Intravitreales Bevacizumab bei der neovaskulären altersabhängigen Makuladegeneration

A comparison of responses to intravitreal bevacizumab, ranibizumab, or aflibercept injections for neovascular age-related macular degeneration

PURPOSE

To compare the responses of intravitreal injections of bevacizumab, ranibizumab, or aflibercept for the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

This retrospective study examined 232 eyes of 232 patients who received intravitreal anti-vascular endothelial growth factor (VEGF) injections due to treatment-naïve nAMD. All patients, who were followed-up for at least 1 year, were treated with intravitreal injections monthly until 3 months, and then as needed. We evaluated the effects of intravitreal injections for treatment of nAMD using the central macular thickness (CMT), subretinal fluid (SRF), pigment epithelial detachment (PED) size, and best-corrected visual acuity (BCVA).

RESULTS

CMT, SRF, PED size, and BCVA (LogMAR) were significantly decreased after treatment with all three anti-VEGF agents. Overall, the bevacizumab, ranibizumab, and aflibercept treatments showed no significant differences in their responses. However, the aflibercept injections decreased PED size more quickly than bevacizumab injections (P = 0.034).

CONCLUSIONS

Bevacizumab, ranibizumab, and aflibercept injections are effective treatments for nAMD and have similar responses, although the number of injections of aflibercept was fewer than other anti-VEGF agents. In addition, aflibercept injections may be a better choice than other anti-VEGF agents for cases of severe increases in PED height.

Is Spectral-Domain Optical Coherence Tomography Always Able to Detect the Anti-Vascular Endothelial Growth Factor Action on Neovascular Membrane

<b><i>Purpose:</i></b> To show the presence of an active neovascular membrane in age-related macular degeneration even if optical coherence tomography (OCT) does not detect intra- or subretinal edema. <b><i>Methods:</i></b> This is a retrospective case report. During the follow-up after the intravitreal injection, 3 patients showed no intraretinal or subretinal edema by OCT; however, there was a progressive reduction in their visual acuity; thus, a fluorangiography (FA) examination was performed. <b><i>Results:</i></b> In these 3 cases, FA showed an active neovascular network. <b><i>Conclusion:</i></b> OCT could show a real reduction in the edema, but it is not always able to detect neovessel presence. Intravitreal injection could improve the vessel permeability without care and delete the neovascular network.

Bevacizumab versus ranibizumab for neovascular age-related macular degeneration: a Meta-analysis

AIM

To systematically compare the efficacy and safety of off-label bevacizumab versus licensed ranibizumab intravitreal injections as well as monthly regimen versus pro re nata [PRN (as needed)] regimen in the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

Relevant publications were identified through automatically retrieve of database and manually retrieving. The methodological quality of studies included was assessed using the Jadad score and the risk-of-bias assessment. The efficacy estimates were measured by the weight mean difference (WMD) for the improvement of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) reduction. The safety estimates were measured by odds ratios (OR) for adverse events rates. Statistical analysis was conducted by Revman 5.2.7.

RESULTS

Seven studies were included in the Meta-analysis. There were no statistically significant differences between bevacizumab and ranibizumab in BCVA at 1 and 2y (P=0.37, P=0.18, respectively), However, both drugs has better BCVA given monthly than given as needed at 1 and 2y (P<0.05). The results demonstrated the mean decrease in CRT was less in bevacizumab group than ranibizumab group at 1y (P<0.05), while the difference was not significant at 2y (P=0.24). Treatment monthly gained much more decrease in CRT at 1 and 2y (P<0.005). There were no differences between drugs in the rates of death, arterial thrombotic events and venous thrombotic events (P=0.41, P=0.55, P=0.10, respectively), while the rates of medical dictionary for regulatory activities (MedDAR) system organ class events and ≥1 systemic serious adverse events were higher in bevacizumab group than ranibizumab group (P<0.05). But the incidences of death, arterial thrombotic events, venous thrombotic events, MedDAR system organ class events as well as ≥1 systemic serious adverse events were not statistically different between both treatment regimens of monthly and as needed (P=0.14, P=0.76, P=0.73, P=0.12, P=0.11, respectively).

