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Awh KC, Mahmoudzadeh R, Salabati M, Mansour HA, Bechay J, Magagna J, Regillo CD, Ho AC, Garg SJ, Hsu J. Outcomes of Intentionally Suspending Treatment in Eyes With Advanced Neovascular Age-Related Macular Degeneration. Am J Ophthalmol 2023; 256:20-26. [PMID: 37517527 DOI: 10.1016/j.ajo.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/02/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To determine the outcomes of intentionally suspending anti-vascular endothelial growth factor (anti-VEGF) injections in eyes with advanced neovascular age-related macular degeneration (nAMD). DESIGN Retrospective cohort study. METHODS The study sample comprised 93 patients with nAMD and best available Snellen visual acuity (VA) ≤20/400 in which anti-VEGF treatment was suspended by the treating physician. VA and optical coherence tomography (OCT) characteristics were evaluated to determine visual and anatomical outcomes up to 24 months after treatment suspension. RESULTS A total of 93 eyes from 93 patients who had received a mean of 16 anti-VEGF injections over a mean of 962 (SD 562) days were included. Comparing the treatment suspension visit to 24 months later, no significant change in mean central foveal thickness (163 [SD 118, range 19-704] μm vs 164 [SD 217, range 19-1468], P = .97), greatest lesion diameter (2547 [SD 1294, range 134-5707] μm vs 2442 [SD 1158, range 421-5305] μm, P = .43), greatest lesion thickness (194 [SD 136, range 0-618] μm vs 205 [SD 131, range 0-573] μm, P = .40), or VA (1.87 [SD 0.37], 20/1482, vs 1.94 [SD 0.28], 20/1741, P = .16) was found. In total, 7 eyes (7.5%) restarted treatment following a mean of 977 (SD 450) days after treatment suspension. CONCLUSIONS Suspension of anti-VEGF injections in eyes with advanced nAMD and VA ≤20/400 may be reasonable in cases where the treating physician deems additional treatment is unlikely to provide benefit. Although the visual and anatomical findings remained stable after treatment suspension in most, a small number restarted anti-VEGF therapy, suggesting that eyes should still be monitored for disease progression.
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Affiliation(s)
- Katherine C Awh
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania
| | - Raziyeh Mahmoudzadeh
- The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Mirataollah Salabati
- The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Hana A Mansour
- The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Joseph Bechay
- Department of Ophthalmology, The George Washington University School of Medicine and Health Sciences (J.B.), Washington, District of Columbia, USA
| | - John Magagna
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania
| | - Carl D Regillo
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania; The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Allen C Ho
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania; The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Sunir J Garg
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania; The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania
| | - Jason Hsu
- From the Sidney Kimmel Medical College, Thomas Jefferson University (K.C.A., J.M., J.H.), Philadelphia, Pennsylvania; The Retina Service of Wills Eye Hospital, Wills Eye Physicians-Mid Atlantic Retina (R.M., M.S., H.A.M., C.D.R., A.C.H., S.J.G., J.H.), Philadelphia, Pennsylvania.
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Cho SC, Park KH, Park SJ, Joo K, Woo SJ. Discontinuation of treatment and retreatment of neovascular age-related macular degeneration in the real-world: Bundang AMD cohort study report 5. Front Med (Lausanne) 2023; 10:1204026. [PMID: 37492247 PMCID: PMC10364640 DOI: 10.3389/fmed.2023.1204026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/05/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction This single-center retrospective cohort study investigated the incidence rate and risk factors for the discontinuation of anti-vascular endothelial growth factor (VEGF) injections and retreatment in typical neovascular age-related macular degeneration (tnAMD) and polypoidal choroidal vasculopathy (PCV) in the real-world setting. Methods A total of 488 eyes with either tnAMD (n = 334) or PCV (n = 154) followed up for ≥3 years were analyzed. The discontinuation of treatment was defined as the cessation of anti-VEGF injections for 1 year or longer. Eyes with discontinuing treatment were subdivided into group A: eyes with stable responses (complete or incomplete resolution) and group B: those with no expectation of visual gain or poor response. The proportion and median time of discontinuation of treatment or retreatment were analyzed. The visual prognosis and the associated risk factors for the discontinuation of treatment or retreatment were also investigated. Results The mean follow-up period was 8.1 ± 3.4 years. Of 488 eyes, discontinuation of the treatment occurred in 322 eyes (66.0%), and the median time to discontinuation was 1.5 years after the initial injection. Of 297 eyes with discontinuation of treatment excluding 25 eyes with vitrectomy or photodynamic therapy after the discontinuation of the injection, 277 eyes belonged to group A and the remaining 20 eyes belonged to group B. Of the 277 eyes discontinuing treatment with a stable response, 185 eyes (66.8%) were given retreatment. The median time to retreatment was 3.3 years after the discontinuation of the injections. PCV and the lower annual number of injections were the significant factors associated with discontinuation. Younger age, male gender, and PCV were the significant factors for the retreatment. Conclusion Our long-term real-world study showed that two-thirds of eyes with neovascular age-related macular degeneration (nAMD) had the discontinuation of the anti-VEGF injections and two-thirds of eyes discontinuing treatment with stable responses experienced retreatment. Long-term follow-up and regular monitoring are needed to detect the recurrence.
