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Bevacizumab for neovascular
age-related macular degeneration in Chinese patients in a clinical setting
Danny Siu-Chun Ng1,
Alvin
Kwan-Ho Kwok2, Justin Man-Kit Tong3, Clement Wai-Nang Chan1,
Walton Wai-Tat Li2
1Department of
Ophthalmology & Visual Sciences, the Chinese University of Hong Kong, Hong
Kong, China
2Department of
Ophthalmology, Hong Kong Sanatorium and Hospital, Hong Kong,
China
3Department of
Ophthalmology, United Christian Hospital, Hong Kong, China
Correspondence
to: Alvin Kwan-Ho Kwok.
Department of
Ophthalmology, Hong Kong Sanatorium and Hospital, 5/F, Central Block
2 Village
Road, Happy Valley, Hong Kong, China. alvinkwok@hksh.com
Received: 2015-02-05 Accepted: 2015-07-10
Abstract
AIM: To determine the outcome
of non-investigational treatment with intravitreal bevacizumab
(IVB) in
neovascular age-related macular degeneration (AMD) patients.
METHODS: Retrospective chart
review of 81 eyes with neovascular AMD followed-up for at least 12mo and
received 3-monthly loading IVB injections. Re-treat was based upon the
individual clinician’s judgment. Best-corrected visual acuity (BCVA) and
optical coherence tomography measurements of central foveal thickness outcomes
were evaluated at 12, 24mo.
RESULTS: Eighty-one eyes (of 75
patients) completed 12mo of follow-up and 44 eyes (of 41
patients) completed 24mo of follow-up. The mean baseline
logMAR BCVA significantly improved from 0.94±0.69 to 0.85±0.68 at 12mo (P<0.001) and from 0.91±0.65 to 0.85±0.60 (P=0.004) at 24mo. The proportion of eyes that
lost <15 logMAR letters at 12mo was 90.1% and at 24mo was 81.8%. IVB was
effective in improving visual acuity in both treatment naïve and previous
photodynamic therapy (PDT)-treated subgroups. Treatment naive patients required
significantly fewer injections than patients with prior PDT. Multiple
regression analysis identified that poorer baseline visual acuity was
associated with greater improvement in visual acuity (P=0.015).
CONCLUSION: Fewer injections in
clinical practice may result in suboptimal visual outcomes compared with
clinical trials of IVB in neovascular AMD patients. Poor baseline visual acuity
and prior PDT treatment may also improve vision after IVB. The safety and
durability of effect was maintained at 24mo.
KEYWORDS: bevacizumab; age-related macular
degeneration; Chinese
Citation: Ng DS, Kwok AK, Tong JM, Chan CW, Li WW.
Bevacizumab for neovascular age-related macular degeneration in Chinese
patients in a clinical setting. Int J Ophthalmol 2016;9(3):424-430
INTRODUCTION
In recent
years, the development of vascular endothelial growth factor (VEGF) inhibitors
that can be intravitreally injected has revolutionized the therapeutic approach
for neovascular age-related macular degeneration (AMD). Tightly controlled
multicenter randomized controlled studies have convincingly shown the treatment
benefits for neovascular AMD patients with ranibizumab (Lucentis, Genetech, San Francisco,
California, USA), bevacizumab (Avastin, Genetech, San Francisco, California,
USA) and aflibercept (Eylea, Bayer Healthcare Pharmaceuticals,
Berlin, Germany)[1-5]. Ranibizumab is licensed for AMD
since 2007 and aflibercept in 2012. Both drugs are approved by the National
Institute for Health and Clinical Excellence in United Kingdom and the Hospital
Authority in Hong Kong, whereas bevacizumab is not. Given the substantial
higher costs of ranibizumab and aflibercept, many private patients still prefer
off-label use of bevacizumab for AMD. Nevertheless, in clinical trials, rigid
treatment and follow-up protocols are usually mandated and patients are
recruited according to strict inclusion and exclusion criteria to ensure
validity of results. Furthermore, a heavy treatment burden on all parties involved
in routine clinical practice has led to dosing regimens that are less intensive
than those used in clinical trials, such as the PrONTO and treat-and-extend
regimens[6-7]. It is uncertain whether identical outcomes from
clinical trials will be replicated in the wider community in everyday practice.
Here, we describe the safety and efficacy of intravitreal bevacizumab (IVB)
over 12-24mo of non-investigational treatment in a non-selected
population of neovascular AMD patients.
