Neovascular age-related macular degeneration: decision making and optimal management

The Role of Medical Image Modalities and AI in the Early Detection, Diagnosis and Grading of Retinal Diseases: A Survey

Traditional dilated ophthalmoscopy can reveal diseases, such as age-related macular degeneration (AMD), diabetic retinopathy (DR), diabetic macular edema (DME), retinal tear, epiretinal membrane, macular hole, retinal detachment, retinitis pigmentosa, retinal vein occlusion (RVO), and retinal artery occlusion (RAO). Among these diseases, AMD and DR are the major causes of progressive vision loss, while the latter is recognized as a world-wide epidemic. Advances in retinal imaging have improved the diagnosis and management of DR and AMD. In this review article, we focus on the variable imaging modalities for accurate diagnosis, early detection, and staging of both AMD and DR. In addition, the role of artificial intelligence (AI) in providing automated detection, diagnosis, and staging of these diseases will be surveyed. Furthermore, current works are summarized and discussed. Finally, projected future trends are outlined. The work done on this survey indicates the effective role of AI in the early detection, diagnosis, and staging of DR and/or AMD. In the future, more AI solutions will be presented that hold promise for clinical applications.

Accuracy of a Machine-Learning Algorithm for Detecting and Classifying Choroidal Neovascularization on Spectral-Domain Optical Coherence Tomography

Background: To evaluate the performance of a machine-learning (ML) algorithm to detect and classify choroidal neovascularization (CNV), secondary to age-related macular degeneration (AMD) on spectral-domain optical coherence tomography (SD-OCT) images. Methods: Baseline fluorescein angiography (FA) and SD-OCT images from 1037 treatment-naive study eyes and 531 fellow eyes, without advanced AMD from the phase 3 HARBOR trial (NCT00891735), were used to develop, train, and cross-validate an ML pipeline combining deep-learning–based segmentation of SD-OCT B-scans and CNV classification, based on features derived from the segmentations, in a five-fold setting. FA classification of the CNV phenotypes from HARBOR was used for generating the ground truth for model development. SD-OCT scans from the phase 2 AVENUE trial (NCT02484690) were used to externally validate the ML model. Results: The ML algorithm discriminated CNV absence from CNV presence, with a very high accuracy (area under the receiver operating characteristic [AUROC] = 0.99), and classified occult versus predominantly classic CNV types, per FA assessment, with a high accuracy (AUROC = 0.91) on HARBOR SD-OCT images. Minimally classic CNV was discriminated with significantly lower performance. Occult and predominantly classic CNV types could be discriminated with AUROC = 0.88 on baseline SD-OCT images of 165 study eyes, with CNV from AVENUE. Conclusions: Our ML model was able to detect CNV presence and CNV subtypes on SD-OCT images with high accuracy in patients with neovascular AMD.

OPTICAL COHERENCE TOMOGRAPHY, FLUORESCEIN ANGIOGRAPHY, AND DIAGNOSIS OF CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION

In a prospective study, spectral domain optical coherence tomography and fluorescein angiography, combined with color fundus photograph used as a first diagnostic test in patients aged 50 years or older, had a similar sensitivity and specificity for the diagnosis of choroidal neovascularization in age-related macular degeneration.

To determine the sensitivity and specificity of different retinal imaging combinations for the diagnosis of choroidal neovascularization (CNV) in age-related macular degeneration.

Patient experience of treatment decision making for wet age-related macular degeneration disease: a qualitative study in China

OBJECTIVES

This study aimed to investigate the experience of patients with wet age-related macular degeneration (wAMD) in treatment decision-making process.

DESIGN

A descriptive qualitative study was designed by using semistructured interviews, and the data analysis was conducted with the thematic analysis approach.

PARTICIPANTS AND SETTING

A convenient and purposive sample of 21 participants diagnosed with wAMD was recruited from May 2018 to September 2018. The study was conducted in the Eye Clinic of Southwest Hospital of Army Medical University in Chongqing located in the southwest of China.

