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

Efficacy, Safety, and Treatment Burden of Aflibercept 2 mg and Ranibizumab in Retinal Vein Occlusion: A Systematic Review and Meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to provide an updated evidence base for clinical decision-making by comparing the efficacy and safety of aflibercept 2 mg and ranibizumab in treating retinal vein occlusion (RVO).

METHODS

A systematic search was conducted using eight databases up to December 2021. Randomized controlled trials (RCTs) and real-world studies (RWSs) comparing aflibercept and ranibizumab in patients with RVO were evaluated. The primary outcomes assessed were efficacy, number of injections administered, and adverse events.

RESULTS

Three RCTs (424 patients) and 11 RWSs (1415 patients) were included. For central RVO (CRVO), RCTs demonstrated a comparable efficacy, whereas RWSs showed that mean changes from baseline in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were significantly greater with aflibercept compared to ranibizumab; the number of injections of aflibercept was fewer than that of ranibizumab in RCTs, but similar in RWSs. For branch RVO (BRVO), no statistically significant difference in efficacy between the two drugs in RCTs/RWSs was observed, with fewer injections of aflibercept at 12 months in RWSs. The safety profiles of both drugs were similar for both CRVO and BRVO.

CONCLUSIONS

For CRVO, aflibercept had similar efficacy and safety profile but with fewer injections versus ranibizumab in RCTs; RWSs showed greater BCVA improvement and CRT reduction with aflibercept than ranibizumab. For BRVO, RCTs showed similar in efficacy, safety, and injection numbers for both drugs, while RWSs demonstrated that aflibercept required fewer injections at 12 months of follow-up. Overall, this study provides updated evidence for clinical decision-making in the treatment of RVO.

Cardiovascular Outcomes with Intravitreal Anti-Vascular Endothelial Growth Factor Therapy in Patients with Diabetes: A Real-World Data Analysis

BACKGROUND

Anti-vascular endothelial growth factor (anti-VEGF) therapy is commonly used intravitreally for diabetic proliferative retinopathy, but when used systemically for treating cancers, an excess of cardiovascular disease (CVD) events has been noted. The latter is of concern for people with diabetes, who are at higher risk of CVD. This study aims to explore the relationship between incident CVD and intravitreal anti-VEGF therapy in patients with diabetes, compared to other therapies, using a large real-world global federated dataset.

METHODS

Data were analysed using TriNetX, a global electronic medical real-world ecosystem. The study included adults with diabetes and excluded those with a history of CVD prior to the time window of data extraction. Patients were categorised into two cohorts: anti-VEGF therapy or control cohort (laser or steroid therapies). The cohorts were 1:1 propensity score-matched for age, sex, ethnicity, body mass index, systolic blood pressure, HbA1c, and cardiovascular medications. Outcomes analysed at 1, 6 and 12 months were: (1) mortality; (2) acute myocardial infarction (MI); (3) cerebral infarction; and (4) heart failure. Relative risk analyses were performed using the built-in R statistical computing platform on TriNetX.

RESULTS

In patients with diabetes (n = 2205; mean age 58.8 ± 15.8, Std diff 0.05; 56% male), anti-VEGF therapy was associated with a numerical but non-statistically significant increased CVD risk over 1, 6, and 12 months: Mortality over 1 month (RR 1; 95% CI 0.42, 2.40), 6 months (RR 1.46; 95% CI 0.72, 2.95) and 12 months (RR 1.41; 95% CI 0.88, 2.27). There was no excess of acute MI over 1 (RR n/a: not applicable; 0/0: 0 events in the anti-VEGF group/0 events in the control group), 6 and 12 months (RR n/a; 0/10 events); cerebral infarction over 1, 6 months (RR n/a; 0/0 events), and 12 months (RR n/a; 0/10); and heart failure over 1 month (RR n/a; 0/0 events), 6 months (RR 1; 95% CI 0.42, 2.40) and 12 months (RR 1; 95% CI 0.42, 2.34).

CONCLUSIONS

There was no statistically significant risk of cardiovascular-related events in the short or medium term in patients with diabetes who received intravitreal anti-VEGF therapy, despite a small increase in the number of CVD events. Our study supports the real-world safety of intravitreal anti-VEGF therapy in patients with diabetes free of baseline CVD.

