Through the Eyes of Patients: Understanding Treatment Burden of Intravitreal Anti-VEGF Injections for nAMD Patients in Norway

Intravitreal therapeutic nanoparticles for age-related macular degeneration: Design principles, progress and opportunities

Age-related macular degeneration (AMD) is a leading cause of vision loss in the elderly. The current standard treatment for AMD involves frequent intravitreal administrations of therapeutic agents. While effective, this approach presents challenges, including patient discomfort, inconvenience, and the risk of adverse complications. Nanoparticle-based intravitreal drug delivery platforms offer a promising solution to overcome these limitations. These platforms are engineered to target the retina specifically and control drug release, which enhances drug retention, improves drug concentration and bioavailability at the retinal site, and reduces the frequency of injections. This review aims to uncover the design principles guiding the development of highly effective nanoparticle-based intravitreal drug delivery platforms for AMD treatment. By gaining a deeper understanding of the physiology of ocular barriers and the physicochemical properties of nanoparticles, we establish a basis for designing intravitreal nanoparticles to optimize drug delivery and drug retention in the retina. Furthermore, we review recent nanoparticle-based intravitreal therapeutic strategies to highlight their potential in improving AMD treatment efficiency. Lastly, we address the challenges and opportunities in this field, providing insights into the future of nanoparticle-based drug delivery to improve therapeutic outcomes for AMD patients.

Treatment burden on patients receiving intravitreal anti-VEGF for wet age-related macular degeneration

PURPOSE

The aim of this study was to map the treatment burden for patients with wet age-related macular degeneration (wAMD).

METHOD

Patients with ongoing treatment with anti-VEGF for wAMD at a Swedish eye unit underwent a survey about the time spent receiving treatment, caregiver assistance, way of transportation, self-rated vision and negative experiences associated with the treatment such as discomfort, anxiety or transportation problems. Information about current visual acuity, number of treatments and current treatment intervals were obtained from medical records.

RESULTS

The study included 93 patients with an average age of 79.9 years, 68% were women. The average interval between treatments was 7.3 weeks, and 26% had active treatment in both eyes. On average, patients had to spend 2.7 h (2.4-2.9: 95% CI) per treatment and a caregiver assisted the patient in 58% of cases. Caregivers spent on average 2.6 h (2.5-2.8: 95% CI) per visit, and 19% needed to take time off work. The majority (91%) of patients did not experience any transportation problems associated with treatment. A multivariate logistic regression analysis showed a significantly lower odds ratio for discomfort with higher self-rated vision and a significantly higher odds ratio for discomfort with longer treatment intervals.

DISCUSSION

Anti-VEGF treatment is an effective treatment for wAMD. However, the relatively short treatment intervals place a considerable burden on patients and their relatives regarding time. Although the patients in this study had to spend a lot of time to receive treatment, the majority did not experience any problems associated with treatment.

Home Optical Coherence Tomography Monitoring for Neovascular Age-Related Macular Degeneration: Transformative Technology or Cool Toy?

The pending introduction of home-based optical coherence tomography (OCT) in managing neovascular age-related macular degeneration (nAMD) has sparked interesting debates. Advocates assert that home-based OCT will revolutionize care of patients with nAMD, while skeptics question its real-world viability and point out its potential drawbacks. This article delves into the dichotomy, presenting the "pro" argument highlighting the transformative potential of home OCT and the "con" perspective, which scrutinizes the limitations and challenges to adapting the technology to the real-world setting. By exploring both sides of the discourse, we aim to address the promises and complexities surrounding the role of home OCT in the management of nAMD.

Outcomes of Treatment-Resistant Neovascular Age-Related Macular Degeneration Switched from Aflibercept to Faricimab

PURPOSE

Although previous studies have demonstrated the efficacy of faricimab in treatment-naive patients with neovascular age-related macular degeneration (nAMD), its outcomes in patients switched from aflibercept are less understood. This study aimed to assess clinical anatomical and functional outcomes of switching to faricimab in patients undergoing aflibercept intravitreal injections (IVIs) for nAMD with suboptimal response.

