Ranibizumab: a review of its use in the treatment of neovascular age-related macular degeneration

Mast cells in human choroid and their role in age-related macular degeneration (AMD)

The role of mast cells in physiologic and pathological processes extends far beyond the allergy processes: they are involved in wound healing, chronic inflammation, and tumor growth. This short article emphasizes the role played by mast cells in age-related macular degeneration (AMD). Mast cells can induce angiogenesis and are present around Bruch's membrane during the early and late stages of choroidal neovascularization in AMD. Proteolytic enzymes released by mast cells lead to thinning of the choroid in AMD as well as degradation of vascular basement membranes and Bruch's membrane, which in turn could result in retinal pigment epithelial death and choriocapillaris degeneration in geographical atrophy and exudative AMD.

A novel capsid-XL32-derived adeno-associated virus serotype prompts retinal tropism and ameliorates choroidal neovascularization

Gene therapy has been adapted, from the laboratory to the clinic, to treat retinopathies. In contrast to subretinal route, intravitreal delivery of AAV vectors displays the advantage of bypassing surgical injuries, but the viral particles are more prone to be nullified by the host neutralizing factors. To minimize such suppression of therapeutic effect, especially in terms of AAV2 and its derivatives, we introduced three serine-to-glycine mutations, based on the phosphorylation sites identified by mass spectrum analysis, to the XL32 capsid to generate a novel serotype named AAVYC5. Via intravitreal administration, AAVYC5 was transduced more effectively into multiple retinal layers compared with AAV2 and XL32. AAVYC5 also enabled successful delivery of anti-angiogenic molecules to rescue laser-induced choroidal neovascularization and astrogliosis in mice and non-human primates. Furthermore, we detected fewer neutralizing antibodies and binding IgG in human sera against AAVYC5 than those specific for AAV2 and XL32. Our results thus implicate this capsid-optimized AAVYC5 as a promising vector suitable for a wide population, particularly those with undesirable AAV2 seroreactivity.

Esophageal Ulcer After Intravitreal Ranibizumab Injection in a Patient With Age-Related Macular Degeneration

Ranibizumab is a monoclonal antibody fragment targeted against vascular endothelial growth factor (VEGF) A isoform (VEGF-A). This study aimed to report a case of esophageal ulcer that developed soon after intravitreal ranibizumab injection in a patient with age-related macular degeneration (AMD). A 53-year-old male patient diagnosed with AMD received ranibizumab through intravitreal injection in the left eye. Mild dysphagia occurred 3 days after receiving intravitreal ranibizumab injection for the second time. The dysphagia exacerbated remarkably and was accompanied by hemoptysis 1 day after receiving ranibizumab for the third time. Severe dysphagia accompanied by intense retrosternal pain and pant emerged after injecting ranibizumab for the fourth time. An esophageal ulcer was observed through ultrasound gastroscopy, covered with fibrinous tissue, and surrounded by flushing and congestive mucosae. The patient received proton pump inhibitor (PPI) therapy combined with traditional Chinese medicine (TCM) after discontinuation of ranibizumab. The dysphagia and retrosternal pain were gradually relieved after treatment. Afterwards, the esophageal ulcer has not relapsed since permanent discontinuation of ranibizumab. To our best knowledge, this was the first case of esophageal ulcer related to intravitreal ranibizumab injection. Our study indicated that VEGF-A played a potential role in the development of esophageal ulceration.

The state-of-the-art pharmacotherapeutic management of neovascular age-related macular degeneration

INTRODUCTION

Age-related macular degeneration (AMD) is a major cause of central visual loss in the developed world. Although the pathogenesis is not fully understood, vascular endothelial growth factor (VEGF) is considered the most important growth factor involved in angiogenesis and exudation in neovascular AMD eyes. Advances in anti-VEGF agents have changed the treatment approach for wet AMD, allowing better outcomes in visual acuity and retinal anatomy.

AREAS COVERED

The present review describes the main pharmacological and clinical characteristics of anti-VEGF drugs, focusing firstly on the molecules commonly in use and then on the new candidate therapies. We performed a comprehensive literature search using the PubMed database from 1 January 1993 to 1 June 2022, with search terms including anti-VEGF, biosimilar, neovascular macular degeneration, AMD, and safety.

EXPERT OPINION

The management of AMD is still onerous for both the physician and patient due to the great number of required injections. Current research is underway to resolve not only the economic burden but also the discomfort of patients, aiming to develop a drug with a different or a multiple target, increasing the potency whilst maintaining a good safety profile. Furthermore, clinical research is currently investigating different forms of drug administration.

