Anti-VEGF agents beneficial to RVO

Vascular endothelial growth factor (VEGF) antagonists may provide significant longterm benefit to patients with macular oedema caused by branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), said Dr Peter A. Campochiaro, at the Macula 2011 and Atlantic Coast Retina Club meeting of the Wills Eye Institute.

"Previously, grid laser therapy was the only available treatment for macular oedema caused by BRVO and there was no treatment for macular oedema caused by CRVO," said Dr Campochiaro, professor, Department of Ophthalmology, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine, Baltimore.

But two large phase III studies, BRAVO for patients with BRVO and CRUISE for patients with CRVO, have now demonstrated that ranibizumab (Lucentis, Genentech) provides benefit in both conditions.

Patients were given six monthly injections of 0.3 mg or 0.5 mg of ranibizumab or sham.

At the month 6 primary endpoint in BRAVO, patients in the two ranibizumab groups showed a mean improvement in ETDRS letter score of 18.3 (0.5 mg) and 16.6 (0.3 mg) compared with 7.3 in the sham group.

During the next 6 months, patients in all three groups were evaluated each month and could receive an injection of ranibizumab if they met re-treatment criteria. This 'treatment as needed' protocol provided good maintenance of visual gains in the ranibizumab groups; the change from baseline in ETDRS letter score at month 12 was 18.3 (0.5 mg) and 16.4 (0.3 mg).

It also resulted in substantial improvement in the sham group for which the change from baseline letter score at month 12 was 12.1.

At the month 6 primary endpoint in CRUISE, patients in the two ranibizumab groups showed a mean improvement in ETDRS letter score of 14.9 (0.5 mg) and 12.7 (0.3 mg), compared with 0.8 in the sham group.

During the next 6 months, patients in all three groups received 'treatment as needed', and it provided good maintenance of visual gains in the ranibizumab groups; the mean change from baseline in ETDRS letter score at month 12 was 13.9 (0.5 mg) and 13.9 (0.3 mg).

It also resulted in substantial improvement in the sham group for which the mean change from baseline letter score at month 12 was 7.3.

The only data available for time points longer than 1 year are from relatively small pilot trials. Twenty patients with BRVO given three monthly injections of ranibizumab had a mean improvement of 16.1 letters. After that, they were seen every 2 months and were given an injection of ranibizumab if foveal thickness was ≥250 µm with optical coherence tomography (OCT) (Stratus III, Carl Zeiss Meditec).

At month 24, the mean improvement in BCVA was 17.8 letters, 60% had a Snellen equivalent of 20/40 or better, and 65% had foveal thickness ≤250 µm. This indicates that visits every 2 months with injections of ranibizumab as needed is sufficient to control oedema and maintain vision in patients with BRVO.