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.

Optical Coherence Tomography Features for Identifying Posttreatment Complete Polypoidal Regression in Polypoidal Choroidal Vasculopathy

“…However, for eyes with incomplete polypoidal regression, that is, feature D on OCT, several studies have suggested that these eyes have a relatively high risk for recurrent, large subretinal hemorrhage 11,12. Thus, recognizing this feature may have clinical relevance wherein this feature suggests that discontinuing treatment should be done cautiously, since a vision-threatening condition, namely large subretinal hemorrhage, might have an increased risk of developing in the absence of continued treatment for eyes with incomplete polypoidal regression 24…”

“…11,12 Thus, recognizing this feature may have clinical relevance wherein this feature suggests that discontinuing treatment should be done cautiously, since a vision-threatening condition, namely large subretinal hemorrhage, might have an increased risk of developing in the absence of continued treatment for eyes with incomplete polypoidal regression. 24…”

Current Trends in Clinical Characteristics, Diagnosis, and Treatment of Polypoidal Choroidal Vasculopathy: A Perspective from Vietnam

“…The Asia-Pacific Vitreo-retina Society recommended use of aflibercept according to the treat-and-extend regimen to provide personalized care to patients with PCV [ 89 ].…”

Ranibizumab port delivery system: a clinical perspective

“…Between the possible regimens, studies have shown that proactive treatment and more frequent dosing leads to improved visual outcomes (fixed and T&E vs PRN). 18 20 In addition, PRN dosing highlighted the dangers of undertreatment with patients achieving the worst VA outcomes of any regimen. 6 19 20 Other studies have added that T&E can lead to non-inferior visual acuity outcomes in nAMD patients while reducing the burden on both the patient and healthcare system overall.…”

“… 6 19–21 These factors allowed T&E regimens to become the standard clinical practice of many providers. 18 23–27 …”