An Optical Coherence Tomography-Guided, Variable
`Dosing Regimen with Intravitreal Ranibizumab
`(Lucentis) for Neovascular Age-related
`Macular Degeneration
`
`ANNE E. FUNG, GEETA A. LALWANI, PHILIP J. ROSENFELD, SANDER R. DUBOVY, STEPHAN MICHELS,
`WILLIAM J. FEUER, CARMEN A. PULIAFITO, JANET L. DAVIS, HARRY W. FLYNN, JR,
`AND MARIA ESQUIABRO
`
`● PURPOSE: To evaluate an optical coherence tomogra-
`phy (OCT)-guided, variable-dosing regimen with intrav-
`itreal ranibizumab for the treatment of patients with
`neovascular age-related macular degeneration (AMD).
`● DESIGN: Open-label, prospective, single-center, non-
`randomized, investigator-sponsored clinical study.
`● METHODS: In this two-year study, neovascular AMD
`patients with subfoveal choroidal neovascularization
`(CNV) (n ⴝ 40) and a central retinal thickness of at
`least 300 ␮m as measured by OCT were enrolled to
`receive three consecutive monthly intravitreal injections
`of ranibizumab (0.5 mg). Thereafter, retreatment with
`ranibizumab was performed if one of the following
`changes was observed between visits: a loss of five letters
`in conjunction with fluid in the macula as detected by
`OCT, an increase in OCT central retinal thickness of at
`least 100 ␮m, new-onset classic CNV, new macular
`hemorrhage, or persistent macular fluid detected by OCT
`at least one month after the previous injection of ranibi-
`zumab.
`● RESULTS: At month 12, the mean visual acuity im-
`proved by 9.3 letters (P < .001) and the mean OCT
`central retinal thickness decreased by 178 ␮m (P <
`.001). Visual acuity improved 15 or more letters in 35%
`of patients. These visual acuity and OCT outcomes were
`achieved with an average of 5.6 injections over 12
`months. After a fluid-free macula was achieved, the mean
`injection-free interval was 4.5 months before another
`reinjection was necessary.
`● CONCLUSION: This OCT-guided, variable-dosing reg-
`imen with ranibizumab resulted in visual acuity outcomes
`similar to the Phase III clinical studies, but required
`fewer intravitreal injections. OCT appears useful for
`
`See accompanying Editorial on page 679.
`Accepted for publication Jan 13, 2007.
`From the Bascom Palmer Eye Institute, University of Miami Miller
`School of Medicine, Miami, Florida (G.A.L., P.J.R., S.R.D., W.J.F.,
`C.A.P., J.L.D., H.W.F., M.E.); Pacific Eye Associates, California Pacific
`Medical Center, San Francisco, California (A.E.F.); University Eye
`Hospital Vienna, Austria (S.M.).
`Inquiries to Philip J. Rosenfeld, Bascom Palmer Eye Institute, Univer-
`sity of Miami Miller School of Medicine, 900 N.W. 17th Street, Miami,
`FL 33136; e-mail: prosenfeld@med.miami.edu
`
`determining when retreatment with ranibizumab is
`necessary.
`(Am J Ophthalmol 2007;143:566 –583.
`© 2007 by Elsevier Inc. All rights reserved.)
`
`I NHIBITION OF VASCULAR ENDOTHELIAL GROWTH FAC-
`
`tor-A (VEGF) is an effective strategy for the treatment
`of neovascular
`age-related macular
`degeneration
`(AMD).1– 4 The most effective treatment uses ranibizumab
`(Lucentis, Genentech Inc, South San Francisco, Califor-
`nia, USA), a recombinant, humanized, monoclonal anti-
`body antigen-binding fragment (Fab) that neutralizes all
`biologically active forms of VEGF.5 In the two Phase III
`clinical studies using intravitreal injections of ranibizumab,
`mean visual acuity improved over 24 and 12 months,
`respectively.2,3 This was the first therapy for neovascular
`AMD to show any improvement in mean visual acuity. In
`these studies, statistically significant benefits were observed
`for all the primary and secondary efficacy endpoints when
`compared with control groups. To obtain these impressive
`results, investigators followed a fixed-dosing regimen re-
`quiring an injection of ranibizumab, 0.5 mg or 0.3 mg,
`every month for two years.
