Combined intravitreal bevacizumab and grid laser photocoagulation for macular edema secondary to branch retinal vein occlusion

Combination intravitreal anti-vascular endothelial growth factor inhibitors and macular laser photocoagulation relative to intravitreal injection monotherapy in macular oedema secondary to retinal vein occlusion: a meta-analysis of randomized controlled trials

BACKGROUND/OBJECTIVES

This meta-analysis investigates the efficacy and safety of intravitreal anti-VEGF injections (IVI) compared to combination laser photocoagulation and IVI (LPC-IVI) in treating macular oedema secondary to retinal vein occlusion (RVO).

SUBJECTS/METHODS

A literature search of MEDLINE, EMBASE and Cochrane CENTRAL was conducted from inception until March 2021. Randomized controlled trials that reported relevant efficacy and/or safety parameters following LPC-IVI relative to IVI were included. Meta-analysis was conducted with a random effects model. The primary outcome was best-corrected visual acuity (BCVA), while secondary outcomes were central macular thickness (CMT), central retinal thickness (CRT), central subfield thickness (CST), number of IVIs received, and incidence of adverse events.

RESULTS

A total of 10 studies were included, for which 362 eyes were randomized to LPC-IVI and 365 to IVI. In comparing macular laser photocoagulation with IVI (MLP-IVI) in BRVO patients, no significant differences were seen in final BCVA (p = 0.78) or change in BCVA (p = 0.09) after treatment. Similarly, no significant differences were seen in final CMT (p = 0.54), change in CMT (p = 0.33), final CRT (p = 0.90), change in CRT (p = 0.97), or number of injections required (p = 0.78). The same results were seen in subgroup analyses for macular laser without peripheral laser in BRVO and CRVO patients. Consistent results were observed when considering peripheral LPC-IVI to IVI in BRVO and CRVO.

CONCLUSIONS

No significant differences were seen between combination MLP-IVI or peripheral LPC-IVI relative to IVI monotherapy for final BCVA or OCT parameters in macular oedema secondary to RVO.

Navigated laser and aflibercept versus aflibercept monotherapy in treatment-naïve branch retinal vein occlusion: A 12-month randomized trial

PURPOSE

Angiostatic agents have proven effective in the treatment of macular oedema in patients with branch retinal vein occlusion (BRVO). However, treatment is inconvenient and expensive, and novel treatment regimens are warranted. We aimed to evaluate if combination treatment of navigated central retinal laser and aflibercept lowered the treatment burden in these patients.

METHODS

Treatment-naïve patients with BRVO and macular oedema were included at two centres and randomized 1:1 to three monthly injections of 2.0 mg aflibercept with (Group A) or without (Group B) navigated central laser, followed by aflibercept as needed from month 4 through 12. Re-treatment need was evaluated, and secondary endpoints included functional and anatomical outcomes and safety evaluated by retinal microperimetry.

RESULTS

We evaluated 41 eyes of 41 patients with a mean age of 69.6 years. Baseline median best-corrected visual acuity (BCVA) was 70.0 letters, and median central retinal thickness (CRT) was 502 μm with no difference between Groups A (n = 21) and B (n = 20). Percentage of patients needing re-treatment after month three was 71% and 80% (p = 0.72). At month 12, groups did not differ in number of injections after loading (1 versus 2, p = 0.43), change in BCVA (+12.8 versus +15.1 letters, p = 0.48), CRT (-195 versus -181 μm, p = 0.82), or retinal sensitivity (+3.3 versus +4.1 dB, p = 0.67).

CONCLUSION

In treatment-naïve BRVO patients, addition of navigated central laser to aflibercept did not lower treatment burden or affect functional or anatomical outcomes. A low number of intravitreal injections were needed for successful outcome in both treatment arms.

Comparison of the efficiency of anti-VEGF drugs intravitreal injections treatment with or without retinal laser photocoagulation for macular edema secondary to retinal vein occlusion: A systematic review and meta-analysis

Objective: To compare the efficiency of anti-VEGF drugs intravitreal injections(IVI) treatment with or without retinal laser photocoagulation(LPC) for macular edema(ME) secondary to retinal vein occlusion(RVO).

Methods: The randomized controlled trials and retrospective studies including anti-VEGF drug IVI combined with retinal LPC and single IVI in the treatment of macular edema secondary to RVO were collected in PubMed, Medline, Embase, Cochrane Library, and Web of Science. We extracted the main outcome indicators including the best corrected visual acuity (BCVA), central macular thickness(CMT), the number of injections and the progress of retinal non-perfusion areas(NPAs) for systematic evaluation, to observe whether IVI + LPC could be more effective on the prognosis of RVO. We use Review Manager 5.4 statistical software to analyze the data

Results: 527 articles were initially retrieved. We included 20 studies, with a total of 1387 patients who were divided into the combination(IVI + LPC) treatment group and the single IVI group. All the patients completed the ocular examination including BCVA, slit-lamp test, fundus examination and Optical Coherence Tomography(OCT) test before and after each treatment. There was no statistical difference between the combination treatment group and single IVI group on BCVA(WMD = 0.12,95%CI = -3.54–3.78,p = 0.95),CMT(WMD = -4.40,95%CI = -21.33–12.53,p = 0.61) and NPAs(WMD = 0.01,95%CI = -0.28–0.30,p = 0.94).However, the number of IVI was decreased significantly in the combination treatment group in BRVO patients, compared to that in the single IVI group(WMD = -0.69,95%CI = -1.18∼-0.21,p = 0.005).

Conclusion: In the treatment of RVO patients with macular edema, the combination of IVI and retinal LPC neither improves BCVA nor reduces CMT significantly compared with the single IVI treatment. However, the combination treatment can decrease the number of intravitreal injections in patients with BRVO, while it is not observed in CRVO patients.

