Double-dose investigation of aflibercept in neovascular age-related macular degeneration (DIANA): a real-world study

BACKGROUND

To investigate the clinical effects of double-dose (4 mg) aflibercept treatment in neovascular age-related macular degeneration (nAMD), compared with the standard-dose (2 mg) treatment.

METHODS

A total of 108 eyes from 97 patients with nAMD and received intravitreal aflibercept 2 mg and/or 4 mg treatment were retrospectively reviewed. The changes of central macular thickness (CMT)/ pigmental epithelium detachment height and the recurrence rate of exudation during the 12-month follow-up were compared between the 2 mg group and the 4 mg group. Self-control comparisons (2 mg switch to 4 mg) were also made between two regimens.

RESULTS

Compared with the 2 mg group, tendencies of lower intraretinal fluid incidence and more CMT reduction were observed in the 4 mg group. The later one was also observed when eyes switching from 2 mg to 4 mg regimen. The median remission interval was 5 months in the 4 mg group, 2 months longer than the 3 months in the 2 mg group (P = 0.452). Injections needed in the 4 mg group were 3.644 ± 1.670, less than the 4.286 ± 2.334 injections in the 2 mg group within 12 months as well (P = 0.151). However, no associated vision benefits were gained from the double-douse regimen. No markedly increased-intraocular pressure events, or other adverse events were found in two groups.

CONCLUSIONS

Compared to the aflibercept 2 mg treatment in nAMD, tendencies of anatomic gains and relieving treatment burden were brought by the aflibercept 4 mg treatment. This study may have additional importance, given the further application of high-dose aflibercept in real-world settings.

Treatment strategy for HER2-negative advanced gastric cancer: salvage-line strategy for advanced gastric cancer

After immune checkpoint inhibitor (ICI) comes into third-line treatment of advanced gastric cancer, the therapeutic strategy has been dramatically changed. Recent first-line regimen, which consists of ICI and chemotherapeutic agents, prolonged progression-free survival, and subsequent treatment options enabled continuous treatment beyond second-line therapy. Moreover, the advent of vascular endothelial growth factor (VEGF)-targeted agents including angiogenesis inhibitors and TKIs provides an opportunity of considering the interaction between ICI and anti-VEGF agents, and facilitating novel treatment proposal. Although clinical benefit of prolonged VEGF blockade after disease progression has not been confirmed in gastric cancer, combination therapy of cytotoxic agents and anti-VEGF agent, such as irinotecan plus ramucirumab demonstrated favorable objective response rate and progression-free survival in third- or later-line setting. In this review, we discuss recent progress and future directions of later-line treatments of HER2-negative advancer gastric cancer.

Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): five-year outcomes of a randomised trial

Background

Concerns remain over the long-term safety of vascular endothelial growth factor (VEGF) inhibitors to treat retinopathy of prematurity (ROP). RAINBOW is an open label randomised trial comparing intravitreal ranibizumab (in 0.2 mg and 0.1 mg doses) with laser therapy in very low birthweight infants (<1500 g) with ROP.

Methods

Of 201 infants completing RAINBOW, 180 were enrolled in the RAINBOW Extension Study. At 5 years, children underwent ophthalmic, development and health assessments. The primary outcome was visual acuity in the better-seeing eye. The study is registered with ClinicalTrial.gov, NCT02640664.

Findings

Between 16-6-2016 and 21-4-2022, 156 children (87%) were evaluated at 5 years. Of 32 children with no acuity test result, 25 had a preferential looking test, for 4 children investigators reported low vision for each eye, and in 3 further children no vision measurement was obtained. 124 children completed the acuity assessment, the least square mean (95% CI) letter score in the better seeing eye was similar in the three trial arms-66.8 (62.9-70.7) following ranibizumab 0.2 mg, 64.6 (60.6-68.5) following ranibizumab 0.1 mg and 62.1 (57.8-66.4) following laser therapy; differences in means: ranibizumab 0.2 mg v laser: 4.7 (95% CI: -1.1, 10.5); 0.1 mg v laser: 2.5 (-3.4, 8.3); 0.2 mg v 0.1 mg: 2.2 (-3.3, 7.8). High myopia (worse than -5 dioptres) in at least one eye occurred in 4/52 (8%) children following ranibizumab 0.2 mg, 8/55 (15%) following ranibizumab 0.1 mg and 11/45 (24%) following laser therapy (0.2 mg versus laser: odds ratio: 3.99 (1.16-13.72)). Ocular and systemic secondary outcomes and adverse events were distributed similarly in each trial arm.

Interpretation

5-year outcomes confirm the findings of the original RAINBOW trial and a planned interim analysis at 2 years, including a reduced frequency of high myopia following ranibizumab treatment. No effects of treatment on non-ocular outcomes were detected.

Funding

Novartis Pharma AG.

Changes in ocular blood flow in patients with neovascular age-related macular degeneration after intravitreal injection of ranibizumab biosimilar and brolucizumab

PURPOSE

To assess ocular blood flow (OBF) changes in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal injections of ranibizumab biosimilar (IVRbs) or brolucizumab (IVBr).

METHODS

This retrospective longitudinal study included 43 eyes of 43 patients (74.5 ± 9.8 years old, male to female ratio 31:12) with nAMD treated with IVBr (29 eyes) or IVRbs (14 eyes). OBF in the optic nerve head (ONH) and choroid (Ch) was measured with laser speckle flowgraphy (Softcare Co., Ltd., Fukutsu, Japan) before and one month after treatment. Changes in mean blur rate (MBR) before and after each treatment were tested using Wilcoxon's signed-rank tests and mixed-effect models for repeated measures.

RESULTS

In the IVBr group, MBR was significantly reduced in both the ONH and Ch (p < 0.01). In contrast, the IVRbs group showed no significant change in MBR in either the ONH or Ch (p = 0.56, p = 1). The linear mixed effect model showed a significant interaction between time and anti-VEGF drugs for MBR in both the ONH and Ch (ONH: p = 0.04; Ch: p = 0.002). A post hoc pairwise comparison of estimated marginal means showed that MBR decreased significantly only after IVBr (p < 0.001).

CONCLUSION

Our findings suggest that the short-term impact on OBF varies depending on the drug used for nAMD.

