Therapies for Macular Edema Associated with Branch Retinal Vein Occlusion OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Retina/Vitreous Panel: Justis P. Ehlers, MD,¹ Stephen J. Kim, MD,² Steven Yeh, MD,³ Jennifer E. Thorne, MD, PhD,⁴ Prithvi Mruthyunjaya, MD, MHS,⁵ Scott D. Schoenberger, MD,⁶ Sophie J. Bakri, MD⁷

Ophthalmology, September 2017, Vol 124, 1412-1423© 2017 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Purpose: To evaluate the available evidence on the ocular safety and efficacy of current therapeutic alternatives for the management of macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

Methods: Literature searches were last conducted on January 31, 2017, in PubMedwith no date restrictions and limited to articles published in English, and in the Cochrane Database without language limitations. The searches yielded 321 citations, of which 109 were reviewed in full text and 27 were deemed appropriate for inclusion in this assessment. The panel methodologist assigned ratings to the selected studies according to the level of evidence.

Results: Level I evidence was identified in 10 articles that addressed anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME, including intravitreal bevacizumab (5), aflibercept (2), and ranibizumab (4). Level I evidence was identified in 6 studies that examined intravitreal corticosteroids, including triamcinolone (4) and the dexamethasone implant (2). Level I evidence also was available for the role of macular grid laser photocoagulation (7) and scatter peripheral laser surgery (1). The inclusion of level II and level III studies was limited given the preponderance of level I studies. The number of studies on combination therapy is limited.

Conclusions: Current level I evidence suggests that intravitreal pharmacotherapy with anti-VEGF agents is effective and safe for ME secondary to BRVO. Prolonged delay in treatment is associated with less improvement in visual acuity (VA). Level I evidence also indicates that intravitreal corticosteroids are effective and safe for the management of ME associated with BRVO; however, corticosteroids are associated with increased potential ocular side effects (e.g., elevated intraocular pressure, cataracts). Laser photocoagulation remains a safe and effective therapy, but VA results lag behind the results for anti-VEGF therapies.

¹ Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
² Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
³ Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
⁴ Division of Ocular Immunology, Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
⁵ Byers Eye Institute, Stanford University, Palo Alto, California
⁶ Retina Physicians & Surgeons, Inc., Dayton, Ohio
⁷ Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota