The role of anti-VEGF agents in myopic choroidal neovascularization: Current standards and future outlook

ABSTRACT

Introduction: The global prevalence of pathologic myopia is 0.9-3.1%, and visual impairment is found in 0.1-0.5% of European and 0.2-1.4% of Asian studies. Myopic choroidal neovascularization (mCNV) affects 5.2-11.3% of pathologic myopia patients and is a leading cause of vision impairment in the working-age population. Characteristic morphological changes and visual-acuity decrease are diagnostic features. Vascular-Endothelial-Growth-Factor (VEGF) has been identified as a trigger for pathologic neovascularization in these highly myopic patients.

Areas Covered: We cover the epidemiology, pathology and diagnostic aspects of mCNV. The history of therapeutic interventions is described, followed by an overview of current standard-of-care (SOC)–blocking VEGF using bevacizumab (off–label), ranibizumab or aflibercept and improving vision up to 13.5-14.4 letters. Despite good efficacy, an unmet medical need remains. We summarize ongoing and future developments of new drugs to treat or potentially cure mCNV.

Expert Opinion: mCNV is a major global health concern. Early detection and treatment is key for a satisfying outcome. The current SOC, VEGF inhibitors, affords good therapeutic efficacy and reasonable disease stabilization with few intravitreal treatments per year. However, the long-term prognosis is still unsatisfactory, and side-effects like chorioretinal atrophy development are of concern. Therefore, efforts should be intensified to develop more effective therapies.

KEYWORDS:

• Pathologic myopia
• myopic CNV
• atrophy
• epidemiology
• therapy
• anti-VEGF
• ranibizumab
• bevacizumab
• aflibercept

Article highlights

• The prevalence of mCNV in patients affected by high myopia ranges between 5.2% and 11.3%.

• mCNV presents with acute onset of central scotoma, metamorphopsia, and decreased visual acuity. Patients should be promptly seen by a retina specialist and treatment should be initiated in a timely manner.

• Past treatment approaches included verterporfin photodynamic therapy. Current standards of care are intravitreal administered anti-VEGF agents, in particular ranibizumab and aflibercept, which are approved for the treatment of mCNV. A single injection followed by an as-needed approach can successfully suppress disease activity and does not seem to be inferior compared to a loading dose of monthly administered injections

• Several new approaches including slow release devices and the blockage of PDGF are currently evaluated for VEGF-mediated retinal pathologies and may in the future serve as effective therapies to treat mCNV. This box summarizes key points contained in the article.

Declaration of interest

M Munk has received consultant fees from Novartis, a travel grant from Bayer and support from Lumithera. S Wolf and M Zinkernagel receive grants from the Swizz National Science Foundation (SNSF), non-financial support from Heidelberg Engineering. S Wolf has received support from Alcon, Allergan, Bayer Healthcare, Novartis Pharma and Roche outside the submitted work, and M Zinkernagel is a stockholder in Novartis, and receives support from Allergan, Bayer Healthcare and Novartis Pharma outside the submitted work. R Ruckert is a stockholder in Novartis, Roche, Bayer and Ophthotech and A Ebneter has received honoraria from Bayer for lectures and a travel grant from Allergan. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.