Targeting vascular endothelial growth factor using retinal gene therapy

Pharmacotherapies targeting vascular endothelial growth factor (VEGF) have revolutionized the management for neovascular retinal disorders including diabetic retinopathy and neovascular age-related macular degeneration. However, the burden of frequent injections, high cost, and treatment resistance in some patients remain unresolved. To overcome these challenges, newer generations of anti-angiogenic biological therapies, engineered proteins, implantable delivery systems, and biopolymers are currently being developed to enable more sustained, longer-lasting treatments. The use of gene therapies for pathologic angiogenesis has garnered renewed interests since the first FDA-approval of a gene therapy to treat inherited retinal diseases associated with biallelic RPE65 mutations. Newer generations of viral vectors and novel methods of intraocular injections helped overcome ocular barriers, improving the efficiency of transduction as well as safety profile. In addition, unlike current anti-VEGF gene therapy strategies which employ a biofactory approach to mimic existing pharmacotherapies, novel genome editing strategies that target pro-angiogenic factors at the DNA level offer a unique and distinct mechanistic approach that can potentially be more precise and lead to a permanent cure. Here, we review current anti-VEGF therapies and newer pharmacologic agents under development, examine technologies and progress in adapting anti-VEGF gene therapies, and explore the future application of CRISPR-Cas9 technology to suppress ocular angiogenesis.

Ranibizumab: A Review in Retinopathy of Prematurity

Ranibizumab (Lucentis^®) is a monoclonal antibody fragment targeted against VEGF-A that is the first approved anti-VEGF agent for the treatment of retinopathy of prematurity (ROP). In the pivotal, randomized, phase III RAINBOW trial in infants with ROP, the majority of intravitreal ranibizumab recipients experienced treatment success at 24 weeks, with a numerically greater treatment success rate in the ranibizumab 0.2 mg (80% of patients) than laser therapy (66%) group without reaching statistical significance for superiority. Long-term effects on vision following ranibizumab treatment are not yet known, but interim analyses from the RAINBOW extension study do not show evidence of degraded vision. Adverse reactions to ranibizumab in pediatric patients were consistent with the known safety profile in adults, with most adverse reactions attributed to the intravitreal injection procedure. Furthermore, systemic VEGF suppression was not observed in clinical trials, which is congruent with the rapid systemic clearance of ranibizumab. Overall, ranibizumab is an effective and generally well tolerated treatment for ROP and is not associated with systemic VEGF suppression. Although results for its long-term effects on vision are not yet available, ranibizumab is a promising alternative option to laser therapy for treating ROP.

The Role of Inflammation in Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a blinding eye disease which incidence gradually increases with age. Inflammation participates in AMD pathogenesis, including choroidal neovascularization and geographic atrophy. It is also a kind of self-protective regulation from injury for the eyes. In this review, we described inflammation in AMD pathogenesis, summarized the roles played by inflammation-related cytokines, including pro-inflammatory and anti-inflammatory cytokines, as well as leukocytes (macrophages, dendritic cells, neutrophils, T lymphocytes and B lymphocytes) in the innate or adaptive immunity in AMD. Possible clinical applications such as potential diagnostic biomarkers and anti-inflammatory therapies were also discussed. This review overviews the inflammation as a target of novel effective therapies in treating AMD.

Aucuba japonica extract inhibits retinal neovascularization in a mouse model of oxygen-induced retinopathy, with its bioactive components preventing VEGF-induced retinal vascular hyperpermeability

Neovascularization in the retina is common pathophysiology of diabetic retinal microvasculopathy and exudative macular degeneration. Our study assessed the inhibitory activity of an ethanol-based extract of Aucuba japonica (AJE) on abnormal angiogenesis in the retina with a hyperoxia-induced neovascular retinopathy model. The inhibitory effects of aucubin, quercetin, and kaempferol, bioactive compounds, from A. japonica, on retinal vascular hyperpermeability were also examined. On the 7th postnatal day (P7), the C57BL/6 pups were exposed to a hyperoxic environment with 75% oxygen to develop the experimental angiogenesis in retinas. On the 12th postnatal day (P12), the pups were then returned to the normal atmospheric pressure of oxygen. From P12 to P16, the administration was intraperitoneal. The dose per day was 250 mg per kg weight. Retinal neovascularization was measured with retinal flat mounts prepared on P17. We also measured the vascular leakage mediated by the vascular endothelial growth factor (VEGF) in retinas. Mice treated with AJE had markedly smaller neovascular lesions, in comparison with vehicle-administered mice. AJE downregulated the expression of both VEGF protein and mRNA. In addition, aucubin, quercetin, and kaempferol ameliorated VEGF-induced retinal vascular leakage. The results of our study suggest that AJE is a potent antiangiogenic substance. AJE could also serve as a therapeutic agent for abnormal growth of vessels in the retina in patients with ischemic retinopathy. The bioactive compounds of AJE may be responsible for its antiangiogenic abilities.

