Retinal pigment epithelium tears following intravitreal ranibizumab therapy

Retinal pigment epithelial tears

A retinal pigment epithelial (RPE) tear is a well-known complication of retinal pigment epithelial detachments (PED) and may cause a significant visual impairment. The most common cause is a vascularized PED in patients with exudative age-related macular degeneration (AMD). The development of diagnostic imaging techniques brings us closer to the etiology and pathophysiological mechanisms of this entity, offering us new strategies for treatment and follow-up. The advent of intravitreal antiangiogenic treatment (anti-VEGF) has led to an increase in the number of reported cases of RPE tears, which are an important vision-limiting factor during treatment. However, RPE tears may occur spontaneously or as a consequence of thermal laser treatment, photodynamic therapy or anti-VEGF therapy. It is accepted that the mechanism of RPE tears is multifactorial. The optimization of the functional outcome of this complication has been described with continuous treatment with antiangiogenic drugs. The goal of the present review is to evaluate the incidence, risk factors and treatment of RPE tears.

RETINAL PIGMENT EPITHELIAL TEAR AND ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EXUDATIVE AGE-RELATED MACULAR DEGENERATION: Clinical Course and Long-Term Prognosis

BACKGROUND

To document the long-term outcome in cases of retinal pigment epithelial (RPE) tears after treatment of vascularized pigment epithelial detachments with anti-vascular endothelial growth factor therapy.

METHODS

A retrospective analysis of the long-term outcome of a consecutive series of eyes with RPE tear developed during anti-vascular endothelial growth factor therapy for pigment epithelial detachment associated with choroidal neovascularization or retinal angiomatous proliferation (vascularized pigment epithelial detachment) was performed. Best-corrected visual acuity (BCVA), spectral domain optical coherence tomography, and autofluorescence images and also fluorescein angiograms were analyzed to determine the functional and morphologic development over time.

RESULTS

The long-term outcome of 22 eyes (21 patients, 13 women and 8 men; 65-85 years; mean: 76 years) with RPE tear was performed with minimal follow-up of 3 years (range: 3-5 years, mean: 44 months) and re-treatment with different therapeutic strategies. The eyes were differentiated in 2 groups according to the course of BCVA after the first 2 years of follow-up: Group 1 (11 eyes) demonstrated a stabilized or improved BCVA after 2 years and Group 2 (11 eyes) demonstrated a decrease in BCVA after 2 years. The initial BCVA between both groups was comparable. Also the mean initial size of the RPE tear was the same between the 2 groups, the area of the RPE tear decreased continuously during follow-up in Group 1, whereas this was the case in Group 2 only at the beginning of treatment with a further increase of the size of the RPE tear with longer follow-up. This corresponded with a different morphologic development between the two groups. In Group 1, increasing recovery of autofluorescence at the RPE-free area was visible beginning from the outer border, whereas in Group 2, further growth of the neovascular complex in the area of the RPE tear was observed resulting in larger fibrovascular scars. In addition, in both groups, the development of hyperreflective tissue was seen on spectral domain optical coherence tomography in the RPE-free area. The major therapeutic difference between the 2 groups was a significantly larger number of injections especially during the first year in Group 1.

CONCLUSION

The development of RPE tear after anti-vascular endothelial growth factor therapy for vascularized pigment epithelial detachment in exudative age-related macular degeneration does not necessarily result in large disciform scars and functional loss, but multiple injections seem to be beneficial especially in the first year. With this strategy, RPE tears seem to be covered by autofluorescent and hyperreflective tissue and a regrowth of the neovascular complex can be prohibited. As a result, photoreceptor cells regain their metabolic support with functional recovery.

Safety monitoring of ophthalmic biologics: a systematic review of pre- and postmarketing safety data

PURPOSE

The present study evaluates the safety of the biologics approved for the treatment of ocular diseases.

METHODS

The European medicines agency Website was searched to identify biologics with approved ophthalmologic therapeutic indications. A systematic search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and the International Clinical Trials Registry Platform up to December 2013. Pre-marketing, phase III randomized controlled trials (RCT), postmarketing clinical trials, observational longitudinal studies, and case reports involving adverse events (AE) were included. Methodological quality was assessed by Downs & Black checklist. All European spontaneous reports of AE included in the Eudravigilance up to December 2013 were also considered. AE were classified as ocular (related and non-related with the injection procedure) and non-ocular (related or non-related with vascular endothelial growth factor inhibition). Incidences of all reported AEs were estimated.

