PROSPECTIVE STUDY OF INTRAVITREAL TRIAMCINOLONE ACETONIDE VERSUS BEVACIZUMAB FOR MACULAR EDEMA SECONDARY TO CENTRAL RETINAL VEIN OCCLUSION

Glucocorticoid-Induced Ocular Hypertension and Glaucoma

Glucocorticoid (GC) therapy is indicated in many diseases, including ocular diseases. An important side-effect of GC therapy is GC-induced ocular hypertension (GIOHT), which may cause irreversible blindness known as GC-induced glaucoma (GIG). Here, we reviewed the pathological changes that contribute to GIOHT including in the trabecular meshwork and Schlemm's canal at cellular and molecular levels. We also discussed the clinical aspects of GIOHT/GIG including disease prevalence, risk factors, the type of GCs, the route of GC administration, and management strategies.

A systematic review and meta-analysis of the effect of intravitreal VEGF inhibitors on cardiorenal outcomes

BACKGROUND

Vascular endothelial growth factor inhibitors (VEGFi) have transformed the treatment of many retinal diseases, including diabetic maculopathy. Increasing evidence supports systemic absorption of intravitreal VEGFi and development of significant cardiorenal side effects.

METHODS

Systematic review and meta-analysis (PROSPERO: CRD42020189037) of randomised controlled trials of intravitreal VEGFi treatments (bevacizumab, ranibizumab and aflibercept) for any eye disease. Outcomes of interest were cardiorenal side effects (hypertension, proteinuria, kidney function decline and heart failure). Fixed-effects meta-analyses were conducted where possible.

RESULTS

There were 78 trials (81 comparisons; 13 175 participants) that met criteria for inclusion: 47% were trials in diabetic eye disease. Hypertension (29 trials; 8570 participants) was equally common in VEGFi and control groups (7.3 versus 5.4%; RR 1.08 [0.91; 1.28]). New or worsening heart failure (10 trials; 3384 participants) had similar incidence in VEGFi and control groups (RR 1.03 [0.70; 1.51]). Proteinuria (5 trials; 1902 participants) was detectable in some VEGFi-treated participants (0.2%) but not controls (0.0%; RR 4.43 [0.49; 40.0]). Kidney function decline (9 trials; 3471 participants) was similar in VEGFi and control groups. In participants with diabetic eye disease, risk of all-cause mortality was higher in VEGFi-treated participants (RR 1.62 [1.04; 2.46]).

CONCLUSION

In trials of intravitreal VEGFi, we did not identify an increased risk of cardiorenal outcomes, though these outcomes were reported in only a minority of cases. There was an increased risk of death in VEGFi-treated participants with diabetic eye disease. Additional scrutiny of post-licensing observational data may improve recognition of safety concerns in VEGFi-treated patients.

Antivascular endothelial growth factor for macular oedema secondary to retinal vein occlusion: a systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of antivascular endothelial growth factor (anti-VEGF) agents in treating macular oedema due to retinal vein occlusion (RVO-ME).

Methods

Studies of randomised controlled trials were searched in PubMed, EMBASE, Cochrane databases and ClinicalTrials.gov registry. RevMan V.5.4 software and GRADE were used to synthesise the data and validate the evidence, respectively.

Results

Seventeen studies were included in this meta-analysis. The anti-VEGF agents showed significant better mean best-corrected visual acuity (BCVA) improvement, more patients with ≧15 Early Treatment in Diabetic Retinopathy Study (ETDRS) letters gained and fewer patients with ≧15 ETDRS letters lost, more effectiveness at reducing central retinal thickness (CRT) and improving the quality of life than sham and steroids both at 6 and 12 months. Compared with laser, the anti-VEGF agents showed significant BCVA improvement and more effectiveness at CRT both at 6 and 12 months. The proportion of eyes gaining ≧15 ETDRS letters was greater in the anti-VEGF group at 6 months. The anti-VEGF and other three groups reported similar levels of non-ocular serious adverse events (SAEs). The incidence of eye pain was significantly higher in the anti-VEGF group than in the sham group. There was a significant increase in the incidence of ocular AEs and conjunctival haemorrhage in the anti-VEGF group compared with the laser group. The incidence of elevated intraocular pressure and cataract was significantly higher in the steroid group than in the anti-VEGF group.

Conclusions

This meta-analysis suggested that treatment of ME secondary to RVO with anti-VEGF improves visual and anatomical outcomes compared with other treatments. Thus, anti-VEGF treatment is the first choice for treating patients with ME secondary to RVO.

Analysis of intravitreal bevacizumab treatment for macular oedema due to retinal vein occlusion

PURPOSE

Our aim was to analyse the clinical effect of intravitreal bevacizumab treatment for macular oedema due to central/branch retinal vein occlusion (CRVO/BRVO). The end points were final best-corrected visual acuity (BCVA), BCVA improvement, final central 1-mm macular subfield thickness (CST) and change in CST.

METHODS

Our study included 34 CRVO and 25 BRVO patients. Patients received intravitreal bevacizumab (IVB) treatment at our department. Our control group consisted of 50 CRVO and 30 BRVO patients, who had not received this treatment because their disease developed before the anti-VEGF treatment became available. For statistical analysis, two-sample t-test, Pearson's correlation, and ANOVA were used. The level of significance was defined at p < 0.05.

RESULTS

With the two-sample t-test we found significant improvement of BCVA in the IVB-treated group (CRVO: 0.171 ± 0.270, p1 = 3.25×10-4; BRVO: 0.215 ± 0.282, p2 = 5.52×10-4). The difference in BCVA improvement was also significant compared to the control group (CRVO: p1 = 3.46×10-4; BRVO: p2 = 0.003). Significant decrease was observed in the CST in the treated group (CRVO: -345.114 ± 280.577, p1 = 6.94×10-9; BRVO: -151.875 ± 174.341, p2 = 1.67×10-4). In case of BRVO patients the final BCVA was significantly better in the treated group (0.617 ± 0.334) compared to the control group (0.406 ± 0.357), p = 0.016.

CONCLUSION

IVB treatment results in significantly better final visual acuity and leads to significantly increased BCVA improvement compared to patients with RVO-induced macular oedema receiving no treatment.

The effects of intravitreal injections on intraocular pressure and retinal nerve fiber layer: a systematic review and meta-analysis

The number of eye diseases treated with intravitreal injections is increasing. Obviously, an injection of fluid into the eye results in an increase of intraocular pressure (IOP), the main risk factor for glaucoma. However, the effect of these repeated IOP increases on the eye is unclear. Therefore, we performed a systematic review with meta-analyses. PubMed, Embase and Clinical Trials Registries were searched for articles investigating the relationship between intravitreal injections (anti-vascular endothelial growth factor [anti-VEGF] or steroids) and either IOP, retinal nerve fiber layer (RNFL)-thickness and glaucoma. Multiple meta-analyses were performed, combining data on intravitreal injection of anti-VEGF medication and dexamethasone implants. A total of 74 articles were eligible for meta-analyses. The short-term effect of an intravitreal injection of anti-VEGF showed a statistically significant increase in IOP. One day after injection of anti-VEGF, however, IOP was significantly lower than baseline. The long-term time-intervals showed no significant difference in IOP. After intravitreal injection of a dexamethasone implant, IOP was significantly higher than baseline 1 month post-injection. RNFL-thickness was significantly reduced 6 and 12 months post-injection of anti-VEGF, as well as at end of follow up. Caution is advised when using intravitreal medication, especially when treating patients with advanced glaucoma; in these cases, prophylactic IOP-lowering medication may be considered.