CONCLUSION

Bevacizumab was equivalent to ranibizumab for BCVA, however bevacizumab tended to gain less decrease in CRT and had higher rates of serious adverse events. Compared with treatment as needed, treatment monthly showed superior efficacy in BCVA improvement and CRT reduction, while the rates of adverse events were similar in the two dosing regimens.

Phacoemulcification with intravitreal bevacizumab injection in patients with cataract and coexisting diabetic retinopathy: prospective randomized study

OBJECTIVE

To evaluate efficacy of intravitreal injection of bevacizumab at the time of cataract surgery on the postoperative progression of diabetic retinopathy (DR) and diabetic maculopathy.

METHODS

Patients were randomized to a standardized procedure of phacoemulsification with intraocular lens implantation alone (control group; 30 eyes) or to receive 1.25 mg intravitreal bevacizumab (0.05 mL of solution prepared from avastin, 100 mg/4 mL vial) at the end of surgery (IVB group; 27 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination at each postoperative visit during a 6-month follow-up.

RESULTS

There were no significant differences in central macular thickness (CMT), BCVA, or systemic condition between the control and IVB groups at baseline. Progression of diabetic maculopathy occurred in 15 eyes (50%) in the control group and 2 eyes (7.4%) in the intervention group (P = 0.0008). There was no statistically significant difference in postoperative visual acuity between the 2 groups after 6 months (P = 0.5). Five eyes in the control group and 1 eye in the intervention group progressed to neovascular glaucoma. Difference in mean postoperative CMT was not statistically significant between both groups (P = 0.54).

CONCLUSIONS

Intravitreal administration of 1.25 mg bevacizumab at the time of cataract surgery was safe and effective in preventing the progression of DR and diabetic maculopathy in patients with cataract and DR.

Pharmacokinetics of intravitreal bevacizumab (Avastin®) in rabbits

PURPOSE

To describe the pharmacokinetics of intravitreal bevacizumab (Avastin®) in rabbits.

METHODS

The right eye of 20 rabbits was injected intravitreally with 1.25 mg/0.05 mL bevacizumab. Both eyes of four rabbits each time were enucleated at days 1, 3, 8, 15, and 29. Bevacizumab concentrations were measured in serum, aqueous humor, and vitreous.

RESULTS

Maximum vitreous (406.25 μg/mL) and aqueous humor (5.83 μg/mL) concentrations of bevacizumab in the right eye were measured at day 1. Serum bevacizumab concentration peaked at day 8 (0.413 μg/mL) and declined to 0.032 μg/mL at 4 weeks. Half-life values in right vitreous, right aqueous humor, and serum were 6.61, 6.51, and 5.87 days, respectively. Concentration of bevacizumab in the vitreous of the noninjected eye peaked at day 8 (0.335 ng/mL) and declined to 0.218 ng/mL at 4 weeks. In the aqueous humor of the noninjected eye, maximum concentration of bevacizumab was achieved at day 8 (1.6125 ng/mL) and declined (to 0.11 ng/mL) at 4 weeks.

CONCLUSION

The vitreous half-life of 1.25 mg/0.05 mL intravitreal bevacizumab was 6.61 days in this rabbit model. Maximum concentrations of bevacizumab were reached at day 1 in both vitreous and aqueous humor of the right eye and at day 8 in the serum. Very low concentrations of bevacizumab were measured in the fellow noninjected eye.

Efficacy of intravitreal bevacizumab (Avastin) therapy for early and advanced neovascular age-related macular degeneration

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab therapy for early and advanced neovascular age-related macular degeneration (ARMD).

METHODS

A consecutive series of eyes with neovascular ARMD treated with monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml) as long as there was evidence of activity on fluorescein angiography (FA) and optical coherence tomography (OCT) was included and observed for 6 months. For further analysis they were assigned to either an early (untreated/newly diagnosed) or an advanced (predominantly fibrotic/pre-treated) ARMD group. We examined distance visual acuity (VA) with Early Treatment Diabetic Retinopathy Study (ETDRS) charts and central retinal thickness with OCT, as well as lesion size and safety aspects.

