INTRAVITREAL RANIBIZUMAB VERSUS BEVACIZUMAB FOR TREATMENT OF MYOPIC CHOROIDAL NEOVASCULARIZATION

Treatment of myopic choroidal neovascularization: a network meta-analysis and review

PURPOSE

This is, to our knowledge, the first network meta-analysis aiming to compare all treatment modalities for myopic choroidal neovascularization (CNV).

METHODS

After the electronic databases were searched, two independent reviewers screened titles, abstracts, full-texts, and extracted information. Primary endpoints were change in visual outcome and central retinal thickness. We used a network meta-analysis to compare treatment outcomes in the early (≤ 6 months) and late (> 6 months) phase.

RESULTS

We included 34 studies (2,098 eyes) in our network meta-analysis. In the early phase, the use of anti-VEGF led to a gain of 14.1 letters (95% CI, 10.8-17.4) compared to untreated patients (p < 0.0001), 12.1 letters (95% CI, 8.3-15.8) to photodynamic therapy (PDT) (p < 0.0001), 7.5 (95% CI, 1.2-13.8) letters to intravitreal triamcinolone acetonide (TCA) (p = 0.019), and - 2.9 letters (95% CI, - 6.0-0.2) to the combination of anti-VEGF and PDT (p = 0.065). In the later phase, these results were largely maintained. There were no significant differences in visual outcomes between patients treated with 1 + PRN and 3 + PRN. However, the 1 + PRN group received 1.8 (SD 1.3), while the 3 + PRN group received 3.2 (SD 0.9) injections within 12 months (p < 0.0001).

CONCLUSION

This network meta-analysis confirms that anti-VEGF is the most effective treatment for myopic CNV using the 1 + PRN treatment strategy.

Comparison of anatomical and functional outcomes of treating myopic choroidal neovascularization with bevacizumab or ranibizumab

PURPOSE

To compare results of treatment with bevacizumab and ranibizumab injections in myopic choroidal neovascularization (mCNV).

METHODS

Retrospective, observational case series.

PARTICIPANTS

patients with mCNV treated with bevacizumab or ranibizumab injections. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) on optical coherence tomography (OCT) scans were collected at baseline, after 3, 6, 12, 24 months and the last visit.

MAIN OUTCOME MEASURES

mean change in BCVA and CRT.

RESULTS

We included 85 eyes treated with bevacizumab and 125 eyes treated with ranibizumab. There was no difference between the groups regarding BCVA and CRT change. CNV recurrence occurred at the mean time of 66.1 ± 3.7 and 57.3 ± 6.4 months in the bevacizumab- and ranibizumab-treated eyes, respectively (p = 0.006). During the first year 6.9% eyes in the bevacizumab group vs. 27.5% in the ranibizumab group had CNV recurrence (p = 0.001). Risk factors for recurrence of CNV were baseline CNV area (aHR 1.20, 95%CI 1.0-1.32, p = 0.04), subfoveal CNV (aHR 2.13, 95% CI 1.16-3.93, p = 0.01) and ranibizumab treatment (aHR 2.31, 95% CI 1.16-3.93, p = 0.008).

CONCLUSION

Eyes treated with bevacizumab and ranibizumab can achieve similar anatomical and functional improvement. CNV recurrence may occur earlier and more frequently during the first year in eyes treated with ranibizumab.

Risk factors for myopic choroidal neovascularization-related macular atrophy after anti-VEGF treatment

Purpose

The study aimed to evaluate risk factors for macular atrophy (MA) associated with myopic choroidal neovascularization (mCNV) during long-term follow-up after intravitreal anti-vascular endothelial growth factor (VEGF) treatment in highly myopic eyes.

Methods

The medical records of patients who received intravitreal injection of anti-VEGF agents as mCNV treatment and were followed-up for more than 36 months were retrospectively reviewed. The risk factors for the development of mCNV-MA, which is the fovea-involving patchy atrophy lesion adjacent to mCNV, were investigated using the Cox proportional hazard model.

Results

A total of 82 eyes (74 patients) were included in the study. The mean age at anti-VEGF treatment was 56.3 ± 12.5 years (range, 26–77), and the mean follow-up period was 76.3 ± 33.5 months (range, 36–154). During follow-up, mCNV-MA developed in 27 eyes (32.9%), and its occurrence was estimated to be 24.5% at 3 years and 37.3% at 5 years after the first anti-VEGF treatment. Old age (hazard ratio [HR] = 1.054, 95% confidence interval [CI]: 1.018–1.091; P = 0.003) and greater CNV size at baseline (HR = 2.396, CI: 1.043–5.504; P = 0.040) were significant factors for mCNV-MA development. Eyes with a thinner subfoveal choroid were more likely to show faster enlargement of the mCNV-MA during follow-up.