Use of Anti-VEGF Drugs in Retinal Vein Occlusions

Retinal vein occlusion (RVO) is one of the most prevalent causes of visual loss in the Western World. Its pathogenesis is still not completely known. Chronic macular edema and ischemia compromise the functional and anatomical status of the retina. Antivascular endothelial growth factor (anti-VEGF) injections have demonstrated better results than other previous options, including observation or laser therapy. This narrative review aims to analyze the current aspects related to these drugs.

Baseline clinical features predict visual outcome in young patients with central retinal vein occlusion

PURPOSE

To evaluate prognostic factors in young patients with central retinal vein occlusion (CRVO).

METHODS

Retrospective case series. CRVO patients aged ≤ 50 and follow-up ≥ 6 months were enrolled. The best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, 3 months, 6 months, and last visit were documented. Severity of retinopathy was graded by comparing to standard photos. Prognostic factors associated with visual outcome at 6 months were evaluated by multiple linear regression models.

RESULTS

A total of 73 eyes from 69 patients with mean age 37.6 ± 8.5 were enrolled. Forty-seven (68%) patients were male. The mean follow-up duration was 25.9 ± 23.0 months. LogMAR BCVA improved from 0.979 ± 0.785 at baseline to 0.594 ± 0.748 at the 6 months (p < 0.001) and CRT improved from 475 ± 222 μm to 299 ± 104 μm (p < 0.001). Forty-eight (66%) eyes required anti-vascular endothelial growth factor (anti-VEGF) treatment. The mean number of injections was 2.25 ± 1.41 in the first 6 months and 75% of eyes received ≦ 3 injections during the clinical course. The baseline BCVA (coefficient 0.518, p < 0.001), grade of retinal hemorrhage (coefficient 0.230, p = 0.006), grade of retinal venous engorgement (coefficient 0.238, p = 0.011), grade of optic disc edema (coefficient - 0.226, p = 0.005), and diabetes mellitus (coefficient 0.264, p = 0.047) were the independent factors associated with visual outcome at 6 months.

CONCLUSIONS

Baseline clinical features are useful for the prediction of visual outcome at 6 months in young CRVO patients.

Clinical Effectiveness of Intravitreal Therapy With Ranibizumab vs Aflibercept vs Bevacizumab for Macular Edema Secondary to Central Retinal Vein Occlusion: A Randomized Clinical Trial

Importance

The comparative clinical effectiveness of ranibizumab, aflibercept, and bevacizumab for the management of macular edema due to central retinal vein occlusion (CRVO) is unclear.

Objective

To determine whether intravitreal aflibercept or bevacizumab compared with ranibizumab results in a noninferior mean change in vision at 100 weeks for eyes with CRVO-related macular edema.

Design, Setting, and Participants

This prospective, 3-arm, double-masked, randomized noninferiority trial (Lucentis, Eylea, Avastin in Vein Occlusion [LEAVO] Study) took place from December 12, 2014, through December 16, 2016, at 44 UK National Health Service ophthalmology departments. Inclusion criteria included age 18 years or older, visual impairment due to CRVO-related macular edema of less than 12 months with best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score (approximate Snellen equivalent) in the study eye between 19 (20/400) and 78 (20/32), and spectral domain optical coherence tomography imaging central subfield thickness of 320 μm or greater. Data were analyzed from March 4, 2019, to April 26, 2019.

Interventions

Participants were randomized (1:1:1) to receive repeated intravitreal injections of ranibizumab (0.5 mg/0.05 mL) (n = 155), aflibercept (2.0 mg/0.05 mL) (n = 154), or bevacizumab (1.25 mg/0.05 mL) (n = 154) for 100 weeks.

Main Outcomes and Measures

Adjusted mean change in BCVA in the study eye at 100 weeks wherein noninferiority was concluded if the lower bounds of the 95% CI of both the intention-to-treat and the per protocol analyses were above -5 letters.

Results

Of 463 participants, 265 (57.2%) were male, with a mean (SD) age of 69.1 (13.0) years. The mean (SD) gain in BCVA letter score was 12.5 (21.1) for ranibizumab, 15.1 (18.7) for aflibercept, and 9.8 (21.4) for bevacizumab at 100 weeks. Aflibercept was noninferior to ranibizumab (intention-to-treat-adjusted mean BCVA difference, 2.23 letters; 95% CI, -2.17 to 6.63 letters; P < .001). Bevacizumab was not noninferior to ranibizumab (intention-to-treat-adjusted mean BCVA difference, -1.73 letters; 95% CI, -6.12 to 2.67 letters; P = .07). The per protocol analysis conclusions were similar. Fewer mean injections were given in the aflibercept group (10.0) than in the ranibizumab (11.8) group (mean difference at 100 weeks, -1.9; 95% CI, -2.9 to -0.8).

Conclusions and Relevance

Mean changes in vision after treatment of macular edema due to CRVO were no worse using aflibercept compared with ranibizumab. Mean changes in vision using bevacizumab compared with ranibizumab were inconclusive regarding vision outcomes (ie, the change in visual acuity from baseline, on average, may be worse or may not be worse when using bevacizumab compared with ranibizumab).

Trial Registration

ISRCTN13623634.

Intravitreal Medications for Retinal Vein Occlusion: Systematic Review and Meta-analysis

Purpose

To evaluate the outcomes of different intravitreal injections for the treatment of retinal vein occlusion including central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).

Methods

PubMed, Cochrane, the metaRegister of ControlledTrials, and ClinicalTrials were searched for intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and steroids with relevant keywords and date limitation of 2009-2018. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were visual acuity (VA) and central macular thickness (CMT).

Results

Out of 681 studies, 36 articles (including 21 reporting CRVO and 15 dealing with BRVO) were selected for systematic review. All five intravitreal drugs including triamcinolone, dexamethasone, ranibizumab, bevacizumab, and aflibercept showed improvement of CMT and VA as compared to placebo or laser treatment. Six randomized controlled trials were selected for meta-analysis in RVO patients. The pooled mean difference of visual improvement between sham and ranibizumab was 12.7 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (95%CI: 11.00 to 13.2), and the pooled mean difference in CMT reduction was 221μm (95%CI: 153 to 284); both changes were significantly in favor of ranibizumab. The pooled mean difference of visual improvement between bevacizumab and triamcinolone was 5.3 ETDRS letters in favor of bevacizumab (95%CI: 16 μm to 17.5 μm). Triamcinolone led to 68.1 μm greater CMT reduction than bevacizumab (95%CI: 58 μm to 76 μm). However, none of these differences were statistically significant.

Conclusion

Treatment with anti-VEGF agents in RVO is superior to observation. No significant difference was seen between the eyes treated with bevacizumab or triamcinolone based on these results.

Real-Life Evidence for Using a Treat-and-Extend Injection Regime for Patients with Central Retinal Vein Occlusion

Introduction

To report the 52-week treatment outcomes with intravitreal injections of aflibercept using a treat-and-extend regimen for treating macular edema secondary to central retinal vein occlusion (CRVO).

