Patients with retinal conditions, including branch retinal vein occlusion (BRVO) and diabetic macular edema (DME), are seeing varying clinical responses to anti-VEGF therapies as practitioners adjust dosing intervals based on real-world and clinical trial data.
Recent case reports highlight how clinicians manage treatment-naive eyes and those requiring switches to second-generation drugs, Ophthalmology Times reported.
In one case, a 66-year-old woman diagnosed with superior temporal BRVO and macular edema began treatment with faricimab following the phase 3 BALATON trial protocol (NCT04740905). Her baseline best-corrected visual acuity (BCVA) was 20/100 with a central subfield thickness (CST) of 556 µm.
Following six monthly loading doses, her condition stabilized, allowing for a treat-and-extend schedule that reached 16-week intervals.
“There is some advantage in going on to the second-generation drugs early on rather than waiting too long,” Malik told Ophthalmology Times while discussing real-world data on treatment-naive and switch-therapy eyes.
Aflibercept 8 Mg Improves DME Clinical Outcomes
Clinical approaches to DME sometimes prioritize patient-specific responses over rigid schedules. In a real-world case of a 72-year-old man with type 2 diabetes and center-involving DME, physicians observed significant fluid resolution after switching to aflibercept 8 mg. His baseline BCVA was 20/80 with a central retinal thickness (CRT) of 423 µm.
After three monthly loading doses, the patient’s CRT improved to 210 µm, and his BCVA reached 20/40 by week 15. Although subretinal fluid remained present at the eight-week mark, the fluid resolved completely by the subsequent follow-up. Malik said that “sometimes waiting is OK,” and the clinical team planned to extend the patient’s treatment interval to 12 weeks.
Clinical Observations on Retinal Fluid
Monitoring fluid dynamics remains a primary metric for determining the success of anti-VEGF injections. In another case involving an extended 16-week interval, a patient maintained a BCVA of 20/60 with a CRT of 192 µm at week 40, despite a trace amount of subretinal fluid.
Data from the BALATON trial case also showed that even when a mild recurrence occurs—such as the CST increase to 369 µm recorded at injection 10—maintaining the interval can remain a viable strategy if visual acuity stays stable.
At the study exit for that patient, BCVA was 20/40 with a CST of 327 µm. Six months after that final injection, the patient’s BCVA was 20/63, and at 12 months, it reached 20/50 with a CST of 379 µm.
How Clinicians Determine Treat-And-Extend Intervals
How is the treat-and-extend interval determined for BRVO patients? Clinicians often begin with monthly loading doses before gradually extending the time between injections. In the BALATON trial case, the interval was increased by four weeks per visit until reaching 16 weeks, provided the anatomical and functional results remained stable.
While complete resolution is the goal, some cases show that visual acuity can remain stable despite trace amounts of subretinal fluid. As seen in the 72-year-old patient case, clinical teams may choose to extend treatment intervals to 12 weeks once significant improvement is achieved, even if total fluid clearance takes additional time.
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