Chronic nAMD With Cataract Complications: Visual Stabilization Through Sequential Anti-VEGF Strategies | Ophthalmology Times

Treatment-Resistant Retinal Disease Management With Sequential Anti-VEGF Strategies

This comprehensive presentation examines complex retinal disease management using sequential anti-VEGF therapies, supported by pharmacokinetic modeling from 17 aflibercept trials involving 2700 individuals. The data demonstrates that aflibercept 8 mg exhibits 34.4% slower clearance from the eye compared with 2 mg, extending effective drug concentrations by 6 to 8 weeks and providing therapeutic durability of 12 to 20 weeks. This enhanced pharmacokinetic profile enables extended dosing intervals while maintaining superior anatomic responses, which is particularly beneficial for treatment-resistant cases.

Three clinical cases illustrate strategic drug switching and dosing modifications. The first involves an 83-year-old patient with diabetic macular edema whose condition deteriorated over 3 years on aflibercept 2 mg and worsened further with faricimab, achieving dramatic improvement with aflibercept 8 mg (vision improved from 20/70 to 20/40, central thickness reduced from more than400 to 351 microns). The second case involves a 62-year-old patient with AMD who experienced intraocular pressure complications with standard 8 mg dosing, successfully managed through innovative volume reduction to 0.06 ml (6.86 mg), achieving complete macular drying while avoiding pressure spikes. The third case features a 76-year-old patient with nAMD who developed sterile inflammatory responses to aflibercept (both 2 and 8 mg formulations) but responded well to treatment, ultimately requiring drug rotation to faricimab for long-term management.

These cases highlight the importance of individualized treatment strategies and the availability of multiple anti-VEGF agents with different molecular structures and developmental pathways. The presentation emphasizes that drug diversity reduces cross-antigenicity and immune response risks, enabling physicians to optimize outcomes through sequential therapy approaches. Key clinical insights include the superior efficacy of high-dose aflibercept for treatment-resistant cases, the feasibility of dose modifications to manage complications, and the strategic value of having multiple therapeutic options to address individual patient responses and tolerance profiles.