The Effect of Intravitreal Anti-VEGF on the Pigment Epithelial Detachment in Eyes with the Exudative Type of Age-Related Macular Degeneration

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

Comparison of the effects of anti-vascular endothelial growth factor treatments on pigment epithelial detachment in age-related macular degeneration

PURPOSE

The aim of this study is to compare structural and visual outcomes of naive neovascular age-related macular degeneration patients with significant pigment epithelial detachment (PED), treated with ranibizumab and aflibercept.

METHODS

This was a retrospective case series that included 33 naive patients treated with ranibizumab and 25 with aflibercept. The patients were followed with pro re nata (PRN) after first three intravitreal injections. LogMAR visual acuity, PED height and radius on spectral domain optical coherence tomography findings were compared.

RESULTS

Baseline mean PED height was 270.39 ± 114.14 µm and 315.24 ± 115.8 µm (p = 0.14); baseline mean PED radius was 2063.64 ± 942.75 µm and 1958.88 ± 452.22 µm (p = 0.61); and baseline BCVA was 1.16 ± 0.73 and 1.09 ± 0.69 (p = 0.73), for ranibizumab, and aflibercept group, respectively. In aflibercept group, there was statistically significant decrease in PED height at first, third and 12th months. In PED radius, decrease was greater in aflibercept group, however not significant. In addition, in aflibercept group visual acuity was better at all three months; however, none of them were significant.

CONCLUSION

Although the maximum improvement was seen at third month, final visual acuity and parameters of PED were better in aflibercept group. The efficacy of the both drug to choroidal neovascularization was known; however, in cases with significant PED, aflibercept can be consider for the first-level treatment.

Influence of pigment epithelial detachment on visual acuity in neovascular age-related macular degeneration

Pigment epithelial detachment (PED), the anatomical separation of the retinal pigment epithelium from the Bruch membrane, is common in many chorioretinal diseases, including neovascular age-related macular degeneration. PED is present in about 30% to 80% of neovascular age-related macular degeneration patients based on the CATT, EXCITE, and VIEW studies. The influence of PED on visual acuity is controversial as a result of inconsistent results reported by various studies. With advances in imaging technologies, it is possible to evaluate not only the presence or absence of PED, but also detailed quantitative parameters, such as height, width, greatest linear diameter, area, volume, and reflectivity within the PED. We performed a comprehensive literature review to evaluate the relationship of PED with visual acuity. In summary, the presence or persistence of a PED may still be compatible with relatively good visual acuity. There is no strong evidence that the presence of a PED or aspects of its morphology has a significant impact on visual acuity. The presence of a PED may be predictive of the need for more regular treatment. More well-designed studies with standardized PED definitions and classifications are needed to evaluate the relationship between PED and visual acuity.

OPTIMAL MANAGEMENT OF PIGMENT EPITHELIAL DETACHMENTS IN EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

A comprehensive literature search suggests that anti–vascular endothelial growth factor therapy is effective in treating eyes with pigment epithelial detachment due to neovascular age-related macular degeneration. This therapy should focus primarily on vision gains because there is no apparent correlation between anatomical and functional improvement in most eyes with pigment epithelial detachment and neovascular age-related macular degeneration.

Purpose:

This review aimed to determine the optimal management of retinal pigment epithelial detachments (PEDs) in neovascular age-related macular degeneration (nAMD) based on review of available evidence in the literature.

Methods:

A comprehensive literature review evaluates previous retrospective and prospective studies that assessed the treatment of PEDs in nAMD.

Results:

Studies illustrated that anti–vascular endothelial growth factor (VEGF) therapy can be effective in eyes with PED secondary to nAMD. Similar visual outcomes are associated with different anti-VEGF treatments. Higher anti-VEGF doses may improve anatomical response, without correlation with vision improvement. Fibrovascular PEDs may be difficult to treat, but even these eyes can gain vision with anti-VEGF therapy. A retinal pigment epithelial tear may develop in 15% to 20% of eyes with PEDs after anti-VEGF therapy, especially in PEDs greater than 500 µm to 600 µm in height; however, vision may stabilize with continued therapy. Atrophy may complicate eyes with PED and nAMD after anti-VEGF therapy, especially in association with complete PED resolution.

Conclusion:

Available literature suggests that anti-VEGF therapy is safe and efficacious for PED and nAMD. Treatment should focus on vision gains rather than PED resolution because there is no apparent correlation between anatomical and functional improvement in most eyes with PED and nAMD.

Priority options of anti-vascular endothelial growth factor agents in wet age-related macular degeneration under the National Health Insurance Program

BACKGROUND

Age-related macular degeneration (AMD) is a leading cause of blindness worldwide, for which intravitreal injection of anti-vascular endothelial growth factor (VEGF) is the primary treatment option. The purpose of the current study was to investigate the prioritization of anti-VEGF agents for wet AMD under the National Health Insurance (NHI) Program, and their clinical outcomes.

METHODS

Patients who were diagnosed with active choroidal neovascularization caused by AMD, and who met the criteria for reimbursement for anti-VEGF therapy by the NHI program in Taiwan between August 1, 2014 and May 31, 2015, were included in the study. Factors potentially influencing the choice of treatment agent were analyzed, and clinical outcomes were compared between the two different agents and their protocols.

