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Jackson TL, Soare C, Petrarca C, Simpson A, Neffendorf JE, Petrarca R, Muldrew KA, Peto T, Chakravarthy U, Membrey L, Haynes R, Costen M, Steel DHW, Desai R. Epimacular brachytherapy for previously treated neovascular age-related macular degeneration: month 36 results of the MERLOT randomised controlled trial. Br J Ophthalmol 2022:bjophthalmol-2021-320620. [PMID: 35217515 DOI: 10.1136/bjophthalmol-2021-320620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM To assess the long-term safety and efficacy of epimacular brachytherapy (EMB) for chronic, active, neovascular age-related macular degeneration (nAMD). METHODS This pivotal, randomised, controlled surgical device trial recruited patients with chronic nAMD receiving intravitreal ranibizumab from 24 UK hospitals. Participants were randomised to either pars plana vitrectomy with 24 Gray EMB and pro re nata (PRN) ranibizumab (n=224) or PRN ranibizumab monotherapy (n=119). Although masking was not possible, masked clinicians assessed best-corrected visual acuity (BCVA) and imaging. After month 24, participants reverted to standard care, with either ranibizumab or aflibercept, returning for a month 36 study visit. RESULTS Of 363 participants, 309 (85.1%) completed month 36. The number of injections was 12.1±8.1 in the EMB group versus 11.4±6.1 in the ranibizumab group (difference 0.7, 95% CI of difference -0.9 to 2.3, p=0.41) between months 1 and 36, and 3.6±3.3 (n=200) versus 3.9±2.7 (n=102) (difference -0.3, 95% CI of difference -1.0 to 0.4, p=0.43) between months 25 and 36 (standard care). Over 36 months, BCVA change was -19.7±18.5 letters in the EMB group and -4.8±12.5 in the ranibizumab group (difference -14.9, 95% CI of difference -18.5 to -11.2, p<0.0001). The month 36 BCVA of 20 EMB-treated participants with microvascular abnormalities (MVAs) at month 24 was similar to EMB-treated participants without MVAs (-21.8 vs -19.4 letters, p=0.65). CONCLUSION EMB does not reduce the number of anti-vascular endothelial growth factor (VEGF) injections, either within or outside of a trial setting, and is associated with worse BCVA than anti-VEGF monotherapy. TRIAL REGISTRATION NUMBER NCT01006538.
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Affiliation(s)
- Timothy L Jackson
- Faculty of Life Sciences and Medicine, King's College London, London, UK .,King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
| | - Cristina Soare
- King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
| | - Caroline Petrarca
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrew Simpson
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
| | - James E Neffendorf
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
| | - Robert Petrarca
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
| | | | - Tunde Peto
- Reading Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Usha Chakravarthy
- NetwORC UK, Central Angiographic Reading Centre, Queen's University Belfast, Belfast, UK
| | - Luke Membrey
- Department of Ophthalmology, Maidstone Hospital, Maidstone, UK
| | - Richard Haynes
- Department of Ophthalmology, Bristol Eye Hospital, Bristol, UK
| | - Mark Costen
- Department of Ophthalmology, Hull Royal Infirmary, Hull, UK
| | - David H W Steel
- Department of Ophthalmology, Sunderland Eye Infirmary, Sunderland, UK.,Biosciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Riti Desai
- King's Ophthalmology Research Unit (KORU), King's College Hospital, London, UK
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Wallsh JO, Gallemore RP. Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options. Cells 2021; 10:cells10051049. [PMID: 33946803 PMCID: PMC8145407 DOI: 10.3390/cells10051049] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023] Open
Abstract
Anti-vascular endothelial growth factor (anti-VEGF) therapy currently plays a central role in the treatment of numerous retinal diseases, most notably exudative age-related macular degeneration (eAMD), diabetic retinopathy and retinal vein occlusions. While offering significant functional and anatomic benefits in most patients, there exists a subset of 15–40% of eyes that fail to respond or only partially respond. For these cases, various treatment options have been explored with a range of outcomes. These options include steroid injections, laser treatment (both thermal therapy for retinal vascular diseases and photodynamic therapy for eAMD), abbreviated anti-VEGF treatment intervals, switching anti-VEGF agents and topical medications. In this article, we review the effectiveness of these treatment options along with a discussion of the current research into future directions for anti-VEGF-resistant eyes.
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Affiliation(s)
- Josh O. Wallsh
- Department of Ophthalmology, Albany Medical College, Albany, NY 12208, USA;
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