Visual acuity change after intravitreal bevacizumab for exudative age-related macular degeneration in relation to subfoveal membrane type

Fluorescein angiographic characteristic in predominantly classic and occult types of neovascular age-related macular degeneration treated with ranibizumab

Background and purpose:

Randomised-controlled clinical trials (the ANCHOR and MARINA) examined the intravitreal anti-vascular endothelial growth factor (anti-VEGF) efficacy for eyes having fluorescein angiographic classic and occult (OCC) neovascular lesions. No significant difference in the treatment response between the lesion types was observed. Fundus fluorescein angiography and optical coherence tomography (OCT) are complementary devices that provide information about neovascular age-related macular degeneration (n-AMD). The aim of this retrospective study was to compare the clinical aspects of fluorescein angiographic characteristics in predominantly classic (PDC) and OCC subtypes of n-AMD treated with intravitreal ranibizumab.

Methods:

Treatment-naive fluorescein angiographic OCC-n-AMD and PDC-n-AMD patients, who received monthly intravitreal ranibizumab for 3 months after baseline, and were followed-up with pro re nata injections between March 2013 and February 2018, were included. Means of the visual acuity (VA), central macular thickness (CMT), and intravitreal injection and visit numbers of the groups were compared throughout 24 months.

Results:

We included 41 eyes of PDC-n-AMD patients and 36 eyes of OCC-n-AMD patients. The mean ages were 74.5 ± 10.6 and 71.9 ± 9.4, respectively. The baseline, and 3-, 6-, 12-, 18-, and 24-month VA results of the OCC group were significantly better than those in the PDC. However, VA gain in the PDC group at 3, 6, and 12 months was significantly higher than that in the OCC group. The mean of baseline CMT of the PDC (353 ± 118 µm) was significantly higher than that in the OCC group (293 ± 64 µm). No significant differences in terms of the number of visits or injections, or CMT change from the baseline values between groups were observed.

Conclusion:

The OCC-n-AMD patients had better baseline and follow-up VA and CMT means than the PDC-n-AMD patients. However, the PDC-n-AMD patients are expected to benefit more than the OCC-n-AMD patients in terms of VA gains.

Treat-and-extend approach with aflibercept: Effects on different subtypes of age-related choroidal neovascularisation

OBJECTIVE

To describe functional/morphological outcomes of treat-and-extend (TAE) with aflibercept in different subtypes of neovascularizations (CNV) secondary to exudative age-related macular degeneration (AMD).

METHODS

Retrospective study was conducted on 30 eyes of 30 patients treated with 2 mg-aflibercept according to a TAE protocol. Examinations included best corrected visual acuity (BCVA), number of injections, and visits needed. A quantitative/qualitative analysis was also performed with fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) at baseline, and at 3, 6, and 12 months.

RESULTS

BCVA significantly improved from 0.61±0.26 logMAR to 0.38±0.34 logMAR. Among the total AMD patients, type 1 CNV was diagnosed in 11 eyes (36%), type 2 CNV in 7 eyes (23%), mixed CNV in 5 eyes (16%), and type 3 CNV or retinal angiomatous proliferation (RAP) in 7 eyes (23%). The final mean number of injections was 7.5±1.65, 8.71±0.76, 7.4±0.89, 7.2±0.7, and number of visits 6.6±2.17, 7.89±1.46, 5.8±1.7, and 7.14±1.57, respectively in type 1, type 2, mixed, and type 3 or RAP. There was no difference between the different subtypes of CNV (P>.05).

CONCLUSIONS

Aflibercept in TAE is effective for all exudative-AMD subtypes. No significant differences in patient's visual gain, mean number of injections, or number of visits needed were found among the subtypes of CNV.

Preferred therapies for neovascular age-related macular degeneration

PURPOSE OF REVIEW

This report reviews the current treatment strategies and the most recent clinical trials in the treatment of neovascular age-related macular degeneration.

RECENT FINDINGS

The functional and anatomic outcomes achieved in the pivotal ranibizumab trials with monthly injections set the standard for comparison. Since then, various modified dosing regimens with the aim of lessening the treatment burden associated with monthly injections have been investigated. Additionally, level I evidence now exists for the noninferiority of bevacizumab, as compared to ranibizumab, in the treatment of neovascular age-related macular degeneration (AMD) through 1 year of follow-up. Aflibercept has emerged as a new anti- vascular endothelial growth factor (VEGF) therapy showing encouraging treatment results at 1 year. Novel treatments combined with anti-VEGF agents such as localized radiation are currently being investigated.

SUMMARY

Anti-VEGF monotherapy remains the preferred therapy for the management of neovascular AMD at the present time. Aflibercept is a new, FDA-approved, effective, anti-VEGF agent available for clinical use. Ongoing clinical trials will help determine the optimal dosing regimens for all of these agents, as well as the long-term efficacy and safety of combination therapy modalities.

Intravitreal bevacizumab treatment for exudative age-related macular degeneration with good visual acuity

PURPOSE

To investigate the effect of intravitreal bevacizumab on the visual and anatomic outcome of patients with exudative age-related macular degeneration presenting with good visual acuity (VA).

