Short-term outcomes of aflibercept for neovascular age-related macular degeneration in eyes previously treated with other vascular endothelial growth factor inhibitors

Short-Term Real-World Outcomes of Intensive Aflibercept Injection for Refractory Neovascular Age-Related Macular Degeneration

Background: The aim of this study is to report short-term outcomes after the shortening of the treatment interval to 4 weeks with a treat-and-extend (TAE) regimen (Si4w) of aflibercept in patients with refractory neovascular age-related macular degeneration (nAMD). Methods: This retrospective study included 34 patients given aflibercept with a TAE regimen of a minimum of a 4-week interval when they had a limited response to bimonthly aflibercept. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) were compared before and after Si4w. The resolution of subretinal and intraretinal fluid before and after Si4w was also examined. The risk factors associated with persistent fluid were analyzed. Results: The average treatment duration until initiation of Si4w was 57.82 ± 28.59 months, with an average of 23.64 ± 12.40 injections administered. The BCVA was not significantly improved after Si4w. The CMT decreased significantly from 427.91 ± 125.74 μm to 336.38 ± 121.67 μm at the third visit (p < 0.001). Eighteen eyes (52.9%) showed complete resolution, and twenty-three eyes (67.6%) experienced complete resolution at least once during the three visits. The duration of fluid before Si4w was significantly associated with complete resolution (p = 0.011). Conclusions: Si4w of aflibercept showed satisfactory anatomical outcomes with complete resolution of fluid in patients with a limited response to bimonthly aflibercept injections, and should be considered as a useful treatment option.

Short-term outcomes of switching to brolucizumab in japanese patients with neovascular age-related macular degeneration

PURPOSE

To evaluate the outcomes of a 6-month follow-up after switching to brolucizumab from aflibercept to treat neovascular age-related macular degeneration (AMD) in Japanese patients.

STUDY DESIGN

Retrospective observational study.

METHODS

We studied 45 consecutive eyes of 42 patients diagnosed with neovascular AMD, who were switched to intravitreal brolucizumab injection (IVBr) after receiving intravitreal aflibercept injection (IVA) using a treat-and-extend (TAE) regimen. Patients who had brolucizumab-associated intraocular inflammation (IOI) were excluded from the study. The mean changes in the logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA), central foveal thickness (CFT), central choroidal thickness (CCT), and treatment intervals were evaluated at 6 months after the switch to IVBr.

RESULTS

One eye of 1 patient was excluded because of IOI after the switch; 44 eyes of 41 patients were enrolled in this study. The mean logMAR BCVA was maintained throughout the follow-up period when compared with the baseline value (P > .05 at 6 months). However, the mean CFT and CCT at 6 months had decreased significantly (P < .05 and P < .001, respectively). The mean treatment interval was extended from 5.75 to 8.12 weeks.

CONCLUSION

Switching to brolucizumab from aflibercept using a TAE regimen might be effective for maintaining functional outcomes and extending intervals in Japanese patients with AMD.

Outcomes after switching eyes that were stable on aflibercept to ranibizumab versus continuing aflibercept in neovascular age-related macular degeneration

PURPOSE

To describe outcomes of neovascular age-related macular degeneration (nAMD) eyes that were stable on aflibercept but switched to ranibizumab compared to eyes maintained on aflibercept over the same period.

METHODS

In this retrospective cohort study, eyes switched from aflibercept to ranibizumab due to intraocular inflammation (IOI) concerns with aflibercept were identified. Data was gathered from 3 visits pre-switch, switch visit (Sw), and 3 visits post-switch (P1, P2, P3). Similar data was gathered on eyes eligible to switch but continued on aflibercept with the middle visit considered the "presumed switch." Outcome measures included visual acuity (VA) and central foveal thickness (CFT).

RESULTS

A total of 142 eyes were analyzed with 71 in each of the switch and aflibercept groups. In the switch group, mean CFT increased from 165.7 µm at Sw to 184.7 µm at P1 (p = 0.009), 180.9 µm at P2 (p = 0.007), and 183.3 µm at P3 (p = 0.004). VA changed from logMAR 0.43 (20/54) at Sw to 0.49 (20/61) at P1 (p = 0.02), 0.54 (20/69) at P2 (p = 0.008), and 0.53 (20/68) at P3 (p = 0.04). In the aflibercept group, no significant change in CFT was found over the same period. VA changed from logMAR 0.56 (20/72) at the "presumed switch" to 0.58 (20/76) at P1 (p = 0.085), 0.62 (20/83) at P2 (p = 0.001), and 0.59 (20/77) at P3 (p = 0.14).

CONCLUSIONS

nAMD eyes that were stable or improving on aflibercept but were switched to ranibizumab worsened, while those in a comparable group maintained on aflibercept remained fairly stable, suggesting a potential efficacy difference between the two drugs.

Short-Term Outcomes following "Switching" to Monthly Ranibizumab in Neovascular Age-Related Macular Degeneration Showing Insufficient Response to Bimonthly Aflibercept

Results

CRT and logMAR VA were 349.62 ± 223.51 μm and 0.50 ± 0.23 at the baseline and 274.69 ± 148.77 μm and 0.46 ± 0.24, 311.54 ± 192.90 μm and 0.45 ± 0.20 at 1 month after the first and third ranibizumab injections, respectively. The CRT decrease during three ranibizumab injections was statistically significant (38.08 ± 69.52 μm, p=0.033). Change in VA was not statistically significant. The percentage of eyes with SRF was 100% at baseline and 53.8%, 76.9%, and 69.2% one month after each ranibizumab injections. The percentage of eyes with IRF was 38.5% at baseline and 23.1%, 23.1%, and 15.4%, respectively, after switching.

Conclusion

Switching to monthly ranibizumab in nAMD showing an insufficient response to bimonthly aflibercept led to immediate anatomical improvement. It can be considered in countries where the healthcare insurance system limits the minimum injection interval of aflibercept.

Visual outcomes, safety profile and morphometric response of optical coherence tomography biomarkers to ranibizumab biosimilar treatment in neovascular age-related macular degeneration: Real-world evidence

Purpose:

The aim of this study was to evaluate the safety, efficacy, and morphological response of intravitreal ranibizumab biosimilar (Razumab) in neovascular age-related macular degeneration (n-AMD) up to 12 weeks.

Methods:

Retrospective analysis of 20 eyes of n-AMD receiving 4 weekly intravitreal Razumab. Main outcome measures were mean change in best-corrected visual acuity (BCVA), intraretinal-fluid (IRF), subretinal-fluid (SRF), central-subfield thickness (CSFT), maximum central-retinal thickness (CRT), and dimensions of pigment epithelial detachment (PED) from baseline to weeks 4, 8 and 12.

Results:

Improvement in BCVA was seen at all visits, although not significantly (4 weeks: P = 0.18; 8 weeks: P = 0.4; 12 weeks: P = 0. 06). At 12 weeks, 90% of eyes either maintained or had an improvement in BCVA, with 40% of them showing an improvement of ≥3-lines and only 5% of them losing ≥3-lines of visual acuity. The median PED height and PED width reduced by 20.5 µm (P = 0.03) and 557.5 µm (P = 0.14), respectively, along with a mean reduction of 57.26 µmin CSFT (P < 0.001) and 44.15 µm in CRT (P = 0.004), respectively, at 12 weeks. On qualitative analysis, resolution of SRF and IRF was observed in 45% and 25% of eyes ‘ at 12 weeks. There were no serious ocular or systemic side effects identified.

Conclusion:

In real-world scenario, Razumab is an efficacious and economical anti-vascular endothelial growth factor (anti-VEGF) agent for optimal management of n-AMD. The therapeutic outcomes demonstrated reasonable stabilization and improvement in visual acuity, favorable anatomical outcomes pertaining to OCT-biomarkers with an acceptable safety profile.

Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study

BACKGROUND

Brolucizumab has recently been approved in Europe as a novel treatment for patients with neovascular age-related macular degeneration (nAMD). We report on early experiences with real-world outcomes of switch to brolucizumab therapy in previously anti-vascular endothelial growth factor (anti-VEGF)-treated patients.

METHODS

Patients with recalcitrant nAMD were switched to brolucizumab therapy. Functional and structural parameters 4 weeks after first brolucizumab injection were evaluated including best-corrected visual acuity (BCVA (logMAR)), foveal centre point (FCP (µm)), central subfield retinal thickness (CSRT (µm)) and macular volume (mm³).

RESULTS

Sixty-three eyes of 57 patients with nAMD (52.6% females) with a mean (±SD) age of 79.5±6.7 years were included. Mean change of BCVA was 0.03±0.14 logMAR (p=0.115). Significant reductions were recorded for FCP with a mean (±SD) change of -66.81±72.63 µm, -66.76±60.71 µm for CSRT and -0.27±0.24 mm³ for macular volume (all p<0.001). Intraocular inflammation was observed in seven eyes of seven patients, including one case of retinal vasculitis.

