Direct photocoagulation to leakage points to treat chronic macular edema associated with branch retinal vein occlusion: a pilot study

MACULAR SENSITIVITY CHANGE AFTER COMPLEMENTARY LASER THERAPY AFTER RANIBIZUMAB INTRAVITREAL INJECTION IN BRANCH RETINAL VEIN OCCLUSION

PURPOSE

We examined the effect of ranibizumab with or without laser photocoagulation on retinal sensitivity in eyes with branch retinal vein occlusion.

METHODS

Prospective randomized control study. Thirty patients with branch retinal vein occlusion received intravitreal injection of ranibizumab in a monthly pro re nata regimen. Fifteen patients received ranibizumab monotherapy alone (monotherapy group). The remaining 15 patients received rescue laser therapy at 3 or 9 months (combined group). The retinal sensitivity was measured at 32 points within central 8°, and the average of the main occlusion side among the 16 upper or 16 lower points was defined as the affected area sensitivity.

RESULTS

In comparing the monotherapy group and the combined group, the number of injections during the 12 months was 5.4 versus 4.9, the change in retinal thickness ( µ m) was -254 versus -197, the ETDRS letters of improvement was +18.3 versus +19.6, and the change in the affected area sensitivity (dB) was +7.1 versus +4.6. At 12 months, all these results were significantly improved compared with their respective baselines, but none of the differences between the two groups reached statistical significance.

CONCLUSION

Retinal sensitivity at 12 months improved in both the monotherapy group and the combined group. The additional laser did not reduce the number of injections or further improve visual acuity nor did it affect retinal sensitivity.

Improving blood flow in occluded veins to reduce anti-vascular endothelial growth factor injections for branch retinal vein occlusion

Purpose

To assess the relationship between improving blood flow via arteriovenous (AV) sheathotomy without vitrectomy and the total number of anti-vascular endothelial growth factor injections (VEGF) required to treat branch retinal vein occlusion (BRVO).

Methods

In this prospective, clinical case series, 16 eyes of 16 patients at the Toho University Sakura Medical Center with best-corrected visual acuity (BCVA) of 20/40 or worse due to macular edema associated with BRVO were analyzed for 12 months. AV sheathotomy was performed without vitrectomy for all cases. On the second day after surgery, anti-VEGF was injected into the operated eye. During the 12-month follow-up after surgery, pro re nata injections were administered when changes in foveal exudation and BCVA were evident. The blood flow of the occluded vein was assessed before and after AV sheathotomy during the operation using laser speckle flowgraphy. The total number of anti-VEGF injections, central retinal thickness (CRT), and BCVA 12 months after surgery were examined.

Results

The changes in CRT and BCVA from baseline to month 12 were statistically significant (P < 0.01). No additional anti-VEGF injections were required for nine of 16 eyes (56.3%) during the 12 months. The total number of anti-VEGF injections for 12 months correlated with the change rate of blood flow in an occluded vein before and after AV sheathotomy (r = -2.816, P = 0.022).

Conclusions and Importance

Improved blood flow in occluded vein may reduce the need for anti-VEGF injections in BRVO.

Healing rate of macular edema secondary to branch retinal vein occlusion in two years after initiation of intravitreal ranibizumab later combined with other treatment as needed and characteristics of refractory cases

PURPOSE

To investigate the 2-year healing rate of macular edema (ME) secondary to branch retinal vein occlusion (BRVO) treated initially with intravitreal ranibizumab (IVR) and later combined with other treatment as needed, and the characteristics of refractory cases.

METHODS

130 patients (130 eyes) with BRVO-ME who received IVR initially were studied. Anti-vascular endothelial growth factor drug was additionally administered when ME relapsed or persisted. Photocoagulation was performed when the non-perfusion area (NPA) was ≥5 disc diameter (DD), and/or when ME relapsed due to microaneurysm. Patients were classified into a healed group [ME resolved in <2 years or mild ME remained without best-corrected visual acuity (BCVA) loss for ≥6 months] or refractory group (ME persisted for ≥2 years).

RESULTS

110 eyes were classified into the healed group, and 20 eyes into the refractory group. The healed group and refractory group had, respectively, mean follow-up periods of 21.2 and 37.4 months, and frequencies of NPA ≥5 DD of 55.5 and 25.0% (p = 0.015). In the healed group, mean BCVA (logMAR) improved significantly compared to baseline in all the periods until 24 months after treatment initiation and at the last visit (p<0.001). In the refractory group, mean BCVA improved significantly compared to baseline until 12 months after treatment initiation (p<0.05 for all periods), but was not significantly different at 18 or 24 months or at the last visit.

CONCLUSION

In patients with BRVO-ME treated initially with IVR and later given additional treatments as needed, the healing rate was 84.6%. In eyes that healed within 2 years, BCVA improved relative to baseline throughout 24 months and at the last visit. In refractory eyes, BCVA improved only until 12 months, and thereafter deteriorated to baseline level at the last examination.