Visual acuity after intravitreal ranibizumab with and without laser therapy in the treatment of macular edema due to branch retinal vein occlusion: a 12-month retrospective analysis

AIM

To identify factors contributing to visual improvement after treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO), and to assess the interaction between laser therapy and intravitreal ranibizumab (IVR).

METHODS

We retrospectively reviewed the medical records of patients who had been treated for BRVO-related ME at our hospital. Records were traceable for at least 12mo, and evaluated factors included age, sex, medical history, smoking history, treatment methods, foveal hemorrhage, and change in visual acuity. Treatments included laser therapy, IVR, sub-Tenon's capsule injection of triamcinolone (STTA), a combination, or no intervention. Multivariate logistic regression analysis and interaction terms were used to assess the clinical efficacy of the treatments, and odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Seventy-three patients (34 men, 39 women; 73 eyes) with a mean age of 69.4±12.1y were included. Patients who underwent IVR monotherapy, laser monotherapy, and STTA+laser had significantly higher best corrected visual acuity at 12mo compared to baseline (P<0.001, <0.001, and 0.019, respectively). Logistic regression analysis without interaction terms found that IVR was a significant visual acuity recovery factor (adjusted OR: 3.89, 95%CI: 1.25-12.1, P=0.019). Adjusted OR using an interaction model by logistic regression was 16.6 (95%CI: 2.54-108.47, P=0.003) with IVR treatment, and 8.25 (95%CI: 1.34-50.57, P=0.023) with laser treatment. No interaction was observed (adjusted OR: 0.07, 95%CI: 0.01-0.75, P=0.029).

CONCLUSION

IVR contributes to improvements in visual acuity at 12mo in ME secondary to BRVO. No interaction is observed between laser therapy and IVR treatments.

Real-World Outcomes in Patients with Branch Retinal Vein Occlusion- (BRVO-) Related Macular Edema Treated with Anti-VEGF Injections Alone versus Anti-VEGF Injections Combined with Focal Laser

The purpose of this study was to assess outcomes in a real-world nonclinical trial setting of antivascular endothelial growth factor (VEGF) injections alone vs. focal laser combined with anti-VEGF injections in patients with branch retinal vein occlusion- (BRVO-) related macular edema (ME). This study included 88 BRVO with ME patients who were treated over three years at both a tertiary referral center in the Birmingham metropolitan area and satellites in rural Alabama. One group received only anti-VEGF injections (n = 56); the other group received both anti-VEGF injections and focal laser (n = 32). The following outcome measures were evaluated: initial and final visual acuities (VA), initial central subfield thickness (CST) on OCT, number of injections, number of lasers, percentage of patients with a gain of 3 lines of VA, percentage of patients with VA better than or equal to 20/40, and percentage of patients with VA worse than or equal to 20/200. We found that there was no difference in initial VA (p=0.913) or CST (p=0.961) between the two groups. The injection only group required a median of 7 injections, while the combination group required a median of 4 injections, but this was not a statistically significant difference (p=0.117). There was no difference in final VA (p=0.414) or any of the other visual outcomes between the two groups. In conclusion, focal laser did not decrease the number of injections required or improve the VA in BRVO-related ME. Although visual outcomes were similar in both groups, focal laser does not appear to be of additional benefit in BRVO-related ME in the anti-VEGF era.

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.

Combination of Ranibizumab with macular laser for macular edema secondary to branch retinal vein occlusion: one-year results from a randomized controlled double-blind trial

Background

It is not clear whether macular laser combined with anti-vascular endothelial growth factor (VEGF) can reduce the number of anti-VEGF injections in the treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Our study aimed to investigate the effects of intravitreal ranibizumab with or without macular laser for ME secondary to BRVO and its associated number of anti-VEGF injections.

Methods

This is a prospective, randomized, double-blind, monocentric trial.80 patients were enrolled and 64 patients fulfilled the study requirements. All patients received a minimum of 3 initial monthly ranibizumab injections, pro re nata (PRN) dosing thereafter VA and CRT stabilization criteria-driven PRN treatment. Laser was given 7 days after third ranibizumab injection in ranibizumab with laser group. The follow-up time of this study was 1 year. Best corrected visual acuity (BCVA) improvement, central retinal thickness (CRT) reduction and number of injections of patients were compared between two groups. T-test, non-parametric Wilcoxon test and chis-square tests were adopted for between-group comparisons.

Results

Thirty patients received intravitreal ranibizumab 0.5 mg alone and 34 patients received intravitreal ranibizumab 0.5 mg with macular laser. At 52 week, BCVA increased significantly and CRT decreased significantly in both groups (P < 0.001). However, there was no significant difference in BCVA improvement with baseline BCVA adjusted (p = 0.5226), and in the CRT reduction (P = 0.4552) between two groups after 52 weeks. There was also no significant difference in the number of injections between the two groups. (P = 0.0756). There was also no significant difference between ischemic and non-ischemic groups in BCVA improvement, CRT reduction and number of injections (P > 0.05).

Conclusions

Our study suggests that ranibizumab combined with macular laser is effective in the treatment of ME secondary to BRVO after 1 year of treatment with 3 + PRN regimen. However, combination of macular grid photocoagulation showed no beneficial anatomical or functional effect during follow-up period, nor did it reduce the number of ranibizumab injections, either in ischemic group or non-ischemic group. We suggest that there is no need to combine macular grid photocoagulation in the treatment of ME secondary to BRVO in the future.

Trial registration

Clinical Trials NCT03054766. https://register.clinicaltrials.gov.Prospectively registered.

Is there still a role of macular laser treatment in branch retinal vein occlusion in the era of intravitreal injections?

