Central retinal vein occlusion (CRVO)

Outline:
Laser - CVOS
Ranibizumab - CRUISE > HORIZON > RETAIN, RELATE, CRYSTAL
Aflibercept - GALILEO + COPERNICUS
Avastin vs Lucentis vs Eylia: LEAVO
Steroids - SCORE, GENEVA, SHASTA, COMRADE-C



Central Vein Occlusion Study (CVOS) 1995 ⏩
n=181, 3y
Study questions: Scatter laser for CME vs observation. Prophylaxis of NV with PRP after CRVO?Study resutls: Ischemic or non-perfused CRVO defined in this study as >10DA of CNP. Grid Laser improved CME, not VA therefor not indicated. NVI risk reduced by PRP from 34% to 20%, prophylactic PRP-not beneficial. 10% of perfused CRVO had developed NVI/NVA compared to 35% of ischemic CRVOs. At 3 years, there was a 45% of NVG in ischemic CRVO. 16% of initially nonischemic CRVOs converted to ischemic by 4 months of follow-up, 34% of initially perfused eyes converted to nonperfused status after 3 years.

A Randomized Trial Comparing the Efficacy and Safety of Intravitreal Triamcinolone With Standard Care to Treat Vision Loss Associated With Macular Edema Secondary to Central Retinal Vein Occlusion The Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE), 2009 ⏩
N=271, 1y
Study question: Observation vs IVT triamcinolone 1mg VS 4mg for CME d/t CRVO (and BRVO)
Results: Gained 15 ETDRS letters: 29% in laser, 27% for 1mg, 26% for 4mg, 7% observation. IVT steroid better than observation. Average 2 inj in 1 year. Elevated IOP and cataract were similar for the observation and 1-mg groups, but higher in the 4-mg group. See SCORE2 from 2017.

Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion (GENEVA), 2010 ⏩
n=1267, 6m
Study question: Dexamethasone intravitreal implant (OZURDEX) 0.7mg vs 0.35mg vs sham for macular edema d/2 CRVO (and BRVO).

Results: Improvement in BCVA was seen in 1w, greater in both DEX implant groups compared with sham at all follow-up visits, peaked at 60w (~9 letters) and returned to base-line by 6m. IOP of > or =25 mmHg peaked at 16% at day 60 (both doses) and was not different from sham by day 180. No significant difference in secondary cataract. 12.5% had IOP elevation of 10mm or more. See also the SHASTA study from 2014 below.

Ranibizumab for Macular Edema following Central Retinal Vein Occlusion (CRUISE), 2010 ⏩ 

n=392, 12m

Study question: Ranibizumab 0.3mg VS 0.5mg VS sham for ME d/t CRVO. 6 q1m injections then PRN (sham switched to PRN). Study results: Gain-13.9 letters. Improvements from baseline are maintained with PRN.  50% less injections with PRN. See extension HORIZON published in 2012.

Ranibizumab for macular edema due to retinal vein occlusions: long-term follow-up (HORIZON), 2012 ⏩ (there is a HORIZON for DME as well).
n=304 from CRUISE + 304 from BRAVO, 12mo
Study question: This is an extension of CRUISE see above (and BRAVO). All patients on PRN of Ranibizumab q3m. Study results: The mean change from baseline BCVA at month 12 in CRVO patients was -4.2 (sham/0.5 mg), -5.2 (0.3/0.5 mg), and -4.1 (0.5 mg), respectively. PRN at q3m yields deterioration of VA. No new safety issues. See extension RETAIN from 2014.


Long-term Outcomes in Patients with Retinal Vein Occlusion Treated with Ranibizumab (RETAIN), 2014 ⏩
n=34 BVO, 32 CRVO. 2y extension. Mean-49m
Study Question: Pateints from BRAVO and CRUISE. Long term follow-up with Ranibizmab + Scatter. Study results:  44% had edema resolution & improvement in BCVA (25.2 vs. 4.3 letters for unresolved edema). Mean number of injections in unresolved patients in year 4 was 5.9. Final BCVA of 20/40 or better was 64.3% vs. 27.8%. Nine received scatter, only 1 had resolution of edema.



