Treating complex cases of nAMD and DME

(Image Credit: AdobeStock/cherryandbees)

Expert retina specialists presented 3 complex cases, treatment strategies, and key insights for managing neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) with the latest treatments during an Ophthalmology Times Grand Rounds discussion.

Case 1: Treatment-naive PDR and DME

Carl Danzig, MD, a retina specialist at Rand Eye Institute in Deerfield Beach, Florida, described a case of a 48-year-old treatment-naive man with a history of diabetes and both proliferative diabetic retinopathy (PDR) and DME who presented with blurry vision in the right eye. The vision was 20/30 bilaterally, and the IOPs were 15 and 14 mm Hg in the right and left eyes, respectively. There was no iris neovascularization, and there were clear lenses. The right eye had neovascularization elsewhere (NVE), dot-and-blot hemorrhages, cotton-wool spots, preretinal hemorrhage, DME, and a chorioretinal scar temporally. The left eye had no NVE or disc neovascularization, dot-and-blot hemorrhages, and a cotton-wool spot with some extrafoveal edema and moderate nonproliferative DR. His hemoglobin A1C level was well controlled at 5.6%.

The patient ultimately underwent 5 injections of faricimab (Vabysmo; Roche/Genentech). The vision improved to 20/20, and the central subfield thickness decreased from 456 to 305 μm.

Danzig’s first-line treatment for PDR is always an anti-VEGF or bispecific agent, specifically faricimab in this case because of the dual pathway inhibition of VEGF and angiopoietin-2. Although such a patient would often undergo laser treatment, Danzig was confident about using monotherapy because of the diabetic control. Adrienne Scott, MD, a retina specialist at the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland, noted that a key take-home point is follow-up of these patients to ascertain that the neovascularization does not recur and that DR and DME are well controlled.

Case 2: Treating nAMD with a PED

Scott described a 73-year-old man with long-standing intermediate AMD who presented with a new-onset central scotoma in the right eye. His ocular history was negative; his family history was positive for nAMD. The vision was 20/32 bilaterally with 2+ brunescent cataracts. The patient had multiple large soft drusen throughout the macula and some drusenoid pigment epithelial detachments (PEDs), possibly fibrovascular in nature.

The patient received anti-VEGF therapy, ie, aflibercept (Eylea; Regeneron), in the right eye, with very little anatomic response in the PED height. Despite repeated injections every 4 weeks, the height of the PED continued to increase; the vision had been stable but decreased to 20/50. An optical coherence angiogram confirmed choroidal vascularization.

When the patient experienced an embolic stroke 3 hours after an aflibercept treatment, the injections were discontinued for 2 months. Neurologic and neuro-ophthalmologic consultations resulted in cautious continuation of the injections. The vision decreased to 20/80, with cataract progression.

Administration of faricimab resulted in some consolidation of the PED and decreased subretinal fluid. The vision was 20/125, and cataract surgery is pending.

Scott said she usually starts with first-line aflibercept. The current patient began treatment before faricimab was available. The patient is now treated every 4 weeks with faricimab.

Scott commented that this patient’s PED was striking and that the height of the PED put him at risk for a PED rip, possibly with sudden visual loss, despite anti-VEGF therapy. “I am impressed with some of the faricimab data and the PED responses, and I wonder if the anti-angiopoietin pathway inhibition is somehow implicated in the anatomic response and improvement in PEDs,” she commented.

Case 3: nAMD with geographic atrophy

Roger Goldberg, MD, a retina specialist at Bay Area Retina Associates in Walnut Creek, California, reported a case of a 71-year-old woman with bilateral slow-onset blurred vision. The right eye had geographic atrophy (GA) and drusen. Baseline angiography showed no leakage, and optical coherence tomography (OCT) showed drusen in atrophic areas. The left eye had intermediate AMD, a lot of drusen, no significant atrophy, and no leakage. She also had cataracts and underwent bilateral cataract surgery, which was uneventful. Four months later, she reported bilateral blurred vision. No posterior capsule opacification was present.

Fluorescein angiography (FA) showed leakage in the right eye and a small, superior macular hemorrhage. New leakage was present in the left eye. The right eye had subretinal hyperreflective material (SHRM) adjacent to the GA, but suggestion of leakage at the hemorrhage is present. The left eye had SHRM, intraretinal fluid, and an enlarged PED.

The patient had new-onset bilateral wet AMD and was treated with faricimab. One month later, the fluid resolved bilaterally as did the hemorrhage in the right eye. Atrophic areas were still present. She was treated with a treat-and-extend regimen, and her treatment is currently extended to a 10-week interval on faricimab bilaterally.

After 6 months, the hemorrhage resolved. Atrophic areas were present with a small burden of GA but great control of the exudative AMD. The patient’s vision is now 20/25 bilaterally.

Despite many retina specialists using FA less often, Goldberg said he finds ultrawidefield FA particularly helpful for diabetic patients. He explained that the status of the peripheral retina is informative and predictive of a patient’s risk. He performs it in new-onset wet AMD because it is sometimes helpful.

Danzig said he sometimes uses FA in patients with wet AMD to quantify lesion size. However, in older patients, he may perform OCT angiography to determine the size of the neovascular membrane. “For my patients [with diabetes] and those with retinal vein occlusion, ultrawidefield FA is commonplace,” he said.

Scott commented that she would not treat the GA at this point. She explained that the treatment is not risk free and which patients are at risk is unknown. She currently monitors the GA during treatment.