`The first suggestion that frequent intravitreal injections
`of ranibizumab could result in improved visual acuity came
`from the earlier Phase I/II studies.6,7 In these studies,
`ranibizumab was injected every two or four weeks into eyes
`of patients with neovascular AMD and these patients were
`followed for 140 days or 210 days. The number of ranibi-
`zumab injections ranged from five to nine depending on
`the study and the cohort within each study. Despite
`differences in the overall number of injections, the out-
`comes from these studies were very similar. Mean visual
`acuity improved and these improvements were associated
`with an absence of angiographic leakage from choroidal
`neovascularization (CNV) and an absence of fluid in the
`macula as assessed by optical coherence tomography
`(OCT) (Rosenfeld PJ, unpublished data, 2003).
`After completion of these Phase I/II studies, most of the
`study participants enrolled in an open-label extension
`study to evaluate the safety and tolerability of long-term
`(up to four years) continued treatment with intravitreal
`
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`
`© 2007 BY ELSEVIER INC. ALL RIGHTS RESERVED.
`
`0002-9394/07/$32.00
`doi:10.1016/j.ajo.2007.01.028
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`injections of ranibizumab (Heier JS and associates. ARVO
`2005, E-Abstract 1393). Although the extension study
`initially required monthly injections of ranibizumab after
`the patient was enrolled, the study was subsequently
`amended to permit reinjection only if needed as deter-
`mined by the treating physician. As a result of retreatment
`being offered at the discretion of the investigator, some
`patients received monthly injections with ranibizumab to
`maintain their visual acuity, whereas others were rein-
`jected less frequently or not at all. During this extension
`study at the Bascom Palmer Eye Institute, OCT imaging
`was used to follow many of these patients in conjunction
`with fluorescein angiography, and OCT appeared to detect
`the earliest signs of fluid reaccumulating in the macula
`even before leakage could be detected by fluorescein
`angiography (Rosenfeld PJ, unpublished data, 2003).
`Based on these observations from the Phase I/II and
`extension studies, an investigator sponsored trial known as
`the Prospective Optical coherence tomography imaging of
`patients with Neovascular AMD Treated with intra-Ocu-
`lar ranibizumab (Lucentis) [PrONTO] study was designed
`to investigate the role of OCT imaging in a variable dosing
`regimen with ranibizumab at the Bascom Palmer Eye
`Institute. This report describes the 12 month results of the
`PrONTO Study.
`
`METHODS
`
`PRONTO IS A TWO-YEAR, OPEN-LABEL, PROSPECTIVE, SIN-
`gle-center clinical study designed to investigate the effi-
`cacy, durability, and safety of a variable dosing regimen
`with intravitreal ranibizumab in patients with neovascular
`AMD. The PrONTO Study is an investigator sponsored
`trial supported by Genentech, Inc, and performed with the
`approval of the Food and Drug Administration. Before
`the initiation of the study, additional approval for the
`PrONTO study was obtained from the Institutional Re-
`view Board at the University of Miami Miller School of
`Medicine. Informed consent was obtained from all patients
`before determination of full eligibility, and the study was
`performed in accordance with the Health Insurance Port-
`ability and Accountability Act (HIPAA). The PrONTO
`Study is registered at www.clinicaltrials.gov, and the clin-
`ical trial accession number is NCT00344227.
`The major efficacy end points were the change in visual
`acuity and OCT measurements from baseline and the
`number of ranibizumab injections required over two years.
`Other efficacy end points included the number of consec-
`utive monthly injections required from baseline to achieve
`a fluid-free macula as determined by OCT. After a fluid-
`free macula was achieved, the durability of the treatment
`effect was determined by calculating the time until the
`next injection was needed because of fluid reaccumulating
`in the macula, otherwise known as the injection-free
`interval. Finally, after the injections resumed, we calcu-
`
`TABLE 1. Major Eligibility Criteria for Enrollment into the
`PrONTO Study
`
`Inclusion criteria
`Age 50 years or older.
`Active primary or recurrent macular neovascularization
`secondary to AMD involving the central fovea in the study
`eye with evidence of disease progression.
`OCT central retinal thickness ⱖ300 microns.
`Best-corrected visual acuity, using ETDRS charts, of 20/40
`to 20/400 (Snellen equivalent) in the study eye.
`Exclusion criteria
`More than three prior treatments with verteporfin
`photodynamic therapy.
`Previous participation in a clinical trial (for either eye)
`involving antiangiogenic drugs (pegaptanib, ranibizumab,
`anecortave acetate, protein kinase C inhibitors).
`Previous subfoveal focal laser photocoagulation in the study
`eye.