DESIGN

Retrospective case series.

SUBJECTS

Patients with nAMD at a single tertiary care center who were switched from aflibercept to faricimab due to persistent suboptimal response.

METHODS

Patients had received a minimum of 6 consecutive IVIs of aflibercept and showed persistent presence of intraretinal (IRF) or subretinal fluid (SRF) on OCT despite receiving aflibercept at 4 or 6-weekly intervals at the time of the switch. Patients receiving 4-weekly aflibercept were switched with either 2 or 3 loading doses of 4-weekly faricimab injections. Regression models were used to identify predictors of clinical outcomes.

MAIN OUTCOME MEASURES

Visual acuity, central macular thickness (CMT), and OCT parameters were assessed preswitch and postswitch.

RESULTS

Eighty-one eyes of 68 patients were included. The mean age was 79.1 years (standard deviation: 8.9), and females constituted 53% of cases. A statistically significant reduction in CMT was observed postswitch (P < 0.0001). The proportion of cases with IRF (P = 0.0219) and SRF (P < 0.000) decreased significantly. Overall clinical improvement on OCT was noted in 80% of patients. No significant improvement in ETDRS vision was observed. There was no evidence that switching regimen (2 vs. 3 loading doses) had an independent effect on clinical outcomes.

CONCLUSION

Among patients with treatment-resistant nAMD, switching from aflibercept to faricimab may serve as a safe and effective option. Significant anatomical improvements were observed, with a trend toward visual stability. The loading regimen with 2 faricimab injections appeared to be sufficient for nonnaive patients. However, a longer follow-up and larger studies are warranted to confirm these findings.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Gene therapy for age-related macular degeneration: potential, feasibility, and pitfalls

PURPOSE OF REVIEW

The landscape for age-related macular degeneration (AMD) is rapidly changing with addition of biosimilars and now United States Food and Drug Administration (FDA) approved nonneovascular AMD (nnAMD) treatment options. These developments have inspired a burgeoning pipeline of gene therapy approaches focused on similar antivascular endothelial growth factors (VEGF) and complement related pathways. Historic and more recent setbacks in the gene therapy pipeline, including intraocular inflammatory reactions, have raised important concerns for adverse events related to AMD therapeutics both for gene and nongene approaches. The specific clinical profile of these therapeutics approaching later stage clinical trials are complex and under active investigation; however, these options hold promise to disrupt the current landscape and change management paradigms for one of the leading causes of vision loss worldwide.

RECENT FINDINGS

This review covers current gene therapy approaches for neovascular AMD (nAMD) and nnAMD. Intravitreal, suprachoroidal, and subretinal delivery routes are discussed with attention to technical procedure, capabilities for transgene delivery to target tissue, immunogenicity, and collateral effects. Suprachoroidal delivery is an emerging approach which may bridge some of the practical drawbacks for intravitreal and subretinal methods, though with less elaborated immunologic profile. In parallel to delivery modification, viral vectors have been cultivated to target specific cells, with promising enhancements in adeno-associated viral (AAV) vectors and persistent interest in alternate viral and nonviral delivery vectors. Ongoing questions such as steroid or immunosuppressive regimen and economic considerations from a payer and societal perspective are discussed.

SUMMARY

The present review discusses emerging gene therapy options which could foster new, more durable nAMD and nnAMD therapeutics. These options will need refinement with regards to route, vector, and dosage, and specialists must decipher the specific clinical risk benefit profile for individual patients. Ongoing concerns for immunogenicity or dosage related adverse events could stifle progress, while further vector development and refined delivery techniques have the potential to change the safety and efficacy of currently options in the pipeline.

Saffron therapy for the ongoing treatment of age-related macular degeneration

OBJECTIVE

To assess the long-term efficacy and safety of oral saffron, a natural antioxidant, in treating mild/moderate age-related macular degeneration (AMD).

