Asian Age-Related Macular Degeneration: Current Concepts and Gaps in Knowledge

Genetics in neovascular age-related macular degeneration susceptibility and treatment response to anti-VEGF intravitreal injection: A case series study

BACKGROUND

To identify genotypes associated with neovascular age-related macular degeneration (nAMD) and investigate the associations between genotype variations and anti-vascular endothelial growth factor (VEGF) treatment response.

METHODS

This observational, retrospective, case series study enrolled patients diagnosed with nAMD who received anti-VEGF treatment in National Taiwan University Hospital with at least one-year follow-up between 2012 and 2020. A genome-wide association study (GWAS) was conducted on enrolled patients and controls. Correlations between the genotypes identified from GWAS and the treatment response of functional/anatomical biomarkers, including visual acuity (VA), presence of intraretinal or subretinal fluid (SRF), serous or fibrovascular pigmented epithelium detachment (PED), and disruption of the ellipsoid zone (EZ), were analysed.

RESULTS

In total, 182 patients with nAMD and 1748 controls were enrolled. GWAS revealed 16 single nucleotide polymorphisms (SNPs) as risk loci for nAMD, including seven loci in CFH and ARMS2/HTRA1 and nine novel loci, including rs117517872 and rs79835234(COPB2-DT), rs7525578(RAP1A), rs2123738(LOC105376755), rs1374879(CNTN3), rs3812692(SAR1A), rs117501587(PRKCA), rs9965945(CNDP1), and rs189769231(MATK). Our study revealed rs800292(CFH), rs11200638(HTRA1), and rs2123738(LOC105376755) correlated with poor treatment response in VA (P = 0.005), SRF (P = 0.044), and fibrovascular PED (P = 0.007), respectively. Rs9965945(CNDP1) was correlated with poor response in disruption of EZ (P = 0.046) and serous PED (P = 0.049).

CONCLUSIONS

Among the 16 SNPs found in the GWAS, four loci-CFH, ARMS2/HTRA1, and two novel loci-were correlated with the susceptibility of nAMD and anatomical/functional responses after anti-VEGF treatment.

Perpetuating ability to live life as usual: a grounded theory study of persons living with age-related macular degeneration

BACKGROUND

Age-Related Macular Degeneration (AMD) is an eye disease associated with age that causes progressive and irreversible loss of central vision, while the peripheral visual ability remains. The occurrence of and especially late AMD is estimated to increase extensively to 2040 among persons aged ≥ 65 in Scandinavia, due to an increasing aging population.

OBJECTIVES

The present study explored what it means to live with AMD through the eyes of those living with the condition.

METHODS

This is an explorative interview study. People who were ≥ 65 years old, living in their own homes, and diagnosed with advanced dry AMD in one or both eyes, causing a visual acuity of no more than 0.3 or worse in the best eye, were invited to participate in the study. The method chosen was the constructivist grounded theory, where reality is seen as fundamentally social and processual and a way of accessing the participants' experiences, thoughts, and feelings.

RESULTS

In total, 12 interviews were conducted. Living with dry AMD confronted different problems and challenges. The substantive theory, Perpetuating ability to live life as usual, is characterised by a desire to continue life as usual, which requires an acceptance of the disease's progress, self-acceptance of the new me, and an acceptance that the new life needs to be lived a little more carefully. Moreover, the participants used three strategies to resolve their main concern by maintaining an everyday life 1) Navigating the new normal, 2) Trusting own ability, and 3) Interdepending.

CONCLUSION

Maintaining an everyday life is the primary concern among people with AMD. In supporting self-care, gaining information about the subjective experience to support their everyday living is of the utmost importance. This grounded theory captures valuable knowledge of how the older adults resolved their main concern "you got to keep on" despite their affected vision by "facing the fact" live life as usual since since life goes on. Our study also gives rise both to implications for research and practice in order to strengthen older people with AMD facing their future challenges.

TRIAL REGISTRATION

The Swedish Ethical Review Authority (EPN 2021/02877).