CONCLUSIONS

The results of the SHIFT study indicate that switch to brolucizumab may represent a treatment option in patients with nAMD poorly responsive to other anti-VEGF agents. Further long-term analyses appear prudent to assess efficacy and safety of brolucizumab in a routine clinical setting.

Beneficial switch from aflibercept to ranibizumab for the treatment of refractory neovascular age-related macular degeneration

Purpose

The aim of this study was to evaluate the effects of switching to ranibizumab in patients with neovascular age-related macular degeneration (nAMD) refractory to aflibercept treatment and to identify predictive factors for switch response.

Methods

A retrospective chart review was conducted including 32 eyes from 26 patients with refractory nAMD, who switched from monthly intravitreal aflibercept treatment (≥ 6 months) to ranibizumab. Outcome measures included changes in visual acuity (VA), intraretinal fluid (IRF), subretinal fluid (SRF), pigment epithelial detachment (PED), and central retinal thickness (CRT), evaluated at 6 months before switch (T1), at the time of switch (T2), and 3 months post-switch (T3).

Results

There was an increase in CRT from T1 to T2, which decreased after switch from T2 to T3. Regression analysis of the changes per month observed between time points showed significant differences in PED height (p = 0.02), SRF (p = 0.01), and neuroretinal thickness as a measure for IRF (p = 0.03). No significant change was found for VA. Predictive factors for better switch response included an exacerbation between T1 and T2, thicker measurements at T2, male sex, shorter treatment duration before switch, and fewer preceding injections. No association with preceding switch was found.

Conclusion

Patients with nAMD refractory to aflibercept benefit from switching to ranibizumab, particularly those whose condition worsened prior to the switch. This may be explained by drug tolerance to aflibercept. Our findings may facilitate making appropriate treatment decisions, potentially improving patient outcomes.

Impact of switching from ranibizumab to aflibercept on the number of intravitreous injection and follow up visit in wet AMD: results of real life ELU study

AIM

To study if one of the two molecules could lead to a lower number of follow up visits and intra-vitreous injection (IVI) with the same efficacy.

METHODS

ELU (or "elected" in French) study is a retrospective study conducted in real life in patients presenting suboptimal response after ranibizumab IVI (phase 1) and secondary switched to aflibercept (phase 2). The number of follow up visits and IVI were compared in both phases. Visual acuity (VA) evolution and "switching" reasons were secondary analyzed.

RESULTS

We retrospectively included data of 33 patients (38 eyes) with age-related macular degeneration (AMD; mean age: 77±7.7y). The number of monthly follow up visits [median (Q1; Q3)]: was significantly lower with aflibercept (phase 2), respectively 1.0 (0.81; 1.49) visits in phase 1, versus 0.79 (0.67; 0.86) visits in phase 2. The median number of monthly IVI also significantly decreased in phase 2, respectively 0.67 (0.55; 0.90) IVI in phase 1, versus 0.55 (0.45; 0.67) IVI in phase 2. The mean VA evolution (VA final-VA initial) was similar in both phases, (P>0.05). Whatever the reason for "switching" (loss of efficacy, tachyphylaxis, tolerance problems), there was no incidence on VA evolution over the time.

CONCLUSION

Our results show that switching from ranibizumab to aflibercept in "suboptimal" patients significantly reduce the number of follow up visits and IVI, with a comparable efficacy. This decrease in visit number could improve patients' quality of life and reduce surgical risk by reducing the number of injections.

Priority options of anti-vascular endothelial growth factor agents in wet age-related macular degeneration under the National Health Insurance Program

BACKGROUND

Age-related macular degeneration (AMD) is a leading cause of blindness worldwide, for which intravitreal injection of anti-vascular endothelial growth factor (VEGF) is the primary treatment option. The purpose of the current study was to investigate the prioritization of anti-VEGF agents for wet AMD under the National Health Insurance (NHI) Program, and their clinical outcomes.

METHODS

Patients who were diagnosed with active choroidal neovascularization caused by AMD, and who met the criteria for reimbursement for anti-VEGF therapy by the NHI program in Taiwan between August 1, 2014 and May 31, 2015, were included in the study. Factors potentially influencing the choice of treatment agent were analyzed, and clinical outcomes were compared between the two different agents and their protocols.

RESULTS

A total of 166 treatment applications in 166 eyes from 159 patients were enrolled in the study. Age, laterality, presence of retinal pigment epithelial detachment, history of hypertension, coronary artery disease, and cerebral vascular accidents were significantly associated with the selection of the anti-VEGF agent. Treatment patterns and clinical outcomes were similar between the patients treated with ranibizumab and those treated with aflibercept. Significantly fewer injections were given during the follow-up period in those treated with aflibercept.

CONCLUSION

Under the restrictive insurance program in Taiwan, more patients and ophthalmologists chose to treat wet AMD using aflibercept. However, in clinical practice, no significant differences in efficacy or clinical outcomes were found between the patients treated with ranibizumab and those treated with aflibercept.

"What should I inject next?" Challenging treatment decisions in the multiple anti-VEGF: a review of publications exploring anti-VEGF switching for nAMD

PURPOSE

The purpose of our work was to collate information from studies published to date focusing on switching in anti-VEGF therapy and describe the currently available data on anti-VEGF switching in nAMD.

METHODS

A PubMed search of published articles from January 2010 to January 2017 was conducted. Published studies were compared in parameters of sample size, reason for switch, duration of follow-up, and switch outcome (functional and anatomical).

RESULTS

Our search revealed 31 relevant publications. Switching from bevacizumab to ranibizumab mostly resulted in improvement in visual acuity (VA) and anatomical outcomes (CMT, CRT; 7/8 and 6/8 studies, respectively), whereas switching from ranibizumab to bevacizumab was less effective (no VA or anatomical improvement in 2/4 studies). Switching from either agent to aflibercept resulted mostly in improvement of anatomical outcomes (19/21 studies), but rarely in VA improvement (6/21 studies). Not all results were statistically significant, likely due to small sample sizes.

CONCLUSION

Switching anti-VEGF therapy from bevacizumab to ranibizumab might be of benefit (functionally and anatomically) for patients who failed to improve with intravitreal bevacizumab injections, whereas switching from either agent to aflibercept resulted mostly in reduced macular thickness only.

VISUAL ACUITY IMPROVEMENT WHEN SWITCHING FROM RANIBIZUMAB TO AFLIBERCEPT IS NOT SUSTAINED

PURPOSE

To assess whether visual benefits exist in switching to aflibercept in patients who have been chronically treated with ranibizumab for neovascular age-related macular degeneration.

METHODS

A multicenter, national, electronic medical record database study was performed. Patients undergoing six continuous monthly ranibizumab injections and then switched to continuous aflibercept were matched to those on continuous ranibizumab therapy. Matching was performed in a 2:1 ratio and based on visual acuity 6 months before and at the time of the switch, and the number of previous ranibizumab injections.

RESULTS

Patients who were switched to aflibercept demonstrated transiently significant improvement in visual acuity that peaked at an increase of 0.9 Early Treatment Diabetic Retinopathy Study letters 3 months after the switch, whereas control patients continued on ranibizumab treatment showed a steady decline in visual acuity. Visual acuity differences between the groups were significant (P < 0.05) at 2, 3, and 5 months after the switch. Beginning at 4 months after the switch, the switch group showed a visual acuity decline similar to the control group.

CONCLUSION

Transient, nonsustained improvement in visual acuity occurs when switching between anti-vascular endothelial growth factor agents, which may have implications in treating patients on chronic maintenance therapy on one anti-vascular endothelial growth factor medication.

HIGH-DOSE HIGH-FREQUENCY AFLIBERCEPT FOR RECALCITRANT NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

This retrospective study demonstrated 4 mg monthly aflibercept is effective in treating recalcitrant neovascular age-related macular degeneration. Sustainable significant anatomical improvement was shown starting 1 month after initiating the treatment, and 45% of the treated eyes showed vision improvement of 1 line or more at the last visit.

Purpose:

To determine the efficacy of monthly (0.1 mL/4 mg) aflibercept for refractory neovascular age-related macular degeneration (wet age-related macular degeneration).

Methods:

This was a retrospective interventional case series in which patients with wet age-related macular degeneration were treated with stepwise dose escalation. Nonvitrectomized patients resistant to monthly (Q4W) ranibizumab/bevacizumab were switched to 2 mg aflibercept every 8 weeks. With resistance, they were escalated to Q4W 2 mg aflibercept, then Q4W 4 mg (high dose high frequency, 4Q4W) aflibercept. Resistance was defined as ≥2 recurrences after being dry following ≥3 injections or persistent exudation on treatment of ≥5 injections.

