Patient Case #2: 83-Year-Old Male With Neovascular AMD

Daniel F Kiernan, MD, FACS, reviews the case of an 83-year-old male patient with neovascular AMD.

Daniel F. Kiernan, MD, FACS: In the second case, an 83-year-old man is referred by an optometrist for a retinal exam. He’s complaining of worsening vision and retinal edema in the left eye for 1 month. He has a medical history of hypertension and GERD [gastroesophageal reflux disease] that are controlled in medication, and he has an ocular history of prior cataract surgeries with intraocular lens implantation in both eyes as well as dry AMD [age-related macular degeneration] in both eyes. The patient has Medicare and a secondary insurance plan.

On February 2, 2022, the patient’s vision is 20/50 in the right eye and 21/50 in the left eye, with normal pressure. Pseudophakia was seen on slit lamp exam. Dilated exam shows drusen RPE [retinal pigment epithelium] changes in both eyes with macular edema present in the left eye. In the following slides, you can see some testing. Fundus photos show drusen in both eyes. Below that, the OCT [optical coherence tomography] of the left eye shows intraretinal edema and drusen. Angiography of the left eye shows early hyperfluorescence due to staining of drusen and some perimacular leakage, which is a little more prominent on the right image. This is consistent with choroidal neovascularization.

However, a small amount of disc leakage could be more consistent with postoperative CME [cystoid macular edema] and postsurgical inflammation. Of note, the patient was pseudophakic. It’s not listed, but they had had an intraocular lens exchange 6 months prior to presentation in that left eye. Because of the suspicion that this might be related to postsurgical uveitis or cystoid macular edema, I restarted the patient’s cataract surgery drops—a corticosteroid, a nonsteroidal anti-inflammatory, and a carbonic anhydrase inhibitor for the left eye—with the goal of drying up that macular edema. The plan was to follow up in a few days to do that angiogram, as well as in 2 or 3 weeks for reevaluation.

Two or 3 weeks later, on February 25, 2022, there was still fluid present—a little more on central subfield thickness—and the vision had gotten worse. This changed my mode of thinking from postoperative CME inflammation to wet age-related macular degeneration. I stopped the eye drops and proceeded with an aflibercept injection that day. The patient wanted to have a driver with him, so they came back about a week later, and we proceeded with their first shot. On April 5, 2022, when the patient came back, we saw an improvement of vision: 21/50 in the left eye with reduction of retinal thickness and edema. We proceeded with a second shot of aflibercept and saw them a month later.

Curiously, the vision improved a bit, but there appeared to be more fluid and an increased amount of intraretinal edema on the left eye, so we continued with the third aflibercept. I saw the patient a month later, and vision had then dropped a line, to 20/60. They had persistent edema, specifically intraretinal fluid on OCT. Nevertheless, we persisted with a fourth aflibercept in that eye. Five weeks later, their vision had dropped again to 20/70. The OCT looked worse, with more intraretinal macular edema.

At this point, the plan changed. I was concerned that they might be developing something like tachyphylaxis, or short-term tachyphylaxis. I wanted to prove to myself that the patient is having a biological response to aflibercept. I gave him another shot that day, the fifth 1 in the left eye, and planned to see him back in 1 week to judge if they did have a biological response. A week later, they definitely had a response with decreased edema and stability of vision, but it was still limited. I’d hoped that all the fluid would go away shortly after that shot, but there was still persistent fluid.

Nevertheless, we plan to follow up in 3 weeks. We decided to switch the product from aflibercept to the new faricimab to see if that might help dry up some of the fluid more effectively, as it had in the clinical trials. We saw them on August 17, 2022. Their vision was 20/60 in the left eye. Macular edema had gotten worse since the last exam, and we proceeded with the first faricimab in that eye. Unfortunately, a month later, the patient came back not particularly happy. I saw that their vision had dropped to 20/200 in that eye, and the fluid had dramatically increased since the last exam. Extensive examination should have no evidence of iritis or detritus in the left eye, or any evidence of any other ocular retinitis or vasculitis.

Because of my concern of this drop in vision, I went back to aflibercept. The patient had not had any idiosyncratic effects before with it. I saw them a month later, and they had improved in terms of their vision and fluid. There’s still edema present, and the vision had dropped back down to 20/60, which seemed to be the best vision possible with Eylea. Nevertheless, it was an improvement over the idiosyncratic reaction we saw with the faricimab. We were more happy with that, so we proceeded with an additional aflibercept. I last saw them on November 16, 2022, when their vision was stable at 20/60, and there was persistent but stable intraretinal macular edema seen on the OCT. Our plan was to continue monthly aflibercept in the left eye.

Transcript edited for clarity

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