Recurrence Rate of Choroidal Neovascularization in Neovascular Age-Related Macular Degeneration Managed with a Treat–Extend–Stop Protocol

Two-year outcomes of intravitreal brolucizumab for neovascular age-related macular degeneration: treat, extend, and stop-protocol

PURPOSE

To investigate the real-world 2-year treatment outcomes of intravitreal brolucizumab (IVBr) for neovascular age-related macular degeneration (nAMD).

METHODS

This multicenter, prospective, and interventional study included 53 eyes treated with brolucizumab from October 2020 to August 2021 at 3 institutions. A modified treat-and-extend (TAE) regimen with predefined discontinuation criteria was used. The mTAE regimen was discontinued if patients responded positively and achieved a treatment interval of 16 weeks twice with no sign of recurrence. The number of patients discontinuing TAE and the visual and anatomic changes at 1 and 2 years after the first IVBr were evaluated.

RESULTS

Thirty-eight eyes from 38 patients (71%) completed the 2-year observation period and 7 eyes from 7 patients experienced intraocular inflammation (IOI). Of these 38 patients, 18 (47%) could discontinue the TAE at a median [interquartile range] of 13.1 [12.9-16.8] months after the first IVBr. Best-corrected visual acuity, central subfield retinal thickness, and central choroidal thickness were significantly improved compared with baseline at both 1 and 2 years after the first IVBr (all P < 0.001). An extension study revealed a 1-year recurrence rate of 5.6% (standard deviation, 5.4%) after TAE discontinuation.

CONCLUSIONS

While IOI is a concern with brolucizumab, careful observation allows discontinuing the TAE regimen in patients treated with IVBr. Moreover, brolucizumab may reduce the risk of recurrence after treatment interruption.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry ( http://www.umin.ac.jp/ ; R000050688 UMIN 000044374).

Long-term results of treatment of neovascular age-related macular degeneration using antiangiogenic drugs: A review of the literature

Age-related macular degeneration (AMD) is one of the main causes of visual acuity (VA) loss in people over 50 years of age worldwide, with neovascular AMD (nAMD) accounting for 80% of cases of severe vision loss due to this disease. Anti-vascular endothelial growth factor (anti-VEGF) drugs have been used for the treatment of this disease for more than a decade, changing drastically the visual prognosis of these patients. However, initial studies reporting data on outcomes were short term. Currently, there are different series published on the long-term results of AMD after treatment with anti-VEGF, and the aim of this review is to synthesize these results. The mean follow-up of the included studies was 8.2 years (range 5-12 years). The mean initial VA was 55.3 letters in the Early Treatment Diabetic Retinopathy Study (ETDRS) (range 45.6-65) and the mean final VA was 50.1 letters (range 33.0-64.3), with a mean loss of 5.2 letters. At the end of follow-up, 29.4% of the patients maintained a VA > 70 letters. The 67.9% of patients remained stable at the end of follow-up (< 15 letter loss), with a severe loss (≥ 15 letters) of 30.1%. Fibrosis and atrophy were the main causes of long-term VA loss, occurring at the end of follow-up in 52.5% and 60.5%, respectively.

One-year visual and anatomical outcomes of intravitreal faricimab injection for neovascular age-related macular degeneration after prior brolucizumab treatment

This single-center retrospective cohort study analyzed the 1-year real-world treatment outcomes of 63 consecutive eyes (of 60 patients) with neovascular age-related macular degeneration (nAMD) that were switched from intravitreal brolucizumab (IVBr) to intravitreal faricimab (IVF) and managed on a treat-and-extend regimen with discontinuation criteria. After the switch, patients opted to continue IVF, to switch back to IVBr, or receive photodynamic therapy (PDT). Thirty-eight patients continued IVF, 16 patients were switched back to IVBr, 2 patients received PDT, and 4 patients paused treatment. Best-corrected visual acuity (BCVA), central subfield thickness (CST), subfoveal choroidal thickness (sf-CT), and injection intervals were compared immediately before and 1 year after the initial IVF. Whereas there was no change in BCVA and CST; 0 [- 0.0969 to 0.125, P = 0.58], - 1.5 [- 27.8 to 13.5, P = 0.11] µm, respectively, sf-CT decreased significantly; - 19.5 [- 45.5 to 7.75, P = 0.015] µm. The patients switched back showed no significant change in sf-CT. The injection interval extended significantly in the IVF continuation and the switch-back group (2.0 and 3.0 weeks, respectively; [P = 0.0007 and 0.0078]) in eyes with a pre-switching interval of less than 12 weeks. Faricimab shows promise as a safe and effective alternative to brolucizumab for treating nAMD.

INCIDENCE AND CHARACTERISTICS OF NEOVASCULAR AGE-RELATED MACULAR WITH OVER A 12-MONTH REMISSION AFTER THREE MONTHLY AFLIBERCEPT ADMINISTRATION: 60 Months Results of a Pro Re Nata Regimen

PURPOSE

To investigate the characteristics of patients with over a 12-month remission after 3 monthly intravitreal aflibercept injections followed by a pro re nata regimen for exudative age-related macular degeneration (AMD).

METHODS

One hundred forty-four eyes with exudative AMD were included. All patients received 3 monthly intravitreal aflibercept injections as a loading dose, followed by an as-needed regimen for 60 months. Patients were classified into the remission and recurrence groups depending on the presence or absence of a 12-month remission. ARMS2 A69S and CFH I62V were genotyped in all cases.

RESULTS

During the study, 82 eyes (56.9%) showed 12 months or more remission at least once. The cumulative incidence rate of a 12-month remission showed a plateau pattern and converged to 60% (y = -166.26x-2.172 + 0.6, R2 = 0.8168). Patients in the remission group were younger than those in the recurrence group (P < 0.001) and had less risk allele frequency of the ARMS2 gene than the recurrence group (P < 0.001). The longer the remission interval was prolonged, the better visual acuity was achieved at the 60-month visit (P < 0.001).

CONCLUSION

Fifty-seven percent of patients showed a 12-month remission or more at least once during a 60-month follow-up, suggesting that patients with no reactivation can prolong the treatment interval.

One-year outcome of brolucizumab for neovascular age-related macular degeneration in Japanese patients

A new anti-vascular endothelial growth factor agent, brolucizumab, was approved by the United States Food and Drug Administration in 2019. We evaluated whether brolucizumab reduces the treatment burden of neovascular age-related macular degeneration (nAMD) after switching by examining 1-year treatment outcomes in a real-world setting. This retrospective single-institution study included 107 consecutive eyes with nAMD treated with brolucizumab. Among these eyes, 30 with treatment-naïve nAMD and 77 treated with other anti-VEGF agents for more than a year were included. All eyes were managed using a treat and extend (TAE) or modified TAE regimen. The last injection intervals at 52 weeks were 12.9 and 12.1 weeks in the treatment-naïve and switch therapy groups, respectively. Among switch therapy group patients whose pre-switch injection intervals were shorter than 120 days (n = 62 eyes), the injection interval was significantly longer after the switch than before, with a mean difference of 2.7 weeks (P < 0.0001). Intraocular inflammation events occurred in 2 and 7 treatment-naïve and switch therapy patients, respectively. In conclusion, brolucizumab might reduce the treatment burden in patients who required the injection of other anti-VEGF agents with a 120-day interval or shorter, despite a relatively high discontinuation rate due to intraocular inflammation.

