A systematic review to assess the 'treat-and-extend' dosing regimen for neovascular age-related macular degeneration using ranibizumab

Home Optical Coherence Tomography Monitoring for Neovascular Age-Related Macular Degeneration: Transformative Technology or Cool Toy?

The pending introduction of home-based optical coherence tomography (OCT) in managing neovascular age-related macular degeneration (nAMD) has sparked interesting debates. Advocates assert that home-based OCT will revolutionize care of patients with nAMD, while skeptics question its real-world viability and point out its potential drawbacks. This article delves into the dichotomy, presenting the "pro" argument highlighting the transformative potential of home OCT and the "con" perspective, which scrutinizes the limitations and challenges to adapting the technology to the real-world setting. By exploring both sides of the discourse, we aim to address the promises and complexities surrounding the role of home OCT in the management of nAMD.

Efficacy, safety, and treatment burden of treat-and-extend versus alternative anti-VEGF regimens for nAMD: a systematic review and meta-analysis

This study aimed to compare efficacy and treatment burden of treat-and-extend (T&E) anti-VEGF against fixed and pro re nata (PRN) regimens for neovascular age-related macular degeneration (nAMD). MEDLINE, CENTRAL, and EMBASE were searched. Randomized-controlled trials and observational studies comparing T&E to PRN or fixed dosing for treatment-naïve AMD patients were included. Mean difference (MD) for visual acuity (VA) and number of injections are presented. Risk of bias was assessed according to Cochrane guidelines. Methodology was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). VA improvement was similar with T&E and fixed dosing at one (MD -0.08 letters, p = 0.95) and two years (MD 0.58 letters, p = 0.62). In contrast, VA improvements were significantly greater for T&E when compared against a PRN regimen at one (MD 3.95 letters, p < 0.0001) and two years (MD 4.08 letters, p < 0.001). Significantly fewer ranibizumab injections were administered in the T&E arm at one (MD -2.42 injections, p < 0.0001) and two years (MD -6.06 injections, p < 0.00001) relative to fixed dosing. Fewer aflibercept injections were likewise administered to patients on a T&E regimen versus fixed dosing at one year (MD -0.78 injections, p < 0.0001). Low-certainty evidence from the present synthesis implies that T&E preserves VA similar to fixed schedules with significantly fewer injections at one and two years. Also, patients with T&E dosing achieved better VA outcomes than those on PRN regimen but T&E dosing was associated with more injections.

Risk Factors and Treatment Strategy for Retinal Vascular Occlusive Diseases

Retinal occlusive diseases are common diseases that can lead to visual impairment. Retinal artery occlusion and retinal vein occlusion are included in the clinical entity, but they have quite different pathophysiologies. Retinal artery occlusion is an emergent eye disorder. Retinal artery occlusion is mainly caused by thromboembolism, which frequently occurs in conjunction with life-threatening stroke and cardiovascular diseases. Therefore, prompt examinations and interventions for systemic vascular diseases are often necessary for these patients. Retinal vein occlusion is characterized by retinal hemorrhage and ischemia, which may impair visual function via several complications such as macular edema, macular ischemia, vitreous hemorrhage, and neovascular glaucoma. Even though anti-vascular endothelial growth factor therapy is the current established first-line of treatment for retinal vein occlusion, several clinical studies have been performed to identify better treatment protocols and new therapeutic options. In this review, we summarize the current findings and advances in knowledge regarding retinal occlusive diseases, particularly focusing on recent studies, in order to provide an update for a better understanding of its pathogenesis.

A Real-World, Multicenter, 6-Month Prospective Study in Greece of the Effectiveness and Safety of Ranibizumab in Patients with Age-Related Macular Degeneration Who Have Inadequately Responded to Aflibercept: The “ELEVATE” Study

Purpose

Real-world evidence on short-term outcomes of ranibizumab in wet age-related macular degeneration (wAMD) following inadequate response to aflibercept is scarce. This study aimed to evaluate the functional and anatomic effects of switching to ranibizumab in cases of wAMD previously treated with aflibercept with inadequate response.

Patients and Methods

Prospective, observational study performed in eight ophthalmology hospital/private clinics in Greece, enrolling consented patients with active wAMD, ≥50 years-old, who had initiated ranibizumab ≥28 days and <2 months after their last aflibercept injection. Data were collected at enrollment, and at 1, 3 and 6 months post-treatment onset (post-baseline).

Results

Between September-2015 and November-2017, 103 eligible patients (56.3% females; mean age: 74.8±8.6 years) were consecutively enrolled. The age at AMD diagnosis in the study eye was 71.3±8.8 years. Aflibercept (median of 5 injections received over 11.3 months) had been discontinued for anatomical (in 69.9%) and/or functional (38.8%) reasons. At baseline (median: 24.3 months after wAMD diagnosis), choroidal neovascularization was occult in 69.1% of evaluable study eyes; 60.2% of the study eyes had pigment epithelial detachment (PED); 42.7% cysts; 21.4% fibrosis; 66.0% subretinal, and 59.2% intraretinal fluid. At 6 months post-baseline: a median of 3 ranibizumab injections (range: 1–6) had been received; the best-corrected visual acuity (BCVA)≥0 letter gain rate was 81.8%; the BCVA ≥15 letter gain rate was 17.0%; BCVA gain was 3.2 letters [mean increase: 3.2±10.0 letters; median: 0.0; p = 0.002]; PED greatest basal diameter (GBD; median: 1470.5 μm) also decreased (median decrease: 114.0 μm; p = 0.019). Baseline central retinal thickness (CRT; median: 312.0 μm) remained unchanged. One patient permanently discontinued ranibizumab due to adverse event occurrence, assessed as not causally related to ranibizumab. There were no ranibizumab-related adverse reactions.

Conclusion

Six-month treatment with ranibizumab in aflibercept inadequate responders led to visual acuity and PED GBD improvements, with no statistically significant CRT change.

A Delphi study on the clinical management of age-related macular degeneration

PURPOSE

Age-related macular degeneration (AMD) is one of the main causes of blindness and visual impairment worldwide. As achieving a dry macula is one of the main objectives in AMD management, the purpose of this work was to reach a consensus on the relevance of retinal fluid in function, disease activity control and treatment patterns.

METHODS

Forty-seven Portuguese ophthalmologists specialized in AMD participated in a DELPHI panel. Two rounds of presential meetings were conducted and a cut-off of 80% or more of votes was defined to consider answers consensual.

RESULTS

Consensus was reached for 11 out of 18 questions. These questions focused on the impact of anatomical results on visual acuity, standards exams and parameters to assess disease activity, frequency and factors which influence disease activity assessment, criteria to use non-fixed treatment regimens, usefulness of individualized regimens and conditions for treatment interruption. No consensus was obtained for relevance of the different fluid types in AMD prognosis, frequency of fluid presence assessment, factors commonly associated with progression to geographic atrophy, ideal conditions for a fixed treatment regimen, date of first disease activity assessment and parameters to monitor disease activity.

CONCLUSIONS

Consensus was achieved for over half of the questions assessed through this Delphi study. The questions for which no consensus was reached concerned either subjects that need further investigation or monitoring times which are influenced by resource availability. Raising awareness for these issues will allow the improvement of AMD management and treatment.

Short-Term Efficacy and Safety Outcomes of Brolucizumab in the Real-Life Clinical Practice

To report the early efficacy and safety outcomes of treatment with intravitreal injections of brolucizumab (IVT-B) in patients presenting neovascular age-related macular degeneration (nAMD) in a tertiary clinical setting. A retrospective case series of patients that received IVT-B with a minimum of two injections performed and at least 4 weeks of follow-up after last injection. Nineteen eyes of 19 patients were included. The number of IVT-B performed for the whole cohort was 58 injections; the mean number of IVT-B per patient was 3.0 ± 1.0 (range 2–6); the mean follow-up time was 14.4 ± 9.0 weeks. Mean baseline best-corrected visual acuity was 0.4 ± 0.4 logMAR and at the last follow-up was 0.4 ± 0.6 logMAR (p = 0.778). All eyes showed a reduction in retinal thickness, with the central macular thickness being 470 ± 151 μm at baseline and 360 ± 144 μm at the last follow-up (p = 0.001). Intra-retinal fluid was present at baseline in 12 eyes (63%) and in three eyes (16%) at the last follow-up (p = 0.065). Sub-retinal fluid was present at baseline in 17 eyes (89%) and at the last follow-up in three eyes (16%, p = 0.011). Pigment epithelium detachment was apparent in the 16 eyes (84%) at baseline and was still present in 14 eyes (73%, p = 0.811). One adverse event of intraocular inflammation was reported. In conclusion, our short-term experience showed that brolucizumab was highly effective in restoring the anatomy and in stabilizing the visual acuity of eyes with nAMD. Its safety profile should be evaluated carefully and needs further investigations.