METHODS

A file review was performed for all consecutive patients with newly diagnosed exudative age-related macular degeneration and initial VA of ≥ 20/40 treated in 2005 to 2010 and followed for at least 6 months. Treatment consisted of 3 loading doses of intravitreal bevacizumab every 6 weeks and was repeated when fluid or hemorrhage was present.

RESULTS

The cohort included 130 patients (150 eyes). Mean follow-up was 20.2 ± 13.2 months, and mean number of injections was 11.3 ± 6.2. At the last examination, VA was stable or improved in 106 eyes (70.7%); 11 eyes (7.3%) lost ≥ 3 lines. Mean logarithm of the minimum angle of resolution VA measured 0.22 ± 0.1 (0-0.3) at presentation and 0.22 ± 0.2 (0-1.3) at the last visit. Corresponding values for central macular thickness were 267 ± 75 μm (137-562) and 226 ± 75 μm (75-568) (P = 0.14). The most frequent complication (18 eyes, 12%) was corneal epithelial defects.

CONCLUSION

Prompt intravitreal bevacizumab treatment for newly diagnosed exudative age-related macular degeneration in patients with good initial best-corrected visual acuity is associated with sustained or improved vision and a good safety profile. Attempts should be made to expedite the access of these patients to treatment, regardless of initial VA.

Intravitreal bevacizumab versus combined intravitreal bevacizumab and triamcinolone for neovascular age-related macular degeneration: six-month results of a randomized clinical trial

PURPOSE

To determine whether combined intravitreal bevacizumab (IVB) and triamcinolone (IVT) is more effective than IVB alone in neovascular age-related macular degeneration.

METHODS

This was a prospective, randomized clinical trial performed at two centers. Eligible eyes were assigned randomly to one of the two study arms. In the IVB group, 3 consecutive injections of 1.25 mg of bevacizumab were given 6 weeks apart, while in the IVB/IVT group, the first of the triple IVB injections was combined with 2 mg of IVB. A fourth IVB was injected in eyes demonstrating active choroidal neovascularization at Week 24.

RESULTS

Sixty and 55 eyes were in the IVB and IVB/IVT groups, respectively. Best-corrected visual acuity improved, and central macular thickness was reduced significantly in both groups at all time points. Visual improvement was more pronounced in the IVB/IVT group compared with the IVB group 6 weeks (8.5 ± 14.4 vs. 3.8 ± 8.9 letters, P = 0.04) and 12 weeks (11.8 ± 16.6 vs. 6.2 ± 10.8 letters, P = 0.03) after initiation of therapy. However, there was no significant difference in visual improvement at Week 24 (11.3 ± 17.2 letters in the IVB/IVT group vs. 8.7 ± 15.6 letters in the IVB group, P = 0.40). The IVB/IVT group showed significantly less need for a fourth injection at Week 24 (34.5% vs. 53.3% in the IVB/IVT and IVB groups, respectively, P = 0.04).

CONCLUSION

Mandated therapy with IVB improved best-corrected visual acuity and decreased central macular thickness in neovascular age-related macular degeneration. The addition of low-dose IVT temporarily increased the therapeutic efficacy in the early postinjection period and resulted in fewer requirements for repeat IVB injections at 6 months; however, final levels of visual improvement were comparable in the 2 study groups.

One-year outcomes of less frequent bevacizumab in age-related macular degeneration

PURPOSE

To evaluate whether a less frequent bevacizumab dosing schedule after repeated doses in short intervals would be effective in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration.

METHODS

Twenty-seven treatment-naive eyes of patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration participated in this prospective, noncomparative, and interventional study at the Ulucanlar Eye Training and Research Hospital retina clinic. All lesion types were included. Intravitreal injections (1.25 mg/0.05 mL) of bevacizumab were given with a 6-week interval (Day 0, 6 weeks, and 12 weeks) for 3 months and then given at every 12-week interval up to 48 weeks. Main outcome measures of treatment were mean change in visual acuity and foveal center point retinal thickness from baseline documented by optical coherence tomography at 6, 12, 24, 36, and 48 weeks. The effects of patient age, baseline visual acuity, lesion composition, and lesion size on final visual acuity and loss of <15 letters of logarithm of the minimum angle of resolution (logMAR) at 48 weeks were also assessed.

RESULTS

Of the 27 eyes, 24 eyes of 24 patients (14 men and 10 women) completed the 48-week follow-up and study protocol. Compared with baseline (0.95 ± 0.27 on Early Treatment Diabetic Retinopathy Study charts), mean best-corrected visual acuity improved to 0.77 ± 0.21 logMAR (P < 0.001) at Week 6, to 0.74 ± 0.2 logMAR (P < 0.001) at Week 12, to 0.79 ± 0.257 logMAR (P = 0.03) at Week 24, to 0.85 ± 0.26 logMAR (P = 0.54) at Week 36, and to 0.87 ± 0.27 logMAR (P = 1) at Week 48. The baseline mean center point retinal thickness that was 343 ± 64 μm decreased to 236 ± 40 μm (P < 0.001) at Week 6, to 222 ± 39 μm (P < 0.001) at Week 12, to 237 ± 37 (P < 0.001) at Week 24, to 253 ± 44 μm (P < 0.001) at Week 36, and to 268 ± 58 μm (P = 0.002) at Week 48. The maximal visual benefit obtained during the frequent dosing schedule significantly decreased by doses every 12 weeks at 48 weeks (P < 0.001). This decline in the best-corrected visual acuity gain was associated with an increase in the mean center point retinal thickness on optical coherence tomography. Patients aged <70 years and those having a baseline vision of 20/200 or worse were more likely to gain vision at 48 weeks (P = 0.001 and P = 0.02, respectively). In addition, a lesion ≤ 4 disk areas at baseline was less likely to lose <15 letters from baseline at 48 weeks (P = 0.03). No serious ocular and nonocular adverse events were noted.

