Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Differences in Presentation and Outcomes in Males and Females With Branch Retinal Vein Occlusion

Delaram Mirzania, BS; Akshay S. Thomas, MD, MS; Sandra Stinnett, DrPH; Sharon Fekrat, MD

Abstract

BACKGROUND AND OBJECTIVE:

To investigate the effect of patient sex on presentation and outcomes of branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS:

Retrospective chart review cohort study of 188 eyes with BRVO and cystoid macular edema (CME); 81 treatment-naïve eyes were selected for subgroup analysis.

RESULTS:

Males had better visual acuity (VA) in the BRVO eye at baseline compared to females (log-MAR: 0.49 ± 0.47 vs. 0.62 ± 0.53; P = .04); this was not present at the final visit (males: 0.41 ± 0.40 vs. females: 0.59 ± 0.60; P = .10). In treatment-naïve eyes, both sexes had similar VA at baseline (males: 0.42 ± 0.29 vs. females: 0.59 ± 0.46; P = .09); however, at the final visit, males had better VA compared to females (0.38 ± 0.43 vs. 0.66 ± 0.67; P = .03). On average, males received more anti-VEGF injections when adjusting for follow-up (P = .04).

CONCLUSIONS:

Significant sex differences in VA and treatment of eyes with BRVO and CME were noted. Further investigation is needed to understand sex differences in eyes with BRVO and CME.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:564–572.]

Abstract

BACKGROUND AND OBJECTIVE:

To investigate the effect of patient sex on presentation and outcomes of branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS:

Retrospective chart review cohort study of 188 eyes with BRVO and cystoid macular edema (CME); 81 treatment-naïve eyes were selected for subgroup analysis.

RESULTS:

Males had better visual acuity (VA) in the BRVO eye at baseline compared to females (log-MAR: 0.49 ± 0.47 vs. 0.62 ± 0.53; P = .04); this was not present at the final visit (males: 0.41 ± 0.40 vs. females: 0.59 ± 0.60; P = .10). In treatment-naïve eyes, both sexes had similar VA at baseline (males: 0.42 ± 0.29 vs. females: 0.59 ± 0.46; P = .09); however, at the final visit, males had better VA compared to females (0.38 ± 0.43 vs. 0.66 ± 0.67; P = .03). On average, males received more anti-VEGF injections when adjusting for follow-up (P = .04).

CONCLUSIONS:

Significant sex differences in VA and treatment of eyes with BRVO and CME were noted. Further investigation is needed to understand sex differences in eyes with BRVO and CME.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:564–572.]

Introduction

Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disorder, with an age and sex standardized prevalence of 4.42 per 1,000.1,2 Since the pathogenesis of BRVO has largely been attributed to vascular pathology at the arteriovenous crossing,1,3 as well as possible contribution from systemic hematological abnormalities,4 the risk of occlusion increases with age, atherosclerotic changes, diabetes, hypertension, and smoking, all of which may contribute to arterial changes that lead to adjacent venous compression.4–7

Some observers have found male sex to be a risk factor for BRVO,8 whereas a pooled analysis by Rogers et al.2 using population-based data found no sex differences in the incidence of BRVO. Regardless of sex differences in incidence or overall outcomes, we have previously shown that sex differences exist in clinical features of central retinal vein occlusion (CRVO) such as central subfield thickness (CST), subfoveal choroidal thickness (SCT), and foveal avascular zone (FAZ) size.9 Understanding these sex differences facilitates future investigations to explore how sex may impact clinical features, treatment response, and management approach in eyes with BRVO.

There is an established relationship between BRVO and increased prevalence of cardiovascular disease, including hypertension, peripheral vascular disease, myocardial infarction, and venous disease,1 which has known sex differences.10–13 It is well known that arterial compliance decreases with age and is sex-dependent.11,14,15 Under normal circumstances, highly compliant large arteries protect smaller peripheral vessels from high pressure pulsatile blood flow.11 Thus, loss of compliance can lead to structural changes in the peripheral vascular bed. Given sex differences in risk factors for BRVO, it is important to investigate sex-based prevalence of these risk factors among patients with BRVO.

