Myopic choroidal neovascularisation: current concepts and update on clinical management

Novel Predictors of Visual Outcome in Anti-VEGF Therapy for Myopic Choroidal Neovascularization Derived Using OCT Angiography

PURPOSE

To explore novel prognostic factors associated with visual function and number of anti-vascular endothelial growth factor (VEGF) treatments in eyes with active myopic choroidal neovascularization (mCNV) using OCT angiography (OCTA).

DESIGN

Prospective case series.

PARTICIPANTS

Twenty-eight treatment-naïve eyes with active mCNV from 27 consecutive patients (mean age, 64.4 ± 11.1 years).

METHODS

All eyes received through injection a single loading dose of intravitreal aflibercept (IVA), followed by additional IVA on a pro re nata (PRN) basis during the subsequent 12 months. At baseline, OCTA images of a 3 × 3-mm macular cube were acquired using an OCTA scanner. On binarized and skeletonized OCTA images of the outer retinal layer, OCTA-derived baseline parameters of mCNV-including lesion size, vessel density, vessel length density (VLD), vessel diameter index, and fractal dimension (FD)-were measured and evaluated for correlation with 12-month best-corrected visual acuity (BCVA) and number of additional injections.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were BCVA 12 months after initial treatment and number of additional injections, respectively.

RESULTS

There was no significant difference between baseline and 12-month BCVA (0.37 ± 0.30 and 0.30 ± 0.35 logarithm of the minimal angle of resolution, respectively; P = 0.23). The number of additional injections was 0.93 ± 1.02 (mean ± standard deviation). Baseline VLD, FD, and BCVA were correlated with 12-month BCVA (P = 0.02, r = 0.46; P = 0.02, r = 0.46; and P = 0.02, r = 0.45, respectively), and VLD also was correlated with the number of additional injections (P = 0.03, r = 0.42).

CONCLUSIONS

Exuberant mCNV, which is characterized by high VLD and FD derived using OCTA, is a predictor of poor visual outcomes after a single IVA injection followed by a PRN regimen. Only baseline VLD was correlated with the number of additional IVA injections, which indicates that this parameter could help to determine the optimal anti-VEGF treatment regimen for individual eyes with mCNV.

The Relation of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio with High Axial Myopia

Purpose: To investigate the relation between high axial myopia and neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) values.Methods: Seventy-nine cases were enrolled, 50 myopic and 29 emmetropic. All participants were assigned into three groups: Group I (high myopia with no retinal involvement), Group II (high myopia with retinal involvement) and Group III (control). NLR and PLR values calculated from blood tests were compared among the groups.Results: Mean NLR levels were 2.23 ± 0.78 in Group I, 2.36 ± 1.06 in Group II, and 1.57 ± 0.33 in Group III. Mean PLR levels were 114.62 ± 23.21 in Group I, 145.16 ± 52.36 in Group II, and 91.42 ± 18.73 in Group III. NLR and PLR values in the high myopia groups were significantly higher than in the control group.Conclusion: NLR and PLR values in cases with high axial myopia were higher than in the emmetropic group. Higher inflammation in the degenerative myopic group in particular may be related to pathological chorioretinal changes.

Myopic maculopathy: Current status and proposal for a new classification and grading system (ATN)

Myopia is a highly frequent ocular disorder worldwide and pathologic myopia is the 4th most common cause of irreversible blindness in developed countries. Pathologic myopia is especially common in East Asian countries. Ocular alterations associated with pathologic myopia, especially those involving the macular area-defined as myopic maculopathy-are the leading causes of vision loss in patients with pathologic myopia. High myopia is defined as the presence of a highly negative refractive error (>-6 to -8 diopters) in the context of eye elongation (26-26.5 mm). Although the terms high myopia and pathologic myopia are often used interchangeably, they do not refer to the same eye disease. The two key factors driving the development of pathologic myopia are: 1) elongation of the axial length and 2) posterior staphyloma. The presence of posterior staphyloma, which is the most common finding in patients with pathologic myopia, is the key differentiating factor between high and pathologic myopia. The occurrence of staphyloma will, in most cases, eventually lead to other conditions such as atrophic, traction, or neovascular maculopathy. Posterior staphyloma is for instance, responsible for the differences between a myopic macular hole (MH)-with and without retinal detachment-and idiopathic MH. Posterior staphyloma typically induces retinal layer splitting, leading to foveoschisis in myopic MH, an important differentiating factor between myopic and emmetropic MH. Myopic maculopathy is a highly complex disease and current classification systems do not fully account for the numerous changes that occur in the macula of these patients. Therefore, a more comprehensive classification system is needed, for several important reasons. First, to more precisely define the disease stage to improve follow-up by enabling clinicians to more accurately monitor changes over time, which is essential given the progressive nature of this condition. Second, unification of the currently-available classification systems would establish standardized classification criteria that could be used to compare the findings from international multicentric studies. Finally, a more comprehensive classification system could help to improve our understanding of the genetic origins of this disease, which is clearly relevant given the interchangeable-but erroneous-use of the terms high and pathologic myopia in genetic research.

Diagnostic algorithm utilising multimodal imaging including optical coherence tomography angiography for the detection of myopic choroidal neovascularisation

PURPOSE

To develop a diagnostic algorithm in patients with pathologic myopia who present with typical symptoms or signs of myopic choroidal neovascularisation (mCNV).

METHODS

Retrospective study. Patients with high myopia and suspected mCNV underwent fluorescein angiography (FFA), structural spectral-domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCTA). Active mCNV on one imaging modality plus clinical features were considered as the benchmark reference for the other two tests. Sensitivity was calculated for each modality individually and in combination. Morphological features were noted on SD-OCT and OCTA.