Methods

A retrospective analysis of patients newly diagnosed with CRVO was performed. Patients receiving aflibercept between 1 December 2016 and 31 March 2017 were included in the analysis. Data on age, gender, visual acuity measured on Early Treatment of Diabetic Retinopathy Study charts, presence of macular and peripheral ischemia, anatomical changes observed on spectral domain–optical coherence tomography examination and the number of injections needed were recorded.

Results

The mean gain in vision was 17.8 ± 19.1 (± standard deviation) letters and 15.1 ± 20.2 letters at weeks 24 and 52 of follow-up, respectively. The proportion of patients who gained ≥ 15 letters in best-corrected visual acuity was 52.9% at week 24 and 50% at week 52. The mean reduction in central subfield macular thickness was 331.5 and 311.6 at weeks 24 and week 52, respectively. For the patients completing 52 weeks of follow-up, the mean number of treatments was 4.9 ± 1.3 injections in the first 26 weeks and 3.2 ± 2.0 injections in the second 26 weeks.

Conclusions

The Moorfields protocol for treating macula edema in CRVO achieves a quick response to treatment without over- or under-treating patients with a fixed protocol. Overall, our individualized treat-and-extend protocol achieved real-life outcomes approaching those of clinical trials. As there are currently no such trials using this practically useful regimen, our study provides real-world evidence for using a treat-and-extend protocol for aflibercept in CRVO.

Effect of funding source on reporting bias in studies of intravitreal anti-vascular endothelial growth factor therapy for retinal vein occlusion

PURPOSE

To examine the relationship between industry funding and outcome reporting bias in high-quality studies investigating the use of intravitreal anti-vascular endothelial growth factor (VEGF) agents for patients with macular oedema secondary to branch or central retinal vein occlusion (RVO).

METHODS

This systematic review in PubMed and Ovid MEDLINE examined all randomized clinical trials and meta-analyses published in journals with impact factor of ≥2 that investigated effectiveness of intravitreal anti-VEGF therapy in patients with RVO. The main outcome measure was correspondence between statistical outcome and abstract conclusion wording.

RESULTS

Forty-five studies met inclusion criteria; 38 (84%) showed correspondence between outcome and abstract conclusion without difference between industry-funded and nonindustry-funded publications (p = 0.39) or between publications in journals with impact factor ≥3 versus <3 (p = 0.96).

CONCLUSION

In high-quality studies of intravitreal anti-VEGF therapy for RVO, neither industry funding nor journal impact factor affected the rate of outcome reporting bias.

Long-term management of non-ischemic central retinal vein occlusion with fluocinolone acetonide intravitreal implant 190 μg (ILUVIEN®)

INTRODUCTION

Macular edema after central retinal vein occlusion is a common cause of vision loss. Upregulation of vascular endothelial growth factor and higher levels of inflammatory mediators have been involved in the pathogeny of the macular edema in central retinal vein occlusion.

CASE REPORT

The authors report a case with non-ischemic central retinal vein occlusion that was successfully treated with a single sustained-release fluocinolone acetonide intravitreal implant. After a course of repeated injections of shorter-acting corticosteroid, the affected eye presented a visual acuity of 20/200 and a central subfield foveal thickness of 587 µm. After fluocinolone acetonide in intravitreal implant and during a follow-up period of 12 months, a continuous and sustained increase in visual acuity until 20/25 with significant anatomical improvements and an acceptable safety profile was observed.

CONCLUSION

These results, demonstrate that fluocinolone acetonide intravitreal implant might be an effective treatment option in macular edema secondary to non-ischemic central retinal vein occlusion.

Comparison of the efficacy and safety of drug therapies for macular edema secondary to central retinal vein occlusion

OBJECTIVES

To evaluate the efficacy and safety of anti-vascular endothelial growth factor (VEGF) agents and corticosteroids for the treatment of macular oedema (ME) secondary to central retinal vein occlusion (CRVO).

DESIGN

Systematic review and network meta-analysis.

PARTICIPANTS

Patients from previously reported randomised controlled trials (RCTs) comparing anti-VEGF and corticosteroids for the treatment of ME secondary to CRVO.

METHODS

Literature searches were conducted using PubMed, Medline, Embase, Cochrane Library and clinicaltrials.gov until March 2017. Therapeutic effects were estimated using the proportions of patients gaining/losing ≥15 letters, best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Treatment safety was estimated using the proportions of adverse events, namely increased intraocular pressure (IOP), cataracts, vitreous haemorrhage (VH) and retinal tear. The software ADDIS (V.1.16.8) was used for analysis. Treatment effect and safety of different drugs could be ranked based on simulation.

RESULTS

Eleven RCTs comprising 2060 patients were identified. Regarding patients gaining ≥15 letters, aflibercept and ranibizumab were significantly more effective than sham/placebo at 6 months. Regarding patients losing ≥15 letters at 6 months, ranibizumab showed significant improvement compared with dexamethasone. Aflibercept, bevacizumab or ranibizumab showed greater improvements in BCVA than sham/placebo at 6 months. Intravitreal ranibizumab injection demonstrated greater CRT reduction than both sham and dexamethasone did. Dexamethasone had a higher risk of increased IOP than aflibercept and ranibizumab. Ranibizumab demonstrated a greater risk of cataracts than dexamethasone. Aflibercept and ranibizumab demonstrated low incidence of VH and retinal tear, respectively. Aflibercept had a slight advantage over ranibizumab as assessed by benefit-risk analysis.

CONCLUSIONS

Anti-VEGF agents have advantages in the treatment of ME secondary to CRVO. Aflibercept and ranibizumab showed marked BCVA improvement and CRT reduction. Aflibercept may have a slight advantage over ranibizumab. The results of this study can serve as a reference for clinicians to provide patient-tailored treatment.

PROSPERO REGISTRATION NUMBER

CRD42017064076.

Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline

PURPOSE

To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy.

METHODS

Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations.

RESULTS

All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases.

CONCLUSION

The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients.

Comparison between anti-VEGF therapy and corticosteroid or laser therapy for macular oedema secondary to retinal vein occlusion: A meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Therapeutic effects of anti-VEGF agents, corticosteroids and laser therapy have been previously examined for treating macular oedema secondary to branch and central retinal vein occlusion (BRVO and CRVO). However, anti-VEGF efficacy has not been previously compared to corticosteroid or laser therapy efficacy. We performed a meta-analysis to compare these treatments.

METHODS

Pertinent publications were identified through comprehensive literature searches. Therapeutic effects were estimated using best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP). The Review Manager (version 5.3.5) was used to perform searches.

RESULTS AND DISCUSSION

Eleven randomized, controlled trials that included 1045 RVO patients were identified. For eyes with BRVO, anti-VEGF therapy improved BCVA significantly more than corticosteroid/laser therapy at 3 (P=.0002), 6 (P<.00001) and 12 months (P<.00001). For eyes with CRVO, this difference was only significant at 6 months (P=.002). The same was true when efficacy was examined using CRT at 3 and 6 months (BRVO: both P<.00001, CRVO 6 months: P=.02). Long-term efficacy of anti-VEGF agents was limited in eyes with BRVO and CRVO. Improvements in BCVA were similar at 1 and 3 months (P=.74), but BCVA decreased between 3 and 6 months (P=.03). In contrast, BCVA progressively decreased 1 and 6 months following corticosteroid/laser therapy (both P<.00001). Lastly, eyes that had been treated with anti-VEGF agents had significantly lower IOP changes than eyes treated with corticosteroids/laser 3 and 6 months after initiating therapy (both P<.00001).