Archway Randomized Phase 3 Trial of the Port Delivery System with Ranibizumab for Neovascular Age-Related Macular Degeneration

PURPOSE

To evaluate the safety and efficacy of the Port Delivery System with ranibizumab (PDS) for the treatment of neovascular age-related macular degeneration (nAMD).

DESIGN

Phase 3, open-label, randomized, visual acuity assessor-masked noninferiority and equivalence trial.

PARTICIPANTS

Patients with nAMD diagnosed within 9 months of screening previously treated with and responsive to anti-vascular endothelial growth factor therapy.

METHODS

Patients were randomized 3:2 to treatment with the PDS with ranibizumab 100 mg/ml with fixed 24-week (Q24W) refill-exchanges (PDS Q24W) or intravitreal ranibizumab 0.5-mg injections every 4 weeks (monthly ranibizumab).

MAIN OUTCOME MEASURES

Primary end point was change in best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter (letters) score from baseline averaged over weeks 36 and 40 (noninferiority margin,-4.5 letters; equivalence margin, ±4.5 letters).

RESULTS

Archway enrolled 418 patients; 251 were randomized to and 248 received treatment with the PDS Q24W, and 167 were randomized to and received treatment with monthly ranibizumab. Baseline BCVA was 74.4 letters (PDS Q24W arm) and 75.5 letters (monthly ranibizumab arm; Snellen equivalent, 20/32). Adjusted mean change in BCVA score from baseline averaged over weeks 36 and 40 was +0.2 letters (standard error [SE], 0.5 letters) in the PDS Q24W arm and +0.5 letters (SE, 0.6 letters) in the monthly ranibizumab arm (difference, -0.3 letters; 95% confidence interval, -1.7 to 1.1 letters). PDS Q24W was both noninferior and equivalent to monthly ranibizumab. Of 246 PDS-treated patients assessed for supplemental ranibizumab treatment, 242 (98.4%) did not receive supplemental ranibizumab treatment before the first refill-exchange procedure, including 4 patients who discontinued treatment before the first refill-exchange procedure. Prespecified ocular adverse events of special interest were reported in 47 patients (19.0%) in the PDS Q24W arm and 10 patients (6.0%) in the monthly ranibizumab arm, which included, in the former arm, 4 (1.6%) endophthalmitis cases, 2 (0.8%) retinal detachments, 13 (5.2%) vitreous hemorrhages, 6 (2.4%) conjunctival erosions, and 5 (2.0%) conjunctival retractions. Most ocular adverse events in the PDS Q24W arm occurred within 1 month of implantation.

CONCLUSIONS

Archway met its primary objective and PDS Q24W demonstrated noninferior and equivalent efficacy to monthly ranibizumab, with 98.4% of PDS-treated patients not receiving supplemental treatment in the first 24-week interval.

Rates of RNFL Thinning in Patients with Suspected or Confirmed Glaucoma Receiving Unilateral Intravitreal Injections for Exudative AMD

PURPOSE

This study evaluated whether the rate of retinal nerve fiber layer (RNFL) thinning is faster in eyes receiving intravitreal injections than in fellow uninjected eyes among patients suspected of having or confirmed to have glaucoma and exudative age-related macular degeneration (AMD).

DESIGN

Retrospective comparative cohort study.

METHODS

Patients with a diagnosis of unilateral exudative AMD and confirmed to have or suspected of having glaucoma in both eyes receiving unilateral intravitreal injections were identified. Those with ≥3 RNFL optical coherence tomography scans and ≥6 injections were included in the study. Rates of RNFL thinning in the injected eye versus the uninjected eye were estimated using linear mixed models. The main outcome measurement was the differences in rates of RNFL thinning in the injected versus the fellow uninjected eye. The effects of postinjection elevation of intraocular pressure (IOP), injection frequency, and number of injections were also evaluated.

RESULTS

A total of 53 patients met the inclusion criteria, receiving 26.4 ± 15.9 intravitreal injections. The average rate of RNFL thinning in uninjected eyes was -0.620 μm/year (P = .029). Injected eyes had an additional incremental loss of -0.385 μm/year, but this value was not statistically significant (95% confidence interval [CI]: -1.147 to 0.379 μm/year; P = .324). Subgroup analysis with only glaucoma patients (n = 33) also demonstrated a nonsignificant effect of injections (-0.568 μm/year; 95% CI: -1.454 to 0.319 μm/year; P = .212). Postinjection IOP elevation, injection frequency, and total number of injections were not associated with faster RNFL loss.

CONCLUSIONS

Among exudative AMD patients with glaucoma or suspected of having glaucoma, the rate of RNFL thinning in eyes receiving intravitreal injections did not significantly differ from that of fellow uninjected eyes.

Prospective, Longitudinal Pilot Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

OPTICAL COHERENCE TOMOGRAPHY LEAKAGE IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Identification of Choroidal Neovascularization Activity by Location and Quantification of Abnormal Fluid Under Anti-Vascular Endothelial Growth Factor Therapy

This study shows that optical coherence tomography leakage can identify and locate choroidal neovascularization–related abnormal fluid and its change after anti–vascular endothelial growth factor treatment in neovascular age-related macular degeneration eyes. Low optical reflectivity ratio correlates with functional outcome and may be a marker of early choroidal neovascularization reactivation. Simultaneous optical coherence tomography angiography examination provides a noninvasive analysis of fluid and choroidal neovascularization vascular morphology.

Purpose:

To test optical coherence tomography leakage in the identification and quantification of choroidal neovascularization–related fluid, its change after anti–vascular endothelial growth factor therapy in neovascular age-related macular degeneration eyes and its relation to functional outcome.

Methods:

Prospective analysis of a cohort of neovascular age-related macular degeneration cases treated with 2.0-mg intravitreal aflibercept. Eyes included were analyzed before, 1-week, and 1-month after one injection. Best-corrected visual acuity was assessed using Early Treatment Diabetic Retinopathy Study method. Optical coherence tomography leakage maps depicting low optical reflectivity (LOR) sites were acquired with OCT Cirrus AngioPlex (Zeiss, Dublin, CA). The LOR area ratio was correlated to retinal thickness and best-corrected visual acuity. Optical coherence tomography angiography was simultaneously performed.

Results:

Twenty-two eyes of 18 patients with neovascular age-related macular degeneration were included. The LOR ratio of the full retina scan and retinal pigment epithelium–Bruch layer decreased from baseline to Month 1 (P < 0.05). Changes in retinal thickness and LOR ratio were positively correlated (P < 0.05). Best-corrected visual acuity change correlated with the outer segment layer LOR change (rho = −0.53, P = 0.014), and LOR was inferior in better responders (P = 0.021). Optical coherence tomography leakage identified eyes with recurrent fluid in the external layers.

Conclusion:

Optical coherence tomography leakage identified and quantified the fluid related to choroidal neovascularization activity. Low optical reflectivity change in the outer segment layer correlates with functional outcome and increasing LOR in the external layers may be a marker of early recurrence. Combining optical coherence tomography angiography and optical coherence tomography leakage allows both for choroidal neovascularization morphology and activity analysis.

PRN Treatment of Neovascular AMD with Cycles of Three Monthly Injections

Purpose

To report the one and two year outcome of cycles of three, monthly anti-VEGF injections given upon reactivation of the disease in eyes with neovascular age-related macular degeneration (nAMD).

Methods

Retrospective study of naïve nAMD cases with more than one year of follow-up, treated with a protocol of cycles of three monthly injections of anti-VEGF drugs upon reactivation. Visual acuity (VA) and central macular thickness (CMT) are the main outcome measures.

Results

Twenty-six patients with a mean age of 78.15 ± 9.29 years (57.7% female) were included. The mean follow-up was 30.89 ± 6.95 months. Treatment started with bevacizumab in all patients but in six patients was switched to aflibercept due to inadequate response to intravitreal bevacizumab injection. The mean VA at baseline and at 12 and 24 months was 53.87 ± 21.84, 60.54 ± 21.13, and 53.68 ± 27.16 ETDRS letters, respectively. Patients gained a mean of 6.67± 13.7 (p = 0.013, 95% CI= 0.60 to 12.65) and 0.77±15.21 (p = 0.4, 95% CI: –5.65 to 7.2) letters at 12 and 24 months. CMT at baseline, 12, and 24 months was 403.55 ± 147.59, 323.95 ± 79.58, and 298.59 ± 77.161 µm, respectively. The number of injections in the first and second years were 7.65 ± 2.64 and 5.52 ± 3.01, respectively. Three eyes (12.5%) lost >15 letters at 24 months.