Predictors of stoppage and recurrence of choroidal neovascularization with a Treat- Extend-Stop protocol: 4-year follow-up

OBJECTIVE

To analyze the long-term results of treatment of active age-related macular degeneration (AMD) with anti-vascular endothelial growth factor (VEGF) agents using the treat-extend-stop (TES) approach, defining predictive factors for stoppage of the treatment and recurrences in a real-world setting.

METHODS

Data from 191 eyes treated with intravitreal injections for choroidal neovascularization due to AMD were retrospectively reviewed. Changes in best-corrected visual acuity (BCVA) and membrane activity (optical coherence tomography) were recorded and evaluated over a 48-month follow-up. Logistic regression analysis was used to determine predictors of treatment stoppage and recurrences after stoppage.

RESULTS

BCVA improvement was found in 70.5% of eyes at 48 months, and remaining signs of activity in 27.9%. Disease inactivity was achieved in 69 eyes (31.9%), with a relapse of the membrane in 29 of these eyes (42.0%). Significant independent predictors of treatment stoppage were found: no foveal membrane, inactive membrane at 12, 24, 36 and 48 months, extension interval>8 weeks at 12 and 24 months,>15 injections at 24 months, and baseline BCVA>61 letters. Concerning recurrent membranes, only the presence of membrane activity at 36 months and baseline BCVA>61 letters were independent predictors.

CONCLUSIONS

Anti-VEGF treatment of AMD using the TES protocol allows for successful visual restoration in most patients, with more likely disease inactivity in those eyes with better baseline BCVA, maintaining signs of membrane inactivity during the first two years of follow-up and requiring fewer injections.

BILATERAL PERIPAPILLARY CHOROIDAL NEOVASCULARIZATION IN AN OTHERWISE HEALTHY TEENAGER TREATED WITH ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS

PURPOSE

This case report describes the presentation, diagnostic reasoning, and successful management of a 14-year-old teenage boy found to have bilateral peripapillary choroidal neovascularization.

METHODS

This is a case of a teenage boy with an unremarkable ocular and systemic history presenting with decreased visual acuity, macular edema, and bilateral peripapillary choroidal neovascularization.

RESULTS

After intravitreal antivascular endothelial growth factor injections, the patient's visual acuity improved. Imaging further revealed that the initially present macular edema, subretinal fluid, and peripapillary choroidal neovascularizations markedly improved after treatment.

CONCLUSION

Peripapillary choroidal neovascularizations are often not trivial to diagnose. As this report illustrates, work-up with different modalities is extremely valuable, and antivascular endothelial growth factor injections may help decrease exudation and improve visual outcomes.

Is there any association between the frequency of wet age-related macular degeneration recurrences and the seasons of the year?

PURPOSE

To investigate whether a seasonal distribution of the frequency of exudative age-related macular degeneration (wet AMD) recurrences exists.

METHODS

In total, 129 eyes with 171 recurrences in patients suffering from wet AMD were included in the study. All the patients had been treated with intravitreal anti-VEGF injections according to Pro Re Nata treatment regimen. Recurrence was defined as the re-detection of sub-retinal fluid, intraretinal fluid, and/or sub-macular hemorrhage in optical coherence tomography scans, after at least two consecutive monthly examinations with a "dry" macula. The year was divided in three 4-month periods (zone A: June-September, zone B: October-January, and zone C: February-May) based on the weather conditions prevailing in each period. Mean temperature and hours of sunlight exposure were the main weather markers recorded.

RESULTS

Eighty-two recurrences (48%) occurred during the period June-September, 50 (29.2%) during the period October-January, and 39 (22.8%) during the period February-May (Chi-square = 17.5, p < 0.001). Among the groups, neither patients' age (78 ± 8 years A, 76 ± 7 years B, and 79 ± 8 years C, p = 0.15) nor gender status (40% men A, 36% men B, and 51% men C, p = 0.35) differed significantly. Mean temperature was 27.6 ± 1.8 °C, 15.1 ± 4.6 °C, and 16.5 ± 4.4 °C in zones A, B, and C, respectively. Hours (h) of sunlight exposure (average hours/month) were 344 ± 34 h, 188 ± 42 h, and 223 ± 57 h in zones A, B, and C.

CONCLUSION

We demonstrated that the frequency of wet AMD recurrences is significantly elevated during the warmer months, possibly due to the higher levels of UV radiation and mean temperature. Further research is necessary to validate our findings.

Aflibercept more effectively weans patients with neovascular age-related macular degeneration off therapy compared with bevacizumab

BACKGROUNDStudies assessing the efficacy of therapies for neovascular age-related macular degeneration (nvAMD) have demonstrated that aflibercept may have a longer treatment interval than its less-expensive alternative, bevacizumab. However, whether this benefit justifies the additional cost of aflibercept remains under debate. We have recently reported that a treat-and-extend-pause/monitor approach can be used to successfully wean 31% of patients with nvAMD off anti-VEGF therapy. Here, we examined whether the choice of therapy influences the outcomes of this approach.METHODSIn this retrospective analysis, 122 eyes of 106 patients with nvAMD underwent 3 consecutive monthly injections with either aflibercept (n = 70) or bevacizumab (n = 52), followed by a treat-and-extend protocol, in which the decision to extend the interval between treatments was based on visual acuity, clinical exam, and the presence or absence of fluid on optical coherence tomography. Eyes that remained stable 12 weeks from their prior treatment were given a 6-week trial of holding further treatment, followed by quarterly monitoring. Treatment was resumed for worsening vision, clinical exam, or optical coherence tomography findings.RESULTSAt the end of 1 year, eyes receiving bevacizumab had similar vision but required more injections (8.7 ± 0.3 treatments vs. 7.2 ± 0.3 treatments) compared with eyes receiving aflibercept. However, eyes treated with aflibercept were almost 3 times more likely to be weaned off treatment (43% vs. 15%) compared with eyes treated with bevacizumab at the end of 1 year.CONCLUSIONThese observations expose an advantage of aflibercept over bevacizumab and have important clinical implications for the selection of therapy for patients with nvAMD.FUNDINGThis work was supported by the National Eye Institute, NIH grants R01EY029750 and R01EY025705, Research to Prevent Blindness, the Alcon Young Investigator Award from the Alcon Research Institute, and the Branna and Irving Sisenwein Professorship in Ophthalmology.

