ALTERATIONS OF VASCULAR PIGMENT EPITHELIUM DETACHMENTS ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION DURING UPLOAD WITH INTRAVITREAL RANIBIZUMAB

Reliability and Reproducibility of Pigment Epithelial Detachment Volume Measurements in AMD Using a New Tool: ReVAnalyzer

BACKGROUND AND OBJECTIVE

To describe and present the reliability and reproducibility of a new software, Retinal Volume Analyzer (ReVAnalyzer), for pigment epithelium detachment (PED) volume quantification.

PATIENTS AND METHODS

This is a retrospective study including patients with PEDs secondary to exudative age-related macular degeneration (AMD). Macular volume scans on spectral-domain optical coherence tomography on enhanced depth imaging mode were performed in all eyes. Image batches were then exported in .xml format to the ReVAnalyzer software. A semiautomated PED volume measurement was performed by three independent readers (RBG, VC, OS) twice, at the beginning and end of a 15-day period. Bland-Altman assessment for agreement was used to compare intra- and interobserver observations.

RESULTS

Twenty eyes of 20 patients presenting with PED were analyzed. Bland-Altman analysis indicated a good agreement between inter- and intraobserver measurements. The intraclass correlation coefficient for intraobserver PED volume measurements and between the three observers (interobserver) was greater than 0.99, demonstrating high reproducibility and consistency of the methodology.

CONCLUSIONS

ReVAnalyzer is a reliable tool that can assist in the analysis of PED volume with high reproducibility. This type of specific retinal volume analysis can be of help for monitoring disease activity and therapeutic response in AMD. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e242-e249.].

Ranibizumab versus aflibercept for the treatment of vascularized pigment epithelium detachment due to age-related macular degeneration

PURPOSE

To compare the efficacy and safety of two intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, ranibizumab and aflibercept, for the treatment of vascularized pigment epithelium detachment (vPED) due to age-related macular degeneration (AMD) in a follow-up time of 12 months.

METHODS

Participants in this study were 71 patients (71 eyes) with vPED due to AMD, who were treated with intravitreal 0.5 mg ranibizumab (n = 38) or 2.0 mg aflibercept (n = 33) and had at least 12-month follow-up. All patients underwent best-corrected visual acuity (BCVA) measurement and optical coherence tomography at baseline and at every visit. The PED height, the presence of subretinal fluid (SRF), intraretinal fluid and diffuse macular edema (DME) were recorded at each visit.

RESULTS

There was a statistically significant difference in BCVA between the two groups at month 12 in favor of aflibercept. However, both agents were found to improve or stabilize BCVA in the majority of patients at the end of the follow-up. The change in PED height did not differ significantly between the two groups at the end of the follow-up with similar number of injections. At month 12, there was a significant improvement in SRF presence in both groups compared to baseline.

CONCLUSIONS

Although aflibercept was found to be superior to ranibizumab regarding BCVA improvement, both agents showed anatomical effectiveness with significant reduction in PED height and SRF absorption in patients with vPED due to AMD.

Response of vascular pigment epithelium detachment due to age-related macular degeneration to monthly treatment with ranibizumab: the prospective, multicentre RECOVER study

PURPOSE

To assess the effects of monthly intravitreal ranibizumab injections in patients with vascularized pigment epithelium detachment (vPED) secondary to age-related macular degeneration (AMD).

METHODS

A total of 40 patients were prospectively observed and treated monthly with 0.5 mg ranibizumab injections (ClinicalTrials.gov Ident. NCT00976222). Inclusion criterion was a treatment-naïve vPED lesion with a minimum height of ≥200 μm. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) were evaluated at all visits. Fluorescein angiography and indocyanine green angiography were performed at baseline and quarterly. Lesions were differentiated between serous vascular PED (svPED, group A, 29 patients) and fibrovascular PED (fPED, group B, 11 patients). Primary outcome was the effectivity of continuous monthly treatment during a 12-month period as measured in change in BCVA. Secondary outcomes were change in PED height and PED greatest linear diameter (GLD). Further secondary outcomes were the presence of subretinal fluid and prognostic markers of an impending retinal pigment epithelium (RPE) tear: PED lesion height and diameter, ratio of choroidal neovascularization (CNV) size to PED size, hyperreflective lines in near-infrared images, microrips and subretinal cleft.