Conclusions

In mCNV eyes treated with intravitreal anti-VEGF agents, older age and greater mCNV size at baseline were risk factors for the development of MA during long-term follow-up, which was associated with a poor visual prognosis.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Vascular endothelial growth factor inhibitors for predominantly Caucasian myopic choroidal neovascularization: 2-year treatment outcomes in clinical practice: data from the Fight Retinal Blindness! Registry

Purpose

To report the 24‐month outcomes of vascular endothelial growth factor (VEGF) inhibitors for myopic choroidal neovascularization (mCNV) in predominantly Caucasian eyes in routine clinical practice.

Methods

Retrospective analysis of treatment‐naïve eyes starting intravitreal injection of VEGF inhibitors of either bevacizumab (1.25 mg) or ranibizumab (0.5 mg) for mCNV from 1 January 2006 to 31 May 2018 that were tracked in the Fight Retinal Blindness! registry.

Results

We identified 203 eyes (bevacizumab–85 and ranibizumab–118) of 189 patients. The estimated mean (95% CI) change in VA over 24 months for all eyes using longitudinal models was +8 (5, 11) letters with a median (Q1, Q3) of 3 (2, 5) injections given mostly during the first year. The estimated mean change in VA at 24 months was similar between bevacizumab and ranibizumab [+9 (5, 13) letters for bevacizumab versus +9 (6, 13) letters for ranibizumab; p = 0.37]. Both agents were also similar in the mCNV activity outcomes, treatment frequency and visit frequency.

Conclusions

The 24‐month treatment outcomes of VEGF inhibitors for mCNV were favourable in this largest series yet reported of predominantly Caucasian eyes in routine clinical practice, with approximately two lines of visual gain and a median of three injections given mostly during the first year. These outcomes are similar to those reported for predominantly Asian eyes. Bevacizumab appeared to be as safe and effective as ranibizumab.

Safety review of anti-VEGF therapy in patients with myopic choroidal neovascularization

INTRODUCTION

Anti-angiogenesis therapy with intravitreal anti-VEGF agents is now the standard-of-care treatment for myopic choroidal neovascularization (CNV).

AREAS COVERED

We provide a critical review of the safety of all the anti-VEGF agents currently used for treating myopic CNV including ranibizumab, aflibercept, conbercept, bevacizumab, and ziv-aflibercept.

EXPERT OPINION

Anti-VEGF therapy for myopic CNV with the currently available anti-VEGF drugs generally have favorable safety outcomes in the short-term. Nonetheless, ocular adverse events following anti-VEGF therapy for myopic CNV may develop and these include worsening or new development of myopic traction maculopathy, increased risk of retinal detachment, and progression of chorioretinal atrophy. Clinicians should be aware of these potential complications and evaluate them before and after anti-VEGF therapy.

Anti-VEGF Therapy in Myopic CNV

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

Comparison of structural and functional outcome of aflibercept versus ranibizumab in patients with myopic choroidal neovascularization

PURPOSE

To compare visual functional improvement and retinal structural changes of aflibercept versus ranibizumab for the management of treatment-naïve choroidal neovascularization related to pathological myopia.

PATIENTS AND METHODS

A prospective randomized study included patients suffering from myopic choroidal neovascularization. Patients received three intravitreal injections of aflibercept (2 mg) or ranibizumab (0.5 mg) in 1:1 ratio every 4 weeks. Ophthalmic evaluation and optical coherence tomography were performed at baseline, 1, 2, and 3 months after last injection. Primary outcome measure was the visual acuity change from baseline to month 3 after injection. Secondary outcome measures included change in retinal thickness and the relation of morphological and functional changes to baseline assessment parameters.

RESULTS

A total of 48 myopic patients (48 eyes) suffering from myopic choroidal neovascularization were randomly assigned to receive either aflibercept (Group A) or ranibizumab (Group B). In Group A, best-corrected visual acuity significantly improved from 0.53 ± 0.10 logMAR to 0.38 ± 0.11 logMAR, at 3 months, and from 0.55 ± 0.11 logMAR to 0.39 ± 0.12 logMAR in Group B. Whereas, retinal thickness reduced from 317.7 ± 53.6 µm to 164.5 ± 81.9 µm in Group A, and from 321.1 ± 98.8 µm at baseline to 178.9 ± 64.5 µm in Group B at month 3. Changes in best-corrected visual acuity and central macular thickness were statistically insignificant between the two groups at final visit.

CONCLUSION

Both aflibercept and ranibizumab provided a significant improvement in visual acuity and retinal thickness in patients with myopic choroidal neovascularization. Comparable functional and architectural results were achieved by both treatment modalities.

