[Evaluation of Ophthalmic Follow-up Care of Former Pre-term and Full-term Infants Aged from 4 to 10 Years in Germany - Results of the Wiesbaden Prematurity Study (WPS)]. / Evaluation der augenärztlichen Versorgung ehemaliger früh- und reifgeborener Kinder im Alter von 4 bis 10 Jahren in Deutschland ­ Ergebnisse der Wiesbaden Prematurity Study (WPS).

BACKGROUND: The purpose of this investigation was to analyse the ophthalmic follow-up care of former pre-term and full-term born infants aged 4 to 10 years in the clinical practice and the comparison to the recommendations of the national ophthalmic guidelines. METHODS: For the prospective Wiesbaden Prematurity Study (WPS), 503 infants were examined: 239 former pre-term infants (PT) with gestational age (GA) ≤ 32 weeks and 264 former full-term born infants (FT) with a GA ≥ 37 weeks aged 4 to 10 years. Ophthalmic examination was performed including refractive measurements and orthoptic examination. Anisometropia was defined as a difference of ≥ 1 D spherical equivalent. Data was assessed if an ophthalmological examination was performed after hospital discharge, and how many times the ophthalmologist was contacted within the last 12 months. RESULTS: Overall, strabismus and anisometropia were present in 18 and 10% of all PT, and in 2 and 5% of all FT infants, respectively. In infants aged 4 to 6 years, 65% of all former PT and 42% of all former FT had ophthalmological contacts within the last year (p = 0.002). 15% of the pre-term infants with strabismus did not have an ophthalmological examination within the last year. The parents of three former pre-term infants reported that they never had an ophthalmologic examination after hospital discharge. CONCLUSION: Two-thirds of the former pre-term infants participated in a screening examination at the age of 4 to 6 years in the last year according to their parents, which is recommended by the guidelines for the care of former pre-term infants. There is still room for improvement to provide best ophthalmological care for this vulnerable population that have high risk for strabismus and amblyopia.

Onset of Retinal Pigment Epithelium Atrophy Subsequent to Anti-VEGF Therapy in Patients with Neovascular Age-Related Macular Degeneration.

PURPOSE: The aim of this study was to evaluate risk factors for the development of retinal pigment epithelium (RPE) atrophy in patients with neovascular age-related macular degeneration (nAMD). PROCEDURES: This post hoc analysis of the prospective RESPONSE study includes 52 therapy-naive nAMD patients without baseline RPE atrophy, who were treated with ≥9 anti-vascular endothelial growth factor (VEGF) injections for ≥3 years. RPE atrophy was assessed via multimodal imaging. Baseline aqueous VEGF and serum complement levels (C3d/C3) were measured. Risk factors for atrophy development were evaluated via logistic regression analysis. RESULTS: Atrophy onset was significantly associated with the duration of nAMD (mean 5.34 years; odds ratio = 1.83, p = 0.012). Anti-VEGF injection number, age, C3d/C3 ratio, baseline intraocular VEGF, or delay to the first treatment had no influence on RPE atrophy. CONCLUSIONS: The duration of treatment-requiring nAMD was identified as primary risk factor for the onset of concomitant RPE atrophy after commencing therapy. Targeting concomitant atrophy in nAMD patients might improve the long-term prognosis of the disease.

Correlation of morphological parameters and visual acuity with neurological development in former preterm children aged 4-10 years.

