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Pu J, Zhuang X, Li M, Zhang X, Su Y, He G, Hao X, Wen F. Analyzing Formation and Absorption of Avascular Subretinal Hyperreflective Material in nAMD From OCTA-Based Insights. Am J Ophthalmol 2024; 267:192-203. [PMID: 38914153 DOI: 10.1016/j.ajo.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE To investigate the formation and absorption of avascular subretinal hyperreflective material (avSHRM) in neovascular age-related macular degeneration (nAMD) based on optical coherence tomography angiography (OCTA) characteristics. DESIGN Prospective cohort study. METHODS This study included patients with treatment-naive nAMD who were followed up for 3 months. Subjects were classified into an avSHRM group and a non-avSHRM group based on the presence of avSHRM at baseline. Quantitative OCTA characteristics including explant area, perimeter, vessel area, density, length, junctions, endpoints, lacunarity, maximum vessel caliber, vessel dispersion, and fractal dimension were assessed, and 3-dimensional volume and optical density ratio (ODR) of avSHRM were measured. Comparison analyses, correlation coefficients, and regression models were applied to explore factors associated with avSHRM formation and absorption. RESULTS A total of 88 eyes from 88 patients (39 female) were enrolled. Compared to the non-avSHRM group, the avSHRM group exhibited a more intricate vasculature, characterized by higher values of macular neovascularization (MNV) perimeter, vessel area, total vessel length, total number of junctions, and total number of endpoints (all P < .05), as well as the maximum vessel caliber (P < .001). In the multivariate model, which was adjusted for age, sex, and types of medications, avSHRM absorption was correlated with baseline average vessel length, maximum vessel caliber, and avSHRM ODR (standardized β = 0.274, -0.367, and -0.334; P = .049, .010, and .018, respectively), with an adjusted R² of 0.453. CONCLUSIONS Quantitative OCTA measurements can be used for assessing the dynamics of avSHRM in nAMD. Patients with more complex vasculature are at higher risk for avSHRM formation. Average vessel length, maximum vessel diameter, and avSHRM ODR play a role in its absorption.
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Affiliation(s)
- Jiaxin Pu
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xuenan Zhuang
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China; Department of Ophthalmology (X.Z.), Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Miaoling Li
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xiongze Zhang
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Yongyue Su
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Guiqin He
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xinlei Hao
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Feng Wen
- From the State Key Laboratory of Ophthalmology (J.P., X.Z., M.L., X.Z., Y.S., G.H., X.H., F.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China.
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Rush RB. One-Year Outcomes of Faricimab Treatment for Aflibercept-Resistant Neovascular Age-Related Macular Degeneration. Clin Ophthalmol 2023; 17:2201-2208. [PMID: 37547172 PMCID: PMC10404054 DOI: 10.2147/opth.s424315] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose To assess the 12-month outcomes of intravitreal faricimab (IVF) in treatment-resistant neovascular age-related macular degeneration (nAMD) subjects recalcitrant to intravitreal aflibercept (IVA). Methods This study was conducted as a retrospective interventional case series of nAMD patients receiving treatment at a single private practice institution. All included patients at baseline had undergone six or more IVA injections over the previous 12 months, four or more IVA injections over the previous 6 months, had a central macular thickness (CMT) ≥320 µm on optical coherence tomography (OCT), and were observed to have intraretinal and/or subretinal fluid on OCT assessment. The baseline exam for the purpose of this study was considered the visit in which the patient was switched from IVA to IVF. Patients were managed with a real-world treat-and-extend protocol and followed over a 12-month study period. Results A total of 54 eyes of 54 subjects were analyzed. Overall, 31.5% (17/54) of subjects attained a treatment interval ≥8 weeks and had a fluid-free macula on OCT at 12 months. The CMT on OCT decreased from 395.4 (383.5-407.3) µm at baseline to 350.0 (335.1-364.8) µm at the end of the 12-month study interval (p<0.01). There were 16.7% (9/54) of subjects who gained three or more lines of Snellen visual acuity at the end of the study. Visual acuity improved from 0.72 (0.67-0.77) logMAR (Snellen 20/105) at baseline to 0.59 (0.55-0.64) logMAR (Snellen 20/78) at the end of the study (p<0.01). Conclusion A clinically significant minority of aflibercept-resistant nAMD subjects may attain longer treatment intervals and improved outcomes at 12 months after switching to IVF when a treat-and-extend treatment protocol is utilized. IVF use may be considered whenever resistance to IVA is encountered in this patient population.
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Affiliation(s)
- Ryan B Rush
- Department of Ophthalmology, Panhandle Eye Group, Amarillo, TX, USA
- Department of Ophthalmology, Southwest Retina Specialists, Amarillo, TX, USA
- Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX, USA
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Fang L, Sheng H, Tan Y, Zhang Q. Prevalence of diabetes in the USA from the perspective of demographic characteristics, physical indicators and living habits based on NHANES 2009-2018. Front Endocrinol (Lausanne) 2023; 14:1088882. [PMID: 36960397 PMCID: PMC10028205 DOI: 10.3389/fendo.2023.1088882] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023] Open
Abstract
Objective To determine differences in DM in the U.S. population according to demographic characteristics, physical indicators and living habits. Methods 23 546 participants in the 2009 to 2018 National Health and Nutrition Examination Survey (NHANES) who were 20 year of age or older and not pregnant. All analyses used weighted samples and considered the stratification and clustering of the design. Specific indicators include length of leg (cm), BMI (kg/cm2), TCHOL (mg/dL), fasting plasma glucose (mg/dL) and comparison of means and the proportion of participants with DM. Results The prevalence of DM in the USA has been rising modestly in the past decade, and were consistent and robust for the observed differences in age, sex, and ethnicity. Compared with white participants, black participants and Mexican-American were both more likely (P<0.001) to have diabetes: 14.6% (CI, 13.6% to 15.6%) among black participants, 10.6% (CI, 9.9% to 11.3%) among white participants, and 13.5% (CI, 11.9% to 15.2%) among Mexican-American participants. The prevalence of diabetes is increasing with age, males peaked around the 60s, and women around the 70s. The overall mean leg length and TCHOL was lower in diabetics than in non-diabetics (1.07 cm, 18.67 mg/dL, respectively), while mean BMI were higher in diabetics than in non-diabetics (4.27 kg/cm2). DM had the greatest effect on decline of TCHOL in white participants (23.6 mg/dL), less of an effect in black participants (9.67 mg/dL), and the least effect in Mexican-American participants (8.25 mg/dL). Notably, smoking had great effect on percent increment of DM in whites (0.2%), and have little effect on black and Mexican-Americans. Conclusions DM is more common in the general population than might be clinically recognized, and the prevalence of DM was associated to varying degrees with many indicators of demographic characteristics, physical indicators, and living habits. These indicators should be linked with medical resource allocation and scientific treatment methods to comprehensively implement the treatment of DM.
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Affiliation(s)
- Ling Fang
- Shaanxi Key Laboratory of Chinese Medicine Encephalopathy, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Huafang Sheng
- Department of Laboratory Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Yingying Tan
- Shaanxi Key Laboratory of Chinese Medicine Encephalopathy, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Qi Zhang
- Shaanxi Key Laboratory of Chinese Medicine Encephalopathy, Shaanxi University of Chinese Medicine, Xianyang, China
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Rush RB, Rush SW. Intravitreal Faricimab for Aflibercept-Resistant Neovascular Age-Related Macular Degeneration. Clin Ophthalmol 2022; 16:4041-4046. [PMID: 36532820 PMCID: PMC9747838 DOI: 10.2147/opth.s395279] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/30/2022] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the short-term effects of intravitreal faricimab (IVF) in treatment-resistant neovascular age-related macular degeneration (nAMD) subjects previously treated with intravitreal aflibercept (IVA). METHODS A retrospective review was conducted on nAMD patients undergoing IVA therapy at a single private practice institution. Subjects were divided into Study and Control groups. Both Study and Control subjects had undergone ≥6 IVA treatments during the previous 12 months, ≥4 IVA treatments during the previous 6 months, had a central macular thickness (CMT) on optical coherence tomography (OCT) of ≥300 microns, and had observable intraretinal and/or subretinal fluid on OCT prior to group assignment. Study subjects were switched from IVA to IVF and received 3 treatments within 4 months. Control subjects remained on IVA during the same time period and received 3 treatments within 4 months. RESULTS There were a total of 55 subjects analyzed. There were 39.3% (11/28) in the Study Group and 7.4% (2/27) in the Control Group attaining a CMT of less than 300 microns without retinal fluid on OCT at the end of the 4-month study period (p = 0.004). There were 35.7% (10/28) in the Study Group and 7.4% (2/27) in the Control Group gaining 2 or more lines of visual acuity at the end of the 4-month study period (p = 0.008). CONCLUSION IVF can improve the visual and anatomic outcomes in a significant minority of treatment-resistant nAMD subjects previously managed with IVA. A greater follow-up period is needed to determine if such improvements can be maintained.
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Affiliation(s)
- Ryan B Rush
- Panhandle Eye Group, Amarillo, TX, USA
- Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX, USA
- Southwest Retina Specialists, Amarillo, TX, USA
| | - Sloan W Rush
- Panhandle Eye Group, Amarillo, TX, USA
- Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX, USA
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Wu AK, Perkins SW, Singh RP. Characterizing Early Residual Fluid in Neovascular Age-Related Macular Degeneration using Machine Learning in Routine Clinical Practice. Ophthalmol Retina 2022; 6:1154-1164. [PMID: 35760356 DOI: 10.1016/j.oret.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Neovascular age-related macular degeneration (nAMD) often requires intensive therapy with anti-VEGF injections. In prior post hoc studies, early residual fluid (ERF) after the loading phase was associated with poorer treatment outcomes. This retrospective study examined the impact of ERF on vision using machine learning (ML) methods in routine clinical practice. DESIGN Retrospective cohort. PARTICIPANTS This study included treatment-naïve patients with nAMD who were initiated on anti-VEGF between 2012 and 2018, with at least 1 year of follow-up. METHODS Overall, 286 patients with nAMD were included. An ML algorithm quantified intraretinal fluid (IRF), subretinal fluid (SRF), and total retinal fluid from OCTs. The ERF group included those with fluid at week 12 and was further stratified by fluid subtype. Paired t tests and analysis of variance compared best visual acuity (BVA) and fluid among subgroups, and a quartile analysis correlated fluid volumes to week 52 BVA. The risk of ERF was predicted from baseline factors using 3 ML methods: Ridge logistic regression, k nearest neighbors classification, and support vector classification. MAIN OUTCOME MEASURES Mean change in BVA from baseline to week 52 according to week 12 fluid status. RESULTS At week 12, 58.4% of patients had ERF. The breakdown of those in the ERF group included SRF-only (45.5%), IRF-only (21.6%), and IRF and SRF (32.9%). The ERF and ERF-free groups had similar BVA gains from baseline to week 52 (+5.7 ± 15.4 vs. +4.9 ± 18; P = 0.69). Examining specific ERF subgroups revealed no significant differences among the IRF-only (+4.6 ± 16.4), SRF-only (+5.6 ± 12.5), and IRF and SRF (+6.6 ± 18.5, P = 0.93) groups. Quartile analysis of week 12 fluid revealed no predictive pattern for BVA gains. Three ML methods were developed to predict those at risk for ERF achieved equivalent performance, with F1 score of 0.73 to 0.76. CONCLUSIONS These results diverge from prior post hoc studies, in that there was no significant difference in long-term BVA gains between ERF and ERF-free cohorts, as well as between the week 12 fluid subgroups.
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Affiliation(s)
- Anna K Wu
- Case Western University School of Medicine, Cleveland, Ohio; Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott W Perkins
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Rishi P Singh
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
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Wu AK, Perkins SW, Sachin S, Singh RP. The Impact of Early Residual Fluid After Anti-Vascular Endothelial Growth Factor Initiation in Patients With Neovascular Age-Related Macular Degeneration: A Meta-Analysis Review. Ophthalmic Surg Lasers Imaging Retina 2022; 53:506-513. [PMID: 36107627 DOI: 10.3928/23258160-20220726-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fluid in neovascular age-related macular degeneration is often used to assess patient response to anti-vascular endothelial growth factor therapy. Various studies theorize that early residual fluid (ERF), noted as persistence of intraretinal fluid and subretinal fluid after the anti-vascular endothelial growth factor loading phase (LP), may be predictive of visual outcomes. This meta-analysis examined the existing literature on the relationship between ERF and long-term visual acuity (VA) and found that those who were fluid-free after the LP tended to have the highest VA gains overall. Early intraretinal fluid appeared to be associated with reduced VA gains, whereas the impact of early sub-retinal fluid was more debated. For those with ERF, monthly or more frequent dosing regimens following the LP appeared most optimal for VA. As most studies in this review were post hoc analyses, this highlights the need for real-world studies investigating ERF and its effect on visual outcomes in neovascular age-related macular degeneration. [Ophthalmic Surg Lasers Imaging Retina 2022;53:506-513.].