The selection of highly specific and selective aptamers using modified SELEX and their use in process analytical techniques for Lucentis bioproduction

Aptamers for Lucentis were selected using 10 rounds of a modified and highly stringent SELEX process. Affinity column chromatography was used for the binding, partitioning, and elution steps, and the regeneration of ssDNA was performed via asymmetric PCR in the SELEX process. The interaction of aptamers with Lucentis was studied by means of the HADDOCK web server docking program. In addition, the secondary structures of aptamers were interrogated using the mfold web server to check common regions responsible for better affinity towards Lucentis. The two best aptamers for Lucentis (aptamers 1 and 25) were found to have dissociation constant (K_d) values between 23 and 35 nM by means of thermofluorimetric and non-faradaic impedance spectroscopy (NFIS) analysis. The low dissociation constants in the nanomolar range showed the high specificities of the aptamers for Lucentis. Selectivity tests were also performed using both aptamers with different proteins in which negligible responses were obtained from interfering proteins with respect to Lucentis. Although neither of the two aptamers showed prominent responses to the interfering proteins, slightly better selectivity was shown by aptamer 1. The same aptamers were tested for their application in the detection of Lucentis in spiked and real media broth samples. For this detection test, interdigitated (IDT) gold electrodes on a glass substrate were fabricated using standard photolithography and thermal deposition techniques. NFIS measurements were used for the label-free detection of Lucentis in samples. The linear ranges of detection for aptamers 1 and 25 were found to be 22–100 nM and 40–100 nM, respectively. The LODs for aptamers 1 and 25 were calculated to be 22 nM and 40 nM, respectively, which were significantly better than the values from a HPLC-based detection method (about 240 nM). The real sample analysis results were cross-checked via a standard HPLC method, and better correlation was found between the HPLC and aptamer 1 results than the aptamer 25 results; hence, aptamer 1 can be further analyzed and tested for use in affinity column chromatography and detection-kit/chip-based PAT for Lucentis bioproduction.

Highly specific and selective aptamers for Lucentis were selected using 10 rounds of a modified and highly stringent SELEX process.

Omega-3 and ranibizumab for age-related macular degeneration: A systematic review protocol

BACKGROUND

Omega-3 and ranibizumab (O3R) has been reported to treat age-related macular degeneration (ARMD) effectively. However, up to the present, no systematic review specifically addressed the efficacy of O3R for the treatment of ARMD. Therefore, in this study, we will propose to assess the efficacy and safety of O3R for the treatment of ARMD.

METHODS

We will search PUMBED, EMBASE, CINAHI, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, Wanfang Data, as well as the gray literature from inception up to the present. We will accept randomized controlled trials for assessing the efficacy and safety of O3R for ARMD. The primary outcomes include change in best corrected visual acuity and central retinal thickness. The secondary outcomes consist of changes in subfoveal choroidal thickness, macular atrophy, retinal average sensitivity, contrast sensitivity, glare disability, and quality of life. In addition, incidence and severity of adverse events will also be evaluated. Cochrane Collaboration tool will be used to assess the risk of bias for each included study. In addition, Grading of Recommendations Assessment, Development, and Evaluation tool will be utilized to assess the overall strength of the evidence. Two authors will independently carry out all procedures and any divergences will be solved through discussion with a third author. If it is possible, we will conduct meta-analysis and subgroup analysis concerning different interventions, risk of bias, and outcome measurements.

RESULTS

In this proposed study, we outline details of the aims and methods of efficacy and safety of O3R for the treatment of ARMD.

CONCLUSION

The findings of this systematic review will summarize current evidence of O3R for the treatment of patients with ARMD.

DISSEMINATION AND ETHICS

The results of the present study are expected to be published by peer-reviewed journals. This is a literature-based study. Thus, ethical approval is unnecessary for this study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019121177.