RESULTS

Twenty-seven eyes of 26 patients were analysed. Sensitivity of SD-OCT or FFA alone was 85.19% (23/27 eyes). Sensitivity of OCTA was 74.07% (20/27 eyes). The sensitivity for SD-OCT combined with OCTA was 96.16% and combined with FFA was 97.80%. On OCTA, a "tight net" appearance was seen in 16 eyes (80%); a core vessel was visible in seven eyes (35%), all with active lesions. A "perilesional halo" was visible in 11 eyes (55%) of which 10 had active lesions.

CONCLUSION

When combined, OCTA and SD-OCT or SD-OCT and FFA showed similar higher sensitivities than each modality alone. A tight vascular net and the combination of a perilesional halo and a visible core on OCTA may serve as biomarkers of mCNV activity.

Pharmacotherapy of Myopic Choroidal Neovascularization

BACKGROUND

Myopic choroidal neovascularization (CNV) is a common cause of central visual loss in patients with high myopia, and the most common form of CNV in younger individuals. Pharmacologic therapy is the current mainstay of treatment of these patients.

METHODS

Review of pharmacological treatment options for myopic CNV, which primarily involves intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF) agents.

RESULTS

At this time, anti-VEGF therapy agents are the first-line therapy in these patients. Comparative trials have not identified any major differences in treatment outcomes between aflibercept, bevacizumab, and ranibizumab. Only ranibizumab is approved for this indication in the US. Best visual outcomes are associated with younger age, smaller lesion size, and absence of chorioretinal atrophy.

CONCLUSION

Anti-VEGF therapy is generally very effective in the treatment of myopic CNV.

Optical Coherence Tomography Angiography in Eyes with Indeterminate Choroidal Neovascularization: Results from the AVATAR study

OBJECTIVE

To evaluate the use of optical coherence tomography angiography (OCTA) to detect choroidal neovascularization (CNV) in eyes with indeterminate CNV features on conventional imaging.

DESIGN

The AVATAR study is a prospective observational study of OCTA in patients undergoing routine spectral-domain optical coherence tomography (SD-OCT) for macular disease.

PARTICIPANTS

Subjects enrolled in the AVATAR study for which CNV was considered as part of a differential diagnosis based on clinical exam and/or prior imaging, but in whom the presence of CNV was not definitive on SD-OCT and fluorescein angiography (FA) imaging.

INTERVENTIONS

All patients were imaged with the Avanti RTVue XR HD (Optovue, Fremont, CA) and the Cirrus HD-OCT (Zeiss, Oberkochen, Germany) systems.

MAIN OUTCOME MEASURES

OCTA scans were assessed for the presence or absence of CNV. SD-OCT scans were assessed for the presence of fluid, hyperreflective material, serous pigment epithelial detachment (PED), shallow irregular PED, vitreomacular adhesion, epiretinal membrane, retinal pigment epithelium atrophy and central subfield retinal thickness. Univariate and multivariate logistic regression analyses were performed to identify features on SD-OCT associated with the presence of CNV on OCTA.

RESULTS

Twenty-nine eyes of 29 patients met the criteria for inclusion. A CNV lesion was detected on OCTA in 8 (28%) eyes; 21 (72%) eyes were negative for CNV. After adjusted for age, gender and central subfield retinal thickness, the presence of shallow irregular PED [odds ratio, 148; 95% confidence interval, 3.22-6830; p = 0.011], as well as the combinations of intraretinal fluid and sub-retinal pigment epithelium material [odds ratio, 16.8; 95% confidence interval, 1.43-198; p = 0.025] on SD-OCT were significantly associated with the presence of CNV on OCTA.

CONCLUSIONS

OCTA enabled the identification of CNV that was otherwise indeterminate with prior imaging in select eyes. The presence of a shallow irregular PED as well as intraretinal fluid combined with sub-retinal pigment epithelium material were both associated with the presence of CNV. OCTA may be a valuable adjunct to conventional SD-OCT and FA imaging in the detection and surveillance of CNV, particularly in diagnostic dilemmas.

Real-world data on ranibizumab for myopic choroidal neovascularization due to pathologic myopia: results from a post-marketing surveillance in Japan

Objectives

The aim of this study was to obtain real-world clinical data on the safety and efficacy of ranibizumab treatment for myopic choroidal neovascularization (CNV) due to pathologic myopia.

Methods

This was a prospective, observational, post-marketing surveillance study in ranibizumab-naive Japanese patients with myopic CNV. Patients who initiated ranibizumab treatment were registered and prospectively observed over 12 months. Safety endpoints were the incidence of ocular and non-ocular adverse drug reactions (ADRs) and serious adverse events (SAEs). The efficacy endpoint included the average change in best-corrected visual acuity (BCVA) in logarithm of the minimal angle of resolution (logMAR) units (logMAR BCVA) from baseline to the last observation.

Results

Three hundred and eighteen patients were included in the safety analysis population. Of these 79.9% were female and the mean age was 65.5 years. The incidences of SAEs and ADRs were 0.6 and 0.3%, respectively. A total of 268 patients (84.0%) completed the 12-month study period. The mean (±SD) and median number of ranibizumab injections were 2.0 ± 1.5 and 1.0 during the 12-month study period, respectively. The number of ranibizumab injections received was one in 52.2% of patients and less than or equal to three in 89.2%. The mean change in logMAR BCVA from baseline to month 12 was −0.193, and the mean logMAR BCVA improved from 0.517 to 0.319 between baseline and month 12.

Conclusions

This study showed that ranibizumab is generally well tolerated, and that a minimum number of injections were necessary to produce a therapeutic effect in Japanese myopic CNV patients in a real-world setting.

