Long-term Progression of Type 1 Neovascularization in Age-related Macular Degeneration Using Optical Coherence Tomography Angiography

Analysis of factors affecting prognosis of the visual acuity and baseline risk factors for subretinal fibrosis in neovascular age-related macular degeneration patients

Background

To evaluate factors affecting visual acuity prognosis in patients with neovascular age-related macular degeneration (nAMD) following anti-vascular endothelial growth factor (anti-VEGF) therapy via intravitreal injection and to identify baseline risk factors for subretinal fibrosis (SF).

Methods

A retrospective study of 64 nAMD eyes treated with intravitreal anti-VEGF treatment over 12 months of follow-up was conducted. Demographic and optical coherence tomography characteristics at baseline were recorded to explore the relevant factors affecting visual acuity outcome. Find baseline risk factors for SF development. The primary baseline measures included OCT qualitative and quantitative indicators, and optical coherence tomography angiography (OCTA) quantitative features.

Results

BCVA (logMAR) at 12 months was positively correlated with age (r = 0.258, p = 0.040), baseline BCVA (r = 0.749, p < 0.001), central macular thickness (CMT) (r = 0.413, p < 0.001), subretinal hyperreflective material (SHRM) (r = 0.304, p = 0.014), intraretinal fluid (IRF) (r = 0.423, p < 0.001), type 2 macular neovascularization (MNV) (r = 0.272, p = 0.029), and ellipsoidal zone breaks (r = 0.299, p = 0.016), and hyperreflective foci (HF) (r = 0.264, p = 0.035). Eyes with SF had worse baseline BCVA (p < 0.001), greater CMT (p = 0.009), and a higher prevalence of IRF (p = 0.005), type 2 MNV (p = 0.001), SHRM (p = 0.012), and HF (p = 0.028). Logistic binary regression analysis showed that baseline BCVA (logMAR) (OR = 0.02, 95% CI: 0.00-0.45, p = 0.013), HF (OR = 0.11, 95% CI: 0.01-0.95, p = 0.045), and type 2 MNV (OR = 0.08, 95% CI: 0.01-0.88, p = 0.039) were independent risk factors of subretinal fibrosis. As for quantitative OCTA parameters, eyes with subretinal fibrosis had a larger microvascular lesion size (p = 0.003), larger vessels area (p = 0.002), higher number of vessel junctions (p = 0.042) and endpoints (p = 0.024), longer total vessel length (p = 0.005), and lower vessel length density (p = 0.042).

Conclusion

This study enplores baseline OCT and OCTA characteristics associated with subretinal fibrosis in nAMD patients. This information can help predict the occurrence and progression of subretinal fibrosis, potentially leading to more personalized treatment approaches for nAMD patients.

Regression of the Flow Signal from the Neovascular Network in AMD Neovascular Membranes Treated with Faricimab

OBJECTIVES

To report the occurrence of the regression of the flow signal from the neovascular network in macular neovascularizations (MNVs), developing in the context of age-related macular degeneration (AMD), treated with faricimab in a treat-and-extend regimen.

METHODS

Eyes affected by AMD-related MNV and treated with faricimab intravitreal injections in a treat-and-extend (TE) regimen were consecutively retrospectively screened in five specialized retina centers. Changes in neovascular network characteristics during the course of the treatment were analyzed. The availability of high-quality optical coherence tomography angiography (OCTA) at the beginning of the treatment and at the regression of the MNV was necessary for inclusion. According to greatest linear diameter (GLD) changes during treatment, eyes were divided into three groups: a complete regression (CR) group, a partial remission (PR) group (a reduction of at least 50% of the GLD from baseline to last follow-up), and a stable group (stable/showing a reduction lower than 50% of the GLD from baseline to follow up).

RESULTS

One hundred and ten (110) eyes were included. The CR group was composed of 12 eyes (10.9%), while the PR group represented 60.9% of the study population. CR occurred after a mean of 6.0 ± 1.4 months, ranging from 4 to 8 months. Time to regression was significantly lower in eyes naïve to treatment before the study compared with the others (p = 0.022). A significantly lower baseline GLD was detected in the CR group (1292.2 ± 195.6 μm) compared with the PR group (1324.6 ± 135.6 μm) and the stable group (1412.5 ± 110.9 μm) (omnibus p = 0.003).

CONCLUSIONS

Complete regression of the flow signal from the MNV neovascular network documented with OCTA may occur during TE regimens with faricimab. In treatment-naïve eyes, regression occurs earlier during the treatment.

Choroidal biomarkers in age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of central visual impairment in the elderly. The exact pathophysiological mechanisms for AMD remain uncertain. Several studies suggest that choroidal abnormalities and alterations are critical in AMD progression. The transition from manual to automated segmentation and binarization techniques has resulted in accurate and precise measurements of different choroidal parameters. These qualitative and quantitative parameters, known as choroidal imaging biomarkers, have advanced from basic vertical subfoveal choroidal thickness to more intricate 3-dimensional choroidal reconstruction methods in the last decade. Therefore, a comprehensive evaluation of choroidal metrics may investigate valuable insights into AMD, potentially guiding the future development of customized therapeutic strategies and personalized patient care in AMD management. We describe the role of different choroidal biomarkers in evaluating patients with AMD and their contribution to management.

Overview of the Use of Optical Coherence Tomography Angiography in Neovascular Age-Related Macular Degeneration

The aim of this review is to present and discuss the use of optical coherence tomography angiography (OCTA) in age-related macular degeneration (AMD). OCTA is a non-invasive imaging procedure that gives a detailed indirect view of physiological and pathological vessels in the retina and choroid membrane. Compared with dye-based imaging, OCTA provides a segmented presentation of the individual vascular layers and plexuses, thus enabling previously unattainable differentiation and classification of pathological vascular changes within or underneath the retina. In particular, OCTA facilitates early detection of exudative macular neovascularizations (MNV) so that treatment with anti-VEGF medication can be initiated. Moreover, in the context of both screening and therapy monitoring, it is hoped that OCTA can provide more detailed data to enable greater personalization of treatment and follow-up. The image quality of OCTA is, however, susceptible to artifacts, and validation of the results by studies is required. Recent developments have shown constant improvement both in the algorithms for image calculation and avoidance of artifacts and in image quality, so the scope of OCTA will certainly expand with time.

Optical coherence tomography angiography in neovascular age-related macular degeneration: comprehensive review of advancements and future perspective

Optical coherence tomography angiography (OCTA) holds promise in enhancing the care of various retinal vascular diseases, including neovascular age-related macular degeneration (nAMD). Given nAMD's vascular nature and the distinct vasculature of macular neovascularization (MNV), detailed analysis is expected to gain significance. Research in artificial intelligence (AI) indicates that en-face OCTA views may offer superior predictive capabilities than spectral domain optical coherence tomography (SD-OCT) images, highlighting the necessity to identify key vascular parameters. Analyzing vasculature could facilitate distinguishing MNV subtypes and refining diagnosis. Future studies correlating OCTA parameters with clinical data might prompt a revised classification system. However, the combined utilization of qualitative and quantitative OCTA biomarkers to enhance the accuracy of diagnosing disease activity remains underdeveloped. Discrepancies persist regarding the optimal biomarker for indicating an active lesion, warranting comprehensive prospective studies for validation. AI holds potential in extracting valuable insights from the vast datasets within OCTA, enabling researchers and clinicians to fully exploit its OCTA imaging capabilities. Nevertheless, challenges pertaining to data quantity and quality pose significant obstacles to AI advancement in this field. As OCTA gains traction in clinical practice and data volume increases, AI-driven analysis is expected to further augment diagnostic capabilities.

Optical Coherence Tomography Angiography: A 2023 Focused Update on Age-Related Macular Degeneration

Optical coherence tomography angiography (OCTA) has extensively enhanced our comprehension of eye microcirculation and of its associated diseases. In this narrative review, we explored the key concepts behind OCTA, as well as the most recent evidence in the pathophysiology of age-related macular degeneration (AMD) made possible by OCTA. These recommendations were updated since the publication in 2020, and are targeted for 2023. Importantly, as a future perspective in OCTA technology, we will discuss how artificial intelligence has been applied to OCTA, with a particular emphasis on its application to AMD study.

Polypoidal Choroidal Vasculopathy: Evaluation Based on 3-Dimensional Reconstruction of OCT Angiography

OBJECTIVE

Three-dimensional (3D) reconstruction using swept-source OCT angiography (SS-OCTA) can provide insights into the nature and structure of polypoidal choroidal vasculopathy (PCV) and its component parts, the polypoidal lesion (PL) and the branching neovascular network (BNN). This study aims to describe novel observations of PCV using 3D reconstruction of SS-OCTA, and to compare these observations with similar images of type I macular neovascularization (MNV) typical neovascular age-related macular degeneration (nAMD).

DESIGN

Clinical case series.

SUBJECTS

Patients with PCV in either eye from clinical studies conducted in a tertiary retina center.

METHODS

Images with prespecified SS-OCTA imaging protocol were obtained and reconstructed in 3D. Forty neovascularization lesions (30 PCV and 10 typical nAMD) based on SS-OCTA were analyzed.

MAIN OUTCOME MEASURES

The following 3 specific features were evaluated: (1) the pattern of flow signal within the PLs as either homogenous or showing internal vascular architecture; (2) the configuration of the BNN as hypermature, mature, or immature; and (3) the spatial arrangement of the PLs in relation to the BNN. Comparisons were made between PCV and typical nAMD.

