There are quite a few anti-VEGFs that are used in ophthalmic practice to treat a variety of conditions. Ranibizumab {(Lucentis; Genentech, South San Francisco, CA) (Razumab; Intas Pharmaceutical Ltd, Ahmedabad, India * Biosimilar of ranibizumab approved only in India) Bevacizumab (Avastin; Genentech, South San Francisco, CA) and Aflibercept (Eylea; Regeneron, Tarrytown, NY)} are currently being used in the management of diabetic macular oedema (DME), uveitic macular oedema, retinal vein occlusions and neovascular age related macular degeneration (nAMD) [1]. Is the recently FDA approved brolucizumab (Beovu, Novartis) just another drug in the armamentarium of anti-VEGFs (vascular endothelial growth factor) or does it have something else to offer [2]?

Pegaptanib sodium, the first anti-VEGF approved, is a pegylated ribonucleic acid aptamer which binds near the heparin-binding domain of VEGF-A, thus preventing VEGF165, making it a selective anti-VEGF agent. Ranibizumab, the second anti-VEGF agent approved for the treatment of nAMD is a chimeric molecule derived from a murine full-length monoclonal antibody which binds to, and inhibits, the biologic activity of all active forms of VEGF-A. Razumab is the biosimilar of ranibizumab, which is a recombinant humanized IgG1 monoclonal antibody fragment. Bevacizumab, an anticancer drug with a larger size and lower affinity also inhibits all isoforms of VEGF and is being used in a small dose. Aflibercept is a VEGF Trap-eye that binds to all VEGF-A and VEGF-B isoforms as well as to placental growth factor. The latest drug brolucizumab is a humanized single-chain antibody fragment inhibitor of all isoforms of vascular endothelial growth factor-A (VEGF-A) and has a molecular weight of just 26 kDa when compared to its predecessors, bevacizumab (149 kDa), ranibizumab (48 kDa) and aflibercept (115 kDa). This is the smallest monoclonal antibody ever made in medicine [3].

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