Efficacy and safety of widely used treatments for macular oedema secondary to retinal vein occlusion: a systematic review

Focal Photocoagulation as an Adjunctive Therapy to Reduce the Burden of Intravitreal Injections in Macula Edema Patients, the LyoMAC2 Study

AIM

To assess the efficacy of focal photocoagulation of capillary macroaneurysms (CMA) to reduce the burden of intravitreal injections (IVI) in patients with macular edema (ME).

MATERIALS AND METHODS

Retrospective multicenter study in patients with diabetic ME or ME secondary to retinal vein occlusion (ME-RVO). CMA associated with ME were selectively photocoagulated. Patients were followed for one year after photocoagulation.

RESULTS

93 eyes of 76 patients were included in this study. At 6 months after the laser (n = 93), there was a significant decrease in mean macular thickness (from 354 µm to 314 µm, p < 0.001) and in mean IVI number (from 2.52 to 1.52 at 6 months, p < 0.001). The mean BCVA remained stable (0.32 and 0.31 logMAR at baseline and 6 months, p = 0.95). At 12 months (n = 81/93), there was a significant decrease in mean macular thickness (from 354 µm to 314 µm, p < 0.001) and in mean IVI number (from 4.44 to 2.95 at 12 months, p < 0.001), while the mean BCVA remained stable (0.32 and 0.30 logMAR at baseline and 12 months, p = 0.16).

CONCLUSION

Focal laser photocoagulation of CMA seems to be effective and safe for reducing the burden of IVI in patients with ME. Their screening during the follow-up should be considered closely.

Efficacy of single-dose intravitreal dexamethasone implantation for retinal vein occlusion patients with refractory macular edema: A systematic review and meta-analysis

Purpose: To assess the functional and anatomical consequences of single-dose dexamethasone (DEX) implants for the treatment of refractory macular edema (ME) secondary to retinal vein occlusion (RVO) after anti-vascular endothelial growth factor agents.

Methods: A literature search of studies on switching therapy to DEX implants from anti-VEGF agents in refractory RVO patients was performed with five electronic databases (PubMed, Embase, Web of Science, MEDLINE, and Cochrane Library) prior to January 2022. The main outcomes included best-corrected visual acuity (BCVA) and central macular thickness (CMT) changes at different follow-up endpoints from baseline. All analyses were performed using Stata version 15.0.

Results: The final analysis included four eligible studies with a total of 99 patients. After single-dose DEX implant application, BCVA improved significantly at 2, 3, and 6 months with an average gain of −0.23 logarithm of the minimum angle of resolution (logMAR) (p = 0.004), −0.20 logMAR (p = 0.027), and -0.09 logMAR (p = 0.021), respectively. Mean CMT reduction was also significant from baseline to 2 months (-241.89 μm, p &lt; 0.001), 3 months (−222.61 μm, p &lt; 0.001), and 6 months (−90.49 μm, p &lt; 0.001). No serious adverse events were observed in any of the included studies.

Conclusion: This meta-analysis showed that RVO patients with refractory ME could benefit significantly from switching therapy to DEX implantation, with efficacy lasting 6 months after a single-dose application. Intravitreal DEX implantation is a safe and effective option for refractory cases.

Role of the choroidal vascularity index in branch retinal vein occlusion (BRVO) with macular edema

Purpose

To assess choroidal vasculature changes in eyes with branch retinal vein occlusion (BRVO) and macular edema (ME) using the choroidal vascularity index (CVI) and evaluate the effectiveness of CVI as a prognostic biomarker.

Methods

35 patients with monocular BRVO and ME were analyzed retrospectively. Luminal and stromal areas in choroids of swept-source optical coherence tomography were calculated using the image binarization technique. The CVI was calculated as the ratio of the luminal to total choroidal area. The CVI of BRVO and ME eyes were compared with that of the unaffected fellow and post anti-vascular endothelial growth factor (VEGF) injected eyes. A regression analysis was performed on the choroidal parameters, logMAR visual acuity (VA) two years post disease onset and central macula thickness (CMT).

Results

The CVI of BRVO and ME eyes was significantly lower than the fellow and post-injected eyes (p<0.05). The regression analysis showed a strong association between two years after logMAR VA and the CVI of fellow eyes (R² = 0.433, p<0.001). Remarkable correlations were observed in the CVI and subfoveal choroidal thickness of BRVO and ME eyes (R² = 0.189, 0.155, respectively, p<0.05). The CMT of diseased eyes were also significantly associated with the CVI of unaffected fellow eyes (R² = 0.113, p<0.05).

Conclusions

The alteration of CVI in BRVO and ME suggests that choroidal vasculature might be affected by extracellular fluid shift and VEGF changes. The fellow eye CVI could be a useful supplementary prognostic biomarker.

Comparison of the effects of aflibercept and dexamethasone in central retinal vein occlusion with serous retinal detachment

Clinical relevance: Previous studies have shown the efficacy of aflibercept and dexamethasone in central retinal vein occlusion. However, the efficacy of these two drugs in central retinal vein occlusion accompanied by serous macular detachment has not been investigated and compared. This results in a search for more precise data to evaluate the effects of two drugs in real-world studies.Background: The aim of this study is to compare the efficacy of intravitreal aflibercept and dexamethasone implantation injections in central retinal vein occlusion accompanied by serous retinal detachment.Methods: Sixty-eight eyes of 68 patients with treatment-naive macular oedema post-central retinal vein occlusion were enrolled in the retrospectively designed study. All of the patients had serous retinal detachment at baseline. The patients received three intravitreal aflibercept injections with an interval of four weeks and followed by pro re nata treatment protocol (intravitreal aflibercept group, n = 37) or a single dose dexamethasone implantation injection (dexamethasone implantation group, n = 31). Best-corrected visual acuity, central retinal thickness and the height of serous retinal detachment parameters were compared at baseline, and in the first, second, third and sixth months.Results: The groups were similar in terms of baseline characteristics (p > 0.05 for all). The visual gain was greater in the intravitreal aflibercept group (p = 0.013). While the intravitreal aflibercept group had a significant central retinal thickness decrease in the first and sixth months (p = 0.011 and p = 0.001, respectively), this superiority was not observed during the entire follow-up period (p = 0.212). There was no difference in serous retinal detachment resolution between the groups (p = 0.403). Two patients in the intravitreal aflibercept group (5.4%) and five patients in the dexamethasone implantation group (16.1%) had serous retinal detachment at the final visit (p = 0.158).Conclusion: Both intravitreal aflibercept and dexamethasone implantation injections seemed to be effective in the treatment of central retinal vein occlusion with serous retinal detachment. Intravitreal aflibercept treatment yielded better results in terms of visual gain and showed a faster anatomical response.

Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT

BACKGROUND

Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period.

OBJECTIVE

The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion.

DESIGN

This was a three-arm, double-masked, randomised controlled non-inferiority trial.

SETTING

The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018.

PARTICIPANTS

A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial.

INTERVENTIONS

The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154).

MAIN OUTCOME MEASURES

The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years.

RESULTS

The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year.

LIMITATIONS

The comparison of aflibercept and bevacizumab was a post hoc analysis.

CONCLUSION

The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered.

FUTURE WORK

To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13623634.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.

Cost-effectiveness analysis of ranibizumab for retinal vein occlusion patients in China from the societal perspective

BACKGROUND

Clinical trials in China have demonstrated that ranibizumab can improve the clinical outcomes of branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). However, no economic evaluation of ranibizumab has been conducted among Chinese patient population.

METHODS

To provide insights into the economic profile of ranibizumab among Chinese RVO population, a Markov state-transition model was used to predict the outcomes of ranibizumab comparing to laser photocoagulation and observational-only care from the societal perspective. This model simulated changes in patient visuality, quality-adjusted of life years (QALY), medical costs, and direct non-medical costs of individuals with visual impairment due to BRVO or CRVO in lifetime. The base-case analysis used an annual discount rate of 5% for costs and benefits following the China Guidelines for Pharmacoeconomic Evaluations. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model.

RESULTS

The base-case incremental cost-effectiveness ratio (ICER) comparing ranibizumab to laser photocoagulation was ¥65,008/QALY among BRVO patients and was ¥65,815/QALY among CRVO patients, respectively. Comparing to the 2019 gross domestic product (GDP) per capita of ¥71,000, both two ICERs were far below the cost-effective threshold at three times of GDP per capita (¥213,000). The deterministic and probabilistic sensitivity analyses demonstrated the base-case results were robust in most of the simulation scenarios.

CONCLUSION

The current Markov model demonstrated that ranibizumab may be cost-effective compared with laser photocoagulation to treat BRVO and cost-effective compared to observation-only care to treat CRVO in China from the societal perspective.

Non-dipping pattern of nocturnal blood pressure as a risk factor for macular ischemia in branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is ocular vascular disease affecting approximately 14 million people worldwide, and is closely associated with high blood pressure (BP). Although macular ischemia is a critical factor in the visual prognosis of BRVO, the relationship between macular ischemia and different patterns of nocturnal BP is unknown. Here, we investigated whether a dipping pattern of nocturnal BP is associated with the development of macular ischemia in patients with BRVO. A total of 273 patients were reviewed; of these, 86 (86 eyes) patients were included. All recruited patients had a macular thickness map by optical coherence tomography and underwent 24-h ambulatory BP monitoring. According to their dipping patterns, the participants were divided into dipper and non-dipper groups. The non-dipper group had worse visual outcomes at the initial and 6-month visits (P = 0.014 and P = 0.003, respectively). Five of 32 eyes (15.6%) in the dipper group and 32 of 54 (59.3%) in the non-dipper group had macular ischemia. In a multivariate analysis, the night-to-day systolic BP ratio was associated with the degree of macular ischemia (β = − 0.313, P = 0.004). Thus, a non-dipping pattern may be a risk factor for macular ischemia in patients with BRVO.

Evaluation of Microvascular Structure Changes after Conbercept Treatment on Macular Edema Secondary to Retinal Vein Occlusion

Aims

To confirm the therapeutic efficacy of conbercept for the treatment of macular edema (ME) secondary to retinal vein occlusion (RVO) by using optical coherence tomography angiography (OCTA) and to find out the differences in therapeutic efficacy between ischemic and nonischemic retinal vein occlusion (iRVO or non-iRVO) after conbercept treatment.

Methods

In this prospective, randomized, and comparative study, 60 unilateral eyes suffered from RVO combined with macular edema were included and fellow eye as controls. After an initial intravitreal injection of conbercept (IVIC), a pro re nata (PRN) strategy was adopted, and the follow-up time was 6 months. The foveal avascular zone (FAZ), vascular density of superficial capillary plexus (SCP), and vascular density of deep retinal capillary plexus (DCP), nonperfused areas (NPAs) were evaluated with OCTA on baseline and after treatment.

Results

The mean intravitreal injection number was 2.9 ± 0.89 times during six months in iRVO patients and 2.1 ± 0.86 times in non-iRVO patients, with statistically significant difference (p < 0.05). On baseline, central macular thickness (CMT) and FAZ were significantly thickened and enlarged compared to those of healthy fellow eyes; the vascular density of SCP and DCP were significantly decreased, and the differences were statistically significant (p < 0.05). Compared to baseline, after treatment, the best-corrected visual acuity (BCVA) was improved in either iRVO or non-iRVO (−0.601 ± 0.387, −0.241 ± 0.341 logMAR, p < 0.05). In iRVO, the improvement was more substantial than that of the non-iRVO group. FAZ in the non-iRVO group had significantly decreased compared to that in iRVO group (−0.044 ± 0.040 versus 0.014 ± 0.043 mm², p < 0.05). CMT, the vascular density of SCP, and DCP had no significant difference.

Conclusions

The changes of microvascular structure can be quantitatively evaluated by using OCTA for the patients with RVO. Conbercept had a significant effect on treatment of RVO with macular edema. A more profound effect was achieved in the iRVO group on visual improvement and FAZ reduction in the non-iRVO group after conbercept treatment.

A systematic review and meta-analysis to compare the efficacy of conbercept with ranibizumab in patients with macular edema secondary to retinal vein occlusion

BACKGROUND

The objective of this review and meta-analysis is to investigate the efficacy of conbercept and ranibizumab, combined with or without laser photocoagulation, in patients with macular edema secondary to retinal vein occlusion (RVO-ME).

METHODS

Several databases have been used to identify relevant publications. After screening, a meta-analysis was conducted to compare conbercept and ranibizumab with the support of RevMan 5.3 (Cochrane Library Software, Oxford, UK).