RESULTS

All PLs exhibited internal vascular architecture in the form of coil-like loops and none exhibited homogenous flow. Small focal nodules were present within this internal vascular architecture in 70% of PLs. Branching neovascular networks exhibited a hypermature/mature configuration (100 vs. 50%, P < 0.01) and were associated with thicker choroid compared with typical nAMD type 1 MNV (238.7 ± 104.3 vs. 155.6 ± 49.2, P = 0.02). The BNN and PL were located at distinct anteroposterior planes in 81% of the eyes.

CONCLUSIONS

We identified proliferating vasculature in both the PL and the BNN. Comparison of the configuration suggests that the BNN represents a more chronic and inactive lesion than the PL.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Lesion area progression in eyes with neovascular age-related macular degeneration treated using a proactive or a reactive regimen

BACKGROUND

To compare the change in lesion area over 4 years of follow-up in eyes with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents using either a proactive or a reactive regimen in routine clinical practice.

METHODS

This was a multicentre, retrospective comparative study. Totally, 202 treatment-naïve nAMD eyes (183 patients) received anti-VEGF therapy according to a proactive (n = 105) or reactive (n = 97) regimen. Eyes were included if they had received anti-VEGF injections for a period of at least 4 years and had baseline fluorescein angiography and annual optical coherence tomography (OCT) imaging. Two masked graders independently delineated the lesion's margins from serial OCT images and growth rates were calculated.

RESULTS

At baseline, the mean [SD] lesion area was 7.24 [5.6] mm2 in the proactive group and 6.33 [4.8] mm2 in the reactive group respectively (p = 0.22). After four years of treatment, the mean [SD] lesion area in the proactive group was 5.16 [4.5] mm2 showing a significant reduction compared to the baseline (p < 0.001). By contrast, the mean [SD] lesion area kept expanding in the reactive group during the follow-up and was 9.24 [6.0] mm2 at four years (p < 0.001). The lesion area at 4 years was significantly influenced by treatment regimen, baseline lesion area, and proportion of visits with active lesions.

CONCLUSIONS

Eyes treated using a reactive strategy had an increased lesion area and worse visual outcomes at 4 years. By contrast, the proactive regimen was associated with fewer recurrences of active disease, shrinkage of the lesion area, and better vision at four years.

PREDICTIVE ROLES OF QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES IN PROGNOSIS OF MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To explore the predictive roles of the morphologic features of neovascularization in the prognosis of myopic choroidal neovascularization.

METHODS

In this retrospective case series study, quantitative morphologic features of neovascularization were obtained from the optical coherence tomography angiography images. According to the number of anti-vascular endothelial growth factor injections administered within 1 year, the eyes were classified into a stable group (≤2 injections) or an unstable group (>2 injections). Best-corrected visual acuity was recorded before the treatment and at the 1-year follow-up.

RESULTS

Overall, 50 eyes with treatment-naive myopic choroidal neovascularization were included; 26 in the stable group and 24 in the unstable group. Multivariate analysis showed that the eyes in the unstable group were associated with a larger lesion area (odds ratio = 2.596, P = 0.012), higher junction density (odds ratio = 1.611, P = 0.014), and higher end point density (odds ratio = 1.435, P = 0.023).The area under the receiver operating characteristic curve of the multivariate model was 0.865, with 91.7% sensitivity and 65.4% specificity. The final best-corrected visual acuity was significantly correlated with the lesion area (β = 0.152, P = 0.032) after adjusted for age, sex, and baseline best-corrected visual acuity.

CONCLUSION

Lesions with larger areas and higher end point and junction densities tended to have more frequent anti-vascular endothelial growth factor injections and worse visual outcomes in eyes with myopic choroidal neovascularization.

Fibrosis in neovascular age-related macular degeneration: A review of definitions based on clinical imaging

Despite the success of antiangiogenic therapy in controlling exudation in neovascular age-related macular degeneration (nAMD), the involvement of the outer retina in fibrosis results in gradual vision loss over time. The development of drugs that prevent or ameliorate fibrosis in nAMD requires that it is accurately detected and quantified with reliable endpoints and identification of robust biomarkers. Achievement of such an aim is currently challenging due to the lack of a consensus definition of fibrosis in nAMD. As a first step towards the establishment of a clear definition of fibrosis, we provide an extensive overview of the imaging modalities and criteria used to characterize fibrosis in nAMD. We observed variety in the selection of individual and combinations of imaging modalities, and criteria for detection. We also observed heterogeneity in classification systems and severity scales for fibrosis. The most commonly used imaging modalities were color fundus photography, fluorescein angiography and optical coherence tomography (OCT). A multimodal approach was frequently utilized. Our review suggests that OCT offers a more detailed, objective and sensitive characterization than color fundus photography/fluorescein angiography. Thus, we recommend it as a primary modality for fibrosis evaluation. This review provides a basis for future discussions to reach a consensus definition using standardized terms based on a detailed characterization of fibrosis, its presence and evolution, and taking into consideration impact on visual function. Achieving this goal is of paramount importance for the development of antifibrotic therapies.

Growth of nonexudative macular neovascularization in age-related macular degeneration: an indicator of biological lesion activity

PURPOSE

To investigate the growth of nonexudative macular neovascularization (MNV) in age-related macular degeneration (AMD) using swept-source optical coherence tomography angiography (SS-OCTA).

METHODS

Patients with treatment-naïve nonexudative AMD in one eye and exudative AMD in the fellow eye who underwent SS-OCTA imaging for at least 12 months were retrospectively reviewed. The MNV area measurement was quantified in eyes with treatment-naïve nonexudative MNV using ImageJ for analysing the correlation between MNV growth and the onset of exudation, as well as evaluating the consistency of the MNV growth rate during the subclinical and exudative stages. Kaplan-Meier survival analysis and logistic regression analyses were used.

RESULTS

In total, 45 eyes with treatment-naïve nonexudative AMD from 45 patients were enrolled. Treatment-naïve nonexudative MNV was identified in 21 eyes (46.67%) at baseline. The development of exudative findings was noted in eight eyes (17.78%), including six eyes with previously noted nonexudative MNV. Eyes with growing MNV (increase in area ≥50% within 12 months) had an increased risk of exudation and developed exudation earlier than eyes with stable MNV (13.60 [6.43-20.77] months versus 31.11 [26.61-35.62] months, P < 0.0001, Log-rank test). Consistent growth pattern of MNV lesions was further identified in eyes with growing MNV during anti-VEGF treatment.

CONCLUSION

SS-OCTA allows to qualitatively and quantitatively evaluate nonexudative MNV in AMD patients. Growing MNV involved higher probabilities and a faster onset of exudation compared to stable MNV. Identifying the growth of MNV on OCTA might be helpful for establishing treatment strategies and follow-up planning.

Quantitative assessment of choriocapillaris flow deficits and type 1 macular neovascularization growth in age-related macular degeneration

During the past 15 years, new treatment paradigms for neovascular age-related macular degeneration (nvAMD) have evolved due to the advent of intravitreal anti-vascular endothelial growth factor (VEGF) therapy and rapid advances in retinal imaging. Recent publications describe eyes with type 1 macular neovascularization (MNV) as showing more resistance to macular atrophy than eyes with other lesion types. We sought to explore whether the perfusion status of the native choriocapillaris (CC) surrounding type 1 MNV influences its pattern of growth. To evaluate this effect, we analyzed a case series of 22 eyes from 19 nvAMD patients with type 1 MNV exhibiting growth on swept-source optical coherence tomography angiography (SS-OCTA) over a minimum follow-up of 12 months. We observed an overall weak correlation between type 1 MNV growth and CC flow deficits (FDs) average size (τ = 0.17, 95% CI [- 0.20, 0.62]) and a moderate correlation with CC FD % (τ = 0.21, 95% CI [- 0.16, 0.68]). Type 1 MNV was located beneath the fovea in most of the eyes (86%) and median visual acuity was 20/35 Snellen equivalent. Our results support that type 1 MNV recapitulates areas of CC blood flow impairment while serving to preserve foveal function.

Clinical Use of Optical Coherence Tomography Angiography in Retinal Diseases

The advent of optical coherence tomography angiography (OCTA) is one of the cornerstones of fundus imaging. Essentially, its mechanism depends on the visualization of blood vessels by using the flow of erythrocytes as an intrinsic contrast agent. Although it has only recently come into clinical use, OCTA has become a non-invasive diagnostic tool for the diagnosis and follow-up of many retinal diseases, and the integration of OCTA in multimodal imaging has provided a better understanding of many retinal disorders. Here, we provide a detailed overview of the current applications of OCTA technology in the diagnosis and follow-up of various retinal disorders.

QUANTIFIED ANASTOMOTIC AREAS OF NEOVASCULARIZATION AS FACTORS ASSOCIATED WITH FREQUENT RECURRENCE IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

PURPOSE

To investigate the quantitative characteristics of anastomoses of macular neovascularization (MNV) in neovascular age-related macular degeneration using optical coherence tomography angiography according to the frequency of intravitreal injections.

METHODS

Eighty-six eyes of 86 patients treated for neovascular age-related macular degeneration were classified into two groups based on the number of intravitreal injections administered over 12 months: stable (<3) and unstable (≥3). Anastomotic areas were defined as areas surrounded by neighboring vessels in the MNV; their total number, mean area, maximal and minimal diameters (i.e., maximal and minimum Feret diameters), and ratio (Feret aspect ratio) were analyzed in the inner and outer areas of the MNV.

