A comparative study of type 1 neovascularization: Neovascular age-related macular degeneration versus pachychoroid neovasculopathy

PURPOSE

This study aimed to compare type 1 choroidal neovascularization (CNV) characteristics in eyes with pachychoroid neovasculopathy (PNV) and neovascular age-related macular degeneration (nAMD) using optical coherence tomography angiography (OCTA).

METHODS

Treatment naive 23 eyes of 23 patients with PNV and 24 eyes of 24 patients with nAMD were evaluated. The height of pigment epithelial detachment (PED) and the central macular thickness were determined. OCTA sensitivity, CNV area, morphological patterns, and retinal superficial capillary plexus vessel density (SCP-VD) values were compared. The frequency of quiescent CNV, subretinal hyperreflective exudation (SHE), subretinal/intraretinal fluid, serous PED, double-layer sign (DLS), and pachyvessels were noted.

RESULTS

CNV was detected on OCTA in 83.3% of nAMD eyes and 91.3% of PNV eyes (p = 0.66). Indistinct pattern was more common (74% vs 50%) and the CNV area (mm²) was smaller in PNV (0.77 ± 0.54 vs 1.57 ± 1.43) but did not reach significant levels (p = 0.27 and 0.33 respectively). SCP-VD was similar between the groups (p = 0.38). Statistically significant differences were found between groups in age and subfoveal choroidal thickness (p < 0.05). DLS and pachyvessels were found to be more frequently in PNV (p < 0.05). However, both groups had similar rates of quiescent CNV, SHE, subretinal/intraretinal fluid, and serous PED (p > 0.05).

CONCLUSION

Morphological features, area, and activation findings of type 1 CNV may play a limited role in differentiating nAMD and PNV cases.

RETINAL FLUID AND THICKNESS AS MEASURES OF DISEASE ACTIVITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

PURPOSE

Retinal fluid and thickness are important anatomical features of disease activity in neovascular age-related macular degeneration, as evidenced by clinical trials that have used these features for inclusion criteria, retreatment criteria, and outcome measures of the efficacy of intravitreal injections of anti-vascular endothelial growth factor agents.

METHODS

A literature review of anatomical measures of disease activity was conducted.

RESULTS

Treatment goals for neovascular age-related macular degeneration include improving/maintaining vision by drying the retina, and several analyses have evaluated the relationship between visual function and anatomy. The change in retinal thickness has been found to correlate with the change in the visual acuity, and variation in retinal thickness may predict visual acuity outcomes. In addition, specific fluid compartments may have different prognostic values. For example, the presence of intraretinal fluid has been associated with poorer visual acuity, whereas the presence of subretinal fluid has been associated with better visual acuity. Retinal fluid and thickness are important for selecting dosing interval durations in clinical trials and clinical practice.

CONCLUSION

Retinal thickness and retinal fluid are common anatomical measures of disease activity in neovascular age-related macular degeneration. Further research is required to fully elucidate the relationship between anatomical features and visual outcomes in neovascular age-related macular degeneration.

Predictive Factors for Long-Term Outcomes of Cataract Surgery in Patients Receiving Active Treatment for Neovascular Age-Related Macular Degeneration

Background: the safety and efficacy of cataract surgery in eyes with exudative neovascular age-related macular degeneration (nAMD), receiving active treatment, remain unclear. We evaluated the long-term outcomes and associated predictive factors of cataract surgery in eyes with exudative nAMD. Methods: this retrospective cohort study included 65 eyes (61 patients) treated with anti-vascular endothelial growth factor (VEGF) injections within six months preoperatively. Changes in best-corrected visual acuity (BCVA) and anti-VEGF treatment patterns from before to up to four years after surgery were assessed. Predictive factors were identified in association with one-year surgical outcomes. Results: the BCVA improved at six months (p < 0.001) and was maintained for three years postoperatively. The interval between anti-VEGF injections increased 3.4 times postoperatively (p = 0.001). Risk factors for poor BCVA were low preoperative BCVA (p < 0.001) and prolonged nAMD duration (p = 0.003). Prolonged nAMD duration and short exudation-free period were associated with more frequent postoperative anti-VEGF treatments (p = 0.028 and p = 0.003, respectively). AMD subtypes were not associated with both vision and injection pattern outcomes. Conclusions: patients with cataracts receiving nAMD treatment can safely undergo surgery with favorable long-term visual benefits. The preoperative BCVA, nAMD duration, and exudation-free period are potential predictors of surgery outcomes.

Neovascular age-related macular degeneration at treatment intervals of 14 weeks or greater

BACKGROUND

We assessed the proportion of eyes with neovascular age-related macular degeneration (nAMD) in routine clinical practice that reach ≥14 week treatment intervals and their outcomes.

METHOD

We analysed data from the Fight Retinal Blindness! (FRB!) Project database, a prospectively designed registry of 'real-world' outcomes. Treatment-naive eyes starting vascular endothelial growth factor (VEGF) inhibitors for nAMD from 1st January 2006 were included. Eyes were defined to have reached the ≥14 week treatment interval if they received ≥2 consecutive injections at treatment intervals of ≥14 week but not exceeding 26 weeks. Outcomes were reported in a subgroup of eyes that had 12 months of follow-up from reaching this interval.