Conclusion

This protocol can stabilize or improve vision in 87.5% of nAMD patients and can reduce the number of visits.

Real-Time Monitoring the Effect of Cytopathic Hypoxia on Retinal Pigment Epithelial Barrier Functionality Using Electric Cell-Substrate Impedance Sensing (ECIS) Biosensor Technology

Disruption of retinal pigment epithelial (RPE barrier integrity is a hallmark feature of various retinal blinding diseases, including diabetic macular edema and age-related macular degeneration, but the underlying causes and pathophysiology are not completely well-defined. One of the most conserved phenomena in biology is the progressive decline in mitochondrial function with aging leading to cytopathic hypoxia, where cells are unable to use oxygen for energy production. Therefore, this study aimed to thoroughly investigate the role of cytopathic hypoxia in compromising the barrier functionality of RPE cells. We used Electric Cell-Substrate Impedance Sensing (ECIS) system to monitor precisely in real time the barrier integrity of RPE cell line (ARPE-19) after treatment with various concentrations of cytopathic hypoxia-inducing agent, Cobalt(II) chloride (CoCl₂). We further investigated how the resistance across ARPE-19 cells changes across three separate parameters: R_b (the electrical resistance between ARPE-19 cells), α (the resistance between the ARPE-19 and its substrate), and C_m (the capacitance of the ARPE-19 cell membrane). The viability of the ARPE-19 cells and mitochondrial bioenergetics were quantified with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay and seahorse technology, respectively. ECIS measurement showed that CoCl₂ reduced the total impedance of ARPE-19 cells in a dose dependent manner across all tested frequencies. Specifically, the ECIS program’s modelling demonstrated that CoCl₂ affected R_b as it begins to drastically decrease earlier than α or C_m, although ARPE-19 cells’ viability was not compromised. Using seahorse technology, all three concentrations of CoCl₂ significantly impaired basal, maximal, and ATP-linked respirations of ARPE-19 cells but did not affect proton leak and non-mitochondrial bioenergetic. Concordantly, the expression of a major paracellular tight junction protein (ZO-1) was reduced significantly with CoCl_2-treatment in a dose-dependent manner. Our data demonstrate that the ARPE-19 cells have distinct dielectric properties in response to cytopathic hypoxia in which disruption of barrier integrity between ARPE-19 cells precedes any changes in cells’ viability, cell-substrate contacts, and cell membrane permeability. Such differences can be used in screening of selective agents that improve the assembly of RPE tight junction without compromising other RPE barrier parameters.

Comparing Effectiveness of Three Different Anti-VEGF Treatment Regimens for Neovascular Age-Related Macular Degeneration: Two Years' Real-World Clinical Outcomes

Purpose

To compare and report the 2-year treatment outcomes from 3 different anti-VEGF treatment regimens in treating neovascular aged-related macular degeneration (nAMD): Ranibizumab pro re nata (Ranibizumab-PRN); Ranibizumab treat and extend (Ranibizumab-T&E); Aflibercept fixed first year dosing (7 injections) with treat and extend in subsequent year (Aflibercept-Fixed).

Methods

All treatment-naïve nAMD patients who completed 24 months of monitoring from a single treatment center were included. Patients received the initial loading dose of three injections (4-weekly interval), followed by one of the 3 treatment regimens. Primary outcomes were changes in visual acuity (VA) and central retinal thickness (CRT). Secondary outcome was number of injections required in each year. Data analysis included last observation carried forward (LOCF) for patients with incomplete year-2 follow-up.

Results

A total of 249 eyes (230 patients) were studied: 121 Ranibizumab-PRN; 65 Ranibizumab-T&E, and 63 Aflibercept-Fixed. Baseline median VA (ETDRS letters) for Ranibizumab-PRN, Ranibizumab-T&E, and Aflibercept-Fixed was 53.9, 61.1, and 54.9 letters, achieving final VA of 54.9, 65.1, and 65.1 letters, respectively. Hence, the number of letters increased at the end of 24 months for each group was +1.0 (Ranibizumab-PRN), +4.0 (Ranibizumab-T&E), highest +10.2 in Aflibercept-Fixed group. Median number of injections over 2 years (year-1/year-2) was 5/1 for Ranibizumab-PRN, 9/6 for Ranibizumab-T&E, and 7/5 for Aflibercept-Fixed. Both Ranibizumab-T&E and Aflibercept-Fixed also shared the same reduction of median CRT (115 µm), higher than Ranibizumab-PRN (83 µm).

Conclusion

We report VA improvement from all three different treatment regimens with both Aflibercept-Fixed and Ranibizumab-T&E regimens achieving the same higher final VA. Aflibercept-Fixed dosing may have more favorable efficacy with the highest VA gain and comparatively lower dosing frequency whereas Ranibizumab-T&E may be more efficient than Ranibizumab-PRN regimen, according to our study.

Questionnaire to Assess Life Impact of Treatment by Intravitreal Injections (QUALITII): Development of a patient-reported measure to assess treatment burden of repeat intravitreal injections

Objective

To understand patient burden of treatment of repeated intravitreal injections (IVI) in the management of exudative retinal diseases.

Methods and analysis

Participants were sampled from a large urban retina specialty practice in Houston, Texas, USA, based on history of ongoing receipt of IVI. The 50-item Questionnaire to Assess Life Impact of Treatment by Intravitreal Injections questionnaire was developed to evaluate the patient experience including discomfort, anxiety, inconvenience and satisfaction. Categorial principal components analysis (CATPCA) was performed to assess construct validity and internal consistency. A subset of these items was used to establish a measure of total treatment burden, referred to as the IVI Treatment Burden Score (TBS).

Results

142 patients participated in this study. CATPCA analysis revealed five dimensions of patient burden: disruption of normal routine or capacity, anxiety, frequency of visits, chronicity of disease and perceived treatment value or satisfaction. Together, these dimensions accounted for 67% of variance explained. Cronbach's alpha was 0.97. The most frequently cited cause of discomfort was the feeling after anaesthetic wore off. The most common source of anxiety was fear of injection and associated discomfort or pain. Regarding inconvenience, patients reported temporary postinjection debilitation, requiring an average of 8 hours for recovery per treatment. The most frequently identified sources of satisfaction were confidence in the provider or treatment and interactions with staff.

Conclusions

Understanding and quantifying the patient burden associated with repeated IVI for exudative retinal diseases can reveal opportunities to improve delivery methods. The TBS could serve to inform strategies to maximise treatment adherence and optimise patient experiences.

Associations of Variation in Retinal Thickness With Visual Acuity and Anatomic Outcomes in Eyes With Neovascular Age-Related Macular Degeneration Lesions Treated With Anti-Vascular Endothelial Growth Factor Agents

Question

Are fluctuations in retinal thickness associated with visual and anatomic outcomes in eyes with neovascular age-related macular degeneration treated with anti–vascular endothelial growth factor drugs?

Findings

In this study of 1731 participants from 2 randomized clinical trials, increasing variation in retinal thickness was associated with worse outcomes in post hoc analyses of protocol-directed treatment regimens.

Meaning

These findings suggest that fluctuating activity may be a marker for poor prognosis in eyes with neovascular age-related macular degeneration treated with anti–vascular endothelial growth factor drugs.

Importance

When initiating anti–vascular endothelial growth factor (VEGF) treatment for patients with neovascular age-related macular degeneration (nAMD), knowledge of prognostic factors is important for advising patients and guiding treatment. We hypothesized that eyes with greater fluctuation in retinal thickness over time have worse outcomes than eyes with less variation.

Objective

To investigate whether visual and anatomic outcomes in eyes with nAMD initiating anti-VEGF treatment are associated with fluctuations in retinal thickness.

Design, Setting, and Participants

In this study using data from the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) and the Inhibition of VEGF in Age-Related Choroidal Neovascularization (IVAN) randomized clinical trial, people with previously untreated nAMD were included. Data were collected from February 2008 to November 2012, and data were analyzed from April 2017 to April 2020.

