Treatment Plan for Branch Retinal Vein Occlusion with Macular Edema on Vabysmo
Continue Vabysmo (faricimab-svoa) 6mg intravitreal injections as the appropriate anti-VEGF therapy for this patient with BRVO-associated macular edema, following a structured treatment regimen with close monitoring for response. 1
Initial Treatment Strategy
Anti-VEGF agents are the preferred first-line therapy for macular edema causing vision loss in BRVO, with a favorable risk-to-benefit profile compared to corticosteroids or laser therapy. 2, 1
Treatment Regimen
Loading phase: Administer monthly injections initially to achieve maximal anatomic and functional improvement, as demonstrated in landmark trials (BRAVO, VIBRANT) that showed 55-61% of patients gaining ≥15 letters with monthly anti-VEGF therapy. 2
Maintenance phase: After initial response, transition to a treat-and-extend protocol or pro re nata (PRN) regimen based on OCT findings and visual acuity. 2, 3
The SCORE2 trial demonstrated that treat-and-extend protocols require approximately 1-2 fewer injections compared to monthly regimens while maintaining similar visual outcomes, though confidence intervals suggest caution in assuming complete equivalence. 2
Monitoring Protocol
Follow-up intervals: Initially every 4 weeks during loading phase, then extend to 8-12 weeks based on response (as done in this case with 3-month follow-up planned). 2, 3
OCT surveillance: Monitor central subfield thickness and presence of intraretinal/subretinal fluid at each visit to guide retreatment decisions. 4
Visual acuity assessment: Document BCVA at each visit; patients achieving ≥20/40 vision with resolved edema may qualify for extended intervals. 3
Response Assessment and Treatment Adjustments
If inadequate response after 6 months of anti-VEGF therapy (persistent edema or vision loss), consider switching to alternative anti-VEGF agent or adding corticosteroid therapy. 2, 1
Criteria for Treatment Modification
Good responders (resolution of edema, vision improvement): Continue current anti-VEGF on treat-and-extend protocol, potentially extending to 12-week intervals. 2, 3
Poor responders (persistent edema after 6 months): Consider dexamethasone implant as rescue therapy or switch to alternative anti-VEGF agent. 2, 1
Recent evidence suggests faricimab (Vabysmo) may be particularly effective in treatment-resistant cases, with significant improvements in central subfield thickness and intraretinal fluid resolution. 4
Safety Considerations
Severe adverse events are uncommon with anti-VEGF therapy, including endophthalmitis (0.0-0.9%), retinal detachment, and elevated IOP. 2, 1
No increased arterial thromboembolic events have been demonstrated in meta-analyses of anti-VEGF treatment for RVO. 2, 1
Use povidone-iodine antiseptic before all intravitreal injections; routine antibiotic eye drops are not recommended. 2
IOP elevations are particularly common with corticosteroids (not anti-VEGF agents), making anti-VEGF the safer first-line choice. 2, 1
Systemic Risk Factor Management
Aggressively optimize diabetes control (current HbA1c 6.4%) and coordinate with primary care to address all modifiable risk factors including hypertension and lipid levels. 5, 6
Diabetes is a major risk factor for RVO, and systemic management is essential for preventing recurrence and optimizing treatment response. 5, 6
Cases with recognizable systemic causes (like this patient's Type 2 diabetes) require combined anti-VEGF therapy and systemic disease management for satisfactory long-term results. 6
Common Pitfalls to Avoid
Do not discontinue treatment prematurely: The HORIZON trial showed that approximately half of patients required ongoing treatment or laser photocoagulation to maintain gains. 2
Do not use corticosteroids as first-line therapy: While effective, they carry higher risks of cataract formation and glaucoma compared to anti-VEGF agents. 2, 1
Do not delay treatment: Early intervention with anti-VEGF therapy provides superior visual outcomes compared to observation or delayed treatment. 1
Monitor for conversion to ischemic BRVO: Although this patient has nonischemic BRVO, ongoing surveillance is needed as RVOs exist on a spectrum of ischemia. 5