Photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularization in pathologic myopia: a long-term follow-up study

Chorioretinal Atrophic Lesions Evolution in Patients with Quiescent Myopic Choroidal Neovascularization Followed for More Than 10 Years

Purpose

To evaluate the progression of chorioretinal atrophic areas associated with myopic choroidal neovascularization (CNV) in high myopic patients followed by a minimum period of 10 years.

Patients and Methods

Patients with myopic CNV lesions that achieved clinical and structural remissions over 10 years of follow-up were included. Medical records were reviewed for CNV characterization and treatment, best-corrected visual acuity at baseline (BCVA0), immediately after the last treatment (BCVA1) and at the latest visit (BCVA2). Fundus autofluorescence (FAF) was used to quantify the amount of atrophic area increase per year associated with the treated myopic CNV lesion. The first FAF performed after treatment suspension (FAF1) was compared with the most recent exam (FAF2).

Results

Thirty-six eyes from 36 patients were included. Mean total follow-up was 12.38 ± 2.68 years. Mean number of intravitreal injections (IVI) was 12.50 ± 12.40 and 25% of the eyes had previous treatment with photodynamic therapy (PDT). Mean improvement between BCVA0 and BCVA1 was 5.58 ± 15.98 letters (p < 0.001). However, a drop of 8.03 ± 12.25 letters was noticed between BCVA1 and BCVA2. FAF1 was 6.34 ± 4.92mm2 and increased to 9.88 ± 7.56mm2 (3.54 ± 3.79mm2 variation p < 0.001). The mean growth rate of the atrophic area was 0.89 ± 0.84mm2 per year. BCVA2 negatively correlated with FAF2 (k = -0.498, p = 0.002) being worse in patients with higher atrophic area growth rate (k = -0.341, p = 0.042). Eyes treated with PDT needed less IVI (5.89 ± 5.21 vs 14.70 ± 13.36, p = 0.008) but had larger FAF1 (9.80 ± 5.33 vs 5.19 ± 4.27, p = 0.013) and FAF2 (16.05 ± 7.10 vs 7.83 ± 6.63, p = 0.003). Hypothyroidism was associated with higher atrophy growth rate (1.55 ± 1.15 vs 0.73 ± 0.67, p = 0.016).

Conclusion

This research demonstrates the importance of chorioretinal atrophy progression after myopic CNV lesions regression and its impact on visual prognosis, reporting a mean yearly growth of 0.89 mm2 in atrophic areas. Previous treatment with PDT and hypothyroidism were identified as risk factors associated with larger atrophic areas and worse visual outcomes.

INTRAVITREAL ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR FOR THE TREATMENT OF CHOROIDAL NEOVASCULARIZATION SECONDARY TO OCULAR HISTOPLASMOSIS: Ten-Year Follow-Up

PURPOSE

To assess the long-term efficacy of intravitreal antivascular endothelial growth factor injections (IVI), alone or in combination with verteporfin photodynamic therapy (IVI/PDT), for management of choroidal neovascularization secondary to presumed ocular histoplasmosis syndrome (POHS).

METHODS

Retrospective, comparative, interventional case series analyzing 82 eyes in 74 patients treated with either IVI or IVI/PDT for presumed ocular histoplasmosis syndrome choroidal neovascularization from January 2006 to January 2021.

RESULTS

The average logarithm of the minimum angle of resolution VA in year 5 was 0.40 (20/50) and 0.52 (20/67) for IVI versus IVI/PDT groups, respectively ( P = 0.33), and in year 10 was 0.53 (20/58) and 0.64 (20/86), respectively ( P = 0.50). The average number of annual injections over the first 5 years of follow-up was 3.3 versus 1.7 for IVI versus IVI/PDT groups, respectively ( P < 0.001), and over 10 years was 3.3 versus 1.6, respectively ( P < 0.001). Treatment-free interval of 5 years was reached by 39% versus 60% in IVI versus IVI/PDT groups, respectively ( P = 0.95).