CONCLUSION

Although intravitreal bevacizumab administration on a schedule of a 6-week injection interval for 3 months followed by every 12-week interval for neovascular age-related macular degeneration provided an improvement or stabilization in best-corrected visual acuity with anatomical improvement. This dosing strategy is unable to maintain the visual acuity and optical coherence tomography benefits seen with more frequent dosing.

Bilateral intravitreal bevacizumab injection for exudative age-related macular degeneration: effect of baseline visual acuity

PURPOSE

To assess side differences in patients undergoing bilateral intravitreal bevacizumab injections as treatment of exudative age-related macular degeneration (AMD).

METHODS

The clinical interventional case series study included 48 patients (96 eyes) who consecutively and bilaterally received 3 intravitreal bevacizumab injections. The mean age was 76.5±7.5 years (range: 59-88 years). Follow-up was 6 months. Main outcome parameters were best-corrected visual acuity (BCVA) and measurements by optic coherence tomography. The eyes of the same patient were assigned to a study group 1 for the eye with the higher visual acuity at baseline, and study group 2 for the contralateral eye with the lower visual acuity at baseline.

RESULTS

The increase in BCVA was significantly (P=0.02) greater in group 2 (0.07±0.25 logarithm of the minimum angle of resolution, LogMAR) than in group 1 (0.05±0.29 LogMAR). The height of a detached retinal pigment epithelium, the height of subretinal fluid, and the tissue thickness of the macula decreased significantly (P<0.05) in group 2 during follow-up, whereas these parameters did not markedly change in the eyes of group 1 (P=0.96, P=0.38, and P=0.07, respectively). The reduction in the height of a detached retinal pigment epithelium and in the height of subretinal fluid was significantly more pronounced in group 2 than in group 1 (P=0.03, P=0.04, respectively).

CONCLUSIONS

After an initial set of 3 bilateral bevacizumab injections, patients with bilateral exudative AMD have a higher likelihood for an improvement in vision in the worse-seeing eye at baseline than in the better-seeing eye.

Intravitreal bevacizumab for exudative age-related macular degeneration in clinical practice

PURPOSE

The purpose of this study was to evaluate whether baseline visual acuity and baseline anatomy of the macula influence visual outcome in patients receiving intravitreal bevacizumab as treatment of exudative age-related macular degeneration (AMD) in clinical practice.

METHODS

This clinical case series study included 319 patients (406 eyes) who consecutively received intravitreal injections of bevacizumab for treatment of exudative AMD. The intervals between injections were 6 weeks and postinjection examinations were performed at 4 weeks after injection. Mean follow-up was 3.6 months.

RESULTS

After 3 injections of bevacizumab, best-corrected visual acuity (BCVA) significantly (P<0.01) improved in eyes with a baseline BCVA of less than 0.2 (group 1; 138 eyes; -0.10±0.43 LogMAR) and in eyes with a baseline BCVA ≥0.2 and <0.4 (group 2; 117 eyes; -0.06±0.24 LogMAR), but BCVA deteriorated in eyes with a baseline BCVA of ≥0.4 (group 3; 151 eyes; 0.09±0.32 LogMAR). Correspondingly, regression analysis revealed that improvement in BCVA after 3 intravitreal bevacizumab injections was significantly (P=0.001) associated with a low baseline BCVA. After the first injection of bevacizumab, changes in optical coherent tomography measurements of the macula (height of subretinal fluid, macular tissue thickness) were statistically significant for group 1 (P=0.03, P=0.03, respectively) and group 2 (P=0.01, P=0.02, respectively), but not for group 3 (P=0.85, P=0.22, respectively).

CONCLUSIONS

In clinical practice, patients with exudative AMD and a baseline BCVA of <0.2 have a better prognosis for an increase in BCVA after intravitreal bevacizumab injections than patients with a higher baseline BCVA.

Neuroprotective effect of intravitreal cell-based glucagon-like peptide-1 production in the optic nerve crush model

PURPOSE

To examine the effect of intraocularly produced glucagon-like peptide-1 (GLP-1) on the survival rate of retinal ganglion cells in an optic nerve crush model.

METHODS

Forty-one Sprague--Dawley rats were divided into a study group (21 animals) in which 4 beads with 3000 genetically modified cells to produce GLP-1 were intravitreally implanted into the right eye; a saline control group (n = 12) with intravitreal saline injection; and a GLP-1 negative bead control group (n = 8) in which 4 beads with 3000 cells without GLP-1 production were intravitreally implanted. The right optic nerves of all animals were crushed in a standardized manner. After labeling the retinal ganglion cells by injecting 3% fluorogold into the superior colliculus, the animals were sacrificed, and the ganglion cells were counted on retinal flat mounts.

