1-year outcomes of a high-dose aflibercept injection [4 mg 2+ pro re nata (PRN) scheme] for individuals with myopic choroidal neovascularization (mCNV) through optical coherence tomography (OCT) follow-ups. A total of 16 consecutive patients (7 males and 9 females; sixteen eyes) with mCNV were enrolled in this retrospective study. The mean age was 30.5±3.35 years and mean spherical equivalent was -7.31±0.90 D. Subjects received 4 mg aflibercept intravitreal injection on the day of diagnosis and 35 days later. Further injections of aflibercept were required when the following were detected by OCT and fluorescein angiography: i) Decrease in best corrected visual acuity (BCVA); ii) aggravation of metamorphopsia; iii) macular oedema; iv) macular haemorrhage; v) increase in retinal thickness; and vi) leakage. Ophthalmic examination and OCT were performed at the baseline, as well as at 1, 2, 4, 6, 8, 10 and 12 months after the initial aflibercept injection. BCVA and central retinal thickness (CRT) were evaluated at each follow-up. The results showed that the vision of all subjects improved following the aflibercept intravitreal injection. The mean BCVA improved from 0.35±0.15 logarithm of the minimal angle of resolution (logMAR) at the baseline to 0.12±0.05 logMAR at final follow-up (P<0.05). A reduction in metamorphopsia was observed and the mean CRT was reduced from 345.38±34.69 µm of pre-treatment levels to 222.75±8.98 µm at the last postoperative visit (P<0.05). The mean number of injections in the present study was 2.13±0.5. Out of all patients, 13 received two injections and 3 subjects received three injections. The mean follow-up was 13.41±1.17 months. Based on the outcomes, it was found that an intravitreal injection of high-dose aflibercept (4 mg 2+PRN scheme) is effective for vision improvement and stabilization. In addition, it also significantly alleviated metamorphopsia and reduced the CRT in patients treated with mCNV. During the follow-up, the eyesight of the patients was stable.

Characteristics and response of subretinal hyperreflective material to anti-vascular endothelial growth factor in myopic choroidal neovascularization

This retrospective study evaluated the characteristics and response of subretinal hyperreflective material (SHRM) to anti-vascular endothelial growth factor (VEGF) treatment in eyes with myopic choroidal neovascularization (CNV). The visual acuity (VA) was assessed at 3, 6, and 12 months after initiating anti-VEGF treatment in 116 patients (119 eyes) with SHRM and myopic CNV. Multimodal imaging, including color fundus photography, fluorescein angiography (FA), and optical coherence tomography angiography (OCT-A), were performed. We compared type 2 neovascularization (NV) (n = 64), subretinal hyperreflective exudation (SHE) (n = 37), NV with hemorrhage (n = 15), and fibrosis (n = 3). The type 2 NV group, and NV with hemorrhage groups showed significant VA improvement after 12 months of treatment (p < 0.05 in both groups); the SHE group failed to show improvement (p = 0.366). All groups showed a significant reduction in central foveal thickness after 12 months of treatment (all p < 0.05). The SHE group had a significantly higher incidence of interrupted ellipsoid zone than the other groups (p < 0.05). Myopic CNV can present as SHRM on OCT-A. Visual prognoses vary in different SHRM types. OCT-A and FA may help predict the outcomes of different subtypes of myopic CNV. SHE is predictive of outer retinal layer atrophy in patients with various SHRM types.

Half-Fluence, Half-Dose Photodynamic Therapy: Less Direct Damage but More Inflammation?

Objective: To present clinical findings and multimodal imaging of three patients who developed bacillary layer detachments (BALADs) shortly after half-fluence, half-dose (HFHD) verteporfin photodynamic therapy (PDT). Methods: Retrospective observational case series. Three patients were treated with HFHD-PDT for (1) macular neovascularisation five years after resolved central serous chorioretinopathy (CSC), (2) persistent serous retinal detachment (SRD) from chronic CSC, and (3) neovascular age-related macular degeneration with persistent SRD despite intravitreal anti-VEGF therapy. Results: Each patient developed a BALAD after HFHD-PDT. Acute fulminant exudation caused subretinal fluid expansion into the inner photoreceptor layer, cleaving myoid from ellipsoid zones in the central macula. Subretinal fluid and the BALADs subsequently resolved over 6–8 weeks. Conclusions: The subretinal fluid and BALAD following HFHD-PDT were transient and did not cause photoreceptor damage over a 6-month follow-up period. We speculate that the reduced-impact HFHD protocol decreases direct tissue damage but increases proinflammatory cytokines. The long-term pathophysiological consequences of the resolved BALADs are unknown.

Long-Term Outcomes of High-Dose Conbercept Treatment for Myopic Choroidal Neovascularization and Idiopathic Choroidal Neovascularization

INTRODUCTION

The aim of the study was to report 2-year outcomes of intravitreal injection of high-dose conbercept (1 mg 2 + PRN scheme) for subjects with myopic choroidal neovascularization (mCNV) and idiopathic choroidal neovascularization (iCNV) by optical coherence tomography angiography follow-up.

METHODS

A total of 38 subjects (38 eyes) were enrolled in this retrospective study, which were divided into group A (mCNV, 20 subjects, 20 eyes) and group B (iCNV, 18 subjects, 18 eyes). All subjects received 1.0 mg of conbercept intravitreally at diagnosis and again 35 days later. Additional conbercept injection was administered upon findings of decreased best-corrected visual acuity (BCVA); metamorphosis aggravation, macular hemorrhage, or edema; increased central retinal thickness (CRT); or leakage observed by fluorescein angiography. The BCVA, CRT, and CNV areas of the two groups were evaluated at baseline and at 1, 2, 4, 6, 12, and 24 months after surgery.

RESULTS

The BCVA of group A improved from 0.31 ± 0.16 logMAR at baseline to 0.12 ± 0.03 logMAR at the final follow-up (p < 0.001), while in group B the corresponding improvement was from 0.33 ± 0.16 logMAR at baseline to 0.12 ± 0.03 logMAR at the final follow-up (p < 0.001). Visual acuity improved in 17 subjects in group A and 15 in group B, while it remained stable in 3 subjects in each of groups A and B. CRT decreased from 311.83 ± 30.95 μm in group A and 351.17 ± 37.09 μm in group B preoperation to 229.56 ± 5.75 μm and 227.67 ± 4.98 μm at 24-month follow-up, respectively (p < 0.001 in groups A and B). Metamorphopsia was improved in subjects in groups A and B. CNV had disappeared in the two groups at the last postoperative visit. The BCVA, CRT, and CNV areas showed no statistical differences between the two groups at 6-, 12-, and 24-month follow-up (p > 0.05).

CONCLUSION

Intravitreal injection of conbercept (1 mg 2 + PRN scheme) is effective for treating patients with mCNV or iCNV, which can improve and stabilize vision as well as dramatically alleviate metamorphopsia.

Incidence, predictors and re-treatment outcomes of recurrent myopic choroidal neo-vascularization

Objectives

To evaluate incidence, predictors, and re-treatment outcome of recurrent myopic choroidal neovascularization (m-CNV).

Methods

Retrospective consecutive observational series. From year 2014 to 2019, 167 eyes of 167 patients of treatment naïve m-CNV were enrolled. 59 and 108 eyes were treated with intra-vitreal ranibizumab and bevacizumab mono-therapy, respectively. Recurrence was defined as re-appearance of CNV activity, confirmed on optical coherence tomography (OCT) after at least 3 months of cessation of anti-VEGF therapy. Incidence of recurrence, predictors and re-treatment outcomes were studied.