The visual prognosis of eyes with BRVO is related in part to the development of cystoid macular edema (CME)16 due to blood-retinal barrier breakdown4 and elevated intravitreal levels of vascular endothelial growth factor (VEGF) and interleukin 6.17 These inflammatory markers are implicated in the acute stress response,18 leading to vascular permeability.19 It is established that the inflammatory profiles of men and women differ, creating variable responses to stress.20 Therefore, the impact of sex on the response to anti-inflammatory and anti-VEGF therapies may reveal disease insights. Studies in small cohorts of patients with CME secondary to BRVO have found no sex difference in predicting response to intravitreal anti-VEGF treatment.16,21 However, to date, there have been no large cohort studies investigating the effect of patient sex on the response of CME to current therapies in eyes with BRVO.

In this study, we describe sex differences in the presenting features, treatment patterns, and clinical outcomes of patients with CME secondary to BRVO.

Patients and Methods

Study Population

The Duke University School of Medicine Institutional Review Board approved the conduct of this study. The Duke Enterprise Data Unified Content Explorer system was used to identify patients with BRVO seen in the Retina Division at the Duke Eye Center between January 1, 2009, and July 1, 2016. Patients with BRVO and CME on presentation were selected as the primary sample; patients with BRVO and CME on presentation who had received no treatment prior to presentation and had at least 12 months of follow-up were subdivided into a treatment-naïve sample for subgroup analysis. Patients whose date of BRVO diagnosis was unknown were excluded.

Data Collection

This study was conducted in accordance with the Declaration of Helsinki. Data were retrospectively reviewed and collected in compliance with the Health Insurance Portability and Accountability Act. Demographic information such as age, sex, race, active medications, and medical comorbidities at the time of BRVO diagnosis was collected. Medical and ocular history, clinical characteristics, treatment patterns, multimodal imaging findings, and clinical outcomes were also collected for each patient. Clinical characteristics included corrected VA, duration of symptoms prior to presentation, location of BRVO, eye laterality, and lens status. At the baseline and final visits, corrected VA and intraocular pressure (IOP) were measured in both eyes. An Early Treatment Diabetic Retinopathy Study (ETDRS) chart was used to measure VA, which was then converted to the logarithm of the minimum angle of resolution (logMAR) scale.

CST, SCT, and CME prevalence were evaluated with spectral-domain optical coherence tomography (OCT) imaging at the baseline and final visits. The baseline visit was defined as the first visit at our institution for the evaluation of BRVO, and the final visit was the last available examination of the BRVO eye.

Statistical Analysis

All statistical analyses were performed using SAS/STAT software Version 9.4. For continuous variables, Wilcoxon rank-sum or Kruskal-Wallis test of difference were used. For categorical values, a two-tailed Fisher's exact test of difference between proportions was used. For comparing frequencies in two categorical values, a chi square test was used. For pair-wise differences between groups, Least squares means was used. All P values less than .05 were considered statistically significant. Data for continuous variables are presented as mean (± standard deviation) or mean (± 95% confidence interval [CI]).

Results

Patient Demographics and Risk Factors

The total study population included 424 eyes of 397 patients, of which, 175 (41%) were male eyes and 249 (59%) were female eyes. Of the total population, 188 eyes presented with CME at baseline; this group defined the primary study group. Macular involvement, defined by superotemporal or inferotemporal location of BRVO with associated macular intraretinal hemorrhage, was assessed. The location of BRVO and presence of CME in the primary study group and treatment-naïve eyes are summarized in Tables 1A2B.

