Anti-VEGF for neovascular ARMD: visual improvement as the goal of therapy?

In the era of anti-vascular endothelial growth factor (VEGF) therapy for exudative age-related macular degeneration (ARMD), a paradigm shift has emerged. Until then, photodynamic therapy (PDT) was considered a successful therapeutic option, basically slowing down visual deterioration compared with the natural course. A milestone in drug therapy for ARMD was the introduction of pegaptanib, the first anti-VEGF drug for ocular use. For the first time, in about 10% a visual improvement in ARMD was reported.1 Initial study data on treatment with ranibizumab showed that up to 40% of patients experienced a significant increase in visual acuity (VA) independent of the type of neovascular lesion.2 3 Long-term data up to 2 years have been published and demonstrated that the initial positive effect could be maintained by multiple, repeated injections.

When the impressive results of ranibizumab leaked out (albeit the drug was not available outside the studies), Philip Rosenfeld reported on his impressive observations after intravitreal bevacizumab for refractive exudative ARMD (ASRS meeting, Montreal, June 2005).4 Bevacizumab had been approved as an adjunct to therapy of metastatic colon carcinoma in 2004. Marketed as Avastin, the drug was available in most countries. The retina community received the exciting news immediately. With patients desperately waiting for more potent treatment options and ranibizumab still in the process of FDA approval and the knowledge that an effective drug is already accessible, off-label bevacizumab had become almost routine in clinical practice. By autumn 2006, …