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

Morphological and functional retinal changes in neovascular age-related macular degeneration treated with intravitreal bevacizumab

Purpose

This study was conducted to determine the morphological and functional retinal changes in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal bevacizumab 1.25 mg.

Methods

This was a prospective, nonrandomized, interventional study. Eighteen eyes of 18 subjects with nAMD were treated with intravitreal bevacizumab (1.25 mg) injection. Subjects underwent complete ophthalmic evaluation which included visual acuity, slitlamp examination, tonometry, binocular ophthalmoscopy, optical coherence tomography (OCT), and MP1 microperimetry before the intravitreal injection and the follow-up at 1 and 3 months. Test of significance such as Chi-squared test, paired ttest and oneway analysis of variance (ANOVA) linear trend were used to compare the pre- and post-anti-VEGF outcomes. Intraclass correlation was done to assess the intra observer variability.

Results

Mean retinal sensitivity had increased from 3.77 ± 3.13 dB at baseline to 4.93 ± 2.42 dB at 3 months (P = 0.05). Visual acuity improved from 0.62 ± 0.36 at baseline to 0.52 ± 0.36 at 1 month and 0.48 ± 0.34 at 3-month followup, but overall change was not significant (P = 0.40). There was a significant reduction in central foveal thickness (CFT) from 274.61 ± 117.95 at baseline to 179.83 ± 84.18 at 1 month and 179.00 ± 126.55 at 3-month follow-up (P = 0.013).

Conclusion

Intravitreal bevacizumab (1.25 mg) injection in nAMD improves retinal function, quantified by retinal sensitivity, scotoma characteristics, fixation stability by MP 1 microperimetry and morphological parameters quantified by CFT in SDOCT. These changes show the effectiveness of treatment with intravitreal bevacizumab in nAMD.

Comparison of intravitreal ziv-aflibercept and bevacizumab monotherapy in treatment-naive polypoidal choroidal vasculopathy

Purpose

To report the visual and anatomical outcomes of intravitreal ziv-aflibercept (IVZ) and bevacizumab (BVZ) monotherapy in treatment-naive polypoidal choroidal vasculopathy (PCV).

Methods

This was a retrospective case series of 16 eyes (8 eyes each in IVZ and BVZ groups). The study period was from January 2016 to March 2018. The inclusion criteria were treatment-naive PCV patients who were treated with either IVZ or BVZ monotherapy on pro re nata protocol and followed up monthly for 6 months. The change in best-corrected visual acuity (BCVA), central macular thickness (CMT), and pigment epithelial detachment (PED) height was measured at baseline and 6 months.

Results

A total of 16 eyes were studied. IVZ group had an improvement in BCVA by 0.15 logarithm of minimum angle of resolution (logMAR; approximately 1.5 lines) at 6 months, whereas BVZ group had a reduction in BCVA by 0.21 logMAR (approximately 2 lines) (P = 0.027). Five patients and one patient in IVZ and BVZ groups, respectively, had ≥5 letters gain of BCVA. IVZ group had significant reduction in PED height (P = 0.048), whereas the change in CMT was not significant at 6 months (P = 0.681). The mean number of injections (2.87 ± 0.83 in IVZ and 2.25 ± 0.89 BVZ group; P = 0.168) and longest treatment-free interval (3.00 ± 2.20 months in IVZ and 2.12 ± 1.96 months in BVZ group; P = 0.41) were not significantly different.

Conclusion

The visual and anatomical outcomes in terms of PED reduction in treatment-naive PCV patients were better in IVZ group compared with BVZ. IVZ monotherapy is a viable, cost-effective alternative in these patients with good safety profile.

Inhibition of Pterygium Fibroblast Migration and Outgrowth by Bevacizumab and Cyclosporine A Involves Down-Regulation of Matrix Metalloproteinases-3 and -13

We examined the connection between matrix metalloproteinase (MMP) expression/activity and pterygium fibroblast migration, and how these were affected by bevacizumab and/or cyclosporine A (CsA). Fibroblasts were obtained from 20 pterygia and 6 normal conjunctival specimens. Expression levels of MMP-3 and MMP-13 were examined after bevacizumab administration. Immunofluorescence staining was used to examine expression of both MMPs in fibroblasts migrating out from explanted pterygium tissues. Rates of cell migration from explant-cultured pterygia tissues and scratch-wounded confluent pterygium fibroblasts were examined in the presence of MMP-3 or MMP-13 inhibitors, as well as bevacizumab and/or CsA. A scratch wound healing migration assay was performed to determine the effects of bevacizumab and/or CsA. Protein expression of both MMPs in pterygium tissues and in cells migrating from organ-cultured pterygium tissues was greater than that observed in normal cells. Inhibition of the activities of both MMPs decreased their expression levels; these were also significantly reduced in bevacizumab-injected pterygium tissues. Bevacizumab significantly reduced the expression of both MMPs and cell migration. Pretreatment with CsA prior to bevacizumab exposure markedly inhibited cell migration and the expression of both MMPs. CsA enhanced the inhibitory effects of bevacizumab on pterygium fibroblast migration in vitro, possibly by inhibiting expression of both MMPs. These findings suggest that combined CsA and bevacizumab treatment may provide a potential therapeutic strategy for reducing the rate of pterygium recurrence.

