USyd
Ophthalmology Retina
2019 August

Outcomes of Suspending VEGF Inhibitors for Neovascular Age-Related Macular Degeneration When Lesions Have Been Inactive for 3 Months

Vuong Nguyen, Anagha Vaze, Samantha Fraser-Bell, Jennifer Arnold, Rohan W Essex, Daniel Barthelmes, Mark C Gillies, Fight Retinal Blindness! Study Group

Abstract

Purpose: Currently, little evidence supports the safety of suspending vascular endothelial growth factor (VEGF) inhibitors for neovascular age-related macular degeneration (nAMD). We assessed the outcomes of eyes in which this seems to have been attempted.

Design: Observational study from a prospectively designed database.

Participants: Eyes enrolled in the Fight Retinal Blindness! registry of nAMD treatment outcomes were considered to have suspended treatment if they had a 3-month or longer documented period of inactivity of the choroidal neovascular lesion with no further treatments unless the lesion re-activated.

Methods: Time and proportion to re-activation of the lesion were analyzed using Kaplan-Meier survival curves. Visual outcomes after treatment suspension were assessed with paired t tests.

Main outcome measures: The proportion of eyes resuming treatment because of lesion re-activation, change in visual acuity (VA) at time of re-activation, and recovery of vision 12 months later.

Results: We identified 434 eyes in which treatment was suspended and that were tracked for at least 12 months thereafter. The estimated percentage of eyes re-activating in the first year after treatment suspension was 41%, increasing to 79% by the fifth year. The median time to re-activation was 504 days. The 275 eyes whose lesion was observed to re-activate lost a mean of 4.2 letters (95% confidence interval [CI], -5.6 to -2.8 letters; P < 0.001) from the last injection to the time of re-activation; 206 eyes resumed treatment for at least 12 months after re-activation and recovered a mean of +1.2 letters (95% CI, -0.4 to 2.7 letters; P = 0.133), resulting in a net loss of 3.3 letters (95% CI, 2.3-5.1 letters; P < 0.001) compared with VA at treatment suspension. Lower VA at the time of suspension and longer duration of treatment were associated with reduced risk of re-activation. Median time to re-activation was substantially greater when eyes had been treated for at least 3 years. Conclusions: Fewer than half of the eyes in which treatment was suspended re-activated in the first year, but most re-activated by the fifth year. Caution should be exercised to avoid suspending treatment prematurely. Further research is warranted to identify the eyes in which treatment may be suspended safely.