David A. Eichenbaum, MD, FASRS, Management of AMD/DME - Episode 1

Patient Case #1: 74-Year-Old Male With DME

David A. Eichenbaum, MD, FASRS, reviews the case of a 74-year-old male with diabetic macular edema (DME).

David A. Eichenbaum, MD, FASRS: This patient is a poor fellow who’s had diabetic macular edema for over a decade. He is a 74-year-old man who used to have poorly controlled diabetes and has a number of vasculopathic complications and associated conditions, all of which are controlled. He previously had a myocardial infarction, and has anticoagulated. His blood sugars have improved substantially over the past 10 to 15 years, his cholesterol is controlled, and he has some hyperthyroidism, which also is well controlled. He has suffered because of his previous history of poorly controlled diabetes with diabetic macular edema in both eyes. His right eye has been especially challenging and difficult to get a handle on. It’s hard to stay on top of it. He didn’t do well with intraocular steroids with a significant corticosteroid response, and he’s received laser therapy and intravitreal injections starting with ranibizumab, then aflibercept, and has been receiving aflibercept every 4 to 5 weeks in the right eye for years. His right eye continues to bother him and has 20/40 acuity. Despite a long history of vasculopathic disease and diabetes, he remains quite active and he’d like to see it get better.

Here’s how he looks in February of 2022. This is pretty much his typical look about 5 weeks after an aflibercept injection. He has some central cystic change and intraretinal fluid consistent with diabetic macular edema. He has a couple of floaters, which are apparent on the near-infrared photo on the left side of the screen, and his visual acuity is 20/40. This is his longstanding monthly antiangiogenic injection at baseline.

At this visit, the patient and I discussed the option of trying faricimab as a bispecific injection with both angiopoietin-2 inhibition and ongoing VEGF [vascular endothelial growth factor] suppression, which he has enjoyed, and with aflibercept treatment in an effort to improve his anatomy somewhat and potentially give him a less frequent and less burdensome treatment interval if he achieves a better visual and anatomic outcome. So I treated him with his first faricimab injection in the right eye on February 16. And on the next slide we’ll see the outcome of that.

Five weeks following this injection, he has both subjective and objective improvement in his visual acuity, reading another line and a half on the eye chart. Anatomically, on the OCT-B [optical coherence tomography-B] scan, we see an improvement in those longstanding cystic spaces and some partial reconstitution of a foveal contour. There are some microcystic type of changes, which are persistent, but he’s very happy, he’s encouraged, and he goes on to receive another faricimab injection at this date.

Here we see him following that second faricimab injection, and he has improved. His cystic spaces are still somewhat smaller. His acuity is stable, and he’s very happy with this new treatment with the bispecific medication. I’ve got to think to myself that the angiopoietin suppression is the difference. That’s what’s changed his anatomy for the better following the inception of faricimab treatment.

I begin to extend him out slightly, and at this visit he’s 6 weeks from his second faricimab injection. I’m going to be very gentle on his extension because I don’t want to lose the success we’ve achieved by switching him to faricimab from aflibercept. However, I do want the patient to enjoy a less burdensome treatment interval. He does continue to have an essentially dehydrated central foveal space. He does still have some blunting of his foveal contour, but certainly looks better than when he was receiving antiangiogenic monotherapy. He does have a couple of cysts present, as you can see just off center. But I’m happy to see him doing well with better anatomy, better vision, and a little bit of extension for starters. We’ll have to see where he can go, and where we can head as far as how he does going forward, but I’m excited to see him doing well on this new class of bispecific suppression.

Transcript Edited for Clarity