Incidence and risk factors for neovascular age-related macular degeneration in the fellow eye

Incidence and risk factors of fellow-eyes wet conversion in unilateral neovascular age-related macular degeneration over 15-year follow-up

PURPOSE

Incidence and risk factors of fellow eye wet conversion in unilateral neovascular age-related macular degeneration (nAMD) over 15-years follow-up.

METHODS

This retrospective study reviewed 593 unilateral nAMD patients with a minimum of five years up to 15 years of follow-up. The demographic data, visual acuity, fellow eye nAMD conversion rate, and the number of anti-vascular endothelial growth factor (anti-VEGF) injections in the primary eye were evaluated. Also, the nAMD-converted fellow eyes were divided into two groups based on the time of conversion (less and more than two years from the first injection in the primary eye). Based on the data types, the T-test, Chi-square, and Mann-Whitney U test were used to analyze.

RESULTS

The total cases were 593 patients, and 248 eyes (41.82%) converted to nAMD in the mean interval of 34.92 ± 30.62 months. The males exhibited a predisposition to wet conversion at 2.54 years earlier than their female counterparts (P = 0.025). In all the converted fellow eyes, the mean age was 2.3 years higher at presentation in the group who converted within two years of follow-up in compared to eyes that converted after two years (79.82 ± 8.64 vs 77.51 ± 8.5 years, P = 0.035). Additionally, eyes converting within two years had a mean baseline LogMAR visual acuity of 0.44 ± 0.47, compared to 0.32 ± 0.41 for conversions after two years (P = 0.014).

CONCLUSION

This study reported that males showed a predisposition to fellow eye nAMD conversion at an earlier age. Additionally, there was a trend of faster fellow eye nAMD conversion in individuals with higher age and lower baseline visual acuity.

KEY MESSAGES

What is known • Certain risk factors may make the fellow eye of neovascular age-related macular degeneration (nAMD) more likely to progress to wet conversion. • Identifying these risk factors for fellow eye wet conversion can help prevent it, potentially preserving the patient's vision quality for a longer duration. • The studies on the incidence of wet conversion in the fellow eye have yielded controversial results. What is new • During the 15-year follow-up period, nearly half (47.58%) of the fellow eyes that underwent wet conversion did so within the initial two years following the wet conversion of the first eye. • Males showed a predisposition to fellow eye nAMD conversion at an earlier age. • There was a trend of faster fellow eye nAMD conversion in individuals with higher age and lower baseline visual acuity.

Factors associated with loss to follow-up in patients with advanced age-related macular degeneration: A telehealth recall initiative

INTRODUCTION

Patients with advanced age-related macular degeneration (AMD) frequently experience loss to follow-up (LTFU), heightening the risk of vision loss from treatment delays. This study aimed to identify factors contributing to LTFU in patients with advanced AMD and assess the effectiveness of telephone-based outreach in reconnecting them with eye care.

METHODS

A custom reporting tool identified patients with advanced AMD who had not returned for eye care between 31 October 2021 and 1 November 2022. Potentially LTFU patients were enrolled in a telephone outreach programme conducted by a telehealth extender to encourage their return for care. Linear regression analysis identified factors associated with being LTFU and likelihood of accepting care post-outreach.

RESULTS

Out of 1269 patients with advanced AMD, 105 (8.3%) did not return for recommended eye care. Patients LTFU were generally older (89.2 ± 8.9 years vs. 87.2 ± 8.5 years, p = 0.02) and lived farther from the clinic (25 ± 43 miles vs. 17 ± 30 miles, p = 0.009). They also had a higher rate of advanced dry AMD (26.7% vs. 18.5%, p = 0.04) and experienced worse vision in both their better-seeing (0.683 logMAR vs. 0.566 logMAR, p = 0.03) and worse-seeing (1.388 logMAR vs. 1.235 logMAR, p = 0.04) eyes. Outreach by a telehealth extender reached 62 patients (59%), 43 through family members or healthcare proxies. Half of the cases where a proxy was contacted revealed that the patient in question had died. Among those contacted directly, one third expressed willingness to resume eye care (20 patients), with 11 scheduling appointments (55%). Despite only two patients returning for in-person eye care through the intervention, the LTFU rate halved to 4.4% by accounting for those patients who no longer needed eye care at the practice.

CONCLUSIONS

There is a substantial risk that older patients with advanced AMD will become LTFU. Targeted telephone outreach can provide a pathway for vulnerable patients to return to care.

