Switch to aflibercept or ranibizumab after initial treatment with bevacizumab in eyes with neovascular AMD.

BACKGROUND: To evaluate changes in central macular thickness (CMT) and visual outcome in patients with neovascular age-related macular degeneration (AMD) treated initially with bevacizumab and subsequently switched to either aflibercept or ranibizumab. METHODS: Observational clinical study was performed. We measured the structural outcome (CMT on SD-OCT; µm) and the visual outcome (best corrected visual acuity (BCVA); logMAR), as follows: before treatment (at baseline), following bevacizumab treatment (switch follow-up) and after switching from bevacizumab to aflibercept- or ranibizumab treatment (final follow-up, AG/, RG). RESULTS: From a total of 96 eyes treated with intravitreal injections of bevacizumab (10.5 ± 7.6 (mean ± SD)), 58 eyes switched to aflibercept (6.5 ± 3.9; AG) and 38 eyes switched to ranibizumab (7.1 ± 5.3; RG) (≥ 3 injections, each). In addition, these eyes were compared to 37 eyes under bevacizumab monotherapy. PRIMARY OUTCOME: In the AG, the CMT decreased slightly from 430 ± 220 µm at baseline to 419 ± 212 µm at switch follow-up (p = 0.86), but decreased significantly to 318 ± 159 µm at final follow-up, AG (p < 0.0001). In the ranibizumab group (RG), the CMT increased from 396 ± 174 µm at baseline to 499 ± 333 µm at switch follow-up (p = 0.012), but decreased significantly to 394 ± 202 µm at final follow-up, RG (p = 0.007). Secondary outcome: In the AG, the mean BCVA worsened from logMAR 0.57 ± 0.33 at baseline to 0.63 ± 0.30 at switch follow-up and improved slightly to 0.53 ± 0.71 at final follow-up, AG (p = 0.46). In the RG, mean BCVA worsened from 0.57 ± 0.28 at baseline to 0.64 ± 0.31 at switch follow-up and improved slightly to 0.60 ± 0.36 at final follow-up, RG (p = 0.64). CONCLUSION: Switching from bevacizumab to either aflibercept, or ranibizumab, has a strong anatomical effect in eyes with neovascular AMD. Nevertheless, even if the switch to aflibercept shows a minimal functional benefit over that to ranibizumab, visual prognosis remains limited.

Efficacy of Vitrectomy Combined with Subretinal Recombinant Tissue Plasminogen Activator for Subretinal versus Subpigment Epithelial versus Combined Hemorrhages.

BACKGROUND: The aim of this study was to compare the outcomes after subretinal recombinant tissue plasminogen activator (rtPA) treatment for subretinal hemorrhages (SRH), subpigment epithelial hemorrhages (SPH), and combined subretinal and subpigment epithelial hemorrhages (CH). METHODS: An observational analysis of patients treated with subretinal rtPA was performed. The primary endpoint was the assessment of visual improvement (best-corrected visual acuity, BCVA) after surgery. Secondary endpoints were evaluation of the maximal hemorrhage diameter (MHD) and central macular thickness (CMT) measured by spectral domain optical coherence tomography. RESULTS: From a total of 83 eyes included in the study, 19 eyes showed SRH, 11 eyes SPH, and 53 eyes CH. For SRH and CH, the mean BCVA, MHD, and CMT improved significantly (p < 0.05). For patients with SPH, both the mean MHD and CMT decreased significantly (p < 0.05), whereas the mean BCVA improved only slightly after surgery (p = 0.28). CONCLUSION: Vitrectomy combined with subretinal rtPA injection and gas or air tamponade has a strong functional and anatomical effect on both SRH and CH and also seems to slightly improve the anatomical outcome in SPH.

Response to bevacizumab after treatment with aflibercept in eyes with neovascular AMD.

PURPOSE: To study the visual outcome and change in central macular thickness (CMT) in patients with neovascular age-related macular degeneration (AMD) who were previously treated with aflibercept (VEGF Trap-Eye, Eylea) and were subsequently switched to bevacizumab (Avastin). METHODS: In this observational analysis, 19 eyes initially treated with at least 3 injections of bevacizumab after initial treatment with at least 3 injections of aflibercept are reported. Outcome measures were Snellen visual acuity (best-corrected visual acuity (BCVA) and CMT measured by spectral-domain optical coherence tomography. RESULTS: A total of 19 eyes initially treated with 6.5 ± 2.8 intravitreal injections of aflibercept were switched to 5.4 ± 3.2 injections of bevacizumab. Median BCVA decreased from 20/94 to 20/113 after aflibercept and increased slightly to 20/101 after bevacizumab (p = 0.84, Friedman test). Of all 19 eyes, 36.8% achieved gain in visual acuity of more than 1 line and 21.1% of more than 3 lines. The CMT decreased slightly from 433 ± 229 µm at baseline to 367 ± 198 µm after aflibercept treatment (p = 0.18, Wilcoxon test) and decreased statistically significantly to 335 ± 184 µm after bevacizumab treatment (p = 0.0065, Wilcoxon test). CONCLUSIONS: Switching from aflibercept to bevacizumab treatment has an equivalent anatomical effect in eyes with neovascular AMD as switching from bevacizumab to aflibercept. Therefore, switching back to bevacizumab might represent a reasonable therapy strategy to overcome tachyphylaxis during long-term monotherapy with aflibercept.

Evaluation of fixation pattern and reading ability in patients with Leber hereditary optic neuropathy.

BACKGROUND: Leber hereditary optic neuropathy (LHON) is characterized by progressive loss of central vision leading to impaired reading ability. The aim of this study was to evaluate sensory adaptation and reading ability in LHON patients. METHODS: This prospective pilot study included 12 male patients with a clinical diagnosis and a positive genetic analysis of LHON, who matched the inclusion criteria of a central scotoma on visual field testing and the use of magnifying aids to read. Examination included best-corrected visual acuity, magnification need, reading speed, and evaluation of fixation by corneal reflexes and by Rodenstock scanning laser ophthalmoscope (SLO). Central scotoma was assessed by conventional perimetry (Tübingen Automated Perimeter) and microperimetry (NIDEK MP1). RESULTS: Mean magnification need was 13.2 ± 7.3-fold (range: 2- to 25-fold). Mean reading speed was 53 ± 18 words per minute (WPM) (range: 24-85 WPM). With automated perimetry, all patients showed central scotomas with a mean radius of 13° ± 7° (range: 1°-30°) in the better eye. Microperimetry in all patients showed fenestrated central scotomas. Eccentric fixation with a preferred retinal locus (PRL) was detected with SLO examination and microperimetry correlated well in 11 of 12 patients. The SLO results showed no systematic pattern in the placement of the PRL; however, 7 of 12 patients (58%) placed their PRL in an unfavorable location left or below the fovea. In 8 of 12 patients, fixation was unstable. Between reading speed and central scotoma size, there was a statistically significant negative correlation (P = 0.021, r = -0.65). CONCLUSIONS: The percentage of unfavorable PRL locations was extremely high compared with other disorders with central scotomas. Unstable fixation and fenestrated central scotomas led to difficulties in reading. Early rehabilitation and, if necessary, eccentric viewing training should be considered in LHON patients.