PURPOSE: The objective of this study was to investigate the relationship between visual acuity, peripapillary retinal nerve fibre layer (pRNFL), retinal thickness at the fovea and other factors with the neurologic status of former preterm children. METHODS: In this cross-sectional hospital based study in a maximum care tertiary centre, detailed anthropometric and ophthalmological data of former preterm children ranging from 4 to 10 years of age with a gestational age (GA) ≤32 weeks were assessed. Analyses of the correlation between pRNFL and foveal thickness, as well as visual acuity (VA) parameters at 4-10 years of age, with neurological development were evaluated at 2 years of age by Bayley Scales II of Infant Development, including Psychomotor Developmental Index (PDI) and Mental Developmental Index (MDI). RESULTS: Data were available for 106 former preterm children. Univariate analysis revealed a correlation between PDI with pRNFL thickness (B = 0.43; p = 0.013), VA (B = -29.2; p < 0.001), GA (B = 2.7; p = 0.002), retinopathy of prematurity (ROP; B = -16.3; p < 0.001) and intraventricular haemorrhages (IVH; B = -22.9; p < 0.001) but not with strabismus or foveal thickness. In the multivariable analysis, the association remained for visual acuity and IVH, but not for pRNFL thickness or ROP. Mental Developmental Index (MDI) was associated with visual acuity (B = -34.3; p = 0.001), GA (B = 2.53; p = 0.02) and IVH (B = -15.4; p = 0.02), the latter also in the multivariable analysis. CONCLUSION: This study revealed an association between PDI at 2 years of age and lower visual acuity later in childhood. However, there was no correlation between retinal morphology and neurologic outcome in former preterm children after adjusting for several potential confounders.

Prevalence and associated factors of strabismus in former preterm and full-term infants between 4 and 10 Years of age.

BACKGROUND: Limited data exist collating most of the associated factors for strabismus in one analysis. The aim of this study was to assess the prevalence of strabismus and to analyse associated factors in former preterm and full-term infants. METHODS: In this cross-sectional study, 239 former preterm infants with gestational age (GA) ≤ 32 weeks and 264 former full-term born infants with GA ≥ 37 weeks underwent detailed ophthalmologic examination in the age of 4-10 years and perinatal data assessment for risk factor analysis. Ophthalmologic examinations included cover testing, best corrected visual acuity, cycloplegic objective refraction, slit lamp as well as fundus examinations. For association analysis with strabismus, the following data was collected and included in multivariable analysis: sex, age at examination, anisometropia, myopic and hyperopic refractive error (≥ 3 dioptres), astigmatism, birth weight percentile, gestational age, retinopathy of prematurity occurrence, maternal age at childbirth, mother smoking, breastfeeding < 3 months, artificial ventilation, intraventricular bleeding, and other perinatal adverse events. RESULTS: Overall, 4/264 (2%) full-term infants, 15/125 (12%) preterm-infants with GA 29-32 weeks without ROP, 13/59 (22%) preterm infants with GA ≤ 28 weeks without ROP and 14/55 (26%) with GA ≤ 32 weeks with retinopathy of prematurity were affected by strabismus. In the multivariable regression model strabismus was associated with GA (OR = 0.84 per week; p = 0.001), hyperopic refractive error (OR = 4.22; p = 0.002) and astigmatism (OR = 1.68; p = 0.02). CONCLUSION: This investigation highlights that low gestational age and refraction of the eye are independent risk factors for strabismus, while the other factors show less independent influence.

Corneal Aberrations in Former Preterm Infants: Results From The Wiesbaden Prematurity Study.

Purpose: To compare corneal aberrations in former preterm infants to that of full-term infants. Methods: A prospective cross-sectional study was carried out measuring the corneal shape with Scheimpflug imaging in former preterm infants of gestational age (GA) ≤32 weeks and full-term infants with GA ≥37 weeks now being aged between 4 to 10 years. The main outcome measures were corneal aberrations including astigmatism (Zernike: Z2-2; Z22), coma (Z3-1; Z31), trefoil (Z3-3; Z33), spherical aberration (Z40) and root-mean square of higher-order aberrations (RMS HOA). Multivariable analysis was performed to assess independent associations of gestational age groups and of retinopathy of prematurity (ROP) occurrence with corneal aberrations adjusting for sex and age at examination. Results: A total of 259 former full-term and 226 preterm infants with a mean age of 7.2 ± 2.0 years were included in this study. Statistical analysis revealed an association of extreme prematurity (GA ≤28 weeks) with higher-order and lower-order aberrations of the total cornea. Vertical coma was higher in extreme prematurity (P < 0.001), due to the shape of the anterior corneal surface, while there was no association with trefoil and spherical aberration. ROP was not associated with higher-order aberrations when adjusted for gestational age group. Conclusions: This study demonstrated that specific corneal aberrations were associated with extreme prematurity rather than with ROP occurrence.

