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Carta V, Lixi F, Tatti F, Peiretti E. Effect of Intravitreal Brolucizumab in the Treatment of Polypoidal Choroidal Vasculopathy With Foveal Lipid Exudation. Cureus 2023; 15:e47942. [PMID: 38034243 PMCID: PMC10685085 DOI: 10.7759/cureus.47942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
A 71-year-old woman with a history of blurred vision in her right eye for nearly two months came to our attention. A complete ophthalmological evaluation, including best-corrected visual acuity measurement, fundus examination, spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography, was performed. Multimodal imaging showed the presence of a polypoidal choroidal vasculopathy (PCV) lesion surrounded by diffuse hard exudates in the macular area. Our patient received three monthly intravitreal injections of brolucizumab during the loading phase, followed by an intravitreal injection every eight weeks for a total of 48 weeks of follow-up. The therapy appeared to be effective for improving both visual and anatomical outcomes revealing an important regression of the PCV and an almost complete reabsorption of lipid exudates. Intravitreal brolucizumab could be considered an effective treatment in the management of lipid exudation in PCV patients.
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Affiliation(s)
- Valentina Carta
- Department of Surgical Sciences, Eye Clinic, University of Cagliari, Cagliari, ITA
| | - Filippo Lixi
- Department of Surgical Sciences, Eye Clinic, University of Cagliari, Cagliari, ITA
| | - Filippo Tatti
- Department of Surgical Sciences, Eye Clinic, University of Cagliari, Cagliari, ITA
| | - Enrico Peiretti
- Department of Surgical Sciences, Eye Clinic, University of Cagliari, Cagliari, ITA
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Venkatesh R, Mangla R, Sharief S, Arora S, Reddy NG, Yadav NK, Chhablani J. Onion ring sign on spectral domain optical coherence tomography in diabetic macular edema: Its evolution and outcomes. Eur J Ophthalmol 2023; 33:2006-2013. [PMID: 36703256 DOI: 10.1177/11206721231154187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To report evolution and outcomes of hyperreflective crystalline deposit (HCD) on optical coherence tomography (OCT) in diabetic maculopathy (DM). METHODS Patients with DM showing HCD on OCT for the first time between June 2017 and May 2021 were included in the study. Demographic, ophthalmic and OCT features were documented and analysed. Factors leading to the development of HCD and its effect on the functional outcome were analysed and described in this study. RESULTS Sixty cases of HCD were identified in 45 (males -33; females - 12) patients for the first-time during the defined study period. Mean age of the eligible patients was 61.53 ± 8.19 years. Average duration of diabetes was 13.82 ± 7.38 years. Mean visual acuity of these patients was 0.902 ± 0.438 logMAR units (Snellen equivalent = 20/160). Patients with HCD showed subretinal hard exudates, were on anti-cholesterol medications (n = 36, 80%) and showed reduced visual acuity (20/160) if the HCD involved the fovea. The median time taken for the development of HCD was 28 months. Mean follow-up duration of the study was 26.19 ± 27.98 months. Persistence of HCD in all cases (n = 42, 100%) was noted at the last follow-up visit. CONCLUSION Horizontal, single or multi-layered HCDs on OCT in DM represent intraretinal or subretinal cholesterol crystal precipitates evolving from the hard exudates identical to the "onion ring sign" seen in neovascular AMD. HCDs or CCs depict deranged lipid metabolism, chronic vascular leakage and can lead to substantial visual impairment if the fovea gets involved.
