Ranibizumab for Branch Retinal Vein Occlusion Associated Macular Edema Study (RABAMES): six-month results of a prospective randomized clinical trial

A systematic review and meta-analysis of the effect of intravitreal VEGF inhibitors on cardiorenal outcomes

BACKGROUND

Vascular endothelial growth factor inhibitors (VEGFi) have transformed the treatment of many retinal diseases, including diabetic maculopathy. Increasing evidence supports systemic absorption of intravitreal VEGFi and development of significant cardiorenal side effects.

METHODS

Systematic review and meta-analysis (PROSPERO: CRD42020189037) of randomised controlled trials of intravitreal VEGFi treatments (bevacizumab, ranibizumab and aflibercept) for any eye disease. Outcomes of interest were cardiorenal side effects (hypertension, proteinuria, kidney function decline and heart failure). Fixed-effects meta-analyses were conducted where possible.

RESULTS

There were 78 trials (81 comparisons; 13 175 participants) that met criteria for inclusion: 47% were trials in diabetic eye disease. Hypertension (29 trials; 8570 participants) was equally common in VEGFi and control groups (7.3 versus 5.4%; RR 1.08 [0.91; 1.28]). New or worsening heart failure (10 trials; 3384 participants) had similar incidence in VEGFi and control groups (RR 1.03 [0.70; 1.51]). Proteinuria (5 trials; 1902 participants) was detectable in some VEGFi-treated participants (0.2%) but not controls (0.0%; RR 4.43 [0.49; 40.0]). Kidney function decline (9 trials; 3471 participants) was similar in VEGFi and control groups. In participants with diabetic eye disease, risk of all-cause mortality was higher in VEGFi-treated participants (RR 1.62 [1.04; 2.46]).

CONCLUSION

In trials of intravitreal VEGFi, we did not identify an increased risk of cardiorenal outcomes, though these outcomes were reported in only a minority of cases. There was an increased risk of death in VEGFi-treated participants with diabetic eye disease. Additional scrutiny of post-licensing observational data may improve recognition of safety concerns in VEGFi-treated patients.

[Ischemia and laser photocoagulation in retinal vein occlusion]

BACKGROUND

Retinal vein occlusions (RVO) are associated with retinal ischemia to a highly variable extent. An ischemic retina may lead to the development of neovascularization and further to secondary complications such as neovascular glaucoma, vitreous hemorrhage or tractional retinal detachment. Numerous factors such as vascular endothelial growth factor (VEGF) and other cytokines are produced in the ischemic area, which cause macular edema. Before the introduction of intravitreal drug injections (IVI), retinal laser photocoagulation was the leading form of treatment. Macular laser photocoagulation was applied in the form of focal laser or grid laser in patients with branch retinal vein occlusion (BRVO) to treat macular edema. In patients with ischemic RVO, panretinal laser photocoagulation (PRP) was recommended for treatment of secondary neovascular complications. The value of laser treatment in the management of patients with RVO changed after the introduction of IVI treatment.

AIM

This article presents a review of the current study results and the recommendations for performing laser photocoagulation of the central and peripheral retina in patients with RVO.

CONCLUSION

Conventional focal or grid laser photocoagulation has been replaced by IVI treatment in the management of macular edema secondary to BRVO; however, macular laser treatment can still be considered in patients with BRVO if the macular edema persists despite the use of available IVI drugs. The use of central laser photocoagulation in these cases is based on the findings of fluorescein angiography. Disseminated panretinal laser photocoagulation is still indicated in RVO patients who have large areas of nonperfusion, have developed neovascularization and/or late complications. Targeted laser photocoagulation of the peripheral areas of nonperfusion has recently been recommended by several authors and is expected to improve not only the visual outcome of IVI treatment, but more importantly to also reduce the duration of treatment and the number of re-injections needed. Clear evidence for targeted laser treatment is not yet available and is a focus of currently ongoing prospective randomized studies.

Antivascular endothelial growth factor for macular oedema secondary to retinal vein occlusion: a systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of antivascular endothelial growth factor (anti-VEGF) agents in treating macular oedema due to retinal vein occlusion (RVO-ME).

Methods

Studies of randomised controlled trials were searched in PubMed, EMBASE, Cochrane databases and ClinicalTrials.gov registry. RevMan V.5.4 software and GRADE were used to synthesise the data and validate the evidence, respectively.

Results

Seventeen studies were included in this meta-analysis. The anti-VEGF agents showed significant better mean best-corrected visual acuity (BCVA) improvement, more patients with ≧15 Early Treatment in Diabetic Retinopathy Study (ETDRS) letters gained and fewer patients with ≧15 ETDRS letters lost, more effectiveness at reducing central retinal thickness (CRT) and improving the quality of life than sham and steroids both at 6 and 12 months. Compared with laser, the anti-VEGF agents showed significant BCVA improvement and more effectiveness at CRT both at 6 and 12 months. The proportion of eyes gaining ≧15 ETDRS letters was greater in the anti-VEGF group at 6 months. The anti-VEGF and other three groups reported similar levels of non-ocular serious adverse events (SAEs). The incidence of eye pain was significantly higher in the anti-VEGF group than in the sham group. There was a significant increase in the incidence of ocular AEs and conjunctival haemorrhage in the anti-VEGF group compared with the laser group. The incidence of elevated intraocular pressure and cataract was significantly higher in the steroid group than in the anti-VEGF group.

Conclusions

This meta-analysis suggested that treatment of ME secondary to RVO with anti-VEGF improves visual and anatomical outcomes compared with other treatments. Thus, anti-VEGF treatment is the first choice for treating patients with ME secondary to RVO.

[Retinal vein occlusion : Intravitreal pharmacotherapies and treatment strategies for the management of macular edema]

Intravitreal injection treatment for the management of macular edema as an expression of increased capillary permeability and leakage constitute the mainstay of treatment in retinal vein occlusion. In contrast to diabetic retinopathy or neovascular age-related macular degeneration, permanent and complete functional and morphological restoration can be achieved, as retinal vein occlusions are usually associated with risk factors, but do not represent the manifestation form of an underlying systemic or degenerative chronic disorder; however, successful long-term management of retinal vein occlusion -associated macular edema usually requires intensive and also long-term continued treatment with vascular endothelial growth factor (VEGF) inhibitors or with a less favorable side effect profile, dexamethasone. A functional treatment success can be maintained over the long term by both pro re nata (PRN) or treat and extend (T&E) regimens. In contrast, according to the currently available data, the combination of anti-VEGF administration and grid laser treatment has no additional benefit compared to monotherapy. In patients with recalcitrant macular edema, switching to another intravitreal agent may be considered during the course of treatment, although a true therapeutic benefit with respect to the development of visual acuity has not yet been proven. The current review summarizes the relevant aspects in the management of RVO-associated macular edema and provides the foundations for the application of successful treatment strategies.

Comparison of the efficiency of anti-VEGF drugs intravitreal injections treatment with or without retinal laser photocoagulation for macular edema secondary to retinal vein occlusion: A systematic review and meta-analysis

Objective: To compare the efficiency of anti-VEGF drugs intravitreal injections(IVI) treatment with or without retinal laser photocoagulation(LPC) for macular edema(ME) secondary to retinal vein occlusion(RVO).

