Sequential therapy with ranibizumab and dexamethasone intravitreal implant is better than dexamethasone monotherapy for macular oedema due to retinal vein occlusion

Combination Therapy with Anti-VEGF and Intravitreal Dexamethasone Implant for Macular Edema Secondary to Retinal Vein Occlusion

PURPOSE

To compare the safety and efficacy of intravitreal injection of ranibizumab alone or ranibizumab combined with dexamethasone intravitreal implant in the treatment of macular edema secondary to retinal vein occlusion.

STUDY DESIGN

A single center, case-controlled, prospective cohort study (Clinical Trail Registration Number: ChiCTR2400080048).

METHODS

A total of 44 patients were enrolled and randomized into the ranibizumab group (n = 23) and the combination group (ranibizumab combined with dexamethasone intravitreal implant) (n = 21). All patients received ranibizumab intravitreal injections in the first three months as the initial treatment. For the ranibizumab group, patients might receive repeat injections in case of the recurrence of macular edema; For the combination group, patients received an intravitreal injection of dexamethasone implant after the first injection of ranibizumab at the day 15. The main outcome was best-corrected visual acuity (BCVA) and reduction of central macular thickness. The secondary outcome were the numbers of recurrence, the average injection interval, and the numbers of injection. Adverse events were also recorded.

RESULTS

The BCVAs in both groups were significantly improved compared with the baselines (all p < 0.001), but more increment in BCVA was noticed at the 3-month in the combination group (p = 0.022). Both groups showed a reduction of central macular thickness at all time points (p < 0.05). However, the combination group did not exhibit higher central macular thickness-reducing effects than the ranibizumab group (p > 0.05). Compared with the combination group, the ranibizumab group suffered a higher number of recurrences of macular edema (p < 0.001), a lower interval of injection (p = 0.050), and a higher number of injection (p < 0.011). The incidence of adverse events was not significant between the two groups (p = 0.944).

CONCLUSIONS

Ranibizumab combined with dexamethasone injection sustainably improved the BCVA of retinal vein occlusion patients with a good safety profile.

Intravitreal Injection of Anti-Vascular Endothelial Growth Factors Combined with Corticosteroids for the Treatment of Macular Edema Secondary to Retinal Vein Occlusion: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid combination therapy for the management of treatment-naïve or recurrent/refractory macular edema caused by retinal vein occlusion (RVO) in comparison with anti-VEGF monotherapy.

METHODS

In this systematic review and meta-analysis study, the data from publications in the electronic databases including PubMed, Embase, Cochrane Library Central Register of Controlled Trials, ISI and Scopus from January 1, 2007, through November 20, 2020, were compiled. Heterogeneity was statistically quantified by the I2 statistic, and meta-analysis was performed using a random-effects model.

RESULTS

Twenty-four related studies were identified, including a total of 1280 eyes, which consisted of 685 and 507 patients with central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO), respectively. This study demonstrated a greater improvement in best-corrected visual acuity (BCVA) in the combination group compared to anti-VEGF monotherapy for both CRVO and BRVO cases at 6 months after initiating therapy. The improvement in vision was more notable in BRVO cases than in CRVO cases. However, the changes in central macular thickness (CMT) did not differ significantly between the different treatment approaches, and the results were inconclusive. Including all cases with RVO, there was no inferiority in terms of BCVA improvement and CMT reduction in the triamcinolone subgroup compared with the slow-release dexamethasone implant subgroup. A greater improvement was noticed in terms of BCVA in the sequentially treated subgroup compared to the simultaneous treatment subgroup, while there was a greater reduction in CMT in the simultaneous subgroup with the highest reduction recorded at 1 month after treatment.

CONCLUSIONS

This study suggests that combination therapy with intravitreal anti-VEGF and corticosteroid (such as intravitreal or subtenon triamcinolone or dexamethasone implant) has a slightly better effect on improving BCVA in cases with BRVO or CRVO at 6 months compared to monotherapy.

