The Effect of Anti-VEGF Injections on Macular Atrophy
February 2, 2020
San Diego County Optometric Society Newsletter: Retina Corner
By Nikolas J.S. London, MD FACS
President and Director of Clinical Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
Dear SDCOS membership,
Happy February everyone, I hope that you are all having a wonderful start to 2020. This past year was challenging for us at RCSD as we watched Paul Tornambe valiantly fight a disease that he eventually succumbed to. Paul was a hero to me, and will be forever missed. I appreciate everyone who has reached out with condolences. More than anything, I love hearing the stories people have shared. Thank you. This month I wanted to discuss a topic that makes me think of Paul. He often commented to me that we are in a unique position as physicians to help patients, but to be careful as our treatment options are often double-edged swords, and that there are few conditions that we cannot make worse with our well-intentioned intervention. One of those conditions is macular degeneration.
We are all aware of the two types of AMD, dry and wet, and we all know that wet has outstanding treatment options with better drugs on the horizon. We have also discussed in these articles the less common form of advanced AMD, geographic atrophy (GA), where the macular RPE slowly dies and leads to an irreversible loss of central vision. Unfortunately, some patients have both wet AMD and GA. In general they do well as long as the GA spares the fovea, but the GA progresses with no current treatment options, and foveal involvement is inevitable given enough time. Moreover, while the data is conflicting, there is concern that the anti-VEGF injections used to treat wet AMD will actually exacerbate GA. If this is true, we as retina surgeons must be careful to treat patients conservatively with just enough injections to maintain patients’ vision, and must also select the treatment options that have the lowest potential for harm. For anti-VEGF injections in wet AMD, we have several “brands” to choose from, aflibercept (Eylea, Regeneron), ranibizumab (Lucentis, Genentech), brolucizumab (Beovu, Novartis), and bevacizumab (Avastin, Genentech).
In a recent publication in Ophthalmology, Gilles and associates compared aflibercept and ranibizumab in terms of atrophy development. This was a well-designed, randomized, phase 4 trial. They enrolled nearly 300 patients, assigned them to either ranibizumab or aflibercept, and compared change in the size of geographic atrophy at baseline to month 24 for the two groups. Both groups received the same number of injections, about 9.5 per year. The change in area of geographic atrophy was similar between the groups, with no significant differences in either the growth of GA, or the proportion of patients with GA. These results are reassuring, and give confidence to choose the best anti-VEGF injection for wet AMD patients based on other criteria, but I will certainly continue to watch this topic as additional data comes to light.
Thanks again for reading. Please don’t ever hesitate to contact me.
Best wishes, and until next time,