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Teddy Lyu, Brian Lehpamer, Scott E. Brodie; Reversible and Irreversible Sequelae of Interrupting Anti-VEGF Therapy. Invest. Ophthalmol. Vis. Sci. 2012;53(14):931.
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Various strategies have been described for the use of intravitreal Anti-VEGF injections in the treatment of macular diseases. These strategies involve injections of bevacizumab (Avastin®) or ranibizumab (Lucentis®) at monthly, PRN, or "Inject-And-Extend" intervals. While good outcomes have been reported following close surveillance and timely treatments, there is limited data describing the sequalae, reversible or irreversible, from interruptions in therapy. This study examines the effects of Anti-VEGF treatment interruptions on best-corrected visual acuity.
A retrospective chart review included 79 eyes from 76 patients who received monthly intravitreal injections of bevacizumab (1.25 mg/0.05 mL) or ranibizumab (0.5 mg/0.05 mL). Of the 79 eyes, 33 eyes were treated for exudative age-related macular degeneration, 18 eyes were treated for central or branch retinal vein occlusion, and 28 eyes were treated for clinically significant macular edema. Inclusion criteria included eyes having had at least three consecutive monthly Anti-VEGF injections, an interruption in treatment of at least one month, followed by three consecutive monthly injections. The following parameters were followed: mean number of injections, mean duration of Anti-VEGF treatment interruption, pre-interruption visual acuity, post-interruption visual acuity, final visual acuity. Visual acuity was measured using the Snellen scale.
The ARMD, Vein Occlusion, and CSME groups received an average of 16.8, 5.28, and 5.29 monthly injections, respectively. The average lengths of treatment interruption were 4.87 (ARMD), 3.67 (Vein Occlusion), and 2.68 (CSME) months. In the ARMD group, 43% (14/33) suffered a loss of one or two lines, and 15.2% (5/33) suffered a loss of greater than two lines after treatment hiatus. In the Vein Occlusion group, 39% (7/18) suffered a loss of one or two lines, and 11.1% (2/18) suffered a loss of greater than two lines after treatment hiatus. And finally, in the CSME group, 25% (7/28) suffered a loss of one or two lines, and 3.6% (1/28) suffered a loss of greater than two lines after treatment hiatus. The visual acuity loss appears to be irreversible in the majority of cases. Only three eyes in the ARMD, zero eyes in the Vein Occlusion, and two eyes in the CSME group recovered to the pre-hiatus visual acuity after resuming monthly injections.
We demonstrated that a substantial percentage of patients who undergo treatment hiatus are at risk of visual acuity loss. Visual acuity shows some recovery with resumption of treatment. However, in our subset of patients with loss of visual acuity after hiatus, the visual acuity loss is mostly irreversible.
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