RESULTS

Of the 3907 treatment-naïve eyes that started treatment during the identified periods on a treat-and-extend regimen and received at least 8 injections over the first 2 years, 402 (10%) eyes received at least 2 consecutive injections at an interval of ≥14 week during their follow-up. Fifty-two percent of these eyes maintained vision to 12 months, however only 40% stayed at this interval and 25% of the lesions reactivated.

CONCLUSION

We found that only 10% of eyes with nAMD were extended beyond a 13-week injection interval and that over half had returned to a shorter interval by 12 months. Eyes that stayed at this extended treatment interval maintained stable vision. More data on the outcomes of eyes treated with intervals longer than 3 months are required to establish whether emerging VEGF inhibitors provide a more sustained effect than the currently available drugs.

ASSOCIATION BETWEEN ANATOMICAL AND CLINICAL OUTCOMES OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR

PURPOSE

Assess the relationship between subretinal fluid (SRFL), intraretinal fluid, and visual outcomes of neovascular age-related degeneration in routine clinical practice.

METHODS

Treatment-naive eyes enrolled in the Fight Retinal Blindness! registry after January 2017 were identified. Lesion activity was graded at each visit as inactive, active not SRFL only (A-NSRFL only), or active SRFL only (A-SRFL only). Eyes were grouped based on initial activity as follows: 1) initially A-NSRFL only or 2) initially A-SRFL only, and their predominant activity status over 12 months was as follows: 1) mostly inactive, 2) mostly A-NSRFL only, or 3) mostly A-SRFL only.

RESULTS

Seven hundred and three eyes were eligible for analysis. Initially A-NSRFL only had a similar adjusted mean 12-month visual acuity change to initially A-SRFL eyes (5.7 vs. 6.9 letters; P = 0.165), but their final visual acuity was worse (62.5 vs. 67.5 letters at 12 months; P = 0.003). The adjusted mean 12-month visual acuity change between the predominant activity groups was significantly different (P = 0.005), with mostly inactive (7.6 letters) and mostly A-SRFL only (7.5 letters) eyes gaining more than mostly A-NSRFL only eyes (3.6 letters).

CONCLUSION

Eyes with SRFL only had similar outcomes at 1 year to eyes that were mostly inactive. Intraretinal fluid was associated with worse visual outcomes, highlighting the importance of distinguishing between intraretinal fluid and SRFL when managing neovascular age-related degeneration.

Subretinal hyperreflective material morphology in neovascular age-related macular degeneration: A case control study

Purpose:

The aim of this study was to evaluate the association of morphological features of subretinal hyperreflective material (SHRM) with visual acuity (VA), geographic atrophy (GA) and scar formation in eyes with neovascular age-related macular degeneration (neovascular AMD) and to compare with controls of neovascular AMD without SHRM.

Methods:

Retrospective analysis of 157 wet AMD eyes with SHRM and 50 eyes without SHRM treated with Anti-VEGF. Baseline spectral domain-OCT characteristics (SHRM location, height, width, area, reflectivity, border definition) were collected and were correlated with VA at baseline, 3, 6, 12 months and looked for development of scar and geographical atrophy (GA) and were compared to the control group.

Results:

When compared to the control, baseline parameters with a significant predictive value of 12-VA were presence of SHRM, foveal involvement of SHRM, high reflective SHRM, well-defined SHRM borders and thick SHRM. VA was decreased with greater SHRM height, width and area (P < 0.001). Decreasing reflectivity of SHRM lesions and disappearance of SHRM correlated with better VA at 12 months (P < 0.05). At 12 months, scar and GA was present more often in eyes with persistent SHRM than in eyes with SHRM that resolved and those without SHRM in the control group.

Conclusion:

SHRM can be considered as a surrogate OCT biomarker in predicting final visual outcome in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision at 12-follow-up were presence of SHRM involving the fovea, well-defined SHRM borders, greater SHRM height, width and area and persistence of SHRM with Anti-VEGF therapy.

Aflibercept Treatment Results and Association with Baseline Characteristics in Cases of Newly Diagnosed Neovascular Age-Related Macular Degeneration

Objectives:

To evaluate functional and anatomical responses to intravitreal aflibercept (IVA) treatment in newly diagnosed and untreated neovascular age-related macular degeneration (nvAMD) cases and to investigate the effect of baseline lesion characteristics on anatomical responses.

Materials and Methods:

This prospective, cross-sectional study included a series of 139 eyes of 133 patients that were diagnosed with active nvAMD and had not been treated. All eyes were subjected to complete ophthalmological examination, spectral-domain optical coherence tomography and fluorescein angiography, and 42 eyes also underwent indocyanine green angiography. IVA treatment was performed using a “treat and extend” regimen after 3 injections at 4-6 weeks intervals. Anatomical and functional responses at 4 weeks after the last injection were evaluated in eyes that completed 3 injections and the subgroup of eyes that completed 6 IVA injections. The effect of baseline lesion characteristics on IVA treatment results was also investigated.

Results:

All 139 eyes included in the study received 3 IVA injections (group 1) and 62 received 6 IVA injections. Both groups showed statistically significant improvement in best-corrected visual acuity (p<0.001 for both). The rate of complete response was 54.6% and 58.0% in groups 1 and 2, respectively. In group 1, the presence of pigment epithelial detachment (PED) and serous PED were identified as negative initial factors (p=0.043, p=0.005, respectively). However, none of the baseline characteristics were significantly associated with anatomical response in group 2.

