21 April 2024

Another first at Department of Ophthalmology, UKM

The first injection of a novel anti-vascular endothelial growth factor (anti-VEGF) agent for wet neovascular age-related macular degeneration (nAMD) with dual action, faricimab was performed by the Vitreoretinal 1 (Pink) team of Department of Ophthalmology, Faculty of Medicine, UKM on 21 March 2024. The patient was a 84-year-old lady with nAMD who had been on serial injections of various anti-VEGF agents for the preceding 2 years. While her vision was relatively good at 6/9, N6 in the affected eye, she was unable to extend her injection intervals beyond 4 weeks with residual subretinal fluid (SRF) on optical coherence tomography (OCT) (Figure 1) that would not resolve. She also complained of visual distortion (metamorphopsia). A decision was made to offer this new agent following evidence in the medical literature as to the effectiveness and safety of this agent for patients unable to extend their treatment interval or who had persistent fluid1. It has been approved by the FDA for treatment of nAMD.

The intravitreal injection (injection into the vitreous cavity, ie cavity behind the lens, in front of the retina) was performed successfully by Dr Yong Meng Hsien, senior lecturer and consultant ophthalmologist, under sterile technique and topical anaesthesia at the Eye Clinic, Hospital Canselor Tuanku Muhriz @ UKM. (Figure 2) At one-week review, the patient was comfortable with no side effects or complaints. At one month’s review, her OCT showed resolution of SRF, reduction of metamorphopsia and her vision improved to 6/6,N6. (Figure 3). 

Faricimab-svoa 6 mg (VabysmoTM, Genentech, USA)  is a bispecific monoclonal antibody with dual inhibition of VEGF-A and angiopoietin 2 (Ang-2). These 2 mechanisms are believed to be involved in the pathway leading to nAMD. nAMD being a cause of central vision loss affecting the elderly population, due to leaky new blood vessels that distort the normal anatomy of the macula, the most sensitive part of the retina responsible for near vision. Anti-VEGF agents have been found to be the gold standard therapy for most cases of nAMD. Nevertheless, a significant proportion of patients (up to 30%) have reduced response (resistant) or response that requires close injection intervals to maintain a dry retina and improved vision. The injections are performed through a safe location in the eye under aseptic technique and with topical anaesthesia. It is hoped that this new agent, with its dual action will offer better treatment response and longer injection intervals in the Malaysian population as well as that seen in overseas trials.

Reported by:

Dr. Yong Meng Hsien

Prof. Dr. Mae-Lynn Catherine Bastion

[1. Heier JS, Khanani AM, Quezada Ruiz C, et al. Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials. Lancet. 2022;399(10326):729–740. doi: 10.1016/S0140-6736(22)00010-1]

 

Figure 1: Spectral domain OCT (SD-OCT) images showing the macula of the patient prior to injection with Faricimab. There is persistent fluid under the retina as indicated by the blue arrow.

 

Figure 2: Procedure of intravitreal injection performed in the clean procedure room of Eye Clinic, HCTM

 

Figure 3: SD-OCT after faricimab injection showing resolution of SRF, reduction of metamorphopsia and her vision improving to 6/6,N6.