Results:

Thirty-three eyes of 28 patients were treated with 4Q4W aflibercept and followed for a mean of 16 months. A dry retina (no intraretinal or subretinal fluid) was achieved after initiating 4Q4W aflibercept treatment at a mean of 3.8 months. Central foveal thickness, maximum foveal thickness, intraretinal fluid, subretinal fluid, and retinal pigment detachment height decreased significantly at 1 month after initiating the 4Q4W aflibercept, and the morphologic therapeutic effect was sustained until the last visit. Forty-five percent of eyes had one or more lines of vision improvement. New geographic atrophy developed in 9% of eyes during follow-up. No ocular or systemic adverse events occurred after initiating 4Q4W aflibercept.

Conclusion:

Intravitreal high-dose high-frequency aflibercept is an effective treatment for patients with refractory wet age-related macular degeneration.

A Prospective Randomized Comparative Dosing Trial of Ranibizumab In Bevacizumab-Resistant Diabetic Macular Edema: The REACT Study

Purpose

To assess the efficacy of ranibizumab for persistent diabetic macular edema (DME) previously treated with bevacizumab and compare monthly vs treat-and-extend (TAE) dosing.

Design

12-month, open-label, prospective randomized comparative dosing study.

Participants

27 participants with persistent foveal-involving DME recently treated with bevacizumab.

Methods

All subjects were to receive three initial monthly 0.3 mg ranibizumab injections before randomization to monthly (n=15) or TAE (n=12) injection protocols over 12 months. Treatment interval was extended by two weeks up to a maximum interval of 12 weeks in the TAE group if central subfield thickness (CST) was ≤ 300 μm or complete absence of intraretinal or subretinal fluid on the macular cube was observed. Follow-up interval was decreased by 2 weeks if CST increased above 300 μm with associated intraretinal and/or subretinal fluid.

Main Outcome Measures

Change in Early Treatment of Diabetic Retinopathy Study (ETDRS) best corrected visual acuity (BCVA), CST, adverse events.

Results

Prior to study enrollment, subjects received an average of 8.6 bevacizumab injections. At month 12, mean ETDRS BCVA improved by + 5.3 letters (p<0.05) and mean CST decreased by -99.6 μm (p<0.01) in all patients. At study exit, 18.5 % of subjects gained ≥ 3 lines of vision and 3.7% of subjects lost ≥ 3 lines. Patients treated via the TAE protocol gained +8.4 letters and decreased CST by -120.2 μm whereas those treated by monthly injection gained +2.7 letters and decreased CST by -83.1 μm at month 12.

Conclusions

Following conversion to ranibizumab in eyes with persistent DME refractory to bevacizumab, significant functional and anatomic improvements were noted. Visual and anatomical outcomes were similar in TAE and monthly treatment protocols.

36-Month Evaluation of Intravitreous Aflibercept Injection for Wet Age-Related Macular Degeneration in Patients Previously Treated With Ranibizumab or Bevacizumab

BACKGROUND AND OBJECTIVE

In the ASSESS study, patients with neovascular age-related macular degeneration transitioned from other anti-vascular endothelial growth factor therapies to intravitreous aflibercept (Eylea; Regeneron, Tarrytown, NY) injections (IAI). The purpose was to determine the 36-month outcomes following the change from a fixed 24-month IAI dosing regimen to a routine clinical practice regimen.

PATIENTS AND METHODS

Patients were treated with a fixed bimonthly regimen for the first 2 years. In the third year, patients were managed according to routine clinical practice.

RESULTS

A total of 18 patients completed the 36 months and were considered for statistical analyses. At 36 months, a nonsignificant decrease of -37.8 μm in central subfield thickness and a nonsignificant gain of 5.8 letters from baseline were observed.

CONCLUSION

Despite the significant visual and anatomical gains observed in the 2 years of fixed-dosing IAI, there was gradual decline in these improvements when patients were transitioned to a variable regimen. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:179-185.].

Placental growth factor and its potential role in diabetic retinopathy and other ocular neovascular diseases

The role of vascular endothelial growth factor (VEGF), including in retinal vascular diseases, has been well studied, and pharmacological blockade of VEGF is the gold standard of treatment for neovascular age‐related macular degeneration, retinal vein occlusion and diabetic macular oedema. Placental growth factor (PGF, previously known as PlGF), a homologue of VEGF, is a multifunctional peptide associated with angiogenesis‐dependent pathologies in the eye and non‐ocular conditions. Animal studies using genetic modification and pharmacological treatment have demonstrated a mechanistic role for PGF in pathological angiogenesis. Inhibition decreases neovascularization and microvascular abnormalities across different models, including oxygen‐induced retinopathy, laser‐induced choroidal neovascularization and in diabetic mice exhibiting retinopathies. High levels of PGF have been found in the vitreous of patients with diabetic retinopathy. Despite these strong animal data, the exact role of PGF in pathological angiogenesis in retinal vascular diseases remains to be defined, and the benefits of PGF‐specific inhibition in humans with retinal neovascular diseases and macular oedema remain controversial. Comparative effectiveness research studies in patients with diabetic retinal disease have shown that treatment that inhibits both VEGF and PGF may provide superior outcomes in certain patients compared with treatment that inhibits only VEGF. This review summarizes current knowledge of PGF, including its relationship to VEGF and its role in pathological angiogenesis in retinal diseases, and identifies some key unanswered questions about PGF that can serve as a pathway for future basic, translational and clinical research.

Benefits of aflibercept treatment for age-related macular degeneration patients with good best-corrected visual acuity at baseline

Currently, age-related macular degeneration (AMD) is treated while patients exhibit good best-corrected visual acuity (BCVA). However, previous clinical trials only include patients with poor BCVA. We prospectively analyzed the benefits of intravitreal aflibercept (IVA) treatment for AMD patients exhibiting good BCVA at baseline. Twenty-nine treatment-naive AMD patients (29 eyes) with BCVA better than 0.6 (74 letters in ETDRS chart) were treated with IVA once a month for 3 months and every 2 months thereafter with no additional treatments. Improvement in mean BCVA, measured using the conventional Landolt C chart, contrast VA chart, and functional VA (FVA) system, and reductions in mean central retinal thickness (CRT), central choroidal thickness, macular volume (MV), and choroidal area on optical coherence tomography images were observed at 6 and 12 months. Improvements in contrast VA and FVA scores, in contrast to conventional BCVA, correlated with MV reduction; no VA scores correlated with a reduced CRT. The MV correlated with choroidal area after IVA. No severe adverse events occurred. IVA improved visual function, retinal condition, and quality of life evaluated by Visual Function Questionnaire, and was beneficial in these patients. The contrast VA and FVA scores and MVs, which detect subtle changes, helped demonstrate the benefits.

Two-Year Outcome of Aflibercept in Patients with Pigment Epithelial Detachment due to Neovascular Age-Related Macular Degeneration (nAMD) Refractory to Ranibizumab

Purpose

To evaluate the response of intravitreal aflibercept injection (IAI) in eyes with detachment of retinal pigment epithelium (DEP) secondary to nAMD refractory to monthly ranibizumab.

Patients and Methods

This is a retrospective, multicenter study. All patients received 3 IAI then treated as needed every 4 weeks for 12 months. During the second year, the eyes were treated with a treat- and-extend regimen.

Results

Forty-four eyes were included. Best-corrected visual acuity improved significantly after the loading phase (3.1 ± 6.4 letters) and at 6 months (2.8 ± 6.4 letters), but change was not significant at 1 year and 2 years. The height of the DEP was significantly decreased at 3 months and 6 months, but the difference did not reach statistical difference at 1 and 2 years. Rate of eyes with complete resolution of exudation was 59% after the loading phase and 34.3% at 2 years. Mean interval of anti-VEGF injection was extended from 31 ± 2.6 days to 61 ± 5 days after conversion.

Conclusions

Aflibercept intravitreal injection in patients with fibrovascular DEP due to nAMD who respond poorly to monthly ranibizumab led to short-term functional and anatomical improvement. Reduction of intravitreal injection frequency was obtained until 2 years of follow-up.

Switch to Aflibercept in the Treatment of Neovascular AMD: Long-Term Results

Purpose

To report the long-term clinical outcomes after switching from intravitreal bevacizumab or ranibizumab to aflibercept therapy in eyes with AMD.

Methods

Retrospective analysis of changes in BCVA, SD-OCT image, and frequency of injections after 1, 2, and 3 years of follow-up.