`Laser photocoagulation (juxtafoveal or extrafoveal) in the
`study eye within one month preceding day 0.
`Subfoveal fibrosis or atrophy in the study eye.
`History of vitrectomy surgery in the study eye.
`Aphakia or absence of the posterior capsule in the study
`eye.
`History of idiopathic or autoimmune-associated uveitis in
`either eye.
`
`AMD ⫽ age-related macular degeneration; PrONTO ⫽ Pro-
`spective Optical coherence tomography imaging of patients with
`Neovascular AMD Treated with intra-Ocular ranibizumab study;
`OCT ⫽ optical coherence tomography; ETDRS ⫽ Early Treat-
`ment of Diabetic Retinopathy Study.
`
`lated the follow-up number of reinjections required to once
`again achieve a fluid-free macula.
`At the start of the study, only one eye of a patient was
`determined to be eligible and assigned as the study eye.
`The major eligibility criteria are shown in Table 1. The
`major inclusion criteria included a diagnosis of neovascular
`AMD with a baseline protocol visual acuity letter score
`from 20 to 70 letters using the Early Treatment Diabetic
`Retinopathy Study chart at two meters (Snellen equiva-
`lent of 20/40 to 20/400) obtained using a standard refrac-
`tion protocol8 and an OCT 1 mm central retinal thickness
`of at least 300 ␮m. There were no exclusion criteria for
`preexisting cardiovascular, cerebrovascular, or peripheral
`vascular conditions. Of note, all fluorescein angiographic
`lesion types and lesion sizes were eligible for the study. The
`angiographic lesion types at baseline were independently
`assessed by three of the investigators (P.J.R., S.R.D., and
`G.A.L.) and agreement was reached on all interpretations.
`The diagnosis of retinal angiomatous proliferation (RAP)
`was independently assessed for each lesion using the
`characteristic features which included intraretinal hemor-
`rhage, intraretinal vascular anastomoses, and the OCT
`appearance of a retinal pigment epithelial detachment
`
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`TABLE 2. The Number of Times Each Criterion was Used Alone or in Combination With Other Criteria to Retreat Neovascular
`AMD Patients With Ranibizumab After Month 2 Through Month 12
`
`Retreatment criteria
`
`Only one criterion
`observed for
`retreatment
`
`Vision loss (ⱖ5 letters)
`associated with fluid
`detected by OCT
`
`Increase in central
`retinal thickness
`ⱖ100 microns
`
`New-onset
`hemorrhage
`
`New classic
`CNV
`
`Vision loss (ⱖ5 letters) associated with fluid detected by OCT
`Increase in central retinal thickness ⱖ100 microns
`New-onset hemorrhage
`New classic CNV
`Persistent fluid following last injection
`
`31
`12
`12
`7
`30
`
`—
`4*
`5*
`0
`—
`
`4*
`—
`4*
`0
`—
`
`5*
`4*
`—
`1
`—
`
`0
`0
`1
`—
`—
`
`AMD ⫽ age-related macular degeneration; OCT ⫽ optical coherence tomography; CNV ⫽ choroidal neovascularization.
`Most patients fulfilled only one criterion for reinjection as listed in the second column, but some patients fulfilled two or more criteria and
`are listed in columns 3 to 6.
`*Two of these individuals had three criteria for reinjection: vision loss (ⱖ5 letters) associated with fluid detected by OCT, increase in central
`retinal thickness ⱖ100 microns, and new onset hemorrhage.
`
`with overlying cystic changes in the retina. In calculating
`lesion areas, we assumed a standard disk diameter of 1.8
`mm and a standard disk area (DA) of 2.54 mm2. All digital
`fundus photography was performed using Topcon TRC-
`50IX retinal cameras (Topcon America Corp (TAC),
`Paramus, New Jersey, USA) with a 35 degree viewing
`angle and the images were stored using the Topcon
`Imagenet software (version 2.14, Windows 2000 v.5.0;
`Paramus, New Jersey, USA). Images were then transferred
`to an OIS workstation (OIS Winstation XP 10 3000 Auto
`Import Capture version 10.2.59; Sacramento, California,
`USA) where the lesion areas were measured.
