RGUHS Nat. J. Pub. Heal. Sci Vol: 15 Issue: 2 eISSN: pISSN
Dear Authors,
We invite you to watch this comprehensive video guide on the process of submitting your article online. This video will provide you with step-by-step instructions to ensure a smooth and successful submission.
Thank you for your attention and cooperation.
1Mohan S, Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India.
2Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
3Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
4Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
*Corresponding Author:
Mohan S, Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India., Email: smohanms17224w@gmail.com
Abstract
Brolucizumab, a humanized single-chain antibody fragment targeting VEGF-A, is approved for neovascular age-related macular degeneration (nAMD) and is being studied for other retinal conditions, including polypoidal choroidal vasculopathy (PCV). This case report presents a 79-year-old Indian male with idiopathic PCV in the right eye, characterized by diminished vision and a large serous pigment epithelial detachment (PED) (1092 μm). He was treated with a pro re nata (PRN) regimen of intravitreal Brolucizumab (6 mg/0.05 ml). After the first injection, PED reduced to 68 μm but later resurfaced (423 μm), requiring a second injection. Subsequent follow-ups showed fluctuations in fluid levels, necessitating a third injection, after which complete resolution was observed. This case highlights Brolucizumab’s effectiveness in managing serous PED in IPCV, with repeated administration improving long-term fluid resolution.
Keywords
Downloads
-
1FullTextPDF
Article
Introduction
Polypoidal Choroidal Vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), characterized by the dilation of polypoidal structures and a branching vascular network. This network is typically located beneath the Retinal Pigment Epithelium (RPE) and above Bruch’s membrane.1
A key factor in vision impairment among patients with age-related macular degeneration (AMD) is Retinal Pigment Epithelium Detachment (PED). PEDs occur when the RPE separates from the underlying Bruch’s membrane and are classified based on subretinal material into hemorrhagic, fibrovascular, drusenoid, and serous types.2 PCV presents distinct features in Indocyanine Green Angiography (ICGA) and Optical Coherence Tomography (OCT) and is frequently associated with recurrent subretinal hemorrhages and fluid accumulation.3,4 If left untreated, PCV can lead to permanent vision loss.5
The standard treatment for PCV includes intravitreal anti-vascular endothelial growth factor (VEGF) agents, either alone or in combination with photodynamic therapy using verteporfin.3 Brolucizumab, a single-chain antibody fragment with a high affinity for VEGF, is one such agent used in PCV management.6 Its low molecular weight (26 kDa) allows for higher drug concentration per injection, potentially leading to prolonged efficacy and improved tissue penetration.7 These benefits are attributed to Brolucizumab’s high molar concentration and small molecular size.8
Studies suggest that Brolucizumab effectively reduces disease activity, even in cases of treatment-resistant neovascular AMD.9 However, concerns remain regarding its safety, including reports of intraocular inflammation (IOI) and retinal vasculitis, with or without vascular occlusion. Despite these risks, Brolucizumab has demonstrated favorable functional and anatomical outcomes in neovascular AMD treatment.10
Case history
A 79-year-old Indian male with a history of hypertension presented with a two-month history of diminished vision (DOV) and distortion of vision in his right eye. An initial ocular examination revealed pseudophakia in both eyes. The patient had corrected visual acuity of 6/9 in the left eye and 6/18 in the right eye. Fundus examination of the right eye showed bulbous, orange-red lesions protruding from the choroid into the subretinal space, characteristic of PCV. In the left eye, a few yellowish lesions were observed in the paramacular region. Gonioscopy and intraocular pressure (IOP) were within normal limits. Optical Coherence Tomography (OCT) of the right eye revealed a large serous pigment epithelial detachment (PED) measuring 1092 μm, while Indocyanine Green Angiography (ICGA) confirmed idiopathic PCV (IPCV) in the right eye (Figure 1).
Intervention/Treatment regimen
IPCV, observed in the proper ocular organ, was treated through injections of 6 mg/0.05 ml of Brolucizumab, an anti VEGF medication. Brolucizumab injection was advised in the right eye for IPCV. One month after the first injection, improvement in DOV was reported. Post injection, the OCT showed a reduction in serous PED dimensions from 1092 μm to 68 μm (Figure 2).
A follow-up after one month showed resurfacing of serous PED measuring 423 μm. Therefore, the patient was advised for a second injection of Brolucizumab. One month after the second injection, the volume of serous fluid decreased from 423 μm to 77 μm, as shown in the OCT (Figure 3a and 3b).
The subsequent follow-up OCT showed an increase in fluid volume and serous PED measuring 181 μm. The patient was then advised to take a third injection. In the follow-up after the third injection, it was found in the OCT that the serous fluid had entirely resolved. (Figure 4). The patient has been advised with a follow-up visit for further examination.
