Effects of vitreomacular adhesion on anti-vascular endothelial growth factor treatment for exudative age-related macular degeneration

Vitreomacular interface abnormalities in the Ghanaian African

BACKGROUND/OBJECTIVE

Describe vitreomacular interface abnormalities (VMIA) using spectral-domain optical coherence tomography (SD-OCT), and correlations with age-related macular degeneration (AMD) grade in Ghanaian Africans.

SUBJECTS/METHODS

Prospective, cross-sectional study of adults aged ≥50 years recruited in Ghana AMD Study. Participant demographics, medical histories, ophthalmic examination, digital colour fundus photography (CFP) were obtained. High-resolution five-line raster OCT, Macular Cube 512 × 128 scans, and additional line scans in areas of clinical abnormality, were acquired. SD-OCT VMI features classified by International Vitreomacular Traction Study Group system and relationships to AMD grade were evaluated.

OUTCOMES

VMIA prevalence, posterior vitreous detachment (PVD), vitreomacular adhesions (VMA), vitreomacular traction (VMT), epiretinal membranes (ERM), correlations with AMD grade.

RESULTS

The full Ghana AMD cohort included 718 participants; 624 participants (1248 eyes) aged ≥50 years (range = 50-101, mean = 68.8), 68.9% female were included in this analysis. CFP with OCT scans were available for 776 eyes (397 participants); 707 (91.1%) had gradable CFP and OCT scans for both AMD and VMI grading forming the dataset for this report. PVD was absent in 504 (71.3%); partial and complete PVD occurred in 16.7% and 12.0% respectively. PVD did not increase with age (p = 0.720). VMIA without traction and macular holes were observed in 12.2% of eyes; 87.8% had no abnormalities. VMIA was not significantly correlated with AMD grade (p = 0.819).

CONCLUSIONS

This provides the first assessment of VMIA in Ghanaian Africans. VMIA are common in Africans; PVD may be less common than in Caucasians. There was no significant association of AMD grade with VMIA.

Prevalence and Associations of Epiretinal Membranes in an Elderly English Population: The Bridlington Eye Assessment Project

Purpose: To determine the prevalence and risk factors of epiretinal membranes (ERMs) in an adult English population. Methods: The Bridlington Eye Assessment Project is a population-based study of eye disease among residents aged 65 years or older. Comprehensive interviews and ophthalmic examinations were conducted to assess potential risk factors. Digital mydriatic nonstereoscopic 30° colour fundus photography (CFP) was performed. ERMs were classified as primary/idiopathic or secondary on the basis of findings from the ocular examination and the structured questionnaire. Logistic regression models were used to determine the independence of potential risk factors for idiopathic ERMs. Results: In a comprehensive screening of 3588 patients aged over 65, we identified an eye-based prevalence of ERMs of 4.26% and a subject-based prevalence of ERMs of 6.88%. The majority of these cases were idiopathic in nature (90.7%), while 9.3% were secondary ERMs; predominantly, there was a history of cataract surgery (43.5%). No significant correlation between idiopathic ERMs and factors such as age, gender, diabetes, hypertension, a history of stroke, or the presence of AMD was found. Conclusions: The prevalence of ERMs in an elderly English population and the proportion of idiopathic and secondary ERMs are similar to previous reports. However, in elderly patients aged over 65 years, age is not a risk factor for the presence of idiopathic ERMs. The presence of diabetes, hypertension, a history of stroke, and AMD of any grade was not associated with ERMs.

[Vitreous body in the treatment of exudative age-related macular degeneration : The medium is the message]

BACKGROUND

Intravitreal anti-vascular endothelial growth factor (VEGF) is the standard treatment for exudative age-related macular degeneration (AMD). The constitution of the vitreomacular interface varies greatly in cases of attached (with or without traction) or detached vitreous body, which can impact the effectiveness of the anti-VEGF treatment.

OBJECTIVE

Based on the current literature this article displays the current state of the science on whether the constitution of the vitreous body has an effect on the anti-VEGF treatment.

MATERIAL AND METHODS

The published data extracted from current trials and post hoc analyses concerning this topic are presented and put into the clinical context.

RESULTS

The presence of a vitreomacular adhesion reduces the efficacy of anti-VEGF treatment of exudative AMD. Posterior vitreous body detachment represents a positive prognostic factor concerning the efficacy of anti-VEGF treatment but not necessarily the prognosis for visual acuity.

CONCLUSION

Patients with attached vitreous body need a more intensive treatment monitoring compared to patients with detached vitreous body. Therefore, in eyes with initial posterior vitreous body detachment receiving a treat and extend regimen, the interval between anti-VEGF injections can be extended to 4 instead of 2 weeks without endangering the success of treatment.

Central posterior hyaloid fibrosis: evolution and outcomes

PURPOSE

To report contributory factors and clinical outcomes of central posterior hyaloid fibrosis (CPHF) associated with neovascular age-related macular degeneration (nAMD).

METHODS

In this retrospective, single-center study, patients with CPHF and nAMD were included. Demographic and imaging characteristics, as well as the anatomical and functional outcomes, of these patients were analysed.

RESULTS

We identified 530 eyes in 273 patients with chronic predominantly scarred macular neovascularisation (MNV), and 32 eyes in 29 patients revealed CPHF, representing a prevalence of 6%. Patients had a mean age of 72.76 years. Before and during the development of CPHF, Type 2 MNV was observed in all eyes. At the time of MNV diagnosis, mean logMAR visual acuity was 1.308 ± 0.559 (20/407). The average time to develop CPHF was 27.3 months since the diagnosis of MNV. At the time of CPHF identification, the mean logMAR visual acuity was 1.498 ± 0.374 (20/630). RPE tear was observed in 6% (n = 2) of CPHF eyes. The average number of intravitreal anti-VEGF injections administered prior to the diagnosis of CPHF was 2.4 and after the onset of CPHF was 0.9. The final visual acuity was not significantly different at the final follow-up visit [1.304 ± 0.42 (20/402); p = 0.646].

CONCLUSION

Rarely observed in eyes with predominantly scarred subfoveal type 2 MNVs and extensive subretinal fibrosis, CPHF is associated with poor visual outcomes. Its presence could possibly suggest a profibrotic effect of MNV on the posterior hyaloid.

TRIAL REGISTRATION NUMBER

Not applicable.

Central posterior hyaloidal fibrosis - A novel optical coherence tomography feature associated with choroidal neovascular membrane

Purpose

To describe a novel optical coherence tomography (OCT) finding at the vitreomacular interface (VMI), and report its association with advanced choroidal neovascularisation (CNV).

Observations

Optical coherence tomography (OCT) scans performed at three retinal imaging centres at Amanat Eye Hospital, Pakistan from May 2016 till May 2021 were reviewed. A specific change at the vitreomacular interface was noted consisting of abnormal hyper reflectivity at the point of attachment of the posterior hyaloid membrane to the foveal center which appears to 'fill in' the foveolar depression.Eight eyes of eight patients were identified. All affected eyes had advanced CNV and persistent vitreofoveolar adhesion. In all eyes, the foveal contour (concavity) was maintained and there was no inner retinal surface wrinkling which differentiates this OCT feature from vitreomacular traction or epiretinal membranes. The authors propose the term Central Posterior Hyaloidal Fibrosis (CPHF) for this specific OCT finding.

Conclusions and Importance

Central Posterior Hyaloidal Fibrosis (CPHF) is a newly reported OCT finding associated with advanced CNV, which may represent a possible profibrotic influence of a choroidal neovascular membrane to the overlying posterior hyaloid adhesion.

