Aflibercept for age-related macular degeneration: 4-year outcomes of a ‘treat-and-extend’ regimen with exit-strategy

The role of peripheral blood microRNAs in the pathogenesis and treatment response of age-related macular degeneration

Age-related macular degeneration is a leading cause of vision loss in aging populations, driven by complex interactions between genetic, environmental, and molecular factors. MicroRNAs have emerged as crucial regulators of cellular processes such as oxidative stress, inflammation, and angiogenesis, all of which contribute to AMD pathogenesis. This narrative review aims to summarize the involvement of peripheral blood microRNAs in the pathogenesis of AMD, focusing on key pathways such as oxidative stress, inflammation, and angiogenesis. Additionally, it explores their potential as biomarkers for predicting treatment response, particularly to anti-VEGF therapies. The potential of miRNAs as noninvasive biomarkers for early diagnosis and personalized treatment strategies is also explored, highlighting future directions for research.

Exit Strategy for Treatment of Neovascular Age-Related Macular Degeneration in a Real-World Setting: Wishful Thinking?

INTRODUCTION

To analyze our outcome for patients with neovascular age-related macular degeneration (nAMD) treated with aflibercept in a treat-and-extend regimen pursuing an exit strategy (with best possible adherence to the "Bern" exit criteria) over 6 years in a real-world setting. The primary objective of the study was to investigate the proportion of patients who were able to achieve and maintain treatment exit.

METHODS

This is a retrospective chart review study of treatment-naïve patients diagnosed with nAMD receiving intravitreal aflibercept injections performed at our department with at least 2 years of follow-up visits. The primary outcome was the percentage of patients able to achieve and maintain the treatment exit regarding intravitreal anti-VEGF injections. Further outcome measures were best-corrected visual acuity (BCVA), incidence of recurrence after treatment cessation, duration of therapy, and number and intervals of injections.

RESULTS

There were 31 eyes of 25 patients included in this retrospective study. The observation period was from September 1, 2017 to August 31, 2023. Of all included patient eyes, 22.6% (n = 7) reached exit criteria. Of all the "exit" patients, 28.6% (n = 2) suffered from disease relapse and therapy was restarted at a mean (± SD) of 41.5 ± 12.5 weeks (range: 29 to 54 weeks). Regarding the eyes that met treatment exit, 5 of 31 (16.1%) had no disease recurrence in the observed study period. The median BCVA (Snellen decimal; ± interquartile range: IQR) changed from 0.63 (0.27) at baseline to 0.63 (0.4) in the first year, 0.63 (0.3) in the second year, 0.63 (0.46) in the third year, 0.63 (0.3) in the fourth year, 0.63 (0.4) in the fifth year, and 0.4 (0.04) in the sixth year. The median number of injections (± IQR) per eye in the first year of treatment was 8 (2), in the second year 5 (2), in the third year 5 (2.5), in the fourth year 5 (1), in the fifth year 3 (0.8), and in the sixth year 3 (0). Extension of the treatment interval after the loading phase in weeks was achieved up to a median (± IQR) of 5.8 (4) in the first year, 8.4 (6) in the second year, 8 (5.7) in the third year, 9.4 (5.6) in the fourth year, 7 (6.9) in the fifth year, and 8.4 (3.1) in the sixth year of observation.

DISCUSSION

Our study indicates a lower rate of patients reaching exit criteria with a treat-and-extend regimen compared to clinical study settings, and a similar recurrence rate of nAMD after treatment cessation. Nonadherence to a strict treat-and-extend protocol might influence the result.

Two-Year Switzerland Cohort Results from a Global Observational Study Investigating Proactive Dosing with Intravitreal Aflibercept 2 mg in Neovascular Age-Related Macular Degeneration

