Repeat Intravitreal Injections Research Articles

Does addition of intravitreal bevacizumab confer additional benefit in management of proliferative diabetic retinopathy?

To evaluate visual outcome and complications of PDR after treatment with Intravitreal Bevacizumab followed by Pan Retinal Photocoagulation A hospital based retrospective study was done in the Department of Ophthalmology, to evaluate visual outcome and complications of PDR after treatment with intravitreal Bevacizumab followed by Pan Retinal Photocoagulation. Visual Acuity, Dilated fundus examination, OCT macula were done on subsequent follow ups 135 eyes of 133 patients were included in the study.The mean pre procedure visual acuity is 0.639±0.5327 which improved to 0.451±0.4089 post procedure. P value is <0.001 which is statistically significant.i.e, 94 (69.62%) eyes had improved vision, 21(15.55%) had stable vision and 20(14.81%) eyes had decreased vision. After injection followed by PRP out of 135 eyes,4(2.96%) eyes developed vitreous hemorrhage which resolved with repeat intravitreal anti-VEGF injection, 6(4.44%) eyes developed diabetic macular edema,3(2.2%) eyes developed Neovascularisation of iris and 4(2.96%)eyes developed vitreous hemorrhage with traction retinal detachment.From our study it appears that addition of intravitreal anti VEGF to Pan Retinal Photocoagulation for PDR confers the additional benefit of less incidence of vitreous hemorrhage and less incidence of traction retinal detachment requiring surgery in the 1 one year of follow up. This amounts to more compliance by the patient for taking the treatment as well as better visual outcome

Small-Molecule-Directed Endogenous Regeneration of Visual Function in a Mammalian Retinal Degeneration Model.

Degenerative retinal diseases associated with photoreceptor loss are a leading cause of visual impairment worldwide, with limited treatment options. Phenotypic profiling coupled with medicinal chemistry were used to develop a small molecule with proliferative effects on retinal stem/progenitor cells, as assessed in vitro in a neurosphere assay and in vivo by measuring Msx1-positive ciliary body cell proliferation. The compound was identified as having kinase inhibitory activity and was subjected to cellular pathway analysis in non-retinal human primary cell systems. When tested in a disease-relevant murine model of adult retinal degeneration (MNU-induced retinal degeneration), we observed that four repeat intravitreal injections of the compound improved the thickness of the outer nuclear layer along with the regeneration of the visual function, as measured with ERG, visual acuity, and contrast sensitivity tests. This serves as a proof of concept for the use of a small molecule to promote endogenous regeneration in the eye.

Ocular Safety and Toxicokinetics of Bevacizumab-bvzr (Zirabev), a Bevacizumab Biosimilar, Administered to Cynomolgus Monkeys by Intravitreal Injection.

Purpose: Bevacizumab-bvzr (Zirabev®), a recombinant humanized monoclonal antibody targeting vascular endothelial growth factor and a biosimilar to bevacizumab, is approved for intravenous administration for various indications worldwide. The objectives of this study were to evaluate the ocular toxicity, systemic tolerability, and toxicokinetics (TKs) of bevacizumab-bvzr following repeat intravitreal (IVT) injection to cynomolgus monkeys. Methods: Male monkeys were administered saline, vehicle, or bevacizumab-bvzr at 1.25 mg/eye/dose once every 2 weeks (3 doses total) for 1 month by bilateral IVT injection, followed by a 4-week recovery phase to evaluate the reversibility of any findings. Local and systemic safety was assessed. Ocular safety assessments included in-life ophthalmic examinations, tonometry (intraocular pressure, IOP), electroretinograms (ERGs), and histopathology. In addition, concentrations of bevacizumab-bvzr were measured in serum and in ocular tissues (vitreous humor, retina, and choroid/retinal pigment epithelium) and ocular concentration-time profiles and serum TKs were evaluated. Results: Bevacizumab-bvzr was tolerated locally and systemically, with an ocular safety profile comparable to the saline or vehicle control group. Bevacizumab-bvzr was observed in both serum and in the evaluated ocular tissues. There were no bevacizumab-bvzr-related microscopic changes or effects on IOP or ERGs. Bevacizumab-bvzr-related trace pigment or cells in vitreous humor (in 4 of 12 animals; commonly associated with IVT injection) and transient, nonadverse, mild ocular inflammation (in 1 of 12 animals) were noted upon ophthalmic examination and fully reversed during the recovery phase. Conclusions: Bevacizumab-bvzr was well tolerated via biweekly IVT administration in healthy monkeys, with an ocular safety profile comparable to saline or its vehicle control.

