A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Retina/Vitreous Panel:
Steven Yeh, MD,1 Stephen J. Kim, MD,2 Allen C. Ho, MD,3 Scott D. Schoenberger, MD,4 Sophie J. Bakri, MD,5 Justis P. Ehlers, MD,6 Jennifer E. Thorne, MD, PhD7
Ophthalmology, April 2015, Vol 122, 769-778 © 2015 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Purpose: To review the available evidence regarding the safety and efficacy of therapies for the treatment of macular edema (ME) associated with central retinal vein occlusion (CRVO).
Methods: A literature search of the PubMed database was last conducted in March 2014 with no date restrictions but limited to articles published in English. A literature search of the Cochrane Library was also conducted in March 2014 with no date restrictions and without a language limitation. The combined searches yielded 108 citations, of which 20 were deemed clinically relevant for the Ophthalmic Technology Assessment Committee Retina/Vitreous panel to review in full text. Three additional studies were also identified for panel review. The level of evidence of these selected studies was reviewed by the panel methodologist.
Results: There were 7 citations representing 4 clinical trials that provided level I evidence supporting the use of anti-vascular endothelial growth factor (VEGF) pharmacotherapies for ME associated with CRVO, including intravitreal ranibizumab (2), aflibercept (3), and bevacizumab (2). There are 3 citations representing 2 studies with level I evidence for intravitreal corticosteroid injection either with dexamethasone intravitreal implant (2 citations) or triamcinolone (1 citation), although cataract and glaucoma were observed in these studies. Level I evidence is available on the limited benefit of macular grid-pattern laser photocoagulation (1 citation). Eight other citations reviewed were rated as level II, and 4 citations were rated as level III. Long-term efficacy results (≥2 years of follow-up) are limited to intravitreal ranibizumab at this time, and few studies have evaluated combination therapy with anti-VEGF and corticosteroid versus monotherapy of either class of drug.
Conclusions: Level I evidence indicates that intravitreal anti-VEGF pharmacotherapy is safe and effective over 2 years for ME associated with CRVO and that delay in treatment is associated with worse visual outcomes. In addition, level I evidence demonstrates short-term efficacy of intravitreal corticosteroid but also an association with a higher frequency of adverse events.
1Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.
2Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tenessee.
3Mid Atlantic Retina, Wills Eye Institute, Philadelphia, Pennsylvania.
4Retina Physicians & Surgeons, Inc., Dayton, Ohio.
5Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
6Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
7Division of Ocular Immunology, Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.