Consistent Long-Term Therapy of Neovascular Age-Related Macular Degeneration Managed by 50 or More Anti-VEGF Injections Using a Treat-Extend-Stop Protocol

Long-term results of treatment of neovascular age-related macular degeneration using antiangiogenic drugs: A review of the literature

Age-related macular degeneration (AMD) is one of the main causes of visual acuity (VA) loss in people over 50 years of age worldwide, with neovascular AMD (nAMD) accounting for 80% of cases of severe vision loss due to this disease. Anti-vascular endothelial growth factor (anti-VEGF) drugs have been used for the treatment of this disease for more than a decade, changing drastically the visual prognosis of these patients. However, initial studies reporting data on outcomes were short term. Currently, there are different series published on the long-term results of AMD after treatment with anti-VEGF, and the aim of this review is to synthesize these results. The mean follow-up of the included studies was 8.2 years (range 5-12 years). The mean initial VA was 55.3 letters in the Early Treatment Diabetic Retinopathy Study (ETDRS) (range 45.6-65) and the mean final VA was 50.1 letters (range 33.0-64.3), with a mean loss of 5.2 letters. At the end of follow-up, 29.4% of the patients maintained a VA > 70 letters. The 67.9% of patients remained stable at the end of follow-up (< 15 letter loss), with a severe loss (≥ 15 letters) of 30.1%. Fibrosis and atrophy were the main causes of long-term VA loss, occurring at the end of follow-up in 52.5% and 60.5%, respectively.

Safety and efficacy of ixoberogene soroparvovec in neovascular age-related macular degeneration in the United States (OPTIC): a prospective, two-year, multicentre phase 1 study

Background

Gene therapy, successfully used in rare, monogenetic disorders, may prove to be a durable management approach for common, polygenetic conditions, including neovascular age-related macular degeneration (nAMD). Repeated injections, oftentimes monthly, and possibly for decades, of vascular endothelial growth factor antagonists (anti-VEGF), is the standard for nAMD. We hypothesised that an in-office, intravitreal administration of ixoberogene soroparvovec (ixo-vec, formerly ADVM-022), a single-dose gene therapy encoding for the proven anti-VEGF protein, aflibercept, would transform retinal cells to continually produce aflibercept to minimise treatment burden in nAMD.

Methods

In this two-year, open-label, prospective, multicentre phase 1 study, patients with nAMD responding to anti-VEGF were assigned to four cohorts differing by ixo-vec dose (2 × 1011 vs 6 × 1011 vector genomes (vg/eye)) and prophylactic steroids (oral prednisone vs topical difluprednate). The primary outcome was the type, severity, and incidence of ocular and systemic adverse events (AEs); secondary endpoints included vision, central subfield thickness (CST), and the number of supplemental injections. This study was registered with ClinicalTrials.gov, NCT03748784.

Findings

Thirty patients with nAMD were enrolled between November 14, 2018 and June 30, 2020 at nine study sites in the United States. No systemic ixo-vec related AEs were noted. Across both dose groups the most common adverse event was anterior chamber cell, which was reported in 11 participants in the 6 × 1011 dose group and in 7 participants in the 2 × 1011 dose group; intraocular inflammation was responsive to topical corticosteroids, with no anterior chamber cells or vitreous cells observed in 2 × 1011 vg/eye patients at the end of the study. Vision and CST remained stable throughout two years with annualised anti-VEGF injections reduced by 80% (10.0 mean annualised anti-VEGF injections to 1.9) in 2 × 1011 vg/eye and 98% (9.8 mean annualised anti-VEGF injections to 0.2) in 6 × 1011 vg/eye cohorts.

Interpretation

Ixo-vec was generally well-tolerated, maintained vision, and improved anatomical outcomes in nAMD, with a substantial reduction in anti-VEGF injections. A single administration of an in-office gene therapy, with vectorised protein with an already established clinical benefit, has the potential to revolutionise the management of common ocular disorders requiring ongoing, frequent therapeutic interventions.

Funding

Adverum Biotechnologies.

Outcomes of Intentionally Suspending Treatment in Eyes With Advanced Neovascular Age-Related Macular Degeneration

PURPOSE

To determine the outcomes of intentionally suspending anti-vascular endothelial growth factor (anti-VEGF) injections in eyes with advanced neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective cohort study.

METHODS

The study sample comprised 93 patients with nAMD and best available Snellen visual acuity (VA) ≤20/400 in which anti-VEGF treatment was suspended by the treating physician. VA and optical coherence tomography (OCT) characteristics were evaluated to determine visual and anatomical outcomes up to 24 months after treatment suspension.

RESULTS

A total of 93 eyes from 93 patients who had received a mean of 16 anti-VEGF injections over a mean of 962 (SD 562) days were included. Comparing the treatment suspension visit to 24 months later, no significant change in mean central foveal thickness (163 [SD 118, range 19-704] μm vs 164 [SD 217, range 19-1468], P = .97), greatest lesion diameter (2547 [SD 1294, range 134-5707] μm vs 2442 [SD 1158, range 421-5305] μm, P = .43), greatest lesion thickness (194 [SD 136, range 0-618] μm vs 205 [SD 131, range 0-573] μm, P = .40), or VA (1.87 [SD 0.37], 20/1482, vs 1.94 [SD 0.28], 20/1741, P = .16) was found. In total, 7 eyes (7.5%) restarted treatment following a mean of 977 (SD 450) days after treatment suspension.

CONCLUSIONS

Suspension of anti-VEGF injections in eyes with advanced nAMD and VA ≤20/400 may be reasonable in cases where the treating physician deems additional treatment is unlikely to provide benefit. Although the visual and anatomical findings remained stable after treatment suspension in most, a small number restarted anti-VEGF therapy, suggesting that eyes should still be monitored for disease progression.

Real-world evidence in the use of Bevacizumab in age-related macular degeneration (ArMD): a scoping review

PURPOSE

Pharmacological treatments for age-related macular degeneration (ArMD) include anti-vascular endothelial growth factor therapies. Bevacizumab is used off-label, as it has no indication for ArMD. This study aims to identify and describe literature on real-world evidence of bevacizumab (originator or biosimilars) use in ArMD.

METHODS

A scoping review was conducted in Medline, CINAHL and Embase databases. Studies published in English after September 2017, conducted in USA, including adults (≥ 18 years old) with ArMD who received treatment with bevacizumab for ArMD were included. The review was further limited to peer-reviewed observational studies that quantitatively analyze either clinical or patient-reported outcomes among patients treated with bevacizumab for ArMD.

RESULTS

The search strategy retrieved 543 studies. After title and abstract screening, a total of 142 studies were selected for full-text review leading to a total of 12 studies qualifying for data charting. All were retrospective studies. Five (41.6%) of the studies had less than 500 eyes included in the analysis, and the rest had over a thousand eyes. All except one study reported clinical outcomes (visual acuity was the main outcome in 8 (66.6%) studies). There were 3 (25%) studies reporting adverse events of bevacizumab intravitreal injections. None of the studies specified using biosimilars for bevacizumab and none mentioned patient-reported outcomes.

CONCLUSION

The lack of studies aiming to study the patient-reported outcomes as well as the use of biosimilars of bevacizumab in ArMD makes this field a potential for future research. The different exposures and times to follow-up make it difficult to compare results among the selected studies.