RESULTS

Pegaptanib, ranibizumab, and aflibercept were identified as ophthalmic biologics. Fourteen premarketing RCT, 7 postmarketing clinical trials, 31 observational studies, along with 31 case reports and 7,720 spontaneous reports were identified and included in this study. Both in pre- and postmarketing settings, ocular AEs were more frequent than non-ocular AEs. Premarketing safety data inform the most common AEs. Postmarketing studies suggest an increased number of events such as retinal pigmented epithelium tears (0.6%-24%), thromboembolic events (0.8%-5%), and mortality (2.8%-4%).

CONCLUSIONS

This study highlights the need to properly evaluate the risk for rare, serious, and long-term AEs, such as thromboembolic events, since they can lead to imbalances in the benefit-risk ratio of biologics in ophthalmology.

[Relationship between intravitreal anti-VEGF therapy and subretinal hemorrhage in patients with exudative age-related macular degeneration]

PURPOSE

To assess and compare frequencies and incidence rates of subretinal hemorrhage (SRH) after intravitreal anti-VEGF injections and spontaneous SRH in patients with exudative age-related macular degeneration (AMD).

PATIENTS AND METHODS

This retrospective monocentric study included 1079 patients followed for exudative AMD in the ophthalmology department of the university hospital of Dijon from January 2007 to July 2012. For each SRH occuring during this period, the number of previous treatments with intravitreal anti-VEGF was determined, as well as the time between the last injection and the hemorrhage. The SRH was considered as an adverse effect of the anti-VEGF injection if it occurred within 2 months after the last IVT (post-IVT SRH). Frequencies and incidence rates of post-IVT SRH and spontaneous SRH were calculated.

RESULTS

Sixty-six SRH's occurred during the study period with a total frequency of 6.12% (CI95% [4.69-7.55]). Frequencies of spontaneous and post-IVT SRH were respectively 5.65% (CI95% [4.28-7.03]) and 0.46% (CI95% [0.06-0.87]), representing a 12.2 ratio. Post-IVT SRH incidence was 8.3/1000 patient-years (CI95% [1.0-15.5]) and the spontaneous SRH incidence rate was 11.6/1000 patient-years (CI95% [8.3-14.8]), (P=0.472). The incidence rate ratio was 0.72 (CI95% [0.29-1.78]).

CONCLUSION

This study did not show a statistically significant change in the incidence of SRH after intravitreal anti-VEGF therapy. The benefit/risk ratio of intravitreal anti-VEGF injections for exudative AMD remains high.

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.

Causes of unsuccessful ranibizumab treatment in exudative age-related macular degeneration in clinical settings

PURPOSE

To identify the causes of loss of vision after ranibizumab therapy in patients with exudative age-related macular degeneration treated in three clinical settings.

METHODS

A retrospective multicentric analysis of 290 consecutive eyes comprising cohorts from 3 clinical settings showed that 21 eyes lost ≥ 15 letters on the Early Treatment Diabetic Retinopathy Study chart 1 year after the start of ranibizumab treatment. Fundus images of these eyes were analyzed by two independent readers to investigate the causes of visual loss. The three cohorts were compared. A search was made for factors predisposing to visual loss. A second analysis was performed to compare the baseline characteristics of patients who gained (visual acuity gainers) or lost (visual acuity losers) ≥ 15 letters.

RESULTS

Among the 290 eyes included, the proportions from each center experiencing visual loss were not significantly different (mean, 7.24%, P = 0.2631). Mean visual loss of affected eyes was 27 letters. There was no significant difference between these eyes and others as regards age and gender of patients, laterality, type of choroidal neovascularization, number of visits, or initial visual acuity. Visual loss was secondary to the progression of atrophy in eight eyes, fibrosis in five eyes, a combination of fibrosis and atrophy in three eyes, severe subretinal hemorrhage in three eyes, and retinal pigment epithelial tear in two eyes. A significant difference between visual acuity gainers and losers was observed for 2 parameters: age of patients, 80.9 ± 5.3 years in visual acuity losers versus 77.5 ± 7.3 years in visual acuity gainers (P = 0.0473) and visual acuity at diagnosis, respectively, 56.2 ± 11.2 versus 49.0 ± 12.0 (P = 0.0288).