Electrospraying an enabling technology for pharmaceutical and biomedical applications: A review

Electrospraying (ES) is a robust and versatile technique for the fabrication of micro- and nanoparticulate materials of various compositions, morphologies, shapes, textures and sizes. The physics of ES provides a great degree of flexibility towards the materials design of choice with desired physicochemical and biological properties. Not surprising, this technology has become an important tool for the production of micro- and nanostructured materials, especially in the pharmaceutical and biomedical arena. In this review, a basic introduction to the fundamentals of ES along with a brief description of the experimental parameters that can be manipulated to obtain micro- and nanostructured materials of desired composition, size, and configuration are outlined. A greater focus of this review is to bring to light the broad range of electrosprayed materials and their applications in drug delivery, biomedical imaging, implant coating, tissue engineering, and sensing. Taken together, this review will provide an appreciation of this unique technology, which can be used to fabricate micro- and nanostructured materials with tremendous applications in the pharmaceutical and biomedical fields.

c-Jun-mediated microRNA-302d-3p induces RPE dedifferentiation by targeting p21Waf1/Cip1

Dedifferentiation of retinal pigment epithelium (RPE) cells and choroidal neovascularization (CNV) contributes to the pathogenesis of age-related macular degeneration (AMD). MicroRNAs (miRNAs) have crucial roles in AMD onset and progression. We thus aim to investigate the effects of miRNAs on RPE dedifferentiation and endothelium cell (EC) behavior, and analyze its downstream pathways. We have previously identified miR-302d-3p as the most downregulated miRNA signature along with RPE differentiation. Herein, in vitro study supported that miR-302d-3p induces RPE dedifferentiation typified by reduction of RPE characteristic markers, interrupts its phagocytosis, and promotes its migration, proliferation, and cell-cycle progression. c-Jun was identified as a potential upstream transcript factor for MIR302D, which might modulate RPE function by regulating miR-302d-3p expression. P21^Waf1/Cip1, a cyclin-dependent kinase inhibitor encoded by the CDKN1A gene, was identified as a downstream target of miR-302d-3p. Our data suggested that p21^Waf1/Cip1 could promote RPE differentiation, and inhibit its proliferation, migration, and cell-cycle progression. We also demonstrated that miR-302d-3p suppresses RPE differentiation through directly targeting p21^Waf1/Cip1. In addition, the miR-302d-3p/CDKN1A axis was also involved in regulating tube formation of ECs, indicating its potential involvement in CNV formation. Taken together, our study implies that miR-302d-3p, regulated by c-Jun, contributes to the pathogenesis of both atrophic and exudative AMD. MiR-302d-3p promotes RPE dedifferentiation, migration, proliferation and cell-cycle progression, inhibits RPE phagocytosis, and induces abnormal EC behavior by targeting p21^Waf1/Cip1. Pharmacological miR-302d-3p inhibitors are prospective therapeutic options for prevention and treatment of AMD.

Aster koraiensis Extract and Chlorogenic Acid Inhibit Retinal Angiogenesis in a Mouse Model of Oxygen-Induced Retinopathy

Aster koraiensis extract (AKE) is a standard dietary herbal supplement. Chlorogenic acid (CA) is the major compound present in AKE. Retinal neovascularization is a common pathophysiology of retinopathy of prematurity, diabetic retinopathy, and wet form age-related macular degeneration. In this study, we aimed to evaluate the effects of AKE and CA on retinal neovascularization in a mouse model of oxygen-induced retinopathy (OIR). Vascular endothelial growth factor- (VEGF-) induced tube formation was assayed in human vascular endothelial cells. Experimental retinal neovascularization was induced by exposing C57BL/6 mice to 75% oxygen on postnatal day 7 (P7) and then returning them to normal oxygen pressure on P12. AKE (25 and 50 mg/kg/day) and CA (25 and 50 mg/kg/day) were administered intraperitoneally for 5 days (P12–P16). Retinal flat mounts were prepared to measure the extent of retinal neovascularization at P17. The incubation of human vascular endothelial cells with AKE and CA (1–10 μg/mL) resulted in the inhibition of VEGF-mediated tube formation in a dose-dependent manner. The neovascular area was significantly smaller in AKE or CA-treated mice than in the vehicle-treated mice. These results suggest that AKE is a potent antiangiogenic agent and that its antiangiogenic activity may, in part, be attributable to the bioactive component CA.