Long-term changes in the choroidal thickness in patients with unilateral central retinal vein occlusion

The purpose of this study was to investigate the long-term changes in the choroidal thickness in central retinal vein occlusion (CRVO) following anti-vascular endothelial growth factor (VEGF) treatment. This retrospective study included 41 eyes from 41 patients with treatment-naïve unilateral CRVO. We compared the best-corrected visual acuity (BCVA), subfoveal choroidal thickness (SFCT), and central macular thickness (CMT) of CRVO eyes with those of fellow eyes at baseline, 12 months, and 24 months. Baseline SFCT was significantly higher in CRVO eyes than in fellow eyes (p < 0.001); however, there was no significant difference in the SFCT between CRVO eyes and fellow eyes at 12 months and 24 months. When compared with baseline SFCT, SFCT significantly decreased at 12 months and 24 months in CRVO eyes (all p < 0.001). In patients with unilateral CRVO, SFCT in the CRVO eye was significantly thicker than in the fellow eye at baseline, and after 12 months and 24 months, there was no difference from the fellow eye.

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.

Intravitreal Dexamethasone Implant Has Better Retinal Perfusion than Anti-Vascular Endothelial Growth Factor Treatment for Macular Edema Secondary to Retinal Vein Occlusion: A Five-Year Real-World Study

PURPOSE

The purpose of the study was to investigate the long-term effect of intravitreal dexamethasone (DEX) implant and anti-vascular endothelial growth factor (VEGF) injection on macular edema (ME) secondary to retinal vein occlusion (RVO) in a real-world setting.

METHODS

The medical records of RVO-ME cases, with intravitreal injections and followed up for at least 5 years, were retrospectively reviewed. Changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) were primary outcomes. Images of fluorescence angiography and swept-source optical coherence tomography angiography were analyzed. Foveal avascular zone (FAZ) metrics and perfusion density at the last visit were also compared between the two treatments.

RESULTS

A total of 16 patients were recruited, 8 in the anti-VEGF group and 8 in the DEX group. At the 5th year, the BCVA and the CMT in the DEX group were not different from those in the anti-VEGF group (0.69 ± 0.36 LogMAR vs. 0.57 ± 0.30 LogMAR, p = 0.574; 183.25 ± 97.31 µm vs. 195.38 ± 40.92 µm, p = 0.442). Compared with the anti-VEGF group, the DEX group had higher FAZ circularity index (0.57 ± 0.14 vs. 0.68 ± 0.14, p = 0.130) and higher retinal perfusion density (0.45 ± 0.02 vs. 0.39 ± 0.03, p = 0.001), especially in the deep capillary plexus.

CONCLUSION

DEX implant and anti-VEGF injection had comparative long-term effects on RVO-ME. Compared with the anti-VEGF treatment, the DEX treatment had advantages in maintaining retinal perfusion in patients with RVO.

Short- and Long-Term Visual Outcomes in Patients Receiving Intravitreal Injections: The Impact of the Coronavirus 2019 Disease (COVID-19)-Related Lockdown