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Patil NS, Mihalache A, Dhoot AS, Popovic MM, Muni RH, Kertes PJ. Association Between Visual Acuity and Residual Retinal Fluid Following Intravitreal Anti-Vascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-analysis. JAMA Ophthalmol 2022; 140:611-622. [PMID: 35551359 PMCID: PMC9100487 DOI: 10.1001/jamaophthalmol.2022.1357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/22/2022] [Indexed: 11/14/2022]
Abstract
Importance The association between residual subretinal fluid (SRF) and intraretinal fluid (IRF) and visual acuity following anti-vascular endothelial growth factor (VEGF) treatment is not well understood. Objective To examine the association of residual retinal fluid, SRF, and IRF with visual acuity following anti-VEGF treatment in patients with neovascular age-related macular degeneration (nAMD). Data Sources A systematic literature search was performed from January 2005 to August 2021 using Ovid MEDLINE, Embase, and the Cochrane Library. Study Selection Peer-reviewed articles reporting on visual acuity stratified by the presence or absence of any residual SRF, IRF, or any retinal fluid at last study observation after intravitreal bevacizumab, ranibizumab, aflibercept, or brolucizumab in patients with nAMD were included. Studies that were noncomparative, included fewer than 10 eyes, or reported on other anti-VEGF agents were excluded. Data Extraction and Synthesis Two independent reviewers conducted data extraction and synthesis. The Cochrane risk of bias tool 2 and ROBINS-I were used to assess risk of bias and GRADE evaluation was conducted to assess certainty of evidence. Main Outcomes and Measures Primary outcomes were BCVA at last study observation, change in BCVA from baseline, and retinal thickness at last study observation. Results In this systematic review and meta-analysis, 11 studies (6 randomized clinical trials [RCTs]) comprising 3092 eyes were included in our analysis. Across all included studies, the BCVA of eyes with residual SRF was better than eyes without SRF (weighted mean difference [WMD], 3.1 letter score; 95% CI, 0.05 to 6.18; P = .05; GRADE, low certainty of evidence; 6 studies; 1931 eyes) but similar in RCTs (WMD, 2.7 letter score; 95% CI, -2.40 to 7.84; P = .30; GRADE, low certainty of evidence; 3 studies; 1406 eyes). The BCVA of eyes with residual IRF was worse than that of eyes without IRF (WMD, -8.2 letter score; 95% CI, -11.79 to -4.50; P < .001; GRADE, low; 7 studies; 2114 eyes). Conclusions and Relevance The findings suggest that the presence of residual SRF was associated with slightly better BCVA at last study observation; however, baseline differences in BCVA existed and this conclusion was primarily driven by 1 study. The presence of residual IRF was associated with substantially worse BCVA at last study observation and less improvement of BCVA from baseline. The conclusions are limited by the inclusion of data from observational studies, heterogeneity, and a low certainty of evidence.
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Affiliation(s)
- Nikhil S. Patil
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mihalache
- Department of Basic Medical Sciences, Faculty of Sciences, University of Western Ontario, London, Ontario, Canada
| | - Arjan S. Dhoot
- Undergraduate Medical Education, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marko M. Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Rajeev H. Muni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Ophthalmology, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Peter J. Kertes
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Efficacy Outcomes of Brolucizumab Versus Aflibercept in Neovascular Age-Related Macular Degeneration Patients with Early Residual Fluid. Ophthalmol Retina 2022; 6:377-386. [PMID: 34968756 DOI: 10.1016/j.oret.2021.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare the outcomes of brolucizumab versus aflibercept in patients with neovascular age-related macular degeneration with early residual fluid in the HAWK and HARRIER studies. DESIGN Post hoc analysis using pooled data from the phase 3 studies HAWK (NCT02307682) and HARRIER (NCT02434328). PARTICIPANTS The early residual fluid cohort for this post hoc analysis consisted of patients treated with either brolucizumab 6 mg (n = 730 patients) or aflibercept 2 mg (n = 729 patients) and who had the presence of intraretinal fluid (IRF), subretinal fluid (SRF), or both verified by spectral-domain OCT at the week 12 clinic visit. METHODS After 3 initial monthly doses, patients treated with brolucizumab received injections every 12 weeks (q12w) or every 8 weeks (q8w), depending on the neovascular age-related macular degeneration disease activity, whereas patients treated with aflibercept received fixed q8w dosing. MAIN OUTCOME MEASURES The mean change in best-corrected visual acuity and central subfield thickness (CST) from the baseline to that at weeks 48 and 96, the proportion of patients treated with brolucizumab remaining on q12w dosing to week 96, and the change in fluid status at weeks 48 and 96. RESULTS All analyses were based on 149 of 730 (20.4%) patients treated with brolucizumab and 217 of 729 (29.8%) patients treated with aflibercept with spectral-domain OCT-verified IRF, SRF, or both at their week 12 visit. The best-corrected visual acuity improvements from baseline at weeks 48 and 96 were numerically better for brolucizumab than for aflibercept (least square mean [standard error] 7.9 ± 1.1 vs. 4.6 ± 0.9 and 7.4 ± 1.3 vs. 2.9 ± 1.1 letters, respectively). The CST reductions from baseline at weeks 48 and 96 were consistently greater with brolucizumab than with aflibercept (least square mean [standard error], μm: -194.9 ± 13.7 vs. -123.9 ± 11.3; and -201.1 ± 14.5 vs. -134.2 ± 12.0, respectively). At weeks 48 and 96, patients treated with brolucizumab had a 40.4% and 31.3% probability of remaining on q12w dosing intervals, respectively. Fewer patients treated with brolucizumab had remaining IRF, SRF, or both at weeks 48 and 96 than patients treated with aflibercept (59.1% vs. 75.1% and 49.0% vs. 60.4%, respectively). CONCLUSIONS In patients with early residual fluid, defined as spectral-domain OCT-verified IRF, SRF, or both at the week 12 clinic visit, brolucizumab resolved the early residual fluid and reduced CST more effectively than aflibercept, resulting in greater best-corrected visual acuity improvements through week 96 of anti-VEGF treatment.
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Jhaveri C, Wykoff CC, Khanani AM, Eandi CM, Chang A, B G, Gedif KA, Singer M. Early Residual Fluid-Free Status and Long-Term BCVA Outcomes: A Treatment Agnostic, Post Hoc Analysis of Pooled HAWK and HARRIER Data. Am J Ophthalmol 2022; 236:12-19. [PMID: 34695400 DOI: 10.1016/j.ajo.2021.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of this study was to determine associations between early residual fluid (ERF)-free status and improved long-term visual outcomes. DESIGN This was a retrospective clinical cohort study from a post hoc analysis of 2 phase III clinical trials' data. METHODS Independent of treatment allocation, patients from the multicenter, prospective, randomized, double-masked HAWK and HARRIER trials who received either brolucizumab 6 mg or aflibercept 2 mg were split into 2 cohorts depending on the presence or absence of ERF at week 12. In addition, similar analyses were performed on the presence or absence of early residual intraretinal fluid (IRF) and subretinal fluid (SRF) at week 12. The 2 groups, ERF-free (n = 1051) and ERF (n = 366) patients were compared. Changes from baseline in best corrected visual acuity (BCVA) and central subfield thickness (CST) were determined. RESULTS From week 12 to 96, patients who were ERF free had greater least squares (LS) mean increases from baseline for BCVA and CST compared to ERF patients. Greater LS mean differences in BCVA from week 12 to 96 were noted between ERF-free and ERF patients. A greater proportion of patients in the ERF-free cohort reported a ≥5, ≥10, or ≥15 letter improvement, and a higher proportion reported BCVA ≥70 letters from baseline to week 96 compared to patients with fluid. CONCLUSIONS Improvements in visual outcomes in ERF-free patients were greater than in ERF patients occurring as early as 4 weeks (week 12) after the last loading dose and continued to week 96. Therefore, ERF status may be a useful indicator of anti-vascular endothelial growth factor treatment response.
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Affiliation(s)
- Chirag Jhaveri
- Retina Consultants of Austin (C.J.), Austin Research Center for Retina, Austin, Texas, USA; Dell Medical School (C.J.), University of Texas at Austin, Austin, Texas, USA
| | - Charles C Wykoff
- Retina Consultants of Texas (C.C.W.), Retina Consultants of America; Blanton Eye Institute (C.C.W), Houston Methodist Hospital, Houston, Texas, USA
| | - Arshad M Khanani
- Sierra Eye Associates (A.M.K.), Reno, Nevada, USA; Reno School of Medicine (A.M.K.), The University of Nevada, Reno, Nevada, USA
| | - Chiara M Eandi
- Department of Surgical Science (C.M.E.), University of Torino, Torino, Italy; Department of Ophthalmology (C.M.E.), University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Andrew Chang
- Sydney Retina Clinic (A.C.); Sydney Eye Hospital; Save Sight Institute, University of Sydney, Sydney, Australia
| | - Guruprasad B
- Novartis Pharmaceuticals (G.B, K.A.G.), East Hanover, New Jersey, USA
| | | | - Michael Singer
- Medical Center Ophthalmology Associates (M.S), University of Texas Health Center, San Antonio, Texas, USA.
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To investigate treat and extend versus pro re nata regimen in neovascular age-related macular degeneration: results from the IDEM study. Graefes Arch Clin Exp Ophthalmol 2022; 260:2149-2156. [PMID: 35020019 DOI: 10.1007/s00417-021-05543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 12/17/2021] [Accepted: 12/27/2021] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The purpose of this study is to report the 24-month outcomes of a pro re nata (PRN) compared with a treat and extend (T&E) regimen in patients previously treated for neovascular age-related macular degeneration (nAMD). METHODS This was a 2-year prospective, single-center study. Previously treated patients for nAMD were randomized into two regimen groups: T&E and PRN groups. Main outcome measured was change in best corrected visual acuity (BCVA) from baseline to month 24. Secondary outcomes encompassed anatomical features such as central retinal thickness (CRT), number of intravitreal injections (IVI), and visits required. RESULTS A total of 124 eyes received the T&E (n = 61) or PRN (n = 63) regimen. At month 24, the mean BCVA change was -4.4 early treatment diabetic retinopathy study (ETDRS) letters (T&E) and -3.4 ETDRS letters (PRN), with a difference of +1.1 ETDRS letters (95% CI [-2.25]; p = 0.006). The mean change in CRT was -10.6 µm (T&E) and -7.9 µm (PRN), with a difference of +2.6 µm (95% CI [+19.2]; p = 0.004). The T&E group had received a mean of +4.6 more injections (95% CI [-7.06; -2.12]; p < 0.001) at month 24. CONCLUSION There was statistically proven non-inferiority between the PRN and T&E regimens in terms of visual and anatomical outcomes at 24 months, with significantly more IVI administered in the T&E regimen.
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11
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Ehlers JP, Zahid R, Kaiser PK, Heier JS, Brown DM, Meng X, Reese J, Le TK, Lunasco L, Hu M, Srivastava SK. Longitudinal Assessment of Ellipsoid Zone Integrity, Subretinal Hyperreflective Material, and Subretinal Pigment Epithelium Disease in Neovascular Age-Related Macular Degeneration. Ophthalmol Retina 2021; 5:1204-1213. [PMID: 33640493 PMCID: PMC8387490 DOI: 10.1016/j.oret.2021.02.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/01/2021] [Accepted: 02/22/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To assess longitudinally the effect of anti-vascular endothelial growth factor (VEGF) treatment on ellipsoid zone (EZ) integrity, subretinal hyperreflective material (SHRM), and the sub-retinal pigment epithelium (sub-RPE) compartment in eyes with neovascular age-related macular degeneration (nAMD). DESIGN Post hoc analysis of the OSPREY clinical trial, a prospective, double-masked, phase 2 study comparing brolucizumab 6 mg with aflibercept 2 mg over 56 weeks. PARTICIPANTS Participants with treatment-naïve nAMD at the initiation of the trial were included in the analysis. METHODS Eyes were evaluated with spectral-domain OCT at 4-week intervals in the OSPREY trial (n = 81). Spectral-domain OCT scans collected from each visit were segmented automatically using a proprietary, machine learning-enabled higher-order feature-extraction platform for retinal layer, SHRM, and sub-RPE boundary lines, which were evaluated and corrected as needed by masked trained graders. The current analysis focused only on patients evaluated with the Cirrus (Zeiss) platform (n = 28). MAIN OUTCOME MEASURES Outcome measures included change from baseline in EZ-RPE (i.e., photoreceptor outer segment) volume, EZ-RPE central subfield thickness (CST), total EZ attenuation, SHRM volume, SHRM CST, and total sub-RPE volume. The correlation between each of these measures and best-corrected visual acuity (BCVA) at each visit was evaluated. RESULTS EZ-RPE volume and EZ-RPE CST showed significant increases, and total EZ attenuation, SHRM volume, SHRM CST, and total sub-RPE volume showed significant decreases from baseline at each visit from weeks 4 through 56 (P < 0.05 at each visit). Ellipsoid zone integrity measures and SHRM volume correlated significantly with BCVA at most visits (P < 0.05). No significant correlation was found between total sub-RPE volume and BCVA. CONCLUSIONS EZ integrity, SHRM, and sub-RPE disease features in eyes with nAMD showed improvement as early as week 4 of anti-VEGF treatment. EZ integrity measures and SHRM volume were predictors of visual acuity over the first year of treatment.
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Affiliation(s)
- Justis P Ehlers
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Robert Zahid
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | - Peter K Kaiser
- Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Xiangyi Meng
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | - Jamie Reese
- Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Thuy K Le
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leina Lunasco
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ming Hu
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sunil K Srivastava
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Center for Ocular Research and Evaluation, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
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Yeung L, Hsieh YT, Yang CH, Chen LJ, Chen SJ, Cheng CK, Sheu SJ, Tsai CY, Wu TT, Wu WC, Chen SN. Management of neovascular age-related macular degeneration: Taiwan expert consensus. J Formos Med Assoc 2021; 120:2061-2071. [PMID: 34274193 DOI: 10.1016/j.jfma.2021.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 04/20/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022] Open
Abstract
Neovascular age-related macular degeneration (nAMD) is a leading cause of irreversible vision loss. The present consensus provides suggestions on diagnosis, evaluation, treatment, and follow-up strategies for nAMD from a panel of 11 practicing ophthalmologists. The experts suggest that the baseline visit for nAMD management should include a comprehensive ophthalmologic examination via a multimodal approach consisting of visual and anatomical evaluation. Patients diagnosed with nAMD should be subjected to treatment with the goal of maintaining visual function while diminishing anatomical disease activity and minimizing treatment burden. Currently, anti-VEGF therapy is the main treatment strategy for nAMD, and evaluation involving comprehensive ophthalmologic examination within 1 month of completion of the loading phase comprising three monthly injections is recommended to guide subsequent management. Either a treat-and-extend or pro re nata regimen can be considered for the maintenance phase of anti-VEGF therapy, and the regimen should be chosen and adjusted according to disease activity, reimbursement criteria, financial burden, and patient preferences. In the event of inactive nAMD or poor treatment outcomes, after thorough evaluation and patient education, anti-VEGF therapy may be stopped. The consensus provides practical nAMD management guidelines for ophthalmologists and fellow healthcare professionals.
