Intravitreal aflibercept and ranibizumab for pachychoroid neovasculopathy

Abstract

This retrospective study was to compare the efficacy of intravitreal injection of ranibizumab and aflibercept for patients with pachychoroid neovasculopathy. 54 eyes were initially treated with 3 monthly loading injections of ranibizumab or aflibercept. Treatment switching from ranibizumab to aflibercept, and aflibercept to photodynamic therapy was done at 3 months in case of incomplete fluid absorption. At 3 months, the rate of complete fluid absorption was significantly higher in the aflibercept-treated group than in the ranibizumab-treated group (82.6% vs 51.6%, p = 0.018). The mean reduction of subfoveal choroidal thickness was significantly greater in the aflibercept group than in the ranibizumab group (-35 µm vs -9 µm, p = 0.013). There was no significant difference between the two groups in terms of visual improvement or decrease in central macular thickness. Complete fluid absorption was achieved after switching from ranibizumab to aflibercept in 13 of 15 eyes (86.7%). Adjunctive photodynamic therapy was required in 6 eyes. In conclusion, treatment mainly with anti-vascular endothelial growth factor effectively improved visual acuity within 12 months (from 20/56 to 20/44 at 3 months and to 20/36 at 12 months). Aflibercept was superior to ranibizumab in achieving dry macula and reducing choroidal thickness at 3 months.

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1

The case of a 69-year-old male who was switched to aflibercept injections due to the poor response to ranibizumab. (Top left) Color fundus photograph shows reduced background fundus tessellation without drusen. (Top second) Fluorescein angiography demonstrates ill-defined late leakage. (Top third) Late-phase indocyanine green angiography exhibits focal hyperfluorescent spots and choroidal vascular hyperpermeability within the posterior pole. (Top right) Fundus autofluorescence image shows hyperfluorescence in the area inferior to the fovea. (Bottom left) Spectral-domain optical coherence tomography (OCT) at baseline reveals Type 1 neovascularization, which was confirmed on swept-source OCT angiography (inlet). Multiple dilated Haller vessels with attenuation of choriocapillaris are seen beneath the lesion. Best-corrected visual acuity (BCVA) of the right eye was 20/63 at baseline. (Bottom middle) After three loading injections of ranibizumab, subretinal fluid remained and BCVA decreased to 20/80. (Bottom right) Treatment was switched to aflibercept, and after three consecutive injections, complete fluid absorption was achieved and BCVA improved to 20/40. The subfoveal choroidal thickness decreased from 354 µm at baseline, to 341 µm after ranibizumab injections, and 293 µm after aflibercept injections.

Figure 2

Changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) during the 12-month follow-up period. The mean BCVA and CMT improved at 3 months after three loading anti-vascular endothelial growth factor injections, and after the treatment switch, those outcomes further improved at 12 months.

Figure 3

Multimodal imaging features of pachychoroid neovasculopathy. (Top row) Images of the eye of a 52-year-old female. Fluorescein angiography (FAG) shows minimal leakage, and indocyanine green angiography (ICGA) images show a small neovascular network on the early phase (arrow) and choroidal vascular hyperpermeability (CVH) in the mid-to-late phase. Spectral-domain optical coherence tomography (SD OCT) through the lesion demonstrates Type 1 neovascularization, which is apparent on swept-source OCT angiography (SS OCTA, inlet). The arrow indicates the presume site of feeder vessel ingrowth. The subfoveal choroidal thickness is 311 µm. (Middle row) Images of the eye of a 65-year-old male. FAG shows leakage at the fovea, while neovascular network is not evident on early-phase ICGA. Late-phase ICGA shows CVH at the posterior pole. A small pigment epithelial detachment is noted on SD OCT, which is revealed as choroidal neovascularization on SS OCTA (inlet). The subfoveal choroidal thickness was 520 µm while dilated Haller vessel is not apparent. (Bottom row) Images of the eye of a 68-year-old male. Late-phase FAG reveals ill-defined leakage. Abnormal choroidal vessels without polypoidal lesions are noted in the early-phase ICGA and CVH in the mid-to-late phase. SD OCT shows Type 1 neovascularization and the is 509 µm. Dilated Haller vessels (asterisks) are noted with loss of overlying choriocapillaris and Sattler layers below the area in and around the Type 1 neovascularization lesion. Choroidal neovascular network is evident on SS OCTA (inlet).