RESULTS

The retinal ganglion cell density of the right eyes was significantly higher in the study group (median: 2081 cells/mm(2) ; range: 1182-2953 cells/mm(2) ) than in the GLP-1 bead negative control group (median: 1328 cells/mm(2) ; range: 1007-2068 cells/mm(2) ; p = 0.002) and than in the saline control group (median: 1777 cells/mm(2) ; range: 1000-2405 cells/mm(2) ; p = 0.07). Correspondingly, the survival rate (ratio of retinal ganglion cell density of right eye/left eye) was significantly higher in the study group (median: 0.72; range: 0.40-1.04) than in the GLP-1 bead negative control group (median: 0.44; range: 0.36-0.68; p = 0.003) and than in the saline control group (median: 0.56; range: 0.36-0.89; p = 0.03).

CONCLUSION

Glucagon-like peptide-1 produced by intravitreally implanted cell beads was associated with a higher survival rate of retinal ganglion cells after an experimental optic nerve crush in rats.

Pharmacotherapy for neovascular age-related macular degeneration: an analysis of the 100% 2008 medicare fee-for-service part B claims file

PURPOSE

To describe the usage patterns of pharmacological treatments for neovascular age-related macular degeneration (AMD) in Medicare fee-for-service beneficiaries.

DESIGN

Retrospective review of all Medicare fee-for-service Part B claims for neovascular AMD during 2008.

METHODS

Medicare beneficiaries having undergone treatment were identified. The data collected for each visit for a given beneficiary included age, race, gender, Medicare region, state/zip code of residence, date of visit, whether or not the beneficiary had a treatment, the type and amount of drug, and dollars paid by Medicare. The main outcome measures were the number and rate of treatments, the types of drugs used for treatment, and the payments for these drugs.

RESULTS

Of the 222 886 unique beneficiaries, 146 276 (64.4%) received bevacizumab and 80 929 (35.6%) received ranibizumab. A total of 824 525 injections were performed with 480 025 injections of bevacizumab (58%) and 336 898 injections of ranibizumab (41%). National rates of injections per 100 000 fee-for-service Part B Medicare beneficiaries for bevacizumab and ranibizumab were 1506 and 1057, respectively. Total payments by Medicare were $20 290 952 for bevacizumab and $536 642 693 for ranibizumab. In 39 out of 50 states, the rate of injection was higher for bevacizumab compared with ranibizumab.

CONCLUSIONS

In 2008, bevacizumab was used at a higher rate than ranibizumab for the treatment of neovascular AMD. Even though bevacizumab accounted for 58% of all injections, Medicare paid $516 million more for ranibizumab than bevacizumab. These data suggest that despite its off-label designation, intravitreal bevacizumab is currently the standard-of-care treatment for neovascular AMD in the United States.

Intravitreal bevacizumab for exudative age-related macular degeneration: effect on different subfoveal membranes

PURPOSE

The purpose of this study was to assess an association between specific types of subfoveal neovascularization and the change in visual acuity after intravitreal injections of bevacizumab (F. Hoffmann-La Roche AG, Basel, Switzerland) as treatment for exudative age-related macular degeneration.

METHODS

This retrospective clinical interventional comparative study included 307 patients (378 eyes) who received 3 consecutive intravitreal injections of bevacizumab at intervals of 2 months each. The study group was divided into eyes with a predominantly or purely classic type of subfoveal neovascular membrane (n = 81), those with an occult type with or without minimally classic subfoveal neovascularization (n = 232), and eyes with a detachment of the retinal pigment epithelium (n = 65).

RESULTS

The gain in best-corrected visual acuity did not vary significantly among the 3 subgroups at 2 months after baseline (P = 0.35 and P = 0.27), at 4 months after baseline (P = 0.63 and P = 0.56), or at the final follow-up at 7 months after baseline (P = 0.85 and P = 0.76). In multivariate linear regression analysis, the gain in best-corrected visual acuity at the final follow-up was significantly associated with the best-corrected visual acuity at baseline (P < 0.001). It was not significantly associated with age (P = 0.61), sex (P = 0.12), self-reported diabetes (P = 0.79), lens status (P = 0.84), or type of subfoveal neovascularization (P = 0.53).

CONCLUSION

After an intravitreal application of bevacizumab given as therapy for exudative age-related macular degeneration at 2-month intervals, the patient's gain in visual acuity did not depend on the type of the subfoveal neovascular membranes.

Intravitreal bevacizumab in vascular pigment epithelium detachment as a result of subfoveal occult choroidal neovascularization in age-related macular degeneration

PURPOSE

The purpose of this study was to evaluate the effect of intravitreally administered bevacizumab on untreated vascularized pigment epithelium detachment (PED) in sub- or juxtafoveal occult choroidal neovascularization as a result of age-related macular degeneration.

METHODS

In this retrospective study, 28 untreated eyes of 26 patients (4 men, 22 women; mean age, 74.6 ± 7.2 years) with PED and sub- or juxtafoveal occult choroidal neovascularization as a result of age-related macular degeneration and additional intra- and/or subretinal fluid were treated with intravitreal injections of 1.25 mg bevacizumab. Baseline and follow-up visits included best-corrected visual acuity, complete ophthalmic examination, and Stratus optical coherence tomography. Fluorescein angiography was performed at baseline. Reinjections were performed if intra- and/or subretinal fluid persisted or recurred or PED increased.