RESULTS

Forty-four and 42 eyes were classified into the stable and unstable groups, respectively. The eyes in the unstable group had larger anastomotic areas with longer minimum Feret diameters and longer perimeters in the outer MNV. In the logistic regression analysis, instability was associated with a larger anastomotic area and a longer minimum Feret diameter in the outer MNV. Multivariate analysis revealed that a longer minimum Feret diameter in the outer MNV was the most significant factor ( P = 0.03).

CONCLUSION

The quantitative characteristics of the anastomotic areas in the MNV might indicate the need for intravitreal injections in patients with neovascular age-related macular degeneration.

LONG-TERM MORPHOLOGIC CHANGES IN MACULAR NEOVASCULARIZATION UNDER AFLIBERCEPT TREATMENT WITH A TREAT-AND-EXTEND REGIMEN

PURPOSE

To examine the morphologic changes in macular neovascularization (MNV) secondary to age-related macular degeneration after 2 years of aflibercept treatment under a treat-and-extend (T&E) regimen.

METHODS

This retrospective study analyzed the medical records for 26 eyes of 25 patients diagnosed with treatment-naive neovascular age-related macular degeneration and treated with aflibercept under a treat-and-extend regimen for 2 years. The areas of the MNV and vascular structures were assessed using swept-source optical coherence tomography angiography at baseline and after 2 years of treatment.

RESULTS

The mean MNV area increased significantly from 0.65 ± 0.42 mm 2 at baseline to 0.78 ± 0.45 mm 2 at 2 years. At 2 years, the mean change in the MNV area from baseline was 22% (interquartile range: 4%-60%). The baseline MNV area was negatively correlated with the change ratio of the MNV areas at 2 years and baseline ( R = -0.68, P < 0.001). Nine of the 26 eyes (34.6%) showed newly formed mature vessels, and 7 eyes (26.9%) showed prominently developing preexisting mature vessels.

CONCLUSION

Macular neovascularization expanded and showed vascular maturation under aflibercept treatment with a treat-and-extend regimen. The smaller the MNV at baseline, the greater is its expansion in 2 years.

Practical guidance for imaging biomarkers in exudative age-related macular degeneration

We provide an overview of current macular imaging techniques and identify and describe biomarkers that may be of use in the routine management of macular diseases, particularly exudative age-related macular degeneration (n-AMD). This perspective includes sections on macular imaging techniques including optical coherence tomography (OCT) and OCT angiography (OCTA), classification of exudative AMD, and biomarkers in structural OCT and OCTA. Fluorescein angiography remains a vital tool for assessing the activity of neovascular lesion, while indocyanine green angiography is the preferred option for choroidal vessels imaging in neovascular AMD. OCT provides a non-invasive three-dimensional visualization of retinal architecture in vivo and is useful in the diagnosis of many imaging biomarkers of AMD-related neovascular lesions including lesion activity. OCTA is a recent advance in OCT technology that allows accurate visualization of retinal and choroidal vascular flow. OCT and OCTA have led to an updated classification of exudative AMD lesions and provide several biomarkers that help to establish a diagnosis and the disease activity status of neovascular lesions. Individualization of therapy guided by OCT and OCTA biomarkers has the potential to further improve visual outcomes in exudative AMD. Moving forwards, integration of technologically advanced imaging equipment with AI software will help ophthalmologists to provide patients with the best possible care.

Biomarkers of macular neovascularisation activity using optical coherence tomography angiography in treated stable neovascular age related macular degeneration

BACKGROUND

The aim of this study was to describe features of disease activity in patients with treated stable macular neovascularisation (MNV) in neovascular age related macular degeneration (nAMD) using optical coherence tomography angiography (OCTA).

METHODS

Thirty-two eyes of 32 patients with nAMD were included in this prospective, observational study. These patients were undergoing treatment with aflibercept on a treat-and-extend regimen attending an extension to a 12-week treatment interval.

RESULTS

All subjects had no macular haemorrhage and no structural OCT markers of active MNV activity at the index 12-week treatment extension visit. 31/32 OCTA images were gradeable without significant imaging artefact. The mean MNV size was 3.6mm² ± 4.6mm² and 27 (87.1%) had detectable MNV blood flow. 29/31 (93.5%) subjects had MNV with mature phenotypes including 10 non-specific, 10 tangle and 3 deadtree phenotypes. MNV halo and MNV central feeder vessel were noted in 18 (58.1%) and 19 (61.3%) of subjects respectively; only 1 (3.2%) subject was noted to have a MNV capillary fringe.

CONCLUSIONS

MNV blood flow is still detectable using OCTA in the majority of subjects in this study with treated stable MNV. OCTA features associated included MNV mature phenotype, MNV feeder vessel, MNV halo and absence of capillary fringe.

Nascent Geographic Atrophy as a Predictor of Type 3 Macular Neovascularization Development

PURPOSE

To investigate the association of nascent geographic atrophy (GA) preceding the development of exudative type 3 macular neovascularization (MNV) in patients with age-related macular degeneration (AMD).

DESIGN

Retrospective longitudinal study.

PARTICIPANTS

Patients with AMD diagnosed with treatment-naive exudative type 3 MNV in 1 or both eyes were evaluated. Inclusion criteria included serial tracked structural OCT examinations for ≥ 2 years before the detection of exudative type 3 MNV.

METHODS

Clinical characteristics and retinal imaging, including structural OCT at baseline and at each follow-up examination, were analyzed. Eyes showing the presence of nascent GA during the follow-up were selected for analysis of prevalence, and clinical characteristics at the site of subsequent type 3 MNV development.

MAIN OUTCOME MEASURES

Description of the prevalence and clinical characteristics of nascent GA at the site of subsequent type 3 MNV development.

RESULTS

Overall, 97 eyes affected by type 3 MNV meeting inclusion criteria were analyzed. Of 97 eyes (71 patients), 22 eyes of 21 patients (mean age 82 ± 9 years) showed nascent GA preceding exudative type 3 MNV. The observed prevalence of nascent GA preceding exudative type 3 MNV was 22.7% (95% confidence interval, 14.4%-31.0%). Exudative type 3 MNV developed a mean of 9 ± 6 months after detection of nascent GA. The presence of reticular pseudodrusen in the study eye did not significantly influence the timing of exudative type 3 MNV development after the observation of nascent GA (P > 0.1 in all analyses). Reduced best-corrected visual acuity was recorded at the exudative type 3 stage in comparison with the nascent GA stage (P = 0.003).

CONCLUSIONS

As nascent GA may precede the development of exudative type 3 MNV, the detection of nascent GA in eyes with AMD may warrant closer surveillance to identify early exudative type 3 MNV warranting treatment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Optical coherence tomography angiography for the detection of macular neovascularization-comparison of en face versus cross-sectional view

PURPOSE

To evaluate sensitivity and specificity of swept source-optical coherence tomography angiography (SS-OCTA) en face images versus cross-sectional OCTA versus a combination of both for the detection of macular neovascularization (MNV).

DESIGN

Prospective cohort study.

PARTICIPANTS

Consecutive patients with various chorioretinal diseases and subretinal hyperreflective material (SHRM) and/or pigment epithelial detachment (PED) on OCT possibly corresponding to MNV in at least one eye.

METHODS

102 eyes of 63 patients with fluorescein angiography (FA), OCT and SS-OCTA performed on the same day were included. FA images, the outer retina to choriocapillaris (ORCC) OCTA en face slab, a manually modified en face slab ('custom slab'), cross-sectional OCTA and a combination of OCTA en face and cross-section were evaluated for presence of MNV.

MAIN OUTCOME MEASURES

Sensitivity and specificity for MNV detection, as well as the concordance was calculated using FA as the reference.

RESULTS

OCTA en face imaging alone yielded a sensitivity of 46.3% (automated)/78.1% (custom) and specificity of 93.4% (automated)/88.5% (custom) for MNV detection. Cross-sectional OCTA (combination with en face) resulted in a sensitivity of 85.4% (82.9%) and specificity of 82.0% (85.3%). Concordance to FA was moderate for automated en face OCTA (κ = 0.43), and substantial for custom en face OCTA (κ = 0.67), cross-sectional OCTA (κ = 0.66) and the combination (κ = 0.68).

CONCLUSION

Segmentation errors result in decreased sensitivity for MNV detection on automatically generated OCTA en face images. Cross-sectional OCTA allows detection of MNV without manual modification of segmentation lines and should be used for evaluation of MNV on OCTA.

Switching to brolucizumab from aflibercept in age-related macular degeneration with type 1 macular neovascularization and polypoidal choroidal vasculopathy: an 18-month follow-up study

PURPOSE

To assess the effect of switching to brolucizumab from aflibercept on eyes with type 1 macular neovascularization (MNV) and polypoidal choroidal vasculopathy (PCV) at 18 months.

METHODS

This study was a retrospective, observational case series that included 19 eyes of 19 patients with type 1MNV and 23 eyes of 22 patients with PCV. We compared the injection intervals, visual acuity, total lesion size, and the number of polypoidal lesions between baseline and 18 months. The correlations between the data including treatment interval, total lesion size, and the number of polyps were also assessed.

