Recurrence of macular edema in retinal vein occlusions after treatment with intravitreal ranibizumab (Lucentis)

Associations between the Vessel Density in Deep Vascular Plexus and Macular Edema Recurrences in Patients with Retinal Vein Occlusion

INTRODUCTION

The aim of this study was to study the relationships between vessel density (VD) in different retinal vascular plexus and retinal vein occlusion-macular edema (RVO-ME) recurrence using wide-field swept source optical coherence tomography angiography (OCTA).

METHODS

Patients with a history of central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with macular edema in the Department of Ophthalmology, Shanghai General Hospital, from May 25, 2020, to January 12, 2023, were retrospectively reviewed and recruited. All patients were followed up for at least 6 months and divided in the release group and the recurrence group. The optical coherence tomography and OCTA examination were performed. Demographics, retinal structural, and angiographic data were collected and compared between two groups. The ordinal logistic regression was performed to assess the risk factors for RVO-ME.

RESULTS

A total of 85 patients were enrolled in this study. Among them, 30 patients had CRVO, while 55 had BRVO. The VD in the 6-9 mm ring in deep vascular plexus (DVP) was significantly higher in the recurrence group (25.414 ± 6.068% in the release group vs. 27.574 ± 7.767% in the recurrence group, p = 0.036). More patients with mean VD of the 6-9 mm ring in DVP no less than 30% were observed in the recurrence group (observed n = 20, expected n = 14.4, p = 0.043). The ordinal logistic regression reported that patients with mean VD of the 6-9 mm ring in DVP ≥30% had risk of RVO-ME increased to 11.508 (95% CI: 1.745-75.944, p = 0.011), when compared to the patients with mean VD of the 6-9 mm ring in DVP <20%, even with RVO type, baseline central macular thickness weighed.

CONCLUSION

High vessel density of the 6-9 mm ring in DVP, especially those ≥30%, was associated with macular edema recurrences in patients with retinal vein occlusion.

Increased intraocular inflammation in retinal vein occlusion is independent of circulating immune mediators and is involved in retinal oedema

We aim to understand the link between systemic and intraocular levels of inflammatory mediators in treatment-naïve retinal vein occlusion (RVO) patients, and the relationship between inflammatory mediators and retinal pathologies. Twenty inflammatory mediators were measured in this study, including IL-17E, Flt-3 L, IL-3, IL-8, IL-33, MIP-3β, MIP-1α, GRO β, PD-L1, CD40L, IFN-β, G-CSF, Granzyme B, TRAIL, EGF, PDGF-AA, PDGF-AB/BB, TGF-α, VEGF, and FGFβ. RVO patients had significantly higher levels of Flt-3 L, IL-8, MIP-3β, GROβ, and VEGF, but lower levels of EGF in the aqueous humor than cataract controls. The levels of Flt-3 L, IL-3, IL-33, MIP-1α, PD-L1, CD40 L, G-CSF, TRAIL, PDGF-AB/BB, TGF-α, and VEGF were significantly higher in CRVO than in BRVO. KEGG pathway enrichment revealed that these mediators affected the PI3K-Akt, Ras, MAPK, and Jak/STAT signaling pathways. Protein-Protein Interaction (PPI) analysis showed that VEGF is the upstream cytokine that influences IL-8, G-CSF, and IL-33 in RVO. In the plasma, the level of GROβ was lower in RVO than in controls and no alterations were observed in other mediators. Retinal thickness [including central retinal thickness (CRT) and inner limiting membrane to inner plexiform layer (ILM-IPL)] positively correlated with the intraocular levels of Flt-3 L, IL-33, GROβ, PD-L1, G-CSF, and TGF-α. The size of the foveal avascular zone positively correlated with systemic factors, including the plasma levels of IL-17E, IL-33, INF-β, GROβ, Granzyme B, and FGFβ and circulating high/low-density lipids and total cholesterols. Our results suggest that intraocular inflammation in RVO is driven primarily by local factors but not circulating immune mediators. Intraocular inflammation may promote macular oedema through the PI3K-Akt, Ras, MAPK, and Jak/STAT signaling pathways in RVO. Systemic factors, including cytokines and lipid levels may be involved in retinal microvascular remodeling.

