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Invited Commentary
January 24, 2019

Secondary End Points in the RIVAL Study

Author Affiliations
  • 1Leeds Teaching Hospitals National Health Service Trust, Leeds, England
  • 2Hull and East Yorkshire Eye Hospitals National Health Service Trust, Yorkshire, England
JAMA Ophthalmol. Published online January 24, 2019. doi:10.1001/jamaophthalmol.2018.6807

Late age-related macular degeneration (AMD) typically leads to visual impairment as a result of neovascular AMD or geographic atrophy (GA) or a combination of both. The Age-Related Eye Disease Study 2 (AREDS2) reported an increasing loss of visual acuity in eyes with baseline and incident GA and described an association between progression and ocular and systemic characteristics.1 In the Comparison of AMD Treatment Trials (CATT) and Inhibition of Vascular Endothelial Growth Factor (VEGF) in Age-related Choroidal Neovascularization (IVAN) studies, 18% and 30% of eyes, respectively, that were treated for neovascular AMD also developed GA within 2 years.2,3 With a longer follow-up, macular atrophy may be one of the most important factors that is associated with visual outcomes after treatment for neovascular AMD. Both CATT and IVAN reported an increased risk with continuous treatment, but the results conflicted regarding the risks associated with a particular therapy.2,3 The uncertainty of whether any or specific treatments for neovascular AMD add to the risk of visual loss from GA remains a concern for both patients and their ophthalmologists. The primary aim of the Comparison of Ranibizumab and Aflibercept for the Development of GA in (Wet) AMD Patients (RIVAL) study, described in this issue of JAMA Ophthalmology by Gillies et al,4 is to investigate the development of new GA in eyes that are treated with either aflibercept or ranibizumab using an identical “treat-and-extend” regimen, and the 2-year data for this primary end point are highly anticipated.