Macular morphology in former preterm and full-term infants aged 4 to 10 years.

OBJECTIVE: To analyse macular retinal and choroidal layer thickness in former preterm and full-term infants and to assess associated perinatal influence factors and functional correlation. METHODS: This prospective controlled, cross-sectional, hospital-based study in a tertiary center of maximum care examined former preterm infants with a gestational age (GA) ≤ 32 weeks and full-term neonates currently aged 4 to 10 years. We investigated data from 397 infants, analysing total foveal retinal thickness and six distinct macular retinal layer and choroidal layer measurements via spectral-domain optical coherence tomography. Multivariable linear regression analysis was performed to investigate associations of layer thickness with GA and retinopathy of prematurity (ROP). RESULTS: Total retinal thickness in the fovea was thicker in former preterm infants with GA ≤ 28 weeks and in those with GA between 29-32 weeks compared to full-term infants independently of ROP. Occurrence of ROP was also associated with increased foveal thickness. Ganglion cell layer together with inner plexiform layer (GCL+IPL) was thinner in infants with GA ≤ 28 weeks than in full-term infants at 1000 and 2000µm distance from the fovea, but no association with ROP was present. Similar results were found for the photoreceptor layer. Total foveal retinal thickness was associated with low visual function. CONCLUSION: This study identified low gestational age and ROP occurrence as main determinants for foveal thickening. Furthermore, thinned GCL+IPL measurements were associated with lower gestational age. This study highlights the prognostic value of these maturity parameters influencing retinal morphology, which may affect visual function.

Axial Length and Anterior Segment Alterations in Former Preterm Infants and Full-Term Neonates Analyzed With Scheimpflug Imaging.

PURPOSE: To compare the axial length and anterior segment alterations in preterm infants with and without retinopathy of prematurity with those of full-term infants. METHODS: The Wiesbaden Prematurity Study investigated 503 participants of former gestational age ≤32 weeks and gestational age ≥37 weeks now being aged 4 to 10 years. This study included 485 participants in the prospective controlled cross-sectional, hospital-based study with successful Pentacam Scheimpflug imaging. Anterior segment parameters, axial length measurements, and associated factors were analyzed. RESULTS: Corneal thickness did not differ between former preterm and full-term infants. Significant differences were found between preterm and full-term infants now aged ≤7 years for spherical equivalent, astigmatism, corneal diameter, and axial length. In preterm infants aged ≥8 years compared with full terms of the same age, we found a significant difference only in the corneal diameter. In multivariable analysis of the corneal diameter, we detected an association with birth weight and perinatal adverse events. Astigmatism correlated with birth weight and laser treatment, anterior chamber depth with birth weight, laser treatment and age at examination, and axial length with birth weight and age at examination. CONCLUSIONS: This study demonstrated altered axial length and anterior segment morphology in former preterm infants, especially in the first years of life. In addition, we observed that preterm infants seemed to catch up, so that the differences in ocular growth in terms of spherical equivalent, astigmatism, and axial length decreased within the first 8 years of life.

Functional analysis and associated factors of the peripapillary retinal nerve fibre layer in former preterm and full-term infants.