Understanding the science of fungal endophthalmitis - AIOS 2021 Sengamedu Srinivas Badrinath Endowment Lecture

Fungal endophthalmitis is a potentially blinding condition. It is more often reported from Asia, including India. The incidence is lower than bacterial endophthalmitis. But it is relatively more challenging to treat than bacterial endophthalmitis. Many eyes may need therapeutic keratoplasty and/or evisceration. The current mainstays of treatment are vitrectomy irrespective of the presenting vision, intravitreal antifungal agents, and systemic therapy; additionally, the patients could require prolonged treatment with repeat vitreous surgeries and intravitreal injections. Difficulty in clinical diagnosis, delay in microbiological culture, and limited options of antifungal drugs make the treatment more difficult and less rewarding. Three common fungi causing endophthalmitis are Aspergillus, Fusarium, and Candida. The former two are molds, often identified in exogenous endophthalmitis, postoperative and traumatic; the latter is yeast and is more often identified in endogenous endophthalmitis. A faster diagnosis with newer molecular microbiological technologies might help institute treatment earlier than it is currently possible. A target trial using big data from different regions of the world might emulate a randomized clinical trial to design a definite treatment strategy. Given fewer antifungal drugs, one must be mindful of antifungal stewardship to prevent resistance to the existing drugs.

Questionnaire to Assess Life Impact of Treatment by Intravitreal Injections (QUALITII): Development of a patient-reported measure to assess treatment burden of repeat intravitreal injections

ObjectiveTo understand patient burden of treatment of repeated intravitreal injections (IVI) in the management of exudative retinal diseases.Methods and analysisParticipants were sampled from a large urban retina specialty practice in...

Treatment Strategies in Acute Post-operative Endophthalmitis after Cataract Surgery at a Tertiary Eye Hospital in Nepal: A 5-year Retrospective Review.

Despite best possible preventive measures, acute postoperative endophthalmitis (POE) is still the most devastating, sight-threatening complication after intraocular surgery and the most feared complication by treating surgeons. It is a retrospective study of 22 eyes diagnosed as acute POE following cataract surgery in the last 5 years (2015-2019), aimed to evaluate the treatment strategies used in its management. Main outcome measures evaluated were rates of repeat intravitreal injection, adjunctive therapeutic regimens, pars plana vitrectomy (PPV) and visual outcome. Twenty one eyes (95.45%) received repeated intravitreal injection. Adjuvant intravitreal steroid was used in 12 eyes (54.54%), oral steroid in 16 eyes (72.72%) and oral antibiotic in 8 eyes (36.36%). PPV was done in 8 eyes (34.78%) and all 8 eyes that underwent PPV had a vision of Hand Movement (HM) close to face. 7 eyes (87.5%) had early PPV within 1 week of diagnosis. The median best corrected visual acuity (BCVA) improved from 1.00 logMar to 0.8 logMar following treatment at 3 months follow up (p= 0.117). Repeat intravitreal injections were commonly employed. Early PPV was performed more commonly regardless of the visual acuity at the time of diagnosis of acute POE.

Using the West Midlands CONCERT to characterise regional incidence of acute-onset post cataract surgery endophthalmitis

BackgroundWhilst research and innovation is embedded within the UK’s National Health Service (NHS) constitution, Doctors-in-training have little opportunity to contribute to designing, leading and recruiting into clinical trials or cohort studies. We formed the West MidlandsCollaborativeOphthalmologyNetwork forClinicalEffectiveness &Research byTrainees (The West Midlands CONCERT) and undertook a characterisation of post cataract surgery endophthalmitis as a proof-of-concept study to test the feasibility of the CONCERT model.MethodsDoctors-in-training formed a collaborative working group to test the concept of delivering a pan-regional clinical effectiveness study across multiple hospital sites by performing retrospective analyses of post cataract endophthalmitis over a 6-year period.ResultsOverall, 157,653 cataract surgeries were performed by participating centres accredited to deliver the Royal College of Ophthalmologists training curriculum. Thirty-eight cases of post cataract endophthalmitis were identified, giving an incidence of 2.41 per 10,000 cases (0.0241%). A further 15 endophthalmitis cases presented who had surgery in non-training centres, giving a total of 53 cases. The most common organisms were S. epidermidis (14 (51.9%)) and P. aeruginosa (5 (18.5%)). Anterior-chamber and vitreous sampling yielded positive culture in 33.3% (6/18) and 50.9% (27/53), respectively. At 6 months follow-up, 19 (51.4%) patients achieved visual acuities of ≤0.5 LogMAR. Repeat intravitreal injections (11 (20.8%)) and vitrectomy (n = 22 (41.5%)) were not associated with better outcomes.ConclusionsUsing post cataract endophthalmitis as a pilot cohort, this study highlights the feasibility of using the CONCERT model for studies across multiple sites. A UK-CONCERT could provide a powerful infrastructure enabling characterisation of patient cohorts and a platform for high-quality interventional studies, improving patient care.