`OCT (Stratus OCT, Carl Zeiss Meditec, Dublin, Cali-
`fornia, USA) quantitative assessments were obtained using
`six diagonal fast, low density scans (low resolution, 128
`A-scans per diagonal). The central 1 mm central retinal
`thickness measurements were obtained from the macular
`thickness maps calculated from the six low-resolution fast
`scans after it was confirmed that the two boundaries
`delineated as
`the internal
`limiting membrane (inner
`boundary) and the retinal pigment epithelium (RPE) and
`the Bruch membrane (outer boundary) were appropriately
`identified by the validated internal algorithm. If bound-
`aries were incorrectly identified, then the scans were
`repeated until the boundaries were accurately identified by
`the algorithm. The central retinal thickness was defined as
`the distance between these inner and outer boundaries and
`did not include any fluid under the RPE. Eligible patients
`were required to have a 1 mmcentral retinal thickness of
`at least 300 ␮m. OCT qualitative assessments were per-
`formed using all six diagonal slow, high density scans (high
`resolution, 512 A-scans per diagonal). These high resolu-
`tion diagonal scans were used to evaluate whether fluid was
`present in the macula and whether retreatment was
`needed. For the purposes of this study, fluid in the macula
`was identified as intraretinal fluid (cysts) and subretinal
`fluid, and a fluid-free macula was defined by the absence of
`retinal cysts and subretinal fluid as determined by OCT.
`
`Fluid under the RPE, otherwise known as a pigment
`epithelial detachment (PED), was recorded as an OCT
`finding in the macula but not included in any of the
`retreatment criteria. The decision not to include a PED in
`the retreatment criteria was based on prior anecdotal
`observations from the Phase I/II extension study with
`ranibizumab. In the extension study, there appeared to be
`little correlation between the presence of a PED and visual
`acuity. In addition, PEDs could remain stable for months
`and resolution of fluid within the PED was thought to be
`a lagging indicator of VEGF activity. In contrast, macular
`cysts and subretinal fluid appeared to respond more rapidly
`to the presence or absence of VEGF.
`During the screening process, patients underwent a
`complete physical exam with laboratory testing. Labora-
`tory testing consisted of an electrocardiogram, complete
`blood count, and chemistry panel performed at baseline
`and at month 12. Blood pressure measurements were
`performed at every visit. Eligible patients underwent visual
`acuity testing and ophthalmoscopic examinations at base-
`line, day 14, day 30, day 45, day 60, and monthly
`thereafter. Fundus photography and OCT imaging were
`performed at baseline and on days one, two, four, seven,
`14, and 30 after the first two monthly injections, and
`monthly thereafter. Fluorescein angiography was per-
`formed at baseline, month 1, month 2, month 3, and every
`three months thereafter. All ophthalmic photographers
`and OCT technicians involved in the study were previ-
`ously certified to participate in Food and Drug Adminstra-
`tion–approved clinical trials at the Bascom Palmer Eye
`Institute.
`After determination of eligibility, patients received an
`intravitreal injection of ranibizumab (LUCENTIS, Ge-
`nentech, Inc) using a standard protocol at the Bascom
`Palmer Eye Institute. The eye was topically anesthetized
`with sterile 4% lidocaine and a povidone-iodine (10%)
`scrub was performed on the lids and lashes. A sterile
`speculum was placed between the lids, and povidone-
`
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`TABLE 3. Visual Acuity of Eyes With Neovascular AMD Treated With a Variable-Dosing Regimen of Ranibizumab
`Through 12 Months
`
`Patients’ study eyes
`(n ⫽ 40)
`
`Mean (P value)*
`
`Median (P value)†
`
`Baseline visual acuity
`letters (Snellen
`equivalent)
`
`Day 14 visual acuity
`letters (Snellen
`equivalent)
`
`Month 1 visual acuity
`letters (Snellen
`equivalent)
`
`Month 3 visual acuity
`letters (Snellen
`equivalent)
`
`Month 12 visual acuity
`letters (Snellen
`equivalent)
`
`Change in visual acuity
`letter scores from
`baseline to month 12
`visual acuity letters
`(Snellen equivalent)
`
`56.2
`20/80⫹1
`57
`20/80⫹2
`
`65.5
`67.0
`63.9
`63.1
`20/50 (P ⬍ .001)
`20/50⫺2 (P ⬍ .001) 20/50⫺1 (P ⬍ .001) 20/50⫹2 (P ⬍ .001)
`68
`65.0
`66.0
`71.0
`(20/50) (P ⬍ .001) 20/50⫹1 (P ⬍ .001) 20/40⫹1 (P ⬍ .001) 20/40⫺2 (P ⬍ .001)
`
`⫹9.3
`
`⫹11.0
`
`AMD ⫽ age-related macular degeneration.
