JOURNAL CLUB

RECENT NOTEWORTHY STUDIES TO STIMULATE DISCUSSION AND DEBATE

■ Anti-VEGF in ROP. To evaluate the outcomes in the eyes of premature infants with retinopathy of prematurity (Figure), retinal physicians collaborating between Mexico City and Denver, CO, undertook an interventional case series of six eyes of three patients.

All six eyes were treated with intravitreal injections of ranibizumab (Lucentis, Genentech, South San Francisco, CA), and assessed for regression of neovascularization and recurrence. After a single injection, all six eyes showed complete resolution of neovascularization, with no recurrence over three years of follow-up.

Although very small, the study is the first publication that is not a case study evaluating ranibizumab as a monotherapy for ROP.

Castellanos MA, Schwartz S, García-Aguirre G, Quiroz-Mercado H. Short-term outcome after intravitreal ranibizumab injections for the treatment of retinopathy of prematurity. Br J Ophthalmol. 2013;97:816-819.

■ Hydroxychloroquine and AMD protection. Although it has been linked to retinal toxicity, the antimalarial hydroxychloroquine has also been linked to a lower incidence of AMD in patients with rheumatoid arthritis who take the drug.

Ophthalmologists in Israel investigated the role of the drug in AMD protection in a retrospective study of 54 eyes of 27 patients with RA, comparing the cohort with an age-matched group of healthy eyes and with the eyes of RA patients who had not taken hydroxychloroquine.

They found that patients treated with the drug had a significantly thicker retinal pigment epithelium as measured on OCT (60.4 ±7.4 µm).

Despite the study’s retrospective nature, the authors stated thicker RPE could explain the lower rate of AMD.

Pikkel J, Chassid O, Sharabi-Nov A, Beiran I. A retrospective evaluation of the effect of hydroxyquinine on RPE thickness. Graefes Arch Clin Exp Ophthalmol. 2013;25:1687-1690.

Figure. A case of ROP from a case series of patients with zone 1 disease who were treated with anti-VEGF.

■ VMA in retinal disease. A systematic review and meta-analysis published by doctors in the United Kingdom showed that eyes with wet AMD are more than twice as likely to develop vitreomacular adhesion (VMA) and are less likely to develop posterior vitreous detachments.

Reviewing 16 articles published since 1946 on VMA, vitreomacular traction (VMT), and complete and partial PVD appearing with DME, AMD, or RVO, the authors found a 23% prevalence of VMA in eyes with wet AMD. Insufficient data were available to assess the rate of vitreous attachment in DME, but VMT occurred in 188 cases. Roughly 30% of eyes with any type of RVO had PVDs.

The authors expressed confidence that rates of VMA and PVD in AMD are based on sufficient-quality data. They suggested more research on attachment in eyes with RVO and DME.

Jackson TL, Nicod E, Angelis A, et al. Vitreous attachment in age-related macular degeneration, diabetic macular edema, and retinal vein occlusion: a systematic review and metaanalysis. Retina. 2013;33:1099-1108.

■ Aflibercept after anti-VEGF failure. In the first published study of aflibercept (Eylea, Regeneron, Tarrytown, NY) in cases of AMD resistant to treatment with bevacizumab (Avastin, Genentech) or ranibizumab, doctors at the University of Iowa have concluded that the newer drug can be helpful.

In a retrospective chart review, the authors examined 36 eyes of 31 patients. The number of injections of either ranibizumab or bevacizumab ranged from six to 74. After three monthly injections of aflibercept, 50% of the eyes experienced a reduction in fluid, with 41.7% of that half maintaining that improvement. Central macular thickness also improved, although visual acuity did not.

The authors suggested that scarring might explain the lack of improvement in VA, and they stated that aflibercept could be considered on an individual basis for patients with recalcitrant fluid after treatment with bevacizumab or ranibizumab.

Bakall B, Folk JC, Boldt HC, et al. Aflibercept therapy for exudative age-related macular degeneration resistant to bevacizumab and ranibizumab. Am J Ophthalmol. 2013;156:15-22.

■ A new form of late AMD? For some time, AMD has been divided into the dry and wet forms, but new research has indicated that a variety could exist that is not yet included in the current classification systems.

In a retrospective study of consecutive patients with clinical diagnoses of pseudodrusen, Richard F. Spaide, MD, of Vitreous Retina Macula Consultants of New York, examined the records of 58 eyes of 33 patients from a 2010 study. Thirty-four of these eyes developed CNV, one developed branch RVO, and two were lost to follow-up.

Dr. Spaide evaluated the remaining 21 eyes for the presence of subretinal drusenoid deposits on OCT and evaluated changes in the eyes over time using time-lapse video. He truncated follow-up when an eye developed CNV or a retinal-vascular issue.

Of the 21 eyes, CNV developed in nine, two developed branch RVO, one eye was lost to follow-up, and one eye was in a patient who died. These events occurred over a mean of 2.9 years.

Further, Dr. Spaide observed regression of subretinal drusenoid deposits in nine of the eyes. In these eyes, decreases in photoreceptor length occurred, resulting in a final photoreceptor length 74.4% of the original value. The underlying choroid also diminished in size, to 81.4% of its original value. Eyes without regression of subretinal deposits did not experience these losses.

According to Dr. Spaide, these losses of outer retinal structure constitute a form of age-related change distinct from CNV or GA. He encouraged additional study into this phenomenon, particularly using OCT, which has greater sensitivity in detecting pseudodrusen. RP

Spaide RF. Outer retinal atrophy after regression of subretinal drusenoid deposits as a newly recognized form of late age-related macular degeneration. Retina. 2013 Jun 12. [Epub ahead of print].