EGHB010, a Standardized Extract of Paeoniae Radix and Glycyrrhizae Radix, Inhibits VEGF-Induced Tube Formation In Vitro and Retinal Vascular Leakage and Choroidal Neovascularization In Vivo

EGHB010 is a hot water extract of the rhizome mixture of Paeonia lactiflora Pallas and Glycyrrhiza uralensis Fisch. Choroidal neovascularization (CNV) and vascular leakage are the common pathophysiologies of age-related macular degeneration. In this study, we aimed to evaluate the effect of EGHB010 on retinal vascular leakage and laser-induced CNV in a rat model. Vascular endothelial growth factor- (VEGF-) induced tube formation was assayed in human retinal microvascular endothelial cells. Intravitreal VEGF-induced blood-retinal barrier breakdown was assayed in Sprague-Dawley rats. Experimental CNV was induced by laser photocoagulation in Brown Norway rats. EGHB010 (50 and 100 mg/kg/day) was administered orally for 10 days after laser photocoagulation. Choroidal flat mounts were prepared to measure the lesion size of CNV. Incubation of retinal vascular endothelial cells with EGHB010 (12.5 and 25 μg/mL) resulted in the inhibition of VEGF-induced tube formation in a dose-dependent manner. VEGF-mediated retinal vascular leakage was blocked by the oral administration of EGHB010. The CNV area was significantly lower in EGHB010-treated rats than in vehicle-treated rats. These results suggest that EGHB010 is a potent antiangiogenic agent. Thus, the oral administration of EGHB010 may have a beneficial effect in the treatment of vascular leakage and CNV in patients with age-related macular degeneration.

Tristetraprolin regulates the decay of the hypoxia-induced vascular endothelial growth factor mRNA in ARPE-19 cells

The aim of the present study was to investigate the effects of tristetraprolin (TTP) on the vascular endothelial growth factor (VEGF) mRNA and protein expression levels in retinal pigment epithelial cells under hypoxic conditions, and to consider the possibility of using TTP as a novel treatment tool for neovascular age‑related macular degeneration (AMD). Overexpression of TTP reduced the expression and secretion levels of VEGF in ARPE‑19 cells under hypoxic conditions. TTP destabilized the VEGF mRNA by binding to adenosine and uridine‑rich elements regions in its 3'‑untranslated region. Furthermore, conditioned medium (CM) from TTP‑overexpressing ARPE‑19 cells suppressed the tube formation in human umbilical vein endothelial cells compared with hypoxic CM. These findings indicate that regulation of TTP expression may be a promising therapeutic tool for neovascular AMD, however, further research is required.

The role of sub-retinal fluid in determining treatment outcomes in patients with neovascular age-related macular degeneration--a phase IV randomised clinical trial with ranibizumab: the FLUID study

Background

With increasing experience using anti-VEGF therapy for the treatment of neovascular age-related macular degeneration (nAMD), ophthalmologists have shifted away from a “one size fits all” to an “individualised” approach based on disease activity with the aim of achieving a fluid-free retina. The FLUID study investigates the non-inferiority of a Treat and Extend (T&E) protocol of 0.5 mg ranibizumab, which allows treatment extension in the presence of incomplete resolution of sub-retinal fluid (SRF) ≤200 μm at the foveal centre relative to a T&E protocol that requires complete resolution of all retinal fluid (i.e., both SRF and intra-retinal fluid [IRF]) in patients with nAMD.

Methods/Design

This 24 month, randomised, phase IV trial has completed recruitment of treatment-naïve patients randomised 1:1 to ranibizumab “intensive” treatment (complete resolution of IRF and SRF) or ranibizumab “relaxed” treatment (resolution of IRF or >200 μm SRF only at foveal centre). Patients in both arms follow a T&E regimen where extension decisions are based upon assessment of lesion activity: loss of ≥5 letters of visual acuity, new haemorrhage, presence of IRF and SRF on an optical coherence tomography (OCT) scan. The determination of SRF is conducted at a reading centre while the assessment of IRF is physician-determined. The primary endpoint is the mean change in best-corrected visual acuity (BCVA) from baseline to 24 months. Secondary endpoints include the mean change in central retinal thickness (CRT) from baseline to 12 and 24 months, the number of ranibizumab injections administered at 12 and 24 months, and the pharmacogenomic assessment of AMD Gene Consortium-identified single-nucleotide polymorphisms (SNPs) and their association with treatment response. Three hundred and forty seven (347) patients have been recruited by 16 Australian sites within approximately 16 months. A protocol to adjudicate on SRF has been established by the central reading centre and is demonstrating good concordance with investigator assessment.

Discussion

This study will provide important insights into retreatment criteria for managing nAMD using a T&E regimen. The current paper describes the clinical rationale for using a less intensive treatment approach using ranibizumab and details of the treatment protocol.

Trial registration

Trial registration number: NCT01972789. Date of registration: 24th October 2013.

Understanding the patient's lived experience of neovascular age-related macular degeneration: a qualitative study

PURPOSE

In industrialised populations age-related macular degeneration (ARMD) is the leading cause of visual disability of the elderly. Successful new treatment with anti-endothelial growth factors for neovascular-classified ARMD has led to a divergence in treatment and experiences of people ARMD. This study aimed to understand the participant's experience of neovascular ARMD, including ongoing treatment with anti-vascular endothelial growth factor.