Direct Photocoagulation for Treating Microaneurysms with Hyperreflective Ring in Eyes with Refractory Macular Edema Associated with Branch Retinal Vein Occlusion

Microaneurysms (MAs) with hyperreflective rings are sometimes detected in eyes with refractory macular edema (ME) associated with branch retinal vein occlusion (BRVO) for more than 12 months after onset when examined using optical coherence tomography (OCT). We proposed that these MAs could result in refractory ME secondary to BRVO and hypothesized that OCT-guided direct photocoagulation of MAs could result in a reduction in refractory ME. Eleven eyes (from eleven different patients) with refractory ME associated with BRVO for more than 12 months following initial treatment were included. The mean number of MAs in each eye at baseline was 3.5 ± 2.0 (range, 1–8). The mean central subfield thickness, central macular volume, and parafoveal macular volume significantly decreased 6 months following initial direct photocoagulation when compared with those at baseline (baseline = 378.7 ± 61.8 μm, post-treatment = 304.2 ± 66.7 μm, p = 0.0005; baseline = 0.3 ± 0.049 mm³, post-treatment = 0.24 ± 0.053 mm³, p = 0.001; and baseline = 2.5 ± 0.14 mm³, post-treatment = 2.28 ± 0.15 mm³, p = 0.001, respectively). Moreover, the mean best-corrected visual acuity significantly improved 6 months following initial direct photocoagulation when compared with that at baseline (baseline = 0.096 ± 0.2 logarithm of the minimum angle of resolution (logMAR), post-treatment = 0.0077 ± 0.14 logMAR, p = 0.031). Direct photocoagulation could be suggested as a treatment option for refractory ME associated with BRVO in MAs with a hyperreflective ring on OCT.

Efficacy of Modified Treat-and-Extend Regimen of Aflibercept for Macular Edema from Branch Retinal Vein Occlusion: 2-Year Prospective Study Outcomes

This study aimed to evaluate the long-term (24-month) efficacy and safety of a modified treat-and-extend (mTAE) regimen of aflibercept for macular edema (ME) due to branch retinal vein occlusion (BRVO). This was a prospective multicenter intervention study. We evaluated 50 eyes in 50 patients with ME due to BRVO enrolled between October 2016 and September 2017. The patients received intravitreal aflibercept (IVA) injections according to a mTAE regimen for 24 months. This study reports the secondary endpoints of best-corrected visual acuity (BCVA) and central subfield thickness (CST) at 24 months and compares them with previously reported primary endpoints. Compared with baseline BCVA and CST of 0.33 (0.27) and 488 (165) µm (mean (standard deviation)), respectively, BCVA and CST were significantly improved at 12 and 24 months (12 months: 0.059 (0.19) LogMAR and 299 (112) µm; 24 months: 0.034 (0.18) LogMAR and 272 (81) µm, respectively; both p < 0.0001). Over the 24-month period, the mean number of IVA injections and clinic visits was 7.4 (3.3) and 11.1 (2.0), respectively. The mTAE regimen of IVA injections for ME due to BRVO was effective for improving BCVA and reducing CST over 24 months. This regimen shows promise for reducing the number of injections and clinic visits.

Morphologic Classifications and Locations of Microaneurysms and Clinical Relevance in Branch Retinal Vein Occlusion

Purpose

To classify microaneurysms (MAs) and investigate the relationships with retinal edema in eyes with branch retinal vein occlusion (BRVO).

Study Design

Retrospective, observational, consecutive case series.

Methods

Eyes with MAs due to BRVO that underwent optical coherence tomography angiography (OCTA) were enrolled. MAs on OCTA images were morphologically classified into six types: focal bulge, saccular, fusiform, mixed (saccular/fusiform), pedunculated, and irregular. The frequency, size, location, and relationships with retinal edema also were investigated.

Results

Twenty-four eyes of 23 patients (12 men, 11 women; mean age, 68.0 years) were enrolled. A total of 244 MAs were detected on the OCTA images. The focal bulge and saccular types accounted for over 70% of all MAs. Smaller MAs such as the focal bulge or saccular type also were detected both at the edge of the nonperfused areas (NPAs) and in collateral vessels. In contrast, larger MAs such as the pedunculated or irregular types tended to form at the edges of the NPAs. Older age, the presence of MAs in the collateral vessels, and the absence of pedunculated type were independent predictive factors for retinal edema but not the MA size, or presence in the retinal deep capillary plexus. After treatment, the mean retinal thickness decreased significantly, but the mean MA size remained unchanged.

Conclusion

OCTA enables morphologic classification, three-dimensional analysis, and investigation of the longitudinal changes of MAs with noninvasive volumetric quantification, leading to a better understanding of the pathology of MAs in eyes with BRVO.

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.

Microaneurysms cause refractory macular edema in branch retinal vein occlusion

Intravitreal anti-vascular endothelial growth factor (VEGF) agents can treat macular edema (ME) in branch retinal vein occlusion (BRVO). However, refractory ME, the mechanism of which is not well elucidated, occurs frequently. Sixty-six eyes with ME secondary to BRVO were enrolled in this retrospective observational case-control study. Twenty eyes received a sub-Tenon’s capsule injection of triamcinolone acetonide (STTA), 22 eyes an intravitreal anti-VEGF injection (ranibizumab), 16 eyes were switched from STTA to ranibizumab, 4 eyes underwent vitrectomy, and 4 eyes were untreated. Multiple regression analysis and multivariate logistic regression analysis were conducted, respectively, to identify independent predictors of visual acuity (VA) prognosis and risk factors for refractory ME longer than 1 year. The mechanism of refractory ME and therapeutic approaches for identified risk factors also were investigated. Thirty-four (52%) eyes had refractory ME for over 1 year. Microaneurysms were identified as risk factors for refractory ME, leading to poor final VA. Ranibizumab suppressed microaneurysm formation and refractory ME, with early administration more effective. For already formed microaneurysms, laser photocoagulation reduced additional treatments. Microaneurysms may cause refractory ME in BRVO. Alternative therapy to suppress microaneurysms should be considered to prevent refractory ME in patients with BRVO.