Combined use of intravitreal bevacizumab and oral steroid treatment in three diabetic papillopathy patients: a diagnostic and treatment challenge.

Purpose: To describe a case series of patients who experienced hemorrhagic complications following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Methods: In a small case series of 3 patients with retinal disorders, imaging with ultrasound biomicroscopy (UBM) was performed within 1 day following anti-VEGF injection. Results: The first patient had a mild vitreous hemorrhage, and UBM demonstrated a suspected needle track through the pars plana; the hemorrhage cleared spontaneously. The second patient had a dense vitreous hemorrhage as well as hyphema, and UBM demonstrated a suspected needle track through the pars plicata; the hemorrhage did not clear and the patient was subsequently treated elsewhere with pars plana vitrectomy. The third patient had a subconjunctival hemorrhage but no vitreous hemorrhage, and UBM demonstrated no definite evidence of a needle track. Conclusion: In some patients with vitreous hemorrhage following anti-VEGF injection, a suspected needle track may be imaged with UBM within 1 day following injection.

Risk, Prevalence, and Progression of Glaucoma in Eyes With Age-Related Macular Degeneration Treated With Intravitreal Anti–Vascular Endothelial Growth Factor Injections

Purpose: To assess the long-term outcome of neovascular age-related macular degeneration (AMD) treated with multiple intravitreal anti-vascular endothelial growth factor (VEGF) injections. Methods: All patients treated with over 30 intravitreal anti-VEGF injections for neovascular AMD between 2007 and 2014 were retrospectively reviewed. Results: A total of 67 eyes received 2,960 (mean 45 ± 9.1 per eye) anti-VEGF injections. Eyes with good final visual acuity (VA) had better initial VA (p = 0.020) and maintained it. Patients with moderate-to-poor final VA improved significantly after the first 3 monthly injections, and thereafter deteriorated consistently, mostly during the third (p = 0.019) and fourth (p = 0.006) years. Eyes with worse final VA had more intraretinal fluid (p = 0.05) and subretinal fibrosis (p = 0.04). Conclusion: Two distinct clinical courses were identified: good final VA was associated with initial and long-term stability of good VA; eyes with worse final VA had worse initial VA, progressive deterioration following the initial improvement, and more scarring and intraretinal fluid. This probably underscores the long-term benefits of early detection and treatment.

Purpose:The aim of this study was to analyze the impact on vision due to delay in presentation of patients requiring intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, consequent to COVID-19-related travel restrictions.Methods:Data were collected retrospectively of patients who received anti-VEGF injections during four months of the COVID-19 pandemic. Visual acuities, indication for treatment were noted along with basic demographic characteristics.Results:Data were analyzed for 303 eyes of 263 patients. The indication for treatment was age-related macular degeneration (AMD) in 60 eyes (19.8%), while 162 eyes (53.5%) had Diabetic Macular Edema, 71 eyes (23.4%) had Retinal Vein Occlusion and 10 eyes (3.3%) had other diagnosis. The visual acuity in the treatment naïve eyes (Group A, n = 168) was significantly worse (P < 0.001) than those who presented for retreatment (Group B, n = 135). In Group B, there was a significant decline in vision for the entire cohort (P = 0.009) and those with AMD (P = 0.036). Those in Group B presented at a mean interval of 19.1 ± 10.6 (range, 4–64) weeks for retreatment.Conclusion:The COVID-19 pandemic has led to a delay in patients receiving anti-VEGF injections. The visual acuity is worse in both treatment naïve as well as those requiring retreatment. This could have long-term impact on vision of patients requiring this vision preserving treatment.

