Functional and anatomical outcome of eyes with neovascular age-related macular degeneration treated with intravitreal ranibizumab following an exit strategy regimen

The Influence of COVID-19 on the Stability of Patients with Neovascular Age-Related Macular Degeneration with Different Treatment Regimens

Introduction

To explore the impact of coronavirus disease 2019 (COVID-19) on the stability of patients with neovascular age-related macular degeneration (nAMD) receiving the treat and extend (T&E) or the pro re nata (PRN) treatment regimen and to identify indicators that may predict the disease stability of nAMD.

Methods

This is a retrospective study of patients with nAMD treated at the Second Affiliated Hospital of Harbin Medical University whose treatment schedule was interrupted at least once between 1 February and 31 May 2020. The demographic and clinical characteristics, including the best corrected visual acuity (BCVA), optical coherence tomography (OCT) features, subfoveal choroidal thickness (SFCT), interval between the last injection and the beginning of the pandemic, and the number of anti-vascular endothelial growth factor (VEGF) injections, were analyzed.

Results

A total of 209 stable patients with nAMD (122 eyes received the T&E regimen; 87 eyes received the PRN regimen) were identified. Compared to those who received the PRN regimen, the patients who received the T&E regimen were more stable during the first visit after COVID-19 (53.3% vs. 33.3%, P = 0.004), the BCVA was significantly better (58.5 letters vs. 56 letters, P = 0.006), and the CRT fluctuated only slightly (15 μm vs. 35 μm, P = 0.001). Furthermore, a multivariate logistic regression analysis showed that stable patients with nAMD with type 1 choroidal neovascularization (CNV) (OR 2.493 [95% CI 1.179–5.272], compared with type 2 CNV; P = 0.017; OR 2.912 [95% CI 1.133–7.485], compared with retinal angiomatous proliferation; P = 0.026) or with pigment epithelial detachment (PED) were more likely to remain stable when treatment was interrupted (OR 0.392 [95% CI 0.181–0.852], compared with no PED; P = 0.018).

Conclusion

Compared to patients who received the PRN treatment regimen, stable patients with nAMD who received the T&E treatment regimen could better maintain stability when the treatments were suddenly interrupted by the COVID-19 pandemic. In addition, patients with type 1 CNV or patients with PED were more likely to remain stable. At present, the COVID-19 pandemic is becoming increasingly normalized, and the T&E regimen can become a more advanced treatment option for patients undergoing therapy.

EXIT STRATEGY IN A TREAT-AND-EXTEND REGIMEN FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION

The analysis of an exit strategy in a treat-and-extend regimen for neovascular age-related macular degeneration revealed a high percentage of patients who met exit criteria and a relatively low incidence of recurrences.

Purpose:

To evaluate the outcome of an exit strategy in a treat-and-extend regimen for neovascular age-related macular degeneration.

Methods:

Five hundred and ninety-eight eyes of 488 patients with neovascular age-related macular degeneration receiving intravitreal anti–vascular endothelial growth factor injections according to a treat-and-extend regimen were included in this retrospective study. A treat-and-extend regimen with either interval extension by 2 weeks or shortening by 1 week was used. “Exit criteria” were defined as 3 consecutive injections 16 weeks apart with stable findings after which the patient was exited from treatment and followed up at 3 to 4 monthly intervals without therapy. Best-corrected visual acuity, central retinal thickness at treatment initiation and termination, incidence of recurrence after treatment termination, presence of characteristics in the optical coherence tomography, duration of therapy, number and intervals of injections were analyzed.

Results:

Seventeen percent of all included eyes met the exit criteria. The mean number of anti–vascular endothelial growth factor injections was 23.7 ± 14.7 with a mean treatment duration of 4.5 ± 2.5 years. Twelve percent reached exit with the minimal number of injections. Thirteen percent had recurrent disease after a mean of 37 ± 16 weeks. In the subgroup with recurrent disease, rate of pigment epithelial detachment at treatment termination was significantly higher than without recurrence (77% vs. 30%, P = 0.0018) with a significant higher proportion of serous pigment epithelial detachment (31% vs. 7%, P = 0.0247).

Conclusion:

The high percentage of patients meeting the exit criteria and the relatively low incidence of recurrences underline the usefulness of a predefined exit strategy. However, in a subgroup of patients, continuation of therapy may be advisable.

The impact of ganglion cell layer cysts in diabetic macular oedema treated with anti-vascular endothelial growth factor

PURPOSE

To investigate the prevalence and impact of ganglion cell layer cysts (GCLC) in patients with diabetic macular oedema (DME) under continuous anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

The clinical findings and spectral domain optical coherence devices of baseline visits and follow-up after 12-24 and 36 months of DME patients under continuous anti-VEGF therapy were retrospectively collected and analysed for the impact of GCLC cysts. Previously established prognostic parameters were also assessed.

