Different antivascular endothelial growth factor treatments and regimens and their outcomes in neovascular age-related macular degeneration: a literature review

Treatment patterns and visual acuity change of AMD patients, before, during and after the COVID-19 pandemic lockdowns: A large cohort

PURPOSE

To evaluate the impact of the changes in treatment patterns before, during and after the COVID-19 pandemic on best-corrected visual acuity (BCVA) in previously treated neovascular age-related macular degeneration (nAMD) patients.

METHODS

A multi-centre, retrospective, observational study of consecutive nAMD patients during 2019-2021. Data collected included demographics, BCVA, dates of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections and clinic visits.

RESULTS

A total of 1652 eyes of 1652 nAMD patients were included, out of which 850 eyes were assessed in 2019 (pre-COVID-19), 630 eyes were assessed in 2020 (COVID-19) and 974 eyes were assessed in 2021 (post-COVID-19). During the COVID-19 period, the mean number of anti-VEGF injections was significantly lower than the corresponding pre-COVID-19 and post-COVID-19 periods (5.55 compared to 6.13 and 6.60, respectively p < 0.01). A constant lower ratio of injections per patient/month was observed during COVID-19 compared to previous and following years, with a notable decline during March-April, reaching a ratio of 0.4 in 2020 versus 0.65 in 2019 and 0.62 in 2021 (p < 0.01). Baseline BCVA (0.825, p < 0.001), number of injections (-0.007, p < 0.001), gender (-0.027, p = 0.037) and age (0.004, p < 0.001) were shown to be significant predictors of final BCVA.

CONCLUSION

During the COVID-19 period, patients were treated with significantly less intravitreal anti-VEGF injection compared to the previous year with compensation in the following year. These changes in treatment patterns did not have a significant impact on BCVA outcomes. Age, gender, baseline BCVA and number of injections are predictors of final visual outcomes.

Using Smartphone Chatbot for Postoperative Care after Intravitreal Injection during COVID-19 Period: A Retrospective Cohort Study

BACKGROUND

During COVID-19 pandemic period, it was difficult for the patients regular and scheduled follow-up in outpatient department, especially when lock-down. However, early detection of patients with initial infection or other serious conditions after ocular surgeries, such as intravitreous injection (IVI) for age-related macular degeneration (AMD).

OBJECTIVE

We accessed a postoperative care chatbot system (PCCS) in smartphone for patients to self-report postoperative symptoms/signs with an instant bidirectional feedback system.

METHODS

During the COVID-19 level 3 epidemic alert in July 2021 in Taiwan, the PCCS alerted the patient to report and grade six ocular symptoms/signs associated with ocular inflammation or retinal detachment. Patients used the PCCS for 7 days postoperatively to assess their symptoms/signs per day after receiving an alert. The data automatically collected using a cloud computer system judged the grade and sent messages to medical staff for further medical assistance. User's satisfaction questionnaire was collected on the 7th day.

RESULTS

One hundred and eighty-five patients participated in this study. There were 26 reports (3.03%) of symptom grade deterioration (increased blurred vision, eye swelling, nausea, and floater/flash) in 12 patients (6.5%). No gender difference for the earlier medical consultation. One case occurred endophthalmitis and improved after 2 times prompt IVI antibiotics. 87% of patients were satisfied or very satisfied to communicate their symptoms instantly with the app, willing to use it again and considered it could improve quality of care. The incidence of earlier medical consultation is 3.8% (7/185) and the incidence of endophthalmitis is 0.5% (1/185).

CONCLUSIONS

The chatbot system, designed for self-reporting postoperative symptoms and providing instant bidirectional feedback on smartphones, could be beneficial for enhancing early medical consultation without gender differences in AMD patients who receiving intravitreal injections. It achieves satisfactory response from patients.

CLINICALTRIAL

COVID-19 Pandemic Lockdowns Impact on Visual Acuity of Neovascular AMD Patients: A Large cohort

PURPOSE

Evaluating the impact of delayed care, secondary to COVID-19 pandemic lockdowns, on visual acuity in previously treated neovascular AMD (nAMD) patients.

METHODS

A multi-center, retrospective, study of nAMD patients previously treated with anti-VEGF injections who were followed-up during 2019 (pre COVID-19) and compared to nAMD patients during 2020 (COVID-19).