RESULTS

Treatment intervals were significantly extended; from 7.4 ± 1.4 weeks to 11.6 ± 2.6 weeks for type 1 MNV, p < 0.001; from 6.9 ± 1.3 to 11.7 ± 3.1 weeks for PCV, p < 0.001. In type 1 MNV eyes, strong correlation was found between total lesion size and brolucizumab injection intervals (r =  - 0.81; p = 0.0002) and moderate correlation was found between treatment frequency with aflibercept and that with brolucizumab (r = 0.76; p = 0.040). In PCV eyes, we found strong correlation between the number of polyps and brolucizumab treatment frequency (r =  - 0.81; p = 0.0016) and moderate correlation between total lesion size and brolucizumab treatment interval (r =  - 0.48; p = 0.034). Intraocular inflammation occurred in 2 of 19 eyes (10.3%) with type 1 MNV and 5 of 23 eyes (21.7%) with PCV.

CONCLUSION

The properties to extend brolucizumab injection intervals might be the smaller lesion size and lower aflibercept frequency for type 1 MNV and the smaller number of polyps and the smaller size of lesion for PCV.

Optical coherence tomography angiography patterns of type 1 macular neovascularization in age-related macular degeneration patients

PURPOSE

To compare morphologic characteristics of type 1 macular neovascularization (MNV) flow pattern in treatment-naïve and previously treated patients with age-related macular degeneration (AMD) as assessed by optical coherence tomography angiography (OCTA).

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

Macular OCT angiography images were acquired using RTVue XR Avanti with AngioVue. Distinct morphologic biomarkers and quantifiable features of the neovascular membranes were studied on en-face projection images comparing treatment-naïve and previously treated patients.

RESULTS

The study included 68 eyes of 58 patients. Among them, 24 eyes were treatment-naïve, and the remaining eyes had received a mean of 19.6 injections. Immature lesions were more associated with treatment-naïve eyes and hyper-mature lesions were associated with previously treated eyes (p = 0.005). Tangle pattern was associated with treatment-naïve eyes (p = 0.013), whereas mature core vessels and sea fan pattern were associated more with previously treated eyes (p = 0.001 and p = 0.044, respectively). Vascular density of the neovascular membrane was higher in the treatment-naïve group (p = 0.036) and the average MNV area was similar between the 2 groups (p = 0.683).

CONCLUSIONS

Based on OCTA, morphologic biomarkers of type 1 MNV might be an indication of previous treatment. The MNV pattern can improve our understanding of its maturation under anti-VEGF treatment and might be valuable to better guide therapeutic decisions and provide more personalized care to patients with AMD.

Quantitative approaches in multimodal fundus imaging: State of the art and future perspectives

When it first appeared, multimodal fundus imaging revolutionized the diagnostic workup and provided extremely useful new insights into the pathogenesis of fundus diseases. The recent addition of quantitative approaches has further expanded the amount of information that can be obtained. In spite of the growing interest in advanced quantitative metrics, the scientific community has not reached a stable consensus on repeatable, standardized quantitative techniques to process and analyze the images. Furthermore, imaging artifacts may considerably affect the processing and interpretation of quantitative data, potentially affecting their reliability. The aim of this survey is to provide a comprehensive summary of the main multimodal imaging techniques, covering their limitations as well as their strengths. We also offer a thorough analysis of current quantitative imaging metrics, looking into their technical features, limitations, and interpretation. In addition, we describe the main imaging artifacts and their potential impact on imaging quality and reliability. The prospect of increasing reliance on artificial intelligence-based analyses suggests there is a need to develop more sophisticated quantitative metrics and to improve imaging technologies, incorporating clear, standardized, post-processing procedures. These measures are becoming urgent if these analyses are to cross the threshold from a research context to real-life clinical practice.

Towards a better understanding of non-exudative choroidal and macular neovascularization

Non-exudative macular and choroidal neovascularization (MNV and CNV) usually refers to the entity of treatment-naïve type 1 neovascularization in the absence of associated signs of exudation. Histopathological studies, dating back in the early 70s, identified the presence of non-exudative MNV, but the first clinical report of this finding was in the late 90s using indocyanine green angiography in eyes with age-related macular degeneration (AMD). With more advanced retinal imaging, there has been an ever increasing appreciation of non-exudative MNV associated with AMD and CNV with other macular disorders. However, consensus regarding the exact definition and the clinical management of this entity is lacking. Furthermore, there may be variation in the imaging features and clinical course suggesting that a spectrum of disease may exist. Herein, we review the large body of published work that has provided a better understanding of non-exudative MNV and CNV in the last decade. The prevalence, multimodal imaging features, clinical course, and response to treatment are discussed to elucidate further key insights about this entity. Based on these observations, this review also proposes a new theory about the origin and course of different sub-types of non-exudative MNV/CNV which can have different etiologies and pathways according to the clinical context of disease.

Detection of pachychoroid neovasculopathy with optical coherence tomography angiography versus dye angiography imaging

BACKGROUND

To investigate the sensitivity and specificity of optical coherence tomography angiography (OCTA) versus dye angiography for detecting pachychoroid neovasculopathy (PNV) and to determine the morphological factors that affect PNV detection.

METHODS

Patients with pachychoroid phenotype were prospectively enrolled and underwent multimodal imaging examinations during the same visit. The diagnostic accuracy of fundus fluorescein angiography (FFA), FFA combined with indocyanine green angiography (ICGA) and OCTA for PNV was evaluated using multimodal imaging as the reference. Multimodal parameters of PNV were qualitatively and quantitatively assessed.

RESULTS

PNV was detected in 58 eyes (46 patients) out of 340 pachychoroid eyes (201 patients) according to reference standard. Patients with PNV eyes were significantly older (54.6±7.56 vs. 48.2±9.1 years), were more likely to have a chronic central serous chorioretinopathy history (CSC) (93.1% vs. 12.4%) and had a worse visual acuity (0.30±0.22 vs. 0.58±0.30) than those without PNV eyes (all P<0.001). The sensitivity of FFA, FFA combined with ICGA, and OCTA in detecting PNV in patients with the pachychoroid phenotype was 67.2%, 63.8% and 98.3%, respectively, and the specificity was 87.2%, 96.8% and 100.0%, respectively. PNV not identified by dye angiography was more manifested as the absence of late plaque hypercyanescence on ICGA (P<0.001) and overall smaller capillaries without a distinct pattern (P=0.001), fewer core vessels (P=0.002) and smaller area (P=0.044).

CONCLUSIONS

OCTA showed superior detection rate and accuracy for identifying PNV over dye angiography. In case multimodal imaging is unavailable, OCTA can be an effective and noninvasive method for monitoring PNV and guiding treatment decisions.

Prediction of the short-term efficacy of anti-VEGF therapy for neovascular age-related macular degeneration using optical coherence tomography angiography

Background

To evaluate whether the specific choroidal neovascularization (CNV) characteristics measured using optical coherence tomography angiography (OCTA) can predict the 6-month prognosis of neovascular age-related macular degeneration (nAMD) after anti-vascular endothelial growth factor (anti-VEGF) therapy.

Methods

Patients with type 1, type 2, or mixed-type neovascularization (NV) were prospectively included. Participants underwent an initial loading phase of three consecutive monthly intravitreal injections of Conbercept (0.5 mg) and were switched to a pro re nata (PRN) treatment strategy. OCTA images were evaluated for eyes that underwent follow-up assessments for more than 6 months. CNV lesions were manually segmented, and the CNV area, vessel area, greatest vascular caliber (GVC), and greatest linear dimension (GLD) were compared between responders and non-responders. Two masked graders independently measured the above-mentioned parameters using OCTA, and consistency was assessed using the intraclass correlation coefficient (ICC) values. Multiple logistic regression analysis was performed to evaluate the effect of a 3-month change in the CNV area, GLD, and GVC on the 6-month response to anti-VEGF agents.

Results

Among the 60 eyes of 60 patients with nAMD, 39 were responders and 21 were non-responders. The proportion of CNV types was significantly different between responders and non-responders (P = 0.009). Patients with type 2 or mixed NV seemed more likely to respond to the treatment (28.2% vs. 0.0%, and 30.8% vs. 23.8%, respectively). The change in GVC showed a significant difference between responders (− 4.98 ± 17.17 μm) and non-responders (11.01 ± 14.10 μm) after three monthly intravitreal anti-VEGF injections. Multiple logistic regression analysis showed that only the change in GVC remained significant after controlling for baseline GVC, injection number, and CNV type (adjusted OR = 1.083; P = 0.008).

Conclusions

Type 2 and mixed-type NV were significantly associated with a better response to anti-VEGF therapy. Changes in GVC after 3 months of treatment were significantly associated with a response to anti-VEGF therapy at 6 months.

OCT angiography biomarkers in type 1 choroidal neovascularisation after one year of aflibercept treatment

OBJECTIVE

To assess the activity of biomarkers, through OCT angiography (OCTA), of choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD) treated with aflibercept. As secondary endpoints, visual acuity (VA) and the relationship between biomarkers and visual prognosis were also studied.

MATERIAL AND METHODS

Prospective study that examined 33 eyes of 40 naïve patients with type 1 CNV secondary to AMD, who had been treated with aflibercept, according to summary of product characteristics, for one year. The patients were evaluated at the time of diagnosis, and at 4, 8 and 12 months.

RESULTS

The mean VA gain at 12 months was 15.2 ± 3.3 letters. The area of lesion decreased 1.2 ± 1.0 mm2 in the 4th month (P < .0001), remaining stable afterwards. The presence of tiny capillaries, anastomosis and perilesional hypointense halo was reduced by 85%, 70% and 25%, respectively, at 12 months of follow-up. The peripheral vascular arcade changed morphology, from having a leafy appearance to having a sharp appearance in 90% of cases. The size of the lesion and the presence/absence of perilesional hypointense halo were independently associated with the final VA, in such a way that larger lesions and the absence of a perilesional hypointense halo at the baseline visit were associated with less VA gain.