CONCLUSION

Our study found both IVI and IVI/PDT to be effective in long-term management of presumed ocular histoplasmosis syndrome choroidal neovascularization, with a fewer number of annual injections and longer treatment-free interval in the combination group. However, given the limitations of a retrospective study, a prospective randomized study is necessary to determine whether the addition of PDT significantly decreases treatment burden.

A systematic review of clinical practice guidelines for myopic macular degeneration

Background

Myopic macular degeneration (MMD) is a primary cause of blindness and visual impairment in many parts of the world. A review of clinical practice guidelines (CPGs) for intervention selection are required with the increasing demand for MMD management in clinical practice as well as in national health services. Therefore, we aim to systematically review CPGs for MMD and assist the recommendations development of the Package of Eye Care Interventions (PECI) program of the World Health Organization.

Methods

A systematic review of CPGs published on MMD between 2010 and April 2020 was conducted. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Cochrane systematic reviews were also included when the evidence from included CPGs were inadequate or contradict.

Results

After applying exclusion criteria and conducting the quality appraisal, two CPGs were finally included. The average of the AGREE II ratings for the identified Guidelines were 56 and 63 respectively (7 for each item). To provide further information on interventions for MMD, one Cochrane review on MMD was additionally identified and included in the study. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) drugs were recommended for patients with myopic choroidal neovascularization (mCNV) as first-line therapy to improve vision and reduce central macular thickness, and ranibizumab showed significant effectiveness compared to photodynamic therapy (PDT). PDT was recommended to be performed in those resistant to the treatment by one CPG but lacked of adequate description and support. Data extracted from the Cochrane systematic reviews indicated that anti-VEGF therapy for mCNV had significant effectiveness in improving visual acuity and reducing CMT compared to PDT with moderate to low certainty of evidence. Ranibizumab and bevacizumab were considered as equally effective with moderate certainty.

Conclusions

The outcomes of this review suggest that high quality clinical practice guidelines for MMD management are limited. Intravitreal injection of anti-VEGF agents was recommended as an effective intervention to treat myopic CNV as the first-line treatment, while there was inadequate guidance for the application of PDT in myopic CNV management. The use of other interventions for MMD were not recommended at this time and additional evidence is called for.

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.

Cost of myopic patients with and without myopic choroidal neovascularisation

OBJECTIVE

To study the costs associated with high myopia (HM) with choroidal neovascularisation (mCNV) or without mCNV.

METHODS

Observational, retrospective, cross-sectional, and multicentre study (HM and mCNV) conducted on adult patients. Annualised medical direct cost (MDC) from the perspective of the National Health System, the non-medical direct cost (nMDC) from the patient perspective, and productivity losses were calculated.

RESULTS

A total of 137 mCNV and 48 HM patients were included (mean age [SD]: 55.1 [2.8] vs. 54.7 [13.8]; P=.2), with 80% women in both groups. The observation time (months) ranged from 17.9 (9.6) right eye (RE) and 20.0 (9.7), left eye (LE) in mCNV and 47.1 (21.5) RE/45.5 (20.7) LE in MM. A higher percentage of emergency room visits was observed in mCNV vs. HM patients (41.7 vs. 25%; P=.06) and retinal specialists (91.2 vs. 77.1%; P=.01). The MDC was higher in mCNV: € 1,985 (95% CI: 1772-2198) vs. € 356 (251-480) HM, P<.001. The nMDC was also higher in mCNV: € 256 (11-524) vs. €19 (11-26) HM, P>.4. The number of affected eyes, the follow-up time, and the mCNV were factors associated with direct costs. The impact on work productivity was higher in mCNV (quite/very concerned): 27.7 vs. 10.4% HM. The mCNV showed a significant association with activity impairment (OR: 3.47, 95% CI: 10.101-1.195).

CONCLUSIONS

mCNV involves higher medical costs than HM. In addition, mCNV patients have a greater need of care and assistive devices, and greater impact of the disease in their work productivity.