We aimed to evaluate whether macular laser still has a role in the treatment of macular oedema (MO) caused by branch retinal vein occlusion (BRVO) and provide an overview of recent studies on commonly available treatment options. A literature search was last conducted in PubMed on 26 February 2019, limited to human randomized controlled trials published in English since 2008. Seventeen articles addressing 13 trials were included in this assessment. In trials evaluating intravitreal corticosteroid and macular laser, triamcinolone was non-inferior to laser in regard to visual acuity (VA) and central retinal thickness (CRT) outcomes. Combination treatment of dexamethasone and laser resulted in better VA and lower CRT after 6 months. In trials evaluating vascular endothelial growth factor (VEGF) inhibitors versus macular laser treatment, or sham and rescue laser, better VA and CRT of VEGF inhibition treatment was consistently reported. Results of combination treatment versus VEGF inhibition monotherapy were inconsistent, with four of six studies reporting comparable outcomes and injection burden. Study comparison was affected by considerable differences in study design and inadequate reporting of laser protocol and rescue laser. Studies evaluating angiostatic treatment as monotherapy largely report the use of rescue laser, indicating that some patients would benefit from supplemental laser treatment even in the era of intravitreal therapy. Thus, we suggest further studies on optimal design of combination therapy prioritizing longer follow-up time to sufficiently evaluate the delayed effect of laser.

Bevacizumab versus ziv-aflibercept in branch retinal vein occlusion

Purpose:

To compare the effectiveness of treatment with intravitreal bevacizumab (IVB) and ziv-aflibercept (IVZ) in patients with macular edema (ME) post-branch retinal vein occlusion (BRVO).

Methods:

Patients with treatment naïve ME post-BRVO were included retrospectively if they received either IVB (0.05 ml/1.25 mg) or IVZ (0.05 ml/1.25 mg) monotherapy with a follow up of 12 months.

Results:

Thirty-two and 17 eyes received IVB and IVZ, respectively. The mean improvement in best corrected visual acuity (BCVA) was 0.36 ± 0.3 logarithm of minimum angle of resolution (logMAR) in the IVB group and 0.27 ± 0.3 in the IVZ group (P = 0.35). The mean change in central macular thickness was 178.9 ± 180.9 and 173.5 ± 344.4 μm in IVB and IVZ groups, respectively (P = 0.94). The mean number of injections was higher in the IVB group (4.0 ± 1.8) compared with 1.82 ± 0.8 in the IVZ group (P < 0.0001). The IVZ group had significantly fewer number of visits (P < 0.0001) and longer maximum treatment-free intervals (P = 0.0081).

Conclusion:

IVZ appears to be cost-effective with the similar visual outcome and less number of visits in comparison to IVB.

Bevacizumab versus bevacizumab and macular grid photocoagulation for macular edema in eyes with non-ischemic branch retinal vein occlusion: results from a prospective randomized study

BACKGROUND

The objective of the study was the investigation of the effects of intravitreal bevacizumab (BEV) with or without additional macular grid laser photocoagulation (GRID) for macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

METHODS

Prospective, randomized, monocentric study. Thirty-two patients were included. Initially, all eyes in both groups received three monthly injections of BEV, followed by additional injections if re-treatment criteria were met. In the BEV + GRID group, photocoagulation was performed 2 weeks after the first BEV injection and laser re-treatment was allowed. The follow-up was 38 weeks. Main outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Changes of foveal avascular zone (FAZ) and of retinal ischemia, as well as the number of injections were also evaluated.

RESULTS

Sixteen eyes were randomized into each group. At baseline, BCVA was similar in both groups (BEV + GRID: 20/71; BEV: 20/60; P = 0.51). At 38 weeks, BCVA significantly improved in the two groups (BEV + GRID gain of 9 ± 11.2 letters and 16.25 ± 10.08 letters in the BEV) with no difference between them (P < 0.06). With regard to anatomical findings, initial CRT in BEV + GRID was 496.2 μm ± 138.4 μm and 538.9 μm ± 156.9 μm in BEV (P < 0.1697). At 38 weeks, CRT decreased in both groups significantly, 98.2 μm in the BEV + GRID (P = 0.02) and 141.7 μm in the BEV group (P = 0.01), with no significant difference between groups (P < 0.17). The area of FAZ a significantly increased in both groups (41% (P = 0.04) in BEV + GRID; 35% (P = 0.03) in BEV) during the study and the grade of peripheral ischemia remained unchanged. The mean number of injections was 3.8 (range 3-6) with no significant difference between groups.

CONCLUSIONS

Our data demonstrate a beneficial effect of bevacizumab in ME in eyes with BRVO. A loading phase of three injections led to a significant improvement in vision in both groups, which persisted at week 38. Additional grid laser photocoagulation exhibited no beneficial functional or anatomical effect during the study, nor did it reduce the number of injections. The FAZ area increased significantly in both groups, but overall retinal ischemia did not. Further studies investigating more numerous eyes and longer follow-up are needed to confirm these data.

Combination of Grid Laser Photocoagulation and a Single Intravitreal Ranibizumab as an Efficient and Cost-Effective Treatment Option for Macular Edema Secondary to Branch Retinal Vein Occlusion

Our prospective comparative study of 60 patients aimed to compare the efficacy and feasibility of a single injection ranibizumab versus a single grid laser photocoagulation and versus a combined treatment in macular edema secondary to branch retinal vein occlusion in Asian population. Patients were randomized 1:1:1 (n = 20/group) into grid laser (LAS), the ranibizumab (RAN), and the combination (COM) group. Outcomes were measured as best-corrected visual acuity (BCVA) and central macular thickness (CMT). There were significant differences in mean BCVA between the three groups at 1 week and 1 month (p < 0.05) and in mean CMT at 1 week and 1, 3, 6, and 12 months (p < 0.05). Overall, best results were observed in the combination group. However, the RAN and COM groups achieved very similar results. At 12 months, the CMT in all three groups was decreased compared with baseline (p < 0.05). Our results allow to conclude that the effect of early treatment with a single injection of intravitreal ranibizumab (cost reduction) and the stabilizing effect of grid laser photocoagulation is indeed an effective, feasible, and safe regiment for macular edema secondary to BRVO in Chinese patients, allowing to obviate the need for repeated intravitreal injections and thus reduce the adverse events, therapy duration, patients' malcompliance, and adverse events. A single ranibizumab therapy however is a comparable alternative.