Results

164 eyes were analyzed, 101 eyes switched from bevacizumab (group 1) and 63 from ranibizumab (group 2). One year after the switch, there was an overall nonsignificant mean decrease of 2 ETDRS letters in BCVA. Three years after, there was an overall mean decrease of 7 ETDRS letters, which was statistically significant. A significant improvement in the mean CRT was found at 1, 2, and 3 years. There was a significant decrease in the mean number of injections per year (7.8 to 6.5, p < 0.005) between the first and third year.

Conclusion

Aflibercept can be useful in the management of refractory neovascular AMD, with a good morphological response. However, in the long-term, BCVA stabilization was not achieved.

The Impact of Switching Anti-Vascular Endothelial Growth Factor Therapy in the Management of Exudative Age-Related Macular Degeneration

Switching of anti-vascular endothelial growth factor (VEGF) therapy in the management of poorly responsive exudative age-related macular degeneration (AMD) has had suggested benefits in individual reports that have yet to be consolidated. In this retrospective review, 24 studies published between 2009 and 2014 were identified. Reasons for switching included tachyphylaxis, health insurance coverage, cost issues, and nonresponse or inadequate response. Nine studies had data that could be used for comparison between studies. Median follow-up was 10.6 months (range: 4.2 months to 21.8 months). Mean baseline visual acuity (VA) ranged from 0.42 logMar to 0.94 logMar (standard deviation [SD] range: 0.05 logMar to 0.50 logMar) and mean VA on final follow-up ranged from 0.38 logMar to 0.78 logMar (SD range: 0.08 logMar to 0.50 logMar). Five of nine studies reported no statistically significant change in vision, and five of nine studies reported a statistically significant improvement in central retinal thickness. This review found that switching anti-VEGF did not confer significant improvement of VA, although it provided some anatomical improvement. Pertinent considerations for evaluating response following anti-VEGF therapy are also presented in this review. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:859-869.].

One-year outcome of intravitreal ziv-aflibercept therapy for non-responsive neovascular age-related macular degeneration

Aim

To evaluate 12-month outcome of intravitreal ziv-aflibercept (IVZ) therapy in eyes with neovascular age-related macular degeneration (nAMD) that are non-responsive to bevacizumab and ranibizumab.

Methods

This retrospective study included 16 eyes (14 patients) with nAMD who were on prior treatment with bevacizumab and ranibizumab and were treated with as-needed IVZ (1.25 mg/0.05 mL) for 12 months. The primary outcome measure was the mean change in best corrected visual acuity (BCVA) and secondary outcome measures included mean change in central macular thickness (CMT), retinal pigment epithelial detachment (RPED) heights, longest treatment free interval, presence of subretinal fluid (SRF) and intraretinal fluid (IRF) and adverse events.

Results

There was no change in the mean logarithm of minimum angle of resolution (logMAR) BCVA at baseline and following treatment with IVZ therapy (p=0.978). The mean number of IVZ injections during 12 months was 5.9±3.3, and the mean number of antivascular endothelial growth factors (VEGFs) injections prior to switching to IVZ was 8.4±4.7. The mean treatment free interval was longer during IVZ therapy (114.4±67.1 days) compared with 76.3±54.6 days before IVZ therapy (p=0.03). Five (31.25%) eyes had visual gains of at least 0.1 logMAR, 3 (18.75%) eyes had stable BCVA (within 0.1 logMAR) and 8 (50%) eyes had BCVA decline of at least 0.1 logMAR. There was no significant difference in the mean CMT, RPED heights and presence of IRF and SRF at 12 months compared with baseline. No adverse events were noted.

Conclusion

IVZ increased the treatment free interval in non-responders but no significant change in visual and anatomic outcomes.

Evaluation of Aflibercept Treatment Responses in Eyes with Bevacizumab/Ranibizumab-resistant Wet Age-related Macular Degeneration

Objectives:

To evaluate anatomic and functional results after switching from intravitreal bevacizumab or ranibizumab treatment to aflibercept for wet (neovascular) age-related macular degeneration.

Materials and Methods:

This retrospective study included 22 eyes of 22 patients resistant to treatment with at least 6 injections of bevacizumab or ranibizumab. The first three injections had been applied monthly, the others pro re nata (PRN). Outcome measures were follow-up period, injection number, best corrected visual acuity (BCVA), central retinal thickness (CRT) and pigment epithelial detachment (PED) height. Dosing regimen of aflibercept was determined PRN. The patients were examined monthly. In all visits, BCVA and optical coherence tomography results were assessed together and injections were applied according to these findings. Patients with at least three months of follow-up were included in the study.

Results:

Twenty-two eyes of 22 patients treated with bevacizumab or ranibizumab were switched to aflibercept therapy. Seven patients had serous PED and 4 patients had fibrovascular PED. The mean follow-up periods for these groups were 20.59±6.76 months and 8.68±3.79 months, respectively. The mean injection numbers were 10.5±3.61 vs 4.54±1.56. Statistically significant reductions were noted in CRT (533.86±164.06 µm vs 412.04±143.86 µm, p<0.05). BCVA levels were almost equal before and after switching (0.18±0.17 vs 0.18±0.14). Serous and fibrovascular PED heights decreased suboptimally from 460±281.51 µm to 282.42±175.76 µm (p>0.05) for serous PEDs and 251.25±43.85 µm to 225.75±73.09 µm (p>0.05) for fibrovascular PEDs.

Conclusion:

Switching to aflibercept resulted in significant improvement in CRT, but not in BCVA or PED heights.

Real-Life Experience with Aflibercept and Ranibizumab in the Treatment of Newly Diagnosed Neovascular Age-Related Macular Degeneration over 24 Months

PURPOSE

Comparative data appertaining to the long-term effects of Aflibercept or Ranibizumab in newly diagnosed cases of neovascular age-related macular degeneration (nAMD) over follow-up periods exceeding 12 months in clinical routine are scarce.

METHODS

In this retrospective comparative analysis, a case series of patients with treatment-naïve nAMD and requiring anti-vascular endothelial growth factor (VEGF) therapy in a routine clinical setting were treated with either Aflibercept [Afl (n = 106)] or Ranibizumab [Ran (n = 47)]. During the drug-loading phase, 3 monthly injections were administered. Thereafter, a treat-and-extend protocol was pursued for a maximum of 24 months. Ran was administered predominantly in eyes with classical lesions; Afl was administered in all others. The primary outcome parameters included anatomical and functional stability after 24 months.

RESULTS

Patients were comparable regarding age, gender distribution, and lens status. Fewer patients presented with intraretinal fluid in the Afl- than in the Ran group at diagnosis (46.2% vs. 67.4%; P = 0.02), but not after the drug-loading phase. After the drug-loading phase, visual acuity [-4.2 letters (Afl) vs. -4.5 letters (Ran); P = 0.78] and the central foveal thickness remained stable. Linked to the lesion type, the number of scheduled clinical visits during the course of 24 months was higher for the Ran- than for the Afl group [11.9 ± 4.7 visits (Ran) vs. 8.4 ± 3.1 visits (Afl); P = 0.0005]. However, the total number of injections was similar [10.5 ± 2.8 (Ran) vs. 11.7 ± 3.6 (Afl); P = 0.06].

CONCLUSIONS

Based on tailoring according to the lesion type in cases of nAMD, the anatomical and the functional outcomes of treatment with either Afl or Ran were comparable for a maximum of 2 years.

ANGIOGRAPHIC FINDINGS OF RANIBIZUMAB-RESISTANT POLYPOIDAL CHOROIDAL VASCULOPATHY AFTER SWITCHING TO A TREAT-AND-EXTEND REGIMEN WITH INTRAVITREAL AFLIBERCEPT

PURPOSE

The aim of this study was to study the angiopathic findings of ranibizumab-resistant polypoidal choroidal vasculopathy after switching to a treat-and-extend regimen with intravitreal aflibercept.

METHODS

The authors retrospectively reviewed 17 eyes of 17 Japanese patients with polypoidal choroidal vasculopathy (10 men and 7 women, age: 73.8 ± 7.4 years) who were treated with intravitreal aflibercept (2 mg/0.05 mL) injections from February 2013 to August 2014 at Tokyo University Hospital. All patients had switched to aflibercept because their polypoidal choroidal vasculopathy had been refractory to ranibizumab.

RESULTS

The mean logMAR best-corrected visual acuity at baseline and after 12 months of therapy was 0.30 ± 0.29 (Snellen equivalent: 20/40) and 0.17 ± 0.26 (20/30) (paired t-test P < 0.001). Visual acuity remained stable in 5 cases (29%), deteriorated in 3 (18%), and improved in 9 (53%). Branching vascular networks persisted in all 17 eyes but shrank in 15 (88%). The mean lesion diameter was 3329 ± 1261 μm at baseline and 3180 ± 1247 μm after 12 months (P = 0.0002).

CONCLUSION

A treat-and-extend regimen with intravitreal aflibercept for ranibizumab-resistant patients resulted in branching vascular network shrinkage over a 1-year period.