Preoperative Bevacizumab for Tractional Retinal Detachment in Proliferative Diabetic Retinopathy: A Prospective Randomized Clinical Trial

PURPOSE

To assess the effectiveness and safety of an intravitreal injection of 1.25 mg bevacizumab (IVB) as a preoperative adjunct to small-gauge pars plana vitrectomy (PPV) compared with PPV alone in eyes with tractional retinal detachment secondary to proliferative diabetic retinopathy.

METHODS

This prospective, double-masked, randomized, multicenter, active-controlled clinical trial enrolled 224 eyes of 224 patients between November 2013 and July 2015. All eyes underwent a baseline examination including best-corrected visual acuity, color photos, optical coherence tomography, and fluorescein angiography. Data were collected on intraoperative bleeding, total surgical time, early (<1 month) postoperative vitreous hemorrhage, and mean change in best-corrected visual acuity at 12 months. P < .05 was considered statistically significant.

RESULTS

A total of 214 patients (214 eyes) were randomized in a 1:1 ratio to PPV plus IVB ([study group] 102 eyes) or PPV plus sham ([control] 112 eyes). Iatrogenic retinal breaks were noted intraoperatively in 35 eyes (34.3%) in the study group, and 66 eyes (58.9%) in the control group (P = .001). Grade 2 intraoperative bleeding was noted in 32 (31.3%) eyes in the study group and 58 (51.7 %) eyes in the control group (P = .001). Endodiathermy was necessary in 28 (27.4 %) eyes in the study group, compared with 75 (66.9%) eyes in the control group (P = .0001). Mean surgical time was 71.3 ± 32.1 minutes in the study group and 83.6 ± 38.7 minutes in the control group (P = .061).

CONCLUSION

Preoperative IVB seems to reduce intraoperative bleeding, improving surgical field visualization, and reducing intraoperative and postoperative complications. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Comparison of Intravitreal Aflibercept and Ranibizumab for Treatment of Myopic Choroidal Neovascularization: One-Year Results-A Retrospective, Comparative Study

Purpose

To compare one-year treatment outcomes of intravitreal aflibercept (IVA) and intravitreal ranibizumab (IVR) for treatment of myopic choroidal neovascularization (mCNV).

Methods

The medical records of a total of 30 eyes diagnosed with mCNV and underwent IVA or IVR treatment for a minimum one-year follow-up were studied retrospectively. All the subjects had an axial length >26 mm and received a 1 + PRN (pro re nata) regimen IVA or IVR. Best-corrected visual acuity (BCVA) and central macular thicknesses (CMT) on optical coherence tomography were evaluated before and after treatment.

Results

There were 12 eyes in IVA group, with a mean age of 60.0 ± 10.2 years. The mean BCVA significantly improved from baseline 1.54 ± 0.76 to 0.85 ± 0.61 and the mean CMT significantly decreased from baseline 384.3 ± 119.1 μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and p : 0.024 and p : 0.024 and.

Conclusions

Both IVA and IVR treatment modalities resulted in similar anatomical outcomes but IVA had better visual outcomes in treatment of mCNV.

Structural and optical coherence tomography angiography in myopic choroidal neovascularization: Agreement with conventional fluorescein angiography

PURPOSE

To evaluate the agreement between fluorescein angiography and structural optical coherence tomography in diagnosing and monitoring the activity of myopic choroidal neovascularization and to provide a comparative analysis with optical coherence tomography angiography.

METHODS

Thirteen patients with active myopic choroidal neovascularization were prospectively enrolled. At the baseline, 2-month, and 6-month visits, each patient underwent a complete ophthalmological examination, including best-corrected visual acuity assessment, fundus examination, fluorescein angiography, and optical coherence tomography with structural and angiographic assessment. Sensitivity and specificity for all optical coherence tomography parameters were evaluated taking fluorescein angiography as the reference examination.

RESULTS

At the baseline, fluorescein angiography confirmed myopic choroidal neovascularization leakage in all patients. Structural optical coherence tomography demonstrated intraretinal or subretinal fluid in 61% of cases, fuzzy borders and absence of external limiting membrane visibility in 84% of cases, and subretinal hyperreflective exudation in 53% of cases. Sensitivity to the presence of retinal fluid and subretinal hyperreflective exudation was lower than sensitivity to fuzzy borders and external limiting membrane visibility, which reached 84%. During ranibizumab therapy, external limiting membrane visibility showed a higher sensitivity (100%) compared with fuzzy borders and subretinal hyperreflective exudation (66.6%) while displaying an equal specificity of 100%. At baseline and final visit, sensitivity increased to 100% when all structural optical coherence tomography parameters were pooled. Optical coherence tomography angiography detected myopic choroidal neovascularization at baseline, 2-month, and 6-month visits in 92%, 76%, and 76% of cases, respectively.

