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  • Residual fluid after anti-VEGF therapy for AMD may not be tolerable or beneficial

    Retina/Vitreous

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    Review of: Impact of retinal fluid-free months on outcomes in neovascular age-related macular degeneration: A treatment agnostic analysis of the HAWK and HARRIER studies

    Eichenbaum D, Brown D, Ip M, et al. Retina, April 2023

    The absence of intraretinal or subretinal residual fluid after anti-VEGF treatment for neovascular age-related macular degeneration (AMD) was shown to positively correlate with both anatomic and visual outcomes in this 2-year post hoc study, with the biggest improvements seen in eyes with the greatest number of fluid-free follow-up visits.

    Study design

    This was a post hoc analysis of data from the HAWK and HARRIER randomized controlled trials (RCTs)—which looked at the safety and efficacy of brolucizumab compared to aflibercept—examining the cumulative influence of intraretinal fluid (IRF) and subretinal fluid (SRF) on final visual acuity and central subfield thickness (CSFT). This treatment-agnostic, pooled analysis grouped eyes into 5 categories based on total fluid-free visits (FFVs) after the loading phase, from “never dry” (category 1) to “always dry” (category 5). Findings were also stratified by 3 fluid compartment definitions: IRF only, SRF only, or IRF and SRF. End points included the number of FFVs, change in BCVA from baseline, and change of central subfield thickness (CSFT) from baseline.

    Outcomes

    Category 4 ("nearly always dry," 15–21 FFVs) comprised the most patients (39%–43%, depending on the definition of FFV). Regardless of fluid compartment, patients with more FFVs (better anatomical outcomes) consistently showed better BCVA and CSFT outcomes. Eyes in categories 4 and 5 (the most FFVs) experienced the greatest improvements in both measures, whereas eyes in categories 1 and 2 (the least FFVs) experienced the fewest changes in BCVA and CSFT.

    Limitations

    One limitation of this study is its structure as a post hoc analysis. Furthermore, FFVs were grouped into 5 categories in 7 visit increments, rather than by the number of patients per category. Thus, some categories had more patients than others, which makes subanalysis difficult.

    Clinical significance

    Compared to other studies that have suggested SRF may be tolerable or even beneficial,1,2 this post hoc analysis supports the intolerance of all fluid, no matter the fluid compartment, for the successful longitudinal treatment of AMD.

    Financial Disclosures: Dr. Rebecca Soares discloses no financial relationships.

    References:

    1 Jaffe G, et al. Ophthalmology. 2013;120:1860–1870. 

    2 Guymer R, et al. Ophthalmology. 2019;126:723–734