Intravitreal aflibercept in neovascular age-related macular degeneration previously treated with ranibizumab

AIM

To report the change in visual acuity and central macular thickness (CMT) following treatment with intravitreal aflibercept injections in patients with neovascular age-related macular degeneration (nAMD) with suboptimum response to ranibizumab.

METHODS

This was a retrospective study. The inclusion criteria were patients with nAMD who responded poorly to ranibizumab. Patients then received either 3 consecutive aflibercept injections followed by pro re nata (PRN) treatment or PRN alone. Primary endpoints were mean change in best-corrected visual acuity (BCVA) and CMT at 12mo. Secondary endpoints were number of injections and adverse events.

RESULTS

Forty-nine eyes from 49 patients met the inclusion criteria and completed 12-month follow up on aflibercept. Thirty-eight eyes received 3 consecutive aflibercept injections followed by PRN treatment and 11 eyes received PRN injections alone. At 12mo, mean BCVA improved by one letters (logMAR 0.56±0.31 to 0.54±0.34) and mean CMT decreased from 303.9±82.1 to 259.2±108.3 µm. Four percent of eyes gained 15 letters or more, 6% lost more than 15 letters and the remaining 90% had stable BCVA. The mean number of aflibercept injections was 6. There was one case of infectious endophthalmitis.

CONCLUSION

Intravitreal aflibercept in patients with nAMD with a previous suboptimal response to ranibizumab resulted in an anatomical improvement in macular appearance at 12mo without a corresponding improvement in visual acuity.

Switch to Aflibercept in Diabetic Macular Edema Patients Unresponsive to Previous Anti-VEGF Therapy

Purpose. The aim was to evaluate the efficacy of aflibercept in patients with diabetic macular edema (DME) unresponsive to prior anti-VEGF therapy. Methods. Retrospective review of DME unresponsive to previous anti-VEGF switched to aflibercept with 3 months of follow-up. Changes in best correct visual acuity (BCVA), central retinal thickness (CRT), and frequency of injections were analyzed. The percentage of subjects who had ≥20/40 (logMAR equivalent 0.3) and ≤20/200 (logMAR equivalent 1) was evaluated. Results. A total of 32 eyes from 26 patients were included. Mean age was 65 ± 10 years old. The mean number of previous anti-VEGF injections was 5.34 ± 2.38, and the mean number of aflibercept injections at the end of the study was 2.00 ± 0.00. The CRT at baseline was 501.47 ± 150.51 μm and 367.97 ± 124.61 μm at 3 months of follow-up (P < 0.001). The logMAR BCVA at baseline was 0.71 ± 0.36 and 0.65 ± 0.33 at the end of the follow-up (P = 0.037). At baseline, 12.5% of patients had ≥20/40 compared with 25% at the end of follow-up. At baseline, 28.13% of patients had 20/200 or inferior vision compared with 15.63% at the end of the follow-up. Conclusions. DME patients unresponsive to previous multiple ranibizumab injections demonstrate a significant anatomical and functional improvement with the switch to aflibercept.

Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) study

PurposeThe purpose of this study is to evaluate an early switch to aflibecept in eyes with neovascular age-related macular degeneration (nvAMD) showing partial or lack of response for initial therapy with bevacizumab.MethodsThe Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) was a prospective, multicenter, single-arm clinical trial. Eyes with nvAMD having incomplete response to 3-9 prior bevacizumab injections were recruited. Three monthly intravitreal aflibercept (2 mg) injections were administered, followed by two bi-monthly injections and a final examination at week 28. An optional injection was allowed at week 20.ResultsForty-seven eyes of 46 patients (mean±SD age 76±8 years) were recruited. The mean number of prior bevacizumab injections was 5.5±2.9. The mean visual acuity improved from 60.3±10 ETDRS letters at baseline to 63.1±15 letters at week 28 (P=0.02, paired t-test). The central subfield thickness (CST) reduced from 409±127 micron at baseline to 330±110 microns at week 4 (P=0.0002; paired t-test), and 277±70 microns at week 28 (P=0.00002; paired t-test). Twenty-two eyes had three to five prior bevacizumab injections (mean 5.1±0.7), and 25 eyes had six to nine prior injections (7.32±1.2). Both groups had reduced CST from baseline to week 28 (P=0.0004 and P=0.0007; paired t-test, respectively). Thirty-five (75%) eyes required the optional additional aflibercept injection at week 20.ConclusionsThe ASLI study demonstrated improved BCVA and reduced CST following an early switch to aflibercept therapy in eyes with prior incomplete response to initial therapy with three to nine bevacizumab injections.

A 24-Month Evaluation of Aflibercept for Wet Age-Related Macular Degeneration in Patients Previously Receiving Ranibizumab or Bevacizumab

PURPOSE

To report the 24-month results and predictive factors for outcomes in patients transitioned from other anti-vascular endothelial growth factor agents to aflibercept for the treatment of exudative age-related macular degeneration (AMD).

DESIGN

A prospective, single arm, investigator-initiated study.

PARTICIPANTS

A total of 24 patients participated in the study and 87.5% (n = 21) completed the 24 month assessments. Patients were included if they had an active exudative AMD confirmed by fluorescein angiography, presence of fluid on spectral-domain optical coherence tomography (OCT) or new hemorrhage on clinical examination, Electronic Early Treatment Diabetic Retinopathy Study vision of 25 to 80 letters (Snellen equivalent of approximately 20/25-20/320), prior bevacizumab or ranibizumab injections within 3 months of enrollment, and an initial response on OCT defined as a decrease of retinal edema and/or subretinal fluid to anti-vascular endothelial growth factor injections.

METHODS

Patients were treated the first 3 months with 2 mg of intravitreal aflibercept monthly, followed by a fixed bimonthly schedule for 24 months. At each study visit, visual acuity and a spectral-domain OCT scanning of both eyes were performed.

MAIN OUTCOME AND MEASURES

The mean absolute change from baseline in central subfield thickness at month 24, mean change from baseline in best-corrected visual acuity (BCVA) score, change from baseline in macular volume, and cube average thickness by spectral-domain OCT. Additionally, predictive factors associated with final visual and anatomic outcomes at month 24.

RESULTS

A mean decrease in central subfield thickness of -41 μm (P = 0.004) was observed with a mean increase in ETDRS BCVA of +10.4 letters (P < 0.001). At study entry, BCVA was a significant predictive factor for BCVA change at month 24 (rho = -0.59; P = 0.003). Also, the duration between AMD diagnosis and study entry was a significant factor for central subfield thickness change at month 24 (rho = -0.51; P = 0.011).

CONCLUSIONS

In nonnaïve patients with active exudative AMD, treatment with a fixed intravitreal aflibercept dosing regimen for 24 months demonstrated sustained improvements in anatomy and vision in patients transitioned from other anti-vascular endothelial growth factor agents and stability when compared with 12-month outcomes. Patients who benefited most were those with worse vision at entry and longer duration of disease.

Pharmacokinetic aspects of retinal drug delivery

Drug delivery to the posterior eye segment is an important challenge in ophthalmology, because many diseases affect the retina and choroid leading to impaired vision or blindness. Currently, intravitreal injections are the method of choice to administer drugs to the retina, but this approach is applicable only in selected cases (e.g. anti-VEGF antibodies and soluble receptors). There are two basic approaches that can be adopted to improve retinal drug delivery: prolonged and/or retina targeted delivery of intravitreal drugs and use of other routes of drug administration, such as periocular, suprachoroidal, sub-retinal, systemic, or topical. Properties of the administration route, drug and delivery system determine the efficacy and safety of these approaches. Pharmacokinetic and pharmacodynamic factors determine the required dosing rates and doses that are needed for drug action. In addition, tolerability factors limit the use of many materials in ocular drug delivery. This review article provides a critical discussion of retinal drug delivery, particularly from the pharmacokinetic point of view. This article does not include an extensive review of drug delivery technologies, because they have already been reviewed several times recently. Instead, we aim to provide a systematic and quantitative view on the pharmacokinetic factors in drug delivery to the posterior eye segment. This review is based on the literature and unpublished data from the authors' laboratory.

PIGMENT EPITHELIAL DETACHMENT RESPONSE TO AFLIBERCEPT IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION REFRACTORY TO RANIBIZUMAB: Time Course and Drug Effects

PURPOSE

To investigate the time course of pigment epithelium detachment (PED) height and its change after anti-vascular endothelial growth factor switch from ranibizumab to aflibercept in neovascular age-related macular degeneration.