Results

Overall, mean age and spherical equivalence (SE) was 47.95 ± 14.72 years and -12.19 ± 4.93 D respectively. Males constituted 50.9%. 44 eyes (26.4%) had a recurrence during a mean follow up of 16.5 ± 12.86 months. Kaplan-Meier survival analysis showed the risk of recurrence was 8, 26 and, 33.6% at 6, 12 and 18 months, respectively. Age (p = 0.511), gender (p = 0.218), SE (p = 0.092), anti-VEGF (p = 0.629) and baseline BCVA (p = 0.519) did not influence recurrence. Number of injections administered to control the disease in the first episode was the only significant predictor of recurrence (Cox Proportional Hazard Ratio 2.89–3.07, 95% Confidence Interval: 1.28–7.45; p = 0.005). At 12 months, eyes requiring one injection in first episode had a recurrence rate of 12% versus 45% in eyes requiring 3 or more injections in the first episode. A mean number of 1.9 additional injections per eye was needed during re-treatment. Final BCVA in the recurrence group was similar to that of non-recurrence group (0.53 ± 0.40 versus 0.55 ± 0.36 LogMAR; p = 0.755). Baseline BCVA (p = 0.0001) was the only predictor of final visual outcome irrespective of anti-VEGF drug (p = 0.38).

Conclusion

Eyes requiring greater number of injections for disease control in first episode are “at risk” of early m-CNV recurrence. However, recurrence does not adversely affect visual outcome, if treated adequately.

The efficacy of different anti-vascular endothelial growth factor agents and prognostic biomarkers in monitoring of the treatment for myopic choroidal neovascularization

PURPOSE

To evaluate anatomical and visual results of eyes with naive myopic choroidal neovascularization (mCNV) in patients treated with intravitreal anti-vascular endothelial growth factor (VEGF) therapies.

MATERIAL AND METHODS

This is a retrospective, non-randomized, comperative, intervetional study. One hundred fourteen eyes of 114 patients with mCNV who underwent intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR) or intravitreal aflibercept (IVA) monotherapy injections were enrolled into the study. The best corrected visual acuity (BCVA), central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) were compared among the groups during the follow-up periods at the beginning, months 1, 3, 6, 12, and the final visit.

RESULTS

The mean age of the patients was 47.76 ± 10.57 years (range, 33-72 years) and the mean follow-up period was 23.34 ± 6.81 months (range, 13-38 months). The mean BCVA denoted a significantly improve at each group (p < 0.05). In terms of an inter-group analysis of all 3 groups, at months 1, 6, and 12 and final visit, the BCVA were statistically significantly better in the IVA group when compared to both IVB and IVR groups (p = 0.021, p = 0.032, p = 0.024, p = 0.012). There was a significant decrease in CMT following IVB (236.49 ± 40.91 μm-190.74 ± 50.12 μm), IVA (232.91 ± 46.29 μm-193.73 ± 46.81 μm) and IVR (234.78 ± 45.37 μm-192.21 ± 37.27 μm) between baseline and final visit (p = 0.018, p = 0.002, p < 0.001, respectively). There was a statistically significant decrease in SFCT values between baseline and final examination only in the IVA group (p < 0.001). The mean number of injections were 9.18 ± 3.18 (range; 3 to 13) in IVB, 6.46 ± 2.93 (range; 3-11) in IVR and 4.45 ± 1.42 (range; 2-7) in IVA (p = 0.028).

CONCLUSION

All three anti-VEGFs were found to be effective in terms of visual results in patients with mCNV. However, we demonstrated that IVA reduces the need for anti-VEGF when compared to patients who received both IVB and IVR. Furthermore, IVA induced a prominent reduction in SFCT, whereas IVR and IVB did not have a significant action on SFCT.

Global Tendency and Frontiers of Research on Myopia From 1900 to 2020: A Bibliometrics Analysis

Background:

Myopia is one of the most common causes of vision impairment in children and adults and has become a public health priority with its growing prevalence worldwide. This study aims to identify and evaluate the global trends in myopia research of the past century and visualize the frontiers using bibliometric analysis.

Methods

The literature search was conducted on the Web of Science for myopia studies published between 1900 and 2020. Retrieved publications were analyzed in-depth by the annual publication number, prolific countries and institutions, core author and journal, and the number of citations through descriptive statistics. Collaboration networks and keywords burst were visualized by VOSviewer and CiteSpace. Myopia citation network was visualized using CitNetExplorer.

Results

In total, 11,172 publications on myopia were retrieved from 1900 to 2020, with most published by the United States. Saw SM, from the National University of Singapore, contributed the most publications and citations. Investigative Ophthalmology &amp; Visual Science was the journal with highest number of citations. Journal of Cataract and Refractive Surgery with the maximum number of publications. The top 10 cited papers mainly focused on the epidemiology of myopia. Previous research emphasized myopia-associated experimental animal models, while recent keywords include “SMILE” and “myopia control” with the stronger burst, indicating a shift of concern from etiology to therapy and coincided with the global increment of incidence. Document citation network was clustered into six groups: “prevalence and risk factors of myopia,” “surgical control of myopia,” “pathogenesis of myopia,” “optical interventions of myopia,” “myopia and glaucoma,” and “pathological myopia.”

Conclusions

Bibliometrics analysis in this study could help scholars comprehend global trends of myopia research frontiers better. Hundred years of myopia research were clustered into six groups, among which “prevalence and risk factors of myopia” and “surgical control of myopia” were the largest groups. With the increasing prevalence of myopia, interventions of myopia control are a potential research hotspot and pressing public health issue.

Ten-Year Outcomes of Intravitreal Bevacizumab for Myopic Choroidal Neovascularization: Analysis of Prognostic Factors

The current standard treatment of myopic choroidal neovascularisation (mCNV) is intravitreal injection of VEGF antagonists. This study was proposed to assess efficacy and safety of intravitreal bevacizumab (IVB) for the treatment of mCNV across a 10-year follow-up. Thirty eyes of thirty patients with treatment-naïve mCNV who underwent IVB and were followed up with for a minimum of ten years were recruited for the present retrospective cohort study. All participants were treated with three monthly IVB at baseline and then evaluated and treated under pro re nata (PRN) schedule. Outcome measures were to determine BCVA changes over years and identify the predictive factors of both final visual outcome and need for retreatment. Analysis of the main involved prognostic factors with correlations among variables is reported. Visual acuity remained stable at 10-year follow-up (p = 0.001) with the greatest improvement at 2 years (p < 0.0001) in all CNV locations. Baseline BCVA correlated positively with final BCVA (β = 0.88, p < 0.0001, R²: 0.75). No predictive factors for the need of additional injections were identified. Retinal and choroidal thickness significantly reduced over time but without correlation with the number of injections. CNV max height and area significantly decreased at 10 years (p < 0.0001 and p = 0.003, respectively), with complete regression of mCNV lesion in 40% of subjects. Intravitreal bevacizumab resulted as long-term effective and safe therapy for mCNV with sustained results at 10 years.

