Comparison of the Efficacy of Intravitreal Aflibercept and Bevacizumab for Macular Edema Secondary to Branch Retinal Vein Occlusion

Efficacy of as-needed intravitreal injection compared to 3-monthly loading of anti-vascular endothelial growth factor agents for branch retinal vein occlusion

We investigated the efficacy of intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents in branch retinal vein occlusion (BRVO). Databases, including PubMed, EMBASE, and the Cochrane Library, were searched on November 11, 2022. Studies comparing the pro-re-nata (PRN) regimen after the first treatment (PRN group) to three consecutive monthly injection regimens followed by the PRN regimen (3 + PRN group) were investigated. The primary outcomes were the change in best-corrected visual acuity (BCVA) and the change in central retinal thickness (CRT), with the secondary outcome being the injection frequency. Among 195 reports on anti-VEGF treatment, six comparative studies were included in this meta-analysis. The two groups had no statistically significant differences in terms of BCVA or CRT. However, the total number of injections during follow-up was significantly lower in the PRN group than in the 3 + PRN group (95% CI - 2.09 to - 0.83). The as-needed injection regimen is as effective as 3-monthly loading in terms of anatomical and functional improvement for BRVO, along with a lower treatment burden for patients and physicians.

Therapeutic Effects of Combination Therapy and Photobiomodulation Therapy on Retinal Regeneration

Introduction: Many systemic and ocular diseases cause macular edema (ME). Macular edema is seen in two primary forms; the first is diffuse thickening of the macula, and the other is a macula with a distinct petaloid (cloverleaf) appearance called cystoid macular edema. Macular edema has a known role in the reduction of visual equity, and many options have been proposed for the reversal of this condition. Methods: Articles on the effects of macular laser grid photocoagulation on diabetic macular edema (DME) or cystoid macular edema published between 2000 and 2022 were collected from PubMed, Google Scholar, and Web of Science. The following keywords were used for the search: "macular laser photocoagulation", "macular edema", "cystoid macular edema", "intravitreal pharmacotherapies", and "antivascular endothelial growth factor". Two hundred nineteen articles were found in google scholar and 165 articles in PubMed, and a total of 58 articles were included in the study after applying the exclusion criteria. Results: We investigated the effects of various lasers photocoagulation such as Focal and/or grid macular laser, subthreshold micropulse laser (SMPL), as well as intravitreal pharmacotherapies with triamcinolone acetonide, and fluocinolone, and extended released intraocular implants such as Ozurdex, Retisert, Iluvien, and anti-vascular endothelial growth factors such as bevacizumab (Avastin), Eyela, and Lucentis. Corticosteroids were more effective than lasers, although some researchers have found that lasers and combined lasers and corticosteroids are more effective. In addition, some studies have shown that the frequency and concentrations of intravitreal pharmacotherapies are effective in increasing visual outcomes. Conclusion: The results of the studies showed that the combined intravitreal corticosteroids are much more effective in improving visual acuity (VA) than a single corticosteroid, and the low concentration of the drug is safer. Still, corticosteroids have side effects such as increased intraocular pressure and glaucoma. Therefore, combining the medication with a laser is much more reasonable than each alone. Also, the subthreshold photocoagulation laser (670 nm) is better at reducing the central macular thickness (CMT) and improving VA than the micro pulse yellow laser and pan-retinal photocoagulation (PRP).

Efficacy of intravitreal ziv-aflibercept in patients with macular edema following retinal vein occlusion in Korle-Bu Teaching Hospital, Ghana: a retrospective case series

AIM

To evaluate the efficacy of ziv-aflibercept in Ghanaian patients with macular edema (ME) secondary to retinal vein occlusion (RVO).

METHODOLOGY

In this retrospective study, the medical records of patients with ME secondary to RVO who had been treated with intravitreal ziv-aflibercept (IVZ) (1.25 mg/0.05 ml), as part of routine clinical practice, on pro re nata basis with a minimum follow-up of 6 months were retrieved and analyzed. The main outcome measures are mean change in best-corrected visual acuity (BCVA) and central subfield foveal thickness (CSFT) measured on optical coherence tomography from baseline to 12 months post-IVZ, and ocular and systemic safety.

