Rishi Singh, MD: Impact of Early Anatomical Dryness on Visual Outcomes

A new study presented at the American Academy of Ophthalmology (AAO) 2019 Annual Meeting in San Francisco is shedding further light on the association of intraretinal fluid and visual function outcomes in patients with neovascular age-related macular degeneration(nAMD).

To evaluate the relationship between early best corrected visual acuity(BCVA) outcomes and anatomic dryness treatment response by fluid location within the first 12 weeks of treatment, investigators conducted a post hoc analysis of patients from the VIEW trial. From patients in the VIEW 1 and VIEW 2 studies, a cohort of 1815 eyes with known retinal fluid status at baseline through week 12.

Of the eyes examined in the analysis, 511(28%) were categorized as persistent dry, which investigators defined as no fluid at weeks 4, 8, and 12. The remaining 1304(72%) were classified as not persistent dry.

Results of the study revealed more patients were persistent dry at week 12 with 2mg intravitreal aflibercept every 4 weeks and every 8 weeks than with ranibizumab every 4 weeks. Observed BCVA gains were similar for persistent dry and not persistent.

In an analysis with combined groups, the difference in BCVA gains for persistent dry versus not persistent dry with intraretinal fluid was 1.7 letters (95% CI 0.6, 2.8) at week 24. Investigators noted a within-group letter difference in BCVA gains for persistent dry compared with not persistent dry with intraretinal fluid of 3.4 (95% CI 1.6, 5.2) in the ranibizumab 4 week group, -0.3 (-2.1, 1.5) in the 2 mg aflibercept every 4 weeks group, and 2.2 (0.1, 4.3) for the 2 mg aflibercept every 8 weeks group.

For his take on the interpretation of the results, MD Magazine® sat down with study presenter Rishi Singh, MD, staff physician at Cole Eye Institute Cleveland Clinic, between sessions at AAO 2019.

MD Mag: Based on your analyses of the VIEW studies, what can presence of fluid early in treatment tell physicians about visual outcomes?

Singh: So, the study that was done as part of the American Academy of Ophthalmology presentation was a sub analysis of the VIEW 1 to VIEW 2 studies and in the trial what they did was they actually looked at patients in that loading period and looked to see what effect that fluid had on final visual outcomes in the patients. What they found were 2 very important things.

First, that the drying effect really affected some quality of life scores. So, for the patients the inability to drive or some other quality of life issues that patients face beyond vision was evaluated and found to be significant and those patients who were drier at the end of the loading period versus those who are not. In addition, what they found was that in the infinite loading period you developed persistent fluid that that had some detriment on long-term visual outcome and in particular it was the patients who had intraretinal fluid who had a detriment in long-term visual outcomes—it wasn't just the total amount of fluid or the subretinal fluid, but particularly the internal fluid that was there.

Now, this is the third trial to show intraretinal fluid correlation with long-term visual acuity impact. I think that's an important finding for clinicians to take home, because if you don't see a resolution of intraretinal fluid early in the treatment you should be concerned and should consider potentially switching therapies to an agent that would do it so that you don't lose vision or leave vision on the table.