Combined Vitrectomy and Anti-VEGF Treatment for Stage 4 Retinopathy of Prematurity With Extensive Neovascular Proliferation.

To study the role of combined vitrectomy and intravitreal anti-vascular endothelial growth factor (VEGF) injection for stage 4 retinopathy of prematurity (ROP) with extensive neovascular proliferation. In a retrospective interventional study at a tertiary eye care center, 15 eyes (9 infants) with advanced stage 4 ROP underwent 25-gauge vitrectomy combined with intravitreal 0.625 mg of bevacizumab (n = 12) or 0.25 mg of ranibizumab (n = 3) injection and were followed up until 65 weeks' postconceptional age (PCA). The perinatal history, tractional retinal detachment (TRD) characteristics (zone, stage, and presence of "plus" disease), treatment details, and anatomical outcomes were reviewed. The main outcome measures were fibrovascular tissue and TRD regression and final macular status. Mean gestational age and birth weight were 28.5 ± 1.2 weeks and 1,167 ± 185 g, respectively. Thirteen eyes had zone I disease and 2 eyes had zone II disease. Thirteen eyes were stage 4A and 2 eyes were stage 4B ROP. The morphology was aggressive posterior ROP in 10 eyes. The mean PCA at surgery was 37.8 ± 2.3 weeks. Lensectomy was also performed in 2 eyes. Rapid fibrovascular tissue regression was seen in 14 eyes within 2 weeks, followed by TRD regression and macular vascularization, although 2 eyes had macular pucker formation. Persistent vitreous bleeding was present in 1 eye, which needed lavage, and eventually the TRD regressed. Disease reactivation was noted in 1 eye at 5 weeks and was managed with repeat intravitreal anti-VEGF injection. Anti-VEGF treatment combined with vitrectomy leads to rapid disease regression in advanced stage 4 ROP with extensive neovascular proliferation. [J Pediatr Ophthalmol Strabismus. 2020;57(1):61-66.].

International Practice Patterns for the Management of Acute Postsurgical and Postintravitreal Injection Endophthalmitis: European Vitreo-Retinal Society Endophthalmitis Study Report 1

To study the practice patterns for the management of acute postoperative and postinjection endophthalmitis. Retrospective, interventional, nonrandomized, multicenter study. Data on 237 eyes diagnosed with acute endophthalmitis occurring after intraocular surgery or procedures provided by 57 retina specialists from 28 countries. Rates of pars plana vitrectomy (PPV), repeat intravitreal injection, and adjunctive therapeutic regimens (local and systemic antibiotics and steroids). Of 237 analyzed eyes, acute endophthalmitis secondary to cataract surgery or secondary lens implantation represented 64.6% of cases (153 eyes), whereas the remaining were secondary to intravitreal injections (35 eyes [14.8%]), PPV (29 eyes [12.2%]), and other intraocular surgeries (20 eyes [8.4%]). All eyes received intravitreal antibiotics on the same day of diagnosis. Overall, early PPV was used within the first week of presentation in 176 eyes (74.3%). There was no statistical difference in the proportion of eyes requiring a second intravitreal injection of antibiotics whether the eye was managed primarily with intravitreal antibiotics alone versus early PPV plus intravitreal antibiotics (29.5% [18 eyes] vs. 25.0% [44 eyes], respectively). Adjunctive therapies in the form of intravitreal steroids, systemic steroids, and systemic antibiotics were used in 25.3%, 21.9%, and 66.6% of eyes, respectively. The absence of disc or macular view and absence of endophthalmitis after cataract surgery were associated with an increased likelihood for early PPV (odds ratios 4.1 and 5.1, respectively). Pars plana vitrectomy was frequently performed regardless of the presenting vision in eyes with endophthalmitis after cataract surgery and intravitreal injections. Increased vitreous opacification was associated with a higher probability for performing PPV.

