Author: Polona Jaki Mekjavic (Slovenia)
Co-authors: Dhariana Acon, Anat Loewenstein, Timothy Y.Y. Lai, Patricia A. D’Amore, Vincent Daien, Annabelle A. Okada
Studies have demonstrated that 66–100% of patients with retinal disease receiving treatment with intravitreal injections (IVI) of anti-vascular endothelial growth factor (VEGF) experience an immediate rise in intraocular pressure (IOP), while according to some authors, 4–15% of patients may develop long-term ocular hypertension. Consensus is required on the optimal management of IOP elevation for ophthalmologists treating patients with anti-VEGF IVI.
A team of retinal disease experts from the Vision Academy collaborated to develop recommendations on key principles for managing elevation in IOP that results from anti-VEGF IVI. The Vision Academy comprises over 90 international retinal experts who collaborate to provide collective recommendations on clinical challenges in areas where there is a lack of conclusive evidence. Vision Academy recommendations are subject to a validation process to ensure there is consensus and endorsement from the entire group.
Literature searches were performed using the MEDLINE/PubMed database; the cut-off date was November 2020 and searches were restricted to English-language publications. The results were used to inform the Vision Academy recommendations.
Risk factors for IOP elevation during anti-VEGF treatment include previous diagnosis/family history of glaucoma, history of retinal vein occlusion, frequent injections, and higher pre-treatment IOP. Topical anti-glaucoma monotherapy is often sufficient to reverse moderate IOP elevation; some patients may require 2–4 medications, laser trabeculoplasty, or filtering surgery. Patients with sustained IOP elevation require regular assessment by a glaucoma specialist to ensure optimized treatment/monitoring. Measurement of IOP and direct observation of the optic disc should be performed prior to each injection. Additional monitoring may include automated static perimetry and optical coherence tomography for retinal nerve fiber layer imaging at baseline and every 8–12 months. For patients with retinal vein occlusion or severe diabetic retinopathy, gonioscopy should be performed at baseline and every 4–6 months to exclude angle neovascularization. For patients with advanced glaucoma or reduced retinal nerve fiber layer thickness, IOP should be measured after each injection and prophylactic anti-IOP treatment prior to each IVI considered. Post-injection acetazolamide may be required where glaucomatous optic neuropathy is progressing despite IOP-lowering treatments. As higher IVI frequency has been linked to IOP elevation, switching to a treat-and-extend regimen may reduce the risk of visual function loss due to glaucoma.
Ophthalmologists should be aware of the risk factors for IOP elevation in patients receiving anti-VEGF IVI, and they should ensure appropriate monitoring and treatment with the involvement of a glaucoma specialist. The risk of decline in visual function due to glaucoma versus retinal disease must be balanced; if a critical stage of glaucoma is reached, discontinuation of anti-VEGF IVI may need to be considered.
The Vision Academy is supported by Bayer. Writing and editorial assistance was provided by Hollie Robinson, PhD and Rebecca Fletcher, (BA) Hons, of Complete HealthVizion, Ltd., McCann Health Medical Communications, funded by Bayer Consumer Care AG, Pharmaceuticals, Basel, Switzerland. PJM received honoraria for consultancy and lecture fees from Bayer, Novartis, and Roche. DA received lecture fees from Bayer HealthCare Pharmaceuticals. AL is a consultant for Allergan, Bayer, Kanghong, Novartis, Roche, ForSight Labs, and Notal Vision. TYYL received honoraria for consultancy and lecture fees from Bayer HealthCare Pharmaceuticals, Novartis, and Roche. PAD is on the Scientific Advisory Board of Glauconix, Inc. and Novelty Nobility Inc., is a consultant for Abpro Corporation and INGENIA Therapeutics, and is co-founder of SAYHT Therapeutics. VD received honoraria from Bayer and Theapharma. AAO received research grants from Alcon Pharma, Bayer Yakuhin, Mitsubishi Tanabe Pharma, Novartis Pharma, and Santen, and personal fees from AbbVie Japan, Alcon Pharma, Allergan Japan, Astellas Japan, Bayer Healthcare AG, Bayer Yakuhin, Biocon Biologics, Chugai, Daiichi-Sankyo, Mitsubishi Tanabe Pharma, Novartis Pharma, Otsuka, Senju, and Santen.