BRVO Characteristics in Total Study Population (N = 424)

Table 1A:

BRVO Characteristics in Total Study Population (N = 424)

BRVO Characteristics in Eyes With Macular Involvement (N = 253) in Total Study Population

Table 1B:

BRVO Characteristics in Eyes With Macular Involvement (N = 253) in Total Study Population

BRVO Characteristics in Treatment-Naïve Eyes (N = 145)

Table 2A:

BRVO Characteristics in Treatment-Naïve Eyes (N = 145)

BRVO Characteristics in Treatment-Naïve Eyes With Macular Involvement (N = 93)

Table 2B:

BRVO Characteristics in Treatment-Naïve Eyes With Macular Involvement (N = 93)

The average age of onset of BRVO was similar between male and female patients (68.48 ± 10.23 vs. 69.67 ± 12.98; P = .52). Although the majority of our sample was Caucasian (115/188; 61.2%), there were no sex differences in the race distribution in our sample (P = .09).

Known risk factors for BRVO were not significantly different between males and females (hypertension, P = .85; diabetes, P = 1.00; current smoker, P = 1.00) (See Table A, available at www.healio.com/OSLIRetina, for the proportion of patients with known risk factors for BRVO at the time of presentation). Among current smokers, there was no significant difference in the likelihood of retinal vein occlusion (RVO) occurring in the unaffected fellow eye (males: 1/16 [6.25%] vs. females: 1/20 [5%]; P = .92). A similar proportion of males and females were on anti-platelet (aspirin 81 mg, P = .16; aspirin 325 mg, P = .44; clopidogrel [Plavix; Bristol-Myers Squibb, New York, NY], P = 1.0) and anticoagulant medications (warfarin, P = .60; rivaroxaban [Xarelto; Janssen, Leverkusen, Germany], P = 1.0; apixaban, P = .28) at the time of BRVO diagnosis. There was no significant difference between males and females in lens status (P = .12) and a diagnosis of glaucoma (P = .21) at the time of BRVO diagnosis.

Percent of Patients With Known Risk Factors at the Time of BRVO Diagnosis

Table A:

Percent of Patients With Known Risk Factors at the Time of BRVO Diagnosis

Among female patients older than 50 years of age, there was no significant difference in the age of onset of BRVO between patients on hormone replacement therapy (HRT) and those not on HRT (76.0, 95% CI, 67.2–84.8 vs. 72.2, 95% CI, 69.4–74.0; difference: 3.83 years, CI: −13.02 to 5.35; P = .41). This held true when controlling for current smoker status (75.7, 95% CI, 66.1–85.2 vs. 71.5, 95% CI, 67.5–75.5; difference: 4.16 years, 95% CI, −14.99 to 6.66; P = .44), hypertension (75.8, 95% CI, 66.4–85.3 vs. 72.1, 95% CI, 68.7–75.5; difference: 3.77 years, 95% CI, −13.14 to 5.61; P = .43), and diabetes (74.3, 95% CI, 65.5–83.2 vs. 71.2, 95% CI, 68.3–74.1; difference: 3.07 years, 95% CI, −12.15 to 6.00; P = .50) individually, as well as when controlling for all three variables (72.3, 95% CI, 61.6–83.0 vs. 70.0, 95% CI, 65.2–74.7; difference: 2.34 years, 95% CI, −13.34 to 8.66; P = .67). No patients were taking other exogenous hormones.

Baseline and Final Clinical Characteristics

The average length of follow-up was 30.3 (± 31.3) months for males and 28.4 (± 29.9) months for females (P = .67). In our primary sample of 188 eyes, corrected ETDRS VA in the BRVO eye at baseline was significantly better for males compared to females (logMAR: 0.49 ± 0.47 [VA 20/62] vs. 0.62 ± 0.53 [VA 20/83]; P = .04); however, at the final visit, the VA was similar between males and females (0.41 ± 0.40 [VA 20/51] vs. 0.59 ± 0.60 [VA 20/78]; P = .10). In the treatment-naïve sample of 81 eyes, males and females had similar VA in the BRVO eye at baseline (0.42 ± 0.29 [20/53] vs. 0.59 ± 0.46 [20/78]; P = .09), but VA at the final visit was significantly better in males than females (0.38 ± 0.43 [VA 20/48] vs. 0.66 ± 0.67 [VA 20/91]; P = .03).

