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Study: History of multiple intravitreal anti-VEGF injections not associated with IOP elevation
In a study to assess the long-term effects of multiple intravitreal antivascular endothelial growth factor injections, Kim and colleagues found that IOP elevation was more prevalent in eyes with retinal vein occlusion than with age-related macular degeneration after the injections.
The respective cohort study also demonstrated that a history of intravitreal anti-VEGF injections does not increase the risk for IOP elevation.
Researchers evaluated patients who were treated with more than three injections and were tracked for more than 12 months after their last injection. They defined IOP elevation as an increase of 5 mmHg above the baseline measurement on two consecutive visits. Using the Cox proportional hazard model, the researchers calculated the ratio for each risk factor for IOP elevation.
As detailed in the American Journal of Ophthalmology study, 629 eyes with neovascular AMD and 95 eyes with retinal vein occlusion were ultimately included in the analysis.
Results showed that 3% of eyes with neovascular AMD and 7.4% of eyes with retinal vein occlusion saw IOP elevation after multiple anti-VEGF injections. Researchers determined that the following were significant risk factors for IOP elevation after multiple anti-VEGF injections: a low baseline IOP, a history of glaucoma or a diagnosis of RVO.
"We suggest from our current analyses that a “treat-and-extend” dosing regimen for intravitreal anti-VEGF injections is not a significant risk factor for IOP elevation," the authors said.
"Anti-VEGF therapy requires multiple injections during an extended period, but IOP elevation was noted in our current patient cohort at a low rate and extent,” they said. “Underlying intrinsic factors that could substantially affect the IOP, including a diagnosis of retinal vein occlusion and a history of glaucoma, were found to be related to IOP elevation during multiple intravitreal injections.
"Hence, it would be prudent for clinicians to recognize the possibility of IOP elevation after multiple intravitreal anti-VEGF injections in retinal vein occlusion patients with a history of glaucoma, even though the overall incidence is likely to be low," the researchers concluded.
Perspective
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In addition to their currently unparalleled efficacy, one of the oft-cited advantages of intravitreal anti-VEGF agents in the treatment of ocular neovascular disease is post-treatment IOP stability. Short-term volume-mediated increases notwithstanding, sustained post-treatment IOP elevation (≥5 mm Hg) has not been consistently reported in randomized clinical trials of anti-VEGF agents, but has been suggested in some case series and retrospective analyses. Variables hypothesized as important have included agent utilized, compounding impurities, immunologic responses, comorbidities, number and frequency of injections, and globe biomechanics.
The authors report a relatively low overall incidence of sustained IOP elevation (3.7%) in a Korean population with a treat-and-extend dosing regimen for age-related macular degeneration and retinal vein occlusion (RVO) utilizing bevacizumab and ranibizumab. The elevation was unrelated to any injection parameter but was more common in patients with RVO (7.4%) and/or a history of glaucoma, two conditions independently associated with increased IOP. Most IOP elevations were categorized as mild and self-limiting. Interestingly, and at present inexplicably, nearly half the patients who experienced a sustained IOP elevation in their treated eye demonstrated the same in their untreated fellow eye.
The authors conclude that while the risk of post-anti-VEGF injection sustained IOP elevation is low, practitioners must remain vigilant, particularly in patients already prone to increased IOP, including those with pre-existing glaucoma or being treated for RVO.
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Am J Ophthalmol. 2014;doi: 10.1016/j.ajo.2014.02.035.