RESULTS

A total of 1,192 nAMD patients with a mean age of 81.5 years met the inclusion criteria. Of these, 850 patients were assessed in 2019 (pre COVID-19) and 630 patients assessed in 2020 (COVID-19). 308 patients were assessed through both 2019-2020 and thus were included in both cohorts. There was no significant difference between the years 2020 and 2019 in terms of baseline and change in BCVA (p=0.342, p=0.911 respectively). Mean number of anti-VEGF injections was significantly lower (5.55 Vs 6.13, p<0.01), with constant lower ratio of injections per patient in the COVID-19 period. Baseline BCVA (0.859, p<0.01), number of injections (-0.006, p=0.01) and age (0.003, p<0.01) were predictors of final BCVA.

CONCLUSIONS

In nAMD patients, delayed care secondary to COVID-19 pandemic lockdowns has no statistically significant impact on BCVA. Baseline BCVA, older age and lower number of yearly anti VEGF injections are predictors for decrease BCVA.

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

Efficacy of a New Commercial Ocular Spray Containing Oftasecur Citrus Extract for Reducing Microbial Load in the Conjunctiva of Patients Receiving Intravitreal Injections

INTRODUCTION

The control of conjunctival microbial load is crucial for patients receiving intravitreal injections (IVTs) in order to reduce the risk of endophthalmitis. The purpose of this work was to assess the antimicrobial activity of a new commercial ocular spray containing Biosecur citrus extract (Oftasecur^®, Off Health, Florence, Italy).

METHODS

This prospective cross-sectional pilot study included patients receiving IVTs who were instructed to apply Oftasecur spray onto the eye to be injected four times daily starting 4 days before surgery. The contralateral eye was considered the control. A conjunctival swab for microbiological analysis was performed in both eyes before starting study treatment and at the time of the injection. The Brief Ocular Discomfort Inventory (BODI) questionnaire was administered to patients based on an 11-point scale (0 for no discomfort and 10 for maximum discomfort).

RESULTS

Thirty patients (15 male, 15 female; mean age 64.7 ± 11.6 [standard deviation, SD] years) were included. Before starting treatment, 53.3% of the total eyes tested positive during the microbiological analysis. After the treatment period, only 20% of the eyes tested positive at the time of injection, showing a significant reduction in the microbial load (p < 0.01). Moreover, in the treated arm, the positive swabs before and after the prophylactic treatment with Oftasecur ocular spray showed a significant reduction (from 70.4% to 29.6%; p = 0.003, McNemar's test). Oftasecur ocular spray was well tolerated, with an average BODI score of 1.2 (± 0.70 SD).

CONCLUSION

Oftasecur ocular spray showed antimicrobial activity that significantly reduced the microbial load in patients receiving intravitreal injections. Therefore, it may have a role in the prophylaxis of infection in the setting of IVTs.

AI-based monitoring of retinal fluid in disease activity and under therapy

Retinal fluid as the major biomarker in exudative macular disease is accurately visualized by high-resolution three-dimensional optical coherence tomography (OCT), which is used world-wide as a diagnostic gold standard largely replacing clinical examination. Artificial intelligence (AI) with its capability to objectively identify, localize and quantify fluid introduces fully automated tools into OCT imaging for personalized disease management. Deep learning performance has already proven superior to human experts, including physicians and certified readers, in terms of accuracy and speed. Reproducible measurement of retinal fluid relies on precise AI-based segmentation methods that assign a label to each OCT voxel denoting its fluid type such as intraretinal fluid (IRF) and subretinal fluid (SRF) or pigment epithelial detachment (PED) and its location within the central 1-, 3- and 6-mm macular area. Such reliable analysis is most relevant to reflect differences in pathophysiological mechanisms and impacts on retinal function, and the dynamics of fluid resolution during therapy with different regimens and substances. Yet, an in-depth understanding of the mode of action of supervised and unsupervised learning, the functionality of a convolutional neural net (CNN) and various network architectures is needed. Greater insight regarding adequate methods for performance, validation assessment, and device- and scanning-pattern-dependent variations is necessary to empower ophthalmologists to become qualified AI users. Fluid/function correlation can lead to a better definition of valid fluid variables relevant for optimal outcomes on an individual and a population level. AI-based fluid analysis opens the way for precision medicine in real-world practice of the leading retinal diseases of modern times.