RESULTS

Forty-four patients (44 eyes) were enrolled (21 early lesions, 23 advanced lesions). Mean VA changed from 0.74 logMAR at baseline to 0.68 logMAR at month 6 (P = 0.01). Improvement in VA was statistically significant only in eyes with early lesions (n = 21) from month 1 (P = 0.015) up to month 6 (P = 0.03). The changes in central retinal thickness (CRT) (P < 0.001) and total lesion size (P < 0.001) were significant in both groups (early and advanced) at all time-points during follow-up. No significant ocular or systemic adverse effects were observed.

CONCLUSION

Intravitreal bevacizumab was tolerated well by our patients and we did not identify any apparent short-term safety concerns. We observed stabilization in VA overall, with significant improvement in the early lesion group.

Primary intravitreal bevacizumab for diffuse diabetic macular edema: the Pan-American Collaborative Retina Study Group at 24 months

PURPOSE

To report the 24-month anatomic and Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) response after primary intravitreal bevacizumab (Avastin; Genentech, Inc., San Francisco, CA; 1.25 or 2.5 mg) in patients with diffuse diabetic macular edema (DDME). In addition, a comparison of the 2 different doses of intravitreal bevacizumab (IVB) used is presented.

DESIGN

Retrospective, multicenter, interventional, comparative case series.

PARTICIPANTS

The clinical records of 115 consecutive patients (139 eyes) with DDME at 11 centers from 8 countries were reviewed.

METHODS

Patients were treated with at least 1 intravitreal injection of 1.25 or 2.5 mg of bevacizumab. All patients were followed up for 24 months. Patients underwent ETDRS BCVA testing, ophthalmoscopic examination, optical coherence tomography (OCT), and fluorescein angiography (FA) at the baseline, 1-, 3-, 6-, 12-, and 24-month visits.

MAIN OUTCOME MEASURES

Changes in BCVA and OCT results.

RESULTS

The mean age of the patients was 59.4+/-11.1 years. The mean number of IVB injections per eye was 5.8 (range, 1-15 injections). In the 1.25-mg group at 1 month, BCVA improved from 20/150 (0.88 logarithm of the minimum angle of resolution [logMAR] units) to 20/107, 0.76 logMAR units (P<0.0001). The mean BCVA at 24 months was 20/75 (0.57 logMAR units; P<0.0001). Similar BCVA changes were observed in the 2.5-mg group: at 1 month, BCVA improved from 20/168 (0.92 logMAR units) to 20/118 (0.78 logMAR units; P = 0.02). The mean BCVA at 24 months was 20/114 (0.76 logMAR units; P<0.0001). In the 1.25-mg group, the mean central macular thickness (CMT) decreased from 466.5+/-145.2 microm at baseline to 332.2+/-129.6 microm at 1 month and 286.6+/-81.5 microm at 24 months (P<0.0001). Similar results were obtained in the 2.5-mg group.

CONCLUSIONS

Primary IVB at doses of 1.25 to 2.5 mg seem to provide stability or improvement in BCVA, OCT, and FA in DDME at 24 months. The results show no evident difference between IVB at doses of 1.25 or 2.5 mg.

Pseudoxanthoma elasticum: genetics, clinical manifestations and therapeutic approaches

Pseudoxanthoma elasticum (PXE) is an inherited disorder that is associated with accumulation of mineralized and fragmented elastic fibers in the skin, vascular walls, and Bruch's membrane in the eye. Clinically, patients exhibit characteristic lesions of the posterior segment of the eye including peau d'orange, angioid streaks, and choroidal neovascularisations, of the skin including soft, ivory-colored papules in a reticular pattern that predominantly affect the neck and large flexor surfaces, and of the cardiovascular system with peripheral and coronary arterial occlusive disease as well as gastrointestinal bleedings. There is yet no definitive therapy. Recent studies suggest that PXE is inherited almost exclusively as an autosomal recessive trait. Its prevalence has been estimated to be 1:25,000-100,000. Very recently, the ABCC6 gene on chromosome 16p13.1 was found to be associated with the disease. Mutations within ABCC6 cause reduced or absent transmembraneous transport that leads to accumulation of extracellular material. Presumably, this mechanism causes calcification of elastic fibers. Despite the characteristic clinical features, the variability in phenotypic expressions, and the low prevalence may be responsible for the disease being underdiagnosed. This review compiles and summarizes current knowledge of PXE pathogenesis and clinical findings. Furthermore, different therapeutic strategies to treat retinal manifestations are discussed, including thermal laser coagulation, photodynamic therapy, and intravitreal injections of drugs inhibiting vascular endothelial growth factor.