Background/Objectives: XTEND is the largest global, prospective, observational study of treatment-naïve patients with neovascular age-related macular degeneration (nAMD) receiving 2 mg of intravitreal aflibercept (IVT-AFL) in routine clinical practice designed to examine the real-world effectiveness of IVT-AFL proactive treatment regimens. The outcomes from the Switzerland cohort are reported here. Methods: Patients aged ≥50 years were eligible if they planned to receive IVT-AFL 2 mg. After three initial monthly IVT-AFL injections, treatment intervals could be extended (4-week minimum treatment interval). Visual and anatomic outcomes, treatment exposure, and safety were assessed. Statistics were descriptive. Results: Fifty-one patients were treated. At baseline, the mean ± standard deviation (SD) best-corrected visual acuity (BCVA) was 64.9 ± 17.9 letters, and central subfield thickness (CST) was 402 ± 106 µm. At month (M) 12 and M24, the mean (95% confidence interval [CI]) change from baseline in BCVA was +5.7 (1.9, 9.4) and +5.6 (1.3, 9.8) letters, respectively. In patients with a high baseline BCVA (≥70 letters [n = 28; mean ± SD: 77.5 ± 4.8 letters]), BCVA was maintained at ≥70 letters at M12 and M24 (mean change from baseline [range] +1.0 [-15.0, 11.0] and +1.1 [-10.0, 14.0], respectively). At M12 and M24, the mean (95% CI) change in CST was -125 (-161, -90) µm and -127 (-162, -93) µm, respectively. Patients received a mean ± SD of 9.5 ± 3.2 and 13.7 ± 6.0 injections by M12 and M24, respectively. No safety concerns were identified. Conclusions: In Swiss routine clinical practice, functional and anatomic improvements were achieved with IVT-AFL 2 mg proactive treatment in patients with nAMD over 24 months despite a relatively high baseline BCVA.

Recurrence of neovascular age-related macular degeneration after discontinuation of modified treat and extend treatment

We evaluated the incidence and risk factors for recurrence in patients with neovascular age-related macular degeneration (nAMD) who discontinued anti-vascular endothelial growth factor (VEGF) therapy under a modified treat-and-extend (TAE) protocol. A retrospective analysis of 68 patients was conducted. Therapy was discontinued after extending the treatment interval to ≥ 5 months and maintaining disease stability for 6 months. The modified TAE protocol included three phases: loading, observation, and TAE, with initial treatment intervals determined by the first recurrence interval. Recurrence rates were 22.2%, 42.2%, and 54.4% at 1-, 2-, and 3-year follow-ups, respectively. The median time to recurrence was 16 months, with patients receiving an average of 7.7 injections before discontinuation. Intraretinal cysts were significantly more prevalent in patients with recurrence. Rapid early response to treatment was associated with a lower risk of exudative recurrence. Vision loss of two or more lines occurred in five patients despite treatment resumption; all exhibited subretinal hemorrhages on baseline imaging. The modified TAE protocol allows for successful therapy discontinuation with fewer injections and reduced recurrence rates. Patients with a favorable early response to anti-VEGF therapy had a lower risk of recurrence.

High dose aflibercept treatment in naive neovascular age-related macular degeneration

BACKGROUND

To evaluate the efficacy and safety of intravitreal injections of 4 mg (high dose) of aflibercept in treatment-naive patients with neovascular AMD(nAMD) with treat and extend(TREX) dosing regimens, and to determine the frequency of injections.

METHODS

In this interventional, retrospective study a total of 15 eyes of 14 patients (eight female and 9 male) with nAMD were included. All patients were examined and OCT imaging was performed at the time of initial presentation, on the day of each injection and at subsequent follow-up visits. Each eye received intravitreal injections of 4 mg/0.1 mL aflibercept at the dose of every 4 weeks for three months (loading phase) after that 4 mg high dose of aflibercept was applied as the TREX regime. The eyes with a minimum follow-up time of 12 months are included.

RESULTS

The mean age of the patients was 74.9 ± 7.3(61-85) years and the mean follow-up time was 20.33 ± 8.7(12-34) months. Total number of injections were 9.3 ± 3.0 (5-14) during the follow-up period. A statistically significant increase was found in terms of best-corrected visual acuity and central macular thickness between mean baseline values and at 1, 3, 6, 12 months, and the final examination(p < 0.05 for each comparison). No complication was observed during follow-up.

CONCLUSIONS

High-dose Aflibercept of 4 mg/0.1 mL application with the TREX regimen was found to be efficient and safe. High-dose may also help to reduce the frequency of injections and visits in the follow-up period in eyes with nAMD. Prospective studies with large series are warranted.

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).