Design and Baseline Characteristics of the HELP Study: An Extended and Long-Term Observation of Pathological Myopia in Caucasians

PURPOSE

To assess the natural disease progression of high myopia in Caucasians considered at risk for the development of myopic choroidal neovascularization (mCNV).

METHODS

Subjects were recruited in 25 clinical sites between June 2014 and June 2016. Main inclusion criteria included axial length of ≥26 mm, best-corrected visual acuity ≥0.05 decimal equivalent and presence of at least one out of five predefined morphological disease risk criteria. These were (1) subfoveal choroidal thinning < 50 µm, (2) enhanced choroidal curvature length > 6,300 µm, (3) lacquer cracks, (4) patchy atrophy > 5 mm2 and (5) preexisting mCNV in the fellow eye (German Clinical Trial Register DRKS00007761).

RESULTS

A total of 150 participants (66% females) with a mean age of 57.2 (±12.7) years (range 21.9-86.2 years) were included. The disease criteria most frequently encountered were choroidal thinning (33.3%) and lacquer cracks (32.7%). Enhanced choroidal curvature length was detected in only 8 subjects and always occurred in combination with other disease criteria. Presence of patchy atrophy was found to be more common in older subjects (p = 0.0012) and also associated with a more severe disease manifestation.

CONCLUSION

The baseline data of this study indicate that enhanced choroidal curvature might be less common in Caucasians than in Asian populations. Further, disease severity in patients with high myopia is relatively high in the presence of patchy atrophy.

Anti-Vascular Endothelial Growth Factor Therapy for Myopic Choroidal Neovascularization

Myopic choroidal neovascularization (CNV) is one of the most vision-impairing complications in patients with pathologic myopia. It is also one of the most frequently encountered non.age-related macular degeneration causes of CNV and affects young patients in the working age group. Fluorescein angiography (FA) and spectral domain optical coherence tomography (OCT) are generally indicated to confirm the diagnosis of active myopic CNV before initiation of treatment. Without treatment, natural history studies have shown that the vision outcome can be very poor. More recently, a number of retrospective, prospective and phase 3, multicenter, randomized controlled trials have established the safety and efficacy of intravitreal anti.vascular endothelial growth factor (VEGF) agents for the treatment of myopic CNV. Long-term follow-up studies have found that some of the initial vision gained after intravitreal anti-VEGF therapy may not be maintained, owing to the presence and progression of chorioretinal atrophy (CRA) adjacent to the CNV. Further research on clinical and imaging characteristics may elucidate the prognostic factors that are crucial to optimizing the treatment and prevention of visual impairment associated with myopic CNV.

Diagnosis and treatment guideline for myopic choroidal neovascularization due to pathologic myopia

Pathologic myopia is a leading cause of visual impairment. Development of myopic choroidal neovascularization (CNV) is one of the most common complications that leads to central vision loss in patients with pathologic myopia. If left untreated, it can cause scarring with expanding macular atrophy leading to irreversible visual loss in a period as short as 5 years. Advancements in multimodal imaging technology have furthered our understanding of the condition; however, further studies are necessary to extend its utility in the diagnosis of myopic CNV. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has become the standard-of-care and the recommended first-line treatment option for myopic CNV. Long-term studies have demonstrated that early treatment of confirmed myopic CNV cases with an intravitreal anti-VEGF agent is useful to avoid late-stage complications. This strategy has also been shown to achieve visual outcome improvements for up to 4 years and visual stabilization up to 6 years. This review article provides an overview of the current knowledge on myopic CNV and discusses recent updates in the diagnosis and management of the condition. Furthermore, treatment recommendations are provided based on the authors' expert opinions.

Anti-vascular endothelial growth factor therapy for the treatment of myopic choroidal neovascularization

Myopic choroidal neovascularization (CNV) is a sight-threatening condition which occurs in eyes with myopia, particularly in those with pathologic myopia. It is the most common cause of CNV among patients younger than 50 years. Hemorrhage and exudation from the CNV lesion may eventually result in scarring or chorioretinal atrophy. While myopic CNV was previously treated with focal laser photocoagulation or photodynamic therapy (PDT), the current treatment of choice is anti-vascular endothelial growth factor (VEGF) agents. Many studies have demonstrated the efficacy of intravitreal anti-VEGF agents in the treatment of myopic CNV. The RADIANCE study reported that intravitreal ranibizumab was superior to PDT in eyes with myopic CNV (at 3 months, both groups receiving intravitreal ranibizumab gained 10.5 and 10.6 letters vs 2.2 letters among patients receiving PDT). In addition, the study demonstrated similar visual outcomes in eyes treated on the basis of visual acuity stabilization or disease activity criteria. Other clinical studies have provided evidence for the efficacy of ranibizumab and aflibercept in the treatment of myopic CNV. This review addresses the epidemiology, pathophysiology, and imaging characteristics of myopic CNV, and discusses the evidence for the efficacy of anti-VEGF agents as compared to laser photocoagulation and PDT.

Dual-stage deep learning framework for pigment epithelium detachment segmentation in polypoidal choroidal vasculopathy

Worldwide, polypoidal choroidal vasculopathy (PCV) is a common vision-threatening exudative maculopathy, and pigment epithelium detachment (PED) is an important clinical characteristic. Thus, precise and efficient PED segmentation is necessary for PCV clinical diagnosis and treatment. We propose a dual-stage learning framework via deep neural networks (DNN) for automated PED segmentation in PCV patients to avoid issues associated with manual PED segmentation (subjectivity, manual segmentation errors, and high time consumption).The optical coherence tomography scans of fifty patients were quantitatively evaluated with different algorithms and clinicians. Dual-stage DNN outperformed existing PED segmentation methods for all segmentation accuracy parameters, including true positive volume fraction (85.74 ± 8.69%), dice similarity coefficient (85.69 ± 8.08%), positive predictive value (86.02 ± 8.99%) and false positive volume fraction (0.38 ± 0.18%). Dual-stage DNN achieves accurate PED quantitative information, works with multiple types of PEDs and agrees well with manual delineation, suggesting that it is a potential automated assistant for PCV management.

