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Repeated anti-VEGF injections for neovascular AMD increase IOP
Anti-VEGF injections increased IOP in eyes being treated for neovascular age-related macular degeneration, according to a study.
“Overall, our data support an ocular hypertensive action of anti-VEGF drugs probably mediated by a direct action on the trabecular meshwork,” the study authors said.
Data were culled from the IVAN trial. The analysis included 610 patients with active, treatment-naïve neovascular AMD. Patients were randomly assigned to receive Avastin (bevacizumab, Genentech) or Lucentis (ranibizumab, Genentech) monthly or as needed.
Goldmann applanation tonometry was performed monthly in both eyes before treatment and in the study eye after injection. At least two readings were made in each eye. Untreated fellow eyes served as controls.
The median interval of active participation in the IVAN trial was 23.6 months. The median interval between injections was 1 month.
For every month of participation in the IVAN trial, pre-injection IOP increased 0.02 mm Hg and post-injection IOP increased 0.03 mm Hg; both increases were statistically significant (P < .001 and P = .002, respectively).
The between-eye difference in IOP increased significantly (0.01 mm Hg, P < .001) with longer participation in the study.
Bevacizumab and ranibizumab yielded similar outcomes on all three measures. – by Matt Hasson
Disclosure: Foss reports no relevant financial disclosures. See the study for a full list of all other authors’ relevant financial disclosures.
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The IVAN study was a 2-year prospective, randomized trial that compared intravitreal ranibizumab to bevacizumab in either a continuous (monthly) or discontinuous (as needed-like) regimen for the treatment of neovascular age-related macular degeneration (AMD). This analysis by Foss and colleagues from the IVAN study group addresses a potentially important issue of sustained intraocular pressure (IOP) elevation with long-term intravitreal anti-VEGF therapy. It confirms that anti-VEGF injections cause a statistically significant rise in IOP over time.
Although it may appear at first glance that the very small mean rise in IOP of 0.02 mm Hg/month is not clinically significant, it must be kept in mind that the course of anti-VEGF therapy for neovascular AMD will typically extend over several years, and previous studies indicate that the risk of sustained IOP elevation in patients on anti-VEGF treatment is related to the total number of injections. Those studies show that the proportion of patients having significant IOP elevation is in the 3-12% range, and it is most likely to be seen in eyes that have received more than 20 injections. Therefore, it is unlikely to encounter a patient on a course of anti-VEGF therapy for AMD having clinically meaningful, sustained IOP elevation in the first year or two of therapy, but, thereafter, a significant proportion of patients eventually may need IOP management.
Ophthalmologist treating patients with anti-VEGF agents need to be aware of this long-term side effect to avoid the potential of glaucomatous optic nerve damage should significant IOP elevation go unnoticed.
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Foss AJE, et al. Br J Ophthalmol. 2016;doi:10.1136/bjophthalmol-2015-307595.