Purpose: To investigate the short- and long-term impact of COVID-19—related lockdown on the vision of patients requiring intravitreal injections (IVI) for neovascular Age-related Macular degeneration (nvAMD), diabetic retinopathy (DR), central retinal vein occlusion (CRVO), or branch retinal vein occlusion (BRVO). Methods: This is a retrospective study from the Retina department of three Mass Eye and Ear centers. Charts of patients age of ≥ 18 years with any of the abovementioned diagnoses who had a scheduled appointment anytime between 17 March 2020 until 18 May 2020 (lockdown period in Boston, Massachusetts) were reviewed at baseline (up to 12 weeks before the lockdown), at first available follow-up (=actual f/u) during or after the lockdown period, at 3 months, 6 months, and at last available completed appointment of 2020. Results: A total of 1001 patients met the inclusion criteria. Of those patients, 479 (47.9%) completed their intended f/u appointment, while 522 missed it (canceled and “no show”). The delay in care of those who missed it was 59.15 days [standard deviation (SD) ± 49.6]. In these patients, significant loss of vision was noted at actual f/u [Best corrected visual acuity (BCVA) in LogMAR (Logarithm of the Minimum Angle of Resolution)—mean (±SD)—completed: 0.45 (±0.46), missed: 0.53 (±0.55); p = 0.01], which was more prominent in the DR group [Visual acuity (VA) change in LogMAR—mean (±SD); completed: 0.04 (±0.28), missed: 0.18 (±0.44); p = 0.02] and CRVO [completed: −0.06 (±0.27), missed: 0.11 (±0.35); p = <0.001] groups followed by nvAMD [completed: 0.006 (±0.16), missed: 0.06 (±0.27); p = 0.004] and BRVO [completed: −0.02 (±0.1), missed: 0.03 (±0.14); p = 0.02] ones. Overall, a higher percent of people who missed their intended f/u experienced vision loss of more than 15 letters at last f/u compared to those who completed it [missed vs. completed; 13.4% vs. 7.4% in nvAMD (p = 0.72), 7.8% vs. 6.3% in DR (0.84), 15.5% vs. 9.9% in CRVO (p < 0.001) and 9.6% vs. 2% in BRVO (p = 0.48)]. Conclusions: Delay in care of about 8.45 weeks can lead to loss of vision in patients who receive IVI with DR and CRVO patients being more vulnerable in the short-term, whereas in the long-term, CRVO patients followed by the nvAMD patients demonstrating the least vision recovery. BRVO patients were less likely to be affected by the delay in care. Adherence to treatment is key for maintaining and improving visual outcomes in patients who require IVI.

Predictors of vision-related quality of life in patients with macular oedema receiving intra-vitreal anti-VEGF treatment

PURPOSE

To determine which demographic and clinical characteristics are predictive of vision-related quality of life (VrQoL) and quality of life (QoL) in patients with macular oedema receiving intravitreal anti-vascular endothelial growth factor (VEGF) treatment.

METHODS

Vision-related quality of life (VrQoL) and quality of life (QoL) were measured in 712 patients with retinal exudative disease receiving anti-VEGF treatment at baseline, 6 and 12 months. VrQoL was measured using an item-response theory based 47-question item bank (EyeQ), whereas QoL was measured using the EuroQol Five Dimensions (EQ-5D) questionnaire. The EQ-5D score was dichotomized into a perfect score of 1 and a suboptimal score of <1. Demographic and clinical patient characteristics were considered as possible predictors of (Vr)QoL. Prediction models for (Vr)QoL were created with linear mixed models and generalised estimating equations, using a forward selection procedure.

RESULTS

A worse VrQoL was predicted by poorer LogMAR visual acuity of the better eye, female sex, single civil status, older age, longer length of anti-VEGF treatment at baseline and the presence of non-ocular and ocular comorbidities. Suboptimal EQ-5D scores were predicted by poorer LogMAR visual acuity of the better eye, female sex, single civil status, older age, the presence of non-ocular comorbidities and a lower educational background.

CONCLUSIONS

Along with visual acuity of the better eye, which is the main factor used in clinical decision making, other patient characteristics should also be considered for the risk assessment of (Vr)QoL, such as sex, age, civil status, comorbidities and length of anti-VEGF treatment.

The Quantification and Impact of Persistent Retinal Fluid Compartments on Best-Corrected Visual Acuity of Patients With Retinal Vein Occlusion

BACKGROUND AND OBJECTIVES

To evaluate the impact of persistent intraretinal fluid (IRF) and subretinal fluid (SRF) on best visual acuity (BVA) of patients with retinal vein occlusions (RVOs).

PATIENTS AND METHODS

This retrospective cohort study observed 92 treatment-naïve patients with RVO during 12 months of treatment with anti-vascular endothelial growth factor agents. Deep learning was used to quantify IRF and SRF volumes, and linear mixed effects regression modeled the impact on BVA.

RESULTS

Average IRF volume declined -923.1 ± 2,382.5 nL from baseline to 12 months (P < .001). Average SRF volume declined -35.4 ± 223.4 nL from baseline to 12 months (P = .139). linear mixed effects regression modeling disclosed IRF≥ 1,616 nL at all time points predicted a -10.38 letter loss at 12 months (95% CI, -14.58 to -5.9 letters; P < .001). A similar relationship was not found for SRF.