Early Optical Coherence Tomography Biomarkers for Selected Retinal Diseases-A Review

Optical coherence tomography (OCT) is a non-invasive, easily accessible imaging technique that enables diagnosing several retinal diseases at various stages of development. This review discusses early OCT findings as non-invasive imaging biomarkers for predicting the future development of selected retinal diseases, with emphasis on age-related macular degeneration, macular telangiectasia, and drug-induced maculopathies. Practitioners, by being able to predict the development of many conditions and start treatment at the earliest stage, may thus achieve better treatment outcomes.

Second eyes to develop neovascular age-related macular degeneration have fewer symptoms and better one-year visual outcomes

BACKGROUND

This study compares the visual and anatomical outcomes for the eyes of patients who developed sequential neovascular age-related macular degeneration (nAMD), both at the time of diagnosis and at one year after treatment.

METHODS

The study comprised a retrospective case series of 52 patients whose eyes were diagnosed sequentially with nAMD. All eyes were treated with three monthly loading doses of anti-vascular endothelial growth factor agents, followed by further intravitreal injections, as required. Baseline characteristics and outcomes at one year after diagnosis and initial treatment were compared between first and second eyes and included visual acuity (VA), central macular thickness (CMT), and pigment epithelial detachment (PED) height on optical coherence tomography (OCT) imaging.

RESULTS

VA at diagnosis was better for second eyes compared with first eyes to develop nAMD (logMAR 0.68 ± 0.51 versus logMAR 0.41 ± 0.34, P = 0.002) and remained so at one year (logMAR 0.61 ± 0.60 versus logMAR 0.42 ± 0.37, P = 0.041). Similarly, PED height at diagnosis was higher in first eyes (225 ± 176 μm versus 155 ± 144 μm, P = 0.003) and also at one year (188 ± 137 μm versus 140 ± 112 μm, P = 0.019). Whereas most patients reported symptoms at first eye diagnosis (71.2%), half as many second eyes were symptomatic (28.8%, P < 0.001). Significantly more symptomatic first eyes experienced visual distortions (32.4% versus 13.3%) or scotomas (29.4% versus 6.7%), compared with a less specific visual complaint of blurry vision (38.2% versus 80.0%, P = 0.006).

CONCLUSIONS

Compared with first eyes to develop nAMD, second eyes tended to have better vision, smaller PED heights, and fewer symptoms likely because monitoring permitted earlier diagnosis.

Visual acuity and causes of central visual loss in the adult Danish population 2020-2022. Results from the FORSYN study

PURPOSE

Knowledge of visual health in the population is necessary for designing and implementing measures to handle visual handicap. The purpose of the FORSYN (Forekomst af synshandicap og synshjaelpemidler i Danmark) project was to study visual health in the Danish population 2020-2022 after implementation of the recent advances in the management of choroidal and retinal vascular disease. The present study reports visual acuity and causes of central visual loss from this study.

METHODS

A population-representative sample of 10 350 citizens living within 40 kilometres from Aarhus University Hospital were invited to answer a questionnaire about quality of life related to vision, measurement of visual acuity and a non-mydriatic examination of the eyes. The data were corrected for selection bias on the basis of demographic and socioeconomic factors so that the results could be projected to represent the adult Danish population.

RESULTS

Population-adjusted visual acuity in ETDRS letters (mean ± SD) differed significantly (p < 0.0001) among the worse eye (84.1 ± 0.25), the better eye (88.4 ± 0.11) and binocularly (89.2 ± 0.15). Social blindness affected 0.22% (95% CI: 0.14%-0.33%) of the population and was in none of the studied persons due to exudative age-related macular degeneration (AMD) or diabetic retinopathy. The most frequent causes of visual loss were atrophic AMD, neuro-ophthalmic disorders and other chorioretinal diseases.

CONCLUSIONS

Recent advances in the therapy of chorioretinal vascular diseases have been paralleled with a reduction in central vision loss secondary to exudative AMD and diabetic retinopathy in Denmark. The demographic development can be expected to increase the demand for treatments of vision-threatening diseases that mainly affect older persons.

