This article is more than 5 years old. Information may no longer be current.
Researcher recommends frequent patient follow-up for retinal vein occlusion
Click Here to Manage Email Alerts
Shree K. Kurup
Prompt treatment with close follow-up intervals translates into better clinical outcomes for patients with retinal vein occlusion, according to one researcher.
“We have noticed that the more you delay treatment, the worse the recovery,” Shree K. Kurup, MD, director of research at Wake Forest University Eye Center, said.
Recovery is not as good in a patient whose first anti-VEGF injection is done on day 90 as in a patient whose first injection is on day 1, Kurup said, even if both patients have identical vein occlusion and ultimately the same number of injections over a 1-year period. This is especially evident in central retinal vein occlusion, he said.
“The [GALILEO] study concluded that it is better for patients with retinal vein occlusion (RVO), especially central retinal vein occlusion, to be treated quickly,” Kurup said. “Observation is not a good option.”
One way to avoid a less successful recovery is to increase the number of visits and therapies or consider longer-acting therapies, such as a slow-release steroid implant, Kurup said.
Frequent follow-up
“Following up a patient with RVO is very different from following up a patient with macular degeneration,” Kurup said.
Figure. Ischemic CRVO with neovascularization elsewhere and vitreous hemorrhage managed after vitrectomy with 12 anti-VEGF injections and three dexamethasone implants. After vitrectomy for persistent vitreous hemorrhage (top), patient sees 20/200 in 2010. Patient in 2014 (bottom) sees 20/50 with no collateral circulation evident. Mild CME was responsive to as-needed anti-VEGF.
Images: Kurup SK
Initially, patients should be followed up at least monthly because nonischemic RVO converts to ischemic RVO in one-third of patients within 3 months, he said.
“So, although your impression on day 1 is that many patients seem fine, you should not follow up less frequently,” Kurup said. “In truth, there is nothing that predicts who is going to have a conversion. Therefore, it is important for all patients to be seen on a monthly basis rather than waiting 3 months.”
For RVO patients with significant cystoid macular edema (CME), Kurup usually begins treatment with an anti-VEGF injection — either Lucentis (ranibizumab, Genentech) or Eylea (aflibercept, Regeneron) — followed 2 weeks later with Ozurdex (dexamethasone intravitreal implant, Allergan), which lasts up to 4 to 5 months.
“This protocol allows me to slightly extend the patient’s follow-up,” he said. “The burden of drug use is also decreased by administering fewer injections over the long run.”
Kurup presented study results of using Ozurdex for RVO at the 2013 meeting of the American Society of Retina Specialists.
“We found that the implant is a judicious option and that the risk of [its] leading to glaucoma is low compared to other steroids, only about 3%,” he said. “For those patients at risk, the implant can be removed from the eye in 5 minutes.”
Combination therapy
The combination therapy of injection and implant works well because dexamethasone addresses the inflammatory components associated with RVO, Kurup said, whereas the anti-VEGF addresses the vascular endothelial growth factor alone. Kurup brings back patients 2 weeks after insertion of the implant and then 1 month later.
“Going forward, I stagger patient visits based on how they are responding,” he said.
Kurup schedules monthly injections for patients with persistent CME, even in eyes with minimal CME.
“Generally, patients who receive monthly injections do better than an injection once every 2 to 3 months,” he said.
All patients are followed up until their vision recovers to baseline or near baseline (one or two lines). For patients with RVO and CME, Kurup images with optical coherence tomography and fluorescein angiography at every visit that the clinical picture does not follow or correlate with the anatomical details.
The follow-up schedule is absolutely part of the treatment decision for RVO, Kurup said.
“Clinicians should also collaborate with patients as to how often they wish to be seen, and it is the behavior of the vein occlusion that drives the therapy,” he said.
The goals of therapy vary based on a patient’s ocular and functional status. A patient with poor vision related to RVO in one eye who has good social support at home might have different expectations from treatment than a patient who has bilateral poor vision and is the primary caregiver for others at home.
“Realistically, with the volume the average retinal specialist carries, it’s impractical to say, ‘I am following every patient very closely,’ yet it remains critical to patient outcomes in RVO management to keep close follow-up intervals during the period when the RVO is still active.” Kurup said. “The endpoint is that you do not want any macular edema in an eye with vein occlusion, in contrast to [treating] AMD, where you can leave a little subretinal fluid with a [pigment epithelial detachment] and observe.” – by Bob Kronemyer