Best practices for treatment of retinal vein occlusion. Curr Opin Ophthalmol. 2012;23:175-181. [PMID: 22450223 DOI: 10.1097/icu.0b013e3283524148]

Effects of Repeated Intravitreal Injections of Dexamethasone Implants on Intraocular Pressure: A 4-Year Study

Purpose

Dexamethasone and other corticosteroids are administered intravitreally to treat a variety of retinal diseases. As a side effect, they can alter intraocular pressure (IOP). The purpose of this study is to describe the incidence, severity, and management of ocular hypertension following the administration of multiple intravitreal injections of dexamethasone implants.

Materials and Methods

A total of 78 eyes of 78 subjects (males 62%; females 38%; mean age 67 ± 13 years SD) received a total of 152 intravitreal injections of 0.7 mg dexamethasone implants over 4 years. Indications included retinal vein occlusion (87%), diabetic macular edema (9%), wet-type age-related macular degeneration (4%). Ocular hypertension was defined as intraocular pressure above 23 mmHg or any pressure increase of 10 mmHg or more from baseline values. IOP was measured by applanation tonometry before the injection (T0), as well as one week (T1), one month (T2), and three months (T3) afterwards.

Results

Five percent (4/78) of subjects developed ocular hypertension after the 1st injection. On the second and third rounds, additional 7.2% (3/42) and 4.2% (1/24) of subjects developed the same side effect. Among the 8 subjects who received a fourth injection, none was found with OHT. Pressure elevations were detected at T2 and T3. In all patients, topical medical therapy was sufficient to lower the IOP below threshold. Mean pressure variations following the first injection as compared to previous recorded values were +0.97 mmHg (T1), +0.92 mmHg (T2), and -0.41 mmHg (T3) (p < 0.05). Mean pressure variations following the second injection were +0.54 mmHg (T1), +0.23 mmHg (T2) and -0.66 mmHg (T3) (p < 0.05).

Conclusion

Ocular hypertension is a recognized side effect of intravitreal dexamethasone. Some patients develop it right after the first injection, while others develop it subsequently, on the 2nd or 3rd round. This side effect becomes most apparent 30-90 days following the implantation procedure and responds well to topical pressure-lowering medications.

Efficacy of intravitreal Lucentis injection on major and macular branch retinal vein occlusion

Background

The objective of our study was to assess the efficacy of intravitreal Lucentis injection on major and macular branch retinal vein occlusion (BRVO).

Methods

In this retrospective analysis, 43 patients (major BRVO n = 24; macular BRVO, n = 19) were treated with intravitreal injection of Lucentis with a 1 + PRN regimen, which is diagnosed by fluorescein fundus angiography (FFA). “1 + PRN”, namely, one intravitreal injection of Lucentis at the baseline, and then continue or stop according to the condition of the patient. The following observation indexes were measured at baseline and follow-up (1–6 months): best corrected visual acuity (BCVA), foveal thickness (CFT), total retinal volume with macular diameter of 6 mm. During the follow-up, repeated injections were given according to patients’ demand, and the number of injections was recorded.

Result

The observation indexes of patients with BRVO were significantly improved after 6 months of Lucentis treatment in both major and macular groups, including BCVA, CFT and the retinal volume of the 6 mm-diameter macula. Interestingly, there were significant differences in the therapeutic effect between the two groups, and the macular group had better therapeutic effect than the major group with the less number of repeated injections.

Conclusions

To sum up, intravitreal injection of Lucentis was effective for both major and macular BRVO, and the efficacy in macular subtype group was better than that in major subtype group with the more obviously improvement and the less number of injections.

Implementation of Lean healthcare methodology in designing an Intravitreal Injection Center: first Italian experience

PURPOSE

The principles of the Lean methodology, introduced by Toyota to improve productivity, are relevant to other settings, including healthcare. We aimed to use Lean methodology to design a new setting in our ophthalmology clinic to improve the management of patients receiving an intravitreal injection for ocular diseases.

METHODS

The location of services, days of operation, scheduling and processing of patients, utilization of staff, data recording methods, and examination and surgical procedures were analyzed, and a new Intravitreal Injection Center was developed according to Lean principles.

RESULTS

The new setting, which is confined to a single floor, in contrast to the previous system, which necessitated that patients visit various locations spread over three floors of the hospital, demonstrated benefits for patients and improved the flow and management of patients through the system with a need for fewer team members. The intravitreal injection service improved with regard to both the quality and speed of the overall procedure and the efficient use of staff.

CONCLUSION

Our aim to achieve a fast and one-way route to move patients through intravitreal injection administration was achieved, limiting any waste of time and space and improving the capacity management of the center. The system is of relevance to other ophthalmology clinic settings and facilitates the collection of valuable epidemiological and clinical information on the response of patients to different drugs and treatment regimens.

A Meta-Analysis of Cardiovascular Events Associated with Intravitreal Anti-VEGF Treatment in Patients with Retinal Vein Occlusion

Purpose: Retinal vein occlusion is associated with an increased risk of cardiovascular diseases. Anti-vascular endothelial growth factor has been widely used as a treatment option. However, the systemic safety of intravitreal anti-vascular endothelial growth factor for retinal vein occlusion patients is still unclear.Materials and Methods: A meta-analysis was conducted to investigate all randomized controlled trials published up to February 2019 of retinal vein occlusion patients who received intravitreal anti-vascular endothelial growth factor vs. control treatments. Fixed effect models were used and results were reported as odds ratios and 95% confidence intervals.Results: Eight trials that evaluated 2320 patients were retrieved. Anti-vascular endothelial growth factor did not significantly increase the risks of cardiovascular events (odds ratio,1.54; 95% confidence interval, 0.66-3.57), hypertension (odds ratio, 0.92; 95% confidence interval, 0.63-1.33), or heart rate disorders (odds ratio,1.53; 95% confidence interval, 0.37-6.28) when compared with control treatment. Subgroup analyses did not show a significant increase of cardiovascular events in aflibercept (odds ratio,1.96; 95% confidence interval, 0.44-8.81) vs. ranibizumab trials (odds ratio, 1.47; 95% confidence interval, 0.54-4.02); 0.5 mg ranibizumab trials (odds ratio, 1.73; 95% confidence interval, 0.61-4.96) vs. 0.3 mg ranibizumab trials (odds ratio, 0.70; 95% confidence interval, 0.14-3.59); nor branch retinal vein occlusion (odds ratio, 1.32; 95% confidence interval, 0.40-4.33) vs. central retinal vein occlusion trials (odds ratio, 1.93; 95% confidence interval, 0.59-6.29).Conclusions: Intravitreal administration of anti-vascular endothelial growth factor did not significantly increase the risks of cardiovascular events, hypertension or heart rate disorders in retinal vein occlusion patients.