Conclusion:

In our study, it was determined that successful anatomical and functional results were achieved with 3 and 6 doses of IVA in eyes with newly-diagnosed and untreated nvAMD. Among baseline characteristics, the presence of PED and serous PED in particular were found to be factors affecting treatment response negatively.

The influence of delayed treatment due to COVID-19 on patients with neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

Purpose:

To explore the impact of coronavirus disease 2019 (COVID-19) on the prognosis of patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and share the experience in managing them during pandemics.

Method:

This is a retrospective study of nAMD and PCV patients treated at Peking Union Medical College Hospital from 31 December 2019 to 1 August 2020. Baseline demographic and clinical characteristics, best corrected visual acuity (BCVA), optical coherence tomography (OCT) features, duration of delayed treatment and number of anti-vascular endothelial growth factor (VEGF) injections were analyzed.

Results:

A total of 130 nAMD patients (155 eyes) and 76 PCV patients (89 eyes) were identified. Compared to the conditions before COVID-19, the BCVA of delayed cases decreased significantly, and the proportion of patients presenting with sub-macular scar was significantly greater in the delayed treatment group (p < 0.05). The BCVA of non-delayed cases remained stable, with the percentage of patients with disease activity sub-retinal fluid and hemorrhage at the fovea decreasing significantly (p < 0.05). The stable cases who did not require anti-VEGF treatment had significantly worse baseline and final BCVA, these patients were likely to be chronic and ‘burnt out’ cases with significantly worse anatomical structures (p < 0.05).

Conclusions:

The delayed cases due to the pandemic suffered compromised visual function and a higher rate of sub-macular scar formation, while the visual function of non-delayed cases remained stable with favorable anatomical outcomes, suggesting the importance of regular follow-up for nAMD and PCV patients. Besides, effective measures of hospitals during pandemics are crucial to provide timely treatment for chronic disease.

Switching to Brolucizumab in Neovascular Age-Related Macular Degeneration Incompletely Responsive to Ranibizumab or Aflibercept: Real-Life 6 Month Outcomes

Purpose: The aim of this study was to evaluate the effect of switching treatment in eyes with neovascular age-related macular degeneration (nAMD) and treatment intervals of ≤6 weeks to brolucizumab. Methods: In this prospective series, eyes with persisting retinal fluid under aflibercept or ranibizumab every 4–6 weeks were switched to brolucizumab. Visual acuity (BCVA), reading acuity (RA), treatment intervals, central subfield thickness (CST), and the presence of intra- and subretinal fluid were recorded over 6 months. Results: Seven of 12 eyes completed the 6 month follow-up and received 4.4 ± 0.5 brolucizumab injections within 28.0 ± 2.8 weeks. Treatment intervals increased from 5.3 ± 0.9 weeks to 9.0 ± 2.8 weeks (95% confidence interval of extension (CI): 1.6 to 5.9). BCVA improved from 67.8 ± 7.2 to 72.2 ± 7.5 (95% CI: −0.3 to 9.1) ETDRS letters, RA improved from 0.48 ± 0.15 to 0.31 ± 0.17 LogRAD (95% CI: 0.03 to 0.25), and CST improved from 422.1 ± 97.3 to 353.6 ± 100.9 µm (95% CI: −19.9 to 157.1). Treatment was terminated early in five eyes (two intraocular inflammations with vascular occlusion without vision loss, one stroke, and two changes in the treatment plan). Conclusions: Improvement in visual performance and longer treatment intervals in our series over 6 months indicate the potential of brolucizumab to reduce the treatment burden in nAMD, while two instances of intraocular inflammation were encountered.

Cytokine and Chemokine Profile Changes in Patients with Neovascular Age-Related Macular Degeneration After Intravitreal Ranibizumab Injection for Choroidal Neovascularization

Objective

To investigate the concentrations of cytokine and chemokines profiling in aqueous humor for choroidal neovascularization (CNV) due to neovascular age-related macular degeneration (nAMD) before and during Intravitreal injection of ranibizumab (IVR) and its relation with the disease’s active state.

Methods

The cytokine levels in aqueous humour were detected by the Bio-Plex^® 200 System and the Bio-Plex™ Human Cytokine Standard 27-Plex, Group I. Aqueous humour samples of experimental group were collected from 19 patients diagnosed nAMD at baseline and at 1 month after IVR. Aqueous humour samples of control group were collected from 20 patients undergoing cataract surgery.

Results

Aqueous humor levels of basic fibroblast growth factor (basic FGF) and RANTES were significantly lower in nAMD patients than in the control group (P=0.044 and P<0.001, respectively). Vascular endothelial growth factor-A (VEGF-A) was significantly higher in nAMD patients than in the control group (P < 0.001). The average Eotaxin levels were significantly higher in nAMD patients after IVR than before (P=0.03). Contrarily, the average VEGF-A levels were significantly lower in AMD patients after IVR than before (P < 0.001).

Conclusion

Angiogenic, growth factors and inflammatory are involved in the formation of neovascularization of AMD patients. IVR did not cause significant differences in any growth factors or inflammatory cytokines in nAMD patients with the exception of VEGF.