CONCLUSIONS

The OCTA is a useful, non-invasive tool that provides quantitative and qualitative information on the remodelling of the CNV vascular network after antiangiogenic therapy.

Morphology of en face Haller vessel and macular neovascularization at baseline and 3 months as predictive factors in age-related macular degeneration

The clinical implication of en face imaging of Haller vessels and macular neovascularization (MNV) in neovascular age-related macular degeneration (nAMD) is not well established. The purpose of this study is to investigate whether the early-phase morphology of en face Haller vessel and MNV is related to the injection frequency and visual outcome in treatment-naïve nAMD. En face images of Haller vessel and MNV were acquired from 52 eyes at baseline, after three loading doses and at 12 months later using optical coherence tomography (OCT) and OCT angiography. Vessel area, diameter, length, intersection number, fractal dimension, and lacunarity were calculated. Patients were classified according to the injection frequency (< 5 as the infrequent group) and visual gain (≥ 0.3 logMAR) over 12 months. The infrequent group was associated with a longer Haller vessel length after loading doses (OR 3.05, P = 0.01), while visual gain was associated with a smaller maximal MNV diameter after loading doses (OR 0.22, P = 0.03). A predictive model for frequent injection based on the Haller vessel length demonstrated an AUC of 0.71. In conclusion, the en face Haller vessel and MNV morphology after loading doses can be used as biomarkers for the injection frequency and visual gain during the first year in treatment-naïve nAMD patients.

ASSOCIATION OF FLOW SIGNALS WITHIN POLYPS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY WITH TREATMENT RESPONSES AFTER COMBINATION THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To evaluate the changes of blood circulation within the polypoidal lesions by OCT angiography in eyes with polypoidal choroidal vasculopathy after combination therapy with aflibercept and photodynamic therapy.

METHODS

A total of 46 eyes from 46 patients who underwent the combination therapy for polypoidal choroidal vasculopathy were followed for more than 6 months. OCT angiography, covering an area 6 mm2 × 6 mm2 including the macula, were performed at baseline, 2 weeks, and 3 months and 6 months post-treatment.

RESULTS

The subretinal fluid resolved within 3 months after treatment in 44 eyes (95.7%), and 27 eyes (58.7%) showed no recurrence, with no additional treatment. Seventeen eyes (37.0%) showed recurrence, and two eyes (4.3%) showed poor response. On OCT angiography at 2 weeks after treatment, flow signals were detected in 3 of 27 eyes (11.1%) without recurrence and in 8 of 19 eyes (42.1%) with recurrence or poor responses. A detectable flow signal at 2 weeks was significantly associated with recurrence or poor response (P = 0.032).

CONCLUSION

Persistent flow signals within polyps on OCT angiography at 2 weeks after combination therapy suggest less effectiveness of the initial treatment.

Quantitative OCT angiography findings according to pattern classification of type 1 neovascularization exudative age-related macular degeneration

OBJECTIVES

To define neovascularization (NV) patterns and their association with exudative activity in type 1 neovascular age-related macular degeneration (NVAMD).

METHODS

In optical coherence tomography angiography (OCTA) images of type 1 NVAMD, we stratified NV patterns according to whether they contained core vessel (C+/C-) and fine branching vessels (F+/F-) or not into C - F +, C + F +, and C + F - groups. Qualitative analyses assessing the status of peripheral tiny branching, inner branching capillaries, arcade, loop, and perilesional halo and quantitative analyses considering the NV area, length, density, and numbers of junctions and endpoints (open-ended vessels) in NV were conducted according to NV patterns and the presence of exudation on structural OCT.

RESULTS

Among 96 eyes, exudation was found in the C - F + (33.3%) and C + F + (47.6%) groups, related to peripheral tiny branching in both groups (p = 0.022 and p < 0.001) and perilesional halo in the C + F + group (p < 0.001). Peripheral arcades, inner branching capillaries, and loops were observed in more than half (68.3%, 58.7%, and 69.8%) in the C + F + group but not related with exudative activity in the C + F + group. In quantitative analysis, the number of endpoints was associated with exudation in univariate and multivariate analyses (p = 0.011 and p = 0.016) in C + F + group.

CONCLUSIONS

After pattern classification, type 1 NV patterns with fine branching vessels were considered to have exudative activity compared to NV without fine branching. The quantitative analysis of type 1 NV according to patterns showed the presence of peripheral tiny branching vessels was associated with NV activity.

Baseline predictors for subretinal fibrosis in neovascular age-related macular degeneration

To find baseline predictors for subretinal fibrosis (SF) in neovascular age-related macular degeneration (nAMD). Forty-five eyes of 45 participants with treatment-naïve nAMD were consecutively enrolled and treated according to a standardized treat-and-extend protocol. Spectral-domain optical coherence tomography (OCT), color fundus photography and fluorescein angiography as well as novel imaging modalities polarization-sensitive OCT and OCT angiography (OCTA) were performed to detect SF after 1 year and find baseline predictors for SF development. Baseline OCTA scans were evaluated for quantitative features such as lesion area, vessel area, vessel junctions, vessel length, vessel endpoints and mean lacunarity. Additionally, the type of macular neovascularization, the presence of subretinal fluid, intraretinal fluid (IRF), subretinal hyperreflective material (SHRM), retinal hemorrhage as well as best-corrected visual acuity (BCVA) were evaluated. After 12 months 8 eyes (18%) developed SF. Eyes with SF had worse baseline BCVA (p = .001) and a higher prevalence of IRF (p = .014) and SHRM at baseline (p = .017). There was no significant difference in any of the evaluated quantitative OCTA parameters (p > .05) between eyes with and without SF. There were no quantitative baseline microvascular predictors for SF in our study. Low baseline BCVA, the presence of IRF and SHRM, however, are easily identifiable baseline parameters indicating increased risk.

Synthetic anti-angiogenic genomic therapeutics for treatment of neovascular age-related macular degeneration

In light of the intriguing potential of anti-angiogenic approach in suppressing choroidal neovascularization, we attempted to elaborate synthetic gene delivery systems encapsulating anti-angiogenic plasmid DNA as alternatives of clinical antibody-based therapeutics. Herein, block copolymer of cyclic Arg-Gly-Asp-poly(ethylene glycol)-poly(lysine-thiol) [RGD-PEG-PLys(thiol)] with multifunctional components was tailored in manufacture of core-shell DNA delivery nanoparticulates. Note that the polycationic PLys segments were electrostatically complexed with anionic plasmid DNA into nanoscaled core, and the tethered biocompatible PEG segments presented as the spatial shell (minimizing non-specific reactions in biological milieu). Furthermore, the aforementioned self-assembly was introduced with redox-responsive disulfide crosslinking due to the thiol coupling. Hence, reversible stabilities, namely stable in extracellular milieu but susceptible to disassemble for liberation of the DNA payloads in intracellular reducing microenvironment, were verified to facilitate transcellular gene transportation. In addition, RGD was installed onto the surface of the proposed self-assemblies with aim of targeted accumulation and internalization into angiogenic endothelial cells given that RGD receptors were specifically overexpressed on their cytomembrane surface. The proposed anti-angiogenic DNA therapeutics were validated to exert efficient expression of anti-angiogenic proteins in endothelial cells and elicit potent inhibition of ocular neovasculature post intravitreous administration. Hence, the present study approved the potential of gene therapy in treatment of choroidal neovascularization. In light of sustainable gene expression properties of DNA therapeutics, our proposed synthetic gene delivery system inspired prosperous potentials in long-term treatment of choroidal neovascularization, which should be emphasized to develop further towards clinical translations.

Nonexudative morphologic changes of neovascularization on optical coherence tomography angiography as predictive factors for exudative recurrence in age-related macular degeneration

PURPOSE

To evaluate morphologic changes of choroidal neovascularization (CNV) on optical coherence tomography angiography (OCTA) during the nonexudative period and to correlate the features and timing of recurrence in neovascular age-related macular degeneration. (AMD).

METHODS

Two hundred thirty-eight eyes with type 1 CNV were retrospectively reviewed. For cases with exudative recurrence, OCTA images were tracked for analysis between the recurrences. Qualitative parameters of morphologic changes of CNV on OCTA, including tiny branching vessels, anastomotic loops, peripheral vascular arcade, and perilesional halo, were correlated with the features of exudative recurrence.

RESULTS

Exudative recurrence was identified in 163 cases, and among them, nonexudative morphological changes in CNV were identified using OCTA in 45 cases. For the cases with nonexudative changes on OCTA, exudative recurrence eventually developed within 0.5-3.5 months (mean, 2.3 ± 2.0 months) after identifying morphologic changes OCTA. The following changes in CNV were revealed on OCTA: tiny branching vessels in 53.3% (24/45) of cases, anastomotic loops in 40.0% (18/45), peripheral vascular arcades in 44.4% (20/45), and perilesional halo in 35.6% (16/45). Among the morphologic parameters, development of tiny branching vessels was significantly associated with early exudative recurrence (1.5 ± 1.2 months, p = 0.019), higher incidence of intraretinal fluid (IRF) (p = 0.016), and subretinal or subretinal pigment epithelial hemorrhage (p = 0.023) at recurrence, compared with other morphologic changes.