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Affiliation(s)
- Soo Chang Cho
- Department of Ophthalmology, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Kyu Hyung Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Jun Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kwangsic Joo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Dhingra N, Upasani D, Ghanchi FD. Patterns of treatment discontinuation in patients receiving anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Indian J Ophthalmol 2022; 70:2065-2070. [PMID: 35647983 PMCID: PMC9359266 DOI: 10.4103/ijo.ijo_3066_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: To report the reasons for treatment discontinuation within 5 years in patients receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD). Methods: A retrospective case-notes review of patients commenced on anti-VEGF for nAMD who failed to complete 5 years of follow-up was undertaken. The reasons for treatment discontinuation, baseline age, baseline visual acuity (VA) in Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and the VA change at the last follow-up were recorded. Age-specific all-cause mortality was calculated for deceased patients. Results: Of the 1177 patients, 551 patients (46.8%) failed to complete the 5-year follow-up. The reasons for treatment discontinuation were death (251), early discharge due to stable disease (110), further treatment deemed futile (100), failure to attend (15), ill health (14), patient choice (7), and transfer of care (1). In 53 patients, no reason was documented. The mean baseline age of those who completed the 5-year follow-up (77.4 ± 7.8 years, 95% confidence interval (CI): 76.8–77.9) was significantly lower than those who discontinued the treatment for any reason (82 ± 7.7 years, 95% CI: 81.4–82.6) (P < 0.0001). Survival analysis showed that baseline VA was not a factor in treatment discontinuation; however, visual stability (±5 letters from baseline) was associated with treatment continuation. The age-specific all-cause mortality in deceased patients was lower than that in the general population. Conclusion: At 5 years, only 53% of patients remained in active care, and death was the most common reason for treatment discontinuation. Lower baseline age and VA stability during therapy were associated with treatment continuation.
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Affiliation(s)
- Narendra Dhingra
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, WF1 2DG, UK
| | - Deepa Upasani
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, WF1 2DG, UK
| | - Faruque D Ghanchi
- Bradford Teaching Hospitals, NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, UK
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Zaytseva OV, Neroeva NV, Okhotsimskaya TD, Bobykin EV. [Current view on the issue of insufficient effectiveness of anti-VEGF therapy for age-related macular degeneration]. Vestn Oftalmol 2022; 138:90-99. [PMID: 35234427 DOI: 10.17116/oftalma202213801190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Due to the significant medical and social importance of neovascular (wet) age-related macular degeneration (wAMD), increasing the effectiveness of anti-VEGF therapy used to treat this disease is one of the high-priority problems in modern retinology. This article focuses on pathobiological aspects and clinical manifestations of incomplete responses to anti-VEGF therapy of wAMD, considers the proposed ways to improve the terminology and classification of responses to therapy, as well as the assessment of its correctness and effectiveness of the treatment. It also discusses the available ways to optimize anti-VEGF therapy and define the criteria of its termination in cases when the treatment proves to be futile.
