Ranibizumab for vascularized pigment epithelial detachment: 1-year anatomic and functional results

CLINICAL OUTCOMES OF DIFFERENT SUBTYPES OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION DURING AFLIBERCEPT TREATMENT

PURPOSE

To prospectively evaluate the outcomes of different subtypes of neovascular age-related macular degeneration during intravitreal aflibercept monotherapy.

METHODS

Forty-four eyes of 44 patients with treatment-naïve polypoidal choroidal vasculopathy (PCV, n = 12), hemorrhagic choroidal neovascularization (hCNV, n = 12), pigment epithelium detachment (PED, n = 11), or retinal angiomatous proliferation (RAP, n = 9) were included and followed for 12 months. All patients received intravitreal aflibercept monotherapy.

RESULTS

Mean visual acuity at baseline in PCV was 67 ± 16 Early Treatment Diabetic Retinopathy Study letters (20/50 Snellen equivalent), in hCNV 55 ± 21 (20/80), in RAP lesions 64 ± 11 (20/50), and in PED 74 ± 7 (20/32). At Month 12, visual acuity in PCV was 66 ± 16 (20/50), in hCNV 69 ± 17 (20/40), in RAP 68 ± 12 (20/50), and in PED 69 ± 18 (20/40). At the 12-month follow-up, visual acuity improved or was stable (±5 letters from baseline) in 84% of eyes (37/44 patients), with hCNV showing the greatest mean visual acuity gain. Mean central retinal thickness in patients with PCV was 523 ± 251 µm, in hCNV 497 ± 171, in RAP lesions 573 ± 132, and in PED 541 ± 158 and decreased to 310 ± 91 µm in PCV, 323 ± 75 µm in hCNV, 357 ± 173 µm in RAP lesions, and 422 ± 150 µm in PED. The mean area of atrophy increased from 2.0 ± 3.6 mm2 at baseline to 4.6 ± 8.6 mm2 at Month 12 (mean difference [95% confidence interval] -0.8 [-8.5 to 7.0], P = 0.8), with the greatest atrophy in patients with PED at Month 12.

CONCLUSION

All subtypes of neovascular age-related macular degeneration showed anatomical improvement and stabilization of visual function during intravitreal treatment.

Influence of pigment epithelial detachment on visual acuity in neovascular age-related macular degeneration

Pigment epithelial detachment (PED), the anatomical separation of the retinal pigment epithelium from the Bruch membrane, is common in many chorioretinal diseases, including neovascular age-related macular degeneration. PED is present in about 30% to 80% of neovascular age-related macular degeneration patients based on the CATT, EXCITE, and VIEW studies. The influence of PED on visual acuity is controversial as a result of inconsistent results reported by various studies. With advances in imaging technologies, it is possible to evaluate not only the presence or absence of PED, but also detailed quantitative parameters, such as height, width, greatest linear diameter, area, volume, and reflectivity within the PED. We performed a comprehensive literature review to evaluate the relationship of PED with visual acuity. In summary, the presence or persistence of a PED may still be compatible with relatively good visual acuity. There is no strong evidence that the presence of a PED or aspects of its morphology has a significant impact on visual acuity. The presence of a PED may be predictive of the need for more regular treatment. More well-designed studies with standardized PED definitions and classifications are needed to evaluate the relationship between PED and visual acuity.

Subretinal pigment epithelium fibrotic tissue morphological changes after a single anti-vascular endothelial growth factor injection in age-related macular degeneration

Aims

To demonstrate and evaluate the morphological changes of multilayered fibrovascular pigment epithelial detachment (PED) to a single anti-vascular endothelial growth factor (VEGF) injection in age-related macular degeneration (AMD).

Methods

We retrospectively analysed the morphological changes of 30 eyes with exudative AMD showing fibrotic multilayered PED, between two consecutive visits. All patients had one anti-VEGF intravitreal injection at the first visit. We quantitatively analysed the different compartments within the PED and their morphological response.

Results

The mean follow-up time interval between the first and the second visit was 32.46±4.64 days. We defined three optical coherence tomography zones within the PED: a subretinal pigment epithelium inhomogeneous hyporeflective space (layer 1), a hyper-reflective band beneath layer 1 (layer 2), and a hyporeflective space between the Bruch’s membrane and layer 2 (layer 3). The mean height of layer 1 was 142±44.63 and 99.30±39.79 µm at visits 1 and 2, respectively. The mean thickness of layer 2 was 101.42±46.66 and 82.76±35.24 µm at visits 1 and 2, respectively. The mean height of layer 3 was 35.77±32.77 and 5.66±8.68 µm at visits 1 and 2, respectively (p=0.009). The mean height change for layer 1 was statistically significantly higher than for layer 2 (p=0.0002).

Conclusions

Fibrovascular PED was compartmented into three layers with different reflectivities that morphologically responded differently to a single anti-VEGF injection. Layer 2 had a statistically significantly lower response compared with layer 1, suggesting the hypothesis of a fibrotic component in layer 2.

