Downloaded from http://journals.lww.com/apjoo by BhDMf5ePHKbH4TTImqenVHwXmMsAVI5ghXUtgbghSWAOD9hFWtksIVjadEMQbOrn on 12/08/2019 Quantitative Reduction in Central Foveal Thickness After First Anti-VEGF Injection as a Predictor of Final Outcome in BRVO Patients Rupak Roy, MS, Kumar Saurabh, MS, Avirupa Ghose, MS, Dhileesh P. Chandrasekharan, MS, Preeti Sharma, DOMS, Swakshyar Saumya Pal, and Sudipta Das, MS From Vitreo Retina Services, Aditya Birla Sankara Nethralaya, Kolkata, India. Received for publication February 28, 2016; accepted September 5, 2016. The authors have no funding or conflicts of interest to declare. The authors’ contributions to the study are as follows: design and conduct of the study (R.R., K.S., S.S.P., S.A.S.); collection, management, analysis, and interpretation of the data (A.G., D.P.C., P.S., R.R.); and preparation, review, or approval of the manuscript (S.S.P., S.A.S., R.R., K.S.). Reprints: Kumar Saurabh, Aditya Birla Sankara Nethralaya, Unit of Medical Research Foundation, 147 Mukundpur, E. M. Bypass, Kolkata, India 700099. E-mail: vrfellow@gmail.com. Copyright © 2017 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.22608/APO.201644 Purpose: To analyze the predictive ability of quantitative reduction in central foveal thickness (CFT) after the first anti–vascular endothelial growth factor (anti-VEGF) injection to assess final outcome in branch retinal vein occlusion (BRVO) patients. Design: A retrospective interventional consecutive case series. Methods: We retrospectively reviewed 60 treatment-naive BRVO pa- tients. All the patients were treated with bevacizumab injection pro re nata. We measured the reduction in CFT 1 month after injection and at each visit along with other optical coherence tomography (OCT) features like external limiting membrane (ELM) integrity, ellipsoid zone (EZ) in- tegrity, and foveal bulge (FB). Results: At final follow-up more patients in the >25% CFT reduction group had a better mean best-corrected visual acuity (BCVA) and dry macula as compared with the ≤25% group (0.25 logMAR vs 0.46 log- MAR, P = 0.03; 28 eyes vs 9 eyes, P = 0.005). Based on the final vi- sual outcome we divided patients into 2 groups: group 1, BCVA ≥ 20/40; group 2, BCVA < 20/40. Analysis at 1 month after injection revealed the ELM was intact in 27 (73%) and 5 (21.7%), EZ was intact in 28 (75.7%) and 11 (47.8%), and FB was intact in 12 (32.4%) and 2 (8.7%) patients, respectively, in groups 1 and 2 (P = 0.001, 0.02, 0.03). Conclusions: Patients who have more than a 25% reduction 1 month after the first anti-VEGF injection and a restored ELM, EZ, and FB have a significantly higher likelihood of achieving BCVA ≥ 20/40. Key Words: BRVO, SD-OCT, anti-VEGF, ellipsoid zone, quantitative response (Asia-Pac J Ophthalmol 2017;6:261–265) M acular edema (ME) is the major cause of vision loss in eyes with branch retinal vein occlusion (BRVO). 1 Intra- vitreal bevacizumab (IVB) has been used to treat ME in eyes with BRVO and has yielded promising results. 2 Intravitreal bevacizumab has been used both in monthly injection regi- mens and on a pro re nata (PRN) basis. 3–7 However, a certain proportion of BRVO patients do not regain vision even after resolution of ME. 1,8 Various studies have attempted to answer this question and have established spectral domain optical co- herence tomography (SD-OCT) predictors to determine the prognosis of eyes with ME due to BRVO. 1,8 Integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) at baseline are 2 such markers that have been associated with better final visual outcome. 1 Foveal bulge (FB) is another nov- el marker used to predict the visual outcome of BRVO. Foveal bulge is the site at the base of fovea that has maximum cone density. Its presence after resolution of ME has been associ- ated with better visual outcomes in BRVO. 8 materials and methods This was a retrospective review of medical records of consecutive patients with BRVO presenting at a tertiary care center in eastern India between January 2013 and December 2013. The study was approved by the institutional review board and it followed the tenets of the Declaration of Helsinki. Treatment-naive patients with disease onset within the past 3 months were included in the study. Exclusion criteria were as follows: (1) intraocular surgery, including cataract extraction and any intravitreal injection before the treatment; (2) laser treatments, including panretinal photocoagulation, posterior capsulotomy, or grid macular photocoagulation before the treatment; or (3) the presence of co-morbid retinal pathologies like diabetic retinopathy and age-related macular degeneration. Age, sex, and laterality were noted from the medical re- cords. Best-corrected visual acuity (BCVA) was noted with Snellen chart and was converted to the logarithm of the mini- mum angle of resolution (logMAR) scale. Anterior segment examination with slit lamp, fundus examination with indirect ophthalmoscope, and slit lamp biomicroscopy were performed Branch retinal vein occlusion is an acute event with a sudden explosion of intravitreal vascular endothelial growth factor (VEGF). The levels of VEGF in aqueous humor cor- relate strongly with the degree of ME in BRVO patients. 9 However, in day-to-day clinical practice it is not possible to measure actual VEGF levels in every patient. Initial quantita- tive OCT-based reduction of central foveal thickness (CFT) in response to anti-VEGF may provide a clue to the VEGF levels and act as a prognostic indicator. The response to anti-VEGF at 3 months from baseline after monthly injections was examined as a predictor of visual outcome in BRVO patients. 10 This study evaluated the predic- tive ability of CFT reduction at 1 month after the first injec- tion. Our study aimed to utilize various SD-OCT parameters such as the integrity of the EZ, ELM, and FB and combine them with 1-month reduction in CFT after IVB to provide a prognostic tool for final visual outcome in eyes with ME due to BRVO. Copyright © 2017 Asia-Pacifc Academy of Ophthalmology. Unauthorized reproducton of this artcle is prohibited. ORIGINAL CLINICAL STUDy Asia-Pacifc Journal of Ophthalmology • Volume 6, Number 3, May/June 2017 www.apjo.org | 261