Abstract
BACKGROUND: Anti-vascular endothelial growth factor (VEGF) intravitreal injection treatment (IVT)s are gold standard for various neovascular retinal diseases, including neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and macular edema due to retinal vein occlusion (RVO). Same day bilateral IVTs are commonly performed off-label worldwide to reduce patient burden, despite limited safety data. This study evaluates the safety and management of bilateral same day anti-VEGF injections within a treat-and-extend regimen (TER) and proposes a clinical guideline for coordination of bilateral treatment. METHODS: This retrospective observational study analysed electronic health records of 428 included patients treated bilaterally with ranibizumab 0.5mg or aflibercept 2mg at the VISTA Augenklinik (Binningen, Switzerland) between 2015 and 2019. Patients included had bilateral macular edema due to nAMD, DME, or RVO and received at least two cycles of same day bilateral anti-VEGF injections within the TER. Treatment coordination followed one of four strategies: Equal TER, Coordinated TER, Mixed TER and pro re nata (PRN), and Asynchronous TER. Unilateral IVTs were also recorded during the same period in the same patient cohort. Ocular and systemic adverse events (AEs) were compared between unilateral and bilateral injections using Fisher's exact test. RESULTS: A total of 15,825 anti-VEGF injections were administered: 4,766 bilateral same day injections ([Formula: see text]) and 6,293 unilateral injections. Treatment intervals were synchronised according to visual acuity potential and disease activity. A treatment regime for bilateral IVTs has been established and is provided in the manuscript. The most frequently reported ocular AEs were conjunctival haemorrhage and sicca symptoms. Systemic AEs such as cerebrovascular and cardiovascular events were rare, with no significant difference between bilateral and unilateral injections. CONCLUSION: Bilateral same day intravitreal anti-VEGF injections within a TER regimen appear to be safe with no significant increase in ocular or systemic AEs compared to unilateral treatment. Coordinating bilateral IVTs using the clinical guideline presented in this study may reduce treatment visits, ease patient burden and improve compliance. Larger prospective studies are needed to confirm safety and support standardised guidelines for bilateral IVTs.