RESULTS

A total of 110 eyes of 110 DME patients (mean age 64 ± 10 years) were included. At baseline, 17% eyes had GCLC. With GCLC, the best-corrected visual acuity (BCVA) improvement was in mean 8.4 ± 2.4 Early-Treatment-Diabetic-Retinopathy-Study (ETDRS) letters less over the course of 36 months compared to the group lacking GCLC (p = 0.0009). Eyes with GCLC showed 68 ± 23.4 μm less central retinal thickness (CRT) decrease than eyes lacking GCLC (p < 0.0001). In the linear mixed effect models including external limiting membrane disruption, disintegration of inner retinal layer and epiretinal membrane, GCLC remained a statistical significant factor for the outcome parameter CRT, but missed statistical significance for BCVA.

CONCLUSION

Ganglion cell layer cysts (GCLC) seem to impact outcome in DME in patients receiving long-term treatment. This prognostic factor warrants further evaluation in the context of already well-established outcome parameters.

Changing vision: a review of pharmacogenetic studies for treatment response in age-related macular degeneration patients

Nonresponsiveness to age-related macular degeneration (AMD) treatments has become a growing concern in ophthalmology. Disparity among publications that have assessed pharmacogenetic (PGx) connections between AMD disease genes and treatments has delayed the implementation of PGx testing in AMD. We assessed all AMD PGx publications to identify the degree of agreement for publications within similar ethnic cohorts and worldwide, and the causes for differences in study outcomes. There are no accepted genotype–phenotype correlations, either within similar ethnic cohorts or worldwide. The diversity of measured outcomes, treatment protocols and statistical methods used may be causing this discrepancy. A universally accepted treatment protocol and the creation of agreed response group classification may bridge the gap between AMD PGx publications.

RECURRENCE OF CHOROIDAL NEOVASCULARIZATION LESION ACTIVITY AFTER AFLIBERCEPT TREATMENT FOR AGE-RELATED MACULAR DEGENERATION

PURPOSE

To examine the recurrence rate of choroidal neovascularization (CNV) lesion activity in age-related macular degeneration (AMD) and associated factors after 1-year aflibercept treatment.

METHODS

Age-related macular degeneration eyes with 1-year aflibercept fixed-regimen treatment and a follow-up period of at least 18 months from the initial aflibercept injection for treatment-naive exudative AMD were retrospectively evaluated. The recurrence rate was examined. Age, gender, visual acuity, AMD subtype, greatest linear dimension, and retinal and choroidal thicknesses at the 12th month examination were compared between eyes with and without recurrence. Presence of remnant polyps and pigment epithelial detachment (PED) morphology were also compared in polypoidal choroidal vasculopathy (PCV) eyes.

RESULTS

Of the 98 eyes studied, 69 displayed a dry macula at the 12th month examination; 43.7% exhibited recurrence during the subsequent 12-month period in Kaplan-Meier analysis. Although no factors associated with recurrence were detected in AMD, remnant polyps and pigment epithelial detachment morphology at the 12th month examination were significantly associated with recurrence in polypoidal choroidal vasculopathy (P = 0.018 and 0.048, respectively).

CONCLUSION

Continuous, proactive treatment would be considered overtreatment for more than half of the AMD eyes that achieved a dry macula. Angiography and optical coherence tomography analyses may be useful for predicting recurrence in polypoidal choroidal vasculopathy eyes.

Inner retinal layer change in glaucoma patients receiving anti-VEGF for neovascular age related macular degeneration

PURPOSE

The purpose was to evaluate the effects of long-term anti-VEGF treatment on the retinal nerve fiber layer (RNFL) and retinal ganglion cell layer (RGCL) thickness for patients with neovascular AMD and glaucoma.

METHODS

Medical records of respective patients who had received more than 15 anti-VEGF injections were reviewed. Initial and latest SD-OCT macular scans were segmented and changes of the RNFL and RGCL thickness at the four outer ETDRS quadrants were evaluated. Secondary outcome measures included changes of visual field parameters seen in automated perimetry.

RESULTS

Sixteen patients were included (mean age 78 ± 6 years). The mean total number of anti-VEGF injections was 39 ± 16. The mean treatment duration was 6.1 ± 2.1 years. The mean IOP decreased from 18 ± 5 mmHg at baseline to 15 ± 5 mmHg at the last visit (p = 0.026). The mean RNFL thickness volume of the outer ETDRS quadrants (0.98 ± 0.18 mm³ to 0.97 ± 0.18 mm³ p = 0.61) and its average thickness (37.9 ± 7.3 μm to 37.2 ± 7.4 μm, p = 0.6) did not significantly change. However, the average RGCL thickness decreased significantly from 0.86 ± 0.12 mm³ to 0.79 ± 0.11 mm³ (p = 0.01), and from 27.7 ± 4.2 to 25.9 ± 3.7 μm (p = 0.01). Number of injections correlated with the RGCL change (r2 = 0.36, p = 0.01). The mean sensitivity, mean defect and absolute scotomata did not significantly change with p-values of 0.28, 0.21 and 0.07, respectively.