Anti-VEGF-resistant subretinal fluid is associated with better vision and reduced risk of macular atrophy

BACKGROUND/AIM

To evaluate relationships between subretinal fluid (SRF), macular atrophy (MA) and visual outcomes in ranibizumab-treated neovascular age-related macular degeneration (nAMD).

METHODS

This post hoc HARBOR trial (NCT00891735) analysis included ranibizumab-treated (0.5 or 2.0 mg, monthly or as-needed, all treatment arms pooled) eyes with nAMD and baseline (screening, baseline and week 1) SRF. SRF presence, SRF thickness (0, >0-50, >50-100 and >100 µm) and subretinal fluid volume (SRFV) were determined by spectral domain optical coherence tomography (SD-OCT). Best-corrected visual acuity (BCVA) was assessed. MA was identified using fluorescein angiograms and colour fundus photographs, as well as SD-OCT.

RESULTS

Seven hundred eighty-five of 1097 eyes met analysis criteria. In eyes without baseline MA, residual versus no SRF at month (M) 3 was associated with lower MA rates at M12 (5.1% vs 22.1%) and M24 (13.3% vs 31.2%) (both p<0.0001); MA percentages at M12/M24 were similar among patients with residual SRF at M6. Higher baseline SRFV was associated with a lower MA rate. Greater mean BCVA was observed with residual SRF of any thickness (>0-50 µm, 71.2 letters; >50-100 µm, 71.3 letters; >100 µm, 69.2 letters) versus no SRF (63.6 letters), but the change in BCVA from baseline to M12 or M24 was the same for eyes with or without treatment-resistant subretinal fluid (TR-SRF) at M3 or M6.

CONCLUSION

TR-SRF was not detrimental to vision outcomes over 2 years, regardless of thickness. MA rates were significantly higher without TR-SRF.

Neovascular age-related macular degeneration: A review of findings from the real-world Fight Retinal Blindness! registry

The use of vascular endothelial growth factor (VEGF) inhibitors has revolutionised the treatment of neovascular age‐related macular degeneration (nAMD) since the pivotal Phase III studies demonstrated their efficacy more than 10 years ago. The Fight Retinal Blindness! project was developed to track the treatment outcomes of patients with nAMD in real‐world practice. Data from this registry have been used to answer several clinically relevant questions related to the treatment of nAMD including the effect of under‐treatment, the comparative effectiveness of different anti‐vascular endothelial growth factor agents, long‐term treatment outcomes, identifying optimal treatment regimens and the rate and outcomes of rare adverse events. Observational studies are a valuable complement to the shortcomings of clinical trials and a combination of data from real‐world settings and clinical trials are necessary to provide evidence on how to achieve the best outcomes for individual patients with nAMD.

Real-World Effectiveness, Treatment Pattern, and Safety of Ranibizumab in Korean Patients with Neovascular Age-Related Macular Degeneration: Subgroup Analyses from the LUMINOUS Study

Purpose

To evaluate the real-world effectiveness, treatment patterns, and safety of ranibizumab in Korean patients with neovascular age-related macular degeneration (nAMD).

Methods

LUMINOUS™ is a 5-year, global, prospective, observational, open-label study. Adults aged ≥18 years who were either treatment-naïve or prior-treated were enrolled and treated with ranibizumab 0.5 mg as per the local label. Outcome measures included mean (± standard deviation [SD]) changes from baseline in visual acuity (VA) and central retinal thickness (CRT), and rate of ocular and non-ocular adverse events (AEs).

Results

Overall, 367 Korean patients with nAMD (152 treatment-naïve and 215 prior-treated) were enrolled. The mean (SD) VA changes from baseline at 1-year were +10.1 (±21.77; P=0.0005) and +1.4 (±15.17; P=0.2142) Early Treatment Diabetic Retinopathy Study letters, with mean numbers of injections of 5.2 and 3.4 in the treatment-naïve and prior-treated groups, respectively. VA gains were greater in patients with lower baseline VA, who received a loading dose, and with polypoidal choroidal vasculopathy (PCV). Multivariate logistic regression analyses demonstrated younger age, worse baseline VA, and those who received loading dose being associated with higher odds of any gain in VA at 1 year (P<0.05). Mean (SD) CRT changes from baseline were –126.7 (±174.90) µm (P<0.0001) and +10.8 (±89.62) µm (P=0.5833) in the treatment-naïve and prior-treated groups, respectively, with greater reductions observed in patients with PCV. Ocular and non-ocular AEs were reported in 8.4% (n=31) and 10.1% (n=37) of patients, respectively.

Conclusion

The LUMINOUS study confirms real-world effectiveness and safety of ranibizumab in Korean patients with nAMD; factors including age, baseline VA, and loading-dose were associated with VA gain at one-year post-treatment.

Association between retinal thickness variation and visual acuity change in neovascular age-related macular degeneration

BACKGROUND

To assess the association between variation in retinal central subfield thickness (CSFT) with best-corrected visual acuity (BCVA) change in patients receiving vascular endothelial growth factor (VEGF) inhibitor therapy for neovascular age-related macular degeneration (nAMD).