The role of blood neutrophil lymphocyte ratio in predicting the initial response to anti-VEGF treatment in neovascular AMD patients

PURPOSE

Vascular endothelial growth factor (VEGF) has a critical role in age-related macular degeneration (AMD), and intravitreal injection of anti-VEGF drugs is the mainstay of neovascular AMD treatment. Blood neutrophil-to-lymphocyte ratio (NLR) is shown to be a biomarker of inflammation in AMD. We aimed to investigate the role of NLR in predicting favorable short-term anti-VEGF treatment results in neovascular AMD patients.

METHODS

A total of 112 patients diagnosed with exudative AMD and had taken 3 monthly intravitreal bevacizumab injections were analyzed retrospectively. Medical records were reached to obtain neutrophil and lymphocyte values to calculate NLR. Best-corrected visual acuity and central macular thickness (CMT) measurements were recorded at each visit. T test or Mann-Whitney U test was used to compare continuous variables, and chi-square test was used to compare categorical variables. Receiver operating characteristics curve (ROC) analysis was performed to determine cut-off, sensitivity, and specificity values. P value of ≤ 0.05 was considered statistically significant.

RESULTS

The mean age was 68.1 ± 7.2 years, and the mean NLR was 2.11 ± 0.81. The ROC analysis revealed a cut off value of 2.0 for NLR to predict at least 100 μm CMT change (sensitivity 87.1%; specificity 87.8%) and a cut off value of 2.4 for NLR to predict at least 0.1 logMAR visual improvement (sensitivity 77.2%; specificity 64.8%) after 3 monthly IVT bevacizumab injections.

CONCLUSION

NLR can provide additional prognostic information for the identification of patients with a good initial response to anti-VEGF therapy.

SCORE2 Report 24: Nonlinear Relationship of Retinal Thickness and Visual Acuity in Central Retinal and Hemiretinal Vein Occlusion

PURPOSE

To investigate whether a nonlinear association between central subfield thickness (CST) on spectral-domain OCT and concurrent visual acuity letter score (VALS) exists in eyes treated initially with aflibercept or bevacizumab for macular edema associated with central retinal vein occlusion (CRVO) or hemiretinal vein occlusion (HRVO) in the Study of Comparative Treatments for Retinal Vein Occlusion 2 (SCORE2).

DESIGN

Long-term follow-up after a randomized clinical trial from 64 centers in the United States.

PARTICIPANTS

Participants were followed up to 60 months and treated at investigator discretion after completing the 12-month treatment protocol.

METHODS

Two-segment linear regression models were compared with simple linear regression models of VALS on CST. Pearson correlation coefficients were calculated to assess strength of CST and VALS associations.

MAIN OUTCOME MEASURES

Central subfield thickness was measured by OCT and VALS by the electronic Early Treatment Diabetic Retinopathy Study methodology.

RESULTS

Estimated inflection points, reflecting turning points at which the CST and VALS association changes from positive to negative, calculated at 7 postbaseline visits, range from 217 to 256 μm. A strongly positive correlation exists to the left of each estimated inflection point, ranging from 0.29 (P < 0.01 at month 60) to 0.50 (P < 0.01 at month 12), and a strongly negative correlation exists to the right of each estimated inflection point, ranging from -0.43 (P < 0.01 at month 1) to -0.74 (P < 0.01 at month 24). Randomization statistical tests showed that 2-segment models are favored over 1-segment models for all postbaseline months (P < 0.001 for all tests performed).

CONCLUSIONS

The relationship between CST and VALS in eyes with CRVO or HRVO after treatment with anti-vascular endothelial growth factor (VEGF) therapy is not simply linear. The usually modest correlations between OCT-measured CST and visual acuity belie strong left and right correlations present in 2-segment models. Post-treatment CST close to the estimated inflection points showed the best expected VALS. The SCORE2 participants with a post-treatment CST after treatment close to the estimated inflection points of 217 to 256 μm showed the best VALS. In patients treated with anti-VEGF for macular edema associated with CRVO or HRVO, a thinner retina is not always associated with better VALS.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Cataract surgery in neovascular AMD: impact on visual acuity and disease activity

BACKGROUND

Cataract and neovascular age-related macular degeneration (nAMD) often co-exist and both contribute to impaired vision. It has been debated whether cataract surgery can increase nAMD activity. The purpose of this retrospective study was to investigate the impact of cataract surgery on visual acuity, treatment intensity for nAMD and macular morphology in patients with on-going treatment for nAMD.

METHODS

Data was obtained from the Swedish Macular Register, the Swedish National Cataract Register, optical coherence tomography (OCT) images and patient charts. All eyes were treated at the Department of Ophthalmology at the County Hospital of Västmanland, Västerås, Sweden. Follow-up was 6 months after surgery. The study was approved by the Swedish Ethical Review Authority.

RESULTS

In total, 156 patients (168 eyes) were included. The mean age at cataract surgery was 82 (standard deviation, SD 6) years. Both distance and near visual acuity improved after surgery. Distance visual acuity increased from 59 (SD 12) to 66 (SD 15) letters ETDRS (P < 0.001). Proportion of eyes with normal near visual acuity increased from 12 to 41%. The anti-vascular endothelial growth factor (VEGF) treatment intensity remained unchanged: mean of 3.4 (SD 1.9) and 3.3 (SD 1.7) treatments were given 6 months pre- and postoperatively, respectively. The prevalence of intraretinal fluid (IRF) in the macula increased from 22 to 31% postoperatively, while subretinal fluid, fluid under the pigment epithelium (sub-RPE fluid) and central retinal thickness were unaltered. In eyes with new IRF, improvement in visual acuity and number of anti-VEGF treatments were similar to eyes without new IRF.

CONCLUSION

Cataract surgery improved visual acuity in patients with on-going treatment for nAMD and did not affect anti-VEGF treatment intensity. Macular morphology remained unchanged. The slight increase in intraretinal fluid after surgery was not found to affect visual acuity or anti-VEGF treatment intensity. It is hypothesized that this might indicate that it represents degenerative intraretinal cystic fluid.

[Late sequelae of retinopathy of prematurity in infancy]

BACKGROUND

Retinopathy of prematurity (ROP) is one of the most frequent causes of severe visual impairment or blindness in childhood and can lead to severe late complications in children even after the initial disease has resolved.