SUBJECTS
AND METHODS
The study was performed in
accordance with the standards of the Declaration of Helsinki and was approved
by the Institutional Review Board of the Hong Kong Sanatorium and Hospital.
Patients were informed about the off-label conditions of IVB. Women of childbearing
age were also informed about the possible risks to the fetus and contraception
was advised throughout the following 3mo after injection. At each
post-injection visit, patients were monitored for ocular side effects [best-corrected visual
acuity (BCVA), intraocular pressure (IOP) measurements, indirect
ophthalmoscopy, slit-lamp biomicroscopy] and systemic side effects
(medication changes, high blood pressure, signs of cerebrovascular accidents,
myocardial infarctions or ischemia).
Since June 5th,
2006, every patients receiving anti-VEGF injection
(ranibizumab and bevacizumab) in the injection room of the outpatient clinic at
the Hong Kong Sanatorium and Hospital would have a prospectively designed audit
form that the respective doctor had to fill out and then filed. Another
injection logbook also recorded the date, patient name, and doctor name of
every injection. The medical records of all such cases from June 5th,
2006 to December 17th, 2010 were reviewed. All Chinese patients >50y
with provisional diagnosis of neovascular AMD followed-up for at least 12mo and received
IVB
injections were included in the study regardless of baseline visual acuity,
choroidal neovascularization (CNV) size, location (subfoveal or juxtafoveal)
and composition (classic lesions including both predominantly and minimally
classic types, or occult lesions). In all patients, the baseline fluorescein angiography (FA) was independently
assessed by two of the investigators (Ng DS and Tong JM) to confirm CNV leakage
and lesion composition. Lesions obscured by severe subretinal haemorrhage were
categorized as undetermined. The exclusion criteria were: 1) history of
photodynamic therapy (PDT) or intravitreal triamcinolone (TA) during
follow-up period after bevacizumab; 2) any form of combination therapy; 3) cataract extraction
after bevacizumab; 4) CNV attributable to any cause other than AMD (such
as myopic degeneration); 5) either polypoidal choroidal
vasculopathy or retinal angiomatous proliferation confirmed by indocyanine green
angiograph; 6) presence of comorbid ocular conditions, particularly
diabetic retinopathy, that might compromise visual acuity.
All patients received a
comprehensive baseline ophthalmological examination, including
BCVA, IOP measurements, indirect
ophthalmoscopy and slit-lamp biomicroscopy. The documented findings from
Stratus optical coherence tomography (OCT) (Carl Ziess, Dublin, CA, USA) and FA
were
reviewed. BCVA was recorded in Snellen decimal values and converted to the
logarithm of the minimal angle of resolution (logMAR) units. Visual acuity of
counting fingers was equal to 2.30 logMAR units (decimal Snellen acuity of
0.005) and hand movement was equal to 2.70 (decimal Snellen acuity of 0.002).
BCVA was converted to logMAR letters for standardization with the published
results from clinical trials.
Details of the standard
protocol for IVB injection have been reported previously[8]. The
intravitreal doses of 1.25 mg bevacizumab was injected in an
office setting by 8 ophthalmologists using 30-guage needle at 3.5-4 mm post-limbus.
Prophylactic topical antibiotics were applied for a few days to 1wk after the injection.
Bevacizumab injection was given at the baseline visit, with a fixed 4-6 weekly
injection regimen for the next 2mo. No defined protocol for
re-treatment was available, and the decision to re-treat was based upon the
individual clinician’s judgment on the presence of persistent subretinal fluid,
new onset of macular hemorrhage, worsening visual acuity, increased retinal
thickening by OCT and/or increased leakage of CNV assessed by FA.
At each follow-up visit,
data were collected on the patients’ BCVA, whether they received retreatment,
OCT measurements (if available), adverse ocular and systemic events, and the
date of visit. The visits closest to the time points at 1, 3, 6, 12, 18, 24mo were analyzed.
Statistical analysis was performed using SPSS (SPSS Inc. Chicago, IL, USA).
Two-tailed paired t tests were used to compare visual acuities between
different time points and unpaired t tests for comparison of parametric
continuous variables between subgroups. Categorical variables were compared
using Chi-square test. Multivariate analysis by linear regression was performed
to evaluate the association of pretreatment covariates including age, gender,
prior treatment with PDT, CNV lesion type, greatest linear diameter (mm) of
CNV, baseline BCVA, baseline central foveal thickness (CFT) measured by OCT and
duration of symptoms (mo) as reported by patients. The mean BCVA change at 12, 24mo from baseline were chosen
as the outcomes for multivariate analysis. A P value of <0.05 was considered statistically significant.