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Affiliation(s)
- Ling Yeung
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ting Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lee-Jen Chen
- Department of Ophthalmology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Kuo Cheng
- Department of Ophthalmology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan; Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Yao Tsai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Ophthalmology, Taipei City Hospital, Taipei, Taiwan
| | - Tsung-Tien Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Chi Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - San-Ni Chen
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan; College of Medicine, Chung-Shan Medical University, Taichung, Taiwan; Department of Optometry, College of Nursing and Health Science, Da-Yeh University, Changhua, Taiwan.
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13
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Effect of retinal thickness variability on visual outcomes and fluid persistence in neovascular age-related macular degeneration: a post hoc analysis of the HAWK and HARRIER studies. Retina 2021; 42:511-518. [PMID: 34923515 DOI: 10.1097/iae.0000000000003349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the association between central subfield thickness (CST) variability and visual outcomes in eyes with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor therapies. METHODS In this post hoc, treatment-agnostic analysis, patients (N=1752) were grouped into quartiles of increasing CST variation. The association between CST variability and best-corrected visual acuity (BCVA) was measured from baseline, or from the end of the loading phase, until the end of the study using a multilevel modelling for repeated measures model. The association between CST variability and the presence of retinal fluid was also assessed. RESULTS Increased CST variability was associated with worse BCVA outcomes at the end of study, with a least square mean difference in BCVA of 8.9 ETDRS letters between the quartiles with the lowest and highest CST variability at the final visit. Increased variability was also associated with a higher mean fraction of visits with the presence of fluid. CONCLUSIONS More stable CST was associated with better visual outcomes at the end of treatment suggesting that CST variability may provide a more reliable prognostic marker of visual outcomes than the presence of fluid alone, with potential to enhance the clinical care of nAMD patients.
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14
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Łądkowska J, Gawęcki M, Szołkiewicz M. Efficacy of Anti-Vascular Endothelial Growth Factor Treatment in Neovascular Age-Related Macular Degeneration and Systemic Cardiovascular Risk Factors. J Clin Med 2021; 10:jcm10194595. [PMID: 34640613 PMCID: PMC8509122 DOI: 10.3390/jcm10194595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 01/01/2023] Open
Abstract
This study evaluates whether the presence of cardiovascular risk factors (CRFs) affects functional and morphological responses to anti–vascular endothelial growth factor (VEGF) therapy in patients with neovascular age-related macular degeneration (nAMD). Retrospective analysis included 98 treatment-naïve eyes followed for at least 12 months. Patients received intravitreal injections of ranibizumab or aflibercept with the dosage and regimen set according to each manufacturer’s recommendations for their product. Parameters evaluated at each follow-up visit included best-corrected visual acuity and central retinal thickness. Additionally, the presence of the following CRFs was evaluated: male sex, age of older than 70 years, history of current or past smoking, systemic arterial hypertension, diabetes mellitus, total hypercholesterolemia, low-density lipoprotein hypercholesterolemia, high-density lipoprotein concentration of 45 mg/dL or less, atherogenic dyslipidemia, family history of cardiovascular disease, and chronic kidney disease. A statistically significant better letter gain in visual acuity (p = 0.012) and greater percentage of responders (p = 0.035)—that is patients in whom best corrected visual acuity was stabilized or improved at 12 months—were noted among patients without a diagnosis of arterial hypertension. A statistically significant better mean visual improvement was also achieved in patients with higher total cholesterol plasma levels (p = 0.004), but this finding was not reflected in the significantly higher percentage of responders. The presence of remaining analyzed risk factors did not substantially affect the results of treatment. Systemic arterial hypertension is an independent factor leading to a poor functional outcome following anti-VEGF therapy in patients with nAMD. Effects of anti-VEGF treatment in patients with high total cholesterol levels should be analyzed in further research.
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Affiliation(s)
- Joanna Łądkowska
- Department of Ophthalmology, Pomeranian Hospitals, 84-200 Wejherowo, Poland;
| | - Maciej Gawęcki
- Dobry Wzrok Ophthalmological Clinic, 80-280 Gdansk, Poland
- Correspondence:
| | - Marek Szołkiewicz
- Department of Cardiology and Interventional Angiology, Kashubian Center for Heart and Vascular Diseases, Pomeranian Hospitals, 84-200 Wejherowo, Poland;
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15
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Phan LT, Broadhead GK, Hong TH, Chang AA. Predictors of Visual Acuity After Treatment of Neovascular Age-Related Macular Degeneration - Current Perspectives. Clin Ophthalmol 2021; 15:3351-3367. [PMID: 34408393 PMCID: PMC8364912 DOI: 10.2147/opth.s205147] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
Visual acuity is a key outcome measure in the treatment of neovascular age-related macular degeneration (nAMD) using anti-vascular endothelial growth factor agents. Large variations in visual responses between individuals within clinical trials and real-world studies may relate to underlying differences in patient and treatment factors. Most notably, a better baseline visual acuity, younger age and smaller choroidal neovascularization lesion size have been strongly associated with achieving better visual outcomes. In addition, there is emerging evidence for other roles including genetic factors and anatomical variables such as fluid status. Apart from patient-related factors, treatments that favor a higher number of injections tend to provide better visual outcomes. Overall, the identification of predictive factors does not currently play an essential role in the clinical management of patients with nAMD. However, they have allowed for the understanding that early detection, timely management and close monitoring of the disease are required to achieve optimal visual outcomes. Further investigation into predictive factors alongside the development of novel therapeutic agents may one day provide a means to accurately predict patient outcomes. Treatment regimens that offer flexible dosing patterns such as the treat-and-extend strategy currently provide a degree of personalization during treatment.
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Affiliation(s)
- Long T Phan
- Sydney Retina, Sydney, New South Wales, Australia.,Discipline of Orthoptics, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Broadhead
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew A Chang
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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16
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Kaiser PK, Wykoff CC, Singh RP, Khanani AM, Do DV, Patel H, Patel N. RETINAL FLUID AND THICKNESS AS MEASURES OF DISEASE ACTIVITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2021; 41:1579-1586. [PMID: 33949342 PMCID: PMC8297539 DOI: 10.1097/iae.0000000000003194] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Retinal fluid and thickness are important anatomical features of disease activity in neovascular age-related macular degeneration, as evidenced by clinical trials that have used these features for inclusion criteria, retreatment criteria, and outcome measures of the efficacy of intravitreal injections of anti-vascular endothelial growth factor agents. METHODS A literature review of anatomical measures of disease activity was conducted. RESULTS Treatment goals for neovascular age-related macular degeneration include improving/maintaining vision by drying the retina, and several analyses have evaluated the relationship between visual function and anatomy. The change in retinal thickness has been found to correlate with the change in the visual acuity, and variation in retinal thickness may predict visual acuity outcomes. In addition, specific fluid compartments may have different prognostic values. For example, the presence of intraretinal fluid has been associated with poorer visual acuity, whereas the presence of subretinal fluid has been associated with better visual acuity. Retinal fluid and thickness are important for selecting dosing interval durations in clinical trials and clinical practice. CONCLUSION Retinal thickness and retinal fluid are common anatomical measures of disease activity in neovascular age-related macular degeneration. Further research is required to fully elucidate the relationship between anatomical features and visual outcomes in neovascular age-related macular degeneration.
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Affiliation(s)
- Peter K. Kaiser
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Charles C. Wykoff
- Retina Consultants of Texas, Retina Consultants of America, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas;
| | - Rishi P. Singh
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Arshad M. Khanani
- Sierra Eye Associates, Reno, Nevada
- University of Nevada, Reno School of Medicine, Reno, Nevada
| | - Diana V. Do
- Byers Eye Institute, Stanford University, Palo Alto, California; and
| | - Hersh Patel
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | - Nikhil Patel
- Novartis Pharmaceuticals, East Hanover, New Jersey
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17
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Ogura Y, Jaffe GJ, Cheung CMG, Kokame GT, Iida T, Takahashi K, Lee WK, Chang AA, Monés J, D'Souza D, Weissgerber G, Gedif K, Koh A. Efficacy and safety of brolucizumab versus aflibercept in eyes with polypoidal choroidal vasculopathy in Japanese participants of HAWK. Br J Ophthalmol 2021; 106:994-999. [PMID: 34301613 PMCID: PMC9234403 DOI: 10.1136/bjophthalmol-2021-319090] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/28/2021] [Indexed: 11/25/2022]
Abstract
Purpose To compare the efficacy and safety of brolucizumab versus aflibercept in eyes with polypoidal choroidal vasculopathy (PCV) over 96 weeks in the HAWK study. Design HAWK was a global, 2-year, randomised, double-masked, multicentre phase III trial in participants with neovascular age-related macular degeneration. Methods Of the Japanese participants with PCV, 39 received brolucizumab 6 mg and 30 received aflibercept 2 mg. After 3 monthly loading doses, brolucizumab-treated eyes received an injection every 12 weeks (q12w) but were adjusted to q8w if disease activity was detected. Aflibercept-treated eyes received fixed q8w dosing. Mean change in best-corrected visual acuity (BCVA), the proportion of participants on q12w, retinal thickness, retinal fluid changes and safety were assessed to Week 96. Results Mean change in BCVA (early treatment diabetic retinopathy study (ETDRS) letters) from baseline to week 48/week 96 was+10.4/+11.4 for brolucizumab and +11.6/+11.1 for aflibercept. For brolucizumab-treated eyes, the probability of only q12w dosing after loading through week 48 was 76%, and 68% through week 96. Fluid resolution was greater with brolucizumab than aflibercept: respective proportions of eyes with intraretinal fluid and/or subretinal fluid were 7.7% and 30% at week 48% and 12.8% and 16.7% at week 96. Brolucizumab exhibited an overall well-tolerated safety profile despite a higher rate of intraocular inflammation compared with aflibercept. Conclusion In Japanese eyes with PCV, brolucizumab q12w/q8w monotherapy resulted in robust and consistent BCVA gains that were comparable to q8w aflibercept dosing. Anatomical outcomes favoured brolucizumab over aflibercept, with 76% of brolucizumab participants maintained on q12w dosing after loading to week 48.
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Affiliation(s)
- Yuichiro Ogura
- Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Glenn J Jaffe
- Department of Ophthalmology, Duke University, Durham, North Carolina, USA
| | | | - Gregg T Kokame
- University of Hawaii School of Medicine, Honolulu, Hawaii, USA
| | - Tomohiro Iida
- Department of Ophthalmology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kanji Takahashi
- Department of Ophthalmology, Kansai Medical University, Moriguchi, Japan
| | - Won Ki Lee
- Nune Eye Hospital, Seoul, Republic of Korea
| | - Andrew A Chang
- Sydney Retina Clinic, Sydney Eye Hospital, Sydney University, Sydney, New South Wales, Australia
| | - Jordi Monés
- Institut de la Màcula, Barcelona, Spain.,Barcelona Macula Foundation, Barcelona, Spain
| | | | | | | | - Adrian Koh
- Eye and Retina Surgeons, Camden Medical Centre, Singapore
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18
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Costanzo E, Parravano M, Giannini D, Borrelli E, Sacconi R, Querques G. Imaging Biomarkers of 1-Year Activity in Type 1 Macular Neovascularization. Transl Vis Sci Technol 2021; 10:18. [PMID: 34111264 PMCID: PMC8131998 DOI: 10.1167/tvst.10.6.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the predictive value of optical coherence tomography (OCT) and OCT angiography (OCTA) parameters at baseline on lesion's activity at the 1-year follow-up in type 1 macular neovascularizations (MNVs) treated with 1-year fixed regimen of intravitreal aflibercept injections (q8 IAIs). Methods All patients were imaged by structural OCT to evaluate central macular thickness (CMT), subretinal fluid (SRF), subretinal hyper-reflective material (SHRM), intraretinal fluid (IRF) and intraretinal hyper-reflective dots (HRDs), and by Swept-Source OCTA to measure baseline MNV area, perfusion density (PD), vessel length density (VLD), and vessel diameter index. At the end of q8 IAI, patients were classified in two groups: active-MNV (A-MNV) and inactive-MNV (I-MNV), considering the OCT signs of activity. Three binary logistic regression models were developed: (1) OCT-based, (2) OCTA-based, and (3) OCT/OCTA-based model. Results Thirty-one treatment-naïve type 1 MNVs were enrolled (13 A-MNV and 18 I-MNV). No differences were observed in baseline OCT and OCTA characteristics between A-MNV and I-MNV. Among the models developed, model 3 that combined OCT/OCTA parameters showed a performance of 87.5% and excellent sensitivity for A-MNV lesions (100%). By analyzing the model, the A-MNV group appears more likely to show at baseline SRF, greater CMT, wider MNV area, and lower PD and VLD compared to I-MNV. Conclusions Our study demonstrated that the combination of baseline OCT and OCTA parameters allowed to achieve a good models’ performance in the prediction of MNV activity permitting to correctly classifying the active lesions at the end of follow-up period, with excellent sensitivity. Translational Relevance OCT/OCTA could integrate statistical models potentially useful for artificial intelligence.