Two-Year Real-World Results for Aflibercept Using the Treat-and-Extend Regimen in Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

INTRODUCTION

To evaluate the real-world efficacy of aflibercept using the treat-and-extend (TnE) regimen in treating neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and to analyze biomarkers using optical coherence tomography (OCT) to predict treatment outcomes.

METHODS

Patients diagnosed with nAMD or PCV who received an intravitreal injection of aflibercept following the TnE regimen for ≥ 2 years were retrospectively reviewed. Data on best-corrected visual acuity (BCVA), number of injections, treatment interval, and OCT biomarkers, including central macular thickness, presence of subretinal fluid (SRF), and serous pigmented epithelial detachment, were collected at baseline and at 3, 6, 12, 18, and 24 months after the first injection.

RESULTS

A total of 43 patients were enrolled in this study, 24 of whom were diagnosed with nAMD and 19 with PCV. The BCVA in logMAR (mean ± standard deviation) improved from 0.75 ± 0.41 (baseline) to 0.60 ± 0.41 (P = 0.002) at 3 months after treatment initiation, and further improved to 0.66 ± 0.46 at 24 months (P = 0.137). The number of injections (mean ± standard deviation) within the 2-year treatment course was 10.95 ± 3.65. At month 24 of the TnE regimen, the treatment interval was extended to ≥ 16 weeks in 60.5% of all cases and to 78.9% of the PCV cases. After three loading injections, persistent subretinal fluid and intraretinal fluid were predictive of more frequent injections (P = 0.026) and poorer visual outcomes (P = 0.050), respectively.

CONCLUSION

Aflibercept combined with a TnE regimen was effective in treating nAMD and PCV in a real-world setting. The treatment interval could be extended to ≥ 16 weeks in 60.5% of the cases after a 2-year treatment regimen. OCT can be used to predict the treatment course and visual outcomes.

Analysis of Systemic and Serum Risk Factors in Patients with Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

INTRODUCTION

It remains controversial whether polypoidal choroidal vasculopathy (PCV) represents a subtype of neovascular age-related macular degeneration (nAMD) or is a distinct disease entity. This study aimed to compare and analyze systemic and serum risk factors for nAMD and PCV in an aging Chinese population.

METHODS

A retrospective study was performed on 108 patients with nAMD, 131 patients with PCV, and 219 control subjects. Serum levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), apolipoprotein A1 (APOA1), apolipoprotein B (APOB), complement 3 (C3), and complement 4 (C4) together with data on systemic risk factors, including hyperlipidemia, hypertension, diabetes mellitus (DM), coronary artery disease (CAD), and asthma, were collected. Chi-square tests, independent-samples t tests, and binary logistic regression analyses were performed to evaluate the associations of risk factors with nAMD and PCV.

RESULTS

Patients with PCV and those with nAMD were likely to have hyperlipidemia (P < 0.001). CAD (P = 0.020) and hypertension (P = 0.006) correlated significantly with nAMD and PCV, respectively. Although no association of age and asthma with PCV or nAMD was found (P > 0.05), DM was associated with PCV development (OR = 0.535, P = 0.044). Regarding serum risk factors, HDL, LDL, TG, APOB, and C3 were significantly associated with nAMD (OR < 0.001, P < 0.001; OR = 0.028, P < 0.001; OR = 0.175, P < 0.001; OR = 0.922, P = 0.022; OR < 0.001, P < 0.001) and PCV (OR = 0.001, P = 0.001; OR = 0.097, P = 0.003; OR = 0.410, P = 0.037; OR = 0.895, P = 0.001; OR = 0.001, P < 0.001). Compared with nAMD, higher levels of HDL (P = 0.003) and LDL (P = 0.016) and lower levels of TG (P = 0.039) were found in patients with PCV, but the association of systemic risk factors between the two diseases was not significant (P > 0.05).

CONCLUSION

Our findings indicate that hyperlipidemia is significantly associated with both nAMD and PCV. Serum lipid and complement levels have an effect on the pathogenesis of nAMD and PCV, and consideration of the differences between systemic and serum risk factors should be taken into account in clinical management.

