Choroidal Thickness Changes After Intravitreal Ranibizumab for Exudative Age-Related Macular Degeneration

Choroidal thickness after anti-vascular endothelial growth factor in typical neovascular age-related macular degeneration - A systematic review and meta-analysis

Age-related macular degeneration (AMD) is one of the leading causes of blindness in the world and anti-vascular endothelial growth factor (VEGF) injections have been the standard of care for the wet/neovascular variant since 2004. Currently, there are conflicting reports regarding its effect on the choroid, which supplies outer retina with oxygen and other nutrients. We synthesize available information of anti-VEGF on choroidal thickness (CT) in treatment-naïve typical neovascular AMD patients during the initial 12-week loading phase. We found 43 studies involving 1901 eyes from 1878 patients were included. Meta-analysis of 35 studies reporting CT at baseline and after 12 weeks suggested a significant decrease in CT with anti-VEGF treatment. A greater mean change with aflibercept compared to ranibizumab was found in subgroup analyses of sub-foveal CT in types 1 and 2 macular neovascularization. The long-term consequences of reduced CT in neovascular AMD remain unclear and require further targeted studies.

Choroidal Thickness Changes After Intravitreal Aflibercept Injections in Treatment-Naïve Neovascular AMD

Introduction

Choroidal thickness (CT) plays an important role in the pathogenesis of various ocular diseases, including neovascular age-related macular degeneration (nAMD). Previous studies evaluated the CT variations after anti-vascular endothelial growth factor (VEGF) injections in patients with nAMD, but the results are still controversial. The present study aimed to evaluate the CT at different times (15, 30, 60, 90, and 365 days) after intravitreal aflibercept injections and its correlation with the baseline CT in treatment-naïve patients with nAMD. Secondly, the study evaluated the correlation between CT variation at 365 days and the number of intravitreal injections received.

Methods

This was a prospective, open-label, single-arm pilot study. Twenty-one treatment-naïve nAMD eyes were enrolled. The study population underwent three monthly aflibercept injections (loading phase) and additional injections as needed (pro re nata regimen). A complete ophthalmological examination, including optical coherence tomography (OCT) was performed at each visit. CT was measured manually by two independent observers. All patients were evaluated at baseline and at 15, 30, 60, 90, and 365 days after the first intravitreal injection.

Results

CT showed a statistically significant reduction at days 15, 90, and 365 in comparison to baseline. However, the major reduction of CT was observed at day 15 and in eyes with a thicker choroid at baseline. No significant correlation between CT variation and the number of injections performed was found.

Conclusion

Our findings contribute to clarifying the role of aflibercept injections in choroidal vasculature, confirming its effect after the first 2 weeks. Moreover, CT can be considered as a potential biomarker, as it reflects the pharmacological effect of anti-VEGF drugs.

Factors for Visual Acuity Improvement After Anti-VEGF Treatment of Wet Age-Related Macular Degeneration in China: 12 Months Follow up

Purpose: To evaluate the treatment solutions and effectiveness of intravitreal ranibizumab (RBZ) or conbercept in patients with wet age-related macular degeneration (wAMD) in a real-life setting in China.

Methods: The medical records of 368 patients with wAMD who started RBZ or conbercept treatment between 1 May 2014 and 30 April 2018 were evaluated. All patients were defined on fundus angiography at baseline to determine the subtype of AMD (PCV or CNV). We report visual acuity (VA) and central retinal thickness (CRT) measurements at baseline and 12 months.

Results: The average number of anti-VEGF injections was 2.1 ± 1.2. The BCVA improvement of these two groups was similar with a difference of 1.00 letter (95% CI: −1.4~3.4, p = 0.8505). At the end of the study, a BCVA increase of at least 5 letters was determined to be a satisfactory efficacy endpoint. Several factors were related to the possible improvement in the satisfactory efficacy endpoint, including female sex (OR 2.07, 95% CI 1.22~3.51), number of injections (OR 1.40, 95% CI 1.12~1.75) and VA change at the first month (OR 13.75, 95% CI 7.41~25.51). Additionally, some factors were related to the possible reduction in the satisfactory efficacy endpoint, including diabetes (OR 0.27, 95% CI 0.10~0.73) and disease history (OR 0.75, 95% CI 0.57~0.98).

Conclusion: Our study demonstrates that anti-VEGF drugs can effectively improve BCVA and reduce CRT in AMD patients. Sex, number of injections, VA change at the first month, diabetes and disease history are the most important factors affecting visual acuity.