METHODS

CSFT measurements were obtained from 141 eyes (total 1300 scans). SD of CSFT was calculated. The eyes were categorised into CSFT variation tertiles. Multiple linear regression was used to examine the association between the CSFT tertiles and BCVA change at 12 mo, adjusting for differences in baseline demographic and clinical characteristics.

RESULTS

At 12 mo, the mean BCVA of the high CSFT variation group (50.6 letters) was significantly lower than the low and moderate CSFT variation groups (57.5 and 59.8 letters, respectively), P = .02. The adjusted mean BCVA gains were +1.7, +7.2, and +7.8 letters in the high, moderate and low CSFT variation groups, respectively (P = .03).

CONCLUSIONS

A greater variation in retinal thickness during VEGF inhibitor therapy for nAMD is associated with a less favourable visual outcome. CSFT stability is useful in prognosticating visual outcomes in VEGF inhibitor therapy for nAMD.

Clinical Characteristics and Outcomes of Eyes with Intraocular Inflammation after Brolucizumab: Post Hoc Analysis of HAWK and HARRIER

PURPOSE

This analysis of the pivotal phase III HAWK and HARRIER trials aimed to provide insights on the timing of presentation, management, and outcomes of intraocular inflammation (IOI)-related adverse events (AEs), as reported by investigators in these trials.

DESIGN

Post hoc analysis of investigator-reported IOI-related AEs in HAWK and HARRIER.

PARTICIPANTS

Of 1088 brolucizumab-treated eyes (3 mg or 6 mg), 49 eyes experienced at least 1 IOI-related AE and were included in this analysis.

METHODS

Reports of IOI-related AEs were analyzed and descriptive statistics were provided for outcome measures.

MAIN OUTCOME MEASURES

Incidence and description of eyes with IOI-related AEs, timing of presentation, management, clinical outcomes, and brolucizumab treatment after the first IOI-related AE.

RESULTS

A total of 70 IOI-related AEs were reported in 49 eyes. Prior to the onset of first IOI-related AE, eyes received a mean (standard deviation [SD]) of 3.9 (2.2) brolucizumab injections. Median (25th-75th percentile) time to first IOI-related AE from the last administered brolucizumab injection was 18.0 (4.0-29.0) days. Of the 70 AEs, 61 (87.1%) were treated, the majority with topical corticosteroids; systemic and intraocular corticosteroids were used for 3 AEs each. Overall, inflammation resolved completely in 39 (79.6%) eyes, resolved with sequelae in 5 (10.2%) eyes, and did not resolve in 5 (10.2%) eyes by end-of-study. Overall, mean (SD) best-corrected visual acuity (BCVA) change from baseline to end-of-study, before AE to the lowest BCVA in 3 months after AE, and from before AE to end-of-study were -0.84 (20.6), -16.31 (17.6), and -0.22 (18.9) ETDRS letters, respectively. Of the 36 (73.5%) eyes that continued on brolucizumab after first IOI-related AE, 24 completed the trials and 12 discontinued; mean (SD) BCVA change in these eyes was 2.6 (17.6), 7.8 (13.2), and -7.7 (21.3) ETDRS letters, respectively, from baseline to end-of-study. The remaining 13 (26.5%) eyes were not treated with brolucizumab after first IOI-related AE and had mean (SD) BCVA change of -10.4 (25.5) ETDRS letters from baseline to end-of-study.

CONCLUSIONS

Findings of this analysis highlight the need for continued vigilance and monitoring for any signs of IOI-related events in patients receiving brolucizumab.

Anatomical effects of intravitreal anti-vascular endothelial growth factor injections on inner layers of the lesion-free retina

PURPOSE

The primary aim of the study was to investigate the effects of anti-vascular endothelial growth factor (VEGF) injections on the inner retinal layer anatomy of the lesion-free retina in eyes treated for neovascular age-related macular degeneration (nAMD). The secondary aim was to compare the changes of inner retinal layers in the lesion-free region of treated eyes with the same region of the untreated, fellow eyes and, thus, to elucidate any adverse effect of anti-VEGF treatments independently of 1-year aging changes.

METHODS

This was a retrospective, longitudinal, case-control study of 50 eyes of 25 patients. Twenty-five eyes with nAMD comprised the study group (16 eyes treated with aflibercept and 9 eyes treated with ranibizumab) and 25 fellow eyes with dry AMD (16 eyes in AREDS 2 and 9 eyes in AREDS 3) comprised the fellow eye group. Spectral-domain optical coherence tomography (SD-OCT) measurements were done at pre-treatment, 1 month after three loading anti-VEGF injections and at the end of 1 year. The retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL) thicknesses and total retinal thickness in the macula were measured. Thicknesses of inner retinal layers which were lesion-free in the outer nasal subfield of ETDRS grid were analysed and the changes in thicknesses during the follow-up period were compared between study and fellow eye groups. Paired t-test for normally distributed variables was applied for analyses of differences for the comparison of the results across the pre-and the post-. A p value of less than 0.05 was considered statistically significant.

RESULTS

The mean number of injections was 5.76 ± 1.26 in the study group in 1 year. The mean decrease in total retinal thickness was significant with 6.08 ± 9.05 µm (p= 0.003) in nAMD group and was insignificant with 0.32 ± 1.03 µm (p> 0.05) in fellow eye group with dry AMD. Most of the retinal thickness decrease was during first three injections in nAMD group. Total retinal thickness and GCL thickness were thinner in the study group at every follow-up examination, but the difference between groups was not statistically significant (p> 0.05). RNFL, GCL, IPL, and INL thicknesses did not demonstrate a statistically significant change in both study and fellow eye groups during 1 year follow-up period (p> 0.05).

