Central retinal vein occlusion: modifying current treatment protocols

Abstract

Central retinal vein occlusion (CRVO) is a common retinal vascular disorder that can result in severe visual acuity loss. The randomized control study, CRUISE, helped establish anti-VEGFs as the standard of care in cases with CRVO. The extension studies for CRUISE; HORIZON and RETAIN showed that not all visual gains are maintained beyond the first year. In addition, patients showed different behavior patterns; with some patients showing complete response with few recurrences, whereas others showed partial or even no response with multiple recurrences. Long-term follow-up demonstrated that patients responding poorly to anti-VEGFs tended to do so early in the course of treatment. It also demonstrated the effectiveness of a pro re nata (PRN) protocol for improving vision and maintaining these gains over long-term follow-ups. The SHORE study further illustrated this point by demonstrating that there were minimal differences in visual outcomes between patients receiving monthly injections and patients being treated PRN. In this review we analyzed the data from the major randomized clinical trials (RCT) that looked at anti-VEGFs as the primary treatment modality in patients with CRVO (CRUISE and the extension studies HORIZON and RETAIN for ranibizumab as well as GALILEO and COPERNI-CUS for aflibercept). In addition, we looked at SCORE and GENEVA to help determine whether there is a place for steroids as a first line therapy in current treatment practice. We then explored alternative treatment regimens such as laser therapy and switching between anti-VEGF agents and/or steroids for non or partially responding patients. Finally, we propose a simplified modified treatment algorithm for patients with CRVO for better long-term outcomes in all types of responders.

Real-World Outcomes of Anti-VEGF Treatment for Retinal Vein Occlusion in Portugal

“…Among other therapeutic indications, ranibizumab and aflibercept are approved by the Food and Drug Administration and European Medicines Agency for the treatment of visual impairment due to macular edema secondary to BRVO or CRVO (2)(3)(4), while bevacizumab is used off-label worldwide (2,5,6) if ranibizumab or aflibercept are unavailable or due to economic considerations (6).…”

Impact of the LEAVO Study in Asia

“…Clinicians might therefore try to reduce the number of initial loading injections and extend the follow-up and retreatment intervals for longer duration. In contrast to previous studies on CRVO macular oedema such as CRUISE, COPERNICUS, GALILEO and SCORE2, which required six initial 4weekly loading anti-VEGF injections [8,10,11], the LEAVO Study performed only four initial injections at 4weekly intervals [7]. By giving four rather than six initial injections, the extent of visual acuity gain at 24 weeks in the aflibercept group was lower in the LEAVO Study (mean 13.4 letters) compared with COPERNICUS (mean 17.3 letters) and SCORE2 studies (mean 18.2 letters).…”

The CD40-ATP-P2X7 Receptor Pathway: Cell to Cell Cross-Talk to Promote Inflammation and Programmed Cell Death of Endothelial Cells

“…Ischemic retinopathies including those caused by central retinal artery occlusion, retinal vein occlusion, and retarded retinal vascular development in premature infants are important causes of permanent visual impairment and blindness in adults and children (45)(46)(47). Like DR, inflammatory responses including TNF-α, IL-1β, nitro-oxidative stress, and chemokines likely play an important role in the pathogenesis of these diseases (48).…”