Licochalcone A alleviates laser-induced choroidal neovascularization by inhibiting the endothelial-mesenchymal transition via PI3K/AKT signaling pathway

Choroidal neovascularization (CNV) is a hallmark of wet age-related macular degeneration, which severely impairs central vision. Studies have shown that endothelial-mesenchymal transition (EndMT) is involved in the pathogenesis of CNV. Licochalcone A (lico A), a flavonoid extracted from the root of licorice, shows the inhibition on EndMT, but it remains unclear whether it can suppress the formation of CNV. The aim of this study is to investigate the effects of lico A on laser-induced CNV, and EndMT process in vitro and vivo. We established the model of CNV with a krypton laser in Brown-Norway rats and then intraperitoneally injected lico A. Our experimental results demonstrated that the leakage of CNV was relieved, and the area of CNV was reduced in lico A-treated rats. Cell migration and tube formation in oxidized low-density lipoprotein (Ox-LDL)-stimulated HUVECs were inhibited by lico A and promoted by PI3K activator 740Y-P. The protein expressions of snai1 and α-SMA were increased, and CD31 and VE-cadherin were decreased in the model rats of CNV, but partially reversed after treatment with lico A. The expression of CD31 was decreased and α-SMA was increased in OX-LDL-treated HUVECs, which was further strengthened by 740Y-P, while the expression of CD31 was up-regulated and α-SMA was down-regulated in lico A treated HUVECs. Our data revealed that EndMT process was alleviated by lico A. Meanwhile, PI3K/AKT signaling pathway was activated in model rat of CNV and Ox-LDL-stimulated HUVECs, which can be suppressed with treatment of lico A. Our experimental results confirmed for the first time that lico A has the potential to alleviate CNV by inhibiting the endothelial-mesenchymal transition via PI3K/AKT signaling pathway.

Recurrence of neovascular age-related macular degeneration after cessation of treat and extend regimen

The appropriate timing of treatment cessation after treat and extend (TAE) regimen for age-related macular degeneration has not been established. This study aimed to investigate the incidence and risk factors of recurrence after cessation of the TAE regimen. We included patients who received and discontinued the TAE regimen, after extension of the treatment interval to ≥ 12 weeks. Forty-nine patients were included in the study. The estimated recurrence rates were 33% at 1 year and 48% at 2 years after treatment cessation, respectively. Good visual acuity at cessation and a large number of injections in the 6 months before cessation were significant risk factors. Higher chances of recurrence were associated with < 0.1 logarithm of the minimum angle of resolution (logMAR) at cessation (P < 0.002). Meanwhile, five patients with visual acuity ≥ 1.0 logMAR at cessation did not show recurrence. Among the 25 recurrences, two lines of vision loss were noted in only two cases after resumed treatment. This study confirmed the importance of the number of injections in reducing recurrence and the association between visual acuity and recurrence. Recurrence is generally well-controlled with resumed treatment.

Unusual visual loss in a patient with exudative macular degeneration

Purpose

To describe a case of marked vision loss in a patient with neovascular age-related macular degeneration after choroidal neovascular membrane (CNV) improvement and stabilization.

Observations

An 82-year-old male presented with 20/800 vision having dropped from 20/50 three months prior. He had been undergoing active treatment for exudative macular degeneration over the past seven years, the CNV had stabilized. An extensive ophthalmic workup was performed revealing no CNV progression and no ophthalmic cause was identified for visual loss. An MRI of the brain was obtained, which showed a metastatic brain lesion in the occipital lobe, and subsequent workup determined it originated from an adenosquamous carcinoma of the lung.

Conclusions

When there is unexplained visual loss in an otherwise stable patient with macular degeneration, suspicion for non-retinal related causes of visual loss could alter the morbidity and mortality for patients with systemic diseases.

The Influence of COVID-19 on the Stability of Patients with Neovascular Age-Related Macular Degeneration with Different Treatment Regimens

Introduction

To explore the impact of coronavirus disease 2019 (COVID-19) on the stability of patients with neovascular age-related macular degeneration (nAMD) receiving the treat and extend (T&E) or the pro re nata (PRN) treatment regimen and to identify indicators that may predict the disease stability of nAMD.

Methods

This is a retrospective study of patients with nAMD treated at the Second Affiliated Hospital of Harbin Medical University whose treatment schedule was interrupted at least once between 1 February and 31 May 2020. The demographic and clinical characteristics, including the best corrected visual acuity (BCVA), optical coherence tomography (OCT) features, subfoveal choroidal thickness (SFCT), interval between the last injection and the beginning of the pandemic, and the number of anti-vascular endothelial growth factor (VEGF) injections, were analyzed.

Results

A total of 209 stable patients with nAMD (122 eyes received the T&E regimen; 87 eyes received the PRN regimen) were identified. Compared to those who received the PRN regimen, the patients who received the T&E regimen were more stable during the first visit after COVID-19 (53.3% vs. 33.3%, P = 0.004), the BCVA was significantly better (58.5 letters vs. 56 letters, P = 0.006), and the CRT fluctuated only slightly (15 μm vs. 35 μm, P = 0.001). Furthermore, a multivariate logistic regression analysis showed that stable patients with nAMD with type 1 choroidal neovascularization (CNV) (OR 2.493 [95% CI 1.179–5.272], compared with type 2 CNV; P = 0.017; OR 2.912 [95% CI 1.133–7.485], compared with retinal angiomatous proliferation; P = 0.026) or with pigment epithelial detachment (PED) were more likely to remain stable when treatment was interrupted (OR 0.392 [95% CI 0.181–0.852], compared with no PED; P = 0.018).

Conclusion

Compared to patients who received the PRN treatment regimen, stable patients with nAMD who received the T&E treatment regimen could better maintain stability when the treatments were suddenly interrupted by the COVID-19 pandemic. In addition, patients with type 1 CNV or patients with PED were more likely to remain stable. At present, the COVID-19 pandemic is becoming increasingly normalized, and the T&E regimen can become a more advanced treatment option for patients undergoing therapy.

Long term results of patients with neovascular age-related macular degeneration switched from other anti-VEGF agents to intravitreal Aflibercept

Background

This study explores the long term anatomic and functional results of patients who were switched to intravitreal aflibercept injections (IAI) after being initially managed with other anti-VEGF agents for neovascular age-related macular degeneration (nAMD).

Methods

Patients with nAMD were included if they started with another anti-VEGF agent and were switched to IAI. Subjects had at least 3 years of consistent therapy with IAI and at least 1 injection quarterly.

Results

Eighty-eight patients had at least 3 years of treatment while 58 of those patients, had at least 4 years of IAI. Average treatment time with other anti-VEGF agents was 32 months prior to switching. Baseline best corrected vision (VA) was 59.4 letters (20/70 + 2). At time of switch, VA increased significantly to 66.7 letters (20/50 + 2). At 3 months after switch, VA increased significantly to 69.0 (20/40−) letters. After 3 years of consistent IAI, vision was 67.5 letters (20/40−2), and for those patients that completed 4 years of therapy, the average VA was 66.0 letters (20/50 + 2), with a gain of 6.6 letters over baseline vision. 32.1% of patients gained 3 or more lines of vision. Initial central macular thickness (CMT) was 369 µm, which improved to 347 µm at time of switch, and further improved at 3 months to 301 µm and was maintained over time.

