Effects of Intravitreal Anti-VEGF Therapy on Glaucoma-like Progression in Susceptible Eyes

Abstract

Précis: Intravitreal anti-vascular endothelial growth factor (VEGF) injections may accelerate glaucomatous change in patients with preexisting glaucoma or ocular hypertension (OHT). The safety of long-term injections in this specific population may be reflected in the need for additional glaucoma interventions. Purpose: The purpose of this study was to investigate whether repeated anti-VEGF injections accelerate structural and functional glaucomatous change in eyes with preexisting glaucoma or OHT. Materials and Methods: This is a retrospective, observational study of injected and noninjected fellow eyes. A total of 28 patients with preexisting glaucoma or OHT, who received ≥6 unilateral anti-VEGF injections for concurrent neovascular retinal disease, were selected for chart review. Primary outcome measures were rate of visual field loss in dB/year, rate of change in retinal nerve fiber layer (RNFL) thickness in microns/year, and need for additional glaucoma medications, surgery, or laser. Results: The number of eyes requiring additional glaucoma surgery or laser was 8 of 28 (28.6%) for the injected group and 2 of 28 (7.1%) for the noninjected group. A significantly greater proportion of injected eyes required invasive glaucoma intervention (P=0.034). Average rate of decline in mean deviation and change in pattern standard deviation were both significantly greater in injected eyes (P=0.029; P=0.019). Estimated mean rate of global retinal nerve fiber layer change was −4.27 µm/y for the injected group and −1.17 µm/y for the noninjected group and was significant only for injected eyes (P=0.014). Only the superior quadrant exhibited thinning that was significantly different between groups (P=0.030). Conclusions: Intravitreal injections were associated with accelerated functional and structural glaucoma-like change in susceptible eyes. Clinicians should assess the need for glaucoma medications or other interventions over the course of anti-VEGF therapy.

Prophylaxis with intraocular pressure lowering medication and glaucomatous progression in patients receiving intravitreal anti-VEGF therapy

“…Over 3y of follow up, 44.6% of patients who received 7 or more injections per year required glaucoma surgery, with an adjusted rate ratio of 2.48 (95%CI: 1.25-4.93) for individuals receiving surgery versus matched controls not requiring surgery. Similarly, our previous study of glaucomatous eyes found that a significantly greater proportion of anti-VEGF treated eyes later underwent invasive glaucoma intervention [17] . In the present study, 30.4% of non-pretreated patients and 25% of pretreated patients required additional pressure-lowering medication over the follow up period.…”

“…Compared to patients without preexisting glaucoma, those with concurrent glaucoma or OHT have higher rates of sustained pressure elevation after multiple injections [8][9][10] . The evidence on treatment-associated retinal nerve fiber layer (RNFL) thinning in non-glaucomatous eyes is controversial [11][12][13][14][15] , but studies of glaucomatous eyes suggest that repetitive injections may be associated with accelerated structural change [16][17][18] . These findings call into question the safety of long-term therapy for glaucoma patients, as they may be predisposed to OHT and associated complications.…”

Efficacy of an Anti-Semaphorin 3A Neutralizing Antibody in a Male Experimental Retinal Vein Occlusion Mouse Model

“… 8 , 9 Therefore, targeting VEGF-A is a reasonable treatment strategy for intraretinal edema. However, recent studies suggest that anti-VEGF therapies might cause adverse events, such as retinal thinning, 10 , 11 retinal pigment epithelial atrophy, 12 and tractional retinal detachment due to increasing fibrotic tissue, 12 , 13 which can lead to irreversible vision loss. One strategy to address these problems is to develop new treatments that target factors other than VEGF-A, working either in conjunction with current treatments or as a novel monotherapy.…”

Comparison of risks of arterial thromboembolic events and glaucoma with ranibizumab and aflibercept intravitreous injection: A nationwide population‐based cohort study

“…An acute elevation in IOP after intravitreal injection has been reported in several studies [ 36 – 38 ], and it has been suggested that the repeated transient elevations in IOP after intravitreal injection could be correlated with an increased incidence of glaucoma [ 39 ]. Elevations in IOP may become frequent with receiving long term intravitreal anti-VEGF injections, and previous studies have demonstrated that the development or progression of glaucoma is associated with intravitreal injections [ 40 , 41 ]. The risk of glaucoma after intravitreal injections is concerned because patients with chronic retinal diseases may require multiple injections over time.…”