Aflibercept in the treatment of neovascular age-related macular degeneration in previously treated patients.

PURPOSE: To study the visual outcomes and change in central macular thickness (CMT) in patients with neovascular age-related macular degeneration (AMD) who were previously treated with ranibizumab (Lucentis) and/or bevacizumab (Avastin) and were subsequently switched to aflibercept (VEGF Trap-Eye; Eylea). METHODS: Retrospective study of patients who received intravitreal aflibercept from December 2011 to December 2012 and had previous anti-vascular endothelial growth factor treatment for AMD. The main outcome measures were best-corrected visual acuity (BCVA) and CMT as measured by optical coherence tomography. RESULTS: The study population included 30 patients aged 80.4±1.45 (mean±SEM) who received 6.27±0.37 (range 4-11) aflibercept injections. Eighteen patients had previously received only bevacizumab (12.4±2.18 injections), 2 had received only ranibizumab (19±6 injections), and 10 had received both ranibizumab and bevacizumab (mean 19.3 injections). BCVA logMAR at the initial visit (aflibercept initiation) was 0.506±0.054 (mean VA 20/64), and then, follow ups at 1-month 0.504±0.055 (20/64) P=0.903, 3-months 0.458±0.061 (20/57) P=0.112, 6-months 0.413±0.071 (20/52) P=0.036, and 12-months 0.521±0.076 (20/66) P=0.836. CMT at the initial visit was 261±10.9, and then, at 1-month 238±12.4 P=0.021, 3-months 245±10.6 P=0.102, 6-months 245±10.4 P=0.099, and 12-months 237±10.2 P=0.012. Results were similar in a subset of patients (n=15) with central macular edema or submacular fluid at aflibercept initiation. While on aflibercept, 2 patients developed intraocular pressure increases that required treatment. CONCLUSIONS: These findings demonstrate a significant decrease in CMT but no statistically significant improvement in BCVA through the 12-month follow up in patients previously treated who were switched to aflibercept for AMD. Patients may develop ocular hypertension after multiple aflibercept injections.

A remote upstream element regulates tissue-specific expression of the rat aggrecan gene.

The regulation of chondrogenesis and of the genes expressed as markers of chondrocyte differentiation is poorly understood. The hyaluronan-binding proteoglycan aggrecan is an essential and specific component of cartilage, but the aggrecan proximal promoter is expressed in an unregulated fashion in vitro. DNA comprising the rat aggrecan gene (83 kb including the 30-kb first intron) was surveyed for active elements, which would impart selective expression to the aggrecan promoter in transfection assays in vitro. A 4.7-kb DNA fragment (P3) with cell-specific enhancer activity was discovered approximately 12 kb upstream of the transcription start site; this active DNA fragment is position- and orientation-independent, and strongly stimulates aggrecan promoter expression in chondrocytes, while weakly suppressing transcription in fibroblasts. Most of this activity has been localized to P3-7, a 2.3-kb internal fragment of P3. Another enhancer element (A23), which is not tissue-specific, was discovered about 70 kb downstream of the transcription start site. Several lines of transgenic mice were created using combinations of these DNA elements to drive the lacZ reporter gene. Neither a short (900 bp) nor a long (3.7 kb) promoter alone showed detectable expression in 14.5-day embryos, whereas placing the P3 tissue-specific enhancer together with P0 gave strong expression restricted to embryonic cartilage of transgenic mice. The A23 downstream enhancer in conjunction with P0 did not confer expression. This is the first report of a gene control region which confers authentic tissue-specific regulation of aggrecan in vitro or in vivo and should greatly facilitate understanding the coordinate regulation of chondrocytic genes.