Intravitreal afibercept and ranibizumab for PCV
Reviewed by Efrosini Papagiannuli

This is a retrospective, interventional series comprising 98 eyes with polypidal choroidal vasculopathy (PCV) with the aim of comparing treatments with afibercept and ranibizumab, highlighting any differences in their efficacy. Case notes and imaging (FFA / ICG / OCT) were reviewed covering a period from May 2013 to September 2014, at a single hospital. Patients with PCV were included if they were >50 years old, had confirmed PCV on FFA / ICG, were treatment naïve at diagnosis, had only received one type of treatment (afibercept or ranibizumab) and had been followed up monthly for a minimum of 12 months. The primary outcome was a mean change in best corrected visual acuity (BCVA) with a secondary outcome of change in central foveal thickness (CFT). These were measured at three, six, nine and 12 months. Additional outcomes included the percentage of patients who had gained or lost >3 lines in vision in this period and the rate of regression of the polyp. All patients were given the standard three loading doses of each drug, with further intravitreal injections if there was visual deterioration of >2 lines (logMAR), persistent haemorrhage / fluid at the macula for at least one month after the previous injection on OCT, or evidence of an active PCV on FFA / ICG. There were 38/98 eyes that received afibercept injections and 60/98 eyes that received ranibizumab. At baseline there were no significant differences between the two groups in terms of BCVA, CFT, lesion size (GLD), incidence of subretinal haemorrhage or incidence of pigment epithelial detachment (PED). Whilst both groups showed a significant improvement in BCVA from baseline to three, six and nine months, there was no significant difference between the two groups. In the afibercept group the mean BCVA improved from 0.63+/-0.49 to 0.44+/-0.37 at 12 months, whereas in the ranibizumab group BCVA improved from 0.66+/-0.43 to 0.49+/-0.36 in the same period. In total, at 12 months 31.6% (12/38) of afibercept treated eyes showed an improvement of >3 lines in BCVA and 23.6% (9/38) showed a deterioration of >3 lines. In the ranibizumab group the respective rates were 26.7% (16/60) for >3 lines gain and 20.0% (12/60) for >3 lines loss. The mean CFT had decreased significantly over the 12 month study period from 396 +/-167 microns to 212 +/-144 microns in the afibercept group and from 402 +/-198 microns to 240 +/-183 microns in the ranibizumab group (p<0.001 in both). However, there was no significant difference between the two groups. Total regression of polyps occurred in 15/38 eyes (39.5%) in the afibercept group, versus 13/60 eyes (21.6%) in the ranibiumab group (p=0.007). The authors discuss the merits of afibercept versus ranibizumab in their findings, in that it was more effective in inducing total polyp regression and also allowed more patients to gain >3 lines of vision during the study period. They speculate whether this could be due to a better affinity in binding not only VEGF-A, but perhaps also VEGF-B and PIGF and also positively affecting choroidal vascular permeability. The authors highlight the limitations of their study, including its retrospective nature, the lack of randomisation to treatment group, and the variation in reinjection periods between the two drugs. They briefly discuss treatments with photodynamic therapy (PDT) and suggest that combining afibercept with PDT for PCV, may lead to even higher poly regression rates and recommend further studies to evaluate this. 

Intravitreal afibercept and ranibizumab injections for polypoidal choroidal vasculopathy.
Cho HJ, Kim KM, Kim HS, et al.
AMERICAN JOURNAL OF OPHTHALMOLOGY
2016;165:1-6.