Comparison of visual acuity outcomes between ranibizumab and bevacizumab treatment in neovascular age-related macular degeneration

AIM: To compare visual acuity (VA) outcomes between intravitreal injection of bevacizumab and ranibizumab in the treatment of neovascular age-related macular degeneration (AMD). METHODS: We conducted a consecutive, retrospective case series study in patients with newly diagnosed all type choroidal neovascularization (CNV) secondary to AMD who received an intravitreal injection of bevacizumab (1.25mg) or ranibizumab (0.3mg) at Lions Eye Institute, Western Australia from Mar. 2006 to May 2008. All patients received injection at baseline with additional monthly injections given at the discretion of the treating physician. Main outcome measures were changes in VA. RESULTS: There were 371 consecutive patients received injection at least in one eye with at least 6 months of follow up (median of 12.0 months). Bevacizumab treatment prevented 221 out of 278 (79.5%) patients from losing < 15 letters in VA compared with 79 out of 93 (84.9%) of ranibizumab treated patients (P=0.25). While 68 (24.5%) of bevacizumab treated patients gained ≥15 letters of VA compared with 24 (25.8%) of ranibizumab treated patients (P=0.79). 75.3% and 66.2% patients benefited from ranibizumab and bevacizumab respectively with final VA better than 6/60 (P=0.10). Multivariate analysis showed that pre-treatment VA was negatively associated with benefit outcome. Assignment of injection was not associated with VA outcome of benefit after adjusting the covariate (P=0.857). CONCLUSION: There are no difference in treatment efficacy in terms of VA between bevacizumab and ranibizumab in routine clinical condition.     

Anti-VEGF-refractory Exudative Age-related Macular Degeneration: Differential Response According to Features on Optical Coherence Tomography

Purpose

To describe optical coherence tomography (OCT) characteristics of neovascular age-related macular degeneration (AMD) patients refractory to intravitreal anti-vascular endothelial growth factor (VEGF) injections (ranibizumab, bevacizumab) and their responses to alternative anti-VEGF agents or photodynamic therapy (PDT).

Methods

A retrospective review of 267 neovascular AMD patients treated with intravitreal anti-VEGF injections.

Results

Twenty patients (7.5%) were refractory to anti-VEGF injections (stationary or increased retinal exudation despite three or more monthly injections). They were grouped into either the extensive intraretinal fluid group (IRF group, 9 patients) or the subretinal fluid only group (SRF group, 11 patients) according to OCT findings. In the IRF group, response rates to subsequent treatment were 0% (0 / 7) for bevacizumab, 50% (3 / 6) for ranibizumab and 50% (3 / 6) for PDT ± anti-VEGF. Three out of four bevacizumab-refractory patients showed response to ranibizumab as a secondary treatment. In the SRF group, response rates were lower with 0% (0 / 7) for bevacizumab, 22.2% (2 / 9) for ranibizumab and 28.6% (2 / 7) for PDT ± anti-VEGF. One out of four bevacizumab-refractory patients responded to ranibizumab. The visual outcome was worse in the IRF group (median 20 / 1,000) than in the SRF group (median 20 / 100).

Conclusions

In anti-VEGF-refractory neovascular AMD, patients with extensive IRF refractory to bevacizumab can be responsive to ranibizumab while patients with SRF may be refractory to both, suggesting a different pathophysiology and intraocular pharmacokinetics.     

Long-term visual outcome of pigment epithelial tears in association with anti-VEGF therapy of pigment epithelial detachment in AMD

Purpose

Retinal pigment epithelium (RPE) tears may develop as a complication after anti-VEGF (vascular endothelial growth factor) treatment for pigment epithelial detachments (PEDs) in exudative age-related macular degeneration (AMD). This retrospective study analyses best-corrected visual acuity (BCVA) and foveal involvement after RPE tears that are associated with anti-VEGF therapy due to PED in exudative AMD.