RESULTS

The mean age of the participants was 64.48 years (ranging 50-81 years), and the duration of the disease ranged from 6 months to 48 months. Four major themes were identified from the original data analysis. These themes included facing the darkness (choosing from light and darkness and living in pain), constraints on decision making (doctor-oriented decision making, inadequacy of options and time), weighing alternatives (family influence, financial burden and maintaining social function) and decision-making support (professional decision-making assistance and peer support).

CONCLUSION

This is a qualitative study attempting to explore the patient experience of treatment decision making for wAMD disease in China. Previous literature has focused on treatment effect and symptoms, rather than the individual experience and the wide contexts from a sociocultural perspective. Further studies, such as cross-sectional studies, can be used to describe the status and determine the influencing factors of decision0making process, so as to develop an impact factor model of decision making and to formulate an intervention for patients with wAMD.

Outcomes in Neovascular Age-Related Macular Degeneration when Neovascular Lesion Activity Is Uncertain: Observational Study

PURPOSE

To determine the characteristics and outcomes of eyes with neovascular age-related macular degeneration (nAMD) in which choroidal neovascular (CNV) lesion activity was graded as uncertain.

DESIGN

Prospective, database, observational study.

PARTICIPANTS

Treatment-naïve patients with nAMD tracked by the Fight Retinal Blindness! (FRB!) registry initiating treatment between January 1, 2008, and January 1, 2014, with 2 years of follow up.

METHODS

Lesion activity was determined by the clinical judgment of the providing physician on the basis of clinical examination with ancillary testing. Eye-based analysis investigated clinical characteristics and outcomes by proportion of visits with uncertain CNV lesion activity. Encounter-based analysis investigated CNV lesion grading over time with corresponding treatment and follow up.

MAIN OUTCOME MEASURES

Change in mean visual acuity (number of letters read on a logarithm of the minimum angle of resolution chart) at 2 years. Secondary outcomes included the number of visits and injections.

RESULTS

We identified 1631 eyes of 1419 patients with 27 974 visits to 46 retinal specialists. The CNV lesion activity was uncertain at 4601 encounters (16.4%) and experienced by the majority of eyes (52%) and providers (72%). Uncertainty of CNV lesion activity did not significantly decline with increasing number of visits in individual patients (P = 0.97) but did decline from 32% in 2010 to 4% in 2015 (P < 0.001). Eyes having no visits with uncertain CNV lesion grading gained more letters (mean, 7.0) than eyes with moderate or high levels of uncertainty (mean, 3.98 and 3.37; P = 0.03 and 0.02, respectively). The mean probability of receiving an injection was higher in visits with active (0.89) compared with inactive (0.68, P < 0.001) and uncertain (0.69, P < 0.001) CNV lesion activity. Subsequent follow-up length was also decreased in visits with active (mean ± standard deviation [SD], -0.9±39 days) compared with inactive and uncertain CNV lesion activity (mean ± SD, 1.9±39 days, P < 0.001, and 2.4±39 days, P < 0.001, respectively).

CONCLUSIONS

Rates of uncertainty regarding CNV lesion activity were high, and eyes with higher rates of uncertain CNV activity had worse outcomes. Further studies are warranted to establish whether eyes should be treated more aggressively when the activity status of the CNV lesion is uncertain.

Ranibizumab (Lucentis) versus Bevacizumab (Avastin) for the Treatment of Age-Related Macular Degeneration: An Economic Disparity of Eye Health

Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly, and the advent of anti-vascular endothelial growth factor agents (VEGF) has revolutionized treatment for neovascular AMD. Two of the most popular anti-VEGF agents, ranibizumab (Lucentis; Genentech/Roche) and bevacizumab (Avastin; Genentech/Roche), effectively treat neovascular AMD but have a substantial difference in price. Multiple level 1 trials have demonstrated that bevacizumab is noninferior to ranibizumab in the treatment of neovascular AMD and that both have similar safety profiles. The decision to use one drug over the other is multifactorial with influences from industry as well as individual physician biases. However, the additional billions spent on ranibizumab result in a large economic disparity that is not rationalized by cost effectiveness models.