Treatment of myopic choroidal neovascularization with intravitreal ranibizumab injections: the role of age

PURPOSE

The aim of this study was to explore the role of age as a prognostic factor for the outcome of myopic choroidal neovascularization (CNV) treatment with intravitreal ranibizumab injections.

METHODS

A retrospective review of charts of patients treated with intravitreal injections of ranibizumab for the treatment of myopic CNV was done. Patients with other ophthalmic disease were excluded. Patients were followed for at least 2 years. The correlation between age and the change in visual acuity and the number of injections during treatment was investigated.

RESULTS

Age of the patients was significantly correlated with the number of injections that the patients received (Pearson's r=0.585, P=0.005). Also, it was significantly correlated with improvement in corrected distance visual acuity, defined as the difference between final and initial LogMAR corrected distance visual acuity (Pearson's r=0.614, P=0.003).

CONCLUSION

Age significantly affects the visual outcome of myopic CNV treatment with ranibizumab. Younger patients in our study needed fewer intravitreal injections and achieved a more significant improvement in vision.

Features of optical coherence tomography predictive of choroidal neovascularisation treatment response in pathological myopia in association with fluorescein angiography

BACKGROUND/AIMS

The aim of this study was to evaluate the usefulness of several optical coherence tomography (OCT) findings to estimate choroidal neovascularisation (CNV) activity in pathological myopia using fluorescein angiography (FA) as a reference.

METHODS

This was a single-centre, retrospective study. The medical records of patients with active myopic CNV who received intravitreal bevacizumab treatment were reviewed. Parameters to monitor CNV activity were morphological features of CNV on OCT, such as CNV height, central foveal thickness, intraretinal cysts, subretinal fluid, fuzziness of the CNV border, CNV network area on FA, and haemorrhage or exudation on fundus photo.

RESULTS

There were 46 patients with active CNV enrolled in this study. After intravitreal bevacizumab treatment, all the previously mentioned parameters of CNV were significantly improved. Using logistic regression analyses with backward elimination, the fuzzy border seen on OCT showed the most significant correlation with improvement of leakage on FA, when compared with other variables such as intraretinal cysts, subretinal fluid or central foveal thickness (R²=0.324, p=0.009).

CONCLUSION

Our study showed that the fuzziness of the hyper-reflective CNV margin showed the most significant improvement and the strongest correlation with the improvement of CNV leakage on FA after intravitreal bevacizumab injections, suggesting its important role as an OCT parameter for the assessment of myopic CNV activity.

SUBRETINAL FIBROSIS AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EYES WITH MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To assess the incidence and risk factors of subretinal fibrosis and their impact on visual outcome in eyes with myopic CNV.

METHODS

Medical records of 72 eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy in a pro re nata regimen for myopic CNV that followed up for more than 1 year were retrospectively reviewed. The presence of subretinal fibrosis after anti-VEGF therapy was determined using both fundus photographs and optical coherence tomography. The incidence and risk factors of subretinal fibrosis were evaluated, and best-corrected visual acuity was compared between the eyes with and without subretinal fibrosis.

RESULTS

The incidences of subretinal fibrosis during the 1-year and whole follow-up period were 31.9% and 36.1%, respectively. Occurrence of subretinal fibrosis was associated with frequent CNV recurrence (P = 0.005) and poor baseline best-corrected visual acuity (P = 0.044) in a Cox proportional hazard model. Anatomically, the eyes with subretinal fibrosis showed more frequent progression of chorioretinal atrophy (95.7% vs. 71.4%, P = 0.027) and less frequent photoreceptor recovery (17.4% vs. 65.3%, P < 0.001) after anti-VEGF therapy. Occurrence of subretinal fibrosis was associated with poor vision at baseline (P = 0.011) and the final visit (P = 0.008) when compared with the findings in the nonoccurrence group.

CONCLUSION

Development of subretinal fibrosis after anti-VEGF therapy was common in eyes with myopic CNV and was associated with CNV recurrence. Myopic eyes with subretinal fibrosis show progressive chorioretinal atrophy and poor visual outcome.

Projection artifact removal improves visualization and quantitation of macular neovascularization imaged by optical coherence tomography angiography

PURPOSE

To visualize and quantify the size and vessel density of macular neovascularization (MNV) using optical coherence tomography angiography (OCTA) with a projection artifact removal algorithm.

DESIGN

Multicenter, observational study.

PARTICIPANTS

Subjects with MNV in at least one eye.

METHODS

Patients were imaged using either a swept-source OCT angiography (SS-OCTA) prototype system or a spectral-domain OCT angiography (SD-OCTA) prototype system. The optical microangiography (OMAG) algorithm was used to generate the OCTA images. Projection artifacts from the overlying retinal circulation were removed from the OMAG OCTA images using a novel algorithm. Following removal of the projection artifacts from the OCTA images, we assessed the size and vascularity of the MNV. Concurrent fluorescein angiography (FA) and indocyanine green angiography (ICGA) images were used to validate the artifact-free OMAG images whenever available.

MAIN OUTCOME MEASURES

Size and vascularity of MNV imaged with OCTA before and after the use of a projection-artifact removal algorithm.