Spectral-domain optical coherence tomography combined with electroretinography in the assessment of conbercept for neovascular age-related macular degeneration: a preliminary study

Objective

To observe the effect of three consecutive intravitreal injections of conbercept in the treatment of neovascular age-related macular degeneration (nAMD), to investigate the correlation between retinal anatomy and retinal function by spectral-domain optical coherence tomography (SD-OCT) and electroretinography (ERG), to evaluate the short-term clinical efficacy of conbercept in the treatment of nAMD, and to explore the value of ERG as a predictor of treatment efficacy.

Method

A retrospective investigation was conducted on 36 patients (36 eyes) treated with intravitreal injections of conbercept at 0.5 mg a month for three consecutive courses. Data collected included the best corrected visual acuity (BCVA), central retinal thickness (CRT), retinal pigment epithelium (RPE) elevation volume in 1 mm-diameter (1RV), 3 mm-diameter (3RV), and 6 mm-diameter circles around the fovea (6RV), amplitude density and latency of the P1 wave in the multifocal electroretinography (mf-ERG) R1 ring and amplitude and latency in full-field electroretinography (ff-ERG) at baseline and monthly. The paired t test was used to compare the difference between pre- and posttreatment. Pearson correlation analysis was used to analyze the correlation between macular retinal structure and function. The difference was significant when p < 0.05.

Results

At 12 weeks, the BCVA, CRT, 1RV, 3RV, 6RV, the P1 wave amplitude density of the mf-ERG R1 ring and the ff-ERG amplitude parameters were all significantly improved (p < 0.001). The BCVA in logMAR was positively correlated with CRT; 1RV, 3RV, and 6RV were negatively correlated with the amplitude density and latency of the mf-ERG R1 ring P1 wave. There were no severe ocular or systemic complications during the follow-up period.

Conclusion

Conbercept is useful for the short-term treatment of nAMD. It can safely improve the visual acuity of affected eyes and restore the structure and function of the retina. ERG could serve as an objective indicator of function for evaluating the efficacy of and determining the need for retreatment during nAMD treatment.

Seven-year outcomes following intensive anti-vascular endothelial growth factor therapy in patients with exudative age-related macular degeneration

BACKGROUND

Anti-vascular endothelial growth factor (VEGF) therapy is currently the most effective therapy of exudative age-related macular degeneration (AMD). The aim of this study was to assess long-term benefits of intensive aflibercept and ranibizumab anti-VEGF therapy in patients with exudative AMD.

METHODS

Two clinical trial sites recruited their original subjects for a re-evaluation 7 years after the baseline visit of the phase-3 Vascular Endothelial Growth Factor (VEGF) Trap-Eye: Investigation of Efficacy and Safety in Wet Age-Related Macular Degeneration (VIEW 2) trial. Forty-seven eyes of 47 patients with AMD originally treated with ranibizumab (14 eyes) or aflibercept (33 eyes) were included.

RESULTS

Mean number of injections was 17.8 ± 3.0 during participation in the VIEW 2 trial. Fourteen of 47 (30%) eyes were given additional injections with a mean number of 5.7 ± 4.5 after the trial. At a mean follow-up time of 82 ± 5 months best corrected visual acuity (BCVA) remained stable or improved (≤ 10 letters lost) in 55% of patients in the entire study population, in 43% in the ranibizumab group and in 60% in the aflibercept group. In both groups combined mean BCVA was 54 ± 13 letters at baseline, 65 ± 17 letters at the end of the intensive phase and 45 ± 25 letters at the end of follow-up. There was no statistically significant difference in BCVA between the two groups at baseline (p = 0.88) and at the end of follow-up (p = 0.40). Macular atrophy was observed in 96% of eyes, average area was 7.22 ± 6.31 mm² with no statistically significant difference between groups (p = 0.47). Correlation between BCVA at end-of-follow-up and the area of atrophy was significant (p < 0.001). At the end of follow-up, fluid was detected in 7 of 47 eyes (15%) indicating disease activity.

CONCLUSION

Long-term efficacy of aflibercept and ranibizumab was largely consistent. Following a two-year intensive therapy with as-needed regimen, BCVA was maintained or improved in almost half of the patients and in the ranibizumab group and more than half of the patients in the aflibercept group with very few injections. In a remarkable proportion of eyes, BCVA declined severely which underlines the need for long-term follow-ups and may indicate a more prolonged intensive therapy.

TRIAL REGISTRATIONS

VIEW 2 study: ClinicalTrials.gov ID: NCT00637377, date of registration: March 18, 2008. Long-term follow-up: IRB nr.: SE RKEB 168/2022, ClinicalTrials.gov ID: NCT05678517, date of registration: December 28, 2022, retrospectively registered.

Longer treatment intervals are associated with reduced treatment persistence in neovascular age related macular degeneration

AIMS

To test the hypothesis that patients treated for neovascular age related macular degeneration (nAMD) with longer treatment intervals are more likely to persist with treatment.

METHODS

Data were obtained from the prospectively-defined Fight Retinal Blindness! registry. Treatment interval at 2 years was stratified based on the mean treatment interval over the three visits prior to and including the 2-year visit. Rates of non-persistence to follow-up were assessed from 2 to 5 years.

RESULTS

Data from 1538 eyes were included. The overall rate of non-persistence was 51% at 5 years. Patients on longer treatment intervals (12-weeks) at 2 years were found to be less persistent to long-term follow-up. These eyes were found to have fewer active disease visits in the first 2 years (40%) than eyes treated at 4-weekly intervals (66%, p < 0.001). In the multivariable analysis, better vision at 2 years was associated with a lower risk of non-persistence (hazards ratio [HR] [95% CI]: 0.95 [0.93, 0.97], P < 0.001), while longer treatment intervals (HR [95% CI]: 1.31 [0.95, 1.8] and 1.54 [1.15, 2.06] for 12-week and > 12-week intervals vs. 4-week intervals, respectively, P = 0.002) and older patients (HR [95% CI]: 1.03 [1.02, 1.04], p < 0.001) were at higher risk of non-persistence.

CONCLUSIONS

We found that patients on longer treatment intervals at 2 years were more likely to be non-persistent with treatment in later years. Reinforcing the need for ongoing treatment is important for patients on longer intervals who may feel complacent or that treatment is no longer effective, particularly if newer, longer lasting agents become widely available.

[Three-year follow-up study of clinical effectiveness of antiangiogenic therapy for neovascular age-related macular degeneration]

PURPOSE

The study analyzes long-term (three years) clinical effectiveness of anti-VEGF treatment of neovascular age-related macular degeneration (nAMD) and attempts to identify the most clinically significant associations between the functional and structural parameters.

MATERIAL AND METHODS

The study included 122 patients (122 eyes) diagnosed with nAMD, mean age -73.4±6.6 years old. Prospective follow-up lasted 144 weeks. All patients were treated with angiogenesis inhibitor (aflibercept 2 mg), and most of them (72.9%) - according to the Treat-and-Extend protocol.

RESULTS

The average number of injections was 7.39±1.28, 4.63±0.97 and 4.06±0.81 during the first, second and third years of the follow-up, respectively. The mean baseline best-corrected visual acuity (BCVA) was 0.24±0.21. After three loading doses, BCVA increased to 0.33±0.26 (+0.09; 37.5%), by the end of follow-up BCVA was 0.35±0.27 (+0.11; 45.8%). Central retinal thickness (CRT) decreased from 314.89±88.07 μm to 234.4±42.8 μm (a 25.5% decrease) by the end of the follow-up. After three loading injections baseline functional and anatomical parameters had the most significant correlations (r≥0.7, p<0.05) with intraretinal fluid, ellipsoid zone integrity and the area of macular atrophy.