The Efficacy of Simultaneous Injection of Dexamethasone Implant and Ranibizumab Into Vitreous Cavity on Macular Edema Secondary to Central Retinal Vein Occlusion

The purpose of this study was to determine the safety and effectiveness of simultaneous vitreous injection of dexamethasone implant and ranibizumab on macular edema secondary to central retinal vein occlusion (CRVO). We conducted a 6-month retrospective self-control study. Twenty-five patients diagnosed with macular edema secondary to CRVO were enrolled in this study. The patients received intravitreal injection of dexamethasone implant and ranibizumab. The changes in best corrected visual acuity (BCVA), central retinal thickness (CRT) and interocular pressure (IOP) before and at 2w, 1, 2, 3, 4, 5, 6 m after injection were recorded and compared. The adverse reactions in eyes and whole body were observed. The BCVA of all patients at 2 w (61.8 ± 5.42), 1 m (68.68 ± 5.23), 2 m (70.8 ± 5.8), 3 m (68.44 ± 5.61), 4 m (65.76 ± 5.76), 5 m (67.08 ± 5.57), and 6 m (70.12 ± 5.46) after surgery were significantly higher than that before surgery (52.2 ± 5.06,p < 0.01), and CRT of all patients at 2w (393.36 ± 52.66 um), 1 m (334.52 ± 32.95 um), 2 m (298.800 ± 29.97 um), 3 m (309.080 ± 28.78 um), 4 m (345.48 ± 39.81 um), 5 m (349.080 ± 29.88 um), and 6 m (309.76 ± 30.41 um) after surgery were significantly reduced than that before surgery (583.76 ± 121.09 um, p < 0.01). Macular edema recurred in an average of 4.44 ± 0.51 months after treatment, and those patients received combined treatment again. During follow-up, the most common adverse reactions were subconjunctival hemorrhage and increased intraocular pressure, with the incidence of 22% (11/50) and 18% (9/50) respectively. In all cases, the increased intraocular pressure could be controlled by a single intraocular pressure reducing drug. No patient needed to receive anti-glaucoma surgery. The overall incidence of lens opacity was 4% (2/50). After the first injection, no case showed lens opacity. After re-injection, 2 patients (2 eyes) (8%) developed lens opacity. None of the patients showed serious ocular adverse reactions or systemic complications such as vitreous hemorrhage, retinal detachment, endophthalmitis, uveitis or ocular toxicity. The simultaneous vitreous injection of dexamethasone implant and ranibizumab can significantly improve the visual acuity and anatomical prognosis in macular edema secondary to central retinal vein occlusion (CRVO-ME) patients, exhibiting good safety and effectiveness.

Simultaneous intravitreal dexamethasone and aflibercept for refractory macular edema secondary to retinal vein occlusion

PURPOSE

To assess the functional and anatomical outcomes of concurrent administration of aflibercept injection and dexamethasone (DEX) implant in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), refractory to each of the two drugs previously administered as monotherapy. Secondary outcomes included the number of retreatments required in a 12-month follow-up and safety.

METHODS

This is a prospective, interventional case series of consecutive patients with refractory ME secondary to RVO, followed over a year. One injection of aflibercept was followed by a DEX implant on the same day; retreatment was driven by the persistence of ME on SD-OCT at least 4 months after the previous combined therapy. Central retinal thickness (CRT), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were collected at 1 month and then every 2 months until the end of follow-up.

RESULTS

Thirty eyes of 30 Caucasian patients were enrolled; mean duration of RVO before the first combined treatment was 25 ± 5 months (range 11 ± 30). Baseline BCVA was 0.73 ± 0.5 LogMAR, with no significant changes at 12 months (0.77 ± 0.51 μm, p = 0.2). Baseline CRT was 578.3 ± 161 μm, reducing to 352.5 ± 81 μm at 12 months (p = 0.003). Thirteen eyes (43.3%) required a second treatment. Twenty eyes (66.6%) showed no ME at the end of follow-up. One patient (3.3%) required topical IOP-lowering therapy during the study.

CONCLUSION

In eyes with ME secondary to RVO unresponsive to either aflibercept or DEX administered singularly, a combination therapy with simultaneous administration of aflibercept and DEX was effective in resolving ME, despite the absence of visual improvement. Earlier combined treatment in the course of the disease might lead to better functional outcomes.

The anti-inflammatory and anti-oxidative effects of conbercept in treatment of macular edema secondary to retinal vein occlusion