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Affiliation(s)
- Ramesh Venkatesh
- Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, India
| | - Rubble Mangla
- Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, India
| | - Shama Sharief
- Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, India
| | - Sahil Arora
- Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, India
| | | | - Naresh Kumar Yadav
- Department of Retina and Vitreous, Narayana Nethralaya, Bengaluru, India
| | - Jay Chhablani
- Medical Retina and Vitreoretinal Surgery, University of Pittsburgh School of Medicine, Pittsburg, PA, USA
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Sánchez‐Monroy J, Nguyen V, Puzo M, Calvo P, Arruabarrena C, Monaco P, Chilov M, Keegan D, Barthelmes D, Gillies M. Subretinal fluid may protect against macular atrophy in neovascular age‐related macular degeneration: 5 years of follow‐up from Fight Retinal Blindness registry. Acta Ophthalmol 2022; 101:457-464. [PMID: 36536538 DOI: 10.1111/aos.15309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of the study was to assess the association of macular atrophy (MA) according to the activity of macular neovascularization (MNV) (inactive, only subretinal fluid [SRFL], or active, i.e. including intraretinal fluid [IRFL]) using optical coherence tomography (OCT) in patients with neovascular age-related macular degeneration (nAMD). METHODS Multicentric observational study. Treatment-naïve nAMD eyes without subfoveal MA or subretinal fibrosis (SF) at baseline were included since 1st January 2010 and 30th September 2016 to allow up to 5 years of treatment follow-up. Eyes were grouped based on their predominant activity status as: (1) mostly inactive, (2) mostly active non-SRFL only [IRFL] or (3) mostly active-SRFL only [onlySRFL]. Kaplan-Meier survival curves estimated the time to development of MA or SF. Cox proportional hazards models evaluated predictors of developing subfoveal MA or SF. The main outcome measure was the risk of developing MA according to predominant MNV activity. RESULTS A total of 973 eyes were eligible for analysis. OnlySRFL eyes had lower risk of developing subfoveal MA (HR [95% CI]: 0.56 [0.36, 0.88]; p = 0.024) and extrafoveal MA (HR [95% CI]: 0.41 [0.27, 0.61]; p < 0.001) than IRFL eyes. IRFL eyes had lower visual acuity (VA) (54.5 letters) and the highest proportion of eyes with vision ≤35 letters (25%) at 5 years while onlySRFL eyes had comparable 5-year VA (63.7 letters) to inactive eyes (63.7 letters). CONCLUSION Subretinal fluid appears to protect against MA. Distinguishing the compartment of retinal fluid and understanding its relationship with MA and SF can guide the management of nAMD.
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Affiliation(s)
| | - Vuong Nguyen
- Discipline of Ophthalmology Save Sight Institute, the University of Sydney, Sydney Medical School Sydney Australia
| | - Martin Puzo
- Department of Ophthalmology Miguel Servet University Hospital Zaragoza Spain
| | - Pilar Calvo
- Department of Ophthalmology Miguel Servet University Hospital Zaragoza Spain
| | | | - Pietro Monaco
- Department of Ophthalmology San Martino Hospital Belluno Italy
| | - Michael Chilov
- Department of Ophthalmology Concord Repatriation Hospital Sydney New South Wales Australia
| | | | - Daniel Barthelmes
- Discipline of Ophthalmology Save Sight Institute, the University of Sydney, Sydney Medical School Sydney Australia
- Department of Ophthalmology Zurich, University Hospital Zurich University of Zurich Zurich Switzerland
| | - Mark Gillies
- Discipline of Ophthalmology Save Sight Institute, the University of Sydney, Sydney Medical School Sydney Australia
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Toto L, Ruggeri ML, D'Aloisio R, De Nicola C, Trivigno C, Cerino L, Di Marzio G, Di Nicola M, Porreca A, Mastropasqua R. Brolucizumab Intravitreal Injection in Macular Neovascularization Type 1: VA, SD-OCT, and OCTA Parameter Changes during a 16-Week Follow-Up. Ophthalmic Res 2022; 66:218-227. [PMID: 36162382 DOI: 10.1159/000526851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/31/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to assess early anatomical and functional changes after brolucizumab intravitreal injection (BIVI) in patients with age-related macular degeneration (AMD) and macular neovascularization type 1 (MNV1). METHODS A total of 24 eyes of 24 patients suffering from naïve AMD with MNV1 candidates to BIVI as per label with q12/q8 dosing regimen after the loading dose were enrolled in this prospective study. Main outcome measures during a 16-week follow-up period included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal subretinal fluid (SSRF) thickness (SSRFT), subfoveal sub-retinal pigment epithelium (RPE) fluid thickness (SSRPEFT), subfoveal choroidal thickness (SFCT), and pigment epithelial detachment (PED) maximum height (PED-MH). In addition, MNV1 flow area; percentages of eyes with intraretinal fluid (IRF), subretinal fluid, and sub-RPE fluid at different time points; and percentages of eyes candidates to a q8 or q12 injection interval after disease activity assessment at week 16 were evaluated. RESULTS BCVA improved significantly from baseline (T0) to week 12 (T3) (p = 0.028). CMT showed a significant reduction from 456 ± 123 