Therapeutic effect of intravitreal injections of ranibizumab for the treatment of macular choroidal neovascularization caused by pathological myopia

The aim of the present study was to evaluate the clinical efficacy and safety of intravitreal ranibizumab injections for the treatment of macular choroidal neovascularization (CNV) caused by pathological myopia. Between one and four intravitreal injections of ranibizumab were administered to 61 eyes from 61 patients who were diagnosed with macular CNV caused by pathological myopia. Following injection, the best-corrected visual acuity (BCVA), central macular thickness (CMT) and fundus fluorescein angiography (FFA) findings were evaluated monthly for a period of 6 months. Among the 61 eyes, 10 eyes received one injection, 44 received two injections, six received three injections and one received four injections (average, 1.97 injections). The BCVA was 0.02±0.01 prior to treatment and 0.30±0.03 subsequent to treatment, and this difference was statistically significant (P<0.01). The CMT was reduced by an average of 45.1 µm. Regarding the FFA results, 56 eyes had no CNV fluorescence leakage and five eyes had CNV fluorescence leakage following treatment; however, the intensity of CNV fluorescence leakage in the five eyes following treatment was lower than that prior to treatment. As a treatment for pathological myopia-induced macular CNV, intravitreal injections of ranibizumab may improve eyesight as well as the macular retinal tissue structure; thus, this is a safe and effective treatment method.

Anti-VEGF treatment for myopic choroid neovascularization: from molecular characterization to update on clinical application

Choroidal neovascularization (CNV) secondary to pathologic myopia has a very high incidence in global, especially in Asian, populations. It is a common cause of irreversible central vision loss, and severely affects the quality of life in the patients with pathologic myopia. The traditional therapeutic modalities for CNV secondary to pathologic myopia include thermal laser photocoagulation, surgical management, transpupillary thermotherapy, and photodynamic therapy with verteporfin. However, the long-term outcomes of these modalities are disappointing. Recently, intravitreal administration of anti-VEGF biological agents, including bevacizumab, ranibizumab, pegaptanib, aflibercept, and conbercept, has demonstrated promising outcomes for this ocular disease. The anti-VEGF regimens are more effective on improving visual acuity, reducing central fundus thickness and central retina thickness than the traditional modalities. These anti-VEGF agents thus hold the potential to become the first-line medicine for treatment of CNV secondary to pathologic myopia. This review follows the trend of “from bench to bedside”, initially discussing the pathogenesis of myopic CNV, delineating the molecular structures and mechanisms of action of the currently available anti-VEGF drugs, and then systematically comparing the up to date clinical applications as well as the efficacy and safety of the anti-VEGF drugs to the CNV secondary to pathologic myopia.

Myopic choroidal neovascularisation: current concepts and update on clinical management

Choroidal neovascularisation (CNV) is a common vision-threatening complication of myopia and pathological myopia. Despite significant advances in understanding the epidemiology, pathogenesis and natural history of myopic CNV, there is no standard definition of myopic CNV and its relationship to axial length and other myopic degenerative changes. Several treatments are available to ophthalmologists, but with the advent of new therapies there is a need for further consensus and clinical management recommendations. Verteporfin photodynamic therapy has been an established treatment for subfoveal myopic CNV for many years, but this treatment does not restore visual acuity and is associated with long-term chorioretinal atrophy. More recently, clinical trials investigating the efficacy and safety of anti-vascular endothelial growth factor agents in patients with myopic CNV have demonstrated substantial visual acuity gains and quality of life increases compared with photodynamic therapy. These enhanced outcomes provide updated evidence-based clinical management guidelines of myopic CNV, and increase the need for a generally accepted definition for myopic CNV. This review critically summarises the latest myopic CNV literature in the context of clinical experience and recommends a myopic CNV treatment algorithm.

