MACULAR OEDEMA

Anti-VEGF agents have a key role to play in the treatment of retinal vein occlusion (RVO), Francesco Bandello MD, FEBO told a session of the 15th EURETINA Congress in Nice, France.

Macular oedema is by far the most frequent cause of visual loss in RVO, and sequelae such as cystic degeneration, macular hole, epiretinal membrane and macular atrophy can be devastating, said Dr Bandello, Professor of Ophthalmology, Vita-Salute University, Milan, Italy.

“Both the BRAVO and the CRUISE studies offered unequivocal evidence that early treatment with anti-VEGF gives the best chance of visual recovery for patients with macular oedema,” he said.

What about patients who present late? “It’s also important to remember these studies show that later treatment, for example six months after onset, remains worthwhile,” added Dr Bandello.

Patients who completed either BRAVO or CRUISE studies could enter the 24-month open-label extension, HORIZON study, to receive ranibizumab 0.5mg PRN.

“After 12 months, best corrected visual acuity improvements from BRAVO were maintained in patients with branch retinal vein occlusion (BRVO), although a slight decrease was observed in patients with central retinal vein occlusion (CRVO). This suggests that more frequent assessments, by which I mean more than three-monthly, may be required to maintain visual acuity in these patients,” said Dr Bandello.

Additionally, Dr Bandello advocated an aggressive approach to treatment, which he considers superior to PRN treatment. What about macular ischaemia? Is this a contraindication for anti-VEGF treatment in RVO? Dr Bandello does not think so.

“An article published by Campochiaro et al in Ophthalmology in 2013 showed that patients treated with ranibizumab had less retinal non-perfusion compared to sham-treated patients,” he said.

CONTRAINDICATION

Therefore, physicians should not consider ischemia to be a contraindication. Further, sham-treated patients develop less non-perfusion after the switch has been made to ranibizumab, he noted.

In this respect, early fluorescein angiography is crucial. “It’s important to understand what’s going on in the retina. A paper once published in Ophthalmology analysed the reasons for mistakes in retinal disease, and discovered that CRVO was the disease most frequently misdiagnosed, especially in chronic cases. After initial evaluation, clinical evaluation and optical coherence tomography are sufficient,” said Dr Bandello.

He reminded delegates that, although there is no large-scale hard data for bevacizumab. “I think we can assume that this molecule is non-inferior to ranibizumab for RVO,” he said.

Francesco Bandello: Bandello.Francesco@HSR.it