µm at T0 to 265 ± 85 µm at T3 (p < 0.001). SSRFT and SSRPEFT reduced significantly as well (p < 0.001 and p = 0.049, respectively). PED-MH and SFCT reduced significantly at the different time points (p = 0.020; p = 0.006, respectively). IRF presence changed significantly from 41.7% of eyes at T0 to 20.8% at T3 (p = 0.045). SSRF reduced significantly during follow-up, being present in 62.5% of eyes at T0 and 4.2% of eyes at T3 (p < 0.001). Subfoveal sub-RPE fluid decreased significantly during time, being present in 20.8% of eyes at T0 and 0% at T3 (p = 0.013). Most of the eyes (18 eyes, 75%) at week 16 after disease activity assessment were shifted in the q12 interval, and only a minority of eyes shifted in a q8 interval (6 eyes, 25%). CONCLUSION Brolucizumab is efficient in AMD patients with MNV1 by reducing all retinal fluids during the loading phase and shows reduction of macular thickness, choroidal thickness, and PED height. Most eyes at disease activity assessment (75%) fall into 12-week interval and the minority (25%) into the 8-week interval.
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Affiliation(s)
- Lisa Toto
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Maria Ludovica Ruggeri
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Rossella D'Aloisio
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Chiara De Nicola
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Chiara Trivigno
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Luca Cerino
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Guido Di Marzio
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | - Marta Di Nicola
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. D'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Annamaria Porreca
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. D'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Rodolfo Mastropasqua
- Ophthalmology Clinic, Department of Neurosciences, Imaging and Clinical Science, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
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Karasavvidou EM, Tranos P, Panos GD. Brolucizumab for the Treatment of Degenerative Macular Conditions: A Review of Clinical Studies. Drug Des Devel Ther 2022; 16:2659-2680. [PMID: 35971530 PMCID: PMC9375562 DOI: 10.2147/dddt.s378450] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/04/2022] [Indexed: 12/13/2022] Open
Abstract
Age-related macular degeneration (AMD), diabetic retinopathy and retinal vein occlusion represent some of the commonest degenerative conditions that lead to severe vision impairment in the developed countries. The gold standard treatment of complications associated with these conditions is the intravitreal administration of anti-vascular endothelial growth factor (VEGF) agents. Brolucizumab is a newly developed, humanised, single-chain fragment of a monoclonal antibody binding all VEGF-A isoforms, which was recently approved for the treatment of neovascular AMD. Intravitreal brolucizumab promises to reduce treatment burden for nAMD patients by achieving comparable therapeutic outcomes with fewer clinic visits. Promising also appears its use for the treatment of more challenging maculopathies like diabetic macular oedema (DMO). The aim of this review is to describe the special pharmacological properties of brolucizumab and display the outcomes of the most important clinical trials and real-world studies regarding its efficacy and safety for the management of degenerative macular disorders.
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Affiliation(s)
| | | | - Georgios D Panos
- Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Ferro Desideri L, Traverso CE, Nicolò M. Brolucizumab: a novel anti-VEGF humanized single-chain antibody fragment for treating w-AMD. Expert Opin Biol Ther 2021; 21:553-561. [PMID: 33899632 DOI: 10.1080/14712598.2021.1915278] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Wet age-related macular degeneration (w-AMD) represents the leading cause of visual impairment in the elderly in the developed countries. Intravitreal antivascular endothelial growth factor (VEGF) drugs are currently considered as the first-line treatment option for treating w-AMD; however, the frequent injection intervals have lit the way to investigate novel anti-VEGF agents allowing a more extended treatment regimen. Brolucizumab is a single-chain antibody fragment targeting all the isoforms of VEGF-A. Phase III HAWK and HARRIER trials have shown a longer durability and superior anatomical outcomes as compared with the standard of care by adopting a quarterly regimen for treating w-AMD. Brolucizumab has been approved in Europe, USA, and Japan for the management of w-AMD. AREAS COVERED This article presents an overview of w-AMD and investigates the progress of brolucizumab through clinical trials. It offers insights into where brolucizumab may be placed in the current market of anti-VEGF agents and its potential advantages over the previous molecules adopted for treating w-AMD. EXPERT OPINION The possibility of administering brolucizumab with more dilated treatment intervals represents an important advantage to decrease the treatment burden and improve patient compliance. Brolucizumab represents a possible drug switching option in non-responding patients to other anti-VEGF drugs.