Pharmacokinetics of intravitreal macromolecules: Scaling between rats and rabbits

Rats are widely used to study ocular drug responses, whereas rabbits are the most widely used preclinical model of ocular pharmacokinetics. Despite their wide use in evaluation of intravitreally injected drugs, translational information about pharmacokinetics and dose scaling between rats and rabbits is missing. In this study, we investigated intravitreal pharmacokinetics in rats and rabbits using non-invasive ocular fluorophotometry. Fluorescein and fluorescently labeled molecules (dextrans) with different molecular weights (376 Da, 10, 150 and 500 kDa), were injected into the vitreous of rabbits and rats. Intravitreal concentrations of the compounds were determined and pharmacokinetic parameters were calculated. Overall, the elimination half-lives of the macromolecules in rat vitreous were 5-6 times shorter than in rabbits, and the half-lives were prolonged at increasing molecular weights. The apparent volumes of distribution for tested compounds in rats and rabbits were in the range of the anatomical vitreal volumes. In both species, anterior route of elimination was predominant for the dextrans, whereas fluorescein was mainly eliminated via posterior route. Rabbit-to-rat ratios for intravitreal clearance were in the range of 2 to 5 for dextrans. Therefore, 2-5 times higher doses are needed for similar drug exposure in rabbits than in rats. Also, the shorter half-lives of macromolecules in the rat vitreous must be taken into account in translation to rabbit and human studies. The scaling factors presented herein will augment translational drug development for eye diseases.

Hypochlorous acid antiseptic washout improves patient comfort after intravitreal injection: A patient reported outcomes study

Purpose:

Current ocular antiseptic practice for intravitreal injection (IVI) employs 5% povidone–iodine (Betadine^®) drops which frequently cause ocular discomfort and prolonged irritation. In an effort to improve comfort while maintaining efficacy, we studied a hypochlorous acid (HOCL 0.01%) spray washout prior to injection.

Methods:

Patients had received a minimum of 3 IVIs prepared with Betadine^® antisepsis prior to entry in this study. Their subsequent IVIs were prepared with Betadine^® followed by HOCL 0.01% washout. Facets of comfort were measured by a Likert-scaled questionnaire to compare their experiences after IVI.

Results:

Thirty-seven participants were enrolled. Addition of HOCL 0.01% spray after Betadine^® reduced the duration of discomfort (P = 0.001) and need for artificial tears postinjection (P = 0.003). It improved their reported quality of life (P = 0.04) and sleep (P = 0.01). There were neither HOCL-related side effects nor endophthalmitis during this study.

Conclusion:

Topical HOCL 0.01% spray after topical Betadine^® antisepsis significantly improved patient comfort following IVIs.

State-of-the art pharmacotherapy for non-neovascular age-related macular degeneration

INTRODUCTION

Age-related macular degeneration (AMD) is the most common cause of blindness among the elderly in the industrialized world. While effective treatment is available for neovascular AMD, no therapy is successful for the non-neovascular form. Herein, the authors report the current knowledge on non-neovascular AMD pathogenesis and the promising research on treatments.

AREAS COVERED

In the present review, the authors summarize the most recent advances in the treatment of non-neovascular AMD and provide an update on current treatment strategies. Evidence available from preclinical and clinical studies and from a selective literature search is reported.

EXPERT OPINION

When investigating AMD, numerous pathological cascades and alterations of physiological processes have been investigated. It is well-known that AMD is a multifactorial disease, with environmental causes and genetics playing a role. Perturbations in multiple pathogenic pathways have been identified and this led to the development of several molecules directed at specific therapeutic targets. However, despite the huge research effort, the only proven approach so far is oral antioxidant supplementation. We believe that, in addition to successful advancement of promising drugs, further research should be directed at tailoring therapy to specific patient groups, eventually employing a combinational therapy strategy.

Nonresponders to Ranibizumab Anti-VEGF Treatment Are Actually Short-term Responders: A Prospective Spectral-Domain OCT Study

PURPOSE

To investigate the inter-individual variability in duration of anti-vascular endothelial growth factor (VEGF) treatment effect in neovascular age-related macular degeneration (nvAMD).

DESIGN

Prospective observational multi-centered study.

PARTICIPANTS

Forty-eight patients with nvAMD treated with anti-VEGF injections were included. Both treatment naive (n=25) as well as patients who had previously received treatment with ranibizumab (n=23) more than one month prior to their enrollment were recruited.

METHODS

Patients received injection with ranibizumab (0.5 mg/0.05 ml) and were followed weekly for 4 weeks with spectral-domain OCT (SD-OCT) assessing the time to maximal reduction of central retinal thickness (CRT) and the presence of intraretinal and subretinal fluid. Other data collected included age, gender, visual acuity, axial length, lens status, and previous injections. The Shapiro-Wilk test was used to examine normal distributions for all variables. Correlations were examined by calculating Spearman's correlation coeficient. Distributions of quantitative variables are described as means (±SD). Qualitative variables are summarized by counts and percentage.

MAIN OUTCOME MEASURES

Time to maximal reduction of CRT and intra- and subretinal fluid after ranibizumab injection.