Anti-VEGF Therapy in Myopic CNV

In this narrative-review, we report the most recent data from the literature of anti-vascular endothelial growth factor treatment for myopic choroidal neovascularization (mCNV). Myopic CNV is the most frequent sight-threatening complication of pathologic myopia. The natural course of mCNV can result in expanding macular atrophy and /or fibrosis, leading to irreversible visual loss after 5 years. Retinal multimodal imaging is mandatory for early diagnosis and monitoring of the disease during treatment. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended as the first-line treatment option for mCNV. Prompt treatment of active mCNV with intravitreal anti-VEGF therapy has been demonstrated to be effective in terms of visual outcome improvements reducing the occurrence of late-stage complications.

Evaluation of Carboxymethylcellulose Sodium plus Glycerin (Optive®) in Ocular Discomfort after Anti-Vascular Endothelial Growth Factor Intravitreal Injection Therapy: A Prospective Study

OBJECTIVE

The aim of this study was to evaluate the efficacy of a mix of carboxymethylcellulose and glycerin (Optive®) after intravitreal injection therapy (IVT) with anti-vascular endothelial growth factor for reducing ocular discomfort in patients.

METHODS

We prospectively included patients who were naïve to any IVT. No artificial tear treatment was prescribed after the first IVT. After the second IVT, all patients instilled 3 drops per day of Optive® for 3 days. Every patient answered a questionnaire concerning the ocular discomfort at 72 h after both IVTs and a questionnaire about tolerance to treatment after the second IVT.

RESULTS

We included 45 patients (mean age 72.3 years [range 23-94], 25 females); 14 (34.1%) reported a feeling of grittiness after the first IVT but not after the second (p = 0.01); 12 (29.3%) complained of global discomfort after the first IVT but not after the second (p = 0.14); and 11 (26.8%) reported a watery eye after the first IVT but not after the second (p = 0.21); 37/45 (82%) patients felt ocular discomfort after IVT.

CONCLUSION

Most patients felt ocular discomfort after IVT. Instillation of Optive® significantly alleviated the feeling of grittiness for more than half of the patients.

The Role of Photoactivated and Non-Photoactivated Verteporfin on Tumor

Verteporfin (VP) has long been clinically used to treat age-related macular degeneration (AMD) through photodynamic therapy (PDT). Recent studies have reported a significant anti-tumor effect of VP as well. Yes-associated protein (YAP) is a pro-tumorigenic factor that is aberrantly expressed in various cancers and is a central effector of the Hippo signaling pathway that regulates organ size and tumorigenesis. VP can inhibit YAP without photoactivation, along with suppressing autophagy, and downregulating germinal center kinase-like kinase (GLK) and STE20/SPS1-related proline/alanine-rich kinase (SPAK). In addition, VP can induce mitochondrial damage and increase the production of reactive oxygen species (ROS) upon photoactivation, and is an effective photosensitizer (PS) in anti-tumor PDT. We have reviewed the direct and adjuvant therapeutic action of VP as a PS, and its YAP/TEA domain (TEAD)-dependent and independent pharmacological effects in the absence of light activation against cancer cells and solid tumors. Based on the present evidence, VP may be repositioned as a promising anti-cancer chemotherapeutic and adjuvant drug.

Updates on the Management of Ocular Vasculopathies with VEGF Inhibitor Conbercept

Purpose: To provide a detailed review on the therapeutic efficacy of conbercept for the management of ocular vasculopathies. Methods: A comprehensive literature search of various electronic databases was performed. Results: Ocular vasculopathy is one of the major causes of visual impairment and blindness which includes a range of disorders. Vascular endothelial growth factor (VEGF) regulates angiogenesis, enhances vascular permeability, and drives the formation of neovascularization. Anti-VEGF therapy has been shown to prevent vision loss or potentially improve vision in patients with exudative or neovascular retinal disease. The most recent anti-VEGF drug in China is conbercept. In the USA and Europe, bevacizumab is the most recently approved anti-VEGF agent. Conclusions: Conbercept serves as another anti-VEGF option for patients with neovascular AMD and other retinal vascular disorders. There have not been many clinical trials that study conbercept as compared with other currently available anti-VEGF drugs. There is a need for large-scale, well-designed, randomized clinical trials to ensure its long-term safety and efficacy and to determine if it has any advantages over other anti-VEGF agents.

Results of Ranibizumab Treatment of the Myopic Choroidal Neovascular Membrane according to the Axial Length of the Eye

Aim

A retrospective evaluation of the results of treatment of myopic choroidal neovascularization (mCNV) with intravitreal injections of ranibizumab in a pro re nata (PRN) regimen in three groups of patients distributed according to axial length.

Methods

The paper presents a retrospective multicenter study carried out with the cooperation of several Departments of Ophthalmology in the Czech Republic. The study included 60 eyes of 60 patients suffering from mCNV, divided according to axial length into three groups. The first group consisted of 20 patients with an axial length of the eyes shorter than 28 mm (Group 1), the second group included 27 patients with axial lengths ranging from 28 mm to 29.81 mm (Group 2), and 13 patients had axial lengths longer than 30 mm (Group 3). All patients were first administered 3 initial intravitreal ranibizumab injections at monthly intervals (loading phase), and other injections were administered according to a PRN treatment regimen. Patients were evaluated before treatment and then at intervals of 3, 6, 9, and 12 months. The effect of ranibizumab treatment on the functional and morphological parameters of the affected eye was evaluated.

Results

The average baseline BCVA ± SD in Group 1 was 52.6 ± 12.5 letters of ETDRS optotypes, and at the end of the one-year follow-up, it was 63.3 ± 11.8 letters. The average baseline of CRT ± SD in this group was 377.4 ± 80.0 μm, and in the 12th month, it was 311.1 ± 63.7 μm. The average baseline BCVA ± SD in Group 2 was 50.2 ± 9.0 ETDRS letters, and at the end of the follow-up, it was 60 ± 12.4 letters. The average baseline of CRT ± SD in Group 2 was 391.2 ± 85.2 μm, and in the 12th month, it was 323.9 ± 91.2 μm. In Group 3, the average baseline of BCVA was 48.5 ± 14.5 ETDRS letters, and at the end of the one-year follow-up, it was 55.7 ± 16.1 letters. The average baseline CRT ± SD for Group 3 was 342.1 ± 94.9 μm, and after 12 months, it was 287.8 ± 88.4 μm. An improvement of BCVA by ≥15 letters of ETDRS optotypes was achieved by 3 patients of 20 (15%) in Group 1, by 5 patients of 27 (18.5%) in Group 2, and by 3 patients of 13 (23.1%) in Group 3. All these changes were statistically significant in comparison with the input values (p < 0.05).

Conclusion

Ranibizumab treatment in patients with mCNV in our study resulted in statistically significant improvement in BCVA and a decrease in CRT in all groups of patients. Our results from a routine clinical practice correspond with the results of large clinical studies; we confirm a particularly good effect of treatment in patients with axial lengths of the eye smaller than 28 mm.