CONCLUSION

The study confirms that the new indicators of myopic choroidal neovascularization activity are more reliable than the presence or absence of retinal fluid. Optical coherence tomography angiography identified myopic choroidal neovascularization in most patients in the diagnostic phase and during treatment monitoring and could be considered as an alternative to fluorescein angiography in selected patients.

LONG-TERM OUTCOMES OF RANIBIZUMAB TREATMENT OF MYOPIC CHOROIDAL NEOVASCULARIZATION IN EAST-ASIAN PATIENTS FROM THE RADIANCE STUDY

A retrospective cohort study of East-Asian patients previously treated with ranibizumab for myopic choroidal neovascularization in the RADIANCE trial. Clinical charts were reviewed to assess long-term efficacy and safety. Visual acuity was sustained for additional 36 months after trial completion with few patients requiring additional treatment and no new safety concerns observed.

Purpose:

To evaluate long-term efficacy and safety of ranibizumab for treatment of myopic choroidal neovascularization (mCNV) in clinical practice.

Methods:

Noninterventional, retrospective cohort study of East-Asian patients previously treated with ranibizumab during the RADIANCE trial. Forty-one patients who completed the RADIANCE trial were followed-up for up to 48 months (post-RADIANCE observation period). Outcome measures were best-corrected visual acuity changes from baseline (assessed at RADIANCE trial initiation), mCNV recurrences, and ocular adverse events.

Results:

Mean visual gain from baseline best-corrected visual acuity (56.5 ± 12.1 letters) (20/80) was significant at 12 months (+14.3 ± 11.4 letters, n = 40, P < 0.0001), 24 months (+10.4 ± 22.3 letters, n = 31, P = 0.0143), 30 months (+11.0 ± 22.4 letters, n = 29, P = 0.0134), 42 months (+12.9 ± 20.9 letters, n = 25, P = 0.0051), and 48 months (+16.3 ± 18.7, n = 16, P = 0.0034). Of the 16 patients who completed 48 months of follow-up, 63% gained ≥10 letters and 13% lost ≥10 letters. Over the post-RADIANCE observation period, 83% of patients required no further treatment for mCNV, 10% experienced mCNV recurrences, and 12% experienced a nonserious ocular adverse event. Patients who required additional treatment for mCNV received a mean of 5.0 (SD 5.9, range 1.0–18.0) ranibizumab injections.

Conclusion:

Best-corrected visual acuity gained at the end of the RADIANCE trial was sustained over additional 36 months of follow-up. Few patients required further treatment and no new safety concerns were observed.

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

OBJECTIVES

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

DESIGN

Systematic review and random-effects meta-analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42015022041.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pharmacotherapy of Myopic Choroidal Neovascularization

BACKGROUND

Myopic choroidal neovascularization (CNV) is a common cause of central visual loss in patients with high myopia, and the most common form of CNV in younger individuals. Pharmacologic therapy is the current mainstay of treatment of these patients.

METHODS

Review of pharmacological treatment options for myopic CNV, which primarily involves intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF) agents.

RESULTS

At this time, anti-VEGF therapy agents are the first-line therapy in these patients. Comparative trials have not identified any major differences in treatment outcomes between aflibercept, bevacizumab, and ranibizumab. Only ranibizumab is approved for this indication in the US. Best visual outcomes are associated with younger age, smaller lesion size, and absence of chorioretinal atrophy.

CONCLUSION

Anti-VEGF therapy is generally very effective in the treatment of myopic CNV.

Intravitreal aflibercept versus bevacizumab for treatment of myopic choroidal neovascularization