CONCLUSIONS

Repeated anti-VEGF injections in nAMD appear to have no significant effect on the RNFL, GCL, IPL, and INL thicknesses of the lesion-free retina. Additionally, there was no significant difference in inner retinal layer changes between in eyes treated with anti-VEGF injections for nAMD and fellow eye group during 1-year follow-up.

Evaluation of Aqueous Flare Intensity in Eyes Undergoing Intravitreal Bevacizumab Therapy to Treat Neovascular Age-Related Macular Degeneration

Purpose: To evaluate the effect of repeated intravitreal bevacizumab injections on blood-aqueous barrier permeability in eyes with neovascular age-related macular degeneration (AMD).

Patients and Methods: Forty-eight consecutive patients with neovascular AMD received 3 intravitreal bevacizumab injections (1 mg) every 30–40 days. Subjects were followed for a period of 4 months and were examined at baseline, 1 day and 1 month after each injection. A control group comprised of 19 neovascular AMD patients waiting to begin anti-vascular endothelial growth factor (VEGF) therapy. Anterior chamber (AC) inflammation was evaluated with biomicroscopy and laser flare photometry.

Results: None of the subjects treated with bevacizumab had detectable ocular inflammation during follow-up. An analysis for variance (ANOVA) of the mixed-effects model has shown neither an effect between treatment and control group (p = 0.921), nor over the time course of the follow-up (p = 0.773). Before treatment, median AC inflammation was 6.7 photons/ms (range: 3.5–18.2 photons/ms). One month after the first, second, and third injections, median laser flare was 6.4, 6.8, and 6.6 photons/ms, respectively, none of which were significantly different from baseline (all p > 0.05). Blood-aqueous barrier permeability did not change between injections and was not different from the control group.

Conclusion: Inflammation induced by intravitreal bevacizumab was not detected by examination or flare photometry. This suggests that monthly bevacizumab dosing seems to be safe. The absence of AC inflammation could also reflect the known anti-inflammatory properties of anti-VEGF agents.

Therapeutic Efficacy of a Novel Acetylated Tetrapeptide in Animal Models of Age-Related Macular Degeneration

It has been shown previously that a novel tetrapeptide, Arg-Leu-Tyr-Glu (RLYE), derived from human plasminogen inhibits vascular endothelial growth factor (VEGF)-induced angiogenesis, suppresses choroidal neovascularization in mice by an inhibition of VEGF receptor-2 (VEGFR-2) specific signaling pathway. In this study, we report that a modified tetrapeptide (Ac-RLYE) showed improved anti-choroidal neovascularization (CNV) efficacy in a number of animal models of neovascular age-related macular degeneration (AMD) which include rat, rabbit, and minipig. The preventive and therapeutic in vivo efficacy of Ac-RLYE via following intravitreal administration was determined to be either similar or superior to that of ranibizumab and aflibercept. Assessment of the intraocular pharmacokinetic and toxicokinetic properties of Ac-RLYE in rabbits demonstrated that it rapidly reached the retina with minimal systemic exposure after a single intravitreal dose, and it did not accumulate in plasma during repetitive dosing (bi-weekly for 14 weeks). Our results suggested that Ac-RLYE has a great potential for an alternative therapeutics for neovascular (wet) AMD. Since the amino acids in human VEGFR-2 targeted by Ac-RLYE are conserved among the animals employed in this study, the therapeutic efficacies of Ac-RLYE evaluated in those animals are predicted to be observed in human patients suffering from retinal degenerative diseases.

MANAGEMENT OF RETINAL PIGMENT EPITHELIUM TEAR DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY

PURPOSE

This article aims to review current evidence on the development, diagnosis, and management of retinal pigment epithelium (RPE) tear during anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

Literature searches were performed using MEDLINE/PubMed databases (cut-off date: August 2019).

RESULTS

Three key recommendations were made based on existing literature and clinical experience: 1) Multimodal imaging with color fundus photography, optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence imaging, optical coherence tomography-angiography, and/or fluorescein angiography are recommended to diagnose RPE tear and assess risk factors. Retinal pigment epithelium tears can be graded by size and foveal involvement. 2) Patients at high risk of developing RPE tear should be monitored after each anti-VEGF injection. If risk factors worsen, it is not yet definitively known whether anti-VEGF administration should be more frequent, or alternatively stopped in such patients. Prospective research into high-risk characteristics is needed. 3) After RPE tear develops, anti-VEGF treatment should be continued in patients with active disease (as indicated by presence of intraretinal or subretinal fluid), although cessation of therapy should be considered in eyes with multilobular tears.

CONCLUSION

Although evidence to support the assumption that anti-VEGF treatment contributes to development of RPE tear is not definitive, some data suggest this link.

Bevacizumab simultaneous combined with dexamethasone implant for treatment of neovascular serous retinal pigment epithelial detachment secondary to neovascular age-related macular degeneration

PURPOSE

To evaluate the add-on effect of simultaneous intravitreal dexamethasone implant to bevacizumab for treatment of neovascular serous retinal pigment epithelial detachment (PED) secondary to neovascular age-related macular degeneration (nAMD).

