Longer anti-VEGF intervals in AMD, BRVO, and DME: 3 clinical cases

How quickly do eyes respond to newer anti-VEGF agents, and when can treatment intervals be lengthened? A Modern Retina Clinical Forum roundtable held in New York, New York, was moderated by Deepika Malik, MD, a vitreoretinal surgeon at Ophthalmic Consultants of Long Island. She presented 3 cases covering neovascular age-related macular degeneration (AMD), branch retinal vein occlusion (BRVO), and diabetic macular edema (DME).

Neovascular AMD after bevacizumab

The first patient was a woman aged 76 years with neovascular AMD in the left eye, diagnosed more than 8 months earlier. The fellow eye had early-stage nonexudative AMD. She had received 3 bevacizumab injections every 4 weeks and still had subretinal fluid on optical coherence tomography (OCT), with best-corrected visual acuity (BCVA) of 20/150 and central retinal thickness (CRT) of 318 µm.

She wanted to extend her treatment intervals and was switched to aflibercept 8 mg with 3 monthly loading doses. At 4 weeks, BCVA was 20/100 and CRT was 219 µm; at 8 weeks, BCVA was 20/80 and CRT was 186 µm. Malik asked attendees whether, at that point, they would continue at 4-week intervals, extend, or change agents.

The interval was extended directly to every 16 weeks after loading. At approximately week 24, BCVA was 20/60 (20/50−2 with pinhole) and CRT was 208 µm, with a sliver of fluid visible. At approximately week 40, BCVA was 20/60 (20/50 with pinhole), CRT was 192 µm, and trace subretinal fluid remained.

Discussing real-world data on treatment-naive, early-switch, and late-switch eyes, Malik said “there is some advantage in going on to the second-generation drugs early on rather than waiting too long.”

BRVO on faricimab

The second patient, a woman aged 66 years, had blurred vision in the right eye for 2 weeks before diagnosis of a superior temporal BRVO with macular edema. Baseline BCVA was 20/100 and central subfield thickness (CST) was 556 µm. Malik said the case came from the phase 3 BALATON trial (NCT04740905), and the patient began faricimab with monthly loading doses.

After 1 injection, CST fell to 342 µm and BCVA improved to 20/80. After 6 monthly loading doses, treatment moved to a treat-and-extend schedule, with BCVA of 20/40 and CST of 321 µm when treat-and-extend began. The interval was extended by 4 weeks per visit to every 16 weeks.

At injection 10, a mild recurrence was recorded at the 16-week interval (CST 369 µm, BCVA 20/40), and the interval was maintained. At study exit, 16 weeks later, BCVA was 20/40 and CST was 327 µm, and no injection was given. Six months after injection 10, BCVA was 20/63 and CST was 385 µm; at 12 months, BCVA was 20/50 and CST was 379 µm.

Treatment-naive DME

The third patient was a man aged 72 years with type 2 diabetes (hemoglobin A1c 8.4%) and about 3 weeks of blurred vision in the left eye. He had treatment-naive center-involving DME with a large pocket of subretinal fluid, cystic intraretinal fluid extending nasally, and intraretinal lipid. Baseline BCVA was 20/80 and CRT was 423 µm. Malik noted that this was a real-world case rather than a clinical trial case.

He began aflibercept 8 mg with 3 monthly loading doses. After the first injection, BCVA was 20/60 and CRT was 331 µm; Malik noted that intraretinal fluid had nearly resolved, while hard exudate and subretinal fluid remained. At 8 weeks, when the third dose was given, BCVA was 20/60 and CRT was 298 µm, and subretinal fluid was still present.

The patient returned about 7 weeks later, at approximately week 15. The fluid had resolved completely, BCVA was 20/40, and CRT was 210 µm.

Malik said that “sometimes waiting is OK.” The plan was to extend the interval to every 12 weeks.