RESULTS

In this study, 9 randomized controlled trials and 6 retrospective trials were included with a total of 1180 patients. No significant difference was found in best corrected visual acuity (BCVA) or central macular thickness (CMT) in the baseline parameters [BCVA (weighted mean difference (WMD): -0.01; 95% confidence interval CI: -0.03 to 0.01; P = .17), CMT (WMD: 20.14; 95% CI: -26.70 to 66.97; P = .40). No significant differences were found in the improvements of BCVA and adverse events (AEs) between the 2 groups after injection of loading dosage [the 1st month BCVA (WMD: -0.01; 95% CI: -0.04 to 0.02; P = .54),the 3rd month BCVA (WMD: -0.02; 95% CI: --0.05 to 0.01; P = .23), the 6th month BCVA (WMD: -0.02; 95% CI: -0.05 to 0.01; P = .27), AEs (odds ratio: 0.84; 95% CI: 0.38 to 1.84; P = .66)]. However, there were significant differences between conbercept and ranibizumab treatment in terms of CMT [1st month CMT (WMD: -11.70; 95% CI: -19.71 to -3.68; P < .01), 3rd month CMT (WMD: -10.08; 95% CI: -15.62 to -4.53; P < .01), 6th month CMT (WMD: -15.83; 95% CI: -22.88 to -8.78; P < .01)] and the number of injections (WMD, -0.36; 95% CI: -0.68 to -0.04; P = .03).

CONCLUSION

The current pooled evidence suggested that both therapies of intravitreal conbercept and intravitreal ranibizumab with or without laser photocoagulation are effective in vision function in RVO-ME patients, and confirmed that conbercept has advantages over ranibizumab in terms of CMT and the number of injections for treating RVO-ME. In addition, conbercept has the statistically same visual gains and safety as ranibizumab in RVO-ME patients. Longer-term follow-up surveys on the safety and effectiveness of these 2 treatment regimens are required.

Use of Anti-VEGF Drugs in Retinal Vein Occlusions

Retinal vein occlusion (RVO) is one of the most prevalent causes of visual loss in the Western World. Its pathogenesis is still not completely known. Chronic macular edema and ischemia compromise the functional and anatomical status of the retina. Antivascular endothelial growth factor (anti-VEGF) injections have demonstrated better results than other previous options, including observation or laser therapy. This narrative review aims to analyze the current aspects related to these drugs.

Comparison of Ranibizumab versus Aflibercept in Treating Macular Edema among Patients with Serous Retinal Detachment Secondary to Branch Retinal Vein Occlusion

Purpose: To compare the effectiveness of ranibizumab and aflibercept in macular edema (ME) with serous retinal detachment (SRD) following branch retinal vein occlusion (BRVO).Methods: Once every month for 3 months, 33 patients were treated with ranibizumab (Group 1), whereas 30 others were treated with aflibercept (Group 2). In 9 months after that, patients were evaluated every 4 weeks and received additional injections if they met prespecified criteria for retreatment. Corrected visual acuity (BCVA), central foveal thickness (CFT), and height of SRD was measured.Results: During the first 3 months, the improvement of CFT, BCVA, and height of SRD were greater in Group 2 than Group 1. Those differences disappeared in the subsequent 9 months, and changes in CFT, BCVA, and height of SRD were similar between groups at all other visits.Conclusion: Aflibercept was more effective than ranibizumab from baseline to Month 3 in ME with SRD following BRVO.

Assessment of Patient Pain Experience During Intravitreal Ranibizumab and Aflibercept Injection

PURPOSE:

The aim of this study was to compare the pain scores of the patients during intravitreal injection of ranibizumab and aflibercept based on patient feedback.

MATERIALS AND METHODS:

Seventy-two eyes of 72 patients, who had not previously undergone any intravitreal injection procedures, were included in this study. Thirty-eight patients received ranibizumab, and 34 patients received aflibercept injections. The pain was measured by visual analog scale (VAS). Patients were asked to rate their pain experienced during the injection between 0 (no pain) and 10 (worst pain ever felt) on VAS just after the injection.

RESULTS:

VAS pain scores in ranibizumab and aflibercept groups were 3.28 ± 2.45 and 4.20 ± 2.30, respectively. There was a significant difference in average VAS pain scores between groups (P = 0.04).

CONCLUSION:

VAS pain scores in aflibercept group were found to be significantly higher than the scores in the ranibizumab group.

Efficacy and Safety of Ranibizumab in Asian Patients with Branch Retinal Vein Occlusion: Results from the Randomized BLOSSOM Study

PURPOSE

To assess the efficacy and safety profile of intravitreal ranibizumab 0.5 mg in Asian patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO).

DESIGN

A 12-month, phase III, double-masked study.

PARTICIPANTS

A total of 283 patients with BRVO.

METHODS

Patients aged ≥18 years were randomized (2:1) to receive ranibizumab 0.5 mg or sham. The ranibizumab group received a minimum of 3 monthly intravitreal injections until stable maximal visual acuity (VA) was achieved followed by an individualized VA stabilization criteria-driven pro re nata (PRN) regimen. Patients in the sham group received sham injections up to month 5 and could receive ranibizumab 0.5 mg PRN from month 6.

MAIN OUTCOME MEASURES

Mean average change in best-corrected VA (BCVA) from baseline to month 1 through month 6 and safety up to month 12.

RESULTS

At baseline, patients' mean (standard deviation [SD]) BCVA and central subfield thickness (CSFT) were 57.4 (11.7) letters and 525 (193.4) μm, respectively. Compared with sham, ranibizumab treatment resulted in superior VA gains. The least squares (LS) mean average change in BCVA from baseline to month 1 to month 6 in ranibizumab and sham groups was +12.5 and +5.0 letters, respectively (LS mean difference between ranibizumab vs. sham: +7.5 letters [95% confidence interval, 5.5-9.5], 1-sided P < 0.001). The LS mean change from baseline at month 12 in the ranibizumab versus sham groups in BCVA was +16.4 (14.9-17.8) versus +11.4 (9.3-13.5) letters and in CSFT was -280.0 (-291.6 to -268.4) versus -269.7 (-286.2 to -253.1) μm. The mean (SD) number of injections over 12 months was 7.0 (2.55) in the ranibizumab group and 3.6 (1.60) in the sham with ranibizumab group. No new safety findings were reported.