Mapping research trends of retinal vein occlusion from 2009 to 2018: a bibliometric analysis

Objectives

To map publication trends and explore research hotspots of retinal vein occlusion (RVO) study.

Methods

Based on Web of Science Core Collection (WoSCC), a bibliometric analysis was carried out. The knowledge map was constructed by VOSviewer v.1.6.10 to visualize the annual publication number, the distribution of countries, international collaborations, author productivity, source journals, cited reference and keywords in this field.

Results

A total of 2,135 peer-reviewed papers were retrieved on RVO from 2009 to 2018. The United States ranks highest among countries with the most publications and the most active institution was Kyoto University. Noma H contributed the most publications in this field. Retina-The Journal of Retinal and Vitreous Disease was the most prolific journal in RVO research. The top cited references mainly presented anti-VEGF medications on the management of RVO. The keywords formed six clusters: (1) Risk factors and pathogenesis of RVO; (2) Metabolismof RVO; (3) Therapeutic use of corticosteroids on RVO; (4) Diagnostic methodsof RVO; (5) Management of macular edema secondary to RVO (6) Anti-VEGFtreatment of RVO.

Conclusions

The six major research hotspots could provide an insight into RVO research and valuable information for researchers to identify potential collaborators and partner institutions.

Intravitreal dexamethasone implants versus intravitreal anti-VEGF treatment in treating patients with retinal vein occlusion: a meta-analysis

Background

Retinal vein occlusion (RVO) is a common retinal venous disorder that causes vision loss. No specific therapy has been developed. Controversy exists regarding two treatments: intravitreal dexamethasone implants and anti-vascular endothelial growth factor (VEGF). The goal of this study is to compare the effectiveness and safety of dexamethasone implants and anti-VEGF treatment for RVO.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for studies comparing dexamethasone implants with anti-VEGF in patients with RVO. Best-corrected visual acuity (BCVA), central subfield thickness (CST), intraocular pressure changes, conjunctival haemorrhage, reduced VA, and macular oedema were extracted from the final included studies. RevMan 5.3 was used to conduct the quantitative analysis and bias assessment.

Results

Four randomised controlled trials assessing 969 eyes were included. The anti-VEGF treatment showed better BCVA improvement (mean difference [MD] = − 10.59, P < 0.00001) and more CST decrease (MD = − 86.71 μm, P = 0.02) than the dexamethasone implants. However, the dexamethasone implants required fewer injections. As for adverse effects, the dexamethasone implants showed significantly higher intraocular pressure (IOP) and more cataracts than the anti-VEGF treatment. No significant differences were found in conjunctival haemorrhage, reduced VA, and macular oedema.

Conclusions

Anti-VEGF treatment showed better functional and anatomical improvement with less risk of IOP elevation and cataract formation compared to dexamethasone implants. Thus, anti-VEGF treatment is the first choice for treating RVO patients.

Efficacy of Multiple Dexamethasone Intravitreal Implants for Refractory Retinal Vein Occlusion-Related Macular Edema and Effect of Prior Vitrectomy

Purpose: To evaluate the efficacy of dexamethasone intravitreal implants (DEX implant) in patients with treatment-resistant macular edema (ME) owing to branch and central retinal vein occlusion (BRVO/CRVO), and the influence of prior vitrectomy on this treatment. Methods: Multicenter retrospective chart review was performed on 40 CRVO and 32 BRVO eyes with persistent ME despite intravitreal anti-vascular endothelial growth factor agents and/or intravitreal triamcinolone, and/or laser therapy. Each patient received ≥1 dexamethasone 700 μg implant between March 2011 and December 2015. Thirteen patients underwent prior vitrectomy. Data were collected on best-corrected visual acuity (BCVA), central macular thickness (CMT), time to relapse, and adverse events. Results: At the end of follow-up, BRVO eyes had a lesser CMT reduction from baseline compared to CRVO eyes (-122.50 ± 152.47 μm and -202.26 ± 194.09 μm, respectively). Neither BRVO nor CRVO eyes had a sustained BCVA benefit (P = 0.7041 and P = 0.7027, respectively). Vitrectomized and nonvitrectomized eyes overall had a sustained significant CMT reduction throughout the study with -192.46 ± 172.62 μm and -164.02 ± 180.36 μm, respectively, at final follow-up. Similar time to relapse of 24.4 ± 6.5 and 23.3 ± 13.5 weeks, respectively, was observed. By the end of follow-up, BCVA had only improved in vitrectomized eyes. However, multivariable regression analyses showed no significant association between vitrectomy status and CMT or BCVA change after the first and last injection. Cataract formation and ocular hypertension occurred in 25% and 17%, respectively. Conclusions: Multiple DEX implant are effective in reducing CMT in patients resistant to previous treatments and appear to be similarly effective in vitrectomized and nonvitrectomized eyes.

Real-World Results of Switching Treatment from Ranibizumab to Aflibercept in Macular Oedema Secondary to Branch Retinal Vein Occlusion

Introduction

To investigate treatment outcomes after switching from ranibizumab to aflibercept intravitreal injections in patients with macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

Methods

Eligible patients with refractory MO secondary to BRVO, post treatment with a minimum of three intravitreal injections of ranibizumab at 4-weekly intervals were recruited. Suboptimal or non-responders were defined as patients who had persistent intraretinal fluid (< 75% decrease from baseline) despite a minimum of three consecutive injections. These patients were switched to aflibercept injections on an as-needed basis. The primary study outcomes assessed trends in best-corrected distance visual acuity (BCVA) and central retinal thickness (CRT). To compare means of BCVA and CRT, a paired t test two-tailed with a level of significance set at 0.05 was used. Pearson correlation coefficient was also applied to demonstrate correlation. Participants were followed up for a period of 24 weeks after switching.