Macular vessel reduction as predictor for recurrence of macular oedema requiring repeat intravitreal ranibizumab injection in eyes with branch retinal vein occlusion

AimTo determine whether there are factors that can predict the frequency of recurrences of macular oedema associated with branch retinal vein occlusion (BRVO).MethodsWe reviewed the medical records of 31 eyes...

Evolution of Intravitreal Therapy for Retinal Diseases—From CMV to CNV: The LXXIV Edward Jackson Memorial Lecture

To present the evolution of intravitreal therapy for retinal diseases and its impact on clinical practice. Retrospective literature review and personal perspective. Retrospective literature review and personal perspective. Pharmacotherapeutic advances in retinal disease have been remarkable over the last 25 years. Almost all of the new drugs developed have required intravitreal administration to be highly effective, leading to an exponential increase in the annual number of intravitreal injections given. The use of intravitreal antibiotic injections to treat endophthalmitis, usually on a one-time basis, first familiarized ophthalmologists with this method of drug delivery. Ganciclovir was the first widely available, relatively inexpensive compounded drug that was used for repeat intravitreal injection to treat a chronic retinal disease, followed by triamcinolone for diabetic macular edema and bevacizumab for neovascular age-related macular degeneration. Ganciclovir was formulated for sustained-release drug delivery to avoid frequent intravitreal injections, a goal that has been more elusive for anti-VEGF drugs. Political obstacles encountered while conducting some of the trials to evaluate these treatments were substantial. Addressing the issues they raised led to important national policy changes that will impact the conduct of future clinical trials. The first comparative efficacy trial of intravitreal therapies was the Comparison of AMD Treatments Trials (CATT). The primary results from CATT and the many publications that followed continue to shape the use of intravitreal therapy today. Intravitreal therapy has proven highly effective for the treatment of many retinal diseases. The treatment burden for patients from numerous injections, the cost to health care systems, and the impact on workflows in clinical practice have been substantial. Efforts to develop effective intravitreal therapies with reduced treatment burden and cost are ongoing.

An experience of management of cluster endophthalmitis in western hilly rural region of Nepal: A descriptive, interventional study

Infectious endophthalmitis is among the most serious complications of cataract surgery. Cluster endophthalmitis is defined as five or more cases of endophthalmitis occurring on a particular day in a single operating room in one centre. The study aimed to find out causative organisms, ocular status and visual outcome after an outbreak of cluster endophthalmitis in a high volume cataract surgery in a camp. A descriptive, interventional study was carried out in 18 suspected cases of acute endophthalmitis after manual small incision cataract surgery in a single day. All clinically suspected cases underwent vitreous tap and received intravitreal injections. Vitreous samples were sent for staining and KOH mount, culture, sub-culture and sensitivity test was carried out in all vitreous specimens. Standard treatment protocol was followed. Patients were followed up till six weeks. Of the 89 eyes operated, 18 (20.2%) eyes underwent vitreous tap and intravitreal injections. Mean duration of presentation was 36 hours (24 – 48 hours). Commonest presenting symptom was redness 18 (100%), pain 83.3% (15) followed by decreased vision 77.8% (14). 10 (55.6%) eyes were culture negatives while, 8 (44.4%) were culture positive for pseudomonas aeruginosa. Six (33.3%) eyes needed core vitrectomy and repeat intravitreal injections, whereas 2 (11.1%) eyes needed repeat intravitreal injections only. Eight eyes (44.4%) got a normal visual acuity; two eyes (11.1%) fair and 8 eyes (44.4%) had poor visual acuity according to World Health Organisation (WHO) guidelines. Four eyes (22.2%) needed evisceration, while three (16.7%) eyes progressed to phthisis bulbi. Acute post operative endophthalmitis is a serious complication following cataract surgery. Prognosis of cluster endophthalmitis with proven culture positivity to pseudomonas infection is poor even with prompt standard management.