Evaluation of the Effectiveness of Treatment with Dexamethasone Intravitreal Implant in Cystoid Macular Edema Secondary to Retinal Vein Occlusion

Purpose

To evaluate retinal functional improvement by means of visual acuity and retinal sensibility examination after intravitreal dexamethasone implant in patients affected by cystoid macular edema secondary to retinal vein occlusion.

Methods

Twenty-six consecutive patients affected by retinal vein occlusion complicated by cystoid macular edema were enrolled in this prospective interventional study. All patients underwent a baseline complete ophthalmological evaluation as well as retinal angiography, OCT examination, and microperimetry evaluation. Each patient was treated with intravitreal injection of a long-term steroid implant (Ozurdex, Allergan). Follow-up evaluations were performed at months 1, 3, and 6 and completed by OCT and MP1 examination. Clinical data underwent statistical analysis.

Results

Baseline functional evaluation showed mean visual acuity of 0,63±0,42 LogMAR and retinal sensitivity of 7,93±4,73 dB (mean±standard deviation); after treatment, at day 30 we found, respectively, 0,43±0,38 LogMAR (p<0.05, compared to baseline) and 10,15±4,410 dB (p<0.05); at day 90, we found 0,44±0,32 (p<0.05) and 9.61±4,29 dB (p<0.05); at day 180, we found 0,41±0,31 (p<0.05) and 9,95±3,79 dB (p<0.05). Fixation pattern improved significantly (p<0.05), showing a stable fixation in 30% of patients at baseline, increasing to 77% of patients at day 180. Baseline morphological evaluation showed a central retinal thickness (CRT) of 398,21±181,65 μm after treatment; we found a CRT of 222,64±95,21 μm at day 30 (p<0.05, compared to baseline), 307,50±120,25 μm (p<0.05) at day 90, and 294,93±135,86 μm (p<0.05) at day 180. About 15,3% patients showed already at month 3 a recurrence of macular edema. They underwent a retreatment before month 6 as for treatment guidelines.

Conclusion

Our detailed analysis showed the significative increase in retinal function in the early phases of the follow-up. Retinal sensibility showed a stronger correlation than VA in macular edema reabsorption, better underlying the progressive functional recovery and increase in quality of vision and life for the patients. This trial is registered with ClinicalTrials.gov NCT03559491.

[Current approach and the role of laser photocoagulation in the treatment of retinal vein occlusions]

Despite the emergence of new approaches in the treatment of retinal vein thrombosis and post-thrombotic complications, namely, intravitreal pharmacotherapy and surgical treatment, laser photocoagulation continues to play a significant role in the management of patients with this pathology. Although the method of laser photocoagulation has been used for quite a long time, different views exist on its indications and execution in specific clinical situations. At that, not all opinions regarding the use of laser photocoagulation in thrombosis are based on convincing clinical studies. The aim of this work was to summarize current literature data on the use of laser photocoagulation in the integrated treatment of retinal vein occlusions and, also, to show which aspects of the treatment of thromboses can be considered well-established and reasonable and which remain a subject of debate.

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.

Therapies for Macular Edema Associated with Branch Retinal Vein Occlusion: A Report by the American Academy of Ophthalmology

PURPOSE

To evaluate the available evidence on the ocular safety and efficacy of current therapeutic alternatives for the management of macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

METHODS

Literature searches were last conducted on January 31, 2017, in PubMed with no date restrictions and limited to articles published in English, and in the Cochrane Database without language limitations. The searches yielded 321 citations, of which 109 were reviewed in full text and 27 were deemed appropriate for inclusion in this assessment. The panel methodologist assigned ratings to the selected studies according to the level of evidence.

RESULTS

Level I evidence was identified in 10 articles that addressed anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME, including intravitreal bevacizumab (5), aflibercept (2), and ranibizumab (4). Level I evidence was identified in 6 studies that examined intravitreal corticosteroids, including triamcinolone (4) and the dexamethasone implant (2). Level I evidence also was available for the role of macular grid laser photocoagulation (7) and scatter peripheral laser surgery (1). The inclusion of level II and level III studies was limited given the preponderance of level I studies. The number of studies on combination therapy is limited.

CONCLUSIONS

Current level I evidence suggests that intravitreal pharmacotherapy with anti-VEGF agents is effective and safe for ME secondary to BRVO. Prolonged delay in treatment is associated with less improvement in visual acuity (VA). Level I evidence also indicates that intravitreal corticosteroids are effective and safe for the management of ME associated with BRVO; however, corticosteroids are associated with increased potential ocular side effects (e.g., elevated intraocular pressure, cataracts). Laser photocoagulation remains a safe and effective therapy, but VA results lag behind the results for anti-VEGF therapies.

New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion

For years, branch retinal vein occlusion is still a controversial disease in many aspects. An increasing amount of data is available regarding classification, pathogenesis, risk factors, natural history, and therapy of branch retinal vein occlusion. Some of the conclusions may even change our impression of branch retinal vein occlusion. It will be beneficial for our doctors to get a deeper understanding of this disease and improve the treatment skills. The aims of this review is to collect the information above and report new ideas especially from the past a few years.

Risk factors of recurrence of macular oedema associated with branch retinal vein occlusion after intravitreal bevacizumab injection

BACKGROUND/AIMS

To identify risk factors of recurrence of macular oedema in branch retinal vein occlusion (BRVO) after intravitreal bevacizumab (IVB) injection.