RESULTS

Patients received 3.2 ± 1.8 injections (follow-up 37.9 ± 18.3 weeks). Mean maximum PED height showed a tendency to decrease (372 ± 150.5 μm to 290.3 ± 189 μm; P = 0.094). In 14 eyes (53.8%), PED height was reduced at last visit, including complete flattening in 1 eye. Mean visual acuity remained stable (0.58 ± 0.30 logarithm of the minimum angle of resolution to 0.58 ± 0.37 logarithm of the minimum angle of resolution; P = 0.905). Pigment epithelium detachment response to treatment did not correlate with baseline PED height or visual acuity at baseline or at the last visit. One patient sustained a retinal pigment epithelium rip, and another patient sustained an extensive subretinal hemorrhage.

CONCLUSION

During bevacizumab therapy, mean PED height decreases in 50% of patients. No predictive factors for the response of PED to bevacizumab treatment could be identified. Treatment of PED with bevacizumab might result in a long-term functional benefit compared with the natural course.

Combined intravitreal bevacizumab and triamcinolone in exudative age-related macular degeneration

PURPOSE

We report on the combined application of intravitreal bevacizumab and triamcinolone acetonide for treatment of exudative age-related macular degeneration (AMD).

METHODS

 The clinical interventional case-series study included 16 patients (16 eyes) with exudative AMD who had previously received 3.5±1.8 mono-injections of bevacizumab (1.5mg) without significant improvement in visual acuity (VA) or reduction in macular exudation. All patients underwent a combined intravitreal injection of bevacizumab (1.5mg) and triamcinolone acetonide (about 20mg). Main outcome measures were VA and macular thickness as determined by optical coherence tomography. All patients were re-examined at 2-3months after the intervention.

RESULTS

Visual acuity improved significantly (p=0.03) from 0.80±0.40 logMAR prior to the combined injection to 0.65±0.42 logMAR at 3 months after the injection. An improvement of ≥1Snellen line was found in eight subjects, an increase of ≥2lines in five subjects, and an improvement of ≥3lines in two subjects. One patient lost 1line and one patient lost 3lines. Central retinal thickness decreased significantly from 272±62μm to 220±47μm (p=0.03). At the 6-month follow-up examination, central retinal thickness had increased again to 319±142μm, which was not significantly (p=0.30) different from baseline measurements.

CONCLUSIONS

The combined intravitreal application of bevacizumab and triamcinolone may temporarily be helpful in the treatment of exudative AMD if previous intravitreal bevacizumab mono-injections have failed to improve vision and reduce macular oedema.

Long-term follow-up after multiple intravitreal bevacizumab injections for exudative age-related macular degeneration

PURPOSE

To analyze the long-term effect of multiple intravitreal injections of bevacizumab as therapy of exudative age-related macular degeneration (AMD).

METHODS

The retrospective clinical interventional case series study included 45 patients (48 eyes) who received intravitreal injections of bevacizumab (1.5 mg) for treatment of exudative AMD and for whom the follow-up was >2 years. All patients received an initial series of 3 injections applied in intervals of 6-8 weeks. Subsequent injections were given in intervals ranging between 2 and 6 months. The mean number of all injections performed per eye was 8.6 +/- 2.5. The mean follow-up was 27.8 +/- 3.6 months. The main outcome parameters were best-corrected visual acuity (BCVA) and foveal thickness measurements by optical coherence tomography (OCT).

RESULTS

Mean BCVA improved from 0.62 +/- 0.30 LogMAR at baseline to 0.55 +/- 0.28 LogMAR (P = 0.03) at 1 month after the 3 initial injections. At the end of follow-up, BCVA decreased significantly (P = 0.02) to 0.76 +/- 0.41 LogMAR. Bivariate correlation tests showed that the change in BCVA from baseline to the final examination at the end of follow-up was significantly associated only with the baseline BCVA (correlation coefficient r = 0.39, P = 0.006). The height of the subretinal fluid reduced significantly (P = 0.004) at 1 month after the 3 initial injections and remained so till the final follow-up (P = 0.01).

CONCLUSIONS

Multiple intravitreal bevacizumab injections initially led to an improvement in visual acuity, finally, however, failed to stabilize visual acuity after a follow-up of >2 years.

Clinical and histological findings after intravitreal injection of bevacizumab (Avastin) in a porcine model of choroidal neovascularization

PURPOSE

To examine the effect of intravitreally injected bevacizumab (Avastin) on the histological and angiographic morphology of choroidal neovascularization (CNV) in a masked and placebo-controlled animal study.

METHODS

Choroidal neovascularization was induced surgically in 11 porcine eyes by perforating Bruch's membrane with a retinal perforator. After closure of the ports used for the vitrectomy, which was performed to facilitate the Bruch's membrane rupture, 0.05 ml of either bevacizumab or Ringer-Lactat (placebo) was injected into the vitreous cavity. Eyes were enucleated after 14 days. Fundus photographs and fluorescein angiograms (FAs) were obtained immediately prior to enucleation. Sections of formalin- and paraffin-embedded eyes were examined by light microscopy and by immunohistochemical staining.

