Ophthalmologists highlight treatment options for retinal vascular diseases

(Image Credit: AdobeStock/crevis)

Reviewed by Jaclyn Kovach, MD

A recent Ophthalmology Times Grand Rounds panel in Miami Beach, Florida, discussed advanced solutions and achieving superior outcomes with durable treatments in patients with challenging retinal vascular diseases. The discussion centered on 2 patients with neovascular age-related macular degeneration (nAMD) and 2 with diabetic macular edema (DME). Here are some of the highlights.

Treating nAMD

Case 1

Adi Smith, MD, from the South Florida Retina Institute in Aventura, Florida, described the case of a 65-year-old White man with nAMD and a large refractory pigment epithelial detachment (PED) with adjacent subretinal fluid. The patient presented with decreased left-eye vision to 20/50 for 1 week. The right-eye vision was 20/20 with mild and moderate drusen. He had a history of dry AMD and cataract surgery, takes Age-Related Eye Disease Studies vitamins (Bausch & Lomb), and is a nonsmoker.

The patient began treatment in September 2019 with an injection of aflibercept (Eylea; Regeneron Pharmaceuticals) and over an extended treatment course by June 2023 had received 22 injections of the drug, 2 injections of bevacizumab (Avastin; Genentech), and
10 injections of ranibizumab (Lucentis; Genentech), and was ultimately switched to faricimab (Vabysmo; Genentech), at which time the vision was counting fingers. Four weeks into the every-4-week faricimab regimen, the visual acuity (VA) was 20/250 and 5 months later, in February 2024, it was 20/70.

Before the switch to faricimab, the persistent PED was enlarging with more intraretinal fluid; the PED started to flatten over time and overlying subretinal fluid and intraretinal fluid were present despite the various anti-VEGF treatments. After 1 faricimab injection, the PED and the subretinal and intraretinal fluid resolved in a “dramatic response,” according to Smith.

Smith said the patient, who is now very happy, is treated at 6-week intervals, with longer treatment intervals expected.

The ensuing conversation about the helpfulness of optical coherence tomography angiography (OCTA) in patients such as the current one showed that OCTA will show the presence/absence of active choroidal neovascularization.

Another interesting discussion was about the number of injections of a specific drug administered before switching treatments is considered.

The panelists agreed that the patient’s individualized response to treatment drove the decision-making process regarding the number of injections.

A discussion of treatment intervals revealed that some but not all patients can be extended to 16 weeks, based on disease changes over time. The commercials for faricimab may be fueling patients’ desire for 16-week intervals, but physicians cannot guarantee that timeline.

Case 2

Jaclyn Kovach, MD, from Bascom Palmer Eye Institute in Naples, Florida, described an 82-year-old patient with wet AMD and persistent subretinal fluid in the right eye despite years of monthly aflibercept injections. The patient was switched to brolucizumab (Beovu; Novartis) when it received FDA approval and then back to monthly aflibercept. OCTA showed a small amount of intraretinal fluid; the best-corrected VA was 20/50. Six weeks after switching to the first faricimab injection, the fluid resolved but the vision stayed at 20/60; 7 weeks after the second faricimab injection the vision increased to 20/40 with no recurrence of fluid.

The plan for the patient is to continue to increase the treatment intervals. The feeling is that extending the treatment intervals is important to both the patients and physicians to minimize risk and eliminate “injection fatigue.”

Treating DME

Case 1

Katherine Talcott, MD, from the Cole Eye Institute, Cleveland Clinic, in Cleveland, Ohio, presented the case of a 49-year-old man with DME who was lost to follow-up. The patient spent most of his time working at a computer. His type 2 diabetes was treated with insulin; the last hemoglobin A1c (HbA1c) level from 2 years prior was 9.5. It was unclear whether he had been receiving regular medical care. Imaging showed intraretinal fluid in the symptomatic right eye with 20/40 vision. The blurry left-eye vision was 20/20 with some intraretinal fluid.

After 3 monthly injections of bevacizumab, the vision in the right eye improved to 20/20 but substantial fluid persisted. The patient was switched to aflibercept and the intraretinal fluid began to improve; after 10 injections the vision was 20/20 and the blurriness resolved. After the patient was switched to an as-needed regimen, he was lost to follow-up because of a family death and caring for an older parent. As a result, his health declined. An evaluation 1 year later showed a VA decrease to 20/50 and significant fluid. Treatment with 1 faricimab injection resulted in 20/20 vision and resolution of the fluid.

Talcott pointed out that this response was a big change from the persistent fluid seen at the start of his treatment; 2 months later the eye still looked “fantastic.”

The panelists engaged in a discussion of resuming treatment of patients who had been lost to follow-up and switching them to a drug that provides more durable results. Many expressed feeling comfortable having more durable agents available to treat these patients because when the patients return, the chances are that their macula status will be better.

Talcott said she treats patients with DME differently from patients with AMD and determines how bothersome the symptoms are and their visual needs before starting injections.

Physicians were not concerned about how often they evaluate their patients with DME, but they were most concerned about those with severe nonproliferative diabetic retinopathy (NPDR) or those with NPDR with some fluid and the risk of developing proliferative disease. They take this opportunity with patients to emphasize the importance of disease control and lowering the HbA1c level to reduce the risk of proliferation.

Case 2

Greg Budoff, MD, from Retina Consultants in Hartford, Connecticut, presented the case of a 58-year-old woman with DME, well-controlled diabetes, and an HbA1c level of 6.2 who achieved an extended treatment interval. The patient had been referred for bilateral decreases in vision secondary to DME; the right-eye vision was 20/40 and the left-eye vision was 20/60. She has significant diabetic retinopathy.

The patient was started on monthly bilateral aflibercept injections and gradual improvement occurred over the next few months; after the fourth injection, the macular edema persisted and the vision was stable. After this, she was switched to faricimab and the edema and vision continued to improve. At this point, the treatment interval was extended from every 4 weeks.

Budoff wanted to reexamine her in 7 or 8 weeks, but she returned at 11 weeks, at which time she was doing well. At 10 weeks and 12 weeks later, the retina was dry. She is returning currently at 15-week intervals and continues to do well.

Budoff was less than enthusiastic about an as-needed regimen because he said those patients tend to not return for an examination until a problem develops. He explained that while continuing to treat and extend the injections if the edema develops again, clinicians can significantly reduce the degree to which the edema develops.

Other clinicians consider the individual patient but give them the option of as-needed treatment; if that fails, the patient can resume a treat-and-extend regimen.

The participants also discussed the role of steroids for managing DME, considering the availability of more durable anti-VEGF drugs. Steroids may have a place in the treatment of recalcitrant patients with a great deal of intraretinal fluid on OCTA images and for those with no or little response to the anti-VEGF drugs.

The physicians believe it is important to continue to use and to know how to use steroids and to be able to talk to the patients about their risks and benefits.

Focal laser can be used in specific scenarios such as in patients with good vision with non–center-involving DME but with some fluid. Laser treatment has the potential in some cases to prevent the need for anti-VEGF drugs altogether.

The physicians pointed out that there is a generational difference in the use of laser, with older doctors using it more.

The take-home message of this case-based discussion is that the availability of long-
duration treatments for both AMD and DME can be life-enhancing for patients by lessening their treatment burden and for physicians by easing practice demands.

Jaclyn Kovach, MD

E: jkovach@med.miami.edu

Kovach is a professor of clinical ophthalmology at the Bascom Palmer Eye Institute in Naples, Florida.