Opportunities and challenges in the development of combination therapy for the treatment of retinal diseases

Ranibizumab, a humanized monoclonal antibody fragment (fragment, antigen binding, FAB) that neutralizes all of the soluble isoforms of vascular endothelial growth factor (VEGF)-A, was a significant step forward in the control of age-related macular degeneration. However, this agent, like others with the same mechanism, has several limitations. Although ranibizumab preserves vision in almost all patients, only a fraction achieves a halving of the visual angle. By inhibiting the activities of VEGF, ranibizumab blocks the continued growth of choroidal neovascularization, but existing neovascular lesions do not regress. Further, ranibizumab addresses only the increased production of VEGF; it does not address the underlying cause of enhanced cytokine production. Although ranibizumab is well tolerated, the course of the disease is unpredictable, necessitating frequent patient monitoring and treatment. Although strategies that guide retreatment based on the reoccurrence of retinal edema can be used to reduce treatment burden, this strategy may not provide optimal patient benefit. Because of these limitations, the identification of effective adjunctive therapies is considered an urgent goal.