CONCLUSION

Development of tiny branching vessels of CNV on OCTA during the nonexudative period was associated with early exudative recurrence, including IRF or hemorrhage. Identifying the nonexudative changes of CNV on OCTA might predict exudative recurrence and provide additional parameters for monitoring neovascular AMD.

Choroidal Neovascularization and Haller Vessel Morphology Associated with Vision and Treatment Number after 1 year in Age-related Macular Degeneration

Purpose

The present study aimed to quantify various factors of vessel morphology, including vessel diameter, length, and complexity (fractal dimension and lacunarity) of both choroidal neovascularization (CNV) and en face Haller vessels using optical coherence tomography angiography (OCTA) and en face structural optical coherence tomography in typical neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) and to identify factors associated with visual acuity (VA) loss and number of injections within a year after the day of OCTA.

Methods

We retrospectively analyzed 43 eyes of nAMD patients and 33 eyes of PCV patients whose OCTA was performed at least 12 months after an initial anti-vascular endothelial growth factor treatment. Quantitative parameters, including vessel area, vessel diameter, vessel length, fractal dimension, and lacunarity were analyzed from en face images of CNV and Haller vessels. Clinical information, including logarithm of the minimum angle of resolution visual acuity and injection number of anti-vascular endothelial growth factor were acquired after 12 months from OCTA date. Using logistic regression analyses, parameters associated with logarithm of the minimum angle of resolution VA loss of 0.2 or more (VA loss group) and a number of injections of four or more (unstable group) after 12 months were analyzed.

Results

In typical nAMD, the VA loss group was associated with a smaller number of intersections of Haller vessels. The unstable group was associated with an increased lacunarity of CNV in typical nAMD. In PCV, both VA loss and unstable groups were associated with a higher maximal diameter of Haller vessels.

Conclusions

VA loss and injection number of nAMD and PCV 12 months after OCTA imaging were associated with different morphological parameters of CNV and Haller vessels. Therefore, quantitative analyses of both CNV and Haller vessels from OCTA and en face optical coherence tomography might provide prognostic information about visual outcome and injection frequency within 12 months after OCTA imaging.

ASSOCIATION OF TREATMENT RESPONSE WITH QUANTITATIVE CHANGES IN CHOROIDAL NEOVASCULARIZATION AND CHOROIDAL VESSEL IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the association between treatment response and quantitative morphological changes in choroidal neovascularization and outer choroidal vessels using optical coherence tomography angiography (OCTA) and en face OCT in neovascular age-related macular degeneration (nAMD).

METHODS

We retrospectively analyzed 75 eyes of typical nAMD patients and 53 polypoidal choroidal vasculopathy eyes of 124 patients with OCTA performed at least 6 months after initial antivascular endothelial growth factor treatment. Quantitative parameters, including vessel area, vessel diameter, branch vessel length, fractal dimension, and lacunarity were analyzed based on en face images of the choroidal neovascularization and choroidal vessel in Haller's layer. Parameters associated with loss of logarithm of the minimum angle of resolution visual acuity with the basis of 0.3 and the treatment interval (good vs. poor responder based on 12 weeks) were analyzed. Analyses were conducted for "before OCTA" (initial visit to OCTA) and "after OCTA" (OCTA to 6 months post-OCTA).

RESULTS

In typical nAMD, visual acuity loss before OCTA was associated with a higher SD of choroidal neovascularization diameter and lower choroidal fractal dimension. Visual acuity loss after OCTA in typical nAMD was associated with higher lacunarity of the choroid. Poor responders before OCTA were not associated with any factor. Poor responders after OCTA were associated with a lower SD of outer choroidal vessel diameter in typical nAMD. In polypoidal choroidal vasculopathy, no factor was associated with clinical outcomes in either period.

CONCLUSION

Quantitative analyses of choroidal neovascularization on OCTA and choroidal vessels on en face OCT provide information about treatment response, including changes in visual acuity and treatment interval, in nAMD.

QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY PARAMETER VARIATIONS AFTER TREATMENT OF MACULAR NEOVASCULARIZATION SECONDARY TO AGE-RELATED MACULAR DEGENERATION

PURPOSE

Macular neovascularization (MNV) secondary to age-related macular degeneration can be characterized by quantitative optical coherence tomography angiography. The aim of the study was to assess the evolution of quantitative optical coherence tomography angiography parameters after 1 year of antivascular endothelial growth factor injections.

METHODS

Naive age-related macular degeneration-related MNV eyes were prospectively recruited to analyze optical coherence tomography and optical coherence tomography angiography parameters, including MNV vessel tortuosity (VT) and reflectivity, at baseline and at the end of the follow-up. Macular neovascularization eyes were categorized by a MNV VT cutoff, and quantitative parameter variations were documented after 1 year of treatment. We divided MNV eyes into Group 1 (MNV VT < 8.40) and Group 2 (MNV VT > 8.40).

RESULTS

Thrity naive age-related macular degeneration-related MNV eyes (30 patients) were included. Our cohort included 18 Type 1 MNV and 12 Type 2 MNV lesions. Baseline central macular thickness (411 ± 85 µm) improved to 323 ± 54 µm at 1 year (P < 0.01). Only Group 1 MNV displayed significant visual improvement. Macular neovascularization VT values remained stable over the follow-up in both subgroups. Group 2 MNV eyes showed increased MNV reflectivity and increased MNV area at the end of the follow-up. Quantitative retinal capillary plexa parameters were found to be worse in Group 2 MNV. Outer retinal atrophy occurred in 2 of the 18 eyes in MNV Group 1 (11%) and in 6 of the 12 eyes in MNV Group 2 (50%) after 1 year. Vessel density proved to be always worse in Group 2 than in Group 1.

CONCLUSION

Macular neovascularization VT provides information on the blood flow and identifies two subgroups with different final anatomical and visual outcomes, regardless of the treatment effect.

AI-based monitoring of retinal fluid in disease activity and under therapy

Retinal fluid as the major biomarker in exudative macular disease is accurately visualized by high-resolution three-dimensional optical coherence tomography (OCT), which is used world-wide as a diagnostic gold standard largely replacing clinical examination. Artificial intelligence (AI) with its capability to objectively identify, localize and quantify fluid introduces fully automated tools into OCT imaging for personalized disease management. Deep learning performance has already proven superior to human experts, including physicians and certified readers, in terms of accuracy and speed. Reproducible measurement of retinal fluid relies on precise AI-based segmentation methods that assign a label to each OCT voxel denoting its fluid type such as intraretinal fluid (IRF) and subretinal fluid (SRF) or pigment epithelial detachment (PED) and its location within the central 1-, 3- and 6-mm macular area. Such reliable analysis is most relevant to reflect differences in pathophysiological mechanisms and impacts on retinal function, and the dynamics of fluid resolution during therapy with different regimens and substances. Yet, an in-depth understanding of the mode of action of supervised and unsupervised learning, the functionality of a convolutional neural net (CNN) and various network architectures is needed. Greater insight regarding adequate methods for performance, validation assessment, and device- and scanning-pattern-dependent variations is necessary to empower ophthalmologists to become qualified AI users. Fluid/function correlation can lead to a better definition of valid fluid variables relevant for optimal outcomes on an individual and a population level. AI-based fluid analysis opens the way for precision medicine in real-world practice of the leading retinal diseases of modern times.

Correlation of Retinal Thickness and Swept-Source Optical Coherence Tomography Angiography Derived Vascular Changes in Patients with Neovascular Age-Related Macular Degeneration

Purpose: The aim of this study was to investigate whether structural OCT changes, in specific retinal thickness, is associated with the vascular response within the nAMD CNV lesion. In other words, whether SSOCTA derived parameters may prove suitable to assess CNV activity in future.Methods: During the first 3 months patients were prospectively followed with visits at days 7, and 14 after each anti-VEGF treatment up to day 90. At baseline, day 30 and 60 Aflibercept was administered. OCT-derrived retinal thickness (RT) and OCTA-derived CNV lesion parameters (vessel area [VA]), total vessel length [TVL], total number of junctions [TNJ], junction density [JD]) were determined. Parameters were exported from SSOCT/A (PlexElite, Zeiss) images using the semi-automated AngioTool software. Additionally, the superficial and deep vascular plexus fractal dimension of the para- and perifoveal region were identified. Consequently, all OCTA derived parameters were correlated with RT.Results: 16 consecutive patients presenting with treatment-naïve, SSOCTA-positive CNV lesions were included. A weak to moderate statistically significant correlation was found between the mean RT of the inner as well as the outer ETDRS ring with the SSOCTA-derived vascular markers vessel area (VA; r² = -0.38, p < .001; r² = -0.47, p < .001, respectively), total vessel length, (TVL; r² = -0.38, p < .001; r² = -0.48, p < .001, respectively) and total number of junctions (TNJ; r² = -0.35, p < .001; r² = -0.44, p < .001, respectively). Junctions density (JD), and all variables based on fractal dimension (FD) did not show statistically significant correlations with retinal thickness measurements.Conclusions: In summary, we could confirm a moderate, however, statistically significant correlation between mean para- and perifoveal retinal thickness and the SSOCTA derived vascular parameters VA, TVL, and TNJ. This leads us to the conclusion that an SSOCTA-based activity analysis of the CNV complex is not yet a substitute for retinal thickness or in-depth fluid analysis in patients with nAMD.

