Management of retinal vascular diseases: a patient-centric approach

Abstract

Retinal vascular diseases are a leading cause of blindness in the Western world. Advancement in the clinical management of these diseases has been fast-paced, with new treatments becoming available as well as license extensions of existing treatments. Vascular endothelial growth factor (VEGF) has been implicated in certain retinal vascular diseases, including wet age-related macular degeneration (AMD), diabetic macular oedema (DMO), and retinal vein occlusion (RVO). Treatment of wet AMD and visual impairment due to either DMO or macular oedema secondary to RVO with an anti-VEGF on an as needed basis, rather than a fixed schedule, allows an individualised treatment approach; providing treatment when patients are most likely to benefit from it, while minimising the number of unnecessary intravitreal injections. Thus, an individualised treatment regimen reduces the chances of over-treatment and under-treatment, optimising both the risk/benefit profile of the treatment and the efficient use of NHS resource. Streamlining of treatment for patients with wet AMD and visual impairment due to either DMO or macular oedema secondary to RVO, by using one treatment with similar posology across all three diseases, may help to minimise burden of clinic capacity and complexity and hence optimise patient outcomes. Informed treatment decisions and efficient clinic throughput are important for optimal patient outcomes in the fast-changing field of retinal vascular diseases.

Figure 1

Mean changes from baseline in VA with monthly 0.5 mg ranibizumab in patients with wet AMD with minimally classic/occult CNV, in the MARINA study. Only data from the licensed dose of ranibizumab (0.5 mg) are shown. P-value shown is for difference in mean change in VA vs sham at 24 months. ETDRS, Early Treatment Diabetic Retinopathy Study. Adapted from Rosenfeld et al.

Figure 2

Mean changes from baseline in VA in patients with wet AMD with quarterly 0.5 mg ranibizumab following a loading phase of 3 monthly injections, in the PIER study. Only data from the licensed dose of ranibizumab (0.5 mg) are shown. Arrows indicate injection time point. P-value shown is for difference in mean change VA vs sham at 12 months. ETDRS, Early Treatment Diabetic Retinopathy Study. Adapted from Regillo et al, Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER study year 1. Am J Ophthalmol 2008; 145: 239–248, with permission from Elsevier © 2008.

Figure 3

Mean changes from baseline in VA in wet AMD in three subgroups of patients receiving 0.5 mg ranibizumab in the PIER study. Adapted from Holz et al, The effects of a flexible visual acuity-driven ranibizumab treatment regimen in age-related macular degeneration: outcomes of a drug and disease model. Invest Ophthalmol Vis Sci 2010; 51(1): 405–412, with permission from Association for Research in Vision and Ophthalmology © 2010.

Figure 4

Mean changes from baseline in VA in patients with DMO in the DRCR.net Protocol I study. No equivalent to the unpreserved triamcinolone formulation used in this study is currently available in the United Kingdom. P-values shown are for difference in mean change in VA vs sham plus prompt laser at 52 weeks. Adapted from Elman et al, Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology 2010; 117(6): 1064–1077, e1035, with permission from Elsevier © 2010.

Figure 5

Mean changes from baseline in VA in patients with macular oedema secondary to RVO. Mean changes from baseline in VA in patients with (a) BRVO in the BRAVO study (adapted from Brown et al, Sustained benefits from ranibizumab for macular edema following branch retinal vein occlusion: 12-month outcomes of a phase III study. Ophthalmology 2011; 118(8): 1594–1602, with permission from Elsevier © 2011) and (b) CRVO in the CRUISE study (adapted from Campochiaro 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(10): 2041–2049, with permission from Elsevier © 2011). Only data from the licensed dose of ranibizumab (0.5 mg) are shown. ^†Sham patients received 0.5 mg ranibizumab PRN treatment from months 6 to 11. P-values shown are for difference in mean change VA vs sham/ranibizumab. ETDRS, Early Treatment Diabetic Retinopathy Study.