CONCLUSIONS

In Asian patients with BRVO, individualized PRN ranibizumab treatment was statistically superior to sham at month 6 and led to early visual gains that were maintained up to 12 months. Results from the sham group indicate the importance of early treatment in achieving optimal visual outcomes in BRVO. The safety of ranibizumab in this study was consistent with the well-established safety profile of ranibizumab.

Changes in Peripapillary Microvasculature and Retinal Thickness in the Fellow Eyes of Patients With Unilateral Retinal Vein Occlusion: An OCTA Study

Purpose

To evaluate changes in peripapillary microvascular parameters in the fellow eyes of patients with unilateral retinal vein occlusion (RVO) using optical coherence tomography angiography (OCTA) and to determine the relationships between peripapillary microvasculature and retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GC-IPL) thickness.

Methods

Eighty-three patients with unilateral RVO (50 patients with branch RVO and 33 with central RVO) and 83 normal controls were enrolled. OCTA (Cirrus HD-OCT 5000 with AngioPlex) 6 × 6-mm scans centered on the optic disc were acquired. Peripapillary vessel density (VD) and perfusion density (PD) were automatically calculated.

Results

The average RNFL and GC-IPL thicknesses in the fellow eyes of RVO patients were significantly thinner than in normal controls (93.5 vs. 96.6 μm, P = 0.013 and 81.3 vs. 84.1 μm, P = 0.003, respectively). In the fellow eyes of patients with unilateral RVO, the peripapillary VD of the inner ring, outer ring, and full area (17.47, 18.50, and 17.89, respectively) were significantly lower than those of controls (17.87, 18.87, and 18.27, respectively). The peripapillary PD of the inner ring, outer ring, and full area (0.456, 0.467, and 0.456, respectively) were also significantly lower than those of controls (0.468, 0.476, and 0.466, respectively). RNFL and GC-IPL thicknesses were correlated with both peripapillary VD and PD.

Conclusions

OCTA revealed that peripapillary microvascular parameters in the fellow eyes of patients with unilateral RVO were decreased, and GC-IPL and RNFL thinning were also observed. The RNFL and GC-IPL thicknesses were positively correlated with both peripapillary VD and PD.

Quantitative measurement of vascular density and flow using optical coherence tomography angiography (OCTA) in patients with central retinal vein occlusion: Can OCTA help in distinguishing ischemic from non-ischemic type?

Background

To evaluate microvascular changes and quantitative parameters in patients with central retinal vein occlusion (CRVO) by using optical coherence tomography angiography (OCTA) and finding difference between presumably ischemic and non ischemic CRVO.

Methods

Patients with CRVO (31) and healthy control (20) were enrolled in this observational case control study. The OCTA was done for each patient and control subject. In macular area 2 images were taken for each eye (3 × 3 mm and 8 × 8 mm). The images were analyzed at three capillary plexuses (superficial and deep retinal capillary layers and choriocapillaris layer).

Results

Thirty-one patients with CRVO (mean age 60.00 ± 13.72 years) and 20 healthy age/gender matched subjects (mean age 54.10 ± 12.33 years) were enrolled in this study (p = 0.095). The mean visual acuity of patients was 0.47 ± 0.54 LogMAR. Eyes with CRVO as compared with fellow eyes and control group showed significant reduction of flow in superficial (1.171 ± 0.262 vs. 1.362 ± 0.285 vs. 1.453 ± 0.105) and deep capillary plexus (1.042 ± 0.402 vs. 1.331 ± 0.315 vs. 1.526 ± 0.123) and choriocapillaris (1.206 ± 0.543 vs. 1.841 ± 0.308 vs. 1.966 ± 0.05) and vascular density in superficial (45.92 ± 4.2 vs. 50.99 ± 4.35 vs. 52.85 ± 2.99) and deep (48.03 ± 4.71 vs. 55.86 ± 3.81 vs. 58.2 ± 2.65) capillary plexuses. Some parameters (flow of both retinal capillary plexuses and parafoveal vascular density in deep plexus) showed significantly reduction in fellow eyes than control group. The parameters including flow [superficial (1.014 ± 0.264 vs. 1.279 ± 0.19) and deep (0.873 ± 0.442 vs. 1.152 ± 0.32) capillary plexuses and choriocapillaris (0.79 ± 0.327 vs. 1.424 ± 0.51)] and vascular density [superficial (44.24 ± 2.13 vs. 46.58 ± 4.13) and deep (45.28 ± 3.5 vs. 49.32 ± 3.94) capillary plexuses] were lower significantly in ischemic type than non ischemic CRVO. The most damaged parameter was flow in deep capillary plexus. The model with smallest Akaike information criterion and Bayesian information criterion was chosen as the best model. For easier calculation, we also calculated the reduced model. By choosing the threshold of 12.6, the formula [3.9 × F_1S + 0.8 × F_3S] can diagnose the presumably ischemic CRVO from non ischemic type with AUC of 0.84, sensitivity of 100% and specificity of 69%. (F_1S: flow in the central 1 mm-radius-circle of superficial plexus and F_3S: flow in the central 3 mm-radius-circle of superficial plexus).

Conclusion and relevance

In CRVO patients, the OCTA can accurately evaluate changes in microvascular structures. It may help in differentiation ischemic CRVO from non-ischemic CRVO.

Effect of intravitreal ranibizumab on serous retinal detachment in branch retinal vein occlusion

Purpose

The aim of this study was to evaluate the effect of initial intravitreal ranibizumab injection on visual acuity (VA) and central macular thickness (CMT) for the treatment of macular edema (ME) with and without serous retinal detachment (SRD) secondary to branch retinal vein occlusion (BRVO).

Materials and methods

Fifty-two BRVO eyes, treated with intravitreal ranibizumab injection for ME with and without SRD, were retrospectively reviewed. Patients were divided into two groups according to spectral domain optical coherence tomography (SD-OCT). The efficacy of intravitreal ranibizumab injection at first month was assessed by analyzing the change in best-corrected VA and reduction in CMT with SD-OCT.