METHODS

The records of 63 patients who underwent IVB injection for macular oedema secondary to BRVO with at least 6 months of follow-up were reviewed. Patients were evaluated at baseline with fluorescein angiography (FA), optical coherence tomography (OCT) and ultra-wide-field fundus photography (WFP). During follow-up, OCT and WFP were repeated. The area of retinal haemorrhage, central retinal thickness (CRT), area (mm²) of capillary non-perfusion within the 1 mm (NPA1), 1-3 mm and 6 mm zones of the ETDRS circle, foveal capillary filling time, degree (°) of foveal capillary network destruction and FA pattern were analysed.

RESULTS

Macular oedema recurred in 41 of 63 (65.1%) eyes after initial IVB injection. A binary logistic regression model showed that NPA1 (OR=434.97; 95% CI=5.52 to 34262.12, p=0.006) and initial CRT (OR=1.004; 95% CI=1.000 to 1.008, p=0.015) were significantly associated with the recurrence of macular oedema. Receiver operating characteristic curve analysis identified an NPA1 of 0.36 mm² (AUC: 0.735, sensitivity: 70.7%; specificity: 63.6%) and an initial CRT of 570 µm (AUC: 0.745, sensitivity: 63.4%; specificity: 77.3%) as cut-off values for predicting recurrence of macular oedema.

CONCLUSIONS

Patients with BRVO with non-perfusion of more than half of the 1 mm zone of the ETDRS circle or with an initial CRT >570 µm should be closely monitored for macular oedema recurrence within 6 months of IVB injection.

Grid laser with modified pro re nata injection of bevacizumab and ranibizumab in macular edema due to branch retinal vein occlusion: MARVEL report no 2

PURPOSE

The purpose of this study was to prospectively study the efficacy of grid laser combined with intravitreal bevacizumab or ranibizumab in eyes with macular edema due to branch retinal vein occlusion.

PATIENTS AND METHODS

Treatment-naïve eyes were enrolled to receive injections of ranibizumab or bevacizumab. During the first 6 months, patients were evaluated monthly and injected if the best-corrected visual acuity changed by five or more letters or fluid was noted on spectral domain optical coherence tomography (OCT); during the next 6 months, patients were evaluated bimonthly and injected only if the best-corrected visual acuity decreased by five or more letters with the associated fluid. Grid laser photocoagulation was performed if there was fluid on OCT and was repeated if patients were eligible after a minimum interval of 3 months.

RESULTS

The mean numbers of ranibizumab and bevacizumab injections were, respectively, 3.2±1.5 and 3.0±1.4 in the first 6 months and 0.3±0.6 and 0.3±0.6 in the last 6 months. Moreover, 55/75 (73.33%) participants did not receive any injections in the last 6 months. The mean reductions in central retinal thickness at 12 months were 165.67 μm (P<0.001; 95% confidence interval -221.50 to -135.0) in the ranibizumab group and 184.78 μm (P<0.001; 95% confidence interval -246.49 to -140.0) in the bevacizumab group (P=0.079). More patients in the bevacizumab group compared to those in the ranibizumab group required rescue laser at 12 months (20 vs eleven; P=0.06).

CONCLUSION

Bimonthly evaluations after month 6 with very few pro re nata injections were effective in maintaining visual gains achieved during the first 6 months. Grid laser photocoagulation is effective in maintaining the vision even in the presence of fluid on OCT, although it's required more often in patients treated with bevacizumab.

Effect of leaking capillaries and microaneurysms in the perifoveal capillary network on resolution of macular edema by anti-vascular endothelial growth factor treatment

PURPOSE

To investigate the effect of leaking capillaries and microaneurysms (MAs) in the perifoveal capillary network (PCN) on the treatment of fovea-involving macular edema (ME) secondary to branch retinal vein occlusion (BRVO) by intravitreal ranibizumab (IVR) injections combined with focal, grid, and scatter laser photocoagulation.

METHODS

Retrospective comparative case series. The MA (+) group consisted of 12 patients with leaking MAs in the PCN and the MA (-) group contained 11 patients without. At 6 months following the initial IVR injection, best corrected visual acuity (BCVA) was evaluated as the primary outcome. Secondary outcomes included central macular thickness (CMT) and the number of IVR injections performed in a pro re nata (PRN) regimen when CMT was ≥300 µm and vision deteriorated by 0.1 logMAR or greater.

RESULTS

Mean BCVA improved by 0.30 ± 0.25 logMAR in the MA (-) group and 0.28 ± 0.20 logMAR in the MA (+) group (both P < 0.0001). Mean CMT was reduced by 237.6 ± 221.4 µm (P < 0.0001) in the MA (-) and 158.2 ± 152.1 µm (P < 0.01) in the MA (+) group. The degrees of improvement in BCVA (P = 0.74) and CMT (P = 0.33) did not vary significantly between the groups. The mean number of additional IVR injections was significantly less in the MA (-) group than in the MA (+) group (2.2 ± 1.0 vs 3.0 ± 0.8; P = 0.04).

CONCLUSIONS

Although leaking MAs and capillaries in the PCN did not adversely affect improvements in BCVA and CMT, these manifestations led to an increased number of IVR injections needed to sustain resolution of ME involving the fovea.

Macular grid laser photocoagulation for branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion (BRVO) is the second most common cause of retinal vascular abnormality after diabetic retinopathy. Persistent macular oedema develops in 60% of eyes with a BRVO. Untreated, only 14% of eyes with chronic macular oedema will have a visual acuity (VA) of 20/40 or better. Macular grid laser photocoagulation is used for chronic non-ischaemic macular oedema following BRVO and has been the mainstay of treatment for over 20 years. New treatments are available and a systematic review is necessary to ensure that the most up-to-date evidence is considered objectively.