The Evaluation of a Two-Year Outcome of Intravitreal Conbercept versus Ranibizumab for Pathological Myopic Choroidal Neovascularization

Aim: The aim of this study was to evaluate and compare the 24-month follow-up results of intravitreal conbercept with ranibizumab in the treatment of choroidal neovascularization (CNV), secondary to pathological myopia (PM). Methods: Fifty-nine patients' 64 eyes with pathological myopic CNV were retrospectively reviewed. Thirty-one eyes underwent conbercept treatment (group C) and 33 eyes underwent ranibizumab treatment (group R), respectively. No patients have received any treatment before. The main outcome of the best-corrected visual acuity (BCVA) uses an international standard visual acuity chart and is converted to the minimum resolution logarithm (LogMAR) visual acuity. Results: There were no significant differences between the two groups at the baseline statisticlly. At 24 months, the mean logMAR BCVA of group C increased from 0.95 ± 0.54 to 0.58 ± 0.39 (P < .001) and the mean central macular thickness (CMT) decreased from 280.97 ± 62.69 μm to 242.35 ± 90.39 μm (P = .033). The mean logMAR BCVA of group R increased from 0.86 ± 0.40 to 0.54 ± 0.28 (P < .001) and the mean CMT was reduced from 303.58 ± 61.95 μm to 251.82 ± 84.74 μm (P = .005). There was no significant difference in logMAR BCVA and CMT between the two groups (P = .962, P = .667, respectively). The mean number of injections was 3.94 ± 1.88 in group C and 4.06 ± 1.82 in group R (P = .788). During the follow-up period, no ocular complications and systemic adverse reactions were observed. Conclusion: Similar visual acuity and improved morphology were achieved in both groups. The two drugs were also found to be safe and effective in the treatment of pathological myopic CNV.

Comparison of intravitreal bevacizumab and ranibizumab used for myopic choroidal neovascularization: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the effect of intravitreal bevacizumab (IVB) and ranibizumab (IVR) for the treatment of choroidal neovascularization (CNV) secondary to pathologic myopia (PM) by meta-analysis.

METHODS

Pertinent publications of randomized controlled trials (RCTs) were identified through systemic searches of PubMed, EMBASE, Web of science, Cochrane Library, clinicaltrials.gov, CNKI, CQVIP, and Wanfang database. All comparative studies of IVB or IVR as treatment for CNV secondary to pathologic myopia were included. Meta-analysis of these RCTs was performed using Review Manager 5.3 software. The χ test and I values were used to analyze heterogeneity. Measurements included best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

A total of 3 randomized controlled clinical trials involving 158 eyes were included, 81 eyes in IVB group and 77 eyes in IVR group. Compared with baseline, at 1, 3, 6, and 12 months after IVB or IVR treatment, BCVA was significantly increased. Change of BCVA at 1, 3, 6, and 12 months did not vary significantly between IVB and IVR group (1 month: Z = 0.30, 95% CI = -0.08 to 0.11, P = .76; 3 months: Z = 0.36, 95% CI = -0.10 to 0.15, P = .72; 6 months: Z = 0.17, 95% CI = -0.10 to 0.12, P = .86; 12 months: Z = 0.64, 95% CI = -0.15 to 0.08, P = .52).

CONCLUSION

Both IVR and IVB can significantly improve BCVA of eyes with mCNV, but there was no significant difference between the 2 therapies on the treatment of mCNV.

Retinal vascular changes and aqueous humor cytokines changes after aflibercept intravitreal injection in treatment-naïve myopic choroidal neovascularization

The aim of the study was to assess retinal vascular changes using optical coherence tomography angiography (OCTA) and aqueous humour changes of vascular endothelial growth factor (VEGF) and placental growth factor (PIGF) levels in treatment-naïve myopic choroidal neovascularization (mCNV) after aflibercept intravitreal injection. To explore the correlation between clinical and laboratory parameters. Fifteen eyes of 15 patients with treatment-naïve mCNV underwent 2 intravitreal injections of aflibercept. Main outcome measures were best corrected visual acuity (BCVA), central retinal thickness (CRT) and external limiting membrane (ELM) visualization at OCT, lesion area and leakage at fluorescein angiography (FA), OCTA flow area and selected area at baseline and after the injections. Analysis of VEGF and PlGF in the aqueous humor was performed before each injection in cases and prior to cataract surgery on 10 patients as included as controls. Median BCVA increased from 0.6 to 0.3 logMAR (p < 0.001); CRT decreased from 387.5 to 267 micron (p < 0.001); FA area from 0.8 to 0.5 mm² and OCTA area from 0.9 to 0.5 mm² (p = 0.005). PIGF values changed from 1.8 to 1.4 pg/ml (p = 0.019) and VEGF values from 3.4 to 0.5 pg/ml (p = 0.008). A significant correlation was found after treatment between PIGF levels and BCVA (rho = 0.006) and VEGF levels and BCVA (rho = 0.018); between PlGF and CRT (rho = 0.020), PlGF and ELM visualization (rho = 0.002) and PlGF and FA leakage (rho < 0.001). Our results showed a significant reduction of mCNV area after aflibercept in both FA and OCTA measurements; an improvement of BCVA, and a reduction of VEGF and PIGF levels related to inactivity of the disease.

Epidemiology, treatment pattern and health care utilization of myopic choroidal neovascularization: a population based study

PURPOSE

To investigate the prevalence and incidence of myopic choroidal neovascularization (CNV) in Taiwan, including the health care utilization and treatment-associated costs.

METHODS

A retrospective cohort study using existing data from the Taiwanese National Health Insurance claims database to identify patients who had a diagnosis of myopic CNV recorded from 1 January 2009 to 31 December 2011. The prevalence of myopic CNV was monitored during this period, and the frequency and cost of both treatment visits and monitoring visits were analyzed for 2 years following diagnosis.

RESULTS

The prevalence of myopic CNV was 0.017%. In total, 9068 patients with myopic CNV were identified, 12.3% (n = 1111) of whom were treated. Of those treated, 72.0% (n = 800) received intravitreal anti-vascular endothelial growth factor injections (IVI); the remainder received either photodynamic therapy with verteporfin (vPDT), laser photocoagulation, or a combination of therapies. IVI was associated with the largest number of treatment visits as well as a higher administrative (non-drug) cost per treatment visit (a mean of USD 57.18). vPDT alone was associated with a higher overall cost per treatment visit and more monitoring visits than IVI or laser photocoagulation. Costs for monitoring visits were highest for IVI.

CONCLUSIONS

The prevalence of myopic CNV was lower than that reported in previous studies, possibly because of differences in age distribution in the populations studied. The frequencies of treatment administered were similar to those reported in previous studies; however, a cost-effectiveness comparison could not be made owing to lack of data in previous studies.

Anti-vascular endothelial growth factor for choroidal neovascularisation in people with pathological myopia

BACKGROUND

Choroidal neovascularisation (CNV) is a common complication of pathological myopia. Once developed, most eyes with myopic CNV (mCNV) experience a progression to macular atrophy, which leads to irreversible vision loss. Anti-vascular endothelial growth factor (anti-VEGF) therapy is used to treat diseases characterised by neovascularisation and is increasingly used to treat mCNV.

OBJECTIVES

To assess the effects of anti-vascular endothelial growth factor (anti-VEGF) therapy for choroidal neovascularisation (CNV), compared with other treatments, sham treatment or no treatment, in people with pathological myopia.

SEARCH METHODS

We searched a number of electronic databases including CENTRAL and Ovid MEDLINE, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform ICTRP). We did not use any date or language restrictions in the electronic searches for trials. Electronic databases were last searched on 16 June 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing anti-VEGF therapy with another treatment (e.g. photodynamic therapy (PDT) with verteporfin, laser photocoagulation, macular surgery, another anti-VEGF), sham treatment or no treatment in participants with mCNV.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two authors independently screened records, extracted data, and assessed risk of bias. We contacted trial authors for additional data. We analysed outcomes as risk ratios (RRs) or mean differences (MDs). We graded the certainty of the evidence using GRADE.