Conclusion

Patients switched to IAI can maintain vision over the long term. Patients treated on average for 5.7 years, had a visual gain of 8.1 letters after 3 years and 6.6 letters after 4 years of IAI therapy. CMT significantly improved following the switch and was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00361-9.

Effects of suspension of anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration in clinical setting

Purpose

To investigate the outcomes of a suspension of anti-vascular endothelial growth factor (anti-VEGF) treatments in the eyes with neovascular age-related macular degeneration (nAMD).

Methods

This was a retrospective study that examined eyes having no exudation for 48 weeks while undergoing intravitreal anti-VEGF injections every 12 to 16 weeks. The rate and time of recurrences, best-corrected visual acuity (BCVA), central subfield thickness (CST), number of visits, and reactivity to anti-VEGF were determined after the suspension of the anti-VEGF treatments.

Results

In 34 eyes of 34 patients, 17 eyes (50.0%) had a recurrence during the 24-month follow-up period. The median time of a recurrence was 10 months. The BCVA was maintained for 24 months after the suspension regardless of the development of any recurrences. In 41.7% of the eyes that resumed treatment, the duration of exudation suppression by the anti-VEGF therapy was shorter than 12 weeks during the 12 months after restarting the anti-VEGF treatments. There was a significant increase in the number of visits during the first year after beginning the suspension versus during the 1 year before the suspension (non-recurrence group; P = 0.007, recurrence group; P = 0.001).

Conclusion

Although one-half of the eyes had a recurrence within 24 months after a suspension of anti-VEGF treatment, the BCVA was maintained after a resumption of the anti-VEGF treatments. However, the number of hospital visits increases regardless of the recurrences and the lesion stability is altered by the anti-VEGF suspension. Clinicians should explain both the advantages and disadvantages of anti-VEGF suspension to nAMD patients.

Aqueous proteins help predict the response of patients with neovascular age-related macular degeneration to anti-VEGF therapy

BackgroundTo reduce the treatment burden for patients with neovascular age-related macular degeneration (nvAMD), emerging therapies targeting vascular endothelial growth factor (VEGF) are being designed to extend the interval between treatments, thereby minimizing the number of intraocular injections. However, which patients will benefit from longer-acting agents is not clear.MethodsEyes with nvAMD (n = 122) underwent 3 consecutive monthly injections with currently available anti-VEGF therapies, followed by a treat-and-extend protocol. Patients who remained quiescent 12 weeks from their prior treatment entered a treatment pause and were switched to pro re nata (PRN) treatment (based on vision, clinical exam, and/or imaging studies). Proteomic analysis was performed on aqueous fluid to identify proteins that correlate with patients' response to treatment.ResultsAt the end of 1 year, 38 of 122 eyes (31%) entered a treatment pause (≥30 weeks). Conversely, 21 of 122 eyes (17%) failed extension and required monthly treatment at the end of year 1. Proteomic analysis of aqueous fluid identified proteins that correlated with patients' response to treatment, including proteins previously implicated in AMD pathogenesis. Interestingly, apolipoprotein-B100 (ApoB100), a principal component of drusen implicated in the progression of nonneovascular AMD, was increased in treated patients who required less frequent injections. ApoB100 expression was higher in AMD eyes compared with controls but was lower in eyes that develop choroidal neovascularization (CNV), consistent with a protective role. Accordingly, mice overexpressing ApoB100 were partially protected from laser-induced CNV.FundingThis work was supported by the National Eye Institute, National Institutes of Health grants R01EY029750, R01EY025705, and R01 EY27961; the Research to Prevent Blindness, Inc.; the Alcon Research Institute; and Johns Hopkins University through the Robert Bond Welch and Branna and Irving Sisenwein professorships in ophthalmology.ConclusionAqueous biomarkers could help identify patients with nvAMD who may not require or benefit from long-term treatment with anti-VEGF therapy.

Optimal approaches and criteria to treat-and-extend regimen implementation for Neovascular age-related macular degeneration: experts consensus in Taiwan

The management of neovascular age-related macular degeneration (nAMD) has taken a major stride forward with the advent of anti-VEGF agents. The treat-and-extend (T&E) approach is a refined management strategy, tailoring to the individual patient’s disease course and treatment outcome. To provide guidance to implementing anti-VEGF T&E regimens for nAMD in resource-limited health care systems, an advisory board was held to discuss and generate expert consensus, based on local and international guidelines, current evidence, as well as local experience and reimbursement policies. In the experts’ opinion, treatment of nAMD should aim to maximize and maintain visual acuity benefits while minimizing treatment burden. Based on current evidence, treatment could be initiated with 3 consecutive monthly injections. After the initial period, treatment interval may be extended by 2 or 4 weeks each time for the qualified patients (i.e. no BCVA loss ≥5 ETDRS letters and dry retina), and a maximum interval of 16 weeks is permitted. For patients meeting the shortening criteria (i.e. any increased fluid with BCVA loss ≥5 ETDRS letters, or presence of new macular hemorrhage or new neovascularization), the treatment interval should be reduced by 2 or 4 weeks each time, with a minimal interval of 4 weeks. Discontinuation of anti-VEGF may be considered for those who have received 2–3 consecutive injections spaced 16 weeks apart and present with stable disease. For these individuals, regular monitoring (e.g. 3–4 months) is recommended and monthly injections should be reinstated upon signs of disease recurrence.

Management of neovascular age-related macular degeneration: Taiwan expert consensus

Neovascular age-related macular degeneration (nAMD) is a leading cause of irreversible vision loss. The present consensus provides suggestions on diagnosis, evaluation, treatment, and follow-up strategies for nAMD from a panel of 11 practicing ophthalmologists. The experts suggest that the baseline visit for nAMD management should include a comprehensive ophthalmologic examination via a multimodal approach consisting of visual and anatomical evaluation. Patients diagnosed with nAMD should be subjected to treatment with the goal of maintaining visual function while diminishing anatomical disease activity and minimizing treatment burden. Currently, anti-VEGF therapy is the main treatment strategy for nAMD, and evaluation involving comprehensive ophthalmologic examination within 1 month of completion of the loading phase comprising three monthly injections is recommended to guide subsequent management. Either a treat-and-extend or pro re nata regimen can be considered for the maintenance phase of anti-VEGF therapy, and the regimen should be chosen and adjusted according to disease activity, reimbursement criteria, financial burden, and patient preferences. In the event of inactive nAMD or poor treatment outcomes, after thorough evaluation and patient education, anti-VEGF therapy may be stopped. The consensus provides practical nAMD management guidelines for ophthalmologists and fellow healthcare professionals.

Visual Outcome and Treatment Frequency of Anti-VEGF Therapy Using the Treat-and-Extend and Treatment Cessation Regimen for Exudative Age-Related Macular Degeneration and Pachychoroid Neovasculopathy

Purpose

To report the results of anti-vascular endothelial growth factor (VEGF) therapy using treat-and-extend (TAE) and treatment cessation regimens for exudative age-related macular degeneration (AMD) and pachychoroid neovasculopathy (PN).

