Safety and efficacy of anti-vascular endothelial growth factor (VEGF) plus corticosteroids versus anti-VEGF alone for macular edema from retinal vein occlusion: A systematic review and meta-analysis

Summary

Systematic review and meta-analysis. BRVO ME anti-VEGF + steroids vs anti-VEGF alone: Combined Rx modest efficacy with fewer injections, but increased risk for elevated IOP and cataract surgery.

Abstract

We evaluate the efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid combination therapy versus anti-VEGF monotherapy for both branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO)-related macular edema. A systematic search identified randomized controlled trials (RCTs) comparing the 2 modalities. Non-RCTs, studies with steroid monotherapy as the only comparator and macular edema from other causes were excluded. Visual, anatomical, safety, and injection-related outcomes were assessed. Twenty RCTs comprising 2040 patients were included. Combination therapy showed better best-corrected visual acuity (BCVA) (Mean Difference [MD] -0.09; 95 % CI -0.12 to -0.07; p < 0.00001), reduced central macular thickness (CMT) (MD -24.42; 95 % CI -35.32 to -13.52; p < 0.0001), lower edema recurrence (Odds Ratio [OR] 0.49; 95 % CI 0.30-0.80; p = 0.004), reduced need for PRN anti-VEGF injections (OR 6.77; 95 % CI 3.41-13.46; p < 0.00001), higher intraocular pressure (IOP) within normal range up to 6 months (MD 0.64; 95 % CI 0.20-1.07; p = 0.004) and increased cataract surgery risk (OR 7.95; 95 % CI 1.35-46.75; p = 0.02). Subgroup analysis showed BCVA improvement, fewer injections, reduced PRN need, and higher IOP in CRVO, and reduced recurrence in BRVO. Triamcinolone acetonide improved BCVA while intravitreal dexamethasone implant lowered CMT, and both agents reduced PRN injections. Combination therapy provides modest improvement in efficacy outcomes and fewer injections, particularly in CRVO, but increases risk of IOP elevation and cataract surgery. Reduced injection frequency may not necessarily translate to overall lower treatment burden and costs due to frequent monitoring of steroid-related complications.