WHAT IS NEW AND CONCLUSION

Anti-VEGF agents improve BCVA and reduce CRT more effectively and longer than corticosteroid/laser in eyes with RVO. Anti-VEGF agents also have a lower risk of elevating IOP. Additionally, anti-VEGF agents are more effective for treating BRVO than CRVO.

Short-term efficacy of intravitreal triamcinolone acetonide for macular edema secondary to retinal vein occlusion that is refractory to intravitreal bevacizumab

AIMS

To evaluate the 1-month efficacy of intravitreal triamcinolone acetonide (TA) in treating macular edema secondary to retinal vein occlusion (RVO) that was refractory to intravitreal bevacizumab.

MATERIALS AND METHODS

This retrospective, observational study included 23 eyes from 23 patients with macular edema secondary to RVO. Macular edema that did not respond to two or more consecutive intravitreal bevacizumab injections was treated with intravitreal TA. Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared before and one month after TA injection.

RESULTS

Fifteen eyes were diagnosed with central RVO, and eight eyes were diagnosed with branch RVO. All patients were previously treated with 2.4 ± 0.6 intravitreal bevacizumab injections. The TA injection was performed, on average, 5.8 ± 1.4 weeks after the last bevacizumab injection. The CFT before TA injection was 516.6 ± 112.4 μm and significantly decreased to 402.3 ± 159.7 μm after TA therapy (P < 0.001). The logarithm of the minimal angle of resolution BCVA was 0.72 ± 0.34 before TA therapy and was not significantly improved by the treatment (0.67 ± 0.35, P = 0.119), despite a decrease in CFT. However, seven eyes (30.4%) had a BCVA gain of one or more lines.

CONCLUSIONS

Intravitreal TA therapy was beneficial in some patients with macular edema secondary to RVO that was refractory to intravitreal bevacizumab therapy. This study suggests that intravitreal TA should be considered as a treatment option for refractory macular edema.

RETINAL VEIN OCCLUSIONS, FROM BASICS TO THE LATEST TREATMENT

PURPOSE

To review the pathophysiology, diagnosis, and updated treatments of retinal vein occlusions (RVOs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and treatments (including both medical and surgical treatments) of RVO. Based on this review, a comprehensive overview was provided regarding the topic of RVO and focused on recent treatment updates.

RESULTS

Retinal vein occlusions have an age- and sex-standardized prevalence of 5.20 per 1,000 for any RVO, 4.42 per 1,000 for branch RVO, 0.80 per 1,000 for central RVO. Worldwide, an estimated 16.4 million adults are affected by RVOs, with 2.5 million affected by central RVO and 13.9 million affected by branch RVO. Retinal vein occlusion is recognized as an important cause of blindness and the diagnostic approaches and treatment options for RVO are reviewed and reported. The current treatment options including medical treatments (bevacizumab, ranibizumab, aflibercept, triamcinolone, and dexamethasone implants) and surgical alternatives were reviewed and reported with summaries on the corresponding strength of evidence.

CONCLUSION

Despite the understanding of this disease entity, challenges persist in the long-term treatment of RVO-related complications and visual loss. This review provided a detailed summary on the rationality and efficacy of recently developed treatment regimes and evaluated the potential benefit of combination therapy.

Central retinal vein occlusion: modifying current treatment protocols

Central retinal vein occlusion (CRVO) is a common retinal vascular disorder that can result in severe visual acuity loss. The randomized control study, CRUISE, helped establish anti-VEGFs as the standard of care in cases with CRVO. The extension studies for CRUISE; HORIZON and RETAIN showed that not all visual gains are maintained beyond the first year. In addition, patients showed different behavior patterns; with some patients showing complete response with few recurrences, whereas others showed partial or even no response with multiple recurrences. Long-term follow-up demonstrated that patients responding poorly to anti-VEGFs tended to do so early in the course of treatment. It also demonstrated the effectiveness of a pro re nata (PRN) protocol for improving vision and maintaining these gains over long-term follow-ups. The SHORE study further illustrated this point by demonstrating that there were minimal differences in visual outcomes between patients receiving monthly injections and patients being treated PRN. In this review we analyzed the data from the major randomized clinical trials (RCT) that looked at anti-VEGFs as the primary treatment modality in patients with CRVO (CRUISE and the extension studies HORIZON and RETAIN for ranibizumab as well as GALILEO and COPERNICUS for aflibercept). In addition, we looked at SCORE and GENEVA to help determine whether there is a place for steroids as a first line therapy in current treatment practice. We then explored alternative treatment regimens such as laser therapy and switching between anti-VEGF agents and/or steroids for non or partially responding patients. Finally, we propose a simplified modified treatment algorithm for patients with CRVO for better long-term outcomes in all types of responders.

Comparison of intravitreal bevacizumab with intravitreal triamcinolone acetonide for treatment of cystoid macular edema secondary to retinal vein occlusion: a Meta-analysis

AIM

To compare the effects of intravitreal injection of bevacizumab (IVB) with intravitreal triamcinolone acetonide (IVTA) on the treatment of cystoid macular edema (CME) secondary to retinal vein occlusion (RVO).

METHODS

A literature search was conducted using PubMed, the Cochrane Central Register of Controlled Trials, Web of Science and the Chinese Biomedical Database. The comparison was divided into two groups, group 1 conducted comparison in branch RVO (BRVO) or central RVO (CRVO), group 2 conducted comparison in ischemic-RVO or nonischemic-RVO. Pooled mean differences (MDs) for changes in visual acuity (VA), central macular thickness (CMT) and intraocular pressure (IOP) were calculated in groups at 4, 12 and 24wk after treatment respectively.

RESULTS

Eight studies comparing the efficacy of IVB with IVTA were included in the Meta-analysis. In group 1, in BRVO, significant difference was shown on the comparison of CMT at 24wk (MD, -45.66; 95% CI, -76.03 to -15.28; P=0.003), IVB was effective on BRVO for at least 24wk; no significant differences were found in the comparison of VA at each time points (P>0.05 respectively). In CRVO, no significant differences were found in the comparison of VA or CMT between IVB and IVTA at each time points (P>0.05, respectively). In group 2, in ischemic-RVO, significant differences were shown in the comparison of VA (MD, -0.28; 95% CI, -0.42 to -0.14; P<0.0001) and CMT (MD, -86.50; 95% CI, -151.18 to -22.43; P=0.008) at 24wk; In nonischemic-RVO, no significant differences were demonstrated in the comparison of VA or CMT between IVB and IVTA at each time points (P>0.05, respectively). The occurrence of high IOP was much lower in IVB group.

CONCLUSION

This Meta-analysis suggested that IVB was effective in decreasing CMT in BRVO for at least 24wk, IVB is more effective on improving VA and reducing CMT in ischemic-RVO. IVB is more promising on RVO than IVTA.