Methods

We retrospectively studied 101 treatment-naïve eyes of 101 patients with exudative AMD and PN that underwent anti-VEGF therapy using TAE and treatment cessation regimen with a follow-up period of ≥12 months. Best-corrected visual acuity (BCVA), treatment frequency, and number of eyes with successful treatment cessation were measured. Successful treatment cessation was defined as dry macula retention without treatment for >16 weeks after the last injections. Factors related to the successful treatment cessation were evaluated.

Results

BCVA was maintained at the last visit with a mean follow-up period of 49.9 ± 26.9 months. The injection number decreased from 6.8 ± 2.31 at the first year to 3.7 ± 3.64 at the fifth year. At the last visit, 48 (47.5%) eyes were being treated at an interval of ≥12 weeks or were under treatment cessation. Successful treatment cessation during the follow-up period and at the last visit were achieved in 56 (55.4%) and 27 (26.7%) eyes, with a median treatment-free period of 66 and 126 weeks, respectively. Good early treatment response and a small recurrence number were associated with successful treatment cessation at the last visit.

Conclusion

Patients with good early response to treatment and fewer recurrences may achieve treatment cessation. This information could help physicians predict the achievement of treatment cessation for a considerable period.

Neovascular age-related macular degeneration: A review of findings from the real-world Fight Retinal Blindness! registry

The use of vascular endothelial growth factor (VEGF) inhibitors has revolutionised the treatment of neovascular age-related macular degeneration (nAMD) since the pivotal Phase III studies demonstrated their efficacy more than 10 years ago. The Fight Retinal Blindness! project was developed to track the treatment outcomes of patients with nAMD in real-world practice. Data from this registry have been used to answer several clinically relevant questions related to the treatment of nAMD including the effect of under-treatment, the comparative effectiveness of different anti-vascular endothelial growth factor agents, long-term treatment outcomes, identifying optimal treatment regimens and the rate and outcomes of rare adverse events. Observational studies are a valuable complement to the shortcomings of clinical trials and a combination of data from real-world settings and clinical trials are necessary to provide evidence on how to achieve the best outcomes for individual patients with nAMD.

Inflammatory Choroidal Neovascular Membranes: Clinical Profile, Treatment Effectiveness, and Visual Prognosis

Purpose

To characterise a sample of patients with inflammatory choroidal neovascularization (I-CNV), including clinical profile, underlying aetiology and its course, treatments performed, associated clinical response, and visual prognosis.

Methods

Retrospective analysis of patients with a diagnosis of I-CNV followed at the Ophthalmology Department of Centro Hospitalar Universitário de São João (CHUSJ). Clinical and visual outcomes were classified according to the difference in visual acuity after treatment.

Results

Twenty eyes from 17 patients were analysed (11 female and 6 male patients, mean age 41.90 ± 16.457 years at CNV diagnosis). Punctate inner choroidopathy/multifocal choroiditis was the predominant inflammatory aetiology (10 patients, 58.82%). Median follow-up time was 46 months (range 10 to 188 months). Neovascularization was treated with intravitreal anti-VEGF injections (bevacizumab, aflibercept, and ranibizumab), and inflammation with anti-inflammatory/immunosuppressive therapy (oral, intravenous, and/or intravitreal corticosteroids; oral cyclosporine or methotrexate). Intravitreal anti-VEGF agents had a median number of 7.00 injections (IQR, 4.25 to 29.00). Visual acuity among 20 eyes had a mean gain of 15.10 ± 12.998 ETDRS letters after anti-VEGF treatment (p=0.000051). According to our classification, 16 had an improved outcome (80.00%), 3 had a stable outcome (15.00%), and 1 had a worsened visual outcome (5.00%). In addition, 13 eyes (65.00%) had a final VA equal to or greater than 65 letters. Recurrence was seen in 3 eyes (15.00%). Complications included cataract (6 patients) and ocular hypertension (4 patients).

Conclusion

A combined approach with anti-VEGF agents and anti-inflammatory therapy was effective in I-CNV treatment, and an overall good visual prognosis was attainable. Intensive follow-up was fundamental in the management of both the primary inflammatory and secondary neovascular conditions.

Results of patients with neovascular age-related macular degeneration managed by a treat-extend-stop protocol without recurrence

PURPOSE

To assess vision, injection quantity, initial lesion size, and final anatomic status in patients with nAMD completing the treat-extend-stop (TES) protocol.

METHODS

Patients with nAMD received ≥ 3 monthly anti-VEGF injections followed by 1-2 week injection interval extensions, with intra/subretinal fluid resolution on SD-OCT, to 12 weeks. With quiescent disease, and 2 quarterly injections, patients were monitored alone beginning at 4 weeks extending by 1-2 week intervals until quarterly monitoring.

RESULTS

Eighty-eight of 143 eyes with nAMD completed the TES protocol without disease recurrence. Sixteen (18.2%) developed sub-foveal geographic atrophy (GA), 25 (28.4%) developed fibrovascular scarring (FV) and 47 (53.4%) developed regressed choroidal neovascularization (rCNV) with 16.9 ± 13.3 average injections between the 3 groups which was not statistically significant. Average treatment time was 30.3 ± 26.1 months and subsequent follow-up was 23.2 ± 19.8 months. Average lesion size for FV was 18.77 ± 10.8mm² vs. GA at 12.00 ± 9.99mm² vs. regressed CNV at 7.12 ± 6.5mm² (p < 0.05). Pre, post, and final vision for GA was 39.6 letters (20/160) vs. 32.7 letters (20/200 + 2, p = 0.4725) vs. 25.0 letters (20/320, p = 0.0865); FV was 22.4 letters (20/400 + 2) vs. 11.6 letters (20/640, p = 0.0351) vs. 11.0 letters (20/640 + 1, p = 0.0226), and rCNV was 56.4 letters (20/80 + 1) vs. 69.5 letters (20/40, p < 0.001) vs. 67.3 letters (20/40-2, p = 0.0016). In the rCNV group, 17/46 eyes gained ≥ 3 lines and 30/46 eyes achieved ≥ 20/40 vision. Non-central GA expanded 0.226 ± 0.126 mm vs. 0.225 ± 0.098 mm during and after treatment completion over 24 months (p = 0.99).

CONCLUSIONS

Central GA or FV portends worse visual outcomes vs. rCNV after cessation of therapy. Anti-VEGF therapy may not affect the rate of GA expansion. Final anatomic character and location are key determinants of final vision.

RATES OF EXUDATIVE RECURRENCE FOR EYES WITH INACTIVATED WET AGE-RELATED MACULAR DEGENERATION ON 12-WEEK INTERVAL DOSING WITH BEVACIZUMAB THERAPY

PURPOSE

To determine the recurrence rate of exudative age-related macular degeneration (wet AMD) in patients on 12-week dosing interval anti-vascular endothelial growth factor (anti-VEGF) bevacizumab therapy.