RESULTS

Placebo-injected eyes exhibited the highest propensity to leak, with five of six eyes leaking on FA, whereas only one of five bevacizumab-injected eyes exhibited leakage. On histological examination, all 11 eyes contained CNV membranes of similar size, regardless of treatment. The number of vascular endothelial cells was significantly reduced (p = 0.03) in CNV membranes from eyes that had been injected with bevacizumab when compared with CNV membranes from placebo-injected eyes. There was a trend towards more retinal pigment epithelium cells (p = 0.16) and fewer glial fibres (p = 0.08) in membranes from bevacizumab-treated eyes compared with placebo-treated eyes. Bevacizumab was identified immunohistochemically in the inner limiting membrane (ILM) and to a lesser degree in the remaining retina. Strong staining was also detected in both retinal blood vessels and entire CNV membranes with no cellular predisposition. Vascular endothelial growth factor expression was found in the CNV membranes, in the ILM, in the ganglion cell layer, in Müller cells throughout the neuroretina and in retinal blood vessels.

CONCLUSIONS

Bevacizumab significantly reduced the proliferation of vascular endothelial cells in CNV membranes and showed a strong trend towards a reduction of leakage from these membranes. After a single injection, bevacizumab did not exhibit a size reducing effect on CNV, but it was still present in the membranes 14 days after intravitreal injection.

Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration in treatment-naive patients

PURPOSE

To report the effects of intravitreal bevacizumab (Avastin) in treatment-naive patients with exudative age-related macular degeneration (ARMD) assessed by visual acuity (VA), optical coherence tomography (OCT) and contrast sensitivity.

METHODS

 A prospective, uncontrolled, pilot study of 26 eyes of 26 patients, all previously treatment-naive to photodynamic therapy, argon laser or anti-vascular endothelial growth factor (VEGF), were treated with one or more intravitreal injections of 1.25 mg bevacizumab. Of the 26 patients, 15 (57.7%) had occult choroidal neovascularization (CNV), 6 (23.1%) had predominantly classic CNV and 5 (19.2%) had minimally classic CNV. Ophthalmic outcome measures included changes in standardized Early Treatment Diabetic Research Study (ETDRS) VA, contrast sensitivity and OCT. The patients were examined at baseline and 1 week, 6 weeks, 3 months and 6 months after the first injection. Re-treatment was given on an 'as needed' basis.

RESULTS

 Twenty-four eyes of 24 patients completed 6 months of follow-up. Two patients chose to discontinue the study. Mean ETDRS VA score improved from 55 letters at baseline to 60 letters at 1 week (P < 0.01) and to 61 letters at 6 weeks (P < 0.01). No significant improvement in VA from baseline was found after 3 and 6 months. Patients with pigment epithelial detachment (PED) had a significantly worse outcome in VA at 6 months. Contrast sensitivity improved from baseline to 3 or 6 months, but this improvement was not statistically significant. Mean macular thickness decreased significantly from baseline to all follow-up examinations (P < 0.01).

CONCLUSION

 Mean ETDRS VA improved significantly after 1 and 6 weeks; thereafter, it remained stable throughout the study period. Macular thickness improved significantly at all time points. The results indicate that 1.25 mg intravitreal bevacizumab is associated with functional as well as morphological improvement among treatment-naive ARMD patients.

Efficacy of intravitreal bevacizumab (Avastin) therapy for early and advanced neovascular age-related macular degeneration

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab therapy for early and advanced neovascular age-related macular degeneration (ARMD).

METHODS

A consecutive series of eyes with neovascular ARMD treated with monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml) as long as there was evidence of activity on fluorescein angiography (FA) and optical coherence tomography (OCT) was included and observed for 6 months. For further analysis they were assigned to either an early (untreated/newly diagnosed) or an advanced (predominantly fibrotic/pre-treated) ARMD group. We examined distance visual acuity (VA) with Early Treatment Diabetic Retinopathy Study (ETDRS) charts and central retinal thickness with OCT, as well as lesion size and safety aspects.

RESULTS

Forty-four patients (44 eyes) were enrolled (21 early lesions, 23 advanced lesions). Mean VA changed from 0.74 logMAR at baseline to 0.68 logMAR at month 6 (P = 0.01). Improvement in VA was statistically significant only in eyes with early lesions (n = 21) from month 1 (P = 0.015) up to month 6 (P = 0.03). The changes in central retinal thickness (CRT) (P < 0.001) and total lesion size (P < 0.001) were significant in both groups (early and advanced) at all time-points during follow-up. No significant ocular or systemic adverse effects were observed.

CONCLUSION

Intravitreal bevacizumab was tolerated well by our patients and we did not identify any apparent short-term safety concerns. We observed stabilization in VA overall, with significant improvement in the early lesion group.

Intravitreal bevacizumab (Avastin) for age-related macular degeneration: a critical analysis of literature

PURPOSE

The current medical environment demands that quality health care is delivered at an affordable cost through the use of objective, unbiased clinical data. This study was undertaken to review the current literature on bevacizumab for age-related macular degeneration and its value in determining best clinical practice.