Methods: The randomized controlled trials and retrospective studies including anti-VEGF drug IVI combined with retinal LPC and single IVI in the treatment of macular edema secondary to RVO were collected in PubMed, Medline, Embase, Cochrane Library, and Web of Science. We extracted the main outcome indicators including the best corrected visual acuity (BCVA), central macular thickness(CMT), the number of injections and the progress of retinal non-perfusion areas(NPAs) for systematic evaluation, to observe whether IVI + LPC could be more effective on the prognosis of RVO. We use Review Manager 5.4 statistical software to analyze the data

Results: 527 articles were initially retrieved. We included 20 studies, with a total of 1387 patients who were divided into the combination(IVI + LPC) treatment group and the single IVI group. All the patients completed the ocular examination including BCVA, slit-lamp test, fundus examination and Optical Coherence Tomography(OCT) test before and after each treatment. There was no statistical difference between the combination treatment group and single IVI group on BCVA(WMD = 0.12,95%CI = -3.54–3.78,p = 0.95),CMT(WMD = -4.40,95%CI = -21.33–12.53,p = 0.61) and NPAs(WMD = 0.01,95%CI = -0.28–0.30,p = 0.94).However, the number of IVI was decreased significantly in the combination treatment group in BRVO patients, compared to that in the single IVI group(WMD = -0.69,95%CI = -1.18∼-0.21,p = 0.005).

Conclusion: In the treatment of RVO patients with macular edema, the combination of IVI and retinal LPC neither improves BCVA nor reduces CMT significantly compared with the single IVI treatment. However, the combination treatment can decrease the number of intravitreal injections in patients with BRVO, while it is not observed in CRVO patients.

Estimating ranibizumab injection numbers and visual acuity at 12 months based on 2-month data on branch retinal vein occlusion treatment

Anti-vascular endothelial growth factor treatment for macular edema secondary to branch retinal vein occlusion generally provides good visual acuity (VA) improvement but may require repeated injections for years. To reduce the number of patients who suffer from avoidable VA loss caused by treatment drop-out, providing prospects of the correlation between expected vision improvement and required number of injections at the early stages of treatment may be helpful. In this post hoc analysis of the phase IV, randomized, open-label ZIPANGU study, we investigated the correlation between the data from Month 2 and Month 12 in terms of VA and required ranibizumab injection numbers. Fifty-nine patients were evaluated (ranibizumab monotherapy, 29; combination therapy, 30). In the monotherapy group, patients who received 1 and 3 injections by Month 2 received a mean total of 2.8 and 8.3 injections during the year, respectively. Data from the combination group were similar. The correlation coefficients for VA scores at Months 2 and 12 were 0.60 and 0.51 for the monotherapy and combination groups, respectively (both p < 0.01). Based on VA and injection numbers at Month 2 of treatment, physicians could provide rough prospects on patients’ expected final VA and required number of injections.

Comparative Efficacy of Pharmacotherapy for Macular Edema Secondary to Retinal Vein Occlusion: A Network Meta-analysis

Purpose: This network meta-analysis was conducted to obtain the relative effectiveness of different pharmacotherapy of macular edema secondary to retinal vein occlusion (RVO) by summarizing all available evidences.

Methods: PubMed, Embase, and Cochrane Library databases were searched for all relevant randomized controlled trials. The outcomes were estimated through a network meta-analysis, including the mean change in best-corrected visual acuity (BCVA) from baseline, the proportion of patients who gained ≥15 letters in BCVA from baseline, the mean change in central retinal thickness (CRT).

Results: We identified 15 randomized controlled trials (RCTs) involving 3,431 patients with RVO in our study. Different therapeutic regimens were compared including three anti-vascular endothelial growth factor (VEGF) agents (ranibizumab, bevacizumab, and aflibercept), ranibizumab with laser, dexamethasone intravitreal implant, and laser. For branch RVO, ranibizumab 0.5 mg monthly [weighted mean difference (WMD) = 11, 95% confidence intervals (CrI) 3.6 to 19], ranibizumab 0.5 mg 3 + pro re nata (WMD = 9.4, 95% CrI 0.43–18) is most effective in terms of changes of BCVA and 15 letters or more of BCVA improvement. For central RVO, three anti-VEGF regimens can improve visual acuity and there is no significant difference of efficacy among ranibizumab, bevacizumab and aflibercept (p > 0.05). Ranibizumab 0.5 mg monthly could achieve additional efficacy in CRT reduction in eyes with branch RVO or central RVO (WMD = -130, 95% CrI -400 to 140 or WMD = -280, 95% CrI -590 to 16)). Dexamethasone intravitreal implant (WMD = 1.7, 95% CrI -4.2 to 7.1 or WMD = 0.38, 95% CrI -9.8 to 8.8)) did not show a significant improvement in visual acuity at the end of 6 months follow-up in eyes with branch RVO or central RVO.

Conclusion: In summary, this network meta-analysis demonstrated several anti-VEGF agents had equivalent effects on mean visual acuity changes and anatomical recovery in 6 months in eyes with branch or central RVO. Only one injection of dexamethasone intravitreal implant in 6 months could not maintain the visual benefit. Patients and clinicians could choose pharmacotherapies with further consideration toward personal factors.

Risk of Death Associated With Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: A Systematic Review and Meta-analysis

Importance

Although intravitreal anti-vascular endothelial growth factor (VEGF) treatment represents the first-line therapy for many retinal diseases, the issue of their systemic safety is debatable.

Objectives

To assess whether intravitreal anti-VEGF therapy might be associated with increased risk of mortality and which variables are associated with the increase.

Data Sources

PubMed, MEDLINE, and Embase databases, the Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to May 6, 2019.

Study Selection

Randomized clinical trials comparing intravitreal anti-VEGF treatment with control groups and with follow-up of at least 6 months were selected.

Data Extraction and Synthesis

Data were independently collected by 2 investigators. Meta-analyses were conducted using the frequentist and Bayesian methods. For the frequentist approach, random- and fixed-effects models were used, with random-effects models considered the primary technique. Odds ratios (ORs) with 95% CIs were computed. For the bayesian approach, uninformative and informative priors were used. Odds ratios with 95% credible intervals (CrIs) were computed. Meta-regression analyses were based on random-effects models.

Main Outcomes and Measures

The primary outcome measure was the all-cause death rate. Secondary outcomes included meta-regression analyses on the following variables: type of drug, number of injections, follow-up time, diagnosis, and cardiovascular risk.

Results

Of 2336 studies identified, 34 unique studies with 8887 unique participants were included in the present meta-analysis. For the frequentist analysis, fixed- and random-effects models yielded similar estimates (ORs, 1.34 [95% CI, 0.95-2.07; P = .09] and 1.34 [95% CI, 0.89-2.01; P = .17], respectively). For the Bayesian approach, noninformative and informative priors yielded similar results (ORs, 1.34 [95% CrI, 0.79-2.34; 0.13 probability of OR≤1.00] and 1.40 [95% CrI, 0.82-2.32; 0.11 probability of OR≤1.00], respectively). Meta-regression analyses showed the following risk for 1 injection more: frequentist OR of 1.12 (95% CI, 1.04-1.22; P = .005) and Bayesian OR of 1.06 (95% CrI, 0.98-1.15; 0.06 probability of OR≤1.00).

Conclusions and Relevance

In this study, no difference was found in the mortality rate between intravitreal anti-VEGF treatment and control groups. Additional data seem warranted to determine whether the mortality rate is increased in patients receiving a greater number of injections.

Short-term effects of intravitreal Conbercept injection combined with laser photocoagulation on macular edema secondary to ischemic retinal vein occlusion

AIM

To observe changes in the best-corrected visual acuity (BCVA), central macular thickness (CMT), and central choroidal thickness (CCT) of patients with macular edema (ME) secondary to ischemic retinal vein occlusion (iRVO) following intravitreal Conbercept injection.