RESULTS
Of the 118 cases with CNV
secondary to AMD, 81 eyes of 75 patients met the inclusion criteria with
follow-up of 12mo. From these cases, 44 eyes (of 41 patients) completed
24mo of
follow-up. The mean±standard deviation
follow-up period for all included patients was 22.7±10.6mo. Patients’ demographics and clinical characteristics
are presented in Table 1.
Table 1 Demographics and clinical characteristics of
neovascular AMD patients who completed 12 and 24mo of follow-up 
, n (%)
|
Parameters |
12mo |
24mo |
|
No.
of eyes |
81 |
44 |
|
Male |
41 (50.6) |
20 (45.5) |
|
Female |
40 (49.4) |
24 (54.5) |
|
Age (a) |
77.04±8.86 |
76.43±8.64 |
|
Past health |
|
|
|
Hypertension |
46 (56.8) |
20 (59.1) |
|
Smoker |
11 (13.6) |
5 (11.4) |
|
Taking antiplatelet drugs |
13 (16.0) |
6 (13.6) |
|
Cerebrovascular accident |
2 (2.5) |
1 (2.3) |
|
Past ophthalmic history |
|
|
|
Pseudophakic |
51 (63.0) |
28 (63.8) |
|
Glaucoma |
8 (9.9) |
6 (13.6) |
|
Duration of symptoms (mo) |
5.7±5.2 |
5.6±5.3 |
|
Previous treatments |
|
|
|
Prior PDT treatment |
20 (24.7) |
16 (36.4) |
|
Previous TA |
1 (1.2) |
1 (2.3) |
|
Previous pars plana vitrectomy |
4 (4.9) |
4 (9.1) |
|
FA findings |
|
|
|
CNV lesion size (MPS DA) |
2.84±2.49 |
2.37±2.23 |
|
Classic type |
8 (9.9) |
5 (11.4) |
|
Occult type |
22 (27.2) |
18 (40.9) |
|
Juxtafoveal CNV |
4 (4.9) |
2 (4.5) |
|
Treatment dosing and frequency |
|
|
|
Dose of 2.50 mg IVB |
5 (6.2) |
3 (6.8) |
|
No. of patients required retreatment |
36 (44.4) |
25 (56.8) |
|
No. of Injections |
4.7±2.4 |
9.2±6.1 |
MPS
DA: Macular photocoagulation study disc areas.
The mean baseline BCVA in
logMAR units of the 81 eyes was 0.94±0.69. This improved to 0.85±0.63 at the 3mo (P<0.001)
(Figure 1A). The statistically significant improvement of visual acuity was
maintained at 12mo (P<0.001),
and the mean BCVA in logMAR units was 0.85±0.68 with a mean gain of 0.10±0.67 logMAR units from baseline. For the 44 eyes that
completed 24mo of follow-up, the mean BCVA in logMAR units improved
significantly from baseline 0.91±0.65 to
0.82±0.60 at 12mo (P=0.002) and 0.85±0.60 (P=0.004)
at 24mo (Figure 1B). The slight drop in vision from 12mo to 24mo was not statistically
significant (mean change=0.03 logMAR units, P=0.085). The mean gain of BCVA at 24mo was 0.06±0.59 from baseline. The mean number
of injections given during the 12mo and 24mo periods were 4.6 (range
3-10) and 9.2 (range 3-21), respectively.
Figure 1 Changes in the mean
logarithm of the minimum angle of resolution (logMAR) BCVA following IVB
treatment A: Eyes (n=81)
that completed 12mo of follow-up; B: Eyes (n=44) that completed 24mo of follow-up.
For comparison with
clinical trials, visual acuity was converted into logMAR letters (Table 2). The
number of eyes that gained >15 logMAR letters was 27 out of 81 eyes
(33.3%) at 12mo and 12 out of 44 eyes (27.3%) at 24mo. The number of eyes that
lost <15 logMAR letters at 12mo was 73 out of 81 eyes
(90.1%) and at 24mo was 36 out of 44 eyes (81.8%).