CONCLUSION

Persistent IRF may be an important prognostic biomarker for BVA outcomes in real-world patients with RVO. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:139-147.].

Treatment of Macular Edema in Vascular Retinal Diseases: A 2021 Update

Macular edema (ME) is associated with various conditions; however, the main causes of ME are retinal vein occlusion (RVO) and diabetes. Laser photocoagulation, formerly the gold standard for the treatment of ME, has been replaced by anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections. Despite its efficiency, this treatment requires frequent injections to preserve the outcomes of anti-VEGF therapy, and as many patients do not sufficiently respond to the treatment, ME is typically a chronic condition that can lead to permanent visual impairment. Generalized recommendations for the treatment of ME are lacking, which highlights the importance of reviewing treatment approaches, including recent anti-VEGFs, intravitreal steroid implants, and subthreshold micropulse lasers. We reviewed relevant studies, emphasizing the articles published between 2019 and 2021 and using the following keywords: macular edema, diabetic macular edema, retinal vein occlusion, laser photocoagulation, anti-VEGF, and intravitreal injections. Our results revealed that a combination of different treatment methods may be beneficial in resistant cases. Additionally, artificial intelligence (AI) is likely to help select the best treatment option for patients in the near future.

Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT

BACKGROUND

Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period.

OBJECTIVE

The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion.

DESIGN

This was a three-arm, double-masked, randomised controlled non-inferiority trial.

SETTING

The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018.

PARTICIPANTS

A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial.

INTERVENTIONS

The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154).

MAIN OUTCOME MEASURES

The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years.

RESULTS

The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year.

LIMITATIONS

The comparison of aflibercept and bevacizumab was a post hoc analysis.

CONCLUSION

The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered.

FUTURE WORK

To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13623634.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.

Photocoagulation for retinal vein occlusion

The role of photocoagulation in retinal vein occlusion (RVO) has been studied since 1974. The most serious complications of central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) are: (i) visual deterioration, most commonly due to macular edema, and (ii) the development of ocular neovascularization (NV), particularly neovascular glaucoma (NVG), with hazardous consequences for vision and even the eye itself. Before discussing the role of photocoagulation in the management of NV and macular edema in RVO, it is crucial to gain a basic scientific understanding of the following relevant issues: classification of RVO, ocular NV in RVO, and the natural history of macular edema and visual outcome of RVO. These topics are discussed. In CRVO, ocular NV is a complication of ischemic CRVO but not of nonischemic CRVO. Photocoagulation has been advocated to prevent and/or treat the development of ocular NV and NVG. Since NVG is the most dreaded, intractable and blinding complication of ischemic CRVO, the role of photocoagulation and its management are discussed. Findings of three randomized, prospective clinical trials dealing with photocoagulation in ischemic CRVO are discussed. The role of photocoagulation in the management of ocular NV and macular edema in BRVO, and three randomized, prospective clinical trials dealing with those are discussed. Recent advent of intravitreal anti-VEGF and corticosteroid therapies has drastically changed the role of photocoagulation in the management of macular edema and NV in CRVO and BRVO. This is discussed in detail.

Fluctuations in Macular Thickness in Patients with Retinal Vein Occlusion Treated with Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

To evaluate macular thickness fluctuations in patients with retinal vein occlusions (RVOs) treated with anti-vascular endothelial growth factor (VEGF) agents and to assess whether patients with larger fluctuations have poorer visual outcomes.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Treatment-naive patients with RVO.

METHODS

Central subfield thickness (CST), cube volume (CV), and cube average thickness (CAT) were collected from OCT images obtained at baseline and 3, 6, 9, and 12 months, and standard deviations (SDs) across 12 months were calculated. Mixed-effects regression was performed to examine the relationship between macular thickness SD and 12-month visual acuity (VA). Standard multiple regression was performed to identify predictors of macular thickness SD.

MAIN OUTCOME MEASURES

Standard deviations across 12 months for CST, CV, and CAT and VA at 12 months.

