Author: Dinah Zur (Israel)
Co-authors: Robyn Guymer, Jean-François Korobelnik, Jennifer Arnold, on behalf of the Vision Academy
Purpose
The presence of retinal fluid on optical coherence tomography (OCT) scans is the main morphological biomarker of disease activity influencing a clinician’s re-treatment decisions when treating neovascular age-related macular degeneration (nAMD) with anti-vascular endothelial growth factor (VEGF) intravitreal injections (IVI). However, recent evidence on the impact of residual fluid in different retinal compartments suggests that differentiation of fluid location is required to best guide individualized treatment protocols.
Setting/Venue
Selected members of the Vision Academy met to review the influence of fluid on treatment outcomes in nAMD, with a particular focus on the criteria for re-treatment with anti-VEGF IVI according to fluid status. The Vision Academy comprises over 90 international retinal experts who collaborate to provide collective recommendations on clinical challenges in areas where there is a lack of conclusive evidence. Vision Academy recommendations are subject to a validation process to ensure there is consensus and endorsement from the entire group.
Methods
Existing data on the use of residual fluid to guide decision-making in nAMD were identified by literature searches performed using the MEDLINE/PubMed database; the cut-off date was January 2021 and searches were restricted to English-language publications only. These insights were used to develop an algorithm to guide treatment decisions for patients with nAMD according to residual fluid status.
Results
At baseline, macular neovascularization type, size, and location in relation to the fovea should be recorded. Disease activity should be monitored by best corrected visual acuity (BCVA), examination for retinal hemorrhage, and OCT. Fluid status should be assessed in each retinal compartment. Monthly anti-VEGF IVI should be administered during the induction phase and until maximal anatomical effect is achieved. If intraretinal fluid (IRF) and/or subretinal fluid (SRF) amounts are reducing, treatment should be continued without interval extension until resolution/stability is reached. During the maintenance phase, the treatment interval should be individually adjusted. In cases of disease inactivity (i.e., absence of IRF and SRF, no new retinal hemorrhage, and no decrease in BCVA attributable to disease reactivation), intervals can be extended by 2 weeks if using a treat-and-extend regimen. Disease stability/control is compatible with stable persistent residual SRF despite at least 3 monthly IVI. In the absence of any other signs of disease activity, treatment intervals may be maintained or cautiously increased. Persistent stable IRF can result from atrophic degeneration and often has other OCT signs to determine its origin. IRF due to persistent VEGF activity is considered a risk factor for continued vision loss and should not be tolerated.
Conlusions
The suggested treatment algorithm for those on a treat-and-extend regimen reflects recent data, taking into consideration the impact of residual fluid in different retinal compartments on visual acuity and our increased understanding of how to interpret fluid within the retina in patients with nAMD treated with anti-VEGF IVI. It hereby offers a more individualized approach which allows tolerance of stable amounts of residual SRF.
Financial Disclosure
The Vision Academy is supported by Bayer. Writing and editorial assistance was provided by Hollie Robinson, PhD and Rebecca Fletcher, (BA) Hons, of Complete HealthVizion, Ltd., McCann Health Medical Communications, funded by Bayer Consumer Care AG, Pharmaceuticals, Basel, Switzerland. DZ is a consultant for Allergan/AbbVie, Bayer, Novartis, and Roche. RG is a consultant for Apellis, Bayer, Novartis, and Roche/Genentech. JFK is a consultant for Allergan, Bayer, Kanghong, Novartis, Roche, Thea, and Zeiss. JA is a consultant for Bayer, Novartis, and Allergan.
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