`*Paired the Student t test.
`†Paired the Wilcoxon signed-rank test.
`
`TABLE 4. OCT Central Retinal Thickness of Eyes With Neovascular AMD Treated With a Variable-Dosing Regimen of
`Ranibizumab Through 12 Months
`
`Patients’ study eyes
`(n ⫽ 40)
`
`Baseline central
`retinal thickness (␮m)
`
`Day 1 central retinal
`thickness (␮m)
`
`Month 1 central retinal
`thickness (␮m)
`
`Month 3 central retinal
`thickness (␮m)
`
`Month 12 central retinal
`thickness (␮m)
`
`Change in central retinal
`thickness (␮M) from
`baseline to month 12
`
`Mean (P value)*
`Median (P value)†
`
`393.9
`384.5
`
`347.1 (P ⬍ .001)
`336.0 (P ⬍ .001)
`
`237.2 (P ⬍ .001)
`203.5 (P ⬍ .001)
`
`204.3 (P ⬍ .001)
`186.0 (P ⬍ .001)
`
`216.1 (P ⬍ .001)
`199.0 (P ⬍ .001)
`
`⫺177.8
`⫺185.5
`
`OCT ⫽ optical coherence tomography; AMD ⫽ age-related macular degeneration.
`*Paired the Student t test.
`†Paired the Wilcoxon signed-rank test.
`
`TABLE 5. Distribution of OCT Lesion Characteristics From Baseline Through Month 3 in Neovascular AMD Patients Treated With
`Ranibizumab at Day 0, Month 1, and Month 2
`
`OCT lesion characteristics
`(n ⫽ 40)
`
`Day 0
`n (%)
`
`Retinal cysts
`Subretinal fluid
`RPE detachment
`Epiretinal membrane
`RPE tear
`
`36 (90%)
`30 (75%)
`29 (72.5%)
`9 (22.5%)
`0
`
`Day 7
`n (%)
`
`7 (17.5%)
`19 (47.5%)
`27 (67.5%)
`9 (22.5%)
`1 (2.5%)
`
`Day 14
`n (%)
`
`6 (15%)
`15 (37.5%)
`24 (60%)
`9 (22.5%)
`1 (2.5%)
`
`Month 1
`n (%)
`
`6 (15%)
`9 (22.5%)
`23 (57.5%)
`9 (22.5%)
`1 (2.5%)
`
`Month 2
`n (%)
`
`3 (7.5%)
`3 (7.5%)
`18 (45%)
`9 (22.5%)
`1 (2.5%)
`
`Month 3
`n (%)
`
`3* (7.5%)
`1* (2.5%)
`15 (37.5%)
`9 (22.5%)
`1 (2.5%)
`
`OCT ⫽ optical coherence tomography; RPE ⫽ retinal pigment epithelium; AMD ⫽ age-related macular degeneration.
`*One eye had both residual retinal cysts and subretinal fluid.
`
`iodine (5%) drops were applied over the ocular surface
`three times over several minutes. Additional topical anes-
`thesia was achieved by applying a sterile cotton swab
`soaked in sterile 4% lidocaine to the area designated for
`injection in the inferotemporal quadrant. Ranibizumab
`(0.05 ml, 0.5 mg) in a tuberculin syringe with a 30-gauge
`needle was injected through the pars plana into the
`vitreous cavity through the sclera 3 to 4 mm posterior to
`the limbus. Post-injection light perception was assessed
`and the intraocular pressure was monitored until it was
`lower than 30 mm Hg. The patient was instructed to apply
`
`moxifloxacin antibiotic drops (vigamox 0.5% solution) to
`the study eye four times per day for three days. All patients
`received a call within 24 hours to assess their status and
`remind them to use their antibiotic drops.
`Intravitreal injections of ranibizumab were administered
`to all patients at baseline, month 1, and month 2.
`Additional reinjections were given if any of the following
`changes were observed by the evaluating physician as
`shown in Table 2: (1) visual acuity loss of at least five
`letters with OCT evidence of fluid in the macula, (2) an
`increase in OCT central retinal thickness of at least 100
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`FIGURE 1. Mean and median change in visual acuity through
`12 months of eyes with neovascular age-related macular degen-
`eration (AMD) treated with a variable dosing intravitreal
`ranibizumab regimen. Vertical lines are 1 standard error of the
`means.