METHODS

Twenty-five participants from one clinical site were qualitatively interviewed to elicit their experiences of treatment for neovascular ARMD.

RESULTS

Two major themes were identified. A life negotiated by neovascular ARMD captures the participants' experience of living with the condition and treatment regime for neovascular ARMD. The second major theme: Uncertainty displayed their appraisal of life, treatment and their perceived future.

CONCLUSIONS

Anxieties concerning the injections, new limitations to lifestyles, and an uncertain future all emerged from the data analysis. However, thankfulness for the treatment, the importance of familiar patterns in treatments and recovery and a guarded optimism also emerged. Knowledge of the experiences, anxieties and concerns of this patient population can be used to inform clinical practice and lead to patient-centred care.

A randomized trial to compare the safety and efficacy of two ranibizumab dosing regimens in a Turkish cohort of patients with choroidal neovascularization secondary to AMD

PURPOSE

To compare visual outcomes, number of visits and ranibizumab injections in patients treated with a Wait & Extend (W&E) or Treat & Observe (T&O) regimen.

METHODS

This 12-month, randomized, multicentre, open-label study enrolled patients aged ≥ 50 years with choroidal neovascularization (CNV) secondary to AMD who had not received anti-VEGF agents. Patients received three monthly injections of ranibizumab before randomization (1:1): (i) T&O patients were examined monthly and retreated if needed, (ii) W&E patients had a follow-up visit 1 month later. If no lesions were active, the interval to the next visit was extended by 2 weeks to a maximum of 8 weeks. Active lesions were re-treated and the follow-up schedule restarted. Primary end-point was change in BCVA at Month 12.

RESULTS

Of the 104 screened patients, 99 were eligible and received ≥ 1 ranibizumab injection; 93 were randomized (T&O: 45, W&E: 48). The median (interquartile range [IQR]) change in BCVA (logMAR) from baseline at Month 12 was similar between groups (T&O: -0.12 [0.38]; W&E: -0.18 [0.32], p = 0.267). Median (IQR) number of visits at study end (including screening, baseline and control visit after 1st injection) was 15.0 (1.0) for T&O, and 12.0 (2.0) for W&E (p < 0.001). Injection numbers were similar between groups (median [IQR]: 6.0 [3.0] and 5.0 [4.0], respectively, p = 0.215). Adverse events were similar between groups.

CONCLUSION

W&E regimen resulted in a similar efficacy and safety profile to the labelled T&O regimen in patients with CNV secondary to AMD, and may help reduce the burden of follow-up visits.

Vision Rehabilitation in Patients with Age-related Macular Degeneration

Background

The aim of this study was to investigate the rehabilitative process and visual rehabilitation outcomes in patients with central vision loss due to age-related macular degeneration (AMD).

Methods

Ninety-five subjects with AMD selected from the attendees of the National Centre of Services and Research for the Prevention of Blindness and Rehabilitation of Low Vision Patients—International Agency for Prevention of Blindness—IAPB Italia Onlus, were evaluated for this retrospective study. Low vision examination included psychological counseling, best corrected visual acuity (BCVA), near visual acuity, Pelli-Robson contrast sensitivity, and fixation stability analysis. Once the clinical assessment was completed, patients attended a low-vision rehabilitative pathway based on visual stimulation, devices training and, if needed, psychological support. Required magnification and reading speed were also evaluated.

Results

For the whole sample, the mean BCVA of the better eye was 0.7 (±0.2) LogMAR and of the worse eye was 1 (±0.2) LogMAR. Restoring reading ability was the most important focus for the patients examined as it was requested by 85% of the whole sample. Mean power of optical magnifying aids for near activities was 10.6 (±9.1) positive spherical diopters. Mean reading speed for the whole sample was 33.1 (±18.2) words per minute (wpm) before visual rehabilitation sessions and increased to 55.2 (±33.1) wpm after visual rehabilitation path. To cope with distance difficulties, 78 distance refractive correction, 10 Galilean telescopes, and 7 Keplerian telescopes were prescribed. For intermediate distance activities, 22 compensation lenses and 10 Galilean telescopes were suggested. Moreover, PC magnifier softwares were prescribed to nine patients. Sixty-five polarized medical filters were prescribed to reduce glare of sunlight. Because of unstable fixation in their better eye (32.3% (±19.7) within 2° circle and 54.8% (±22.9) within 4° circle) and visual acuity < 1.2 LogMAR in the fellow eye, 38 subjects, before starting the devices training sessions, attended a bio-feedback rehabilitation session with flickering pattern stimulus. In these subjects, fixation stability increased significantly to 75.6 (±14.9) within 2° and 89.4 (±19.5) within 4° ( P < 0.05), respectively.