Management of Choroidal Neovascularization Secondary to Pathological Myopia: The Era of Changes

Choroidal neovascularization (CNV) secondary to pathological myopia is an important cause of significant visual impairment in young adults. High myopia is particularly prevalent in Asian population. New scientific contributions have been made to the understanding of high myopia and myopic CNV. Treatment for myopic CNV has previously relied on photodynamic therapy, laser photocoagulation, and submacular surgery. The treatment outcomes from these modalities are, however, controversial. The introduction of antiangiogenic agents including bevacizumab and ranibizumab has brought the treatment of myopic CNV into a new era. The purpose of this review was to provide an overview of the natural history of myopic CNV, the prognostic factors, and the various treatment options including laser photocoagulation and photodynamic therapy, with particular attention on antiangiogenic agents.

Comparison of foveal-sparing with foveal-involving photodynamic therapy for myopic choroidal neovascularization

PURPOSE

To evaluate the visual outcomes of choroidal neovascularization (CNV) secondary to pathological myopia in eyes treated with photodynamic therapy (PDT), and to determine the effect of lesion location and foveal involvement on visual prognosis.

METHODS

Interventional case series of 24 consecutive patients with myopic CNV treated with PDT. The main outcome measure was final LogMAR visual acuity (VA).

RESULTS

Of 24 eyes, the CNV lesion was subfoveal in 11 and extrafoveal in 13. Overall, the mean LogMAR VA at 24 months was 0.72. Extrafoveal CNV lesions achieved significantly better final VA compared with subfoveal CNV (LogMAR 0.45 vs 1.05, P=0.012). Eyes with extrafoveal CNV lesions were subdivided into foveal-sparing PDT (where the PDT laser spot did not involve the foveal center) and foveal-involved PDT (where the PDT laser covered the fovea). At all time points, the group with foveal-sparing PDT had significantly better VA compared with the foveal-involved group. The final LogMAR VA for the foveal-sparing PDT group was 0.26 compared with 1.00 for the foveal-involved PDT group (P=0.003). At 24 months, 77.8% of foveal-sparing PDT cases achieved VA of ≥ 20/40, compared with 25% of foveal-involved PDT cases and 9.1% of subfoveal CNV lesions (P=0.006).

CONCLUSION

For patients with myopic CNV, foveal-sparing PDT results in significantly better long-term visual outcomes compared with those with foveal-involved PDT. Foveal-sparing PDT may be of value for treatment of myopic CNV patients who are not suitable for treatment with anti-vascular endothelial growth factor injections.

Intravitreal bevacizumab for extrafoveal choroidal neovascularization secondary to pathologic myopia

PURPOSE

To assess the effects of intravitreal bevacizumab injections in the treatment of extrafoveal choroidal neovascularization (CNV) associated with pathologic myopia.

METHODS

Patients diagnosed with pathologic myopia complicated by extrafoveal CNV were considered in this prospective, open-label interventional study. All patients underwent a complete ophthalmologic examination, including Early Treatment Early of Diabetic Retinopathy Study (ETDRS) visual acuity measurement, optical coherence tomography, and fluorescein angiography. The protocol treatment included a first injection, followed by repeated injections over a 24-month follow-up period on the basis of optical coherence tomography and angiographic features, monitored monthly. Primary outcomes were the mean changes in best-corrected visual acuity and the proportion of eyes gaining at least 15 letters at the 24-month examination. Secondary outcomes included central macular thickness, size of the CNV, and extension to the fovea.

RESULTS

Fifteen patients were included in the study. Mean best-corrected visual acuity changed from 0.47 logarithm of the minimum angle of resolution (20/60 Snellen equivalent) at baseline to 0.22 logarithm of the minimum angle of resolution (20/30 Snellen equivalent) at the 24-month examination. An improvement of at least 3 ETDRS lines was achieved by 7 eyes (46.6%) at the 24-month examination. Mean central macular thickness changed from 313 μm to 254 μm at the 24-month examination (P = 0.008). Mean CNV size decreased from 348 μm2 to 251 μm2 at 24 months (P = 0.029).

CONCLUSION

Intravitreal bevacizumab injection is a beneficial treatment for extrafoveal CNV associated with pathologic myopia.