METHODS

A 72-year-old male patient was previously treated with intravitreal bevacizumab and aflibercept for neovascular serous PED secondary to nAMD. Because of the recurrences in neovascular PED patient was treated with simultaneous intravitreal injection of bevacizumab and dexamethasone implant.

RESULTS

At the initial visit, the patient's the best corrected visual acuity (BCVA) in the left eye was 20/800. His left eye had neovascular serous PED with a height of 1100 µm and a largest linear diameter of 3953 µm accompanied by subretinal fluid. He received four intravitreal bevacizumab and five intravitreal aflibercept injections. Although there was a decrease in PED sizes from time to time during the 16-month treatment period, PED height was 926 µm and PED greatest linear diameter was 5820 µm at the end of 16th month. Later, the patient could not have an injection for 3 months (he could not come to his controls during the pandemic period), and when he arrived 3 months later, the PED height was 910 µm and the greatest linear diameter was 5830 µm. With a single simultaneous intravitreal injection of bevacizumab and dexamethasone implant, the PED regressed to 168 µm in height after 3 months. The BCVA increased to 20/200. Any clinical toxic effects did not occur and intraocular pressure did not rise for 3 months after injection.

CONCLUSION

Simultaneous intravitreal bevacizumab and dexamethasone implant injection effectively and safely treated treatment-resistant neovascular serous PED. This therapy may be a novel alternative therapy for treatment resistant neovascular serous PED secondary to nAMD. However, further studies are required to understand its effectiveness and safety.

Real-World Performance of a Self-Operated Home Monitoring System for Early Detection of Neovascular Age-Related Macular Degeneration

The real-world performance of a home telemonitoring strategy (ForeseeHome AMD Monitoring System^®, Notal Vision, Inc.,Manassas VA, USA) was evaluated and compared to the device arm of the AREDS2-HOME study among patients with intermediate AMD (iAMD) who converted to neovascular AMD (nAMD). All patients with confirmed conversion to nAMD who used the home monitoring system from 10/2009 through 9/2018 were identified by Notal Vision Diagnostic Clinic’s medical records. Selected outcome variables were evaluated, including visual acuity (VA) at baseline and at conversion, and change in visual acuity (VA) from baseline to time of conversion. In total, 8991 patients performed 3,200,999 tests at a frequency of 5.6 ± 3.2 times/week. The 306 eyes that converted from iAMD to nAMD over the study period (a 2.7% annual rate) were included in the analyses. There was a median (interquartile range) change of −3.0 (0.0–(−10.0)) letters among converted eyes, 81% [95% confidence interval (72–88%)] maintained a VA ≥ 20/40 at the time of conversion, while 69% of the conversion detections were triggered by system alerts. The real-world performance of an at-home testing strategy was similar to that reported for the device arm of the AREDS2-HOME study. The home telemonitoring system can markedly increase early detection of conversion to nAMD.

Comparison of intravitreal injections of Ranibizumab and Aflibercept in neovascular age related macular degeneration

Clinical relevance: Pivotal studies are based on strict treatment regimens of vascular endothelial growth factor blocking drugs in neovascular age-related macular degeneration. However, looser regimens with poorer results have been reported in real-world studies with various outcomes. This results in a search of more precise data to rely on in the management of patients with neovascular age-related macular degeneration.Background: The aim of this study is to analyse the real-world outcome of vascular endothelial growth factor blocking agents in neovascular age-related macular degeneration.Methods: This is a retrospective comparative study of treatment-naïve patients who received intravitreal aflibercept or ranibizumab administration for neovascular age-related macular degeneration for at least 12 months on an as needed regimen following a loading phase of three-monthly injections. Full eye examination and optical coherence tomography scans were provided at all visits. The drugs were compared on the basis of visual acuity, central macular thickness, and subfoveal choroidal thickness. The baseline optical coherence tomography features were analysed seeking a correlation with the outcome.Results: One hundred and forty-one eyes were enrolled. The mean age was 71.7 ± 8.5 years. Sixty-eight (48.2%) patients received aflibercept and 73 (51.8%) received ranibizumab injections. The mean number of injections was 6.5 ± 2.5. The mean number of injections were also similar between groups (6.4 ± 2.5 vs. 6.5 ± 2.6, respectively, p = 0.783). At one year, both drugs caused significant increase in visual acuity and decrease in central macular thickness and subfoveal choroidal thickness.Conclusion: In a real-world setting, aflibercept and ranibizumab yielded similar results at one year in the management of neovascular age-related macular degeneration.