Efficacy and safety of two or more dexamethasone intravitreal implant injections for treatment of macular edema related to retinal vein occlusion (Shasta study), 2014 ⏩
n=289, 3m s/p last injection
Study question: Retrospective study looking at efficacy of multiple ozurdex injections since GENEVA (see aboce) patients had only 1-2.Study results: 2-9 injectiosn, mean 3.2. Mean interval 5.6 months. 59.7% of BRVO and 66.7% of CRVO gained ≥ 2-lines. IOP increase (≥ 10 mmHg) occurred in 32.6% of patients; 29.1% needed topical tx. 1.7% of patients required incisional glaucoma surgery

Scatter Photocoagulation Does Not Reduce Macular Edema or Treatment Burden in Patients with Retinal Vein Occlusion (RELATE), 2015 ⏩
CRVO n=39, BRVO n=42. 144w
Study question: Ranibizumab 0.5 or 2mg for 24w. 6 mandatory inj. Then PRN with Laser VS without laser. Study results: Dosage did not differ in VA. 2mg had better CMT. Laser did not effect burden or # inj, did cause elevation in CMT


Intravitreal aflibercept injection for macular edema due to central retinal vein occlusion
COPERNICUS (2014) ⏩, GALLILEO (2014) ⏩, Combined results (2017) ⏩
n=188 + 177. 24m
Study question: Two parallel studies. Aflibercept for CME d/t CRVO vs sham. 24 weeks of q1m, then PRN q1m till 52w. 2nd year PRN q3m. Study results: At 6 months there was a mean gain of 18 letters with monthly tx, and this was slightly reduced to 13-14 when tx was switched to PRN with a mandatory injection at least every 3 months

Clinical Efficacy and Safety of Ranibizumab Versus Dexamethasone for Central Retinal Vein Occlusion (COMRADE C): A European Label Study, 2016 ⏩
n=243, 6m
Study question: monthly Ranibizumab followed by PRN VS 1 Ozurdex with PRN sham. Study results: average BCVA gain was significantly higher with ranibizumab (12.86 vs 2.96 letters). Mean injection number of Ranibizumab was 4.52. More ocular AEs in the dexamethasone group (86.6% vs 55.6%). $ Novartis. See COMRADE B for BRVO.

Effect of Bevacizumab vs Aflibercept on Visual Acuity Among Patients With Macular Edema Due to Central Retinal Vein Occlusion (SCORE2), 2017 ⏩
n=362, 6m
Study question: macular edema due to central retinal or hemiretinal vein occlusion. Bevacizumab (1.25 mg; n = 182) VS Aflibercept (2.0 mg; n = 180) q4w.
Study results: mean increase from baseline of 18.6 in the bevacizumab group VS 18.9 for aflibercept: meeting criteria for noninferiority. See SCORE from 2009.



Sustained Benefits from Ranibizumab for Central Retinal Vein Occlusion with Macular Edema: 24-Month Results of the CRYSTAL Study, 2018 ⏩
n=257, 24mo
Study question: PRN regimen after 3 mandatory monthly Ranibizumab inj. Study results: Mean gain in BCVA at month 24 was 12.1+ letters. VA gains were similar in patients with or without baseline macular ischemia. Higher gain when CRVO duration <3 months (13.2 vs 10.5 letters when duration > 9mo). Mean # injections up to month 23 was 13.1.


Clinical Effectiveness of Intravitreal Therapy With Ranibizumab vs Aflibercept vs Bevacizumab for Macular Edema Secondary to Central Retinal Vein Occlusion (LEAVO), 2019 ⏩
n=463, 100w
Study Question: Ranibizumab vs Aflibercept vs Bevacizumab for CME secondary to CRVO.
Study Results: aflibercept  noninferior to ranibizumab. Bevacizumab non-inferior to  ranibizumab
 change in vision at 100 weeks for eyes with CRVO-related macular edema. The mean gain in BCVA letter score was 12.5 for ranibizumab, 15.1 for aflibercept, and 9.8 for bevacizumab. Fewer aflibercept injections (10.0) compared with ranibizumab (11.8).



Abbreviations used on this page:
# - count, number
$ - Study financial support, when relevant
CME - central macular edema

CNP - Capillary non-prefusion
CRVO - Central vein occlusion

DA - disc area
d/t - due to
inj - injections
mo - months
NV - Neo-vascularization

NVG - neo-vascular glaucoma
NVI - New-vascularization of iris

PRN - Pro re nata, monthly follow-up with treatment as needed
PRP - Pan-retinal photocoagulation
RNZ - Ranibizumab

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🚧 Last update: May 30th 2021. This page is still under construction as we have many more papers to add, if you have any suggestions just send us a line using the "contact us" form at the bottom of the page