Intraocular pharmacokinetics of bevacizumab after a single intravitreal injection in humans

PURPOSE

To investigate intraocular concentrations and pharmacokinetics of bevacizumab after a single intravitreal injection in humans.

DESIGN

Prospective, noncomparative, interventional case series.

METHODS

We included 30 nonvitrectomized eyes of 30 patients (age range, 43 to 93 years) diagnosed with clinically significant cataract and concurrent macular edema secondary to neovascular age-related macular degeneration, diabetic retinopathy, or retinal venous occlusion in the same eye. All patients received an intravitreal injection of 1.5 mg bevacizumab. Between one and 53 days after injection, an aqueous humor sample was obtained during elective cataract surgery. Concentrations of unbound bevacizumab in these samples were quantified by enzyme-linked immunosorbent assay.

RESULTS

Concentration of bevacizumab in aqueous humor peaked on the first day after injection with a mean concentration (c(max)) of 33.3 microg/ml (range, 16.6 to 42.5 microg/ml) and subsequently declined in a monoexponential fashion. Nonlinear regression analysis determined an elimination half-time (t(1/2)) of 9.82 days (R(2) = 0.81). No significant differences between diagnosis subgroups were noted.

CONCLUSIONS

In human nonvitrectomized eyes, the aqueous half-life of 1.5 mg intravitreally injected bevacizumab is 9.82 days.

Combined treatment of acute subretinal haemorrhages with intravitreal recombined tissue plasminogen activator, expansile gas and bevacizumab: a retrospective pilot study

PURPOSE

To assess the effectiveness of consecutive intravitreal injections of recombined tissue plasminogen activator (rtPA), expansile gas and bevacizumab in eyes with acute subretinal haemorrhage (SRH).

METHODS

A retrospective, non-randomized consecutive case series included 19 eyes in 19 patients with SRH related to exudative age-related macular degeneration (AMD). The initial size of the subfoveal SRH was 1-3 disc diameters. Each patient received a triple procedure using 0.05 ml rtPA (50 microg), 0.3 ml of sulphur hexafluoride (SF6) gas and 0.05 ml bevacizumab (1.25 mg). Lesion size, location of the SRH and early treatment in diabetic retinopathy study (ETDRS) visual acuity were evaluated pretreatment as well as 1 and 3 months after the procedure.

RESULTS

At the initial presentation, the patients' mean age was 77 years (range 63-88 years) and the mean duration of symptoms was 9.3 days (range 4-12 days). The mean visual acuity pretreatment (20/133) improved significantly to 20/86 at 1 month and to 20/74 at 3 months. The mean ETDRS visual acuity improved from baseline by 2.1 lines at 1 month (Wilcoxon ranks test; P < 0.005) and 3.7 lines at 3 months after treatment (Wilcoxon ranks test; P < 0.005). None of our patients had reading visual acuity prior to treatment, with visual acuity below 0.3. One month after the triple procedure, 25% of our patients had reading visual acuity (> or = 0.4); at 3 months, the figure was 35%. A successful inferior displacement of the SRH was achieved in 17/19 eyes. Eyes with elevated intraocular pressure were treated immediately by a corneal paracentesis.

CONCLUSION

The intravitreal application of rtPA, gas and bevacizumab appears to be beneficial and well tolerated in the treatment of SRH in the short term. The triple approach seems a logical alternative to the current combined dual approach in limiting the progression of the underlying disease and achieving better visual outcome. Further randomized evaluations are warranted.