Results

Thirty-eight eyes of 38 patients were included in the study. Patients had an average of 8.37 ranibizumab intravitreal injections over a mean period of 12 months presenting suboptimal or no response. A significant decrease of mean CRT from 388.63 ± 93.4 μm to 290.29 ± 93.5 μm (p < 0.001) and an improvement in mean BCVA from logMAR 0.66 ± 0.38 to logMAR 0.57 ± 0.27 (p = 0.025) was achieved after an average of 2.27 aflibercept injections.

Conclusions

Given the spectrum of therapies available to date for the management of MO secondary to BRVO, aflibercept appears to be an effective treatment option in cases refractory to ranibizumab. This study based on a small cohort of patients indicates that satisfactory results on retinal anatomy and visual outcomes can be accomplished with a smaller number of injections. Larger-scale studies are needed to extrapolate these promising results.

Effect of dexamethasone intravitreal implant (Ozurdex®) on corneal endothelium in retinal vein occlusion patients : Corneal endothelium after dexamethasone implant injection

BACKGROUND

To assess corneal endothelial cell changes after intravitreal dexamethasone (DEX) implant (Ozurdex®) injection in patients with macular edema secondary to retinal vein occlusion (RVO).

METHODS

Twenty-two eyes of 22 patients were assessed prospectively after intravitreal 0.7 mg DEX implant injection. Twenty-two eyes of 22 healthy volunteers served as control group. Corneal endothelial cell parameters including endothelial cell density (ECD), coefficient of variation of cell size (CV), percentage of hexagonality (Hex) and central corneal thickness (CCT) were analyzed before and 1 and 3 months after injection by specular microscopy. The results of the study were compared statistically.

RESULTS

There were 17 (77.3%) patients with branch RVO and 5 (22.7%) patients with central RVO. Mean intraocular pressure (IOP) was 14.73 mmHg before injection, 17.05 mmHg at 1 month and 17.15 mmHg at 3 months after injection. Mean IOP at 1 and 3 months were significantly higher than pre-injection value (p = 0.002 and p = 0.003, respectively). There was a statistically significant reduction in mean ECD at 3 months after injection compared to pre-injection and 1 month (p = 0.013, p = 0.009, respectively) in the injected eyes. Mean ECD showed no significant difference in the uninjected fellow eyes during the follow up (p>0.05). Mean CV and Hex did not reveal a statistically significant difference in injected and uninjected fellow eyes (p > 0.05). No significant change was observed in mean CCT values during the follow up (p = 0.8).

CONCLUSION

Intravitreal dexamethasone implant may cause a transient reduction in corneal endothelial cell density in short term without changing cell morphology.

Comparison between intravitreal bevacizumab and posterior sub-tenon injection of triamcinolone acetonide in macular edema secondary to retinal vein occlusion

Aim

To compare the efficacy and safety between posterior sub-tenon injection of triamcinolone acetonide (PSTA) and intravitreal injection of bevacizumab (Avastin) (IVIA) in the treatment of macular edema secondary to retinal vein occlusion.

Patients and methods

A total of 45 eyes were retrospectively enrolled (23 eyes with intravitreal bevacizumab and 22 eyes with posterior sub-tenon triamcinolone acetonide). Main endpoints included logMAR of best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) before and after treatment at 6 months.

Results

The mean logMAR improved from 0.78 to 0.56 at 6 months for intravitreal bevacizumab (p=0.001), and from 0.91 to 0.79 and 0.87 at 3 and 6 months (p=0.038 and 0.13), respectively, for sub-tenon triamcinolone acetonide. At 6 months, the BCVA was significantly better in the bevacizumab group (p=0.02). Both groups' mean CMT significantly improved, from 478 µm at baseline to 295 µm at 6 months in IVIA group (p<0.001) and from 419 µm at baseline to 350 µm in PSTA group (p=0.012); however, this was not different between the groups at 6 months (p=0.065). Recurrence of macular edema was not different between the groups either (p=0.08). Poorer final vision was associated with poorer baseline BCVA and diagnosis of central retinal vein occlusion after adjustment for age and sex (p<0.001 and 0.012, respectively). Significant elevation of IOP was noted at 3 months in the PSTA group, but declined at 6 months compared with baseline (p=0.002 and 0.41, respectively).

Conclusion

Intravitreal bevacizumab seemed to achieve better visual acuity compared with posterior sub-tenon injections of triamcinolone acetonide at 6 months, while CMT was comparable. PSTA still resulted in transient IOP elevation.

Real-Life Clinical Effectiveness of Razumab® (the World's First Biosimilar of Ranibizumab) in Retinal Vein Occlusion: A Subgroup Analysis of the Pooled Retrospective RE-ENACT Study

BACKGROUND

This subgroup analysis of the RE-ENACT study evaluates the effectiveness of Razumab® (the world's first biosimilar of ranibizumab by Intas Pharmaceuticals Ltd.) in Indian patients with retinal vein occlusion (RVO).

METHODS

The data on patients with RVO who had received ≥3 injections of Razumab® between January and August 2016 were analyzed. Endpoints were: improvement in best corrected visual acuity (BCVA), and a decrease in central macular thickness (CMT), intraretinal fluid (IRF), and subretinal fluid (SRF) from baseline at weeks 4, 8, and 12.

RESULTS

Of 160 patients, the majority (61.87%) were men. The mean (±SE) BCVA improved from baseline (0.76 ± 0.04) to week 4 (0.73 ± 0.03; p = 0.0656), which attained significance at week 8 (0.55 ± 0.02; p < 0.0001) and week 12 (0.47 ± 0.02; p < 0.0001). The mean (±SE) CMT significantly decreased from baseline (447.60 ± 10.91 μm) to week 4 (431.84 ± 10.92 μm; p = 0.0028), week 8 (339.28 ± 8.12 μm; p < 0.0001), and week 12 (298.23 ± 6.68 μm; p < 0.0001). The proportion of patients with IRF and SRF significantly (p < 0.0001) decreased from baseline to weeks 4, 8, and 12 (IRF: from 70.63 to 45.63, 39.38, and 30.00%, respectively; SRF: from 65.63 to 37.50, 28.13, and 24.38%, respectively). A subgroup analysis of branch RVO and central RVO showed similar results. No new safety concerns were observed.