METHODS AND ANALYSIS

Open-label, extension trial of 93 adults (>50 years) with mild/moderate AMD and vision >20/70 Snellen equivalent in at least 1 eye. Exclusion criteria included confounding visual lesions or significant gastrointestinal disease impairing absorption.Participants were given oral saffron supplementation (20 mg/day) for 12 months. Those already consuming Age-Related Eye Diseases Study (AREDS) supplements or equivalent maintained these.Primary outcomes included changes in multifocal electroretinogram (mfERG) response density and latency, and changes in best-corrected visual acuity (BCVA). Secondary outcomes included safety outcomes, changes in mfERG and BCVA among participants on AREDS supplements and changes in microperimetry.

RESULTS

At 12 months, mean mfERG response density was significantly higher in rings 1, 2 and overall (p<0.001 for all) but not in rings 3-6, and there was no difference in response between those taking AREDS supplements and those not (p>0.05). Mean mfERG latency was not significantly different in any of rings 1-6 or overall (p>0.05 for all), again with no difference between those taking AREDS supplements or not (p>0.05). Mean BCVA was 1.6 letters worse (p<0.05) with no difference between those on AREDS supplements or not, and this may have been related to cataract progression. No saffron-related serious adverse events were detected.

CONCLUSION

Saffron supplementation modestly improved mfERG responses in participants with AMD, including those using AREDS supplements. Given the chronic nature of AMD, longer-term supplementation may produce greater benefits.

Effect of Needle Gauge Size on Pain During Intravitreal Anti-VEGF Injection: A Systematic Review and Network Meta-Analysis

INTRODUCTION

Concerns related to pain from intravitreal injections are one of the key factors mentioned by patients when asked about therapy. In this systematic review and network meta-analysis, we evaluate the literature of comparative clinical trials on the relationship between needle gauge size and pain experience during intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy.

METHODS

We searched 12 literature databases on 14 October 2023 for comparative studies of gauge sizes for intravitreal anti-VEGF injections. The primary outcome of interest was the reported pain experience immediately after the injection. All outcomes of pain were transformed into standardized effect sizes using Cohen's d. Using a network meta-analysis approach, we were able to compare all gauge sizes and rank them according to the reported pain experience.

RESULTS

We identified nine eligible studies with data on a total of 998 patients and 1004 eyes. Needle sizes studied were 26-gauge, 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge. A complete network was present, which allowed for a network meta-analysis. We used the thickest (26-gauge) needle as the reference group and observed a clear trend of lower pain experience with thinner gauge sizes (d: -0.4, d: -2.7, d: -3.8, d: -4.8, d: -4.5, and d: -5.3; respectively, for 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge).

CONCLUSION

A gauge size of 30 or thinner may minimize patient discomfort related to intravitreal anti-VEGF therapy.

Fixed Quarterly Dosing of Aflibercept after Loading Doses in Neovascular Age-Related Macular Degeneration in Chinese Eyes

We aimed to investigate the success rate of planned fixed quarterly aflibercept injections after three loading doses (QDA3L) to achieve stability without recurrence in neovascular age-related macular degeneration (nAMD) at a tertiary eye centre. A retrospective study was conducted over five years (2017-2021) by including all consecutive cases of nAMD treated with three initial aflibercept injections four weeks apart, followed by planned injection appointments every 12 to 16 weeks starting from week 20. The primary endpoint was to determine the proportion of patients who maintained disease inactivity at week 52 and week 104. A total of 40 eyes of 40 patients were included. The overall mean age was 80.8, with a male preponderance. The overall success rate in our study population was 52.9% and 53.6% at week 52 and week 104, respectively. The fovea remained dry at 85.3% at week 52 and 82.1% at week 104, and 85.3% and 85.7% of subjects lost fewer than 15 ETDRS letters at week 52 and week 104, respectively. While this study does not suggest the superiority of this regimen, the success and failure rates obtained in our study can be used in the counselling process for this particular fixed treatment regimen for nAMD.