Case Studies

Suboptimal Responder Treated with Aflibercept

By Jeffrey S. Heier, MD, Ophthalmic Consultants of Boston

In this case study, a 77-year-old man was diagnosed with AMD in his right eye and had an initial VA of 20/100. As the disease progressed, his VA decreased to 20/400 after 11 anti-VEGF injections, and he had chronic, persistent subretinal fluid on OCT. We began triple therapy consisting of photodynamic therapy, intravitreal bevacizumab (Avastin, Genentech), and intravitreal triamcinolone (Kenalog).

Over the course of the next 2 years, he underwent three courses of the triple therapy and his vision improved to 20/200, but he still had persistent subretinal fluid. We also tried double-dose intravitreal ranibizumab (Lucentis, Genentech) and yet he still had worsening disease, with fluctuation in vision from 20/100 to 20/200. At this point, he had undergone 25 anti-VEGF injections, including 14 double-dosed Lucentis.

After multiple double-dose ranibizumab, the patient’s vision was 20/100, but subretinal fluid remained. We initiated intravitreal aflibercept (Eylea, Regeneron), and after the first injection of aflibercept, the VA was 20/200, but on OCT there was anatomic improvement. At 6 weeks, we injected aflibercept for the second time (vision had improved to 20/100, but fluid still remained). We followed up 7 weeks later, injecting with a third aflibercept treatment; his VA had declined to 20/200 and some of the anatomic improvement was regressing.

At the fourth intravitreal injection 4 weeks later, the VA had improved to 20/80, and there was noticeable improvement of subretinal fluid on OCT. A final intravitreal aflibercept injection was given 5 weeks after that, and the anatomic changes have been maintained along with improved vision. We continue to monitor this patient every 4-5 weeks. ✦