Baseline and final CST in the BRVO and non-BRVO eyes and SCT in the BRVO eyes were analyzed and compared between males and females in both the primary study group and treatment-naïve group, the findings are summarized in Tables 3A and 3B, respectively.

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Total Study Population

Table 3A:

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Total Study Population

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Treatment-Naïve Eyes

Table 3B:

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Treatment-Naïve Eyes

The baseline prevalence of neovascularization (P = .24), vitreous hemorrhage (P = .40), and foveal hemorrhage (P = .69) was not significantly different between males and females. Fluorescein angiography was performed on 23 men and 28 women at the baseline visit. Seven percent of males and 20% of females presented with FAZ enlargement at baseline, which was not significantly different (P = .21). Similarly, in the treatment-naïve sample at baseline, no significant sex differences were found in the presence of neovascularization (P = .49), vitreous hemorrhage (P = 1.00), foveal hemorrhage (P = .55), or the proportion of males and females who presented with FAZ enlargement (27% vs. 0%; P = .15).

All patients included in the study had CME at baseline; however, in both the primary sample and the treatment-naïve sample, there were no significant sex differences in the prevalence of CME at the final visit. In the primary sample, 48% of males (37/76) and 53% of females (60/112) had CME at the final visit (P = .10); in the treatment-naïve subgroup, 51% of males (21/41) and 63% of females (27/43) had CME at the final visit (P = .33).

Treatment Patterns

In the primary study group, 66.7% of females and 33.3% of males were lost to follow-up, which approached significance (P = .054). In the primary study group, males and females received similar treatment, except for average number of anti-VEGF injections received, overall. Among the patients who received anti-VEGF injections, females received an average of 6.93 (± 6.40) anti-VEGF injections and males received an average of 10.16 (± 11.05) anti-VEGF injections (P = .053). This difference persisted when adjusting for days of follow-up (P = .04). In the treatment-naïve group, the average number of anti-VEGF injections received overall was significantly higher in males than females (16 vs. 9.16; P = .01), even when adjusting for follow-up time (P = .01). The average number of intravitreal anti-VEGF injections and corticosteroid treatments for the primary study group and treatment-naïve eyes are summarized in Tables 4A and 4B, respectively.

Treatment Patterns in BRVO Eyes in the Primary Sample

Table 4A:

Treatment Patterns in BRVO Eyes in the Primary Sample

Treatment Patterns in BRVO Eyes in Treatment-Naïve Eyes

Table 4B:

Treatment Patterns in BRVO Eyes in Treatment-Naïve Eyes

Among patients for whom data were available, three out of 67 males (4.4%) and three out of 94 females (3.2%) developed a subsequent RVO in the fellow eye (P = .09). The odds of having a subsequent RVO in the fellow eye for females compared to males were 1.4 (95% CI, 0.28–7.27; P = .67). After adjusting for smoking, the odds were 1.2 (95% CI, 0.19–7.56; P = .83).

Discussion

We sought to determine whether sex has an impact on the presenting features, treatment patterns, and clinical outcomes in persons with BRVO. We investigated these differences in patients who presented with BRVO and CME. Our key findings are as follows: 1) The risk factor profile was similar across both sexes; 2) males had significantly better VA at presentation; 3) treatment-naïve males had significantly better VA at the final visit; 4) all other clinical features including CST, SCT, and prevalence of FAZ enlargement were similar between the two sexes, irrespective of treatment naivety; 5) there was no significant difference in the proportion of males and females with persistent CME at the final visit; 6) female patients received significantly fewer anti-VEGF injections overall.

Current literature is mixed regarding the role of sex as a risk factor for the development of BRVO.2,8 These studies, however, were not designed to evaluate sex differences in BRVO, and only considered sex as a possible variable impacting incidence and prevalence of BRVO, regardless of severity. On the other hand, our study investigates sex differences regarding various characteristics in eyes with BRVO and CME. Our findings suggest that sex does not play a role in the presence of CME in eyes with macula-involving BRVO.