Steroids in Central Retinal Vein Occlusion: Is There a Role in Current Treatment Practice?

With the current widespread use of anti-VEGFs in the treatment of central retinal vein occlusion (CRVO), the role for steroids has become greatly diminished. Recent large scale randomized control trials (RCTs) have established the efficacy and safety of anti-VEGFs in the treatment of CRVO. Steroids are known to cause elevations in intraocular pressure as well as increase the risk of cataract formation. With that in mind many ophthalmologists are injecting steroids less frequently. This paper aims to review some of the data pertaining to the use of steroids either as a first line monotherapy, adjunct therapy, or an alternative therapy to help answer the question: Is there currently any role for steroids in the management of CRVO?

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Comparison of the effects of intravitreal bevacizumab and triamcinolone acetonide in the treatment of macular edema secondary to central retinal vein occlusion

AIM

To compare the effects of intravitrealbevacizumab (IVB) and intravitreal triamcinolone acetonide (IVT) in the treatment of macular edema (ME) secondary to central retinal vein occlusion (CRVO).

MATERIALS AND METHODS

There were 20 patients treated with IVB (1.25 mg/0.05 mL) and 16 treated with IVT (4 mg/0.1 mL). The two groups were compared with regard to best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography (OCT), slit-lamp biomicroscopy and fundus fluorescein angiography results, intraocular pressure (IOP), numbers of injections, and adverse events.

RESULTS

The mean follow-up times in the IVB and IVT groups were 17.45±8.1 months (range: 8-33 months) and 19.94±10.59 months (range: 6-40 months), respectively (P = 0.431). Visual acuity increased and CMT decreased significantly within both groups, but no differences were observed between the groups (P = 0.718). The percentages of patients with increased IOP and iatrogenic cataracts were significantly higher in the IVT group than in the IVB group.

CONCLUSIONS

Treatment with IVB and IVT both resulted in significant improvement in visual acuity and a decrease in CMT in patients with ME secondary to non-ischemic CRVO, with no difference between the two treatments. The incidence of adverse events, however, was significantly greater in the IVT group than in the IVB group. IVB may be preferred over IVT for the treatment of ME in patients with non-ischemic CRVO.

Therapies for macular edema associated with central retinal vein occlusion: a report by the American Academy of Ophthalmology

PURPOSE

To review the available evidence regarding the safety and efficacy of therapies for the treatment of macular edema (ME) associated with central retinal vein occlusion (CRVO).

METHODS

A literature search of the PubMed database was last conducted in March 2014 with no date restrictions but limited to articles published in English. A literature search of the Cochrane Library was also conducted in March 2014 with no date restrictions and without a language limitation. The combined searches yielded 108 citations, of which 20 were deemed clinically relevant for the Ophthalmic Technology Assessment Committee Retina/Vitreous panel to review in full text. Three additional studies were also identified for panel review. The level of evidence of these selected studies was reviewed by the panel methodologist.

RESULTS

There were 7 citations representing 4 clinical trials that provided level I evidence supporting the use of anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME associated with CRVO, including intravitreal ranibizumab (2), aflibercept (3), and bevacizumab (2). There were 3 citations representing 2 studies with level I evidence for intravitreal corticosteroid injection with dexamethasone intravitreal implant (2 citations) or triamcinolone (1 citation), although cataract and glaucoma were observed in these studies. Level I evidence is available on the limited benefit of macular grid-pattern laser photocoagulation (1 citation). Eight other citations reviewed were rated as level II, and 4 citations were rated as level III. Long-term efficacy results (≥2 years of follow-up) are limited to intravitreal ranibizumab at this time, and few studies have evaluated combination therapy with anti-VEGF and corticosteroid versus monotherapy of either class of drug.

CONCLUSIONS

Level I evidence indicates that intravitreal anti-VEGF pharmacotherapy is safe and effective over 2 years for ME associated with CRVO and that delay in treatment is associated with worse visual outcomes. In addition, level I evidence demonstrates short-term efficacy of intravitreal corticosteroid but also an association with a higher frequency of adverse events.

Three intravitreal bevacizumab versus two intravitreal triamcinolone injections in recent onset central retinal vein occlusion

PURPOSE

To evaluate the effects of repeated intravitreal injections of bevacizumab (IVB) versus triamcinolone acetonide (IVT) in the treatment of acute central retinal vein occlusion (CRVO).

METHODS

In this randomized clinical trial, 86 eyes with recent onset (<12 weeks) CRVO were assigned to two groups: IVB group (43 eyes) that received three monthly injections of 1.25 mg of IVB, and IVT group (43 eyes) that received two injections of 2 mg IVT 2 months apart. Outcomes were best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) changes.

RESULTS

Mean BCVA improved significantly at 6 months in both groups; from 0.87 ± 0.49 to 0.41 ± 0.35 logMAR in IVB group, and from 0.81 ± 0.45 to 0.62 ± 0.48 logMAR in IVT group (p < 0.001). However, between-group differences reach a significant level at months 4 (p = 0.003) and 6 (p < 0.001) in favour of the IVB group. In terms of CMT reduction, the difference between the groups was statistically significant (p = 0.002) at month 6. Significant differences were noted more in the ischaemic cases in favour of the IVB group. Mean IOP rise was significantly higher in the IVT group at all visits.

CONCLUSIONS

Both 3-times monthly IVB injections and 2-times IVT injections could be effective in cases with recent onset CRVO up to 6 months. However, considering the better outcomes after IVB injections and the potential complications of IVT injections, we would recommend prescheduled repeated IVB injections for such cases. The observed favourable responses were more pronounced in the ischaemic types; nevertheless, this should be confirmed in larger studies.

The safety of intravitreal bevacizumab monotherapy in adult ophthalmic conditions: systematic review

OBJECTIVES

To assess the safety of intravitreal bevacizumab (IVB) as a monotherapy and to evaluate the relationship between quality of treatment and adverse events.

DATA SOURCES

Cochrane Library, Ovid MEDLINE, MEDLINE in-process, Ovid EMBASE and Toxicology Literature Online (TOXLINE) from January 2009 to May 2012. Studies included in an earlier systematic review were also assessed for inclusion.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Randomised controlled trials (RCTs), controlled trials or observational studies including ≥10 participants reporting adverse events data following IVB monotherapy as a primary treatment in patients (aged 18 years or more) with any eye condition were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study selection was undertaken independently by a minimum of two reviewers using pre-defined criteria. Data abstraction and quality assessment were performed by one reviewer, and then checked by a second reviewer. Study quality was assessed for only RCTs in accordance to the Cochrane Risk of Bias Tool. Additional items relating to safety data were also assessed. Results were tabulated or meta-analysed as appropriate.

RESULTS

22 RCTs and 67 observational studies were included. Only two RCTs reported valid safety data. Rates of serious adverse events following treatment were low. There was insufficient data to explore the relationship between the incidence of adverse events and quality of IVB injection.

LIMITATIONS

A majority of relevant existing studies were characterised by small sample sizes, unclear diagnostic criteria and reporting of safety outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Available evidence demonstrates low rates of serious local and systemic adverse events following treatment. However, the role of IVB quality in the incidence of adverse events remains unclear. Robust evidence is needed to examine the relationship between the incidence of adverse events and variables such as injection techniques, pre-existing risk factors (eg, immunosuppression, cross-contamination) and quality of IVB treatment.