Factors affecting visual outcome of myopic choroidal neovascularization treated with verteporfin photodynamic therapy

AIM

To evaluate the visual outcomes of choroidal neovascularization (CNV) secondary to pathological myopia and the impact of novel risk factors affecting the final visual outcome.

METHODS

Interventional case series of 18 consecutive patients with pathological myopia treated with photodynamic therapy (PDT). Inclusion criteria were spherical equivalent -6D or worse or features of pathological myopia on retinal examination. The main outcome measure was final best-corrected visual acuity (BCVA).

RESULTS

Of 18 eyes, 13 (72.2%) avoided moderate visual loss (≥3 lines of LogMAR BCVA) and 5 eyes (27.8%) improved by at least 1 line after 1 year. Patients with LogMAR BCVA ≤0.3 (Snellen equivalent 20/40) at one year were younger than those with BCVA >0.3 (mean age 39.0 vs 61.6 years, P=0.001). A higher proportion of eyes with greatest linear dimension (GLD) of ≤1000µm avoided moderate visual loss (100% vs 50%, P=0.026). Among patients who were treated within 2 weeks of visual symptoms, 88.9% avoided the loss of 3 or more lines compared to 55.6% for those who presented later. The mean improvement in LogMAR BCVA of those with GLD ≤1000µm was +0.12 compared to a loss of 0.55 LogMAR units for those with GLD >1000µm (P=0.02). Visual outcomes were not associated with gender or refractive error.

CONCLUSION

Good visual outcome in myopic CNV is associated with younger age, smaller lesion size and earlier initiation of treatment. These factors are relevant for ophthalmologists considering treatment options for myopic CNV.

Choroidal neovascularization in pathological myopia

Myopic choroidal neovascularization (CNV) is one of the leading causes of visual impairment worldwide. The clinical and socioeconomic impact of myopic CNV in Asian countries is particularly significant due to rising trend in the prevalence and severity of pathological myopia. The exact pathogenesis of myopic CNV remains unclear and there is paucity of information with respect to incidence and risk factors for myopic CNV from prospective studies. Furthermore, there are no recognized measures that may prevent or delay the development of CNV in eyes with pathological myopia. Advances have been made in the diagnosis and characterization of myopic CNV over the years. Until recently, treatment modalities for myopic CNV were limited to thermal laser photocoagulation and photodynamic therapy with verteporfin, both these modalities primarily aim at prevention of further visual loss. In the last 5 years, inhibitors of vascular endothelial growth factor (VEGF) have been used successfully and may improve vision to some extent. Nevertheless, the long-term safety and efficacy of anti-VEGF agents remains unknown. Furthermore, the risk of developing chorioretinal atrophy remains the key factor in determining the final visual outcome. This review article summarizes the current literature on myopic CNV, highlighting new evolving diagnostic and treatment modalities, prognostic factors influencing visual outcome, and areas of future research.

Anti-vascular endothelial growth factor for myopic choroidal neovascularization

Myopic choroidal neovascularization (CNV) is a vision-threatening complication in the eyes with pathological myopia, which is particularly prevalent among young and middle-aged Asians globally. To date, the verteporfin in photodynamic therapy study is the only randomized-controlled study in treatment of subfoveal myopic CNV. However, its long-term benefit is controversial. Recently, intravitreal injections of anti-vascular endothelial growth factors have shown promising results. In the absence of randomized-controlled trial comparing the efficacy of anti-vascular endothelial growth factors with photodynamic therapy and placebo, the purpose of this article is to review the current studies on functional and anatomical outcomes in both subfoveal and juxtafoveal myopic CNV. Furthermore, the influences of various doses and frequencies, as well as age and previous photodynamic therapy treatment on its effect are described.

Long-term results of photodynamic therapy for choroidal neovascularization in Japanese patients with pathologic myopia

OBJECTIVE

To determine the results of photodynamic therapy (PDT) in highly myopic eyes with choroidal neovascularization (CNV).