CONCLUSION

Patients under long term treatment with anti-VEGF and concurrent glaucoma show significant decrease in macular RGLC volume. However, this decrease is comparable to reported RGCL decrease in patients under anti-VEGF treatment without underlying glaucoma and suggests that glaucoma patients may not be at a higher risk for losing macular RNFL and RGCL, at least if adequate control of intraocular pressure is maintained.

Macular atrophy in patients with long-term anti-VEGF treatment for neovascular age-related macular degeneration

PURPOSE

To identify the prevalence and progression of macular atrophy (MA) in neovascular age-related macular degeneration (AMD) patients under long-term anti-vascular endothelial growth factor (VEGF) therapy and to determine risk factors.

METHOD

This retrospective study included patients with neovascular AMD and ≥30 anti-VEGF injections. Macular atrophy (MA) was measured using near infrared and spectral-domain optical coherence tomography (SD-OCT). Yearly growth rate was estimated using square-root transformation to adjust for baseline area and allow for linearization of growth rate. Multiple regression with Akaike information criterion (AIC) as model selection criterion was used to estimate the influence of various parameters on MA area.

RESULTS

Forty-nine eyes (47 patients, mean age 77 ± 14) were included with a mean of 48 ± 13 intravitreal anti-VEGF injections (ranibizumab:37 ± 11, aflibercept:11 ± 6, mean number of injections/year 8 ± 2.1) over a mean treatment period of 6.2 ± 1.3 years (range 4-8.5). Mean best-corrected visual acuity improved from 57 ± 17 letters at baseline (= treatment start) to 60 ± 16 letters at last follow-up. The MA prevalence within and outside the choroidal neovascularization (CNV) border at initial measurement was 45% and increased to 74%. Mean MA area increased from 1.8 ± 2.7 mm² within and 0.5 ± 0.98 mm² outside the CNV boundary to 2.7 ± 3.4 mm² and 1.7 ± 1.8 mm² , respectively. Multivariate regression determined posterior vitreous detachment (PVD) and presence/development of intraretinal cysts (IRCs) as significant factors for total MA size (R² = 0.16, p = 0.02). Macular atrophy (MA) area outside the CNV border was best explained by the presence of reticular pseudodrusen (RPD) and IRC (R² = 0.24, p = 0.02).

CONCLUSION

A majority of patients show MA after long-term anti-VEGF treatment. Reticular pseudodrusen (RPD), IRC and PVD but not number of injections or treatment duration seem to be associated with the MA size.

Effectiveness of Intravitreal Injection of Ranibizumab for Neovascular Age-Related Macular Degeneration with Serous Pigment Epithelial Detachment

Background

We sought to observe the effectiveness of intravitreal injection of ranibizumab in treating neovascular age-related macular degeneration (nAMD) with serous pigment epithelial detachment (sPED).

Material/Methods

A retrospective, noncomparative case series was performed. Twenty-3 eyes of 23 patients with sPED secondary to nAMD who had received intravitreal injections of ranibizumab were included in this study. All patients underwent best-corrected visual acuity (BCVA), synchronous fluorescein fundus angiography (FFA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT) examinations. All patients were treated with pro re nata intravitreal injections after 3 loading doses of ranibizumab and were followed up for 12 months. The differences in the BCVAs, maximum PED heights, PED volumes and CFTs of the affected eyes were compared between the baseline and last visit.

Results

Twelve months after the first injection, improved visual acuity was observed in 16 of the 23 eyes. 4 eyes exhibited stable visual acuity, and 3 eyes exhibited impaired visual acuity. The mean post-injection logMAR BCVA was 0.58±0.05, which was much better than that at baseline (0.76±0.08; t=1.751, P=0.0869). The mean maximum PED height at baseline was 350.17±35.73μm and it was decreased to 238.87±36.87μm (t=2.192, P=0.0337) at the last visit. The mean PED volume after injection was 0.34±0.1 mm³, which was significantly decreased compared with that at baseline (0.81±0.21 mm³; t=2.021, P=0.0494).The mean CFT decreased, but this difference was not statistically significant (t=1.003, P=0.3211). None of the patients exhibited endophthalmitis, uveitis or RPE tears.

Conclusions

Intravitreal injection of ranibizumab for the treatment of neovascular age-related macular degeneration with serous pigment epithelial detachment safely and effectively improved the patients’ visual acuities and decreased their PED heights volumes.