RESULTS

One hundred thirty-four eyes, including 71 with branch RVO (BRVO) and 63 with central RVO (CRVO), were evaluated. Mean baseline and 12-month CST were 488.6 ± 165.0 μm and 334.3 ± 131.9 μm (change, -154.3 ± 210.2 μm; P < 0.001), with CST SD of 114.1 ± 77.0 μm. Baseline and 12-month VA were 52.8 ± 20.9 letters and 65.9 ± 17.3 letters (change, +13.1 ± 20.3 letters; P < 0.001). Central subfield thickness SD was a significant negative predictor of 12-month VA (-5.21 letters/100 μm; 95% confidence interval [CI], -10.21 to -0.22 letters/100 μm; P = 0.041) when adjusting for baseline factors and injections. Baseline CST and number of injections were not predictive (P ≥ 0.101). Stratification by CST SD demonstrated a 10-letter difference in 12-month VA between the first and fourth quartiles. Baseline CST and RVO diagnosis were the only significant predictors of CST SD (CRVO vs. BRVO: +34.64 μm/100 μm [95% CI, 29.33-39.94 μm/100 μm; P < 0.001] and +22.13 μm/100 μm [95% CI, 4.81-39.44 μm/100 μm; P = 0.013]). Associations using CV and CAT were similar.

CONCLUSIONS

Larger macular thickness fluctuations are associated with poorer visual outcomes in patients with RVO treated with anti-VEGF agents. Macular thickness fluctuations, in addition to absolute macular thickness, may be an important prognostic biomarker in these patients.

Effects of Switching from Anti-VEGF Treatment to Triamcinolone Acetonide in Eyes with Refractory Macular Edema Associated with Diabetic Retinopathy or Retinal Vein Occlusion

Purpose

To evaluate the efficacy of switching from intravitreal antivascular endothelial growth factor (VEGF) agents to triamcinolone acetonide (TA) in eyes with diabetic macular edema (DME) or with retinal vein occlusion-associated macular edema (RVO-ME) on the resolution of the macular edema (ME).

Methods

The medical records of 11 eyes of 11 patients with DME and 9 eyes of 9 patients with RVO-ME whose MEs were refractory to anti-VEGF treatment were reviewed. The central retinal thickness (CRT), best-corrected visual acuity (BCVA), intraocular pressure (IOP), and the mean interval of the recurrences were measured during the anti-VEGF treatment and after switching to the TA injections.

Results

Switching to TA injections significantly increased the mean interval for recurrences from 9.2 ± 2.7 weeks to 22.3 ± 12.9 weeks in eyes with DME (P = 0.006). In eyes with RVO-ME, the mean period of recurrence was 12.3 ± 5.6 weeks before and 11.6 ± 4.4 weeks after the switch (P = 0.44). The mean interval for recurrence was extended to more than 8 weeks in 7 of 11 eyes with DME, but none of the eyes with RVO-ME had a prolongation of more than 4 weeks. An elevation of the IOP was observed in 3 of the 20 eyes after the TA injection.

Conclusions

These findings indicate that switching to TA injections can be a good option for DME eyes refractory to anti-VEGF injections but not for the RVO-ME eyes.

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.

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

BACKGROUND

Branch retinal vein occlusion (BRVO) is one of the most commonly occurring retinal vascular abnormalities. The most common cause of visual loss in people with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss. Limitations to this treatment exist, however, and newer modalities may have equal or improved efficacy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has recently been used successfully to treat MO resulting from a variety of causes.

OBJECTIVES

To investigate the efficacy and gather evidence from randomised controlled trials (RCTs) on the potential harms of anti-vascular endothelial growth factor (VEGF) agents for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); MEDLINE Ovid; Embase Ovid; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. The date of the last search was 12 June 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating BRVO. Eligible trials had to have at least six months' follow-up where anti-VEGF treatment was compared with another treatment, no treatment, or placebo. We excluded trials where combination treatments (anti-VEGF plus other treatments) were used; and trials that investigated the dose and duration of treatment without a comparison group (other treatment/no treatment/sham).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data using standard methodological procedures expected by Cochrane. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and 12 months of follow-up. The secondary outcomes were the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean visual acuity (VA) change at six and 12 months, as well as the change in central retinal thickness (CRT) on optical coherence tomography from baseline at six and 12 months. We also collected data on adverse events and quality of life (QoL).

