Visual and Anatomic Responses in Patients With Neovascular Age-Related Macular Degeneration and a Suboptimal Response to Anti-VEGF Therapy Switched to Faricimab

Abstract

Purpose: To determine the efficacy of switching to intravitreal (IVT) faricimab in patients with treatment-resistant neovascular age-related macular degeneration (nAMD) and determine the rates of reversion to the original antivascular endothelial growth factor (anti-VEGF) therapy. Methods: A retrospective chart review was performed of patients with nAMD and persistent fluid on optical coherence tomography previously treated with anti-VEGF injections who received at least 1 IVT faricimab injection between March 1, 2022, and January 31, 2023. Results: The study comprised 135 eyes of 119 patients. Before switching to IVT faricimab, the mean number of anti-VEGF injections in the previous 12 months was 10.7 ± 2.6 (SD) with a mean interval of 4.8 ± 1.3 weeks (range, 2-8). The mean follow-up was 11.6 ± 2 months. Thirty eyes (22.2%) switched to IVT faricimab returned to the original therapy. Of the 105 eyes remaining on IVT faricimab, 66 (62.9%) had no fluid at the last follow-up. Compared with the original treatment, there was a significant improvement in logMAR visual acuity at the last follow-up in eyes on IVT faricimab (0.42 vs 0.38; P < .01) and in central subfield thickness (286 µm vs 246 µm; P < .0001). There was also a significant increase in the dosing interval after the third injection vs before IVT faricimab was prescribed (4.8 weeks vs 5.5 weeks; P < .001). Conclusions: Faricimab has a potent drying effect and potential for increasing the injection interval in many eyes with nAMD and persistent fluid on other anti-VEGF agents. Although nearly 25% of eyes reverted to the original therapy because of an insufficient response or adverse events, the majority did not achieve fluid resolution after reversion.

Keywords: aflibercept; bevacizumab; faricimab; neovascular age-related macular degeneration; vascular endothelial growth factor.

Figure 1.

Kaplan-Meier plot of the survival probability of persistent retinal fluid as a function of follow-up time.

Figure 2.

Optical coherence tomography of complete fluid resolution in a patient switched to IVT faricimab. (A) A 92-year-old man with significant IRF and SRF and a VA of 20/50 on aflibercept injections every 5 weeks. (B) He was subsequently treated with IVT faricimab, with fluid resolution after 1 injection and a VA of 20/30. The injection interval was increased to 8 weeks. (C) CST before starting IVT faricimab. (D) CST after 1 IVT faricimab injection. Abbreviations: CST, central subfield thickness; ILM, internal limiting membrane; IRF, intraretinal fluid; IVT, intravitreal; RPE, retinal pigment epithelium; SRF, subretinal fluid; VA, visual acuity.

Figure 3.

Optical coherence tomography of stepwise fluid resolution in a patient switched to IVT faricimab. (A) A 94-year-old woman with significant IRF and SRF and a VA of 20/70 on aflibercept injections every 4 weeks. (B) After she was switched to IVT faricimab, the VA improved to 20/40 after 2 injections, with marked fluid resolution. (C) Further resolution of fluid after 4 IVT faricimab injections every 4 weeks. (D) CST before starting IVT faricimab. (E) CST after 2 IVT faricimab injections. (F) CST improvement after 4 IVT faricimab injections. Abbreviations: CST, central subfield thickness; ILM, internal limiting membrane; IRF, intraretinal fluid; IVT, intravitreal; RPE, retinal pigment epithelium; SRF, subretinal fluid; VA, visual acuity.

Figure 4.

Optical coherence tomography of worsening fluid in a patient switched to IVT faricimab. (A) A 92-year-old woman with significant IRF and SRF and a VA of 20/40 on aflibercept injections every 5 weeks. (B) After she was switched to IVT faricimab, the fluid worsened and the VA was 20/50 after 1 faricimab injection. (C) After the patient was switched back to aflibercept the IRF resolved over time, although the SRF persisted. (D) CST before starting IVT faricimab. (E) CST worsening after 1 IVT faricimab injection. (F) CST improvement at the last follow-up after reverting to aflibercept. Abbreviations: CST, central subfield thickness; ILM, internal limiting membrane; IRF, intraretinal fluid; IVT, intravitreal; RPE, retinal pigment epithelium; SRF, subretinal fluid; VA, visual acuity.