METHODS

Randomised controlled trials (RCTs) and observational studies that met the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria were identified from the current literature for further analysis. Data concerning treatment dosing regimens, response to treatment, complications, and factors influencing outcome and safety were extracted and compiled into a database.

RESULTS

As of January 2009, there were 5 RCTs that compared the outcomes of bevacizumab to other treatment options and 50 studies that met the STROBE criteria with similar visual and anatomical outcomes between RCTs and observational studies. Although the doses and dosing frequencies varied between the studies, the mean gain in vision at 3 months was +7.76+/-5.4 ETDRS letters (range +2 to +14.4); an effect that was maintained at 6 months in studies with longer follow-up. Predominantly classic lesions were the most responsive of all lesion subtypes. The complication profiles/rates were similar to those reported with other anti-vascular endothelial agents.

CONCLUSIONS

There is sufficient scientific and statistical evidence to advocate the effective use of OCT-guided administration of intravitreal bevacizumab for neovascular AMD. This is reflected in our study outcome measures that are comparable to findings published from recent well-conducted RCTs on intravitreal ranibizumab at the same time point.

Bevacizumab (Avastin) for the treatment of ocular disease

The use of intravitreal bevacizumab (Avastin) has greatly expanded since its introduction into ophthalmic care 3 years ago. A PubMed search on 1 August 2008 revealed 51 ocular disease processes that have been treated with bevacizumab. The majority of publications consist of case reports or retrospective case series and their number is increasing quickly. It is important to collate the experiences gained to date to properly inform our clinical decision making and improve the design of future clinical trials. Current studies cannot easily be combined in a meta-analysis given the lack of standardized data and the wide variety of disorders studied in small numbers. This paper will describe the attempted uses of intravitreal bevacizumab and its efficacy for each ocular disease in addition to discussing safety. Comments regarding appropriate use of this treatment are based on our current level of knowledge. It is clear that the initial encouraging results described in this paper warrant further study of intravitreal bevacizumab in larger, controlled, randomized trials.

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.

Antivascular endothelial growth factor therapy for neovascular age-related macular degeneration

PURPOSE OF REVIEW

The most important recent advance in the treatment of neovascular age-related macular degeneration (AMD) is the development of antivascular endothelial growth factor (anti-VEGF) therapeutic agents that preserve and improve visual acuity by arresting choroidal neovascular growth and reducing vascular permeability. This review describes the current literature on the use of this therapeutic approach in the management of neovascular AMD.

RECENT FINDINGS

Two anti-VEGF agents, pegaptanib sodium and ranibizumab, are currently approved by the United States Food and Drug Administration for the treatment of neovascular AMD. In addition, off-label use of a third anti-VEGF agent, bevacizumab, as a treatment option for neovascular AMD has become common worldwide. Other anti-VEGF agent strategies that have shown efficacy include small interfering RNA agents to silence the VEGF gene and receptor and the fusion protein VEGF trap.

SUMMARY

The accumulation of preclinical and clinical evidence implicating VEGF-A in the pathogenesis of neovascular AMD has provided a strong rationale for the development of anti-VEGF agents for this disease. Anti-VEGF therapies have been used successfully in the clinic, encouraging their use in the treatment of other neovascular eye diseases.

Early intravitreal bevacizumab for non-ischaemic central retinal vein occlusion

PURPOSE

To evaluate the effect of early intravitreal bevacizumab injections for the treatment of macular oedema caused by non-ischaemic central retinal vein occlusion (CRVO).

METHODS

The study included 25 patients (25 eyes) with macular oedema caused by non-ischaemic central retinal vein occlusion, who received three intravitreal injections of 1.5 mg bevacizumab with an interval of 6 weeks between the injections. Mean duration of central retinal vein occlusion prior to the first injection was 4.2 +/- 3.6 days. All patients were re-examined 1, 3 and 6 months after the first injection. The main outcome parameters were visual acuity and macular thickness, as measured by optical coherence tomography.

RESULTS

Mean visual acuity improved significantly from 0.97 +/- 0.40 logMAR at baseline to 0.70 +/- 0.42 logMAR (P = 0.007) at 1 month, 0.69 +/- 0.46 (P = 0.006) 3 months and 0.69 +/- 0.52 (P = 0.015) 6 months after the first injection. Mean central retinal thickness decreased significantly from 530 +/- 152 microm at baseline to 347 +/- 127 microm (P < 0.001) at 1 month, 370 +/- 165 microm (P < 0.001) 3 months and 346 +/- 129 microm (P < 0.001) 6 months (P < 0.001) after the first injection. The increase in visual acuity correlated significantly (P < 0.01) with the decrease in macular thickness. Mean intraocular pressure was 14.2 +/- 3.2 mmHg at baseline and did not differ significantly from the measurement obtained at 1 month (P = 0.59), 3 months (P = 0.88) and 6 months after the first injection (P = 0.65).

CONCLUSION

Intravitreal bevacizumab injections given shortly after onset of non-ischaemic central retinal vein occlusion may result in a significant increase in vision and a corresponding decrease in macular oedema.

Applying the CONSORT and STROBE statements to evaluate the reporting quality of neovascular age-related macular degeneration studies

PURPOSE

To evaluate the quality of reporting in the neovascular age-related macular degeneration (nvAMD) literature by applying the Consolidated Standards for Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement writing standards.

