Conversion back to bevacizumab or ranibizumab for recurrent neovascular activity with aflibercept in age-related macular degeneration: a case series

BACKGROUND Neovascular age-related macular degeneration often requires chronic therapy with anti-VEGF agents, and patients with recurrent disease are challenging to manage. METHODS This retrospective case series evaluates patients who were switched from bevacizumab or ranibizumab to aflibercept and then back again because of recurrent fluid on optical coherence tomography (OCT) by reporting changes in OCT measurements over the course of medication changes. RESULTS Twenty-one eyes in nineteen patients received an average of 20.7 bevacizumab and/or ranibizumab injections and then an average of 7.2 aflibercept injections before being switched back to bevacizumab or ranibizumab because of recurrent fluid on OCT. Median central macular thickness improved on transition from bevacizumab or ranibizumab (317 μm) to aflibercept (285 μm; p = 0.034), then worsened over the course of aflibercept treatment (296 μm; p = 0.080), but improved again with transition from aflibercept back to bevacizumab or ranibizumab (283 μm; p = 0.016). The total volume of subretinal fluid, intraretinal fluid, and pigment epithelial detachments also decreased on transition from bevacizumab or ranibizumab (2.56 mm3) to aflibercept (2.44 mm3; p = 0.080), then worsened over the course of aflibercept treatment (3.18 mm3; p = 0.019), and improved again on transition back to bevacizumab or ranibizumab (2.11 mm3; p = 0.016). CONCLUSIONS While aflibercept appears initially effective, some patients develop recurrent fluid with aflibercept that improves with transition back to bevacizumab or ranibizumab. Rotating anti-VEGF agents may be beneficial with recurrent neovascular activity.