[Monitoring of AMD patients on anti-vascular endothelial growth factor (VEGF) treatment. Practical notes on functional and anatomical examination parameters from drug approval studies, specialist information and case series]

Age-related macular degeneration (AMD) is one of the most common causes of blindness in western industrialised nations. Most AMD patients suffer from the dry early form of AMD; however, wet AMD with choroidal neovascularization (CNV) is the main cause of blindness in all AMD patients. New prospects have been developed in AMD treatment using pharmacological methods available for treating all subtypes of exudative AMD. A number of inhibiting and inducing growth factors, such as vascular endothelial growth factor (VEGF), are particularly important in the pathophysiology of wet AMD. The secreted VEGF appears to play a crucial role in the pathogenesis of CNV and macular edemas as a result of its angiogenetic and permeability-enhancing effect. This recognition led to the treatment approach now used, i.e., competitive VEGF blocking through intravitreal adminsitration of anti-VEGF drugs. The anti-VEGF durgs lead to a rapid decrease in retinal thickness. Optical coherence tomography (OCT) is a valuable monitoring tool, but may only be used to assist in decision-making. Clinical follow-up of patients and further treatment recommendations must always be guided by the overall clinical picture. Visual acuity is regarded as the decisive criterion for repeat treatment.

[Intravitreal injection. Monitoring to avoid postoperative complications]

Intravitreal injection is generally regarded as safe. Many of the potential complications caused by this procedure are extremely rare and can be avoided by careful inspection beforehand and proper performance of the injection. In rare cases, however, the administered drugs may cause various pharmacological side effects. This article summarizes the safety profiles of Macugen and Lucentis from the drug approval studies and describes initial findings on possible or observed side effects after intravitreal administration of Avastin. In addition, important points to observe in order to avoid intra- and postoperative complications are provided.

[Therapeutic anti-VEGF in ophthalmology: physiopathology and treatment of age-related macular degeneration]

Bei der altersabhängigen Makuladegeneration (AMD) handelt es sich um eine komplexe Erkrankung des Netzhaut-/Pigmentepithel-/ Aderhaut-Komplexes, die typischerweise zu einem Verlust der Sehschärfe und des zentralen Gesichtsfeldes führt. Bei der häufigen neovaskulären Spätform kann ein Sehverlust mittels VEGF-Inhibitoren verhindert und bei einem Teil der Patienten sogar erstmals eine Sehverbesserung erreicht werden.

Intravitreal bevacizumab (Avastin) treatment of diffuse diabetic macular edema in an Indian population

BACKGROUND

To report the anatomic and visual acuity response after intravitreal bevacizumab (Avastin) in patients with diffuse diabetic macular edema.

DESIGN

Prospective, interventional case series study.

MATERIALS AND METHODS

This study included 20 eyes of metabolically stable diabetes mellitus with diffuse diabetic macular edema with a mean age of 59 years who were treated with two intravitreal injections of bevacizumab 1.25 mg in 0.05 ml six weeks apart. Main outcome measures were 1) early treatment diabetic retinopathy study visual acuity, 2) central macular thickness by optical coherence tomography imaging. Each was evaluated at baseline and follow-up visits.

RESULTS

All the eyes had received some form of laser photocoagulation before (not less than six months ago), but all of these patients had persistent diffuse macular edema with no improvement in visual acuity. All the patients received two injections of bevacizumab at an interval of six weeks per eye. No adverse events were observed, including endophthalmitis, inflammation and increased intraocular pressure or thromboembolic events in any patient. The mean baseline acuity was 20/494 (log Mar=1.338+/-0.455) and the mean acuity at three months following the second intravitreal injection was 20/295 (log Mar=1.094+/-0.254), a difference that was highly significant ( P =0.008). The mean central macular thickness at baseline was 492 microm which decreased to 369 microm ( P =0.001) at the end of six months.

CONCLUSIONS

Initial treatment results of patients with diffuse diabetic macular edema not responding to previous photocoagulation did not reveal any short-term safety concerns. Intravitreal bevacizumab resulted in a significant decrease in macular thickness and improvement in visual acuity at three months but the effect was somewhat blunted, though still statistically significant at the end of six months.