Real-Life Efficacy of Bevacizumab Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion according to Pro Re Nata or Treat-and-Extend Regimen in Eyes with or without Epiretinal Membrane

Purpose. To present real-life data of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO) treated with bevacizumab (BVZ); determine the possible influence of epiretinal membrane (ERM) on treatment efficacy; and compare treatment outcomes in a treat-and-extend regimen (TER) versus pro re nata (PRN). Methods. We carried out a retrospective analysis of 58 eyes (56 patients) with new-onset CRVO treated only with intravitreal bevacizumab according to TER or PRN. Outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and 12 months after the first treatment, number of visits and injections, and presence of ERM confirmed by optical coherence tomography in the first 6 months. Results. At 12 months, the mean number of injections was 6.3 across all eyes, with significantly more injections given in TER ( $p<0.001$ ). Mean CRT improved from 627 μm to 359 μm ( $p<0.001$ ) in all eyes, with improvement noted in TER ( $p<0.001$ ), PRN ( $p<0.001$ ), ERM ( $p=0.003$ ), and non-ERM ( $p<0.001$ ) subgroups. The mean BCVA gain was +13.6 letters, and the mean BCVA improved from 0.81 to 0.54 LogMAR ( $p<0.001$ ) in all eyes. BCVA improvement from baseline was significant in TER ( $p<0.001$ ) and non-ERM ( $p<0.001$ ) but not in PRN ( $p=0.08$ ) or ERM ( $p=0.2$ ) subgroups. Seven eyes, all receiving PRN treatment, developed neovascularization. Conclusions. Intravitreal bevacizumab according to either PRN or TER resolved edema and stabilized vision in the first 12 months, with TER yielding significant visual improvement and avoiding neovascular complications. ERM had no influence on bevacizumab efficacy in reducing ME in CRVO during 12 months of treatment.

Influence of vitreomacular interface score on treatment outcomes of anti-VEGF therapy for neovascular age-related macular degeneration

BACKGROUND

To quantitatively evaluate the vitreomacular interface of eyes with neovascular age-related macular degeneration (AMD) and to investigate its association with the 1-year treatment outcome following intravitreal injections of aflibercept (IVA).

METHODS

This prospective observational case series included 59 eyes of 59 consecutive patients with treatment-naïve neovascular AMD who were treated with three monthly IVA and subsequent four bi-monthly IVA and were followed up for 1 year. We estimated posterior vitreous detachment at 1, 9, and 25 macular points within an area of 6 × 6 mm² at the center of the fovea using the built-in enhanced vitreous visualization mode of swept-source optical coherence tomography. One year after the initial IVA, we classified the eyes into either wet or dry groups.

RESULTS

The wet and dry groups included 12 and 47 eyes, respectively. The resistance rate against IVA was 20.3%. The 25-point interface score was higher in the wet group than in the dry group (23.0 ± 4.3 vs. 18.6 ± 9.8, P = 0.03), whereas there were no significant between-group differences in the 9-point and 1-point scores (P = 0.21, and 0.47, respectively) or in the other studied parameters. Multivariable analysis revealed that the 25-point vitreomacular interface score was strongly correlated with subfoveal choroidal thickness (P = 0.02, β =  - 0.31).

CONCLUSIONS

Our findings suggest that wide-ranged separation of the posterior vitreous membrane from the retina induces poor response to IVA.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

The effect of posterior vitreous detachment on aflibercept response in diabetic macular oedema

PURPOSE

To investigate the effect of posterior vitreous detachment (PVD) on aflibercept response in treatment-naïve diabetic macular oedema (DME).

DESIGN

A retrospective cohort study.

METHODS

One hundred and fifty eyes of 150 treatment-naïve patients with DME were enrolled. The patients were divided into three groups according to their PVD status: group 1 (no PVD during injections), group 2 (PVD during injections) and group 3 (PVD already present initially). Three consecutive aflibercept injections at intervals of 1 month were applied to all patients. The efficacy of the aflibercept treatment on DME was assessed by comparing changes in central retinal thickness (CRT) and best-corrected visual acuity (BCVA) values after three loading dose injections.

RESULTS

After three consecutive injections, the mean reduction of CRT in groups 1, 2 and 3 were -199.6±106.9, -224.9±124.1 and -210.7±126.3, respectively. The decrease in CRT was significant in all groups (p<0.001 in all groups, paired-samples t-test); however, mean changes in CRT were similar among groups (all p>0.05, one-way analysis of variance (ANOVA)). The mean improvement in BCVA in groups 1, 2 and 3 was 6.6±0.9, 6.5±0.8 and 6.1±0.4 ETDRS letters, respectively. The improvement of BCVA was significant in all groups (p<0.001 in all groups, paired-samples t-test) and mean changes were similar between groups (p>0.05, one-way ANOVA). There was no significant relationship between the presence or development of PVD and the mean decrease of CRT and improvement of BCVA (for CRT r=-0.052, p=0.531 and for BCVA r=-0.078, p=0.342).

CONCLUSION

In the present study, it was observed that the efficacy of aflibercept treatment in patients with DME did not depend on PVD status.

Effect of posterior vitreous detachment on treat-and-extend versus monthly ranibizumab for neovascular age-related macular degeneration

AIMS

To investigate the impact of posterior vitreous detachment (PVD) on the efficacy of treat-and-extend (T&E) ranibizumab in neovascular age-related macular degeneration.

METHODS

In a post hoc analysis of a randomised controlled clinical trial, spectral-domain optical coherence tomography images of treatment-naïve patients randomised to receive T&E (n=265) or monthly (n=264) ranibizumab for 12 months were included. Certified, masked graders diagnosed the presence or the absence of complete PVD. The main outcome measures were the mean change in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at month 12, the number of administered ranibizumab injections and the proportion of patients extended to more than 8 weeks.

RESULTS

At baseline, complete PVD was present in 51% and 56% of patients in the monthly and T&E arms, respectively. Mean change in BCVA at month 12 was +9.0 (PVD) vs +9.5 letters (no PVD, p=0.78) in monthly treated eyes, and +6.0 (PVD) vs +7.5 letters (no PVD, p=0.42) in T&E treated eyes. Conversely, mean change in CRT at month 12 was -174 (PVD) vs -173 µm (no PVD, p=0.98) in the monthly arm, and -175 (PVD) vs -164 µm (no PVD, p=0.58) in the T&E arm. In T&E treated patients, the median number of injections was eight vs nine (p=0.035). 71% of PVD eyes were extended successfully, compared with 55% of eyes without PVD (p=0.005).

CONCLUSION

PVD was not found to impact functional and anatomical outcomes of T&E ranibizumab therapy. However, patients without a complete PVD required more retreatments and were significantly less likely to be successfully extended.

TRIAL REGISTRATION NUMBER

NCT01948830.

Effect of vitreomacular adhesion on the treatment outcomes in the STOP-Uveitis clinical trial for non-infectious uveitis

Purpose

To evaluate the role of vitreomacular adhesion (VMA) in visual and anatomic outcomes in patients with non-infectious uveitis.

Design

Phase 2 clinical trial

Participants

Data from the Safety, Tolerability, and Efficacy of Tocilizumab in Patients with Non-infectious Uveitis (STOP-Uveitis) study was analyzed.

Methods

In the STOP-Uveitis study, patients with non-infectious uveitis (NIU) received monthly intravenous infusions of either 4 or 8 mg/kg tocilizumab until month 6 (M6). Spectral domain optical coherence tomography (SD-OCT) images of patients that completed M6 of the study were analyzed at baseline to stratify the patients by the presence (VMA+) or absence (VMA−) of VMA. Patients with vitreomacular traction (VMT) or epiretinal membrane causing structural abnormalities within center 1 mm were excluded. All images were graded by two independent graders.

Main outcome measures

Mean change in best-corrected visual acuity (BCVA), central retinal thickness (CRT), and vitreous haze (VH) at M6.