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Affiliation(s)
- Lorenzo Ferro Desideri
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | - Carlo Enrico Traverso
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy.,Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Massimo Nicolò
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy.,Ospedale Policlinico San Martino IRCCS, Genoa, Italy.,Fondazione per La Macula Onlus, Genoa, Italy
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Li E, Donati S, Lindsley KB, Krzystolik MG, Virgili G. Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2020; 5:CD012208. [PMID: 32374423 PMCID: PMC7202375 DOI: 10.1002/14651858.cd012208.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management. OBJECTIVES To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for trial selection, data extraction, and analysis. MAIN RESULTS We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 μm in the monthly injection group; the MD compared with standard PRN was 21 μm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 μm (95% CI 37 to -81 μm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 μm in the monthly group; the MD with the extended-fixed group was 8 μm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results. AUTHORS' CONCLUSIONS We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.
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Affiliation(s)
- Emily Li
- Transitional Year Residency Program, Signature Healthcare Brockton Hospital, Brockton, MA, USA
| | - Simone Donati
- Department of Surgical and Morphological Sciences, Section of Ophthalmology, University of Insubria, Varese-Como, Varese, Italy
| | - Kristina B Lindsley
- Life Sciences, Oncology, & Genomics, IBM Watson Health, Baltimore, Maryland, USA
| | - Magdalena G Krzystolik
- Department of Ophthalmology, Retina Service, Mass Eye and Ear Infirmary, Providence, RI, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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Nguyen QD, Das A, Do DV, Dugel PU, Gomes A, Holz FG, Koh A, Pan CK, Sepah YJ, Patel N, MacLeod H, Maurer P. Brolucizumab: Evolution through Preclinical and Clinical Studies and the Implications for the Management of Neovascular Age-Related Macular Degeneration. Ophthalmology 2020; 127:963-976. [PMID: 32107066 DOI: 10.1016/j.ophtha.2019.12.031] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 01/10/2023] Open
Abstract
Improving or maintaining visual acuity is the main goal for the treatment of neovascular age-related macular degeneration (nAMD). Current nAMD standard of care dictates frequent intravitreal (IVT) anti-vascular endothelial growth factor (VEGF) injections, which places a substantial burden on patients, caregivers, and physicians. Brolucizumab, a newly developed anti-VEGF molecule for nAMD treatment, has demonstrated longer durability and improvement in visual and anatomic outcomes in clinical studies in a q12-week regimen, indicating its potential to reduce treatment burden as an important therapeutic tool in nAMD management. This review focuses on the development of brolucizumab and the preclinical and clinical studies evaluating its efficacy, tolerability, and safety. Brolucizumab (also known as "RTH258" and "ESBA1008") is a humanized, single-chain variable fragment (scFv) antibody with a molecular mass of approximately 26 kDa that inhibits VEGF-A. Preclinical studies show that brolucizumab readily penetrates the retina to reach the retinal pigment epithelium (RPE)/choroid with minimal subsequent systemic exposure. The safety, tolerability, and efficacy of a single IVT brolucizumab administration in patients with treatment-naïve nAMD were first demonstrated in the SEE Phase 1/2 study. The OSPREY Phase 2 study showed brolucizumab to be as efficacious as aflibercept in a q8-week regimen with regard to best-corrected visual acuity (BCVA) and brolucizumab achieving greater fluid resolution. Brolucizumab-treated patients in the OSPREY study were subsequently challenged with a q12-week dosing interval, and the outcomes provided key information for the study design and end points of the Phase 3 studies. In the HAWK and HARRIER Phase 3 studies, after 3 monthly loading injections, brolucizumab treatment regimen (q12-week or q8-week) was guided by individual disease activity assessment using functional and anatomic parameters (central subfield thickness [CST], intraretinal fluid [IRF], or subretinal fluid [SRF]) versus aflibercept (q8-week). Fewer brolucizumab 6-mg treated eyes had disease activity versus aflibercept, and anatomic outcome results at weeks 16 and 48 demonstrate brolucizumab as a potent drying agent. Moreover, of patients treated with 6 mg brolucizumab, 55.6% and 51.0% maintained a q12-week dosing interval immediately after the loading phase until week 48 in HAWK and HARRIER, respectively. These Phase 3 studies demonstrated that the brolucizumab q12-week regimen maintains efficacy and safety while reducing treatment burden associated with regular IVT injections for patients with nAMD.