Ocular Photodynamic Therapy – Standard Applications and New Indications (Part 2)

Photodynamic therapy (PDT) has become a well-established treatment for vascular forms of age-related macular degeneration (AMD). The implementation of evidence-based medicine principles into the treatment regimen of AMD seems to be immensly important, since AMD continues to be the most frequent cause of blindness among patients older than 65 years in industrialized countries. Numerous randomized prospective studies demonstrated high levels of evidence for the efficacy of various treatment approaches such as laser photocoagulation, PDT, subretinal surgery or novel anti-angiogenic drugs [Arch Ophthalmol 2006;124:597-599]. The high evidence shown by these studies supported the rationale to use PDT also in additional, less frequent, vasoproliferative diseases. Although these 'case series' and 'individual case control studies' have a low level of evidence, they give us important information for treatment decisions in these rare conditions. The goal of this survey is to review the current literature regarding PDT in vasoproliferative and exudative ocular diseases outside AMD. Many studies modified the treatment parameters of PDT to address the specific pathology of the underlying disease. Table 1 summarizes the diseases and treatment parameters that are described in this part 2, the entire table of this review is included in part 1 (www.karger.com/doi/10.1159/ 000101922).

Retinale Pigmentepithelrisse nach intravitrealem Bevacizumab bei AMD

PURPOSE

Intravitreal injection of the antibody bevacizumab is unofficially becoming more and more the "standard of care" in the treatment of neovascular AMD. After initial concerns about possible systemic adverse events of the drug, intravitreal injection has as yet shown a very good safety profile. Due to the common application of this VEGF inhibitor it is of great importance to report complications that may be related to the use of bevacizumab. In this scope we present a series of patients with predominantly serous detachment of the retinal pigment epithelium (PED), who developed a tear (rip) in the retinal pigment epithelium (RRPE) after intravitreal application of bevacizumab.

METHODS

Our data are based on a prospective, consecutive, interventional case series of 420 patients with neovascular AMD. These patients received at least 1 intravitreal application of 1.25 mg bevacizumab within the period of 1 year. Follow-up examinations were every 4-6 weeks. Visits were documented with best corrected visual acuity according to the ETDRS standard, biomicroscopy of the retina, intraocular pressure measurement, evaluation of central retinal thickness, fluorescein angiography and fundus photography.

RESULTS

Of 420 patients, 74 were classified as having predominantly serous PED. In the further course 13 out of 74 patients developed RRPE. Patients who had an intact subfoveal RPE, gained vision scores of 1.4+/-8.3 ETDRS letters (span width -15 to 14) despite RRPE or had stable Snellen vision of 0.0+/-0.1 logMar. In contrast patients with no subfoveal RPE due to RRPE showed loss of vision of -6.2+/-7.2 ETDRS letters (span width -15 to 1).

CONCLUSION

This case series describes RRPE as a novel complication of intravitreal anti-VEGF therapy with bevacizumab. However, it seems that this complication is limited to the entity of predominantly serous PED. These patients should therefore be informed about the risk of RRPE before initiating anti-VEGF therapy with bevacizumab, although the reverse conclusion to generally exclude patients with PED from anti-VEGF therapy is not justifiable due to therapeutic efficiency and associated gain of vision.

Non-responders to bevacizumab (Avastin) therapy of choroidal neovascular lesions

AIMS

To determine the characteristics of "non-responders" to intravitreal bevacizumab treatment in choroidal neovascularisation (CNV).

METHODS

Forty-three patients with visual loss due to neovascular age-related macular disease (ARMD) (44 eyes) underwent intravitreal injections of 1.25 mg (0.05 ml) bevacizumab and were followed up every 4 weeks for 2, 3 or 6 months. Re-injection was performed when persistent leakage of the CNV was determined by fluorescein angiography and retinal oedema was assessed by optical coherence tomography (OCT). Non-responders were defined as those patients having reduced or stable visual acuity at the last follow-up.