Results

Out of 37 patients randomized in the STOP-Uveitis study, 48 eyes (27 patients) were eligible based on the study criteria. At baseline, 19 eyes were classified as VMA+, and 32 eyes were classified as VMA−. The distribution of two doses of TCZ (4 mg/kg and 8 mg/kg) were similar between the two groups. At M6, the mean improvement in BCVA was 2.00 ± 5.3 and 6.50 ± 7.98 letters in the VMA+ and VMA− groups, respectively (p = 0.02). The mean improvement in CRT was 34.85 ± 72.36 and 80.37 ± 157.21 μm in the VMA+ and VMA− groups, respectively (p = 0.18). Similarly, the mean change in VH was − 0.65 ± 0.47 and − 0.76 ± 0.71 in the VMA+ and VMA− groups, respectively (p = 0.32). Out of 16 eyes with VMA at baseline, 3 eyes developed posterior vitreous detachment (PVD) at M6. The mean change in BCVA was significantly higher (p = 0.02), while CRT and VH score were similar (p > 0.05) in eyes with PVD compared to eyes with persistent VMA.

Conclusions

The absence of VMA or development of PVD in eyes with VMA seems to have a beneficial effect on the vision of subjects receiving treatment for uveitis. Therefore, patients with uveitis should be assessed using SD-OCT for the presence of vitreomacular interface abnormalities.

Four-Year Outcome of Aflibercept for Neovascular Age-Related Macular Degeneration and polypoidal choroidal vasculopathy

Intravitreal injections of anti-vascular endothelial growth factor agents such as ranibizumab and aflibercept are the first-line treatment for neovascular age-related macular degeneration (AMD). However, data about long-term outcome in real-world clinical practice is scarce. We recruited 98 AMD patients and investigated four-year visual outcome. During the four years, 25 patients dropped out. The survivors received 7.0 ± 0.1 injections during the first year and 8.0 ± 7.4 injections in the following three years. The logarithm of minimum angle of resolution (logMAR) at baseline, year one, and year four was 0.28, 0.14 (P = 0.033), and 0.22 (P = 0.697), respectively. The gain of vision was not different among AMD subtypes (typical AMD, polypoidal choroidal vasculopathy, and retinal angiomatous proliferation; P = 0.513) Among the investigated factors, the presence of external limiting membrane (ELM), the absence of vitreoretinal adhesion, and thicker choroid at baseline were associated with better logMAR values at year four (coefficient beta = -0.388, 0.201, and -0.001; P = 7.34 × 10^-6; 0.01, and 0.028, respectively). In the present study, vision was retained at baseline level after the four-year treatment with aflibercept. The status of ELM, vitreoretinal adhesion, and choroidal thickness were predictive factors for final vision.

The role of posterior vitreous detachment on the efficacy of anti-vascular endothelial growth factor intravitreal injection for treatment of neovascular age-related macular degeneration

Purpose:

A prospective cohort study investigating the effect of posterior vitreous detachment (PVD) on the efficacy of intravitreal bevacizumab for exudative age-related macular degeneration (AMD), in view of evidence that the vitreoretinal interface impacts the severity of the disease.

Methods:

Treatment-naïve AMD eyes with (+) complete PVD and without (−) PVD on ultrasonography received three monthly and then pro re nata bevacizumab injections. Best-corrected visual acuity (BCVA) on Snellen charts and optical coherence tomography (OCT) findings were recorded for 12 months. Secondary analysis included PVD definition and group allocation according to OCT baseline scan.

Results:

Forty-one eyes of 34 patients met the inclusion criteria. At 12 months, median BCVA improved by 0.12 logMAR in the PVD+ group [interquartile range (IQR) −0.52, 0.03, P = 0.140] and remained the same in the PVD− group (IQR −0.12, 0.15, P = 0.643). Median central retinal thickness improved by 43.5 μm and 43 μm in the PVD+ (IQR −143, 3, P = 0.016) and PVD− group (IQR −90, −14, P = 0.008), respectively. All parameters were similar in the two groups at final follow up (P > 0.05). The secondary analysis included 32 eyes of 26 patients and showed no significant differences between the groups at the 12 months endpoint (P > 0.05).

Conclusion:

Our findings show no significant impact of PVD as assessed by ultrasound or by OCT on visual and anatomical outcomes in exudative AMD treated with bevacizumab.

Influence of the Vitreoretinal Interface on the Treatment with Anti-VEGF for Exudative Age-Related Macular Degeneration

PURPOSE

To investigate the influence of the vitreoretinal interface on the outcomes of different ranibizumab regimens for exudative age-related macular degeneration.

METHODS

We conducted a retrospective subanalysis of 2 prospective clinical trials. Patients were treated with ranibizumab for 12 months according to 3 different regimens: pro-re-nata (PRN), treat and extend (T&amp;E), and monthly. Vitreoretinal interface was assessed for absence (group ON) or presence (group OFF) of posterior vitreous detachment (PVD).

RESULTS

We included 64 eyes from 64 patients. Visual improvement was poorer for group ON (0.3 ± 10.7 letters) than for group OFF (9.2 ± 13.3; p = 0.007). A significant difference in letters of improvement between groups was observed in the PRN cohort (ON: -5.0 ± 12.9; OFF: 11.4 ± 11.9; p = 0.003), but not in the cohorts with monthly (ON: 5.7 ± 7.8; OFF: 7.9 ± 15.2; p = 0.735) or T&amp;E (ON: 4.3 ± 4.3; OFF: 7.8 ± 11.1; p = 0.424) treatment.

CONCLUSION

The negative impact of absence of PVD is regimen dependent, with monthly dosing providing similar outcomes to PVD patients. In the absence of PVD (group ON), PRN should be avoided, and T&amp;E might be an alternative.

Visual function response to ocriplasmin for the treatment of vitreomacular traction and macular hole

PURPOSE

To assess the effect of an intravitreal ocriplasmin injection on visual function, measured using visual acuity (VA) and vision-related quality of life.

METHODS

Post hoc analysis of prespecified secondary end-points in two multicentre, randomized, double-masked, phase 3 clinical trials. A total of 652 participants with symptomatic vitreomacular adhesion were enrolled, of whom 464 received a single intravitreal injection of 125 μg ocriplasmin and 188 received a single intravitreal placebo injection. Based on principal components analysis results, visual function response (VFR) was defined as either a VA improvement of ≥2 lines; or an improvement in the composite score of the National Eye Institute Visual Function Questionnaire (VFQ-25) exceeding the minimal clinically important difference (MCID), estimated using the standard error of measurement approach; or an improvement in the VFQ-25 driving subscale score exceeding the MCID. The main outcome measure was VFR at 6 months.

RESULTS

A VFR occurred in 55.1% of the ocriplasmin group versus 34.2% of the placebo injection group (p < 0.0001). This comprised 23.7% versus 11.2% (p = 0.0003) with a ≥ 2-line VA improvement, 35.9% versus 22.7% (p = 0.0016) for the VFQ-25 composite score, and 10.2% versus 6.2% (p = 0.1697) for the driving subscale.

CONCLUSION

Ocriplasmin produces a clinically meaningful visual function benefit.

Influence of vitreomacular interface on anti-vascular endothelial growth factor treatment outcomes in neovascular age-related macular degeneration: A MOOSE-compliant meta-analysis

The aim of the study was to evaluate the influence of vitreomacular interface configuration on treatment outcomes after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (AMD).The Pubmed, Embase, and Cochrane Central Register of Controlled Trials databases were searched to identify relevant prospective or retrospective studies that evaluate the influence of vitreomacular adhesion (VMA) or vitreomacular traction (VMT) on functional and anatomical outcomes in neovascular AMD patients treated with anti-VEGF agents. The outcome measures were the mean change in best corrected visual acuity (BCVA) from baseline, the mean change in central macular thickness (CMT) from baseline, and the mean injection numbers of anti-VEGF treatment from baseline.In total, 9 studies were selected for this meta-analysis, including 2156 eyes (404 eyes in the VMA/VMT group and 1752 eyes in the non-VMA/VMT group). In neovascular AMD patients treated with anti-VEGF agents, the VMA/VMT group was associated with poorer visual acuity gains and CMT reductions at 1 year (WMD [95% CI], -6.17 [-11.91, -0.43] early treatment diabetic retinopathy study (ETDRS) letters, P = .04; WMD [95% CI], 22.19 [2.01, 42.38] μm, P = .03, respectively). There was no significant difference between 2 groups in the mean BCVA change and the CMT change over 2 years (WMD [95% CI], -5.59 [-21.19, 10.01] ETDRS letters, P = .48; WMD [95% CI], 6.56 [-24.78, 37.90] μm, P = .68, respectively). There was no significant difference in the mean injection numbers between 2 groups at 1 year (WMD [95% CI], 0.36 [-0.19, 0.90], P = .21), whereas the VMA/VMT group had a significantly higher mean injection numbers over 2 years (WMD [95% CI], 1.14 [0.11, 2.16], P = .03).The limited evidence suggests that vitreomacular interface configuration have a significant influence on the visual acuity gain and CMT reduction at 1 year, injection numbers at 2 years in neovascular AMD patients treated with anti-VEGF agents. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among study designs. Eyes with VMA/VMT on optical coherence tomography at baseline may require more intensive treatment with decreased response to anti-VEGF agents.