Intravitreal ranibizumab for pigment epithelium detachment with subfoveal occult choroidal neovascularization: a prospective 24-month case series

PURPOSE

To assess the effects of intravitreal ranibizumab injection in patients affected by pigment epithelial detachment associated with occult subfoveal choroidal neovascularization.

DESIGN

Prospective, interventional case series.

METHODS

PARTICIPANTS

Forty eyes of 40 patients were considered for the purpose of the study. Consecutive patients were recruited for a 24-month study. All patients underwent a complete ophthalmic examination, including best-corrected visual acuity on Early Treatment Diabetic Retinopathy Study (ETDRS) charts. After a 3-monthly loading phase, further intravitreal ranibizumab injections were administered on the basis of detection of any type of fluid on optical coherence tomography.

PRIMARY OUTCOME MEASURES

Changes in mean best-corrected visual acuity at 12 and 24 months and the proportion of eyes losing fewer than 15 letters (corresponding to 3 ETDRS lines) from baseline visual acuity.

SECONDARY OUTCOME MEASURES

Changes in central macular thickness on optical coherence tomography and variation in mean area of the entire lesion.

RESULTS

Forty patients were included. Mean best-corrected visual acuity decreased from 20/66 (58 ETDRS letters) to 20/83 (53 letters) at 12 months and 20/112 (489 ETDRS letters) at 24 months (P = .003). Eighty percent and 67.5% of eyes lost fewer than 3 lines at 12 and 24 months, respectively. Mean central macular thickness passed from 545 μm to 428 μm at 12 months and 426 μm at 24 months. Mean lesion area changed from 6826 μm(2) to 6312 μm(2) at 12 months and 6010 μm(2) at 24 months.

CONCLUSIONS

The treatment of pigment epithelial detachment associated with occult subfoveal choroidal neovascularization with intravitreal ranibizumab injection after a 3-monthly loading phase and pro re nata strategy can lead to partial results over a 24-month follow-up. Further investigations are warranted to establish the best therapeutic approach to this disease.

Information used to decide on retreatment of exudative age-related macular degeneration with anti-VEGF in clinical practice

Purpose. To record the information used in order to make a retreatment decision in patients with exudative age-related macular degeneration (AMD) and to assess if an optical coherence tomography (OCT)-only follow-up clinic would suffice.
Methods. Two hundred patients under treatment with intravitreal anti-vascular endothelial growth factor injections (anti-VEGF) for exudative AMD were included. Each patient had previously received at least 3 intravitreal anti-VEGF injections (loading dose) (range 3-24 injections). Clinicians seeing the patients beyond the third injection were asked to document the criteria used to make a retreatment decision.
Results. Overall, in 171 (85.5%) cases the retreatment decision was based on OCT findings of intraretinal or subretinal fluid alone. Diagnosis of recurrence requiring treatment would have been missed in 12 cases (6%), if OCT-only data had been used and funduscopy or visual function criteria had been omitted. Decision was based solely on functional criteria in only 2% of the cases. The retreatment decision was based on evaluation of morphologic funduscopic or OCT criteria in 187 (93.5%) cases.
Conclusions. With the increasing number of patients having follow-up after anti- VEGF treatment, efficient systems of follow-up are required. Although most retreatment decisions could have been made by qualitative assessment of OCT images alone, the examination has considerable limitations. Optical coherence tomography in combination with color fundus photography could serve as screening tools for a rational implementation of other invasive imaging techniques such as fundus fluorescein angiography and indocyanine green angiography in decision-making.

Influence of diabetes on macular thickness measured using optical coherence tomography: the Singapore Indian Eye Study

PURPOSE

To determine the influence of diabetes, diabetic retinopathy (DR), and other factors on macular thickness, measured using optical coherence tomography (OCT), in a population-based sample.

METHODS

Data from the population-based Singapore Indian Eye Study were analyzed. We measured macular thickness using Stratus OCT Fast Macular Thickness scan protocol in 228 participants with diabetes mellitus (including 167 without DR, 44 with mild DR, 17 with moderate or severe DR) and 72 non-diabetic controls without macular oedema or other macular lesions. Analysis was done on right eyes.

RESULTS

The mean age of participants was 60.1 ± 10.1 years, with 53.8% men. Macular thickness measurements did not differ significantly between diabetic participants with no or mild DR and non-diabetic participants. Diabetic participants with moderate or severe DR had greater foveal and temporal outer macula thickness compared with those with no or mild DR (P=0.003). In a multivariate linear regression model, older age (P=0.009), male gender (P=0.005), and lower spherical equivalent (P=0.001) were other factors associated with greater foveal thickness in all participants after controlling for body mass index, glycosylated haemoglobin, total cholesterol, and mean systolic blood pressure.