CONCLUSIONS

Analysis of the morphological and functional outcomes by the end of the first year demonstrates the feasibility of preserving the results while reducing the number of visits and injections according to the Treat-and-Extend protocol. Achieving maximum improvement of functional parameters most significantly correlated with changes in such biomarkers as central retinal thickness, area of macular atrophy and integrity of the ellipsoid zone.

Long-Term Visual Outcomes in Exudative Age-Related Macular Degeneration Patients With Unanticipated Gaps in Therapy

BACKGROUND AND OBJECTIVES

This study's objective was to describe long-term visual outcomes of patients with age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor injections who were lost to follow-up and then resumed treatment with anti-vascular endothelial growth factor injections.

MATERIALS AND METHODS

This was a retrospective cohort study of eyes with at least 7 years of follow-up following the initiation of treatment for wet AMD with and without gaps in therapy.

RESULTS

The baseline mean logMAR visual acuity was 0.65 ± 0.5 (Snellen acuity 20/89) in eyes with gaps in therapy and 0.53 ± 0.3 (20/68) in eyes without gaps. In the initial 7-year follow-up period, the eyes with gaps in therapy had significantly worse visual acuity (P < .001) and this remained significant when accounting for baseline visual acuity (P < .001).

CONCLUSIONS

Gaps in intravitreal injection therapy for exudative AMD were negatively associated with visual acuity. Adherence to therapy is important to address in the care of patients with exudative AMD. [Ophthalmic Surg Lasers Imaging Retina 2022;53:481-489.].

Delayed anti-VEGF injections during the COVID-19 pandemic and changes in visual acuity in patients with three common retinal diseases: A systematic review and meta-analysis

The COVID-19 pandemic disrupted the regular injections of anti-vascular endothelial growth factor (anti-VEGF) in patients with various retinal diseases globally. It is unclear to what extent delayed anti-VEGF injections have worsened patients’ visual acuity. We performed a meta-analysis to assess the impact of delayed anti-VEGF injections on the best-corrected visual acuity (BCVA) in patients with neovascular age-related macular degeneration (nAMD), retinal vein occlusion (RVO), and diabetic macular edema (DME). We searched four computer databases (EMBASE, MEDLINE, Web of Science, Scopus) from inception to January 5, 2022. Data were pooled using the random-effects model. Results were reported by less than 4 months and 4 months or longer for the time period between the first injection during the pandemic and the last pre-pandemic injection. All BCVA measures were converted to the logarithm of the minimum angle of resolution (logMAR) for analyses. Among patients who received injections 4 months or longer apart, the mean difference in BCVA was 0.10 logMAR (or 5 ETDRS letters) (95% confidence interval [CI] 0.06∼0.14) for nAMD patients, 0.01 logMAR (or∼ 1 ETDRS letter) (95% CI -0.25∼0.27) for RVO patients, and 0.03 logMAR (or ∼1 ETDRS letters) (95% CI -0.06∼0.11) for DME patients. These results suggest that patients with nAMD needing scheduled anti-VEGF injections may require priority treatment over those with RVO and DME in the event of disturbed anti-VEGF injections from COVID-19 lockdowns or similar scenarios.

The Influence of COVID-19 on the Stability of Patients with Neovascular Age-Related Macular Degeneration with Different Treatment Regimens

Introduction

To explore the impact of coronavirus disease 2019 (COVID-19) on the stability of patients with neovascular age-related macular degeneration (nAMD) receiving the treat and extend (T&E) or the pro re nata (PRN) treatment regimen and to identify indicators that may predict the disease stability of nAMD.

Methods

This is a retrospective study of patients with nAMD treated at the Second Affiliated Hospital of Harbin Medical University whose treatment schedule was interrupted at least once between 1 February and 31 May 2020. The demographic and clinical characteristics, including the best corrected visual acuity (BCVA), optical coherence tomography (OCT) features, subfoveal choroidal thickness (SFCT), interval between the last injection and the beginning of the pandemic, and the number of anti-vascular endothelial growth factor (VEGF) injections, were analyzed.

Results

A total of 209 stable patients with nAMD (122 eyes received the T&E regimen; 87 eyes received the PRN regimen) were identified. Compared to those who received the PRN regimen, the patients who received the T&E regimen were more stable during the first visit after COVID-19 (53.3% vs. 33.3%, P = 0.004), the BCVA was significantly better (58.5 letters vs. 56 letters, P = 0.006), and the CRT fluctuated only slightly (15 μm vs. 35 μm, P = 0.001). Furthermore, a multivariate logistic regression analysis showed that stable patients with nAMD with type 1 choroidal neovascularization (CNV) (OR 2.493 [95% CI 1.179–5.272], compared with type 2 CNV; P = 0.017; OR 2.912 [95% CI 1.133–7.485], compared with retinal angiomatous proliferation; P = 0.026) or with pigment epithelial detachment (PED) were more likely to remain stable when treatment was interrupted (OR 0.392 [95% CI 0.181–0.852], compared with no PED; P = 0.018).

Conclusion

Compared to patients who received the PRN treatment regimen, stable patients with nAMD who received the T&E treatment regimen could better maintain stability when the treatments were suddenly interrupted by the COVID-19 pandemic. In addition, patients with type 1 CNV or patients with PED were more likely to remain stable. At present, the COVID-19 pandemic is becoming increasingly normalized, and the T&E regimen can become a more advanced treatment option for patients undergoing therapy.

Long term results of patients with neovascular age-related macular degeneration switched from other anti-VEGF agents to intravitreal Aflibercept

Background

This study explores the long term anatomic and functional results of patients who were switched to intravitreal aflibercept injections (IAI) after being initially managed with other anti-VEGF agents for neovascular age-related macular degeneration (nAMD).

Methods

Patients with nAMD were included if they started with another anti-VEGF agent and were switched to IAI. Subjects had at least 3 years of consistent therapy with IAI and at least 1 injection quarterly.

Results

Eighty-eight patients had at least 3 years of treatment while 58 of those patients, had at least 4 years of IAI. Average treatment time with other anti-VEGF agents was 32 months prior to switching. Baseline best corrected vision (VA) was 59.4 letters (20/70 + 2). At time of switch, VA increased significantly to 66.7 letters (20/50 + 2). At 3 months after switch, VA increased significantly to 69.0 (20/40−) letters. After 3 years of consistent IAI, vision was 67.5 letters (20/40−2), and for those patients that completed 4 years of therapy, the average VA was 66.0 letters (20/50 + 2), with a gain of 6.6 letters over baseline vision. 32.1% of patients gained 3 or more lines of vision. Initial central macular thickness (CMT) was 369 µm, which improved to 347 µm at time of switch, and further improved at 3 months to 301 µm and was maintained over time.

Conclusion

Patients switched to IAI can maintain vision over the long term. Patients treated on average for 5.7 years, had a visual gain of 8.1 letters after 3 years and 6.6 letters after 4 years of IAI therapy. CMT significantly improved following the switch and was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00361-9.