METHODS

This retrospective study included 60 eyes of 50 consecutive patients with neovascular age-related macular degeneration who showed refractory intraretinal or subretinal fluid (≥9 months) despite monthly ranibizumab treatment and an associated PED (height ≥150 μm). The treatment was switched to aflibercept, and patients were followed-up for at least 9 months. Data on the height and type of PED, exudative fluid, and best-corrected visual acuity were collected at four different time points (two before and two after the drug switch).

RESULTS

The maximal PED height was significantly decreased over time, both under ranibizumab and aflibercept treatment. However, the reduction was significantly greater during the 3 months after the switch to aflibercept, due to two outliers. Visual acuity remained stable. Complete resolution of intraretinal or subretinal fluid was observed in 9 cases (15%) at 3 months after switch, allowing for treatment interval extension.

CONCLUSION

Maximal PED height continuously decreased over time. Switching the intravitreal anti-vascular endothelial growth factor medication from ranibizumab to aflibercept had a significantly stronger short-term effect on PED height reduction, without changes in visual acuity.

Evaluating Efficacy of Aflibercept in Refractory Exudative Age-Related Macular Degeneration With OCT Segmentation Volumetric Analysis

BACKGROUND AND OBJECTIVE

To use automated segmentation software to analyze spectral-domain optical coherence tomography (SD-OCT) scans and evaluate the effectiveness of aflibercept (Eylea; Regeneron, Tarrytown, NY) in the treatment of patients with exudative age-related macular degeneration (AMD) refractory to other treatments.

PATIENTS AND METHODS

Retrospective chart review of 16 patients refractory to bevacizumab (Avastin; Genentech, South San Francisco, CA)/ranibizumab (Lucentis; Genentech, San Francisco, CA) treatment was conducted. Visual acuity, central foveal thickness (CFT), maximum fluid height, pigment epithelial detachment (PED) volume, sub-retinal fluid (SRF) volume, fluid-free time interval, and adverse effects were evaluated. Automated segmentation analysis was used to quantify improvement.

RESULTS

With aflibercept treatment, there was a statistically significant improvement in visual acuity by 1 line (P = .020), in CFT by 74.02 µm (P = .001), and in maximum fluid height by 31.9 µm (P= .011). Total PED and SRF volume also decreased significantly by 1.50 µm(3) × 10(8) µm(3) (P = .013). Anatomic improvement was confirmed by automated segmentation analysis.

CONCLUSION

This study demonstrates utility of automated segmentation software in quantifying anatomic improvement with aflibercept treatment in exudative AMD refractory to other anti-vascular endothelial growth factor treatments.

High-frequency aflibercept injections in persistent neovascular age-related macular degeneration

PURPOSE

To report the 1-year outcomes of every-4-weeks (Q4W) as-needed aflibercept treatment in resistant neovascular age-related macular degeneration (nAMD) patients who had been treated and failed prior bevacizumab or ranibizumab injections, and who also responded poorly to every-8-weeks (Q8W) aflibercept treatment.

METHODS

Forty-three eyes of 39 patients with persistent nAMD despite monthly bevacizumab and/or ranibizumab injections and who were switched to Q8W 2-mg aflibercept injections, but showed persistence of fluid were included. Patients were treated with as-needed Q4W aflibercept injections with monthly monitoring. Maximum retinal thickness (MRT), central macular thickness (CMT), maximum pigment epithelial detachment height (PED) and best-corrected visual acuity (BCVA) were assessed and compared to baseline when high-frequency aflibercept was initiated.

RESULTS

A mean of 8 (interquartile range, 4-11) Q4W injections were given during the follow-up. MRT and CMT significantly decreased at all follow-up visits (p < 0.05); however, there was no significant change in maximum PED height (p > 0.05) at any visit. Mean BCVA was 0.38 ± 0.28 (logMAR) (≈20/63, Snellen) at baseline, and 0.4 ± 0.34 (logMAR) (≈20/76, Snellen) at 1 year (p = 0.76). Seventy-two percent of eyes maintained a final BCVA of 20/63 or better. Twelve eyes (28 %) had some subretinal scar tissue formation and 5 eyes (11.6 %) had evidence of atrophy at 1 year.

CONCLUSION

A stepwise algorithm with Q4W as-needed aflibercept treatment led to anatomic improvement in previously treated eyes which failed other therapies, including aflibercept every 8 weeks. Lack of visual improvement may be due to a ceiling effect as our eyes generally had good visual acuity.

Clinical experience of switching anti-VEGF therapy from ranibizumab to aflibercept in age-related choroidal neovascularization

PURPOSE

To report the response of participants switching from ranibizumab to aflibercept treatment for neovascular age-related macular degeneration (nAMD) requiring further anti-vascular endothelial growth factor treatment.

METHODS

In this retrospective case review of 68 participants treated in a single hospital, all participants, prior to switching, received ranibizumab injections only. Best-corrected visual acuity (BCVA), clinical examination, and optical coherence tomography (OCT) were performed at each visit. Active nAMD was defined as persistent intraretinal or subretinal fluid on OCT. Participants had their first aflibercept injection at baseline and 2 more injections at 2 monthly intervals. Afterwards, they were followed up every 6-8 weeks and given injections as needed. The main outcome measures were visual acuity and the OCT central retinal thickness (CRT), average thickness (AT), and total macular volume (TMV).

RESULTS

The BCVA at baseline visit was 0.57 ± 0.33 log MAR and the final BCVA was 0.54 ± 0.37 log MAR (p = 0.215). The CRT mean change was -75.6 ± 85.6 (p = 0.001), the AT mean change was -24.2 ± 27.2 (p = 0.001), and TMV mean change was -0.69 ± 0.78 (p = 0.001). There were no significant ophthalmic complications related to treatments.

CONCLUSIONS

Intravitreal aflibercept improved anatomic outcomes (as measured by OCT) in eyes with nAMD that were previously treated with intravitreal ranibizumab and were still active. There was no statistically significant difference in logMAR visual acuity in participants who switched to aflibercept with a follow-up of at least 6 months.

INTRAVITREAL AFLIBERCEPT FOR CHOROIDAL NEOVASCULARIZATION DUE TO AGE-RELATED MACULAR DEGENERATION UNRESPONSIVE TO RANIBIZUMAB THERAPY

PURPOSE

To assess the efficacy of intravitreal injection of aflibercept for treating choroidal neovascularization due to age-related macular degeneration unresponsive to ranibizumab.

METHODS

Prospective noncomparative study. Indication for conversion to aflibercept (2.0 mg) was a failed response to ranibizumab, defined as persistent or recurrent subretinal and/or intraretinal fluid on spectral domain optical coherence tomography. Best-corrected visual acuity (Early Treatment Diabetic Retinopathy Study letter score), fluorescein angiography, indocyanine green angiography, and spectral domain optical coherence tomography were performed at baseline. Patients were followed up monthly, and retreatment was considered at physician discretion based on functional and morphological patterns.

RESULTS

Ninety-two eyes were included in the study. At 12 months, mean best-corrected visual acuity (±SD) change was +1.8 (±10.3), Early Treatment Diabetic Retinopathy Study letters and central retinal thickness (±SD) decreased on average by 112 (±173) μm. Patients received a mean of 3.5 ± 1.8 injections. No significant adverse event was observed during the follow-up.

CONCLUSION

A low number of intravitreal aflibercept injections reversed the preswitching trend toward losing vision and produced stable visual acuity and morphological improvements for up to 12 months in patients with neovascular age-related macular degeneration, not responding to ranibizumab.

Short-term effect of aflibercept on visual acuity and central macular thickness in patients not responding to ranibizumab and bevacizumab

PURPOSE

To analyze the clinical outcome of treatment with aflibercept in patients not responding to ranibizumab and bevacizumab.

METHODS

Retrospective review of 32 eyes from 30 consecutive patients with choroidal neovascularization (CNV) who showed no response to treatment with ranibizumab or bevacizumab and were switched to aflibercept. Visual acuity, central macular thickness (CMT) and presence or absence of intraretinal or subretinal fluid were analyzed before switching to aflibercept, after each of three uploading dose injections of aflibercept and 6, 8 and 10 weeks after the third aflibercept injection. All eyes had previous ranibizumab injections and the mean number of previous injections was 14.75 (± 7.38). Mean duration of previous anti-vascular endothelial growth factor (VEGF) treatment was 38 months (± 27.35 months).

RESULTS

Mean visual acuity before switching to aflibercept was 0.40 ± 0.30 logMAR. After the third injection visual acuity was 0.3 ± 0.3 logMAR and 10 weeks after the third injection it was 0.50 ± 0.20 logMAR. No significant differences were seen during treatment and follow-up. The mean CMT was 394 ± 118 µm at baseline, at follow-up (first, second and third, group week 6, group week 8 and group week 10) it was 317 ± 108 µm, 301 ± 99 µm, 292 ± 83 µm, 270 ± 78 µm, 340 ± 146 µm and 377 ± 92 µm, respectively. Significant reductions in CMT were seen between the first and third follow-up injections and at group week 8. Of the patients 59.4 % were complete non-responders to aflibercept.