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Affiliation(s)
- O V Zaytseva
- Helmholtz National Medical Research Center of Eye Diseases, Moscow, Russia.,A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - N V Neroeva
- Helmholtz National Medical Research Center of Eye Diseases, Moscow, Russia
| | - T D Okhotsimskaya
- Helmholtz National Medical Research Center of Eye Diseases, Moscow, Russia
| | - E V Bobykin
- Ural State Medical University, Yekaterinburg, Russia
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Hypothetical Switch of Anti-Vascular Endothelial Growth Factor in Neovascular Age-Related Macular Degeneration: An ARIES Post Hoc Analysis. Ophthalmol Ther 2022; 11:613-627. [PMID: 35066801 PMCID: PMC8784022 DOI: 10.1007/s40123-021-00448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Switching to an alternative anti-vascular endothelial growth factor (anti-VEGF) agent has been suggested for patients with neovascular age-related macular degeneration (nAMD) who have a suboptimal response to initial therapy. However, post hoc analyses of some studies have shown that continuation of initial anti-VEGF therapy is, in many cases, associated with stable visual outcomes or gradual gains. Methods This ARIES (ClinicalTrials.gov Identifier: NCT02581891) post hoc analysis describes outcomes in patients with treatment-naïve nAMD receiving treat-and-extend intravitreal aflibercept (IVT-AFL) for 104 weeks, who were identified as meeting criteria for an early hypothetical switch. Patients were categorized retrospectively according to six criteria (presence of central intraretinal and/or subretinal fluid at week 8 or 24, with/without a next planned treatment interval ≤ 8 weeks, and with/without gains in best-corrected visual acuity [BCVA] ≤ 5 letters [with absolute BCVA < 70 letters]). Results Hypothetical switch criteria were largely met due to the presence of central subretinal fluid rather than intraretinal fluid. Depending on the criterion, 8–46% of patients were considered to be hypothetical switchers. BCVA outcomes were not worse in the hypothetical switchers, irrespective of criteria. Using criteria of intraretinal/subretinal fluid at week 24 and a next planned treatment interval ≤ 8 weeks, mean changes in BCVA (letters) from baseline in hypothetical switchers and non-switchers were: + 6.1 (95% confidence interval [CI] 3.4, 8.8) and + 6.6 (95% CI 4.7, 8.6), respectively, at week 24; + 8.2 (95% CI 5.0, 11.3) and + 7.5 (95% CI 5.3, 9.7), respectively, at week 52; and + 5.7 (95% CI 1.3, 10.1) and + 3.4 (95% CI 0.1, 6.7), respectively, at week 104. Conclusions In newly diagnosed nAMD, there appears little rationale for early switching from IVT-AFL since, with continuous proactive treatment, comparable visual gains can be achieved by patients meeting hypothetical switch criteria compared with those who initially respond well on a treat-and-extend regimen. However, further prospective studies are needed. Trial registration ClinicalTrials.gov Identifier: NCT02581891. Video Summary Video summary of the ARIES Post Hoc Analysis “Hypothetical Switch of Anti-Vascular Endothelial Growth Factor in Neovascular Age-Related Macular Degeneration” (MP4 54283 KB)
Supplementary Information The online version contains supplementary material available at 10.1007/s40123-021-00448-w.
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Chaikitmongkol V, Sagong M, Lai TYY, Tan GSW, Ngah NF, Ohji M, Mitchell P, Yang CH, Ruamviboonsuk P, Wong I, Sakamoto T, Rajendran A, Chen Y, Lam DSC, Lai CC, Wong TY, Cheung CMG, Chang A, Koh A. Treat-and-Extend Regimens for the Management of Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy: Consensus and Recommendations From the Asia-Pacific Vitreo-retina Society. Asia Pac J Ophthalmol (Phila) 2021; 10:507-518. [PMID: 34839342 PMCID: PMC8673847 DOI: 10.1097/apo.0000000000000445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/20/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Review and provide consensus recommendations on use of treat-and-extend (T&E) regimens for neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) management with relevance for clinicians in the Asia-Pacific region. METHODS A systematic search of MEDLINE, EMBASE, and Cochrane databases, and abstract databases of the Asia-Pacific Vitreo-retina Society, European Society of Retina Specialists, American Academy of Ophthalmology, and Controversies in Ophthalmology: Asia-Australia congresses, was conducted to assess evidence for T&E regimens in nAMD. Only studies with ≥100 study eyes were included. An expert panel reviewed the results and key factors potentially influencing the use of T&E regimens in nAMD and PCV, and subsequently formed consensus recommendations for their application in the Asia-Pacific region. RESULTS Twenty-seven studies were included. Studies demonstrated that T&E regimens with aflibercept, ranibizumab, or bevacizumab in nAMD, and with aflibercept in PCV, were efficacious and safe. The recommendation for T&E is, after ≥3 consecutive monthly loading doses, treatment intervals can be extended by 2 to 4 weeks up to 12 to 16 weeks. When disease activity recurs, the recommendation is to reinject and shorten intervals by 2 to 4 weeks until fluid resolution, after which treatment intervals can again be extended. Intraretinal fluid should be treated until resolved; however, persistent minimal subretinal fluid after consecutive treatments may be tolerated with treatment intervals maintained or extended if the clinical condition is stable. CONCLUSIONS T&E regimens are efficacious and safe for nAMD and PCV, can reduce the number of visits, and minimize the overall burden for clinicians and patients.