PURPOSE

The present study summarizes possible late effects in childhood after treated and untreated ROP. A special focus is on the development of myopia, retinal detachment, as well as neurological and pulmonary development after anti-vascular endothelial growth factor (VEGF) treatment.

MATERIAL AND METHODS

This work is based on a selective literature search on late effects in childhood of treated or untreated ROP.

RESULTS

Preterm infants have an increased risk of developing high-grade myopia. Interestingly, several studies indicate that the risk of myopia is reduced following anti-VEGF treatment. With anti-VEGF treatment, however, late recurrences after initial response are possible even after several months, making long-term and frequent follow-up examinations essential. Controversy exists regarding the possible negative effects of anti-VEGF treatment on neurological and pulmonary development. After both treated and untreated ROP, rhegmatogenous, tractional or exudative retinal detachment, vitreous hemorrhage, high myopia and strabismus are possible late complications.

DISCUSSION

Children with a history of ROP with or without treatment have an increased risk for late ocular sequelae, such as high myopia, retinal detachment, vitreous hemorrhage and strabismus. A seamless transition from ROP screening to pediatric and ophthalmological follow-up care is therefore essential for timely detection and treatment of possible refractive errors, strabismus, or other amblyogenic changes.

The role of serum metrics in anti- VEGF treatment for macular edema induced by retinal vein occlusion

AIM

To evaluate association between pretreatment serum metrics and best corrected visual acuity ( BCVA) of patients with macular edema secondary to retinal vein occlusion and its subtypes after intravitreal ranibizumab or conbercept implant.

METHODS

This prospective research included 201 patients(201 eyes) who were diagnosed with macular edema secondary to retinal vein occlusion at Heibei Eye Hospital between January 2020 and January 2021, who all received intravitreal anti- vascular endothelial growth factor treatment. Serum metrics were measured before the first treatment, and correlations between BCVA and each of four parameters- platelets, neutrophil- to- lymphocyte ratio(NLR), platelet- to- lymphocyte ratio(PLR) and monocyte- to- lymphocyte ratio(MLR)- were analyzed to identify predictors of effective intravitreal injection treatment outcomes.

RESULTS

The mean platelets was significantly different in the effective and ineffective group for RVO-ME (273.02 ± 41.49 × 109/L,214.54 ± 44.08 × 109/L P < 0.01),BRVO-ME (269.43 ± 49.52 × 109/L,214.72 ± 40.42 × 109/L P < 0.01), and CRVO-ME (262.32 ± 32.41 × 109/L,209.27 ± 42 0.91 × 109/L P < 0.01). The cutoff value of the platelets was 266.500, the area under the curve was 0.857,and the sensitivity and specificity were 59.8% and 93.6%, respectively. The mean PLR was significantly different in the effective and ineffective group for RVO-ME (154.66 ± 49.60, 122.77± 44.63 P < 0.01),BRVO-ME (152.24 ± 54.99, 124.72 ± 41.46 P = 0.003), and CRVO-ME (152.06±44.23, 118.67 ± 41.80 P = 0.001). The cutoff value of the platelets was 126.734, the area under the curve was 0.699, and the sensitivity and specificity were 70.7% and 63.3%, respectively. There were no statistical differencies between the effective and ineffective group(RVO- ME and its subtypes) in NLR and MLR.

CONCLUSION

Higher pretreatment platelets and PLR were associated with BCVA in patients with RVO- ME and its subtypes who were treated with anti- VEGF drugs. The platelets and PLR may be used as predictive and prognostic tools for effective intravitreal injection treatment outcomes.

[Prospective noninterventional BLUE SKY study evaluating the efficacy of brolucizumab in treatment-naïve and previously treated patients with neovascular AMD]

Intravitreal injection of anti-vascular endothelial growth factor (VEGF) is the standard treatment for patients with neovascular age-related macular degeneration (nAMD). In addition to the approved substances ranibizumab (Lucentis®, Novartis) and aflibercept (Eylea®, Bayer), bevacizumab (Avastin®, Roche) is also available. Furthermore, brolucizumab (Beovu®, Novartis) has been approved and has been available in Germany since April 2020. The multicenter, noninterventional prospective BLUE SKY study investigates brolucizumab treatment with different schemes in 600 treatment-naive and pretreated nAMD patients in routine clinical practice over a 24-month period. Besides general patient data, visual acuity and treatment data will be documented. Fluorescein angiography, fundus photography, spectral domain optical coherence tomography and swept-source optical coherence tomography angiography will be performed and analyzed by reading centers. The focus of the analysis will be on the intraretinal and subretinal fluid distribution as well as morphological MNV changes and injection frequency. Also, safety and adverse drug effects of brolucizumab, with a specific focus on inflammatory complications, particularly retinal (occlusive) vasculitis will be evaluated.

Wide-field swept-source OCT angiography of the periarterial capillary-free zone before and after anti-VEGF therapy for branch retinal vein occlusion

BACKGROUND

The aim of the study was to investigate the changes in the periarterial capillary-free zone (paCFZ) after anti-vascular endothelial growth factor (VEGF) therapy in patients with branch retinal vein occlusion (BRVO) by wide-field swept-source optical coherence tomography angiography (SS-OCTA) and assess their associations with clinical outcomes.

METHODS

In this retrospective observational study of 54 treatment-naïve BRVO patients with macular edema, we reviewed the findings of 12 × 12 mm² SS-OCTA at baseline, 3, 6, and 12 months after intravitreal ranibizumab injections. The paCFZ and major retinal artery areas were measured on SS-OCTA images. The paCFZ area to artery area (P/A) ratio was calculated.

RESULTS

The paCFZ areas and P/A ratios of first- and second-order arteries were significantly greater in BRVO eyes than in contralateral eyes (all P < 0.01), but there were no differences in the first- and second-order artery areas (P = 0.20 and 0.25, respectively). The paCFZ areas and P/A ratios decreased significantly at 3, 6, and 12 months after anti-VEGF therapy (all P < 0.01). The baseline P/A ratio was significantly correlated with the baseline best-corrected visual acuity (BCVA), central retinal thickness, and their improvements at 3, 6, and 12 months (all P < 0.05). Baseline BCVA and P/A ratios of first- and second-order arteries were independently associated with the final BCVA in multivariate linear regression.