Main Outcomes and Measures

Foveal center point thicknesses (FCPTs) were extracted from 1165 study eyes from CATT and 566 study eyes from the IVAN trial, excluding those with 3 measurements or less. For each eye, the SD of FCPT was calculated. Eyes were grouped by FCPT SD quartile. Associations of FCPT SD quartile with outcomes were quantified at month 24 or the last available visit by linear or logistic regression, adjusting for baseline best-corrected visual acuity (BCVA) and randomized allocations to drug and treatment regimen, for BCVA, development of fibrosis, and development of macular atrophy.

Results

Of the 1731 included patients, 1058 (61.1%) were female, and the mean (SD) age was 78.6 (7.4) years. The median (interquartile range) FCPT SD was 40.2 (27.1-61.2) in the IVAN cohort and 59.0 (38.3-89.4) in the CATT cohort. After adjustment for baseline BCVA and trial allocations, BCVA worsened significantly across the quartiles of FCPT SD; the difference between the first and fourth quartiles was −6.27 Early Treatment Diabetic Retinopathy Study letters (95% CI, −8.45 to −4.09). The risk of developing fibrosis and macular atrophy also increased across FCPT SD quartiles. Odds ratios ranged from 1.40 (95% CI, 1.03 to 1.91) for quartile 2 to 1.95 (95% CI, 1.42 to 2.68) for quartile 4 for fibrosis and from 1.32 (95% CI, 0.90 to 1.92) for quartile 2 to 2.10 (95% CI, 1.45 to 3.05) for quartile 4 for macular atrophy.

Conclusions and Relevance

Greater variation in retinal thickness in eyes with nAMD during treatment with anti-VEGF was associated with worse BCVA and development of fibrosis and macular atrophy in these post hoc analyses, despite protocol-directed treatment frequency. Practitioners may want to consider variation in retinal thickness when advising patients about their prognosis.

Digital Technology for AMD Management in the Post-COVID-19 New Normal

PURPOSE

The COVID-19 pandemic has put strain on healthcare systems and the availability and allocation of healthcare manpower, resources and infrastructure. With immediate priorities to protect the health and safety of both patients and healthcare service providers, ophthalmologists globally were advised to defer nonurgent cases, while at the same time managing sight-threatening conditions such as neovascular Age-related Macular Degeneration (AMD). The management of AMD patients both from a monitoring and treatment perspective presents a particular challenge for ophthalmologists. This review looks at how these pressures have encouraged the acceptance and speed of adoption of digitalization.

DESIGN AND METHODS

A literature review was conducted on the use of digital technology during COVID-19 pandemic, and on the transformation of medicine, ophthalmology and AMD screening through digitalization.

RESULTS

In the management of AMD, the implementation of artificial intelligence and "virtual clinics" have provided assistance in screening, diagnosis, monitoring of the progression and the treatment of AMD. In addition, hardware and software developments in home monitoring devices has assisted in self-monitoring approaches.

CONCLUSIONS

Digitalization strategies and developments are currently ongoing and underway to ensure early detection, stability and visual improvement in patients suffering from AMD in this COVID-19 era. This may set a precedence for the post COVID-19 new normal where digital platforms may be routine, standard and expected in healthcare delivery.

Efficacy of a Treat-and-Extend Regimen With Ranibizumab in Patients With Neovascular Age-Related Macular Disease: A Randomized Clinical Trial

Importance

Although the Canadian Treat-and-Extend Analysis Trial With Ranibizumab in Patients With Neovascular Age-Related Macular Disease (CANTREAT) reported herein and the Treat and Extend study provided data to show noninferiority of treat-and-extend (T&E) at 12 months, to date there are few data on 24-month T&E trials compared with monthly dosing.

Objective

To compare the efficacy of ranibizumab using a T&E regimen to monthly dosing in treatment-naive patients with neovascular age-related macular degeneration (nAMD) after 24 months.

Design, Setting, and Participants

A randomized, open-label, multicenter, noninferiority intention-to-treat trial with a margin of -5 letters in best-corrected visual acuity (BCVA) from baseline to 12 months between groups was conducted at 27 treatment centers in Canada. Participants included 580 patients with treatment-naive choroidal neovascularization secondary to AMD. The study was conducted from May 8, 2013, to August 28, 2018, and data analysis was performed between August 29 and September 12, 2018.

Interventions

Patients with nAMD were randomized 1:1 to receive intravitreal ranibizumab, 0.5 mg, in either a T&E or monthly dosing regimen.

Main Outcomes and Measures

Mean change in BCVA in Early Treatment of Diabetic Retinopathy Study letters from baseline to month 24.

Results

Of the 580 randomized patients, 350 were women (60.3%) and 547 were white (94.3%). Mean (SD) age was 78.8 (7.8) years. By the end of month 24, 466 of the 580 randomized patients (80.3%) had completed the study and participants in the T&E arm received a mean of 17.6 injections compared with 23.5 injections for the monthly arm, for a difference of 5.9 injections and visits over 2 years (95% CI, 5.4-6.5; P < .001). The mean (SD) BCVA improvement was not worse with the T&E arm, 6.8 (14.1) letters vs 6.0 (12.6) letters, compared with the monthly arm (difference, 0.9; 95% CI, -1.6 to 3.3; P = .21). There was a gain of 15 or more letters in 25.5% of the T&E group and 23.1% of the monthly treatment group (difference, 2.4%; 95% CI, -6.8% to 11.6%; P = .59) and a loss of 15 or more letters in 6.5% of the T&E group and 5.8% of the monthly treatment group (difference, -0.7%; 95% CI, -9.9% to 8.5%; P = .85).

Conclusions and Relevance

These findings suggest that change in vision from baseline is not worse with a T&E compared with a monthly regimen of ranibizumab for nAMD through 24 months, achieving clinically meaningful improvements in BCVA despite fewer injections and visits.

Trial Registration

ClinicalTrials.gov identifier: NCT02103738.

Bimonthly, treat-and-extend and as-needed ranibizumab in naïve neovascular age-related macular degeneration patients: 12-month outcomes of a randomized study

PURPOSE

To assess the noninferiority of the treat-and-extend (T&E) and fixed bimonthly regimens of 0.5 mg intravitreal ranibizumab as compared with the pro re nata (PRN) in naïve patients with neovascular age-related macular degeneration (nAMD).

METHODS

Phase IV, randomized, 12-month, multicentre trial. Patients aged ≥50 years with nAMD and visual impairment [best-corrected visual acuity (BCVA) between 23 and 78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters] were eligible. Patients (one eye per patient) were randomized to bimonthly, n = 103, T&E, n = 99 or PRN, n = 104. Noninferiority was established at five letters ETDRS.

RESULTS

The mean (95% CI) difference in BCVA at 12 months was 7.2 (4.2-10.2), 6.4 (2.9-9.8), and 8.0 (51.1-11.0) in the bimonthly, T&E and PRN, respectively. The bimonthly or T&E regimens were not inferior to the PRN scheme. All regimens were associated with a significant reduction of central subfield thickness and volume. The mean (95% CI) number of injections in the bimonthly regimen (7.6, 7.5-7.7) was similar as compared with the PRN regimen (7.4, 6.7-8.0) (p = 0.159) but lower than in the T&E regimen (9.3, 8.9-9.7) (p < 0.001).

CONCLUSION

At 12 months, bimonthly and T&E ranibizumab were noninferior to PRN in naïve nAMD.

Treat and extend versus fixed regimen in neovascular age related macular degeneration: A systematic review and meta-analysis

PURPOSE

To compare efficacy of treat and extend (T&E) versus fixed regimen treatment protocols in neovascular age-related macular degeneration (nAMD).

METHODS

Randomized clinical trials (RCTs) comparing T&E versus fixed regimen protocols for nAMD were systematically searched. Primary outcome was to compare the mean best corrected visual acuity (BCVA) change in T&E regimen versus fixed regimen. Secondary outcomes were change in the mean optical coherence tomography (OCT) central retinal thickness (CRT) and mean number of injections. Standardized mean difference (SMD) along with 95% confidence intervals (CIs) were calculated. Random-effect models were used for meta-analyses.