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Affiliation(s)
| | | | | | - Enrico Borrelli
- Department of Ophthalmology, IRCCS Ospedale San Raffaele, University Vita-Salute, Milan, Italy
| | - Riccardo Sacconi
- Department of Ophthalmology, IRCCS Ospedale San Raffaele, University Vita-Salute, Milan, Italy
| | - Giuseppe Querques
- Department of Ophthalmology, IRCCS Ospedale San Raffaele, University Vita-Salute, Milan, Italy
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19
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Mettu PS, Allingham MJ, Cousins SW. Incomplete response to Anti-VEGF therapy in neovascular AMD: Exploring disease mechanisms and therapeutic opportunities. Prog Retin Eye Res 2021; 82:100906. [PMID: 33022379 PMCID: PMC10368393 DOI: 10.1016/j.preteyeres.2020.100906] [Citation(s) in RCA: 162] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
Intravitreal anti-vascular endothelial growth factor (VEGF) drugs have revolutionized the treatment of neovascular age-related macular degeneration (NVAMD). However, many patients suffer from incomplete response to anti-VEGF therapy (IRT), which is defined as (1) persistent (plasma) fluid exudation; (2) unresolved or new hemorrhage; (3) progressive lesion fibrosis; and/or (4) suboptimal vision recovery. The first three of these collectively comprise the problem of persistent disease activity (PDA) in spite of anti-VEGF therapy. Meanwhile, the problem of suboptimal vision recovery (SVR) is defined as a failure to achieve excellent functional visual acuity of 20/40 or better in spite of sufficient anti-VEGF treatment. Thus, incomplete response to anti-VEGF therapy, and specifically PDA and SVR, represent significant clinical unmet needs. In this review, we will explore PDA and SVR in NVAMD, characterizing the clinical manifestations and exploring the pathobiology of each. We will demonstrate that PDA occurs most frequently in NVAMD patients who develop high-flow CNV lesions with arteriolarization, in contrast to patients with capillary CNV who are highly responsive to anti-VEGF therapy. We will review investigations of experimental CNV and demonstrate that both types of CNV can be modeled in mice. We will present and consider a provocative hypothesis: formation of arteriolar CNV occurs via a distinct pathobiology, termed neovascular remodeling (NVR), wherein blood-derived macrophages infiltrate the incipient CNV lesion, recruit bone marrow-derived mesenchymal precursor cells (MPCs) from the circulation, and activate MPCs to become vascular smooth muscle cells (VSMCs) and myofibroblasts, driving the development of high-flow CNV with arteriolarization and perivascular fibrosis. In considering SVR, we will discuss the concept that limited or poor vision in spite of anti-VEGF may not be caused simply by photoreceptor degeneration but instead may be associated with photoreceptor synaptic dysfunction in the neurosensory retina overlying CNV, triggered by infiltrating blood-derived macrophages and mediated by Müller cell activation Finally, for each of PDA and SVR, we will discuss current approaches to disease management and treatment and consider novel avenues for potential future therapies.
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Affiliation(s)
- Priyatham S Mettu
- Duke Center for Macular Diseases, Department of Ophthalmology, Duke University School of Medicine, Durham, NC, NC.
| | - Michael J Allingham
- Duke Center for Macular Diseases, Department of Ophthalmology, Duke University School of Medicine, Durham, NC, NC
| | - Scott W Cousins
- Duke Center for Macular Diseases, Department of Ophthalmology, Duke University School of Medicine, Durham, NC, NC; Department of Immunology, Duke University School of Medicine, Durham, NC, USA
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20
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Importance of Anatomical Efficacy for Disease Control in Neovascular AMD: An Expert Opinion. Ophthalmol Ther 2021; 10:231-243. [PMID: 33840064 PMCID: PMC8079469 DOI: 10.1007/s40123-021-00342-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Neovascular age-related macular degeneration (nAMD) presents a significant treatment burden for patients, carers and medical retina services. However, significant debate remains regarding how best to manage nAMD when assessing disease activity by optical coherence tomography (OCT), and particularly the significance of different types of fluid and how the understanding of anatomical efficacy can influence treatment strategies. This article provides opinion on the practical implications of anatomical efficacy and significance of fluid in the management of nAMD and proposes recommendations for healthcare professionals (HCPs) to improve understanding and promote best practice to achieve disease control. Methods An evidence-based review was performed and an expert panel debate from the Retina Outcomes Group (ROG), a forum of retinal specialists, provided insights and recommendations on the definition, role and practical implications of anatomical efficacy and the significance of fluid at the macula in the management of nAMD. Results The ROG has developed recommendations for achieving disease control through a zero-tolerance approach to the presence of fluid in nAMD as patients who avoid fluctuations in fluid at the macula have better visual outcomes. Recommendations cover five key areas: service protocol, training, regimen, multidisciplinary teams and engagement. This approach facilitates more standardised protocol-based treatment strategies. Conclusions Targeting a fluid-free macula and aiming for disease control are essential to improve outcomes. As new therapies and technologies become available, drying the macula and maintaining disease control will become even more achievable. The outlined recommendations aim to promote best practice among HCPs and medical retina services to improve patient outcomes.
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Kodjikian L, Parravano M, Clemens A, Dolz-Marco R, Holz FG, Munk MR, Nicolò M, Ricci F, Silva R, Talks SJ, Verma RK, Zarranz-Ventura J, Zweifel SA. Fluid as a critical biomarker in neovascular age-related macular degeneration management: literature review and consensus recommendations. Eye (Lond) 2021; 35:2119-2135. [PMID: 33795837 PMCID: PMC8302650 DOI: 10.1038/s41433-021-01487-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 12/23/2022] Open
Abstract
Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France.,UMR-CNRS 5510 Matéis, Villeurbanne, INSA de Lyon, Université Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | | | - Andreas Clemens
- Novartis Pharma AG, Basel, Switzerland.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Marion R Munk
- Department of Ophthalmology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Massimo Nicolò
- University Eye Clinic of Genoa DINOGMI, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Federico Ricci
- Department of Experimental Medicine, University Tor Vergata, Rome, Italy
| | - Rufino Silva
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra (ICBR-FMUC), Coimbra, Portugal.,Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal.,Association of Innovation and Biomedical Research in Light and Image (AIBILI), Coimbra, Portugal
| | - S James Talks
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Javier Zarranz-Ventura
- Hospital Clínic de Barcelona, Barcelona, Spain.,Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sandrine A Zweifel
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
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22
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Pouw AE, Greiner MA, Coussa RG, Jiao C, Han IC, Skeie JM, Fingert JH, Mullins RF, Sohn EH. Cell-Matrix Interactions in the Eye: From Cornea to Choroid. Cells 2021; 10:687. [PMID: 33804633 PMCID: PMC8003714 DOI: 10.3390/cells10030687] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/03/2021] [Accepted: 03/16/2021] [Indexed: 02/07/2023] Open
Abstract
The extracellular matrix (ECM) plays a crucial role in all parts of the eye, from maintaining clarity and hydration of the cornea and vitreous to regulating angiogenesis, intraocular pressure maintenance, and vascular signaling. This review focuses on the interactions of the ECM for homeostasis of normal physiologic functions of the cornea, vitreous, retina, retinal pigment epithelium, Bruch's membrane, and choroid as well as trabecular meshwork, optic nerve, conjunctiva and tenon's layer as it relates to glaucoma. A variety of pathways and key factors related to ECM in the eye are discussed, including but not limited to those related to transforming growth factor-β, vascular endothelial growth factor, basic-fibroblastic growth factor, connective tissue growth factor, matrix metalloproteinases (including MMP-2 and MMP-9, and MMP-14), collagen IV, fibronectin, elastin, canonical signaling, integrins, and endothelial morphogenesis consistent of cellular activation-tubulogenesis and cellular differentiation-stabilization. Alterations contributing to disease states such as wound healing, diabetes-related complications, Fuchs endothelial corneal dystrophy, angiogenesis, fibrosis, age-related macular degeneration, retinal detachment, and posteriorly inserted vitreous base are also reviewed.
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Affiliation(s)
- Andrew E. Pouw
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Mark A. Greiner
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Razek G. Coussa
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Chunhua Jiao
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Ian C. Han
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Jessica M. Skeie
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
| | - John H. Fingert
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Robert F. Mullins
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
| | - Elliott H. Sohn
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; (A.E.P.); (M.A.G.); (R.G.C.); (C.J.); (I.C.H.); (J.M.S.); (J.H.F.); (R.F.M.)
- Institute for Vision Research, University of Iowa, Iowa City, IA 52242, USA
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23
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Ehlers JP, Clark J, Uchida A, Figueiredo N, Babiuch A, Talcott KE, Lunasco L, Le TK, Meng X, Hu M, Reese J, Srivastava SK. Longitudinal Higher-Order OCT Assessment of Quantitative Fluid Dynamics and the Total Retinal Fluid Index in Neovascular AMD. Transl Vis Sci Technol 2021; 10:29. [PMID: 34003963 PMCID: PMC7995350 DOI: 10.1167/tvst.10.3.29] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/17/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the feasibility of assessing quantitative longitudinal fluid dynamics and total retinal fluid indices (TRFIs) with higher-order optical coherence tomography (OCT) for neovascular age-related macular degeneration (nAMD). Methods A post hoc image analysis study was performed using the phase II OSPREY clinical trial comparing brolucizumab and aflibercept in nAMD. Higher-order OCT analysis using a machine learning-enabled fluid feature extraction platform was used to segment intraretinal fluid (IRF) and subretinal fluid (SRF) volumetric components. TRFI, the proportion of fluid volume against total retinal volume, was calculated. Longitudinal fluid metrics were evaluated for the following groups: all subjects (i.e. treatment agnostic), brolucizumab, and aflibercept. Results Mean IRF and SRF volumes were significantly reduced from baseline at each timepoint for all groups. Fluid feature extraction allowed high-resolution assessment of quantitative fluid burden. A greater proportion of brolucizumab participants achieved true zero and minimal fluid (total fluid volume between 0.0001 and 0.001mm3) versus aflibercept participants at week 40. True zero fluid during q12 brolucizumab dosing was achieved in 36.6% to 38.5%, similar to the 25.6% to 38.5% during the corresponding q8 aflibercept cycles. TRFI was significantly reduced from baseline in all groups. Conclusions Higher-order OCT analysis demonstrates the feasibility of fluid feature extraction and longitudinal volumetric fluid burden and TRFI characterization in nAMD, supporting a unique opportunity for fluid burden assessment and the impact on outcomes. Translational Relevance Detection and characterization of disease activity is vital for optimal treatment of nAMD. Longitudinal assessment of fluid dynamics and the TRFI provide important proof of concept for future automated tools in characterizing disease activity.
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Affiliation(s)
- Justis P. Ehlers
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Julie Clark
- Formerly Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Atsuro Uchida
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Natalia Figueiredo
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Babiuch
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Katherine E. Talcott
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Leina Lunasco
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thuy K. Le
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ming Hu
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Jamie Reese
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sunil K. Srivastava
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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Lukic M, Eleftheriadou M, Hamilton RD, Rajendram R, Bucan K, Patel PJ. Four-year outcomes of aflibercept treatment for neovascular age-related macular degeneration: Results from real-life setting. Eur J Ophthalmol 2020; 31:1940-1944. [PMID: 32586117 DOI: 10.1177/1120672120938565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND To assess long-term structural and functional outcomes of intravitreal aflibercept (Eylea®) treatment for neovascular macular degeneration (nAMD) in a real-word setting. DESIGN AND METHODS This was a retrospective, single-centre, non-randomized interventional cohort analysis. Data from treatment-naive patients with nAMD funded for treatment with intravitreal aflibercept in the period between 1 September 2013 and 28 February 2014 and who finished 4-year follow-up entered the analysis. Epidemiological data, visual acuity (VA) measured on ETDRS charts and injection numbers were recorded. Spectral domain optical coherence tomography (SD-OCT) data including presence or absence of macular fluid and automated central subfield macular thickness (CSMT) at year 1, 2, 3 and 4 were also recorded. RESULTS Ninety-four eyes of 89 patients finished 4-year follow-up. The mean number of aflibercept injections received over 4 years was 19.3. At baseline, the mean VA (SD) (Snellen) was 54.1 ± 15.5 (20/100) ETDRS letters whilst the mean CSM (SD) was 296 ± 81 µm. At 4 years, the mean VA (SD) (Snellen) was 60.4 ± 20.0 (20/63) ETDRS letters (p < 0.0001). Mean CSMT (SD) was 218 ± 79 μm (p < 0.0001). Thirty-three percent of eyes gained ⩾15 ETDRS letters at end of 4 years, and 66 (70%) eyes had no macular fluid at the end of the follow-up. CONCLUSION AND RELEVANCE The results suggest that good long-term morphological and functional treatment outcomes can be achieved using intravitreal aflibercept for nAMD in a real-life clinical setting.
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Affiliation(s)
- Marko Lukic
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Maria Eleftheriadou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Robin D Hamilton
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ranjan Rajendram
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Kajo Bucan
- Ophthalmology Department, University Hospital Centre Split, Split, Croatia
| | - Praveen J Patel
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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25
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Schroeder M, Westborg I, Lövestam Adrian M. Twelve per cent of 6142 eyes treated for neovascular age-related macular degeneration (nAMD) presented with low visual outcome within 2 years. Analysis from the Swedish Macula Registry (SMR). Acta Ophthalmol 2020; 98:274-278. [PMID: 31517440 PMCID: PMC7216980 DOI: 10.1111/aos.14239] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/10/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To analyse characteristics from the SMR to explore the risk factors for visual acuity (VA) below ≤ 35 letters of the Early Treatment Diabetic Retinopathy Study (ETDRS) due to nAMD during a two-year follow-up. METHODS This study evaluates 6142 treatment-naïve eyes, with focus on a subgroup of 780 eyes with final VA outcome of ≤ 35 letters, regarding differences of baseline characteristics, change of VA, number of injections and choice of drug to predict visual outcome. RESULTS Patients with final VA ≤ 35 letters were older; p < 0.0001, and received fewer injections, 6.2 ± 3.8 vs. 8.7 ± 5.4; p < 0.00001. Only 4% of all patients with ≥ 70 letters baseline VA decreased to a final VA of ≤ 35 letters. The two groups with a final VA of ≤ 35 letters and VA > 35 letters presented the following baseline lesion locations; p = 0.001; 61% vs. 57% subfoveal, 18% vs. 21% juxtafoveal and 4% vs. 6% extrafoveal. Lesion size, in the group with final VA ≤ 35 letters, was 2805 ± 2093 μm vs. 2440 ± 1637 μm in the group with a VA of > 35 letters; p = 0.005. A logistic regression analysis including baseline VA, best- or worse-seeing eye, age, membrane size, membrane location, symptom duration showed VA; p = < 0.0001, best- or worse-seeing eye; p = 0.026, age; p = < 0.0001, and membrane size; p = 0.002 to predict a decline of VA within 2 years. CONCLUSIONS In eyes treated for wet AMD and studied for 2 years, 12.7% of eyes declined to a final VA of ≤ 35 letters. Visual acuity, worse-seeing eye treated, age and membrane size turned out as the baseline characteristics that had significantly influenced visual decline to ≤ 35 letters during the two-year follow-up.