CONCLUSION

Although uncommon, visual loss may occur during ranibizumab treatment and is because of the natural course of age-related macular degeneration in most cases.

Retinal pigment epithelial tears following ranibizumab therapy for fibrovascular retinal pigment epithelial detachment due to occult age-related macular degeneration

BACKGROUND

The aim of this paper is to report the incidence of retinal pigment epithelial (RPE) tears in patients treated with ranibizumab for subfoveal fibrovascular retinal pigment epithelial detachment (FVPED) due to occult age-related macular degeneration (AMD).

MATERIAL/METHODS

Thirty patients were treated according to the following schedule: saturation phase, further treatment was based on activity of the degeneration process. Visual acuity (VA), optical coherence tomography (OCT) and fluorescein angiography (FA) parameters were evaluated and compared.

RESULTS

Patients had a mean improvement of +4.7 ± 8.1 letters at month 12. The mean number of needed injections was 6.8 ± 1.8 (range, 3 to 9). RPE tears in fovea occurred in 8 cases (27% of all patients). Analysis of variance revealed significant upper mean values of ETDRS letters for the subgroup without RPE tears. Mean values of PED height were significant upper for RPE tears without baseline. Statistical analysis revealed that in the subgroup without RPE tears mean values of VA significantly differed in succeeding periods compare to baseline (P<0.001). Visual improvement or stabilization was observed in 90.9% of patients without RPE tears (significant improvement of 15 or more letters in 22.7% - 5/22) and in 87.5% of patients with RPE tears (significant improvement was not observed). Baseline leakage parameters, lesion and leakage parameters at month 12 were significantly higher in patients with RPE tears. The chi-square test revealed statistically significant associations between RPE tears and subretinal fluid in OCT (P<0.05) at month 12.

CONCLUSIONS

In eyes with FVPED and RPE tears treated with ranibizumab, stabilization of visual acuity without significant improvement is predictable. One of the risk factors common to RPE tears may be baseline leakage parameters and pretreatment distorted RPE contour in OCT. During ranibizumab therapy in eyes with RPE tears, upper parameters of FVPED height may occur without significant differences in fovea and macula volume compare to eyes without RPE tears.

Incidence of retinal pigment epithelial tears after intravitreal ranibizumab injection for neovascular age-related macular degeneration

OBJECTIVE

To explore the association between treatment for neovascular age-related macular degeneration (AMD) and incidence and timing of retinal pigment epithelium (RPE) tears in ranibizumab-treated patients versus control treatment.

DESIGN

Results from 3 phase III clinical trials (ANti-VEGF antibody for the treatment of predominantly classic CHORoidal neovascularization in age-related macular degeneration [ANCHOR], Minimally classic/occult trial of the Anti-VEGF antibody Ranibizumab In the treatment of Neovascular Age-related macular degeneration [MARINA], and A Phase IIIb, Multicenter, Randomized, Double-Masked, Sham Injection-Controlled Study of the Efficacy and Safety of Ranibizumab in Subjects with Subfoveal Choroidal Neovascularization [CNV] with or without Classic CNV Secondary to Age-Related Macular Degeneration [PIER]) were retrospectively reviewed to identify patients who developed RPE tears during the study period, detected on fluorescein angiography performed at prespecified intervals.

PARTICIPANTS

Patients with baseline and post-baseline angiographic assessments.

METHODS

Patients received intravitreal ranibizumab (0.3 or 0.5 mg) or control treatment (verteporfin photodynamic therapy [PDT] in ANCHOR and sham intravitreal injections in ANCHOR, MARINA, and PIER).

MAIN OUTCOME MEASURES

Incidence and timing of RPE tears during the treatment period.