METHODS

A retrospective chart review was performed on wet AMD patients treated with anti-VEGF therapy using a "treat-and-extend" methodology at one physician's practice site over 2 years (2012-2014). Charts were evaluated for visual acuity, anti-VEGF agent used, treatment interval, duration of treatment, trials off of anti-VEGF therapy, evidence of exudation, and wet AMD recurrence characteristics.

RESULTS

Three hundred and twenty-one wet AMD patients were treated. Fifty-seven eyes were without active exudation by clinical examination or optical coherence tomography (OCT) and were maintained on repeating 12-week interval suppressive anti-VEGF therapy. Sixteen percent (8/49) showed exudation recurrence with an average 10% cumulative recurrence rate per year for eyes on bevacizumab. Eight eyes without active exudation were discontinued off of bevacizumab therapy. Sixty-three percent (5/8) demonstrated recurrence on average 4 months after stopping therapy.

CONCLUSION

The findings in this study suggest that if a patient can be extended to 12-week interval bevacizumab therapy, there is on average a 10% chance of recurrence with each successive year. If anti-VEGF therapy is discontinued in these patients, there is an increased chance of recurrence by 4 months.

Minimal Residual Disease in Neovascular Age-Related Macular Degeneration

With the advent of long-acting anti-vascular endothelial growth factor substances, "healing of AMD (age-related macular degeneration)" might be easily assumed due to prolonged treatment intervals. Adoption of the oncological concept of minimal residual disease for quiescent choroidal neovascularization (CNV) lesions might enhance the importance of continued monitoring, and spur research into the core of the disease, i.e., CNV biology.

Recurrent Neovascular Age-Related Macular Degeneration after Discontinuation of Vascular Endothelial Growth Factor Inhibitors Managed in a Treat-and-Extend Regimen

PURPOSE

To investigate the recurrence rate of active macular neovascularization in patients with neovascular age-related macular degeneration (nAMD) previously followed up in a treat-and-extend (TE) regimen in which treatment had been stopped because of disease stability.

DESIGN

Prospective cohort study.

PARTICIPANTS

One hundred five patients with nAMD previously followed up in a TE regimen treated with aflibercept injections.

METHODS

All patients with a dry macula on 3 consecutive visits 12 weeks apart were eligible to participate in the study. Patients were examined at baseline and then monitored for disease recurrence 4, 6, 8, 10, and 12 months after the last injection.

MAIN OUTCOME MEASURES

The proportion of patients with recurrent disease within 12 months after the last injection. Change in best-corrected visual acuity (BCVA) at the time of recurrence and after resumed therapy.

RESULTS

Evidence of recurrent nAMD was seen in 54 of 102 patients (52.9%) after 12 months of follow-up. The mean time to recurrence after the last injection was 6.7 ± 2.2 months. The BCVA decreased from 71.7 ± 10.0 Early Treatment Diabetic Retinopathy Study (ETDRS) letters at baseline to 68.1 ± 11.1 ETDRS letters at the recurrence (P = 0.12). After treatment resumed, BCVA increased to 71.4 ± 10.0 ETDRS letters (P = not significant compared with baseline). Patients with a pigment epithelial detachment (PED) at baseline showed a 74% (14/19) recurrence rate compared with 48% (40/83) in patients without a PED (P < 0.05). Only 22 of 54 patients (40.7%) with recurrent disease showed symptoms of visual loss or metamorphopsia.

CONCLUSIONS

Recurrent nAMD is common in previously stable patients for whom anti-VEGF injections have been suspended. It is difficult to predict which patients will experience a recurrence, and most of these patients do not show symptoms in the early stages of reactivation. Long-term follow-up is important, and early detection of recurrent disease can improve the chances for maintained visual function.

[Antiangiogenic therapy of neovascular age-related macular degeneration]

The problem associated with the prevalence of retinal diseases, and age-related macular degeneration (AMD) in particular, is undoubtedly relevant. This aspect is based on steadily growing statistics on morbidity, a high number of randomized controlled trials (RCT) and published real world data (RWD). The analysis of RCT results being published by researchers on 15.05.19 showed 2915 studies were registered on the subject of retinal diseases; that exceeds the number of studies on glaucoma by approximately 1.38 times (2118 studies) and conjunctival lesions by 2.37 times (1230 studies). AMD is one of the leading causes of irreversible vision loss and blindness; its neovascular form leads to blindness in 80-90% of all cases. Even though the topic of nAMD therapy is widely highlighted in modern ophthalmology, today there are many aspects that require targeted solutions. The main controversial issues that determine the complexity of therapy and patient management include discrepancies in determination of reference points (disease activity criteria) for implementation of anti-VEGF dosing regimens, patients' compliance, prioritization issues in treatment, its continuity with potential for the increase of intervals between injections and monitoring visits.

Relapse of pathological angiogenesis: functional role of the basement membrane and potential treatment strategies

Blinding eye diseases such as corneal neovascularization, proliferative diabetic retinopathy, and age-related macular degeneration are driven by pathological angiogenesis. In cancer, angiogenesis is key for tumor growth and metastasis. Current antiangiogenic treatments applied clinically interfere with the VEGF signaling pathway-the main angiogenic pathway-to inhibit angiogenesis. These treatments are, however, only partially effective in regressing new pathologic vessels, and the disease relapses following cessation of treatment. Moreover, the relapse of pathological angiogenesis can be rapid, aggressive and more difficult to treat than angiogenesis in the initial phase. The manner in which relapse occurs is poorly understood; however, recent studies have begun to shed light on the mechanisms underlying the revascularization process. Hypotheses have been generated to explain the rapid angiogenic relapse and increased resistance of relapsed disease to treatment. In this context, the present review summarizes knowledge of the various mechanisms of disease relapse gained from different experimental models of pathological angiogenesis. In addition, the basement membrane-a remnant of regressed vessels-is examined in detail to discuss its potential role in disease relapse. Finally, approaches for gaining a better understanding of the relapse process are discussed, including prospects for the management of relapse in the context of disease.

Reactivation of CNV after Discontinuation of Bevacizumab Treatment of Age-Related Macular Degeneration

INTRODUCTION

Treatment of exudative age-related macular degeneration (ARMD) has shifted to pro re nata and treat-extend-stop strategies. However, a rational discontinuation strategy is lacking. To develop such a strategy, it is important to determine choroidal neovascularization (CNV) recurrence rates after anti-VEGF treatment is discontinued. Here we report prospective data on persistent and recurrent CNV activity after discontinuation of bevacizumab treatment.

METHODS

This prospective, single-center clinical trial enrolled 191 patients with exudative ARMD. Patients were randomly assigned to receiving intravitreal bevacizumab injections every 4, 6, or 8 weeks for 1 year. CNV activity was determined in the 157 patients who completed the 1-year treatment regimen. Patients with inactive CNV were then followed for signs of CNV reactivation.

