Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus

Abstract

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Anti-VEGF Therapy for Retinal Vein Occlusion

“…Treatment with VEGF-Inhibitors starts with an "upload" of 3 monthly injections, followed by re-evaluation with spectral-domain optical coherence tomography (OCT) and re-treatment. On the basis of published recommendations and evidence we developed a Figure to present our recommendations ( Figure 1) [1,[18][19][20] . A recent guideline well illustrating the treatment of RVO is a consensus of an expert panel in Canada [18] .…”

“…On the basis of published recommendations and evidence we developed a Figure to present our recommendations ( Figure 1) [1,[18][19][20] . A recent guideline well illustrating the treatment of RVO is a consensus of an expert panel in Canada [18] . The therapy algorithm suggests a baseline assessment with a clinical evaluation as well as assessment for neovascularization and macular edema with OCT.…”

“…The longer the consequent re-treatment, the better is the prognosis for sustained visual acuity. The clinical trials for approval of ranibizumab and aflibercept (CRUISE, BRAVO, GALILEO, COPERNICUS, VIBRANT) all showed that the sham group receiving anti-VEGF injections after 6-12 months delay had worse results than the group of patients treated with anti-VEGF injections from baseline [1,18] . The treatment delay of 6 months in the sham/control group led to a smaller gain of letters in BCVA.…”

“…According to our recommended scheme, first re-evaluation takes place after the upload of 3 monthly anti-VEGF injections (Figure 1) [18] . Recommendation for patients with stable vision and no fluid on OCT is PRN treatment with frequent evaluations; initially monthly which can be further extended when nomacular edema re-occurs.…”

“…Formacular edema with a visual acuity better than 20/40 observation and close follow-up can be considered as an alternative, as the expert panel decided for their consensus. With visual acuity better than 20/40 there is no study experience since patients were excluded inrandomized controlled clinical trials(RCTs)with such a good vision [18] . But recent data show better prognosis for patients the sooner treatment is initiated.…”