MAIN RESULTS

The present review included six studies which provided data on the comparison between anti-VEGF with PDT, laser, sham treatment and another anti-VEGF treatment, with 594 participants with mCNV. Three trials compared bevacizumab or ranibizumab with PDT, one trial compared bevacizumab with laser, one trial compared aflibercept with sham treatment, and two trials compared bevacizumab with ranibizumab. Pharmaceutical companies conducted two trials. The trials were conducted at multiple clinical centres across three continents (Europe, Asia and North America). In all these six trials, one eye for each participant was included in the study.When compared with PDT, people treated with anti-VEGF agents (ranibizumab (one RCT), bevacizumab (two RCTs)), were more likely to regain vision. At one year of follow-up, the mean visual acuity (VA) in participants treated with anti-VEGFs was -0.14 logMAR better, equivalent of seven Early Treatment Diabetic Retinopathy Study (ETDRS) letters, compared with people treated with PDT (95% confidence interval (CI) -0.20 to -0.08, 3 RCTs, 263 people, low-certainty evidence). The RR for proportion of participants gaining 3+ lines of VA was 1.86 (95% CI 1.27 to 2.73, 2 RCTs, 226 people, moderate-certainty evidence). At two years, the mean VA in people treated with anti-VEGFs was -0.26 logMAR better, equivalent of 13 ETDRS letters, compared with people treated with PDT (95% CI -0.38 to -0.14, 2 RCTs, 92 people, low-certainty evidence). The RR for proportion of people gaining 3+ lines of VA at two years was 3.43 (95% CI 1.37 to 8.56, 2 RCTs, 92 people, low-certainty evidence). People treated with anti-VEGFs showed no obvious reduction (improvement) in central retinal thickness at one year compared with people treated with PDT (MD -17.84 μm, 95% CI -41.98 to 6.30, 2 RCTs, 226 people, moderate-certainty evidence). There was low-certainty evidence that people treated with anti-VEGF were more likely to have CNV angiographic closure at 1 year (RR 1.24, 95% CI 0.99 to 1.54, 2 RCTs, 208 people). One study allowed ranibizumab treatment as of month 3 in participants randomised to PDT, which may have led to an underestimate of the benefits of anti-VEGF treatment.When compared with laser photocoagulation, there was more improvement in VA among bevacizumab-treated people than among laser-treated people after one year (MD -0.22 logMAR, equivalent of 11 ETDRS letters, 95% CI -0.43 to -0.01, 1 RCT, 36 people, low-certainty evidence) and after two years (MD -0.29 logMAR, equivalent of 14 ETDRS letters, 95% CI -0.50 to -0.08, 1 RCT, 36 people, low-certainty evidence).When compared with sham treatment, people treated with aflibercept had better vision at one year (MD -0.19 logMAR, equivalent of 9 ETDRS letters, 95% CI -0.27 to -0.12, 1 RCT, 121 people, moderate-certainty evidence). The fact that this study allowed for aflibercept treatment at 6 months in the control group might cause an underestimation of the benefit with anti-VEGF.People treated with ranibizumab had similar improvement in VA recovery compared with people treated with bevacizumab after one year (MD -0.02 logMAR, equivalent of 1 ETDRS letter, 95% CI -0.11 to 0.06, 2 RCTs, 80 people, moderate-certainty evidence).Of the included six studies, two studies reported no adverse events in either group and two industry-sponsored studies reported both systemic and ocular adverse events. In the control group, there were no systemic or ocular adverse events reported in 149 participants. Fifteen people reported systemic serious adverse events among 359 people treated with anti-VEGF agents (15/359, 4.2%). Five people reported ocular adverse events among 359 people treated with anti-VEGF agents (5/359, 1.4%). The number of adverse events was low, and the estimate of RR was uncertain regarding systemic serious adverse events (4 RCTs, 15 events in 508 people, RR 4.50, 95% CI 0.60 to 33.99, very low-certainty evidence) and serious ocular adverse events (4 RCTs, 5 events in 508 people, RR 1.82, 95% CI 0.23 to 14.71, very low-certainty evidence). There were no reports of mortality or cases of endophthalmitis or retinal detachment.There was sparse reporting of data for vision-related quality of life (in favour of anti-VEGF) in only one trial at one year of follow-up. The studies did not report data for other outcomes, such as percentage of participants with newly developed chorioretinal atrophy.

AUTHORS' CONCLUSIONS

There is low to moderate-certainty evidence from RCTs for the efficacy of anti-VEGF agents to treat mCNV at one year and two years. Moderate-certainty evidence suggests ranibizumab and bevacizumab are equivalent in terms of efficacy. Adverse effects occurred rarely and the trials included here were underpowered to assess these. Future research should be focused on the efficacy and safety of different drugs and treatment regimens, the efficacy on different location of mCNV, as well as the effects on practice in the real world.

Clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization

BACKGROUND/PURPOSE

This study aims to evaluate the clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization.

METHODS

We conducted a retrospective study of 55 patients with macular coin hemorrhage who were followed for at least 3 months from January 1997 to December 2013 at Shin Kong Wu Ho-Su Memorial Hospital (Taipei, Taiwan). All patients were evaluated using fluorescein angiography and optical coherence tomography for the detection of choroidal neovascularization (CNV). We also recorded clinical characteristics such as age, sex, refractory error, and myopic fundus, to determine the relationship between CNV and non-CNV associated macular hemorrhage.

RESULTS

A total of 55 patients (30 females, 54.55%) were reviewed. The mean age was 39.7 years old. The CNV group was found to be significantly older than the non-CNV group (p < 0.05), and there was no significant difference between sex, visual acuity myopic severity, and the prevalence of fundus findings between CNV and non-CNV groups. Twenty one patients (38.18%) were found to have CNV and were all treated with intravitreal antivascular endothelial growth factor (VEGF). The other 34 patients without CNV were not treated. In both groups, the visual acuity significantly improved (anti-VEGF treated, CNV associated group, 0.7 to 0.39, p = 0.002, and untreated, non-CNV associated group, 0.56 to 0.34, p = 0.0018, respectively).

CONCLUSION

Age significantly correlated to the CNV formation in high myopia with macular hemorrhage. Favorable visual outcomes were found in pathological myopic macular hemorrhage either in the anti-VEGF treated, CNV associated group or in the untreated, non-CNV associated group.

Development and use of specific ELISA methods for quantifying the biological activity of bevacizumab, cetuximab and trastuzumab in stability studies

Bevacizumab (BVZ), cetuximab (CTX) and trastuzumab (TTZ) are monoclonal antibodies (mAbs) used worldwide for the treatment of several widespread kinds of cancer. They are marketed as medicines under their respective tradenames: Avastin(®), Erbitux(®) and Herceptin(®). The aim of this research was to develop in-house specific enzyme-linked immunosorbent assays (ELISA) to assess the long-term stability of these three mabs. These assays assess the biological functionality of the mAbs by quantifying their biological activity. For this purpose, we developed an indirect ELISA procedure whereby the specific antigens against which the mAbs are directed are used as specific "capturing" antibodies on the ELISA plates. We therefore used vascular endothelial growth factor (VEGF) in the ELISA for BVZ; human epidermal growth factor receptor (hEGFR) in the ELISA for CTX and human receptor HER2 (hHER2) in the ELISA for TTZ. After the mAbs had attached to their antigen, we used an anti-human IgG (whole molecule) peroxidase-conjugate and o-phenylenediaminedihydrochloride substrate. The reaction was stopped using sulphuric acid and absorbance was recorded at a wavelength of 450nm. The three ELISA methods were validated in terms of calibration models, range of the assay, limits of detection and quantitation, intra and interday precision and accuracy, and specificity by cross reactions. Forced degradation studies were also conducted on the medicines, providing useful information. Finally, the proposed ELISA were successfully used in a long-term stability study to quantify the remaining biological activity in medicines that had been opened and then stored under two different storage conditions, i.e. refrigerated at 4°C and frozen at -20°C. Results indicated that BVZ (Avastin(®)) is the most stable of the three in terms of its biological functionality.