Methods

A total of 37 patients with RPE tears during anti-VEGF therapy (bevacizumab 12, ranibizumab 21 and pegaptanib 4 eyes) for progressive PED in AMD (PED with occult choroidal neovascularization 25 eyes and PED with retinal angiomatous proliferation 12 eyes) were included in this study. We analyzed BCVA and different morphologic aspects by means of appearance on fluorescein angiography and optical coherence tomography. Mean follow-up was 88 weeks.

Results

RPE tears were diagnosed a mean of 56 days after the first injection. BCVA deteriorated after RPE tear and during follow-up significantly (P<0.001), with 53.2% of eyes being legally blind (WHO, world health organization) at 12 months. RPE-free foveal area, foveal wrinkling of the RPE, and fibrotic scar development were significantly associated with worse visual acuity.

Discussion

RPE tears can be observed in 12–15% of treated eyes during anti-VEGF therapy for PED in exudative AMD. Owing to the close time relationship with the therapy, this complication must be taken into consideration. Visual prognosis is associated with a decrease in vision in the long term, often resulting in a severe visual disability. Relevant factors for a negative visual prognosis were the potential foveal involvement of the central RPE and morphologic fibrovascular transformation of the RPE tear.     

Influence of seasonal sunlight intensity and iris color on the anti-VEGF therapy for neovascular age-related macular degeneration

Purpose

To investigate the influence of seasonal light intensity and patients'' iris color on the visual recovery after anti-vascular endothelial growth factor (VEGF) therapy with ranibizumab or bevacizumab for neovascular age-related macular degeneration (AMD).

Methods

The visual acuity of 555 eyes (529 patients) with neovascular AMD was evaluated after intravitreal injections of either ranibizumab or bevacizumab in respect to global radiation intensity and iris color.

Results

The functional results during anti-VEGF therapy revealed a seasonal oscillation with a negative correlation between visual recovery and global radiation intensity (R²=−0.756, P=0.004). Although the influence of the sunlight intensity on the visual recovery was significant after the first injection, this effect vanished within the continuous course of treatment. Regarding the improvement of functional recovery depending on iris color, dark-colored eyes (16.0%) gained 8.5±10.0 letters after the first injection and 9.9±12.8 letters after the second injection, compared with 3.4±8.6 letters and 4.4±11.0 letters in light-colored eyes (84.0%), respectively (P=0.005 and P=0.019).

Conclusions

Our results indicate that seasonal sunlight intensity and iris color might influence the visual recovery of neovascular AMD patients undergoing anti-VEGF therapy. Our findings may be used as suggestions to refine individual anti-VEGF therapy regimens, especially in patients with light-colored eyes.     

Aflibercept Treatment for Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy Refractory to Anti-vascular Endothelial Growth Factor

Purpose

To report the results of switching treatment to vascular endothelial growth factor (VEGF) Trap-Eye (aflibercept) in neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to anti-VEGF (ranibizumab and bevacizumab).

Methods

This is a retrospective study involving 32 eyes from 29 patients; 18 were cases of neovascular AMD and 14 were cases of PCV. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) of spectral-domain optical coherence tomography were evaluated.

Results

BCVA and CMT improved from 0.58 to 0.55 (p = 0.005) and from 404 to 321 µm (p < 0.001), respectively, after switching to aflibercept. The 14 eyes that received 6 or more aflibercept injections remained stable at 0.81 to 0.81 and 321 to 327 µm (p = 1.0, 0.29), respectively, after 3 aflibercept injections. The 10 eyes that received 3 or more bevacizumab injections after 3 or more aflibercept injections worsened, from 0.44 to 0.47 and from 332 to 346 µm (p = 0.06, 0.05), respectively. The results showed similar improvement of BCVA and CMT in neovascular AMD and PCV.

Conclusions

Aflibercept seems to be effective for improvement and maintenance of BCVA and CMT for neovascular AMD and PCV refractory to anti-VEGF. Switching from aflibercept back to bevacizumab treatment may not be a proper strategy.     

