Short-term outcomes in patients with branch retinal vein occlusion who received intravitreal aflibercept with or without intravitreal ranibizumab

Branch retinal vein occlusion treated with anti-VEGF: to switch or not to switch?

OBJECTIVE

To evaluate visual outcomes after switching from bevacizumab to ranibizumab or aflibercept in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

DESIGN

A retrospective, multi-center, observational study.

PARTICIPANTS

Patients diagnosed with BRVO and were treated with at least 3 bevacizumab injections, before anti VEGF switch.

METHODS

The follow-up period was 36 months, and the primary study outcomes assessed changes in best corrected visual acuity (BCVA) after anti VEGF switch.

RESULTS

A total of 263 eyes of 263 patients with a mean age of 71.5 ± 11.2 years of which 50% were of male gender met the inclusion criteria. Of them, 175 eyes did not undergo switch, whereas 88 eyes underwent anti-VEGF switch. There was not a significant difference in mean age (p = 0.634) and gender (p = 0.269) between the groups. Baseline BCVA of the no-switch group was 0.47 ± 0.43 logMAR (20/59 Snellen) versus 0.6 ± 0.49 logMAR (20/79 Snellen) (p = 0.031) in the switch group, and at 36-months it was 0.41 ± 0.39 (20/51 Snellen) logMAR versus 0.54 ± 0.49 logMAR (20/69 Snellen) (p = 0.035), respectively. The difference between the rate of change in BCVA per year was insignificant between groups (p = 0.414). In multivariate analysis, baseline BCVA was the single significant predictor for switch (beta 0.137, p = 0.035). Patients with more than one anti-VEGF switch suffer from decrease in BCVA.

CONCLUSIONS

Worse baseline BCVA is a significant predictor for anti-VEGF switch execution, though the switch has no significant impact on the change in BCVA over time. Multiple anti-VEGF switch is not recommended.

Real-Life Efficacy of Bevacizumab Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion according to Pro Re Nata or Treat-and-Extend Regimen in Eyes with or without Epiretinal Membrane

Purpose. To present real-life data of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO) treated with bevacizumab (BVZ); determine the possible influence of epiretinal membrane (ERM) on treatment efficacy; and compare treatment outcomes in a treat-and-extend regimen (TER) versus pro re nata (PRN). Methods. We carried out a retrospective analysis of 58 eyes (56 patients) with new-onset CRVO treated only with intravitreal bevacizumab according to TER or PRN. Outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and 12 months after the first treatment, number of visits and injections, and presence of ERM confirmed by optical coherence tomography in the first 6 months. Results. At 12 months, the mean number of injections was 6.3 across all eyes, with significantly more injections given in TER ( $p<0.001$ ). Mean CRT improved from 627 μm to 359 μm ( $p<0.001$ ) in all eyes, with improvement noted in TER ( $p<0.001$ ), PRN ( $p<0.001$ ), ERM ( $p=0.003$ ), and non-ERM ( $p<0.001$ ) subgroups. The mean BCVA gain was +13.6 letters, and the mean BCVA improved from 0.81 to 0.54 LogMAR ( $p<0.001$ ) in all eyes. BCVA improvement from baseline was significant in TER ( $p<0.001$ ) and non-ERM ( $p<0.001$ ) but not in PRN ( $p=0.08$ ) or ERM ( $p=0.2$ ) subgroups. Seven eyes, all receiving PRN treatment, developed neovascularization. Conclusions. Intravitreal bevacizumab according to either PRN or TER resolved edema and stabilized vision in the first 12 months, with TER yielding significant visual improvement and avoiding neovascular complications. ERM had no influence on bevacizumab efficacy in reducing ME in CRVO during 12 months of treatment.

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.

Ranibizumab and aflibercept intravitreal injection for treatment naïve and refractory macular oedema in branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion complicated by macular oedema is a common disease treated with intravitreal injection of anti-vascular endothelial growth factor. Controversy exists surrounding anti-vascular endothelial growth factor selection for both treatment naïve and refractory cases.

METHODS

A retrospective electronic medical record review at a single UK centre generated a cohort of 259 treatment naïve eyes from 258 patients receiving ranibizumab, aflibercept or a combination (n = 83, 97 and 79, respectively) from 2013 to 2018 with ⩾6 months follow-up. Number of intravitreal injections, visual acuity and macular oedema presence were noted at 3, 6, 12, 24, 36 and 48 months. A subgroup analysis examined refractory cases switched from ranibizumab to aflibercept (n = 77) or maintained on ranibizumab (n = 35).

