Advanced therapies for retinal vascular diseases

(Image Credit: AdobeStock/Panama)

A panel of retina specialists discussed highlights from a recent Ophthalmology Times Grand Rounds event. The topic was the use of advanced therapies for retinal vascular diseases, including age-related macular degeneration (AMD), diabetic macular edema (DME), and central retinal vein occlusion (CRVO). The discussion focused on the durability of therapies, reduced treatment burden, and experiences in managing different lesion types.

Case 1: Treatment-naive neovascular AMD

David R. Lally, MD, from New England Retina Consultants in Springfield, Massachusetts, presented the case of a 79-year-old pseudophakic Caucasian man with AMD. He highlighted the superior durability of newer treatments.

The patient, with a history of cardiovascular issues, presented with distorted central vision in the left eye for 3 weeks’ duration. His presenting visual acuities (VAs) were 20/30 in the right eye and 20/50 in the left eye.

Imaging revealed early dry AMD in the right eye and a pigment epithelial detachment (PED) with soft drusen, subretinal, and intraretinal fluid. In the left eye, the thickest retinal area above the foveola contained a small PED, a hyperreflective intraretinal lesion surrounded by intraretinal edema, and a small intraretinal hemorrhage.

The patient received an intravitreal injection of faricimab (Vabysmo, Genentech). Six weeks later, the VA improved to 20/25, with almost complete resolution of intraretinal fluid and complete resolution of subretinal fluid and intraretinal hemorrhage. Over 13 months, the patient received 5 injections, with treatment intervals extended to 9, 12, 13, and 15 weeks.

“This patient had rapid resolution of fluid with treatment durability and a low number of treatments,” Lally commented, noting that rapid retinal drying may depend on the lesion types present in individual patients.

Case 2: DME with severe vision loss

Scott D. Walter, MD, MSc, FASRS, from Retina Consultants in Hartford, Connecticut, described a 64-year-old man with uncontrolled type 2 diabetes and bilateral DME. The patient had severe vision loss for about 1 year, with a VA of 20/400 in the right eye and counting fingers at 2 feet in the left eye.

Imaging of the right eye showed diffuse intraretinal fluid and subretinal fluid involving the fovea. The left eye demonstrated prefoveal neovascularization. Walter treated the right eye with 4 loading-dose injections of faricimab at intervals of 4 to 6 weeks. The left eye received the same treatment schedule with ranibizumab (Lucentis, Genentech), enabling a comparison of the 2 drugs.

Five weeks after the initial faricimab injection, the intraretinal fluid resolved, and subretinal fluid was improving. After a second injection, further anatomic improvement was observed. Angiographic findings showed a reduction in leakage after the third injection.

For the left eye, 4 loading doses of ranibizumab were administered. After 1 injection, imaging showed decreased intraretinal fluid and regressed neovascularization at 5 weeks. Following the second dose, a slight rebound fluid fluctuation was observed. After a third injection, drying improved, but some foveal center fluid persisted, requiring shortened treatment intervals.

Walter concluded that faricimab was superior to ranibizumab in reducing microaneurysm leakage and resolving lesions in this patient.

Case 3: Persistently active CRVO

Lisa J. Faia, MD, from Associated Retinal Consultants in Royal Oak, Michigan, presented the case of a 60-year-old man with a VA of 20/25-1 in the left eye and 20/20 in the right eye. The left eye exhibited retinal hemorrhages, vascular tortuosity, leakage, and peripheral capillary dropout. A diagnosis of CRVO with macular edema (ME) was made.

Treatment began with 2 intravitreal injections of bevacizumab (Avastin, Genentech) at 4-week intervals. However, the VA worsened to 20/30, and ME persisted. The treatment was then switched to ranibizumab, with 2 injections administered every 4 weeks. This improved the VA to 20/20 but did not resolve the ME.

The patient was subsequently switched to faricimab, receiving 3 injections at 4-week intervals, followed by extensions to 6 and 8 weeks. At the last visit, the VA had improved to 20/15. Faia noted that CRVO is a relatively new indication for faricimab, and clinicians are still gaining experience with its use.

Case 4: Neovascular AMD with PED

Sumit Sharma, MD, MSc, FASRS, from the Cole Eye Institute at the Cleveland Clinic, in Ohio, described a 78-year-old Caucasian woman who presented with visual distortion and a decreased VA of 20/40. Imaging revealed a severe retinal PED with a small amount of fluid.

The patient, diagnosed with wet AMD, initially received bevacizumab injections every 4 weeks. While fluid decreased and VA improved, the PED increased in size over time.

The patient refused to switch medications until missing an injection resulted in VA decline. She then switchedto aflibercept (Eylea, Regeneron Pharmaceuticals). Despite 31 aflibercept injections, fluid increased, and a slightly longer treatment interval was required.

Switching to faricimab led to significant fluid reduction after 1 injection, with VA improving to 20/30. After 3 injections, PED flattening caused a 2-diopter refractive shift, improving VA to 20/25. Treatment intervals were ultimately extended to 8 weeks.

Sharma suggested that angiopoietin-2 inhibition by faricimab may play a role in its efficacy, warranting further study as experience with the drug increases.