Consequences of Real-World Surveillance of Fellow Eyes in Neovascular Age-Related Macular Degeneration

This study investigated whether the interval of monitoring at-risk, fellow eyes of patients with unilateral neovascular age-related macular degeneration (nAMD) has any bearing on the severity of the disease at the time of diagnosis. The study comprised a retrospective, cross-sectional comparative case series of treatment-naïve eyes in patients who were diagnosed sequentially with nAMD. We compared the visual acuity (VA) and central macular thickness (CMT) of patients who were actively receiving intravitreal injections (IVIs) of anti-vascular endothelial growth factor (anti-VEGF) agents at the time of second eye diagnosis with the VA and CMT of patients who had ceased treatment in their first eye because of reaching end-stages of disease. Intervals of visits and frequency of monitoring the macula of fellow eyes by means of optical coherence tomography (OCT) were abstracted from the medical record. We found that the at-risk fellow eyes of patients who had stopped treatment for nAMD in their first eye prior to fellow eye conversion were monitored significantly less frequently than the fellow eyes of patients who continued to receive treatment at the time of second eye diagnosis. Despite less frequent monitoring, VA and CMT were similar at the time of fellow eye diagnosis for both groups.

What about the fellow eye in treatment of neovascular age-related macular degeneration? Analysis of data from the Swedish macula register

PURPOSE

To analyse the development of neovascular age-related macular degeneration (nAMD) in the fellow eye in patients initially presenting with unilateral nAMD, using data from the Swedish Macula Register.

METHODS

This observational study included data on treatment-naïve patients who initially underwent unilateral treatment for nAMD, and then required bilateral treatment, between 2010 and 2018, according to the Swedish Macula Register (SMR). The data were also stratified according into three time periods (2010-2013; 2014-2016; 2017-2018). Treatment duration, best-corrected visual acuity (BCVA) in the first and second eye, number of injections in the first eye before falling ill in the second, and the time between the last injection in the first eye and the start of treatment of the fellow eye were analysed.

RESULTS

5216 out of 28 670 (18%) patients treated for nAMD subsequently required bilateral treatment. The mean age was 77.7 ± 7.3 years, and 69% were female. The mean duration of treatment of the first eye before nAMD was diagnosed in the fellow eye was 1.58 years, and the mean number of injections in the first eye was 8.9 ± 8.6. Best-corrected visual acuity, according to the ETDRS chart, was higher in the second eye at the time when treatment started in that eye compared to treatment start in the first eye: 62.8 (14.7) versus 57.6 (15.5); p < 0.001, and was higher in the 66% whose first eye was still undergoing treatment: 63.6 ± 14.5 versus 61.0 ± 14.8; p = 0.001.

CONCLUSIONS

The mean duration of treatment of the first eye before treatment started in the fellow eye was 19 months, and treatment of the second eye had started within 2 years in 61% of the patients. Best-corrected visual acuity was higher in the second eye than in the first eye at the start of treatment of that eye and was higher in the second eye at the start of treatment of that eye when the first eye was still being treated.

From Data to Deployment: The Collaborative Community on Ophthalmic Imaging Roadmap for Artificial Intelligence in Age-Related Macular Degeneration

OBJECTIVE

Health care systems worldwide are challenged to provide adequate care for the 200 million individuals with age-related macular degeneration (AMD). Artificial intelligence (AI) has the potential to make a significant, positive impact on the diagnosis and management of patients with AMD; however, the development of effective AI devices for clinical care faces numerous considerations and challenges, a fact evidenced by a current absence of Food and Drug Administration (FDA)-approved AI devices for AMD.

PURPOSE

To delineate the state of AI for AMD, including current data, standards, achievements, and challenges.

METHODS

Members of the Collaborative Community on Ophthalmic Imaging Working Group for AI in AMD attended an inaugural meeting on September 7, 2020, to discuss the topic. Subsequently, they undertook a comprehensive review of the medical literature relevant to the topic. Members engaged in meetings and discussion through December 2021 to synthesize the information and arrive at a consensus.

RESULTS

Existing infrastructure for robust AI development for AMD includes several large, labeled data sets of color fundus photography and OCT images; however, image data often do not contain the metadata necessary for the development of reliable, valid, and generalizable models. Data sharing for AMD model development is made difficult by restrictions on data privacy and security, although potential solutions are under investigation. Computing resources may be adequate for current applications, but knowledge of machine learning development may be scarce in many clinical ophthalmology settings. Despite these challenges, researchers have produced promising AI models for AMD for screening, diagnosis, prediction, and monitoring. Future goals include defining benchmarks to facilitate regulatory authorization and subsequent clinical setting generalization.

