DME Management With Transition to High-Dose Aflibercept Following Suboptimal Response to Standard Anti-VEGF Therapy

DME Management With High-Dose Aflibercept Summary

This presentation discusses DME management, focusing on transitioning to high-dose aflibercept following suboptimal responses to standard anti-VEGF therapy. The session was part of a Case-Based Roundtable meeting held in conjunction with the American Society of Retina Specialists Scientific Meeting, examining structural differences among anti-VEGF agents and their clinical implications for treatment durability and efficacy.

The case study involves an 83-year-old female patient with DME who had been treated for 9 years, initially with temporal grid laser photocoagulation and bevacizumab every 4 to 6 weeks, then switched to aflibercept 2 mg due to worsening edema and visual acuity fluctuating between 20/25 and 20/50. Over 3 1/2 years of aflibercept 2 mg treatment every 4 to 6 weeks, the patient showed declining visual acuity and increasing macular edema, progressing to 20/40 vision with significantly increased central macular thickness. A subsequent switch to faricimab resulted in further deterioration, with vision worsening to 20/70 and increased macular edema after 3 monthly injections.

The breakthrough came after a transition to aflibercept 8 mg (high-dose), which produced rapid improvement. After 3 monthly doses, the patient's visual acuity improved to 20/40, and central retinal thickness decreased significantly from more than 400 to 351 microns. Extended dosing every 7 weeks maintained stable 20/40 vision with central thickness around 340 microns. The presentation emphasizes that aflibercept 8 mg demonstrates superior anatomic responses compared with 2 mg, particularly in patients with thicker maculas and switching scenarios. This higher molar dose extends drug durability and shifts tissue equilibrium to favor lower VEGF concentrations, resulting in better retinal drying capabilities.