Intravitreal Topotecan Inhibits Laser-induced Choroidal Neovascularization in a Rat Model

Purpose:

A two-phase preclinical study was designed to determine the safe dose of intravitreal topotecan and its inhibitory effect on experimental choroidal neovascularization (CNV) in a rat model.

Methods:

In phase I, 42 rats were categorized into 6 groups, 5 of which received intravitreal topotecan injections of 0.125 μg, 0.25 μg, 0.5 μg, 0.75 μg, and 1.0 μg/5 μl, respectively; the control group received an injection of normal saline. Ophthalmic examination and electroretinography (ERG) were performed on days 7 and 28, and enucleated globes were processed for histopathology and immunostaining for glial fibrillary acidic protein. In phase II, CNV was induced via laser burns in 20 rats and the animals were divided into 2 groups. One group received topotecan and the other received normal saline intravitreally. Four weeks later, mean scores of fluorescein leakage on fluorescein angiography as well as mean CNV areas on histology sections were compared.

Results:

In phase I, clinical, ERG and histopathologic results were unremarkable in terms of retinal toxicity in all groups. Based on the results of phase I, a dose of 1 μg/5 μl topotecan was chosen for phase II. Leakage scores obtained from late-phase fluorescein angiography were significantly lower in topotecan-treated than control eyes (P < 0.01) four weeks after induction of CNV. Compared to control eyes, topotecan-treated eyes showed a significantly lower incidence of fibrovascular proliferation (8.7% vs. 96.2%) and significantly smaller areas of CNV (P < 0.01).

Conclusion:

Intravitreal injection of topotecan at a dose of 1 μg/5 μl is safe and may be a promising treatment for CNV.

Current knowledge and trends in age-related macular degeneration: genetics, epidemiology, and prevention

PURPOSE

To address the most dynamic and current issues concerning human genetics, risk factors, pharmacoeconomics, and prevention regarding age-related macular degeneration.

METHODS

An online review of the database Pubmed and Ovid was performed, searching for the key words: age-related macular degeneration, AMD, pharmacoeconomics, risk factors, VEGF, prevention, genetics and their compound phrases. The search was limited to articles published since 1985 to date. All returned articles were carefully screened and their references were manually reviewed for additional relevant data. The webpage www.clinicaltrials.gov was also accessed in search of relevant research trials.

RESULTS

A total of 366 articles were reviewed, including 64 additional articles extracted from the references and 25 webpages and online databases from different institutions. At the end, only 244 references were included in this review.

CONCLUSION

Age-related macular degeneration is a complex multifactorial disease that has an uneven manifestation around the world but with one common denominator, it is increasing and spreading. The economic burden that this disease poses in developed nations will increase in the coming years. Effective preventive therapies need to be developed in the near future.

Comparison of the efficacy of aflibercept, ranibizumab, and bevacizumab in an RPE/choroid organ culture

PURPOSE

Anti-VEGF treatment is the therapy of choice in age-related macular degeneration and is also applied in diabetic macular edema or retinal vein occlusion. Recently, aflibercept has been approved for therapeutic use. In this study, we investigate the efficacy of aflibercept in comparison with the VEGF-antagonists ranibizumab and bevacizumab in RPE/choroid organ cultures.

METHODS

RPE/choroid organ cultures were prepared from freshly slaughtered pigs' eyes. Organ cultures were treated with 125 μg/ml aflibercept, ranibizumab, or bevacizumab, and the VEGF content of the supernatant was evaluated over the course of 7 days. Additionally, the minimal concentration of VEGF inhibition was evaluated in organ cultures, measured after 6 h of application.