CONCLUSION

Aflibercept results in improvement in CMT in non-responders to ranibizumab and bevacizumab as long as therapy is given continuously and can therefore be an alternative therapy.

Fixed bimonthly aflibercept in naïve and switched neovascular age-related macular degeneration patients: one year outcomes

AIM

To determine real life clinical outcomes in poorly responsive and treatment-naïve neovascular age related macular degeneration (nvAMD) patients using bimonthly fixed dosing aflibercept regimen.

METHODS

This was a retrospective study of 165 eyes with nvAMD started on aflibercept at Southampton Eye Unit between June 2013 and June 2014. Patients were either switched from pro re nata (PRN) ranibizumab/bevacizumab due to poor response (107 eyes), or treatment-naïve (58 eyes). Patients initially received 3-monthly intravitreal aflibercept injections followed by 2-monthly fixed doses. Clinic visits were scheduled at month 0, 4, 10 and 12. Mean change in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline were assessed using the Wilcoxon signed-rank test. The proportion of patients maintaining BCVA (<15 letters loss) at 12mo was also evaluated.

RESULTS

Mean BCVA change at month 12 was +3.29 and +4.67 letters in the switched and naïve aflibercept groups respectively (P<0.01). BCVA was maintained in 95.3% of switched and 96.6% of naïve patients. CRT at month 12 showed a decrease of -6.16 µm in the switched group and -35.36 µm in the naïve group (P<0.01). Patients previously treated with ranibizumab/bevacizumab had on average received 7.4 ranibizumab/bevacizumab injections over 12.6mo, attending 10 clinic visits. The fixed dosing aflibercept regimen required an average of 7.1 injections (naïve group), 7.5 injections (switched group) and 4 clinic visits per year.

CONCLUSION

Fixed bimonthly aflibercept is effective in both treatment-naïve and poorly responsive nvAMD patients. Adopting a fixed dosing regimen can reduce patient burden without compromising on outcomes.

Long-Term Results of Pro Re Nata Regimen of Aflibercept Treatment in Persistent Neovascular Age-Related Macular Degeneration

PURPOSE

To determine the 24-month results of patients who had pro re nata (PRN) aflibercept treatment owing to recurrent or resistant neovascular macular degeneration.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Eighty-one eyes of 78 patients with resistant or multiple recurrences of intraretinal or subretinal fluid while receiving monthly bevacizumab or ranibizumab injections and were switched to strict, as-needed aflibercept treatment with every-8-weeks spectral-domain optical coherence tomography (SDOCT)-guided monitoring were included. If there was a persistence of fluid despite this treatment, more frequent aflibercept injections were considered. Anatomic outcomes including maximum retinal thickness, central macular thickness, maximum pigment epithelial detachment height, maximum fluid height, and visual acuity (VA) were assessed at given follow-ups.

RESULTS

All anatomic endpoints significantly improved following 3 consecutive aflibercept injections, which were maintained through 24 months (P < .05 for all endpoints at all visits). Thirty-seven eyes (45.6%) required more frequent injections with monthly SDOCT-guided monitoring at a median of 37 weeks (interquartile range, 30-62 weeks) to adequately treat the retinal fluid. Seventy-one of 81 eyes (87.7%) became completely dry on at least 1 follow-up visit; however, there was no significant improvement in VA during the study period.

CONCLUSION

Aflibercept injection with an as-needed regimen was effective in many eyes previously treated with monthly bevacizumab or ranibizumab injections that had persistent or recurrent fluid. Despite significant improvement in anatomic outcomes, vision remained stable throughout the 2-year follow-up, likely because this cohort of patients had advanced choroidal neovascular membrane upon enrollment (recurrent or resistant).

Worsening anatomic outcomes following aflibercept for neovascular age-related macular degeneration in eyes previously well controlled with ranibizumab

Purpose

Antivascular endothelial growth factor injection is the mainstay of treating neovascular age-related macular degeneration (AMD). Previous studies have shown that switching treatment from ranibizumab to aflibercept led to an improvement in eyes with recalcitrant activity. Herein, we identify a unique subset of patients whose eyes with neovascular AMD were previously well controlled with ranibizumab injections were then worsened after being switched to aflibercept.

Methods

This is a retrospective interventional case series. Eyes with neovascular AMD, previously well controlled with monthly injections of ranibizumab, which then developed worsening of subretinal fluid after being switched to aflibercept were included.

Results

A total of 17 eyes were included. All eyes developed increased subretinal fluid when switched from ranibizumab to aflibercept. Fourteen patients were switched back to ranibizumab after a single injection of aflibercept and had subsequent rapid resolution of subretinal fluid. Three patients continued with monthly aflibercept injections for two subsequent months and demonstrated the persistence of the increased subretinal fluid until they were switched back to treatment with ranibizumab at which time the fluid resolved. No eye had persistent decline in visual acuity.

Conclusion

Switching from intravitreal ranibizumab to aflibercept in eyes with well-controlled neovascular AMD may result in worsening in a subset of patients and resolves when therapy is switched back to ranibizumab.

Aflibercept as First-Line Therapy in Patients with Treatment-Naïve Neovascular Age-Related Macular Degeneration: Prospective Case Series Analysis in Real-Life Clinical Practice

PURPOSE

To assess the 13-month effectiveness and safety of aflibercept in naïve patients with neovascular age-related macular degeneration (nvAMD) in a real-life clinical setting.

METHODS

Thirty-two treatment-naïve patients with nvAMD participated in a prospective two-center study. Patients received intravitreal injections of aflibercept (Eylea®), a loading dose of three monthly injections (2 mg/0.05 ml) every 4 weeks for the first 3 months, followed by intravitreal injections every 2 months.

RESULTS

At 3 and 13 months, the mean best-corrected visual acuity improved significantly as compared with baseline (logMAR 0.53 ± 0.30 and 0.55 ± 0.32 vs. 0.30 ± 0.24, respectively, p < 0.001). At 3 and 13 months, 46.8% of patients (15/32) gained ≥15 ETDRS letters. The mean decrease in central macular thickness was also significant at 3 months (252 ± 35 µm) and at 13 months (249 ± 38 µm) as compared with pretreatment values (383 ± 76 µm) (p < 0.01). Also, 50% resolution of pigment epithelial detachment (PED) was observed in 8 out of 9 eyes (88.9%) with PED at baseline. Intravitreal injections were well tolerated and no adverse events were recorded.

CONCLUSION

Aflibercept was effective and safe for treating nvAMD in naïve patients in routine daily practice.

Predictors of Outcome in Patients with Neovascular Age-Related Macular Degeneration Switched from Ranibizumab to 8-Weekly Aflibercept

PURPOSE

The purpose of this study was to evaluate the outcomes over 12 months in patients with neovascular age-related macular degeneration (nAMD) with insufficient response to ranibizumab who were switched directly to 8-weekly fixed dosing of aflibercept without a loading phase.

DESIGN

Retrospective interventional study.

PARTICIPANTS

Consecutive patients with nAMD who were switched from pro re nata (PRN) intravitreal ranibizumab to 8-weekly fixed aflibercept because of persistent disease activity from November 1, 2013, to September 30, 2014, were included.

METHODS

Demographic data, visual acuity (VA), and spectral-domain optical coherence tomography characteristics over time were evaluated to determine the prognostic indicators of final visual outcome at 12 months.

MAIN OUTCOME MEASURES

The VA, central subfield thickness (CST), presence of macular fluid at month 12 compared with baseline, and the definition of prognostic indicators of final visual outcome at month 12.

RESULTS

A total of 431 patients (447 eyes) were included in this study. There was no statistically significant difference in VA between baseline and month 12 (P = 0.79), whereas the CST significantly decreased at month 12 compared with baseline (P < 0.001). At the 12-month follow-up, 48.3% of eyes had no macular fluid compared with 8.5% at baseline. The mean number of injections at month 12 was 6.8±1.75. Poor prognostic indicators included increasing age, increasing CST, the presence of intraretinal fluid, pigment epithelial detachment, and subfoveal thickening.

CONCLUSIONS

Patients who have not yet "responded" to PRN ranibizumab seem to exhibit retinal dehydration after switching to aflibercept, whereas there was no demonstration of VA benefit. Baseline features at the point of switching can independently predict outcomes.