RESULTS

Mean BCVA was 56.9 ± 11.5 letters (A: 55.4 ± 10.8; B: 59.1 ± 13.4) at baseline and 55.1 ± 15.9 (A: 53.7 ± 17.0; B: 58.9 ± 12.7) at 12-month follow-up. Excluding the RPE tear patients, the svPED group showed an increase in BCVA from 56.1 ± 10.3 at baseline to 62.4 ± 10.2 at 12-month follow-up (p = 0.048). Best-corrected visual acuity in patient who developed a RPE tear was 55.8 ± 12.5 at baseline and 37.1 ± 14.9 at 12-month follow-up. The mean change in PED height was -242.1 μm ± 285.5 (A: -427.3 μm ± 299.7; B: -51.6 μm ± 99.5). The mean decrease in PED GLD was -471.8 μm ± 727.6 (A: -738.9 μm ± 788.2; B: -10.4 μm ± 185.6). In group A, 10 patients developed a RPE tear (25%) after a mean of 3.6 injections. No tear was documented in group B. Lesion height, ratio of CNV size to PED size and presence of hyperreflective lines differed significantly between patients with and without RPE tear development.

CONCLUSION

Serous vascular PED lesions showed an improvement regarding BCVA and morphologic characteristics unless an RPE tear occurred. In fPED lesions, a functional and morphological stabilization was observed. Monthly ranibizumab injections are an effective treatment regarding the resorption of subretinal fluid in vPED due to AMD. Patients should be screened for the presence of morphologic risk factors for RPE tear development before and during treatment.

Real-world visual acuity outcomes between ranibizumab and aflibercept in treatment of neovascular AMD in a large US data set

Purpose

To examine 12-month real-world visual acuity outcomes and treatment patterns in neovascular age-related macular degeneration (nAMD) eyes, including those with pigment epithelial detachment (PED), receiving ranibizumab or aflibercept.

Patients and methods

Electronic medical records were used to identify ranibizumab or aflibercept-treated nAMD eyes with 12 months follow-up from first prescription. The primary objective was to compare mean change in visual acuity (VA) between index and month 12, in eyes treated with ranibizumab and aflibercept to assess the non-inferiority of ranibizumab vs aflibercept using a −5 letter non-inferiority margin. The number of injections and non-injection visits during follow-up were key secondary objectives.

Results

A total of 3350 ranibizumab and 4300 aflibercept treatment-naive eyes were included. At month 12, mean change from index in VA letter score was −0.30 for ranibizumab and −0.19 for aflibercept (P=0.81). The adjusted difference of mean change was −0.14 (−0.79 to 0.51) (P=0.67) (generalized estimating equations method) confirming the non-inferiority of ranibizumab. Eyes received a similar number of injections during follow-up. The mean (±SD) number of ranibizumab and aflibercept injections were 6.70 (±2.54) and 7.00 (±2.40), respectively (P<0.0001). In PED eyes, the mean (±SD) change between baseline to month 12 was 1.25 (±11.3) for ranibizumab and −0.39 (±13.3) for aflibercept (adjusted between-group difference 1.80 (−0.71 to 4.30; P=0.16)) achieved with a mean (±SD) 7.85 (±2.68) ranibizumab and 7.47 (±2.45) aflibercept injections, (P=0.11).

Conclusions

Ranibizumab and aflibercept treatment yielded comparable VA outcomes in nAMD eyes, including those with PED, with similar treatment patterns over 12 months in real-world clinical practice.