Table 2 Comparisons of 1y
results from clinical trials with the present study
|
Clinical trials |
ANCHOR[2] |
MARINA[1] |
PIER [9] |
PrONTO[6] |
CATT (ranibizumab-monthly)[3] |
CATT (bevacizumab-monthly)[3] |
CATT (ranibizumab-as needed)[3] |
CATT (bevacizumab-as needed)[3] |
Present study |
|
Eyes that lost ＜15 letters (%) |
96.4 |
94.6 |
90.2 |
95.0 |
94.4 |
94.0 |
95.4 |
91.5 |
90.1 |
|
Eyes that improved by 15
or more letters (%) |
40.3 |
33.8 |
13.1 |
35.0 |
34.2 |
31.3 |
24.9 |
28.0 |
33.3 |
|
Mean BCVA change
(letters) |
+11.3 |
+7.2 |
-0.2 |
+9.3 |
+8.5 |
+8.0 |
+6.8 |
+5.9 |
+4.8 |
|
No. of
Injections |
12 |
12 |
6 |
5.6 |
12 |
12 |
6.9 |
7.7 |
4.6 |
The mean CFT at baseline
was 310.82 µm and was decreased to 214.41 µm at 12mo (n=81) and 217.26 µm at 24mo (n=44). The mean reduction of CFT
compared with baseline was statistically significant; 119.44 µm at 12mo (P=0.001) and 116.73 µm at 24mo (P=0.026) (Figure 2).
Figure 2 Changes in the mean OCT CFT (µm) following IVB
treatment A: Eyes (n=81) that completed 12mo of follow-up; B: Eyes (n=44)
that completed 24mo of follow-up.
The
mean gain in BCVA in treatment naïve patients was 0.02±0.46 (P=0.025) and 0.06±0.69 (P=0.032)
logMAR units at 12mo (n=61) and 24mo (n=28), respectively. The mean gain in BCVA of
the subgroup of patients with prior PDT was 0.10±0.15 (P=0.035) and
0.11±0.13 (P=0.044) logMAR units at 12mo (n=20) and 24mo (n=16),
respectively. This subgroup required a mean of 6.6 injections during the first
12mo,
which was significantly more than the treatment naïve group (mean
injections=4.0, P=0.002). This
statistically significant difference was maintained throughout the second year;
in which the prior PDT group (n=16)
received a mean of 5.5 injections and the treatment naive group received a mean
of 2.8 injections (P=0.014). The mean
time interval from the previous PDT till first IVB injection was 5.27±3.70mo. Pretreatment
characteristics had no statistically significant difference between treatment
naive
and prior PDT groups. Multiple linear regression analysis
was performed with all baseline factors: age, gender, CNV size, CNV lesion
subtypes, duration of CNV, previous PDT treatment and baseline CFT had no
association with change in BCVA at 12mo. Only baseline visual acuity was a
significant predictor of mean BCVA change at 12mo (regression coefficient B=1.68, P=0.015) and at 24mo (regression coefficient B=0.705, P=0.024) in regression model.
DISCUSSION
The perceived clinical
similarities to ranibizumab and the much cheaper cost of bevacizumab had led to
its widespread use in ophthalmic patients even before data was available from
clinical trials of head-to-head comparison between the two drugs. Comparison of
AMD treatments trial was a two-year investigation that enrolled and randomized
1107 patients with CNV into four different treatment groups: ranibizumab or
bevacizumab in a monthly or an as-needed regimen[3-4]. The study was performed without financial support
from the pharmaceutical industry, a rarity for prospective trials of this size.
At 12mo, bevacizumab administered monthly was equivalent to
ranibizumab administered monthly, with 8.0 and 8.5 ETDRS letters gained,
respectively. Bevacizumab administered as needed was equivalent to ranibizumab
as needed, with 5.9 and 6.8 ETDRS letters gained respectively[3].
Our study obtained a mean gain of 4.76 letters at 12mo. The proportion of
patients who gained >15 letters was 33.3%, which was similar
to the results from randomized control trials (RCTs) (Table 2). However, the
proportion of patients who did not have a decrease in visual acuity of 15 letters
or more from baseline was slightly lower (90.1%) in our series when compared
with the cohorts in clinical trials (Table 2). Similar to the CATT study, most
of the change in mean visual acuity occurred during the first year, with
relative little change during the second year[4]. Nonetheless,
for patients that completed 24mo of follow-up in this study, 27.3% of
eyes gained >15 letters and 81.8% lost <15 letters.
