Acute retinal pigment epithelial tear in the untreated fellow eye following repeated bevacizumab (Avastin™) injections

Ocular side effects of oncological therapies: Review

With the advance of cancer therapy in recent years, the knowledge of the mechanisms involved in this disease has increased, which has meant an increase in the quality of life and survival of patients with tumor pathologies previously considered incurable or refractory to treatment. The number of drugs used has increased exponentially in number, and although the implicit toxicity is lower than that of conventional antineoplastic therapy, they lead to the appearance of new associated adverse effects that the ophthalmologist must recognize and manage.

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

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

Prospective evaluation of the incidence and risk factors for the development of RPE tears after high- and low-dose ranibizumab therapy

PURPOSE

To prospectively determine the incidence and risk factors for retinal pigment epithelial (RPE) tears in eyes with vascularized pigment epithelial detachments (PED) and exudative age-related macular degeneration receiving antivascular endothelial growth factor therapy.

METHODS

Eyes were prospectively randomized into 1 of 4 arms: 1) 0.5 mg of ranibizumab monthly for 12 months; 2) 0.5 mg of ranibizumab monthly for 3 months and then pro re nata on the basis of clinical and optical coherence tomography-guided indications; 3) high-dose 2.0 mg of ranibizumab monthly for 12 months; or 4) 2.0 mg of ranibizumab monthly for 3 months and then pro re nata thereafter. All PEDs were measured for height, greatest linear diameter, and surface area at baseline. The incidence of RPE tears in the entire 4-arm cohort was determined at the end of 12 months. Eyes were divided into two groups (tear vs. nontear) and statistically compared to determine risk factors for the development of RPE tear.

RESULTS

Of 37 eyes, a total of 5 developed postranibizumab RPE tears during the course of the study (incidence 14%). Four of the 5 tears occurred in the high-dose 2.0-mg groups. Baseline PED height, surface area, and greatest linear diameter were significantly greater in the group that developed RPE tears versus the nontear group (P = 0.018, 0.031, and 0.048, respectively). There were significantly more eyes with PED height >550 microns in the RPE tear group (4 of 5, 80%) compared with the nontear group (9 of 32, 18%) (P = 0.042). The presence of PED height >550 microns was associated with an increased tear rate from 14% to 31%. Furthermore, retrospective identification of a ring sign or Grade 1 tear at baseline, in addition to PED height >550 microns, was associated with a further increase in the tear rate to 67%.

CONCLUSION

In this study, the prospective incidence of RPE tears was ∼14%. A baseline PED height >550 microns and presence of a Grade 1 tear, or positive ring sign, were identified as high-risk factors for the subsequent development of an RPE tear.

Bevacizumab-induced transient sixth nerve palsy in ovarian cancer: A case report

We report a case of transient sixth nerve palsy after systemic administration of bevacizumab. Two days after systemic administration of bevacizumab in conjunction with gemcitabine and carboplatin in a 67-year-old woman with recurrent primary ovarian cancer, the patient developed sixth nerve palsy. After bevacizumab was stopped, the complete left sixth nerve palsy resolved spontaneously over the course of 3 months. This is the first reported case of bevacizumab-induced cranial sixth nerve palsy in the treatment of gynecologic malignancy.

The ophthalmological complications of targeted agents in cancer therapy: what do we need to know as ophthalmologists?

Recently, there has been an increase in the use of targeted therapies for cancer treatments. Nevertheless, the ocular side-effects of the commonly used targeted agents are generally under-reported and not well studied in the literature. We conducted multiple searches in databases, including Medline, EMBASE, Cochrane Library and conference proceedings, using the following strings: 'name of targeted therapeutic agent (both generic and commercial names)' AND 'eye OR ocular OR vision OR ophthalmological'. Various targeted agents have been found to be associated with ocular side-effects due to their specific targeting of activities in the eye. Imatinib commonly causes periorbital oedema, epiphora and occasionally conjunctival haemorrhage. Cetuximab causes corneal lesions, meibomian gland dysfunction, periorbital and lid dermatitis, blepharitis and conjunctivitis. Erlotinib is related to various ocular toxicities, mainly on the ocular surface, and perifosine has been reported to be associated with severe keratitis. Bevacizumab could potentially disrupt intrinsic ocular circulation and lead to the development of thromboembolic events; there are rare reported cases of optic neuritis or optic neuropathy. Other targeted agents, such as trastuzumab, sunitinib and crizotinib, also have specific ocular toxicities. In conclusion, ocular effects of targeted agents are not uncommon in cancer patients receiving targeted therapy. Ophthalmologists should have high indexes of suspicion to diagnose and treat these complications promptly.