Choriocapillaris Vascular Density Changes: Healthy vs. Advanced Exudative Age-Related Macular Degeneration Previously Treated with Multiple Anti-VEGF Intravitreal Injections

Purpose: To assess choriocapillaris vascular density (VD) in healthy and advanced exudative age-related macular degeneration (ae-AMD) patients by new full-range optical coherence tomography angiography (OCT-A). Method: In this observational, cross-sectional study, 21 healthy and 21 ae-AMD eyes, already treated with anti-VEGF, were enrolled. Angio-View retina patterns centered on fovea (6.4 × 6.4 mm) were acquired for all participants using Solix full-range OCT (Optovue Inc., Freemont, CA, USA). The main outcome was to compare choriocapillaris VD between healthy and ae-AMD eyes. Automated measurements of whole image choriocapillaris VD (%) and fovea grid-based (%) were collected for the analysis. Angio-View patterns were used to assess the flow area (mm²) of macular neovascularization (MNV) by contour flow measure algorithm. Best-corrected visual acuity (BCVA) of both groups was also used for the statistical analysis. Results: The mean age was 60.9 (±8.3) in healthy and 73.33 (±15.05) in ae-AMD eyes. The mean BCVA (ETDRS letters) was 98.47 (±1.50) in healthy and 7.04 (±5.96) in ae-AMD eyes. The Mann–Whitney test comparing choriocapillaries VD for whole and fovea healthy and ae-AMD eyes showed statistical significance (p < 0.0001 (t = 4.91; df = 40) and p < 0.0001 (t = 6.84; df = 40), respectively). Regarding, the correlation between MNV and VD of choriocapillaries, neither whole nor fovea areas were statistically significant (F = 0.38 (R² = 0.01) and 1.68 (R² = 0.08), respectively). Conclusions: Choriocapillaris VD showed a statistically significant reduction in comparison to healthy eyes in ae-AMD eyes. Choriocapillaris impairment can be seen in the early phase of MNV pathogenesis.

Long-term effect of intravitreal aflibercept treatment on choroidal vascularity index in neovascular age-related macular degeneration

BACKGROUND

Our aim is to examine the effect of intravitreal aflibercept treatment on the choroidal vascularity index in eyes with neovascular age-related macular degeneration (nARMD) using the binarization method.

METHODS

Included in the study were the 38 eyes of 38 patients diagnosed with nARMD and treated with intravitreal aflibercept at our clinic. The patients' 12-month records were reviewed retrospectively. Patients' choroidal thickness (CT) was measured at baseline, 3rd month, 6th month, and 12th month on EDI-OCT images. We calculated luminal area (LA), stromal area (SA), total choroidal area (TCA), and choroid vascular index (CVI) values using binarization.

RESULTS

The mean age of the patients was 70,1 ± 8 years. The mean of injections over 12 months was 5.6 ± 2. Baseline values were CT 224 µm, LA 0,214 mm², SA 0,119mm², TCA 0,333 mm², and CVI 64% respectively. At the 3rd month, values were CT 223 µm, LA 0,212 mm², SA 0,121 mm², TCA 0,332 mm², and CVI 64%, respectively. The 6th-month values were CT 221 µm, LA 0,204 mm², SA 0,116 mm², TCA 0,320 mm², and CVI 64%, respectively, and 12-month values were CT 218 µm, LA 0,204 mm², SA 0,112 mm², TCA 0,318 mm², and CVI 64%, respectively. According to LogMAR, BCVA was 0.59 at baseline, 0.56 at 3 months, 0.52 at 6 months, and 0.51 at 12 months. At the end of month 12, we observed a statistically significant decrease in CT. No significant changes were observed in other parameters. When the number of injections was correlated with CVI, CT, and BCVA, a significant negative correlation was observed with CVI CONCLUSIONS: Aflibercept treatment reduces CT by affecting not only luminal but also stromal areas of the choroid in the long term but does not change the CVI. However, as the number of injections increases, CVI decreases.

Choroidal structural changes determined by the binarization method after intravitreal aflibercept treatment in neovascular age-related macular degeneration

AIM

To assess the choroidal structural alterations after intravitreal injection of aflibercept in neovascular age-related macular degeneration (nAMD).

METHODS

Fifty eyes with treatment-naïve nAMD were evaluated at baseline, 3^rd, and 12^th month. Fifty eyes of 50 healthy subjects were also included as controls. Choroidal thickness (CT) was measured in the subfoveal region. Total circumscribed choroidal area (CA), luminal area (LA), stromal area (SA), and choroidal vascularity index (CVI) was calculated using Image J.