To investigate the effects of conbercept on inflammatory and oxidative response in macular edema secondary to retinal vein occlusion (RVO-ME). Retinal microvasculature were detected by optical coherence tomographic angiography (OCTA). The inflammation related factors including prostaglandin E1 (PGE1), prostaglandin E2 (PGE2), prostaglandin F2a (PGF2a), intercellular cell adhesion molecule-1 (ICAM-1) and macrophage inflammatory protein-1 (MIP-1) were determined in human and mice with RVO-ME. OCTA images showed that capillary non-perfusion, enlargement of the foveal avascular zone, telangiectatic vessels and some forms of intraretinal edema in RVO-ME and all these were alleviated by conbercept treatment. PGE1, PGE2, PGF2a, ICAM-1 and MIP-1 in aqueous fluid extracted from RVO-ME patients was significantly increased compared with non-RVO subjects, intravitreal injection of conbercept partly reduced ICAM-1 and MIP-1 levels but not PGE1, PGE2 and PGF2a. The glutathione level was reduced in aqueous fluid extracted from RVO-ME patients but was restored after conbercept treatment. The inflammation, angiogenesis and ROS generation was increased in RVO-ME mice, conbercept partly inhibited these effects. Mechanistically, conbercept inhibited vascular endothelial growth factor (VEGF), ICAM-1, MIP-1, NOX-1 and NOX-4 protein expressions, but not PGE1, PGE2 and PGF2a expressions. Conbercept alleviates RVO-ME through inhibiting inflammation, angiogenesis and oxidative responses. These findings further reveals the molecular mechanism of conbercept for treatment of RVO-ME.

Characteristics of retinal vein occlusion with final vision better than 78 letters after sequential therapy with ranibizumab and triamcinolone acetate

AIM

To analyze the reasons that may lead to the different vision result by combining the ranibizumab and triamcinolone acetate (TA) in sequence to treat macular edema in retinal vein occlusion (RVO).

METHODS

Ranibizumab and TA were combined in sequence to treat 43 patients with macular edema secondary to RVO. Six months after the treatment, patients with central fovea thickness (CFT) less than 300 µm in optical coherence tomography (OCT) were collected into Groups I and II, based on vision acuity (VA) better than 78 letters or less than 60 letters. The age, baseline VA, duration from onset to treatment, CFT at the baseline, sub-retinal fluid (SRF), sub-foveal exudates and injection times of TA and ranibizumab were taken into comparison.

RESULTS

The mean age of the subjects was 46.4y in Group I but 57.5y in Group II. The difference of age was significant between groups (P<0.01). The mean baseline VA was 51.4 letters in Group I and 43.9 letters in Group II (P<0.05). The baseline CFT were 670.9 µm in Group I with SRF in 54.3% patients and 678.1 µm in Group II with SRF in 52.9% (P>0.05). The mean number of injections of TA was 0.9 and the mean number of injections of ranibizumab was 2.3 in Group I but 1.7 and 2.9 respectively in Group II. The treatment times of ranibizumab had no difference between the 2 groups (P>0.05) but the difference of TA injection times was significant, P<0.05. Subfoveal exudates at final stage happened in no subjects in Group I but in 45.83% subjects in Group II.

CONCLUSION

This combined treatment is safer than TA injection and cheaper than ranibizumab injection alone. Younger patients and earlier treatment will help to get better vision outcome. Subfoveal exudates at the final stage have significant relationship with vision outcome. No relationship existed between the baseline CFT, SRF and the vision outcome.

Retrospective, controlled observational case study of patients with central retinal vein occlusion and initially low visual acuity treated with an intravitreal dexamethasone implant

Background

Patients with initially low visual acuity were excluded from the therapy approval studies for retinal vein occlusion. But up to 28 % of patients presenting with central retinal vein occlusion have a baseline BCVA of less than 34 ETDRS letters (0.1). The purpose of our study was to assess visual acuity and central retinal thickness in patients suffering from central retinal vein occlusion and low visual acuity (<0.1) in comparison to patients with visual acuity (≥0.1) treated with Dexamethasone implant 0.7 mg for macular edema.

Methods

Retrospective, controlled observational case study of 30 eyes with macular edema secondary to central retinal vein occlusion, which were treated with a dexamethasone implantation. Visual acuity, central retinal thickness and intraocular pressure were measured monthly. Analyses were performed separately for eyes with visual acuity <0.1 and ≥0.1.

Results

Two months post intervention, visual acuity improved only marginally from 0.05 to 0.07 (1 month; p = 0,065) and to 0.08 (2 months; p = 0,2) in patients with low visual acuity as compared to patients with visual acuity ≥0.1 with an improvement from 0.33 to 0.47 (1 month; p = 0,005) and to 0.49 (2 months; p = 0,003). The central retinal thickness, however, was reduced in both groups, falling from 694 to 344 μm (1 month; p = 0.003,) to 361 μm (2 months; p = 0,002) and to 415 μm (3 months; p = 0,004) in the low visual acuity group and from 634 to 315 μm (1 month; p < 0,001) and to 343 μm (2 months; p = 0,001) in the visual acuity group ≥0.1. Absence of visual acuity improvement was related to macular ischemia.