Neovascular age-related macular degeneration: A review of findings from the real-world Fight Retinal Blindness! registry

The use of vascular endothelial growth factor (VEGF) inhibitors has revolutionised the treatment of neovascular age-related macular degeneration (nAMD) since the pivotal Phase III studies demonstrated their efficacy more than 10 years ago. The Fight Retinal Blindness! project was developed to track the treatment outcomes of patients with nAMD in real-world practice. Data from this registry have been used to answer several clinically relevant questions related to the treatment of nAMD including the effect of under-treatment, the comparative effectiveness of different anti-vascular endothelial growth factor agents, long-term treatment outcomes, identifying optimal treatment regimens and the rate and outcomes of rare adverse events. Observational studies are a valuable complement to the shortcomings of clinical trials and a combination of data from real-world settings and clinical trials are necessary to provide evidence on how to achieve the best outcomes for individual patients with nAMD.

Long-term outcomes of intravitreal anti-VEGF therapies in patients affected by neovascular age-related macular degeneration: a real-life study

PURPOSE

To describe real-life data from wet age-related macular degeneration (AMD) patients treated with anti-vascular endothelial growth factors (VEGFs) and to compare our results with previous studies and clinical trials.

METHODS

This retrospective monocentric cohort study analyzed 865 eyes of 780 wet-AMD patients treated with an anti-VEGF treat-and-extend regimen over a long-term follow-up period. Aflibercept and Ranibizumab were considered first-line agents whereas Bevacizumab was reserved for use on a compassionate basis in patients not meeting treatment criteria. All patients underwent a best corrected visual acuity (BCVA) assessment at each follow-up visit.

RESULTS

One-year follow-up figures were available for 82.5% of patients, whilst follow-up data was recorded for 55.6%, 37.6%, 25.1%, and 15.0% of the cohort at years 2, 3, 4, and 5 respectively. Patients treated with Bevacizumab received fewer yearly injections than those treated with Ranibizumab. However, no significant difference in the number of injections per year was detected in other comparisons between groups. Whilst our data showed no significant difference in mean BCVA between the three groups, there was a gradual deterioration of visual function over time for the patient cohort as a whole.

CONCLUSION

No significant differences between the 3 anti-VEGF molecules were recorded in wet-AMD patients in real-life conditions. Despite the long-term therapy, we found a slight reduction in visual function especially after the third year of treatment.

Long-term outcomes of polypoidal choroidal vasculopathy in comparison with typical exudative age-related macular degeneration

PURPOSE

To compare long-term outcomes between typical exudative age-related macular degeneration (TexAMD) and polypoidal choroidal vasculopathy (PCV), and to investigate factors related to the outcomes.

METHODS

This retrospective study included 319 eyes (164 with TexAMD and 155 with PCV) treated with anti-vascular endothelial growth factor and followed more than 5 years. The primary outcome was visual acuity (VA) change from baseline to final visit. Linear regression analyses were used to determine factors associated with final VA.

RESULTS

Baseline logMAR VA was 0.7 ± 0.5 in the TexAMD group and 0.5 ± 0.4 in the PCV group (p < 0.001). After a mean follow-up of 9 years, final VA was also significantly worse in the TexAMD group than in the PCV group (0.9 ± 0.6 vs. 0.6 ± 0.5; p < 0.001). The PCV group showed longer maintenance of improved vision and later onset of significant visual decline than the TexAMD group. In multivariate analysis, loss to follow-up, worse baseline VA, macular atrophy, and subretinal fibrosis were significantly associated with poor final VA in both groups.

CONCLUSION

PCV eyes showed relatively favorable long-term visual outcome than TexAMD eyes. The results of this study emphasized the importance of compliance with treatment, along with other well-known prognostic factors.

Results of patients with neovascular age-related macular degeneration managed by a treat-extend-stop protocol without recurrence

PURPOSE

To assess vision, injection quantity, initial lesion size, and final anatomic status in patients with nAMD completing the treat-extend-stop (TES) protocol.

METHODS

Patients with nAMD received ≥ 3 monthly anti-VEGF injections followed by 1-2 week injection interval extensions, with intra/subretinal fluid resolution on SD-OCT, to 12 weeks. With quiescent disease, and 2 quarterly injections, patients were monitored alone beginning at 4 weeks extending by 1-2 week intervals until quarterly monitoring.

RESULTS

Eighty-eight of 143 eyes with nAMD completed the TES protocol without disease recurrence. Sixteen (18.2%) developed sub-foveal geographic atrophy (GA), 25 (28.4%) developed fibrovascular scarring (FV) and 47 (53.4%) developed regressed choroidal neovascularization (rCNV) with 16.9 ± 13.3 average injections between the 3 groups which was not statistically significant. Average treatment time was 30.3 ± 26.1 months and subsequent follow-up was 23.2 ± 19.8 months. Average lesion size for FV was 18.77 ± 10.8mm² vs. GA at 12.00 ± 9.99mm² vs. regressed CNV at 7.12 ± 6.5mm² (p < 0.05). Pre, post, and final vision for GA was 39.6 letters (20/160) vs. 32.7 letters (20/200 + 2, p = 0.4725) vs. 25.0 letters (20/320, p = 0.0865); FV was 22.4 letters (20/400 + 2) vs. 11.6 letters (20/640, p = 0.0351) vs. 11.0 letters (20/640 + 1, p = 0.0226), and rCNV was 56.4 letters (20/80 + 1) vs. 69.5 letters (20/40, p < 0.001) vs. 67.3 letters (20/40-2, p = 0.0016). In the rCNV group, 17/46 eyes gained ≥ 3 lines and 30/46 eyes achieved ≥ 20/40 vision. Non-central GA expanded 0.226 ± 0.126 mm vs. 0.225 ± 0.098 mm during and after treatment completion over 24 months (p = 0.99).

CONCLUSIONS

Central GA or FV portends worse visual outcomes vs. rCNV after cessation of therapy. Anti-VEGF therapy may not affect the rate of GA expansion. Final anatomic character and location are key determinants of final vision.

Association Between the Degree of Inclusion of Components Identified on Fluorescein or Indocyanine Green Angiography in Target Spots and Relapse of Exudate in Eyes with Polypoidal Choroidal Vasculopathy and Typical Age-Related Macular Degeneration After Photodynamic Therapy

Purpose

To investigate the association between the inclusion of components identified on images in target spots of photodynamic therapy (PDT) and exudate relapse in eyes with age-related macular degeneration (AMD).

Methods

Forty-one eyes (39 patients) with polypoidal choroidal vasculopathy (PCV) and 32 eyes (31 patients) with typical AMD (tAMD) who underwent PDT were retrospectively investigated. Each component identified on fluorescein (FA) or indocyanine angiography (IA), optical coherence tomography (OCT), or color photography was graded as not depicted, covered with a margin ≥500 µm or <500 µm, and protruding. Associations between these grades and the dry rate (proportion of subjects with continuous absence of exudate over following 12-month period) and the relapse index (2 × number of injections administered + accumulation of exudate for 12 months post-PDT) were investigated.

Results

In PCV, the association between worse coverage and decreasing dry rates for feeder vessels and polyps approached statistical significance. With coverage margins ≥500 µm, dry rate tended to be greater than with coverage margins <500 µm for feeder vessels, classic lesions, and occult lesions on FA. In the tAMD group, coverage with margins ≥500 µm tended to yield a higher dry rate than coverage with margins <500 µm for CNV on IA. Coverage with margins ≥500 µm for occult and classic lesions on FA yielded no dry subjects, and all subjects with classic lesions or staining had recurrence (P = 0.009 and 0.050). Worse coverage and worse dry rate in PCV and worse relapse index in tAMD were related to pigment epithelial detachment on OCT (P = 0.040 and 0.006).