Concentrations of unbound bevacizumab in the aqueous of untreated fellow eyes after a single intravitreal injection in humans

PURPOSE

To determine the concentration of unbound bevacizumab in untreated fellow eyes after contralateral intravitreal injection of bevacizumab.

METHODS

A total of 18 eyes received intravitreal injections of 1.5 mg bevacizumab. Nine probes were obtained in the injected eye and nine in the fellow eye. Each group contained three individual eyes. Aqueous humour samples were obtained during uneventful phacoemulsification at three intervals 1-7 days (group a), 8-12 days (group b) or 13-28 days (group c).

RESULTS

In untreated fellow eyes, the concentration of unbound bevacizumab was below the detectable limit of the ELISA (5 ng/ml in all samples). The mean concentration of unbound bevacizumab in the injected eye declined from 28.6 μg/ml (group a), 16.5 μg/ml (group b) to 7.4 μg/ml (group c).

CONCLUSIONS

There are no pharmacological indications for a significant concentration of unbound bevacizumab in the anterior chamber of contralateral eyes in humans.

Pegaptanib sodium treatment in neovascular age-related macular degeneration: clinical experience in Germany

BACKGROUND

The VEGF Inhibition Study In Ocular Neovascularisation (VISION) reported the efficacy of intravitreal (ITV) vascular endothelial growth factor (VEGF) inhibition with pegaptanib sodium (Macugen((R))) for the treatment of neovascular age-related macular degeneration (AMD). This paper reports clinical experience with pegaptanib sodium for the treatment of occult or minimally classic choroidal neovascularization (CNV) due to AMD.

MATERIAL AND METHODS

The study included 50 eyes (in 49 patients) with either occult CNV or minimally classic CNV secondary to neovascular AMD who were not eligible for photodynamic therapy (PDT). Study data were analyzed retrospectively. During the 6-month study, patients were administered an average 2.74 injections of 0.3 mg ITV pegaptanib sodium. Angiography and optical coherence tomography (OCT) examinations were carried out and intraocular pressure (IOP) and visual acuity (VA) were measured at baseline, at 3 months and at 6 months. An eye examination was performed and VA was measured the 2 days following treatment and then again at weeks 4-6, and at 3 and 6 months. OCT, VA, and IOP were also assessed at 1 month.

RESULTS

ITV pegaptanib sodium was well tolerated and no treatment complications arose. Mean VA was measured as: 0.37 +/- 0.24 at baseline; 0.37 +/- 0.25 at 1 month; 0.37 +/- 0.25 at 3 months and 0.40 +/- 0.26 at 6 months. VA was stabilized in approximately 90% of eyes treated with pegaptanib sodium. OCT examination showed a minimal change in central retinal thickness (CRT) during the course of the study, from 251.19 mum at baseline to 251.63 mum at 6 months. No elevation in IOP was measured during treatment at 4-6 months in patients receiving pegaptanib sodium.

CONCLUSIONS

ITV therapy with pegaptanib sodium for occult and minimally classic CNV secondary to neovascular AMD offered good efficacy with a favorable adverse events profile. The majority of patients showed stabilization in all assessed parameters. In clinical practice, careful consideration should be given to the use of nonselective VEGF inhibition in patients with a high cardiovascular risk profile or in those with a history of thromboembolic events.

Descending doses of intravitreal bevacizumab for the regression of diabetic neovascularization

PURPOSE

To report short-term regression of neovascularization after varying intravitreal doses of bevacizumab (Avastin®; Genentech, San Francisco, California, USA) in patients with proliferative diabetic retinopathy (PDR).