Aim: This study aimed to evaluate the visual and anatomical outcomes following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in patients with diffuse diabetic macular edema (DME). The primary objective was to assess improvement in best-corrected visual acuity (BCVA) and reduction in central retinal thickness (CRT) as measured by spectral domain optical coherence tomography (OCT). Methods: A descriptive cross-sectional study was conducted at the Ophthalmology Department of Bahawal Victoria Hospital, Bahawalpur, over a six-month period. A total of 147 treatment-naïve patients aged 20–60 years with type 2 diabetes and diffuse DME confirmed by OCT (CRT ≥290 µm) were included. Participants received three monthly intravitreal anti-VEGF injections (bevacizumab, ranibizumab, or aflibercept). Visual acuity was assessed using Snellen’s chart and CRT was measured via OCT before treatment and two weeks after the third injection. The primary endpoint was defined as achieving both BCVA ≥20/40 and CRT ≤290 µm post-treatment. Secondary endpoints included changes in BCVA (in Snellen lines) and CRT (in micrometers). Data were analyzed using SPSS version 25.0. Results: Following three intravitreal anti-VEGF injections, there was a statistically significant improvement in both visual and anatomical outcomes. The proportion of patients achieving BCVA ≥20/40 increased from 12.2% pre-treatment to 48.3% post-treatment (p &lt; 0.001), with a mean gain of 3.2 ± 1.5 Snellen lines. Mean CRT decreased significantly from 410.5 ± 45.6 µm at baseline to 287.3 ± 32.4 µm post-treatment (p &lt; 0.001), with 65.3% of patients achieving CRT ≤290 µm. A combined outcome of improved BCVA and reduced CRT was achieved in 42.2% of patients. No major adverse events were reported, and transient intraocular pressure spikes occurred in 5% of cases. Conclusion: Intravitreal anti-VEGF therapy is effective in improving both visual acuity and reducing macular thickness in patients with diffuse diabetic macular edema. Early response to treatment, as assessed by OCT, can guide further management. While most patients benefit from anti-VEGF therapy, approximately 40% show partial or no improvement, highlighting the need for early identification of non-responders and consideration of alternative treatment strategies. Regular OCT monitoring and individualized treatment approaches are essential for optimizing long-term outcomes in patients with DME.

BACKGROUND The aim of this study was to determine the levels of vascular endothelial growth factor (VEGF) in the aqueous humor and the effect of intravitreal anti-VEGF injection combined with panretinal photocoagulation (PRP) on the management in diabetes mellitus (DM) patients with neovascular glaucoma (NVG). &#x0D; METHODS This study was a prospective, interventional study in DM patients with NVG. Paracentesis followed by intravitreal bevacizumab (IVB) injection was performed in all eyes. The concentration of VEGF obtained from paracentesis was measured. In week-1, the intraocular pressure (IOP), sectorial iris neovascularization (NVI), and visual acuity were documented, and management was continued with PRP laser over a period of 1 week. All parameters and additional interventions performed after PRP were also recorded. &#x0D; RESULTS A total of 18 eyes from 17 patients were studied. The mean (SD) level of VEGF in the aqueous humor was 3,864 (1,468) pg/ml, and the mean (SD) of initial IOP was 39 (10.2) mmHg. There was a significant reduction in IOP in week-1 after the first intervention to 24.4 (8.0) mmHg (p = 0.001); however, at 2 weeks the IOP increased to 30.4 (6.7) mmHg. NVI showed significant regression in week-1 after IVB combined with PRP laser (p &lt; 0.05). All eyes required additional glaucoma implants (14 eyes) and cyclocryotheraphy (4 eyes). &#x0D; CONCLUSIONS In the eyes of diabetes patients with NVG, VEGF levels were high. With the use of IVB, the IOP was reduced, and NVI regressed; however, due to the severe stages of disease, all eyes required glaucoma surgery.

Purpose To evaluate the rate of presumed endophthalmitis (EO) after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections performed in an operating room (OR) under sterile conditions in mainland China. Methods Retrospective single-center study between September 2012 and December 2017 at Beijing Tongren Eye Center, Beijing, China. Intravitreal injection database was reviewed. All anti-VEGF injections were performed using a standardized sterile technique in an OR. Injection protocols included antibiotics for 3 days pre-injection, topical 5% povidone-iodine rinsing before the procedure, and post-injection antibiotics for 3 days. Results A total of 37,830 intravitreal injections were performed at Beijing Tongren Eye Center. Three cases were managed as presumed EO (0.0079%). Positive cultures were documented in 2 of 3 cases. EO incidence following ranibizumab and conbercept administration was 0.0088% (3 in 33,930) and 0% (0 in 3,900), respectively. No significant difference was detected between the two drugs (P = 0.745). Conclusions Very low EO rates were seen in mainland China using a standardized sterile technique in an OR. However, EO could not be completely avoided.