CONCLUSION

Razumab® (biosimilar of ranibizumab) effectively improved visual acuity and disease outcomes in patients with RVO in a real-world setting with no new safety concerns.

Standardized care by redesign of an intravitreal injection pathway

PURPOSE:

Intravitreal injection of medication is a rapid rising surgical intervention in modern ophthalmological care. With increasing numbers, the caseload of complications follows and the burden on daily clinical organization increases. This study focuses on developing a standardized treatment protocol to improve care and reduce hazard.

METHODS:

A standardized treatment protocol was designed and educated to the involved medical doctor and registered nurse. An independent observer used this protocol to evaluate the actions performed during the intravitreal injection. Data on the included patients and products injected were collected.

RESULTS:

In total, 180 injections of 134 patients were observed between 1 December 2011 and 18 October 2012, divided over 16 measurements. From the fifth measurement on, a 100% protocol adherence for the time out procedure was achieved and maintained over time, with a transient insignificant decrease. The performance of actions of the medical doctor and assisting registered nurse followed the same trend with a rapid increase and 100% protocol adherence. No microorganism caused development of endophthalmitis was recorded.

CONCLUSION:

The optimization of an intravitreal injection care pathway leads to a more standardized intervention process with no apparent reduction in clinical efficiency and safety.

The effects of repeated Ozurdex injections on ocular hypertension

Purpose

The purpose of this study was to correlate the degree of ocular hypertension with the number of Ozurdex injections.

Methods

Intraocular pressure (IOP) fluctuations for a total of 183 injections were studied over a period of at least 12 months. The main indications for treatment were uveitis, diabetic macular edema, and retinal vein occlusion.

Results

Results of the study demonstrate that repeated Ozurdex injections do not increase the frequency of IOP spikes beyond 30 mmHg. For lower IOPs, however, a positive correlation exists. Furthermore, patients with primary open angle glaucoma and uveitis had the highest IOP response to repeated injections. On average, patients with an IOP of ≥28.6 mmHg received pressure lowering medications, after which their IOP reached a stable level (16.7 mmHg) without the need for additional interventions.

Conclusion

The data support the conclusion that multiple Ozurdex injections does not increase the frequency of IOP spikes beyond 30 mmHg, but patients still must be closely monitored if they have a history of primary open angle glaucoma.

Feasibility study on robot-assisted retinal vascular bypass surgery in an ex vivo porcine model

PURPOSE

To describe a new robot-assisted surgical system for retinal vascular bypass surgery (RVBS) and to compare the success rate with freehand RVBS.

METHODS

A robot-assisted system for retinal microsurgery was constructed to include two independent robotic arms. A 23-gauge light probe and an intraocular forceps were affixed to the arm end effectors to perform the intraocular manipulation. Harvested porcine eyes were introduced to be established animal models of closed-sky eyeballs after that pars plana vitrectomy using temporary keratoprosthesis was performed by a skilful surgeon. Retinal vascular bypass surgery (RVBS) was performed by an inexperienced ophthalmologist to test the ease of use. A stainless steel wire (45-μm pipe diameter) was used as an artificial vessel. Before RVBS, the wires were prepositioned at the retinal surface of the eyes. The Control group (n = 20) underwent freehand RVBS, and the Experimental group (n = 20) underwent robot-assisted RVBS. To create the simulated bypass, the distal end of the wire was inserted into the selected vessel and advanced ~4 mm away from the optic disc. If successful, then the proximal wire end was inserted and advanced ~2 mm towards the optic disc. The difference in the success rate for the freehand and robot-assisted procedures was analysed by the chi-square test.

RESULTS

The success rate for the freehand RVBS was 5% (1/20 eyes). In contrast, the robot-assisted success rate was 35% (7/20) of eyes (p < 0.05).

CONCLUSION

This study demonstrated the feasibility of robot-assisted RVBS in ex vivo porcine eyes. The robotic system increased the accuracy and stability of manipulation by eliminating freehand tremor, leading to a higher surgical success rate.

Expression of the angiogenic mediator, angiopoietin-like 4, in the eyes of patients with proliferative sickle retinopathy

The recent success of therapies directly targeting the angiogenic mediator, vascular endothelial growth factor (VEGF), for the treatment of proliferative diabetic retinopathy has encouraged clinicians to extend the use of anti-VEGF therapies for the treatment of another ischemic retinal vascular disease, proliferative sickle cell retinopathy (PSR), the most common cause of irreversible blindness in patients with sickle cell disease. However, results from case reports evaluating anti-VEGF therapies for PSR have been mixed. This highlights the need to identify alternative therapeutic targets for the treatment of retinal neovascularization in sickle cell patients. In this regard, angiopoietin-like 4 (ANGPTL4) is a novel angiogenic factor regulated by the transcription factor, hypoxia-inducible factor 1, the master regulator of angiogenic mediators (including VEGF) in ischemic retinal disease. In an effort to identify alternative targets for the treatment of sickle cell retinopathy, we have explored the expression of ANGPTL4 in the eyes of patients with PSR. To this end, we examined expression and localization of ANGPTL4 by immunohistochemistry in autopsy eyes from patients with known PSR (n = 5 patients). Complementary studies were performed using enzyme-linked immunosorbent assays in aqueous (n = 8; 7 patients, 2 samples from one eye of same patient) and vitreous (n = 3 patients) samples from a second group of patients with active PSR. We detected expression of ANGPTL4 in neovascular tissue and in the ischemic inner retina in PSR, but not control, eyes. We further observed elevated expression of ANGPTL4 in the aqueous and vitreous of PSR patients compared to controls. These results suggest that ANGPTL4 could contribute to the development of retinal neovascularization in sickle cell patients and could therefore be a therapeutic target for the treatment of PSR.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.