Quantitative Analysis of the Activity in Choroidal Neovascularizations after a Single Anti-VEGF Injection: OCT Versus OCT Angiography

PURPOSE

To analyze early quantitative changes in the choroidal neovascularization (CNV) area observed with optical coherence tomography angiography (OCTA) after single anti-vascular endothelial growth factor (anti-VEGF) injection.

MATERIALS AND METHODS

Treatment-naive patients with CNV secondary to neovascular age-related macular degeneration were analyzed immediately before and ~4 weeks after anti-VEGF injection. The primary endpoints of the study included changes in CNV total and vascular area. Secondary endpoints were best-corrected visual acuity (BCVA), central macular thickness (cMT), central total macular thickness (cTMT), and subfoveal choroidal thickness (SFCT).

RESULTS

A total of 27 patients (69.19 ± 5.91 years, 21 men/6 women, 14 type 1 NV, 11 type 2 NV, and 2 type 3 NV) were included in the study. There was a significant increase in BCVA and decreases in cMT, cTMT, and SFCT after treatment (p<0.05 for all). CNV total and vascular area changed by -11.55 ± 44.26% (95% confidence interval [CI]: -29.06 and 5.95; p=0.269) and -21.06 ± 41.2% (95% CI: -36.45/-5.67; p=0.786), respectively. The cases with decreased cTMT were accompanied by a decrease in CNV area only in 37% of the cases. No significant correlation was detected between cTMT and CNV total and vascular area percentage changes (r = -0.06, p=0.74; r = 0.02, p=0.9, respectively).

CONCLUSIONS

Changes in CNV total and vascular area seem to have limited sensitivity as a biomarker in terms of activation, as wide variability was observed in CNV area after anti-VEGF injection.

Assessing the long-term evolution of type 3 neovascularization in age-related macular degeneration using optical coherence tomography angiography

PURPOSE

To analyze the evolution of type 3 neovascularization in eyes with age-related macular degeneration during anti-vascular endothelial growth factor (VEGF) treatment using optical coherence tomography angiography (OCTA) analysis.

METHODS

Forty-one treatment-naïve eyes (37 patients) with type 3 neovascularization were retrospectively included in the study. The growth and morphological changes in the type 3 lesions, which were recorded using OCTA, were compared across time.

RESULTS

The high-flow signal of the lesion on OCTA was significantly increased at the sub-retinal pigment epithelium (RPE) and the choriocapillaris during anti-VEGF treatment. The detection rate of the flow signal in the sub-RPE increased from 50.0% at baseline and 51.2% at 12 months to 65.9% at 24 months (P = 0.013). The flow signal extending into the choriocapillaris was detected in 0% of the eyes at baseline, 9.8% of the eyes at 12 months, and 17.1% of the eyes at 24 months (P = 0.018). The presence of subretinal drusenoid deposits (SDD) was significantly more frequent in the group with extension into the choriocapillaris (100%) than in the group without (61.8%, P = 0.036). For the four eyes with extension into the choroid, the morphological feature of the lesion on en face OCTA evolved into a tangled vascular network, similar to type 1 neovascularization.

CONCLUSION

OCTA analysis revealed that type 3 neovascularization gradually extended downward toward the sub-RPE and choroid during anti-VEGF treatment. The extension of the lesion into the choriocapillaris, suggesting retinal-choroidal anastomosis, was significantly more frequent in eyes with SDD.

Profiling neovascular age-related macular degeneration choroidal neovascularization lesion response to anti-vascular endothelial growth factor therapy using SSOCTA

Purpose

To identify the changes in distinct vascular parameters of choroidal neovascularization (CNV) in eyes with treatment‐naïve neovascular age‐related macular degeneration (nAMD) during the primary response to anti‐VEGF therapy using aflibercept.

Methods

Patients were prospectively followed during the first 3 months according to a standardized protocol with mandatory visits at days 7 and 14 after each anti‐VEGF treatment up to day 90. Fourteen eyes were seen in addition at days 1 and 3 post‐initial injection. Aflibercept was administered at baseline (BL), day 30 and 60. 6 × 6mm SSOCTA (PlexElite, Zeiss) images were acquired. Using the semi‐automated AngioTool, CNV area, vessel area, vessel density (VD), the number of junctions, junctions density, total vessel length, average vessel length, total number of endpoints and lacunarity were assessed.

Results

Thirty‐two consecutive patients presenting with treatment‐naïve, SSOCTA‐positive CNV lesions were included. Close follow‐up showed a characteristic neovascular response curve with a dynamic decrease in lesion size within days and a reactive increase following 2 weeks after initial treatment. An undulating pattern was seen for all neovascular parameters except for vascular density, with variable statistical significance. Due to a flattening of the therapeutic response as early as after the second treatment, CNV lesion size and most of the related parameters had an increase in activity above baseline values at the end of the loading phase. Lesion size was the leading feature of reactivation by a mean increase of 19.3% after three monthly aflibercept injections. Subgroup analysis based on lesion size revealed a significant correlation between best‐corrected visual acuity and quantitative change in lesion size over time, but not baseline size.

Conclusions

Using SSOCTA, a morphologic neovascular response pattern can be identified in anti‐VEGF treatment of CNV. A synchronized early decrease and consecutive reactivation in a large spectrum of neovascular biomarkers including size and internal structure are visualized in a qualitative and quantitative manner. SSOCTA analyses allow new insights in CNV morphology changes and therapeutic response.

Optical Coherence Tomography Angiography of the Choriocapillaris in Age-Related Macular Degeneration

The advent of optical coherence tomography angiography (OCTA) has allowed for remarkable advancements in our understanding of the role of the choriocapillaris in age-related macular degeneration (AMD). As a relatively new imaging modality, techniques to analyze and quantify choriocapillaris images are still evolving. Quantification of the choriocapillaris requires careful consideration of many factors, including the type of OCTA device, segmentation of the choriocapillaris slab, image processing techniques, and thresholding method. OCTA imaging shows that the choriocapillaris is impaired in intermediate non-neovascular AMD, and the severity of impairment may predict the advancement of disease. In advanced atrophic AMD, the choriocapillaris is severely impaired underneath the area of geographic atrophy, and the level of impairment surrounding the lesion predicts the rate of atrophy enlargement. Macular neovascularization can be readily identified and classified using OCTA, but it is still unclear if neovascularization features with OCTA can predict the lesion’s level of activity. The choriocapillaris surrounding macular neovascularization is impaired while the more peripheral choriocapillaris is spared, implying that choriocapillaris disruption may drive neovascularization growth. With continued innovation in OCTA image acquisition and analysis methods, advancement in clinical applications and pathophysiologic discoveries in AMD are set to follow.

Multimodal Imaging Features and Clinical Relevance of Subretinal Lipid Globules

PURPOSE

To describe the presence of subretinal lipid globules (SLG), analyze the multimodal imaging features inherent in their optical properties, and provide a means to distinguish them from other retinal structures and clinical signs.

DESIGN

Retrospective cohort study.

METHODS

The clinical data and multimodal imaging features of 39 patients (49 eyes) showing SLG were evaluated. Patients underwent color fundus photography, near-infrared reflectance (NIR), spectral-domain (SD) and swept-source (SS) optical coherence tomography (OCT) and OCT angiography. In vitro phantom models were used to model OCT optical properties of water, mineral oil, and intralipid droplets and to investigate the optical mechanisms producing hypertransmission tails beneath SLG.

RESULTS

The SLG were not visible in color fundus photographs or in NIR images. With both SD- and SS-OCT B-scans, SLG appeared as 31-157 μm, round, hyporeflective structures demonstrating a characteristic hypertransmission tail previously described with lipid globules found in the choroid and in neovascular membranes. Similarly, with en face OCT, SLG appeared as small, round, hyporeflective structures. SLG were encountered most often in eyes with neovascular age-related macular degeneration (AMD) that had type 1 macular neovascularization (MNV) (91.1%). Of those eyes, 93.3% were receiving intravitreal antivascular endothelial growth factor (VEGF) therapy (median of 15 injections) with a mean follow-up of 52.6 months. The number of prior injections positively correlated with the number of SLG. The detection of MNV preceded the presence of SLG in 66.7% of cases. En face OCT showed that, in many eyes (49%), SLG appeared in clusters of >10. In 38.8% of eyes, SLG were found overlying type 1 MNV, and in 44.9% of eyes, often those with more numerous SLG, the SLG were located near the lesion border. In 2 eyes with AMD followed for nonexudative type 1 MNV, SLG were detected prior to the detection of other imaging signs of exudation. SLG were observed in several other exudative macular diseases. Phantom models demonstrated that the hypertransmission tail beneath SLG is related to a lensing effect produced by these hyporeflective spherical structures.

CONCLUSIONS

SLG are a newly recognized OCT feature frequently seen in eyes receiving intravitreal anti-VEGF therapy for type 1 MNV due to AMD. OCT B-scans show SLG as small, round, hyporeflective structures with a characteristic hypertransmission tail. This OCT signature is influenced by the OCT focal plane, and it relates to reduced signal attenuation through oil and a lensing effect created by a higher refractive index compared to surrounding tissue.

IMPLICATIONS OF THE MORPHOLOGIC PATTERNS OF TYPE 1 MACULAR NEOVASCULARIZATION ON MACULAR ATROPHY GROWTH ON PATIENTS UNDER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT

PURPOSE

To evaluate the correspondence between macular atrophy (MA) progression and Type 1 macular neovascularization morphology during long-term anti-vascular endothelial growth factor treatment for exudative neovascular age-related macular degeneration.

