Age-related macular degeneration (AMD) is one of the leading causes of blindness. Pigment epithelial detachments (PED) can accompany neovascular AMD (nAMD) in as many as 62% of patients.
- Coscas F.
- Coscas G.
- Souied E.
- Tick S.
- Soubrane G.
Optical coherence tomography identification of occult choroidal neovascularization in age-related macular degeneration.
PEDs are thought to be formed by the accumulation of fluid, blood, drusenoid material or fibrovascular tissue, which separates the retinal pigment epithelium from Bruch's membrane.
- Pepple K.
- Mruthyunjaya P.
Retinal pigment epithelial detachments in age-related macular degeneration: classification and therapeutic options.
Anti-VEGF treatment has become the mainstay of treatment for neovascular AMD. However, there is a paucity in the literature on the effects of aflibercept on PEDs secondary to nAMD. In this issue, Diaconita et al. (2019) report on their prospective, exploratory, open-label study aimed at understanding the effects of intravitreal aflibercept in treating patients with PED secondary to nAMD.
- Diconita V.
- Li B.
- Pal L.
- Bahnacy F.
- Gonder J.R.
Prospective evaluation of aflibercept in the treatment of pigment epithelial detachments secondary to neovascular age related macular degeneration.
The authors recruited 36 patients (37 eyes) who were ≥55 years of age with PEDs secondary to nAMD and no previous anti-VEGF injections. Patients were injected with 2 mg of aflibercept on a monthly basis for three months followed by bimonthly injections for another nine months. Measures of patients’ vision-related quality of life and best corrected visual acuity (BCVA), ophthalmic examinations, optical coherence tomography (OCT), and fluorescein angiography (FA) were performed on a regular basis. Indocyanine green (ICG) studies were also performed at baseline, 4 month, and 12 months. In addition to the study schedule, patients also received injections when needed in the case of disease progression or recurrence. Patients were classified into two categories based on OCT changes at 4 months: responders (OCT reduction of PED size ≥ 25%) or partial responders (OCT measured reduction of PED size < 25%).
Of the 37 eyes included in the study, 27 (73.0%) were responders to aflibercept injections. The authors showed that PED height reduction was significantly different even after receiving one injection when comparing responders to partial responders. On average at 2 months (after 1 injection), PED height was 336.5 µm in responders compared with 63.9 µm in partial responders and at 12 months, PED height reduction was 348.6 µm in responders vs. 94.5 µm in partial responders. Similarly, after 12 months of injections, the BCVA of patients had an average gain of 10.1 ETDRS letters, with 14.0 letters in responders versus 0.5 letters in partial responders. At the end of one year, complete resolution of the PED was achieved in about one-third (32.3%) of patients. One patient, who had the largest PED (1009 µm), suffered a retinal tear, otherwise there were no other complications.
Similar to the current study, previous retrospective studies have also shown a decrease in PED height after aflibercept use.
- He L.
- Silva R.A.
- Moshfeghi D.M.
- Blumenkranz M.S.
- Leng T.
Aflibercept for the treatment of retinal pigment epithelial detachments.
- Hata M.
- Oishi A.
- Tsujikawa A.
- et al.
Efficacy of intravitreal injection of aflibercept in neovascular age-related macular degeneration with or without choroidal vascular hyperpermeability.
Furthermore, two prospective studies showed a reduction in PED size when patients were switched to aflibercept after failing ranibizumab treatment.
Intravitreal aflibercept in neovascular age-related macular degeneration with limited response to ranibizumab: a treat-and-extend trial.
Intravitreal aflibercept in treatment-resistant pigment epithelial detachment.
In addition to the decrease in PED height, Diaconita et al. found significant vision gain in patients receiving aflibercept. As noted by the authors, some of the limitations of this study include small sample size and lack of control group. Overall, the study provides valuable evidence for the use of aflibercept in the treatment of nAMD associated PEDs, and it suggests that patients who show good initial response (responders) after 3 injections will likely have significantly better final outcomes compared with patients who do not show much improvement (partial responders). However, further studies are required to better understand treatment response.
Clinical practice point: Aflibercept shows significant promise in the improvement of visual acuity and reduction of PED height in the setting of nAMD. Patients who show good OCT response through the reduction of PED height after the first couple of injections of aflibercept will likely have better final outcomes compared with patients who do not respond initially.