`
`FIGURE 2. Mean and median change in the optical coherence
`tomography (OCT) central retinal
`thickness through 12
`months of eyes with neovascular age-related macular degener-
`ation (AMD) treated with a variable dosing intravitreal ranibi-
`zumab regimen. Vertical
`lines are 1 standard error of the
`means.
`
`TABLE 6. Distribution of Visual Acuity Changes in Eyes
`With Neovascular AMD After 3 Doses of Ranibizumab at
`Month 3 and After a Variable-Dosing Regimen From
`Months 3 Through 12
`
`Change in visual acuity from
`baseline through 12 months
`
`Month 3
`40 eyes n (%)
`
`Month 12
`40 eyes n (%)
`
`ⱖ6 line increase
`ⱖ3 line to ⬍6 line increase
`ⱖ1 line to ⬍3 line increase
`No change
`ⱖ1 line to ⬍3 line decrease
`ⱖ3 line decrease
`
`2 (5%)
`11 (27.5%)
`20 (50%)
`5 (12.5%)
`1 (2.5%)
`1 (2.5%)
`
`3 (7.5%)
`11 (27.5%)
`16 (40%)
`5 (12.5%)
`3 (7.5%)
`2 (5%)
`
`AMD ⫽ age-related macular degeneration.
`
`␮m, (3) new macular hemorrhage, (4) new area of classic
`CNV, or (5) evidence of persistent fluid on OCT at least
`one month after the previous injection. All criteria were
`based on comparisons with the previously scheduled visit.
`If a reinjection was performed as part of an unscheduled
`visit, then the patient returned at the next scheduled visit
`for follow-up, but all subsequent reinjection decisions were
`postponed until the next scheduled visit at least one
`month after the injection. If any single criterion for
`reinjection was fulfilled, then the intravitreal injection was
`performed as previously described.
`The major outcome measurements in the PrONTO
`study included Early Treatment Diabetic Retinopathy
`Study visual acuity letter scores, OCT central retinal
`
`FIGURE 3. Distribution of the total number of injections of
`ranibizumab administered per neovascular age-related macular
`degeneration (AMD) patient through 12 months according to
`the Prospective Optical coherence tomography imaging of
`patients with Neovascular AMD Treated with intra-Ocular
`ranibizumab (PrONTO) study criteria.
`
`thickness measurements, the change in visual acuity letter
`scores and OCT measurements from baseline, the consec-
`utive number of injections required to achieve a fluid-free
`macula from baseline, the injection-free interval after a
`fluid-free macula was achieved, the number of consecutive
`reinjections required to achieve a fluid-free macula after
`the fluid started to reaccumulate and injections were
`
`FIGURE 4. Case 1: A 100-year-old woman with neovascular age-related macular degeneration (AMD) diagnosed with
`predominantly classic choroidal neovascularization (CNV) in her left eye, given three ranibizumab injections, and then followed
`through month 12. Color fundus images with early and late phase fluorescein angiographic images are shown at baseline, at month
`3 (one month after the third injection), and then at month 6, month 9, and month 12 without any additional injections of
`ranibizumab. At months 6 and 12, fundus photography was performed using a 50 degree viewing angle rather than the protocol 35
`degree angle.
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`resumed, and the total number of injections received by a
`patient during one year.
`For the mean visual acuity letter scores and central
`retinal thickness measurements during the first 12 months,
`the data were statistically compared with mean baseline
`values using the paired Student t test. Median measure-
`ments were compared with median baseline values using
`the paired Wilcoxon signed-rank test. The influence of
`baseline fluorescein angiographic lesion types on the num-
`ber of
`injections over 12 months was assessed using
`one-way analysis of variance and the Kruskal-Wallis test.
`The influence of baseline acuity and lesion size in disk
`areas on the number of injections and the influence of the
`number of
`injections on visual acuity outcomes were
`assessed using the Pearson correlation analysis and Spear-
`man nonparametric correlation analysis. Statistical signif-
`icance was defined as P ⬍ .05.