DESIGN

Open-label, consecutive, interventional case series.

METHODS

Forty-eight eyes of 46 consecutive Japanese patients with a myopic CNV were studied. The eyes were treated with PDT and were followed up from 1 to 4 years. The best-corrected visual acuities (BCVAs) at the baseline and after the PDT were compared. Multivariate regression analyses were used to determine the factors that were significantly associated with the BCVA at 3 or 4 years.

RESULTS

The mean follow-up period was 3.2 years. Sixty-nine percent of the patients obtained angiographic closure by a single PDT treatment, and the average number of PDT treatments was 1.4. Chorioretinal atrophy developed in 61% of the eyes at 3 years and in 70% of the eyes at 4 years. The BCVA did not change significantly after the PDT. Multivariate regression analyses showed that the BCVA at 3 years was significantly correlated with the baseline BCVA and area of chorioretinal atrophy. Analyses of the 20 patients at 4 years or more showed that in 5 of 7 (71.4%) patients with juxtafoveal CNV, chorioretinal atrophy did not develop and that all had BCVA of 0.5 or better. However, in 12 of the 13 patients with a subfoveal CNV, chorioretinal atrophy developed at 4 years, and 10 of these patients had BCVA of 0.1 or worse.

CONCLUSIONS

In highly myopic patients, 69% obtained angiographic closure by a single PDT treatment, and recurrence was rare. These findings indicate that PDT is still a good option for treating CNVs in highly myopic patients.

Retinal pigment epithelial marginal retraction after photodynamic therapy for choroidal neovascularization in pathologic myopia

PURPOSE

To report the incidence of retinal pigment epithelial (RPE) marginal retraction after verteporfin photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) in pathologic myopia (PM).

METHODS

Retrospective review of 236 patients treated with PDT for subfoveal CNV due to PM.

RESULTS

RPE marginal retraction was found in 3 eyes (1.3%), and a decrease of a mean of five lines of vision was reported to occur 10-15 days after treatment. At the end of followup two eyes lost three lines and one six lines from baseline.

CONCLUSIONS

RPE marginal retraction as an early complication of PDT for subfoveal CNV secondary to PM is rare. The low incidence of this adverse event, however, should not preclude recommendations for PDT in myopic eyes that could benefit from this treatment modality.

Photodynamic therapy with verteporfin for choroidal neovascularization of pathologic myopia in Japanese patients: comparison with nontreated controls

PURPOSE

To examine the effects of photodynamic therapy (PDT) with verteporfin on subfoveal or juxtafoveal choroidal neovascularization (CNV) secondary to pathologic myopia in Japanese patients and to compare the visual outcomes of PDT-treated patients with that of age-matched and visual acuity-matched untreated controls.

DESIGN

Prospective, open-label, consecutive, interventional case series.

METHODS

We prospectively followed up 43 eyes of 42 consecutive patients with pathologic myopia (>6 diopters or axial length>26.5 mm) who received PDT for myopic CNV. In addition, the visual outcomes of these patients who were followed up for more than one year were compared with those of age- and initial visual acuity-matched untreated controls.

RESULTS

The average follow-up was 15.0+/-7.0 months. Patients received an average of 1.40+/-0.73 treatments during follow-up, and 30 eyes (69.8%) required only one treatment. The best-corrected visual acuity (BCVA) improved by more than two Snellen lines in seven eyes (16.3%), decreased in six eyes (14.0%), and remained stable in 30 eyes (69.7%). In three eyes with a juxtafoveal CNV, CNV could not be detected ophthalmoscopically or angiographically after PDT. Statistical analysis showed that the PDT-treated patients had significantly better visual acuity at one year after PDT than the age- and initial BCVA-matched untreated controls.

CONCLUSIONS

These results indicate that PDT was beneficial for maintaining vision in Japanese patients with myopic CNV. The visual outcome after PDT was better than the natural course of the disease as determined from untreated controls. The effect on chorioretinal atrophy around CNV should be investigated with a long-term study.