METHODS

This retrospective study included 33 eyes from 33 patients who received intravitreal injections of Conbercept for ME secondary to iRVO. Treatments were performed on a 3+pro re nata (3+PRN) basis. All of the patients were examined by fundus fluorescein angiography and spectral domain optical coherence tomography at the first visit. Laser photocoagulation was performed in the nonperfusion area of the retina of all eyes after the first injection. BCVA, CMT, and CCT were observed before and after 6mo of treatment. The number of injections necessary to achieve improved vision was also noted.

RESULTS

Following Conbercept treatment, the mean BCVA significantly improved from 0.81±0.39 at baseline to 0.41±0.25 and 0.43±0.29 logMAR in the third and sixth months, respectively (both P=0.000). The CMT of the patients at baseline was 556.75±98.57 µm; 304.78±68.53 and 306.85±76.77 µm 3 and 6mo after treatment, respectively (both P=0.000 vs baseline). The CCTs of the patients at baseline, 3 and 6mo after treatment were 304.63±57.83, 271.31±45.53, and 272.29±39.93 µm, respectively (P=0.026 and 0.035 vs baseline). No severe adverse event relevant to the therapy was noted, and the average number of injections delivered was 3.35.

CONCLUSION

Intravitreal Conbercept injection combined with laser photocoagulation appears to be a safe and effective treatment for ME secondary to iRVO in the short-term.

Cardiovascular Adverse Events With Intravitreal Anti-Vascular Endothelial Growth Factor Drugs: A Systematic Review and Meta-analysis of Randomized Clinical Trials

IMPORTANCE

Systemic safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) is a matter of debate and regular updates are necessary.

OBJECTIVE

To evaluate systemic adverse events (SAEs) associated with intravitreal anti-VEGF drugs compared with non-anti-VEGF treatments in patients with ocular diseases.

DATA SOURCES

Electronic searches were conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases from inception to July 7, 2020.

STUDY SELECTION

Randomized clinical trials conducted in adults with retinal diseases who received intravitreal anti-VEGF drugs.

DATA EXTRACTION AND SYNTHESIS

Studies and treatment characteristics and outcome data were extracted and analyzed, and study quality was evaluated.

MAIN OUTCOMES AND MEASURES

Main outcomes were major cardiovascular events (MACEs) and total mortality. Secondary outcomes included nonocular hemorrhage, components of MACEs, other cardiovascular outcomes, serious SAEs, and all SAEs.

RESULTS

A total of 74 randomized clinical trials were analyzed: 32 trials (43%) included 14 190 patients with age-related macular degeneration (AMD), 24 (32%) included 5424 patients with diabetic retinopathy (diabetic macular edema or proliferative diabetic retinopathy), 17 trials (23%) included 3757 patients with retinal vein occlusion, and 1 trial (1%) included 122 patients with myopic choroidal neovascularization. Anti-VEGF drug administration did not increase MACEs compared with control agents (odds ratio [OR], 1.16; 95% CI, 0.85-1.58) or total mortality (OR, 1.27; 95% CI, 0.82-1.96). There was an interaction (subgroup difference, P = .04) in mortality risk depending on the underlying disease with an increase (OR, 1.80; 95% CI, 1.03-3.16; P = .04) in the risk of death in patients with diabetic retinopathy; however, no increase was observed in patients with AMD or retinal vein occlusion. Administration of anti-VEGF drugs increased the risk of nonocular hemorrhage (OR, 1.46; 95% CI, 1.01-2.10), mainly in patients with AMD.

CONCLUSIONS AND RELEVANCE

Intravitreal anti-VEGF was not associated with an increase in MACEs in the trials examined herein. Increased mortality in patients with diabetes and nonocular hemorrhages, especially in those with AMD, could represent a safety signal, but the evidence was not strong. However, continued surveillance of SAEs remains warranted.

Treatment outcomes of retinal vein occlusion in clinical practice in Nepal

BACKGROUND

This study evaluated the treatment outcomes of retinal vein occlusion (RVO) in a routine clinical practice in Nepal.

METHODS

This was a retrospective analysis of observational data of patients with RVO who attended the retina clinic of the Tilganga Institute of Ophthalmology from 1 November 2017 to 31 October 2018. The main outcome was the mean change in visual acuity (VA) at 12 months from the start of treatment. Other outcomes of interest were the mean change in central subfield thickness (CST) and the number of treatments over 12 months.

RESULTS

A total of 99 eyes (of 99 patients) with RVO (60 - branch RVO [BRVO] and 39 - central RVO [CRVO] were available for the analysis. Eyes with CRVO had worse VA and CST at baseline. Eyes in both groups were similar for age, associated factors for RVO, duration of vision loss and the presence of ischemia at baseline. The mean (95% Confidence Interval [CI]) VA change at 12 months for BRVO was - 0.35 (- 0.46, - 0.23) logMAR (p < 0.001) from a mean (SD) of 0.75 (0.42) logMAR at baseline with 63% achieving VA < 0.3 logMAR while for CRVO it was - 0.35 (- 0.46, - 0.23) logMAR (p = 0.19) from 1.13 (0.61) logMAR at baseline and VA < 0.3 logMAR in 36%. The mean (95% CI) change in CST over 12 months was - 114 (- 189, - 40) μm (p = 0.003) from a mean (SD) of 423 (151) μm at baseline for BRVO and - 184(- 276, - 91) μm (p < 0.001) from 519 (213) μm for CRVO. Patients in both groups received a median of 2 bevacizumab injections over 12 months. Around 37% eyes were lost before 12 months' observation. The mean VA and CST trajectory in these eyes at their last visit was similar to those that completed 12 months.

CONCLUSION

The outcomes of RVO over the 12 months were inferior and the number of treatments fewer than those of the clinical trials and other reports from routine clinical practice. Future studies to identify the treatment barriers are warranted to improve the treatment outcomes in our patients.

Clinical efficacy and safety of Razumab® (CESAR) study: Our experience with the world's first biosimilar Ranibizumab

Purpose

: The aim of this study was to evaluate the efficacy and safety of Razumab (the biosimilar Ranibizumab by Intas Pharmaceuticals Ltd.) for the treatment of chorioretinal vascular diseases such as diabetic macular edema (DME), choroidal neovascular membrane (CNVM), and macular edema secondary to retinal vein occlusion (RVO).

Methods

: We conducted a single-center, retrospective study, including patients with DME, CNVM, and RVO, who had received treatment with Razumab® between October 2018 and September 2019. Primary outcome measures were the changes in corrected distance visual acuity (CDVA) and central foveal thickness (CFT) from baseline to 1 month and 3 months. Secondary outcome measures included intraocular pressure (IOP) at day 1, any signs of ocular inflammation or systemic adverse events during the follow-up.

Results

: One hundred and fifty-three eyes of 141 patients were analyzed. The indications included DME in 70 (45.8%) eyes, CNVM in 70 (45.8%) eyes, and RVO in 13 (8.4%) eyes. Mean CDVA improved from baseline (0.62 ± 0.44) to month 1 (0.45 ± 0.42) and maintained till 3 months (0.42 ± 0.44; P < 0.001). Mean CFT showed significant reduction from baseline (405.68 ± 192.422 μm) to month 1 (286.08 ± 118.36 μm) and month 3 (271 ± 104.24 μm; P < 0.001). None of the eyes recorded IOP >20 mmHg on day 1. No evidence of ocular toxicity or systemic adverse event was noted.