RESULTS

Data from 1298 patients were analyzed. No statistically significant differences in RPE tear incidence were observed. The pooled rate of RPE tears was 1.8% with 0.5 mg ranibizumab, 3.0% with 0.3 mg ranibizumab, and 1.6% in the control group. Most (76%; 16/21) RPE tears in ranibizumab-treated patients were identified within 3 months of initiating treatment, whereas the majority (80%; 4/5) of late-onset RPE tears occurred in control patients. In patients who developed RPE tears, better visual acuity (VA) outcomes were observed in those treated with ranibizumab versus control treatment.

CONCLUSIONS

As studied in these trials, no statistically significant differences in the incidence of RPE tears within a 2-year treatment period were observed in patients who received ranibizumab (0.5 or 0.3 mg) versus control treatment, although most RPE tears with ranibizumab occurred within 3 months of initiating treatment. Mean VA was better in patients who developed RPE tears while receiving ranibizumab than in those who received control treatment, suggesting a potential benefit of continued ranibizumab therapy in patients with neovascular AMD who developed RPE tears.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Long-term visual outcome of pigment epithelial tears in association with anti-VEGF therapy of pigment epithelial detachment in AMD

PURPOSE

Retinal pigment epithelium (RPE) tears may develop as a complication after anti-VEGF (vascular endothelial growth factor) treatment for pigment epithelial detachments (PEDs) in exudative age-related macular degeneration (AMD). This retrospective study analyses best-corrected visual acuity (BCVA) and foveal involvement after RPE tears that are associated with anti-VEGF therapy due to PED in exudative AMD.

METHODS

A total of 37 patients with RPE tears during anti-VEGF therapy (bevacizumab 12, ranibizumab 21 and pegaptanib 4 eyes) for progressive PED in AMD (PED with occult choroidal neovascularization 25 eyes and PED with retinal angiomatous proliferation 12 eyes) were included in this study. We analyzed BCVA and different morphologic aspects by means of appearance on fluorescein angiography and optical coherence tomography. Mean follow-up was 88 weeks.

RESULTS

RPE tears were diagnosed a mean of 56 days after the first injection. BCVA deteriorated after RPE tear and during follow-up significantly (P<0.001), with 53.2% of eyes being legally blind (WHO, world health organization) at 12 months. RPE-free foveal area, foveal wrinkling of the RPE, and fibrotic scar development were significantly associated with worse visual acuity.

DISCUSSION

RPE tears can be observed in 12-15% of treated eyes during anti-VEGF therapy for PED in exudative AMD. Owing to the close time relationship with the therapy, this complication must be taken into consideration. Visual prognosis is associated with a decrease in vision in the long term, often resulting in a severe visual disability. Relevant factors for a negative visual prognosis were the potential foveal involvement of the central RPE and morphologic fibrovascular transformation of the RPE tear.

Retinal pigment epithelium tears after bevacizumab injection

BACKGROUND

The advent of anti-vascular endothelial growth factor (VEGF) treatment for choroidal neovascularization has become the standard of care for wet age-related macular degeneration (AMD). Among the choices, intravitreal bevacizumab, for off-label use, has gained popularity. Recent attention has been on the complications of anti-VEGF treatment, one of them being a retinal pigment epithelial (RPE) tear. A tear in the RPE is a visually devastating complication, most commonly associated with fibrovascular pigment epithelial detachments (PED) in AMD, and may develop during the course of intravitreal bevacizumab treatment.

CASE REPORT

We report a case of an 85-year-old white man with decreased visual acuities of 20/70 in the right eye (O.D.) and 20/150 in the left eye (O.S.) secondary to dry AMD O.D. and wet AMD with a fibrovascular PED O.S. The patient underwent treatment with an intravitreal bevacizumab injection O.S. Six weeks after the initial injection, the patient returned with further declining vision in the left eye secondary to an RPE tear.

CONCLUSION

Intravitreal bevacizumab has proven to be an effective treatment for choroidal neovascularization and shows a significant improvement of vision for wet AMD patients. However, there are risks associated with the procedure. One of the most visually significant is an RPE tear, which can occur at an incidence rate as high as 17%. Optometrists should be aware of this rare, but serious, complication associated with anti-VEGF treatment for wet AMD.