METHODS

Eighty eyes from 76 patients with active neovascularization of the disc (NVD) or elsewhere (NVE) caused by PDR were divided into four groups and treated with a single intravitreal bevacizumab (IVB) injection of 1.25 mg, 600 μg, 300 μg or 150 μg, respectively. All patients underwent ophthalmoscopic examination and fluorescein angiography at baseline, 1 week, 1 month and 2 months later.

RESULTS

No significant ocular or systemic adverse events were observed. In all patients with NVD or NVE, complete resolution of leakage was recorded within the first week or the first month of the injection. Even with the lowest dose (150 μg), regression of neovascularization appeared as early as the first week and lasted for over a month. Recurrence of fluorescein leakage was observed in all groups after the first month and did not correlate with the extent of neovascularization or IVB dose.

CONCLUSION

Short-term results suggest that IVB given below the standard dosage (150–300 μg compared to 1.25 mg) can lead to the achievement of complete regression of diabetic retinal neovascularization within 30–45 days of injection.

Preclinical aspects of anti-VEGF agents for the treatment of wet AMD: ranibizumab and bevacizumab

Three anti-vascular endothelial growth factor (VEGF) therapies are currently used for the treatment of patients with wet age-related macular degeneration (AMD): pegaptanib, ranibizumab, and bevacizumab. Ranibizumab is an antibody fragment approved for the treatment of wet AMD. Bevacizumab is a full-length antibody registered for use in oncology but unlicensed for wet AMD. However, it is used off-label worldwide not only for wet AMD but also for various other ocular diseases associated with macular edema and abnormal vessel growth. We consider aspects of ranibizumab and bevacizumab in relation to their molecular characteristics, in vitro and in vivo properties, and preclinical safety data. Before 2009, most studies described the short-term toxicity of bevacizumab in multiple cell types of the eye. Since 2009, an increasing number of studies have compared the properties of ranibizumab and bevacizumab and investigated their impact on retinal cell functioning. Compared with bevacizumab, ranibizumab neutralizes VEGF better at low concentrations, maintains efficacy for longer, and has a higher retinal penetration and potency. Studies in animals demonstrate ranibizumab to be better localized to the injected eye, whereas bevacizumab appears to have a greater effect in the fellow eye. In humans, a localized and systemic effect has been reported for both molecules. In conclusion, overlapping yet distinct pharmacological properties of ranibizumab and bevacizumab indicate that safety or efficacy data from one cannot be extrapolated to the other.

Effect of intravitreal bevacizumab (Avastin) in neovascular age-related macular degeneration using a treatment regimen based on optical coherence tomography: 6- and 12-month results

PURPOSE

To study the effect of intravitreal bevacizumab therapy on visual and anatomical outcomes in patients with neovascular age-related macular degeneration (AMD) within a follow-up period of 6 and 12 months.

METHODS

A retrospective analysis of 102 eyes of 102 consecutive patients with neovascular AMD evaluated repeated intravitreal bevacizumab (1 or 2.5 mg) injections. Retreatment was performed following an optical coherence tomography (OCT)-based regimen. Ophthalmic examination included best-corrected visual acuity (BCVA), dilated fundus examination and OCT imaging. Data were analysed at baseline, 6 months (24 weeks) and 12 months (48 weeks) after treatment initiation.

RESULTS

BCVA remained stable at 6 months (mean: 0.00+/-0.41 logMAR; p=0.95) and 12 months (mean: +0.02+/-0.43 logMAR; loss of approximately 1 letter; p=0.70) after the first treatment. OCT retinal thickness decreased by a mean of -37.8+/-101.6 microm (p<0.05) compared to baseline at month 6 and -38.6+/-93.3 microm (p<0.05) at month 12. A mean of 2.6+/-1.2 injections were needed to obtain absence of fluid by OCT, and the time to recurrence was 23+/-11 weeks thereafter. There was no difference in BCVA and OCT outcomes between treatment-naive eyes and eyes that had undergone prior treatment.