PURPOSE: The aim of the study was to investigate peripapillary retinal nerve fibre layer thickness (RNFLT) in former preterm infants and full-term neonates using spectral-domain optical coherence tomography (SD-OCT). METHODS: The prospective, controlled, cross-sectional, hospital-based study in a tertiary centre with maximum care examined 503 infants with a former gestational age (GA) of ≥37 and ≤32 weeks now aged between 4 and 10 years. In total, we analysed 432 participants with successful circular peripapillary RNFLT OCT measurements. Main outcome measures were RNFLT correlations to GA, birth weight, occurrence of retinopathy of prematurity (ROP), perinatal adverse events as well as functional correlation. RESULTS: Global RNFLT was thinner in infants with GA ≤28 weeks compared with infants with GA between 29 and 32 weeks (p=0.024), and to full-term neonates (p=0.007) independent of the occurrence of ROP. Multivariable analysis revealed that RNFLT was positively associated with higher birth weight and GA. Furthermore, a decrease of RNFLT was related to reduced visual function in all peripapillary sectors. CONCLUSIONS: The main factors for retinal nerve fibre layer thinning are low birth weight and low GA. In addition, decreased RNFLT was associated with reduced visual function. This demonstrates that preterm infants are at high risk for peripapillary RNFL damage associated with reduced visual function.

Retinal Nerve Fiber Loss in Anti-VEGF Therapy for Age-Related Macular Degeneration Can Be Decreased by Anterior Chamber Paracentesis.

PURPOSE: To analyze peripapillary retinal nerve fiber layer thickness (RNFLT) change after long-term intravitreal anti-VEGF therapy. Patients with regular anterior chamber paracentesis (ACP) prior to intravitreal injections (IVIs) were compared to those without ACP. METHODS: Neovascular age-related macular degeneration (nAMD) was treated in a pro re nata regimen with a minimum of 9 IVIs. RNFLT change was determined in spectral domain optical coherence tomography. RESULTS: In 32 patients without ACP, mean RNFLT loss (-2.16 ± 3.60 µm) was significantly higher than in 44 patients with regular ACP (0.16 ± 3.60; p = 0.029). Both groups were comparable in age (75.0 vs. 76.8 years; p = 0.35), number of IVIs (16.2 vs. 16.6; p = 0.98), and observational time (30.0 vs. 32.3 months; p = 0.32). In patients without ACP, RNFLT loss was higher compared to IVI-naive fellow eyes (p = 0.005), whereas in ACP patients, no difference was detected (p = 0.5). CONCLUSIONS: A moderate RNFLT loss is found in nonglaucomatous patients after injection therapy for nAMD. As it is decreased with regular ACP, tight management of intraocular pressure seems advisable.

Peripapillary Choroidal Thickness in Former Preterm and Full-Term Infants Aged From 4 to 10 Years.

Purpose: The aim of the study was to investigate peripapillary choroidal thickness in former preterm and full-term infants with spectral-domain optical coherence tomography (SD-OCT). Methods: Subanalysis of infants with successful peripapillary choroidal thickness measurements of a prospective, controlled, cross-sectional, hospital-based study in a tertiary center of maximum care. The study examined 503 infants aged 4 to 10 years at the time of examination. Infants were divided into different groups: group 1 born with gestational age (GA) ≥37 weeks, group 2 born with GA between 29 and 32 weeks without ROP (retinopathy of prematurity), group 3 born with GA ≤28 weeks without ROP, and group 4 born with GA ≤32 weeks and presence of ROP. Results: Peripapillary choroidal measurements were available for 388 of 503 participants. No significant differences were found among the four groups for global peripapillary choroidal thickness. Multivariable analysis revealed no association with low GA, birth weight, ROP occurrence, perinatal adverse events, and logMAR visual acuity. Only infants born small for GA (SGA) revealed peripapillary choroidal thinning in the superior (P = 0.033) and nasal (P = 0.024) sectors compared with infants born appropriate for GA (AGA). Infants SGA had lower visual acuity than AGA infants (0.03 ± 0.07 logMAR SGA versus 0.01 ± 0.05 logMAR AGA; P = 0.029). Conclusions: Our results indicate that prematurity itself does not affect choroidal thickness in the peripapillary region. Only infants born SGA revealed peripapillary choroidal thinning compared with AGA infants. Our data indicate that fetal growth restriction leads to choroidal long-term alterations in the peripapillary region.