It has been established that cigarette smoking is associated with an increased incidence of BRVO as well as increased ocular inflammation.7,22 However, Kim et al.23 found that cigarette smoking was not associated with worse outcomes 6 months after onset of BRVO. In our study herein, among current smokers, we found no sex differences in clinical features of eyes presenting with a macula-involving BRVO. Although further studies are required to understand whether these sex differences exist, we hypothesize that because our sample was limited to patients with CME at presentation, we were unable to capture any contribution that cigarette smoking may have had in the development of CME in these BRVO eyes and whether this impact may be more pronounced in either sex. Nonetheless, in macula-involving BRVO, the majority of the eyes had CME at presentation. Thus, our findings suggest that in this group with a possibly poorer prognosis, smoking does not have a sex-specific impact.

Estrogen has been found to be vasoprotective and contribute to later age of onset of systemic vascular diseases in women.24,25 However, our findings suggest that post-menopausal women on estrogen HRT did not have a significantly later age of onset of BRVO than women who were not taking HRT, even when controlling for other risk factors such as smoking, diabetes, and hypertension. Our findings that a vascular disease of the eye such as BRVO is not impacted by estrogen use suggests that further investigation is needed to understand the impact of estrogen on ocular vasculature and how it may differ from the systemic vasculature.

VA is a sensitive indicator of oxygenation of the macula; therefore, pre-treatment VA is an important prognostic indicator for visual outcome in eyes with BRVO.4 In the BRAVO trial,26 12 out of 14 patients in the sham group with baseline VA of 20/200 to 20/500 had VA of 20/200 to 20/500 at 6 months. Other recent analysis of clinical trials have also shown that baseline vision predicts final visual outcome; a post hoc analysis of patients enrolled in the SHORE trial27 showed that better baseline visual acuity (>50 ETDRS letters) was associated with early improvement to 20/40 or better vision with treatment. In our primary study group, we found that men had a significantly better VA at the baseline visit; however, this difference was not present at the final visit. Interestingly, males in this group received a significantly higher number of anti-VEGF injections when adjusting for days of follow-up. Given that both males and females had similar risk factor profiles, it is possible that males with macula-involving BRVO have a higher treatment burden than females with macula-involving BRVO. In our treatment-naïve group, we observed no sex difference in VA at baseline; however, VA was significantly better in males at the final visit. This finding may be explained by the significantly higher number of anti-VEGF injections in treatment-naïve males compared to females, even when adjusting for follow-up time. Notably, the average number of injections at 12 months, including steroid injections, was not significantly different between males and females, regardless of treatment-naivety. Steroids are more likely to be offered to patients who do not have glaucoma or are pseudophakic; however, we did not find a difference among males and females in prevalence of glaucoma or lens status. Thus, we speculate that social factors such as difficulty adhering to the follow-up schedule required for anti-VEGF treatment may have impacted the treatments offered, such that steroids offered a better treatment option for female patients who presented to our institution. This is further supported by our findings that female patients were more likely to be lost to follow-up. Nonetheless, further investigation is required to explore whether sex differences exist in the affected eye's response to treatment and whether such differences may guide treatment decisions.

In our study, we found no sex differences in CST and SCT in the BRVO eye at the baseline and final visits. However, in non-BRVO eyes, men had a significantly higher CST at both the baseline and final visits. This is in agreement with studies on healthy eyes, which suggest that males have an increased CST at baseline.28,29 Furthermore, in a recent analysis of sex differences in CRVO,9 we found that men had a significantly higher CST in the affected eye at the baseline and final visits. It is likely that this difference is due to anatomic differences between the two sexes. If so, our findings that no sex difference exists in CST in the BRVO eyes may actually indicate under- or over-treatment of either sex. Further investigation is required to establish the relationship between CST and sex in the context of BRVO.