One of the potential
reasons for less optimal visual outcome in our study compared with clinical
trials is the lower mean number of injections (4.6 vs 7.7
in CATT year 1, and 9.2 vs 14.1 in CATT year 2). Such
discrepancy in visual outcome of IVB treatment in routine clinical practice was
attributed to poorer compliance to treatment protocol, longer time intervals
between follow-up visits, less number of follow-up OCTs performed and fewer
reinjections[10-16]. The Swedish Lucentis Quality
Registry found a good improvement in visual acuity after 3 injections of ranibizumab,
but this subsequently dropped back to pretreatment levels[13]. Similar
results were found by the WAVE study in Germany and in the French Lumiere study[10,14-15]. Nonetheless, in a multi-center prospective audit of
12mo
outcomes of anti-VEGF for 1140 treatment-naïve AMD patients in Australia that
received a higher mean number of injections (7 injections) than previous
observational studies, the reported improvement was 4.7 logMAR letters, which
was still somewhat less than the visual gain in phase 3 clinical trials[16].
Besides the number of injections, case selection, methods in visual acuity
measurement [using Snellen charts, early treatment diabetic retinopathy
study (ETDRS) charts or electronic visual-acuity tests], OCT parameters in
monitoring disease activity and treatment regimens also contributed to the
differences in visual outcomes in observational studies compared with clinical
trials.
Our study observed that
the greatest increase in visual acuity in the subgroup of patients with baseline
visual acuity <20/320 and patients with poorer visual acuity were not
recruited in clinical trials. Furthermore, our study revealed that the only
statistically significant covariate that influenced visual outcome identified
by regression analysis in our study was baseline BCVA. The MARINA and ANCHOR
subgroup analyses recognized that the most important predictors of visual
acuity outcomes were baseline visual acuity, followed by CNV lesion size and
age[17-18]. It implied that patients with lower baseline visual
acuity probably had a greater chance for improvement from baseline over time
(ceiling effect), and vice versa (floor effect) for those with higher baseline
visual acuity (floor effect). Baseline predictors for 1y visual outcome identified
in CATT study were age, CNV lesion size, and elevation of retinal pigment
epithelium[19]. These predictors did not vary by treatment group
(ranibizumab vs bevacizumab, monthly vs as-needed injections). Our study did
not find a statistically significant association between CNV lesion size and
age in our series, possibly because the sample size was not large
enough and associations between age and CNV lesion size with visual outcome
were weak. Nevertheless, our study has shown that bevacizumab is efficacious in
neovascular AMD patients whose baseline visual acuity is below those who were
recruited in RCTs.
Subgroup analysis in our
study revealed no statistically significant difference in baseline
characteristics and visual outcomes at 12, 24mo between treatment naïve
and prior PDT patients. Carneiro et al [20]
also reported
that bevacizumab was effective in improving visual acuity without a
statistically significant difference between the two groups. Jyothi et al[21]
reported 2 cases of RPE rip at the extrafoveal edge of fibrotic lesion after
anti-VEGF injections in their series of 25 prior PDT-treated eyes. None of the
subjects had increased RPE atrophy and the majority had improved or stabilized
vision (loss of <15 ETDRS letters) at 6mo. Patients who had prior
PDT in our series required significantly more mean number of injections per
year than treatment naive patients at 12mo, possibly because these
patients were more prone to recurrence or persistence of CNV. In theory, prior
PDT may increase retinal and subretinal fibrosis and induce choriocapillary
atrophy which could limit the potential visual recovery of patients subjected
to anti-VEGF[22]. Nevertheless, in clinical
practice, patients who had reactivated or persistent CNV after PDT could still
benefit from IVB because the two therapies may have different mechanisms in
treating neovascular AMD[23].
No significant vision
threatening ocular side effects, such as endophthalmitis and retinal
detachment, occurred in this series during the entire period of follow-up. Nonetheless,
the sample size in our series may be too small to detect ocular adverse events
following IVB. McCannel[24] reported the incidence of
endophthalmitis was 0.049% (approximately 1 of 1949 injections) in a
meta-analysis of 105 531 injections from all major U.S.-based studies from
2005-2010. Arevalo et al[25]
reported no systemic adverse events in the group of neovascular AMD patients
that received 1.25 mg, but for the group that received 2.50 mg, the incidences
of systemic adverse events was higher (2.6% had arterial hypertension and 1.3%
had stroke). No systemic adverse event occurred in our series in which the
majority received 1.25 mg bevacizumab and only 5 patients received 2.50 mg.