Clinical correlation to differences in ranibizumab and aflibercept vascular endothelial growth factor suppression times.

AIM: To determine clinical correlations to intraocular vascular endothelial growth factor A (VEGF-A) suppression times (VSTs) on the treatment of neovascular age-related macular degeneration (nAMD) with ranibizumab (Lucentis) or aflibercept (Eylea). METHODS: Seven of 89 treatment-naïve nAMD eyes showed persistent choroidal neovascular membrane (CNV) activity throughout a spectral domain optical coherence tomography (SD-OCT)-driven pro re nata (PRN) regimen of intravitreal ranibizumab injections over 28±4 months. The treatment was switched to PRN aflibercept injections and patients were followed for another 15±2 months. A total of 160 aqueous humour specimens were collected before the intravitreal injections, and their VEGF-A concentrations were assayed by Luminex multiplex bead analysis (Luminex, Austin, Texas, USA). Intraocular VEGF-A concentrations were correlated to CNV activity shown by SD-OCT. RESULTS: The mean duration of suppression of VEGF-A concentrations in aqueous humour below the lower limit of quantification of our assay was 34±5 (26-69) days for ranibizumab and 67±14 (49-89) days for aflibercept (p<0.001). The percentual reduction of central retinal volume (CRV) 6 weeks after injection was higher for aflibercept compared with ranibizumab (p=0.009). The time point of clinical re-activity occurred about 50% earlier than the respective VST for each ranibizumab and aflibercept. CONCLUSIONS: The VST under aflibercept treatment exceeded that under ranibizumab treatment by a factor of 2. This difference correlated with differential clinical CRV reduction 6 weeks after the respective injection. For both medications, clinical activity was found at a time point as early as 50% of the individual VST. TRIAL REGISTRATION NUMBER: NCT01213667, post-results.

A genetic variant in NRP1 is associated with worse response to ranibizumab treatment in neovascular age-related macular degeneration.

OBJECTIVE: The aim of the study was to investigate the role of single-nucleotide polymorphisms (SNPs) located in the neuropilin-1 (NRP1) gene in treatment response to antivascular endothelial growth factor (VEGF) therapy for neovascular age-related macular degeneration (nvAMD). METHODS: Four SNPs in the NRP1 gene (rs2229935, rs2247383, rs2070296, and rs2804495) were genotyped in a study cohort of 377 nvAMD patients who received the loading dose of three monthly ranibizumab injections. Treatment response was assessed as the change in visual acuity after three monthly loading injections compared with baseline. RESULTS: SNP rs2070296 was associated with change in visual acuity after 3 months of treatment. Patients carrying the GA or AA genotypes performed significantly worse than individuals carrying the GG genotype (P=0.01). A cumulative effect of rs2070296 in the NRP1 gene and rs4576072 located in the VEGF receptor 2 (VEGFR2 or KDR) gene, previously associated with treatment response, was observed. Patients carrying two risk alleles performed significantly worse than patients carrying zero or one risk allele (P=0.03), and patients with more than two risk alleles responded even worse to the therapy (P=3×10). The combined effect of these two SNPs on the response was also seen after 6 and 12 months of treatment. CONCLUSION: This study suggests that genetic variation in NRP1, a key molecule in VEGFA-driven neovascularization, influences treatment response to ranibizumab in nvAMD patients. The results of this study may be used to generate prediction models for treatment response, which in the future may help tailor medical care to individual needs.

Running Exercise in Obese Pregnancies Prevents IL-6 Trans-signaling in Male Offspring.