Cost analysis comparing adjuvant epimacular brachytherapy with anti-VEGF monotherapy for the management of neovascular age-related macular degeneration

Aims

To consider the cost implication of adopting epimacular brachytherapy (EMB) for the treatment of neovascular (wet) age-related macular degeneration (wAMD), compared with ranibizumab or bevacizumab monotherapy.

Methods

This analysis compared the cumulative 3-year costs of anti-VEGF (vascular endothelial growth factor) monotherapy to EMB combined with anti-VEGF therapy. Two patient groups were considered: newly diagnosed (treatment-naïve) patients; and patients already receiving chronic anti-VEGF therapy.

Results

In the treatment-naïve patients, the highest cumulative treatment costs were associated with ranibizumab monotherapy (£25 658), followed by bevacizumab monotherapy (£16 177), EMB with ranibizumab (£14 002), then EMB with bevacizumab (£10 289). In previously treated patients, the highest treatment costs were ranibizumab monotherapy (£18 355), followed by EMB with ranibizumab (£17 428), bevacizumab monotherapy (£16 177), then EMB with bevacizumab (£12 129).

Conclusion

EMB combined with anti-VEGF treatment has the potential to yield considerable cost savings, compared with anti-VEGF monotherapy. If the ongoing large studies of EMB confirm the published feasibility data, then adjuvant EMB may represent a cost-effective alternative to anti-VEGF monotherapy.     

Long-term outcome of intravitreal anti-vascular endothelial growth factor therapy with bevacizumab or ranibizumab as primary treatment for subfoveal myopic choroidal neovascularization

Purpose

To evaluate the long-term efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy as primary treatment for subfoveal myopic choroidal neovascularization (CNV).

Methods

In all, 37 treatment-naïve eyes of 37 patients with subfoveal myopic CNV who received intravitreal bevacizumab (n=22) or ranibizumab (n=15) injections with at least 2 years of follow-up were reviewed. All eyes received initial three loading doses of anti-VEGF at monthly intervals and retreatment was performed in persistent or recurrent CNV. Multivariate regression analyses were performed to determine the prognostic factors for visual outcome.

Results

The mean age was 57.3 years and the mean refractive error was −11.7 D. For all eyes, the mean logMAR best-corrected visual acuity improved from 0.86 (20/145) at baseline to 0.48 (20/60) at 2 years (P<0.001). The mean visual improvement for the bevacizumab and ranibizumab groups at 2 years was 2.8 and 5.1 lines, respectively (P=0.073). There was no significant difference in the proportion of eyes having visual gain of three or more lines or visual loss of three or more lines between the two groups. The mean number of injections was 3.8 for both bevacizumab and ranibizumab groups. Multivariate analyses showed that eyes with higher myopic refractive error were less likely to have visual gain after treatment (P=0.043), while size of CNV was negatively correlated with mean change in vision (P=0.046).

Conclusions

Intravitreal anti-VEGF therapy resulted in long-term visual improvement in myopic CNV. The treatment efficacy in terms of visual gain and number of retreatment appeared to be similar between bevacizumab and ranibizumab.     

Pharmacogenetic Influence of LOC387715/HTRA1 on the Efficacy of Bevacizumab Treatment for Age-Related Macular Degeneration in a Korean Population

Purpose

The purpose of this study was to determine the pharmacogenetic effects of complement factor H (CFH) Y402H, LOC387715 and high-temperature requirement factor A1 (HTRA1) genotypes on the treatment of exudative age-related macular degeneration (AMD) by intravitreal bevacizumab injection in a Korean population.

Methods

Seventy-five patients diagnosed with exudative AMD were treated with intravitreal bevacizumab (2.5 mg) monotherapy. All patients received three initial intravitreal bevacizumab injections every four weeks and were then treated "as needed" based on clinical findings, optical coherence tomography and fluorescein angiography during the 12 month follow-up period after the third injection.

