Myopic choroidal neovascularization: management issues remain

In the modern world, myopia continues to be one of the most common refractive errors and is considered a socially signifi cant problem, since it is a common cause of decreased vision. In connection with the growth of myopia, the risk of developing complications in the fundus increases, leading to the development of degenerative changes in the retina and an irreversible decrease in visual functions in young and middle-aged people. One of these complications is myopic choroidal neovascularization, which leads to a progressive, irreversible decrease in visual acuity and poor prognosis, and the process is often bilateral in nature. The tactics of managing patients with such complications has been determined: antiangiogenic therapy is used – intravitreal therapy with anti-VEGF drugs, which is currently the fi rst choice therapy for this pathology. But in some cases, antiangiogenic therapy is contraindicated, and the question arises about the tactics of managing such patients. The aim: to study treatment options for myopic choroidal neovascularization in patients with myopia in different situations.Material and methods. The paper presents two clinical observations of patients with mChNV, considers the tactics of their management. The patients underwent standard ophthalmological examination, optical coherence tomography (OCT) and OCT-Angio (OPTOPOL Technology, Poland).Conclusions. Women with myopia planning pregnancy need a thorough examination not only by a clinician, but also by an ophthalmologist, since it is necessary to take into account not only the degree of myopia and choose the optimal delivery method, but also to study the state of the retina for the timely diagnosis of degenerative changes in the fundus.

Two Year Study of Aflibercept and Ranibizumab Intravitreal Therapy in Patients with Wet AMD

Background and objectives: The aim of this study was to evaluate the therapeutic results in patients with exudative AMD treated with ranibizumab and aflibercept intravitreal injections over a two-year observation period. Materials and methods: A retrospective observational study was conducted in a clinical hospital on a group of patients who randomly qualified for treatment with Aflibercept (group A) and Ranibizumab (group B) as part of the Polish National Health Fund Medical Program for exudative AMD. Group A consisted of 90 patients, and group B contained 54 patients. The choice of drug in a patient depended solely on the availability of the medication at the time. Before each injection, best corrected visual acuity (BCVA) on the ETDRS scale and central retinal thickness (CRT) were assessed using optical coherence tomography (OCT). Patients from both groups were treated in the first year of treatment with a rigid scheme of 3 doses of 2.0 mg Aflibercept (group A) and 0.5 mg Ranibizumab (group B) at monthly intervals, followed by 4 doses at bimonthly intervals. In the second year, a “pro re nata” scheme was applied. The aim was to evaluate changes in BCVA and CRT after three injections, after 7 injections (about 12 months), and after the second year of therapy (24 months) with reference to the baseline and to compare the effectiveness of the medications. The influences of the following factors were studied: age, gender, initial BCVA, and initial CRT, as well as the number of injections received. Results: No significant statistical differences were found between patients receiving Aflibercept and Ranibizumab therapy in terms of achieving improved visual acuity and reducing retinal thickness after two years of therapy. Conclusions: Both aflibercept and ranibizumab were found to be effective for treating exudative AMD.

Clinical Outcome and Drug Expenses of Intravitreal Therapy for Diabetic Macular Edema: A Retrospective Study in Sardinia, Italy

Background: Diabetic macular edema (DME) is a leading cause of visual loss in working-age adults. The purpose of this retrospective study was to perform an epidemiological analysis on DME patients treated with intravitreal drugs in a tertiary hospital. The clinical outcome, adverse drug reactions (ADRs), and intravitreal drug expenses were assessed. Methods: All DME patients treated with Ranibizumab, Aflibercept, Dexamethasone implant, and Fluocinolone Acetonide implant at the Sassari University Hospital, Italy, between January 2017 and June 2020 were included. Central macular thickness (CMT) and best corrected visual acuity (BCVA) were measured. ADRs and drug expenses were analyzed. Results: Two-hundred thirty-one DME patients (mean age: 65 years) received intravitreal agents. Mean CMT and BCVA were 380 μm and 0.5 LogMAR at baseline, 298 μm and 0.44 logMAR after one year (p = 0.04), and 295 μm and 0.4 logMAR at the end of the follow-up period. A total of 1501 intravitreal injections were given; no major ADRs were reported. Treatment cost was €915,000 (€261,429/year). Twenty non-responders to Ranibizumab or Aflibercept were switched to a Dexamethasone implant. In these patients, mean CMT and BCVA were 468 µm and 0.5 LogMar at the time of switching and 362 µm and 0.3 LogMar at the end of the follow-up (p = 0.00014 and p = 0.08, respectively). Conclusion: Results confirm that Ranibizumab, Aflibercept, and Dexamethasone implant are effective and safe in DME treatment. A switch to Dexamethasone implant for patients receiving Aflibercept or Ranibizumab with minimal/no clinical benefit should be considered.

