Place of New Anti-Vascular Endothelial Growth Factor Agents in Recalcitrant Radiation Maculopathy: Case Reports

Anti-vascular endothelial growth factor (VEGF) therapy is the main treatment alternative in radiation maculopathy as it reduces the macular edema and thereby improves the vision to some extent. The efficacy of newer-generation anti-VEGF agents with greater durability is less known in this entity. This report highlights the administration of faricimab and 8 mg aflibercept in the management of two recalcitrant cases.

We report two cases with radiation retinopathy following the CyberKnife stereotactic radiotherapy for the treatment of choroidal melanoma. A 25-year-old man developed left radiation retinopathy 8 months after the treatment. Though three consecutive posterior subtenon 20 mg triamcinolone acetonide injections within 20 months, followed by two intravitreal 1.25 mg bevacizumab injections together with scatter peripheric laser treatment within 8 months, were given, there was persistent severe macular edema, peripheral retinal ischemia, and retinal neovascularizations (NVEs). He was then treated at our department with seven monthly intravitreal faricimab injections, one subsequent aflibercept 8 mg injection, and additional scatter laser photocoagulation, resulting in modest visual improvement, decreased macular edema, and disappearance of NVEs. The second case was a 35-year-old woman diagnosed with radiation retinopathy 1 year after the treatment for the right uveal melanoma. Despite two posterior subtenon 20 mg triamcinolone acetonide injections performed within 11 months, maculopathy was worsened, and she was treated sequentially with four monthly faricimab and five monthly 8 mg aflibercept injections. Macular edema improved partially, and she experienced some visual improvement.

Despite administering more durable agents (faricimab and aflibercept 8 mg) even monthly, there were modest anatomical and visual improvements in both cases with recalcitrant radiation maculopathy. Our observations were preliminary clinical observations, rather than definitive evidence, regarding the efficacy of faricimab and aflibercept 8 mg in radiation maculopathy.