Conclusion

Polyps in PCV and pigment epithelial detachment (PED) in tAMD were verified as appropriate targets, corresponding to the existing guidelines, and feeder vessels, classic lesion, occult lesion, and PED in PCV and CNV on IA in tAMD were suggested as further targets. OCT was superior to FA for evaluating PED.

Suppression of choroidal neovascularization by silencing of long non-coding RNA IPW

Long noncoding RNAs (lncRNAs) have emerged as the key regulators in the pathogenesis of human disorders. This study aimed to investigate the role of lncRNA-IPW in the progression of choroidal neovascularization (CNV) and the underlying molecular mechanism. IPW was significantly up-regulated in the choroidal tissues of laser-induced CNV mice and in the endothelial cells in response to hypoxic stress. IPW silencing led to reduced formation of CNV in laser-induced CNV model and ex vivo choroidal sprouting model, which could achieve similar therapeutic effects of anti-VEGF on CNV formation. Silencing or transgenic overexpression of IPW could alter endothelial cell viability, proliferation, migration, and tube formation ability in vitro. Mechanistically, IPW silencing led to increased expression of miR-370. Increased miR-370 could mimic the effects of IPW silencing on CNV formation and endothelial angiogenic phenotypes in vivo and in vitro. This study suggests that IPW silencing is a promising strategy for the treatment of neovascular ocular diseases.

Reactivation of CNV after Discontinuation of Bevacizumab Treatment of Age-Related Macular Degeneration

INTRODUCTION

Treatment of exudative age-related macular degeneration (ARMD) has shifted to pro re nata and treat-extend-stop strategies. However, a rational discontinuation strategy is lacking. To develop such a strategy, it is important to determine choroidal neovascularization (CNV) recurrence rates after anti-VEGF treatment is discontinued. Here we report prospective data on persistent and recurrent CNV activity after discontinuation of bevacizumab treatment.

METHODS

This prospective, single-center clinical trial enrolled 191 patients with exudative ARMD. Patients were randomly assigned to receiving intravitreal bevacizumab injections every 4, 6, or 8 weeks for 1 year. CNV activity was determined in the 157 patients who completed the 1-year treatment regimen. Patients with inactive CNV were then followed for signs of CNV reactivation.

RESULTS

After 1 year of treatment, 66 (42%) of the 157 patients still had signs of persistent active CNV. Of the remaining 91 (58%) patients, 61 (67%) needed retreatment for active CNV within the first year after discontinuation of treatment (mean 4.28 ± 0.29 months). CNV was reactivated in 50 (80%) of the 61 patients within 6 months after their final treatment for CNV.

CONCLUSION

Based on quiescent disease, anti-VEGF therapy was discontinued in 58% of the patients after they received bevacizu-mab injections every 4, 6, or 8 weeks for 1 year; 67% showed reactivated CNV within a year after discontinuation. The high reactivation rate of CNV shown in this study should help clinicians to develop rational discontinuation protocols.

TRIAL REGISTRATION

This study is registered as NTR1174 at http://www.trialregister.nl.

Aflibercept for age-related macular degeneration: 4-year outcomes of a ‘treat-and-extend’ regimen with exit-strategy

Aim

To report long-term outcomes on best-corrected visual acuity (BCVA) and treatment intervals with a treat-and-extend (T&E) regimen in patients with neovascular age-related macular degeneration (nAMD).

Methods

This observational study included treatment-naïve patients with nAMD, treated with aflibercept. A specific T&E protocol without a loading phase and predefined exit criteria was administered. After reaching predefined ‘exit-criteria’, the treatment period was complete, and patients were observed three monthly.

Results

Eighty-two patients with a follow-up period of ≥2 years were included. BCVA (mean±SD, ETDRS letters) increased from 51.9±25.2 at baseline to 63.7±17.7 (p<0.0001) at 1 year, 61.7±18.5 (p<0.0001) at 2 years, 62.4±19.5 (p<0.0001, n=61) at 3 years and remained insignificantly higher than baseline at 4 years at 58.5±24.3 (p=0.22). Central subfield thickness (mean±SD, μm) decreased significantly from 387.5±107.6 (p<0.0001) at baseline to 291.9±65.5 (p<0.0001) at 1 year, and remained significantly lower until 4 years at 289.0±59.4 (p<0.0001). Treatment intervals (mean±SD, weeks) could be extended up to 9.3±3.1 weeks at 1 year and remained at 11.2±3.5 weeks at 4 years. Twenty-nine (35%) patients reached exit criteria and continued with three monthly observation only.

Conclusions

After 4 years of treatment, initial vision gains were maintained with a reasonable treatment burden, even without an initial loading phase. Our results on functional outcomes are comparable with large controlled studies.

Long-term Anti-Vascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration: The LATAR Study: Report 1: Ten-Year, Real-World Outcomes

PURPOSE

To report the 10-year outcomes of eyes with neovascular age-related macular degeneration (nAMD) treated with vascular endothelial growth factor (VEGF) inhibitors.

DESIGN

Ten-year, retrospective cohort study.

PARTICIPANTS

A total of 1046 patients who commenced treatment with anti-VEGF for nAMD.

METHODS

Anti-VEGF-naïve eyes diagnosed with nAMD that commenced treatment between November 2006 and December 2009 were identified. Data collected included the baseline demographics, visual acuity (VA), and number of intravitreal injections. Baseline fundus fluorescein angiograms and OCT images were graded for choroidal neovascularization type. OCT images were graded for central macular thickness (CMT) and the presence of fluid over the 10 years.

MAIN OUTCOME MEASURES

Change in vision at 10 years. Secondary outcomes included the proportion of eyes with 20/40 vision or better and 20/200 or worse, the proportion of eyes that were dry on OCT imaging, and the number of injections.

RESULTS

Of 1046 eligible eyes, 10-year data were available for 293 (28%), which were included in the analyses. Eyes received 58.1 (standard deviation [SD], 33.6) injections during the 10 years. The mean CMT decreased from 355.5 μm (SD, 107.8 μm) to 264.2 (SD, 79.5) μm (P < 0.001). The median baseline VA was 60 (interquartile range [IQR], 45-70) letters, which improved by 9 (IQR, 1-14) letters after the first year of treatment (P < 0.001). Over the 10-year period, these initial gains were lost over time with a final VA change of +3 letters (IQR, 8-10 letters, P = 0.162). However, the proportion of eyes with VA 20/40 or better increased from 29% at baseline to 35% at 10 years (P < 0.001). The proportion of eyes at baseline with VA 20/200 or worse was 14% and 17% at 10 years.

CONCLUSIONS

On average, eyes with nAMD maintained starting VA when treated with VEGF inhibitors for 10 years. With ongoing regular treatment, a greater proportion of eyes achieved VA of 20/40 or better at 10 years than at presentation.

Long-term Visual Outcomes after Release from Protocol in Patients who Participated in the Inhibition of VEGF in Age-related Choroidal Neovascularisation (IVAN) Trial

PURPOSE

To describe visual outcomes, frequency of treatment and monitoring visits, and anti-vascular endothelial growth factor drugs used in usual care in participants who exited a trial in which treatment for neovascular age-related macular degeneration (nAMD) was initiated with bevacizumab or ranibizumab.

DESIGN

Multicenter cohort study up to 7 years after trial exit.