Results

The difference in visual acuity improvement among the three genotypes of LOC387715 were statistically significant at six months post-treatment (logarithm of the minimum angle of resolution; TT, 0.346; GT, 0.264; GG, 0.188; p = 0.037). Among the LOC387715 genotypes, the number of additional injections was lower in patients who had the risk T allele (GG, 2.143; GT, 2.000; TT, 1.575; p = 0.064). There was no significant difference between visual acuity and central macular thickness change in the CFH Y402H polymorphism group during the 12 month follow-up period. However, the TC group of CFH Y402H required more additional bevacizumab injections than the TT group (TT, 1.517; TC, 3.363; p = 0.020).

Conclusions

This study demonstrated that different LOC387715/HTRA1 genotypes resulted in different bevacizumab treatment responses on exudative AMD. Patients with the risk allele had an improved treatment response and less need for additional injections. However, patients with the CFH Y402H risk allele needed more additional injections of bevacizumab in order to improve visual acuity. This study illustrates how pharmacogenetic factors may help determine treatment modality and dosing. This could ultimately provide basic data for ''personalized medicine'' in AMD.     

Tear of Retinal Pigment Epithelium following YAG Laser Posterior Capsulotomy in a Patient on Anti-VEGF Treatment for AMD: Six Months’ Follow-Up

Purpose

To present a rare case of retinal pigment epithelium (RPE) rupture following YAG laser posterior capsulotomy (YAG PC) in a patient with exudative age-related macular degeneration (AMD).

Materials and Methods

An 85-year-old pseudophakic male patient on ranibizumab 0.5 mg/0.05 ml treatment due to exudative AMD received YAG PC for dense posterior capsule opacification (PCO) in his right eye. The patient had received his last intravitreal ranibizumab injection 3 months before YAG PC; his macula appeared stable on fundoscopy and optical coherence tomography scans at repeated visits, but his vision deteriorated to counting fingers due to PCO.

Results

Following left eye posterior YAG PC, his best-corrected visual acuity (BCVA) improved to 6/12 (Snellen chart). Despite satisfactory visual results, the patient developed a parafoveal inferotemporal RPE rupture. A decision for further treatment with ranibizumab (0.5 mg/0.05 ml) intravitreal injections was made. After a total of 7 injections, the patient was clinically stable and his BCVA was 6/18 (Snellen chart).

Conclusions

RPE rupture is a well-known, serious complication in patients with exudative AMD, which often has devastating results on patients’ vision. Offering YAG PC to those patients could lead to a rupture of the RPE even in cases which appear to be stable and well controlled. Clinicians should be aware of this complication and inform the patients accordingly.Key Words: Retinal pigment epithelium tear, YAG Laser, Age-related macular degeneration, Pigment epithelial detachment rupture, Ranibizumab     

A Clear Cell Renal Cell Carcinoma Inhibiting the Response to Intravitreal Antivascular Endothelial Growth Factor Therapy in Wet Age-Related Macular Disease

Purpose

Wet age-related macular degeneration (AMD) is an ocular disorder that can be successfully treated with intravitreal antivascular endothelial growth factor (VEGF) therapy. We report a case of incomplete response to intravitreal therapy associated with a clear cell renal cell carcinoma (ccRCC).

Methods

A 72-year-old male with wet AMD responded poorly to intravitreal bevacizumab and ranibizumab injections. The removal of a ccRCC led to the spontaneous stabilization of the choroidal neovascular lesion. The renal carcinoma was examined for Von Hippel-Lindau (VHL) gene alterations. Immunohistochemical profiling of the hypoxia-inducible factor (HIF) pathway addressing the marker HIF-1α and its downstream targets VEGF, glucose transporter 1 and carbonic anhydrase IX was performed.

Results

Genotyping of the ccRCC revealed the presence of a truncating VHL mutation (p.E134fs*25). Immunohistochemistry displayed HIF pathway target activation and VEGF expression in the ccRCC tumour cells. Following tumour removal, the neovascular lesion remained stable for 6 months without any further anti-VEGF therapy.