Evaluating Faricimab in Treatment-Naive Neovascular Age Related Macular Degeneration: A Retrospective Analysis of Real-World Data

Purpose

To evaluate the efficiency and safety of Faricimab on treatment-naive neovascular age related macular degeneration (nAMD) in a real world UK clinic.

Patients and Methods

This single centre, retrospective note review was conducted on treatment-naive patients with nAMD. The data collected included demographics, best corrected visual acuity (BCVA), central macular thickness (CMT), total retinal fluid (TRF), the presence of intraretinal fluid (IRF) and subretinal fluid (SRF).

Results

A total of 66 eyes from 62 patients were analysed. The average age was 77 years (range 36-91) and 54% of patients were female. After the first dose of faricimab, the average BCVA improved by 0.05 LogMAR (+2.5 letters), the average CMT decreased by 65.9μm and 41% of patients were found to be inactive. The follow-up intervals after the third loading dose were divided into 2 subsets of 4 and 8 week extensions. The 4 week extension subset saw a smaller improvement in BCVA (+3 letters) than the 8 week extension (+6 letters) while both had an average decrease in CMT by 86.6 μm. The total retinal fluid decreased by 45% and 70.7%, leaving only 30% and 12.2% residual intraretinal fluid (IRF) and 30% and 24.4% residual subretinal fluid (SRF), respectively. Over a ten-month period, the average number of injections received was 6.6, including 3 initial loading doses. There was only one reported case of an adverse event out of 66 eyes (1/66, 1.5%).

Conclusion

Three loading doses of Faricimab appear efficacious and safe for the treatment of nAMD.

Two-year Outcomes of Intravitreal Aflibercept Injection for Neovascular Age-related Macular Degeneration with "Observe before Treat-and-Extend" Method

PURPOSE

To evaluate 2-year outcomes of intravitreal aflibercept injection for neovascular age-related macular degeneration (nAMD) treated with "observe before treat-and-extend (O-TAE)" strategy in the real-world setting.

METHODS

This retrospective study included treatment-naive nAMD patients treated with aflibercept using O-TAE regimen and followed up for more than 2 years. Patients were observed bimonthly to check recurrence after three monthly loading injections. In case of recurrence, treatment was resumed using the TAE regimen starting from the fourth injection. In case of nonrecurrence, observation was continued. Best-corrected visual acuity (BCVA), central macular thickness (CMT), number of injections, TAE intervals, and proportion of recurrence after dry-up following three loadings were analyzed.

RESULTS

A total of 38 eyes of 34 patients were included. Follow-up period was 37.0 ± 11.0 months. BCVA by logarithm of minimal angle of resolution improved from 0.33 ± 0.29 at baseline to 0.24 ± 0.23 in the first year (p = 0.010) and 0.25 ± 0.22 in the second year (p = 0.054). CMT decreased significantly from 357.43 ± 74.53 μm at baseline to 269.62 ± 48.12 μm in the first year (p < 0.001) and 279.14 ± 54.64 μm in the second year (p < 0.001). Number of injections were 5.11 ± 1.69 in the first year and 3.84 ± 2.39 in the second year. The percentage of eyes with a TAE interval of ≥12 weeks was 37.0% in the first year and 34.4% in the second year. Of the 36 eyes that dried up after three loadings, 28 eyes (77.8%) recurred, and the average period of recurrence was 6.5 months. The remaining eight eyes (22.2%) had no recurrence during the mean follow-up period of 29.7 months.

CONCLUSIONS

This study showed that the newly suggested O-TAE strategy can reduce the treatment burden significantly reducing the number of injections while improving BCVA and CMT in the first and second year.