Conclusion

: Razumab® showed a rapid improvement in CDVA and CFT in most of the eyes with efficacy observed as early as 1 month and maintained till 3 months. The biosimilar Ranibizumab can be a safe and effective low-cost drug for treating macular diseases.

The randomized ZIPANGU trial of ranibizumab and adjunct laser for macular edema following branch retinal vein occlusion in treatment-naïve patients

The ZIPANGU study assessed the efficacy and safety of ranibizumab as a one loading dose + pro re nata (one + PRN) regimen with/without focal/grid laser among treatment-naïve patients suffering from macular edema (ME) following branch retinal vein occlusion (BRVO). ZIPANGU was a phase IV, prospective, randomized, open-label, active-controlled, 12-month, two-arm, multicenter study. Treatment-naïve patients with visual impairment (19–73 letters) caused by ME, defined as central subfield thickness (CSFT) > 300 µm, due to BRVO were randomly assigned to ranibizumab monotherapy (n = 29) or combination therapy (ranibizumab + focal/grid short-pulse laser, n = 30). The primary endpoint was the number of ranibizumab injections. Secondary endpoints were mean changes in best-corrected visual acuity (BCVA) and CSFT, and safety. There were no statistically significant differences in the mean number of ranibizumab injections between monotherapy (4.3 injections) vs. combination (4.1 injections) therapy, or in CSFT. BCVA improvement in the monotherapy arm (22.0 letters) was better than the combination therapy arm (15.0 letters) (p = 0.035). Overall, both regimens appeared to be safe and well tolerated. One + PRN ranibizumab is safe and efficacious in treatment-naïve patients with ME secondary to BRVO. A conjunctive laser treatment did not lead to better functional outcomes or fewer ranibizumab injections.

Anti-vascular endothelial growth factor for macular oedema secondary to branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is one of the most commonly occurring retinal vascular abnormalities. The most common cause of visual loss in people with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss. Limitations to this treatment exist, however, and newer modalities may have equal or improved efficacy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has recently been used successfully to treat MO resulting from a variety of causes.

OBJECTIVES

To investigate the efficacy and gather evidence from randomised controlled trials (RCTs) on the potential harms of anti-vascular endothelial growth factor (VEGF) agents for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); MEDLINE Ovid; Embase Ovid; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. The date of the last search was 12 June 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating BRVO. Eligible trials had to have at least six months' follow-up where anti-VEGF treatment was compared with another treatment, no treatment, or placebo. We excluded trials where combination treatments (anti-VEGF plus other treatments) were used; and trials that investigated the dose and duration of treatment without a comparison group (other treatment/no treatment/sham).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data using standard methodological procedures expected by Cochrane. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and 12 months of follow-up. The secondary outcomes were the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean visual acuity (VA) change at six and 12 months, as well as the change in central retinal thickness (CRT) on optical coherence tomography from baseline at six and 12 months. We also collected data on adverse events and quality of life (QoL).

MAIN RESULTS

We found eight RCTs of 1631 participants that met the inclusion criteria after independent and duplicate review of the search results. These studies took place in Europe, North America, Eastern Mediterranean region and East Asia. Included participants were adults aged 18 or over with VA of 20/40 or worse. Studies varied by duration of disease but permitted previously treated eyes as long as there was sufficient treatment-free interval. All anti-VEGF agents (bevacizumab, ranibizumab and aflibercept) and steroids (triamcinolone and dexamethasone) were included. Overall, we judged the studies to be at moderate or unclear risk of bias. Four of the eight studies did not mask participants or outcome assessors, or both. One trial compared anti-VEGF to sham. At six months, eyes receiving anti-VEGF were significantly more likely to have a gain of 15 or more ETDRS letters (risk ratio (RR) 1.72, 95% confidence interval (CI) 1.19 to 2.49; 283 participants; moderate-certainty evidence). Mean VA was better in the anti-VEGF group at six months compared with control (mean difference (MD) 7.50 letters, 95% CI 5.29 to 9.71; 282 participants; moderate-certainty evidence). Anti-VEGF also proved more effective at reducing CRT at six months (MD -57.50 microns, 95% CI -108.63 to -6.37; 281 participants; lower CRT is better; moderate-certainty evidence). There was only very low-certainty evidence on adverse effects. There were no reports of endophthalmitis. Mean change in QoL (measured using the National Eye Institute Visual Functioning Questionnaire VFQ-25) was better in people treated with anti-VEGF compared with people treated with sham (MD 7.6 higher score, 95% CI 4.3 to 10.9; 281 participants; moderate-certainty evidence). Three RCTs compared anti-VEGF with macular laser (total participants = 473). The proportion of eyes gaining 15 or more letters was greater in the anti-VEGF group at six months (RR 2.09, 95% CI 1.44 to 3.05; 2 studies, 201 participants; moderate-certainty evidence). Mean VA in the anti-VEGF groups was better than the laser groups at six months (MD 9.63 letters, 95% CI 7.23 to 12.03; 3 studies, 473 participants; moderate-certainty evidence). There was a greater reduction in CRT in the anti-VEGF group compared with the laser group at six months (MD -147.47 microns, 95% CI -200.19 to -94.75; 2 studies, 201 participants; moderate-certainty evidence). There was only very low-certainty evidence on adverse events. There were no reports of endophthalmitis. QoL outcomes were not reported. Four studies compared anti-VEGF with intravitreal steroid (875 participants). The proportion of eyes gaining 15 or more ETDRS letters was greater in the anti-VEGF group at six months (RR 1.67, 95% CI 1.33 to 2.10; 2 studies, 330 participants; high-certainty evidence) and 12 months (RR 1.76, 95% CI 1.36 to 2.28; 1 study, 307 participants; high-certainty evidence). Mean VA was better in the anti-VEGF group at six months (MD 8.22 letters, 95% CI 5.69 to 10.76; 2 studies, 330 participants; high-certainty evidence) and 12 months (MD 9.15 letters, 95% CI 6.32 to 11.97; 2 studies, 343 participants; high-certainty evidence). Mean CRT also showed a greater reduction in the anti-VEGF arm at 12 months compared with intravitreal steroid (MD -26.92 microns, 95% CI -65.88 to 12.04; 2 studies, 343 participants; moderate-certainty evidence). People receiving anti-VEGF showed a greater improvement in QoL at 12 months compared to those receiving steroid (MD 3.10, 95% CI 0.22 to 5.98; 1 study, 307 participants; moderate-certainty evidence). Moderate-certainty evidence suggested increased risk of cataract and raised IOP with steroids. There was only very low-certainty evidence on APTC events. No cases of endophthalmitis were observed.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that treatment of MO secondary to BRVO with anti-VEGF improves visual and anatomical outcomes at six and 12 months.

Use of Anti-VEGF Drugs in Retinal Vein Occlusions

Retinal vein occlusion (RVO) is one of the most prevalent causes of visual loss in the Western World. Its pathogenesis is still not completely known. Chronic macular edema and ischemia compromise the functional and anatomical status of the retina. Antivascular endothelial growth factor (anti-VEGF) injections have demonstrated better results than other previous options, including observation or laser therapy. This narrative review aims to analyze the current aspects related to these drugs.

Is there still a role of macular laser treatment in branch retinal vein occlusion in the era of intravitreal injections?