OBJECTIVES

To examine the effects of macular grid laser photocoagulation in the treatment of macular oedema following BRVO.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, EMBASE, Web of Science Conference Proceedings Citation Index, the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 August 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing macular grid laser photocoagulation treatment to another treatment, sham treatment or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five studies conducted in Europe and North America. Four separate trials compared grid laser to no treatment, sham treatment, intravitreal bevacizumab and intravitreal triamcinolone. One further trial compared subthreshold to threshold laser. Two of these trials were judged to be at high risk of bias in one or more domains.In one trial of grid laser versus observation, people receiving grid laser were more likely to gain visual acuity (VA) (10 or more ETDRS letters) at 36 months (RR 1.75, 95% confidence interval (CI) 1.08 to 2.84, 78 participants, moderate-quality evidence). The effect of grid laser on loss of VA (10 or more letters) was uncertain as the results were imprecise (RR 0.68, 95% CI 0.23 to 2.04, 78 participants, moderate-quality evidence). On average, people receiving grid laser had better improvement in VA (mean difference (MD) 0.11 logMAR, 95% CI 0.05 to 0.17, high-quality evidence). In a trial of early and delayed grid laser treatment versus sham laser (n = 108, data available for 99 participants), no participant gained or lost VA (15 or more ETDRS letters). At 12 months, there was no evidence for a difference in change in VA (from baseline) between early grid laser and sham laser (MD -0.03 logMAR, 95% confidence interval (CI) -0.07 to 0.01, 68 participants, low-quality evidence) or between delayed grid laser and sham laser (MD 0.00, 95% CI -0.04 to 0.04, 66 participants, low-quality evidence).The relative effects of subthreshold and threshold laser were uncertain. In one trial, the RR for gain of VA (15 or more letters) at 12 months was 1.68 (95% CI 0.57 to 4.95, 36 participants, moderate-quality evidence); the RR for loss of VA (15 or more letters) was 0.56 (95% CI 0.06 to 5.63, moderate-quality evidence); and at 24 months the change in VA from baseline was MD 0.07 (95% CI -0.10 to 0.24, moderate-quality evidence).The relative effects of macular grid laser and intravitreal bevacizumab were uncertain. In one trial, the RR for gain of 15 or more letters at 12 months was 0.67 (95% CI 0.39 to 1.14, 30 participants, low-quality evidence). Loss of 15 or more letters was not reported. Change in VA at 12 months was MD 0.11 logMAR (95% CI -0.36 to 0.14, low-quality evidence).The relative effects of grid laser and 1mg triamcinolone were uncertain at 12 months. RR for gain of VA (15 or more letters) was 1.13 (95% CI 0.75 to 1.71, 1 RCT, 242 participants, moderate-quality evidence); RR for loss of VA (15 or more letters) was 1.20 (95% CI 0.63 to 2.27, moderate-quality evidence); MD for change in VA was -0.03 letters (95% CI -0.12 to 0.06, moderate-quality evidence). Similar results were seen for the comparison with 4mg triamcinolone. Beyond 12 months, the visual outcomes were in favour of grid laser at 24 months and 36 months with people in the macular grid group gaining more VA.Four studies reported on adverse effects. Laser photocoagulation appeared to be well tolerated in the studies. One participant (out of 71) suffered a perforation of Bruch's membrane, but this did not affect visual acuity.

AUTHORS' CONCLUSIONS

Moderate-quality evidence from one RCT supports the use of grid laser photocoagulation to treat macular oedema following BRVO. There was insufficient evidence to support the use of early grid laser or subthreshold laser. There was insufficient evidence to show a benefit of intravitreal triamcinolone or anti-vascular endothelial growth factor (VEGF) over macular grid laser photocoagulation in BRVO. With recent interest in the use of intravitreal anti-VEGF or steroid therapy, assessment of treatment efficacy (change in visual acuity and foveal or central macular thickness using optical coherence tomography (OCT)) and the number of treatments needed for maintenance and long-term safety will be important for future studies.

Combination therapy with intravitreal bevacizumab and macular grid and scatter laser photocoagulation in patients with macular edema secondary to branch retinal vein occlusion

PURPOSE

To assess the efficacy of combined intravitreal bevacizumab (IVB) and macular grid and scatter laser photocoagulation in the treatment of macular edema secondary to branch retinal vein occlusion (BRVO) over a 12-month period.

METHODS

A prospective, interventional case series study was conducted in 20 patients. Patients were treated with 3 monthly IVB injections, followed by macular grid laser and scatter laser photocoagulation to nonperfused ischemic retina. Repeated IVB injections were performed on an as-needed basis when patients had recurrent macular edema.

RESULTS

The best-corrected visual acuity of 20/40 or better was achieved in 17 eyes (85%) and a vision gain of 3 lines or more was noted in 12/20 eyes (60%). Mean visual acuity improved from 0.68 logMAR at baseline to 0.28 logMAR at 3 months, 0.26 logMAR at 6 months, and 0.26 logMAR at 12 months (P<0.01). The mean central macular thickness (CMT) was 442 μm at baseline and decreased to 266, 264, 300, and 294 μm at 1, 3, 6, and 12 months' follow-up, respectively (P<0.01). A mild rebound CMT increase was noted at 6 months, which was reduced after bevacizumab reinjection. Ten patients (50%) required repeated IVB injections. Fifteen eyes (75%) have complete edema resolution on optical coherence tomography scan at the 12-month return visit. Overall, patients received an average of 4 injections during the 12-month period. No adverse ocular or systemic events were observed following injections.

CONCLUSIONS

Early IVB injections in combination with subsequent macular grid and scatter laser photocoagulation treatment significantly improved vision and reduced macular edema secondary to BRVO. Further studies are warranted to evaluate the long-term outcomes and safety.