Spectral-Domain Optical Coherence Tomography of Subretinal Hyperreflective Exudation in Myopic Choroidal Neovascularization

PURPOSE

To study the effect of anti-vascular endothelial growth factor (VEGF) therapy on subretinal hyperreflective exudation detected by spectral-domain optical coherence tomography (SD OCT) in myopic choroidal neovascularization (CNV).

DESIGN

Retrospective consecutive observational cohort study.

METHODS

Thirty-one eyes of 31 consecutive highly myopic patients with CNV and showing a subretinal hyperreflective exudation on SD OCT were included. Morphologic changes were assessed before and after anti-VEGF therapy, based on the subretinal hyperreflective exudation thickness, retinal thickness at the level of the CNV, and central macular thickness.

RESULTS

After anti-VEGF treatment (mean follow-up of 1.9 ± 0.8 months, mean number of injections 1.8 ± 0.6), the subretinal hyperreflective exudation regressed completely in 29 of 31 eyes (93.5%) and partially in 2 of 31 eyes (6.5%). Mean subretinal hyperreflective exudation thickness, mean retinal thickness at the level of the CNV, and mean central macular thickness significantly decreased from 102 ± 50 μm to 2.6 ± 10.2 μm (P < .0001), from 419 ± 99 μm to 312 ± 64 μm (P < .0001), and from 361 ± 69 μm to 326 ± 72 μm (P = .0008), respectively.

CONCLUSION

The subretinal hyperreflective exudation was an SD OCT finding that correlated with signs of active myopic CNV (either subretinal fluid/intraretinal cysts on SD OCT or dye leakage on fluorescein angiography) and responded to treatment with anti-VEGF agents. The presence of a subretinal hyperreflective exudation on SD OCT could help in making decisions on the need to perform or not perform fluorescein angiography, and regarding treatment or retreatment.

Effect of Factor XIII-A G185T Polymorphism on Visual Prognosis after Photodynamic Therapy for Neovascular Macular Degeneration

Macular degenerations represent leading causes of central blindness or low vision in developed countries. Most of these severe visual disabilities are due to age-related macular degeneration (AMD) and pathologic myopia (PM), both of which are frequently complicated by subfoveal choroidal neovascularization (CNV). Photodynamic therapy with verteporfin (PDT-V) is still employed for CNV treatment in selected cases or in combined regimen. In Caucasian patients, the common polymorphism G185T of factor XIII-A gene (FXIII-A-G185T; rs5985) has been described as predictor of poor angiographic CNV responsiveness to PDT-V. Nevertheless, the prognostic implications of this pharmacogenetic determinant on long-term visual outcome after a PDT-V regimen have not been evaluated. We retrospectively selected Caucasian patients presenting with treatment-naive CNV and receiving standardized PDT-V protocol for two years. The study population included patients affected by subfoveal CNV secondary to AMD or PM. We assessed the correlations between the polymorphic allele T of FXIII-A-G185T and: (1) total number of photodynamic treatments; and (2) change in visual acuity from baseline to the end of the follow-up period. Considering a total study population of 412 patients with neovascular AMD or PM, the carriers of 185 T-allele of FXIII-A (GT or TT genotype) received a higher number of photodynamic treatments than patients without it (GG wild-type genotype) (p < 0.01; mean number of PDT-V: 5.51 vs. 3.76, respectively). Moreover, patients with 185 T-allele of FXIII-A had a more marked worsening of visual acuity at 24 months than those with the GG-185 wild genotype (p < 0.01; mean difference in logMAR visual acuity: 0.22 vs. 0.08, respectively). The present findings show that the G185T polymorphism of the FXIII-A gene is associated with significant differences in the long-term therapeutic outcomes of patients treated with standardized PDT-V protocol. The comprehensive appraisal of both anti-thrombophilic effects due to FXIII-A G185T variant and photo-thrombotic action of PDT-V toward CNV provides several clues about the rationale of this intriguing pharmacogenetic correlation. Further investigations are warranted to outline the appropriate paradigm for guiding PDT-V utilization in the course of the combined therapeutic protocol for neovascular macular degeneration.

Anti-VEGF treatment for myopic choroid neovascularization: from molecular characterization to update on clinical application

Choroidal neovascularization (CNV) secondary to pathologic myopia has a very high incidence in global, especially in Asian, populations. It is a common cause of irreversible central vision loss, and severely affects the quality of life in the patients with pathologic myopia. The traditional therapeutic modalities for CNV secondary to pathologic myopia include thermal laser photocoagulation, surgical management, transpupillary thermotherapy, and photodynamic therapy with verteporfin. However, the long-term outcomes of these modalities are disappointing. Recently, intravitreal administration of anti-VEGF biological agents, including bevacizumab, ranibizumab, pegaptanib, aflibercept, and conbercept, has demonstrated promising outcomes for this ocular disease. The anti-VEGF regimens are more effective on improving visual acuity, reducing central fundus thickness and central retina thickness than the traditional modalities. These anti-VEGF agents thus hold the potential to become the first-line medicine for treatment of CNV secondary to pathologic myopia. This review follows the trend of “from bench to bedside”, initially discussing the pathogenesis of myopic CNV, delineating the molecular structures and mechanisms of action of the currently available anti-VEGF drugs, and then systematically comparing the up to date clinical applications as well as the efficacy and safety of the anti-VEGF drugs to the CNV secondary to pathologic myopia.

One-year outcome of two different initial dosing regimens of intravitreal ranibizumab for myopic choroidal neovascularization

PURPOSE

To evaluate and compare the 12-month outcomes of two different initial dosing regimens of intravitreal ranibizumab for myopic choroidal neovascularization (CNV).

METHODS

We retrospectively reviewed the medical records of 46 consecutive, treatment-naive eyes which received intravitreal ranibizumab for subfoveal and juxtafoveal CNV secondary to pathologic myopia with a follow-up of 12 months. Two groups were created according to different initial dosing regimens: group 1 included 25 eyes treated by a single intravitreal injection; group 2 included 21 eyes treated by three consecutive monthly injections. Additional injections were performed if needed. Patients' demographic data, best-corrected visual acuity (BCVA), recurrence of CNV and total number of treatments were recorded and evaluated.

RESULTS

There was no significant difference between two groups among baseline demographic data. At 12 months, the mean logMAR BCVA improved from 0.58 to 0.23 in group 1 and from 0.55 to 0.22 in group 2 (both p < 0.001; Wilcoxon signed-rank test). The mean logMAR BCVA at 12 months did not differ significantly. The average number of injections was 2.32 (SD 1.22) in group 1 and 3.57 (SD 1.12) in group 2 (p = 0.001; two-tailed t-test). During the follow-up, 17 of 25 eyes in group 1 and 5 of 21 eyes in group 2 received additional injections (p = 0.004).