Conclusion

The somatic VHL mutation correlates with persistent high levels of HIF-1α pathway targets and VEGF expression in the ccRCC. We postulate that this increased VEGF in the tumour and subsequently in the plasma levels could have caused the incomplete response to intravitreal anti-VEGF therapy. Stabilization of the wet AMD following tumour removal indicates that the angiogenic secreting tumour (ccRCC) abrogates the response to VEGF inhibitor therapy. Thus, in cases of poor response to intravitreal anti-VEGF therapy, systemic evaluation including plasma levels of VEGF and/or systemic screening for VEGF-producing tumours should be considered.Key words: Wet age-related macular degeneration, Vascular endothelial growth factor, Von Hippel-Lindau, Renal cell carcinoma, Pseudohypoxia, Bevacizumab, Ranibizumab     

Comparative role of intravitreal ranibizumab versus bevacizumab in choroidal neovascular membrane in age-related macular degeneration

Context:

Ranibizumab and bevacizumab are used widely for treating patients with choroidal neovascular membrane (CNVM) secondary to age-related macular degeneration (AMD).

Aims:

To determine and compare the efficacy and safety of intravitreal ranibizumab and bevacizumab in treatment of CNVM due to AMD.

Settings and Design:

Prospective comparative case series carried out in an eye institute and eye department of a hospital in Kolkata, India.

Materials and Methods:

One hundred and four eyes with CNVM due to AMD were randomized into two groups. Group A (n=54; 24 occult) received monthly intravitreal ranibizumab injections (0.5 mg in 0.05 ml) and Group B (n=50; 22 occult) received monthly bevacizumab injections (1.25 mg in 0.05 ml) for 3 consecutive months and then as per study criteria. Data analysis done using SPSS software. P-value of <0.05 was considered statistically significant.

Results:

The mean best corrected visual acuity (BCVA) in the ranibizumab group increased from 58.19 Early Treatment Diabetic Retinopathy Study (ETDRS) letters at baseline to 64 ETDRS letters at month 3 (P<0.001). In bevacizumab group mean BCVA increased from 56.80 to 61.72 ETDRS letters at month 3 (P<0.001). At the end of 18 months, there was no statistically significant difference between groups A and B with respect to change in BCVA (P=0.563) or central macular thickness (CMT; P=0.281), as measured by optical coherence tomography (Stratus OCT 3000). No significant sight-threatening complications developed.

Conclusions:

Ranibizumab and bevacizumab are equally safe and efficacious in treating CNVM due to AMD.     

Multifocal electroretinogram findings after intravitreal bevacizumab injection in choroidal neovascularization of age-related macular degeneration

Purpose

To evaluate the changes in multifocal electroretinogram (mfERG) and optical coherence tomography (OCT) after intravitreal bevacizumab injection in the treatment of age-related macular degeneration (AMD).

Methods

Twenty-one eyes with choroidal neovascularization secondary to AMD were studied before and after intravitreal bevacizumab injection for best corrected visual acuity (BCVA), OCT, and mfERG.

Results

The BCVA improved, while central macular thickness and total macular volume in OCT decreased after intravitreal bevacizumab injection (p = 0.03, 0.01, and 0.01, respectively). In mfERG, the amplitude of P1, and implicit time of P1 and N1 indicated a statistically significant improvement of retinal response after intravitreal bevacizumab injection.

Conclusions

There is a potential role for mfERG in evaluating the effect on retinal function of intravitreal bevacizumab injection.     

Evaluation of the Response to Ranibizumab Therapy following Bevacizumab Treatment Failure in Eyes with Diabetic Macular Edema

Background/Aims

Bevacizumab and ranibizumab are routinely used to treat diabetic macular edema (DME). We aim to evaluate the usefulness of switching to ranibizumab therapy following bevacizumab treatment failure in eyes with DME.

Methods

We performed a retrospective analysis of a consecutive group of patients with DME who received ranibizumab injections following the failure of bevacizumab injections. The injections were delivered following a pro re nata protocol every 4–6 weeks. The data collected included demographics, systemic and ophthalmic findings, as well as the central subfield thickness according to spectral-domain OCT.