RESULTS

A total of 30 subjects (40 eyes) diagnosed with MNV were imaged. Five patients were imaged before and after intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors. Following the use of the projection artifact removal algorithm, we found improved visualization of the MNV. Lesion sizes and vascular densities were more easily measured on all the artifact-free OMAG images. In eyes treated with vascular endothelial growth factor inhibitors, vascular density was reduced in all five eyes after treatment, and in four eyes, the size of the MNV decreased. One of five patients showed a slight increase in lesion size, but a decrease in vascular density.

CONCLUSIONS

OCTA imaging of MNV using the OMAG algorithm combined with removal of projection artifacts resulted in improved visualization and measurements of the neovascular lesions. OMAG with projection artifact removal should be useful for assessing the response of MNV to treatment using OCTA imaging.

Association of Pediatric Choroidal Neovascular Membranes at the Temporal Edge of Optic Nerve and Retinochoroidal Coloboma

PURPOSE

To describe the characteristics of pediatric choroidal neovascular membranes (CNVs) associated with retinochoroidal and optic nerve coloboma using optical coherence tomography (OCT) and their response to treatment.

DESIGN

Retrospective case series.

METHODS

Retrospective review of children <16 years of age with CNV and retinochoroidal and optic nerve coloboma from 1995-2015 who underwent OCT imaging using either handheld (Bioptigen, Morrisville, NC) or tabletop OCT (Spectralis; Heidelberg, Carlsbad, CA).

RESULTS

Eight eyes of 8 patients (3 males, 5 females) with a mean age of 4.1 ± 3.9 years (range 6 months-10 years) at diagnosis were included. Mean follow-up was 21.4 ± 12.1 months (range 7-38 months). An optic nerve coloboma was present in 2 eyes and combined optic nerve and retinochoroidal coloboma in 6 eyes. In all eyes, CNVs were located at the temporal margin of the coloboma closest to the macula. Fluorescein angiogram characteristics included staining without leakage suggesting inactivity (n = 6) and leakage (n = 2). OCT characteristics included subretinal fluid (n = 5), intraretinal fluid and cysts (n = 1), and subretinal hyperreflective material (n = 7). Two eyes received intravitreal bevacizumab (range 3-6) injections, one of which also underwent focal peripapillary laser. Both eyes showed improvement in subretinal or intraretinal fluid on OCT. Vision at presentation among those quantified ranged from 20/200 to 20/40 and at final follow-up from 20/400 to 20/30. Genetic or systemic abnormalities were seen in 6 patients.

CONCLUSIONS

Association of pediatric CNV occurrence at the temporal margin of retinochoroidal and optic nerve colobomas closest to the fovea has not been established before and careful OCT and angiographic assessment of this region is warranted. The CNV lesions exhibit a varied degree of response to treatment.

Epidemiology, treatment pattern and health care utilization of myopic choroidal neovascularization: a population based study

PURPOSE

To investigate the prevalence and incidence of myopic choroidal neovascularization (CNV) in Taiwan, including the health care utilization and treatment-associated costs.

METHODS

A retrospective cohort study using existing data from the Taiwanese National Health Insurance claims database to identify patients who had a diagnosis of myopic CNV recorded from 1 January 2009 to 31 December 2011. The prevalence of myopic CNV was monitored during this period, and the frequency and cost of both treatment visits and monitoring visits were analyzed for 2 years following diagnosis.

RESULTS

The prevalence of myopic CNV was 0.017%. In total, 9068 patients with myopic CNV were identified, 12.3% (n = 1111) of whom were treated. Of those treated, 72.0% (n = 800) received intravitreal anti-vascular endothelial growth factor injections (IVI); the remainder received either photodynamic therapy with verteporfin (vPDT), laser photocoagulation, or a combination of therapies. IVI was associated with the largest number of treatment visits as well as a higher administrative (non-drug) cost per treatment visit (a mean of USD 57.18). vPDT alone was associated with a higher overall cost per treatment visit and more monitoring visits than IVI or laser photocoagulation. Costs for monitoring visits were highest for IVI.

CONCLUSIONS

The prevalence of myopic CNV was lower than that reported in previous studies, possibly because of differences in age distribution in the populations studied. The frequencies of treatment administered were similar to those reported in previous studies; however, a cost-effectiveness comparison could not be made owing to lack of data in previous studies.

[Role of immunological factors in the development of myopic choroidal neovascularization]

AIM

To study the concentration of cytokines in the aqueous humor of the anterior chamber in patients with myopic choroidal neovascularization (mCNV) and to compare the results to their ophthalmic status.

MATERIAL AND METHODS

A total of 19 patients (19 eyes) with mCNV treated with intravitreal ranibizumab were included in the study. The control group consisted of 15 patients (15 eyes) with myopia who had cataract surgery. Age, sex, and refractive error distribution were similar to that in the study group. All patients underwent a detailed ophthalmic examination as well as immunological study of the aqueous humor for cytokines concentrations using flow fluorometry (Bio-Plex Pro Human Cytokine Panel, 27-Plex, Bio-Rad Laboratories, USA).

RESULTS

Significant differences in concentrations of 10 cytokines were found between the mCNV and study groups. Vascular endothelial growth factor (VEGF) level was twice as low in patients with mCNV as that in the controls (191.15±142.3 pg/ml and 320.06±170.05 pg/ml, respectively) (p<0.05). The other 9 cytokines were higher in mCNV, namely, platelet-derived growth factor (PDGF-BB), inflammatory and anti-inflammatory cytokines (IL-2, IL-15, IL-17А and IL-5, IL-13, respectively), tumor necrosis factor (TNFα), and chemokines (IL-8, RANTES). The degree of myopia as well as morphological and functional changes in the macular zone were shown to be in close correlation with cytokines involved in inflammation and VEGF. VEGF level appeared to be negatively related to axial eye length, refractive error, and three cytokines: IL-13, INF-γ, and RANTES. At the same time, numerous (6, 8 and more) close correlations were established between inflammatory and anti-inflammatory cytokines, chemokines, and growth factors.