Risk factors and clinical significance of prechoroidal cleft in eyes with neovascular age-related macular degeneration in Caucasian patients

OBJECTIVE

The objective of the study was to investigate the prevalence, risk factors and clinical significance of prechoroidal cleft (PC) among neovascular age-related macular degeneration (nAMD) patients in a Caucasian population.

DESIGN

A retrospective observational cohort study.

METHODS

A total of 140 patients with naive nAMD were treated with anti-vascular endothelial growth factor (VEGF) injections and a follow-up of ≥24 months. Optical coherence tomography (OCT) scans were graded for the presence of PC, central subfield foveal thickness (CSFT), maximal retinal thickness (MRT), pigment epithelial detachment (PED), presence of intraretinal fluid (IRF), subretinal fluid (SRF) and subretinal hyper-reflective material (SHRM) at baseline, 3, 6, 12 and 24 months. Best corrected visual acuity (BCVA) and anti-VEGF treatments were recorded.

RESULTS

Out of 140, 21 eyes (15%) developed PC. BCVA improved significantly from 0.68 ± 0.56 to 0.62 ± 0.59 logMAR after 24 months (p = 0.008). The change in BCVA was not related to the presence of cleft (p = 0.208). Multivariate analysis confirmed that higher baseline CSFT (p = 0.011, OR = 1.004, 95%, CI 1.001-1.007) and the presence of multi-layered PED (p < 0.001, OR = 21.153, 95%, CI 5.591-80.026) were both predictive for development of PC. Eyes with PC received more injections than eyes without PC.

CONCLUSION

Prechoroidal cleft was found in 15% of Caucasian nAMD patients treated with anti-VEGF injections and was related to greater retinal and PED height, as well as presence of multi-layered PED. Eyes with PC required more anti-VEGF injections. The presence of PC correlates with disease activity, and intensive anti-VEGF suppression can preserve vision.

Comparison of visual outcomes of polypoidal choroidal vasculopathy and typical neovascular age-related macular degeneration-up to 10 years of follow-up

PURPOSE

To investigate long-term visual outcomes of patients with polypoidal choroidal vasculopathy (PCV) and typical neovascular age-related macular degeneration (nAMD) in the real-world setting.

METHODS

Retrospective, multicenter, noninterventional consecutive cohort study. Two hundred eighty-five eyes of 261 patients with PCV and 902 eyes of 877 patients with typical nAMD, who could be followed up 1 year or longer from 2005 to 2018, were included. Mean changes in best-corrected visual acuity (BCVA) from baseline in the PCV and the typical nAMD groups were compared.

RESULTS

Mean follow-up period of total patients was 4.3 ± 2.8 (1-10) years. Baseline BCVA was better in the PCV group than that in the typical nAMD group (0.59 ± 0.52 versus 0.79 ± 0.63 logMAR, p < 0.001). The mean changes in BCVA from baseline in the PCV and nAMD group were +2.1 and -0.1 letters at 1 year, -0.2 and -3.7 letters at 3 years, -3.9 and -10.5 letters at 5 years and - 8.7 and - 12.1 letters at 7 years, respectively. Before 2006, the initial BCVA was sustained for approximately 1 year in eyes with PCV and for less than half year in eyes with typical nAMD. However, after 2007, when anti-VEGF agents were available, the initial BCVA was sustained for 4 years in eyes with PCV, while it was sustained for 1 year in eyes with typical nAMD.

CONCLUSION

In the real-world, long-term BCVA deteriorated in both PCV and typical nAMD groups, but the PCV group showed better visual outcomes than the typical nAMD group.

Real-World Outcomes of Intravitreal Aflibercept for Neovascular Age-Related Macular Degeneration: A Large-Scale Postmarketing Surveillance in Korea

Purpose

To investigate the efficacy and safety of intravitreal aflibercept (IVT-AFL) in Asian patients with neovascular age-related macular degeneration (nAMD) in a real-world clinical setting.

Patients and Methods

In this analysis of a prospective, regulatory, postmarketing surveillance study for IVT-AFL, 3115 patients with nAMD were included and followed for 8 months. The mean changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were analyzed using last observation carried forward method. A post hoc subgroup analysis and a multivariate logistic regression analysis were also performed to assess factors related to treatment outcomes.