Results

Eight eyes (5 patients) were included in the study. The median number of bevacizumab injections prior to the switch to ranibizumab was 4, and the median number of ranibizumab injections during the study was 2. The mean follow-up period was 541 ± 258 days. The mean central retinal thickness (CRT) (±SEM) was 539 ± 75 μm before the initiation of bevacizumab treatment, and 524 ± 43 μm after the last bevacizumab injection (p = 0.7). It reduced to 325 ± 26 μm following the ranibizumab injections (p = 0.0063). The best-corrected visual acuity (BCVA) improved in 4 eyes and remained stable in 4 eyes following the ranibizumab injections.

Conclusion

A ranibizumab therapy was effective in reducing the CRT in eyes that failed bevacizumab therapy. A BCVA improvement can also occur in these eyes. Switching between anti-vascular endothelial growth factor compounds may be beneficial in eyes with DME.Key Words: Ranibizumab, Bevacizumab, Diabetic macular edema, Treatment failure     

Intravitreal Anti-vascular Endothelial Growth Factor versus Observation in Acute Central Serous Chorioretinopathy: One-year Results

Purpose

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) compared with observation for treating acute central serous chorioretinopathy (CSC).

Methods

A retrospective study of 36 patients with acute CSC, including 21 patients treated with anti-VEGF (anti-VEGF group) and 15 patients with observation (observation group). Patients in the anti-VEGF group received a single dose of bevacizumab or ranibizumab at baseline. Best-corrected visual acuity (BCVA), central foveal thickness (CFT) and resolution of subretinal fluid (SRF) on optical coherence tomography (OCT) were assessed. The integrity of the foveal inner segment/outer segment (IS/OS) line at 12 months was also analyzed.

Results

Resolution of SRF was achieved in 20 of 21 eyes in the anti-VEGF group and in 12 of 15 eyes in the observation group (p = 0.151). Mean BCVA and CFT were not different between the two groups at 12 months (p > 0.05). The amount of change in BCVA, however, differed significantly between the groups (p = 0.044). Final OCT more frequently detected the foveal IS/OS line in the anti-VEGF group than in the observation group (p = 0.012).

Conclusions

In terms of BCVA, anti-VEGF and observation only had similar therapeutic effects in acute CSC patients. In some patients, however, the rapid resolution of SRF by anti-VEGF might reduce the risk of photoreceptor degeneration and improve long-term visual acuity.     

Intravitreal bevacizumab and ranibizumab injections for patients with polypoidal choroidal vasculopathy

Purpose

To compare the effectiveness of intravitreal injection of bevacizumab and ranibizumab in patients with treatment-naïve polypoidal choroidal vasculopathy (PCV).

Methods

A total of 66 and 60 eyes of 121 consecutive patients who received intravitreal bevacizumab (1.25 mg) or ranibizumab (0.5 mg) injection for treatment of PCV were retrospectively reviewed. After initial three loading injections by month, injection was performed as needed. Main outcome measures included best corrected visual acuity (BCVA), foveal center thickness (FCT) as assessed by spectral domain optical coherence tomography (SD-OCT), and change in polypoidal lesion on indocyanine green angiography (ICGA).

Results

At 12 months, average number of injections was 4.72±1.84 in the bevacizumab group and 5.52±1.54 in the ranibizumab group. Mean logarithm of the minimum angle of resolution of BCVA from baseline at 12 months after injection improved by 0.11 in the bevacizumab group (P=0.02) and by 0.14 in the ranibizumab group (P=0.01). Average FCT decreased from 368±62.48 to 298±40.77 μm in the bevacizumab group (P=0.01) and from 371±50.79 to 286±36.93 μm in the ranibizumab group (P=0.01). Polyp regression rate was 24.2% (16 eyes out of 66 eyes) in the bevacizumab group and 23.3% (14 eyes out of 60 eyes) in the ranibizumab group. There was no statistically significant difference in BCVA improvement achieved, FCT improvement achieved, and polyp regression rate between groups.

Conclusion

Intravitreal injections of bevacizumab and ranibizumab have similar effects in stabilization of visual acuity, macular edema, and regression of polypoidal complex with PCV eyes.     