METHODS

Retrospective review of consecutive patients with complete retinal pigment epithelium and outer retina atrophy overlying or in the proximity of macular neovascularization. The assessment of MA was based on spectral domain optical coherence tomography, en-face near infra-red imaging and fundus autofluorescence. Macular neovascularization blood flow morphology was evaluated by swept-source optical coherence tomography-angiography. Qualitative features were categorized per ETDRS sector as: immature, mature; and hypermature pattern. An automatic analysis was designed in MATLAB coding language to compute MA per ETDRS. Measurements were compared between the baseline and the last follow-up visit.

RESULTS

Twenty eyes from 20 patients were included; the mean age was 85.4 (8.3) years. The median follow-up was 1.85 (1.0-2.4) years and the median anti-vascular endothelial growth factor injection rate during follow-up was 4.0 (2.0-5.0) injections/year. During follow-up, sectors with persistence of an immature blood flow pattern had a lower MA growth rate than sectors with mature macular neovascularization flow patterns (P = 0.001).

CONCLUSION

The presence of an immature blood flow pattern on optical coherence tomography-angiography is associated with a lower progression rate of MA.

Treatment-naïve quiescent macular neovascularization secondary to AMD: The 2019 Young Investigator Lecture of Macula Society

PURPOSE

To analyze different clinical and anatomical features in treatment-naïve non-exudative macular neovascularizations (MNVs) secondary to age-related macular disease (AMD).

METHODS

In this retrospective longitudinal study with a minimum follow-up of 1 year, 31 eyes of 28 consecutive AMD patients (mean age 75 ± 9 years) with treatment-naïve non-exudative MNV were enrolled. Patients were divided in: short-term activated MNV group (exudation before 6-month) and quiescent MNV group (per definition no exudation during a minimum 6-month follow-up) showing no or late activation during follow-up (persistently quiescent and long-term activated MNV group, respectively).

RESULTS

During the follow-up (mean duration: 22 ± 9 months) four eyes (13%) showed exudation before 6-month follow-up (short-term activated MNV group), whereas 21 eyes (68%) did not develop signs of exudation (persistently quiescent group), and six eyes (19%) developed exudation after the minimum 6-month follow-up (long-term activated MNV group). Monthly MNV growth rate was significantly higher in the short-term activated MNV group (growth rate of 13.30%/month), vs persistently quiescent MNV group (0.64%/month, p < 0.001) and long-term activated quiescent MNV group (1.07%/month, p < 0.001). Furthermore, at the baseline, perfusion density of short-term activated MNV group was significantly greater in comparison to persistently quiescent MNV group (p = 0.001) and long-term activated MNV group (p = 0.106).

CONCLUSION

We reported two different patterns for subclinical MNVs: subclinical MNVs characterized by short-term activation which could represent simply a pre-exudative stage in the development of an ordinary type 1 MNV, and quiescent MNVs characterized by low rate of growth and possible long-term activation. Analysis of OCT-A features may predict short-term activation for subclinical MNV but no features could predict the long-term activation.

Plexus-specific retinal vascular anatomy and pathologies as seen by projection-resolved optical coherence tomographic angiography

Optical coherence tomographic angiography (OCTA) is a novel technology capable of imaging retinal vasculature three-dimensionally at capillary scale without the need to inject any extrinsic dye contrast. However, projection artifacts cause superficial retinal vascular patterns to be duplicated in deeper layers, thus interfering with the clean visualization of some retinal plexuses and vascular pathologies. Projection-resolved OCTA (PR-OCTA) uses post-processing algorithms to reduce projection artifacts. With PR-OCTA, it is now possible to resolve up to 4 distinct retinal vascular plexuses in the living human eye. The technology also allows us to detect and distinguish between various retinal and optic nerve diseases. For example, optic nerve diseases such as glaucoma primarily reduces the capillary density in the superficial vascular complex, which comprises the nerve fiber layer plexus and the ganglion cell layer plexus. Outer retinal diseases such as retinitis pigmentosa primarily reduce the capillary density in the deep vascular complex, which comprises the intermediate capillary plexus and the deep capillary plexus. Retinal vascular diseases such as diabetic retinopathy and vein occlusion affect all plexuses, but with different patterns of capillary loss and vascular malformations. PR-OCTA is also useful in distinguishing various types of choroidal neovascularization and monitoring their response to anti-angiogenic medications. In retinal angiomatous proliferation and macular telangiectasia type 2, PR-OCTA can trace the pathologic vascular extension into deeper layers as the disease progress through stages. Plexus-specific visualization and measurement of retinal vascular changes are improving our ability to diagnose, stage, monitor, and assess treatment response in a wide variety of optic nerve and retinal diseases. These applications will be further enhanced with the continuing improvement of the speed and resolution of the OCT platforms, as well as the development of software algorithms to reduce artifacts, improve image quality, and make quantitative measurements.

[Fibrovascular transformation of CNV in nAMD after long-term anti-VEGF therapy : Methodological evaluation of quantifying morphological changes]

BACKGROUND

Under long-term anti-VEGF therapy neovascular age-related macular degeneration (nAMD) may result in fibrovascular transformation of choroidal neovascularization (CNV). So far there is a lack of definitions on how a differentiated quantification of the associated morphological changes can best be carried out. This pilot study aimed to define the most appropriate imaging modalities.

PATIENTS AND METHODS

In 56 eyes with fibrotic CNV after at least 2 years of anti-VEGF therapy and at least 12 intravitreal anti-VEGF injections, the following imaging modalities were investigated with respect to the delimitation of vascular and fibrous portions of CNV as well as associated atrophy of retinal pigment epithelium (RPE) and disruption of the ellipsoid zone (EZ): multicolor imaging (MC), fundus autofluorescence (FAF), fluorescein angiography (FA) and indocyanine green angiography (ICGA), spectral domain optical coherence tomography (SD-OCT) and OCT angiography (OCTA).

RESULTS

The vascular portion of fibrotic CNV was best visualized by OCTA, the fibrous portion by SD-OCT. The RPE atrophy was best delimitated by FAF, but differentiation was also possible by MC and ICGA. Disruption of the EZ could be delineated by SD-OCT b‑scan.

CONCLUSION

The use of MC is suitable for visualization of RPE atrophy and the fibrous portion of fibrotic CNV and FAF is suitable for differentiation of RPE atrophy. The SD-OCT can be used to quantify the fibrous portion of CNV; the EZ interruption is delimitable in the b‑scan but not in the transverse structure-scan. The vascular part can best be detected by OCTA.

A practical guide to optical coherence tomography angiography interpretation

Background

Optical coherence tomography angiography (OCTA) can image the retinal vasculature in vivo, without the need for contrast dye. This technology has been commercially available since 2014, however, much of its use has been limited to the research setting. Over time, more clinical practices have adopted OCTA imaging. While countless publications detail OCTA’s use for the study of retinal microvasculature, few studies outline OCTA’s clinical utility.

Body

This review provides an overview of OCTA imaging and details tips for successful interpretation. The review begins with a summary of OCTA technology and artifacts that arise from image acquisition. New methods and best practices to prevent image artifacts are discussed. OCTA has the unique ability among retinovascular imaging modalities to individually visualize each retinal plexus. Slabs offered in standard OCTA devices are reviewed, and clinical uses for each slab are outlined. Lastly, the use of OCTA for the clinical interpretation of retinal pathology, such as diabetic retinopathy and age-related macular degeneration, is discussed.

Conclusion

OCTA is evolving from a scientific tool to a clinical imaging device. This review provides a toolkit for successful image interpretation in a clinical setting.

Quantitative Optical Coherence Tomography Angiography Parameters in Type 1 Macular Neovascularization Secondary to Age-Related Macular Degeneration

Purpose

The purpose of this paper was to study type 1 macular neovascularization (MNV) quantitative optical coherence tomography (OCT) angiography (OCTA) features by means of advanced postprocessing analyses.

Methods

We recruited patients affected by naïve type 1 MNV secondary to age-related macular degeneration (AMD) and age-matched controls. All patients underwent ophthalmologic examination and multimodal imaging. They were treated with pro-re-nata anti-VEGF injections. The ensuing follow-up lasted 24 months. Quantitative OCT and OCTA parameters were statistically analyzed to obtain cutoff values able to distinguish two clinically different patient subgroups. Main outcome measures were best-corrected visual acuity (BCVA), central macular thickness, vessel density of superficial, deep and choriocapillaris plexa, vessel tortuosity (VT) of MNV, vessel dispersion of MNV, number of injections, blooding, pigment epithelium detachment, subretinal fluid, photoreceptor elongation, subretinal fibrosis, and outer retinal atrophy.

Results

Ninety-one eyes (91 patients; 49 men; mean age 78 ± 7 years) and 91 control eyes were included. Mean logarithm of the minimum angle of resolution (logMAR) BCVA was 0.46 ± 0.56 at baseline, increasing up to 0.29 ± 0.30 after 2 years of treatment (P < 0.01). The mean number of intravitreal injections was 7.1 ± 2.0 during the first year and 4.5 ± 1.4 during the second year. A baseline VT cutoff of 8.40 detected two patients’ subgroups differing significantly in terms of BCVA improvement after 2 years of treatment.

Conclusions

OCTA-based classification of type 1 MNV, performed at baseline, provided useful information in terms of the functional outcome achievable after 24 months of anti-VEGF treatment.

Translational Relevance

Quantitative OCTA-based classification of type 1 MNV, performed at baseline, provided useful information in terms of the functional outcome achievable after 24 months of anti-VEGF treatment.