First Author: C.Quijano UK
Co Author(s): S. Younis A. Hamoud
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Central retinal vein occlusion (CRVO) is a common retinal vascular disorder that can cause macular oedema (MO) and visual loss, MO is the most common cause of sight loss in CRVO. Various treatment modalities have been used to block the different pathways of macular oedema pathogenesis with improvement of vision. The most effective way is still unknown. However, vascular endothelial growth factor (VEGF) inhibitors and intraocular steroids showed promising results. New researches proved that delayed treatment is associated with worse visual outcomes. In our study we compared the efficacy and safety of intravitreal injections of three anti-VEGFs and one steroid.
The study was conducted on 68 patients attending the Macula Clinic at the Western Eye Hospital, London UK over a period of 2 years.
A retrospective review of the clinical notes of 68 patients diagnosed with macular oedema secondary to CRVO treated at the Western Eye Hospital was performed. We collected data of 17 patients that received 2.5 mg/0.05ml of Aflibercept (Group 1), 17 patients that received 0.5mg/0.05ml of ranibizumab (Group 2), 17 patients that received 1.25 mg/0.05ml of bevacizumab (Group 3) and 17 patients that were treated with a 0.7 mg dexamethasone implant (Group 4). Study assessment included age, gender, past medical history, changes of best corrected visual acuity (BCVA) measured in LogMAR pre and post treatment, changes of the central retinal thickness (CRT) measured by Cirrus HD-OCT pre and post treatment, number of injections and number of months treated. Complications and side effects were also recorded. P values <0.05 were considered significant.
There were 17 patients in each of the four groups. The mean age at ba (yr) in Group 1, 69 yr in Group 2, 74yr in Group 3, and 63yr in Group 4. The BCVA changed from baseline to the last visit control from 0.93±0.45 to 0.63±0.43 LogMAR (P<0.02) in Group 1, 0.97±0.48 to 0.63±0.38 LogMAR (P<0.002) in Group 2, 1.39±0.53 to 1.16±0.56 LogMAR (P<0.069) in Group 3, 0.97±0.56 to 0.79±0.49 LogMAR(P<0.04) in Group 4. The OCT changed from baseline to the last visit control from 521±261 to 262±76 microns (P<0.0001) in Group 1, 766±165 to 321±118 microns (P<0.000002) in Group 2, 524±178 to 339±189 microns (P<000044) in Group 3, 491±194 to 414±182 microns (P< 0.136) in Group 4. The number of injection over the months treated was 5.7/9.5 in Group 1, 6.4/8.9 in Group 2, 3.5/6.7 in Group 3, 2.2/8.4 in Group 4. There were no reported complications or side effects in 1, 2, 3 group. In Group 4 (patients treated with Dexamethasone) 40% had a rise in the IOP that required topical antiglaucomatous medication. Also and 33% developed worse BCVA seen in the last follow up and this was correlated to cataract development.
Our research demonstrates that intravitreal anti-VEGF is an effective and safe treatment for macular oedema in CRVO. The ranibizumab and aflibercept group showed the most significant improvement of CRT. Aflibercept the one with less number of injections. The bevacizumab group showed significant reduction in CRT, however the change of the BCVA was not significant. Dexamethasone was less effective in reducing CRT when compared to the anti-VEGF groups and this reduction was not significant. The BCVA did not improved in 33% of the cases because they developed lens opacification after a second Dexamethasone intravitreal implant and 40% of the patients experienced a rise in intraocular pressure that required topical antihypertensive therapy. Our results suggest that intravitreal administration of aflibercept and ranibizumab is more effective in the treatment of MO associated to CRVO compared to bevacizumab intravitreal injection and dexamethasone implant. However, we have to take into account that the patients receiving Avastin® as initial treatment have poor presenting BCVA (used as per guidelines of the Royal College of Ophthalmologists) so the results of the BCVA compare to the other groups can be underestimated. The dexamethasone implant group showed a short-term efficacy but an association with a higher frequency of adverse events