Monoclonal Antibodies for the Treatment of Ocular Diseases

Monoclonal antibodies (mAbs) have revolutionized the landscape of cancer therapy, offering unprecedented specificity and diverse mechanisms to combat malignant cells. These biologic agents have emerged as a cornerstone in targeted cancer treatment, binding to specific antigens on cancer cells and exerting their therapeutic effects through various mechanisms, including inhibition of signaling pathways, antibody-dependent cellular cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC), and antibody-dependent cellular phagocytosis (ADCP). The unique ability of mAbs to engage the immune system and directly interfere with cancer cell function has significantly enhanced the therapeutic armamentarium against a broad spectrum of malignancies. mAbs were initially studied in oncology; however, today, treatments have been developed for eye diseases. This review discusses the current applications of mAbs for the treatment of ocular diseases, discussing the specificity and the variety of mechanisms by which these molecules exhibit their therapeutic effects. The benefits, drawbacks, effectiveness, and risks associated with using mAbs in ophthalmology are highlighted, focusing on the most relevant ocular diseases and mAbs currently in use. Technological advances have led to in vitro production methods and recombinant engineering techniques, allowing the development of chimeric, humanized, and fully human mAbs. Nowadays, many humanized mAbs have several applications, e.g., for the treatment of age-related macular disease, diabetic retinopathy, and uveitis, while studies about new applications of mAbs, such as for SARS-CoV-2 infection, are also currently ongoing to seek more efficient and safe approaches to treat this new ocular disease.

Long term follow up of patients with MNV3 treated with intra-vitreal Aflibercept

PURPOSE

MNV3 or Retinal angiomatous proliferation is a subtype of neovascular age-related macular degeneration (nAMD). We present the 5 year long term visual and anatomical outcomes of patients with MNV3 lesions treated with intravitreal Aflibercept.

METHODS

This is a prospective study of treatment naïve patients with reading centre graded MNV3 lesions. After the loading phase, the patients received intravitreal Aflibercept as per the View study up to year 3, thereafter it was given on a prn basis. At each visit, best corrected visual acuity (BCVA) and optical coherence tomography (OCT) central macular thickness (CMT) was measured.

RESULTS

Thirty one patients reached study completion. Mean BCVA of treated eyes had decreased by 0.6 ETDRS letters at the end of year 5 compared with baseline. At study completion, 81% of eyes had stable vision while 19% of eyes had gained 15 letters or more. At study end, 26% of eyes had BCVA of 6/12 or better, while 19% had lost 15 letters or more (all had central foveal photoreceptor loss). There was a maximal mean reduction in CMT of 164 microns (p = <0.0001) while 68% of maculae were fluid free at study completion. Eighty seven percent of treated eyes developed nascent GA, of which in 74% of eyes was involving the fovea.

DISCUSSION

Despite initial improvement in mean BCVA, the improvement in BCVA was not maintained despite good overall control of the MNV3 lesions. The loss of BCVA was most likely due to the majority of eyes developing centre involving macular atrophy.

Aflibercept for central retinal vein occlusions: long-term outcomes of a 'Treat-and-Extend' regimen

BACKGROUND/AIMS

This study reports on the long-term functional and anatomical outcomes of patients with central retinal vein occlusion (CRVO) treated under the Bern treat-and-extend (T&E) protocol.

METHODS

Observational study. Treatment-naive patients with CRVO and consecutive macular oedema treated with aflibercept were included. The T&E protocol involved 2 monthly injections followed by an extension based on individual assessments. At each visit, best-corrected visual acuity (BCVA), optical coherence tomography imaging and a 2 mg aflibercept injection were administered. Changes in BCVA, proportion of patients gaining ≥15 letters, central subfield thickness (CST) and treatment intervals were analysed.

RESULTS

Out of 173 patients, 64 had a follow-up of at least 2 years. BCVA improved from 46.7±25.3 at baseline to 78.3±0.5 at year 9. The proportion of patients with ≥15 letters gained was 56%, 53%, 56%, 62%, 52%, 52%, 43%, 50% and 33% at years 1-9, respectively. CST decreased significantly from 660±242 µm at baseline to 359±63 µm at year 9. Treatment intervals extended from 4 weeks initially to an average of 13.0±4.1 weeks by year 8.

CONCLUSIONS

The T&E regimen for CRVO shows sustained visual improvements and reduced CST over time. Patients maintained stable visual gains for many years, demonstrating the effectiveness of this treatment approach. However, no control group was available to compare our T&E regimen with other strategies.

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.

Two-Year Real-World Results for Aflibercept Using the Treat-and-Extend Regimen in Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

INTRODUCTION

To evaluate the real-world efficacy of aflibercept using the treat-and-extend (TnE) regimen in treating neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and to analyze biomarkers using optical coherence tomography (OCT) to predict treatment outcomes.