CONCLUSIONS

Delivering an FDA-authorized, AI-based device for clinical care in AMD involves numerous considerations, including the identification of an appropriate clinical application; acquisition and development of a large, high-quality data set; development of the AI architecture; training and validation of the model; and functional interactions between the model output and clinical end user. The research efforts undertaken to date represent starting points for the medical devices that eventually will benefit providers, health care systems, and patients.

[Real-life results of anti-VEGF treatment in fellow eyes with nAMD]

PURPOSE

Neovascular age-related macular degeneration (nAMD) often affects both eyes. This study compared real-life outcomes of the first affected eye (1st eye) and the last affected eye (2nd eye) after anti-vascular endothelial growth factor (anti-VEGF) treatment.

MATERIAL AND METHODS

For this retrospective monocenter study 3217 eyes from 2793 patients with nAMD were identified, who received at least 3 anti-VEGF injections between 2006 and 2014 at the University Eye Hospital of Munich. Included in the study were patients with bilateral nAMD when the 1st and 2nd eyes were not previously treated and there was a strict adherence with continuous follow-up for at least 5 years. Corrected visual acuity, number of intravitreal injections and visits as well as central macular thickness were compared.

RESULTS

A total of 72 eyes of 36 patients were included in this analysis. Before anti-VEGF therapy, the group of 2nd eyes showed significantly better mean visual acuity than the 1st eyes (p < 0.001). This difference in visual acuity between 1st and 2nd eyes was noted at all time points throughout the follow-up period (p < 0.05). The mean number of cumulative injections was higher in the group of 2nd eyes (p = 0.04) with a comparable number of visits between both groups. In more than half of all patients the 2nd eye became affected by nAMD within 12 months following treatment initiation of the 1st eye and the majority (83%) followed within 3 years.

CONCLUSION

In unilateral nAMD, regular monitoring of the fellow eye is essential to avoid severe bilateral vision loss. Early diagnosis with rapid initiation of treatment can preserve visual acuity and quality of life.

Characterizing Progression to Neovascular AMD in Fellow Eyes of Patients Treated With Intravitreal Anti-VEGF Injections

BACKGROUND AND OBJECTIVE

The purpose of this study was to assess the real-world incidence of conversion to bilateral neovascular age-related macular degeneration (nAMD) following treatment initiation of nAMD in the initial eye.

PATIENTS AND METHODS

This was a retrospective cohort of electronic health records from retinal centers across the United States (Vestrum Database) of all patients with unilateral nAMD treated with anti-vascular endothelial growth factor therapy.

RESULTS

A total of 22,553 patients with unilateral nAMD were included. Fellow eyes of 8,522 patients (38%) converted to nAMD. Among these, 2,639 (12%), 2,030 (9%), and 1,802 (8%) patients converted in Years 1, 2, and 3, respectively, after diagnosis in the first eye. Fellow eyes had better vision at conversion and 1 year following conversion.

CONCLUSIONS

The fellow eye should be monitored at regular intervals to detect signs of neovascularization. Fellow eyes presented with significantly better vision at diagnosis than the initial eye and maintained better visual acuity with less injections. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:123-128.].

Predicting wet age-related macular degeneration (AMD) using DARC (detecting apoptosing retinal cells) AI (artificial intelligence) technology

OBJECTIVES

To assess a recently described CNN (convolutional neural network) DARC (Detection of Apoptosing Retinal Cells) algorithm in predicting new Subretinal Fluid (SRF) formation in Age-related-Macular-Degeneration (AMD).

METHODS

Anonymized DARC, baseline and serial OCT images (n = 427) from 29 AMD eyes of Phase 2 clinical trial (ISRCTN10751859) were assessed with CNN algorithms, enabling the location of each DARC spot on corresponding OCT slices (n = 20,629). Assessment of DARC in a rabbit model of angiogenesis was performed in parallel.

RESULTS

A CNN DARC count >5 at baseline was significantly (p = 0.0156) related to development of new SRF throughout 36 months. Prediction rate of eyes using unique DARC spots overlying new SRF had positive predictive values, sensitivities and specificities >70%, with DARC count significantly (p < 0.005) related to the magnitude of SRF accumulation at all time points. DARC identified earliest stages of angiogenesis in-vivo.

CONCLUSIONS

DARC was able to predict new wet-AMD activity. Using only an OCT-CNN definition of new SRF, we demonstrate that DARC can identify early endothelial neovascular activity, as confirmed by rabbit studies. Although larger validation studies are required, this shows the potential of DARC as a biomarker of wet AMD, and potentially saving vision-loss.