There were no differences
in endophthalmitis rates or mortality between treatment groups in the CATT
study, however, more patients that received bevacizumab had multiple systemic
serious adverse events than those receiving ranibizumab, 24% vs 19% at 1y and 40% vs 32% at 2y[3-4]. Nonetheless, these adverse events were distributed
across a wide range of organ class, and many seemed unrelated to VEGF
suppression. These adverse events included infections, palpitations and
accidents. In the inhibition of VEGF in age-related choroidal
neovascularization (IVAN) trial, a United Kingdom-based study involving 610
patients comparing bevacizumab with ranibizumab, given either monthly or as
needed, there were more arteriothrombotic events and heart failure with
ranibizumab[26-27]. It has been argued that sample sizes of CATT and
IVAN trials were insufficiently powered to identify differences in drug-related
adverse events. The variable rates of adverse events amongst studied subjects,
and even amongst controls, may suggest type I error[28].
The hypothesis that the
greater binding affinity of aflibercept may equate to a clinically higher
efficacy and/or longer duration of action compared to ranibizumab was tested in
two phase-III non-inferiority studies, VIEW 1 and VIEW 2[5]. It was
demonstrated that both aflibercept monthly and aflibercept every two months
after three initial monthly doses groups were non-inferior to monthly
ranibizumab in terms of the amount of vision gained. Clinically, this may give
patients and physicians another therapeutic option that involves injection
every two months after three loading monthly doses, which could reduce the risk
associated with regular intravitreal injections and the treatment burden to
patients. In a trade-off analysis of efficacy and adverse events of
aflibercept, ranibizumab and bevacizumab in AMD patients, bevacizumab has some
disadvantages in severe side effects compared with the other two licensed
drugs, whereas the efficacy and side effect profiles of ranibizumab and
aflibercept were very similar[29].
Although many factors
determine the choice of anti-VEGF drugs for the treatment of AMD, their
significant difference in cost has been an important factor. The single-dose
cost of aflibercept (US$1850) is comparable to ranibizumab (US$1950), but still
substantially more than bevacizumab (approximately US$50)[29-32]. Since the
single-dose costs and efficacies of the two drugs are comparable, physicians’ use of aflibercept
instead of ranibizumab may largely depend upon their perceptions of the drugs’ durability. The cost of
treating patients with aflibercept 2 mg every 8wk may be approximately half
that with ranibizumab. Cost-conscious physicians, however, will also be forced
to consider the relative merits of more expensive, less frequent dosing with
aflibercept versus the more frequently dosed, lower cost alternative, off-label
bevacizumab. Given the rising demands for healthcare and limited budgets, local
evidence on incremental cost and cost-effectiveness is of particular importance
in deciding the treatment of choice in AMD patients.
Our study was limited by
small sample size. A larger sample size would have allowed for more power to
analyze differences across subgroups. The study evaluated patients who returned
for follow-up appointments, but patients who did poorly or exceptionally well
may have defaulted follow-up visits. Furthermore, there was no
standardized criteria for retreatment. We have converted Snellen acuities to
logMAR letters in an attempt to standardize our results with published clinical
trials for comparison; however, this may not match exactly with ETDRS visual
acuities[33-34]. There were two different dosages
of bevacizumab in this study. Considering the fact that ranibizumab has a
molecular weight approximately one third of bevacizumab, the dose of
bevacizumab containing the same number of molecules would be approximately 1.25
mg[35]. Some physicians
believed that increasing the dosage to 2.50 mg
could improve its efficacy. However, a head-to-head trial revealed no
difference in effect between the two dosages[35].
The significance of data
from observational studies is that they provide an indication of what is
happening in routine clinical practice, in contrast to results of tightly
controlled clinical trials, which may or may not be achievable in routine
practice. Our study can be useful in providing patients’ expectations for
visual stabilization or improvement after receiving less-than-monthly IVB, which may be a more
preferable treatment regimen especially when cost is a concern. More frequent
follow-up visits and OCT assessments of disease activity may optimize efficacy
in clinical practice. Furthermore, our study had revealed that bevacizumab may
be safe and efficacious in neovascular AMD patients who received prior PDT and
in those with baseline BCVA <20/320, while no evidence had been provided by
RCTs on these subgroups.
ACKNOWLEDGEMENTS
Conflicts of Interest:
Ng DS,
None; Kwok AK,
None; Tong JM, None; Chan CW, None; Li WW, None.
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