Results

There were 21 patients with SRD and 31 patients with only CME (no-SRD). CMT was significantly greater in the SRD group than in the CME group (451±62.2 µm vs 383.5±37.2 µm, respectively, P<0.05). After initial intravitreal ranibizumab injection, mean VA improved from 0.87±0.26 logarithm of the minimum angle of resolution (LogMAR) to 0.54±0.27 LogMAR (P<0.01) and CMT decreased from 451±62.2 µm to 379.3±58.6 µm (P<0.001) in the SRD group. In the no-SRD group, mean VA improved from 0.69±0.25 LogMAR to 0.44±0.25 LogMAR (P<0.001) and the CMT decreased from 383.5±37.2 µm to 337.7±39.4 µm (P<0.001) at the first month visit. Eyes with SRD revealed better anatomic results and greater reduction of CMT after intravitreal ranibizumab injection (P<0.01).

Conclusion

VA and CMT can be improved by intravitreal ranibizumab injection in BRVO patients with and without SRD. However, more marked improvement in macular morphology was achieved in patients with SRD than those without SRD.

Predicting the visual acuity for retinal vein occlusion after ranibizumab therapy with an original ranking for macular microstructure

The study investigated predictive factors for best-corrected visual acuity (BCVA) after ranibizumab treatment in patients with macular edema (ME) associated with retinal vein occlusion (RVO) with an original ranking for the impairment of macular microstructure. In this retrospective study, 31 eyes of 31 patients with RVO received 3 monthly consecutive ranibizumab injections and another 3 months of follow-up. An original method was applied to rank the impairment of the external limiting membrane (ELM) and the ellipsoid zone (previously called the photoreceptor inner and outer segment junction, IS/OS) integrity on the baseline optical coherence tomography (OCT) images. Univariate and multivariate linear regression analyses were performed to assess the association between the baseline factors and post-treatment BCVA. ELM integrity and baseline BCVA were shown to be independent factors in the prediction of post-treatment BCVA. Comparison of post-treatment BCVA between original ELM ranks after adjusting for the baseline BCVA revealed the ELM integrity beneath the center of the fovea was important to post-treatment BCVA. ELM integrity in particular beneath the center of the fovea and baseline BCVA may be more useful than other factors in the prediction of visual function in patients with ME secondary to RVO after ranibizumab injections.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.

Comparison between "early" or "late" intravitreal injection of dexamethasone implant in branch (BRVO) or central (CRVO) retinal vein occlusion: six-months follow-up

AIM

The aim of this study was to compare early and late injections of intravitreal dexamethasone implant in patients affected by central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with a six-months follow-up. We assessed whether an earlier treatment start (within seven days from diagnosis) could be more beneficial than a delayed (or late) treatment start (after seven days).

MATERIALS AND METHODS

The study included 81 patients (81 eyes) affected by retinal vein occlusion. Best corrected visual acuity was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS) while central macular thickness (CMT) was measured by spectral-domain optical coherence tomography.

RESULTS

Both types of patients had a positive therapeutic response to dexamethasone, with an increase in visual acuity (ETDRS) and CMT reduction. CRVO patients were characterized by lower ETDRS values at baseline and at the end of the follow-up as compared to BRVO. CRVO patients showed higher CMT values at baseline, after three and six months from injection. No significant differences in therapeutic response to dexamethasone were observed between patients treated early or late, regardless of RVO type.

CONCLUSIONS

This study demonstrates that the therapeutic properties of dexamethasone implant are not significantly influenced by an early or late treatment start in patients affected by BRVO and CRVO, although its therapeutic efficacy seems greater in the former type.

Treatment patterns of ranibizumab intravitreal injection and dexamethasone intravitreal implant for retinal vein occlusion in the USA

Purpose

Ranibizumab, an anti-vascular endothelial growth factor, and dexamethasone, a corticosteroid, have been shown to be effective in treating macular oedema secondary to retinal vein occlusion (RVO) (central RVO (CRVO) and branch RVO (BRVO)). Their real-world usage, however, has yet to be compared. We therefore evaluated ophthalmology visits for both drugs using US patient-level data.

Methods

The IMS Health Real-World Data Medical Claims database was used to identify treatment-naive patients receiving ranibizumab intravitreal injections or dexamethasone intravitreal implants between June 2010 and February 2014 who had 12 months of follow-up data. The primary outcome measure was the mean number of all ophthalmology visits for the two drugs in patients with CRVO and BRVO. Secondary outcome measures included a comparison of treatment visits, non-treatment visits, and time intervals between visits.

Results

Overall, 2822 patients received ranibizumab injections (CRVO, 1178; BRVO, 1644) and 365 received dexamethasone implants (CRVO, 191; BRVO, 174). The mean number (SD) of all ophthalmology visits was higher for patients receiving ranibizumab injections than for those receiving dexamethasone implants (CRVO: 7.2 (3.6) vs 6.2 (3.1), P<0.001; BRVO: 7.1 (3.4) vs 6.3 (3.1), P=0.016).

Conclusions

Patients with RVO receiving ranibizumab injections had a mean of approximately one more visit to their ophthalmologist in the first 12 months of treatment than those treated with dexamethasone implants. The visit burden is therefore not substantially different and physicians should focus on the clinical benefits of these drugs when evaluating treatment options for RVO.

Intravitreal Diclofenac in the Treatment of Macular Edema Due to Branch Retinal Vein Occlusion

BACKGROUND AND OBJECTIVE

To evaluate the effect of a single dose of intravitreal diclofenac on macular edema (ME) due to branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS

In this prospective, interventional case series, 15 eyes with BRVO and ME with central macular thickness (CMT) greater than 250 µm on spectral-domain optical coherence tomography (SD-OCT) were enrolled. All patients were given 0.05 mg/0.1 mL of intravitreal diclofenac under aseptic conditions and followed up for 3 months with respect to best-corrected visual acuity (BCVA), intraocular pressure (IOP), fundus fluorescein angiography, and CMT measured on OCT.

RESULTS

The mean visual acuity improved from 0.115 ± 0.03 preoperatively to 0.356 ± 0.29 at 3 months (P = .002). Mean line improvement was 2.2 ± 1.6. Mean preoperative CMT decreased from 453.2 µm ± 55.3 µm to 340.47 µm ± 101 µm at 3 months postoperatively (P = .001). The mean preoperative IOP was 16.4 mm Hg ± 1.59 mm Hg, whereas the mean postoperative IOP was 16.6 mm Hg ± 1.58 mm Hg (P = .08). None of the 12 phakic eyes showed evidence of cataract progression.