Loss to follow-up (LTFU) after anti-vascular endothelial growth factor (anti-VEGF) injections increases the risk of vision loss among patients with neovascular age-related macular degeneration (nAMD). To report rates of LTFU among patients with nAMD after anti-VEGF injections and to identify risk factors associated with LTFU in this population. This retrospective cohort study of data from 9007 patients who received anti-VEGF injections for treatment of nAMD was performed at an urban, private retina practice with multiple locations from April 1, 2012, to January 12, 2016. Rates of LTFU after anti-VEGF injections. Loss to follow-up was defined as receipt of 1 or more injections with no subsequent follow-up visit within 12 months. Among the 9007 patients (mean [SD] age, 81.2 [8.8] years; 5917 [65.7%] female; 7905 [87.8%] white), 2003 (22.2%) were LTFU. Odds of LTFU were greater among patients 81 to 85 years of age (odds ratio [OR], 1.58; 95% CI, 1.38-1.82; P < .001), 86 to 90 years of age (OR, 2.29; 95% CI, 2.00-2.62; P < .001), and more than 90 years of age (OR, 3.31; 95% CI, 2.83-3.86; P < .001) compared with patients 80 years of age and younger. Odds of LTFU among African American patients (OR, 1.47; 95% CI, 1.00-2.16; P = .05), Asian patients (OR, 2.63; 95% CI, 1.71-4.03; P < .001), patients of other race (OR, 3.07; 95% CI, 1.38-6.82; P = .006), and patients of unreported race (OR, 2.29; 95% CI, 1.96-2.68; P < .001) were greater than odds of LTFU among white patients. Odds of LTFU were greater among patients with regional adjusted gross income of $50 000 or less (OR, 1.52; 95% CI, 1.30-1.79; P < .001), $51 000 to $75 000 (OR, 1.35; 95% CI, 1.17-1.56; P < .001), and $76 000 to $100 000 (OR, 1.28; 95% CI, 1.08-1.50; P = .004) compared with patients with incomes greater than $100 000. Odds of LTFU for patients living 21 to 30 miles (OR, 1.33; 95% CI, 1.05-1.69; P = .02) and more than 30 miles (OR, 1.55; 95% CI, 1.28-1.88; P < .001) from clinic were greater compared with patients who lived 10 miles or less from the clinic. Odds of LTFU were greater among patients who received unilateral injections (OR, 1.44; 95% CI, 1.28-1.61; P < .001) than among patients who received bilateral injections. We found a high rate of LTFU after anti-VEGF injections among patients with nAMD and identified multiple risk factors associated with LTFU among this population. Although our results may not be generalizable, data on LTFU in a clinical practice setting are needed to understand the scope of the problem so that interventions may be designed to improve outcomes.

To summarize the findings of recent reports of short-term and sustained intraocular pressure (IOP) rise associated with intravitreal antivascular endothelial growth factor (VEGF) injections and to guide the management of this infrequent complication. Short-term increases in IOP are common immediately after intravitreal anti-VEGF injection. IOP takes longer to reach a safe level in patients with a history of glaucoma or ocular hypertension. Preinjection medicinal therapy and ocular decompression therapy may blunt this short-term IOP rise. Sustained increases in IOP are relatively infrequent, but are likely to necessitate intervention for IOP-lowering. A 'pro re nata' (PRN) injection protocol may obviate the need for intervention. The pathophysiology of sustained IOP rise is poorly understood, but may relate to repackaging processes undertaken by the pharmacies that compound these agents. Treating physicians should be aware of the potential for short-term and sustained IOP rise associated with intravitreal anti-VEGF injection therapy. Considerations for management include prophylactic IOP-lowering with medicinal therapy and/or preinjection ocular decompression for patients with a history of glaucoma or ocular hypertension and switching to a 'PRN' injection protocol in patients suffering a sustained rise in IOP.