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Affiliation(s)
- Voraporn Chaikitmongkol
- Retina Division, Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, South Korea
| | - Timothy Y Y Lai
- Hong Kong Eye Hospital, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong
- 2010 Retina & Macula Centre, Kowloon, Hong Kong
| | - Gavin S W Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | | | - Masahito Ohji
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Paul Mitchell
- University of Sydney (Westmead Institute for Medical Research), Sydney, NSW, Australia
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Ian Wong
- Department of Ophthalmology, The University of Hong Kong, Hong Kong, China
| | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University, Kagoshima, Japan
| | - Anand Rajendran
- Retina-Vitreous Service, Aravind Eye Care System, Chennai, India
| | - Youxin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China
| | - Dennis S C Lam
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong, China; C-MER International Eye Research Center of The Chinese University of Hong Kong (Shenzhen), Shenzhen, China
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Andrew Chang
- Sydney Retina Clinic, Sydney Eye Hospital, University of Sydney, Sydney, NSW, Australia
| | - Adrian Koh
- Eye & Retina Surgeons, Camden Medical Centre, Singapore
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Mitchell P, Rodríguez FJ, Joussen AM, Koh A, Eter N, Wong DT, Korobelnik JF, Okada AA. MANAGEMENT OF RETINAL PIGMENT EPITHELIUM TEAR DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY. Retina 2021; 41:671-678. [PMID: 33346626 PMCID: PMC7989608 DOI: 10.1097/iae.0000000000003083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This article aims to review current evidence on the development, diagnosis, and management of retinal pigment epithelium (RPE) tear during anti-vascular endothelial growth factor (VEGF) therapy. METHODS Literature searches were performed using MEDLINE/PubMed databases (cut-off date: August 2019). RESULTS Three key recommendations were made based on existing literature and clinical experience: 1) Multimodal imaging with color fundus photography, optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence imaging, optical coherence tomography-angiography, and/or fluorescein angiography are recommended to diagnose RPE tear and assess risk factors. Retinal pigment epithelium tears can be graded by size and foveal involvement. 2) Patients at high risk of developing RPE tear should be monitored after each anti-VEGF injection. If risk factors worsen, it is not yet definitively known whether anti-VEGF administration should be more frequent, or alternatively stopped in such patients. Prospective research into high-risk characteristics is needed. 3) After RPE tear develops, anti-VEGF treatment should be continued in patients with active disease (as indicated by presence of intraretinal or subretinal fluid), although cessation of therapy should be considered in eyes with multilobular tears. CONCLUSION Although evidence to support the assumption that anti-VEGF treatment contributes to development of RPE tear is not definitive, some data suggest this link.
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Affiliation(s)
- Paul Mitchell
- Department of Ophthalmology, Centre for Vision Research, Westmead Institute for Medical Research, the University of Sydney, Sydney, Australia
| | - Francisco J. Rodríguez
- Fundación Oftalmologica Nacional, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | | | - Adrian Koh
- Eye and Retina Surgeons, Camden Medical Centre, Singapore
| | - Nicole Eter
- Department of Ophthalmology, University of Münster Medical Center, Münster, Germany
| | - David T. Wong
- Unity Health Toronto, St. Michael's Hospital, University of Toronto, Canada
| | - Jean-François Korobelnik
- Service d'ophtalmologie, CHU Bordeaux, Bordeaux, France
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team LEHA, UMR 1219, Bordeaux, France; and
| | - Annabelle A. Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
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Futility as the Basis for Suspending Treatment of Neovascular Age-Related Macular Degeneration: An Important but not Easily Defined Concept. Retina 2020; 40:1007-1009. [DOI: 10.1097/iae.0000000000002830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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