Results

Mean BCVA improved from 0.62 to 0.51 logarithm of minimum angle resolution and mean CRT decreased from 383.3 to 289.7 μm, with a mean of 3.4 injections during the 8-month follow-up. In the subgroup analysis, patients who had received 3 initial monthly doses had significantly better anatomical improvements than those treated as needed. Patients with confirmed polypoidal choroidal vasculopathy (PCV) had significantly better anatomical improvements and better visual recovery than those with other types of nAMD. The multivariate regression analysis demonstrated that age, injection number, PCV, and baseline BCVA were significantly associated with higher odds of gaining 3 lines at 8 months, and sex, injection number, PCV, and baseline CRT were associated with CRT ≤250 µm at 8 months. No new safety findings were identified.

Conclusion

IVT-AFL was effective and well tolerated in a real-world setting with a large number of Asian patients with nAMD. Number of injections and PCV were important determinants for improved treatment outcomes.

Ten-Year Progression From Intermediate to Exudative Age-Related Macular Degeneration and Risk Factors: Bundang AMD Cohort Study Report 1

PURPOSE

This study investigated the 10-year incidence of progression from intermediate to exudative age-related macular degeneration (AMD) and identified genetic and environmental factors influencing that progression in the Korean population.

DESIGN

Retrospective, observational cohort study.

METHODS

In total, 632 eyes of 418 patients (age: ≥50 years) with intermediate AMD were enrolled. The incidence of exudative AMD was assessed from color fundus photographs and optical coherence tomography images obtained at baseline and during annual visits. Data regarding lifestyle variables and dietary habits were acquired through comprehensive questionnaires. Genotyping data concerning 3 single nucleotide polymorphisms (SNPs), rs800292 and rs1061170 in the CFH gene and rs10490924 in ARMS2 were also analyzed. The cumulative incidence of exudative changes was estimated using Kaplan-Meier analysis. Associated influential factors were evaluated using univariate and multivariate Cox regression models.

RESULTS

The mean follow-up period was 3.99 ± 2.85 years. The cumulative incidence of progression to exudative AMD was 5.6%, 14.8%, and 28.4% at 2, 5, and 10 years, respectively. Multivariate Cox analysis showed that age (hazard ratio [HR]: 1.041; P = .0393), family history of AMD (HR: 3.175; P = .0184), and pre-existing exudative AMD in the fellow eye (HR: 3.186; P = 5.31 × 10^-5) were positively associated with exudative changes. Regular intake of green tea (HR: 0.632; P = .0475) was associated with a decrease in exudative changes. The ARMS2 SNP rs10490924 (HR: 1.482; P = .0185) showed a significant association with AMD progression.

CONCLUSIONS

The annual progression rate from intermediate to exudative AMD in the Korean population is approximately 2.8%, which is comparable with that for whites. Intake of green tea may be a modifiable protective factor against exudative changes.

Transient accumulation of subretinal fluid after half-fluence photodynamic therapy in neovascular age-related macular degeneration

Background

Photodynamic therapy (PDT) is known to occlude choroidal neovascularisation selectively, and there have been several reports on its adverse effects on the normal choroid and retinal pigment epithelium, resulting in decreased vision.

Methods

This retrospective interventional case series aimed to investigate the changes in visual acuity and retinal thickness in the immediate post-treatment period after half-fluence PDT, administered alone or with anti-vascular endothelial growth factor and steroids, in 29 eyes (26 patients) with neovascular age-related macular degeneration. The patients’ best-corrected visual acuity (BCVA) and central foveal thickness (CFT) on optical coherence tomography images were measured 1 day, 1 week, and 1 month post-treatment.