RESULTS

After 1 year of treatment, 66 (42%) of the 157 patients still had signs of persistent active CNV. Of the remaining 91 (58%) patients, 61 (67%) needed retreatment for active CNV within the first year after discontinuation of treatment (mean 4.28 ± 0.29 months). CNV was reactivated in 50 (80%) of the 61 patients within 6 months after their final treatment for CNV.

CONCLUSION

Based on quiescent disease, anti-VEGF therapy was discontinued in 58% of the patients after they received bevacizu-mab injections every 4, 6, or 8 weeks for 1 year; 67% showed reactivated CNV within a year after discontinuation. The high reactivation rate of CNV shown in this study should help clinicians to develop rational discontinuation protocols.

TRIAL REGISTRATION

This study is registered as NTR1174 at http://www.trialregister.nl.

Four-year outcome of aflibercept administration using a treat-and-extend regimen in eyes with recurrent neovascular age-related macular degeneration

PURPOSE

To investigate the 4-year outcome of aflibercept treatment using a treat-and-extend (TAE) regimen for recurrent neovascular age-related macular degeneration (AMD).

STUDY DESIGN

Retrospective observational study.

METHODS

Data of eyes with recurrent AMD previously treated with anti-vascular endothelial growth factor agents or photodynamic therapy and had started aflibercept treatment using a TAE regimen for the first time were collected. Best-corrected visual acuity (BCVA), intervals of treatments, the presence of exudation, central foveal thickness (CFT), and central choroidal thickness (CCT) were analyzed.

RESULTS

Of 47 consecutive eyes, 30 of the 47 eyes completed a 4-year follow-up. The mean BCVA (logMAR) was sustained over the 4 years (0.37 at baseline, 0.36 at 1 year, 0.36 at 2 years, 0.41 at 3 years, and 0.43 at 4 years, P = 0.21). Of the 30 eyes that completed the follow-up, BCVA of two eyes deteriorated by 0.3 logMAR or more at 4 years. At 4 years, 67% of eyes had extended treatment intervals to > 8 weeks, and 47% of eyes had extended intervals to > 12 weeks. Exudative changes in the macula, seen in all eyes at baseline, were only seen in 50% of the eyes at 4 years. The mean CFT and CCT decreased significantly at 4 years from 332 μm to 248 μm and from 218 μm to 183 μm, respectively.

CONCLUSION

In clinical settings, aflibercept treatment using a TAE regimen may successfully maintain visual acuity for up to 4 years even in recurrent cases of AMD.

Long-Term Outcomes of Switching from Fixed-Dose to As-Needed Regimen for Treating Submacular Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy

Background: The aim of this study was to evaluate outcomes in patients with submacular hemorrhage secondary to polypoidal choroidal vasculopathy (PCV) after switching treatment from a fixed-dose to an as-needed regimen. Methods: This retrospective study included 19 patients with submacular hemorrhage secondary to PCV who were treated with fixed-dose intravitreal aflibercept during the first 56 weeks. After 56 weeks, the treatment regimen was switched to an as-needed regimen. The incidence and timing of lesion reactivation during the as-needed phase were evaluated. The best-corrected visual acuity (BCVA) at baseline (beginning of the regimen) and the final follow-up were compared. Multivariate analysis was performed to determine the factors associated with lesion reactivation. Results: During the mean follow-up period of 27 ± 7.3 months, lesion reactivation was noted in 10 patients (52.6%; mean time period: 12.2 ± 9.1 months) in the as-needed phase. Reactivations were treated with anti-vascular endothelial growth factor (VEGF) injections (mean, 4.1 ± 2.6). The mean logarithm of the minimum angle of resolution (logMAR) BCVA was 0.26 ± 0.34 at baseline and 0.31 ± 0.38 at final follow-up (p = 0.212). Deterioration of ≥0.2 logMAR BCVA was noted in two patients (10.5%). In multivariate analysis, large lesion size was closely associated with a high risk of lesion reactivation (p = 0.009). Conclusion: Visual acuity was relatively stable after switching from a fixed-dose to an as-needed regimen, with no definite visual deterioration in the majority of patients. We conclude that patients with large lesions should be carefully monitored when switching to an as-needed regimen.

Three-year outcome of aflibercept treatment for Japanese patients with neovascular age-related macular degeneration

Background

To evaluate the three-year outcome after intravitreal aflibercept injection (IAI) for neovascular age-related macular degeneration (nAMD).

Methods

Forty-nine treatment-naïve nAMD patients (50 eyes) were enrolled in this prospective study. The eyes received IAI at two-month intervals in the first year. The treatment regimen was changed to IAI based on a treat-and-extend approach in the second and third years.

Results

Twenty-nine eyes of 28 patients were successfully followed up over 36 months. The nAMD subtypes included 15 eyes with typical AMD and 14 eyes with polypoidal choroidal vasculopathy. The number of IAIs performed over the 3 years was 17.2 ± 3.1 (mean ± standard deviation). The mean logMAR, which was 0.42 at baseline, improved to 0.19 (P = 0.001) at 12 months, and 0.26 (P = 0.049) at 36 months. The central retinal thickness (CRT) was 329 ± 120 μm at baseline, 151 ± 38 μm (P < 0.001) at 12 months, and 143 ± 61 μm (P < 0.001) at 36 months. The mean subfoveal choroidal thickness (SFCT) was 288 ± 97 μm at baseline, 243 ± 82 μm (P < 0.001) at 12 months, and 208 ± 63 μm (P < 0.01) at 36 months. The changes in logMAR, CRT, and SFCT over the study period did not differ between typical AMD and PCV.

Conclusion

Long-term aflibercept injection can achieve visual improvement and reduce the thickness of the retina and choroid in nAMD. Morphological improvement of these tissues may not be sufficient to sustain earlier visual improvement over the long-term.

A Trinity regimen with aflibercept for treatment-naïve neovascular age-related macular degeneration: 2-year outcomes

PURPOSE

To evaluate the advantages of the Trinity regimen for treatment-naïve neovascular age-related macular degeneration (nAMD).

METHODS

Thirty-one treatment-naïve nAMD eyes were treated using the Trinity regimen with an intravitreal aflibercept injection (IVA) and evaluated after 24 months. Three treatment methods, pro re nata (PRN), treat and extend (TAE), and fixed regimen were changed depending on recurrence frequency. After the initial treatment, PRN or TAE (started for 4 or 8 weeks) was selected as per the recurrence interval. Subsequently, the recurrence interval became constant, transitioning from a TAE to fixed regimen. When the recurrence frequency became irregular, the treatment regimen was changed to TAE.