Non-dipping pattern of nocturnal blood pressure as a risk factor for macular ischemia in branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is ocular vascular disease affecting approximately 14 million people worldwide, and is closely associated with high blood pressure (BP). Although macular ischemia is a critical factor in the visual prognosis of BRVO, the relationship between macular ischemia and different patterns of nocturnal BP is unknown. Here, we investigated whether a dipping pattern of nocturnal BP is associated with the development of macular ischemia in patients with BRVO. A total of 273 patients were reviewed; of these, 86 (86 eyes) patients were included. All recruited patients had a macular thickness map by optical coherence tomography and underwent 24-h ambulatory BP monitoring. According to their dipping patterns, the participants were divided into dipper and non-dipper groups. The non-dipper group had worse visual outcomes at the initial and 6-month visits (P = 0.014 and P = 0.003, respectively). Five of 32 eyes (15.6%) in the dipper group and 32 of 54 (59.3%) in the non-dipper group had macular ischemia. In a multivariate analysis, the night-to-day systolic BP ratio was associated with the degree of macular ischemia (β = - 0.313, P = 0.004). Thus, a non-dipping pattern may be a risk factor for macular ischemia in patients with BRVO.

COMBINATION THERAPY OF INTRAVITREAL RANIBIZUMAB AND SUBTHRESHOLD MICROPULSE PHOTOCOAGULATION FOR MACULAR EDEMA SECONDARY TO BRANCH RETINAL VEIN OCCLUSION: 6-MONTH RESULT

This study suggests that the combination therapy of intravitreal ranibizumab and 577-nm subthreshold micropulse photocoagulation can treat macular edema secondary to macular edema secondary to branch retinal vein occlusion effectively, by decreasing the frequency of intravitreal ranibizumab injections than intravitreal ranibizumab monotherapy while maintaining good visual acuity at 6 months.

Purpose:

To determine the efficacy of the combination therapy of intravitreal ranibizumab (IVR) and 577-nm yellow laser subthreshold micropulse laser photocoagulation (SMLP) for macular edema secondary to branch retinal vein occlusion cystoid macular edema.

Methods:

Retrospective, consecutive, case–control study. Forty-six eyes of 46 patients with treatment-naive branch retinal vein occlusion cystoid macular edema were enrolled. The IVR + SMLP group consisted of 22 patients who had undergone both SMLP and IVR. Intravitreal ranibizumab group consisted of 24 patients who had undergone IVR monotherapy. Intravitreal ranibizumab therapy was one initial injection and on a pro re nata in both groups, and SMLP was performed at 1 month after IVR in the IVR + SMLP group. Preoperatively and monthly, best-corrected visual acuity and central retinal thickness were evaluated using swept source optical coherence tomography.

Results:

Best-corrected visual acuity and central retinal thickness significantly improved at 6 months in IVR + SMLP and IVR groups. Best-corrected visual acuity and central retinal thickness were not significantly different between the two groups at any time points. The number of IVR injections during initial 6 months in IVR group (2.3 ± 0.9) was significantly greater (P = 0.034) than that in IVR + SMLP group (1.9 ± 0.8).

Conclusion:

The combination therapy of IVR and SMLP can treat branch retinal vein occlusion cystoid macular edema effectively, by decreasing the frequency of IVR injections while maintaining good visual acuity.

Therapeutic Effect of Traditional Chinese Medicine on a Rat Model of Branch Retinal Vein Occlusion

Branch retinal vein occlusion (BRVO) is a common retinal vascular disorder leading to visual impairment. Currently, the general strategies for BRVO are symptomatic therapies. Cardiovascular aspects are essential risk factors for BRVO. The traditional Chinese medicine hexuemingmu (HXMM), consisting of tanshinol and baicalin, dilates the vasculature and accelerates microcirculation. Therefore, the aim of this study was to determine the efficacy and possible mechanism of HXMM in a BRVO rat model established by laser photocoagulation. Successful BRVO rat models were treated with different doses of HXMM. Fundus photography and fluorescein fundus angiography (FFA) of the animals were applied. The retinal layers were measured by optical coherence tomography (OCT). Full-field electroretinography (ffERG) was applied to evaluate the retinal function. The ear vein flow velocity was measured via a microcirculation detector. The expression of the vascular endothelial growth factor (VEGF-α) was measured via western blotting and immunofluorescent staining. Our study found that retinal edema predominantly occurred in the inner nuclear layer (INL) and outer nuclear layer (ONL). The retinal edema of the treated groups was significantly relieved in the early stage of BRVO as visualized via OCT detection and HE staining. The amplitudes of the b wave and oscillatory potentials (OPs) waves of ffERG in the treated groups were increased compared with those of the control group at several detection points (3, 5, 7, 10, 14, and 21 d postocclusion). The expression of VEGF-α was reduced in the treated groups at an early stage of BRVO. Furthermore, the ear vein flow velocity of the HXMM treatment groups was faster than that of the control group. Thus, our study indicates that the traditional Chinese medicine HXMM could ameliorate retinal edema and rescue the retinal structure and function in BRVO models through promoting occluded vein recanalization, improving microcirculation, and regulating the expression of VEGF-α.