Conclusions

Attending a customized low-vision intervention based on a multidisciplinary approach seems to be effective for improving visual functions in AMD. Both optical/electronic magnifiers and specific visual stimulation program can enhance visual performances.

Intravitreal Aflibercept Outcomes in Patients with Persistent Macular Exudate Previously Treated with Bevacizumab and/or Ranibizumab for Neovascular Age-Related Macular Degeneration

Purpose. To assess whether intravitreal aflibercept (2.0 mg) can effectively reduce persistent macular exudate and enhance visual acuity in ranibizumab (0.5 mg) and/or bevacizumab (1.25 mg) treatment resistant patients with neovascular age-related macular degeneration. Methods. This retrospective study included 47 treatment resistant eyes from 47 patients switched to intravitreal aflibercept injections after receiving a minimum of 3 injections with either ranibizumab or bevacizumab. Snellen visual acuity and optical coherence tomography were assessed just prior to the first injection (baseline) and prior to the fourth injection (final). Additionally, anatomical regions of persistent macular exudate were tracked to determine if these areas yielded varying responses to aflibercept. Results. At baseline, patients had received an average of 11.3 injections with any prior anti-VEGF drug (SD 5.96). For whole group analysis, baseline and final central retinal thickness were 370.57 µm and 295.7 µm (P ≤ .001), respectively. Baseline and final retinal fluid volumes were 4.81 mm³ and 4.37 mm³ (P ≤ .001), respectively. Baseline and final logMAR were 0.56 and 0.53 (P = 0.301), respectively. Anatomic location of persistent exudate did not appreciably alter treatment outcome. Conclusion. Central retinal thickness and total retinal fluid volume were reduced in ranibizumab and/or bevacizumab treatment resistant patients following three aflibercept injections. No appreciable change in visual acuity was noted.

Systemic adverse events after intravitreal bevacizumab versus ranibizumab for age-related macular degeneration: a meta-analysis

Objective

To assess whether the incidence of systemic adverse events differs between those who used bevacizumab and those who used ranibizumab in the treatment of age-related macular degeneration (AMD).

Methods

A systematic literature search was conducted to identify randomised controlled trials (RCTs) comparing the use of intravitreal bevacizumab with the use of ranibizumab in AMD patients. Results were expressed as risk ratios (RRs) with accompanying 95% confidence intervals (CIs). The data were pooled using the fixed-effect or random-effect model according to the heterogeneity present.

Results

Four RCTs were included in the final meta-analysis. Overall, the quality of the evidence was high. There were 2,613 treated patients: 1,291 treated with bevacizumab and 1,322 treated with ranibicizumab. No significant differences between bevacizumab use and ranizumab use were found in terms of the incidence of death from all causes, arteriothrombotic events, stroke, nonfatal myocardial infarction, vascular death, venous thrombotic events, and hypertension, with the pooled RRs being 1.11 (0.77, 1.61), 1.03 (0.69,1.55), 0.84 (0.39,1.80), 0.97 (0.48, 1.96), 1.24 (0.63, 2.44), 2.38 (0.94, 6.04), and 1.02 (0.29, 3.62), respectively.

Conclusions

The meta-analysis shows that both treatments are comparably safe. However, the findings from our study must be confirmed in future research via well-designed cohort or intervention studies because of the limited number of studies.

Resveratrol prevents the development of choroidal neovascularization by modulating AMP-activated protein kinase in macrophages and other cell types

The development of choroidal neovascularization (CNV) is a critical step in the pathogenesis of age-related macular degeneration (AMD), a vision-threatening disease. In this study, we used a mouse model of AMD to study the protective effects of resveratrol (RSV) supplementation against CNV as well as the underlying molecular mechanisms. Mice were orally pretreated with RSV daily for 5 days. On the fifth day, the mice underwent laser photocoagulation to induce CNV. One week after laser treatment, CNV volume was significantly lower in the RSV-treated mice compared with vehicle-treated animals. In addition, RSV treatment significantly inhibited macrophage infiltration into the retinal pigment epithelium (RPE)-choroid and suppressed the expression of inflammatory and angiogenic molecules, including vascular endothelial growth factor, monocyte chemotactic protein-1 and intercellular adhesion molecule-1. Importantly, RSV prevented the CNV-induced decrease in activated AMP-activated protein kinase and increase in activated nuclear factor-κB in the RPE-choroid complex. The regulatory effects of RSV on these molecules were confirmed in RPE, microvascular endothelial and macrophage cell lines. Inhibition of macrophage infiltration by RSV was confirmed by in vitro scratch and migration assays. RSV suppressed CNV development, reducing the levels of multiple cytokines secreted from several cell types and inhibiting macrophage migration. The direct effects of RSV on each cell type were confirmed in vitro. Although further studies are needed, RSV could potentially be applied in the clinic to prevent CNV development in AMD.