RESULTS

45% of the patients were non-responders. In this group the initial CNV size was significantly larger than in the responders. Initial reading ability was significantly lower in non-responders, but the initial foveal oedema was similar in both groups. Gains in mean visual acuity and reading ability were independent of lesion type. The proportion of non-responders to responders in the different lesion type groups was equally distributed. Only patients with the classic type of CNV seemed to respond better.

CONCLUSIONS

In this study initial reasons for non-responders to intravitreal bevacizumab treatment in CNV are given. The efficiency of bevacizumab depends on initial lesion size and initial reading ability, but is independent of the amount of intraretinal and subretinal fluid. There was no general ineffectiveness of bevacizumab with any particular lesion type.

Current treatment approaches in diabetic macular edema

PURPOSE

To review current treatment approaches in diabetic macular edema (DME).

METHODS

The underlying pathopathology, classifications and diagnostic examination techniques including fluorescein angiography, optical coherence tomography and stereoscopic biomicroscopy. Treatment modalities with focal or grid argon laser photocoagulation, pars plana vitrectomy with and without peeling of the inner limiting membrane (ILM), as well as intravitreal injections using triamcinolone acetonide or novel vascular endothelial growth factor (VEGF) inhibitors are described.

RESULTS

DME results from a series of biochemical and cellular changes, causing progressive leakage and exudation. Focal and grid photocoagulation remains the standard care for diabetic maculopathy. However, the availability of new agents raises the possibility of improvements if significant benefits can be validated in randomized clinical trials. Posterior vitreous attachments play a critical role through several mechanical or physiological mechanisms. Vitrectomy without ILM removal seems to be effective in reducing the retinal thickness and improving visual acuity.

CONCLUSION

A proper evaluation of the vitreous and retina is fundamental to select the most appropriate treatment approach in DME. While small microaneurysms with focal DME may be treated by conventional focal photocoagulation, diffuse DME which do not respond to grid photocoagulation may benefit from intravitreal injections using triamcinolone acetonide or novel VEGF inhibitors. Eyes with DME and additional vitreous traction may benefit from pars plana vitrectomy without ILM peeling. A combination of laser, pharmacological and surgical treatment modalities may be necessary to maintain central vision in eyes with DME.

[Intravitreal bevacizumab for recurring choroidal neovascularisation]

We administered bevacizumab intravitreally to treat a recurrence of CNV after confocal laser coagulation and photodynamic therapy in a 32-year-old female patient with a single functional eye. Before and after treatment the vision in the affected eye was stable at 1.0. Before administration of the VEGF antibody leakage was distinctly seen on fluorescein angiography, which did not appear on examination after the treatment. Despite the entailed measure of risk we decided in favour of intravitreal application because it seemed promising in view of earlier positive clinical experience with it in exsudative AMD and macular oedema following central retinal vein occlusion. Intravitreal bevacizumab is an alternative that should also be considered for the treatment of idiopathic CNV. Careful clinical studies will follow.

Intraokulare Injektion von Bevacizumab – Eine mögliche Therapie der sekundären CNV bei „angioid streaks“

Angioid streaks are the typical ophthalmological manifestation of the systemic disease pseudoxanthoma elasiticum. Fundoscopy reveals angioid streaks as irregular dark brownish lines radiating from the area around the optic disc. Choroidal neovascularization (CNV) is the major cause of severe visual loss in patients with angioid streaks. Argon-laser treatment of CNV secondary to angioid streaks shows poor results. Photodynamic therapy (PDT) with verteporfin does not seem to be an effective treatment for achieving stabilization of visual acuity and lesion size in CNV secondary to angioid streaks. Results after a combination of the intravitreal application of triamcinolone with PDT did not show the expected benefit. In the era of promising new intravitreal treatments for patients suffering from age-related macular degeneration, it is interesting to observe this effect of angiogenesis inhibitors (bevacizumab, ranibizumab, pegaptanib) in patients with neovascilarization secondary to angioid streaks. In our case, we observed a deterioration in visual acuity and leakage of the CNV after treatment with PDT alone. However, after the intravitreal injection of bevacizumab, we observed an improvement in vision, and the area of neovascularization changed into a fibrotic scar. A controlled study with long-term results is needed to definitively evaluate this kind of treatment.