Five-Year Outcome of Aflibercept Monotherapy for Exudative Age-Related Macular Degeneration with Good Baseline Visual Acuity

We investigated the long-term visual and anatomical outcomes of aflibercept monotherapy for exudative age-related macular degeneration (AMD) with good baseline best-corrected visual acuity (BCVA). A medical chart review was performed for 40 consecutive patients with baseline decimal BCVA ≥ 0.6 secondary to exudative AMD. Three monthly injections were administrated, and thereafter additional injection was performed if needed over 5 years. In total, 13 eyes with neovascular AMD (nAMD) and 27 eyes with polypoidal choroidal vasculopathy (PCV) were enrolled. In both groups, the mean BCVA significantly improved at the 12-month visit (p < 0.05). However, the significant improvement in BCVA disappeared at the 24-month visit, and the final mean BCVA was equivalent to that at baseline (p = 0.17 in the nAMD group and p = 0.15 in the PCV group). The median number of injections required after the loading dose was 15.0 during the 5-year follow-up (nAMD:15.0 vs. PCV:15). During the study period, 37 (92.5%) eyes required retreatment(s). Cox regression analysis demonstrated that the protective allele of ARMS2 A69S was associated with a retreatment-free period from the initial injection (p = 0.041, repeated forward selection method). As-needed aflibercept monotherapy is a preferable treatment option for exudative AMD with good initial visual acuity regardless of nAMD or PCV during the 5-year study period.

Profiling neovascular age-related macular degeneration choroidal neovascularization lesion response to anti-vascular endothelial growth factor therapy using SSOCTA

Purpose

To identify the changes in distinct vascular parameters of choroidal neovascularization (CNV) in eyes with treatment‐naïve neovascular age‐related macular degeneration (nAMD) during the primary response to anti‐VEGF therapy using aflibercept.

Methods

Patients were prospectively followed during the first 3 months according to a standardized protocol with mandatory visits at days 7 and 14 after each anti‐VEGF treatment up to day 90. Fourteen eyes were seen in addition at days 1 and 3 post‐initial injection. Aflibercept was administered at baseline (BL), day 30 and 60. 6 × 6mm SSOCTA (PlexElite, Zeiss) images were acquired. Using the semi‐automated AngioTool, CNV area, vessel area, vessel density (VD), the number of junctions, junctions density, total vessel length, average vessel length, total number of endpoints and lacunarity were assessed.

Results

Thirty‐two consecutive patients presenting with treatment‐naïve, SSOCTA‐positive CNV lesions were included. Close follow‐up showed a characteristic neovascular response curve with a dynamic decrease in lesion size within days and a reactive increase following 2 weeks after initial treatment. An undulating pattern was seen for all neovascular parameters except for vascular density, with variable statistical significance. Due to a flattening of the therapeutic response as early as after the second treatment, CNV lesion size and most of the related parameters had an increase in activity above baseline values at the end of the loading phase. Lesion size was the leading feature of reactivation by a mean increase of 19.3% after three monthly aflibercept injections. Subgroup analysis based on lesion size revealed a significant correlation between best‐corrected visual acuity and quantitative change in lesion size over time, but not baseline size.

Conclusions

Using SSOCTA, a morphologic neovascular response pattern can be identified in anti‐VEGF treatment of CNV. A synchronized early decrease and consecutive reactivation in a large spectrum of neovascular biomarkers including size and internal structure are visualized in a qualitative and quantitative manner. SSOCTA analyses allow new insights in CNV morphology changes and therapeutic response.

Longitudinal Assessment of Ellipsoid Zone Integrity, Subretinal Hyperreflective Material, and Subretinal Pigment Epithelium Disease in Neovascular Age-Related Macular Degeneration

PURPOSE

To assess longitudinally the effect of anti-vascular endothelial growth factor (VEGF) treatment on ellipsoid zone (EZ) integrity, subretinal hyperreflective material (SHRM), and the sub-retinal pigment epithelium (sub-RPE) compartment in eyes with neovascular age-related macular degeneration (nAMD).

DESIGN

Post hoc analysis of the OSPREY clinical trial, a prospective, double-masked, phase 2 study comparing brolucizumab 6 mg with aflibercept 2 mg over 56 weeks.

PARTICIPANTS

Participants with treatment-naïve nAMD at the initiation of the trial were included in the analysis.

METHODS

Eyes were evaluated with spectral-domain OCT at 4-week intervals in the OSPREY trial (n = 81). Spectral-domain OCT scans collected from each visit were segmented automatically using a proprietary, machine learning-enabled higher-order feature-extraction platform for retinal layer, SHRM, and sub-RPE boundary lines, which were evaluated and corrected as needed by masked trained graders. The current analysis focused only on patients evaluated with the Cirrus (Zeiss) platform (n = 28).

MAIN OUTCOME MEASURES

Outcome measures included change from baseline in EZ-RPE (i.e., photoreceptor outer segment) volume, EZ-RPE central subfield thickness (CST), total EZ attenuation, SHRM volume, SHRM CST, and total sub-RPE volume. The correlation between each of these measures and best-corrected visual acuity (BCVA) at each visit was evaluated.

RESULTS

EZ-RPE volume and EZ-RPE CST showed significant increases, and total EZ attenuation, SHRM volume, SHRM CST, and total sub-RPE volume showed significant decreases from baseline at each visit from weeks 4 through 56 (P < 0.05 at each visit). Ellipsoid zone integrity measures and SHRM volume correlated significantly with BCVA at most visits (P < 0.05). No significant correlation was found between total sub-RPE volume and BCVA.

CONCLUSIONS

EZ integrity, SHRM, and sub-RPE disease features in eyes with nAMD showed improvement as early as week 4 of anti-VEGF treatment. EZ integrity measures and SHRM volume were predictors of visual acuity over the first year of treatment.