Session Title: Vascular Diseases and Diabetic Retinopathy IV
Session Date/Time: Sunday 20/09/2015 | 09:00-10:30
Paper Time: 09:24
First Author: : P.Cikatricis UNITED KINGDOM
Co Author(s): : A. Sarmad B. Mushtaq S. Elsherbiny A. Mitra Y. Yang P. Lip
PURPOSE:Published trial results on RVO macular oedema (CMO) using intravitreal single-agents are effective but require up to 9 injections in the first year to stabilise CMO. We hypothesized that a combination therapies of an anti-VEGF agent and steroid injections plus laser could yield compatible good anatomical and visual outcomes and need less injections per year. In the RandO study, we investigated a treatment pathway for all new worsening RVOs with or without CMO, aiming primarily to eliminate ischaemia with anti-VEGF and laser; and CMO with anti-VEGF or Ozurdex.
All new referrals were seen within one month, in a newly established fast-track RVO clinic. Standard assessments included LogMAR vision, slit-lamp biomicroscopy, OCT scan, fluorescein angiogram, intraocular pressure and BP recordings. Intravitreal procedure was performed within 2 weeks in aseptic setting. Review intervals were 4 weekly.
Prospective data collection and analysis on all new RVOs who were treated using the RandO pathway, with up to one year’s review. In RandO pathway, RVO patients with CMO received Ranibizumab loading standard dose of three injections in first three months. Ischaemia and CMO were assessed at each clinic visit. The patient received Ozurdex if CMO showed inadequate response or recurrence. Ranibizumab and laser were given if ischaemia persisted. RVO patients without CMO were initially observed and only received Bevacizumab (loading standard dose of three injections in first three months) if retinopathy worsened. Laser was also applied to ischaemic eyes in this group, and patients would receive the RandO regime if CMO subsequently developed. Vision (Va) and central retinal thickness (CRT) were recorded at baseline and one year, and compared using a paired Wilcoxon test. Number of injections per year and adverse effects were documented.
Forty treatment-naïve RVOs (CRVO:HRVO:BRVO=17:4:19) were studied. Mean age was 67.3 (range 30 to 87). Twenty-seven RVOs presented with CMO; thirteen initial RVOs without CMO were under observation and 8/13 had worsened and received either Bevacizumab or the RandO regime. There were initial 7 RVOs without CMO who received Bevacizumab, only 2 progressed to develop CMO. Our cohort RVOs presented with a wide clinical spectrum: one was rubeotic glaucoma and one was vitreous haemorrhage from neovascularisation. Based on the final total of 30 who received the RandO regime: (i) Baseline Va of 0.60[IQR 0.36-1.00], significantly improved to 0.46[IQR 0.18-0.78] (p=0.033] at 1 year; (ii) Va improvement by 1-line was 63% (by 3-lines was 37%); (iii) Baseline median CRT was 529μm[IQR 479-603], and was significantly reduced to 232μm[IQR 217-253] (p<0.001) at 1 year (97% improved CRT, 76% dry fovea). For all RVOs receiving injections in this cohort, mean number of injections required per year was 5.5 (range 2 to 9); 28% needed ≥7 injections; 76% received Ozurdex and 77% received laser. Adverse effects: 22% with ocular hypertension, and no endophthalmitis. Fifteen percent (6/40) underwent cataract surgery: 5/6 (83%) had worsened CMO or retinopathy at first post-operative review.
Staged combination therapies are effective in treating RVO CMO with less injections needed in one year. Disease severity is related to higher rate of injections needed. The RandO treatment regime offers an effective treatment management strategy for patients with retinal vein occlusions. Assessing and treating ischaemia may enhance early stabilisation of disease. Caution in timing for a cataract procedure in RVO patient who receives active treatment. Capturing and treating RVO retinopathy early before CMO develops may potentially halt the disease progression and prevent complications that require endless interventions.