Cyclic stretch induced-retinal pigment epithelial cell apoptosis and cytokine changes

Background

The pathogenesis of age-related macular degeneration (AMD) is complex. It has been shown that vitreomacular traction (VMT) plays a role in the pathogenesis of AMD. We speculate that the continuous stretch induced by VMT might impair the function of retinal pigment epithelium (RPE) cells and it might also be involved in the progression of AMD.

Methods

Cultured ARPE-19 cells were subjected to cyclic stretch on the Flexcell Strain system at a level of 25% increment on the surface area for 8 h, 14 h, 20 h, 24 h. In another group, the stretch was withdrawn at 14 h and the cell cultured for another 6 h. Then, we observed the changes in morphology, apoptosis and expression of interleukin 6 (IL6) and vascular endothelial growth factor (VEGF) in RPE cells under stretch.

Results

We found that stretch induced the RPE cells to change from a spreading shape into a rounded shape, and that the morphological changes were positively correlated with the duration of the stretch. The expression of pFAK397 and pRac1/cdc42 were elevated in a time-dependent fashion. The stretch resulted in an increase in the apoptosis ratio, with Bcl2, Bax and p53 also showing time-dependent changes. In addition, up-regulation of IL6 and VEGF expression levels was also observed. After withdrawal of the stretch, all of these changes were significantly diminished.

Conclusion

Stretch may induce morphological, cell apoptosis, and up-regulation of cytokines changes in RPE cells, indicating that cyclic stretching may participate in the progression of AMD by impeding the functions of the RPE.

The effect of vitreomacular adhesion in exudative age-related macular degeneration on the results of ranibizumab intravitreal injection

PURPOSE

To investigate whether vitreomacular adhesion (VMA) affects the outcome of anti-vascular endothelial growth factor (VEGF) therapy for the treatment of exudative age-related macular degeneration (AMD) in Japanese patients.

SUBJECTS AND METHODS

Of 88 Japanese AMD patients (28 men and 60 women, mean age: 72.7±7.5 years) who underwent intravitreal injection of ranibizumab for 3 years from 2010 to 2013, this study involved 12 eyes of 12 patients (10 men and two women) in whom VMA was observed based on optical coherence tomography (OCT) findings (VMA [+] group) and 17 eyes of 16 patients (seven men and nine women, control group) in whom no VMA was observed (VMA [-] group). In all enrolled patients, ranibizumab was administered monthly for 3 months, and then administered as needed (ie, pro re nata) when deterioration was observed. The two groups were then compared in regard to changes in visual acuity (VA) and the frequency of ranibizumab administration over a 1-year period.

RESULTS

No significant difference was found between the two groups in regard to the transformation of the mean logarithm of the minimum angle of resolution VA change after the first visit. Over the 1-year treatment, the mean frequency of ranibizumab administration for the VMA (+) group was 5.6±2.5 times and for the VMA (-) group was 3.8±1.1 times, thus illustrating a significant difference between the two groups (Mann-Whitney's U-test: P<0.05).

CONCLUSION

Our findings show that the mean frequency of ranibizumab administration for the VMA (+) group was higher than that in the VMA (-) group, thus indicating that VMA might possibly be involved in the progress of AMD pathology.

The Role of Posterior Vitreous Detachment and Vitreomacular Adhesion in Patients With Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

The aim of this study was to assess the prevalence of posterior vitreous detachment (PVD) and vitreoretinal interface in patients with age-related macular degeneration (AMD).

PATIENTS AND METHODS

This clinical trial included 206 eyes of 138 patients who presented to the authors' clinic between January 2012 and November 2014. Patients were divided into three groups: 98 eyes of 67 patients with exudative AMD, 55 eyes of 36 patients with nonexudative AMD, and 53 eyes of 35 patients having no vitreoretinal disease. All patients underwent complete ocular examination, including best-corrected visual acuity, Goldmann applanation tonometry, fundus photography, spectral-domain optical coherence tomography, and B-mode ultrasonography at 6 months and 12 months after the initial examination.

RESULTS

Total and partial PVD rates were significantly higher at baseline, 6 months, and 12 months in both exudative and nonexudative AMD groups when compared to the control group (Chi-square test, P = .006, P = .001, and P = .009, respectively). The prevalence of total PVD was significantly higher in nonexudative AMD, whereas partial PVD was higher in exudative AMD. The exudative AMD group reported significantly more VMA than the other two groups at baseline, 6 months, and 12 months (Chi-square test, P =.005, P = .003, and P = .019, respectively).

CONCLUSION

This study indicates that the incidence of vitreoretinal interface abnormalities such as partial PVD and vitreomacular adhesion were higher in the exudative AMD group. It can be concluded that abnormal adhesive and tractional forces due to PVD may play a role in the progression of AMD. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:223-229.].

Vitreomacular adhesion or vitreomacular traction may affect antivascular endothelium growth factor treatment for neovascular age-related macular degeneration

OBJECTIVE

The aim of this review is to determine whether vitreomacular adhesion (VMA) or vitreomacular traction (VMT) has an influence on the outcomes of antivascular endothelium growth factor (anti-VEGF) treatment neovascular age-related macular degeneration (nAMD).

METHODS

A systematic literature search was performed in Pubmed.gov, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, SinoMed and ClinicalTrials.gov up to 30 June 2016 to identify eligible studies.

RESULTS

Nine studies and 2212 participants were finally identified. At month 6, the mean improvement in best-corrected visual acuity (BCVA) and mean decline in central retinal thickness (CRT) of the VMA/VMT(+) group was less than that of the VMA/VMT(-) group (95% CI -3.05 to -0.96 letters, p=0.0002; 15.53 to 32.98 μm, p<0.00001; respectively); at month 12, there was a small or only marginally significant difference (-0.01 to 2.00 letters, p=0.05; 0.17 to 23.7 μm, p=0.05; respectively) between the groups. During the 12 months, however, the VMA/VMT(+) group required more injections ((0.25 to 0.95), p=0.0008).

CONCLUSIONS

In using anti-VEGF drugs to treat nAMD, clinicians should take into account the fact that concurrent VMA or VMT might antagonise the efficacy of anti-VEGF drugs during the early stage of treatment.

Short-term outcomes in patients with branch retinal vein occlusion who received intravitreal aflibercept with or without intravitreal ranibizumab

Purpose

The purpose of this study was to determine the short-term outcomes for patients who received intravitreal aflibercept (IVA) with or without intravitreal ranibizumab (IVR) for macular edema (ME) due to branch retinal vein occlusion (BRVO).

Patients and methods

Patients received IVA for ME due to BRVO. Patients who initially received IVA were defined as the treatment-naïve group and those who were switched from IVR to IVA after ME recurrence were defined as the switching group. Patient outcomes were examined at 1 week and 1 month postinjection.

Results

Both groups comprised 27 eyes from 27 patients. There was a significant decrease in central macular thickness (CMT) at 1 week and 1 month postinjection in both groups. There was also a significant improvement in best-corrected visual acuity (BCVA) at 1 week and 1 month postinjection in the treatment-naïve group and 1 month in the switching group. Younger age was associated with a good BCVA at 1 month postinjection in the switching group, and the absence of epiretinal membrane was associated with a reduction in CMT at 1 month postinjection in the switching group.