Optimizing the Anti-VEGF Treatment Strategy for Neovascular Age-Related Macular Degeneration: From Clinical Trials to Real-Life Requirements

This Perspective discusses the pertinence of variable dosing regimens with anti-vascular endothelial growth factor (VEGF) for neovascular age-related macular degeneration (nAMD) with regard to real-life requirements. After the initial pivotal trials of anti-VEGF therapy, the variable dosing regimens pro re nata (PRN), Treat-and-Extend, and Observe-and-Plan, a recently introduced regimen, aimed to optimize the anti-VEGF treatment strategy for nAMD. The PRN regimen showed good visual results but requires monthly monitoring visits and can therefore be difficult to implement. Moreover, application of the PRN regimen revealed inferior results in real-life circumstances due to problems with resource allocation. The Treat-and-Extend regimen uses an interval based approach and has become widely accepted for its ease of preplanning and the reduced number of office visits required. The parallel development of the Observe-and-Plan regimen demonstrated that the future need for retreatment (interval) could be reliably predicted. Studies investigating the observe-and-plan regimen also showed that this could be used in individualized fixed treatment plans, allowing for dramatically reduced clinical burden and good outcomes, thus meeting the real life requirements. This progressive development of variable dosing regimens is a response to the real-life circumstances of limited human, technical, and financial resources. This includes an individualized treatment approach, optimization of the number of retreatments, a minimal number of monitoring visits, and ease of planning ahead. The Observe-and-Plan regimen achieves this goal with good functional results. Translational Relevance: This perspective reviews the process from the pivotal clinical trials to the development of treatment regimens which are adjusted to real life requirements. The article discusses this translational process which- although not the classical interpretation of translation from fundamental to clinical research, but a subsequent process after the pivotal clinical trials - represents an important translational step from the clinical proof of efficacy to optimization in terms of patients' and clinics' needs. The related scientific procedure includes the exploration of the concept, evaluation of security, and finally proof of efficacy.

Ranibizumab for macular edema secondary to retinal vein occlusion: a meta-analysis of dose effects and comparison with no anti-VEGF treatment

Background

To compare the efficacy and tolerability of intravitreal ranibizumab (IVR) 0.5 mg or 0.3 mg with non-anti-vascular endothelial growth factor (VEGF), and to compare the efficacy of IVR 0.5 mg with IVR 0.3 mg in the treatment of macular edema secondary to retinal vein occlusion.

Methods

Relevant studies were selected after an extensive search using the PubMed, EMBASE, Web of Science, and Cochrane Library databases. Outcomes of interest included visual outcomes, anatomic variables, and adverse events.

Results

Four randomized controlled trials (RCTs) met our inclusion criteria. IVR 0.5 mg produced a significantly higher improvement in visual acuity at six months, with pooled weighted mean differences (WMDs) of 12.30 early treatment diabetic retinopathy study (ETDRS) letters (95% CI:10.03, 14.58) (P < 0.001),and led to a higher proportion of patients gaining ≥15 letters (RR, 2.36; 95%CI: 1.86, 2.99; P < 0.001) at the follow-up endpoint, compared with non-anti-VEGF. A more obvious reduction in central foveal thickness (CFT) was observed in the IVR 0.5 mg group than the non-anti-VEGF group, and the mean difference in CFT was statistically significant (WMD, −216.86 μm; 95%CI: −279.01, −154.71; P < 0.001). A similar efficacy was found between the IVR 0.3 mg group and the non-anti-VEGF group. No significant differences were found between IVR 0.5 mg and 0.3 mg. The incidence of iris neovascularization in the non-anti-VEGF group was significantly higher than that of the IVR group.

Conclusions

IVR 0.5 mg or 0.3 mg was more effective than sham injection and laser treatment. IVR 0.3 mg is as effective as IVR 0.5 mg in the treatment of macular edema secondary to retinal vein occlusion.

Current state of therapeutic strategies with ranibizumab in neovascular age-related macular degeneration

PURPOSE OF REVIEW

To summarize the current dosing strategies in the management of neovascular age-related macular degeneration with intravitreal injections of ranibizumab.

RECENT FINDINGS

A variety of therapeutic strategies has been recently described as an alternative to the monthly fixed treatment. The efficacy and local and systemic safety results of each approach is relevant in order to make a clinical decision and to provide patients an accurate information.

SUMMARY

The proposed therapeutic strategies achieve positive visual outcomes when compared with monthly fixed regimen in the clinical trials. However, the real-life practice does not reflect these results. The main cause of this difference is the incapability to adopt any of the different strategies as the clinics are completely booked and this turns into a delay in the diagnostic and treatment visits.