RESULTS

After the initial treatment, 15 eyes (48.4%) were allocated to the PRN group, 12 (38.7%) to the TAE 8-week group, and 4 (12.9%) to the TAE 4-week group. Mean logMAR significantly improved in all cases, 0.53 ± 0.40 at baseline to 0.36 ± 0.34 at 24 months (p < 0.01), in the PRN group (0.63 ± 0.46 to 0.42 ± 0.43, p < 0.01), and the TAE 8-week group (0.44 ± 0.29 to 0.27 ± 0.19, p < 0.05). LogMAR in the TAE 4-week group was maintained. The mean number of injections for all and in the PRN, TAE 8-week, and TAE 4-week groups were 9.7, 5.3, 13.1, and 15.8, respectively, with the PRN group being significantly less (p < 0.01).

CONCLUSION

The Trinity regimen delivered the benefits of the PRN, TAE, and FIXED regimens while minimizing injections during the early treatment phase without visual loss.

TRIAL REGISTRATION

This trial was registered with the University Hospital Medical Information Network (UMIN ID: 000038335).

Predictors of neovascular activity during neovascular age-related macular degeneration treatment based on optical coherence tomography angiography

The advent of anti-vascular endothelial growth factor (VEGF) therapies has remarkably improved the functional outcomes of neovascular age-related macular degeneration (nAMD) patients. However, there are guidelines on how to start treatment, the guidelines for discontinuing treatment are not yet clear. In this respect, the treat-extend-stop (TES) protocol have showed us the possibility of discontinuing treatment. In this study, we tried to investigate optical coherence tomography angiography (OCTA) biomarkers related to recurrence of neovascular activity in eyes with nAMD undergoing treatment using TES protocol. A total of 134 eyes with nAMD were divided into two groups (stop, non-stop) depending on whether they met criteria for stopping anti-VEGF treatment. Quantitative and qualitative OCTA parameters including the morphologic pattern of choroidal neovascularization (CNV) were compared between groups. Of these, 44 eyes (32.8%) were in the stop group and 90 eyes (67.2%) were in the non-stop group. In multivariate regression analysis, closed-circuit pattern of CNV and the presence of peripheral loop were associated with the non-stop group (all p < 0.001). Our results imply that the morphologic appearance of CNV on OCTA after anti-VEGF treatment may be a useful biomarker to predict weaning from treatment.

Risk-based Algorithm-guided Treatment Protocol for the Management of Neovascular Age-related Macular Degeneration

Objectives

To assess outcomes of a risk-based algorithm-guided treatment protocol for neovascular age-related macular degeneration.

Materials and Methods

Two hundred and ten eyes of 184 patients managed with anti-vascular endothelial growth factor (anti-VEGF) agents according to a protocol consisting of one of three initial regimens depending on risk with at least 2 years of follow-up were retrospectively evaluated. The “short-term monthly injections” protocol was used for low-risk patients with low-risk lesions and good fellow-eye vision. Patients with low-risk lesions but without good fellow-eye vision, or those with good fellow-eye vision and high-risk lesions were managed according to the “short-term treat-and-extend (TREX)” protocol. The “extended TREX” protocol was for patients with high-risk lesions and low fellow-eye visual acuity.

Results

The initial treatment plan consisted of short-term monthly injections in 62 eyes (30%), the short-term TREX regimen in 120 eyes (57%), and the extended TREX regimen in 28 eyes (13%). Overall, 63% of cases met the criteria for cessation of treatment. Approximately 58% of these cases had recurrence, at a mean of 13 months. The mean change in VA from baseline was +9.0 letters at 12 months and +8.0 letters at 24 months. VA improved during a mean follow-up of 46.8±22 months, with a mean of 3.4±1.6 anti-VEGF injections per year.

Conclusion

The risk-based algorithm-guided treatment protocol yielded visual outcomes similar to those of the common alternative treatment and monitoring regimens, with a dramatically reduced number of injections, as required by the individual lesion and vision in the fellow eye.

Quarterly Anti-Vascular Endothelial Growth Factor Dosing for Neovascular Age-Related Macular Degeneration: Real-World Clinical Outcomes

BACKGROUND AND OBJECTIVE

Characterize eyes managed with quarterly intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

Treatment-naïve nAMD eyes managed predominately using a treat-and-extend approach that received five or more consecutive quarterly injections from 2005 to 2017.

RESULTS

One hundred fifty eyes were retrospectively identified. During quarterly dosing, a mean of 9.8 injections were given over a mean of 29 months. Ninety-one eyes (61%) had no exudative disease recurrence during quarterly dosing. Thirty-three eyes (22%) experienced exudative activity recurrence, with a mean cumulative yearly recurrence rate of 12% and a mean 6-letter loss of visual acuity (VA). Twenty-four eyes (16%) stopped quarterly treatments; nine (38%) of these subsequently experienced exudative activity recurrence with a mean 8-letter VA loss.

CONCLUSION

In this real-world analysis of nAMD managed with quarterly dosing over a mean of more than 2 years' follow-up, 22% experienced disease recurrence during quarterly dosing, and 38% of eyes that stopped quarterly dosing experienced subsequent exudative disease recurrence. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e250-e256.].

Consistent Long-Term Therapy of Neovascular Age-Related Macular Degeneration Managed by 50 or More Anti-VEGF Injections Using a Treat-Extend-Stop Protocol

PURPOSE

To examine the clinical results for patients with neovascular age-related macular degeneration (nAMD) who were managed with a treat-extend-stop (TES) protocol and received 50 or more injections of anti-vascular endothelial growth factor (VEGF) agents.

DESIGN

Retrospective case study.

PARTICIPANTS

Data for patients from a private retina practice meeting the following criteria were included: diagnosis of nAMD and having received 50 or more intravitreal injections of anti-VEGF agents.

METHODS

The patients' baseline visual acuity (VA; obtained using Snellen charts and converted to Early Treatment Diabetic Retinopathy Study [ETDRS] letters), age, length of follow-up, anti-VEGF agents used, and interval between treatments were obtained. These data were examined through the 51st injection and at the last follow-up examination. Patients were excluded if they lost significant vision because of a diagnosis unrelated to AMD during therapy.

MAIN OUTCOME MEASURES

Visual acuity and complications.

RESULTS

Seventy-one eyes of 67 patients were identified who met inclusion criteria. The mean age of patients was 83.0 years. Women made up 58.2% of the study population, whereas men constituted 41.8%. The mean initial VA was 55.6 ETDRS letters. The mean duration of follow-up at the 51st visit for an injection was 6.5 years, and the mean duration of follow-up at the last visit was 8 years. The mean number of injections at final follow-up was 63.7. The mean interval between treatments at the 51st follow-up was 5.4 weeks, and the mean follow-up at the last examination was 6.4 weeks. Mean VA at the 51st injection was 65.3 letters, and the mean change from baseline was 9.7 letters (P < 0.001, Student paired t test). The mean vision gained at last follow-up was 8.7 letters from baseline (P < 0.001), or 64.3 letters.

CONCLUSIONS

In this study, patients gained a mean of 2 ETDRS lines after 50 injections. This study had a mean follow-up of 8 years, and 35.2% of eyes had a 3-line or more gain in VA at the last follow-up examination. Patients who require consistent long-term anti-VEGF therapy, managed with a TES protocol, are likely able to maintain or improve their vision.