Efficacy and effectiveness of anti-VEGF or steroids monotherapy versus combination treatment for macular edema secondary to retinal vein occlusion: a systematic review and meta-analysis

Abstract

Background Retinal vein occlusion (RVO) is the main cause of retinal vascular blindness. Laser photocoagulation therapy is the regarded as the standard treatment for branch retinal vein occlusion (BRVO) in the guidelines, but it is not effective for macular edema (ME) secondary to central retinal vein occlusion (CRVO). As anti-VEGF (vascular endothelial growth factor) or steroids monotherapy has been used to treat RVO, but each has its advantages and disadvantages. Our purpose was to evaluate the efficacy and safety of intraocular injection of anti-VEGF combined with steroids versus anti-VEGF or steroids monotherapy for ME secondary to RVO. Methods We systematically searched trials on Pubmed, Embase, Cochrane Library, Web of Science and China National Knowledge Infrastructure (CNKI) for RCTs (random clinical trials) or non-RCTs, comparing anti-VEGF or steroids monotherapy to their combination. The primary outcomes were changes in best-corrected visual acuity (BCVA), central macular thickness (CMT) and intraocular pressure (IOP). The pooled data was analyzed by random effects model. Findings A total of 10 studies selected from 366 studies were included in this meta-analysis. Our results favored anti-VEGF with steroids combination therapy in comparison with anti-VEGF {pooled SMD (standardized mean difference), 95% CI, -0.16 [-0.28, -0.04], P = 0.01} or steroids (pooled SMD, 95% CI, -0.56 [-0.73, -0.40], P < 0.00001) alone on changes of BCVA. Compared with anti-VEGF monotherapy group, the combination therapy also had a better effect {pooled MD (mean difference), 95% CI, -9.62 [-17.31, -1.93], P = 0.01)} at improvements on CMT. On the changes of IOP, assessment favored that combination therapy was associated with a better relief of IOP compared to steroids monotherapy group (pooled MD, 95% CI, -5.93 [-7.87, -3.99],P < 0.00001). What’s more, the incidence of ocular hypertension was lower in the combined treatment group compared with control group treated with steroids alone (Odds Ratio, 95% CI, 0.21 [0.06, 0.77], P = 0.02). Results also showed that the combination group can prolong the average time to first anti-VEGF reinjection (MD, 95% CI, 1.74 [0.57, 2.90], P = 0.003) compared to control group treated with anti-VEGF alone. Conclusion Anti-VEGF with steroids combination treatment can enable a better achievement of improving BCVA, CMT, reducing the risk of increased IOP and improving patient prognosis compared to anti-VEGF or steroids therapy alone, lengthening the average time to anti-VEGF reinjection with reducing the injections during follow-up.

Combination Therapy with Anti-VEGF and Intravitreal Dexamethasone Implant for Macular Edema Secondary to Retinal Vein Occlusion

“…A study that compared combination therapy with DEX monotherapy [28] reported that combination therapy provided a synergistic effect and was superior to DEX implant monotherapy for the improvement of VA and CMT. Results of a metaanalysis [29] revealed that combined anti-VEGF and steroid therapy improved BCVA and CMT, reduced the risk of IOP elevation, enhanced patient prognosis, prolonged the average time to anti-VEGF re-injection, and reduced the number of injections during the follow-up period compared with anti-VEGF or steroid monotherapy. In contrast, another study that adopted the ranibizumab and Ozurdex with laser photocoagulation (RandOL) protocol for RVO-ME treatment [30] reported that similar favorable anatomical and visual outcomes were obtained with the combination therapy regimen and monotherapy after one year of treatment.…”

Unilateral retinal vein occlusion in a seven-year-old boy with a high level of lipoproteins (a)

“…Compared to corticosteroids or anti-VEGF treatment alone, the combination of corticosteroids and anti-VEGF treatment resulted in better improvement of BCVA and prognosis, reduced risks of IOP elevation, fewer intraocular injections, and a longer mean time for anti-VEGF reinjection [25,26].…”

Comparison of efficacy of conbercept, aflibercept, and ranibizumab ophthalmic injection in the treatment of macular edema caused by retinal vein occlusion: a Meta-analysis

“…Growing evidence has shown that conbercept can effectively treat RVO-ME [11][12] . Previous systematic reviews and Meta-analysis have compared the effectiveness of anti-VEGF drugs in patients with RVO-ME [13][14][15] . Moreover, anti-VEGF therapy improves best corrected visual acuity (BCVA) and reduces central macular thickness (CMT) more effectively and longer than corticosteroid/laser [16] , although conbercept was excluded.…”