Results

Compared to the pre-treatment CFT (270.38 μm), the mean CFT was significantly increased 1 day post-treatment (387.07 μm, P = 0.001), which then started to decrease, with a mean CFT of 269.32 μm (P = 0.516) at 1 week, and of 240.66 μm (P = 0.066) at 1 month post-treatment. All CFT increases were due to the accumulation of subretinal fluid (SRF), rather than the intraretinal or subretinal pigment epithelium fluid. Relative to the pre-treatment BCVA (0.59 logMAR), the mean BCVA at 1 day (0.74 logMAR, P = 0.005) and 1 week (0.75 logMAR, P = 0.002) post-treatment was significantly deteriorated; however, it recovered to 0.62 logMAR at 1 month. The patterns of change in CFT and BCVA did not differ according to treatment modality.

Conclusions

Half-fluence PDT resulted in accumulation of SRF in the immediate post-treatment period; this damage mostly recovered within a week, and the BCVA was restored within a month.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01867-w.

The comparison of spectral domain optical coherence tomography and indocyanine green angiography in the diagnosis of polypoidal choroidal vasculopathy

OBJECTIVES

To evaluate the diagnostic capability of spectral domain optical coherence tomography (SD-OCT) in patients with potential diagnostic findings for polypoidal choroidal vasculopathy (PCV).

MATERIALS AND METHODS

Ninety-three eyes with potential diagnostic findings for PCV were prospectively evaluated. Patients with multiple retinal pigment epithelial detachment (RPED), sharp RPED peak, RPED notch, hyporeflective lumen representing polyps, double-layer sign and the presence of hyperreflective intraretinal hard exudate were considered as PCV in SD-OCT. The sensitivity and specificity of SD-OCT in the diagnosis of PCV were determined by comparing SD-OCT-based diagnosis with indocyanine green angiography (ICGA).

RESULTS

Sixty-nine (74.2%) of 93 eyes included in the study were confirmed with ICGA and diagnosed as PCV. The sensitivity and specificity of SD-OCT for the diagnosis of PCV were 75.3% and 75%, respectively.

CONCLUSION

The SD-OCT-based method helps clinicians to develop appropriate diagnostic and treatment strategies for patients in whom ICGA cannot be used.

Characteristics of the inner retinal layer in the fellow eyes of patients with unilateral exudative age-related macular degeneration

OBJECTIVE

To investigate the thicknesses of the ganglion cell-inner plexiform layer (GC-IPL) and retinal nerve fiber layer (RNFL) of the fellow eyes of patients with unilateral exudative age-related macular degeneration (AMD).

METHODS

A total of 107 patients with unilateral exudative AMD [34 of typical choroidal neovascularization (tCNV), Group A; 73 of polypoidal choroidal vasculopathy (PCV), Group B] and 73 normal control eyes (Group C) were included. Drusen and subretinal drusenoid deposits were assessed in all participants using fundus photography, autofluorescence, and optical coherence tomography (OCT). The GC-IPL and RNFL thicknesses were measured using Cirrus HD-OCT and compared among groups. Linear regression analyses were used to evaluate the factors associated with GC-IPL thicknesses.

RESULTS

The average GC-IPL thicknesses of Groups A, B, and C were 77.09 ± 3.87, 80.10 ± 6.61, and 80.88 ± 6.50 μm, respectively (p = 0.022). Sectoral GC-IPLs and central macular thicknesses (CMTs) were significantly different among groups (all, p <0.05), whereas none of the RNFL parameters differed significantly (all, p >0.05). Multivariate linear regression analyses revealed that age (p <0.001), CMT (p <0.001), and tCNV (p = 0.013) were significantly associated with average GC-IPL thickness, and the rate of reduction of GC-IPL thickness with increasing age in the fellow eyes of tCNV patients was higher than those in the PCV and control groups.

CONCLUSIONS

Unilateral tCNV patients exhibited statistically significant reduction of the GC-IPL thickness in the fellow eyes, compared to values of the fellow eyes of unilateral PCV patients or control patients. RNFL values trended to be lower but did not reach statistical significance.