Discussion
This investigation suggests that the efficiency of Brolucizumab in attaining full resolution of PED and treating IPCV becomes apparent following the third injection.11 In eyes with nAMD linked to type 1 Choroidal Neurovascularization (CNV), intravitreal Brolucizumab demonstrates effectiveness in mitigating exudative alterations and enhancing visual acuity.12 Prior researchers have observed the complete disappearance of polypoidal lesions in groups treated with Brolucizumab.13 Ito et al., reported a rate of 93% thorough resolution of polypoidal lesions after one year in Japanese patients undergoing intravitreal Brolucizumab injections for IPCV.14 It was found that intravitreal Brolucizumab injections were effective in the improvement of the anatomy and functionality of Japanese patients with IPCV. Dugel et al., stated that overall visual outcomes in patients with AMD showed efficient results in 48 weeks compared to 96 weeks.11 Brolucizumab has exhibited more excellent fluid resolution in comparison to aflibercept.11 The efficacy of Brolucizumab was reported in the treatment of serous PED as a secondary occurrence of IPCV in patients. A similar treatment regimen was followed in Nam et al.15 The patients were reported to have anatomical improvement. Brolucizumab has been identified as a viable and secure therapeutic choice for managing refractory serous PED in patients with PCV. Therefore, the results in this case study align with prior findings in similar investigations conducted on PCV patients.
The present case study’s findings indicate that Brolucizumab demonstrates impressive effectiveness when administered at a concentration of 6 mg/0.05 ml in treating patients with polypoidal lesions associated with IPCV. The drug has shown higher efficacy when administered in longer durations than a single administration. It can be considered an effective treatment regimen for older patients having AMD and history of PCV, and it shows complete resolution of fluid accumulation in a longer duration.
Conflict of Interest
Nil
Supporting File
References
1. Goldhardt R, Rosen BS. Polypoidal choroidal vasculopathy. Curr Ophthalmol Rep 2019;7(1): 66-72.
2. Pepple K, Mruthyunjaya P. Retinal pigment epithelial detachments in age-related macular degeneration: Classification and therapeutic options. Semin Ophthalmol 2011;26(3):198-208.
3. Cheung CM, Lai TY, Ruamviboonsuk P, Chen SJ, Chen Y, Freund KB, et al. Polypoidal choroidal vasculopathy: definition, pathogenesis, diagnosis, and management. Ophthalmology 2018;125(5): 708-24.
4. Wong RLM, Lai TYY. Polypoidal choroidal vasculopathy: An update on therapeutic approaches. J Ophthalmic Vis Res 2013;8(4):359-71.
5. Koh AH, Chen LJ, Chen SJ, Chen Y, Giridhar A, Iida T, et al. Polypoidal choroidal vasculopathy: evidence-based guidelines for clinical diagnosis and treatment. Retina 2013;33(4):686-716.
6. Yannuzzi NA, Freund KB. Brolucizumab: Evidence to date in the treatment of neovascular age-related macular degeneration. Clin Ophthalmol 2019; 13:1323-9.
7. Nguyen QD, Das A, Do DV, Dugel PU, Gomes A, Holz FG, et al. Brolucizumab: Evolution through Preclinical and Clinical Studies and the Implications for the Management of Neovascular Age- Related Macular Degeneration. Ophthalmology 2020;127(7):96376.
8. Dugel PU, Jaffe GJ, Sallstig P, Warburton J, Weichselberger A, Wieland M, et al. Brolucizumab Versus Aflibercept in Participants with Neovascular Age-Related Macular Degeneration: A Randomized Trial. Ophthalmology 2017;124(9):1296-304.
9. Bulirsch LM, Saßmannshausen M, Nadal J, Liegl R, Thiele S, Holz FG. Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study. Br J Ophthalmol 2022;106(9):1288-94.
10. Holz FG, Dugel PU, Weissgerber G, Hamilton R, Silva R, Bandello F, et al. Single-Chain Antibody Fragment VEGF Inhibitor RTH258 for Neovascular Age-Related Macular Degeneration: A Randomized Controlled Study. Ophthalmology 2016;123(5):1080-9.
11. Dugel PU, Singh RP, Koh A, Ogura Y, Weissgerber G, Gedif K, et al. HAWK and HARRIER: Ninety- Six-Week Outcomes from the Phase 3 Trials of Brolucizumab for Neovascular Age-Related Macular Degeneration. Ophthalmology 2021;128 (1):89-99.
12. Matsumoto H, Hoshino J, Mukai R, Nakamura K, Akiyama H. Short-term outcomes of intravitreal brolucizumab for treatment-naïve neovascular age-related macular degeneration with type 1 choroidal neovascularization including polypoidal choroidal vasculopathy. Sci Rep 2021;11(1):1-8.
13. Fukuda Y, Sakurada Y, Kashiwagi K, Matsubara M, Hasebe Y, Sugiyama A, et al. Comparison of outcomes between 3 monthly brolucizumab and aflibercept injections for polypoidal choroidal vasculopathy. Biomedicines 2021;9(9):1164.
14. Ito A, Maruyama-Inoue M, Kitajima Y, Ikeda S, Inoue T, Kadonosono K. One-year outcomes of intravitreal brolucizumab injections in patients with polypoidal choroidal vasculopathy. Sci Rep 2022;12(1):1-6.
15. Nam SW, Byun Z, Ham D Il, Kong M. Response to brolucizumab treatment for refractory serous pigment epithelial detachment secondary to polypoidal choroidal vasculopathy. BMC Ophthal-mol 2022;22(1):1-11.