`
`RESULTS
`
`● BASELINE CHARACTERISTICS: Between August 2004
`and April 2005, 69 patients were screened for the study
`and 40 patients were enrolled. Twenty-nine patients were
`excluded from the study for the following reasons: OCT
`central retinal thickness less than 300 ␮m (nine patients),
`declined participation in the study after screening because
`of the rigorous follow-up schedule (seven patients), visual
`acuity either better than 20/40 or worse than 20/400 (four
`patients), inability to obtain reproducible OCT central
`retinal
`thickness measurements because of unreliable
`boundary detection (three patients), localized retinal de-
`tachment (two patients), previous enrollment in a clinical
`trial involving anti-angiogenic drugs (two patients), RPE
`tear (one patient), and no evidence of macular neovascu-
`larization (one patient). Of the 40 patients enrolled in the
`study, the mean age was 83.5 years (standard deviation
`[SD] ⫽7.2) and the median age was 83 years (range, 69 to
`100 years), 26 were women (65%), and all the participants
`were white. Fifteen eyes (37.5%) were phakic and 25 eyes
`(62.5%) were pseudophakic. Fourteen of the 40 eyes had
`undergone some prior treatment for neovascular AMD
`including intravitreal pegaptanib (four eyes), photody-
`namic therapy (PDT) alone (three eyes), PDT with intra-
`vitreal triamcinolone acetonide (five eyes), PDT followed
`by intravitreal pegaptanib (one eye), and laser photocoag-
`ulation (one eye).
`At baseline, the mean and median visual acuity letter
`scores were 56 (20/80⫹1) and 57 (20/80⫹2), respectively
`
`(Table 3). Baseline mean and median OCT 1 mm central
`retinal thickness measurements were 394 ␮m and 385 ␮m,
`respectively (Table 4). The OCT findings at baseline
`included retinal cysts (36 eyes; 90%), subretinal fluid (30
`eyes; 75%), PED (29 eyes; 72.5%), and epiretinal mem-
`brane (nine eyes, 22.5%; Table 5). At baseline, the
`neovascular lesions were categorized by fluorescein angiog-
`raphy as occult with no classic lesions (10 eyes; 25%),
`minimally classic lesions (23 eyes; 57.5%), and predomi-
`nantly classic lesions (seven eyes; 17.5%). Overall, 10 of
`the 40 lesions (25%) were categorized as RAP lesions. The
`mean and median baseline lesion areas were 3.5 DAs (SD ⫽
`2.4) and 2.8 DAs (range, 0.6 to 10), respectively. The
`baseline mean systolic/diastolic blood pressure was 149/78.
`
`● VISUAL ACUITY AND OCT OUTCOMES AT THREE
`MONTHS: After the first injection of ranibizumab at base-
`line, an improvement in visual acuity was detected by day
`14, the first follow-up visit when visual acuity was mea-
`sured after the first injection (Table 3; Figure 1). The mean
`and median visual acuity scores improved by 6.9 letters
`(P ⬍ .001) and 7.5 letters (P ⬍ .001), respectively. During
`the first three months, visual acuity continued to improve.
`By month three, one month after the third injection, there
`was a mean and median visual acuity increase of 10.8
`letters (P ⬍ .001) and 10.5 letters (P ⬍ .001), respectively.
`At month three, 13 eyes (32.5%) gained at least 3 lines of
`visual acuity, with two eyes (5%) gaining at least 6 lines
`compared with baseline. One eye lost more than 3 lines of
`visual acuity by three months because a tear of the RPE
`developed within seven days after the first injection
`(Tables 5 and 6).
`The improvement in visual acuity was associated with a
`decrease in central retinal thickness (Table 4, Figure 2).
`One day after the first injection of ranibizumab, a statisti-
`cally significant decrease in the central retinal thickness
`was detected with the mean and median thickness mea-
`surements decreasing by 47 ␮m (P ⬍ .001) and 48.5 ␮m
`(P ⬍ .001), respectively. The central retinal thickness
`continued to decrease over the next three months. By
`month three, the mean and median central retinal thick-
`ness measurements had decreased by 189.7 ␮m (P ⬍ .001)
`and 198.5 ␮m (P ⬍ .001), respectively.
`The correlations between the decrease in OCT central
`retinal thickness and the improvement in visual acuity
`were explored using both Pearson correlation and Spear-
`man nonparametric correlation analyses. At one month,
`there were no statistically significant correlations between
`the decrease in central retinal thickness and the improve-
`
`FIGURE 5. Case 1: Optical coherence tomography (OCT) response to the first ranibizumab injection from baseline through month 1 in an eye
`with neovascular age-related macular degeneration (AMD) and predominantly classic choroidal neovascularization (CNV). Vertical (left side)
`and horizontal (right side) OCT scans and central retinal thickness measurements of her left eye are shown at baseline (406 ␮m; visual acuity
`[VA]: 20/80), ranibizumab no. 1 injected; day 1 (327 ␮m); day 2 (307 ␮m); day 4 (281 ␮m); day 7 (225 ␮m); day 14 (219 ␮m; VA: 20/50);
`month 1 (183 ␮m; VA: 20/50), ranibizumab no. 2 injected.