CONCLUSION

This population-based study showed that diabetic participants with moderate or severe DR had thicker foveal measurements, even in the absence of diabetic macula oedema, than non-diabetic controls. Other factors that influenced macular thickness measurements were age, gender, and spherical equivalent. These data may aid the interpretation of OCT findings in persons with diabetes and DR.

Microperimetric changes after intravitreal bevacizumab injection for exudative age-related macular degeneration

PURPOSE

To evaluate the effect of intravitreal bevacizumab on macular function in the cases of exudative age-related macular degeneration (AMD).

METHODS

A total of 21 eyes of 21 patients with exudative AMD were included in this study. In each eye, at baseline and 1, 3 and 6 months after intravitreal bevacizumab injection, logMAR visual acuity, central 4° macular sensitivity, absolute scotoma size, fixation stability and fixation location by MP-1 microperimetry and optical coherence tomography (OCT) foveal morphologic changes were assessed. After the initial treatment phase which included three consecutive injections, the decision to re-treat was based on OCT and clinical findings. Subsequent injections could be administered at least 1 month after the previous injection period according to the OCT-guided treatment regimen.

RESULTS

Mean retinal sensitivity within central 4° (12 points) area had increased from 3.69 ± 3.44 dB at baseline to 7.16 ± 3.27 dB at month 6. In all controls after the treatment, there was significant increase in logMAR visual acuity (p < 0.001) and MP-1 retinal sensitivity (p < 0.001). Mean absolute scotoma in test point location had decreased significantly from 12 of the 76 applied test point locations measured at baseline to five test point locations (-7 test point locations; p < 0.001) at month 6 showing statistical significance. Fixation properties had preserved in all patients 6 months after intravitreal bevacizumab treatment.

CONCLUSION

Intravitreal bevacizumab therapy induced a significant increase in mean retinal sensitivity and significant decrease in mean absolute scotoma size during 6 months. The MP1 microperimetry proved to be a valuable tool in the evaluation of functional benefit of exudative AMD therapy with intravitreal bevacizumab.

Bevacizumab injection in patients with age-related macular degeneration associated with poor initial visual acuity

Purpose. To evaluate functional and anatomic effects of intravitreal bevacizumab in patients with neovascular AMD and initial low visual acuity. Methods. Retrospective case series of 38 eyes with neovascular AMD and initial visual acuity of 20/200 or less, treated with intravitreal bevacizumab injection. Results. Mean followup was 14.1 months ±  7.1 (range: 5 to 24 months). Mean logMAR vision at baseline was 1.38 logMAR ±  0.33, at 6 months was 1.14 logMAR ±  0.37 (P = 0.001) and at 12 months was 1.22 logMar ±  0.33 (P = 0.004). Mean baseline central retinal thickness was 431 μm ±  159.7 at 6 months was 293.43 μm  ±  122.79 (P = 10⁻⁴) and at 12 months was 293.1 μm  ±  130 (P = 0.004). Visual acuity improved in both patients with or without prior PDT treatment. Conclusions. Intravitreal bevacizumab injection may increase the chance of visual acuity gain in neovascular AMD even in cases with initial low visual acuity.

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.

Comparison of intravitreal bevacizumab to photodynamic therapy for polypoidal choroidal vasculopathy: short-term results

Aims:

To compare the short-term therapeutic effects of intravitreal bevacizumab (IVB) to those of photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV).

Materials and Methods:

Retrospective interventional case study. Eighty-nine eyes of 89 patients with symptomatic PCV were treated by IVB or PDT. Eighteen eyes were treated with a single injection of IVB (s-IVB group), 22 eyes with three consecutive monthly IVB injections (m-IVB group), and 49 eyes with PDT alone (PDT group). The best-corrected visual acuity (BCVA) and OCT-determined central foveal thickness (CFT) were evaluated before, and one and three months after the treatment. For statistical analyses, one-factor ANOVA and Chi-square test were used.

Results:

The differences in the BCVA and CFT among the three groups at the baseline were not significant (P=0.992, P=0.981, respectively). Three months after the treatment, the BCVA improved by >0.2 logMAR units in two out of 18 eyes (11%) in the s-IVB group, three out of 22 eyes (14%) in the m-IVB group, and 15 out of 49 eyes (31%) in the PDT group (P=0.124). A decrease in the CFT by >20% was achieved in six out of 18 eyes in the s-IVB group, ten eyes (46%) in the m-IVB group, and 35 eyes (71%) in the PDT group (P=0.009). The resolution of polyps was achieved in three out of 18 eyes in the s-IVB group, one eye (5%) in the m-IVB group and 35 eyes (71%) in the PDT group (P<0.001).

Conclusion:

The better short-term therapeutic outcomes in the PDT group than in the s-IVB and m-IVB groups indicate that PDT may be more effective than IVB in short term after treatment for PCV.