CONCLUSION

Patients with mCNV have been found to have higher than usual levels of inflammatory and anti-inflammatory cytokines, chemokines, and growth factors as well as a significantly decreased VEGF concentration. Immunological status of these patients differs from that in other ocular neovascular diseases suggesting possible involvement of alternative pathogenetic mechanisms.

Complications of Pathologic Myopia

Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. Pathologic myopia may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. Some complications affect visual acuity significantly, showing poor visual prognosis. This article aims to review the types, pathophysiology, treatment, and visual outcome of the complications of PM.

The Prevalence of Myopic Choroidal Neovascularization in the United States: Analysis of the IRIS(®) Data Registry and NHANES

PURPOSE

To determine the prevalence of high myopia (HM), progressive high (degenerative) myopia (PHM), and myopic choroidal neovascularization (mCNV) in the United States.

DESIGN

Cross-sectional study.

PARTICIPANTS

Individuals aged 18 years and older participating in the National Health and Nutrition Examination Survey (NHANES) and patients aged 18 years and older seen in clinics participating in the American Academy of Ophthalmology's Intelligent Research in Sight (IRIS(®)) Registry.

METHODS

We analyzed NHANES data from 2005 to 2008 to determine the prevalence of HM in the United States. This prevalence was then applied to estimates from the US Population Census (2014) to arrive at a population burden of HM at the diopter level in the United States. Data from the IRIS Registry were used to calculate the real-world prevalence rates of PHM and mCNV among patients with HM at the diopter level. This was subsequently applied to this reference population with HM to calculate the diopter-adjusted prevalence and population burden of PHM and mCNV in the United States in 2014.

MAIN OUTCOME MEASURES

High myopia was defined as myopic refractive error of ≤6.0 diopters in the right eye. Progressive HM was defined as HM with the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code of "360.21: Progressive High (Degenerative) Myopia." Myopic CNV was defined as HM with the presence of subretinal/choroidal neovascularization indicated by the ICD-9-CM diagnosis of "362.16: Retinal Neovascularization NOS."

RESULTS

The estimated diopter-adjusted prevalence of HM, PHM, and mCNV was 3.92% (95% confidence interval [CI], 2.82-5.60), 0.33% (95% CI, 0.21-0.55), and 0.017% (95% CI, 0.010-0.030), respectively, among adults in the United States aged 18 years and older in 2014. This translated into a population burden of approximately 9 614 719 adults with HM, 817 829 adults with PHM, and 41 111 adults with mCNV in the United States in 2014.

CONCLUSIONS

Although HM and PHM impose a relatively large burden among adults in the United States, mCNV seems to be a rare disease. Relating data from the IRIS Registry and NHANES could be a novel method for assessing ophthalmic disease prevalence in the United States. Future studies should aim to better assess current treatment patterns and optimal management strategies of this condition.

Ranibizumab in Myopic Choroidal Neovascularization: A Subgroup Analysis by Ethnicity, Age, and Ocular Characteristics in RADIANCE

Purpose: To assess the impact of ethnicity, age, and ocular characteristics on ranibizumab efficacy in myopic choroidal neovascularization (CNV). Methods: In this post hoc subgroup analysis from the phase III RADIANCE study, best-corrected visual acuity (BCVA) outcomes and treatment exposure were analyzed in 105 patients treated with ranibizumab 0.5 mg. Baseline categories included ethnicity, age, baseline BCVA, lesion area, CNV lesion area, refraction sphere, axial length, subretinal fluid, and location of CNV. Results: At month 12, the mean change in BCVA was numerically higher in East-Asians than in Caucasians (17.0 vs. 14.1 letters). The median number of injections varied with ethnicity (East-Asians vs. Caucasians: 2 vs. 3), baseline BCVA (highest vs. lowest: 1 vs. 4), CNV lesion area and lesion area (largest vs. smallest: 5 vs. 1 and 5 vs. 2). Conclusions: East-Asians showed numerically higher BCVA gains than Caucasians. The number of injections varied across subgroups, emphasizing the need for individualized treatment.

Macular Bruch Membrane Holes in Highly Myopic Patchy Chorioretinal Atrophy

PURPOSE

Patchy atrophy is a type of chorioretinal atrophy located outside of the fovea in eyes with myopic retinopathy. Bruch membrane defects have previously been described to occur in highly myopic eyes in foveal chorioretinal atrophy associated with choroidal neovascularization (CNV). We examined whether Bruch membrane defects can be found also in patchy atrophy.

DESIGN

Retrospective observational case series.

METHODS

The study included all patients who were consecutively examined for high axial myopia (axial length ≥26.5 mm) and patchy atrophy in the study period from September to November 2015. The patients underwent a comprehensive ophthalmologic examination including swept-source optical coherence tomography (OCT) of the macula. Main outcome measures were macular Bruch membrane defects.

RESULTS

Out of 22 eyes (17 patients) with patchy atrophy, 21 eyes (96%) showed macular Bruch membrane defects, which were characterized by a lack of Bruch membrane, retinal pigment epithelium (RPE), photoreceptors, and choriocapillaris. At the edges of the macular Bruch membrane defects, the ends of the Bruch membrane were folded and the RPE was upturned. The inner retina overlying the area of the Bruch membrane defect was markedly thinned.

CONCLUSIONS

Macular Bruch membrane defects belong to the hallmarks of a type of myopic chorioretinal atrophy not associated with CNV (ie, patchy atrophy). Considering that Bruch membrane defects were also observed in myopic CNV-related foveal atrophy, macular Bruch membrane defect might be a common finding in fundus lesions related to pathologic myopia.