Bevacizumab for neovascular ocular diseases

OBJECTIVE

To review the efficacy and safety of off-label use of bevacizumab for neovascular ocular diseases.

DATA SOURCES

A PubMed (1966-January 2007) search was conducted using the terms human, intravitreal, bevacizumab, macular, and retinopathy. Meeting abstracts from the American Academy of Ophthalmology, Retina Society, Macula Society, and Association for Research in Vision and Ophthalmology were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Controlled studies, unpublished reports involving 100 or more subjects, and published reports describing 5 or more subjects were reviewed. Only English-language articles were considered.

DATA SYNTHESIS

Intravitreal bevacizumab has been evaluated in 133 patients in unpublished controlled studies. Over 3500 patients have been evaluated in open-label studies with duration of follow-up ranging from 3 months to 1 year. The most common use was neovascular age-related macular degeneration (AMD). Other conditions studied included diabetic retinopathy, pathological myopia, neovascular glaucoma, and macular edema due to diabetes, retinal vein occlusion, or uveitis. Statistically significant improvements in visual acuity, as well as decreases in retinal thickness and the extent of choroidal neovascularization, were noted. Intravitreal bevacizumab was well tolerated over the short term. In a registry compiling adverse experiences of 7113 intravitreal injections, rates of adverse events were less than or equal to 0.21%.

CONCLUSIONS

Uncontrolled studies support a benefit of intravitreal bevacizumab in neovascular AMD for 3 months to 1 year. Low cost is a significant advantage of bevacizumab. Patients should discuss the potential risks and benefits of intravitreal bevacizumab and other available therapies with their physicians before receiving treatment. Controlled trials are needed to characterize the safety and efficacy of intravitreal bevacizumab and determine the optimal treatment regimen.

Intravitreally administered bevacizumab (Avastin) in minimally classic and occult choroidal neovascularization secondary to age-related macular degeneration

BACKGROUND

Anti-vascular endothelial growth factor (anti-VEGF) agents have been shown to be effective in the treatment of neovascular age-related macular degeneration (AMD). Efficacy and safety of intravitreally administered bevacizumab (Avastin), a humanized monoclonal anti-VEGF, was assessed in minimally classic and occult subfoveal choroidal neovascularization (CNV) due to AMD.

METHODS

A prospective interventional study was carried out. Bevacizumab (1.25 mg) was administered intravitreally on a 6-week basis until macular edema, subretinal fluid, and/or pigment epithelial detachment had resolved. Administration was repeated in case of relapse. Ophthalmic evaluations included a complete ophthalmic examination, measurement of the visual acuity (VA), optical coherence tomography, and fluorescein angiography. Main outcome measures were the changes between baseline and last follow-up visit in best-corrected VA, central foveal thickness (CFT) and total macular volume (TMV).

RESULTS

From 102 patients [mean age (range) 74.8 (61-85) years], 102 eyes were included. Median (range) duration of follow-up was 18 (6-24) weeks. Statistically significant changes from baseline were observed in best-corrected VA [increase of 1.29 lines (P=0.001)], CFT [reduction of 56 microm (P=0.01)] and TMV [reduction of 0.80 mm(3) (P<0.0001)]. Positive results were obtained in 65/102 (64%) patients after two to three injections as a mean. In a substantial proportion of patients (38%) followed up for at least 18 weeks, recurrence of leakage requiring additional injections was observed. Treatment was well tolerated; two pigment epithelium rips and ten posterior vitreous detachments were reported.

CONCLUSIONS

Short-term results suggest that intravitreally administered bevacizumab (Avastin) is effective in minimally classic and occult CNV due to AMD. Significant improvements in VA, CFT and TMV were obtained and maintained during follow-up. In some patients, however, recurrence of leakage requiring additional intravitreal injection occurred. Maintenance of the effect of bevacizumab and its safety after repeated and prolonged administration have to be investigated in well-controlled studies.