We aimed to evaluate whether macular laser still has a role in the treatment of macular oedema (MO) caused by branch retinal vein occlusion (BRVO) and provide an overview of recent studies on commonly available treatment options. A literature search was last conducted in PubMed on 26 February 2019, limited to human randomized controlled trials published in English since 2008. Seventeen articles addressing 13 trials were included in this assessment. In trials evaluating intravitreal corticosteroid and macular laser, triamcinolone was non-inferior to laser in regard to visual acuity (VA) and central retinal thickness (CRT) outcomes. Combination treatment of dexamethasone and laser resulted in better VA and lower CRT after 6 months. In trials evaluating vascular endothelial growth factor (VEGF) inhibitors versus macular laser treatment, or sham and rescue laser, better VA and CRT of VEGF inhibition treatment was consistently reported. Results of combination treatment versus VEGF inhibition monotherapy were inconsistent, with four of six studies reporting comparable outcomes and injection burden. Study comparison was affected by considerable differences in study design and inadequate reporting of laser protocol and rescue laser. Studies evaluating angiostatic treatment as monotherapy largely report the use of rescue laser, indicating that some patients would benefit from supplemental laser treatment even in the era of intravitreal therapy. Thus, we suggest further studies on optimal design of combination therapy prioritizing longer follow-up time to sufficiently evaluate the delayed effect of laser.

Comparison of Ranibizumab versus Aflibercept in Treating Macular Edema among Patients with Serous Retinal Detachment Secondary to Branch Retinal Vein Occlusion

Purpose: To compare the effectiveness of ranibizumab and aflibercept in macular edema (ME) with serous retinal detachment (SRD) following branch retinal vein occlusion (BRVO).Methods: Once every month for 3 months, 33 patients were treated with ranibizumab (Group 1), whereas 30 others were treated with aflibercept (Group 2). In 9 months after that, patients were evaluated every 4 weeks and received additional injections if they met prespecified criteria for retreatment. Corrected visual acuity (BCVA), central foveal thickness (CFT), and height of SRD was measured.Results: During the first 3 months, the improvement of CFT, BCVA, and height of SRD were greater in Group 2 than Group 1. Those differences disappeared in the subsequent 9 months, and changes in CFT, BCVA, and height of SRD were similar between groups at all other visits.Conclusion: Aflibercept was more effective than ranibizumab from baseline to Month 3 in ME with SRD following BRVO.

Intravitreal Medications for Retinal Vein Occlusion: Systematic Review and Meta-analysis

Purpose

To evaluate the outcomes of different intravitreal injections for the treatment of retinal vein occlusion including central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).

Methods

PubMed, Cochrane, the metaRegister of ControlledTrials, and ClinicalTrials were searched for intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and steroids with relevant keywords and date limitation of 2009-2018. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were visual acuity (VA) and central macular thickness (CMT).

Results

Out of 681 studies, 36 articles (including 21 reporting CRVO and 15 dealing with BRVO) were selected for systematic review. All five intravitreal drugs including triamcinolone, dexamethasone, ranibizumab, bevacizumab, and aflibercept showed improvement of CMT and VA as compared to placebo or laser treatment. Six randomized controlled trials were selected for meta-analysis in RVO patients. The pooled mean difference of visual improvement between sham and ranibizumab was 12.7 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (95%CI: 11.00 to 13.2), and the pooled mean difference in CMT reduction was 221μm (95%CI: 153 to 284); both changes were significantly in favor of ranibizumab. The pooled mean difference of visual improvement between bevacizumab and triamcinolone was 5.3 ETDRS letters in favor of bevacizumab (95%CI: 16 μm to 17.5 μm). Triamcinolone led to 68.1 μm greater CMT reduction than bevacizumab (95%CI: 58 μm to 76 μm). However, none of these differences were statistically significant.

Conclusion

Treatment with anti-VEGF agents in RVO is superior to observation. No significant difference was seen between the eyes treated with bevacizumab or triamcinolone based on these results.

IMPACT OF RETINAL ISCHEMIA ON FUNCTIONAL AND ANATOMICAL OUTCOMES AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN PATIENTS WITH RETINAL VEIN OCCLUSION

PURPOSE

To compare the impact of the classification of retinal vein occlusion (RVO) into ischemic or nonischemic forms on outcomes after anti-vascular endothelial growth factor therapy.

METHODS

Retrospective review of consecutive patients with RVO evaluated at the Belfast Health and Social Care Trust between July 1, 2014, and December 31, 2015. Outcomes, including gain of ≥10 and ≥15 letters at 12 months, mean change in best-corrected visual acuity from baseline to 12 months, resolution of macular edema at 12 months, and development of neovascular complications and epiretinal membrane after anti-vascular endothelial growth factor therapy, were compared between ischemic and nonischemic eyes using regression models.

RESULTS

One hundred and seventeen eyes (115 patients), 58 with central RVO and 59 with branch RVO, were included. A greater proportion of eyes with ischemic branch RVO gained ≥10 and ≥15 letters at 12 months than those with nonischemic branch RVO (P = 0.005 and P = 0.016, respectively). No statistically significant differences in visual outcomes were observed between ischemic and nonischemic central RVO. Retinal vein occlusion classification was not associated with anatomical outcomes after treatment.

CONCLUSION

Findings support the use of anti-vascular endothelial growth factors in ischemic and nonischemic forms of RVO.

Effect of funding source on reporting bias in studies of intravitreal anti-vascular endothelial growth factor therapy for retinal vein occlusion

PURPOSE

To examine the relationship between industry funding and outcome reporting bias in high-quality studies investigating the use of intravitreal anti-vascular endothelial growth factor (VEGF) agents for patients with macular oedema secondary to branch or central retinal vein occlusion (RVO).

METHODS

This systematic review in PubMed and Ovid MEDLINE examined all randomized clinical trials and meta-analyses published in journals with impact factor of ≥2 that investigated effectiveness of intravitreal anti-VEGF therapy in patients with RVO. The main outcome measure was correspondence between statistical outcome and abstract conclusion wording.

RESULTS

Forty-five studies met inclusion criteria; 38 (84%) showed correspondence between outcome and abstract conclusion without difference between industry-funded and nonindustry-funded publications (p = 0.39) or between publications in journals with impact factor ≥3 versus <3 (p = 0.96).

CONCLUSION

In high-quality studies of intravitreal anti-VEGF therapy for RVO, neither industry funding nor journal impact factor affected the rate of outcome reporting bias.

Short-term effect of intravitreal conbercept injection on major and macular branch retinal vein occlusion

OBJECTIVE

To evaluate the effectiveness of intravitreal conbercept injection on major and macular branch retinal vein occlusion (BRVO).

METHODS

This retrospective analysis involved 43 patients with BRVO (major BRVO n = 24; macular BRVO, n = 19) who were diagnosed by fluorescein fundus angiography (FFA) and injected with intravitreal conbercept. The following outcomes were measured at baseline and follow-up (1-6 months): best-corrected visual acuity (BCVA), central foveal thickness (CFT), total retinal volume in a 6-mm diameter section of the macula, choroidal thickness under the central fovea of the macula, relative area of retinal hemorrhage, complications, and times when repeated injection was performed.

RESULTS

There were significant differences between the two groups in terms of BCVA, CFT, and total retinal volume in a 6-mm diameter section of the macula at 6 months after treatment. Choroidal thickness under the central fovea of the macula and relative area of retinal hemorrhage showed no significant differences between the two groups at 6 months after treatment; however, they significantly differed from baseline measurements.

CONCLUSION

In general, intravitreal injection of conbercept may have a better short-term effect in patients with macular BRVO than in patients with major BRVO.