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Affiliation(s)
| | - Inger Westborg
- Department of Neuroscience, OphthalmologyUppsala UniversityUppsalaSweden
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26
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Arai Y, Takahashi H, Inoda S, Tan X, Sakamoto S, Inoue Y, Fujino Y, Kawashima H, Yanagi Y. Aqueous humour proteins and treatment outcomes of anti-VEGF therapy in neovascular age-related macular degeneration. PLoS One 2020; 15:e0229342. [PMID: 32155173 PMCID: PMC7064238 DOI: 10.1371/journal.pone.0229342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/04/2020] [Indexed: 11/19/2022] Open
Abstract
We aimed to construct a better model for predicting treatment outcomes of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration (nAMD) using the concentrations of aqueous humour proteins at baseline and during treatment. From the data of 48 treatment-naïve nAMD eyes that received intravitreal ranibizumab pro re nata for up to 12 months, we used the aqueous humour concentrations of C-X-C motif chemokine ligand 1 (CXCL1), CXCL12, CXCL13, interferon-γ-induced protein 10, monocyte chemoattractant protein 1 (MCP-1), C-C motif chemokine ligand 11, interleukin 6 (IL-6), IL-10, and matrix metalloproteinase 9 (MMP-9). After stepwise regression, multivariate analysis was performed to identify which predictors were significantly associated with best-corrected visual acuity (BCVA) changes and the number of injections. The results demonstrated that besides male sex (β coefficient = -0.088, P = 0.040) and central retinal thickness (β coefficient = 0.00051 per μm, P = 0.027), MCP-1 (β coefficient = 0.44, P < 0.001) and IL-10 (β coefficient = -0.16, P = 0.033) were significantly correlated with baseline BCVA. Additionally, high MCP-1 at baseline (β coefficient = -0.20, P = 0.015) and low CXCL13 at baseline (β coefficient = 0.10, P = 0.0054) were independently associated with better BCVA change at 12 months. High MMP-9 at the first injection (β coefficient = 0.56, P = 0.01), CXCL12 at the third injection (β coefficient = 0.10, P = 0.0002), and IL-10 at the third injection (β coefficient = 1.3, P = 0.001) were predictor variables associated with the increased number of injections. In conclusion, aqueous humour protein concentrations may have predictive abilities of BCVA change over 12 months and the number of injections in pro re nata treatment of exudative nAMD.
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Affiliation(s)
- Yusuke Arai
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Hidenori Takahashi
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
- Department of Ophthalmology, Graduate School of Medicine, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo, Japan
| | - Satoru Inoda
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Xue Tan
- Department of Ophthalmology, Graduate School of Medicine, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo, Japan
| | - Shinichi Sakamoto
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Yuji Inoue
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
- Department of Ophthalmology, Graduate School of Medicine, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yujiro Fujino
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo, Japan
| | - Hidetoshi Kawashima
- Department of Ophthalmology, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Yasuo Yanagi
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa-shi, Hokkaido, Japan
- Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Medical Retina, Singapore Eye Research Institute, Singapore, Singapore
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27
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Wong DT, Lambrou GN, Loewenstein A, Pearce I, Okada AA. SUSPENDING TREATMENT OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN CASES OF FUTILITY. Retina 2019; 40:1010-1020. [PMID: 31876889 PMCID: PMC7448759 DOI: 10.1097/iae.0000000000002713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide guidance on the management of patients with neovascular age-related macular degeneration and its subtypes who respond poorly to anti-vascular endothelial growth factor (anti-VEGF) therapy, and to identify cases where suspending anti-VEGF treatment may be warranted. METHODS Through a literature review and the combined knowledge and clinical experience of retinal experts, the Steering Committee of the Bayer-sponsored Vision Academy developed an algorithm for determining when to suspend anti-VEGF treatment of neovascular age-related macular degeneration in cases of futility. RESULTS Consideration of factors that may cause suboptimal response to anti-VEGF therapy, such as undertreatment or misdiagnosis of the underlying condition, and factors that may preclude continued treatment, such as injection- or drug-induced complications, is necessary for adjusting treatment protocols in patients who respond poorly to anti-VEGF. If poor response to treatment persists after switching to an alternative anti-VEGF agent and no change in response is observed after withholding treatment for a predetermined period of time ("treatment pause"), anti-VEGF treatment may be considered futile and should be suspended. CONCLUSION This publication introduces an algorithm to guide the management of neovascular age-related macular degeneration in patients showing poor response to anti-VEGF treatment and provides expert guidance for suspending anti-VEGF treatment in cases of futility.
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Affiliation(s)
- David T Wong
- University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | | | - Anat Loewenstein
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ian Pearce
- Royal Liverpool University Hospital, Liverpool, United Kingdom; and
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28
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Yu S, Rückert R, Munk MR. Treat-and-extend regimens with anti-vascular endothelial growth factor agents in age-related macular degeneration. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1698948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Siqing Yu
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Marion R. Munk
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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29
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Dugel PU, Koh A, Ogura Y, Jaffe GJ, Schmidt-Erfurth U, Brown DM, Gomes AV, Warburton J, Weichselberger A, Holz FG. HAWK and HARRIER: Phase 3, Multicenter, Randomized, Double-Masked Trials of Brolucizumab for Neovascular Age-Related Macular Degeneration. Ophthalmology 2019; 127:72-84. [PMID: 30986442 DOI: 10.1016/j.ophtha.2019.04.017] [Citation(s) in RCA: 527] [Impact Index Per Article: 105.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/20/2019] [Accepted: 04/09/2019] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Two similarly designed phase 3 trials (HAWK and HARRIER) compared brolucizumab, a single-chain antibody fragment that inhibits vascular endothelial growth factor-A, with aflibercept to treat neovascular age-related macular degeneration (nAMD). DESIGN Double-masked, multicenter, active-controlled, randomized trials. PARTICIPANTS Patients (N = 1817) with untreated, active choroidal neovascularization due to age-related macular degeneration in the study eye. INTERVENTION Patients were randomized to intravitreal brolucizumab 3 mg (HAWK only) or 6 mg or aflibercept 2 mg. After loading with 3 monthly injections, brolucizumab-treated eyes received an injection every 12 weeks (q12w) and were interval adjusted to every 8 weeks (q8w) if disease activity was present; aflibercept-treated eyes received q8w dosing. MAIN OUTCOME MEASURES The primary hypothesis was noninferiority in mean best-corrected visual acuity (BCVA) change from baseline to Week 48 (margin: 4 letters). Other key end points included the percentage of patients who maintained q12w dosing through Week 48 and anatomic outcomes. RESULTS At Week 48, each brolucizumab arm demonstrated noninferiority to aflibercept in BCVA change from baseline (least squares [LS] mean, +6.6 [6 mg] and +6.1 [3 mg] letters with brolucizumab vs. +6.8 letters with aflibercept [HAWK]; +6.9 [brolucizumab 6 mg] vs. +7.6 [aflibercept] letters [HARRIER]; P < 0.001 for each comparison). Greater than 50% of brolucizumab 6 mg-treated eyes were maintained on q12w dosing through Week 48 (56% [HAWK] and 51% [HARRIER]). At Week 16, after identical treatment exposure, fewer brolucizumab 6 mg-treated eyes had disease activity versus aflibercept in HAWK (24.0% vs. 34.5%; P = 0.001) and HARRIER (22.7% vs. 32.2%; P = 0.002). Greater central subfield thickness reductions from baseline to Week 48 were observed with brolucizumab 6 mg versus aflibercept in HAWK (LS mean -172.8 μm vs. -143.7 μm; P = 0.001) and HARRIER (LS mean -193.8 μm vs. -143.9 μm; P < 0.001). Anatomic retinal fluid outcomes favored brolucizumab over aflibercept. Overall, adverse event rates were generally similar with brolucizumab and aflibercept. CONCLUSIONS Brolucizumab was noninferior to aflibercept in visual function at Week 48, and >50% of brolucizumab 6 mg-treated eyes were maintained on q12w dosing interval through Week 48. Anatomic outcomes favored brolucizumab over aflibercept. Overall safety with brolucizumab was similar to aflibercept (ClinicalTrials.gov; NCT02307682, NCT02434328).
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Affiliation(s)
- Pravin U Dugel
- Retinal Consultants of Arizona, Phoenix, Arizona; University of Southern California, Los Angeles, California.
| | | | - Yuichiro Ogura
- Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2019; 3:CD005139. [PMID: 30834517 PMCID: PMC6419319 DOI: 10.1002/14651858.cd005139.pub4] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to AMD accounts for most cases of AMD-related severe vision loss. Intravitreous injection of anti-vascular endothelial growth factor (anti-VEGF) agents aims to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, to improve vision. OBJECTIVES • To investigate ocular and systemic effects of, and quality of life associated with, intravitreous injection of three anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) versus no anti-VEGF treatment for patients with neovascular AMD• To compare the relative effects of one of these anti-VEGF agents versus another when administered in comparable dosages and regimens SEARCH METHODS: To identify eligible studies for this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (searched January 31, 2018); MEDLINE Ovid (1946 to January 31, 2018); Embase Ovid (1947 to January 31, 2018); the Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to January 31, 2018); the International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com/editAdvancedSearch - searched January 31, 2018); ClinicalTrials.gov (www.clinicaltrials.gov - searched November 28, 2018); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en - searched January 31, 2018). We did not impose any date or language restrictions in electronic searches for trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or versus a control treatment (e.g. sham treatment, photodynamic therapy), in which participants were followed for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We compared outcomes using risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 16 RCTs that had enrolled a total of 6347 participants with neovascular AMD (the number of participants per trial ranged from 23 to 1208) and identified one potentially relevant ongoing trial. Six trials compared anti-VEGF treatment (pegaptanib, ranibizumab, or bevacizumab) versus control, and 10 trials compared bevacizumab versus ranibizumab. Pharmaceutical companies conducted or sponsored four trials but funded none of the studies that evaluated bevacizumab. Researchers conducted these trials at various centers across five continents (North and South America, Europe, Asia, and Australia). The overall certainty of the evidence was moderate to high, and most trials had an overall low risk of bias. All but one trial had been registered prospectively.When compared with those who received control treatment, more participants who received intravitreous injection of any of the three anti-VEGF agents had gained 15 letters or more of visual acuity (risk ratio [RR] 4.19, 95% confidence interval [CI] 2.32 to 7.55; moderate-certainty evidence), had lost fewer than 15 letters of visual acuity (RR 1.40, 95% CI 1.27 to 1.55; high-certainty evidence), and showed mean improvement in visual acuity (mean difference 6.7 letters, 95% CI 4.4 to 9.0 in one pegaptanib trial; mean difference 17.8 letters, 95% CI 16.0 to 19.7 in three ranibizumab trials; moderate-certainty evidence) after one year of follow-up. Participants treated with anti-VEGF agents showed improvement in morphologic outcomes (e.g. size of CNV, central retinal thickness) compared with participants not treated with anti-VEGF agents (moderate-certainty evidence). No trial directly compared pegaptanib versus another anti-VEGF agent and followed participants for one year; however, when compared with control treatments, ranibizumab and bevacizumab each yielded larger improvements in visual acuity outcomes than pegaptanib.Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same RCTs compared the same regimens with respect to gain of 15 or more letters of visual acuity (RR 0.95, 95% CI 0.81 to 1.12; high-certainty evidence) and loss of fewer than 15 letters of visual acuity (RR 1.00, 95% CI 0.98 to 1.02; high-certainty evidence); results showed similar mean improvement in visual acuity (mean difference [MD] -0.5 letters, 95% CI -1.5 to 0.5; high-certainty evidence) after one year of follow-up, despite the substantially lower cost of bevacizumab compared with ranibizumab. Reduction in central retinal thickness was less among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -11.6 μm, 95% CI -21.6 to -1.7; high-certainty evidence); however, this difference is within the range of measurement error, and we did not interpret it to be clinically meaningful.Ocular inflammation and increased intraocular pressure (IOP) after intravitreal injection were the most frequently reported serious ocular adverse events. Researchers reported endophthalmitis in less than 1% of anti-VEGF-treated participants and in no cases among control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to show a meaningful difference between groups (evidence of low- to moderate-certainty). Investigators rarely measured and reported data on visual function, quality of life, or economic outcomes. AUTHORS' CONCLUSIONS Results of this review show the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; studies show that ranibizumab and bevacizumab improved visual acuity in some eyes that received these agents and were equally effective. Available information on the adverse effects of each medication does not suggest a higher incidence of potentially vision-threatening complications with intravitreous injection of anti-VEGF agents compared with control interventions; however, clinical trial sample sizes were not sufficient to estimate differences in rare safety outcomes. Future Cochrane Reviews should incorporate research evaluating variable dosing regimens of anti-VEGF agents, effects of long-term use, use of combination therapies (e.g. anti-VEGF treatment plus photodynamic therapy), and other methods of delivering these agents.