Strategy for the management of macular edema in retinal vein occlusion: the European VitreoRetinal Society macular edema study

Objective. To compare the efficacy of different therapies in the treatment of macular edema associated with retinal vein occlusion (RVO). Design. This is a nonrandomized, multicenter collaborative study. Participants. 86 retina specialists from 29 countries provided clinical information, including choice of treatment and outcome, on 2,603 patients with macular edema including 738 cases of RVO. Methods. Reported data included the type and number of treatments performed, visual acuities, and other clinical and diagnostic findings. Main Outcome Measures. The mean increase in visual acuity and mean number of treatments performed. Results. 358 cases of central retinal vein occlusion (CRVO) and 380 cases of branch retinal vein occlusion (BRVO) were included in this investigation. Taking all RVO cases together, pars plana vitrectomy with internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than other therapies. Those treated with intravitreal antivascular endothelial growth factor (anti-VEGF) injection alone showed the second greatest improvement in vision. Dexamethasone intravitreal implant alone and intravitreal triamcinolone alone both resulted in modest visual gains. Conclusions. In the treatment of macular edema in RVO, vitrectomy with ILM peeling may achieve visual improvement and may be a good option for certain cases. Anti-VEGF injection is the most effective of the nonsurgical treatments.

Intravitreal bevacizumab alone or combined with macular laser photocoagulation for recurrent or persistent macular edema secondary to branch retinal vein occlusion

Background. To evaluate the efficacy of intravitreal bevacizumab (IVB) injection with or without macular laser photocoagulation (MLP) for recurrent or persistent macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods. Thirty-four eyes underwent IVB injection for ME secondary to BRVO as a primary treatment. Twenty of the 34 eyes experienced recurrent or persistent ME after the first IVB. Nine of the 20 eyes (Group 1) were retreated with IVB combined with MLP. The remaining 11 eyes (Group 2) were retreated with IVB alone. Results. In Group 1, the postoperative best corrected visual acuity (BCVA) improved compared with the preoperative value at all follow-up visits, although no statistically significant improvement was observed at 6 months. In contrast, BCVA significantly improved from 0.53 to 0.40 at 6 months (P < 0.05) in Group 2. Conclusion. Combined therapy tended to have a smaller effect on visual acuity compared with IVB monotherapy.

Twenty-Four-Month Results of Intravitreal Bevacizumab in Macular Edema Secondary to Branch Retinal Vein Occlusion

PURPOSE

The aim of this study is to evaluate the long-term efficacy of intravitreal bevacizumab (IVB) in macular edema (ME) due to branch retinal vein occlusion (BRVO) in a real clinical practice setting at a tertiary referral center.

METHODS

A retrospective analysis of a final total number of 35 eyes of 35 patients with a 24-month follow-up was performed.

RESULTS

At 24 months, mean best-corrected visual acuity improved by 0.09 LogMAR units from baseline (95% CI: -0.03-0.24, p = 0.0674). The mean CFT decreased by 75 microns (95% CI: 27-123, p = 0.0026). The median number of injections was 6 (IQR: 3-9). Macular edema showed complete resolution in 12 eyes (34.3%), responded partially in six eyes (17%), recurred in eight eyes (23%), and remained persistent in nine eyes (25.7%, three eyes at six months, one eye at 12 months, three eyes at 18 months and two eyes at 24 months).

CONCLUSION

Our study shows that treatment with IVB in patients with ME due to BRVO during a period of 24 months provided complete resolution of the ME in more than one-third of patients. In one-third of the cases, ME resolved partially or recurred and in less than one-third of patients ME remained persistent. Visual acuity increased significantly in 23% of patients and remained stable in the majority of patients. However, a median number of six injections was necessary to maintain a lasting beneficial effect. Further long-term prospective studies are required comparing intravitreal bevacizumab with other treatment modalities.

Comparison between Intravitreal Triamcinolone with Grid Laser Photocoagulation versus Bevacizumab with Grid Laser Photocoagulation Combinations for Branch Retinal Vein Occlusion

Purpose. To compare the efficacy of intravitreal triamcinolone (IVT) and intravitreal bevacizumab (IVB), both combined with grid laser photocoagulation (GLP) for macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods. Retrospective, comparative study. The newly diagnosed patients with ME secondary to BRVO who were treated with IVT and GLP or IVB and GLP were included. The main outcome measures were changed in the best corrected visual acuity (BCVA) and central retinal thickness (CRT) from the baseline to month 24. Results. Ninety-nine eyes of 99 patients were included. The change in BCVA was not statistically different in any time points between the two groups (P > 0.05, for all). The change in CRT was not statistically different in any time points between the two groups (P > 0.05, for all). The mean number of injections at month 24 was 2.38 ± 1.06 in the IVT+GLP group and 4.17 ± 1.30 in the IVB+GLP group (P = 0.0001). The need for cataract surgery (P = 0.01) and secondary glaucoma (P = 0.03) occurrence were more common in IVT group. Conclusion. Both treatment modalities were effective in the treatment of ME secondary to BRVO. The number of injections was significantly lower in the IVT group than in the IVB group; however cataract and secondary glaucoma were more frequent in the IVT+GLP group than in the IVB+GLP group.

Two-year outcomes of intravitreal bevacizumab therapy for macular oedema secondary to branch retinal vein occlusion

Aim

To determine the 2-year outcomes of intravitreal bevacizumab (IVB) injections in eyes with macular oedema (ME) following branch retinal vein occlusion (BRVO).

Methods

Of 105 consecutive eyes (105 treatment-naïve patients) with ME following BRVO, 89 eyes were followed for 2 years after the first injection. During the 2-year follow-up period, patients were examined at least every 3 months and received an IVB injection (1.25 mg/0.05 mL) if they met prespecified retreatment criteria. Rescue grid laser was permitted based on the findings of the Branch Vein Occlusion Study.