Short-term effectiveness of intravitreal bevacizumab vs. ranibizumab injections for patients with polypoidal choroidal vasculopathy

Purpose

To compare the effectiveness of intravitreal injections of bevacizumab and ranibizumab in patients with treatment-naive polypoidal choroidal vasculopathy (PCV).

Methods

Records from 106 consecutive patients who received intraviteral bevacizumab (n = 58, 1.25 mg) or ranibizumab (n = 52, 0.5 mg) for treatment of PCV were retrospectively reviewed. After three initial monthly loading injections, injection was performed as needed. The main outcome measures included best-corrected visual acuity (BCVA), foveal central thickness (FCT) as assessed by spectral domain optical coherence tomography, and the changes in polypoidal lesions based on an indocyanine green angiography.

Results

The average number of injections was 3.31 ± 1.25 in the bevacizumab group and 3.44 ± 0.92 in the ranibizumab group. Mean logarithm of the minimum angle of resolution of BCVA from baseline to 6 months after injection improved by 0.17 in the bevacizumab group (p = 0.03) and by 0.19 in the ranibizumab group (p = 0.01). Average FCT decreased from 322 ± 62.48 µm to 274 ± 40.77 µm in the bevacizumab group (p = 0.02) and from 338 ± 50.79 µm to 286 ± 36.93 µm in the ranibizumab group (p = 0.02). Polyp regression rate was 20.7% (12 of 58 eyes) in the bevacizumab group and 21.2% (11 of 52 eyes) in the ranibizumab group. There was no statistically significant difference between groups in BCVA improvement achieved, FCT improvement achieved, and polyp regression rate between groups.

Conclusions

Intravitreal injections of bevacizumab and ranibizumab have similar effects in stabilizing of visual acuity, macular edema, and regression of polypoidal complex in PCV eyes over the short term.     

Cost-effectiveness of anti-oxidant vitamins plus zinc treatment to prevent the progression of intermediate age-related macular degeneration. A Singapore perspective

Purpose:

To determine if providing high dose anti-oxidant vitamins and zinc treatment age-related eye disease study (AREDS formulation) to patients with intermediate age-related macular degeneration (AMD) aged 40–79 years from Singapore is cost-effective in preventing progression to wet AMD.

Methods:

A hypothetical cohort of category 3 and 4 AMD patients from Singapore was followed for 5 calendar years to determine the number of patients who would progress to wet AMD given the following treatment scenarios: (a) AREDS formulation or placebo followed by ranibizumab (as needed) for wet AMD. (b) AREDS formulation or placebo followed by bevacizumab (monthly) for wet AMD. (c) AREDS formulation or placebo followed by aflibercept (VIEW I and II trial treatment regimen). Costs were estimated for the above scenarios from the providers’ perspective, and cost-effectiveness was measured by cost per disability-adjusted life year (DALY) averted with a disability weight of 0.22 for wet AMD. The costs were discounted at an annual rate of 3%.

Results:

Over 5400 patients could be prevented from progressing to wet AMD cumulatively if AREDS formulation were prescribed. AREDS formulation followed by ranibizumab was cost-effective compared to placebo-ranibizumab or placebo-aflibercept combinations (cost per DALY averted: SGD$23,662.3 and SGD$21,138.8, respectively). However, bevacizumab (monthly injections) alone was more cost-effective compared to AREDS formulation followed by bevacizumab.

Conclusion:

Prophylactic treatment with AREDS formulation for intermediate AMD patients followed by ranibizumab or for patients who progressed to wet AMD was found to be cost-effective. These findings have implications for intermediate AMD screening, treatment and healthcare planning in Singapore.     

Influence of image compression on the interpretation of spectral-domain optical coherence tomography in exudative age-related macular degeneration

Purpose

To evaluate the effect of image compression of spectral-domain optical coherence tomography (OCT) images in the examination of eyes with exudative age-related macular degeneration (AMD).