The authors performed a retrospective and comparative study to compare the efficacy of intravitreal aflibercept and bevacizumab for patients with myopic choroidal neovascularization (mCNV). The patients with treatment-naïve mCNV received 1 + PRN intravitreal bevacizumab from March 2008 to February 2013, while from March 2013 to July 2016 patients were treated by 1 + PRN intravitreal aflibercept, all with monthly follow-up for 12 months. Primary outcome measures included change in central foveal thickness (CFT) in 1 mm by spectral-domain optic coherence tomography, and best corrected visual acuity (BCVA) at month 12. Complications after injections were recorded. The intra-group changes in CFT and BCVA were compared with Wilcoxon signed rank test, the between-group difference compared with Wilcoxon rank sum test. Fisher's exact test was used for categorical comparison between groups. Seventy-eight eyes of 78 patients were collected. There were 42 eyes in bevacizumab group, with mean age of 53.2 ± 5.4 years and 27 female patients of them. The mean BCVA significantly improved from baseline 0.56 ± 0.35 logMAR to 0.35 ± 0.35 logMAR at Month 12 after bevacizumab treatment (p < 0.001). The mean CFT significantly decreased from baseline 315.3 ± 25.6 μm to 253.7 ± 24.4 μm at Month 12 following intravitreal bevacizumab (p < 0.001). There were 36 eyes in aflibercept group, with mean age of 52.8 ± 6.8 years and 24 female patients of them. The mean BCVA significantly improved from baseline 0.61 ± 0.47 logMAR to 0.38 ± 0.41 logMAR at Month 12 after aflibercept treatment (p < 0.001). The mean CFT significantly decreased from baseline 328.2 ± 19.8 μm to 241.8 ± 27.2 μm at Month 12 following intravitreal aflibercept (p < 0.001). The baseline demographics, lens status, axial length, refractive errors, duration of symptoms, BCVA, and CFT did not differ significantly between groups (p > 0.05). There was no significant difference between bevacizumab and aflibercept groups in BCVA and CFT from Month 1 to Month 12 (p > 0.05). Injection number of aflibercept was 2.11 ± 0.41, less than that of bevacizumab (3.23 ± 0.38) during 12-month period (p = 0.01). There were no systemic thromboembolic event, elevated intraocular pressure, retinal detachment, or infectious endophthalmitis following injections in both groups. We concluded that both aflibercept and bevacizumab can effectively treat choroidal neovascularization in high myopes. Intravitreal aflibercept had similar efficacy but less treatment number than bevacizumab for mCNV during 12-month period.

Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline

PURPOSE

To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy.

METHODS

Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations.

RESULTS

All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases.

CONCLUSION

The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients.

Nine-Year Outcome of Ranibizumab Monotherapy for Choroidal Neovascularization Secondary to Pathologic Myopia

PURPOSE

The aim of this study was to evaluate the 9-year outcome of ranibizumab monotherapy for myopic choroidal neovascularization (mCNV).

METHODS

This was a retrospective, nonrandomized, multicentric study to evaluate the long-term outcomes of mCNV treated with ranibizumab monotherapy for at least 9 years according to a strict pro re nata regimen.

RESULTS

Seventeen eyes of 17 patients (12 women, mean age 57.9 ± 7.7 years) were included. The mean follow-up period was 112.4 ± 3.9 months (range 108-120). The mean difference in best-corrected visual acuity (BCVA) from baseline to the last follow-up was +1.2 ± 15.6 ETDRS letters (p = 0.004, between initial vs. 12 and 24 months). The mean total number of intravitreal injections for each patient was 1.24 ± 1.70 per year (range 2-25). No systemic adverse reactions related to the drug treatment were detected during the 9-year follow-up period.

CONCLUSIONS

Long-term ranibizumab monotherapy treatment induces unchanged or better BCVA compared to baseline after a 9-year treatment in almost all eyes.

Diagnosis and treatment guideline for myopic choroidal neovascularization due to pathologic myopia

Pathologic myopia is a leading cause of visual impairment. Development of myopic choroidal neovascularization (CNV) is one of the most common complications that leads to central vision loss in patients with pathologic myopia. If left untreated, it can cause scarring with expanding macular atrophy leading to irreversible visual loss in a period as short as 5 years. Advancements in multimodal imaging technology have furthered our understanding of the condition; however, further studies are necessary to extend its utility in the diagnosis of myopic CNV. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has become the standard-of-care and the recommended first-line treatment option for myopic CNV. Long-term studies have demonstrated that early treatment of confirmed myopic CNV cases with an intravitreal anti-VEGF agent is useful to avoid late-stage complications. This strategy has also been shown to achieve visual outcome improvements for up to 4 years and visual stabilization up to 6 years. This review article provides an overview of the current knowledge on myopic CNV and discusses recent updates in the diagnosis and management of the condition. Furthermore, treatment recommendations are provided based on the authors' expert opinions.

SUBRETINAL FIBROSIS AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EYES WITH MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To assess the incidence and risk factors of subretinal fibrosis and their impact on visual outcome in eyes with myopic CNV.

METHODS

Medical records of 72 eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy in a pro re nata regimen for myopic CNV that followed up for more than 1 year were retrospectively reviewed. The presence of subretinal fibrosis after anti-VEGF therapy was determined using both fundus photographs and optical coherence tomography. The incidence and risk factors of subretinal fibrosis were evaluated, and best-corrected visual acuity was compared between the eyes with and without subretinal fibrosis.