CONCLUSION

The 6- and 12-month follow-up of repeated intravitreal bevacizumab therapy in eyes with neovascular AMD demonstrated stabilization of vision and no safety concerns. An OCT-based retreatment strategy appears appropriate in the management of patients treated with intravitreal bevacizumab.

Off-label use of bevacizumab for the treatment of age-related macular degeneration: what is the evidence?

There is an active and controversial debate about the role of intravitreal bevacizumab versus approved drugs in the treatment of neovascular age-related macular degeneration (AMD). Because bevacizumab was available prior to the launch of ranibizumab, off-label use of the former became widespread and the cancer drug bevacizumab is the most commonly used medication in ophthalmology nowadays. This review considers every publication identified in MEDLINE using the keywords 'bevacizumab' and 'Avastin' between 1 June 2005 and 31 July 2008. The search identified 511 papers that were evaluated. In 33 studies, there was consistent and clear evidence for the efficacy of bevacizumab in neovascular AMD. However, the highest grade studies (three prospective, randomized, controlled trials) did not attain better than grade 2b level of evidence, and objective evaluation of the benefit of bevacizumab relative to representative controls was therefore not possible. Certainly, the available evidence is inferior to that obtained from the approval studies of ranibizumab and this should influence treatment selection and guidance of patients. These considerations indicate that important quality criteria need to be included in future studies to ensure more meaningful conclusions can be drawn. These include clearly defined inclusion criteria, information about the recruitment procedure (including data on withdrawals, excluded patients, concealed treatment allocation, use of intention-to-treat analyses and blinded assessment procedures). Although preclinical studies have almost exclusively found bevacizumab to be safe, the design utilized in clinical case series cannot rule out a possible increase in adverse events, which already show a high spontaneous incidence in elderly AMD patients. The superior evidence level for ranibizumab and the limited safety data for bevacizumab must be taken into consideration when evaluating the costs that a healthcare system is willing to spend. However, the superior grade of evidence for ranibizumab should not be confused with the (still missing) evidence for superior efficacy. The results of ongoing randomized, controlled, comparative trials will provide further data on the efficacy and cost effectiveness of bevacizumab and ranibizumab in the treatment of AMD. In the meantime, patients should be informed about the alternatives, the price differences and the restricted liability issue when off-label use of bevacizumab is offered.

Intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization in age-related macular degeneration

PURPOSE

This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD).

METHODS

Twelve eyes of 12 patients (mean age 76 +/- 6 years) with mean best corrected visual acuity (BCVA) of 20/100 and occult subfoveal CNV at fluorescein angiography (FA), indocyanine-green (ICG) angiography and optical coherence tomography (OCT), showing intra- or subretinal fluid with or without retinal pigment epithelial detachment (PED), underwent multiple intravitreal injections (mean 2.4 +/- 0.7) of 1.25 mg (0.05 ml) bevacizumab. Visual acuity and OCT findings were assessed at the end of follow-up.

RESULTS

After a mean follow-up of 5.7 +/- 2 months, BCVA improved from 20/100 (range 20/50-20/303) to 20/60 (range 20/28-20/200) (p = 0.038). Five eyes (42%) increased BCVA by > or = 3 lines, six eyes (50%) increased BCVA by < 3 lines and one eye (8%) remained stable. Macular thickness decreased from 298 +/- 71 microm to 223 +/- 72 microm (p = 0.017). No ocular or systemic side-effects were observed.

CONCLUSIONS

Short-term results suggest that multiple intravitreal injections of 1.25 mg bevacizumab are well tolerated and associated with significant improvements in BCVA and decreased retinal thickness by OCT in most patients with treatment-naïve occult CNV. Further evaluation of intravitreal bevacizumab for the treatment of occult CNV is warranted.

Retinal pigment epithelial tears in ranibizumab-treated eyes

PURPOSE

To report the incidence of retinal pigment epithelial (RPE) tears in patients treated with ranibizumab therapy for choroidal neovascularization due to age-related macular degeneration.

DESIGN

: Interventional case series.