Aflibercept Versus Bevacizumab and/or Ranibizumab for Recurrent Macular Edema Secondary to Central Retinal Vein Occlusion

PURPOSE

To compare functional and anatomic outcomes of treatment with intravitreal aflibercept versus bevacizumab and/or ranibizumab in patients with recurrent macular edema (ME) secondary to central retinal vein occlusion (CRVO).

METHODS

Retrospective, comparative case series of patients with recurrent ME in the setting of CRVO. Patients with recurrent ME received treatment with aflibercept (Group 1, G1) or bevacizumab and/or ranibizumab (Group 2, G2). Primary outcome measures were best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

RESULTS

Of the 20 eyes (20 patients) with recurrent ME included in the study, 9 received aflibercept (G1) and 11 received bevacizumab and/or ranibizumab (G2). Median BCVA at recurrence of ME and at most recent follow-up was 20/60 (G1) and 20/80 (G2) and 20/40 (G1) and 20/50 (G2, P > 0.05 for all comparisons), respectively. Median CFT at recurrence of ME and at most recent follow-up was 492 μm (G1) and 448 μm (G2) and 291 μm (G1) and 295 μm (G2, P > 0.05 for all comparisons), respectively. Complete resolution of ME for at least 4 months was found in 78% (G1) and 55% (G2) of patients with a median injection free interval of 11 (G1) and 13 (G2) months (P > 0.05).

CONCLUSIONS

In patients with recurrent ME secondary to CRVO, there was improvement in BCVA and CFT in all groups, although patients treated with aflibercept showed a trend toward better anatomical outcomes decreased need for recurrent injections.

Natural Short-term Course of Recurrent Macular Edema Following Intravitreal Bevacizumab Therapy in Branch Retinal Vein Occlusion

Purpose

To evaluate the 3-month natural course of recurrent macular edema secondary to branch retinal vein occlusion (BRVO) treated with intravitreal bevacizumab.

Methods

This retrospective, observational study included 36 eyes with macular edema secondary to BRVO. All patients were initially treated with intravitreal bevacizumab for macular edema. Recurrence of macular edema was either not treated (untreated group) or treated with a single intravitreal bevacizumab injection (treated group). Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared at the time of recurrence and 3 months later.

Results

At the time of recurrence, the mean CFT and logarithm of the minimum angle of resolution BCVA were 484.9 ± 124.1 µm and 0.58 ± 0.26 in the untreated group (n = 19) and 456.3 ± 126.8 µm and 0.51 ± 0.21 in the treated group (n = 17), respectively. Three months later, the mean CFT and BCVA had changed to 493.7 ± 123.9 µm and 0.62 ± 0.29 in the untreated group and 294.7 ± 104.4 µm and 0.40 ± 0.24 in the treated group, respectively. The differences in CFT and BCVA between the two time points were not significant in the untreated group (p = 0.106 and p = 0.687, respectively), whereas statistically significant differences were noted in the treated group (p = 0.002 and p < 0.001, respectively).

Conclusions

Unlike the first episode of macular edema following BRVO, recurrent macular edema following intravitreal bevacizumab therapy did not spontaneously resolve, suggesting the potential benefit of prompt treatment.

Positively charged armed nanoparticles demonstrate their precise delivery performance for effective treatment of chorioretinal diseases

Positively charged armed nanoparticles can accumulate in the ocular fundus by utilizing the natural intraocular electrical field, and further penetrate into the fundus sub-layers by optimizing their charge density.

The discrepancy between central foveal thickness and best corrected visual acuity in cystoid macular edema secondary to central retinal vein occlusion after intravitreal lucentis® injection

Cystoid macular edema is a common retinal disorder with the potential for significant vision-related morbidity, and intravitreal lucentis(®) injection is confirmed to be an effective therapy approach. In the present study, we investigated the discrepancy between central foveal thickness and best corrected visual acuity in such lesions and infered that intravitreal lucentis(®) injection may help the visual function, related to the renewal of cells.

Onset and duration of visual acuity improvement after dexamethasone intravitreal implant in eyes with macular edema due to retinal vein occlusion

PURPOSE

To evaluate the onset and duration of improvement in best-corrected visual acuity (BCVA) in eyes treated with dexamethasone intravitreal implant 0.7 mg (DEX implant) for macular edema after branch or central retinal vein occlusion.