Methods

Thirty eyes from 30 patients who were diagnosed with exudative AMD were included in this retrospective observational case series. The horizontal OCT scans centered at the center of the fovea were conducted using spectral-domain OCT. The images were exported to Tag Image File Format (TIFF) and 100, 75, 50, 25 and 10% quality of Joint Photographic Experts Group (JPEG) format. OCT images were taken before and after intravitreal ranibizumab injections, and after relapse. The prevalence of subretinal and intraretinal fluids was determined. Differences in choroidal thickness between the TIFF and JPEG images were compared with the intra-observer variability.

Results

The prevalence of subretinal and intraretinal fluids was comparable regardless of the degree of compression. However, the chorio–scleral interface was not clearly identified in many images with a high degree of compression. In images with 25 and 10% quality of JPEG, the difference in choroidal thickness between the TIFF images and the respective JPEG images was significantly greater than the intra-observer variability of the TIFF images (P=0.029 and P=0.024, respectively).

Conclusions

In OCT images of eyes with AMD, 50% of the quality of the JPEG format would be an optimal degree of compression for efficient data storage and transfer without sacrificing image quality.     

Microperimetric changes in neovascular age-related macular degeneration treated with ranibizumab

Purpose

To assess the value of microperimetry in eyes with neovascular age-related macular degeneration previously treated with ranibizumab and now in the maintenance phase of therapy.

Methods

A total of 21 eyes (14 patients) were included. Microperimetry was performed using the Macular Integrity Assessment Device on at least three occasions for each eye. Intravitreal ranibizumab was administered if visual acuity (VA) or optical coherence tomography (OCT) showed signs of active disease.

Results

Five eyes showed no change in VA or OCT findings, and required no intravitreal injections. In these eyes, mean threshold sensitivity (TS) decreased by 13% (paired t-test, P=0.05) during the study period, but fixation stability (FS) was unchanged. In all, 16 eyes showed signs of disease activity, and therefore required ranibizumab injections during the study. In these eyes, VA, central retinal thickness (CRT), FS, and TS remained unchanged during follow-up. Peak TS was noted when CRT was 210 μm; above or below 210 μm, there was a gradual reduction in TS.

Conclusion

This study has provided novel information on the relationship between macular sensitivity, CRT, and VA in the maintenance phase of ranibizumab therapy. Patients with stable VA and CRT may still have deteriorating retinal sensitivity. This is usually a late manifestation and may indicate subclinical CNV activity.     

Residual edema evaluation with ranibizumab 0.5?mg and 2.0?mg formulations for diabetic macular edema (REEF study)

Purpose

To compare the efficacy of ranibizumab 0.5-mg and 2.0-mg intravitreal injections for persistent diabetic macular edema (DME) previously treated with bevacizumab.

Methods

In all, 43 patients with residual center-involved DME following intravitreal bevacizumab were included in this 12-month prospective, nonrandomized, multicenter study. Enrolled patients received three monthly ranibizumab 0.5-mg injections. At month 3, patients with residual macular edema switched to three monthly injections of ranibizumab 2.0-mg. Assessments included monthly visual acuity and spectral-domain optical coherence tomography.

Results

Mean visual acuity improved by +6.4 letters at month 3 and +8.8 letters at month 6. Mean central subfield thickness (CST) decreased by –113 μm at month 3 and –165 μm at month 6. Before enrollment, 29/43 (67.4%) patients showed <10% CST reduction following monthly bevacizumab treatment. After three monthly ranibizumab 0.5-mg injections, 22/29 (75.9%) patients showed >10% reduction in CST, whereas 6 showed <10% reduction. Of these six, three (50%) showed >10% reduction in CST after switching to three monthly ranibizumab 2.0-mg doses. No serious adverse events were observed to month 6.

Conclusion

Ranibizumab 0.5-mg or 2.0-mg may improve visual and anatomic outcomes in patients with DME who demonstrated minimal or no response to bevacizumab therapy. Moreover, increased dosage of ranibizumab (2.0-mg) may provide additional benefit over ranibizumab 0.5-mg in some patients. However, 2.0-mg ranibizumab is not currently commercially licensed or available.