Anti-vascular endothelial growth factor for macular oedema secondary to central retinal vein occlusion

BACKGROUND

Central retinal vein occlusion (CRVO) is a relatively common retinal vascular disorder in which macular oedema may develop, with a consequent reduction in visual acuity. Until recently there has been no treatment of proven benefit, but growing evidence supports the use of anti-vascular endothelial growth factor (anti-VEGF) agents.

OBJECTIVES

To investigate the effectiveness and safety of anti-VEGF therapies for the treatment of macular oedema secondary to CRVO.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 10), Ovid MEDLINE (January 1950 to October 2013), EMBASE (January 1980 to October 2013), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to October 2013), OpenGrey, OpenSIGLE (January 1950 to October 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and Web of Science Conference Proceedings Citation Index-Science (CPCI-S). There were no language or date restrictions in the electronic search for trials. The electronic databases and clinical trials registers were last searched on 29th October 2013.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared intravitreal anti-VEGF agents of any dose or duration to sham injection or no treatment. We focused on studies that included individuals of any age or gender and a minimum of six months follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The primary outcome was the proportion of participants with a gain in best-corrected visual acuity (BCVA) from baseline of greater than or equal to 15 letters (3 lines) on the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Secondary outcomes included the proportion of participants with a loss of 15 letters or more of BCVA, the mean change from baseline BCVA, the mean change in central retinal thickness (CRT), the number and type of complications or adverse outcomes, and the number of additional interventions administered. Where available, we also presented quality of life and economic data.

MAIN RESULTS

We found six RCTs that met the inclusion criteria after independent and duplicate review of the search results. These RCTs included 937 participants and compared outcomes at six months to sham injection for four anti-VEGF agents: aflibercept (VEGF Trap-Eye, Eylea), bevacizumab (Avastin), pegaptanib sodium (Macugen) and ranibizumab (Lucentis). Three trials were conducted in Norway, Sweden and the USA, and three trials were multicentre, one including centres in the USA, Canada, India, Israel, Argentina and Columbia, a second including centres in the USA, Australia, France, Germany, Israel, and Spain, and a third including centres in Austria, France, Germany, Hungary, Italy, Latvia, Australia, Japan, Singapore and South Korea. We performed meta-analysis on three key visual outcomes, using data from up to six trials. High-quality evidence from six trials revealed that participants receiving intravitreal anti-VEGF treatment were 2.71 times more likely to gain at least 15 letters of visual acuity at six months compared to participants treated with sham injections (risk ratio (RR) 2.71; 95% confidence intervals (CI) 2.10 to 3.49). High-quality evidence from five trials suggested anti-VEGF treatment was associated with an 80% lower risk of losing at least 15 letters of visual acuity at six months compared to sham injection (RR 0.20; 95% CI 0.12 to 0.34). Moderate-quality evidence from three trials (481 participants) revealed that the mean reduction from baseline to six months in central retinal thickness was 267.4 µm (95% CI 211.4 µm to 323.4 µm) greater in participants treated with anti-VEGF than in participants treated with sham. The meta-analyses demonstrate that treatment with anti-VEGF is associated with a clinically meaningful gain in vision at six months. One trial demonstrated sustained benefit at 12 months compared to sham. No significant ocular or systemic safety concerns were identified in this time period.

AUTHORS' CONCLUSIONS

Compared to no treatment, repeated intravitreal injection of anti-VEGF agents in eyes with CRVO macular oedema improved visual outcomes at six months. All agents were relatively well tolerated with a low incidence of adverse effects in the short term. Future trials should address the relative efficacy and safety of the anti-VEGF agents and other treatments, including intravitreal corticosteroids, for longer-term outcomes.

Antivascular endothelial growth factors in the treatment of macular oedema secondary to central retinal vein occlusion: a meta-analysis

BACKGROUND

Macular oedema secondary to central retinal vein occlusion is a major cause of vision loss. Intraocuclar anti-vascular endothelial growth factor injection is a promising treatment but lacks clinical evidence of its safety and efficacy.

DESIGN

Meta-analysis.

PARTICIPANTS

Patients from previously reported randomized, controlled trials comparing intravitreal anti-vascular endothelial growth factor versus sham injections.

METHODS

A comprehensive search in MEDLINE, CENTRAL, and EMBASE was conducted for reports published by April 2013. A meta-analysis of the retrieved data was conducted in RevMan 5.2 software.

MAIN OUTCOME MEASURES

Primary outcome measures were changes in best-corrected visual acuity and central retinal thickness from baseline. Secondary outcome measures were the proportion of eyes changing 15 or more letters on the Early Treatment in Diabetic Retinopathy Study chart, the proportion with neovascularization and changes in the 25-item Visual Function Questionnaire. Severe adverse events were summarized to assess safety.

RESULTS

Six trials involving a total of 940 eyes were included in the meta-analysis. The mean difference in 6-month changes in best-corrected visual acuity and central retinal thickness for the anti-vascular endothelial growth factor group were 15.2 Early Treatment Diabetic Retinopathy Study letters (P < 0.00001) and -242.2 μm (P < 0.00001), respectively. Severe adverse event incidence was similar between the groups.

CONCLUSIONS

Intravitreal anti-vascular endothelial growth factor injections were safe and effective for macular oedema secondary to central retinal vein occlusion. The efficacy was rapid and robust. Further trials are needed to determine the detailed indications and therapeutic regimens of anti-vascular endothelial growth factor treatments.

Severe intraocular pressure rise following intravitreal triamcinolone: a national survey to estimate incidence and describe case profiles

PURPOSE

The objective of this study is to estimate the incidence of steroid-induced severe intraocular pressure (IOP) rise following intravitreal triamcinolone acetonide (IVTA) injection and to describe case profiles of the patients affected within the United Kingdom.

PATIENTS AND METHODS

A national survey was carried out to identify cases that had developed severe IOP rise requiring laser or surgery following IVTA through the British Ophthalmic Surveillance Unit. Respondents were mailed a questionnaire and with a follow-up questionnaire 1 year later, to ascertain characteristics of the patients identified. We also carried out a midpoint survey to ascertain national practice of IVTA at the time.

RESULTS

There were 29 confirmed reports of severe IOP rise after IVTA in the 13-month period of surveillance. All the cases were unilateral and the mean time between the IVTA and the maximum recorded IOP was 16 weeks. Six of these patients had pre-existing glaucoma or ocular hypertension, and a further two were known to be 'steroid responders'. Using the adjusted denominators, obtained from our national survey, the estimated annual incidence would be between 3.6 and 9.5 per 1000 injections.

CONCLUSIONS

These results confirm that severe IOP rise after IVTA is an uncommon but serious complication. Data obtained from this national study should aid clinicians in choosing the treatment best suited to their patients.