RESULTS

A total of 166 treatment applications in 166 eyes from 159 patients were enrolled in the study. Age, laterality, presence of retinal pigment epithelial detachment, history of hypertension, coronary artery disease, and cerebral vascular accidents were significantly associated with the selection of the anti-VEGF agent. Treatment patterns and clinical outcomes were similar between the patients treated with ranibizumab and those treated with aflibercept. Significantly fewer injections were given during the follow-up period in those treated with aflibercept.

CONCLUSION

Under the restrictive insurance program in Taiwan, more patients and ophthalmologists chose to treat wet AMD using aflibercept. However, in clinical practice, no significant differences in efficacy or clinical outcomes were found between the patients treated with ranibizumab and those treated with aflibercept.

FLATTENING OF A TREATMENT-RESISTANT RETINAL PIGMENT EPITHELIAL DETACHMENT AFTER A SINGLE INTRAVITREAL INJECTION OF ZIV-AFLIBERCEPT

PURPOSE

To report flattening of a treatment-resistant retinal pigment epithelial detachment (PED) due to neovascular age-related macular degeneration after a single intravitreal injection of ziv-aflibercept (Zaltrap).

METHODS

A 67-year-old woman with a neovascular age-related macular degeneration-related PED was treated with intravitreal injections of bevacizumab and ranibizumab, and in combination with verteporfin photodynamic therapy, before receiving a single intravitreal injection of ziv-aflibercept (1.25 mg/0.05 mL).

RESULTS

The patient presented with a visual acuity of 20/30 in the right eye, a PED height of 581 μm, and a central macular thickness of 381 μm. She received eight intravitreal injections of bevacizumab and ranibizumab, one in combination with photodynamic therapy. The height of the PED and the central macular thickness varied over time, but 3 years later, they measured 382 μm and 418 μm, respectively. A single intravitreal injection of ziv-aflibercept resulted in a dramatic reduction in PED height to 140 μm, which was maintained 2 months later. The visual acuity remained stable, and there were no clinical signs of toxicity.

CONCLUSION

Intravitreal ziv-aflibercept safely and effectively improved a treatment-resistant PED. Intravitreal ziv-aflibercept could become a treatment option for neovascular age-related macular degeneration in countries where aflibercept (Eylea) is not available or its cost is prohibitive, but further studies are necessary to establish efficacy and safety.

Long-Term Results of Pro Re Nata Regimen of Aflibercept Treatment in Persistent Neovascular Age-Related Macular Degeneration

PURPOSE

To determine the 24-month results of patients who had pro re nata (PRN) aflibercept treatment owing to recurrent or resistant neovascular macular degeneration.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Eighty-one eyes of 78 patients with resistant or multiple recurrences of intraretinal or subretinal fluid while receiving monthly bevacizumab or ranibizumab injections and were switched to strict, as-needed aflibercept treatment with every-8-weeks spectral-domain optical coherence tomography (SDOCT)-guided monitoring were included. If there was a persistence of fluid despite this treatment, more frequent aflibercept injections were considered. Anatomic outcomes including maximum retinal thickness, central macular thickness, maximum pigment epithelial detachment height, maximum fluid height, and visual acuity (VA) were assessed at given follow-ups.

RESULTS

All anatomic endpoints significantly improved following 3 consecutive aflibercept injections, which were maintained through 24 months (P < .05 for all endpoints at all visits). Thirty-seven eyes (45.6%) required more frequent injections with monthly SDOCT-guided monitoring at a median of 37 weeks (interquartile range, 30-62 weeks) to adequately treat the retinal fluid. Seventy-one of 81 eyes (87.7%) became completely dry on at least 1 follow-up visit; however, there was no significant improvement in VA during the study period.

CONCLUSION

Aflibercept injection with an as-needed regimen was effective in many eyes previously treated with monthly bevacizumab or ranibizumab injections that had persistent or recurrent fluid. Despite significant improvement in anatomic outcomes, vision remained stable throughout the 2-year follow-up, likely because this cohort of patients had advanced choroidal neovascular membrane upon enrollment (recurrent or resistant).

Endothelin-1 and Nitric Oxide Levels in Exudative Age-Related Macular Degeneration

Purpose:

To evaluate plasma levels of endothelin-1 (ET-1) and nitric oxide (NO) in patients with exudative age-related macular degeneration (AMD).

Methods:

In this study, ET-1 levels, as well as nitrite plus nitrate concentrations as an indicator of plasma NO level, were measured in the plasma of 20 subjects with exudative AMD and compared with 20 healthy age and sex matched controls.

Results:

Mean plasma ET-1 level was significantly higher in exudative AMD patients as compared to control subjects (0.35 ± 0.06 fmol/ml versus 0.17 ± 0.03 fmol/ml, P = 0.015). Patients with exudative AMD also showed significantly lower mean plasma levels of nitrite plus nitrate as compared to the controls (58.9 ± 2.7 µmol/l versus 82.6 ± 5.9 µmol/l, P = 0.001).

Conclusion:

Increased concentrations of ET-1 and reduced levels of NO in the plasma may suggest an imbalance between vasoconstrictor and vasodilator agents, respectively, as a reflection of endothelial dysfunction in the pathogenesis of AMD. These findings may also imply the role of vasoconstriction in exudative AMD.