Abstract
We investigated the efficacy of monthly alternating injections of aflibercept and bevacizumab (MAAB) for maintenance treatment in patients with neovascular age-related macular degeneration (AMD) who showed improvement with the initial monthly injections but presented with rapid worsening after conversion to bimonthly injections. We included 72 patients with neovascular AMD who showed improvement with loading injections of aflibercept. For maintenance treatment, bevacizumab was administered every alternate month between the bimonthly aflibercept injections in 24 (33.3%) eyes showing worsening (MAAB group). The other eyes were treated with aflibercept (BiA group) bimonthly. Baseline low retinal thickness, thick choroid, and presence of intraretinal fluid were associated with worsening after extending the injection intervals. Visual improvement was lower in the MAAB group than in the BiA group, but the final visual outcomes were comparable. Additional bevacizumab stabilized the early fluctuation of retinal thickness, thus maintaining long-term visual stability without increasing the risk of geographic atrophy or disciform scar until the second year. Previously treated eyes or those with polypoidal choroidal vasculopathy responded less to the initial loading doses and showed worsening under the bimonthly regimen. MAAB was effective in preventing anatomical and functional deterioration when bimonthly aflibercept proved insufficient for the maintenance treatment of neovascular AMD.
Highlights
Age-related macular degeneration (AMD) is a leading cause of blindness worldwide.Neovascular AMD is a condition in which abnormal blood vessels grow under the retina and leak fluid
If the previous subretinal or intraretinal fluid increased or new fluid or hemorrhage occurred from month 3 to 4, the patients were categorized into the monthly alternating injections of aflibercept and bevacizumab (MAAB) group, and they were treated with additional bevacizumab injections between the bimonthly aflibercept injections as a maintenance treatment that was part of a fixed regimen
Compared to the bimonthly aflibercept (BiA) group MAAB group had better baseline BCVA (p = 0.001, two-tailed unpaired t-test), but no nificant difference was observed in BCVA at the follow-up visits between the two gro When the injection interval was increased to 2 months, visual acuity in5 tohf e10fourth m was worse than that in the third month in both the groups
Summary
Age-related macular degeneration (AMD) is a leading cause of blindness worldwide. Neovascular AMD is a condition in which abnormal blood vessels grow under the retina and leak fluid. Compared to either ranibizumab or bevacizumab, aflibercept has better pharmacokinetic profile and greater binding affinity to VEGF-A It has been approved as the current regimen and consists of three initial 2-mg monthly injections followed by a bimonthly dosing regimen [4]. Several studies revealed that a majority of the eyes showed anatomical and functional worsening after the extension of the treatment interval to 2 months in clinical practice [6–9] These reports suggested that bimonthly aflibercept dosing may not be optimal for maintenance in some populations of patients, even though they responded well to the initial loading regimen. The present study was designed to identify subpopulations that experienced anatomical and functional worsening, thereby requiring additional injections when aflibercept dosing interval was increased to 2 months, as well as to investigate the efficacy and safety of monthly alternating injections of aflibercept and bevacizumab for the maintenance treatment of neovascular AMD
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