How would you follow up neovascular ARMD after loading dose?

A 72 years old lady presented to me with a history of wet ARMD and has been treated with three injections of Ranibizumab and one injection of Aflibercept, which has been administered six weeks ago with no systemic history; her BCVA is 20/100. Her other eyes show intermediate non-neovascular ARMD

Fundus image

Her Fundus image shows RPE degeneration along with sub RPE scar and Small areas of RPE detachment and drusen.

Fundus image showing fibrovascular ARMD

Fundus Fluorescein angiography

Her FFA shows hyperfluorescence stippled changes parafoveal area which persists and increases in intensity in late stages of angiogram which presents fibrovascular pigment epithelial detachments with RPE degeneration at the central macula.

Early phase of FFA showing stippled hyperfluorescence

Mid phase of FFA showing stippled hyperfluorescence

Late phase of FFA showing stippled hyperfluorescence

Optical coherence tomography

Her Radial OCT scans show irregular RPE detachments with fibrovascular continents and disturbed ellipsoid zone in the inferior nasal to the superior temporal line.

OCT radial scan shows fibrovascular PED

In contrast, the superior nasal to inferior temporal line shows fibrovascular RPE detachment with RPE degeneration and disturbed ellipsoid zone. In the OCT scans, there is no subretinal nor intraretinal fluids.

OCT line scan shows fibrovascular PED

The diagnosis is ARMD with fibrovascular PED

Management

Once the patient already received four anti-VEGF injections, and there are no subretinal nor intraretinal cysts. This means that the lesion is subsiding but still not deactivated completely. So it is wise to switch the patient from monthly injections to treat and extend protocol, which features injecting six weeks after the last monthly injection, then repeat OCT within two months if there is an improvement or no changes, then reinject. Repeat OCT within three months if there is an improvement or no changes. OCT and injection can be repeated every three months. Follow-up should never exceed 12 weeks, in case the of worsening is noted on OCT during treat and extend protocol then switch back to monthly injection.

I have chosen this patient to treat her with intravitreal Aflibercept using a treat and extend protocol because Aflibercept is more effective in treating PED than other commercially available anti-VEGF.

Please check clinical guidelines for Age-related macular degeneration

#INTERPRET_OCT #FFA #Treat_and_Extend #ARMD #PED #Wet #Aflibercept #injection #Intravitreal

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