CONCLUSIONS

Wide-field SS-OCTA shows that anti-VEGF therapy can lead to a significant improvement in the paCFZ parameters in BRVO. Smaller baseline P/A ratios on SS-OCTA tend to predict better visual outcomes at 12 months after anti-VEGF therapy.

SCORE2 Report 17: Macular thickness fluctuations in anti-VEGF-treated patients with central or hemiretinal vein occlusion

PURPOSE

To evaluate macular thickness fluctuations and their association with visual acuity outcome in eyes with macular edema (ME) secondary to central (CRVO) or hemiretinal vein occlusion (HRVO) treated initially with intravitreal aflibercept or bevacizumab.

METHODS

Post hoc analysis of 362 patients with ME secondary to CRVO or HRVO initially randomized to six monthly intravitreal injections of aflibercept or bevacizumab. Three spectral domain optical coherence tomography (SD-OCT) central subfield thickness (CST) fluctuation measures were investigated over Months 1-12: standard deviation (SD), number of turning points (T) for each participant, and a measure denoted as Zigzag reflecting the magnitude of alternating ups and downs in a participant's CST. Main outcome measure is Month 12 visual acuity letter score (VALS).

RESULTS

More fluctuations occurred in eyes randomized to bevacizumab than aflibercept: SD (59.98 vs 32.12; p < 0.0001), T (4.03 vs 3.53; p = 0.02) and Zigzag (24.91 vs 11.60; p = 0.0003). Month 12 VALS is significantly lower for the 4th (highest) quartile of the CST fluctuation measure than for the 1st (lowest) quartile for both SD (mean difference in VALS of 7.87; 95% confidence interval: 3.03, 12.70) and Zigzag (mean difference in VALS of 5.11; 95% confidence interval: 0.29, 9.93). SD and Zigzag quartiles were no longer significantly different after Month 1 VALS was added to the regression analysis.

CONCLUSIONS

Greater CST fluctuation as assessed by SD and Zigzag was negatively associated with Month 12 VALS. However, early post-treatment VALS is a stronger predictor of VALS outcomes than the CST fluctuation measures.

The detrimental effects of delayed intravitreal anti-VEGF therapy for treating retinal pathology: lessons from a forced test-case

Purpose

Determine the anatomical consequences of delaying intravitreal injection (IVI) therapy with anti-vascular endothelial growth factor (anti-VEGF) in patients using treat-and-extend (T&E) protocol.

Methods

Retrospective medical record review of consecutive patients receiving intravitreal anti-VEGF therapy using T&E protocol prior to and during the COVID-19 pandemic.

Results

The study included 923 eyes of 691patients; 58.8% (543 eyes), 25% (231 eyes), and 16.2% (149 eyes) had nvAMD, DME, and RVO, respectively. Mean (± SD) patient age was 74.5 ± 11.7 years. Overall, 56.3% of cases had a delay in therapy of ≥ 7 days; specifically, 56.2%, 61.5%, and 49.0% of nvAMD, DME, and RVO cases, respectively, had a delay. The median delay in days, among cases ≥ 7 days late was 21 (IQR 7 to 42) days, with 21(IQR 7 to 45), 22.5(IQR 8 to 42), and 14(IQR 7 to 33.5) days of delay among patients with nvAMD, DME, and RVO, respectively. Delaying therapy by ≥ 7 days resulted in increased CST in 47.5%, 58.5%, and 58.9% of nvAMD, DME, and RVO cases, respectively, with a significant correlation between the length of treatment delay and the increase in CST (Spearman’s rho: 0.196; p < 0.001).

Conclusions

Delayed IVI treatment in eyes treated with T&E protocol was associated with increased macular thickness with potential consequences with respect to visual outcome.

Temporal variation of optical coherence tomography biomarkers as predictors of anti-VEGF treatment outcomes in diabetic macular edema

PURPOSE

To report a longitudinal analysis of specific optical coherence tomography (OCT) features in eyes with diabetic macular edema (DME) treated with anti-VEGF.

METHODS

A total of 133 eyes of 103 consecutive patients with center-involving DME were included in the study. The eyes were treated between August 2008 and April 2019 with three monthly intravitreal anti-VEGF injections, either with or without prompt or deferred laser, followed by pro re nata (PRN) re-treatment. The following OCT biomarkers were evaluated: subfoveal neuroretinal detachment (SND) (defined as present (SND+) or absent (SND-)), hyperreflective retinal foci (HRF) number (defined as: absent/few(HRF-) or moderate/many (HRF+)), external limiting membrane (ELM) integrity, central macular thickness (CMT), and central retinal thickness (CRT). Changes in SND status and in the number of HRF were evaluated at each DME recurrence throughout the follow-up(FU) period. Mutual correlation among OCT biomarkers and their relationship with visual and anatomic outcomes were assessed both at baseline and over the FU period.

RESULTS

The mean FU was 71.2 months (SD 28.4; min. 12-max. 111). At baseline, the prevalence of SRD+ was 27.8% and a high number of HRF were detected in 41.4% of the eyes. A significant reduction in the number of HRF, CMT, CRT, and in the prevalence of SND was recorded in the post-loading phase (p-value <0.0001). In DME recurrences, the presence of SND+ and HRF+ was significantly more frequent in eyes with baseline SND+ and HRF+ compared to eyes presenting baseline SND- and HRF- (p-value <0.0001). No role of SND (p-value: 0.926) and HRF (p-value: 0.281) as baseline predictors of visual and anatomic outcomes was demonstrated, while a worse visual outcome was significantly correlated with a higher incidence of relapsing SND+ (p-value <0.0001) and HRF+ (p-value <0.0028) throughout the FU period.

CONCLUSION

In this study, SND and HRF were frequently present in DME recurrences with the same pattern exhibited at baseline, suggesting that these OCT biomarkers may characterize a specific pattern of DME that repeats over time. Moreover, the results suggested that the persistence and recurrence of SND and HRF may account for a decrease in visual function more than the baseline prevalence of these biomarkers. Further studies are required to confirm these findings.