PURPOSE: Maternal obesity is known to predispose the offspring to impaired glucose metabolism and obesity associated with low-grade inflammation and hypothalamic dysfunction. Because preventive approaches in this context are missing to date, we aimed to identify molecular mechanisms in the offspring that are affected by maternal exercise during pregnancy. METHODS: Diet-induced obese mouse dams were divided into a sedentary obese (high-fat diet [HFD]) group and an obese intervention (HFD-running intervention [RUN]) group, which performed voluntary wheel running throughout gestation. Male offspring were compared with the offspring of a sedentary lean control group at postnatal day 21. RESULTS: HFD and HFD-RUN offspring showed increased body weight and white adipose tissue mass. Glucose tolerance testing showed mild impairment only in HFD offspring. Serum interleukin-6 (IL-6) levels, hypothalamic and white adipose tissue IL-6 gene expressions, and phosphorylation of signal transducer and activator of transcription 3 in HFD offspring were significantly increased, whereas HFD-RUN was protected against these changes. The altered hypothalamic global gene expression in HFD offspring showed partial normalization in HFD-RUN offspring, especially with respect to IL-6 action. CONCLUSION: Maternal exercise in obese pregnancies effectively reduces IL-6 trans-signaling and might be the underlying mechanism for the amelioration of glucose metabolism at postnatal day 21 independent of body composition.

Epithelial-Mesenchymal Transition (EMT)-Related Cytokines in the Aqueous Humor of Phakic and Pseudophakic Fuchs' Dystrophy Eyes.

PURPOSE: The present study aimed to analyze the expression of epithelial-mesenchymal transition (EMT)-related cytokines in the aqueous humor of phakic and pseudophakic Fuchs' endothelial corneal dystrophy (FECD) eyes and their correlation to FECD severity. METHODS: Aqueous humor samples from phakic FECD eyes (FECDph, n = 9), from pseudophakic FECD eyes more than 1 year after cataract surgery (FECDpsph, n = 13), and from cataract controls without FECD (Controlcat, n = 28) were obtained during Descemet membrane endothelial keratoplasty (DMEK) or cataract surgery. Expression of EMT-related cytokines (TGF-ß1, TGF-ß2, TGF-ß3, MCP-1, BFGF, TNF-α, IL-1ß) was measured using multiplex bead assay. Corneal central-to-peripheral thickness ratio at 3.5 mm from the center (CPTR3.5) was determined as an objective metric for FECD severity before surgery by slit-scanning pachymetry. RESULTS: Pseudophakic FECD eyes showed significantly elevated expression compared with Controlcat and FECDph eyes for TGF-ß1 (P < 0.001, respectively), for TGF-ß2 (P < 0.05, respectively), and MCP-1 (P < 0.001, respectively). Levels of TGF-ß1 (r = 0.6116, P < 0.05) and MCP-1 (r = 0.5934, P < 0.05) were positively correlated with CPTR3.5. No differences in EMT-associated protein levels were detected comparing FECDph eyes and Controlcat eyes. CONCLUSIONS: Simultaneous elevation of TGF-ß1, TGF-ß2, and MCP-1 concentrations in FECDpsph eyes confirms that cataract surgery leads to long-term alterations of the intraocular microenvironment. Positive correlation of increased aqueous TGF-ß1 and MCP-1 levels with CPTR3.5 in pseudophakic FECD eyes suggests that changed cytokine levels may be involved in corneal decompensation after cataract surgery. Unchanged aqueous humor levels of EMT-related proteins analyzed in phakic FECD patients indicate that there is no primary role of these aqueous cytokines in FECD pathogenesis.

A model of the ocular pharmacokinetics involved in the therapy of neovascular age-related macular degeneration with ranibizumab.