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Affiliation(s)
- Sharon D Solomon
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | | | - Magdalena G Krzystolik
- Mass Eye and Ear InfirmaryDepartment of Ophthalmology, Retina Service1 Randall Square, Suite 203ProvidenceRhode IslandUSA02904
| | - Barbara S Hawkins
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
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PROGNOSTIC VALUE OF SUBRETINAL HYPERREFLECTIVE MATERIAL IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH BEVACIZUMAB. Retina 2018; 38:1485-1491. [PMID: 28654630 DOI: 10.1097/iae.0000000000001748] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To study the correlation between subretinal hyperreflective material (SHRM) seen on spectral domain optical coherence tomography at baseline and visual outcomes after intravitreal bevacizumab injection in neovascular age-related macular degeneration. METHODS Consecutive patient charts with treatment-naive center-involved neovascular age-related macular degeneration treated with 3 monthly intravitreal bevacizumab's, continued as needed, from 2011 to 2014 were reviewed. Baseline spectral domain optical coherence tomography SHRM parameters (height, width, area, reflectivity, border definition, and homogeneity) and established optical coherence tomography biomarkers of neovascular activity (intraretinal fluid, subretinal fluid, retinal volume, central retinal thickness, and pigment epithelial detachment presence) were collected. These baseline parameters were correlated with visual acuity at baseline, 3 and 12 months. RESULTS Seventy-three eyes of 73 patients, 47 (64.4%) having central SHRM at baseline, were studied. Mean age was 79.2 ± 8.9 years. Mean best-corrected visual acuity was 0.70 ± 0.57 logarithm of the minimum angle of resolution (20/100), 0.73 ± 0.55 (20/107), and 0.76 ± 0.63 (20/115) at baseline, 3 and 12 months, respectively. Baseline parameters with a significant predictive value of 12-month visual acuity by univariate analysis were presence of intraretinal fluid, presence of SHRM, highly reflective SHRM, well-defined SHRM borders, and thick SHRM. These parameters, with the exception of high reflectivity, were significant on multivariate regression analysis. The most predictive baseline parameter was well-defined SHRM borders. CONCLUSION This study supports the use of SHRM as a prognostic biomarker when interpreting optical coherence tomography in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision 1 year after intravitreal bevacizumab treatment were as follows: presence of central SHRM, well-defined SHRM borders, intraretinal fluid, and thicker SHRM.
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Intravitreal Dexamethasone in Patients with Wet Age-Related Macular Degeneration Resistant to Anti-VEGF: A Prospective Pilot Study. J Ophthalmol 2018; 2018:5612342. [PMID: 30151278 PMCID: PMC6087571 DOI: 10.1155/2018/5612342] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/30/2018] [Indexed: 01/01/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of a single intravitreal dexamethasone implant (DXI) combined with intravitreal antivascular endothelial growth factor (anti-VEGF) therapy, in patients with neovascular age-related macular degeneration (wet-AMD) resistant to conventional treatment. Methods In this randomized, controlled pilot study, 16 eyes of 15 patients, unresponsive to anti-VEGF therapy, were enrolled and randomly assigned to two groups: DXI + anti-VEGF (treatment group: 11 eyes) and monthly anti-VEGF alone (control group: 5 eyes). Patients were treated at baseline and followed for 6 months. Best corrected visual acuity (BCVA), optical coherence tomography (OCT) parameters, and fluorescein angiography (FA) were evaluated. Results Eight eyes (72.7%) in the treatment group and 2 eyes in the control group (40%) showed complete retinal fluid resorption (p=0.049). BCVA showed no significant change from baseline in both the treatment group and the control group (p=0.40 and p=0.29, respectively). Both median central foveal thickness (CFT) and median macular volume showed a greater reduction from baseline in the treatment group. Conclusion In patients showing an incomplete response to anti-VEGF therapy, DXI combined with intravitreal anti-VEGF seems to improve retinal fluid resorption without functional advantage. This trial is registered with ACTRN12618001102268.
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Eleftheriadou M, Gemenetzi M, Lukic M, Sivaprasad S, Hykin PG, Hamilton RD, Rajendram R, Tufail A, Patel PJ. Three-Year Outcomes of Aflibercept Treatment for Neovascular Age-Related Macular Degeneration: Evidence from a Clinical Setting. Ophthalmol Ther 2018; 7:361-368. [PMID: 29982914 PMCID: PMC6258584 DOI: 10.1007/s40123-018-0139-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction To report 3-year treatment outcomes with intravitreal aflibercept injections for neovascular age-related macular degeneration (nAMD) in routine clinical practice. Methods This was a retrospective, single-centre, non-randomized interventional case series analysis. Data from treatment-naïve patients with nAMD treated between 1 October 2013 and 31 February 2014 were included in the analysis. Data including age, gender, vision acuity (VA) measured on Early Treatment of Diabetic Retinopathy Study charts (ETDRS) and injection numbers were recorded. Spectral domain optical coherence tomography (SD-OCT) data including presence or absence of macular fluid and automated central subfield macular thickness (CSMT) at year 1, 2 and 3 were also recorded. Results Of the 157 eyes of 148 patients treated, data from 108 eyes of 102 patients were available at 3-year follow-up. The mean (± SD) age was 80.6 ± 8.3 years with a mean of 154.5 ± 5.4 weeks follow-up. The mean VA changed from 54.4 ± 16 letters at baseline to 60.3 ± 18.1 letters (VA gain 5.9 ± 13.8 letter gain) at 1 year, to 60.8 ± 17.4 letters (VA gain 6.4 ± 14.9 letters) at 2 years and to 61.0 ± 16.6 letters (VA gain 6.6 ± 15.4 letters) at 3 years. The reduction in CSMT was 77.9 ± 101.4 µm with absence of macular fluid in 71% of eyes. The total mean number of injections was 15.9 ± 6.1 at year 3. Conclusion The results suggest that good long-term morphological and functional treatment outcomes can be achieved using aflibercept for nAMD in a clinical setting. Electronic supplementary material The online version of this article (10.1007/s40123-018-0139-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Eleftheriadou
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Maria Gemenetzi
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Marko Lukic
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Philip G Hykin
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Robin D Hamilton
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ranjan Rajendram
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Adnan Tufail
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Praveen J Patel
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.
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Ashraf M, Souka A, Adelman RA. Age-related macular degeneration: using morphological predictors to modify current treatment protocols. Acta Ophthalmol 2018; 96:120-133. [PMID: 29130626 DOI: 10.1111/aos.13565] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/19/2017] [Indexed: 01/09/2023]
Abstract
To assess predictors of treatment response in neovascular age-related macular degeneration (AMD) in an attempt to develop a patient-centric treatment algorithm. We conducted a systematic search using PubMed, EMBASE and Web of Science for prognostic indicators/predictive factors with the key words: 'age related macular degeneration', 'neovascular AMD', 'choroidal neovascular membrane (CNV)', 'anti-vascular endothelial growth factor (anti-VEGF)', 'aflibercept', 'ranibizumab', 'bevacizumab', 'randomized clinical trials', 'post-hoc', 'prognostic', 'predictive', 'response' 'injection frequency, 'treat and extend (TAE), 'pro re nata (PRN)', 'bi-monthly' and 'quarterly'. We only included studies that had an adequate period of follow-up (>1 year), a single predefined treatment regimen with a predetermined re-injection criteria, an adequate number of patients, specific morphological [optical coherence tomography (OCT)] criteria that predicted final visual outcomes and injection frequency and did not include switching from one drug to the other. We were able to identify seven prospective studies and 16 retrospective studies meeting our inclusion criteria. There are several morphological and demographic prognostic indicators that can predict response to therapy in wet AMD. Smaller CNV size, subretinal fluid (SRF), retinal angiomatous proliferation (RAP) and response to therapy at 12 weeks (visual, angiographic or OCT) can all predict good visual outcomes in patients receiving anti-VEGF therapy. Patients with larger CNV, older age, pigment epithelial detachment (PED), intraretinal cysts (IRC) and vitreomacular adhesion (VMA) achieved less visual gains. Patients having VMA/VMT required more intensive treatment with increased treatment frequency. Patients with both posterior vitreous detachment (PVD) and SRF require infrequent injections. Patients with PED are prone to recurrences of fluid activity with a reduction in visual acuity (VA). A regimen that involves less intensive therapy and extended follow-up intervals (4 weekly) can be suggested for patients who show adequate visual response and have both SRF and PVD at baseline. In addition, patients with poor prognostic indicators such as IRC, VMA, large CNV size, older age and poor response at 12 weeks should be extended very cautiously with the possibility of fixed monthly/bimonthly (every 2 months) treatments if they fail to achieve dryness. Patients with PED at baseline should receive monthly/bimonthly injections of anti-VEGF therapy or can be extended very cautiously (two weekly intervals) using a TAE protocol.
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Affiliation(s)
- Mohammed Ashraf
- Ophthalmology Department; Faculty of Medicine; Alexandria University; Alexandria Egypt
| | - Ahmed Souka
- Ophthalmology Department; Faculty of Medicine; Alexandria University; Alexandria Egypt
| | - Ron A. Adelman
- Department of Ophthalmology and Visual Studies; Yale Medical School; European Vitreo-retinal Society (EVRS); New Haven Connecticut USA
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Cebeci Z, Yilmaz YC, Kir N. Real-life experience of ranibizumab therapy for neovascular age-related macular degeneration from Turkey. Int J Ophthalmol 2018; 11:267-273. [PMID: 29487818 PMCID: PMC5824083 DOI: 10.18240/ijo.2018.02.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/31/2017] [Indexed: 11/23/2022] Open
Abstract
AIM To report the real-life experience and clinical results of intravitreal ranibizumab injections to neovascular age-related macular degeneration (nAMD) in a single institution in Turkey. METHODS A total of 101 eyes of 89 patients with nAMD treated with intravitreal ranibizumab injection, followed up for at least 24mo between 2009 and June 2014, which were evaluated retrospectively. A pro re nata (PRN) treatment protocol was performed after the patients had received three, monthly loading injections. Best corrected visual acuity (BCVA) and central macular thickness measurements were evaluated at baseline and 3, 6, 12, 18, and 24mo. Number of injections and visits were also recorded. RESULTS Of the 89 patients, 34 (38.2%) were male and 55 (61.8%) were female and the mean age was 74.0±9.5 (52-91)y. The mean follow-up period was 24.82±4.4 (24-29)mo. Mean number of visits was 8.4±1.12 (7-12) in the first year and 6.6±1.33 (4-12) in the second year. The mean number of injections was 5.8±1.6 (3-10) and 4.2±2.2 (0-9) in the first and second year, respectively. The mean BCVA was 59±15.8 letters at baseline by the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The mean BCVA at 3, 12, and 24mo was 70.3±15.9, 67.9±14.3 and 67.3±16.9 letters, respectively. Improvement in visual acuity for each of the visits from baseline was found to be statistically significant (P<0.01). Visual acuity in 9 eyes at month 3, 7 eyes at month 12, and 13 eyes at month 24 did not change. The mean central macular thickness (CMT) was 437.99±164.78 µm at baseline. The mean CMT was 348.05±138.47 µm, 349.27±139.79 µm, and 344.13±146.30 µm at months 3, 12, and 24, respectively. The decrease in CMT for each of the visits from baseline was found to be statistically significant (P<0.01). CONCLUSION Anatomical and functional achievement are obtained in our study, but the mean number of injections and visits are found to be lower than the findings reported in randomized controlled clinical trials in the literature. However, the mean number of injections and visits in our study are compatible with the findings reported in real-life experience studies in the literature.
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Affiliation(s)
- Zafer Cebeci
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
| | - Yusuf Cem Yilmaz
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
| | - Nur Kir
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34104, Turkey
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Garweg JG, Niderprim SA, Russ HM, Pfister IB. Comparison of Strategies of Treatment with Ranibizumab in Newly-Diagnosed Cases of Neovascular Age-Related Macular Degeneration. J Ocul Pharmacol Ther 2017; 33:773-778. [DOI: 10.1089/jop.2017.0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Justus G. Garweg
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Sophie A. Niderprim
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Hanna Maria Russ
- University of Bern, Bern, Switzerland
- Clinic for Radiology and Nuclear Medicine, University Hospital Lübeck, Lübeck, Germany
- Department of Interventional Radiology, Lübeck, Germany
| | - Isabel B. Pfister
- Swiss Eye Institute, Rotkreuz, Switzerland
- Berner Augenklinik am Lindenhofspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
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Cui J, Sun D, Lu H, Dai R, Xing L, Dong H, Wang L, Wei D, Jiang B, Jiao Y, Jablonski MM, Charles S, Gu W, Chen H. Comparison of effectiveness and safety between conbercept and ranibizumab for treatment of neovascular age-related macular degeneration. A retrospective case-controlled non-inferiority multiple center study. Eye (Lond) 2017; 32:391-399. [PMID: 28937147 PMCID: PMC5805597 DOI: 10.1038/eye.2017.187] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/26/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose To compare the efficacy and safety of conbercept and ranibizumab when administered according to a treat-and-extend (TREX) protocol for the treatment of neovascular age-related macular degeneration (AMD) in China. Patients and methods Between May 2014 and May 2015, 180 patients were treated in a 1 : 1 ratio using conbercept or ranibizumab from four hospitals. Patients received either conbercept 0.5 mg or ranibizumab 0.5 mg intravitreal injections. Follow-up time was 1 year and treated based on a TREX approach. Main outcomes and measures include best-corrected visual acuity (BCVA), using Early Treatment Diabetic Retinopathy Study (ETDRS); number of injections; central retinal thickness (CRT); and leakage of choroidal neovascularization before and after the treatment was analyzed by fluorescein fundus angiography and indocyanine green angiography. Results The 1-year visit was completed by 168 (93.3%) of patients. Mean BCVA was equivalent between two cohorts, and were improved by 12.7±7.770 and 12.3±7.269 letters in the conbercept and ranibizumab cohorts, respectively (P=0.624). There was no significant difference in measured CRT, with a mean decrease of 191.5 μm for conbercept and 187.8 μm for ranibizumab (P=0.773). There was a statistically significant difference (P=0.001) between the drugs regarding the number of treatments: 7.4 for conbercept and 8.7 for ranibizumab. The difference in the distribution of injection intervals was statistically significant between two groups (P=0.011). During the study, there were no cases of endophthalmitis or intraocular inflammation. Conclusion Both drugs had equivalent effects in visual and anatomic gains at 1 year when administered. In the conbercept group, longer treatment intervals were achieved with more patients.