RESULTS

Four RCTs were included, with a total of 649 and 621 eyes in the T&E and fixed regimen cohort at 12 months, and 267 and 249 eyes at 24 months. Pooled analysis of mean BCVA change included all four RCTs at 12 months and two RCTs at 24 months, showing no difference between the two groups (12-month: SMD = 0.08, 95% CI: -0.20 to 0.35, p = 0.55; 24-month: SMD = 0.04, 95% CI: -0.13 to 0.21, p = 0.64). Pooled analysis of OCT CRT change at 12 months included three studies, showing no difference between the two groups (SMD = 0.03, 95% CI: -0.46 to 0.51, p = 0.91). Pooled analysis of mean injection number included all four RCTs at 12 months and two RCTs at 24 months, showing significant difference between the two groups (12-month: SMD = -1.11, 95% CI: -1.67 to -0.56, p < 0.001; 24-month: SMD = -1.34, 95% CI: -1.54 to -1.15, p < 0.001).

CONCLUSION

A T&E regimen proved as effective as a fixed dosage regimen throughout a 24-month follow-up and with a lower number of injections.

Correlation between the rate of intravitreal injections, use of aflibercept as a second-line treatment and visual impairment for wet AMD in Finland

PURPOSE

To correlate the rate of intravitreal anti-VEGF injections and the use of aflibercept as a second-line treatment with visual impairment throughout Finland.

METHODS

Information related to anti-VEGF treatment, proportions of bevacizumab and aflibercept and new visual impairments due to wet age-related macular degeneration (AMD) was gathered from 5 university hospitals and 14 central hospital districts between 2015 and 2017 covering 232 568 injections and 1172 visual impairments.

RESULTS

Between 2015 and 2017, the number of annual total anti-VEGF injections increased from 60 412 to 93 589 (+24.5% annual change) and of aflibercept injections from 8299 to 20 833 (+58.7% annual change). The 3-year average for total anti-VEGF injections ranged from 9.6 to 21.1 (median 13.3) per 1000 citizens between hospital districts and for aflibercept injections from 0.8 to 4.0 (median 1.9). According to the primary protocol for wet AMD, during 2015-2017, the number of total anti-VEGF injections increased from 10.9 to 15.2 per 1000 citizens with the pro re nata (PRN) protocol and from 11.3 to 18.9 with the treat-and-extend regimen (TER). The 3-year average of aflibercept injections as a second-line treatment, but not the total number of anti-VEGF or bevacizumab injections, inversely correlated with new onset visual impairments (R = -0.505, P = 0.027) in the hospital districts. The number of visual impairments did not differ between the hospital districts according to the PRN and TER protocols (1.23 ± 0.41 and 1.14 ± 0.67, respectively, per 1000 citizens aged ≥64 years, P = 0.713).

CONCLUSION

These results emphasize that the use of aflibercept injections as a second-line treatment may decrease new onset visual impairments.

Long-Term Visual Outcomes for a Treat-and-Extend Antivascular Endothelial Growth Factor Regimen in Eyes with Neovascular Age-Related Macular Degeneration: Up to Seven-Year Follow-Up

Purpose

To report long-term visual and anatomical outcomes in eyes with neovascular age-related macular degeneration (nAMD) treated with a treat-and-extend regimen (TER) of intravitreal antivascular endothelial growth factor (anti-VEGF) injections in real-world settings.

Methods

Retrospective cohort study of consecutive patients with nAMD treated with a TER of anti-VEGF intravitreal injections by a single retina specialist (GC). Patients with nAMD who had at least one year of follow-up were identified using an electronic database. Best-corrected visual acuity (BCVA), comprehensive ophthalmologic examination, and macular OCT were performed at each visit. Patients received a loading dose of three monthly intravitreal injections and then were treated according to a TER of bevacizumab, ranibizumab, and/or aflibercept. The number of injections, BCVA, and central retinal thickness (CRT) were evaluated during the follow-up period.

Results

180 eyes from 180 patients were included in the study. Mean age was 75 ± 9 (range: 51–96). Mean BCVA was 0.77 ± 0.64 LogMAR at baseline, 0.69 ± 0.58 LogMAR (p = 0.0057) after loading phase, 0.64 ± 0.55 LogMAR (p = 0.0001) after 6 months of TER, and 0.76 ± 0.71 LogMAR after 6 years of treatment (n = 32 at year 6). CRT decreased significantly after the loading phase (p = 0.0002). The mean number of intravitreal injections per year was 7.6 during the first three years of treatment and then decreased to 5.9 during year 4 to 7.

Conclusions

This retrospective study of 180 nAMD patients treated with a TER of intravitreal anti-VEGF demonstrates an initial improvement of BCVA after loading phase, followed by long-term visual stabilization for at least six years. These results were obtained with a high number of injections, averaging close to six injections per year during long-term follow-up. In light of the natural evolution of nAMD, these data support the long-term efficacy of this treatment under real-world conditions of heterogeneity of patients and type of anti-VEGF used.

Bone Morphogenetic Protein (BMP)4 But Not BMP2 Disrupts the Barrier Integrity of Retinal Pigment Epithelia and Induces Their Migration: A Potential Role in Neovascular Age-Related Macular Degeneration

Disruption of retinal pigment epithelial (RPE) barrier integrity and RPE migration are hallmark features in neovascular age-related macular degeneration (nAMD), but the underlying causes and pathophysiology are not completely well-defined. Herein, we aimed to evaluate the effect of bone morphogenetic proteins (BMPs) on the barrier function and migration of RPE. In particular, we investigated the role of BMP2 and BMP4 in these processes as our analysis of RNA-sequencing (seq) data from human donor eyes demonstrated that they are highly differentially expressed BMP members in macular RPE/choroid versus macular retina. We used electrical cell-substrate impedance sensing (ECIS) system to monitor precisely in real time the barrier integrity and migration of ARPE-19 after treatment with various concentrations of BMP2 or BMP4. Immunofluorescence was also used to assess the changes in the expression and the organization of the key tight junction protein, zona occludens (ZO)-1, in ARPE-19 cells under BMP2 or BMP4 treatment. This was followed by measuring the activity of matrix metalloproteinases (MMPs). Finally, RNA-seq and ELISA were used to determine the local and circulating levels of BMP2 and BMP4 in retinas and serum samples from nAMD donors. Our ECIS results showed that BMP4 but not BMP2 decreased the transcellular electrical resistance (TER) of ARPE-19 and increased their migration in comparison with control (vehicle-treated cells). Furthermore, immunofluorescence showed a disorganization of ZO-1 in BMP4-treated ARPE-19 not in BMP2-treated cells or vehicle-treated controls. This effect of BMP4 was associated with significant increases in the activity of MMPs, specifically MMP2. Lastly, these results were corroborated by additional findings that circulating but not local BMP4 levels were significantly higher in nAMD donor samples compared to controls. Collectively, our results demonstrated unreported effects of BMP4 on inducing RPE dysfunction and suggest that BMP4 but not BMP2 may represent a potential therapeutic target in nAMD.

Action on neovascular age-related macular degeneration (nAMD): recommendations for management and service provision in the UK hospital eye service

This publication and the expert roundtable meeting on which the article is based were sponsored by Bayer plc. Prescribing information for Eylea^® (aflibercept solution for injection) can be found at the end of the article.

This report by a group of UK retina specialists and health professionals considers best practice recommendations for the management of sight-threatening neovascular age-related macular degeneration (nAMD), based on collective experience and expertise in routine clinical practice. The authors provide an update for ophthalmologists, allied healthcare professionals and commissioners on practice principles for optimal patient care and service provision standards. Refinement of care pathways for nAMD has improved access to intravitreal anti-vascular endothelial growth factor therapy but there are still variations in care and reported outcomes between clinic centres. Innovative organisational models of service provision allow providers to better match capacity with increasing demand. The authors review the recent NICE guideline for diagnosis and management of AMD, considerations for switching therapies and stopping treatment and need for regular monitoring of non-affected fellow eyes in patients with unilateral nAMD. Actions for delivery of high-quality care and to improve long-term patient outcomes are discussed. Local pathways need to detail nAMD target time to treat, maintenance of review intervals to ensure proactive treatment regimens are delivered on time and appropriate discharge for patients deemed low risk or no longer benefiting from treatment. Actual visual acuity outcomes achieved and maintenance of the level of vision when disease stability is achieved are considered good measures for judging the quality of care in the treatment of patients with nAMD. Robust community referral pathways must be in place for suspected reactivation of choroidal neovascularisation and rapid referral for second eye involvement. Practical considerations for intravitreal injection therapy are outlined.

