Intravitreal aflibercept for retinal angiomatous proliferation (RAP)
Reviewed by Sofia Rokerya

In this prospective study the authors present the visual and anatomical outcome of patients with RAP lesions who were treated with intravitreal aflibercept. The study cohort of 46 patients reached study completion at week 96. They were all Caucasians, with a mean age of 81.5 (range 67-97) years. There were 34 females (74%) and 29 left eyes (63%). The mean duration of symptoms prior to the initiation of treatment was 7.8 weeks (range four days – 52 weeks). After three initial monthly injections, the patients received aflibercept every eight weeks, up to and including week 48. During weeks 52-96, patients received injections at least every 12 weeks, with monthly evaluations for interim injections if they fulfilled the retreatment criteria. At each visit, best-corrected visual acuity (BCVA), optical coherence tomography (OCT) and central macular thickness (CMT) were measured. Mean BCVA improved by 6.0 (SD 7.9) and 4.8 (SD 7.4) ETDRS letters at 52 and 96 weeks, respectively, from a baseline of 57.3 (SD 12.0) letters (p=0.03 and p=0.02, respectively). The largest improvement in BCVA was seen early in the course of treatment, with a peak gain of eight letters at 20 weeks. At 52 weeks, 45/46 (98%) of patients had maintained their vision (<15 letters of BCVA had been lost), while 10/46 (22%) had gained ≥15 letters. At the 96-week time point, 41 (89%) had maintained their BCVA while 13 (28%) had gained ≥15 letters. Of the five patients who lost ≤15 letters at week 96, four cases were due to central foveal photoreceptor atrophy and one was due to extensive scarring after a submacular haemorrhage. The mean CMT was reduced by 135μm (SD 118μm) at four weeks from a mean of 438μm at baseline (SD 105) (p=<0.0001). At 52 weeks, the mean CMT was reduced by 165μm (SD 156μm) (p=<0.0001) with 83% of maculae being fluid-free, while at week 96, there was a mean reduction in CMT of 162μm (SD 106μm) (p=<0.0001) with 72% of maculae being fluid free. The study demonstrated that a fixed dosing schedule of aflibercept in the first year followed by a capped prn, protocol in the second year was an effective treatment for RAP. Strengths: Largest series to date of treatment-naïve RAP patients, prospective treatment with aflibercept. Patients were reviewed within the time scales of the VIEW study protocol and underwent a BCVA logMAR measurement at each visit. The diagnosis of RAP was confirmed and graded by an independent reading centre. Weaknesses include the absence of a true control group and the relatively small number of patients recruited; these reduce the power.

Intravitreal aflibercept for retinal angiomatous proliferation. Results of a prospective case series at 96 weeks.
Browning AC, O’Brien JM, Vieira RV, et al.
OPHTHALMOLOGICA
2019;242:239-46.