RESULTS

A total of 48 eyes of 48 patients (age 74.8±8.3 years, 62.5% female, 52% treatment naive, 35.4% pseudophakic) were assessed. Two-thirds (64.6%) reached maximal CRT reduction earlier than the standard 4-week interval: 6.3% at 1 week postinjection, 22.9% at 2 weeks postinjection, and 35.4% at 3 weeks postinjection. Only 35.4% of patients had maximal CRT reduction at 4 weeks. Twenty percent of treatment-naive and 34.8% of non-naive patients had a week-4 CRT that was >35 μm thicker than the earlier occuring lowest CRT value (nadir). The time to maximal CRT reduction was not related to axial length, age, lens status, or history of injections.

CONCLUSIONS

Optimal dosing interval for maximal CRT reduction may be less than 4 weeks for a significant proportion of patients. Most patients will be classified as complete responders if intervals less than 4 weeks are used to assess anti-VEGF treatment response. Disease load rather than eye size appears to be the driver of anti-VEGF treatment duration and therefore, dosing interval needs to be optimized in the cohort of short-term responders.

Outcomes in patients receiving fixed-dosed aflibercept for treatment-naïve neovascular age-related macular degeneration during one year of routine clinical practice

OBJECTIVE

To investigate the visual and anatomical outcomes of aflibercept as therapy in patients with treatment-naïve neovascular age-related macular degeneration during one year in routine clinical practice.

METHODS

The study was a retrospective, case series, including 35 patients, 38 eyes, with neovascular age-related macular degeneration that received aflibercept injections (Eylea®). Patients received a loading dose of 3monthly injections (2mg / 0.05ml) followed by intravitreal injections every 2 months.

RESULTS

At 3 and 12 months, the mean best-corrected visual acuity improved significantly as compared with baseline (ETDRS 50.5±14.5 and 53.1±14.5 vs. 39.6±14.7, respectively, P<.05). At 3 and 12 months, the proportion of patients who improved visual acuity by ≥15 letters was 37.1% and 45.7%, respectively. The mean decrease in central macular thickness was also significant after loading dose (239.6±52.0μm) and at 12 month (227±53.2μm) compared with pre-treatment values (370.3±117, 6) (P<.001). Resolution of pigment epithelial detachment (PED) was also observed in 14 out of 20 (70%) eyes with PED at baseline.

CONCLUSION

Aflibercept administered by fixed dosing over one year improved visual acuity and macular morphology in treatment-naïve eyes in routine daily practice.

Bevacizumab dosing every 2 weeks for neovascular age-related macular degeneration refractory to monthly dosing

PURPOSE

To evaluate intravitreal bevacizumab every 2 weeks (biweekly) in refractory neovascular age-related macular degeneration (nAMD).

STUDY DESIGN

Retrospective study.

METHODS

A retrospective study of consecutive nAMD patients unresponsive to monthly intravitreal anti-vascular endothelial growth factor (VEGF) switched to 3-4 biweekly injections.

RESULTS

Twenty-seven eyes of patients aged 82.08  ± 6.85 years were included. Prior to the 2-week interval bevacizumab injections, 74.1% (n=20) were treated with both bevacizumab and ranibizumab, 11.1% (3 eyes) also received aflibercept and 14.8% (4 eyes) had received prior treatment of monthly bevacizumab (average number of injections 21.5 ± 6.7). Best corrected visual acuity (BCVA) remained stable between baseline (logMAR 0.72± 0.60) and follow-up (0.76± 0.66) (p=0.41). Mean central macular thickness and macular volume did not change significantly between baseline and follow-up (p=0.35 and p=0.60, respectively). Six eyes (22.2%) showed morphologic anatomic improvements, while 19 eyes (70.4%) were stable and two eyes (7.4%) deteriorated from baseline. Subretinal fluid completely resolved in 3 of the eyes and improved in the other 3 eyes and in this group (22.2%) both central macular thickness (326.2 ± 101.4 versus 297.5 ± 97.2, p=0.002) and macular volume (8.69 ± 1.69 versus 8.22 ± 1.43, p=0.03) were significantly reduced. No adverse events were observed in any of the treated eyes.

CONCLUSION

This study demonstrates that biweekly bevacizumab injections are effective in nearly one-quarter of nAMD non-responders with no adverse events reported. Switching earlier, rather than later, to this low cost modality may be of benefit for a portion of non-responders to conventional treatment.

Current Evidence for the Prevention of Endophthalmitis in Anti-VEGF Intravitreal Injections

Intravitreal injection of a therapeutic substance is the most common procedure performed in ophthalmology. It has a low incidence of serious complications but is associated with a small chance of endophthalmitis. Although the rate of endophthalmitis is between 0.019% and 0.09%, the associated visual morbidity is often devastating. Procedural changes have evolved over the years to improve patient comfort and reduce injection-related injury and infection. Despite the availability of published evidence, there remains considerable variations and lack of consensus in practical clinical settings. In addition, emerging literature concerning the use of speculums, the use of prophylactic topical antibiotics, and the setting of injections continues to impact the ophthalmologist's injection practice. This article provides an up to date assessment of various aspects of the procedure such as the setting, ventilation, type of anaesthetic, and control of sterility during the procedure; including discussions on performing bilateral eye same-day injections and the use of antibiotics.