Conclusions

In patients with central retinal vein occlusion and initially low visual acuity, a dexamethasone implantation can lead to an important reduction of central retinal thickness but may be of limited use to increase visual acuity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-016-0363-5) contains supplementary material, which is available to authorized users.

RETINAL VEIN OCCLUSIONS, FROM BASICS TO THE LATEST TREATMENT

PURPOSE

To review the pathophysiology, diagnosis, and updated treatments of retinal vein occlusions (RVOs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and treatments (including both medical and surgical treatments) of RVO. Based on this review, a comprehensive overview was provided regarding the topic of RVO and focused on recent treatment updates.

RESULTS

Retinal vein occlusions have an age- and sex-standardized prevalence of 5.20 per 1,000 for any RVO, 4.42 per 1,000 for branch RVO, 0.80 per 1,000 for central RVO. Worldwide, an estimated 16.4 million adults are affected by RVOs, with 2.5 million affected by central RVO and 13.9 million affected by branch RVO. Retinal vein occlusion is recognized as an important cause of blindness and the diagnostic approaches and treatment options for RVO are reviewed and reported. The current treatment options including medical treatments (bevacizumab, ranibizumab, aflibercept, triamcinolone, and dexamethasone implants) and surgical alternatives were reviewed and reported with summaries on the corresponding strength of evidence.

CONCLUSION

Despite the understanding of this disease entity, challenges persist in the long-term treatment of RVO-related complications and visual loss. This review provided a detailed summary on the rationality and efficacy of recently developed treatment regimes and evaluated the potential benefit of combination therapy.

Retinal vein occlusion and the use of a dexamethasone intravitreal implant (Ozurdex®) in its treatment

Purpose

To review published data pertaining to the clinical experience with a dexamethasone intravitreal implant (Ozurdex®) with a view to establishing a clinically based therapeutic regime.

Methods

A PubMed search using the MeSH terms “retinal vein occlusion” and either “pathophysiology” or “dexamethasone intravitreal implant” was undertaken for manuscripts published until August 2015. The analysis included studies involving minimally 15 patients under a prospective design or 30 under a retrospective design, a minimal follow up of 6 months, and at least 2 intravitreal Ozurdex® injections per eye.

Results

In the vast majority of eyes, satisfactory outcomes were achieved with retreatment intervals of between 3 and 5 months. Initial evidence indicates a similar efficacy compared to anti-VEGF therapies as a first-line treatment. Safety concerns associated with the long-term and repeated use of Ozurdex® are not borne out by clinical findings: its implantation is not associated with a sustained increase in intraocular pressure (IOP) over time or with the number of applications.

Conclusion

Compared with anti-VEGF therapies, the burden of retreatment is reduced. In patients with chronic macular edema not responsive to repetitive anti-VEGF therapies, the outcome after dexamethasone implant treatment is encouraging. However, these results are achieved at the expense of side effects typically associated with steroids: in up to 20 % of the Ozurdex®-treated patients, an elevation in IOP, which could be medically controlled in the majority of cases, and cataract formation or progression was observed.

Outcome of intravitreal dexamethasone implant for the treatment of ranibizumab-resistant macular edema secondary to retinal vein occlusion

To assess the effect of intravitreal dexamethasone implant (Ozurdex) for the treatment of macular edema secondary to retinal vein occlusion (RVO) resistant to repeated intravitreal ranibizumab injection. Retrospective review of 11 patients (11 eyes) with ranibizumab-resistant macular edema secondary to RVO. Macular edema was considered refractory to ranibizumab if no change of the pattern of macular fluid on optical coherence tomography and no change of best-corrected visual acuity (BCVA) was observed after at least three consecutive monthly injections, excluding the loading dose. A single Ozurdex injection was performed and BCVA and central foveal thickness (CFT) were reviewed 2, 3, and 6 months after treatment. Mean BCVA improved significantly from 0.51 logarithm of the minimal angle of resolution (log MAR) at baseline to 0.3 log MAR (p = 0.03) at 2 months and 0.29 log MAR (p = 0.003) at 3 months. There was no significant difference in the BCVA between baseline at 6 months (p = 0.62). Mean CFT reduced significantly from 538 µm at baseline to 281 µm at 2 months (p = 0.00003), 281 µm at 3 months (p = 0.00003), and 445 µm at 6 months (p = 0.03). Treatment with Ozurdex results in improvement of BCVA and reduction of CFT in patients with ranibizumab refractory macular edema due to RVO at 3 months. However, it seems that the visual acuity gain may not last up to 6 months, so that a re-injection before this time point could be considered.