• Glaucoma, Retina/Vitreous

    Review of: The 12- and 24-month effects of intravitreal ranibizumab, aflibercept, and bevacizumab on intracocular pressure

    Nanji K, Sarohia G, Kennedy K, et al. Ophthalmology, May 2022

    The lack of understanding about possible increased IOP following intravitreal anti-VEGF injections introduces challenges with determining the frequency of IOP monitoring for patients with glaucoma and the treatment of diabetic macular edema (DME). In an effort to clarify the issue, researchers set out to capture data on long-term IOP elevations following anti-VEGF injections, which could aid ophthalmologists in informing patients regarding the risks and benefits of anti-VEGF therapy and the measures required to counter subsequent effects.

    Study design

    This study evaluated high-quality randomized controlled trials (RCTs) with a network meta-analysis (NMA) to understand whether there is an effect of intravitreal ranibizumab, bevacizumab, and aflibercept on 12- and 24-month intraocular pressure. RCTs evaluating the effect of the above 3 anti-VEGF agents for the treatment of macular degeneration, DME, and RVO were included.

    Outcomes

    The NMA analyzed data from 26 RCTs that included 12,522 eyes. Five examined outcomes included 1) the rate of IOP elevation greater than 5 mmHg on consecutive visits, 2) consecutive IOP measurements of greater than 21 mmHg, 3) IOP increase of more than 10 mmHg, 4) IOP measurements greater than 25 mmHg, and 5) IOP measurements of more than 30 mmHg. The only statistically significant comparison was that of ranibizumab 0.5 mg, which showed higher rates than bevacizumab of IOP measurements greater than 30 mmHg at 12 months, and ranibizumab 0.5 mg showing higher rates as compared to control for consecutive IOP increases of 5 mmHg or more at 24 months. A low certainty of evidence was found for both comparisons. All other comparisons did not show a statistically significant effect of IOP rise at 12 or 24 months.

    Limitations

    IOP measurements were not the primary outcomes of these studies, and thus, the studies did not include standardized measurements for IOP or standardized timing for measurements. Other limitations include variable frequency of IOP measurements and different definitions of IOP increases across the studies.

    Clinical significance

    The current meta-analysis suggests that no sustained increases in IOP result from anti-VEGF injections. This information is particularly valuable for managing patients with both retinal disease and pre-existing glaucoma. It is possible that future intravitreal medications may have a different IOP safety profile.