Biomarkers in Early Response to Brolucizumab on Pigment Epithelium Detachment Associated with Exudative Age-Related Macular Degeneration

Brolucizumab effectiveness in pigment epithelium detachment due to exudative AMD in naïve treatment or non-responder patients

PURPOSE

To investigate outcomes after Brolucizumab injection in naïve treatment or non-responder patients with exudative age-related macular degeneration (AMD).

METHODS

It is a retrospective, comparative, cohort study conducted at the tertiary referral center of the University Hospital Polyclinic of Bari, for 5 years, from November 2017 until May 2022. 41 eyes with wet-AMD (w-AMD) were included, undergoing anti-vascular endothelial growth factor (VEGF) intravitreal injections. The sample was divided into two groups, the Bro-Switch group, and the Bro-Naïve group. The Bro-Switch group previously received a slot of other anti-VEGF intravitreal drugs. The Bro-Naïve group received Brolucizumab (Bro) as the first treatment. The pigment epithelium detachment (PED) and the best-corrected visual acuity (BCVA) outcomes before and after Bro-injection were evaluated.

RESULTS

A significant reduction in PED measurement was registered in all eyes treated with Bro-injection (p = 0.35). The Bro-Naïve group improved better in PED measurement (mean difference: 297.92 ± 72,32) as compared to the Bro-Switch group (mean difference: 185.06 ± 11.07). On the contrary, no significant reduction in BCVA in the two groups was recorded (p = 0.66).

CONCLUSION

We suggest Bro-injection for w-AMD as effective anatomical outcomes in PED flattening, but not similar in visual results. Although this study evaluated short-term outcomes, the hopeful results can lead to interesting medium-long time effects.

Brolucizumab in recalcitrant neovascular age-related macular degeneration-real-world data in Chinese population

This retrospective study aimed to determine the short-term efficacy and safety of brolucizumab treatment for recalcitrant neovascular age-related macular degeneration (nAMD) in a real-world setting in Taiwan. Recalcitrant nAMD patients who were treated with brolucizumab from November 2021 to August 2022 at Taipei Veterans General Hospital were included. Patients were followed for 3 months after switching to brolucizumab. The primary outcomes were changes in mean best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline to the third month. The secondary outcomes included the incidence of intraocular inflammation (IOI), proportion of patients with subretinal and intraretinal fluid (SRF and IRF), and change in pigment epithelial detachment (PED) height from baseline to the third month. The significance level was considered as p < .05 in all tests. A total of 38 patients (40 eyes) with a mean (±SD) age of 76.3 (±10.84) years were included. The baseline BCVA was 0.92±0.64 logMAR, and the CRT and PED height were 329.0±171.18 and 189.8±114.94 um, respectively. The patients had a significant reduction in CRT and resolution of IRF and SRF from baseline to the third month. There were numerical improvements in mean BCVA and PED height, but they were not significant. The percentages of achieving at least 0.1, 0.2, and 0.3 logMAR (equivalent to 5, 10, 15 ETDRS letters) visual gain were 50%, 37.5%, and 30%, respectively, during the first 3 months of follow-up. No IOI occurred in these patients. This study demonstrated that brolucizumab had good short-term structural and functional efficacy in recalcitrant nAMD patients.

Functional and anatomical outcomes of brolucizumab for nAMD in a real-life setting

To report long-term outcomes of brolucizumab in neovascular age-related macular degeneration (nAMD) treatment. Records from 74 patients were retrospectively reviewed. Both naïve eyes and those previously treated with other antiVEGF agents were included. Primary outcomes included variation in best corrected visual acuity (BCVA), central subfield thickness (CST), intraretinal fluid (IRF), subretinal fluid (SRF), and pigment epithelial detachment (PED) dimensions. Outcomes were reviewed after the loading phase, at week 24, and at last follow-up. IOI occurrence represented the secondary outcome. BCVA improved significantly in both groups. In switched eyes, IRF and SRF were significantly reduced at every timepoint, with CST reduction from week 24 (p = 0.005). In naïve group, CST decreased from the loading phase (p = 0.006) and all patients showed dry macula from week 24. A significant reduction in PED maximum high was demonstrated in both groups. In seven naïve eyes, PED completely reabsorbed; a slight increase in PED horizontal maximal diameter was also observed from week 24. IOI occurred in 5.4% of cases. In conclusion, brolucizumab showed a strong drying effect, permitting functional improvement together with fluid reabsorption and an encouraging modification of PED dimension, especially on naïve patients. These results together with the extension of treatment intervals make brolucizumab an efficient therapeutic strategy for nAMD.