Diabetic Retinopathy-Update on Prevention Techniques, Present Therapies, and New Leads

Diabetic retinopathy is the major ocular complication associated with diabetes, and represents the leading cause of legal blindness in the working-age population of developed countries. Although classically diagnosed based on abnormalities of the retinal microvasculature, diabetic retinopathy is now widely recognized as a neurovascular disease. While all patients with diabetes are at increased risk for eye disease including diabetic retinopathy, proactive measures, and timely intervention can prevent or delay subsequent vision loss. Systemic management of diabetes by combined control of glycemia, blood pressure, and serum lipid levels remains the most important method of preventing diabetic retinopathy onset and progression. Once detected, surgical and medical interventions including photocoagulation, vitrectomy, and intravitral drug injection can help preserve vision. However, the need for improved detection methods and therapies that will allow earlier diagnosis and treatment remains apparent. This review summarizes current techniques for the prevention and intervention for diabetic retinopathy, and examines ongoing developments in the search for new endpoints and therapies as they apply to preventing vision loss associated with diabetes.

Long-term outcome of intravitreal triamcinolone acetonide injection for the treatment of uveitis attacks in Behçet disease

PURPOSE

To evaluate the long-term efficacy and safety of intravitreal triamcinolone acetonide (IVTA) injection for posterior segment inflammation in Behçet disease (BD) patients.

METHODS

The authors reviewed the medical records of BD patients who underwent IVTA injection (4 mg/0.1 mL) for posterior uveitis attack unresponsive to systemic immunosuppression and were followed up for more than 24 months.

RESULTS

Forty-nine patients (49 eyes) were included. Mean best-corrected visual acuity improved from 0.89 logMAR units to 0.70, 0.64 at 12, 24 months, respectively. Complete inflammation control was achieved in 87.0% of patients, but 60.0% of them experienced relapse within 12 months. For phakic eyes, cumulative probabilities for cataract surgery were 13.8%, 48.9%, and 60.2% at 12, 24, and 36 months, respectively. Intraocular pressure elevation exceeding 21 mmHg was noted in 40.8%.

CONCLUSIONS

In Behçet uveitis attack that is unresponsive or intolerant to systemic medications, IVTA injection is an effective therapeutic option, although ocular complications could limit its efficacy and repeatability.

Meta-analysis of the effect of intravitreal bevacizumab versus intravitreal triamcinolone acetonide in central retinal vein occlusion

PURPOSE

To further evaluate the effect of intravitreal bevacizumab (IVB) for the treatment of central retinal vein occlusion (CRVO) by meta-analysis.

METHODS

Pertinent publications were identified through PubMed, EMBASE, and the Cochrane Controlled Trials Register up to January 30, 2013. Changes in central macular thickness (CMT) and best-corrected visual acuity (BCVA) were extracted at 4, 12, and 24 weeks after treatment, and a meta-analysis was carried out to compare results between groups receiving IVB and intravitreal triamcinolone acetonide (IVTA).

RESULTS

One randomized controlled trial and 4 comparative studies were identified and included. All of the funnel plots, the Egger's method and Begg method did not show publication bias. Our meta-analysis revealed that BCVA and CMT at 4, 12, and 24 weeks after treatment did not vary significantly between the IVB groups and IVTA groups (BCVA: at 4 weeks, P=0.27; at 12 weeks, P=0.51; at 24 weeks, P=0.64; CMT at 4 weeks, P=0.88; at 12 weeks, P=0.57; at 24 weeks, P=0.64). However, the rate of intraocular pressure rise after intravitreal injection varied significantly between the IVB groups and IVTA groups (P<0.001).

CONCLUSIONS

Our results showed a similar improvement in BCVA and CMT among CRVO patients was obtained after intravitreal injections of both IVB, or IVTA, while the rate of IOP rise was significantly higher in the latter.

Differences in aqueous concentrations of cytokines in macular edema secondary to branch and central retinal vein occlusion

PURPOSE

This study investigates the differential aqueous concentrations of interleukin 6, 8, 1β (IL-6, IL-8, IL-1β, respectively), serum amyloid A (SAA), transforming growth factor (TGF)-β, basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) in eyes with macular edema as a result of a branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO).

PRINCIPAL FINDINGS

Significantly higher concentrations of IL-6, IL-8, IL-1β, TGF-β, bFGF, SAA, and VEGF were found in the aqueous humor of CRVO and BRVO patients than in the aqueous humor of control patients. A significant correlation was observed between the concentration of bFGF and the inner central macular thickness (CMT) of BRVO patients (r = 0.688; P = 0.02). A significant correlation was observed between the concentration of SAA and both the full and outer CMT of the ischemic group (r = 0.545 and 0.683, respectively; P = 0.04 and 0.01, respectively). In the non-ischemic group, the level of IL-6 was significantly associated with inner CMT (r = 0.560; P = 0.03). The full and outer CMT was significantly reduced in CRVO patients when compared with BRVO patients (P = 0.02 and 0.02, respectively) after injection of intravitreal bevacizumab (IVB) at 4 weeks.

SIGNIFICANCE

Serum amyloid A as a major protein involved in the acute and chronic stages of inflammation, and IL-6 and bFGF were significantly associated with the extent of macular edema in patients with RVO. Besides VEGF, other inflammatory cytokines and angiogenesic factors may be associated with RVO. This finding may have implications for the medical treatment of RVO.

Bevacizumab for macular edema secondary to retinal vein occlusion: a systematic review and meta-analysis

PURPOSE

To assess the effect and safety of using single intravitreal bevacizumab (IVB) versus intravitreal triamcinolone acetonide (IVTA) and grid laser photocoagulation (GLP), or a combination of IVB and IVTA for treatment of retinal vein occlusion (RVO)-associated macular edema, mainly exploring its effects on visual acuity (VA) and central macular thickness (CMT).

METHODS

Eligible studies were identified via searching databases, including Medline (PubMed), Web of Science, and the Cochrane Library, without status or other limits up to June 2012.

SELECTION CRITERIA

We include randomized clinical control trials comparing 1.25 mg IVB injection with other treatment strategies, including a 4 mg IVTA injection or GLP or a combination of 1.25 mg IVB and 2 mg IVTA injection, for patients with RVO-associated macular edema. Eligible studies should report both VA and CMT outcomes, and with a minimum follow-up of 4 weeks. Results: Two authors assessed the trial quality and extracted data independently.

MAIN RESULTS

Four studies were included in this study. Comparing to IVTA and GLP, IVB was more effective in improving VA at 1 month (weighted mean difference [WMD], -0.07; 95% confidence interval [CI], -0.10 to -0.05; P<0.00001), 3 months (WMD, -0.24; 95% CI, -0.28 to -0.20; P<0.00001), and 6 months during the follow-up (WMD, -0.17; 95% CI, -0.21 to -0.13; P<0.00001) in patients with RVO-associated macular edema. There was no statistical significance in reducing CMT values throughout the periods. Compared with IVB/IVTA combination, VA improvement became statistically significant at 3 months of follow-up (WMD, -0.26; 95% CI, -0.29 to -0.23; P<0.00001), while no statistical significance was found in both VA values at 1 month of follow-up and CMT values throughout the periods. The occurrence of intraocular pressure (IOP) was much lower in IVB groups.

CONCLUSIONS

IVB is effective in treating patients with RVO-associated macular edema; especially if it has distinct effects, of which, VA could be improved to the utmost extent as well as by the earliest of time. IVB is also effective in decreasing CMT, but without any significant advantages over IVTA or GLP. Furthermore, IVB seems to be safer than IVTA in consideration of IOP increase.