Intravitreal PRN ranibizumab treatment for macular edemadue to branch retinal vein occlusion

BACKGROUND/AIM

To evaluate the effect of intravitreal pro re nata (PRN) ranibizumab treatment from the start on the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) in macular edema (ME) due to branch retinal vein occlusion (BRVO).

MATERIALS AND METHODS

Patients with ME secondary to BRVO, who were treated on a PRN basis after a single intravitreal ranibizumab injection, were retrospectively evaluated. The main outcome measures were changes in BCVA and CRT as measured by optical coherence tomography.

RESULTS

The number of injections over 6 months was 2.43 ± 1.16. The mean BCVA of the patients was 0.84 ± 0.10 logMAR at baseline and 0.41 ± 0.06 at the 6th month (P < 0.001). Mean BCVA of the ischemic BRVO group was 1.06 ± 0.68 logMAR at baseline and 0.44 ± 0.30 logMAR at the 6th month (P < 0.05). Similarly, the mean BCVA of the nonischemic BRVO group was 0.77 ± 0.53 logMAR at baseline and 0.41 ± 0.36 logMAR at the 6th month (P < 0.05). Between groups, there was no significant difference in mean BCVA at any examination.

CONCLUSION

Intravitreal ranibizumab is a safe and effective treatment option for ME due to ischemic and nonischemic BRVO using PRN from the start.

Evaluation of Peripapillary Nerve Fiber Layer after Dexamethasone Implantation (Ozurdex) in Branch Retinal Vein Occlusions

Purpose. To evaluate the peripapillary retinal nerve fiber layer (RNFL) thicknesses of patients treated with intravitreal Ozurdex implant due to branch retinal vein occlusion (BRVO) related macular edema (ME). Methods. Thirty-three eyes of 33 patients treated with Ozurdex implant due to ME associated with BRVO were included in the study. Ophthalmic examinations including determination of best corrected visual acuity (BCVA), measurement of intraocular pressure (IOP), and central macular thickness (CMT) and peripapillary RNFL assessment with optical coherence tomography (OCT) were performed before the injection of Ozurdex implant and during the 6-month follow-up period after the injection. Results. The mean age was 55.2 ± 7.4 (range: 40-68) years. The BCVAs were significantly increased and CMTs were significantly decreased at month 3 and month 6 visits compared to baseline values. The mean IOP was significantly increased from baseline at day 1, week 1, and month 1 visits (p₁ = 0.008, p₂ = 0.018, and p₃ = 0.022, resp.). The average and inferior quadrant peripapillary RNFL thicknesses were significantly reduced at month 6 control visit compared to baseline values (both p < 0.001). Conclusions. Ozurdex implant improved the BCVA and reduced the CMT in the eyes with RVO related ME. However, IOP elevations occurred within the first month after the injection and the average and inferior quadrant RNFL thinning was found six months after the injection. Further controlled studies are warranted.

Retinal vein occlusion and the use of a dexamethasone intravitreal implant (Ozurdex®) in its treatment

Purpose

To review published data pertaining to the clinical experience with a dexamethasone intravitreal implant (Ozurdex®) with a view to establishing a clinically based therapeutic regime.

Methods

A PubMed search using the MeSH terms “retinal vein occlusion” and either “pathophysiology” or “dexamethasone intravitreal implant” was undertaken for manuscripts published until August 2015. The analysis included studies involving minimally 15 patients under a prospective design or 30 under a retrospective design, a minimal follow up of 6 months, and at least 2 intravitreal Ozurdex® injections per eye.

Results

In the vast majority of eyes, satisfactory outcomes were achieved with retreatment intervals of between 3 and 5 months. Initial evidence indicates a similar efficacy compared to anti-VEGF therapies as a first-line treatment. Safety concerns associated with the long-term and repeated use of Ozurdex® are not borne out by clinical findings: its implantation is not associated with a sustained increase in intraocular pressure (IOP) over time or with the number of applications.

Conclusion

Compared with anti-VEGF therapies, the burden of retreatment is reduced. In patients with chronic macular edema not responsive to repetitive anti-VEGF therapies, the outcome after dexamethasone implant treatment is encouraging. However, these results are achieved at the expense of side effects typically associated with steroids: in up to 20 % of the Ozurdex®-treated patients, an elevation in IOP, which could be medically controlled in the majority of cases, and cataract formation or progression was observed.

Comparison of the Efficacy of Intravitreal Aflibercept and Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion

Fifty-two eyes of 52 patients with treatment-naïve macular edema associated with perfused branch retinal vein occlusion were retrospectively reviewed. Twenty-seven cases received PRN intravitreal bevacizumab, and 25 cases were treated by PRN intravitreal aflibercept with monthly follow-ups for 12 months. Both aflibercept and bevacizumab were effective in reduction of macular thickness and improvement of visual acuity for the participants. Both antivascular endothelial growth factor agents had similar efficacy and duration of treatment for these eyes with macular edema secondary to branch retinal vein occlusion during a 12-month period. No serious systemic or ocular adverse events were reported.

Role of aflibercept for macular edema following branch retinal vein occlusion: comparison of clinical trials

For years, the standard of care for branch-retinal-vein-occlusion-associated macular edema was initial observation followed by grid-pattern laser photocoagulation for persistent edema. Newer pharmacologic options have revolutionized the management of branch-retinal-vein-occlusion-associated macular edema, and the visual outcomes of these eyes are better than ever. However, a variety of available treatment options including intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factor agents have established novel challenges with regard to appropriate drug selection. This review summarizes the available clinical studies with special emphasis on the comparison of intravitreal aflibercept with ranibizumab, bevacizumab, and steroid agents.

