title: Blockade of Tumor Necrosis Factor-Alpha: A Role for Adalimumab in Neovascular Age-Related Macular Degeneration Refractory to Anti-Angiogenesis Therapy?
abstract: OBJECTIVE
  To report a case of wet age-related macular degeneration (wet-AMD) refractory to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy in a patient who showed visual and anatomical improvement and stabilization after starting a subcutaneous treatment course with adalimumab, an anti-tumor necrosis factor-alpha (TNF-α) drug, for concomitant Crohn's disease.
  
  
  METHODS
  Observational case report of a female patient. Ophthalmological evaluation was performed by slit lamp and ophthalmoscopy (posterior pole and anterior segment). Best-corrected visual acuity (BCVA) was determined, and imaging was performed by fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT). Intravitreal therapies used and treatment with anti-TNF-α were recorded.
  
  
  RESULTS
  A 64-year-old woman with wet-AMD was treated with fourteen intravitreal injections of ranibizumab (0.5 mg) for a period of 40 months with intervals of 1-6 months. She initially showed a good visual and anatomical response to periodic anti-VEGF treatment but during check visits, anatomical and functional responses deteriorated. At the 40-month follow-up, the patient had developed Crohn's disease, and her rheumatologist started treatment with adalimumab (40 mg subcutaneously every 2 weeks). During the 25 months of treatment with adalimumab, the patient did not require any additional intravitreal anti-VEGF treatments because her BCVA, clinical, and OCT findings improved and remained stable.
  
  
  CONCLUSIONS
  We described a case of a patient with wet-AMD refractory to anti-VEGF therapy, which clinically benefited from subcutaneous adalimumab therapy. Treatment with subcutaneous anti-TNF-α in combination with anti-VEGF therapy avoids the high cost and risks related to multiple intravitreal anti-VEGF injections with good functional and anatomic outcomes.
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Fernández-Vega
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain.
authors.forename: Álvaro
authors.initials: Á
authors.lastname: Fernández-Vega
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Fundación Oftalmológica de Santander, FOSCAL, Floridablanca, Colombia.
authors.forename: Carlos Mario
authors.initials: CM
authors.lastname: Rangel
authors.affiliation: Hospital de Cabueñes, Gijón, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Nicieza
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain.
authors.forename: Eva
authors.initials: E
authors.lastname: Villota-Deleu
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Departamento de Morfología y Biología Celular, Universidad de Oviedo, Oviedo, Spain.
authors.forename: José A
authors.initials: JA
authors.lastname: Vega
authors.affiliation: Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Hospital Universitario Central de Asturias, Oviedo, Spain.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Sanchez-Avila
keywords: Anti-vascular endothelial growth factor; Tumor necrosis factor-alpha inhibitors; Wet age-related macular degeneration