RESULTS

At baseline, subfoveal CT was increased in nAMD patients compared to controls (P=0.321). Eyes with nAMD had a significantly increased total circumscribed CA and SA (P=0.041, 0.005, respectively). The CVI was decreased (P=0.038). In the 3^rd month, the subfoveal CT, LA, and CVI revealed a decrease (P=0.005, P=0.039, 0.043, respectively). In the 12^th month, subfoveal CT, LA, and CVI were decreased in comparison to baseline measures (P<0.001, 0.006, 0.010, respectively).

CONCLUSION

Significant structural alterations are found after intravitreal aflibercept treatment during the 12-month follow-up, in particular at the third month, in eyes with nAMD.

Short-term choroidal vascular changes after aflibercept therapy for neovascular age-related macular degeneration

Introduction

The purpose of this study was to evaluate choroidal vascular changes in patients with neovascular age-related macular degeneration (nAMD) treated with aflibercept injection over a 3-month period.

Methods

Enhanced depth imaging optical coherence tomography scans of 60 eyes with treatment-naïve nAMD and 60 unaffected fellow eyes were retrospectively analyzed. Data was collected at baseline and after 3 monthly intravitreal injections of aflibercept. The ImageJ software was used to binarize OCT scans and measure total choroid area (TCA), luminal area (LA), and stromal area (SA). Choroidal vascularity index (CVI) was defined as the ratio of LA to TCA.

Results

After treatment, subfoveal choroidal thickness (CT) in nAMD eyes significantly decreased from 210. 6 ± 61.6 to 194.6 ± 58.7 μm (P < 0.001), TCA from 1.620 ± 0.502 to 1.500 ± 0.451 mm² (P < 0.001), LA from 1.075 ± 0.335 to 0.985 ± 0.307 mm² (P < 0.001), SA from 0.545 ± 0.176 to 0.516 ± 0.153 mm² (P = 0.005), and CVI from 66.36 ± 2.89 to 65.46 ± 2.87% (P = 0.009). The decrease of CVI after treatment was significantly correlated with baseline CVI (Rs = 0.466, P < 0.001), but not with the change in BCVA and presence of dry macula after treatment (always P > 0.05).

Conclusion

Choroidal thickness and vascularity significantly decreased after treatment with aflibercept in nAMD eyes. Besides the pharmacologic effect on the neovascular lesion, aflibercept may induce vascular changes also on the underlying choroid.

Long-Term Changes in Submacular Choroidal Thickness after Intravitreal Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration: 14-Mo Follow-Up

Purpose: To study (i) the long-term effects of intravitreal ranibizumab treatment on changes in submacular choroidal thickness and (ii) the relationship between any resulting changes in choroidal thickness and visual outcomes following such treatment in patients with neovascular age-related macular degeneration (n-AMD). Methods: Reviewed were medical records of 30 consecutive, treatment-naïve, patients with unilateral n-AMD (n = 30 eyes) and unaffected fellow eyes (n = 26 eyes) (controls). Monthly injections of 0.5 mg ranibizumab were administered until stabilization of n-AMD, with additional injections as needed over the following 14-mo. Choroidal thickness was determined using enhanced-depth imaging-optical coherence tomography (EDI-OCT) before and after initiation of ranibizumab therapy. Choroidal thickness measurements were generated via manual segmentation. Results: The mean age of patients was 71.9 ± 7.4 (56-83) years; the mean best-corrected visual acuity (BCVA) of affected eyes improved from 51.1 to 59.4 letters (p < 0.001); and the mean number of injections was 9.16 ± 1.75. Subfoveal choroidal thickness decreased from 208.3 ± 73.7 μm at baseline to 185.3 ± 70.1 μm at mo-14 (p < 0.001), with significant (p < 0.001) decreases at all measured time points. Choroidal thickness also tended to decline in fellow eyes but was only statistically significant nasally 1,000 μm (p =0.04). Mean changes in choroidal thickness did not correlate with BCVA at mo-14 (p = 0.76). Disciform scars and geographic atrophy (p = 0.017), and BCVA (p < 001) at baseline were predictive of visual outcome. Age (p = 0.001), reticular drusen (p = 0.004), and size of choroidal neovascularized area (p = 0.042) were predictive of decreases in choroidal thickness. Conclusions: Submacular choroidal thickness appeared to decrease significantly in eyes with n-AMD over a 14-mo period of ranibizumab treatment. No corresponding decrease in choroidal thickness occurred in fellow eyes.