A Review of Randomized Trials of Approved Pharmaceutical Agents for Macular Edema Secondary to Retinal Vein Occlusion

There are 3 approved pharmaceutical agents for treating macular edema secondary to retinal vein occlusion (RVO): dexamethasone (a corticosteroid) implant and ranibizumab and aflibercept (both antivascular endothelial growth factor agents). All show a superior ability to improve vision and reduce macular thickness in comparison with sham injections or macular grid laser treatment. Prompt treatment with these agents may lead to a better outcome. A review of randomized trials of injected aflibercept or ranibizumab reveals protocol variations. They include "as needed" injections until functional and anatomical changes are achieved, preceded by either 1 injection or 3 to 6 monthly injections as loading doses. Ocular and systemic adverse effects of vascular endothelial growth factor antagonists for macular edema secondary to RVO are rarely severe. The antiedematous response to a single intravitreal dexamethasone implant is maximal 1 to 3 months after the injection. Intraocular pressure elevation and cataract aggravation should be monitored after the use of intravitreal dexamethasone implants. Intravitreal dexamethasone implants and ranibizumab injections reduce not only macular edema, but also the risk of retinal ischemia and neovascularization in patients with RVO.

Treatment of Retinal Vein Occlusion with Ranibizumab in Clinical Practice: Longer-Term Results and Predictive Factors of Functional Outcome

PURPOSE

To evaluate long-term results and predictors of efficacy in patients with macular edema due to retinal vein occlusion (RVO) treated with intravitreal ranibizumab in a clinical practice setting.

METHODS

The clinical records of patients with a minimum follow-up of 3 years were retrospectively analyzed. Sixteen eyes with branch RVO (BRVO) and 16 with central RVO (CRVO) were included. All patients performed cross-sectional evaluation with best-corrected visual acuity (BCVA), spectral domain optical coherence tomography and fluorescein angiography. The foveal avascular zone (FAZ) was assessed and microstructural morphology of the retina was characterized.

RESULTS

Follow- up was 42.9 ± 9.0 and 44.8 ± 8.0 months in the CRVO and BRVO groups, respectively. Patients with CRVO received on average 6.9 injections, with a final VA gain of 8.3 ± 15.0 letters (p = 0.05). BRVO eyes had on average 5.9 injections, with a final VA gain of 1.6 ± 21.0 letters (p > 0.05). The FAZ area remained stable in both groups (p > 0.05). Baseline BCVA and disruption of the retinal pigment epithelium (RPE) were predictors of final BCVA (p = 0.001 and 0.011, respectively).

CONCLUSION

Although functional outcomes were inferior to those reported in clinical trials, ranibizumab was satisfactory in the long-term treatment of macular edema secondary to RVO and was not associated with increased macular ischemia. Final BCVA depends on baseline BCVA and RPE integrity.

[Retinal vein occlusion management algorithm. Part 3. Neovascular complications]

Neovascular complications severity in central/branch retinal vein occlusion (RVO) correlates with the level of occlusion and the degree of retinal perfusion disturbance. Large areas of retinal non-perfusion (more than half of the total retinal area) are associated with the risk for posterior segment neovascularization as high as 33% and for neovascular glaucoma - 45%. Over the past 30 years there has been an evident declining tendency of neovascular complications rates in the natural course of RVO. In ischemic RVO, anterior segment neovascularization is more aggressive than posterior. Neovascular glaucoma usually develops within the first 6 months of disease and correlates with uncontrolled arterial hypertension. Panretinal photocoagulation (PRP) is a standard treatment for anterior and posterior segment neovascularization in RVO patients. Anti-VEGF agents, if used as monotherapy, lead to rapid, however, short-term remission. Combination therapy, that is anti-VEGF injections and PRP, is the most effective. Intravitreal steroids have demonstrated no effect on ocular neovascularization. If PRP cannot be performed and intraocular pressure levels remain high, one should consider glaucoma drainage implant surgery. Preventive measures for neovascular complications that have proved effective so far include regular follow-ups, individually scheduled intravitreal injections, and PRP for large zones of ischemia.

Approved pharmacotherapy for macular edema secondary to branch retinal vein occlusion: A review of randomized controlled trials in dexamethasone implants, ranibizumab, and aflibercept

There are three approved pharmacotherapies for treating macular edema secondary to branch retinal vein occlusion (BRVO), including corticosteroids (dexamethasone implants) and anti-vascular endothelial growth factor (VEGF) (ranibizumab and aflibercept). They all show superior ability to improve vision and reduce macular thickness, comparing with sham injections or macular grid laser treatment. There is no severe ocular or systemic adverse reaction reported in studies associated with anti-VEGF for macular edema after BRVO. Intraocular pressure elevation and cataract aggravation should be addressed after intravitreal dexamethasone implants. Single intravitreal dexamethasone implant had effective duration as long as four to six months. Intravitreal anti-VEGF requires six monthly injections as loading doses, and then PRN regimen needed according to functional and anatomical changes. Ozurdex and ranibizumab reduce not only macular edema, but also the probability of retinal ischemia and neovascularization in patient s with BRVO. Prompt treatment with these agents can lead to a better outcome.

Neovascular events in eyes with central retinal vein occlusion undergoing serial bevacizumab or ranibizumab intravitreal injections: a retrospective review

PURPOSE

To characterize the onset and type of neovascular events in eyes with central retinal vein occlusion (CRVO) undergoing serial anti-VEGF therapy.

METHODS

Consecutive eyes undergoing serial intravitreal bevacizumab or ranibizumab injections for treatment of CME secondary to CRVO were identified. Pertinent data was retrospectively collected and included type and onset of the neovascular event, and the treatment free interval from last injection until the neovascular event. Kaplan-Meier life table analysis was performed to determine the differential effects of baseline perfusion status, early initiation of anti-VEGF treatment (within 3 months of CRVO onset) versus later treatment, and continuous (1-month±2 weeks) versus discontinuous treatment interval (>1.5 months) on time until neovascular event.

RESULTS

Of 31 eligible eyes, 12 (39%) and 19 (61%) presented with perfused and ischemic CRVO, respectively. The mean duration from CRVO until the onset of any neovascular event was 17.0±10.3 months. The mean treatment-free interval prior to any neovascular event was 6.2±7.3 months. On average, 5.3±3.2 anti-VEGF injections were given prior to any neovascular event. Neovascularization of the iris or angle occurred in 18 eyes (58%), vitreous hemorrhage associated with neovascularization was observed in 9 eyes (29%) and neovascularization of the disc developed in 5 eyes (16%). Neovascular events showed a trend towards occurring later in eyes with perfused CRVO at baseline (log rank test, P=0.07).