METHODS

Patients diagnosed with nAMD or PCV who received an intravitreal injection of aflibercept following the TnE regimen for ≥ 2 years were retrospectively reviewed. Data on best-corrected visual acuity (BCVA), number of injections, treatment interval, and OCT biomarkers, including central macular thickness, presence of subretinal fluid (SRF), and serous pigmented epithelial detachment, were collected at baseline and at 3, 6, 12, 18, and 24 months after the first injection.

RESULTS

A total of 43 patients were enrolled in this study, 24 of whom were diagnosed with nAMD and 19 with PCV. The BCVA in logMAR (mean ± standard deviation) improved from 0.75 ± 0.41 (baseline) to 0.60 ± 0.41 (P = 0.002) at 3 months after treatment initiation, and further improved to 0.66 ± 0.46 at 24 months (P = 0.137). The number of injections (mean ± standard deviation) within the 2-year treatment course was 10.95 ± 3.65. At month 24 of the TnE regimen, the treatment interval was extended to ≥ 16 weeks in 60.5% of all cases and to 78.9% of the PCV cases. After three loading injections, persistent subretinal fluid and intraretinal fluid were predictive of more frequent injections (P = 0.026) and poorer visual outcomes (P = 0.050), respectively.

CONCLUSION

Aflibercept combined with a TnE regimen was effective in treating nAMD and PCV in a real-world setting. The treatment interval could be extended to ≥ 16 weeks in 60.5% of the cases after a 2-year treatment regimen. OCT can be used to predict the treatment course and visual outcomes.

INCIDENCE AND TIMING OF PIGMENT EPITHELIAL DETACHMENT AND SUBRETINAL FLUID DEVELOPMENT IN TYPE 3 MACULAR NEOVASCULARIZATION ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the incidence and timing of pigment epithelial detachment (PED) and subretinal fluid (SRF) development in type 3 macular neovascularization.

METHODS

This retrospective study included 84 patients who were diagnosed with treatment-naïve type 3 macular neovascularization who did not show SRF at diagnosis. All patients were initially treated with three loading injections of ranibizumab or aflibercept. After the initial loading injections, as-needed regimen was performed for retreatment. The development of either PED or SRF was identified. The incidence and timing of PED development in patients without PED at diagnosis and that of SRF development in patients with PED at diagnosis were evaluated.

RESULTS

The mean follow-up period was 41.3 ± 20.7 months after diagnosis. Among the 32 patients without serous PED at diagnosis, PED developed in 20 (62.5%) at a mean of 10.9 ± 5.1 months after diagnosis. PED development was noted within 12 months in 15 patients (46.8%; 75.0% among the PED development cases). In 52 patients with serous PED and without SRF at diagnosis, 15 developed SRF (28.8%) at a mean of 11.2 ± 6.4 months after diagnosis. SRF development was noted within 12 months in nine patients (17.3%; 66.6% among the SRF development cases).

CONCLUSION

PED and SRF developed in a substantial proportion of patients with type 3 macular neovascularization. The average period of development of these pathologic findings was within 12 months of diagnosis, suggesting the need for active treatment during the early treatment period to improve treatment outcomes.

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.

"Treat-and-Extend" Regimen for Exudative Age-Related Macular Degeneration: A Two-Year Retrospective Follow-up Study

BACKGROUND

After the introduction of a "treat-and-extend" regimen (T&E) with aflibercept for exudative age-related macular degeneration, naive eyes were compared with eyes pretreated with a "pro re nata" scheme (PRN).

PATIENTS AND METHODS

The Ethics Committee of Eastern Switzerland approved the retrospective single-centre study (EKOS20/084, project ID: 2020-01193). The study included 342 eyes of 303 patients newly treated with or switched to T&E between January 2018 and March 2018 at the Eye Clinic of the Cantonal Hospital St. Gallen. The gender distribution of the treated eyes was 63.5% (n = 217) female and 36.5% (n = 125) male. The mean age was 81.6 years (SD = 8.6 years). The collective was divided into three groups: 1) naive, untreated eyes (n = 92), 2) eyes with ≤ 6 previous treatments with PRN (n = 37), 3) eyes with > 6 previous treatments with PRN (n = 213). The following parameters were analysed up to December 2019: the evolution of visual acuity, the number of intravitreal injections, the number of recurrences, the duration of the follow-up, the dropout rate, and the duration of the last treatment interval.

