In patients with glaucoma who require treatment for age-related macular degeneration or diabetic macular oedema, aflibercept may be a better choice of therapy than ranibizumab, as it is less likely to result in a delayed and sustained rise in IOP

The science behind the tip

Anti - VEGF injection therapy for age-related macular degeneration or diabetic macular oedema may result in a delayed and sustained rise in IOP (1). Risk factors include: extended treatment duration with multiple injections, history of topical steroid use and the presence of glaucoma (2). Aflibercept (Eylea) is a recombinant fusion protein which has a higher binding affinity to VEGF isoforms than ranibizumab (Lucentis), with longer biological effects in ocular tissues and therefore a reduced dosing regimen is used. The effectiveness in stabilising and improving visual acuity is similar. The incidnce of IOP elevation is lower in patients treated with aflibercept than those treated with ranibizumab (3). The exact mechanism is not known. However, this effect may be a consequence of the fact that aflibercept is less likely to result in reduced aqueous flow through the trabecular meshwork, secondary to protein aggregation and is less likely to cause inflammatory trabeculitis (2).

Contributor: Gordana Sunaric-Mégevand, Geneva

References:

1. Bressler SB, Almukhtar J, Bhorade A et al. Repeated intravitreous ranibizumab injections for diabetic macular oedema and the risk of sustained elevation of intraocular pressure or the need for ocular hypotensive treatment. JAMA Ophthalmol 2015; 133: 589-597.

2. Dedania VS, Bakri SJ. Sustained elevation of intraocular pressure after intravitreal anti - VEGF agents: What is the evidence? Retina 2015; 35: 841-858.

3. Freund KB, Hoang QV, Saroj N, Thomson D. Intraocular pressure in patients with age-related macular degeneration receiving intravitreal aflibercept or ranibizumab. Ophthalmology 2015; 122:1802-1810.

Tip Reviewer: Roger Hitchings
Tip Editors: John Salmon and Gordana Sunaric Mégevand