Short-term outcomes of intravitreal brolucizumab for treatment-naïve neovascular age-related macular degeneration with type 1 choroidal neovascularization including polypoidal choroidal vasculopathy

Abstract

We evaluated the efficacy and safety of loading phase treatment with intravitreal brolucizumab for neovascular age-related macular degeneration (nAMD) with type 1 choroidal neovascularization (CNV). We analyzed consecutive 42 eyes of 40 patients with treatment-naïve nAMD associated with type 1 CNV. Three monthly injections of brolucizumab were completed in 36 eyes (85.7%). In those cases, best-corrected visual acuity (BCVA) was 0.24 ± 0.27 at baseline and improved significantly to 0.12 ± 0.23 after 3 months (P < 0.001). Central macular thickness was 301 ± 110 µm at baseline and decreased significantly to 160 ± 49 µm after 3 months (P < 0.001). Dry macula was achieved in 34 eyes (94.4%) after the loading phase. Central choroidal thickness was 264 ± 89 µm at baseline and decreased significantly to 223 ± 81 µm after 3 months (P < 0.001). Indocyanine green angiography after the loading phase revealed complete regression of polypoidal lesions in 15 of the 19 eyes (78.9%) with polypoidal lesions. Non-infectious intraocular inflammation (IOI) was observed in 8 of 42 eyes (19.0%) during the loading phase, while showing amelioration in response to combination therapy with topical and subtenon injection of steroids. In these eyes, BCVA after 3 months had not deteriorated as compared to that at baseline. These results indicate that loading phase treatment with intravitreal brolucizumab might be effective for improving visual acuity and reducing exudative changes in eyes with nAMD associated with type 1 CNV. Moreover, polypoidal lesions appear to frequently regress after this treatment. However, we must monitor patients carefully for brolucizumab-related IOI, and administer steroid therapy promptly.

Figure 1

Change of average best-corrected visual acuity (BCVA) in 36 eyes with neovascular age-related macular degeneration associated with type 1 choroidal neovascularization treated with 3 monthly intravitreal injections of brolucizumab. BCVA showed significant improvement after the first injection of brolucizumab (*P < 0.01, **P < 0.001). Data are expressed as means.

Figure 2

Change of average central macular thickness (CMT) in 36 eyes with neovascular age-related macular degeneration associated with type 1 choroidal neovascularization treated with 3 monthly intravitreal injections of brolucizumab. CMT showed significant improvement after the first injection of brolucizumab (**P < 0.001). Data are expressed as means.

Figure 3

Change of average central choroidal thickness (CCT) in 36 eyes with neovascular AMD associated with type 1 choroidal neovascularization treated with 3 monthly intravitreal injections of brolucizumab. CCT showed significant improvement after the first injection of brolucizumab (**P < 0.001). Data are expressed as means.

Figure 4

Images of the left eye of a 76-year-old man with polypoidal choroidal vasculopathy. Best-corrected visual acuity (BCVA) was 0.22 logarithm of the minimum angle of resolution (logMAR) units. (A) Color fundus photograph shows retinal pigment epithelium (RPE) degeneration and detachment accompanied by serous retinal detachment (SRD) at the macular area. (B) 12 mm horizontal and vertical B-mode optical coherence tomography (OCT) images through the fovea show dilated outer choroidal vessels associated with RPE detachment and SRD. The CMT and CCT are 388 μm and 360 μm, respectively. (C) Fluorescein angiography (FA) shows window defects, leakage, and pooling to the RPE detachment at the macular area. (D) Indocyanine green angiography (ICGA) shows polypoidal lesions in the RPE detachment. One month after the first injection of brolucizumab: BCVA of the left eye is 0.00 logMAR units. (E) Color fundus photograph shows neither RPE detachment nor SRD but RPE degeneration can be seen in the macular area. (F) 12 mm horizontal and vertical B-mode OCT images through the fovea show no SRD but there are dilated outer choroidal vessels associated with a shallow irregular RPE detachment. The CMT and CCT are 146 μm and 344 μm, respectively. One month after the third injection of brolucizumab: BCVA of the left eye is -0.08 logMAR units. (G) Color fundus photograph shows RPE degeneration at the macular area. (H) 12 mm horizontal and vertical B-mode OCT images through the fovea show dilated outer choroidal vessels associated with a shallow irregular RPE detachment. The CMT and CCT are 148 μm and 303 μm, respectively. (I) FA shows no leakage or pooling but there are window defects at the macular area. (J) ICGA shows no polypoidal lesions.

Figure 5

Fundus images of the right eye of a 77-year-old woman with polypoidal choroidal vasculopathy. She noticed floaters in her right eye approximately 3 weeks after the first injection of brolucizumab. Best-corrected visual acuity (BCVA) was 0.30 logarithm of the minimum angle of resolution (logMAR) units at 1 month after the first intravitreal brolucizumab injection. (A) Ultra-widefield color fundus imaging shows intraocular inflammation including vitritis and retinal vasculitis. (B) Magnified image of the temporal area of (A). Intravitreal brolucizumab therapy was stopped. She was promptly given combination therapy with subtenon injection of triamcinolone acetonide (30 mg/0.75 ml) and 0.1% betamethasone eye drops. BCVA of the right eye was improved to 0.10 logMAR units 1 month after the subtenon injection of triamcinolone acetonide. (C) Ultra-widefield color fundus imaging shows amelioration of the vitritis and retinal vasculitis. (D) Magnified image of the temporal area of (C).