RESULTS

Forty-three eyes were included in this study. Their mean age was 62.8 ± 11.9 years, 67.4% had at least 12-month duration of follow-up, 50% had primary open-angle glaucoma and 38 (88.4%) eyes were treatment naive. There was significant improvement in mean BCVA in LogMAR at 1 month post-initiation of IVZ (0.8 ± 0.5 vs. 1.1 ± 0.6), and visual improvement was maintained up to 12 months (p < 0.001). Eyes with ME following BRVO had better mean BCVA at baseline and on subsequent visits compared to eyes with CRVO/HRVO (p = 0.01). There was significant reduction in mean CSFT up to 12 months post-IVZ injection compared to baseline (p < 0.001). Ocular complications observed were consistent with complications associated with RVO.

CONCLUSION

We have observed significant improvement in functional and anatomic outcomes 12 months post-initiation of IVZ. There is the need to confirm long-term efficacy and safety of IVZ in a large prospective study.

A systematic review of real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion

This review assessed the real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion (BRVO). A meta-analysis of 2530 eyes from 48 real-world studies of therapies for macular oedema secondary to BRVO was conducted. Baseline characteristics, visual, anatomical and safety outcomes were recorded. The weighted mean and weighted estimates from random-effects models were calculated for visual acuity (VA) and central subfield thickness (CST) changes at 6, 12 and 24 months. Primary outcome was change in VA (logMAR letters) at 12 months. Study quality was assessed using the quality appraisal checklist for case series developed by Institute of Health Economics. The mean baseline VA for the pooled data was 54.0 (51.5, 56.5) letters and the mean baseline CST was 501.3 (483.5, 519.1) µm. The random-effects estimate for mean (95% CI) change in VA was 14.6 (12.5, 16.7) letters at 12 months (n = 1727). The random-effects estimate for mean (95% CI) change in CST was -181.7 (-230.7, -132.7) µm at 12 months (n = 1325). The quality of studies varied considerably. Ocular and systemic adverse events were discussed in 79% and 42% of treatment arms respectively, with possible under-reporting. Visual and anatomical gains achieved in the real-world for anti-VEGF therapy were not as impressive as seminal RCTs, possibly due to reduced injection frequency in the real world and differences in baseline characteristics. There is an urgent need for consensus on the minimum efficacy, treatment burden and safety data to collect to strengthen the real-world evidence base.

Effects of Switching to Aflibercept in Treatment Resistant Macular Edema Secondary to Retinal Vein Occlusion

PURPOSE

The aim of this study was to examine 12-month outcomes of eyes switched from intravitreal ranibizumab or bevacizumab to aflibercept for cystoid macular edema due to retinal vein occlusion (RVO).

DESIGN

Retrospective, observation, case series.

METHODS

A retrospective study was performed assessing eyes with RVO switched to aflibercept for at least 12 months. To be included in the study, eyes had to have macular edema despite treatment for at least 6 months with bevacizumab and/or ranibizumab before the switch, central foveal thickness (CFT) ≥300 μm at time of switch, and visual acuity (VA) ≤60 early treatment of diabetic retinopathy score (ETDRS) letters (20/40 Snellen equivalent). Outcome measures included change in VA (in ETDRS letters), CFT, and interval between intravitreal injections.

RESULTS

27 eyes of 27 patients were included in the analysis: 13 with branch RVO, and 14 with central RVO. Mean VA before switch was 54.2 ± 23.7 letters (20/80 Snellen equivalent) and mean CFT was 460.4 ± 178.2 μm. Mean number of previous anti-vascular endothelial growth factor (VEGF) injections was 29.5 ± 19.2. At 12 months, mean VA improved by 8.7 ± 13.2 letters (P < 0.01) and mean CFT decreased by 180.9 ± 207.7 μm compared with baseline (P < 0.01). Mean injection interval increased by 1.6 ± 2.0 weeks to 6.9 ± 1.2 weeks, but this was not statistically significant (P = 0.18).

CONCLUSIONS

In our small retrospective study, eyes switched to intravitreal aflibercept for persistent cystoid macular edema (CME) due to RVO improved vision and macular thickness; however, larger prospective studies are required to validate our findings.