Pre-treatment With Ranibizumab Aggravates PDT Injury and Alleviates Inflammatory Response in Choroid-Retinal Endothelial Cells

Polypoidal choroidal vasculopathy (PCV) is the predominant subtype of exudative age-related macular degeneration in Asians. Although photodynamic therapy (PDT) is widely used for PCV treatment, its long-term beneficial effects are unsatisfactory. Accumulating clinical investigations suggest that combined therapy with anti-vascular endothelial growth factor (anti-VEGF) and PDT is superior to PDT monotherapy. However, the optimal time of anti-VEGF before or after PDT remains controversial, hence it needs to further explore the mechanism underlying combined therapy. PDT causes selective damage to endothelial cells, which determines its angio-occlusive efficiency, yet the impact of anti-VEGF on PDT-induced endothelial injury is unclear. Here, we found that pre- compared to post-treatment with anti-VEGF ranibizumab (rani) significantly aggravates PDT injury in the rhesus macaque choroid-retinal endothelial (RF/6A) cell line. PDT activates apoptosis, necroptosis and NLRP3 inflammasome in RF/6A cells. Pre-treatment with rani promotes PDT-caused apoptosis via triggering caspase 8-mediated extrinsic apoptosis, and caspase 8 might also play a pivotal role in the rani’s function of suppressing PDT-induced necroptosis and NLRP3 inflammasome activation. Our results implicate that pre-treatment with rani may enhance the angio-occlusive efficiency of PDT and alleviate endothelial inflammatory response, which gives it a great advantage over post-treatment.

EFFICACY AND SAFETY OF INTRAVITREAL AFLIBERCEPT AND RANIBIZUMAB IN ASIAN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Subgroup Analyses From the VIEW Trials

PURPOSE

To assess the treatment effect of intravitreal aflibercept and ranibizumab in Asian patients with neovascular age-related macular degeneration.

METHODS

We evaluated data from VIEW 1 and VIEW 2, comparing functional and morphologic outcomes at Week 96 between intravitreal aflibercept 2 mg monthly (2q4) or 2 mg bimonthly after 3 initial monthly doses (2q8) versus ranibizumab 0.5 mg monthly among Asian patients (n = 269) and between Asian and white patients (n = 2044).

RESULTS

In Asian patients, there were no significant differences between intravitreal aflibercept 2q4 and 2q8 compared with ranibizumab in mean gain in best-corrected visual acuity (10.23 and 8.35 vs. 8.51 letters). Reduction in central retinal thickness was greater for intravitreal aflibercept 2q4 (150.43 μm, P = 0.0075) and 2q8 (148.15 μm, P = 0.0126) than ranibizumab (119.46 μm). The proportion of dry retinas was greater for intravitreal aflibercept 2q4 (65.7%, P < 0.01) than ranibizumab (41.7%). There were no differences in outcomes between Asian and white patients. Serious treatment-emergent ocular adverse events occurred in <8% of treated eyes, evenly distributed across subgroups.

CONCLUSION

In Asian patients with neovascular age-related macular degeneration, functional and morphologic outcomes were largely similar between intravitreal aflibercept and ranibizumab groups, and to results seen in white patients.

Genetic Association of Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

Age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) are leading causes of irreversible blindness among the elderly population in developed countries. Although being considered as different subtypes of a same disease, neovascular AMD and PCV have differences in clinical, epidemiological, therapeutic, and genetic profiles. Both AMD and PCV are complex diseases involving multiple genetic and environmental risk factors. Different genetic strategies have been adopted to discover associated genes and variants for neovascular AMD and PCV, including genome-wide association study (GWAS), next-generation sequencing (NGS) based sequence analysis, and candidate gene analyses. So far, a number of susceptible genes have been identified for AMD and/or PCV, such as CFH, ARMS2-HTRA1, C2-CFB-SKIV2L, C3, CETP, and FGD6. Although many of these genes are shared by AMD and PCV, some showed difference between them, such as ARMS2-HTRA1 and FGD6. Also, some of the genes showed ethnic diversities, such as the CFH p.Tyr402His variant. Further larger-scale genomic studies should be warranted to identify more susceptibility genes for AMD and, in particular, PCV among different populations, and differentiate the genetic architectures between neovascular AMD and PCV.

EVEREST study report 4: Fluorescein angiography features predictive of polypoidal choroidal vasculopathy

Importance

It is important to identify features of polypoidal choroidal vasculopathy (PCV) that differentiate it from typical neovascular age‐related macular degeneration (nAMD) on various imaging modalities, including fluorescein angiography (FA).