METHODS

One hundred sixty-four eyes from a large clinical practice were retrospectively reviewed for number of injections and the presence or absence of a fibrovascular retinal pigment epithelial detachment. Main outcome measures were occurrence of RPE tears, and timing of tears following the last injection.

RESULTS

Patients were observed for an average of 11 months. A single patient (0.61%) experienced an RPE tear and this occurred after the first injection. In eyes with a fibrovascular retinal pigment epithelial detachment the incidence was 5%. Lesions containing a fibrovascular retinal pigment epithelial detachment tended to be larger (4.5 versus 3.8 Macular Photocoagulation Study Disc Areas), but this was not statistically significant. (P = 0.63). However, these lesions required more injections on average (P = 0.05).

CONCLUSION

The incidence of RPE tears associated with ranibizumab therapy is low and may result from a predisposition rather than an effect of treatment. Even so, patients undergoing ranibizumab therapy should be counseled regarding this possible complication.

The treatment of wet age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is a progressive disease affecting the macula, the area of the retina that has the highest visual acuity. It can progress to geographic atrophy or choroidal neovascularization.

METHOD

Selective literature review.

RESULTS

The authors discuss the results of therapeutic trials and the treatment recommendations of the ophthalmological societies. Mechanism-targeted treatments and improved modes of administration offer the potential for improved therapy.

CONCLUSIONS

With the advent of the antivascular endothelial growth factor (anti-VEGF) therapy, the prognosis of choroidal neovascularization has changed dramatically. Visual acuity can actually be improved, but, in most cases, the improvement can only be sustained with repeated intravitreal injections.

[Intravitreal injection. Monitoring to avoid postoperative complications]

Intravitreal injection is generally regarded as safe. Many of the potential complications caused by this procedure are extremely rare and can be avoided by careful inspection beforehand and proper performance of the injection. In rare cases, however, the administered drugs may cause various pharmacological side effects. This article summarizes the safety profiles of Macugen and Lucentis from the drug approval studies and describes initial findings on possible or observed side effects after intravitreal administration of Avastin. In addition, important points to observe in order to avoid intra- and postoperative complications are provided.

Retinale Pigmentepithelrisse nach intravitrealem Bevacizumab bei AMD

PURPOSE

Intravitreal injection of the antibody bevacizumab is unofficially becoming more and more the "standard of care" in the treatment of neovascular AMD. After initial concerns about possible systemic adverse events of the drug, intravitreal injection has as yet shown a very good safety profile. Due to the common application of this VEGF inhibitor it is of great importance to report complications that may be related to the use of bevacizumab. In this scope we present a series of patients with predominantly serous detachment of the retinal pigment epithelium (PED), who developed a tear (rip) in the retinal pigment epithelium (RRPE) after intravitreal application of bevacizumab.

METHODS

Our data are based on a prospective, consecutive, interventional case series of 420 patients with neovascular AMD. These patients received at least 1 intravitreal application of 1.25 mg bevacizumab within the period of 1 year. Follow-up examinations were every 4-6 weeks. Visits were documented with best corrected visual acuity according to the ETDRS standard, biomicroscopy of the retina, intraocular pressure measurement, evaluation of central retinal thickness, fluorescein angiography and fundus photography.

RESULTS

Of 420 patients, 74 were classified as having predominantly serous PED. In the further course 13 out of 74 patients developed RRPE. Patients who had an intact subfoveal RPE, gained vision scores of 1.4+/-8.3 ETDRS letters (span width -15 to 14) despite RRPE or had stable Snellen vision of 0.0+/-0.1 logMar. In contrast patients with no subfoveal RPE due to RRPE showed loss of vision of -6.2+/-7.2 ETDRS letters (span width -15 to 1).

CONCLUSION

This case series describes RRPE as a novel complication of intravitreal anti-VEGF therapy with bevacizumab. However, it seems that this complication is limited to the entity of predominantly serous PED. These patients should therefore be informed about the risk of RRPE before initiating anti-VEGF therapy with bevacizumab, although the reverse conclusion to generally exclude patients with PED from anti-VEGF therapy is not justifiable due to therapeutic efficiency and associated gain of vision.