PIGMENT EPITHELIAL DETACHMENT RESPONSE TO AFLIBERCEPT IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION REFRACTORY TO RANIBIZUMAB: Time Course and Drug Effects

PURPOSE

To investigate the time course of pigment epithelium detachment (PED) height and its change after anti-vascular endothelial growth factor switch from ranibizumab to aflibercept in neovascular age-related macular degeneration.

METHODS

This retrospective study included 60 eyes of 50 consecutive patients with neovascular age-related macular degeneration who showed refractory intraretinal or subretinal fluid (≥9 months) despite monthly ranibizumab treatment and an associated PED (height ≥150 μm). The treatment was switched to aflibercept, and patients were followed-up for at least 9 months. Data on the height and type of PED, exudative fluid, and best-corrected visual acuity were collected at four different time points (two before and two after the drug switch).

RESULTS

The maximal PED height was significantly decreased over time, both under ranibizumab and aflibercept treatment. However, the reduction was significantly greater during the 3 months after the switch to aflibercept, due to two outliers. Visual acuity remained stable. Complete resolution of intraretinal or subretinal fluid was observed in 9 cases (15%) at 3 months after switch, allowing for treatment interval extension.

CONCLUSION

Maximal PED height continuously decreased over time. Switching the intravitreal anti-vascular endothelial growth factor medication from ranibizumab to aflibercept had a significantly stronger short-term effect on PED height reduction, without changes in visual acuity.

Retinal Pigment Epithelium Tears: Risk Factors, Mechanism and Therapeutic Monitoring

Tears of the retinal pigment epithelium (RPE) are most commonly associated with vascularised RPE detachment due to age-related macular degeneration (AMD), and they usually involve a deleterious loss in visual acuity. Recent studies suggest an increase in RPE tear incidences since the introduction of anti-vascular endothelial growth factor (anti-VEGF) therapies as well as a temporal association between the tear event and the intravitreal injection. As the number of AMD patients and the number of administered anti-VEGF injections increase, both the challenge of RPE tear prevention and the treatment after RPE tear formation have become more important. At the same time, the evolution of retinal imaging has significantly contributed to a better understanding of RPE tear development in recent years. This review summarises the current knowledge on RPE tear development, predictive factors, and treatment strategies before and after RPE tear formation.

Factors Influencing the Treatment Response of Pigment Epithelium Detachment in Age-Related Macular Degeneration

PURPOSE

To study the effect of various baseline factors, particularly the type of drug (ranibizumab vs aflibercept), on the functional and anatomic response of treatment-naïve pigment epithelial detachment (PED) associated with neovascular age-related macular degeneration (neovascular AMD), after 3 intravitreal injections.

DESIGN

Retrospective consecutive case series.

METHODS

This study included 102 patients (n = 115 eyes) with treatment-naïve neovascular AMD and PED (>150 μm), who were treated with either ranibizumab (n = 68 eyes) or aflibercept (n = 47 eyes). A multivariate analysis using stepwise linear regression was performed in order to assess factors influencing visual acuity improvement, as well as treatment response of PED height after 3 monthly injections.

RESULTS

Multivariate analysis revealed that better visual improvement was associated with lower best-corrected visual acuity (BCVA) at baseline (P = .001), presence of subretinal fluid (P = .001), and retinal angiomatous proliferation (P = .001); PED reduction was associated with higher PED at baseline (P = .001), predominantly serous PED (P = .003), and the use of aflibercept (P = .022). Drug type was not associated with change in BCVA at 3 months.

CONCLUSION

Eyes with neovascular AMD and PED showed significant functional and anatomic response after 3 monthly intravitreal anti-VEGF injections. The functional response depended on baseline BCVA, presence of subretinal fluid, and retinal angiomatous proliferation, while anatomic response was influenced by baseline PED height, degree of vascularization, and drug type. Drug type was not associated with change in BCVA, but had a weak effect on anatomic response.