Efficacy of ranibizumab combined with photodynamic therapy on wet age-related macular degeneration

Efficacy and safety of intravitreal ranibizumab (IVR) combined with photodynamic therapy (PDT) in treating wet age-related macular degeneration (wAMD) were studied. A total of 130 eyes were collected from 130 wAMD patients treated in Affiliated to Qingdao University Yuhuangding Hospital of Yantai, of which 65 were given IVR combined with PDT (combination therapy group) and the remaining 65 were treated with simple IVR (ranibizumab group). The differences in best corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure, choroidal neovascularization (CNV) leakage, levels of serum vascular endothelial growth factor (VEGF) and transforming growth factor-β1 (TGF-β1) as well as complication rate were compared before and after treatment between the two groups. At 1, 3, 6 and 12 months after treatment, combination therapy group had remarkably better BCVA and notably smaller CMT than ranibizumab group. Fundus fluorescein angiography (FFA) showed that the area of macular degeneration was reduced markedly after treatment in both groups, and the area in combination therapy group was evidently smaller than that in ranibizumab group at 1, 3 and 6 months after treatment. At 3 months after treatment, the levels of serum VEGF and TGF-β1 declined obviously in the two groups compared with those before treatment. The IVR combined with PDT can effectively improve the visual acuity, decrease CMT and prominently reduce the area of macular degeneration of wAMD patients, and its therapeutic effects are long-standing and tolerable for the patients, so it is worthy of clinical popularization.

Real-Life Data in the Treatment of Neovascular Age-Related Macular Degeneration: Results from the Imaculaweb Registry Evaluated in a Single Italian Medical Retina Center

<b><i>Introduction:</i></b> The aim of this study is to assess and compare the long-term clinical efficacy of anti-VEGF drugs using the Imaculaweb registry. <b><i>Methods:</i></b> In this observational study based on the Imaculaweb registry, outcome measures were the number of injections, the change in mean visual acuity (VA) and central macular thickness (CMT), and the time between diagnosis and the first injection. <b><i>Results:</i></b> In total, 126 eyes of 109 patients were included in the study. The mean VA was 49.4 ± 21.4, 54.1 ± 22.2, 51.6 ± 24.9, and 48.3 ± 25.7 letters at baseline and at the 1-, 2-, and 3-year follow-ups, respectively. Significant VA increases (<i>p</i> = 0.0002 for the first year and <i>p</i> = 0.045 for the second year) were documented at years 1 and 2 but not at year 3 (<i>p</i> = 0.8). The mean number of injections was 5.2, 2.6, and 2.3 at the 1-, 2-, and 3-year follow-ups, respectively. In the first year, 30% of the patients received at least 7 injections, while only 6.4% received &#x3c;3 injections. CMT decreased significantly during the overall follow-up period, and intra- and subretinal fluid decreased (<i>p</i> &#x3c; 0.0001). <b><i>Conclusion:</i></b> Imaculaweb turned out to be an effective tool to collect and share clinical data as well as to monitor patient outcome.

Evaluation of efficacy and recurrence for anti-vascular endothelial growth factor therapy in idiopathic choroidal neovascularization

Background

This study aimed to evaluate the visual and morphological outcomes of intravitreal anti-VEGF therapy and the recurrence for idiopathic choroidal neovascularization (ICNV).

Methods

This retrospective study included 35 patients (35 eyes) with ICNV from July 2012 to October 2017. All patients received 1 intravitreal anti-VEGF injection followed by pro re nata injections until there was no sign of ICNV activity. This was defined as the first follow-up period. To evaluate ICNV recurrence, we continued to follow-up 27 of the 35 patients for at least 2 years after the initial diagnosis, and the longest follow-up period was 5 years. Additional injection was performed when ICNV recurred. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) were recorded and morphological improvement in optical coherence tomography (OCT) was assessed. Parameters that affect prognosis and recurrence were analysed.

Results

The mean follow-up period was 168.0 ± 34.82 weeks. Mean BCVA improved from 56.20 ± 14.13 letters at baseline to 73.31 ± 12.57 letters (P<0.01); Mean CRT decreased from 353.6 ± 98.70 μm at baseline to 273.1 ± 53.56 μm (P < 0.001) at the end of the first follow-up period. Better baseline BCVA indicated a better morphological improvement (P = 0.026) in OCT: the lesion had completely subsided with recovery of the foveal contour. Those with high baseline BCVA (more than 60 letters) showed significant resolution of CNV lesions (P = 0.036). ICNV recurred in six patients (22.2%), 1 of whom experienced 2 recurrences. The mean timing of recurrence was 90.83 ± 49.02 weeks after diagnosis. There was no significant correlation between ICNV recurrence and the morphological improvement (P = 0.633). The final BCVA in patients with recurrence did not differ from that in patients without recurrence (P = 0.065).

Conclusions

Intravitreal anti-VEGF therapy on a pro re nata basis was effective for treating ICNV. High baseline BCVA indicated a better prognosis. Re-treatment with anti-VEGF could effectively lead to resolution of recurrent ICNV. Disease recurrence had no significant effect on final visual prognosis and had no correlation with the morphological improvement during treatment, suggesting that follow-up for subsequent monitoring should be performed in all ICNV patients.

Patient Preferences for Anti-Vascular Endothelial Growth Factor Treatment for Wet Age-Related Macular Degeneration in Japan: A Discrete Choice Experiment

BACKGROUND

In Japan, intravitreal anti-vascular endothelial growth factor (anti-VEGF) dosing regimens for wet age-related macular degeneration (wAMD) include pro re nata, every 2 months, and treat-and-extend, resulting in different outcomes and patient burden. Although reflecting patient preferences in treatment decision-making is desirable, few studies have examined this in Japan. This study assessed the patients willingness to trade-off between different dosing regimens.

PATIENTS AND METHODS

Patients with wAMD were recruited from four Japanese university hospitals to complete a face-to-face cross-sectional survey. In a discrete choice experiment, patients were asked to choose their preferred option from two anti-VEGF treatment profiles shown side-by-side across a series of choice tasks. The profiles varied on four attributes: number of injections in 12 months, number of physician consultations in 12 months, chance of 1-year visual acuity (VA) improvement, and chance of 2-year VA maintenance. Preference weights were estimated using hierarchical Bayes' models.

RESULTS

Overall, 120 patients (30 treatment naïve and 90 anti-VEGF experienced) completed the survey. Patients were willing to accept an increase from three to approximately eight injections in 12 months to increase the chance of 1-year VA improvement from 25% to 40%. They would be willing to accept 11 injections in 12 months if the chance of 2-year VA maintenance increased from 80% to 96%. The most valued attributes were increasing the chance of 2-year VA maintenance and reducing the number of injections in 12 months, which were each about twice as important as decreasing physician consultations in 12 months and increasing the chance of 1-year VA improvement (p<0.001). Among the dosing regimens, patients most preferred treat-and-extend because of its higher chance of 2-year VA maintenance.

CONCLUSION

Informing patients with wAMD about the likelihood of long-term VA maintenance when selecting treatment may increase the acceptance of an optimal treatment regimen and number of injections.

Increase in the Population of Patients with Neovascular Age-Related Macular Degeneration Who Underwent Long-Term Active Treatment

To investigate changes in the size of the population of patients who are receiving long-term, active treatment for neovascular age-related macular degeneration (AMD). This retrospective, observational study included 3,380 patients who received anti-vascular endothelial growth factor injections (3,974 eyes). The injections performed were divided into the following three groups: group 1, injections performed right after the initial diagnosis; group 2, injections performed <24 months; and group 3, injection performed ≥24 months. Time-dependent changes in the proportion of injections in each group were analyzed. The total number of injections markedly increased from 431 in the 1st quarter of 2014 to 1,323 in the 4th quarter of 2018. There were significant changes in the proportion of injections in each group over time (P < 0.001). The proportions of group 1, group 2, and group 3 in the 1st quarter of 2014 were 17.4%, 65.4%, and 17.2%, respectively. The proportions changed to 10.6%, 50.2%, and 39.5% in the 4th quarter of 2018, respectively. The marked increase in the proportions of group 3 may suggest an increase in the patient population that underwent long-term active treatment. The socioeconomic influence of this trend should be considered when establishing future strategies for neovascular AMD.

Feasibility of support vector machine learning in age-related macular degeneration using small sample yielding sparse optical coherence tomography data

PURPOSE

A retrospective pilot study is conducted to demonstrate the utility of a novel support vector machine learning (SVML) algorithm in a small three-dimensional (3D) sample yielding sparse optical coherence tomography (spOCT) data for the automatic monitoring of neovascular (wet) age-related macular degeneration (wAMD).