Limitations

The limitations of this study are primarily related to its retrospective nature. Because our dataset did not contain every variable from each encounter with all of the patients, it may potentially have biased the interpretation of the data. Specifically, most patients in our study had a known risk factor for BRVO at the time of presentation (ie, hypertension, diabetes, or current smoker); thus, very few patients with BRVO had a systemic work-up, limiting our ability to assess whether systemic etiologies played a role in the development of BRVO. Second, some of our comparisons such as FAZ enlargement were limited by small sample size since not all patients underwent fluorescein angiography or OCT angiography. We had a borderline significant proportion of female patients who were lost to follow-up, which may limit, in part, our interpretation of the outcomes in this study. Finally, our sample was limited to patients seen at a tertiary referral center; therefore, our findings may not be widely generalizable.

In our study, all patients included had CME secondary to BRVO at the baseline visit, and there was no significant difference in the proportion of men and women who had persistent CME at their final visit in either the primary sample or the treatment-naïve group. Although individual differences in medical history and clinical features inform medical decision-making, we observed that men and women received different anti-VEGF therapeutic management despite significantly better VA in males at baseline. Nonetheless, the final clinical features did not reflect the differences seen at baseline. Therefore, our findings emphasize the need to investigate how patient sex impacts the progression of CME secondary to BRVO as well as its response to current real-world treatment protocols. Future studies using national databases may contribute to guidance regarding the understanding of how best to incorporate baseline clinical features into the decision-making tree for treatment algorithms and visual prognosis discussions in the context of patient characteristics and systemic factors, including patient sex.

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BRVO Characteristics in Total Study Population (N = 424)

Variable Male (N = 175) Female (N = 249) P Value

CME at baseline (%) 76 (18) 112 (26) .73

BRVO location
  Inferotemporal 43 (10) 51 (12) .32
  Superotemporal 75 (18) 113 (27) .61

BRVO Characteristics in Eyes With Macular Involvement (N = 253) in Total Study Population

Male (N = 109) Female (N = 144) P Value

CME in Eyes With Macular Involvement, No. of Cases (%) 67 (26) 95 (37) .46

BRVO Location, No. of Cases (%)
  Inferotemporal 25 (10) 27 (11) .41
  Superotemporal 42 (17) 68 (27) .17

BRVO Characteristics in Treatment-Naïve Eyes (N = 145)

Male (N = 64) Female (N = 81) P Value

Variable

CME at baseline, No. of cases (%) 38 (26) 43 (30) .96

BRVO location, No. of cases (%)
  Inferotemporal 20 (14) 22 (15) .59
  Superotemporal 30 (21) 39 (27) .88

BRVO Characteristics in Treatment-Naïve Eyes With Macular Involvement (N = 93)

Male (N = 45) Female (N = 48) P Value

Variable

CME in treatment-naïve eyes with macular involvement, No. of cases (%) 33 (35) 34 (36) .79

BRVO location, No. of cases (%)
  Inferotemporal 15 (16) 13 (14) .51
  Superotemporal 18 (19) 21 (22) .71

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Total Study Population

Male Female P Value*

CST (µm) in All BRVO Eyes, Mean (± SD)
  Baseline 459.3 (174.1) 434.5 (146.9) .48
  Final 334.9 (108.0) 346.6 (126.3) .96
  Change (final-baseline) −143 (181.9) −108 (175.4) .50

CST (µm) in Non-BRVO Eye, Mean (± SD)
  Baseline 284.5 (68.4) 266.0 (70.8) .007
  Final 301.9 (79.0) 269.8 (51.0) .001

CST (µm) in Current Smokers
  Baseline 452.0 (139.9) 416.9 (140.9) .13
  Final 320.9 (79.0) 334.2 (121.5) .69
  Change (final-baseline) −121.0 (121.0) −88.5 (167.6) .33

SCT (µm) in All BRVO Eyes, Mean (± SD)
  Baseline 241.3 (72.7) 232.0 (80.0) .65
  Final 229.3 (73.2) 223.9 (71.2) .83