RESULTS

During the observation period, group 1 showed a statistically significant improvement in visual acuity of + 1.5 ETDRS, while groups 2 and 3 showed a decrease in visual acuity of - 2.9 and - 3.7 ETDRS, respectively. Group 1 had better development of visual acuity than groups 2 and 3 (p = 0.005), while groups 2 and 3 were not significantly different (p = 0.92). The other parameters examined in the three groups did not differ significantly between groups.

CONCLUSIONS

Treatment with aflibercept in T&E shows significantly better visual acuity in naive eyes than in eyes pretreated with PRN.

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

External Limiting Membrane Disruption Predicts Long-Term Outcome in Strict Treat-And-Extend Regimen in Neovascular Age-Related Macular Degeneration

The use of anti-vascular-endothelial growth factor agents for neovascular age-related macular degeneration (nAMD) in different treatment schemes is widely common in clinical practice. However, there is currently limited data on the long-term outcomes of a strict treat-and-extend regimen (TER) and imaging biomarkers to predict both functional outcome and the potential for a TER exit due to success. In this retrospective study we followed treatment-naïve subjects with nAMD starting treatment with either ranibizumab or aflibercept in a TER without loading dose but with predefined exit criteria for up to 8 years. We evaluated both the functional outcome and several spectral-domain optical coherence tomography parameters in a follow-up mode using a standardized protocol. Within the 211 eyes followed for a mean of 60.3 ± 20.9 months, follow-up adherence was high with major part of discontinuations of TER being due to success. Mean best-corrected visual acuity (BCVA) increased from initially 63.9 ± 15.5 ETDRS letters to 70.0 ± 14.7 after 1 year (+6.1 letters, p < 0.001) and to 68.5 ± 18.1 (+4.6 letters, p = 0.028) at 5 years. A worse BCVA (p = 0.001) and a better external limiting membrane (ELM) disruption score at baseline predicted (p = 0.019) BCVA gain at 5 years. The probability of reaching the exit criteria was significantly associated with a better ELM disruption score (p = 0.044) and the absence of a central pigment epithelial detachment (PED) (p = 0.05) at baseline. Significant visual gains were sustained in a long-term TER in a real-world setting. Integrity of ELM at baseline predicted BCVA gain at 5 years and the potential for TER exit due to success.

An insight on the anatomical and functional consequences of aflibercept therapy in age-related macular degeneration

BACKGROUND

Evaluation of anatomical and functional recovery of the retina after aflibercept therapy in neovascular age-related macular degeneration.

MATERIALS AND METHODS

This prospective study enrolled 33 eyes of 33 naive age-related macular degeneration patients with an average age of 69 (55-82) years. Following a thorough ophthalmological examination, baseline color fundus photography, optical coherence tomography and fluorescein angiography were used to assess the angiographic characteristics and classification of the lesions. Multifocal electroretinography and microperimetry were recorded. In the first three months, all patients received three consecutive intravitreal aflibercept injections on a monthly basis. After the initial three doses, non-responders received additional afibercept injections. The baseline, 3rd and 6th month data were recorded for analysis.

RESULTS

The baseline average best-corrected visual acuity (1.05 log MAR) improved dramatically to 0.9 log MAR in the 3rd and 6th months, respectively. The baseline average central macular thickness of 358.5 ± 232.1 μm decreased significantly to 273.0 ± 109.9 μm and 245.5 ± 109.3 μm in the 3rd and 6th months, respectively. The average thickness of the central 1 mm macular region decreased significantly from 349.5 ± 96.4 μm to the 3rd and 6th month values of 320.6 ± 101.9 and 290.5 ± 86.4 μm, respectively. While the mean retinal sensitivity increased significantly from 4.7 ± 3.0 dB to 6.9 ± 3.4 Db, local deficit decreased from -11.6 ± 4.6 dB to -9.4 ± 4.6 dB. Significant improvements were also observed in all rings of N1 and P1 waves.

CONCLUSION

Intravitreal aflibercept therapy resulted in significant morphological improvements that were easily identifiable during the 3rd month. Electrophysiological improvements were delayed only to become statistically significant in the 6th month. However, it has been shown that visual acuity and optical coherence tomography parameters alone may be insufficient for both the morphological and functional assessment of the retina.