BACKGROUND: To develop a model of the pharmacokinetics of vascular endothelial growth factor (VEGF-A) determined in samples of aqueous humour from patients with neovascular age-related macular degeneration (AMD) treated with ranibizumab (Lucentis). METHODS: Post hoc analysis of data from 31 eyes of 31 patients with AMD treated with ranibizumab gathered in a non-randomised, prospective clinical study. VEGF-A concentrations were measured in 440 aqueous humour samples by Luminex multiplex bead analysis (Luminex, Austin, Texas, USA). RESULTS: The kinetics of recovery of VEGF-A from suppression by ranibizumab were well described by a simple model: VEGF-A is produced at a constant individual rate; VEGF-A and ranibizumab disperse rapidly within the vitreous chamber and bind with a known affinity; both are eliminated at identical rates from the vitreous chamber in a constant but individual flow into the anterior chamber, and are finally cleared by draining into the peripheral circulation. Average rates of VEGF-A production were predicted to be 5.8 fmol/day (range: 2.7-10.1 fmol), and elimination half-times predicted to be 3.5 days (range: 2.3-5.5 days). The duration of complete VEGF-A suppression in the aqueous humour averaged 41 days (range: 28-67 days). CONCLUSIONS: The ocular pharmacokinetics of VEGF-A and ranibizumab have been linked for the first time in a simple and plausible model which suggests that it might be possible to anticipate individual VEGF-A suppression times. CLINICAL TRIAL NUMBER: NCT01213667.

Intraocular and systemic inflammation-related cytokines during one year of ranibizumab treatment for neovascular age-related macular degeneration.

PURPOSE: To determine inflammation-related intraocular and systemic cytokine concentrations in neovascular age-related macular degeneration (nAMD) compared with controls and to assess the influence of long-term intravitreal ranibizumab treatment over 1 year. METHODS: Aqueous humour and blood plasma of 21 controls and 17 treatment-naive nAMD patients were collected prior to cataract surgery or ranibizumab treatment. Follow-up specimens in nAMD patients were acquired immediately prior to subsequent ranibizumab injections as needed. Multiplex bead assays were conducted for ten inflammation-related cytokines and vascular endothelial growth factor (VEGF). p-values were Holm-Bonferroni-corrected for multiple comparisons. RESULTS: Prior to ranibizumab treatment, initiation aqueous humour levels of monocyte chemo-attractant protein (MCP)-1/CCL2 (p = 0.005) and vascular cell adhesin molecule (VCAM) (p = 0.002) were elevated in nAMD compared with controls. Other intraocular cytokines did not differ, including VEGF. In plasma, no differences between nAMD patients and controls were found at baseline. Pro re nata ranibizumab treatment over 12 months with 8 ± 2 injections reduced aqueous VEGF (p < 0.0001) with a trend to reduced VEGF plasma concentrations (p = 0.046), with all specimens taken at least 28 days after the previous injection. All other local and systemic cytokines remained unchanged. CONCLUSION: Neovascular age-related macular degeneration is associated with local ocular MCP-1/CCL2 and VCAM elevations, suggesting a local inflammatory involvement in the pathophysiology of nAMD. We did not detect systemic differences. Ranibizumab treatment does not result in local or systemic changes of these cytokines, in contrast to VEGF suppression. MCP-1/CCL2 and VCAM may be potential additional treatment targets for nAMD.

Influence of ocular volume and lens status on pharmacokinetics and duration of action of intravitreal vascular endothelial growth factor inhibitors.