RESULTS

Aflibercept was able to completely inhibit VEGF detection for 6 h at a minimal concentration of 0.031 μg/ml, in contrast to bevacizumab (3.9 μg/ml) and ranibizumab (0.244 μg/ml). A statistically significant VEGF inhibition compared to control could be found for aflibercept and ranibizumab down to and including 0.031 μg/ml, while bevacizumab was significantly reduced compared to control down to a concentration of 0.244 μg/ml and again at 0.061 μg/ml. Inhibition of VEGF after a single aflibercept application of 125 μg/ml could be found over the course of 7 days, with some VEGF detectable at the 7th day. In contrast, VEGF was detectable after 72 h of ranibizumab treatment and some VEGF could already be found 12 h after bevacizumab treatment.

CONCLUSIONS

In conclusion, aflibercept displays a prolonged VEGF inhibition, confirming its effectiveness but also raising concerns about possible side effects of long-term usage.

Effects of aflibercept on primary RPE cells: toxicity, wound healing, uptake and phagocytosis

BACKGROUND/AIM

Anti-VEGF treatment is the therapy of choice in age-related macular degeneration, and is also applied in diabetic macular oedema or retinal vein occlusion. Recently, the fusion protein, aflibercept, has been approved for therapeutic use. In this study, we investigate the effects of aflibercept on primary RPE cells.

METHODS

Primary RPE cells were prepared from freshly slaughtered pigs' eyes. The impact of aflibercept on cell viability was investigated with MTT and trypan blue exclusion assay. The influence of aflibercept on wound healing was assessed with a scratch assay. Intracellular uptake of aflibercept was investigated in immunohistochemistry and its influence on phagocytosis with a phagocytosis assay using opsonised latex beads.

RESULTS

Aflibercept displays no cytotoxicity on RPE cells but impairs its wound healing ability. It is taken up into RPE cells and can be intracellularly detected for at least 7 days. Intracellular aflibercept impairs the phagocytic capacity of RPE cells.

CONCLUSIONS

Aflibercept interferes with the physiology of RPE cells, as it is taken up into RPE cells, which is accompanied by a reduction of the phagocytic ability. Additionally, it impairs the wound healing capacity of RPE cells. These effects on the physiology of RPE cells may indicate possible side effects.

Current knowledge and trends in age-related macular degeneration: today's and future treatments

PURPOSE

To address the most dynamic and current issues concerning today's treatment options and promising research efforts regarding treatment for age-related macular degeneration. This review is aimed to serve as a practical reference for more in-depth reviews on the subject.

METHODS

An online review of the database PubMed and Ovid were performed, searching for the key words age-related macular degeneration, AMD, VEGF, treatment, PDT, steroids, bevacizumab, ranibizumab, VEGF-trap, radiation, combined therapy, as well as their compound phrases. The search was limited to articles published since 1985. All returned articles were carefully screened, and their references were manually reviewed for additional relevant data. The web page www.clinicaltrials.gov was also accessed in search of relevant research trials.

RESULTS

A total of 363 articles were reviewed, including 64 additional articles extracted from the references. At the end, only 160 references were included in this review.

CONCLUSION

Treatment for age-related macular degeneration is a very dynamic research field. While current treatments are mainly aimed at blocking vascular endothelial growth factor, future treatments seek to prevent vision loss because of scarring. Promising efforts have been made to address the dry form of the disease, which has lacked effective treatment.

Living with age-related macular degeneration treatment: Patient experiences of being treated with ranibizumab (Lucentis)(R) intravitreal injections

This study reports the results of a qualitative study of patient experiences of receiving treatment for wet age-related macular degeneration with ranibizumab (Lucentis)(R). Treatment involved monthly hospital visits for assessment and, where required, an intravitreal Lucentis injection. Qualitative narrative interviews were conducted with 22 patients, 18 of whom received treatment and were interviewed at two points during their treatment journey. Interviews allowed participants to reflect on their experiences of being assessed for and receiving this treatment. Overall, treated participants reported that while they had been apprehensive about treatment, the actual experience of it was far less unpleasant than they had expected. However, the data also revealed a number of issues surrounding the provision of information about treatment, as well as service delivery issues, which had considerable impact upon their experience.

