Intravitreal Bevacizumab Treatment for Macular Edema due to Branch Retinal Vein Occlusion in a Clinical Setting

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.

Real-World Outcomes of Anti-VEGF Treatment for Retinal Vein Occlusion in Portugal

PURPOSE

Retinal vein occlusion (RVO) is an important cause of visual disability in the modern world. We aim to evaluate the real-world outcomes of patients with RVO treated with anti-vascular endothelial growth factor (VEGF) in Portugal.

METHODS

We performed a retrospective, observational, multicenter study including 8 centers across Portugal and 200 patients treated with either ranibizumab or bevacizumab. Data were collected at 3 time points: time of diagnosis (0 time point) and 6 and 12 months after initiating treatment. Demographic and clinical data were collected.

RESULTS

Median visual acuity (VA) and central macular thickness (CMT) improved in the branch RVO (BRVO), central RVO (CRVO), bevacizumab, and ranibizumab groups at 6 and 12 months compared to baseline, with CMT improving further only in the CRVO and ranibizumab groups between 6 and 12 months (p = 0.002 and p = 0.001, respectively). The CMT was lower in the ranibizumab group compared to the bevacizumab group both at 6 and 12 months (p<0.02). Median CMT improved in both the good and poor baseline VA groups at 6 and 12 months compared to baseline (p<0.001). Median VA only improved for the group with poor baseline VA at 6 and 12 months of follow-up (p<0.001). Regression analysis identified several baseline variables as predictors of visual outcomes at 6 and 12 months, with different results depending on the analyzed group.

CONCLUSIONS

Both treatments were effective, although less effective than results reported in clinical trials. The morphologic response was better with ranibizumab compared to bevacizumab, although functionally there were no differences.

Comparison of Ranibizumab and Bevacizumab for Macular Edema Associated with Branch Retinal Vein Occlusion

PURPOSE

To assess the effectiveness and safety of intravitreal ranibizumab compared with bevacizumab for the treatment of macular edema associated with branch retinal vein occlusion (BRVO).

METHODS

This was a retrospective study of 80 eyes with macular edema associated with BRVO. Patients received either 0.5 mg of ranibizumab (n = 24) or 1.25 mg of bevacizumab (n = 56) intravitreally. Both groups received three initial monthly injections followed by as-needed injections. The best-corrected visual acuity, central subfield thickness, mean number of injections, and retreatment rate were evaluated monthly for 6 months after the initial injection.

RESULTS

The best-corrected visual acuity significantly improved from logarithm of the minimal angle of resolution (logMAR) 0.55 ± 0.26 at baseline to 0.24 ± 0.26 at 6 months in the ranibizumab group (p < 0.001) and from logMAR 0.58 ± 0.21 at baseline to 0.29 ± 0.25 at 6 months in the bevacizumab group (p < 0.001), which is not a statistically significant difference (p = 0.770). The mean reduction in central subfield thickness at 6 months was 236 ± 164 μm in the ranibizumab group (p < 0.001) and 219 ± 161 μm in the bevacizumab group (p < 0.001), which is not also a statistically significant difference (p = 0.698). The mean numbers of ranibizumab and bevacizumab injections were 3.25 ± 0.53 and 3.30 ± 0.53, respectively (p = 0.602). In addition, after the three initial monthly injections, the retreatment rates for ranibizumab and bevacizumab injections were 20.8% and 26.7%, respectively (p = 0.573).

CONCLUSIONS

Both ranibizumab and bevacizumab were effective for the treatment of BRVO and produced similar visual and anatomic outcomes. In addition, the mean number of injections and the retreatment rates were not significantly different between the groups.

Efficacy of intravitreal bevacizumab for macular edema following branch retinal vein occlusion stratified by baseline visual acuity

PURPOSE

To compare the clinical features and bevacizumab efficacy for macular edema (ME) following branch retinal vein occlusion (BRVO) stratified by baseline visual acuity.

METHODS

This retrospective study included a total 117 eyes from 117 consecutive patients with ME following BRVO, who received PRN intravitreal bevacizumab injection and were followed for more than 6 months. The eyes were categorized into three groups according to baseline best-corrected visual acuity (BCVA) (group A, BCVA <20/200; group B, BCVA ≥20/200 and ≤20/40; group C, BCVA >20/40). Baseline demographics, clinical features, BCVA, and central retinal thickness (CRT) at 1, 3, 6, and 12 months after injection and the number of injections were compared.

RESULTS

Groups A-C included 11, 83, and 23 eyes, respectively. The mean baseline CRT was thickest in group A (810.1, 580.8, and 473.5 μm in groups A-C, respectively; p < 0.001) and the percentage of eyes with macular ischemia increased in the worst BCVA group (45.5, 25.0, and 4.3 % in groups A-C, respectively; p = 0.005). The mean BCVA and CRT improved at 1, 3, 6, and 12 months after treatment compared to baseline values in all groups (all, p < 0.001). The number of injections for 6 months was greater in the worst BCVA group (3.2, 2.3, and 1.9 injections in groups A-C, respectively; p = 0.009).