Use of Intravitreal Ganciclovir as Monotherapy for Bilateral CMV Retinitis in a Tertiary Government Hospital

In a tertiary government hospital where cost is an invariable concern, this report validates monotherapy of intravitreal ganciclovir as an effective option for patients due to affordability and ease of administration compared to systemic therapy. The case also exhibits the potential of intravitreal therapy to improve visual acuity in advance bilateral retinal disease

Recent Advancements in the Medical Treatment of Diabetic Retinal Disease

Diabetic retinal disease remains one of the most common complications of diabetes mellitus (DM) and a leading cause of preventable blindness. The mainstay of management involves glycemic control, intravitreal, and laser therapy. However, intravitreal therapy commonly requires frequent hospital visits and some patients fail to achieve a significant improvement in vision. Novel and long-acting therapies targeting a range of pathways are warranted, while evidence to support optimal combinations of treatments is currently insufficient. Improved understanding of the molecular pathways involved in pathogenesis is driving the development of therapeutic agents not only targeting visible microvascular disease and metabolic derangements, but also inflammation and accelerated retinal neurodegeneration. This review summarizes the current and emerging treatments of diabetic retinal diseases and provides an insight into the future of managing this important condition.

Implementation of An Intravitreal Therapy Online Audit Tool For Neovascular Age-related Macular Degeneration Clinical Outcomes Reporting: Fight Retinal Blindness Spain (FRB-Spain) Project

Purpose: To implement an intravitreal therapy audit tool for neovascular age-related macular degeneration (nAMD) outcome reporting in a tertiary referral center. Methods: Implementation of an online audit tool (Fight Retinal Blindness platform) for nAMD eyes receiving anti-vascular endothelial growth factor (anti-VEGF) intravitreal therapy over a 24-month follow-up period. Data entry was compliant with the ICHOM dataset for nAMD. These data included visual acuity (VA), eye conditions, injection drug and number of injections. Subgroup analysis was performed for treatment-naive (TN) and previously treated (PT) eyes. Results: 234 eyes (191 patients) were included in the study. No significant differences were observed in the subgroup analysis in mean baseline VA (logMAR letters: 58.8 TN vs 62.7 PT, p= 0.081) or final VA at 12 months (TN 61.4 vs PT 62.4; p= 0.703). However, 12 months median VA change favoured TN cases (+4 TN vs +0 PT, p= 0.010) and median number of injections showed no differences (7 TN vs 7 PT, p= 0.644). No statistically significant differences were found at two years on number of injections even though mean final VA showed significant differences (66 TN vs 59.5 PT, p = 0.032) and VA change favoured the TN group (+2.4 TN vs - 4.6 PT, p= 0.003).Conclusion: We have successfully implemented an online tool to evaluate nAMD anti-VEGF treatment delivered in our center. This feasibility study demonstrates that the online audit tool allows evaluating real world intravitreal therapy outcomes and benchmark these results with clinical practice guidelines and other real-life series.

A comparative study between ranibizumab and its first biosimilar razumab in terms of efficacy and safety in DME, RVO and wet AMD associated with CNVM

To compare safety and efficacy of intravitreal therapy between anti vascular endothelial growth factor (Anti-VEGF) Ranibizumab and biosimilar Razumab in diabetic macular oedema (DME), wet age related macular degeneration (AMD) with choroidal neovascular membrane (CNVM) and retinal vein occlusion (RVO). Prospective comparative study involved 60 eyes of 56 adults, randomized into 2 groups from September 2016 to November 2017. Group 1 (n=30) received Ranibizumab (0.5mg in 0.05ml) and group 2(n=30) Razumab (0.5mg in 0.05ml). Initial loading dose of one injection given to all subjects and a pro re nata schedule followed thereafter. Patients received maximum of 3 injections and were followed up to 12 weeks. Best corrected visual acuity (BCVA) and central foveal thickness (CFT) were considered for the primary outcome and adverse drug reactions (ADR) was considered in the secondary outcome. A p value of less than 0.05 was considered statistically significant. The 12-week mean BCVA in group 1 was 0.39 (+-0.24); and in group 2 was 0.53 (+-0.37), which had improved significantly from baseline (group 1 p= 0.007, group 2 p <0.001). Inter group comparison was statistically insignificant (p=0.249). The 12 weeks mean CFT in group 1 was 308 (+-107.26) ; and group 2 was 307.60 (+- 87.15), which had improved significantly from baseline in both groups (p <0.001). Inter group difference was statistically insignificant (p=0.544). One patient in group 2 experienced an ADR (p=0.305). In this study both Ranibizumab and Razumab were safe and efficacious.

Topical interferon in recurrent inflammatory macular edema following a cat bite

Introduction: Treating chronic macular edema (CME) post endophthalmitis is a challenge. Use of steroids may reactivate the infection and repeated intravitreal therapy with anti-vascular growth factor inhibitors (Anti-VEGF) puts the patient again at the risk of exacerbation of inflammation or endophthalmitis. We describe a case of CME post traumatic endophthalmitis successfully treated with topical interferon therapy. Case description: A 34-year-old Asian Indian lady with a history of cat bite to her right eye and treated elsewhere as traumatic endophthalmitis with recurrent macular edema, presented to us 1 year after the injury. She had received anti-VEGF injection for same. Her medical history was non-contributory except for close contact with her cat. Therapeutic trials with oral doxycycline followed by oral albendazole with steroids, as well as repeated anti-VEGF therapy failed to prevent recurrence of CME. Patient’s steroid responsiveness and reluctance for injections, made us to opt for a novel topical Interferon therapy. Macular edema resolved in 2 months. Interruption of interferon therapy due to COVID-lock down resulted in recurrence of the CME, which again responded well to interferon monotherapy. Conclusion: Topical interferon may have a role in the treatment of inflammatory macular edema and can serve as a, safer, economical and non-invasive treatment option compared to intravitreal steroids and anti-VEGFs.