RESULTS

The incidences of subretinal fibrosis during the 1-year and whole follow-up period were 31.9% and 36.1%, respectively. Occurrence of subretinal fibrosis was associated with frequent CNV recurrence (P = 0.005) and poor baseline best-corrected visual acuity (P = 0.044) in a Cox proportional hazard model. Anatomically, the eyes with subretinal fibrosis showed more frequent progression of chorioretinal atrophy (95.7% vs. 71.4%, P = 0.027) and less frequent photoreceptor recovery (17.4% vs. 65.3%, P < 0.001) after anti-VEGF therapy. Occurrence of subretinal fibrosis was associated with poor vision at baseline (P = 0.011) and the final visit (P = 0.008) when compared with the findings in the nonoccurrence group.

CONCLUSION

Development of subretinal fibrosis after anti-VEGF therapy was common in eyes with myopic CNV and was associated with CNV recurrence. Myopic eyes with subretinal fibrosis show progressive chorioretinal atrophy and poor visual outcome.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Management of Myopic Choroidal Neovascularization: Focus on Anti-VEGF Therapy

Myopic choroidal neovascularization (mCNV) is the second most common form of CNV after age-related macular degeneration (AMD). It is a sight-threatening complication of pathologic myopia (PM) and often affects patients in their working years causing significant impact on quality of life. Previous therapies such as photodynamic therapy with verteporfin have shown limited success. Due to the similarities in pathogenesis of mCNV and AMD CNV, anti-vascular endothelial growth factor therapy (anti-VEGF), which has so far been the mainstay of treatment for AMD CNV, has been shown to be effective in the treatment of mCNV and has become the first-line treatment of choice. This article aims to examine briefly the epidemiology and pathophysiology of mCNV, as well as review the evidence for efficacy, safety, and clinical use of anti-VEGF treatment for mCNV.

A Crossover Design for Comparative Efficacy: A 36-Week Randomized Trial of Bevacizumab and Ranibizumab for Diabetic Macular Edema

PURPOSE

To investigate the comparative efficacy of bevacizumab (Avastin) and ranibizumab (Lucentis; both Genentech, Inc, South San Francisco, CA) for diabetic macular edema (DME) using a crossover study design.

DESIGN

Randomized, double-masked, 36-week, 3-period crossover clinical trial.

PARTICIPANTS

Fifty-six subjects with DME involving the center of the macula in one or both eyes.

METHODS

Monthly intravitreous injections of bevacizumab (1.25 mg) or ranibizumab (0.3 mg).

MAIN OUTCOME MEASURES

Comparison of mean changes in visual acuity and central retinal thickness, tested using a linear mixed-effects model.

RESULTS

Based on the linear mixed-effects model, the 3-month estimated mean improvement in visual acuity was 5.3 letters for bevacizumab and 6.6 letters for ranibizumab (difference, 1.3 letters; P = 0.039). Estimated change in optical coherence tomography (OCT) central subfield mean thickness (CSMT) was -89 μm for bevacizumab and -137 μm for ranibizumab (difference, 48 μm; P < 0.001). Incorporating cumulative treatment benefit, the model yielded a predicted 36-week (9-month) average improvement in visual acuity of 7.1 letters (95% confidence interval [CI], 5.0-9.2) for bevacizumab and 8.4 letters (95% CI, 6.3-10.5) for ranibizumab, and a change in OCT CSMT of -128 μm (95% CI, -155 to -100) for bevacizumab and -176 μm (95% CI, -202 to -149) for ranibizumab. There was no significant treatment-by-period interaction (i.e., treatment difference was constant in all 3 periods), nor was there a significant differential carryover effect from one period to the next.

CONCLUSIONS

This trial demonstrated a statistically significant but small relative clinical benefit of ranibizumab compared with bevacizumab for treatment of DME, using a markedly reduced sample size relative to a full comparative efficacy study. The effects on visual acuity and central retinal thickness for the 2 drugs are consistent with those reported at 1 year for the concurrent parallel-group trial by the Diabetic Retinopathy Clinical Research Network testing bevacizumab, ranibizumab, and aflibercept for DME. The 3-period crossover design allowed for meaningful and efficient comparison, suggesting that this approach may be useful for future comparative efficacy studies of anti-vascular endothelial growth factor drugs for DME.

Vascular endothelial growth factor inhibitor use and treatment approach for choroidal neovascularization secondary to pathologic myopia

INTRODUCTION

Myopic choroidal neovascularization (CNV) is the most common cause of CNV in those under 50 years of age. It is a significant cause of visual loss in those with pathologic myopia. The current standard of care involves therapy with intravitreal inhibitors of vascular endothelial growth factor (VEGF).