METHODS

Post hoc analysis of data from 2 previously reported multicenter, 6-month, randomized sham-controlled clinical trials. Patients received a single DEX implant (n = 427) or sham procedure (n = 426) in the study eye. The primary endpoint was the percentage of eyes with ≥ 15-letter improvement in BCVA from baseline at postimplant Day 7.

RESULTS

The baseline mean BCVA was 20/80. At Day 7, 10.3% of DEX implant-treated eyes versus 4.0% of sham-treated eyes (P < 0.001) had ≥ 15-letter improvement in the BCVA, and 27.2% of DEX implant-treated eyes versus 10.6% of sham-treated eyes had ≥ 10-letter improvement (P < 0.001). The mean improvement at Day 7 was 5.3 letters (branch retinal vein occlusion, 5.1; and central retinal vein occlusion, 5.8) with DEX implant and 1.6 letters (branch retinal vein occlusion, 2.3; and central retinal vein occlusion, 0.1) with sham (P < 0.001). The mean time from initial observation of ≥ 15-letter BCVA gain to the last observation of ≥ 15-letter BCVA gain was 70 days.

CONCLUSION

Dexamethasone intravitreal implant treatment led to improvement in BCVA compared with sham procedure as early as postimplant Day 7. The duration of ≥ 3-line improvement was typically 2 to 3 months.

[Management of macular edema secondary to retinal vein occlusion]

BACKGROUND

In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO.

METHODS

A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article.

RESULTS

The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters.

DISCUSSION

Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

Comparison of intravitreal ranibizumab and bevacizumab for the treatment of macular edema secondary to retinal vein occlusion

AIM

To compare the efficacy of ranibizumab and bevacizumab for macular edema due to retinal vein occlusion (RVO).

METHODS

A retrospective study was conducted at a single academic institution. Eighty-one patients naïve to anti-VEGF therapy with RVO and macular edema were identified. Twenty-six eyes were treated with ranibizumab, 33 eyes with bevacizumab, and 22 eyes with bevacizumab then switched to ranibizumab (crossover). The main outcome was change in visual acuity at 3 months, 6 months, and final visit.

RESULTS

The mean visual acuity improved from 20/80 to 20/40 in the ranibizumab (R) group and from 20/125 to 20/60 in the bevacizumab (B) group (P=0.66). The mean change in central subfield thickness (CST) was -186 and -212µm, respectively (P=0.69). Mean time between injections was 94±21.1d in the R group and 103.8±10.5d in the B group (P=0.78). In the crossover group, mean initial visual acuity was 20/125, reached 20/60 at crossover, and remained 20/60 at conclusion (P=0.91).

CONCLUSION

Both ranibizumab and bevacizumab are effective for the treatment of RVO and appear to have similar visual and anatomic outcomes. Changing treatments from bevacizumab to ranibizumab did not result in further gains in visual acuity.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Long term visual outcome after arteriolar constriction in patients with branch retinal vein occlusion

AIM

To evaluate the final best corrected visual acuity (BCVA) in patients with branch retinal vein occlusion (BRVO) treated with either (1) laser arteriolar constriction (ACo) or (2) the standard treatment recommended by the Branch Vein Occlusion Study Group (grid laser photocoagulation (GLP) or only observation (if indication criteria for GLP were not met).

METHODS

358 BRVOs were treated in three different ways: early ACo (n=133) performed ≤9 weeks after onset of BRVO, late ACo (n=62) performed >9 weeks after onset and controls which included GLP and observation (n=163). The groups were further divided according to initial BCVA into: ≤0.1; 0.16-0.3 and ≥0.4.

RESULTS

Based on the proportion of 1 year BCVA≤0.1 as a risk category, the results of early ACo (3.8%) were significantly better than for the controls (22.7%, P<0.001) and late ACo (16.1%, P=0.006). The greatest difference in final BCVA was in patients with the worst initial VA (≤0.1). In the intermediate initial BCVA group 0.16-0.3, a significant difference was only found between the early ACo group and controls (P=0.007). There was no significant difference between any treatment group and prevalence of a final BCVA≤0.1 for patients with an initial BCVA≥0.4.

CONCLUSIONS

Early ACo significantly reduces the prevalence of a final BCVA≤0.1 in patients with BRVO and an initial BCVA≤0.3 compared to controls (standard treatment treated with GLP or observed).