Intravitreal aflibercept for choroidal neovascularisation in angioid streaks

Abstract

Sir, Intravitreal aflibercept for choroidal neovascularisation in angioid streaksChoroidal neovascularisation (CNV) is a well-known complication of angioid streaks (AS). It affects 42-86% of patients and if untreated can result in significant vision loss. 1 Treatment options have included laser photocoagulation and photodynamic therapy; 1,2 with the advent of anti-vascular endothelial growth factor (VEGF) therapies, off-label anti-VEGF has become the treatment of choice and both bevacizumab and ranibizumab have been shown to be effective. [1][2][3] We describe the off-label use of 2 mg intravitreal aflibercept in two patients as primary treatment for AS-associated CNV (AS-CNV). Case reportThe first is a 57-year-old woman with recent left eye (OS) distortion. Visual acuities (VA) were 20/20 right and 20/25 left. Fundoscopy showed bilateral AS and a classic CNV OS (Figures 1a and b). Fluorescein angiography (FA) and CORRESPONDENCE Figure 1 Colour fundus photographs of the first patient, whose sister was known to be affected by AS and pseudoxanthoma elasticum, show bilateral AS, OD (a) and OS (b), along with an extrafoveal greyish area of CNV, with associated subretinal haemorrhages in OS. Early-phase fundus fluorescein angiography demonstrates a well-demarcated lesion (c) with late leakage (d) in OS, compatible with a classic CNV. Spectral-domain optical coherence tomography reveals a neurosensory detachment involving the fovea (e) and a hyperreflective lesion with subretinal fluid above the retinal pigment epithelium in the cross-section through the lesion. After treatment, there was resolution of the foveal subretinal fluid (f) with scarring of the CNV (g).

Intravitreal aflibercept for choroidal neovascularization secondary to angioid streaks in a non-responder to intravitreal ranibizumab

“…In 2 treatment-naïve patients, prompt intervention and administration of 1 and 3 IVIs of aflibercept (pro re nata) resulted in a favorable outcome that was maintained over a period of 12 and 9 months, respectively. 6 Administration of aflibercept in a treat-and-extend regimen resulted in complete restoration of BCVA in another treatment-naïve patient with early stage disease who received 6 IVIs of aflibercept over a period of 1 year. 7 Aflibercept has also been used as first line treatment in a recently published case of polypoidal choroidal vasculopathy secondary to AS.…”

Long-Term Effect of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) Injections in Choroidal Neovascularization Secondary to Angioid Streaks

“…In 2006, the first favorable results for the treatment of CNV secondary to angioid streaks were achieved with bevacizumab [ 9 ]. Afterwards, several small studies about effectiveness of anti-VEGF in CNV secondary to angioid streaks were done with ranibizumab, bevacizumab, and aflibercept [ 17 , 22 – 27 ]. Recently, Sekfali et al concluded that switching from intravitreal ranibizumab to aflibercept represents a valid therapeutic option in patients with refractory or recurrent CNV secondary to angioid streaks [ 14 ].…”

Clinical characteristics and treatment outcomes of angioid streak associated choroidal neovascular membrane (AS-CNV): a Zambian case series

“…In a large series of patients with AS-CNV followed up over 4 years, ranibizumab injections allowed stabilization of BCVA and suppression of angiographic leakage effectively [ 8 ]. Recently aflibercept has shown efficacy in treatment of both refractory and treatment naïve AS-CNV [ 9 , 13 , 14 ]. Aflibercept may offer an additional benefit over other anti-VEGF agents in terms of preventing CNV recurrence as it has a higher affinity for VEGF-A as well as the ability to bind VEGF-B and placental growth factor, resulting in a more effective inhibition of the pathological angiogenic process [ 9 ].…”

“…Recently aflibercept has shown efficacy in treatment of both refractory and treatment naïve AS-CNV [ 9 , 13 , 14 ]. Aflibercept may offer an additional benefit over other anti-VEGF agents in terms of preventing CNV recurrence as it has a higher affinity for VEGF-A as well as the ability to bind VEGF-B and placental growth factor, resulting in a more effective inhibition of the pathological angiogenic process [ 9 ]. Each patient received only 3 loading doses of anti-VEGF therapy (2 patients with ranibizumab and one with aflibercept) without further recurrences of AS-CNV till the last follow-up which was encouraging knowing the fact that CNV in AS has a high tendency of reactivation/recrudescence [ 8 , 12 ].…”

“…A “comet - tail” lesion is a solitary, subretinal, nodular crystalline white body with a tapered white tail of retinal pigment epithelium atrophy extending posterior to the body and are considered pathognomonic of PXE [ 6 , 7 ]. Treatment of AS-CNV remained a challenge earlier, but with the advent of anti-VEGF intravitreal drugs, the long-term efficacy of anti-VEGF therapy to stabilize the CNV and preserve or even improve vision is now proven [ 8 , 9 ]. We present a series of three patients of AS-CNV with comet-tail lesions without pseudoxanthoma elasticum, their clinical characteristics and visual outcome following intravitreal anti-VEGF injections in Zambian setting.…”