Conclusion

IVA is temporarily effective for treating ME due to BRVO regardless of a history of IVR use.

Effect of Epiretinal Membranes on Antivascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration

PURPOSE

To evaluate the effect of epiretinal membranes (ERMs), detected with spectral-domain optical coherence tomography (SD-OCT), on the outcome of antivascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (nAMD).

METHODS

A total of 434 eyes with treatment-naive nAMD were retrospectively included and analyzed. All patients were administered an initial series of 3 monthly loading injections of ranibizumab or aflibercept, followed by further injections as required. The visual and anatomical outcomes were compared between the eyes with ERMs and those without. Features of ERMs at baseline assessed with SD-OCT were evaluated and correlated with visual outcomes.

RESULTS

Sixty-eight eyes (15.7%) with nAMD presented ERMs at baseline. The mean best-corrected visual acuity (BCVA) of these eyes, expressed as the logarithm of the minimum angle of resolution, improved from 0.75 ± 0.48 (Snellen equivalent: 20/112) to 0.59 ± 0.44 (20/77) after 12 months of treatment (P = 0.021). Central foveal thickness also decreased from 381 ± 191 μm to 294 ± 167 μm (P < 0.001). Compared to the eyes without ERMs (366 eyes), the eyes with ERMs had a significantly thicker central fovea after treatment (P = 0.020). However, the intergroup differences in BCVA improvement were not significant. No significant association was found between visual outcome after treatment and ERM features on OCT at baseline.

CONCLUSIONS

In eyes with nAMD, ERMs were infrequent. Central foveal thickness was significantly greater after anti-VEGF treatment in eyes with nAMD and ERMs. However, the presence of ERMs in eyes with nAMD did not affect visual outcome.

The vitreomacular interface in different types of age-related macular degeneration

AIM

To evaluate the vitreomacular interface in cases with wet age-related macular degeneration (AMD) and to compare them to eyes with dry AMD and normal eyes.

METHODS

This was a cross-sectional comparative study that included 87 eyes with wet AMD, 42 eyes with dry AMD and 40 eyes without AMD as a control group. Optical coherence tomography (OCT) examination was performed for all patients to assess the vitreomacular interface.

RESULTS

In the wet AMD group, 34.5% of cases had vitreomacular adhesion (VMA). Only 14.3% of dry AMD cases and 10% of control cases had VMA. There was a significant difference between the control group and the wet AMD group (P=0.004) as well as the dry and wet AMD group (P=0.017). There was also a significant difference between the incidence of VMA in patients with subretinal choroidal neovascularization (CNV, type 1) and intraretinal CNV (type 2 or type 3) (P=0.020).

CONCLUSION

There is an association between posterior vitreous attachment and AMD. There is also an increased incidence of VMA with intra-retinal CNV.

IMAGING AND MEASUREMENT OF THE PRERETINAL SPACE IN VITREOMACULAR ADHESION AND VITREOMACULAR TRACTION BY A NEW SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANALYSIS

PURPOSE

To evaluate a new method for volumetric imaging of the preretinal space (also known as the subhyaloid, subcortical, or retrocortical space) and investigate differences in preretinal space volume in vitreomacular adhesion (VMA) and vitreomacular traction (VMT).

METHODS

Nine patients with VMA and 13 with VMT were prospectively evaluated. Automatic inner limiting membrane line segmentation, which exploits graph search theory implementation, and posterior cortical vitreous line segmentation were performed on 141 horizontal spectral domain optical coherence tomography B-scans per patient. Vertical distances (depths) between the posterior cortical vitreous and inner limiting membrane lines were calculated for each optical coherence tomography B-scan acquired. The derived distances were merged and visualized as a color depth map that represented the preretinal space between the posterior surface of the hyaloid and the anterior surface of the retina. The early treatment d retinopathy study macular map was overlaid onto final virtual maps, and preretinal space volumes were calculated for each early treatment diabetic retinopathy study map sector.

RESULTS

Volumetric maps representing preretinal space volumes were created for each patient in the VMA and VMT groups. Preretinal space volumes were larger in all early treatment diabetic retinopathy study map macular regions in the VMT group compared with those in the VMA group. The differences reached statistical significance in all early treatment diabetic retinopathy study sectors, except for the superior outer macula and temporal outer macula where significance values were P = 0.05 and P = 0.08, respectively. Overall, the relative differences in preretinal space volumes between the VMT and VMA groups varied from 2.7 to 4.3 in inner regions and 1.8 to 2.9 in outer regions.

CONCLUSION

Our study provides evidence of significant differences in preretinal space volume between eyes with VMA and those with VMT. This may be useful not only in the investigation of preretinal space properties in VMA and VMT, but also in other conditions, such as age-related macular degeneration, diabetic retinopathy, and central retinal vein occlusion.

Vitreoretinal interface abnormalities in patients treatedwith ranibizumab for diabetic macular oedema

Purpose

Intravitreal anti-vascular endothelial growth factor (VEGF) agents are effective in the treatment of central involving diabetic macular oedema (DMO). Vitreoretinal interface abnormalities (VRIA) are common in patients with DMO, and the effect of these on the response to anti-VEGF treatment is unclear. Furthermore the effect of anti-VEGF agents on the VRIA itself is uncertain.

Method

Prospective study of consecutive patients treated with ranibizumab (RZB) for DMO as part of routine clinical care in one eye unit over a 1-year period. Visual acuity (Va), central retinal thickness (CRT) and injection frequency data was recorded on an electronic database. Treatment was initiated with four monthly RZB injections and then a monthly PRN regime. All patients underwent high-density spectral-domain optical coherence tomography (SDOCT) at baseline and 12 months. The SDOCTs were graded by two observers masked to the outcome.

Results

One hundred and four eyes (77 patients) were included in the analysis. The mean age was 62 years, and 62% were male. The mean presenting vision was 62 letters and CRT 472 μm. Eighty eyes retained stable Va, and 17 had an improvement in Va. At baseline, 39 eyes had associated focal vitreomacular adhesion (VMA) and by 12 months this reduced to 30 (p = 0.04), with 12 releasing VMA and three developing it. Patients with VMA had significantly better final Va than those without VMA. Improvement in CRT was greatest in those where VMA released during the study. Forty-five eyes had some degree of foveal involving epiretinal membrane (ERM) at baseline, and 28 were considered to have clinically significant ERM. There was no clinically relevant change in ERM during the study. Patients with significant ERM at baseline had a lower final vision. Multivariate analysis showed that ERM and more severe retinopathy at baseline were predictive of less visual improvement (p < 0.01). Shorter intraretinal cyst length, ERM and the absence of VMA at baseline were predictive of a worsened anatomical response (p < 0.001).

Conclusion

VRIA are related to outcome in patients treated with RZB. ERM was associated with a worsened visual and anatomic response, and VMA with an improved anatomical response particularly when spontaneous VMA release occurred during treatment. The presence and severity of ERM was not affected by RZB treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s00417-016-3562-0) contains supplementary material, which is available to authorized users.

Resolution of vitreomacular traction and pigment epithelium detachment

PURPOSE

To report a case of spontaneous combined resolution of vitreomacular traction (VMT) and pigment epithelial detachment (PED).

METHODS

A 70-year-old woman presented with a 10-day history of metamorphopsia in her right eye. Medical history was unremarkable. The patient underwent a complete ophthalmic examination. Best-corrected visual acuity (BCVA) was 20/50 in the right eye. Fundus examination, fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT) revealed a shallow elevated area with irregular edges suggestive of drusenoid avascular PED associated with VMT.

RESULTS

During the follow-up, OCT showed combined resolution of VMT and PED with almost complete normalization of the outer retinal layers; BCVA increased to 20/40.

CONCLUSIONS

The temporal sequence of events in our case strongly suggests that the spontaneous resolution of PED could be the consequence of or could be favorably influenced by the VMT resolution.