CONCLUSIONS

Similar visual improvement was achieved in both groups. Although the eyes with a loading dose of 3 monthly injections required a higher number of total injections over 1 year, there was a much lower rate of retreatment needed.

A systematic review and meta-analysis comparing intravitreal ranibizumab with bevacizumab for the treatment of myopic choroidal neovascularisation

Intravitreal injections of ranibizumab (IVR) and bevacizumab (IVB) have both been used as treatments for myopic choroidal neovascularisation. We aimed to produce a meta-analysis of published literature comparing IVR with IVB for the treatment of myopic choroidal neovascularisation, by searching electronic databases from January 1950 to March 2013. Our search produced three suitable studies that reported on 117 patients in total. The results of the meta-analysis demonstrated that the mean number of lines improvement after IVR appeared better compared with IVB [fixed effects model: SMD = 0.46, 95% CI (0.09, 0.83), z = 2.44, p = 0.01]. The number of patients who had a greater than 3 line improvement was similar between groups [fixed effects model: RR = 0.95, 95% CI (0.67, 1.32), z = 0.33, p = 0.74]. At follow up there was no difference in number of those who had an absence of leakage [fixed effects model: RR = 1.04, 95% CI (0.93, 1.16), z = 0.64, p = 0.52]. There was no statistical significance between the two groups in relation to the number of injections [random effects model: SMD = −0.25, 95% CI (−1.12, 0.61), z = 0.57, p = 0.57]. Early evidence therefore suggests that intravitreal injections of ranibizumab are comparable to intravitreal injections of bevacizumab in the treatment of myopic choroidal neovascularisation. Both treatments result in a statistically significant increase in visual acuity with high numbers of patients maintaining stable vision. Further studies are still needed to strengthen results.

Forty-two-month outcome of intravitreal bevacizumab in myopic choroidal neovascularization

PURPOSE

To evaluate the long-term efficacy of bevacizumab in the treatment of choroidal neovascularization (CNV) secondary to pathological myopia.

METHODS

In this retrospective single-center non-comparative study the medical records of 29 eyes from 29 patients with naïve CNV secondary to high myopia and at least 42 months of follow up were reviewed. All eyes received a loading dose of one intravitreal injection per month for two consecutive months and were retreated on an as-needed basis during the course of follow up. The main outcome measures were post-treatment ETDRS best-corrected visual acuity (BCVA) and visual stabilization over time. Stepwise linear regression analysis was performed to identify prognostic factors for visual acuity gain and final visual acuity outcome at 42 months.

RESULTS

At 42 months of follow-up bevacizumab was associated with the maintenance of significant benefits in visual acuity compared to baseline. No adverse ocular or systemic effects from treatment were encountered. No statistically significant correlations were found between BCVA change and any of the quantitative variables. However, when final BCVA was taken as a dependent variable and CNV size and pre-treatment VA were included as predictors, a bivariate model was identified by stepwise regression which gave a 75 % of explained variance.

CONCLUSIONS

Bevacizumab treatment was found to be efficacious in the treatment of myopic CNV, resulting in stable gains in visual acuity lasting at least 42 months, without any adverse ocular or general events. Myopic CNV size was identified as a significant prognostic factor.

Combined therapy with bevacizumab and photodynamic therapy for myopic choroidal neovascularization: A one-year follow-up controlled study

AIM

To evaluate the efficacy and safety of a combined treatment for myopic choroidal neovascularization (CNV) using photodynamic therapy (PDT) and intravitreal bevacizumab and to compare it with intravitreal bevacizumab monotherapy.

METHODS

Thirty-four eyes with angiographic evidence of myopic CNV were randomly divided into two groups: 17 were treated with one intravitreal bevacizumab injection (1.25 mg) and low-fluence-rate PDT within seven days of the injection (Group A). The other 17 received monotherapy with bevacizumab injections (Group B). Clinical evidence of complications, best corrected visual acuity (BCVA) and fluorescein leakage were evaluated. BCVA and optical coherence tomography (OCT) were evaluated monthly. The timepoints follow-up was established at 6 and 12mo. All patients were retreated following a PRN protocol.

RESULTS

A total of 34 eyes of 34 patients (26 women and 8 men) with a mean age of 62.35 years were included. In Group A (17 eyes) the mean BCVA increased from 0.55±0.13 logMAR before the treatment to 0.40±0.09 logMAR at the 12mo follow-up (P<0.01). In Group B (17 eyes) the mean BCVA increased from 0.60±0.11 logMAR before the treatment to 0.55±0.12 logMAR at the 12mo follow-up (P<0.01). There was no statistically significant difference between the two groups in terms of LogMar visual acuity. In Group A the mean number of combined treatments was 1.8±0.11 per patient; in Group B the mean number of intravitreal bevacizumab injections was 3.1±0.08 per patient. The number of treatments was significantly fewer in Group A (P<0.01). No local or systemic side effects occurred among any of the patients treated in this study.

CONCLUSION

The combination of anti-angiogenic injections and PDT appears to be a safe and effective option for myopic CNV treatment and allows for a significant reduction of intravitreal injections.

Intravitreal anti-vascular endothelial growth factor for choroidal neovascularization secondary to pathologic myopia: systematic review and meta-analysis

PURPOSES

To update existing evidence and evaluate intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections for myopic choroidal neovascularization.

METHODS

The authors conducted comprehensive search in PubMed, EMBASE, Cochrane Library, Biosis Preview, and LILACS. Included studies were categorized by study design. Comparative studies were classified as randomized controlled trials (RCTs) and non-RCT studies, and these two types of studies were presented and meta-analyzed separately for the following comparisons: 1) anti-VEGF versus photodynamic therapy, 2) anti-VEGF monotherapy versus combination therapy with photodynamic therapy, 3) single versus 3 monthly injections followed by pro re nata (PRN) treatment, and 4) ranibizumab versus bevacizumab. Noncomparative prospective series were pooled to estimate mean visual gain, mean retinal thickness change, and the average number of anti-VEGF injections required for myopic choroidal neovascularization. Ocular and systemic adverse events were also summarized.

RESULTS

Literature search yielded 18 comparative studies and 83 noncomparative studies. Superiority of anti-VEGF over photodynamic therapy in a 24-month period was confirmed by 2 RCTs and 6 non-RCT studies. The influence of combined photodynamic therapy was uncertain based on two non-RCT studies. Three non-RCT studies showed that the visual outcomes of 3+PRN injections might be slightly better than 1+PRN injections within 1 year. No difference was observed between ranibizumab and bevacizumab in two RCTs and one non-RCT study. The estimated visual improvement was two lines on average. Adverse events were uncommon as reported.

CONCLUSION

Accumulating evidence confirmed that anti-VEGF injections should be the first-line therapy for myopic choroidal neovascularization.

Risk of choroidal neovascularization among the uveitides

PURPOSE

To evaluate the risk, risk factors, and visual impact of choroidal neovascularization (CNV) in uveitis cases.

DESIGN

Retrospective cohort study.

METHODS

Standardized medical record review at 5 tertiary centers.