PARTICIPANTS

Patients enrolled in the Inhibition of VEGF in Age-related choroidal Neovascularisation (IVAN) trial; after excluding participants from 2 sites and who died or withdrew during the trial, 537 were included in this follow-up cohort.

METHODS

Data were collected between May 26, 2016, and August 24, 2017. Distance visual acuity (DVA) (letters read) in both eyes and treatments for nAMD administered to either eye at all usual care visits were extracted from medical records of all participants until the point of data collection (duration of study eye monitoring).

MAIN OUTCOME MEASURES

Rate of change of DVA during active surveillance of the study eye (study eye monitoring), estimated using a multivariable linear random effects model. Other outcome measures were visit and treatment frequency and switches in anti-vascular endothelial growth factor (VEGF) drug.

RESULTS

Data were obtained for 99% (532/537) of eligible participants. The median duration of study eye monitoring after IVAN exit was 3.3 years (interquartile range [IQR], 1.3-4.7), and median DVA was 58.0 letters (IQR, 34.0-73.0). Study eye DVA deteriorated by 4.3 (95% confidence interval [CI], 3.7-4.9) letters per year. Injection rate did not influence the rate of change in DVA after adjusting for key covariates. After IVAN exit, 174 participants (32%) received no treatment; 332 of 358 (93%) were treated first with ranibizumab, 78 (23%) of whom switched to aflibercept. The DVA was similar among participants who switched or did not switch at the end of study monitoring.

CONCLUSIONS

Approximately 5 years after the IVAN study finished, with unprecedented completeness of follow-up for such a trial, the trajectory of functional decline in the study eye was shown to be greater than that previously reported for incomplete trial cohorts. Anti-VEGF injection rates and treatment switches were not important factors in determining visual acuity outcomes.

Effect of the Duration of Intraretinal or Subretinal Fluid on the Response to Treatment in Undertreated Age-Related Macular Degeneration

We investigated the association between the duration of intraretinal fluid (IRF) or subretinal fluid (SRF) and the response to antivascular endothelial growth factor injection in patients with undertreated age-related macular degeneration (ARMD). The Ethics Committee of Toho University Sakura Medical Center approved this study (no. S18030). Eighty eyes of ARMD patients with VA ≤20/100 were retrospectively assessed. Each injection's efficacy was classified, and the fluid accumulation prior to each injection was evaluated. The effect changes following to accumulated IRF, SRF, the longest persistent IRF period (≥10 months), and their determining factors were evaluated. Throughout observation, acquired refractoriness was rarely associated with increased accumulation of IRF or SRF. The injection span had a tendency to be short, and the polypoidal choroidal vasculopathy and occult choroidal neovasculopathy (CNV) proportions had a tendency to be higher among patients with diminished effects than among those with maintained effects. VA differed significantly with continuous IRF duration, but not with accumulated fluid. The diminishing effect of injections during long-standing IRF was rarely associated with undertreatment. The mechanism underlying acquired refractoriness remains unknown; the effect change demonstrated various patterns, including diminished and improved responses. The longest continuous IRF duration was associated with VA decline. Shortening the duration of continuous IRF may be necessary.

Long-Term Ranibizumab Treatment in Neovascular Age-Related Macular Degeneration: A Belgian Subanalysis from the Global Real-World LUMINOUSTM Study

Purpose

To evaluate long-term, real-world treatment patterns and outcomes of ranibizumab 0.5 mg for neovascular age-related macular degeneration (nAMD) in a Belgian cohort.

Patients and Methods

This Belgian (BE) cohort of the 5-year global observational LUMINOUS study included 229 patients with nAMD. Outcomes included visual acuity (VA), central retinal thickness (CRT) and safety.

Results

The mean age was 79.5±7.7 years. The majority of patients (67.7%) were female and all patients were Caucasian. Most patients previously received ranibizumab with only 17.5% of patients being treatment-naïve. The injection frequency declined over time irrespective of prior treatment status (p<0.0001), with treatment-naïve eyes receiving a mean of 4.2±2.9 yearly injections and prior-ranibizumab eyes 3.6±2.7. Regression analysis confirmed first-year VA increases for treatment-naïve eyes (p=0.002) followed by a slight decrease of -1.8 letters per year. For prior-ranibizumab eyes, the visual changes over 1 year were statistically non-significant (p=0.90) but declined slightly after year one (p<0.0001). Anatomically, the CRT of treatment-naïve eyes decreased over time from baseline (p<0.0001), whereas the CRT of prior-ranibizumab eyes remained stable (p=0.43). No new safety findings were identified.

Conclusion

LUMINOUS-BE reconfirms the well-characterized benefit-risk profile of ranibizumab for nAMD treatment. The observed low injection frequency reflects a need for more rigorous treatment in real-world settings.

Clinical Trial Registration

NCT01318941.

Long-Term Follow-up of Patients with Exudative Age-Related Macular Degeneration Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections

PURPOSE

To determine the long-term visual outcomes and intravitreal injection burden of patients with exudative age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with exudative AMD treated with intravitreal anti-VEGF injections with annual office visits for at least 7 years.

METHODS

Snellen visual acuity was measured at baseline and then annually until the last year of follow-up. The number of injections was recorded on an annual basis during each year of follow-up.

MAIN OUTCOME MEASURES

The change in the frequency of injections over time along with the change in visual acuity each year from the baseline visit through 7 years.

RESULTS

During this period, 533 eyes of 429 patients were treated for exudative AMD. Of these, 391 eyes (73%) met the inclusion criteria of annual office visits and received a mean of 5.8 ± 2.5 intravitreal injections per year. The baseline mean visual acuity was 0.6 ± 0.5 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/80), and the 7-year visual acuity was 0.8 ± 0.6 logMAR (Snellen equivalent, 20/126; P < 0.0001). When compared with the 142 eyes that did not undergo an office visit for a continuous 12-month period, eyes with annual office visits showed similar baseline mean visual acuity (0.7 logMAR vs. 0.6 logMAR; P = 0.2102), but more injections per year (P < 0.0001). Of the 533 total eyes, 124 eyes (23%) maintained better than 20/40 visual acuity at 7 years. These eyes received more injections overall per year (6.5 vs. 5.5 injections per year; P = 0.0007).

CONCLUSIONS

In a real-world setting, eyes that maintained consistent, long-term follow-up received significantly more intravitreal injections per year than eyes with inconsistent follow-up. Eyes with 20/40 or better vision at study conclusion received more injections per year than eyes with worse than 20/40 vision.

Impact of Sub-Retinal Fluid on the Long-Term Incidence of Macular Atrophy in Neovascular Age-related Macular Degeneration under Treat & Extend Anti-Vascular Endothelial Growth Factor Inhibitors

Sub-retinal fluid (SRF) has been discussed as a protective factor against macular atrophy in eyes with neovascular age-related macular degeneration (nAMD).To gauge the impact of SRF on macular atrophy, a database of 310 nAMD eyes was screened for eyes manifesting an SRF-only phenotype under treat & extend anti-VEGF treatment, defined as nAMD expressing CNV exudation beyond the three monthly anti-VEGF loading doses by SRF only without any signs of exudative intra-retinal fluid (IRF) for ≥3 years. Incidence of macular atrophy and treatment responses were evaluated on multimodal imaging, including optical coherence tomography (OCT), blue autofluorescence (BAF) and near-infrared (NIR) confocal scanning laser ophthalmoscopy and fluorescence and indocyanine green angiography (FAG/ICGA). In total, 27 eyes (8.7%) of 26 patients with a mean follow-up of 4.2 ± 0.9 (3–5) years met the inclusion criteria. Mean age was 72 ± 6 (range: 61–86) years. The SRF only phenotype was seen from baseline in 14 eyes (52%), and in 13 eyes (48%) after a mean 1.0 ± 1.3 (1–3) injections. In years 1 to 5, mean 7.5, 5.9, 6.1, 6.1 and 7.0 anti-VEGF injections were given (p = 0.33). Cumulative macular atrophy incidence was 11.5% at year 1, 15.4% throughout years 2 to 4, and 22.4% at year 5. In conclusion, eyes manifesting activity by SRF only in treat & extend anti-VEGF regimen for nAMD seem to exhibit rather low rates of macular atrophy during long-term follow-up. SRF might be an indicator of a more benign form of nAMD.