WIDE-FIELD SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To describe wide-field spectral domain optical coherence tomography morphologic relationships of the vitreous, retina, and choroid in healthy and pathologic eyes.

METHODS

Standardized horizontal, vertical, and two oblique (supertemporal to inferonasal and supranasal to inferotemporal) spectral domain optical coherence tomography sections were collected for each patient. For extramacular imaging, images were obtained from 8 locations: (1) nasal to the optic disk, (2) extreme nasal periphery, (3) superior to the superotemporal vascular arcade, (4) extreme superior periphery, (5) inferior to the inferotemporal vascular arcade, (6) extreme inferior periphery, (7) temporal to the macula, and (8) extreme temporal periphery. Wide-angle montage images of optical coherence tomography from equator-to-equator were composed with a montaging software.

RESULTS

Wide-field spectral domain optical coherence tomography scans were obtained in 10 healthy subjects, in 7 patients with central serous chorioretinopathy, in 5 patients with wet age-related macular degenerations, in 5 patients with dry age-related macular degenerations, in 4 patients with retinitis pigmentosa, and in 1 patient with acute exudative polymorphous vitelliform maculopathy.

CONCLUSION

The novel approach of montaging spectral domain optical coherence tomography images to examine relationships between the choroid, retina, and associated structures adjacent to and outside of the macula may have a number of relevant applications in the study of vitreoretinal interface, paramacular and macular pathologic features.

VITREOMACULAR TRACTION AFFECTS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT OUTCOMES FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the effect of vitreomacular traction (VMT) on visual acuity outcomes and central retinal thickness (CRT) measurements after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for treatment of exudative age-related macular degeneration (AMD).

METHODS

In this retrospective series, the authors evaluate the clinical records and optical coherence tomography of 34 eyes of 32 patients, with VMT confirmed on optical coherence tomography at baseline, to assess the effects of VMT on anti-VEGF therapy for newly diagnosed exudative wet AMD. Best-corrected visual acuity at baseline, 1, 3, 6, 9, and 12 months and CRT at baseline, 3, 6, and 12 months were assessed. Comparison was made with a control group of 29 eyes of 28 patients with wet AMD and no VMT on optical coherence tomography and with key variable-dosing studies for anti-VEGF in exudative AMD (CATT, HARBOR, PrONTO, SUSTAIN, and Gupta et al).

RESULTS

Best-corrected visual acuity results showed a visual acuity improvement that peaked at 3 months with 2.47 letters, well below other variable-dosing studies for anti-VEGF therapy in exudative AMD. This was then followed by a steady decline with mean best-corrected visual acuity at 12 months ending below the baseline level (-1.00 letters) compared with a gain of 9.39 letters in the control group at 12 months. Comparison of the mean CRT in the VMT group between baseline and 12 months showed no significant difference (P = 0.67), whereas the PrONTO study and control groups showed a highly significant difference at 12 months compared with baseline (P < 0.001). Mean CRT values at 6 months and 12 months were essentially at baseline levels (0.26 μm, -0.62 μm, respectively).

CONCLUSION

Vitreomacular traction at baseline, existing concurrently with newly diagnosed exudative AMD treated with intravitreal anti-VEGF therapy on a variable-dosing regime, was associated with poorer visual outcomes and a decreased response to reduction in CRT, compared with a control group of wet AMD without VMT and compared with major variable-dosing studies for intravitreal anti-VEGF in exudative AMD.

INFLUENCE OF VITREOMACULAR INTERFACE ON ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY USING TREAT AND EXTEND TREATMENT PROTOCOL FOR AGE-RELATED MACULAR DEGENERATION (VINTREX)

PURPOSE

To determine the influence of vitreomacular adhesion (VMA) on treatment outcomes in patients with neovascular age-related macular degeneration who were treated with anti-vascular endothelial growth factor agents using a treat and extend treatment regimen.

METHODS

A retrospective consecutive case series of 204 eyes from 181 patients with a minimum of 1 year of follow-up at Wills Eye Hospital Retina Service. Vitreomacular interface characteristics were determined by spectral domain optical coherence tomography. One hundred and fifty-three eyes (75%) had no signs of VMA (non-VMA), and 51 (25%) had VMA.

RESULTS

Baseline mean visual acuity was 20/133 with a mean central retinal thickness of 350.5 μm in the non-VMA group and was 20/145 with 371.8 μm in the VMA group. Mean visual acuity in the non-VMA group was 20/83 and 20/64 at Years 1 and 2, respectively (P < 0.01 to baseline). Mean visual acuity in the VMA group was 20/81 and 20/85 at Years 1 and 2, respectively (P < 0.01 to baseline). The central retinal thickness was 289.71 μm and 267 μm at Years 1 and 2, respectively (P < 0.01 to baseline) in the non-VMA group and was 305.3 μm and 289.24 μm (P < 0.01 to baseline) in the VMA group. The mean total number of injections at Year 1 for non-VMA was 7.4 compared with 8.4 in VMA (P = 0.001) and 5.5 versus 6.7 for the 2 groups in Year 2 (P = 0.027). The mean longest extension at Year 1 was 11.8 weeks compared with 10.1 week (P = 0.005) and for Year 2 was 14.1 weeks compared with 12 weeks (P = 0.041).

CONCLUSION

The vitreomacular interface seems to have a significant influence on anti-vascular endothelial growth factor treatment intervals but not visual acuity or exudative control outcomes. Eyes with VMA on spectral domain optical coherence tomography at baseline may require more intensive treatment with decreased ability to extend treatment intervals.

Efficacy of vitrectomy and inner limiting membrane peeling in age-related macular degeneration resistant to anti-vascular endothelial growth factor therapy, with vitreomacular traction or epiretinal membrane

PURPOSE

We assessed the efficacy of vitrectomy and inner limiting membrane (ILM) peeling, followed by anti-vascular endothelial growth factor (VEGF) therapy, anti-VEGF-resistant age-related macular degeneration (AMD) due to vitreomacular traction (VMT) or epiretinal membrane (ERM).

METHODS

We identified six patients with anti-VEGF-resistant AMD due to VMT or ERM amongst a total of 588 patients with AMD (821 eyes) referred to Okayama University Hospital between February 2012 and May 2014. These patients underwent vitrectomy to release the VMT (4 cases) or remove the ERM (2 cases), along with ILM peeling. The regimen used for intravitreal injections of anti-VEGF reagents after surgery was based on the severity of exudative changes in each patient. Preoperative and postoperative best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements were compared.

RESULTS

After vitrectomy and ILM peeling, all six patients responded to anti-VEGF therapy, which was then able to maintain dry retinas. Mean BCVA did not improve significantly (0.49 ± 0.28 before vs. 0.43 ± 0.38 after surgery, P = 0.538). However, mean CR was significantly decreased after surgery, from 423 ± 83.5 μm to 257 ± 75.8 μm (P = 0.0078).

CONCLUSIONS

Vitrectomy and ILM peeling followed by anti-VEGF therapy may be a useful therapeutic option for anti-VEGF-resistant AMD with VMT or ERM.

EPIRETINAL MEMBRANES IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Effect on Outcomes of Anti-vascular Endothelial Growth Factor Therapy

PURPOSE

To iatients with neovascular age-related macular degenernvestigate the role of epiretinal membrane (ERM) on outcomes of anti-vascular endothelial growth factor therapy in pation (nAMD).

METHODS

This study is a retrospective observational case series and was conducted at the Gazi University School of Medicine, Ankara, Turkey. The reports of the patients with a diagnosis of new-onset nAMD, who were aged at least 50 years and treated with intravitreal anti-vascular endothelial growth factors (ranibizumab or bevacuzimab) between October 2010 and September 2013 in our retina clinic, were reviewed for the vitreomacular interface changes.