Background

PCV was thought to be indistinguishable from nAMD using FA alone. In real‐world practice, indocyanine‐green angiography may often be unavailable or contraindicated.

Design

Analysis of FA images from a prospective, multicentre study.

Participants

Study images of both PCV and nAMD patients from the EVEREST study.

Methods

FA features at baseline were independently graded by masked graders (fellowship‐trained ophthalmologists) using standardized diagnostic algorithms.

Main Outcome Measures

Predictive indicators (sensitivity, specificity, positive and negative predictive values) for PCV.

Results

Of the 95 patients screened, 61 had PCV. Of the 34 screening failures, 15 were diagnosed as nAMD. Hyperfluorescent nodules on FA were observed in 80% of patients with PCV vs 20% with nAMD (P < 0.001). Blocked fluorescence on FA, which corresponded to the presence of subretinal haemorrhage, occurred more frequently among patients with PCV vs nAMD (61.7% vs 13.3%, P = 0.001). Similarly, the leakage characteristic of occult choroidal neovascularization occurred more frequently among patients with PCV vs nAMD (95.0% vs 73.3%, P = 0.026). The positive predictive value for PCV was 94.1% for hyperfluorescent nodules, 94.9% for blocked fluorescence, 83.8% for occult choroidal neovascularization and 82.0% for pigment epithelial detachment.

Conclusions and Relevance

This study demonstrated that certain FA features can be predictive of PCV and may be considered as an indication for retina specialists to perform indocyanine green angiography as confirmatory test.

The Use of Vascular Endothelial Growth Factor Inhibitors and Complementary Treatment Options in Polypoidal Choroidal Vasculopathy: A Subtype of Neovascular Age-Related Macular Degeneration

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD; nAMD) which occurs more commonly in Asian populations as compared to Caucasians. PCV and nAMD share pathological mechanisms, including pathological expression of vascular endothelial growth factor (VEGF). The advent of anti-vascular endothelial growth factor (VEGF) revolutionized the treatment of nAMD. Despite being a subtype of nAMD, PCV responds less well to VEGF inhibitors; thus, photodynamic therapy (PDT) in combination with anti-VEGF treatment may be considered. This review aims to summarize the current evidence for the treatment of PCV, especially whether VEGF inhibitors should be used alone or in combination with PDT.

Utility values for age-related macular degeneration patients in Korea

PURPOSE

Age-related macular degeneration (AMD) is one of the most important causes of blindness globally and may lead to decreased quality of life. Utility values for AMD patients according to sociodemographic and clinical characteristics have been little-studied, particularly among Asian populations.

METHODS

A total of 1,283 AMD patients were identified from the Korean National Health and Nutrition Examination Survey from 2008 to 2012. A 45-degree digital retinal image for each eye was used to identify AMD patients. The utility values, calculated by the three level version of EuroQol-5D, of AMD patients according to sociodemographic and clinical characteristics were determined. The Kruskal-Wallis test was used to identify factors associated with reduced utility values among AMD patients.

RESULTS

The mean utility value for AMD patients was 0.8765. Patients who were older (mean utility value 0.8339), were women (0.8488), had lower education levels (0.8287), were not employed (0.8467), and had lower household income (0.8022) had lower utility values (all p values <0.001). Utility values did not significantly differ according to AMD subtype (p value 0.729), likely due to the lack of enough power as only 48 patients had late AMD. Patients with lower best-eye visual acuity (BEVA) had lower utility values compared to those with high BEVA, even among those with high worst-eye visual acuity (WEVA) (p value <0.001).

CONCLUSION

Sociodemographic factors and visual acuity are important factors in determining the quality of life among AMD patients. Preserving BEVA, regardless of WEVA, may be associated with improved quality of life.

The Modification of Fluorescein Angiography and Its Applications in Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

AIM

To establish a novel retinal angiography method, red-free angiography (RFA), to investigate retinal changes in age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).

