Treat-and-Extend Regimens for the Management of Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy: Consensus and Recommendations From the Asia-Pacific Vitreo-retina Society

Abstract

Purpose: Review and provide consensus recommendations on use of treat-and-extend (T&E) regimens for neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) management with relevance for clinicians in the Asia-Pacific region.

Methods: A systematic search of MEDLINE, EMBASE, and Cochrane databases, and abstract databases of the Asia-Pacific Vitreo-retina Society, European Society of Retina Specialists, American Academy of Ophthalmology, and Controversies in Ophthalmology: Asia-Australia congresses, was conducted to assess evidence for T&E regimens in nAMD. Only studies with ≥100 study eyes were included. An expert panel reviewed the results and key factors potentially influencing the use of T&E regimens in nAMD and PCV, and subsequently formed consensus recommendations for their application in the Asia-Pacific region.

Results: Twenty-seven studies were included. Studies demonstrated that T&E regimens with aflibercept, ranibizumab, or bevacizumab in nAMD, and with aflibercept in PCV, were efficacious and safe. The recommendation for T&E is, after ≥3 consecutive monthly loading doses, treatment intervals can be extended by 2 to 4 weeks up to 12 to 16 weeks. When disease activity recurs, the recommendation is to reinject and shorten intervals by 2 to 4 weeks until fluid resolution, after which treatment intervals can again be extended. Intraretinal fluid should be treated until resolved; however, persistent minimal subretinal fluid after consecutive treatments may be tolerated with treatment intervals maintained or extended if the clinical condition is stable.

Conclusions: T&E regimens are efficacious and safe for nAMD and PCV, can reduce the number of visits, and minimize the overall burden for clinicians and patients.

Conflict of interest statement

Conflicts of interest: VC: honoraria from Bayer, Novartis, Roche for lecture fees and research grants from Bayer, Roche; MS: honoraria from Allergan, Bayer, Novartis, Roche for lecture fees, consultancy and board membership, research grants from Allergan, Bayer, Novartis; TL: honoraria from Allergan, Bayer, Boehringer Ingelheim, Novartis, Roche for consultancy, research grants from Novartis and Roche; GT: honoraria from Allergan, Bayer, Roche, Novartis, Topcon, and research grant from Leica and Santen; NF: honoraria from Bayer, Novartis, and Allergan for lecture fees; MO: honoraria from Bayer, Novartis, Santen, Kowa, Otsuka for lecture fees, research grants from Alcon, Bayer, Hoya, Novartis, Otsuka, Santen, Senju, and consultancy fees from Allergan, Bayer, Chengdu Kanghong Biotechnology, Chugai, Novartis; PM: N/A;

Copyright © 2021 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.

Figures

FIGURE 1

PRISMA flowchart for the article selection process in this systematic review.

FIGURE 2

Flowchart of recommendations for implementation of a T&E regimen for the treatment of patients with nAMD/PCV in the Asia-Pacific region. ∗At least 3 consecutive monthly injections until maximum VA is achieved and/or there are no signs of disease activity. †When using ranibizumab or bevacizumab, extend by 2 weeks; when using aflibercept, extend by 2–4 weeks. ‡Extend at the physician's discretion if visual and anatomic criteria for extension are met. Aflibercept: gradually extend in 2- or 4-week increments up to a maximum of 16 weeks; ranibizumab/bevacizumab: gradually extend by 2 weeks at a time up to a maximum of 12 weeks. §An interval maintenance step (such as that used in ALTAIR) may be implemented, permitting tolerance of some residual SRF when vision has improved or remained stable and there are no signs of disease worsening (such as new subretinal hemorrhage). ¶Shorten at the physician's discretion if visual and anatomic criteria for shortening are met; that is, vision has worsened and/or there are signs of disease worsening (such as recurrence of IRF regardless of recurrent/residual SRF). FFA indicates fundus fluorescein angiography; ICGA, indocyanine green angiography; IRF, intraretinal fluid; nAMD, neovascular age-related macular degeneration; OCT, optical coherence tomography; PCV, polypoidal choroidal vasculopathy; q4, every 4 weeks; SRF, subretinal fluid; T&E, treat-and-extend; VA, visual acuity; VEGF, vascular endothelial growth factor.