99Tc-MDP treatment for the therapy of rheumatoid arthritis, choroidal neovascularisation and Graves' ophthalmopathy

Technetium 99 conjugated with methylene diphosphonate, which is an anti-inflammatory drug, can inhibit macrophage infiltration and downregulate a number of proinflammatory cytokines, such as tumor necrosis factor-α and interleukin-1β. Recently, numerous studies have indicated that it could improve rheumatoid arthritis (RA) activity by upregulating the frequency of peripheral γδ T cells and cluster of differentiation CD4⁺CD25⁺Foxp3⁺ Tregs, affecting the serum cytokine environment, inhibiting osteoclast formation and reducing the concentrations of rheumatoid factor-immunoglobulin M (IgM)/IgG/IgA. As well, it may have a therapeutic role for choroidal neovascularisation (CNV) and Graves' ophthalmopathy (GO). Therefore, it will be a valuable choice in the treatment of RA, CNV and GO.

Advances of optical coherence tomography in myopia and pathologic myopia

The natural course of high-axial myopia is variable and the development of pathologic myopia is not fully understood. Advancements in optical coherence tomography (OCT) technology have revealed peculiar intraocular structures in highly myopic eyes and unprecedented pathologies that cause visual impairment. New OCT findings include posterior precortical vitreous pocket and precursor stages of posterior vitreous detachment; peripapillary intrachoroidal cavitation; morphological patterns of scleral inner curvature and dome-shaped macula. Swept source OCT is capable of imaging deeper layers in the posterior pole for investigation of optic nerve pits, stretched and thinned lamina cribrosa, elongated dural attachment at posterior scleral canal, and enlargement of retrobulbar subarachnoid spaces. This has therefore enabled further evaluation of various visual field defects in high myopia and the pathogenesis of glaucomatous optic neuropathy. OCT has many potential clinical uses in managing visual impairing conditions in pathologic myopia. Understanding how retinal nerve fibers are redistributed in axial elongation will allow the development of auto-segmentation software for diagnosis and monitoring progression of glaucoma. OCT is indispensable in the diagnosis of various conditions associated with myopic traction maculopathy and monitoring of post-surgical outcomes. In addition, OCT is commonly used in the multimodal imaging assessment of myopic choroidal neovascularization. Biometry and topography of the retinal layers and choroid will soon be validated for the classification of myopic maculopathy for utilization in epidemiological studies as well as clinical trials.

Vascular endothelial growth factor inhibitor use and treatment approach for choroidal neovascularization secondary to pathologic myopia

INTRODUCTION

Myopic choroidal neovascularization (CNV) is the most common cause of CNV in those under 50 years of age. It is a significant cause of visual loss in those with pathologic myopia. The current standard of care involves therapy with intravitreal inhibitors of vascular endothelial growth factor (VEGF).

AREAS COVERED

The epidemiology of myopia, high myopia, pathologic myopia, and myopic CNV is reviewed, along with a brief discussion of historical treatments. The pharmacology of the three most commonly used anti-VEGF agents is discussed, with an emphasis on the licensed drugs, ranibizumab and aflibercept. A comprehensive clinical approach to diagnosis and treatment of myopic CNV is presented.

EXPERT OPINION

The current standard of care for myopic CNV is intravitreal inhibition of VEGF, with ranibizumab and aflibercept licensed for intraocular use. The diagnosis, OCT features of disease activity and retreatment algorithm for myopic CNV is different from wet age-related macular degeneration. In the long-term, myopic CNV may be associated with gradual, irreversible visual loss due to progressive chorioretinal atrophy, for which there is currently no treatment.

Posterior scleral reinforcement combined with vitrectomy for myopic foveoschisis

AIM

To investigate the effects of posterior scleral reinforcement (PSR) combined with vitrectomy for myopic foveoschisis.

METHODS

Thirty-nine highly myopic eyes of 39 patients with myopic foveoschisis underwent PSR combined with vitrectomy. Best corrected visual acuity (BCVA), refraction error, and the foveal thickness by optical coherence tomography (OCT) were recorded before and after the surgery, and complications were noted.

RESULTS

The follow-up period was 12mo, and the main focus was on the results of the 12-month follow-up visit. The mean preoperative BCVA was 0.96±0.43 logMAR. At the final follow-up visit, the mean BCVA was 0.46±0.28 logMAR, which significantly improved compared with the preoperative one (P=0.003). The BCVA improved in 33 eyes (84.62%), and unchanged in 6 eyes (15.38%). At the end of follow-up, the mean refractive error was -15.13±2.55 D, and the improvement was significantly compared with the preoperative one (-17.53±4.51 D) (P=0.002). Twelve months after surgery, OCT showed complete resolution of the myopic foveoschisis and a reat-tachment of the fovea in 37 eyes (94.87%) and partial resolution in the remained two eyes (5.13%). The foveal thickness was obviously reduced at 12-month follow-up visit (196.45±36.35 µm) compared with the preoperative one (389.32±75.56 µm) (P=0.002). There were no serious complications during the 12mo follow-up period.

CONCLUSION

PSR combined with vitrectomy is a safe and effective procedure for myopic foveoschisis with both visual and anatomic improvement.

The role of anti-VEGF agents in myopic choroidal neovascularization: Current standards and future outlook

INTRODUCTION

The global prevalence of pathologic myopia is 0.9-3.1%, and visual impairment is found in 0.1-0.5% of European and 0.2-1.4% of Asian studies. Myopic choroidal neovascularization (mCNV) affects 5.2-11.3% of pathologic myopia patients and is a leading cause of vision impairment in the working-age population. Characteristic morphological changes and visual-acuity decrease are diagnostic features. Vascular-Endothelial-Growth-Factor (VEGF) has been identified as a trigger for pathologic neovascularization in these highly myopic patients.