CONCLUSION

Neovascular events occur in eyes with CRVO undergoing serial anti-VEGF therapy, and these events may be delayed compared to the natural history of CRVO-associated neovascularization. Iris neovascularization occurred most frequently.

Onset and duration of visual acuity improvement after dexamethasone intravitreal implant in eyes with macular edema due to retinal vein occlusion

PURPOSE

To evaluate the onset and duration of improvement in best-corrected visual acuity (BCVA) in eyes treated with dexamethasone intravitreal implant 0.7 mg (DEX implant) for macular edema after branch or central retinal vein occlusion.

METHODS

Post hoc analysis of data from 2 previously reported multicenter, 6-month, randomized sham-controlled clinical trials. Patients received a single DEX implant (n = 427) or sham procedure (n = 426) in the study eye. The primary endpoint was the percentage of eyes with ≥ 15-letter improvement in BCVA from baseline at postimplant Day 7.

RESULTS

The baseline mean BCVA was 20/80. At Day 7, 10.3% of DEX implant-treated eyes versus 4.0% of sham-treated eyes (P < 0.001) had ≥ 15-letter improvement in the BCVA, and 27.2% of DEX implant-treated eyes versus 10.6% of sham-treated eyes had ≥ 10-letter improvement (P < 0.001). The mean improvement at Day 7 was 5.3 letters (branch retinal vein occlusion, 5.1; and central retinal vein occlusion, 5.8) with DEX implant and 1.6 letters (branch retinal vein occlusion, 2.3; and central retinal vein occlusion, 0.1) with sham (P < 0.001). The mean time from initial observation of ≥ 15-letter BCVA gain to the last observation of ≥ 15-letter BCVA gain was 70 days.

CONCLUSION

Dexamethasone intravitreal implant treatment led to improvement in BCVA compared with sham procedure as early as postimplant Day 7. The duration of ≥ 3-line improvement was typically 2 to 3 months.

Intravitreal ranibizumab for retinal vein occlusion through 1 year in clinical practice

PURPOSE

To evaluate the efficacy and safety of intravitreal ranibizumab for branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) in daily clinical practice.

METHODS

A prospective study enrolling all patients diagnosed with BRVO or CRVO who received intravitreal ranibizumab therapy at our department.

RESULTS

Fifty-seven patients had BRVO and 49 had CRVO. By 12 months, the patients with BRVO improved a mean of 11.6 (P < 0.0001) ETDRS (Early Treatment Diabetic Retinopathy Study) letters, whereas the patients with CRVO improved a mean of 1.8 letters (P = 0.50). The proportion of patients gaining ≥ 15 ETDRS letters was 26.3% for BRVO and 16.7% for CRVO. The proportion of patients losing ≥ 15 ETDRS letters was 0% for BRVO and 8.3% for CRVO. The reduction in foveal center point thickness at 12 months was 248 μm for BRVO (P < 0.0001) and 222 μm for CRVO (P < 0.0001). Functional outcome did not mirror anatomical outcome, and younger patients had better outcome.

CONCLUSION

Our 12-month results of BRVO treated with intravitreal ranibizumab in daily clinical practice are similar to the results of the BRAVO trial that led to the approval of the therapy. However, our results for CRVO failed to reproduce the results of the CRUISE trial.

Efficacy and safety of two or more dexamethasone intravitreal implant injections for treatment of macular edema related to retinal vein occlusion (Shasta study)

PURPOSE

To evaluate the efficacy, safety, and reinjection interval of dexamethasone intravitreal implant (DEX implant) in branch retinal vein occlusion and central retinal vein occlusion patients receiving ≥ 2 DEX implant treatments.

METHODS

Multicenter (26-site), retrospective chart review study. Data were collected from baseline (at first DEX implant) through 3 months to 6 months after last DEX implant.

RESULTS

Patients (n = 289) received 2 to 9 (mean, 3.2) DEX implants as monotherapy (29.1% of patients) or with adjunctive treatments/procedures. Mean duration of macular edema before first DEX implant was 18.4 months. Mean reinjection interval was 5.6 months. Mean peak change in best-corrected visual acuity from baseline through 4 weeks to 20 weeks after final DEX implant was +1.0 line (P < 0.001). Best-corrected visual acuity and central retinal thickness improved significantly from baseline after each of the first 6 DEX implant injections (P ≤ 0.037); 59.7% of branch retinal vein occlusion and 66.7% of central retinal vein occlusion patients achieved ≥ 2-line best-corrected visual acuity improvement. Intraocular pressure increase (≥ 10 mmHg) occurred in 32.6% of patients; 29.1% used intraocular pressure-lowering medication to treat increases associated with DEX implant. Only 1.7% of patients required incisional glaucoma surgery.

CONCLUSION

Retinal vein occlusion patients treated with multiple DEX implant injections, either alone or combined with other therapies, had improved central retinal thickness and visual acuity with each subsequent injection. No new safety concerns developed with multiple implants.

Combination therapy with dexamethasone intravitreal implant and macular grid laser in patients with branch retinal vein occlusion

PURPOSE

To test a combination of dexamethasone intravitreal implant with macular grid laser for macular edema in patients with branch retinal vein occlusion (BRVO).

DESIGN

Prospective interventional, randomized, multicenter study.

METHODS

Patients with macular edema secondary to BRVO underwent an Ozurdex intravitreal implant at baseline. After 1 month, patients were randomly assigned to 2 study groups. Patients in Group 1 were followed up monthly and retreated with Ozurdex implant whenever there was a recurrence of macular edema or a decrease in best-corrected visual acuity (BCVA). In Group 2 patients macular grid laser was performed between weeks 6 and 8. After that, patients were followed up and retreated as for Group 1.

RESULTS

In Group 1 at 4 months, mean BCVA was 0.49 ± 0.35 logMAR and central retinal thickness (CRT) was 391 ± 172 μm; both improved significantly at 6 months, to 0.32 ± 0.29 logMAR and 322 ± 160 μm, respectively. In Group 2, CRT was reduced significantly to 291 ± 76 μm at 4 months, and BCVA improved to 0.25 ± 0.20 logMAR. At the final visit, BCVA was 0.18 ± 0.14 logMAR and mean CRT was 271 ± 44 μm. The number of Ozurdex implants at 4 months was 12 of 25 (48%) in Group 1 patients vs 3 of 25 (12%) in Group 2 patients (P = .012). At 6 months 3 of 25 patients (12%) in Group 1 vs 0 of 25 (0%) in Group 2 (P = .23) were retreated.