RESULTS

The study included 90 eyes of 90 patients with nAMD. The mean age of the patients was 70 ± 7.5 years, with 35 (38.9%) being male and 55 (61.1%) being female. According to the examinations with optical coherence tomography and B-mode ultrasonography, 43 patients had "concurrent" vitreomacular adhesion (30 focal, 13 broad; Group 1). Twenty-nine patients had complete posterior vitreous detachment (Group 2) and 18 patients (Group 3) had ERM. The number of injections was highest for the patients with ERM (Group 3), and this difference was statistically significant (P < 0.001). The mean interval between injections and the mean longest interval were shorter in Group 3 (P < 0.05).

CONCLUSION

The presence of ERM in association with nAMD seems to increase the number of anti-vascular endothelial growth factor injections and decrease the injection intervals for the treatment of nAMD. Although the anatomical and functional results are similar in eyes with or without ERM, the increased need for anti-vascular endothelial growth factors may mean that these membranes may decrease the penetration of the drugs through these membranes, which may act as a physical barrier. Additionally, increased inflammation in patients with ERM probably requires more frequent injections.

Gas-mediated vitreomacular adhesion release with intravitral ranibizumab injections for exudative age-related macular degeneration

PURPOSE

To evaluate the efficiency of gas-assisted vitreomacular adhesion (VMA) release combined with intravitreal ranibizumab injections for exudative age-related macular degeneration (AMD) patients.

MATERIALS AND METHODS

This prospective, interventional case series included a total of 23 eyes of 22 patients. The eyes were treated with intravitreal injection of 0.3 mL of perfluoropropane (C3F8) gas and concomitant intravitreal ranibizumab injection to stimulate VMA release. After three initial loading injections, additional intravitreal ranibizumab injections were performed pro re nata. Over a 12-month period, monthly examinations were performed for best-corrected visual acuity (BCVA, logMAR; logarithm of the minimum angle resolution), optical coherence tomography, and dilated fundus examinations.

RESULTS

After gas injection, 22 eyes (95.7 %) showed complete VMA release at 1 week. Complete VMA was achieved in all eyes at 2 months after VMA release, without serious ocular adverse events except one patient who developed a retinal tear. Mean BCVA was 0.61 ± 0.37 logMAR (20/81 Snellen equivalents) at baseline and 0.46 ± 0.30 logMAR (20/57 Snellen equivalents) at 12 months (P = 0.135). Mean central macular thickness was 357.9 ± 128.6 μm at baseline and 245.6 ± 60.0 μm at 12 months (P = 0.188). Mean numbers of intravitreal ranibizumab injections were 4.8 ± 2.4 times during 12 months (4 to 8 injections).

CONCLUSION

Gas-assisted VMA release can be used as an efficient alternative for exudative AMD patients with obvious VMA.

Effects of Vitreomacular Traction on Ranibizumab Treatment Response in Eyes with Neovascular Age-related Macular Degeneration

PURPOSE

To investigate the effects of vitreomacular traction (VMT) on ranibizumab treatment response for neovascular age-related macular degeneration (AMD).

METHODS

A retrospective review of 85 eyes of 85 patients newly diagnosed with neovascular AMD was conducted. Patients were eligible if they had received more than three consecutive monthly ranibizumab (0.50 mg) treatments and ophthalmic evaluations. Patients were classified into a VMT (+) group or VMT (-) group according to optical coherence tomography imaging. Best corrected visual acuity and central retinal thickness (CRT) measurements were obtained at three and six months after initial injection.

RESULTS

One month after the third injection, mean visual acuity (VA) increases of 6.36 and 9.87 letters were observed in the VMT (+) and VMT (-) groups, respectively. The corresponding mean CRT values decreased by 70.29 µm and 121.68 µm, respectively. A total 41 eyes were identified as eligible for a subsequent fourth injection; 71.1% of patients (27 eyes) in the VMT (+) group but only 29.8% of patients in the VMT (-) group needed a subsequent fourth injection. Follow-up was extended to six months for 42 of the 85 enrolled patients (49.4%). The trends in VA and optical coherence tomography were found to be maintained at six-month follow-up.

CONCLUSIONS

VA and CRT appeared to be more improved after ranibizumab treatment in the VMT (-) group compared to the VMT (+) group. VMT might antagonize the effect of ranibizumab treatment in a subpopulation of AMD patients.

Influence of the vitreomacular interface on the efficacy of intravitreal therapy for uveitis-associated cystoid macular oedema

PURPOSE

To evaluate the effect of the vitreomacular interface (VMI) on treatment efficacy of intravitreal therapy in uveitic cystoid macular oedema (CME).

METHODS

Retrospective analysis of CME resolution, CME recurrence rate and monthly course of central retinal thickness (CRT), retinal volume (RV) and best corrected visual acuity (BCVA) after intravitreal injection with respect to the VMI configuration on spectral-domain OCT using chi-squared test and repeated measures anova adjusted for confounding covariates epiretinal membrane, administered drug and subretinal fluid.

RESULTS

Fifty-nine eyes of 53 patients (mean age: 47.4 ± 16.9 years) were included. VMI status had no effect on complete CME resolution rate (p = 0.16, corrected p-value: 0.32), time until resolution (p = 0.09, corrected p-value: 0.27) or CME relapse rate (p = 0.29, corrected p-value: 0.29). Change over time did not differ among the VMI configuration groups for BVCA (p = 0.82) and RV (p = 0.18), but CRT decrease was greater and faster in the posterior vitreous detachment (PVD) group compared to the posterior vitreous attachment (PVA) and vitreous macular adhesion (VMA) groups (p = 0.04). Also, the percentage of patients experiencing a ≥ 20% CRT thickness decrease after intravitreal injection was greater in the PVD group (83%) compared to the VMA (64%) and the PVA (16%) group (p = 0.027), however, not after correction for multiple testing (corrected p-value: 0.11).

CONCLUSION

The VMI configuration seems to be a factor contributing to treatment efficacy in uveitic CME in terms of CRT decrease, although BCVA outcome did not differ according to VMI status.

Predictive Value of Retinal Morphology for Visual Acuity Outcomes of Different Ranibizumab Treatment Regimens for Neovascular AMD

PURPOSE

To establish the predictive value of defined retinal morphologic parameters on visual outcomes and re-treatment needs in patients with neovascular age-related macular degeneration (nAMD) receiving ranibizumab treatment.

DESIGN

Post hoc analysis of a prospective, 12-month, multicenter, phase IIIb trial.

PARTICIPANTS

Three hundred fifty-three treatment-naïve patients with nAMD.

METHODS

Available data from 319 treatment-naïve patients receiving ranibizumab 0.3 mg monthly (frequent regimen; n = 102) or ranibizumab 0.3 or 0.5 mg quarterly (pooled 0.3/0.5 mg = infrequent regimen; n = 217) were analyzed to assess the correlations between baseline retinal morphologic parameters and best-corrected visual acuity (BCVA) change (structure-function correlations). The BCVA was measured at monthly visits. Optical coherence tomography scans were acquired monthly for quantitative measures of the central retinal thickness and qualitative assessment of retinal morphologic features. Assessed morphologic parameters included intraretinal cystoid fluid (IRC), subretinal fluid (SRF), pigment epithelial detachment, and vitreomacular interface configuration classification comprising vitreomacular adhesion and posterior vitreous detachment (PVD). An analysis of covariance was conducted to evaluate the impact of retinal morphologic features on BCVA change at month 12.

MAIN OUTCOME MEASURES

Change in BCVA from baseline to month 12 compared between frequent and infrequent treatment arms.

RESULTS

Relevant predictive factors for BCVA change at month 12 were baseline SRF (P = 0.05), PVD (P = 0.03), IRC (P = 0.05), treatment frequency (P < 0.01), and BCVA (P < 0.01). The presence of both SRF and PVD at baseline was associated with similar BCVA gains regardless of treatment frequency (mean difference in BCVA gains at month 12 of +2.6 letters in favor of infrequent treatment). Subretinal fluid was present in 71% of patients, and PVD was present in 64% of patients.

CONCLUSIONS

In patients with both SRF and PVD at baseline, similar BCVA outcomes were observed regardless of treatment frequency. These patients may require less frequent treatments compared with patients without SRF, without PVD, or without either who may require more frequent injections for maintenance of vision. This finding may have implications in clinical practice by helping to tailor an individualized re-treatment interval in nAMD patients.

