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Intravitreal injection of anti-VEGF therapy proven safe, effective for neovascular AMD

Stephen Padilla
21 Jan 2019

Intravitreal injection of antivascular endothelial growth factor (anti-VEGF) therapy is a safe and effective treatment for neovascular age-related macular degeneration (AMD) over 2 years, the period for which data are available in this literature review.

“The best available evidence suggests that continued close follow-up and treatments longer than 2 years are needed to minimize visual loss,” researchers said. “Anti-VEGF pharmacotherapy delivered earlier in the course of neovascular AMD favourably affects visual prognosis.”

Of the 28 citations provided, 16 offered level I evidence supporting the use of anti-VEGF agents for neovascular AMD, which included intravitreal ranibizumab, aflibercept and bevacizumab. There were eight studies the provided level II evidence and four studies with level III evidence. However, only those with level I evidence were included in the evaluation. [Ophthalmology 2019;126:55-63]

Long-term (≥5 years) follow-up data on the efficacy of ranibizumab and bevacizumab were available, but these were subject to bias of incomplete follow-up.

One of the level I studies was the VEGF Inhibition Study in Ocular Neovascularization (VISION) trial, which showed the superiority of pegaptanib vs sham/photodynamic therapy (PDT) at 54 weeks. [N Engl J Med 2004;351:2805-2816]

Two other studies—Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranbizumab in the Treatment of Neovascular AMD (MARINA) and Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD (ANCHOR)—found that ranibizumab anti-VEGF treatment groups had superior visual acuity and optical coherence tomography outcomes vs sham/PDT at 108 weeks. [N Engl J Med 2006;355:1419-1431; N Engl J Med 2006;355:1432-1444]

“Several head-to-head studies demonstrated noninferiority of other anti-VEGF agents compared with ranibizumab,” researchers said.

The Comparison of AMD Treatment Trial (CATT), the Inhibition of VEGF in Age-related Choroidal Neovascularization (IVAN) trial and the Groupe d’Etude Français Avastin versus Lucentis dans la DMLA néovasculaire (GEFAL) study compared outcomes of bevacizumab and ranibizumab. [N Engl J Med 2011;364:1897-1908; Ophthalmology 2012;119:1399-1411; Lancet 2013;382:1258-1267; Ophthalmology 2013;120:2300-2309]

Moreover, the VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD (VIEW 1, VIEW 2) trials compared aflibercept and ranibizumab outcomes. [Ophthalmology 2012;119:2537-2548]

Researchers conducted a literature search of the PubMed and Cochrane Library databases in February 2017, limited to studies published in English, with no date restrictions. A total of 191 citations were found, of which 28 were selected because they were clinical trials and were deemed clinically relevant for the Ophthalmic Technology Assessment Committee Retina/Vitreous Panel to review in full. A level of evidence rating was then assigned to each study by the panel methodologist.

“Future studies should focus on longer-term and the comparative safety and efficacy of anti-VEGF agents for neovascular AMD, explore options for eyes with persistent neovascular activity despite anti-VEGF therapy, and evaluate preventive strategies,” researchers said.

“Greater emphasis should be placed on novel strategies for sustained intraocular delivery of anti-VEGF agents or combination therapies to reduce the burden, cost and risk of injections,” they added.

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