Efficacy Comparison of Intravitreal Anti-VEGF Therapy for Three Subtypes of Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis

Purpose

Intravitreal antivascular endothelial growth factor (anti-VEGF) therapy has been widely used for the treatment of neovascularization (NV) secondary to age-related macular degeneration (AMD). This study aimed to compare the efficacy among different subtypes of neovascular age-related macular degeneration (nAMD).

Methods

PubMed, Embase, and the Cochrane Library were searched for eligible studies. We performed meta-analysis using Review Manager 5.3 and Stata/SE 12.0.

Results

A total of 24 studies met our inclusion criteria and were included in the systematic review. At 3 months, the mean logarithm of the minimum angle of resolution (logMAR) improvements were -0.09, -0.18, and -0.23 for type 1, 2, and 3, respectively, while the mean macular thickness (MT) changes were -104.83, -130.76, and -196.29 μm. At 12 months, the mean changes in Early Treatment of Diabetic Retinopathy Study (ETDRS) letters were 6.38, 8.12, and 9.37, while the MT decrease was 126.51, 126.52, and 139.85 μm, respectively. However, statistically significant difference was only found between type 1 and 3 in vision improvement, both in the short term (p=0.0002) and long term (p=0.01).

Conclusions

The reactivity to VEGF inhibitors varied among different subtypes of nAMD. The efficacy of intravitreal anti-VEGF therapy in type 3 nAMD was statistically better than type 1 when considering vision improvement at 3 and 12 months. Thus, the lesion subtype is a predictor for the treatment outcome which can help guide prognosis.

Clinical response of pigment epithelial detachment associated with neovascular age-related macular degeneration in switching treatment from Ranibizumab to Aflibercept

Background

To study the clinical outcomes of pigment epithelial detachment (PED) associated with neovascular age-related macular degeneration (nAMD) in patients switched from Ranibizumab to Aflibercept.

Methods

Retrospective non-comparative case series. 50 eyes with active nAMD and fovea involving PED of ≥100 μm measured manually using the caliper on the OCT, initially treated with intravitreal Ranibizumab (0.5 mg/0.05 ml) and later switched to Aflibercept (2.0 mg/0.05 ml). The outcome measures of best corrected visual acuity (BCVA), PED height, PED width and number of injections were measured at baseline and at time point of switch, 4 months, 1 year and at last follow up visit post-switch. Three paired t-tests and Pearson’s correlations were calculated to analyze variables at switch and change in variables at 1 year.

Results

After switch to Aflibercept, the improvement of BCVA was 1.84 (p = 0.11), 1.74 (p = 0.21) and 1.16 (p = 0.45) letters, the change in PED height was − 65.6μm (p < 0.001), − 50.64μm (p = 0.007) and − 68.48μm (p < 0.001) and the change in PED width was − 36.6μm (p = 0.514), + 29.7μm (p = 0.922) and + 118.4μm (p = 0.210) at 4 months, 1 year and the last visit respectively. There was a moderate negative correlation between reduction in PED height at 1 year after switch and PED height at the time of switch to Aflibercept (r = − 0.474, p < 0.05).

Conclusion

The improvement in BCVA and change in PED width was not statistically significant however the reduction in PED height was significant after switching treatment to Aflibercept. The change in BCVA at 1 year after switch was not correlated with any of the analyzed anatomical characteristics of PED.

Association of ARMS2 genotype with response to anti-vascular endothelial growth factor treatment in polypoidal choroidal vasculopathy

BACKGROUND

To investigate whether genetic risk variants for age-related macular degeneration (AMD) are associated with response to intravitreal anti-vascular endothelial growth factor (VEGF) in polypoidal choroidal vasculopathy (PCV) patients.

METHODS

This prospective cohort study included 95 treatment-naïve patients that underwent anti-VEGF treatment for PCV for 12 months. Patients were genotyped for 10 single nucleotide polymorphisms in eight AMD-relevant genes. Genotypic association with visual and anatomic outcome measures at 12 months after initial treatment, including mean change in best-corrected visual acuity (BCVA) and total foveal thickness, visual gain of ≥ 15 letters, dry status on optical coherence tomography (OCT), pigment epithelial detachment (PED) regression on OCT, polyp regression on indocyanine green angiography, and injection numbers, were investigated using regression models with adjustment for non-genetic covariates under additive genetic model.

RESULTS

In 81 patients who completed 12-month anti-VEGF monotherapy without photodynamic therapy, significant pharmacogenetic association was found between ARMS2 rs10490924 and PED regression on OCT. Proportions of PED regression were 26.4% for TT, 45.7% for TG, and 63.6% for GG genotype, showing additive effect of G allele for higher chance of PED regression (OR, 2.96; 95% CI, 1.38-6.36; corrected P = 0.043). For entire 95 patients, no significant association was found between candidate polymorphisms and receiving photodynamic therapy within 12 months.

CONCLUSIONS

In PCV patients, ARMS2 rs10490924 showed association with anatomic therapeutic response to anti-VEGF, suggesting pharmacogenetic relationship.