Bevacizumab versus bevacizumab and macular grid photocoagulation for macular edema in eyes with non-ischemic branch retinal vein occlusion: results from a prospective randomized study

BACKGROUND

The objective of the study was the investigation of the effects of intravitreal bevacizumab (BEV) with or without additional macular grid laser photocoagulation (GRID) for macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

METHODS

Prospective, randomized, monocentric study. Thirty-two patients were included. Initially, all eyes in both groups received three monthly injections of BEV, followed by additional injections if re-treatment criteria were met. In the BEV + GRID group, photocoagulation was performed 2 weeks after the first BEV injection and laser re-treatment was allowed. The follow-up was 38 weeks. Main outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Changes of foveal avascular zone (FAZ) and of retinal ischemia, as well as the number of injections were also evaluated.

RESULTS

Sixteen eyes were randomized into each group. At baseline, BCVA was similar in both groups (BEV + GRID: 20/71; BEV: 20/60; P = 0.51). At 38 weeks, BCVA significantly improved in the two groups (BEV + GRID gain of 9 ± 11.2 letters and 16.25 ± 10.08 letters in the BEV) with no difference between them (P < 0.06). With regard to anatomical findings, initial CRT in BEV + GRID was 496.2 μm ± 138.4 μm and 538.9 μm ± 156.9 μm in BEV (P < 0.1697). At 38 weeks, CRT decreased in both groups significantly, 98.2 μm in the BEV + GRID (P = 0.02) and 141.7 μm in the BEV group (P = 0.01), with no significant difference between groups (P < 0.17). The area of FAZ a significantly increased in both groups (41% (P = 0.04) in BEV + GRID; 35% (P = 0.03) in BEV) during the study and the grade of peripheral ischemia remained unchanged. The mean number of injections was 3.8 (range 3-6) with no significant difference between groups.

CONCLUSIONS

Our data demonstrate a beneficial effect of bevacizumab in ME in eyes with BRVO. A loading phase of three injections led to a significant improvement in vision in both groups, which persisted at week 38. Additional grid laser photocoagulation exhibited no beneficial functional or anatomical effect during the study, nor did it reduce the number of injections. The FAZ area increased significantly in both groups, but overall retinal ischemia did not. Further studies investigating more numerous eyes and longer follow-up are needed to confirm these data.

Head-to-head comparison of ranibizumab PRN versus single-dose dexamethasone for branch retinal vein occlusion (COMRADE-B)

PURPOSE

To compare the efficacy and safety of ranibizumab 0.5 mg versus dexamethasone 0.7 mg according to their European labels in macular oedema secondary to branch retinal vein occlusion (BRVO) in a 6-month, phase IIIb, randomized trial.

METHODS

Patients received either monthly ranibizumab for 3 months followed by Pro re nata (PRN) treatment (n = 126) or a sustained-release dexamethasone implant followed by PRN sham injections (n = 118). Main outcomes were mean average change in best-corrected visual acuity (BCVA) from baseline to month 1 through month 6, mean changes in BCVA and foveal centre point thickness (FCPT), and adverse events (AEs).

RESULTS

There was no difference in BCVA gains between the treatments prior to month 3. Best-corrected visual acuity (BCVA) gain with dexamethasone declined thereafter. From month 3 to month 6, mean BCVA change from baseline was significantly higher with ranibizumab than with dexamethasone [raw means (standard deviation):+16.2 (±11) letters versus +9.3 (±10.1) letters]. At month 6, the difference in BCVA gains from baseline was +17.3 letters in the ranibizumab versus +9.2 letters in the dexamethasone group. Patients in the ranibizumab group received a mean of 2.94 loading injections and 1.74 PRN retreatment injections, while those in the dexamethasone group received a single loading injection. Elevated intraocular pressure (IOP) and AEs were more frequent with dexamethasone than ranibizumab treatment.

CONCLUSION

Ranibizumab PRN resulted in greater visual acuity (VA) gains in macular oedema following BRVO compared with single-dose dexamethasone over a 6-month study period, observed from month 3, when administered according to their European label. In clinical practice, retreatment with dexamethasone may be required prior to this point.

Macular cystic changes as predictive factor for the recurrence of macular oedema in branch retinal vein occlusion

AIM

To evaluate the role of small cystic macular changes as a prognostic factor for the recurrence of macular oedema (ME) in patients with branch retinal vein occlusion (BRVO) treated with anti-VEGF drugs.

METHODS

We performed retrospective chart analysis of 116 patients treated with intravitreal injection of ranibizumab (IVR) or bevacizumab (IVB) for ME secondary to BRVO. At the baseline and monthly follow-up visits over a period of 12 months, a comprehensive ophthalmologic examination including best-corrected visual acuity (BCVA) and volume scan of macula using Spectral domain optical coherence tomography (SD-OCT) were performed. Patients without ME (CRT <250 μm) were screened for the presence of intraretinal cysts. In these patients, the changes in BCVA and CRT were evaluated over a period of 12 months and compared with the baseline.

RESULTS

In the IVR group (41 patients), 91 events of macular cysts, without a worsening of BCVA, were detected by OCT. In 89 of 91 events (97%), BCVA and CRT deteriorated significantly (p < 0.0001) within the next 4-11 (in mean 7.1 ± 2.0) weeks. BCVA decreased from 0.38 ± 0.25 to 0.49 ± 0.27 logMAR and CRT increased significantly from 223 ± 43 to 605 ± 244 μm. In the IVB group (19 patients), 54 events of cystic changes were detected. All of these patients showed significant worsening of BCVA from 0.40 ± 0.19 to 0.57 ± 0.22 logMAR and CRT from 251 ± 17 to 490 ± 147 μm within 4-10 (in mean 7.8 ± 2.8) weeks after the first presence of small macular cysts.

CONCLUSION

In BRVO patients treated with anti-VEGF drugs, the macular cystic changes may be used as an early indicator for impending recurrence of ME, with the decrease in BCVA in the following weeks. These patients should be scheduled for a next visit within 6-8 weeks.

Sustained Benefits of Ranibizumab with or without Laser in Branch Retinal Vein Occlusion: 24-Month Results of the BRIGHTER Study

PURPOSE

To evaluate the long-term (24-month) efficacy and safety of ranibizumab 0.5 mg administered pro re nata (PRN) with or without laser using an individualized visual acuity (VA) stabilization criteria in patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Phase IIIb, open-label, randomized, active-controlled, 3-arm, multicenter study.

PARTICIPANTS

A total of 455 patients.

METHODS

Patients were randomized (2:2:1) to ranibizumab 0.5 mg (n = 183), ranibizumab 0.5 mg with laser (n = 180), or laser (with optional ranibizumab 0.5 mg after month 6; n = 92). After initial 3 monthly injections, patients in the ranibizumab with or without laser arms received VA stabilization criteria-driven PRN treatment. Patients assigned to the laser arm received laser at the investigator's discretion.

MAIN OUTCOME MEASURES

Mean (and mean average) change in best-corrected visual acuity (BCVA) and central subfield thickness (CSFT) from baseline to month 24, and safety over 24 months.

RESULTS

A total of 380 patients (83.5%) completed the study. Ranibizumab with or without laser led to superior BCVA outcomes versus laser (monotherapy and combined with ranibizumab from month 6; 17.3/15.5 vs. 11.6 letters; P < 0.0001). Ranibizumab with laser was noninferior to ranibizumab monotherapy (mean average BCVA change: 15.4 vs. 15.0 letters; P < 0.0001). However, addition of laser did not reduce the number of ranibizumab injections (mean injections: 11.4 vs. 11.3; P = 0.4259). A greater reduction in CSFT was seen with ranibizumab with or without laser versus laser monotherapy over 24 months from baseline (ranibizumab monotherapy -224.7 μm, ranibizumab with laser -248.9 μm, laser [monotherapy and combined with ranibizumab from month 6] -197.5 μm). Presence of macular ischemia did not affect BCVA outcome or treatment frequency. There were no reports of neovascular glaucoma or iris neovascularization. No new safety signals were identified.