METHODS

From the anti-vascular endothelial growth factor injection database, 588 consecutive pairs of OCT volumes (57.624 B-scans) were selected in 70 randomly chosen wAMD patients treated with ranibizumab. The SVML algorithm was applied to 183 OCT volume pairs (17.934 B-scans) in 30 patients. Four independent, diagnosis-blinded retina specialists indicated whether wAMD activity was present between 100 pairs of consecutive OCT volumes (9800 B-scans) in the remaining 40 patients for comparison with the SVML algorithm and a non-complex baseline algorithm using only retinal thickness. The SVML algorithm was assessed using inter-observer variability and receiver operating characteristic (ROC) analyses.

RESULTS

The retina specialists showed an average Cohen's κ of 0.57 ± 0.13 (minimum: 0.41, maximum: 0.83). The average κ between the proposed algorithm and the retina specialists was 0.62 ± 0.05 and 0.43 ± 0.14 between the baseline algorithm and the retina specialists. Using each of the four retina specialists as the reference, the proposed method showed a superior area under the ROC curve of 0.91 ± 0.03 compared to the ROC 0.81 ± 0.05 shown by the baseline algorithm.

CONCLUSION

The SVML algorithm was as effective as the retina specialists were in detecting activity in wAMD. Support vector machine learning (SVML) may be a useful monitoring tool in wAMD suited for small samples that yield sparse OCT data possibly derived from self-measuring OCT-robots.

EFFICACY AND SAFETY OF A TREAT-AND-EXTEND REGIMEN WITH AFLIBERCEPT IN TREATMENT-NAIVE PATIENTS WITH TYPE 3 NEOVASCULARIZATION: A 52-Week, Single-Arm, Multicenter Trial

PURPOSE

To evaluate 52-week efficacy and safety of a treat-and-extend regimen of intravitreal aflibercept 2 mg on treatment-naive Type 3 neovascularization lesions.

METHODS

Phase IV, prospective, open-label, single-arm, multicenter trial including patients with untreated Stage I/II Type 3 neovascularization lesions and baseline best-corrected visual acuity between 78 and 23 Early Treatment Diabetic Retinopathy Study letters. Primary endpoint: mean change in best-corrected visual acuity from baseline at 52 weeks.

RESULTS

Thirty-two eyes from 32 patients were included (mean ± SD age: 78.2 ± 7.7 years, 68.8% females, baseline best-corrected visual acuity: 57.9 ± 15.4 [Snellen fraction 20/70]). Best-corrected visual acuity increased by 10.5 ± 15.9 Early Treatment Diabetic Retinopathy Study letters at Week 52 (P = 0.0001). The mean foveal and choroidal thickness decreased by 129.1 ± 80.1 µm (P < 0.0001) and 64.3 ± 96.5 (P = 0.0001), respectively. The proportion of patients with intraretinal/subretinal fluid decreased from 28 (87.5%) at baseline to 3 (11.5%) at Week 52 (P < 0.0001). Pigment epithelial detachment and lesion area showed nonsignificant changes over 52 weeks. The mean number of injections was 8.0 ± 2.0. Seven (21.9%) patients experienced treatment-related adverse events and two (6.3%) experienced serious adverse events; one (3.1%) ocular serious adverse event requiring treatment withdrawal, endophthalmitis, and one (3.1%) nonocular spontaneously resolved serious adverse event, palpitations. One (3.1%) patient experienced an APTC ATE: nonfatal stroke not related to trial treatment.

CONCLUSION

A treat-and-extend regimen of aflibercept improves visual acuity and retinal edema in eyes with Type 3 neovascularization over 52 weeks with good tolerability.

Tolerating Subretinal Fluid in Neovascular Age-Related Macular Degeneration Treated with Ranibizumab Using a Treat-and-Extend Regimen: FLUID Study 24-Month Results

PURPOSE

To test the hypothesis that tolerating some subretinal fluid (SRF) in patients with neovascular age-related macular degeneration (nAMD) treated with ranibizumab using a treat-and-extend (T&E) regimen can achieve similar visual acuity (VA) outcomes as treatment aimed at resolving all SRF.

DESIGN

Multicenter, randomized, 24-month, phase 4, single-masked, noninferiority clinical trial.

PARTICIPANTS

Participants with treatment-naïve active subfoveal choroidal neovascularization (CNV).

METHODS

Participants were randomized to receive ranibizumab 0.5 mg monthly until either complete resolution of SRF and intraretinal fluid (IRF; intensive arm: SRF intolerant) or resolution of all IRF only (relaxed arm: SRF tolerant except for SRF >200 μm at the foveal center) before extending treatment intervals. A 5-letter noninferiority margin was applied to the primary outcome.

MAIN OUTCOME MEASURES

Mean change in best-corrected VA (BCVA), and central subfield thickness and number of injections from baseline to month 24.

RESULTS

Of the 349 participants randomized (intensive arm, n = 174; relaxed arm, n = 175), 279 (79.9%) completed the month 24. The mean change in BCVA from baseline to month 24 was 3.0 letters (standard deviation, 16.3 letters) in the intensive group and 2.6 letters (standard deviation, 16.3 letters) in the relaxed group, demonstrating noninferiority of the relaxed compared with the intensive treatment (P = 0.99). Similar proportions of both groups achieved 20/40 or better VA (53.5% and 56.6%, respectively; P = 0.92) and 20/200 or worse VA (8.7% and 8.1%, respectively; P = 0.52). Participants in the relaxed group received fewer ranibizumab injections over 24 months (mean, 15.8 [standard deviation, 5.9]) than those in the intensive group (mean, 17 [standard deviation, 6.5]; P = 0.001). Significantly more participants in the intensive group never extended beyond 4-week treatment intervals (13.5%) than in the relaxed group (2.8%; P = 0.003), and significantly more participants in the relaxed group extended to and maintained 12-week treatment intervals (29.6%) than the intensive group (15.0%; P = 0.005).

CONCLUSIONS

Patients treated with a ranibizumab T&E protocol who tolerated some SRF achieved VA that is comparable, with fewer injections, with that achieved when treatment aimed to resolve all SRF completely.

Evaluation of Pro-re-Nata (PRN) and Treat and Extend Bevacizumab treatment protocols in Sorsby Fundus Dystrophy

PURPOSE

To describe long-term outcomes with intravitreal Bevacizumab for choroidal neovascularization secondary to Sorsby fundus dystrophy.

MATERIALS/METHODS

Observational case series.

RESULTS

Two sisters of the same family formally diagnosed with Sorsby fundus dystrophy were followed-up for 12 years. The elder sister (S1) presented with significant decline in vision due to choroidal neovascularization in her right eye (OD). She developed choroidal neovascularization 3 years later in her left eye (OS). She was treated with Bevacizumab intravitreal injections on a on a pro-re-nata (PRN) until April 2015, when a treat-and-extend (T&E) approach was adopted. Best corrected visual acuities at the time of switch to T&E were 1.09 OD and 0.85 LogMar OS. Best corrected visual acuities at the last follow-up were LogMar 1.1 OD and 0.82 OS. Her younger sister (S2) presented with best corrected visual acuities of LogMar 0.1 OD and 0.0 OS. She developed choroidal neovascularization 5 years later in both eyes. OS developed choroidal neovascularization 18 months after her right eye. She received Bevacizumab on a pro re nata basis until April 2015 when a switch to a T&E was performed. Best corrected visual acuity in the left eye at the switch to T&E was 0.34 LogMar. At the last follow-up, best corrected visual acuities were LogMar 1.2 OD and 0.29 OS.

CONCLUSION

Bevacizumab is an effective therapy for choroidal neovascularization secondary to Sorsby fundus dystrophy. A T&E protocol appears more effective compared to pro re nata protocol in minimizing recurrence of choroidal neovascularization with potential secondary scar formation or atrophy.

Efficacy and Safety of an Aflibercept Treat-and-Extend Regimen in Treatment-Naïve Patients with Macular Oedema Secondary to Central Retinal Vein Occlusion (CRVO): A Prospective 12-Month, Single-Arm, Multicentre Trial

OBJECTIVES

To evaluate efficacy and safety of an aflibercept treat-and-extend (TAE) regimen in patients with macular oedema (MO) secondary to central retinal vein occlusion (CRVO).

DESIGN SETTING AND PATIENTS

Phase IV, prospective, open-label, single-arm trial in 11 Spanish hospitals. Treatment-naïve patients with <6 month diagnosis of MO secondary to CRVO and best-corrected visual acuity (BCVA) of 73-24 ETDRS letters were included between 23 January 2015 and 17 March 2016.