Resistance to anti-VEGF therapy in neovascular age-related macular degeneration: a comprehensive review

As a progressive chronic disease, age-related macular degeneration (AMD) is the leading cause of irreversible vision impairment worldwide. Experimental and clinical evidence has demonstrated that vascular endothelial growth factor (VEGF) plays a vital role in the formation of choroidal neovascularization. Intravitreal injections of anti-VEGF agents have been recommended as a first-line treatment for neovascular AMD. However, persistent fluid or recurrent exudation still occurs despite standardized anti-VEGF therapy. Patients suffering from refractory or recurrent neovascular AMD may develop mechanisms of resistance to anti-VEGF therapy, which results in a diminished therapeutic effect. Until now, there has been no consensus on the definitions of refractory neovascular AMD and recurrent neovascular AMD. This article aims at clarifying these concepts to evaluate the efficacy of switching drugs, which contributes to making clinical decision more scientifically. Furthermore, insight into the causes of resistance to anti-VEGF therapy would be helpful for developing possible therapeutic approaches, such as combination therapy and multi-target treatment that can overcome this resistance.

Aflibercept in persistent neovascular AMD: comparison of different treatment strategies in switching therapy

PurposeTo evaluate the effects of aflibercept administered according to a pro re nata (PRN) or Fixed Regimen to patients with neovascular AMD and persistent intraretinal/subretinal fluid (IRF/SRF) despite three consecutive ranibizumab injections.MethodsPatients were switched to aflibercept injection (IVA) administered according to a PRN or to a fixed regimen for 1 year in two different retina centers. At baseline each patient underwent a complete ophthalmologic evaluation, including best-corrected visual acuity assessment (BCVA ETDRS chart), fluorescein, and indocyanine green angiography and OCT.ResultsEach group included 36 eyes. After 1 year the PRN group showed BCVA stabilization (63 vs 60 letters, P=0.33), whereas fixed regimen group showed significant BCVA improvement (68 vs 71, P=0.008). The median central retinal thickness decreased by 94 μm in the PRN (P=0.002) and by 148 μm in the fixed regimen group (P≤0.001). Complete IRF/SRF reabsorption was found in 58% of eyes in the PRN and in 42% of eyes in the fixed regimen group. At 1-year visit, the percentage of eyes with pigment epithelium detachment did not significantly decrease, but a height reduction was recorded in both groups. The median number of IVA was 3.5 in the PRN and 7 in the fixed regimen group.ConclusionThe switch to aflibercept with both treatment strategies enabled improvement in morphological parameters and stabilization of visual acuity. BCVA improvement and reduction in vision loss with reduction in retinal thickness, fluid and PED height was achieved with the fixed regimen in previously treated nAMD after 1 year.

Factors Associated With Poor Response to Aflibercept After Switching From Ranibizumab or Bevacizumab in Neovascular Age-related Macular Degeneration

BACKGROUND AND OBJECTIVE

The purpose of this study was to analyze demographic and ocular features of patients with age-related macular degeneration who failed aflibercept (Eylea; Regeneron, Tarrytown, NY) treatment after switching from ranibizumab (Lucentis; Genentech, South San Francisco, CA) or bevacizumab (Avastin; Genentech, South San Francisco, CA).

PATIENTS AND METHODS

Retrospective chart review of patients treated with aflibercept at the Byers Eye Institute from November 2011 to August 2014. Patient visual acuity was noted prior to aflibercept; after 1, 3, and 12 months; and on the most recent visit. Patients who improved vision after switching were compared to patients who lost vision. Demographic and imaging features were analyzed using univariate and multivariate statistics.

RESULTS

Patients who lost vision had significantly higher BMI (P = .013, multivariate) and geographic atrophy (P = .0381, univariate; P = .1, multivariate) compared to patients who improved vision.

CONCLUSION

BMI and geographic atrophy may be considered as potential indicators for poor response to aflibercept after switching from ranibizumab or bevacizumab. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:458-465.].

Guidelines for the Management of Wet Age-Related Macular Degeneration: Recommendations from a Panel of Greek Experts

Purpose

To propose guidelines for the management of patients with wet age-related macular degeneration (wAMD), taking into account the results of large multicenter studies and clinical experience of retina experts.

Method

A team of retina experts developed a consensus paper after three consecutive meetings. The group was focused on guidelines to help clinical decision-making around the definition of successful treatment and the definition of non-response to therapy.

Results

Parameters suggestive of a successful response to treatments included: any gain in best corrected visual acuity (BCVA) or vision loss that is less than 5–10 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, reduction of central retinal thickness, partial or complete absorption of subretinal fluid (SRF), reduction of intraretinal fluid, reduction of pigment epithelial detachment or restoration of the anatomy of outer retinal layers. Non-response to current treatment was considered in the case of loss of BCVA greater than 10 ETDRS letters, increased retinal edema or increase of SRF as evidenced by optical coherence tomography or new bleeding in biomicroscopy.

Conclusion

The introduction of anti-VEGF agents revolutionized the treatment of wAMD. Given the complexity of the disease, the emerging new agents and the difference of cases recruited in clinical trials compared to those appearing in every-day practice, it is essential to individualize treatment options taking into account the results of clinical trials.

The short-term effects of aflibercept on the size of choroidal neovascularization lesion in treatment-resistant neovascular age-related macular degeneration as determined by spectral-domain optical coherence tomography

BACKGROUND AND OBJECTIVES

To evaluate the changes in the size of choroidal neovascularization (CNV) lesion using spectral domain-optical coherence tomography (SD-OCT) in patients with treatment-resistant neovascular age-related macular degeneration (AMD) who were switched from ranibizumab to aflibercept.

MATERIALS AND METHODS

In this prospective case-series, 33 eyes of 30 patients with treatment-resistant neovascular AMD were included. Treatment-resistant neovascular AMD was defined as choriodal neovascularization secondary to AMD determined by subretinal fluid and/or intraretinal fluid/cysts after more than 6 months of monthly ranibizumab therapy. Enrolled eyes were received intravitreal aflibercept injections at weeks 0, 4, and 8. Maximum area of CNV lesion in the cross-sectional area in the B-scan was measured using Heidelberg Eye Explorer software. The same cross-sectional sections containing maximum area of CNV lesion were used during the follow-up. CNV subtypes were determined based on fluorescein angiography images prior to ranibizumab therapy. Main outcome measures were changes in best-corrected visual acuity (BCVA), central subfield thickness (CST), and area of CNV lesion.

RESULTS

There were five classic (15%), seven minimally classic (21%), and 21 occult subtypes of CNV (64%). Four weeks after the third injection, BCVA improvement and reduction of the retinal thickness in nine standard ETDRS subfields were significant (both P < 0.001). Regarding and regardless of CNV subtypes, mean area of CNV lesion decreased significantly at final visit. Overall, a dry macula was achieved in 21 eyes (64%) and 12 eyes (36%) showed decreased or unchanged edema.

CONCLUSIONS

Switching to aflibercept seems to result in reduction of CNV lesion area in short-term follow-up of patients with treatment-resistant neovascular AMD. Lasers Surg. Med. 48:668-677, 2016. © 2016 Wiley Periodicals, Inc.

Conversion to Aflibercept After Prior Anti-VEGF Therapy for Persistent Diabetic Macular Edema

PURPOSE

To evaluate the short-term functional and anatomic outcomes of patients with persistent diabetic macular edema (DME) who were converted from bevacizumab and/or ranibizumab to aflibercept.

DESIGN

Retrospective, interventional, noncomparative, consecutive case series.

METHODS

Only eyes treated with at least 4 consecutive injections of ranibizumab/bevacizumab spaced 4-6 weeks apart prior to conversion and with at least 2 aflibercept injections afterward were considered for inclusion. Pertinent patient demographic, examination, and treatment data were extracted from clinical charts and tabulated for analysis.

RESULTS

Fifty eyes of 37 patients were included. Eyes received a mean of 13.7 bevacizumab/ranibizumab injections prior to conversion, followed by 4.1 aflibercept injections over 4.6 months of subsequent follow-up. The mean logMAR visual acuity at the pre-switch visit was 0.60 ± 0.43 (Snellen equivalent, 20/80). This improved to 0.55 ± 0.48 (Snellen equivalent, 20/70) by the second visit after conversion, corresponding to a mean logMAR change of -0.05 ± 0.22 (P = .12). The average central macular thickness from the pre-switch spectral-domain optical coherence tomography scan was 459.2 ± 139.2 μm. This significantly improved to 348.7 ± 107.8 μm by the second visit following conversion, reflecting a mean decrease of 112 ± 141 μm (P < .0001). The mean intraocular pressure (IOP) recorded at the pre-switch visit was 15.1 ± 3.3 mm Hg. At the second follow-up after converting to aflibercept, the IOP averaged 14.9 ± 3.2 mm Hg, with a mean decrease of 0.2 ± 3.0 mm Hg (P = .63).

CONCLUSIONS

Conversion to aflibercept for persistent DME resulted in significant anatomic improvements. While trends towards improved visual acuity and reduction in IOP were observed, these were not statistically significant.