CLINICAL EFFECTIVENESS OF NEUROTRANSMITTERS PATIENTS WITH PRIMARY GLAUCOMA VEGF INHIBITOR IN PATIENTS WITH CHOROIDAL NEOVASCULARIZATION CAUSED BY DEGENERATIVE MYOPIA

Purpose. Morphological and functional evaluation of results of intravitreal injections of ranibizumab in treatment of choroidal neovascularization (CNV) caused by degenerative myopia (DM). patients and methods. The study included 32 patients (32 eyes) aged from 29 to 55 years with the CNV, developed due to the DM. They received 0.5 mg (0.05 ml) ranibizumab according to the standard. Indications for repeat intravitreal injections of ranibizumab were retention of the CNV activity or its recurrence. In addition to the standard ophthalmologic examination all patients were examined with fluorescein angiography (FAG) with photodetection of fundus picture and optical coherence tomography (OCT) of the retina (sizing subretinal neovascular membrane (SNM), evaluation of retinal foveal thickness (FCS). The study was conducted before the introduction of ranibizumab, monthly during the first 6 months after surgery, and then, in the absence of symptoms of CNV activity, every 2-3 months. The total follow-up was 12 months. results. the transition the CNV in inactive form according to FAG was observed in 25 people (78.1%) was observed after 1 month (single injection of ranibizumab). The angiographic signs of CNV activity remained after the first injection in 7 patients (21/9%). They received second intravitreal injection of ranibizumab. After 3 months from the beginning of observation according to FAG and OCT data relapse of activity of myopic CNV occurred in 5 patients (15.6%) after a single injection, and in 2 patients (6.3%) — after a double injection of ranibizumab. After 6 months according to FAG disappearance of pathological leakage of the dye was diagnosed in 87.5% of patients (28 eyes). After 12 months follow-up all 32 patients had remission of the pathological process with no evidence of CNV activity with formation of local subretinal fibrosis with choriocapillaries atrophy. Conclusions. It took from 1 to 3 (average 1.58) injections of ranibizumab to transfer the active phase of the CNV in inactive. Complete inhibition of the growth and activity of myopic CNV was accompanied by positive morphological and functional results, which led to a significant improvement in visual acuity in 2 times at the observation period of 12 months.

The accuracy of home monitoring to detect disease activity during maintenance therapy for neovascular ARMD.

To report the reproducibility, sensitivity, specificity, and predictive value of home monitoring for disease activity in neovascular age-related macular degeneration (ARMD). Participants were trained to complete three separate home monitoring tasks, designed to identify subtle changes in visual function that may indicate increasing neovascular ARMD disease activity. These included measurement of near acuity and assessments of environmental distortion and overall visual function. The need for repeat intra-vitreal injection, as predicted by home monitoring, was compared to standard clinical assessment involving ETDRS distance acuity, slit lamp examination, and spectral domain ocular coherence tomography. Although all participants were able to complete the home monitoring tasks, the reproducibility of each of the three tasks was modest. Cohen's kappa was 0.118 (p = 0.54) for the comparison of the outcome of the home monitoring exercise with the gold standard of hospital assessment to determine disease activity. The sensitivity of the home monitoring exercise was 33.3 % (95 % CI 15.2-51.4) and the specificity was 77.8 % (95 % CI 61.8-93.8). This study suggests that current tests of visual function, which are readily completed at home, cannot replace traditional clinic-based assessments for neovascular ARMD disease activity. Instead, such tests are likely to remain complementary to standard assessment in clinic.

Intravitreal bevacizumab (Avastin) with peripheral retinal cryotherapy for patients with posterior retinopathy of prematurity and vitreous hemorrhage

Purpose To report the short-term anatomic response of intravitreal bevacizumab (Avastin) and peripheral cryotherapy for the treatment of posterior retinopathy of prematurity (ROP) with vitreous hemorrhage in a small series of patients. Patients and methods This was a retrospective study that included 19 eyes of 14 premature babies with posterior ROP and vitreous hemorrhage in whom conventional laser treatment could not be applied. Patients received an intravitreal injection of bevacizumab (Avastin) together with peripheral retinal cryotherapy. Results Vascularization began to regress within a few days after the injection, but vitreous hemorrhage absorbed more slowly. Repeat intravitreal injections of bevacizumab were administered in eight eyes within 1 month from the first injection. There were varying development of tractional retinal detachments in two of the eyes, but the ROP component quieted in all cases. Conclusion Off-label use of intravitreal bevacizumab with peripheral retinal cryotherapy appears to be useful as a treatment for posterior ROP when laser treatment is precluded. It improves dilatation, regressing and quiescent the disease, and improves visibility.