RESULTS

Among 15,137 uveitic eyes (8868 patients), CNV was rare in the cases of anterior or intermediate uveitis. Among the 4041 eyes (2307 patients) with posterior uveitis or panuveitis, 81 (2.0%) had CNV at presentation. Risk factors included posterior uveitis in general and specific uveitis syndromes affecting the outer retina-retinal pigment epithelium-choroid interface. Among the 2364 eyes (1357 patients) with posterior uveitis or panuveitis and free of CNV at the time of cohort entry, the cumulative 2-year incidence of CNV was 2.7% (95% confidence interval [CI], 1.8% to 3.5%). Risk factors for incident CNV included currently active inflammation (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.26 to 3.60), preretinal neovascularization (aHR, 3.19; 95% CI, 1.30 to 7.80), and prior diagnosis of CNV in the contralateral eye (aHR, 5.79; 95% CI, 2.77 to 12.09). Among specific syndromes, the incidence was greater in Vogt-Koyanagi-Harada syndrome (aHR, 3.37; 95% CI, 1.52 to 7.46) and punctate inner choroiditis (aHR, 8.67; 95% CI, 2.83 to 26.54). Incident CNV was associated with a 2-line loss of visual acuity (+0.19 logarithm of the minimal angle of resolution units; 95% CI, 0.079 to 0.29) from the preceding visit.

CONCLUSIONS

CNV is an uncommon complication of uveitis associated with visual impairment that occurs more commonly in forms affecting the outer retina-retinal pigment epithelium-choroid interface, during periods of inflammatory activity, in association with preretinal neovascularization, and in second eyes of patients with unilateral CNV. Because CNV is treatable, a systematic approach to early detection in high-risk patients may be appropriate.

Vascular endothelial growth factor gene and the response to anti-vascular endothelial growth factor treatment for choroidal neovascularization in high myopia

PURPOSE

To investigate the association between the vascular endothelial growth factor (VEGF) gene polymorphism and the response to anti-VEGF treatment for choroidal neovascularization (CNV) in highly myopic eyes.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 357 unrelated highly myopic Japanese patients with axial lengths ≥26.0 mm in both eyes were eligible, and 83 patients who received anti-VEGF therapy for CNV and could be followed for more than 1 year were included.

METHODS

We genotyped a functional single nucleotide polymorphism in the VEGF gene, rs2010963. The associations between the distribution of the rs2010963 genotype and the number of eyes with maintained or improved visual acuity (VA) were analyzed. Furthermore, multivariable logistic regression analysis was performed to adjust for 7 possible prognostic factors, including age, sex, CNV size, CNV location, administration of loading dose, pretreatment VA, and number of additional treatments.

MAIN OUTCOME MEASURES

The primary end point was maintenance of VA, and secondary end points were progression of chorioretinal atrophy (CRA) and recurrence of CNV.

RESULTS

Mean age and mean axial length were not significantly different among 3 genotypes of rs2010963. The percentage of eyes with maintained or improved VA was significantly higher with the G allele of rs2010963 (P =0.016), and stepwise analysis revealed that both rs2010963 and CNV size were associated with VA maintenance (P =0.040 and 0.033, respectively). The secondary analysis revealed that administration of a loading dose was significantly associated with both CRA progression (P =0.031) and recurrence of CNV (P =0.020), whereas rs2010963 was not.

CONCLUSIONS

These results suggest that the VEGF polymorphism influences the VA prognosis in highly myopic eyes with CNV within 1 year after anti-VEGF treatment. This association was still observed after removing its confounding effect through CNV size. The rs2010963 polymorphism was not associated with CNV recurrence or CRA progression, which indicates that these changes are not tied to intrinsic factors and may be controllable by improving treatment methods.

Current choroidal neovascularization treatment

PURPOSE

This paper aims to describe the current situation of choroidal neovascularization (CNV) treatment.

PROCEDURES

MEDLINE (2001-2013) was searched for original research studies (phase I, II, III), abstracts and review articles concerning CNV therapy, and other related articles. Selected information from related websites was also included.

RESULTS

The management of CNV was developed through laser photocoagulation and photodynamic therapy, and has now evolved into anti-vascular endothelial growth factor (VEGF) use. Patients have achieved better visual acuity and toleration with the development of this therapy strategy. Combination therapy appears to offer a reduced retreatment frequency and long-term maintenance of the benefit with appropriate combination. Other treatment explorations with anti-inflammation and anti-VEGF are also ongoing.

CONCLUSIONS

Anti-VEGF monotherapy has become the first treatment for CNV patients. The investigation of other therapy strategies may prolong the interval of treatment and provide alternatives to CNV treatment.

Intravitreal pegaptanib sodium (Macugen) for treatment of myopic choroidal neovascularization: a morphologic and functional study

BACKGROUND

To report the morphologic and functional outcomes resulting from the use of intravitreal pegaptanib (IVP) sodium (Macugen) in patients with myopic choroidal neovascularization.

METHODS

An open-label, nonrandomized, prospective clinical trial was performed. Morphologic outcome, such as foveal thickness, was assessed by optical coherence tomography, whereas functional outcomes were assessed by best-corrected visual acuity and microperimetry. Treatment protocol consisted of 3 consecutive IVP (0.3 mg/0.05 mL; baseline, 6th week, and 12th week). Follow-up checks were scheduled at the following intervals: baseline, 18, 24, 36, and 48 weeks.

RESULTS

Twenty eyes from 20 patients were studied. All patients completed follow-up at 48 weeks. After IVP, a significant decrease in foveal thickness occurred (-20%), and at the end of follow-up, choroidal neovascularization closure was obtained in all eyes. An improvement of functional parameters was recorded in all patients (best-corrected visual acuity from 25.5 ± 8.09 letters to 45.5 ± 8.16 letters, P < 0.0001; microperimetry from 8.40 ± 2.14 dB to 10.8 ± 2.05 dB, P < 0.01). The mean number of IVP was 3, and none of patients met the re-treatment criterion during the entire follow-up period. Neither ocular nor systemic side effects were observed.

CONCLUSION

The findings demonstrate that the selective inhibition of VEGF-165 isoform by IVP is an effective treatment for myopic choroidal neovascularization.

The rationale of targeting mammalian target of rapamycin for ischemic stroke

Given the current limitation of therapeutic approach for ischemic stroke, a leading cause of disability and mortality in the developed countries, to develop new therapeutic strategies for this devastating disease is urgently necessary. As a serine/threonine kinase, mammalian target of rapamycin (mTOR) activation can mediate broad biological activities that include protein synthesis, cytoskeleton organization, and cell survival. mTOR functions through mTORC1 and mTORC2 complexes and their multiple downstream substrates, such as eukaryotic initiation factor 4E-binding protein 1, p70 ribosomal S6 kinase, sterol regulatory element-binding protein 1, hypoxia inducible factor-1, and signal transducer and activator transcription 3, Yin Ying 1, Akt, protein kinase c-alpha, Rho GTPase, serum-and gucocorticoid-induced protein kinase 1, etc. Specially, the role of mTOR in the central nervous system has been attracting considerable attention. Based on the ability of mTOR to prevent neuronal apoptosis, inhibit autophagic cell death, promote neurogenesis, and improve angiogenesis, mTOR may acquire the capability of limiting the ischemic neuronal death and promoting the neurological recovery. Consequently, to regulate the activity of mTOR holds a potential as a novel therapeutic strategy for ischemic stroke.

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

AIMS

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

METHODS

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24-78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least -6 dioptres. Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

RESULTS

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

CONCLUSIONS

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.