CONCLUSIONS

The BRIGHTER study results confirmed the long-term efficacy and safety profile of PRN dosing driven by individualized VA stabilization criteria using ranibizumab 0.5 mg in patients with BRVO. Addition of laser did not lead to better functional outcomes or lower treatment need. The safety results were consistent with the well-established safety profile of ranibizumab.

Comparison between anti-VEGF therapy and corticosteroid or laser therapy for macular oedema secondary to retinal vein occlusion: A meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Therapeutic effects of anti-VEGF agents, corticosteroids and laser therapy have been previously examined for treating macular oedema secondary to branch and central retinal vein occlusion (BRVO and CRVO). However, anti-VEGF efficacy has not been previously compared to corticosteroid or laser therapy efficacy. We performed a meta-analysis to compare these treatments.

METHODS

Pertinent publications were identified through comprehensive literature searches. Therapeutic effects were estimated using best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP). The Review Manager (version 5.3.5) was used to perform searches.

RESULTS AND DISCUSSION

Eleven randomized, controlled trials that included 1045 RVO patients were identified. For eyes with BRVO, anti-VEGF therapy improved BCVA significantly more than corticosteroid/laser therapy at 3 (P=.0002), 6 (P<.00001) and 12 months (P<.00001). For eyes with CRVO, this difference was only significant at 6 months (P=.002). The same was true when efficacy was examined using CRT at 3 and 6 months (BRVO: both P<.00001, CRVO 6 months: P=.02). Long-term efficacy of anti-VEGF agents was limited in eyes with BRVO and CRVO. Improvements in BCVA were similar at 1 and 3 months (P=.74), but BCVA decreased between 3 and 6 months (P=.03). In contrast, BCVA progressively decreased 1 and 6 months following corticosteroid/laser therapy (both P<.00001). Lastly, eyes that had been treated with anti-VEGF agents had significantly lower IOP changes than eyes treated with corticosteroids/laser 3 and 6 months after initiating therapy (both P<.00001).

WHAT IS NEW AND CONCLUSION

Anti-VEGF agents improve BCVA and reduce CRT more effectively and longer than corticosteroid/laser in eyes with RVO. Anti-VEGF agents also have a lower risk of elevating IOP. Additionally, anti-VEGF agents are more effective for treating BRVO than CRVO.

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.

Comparative study of combined bevacizumab/targeted photocoagulation vs bevacizumab alone for macular oedema in ischaemic branch retinal vein occlusions

PURPOSE

To investigate whether targeted retinal photocoagulation (TRP) of peripheral non-perfused areas (NPAs) could prevent the recurrence of macular oedema (ME) due to branch retinal vein occlusion (BRVO) after intravitreal bevacizumab injection (IVB).

METHODS

Eyes received 1.25 mg IVB only (IVB group) or combined with TRP (IVB + TRP group) of NPAs, more than 5 disc areas identified by fluorescein angiography in the patients with ME secondary to BRVO. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) determined by optical coherence tomography were measured every month for 6 months.

RESULTS

Thirty-eight patients were enrolled and randomized to IVB group (n = 19) and IVB + TRP group (n = 19). Both groups showed similar thinning in CRT at 1 week after IVB, IVB + TRP group maintained thinner retina at 2 (p = 0.0072) and 3 (p = 0.0086) months compared with IVB group in whom turned to thickened almost back to baseline at 3 months. The number of reinjections in IVB group (1.58 ± 0.69) was significantly greater (p = 0.0025) than that in IVB + TRP group (0.83 ± 0.62). BCVA significantly improved at 6 month in IVB + TRP group (p = 0.015), but not in IVB group.

CONCLUSION

TRP of NPAs reduced the amount of ME recurrence following IVB compared to IVB alone.

Clinical Trials in Branch Retinal Vein Occlusion

Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disorder. The management of macular edema has changed considerably over time. The laser is considered the gold standard treatment for over two decades. However, visual recovery with laser is usually slow and incomplete. The advent of intravitreal agents, specifically anti-vascular endothelial growth factors (VEGF) have heralded a new era which promises rapid recovery of vision and quality of vision. Randomized clinical trials have reported optimal results with anti-VEGF agents (ranibizumab, bevacizumab, and aflibercept) compared to laser therapy or steroids. However, nearly 50% of the patients require repeat intravitreal anti-VEGF therapy up to 4 years after initiating therapy to sustain the visual gains. The adverse events (systemic and ocular) of these agents are minimal. Monotherapy with anti-VEGF agents have been found to provide better results than any combination with laser. This review article summarizes evidence from randomized controlled trials evaluating treatment options for the treatment of macular edema secondary to BRVO with a special focus on anti-VEGF therapy.

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.

Effect of leaking capillaries and microaneurysms in the perifoveal capillary network on resolution of macular edema by anti-vascular endothelial growth factor treatment

PURPOSE

To investigate the effect of leaking capillaries and microaneurysms (MAs) in the perifoveal capillary network (PCN) on the treatment of fovea-involving macular edema (ME) secondary to branch retinal vein occlusion (BRVO) by intravitreal ranibizumab (IVR) injections combined with focal, grid, and scatter laser photocoagulation.

METHODS

Retrospective comparative case series. The MA (+) group consisted of 12 patients with leaking MAs in the PCN and the MA (-) group contained 11 patients without. At 6 months following the initial IVR injection, best corrected visual acuity (BCVA) was evaluated as the primary outcome. Secondary outcomes included central macular thickness (CMT) and the number of IVR injections performed in a pro re nata (PRN) regimen when CMT was ≥300 µm and vision deteriorated by 0.1 logMAR or greater.

RESULTS

Mean BCVA improved by 0.30 ± 0.25 logMAR in the MA (-) group and 0.28 ± 0.20 logMAR in the MA (+) group (both P < 0.0001). Mean CMT was reduced by 237.6 ± 221.4 µm (P < 0.0001) in the MA (-) and 158.2 ± 152.1 µm (P < 0.01) in the MA (+) group. The degrees of improvement in BCVA (P = 0.74) and CMT (P = 0.33) did not vary significantly between the groups. The mean number of additional IVR injections was significantly less in the MA (-) group than in the MA (+) group (2.2 ± 1.0 vs 3.0 ± 0.8; P = 0.04).

CONCLUSIONS

Although leaking MAs and capillaries in the PCN did not adversely affect improvements in BCVA and CMT, these manifestations led to an increased number of IVR injections needed to sustain resolution of ME involving the fovea.

Anti-VEGF treatment in branch retinal vein occlusion: a real-world experience over 4 years

PURPOSE

To determine long-term outcome of intraocular antagonism of vascular endothelial growth factor (VEGF) in macular oedema (ME) secondary to branch retinal vein occlusion (BRVO).

METHODS

A total of 28 consecutive patients were treated with either intravitreal bevacizumab (IVB) or intravitreal ranibizumab (IVR) in the first series and were evaluated after a mean follow-up of 5 years for their functional and anatomical outcome.