Visual acuity outcomes of anti-VEGF treatment for neovascular age-related macular degeneration in clinical trials

Anti-VEGF treatment for neovascular age-related macular degeneration (nAMD) has been evaluated in clinical trials. To select the best anti-VEGF drug and the best treatment regimen for nAMD, a thorough understanding of the characteristics of each anti-VEGF drug and treatment regimen is essential. In this review, we summarized visual acuity (VA) changes in 30 previous clinical trials of anti-VEGF treatment for nAMD. In most studies, ranibizumab, aflibercept, and brolucizumab improved the VA by 6 to 12 letters from the baseline VA of 50-65 letters and maintained the VA improvement regardless of the treatment regimen; the VA improved from 0.2-0.4 to 0.3-0.7 in Snellen equivalents. The improvement was rapid during the first month and became slower after the second injection, and 60% to 90% of the VA improvement was attained within the first 3 months. The upper limit of the VA improvement should be determined according to eyes with nAMD themselves, not according to anti-VEGF drugs or treatment regimens. Since a fixed regimen can result in overtreatment, whilst a pro re nata regimen can result in insufficient treatment, a treat-and-extend regimen would be optimal to treat nAMD. Insufficient treatment fails to improve VA to the upper limit and/or to maintain the improved VA, whereas overtreatment can cause macular atrophy. One study reported no difference in the risk of macular atrophy between ranibizumab and aflibercept, whilst many studies have suggested that aflibercept causes more choroidal thinning, one of the risk factors for macular atrophy, than does ranibizumab. Further evaluation of drugs and regimens should be performed from the viewpoint of complications and minimum number of injections required to improve and maintain VA.

An overview of thrombotic complications of old and new anticancer drugs

Thrombosis is a common complication of cancer with a mean prevalence of 15%. Most commonly, this presents as venous thromboembolism; however, other manifestations such as arterial thrombosis or thrombotic microangiopathy may occur. Cancer itself is not only associated with risk factors for thrombotic complications, including intrinsic biological effect of malignant cells, accompanying operations, or the presence of indwellingvascular catheters, but there is also an additional risk caused by anticancer agents including chemotherapy and immunotherapy. In most cases the underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example by vascular endothelial growth factor inhibition). In addition, individual anticancer agents may have specific prothrombotic effects. As in recent years more intense anticancer drugs are administered, such as in myeloablative conditioning regimens preceding stem cell transplantation, thrombosis and in particular thrombotic microangiopathy are a more frequent complication in anticancer treatment.

[Neovascular recurrences in 42 treatment-naive eyes with neovascular age-related macular degeneration (AMD) followed for over 2 years]

INTRODUCTION

The objective of this study was to analyze the reproducibility or variability of the time period to exudative recurrences in patients who were treated with intravitreal injections (IVT) of anti-VEGF (ranibizumab, aflibercept) for exudative age-related macular degeneration (AMD). The data studied included the number of recurrences per year, the time between the last IVT and the recurrence, fluctuation over time in the same patient, and changes in the therapeutic management of these exudative recurrences with regard to repeat induction therapy of three IVT, changes in monitoring protocols, and switches in anti-VEGF molecules.

MATERIALS AND METHODS

We conducted a retrospective, single center, "real-life" study at the Nantes University Hospital, including 33 patients (42 eyes) between March 2012 and March 2017. These were IVT-naive patients, in whom anti-VEGF IVT treatment was initiated for management of exudative AMD, with a follow-up period of at least two consecutive years. The main outcome was the fluctuation in recurrences times for the same patient.

RESULTS

Of the 33 patients included, 9 had bilateral involvement, for a total of 42 eyes. Twenty were women (60.6 %), the median age at inclusion was 78.5 years with a follow-up period of 3.7 years. The average time to recurrence was 11.6 weeks after the last IVT. The first recurrence occurred within 9.8 weeks after the last IVT. 12.3% of the eyes had consisent recurrence times, with fluctuations of less than 2 weeks between the various relapses over the two years of follow-up. a total of 7.1% of the eyes had no exudative recurrences during follow-up. The first exudative recurrence occurred at a mean of 38.2 weeks after diagnosis of the disease, or 37.2 weeks after the first IVT. 14.3% of the recurrences led to the administration of a repeat induction of three intravitreal anti-VEGF injections, 8.6% led to a change in anti-VEGF molecule, and 7.1% to a modification of the treatment protocol.

DISCUSSION

The goal of this study was to analyze the variability of the time to exudative recurrence in patients treated with anti-VEGF IVT in the context of exudative AMD, because, since the advent of anti-VEGF IVT in 2007, few data have been available on long-term follow-up and fluctuations in recurrence times in patients who will receive treatment for several years.

CONCLUSION

Recurrences times are not reproducible over follow-up, particularly in patients experience their first exudative recurrence beyond 8 weeks and in patients with multiple exudative recurrences.

Microvascular comparison in younger and older patients with retinal vein occlusion analyzed by OCT angiography

Background

To compare changes in retinal microvasculature of young and elderly patients with retinal vein occlusion (RVO) after anti-VEGF treatment.

Methods

RVO patients who underwent anti-VEGF treatment were retrospectively reviewed and categorized into two groups based on age. The OCT angiography images were obtained during each visit. Best corrected visual acuity (BCVA), vessel density (VD) and foveal avascular zone (FAZ) were measured and compared between the two groups. Vision improvements and retinal microvasculature changes were also correlated.

Results

Twenty patients with 20 eyes were enrolled in the younger group and 46 patients with 46 eyes were enrolled in the older group. Younger patients demonstrated better BCVA, higher VD and smaller FAZ than older patients at 12 months after the first anti-VEGF treatment. The improvement of VD was observed only in the younger group. A positive correlation between vision improvement and VD increase was noted.

Conclusions

Young patients with RVO can achieve rapid rehabilitation of deep retinal vasculature which lead to a better visual outcome.

