Risk of Recurrence of Neovascular (wet) AMD Following Cessation of Anti-VEGF Injections - an Update
Cumulative risk of recurrence following cessation of anti-VEGF
The paper from The Fight Retinal Blindness! (FRB) registry provides large scale real world data on the risk of recurrence following cessation of anti-VEGF injections (avastin, lucentis or eylea) in patients with neovascular age related macula degeneration (nAMD). As discussed in our previous post, the rate of 50% recurrence is higher than previous reported in single center case series (13% and 37%). Recurrence can also occur in patients receiving ongoing long term anti-VEGF injections every 3 months, and the rate is roughly 10% per year.
The latest study by Aslanis et al. published in Ophthalmology Retina last week adds further evidence that the rate estimated by the FRB study is correct. In this new study, 105 patients with nAMD were treated with eylea on a treat and extend protocol, and treatment is stopped after 3 injections 12 weeks apart with no intraretinal or subretinal fluid. These patients are monitored at 4, 6, 8, 10 and 12 months for disease recurrence.
Essentially the recurrence rate in this study, at 52% by 12 months, is identical to what was found in FRB. Interestingly only 40% of patients with a recurrence are symptomatic, indicating self-monitoring alone without imaging is not sufficient to pick up all recurrences. The rate of recurrence is higher in patients with pigment epithelium detachment (74%) comparing to those without pigment epithelium detachment (48%). The positive relationship between recurrence rate and the presence of pigment epithelium detachment was also reported by Arendt et al. Interestingly, there is no difference in the rate of recurrence among the different subtypes of nAMD (type I, II, or III) in this study, and this lack of relationship was also found in FRB data (personal communiciation, Leo Sheck and Mark Gillies).
In contrast to FRB data (net loss of 3.3 letter), resumption of treatment following a recurrence in this new study leads to restoration of visual acuity back to baseline.
The latest data adds to the evidence that there is a definite and significant risk of recurrence of around 50% in the first year following cessation of anti-VEGF injections in patients with nAMD. This recurrence rate is even higher for patients with pigment epithelium detachments. The risk can be lowered by ongoing anti-VEGF injections every 3 months. On the other hand, it appears, from the latest study, that the vision loss associated with recurrence can be rescued by early treatment, but ongoing frequent monitoring visits are required given not all patients with early recurrence are symptomatic.