Fundamental principles of an anti-VEGF treatment regimen: optimal application of intravitreal anti-vascular endothelial growth factor therapy of macular diseases

BACKGROUND

Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is now considered the gold standard for the treatment of various retinal disorders. As therapy has evolved, so too have the treatment regimens employed by physicians in clinical practice; however, visual outcomes observed in the real world have typically not reflected those reported in clinical trials. Possible reasons for this include a lack of consensus on treatment regimens and a lack of clarity about what the aims of treatment should be.

METHODS

The Vision Academy Steering Committee met to discuss the principles of an ideal treatment regimen, using evidence from the literature to substantiate each point. Literature searches were performed using the MEDLINE/PubMed database (cut-off date: March 2016) and restricted to English-language publications. Studies with fewer than ten patients were excluded from this review.

RESULTS

The Steering Committee identified the following four key principles for the ideal treatment regimen for anti-VEGF management of retinal diseases: 1. Maximize and maintain visual acuity (VA) benefits for all patients 2. Decide when to treat next, rather than whether to treat now 3. Titrate the treatment intervals to match patients' needs 4. Treat at each monitoring visit.

CONCLUSIONS

It is proposed that the adoption of a proactive and more personalized approach in the clinic such as a treat-and-extend regimen will lead to benefits for both the patient and the physician, through a reduction in the associated treatment burden and better utilization of clinic resources. Implementation of the four principles should also lead to better VA outcomes for each patient, with a minimized risk of vision loss.

Effects of Intravitreal Ranibizumab Injection on Chinese Patients with Wet Age-Related Macular Degeneration: 5-Year Follow-Up Results

Purpose. To observe the effect of intravitreal ranibizumab injection on wet age-related macular degeneration (wAMD) over 5 years in Chinese patients. Methods. Thirty-seven patients who were diagnosed with wAMD in our hospital from June 2007 to June 2014 were retrospectively reviewed. The PRN regimen and the treatment and extend regimen were applied. Best corrected visual acuity (BCVA), number of ranibizumab injections, and changes in the choroidal neovascularization (CNV) lesion over 5 years were analyzed. Results. The mean BCVA measured by the ETDRS chart at baseline was 47.4 and 5 years after the treatment it was 34.89 letters, which was significantly different (p = 0.013). Fourteen eyes (37.8%) had improved visual acuity after 5 years. The number of injections in 5 years was 11.53, and most of the injections were in the first two years. Seventeen (45.9%) cases developed fibrous lesions, and 2 (5.4%) cases had atrophic lesions after 5 years. The fibrosis/atrophy was significantly correlated with the injection numbers (Pearson, r = 0.663, and p = 0.000). Conclusion. Most of the patients can maintain visual acuity treated by ranibizumab in the first 3 years. After 5 years, some patients can still improve or maintain visual acuity. Fibrous scarring of the lesion is the main reason for a decrease in vision of wAMD patients.

Occludin S490 Phosphorylation Regulates Vascular Endothelial Growth Factor-Induced Retinal Neovascularization

Occludin is a transmembrane tight junction protein that contributes to diverse cellular functions, including control of barrier properties, cell migration, and proliferation. Vascular endothelial growth factor (VEGF) induces phosphorylation of occludin at S490, which is required for VEGF-induced endothelial permeability. Herein, we demonstrate that occludin S490 phosphorylation also regulates VEGF-induced retinal endothelial cell proliferation and neovascularization. Using a specific antibody, phospho-occludin was located in centrosomes in endothelial cell cultures, animal models, and human surgical samples of retinal neovessels. Occludin S490 phosphorylation was found to increase with endothelial tube formation in vitro and in vivo during retinal neovascularization after induction of VEGF expression. More important, expression of occludin mutated at S490 to Ala, completely inhibited angiogenesis in cell culture models and in vivo. Collectively, these data suggest a novel role for occludin in regulation of endothelial proliferation and angiogenesis in a phosphorylation-dependent manner. These findings may lead to methods of regulating pathological neovascularization by specifically targeting endothelial cell proliferation.

One-year outcome of intravitreal aflibercept injection for age-related macular degeneration resistant to ranibizumab: rapid morphologic recovery and subsequent visual improvement

OBJECTIVE

To describe the 1-year efficacy of aflibercept in Japanese patients with age-related macular degeneration (AMD) who were resistant to ranibizumab treatment.

