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      Anti-VEGF treatment for myopic choroid neovascularization: from molecular characterization to update on clinical application

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          Abstract

          Choroidal neovascularization (CNV) secondary to pathologic myopia has a very high incidence in global, especially in Asian, populations. It is a common cause of irreversible central vision loss, and severely affects the quality of life in the patients with pathologic myopia. The traditional therapeutic modalities for CNV secondary to pathologic myopia include thermal laser photocoagulation, surgical management, transpupillary thermotherapy, and photodynamic therapy with verteporfin. However, the long-term outcomes of these modalities are disappointing. Recently, intravitreal administration of anti-VEGF biological agents, including bevacizumab, ranibizumab, pegaptanib, aflibercept, and conbercept, has demonstrated promising outcomes for this ocular disease. The anti-VEGF regimens are more effective on improving visual acuity, reducing central fundus thickness and central retina thickness than the traditional modalities. These anti-VEGF agents thus hold the potential to become the first-line medicine for treatment of CNV secondary to pathologic myopia. This review follows the trend of “from bench to bedside”, initially discussing the pathogenesis of myopic CNV, delineating the molecular structures and mechanisms of action of the currently available anti-VEGF drugs, and then systematically comparing the up to date clinical applications as well as the efficacy and safety of the anti-VEGF drugs to the CNV secondary to pathologic myopia.

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          Most cited references 70

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          The International Intravitreal Bevacizumab Safety Survey: using the internet to assess drug safety worldwide.

          Off-label intravitreal injections of bevacizumab (Avastin) have been given for the treatment of neovascular and exudative ocular diseases since May 2005. Since then, the use of intravitreal bevacizumab has spread worldwide, but the drug-related adverse events associated with its use have been reported only in a few retrospective reviews. The International Intravitreal Bevacizumab Safety Survey was initiated to gather timely information regarding adverse events from doctors around the world via the internet. An internet-based survey was designed to identify adverse events associated with intravitreal bevacizumab treatment. The survey web address was disseminated to the international vitreoretinal community via email. Rates of adverse events were calculated from participant responses. 70 centres from 12 countries reported on 7113 injections given to 5228 patients. Doctor-reported adverse events included corneal abrasion, lens injury, endophthalmitis, retinal detachment, inflammation or uveitis, cataract progression, acute vision loss, central retinal artery occlusion, subretinal haemorrhage, retinal pigment epithelium tears, blood pressure elevation, transient ischaemic attack, cerebrovascular accident and death. None of the adverse event rates exceeded 0.21%. Intravitreal bevacizumab is being used globally for ocular diseases. Self-reporting of adverse events after intravitreal bevacizumab injections did not show an increased rate of potential drug-related ocular or systemic events. These short-term results suggest that intravitreal bevacizumab seems to be safe.
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            Ultrastructural findings in the primate eye after intravitreal injection of bevacizumab.

            To examine the ultrastructural effect of intravitreal bevacizumab on primate eyes with particular focus set on the choriocapillaris and to examine the influence of vascular endothelial growth factor (VEGF) inhibition on endothelial cell fenestration. Animal study. Four Cynomolgus monkeys received an intravitreal injection of 1.25 mg bevacizumab. The eyes were enucleated and prepared for light and electron microscopy on days one, four, seven, and 14. Control eyes remained untreated. Choriocapillaris endothelial cell fenestrations were quantified. Choriocapillaris endothelial cell fenestrations were significantly reduced after intravitreal injection of bevacizumab. Fenestration was lowest on day four (15.9 +/- 6.7 per 25 microm) and increased again from days seven to 14, but was still significantly lower than in the control (66.2 +/- 9.5 per 25 microm). Densely packed thrombocytes and leukocytes regionally occluded the choriocapillaris lumen of treated eyes. On day one an increased number of leukocytes filled in the choriocapillaris lumen. Photoreceptors were damaged in two of 40 light microscopic sections. On days one to seven, choroidal melanocytes contained giant melanosomes. None of these described features was found in controls. Intravitreal bevacizumab causes ultrastructural changes in the choriocapillaris of primate eyes. A significant reduction of choriocapillaris endothelial cell fenestrations is seen as early as 24 hours after injection and their number increases again after two weeks. These findings may play a role in the early clinical effect of intravitreal bevacizumab for macular edema. Because an increased risk of circulation disturbances in the choriocapillaris cannot be excluded, patients should be carefully monitored.
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              A phase 1 study of KH902, a vascular endothelial growth factor receptor decoy, for exudative age-related macular degeneration.

              To determine the safety, tolerability, and bioactivity of KH902, a fully human fusion protein containing key domains from vascular endothelial growth factor receptors 1 and 2 with human immunoglobulin Fc. Prospective, single-center, open-label, dose-escalating, interventional case series. Twenty-eight patients with choroidal neovascularization (CNV) resulting from exudative age-related macular degeneration (AMD) with lesion size of 12 disc areas or less and best-corrected visual acuity (VA) of 55 letters or worse. A single intravitreal injection of KH902 at 1 of 6 escalating doses if no dose-limiting toxicity (DLT) occurred through postinjection day 14 of the previous dose level. Follow-up examinations were performed on postinjection days 1, 3, 5, 7, 14, 28, and 42. The primary end point was at 42 days, and patients were monitored for an additional 6 weeks (12 weeks total). The primary safety measures were changes from baseline in VA, intraocular pressure (IOP), intraocular inflammation, and production of anti-KH902 antibody. Dose-limiting toxicity was defined as intraocular inflammation, elevated IOP, significantly reduced vision, or retinal hemorrhage within 42 days after injection. Bioactivity measures included mean change from baseline in VA, central retinal thickness, and total macular volume on optical coherence tomography and CNV changes on fluorescein angiography. All patients completed the study with no DLT and no serious or drug-related adverse events. Ocular adverse events were mild to moderate in severity, including transient IOP elevation and injection-site subconjunctival hemorrhage after KH902 injections. No serum anti-KH902 antibodies were detected. On day 42 after injection, the mean change in VA from baseline was +19.6 letters with no subjects losing 1 letter or more and 57% of patients gaining 15 letters or more from baseline. The mean change in center point thickness from baseline was -77.2 μm and the mean decrease in CNV area was 12.6%. No safety concerns were detected after a single, intravitreal injection of KH902 up to 3.0 mg in this phase 1 study. Bioactivity of KH902 was suggested with improvements in VA, reduction in central retinal thickness, and a decrease in CVN area in patients with CNV resulting from exudative AMD, indicating that further study is warranted. Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Drug Des Devel Ther
                Drug Des Devel Ther
                Drug Design, Development and Therapy
                Drug Design, Development and Therapy
                Dove Medical Press
                1177-8881
                2015
                02 July 2015
                : 9
                : 3413-3421
                Affiliations
                [1 ]Tianjin Medical University Eye Hospital, Tianjin Medical University Eye Institute, College of Optometry and Ophthalmology, Tianjin Medical University, Tianjin, People’s Republic of China
                [2 ]Tangshan Eye Hospital, Tangshan, Hebei Province, People’s Republic of China
                Author notes
                Correspondence: Rui Hua Wei, Tianjin Medical University Eye Hospital, College of Optometry and Ophthalmology, Tianjin Medical University, Fukang Road 251, Nankai District, Tianjin 300384, People’s Republic of China, Tel +86 22 5828 0862, Fax +86 22 5828 6434, Email rwei07@ 123456tmu.edu.cn
                Article
                dddt-9-3413
                10.2147/DDDT.S87920
                4494177
                © 2015 Zhang et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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