CONCLUSIONS

The combination of Ozurdex implant and macular grid laser is synergistic in increasing BCVA and lengthening the time between injections.

The ABCs of RVO: a review of retinal venous occlusion

Retinal vein occlusions are important causes of loss of vision; indeed, they are the second most common retinal vascular disease, following diabetic retinopathy. For this reason alone, primary eye-care providers must be well versed in diagnosis and management. Risk factors, though not universally agreed upon, include but are not limited to advancing age, systemic hypertension, arteriolarsclerosis, diabetes, hyperlipidaemia, blood hyperviscosity, thrombophilia, ocular hypertension and glaucoma. Typically, visual loss is secondary to macular oedema and/or retinal ischaemia. Treatment modalities have included observation, systemic thrombolysis and haemodilution, radial optic neurotomy, chorioretinal anastomosis, vitrectomy, laser photocoagulation and intravitreal injection of anti-inflammatory and, most recently, anti-vascular endothelial growth factors.

Two-year outcomes of intravitreal bevacizumab therapy for macular oedema secondary to branch retinal vein occlusion

Aim

To determine the 2-year outcomes of intravitreal bevacizumab (IVB) injections in eyes with macular oedema (ME) following branch retinal vein occlusion (BRVO).

Methods

Of 105 consecutive eyes (105 treatment-naïve patients) with ME following BRVO, 89 eyes were followed for 2 years after the first injection. During the 2-year follow-up period, patients were examined at least every 3 months and received an IVB injection (1.25 mg/0.05 mL) if they met prespecified retreatment criteria. Rescue grid laser was permitted based on the findings of the Branch Vein Occlusion Study.

Results

The baseline logarithm of the minimum angle of resolution visual acuity (VA) was 0.64±0.24 (mean±SD), which significantly (p=0.001) improved 1 month after the first injection to 0.39±0.22. One year after the first injection, VA improved significantly (p=0.001) to 0.33±0.21 and remained 0.34±0.21 until 2 years after the first injection (p=0.001). The changes in foveal thickness were correlated with those of VA during the 2-year follow-up period with a mean of 3.8±1.5 injections (including the first injection).

Conclusions

This relatively large case series study showed favourable 2-year outcomes using bevacizumab to treat ME following BRVO. Bevacizumab provides substantial long-term benefits in the treatment of ME following BRVO.

Morphology of optic disc through heidelberg retina tomograph in retinal vein occlusions alone or in combination with primary open angle glaucoma

Purpose:

To evaluate the morphology of optic discs in eyes suffering from retinal vein occlusion (RVO) alone or in combination with primary open-angle glaucoma (POAG).

Methods:

Prospective, observational study. 48 consecutive patients were enrolled, 30 with unilateral RVO diagnosis, 18 with unilateral retinal vein occlusion (RVO) associated with POAG. We divided RVOs on the basis of occlusion site: arterio-venous crossing (AV-RVO), optic cup (OC-RVO), optic nerve (ON-RVO) with head nerve swelling (ONHS-RVO) or without it (NONHS-RVO). A control group of 25 patients who were sex and age matched was selected.

Results:

Comparing the fellow eyes of the patients with RVO and control healthy eyes, no differences emerged in cup/disc ratio but they came out for the HRT values in Rim Area, cup shape measure and height variation contour (p<0.05).

The most frequent occlusion site was at the level of an arteriovenous crossing in patients not suffering from POAG (36.7%) and at the level of the optic cup in patients with RVO and POAG (50%). In the RVO group without POAG, the OC-RVO subgroup has shown an higher cup area (0.366±0.094) and cup/disc area ratio (0.184±0.063), a lower rim volume (0.374±0.021) and a different cup shape measure (-0.221±0.066) (p<0.05) compared with the AV and NONHS sites. Compared with NONHS group differences emerged also for the fibres parameters and in the height variation contour (0.346±0.081). Also in the RVO group with POAG significant differences (p<0.05) have been surveyed between OC-RVO and other occlusion sites in cup area (0.119±0.029), cup/disc area ratio (0.532±0.09), rim volume (0.374±0.07), cup/shape measure (-0.079±0.013).

Conclusions:

Classification of the analyzed parameters on the basis of the occlusion site provides a basis for which clinical decisions and research on causal factors in future studies can be based on.

Therapeutic potential of intravitreal pharmacotherapy in retinal vein occlusion

Retinal vein occlusion (RVO) is the most common visually disabling disease affecting the retina after diabetic retinopathy. Although the disease entity has long been known, its management is still controversial. Macular edema is the main reason for decreased visual acuity (VA) in this retinal vascular disorder. Recently the vitreous cavity has increasingly been used as a reservoir of drugs for the direct treatment of macular edema through intravitreal injection route. The most widely injected drugs so far have been triamcinolone acetonide (TA) and bevacizumab. The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestions that intravitreal pharmacotherapy by corticosteroids and anti-vascular endothelial growth factors may be useful in the treatment of retinal vein occlusion.

Repeated treatment for macular edema in vein occlusion by intravitreal implant of dexamethasone

Background

Macular edema (ME) treatment has benefited from the recent intravitreal pharmacotherapy development of an intravitreal implant of dexamethasone (Ozurdex^®, Allergan, Irvine, Calif., USA). However, its efficiency has never been illustrated beyond 3 injections.

Case Presentation

We report the case of a 75-year-old woman with inferior branch vein occlusion, who, after laser photocoagulation treatment and recurrence after intravitreal injection of triamcinolone, benefited from 4 injections of Ozurdex. Her macular thickness and visual acuity (VA) progression were assessed for 17 months.

Conclusions

This case report highlights the quick efficiency of Ozurdex on VA and ME with good reproducibility and tolerance, and without tachyphylaxis phenomenon. This is the first illustrated description of 4 consecutive injections for ME induced secondary to retinal vein occlusion.