DESIGN

CONSORT and STROBE impact analysis; literature review.

PARTICIPANTS

Phase III randomized controlled trials (RCTs) of verteporfin photodynamic therapy, pegaptanib, and ranibizumab, and interventional case studies of bevacizumab for nvAMD.

METHODS

A literature search identified eligible articles published before October 31, 2007. We assessed the report quality of Phase III RCTs using the CONSORT statement and case series publications using the STROBE statement, both with indicators relevant to nvAMD.

MAIN OUTCOME MEASURES

Presence or absence of CONSORT or STROBE statement indicators.

RESULTS

Seven publications of Phase III RCTs and 29 publications on bevacizumab interventional case studies for nvAMD met our inclusion criteria. Of 37 possible CONSORT writing guideline items, the mean report quality for RCTs was 30.6 (83%), with a range from 23 to 35 (65%-95%). Of 35 possible STROBE writing guideline items, the mean report quality grade for intravitreal bevacizumab case series was 23 (70%), with a range from 16 to 31 (46%-94%). Among the bevacizumab studies, more than 90% reported scientific background, drug dose and administration, baseline characteristics, unadjusted results, and adverse events. Fewer than 20% reported study size calculations, handling of missing data, or a discussion of bias.

CONCLUSIONS

Since the adoption of the CONSORT standards by Ophthalmology and other journals in 1996, the reporting quality for RCTs has further improved among this cohort of nvAMD articles. On the other hand, no reporting standards for case series have existed until the recent publication of the STROBE statement. In this first application of the STROBE standards to ophthalmology, we found that the small interventional studies in our series had an average reporting score lower than the RCTs, but also that some individual scores were higher than the RCTs. This outcome demonstrates that good, useful articles can be written about small studies. Although not a direct measure of the quality of a study, good reporting allows a reader to assess the validity and applicability of the study's findings.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Relationships between clinical measures of visual function and anatomic changes associated with bevacizumab treatment for choroidal neovascularization in age-related macular degeneration

PURPOSE

This pilot study was undertaken to examine the relationships between clinical measures of visual function and anatomic changes occurring in the eyes treated with bevacizumab for choroidal neovascularization (CNV) due to age-related macular degeneration (AMD).

METHODS

A retrospective review was conducted for 50 eyes that had been treated with at least three injections of bevicizumab for CNV due to AMD, and followed for at least 6 months. Vision outcomes included best-corrected ETDRS chart acuity, scored by best-line read (ETDRS line) and by total letters read (ETDRS letter), and two measures obtained from central acuity perimetry with 98% Michelson contrast targets, the best acuity within 6 degrees of fixation (BA6 degrees ), and global macular acuity (GMA), representing a weighted average of the acuities thresholded at all intercepts within a 10 degrees radius of fixation. Assessment of anatomic outcomes included fibrosis, atrophy, and subretinal hemorrhage grading on fundus photography, CNV size, pigment epithelial detachment (PED) size and grading of CNV leakage on fluorescein angiography, and central retinal PED, and subretinal fluid (SRF) thickness on optical coherence tomography.

RESULTS

Logistic regression analysis showed an association between the vision outcomes of EDTRS letter and BA6 degrees with the change in SRF thickness (R (2): 0.47 and 0.35, respectively). The outcome of the vision measurement of GMA was associated with the change in SRF thickness, in CNV thickness, and in CNV fibrosis grade (R (2): 0.34). No association was noted between the outcomes of ETDRS line with the change in any anatomic outcomes.

CONCLUSION

Acuity perimetry outcomes in this study seemed to offer improved understanding of the relationship between the vision outcomes and the measured anatomic changes. It seemed that neither ocular coherence tomography nor fluorescein angiography alone offered sufficient morphologic markers for prediction of functional outcomes.

Anti-vascular endothelial growth factor pharmacotherapy for age-related macular degeneration: a report by the American Academy of Ophthalmology

OBJECTIVE

To examine the evidence about the safety and efficacy of anti-vascular endothelial growth factor (VEGF) pharmacotherapies for the treatment of neovascular age-related macular degeneration (AMD).

DESIGN

Literature searches were conducted in May and October 2007 in PubMed with no date restrictions, limited to articles published in English, and in the Cochrane Central Register of Controlled Trials without a language limitation and yielded 310 citations. The first author reviewed the abstracts of these articles and selected 73 articles of possible clinical relevance for review by the panel. The panel deemed 64 of these articles sufficiently clinically relevant to review in full text and assigned ratings of level of evidence to each of the selected articles with the guidance of the panel methodologists.

RESULTS

Eleven studies provided level I evidence for intravitreal pegaptanib and ranibizumab for neovascular AMD; there were no studies rated level I for bevacizumab for neovascular AMD. Five studies were rated as level II, which included studies of ranibizumab and bevacizumab, and the remaining 38 articles retrieved were rated as level III. The studies do not provide information about long-term results or the value (comparative effectiveness) and cost-effectiveness of combined therapies.

CONCLUSIONS

Review of the available literature to date suggests that anti-VEGF pharmacotherapy, delivered by intravitreal injection, is a safe and effective treatment for neovascular AMD for up to 2 years. There is level I evidence to support this conclusion for pegaptanib and ranibizumab, but none for bevacizumab at this time.