Structural and clinical changes in previously treated type 1 macular neovascularization in non-responder AMD eyes switched to brolucizumab

PURPOSE

To examine structural and clinical changes in previously treated type 1 macular neovascularization (MNV) in non-responder age-related macular degeneration (nAMD) eyes switched to brolucizumab. Subretinal hyper-reflective material (SHRM), intraretinal (IRF) and subretinal fluid (SRF) presence, fibrovascular-pigment epithelium detachment (PED) height and central macular thickness (CMT) variation were analyzed using optical coherence tomography (OCT).

METHODS

In this prospective study all patients underwent a complete ophthalmological evaluation including structural OCT at baseline (T0), one month (T1), three (T2), four (T3) and six months after switching to brolucizumab treatment (T4). Non-responder criterion was the persistence of IRF and SRF. Moreover, CMT and BCVA had shown worsening or no improvement before switching to brolucizumab. Clinical function and structural activity biomarkers were measured at each visit and changes were analyzed. P value <0.05 was considered statistically significant.

RESULTS

Twenty eyes of twenty patients were enrolled. All the structural variables examined during the follow-up showed significant reductions. Decreases in IRF, SRF and PED were already significant at T1 (p < 0.05). SHRM was significantly reduced at T2 (p < 0.05). Structural biomarkers were absent at T3. At T4, all biomarkers remained stable while SHRM was no longer detectable in 18 patients. Changes in visual acuity from baseline to T4 were not significant.

CONCLUSION

This short-term experience highlights that brolucizumab might be considered an effective treatment option in nAMD with type 1 MNV, as it can promote a reduction of structural activity biomarkers.

Faricimab in neovascular AMD: first report of real-world outcomes in an independent retina clinic

PURPOSE

Assess short-term real-world outcomes in neovascular aged-related macular degeneration (nAMD) treated with novel faricimab.

METHODS

Retrospective case series of nine patients with nAMD (11 eyes) treated with faricimab between May and November 2022. Treatment-naïve patients and non-naïve patients underwent logMAR best corrected visual acuity (BCVA), optical coherence tomography (OCT) DRI OCT-1 Triton (Topcon Corp, Tokyo, Japan), ultra-widefield (UWF) and fundus autofluorescence (FAF) (California Optomap, Optos plc, Dunfermline, Scotland, UK). Previous treatment intervals, number of intravitreal injections, sub/intra retinal fluid (SRF/IRF), central retinal thickness (CRT) and presence/changes in pigment epithelial detachments (PEDs) were recorded.

RESULTS

Mean baseline BCVA and CRT values of patients who switched from other agents were 0.612 ± 0.75 logMAR and 256.16 ± 12.98 µm respectively, with a mean 36-day previous treatment interval. The median number of other previous anti-VEGF intravitreal injections was 8. Mean BCVA at one month significantly improved to 0.387 ± 0.54 logMAR, as well as CRT values which decreased to 245.43 ± 15.34 µm. In the 3 naïve patients, mean baseline BVCA and CRT values were 0.33 ± 0.29 and 874.67 ± 510.86 µm, respectively. At one month follow-up, mean BCVA improved to 0.30 ± 0.29 logMAR and mean CRT was 536.04 ± 36.15 µm. Overall, a significant improvement in BCVA of 0.21 ± 41 logMAR and 238.44 ± 114.9 µm was achieved at one month after the first faricimab intravitreal injection. In addition, a complete resolution of SRF was observed in 6 out of 8 eyes (75%) and of IRF in 2 out of 3 eyes (66.67%), respectively. Drusenoid PED morphology changes were observed in all patients and no drug-related adverse events were observed.

CONCLUSION

Real-world outcomes showed improvement in BCVA and anatomic parameters at an early timepoint, demonstrating the efficacy and durability of faricimab in nAMD patients. Larger numbers of patients and longer follow-up are needed to determine whether the loading dose is required in all, what percentage of patients experience an improvement, and whether improvement it is maintained.

OCTA Biomarker Search in Patients with nAMD: Influence of Retinal Fluid on Time-Dependent Biomarker Response

PURPOSE

Previous studies have identified a link between optical coherence tomography (OCT)-derived and OCT angiography (OCTA)-based parameters in patients with neovascular AMD (nAMD); the latter may serve as direct biomarkers for macular neovascularization (MNV) activity. The aim of this study was to assess the individual influence of retinal thickness (RT) as well as intra- and sub-retinal fluid (IRF, SRF) presence on the treatment response over time as assessed by previously identified OCTA-derived MNV vascular parameters.

METHODS

During the first 3 months of anti-VEGF therapy patients were prospectively followed. RT, SRF and IRF were determined from SSOCT/A (PlexElite, Zeiss) images and using the semi-automated AngioTool software, vessel area (VA), total vessel length (TVL), total number of junctions (TNJ), junction density (JD), vessel density (VD) as well as MNV area were exported. IRF and SRF were identified manually on OCT volume scans .The associations between RT, IRF, and SRF and SSOCTA vascular parameters were analyzed using linear mixed models.