CONCLUSION

Intravitreal diclofenac is safe and effective in improving BCVA and decreasing CMT in patients with BRVO and ME.

Indocyanine-green-guided targeted laser photocoagulation of capillary macroaneurysms in macular oedema: a pilot study

AIMS

In longstanding diabetic macular oedema (DME) or retinal vein occlusion (RVO), capillary macroaneurysms may develop. Indocyanine green angiography (ICGA) has been shown to optimise their detection. Here, we report the anatomical and functional outcome of the elective photocoagulation of capillary macroaneurysms.

METHODS

A retrospective, interventional, two-centre study. In eyes with chronic macular oedema and severe hard exsudates due to diabetic retinopathy or RVO, the presence of capillary macroaneurysms (defined by a diameter larger than 150 µm) was assessed by ICGA and optical coherence tomography (OCT). Capillary macroaneurysms were selectively photocoagulated, the presence of photothrombosis within the lumen being assessed by immediate OCT.

RESULTS

Four eyes from three patients with DME and five eyes from five patients with RVO were included. The median duration of visual loss was 4 years. Median initial visual acuity (VA) was 20/200. The median number of capillary macroaneurysms per eye was 2 (range, 1-8) and their median size was 410 µm (range, 154-603). Six months after photocoagulation, there was a significant reduction in macular thickness (mean±SD, 528 µm±200 vs 271 µm±152, p<0.05) and improvement of VA (mean log MAR, 0.82 vs 0.58, p<0.05).

CONCLUSIONS

During macular oedema with severe hard exsudates due to DME or RVO, systematic detection of capillary macroaneurysms by ICGA followed by their OCT-controlled photocoagulation may be of interest. These results may contribute to re-evaluate the role of photocoagulation in the management of longstanding macular oedema.

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.

"Off-label" use of intravitreal bevacizumab in non-ischemic macular edema secondary to retinal vein obstructions

OBJECTIVE

To evaluate the safety and efficacy of intravitreal Bevacizumab in treatment of non-ischemic macular edema secondary to retinal vein obstruction (RVO).

MATERIALS AND METHODS

A 2-year-retrospective study was performed on 26 patients hospitalized for non-ischemic macular edema secondary to RVO. All the patients underwent a complete ophthalmologic exam, with best corrected visual acuity (BCVA) testing, fundus photography, fluorescein angiography (FA) and macular thickness measurement by optical coherence tomography (OCT). Reevaluation was performed monthly for VA, OCT, and ophthalmoscopy and, at every 3 months, by FA. A standard protocol of 0.05 ml intravitreal Bevacizumab injection was applied. Further administrations were performed according to clinical evolution.

RESULTS

The medium follow-up period was of 9,7 months (6-20 months). There were no significant complications following the procedure. The number of intravitreal Bevacizumab injections varied from 2-5/ patient. All the patients experienced an improvement in VA and a significant regression of macular edema. The smallest number of intravitreal Bevacizumab injections and the best visual prognosis were observed in cases with branch retinal vein obstruction (BRVO) and early presentation (p<0.05).

CONCLUSIONS

As a pathogenic therapy, intravitreal Bevacizumab is a safe, repeatable procedure and it may be considered an effective and lasting treatment for non-ischemic macular edema secondary to RVO. Intravitreal Bevacizumab should be included in the therapeutic protocol of RVO, both for early and delayed presentations. Abbreviations: RVO = retinal vein obstruction, BRVO = branch retinal vein obstruction, CRVO = central retinal branch obstruction, BCVA = best corrected visual acuity, FA = fluorescein angiography, OCT = optical coherence tomography.

Clinical Trials in Branch Retinal Vein Occlusion

Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disorder. The management of macular edema has changed considerably over time. The laser is considered the gold standard treatment for over two decades. However, visual recovery with laser is usually slow and incomplete. The advent of intravitreal agents, specifically anti-vascular endothelial growth factors (VEGF) have heralded a new era which promises rapid recovery of vision and quality of vision. Randomized clinical trials have reported optimal results with anti-VEGF agents (ranibizumab, bevacizumab, and aflibercept) compared to laser therapy or steroids. However, nearly 50% of the patients require repeat intravitreal anti-VEGF therapy up to 4 years after initiating therapy to sustain the visual gains. The adverse events (systemic and ocular) of these agents are minimal. Monotherapy with anti-VEGF agents have been found to provide better results than any combination with laser. This review article summarizes evidence from randomized controlled trials evaluating treatment options for the treatment of macular edema secondary to BRVO with a special focus on anti-VEGF therapy.

Severe Ocular Inflammation Following Ranibizumab or Aflibercept Injections for Age-Related Macular Degeneration: A Retrospective Claims Database Analysis

Purpose: Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents including ranibizumab and aflibercept are used to treat patients with ocular disorders such as neovascular age-related macular degeneration (nAMD); however, the injections are associated with rare instances of severe ocular inflammation. This study compared severe ocular inflammation rates in patients treated with ranibizumab versus aflibercept.

Methods: United States physician-level claims data covering an 18-month period for each therapy were analyzed. The primary analysis compared severe ocular inflammation event rates per 1000 injections. Sensitivity and subgroup analyses evaluated the impact of factors including intraocular surgery, intravitreal antibiotic administration, and previous intravitreal injections.

Results: The analysis included 432,794 injection claims (ranibizumab n = 253,647, aflibercept n = 179,147); significantly, more unique severe ocular inflammation events occurred in patients receiving aflibercept than ranibizumab (1.06/1000 injections, 95% confidence interval [CI], 0.91–1.21, vs. 0.64/1000 injections, 95% CI 0.54–0.74; p < 0.0001). Comparable results were observed for analyses of patients who had undergone glaucoma or cataract surgeries, had antibiotic-associated endophthalmitis, had non-antibiotic-associated endophthalmitis, and were non-treatment-naive. In contrast, no significant differences in severe ocular inflammation claims were recorded in treatment-naive patients who had no record of anti-VEGF treatment in the 6 months preceding the index claim. No significant change occurred in the rate of severe ocular inflammation claims over time following ranibizumab treatment.

Conclusions: Severe ocular inflammation was more frequent following intravitreal injection with aflibercept than with ranibizumab during routine clinical use in patients with nAMD. This highlights the importance of real-world, post-approval, observational monitoring of novel medicines, and may aid clinical decision-making, including choice of anti-VEGF agent.