Best practices for treatment of retinal vein occlusion

PURPOSE OF REVIEW

Retinal vein occlusion (RVO) is a sight-threatening retinal vascular disorder associated with macular edema and neovascularization. Until recently, the standard of care for branch RVO-associated macular edema was grid laser photocoagulation and observation for central RVO-associated macular edema. Neovascularization was treated with scatter laser photocoagulation. The purpose of this article is to review recent findings that have changed our treatments of RVO.

RECENT FINDINGS

The recent development of intravitreal pharmacotherapy has demonstrated benefit with anti-vascular endothelial growth factor (VEGF) agents and corticosteroids for the treatment of RVO-associated macular edema. The intravitreal use of FDA-approved ranibizumab (Lucentis) and a sustained release dexamethasone implant (Ozurdex), along with off-label bevacizumab (Avastin) and preservative-free triamcinolone, has significantly expanded our treatment options and replaced standard of care for treatment of RVO-associated macular edema. Whereas anti-VEGF agents can also induce rapid regression of neovascularization, scatter laser photocoagulation remains the standard of care to prevent neovascular complications.

SUMMARY

Intravitreal pharmacotherapy has revolutionized our treatment of retinal vascular diseases, including RVO. Although these intravitreal agents are effective, our understanding of their specific indications and long-term roles is still evolving. Furthermore, until the underlying occlusive pathophysiology of RVO can be addressed, our treatments will be limited to temporizing therapies against a chronic disease.

Emerging roles for antiangiogenesis factors in management of ocular disease

The first antivascular endothelial growth factor (anti-VEGF) was developed as an anticancer drug for colonic carcinomas. Since then, anti-VEGFs have developed in scope and indications. They have revolutionized the treatment of exudative macular degeneration and have had a major impact on treatment of several other conditions. This has resulted in an increased number of patients seeking treatment with new treatment options and has had a considerable financial impact on health care resources. Anti-VEGFs have been used in the treatment of all age groups of the population ranging from infants where it is used for treatment of retinopathy of prematurity to the elderly where it is used in exudative macular eegeneration.

Intravitreal aflibercept injection for macular edema secondary to central retinal vein occlusion: 1-year results from the phase 3 COPERNICUS study

PURPOSE

To evaluate intravitreal aflibercept injections (IAI; also called VEGF Trap-Eye) for patients with macular edema secondary to central retinal vein occlusion (CRVO).

DESIGN

Randomized controlled trial.

METHODS

This multicenter study randomized 189 patients (1 eye/patient) with macular edema secondary to CRVO to receive 6 monthly injections of either 2 mg intravitreal aflibercept (IAI 2Q4) (n = 115) or sham (n = 74). From week 24 to week 52, all patients received 2 mg intravitreal aflibercept as needed (IAI 2Q4 + PRN and sham + IAI PRN) according to retreatment criteria. The primary endpoint was the proportion of patients who gained ≥15 ETDRS letters from baseline at week 24. Additional endpoints included visual, anatomic, and quality-of-life NEI VFQ-25 outcomes at weeks 24 and 52.

RESULTS

At week 24, 56.1% of IAI 2Q4 patients gained ≥15 letters from baseline compared with 12.3% of sham patients (P < .001). At week 52, 55.3% of IAI 2Q4 + PRN patients gained ≥15 letters compared with 30.1% of sham + IAI PRN patients (P < .001). At week 52, IAI 2Q4 + PRN patients gained a mean of 16.2 letters of vision vs 3.8 letters for sham + IAI PRN (P < .001). The most common adverse events for both groups were conjunctival hemorrhage, eye pain, reduced visual acuity, and increased intraocular pressure.

CONCLUSIONS

Monthly injections of 2 mg intravitreal aflibercept for patients with macular edema secondary to CRVO resulted in a statistically significant improvement in visual acuity at week 24, which was largely maintained through week 52 with intravitreal aflibercept PRN dosing. Intravitreal aflibercept injection was generally well tolerated.

Complications of intravitreal triamcinolone acetonide for macular edema and predictive factors for intraocular pressure elevation

AIM

To investigate the complications of intravitreal triamcinolone acetonide (IVTA) for the treatment of macular edema, and to determine the risk factors for intraocular pressure (IOP) elevation.

METHODS

Charts of patients with macular edema secondary to branch retinal vein occlusion (BRVO), diabetic retinopathy and uveitis who had received IVTA injections were reviewed to document its complications. IOP elevation was defined as a pressure of ≥24mmHg at some point during follow-up. Multivariate logistic regression analysis was performed to characterize baseline risk factors for this elevation.

RESULTS

The study included 111 eyes of 65 female and 46 male patients with a mean follow-up of (11.6±5.1) months. Of the 111 eyes, 52 (46.8%) had macular edema secondary to BRVO, 44 (39.6%) had clinically significant diabetic macular edema (CSDME) and 15 (13.5%) had non-infectious uveitis with macular edema. IOP was recorded ≥ 24mmHg in 38 eyes (34.2%) during the follow-up. Higher baseline IOP (P=0.022), younger age (P=0.003), and male gender (P=0.014) were significant risk factors for IOP elevation after IVTA injection. Eyes with prior vitrectomy were less likely to have IOP elevation (P=0.054). Two eyes (5.2% of eyes with increased IOP) underwent trabeculectomy, and 9 eyes (16.3% of the phakic eyes) necessitated cataract surgery. Other complications included branch vein occlusion (1.8%), sterile endophthalmitis (0.9%) and pseudohypopyon (0.9%).

CONCLUSION

IVTA has side effects with IOP elevation and cataract formation being the two most common. A subset of patients is more prone to developing increased IOP following IVTA, namely, younger male patients with higher baseline IOP.

Retinal Vein Occlusions

Retinal vein occlusions (RVOs) are second to diabetic retinopathy in the prevalence as retinal vascular disorder and are characterized by dilatation of the retinal veins with retinal and subretinal hemorrhages, macular edema, hard retinal exudates, retinal ischemia, and consequent atrophy of the retina and optic nerve. They are differentiated into central RVOs and branch RVOs (BRVO), into ischemic versus nonischemic RVOs, and in the case of BRVOs, into intrapapillary BRVOs and extrapapillary BRVOs. Diagnosis is based on ophthalmoscopy, fluorescein angiography, and spectral-domain optical coherence tomography. The latter can display the presence and integrity of the retinal outer limiting membrane and of the inner and outer segments of the photoreceptors as useful information for prognosis and a guide for treatment. Risk factors for RVOs are glaucoma and arterial hypertension. Ischemic RVOs can develop iris neovascularization and secondary angle-closure glaucoma. Formerly, therapy consisted of laser photocoagulation in a "grid" pattern over the leaking area, leading to a reduction of macular edema and, as adverse effect, to focal retinal destruction. Intravitreal medical therapy including steroids and vascular endothelial growth factor inhibitors shows a marked antiedematous effect leading to an at least temporary reduction in foveal edema and correspondingly improves visual function. Intravitreal medical therapy is associated with the disadvantage of a limited duration of its effect and the advantage of not damaging the retina. A preventive therapy to avoid a recurrence of RVO or the development of an RVO in the contralateral eye has not been proven yet.