Results

The baseline logarithm of the minimum angle of resolution visual acuity (VA) was 0.64±0.24 (mean±SD), which significantly (p=0.001) improved 1 month after the first injection to 0.39±0.22. One year after the first injection, VA improved significantly (p=0.001) to 0.33±0.21 and remained 0.34±0.21 until 2 years after the first injection (p=0.001). The changes in foveal thickness were correlated with those of VA during the 2-year follow-up period with a mean of 3.8±1.5 injections (including the first injection).

Conclusions

This relatively large case series study showed favourable 2-year outcomes using bevacizumab to treat ME following BRVO. Bevacizumab provides substantial long-term benefits in the treatment of ME following BRVO.

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

BACKGROUND

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

METHODS

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

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

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

Efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review

BACKGROUND

Intravitreal agents have replaced observation in macular edema in central (CRVO) and grid laser photocoagulation in branch retinal vein occlusion (BRVO). We conducted a systematic review to evaluate efficacy and safety outcomes of intravitreal therapies for macular edema in CRVO and BRVO.

METHODS AND FINDINGS

MEDLINE, Embase, and the Cochrane Library were systematically searched for RCTs with no limitations of language and year of publication. 11 RCTs investigating anti-VEGF agents (ranibizumab, bevacizumab, aflibercept) and steroids (triamcinolone, dexamethasone implant) with a minimum follow-up of 1 year were evaluated.

EFFICACY CRVO

Greatest gain in visual acuity after 12 months was observed both under aflibercept 2 mg: +16.2 letters (8.5 injections), and under bevacizumab 1.25 mg: +16.1 letters (8 injections). Ranibizumab 0.5 mg improved vision by +13.9 letters (8.8 injections). Triamcinolone 1 mg and 4 mg stabilized visual acuity at a lower injection frequency (-1.2 letters, 2 injections).

BRVO

Ranibizumab 0.5 mg resulted in a visual acuity gain of +18.3 letters (8.4 injections). The effect of dexamethasone implant was transient after 1.9 implants in both indications.

SAFETY

Serious ocular adverse events were rare, e.g., endophthalmitis occurred in 0.0-0.9%. Major differences were found in an indirect comparison between steroids and anti-VEGF agents for cataract progression (19.8-35.0% vs. 0.9-7.0%) and in required treatment of increased intraocular pressure (7.0-41.0% vs. none). No major differences were identified in systemic adverse events.

CONCLUSIONS

Anti-VEGF agents result in a promising gain of visual acuity, but require a high injection frequency. Dexamethasone implant might be an alternative, but comparison is impaired as the effect is temporary and it has not yet been tested in PRN regimen. The ocular risk profile seems to be favorable for anti-VEGF agents in comparison to steroids. Because comparative data from head-to-head trials are missing currently, clinicians and patients should carefully weigh the benefit-harm ratio.

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 common occurring retinal vascular abnormalities. The pathogenesis of BRVO is thought to involve both retinal vein compression and damage to the vessel wall, possibly leading to thrombus formation at sites where retinal arterioles cross retinal veins. The most common cause of visual loss in patients with BRVO is macular oedema (MO). Grid or focal laser photocoagulation has been shown to reduce the risk of visual loss and improve visual acuity (VA) in up to two thirds of individuals with MO secondary to BRVO, however, limitations to this treatment exist and newer modalities have suggested equal or improved efficacy. Recently, antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) has been used successfully to treat MO resulting from a variety of causes. As elevated intraocular levels of VEGF have been demonstrated in patients with retinal vein occlusions there is a strong basis for the hypothesis that anti-VEGF agents may be beneficial in the treatment of vascular leakage and MO.

OBJECTIVES

To investigate the efficacy and safety of intravitreal anti-VEGF agents for preserving or improving vision in the treatment of MO secondary to BRVO.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2012), EMBASE (January 1980 to August 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2012, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 August 2012 and the clinical trials registers on 10 September 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTS of at least six months duration 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. The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity (BCVA) of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and at 12 months of follow-up. The secondary outcomes we report are the proportion of participants who lost greater than or equal to 15 ETDRS letters (3 lines) and the mean VA change at six months and any additional follow-up intervals as well as the change in central retinal thickness on optical coherence tomography (OCT) from baseline and final reported follow-up, the number and type of complications, the number of additional interventions administered and any adverse outcomes. Where available, the cost benefit and quality of life data reported in the primary studies is presented.

MAIN RESULTS

We found one RCT and one quasi-RCT that met the inclusion criteria after independent and duplicate review of the search results. The studies used different anti-VEGF agents and different study groups which were not directly comparable.One multi-centre RCT (BRAVO) conducted in the USA randomised 397 individuals and compared monthly intravitreal ranibizumab (0.3 mg and 0.5 mg) injections with sham injection. The study only included individuals with non-ischaemic BRVO. Although repeated injections of ranibizumab appeared to have a favourable effect on the primary outcome, approximately 50% of the ranibizumab 0.3 mg group and 45% of the ranibizumab 0.5 mg group received rescue laser treatment which may have an important effect on the primary outcome. In addition, during the six-month observation period 93.5% of individuals in the sham group received intravitreal ranibizumab (0.5 mg). This cross-over design limits the ability to compare the long-term impact of ranibizumab versus a pure control group.The second trial was a small study (n = 30) from Italy with limitations in study design that reported a benefit of as-required intravitreal bevacizumab (1.25 mg) over laser photocoagulation in MO secondary to BRVO. We present the evidence from these trials and other interventional case series.

AUTHORS' CONCLUSIONS

The available RCT evidence suggests that repeated treatment of non-ischaemic MO secondary to BRVO with the anti-VEGF agent ranibizumab may improve clinical and visual outcomes at six and 12 months. However, the frequency of re-treatment has not yet been determined and the impact of prior or combined treatment with laser photocoagulation on the primary outcome is unclear. Results from ongoing studies should assess not only treatment efficacy but also, the number of injections needed for maintenance and long-term safety and the effect of any prior treatment.