CONCLUSION

In ME following BRVO, baseline visual acuity correlates with macular ischemia and baseline CRT. Intravitreal bevacizumab treatment results in significant anatomical and functional improvement regardless of baseline visual acuity.

Effects of two different doses of intravitreal bevacizumab on subfoveal choroidal thickness and retinal vessel diameter in branch retinal vein occlusion

AIM

To investigate the effects of two different doses of intravitreal bevacizumab on subfoveal choroidal thickness (SFChT) and retinal vessel diameter in patients with branch retinal vein occlusion.

METHODS

An interventional, restrospective study of 41 eyes of 41 patients who had completed 12mo of follow-up, divided into group 1 (1.25 mg of bevacizumab, 21 eyes of 21 patients) and group 2 (2.5 mg of bevacizumab, 20 eyes of 21 patients). Complete ophthalmic examination, fluorescein angiography, enhanced depth imaging optical coherence tomography and measurement of retinal vessel diameter with IVAN software were performed at baseline and follow-up.

RESULTS

The SFChT changed from 279.1 (165-431) µm at baseline to 277.0 (149-413) µm at 12mo in group 1 (P=0.086), and from 301.4 (212-483) µm to 300.3 (199-514) µm in group 2 (P=0.076). The central retinal arteriolar equivalent (CRAE) changed from 128.8±11.2 µm at baseline to 134.5±8.4 µm at 12mo in group 1, and from 134.6±9.0 µm to 131.4±12.7 µm in group 2 (P=0.767). The central retinal venular equivalent (CRVE) changed from 204.1±24.4 µm at baseline to 196.3±28.2 µm at 12mo in group 1, and from 205.8±16.3 µm to 194.8±18.2 µm in group 2 (P=0.019). The mean central macular thickness (P<0.05) and average best-corrected visual acuity (BCVA; P<0.05) improved in both groups.

CONCLUSION

Changes in the SFChT are not statistically significant and not different according to the doses of bevacizumab. The CRAE did not show significant change, however, the CRVE showed significant decrease regardless of the dose.

The effect of intravitreal bevacizumab on ocular blood flow in diabetic retinopathy and branch retinal vein occlusion as measured by laser speckle flowgraphy

Background

This study evaluated the effect of intravitreal injection of bevacizumab (IVB) on macular edema associated with diabetic retinopathy (DME) or branch retinal vein occlusion (BRVOME) using laser speckle flowgraphy.

Methods

A comparative interventional study of 25 eyes from 22 patients with macular edema (DME group: 12 eyes; BRVOME group: 13 eyes) who underwent IVB. Mean blur rate (MBR) was measured in the retinal artery, retinal vein, optic nerve head (ONH), and choroid before and after IVB.

Results

In the BRVOME group, there was no significant change in MBR in the retinal artery, retinal vein or ONH, but choroidal MBR decreased significantly (P=0.04). In the DME group, the MBR in the retinal artery, retinal vein, ONH, and choroid decreased significantly (P=0.02, P=0.04, P<0.001, and P=0.04, respectively). In the DME group, pre-IVB MBR in the ONH was significantly correlated with post-IVB foveal thickness (R= −0.71, P=0.002). There was no such correlation in the BRVOME group in the ONH.

Conclusion

IVB had a suppressive effect on circulation in eyes with DME but not in those with BRVOME. This suggests that this noninvasive and objective biomarker may be a useful part of pre-IVB evaluations and decision-making in DME.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Retreatment with Ozurdex for macular edema secondary to retinal vein occlusion

PURPOSE

To review the current practice of retreatment with Ozurdex injections in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), and to recommend simple guidelines for Ozurdex reinjection in management of RVO.

METHODS

This was a multicenter retrospective study of patients who received more than 2 Ozurdex injections for the treatment of ME in RVO. Recorded parameters included percent of patients with a 15-letter gain, visual acuity (VA) improvement from baseline, change in central macular thickness (CMT), time to reinjection, and occurrence of any complications.

RESULTS

A total of 128 patients were included, 58 (45.3%) with central RVO (CRVO) and 70 (54.7%) with branch RVO (BRVO). Mean interval for Ozurdex reinjection was 5.9 months following the first injection and 8.7 months following the second. A >15-letter gain in VA was observed in 34 (48.8%) patients with CRVO and 16 (28%) patients with BRVO. Mean overall VA improvement at month 6 did not show significance (p>0.05); however, a significantly better mean VA improvement was seen in treatment-naïve eyes (p<0.03). The CMT was significantly reduced compared to baseline. The mean CMT decreased by 214.6 µm in eyes with BRVO (n = 53) and by 355.1 µm in eyes with CRVO (n = 63) (p = 0.002). Complication rates were very low.

CONCLUSIONS

Repeated injections of Ozurdex are effective and have a favorable safety profile. In current practice, the retreatment interval with Ozurdex injections might be too long, precluding the full therapeutic potential of this treatment modality. A strategy for managing RVO patients treated with Ozurdex on an as-needed basis is provided.