Comment on: Aflibercept for recurrent or recalcitrant polypoidal choroidal vasculopathy in Indian eyes: Early experience.

Sir,

We read with interest the article – “Aflibercept for recurrent or recalcitrant polypoidal choroidal vasculopathy (PCV) in Indian eyes: Early experience,” by Bansal et al.[1] It provides some hope for treatment of this complex and vexing problem.[2] We would like some clarifications and also add some points to help us in the management of idiopathic PCV (IPCV).

Ten patients who were treated with multiple intravitreal injections of Accentrix/Avastin with or without photodynamic therapy (PDT) were included in this study. Were all these patients being treated at your center from the beginning? At what stage of the initial treatment were they labeled as recalcitrant? Was a change of intravitreal drug (from Accentrix to Avastin and vice versa) tried, as tachyphylaxis to a particular anti-vascular endothelial growth factor (VEGF) is known.[3] After how many “no response” injections were they labeled as recalcitrant? They were switched back to the initial treatment in case of no response to Aflibercept. What was the point in switching back if they never responded to that drug in the first place?

What was the reason for including recurrent cases in this study? Our assumption is to reduce the injection load. It cannot be financial as Eylea is far more expensive and for the cost of one Aflibercept injection – several Avastin/Accentrix injections can be given. If they were responding to earlier treatment – would it have been okay to continue? What was the average time taken for recurrence after the last injection (Accentrix/Avastin) in these two cases? Of course one of the two recurrent cases required only two Aflibercept injections for resolution which could be an argument for Aflibercept, but at the same time, the second recurrent case required multiple Aflibercept injections, so success in the recurrent group was only 50%.

Table 1 shows the number of Aflibercept injections to be in the range of 2–6. In two cases you switched to the previous therapy due to no response-after three injections and in one case after six injections. What was the reason for this discrepancy? If a patient does not show any response to any available drug – would it be prudent to stop all treatment considering that injections are not cheap and come with their own complications.[4]

There was no improvement in mean visual acuity although there was a significant reduction of central foveal thickness. Two patients showed some visual improvement (details are not available), seven patients showed stable vision while one showed worsening. It is possible that the visual acuity was poor to start with; hence there was no improvement in spite of anatomical improvement. Taking this into consideration-would you go ahead and recommend this as an initial treatment in all IPCV cases? We may be able to help the patients more by starting with Aflibercept before they have lost vision beyond redemption. This is especially relevant now as Ziv Aflibercept is available now (although off-label, just like Avastin) and that too at a fraction of the cost of Aflibercept. Several studies have shown Aflibercept to be superior to other anti-VEGF drugs in the treatment of IPCV.[5]

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Conflicts of interest

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