[Intraocular inflammation with brolucizumab use : Patient management-diagnosis-therapy]

The anti-vascular endothelial growth factor (anti-VEGF) agent brolucizumab has been approved in the USA in October 2019 and in Europe in February 2020 for the treatment of neovascular age-related macular degeneration (nAMD). The approval was based on the randomized, double-blind phase III studies HAWK and HARRIER with a total of 1817 patients. Brolucizumab 6 mg (administered every 12 or 8 weeks depending on the activity of the disease) showed a non-inferior efficacy in terms of best-corrected visual acuity compared to aflibercept 2 mg (administered every 8 weeks). Initial reports on the use of brolucizumab after its approval in the USA indicated a safety signal of rare adverse events termed as retinal vasculitis and/or retinal vascular occlusion that may result in severe loss of vision. Typically, these events occurred in the presence of intraocular inflammation (IOI). A safety review committee (SRC) subsequently carried out an independent analysis of data from the pivotal studies. This article sets out the current state of knowledge and aims to provide users with orientation-from the authors' perspective-in treating brolucizumab-associated IOI. It appears mandatory to provide patients with information about possible symptoms of IOI. Even though the case reports and the SRC review of HAWK/HARRIER may not yet provide sufficient evidence for any final conclusions, it seems crucial to educate patients about signs and symptoms to ensure an early detection and diagnosis in cases of IOI. Once a patient is diagnosed with IOI, retinal vasculitis, and/or retinal vascular occlusive events, physicians should act promptly with an adequate and intensive anti-inflammatory treatment and brolucizumab treatment should be discontinued. It is important to note that these recommendations are primarily based on the authors' expert opinions and should be considered as guidance in managing these events rather than a formal protocol or guidelines.

Association between early and late response in eyes with central or hemiretinal vein occlusion treated with anti-VEGF agents : SCORE2 report 12: secondary analysis of the SCORE2 clinical trial

PURPOSE

To assess whether early visual acuity letter score change from baseline (ΔVALS) and early spectral domain optical coherence tomography (SD-OCT) measures of center point thickness (CPT) are associated with later ΔVALS in eyes with macular edema due to central or hemiretinal vein occlusion treated with intravitreal aflibercept or bevacizumab.

METHODS

Secondary analysis of a randomized clinical trial of 362 participants.

RESULTS

Considered separately at month 3, CPT (categorized as ≤ 300 μm, > 300 μm) and ΔVALS (categorized as < 5, 5-9, ≥ 10) are predictive of ΔVALS at month 6 (aflibercept: P = 0.02 for CPT and P < 0.0001 for ΔVALS; bevacizumab: P = 0.007 for CPT and P < 0.0001 for ΔVALS) and, except for CPT in the bevacizumab arm, also predictive of ΔVALS at month 12 (aflibercept: P = 0.03 for CPT and P < 0.0001 for ΔVALS; bevacizumab: P = 0.18 for CPT and P < 0.0001 for ΔVALS). Month 3 predictors are also associated with average ΔVALS from months 4 to 12 (CPT P = 0.01 in the aflibercept arm, P = 0.02 in the bevacizumab arm; ΔVALS > 10 versus < 5; P < 0.001 for both aflibercept and bevacizumab). When month 3 measures are considered jointly, ΔVALS effect remains significant for average ΔVALS from months 4 to 12 (aflibercept: P = 0.002; bevacizumab: P < 0.0001) but not CPT (aflibercept: P = 0.18; bevacizumab: P = 0.22).

CONCLUSION

While both month 3 ΔVALS and CPT are predictive of ΔVALS after month 3 through month 12, early ΔVALS has a stronger relationship than CPT with later ΔVALS. SCORE2 registration number is NCT01969708.

Effects of Intravitreal Aflibercept on Retinal Function and Improvement of Macular Edema Associated With Diabetic Retinopathy

Purpose

To determine the effectiveness of intravitreal aflibercept (IVA) on the retinal function in eyes with diabetic macular edema (DME).

Methods

Twenty-five eyes of 25 patients with DME were treated with three consecutive monthly IVA injections. The retinal sensitivities (RS) within the central 10° were determined by microperimetry (MP). The central subfield macular thickness (CMT) was determined by optical coherence tomography, and the implicit times (IT) and amplitudes (Amp) of the flicker electroretinograms (ERGs) were determined from the ERGs elicited and recorded by the RETeval. The number of microaneurysms (MAs) was counted in the fundus photographs. The assessments were made before the IVA injections (pre-IVA) and one week after the IVA injections (post-IVA). The correlations between the reduction ratio of the MA numbers/CMT and RS/IT/Amp were evaluated.

Results

The mean RS improved from 19.9 ± 5.9 dB to 22.0 ± 5.8dB, the CMT decreased from 485.7 ± 90.6 µm to 376.9 ± 81.6 µm, and the number of MAs decreased from 49.6 ± 33.2 to 24.8 ± 18.1 after the IVA injection (all P < 0.01). The changes in the IT from 31.3 ± 3.3 ms to 31.5 ± 3.1 ms and the Amp from 12.2 ± 5.5 µV to 11.3 ± 6.1µV post-IVA were not significant. A significant correlation was found between the relative changes in the CMT and RS (r = −0.43; P = 0.02), the MAs and RS (r = −0.38; P = 0.03). No significant correlation was observed between the relative changes of the number of MAs/CMT and IT/Amp.

Conclusions

IVA can improve both central retinal function and anatomical conformation.

Translational Relevance

A new aspect of aflibercept will be useful for DME treatment.

Macular Hole Surgery in the Case of Wet Age-Related Macular Degeneration Treated with Intravitreal Aflibercept

A 72-year-old male treated with aflibercept (Eylea) due to choroidal neovascularization (CNV) in his left eye developed a full-thickness macular hole (MH) after the second injection. The occurrence of MH in his left eye resulted in further visual acuity deterioration. As a consequence of having developed the MH, the patient was operated on. Phacoemulsification and vitrectomy with internal limiting membrane peeling and 20% SF6 tamponade were performed. MH closure was achieved and best corrected visual acuity improved to the extent allowed by CNV. The patient continued anti-VEGF treatment with Eylea due to wet age-related macular degeneration in his left eye. The observation period of 2 years has been uneventful and visual acuity of 0.2 has remained stable.