AREAS COVERED

The epidemiology of myopia, high myopia, pathologic myopia, and myopic CNV is reviewed, along with a brief discussion of historical treatments. The pharmacology of the three most commonly used anti-VEGF agents is discussed, with an emphasis on the licensed drugs, ranibizumab and aflibercept. A comprehensive clinical approach to diagnosis and treatment of myopic CNV is presented.

EXPERT OPINION

The current standard of care for myopic CNV is intravitreal inhibition of VEGF, with ranibizumab and aflibercept licensed for intraocular use. The diagnosis, OCT features of disease activity and retreatment algorithm for myopic CNV is different from wet age-related macular degeneration. In the long-term, myopic CNV may be associated with gradual, irreversible visual loss due to progressive chorioretinal atrophy, for which there is currently no treatment.

The role of anti-VEGF agents in myopic choroidal neovascularization: Current standards and future outlook

INTRODUCTION

The global prevalence of pathologic myopia is 0.9-3.1%, and visual impairment is found in 0.1-0.5% of European and 0.2-1.4% of Asian studies. Myopic choroidal neovascularization (mCNV) affects 5.2-11.3% of pathologic myopia patients and is a leading cause of vision impairment in the working-age population. Characteristic morphological changes and visual-acuity decrease are diagnostic features. Vascular-Endothelial-Growth-Factor (VEGF) has been identified as a trigger for pathologic neovascularization in these highly myopic patients.

AREAS COVERED

We cover the epidemiology, pathology and diagnostic aspects of mCNV. The history of therapeutic interventions is described, followed by an overview of current standard-of-care (SOC)-blocking VEGF using bevacizumab (off-label), ranibizumab or aflibercept and improving vision up to 13.5-14.4 letters. Despite good efficacy, an unmet medical need remains. We summarize ongoing and future developments of new drugs to treat or potentially cure mCNV.

EXPERT OPINION

mCNV is a major global health concern. Early detection and treatment is key for a satisfying outcome. The current SOC, VEGF inhibitors, affords good therapeutic efficacy and reasonable disease stabilization with few intravitreal treatments per year. However, the long-term prognosis is still unsatisfactory, and side-effects like chorioretinal atrophy development are of concern. Therefore, efforts should be intensified to develop more effective therapies.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NAIVE IDIOPATHIC CHOROIDAL NEOVASCULARIZATION: A Comparative Study

PURPOSE

To determine the clinical characteristics of patients with idiopathic choroidal neovascularization and to compare outcomes between intravitreal bevacizumab (IVB) and ranibizumab as therapy.

METHODS

Retrospective analysis included demographics, the corrected distance visual acuity, details of the ocular examination, imaging, treatment, outcomes, and adverse events. Patients with minimum of 1-year follow-up were included in the study. Primary outcome measure was change in corrected distance visual acuity at the final visit compared with baseline. Secondary outcome measures were change in central macular thickness and subretinal fluid (if present) with treatment and adverse events.

RESULTS

This study included 47 eyes of 45 patients with 30 males. Intravitreal bevacizumab group included 29 eyes (27 patients; with a median age of 39.4 ± 7.3 years). Intravitreal ranibizumab group included 18 eyes (18 patients; median age: 36.8 ± 9.3 years). Median baseline corrected distance visual acuity (logMAR) improved from 0.59 ± 0.38 to 0.2 ± 0.18 (P = 0.03) in intravitreal ranibizumab group and from 0.62 ± 0.41 to 0.18 ± 0.15 logMAR (P = 0.023) in intravitreal bevacizumab group. Median central macular thickness (in micrometers) improved from 315.11 ± 75.24 to 228.24 ± 67 (P = 0.036) in intravitreal bevacizumab group and from 327.24 ± 61.56 to 208 ± 53.42 (P = 0.031) in intravitreal ranibizumab group. There was no significant difference between groups in final corrected distance visual acuity (P = 0.31) or central macular thickness (P = 0.51). No adverse events were noted.

CONCLUSION

Both intravitreal ranibizumab and intravitreal bevacizumab seem equally effective in treating idiopathic choroidal neovascularization with a good safety profile without recurrence.

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

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

Anti-VEGF therapies in the treatment of choroidal neovascularisation secondary to non-age-related macular degeneration: a systematic review

OBJECTIVES

The aim of this study is to systematically review the evidence for anti-vascular endothelial growth factor (VEGF) therapy in choroidal neovascularisation secondary to conditions other than age-related macular degeneration.

DATA SOURCES

MEDLINE, MEDLINE in-process, EMBASE and CENTRAL databases and conference abstracts were searched (from inception to Jan 2014).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Randomised and non-randomised comparative studies with follow-up of at least 6 months were included and were used to assess clinical effectiveness.