Effects of Vitreomacular Adhesion on Age-Related Macular Degeneration

Herein, we review the association between vitreomacular adhesion (VMA) and neovascular age-related macular degeneration (AMD). Meta-analyses have shown that eyes with neovascular AMD are twice as likely to have VMA as normal eyes. VMA in neovascular AMD may induce inflammation, macular traction, decrease in oxygenation, sequestering of vascular endothelial growth factor (VEGF), and other cytokines or may directly stimulate VEGF production. VMA may also interfere with the treatment effects of anti-VEGF therapy, which is the standard treatment for neovascular AMD, and releasing VMA can improve the treatment response to anti-VEGF treatment in neovascular AMD. We also reviewed currently available methods of relieving VMA.

Influence of the Vitreomacular Interface on Treatment Outcomes in the Comparison of Age-Related Macular Degeneration Treatments Trials

OBJECTIVE

To assess the association of the vitreomacular interface with outcomes of eyes treated with anti-vascular endothelial growth factor drugs for neovascular age-related macular degeneration (AMD).

DESIGN

Prospective cohort study within a multicenter, randomized clinical trial.

PARTICIPANTS

Patients enrolled in the Comparison of AMD Treatments Trials (CATT).

METHODS

Treatment was assigned randomly as either ranibizumab or bevacizumab and as 3 different regimens for dosing over a 2-year period. Masked readers at a reading center assessed optical coherence tomography (OCT) scans at baseline and follow-up for vitreomacular traction (VMT) and vitreomacular adhesion (VMA), fluid, and central thickness. Visual acuity (VA) was measured by masked, certified examiners.

MAIN OUTCOME MEASURES

Anatomic features and VA at baseline and 1 and 2 years and number of treatments.

RESULTS

At baseline, 143 patient eyes (12.8%) had VMT or VMA. Compared with those with neither (n = 972), patients with VMT or VMA were younger (mean ± standard error, 75.5 ± 0.6 vs. 79.7 ± 0.24 years; P < 0.0001) and more likely to be male (52.4% vs. 36.2%; P = 0.0003), to be cigarette smokers (68.5% vs. 55.3%; P = 0.003), and to have subretinal fluid on OCT (86.7% vs. 81.0%; P = 0.047). Vitreomacular interface status was not associated with VA at baseline or follow-up. Among eyes treated as needed (n = 598) and followed up for 2 years (n = 516), the mean number of injections was 15.4 ± 0.9 for eyes having VMT at baseline or during follow-up (n = 60), 13.8 ± 0.7 for eyes with VMA at baseline or follow-up (n = 79), and 12.9 ± 0.4 (P = 0.02) for eyes without VMT or VMA (n = 377). In addition, the mean number of injections in eyes treated as needed increased from 13.0 ± 0.3 when VMT was not observed to 13.6 ± 1.3 when observed once and to 17 ± 1.2 when observed more than once during follow-up. At 2 years, geographic atrophy developed in a lower percentage of eyes with VMT or VMA at baseline (11.7%) than with neither condition (22.5%; P = 0.005).

CONCLUSIONS

In eyes in the CATT, VMT and VMA were infrequent. At baseline and follow-up, VMT or VMA were not associated with VA. Eyes with VMT or VMA treated as needed required on average 2 more injections over 2 years.

Enhanced High-Density Line Spectral-Domain Optical Coherence Tomography Imaging of the Vitreoretinal Interface: Description of Selected Cases

PURPOSE

We introduce a new method to observe the morphologic features of the vitreous with spectral-domain optical coherence tomography (SD-OCT) by evaluating and describing the posterior vitreous structure of various selected cases using enhanced high-density (HD) line mode.

METHODS

This is a descriptive case series of SD-OCT images with enhanced HD line at Denver Health Medical Center, University of Colorado School of Medicine, in 2014. The medical records with ocular images for these patients were analyzed.

RESULTS

Enhanced HD line in vitreoretinal mode with SD-OCT offered wide images with well-visible vitreoretinal interface. The posterior precortical vitreous pocket (PPVP), often mistaken as a posterior vitreous detachment on standard retina-based cross line mode, was easily identified. Vitreomacular adhesion and traction, absence or presence of connecting channels between PPVP and Cloquet's canal, liquefied vitreous lacuna, and emulsified silicone oil droplet-layer could be observed.

CONCLUSIONS

SD-OCT using enhanced HD line in vitreoretinal mode enables clear visualization of the posterior vitreous structure and often reclassifies patients previously thought to have a posterior vitreous detachment.

Treating the untreatable patient: current options for the management of treatment-resistant neovascular age-related macular degeneration

Anti-vascular endothelial growth factor (anti-VEGF) agents represent the current standard of care for neovascular age-related macular degeneration (nAMD). Although effective in a majority of cases, a significant proportion of patients have persisting retinal exudation despite regular anti-VEGF therapy. This exudation is considered to produce poorer visual outcomes in these patients. Some of these patients may have misdiagnosed nAMD variants such as polypoidal choroidal vasculopathy; however, the majority of these eyes have what has been termed treatment-resistant nAMD. Currently, the best way to care for these patients is uncertain. Here, we review the evidence for different approaches to the management of treatment-resistant nAMD, including high-dose anti-VEGF therapy, combination regimes and switching of anti-VEGF agents, and discuss possible therapeutic approaches for patients with treatment-resistant nAMD.

Impact of vitreomacular adhesion on ranibizumab mono- and combination therapy for neovascular age-related macular degeneration

PURPOSE

To investigate the influence of vitreomacular adhesion on the efficacy of pro re nata (PRN) ranibizumab monotherapy and verteporfin photodynamic therapy (PDT) combination therapy for neovascular age-related macular degeneration.

DESIGN

Post hoc analysis of prospective randomized 12-month multicenter clinical trial data.

METHODS

PATIENT POPULATION

Total of 255 treatment-naïve patients with subfoveal choroidal neovascularization.

OBSERVATION PROCEDURE

Assessment of the vitreomacular interface on monthly optical coherence tomography with division of patients into the following categories according to continuous 1-year grading: posterior vitreous detachment (n=154), dynamic release of vitreomacular adhesion (n=32), stable vitreomacular adhesion (n=51).

MAIN OUTCOME MEASURES

Mean best-corrected visual acuity (BCVA) letter and central retinal thickness changes at month 12 in the vitreomacular interface groups.

RESULTS

Mean BCVA changes at month 12 were +3.5 (posterior vitreous detachment), +4.3 (release of vitreomacular adhesion), and +6.3 (vitreomacular adhesion) in patients receiving monotherapy (P=.767), and +0.1 (posterior vitreous detachment), +6.6 (release of vitreomacular adhesion), and +9.2 (vitreomacular adhesion) in patients receiving combination therapy (P=.009). Mean central retinal thickness changes were -113 μm (posterior vitreous detachment), -89 μm (release of vitreomacular adhesion), and -122 μm (vitreomacular adhesion) in monotherapy (P=.725) and -121 μm (posterior vitreous detachment), -113 μm (release of vitreomacular adhesion), and -113 μm (vitreomacular adhesion) in combination therapy (P=.924). Mean ranibizumab retreatments during 12 months were 4.9 (posterior vitreous detachment), 6.6 (release of vitreomacular adhesion), and 5.3 (vitreomacular adhesion) in monotherapy (P=.018) and 4.7 (posterior vitreous detachment), 5.2 (release of vitreomacular adhesion), and 5.8 (vitreomacular adhesion) in combination therapy (P=.942).

CONCLUSION

This study adds evidence that the vitreomacular interface status impacts functional outcomes and retreatment requirements. Patients with posterior vitreous detachment achieve acceptable results with fewer injections in PRN monotherapy, but lose potential vision gain with PDT. Patients with other vitreomacular interface configurations may potentially achieve optimized vision outcomes by combination of antiangiogenic treatment and vaso-occlusive PDT.