Association of familial macular degeneration with specific genetic markers: a case report

INTRODUCTION

Age-related macular degeneration is a serious visual disorder of the central retina and was recently reported to be associated with genetic background. Here we describe a genetic link to early onset age-related macular degeneration in members of an Asian family.

CASE PRESENTATION

A 73-year-old Asian woman developed age-related macular degeneration in the fifth decade of her life and her 49-year-old daughter developed age-related macular degeneration. Because of the family history and the early onset, family members were tested for two single nucleotide polymorphism variants (rs10490924 and rs11200638) at a recently identified susceptibility locus for age-related macular degeneration. Both alleles in the 73-year-old woman were of the high-risk variants (T/T for rs10490924 and A/A for rs11200638), and her two daughters and a grandson each carried the risk variants (T and A) one on each allele.

CONCLUSIONS

In a case where multiple family members had early onset age-related macular degeneration, we found two high-risk single nucleotide polymorphism variants in the age-related macular degeneration susceptibility locus, suggesting the combination of the known single nucleotide polymorphism variants as a potent age-related macular degeneration diagnostic indicator.

Comparative efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion: a network meta-analysis

OBJECTIVE

To compare the efficacy and safety of approved treatments for macular oedema secondary to branch retinal vein occlusion (BRVO).

DESIGN

Randomised controlled trials (RCTs) evaluating the efficacy and safety of approved treatments for macular oedema secondary to BRVO were identified from an updated systematic review.

SETTING

A Bayesian network meta-analysis of RCTs of treatments for macular oedema secondary to BRVO.

INTERVENTIONS

Ranibizumab 0.5 mg pro re nata, aflibercept 2 mg monthly (2q4), dexamethasone 0.7 mg implant, laser photocoagulation, ranibizumab+laser, or sham intervention. Bevacizumab and triamcinolone were excluded.

OUTCOME MEASURES

Efficacy outcomes were mean change in best corrected visual acuity (Early Treatment Diabetic Retinopathy Study scale) and the percentage of patients gaining ≥ 15 letters. Safety outcome was the percentage of patients with increased intraocular pressure (IOP)/ocular hypertension (OH).

RESULTS

8 RCTs were identified for inclusion with 1743 adult patients. The probability of being the most efficacious treatment at month 6 or 12 based on letters gained was 54% for ranibizumab monotherapy, 30% for aflibercept, 16% for ranibizumab plus laser (adjunctive or prompt), and 0% for dexamethasone implant, laser or sham. The probability of being the most efficacious treatment for patients gaining ≥ 15 letters was 39% for aflibercept, 35% for ranibizumab monotherapy, 24% for ranibizumab plus laser, 2% for dexamethasone implant, and less than 1% for laser or sham. There was no statistical difference between ranibizumab monotherapy and aflibercept for letters gained (+1.4 letters for ranibizumab vs aflibercept with 95% credible interval (CrI) of -5.2 to +8.5 letters) or the OR for gaining ≥ 15 letters: 1.06 (95% CrI 0.16 to 8.94)). Dexamethasone implant was associated with significantly higher IOP/OH than antivascular endothelial growth factor agents (OR 13.1 (95% CrI 1.7 to 116.9)).

CONCLUSIONS

There was no statistically significant difference between ranibizumab and aflibercept.

Sustained-release fluocinolone acetonide intravitreal insert for macular edema: clinical pharmacology and safety evaluation

INTRODUCTION

Inflammation plays a key role in the pathological processes leading to macular edema. Sustained release, low-dose intraocular corticosteroid delivery devices provide long-term anti-inflammatory therapy. Recently, a novel fluocinolone acetonide intravitreal insert (FAi, Iluvien), has been introduced with promising long-term results in the treatment of macular edema.

AREAS COVERED

An extensive review of the literature in the English language was performed to provide comprehensive information on the pharmacological properties of FAi and its safety and efficacy data from various multi-center randomized clinical trials.

EXPERT OPINION

The FAc, Retisert is a sustained-release device that is surgically implanted in the vitreous and has been approved by the US FDA for the treatment of non-infectious intermediate, posterior or panuveitis. FAi was developed after FAc and is an intravitreal corticosteroid delivery system that allows controlled release of therapeutic levels of fluocinolone acetonide (FA). Initial efficacy and safety data suggest that this delivery system maintains clinical effectiveness for up to 3 years after a single delivery of the device. This second-generation fluocinolone delivery device has shown superior safety results in clinical trials compared to the previous version of the higher dose FAc (0.59 mg). Sustained delivery preparations may help to reduce the treatment burden and its associated risks by decreasing the frequency of intravitreal injections. However, much needs to be learnt from additional clinical trials, post-marketing surveillance and results of extension studies. Concerns of intravitreal corticosteroids, such as cataract and increase in intraocular pressure, remain major challenges for this therapeutic strategy.

Macular grid laser photocoagulation for branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is the second most common cause of retinal vascular abnormality after diabetic retinopathy. Persistent macular oedema develops in 60% of eyes with a BRVO. Untreated, only 14% of eyes with chronic macular oedema will have a visual acuity (VA) of 20/40 or better. Macular grid laser photocoagulation is used for chronic non-ischaemic macular oedema following BRVO and has been the mainstay of treatment for over 20 years. New treatments are available and a systematic review is necessary to ensure that the most up-to-date evidence is considered objectively.