Loss to Follow-up After Intravitreal Anti–Vascular Endothelial Growth Factor Injections in Patients with Diabetic Macular Edema

Super-dose Anti-VEGF (SAVE) Trial: 2.0 mg Intravitreal Ranibizumab for Recalcitrant Neovascular Macular Degeneration–Primary End Point

Long-Term Follow-up of Patients with Exudative Age-Related Macular Degeneration Treated with Intravitreal Anti–Vascular Endothelial Growth Factor Injections

The purpose of this study was to report long-term results of intravitreal antivascular endothelial growth factor therapy in the management of choroidal neovascularization in patients with angioid streaks associated with pseudoxanthoma elasticum. A consecutive series of patients with pseudoxanthoma elasticum and choroidal neovascularization were managed with intravitreal antivascular endothelial growth factor injections (bevacizumab 1.25 mg/0.05 mL or ranibizumab 0.5 mg/0.05 mL). The main outcome measures were visual acuity and greatest lesion height as measured by optical coherence tomography. Nine eyes of nine consecutive patients received intravitreal antivascular endothelial growth factor therapy. During the mean follow-up period of 28.6 months, eyes received an average of 8.4 injections. At baseline, the mean visual acuity was 20/368 (median, 20/60) and improved to 20/281 (median, 20/40) at the last visit (P = 0.14). Visual acuity either improved or stabilized in all 9 eyes (100%). Serial optical coherence tomography measurements showed a mean of 353 mum at baseline and decreased to 146 mum at the last visit (P = 0.005). No complications were noted. These long-term results support the use of intravitreal antivascular endothelial growth factor therapy for the management of choroidal neovascularization in patients with pseudoxanthoma elasticum. Continued experience with intravitreal bevacizumab or ranibizumab in this population will help establish long-term efficacy and better define optimal dosing strategies.

Purpose To evaluate the characteristics of corneal parameters in patients with diabetic macular oedema (DME) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Methods Participants in this study were 36 patients with DME, treated with either intravitreal ranibizumab (n = 16) or aflibercept (n = 20). All participants underwent best-corrected visual acuity (BCVA) measurement, optical coherence tomography and non-contact specular microscopy to evaluate corneal endothelium parameters (endothelial cell density-ECD, hexagonality, coefficient of variation of the cell size and central corneal thickness-CCT), at baseline and at months 6 and 12 after the first intravitreal injection. Comparisons between baseline and months 6 and 12 were performed. Results There was no statistically significant difference regarding ECD, hexagonality, coefficient of variation of the cell size and CCT at month 6 and 12 post initial injection compared to baseline in patients with DME. BCVA improved significantly at month 6 and 12 compared to baseline (p < 0.001 for both comparisons). Central retinal thickness was significantly reduced at month 6 and 12 compared to baseline (p < 0.001 for both comparisons). Conclusion Intravitreal anti-VEGF injections in patients with DME were found not to affect corneal parameters, namely ECD, hexagonality, coefficient of variation of the cell size and CCT at the long-term follow-up of 12 months.

Objective: To evaluate the outcomes and complications of bilateral same-day intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Methods: This is a single-center, retrospective study that included 524 eyes of 262 patients who received concomitant bilateral intravitreal anti-VEGF injections in 2016 at St. Michael’s Hospital, Toronto. If any of the patients were receiving simultaneous bilateral injections on a regular basis prior to 2016, data pertaining to previous injections were also reviewed. Everyone received bevacizumab, ranibizumab, or aflibercept in an office setting. Results: A total of 9,798 intravitreal anti-VEGF injections (4,899 bilateral injection sessions) were performed in 524 eyes of 262 patients. The average number of bilateral injection sessions per patient was 18.7 ± 14.1. Ranibizumab was the most commonly used anti-VEGF drug (83.8%). The incidence of endophthalmitis was 0.01%, and there were 2 episodes of acute intraocular inflammation among the 9,798 injections (0.02%). All 3 cases occurred after treatment with ranibizumab. There were 2 deaths (0.76%) due to nonvascular causes but no vascular related systemic adverse events were reported. Conclusions: Same-day bilateral intravitreal anti-VEGF injections present a low rate of complications and are well tolerated by patients. This safe practice may reduce the burden on the health-care system and on the patients.