DESIGN

Retrospective case series.

PARTICIPANTS

Fourteen consecutive eyes of 14 patients with AMD were enrolled who had no substantial response or developed resistance to intravitreal ranibizumab injections.

METHODS

All patients were subcategorized into one of two subtypes of AMD: seven patients with occult choroidal neovascularization (CNV) and seven with polypoidal choroidal vasculopathy (PCV). Serial intravitreal aflibercept (IVA) injections were administered. Comprehensive ophthalmic examinations, including optical coherence tomography, were conducted at baseline and at follow-up examinations at 1, 3, 6, and 12 months after the initial IVA injection. The best-corrected visual acuity converted to logarithm of the minimum angle of resolution (logMAR) and central macular thickness (CMT) at each follow-up visit were compared with the baseline values. The anatomic response was also assessed with absorption or reduction of fluid in the subretina or subretinal pigment epithelial space.

RESULTS

The logMAR best-corrected visual acuity improved significantly at 3, 6, and 12 months in the total cohort: at 3 and 6 months in patients with occult CNV and at 3 and 12 months in patients with PCV. The CMT decreased significantly at all follow-up visits in the total cohort as well as in both subtypes, except for the CMT at 6 months in PCV patients. The anatomic improvement was also demonstrated in all cases, and pigment epithelial detachments tended to be resolved more rapidly in patients with PCV than in patients with occult CNV.

CONCLUSION

Conversion to IVA was effective in patients with AMD resistant to ranibizumab, showing rapid morphologic improvement. The logMAR visual acuity was raised significantly within 12 months, and the clinical course of visual acuity improvement may differ according to the AMD subtypes.

Interventions for Age-Related Macular Degeneration: Are Practice Guidelines Based on Systematic Reviews?

PURPOSE

Are existing systematic reviews of interventions for age-related macular degeneration incorporated into clinical practice guidelines?

DESIGN

High-quality systematic reviews should be used to underpin evidence-based clinical practice guidelines and clinical care. We examined the reliability of systematic reviews of interventions for age-related macular degeneration (AMD) and described the main findings of reliable reviews in relation to clinical practice guidelines.

METHODS

Eligible publications were systematic reviews of the effectiveness of treatment interventions for AMD. We searched a database of systematic reviews in eyes and vision without language or date restrictions; the database was up to date as of May 6, 2014. Two authors independently screened records for eligibility and abstracted and assessed the characteristics and methods of each review. We classified reviews as reliable when they reported eligibility criteria, comprehensive searches, methodologic quality of included studies, appropriate statistical methods for meta-analysis, and conclusions based on results. We mapped treatment recommendations from the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for AMD to systematic reviews and citations of reliable systematic reviews to support each treatment recommendation.

RESULTS

Of 1570 systematic reviews in our database, 47 met inclusion criteria; most targeted neovascular AMD and investigated anti-vascular endothelial growth factor (VEGF) interventions, dietary supplements, or photodynamic therapy. We classified 33 (70%) reviews as reliable. The quality of reporting varied, with criteria for reliable reporting met more often by Cochrane reviews and reviews whose authors disclosed conflicts of interest. Anti-VEGF agents and photodynamic therapy were the only interventions identified as effective by reliable reviews. Of 35 treatment recommendations extracted from the PPPs, 15 could have been supported with reliable systematic reviews; however, only 1 recommendation cited a reliable intervention systematic review. No reliable systematic review was identified for 20 treatment recommendations, highlighting areas of evidence gaps.

CONCLUSIONS

For AMD, reliable systematic reviews exist for many treatment recommendations in the AAO PPPs and should be cited to support these recommendations. We also identified areas where no high-level evidence exists. Mapping clinical practice guidelines to existing systematic reviews is one way to highlight areas where evidence generation or evidence synthesis is either available or needed.

The role of aflibercept in the management of diabetic macular edema

Diabetic macular edema (DME) represents one of the leading causes of visual impairment in working-age adults. Although there are several proven treatments available for this condition, pharmacotherapy through the use of intravitreal antivascular endothelial growth factor agents has revolutionized the management of DME over the past decade with superior outcomes compared to laser therapy. This review summarizes the pathophysiology and available treatment options for the management of DME, with an emphasis on the efficacy and safety profile of a single particular intravitreal antivascular endothelial growth factor agent, aflibercept.

Advances in pharmacotherapy for wet age-related macular degeneration

INTRODUCTION

In developed countries, neovascular age-related macular degeneration (AMD) is the leading cause of irreversible central blindness. Although AMD pathogenesis is complex and still not fully understood, many involved mechanisms are already partially known and could be promising targets for future therapies. Currently, anti-VEGF drugs are the standard care of this condition.