OBJECTIVES

To examine the effects of macular grid laser photocoagulation in the treatment of macular oedema following BRVO.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, EMBASE, Web of Science Conference Proceedings Citation Index, the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 August 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing macular grid laser photocoagulation treatment to another treatment, sham treatment or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five studies conducted in Europe and North America. Four separate trials compared grid laser to no treatment, sham treatment, intravitreal bevacizumab and intravitreal triamcinolone. One further trial compared subthreshold to threshold laser. Two of these trials were judged to be at high risk of bias in one or more domains.In one trial of grid laser versus observation, people receiving grid laser were more likely to gain visual acuity (VA) (10 or more ETDRS letters) at 36 months (RR 1.75, 95% confidence interval (CI) 1.08 to 2.84, 78 participants, moderate-quality evidence). The effect of grid laser on loss of VA (10 or more letters) was uncertain as the results were imprecise (RR 0.68, 95% CI 0.23 to 2.04, 78 participants, moderate-quality evidence). On average, people receiving grid laser had better improvement in VA (mean difference (MD) 0.11 logMAR, 95% CI 0.05 to 0.17, high-quality evidence). In a trial of early and delayed grid laser treatment versus sham laser (n = 108, data available for 99 participants), no participant gained or lost VA (15 or more ETDRS letters). At 12 months, there was no evidence for a difference in change in VA (from baseline) between early grid laser and sham laser (MD -0.03 logMAR, 95% confidence interval (CI) -0.07 to 0.01, 68 participants, low-quality evidence) or between delayed grid laser and sham laser (MD 0.00, 95% CI -0.04 to 0.04, 66 participants, low-quality evidence).The relative effects of subthreshold and threshold laser were uncertain. In one trial, the RR for gain of VA (15 or more letters) at 12 months was 1.68 (95% CI 0.57 to 4.95, 36 participants, moderate-quality evidence); the RR for loss of VA (15 or more letters) was 0.56 (95% CI 0.06 to 5.63, moderate-quality evidence); and at 24 months the change in VA from baseline was MD 0.07 (95% CI -0.10 to 0.24, moderate-quality evidence).The relative effects of macular grid laser and intravitreal bevacizumab were uncertain. In one trial, the RR for gain of 15 or more letters at 12 months was 0.67 (95% CI 0.39 to 1.14, 30 participants, low-quality evidence). Loss of 15 or more letters was not reported. Change in VA at 12 months was MD 0.11 logMAR (95% CI -0.36 to 0.14, low-quality evidence).The relative effects of grid laser and 1mg triamcinolone were uncertain at 12 months. RR for gain of VA (15 or more letters) was 1.13 (95% CI 0.75 to 1.71, 1 RCT, 242 participants, moderate-quality evidence); RR for loss of VA (15 or more letters) was 1.20 (95% CI 0.63 to 2.27, moderate-quality evidence); MD for change in VA was -0.03 letters (95% CI -0.12 to 0.06, moderate-quality evidence). Similar results were seen for the comparison with 4mg triamcinolone. Beyond 12 months, the visual outcomes were in favour of grid laser at 24 months and 36 months with people in the macular grid group gaining more VA.Four studies reported on adverse effects. Laser photocoagulation appeared to be well tolerated in the studies. One participant (out of 71) suffered a perforation of Bruch's membrane, but this did not affect visual acuity.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from one RCT supports the use of grid laser photocoagulation to treat macular oedema following BRVO. There was insufficient evidence to support the use of early grid laser or subthreshold laser. There was insufficient evidence to show a benefit of intravitreal triamcinolone or anti-vascular endothelial growth factor (VEGF) over macular grid laser photocoagulation in BRVO. With recent interest in the use of intravitreal anti-VEGF or steroid therapy, assessment of treatment efficacy (change in visual acuity and foveal or central macular thickness using optical coherence tomography (OCT)) and the number of treatments needed for maintenance and long-term safety will be important for future studies.

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.

A United Kingdom-based economic evaluation of ranibizumab for patients with retinal vein occlusion (RVO)

OBJECTIVE

This study compares the cost-effectiveness of intravitreal ranibizumab vs observation and/or laser photocoagulation for treatment of macular edema secondary to retinal vein occlusion in a UK-based model.

METHODS

A Markov model was constructed using transition probabilities and frequency of adverse events derived using data from the BRAVO, CRUISE, and HORIZON trials. Outcomes associated with treatments and health states were combined to predict overall health costs and outcomes for cohorts treated with each option.

RESULTS

In branch retinal vein occlusion, ranibizumab produced a gain of 0.518 quality-adjusted life years at an incremental cost of £8141, compared with laser photocoagulation. The incremental cost-effectiveness ratio was £15,710 per quality-adjusted life year, and the incremental cost per month free from blindness was £658. In central retinal vein occlusion, ranibizumab produced a gain of 0.539 quality-adjusted life years at an incremental cost of £9216, compared with observation only. The incremental cost-effectiveness ratio was £17,103, and the incremental cost per month free from blindness was £423.

CONCLUSIONS

These incremental cost-effectiveness ratios are below the £20,000-30,000 range typically accepted as a threshold for cost-effectiveness. This suggests that ranibizumab may be regarded as a cost-effective therapy for patients with macular edema secondary to retinal vein occlusion, relative to grid laser photocoagulation (for BRVO) and observation (for CRVO). Limitations include sparse data for utilities associated with the severity of visual impairment in the WSE in patients with RVO. A lack of direct comparative evidence between ranibizumab and the dexamethasone intravitreal implant for the treatment of BRVO and CRVO and the infeasibility of an indirect comparison due to significant heterogeneity in trial designs prevented the inclusion of this treatment as a comparator in the Markov model.

Treatment of systemic hypertension is important for improvement of macular edema associated with retinal vein occlusion

Background

We report our findings in three cases of unilateral macular edema associated with retinal vein occlusion (RVO) that improved after successful treatment of systemic hypertension alone.

Methods

All three cases had systemic hypertension but no diabetes mellitus or other ocular diseases associated with macular edema. All patients were treated only with medication for systemic hypertension. Optical coherence tomography was performed to determine the foveal thickness before and after treatment.

Results

Case one was a 72-year-old woman with a central RVO who had macular edema in her left eye and a visual acuity (VA) of 20/50. Her blood pressure (BP) was 169/96 mmHg. One month after the initiation of a calcium blocker to treat her systemic hypertension, her BP was decreased, macular edema was reduced, and her VA improved to 20/20. Case two was a 62-year-old woman with branch RVO. Her VA was 20/40 and her BP was 165/97 mmHg. Six weeks after initiation of medication to treat her systemic hypertension, her RVO-related macular edema had decreased and her VA improved to 20/20. Case three was a 71-year-old man with branch RVO. His VA was 20/50 and his BP was 165/87 mmHg. One month after initiation of treatment for systemic hypertension, his RVO-related macular edema had disappeared and his VA improved to 20/20. All three cases had nonischemic RVO by fluorescein angiography, and they did not develop ischemic changes for at least 1 year.

Conclusion

The reduction of macular edema following a decrease in the systemic hypertension suggests that the edema was most likely caused by leakage of fluids from the blood vessels. We recommend that the blood pressure should be measured in all patients with macular edema before initiating intravitreal anti-VEGF therapy.