Bevacizumab versus ziv-aflibercept in branch retinal vein occlusion

Purpose:

To compare the effectiveness of treatment with intravitreal bevacizumab (IVB) and ziv-aflibercept (IVZ) in patients with macular edema (ME) post-branch retinal vein occlusion (BRVO).

Methods:

Patients with treatment naïve ME post-BRVO were included retrospectively if they received either IVB (0.05 ml/1.25 mg) or IVZ (0.05 ml/1.25 mg) monotherapy with a follow up of 12 months.

Results:

Thirty-two and 17 eyes received IVB and IVZ, respectively. The mean improvement in best corrected visual acuity (BCVA) was 0.36 ± 0.3 logarithm of minimum angle of resolution (logMAR) in the IVB group and 0.27 ± 0.3 in the IVZ group (P = 0.35). The mean change in central macular thickness was 178.9 ± 180.9 and 173.5 ± 344.4 μm in IVB and IVZ groups, respectively (P = 0.94). The mean number of injections was higher in the IVB group (4.0 ± 1.8) compared with 1.82 ± 0.8 in the IVZ group (P < 0.0001). The IVZ group had significantly fewer number of visits (P < 0.0001) and longer maximum treatment-free intervals (P = 0.0081).

Conclusion:

IVZ appears to be cost-effective with the similar visual outcome and less number of visits in comparison to IVB.

Current Outcomes of Anti-VEGF Therapy in the Treatment of Macular Oedema Secondary to Branch Retinal Vein Occlusions: A Meta-Analysis

PURPOSE

The current body of evidence on the efficacy and safety of anti-VEGFs for macular oedema secondary to branch retinal vein occlusion (BRVO) is steadily growing as large clinical trials and observational studies are continually completed. The aim of this meta-analysis is to analyse anatomical and functional outcomes in response to anti-VEGF therapy using evidence generated from a pooled analysis of current clinical trials and observational studies.

METHODS

The current meta-analysis includes treatment of BRVO with aflibercept, bevacizumab and ranibizumab from randomised controlled trials and observational studies. Inclusion criteria included peer-reviewed publications with at least a 12-month follow-up period. On literature review using multiple electronic databases (PubMed, Embase and Cochrane), 22 studies met the inclusion criteria. Baseline patient characteristics, study design, sample size and 12- and 24-month change in best corrected visual acuity (BCVA) and central foveal thickness (CFT) as measured on optical coherence tomography imaging were pooled in a meta-analysis. Data were then stratified by study design and anti-VEGF therapy in subgroup analyses.

RESULTS

A total of 1,236 eyes from 22 studies were included in this meta-analysis. Mean baseline BCVA ranged from 66 ETDRS letters (20/50 Snellen equivalent) to 35 letters (20/200 Snellen). Mean baseline CFT ranged from 406.0 to 681.0 µm. Anti-VEGF treatment demonstrated an overall mean improvement in BCVA at 12 months of 14 letters (95% CI 12.0 to 16.2, p < 0.001) and CFT reduction of 228 µm (95% CI -278.9 to -176.1, p < 0.001). The BCVA gains at 12 months were maintained to month 24 with a mean gain of 12.5 letters (95% CI 6.3 to 18.8, p < 0.001), as well as reduction of CFT of 238 µm (95% CI -336.0 to -140.2, p < 0.001). No cases of endophthalmitis or glaucoma were reported in any study.

CONCLUSION

This meta-analysis confirms the comparable safety and efficacy of anti-VEGF therapies for patients with cystoid macular oedema secondary to BRVO. There is a need for randomised prospective comparative trials of anti-VEGF agents for BRVO.

Anti-VEGF treatment of macular edema associated with retinal vein occlusion: patterns of use and effectiveness in clinical practice (ECHO study report 2)

Purpose

To evaluate the efficacy, safety, and injection frequency of vascular endothelial growth factor (VEGF) antagonists in the treatment of macular edema secondary to retinal vein occlusion (RVO) in clinical practice.

Patients and methods

A multicenter retrospective study of the medical records of 165 patients (95 branch RVO, 70 central RVO) treated with at least three anti-VEGF injections in the study eye was conducted. Available data collected for at least 6 months after the first injection included Snellen best-corrected visual acuity (BCVA), central retinal thickness (CRT) by time-domain optical coherence tomography (TD-OCT) or spectral-domain optical coherence tomography (SD-OCT), anti-VEGF injections, other treatments/procedures for RVO, and adverse events.