Three Consecutive Monthly Intravitreal Ranibizumab for Choroidal Neovascularization in Central Serous Choriorethinopathy: A Case Report

Purpose: The author report the result of three consecutive monthly intravitreal ranibizumab injection for choroidal neovascularization (CNV) after bevacizumab injection for chronic central serous rethinopathy (CSR). Methods: A 48 year old man with chronic CSR was treated with intravitreal single dose 2.5 mg bevacizumab. One year after CNV was occurred, and three consecutive monthly intravitreal ranibizumab injections were performed. Results: Four weeks later the first ranibizumab dose, best corrected visual acuity was improved 20/80 to 20/20 and remained stable within one year. Conclusion: Repeat intravitreal ranibizumab injection in CNV after bevacizumab injection for chronic CSR appeared to be an effective treatment option.

Repeat intravitreal triamcinolone acetonide injections in uveitic macular oedema

Editor, Cystoid macular oedema (CME) is the most significant cause of visual loss associated with uveitis (Rothova et al. 1996). Intravitreal triamcinolone (IVTA) has been used successfully as a primary treatment, particularly in unilateral disease, but a single injection lasts only approximately 3 months, and 15–30% of patients develop cataract and 25–45% of patients develop elevated intraocular pressure (IOP) (Kok et al. 2005; van Kooij et al. 2006). Studies investigating repeat IVTA injections in other conditions such as diabetic macular oedema have suggested that they become less effective with time and generate increasing problems with IOP (Chan et al. 2006; Gillies et al. 2007), but there is little evidence regarding the outcome of repeat injections in uveitis. This study was designed to address these issues and to determine whether repeated IVTA injections are a viable treatment option for recurrent uveitic CME. We report a retrospective, consecutive case series of 41 eyes of 35 patients with uveitis recruited from two tertiary referral uveitis clinics. Included eyes had CME proven on optical coherence tomography or fluorescein angiography, were given at least two IVTA injections and were followed up for at least 3 months following their last injection. All injections were given as 4 mg/0.1 ml triamcinolone acetonide (Kenalog), taken straight from the vial. Repeat injections were given in responsive patients if CME recurred, but were not repeated in patients with a marked steroid response. The study was approved by the Research Governance Committee of Moorfields Eye Hospital (LIGS1021) and the Institutional Review Board of Sydney Eye Hospital. Following the first IVTA injection, CME resolved in 36 of 41 eyes (88%) in a mean of 5 weeks (range 1–14 weeks), but recurred in all eyes at a mean of 7 months (range 2–23 months). After the second injection, CME improved in 31 of 41 eyes (76%), but recurred in 25 eyes at a mean of 5 months (range 1–13 months). Twenty patients had a third IVTA injection, and 10 patients had more than three injections. There was a statistically significant improvement in visual acuity after each injection (p < 0.01), with no evidence of reducing efficacy (Fig. 1A). Response to repeat intravitreal injections of triamcinolone acetonide. In (A) mean ± SEM improvement in logMAR visual acuity is shown, indicating no reduction in effect with repeat injections. In (B), the number of patients with IOP which increased to >21 and ≥30 mmHg is indicated. Note that patients with a marked steroid response were not offered further injections, so the number of patients with a steroid response declines over time. Nineteen of 41 eyes (46%) had an IOP increase of 10 mmHg or more from baseline, and 10 eyes (25%) developed an IOP >30 mmHg. However, no eyes required IOP-lowering surgery, and the magnitude of IOP changes did not increase with repeat injections, although patients with a marked steroid response were not offered further injections (Fig. 1B). As expected, repeat IVTA injections were associated with cataract (p < 0.01), and by the time of the fifth IVTA injection, all phakic patients had undergone cataract surgery (Fig. 2). IVTA injection otherwise had a good safety profile: from a total of 118 IVTA injections, only one eye developed IVTA-induced sterile endophthalmitis, and there were no other severe adverse events. Cataract surgery following repeat intravitreal triamcinolone (IVTA) acetonide injections. Kaplan–Meier survival to cataract surgery is shown, indicating that all phakic patients developed visually significant cataract requiring surgery by the fifth IVTA injection. Nineteen patients were being treated with systemic therapy at the start of the study. The mean dose of systemic prednisolone required to control the disease decreased significantly over the course of the study to <7.5 mg/day (Fig. 3), and 11 patients were able to reduce significantly or stop their second-line agents. Systemic immunosuppression. Doses of systemic corticosteroids are indicated (mean ± SEM) and indicate a significant reduction over time to long-term sustainable levels of ≤7.5 mg prednisolone per day. This study demonstrates the effects of repeated intravitreal triamcinolone injections in patients with uveitic CME: best corrected visual acuity (BCVA) improves, with no evidence of tachyphylaxis, and systemic immunosuppressive therapy can be withdrawn in some patients. However, all patients eventually develop cataract, and IOP-lowering medication is needed in nearly 50% of eyes. In summary, repeat IVTA treatment in patients with recurrent uveitic CME is associated with a repeatable improvement in visual acuity and is thus a viable treatment option for recurrent disease.