AREAS COVERED

This review summarizes both the current available and the emerging pharmacological therapies for the management of neovascular AMD. At first, we briefly focused on anti-VEGF compounds that are commonly used. Then, we reviewed the mechanisms of action and potential advantages of new candidate drugs that are being evaluated in clinical trials.

EXPERT OPINION

Although anti-VEGF drugs have shown mild-term good efficacy and safety profile in the treatment of neovascular AMD, they are far away from being a perfect therapy. Pharmacological research should focus on finding new molecular targets in the AMD pathogenetical pathway and on developing longer lasting agents or new drug delivery systems. Besides the development of new drugs, a better characterization of patients is also needed, taking into account variables such as choroidal neovascularization subtypes and genetic factors, in order to identify a tailored treatment for each patient.

Poor responders to bevacizumab pharmacotherapy in age-related macular degeneration and in diabetic macular edema demonstrate increased risk for obstructive sleep apnea

PURPOSE

To investigate the risk for obstructive sleep apnea (OSA) in patients with exudative age-related macular degeneration (AMD) or diabetic macular edema with poor response to anti-vascular endothelial growth factor therapy with bevacizumab (Avastin).

METHODS

Age-related macular degeneration group was categorized into nonexudative, exudative, or poor response exudative. Diabetic macular edema group included patients with nonproliferative diabetic retinopathy and cystoid macular edema. Patients were categorized based on the number of intravitreal injections of bevacizumab received. Both groups were compared with age-matched controls. Patients completed a screening questionnaire to assess the risk for OSA, the main outcome measure.

RESULTS

Of 103 patients with AMD, 56 (54.37%) had nonexudative AMD and 47 (45.63%) had exudative AMD, of which 14 (29.79%) had poor response exudative AMD and were at a significantly higher risk of OSA (P < 0.05). Of 30 diabetic macular edema patients with cystoid macular edema, 4 (19%) received 1 injection, 18 (81.82%) received 2 or more consecutive injections, and 16 (72.73%) received 3 or more consecutive injections. Risk for OSA increased significantly with increasing number of injections (P < 0.05).

CONCLUSION

Patients with exudative AMD and diabetic macular edema with poor response to anti-vascular endothelial growth factor therapy have a significantly higher risk of OSA compared with age-matched controls and should be screened to assess the risk of OSA.

Individualized ranibizumab therapy strategies in year 3 after as-needed treatment for polypoidal choroidal vasculopathy

BACKGROUND

To investigate the third-year results of ranibizumab monotherapy for polypoidal choroidal vasculopathy (PCV) in individualized treatment regimens based on the outcomes during 2 years.

METHODS

One hundred seventy-two consecutive eyes of 163 prospective treatment-naïve patients with PCV were treated with three monthly intravitreal ranibizumab injections followed by as-needed reinjections and completed a 2-year follow-up. Treatment regimens during the third year were selected individually based on their outcomes from the following treatment regimens: as-needed injections based on quarterly examinations, as-needed injections based on monthly examinations, a monthly ranibizumab injection schedule, and the treat-and-extend schedule. Visual acuity (VA) and foveal thickness at the end of the third year and the prevalence of discontinuous follow-up examinations during the third year were evaluated.

RESULTS

Of 163 patients, 35 (21%) patients were excluded; nine patients had discontinuous follow-up examinations during the third year. In 128 eyes of 128 patients studied during the third year, the significant improvements in VA and foveal thickness 2 years after the first injection compared to baseline were maintained at the end of the third year. Six (18%, 6/34) patients treated with as-needed injections based on quarterly examinations had discontinuous follow-up examinations, the prevalence of which differed significantly (P = 0.025) from the other groups.

CONCLUSIONS

The individualized treatment strategies in the third year based on each patient's outcomes during 2 years maintained the improved VA and avoided discontinuation of follow-up during the third year.

Systemic safety of anti-VEGF drugs: a commentary

INTRODUCTION

VEGF is a mediator of angiogenesis. Thus, concerns have been expressed following the use of VEGF inhibitors for the treatment of neovascular age-related macular degeneration (nAMD). Ranibizumab, and more recently aflibercept, are VEGF inhibitors licensed for the treatment of nAMD. Bevacizumab is also used but unlicensed for this application.

AREAS COVERED

A non-systematic review of nAMD trials was undertaken to investigate four outcomes: all-cause mortality, all systemic serious adverse events (SSAEs), arteriothrombotic events (ATEs) and gastrointestinal (GI) complications. Differences in event rates with injections of ranibizumab compared to bevacizumab, aflibercept, photodynamic therapy (PDT) and sham were explored and quantified using fixed-effect meta-analyses.