[ANDROMEDA-an investigation of factors influencing the adherence of patients with neovascular age-related macular degeneration using the newly developed patient questionnaire LAF-IVT]

BACKGROUND

Lack of adherence to treatment is a widespread problem in the anti-VEGF (Vascular Endothelial Growth Factor) treatment of patients with neovascular age-related macular degeneration (nAMD). In contrast to the extent of the lack of treatment adherence, there is so far insufficient evidence for elucidating the causes of nonadherence. The ANDROMEDA study was initiated to investigate the influencing factors on the adherence of nAMD patients to treatment. The focus of the study was on patient reported endpoints, as the perceptions and experiences of the patients are of enormous importance for the investigation of the various aspects of adherence to treatment.

OBJECTIVE

This publication presents the design of the ANDROMEDA study as well as the development of a new patient questionnaire for the assessment of barriers to treatment within the design of the study.

MATERIAL AND METHODS

This prospective noninterventional observational study to assess the compliance of patients with nAMD and anti-VEGF treatment was started at the end of January 2019. It is planned to include 1000 patients in 120 study centers throughout Germany with an observational period of 24 months. Patient interviews on general and vision-related quality of life, treatment satisfaction and possible barriers to treatment will be conducted at the beginning and after 4, 12 and 24 months. All patient visits will be documented by the study centers as part of the clinical routine. To date, there has been no suitable instrument for recording patient-related circumstances and potential barriers to anti-VEGF treatment. Therefore, a specific patient questionnaire for longitudinal assessment of adherence factors to intravitreal (anti-VEGF) therapy (LAF-IVT) was developed as part of the study concept. The questionnaire, developed by an expert panel, was tested via qualitative interviews for its cognitive characteristics ahead of its use.

RESULTS

The results of the study are expected in early 2023. The cognitive examination of the LAF-IVT confirmed the feasibility of the new questionnaire. The practicability and significance of the new instrument can be assessed after completion of the quantitative data collection.

CONCLUSION

The symptoms, barriers, burdens and quality of life effects experienced by patients influence the adherence to treatment and thus the outcome. A better understanding of the patient's views and experiences is the basis for long-term optimization of care.

Intravitreal dexamethasone implants versus intravitreal anti-VEGF treatment in treating patients with retinal vein occlusion: a meta-analysis

Background

Retinal vein occlusion (RVO) is a common retinal venous disorder that causes vision loss. No specific therapy has been developed. Controversy exists regarding two treatments: intravitreal dexamethasone implants and anti-vascular endothelial growth factor (VEGF). The goal of this study is to compare the effectiveness and safety of dexamethasone implants and anti-VEGF treatment for RVO.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for studies comparing dexamethasone implants with anti-VEGF in patients with RVO. Best-corrected visual acuity (BCVA), central subfield thickness (CST), intraocular pressure changes, conjunctival haemorrhage, reduced VA, and macular oedema were extracted from the final included studies. RevMan 5.3 was used to conduct the quantitative analysis and bias assessment.

Results

Four randomised controlled trials assessing 969 eyes were included. The anti-VEGF treatment showed better BCVA improvement (mean difference [MD] = − 10.59, P < 0.00001) and more CST decrease (MD = − 86.71 μm, P = 0.02) than the dexamethasone implants. However, the dexamethasone implants required fewer injections. As for adverse effects, the dexamethasone implants showed significantly higher intraocular pressure (IOP) and more cataracts than the anti-VEGF treatment. No significant differences were found in conjunctival haemorrhage, reduced VA, and macular oedema.

Conclusions

Anti-VEGF treatment showed better functional and anatomical improvement with less risk of IOP elevation and cataract formation compared to dexamethasone implants. Thus, anti-VEGF treatment is the first choice for treating RVO patients.

Incidence and risk factors for neovascular age-related macular degeneration in the fellow eye

PURPOSE

The epidemiology, risk factors, and the effect of anti-VEGF treatment on neovascular age-related macular degeneration (nAMD) have primarily been studied in the first eye developing the disease. The understanding of pathophysiology and planning of follow-up examinations can be improved by knowledge of incidence and risk factors for development of the disease in the fellow eye.

METHODS

In a prospective observational cohort study, epidemiological and clinical risk factors for the development of nAMD in the fellow eye among 2516 patients consecutively diagnosed with the disease from a population of 0.9 million citizens during a period of more than 10 years were studied.

RESULTS

nAMD had been diagnosed in the fellow eye of 541 (21.5%) of the patients. The incidence of fellow-eye involvement increased from approximately 5% in patients initially presenting with bilateral disease to approximately 28% more than 6 years after the diagnosis in the first eye. Visual acuity (VA) was higher and central retinal thickness (CRT) was lower in fellow eyes with nAMD diagnosed later than the first eye. Male gender, increasing leakage area, and peripapillary location of the subretinal neovascular membrane in the first eye reduced the risk of developing disease in the fellow eye.

CONCLUSIONS

The planning of follow-up examinations of patients diagnosed with nAMD in one eye should consider that the risk of fellow-eye involvement is higher within the first 6 years, in women, and when the leakage area in the first eye is small and not located peripapillary.

Early Changes of Retinal Morphology in Therapy of Neovascular Age-Related Macular Degeneration with Three Commonly Used Anti-VEGF Agents

PURPOSE

To compare changes of retinal morphology in the first weeks following injection of anti-VEGF agents for neovascular age-related macular degeneration (nAMD).

PROCEDURES

In a prospective study 50 patients with active choroidal neovascularization secondary to nAMD were monitored weekly by spectral-domain optical coherence tomography for 3 weeks after treatment. Twenty-two patients received bevacizumab, 15 ranibizumab, and 13 aflibercept. Morphological parameters of retinal compartments were compared.

RESULTS

Mean central retinal thickness (391.22 ± 123.41 µm) was reduced by -26.15 µm (p < 0.001) after 1 week, by -12.54 µm (p < 0.001) after 2 weeks, and by -3.52 µm (p = 0.09) after 3 weeks. Mean intraretinal layer thickness changed only significantly between baseline and week 1 (p < 0.001). Mean subretinal thickness also decreased between weeks 1 and 2 (p = 0.01).

CONCLUSIONS

Early morphological changes occur primarily in the first 14 days after treatment. This information could be clinically helpful to evaluate early non-response.

