During Glaucoma Subspecialty Day, two physicians tackled the tough topic of intraocular pressure (IOP) elevation related to anti-VEGF injections. From the glaucoma perspective, Malik Y. Kahook, MD, provided his viewpoint, while the retina perspective was offered by Andrew A. Moshfeghi, MD, MBA, They spoke during “Glaucoma and Retina: Making the Most of the Hand You’re Dealt” (Gla04V).
Background data. In 2009, Dr. Kahook and colleagues published a study on six patients with ocular hypertension following single or multiple bevacizumab injections, with IOP hovering in the range of 30 mm Hg. This was followed by a larger 2011 study comprising 215 eyes; 13 (6%) sustained an IOP rise. In both studies, eyes with preexisting glaucoma were more likely to experience these IOP spikes.
Is this a trend? Around the same time in 2009, physicians from several states started reporting clusters of IOP increases after anti-VEGF injections. This included a cluster of 61 cases in Utah within a cohort of 512 eyes that were treated monthly with compounded bevacizumab. Affected eyes also showed resistance to multiple topical intraocular pressure lowering therapies. But the reason still hasn’t been made clear.
Multiple possible etiologies. Tests performed by Dr. Kahook have ruled out toxicity or concentration-dependent factors. He proposed several factors for these IOP spikes, including mechanical effects of repeated injections, the effect of VEGF inhibitors on trabecular meshwork cells, and contaminants such as silicone oil from repackaged anti-VEGF agents.
Key steps you can take. Dr. Kahook urged his glaucoma colleagues to maintain an open line of communication with retina specialists. He recommended that retina specialists check the IOP before and after each injection, avoid the bleb area when injecting, and adopt a treat-and-extend regimen when possible. Physicians can also consider a performing a paracentesis prior to injecting.
After Dr. Kahook concluded his presentation, Dr. Moshfeghi opened his talk with an overview of anti-VEGF injections and why they are a mainstay for many retina specialists.
Anti-VEGF injections work. Used for a wide array of retinal conditions, anti-VEGF injections are delivered every one to three months, typically with no defined endpoint. The main reason for this aggressive regimen? It works, said Dr. Moshfeghi. He explained that a growing body of data shows that regularly administered injections work well, preserving vision and permitting some patients to regain lost vision. More recent data point to a decline in visual gains with less-consistent dosing.
So, what can you do? “Spread the word and heighten awareness,” Dr. Moshfeghi said, noting that 3% to 12% of patients receiving anti-VEGF injections develop sustained elevations in IOP. This is not a phenomenon restricted to intravitreal steroid injections, he reminded the audience. Although the need for anti-VEGF treatment remains, the regimen can often be modified to balance the IOP risk. His suggestions include using slightly smaller injection volumes (35 or 40 µL), increasing injection intervals, and getting a glaucoma team involved early.
During the lively panel discussion, both physicians agreed that there remains a lack of conclusive data showing whether the choice of anti-VEGF agent is related to IOP elevations. Early diagnosis and early treatment are crucial for good outcomes. “We have to be alert to the fact that IOP can spike significantly and address it when it does happen,” said Dr. Kahook. —Keng Jin Lee.
Watch Glaucoma Subspecialty Day. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda” from the drop-down menu; and click on the “Friday” tab.
Financial disclosures. Dr. Kahook: Alcon Laboratories, Inc.: P; Allergan, Inc.: C; Aurea Medical: C,O,P; Equinox: C,O; Johnson & Johnson Vision: P; New World Medical: P; ShapeTech: O,P; SpyGlass Ophthalmics: C,O,P. Dr. Moshfeghi: Allergan: C; Genentech: C,S; Graybug: C; Novartis Pharma AG: C,S; Ocular Therapeutix: C,O; OptiSTENT: C,O; Placid0, Inc: O; Pr3vent: C,O; Regeneron Pharmaceuticals: C,S.
Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.
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