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Affiliation(s)
- J Cui
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China.,Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - D Sun
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, PR China
| | - H Lu
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - R Dai
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, PR China
| | - L Xing
- Department of Ophthalmology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihaer, Heilongjiang, PR China
| | - H Dong
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - L Wang
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - D Wei
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
| | - B Jiang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, PR China
| | - Y Jiao
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M M Jablonski
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - S Charles
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA.,Charles Retina Institute, Germantown, TN, USA
| | - W Gu
- Department of Orthopedic Surgery and BME-Campbell Clinic, University of Tennessee Health Science Center, Memphis, TN, USA.,Research Service, Veterans Affairs Medical Center, Memphis TN, USA
| | - H Chen
- Center of Integrative Research, The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang, PR China
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Wykoff CC, Ou WC, Brown DM, Croft DE, Wang R, Payne JF, Clark WL, Abdelfattah NS, Sadda SR. Randomized Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration: 2-Year Results of the TREX-AMD Study. Ophthalmol Retina 2017; 1:314-321. [PMID: 31047517 DOI: 10.1016/j.oret.2016.12.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate a prospective treat-and-extend (TREX) management strategy compared with monthly dosing with intravitreal ranibizumab (Lucentis) in neovascular age-related macular degeneration (AMD). DESIGN Prospective, randomized, multicenter clinical trial. PARTICIPANTS Sixty patients with treatment-naïve neovascular AMD randomized 1:2 to monthly or TREX cohorts. METHODS Patients with Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) of 20/32 to 20/500 (Snellen equivalent) were randomized to receive intravitreal 0.5 mg ranibizumab monthly or, according to a TREX protocol, no less frequently than every 12 weeks. After interval extension, if recurrent exudative disease was identified, this maximum interval between treatments was rechallenged according to a strict prospective protocol. MAIN OUTCOME MEASURE Change in ETDRS BCVA from baseline. RESULTS Sixty patients were enrolled and 50 completed month 24, at which point mean ETDRS BCVA letter gains were similar: 10.5 and 8.7 for the monthly and TREX cohorts, respectively (P = 0.64). At month 24, 4 patients (20%) and 12 patients (30%) in the monthly and TREX cohorts, respectively, gained at least 15 letters (P = 0.41). No monthly cohort patient lost more than 2 letters, whereas 5 TREX cohort patients (13%) lost at least 15 letters. Anatomic improvements were similar between the cohorts. Through month 24, the mean number of injections administered was 25.5 (range, 22-27) and 18.6 (range, 10-25) for the monthly and TREX cohorts, respectively (P < 0.001). Among TREX patients completing month 24, 14 (47%) were at an extension interval of 8 weeks or more, and the mean maximum tolerated extension was 8.5 weeks over the course of 2 years. Of the 26 TREX patients (65%) who demonstrated recurrent exudation upon interval extension, the first maximum extension interval was consistent in most eyes (n = 19 [73%]). CONCLUSIONS The TREX neovascular AMD management protocol used with ranibizumab in the Treat-and-Extend Protocol in Patients with Wet Age-Related Macular Degeneration (TREX-AMD) study resulted in visual and anatomic gains comparable with those obtained with monthly dosing, and most patients randomized to TREX therapy demonstrated a relatively consistent maximum extension interval.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas.
| | | | - David M Brown
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas
| | | | - Rui Wang
- Retina Consultants of Houston, Houston, Texas
| | - John F Payne
- Palmetto Retina Center, West Columbia, South Carolina
| | - W Lloyd Clark
- Palmetto Retina Center, West Columbia, South Carolina
| | - Nizar Saleh Abdelfattah
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
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Wykoff CC, Le RT, Khurana RN, Brown DM, Ou WC, Wang R, Clark WL, Boyer DS. Outcomes With As-Needed Aflibercept and Macular Laser Following the Phase III VISTA DME Trial: ENDURANCE 12-Month Extension Study. Am J Ophthalmol 2017; 173:56-63. [PMID: 27702624 DOI: 10.1016/j.ajo.2016.09.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/25/2016] [Accepted: 09/25/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine whether the efficacy and safety achieved with 2.0 mg intravitreal aflibercept injections (IAIs) for diabetic macular edema (DME) during the phase III VISTA DME trial were maintained with individualized, as-needed treatment. DESIGN Phase IV, multicenter, open-label extension study. METHODS Sixty patients completing VISTA DME elected to enter the ENDURANCE extension study. All patients received IAIs in the presence of clinically relevant DME. Patients were observed at 4-, 8-, or 12-week intervals depending on the need for treatment. Main outcome measures were mean IAIs given through month 12 (M12), the proportion of patients receiving no IAIs, and the role of macular laser in decreasing treatment burden among patients requiring ongoing IAIs. RESULTS A mean of 4.5 IAIs were administered through M12. Eighteen (30%) patients required no IAIs, and among those who met IAI retreatment criteria, a mean of 6.0 IAIs were administered through M12. Best-corrected visual acuity gains achieved during VISTA DME were maintained and stable with individualized dosing during ENDURANCE, fluctuating by <1.5 mean letters from the baseline at all time points. Likewise, mean central retinal thickness remained relatively stable during ENDURANCE. Thirty-seven (62%) patients met macular laser criteria at a mean of 19.5 weeks with no significant difference in the frequency of IAIs before or after macular laser. CONCLUSION Vision gains achieved during the 3-year VISTA DME trial were maintained through M12 of the ENDURANCE extension study with a reduced treatment frequency, with 30% of patients receiving no IAIs. No significant reduction in IAI frequency was observed after macular laser application.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas.
| | - Ryan T Le
- Retina Consultants of Houston, Houston, Texas
| | - Rahul N Khurana
- Northern California Retina Vitreous Associates, Mountain View, California
| | - David M Brown
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas
| | | | - Rui Wang
- Retina Consultants of Houston, Houston, Texas
| | - W Lloyd Clark
- Palmetto Retina Center, West Columbia, South Carolina
| | - David S Boyer
- Retina Vitreous Associates Medical Group, Los Angeles, California
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Wykoff CC, Hariprasad SM. DRCR Protocol-T: Reconciling 1- and 2-Year Data for Managing Diabetic Macular Edema. Ophthalmic Surg Lasers Imaging Retina 2016; 47:308-12. [DOI: 10.3928/23258160-20160324-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Holz FG, Tadayoni R, Beatty S, Berger A, Cereda MG, Hykin P, Staurenghi G, Wittrup-Jensen K, Altemark A, Nilsson J, Kim K, Sivaprasad S. Key drivers of visual acuity gains in neovascular age-related macular degeneration in real life: findings from the AURA study. Br J Ophthalmol 2016; 100:1623-1628. [PMID: 27030279 PMCID: PMC5256408 DOI: 10.1136/bjophthalmol-2015-308166] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/04/2016] [Accepted: 02/28/2016] [Indexed: 11/07/2022]
Abstract
Background/aims To identify predictive markers for the outcomes of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration (nAMD). Methods AURA was a retrospective, observational, multicentre study that monitored the 2-year outcomes following intravitreal ranibizumab treatment in patients with nAMD. Using stepwise regression analysis, we evaluated the association between visual acuity outcomes, baseline characteristics and resource utilisation in order to determine which variables are significantly linked to outcomes in AURA. We also examined the relationship between visual acuity outcomes and number of injections received. Results Analyses were performed using data from year 1 (n=1695) and year 2 completers (n=1184). Logistic analysis showed that baseline visual acuity score, age at start of therapy, number of ophthalmoscopies and optical coherence tomography (OCT) (combined) and number of injections (ranibizumab) were significant (p<0.05) prognostic factors for vision maintenance (loss <15 letters) or vision gain (≥15 letters). Patients who received >7 injections (in 1 year) or >14 injections (over 2 years) gained more letters and demonstrated greater vision maintenance (loss of <15 letters) than patients who received fewer injections. There was a significant (p<0.05) association between number of injections and national reimbursement schemes and OCT. Conclusions A number of factors that are predictive of treatment outcomes in a real-life setting were identified. Notably, the decline of treatment benefits may be linked to number of injections and a failure to visit clinicians and receive OCT as required. These findings may be helpful in guiding ophthalmologist treatment decisions under limited time and financial constraints. Trial registration number NCT01447043.
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Affiliation(s)
- Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Ramin Tadayoni
- Department of Ophthalmology, Hôpital Lariboisière, AP-HP, Université Paris 7-Sorbonne Paris Cité, Paris, France
| | - Stephen Beatty
- Department of Ophthalmology, Institute of Eye Surgery, Waterford, Ireland
| | - Alan Berger
- Department of Ophthalmology and Vision Sciences, University of Toronto, and St Michael's Hospital, Toronto, Ontario, Canada
| | - Matteo Giuseppe Cereda
- Department of Biomedical and Clinical Science Luigi Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Philip Hykin
- NIHR Biomedical Centre for Research in Ophthalmology, Moorfields Eye Hospital, London, UK
| | - Giovanni Staurenghi
- Department of Biomedical and Clinical Science Luigi Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | | | | | - Jonas Nilsson
- Mapi Group, Real World Strategy and Analytics, Stockholm, Sweden
| | - Kun Kim
- Mapi Group, Real World Strategy and Analytics, Stockholm, Sweden
| | - Sobha Sivaprasad
- NIHR Biomedical Centre for Research in Ophthalmology, Moorfields Eye Hospital, London, UK.,Department of Ophthalmology, King's College Hospital, London, UK
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Wykoff CC, Croft DE, Brown DM, Wang R, Payne JF, Clark L, Abdelfattah NS, Sadda SR. Prospective Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration: TREX-AMD 1-Year Results. Ophthalmology 2015; 122:2514-22. [PMID: 26391465 DOI: 10.1016/j.ophtha.2015.08.009] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To assess prospectively a treat-and-extend (TREX) management strategy compared with monthly dosing of intravitreal ranibizumab in treatment-naïve neovascular age-related macular degeneration (AMD) patients. DESIGN Phase IIIb, multicenter, randomized, controlled clinical trial. PARTICIPANTS Sixty patients with treatment-naïve neovascular AMD randomized 1:2 to monthly or TREX management. METHODS Patients with Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) from 20/32 to 20/500 (Snellen equivalent) were randomized to receive intravitreal 0.5 mg ranibizumab monthly or according to a TREX protocol. The TREX patients were treated monthly for at least 3 doses, until resolution of clinical and spectral-domain optical coherence tomography evidence of exudative disease activity; the interval between visits then was individualized according to a strict prospective protocol. MAIN OUTCOME MEASURES Mean ETDRS BCVA change from baseline. RESULTS At baseline, mean age was 77 years (range, 59-96 years), mean BCVA was 20/60 (Snellen equivalent), and mean central retinal thickness (CRT) was 511 μm. Fifty-seven eyes (95%) completed month 12, at which point mean BCVA improved by 9.2 and 10.5 letters in the monthly and TREX cohorts, respectively (P = 0.60). The mean number of injections administered through month 12 was 13.0 and 10.1 (range, 7-13) in the monthly and TREX cohorts, respectively (P < 0.0001). Among TREX patients, 7 (18%) were maximally extended, 4 (10%) demonstrated fluid at every visit, and at month 12, 18 (45%) had achieved an extension interval of 8 weeks or more; the mean maximum extension interval between injections after the first 3 monthly doses was 8.4 weeks (range, 4-12 weeks). Most TREX patients who demonstrated recurrent exudative disease activity (17/24 [71%]) were unable to extend beyond their initial maximum extension interval. CONCLUSIONS The TREX neovascular AMD management strategy used in this prospective, randomized, controlled trial resulted in visual and anatomic gains comparable with those obtained with monthly dosing.
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Affiliation(s)
- Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas.
| | | | - David M Brown
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, Texas
| | - Rui Wang
- Retina Consultants of Houston, Houston, Texas
| | - John F Payne
- Palmetto Retina Center, West Columbia, South Carolina
| | - Lloyd Clark
- Palmetto Retina Center, West Columbia, South Carolina
| | - Nizar Saleh Abdelfattah
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
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Rasmussen A, Brandi S, Fuchs J, Hansen LH, Lund-Andersen H, Sander B, Larsen M. Visual outcomes in relation to time to treatment in neovascular age-related macular degeneration. Acta Ophthalmol 2015; 93:616-20. [PMID: 26073051 DOI: 10.1111/aos.12781] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 05/03/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE To study the relation between the interval from diagnosis to initiation of intravitreal injection therapy and visual outcome in neovascular age-related macular degeneration (nAMD) and to report changes over time in fellow-eye status. METHODS Retrospective chart review. The study included 1185 eyes in 1099 patients who began vascular endothelial growth factor inhibitor treatment for nAMD during four separate periods in 2007, 2009, 2011 and 2012 using a fixed loading-dose regimen of three ranibizumab injections. RESULTS Mean best-corrected visual acuity (BCVA) at presentation remained within the range 0.23-0.24 Snellen and the median patient age within 79-80 years, whereas BCVA at first visit after the third injection increased from 0.24 to 0.31 (p < 0.0001) in concert with a shift in preferred practice from separate-day injection to same-day injection. This led to a reduction in the median time to treatment from 16 days to 1 day. The proportion of patients with fellow-eye BCVA 0.05 or worse at presentation with newly diagnosed wet AMD in the incident eye decreased from 38% to 22% (p < 0.0018). The proportion of bilaterally treated patients increased during the study period. CONCLUSION In this study, 2-week-earlier injection was associated with the equivalent of a 5-Early Treatment Diabetic Retinopathy Study letter-gain in mean visual acuity at 3 months after presentation. The difference is larger than expected from the 2-week-longer duration of disease at the study end-point. The study supports that early diagnosis and treatment of nAMD is of value for functional outcomes.
