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Relating to long-term effects of anti-VEGF agents on the retinal circulation,
Mir et al. recently reported a promoting effect on the improvement of
retinal nonperfusion in RVO patients following monthly ranibizumab
injections. 19 This is an interesting aspect, but up to now, no data on long-
term (>36 months) observation exist.
As a rationale for combining or switching drugs or therapeutic methods
one could mention the risk of cumulative toxicity and tachyphylaxis
following repeated monotherapy. Unfortunately, limited evidence for
combination therapy exists. Unpublished data (Wirth et al., Aflibercept
in Branch Retinal Vein Occlusion – clinical outcome 12 months after
changing treatment from bevacizumab/ranibizumab) did show a
prolongation of retreatment intervals, as well as beneficial functional
and anatomic changes after switching from bevacizumab and/or
ranibizumab to aflibercept.
Combination of steroids and anti-VEGF agents may be of significance
in recalcitrant ME, but its superiority (over anti-VEGF alone) remains
to be elucidated. Likewise, up to now, no studies have evaluated the
outcome of anti-VEGF injections alone versus anti-VEGF plus laser
photocoagulation. Apart from that, panretinal laser photocoagulation
1. Klein R, MS, Meuer SM, Klein BE, The 15-year cumulative
incidence of retinal vein occlusion: the Beaver Dam Eye
Study, Arch Ophthalmol, 2008;126:513–8.
2. Hayreh SS, Zimmerman B, McCarthy MJ, Podhajsky P,
Systemic diseases associated with various types of retinal
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3. Nobre Cardoso J, Keane PA, Sim DA, et al., Systematic
evaluation of optical coherence tomography angiography in
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4. Cheung N, Klein R, Wang JJ, et al., Traditional and novel
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5. Hayreh SS, Zimmerman MB, Podhajsky P, Hematologic
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26 was not found to reduce the total VEGF load in BRVO eyes. 20 However,
a recent study indicated that the addition of scatter photocoagulation
to ranibizumab may reduce progression of retinal nonperfusion in
patients with BRVO. 19
To summarise, the achievement of a potential synergistic effect by
combination of different interventions requires further study.
According to the SHORE and HORIZON studies, there is no superiority
in pro re nata (PRN) versus monthly treatment. 21,22 The treat and extend
regimen represents a popular option in clinical practice and has been
shown to reduce treatment burden and associated costs. 23 Initiating
treatment immediately after diagnosis may provide the highest vision
gains. 24 Long-term follow-up data from the RETAIN study demonstrated
that 50% of eyes still required anti-VEGF injections in regular intervals. 25
To date, we have no final answer on the required duration of treatment.
In conclusion, we are fortunate in having a battery of therapeutic
methods available. However, for evidence-based management of BRVO,
larger comparative studies are needed to conclusively evaluate different
therapeutic options as well as their combinations. n
Ophthalmol Vis Sci, 2009;50:1025–32.
11. Noma H, Funatsu H, Yamasaki M, et al., Aqueous humour
levels of cytokines are correlated to vitreous levels and
severity of macular oedema in branch retinal vein occlusion,
Eye (Lond), 2008;22:42–8.
12. Campochiaro PA, Brown DM, Awh CC, et al., Sustained
benefits from ranibizumab for macular edema following
central retinal vein occlusion: twelve-month outcomes of a
phase III study, Ophthalmology, 2011;118:2041–9.
13. Clark WL, Boyer DS, Heier JS, et al., Intravitreal aflibercept
for macular edema following branch retinal vein occlusion:
52-week results of the VIBRANT study, Ophthalmology,
2016;123:330–6. 14. Haller JA, Bandello F, Belfort R Jr, et al., Dexamethasone
intravitreal implant in patients with macular edema related to
branch or central retinal vein occlusion twelve-month study
results, Ophthalmology, 2011;118:2453–60.
15. Ip MS, Scott IU, VanVeldhuisen PC, et al., A randomized
trial comparing the efficacy and safety of intravitreal
triamcinolone with observation to treat vision loss associated
with macular edema secondary to central retinal vein
occlusion: the Standard Care vs Corticosteroid for Retinal
Vein Occlusion (SCORE) study report 5, Arch Ophthalmol,
2009;127:1101–14. 16. Vujosevic S, Midena E, Controversies in pharmacological
treatment of inflammatory component of macular edema,
Curr Pharm Des, 2015;21:4688–93.
17. Garweg JG, Zandi S, Retinal vein occlusion and the use of
a dexamethasone intravitreal implant (Ozurdex(R)) in its
treatment, Graefes Arch Clin Exp Ophthalmol, 2016;254:1257.
18. Wang JK, Su PY, Hsu YR, et al., Comparison of the efficacy of
25. intravitreal aflibercept and bevacizumab for macular edema
secondary to branch retinal vein occlusion, J Ophthalmol,
2016;8421940. Mir TA, Kherani S, Hafiz G, et al., Changes in retinal
nonperfusion associated with suppression of vascular
endothelial growth factor in retinal vein occlusion,
Campochiaro PA, Hafiz G, Mir TA, et al., Scatter
photocoagulation does not reduce macular edema or
treatment burden in patients with retinal vein occlusion: the
RELATE trial, Ophthalmology, 2015;122:1426–37.
Campochiaro PA, Wykoff CC, Singer M, et al., Monthly
versus as-needed ranibizumab injections in patients with
retinal vein occlusion: the SHORE study, Ophthalmology,
2014;121:2432–42. Heier JS, Campochiaro PA, Yau L, et al., Ranibizumab for
macular edema due to retinal vein occlusions: long-term
follow-up in the HORIZON trial, Ophthalmology, 2012;119:802–
9. Rush RB, Simunovic MP, Aragon AV 2nd, Ysasaga JE, Treat-
and-extend intravitreal bevacizumab for branch retinal
vein occlusion, Ophthalmic Surg Lasers Imaging Retina,
2014;45:212–6. Thach AB, Yau L, Hoang C, Tuomi L, Time to clinically
significant visual acuity gains after ranibizumab treatment
for retinal vein occlusion: BRAVO and CRUISE trials,
Campochiaro PA, Sophie R, Pearlman J, et al., Long-term
outcomes in patients with retinal vein occlusion treated
with ranibizumab: the RETAIN study, Ophthalmology,
2014;121:209–19. EUR OP EAN OP H TH ALMIC RE VIE W