Visual impairment is a common problem among Veterans and results in significant reduction in quality of life. Diseases commonly responsible for substantial losses in visual acuity include neovascular ("wet") age-related macular degeneration (AMD), diabetic macular edema (DME), and central or branch retinal vein occlusion (CRVO or BRVO). While the etiologies of these diseases are complex, all are driven at least in part by vascular endothelial growth factors (VEGFs). This has led to the development of several drugs called anti-VEGF agents designed to block these factors and thus limit their damage to the eye. The most commonly used anti-VEGF agents—aflibercept, bevacizumab, and ranibizumab—have been shown to slow and even reverse the vision loss typically seen in patients with AMD, DME, BRVO, and CRVO. The comparative effectiveness, harms, and costs of these drugs are unclear.
This topic was nominated by Dr. Glenn Cockerham, National Program Director for VHA Ophthalmology Services. The scope and key questions of this report were determined during a topic refinement process that included a preliminary review of published peer-reviewed literature, discussion with internal partners and investigators, and consultation with content experts and key stakeholders. This review follows established systematic review methodology and a protocol describing the review plan was posted to the PROSPERO International Prospective Register of Systematic Reviews website before the review was initiated. The key research questions for this review are as follows:
Key Question 1: What is the comparative clinical effectiveness of anti-VEGF agents for retinal/choroidal neovascularization and/or macular edema in adults?
Key Question 2: What are the comparative harms of anti-VEGF agents for retinal/choroidal neovascularization and/or macular edema in adults?
Key Question 3: What is the comparative cost-effectiveness of anti-VEGF