By Purnima S. Patel, MD
Administering anti-VEGFs using a treat-and-extend regimen is a suitable approach to a variety of retinal diseases, but what’s the optimal application in individual patients? This panel of retina specialists offers their consensus based on a literature review and their clinical experience.
Led by Dr. K. Bailey Freund, the panel agreed that monthly injections should continue until maximum response is achieved, which is defined by:
1) Complete resolution of subretinal fluid (SRF) and intraretinal fluid (IRF) without new retinal hemorrhage; and
2) No further reduction of SRF or IRF on OCT for at least 2 consecutive visits in the absence of new retinal hemorrhage.
Furthermore, some panel members would also include:
3) No further flattening of serous or vascularized pigment epithelial detachments; and
4) No further improvement in visual acuity.
The panel agreed that fluorescein angiography (FA) is not necessary in most patients to determine maximum response.
Once maximal response is achieved, treatment intervals can be extended if there is continued absence, which is preferred, or stabilization of fluid (i.e., no change in IRF or SRF or at least 2 consecutive visits). Visual acuity changes should be evaluated in the context of clinical exams and OCT findings if they are to be used in guiding treatment intervals.
The authors recommend careful evaluation of OCT and additional imaging for eyes with persistent SRF or IRF, looking for disruption of the outer retinal structure over fibrovascular tissue, presence of Type 3 choroidal neovascular membranes (retinal angiomatous proliferation), and/or epiretinal membranes and vitreomacular adhesions. FA may be useful to detect lesion growth, while indocyanine green angiography (ICG) may be useful to identify polyps.
The panel agreed that treatment could be extended by up to 2-week intervals if the disease remained stable, with the “standard” maximum interval being 12 weeks. However, the maximum interval should depend on the nature of the disease and be shorter for wet AMD vs. DME or RVO, monocular patients, eyes at high risk of retinal hemorrhaging (e.g., patients taking anticoagulants or those with very large lesions) and eyes treated with shorter-acting anti-VEGF agents.
If a patient shows signs of deterioration resulting from disease activity, the injection interval should be shortened by 1 to 2 weeks for minor changes like small recurrences of fluid or small increases in previously stable fluid on OCT. For severe deterioration (large recurrence of fluid, subfoveal hemorrhaging, large extrafoveal hemorrhage of ≥6 letters of vision loss), the panel recommends considering re-induction of monthly dosing, along with FA or ICG.