`
`VOL. 143, NO. 4
`
`VARIABLE DOSING REGIMEN WITH INTRAVITREAL RANIBIZUMAB
`
`573
`
`Mylan Exhibit 1034
`Mylan v. Regeneron, IPR2021-00880
`Page 8
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`Joining Petitioner: Apotex
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`

`

`574
`
`AMERICAN JOURNAL OF OPHTHALMOLOGY
`
`APRIL 2007
`
`Mylan Exhibit 1034
`Mylan v. Regeneron, IPR2021-00880
`Page 9
`
`Joining Petitioner: Apotex
`
`

`

`TABLE 7. Number of Reinjections With Ranibizumab
`Performed per Month in Eyes With Neovascular AMD
`Using the Variable-Dosing Regimen From Months 3
`Through 12
`
`Follow-up
`visit
`
`Month 3
`Month 4
`Month 5
`Month 6
`Month 7
`Month 8
`Month 9
`Month 10
`Month 11
`Month 12
`
`Number (%) receiving the
`first reinjection after
`month 2 (n ⫽ 33)
`
`Total number (%) reinjected
`at monthly follow-up
`visits(n ⫽ 33)
`
`3 (7.5)
`6 (15.0)
`10 (25.0)
`3 (7.5)
`3 (7.5)
`0
`2 (5.0)
`1 (2.5)
`2 (5.0)
`3 (7.5)
`
`3 (7.5)
`9 (22.5)
`14 (35.0)
`7 (17.5)
`11 (27.5)
`6 (15.0)
`14 (35.0)
`6 (15.0)
`13 (32.5)
`19 (47.5)
`
`AMD ⫽ age-related macular degeneration.
`
`ment in visual acuity (Pearson, r ⫽ .25, P ⫽ .12; Spear-
`man, r ⫽ .23, P ⫽ .15). However, there were significant
`correlations between the decrease in central retinal thick-
`ness at one month and the subsequent improvement in
`visual acuity seen at two months (Pearson, r ⫽ .57, P ⬍
`.001; Spearman, r ⫽ .47, P ⫽ .002) and three months
`(Pearson, r ⫽ .51, P ⫽ .001; Spearman, r ⫽ .36, P ⫽ .021).
`In addition, significant correlations were identified be-
`tween the change in thickness at two months and the
`visual acuity changes at two months (Pearson, r ⫽ .36, P ⫽
`.023; Spearman, r ⫽ .41, P ⫽ .009) and three months
`(Pearson, r ⫽ .31, P ⫽ .05; Spearman, r ⫽ .38, P ⫽ .017).
`Finally, significant correlations were observed between the
`decrease in retinal thickness and the improvement in
`visual acuity at three months (Pearson, r ⫽ .36, P ⫽ .024;
`Spearman, r ⫽ .34, P ⫽ .034).
`The PrONTO OCT definition of fluid in the macula
`included retinal cysts and subretinal fluid, but not sub-RPE
`fluid, otherwise known as a PED. Of the 36 eyes with cystic
`changes in the retina at baseline, 30 eyes showed complete
`resolution of the retinal cysts by day 7 (Table 5). By one
`month after the injection, only six eyes were found to
`contain retinal cysts, with three eyes containing retinal
`cysts at month 2 and month 3. Of the 30 eyes with
`subretinal fluid at baseline as detected by OCT, 19 eyes
`continued to have subretinal fluid at day 7 after the first
`injection, nine eyes continued to have subretinal fluid at
`
`month 1, three eyes at month 2, and only one eye at
`month 3. At the month 3 visit, only three eyes required an
`injection of ranibizumab because of persistent fluid in the
`macula; two eyes with residual retinal cysts and one eye
`with both residual cysts and subretinal fluid (Table 5).
`Fluid contained within a PED appeared to take longer to
`resolve compared with intraretinal cysts and subretinal
`fluid (Table 5). Of the 29 eyes with evidence of a PED at
`baseline, only 14 eyes showed resolution of the PED by
`month 3 with the remaining 15 eyes showing at least some
`decrease in the amount of fluid within the PED. One of the
`eyes with a PED at baseline was the same eye that
`developed a tear of the RPE within seven days after the
`first injection.
`At the month 3 visit, 37 of the 40 eyes did not receive
`an injection. Of the three eyes that did receive an
`injection, two had persistent intraretinal cysts