Ranibizumab and aflibercept intravitreal injection for treatment naïve and refractory macular oedema in branch retinal vein occlusion

Background: Branch retinal vein occlusion complicated by macular oedema is a common disease treated with intravitreal injection of anti-vascular endothelial growth factor. Controversy exists surrounding anti-vascular endothelial growth factor selection for both treatment naïve and refractory cases. Methods: A retrospective electronic medical record review at a single UK centre generated a cohort of 259 treatment naïve eyes from 258 patients receiving ranibizumab, aflibercept or a combination ( n = 83, 97 and 79, respectively) from 2013 to 2018 with ⩾6 months follow-up. Number of intravitreal injections, visual acuity and macular oedema presence were noted at 3, 6, 12, 24, 36 and 48 months. A subgroup analysis examined refractory cases switched from ranibizumab to aflibercept ( n = 77) or maintained on ranibizumab ( n = 35). Results: Eyes receiving ranibizumab or aflibercept had equivocal vision gain at 1 year, 8.0 (95% CI 5.0−11.0) and 9.6 (7.2−12.1) Early Treatment of Diabetic Retinopathy Study letters, respectively. About 35.6% had no macular oedema at 12 months with ranibizumab compared with 50.0% with aflibercept ( p = 0.07) following 5.1 (4.7–5.6) and 6.0 (5.6–6.4) intravitreal injections, respectively. Visual prognosis declined significantly as treatment delay extended ( p = 0.003) which was only apparent with ⩾3 months delay. Eyes with refractory macular oedema also had equivocal functional and anatomical outcomes whether they were maintained on ranibizumab or switched to aflibercept. Conclusion: These real world data demonstrate more modest clinical improvements from anti-vascular endothelial growth factor treatment than reported in clinical trials. The functional outcomes of ranibizumab and aflibercept in both treatment naïve and refractory cases were equivocal while the anatomical outcomes of aflibercept may be superior.