Ophthalmology. Retina最新文献

Topic: This systematic review and meta-analysis investigates the efficacy and safety of anti-VEGF injections compared with surgical intervention in improving visual acuity (VA) and reducing complications for patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (AMD).

Clinical relevance: Determining the optimal intervention for SMH in AMD is crucial for patient care.

Methods: We included studies on anti-VEGF injections or surgical interventions for SMH in AMD from 7 databases, searched up to May 2024. Data extraction and quality assessment were done by 2 independent reviewers. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis employed random-effects models. Primary outcomes were pooled mean logarithm of the minimum angle of resolution VA difference (initial examination minus last follow-up VA) and adverse events rates.

Results: A total of 43 observational studies were included: 21 (960 eyes) on anti-VEGF and 22 (455 eyes) on surgery. Comparisons were made across separate studies due to lack of head-to-head studies. Meta-analysis included 11 anti-VEGF studies (444 eyes) and 12 surgical studies (195 eyes) for VA outcomes. The mean difference in VA was -0.16 (95% confidence interval (CI), -0.24 to -0.08) for anti-VEGF and -0.36 (95% CI, -0.68 to -0.04) for surgery, with no significant difference between groups (chi-square = 1.70, df = 1, P = 0.19). Heterogeneity was high in surgical studies (I² = 96.2%, τ² = 0.23, P < 0.01) and negligible in anti-VEGF studies (I² = 7%, τ² = 0.003, P = 0.38). The GRADE certainty was moderate for anti-VEGF and low for surgery. Anti-VEGF had lower rates of cataract (0% vs. 4.6%), proliferative vitreoretinopathy (0.1% vs. 2.0%), and retinal detachment (0.1% vs. 10.6%), but similar rates of recurrent hemorrhage (5.4% vs. 5.3%). Complications were summarized descriptively due to zero-cell problem.

Conclusion: Both anti-VEGF and surgery treat SMH in AMD with similar VA outcomes but different safety profiles. Anti-VEGF is preferred for less severe hemorrhage, whereas surgery is suited for extensive hemorrhage. Despite uncertain comparative VA outcomes, treatment should be guided by clinical judgment and patient factors.

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective: To compare the efficacy of brolucizumab and aflibercept treatment in reducing the maximum thickness of pigment epithelial detachments (PEDs) and sub-retinal pigment epithelium (sub-RPE) fluid in patients with neovascular age-related macular degeneration in the HAWK and HARRIER studies.

Design: HAWK and HARRIER were 96-week, prospective, randomized, double-masked, controlled, multicenter studies.

Participants: A total of 1775 patients across 11 countries were included in the HAWK study, and 1048 patients across 29 countries were included in the HARRIER study.

Intervention: After 3 monthly loading doses, brolucizumab-treated eyes received injections every 12 weeks or every 8 weeks if disease activity (DA) was detected. Aflibercept-treated eyes received fixed 8-week dosing.

Main outcome measures: Maximum thickness of PEDs and sub-RPE fluid across the macula were assessed at baseline through week 96 in the brolucizumab- and aflibercept-treated patients and in the patient subgroups with DA at week 16 (matched in terms of injection number and treatment interval).

Results: At week 96, there were greater mean percentage reductions from baseline in maximum thickness of both PEDs and sub-RPE fluid in brolucizumab-treated patients vs. aflibercept-treated patients (PED: 19.7% [n = 336] vs. 11.9% [n = 335] in HAWK; 29.5% [n = 364] vs. 18.3% [n = 361] in HARRIER. Sub-RPE fluid: 75.4% vs. 57.3% in HAWK; 86.0% vs. 76.3% in HARRIER). A similar trend in mean percentage reductions was observed in patients with DA at week 16.

Conclusions: This analysis shows that brolucizumab achieved greater reductions in PEDs and sub-RPE fluid thickness than aflibercept in HAWK and HARRIER.

Trial registration: ClinicalTrials.gov Identifiers: NCT02307682 (HAWK) and NCT02434328 (HARRIER).

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: To report 1-year anatomic and functional real-world outcomes of patients with treatment-intensive neovascular age-related macular degeneration (nAMD) switched to faricimab.

Design: Retrospective multicenter cohort study.

