Is Exudative Neovascular AMD a Chronic Disease? Analysis of Long-term Progression under Anti-VEGF Therapy

Abstract

Background Anti-VEGF therapy is the standard treatment for exudative neovascular age-related macular degeneration (nAMD) caused by the development of macular neovascularisation (MNV) with associated fluid exudation. The therapeutic strategies (T&E or PRN) assumed a scarring transformation of the MNV and exit strategies and were formulated accordingly. The present study investigates this hypothesis as a real-life long-term analysis.

Patients 150 eyes of 97 patients were continuously followed up over a mean period of 5.1 years (1 – 14 years) after initiation of anti-VEGF therapy between 2009 – 2017 until 2022. Treatment was based on the PRN regimen analogous to the IVAN study with ranibizumab, aflibercept or bevacizumab. The length and intensity of therapy were evaluated.

Results Of these 150 eyes, 119 (79.3%) required ongoing anti-VEGF therapy, while in 18 eyes (12.0%) therapy could be discontinued due to stabilisation of the situation. In 13 eyes (8.7%), therapy was discontinued due to deterioration in visual acuity to < 0.05. With ongoing therapy, therapy was often protracted, with an indication for therapy at the last documented doctorʼs visit, while stabilisation was often achieved within the first 2 years of treatment. The treatment intensity increased to 7.7 – 8.0 injections/year, especially after 2013, with the introduction of OCT-based treatment criteria. Most eyes (74.8%) with ongoing therapy required 6 – 9 injections/year even in the last three years of treatment.

Conclusion The fact that in the present study there is a long-term and intensive need for therapy in the majority of patients (approx. 80%) with exudative nAMD, supports the assessment that nAMD should be regarded as a chronic disease. Therefore, a proactive treatment strategy with consistent therapy at any sign of lesion activity might be recommended. Particularly in view of the risk of irreversible loss of vision, long term adherence of patients is also crucial for the best possible long term therapeutic outcome.

Fazit

Bereits bekannt:

Die bisherigen PRN- und T&E-Behandlungsstrategien der Anti-VEGF-Therapie bei der nAMD erhofften eine Vernarbung der MNV und Beendigung der Therapie. Um dies im klinischen Alltag zu analysieren, wurde in der vorliegenden Studie die Behandlungsnotwendigkeit im Langzeitverlauf untersucht.

Neu beschrieben:

Bei einem Großteil der Patienten (ca. 80%) war in der vorliegenden Studie eine langfristige und intensive Therapie mit 6 – 9 Injektionen auch nach vielen Jahren bis zum letzten dokumentierten Arztbesuch notwendig und auch nach dieser langen Behandlungszeit war bei Therapieunterbrechung ein massives Auftreten von Exsudationen und folgendem Visusverlust möglich. Dies deutet erneut darauf hin, dass die exsudative nAMD eine chronische Erkrankung ist mit jahrelanger Therapienotwendigkeit. Eine konsequente Therapie bei jeglichen Aktivitätszeichen flankiert mit Initiativen zur kontinuierlichen Patientenadhärenz erscheint daher empfehlenswert, um einen irreversiblen Visusverlust auch nach Jahren zu vermeiden.

Conclusion

What we already know:

The previous PRN and T&E treatment strategies for anti-VEGF therapy in nAMD patients were aimed at achieving scarring of the MNV, enabling discontinuation of treatment. In order to analyze this in everyday clinical practice, in this study we investigated the need for treatment over the long term.

Newly described:

In the majority of patients (approx. 80%) who participated in this study, long-term, intensive therapy with 6 – 9 injections was seen to be necessary even after many years, up until their last documented visit to the doctor, and even after this prolonged treatment period, occurrence of massive exudation and subsequent loss of visual acuity was possible if treatment was interrupted. This again indicates that exudative nAMD is a chronic disease that requires years of treatment. It therefore seems advisable for patients to receive consistent treatment in the event of any signs of activity, accompanied by initiatives for continuous patient adherence, in order to avoid irreversible loss of visual acuity that can occur even years later.

Keywords

exudative nAMD - anti-VEGF therapy - long-term analysis - length of therapy - injection frequency

Publication History

Received: 23 November 2023

Accepted: 28 December 2023

Accepted Manuscript online:
05 January 2024

Article published online:
03 July 2024

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