Adjuvant use of long-acting intravitreal steroids and anti-VEGF agents in monotherapy resistant chronic Wet-Age Related Macular Degeneration.

Abstract

Purpose : Controversy exists regarding the therapeutic use of concomitant intravitreal steroids with anti-VEGF (inhibitory vascular endothelial growth factor) in choroidal neovascularization (CNV) resistant to mainstay treatment. We performed a retrospective observational clinical study in a consecutive cohort of patients’ eyes with persistent CNV anatomically unresponsive to aggressive high-dose high-frequency (HDHF) monotherapy (i.e.: monthly 4 mg aflibercept). We evaluated anatomic and visual changes proceeding a simultaneous intervention in a long-cohort designed to study the therapeutic safety and efficacy of adjuvant steroids with anti-VEGF in resistant chronic Wet-Age Related Macular Degeneration (Wet-AMD).

Methods : A total of 12 eyes with unresponsive CNV despite treatment with alternating anti-VEGF agents (mean: 43.75±SD23.08) was studied. Resistance was considered persistent retinal fluid following HDHF treatment. Combination consisted in the simultaneous administration of anti-VEGF and steroids followed by 2 weeks of prophylactic topical antiglaucoma medication (Timolol 0.5%/Dorzolamide 2%). Slit-lamp, Visual Acuity (BCVA), Intraocular-pressure (IOP), and Optical Coherence Tomography (Heidelberg Spectralis HRA+Spectral Domain (Heidelberg Engineering, Heidelberg, Germany)) measurements of central retinal thickness (CRT) were recorded every 4 weeks for 4 consecutive months. Baseline predictors relating treatment efficacy were evaluated. Outcomes included changes in BCVA, IOP, and reduction in CRT.

Results : Initial analysis showed no safety data complications. Anatomic outcomes were statistically significant evincing a reduction in CRT (p<0.0001) compared to baseline; paired analysis showed an average CRT reduction of 50.90 μm (p<0.05) at 1 month, 76.5 μm (p=0.0336) at 2 months, and 86.33 μm (p=0.0340) at month 3. Association between CNV types and CRT reduction was significant (least-square means: type 1=-81.77, type 2=42.49, RAP/type 3=137.71, p=0.022).

Conclusions : We found combination of steroids and anti-VEGF produces clear anatomic improvement in recalcitrant CNV. Although other studies evidenced visual and anatomic changes consequent of combination, these were not in chronic monotherapy resistant eyes. In such eyes, we found overall disease improvement. Therefore, combination therapy may be useful in treating resistant Wet-AMD.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.