Subjects: Consecutive nAMD patients on 4-weekly treatment interval with either ranibizumab or aflibercept 2 mg in the last 3 visits within a treat-and-extend protocol (high treatment burden) before switch to faricimab at Moorfields Eye Hospital between September 5, 2022 and December 5, 2022.

Methods: Patients with nAMD switched to faricimab were identified from electronic medical records and those who met criteria of high treatment burden were included. Data collected included preswitch and postswitch visual acuity (VA), treatment intervals, baseline macular morphology, central subfield thickness (CST), macular fluid status, and adverse events.

Main outcome measures: Visual acuity, CST, presence of intraretinal fluid, subretinal fluid, and injection intervals over 1 year after switch to faricimab.

Results: A total of 130 of 286 (45.5%) eyes met inclusion criteria of being switched due to high treatment burden and 117 were included in analysis. Before switch, these eyes received mean total number of injections of 33.4 ± 19.6 over a mean of 51.3 ± 34.9 months. Mean number of injections in 12 months preceding switch was 10.1 ± 1.6 and mean interval of the preceding 3 injections was 4.2 ± 0.3 weeks. Mean VA, CST, and percentage of patients with dry macula before switch were 66.0 ± 11.9 ETDRS letters, 259.6 ± 76.0 μm and 18.3% respectively. After switch, there was no statistical difference in mean VA throughout follow-up period. Mean CST statistically significantly reduced after the third faricimab injection and at 12 months by 20.0 μm (P = 0.035) and 22.1 μm (P = 0.041) respectively. Mean treatment intervals increased to 6.9 ± 2.3 weeks (P < 0.005) at 12 months with 42.9% and 11.4% of patients being on ≥8-weekly and ≥12-weekly treatment intervals, respectively.

Conclusions: At 12 months, nAMD patients with previous record of high treatment burden when switched to faricimab maintained VAs and improved anatomic outcomes on extended treatment intervals. Physician bias is inherent in these types of observational studies so a prospective, randomized, controlled trial is recommended to validate these findings.

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: To investigate the discrepancy between visual acuity (VA) decline and foveal involvement in geographic atrophy (GA) secondary to nonexudative age-related macular degeneration (AMD), and to explore how early retinal changes impact the progression of visual impairment.

Design: Retrospective, longitudinal cohort study.

Subjects: This study evaluated 80 eyes from 60 patients (mean age, 74.2 ± 10 years) with progressing non-neovascular AMD.

Methods: Blue-light fundus autofluorescence (FAF) and spectral-domain OCT (SD-OCT) were utilized to monitor GA progression and the onset of foveal involvement. The study analyzed VA changes over an average follow-up of 60 ± 26.4 months, encompassing 785 observations. Mixed-effects models with natural splines assessed the effects of demographic and ocular characteristics on baseline VA and its rate of decline. Survival analyses compared the timing of anatomic changes with the most rapid functional declines, indicated by the highest first derivative of VA trajectories. Discrepancies between visual and anatomic changes were explored using generalized linear mixed-effects models.

Main outcome measures: Monthly VA changes, onset and impact of foveal involvement, and factors influencing baseline VA and rate of decline.

Results: Visual acuity declined consistently by an average of 0.010 logarithm of the minimum angle of resolution (LogMAR) per month (standard error [SE], 0.0003; P < 0.001). The onset of foveal involvement significantly exacerbated this decline, adding an average loss of 0.15 LogMAR (SE, 0.02; P < 0.001). Stabilization of VA typically occurred around 41 months post-foveal involvement. Significant factors associated with worse baseline VA were older age, female gender, unifocal GA morphology, and drusen-associated forms of GA (P < 0.05). The most rapid declines in VA typically occurred about 9 months (interquartile range, 0-27 months) before detectable subfoveal changes. The reticular FAF pattern (27/46 [59%] vs. 2/13 [15%], P = 0.02) and smaller baseline GA lesions (P = 0.01) were associated with faster deterioration preceding visible foveal damage.

Conclusions: This study demonstrates that significant VA loss in GA can precede detectable foveal involvement, suggesting a window for early interventions to slow the progression of visual impairment. Identifying specific GA characteristics and FAF patterns as predictors of rapid VA decline supports the need for personalized treatment strategies to optimize outcomes for patients with nonexudative AMD.

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.