EXPERT OPINION

Anti-VEGF agents can influence vascular health; however, the data suggest no difference in the risk of an ATE or death between anti-VEGF agents. Clinical trials are limited in their size and eligibility criteria and databases of patients treated in routine practice should also be scrutinized.

Bevacizumab versus ranibizumab for neovascular age-related macular degeneration: a Meta-analysis

AIM

To systematically compare the efficacy and safety of off-label bevacizumab versus licensed ranibizumab intravitreal injections as well as monthly regimen versus pro re nata [PRN (as needed)] regimen in the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

Relevant publications were identified through automatically retrieve of database and manually retrieving. The methodological quality of studies included was assessed using the Jadad score and the risk-of-bias assessment. The efficacy estimates were measured by the weight mean difference (WMD) for the improvement of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) reduction. The safety estimates were measured by odds ratios (OR) for adverse events rates. Statistical analysis was conducted by Revman 5.2.7.

RESULTS

Seven studies were included in the Meta-analysis. There were no statistically significant differences between bevacizumab and ranibizumab in BCVA at 1 and 2y (P=0.37, P=0.18, respectively), However, both drugs has better BCVA given monthly than given as needed at 1 and 2y (P<0.05). The results demonstrated the mean decrease in CRT was less in bevacizumab group than ranibizumab group at 1y (P<0.05), while the difference was not significant at 2y (P=0.24). Treatment monthly gained much more decrease in CRT at 1 and 2y (P<0.005). There were no differences between drugs in the rates of death, arterial thrombotic events and venous thrombotic events (P=0.41, P=0.55, P=0.10, respectively), while the rates of medical dictionary for regulatory activities (MedDAR) system organ class events and ≥1 systemic serious adverse events were higher in bevacizumab group than ranibizumab group (P<0.05). But the incidences of death, arterial thrombotic events, venous thrombotic events, MedDAR system organ class events as well as ≥1 systemic serious adverse events were not statistically different between both treatment regimens of monthly and as needed (P=0.14, P=0.76, P=0.73, P=0.12, P=0.11, respectively).

CONCLUSION

Bevacizumab was equivalent to ranibizumab for BCVA, however bevacizumab tended to gain less decrease in CRT and had higher rates of serious adverse events. Compared with treatment as needed, treatment monthly showed superior efficacy in BCVA improvement and CRT reduction, while the rates of adverse events were similar in the two dosing regimens.

Prevention and treatment of injection-related endophthalmitis

BACKGROUND

Intravitreal injections are the fastest growing cause of endophthalmitis and can result in severe vision loss. The prevention, diagnosis and management of such infections remain unclear and at times controversial.

METHODS

We searched Pubmed for keywords "prophylaxis," "endophthalmitis," "intravitreal injection." We focused on studies published in the last 2 years as well as other recent studies with particular attention to data on the incidence, microbiology, prevention, and treatment of injection-related endophthalmitis.

RESULTS

Over 20 relevant studies were found. With povidone-iodine preparation, the per-injection endophthalmitis rate is low at about 0.03%. Antibiotics do not appear to be beneficial for prevention of post-injection endophthalmitis. The best timing of vitrectomy is unclear.

CONCLUSIONS

Antibiotic prophylaxis is probably not needed when giving intravitreal injections. More data is needed to help determine the proper treatment for post-injection endophthalmitis.

Vaccination with a mutated variant of human Vascular Endothelial Growth Factor (VEGF) blocks VEGF-induced retinal neovascularization in a rabbit experimental model

Vascular Endothelial Growth Factor (VEGF) is a key driver of the neovascularization and vascular permeability that leads to the loss of visual acuity of eye diseases like wet age-related macular degeneration, diabetic macular edema, and retinopathy of premature. Among the several anti-VEGF therapies under investigation for the treatment of neovascular eye diseases, our group has developed the vaccine candidate CIGB-247-V that uses a mutated form of human VEGF as antigen. In this work we evaluated if the vaccine could prevent or attenuate VEGF-induced retinal neovascularization in the course of a rabbit eye neovascularization model, based on direct intravitreal injection of human VEGF. Our experimental findings have shown that anti-VEGF IgG antibodies induced by the vaccine were available in the retina blood circulation, and could neutralize in situ the neovascularization effect of VEGF. CIGB-247-V vaccination proved to effectively reduce retinal neovascularization caused by intravitreal VEGF injection. Altogether, these results open the way for human studies of the vaccine in neovascular eye syndromes, and inform on the potential mechanisms involved in its effect.