RESULTS

Eyes receiving ranibizumab or aflibercept had equivocal vision gain at 1 year, 8.0 (95% CI 5.0-11.0) and 9.6 (7.2-12.1) Early Treatment of Diabetic Retinopathy Study letters, respectively. About 35.6% had no macular oedema at 12 months with ranibizumab compared with 50.0% with aflibercept (p = 0.07) following 5.1 (4.7-5.6) and 6.0 (5.6-6.4) intravitreal injections, respectively. Visual prognosis declined significantly as treatment delay extended (p = 0.003) which was only apparent with ⩾3 months delay. Eyes with refractory macular oedema also had equivocal functional and anatomical outcomes whether they were maintained on ranibizumab or switched to aflibercept.

CONCLUSION

These real world data demonstrate more modest clinical improvements from anti-vascular endothelial growth factor treatment than reported in clinical trials. The functional outcomes of ranibizumab and aflibercept in both treatment naïve and refractory cases were equivocal while the anatomical outcomes of aflibercept may be superior.

Clinical efficacy evaluation of treatment of different degrees of retinal vein occlusion with ranibizumab combined with an argon ion laser

The aim of this study was to evaluate the clinical efficacy of an intravitreal injection of ranibizumab combined with argon ion laser photocoagulation therapy in the treatment of different degrees of central retinal vein occlusion (CRVO). A total of 112 CRVO patients including 25 cases of trunk occlusion, 50 cases of branch occlusion and 37 cases of hemiretinal vein-occlusion were enrolled in this study. Patients were treated with an intravitreal injection of 0.5 mg ranibizumab, followed by argon ion laser photocoagulation therapy after 7 days. Patients were followed up for 6 months and the best corrected visual acuity (BCVA), central retinal thickness (CRT), macular edema, and surgical complications were compared. Compared with the control treated with 0.5 mg ranibizumab, the BCVA and macular edema improved while CRT was significantly reduced in all groups treated with 0.5 mg ranibizumab combined with the argon ion laser. Furthermore, no obvious complications were observed in these groups and the effects of ranibizumab combined with argon ion laser photocoagulation on branch occlusion group were the best. Intravitreal injection of ranibizumab combined with argon ion laser photocoagulation therapy has better safety and effectiveness in the treatment of different degrees of CRVO. The trial registration number is 2015–318 and date of registration is 12/10/2015.

Real-World Results of Switching Treatment from Ranibizumab to Aflibercept in Macular Oedema Secondary to Branch Retinal Vein Occlusion

Introduction

To investigate treatment outcomes after switching from ranibizumab to aflibercept intravitreal injections in patients with macular oedema (MO) secondary to branch retinal vein occlusion (BRVO).

Methods

Eligible patients with refractory MO secondary to BRVO, post treatment with a minimum of three intravitreal injections of ranibizumab at 4-weekly intervals were recruited. Suboptimal or non-responders were defined as patients who had persistent intraretinal fluid (< 75% decrease from baseline) despite a minimum of three consecutive injections. These patients were switched to aflibercept injections on an as-needed basis. The primary study outcomes assessed trends in best-corrected distance visual acuity (BCVA) and central retinal thickness (CRT). To compare means of BCVA and CRT, a paired t test two-tailed with a level of significance set at 0.05 was used. Pearson correlation coefficient was also applied to demonstrate correlation. Participants were followed up for a period of 24 weeks after switching.

Results

Thirty-eight eyes of 38 patients were included in the study. Patients had an average of 8.37 ranibizumab intravitreal injections over a mean period of 12 months presenting suboptimal or no response. A significant decrease of mean CRT from 388.63 ± 93.4 μm to 290.29 ± 93.5 μm (p < 0.001) and an improvement in mean BCVA from logMAR 0.66 ± 0.38 to logMAR 0.57 ± 0.27 (p = 0.025) was achieved after an average of 2.27 aflibercept injections.

Conclusions

Given the spectrum of therapies available to date for the management of MO secondary to BRVO, aflibercept appears to be an effective treatment option in cases refractory to ranibizumab. This study based on a small cohort of patients indicates that satisfactory results on retinal anatomy and visual outcomes can be accomplished with a smaller number of injections. Larger-scale studies are needed to extrapolate these promising results.