RESULTS

31 eyes of 31 patients with treatment-naïve and OCTA-positive nAMD MNV were included in this analysis. VA, TVL, TNJ, and MNV area show a statistically significant change over time in response to anti-VEGF treatment, even after correcting for the presence of SRF, IRF, or RT (all p < 0.05). This is not the case for JD and VD (both p > 0.05).

CONCLUSIONS

OCTA-based parameters VA, TVL, TNJ, and MNVarea show a strong response to anti-VEGF therapy over time, independent of the presence of IRF, SRF or RT. We conclude that the above listed OCTA parameters could contribute to our understanding of MNV biology and to guide individualized treatment in the future.

TRIAL REGISTRY

The authors confirm that all ongoing and related trials are registered. ClinicalTrials.gov Number: NCT02521142.

Response to brolucizumab treatment for refractory serous pigment epithelial detachment secondary to polypoidal choroidal vasculopathy

PURPOSE

To report the efficacy and safety of brolucizumab in the treatment of refractory serous pigment epithelial detachment (PED) secondary to polypoidal choroidal vasculopathy (PCV).

METHODS

Twenty-six eyes of 26 patients were included. Intravitreal brolucizumab 6.0 mg was administered, followed by pro re nata (PRN) retreatment at monthly follow-ups. All patients underwent spectralis domain optical coherence tomography (SD-OCT), fluorescein angiography, and indocyanine green angiography before the first brolucizumab injection. SD-OCT was repeated at follow-up visits. The height and width of the serous PEDs, measured using SD-OCT, were analyzed.

RESULTS

The number of previous anti-VEGF injections was 12.3 ± 15.0. During brolucizumab treatment, anatomical improvement was achieved and maintained in the height and width of the PEDs (p < 0.05). However, the visual outcome did not improve significantly (p > 0.05). A good response was achieved in 69.2% of eyes at 1 month and at the last visit. Relapse and complete resolution were observed in 27.8 and 23.1% of patients, respectively. The number of brolucizumab injections was 2.00 ± 0.85. Intraocular inflammation, vascular obstruction, and retinal pigment epithelial tears were not observed.

CONCLUSION

Intravitreal brolucizumab may be an effective and safe treatment option for refractory serous PEDs in patients with PCV.

Short-Term Effects of Brolucizumab in the Treatment of Wet Age-Related Macular Degeneration or Polypoidal Choroidopathy Refractory to Previous Anti-Vascular Endothelial Growth Factor Therapy

Background and objectives: To report the initial response to a single intravitreal brolucizumab (IVI-B) injection in wet age-related macular degeneration (wAMD) or polypoidal choroidopathy (PCV) complicated with either persistent subretinal fluid (SRF) or pigment epithelial detachment refractory to previous anti-vascular endothelial growth factor (anti-VEGF) therapy. Material and methods: In this retrospective study, all eyes received a single IVI-B (6 mg/0.05 mL) for wAMD or PCV with treatment-resistant SRF or PED. Outcome measures included assessment in central retinal thickness (CRT), visual acuity, and evaluation for changes in the SRF or PED on OCT. Follow-up was prior to the first brolucizumab injection, then at 1 week and 5 weeks afterwards. Results: In total, 10 eyes of 10 patients (6 women [60%]) were enrolled. Five patients had wAMD and five patients had PCV. Average age of participants was 67.6 years. All patients received one IVI-B. All patients were not treatment-naïve to anti-VEGF agents. At the first week and fifth week following the first IVI-B, seven out of seven patients (100%) had resolved SRF. However, seven out of nine patients (78%) had no improvement of their PED at 5 weeks follow-up. Mean PED height and width before the first IVI-B was 339.77 µm and 2233.44 µm, respectively. Mean PED height and width at the fifthweek following the first IVI-B was 328.125 µm and 2129.5 µm, respectively. Overall mean visual acuity before the first IVI-B was 0.224; and 5 weeks following the first IVI-B was 0.38. Conclusions: Treatment with brolucizumab resulted in anatomical improvement for all patients with persistent SRF. Limited efficacy was seen for persistent PED. Brolucizumab appears to be a safe and effective option for treatment-resistant SRF. Future multicenter collaborative studies are warranted.

Comparison of the regressive effects of aflibercept and brolucizumab on pigment epithelial detachment

Background

To compare the regressive effects of aflibercept and brolucizumab on pigment epithelial detachment (PED) in age-related macular degeneration.

