Asymmetric response to ranibizumab in mixed choroidal neovascularization in a neovascular age-related macular degeneration diagnosed on OCT angiography - case report

Abstract

Background: To present a case report of a patient with a mixed choroidal neovascular membrane (CNV) with an asymmetric response to ranibizumab diagnosed on optical coherence tomography angiography (OCTa).

Case presentation: A 61-year-old male was referred to our department in September 2017 due to decreased vision in his left eye. Best-corrected visual acuity (BCVA) was 43 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the left eye. Macular edema was present in the left eye, and a mixed CNV was identified on the OCTa. Therapy with intravitreal ranibizumab was commenced. After 5 ranibizumab injections, the BCVA was 42 ETDRS letters, and considerable intraretinal edema was still present. OCTa showed a resolution of the type 2 lesion of the mixed CNV; however, the type 1 lesion had continued to grow. The patient was then switched to intravitreal aflibercept. After 3 monthly aflibercept injections, the BCVA improved to 53 ETDRS letters, and a reduction of the edema was observed on the optical coherence tomography (OCT). OCTa showed a decrease in both the area and vessel density in the type 1 lesion of the CNV. Therapy with aflibercept was continued; however, while the intraretinal edema continued to improve, atrophy developed in the macula and the BCVA worsened to 43 ETDRS letters.

Conclusions: Ranibizumab nonresponse in a neovascular age-related macular degeneration is not uncommon. However, to our knowledge, this is the first described case of an asymmetric response to ranibizumab in a mixed CNV. While the type 2 lesion of the CNV reacted swiftly to the ranibizumab therapy, the type 1 lesion continued to grow. As with some other cases of ranibizumab resistance, switching to aflibercept proved effective.

Keywords: Age‐related macular degeneration; Anti-VEGF; Case report; Mixed CNV; Resistance.

Fig. 1

Color fundus photograph of the left eye showing a circular greyish lesion and edema in the foveal region

Fig. 2

OCT and OCTa of the left eye, a baseline OCT - a dense lesion above a small reflective pigment epithelial detachment and intraretinal cystic edema surrounding the lesion, b baseline OCTa above RPE - type 2 lesion of the mixed CNV, c baseline OCTa below RPE - type 1 lesion of the mixed CNV, d OCT after 3 ranibizumab injections - some reduction of the dense lesion can be observed, however the intraretinal edema is still present, e OCTa above the RPE after 3 ranibizumab injections - just a residual feeder vessel remains, f OCTa below the RPE after 3 ranibizumab injections - increase in both the area and density of the type 1 lesion of the mixed CNV, g OCT after 5 ranibizumab injections – persistent intraretinal edema, h OCTa above the RPE after 5 ranibizumab injections – type 2 lesion of the mixed CNV is completely absorbed, i OCTa below the RPE after 5 ranibizumab injections – further growth of the type 1 lesion of the mixed CNV, j OCT after 3 aflibercept injections - reduction in edema, some intraretinal cysts are still present, k OCTa above the RPE after 3 aflibercept injections – no visible CNV, l OCTa below the RPE after 3 aflibercept injections - reduction in both the area and vessel density in the type 1 lesion of the mixed CNV, m OCT after 7 aflibercept injections - some intraretinal cysts still present in the macula along with atrophy of both the RPE and the outer retinal layers, n OCTa above the RPE after 7 aflibercept injections – no visible CNV, l OCTa below the RPE after 7 aflibercept injections – further reduction in both the area and vessel density in the type 1 lesion of the mixed CNV