STUDY APPRAISAL AND SYNTHESIS METHOD

Risk of bias was assessed using the Cochrane risk of bias tool and modified Newcastle-Ottawa Scale. Meta-analysis was not possible due to methodological heterogeneity.

RESULTS

16 studies met the inclusion criteria (1091 eyes; 963 pathological myopia, 74 other conditions). There was large variation in risk of bias across studies. An improvement in best-corrected visual acuity in anti-VEGF arms over comparators was reported in all studies. The proportion of patients improving by at least 15 letters in anti-VEGF arms ranged from 27.3% to 70%. There were no significant differences between bevacizumab and ranibizumab.

LIMITATIONS

Owing to the rarity of choroidal neovascularisation secondary to conditions other than age-related macular degeneration or pathological myopia, there are unlikely to ever be sufficiently powered trials in these populations.

CONCLUSIONS

Bevacizumab and ranibizumab appear to be effective in improving visual acuity for patients with choroidal neovascularisation secondary to conditions other than age-related macular degeneration. The evidence base is strongest for choroidal neovascularisation secondary to pathological myopia, however, based on current evidence and likely pharmacological pathways, clinicians should consider treatment with either bevacizumab or ranibizumab for rarer causes.

Current and emerging treatment options for myopic choroidal neovascularization

Choroidal neovascularization (CNV) is the main cause of visual impairment in highly myopic patients younger than 50 years of age. There are different treatments for myopic CNV (mCNV), with 5- to 10-year outcomes currently. Chorioretinal atrophy is still the most important determinant factor for visual outcome. The purpose of this study is to provide an overview of the current treatments for mCNV, including laser, surgical management, verteporfin photodynamic therapy, and mainly anti-vascular endothelial growth factor therapy. Emerging treatment options are also discussed.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ranibizumab versus bevacizumab for ophthalmic diseases related to neovascularisation: a meta-analysis of randomised controlled trials

Background

Bevacizumab is believed to be as effective and safe as ranibizumab for ophthalmic diseases; however, its magnitude of effectiveness and safety profile remain controversial. Thus, a meta-analysis and systematic review appears necessary.

Methods

PubMed and EMBASE were systematically searched with no restrictions. All relevant citations comparing ranibizumab and bevacizumab were considered for inclusion. Pooled effect estimates were obtained using a fixed- and random-effects meta-analysis.

Results

Nine independent randomised-controlled clinical trials (RCTs) involving 2,289 participants were identified. Compared with bevacizumab, the overall combined weighted mean difference (WMD) of the mean change in visual acuity for ranibizumab was 0.52 letters (95% CI −0.11–1.14). The odds ratios (ORs) of gaining ≥15, gaining 5–14, losing 5–14 and losing ≤15 letters were 1.10 (95% CI 0.90–1.33), 0.93 (95% CI 0.77–1.11), 0.89 (95% CI 0.65–1.22) and 0.95 (95% CI 0.73–1.25), respectively. The risk of serious systemic events increased by 17% (95% CI 6%–27%, p = 0.0042) for bevacizumab treatment in comparison with ranibizumab. No statistically significant differences between the two treatments were found for the nonfatal arterial thrombotic events, ocular serious adverse, death from vascular and all causes events.

Conclusions

Bevacizumab is not inferior to ranibizumab as a treatment for achieving visual acuity. The use of bevacizumab was associated with an increased risk of developing serious systemic events. Weighing the costs and health outcomes is necessary when selecting between bevacizumab and ranibizumab for ophthalmic diseases. Due to the limitations of the available data, further research is needed.

Myopic choroidal neovascularisation: current concepts and update on clinical management

Choroidal neovascularisation (CNV) is a common vision-threatening complication of myopia and pathological myopia. Despite significant advances in understanding the epidemiology, pathogenesis and natural history of myopic CNV, there is no standard definition of myopic CNV and its relationship to axial length and other myopic degenerative changes. Several treatments are available to ophthalmologists, but with the advent of new therapies there is a need for further consensus and clinical management recommendations. Verteporfin photodynamic therapy has been an established treatment for subfoveal myopic CNV for many years, but this treatment does not restore visual acuity and is associated with long-term chorioretinal atrophy. More recently, clinical trials investigating the efficacy and safety of anti-vascular endothelial growth factor agents in patients with myopic CNV have demonstrated substantial visual acuity gains and quality of life increases compared with photodynamic therapy. These enhanced outcomes provide updated evidence-based clinical management guidelines of myopic CNV, and increase the need for a generally accepted definition for myopic CNV. This review critically summarises the latest myopic CNV literature in the context of clinical experience and recommends a myopic CNV treatment algorithm.