SPARK IMAGEWISE 27 – RETINA

Response to long acting anti VEGF in case of CNV associated with AMD

Dr. Shashank Somani, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A male, 71 years of age, came with complaints of black spot in front of left eye since 8 days which was sudden in onset and increased with time. He was a known case of systemic hypertension since 10 years. His best corrected visual acuity was 6/6, N6 in right eye and 6/18, N18 in left eye. Anterior segment examination showed presence of early cataractous lens changes in both the eyes. Intraocular pressure recorded by Goldmann applanation tonometer was 12 mmHg in both eyes. 

Figure 1: Fundus photograph of the right eye shows cellophane maculopathy (yellow arrow) and a small splinter hemorrhage (green arrow)
Figure 2: Fundus photograph of the left eye shows cellophane maculopathy (yellow arrow) with a rounded area of RPE alteration nasal to the fovea (green arrow) with blunting of the foveal reflex. 
Figure 3: The optical coherence tomography line scan of right eye passing through the fovea shows a normal foveal contour and presence of multiple drusen in the superior part of the retina (green arrows).
Figure 4: The optical coherence tomography line scan of left eye passing through the lesion showing hyperreflectivity in the subretinal space (yellow arrow) suggestive of a CNVM and surrounding hypo reflectivity suggestive of sub-retinal fluid (blue arrow). There is evidence of widening of the outer nuclear layer (green arrow) and splitting of the outer plexiform layer (red arrow) suggestive of early intraretinal edema. 
Figure 5: The optical coherence tomography angiography scan of left eye with a slab passing through avascular complex showing tuft of abnormal blood vessels suggestive of CNVM (green arrow).

Based on the clinical findings, a diagnosis of choroidal neovascular membrane with age related macular degeneration was made and the patient was advised intravitreal anti-VEGF injection for the left eye. The patient was followed up on 1 month after each injection and sequential OCT line scans were taken on each followup. 

Figure 6: SDOCT follow up scans after monthly injections of bevacizumab showing persistence of retinal edema. 
Figure 7: SDOCT follow up scans after monthly injections of bevacizumab showing persistence of retinal edema. 

An option of a long acting anti VEGF was discussed with the patient with an aim to reduce the number of injections and follow up visits. Patient was advised inj Brolucizumab which was done on 17/09/2021.

Figure 8: SDOCT follow up scans after 1 injection of brolucizumab showing complete resolution of macular edema. 

Discussion

This is a typical case of AMD who required multiple injections of anti-VEGF. The patient used to respond to the monthly injections but the edema used to recur again at the end of a month. The management of such a situation includes switching to a treat and extend regime or plan for a long acting anti-VEGF injection. We discussed the options with the patient and he was willing to go for the long acting anti-VEGF – Brolucizumab. The patient was informed about the possible side effects that may  on occasion be associated with the use of Intravitreal Brolucizumab. The response to Brolucizumab was quite satisfactory as the edema got completely resolved and patient did not require an injection even at the end of 2 months at the last follow up. 

Repeated follow ups in cases of AMD  and non availability of an escort apart from the pain and difficulties  associated with monthly injections has been a significant  challenge in  treatment of the elderly population.  This is known to cause treatment drop outs and delay in treatment which could have  a significant impact on vision. Long acting anti-VEGFs are a plausible options in such a scenario and with the availability of these newer molecules take us closer to the goal of  greater efficacy and duration of action.

ReadWise

  1. Chakraborty D, Maiti A, Sheth JU, Boral S, Mondal S, Nandi K, Sinha T, Das A. Brolucizumab in Neovascular Age-Related Macular Degeneration – Indian Real-World Experience: The BRAILLE Study. Clin Ophthalmol. 2021 Sep 7;15:3787-3795. doi: 10.2147/OPTH.S328160. PMID: 34522081; PMCID: PMC8434835.
  2. Dugel PU, Singh RP, Koh A, Ogura Y, Weissgerber G, Gedif K, Jaffe GJ, Tadayoni R, Schmidt-Erfurth U, Holz FG. HAWK and HARRIER: Ninety-Six-Week Outcomes from the Phase 3 Trials of Brolucizumab for Neovascular Age-Related Macular Degeneration. Ophthalmology. 2021 Jan;128(1):89-99. doi: 10.1016/j.ophtha.2020.06.028. Epub 2020 Jun 20. PMID: 32574761.

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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