RESULTS

Time between onset of macular oedema and initial treatment was 5.2 ± 0.4/0.1 ± 0.1 (IVB/IVR) months. A mean of 4 intravitreal injections were given per patients in the first 6 months. In months 7-12 intravitreal injections decreased to 2 and further decreased in the second year (months 13-18: 1.14; months 19-24: 0.5) and third year (months 25-30: 0.4; months 31-36: 0.2). After the fourth year, only two of the 28 patients received further treatment. Average visual acuity (VA) increased by 16 letters after 1 year (p < 0.01) and although not statistically significantly, by a mean of 5 letters (p = 0.3) at long-term evaluation (IVB-group). However, after mean of 5 years, central retinal sensitivity (CRS) improved by 3.6 dB (p = 0.01) and central retinal thickness (CRT) decreased by 161 μm (p = 0.02). In the IVR-group, VA and CRS increased significantly (31 letters and respectively 4.4 dB, p < 0.001) and CRT decreased by 229 μm (p < 0.001) after long-term follow-up. Final functional results were significantly better in patients with treatment initiation <3 months (79 versus 55 letters, p = 0.01). Microvascular abnormalities were detected in 88% (21 of 24 patients), hyperfluorescence in 42% (10 of 24 patients) on wide-field fluorescein angiography in both groups.

CONCLUSIONS

Inhibition of VEGF provides substantial long-term benefits for patients with ME secondary to BRVO. Early treatment with anti-VEGF agents and extended therapeutic surveillance was associated with improved visual recovery.

[Retinal vein occlusion management algorithm. Part 2. Macular edema]

Macular edema (ME) is the most common complication of both ischemic and nonischemic retinal vein occlusion (RVO). If the main trunk of the central retinal vein is involved, ME occurs in 100% of cases. According to the Central Vein Occlusion Study, in 65% of RVO and ME patients with baseline visual acuity (VA) of at least 0.5 (Golovin-Sivtsev chart) or higher, ME may resolve itself without treatment with subsequent VA improvement. Therefore, we recommend a 3-month treatment-free follow-up of nonischemic central RVO (CRVO) and ME patients with VA of 0.5 or higher. If no improvement is noted within this period, treatment is initiated. Immediate treatment is required in patients with cystic ME revealed by optical coherence tomography (OCT) and VA below 0.5. Ischemic maculopathy is extremely unpromising. Modified grid laser photocoagulation should not be used as monotherapy for macular edema. Repeated corticosteroid (Ozurdex) and/or anti-VEGF (ranibizumab, aflibercept) intravitreal injections are considered the first choice treatment for ME in CRVO patients. Efficiency assessments should include monthly OCT. For persistent ME, intravitreal therapy can be supplemented by laser retinal photocoagulation (panretinal or modified grid). Anti-VEGF treatment schemes should be adjusted in BRVO patients as most of their edemas are self-limiting. Of laser photocoagulation techniques, only modified grid is used.

[Retinal vein occlusion: Therapy of retinal vein occlusion]

Treatment of retinal vein occlusion can be systemic or local. Therapeutic strategies include improved blood supply, treatment of the vision-reducing macular edema by intravitreal injection of inhibitors of vascular endothelial growth factors (VEGF) or corticosteroids and laser photocoagulation for neovascular complications. As long as head-to-head studies comparing steroids and VEGF inhibitors have not been published, none of the available intravitreally injected substances can be given priority. Well-known side effects of intravitreal steroids are cataract formation and ocular hypertension whereas VEGF inhibitors need to be frequently injected. Although therapy for retinal vein occlusion is protracted, initial long-term data indicate that treatment can be terminated in at least half of the patients . Finally, a treatment recommendation according to the current state of data is presented.

Comparative efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion: a network meta-analysis

OBJECTIVE

To compare the efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Randomised controlled trials (RCTs) evaluating the efficacy and safety of approved treatments for macular oedema secondary to BRVO were identified from an updated systematic review.

SETTING

A Bayesian network meta-analysis of RCTs of treatments for macular oedema secondary to BRVO.

INTERVENTIONS

Ranibizumab 0.5 mg pro re nata, aflibercept 2 mg monthly (2q4), dexamethasone 0.7 mg implant, laser photocoagulation, ranibizumab+laser, or sham intervention. Bevacizumab and triamcinolone were excluded.

OUTCOME MEASURES

Efficacy outcomes were mean change in best corrected visual acuity (Early Treatment Diabetic Retinopathy Study scale) and the percentage of patients gaining ≥ 15 letters. Safety outcome was the percentage of patients with increased intraocular pressure (IOP)/ocular hypertension (OH).

RESULTS

8 RCTs were identified for inclusion with 1743 adult patients. The probability of being the most efficacious treatment at month 6 or 12 based on letters gained was 54% for ranibizumab monotherapy, 30% for aflibercept, 16% for ranibizumab plus laser (adjunctive or prompt), and 0% for dexamethasone implant, laser or sham. The probability of being the most efficacious treatment for patients gaining ≥ 15 letters was 39% for aflibercept, 35% for ranibizumab monotherapy, 24% for ranibizumab plus laser, 2% for dexamethasone implant, and less than 1% for laser or sham. There was no statistical difference between ranibizumab monotherapy and aflibercept for letters gained (+1.4 letters for ranibizumab vs aflibercept with 95% credible interval (CrI) of -5.2 to +8.5 letters) or the OR for gaining ≥ 15 letters: 1.06 (95% CrI 0.16 to 8.94)). Dexamethasone implant was associated with significantly higher IOP/OH than antivascular endothelial growth factor agents (OR 13.1 (95% CrI 1.7 to 116.9)).

CONCLUSIONS

There was no statistically significant difference between ranibizumab and aflibercept.

Subthreshold grid laser versus intravitreal bevacizumab as second-line therapy for macular edema in branch retinal vein occlusion recurring after conventional grid laser treatment

PURPOSE

To compare the effects of subthreshold grid laser treatment (SGLT) and intravitreal bevacizumab injection (IVBI) for the treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO) recurring after conventional grid laser photocoagulation.

METHODS

Thirty-five eyes were considered in this prospective, randomised, interventional study and treated with micropulse diode laser (SGLT subgroup) or IVBI (IVBI subgroup). SGLT was administered once, whereas IVBI (1.25 mg) was given at baseline and then on a pro re nata regimen according to ME presence on optical coherence tomography (OCT), performed at monthly examinations over a 12-month follow-up. Primary outcome measures were the mean BCVA changes over the follow-up and the decrease in mean central foveal thickness (CFT) on optical coherence tomography (OCT). Secondary outcomes included the proportion of eyes that gained at least 15 letters (approximately three lines) at the 12-month examination.

RESULTS

Eighteen and 17 patients were assigned to SGLT and IVBI subgroups, respectively. At baseline, the subgroups were similar with regard to mean ME duration, BCVA, and CFT. At month 12, mean CFT significantly improved from 484 μm to 271 μm in the IVBI subgroup, whereas it was unchanged in the SGLT subgroup. Mean BCVA changed from 0.92 ± 0.3 (LogMAR) to 0.99 ± 0.2 in the SGLT subgroup; in the IVBI subgroup, mean BCVA showed a statistically significant improvement from 0.94 ± 0.3 to 0.72 ± 0.2. Ten patients in the IVBI subgroup (58 %) and no patient in the SGLT subgroup gained at least three lines.

CONCLUSION

At the 1-year follow-up, IVBI provided a significant functional and anatomical improvement, whereas SGLT failed to demonstrate any beneficial effects. IVBI might be a useful approach in the treatment of recurrent ME secondary to BRVO already treated with conventional grid laser photocoagulation. UMIN registry, number UMIN000005014, URL: http://www.umin.ac.jp/ctr/index.htm.