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Affiliation(s)
- Annette Rasmussen
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
- University of Copenhagen; Copenhagen Denmark
| | - Sara Brandi
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
| | - Josefine Fuchs
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
- University of Copenhagen; Copenhagen Denmark
| | - Louise H Hansen
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
| | - Henrik Lund-Andersen
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
- University of Copenhagen; Copenhagen Denmark
| | - Birgit Sander
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
- University of Copenhagen; Copenhagen Denmark
| | - Michael Larsen
- Department of Ophthalmology; Glostrup Hospital; Glostrup Denmark
- University of Copenhagen; Copenhagen Denmark
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Chin-Yee D, Eck T, Fowler S, Hardi A, Apte RS. A systematic review of as needed versus treat and extend ranibizumab or bevacizumab treatment regimens for neovascular age-related macular degeneration. Br J Ophthalmol 2015; 100:914-917. [PMID: 26516125 DOI: 10.1136/bjophthalmol-2015-306987] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/09/2015] [Accepted: 10/01/2015] [Indexed: 11/03/2022]
Abstract
PURPOSE To evaluate the relative efficacy of as needed versus treat and extend regimen for the treatment of neovascular age-related macular degeneration (AMD). METHODS We conducted a systematic review of studies that evaluated the efficacy of as needed or treat and extend regimen for neovascular AMD by searching multiple databases up to December 2013. Included studies were selected based on study duration of no less than 12 months, availability of outcome data, treatment protocol for as needed groups or pro re nata (PRN) receiving bevacizumab or ranibizumab, and all studies with treat extend protocols following the 'inject and extend' regimen. The outcome data were pooled and analysed. RESULTS 1046 peer reviewed articles meeting our initial search criteria were returned. After further review by two independent reviewers, 8 studies meeting treat and extend protocol and 62 studies meeting PRN protocol were included. The mean improvement in visual acuity in the PRN group was 5.4 ETDRS letters compared with 10.4 ETDRS letters in the treat and extend group. The PRN group received an average of 5.60 injections at 1 year compared with 8.09 in the treat and extend group. Central retinal thickness improved on average by 100.32 µ in the PRN group compared with 87.7 µ in the treat and extend group. CONCLUSIONS Though our study suggests superiority of the treat and extend regimen to PRN treatment in a 12-month period, this review demonstrates the need for randomised clinical trials to confirm our findings and to evaluate long-term efficacy outcomes with these regimens compared with monthly therapy.
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Affiliation(s)
- David Chin-Yee
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Thomas Eck
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Susan Fowler
- Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Angela Hardi
- Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rajendra S Apte
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri, USA
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Matsumiya W, Honda S, Otsuka K, Miki A, Nagai T, Imai H, Kusuhara S, Nakamura M. Comparison of the Effectiveness and Prognostic Factors of Intravitreal Ranibizumab between Typical Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy over 24 Months of Follow-Up. Ophthalmologica 2015; 234:33-9. [PMID: 26112059 DOI: 10.1159/000431000] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 04/23/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare the response to ranibizumab between patients with typical neovascular age-related macular degeneration (tAMD) and those with polypoidal choroidal vasculopathy (PCV), and to determine the predictors for the outcomes. METHODS Fifty-nine eyes from 59 consecutive patients (tAMD: 27 eyes, PCV: 32 eyes) were treated with three monthly ranibizumab injections followed by as-needed retreatment. Best-corrected visual acuity (BCVA) and morphological parameters were evaluated over 24 months of follow-up. RESULTS The mean BCVA in tAMD and PCV patients was significantly improved at 3 months (-0.22 and -0.09 logMAR units, respectively). The improvement in BCVA was sustained up to 24 months in tAMD (p = 0.01) but not in PCV patients. The significant predictor for good response to ranibizumab in tAMD patients was the improvement of BCVA at 3 months, whereas that in PCV patients was the anatomical resolution at 3 months. CONCLUSIONS Ranibizumab is an effective therapy for tAMD and PCV over 24 months. The predictors for good outcome might be different between tAMD and PCV.
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Affiliation(s)
- Wataru Matsumiya
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Barthelmes D, Walton R, Campain AE, Simpson JM, Arnold JJ, McAllister IL, Guymer RH, Hunyor AP, Essex RW, Morlet N, Gillies MC. Outcomes of persistently active neovascular age-related macular degeneration treated with VEGF inhibitors: observational study data. Br J Ophthalmol 2014; 99:359-64. [PMID: 25249615 DOI: 10.1136/bjophthalmol-2014-305514] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To describe outcomes of eyes with wet age-related macular degeneration (AMD) subdivided by lesion activity in a large multicentre cohort study. METHODS Treatment-naive eyes with subfoveal choroidal neovascularisation receiving antivascular endothelial growth factor therapy enrolled in the Fight Retinal Blindness observational study were included. Lesions were graded at each visit as active if there was intraretinal or subretinal fluid attributable to leak from choroidal neovascularisation lesion or fresh haemorrhage. Eyes were divided into four groups; based on the proportion of visits, each eye was graded as active during the first 12 months of treatment (persistent, high, moderate and low activity). RESULTS 655 eyes were included. Similar mean visual acuity changes compared with baseline were observed in all four groups at 12 months (+6.8, +8.3, +6.2 and +5.5 letters for the low, moderate, high and persistent groups, respectively; p<0.001 for each group). The mean number of injections given increased only modestly in groups with more active lesions (7.6, 7.9, 8.4 and 8.3, respectively, p=0.015). Occult and minimally classic lesions were more frequent in the more active groups (p=0.024). CONCLUSIONS Persistent activity of neovascular lesions during 12 months after starting intravitreal therapy was not associated with worse visual outcomes in this observational study of AMD.
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Affiliation(s)
- Daniel Barthelmes
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Richard Walton
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anna E Campain
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Judy M Simpson
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Robyn H Guymer
- Center for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
| | - Alex P Hunyor
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Retina Associates, Chatswood, New South Wales, Australia
| | - Rohan W Essex
- Department of Ophthalmology, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Nigel Morlet
- Department of Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Mark C Gillies
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Zhu M, Chew JK, Broadhead GK, Luo K, Joachim N, Hong T, Syed A, Chang AA. Intravitreal Ranibizumab for neovascular Age-related macular degeneration in clinical practice: five-year treatment outcomes. Graefes Arch Clin Exp Ophthalmol 2014; 253:1217-25. [PMID: 25205618 DOI: 10.1007/s00417-014-2799-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 07/09/2014] [Accepted: 08/07/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents are the established standard of care for neovascular age-related macular degeneration (nAMD). However, data on long-term outcomes of this therapy are limited. The purpose of this study was to assess the visual and anatomical outcomes and safety profile of intravitreal ranibizumab in treating nAMD over a period of five years. METHODS 208 patients (208 eyes) were included in this retrospective case series study. Intervention was an "as-needed" treatment model. Visual acuity (VA), central macular thickness (CMT), ophthalmic examination, and adverse events (AEs) were assessed in each visit. Snellen VA was converted to Early Treatment Diabetic Retinopathy Study letters for analysis. RESULTS The average VA improved by 1.9 letters after one year (p = 0.017), and decreased by 2.4 letters over five years of treatment (p = 0.043). At the end of year five, 11.1 % of patients (23/208) had improved VA by more than 15 letters and 68.8 % (143/208) had VA improvement or loss less than or equal to 15 letters, while 20.2 % of patients (42/208) had a loss of more than 15 letters. Patients with VA of less than 35 letters at baseline showed significant VA improvement after five years of treatment. There was a positive relationship between injection numbers and VA improvement over the five-year period, after adjusting for age and baseline VA (p < 0.0005). Mean CMT decreased by 28.3 μm (p < 0.0005) over five years. Ocular AEs, serious adverse events (SAEs), and systemic SAEs occurred in 4.6 %, 0.48 %, and 2 % of patients, respectively, during the follow-up period. CONCLUSIONS The use of intravitreal ranibizumab in an as-needed treatment regimen over a five-year period was effective in maintaining vision in patients with nAMD and in reducing macular thickness, with a relatively low rate of adverse and serious adverse events.
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Affiliation(s)
- Meidong Zhu
- Sydney Institute of Vision Science, Level 13, 187 Macquarie Street, Sydney, 2000, Australia
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Guo S, Patel S, Baumrind B, Johnson K, Levinsohn D, Marcus E, Tannen B, Roy M, Bhagat N, Zarbin M. Management of pseudophakic cystoid macular edema. Surv Ophthalmol 2014; 60:123-37. [PMID: 25438734 DOI: 10.1016/j.survophthal.2014.08.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 08/24/2014] [Accepted: 08/26/2014] [Indexed: 01/08/2023]
Abstract
Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.
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Affiliation(s)
- Suqin Guo
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA.
| | - Shriji Patel
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Ben Baumrind
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Keegan Johnson
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Daniel Levinsohn
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Edward Marcus
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Brad Tannen
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Monique Roy
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Neelakshi Bhagat
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Marco Zarbin
- Department of Ophthalmology, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
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Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2014; 8:CD005139. [PMID: 25170575 PMCID: PMC4270425 DOI: 10.1002/14651858.cd005139.pub3] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to neovascular AMD accounts for most AMD-related severe vision loss. Anti-vascular endothelial growth factor (anti-VEGF) agents, injected intravitreally, aim to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, improve vision. OBJECTIVES To investigate: (1) the ocular and systemic effects of, and quality of life associated with, intravitreally injected anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) for the treatment of neovascular AMD compared with no anti-VEGF treatment; and (2) the relative effects of one anti-VEGF agent compared with another when administered in comparable dosages and regimens. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to March 2014), EMBASE (January 1980 to March 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 27 March 2014. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or a control treatment (e.g., sham treatment or photodynamic therapy). All trials followed participants for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We analyzed outcomes as risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 12 RCTs including a total of 5496 participants with neovascular AMD (the number of participants per trial ranged from 28 to 1208). One trial compared pegaptanib, three trials ranibizumab, and two trials bevacizumab versus controls; six trials compared bevacizumab with ranibizumab. Four trials were conducted by pharmaceutical companies; none of the eight studies which evaluated bevacizumab were funded by pharmaceutical companies. The trials were conducted at various centers across five continents (North and South America, Europe, Asia and Australia). The overall quality of the evidence was very good, with most trials having an overall low risk of bias.When compared with control treatments, participants who received any of the three anti-VEGF agents were more likely to have gained 15 letters or more of visual acuity, lost fewer than 15 letters of visual acuity, and had vision 20/200 or better after one year of follow up. Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same regimens were compared in the same RCTs, despite the substantially lower cost for bevacizumab compared with ranibizumab. No trial directly compared pegaptanib with other anti-VEGF agents; however, when compared with controls, ranibizumab or bevacizumab yielded larger improvements in visual acuity outcomes than pegaptanib.Participants treated with anti-VEGFs showed improvements in morphologic outcomes (e.g., size of CNV or central retinal thickness) compared with participants not treated with anti-VEGF agents. There was less reduction in central retinal thickness among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -13.97 μm; 95% confidence interval (CI) -26.52 to -1.41); however, this difference is within the range of measurement error and we did not interpret it as being clinically meaningful.Ocular inflammation and increased intraocular pressure after intravitreal injection were the most frequently reported serious ocular adverse events. Endophthalmitis was reported in fewer than 1% of anti-VEGF treated participants; no cases were reported in control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to detect a meaningful difference between groups. Data for visual function, quality of life, and economic outcomes were sparsely measured and reported. AUTHORS' CONCLUSIONS The results of this review indicate the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; ranibizumab and bevacizumab were also shown to improve visual acuity. The information available on the adverse effects of each medication do not suggest a higher incidence of potentially vision-threatening complications with intravitreal injection compared with control interventions; however, clinical trial sample sizes may not have been sufficient to detect rare safety outcomes. Research evaluating variable dosing regimens with anti-VEGF agents, effects of long-term use, combination therapies (e.g., anti-VEGF treatment plus photodynamic therapy), and other methods of delivering the agents should be incorporated into future Cochrane reviews.
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Affiliation(s)
- Sharon D. Solomon
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristina Lindsley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Barbara S. Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Matsumiya W, Honda S, Yanagisawa S, Miki A, Nagai T, Tsukahara Y. Evaluation of clinical and genetic indicators for the early response to intravitreal ranibizumab in exudative age-related macular degeneration. Pharmacogenomics 2014; 15:833-43. [DOI: 10.2217/pgs.14.51] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: This study was conducted to evaluate the possible clinical and genetic indicators for an early response to intravitreal ranibizumab (IVR) in exudative age-related macular degeneration (AMD). Patients & methods: The records of 120 eyes from 120 Japanese patients with treatment-naive exudative AMD were retrospectively reviewed. Three consecutive IVR treatments were performed every month. Achievement of anatomical resolution was evaluated by ophthalmoscopy and optical coherence tomography. Multivariable logistic regression analysis was conducted by analyzing SNPs in the ARMS2 locus (A69S) and in the CFH gene (I62V and Y402H), in addition to clinical factors. Results: The mean central retinal thickness of overall patients was significantly decreased (-120.1 ± 122.8 µm, p = 2.7 × 10-19) at 3 months after the initial treatment. In the logistic regression analysis, the poor anatomical resolution of the lesion at 3 months was associated with the combination of CFH I62V + CFH Y402H variants (p = 0.0021), and the polypoidal choroidal vasculopathy lesions (p = 0.044). Conclusion: The CFH variants and the polypoidal choroidal vasculopathy lesion may influence the early anatomical resolution with IVR in exudative AMD. Original submitted 30 September 2013; Revision submitted 13 March 2014
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Affiliation(s)
- Wataru Matsumiya
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Shigeru Honda
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Suiho Yanagisawa
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Akiko Miki
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Takayuki Nagai
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Yasutomo Tsukahara
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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