Optical coherence tomography angiography findings of fellow eye of proliferative macular telangiectasia type 2: Long term study

PURPOSE

To report the characteristics of non-proliferative fellow eyes in patients with unilateral proliferative macular telangiectasia type 2 (MacTel).

METHODS

This was a multicenter, retrospective study and included fellow eyes of eyes with subretinal neovascular membrane (SRNVM). Multimodal imaging including fundus photography, optical coherence tomography (OCT), and OCT angiography (OCTA) was performed. OCT and OCTA measurements included central macular thickness (CMT), subfoveal choroidal thickness (SFCT), foveal avascular zone (FAZ) area and qualitative parameters such as distortion or enlargement of FAZ, increased inter-vascular spacing, dilated, tortuous vessel at margin of FAZ, crowding of vessel, and loss of choriocapillaris (CC).

RESULTS

Thirteen fellow eyes of 13 patients with mean age of 63.6 ± 12.0 years were included. Fellow eyes had various stages of the diseases - stage 2 (four eyes), 3 (six eyes), and 4 (three eyes). OCTA showed increased intervascular spacing (8; 61.5%), dilated (11; 84.6%), and elongated vessels (8; 61.5%) at the margin of the FAZ, crowding of vessels (6; 46.2%), capillary non-perfusion areas outside the FAZ (4; 30.8%), and areas of CC loss (4; 30.8%). Mean follow-up was 9.1 ± 12.9 months. Out of six eyes with follow-up of ⩾12 months, two developed SRNVM at 18 and 33 months with OCTA showing crowding and entanglement of dilated retinal vessels in deep capillary plexus at baseline which corresponded to the area affected by SRNVM.

CONCLUSION

Fellow eyes of proliferative MacTel showed established disease stages on OCTA with progressive capillary crowding and entanglement of vessels likely corresponding to the future site of SRNVM.

Predicting conversion to wet age-related macular degeneration using deep learning

Progression to exudative 'wet' age-related macular degeneration (exAMD) is a major cause of visual deterioration. In patients diagnosed with exAMD in one eye, we introduce an artificial intelligence (AI) system to predict progression to exAMD in the second eye. By combining models based on three-dimensional (3D) optical coherence tomography images and corresponding automatic tissue maps, our system predicts conversion to exAMD within a clinically actionable 6-month time window, achieving a per-volumetric-scan sensitivity of 80% at 55% specificity, and 34% sensitivity at 90% specificity. This level of performance corresponds to true positives in 78% and 41% of individual eyes, and false positives in 56% and 17% of individual eyes at the high sensitivity and high specificity points, respectively. Moreover, we show that automatic tissue segmentation can identify anatomical changes before conversion and high-risk subgroups. This AI system overcomes substantial interobserver variability in expert predictions, performing better than five out of six experts, and demonstrates the potential of using AI to predict disease progression.

Moorfields AMD database report 2: fellow eye involvement with neovascular age-related macular degeneration

BACKGROUND/AIMS

Neovascular age-related macular degeneration (nAMD) is frequently bilateral, and previous reports on 'fellow eyes' have assumed sequential treatment after a period of treatment of the first eye only. The aim of our study was to analyse baseline characteristics and visual acuity (VA) outcomes of fellow eye involvement with nAMD, specifically differentiating between sequential and non-sequential (due to macular scarring in the first eye) antivascular endothelial growth factor treatment and timelines for fellow eye involvement.

METHODS

Retrospective, electronic medical record database study of the Moorfields AMD database of 6265 patients/120 286 single entries with data extracted between 21 October 2008 and 9 August 2018. The data set for analysis consisted of 1180 sequential, 807 non-sequential and 3410 unilateral eyes.

RESULTS

Mean VA (ETDRS letters±SD) of sequentially treated fellow eyes at baseline was significantly higher (63±13), VA gain over 2 years lower (0.37±14) and proportion of eyes with good VA (≥70 letters) higher (46%) than the respective first eyes (baseline VA 54±16, VA gain at 2 years 5.6±15, percentage of eyes with good VA 39%). Non-sequential fellow eyes showed baseline characteristics and VA outcomes similar to first eyes. Fellow eye involvement rate was 32% at 2 years, and median time interval to fellow eye involvement was 71 (IQR: 27-147) weeks.

CONCLUSION

This report shows that sequentially treated nAMD fellow eyes have better baseline and final VA than non-sequentially treated eyes after 2 years of treatment. Sequentially treated eyes also had a greater proportion with good VA after 2 years.