INTERVENTION

Intravitreal aflibercept 2 mg monthly (3 months) followed by proactive individualized dosing.

MAIN OUTCOMES

Mean change in BCVA after 12 months.

RESULTS

24 eyes (24 patients) were included; mean (SD) age: 62.8 (15.0) years; 54.2% male; median (IQR) time since diagnosis: 7.6 (3.0, 15.2) days. Mean BCVA scores significantly improved between baseline (56.0 (16.5)) and Month 12 (74.1 (17.6)); mean (95% CI) change: 14.8 (8.2, 21.4); P=0.0001. Twelve (50.0%) patients gained ≥15 ETDRS letters. Foveal thickness improved between baseline (mean: 569.4 (216.8) µm) and Month 12 (mean 257.4 (48.4) µm); P < 0.0001. At Month 12, 8.3% patients had MO. The mean (SD) number of injections: 8.3 (3.0). No treatment-related AEs were reported. Five (20.8%) patients experienced ocular AEs. Two nonocular serious AEs were reported.

CONCLUSIONS

An aflibercept TAE regimen improves visual acuity in patients with MO secondary to CRVO over 12 months with good tolerability.

Initiation and maintenance of a Treat-and-Extend regimen for ranibizumab therapy in wet age-related macular degeneration: recommendations from the UK Retinal Outcomes Group

The treatment of neovascular (wet) age-related macular degeneration (AMD) with ranibizumab is now very well established in terms of efficacy and safety. Recent clinical trials and real-world studies have demonstrated the advantages of a Treat-and-Extend (T&E) regimen, and many hospital departments are now in the process of adopting this new regimen in favor of the pro re nata regimen for initiating and continuing ranibizumab therapy for patients with wet AMD. The comprehensive spectrum of issues related to implementation of the regimen is covered qualitatively in ten didactic topics provided by a group of clinicians with direct experience of this regimen in their department. The topics include definition, new and previously treated eyes, management of high-frequency injections, maximum extensions, discontinuing T&E, bilateral cases, clerical, audit, and patient counseling. This article aims to provide a useful resource for the implementation of the T&E regimen. A quantitative summary of the visual outcomes in key publications is also provided in this article. This article should be a valuable resource for staff training.

The Treat-and-Extend Injection Regimen Versus Alternate Dosing Strategies in Age-related Macular Degeneration: A Systematic Review and Meta-analysis

PURPOSE

To assess outcomes of the treat-and-extend (T&E) injection regimen for neovascular age-related macular degeneration (AMD) as compared to either a monthly or a pro re nata (PRN) treatment strategy.

DESIGN

Systematic review and meta-analysis.

METHODS

Studies that compared the T&E regimen with either monthly or PRN dosing for treatment-naïve AMD were included. Trial eligibility, data extraction, and risk of bias were assessed according to Cochrane review methods. Estimates were pooled using random-effects meta-analysis.

RESULTS

Four eligible studies were identified, all using ranibizumab (total N = 940 eyes), including 2 randomized controlled trials comparing T&E to monthly and 2 retrospective reviews comparing T&E to PRN. No studies evaluating aflibercept were identified. Improvements in vision and central retinal thickness were similar between T&E and monthly at 12 months, with a mean difference of -1.79 letters (95% confidence interval [CI]: 3.70, 0.13) and 3.76 μm (95% CI: -13.78, 21.30) in favor of monthly injections. In contrast, visual gains were higher in the T&E compared to the PRN group (difference of +6.18 letters, 95% CI: 3.28, 9.08). Fewer injections were required using the T&E regimen when compared to monthly (mean of -1.6 and -6.9 injections at 12 and 24 months, respectively). A mean of 1.44 more injections was required for the T&E compared to PRN regimen at 12 months; however, this was achieved with fewer visits.

CONCLUSION

Despite the growing preference for the T&E regimen, there is limited head-to-head evidence comparing dosing strategies. The evidence available, however, suggests that at 12 months, T&E is comparable to monthly and superior to PRN dosing for both efficacy and safety outcomes when using ranibizumab.

Safety and Feasibility of a Novel Sparse Optical Coherence Tomography Device for Patient-Delivered Retina Home Monitoring

Purpose

To study a novel and fast optical coherence tomography (OCT) device for home-based monitoring in age-related macular degeneration (AMD) in a small sample yielding sparse OCT (spOCT) data and to compare the device to a commercially available reference device.

Methods

In this prospective study, both eyes of 31 participants with AMD were included. The subjects underwent scanning with an OCT prototype and a spectral-domain OCT to compare the accuracy of the central retinal thickness (CRT) measurements.

Results

Sixty-two eyes in 31 participants (21 females and 10 males) were included. The mean age was 79.6 years (age range, 69–92 years). The mean difference in the CRT measurements between the devices was 4.52 μm (SD ± 20.0 μm; range, −65.6 to 41.5 μm). The inter- and intrarater reliability coefficients of the OCT prototype were both >0.95. The laser power delivered was <0.54 mW for spOCT and <1.4 mW for SDOCT. No adverse events were reported, and the visual acuity before and after the measurements was stable.

Conclusion

This study demonstrated the safety and feasibility of this home-based OCT monitoring under real-life conditions, and it provided evidence for the potential clinical benefit of the device.

Translational Relevance

The newly developed spOCT is a valid and readily available retina scanner. It could be applied as a portable self-measuring OCT system. Its use may facilitate the sustainable monitoring of chronic retinal diseases by providing easily accessible and continuous retinal monitoring.

Injections frequency and health care costs in patients treated with aflibercept compared to ranibizumab: new real-life evidence from Switzerland

Background

Previous analyses of real-life data indicated that injection frequency and health care costs did not differ for anti-VEGF treatment with aflibercept and ranibizumab. The objective of this study was to investigate whether this finding persisted when analysing a longer time period after licensing.

Methods

Retrospective analysis of health insurance claims data of two large Swiss basic health insurance plans including 28% of the Swiss population. Patients qualified for inclusion if aflibercept or ranibizumab treatment had been initiated between June 1, 2013 and November 1, 2014. Within this set, patients with at least 12 months of continuous insurance enrolment in the previous year, 12-month follow-up, and without change of anti-VEGF drug were considered. We examined the distribution of demographic data and patient characteristics between those receiving ranibizumab and those receiving aflibercept. Numbers of injections and associated health care expenditures observed during the 12-month follow-up period after incident treatment were the two outcomes considered. In multivariate regression analyses, controlling for possible confounding factors, we compared differences in these two outcomes between patients treated with aflibercept as compared to ranibizumab.

Results

A total of 3′058 patients were analysed, 790 (26%) receiving aflibercept and 2`268 receiving ranibizumab (74%). The use of aflibercept (average number of injections 6.2) as compared to ranibizumab (average number of injections 5.7) in the follow-up period of 1 to 12 months, was associated with a 12% increase in the injection frequency (95% confidence interval (CI) 6–17%; p < 0.001).

Conclusions

Real-life data contradicts the assumption that aflibercept is used less frequently as compared to ranibizumab. This results in similar total health care expenditures for both anti-VEGF agents.

Genetics of age-related macular degeneration (AMD)

Age-related macular degeneration (AMD) is a progressive blinding disease and represents the leading cause of visual impairment in the aging population. AMD affects central vision which impairs one's ability to drive, read and recognize faces. There is no cure for this disease and current treatment modalities for the exudative form of the disease require repeated intravitreal injections which may be painful, are incompletely efficacious, and represent a significant treatment burden for both the patient and physician. As such, AMD represents a significant and important clinical problem.It is anticipated that in three years' time, 196 million individuals will be affected with AMD. Over 250 billion dollars per year are spent on care for AMD patients in the US. Over half of the heritability is explained by two major loci, thus AMD is considered the most well genetically defined of the complex disorders. A recent GWAS on 43,566 subjects identified novel loci and pathways associated with AMD risk, which has provided an excellent platform for additional functional studies. Genetic variants have been investigated, particularly with respect to anti-VEGF treatment, however to date, no pharmacogenomic associations have been consistently identified across these studies. It may be that if the goal of personalized medicine is to be realized and biomarkers are to have predictive value for determining the magnitude of risk for AMD at the genetic level, one will need to examine the relationships between these pathways across disease state and relative to modifiable risk factors such as hypertension, smoking, body mass index, and hypercholesterolemia. Further studies investigating protective alleles in populations with low AMD prevalence may lead to this goal.