PURPOSE: To assess the effects of ocular axial length, refraction, and lens status on pharmacokinetics and duration of action of the vascular endothelial growth factor (VEGF) inhibitors ranibizumab and bevacizumab after intravitreal injection in humans. METHODS: In 119 eyes of 119 patients, aqueous humor was sampled at different time points after intravitreal injection of ranibizumab or bevacizumab, and either drug or VEGF concentrations were measured by enzyme-linked immunosorbent assays and Luminex multiplex bead technology, respectively. Relative deviation of the measured drug concentrations from the time-corrected mean values was calculated (n = 41). Repetitive VEGF measurements were preformed to identify the duration of complete suppression of ocular VEGF activity for individual eyes (n = 78). In addition, axial length, spherical equivalent refraction, and lens status were determined. RESULTS: For neither ranibizumab nor bevacizumab, a correlation between ocular pharmacokinetics (as measured by relative deviation of drug concentration from the mean) and axial length was detected in phakic eyes (Spearman's correlation coefficient, r = 0.084; P = 0.600). Similarly, the duration of action of intravitreal ranibizumab (as measured by VEGF suppression time) did not correlate with spherical equivalent refraction in phakic eyes (Spearman's correlation coefficient, r = 0.164; P = 0.301) and was not different between phakic and pseudophakic eyes (P = 0.694; Mann-Whitney U test). CONCLUSION: The results indicate that ocular volume and lens status have no relevant impact on ocular pharmacokinetics and duration of action of VEGF-inhibitory drugs and may, thus, be excluded as factors accounting for the high interindividual variability in morphologic and functional responses to intravitreal anti-VEGF therapy.

Long-term alterations of systemic vascular endothelial growth factor levels in patients treated with ranibizumab for age-related macular degeneration.

PURPOSE: To analyze long-term changes of systemic vascular endothelial growth factor (VEGF) levels in patients treated with ranibizumab for neovascular age-related macular degeneration. METHODS: Sixty-one patients with neovascular age-related macular degeneration and 68 age-matched controls were included in the study. Patients were treated with ranibizumab on a pro re nata regimen. Plasma samples were collected before initiation of treatment and after 1 year (30 patients) or 2 years (31 patients) of treatment. Vascular endothelial growth factor was measured by Luminex microbead analysis. RESULTS: At baseline, patients with neovascular age-related macular degeneration and controls did not differ significantly in VEGF levels (P = 0.062). There was a significant decline in systemic VEGF levels of 39.5% after 1 year (34.2 ± 17.2 pg/mL to 20.7 ± 14.0 pg/mL; P = 7.50 × 10(-5)) and of 46.7% after 2 years (40.4 ± 24.1 pg/mL to 21.5 ± 23.3 pg/mL; P = 2.48 × 10(-4)) of treatment. Patients with persistent activity of choroidal neovascularization showed a significantly smaller decrease of plasma VEGF levels than patients with dry intervals despite the higher number of injections (P = 0.048). CONCLUSION: In addition to immediate effects limited to days if not hours, ranibizumab also leads to long-term alterations of systemic VEGF to subnormal levels. Patients with persistent choroidal neovascularization activity showed a less pronounced VEGF decrease. Therefore, VEGF levels might be a useful marker for treatment response.

Predicting non-response to ranibizumab in patients with neovascular age-related macular degeneration.

PURPOSE: To validate known and determine new predictors of non-response to ranibizumab in patients with neovascular age-related macular degeneration (AMD) and to incorporate these factors into a prediction rule. METHODS: This multicenter, observational cohort study included 391 patients treated with ranibizumab for neovascular AMD. We performed genetic analysis for single nucleotide polymorphisms in AMD-associated genes and collected questionnaires regarding environmental factors and disease history. The primary outcome was non-response to treatment, defined as a loss of visual acuity ≥30% of letters. RESULTS: Of the 391 patients, 47 were classified as non-responsive. Independent predictors for non-response were age, baseline visual acuity, diabetes mellitus and accumulation of risk alleles in the CFH, ARMS2 and VEGF-A genes. The area under the receiver operating characteristic curve was 0.77 (95% confidence interval 0.70-0.84). We derived a clinical prediction rule, with possible total risk scores ranging from 0-19 points. The absolute risk of non-response varied from 3-52% between risk score groups. CONCLUSION: This is an important step towards a clinical prediction rule that can aid clinicians in identifying AMD patients with increased likelihood of non-response, and consequently contribute to making shared treatment decisions.