Type 1 Choroidal Neovascularization Evolution by Optical Coherence Tomography Angiography: Long-Term Follow-Up

Purpose

To evaluate structural changes in response to antivascular endothelial growth factor (anti-VEGF) treatment in patients with long-term type 1 choroidal neovascularization (CNV) by optical coherence tomography (OCT) and OCT angiography (OCTA).

Method

This is a longitudinal study that involved a total of 51 eyes with type 1 CNV (35 female and 16 male eyes). Structural OCT and OCTA were performed on all the subjects. AngioVue OCTA (XR Avanti, Optovue, Inc., Fremont, CA) was used to obtain qualitative and quantitative information. All eyes were treated with an anti-VEGF ProReNata (PRN) approach and were followed for a mean of 38.9 months (SD ± 7.22). Best-corrected visual acuity (BCVA) was assessed at each follow-up timepoint.

Results

We observed two kinds of possible evolution of type 1 CNV: “positive evolution,” including stabilization in 20% of patients and chronicity in 35%, and “negative evolution,” in which fibrosis was shown in 18% of patients, chorioretinal atrophy in 25%, and hemorrhage or RPE tears in 2%. The mean BCVA at baseline was 33.67 ± 15.85 ETDRS letters; after 1 and 2 years, it was 31.61 ± 18.04 and 31.18 ± 18.58 ETDRS letters, respectively. The mean BCVA at the end of follow-up was 25.27 ± 20 ETDRS letters. The difference between the values at baseline and at the end of follow-up was not statistically significant (P = 0.06, r² = 0.10).

Conclusions

This study describes an in vivo structural long-term evolution of type 1 CNV by OCT and OCTA. Different possible CNV outcomes were observed. This study suggests that new retinal imaging techniques could be useful tools for assessing the potential retinal changes in the evolution of type 1 CNV to develop personalized medicine. Further studies using OCTA in the long term are needed to better understand why similarly treated type 1 CNV cases evolve differently and produce different results.

Detrimental Effect of Delayed Re-treatment of Active Disease on Outcomes in Neovascular Age-Related Macular Degeneration: The RAMPS Study

PURPOSE

To assess the impact of delaying anti-vascular endothelial growth factor (VEGF) treatment of active disease at any point during a patient's treatment journey on clinical outcomes in a real-world cohort of patients with neovascular age-related macular degeneration (nAMD).

DESIGN

Longitudinal cohort study.

PARTICIPANTS

Consecutive treatment-naive nAMD eyes commencing anti-VEGF monotherapy (bevacizumab, ranibizumab, or aflibercept) from January 2014 from a tertiary eye center in Singapore.

METHODS

We conducted a real-world study using registry data comparing delayed re-treatment (defined as not receiving treatment at 2 or more monitoring visits when disease was graded as active) versus timely re-treatment (defined as receiving treatment when disease was active).

MAIN OUTCOME MEASURES

The primary outcome was the change in visual acuity (VA) in the timely and delayed re-treatment groups at 12 months.

RESULTS

Data from 286 eyes were included and categorized into the timely (188 [66%]) or the delayed (98 ([34%]) group. The mean numbers of anti-VEGF injections over 12 months were similar: 5.6 (standard deviation [SD], 2.9) versus 4.9 (SD, 3.2; P = 0.11) for the timely and delayed groups, respectively. Timely treated patients showed larger gains in VA (6.4 letters [SD, 8.1 letters] vs. 1.2 letters [SD, 5.3 letters; P = 0.04), a higher proportion with VA of 6/12 or better (30% vs. 8%; P = 0.01), and greater reduction in OCT-measured central subfield thickness (135 μm [SD, 154 μm] vs. 87.8 μm [SD, 129 μm]; P = 0.04) at 12 months. A longer delay between detection of active disease and re-treatment was associated with poorer vision outcomes (0.02-letter decrease/day; P = 0.03; R² = 0.29).

CONCLUSIONS

Although it has been established that adequate numbers of injections are required for favorable outcomes, timely re-treatment of active disease also is important. This should be emphasized to patients to ensure optimal outcomes in real-world clinical settings.

Changes in cone-driven functions after intravitreal aflibercept injections in patients with age-related macular degeneration

PURPOSE

To determine the changes in the cone-driven functions in patients with age-related macular degeneration (AMD) treated with intravitreal aflibercept.

METHODS

We studied 44 eyes of 44 patients diagnosed with AMD whose mean age was 75 years. The contralateral unaffected eyes served as controls. All patients were initially treated with 3 consecutive monthly intravitreal aflibercept injections and thereafter with bimonthly injections for 12 months. Full-field cone electroretinograms (cone ERGs) were recorded at the baseline and at 3, 6, and 12 months after beginning the intravitreal aflibercept injections. The cone ERGs were elicited by red stimuli on a blue background. The focal macular ERGs (fmERGs) were elicited by 15 degrees white stimulus spot centered on the fovea. The amplitudes of the a- and b-waves, photopic negative response (PhNR), and sum of the oscillatory potentials (ΣOPs, sum of OP1-3 amplitudes) were analyzed. In addition, the implicit times of the a- and b-waves were also analyzed.

RESULTS

The amplitudes and implicit times of all components of the fmERGs were significantly improved compared to the baseline at 3 months after beginning the intravitreal aflibercept injections (P < 0.0005-0.05). The amplitudes of the a-waves and PhNRs were further increased during the maintenance phase (P < 0.005-0.01). On the other hand, the amplitudes of the full-field a-waves and PhNR of the cone ERGs were significantly reduced at 6 and 12 months compared to the baseline.

CONCLUSIONS

The macular function improved continuously during the maintenance phase of the intravitreal aflibercept injections. In contrast, the cone-driven functions of the more peripheral retina decreased with repeated injections suggesting adverse effects of the intravitreal aflibercept injections on the function of the more peripheral normal retina.

Predictors of neovascular activity during neovascular age-related macular degeneration treatment based on optical coherence tomography angiography

The advent of anti-vascular endothelial growth factor (VEGF) therapies has remarkably improved the functional outcomes of neovascular age-related macular degeneration (nAMD) patients. However, there are guidelines on how to start treatment, the guidelines for discontinuing treatment are not yet clear. In this respect, the treat-extend-stop (TES) protocol have showed us the possibility of discontinuing treatment. In this study, we tried to investigate optical coherence tomography angiography (OCTA) biomarkers related to recurrence of neovascular activity in eyes with nAMD undergoing treatment using TES protocol. A total of 134 eyes with nAMD were divided into two groups (stop, non-stop) depending on whether they met criteria for stopping anti-VEGF treatment. Quantitative and qualitative OCTA parameters including the morphologic pattern of choroidal neovascularization (CNV) were compared between groups. Of these, 44 eyes (32.8%) were in the stop group and 90 eyes (67.2%) were in the non-stop group. In multivariate regression analysis, closed-circuit pattern of CNV and the presence of peripheral loop were associated with the non-stop group (all p < 0.001). Our results imply that the morphologic appearance of CNV on OCTA after anti-VEGF treatment may be a useful biomarker to predict weaning from treatment.