Anti-VEGF treatment improves neurological function in tumors of the nervous system

Research of various diseases of the nervous system has shown that VEGF has direct neuroprotective effects in the central and peripheral nervous systems, and indirect effects on improving neuronal vessel perfusion which leads to nerve protection. In the tumors of the nervous system, VEGF plays a critical role in tumor angiogenesis and tumor progression. The effect of anti-VEGF treatment on nerve protection and function has been recently reported - by normalizing the tumor vasculature, anti-VEGF treatment is able to relieve nerve edema and deliver oxygen more efficiently into the nerve, thus reducing nerve damage and improving nerve function. This review aims to summarize the divergent roles of VEGF in diseases of the nervous system and the recent findings of anti-VEGF therapy in nerve damage/regeneration and function in tumors, specifically, in Neurofibromatosis type 2 associated schwannomas.

Patient-reported outcomes and visual acuity after 12months of anti-VEGF-treatment for sight-threatening diabetic macular edema in a real world setting

AIMS

To examine objective visual acuity measured with ETDRS, retinal thickness (OCT), patient reported outcome and describe levels of glycated hemoglobin and its association with the effects on visual acuity in patients treated with anti-VEGF for visual impairment due to diabetic macular edema (DME) during 12months in a real world setting.

METHODS

In this cross-sectional study, 58 patients (29 females and 29 males; mean age, 68years) with type 1 and type 2 diabetes diagnosed with DME were included. Medical data and two questionnaires were collected; an eye-specific (NEI VFQ-25) and a generic health-related quality of life questionnaire (SF-36) were used.

RESULTS

The total patient group had significantly improved visual acuity and reduced retinal thickness at 4months and remains at 12months follow up. Thirty patients had significantly improved visual acuity, and 27 patients had no improved visual acuity at 12months. The patients with improved visual acuity had significantly improved scores for NEI VFQ-25 subscales including general health, general vision, near activities, distance activities, and composite score, but no significant changes in scores were found in the group without improvements in visual acuity.

CONCLUSIONS

Our study revealed that anti-VEGF treatment improved visual acuity and central retinal thickness as well as patient-reported outcome in real world 12months after treatment start.

Psychological impact of anti-VEGF treatments for wet macular degeneration-a review

Purpose

To review the current literature on the psychological impact of anti-VEGF treatments for wet age-related macular degeneration (wAMD), in terms of patients’ experiences of receiving these treatments, and the impact of these treatments for patients’ mental health and quality of life.

Methods

We critically analyzed current literature evaluating psychological impact of anti-VEGF treatments for wAMD. Primary searches of PubMed, Science Direct, and Web of Science were conducted in July and August of 2015. We reviewed all papers on the topic published until August 5, 2015.

Results

Our literature search found 14 papers addressing the psychological impact of anti-VEGF treatments for wAMD. Results highlighted potential anxieties and experiences of pain caused by receiving regular intravitreal injections. A positive visual outcome of anti-VEGF therapy is associated with positive vision-related QOL outcomes, although such association seems to be dependent on improvements on visual acuity. In the literature reviewed, patients receiving anti-VEGF treatments showed a prevalence rate of depression between 20 and 26 %.

Conclusions

Although anti-VEGF treatments can cause some anxiety and being experienced as a stressful event, especially in the beginning of the treatment, preliminary findings suggest a potential benefit for long-term vision-related quality of life. Further longitudinal and qualitative research should bring more evidence on the positive and negative effects of these treatments on patients’ long-term mental health.

Lack of anti-tumor activity by anti-VEGF treatments in hepatic hemangiomas

Recently, anti-vascular endothelial growth factor (anti-VEGF) agents have been described in the literature as a valid treatment option for symptomatic liver hemangiomas, but only limited evidence supports this notion. The purpose of this study was to elucidate whether or not the administration of anti-VEGF agents can reliably achieve a size reduction in liver hemangiomas. We examined patients with incidental hemangiomas who received anti-angiogenic agents for the treatment of other malignancies. Our study population consisted of 17 colorectal cancer patients and one lung cancer patient carrying 21 hemangiomas who received bevacizumab, and seven renal cell carcinoma patients carrying nine hepatic hemangiomas who received sunitinib. We have measured the liver hemangioma volume on both the pre-treatment and post-treatment computed tomography images and then calculated the volume alteration rates. No statistically significant difference (P = 0.365) in the volume of the liver hemangiomas was observed before (1.1-168.8 cm(3); mean ± SD 19.8 ± 39.7 cm(3)) or after (1.2-163.6 cm(3); 19.3 ± 38.0 cm(3)) bevacizumab treatment. The volume reduction rate ranged from -35.0 to 11.2 % (mean ± SD -1.3 ± 10.8 %). The sunitinib treatment group also showed no statistically significant difference (P = 0.889) in hemangioma volume before (1.2-6.5 cm(3); 3.0 ± 1.8 cm(3)) or after (1.2-6.0 cm(3); 3.0-1.7 cm(3)) treatment. The volume reduction rate ranged from -13.3 to 7.7 % (median: mean ± SD -2.5 ± 6.6 %). We did not observe liver hemangioma shrinkage after bevacizumab or sunitinib treatment. Our data do not support the application of anti-VEGF agents for the treatment of hepatic hemangiomas.

Visual functioning and health-related quality of life in diabetic patients about to undergo anti-vascular endothelial growth factor treatment for sight-threatening macular edema

PURPOSE

To examine patient-reported outcome (PRO) in a selected group of Swedish patients about to receive anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME).

MATERIAL AND METHODS

In this cross-sectional study, 59 patients with diabetes mellitus, who regularly visited the outpatient eye-clinics, were included. Sociodemographic and clinical data were collected and the patients completed PRO measures before starting anti-VEGF treatment. PRO measures assessed eye-specific outcomes (NEI-VFQ-25) and generic health-related quality of life (SF-36).

RESULTS

The participants consisted of 30 men and 29 women (mean age, 68.5years); 54 (92%) patients had type 2 diabetes; 5 (9%) patients had moderate or severe visual impairment; 28 (47%) were classified as having mild visual impairment. Some of the patients reported overall problems in their daily lives, such as with social relationships, as well as problems with impaired sight as a result of reduced distance vision.

CONCLUSIONS

Further studies are needed to investigate PRO factors related to low perceived general health in this patient population. It is important to increase our understanding of such underlying mechanisms to promote improvements in the quality of patient care.