Methods

Eighty-three eyes of 83 patients diagnosed with type 1 macular neovascularization were included and retrospectively analysed using multimodal imaging. Forty-nine eyes were treated with intravitreal aflibercept injections (IVA group), and 34 eyes were treated with brolucizumab (IVBr group), with three consecutive injections administered as induction therapy. Before treatment and 1, 2, and 3 months after the first treatment, the maximum height (MH) and maximum diameter (MD) of the PED were measured using optical coherence tomography in each treatment group.

Results

In the IVA group, MH at baseline (228 ± 169 μm) diminished to 180 ± 150 (P = 0.2558), 165 ± 140 (P = 0.0962), and 150 ± 129 µm (P = 0.0284) at 1, 2, and 3 months after treatment, respectively; the reduction at 3 months was significant. In contrast, in the IVBr group, the MH was 307 ± 254 µm before treatment, and it decreased to 183 ± 156 µm (P = 0.0113), 139 ± 114 µm (P = 0.0003), and 125 ± 126 µm (P < 0.0001) at 1, 2, and 3 months after treatment, respectively, and the reduction at 1 month was significant. In both groups, the MD did not regress significantly.

Conclusions

The results suggested that the MH of PED after IVBr treatment regressed faster than that after IVA treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02617-2.

Brolucizumab Intravitreal Injection in Macular Neovascularization Type 1: VA, SD-OCT, and OCTA Parameter Changes during a 16-Week Follow-Up

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.

Early OCT Angiography Changes of Macular Neovascularization in Patients with Exudative AMD Treated with Brolucizumab in a Real-World Setting

Background

To report on the short-term outcome of intravitreal brolucizumab in patients with neovascular age-related macular degeneration (nAMD).

Methods

This is a prospective, interventional, monocentric study on 10 eyes of 10 patients with a treatment-naïve neovascular AMD. Patients were treated according to the HAWK and HARRIER trials. After loading with 3 monthly injections, eyes received an injection 12 weeks after the upload (q12w) or were adjusted to an 8 week interval (q8w), if disease activity was present 8 weeks after the upload. Main outcome measures were the change in central retinal thickness (CRT) assessed by spectral domain optical coherence tomography (SD-OCT), the change in macular neovascularization (MNV) size on optical coherence tomography angiography (OCTA), and the change in best corrected visual acuity (BCVA) 8 and 12 weeks after the upload. We further assessed clinical parameters that predict the treatment response at baseline based on the need of q8w or q12w injections after the upload.

Results

CRT decreased significantly from 461.7 ± 82.9 μm to 343.6 ± 74.3 μm (p=0.004) 12 weeks after the upload. The MNV size decreased significantly from 0.85 ± 1.1 to 0.75 ± 1.2 mm² (p=0.022). BCVA improved from 0.67 ± 0.4 to 0.55 ± 0.4logMAR but without statistical significance. MNV size in eyes on q12w was considerably smaller compared to that in eyes on q8w (0.54 ± 0.7 mm² vs. 1.98 ± 2.4 mm²). The percentage of eyes without any persistent fluid was 70% (7/10 eyes).

Conclusions

Brolucizumab appears to be a valuable tool for the management of patients with nAMD. Furthermore, MNV size at baseline might serve as an early predictor of treatment response.

Brolucizumab: Evaluation of Compassionate Use of a Complex Anti-VEGF Therapy

Objective

To report a consecutive series of compassionate, off-label use of intravitreal brolucizumab as a rescue therapy for complex, non-responsive macular edema. This report delineates primary diagnosis, indications for treatment, adverse events, and visual and anatomic outcomes after intravitreal brolucizumab.

Methods

A retrospective review of a consecutive clinical case series of 110 eyes treated with intravitreal brolucizumab between January 1st and March 1st. 2020. All patients were included if they received intravitreal brolucizumab in an off-label delivery and had ongoing macular edema in the setting of prior, multiple intravitreal anti-VEGF and/or intravitreal triamcinolone acetonide. All patients had spectral domain OCT documented before, at the time of, and in serial follow-up after intravitreal brolucizumab.

Results

Ninety-eight of 98 patients had marked decrease in macular edema. Indications for treatment were assigned to the primary etiologic diagnosis leading to the macular edema secondary to radiation retinopathy, complex epiretinal membrane, or complex diabetic retinopathy. In this series, sdOCT central point thickness decreased by an average of 71.5 microns, subretinal fluid resolved, and visual acuity was improved in 40% (greater than two Snellen lines) and stable in 60% (within two Snellen lines). No patient experienced a severe adverse event to specifically include vitritis and/or vasculitis.

Conclusion

In this series, brolucizumab intravitreal injection was associated with significant improvement in macular edema in each diagnostic category. No serious complications to treatment were found in this series. Brolucizumab, though associated with known intraocular inflammation and vasculitis, demonstrated marked benefit in these complex eyes previously unresponsive to aggressive intravitreal pharmacotherapy.