AREAS COVERED

We cover the epidemiology, pathology and diagnostic aspects of mCNV. The history of therapeutic interventions is described, followed by an overview of current standard-of-care (SOC)-blocking VEGF using bevacizumab (off-label), ranibizumab or aflibercept and improving vision up to 13.5-14.4 letters. Despite good efficacy, an unmet medical need remains. We summarize ongoing and future developments of new drugs to treat or potentially cure mCNV.

EXPERT OPINION

mCNV is a major global health concern. Early detection and treatment is key for a satisfying outcome. The current SOC, VEGF inhibitors, affords good therapeutic efficacy and reasonable disease stabilization with few intravitreal treatments per year. However, the long-term prognosis is still unsatisfactory, and side-effects like chorioretinal atrophy development are of concern. Therefore, efforts should be intensified to develop more effective therapies.

The efficacy and safety of a novel posterior scleral reinforcement device in rabbits

PURPOSE

To evaluate the efficacy and safety of posterior scleral reinforcement (PSR) device for myopia suppression in rabbits' eyes.

METHODS

PSR surgery was performed on the normal 12 8-week-old New Zealand white rabbits' right eyes. To determine efficacy of the device, ophthalmic examination would be taken at pre-operation and post-operation (1 week, 1 month, 3 months, 6 months, and 1 year), such as A-ultrasound, diopter and B-ultrasound. Evaluation of safety were based on the following indicators: intraocular pressure (IOP), slit lamp, fundus photography, fundus fluorescein angiography and pathological examination after surgery. The efficacy and safety of PSR device were evaluated by comparison (treated eyes and contralateral eyes) of pre and post-operation.

RESULTS

The novel PSR device could significantly shorten axial length (preoperative axial length: 16.36 ± 0.14 mm, postoperative 1 week, 1 month, 3 months, 6 months and 1 year axial lengths: 15.03 ± 0.28 mm, 15.23 ± 0.32 mm, 15.39 ± 0.31 mm, 15.45 ± 0.22 mm and 15.45 ± 0.22 mm; P=0.00037<0.001) in the treated eyes (right eyes) after surgery. At different postoperative time points, the B-ultrasound images showed that the PSR located in appropriate position and supported the posterior sclera very well. At the same time, IOP of treated eyes kept a relatively stable level (preoperative IOP: 12.56 ± 2.01 mmHg, postoperative IOP: ranging from 11.33 ± 1.23 mmHg to 13.44 ± 2.19 mmHg, P>0.05) post-operation 1 year. During observation period, there was no significant inflammatory reaction and complications such as anterior chamber flare, empyema, endophthalmitis, vitreous hemorrhage, retina detachment and retinal choroid neovascularization by slit lamp, fundus photography and fundus fluorescein angiography. In addition, there were no pathologic changes be found by comparison treated eyes group and contralateral group eyes based on pathological examinations.

CONCLUSIONS

In vivo study, effectively and safely, the novel PSR device can inhibit rabbits' axial length elongation during postoperative 1 year. This study demonstrates that this novel PSR could be a potential treatment approach for myopia.

Photodynamic therapy: current role in the treatment of chorioretinal conditions

Verteporfin photodynamic therapy (vPDT) is a selective vaso-occlusive treatment that targets choroidal vascular abnormalities. It was initially developed to treat neovascular age-related macular degeneration using the 'standard' vPDT protocol (verteporfin 6 mg/m(2), vPDT laser fluence 50 J/cm(2)). vPDT therapy has subsequently evolved as an important treatment modality for a range of other chorioretinal conditions including choroidal haemangioma, central serous chorioretinopathy, polypoidal choroidal vasculopathy, and peripapillary choroidal neovascularisation. Various 'safety-enhanced' vPDT protocols have been devised to optimise treatment outcomes, typically using reduced dose verteporfin (verteporfin 3 mg/m(2)) or reduced fluence vPDT (vPDT laser fluence 25 J/cm(2)). This paper reviews the current role of vPDT therapy in the treatment of chorioretinal conditions.

Advance of the application of nano-controlled release system in ophthalmic drug delivery

The ocular prescription application of nanometer materials are mainly concentrated in controlled release systems. Due to the unique properties of nanometer materials such as higher bioavailability and less side effects, it has great advantages in carrying ocular drugs of eye diseases compared with the traditional dosing method. As a result, nano-controlled release system has good application prospect in eye diseases. At present, a variety of different types of nano-controlled release systems have been used to enhance the efficiency of the ocular drugs including nanomicelles, nanoparticles, nanosuspensions, liposomes and dendrimers. In this article, the research progress and the application of nano-controlled release system in ophthalmic drug delivery are reviewed.

Minimizing projection artifacts for accurate presentation of choroidal neovascularization in OCT micro-angiography

Current optical coherence tomography (OCT) based micro-angiography is prone to a projection (or tailing) effect due to the high scattering property of blood within overlying patent vessels, creating artifacts that interfere with the interpretation of retinal angiographic results. In this work, the projection effect in OCT micro-angiography is examined and its causality is explained by strong light scattering and photon propagation within blood. A simple practical approach is then introduced to minimize these artifacts presented in the outer retinal avascular space, especially useful for examining clinical cases with choroidal neovascularization (CNV). Demonstrated through in-vivo human posterior eye imaging of healthy and CNV subjects, the proposed method is shown effective to eliminate the projection artifacts in outer retinal space of OCT micro-angiography, resulting in better visualization of the pathological neovascularization when compared with the current common approaches. In addition, it is also shown that the proposed method is applicable to minimize the projection artifacts appearing in deep retinal layers.