MAIN RESULTS

We found eight RCTs of 1631 participants that met the inclusion criteria after independent and duplicate review of the search results. These studies took place in Europe, North America, Eastern Mediterranean region and East Asia. Included participants were adults aged 18 or over with VA of 20/40 or worse. Studies varied by duration of disease but permitted previously treated eyes as long as there was sufficient treatment-free interval. All anti-VEGF agents (bevacizumab, ranibizumab and aflibercept) and steroids (triamcinolone and dexamethasone) were included. Overall, we judged the studies to be at moderate or unclear risk of bias. Four of the eight studies did not mask participants or outcome assessors, or both. One trial compared anti-VEGF to sham. At six months, eyes receiving anti-VEGF were significantly more likely to have a gain of 15 or more ETDRS letters (risk ratio (RR) 1.72, 95% confidence interval (CI) 1.19 to 2.49; 283 participants; moderate-certainty evidence). Mean VA was better in the anti-VEGF group at six months compared with control (mean difference (MD) 7.50 letters, 95% CI 5.29 to 9.71; 282 participants; moderate-certainty evidence). Anti-VEGF also proved more effective at reducing CRT at six months (MD -57.50 microns, 95% CI -108.63 to -6.37; 281 participants; lower CRT is better; moderate-certainty evidence). There was only very low-certainty evidence on adverse effects. There were no reports of endophthalmitis. Mean change in QoL (measured using the National Eye Institute Visual Functioning Questionnaire VFQ-25) was better in people treated with anti-VEGF compared with people treated with sham (MD 7.6 higher score, 95% CI 4.3 to 10.9; 281 participants; moderate-certainty evidence). Three RCTs compared anti-VEGF with macular laser (total participants = 473). The proportion of eyes gaining 15 or more letters was greater in the anti-VEGF group at six months (RR 2.09, 95% CI 1.44 to 3.05; 2 studies, 201 participants; moderate-certainty evidence). Mean VA in the anti-VEGF groups was better than the laser groups at six months (MD 9.63 letters, 95% CI 7.23 to 12.03; 3 studies, 473 participants; moderate-certainty evidence). There was a greater reduction in CRT in the anti-VEGF group compared with the laser group at six months (MD -147.47 microns, 95% CI -200.19 to -94.75; 2 studies, 201 participants; moderate-certainty evidence). There was only very low-certainty evidence on adverse events. There were no reports of endophthalmitis. QoL outcomes were not reported. Four studies compared anti-VEGF with intravitreal steroid (875 participants). The proportion of eyes gaining 15 or more ETDRS letters was greater in the anti-VEGF group at six months (RR 1.67, 95% CI 1.33 to 2.10; 2 studies, 330 participants; high-certainty evidence) and 12 months (RR 1.76, 95% CI 1.36 to 2.28; 1 study, 307 participants; high-certainty evidence). Mean VA was better in the anti-VEGF group at six months (MD 8.22 letters, 95% CI 5.69 to 10.76; 2 studies, 330 participants; high-certainty evidence) and 12 months (MD 9.15 letters, 95% CI 6.32 to 11.97; 2 studies, 343 participants; high-certainty evidence). Mean CRT also showed a greater reduction in the anti-VEGF arm at 12 months compared with intravitreal steroid (MD -26.92 microns, 95% CI -65.88 to 12.04; 2 studies, 343 participants; moderate-certainty evidence). People receiving anti-VEGF showed a greater improvement in QoL at 12 months compared to those receiving steroid (MD 3.10, 95% CI 0.22 to 5.98; 1 study, 307 participants; moderate-certainty evidence). Moderate-certainty evidence suggested increased risk of cataract and raised IOP with steroids. There was only very low-certainty evidence on APTC events. No cases of endophthalmitis were observed.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that treatment of MO secondary to BRVO with anti-VEGF improves visual and anatomical outcomes at six and 12 months.