Reliability of colour perimetry to assess macular pigment optical density in age-related macular degeneration

Background:

The aim of this study was to determine the intra-session repeatability and inter-examiner reproducibility of the colour perimetry technique when assessing in vivo macular pigment optical density in age-related macular degeneration patients.

Methods:

Age-related macular degeneration patients were classified into four groups: early age-related macular degeneration, intermediate age-related macular degeneration, atrophic age-related macular degeneration and neovascular age-related macular degeneration after undergoing fundus photography (TRC 50DX type IA) and spectral-domain optical coherence tomography analysis (Topcon 3D-2000). Central fixation was confirmed in all patients using the MP-1 microperimeter (Nidek, Padua, Italy). To analyse repeatability, one examiner obtained three consecutive macular pigment optical density measures with MonCV3 device (Metrovision, Perenchies, France). To study agreement between two observers, a second examiner performed another macular pigment optical density measurement in random order. Within-subject standard deviation, coefficient of variation, and intraclass correlation coefficient data were obtained.

Results:

Fifty two (32 females and 20 males) consecutive age-related macular degeneration patients having a mean age of 71.5 ± 8.2 years were recruited. Six had early age-related macular degeneration, 25 had intermediate age-related macular degeneration, 10 had atrophic age-related macular degeneration and 11 had neovascular age-related macular degeneration. For repeatability, coefficient of variation values ranged from 22.3% (neovascular age-related macular degeneration) to 41.0% (atrophic age-related macular degeneration) and intraclass correlation coefficient values from 0.52 (intermediate age-related macular degeneration) to 0.79 (neovascular age-related macular degeneration). For agreement between two examiners, coefficient of variation values ranged from 20.1% (intermediate age-related macular degeneration) to 37.8% (neovascular age-related macular degeneration) and intraclass correlation coefficient values from 0.61 (neovascular age-related macular degeneration) to 0.80 (atrophic age-related macular degeneration).

Conclusion:

The reliability (intra-session repeatability and inter-examiner reproducibility) of colour perimetry technique to assess macular pigment optical density in age-related macular degeneration patients is only moderate. Thus, it cannot be recommended to be performed when evaluating and monitoring age-related macular degeneration patients in the daily clinic.

Focal retinal pigment epithelium atrophy at the location of type 3 neovascularization lesion: a morphologic feature associated with low reactivation rate and favorable prognosis

PURPOSE

To investigate the clinical significance of focal retinal pigment epithelium (RPE) atrophy in the eyes with type 3 neovascularization.

METHODS

This retrospective study included 184 eyes those were diagnosed with type 3 neovascularization and were treated with antivascular endothelial growth factor (VEGF) therapy. Focal RPE atrophy was defined as a localized RPE atrophy found at the same location as the type 3 lesion. The incidence of reactivation after 3 loading injections and the visual outcomes was compared between a focal RPE atrophy group and a nonfocal RPE atrophy group. In the focal RPE atrophy group, the number of injections was compared between before and after the development of RPE atrophy.

RESULTS

The mean follow-up period was 37.6 ± 18.8 months; focal RPE atrophy developed in 24 eyes (13.0%). Reactivation of the lesion after 3 loading injections was significantly less frequent in the focal RPE atrophy group (58.3%) than that in the nonfocal RPE atrophy group (85.0%) (P = 0.004). In the focal RPE atrophy group, the mean best-corrected visual acuity (BCVA) was 0.68 ± 0.28 (Snellen equivalent = 20/95) at diagnosis and 0.70 ± 0.48 (20/100) at the final follow-up. In the nonfocal RPE atrophy group, the values were 0.75 ± 0.34 (20/112) and 1.12 ± 0.68 (20/263), respectively. The BCVA at the final follow-up was significantly better in the focal RPE atrophy group (P < 0.001). The mean number of injections per year was 4.9 ± 1.8 and 1.3 ± 1.6 before and after the development of focal RPE atrophy, respectively (P < 0.001).

CONCLUSIONS

Development of focal RPE atrophy was associated with a low incidence of reactivation of type 3 neovascularization and was therefore predictive of a favorable visual prognosis.

Initiation and maintenance of a Treat-and-Extend regimen for ranibizumab therapy in wet age-related macular degeneration: recommendations from the UK Retinal Outcomes Group

The treatment of neovascular (wet) age-related macular degeneration (AMD) with ranibizumab is now very well established in terms of efficacy and safety. Recent clinical trials and real-world studies have demonstrated the advantages of a Treat-and-Extend (T&E) regimen, and many hospital departments are now in the process of adopting this new regimen in favor of the pro re nata regimen for initiating and continuing ranibizumab therapy for patients with wet AMD. The comprehensive spectrum of issues related to implementation of the regimen is covered qualitatively in ten didactic topics provided by a group of clinicians with direct experience of this regimen in their department. The topics include definition, new and previously treated eyes, management of high-frequency injections, maximum extensions, discontinuing T&E, bilateral cases, clerical, audit, and patient counseling. This article aims to provide a useful resource for the implementation of the T&E regimen. A quantitative summary of the visual outcomes in key publications is also provided in this article. This article should be a valuable resource for staff training.

[Clinical parameters of patients with neovascular age-related macular degeneration : Longterm treatment results of an outpatient clinic]

BACKGROUND

The clinical outcome of neovascular age-related macular degeneration (nAMD) depends on constant follow-up and consistent treatment. Data about the long-term course of intensive anti-vascular endothelial growth factor (VEGF) therapy from outpatient clinics are rare.

OBJECTIVE

The aim of the study was to characterize a population of nAMD patients with long-term follow-up and intensive anti-VEGF therapy.

PATIENTS AND METHODS

In a supra-regional outpatient clinic, we retrospectively identified patients who had received at least 30 intravitreal anti-VEGF injections and were followed for at least 4 years. All patients received an optical coherence tomography(OCT)-controlled Pro-Re-Nata (PRN) therapy regimen according to German guidelines.

RESULTS

We identified 43 patients. Visual acuity at baseline was 0.44 ± 0.24 (1.0-0.1) logMAR. At the end of the follow-up period, visual acuity was 0.63 ± 3.6 (1.3-0.1) logMAR. Patients received a mean of 36.3 ± 8.0 (30-62) injections and were followed for a mean of 6.1 ± 1.8 (4-12) years. They received 6.12 ± 1.5 (3.1-9.9) injections per year. The number of injections in treatment-year one was with 3.67 ± 1.9 (1-8) significantly lower than the mean (p < 0.0001).

CONCLUSION

Despite intensive PRN therapy, visual acuity slowly decreased over time. The mean number of injections was comparable to that of prospective studies. The low number of injections in treatment-year 1 may have been due to a lack of experience with the new treatment agents. The slow decrease in visual acuity in clinical routine as opposed to clinical studies may be attributed to a delay between occurrence of disease activity and treatment.