Results

At baseline prior to anti-VEGF treatment, mean BCVA was 20/80 Snellen equivalent and mean CRT was 499 μm. Mean number of anti-VEGF injections received was 7.1 during the first year, 5.4 during the second year, and 5.9 during the third year; 51.3% (842/1,641) of injections were ranibizumab, 44.1% (724/1,641) were bevacizumab, and 4.6% (75/1,641) were aflibercept. One in five patients received concomitant focal laser treatment. The percentage of patients achieving both BCVA of 20/40 or better and CRT ≤250 μm on TD-OCT or ≤300 μm on SD-OCT at the same visit (primary endpoint) was 26.1% (30/115) after the first anti-VEGF injection and ranged from 20.0% (7/35) to 36.7% (11/30) after the first 16 injections. After each anti-VEGF injection from the 1st to the 16th, <60% of patients achieved 20/40 or better BCVA and ≤70% of patients achieved CRT ≤250 μm on TD-OCT or ≤300 μm on SD-OCT. The most common treatment-related adverse event was blurry or cloudy vision.

Conclusion

In this real-world study, a mean of five to seven anti-VEGF injections was administered yearly, and the response to anti-VEGF therapy was suboptimal in many patients. Anti-VEGF therapy was well tolerated.

Update on the Use of Anti-VEGF Intravitreal Therapies for Retinal Vein Occlusions

The use of anti-vascular endothelial growth factor (VEGF) therapy in ophthalmology has profoundly changed our management and treatment of conditions such as cystoid macular edema, diabetic macular edema, choroidal neovascularization, and other proliferative retinopathies. Although initially used for the treatment of choroidal neovascularization in neovascular age-related macular degeneration, their application has spread rapidly for other indications as their outcomes have often outperformed previously existing treatments. Retinal vein occlusion (RVO) continues to be one of the leading causes of vision loss secondary to macular edema, in addition to macular ischemia and neovascularization in more severe cases. Before the availability of anti-VEGF therapy, the use of macular grid laser and panretinal photocoagulation was the mainstay of treatment of macular edema and neovascularization, respectively, in patients with RVOs. Two landmarks studies established the guidelines of these treatments for nearly a quarter century. Since the availability of anti-VEGF agents, there has been a paradigm shift in the treatment of RVO. Most importantly, there has also been a significant improvement in visual outcomes in these patients. The goal of this article is to provide a review of the pertinent clinical studies that have investigated the use of anti-VEGF in patients with retinal vein occlusions.

Prolongation of injection interval after switching therapy from ranibizumab to aflibercept in Japanese patients with macular edema secondary to branch retinal vein occlusion

PURPOSE

This study was conducted to investigate the outcome of switching therapy from ranibizumab to aflibercept in Japanese patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO) in daily practice.

MATERIALS AND METHODS

This retrospective study enrolled 15 eyes in 15 Japanese patients with ME secondary to BRVO who had been receiving a pro re nata regimen of ranibizumab and had provided written informed consent to switch to aflibercept therapy. The intravitreal injection interval, central retinal thickness, and visual acuity were evaluated before and after switching.

RESULTS

The mean period of ranibizumab treatment was 11.8±4.2 months. The mean observation period after switching to aflibercept was 10.6±3.4 months, and seven patients were observed for more than 12 months after switching. The mean intravitreal injection interval was prolonged by 23.6 days with aflibercept (68.2±26.4 days with ranibizumab vs 91.8±33.2 days with aflibercept; P=0.0011). The mean intravitreal injection interval just before the switch was 81.3±35.6 days and was significantly prolonged to 100.8±34.2 days just after the switch to aflibercept (P=0.0309). The mean central retinal thickness did not change before or after the switch to aflibercept (295±55 μm with ranibizumab vs 276±25 μm with aflibercept; P=0.12). The mean visual acuity also remained at an improved level after the switch. No systemic or ocular side effects were evident during the study period.

CONCLUSION

Switching therapy from ranibizumab to aflibercept in Japanese patients with ME secondary to BRVO prolonged the intravitreal injection interval without anatomical or functional degradation.