The predictive value of subjective symptoms and clinical signs for the presence of treatment-requiring exudative age-related macular degeneration

PURPOSE

The introduction of vascular endothelial growth factor inhibitors for the treatment of exudative age-related macular degeneration (AMD) has increased the referral rates of AMD patients with visual symptoms to treating centres considerably. However, a large proportion of the referred patients do not qualify for treatment implying that considerable resources could be saved if these patients could be identified on the basis of the clinical data available in the referring nonspecialized setting.

METHODS

A prospective observational study of 1682 consecutive patients referred with suspicion of exudative AMD qualifying for intravitreal angiostatic treatment. On the basis of the structured interviewing about symptoms, ophthalmoscopy, optical coherence tomography scanning, and fluorescein angiography, the patients were divided into two groups: one qualifying for and another not qualifying for treatment. Multiple logistic regression was used to identify independent parameters predicting the need for treatment.

RESULTS

The presence of metamorphopsia, dyschromatopsia, retinal haemorrhages and exudates, central retinal thickness, and the absence of micropsia were highly significant individual determinants of treatment-requiring AMD. Sudden onset and worsening of symptoms and the presence of a central dark spot covaried with the occurrence of retinal haemorrhages, whereas reduced visual acuity and blurred vision covaried with the presence of both haemorrhages and exudates.

CONCLUSION

Patients with treatment-requiring AMD can be reliably identified by questioning about the presence of metamorphopsia and dyschromatopsia and the absence of micropsia, combined with ophthalmoscopical detection of retinal haemorrhages and exudates. This information may improve the triage of patients considered for referral.

One-year outcomes using ranibizumab for neovascular age-related macular degeneration: results of a prospective and retrospective observational multicentre study

The Swedish Lucentis Quality Registry is a 12-month, open-label, observational, prospective, and retrospective study of ranibizumab administration for wet AMD. Visual acuity (VA) was measured with Snellen or ETDRS chart in 370 patients (66.8% women; age range 46–93 years). In total, a mean of 4.7 ± 1.6 injections per patient (range 1–10) was given to month 12. Mean VA score was 58.3 ± 12.2 letters before treatment, 63.3 ± 12.5 after 3 injections (Δ4.9 ± 10.1 letters from baseline), and 59.3 ± 16.2 at 12 months (Δ1.0 ± 13.6). VA score from baseline to month 12 was stable in 74.4% of patients, improved by 15 letters/3 lines or more in 14.7%, and decreased by ≥15 letters/3 lines in 10.9% of patients. With a mean of 4.7 ranibizumab injections per patient per year, mean VA was stabilised but not increased. To maintain the initial gain seen after the first three injections, an average of 1.8 ± 1.5 additional injections does not appear to be adequate.

[Treatment of wet age-related macular degeneration with ranibizumab in clinical practice: results and prognostic factors]

OBJECTIVES

To evaluate the efficacy of ranibizumab in wet age-related macular degeneration (ARMD), and to identify prognostic factors.

METHODS

A retrospective longitudinal study of 79 eyes treated with intravitreal Ranibizumab in our hospital due to wet ARMD, with an initial regimen of three consecutive monthly injections, followed by injections on demand based on the exploratory findings. We conducted a descriptive study of the baseline examination (n=79), and 3 (n=79), 6 (n=67) and 12 months (n=49) after starting treatment. The characteristics of the baseline examination and annual examination results were compared using univariate and multivariate analysis.

RESULTS

After the three initial injections, the 93.67% of patients lost fewer than 15 letters, and 19% gained 15 points or more. This result remained similar at 1 year (83.67% and 20.40%, respectively). After 1 year of treatment 40.82% had a VA ≥ 0.3 and 22'45% had a VA ≤ 0.1. We used a median of 5 injections per year. The increased AV at the beginning and the persistence of large intraretinal cysts at 3 months (P=.0013), as well as the development of fibrosis during evolution (P=.0005), are associated with visual deterioration.

CONCLUSIONS

The guidelines used here stabilised or improved visual acuity in most patients. The most favourable cases are those with initially lower VA or large intraretinal cysts resolved after the loading phase. The appearance of fibrosis implies a poor long-term visual prognosis.