The effects of ranibizumab injections on fluorescein angiographic findings and visual acuity recovery in age-related macular degeneration

Aim

The objective of the study reported here was to evaluate the effect of ranibizumab on retinal circulation times and vessel caliber and to analyze the correlation of these factors with visual acuity (VA) prognosis in patients with age-related macular degeneration (AMD).

Subjects and methods

This prospective cohort study included 52 eyes of 46 patients (mean age 73.5 years [standard deviation 7.7]; 28 males, 18 females). The study parameters were best-corrected visual acuity (BCVA), central macular thickness (CMT) (pre- and posttreatment: for 3 months after the last injection), retinal circulation times, diameter of retinal arteriole (DRA), and diameter of retinal vein (DRV) (pre- and posttreatment: after a loading dose of three consecutive injections of ranibizumab with a 4-week interval in the initial phase). The pretreatment, posttreatment measurements, and their differences were recorded for analyses. The injections were repeated when needed. Eyes were grouped into one of two groups according to VA recovery: Group 1, cases showing significant recovery of VA (n=21, 37%), and Group 2, cases showing preservation of VA (n=22, 42%) and deterioration of VA (n=11, 21%). Differences were compared statistically in and between groups. Logistic regression analysis was undertaken to determine the correlation of these parameters with VA recovery.

Results

There was a significant reduction in DRA (P=0.007) and CMT levels (P<0.001) in both study groups after treatment. When the two groups were compared, the differences in pretreatment values of DRA (P=0.001), DRV (P=0.017), CMT (P=0.039), and mean BCVA (P=0.00) were found to be statistically significant. Posttreatment changes in DRA (P=0.013) and mean CMT (P=0.010) were found to be factors related to VA recovery by logistic regression analysis.

Conclusion

Our findings reveal that ranibizumab treatment is associated with decrease in DRA, CMT, and significant improvement in VA recovery. Further, taking into account the cases in which VA was preserved, when needed, ranibizumab should be re-injected after the loading dose.

Aflibercept in wet AMD: specific role and optimal use

Background

Vascular endothelial growth factor (VEGF) is a naturally occurring glycoprotein in the body that acts as a growth factor for endothelial cells. It regulates angiogenesis, enhances vascular permeability, and plays a major role in wet age-related macular degeneration. The consistent association between choroidal neovascularization and increased VEGF expression provides a strong reason for exploring the therapeutic potential of anti-VEGF agents in the treatment of this disorder. Blockade of VEGF activity is currently the most effective strategy for arresting choroidal angiogenesis and reducing vascular permeability, which is frequently the main cause of visual acuity deterioration. In recent years, a number of other molecules have been developed to increase the efficacy and to prolong the durability of the anti-VEGF effect. Aflibercept (EYLEA®; Regeneron Pharmaceutical Inc and Bayer), also named VEGF Trap-eye, is the most recent member of the anti-VEGF armamentarium that was approved by the US Food and Drug Administration in November 2011. Because of its high binding affinity and long duration of action, this drug is considered to be a promising clinically proven anti-VEGF agent for the treatment of wet maculopathy.

Objective

This article reviews the current literature and clinical trial data regarding the efficacy and the pharmacological properties of VEGF-Trap eye and describes the possible advantages of its use over the currently used “older” anti-VEGF drugs.

Methods

For this review, a search of PubMed from January 1989 to May 2013 was performed using the following terms (or combination of terms): vascular endothelial growth factors, VEGF, age-related macular degeneration, VEGF-Trap eye in wet AMD, VEGF-Trap eye in diabetic retinopathy, VEGF-Trap eye in retinal vein occlusions, aflibercept. Studies were limited to those published in English.

Results and conclusion

Two Phase III clinical trials, VEGF Trap-eye Investigation of Efficacy and Safety in Wet AMD (VIEW) 1 and 2, comparing VEGF Trap-eye to ranibizumab demonstrated the noninferiority of this novel compound. The clinical equivalence of this compound against ranibizumab is maintained even when the injections are administered at 8-week intervals, which indicates the potential to reduce the risk of monthly intravitreal injections and the burden of monthly monitoring.