Treatment of unusual thrombotic manifestations

Venous thrombosis rarely occurs at unusual sites such as cerebral, splanchnic, upper-extremity, renal, ovarian, or retinal veins. Clinical features, symptoms, and risk factors of rare thrombotic manifestations are heterogeneous and in large part differ from those typical of the commonest manifestations of venous thrombosis at the lower extremities. The therapeutic approach also varies widely according to the affected site, whether cerebral, abdominal, or extraabdominal. To date, anticoagulant therapy for thrombosis at unusual sites is generally accepted, but the optimal therapeutic approach remains challenging. This review is focused on the treatment of unusual thrombotic manifestations as reported in the most recent guidelines and according to the updated scientific literature.

Correlation between macular vessel density and number of intravitreal anti-VEGF agents for macular edema associated with branch retinal vein occlusion

We evaluated whether the reduction of macular vessel density was correlated with the number of intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents in eyes with a branch retinal vein occlusion (BRVO). The mean vessel density was determined by optical coherence tomography angiography in 29 eyes with macular edema associated with a BRVO. Our results showed that the mean vessel density in the group that had a resolution of the macular edema after one anti-VEGF injection was significantly higher than group that had a recurrence of the macular edema (P = 0.028). Single regression analysis showed that the number of intravitreal injections was significantly correlated with the reduction of the modified vessel density (r = −0.421, P = 0.023) and systemic hypertension (r = 0.377, P = 0.044). Multiple stepwise regression analysis showed that the reduction of the modified vessel density (β = −0.442, P = 0.009) and hypertension (β = 0.403, P = 0.016) were independent factors associated with the number of intravitreal injections. We conclude that the vessel density reduction can be used to predict whether recurrences of the macular edema will develop after the initial anti-VEGF injection in eyes with macular edema associated with a BRVO.

Comparison of subfoveal choroidal thickness in eyes with CRVO and BRVO

BACKGROUND

To evaluate the subfoveal choroidal thickness (SFCT) in eyes with macular edema (ME) secondary to retinal vein occlusion(RVO), and to investigate the short term response after a single intravitreal ranibizumab (IVR) injection. What is more, to compare SFCT and SFCT change between central RVO (CRVO) and branch RVO (BRVO).

METHODS

In the retrospective study, we had collected 36-six treatment-naïve patients with unilateral ME secondary to RVO (including 19 CRVO and 17 BRVO). All patients had received IVR injection after newly diagnosed. The SFCT was measured at the onset and after 2 weeks of IVR injection. Paired t test was performed to compare the SFCT of RVO eyes and fellow eyes, as well as the SFCT of pre-injection and post-injection. In further, independent t test was used to compare SFCT and SFCT change between CRVO eyes and BRVO eyes.

RESULTS

The mean SFCT at the onset was 326.03 ± 30.86 μm in CRVO eyes, which was significantly thicker than that in contralateral fellow eyes (p < 0.01, paired t test), and reduced to 294.15 ± 30.83 μm rapidly after 2 weeks of IVR injection (p < 0.01, paired t test). Similarly, the SFCT in BRVO eyes was significantly thicker than that in contralateral eyes at the onset, and decreased significantly after IVR injection. However, our findings showed that there was no statistically significant difference in SFCT and SFCT reduction after IVR injection between CRVO eyes and BRVO eyes.

CONCLUSIONS

The SFCT in eyes with ME secondary to CRVO and BRVO was significantly thicker than that in fellow eyes, and decreased significantly within a short time in response to a single IVR injection. In further, the study showed that SFCT and SFCT change had no correlation with RVO subtypes.

Quantitative Analysis of Retinal Microvascular Changes after Conbercept Therapy in Branch Retinal Vein Occlusion Using Optical Coherence Tomography Angiography

PURPOSE

To quantitatively evaluate microvascular changes in eyes with macular oedema due to branch retinal vein occlusion (BRVO) using optical coherence tomography angiography (OCTA) before and after intravitreal conbercept injection and the correlation of such changes with best-corrected visual acuity (BCVA) and retinal thickness.

