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Effects of switching from ranibizumab to aflibercept in eyes with exudative age-related macular degeneration
  1. Daniel Barthelmes1,2,
  2. Anna Campain1,
  3. Phuc Nguyen1,
  4. Jennifer J Arnold3,
  5. Ian L McAllister4,
  6. Judy M Simpson5,
  7. Alex P Hunyor1,6,
  8. Robyn Guymer7,
  9. Rohan W Essex8,
  10. Nigel Morlet9,
  11. Mark C Gillies1
  12. for the Fight Retinal Blindness! Project Investigators
    1. 1The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
    2. 2Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
    3. 3Marsden Eye Specialists, Parramatta, Australia
    4. 4The Lions Eye Institute, Center for Ophthalmology and Vision Science, University of Western Australia, Perth, Western Australia, Australia
    5. 5Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
    6. 6Retina Associates, Chatswood, New South Wales, Australia
    7. 7Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Victoria, Australia
    8. 8Department of Ophthalmology, Canberra Hospital, Garran, Australian Capital Territory, Australia
    9. 9Department of Population Health, University of Western Australia, Perth, Western Australia, Australia
    1. Correspondence to Dr Daniel Barthelmes, Department of Ophthalmology University Hospital Zurich Frauenklinikstrasse 24, Zurich 8091, Switzerland; dbar8165{at}


    Aims To examine 12-month outcomes of eyes switching from intravitreal ranibizumab to aflibercept for neovascular age-related macular degeneration (nAMD).

    Methods Database observational study of eyes with nAMD tracked by the Fight Retinal Blindness outcome registry that received ranibizumab for at least 12 months before switching to aflibercept and followed for at least 12 months after the switch. Visual acuity (VA) recorded at 12 months after the switch was analysed using locally weighted scatterplot smoothing curves. Lesion activity was graded according to a prospectively identified definition. Main outcomes were change in VA and treatment intervals 12 months after the treatment switch. Secondary outcomes included change in activity grading, effect of duration of treatment before switching and analysis of eyes that switched back.

    Results A total of 384 eyes switched from ranibizumab to aflibercept after a mean duration of 39.8 months on the original treatment. The mean VA did not change from the time of switching treatment (63.4, SD 15.9 logarithm of the minimum angle of resolution letters) to 12 months later (63.3, SD 16.7). While 10% of eyes gained 10 or more letters 12 months after the switch, 13% lost the same amount. The mean number of injections decreased by around one injection in the 12 months after switching (p<0.001), with a decrease in the proportion of choroidal neovascular membrane lesions that were graded as active. Eyes that had been treated for the longest time (49 or more months) before switching had worse vision at the point of switch but neither change in VA nor treatment interval was different between groups. The small proportion (6.9%) of eyes that switched back again to ranibizumab had already lost a mean of 5.2 letters from the first switch to the switch back and continued to lose vision at a similar rate for at least 6 months.

    Conclusions The mean VA of eyes that switched treatments from ranibizumab to aflibercept was not different 12 months later. There was a modest increase in treatment intervals and a somewhat greater proportion of eyes that were graded as inactive after the switch.

    • Macula
    • Neovascularisation
    • Retina
    • Vision
    • Field of vision

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    • Collaborators Fight Retinal Blindness Investigators: Eye Associates, Sydney, NSW (Dr A Hunt); Retina Associates, Chatswood, NSW (Dr S Fraser-Bell, Dr C Younan); Marsden Eye Specialists, Parramatta, NSW; Gosford Eye Surgeons, Gosford, NSW (Dr S Young); Gladesville Eye Specialists, Gladesville, NSW (Dr S Young); Eyemedics, Adelaide, SA (Dr S Lake, Dr R Phillips, S Lake, Dr M Perks, Dr Saha); Canberra Hospital, Garran, ACT; Centre for Eye Research Australia, East Melbourne, VIC; Victoria Parade Eye Consultants, Fitzroy, VIC (Dr L Lim); Specialist Eye Group, Hornsby Eye Specialists, Hornsby, NSW (Dr S Lal); ADHB, Auckland, NZ (Dr D Squirrell); University Hospital Zurich, University of Zurich, Zurich Switzerland; Retina Specialist Auckland, NZ (Dr R Barnes, Dr D Sharp); Les Manning Practice, Brisbane, QLD (Dr L Manning); Cairns Eye and Laser Clinic, Cairns, QLD (Dr A Field); Doncaster Eye Center, Doncaster, VIC (Dr L Chow).

    • Contributors Substantial contributions to the conception or design of the work: DB, AC, PN, JJA, ILM, JMS, APH, RG, RWE, NM and MCG. Acquisition, analysis or interpretation of data for the work: DB, AC, PN, JJA, ILM, JMS, APH, RG, RWE, NM and MCG. Drafting the work or revising it critically for important intellectual content: DB, AC, PN, JJA, ILM, JMS, APH, RG, RWE, NM and MCG. Final approval of the version to be published: DB, AC, PN, JJA, ILM, JMS, APH, RG, RWE, NM and MCG. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: DB, AC, PN, JJA, ILM, JMS, APH, RG, RWE, NM and MCG.

    • Funding This work was supported by a grant from the Royal Australian NZ College of Ophthalmologists Eye Foundation (2007–2009) and a grant from the National Health and Medical Research Council, Australia (NHRMC 2010-1012).

    • Competing interests JJA, RG, APH, ILM and MCG are members of advisory boards for Novartis and Bayer. JJA and MCG are also members of advisory boards for Allergan. MCG, JJA, APH and RG report personal fees and others from Novartis, others from Bayer, outside the submitted work. DB and APH received a research grant from Novartis.

    • Ethics approval RANZCO HREC and SESIAHS HREC.

    • Provenance and peer review Not commissioned; externally peer reviewed.