Retinal pigment epithelium tears after intravitreal injection of ranibizumab for predominantly classic neovascular membranes secondary to age-related macular degeneration

PURPOSE

Retinal pigment epithelium (RPE) tear is an extremely rare complication in patients with classic neovascular membranes without RPE detachment. We evaluate their incidence and functional outcome following treatment with intravitreal ranibizumab.

METHODS

Observational study of 72 consecutive patients (74 eyes) treated at Jules Gonin University Eye Hospital, Lausanne, with intravitreal ranibizumab 0.5 mg for classic choroidal neovascularization (CNV) between March 2006 and February 2008. Best-corrected visual acuity (BCVA), fundus examination and optical coherence tomography were recorded monthly; fluorescein angiography was performed at baseline and repeated at least every 3 months.

RESULTS

RPE tears occurred in four (5.4%) eyes temporal to the fovea, after a mean of four injections (range 3-6). Mean baseline BCVA was 0.25 decimal equivalent (logMAR 0.67) and improved despite the RPE tear to 0.6 decimal equivalent (logMAR 0.22).

CONCLUSION

RPE tears following intravitreal ranibizumab injections for classic CNV can occur in about 5% of patients, even in the absence of baseline RPE detachment. Nevertheless, vision may improve provided the fovea is not involved.

Ranibizumab for exudative age-related macular degeneration in eyes previously treated with alternative vascular endothelial growth factor inhibitors

BACKGROUND AND OBJECTIVE

To evaluate ranibizumab for exudative age-related macular degeneration previously treated with pegaptanib, bevacizumab, or both.

PATIENTS AND METHODS

This was a retrospective, interventional case series of patients with exudative age-related macular degeneration who were treated with ranibizumab after being initially treated with pegaptanib, bevacizumab, or both. The primary outcome was change in visual acuity following the switch to ranibizumab.

RESULTS

One hundred two eyes of 92 patients were identified. Following the switch to ranibizumab, there was an average gain of 0.7 lines in visual acuity. Ninety-four eyes (92%) lost 3 or fewer lines, 29 eyes (28%) gained more than 3 lines, and 3 eyes (3%) lost more than 6 lines after switching to ranibizumab. Lesion type and time between previous vascular endothelial growth factor inhibitor and ranibizumab did not affect the response.

CONCLUSION

Ranibizumab maintained visual acuity in the majority of patients and appears to be an effective treatment regardless of previous anti-vascular endothelial growth factor therapy.

Submacular haemorrhage after intravitreal bevacizumab compared with intravitreal ranibizumab in large occult choroidal neovascularization

BACKGROUND

Submacular haemorrhage may occur following intravitreal bevacizumab injection for large occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). We report the occurrence of submacular haemorrhage following intravitreal ranibizumab compared with intravitreal bevacizumab for large occult CNV in AMD.

METHODS

Retrospective, comparative evaluation of two interventional case series. Evaluation of consecutive patients with occult CNV > or = 15 mm(2) treated with intravitreal bevacizumab (n = 14) and intravitreal ranibizumab (n = 22) over a 2-year period within a single institution. Postoperative submacular haemorrhage, Early Treatment Diabetic Retinopathy Study-derived visual acuity, preoperative blood pressure and anticoagulant use were noted. The two groups were compared using Fisher's exact test.

RESULTS

The mean surface area of occult CNV at presentation was 20.9 +/- 5.4 mm(2) in the bevacizumab group and 24.0 +/- 11.0 mm(2) in the ranibizumab group. Fresh submacular haemorrhage was seen in 4 out of 14 patients following bevacizumab compared with 0 out of 22 patients following ranibizumab (P = 0.017, odds ratio = 19.29). Mean preoperative blood pressures were very similar between the groups. 28.6% of patients in the bevacizumab group were on oral anticoagulants compared with 31.8% in the ranibizumab group. None of the patients who developed postoperative haemorrhage were on anticoagulants.

CONCLUSIONS

Acute submacular haemorrhages appear to be a significant adverse event following intravitreal bevacizumab in occult CNV > or = 15 mm(2). Intravitreal ranibizumab appears to have a significantly lower incidence of postoperative submacular haemorrhage in occult CNV > or = 15 mm(2). Larger studies are required to identify the most appropriate agent for the treatment of large occult CNV.

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.

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