Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.
Am J Ophthalmol. 2019 Aug;204:26-45. doi: 10.1016/j.ajo.2019.02.036. Epub 2019 Mar 7.
To describe the synergistic benefits and cost savings from the use of optical coherence tomography (OCT) and vascular endothelial growth factor (VEGF) inhibitors, particularly intravitreal bevacizumab, in the treatment of exudative age-related macular degeneration (AMD).
Retrospective literature review and personal perspective.
Retrospective literature review and personal perspective.
The introduction of the first clinically useful OCT instrument coincided with early-phase clinical trials of a drug that would become known as ranibizumab. OCT provided a noninvasive imaging strategy that unambiguously showed the macular fluid associated with exudative AMD and the ability of anti-VEGF therapy to resolve this fluid with concomitant visual acuity improvement. Clinicians came to embrace the use of OCT imaging as the basis for dosing with anti-VEGF drugs, rather than the fixed-interval dosing that was the standard in clinical trials and recommended by industry after approval. But, before ranibizumab was approved for the treatment of exudative AMD, intravenous bevacizumab was approved to treat cancer. Both drugs shared a common molecular lineage, and this led to a clinical trial using intravenous bevacizumab for the treatment of exudative AMD. Intravenous bevacizumab resulted in visual acuity and OCT improvements similar to ranibizumab, and this observation soon led to the intravitreal use of bevacizumab in 2005. Fortuitously, both ranibizumab and bevacizumab were packaged at similar molar concentrations, so similar volumes of both drugs when injected into an eye would result in similar anti-VEGF activity. With ranibizumab not yet commercially available, intravitreal bevacizumab rapidly became adopted worldwide for the treatment of VEGF-driven ocular diseases. Despite numerous attempts by industry and anonymous sources to discredit and prevent its use, bevacizumab spread globally owing to its availability; its low treatment cost, which was $5.50 per 1 mg in the United States; the evidence of efficacy based on OCT imaging and vision improvement; and its perceived safety. In the United States alone, the use of OCT-guided therapy and the use of bevacizumab for the treatment of exudative AMD has saved Medicare over $40 billion since 2008.
The rapid adoption of OCT-guided therapy and the use of intravitreal bevacizumab by the global retinal community has prevented blindness from exudative and neovascular ocular diseases worldwide while saving healthcare providers and patients billions of dollars.
描述光相干断层扫描（OCT）和血管内皮生长因子（VEGF）抑制剂联合应用的协同效益和成本节约，特别是玻璃体内注射贝伐单抗，用于治疗渗出性年龄相关性黄斑变性（AMD）。
回顾性文献回顾和个人观点。
回顾性文献回顾和个人观点。
第一台临床实用 OCT 仪器的问世恰逢一种药物的早期临床试验，这种药物后来被称为雷珠单抗。OCT 提供了一种非侵入性的成像策略，可以明确显示与渗出性 AMD 相关的黄斑积液，以及抗 VEGF 治疗解决这种积液的能力，并伴有视力提高。临床医生开始接受 OCT 成像作为抗 VEGF 药物剂量的基础，而不是临床试验中的固定间隔剂量，也不是批准后行业推荐的剂量。但是，在雷珠单抗被批准用于治疗渗出性 AMD 之前，静脉注射贝伐单抗已被批准用于治疗癌症。这两种药物都有共同的分子谱系，这导致了一项使用静脉注射贝伐单抗治疗渗出性 AMD 的临床试验。静脉注射贝伐单抗可改善视力和 OCT 结果，与雷珠单抗相似，这一观察结果很快导致 2005 年玻璃体内注射贝伐单抗。幸运的是，雷珠单抗和贝伐单抗的包装摩尔浓度相似，因此当注射到眼睛中时，两种药物的相似体积会产生相似的抗 VEGF 活性。由于雷珠单抗尚未上市，玻璃体内注射贝伐单抗在全球迅速被采用，用于治疗 VEGF 驱动的眼部疾病。尽管行业和匿名来源多次试图诋毁和阻止其使用，但贝伐单抗还是因其可获得性、其较低的治疗成本（在美国每 1 毫克 5.50 美元）、基于 OCT 成像和视力改善的疗效证据以及其被认为的安全性而在全球范围内得到推广。仅在美国，自 2008 年以来，OCT 引导治疗的应用和玻璃体内注射贝伐单抗治疗渗出性 AMD，已为医疗保险节省了超过 400 亿美元。
全球视网膜社区迅速采用 OCT 引导治疗和玻璃体内注射贝伐单抗，防止了全世界渗出性和新生血管性眼病导致的失明，并为医疗保健提供者和患者节省了数十亿美元。