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Affiliation(s)
- Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California.
| | - Arup Das
- Department of Surgery, Division of Ophthalmology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Pravin U Dugel
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andre Gomes
- Department of Ophthalmology, University of Sao Paulo, Sao Paulo, Brazil
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Adrian Koh
- Eye and Retina Surgeons, Camden Medical Centre, Singapore, Singapore
| | - Carolyn K Pan
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Nikhil Patel
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | - Heather MacLeod
- Former Employee of Novartis Institutes for Biomedical Research, Novartis, Cambridge, Massachusetts
| | - Patrik Maurer
- Novartis Institutes for Biomedical Research, Novartis, Basel, Switzerland
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Sadda SR, Guymer R, Monés JM, Tufail A, Jaffe GJ. Anti-Vascular Endothelial Growth Factor Use and Atrophy in Neovascular Age-Related Macular Degeneration: Systematic Literature Review and Expert Opinion. Ophthalmology 2019; 127:648-659. [PMID: 32081493 DOI: 10.1016/j.ophtha.2019.11.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 01/15/2023] Open
Abstract
TOPIC To summarize the rates of atrophy, risk factors, and atrophy-associated visual outcomes in patients with neovascular age-related macular degeneration (nAMD) who received anti-vascular endothelial growth factor (VEGF) treatment for macular neovascularization (MNV). CLINICAL RELEVANCE Age-related macular degeneration is a leading cause of vision loss worldwide, and VEGF inhibitors are the primary treatment for nAMD. However, atrophy is observed frequently in eyes treated with anti-VEGF therapy, prompting questions regarding a causative role for these therapies in atrophy development. METHODS PubMed was searched for articles published in the past 5 years (January 1, 2014, through January 10, 2019). Studies including atrophy outcome(s) in patients with age-related macular degeneration who received anti-VEGF treatment were included. Review articles, retrospective studies, case reports or studies, preclinical studies, prevalence data reports, and non-English studies were excluded. Randomization was not required. RESULTS Overall, 145 studies were identified; 29 publications were included, with cohorts ranging from 8 to 1185 eyes. Imaging methods used to assess atrophy varied across studies. All studies confirmed the occurrence of atrophy, and when available, longitudinal data from the included studies demonstrated an increase in atrophy incidence over time. Key risk factors or phenotypes associated with atrophy were fellow eye atrophy, reticular pseudodrusen, increased injections, and type 3 lesion. In addition, visual acuity loss was noted with foveal atrophy. DISCUSSION All studies demonstrated that atrophy occurs in the context of MNV treated with anti-VEGF therapy; however, it is not clear whether anti-VEGF treatment is causative of atrophy versus being associated with atrophy development. The included studies were not designed or powered to assess atrophy as a primary outcome. In addition, it is difficult to determine whether prognostic factors directly affect atrophy. Furthermore, patient populations in clinical trials do not necessarily represent real-world patients. Although phenotypes and risk factors may help to identify those at greater risk of atrophy developing, it is important to recognize that adequately treating exudative MNV remains the best option to optimize vision outcomes in patients with nAMD, particularly given the risk of vision loss with undertreatment observed in the real world.
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Affiliation(s)
- SriniVas R Sadda
- Doheny Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Robyn Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Department of Surgery (Ophthalmology), Melbourne, Australia
| | - Jordi M Monés
- Institut de la Màcula and Barcelona Macula Foundation, Barcelona, Spain
| | - Adnan Tufail
- Institute of Ophthalmology, University College London, and Moorfields Eye Hospital, NHS Trust, London, United Kingdom
| | - Glenn J Jaffe
- Department of Ophthalmology, Duke University, Durham, North Carolina
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