Baseline and Final Clinical Features of BRVO and Non-BRVO Eyes in Treatment-Naïve Eyes

Male Female P Value*

CST (µm) in Treatment-Naïve BRVO Eyes, Mean (± SD)
  Baseline 471.0 (191.6) 457.6 (178.6) .79
  Final 326.9 (86.2) 335.6 (148.9) .31
  Change (final-baseline) −168.0 (200.6) −134.0 (213.8) .73

SCT (µm) in Treatment-Naïve BRVO Eyes, Mean (± SD)
  Baseline 255.4 (89.7) 233.6 (85.8) .52
  Final 231.7 (85.0) 218 (73.2) .55

Treatment Patterns in BRVO Eyes in the Primary Sample

Male Female P Value* P Value* Adjusted for Follow-Up

Treatment with Anti-VEGF Injections 45/112 67/112
  Number of Injections, Mean (SD) 10.16 (11.05) 6.93 (6.40) .053 .04
    Bevacizumab 26/88 36/88
      Number of Injections, Mean (SD) 5.27 (4.31) 3.64 (2.70) .07 .06
    Ranibizumab 15/32 17/32
      Number of Injections, Mean (SD) 11.67 (12.53) 6.71 (6.55) .16 .23
    Aflibercept 19/56 37/56
      Number of Injections, Mean (SD) 7.63 (7.48) 5.92 (4.83) .30 .35

Treatment with Intravitreal Triamcinolone Injections 8/31 13/31
  Number of Injections, Mean (SD) 1.88 (1.64) 1.92 (1.04) .93 .92

Total Number of Injections at 12 Months, Mean (SD) 4.95 (2.77) 4.68 (3.38) .67 .77

Treatment with Intravitreal Dexamethasone Implants 3/6 3/6
  Number of Injections, Mean (SD) 2 (1.00) 2.33 (2.31) .83 .27

Treatment Patterns in BRVO Eyes in Treatment-Naïve Eyes

Male Female P Value* P Value* Adjusted for Follow-Up

Treatment with Anti-VEGF Injections 23/55 32/55
  Number of Injections, Mean (SD) 16 (12.62) 9.16 (6.56) .01 .01
    Bevacizumab 13/34 21/34
      Number of Injections, Mean (SD) 6.92 (5.27) 4.67 (2.89) .11 .14
    Ranibizumab 12/31 9/31
      Number of Injections, Mean (SD) 14 (13.01) 7.67 (4.58) .18 .13
    Aflibercept 10/29 19/29
      Number of Injections, Mean (SD) 11 (8.26) 6.63 (4.55) .07 .11

Treatment with Intravitreal Triamcinolone Injections 5/10 5/10
  Number of Injections, Mean (SD) 1.60 (1.34) 2.80 (0.84) .13 .10

Total Number of Injections at 12 Months, Mean (SD) 6.09 (3.01) 5.65 (3.74) .66 .61

Treatment with Intravitreal Dexamethasone Implants 0 3/3
  Number of Injections, Mean (SD) 2.33 (2.31) -- --

Percent of Patients With Known Risk Factors at the Time of BRVO Diagnosis

Male Female P Value*
Hypertension 81% 79% .85
Diabetes 32% 33% 1.00
Current smoker 28% 28% 1.00
Authors

From the Department of Ophthalmology, Duke University, Durham, North Carolina (DM, AST, SS, SF); and Tennessee Retina, Nashville, Tennessee (AST).

Dr. Thomas is a consultant for Alimera, Avesis, Bausch + Lomb, Genentech, and Zeiss. Dr. Fekrat receives patent royalties from Alcon. The remaining authors report no relevant financial disclosures.

Address correspondence to Sharon Fekrat, MD, Duke University Department of Ophthalmology, 2351 Erwin Rd., Box 3802, Durham, NC 27710; email: sharon.fekrat@duke.edu.

Received: February 23, 2020
Accepted: September 10, 2020

10.3928/23258160-20201005-04

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