Aflibercept treatment for patients with exudative age-related macular degeneration who were incomplete responders to multiple ranibizumab injections (TURF trial)

Abstract

Aim: To determine the efficacy of 2.0 mg aflibercept in the management of patients with recalcitrant exudative age-related macular degeneration (AMD).

Methods: In this prospective, open-label, single-arm clinical trial, patients were seen monthly and given mandatory 2.0 mg aflibercept at baseline, months 1, 2 and 4. Pro re nata (PRN) retreatment at months 3 and 5 was performed upon evidence of disease on spectral domain-optical coherence tomography (SD-OCT). End point at month 6: mean change in Early Treatment Diabetic Retinopathy Study best corrected visual acuity (ETDRS BCVA) and central subfield thickness (CST), mean number of aflibercept injections, percentage of PRN injections required, patients with no fluid on SD-OCT and patients losing >15 letters.

Results: At baseline, 46 patients with a mean of 42 prior antivascular endothelial growth factor-A (anti-VEGF) intravitreal treatments had a mean of 74.2 letters (Snellen equivalent 20/32) and mean CST of 347 µm. ETDRS letters remained stable throughout the trial; at month 6, mean BCVA change was +0.2 letters (range -10 to +13, p=0.71). Anatomically, mean CST improved significantly from baseline at each study visit including -23.6 µm at month 1 and -27.3 µm at month 6 (p=0.018). Seventy-one of 90 (79%) possible PRN injections were required and a mean of 5.6 aflibercept injections out of the maximum six were administered. Ten of 45 (22%) patients had no retinal fluid on SD-OCT at month 6. No patient lost >15 letters.

Conclusions: Aflibercept 2.0 mg treatment maintained mean visual acuity improvements previously achieved with high-dose 2.0-mg ranibizumab injections in recalcitrant wet AMD patients. Aflibercept 2.0 mg treatment led to significant anatomic improvement and was required monthly in most patients.

Clinical trials registration: FDA IND#12462. NCT 01543568.

Trial details: IND 12462, Keywords: Clinical Trial; Degeneration; Macula; Neovascularisation; Retina.

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Figures

Figure 1

Change in mean best-corrected visual acuity (best corrected visual acuity (BCVA); Early Treatment Diabetic Retinopathy Study (ETDRS) letters) over 6 months with standard error (SE) bars.

Figure 2

Case examples. Baseline late-phase fluorescein angiograms (FA) with associated spectral domain optical coherence tomography (SD-OCT) orientations (white dashed line) followed by sequential SD-OCT images at baseline (left), 1 month (centre) and 6 months (right). (A) flattening of pigment epithelial detachment (PED) from baseline associated with retinal pigment epithelial and outer retinal atrophy. (B) flattening of PED with residual subretinal fluid under the fovea at month 6.

Figure 3

Change in central subfield thickness (spectral domain optical coherence tomography (SD-OCT)) over 6 months with standard error (SE) bars. Central subfield thickness was evaluated monthly as well as 7 days after the first aflibercept treatment.