METHODS

Twenty-eight eyes of 28 patients treated with a single intravitreal injection of conbercept for macular oedema due to BRVO were included in this study. The automatically measured values of the vessel density in the superficial (SCP) and deep retinal capillary plexus (DCP), the foveal avascular zone (FAZ) area, the FAZ perimeter, the vessel density within a 300 μm wide ring surrounding the FAZ (FD-300), the acircularity index (AI), the choriocapillaris flow area and the retinal thickness were obtained via OCTA before and at 1 month after initial injection and compared with those of age- and sex- matched healthy subjects.

RESULTS

In BRVO eyes, the vascular density in the SCP and DCP, the FD-300 and the flow area of choriocapillaris were significantly lower than those in healthy eyes, while the AI and the retinal thickness were significantly increased. After treatment, the retinal thickness in eyes with BRVO was significantly decreased in all quadrants, and the mean BCVA dramatically increased from 20/162 to 20/78 (p = 0.0017). The mean flow area of choriocapillaris significantly improved after treatment. Moreover, negative correlations between the logMAR BCVA and the whole vascular density in the SCP and DCP as well as the flow area of choriocapillaris were observed.

CONCLUSION

OCTA enables non-invasive, layer-specific and quantitative assessment of microvascular changes in eyes with BRVO before and after treatment, and it can be used as a valuable imaging tool for the evaluation of the follow-up in BRVO patients.

Intravitreal dexamethasone implants versus intravitreal anti-VEGF treatment in treating patients with retinal vein occlusion: a meta-analysis

Background

Retinal vein occlusion (RVO) is a common retinal venous disorder that causes vision loss. No specific therapy has been developed. Controversy exists regarding two treatments: intravitreal dexamethasone implants and anti-vascular endothelial growth factor (VEGF). The goal of this study is to compare the effectiveness and safety of dexamethasone implants and anti-VEGF treatment for RVO.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for studies comparing dexamethasone implants with anti-VEGF in patients with RVO. Best-corrected visual acuity (BCVA), central subfield thickness (CST), intraocular pressure changes, conjunctival haemorrhage, reduced VA, and macular oedema were extracted from the final included studies. RevMan 5.3 was used to conduct the quantitative analysis and bias assessment.

Results

Four randomised controlled trials assessing 969 eyes were included. The anti-VEGF treatment showed better BCVA improvement (mean difference [MD] = − 10.59, P < 0.00001) and more CST decrease (MD = − 86.71 μm, P = 0.02) than the dexamethasone implants. However, the dexamethasone implants required fewer injections. As for adverse effects, the dexamethasone implants showed significantly higher intraocular pressure (IOP) and more cataracts than the anti-VEGF treatment. No significant differences were found in conjunctival haemorrhage, reduced VA, and macular oedema.

Conclusions

Anti-VEGF treatment showed better functional and anatomical improvement with less risk of IOP elevation and cataract formation compared to dexamethasone implants. Thus, anti-VEGF treatment is the first choice for treating RVO patients.

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.

Comparative efficacy of bevacizumab, ranibizumab, and aflibercept for treatment of macular edema secondary to retinal vein occlusion: a systematic review and network meta-analysis

INTRODUCTION

Anti-vascular endothelial growth factor (VEGF) therapy has become the most commonly used treatment for macular edema secondary to retinal vein occlusion (RVO). Although its superior efficacy as compared to other interventions has been proven, there is a lack of evidence for relative efficacy among anti-VEGF drugs. Areas covered: This work systematically reviewed and compared the efficacy of intravitreal bevacizumab, ranibizumab, and aflibercept for treating macular edema due to RVO. PubMed, EMBASE, and the Cochrane Library were searched from their inception until October 2017. Eleven randomized controlled trials (18 articles; 1830 adult patients) were identified. The proportion of patients who gained at least 15 letters in best-corrected visual acuity (BCVA), mean change from baseline in BCVA, and mean change from baseline in central macular thickness (CMT) were reported and these efficacy outcomes at 6 months were analyzed in network meta-analysis. Expert commentary: Apparently, bevacizumab, ranibizumab, and aflibercept were significantly superior to sham injection in terms of BCVA improvement and CMT reduction and had good safety profiles. However, there were no statistically significant differences in any outcomes among anti-VEGF drugs. In selecting an anti-VEGF drug for individual patients, other factors including affordability, drug availability, and patient characteristics should be considered.