Foveal atrophy and macular hole formation following intravitreal ranibizumab with/without photodynamic therapy for choroidal neovascularization secondary to age-related macular degeneration

Background:To report the occurrence of foveal atrophy and macular hole formation following intravitreal ranibizumab with or without photodynamic therapy for choroidal neovascularization caused by age-related macular degeneration.Methods:This was a retrospective, interventional case series, in which 78 eyes of 76 patients were treated for wet age-related macular degeneration between February 2007 and August 2007. Of these, three eyes developed foveal atrophy following treatment. Two eyes underwent combination photodynamic therapy and intravitreal ranibizumab, and one eye underwent intravitreal ranibizumab alone. One of the two eyes that underwent combination therapy progressed to develop a macular hole.Results:On the first follow-up visit, all three eyes showed thinning of the fovea on optical coherence tomography. Subsequently, treatment was continued with repeat intravitreal ranibizumab injections. At the last follow-up, although choroidal neovascularization regressed in all eyes, extensive foveal atrophy developed in two eyes with macular hole formation in one eye.Conclusion:The possibility of foveal atrophy and macular hole formation must be borne in mind before initiating ranibizumab in combination with or without photodynamic therapy. However, larger studies with longer follow-up are required to understand such adverse effects better.

Intravitreal ranibizumab and bevacizumab to treat diabetic macular edema

Abstract Purpose To report the comparative efficacy of intravitreal bevacizumab and ranibizumab in the treatment of diabetic macular oedema (DME). Methods Interventional, case report series. Two patients who were on treatment for DME by monthly intravitreal ranibizumab in one eye, were started on treatment by intravitreal bevacizumab for DME in the fellow eye. The patients were monthly evaluated by complete ocular examination, best corrected visual acuity (BCVA) performed by certified optometrists and Stratus optical coherence tomography (OCT). Results Eyes treated by intravitreal ranibizumab showed a complete resolution of DME as documented by OCT and significantly improved BCVA. DME recurred after two to three months requiring further injections. The fellow eyes showed a progression of DME and decreased BCVA while untreated. Intravitreal bevacizumab did not induce any significant change in macular thickness or BCVA and did not prevent DME progression. Conclusion Intravitreal ranibizumab seems to improve BCVA and macular thickness in DME though recurrence of the condition makes it necessary to repeat intravitreal injections. Intravitreal bevacizumab does not seem to reduce macular thickness or improve visual function in patients with DME in whom good results had been observed after intravitreal ranibizumab. Commercial interest

SAFETY OF REPEAT INTRAVITREAL INJECTIONS OF BEVACIZUMAB VERSUS RANIBIZUMAB

To compare the safety of repeat intravitreal injections of bevacizumab versus ranibizumab performed on a large series of patients during the past 2 years period of time. Four hundred fifty patients receiving 2,000 injections (1,275 bevacizumab and 725 ranibizumab) were studied retrospectively. Injections performed in a usual examination room under the standard sterile conditions. Follow-up varied from 3 to 24 months. Serious ocular adverse events were uncommon. Only one patient developed retinal detachment (0.05%). Most common procedure-related ocular adverse event was injection-site redness (64.75%). Postoperative subconjuctival hemorrhage occurred after 200 (10%) injections. Patients receiving aspirin treatment were more prone to have subconjuctival hemorrhage (P = 0.0002). Most common drug-related ocular adverse event was uveitis (1.90%), which was treated successfully and lasted no >12 days. There was no statistically significant difference between the patients treated with bevacizumab or ranibizumab regarding the noted adverse events (P > 0.5%). Multiple intravitreal injections of bevacizumab or ranibizumab were both well tolerated and safe. Performing injections on a usual examination room proved safe. Injection-site redness, subconjuctival hemorrhage, and uveitis were the most common ocular adverse events. Aspirin treatment was a risk factor for the development of subconjuctival hemorrhage.