METHODS

Following the venous phase of fundus fluorescein angiography (FFA), the detection mode was switched to red-free reflectance to acquire RFA images using the same parameters.

RESULTS

RFA showed subretinal fluid, polyps, and outer retinal tubulation, with a higher definition than the FFA and red-free reflectance results.

CONCLUSIONS

The absorption coefficients in RFA provided more detailed images for AMD and PCV diagnosis. RFA is therefore a promising approach to supplement FFA.

[Anti-VEGF therapy resistance in neovascular age-related macular degeneration]

With account to the increase in the elderly population in most of the developed countries, the WHO defines age-related macular degeneration (AMD) as one of the main causes of blindness in the world. A large percentage of disability is accounted for by exudative, or neovascular, form of AMD. Today, a total of 5 anti-VEGF drugs exist that are recommended for treatment of exudative AMD: pegaptanib, ranibizumab, bevacizumab, aflibercept, and conbercept. Despite significant progress in the treatment of neovascular AMD yielded by the introduction into clinical practice of anti-VEGF drugs, some patients report a lack (down to complete lack) of response with standard treatment patterns and even a decrease in treatment efficacy after repeated intravitreal injections.

Short-term efficacy of intravitreal conbercept in treatment-naive patients with polypoidal choroidal vasculopathy

Introduction

To evaluate the functional and morphological outcomes of intravitreal conbercept monotherapy in patients with polypoidal choroidal vasculopathy (PCV).

Materials and methods

In this retrospective, observational case series study, we reviewed medical records of 48 eyes (48 patients) with naive PCV that were treated with a series of 3 monthly intravitreal injections of 0.5 mg of conbercept followed by as-needed injections (3+pro re nata). All patients completed at least 6 months of monthly follow-up. Changes in the best-corrected visual acuity, optical coherence tomography, and indocyanine green angiography were retrospectively evaluated.

Results

At 6 months, the mean best-corrected visual acuity significantly improved from 0.89±0.35 (20/160 in Snellen equivalent) at baseline to 0.58±0.26 (Snellen equivalent of 20/80; P<0.001), and 60.42% (29/48) of eyes had an improvement of three lines of vision; the mean central retinal thickness significantly decreased from 333.56±171.04 μm at baseline to 187.65±54.46 μm (P<0.001), and 93.75% (45/48) achieved a dry macula. At 3 months, 6 of 32 eyes (18.75%) showed partial regression of branching vascular network, 14 of 32 (43.75%) patients showed complete resolution of polyps. The mean number of injections was 3.4±0.9 through 6 months. No conbercept-related systemic or ocular adverse effects were observed.

Conclusion

Intravitreal injection of conbercept using "3+pro re nata" regimen significantly improved visual acuity and anatomical outcomes in treatment-naive patients with PCV.

Recommended Guidelines for Use of Intravitreal Aflibercept With a Treat-and-Extend Regimen for the Management of Neovascular Age-Related Macular Degeneration in the Asia-Pacific Region: Report From a Consensus Panel

PURPOSE

To summarize recommendations for the use of intravitreal aflibercept with a treat-and-extend regimen to manage neovascular age-related macular degeneration (nAMD) in the Asia-Pacific region. Although anti-vascular endothelial growth factor therapies have improved the quality of life of patients with nAMD, a leading cause of blindness and visual impairment, the high treatment frequency recommended by current guidelines places a significant burden on patients and healthcare providers.

DESIGN

Recommended guidelines from a consensus panel.

METHODS

An expert panel formed a consensus on recommendations for use of intravitreal aflibercept as treatment of nAMD in the Asia-Pacific region.

RESULTS

After 3 initial monthly doses, treatment interval could be extended by 4-week increments, to a maximum of 12 weeks, in patients with inactive disease. Conversely, in active disease, treatment intervals should be shortened, by 4 weeks, or to 4 weeks in cases of severe recurrence. Treatment could be ceased in patients with stable disease activity after 12 months of treatment at 12-week intervals, as a means to prevent over treatent and lifelong injections.

CONCLUSIONS

These recommendations could potentially minimize the number of treatments while maintaining efficacy and improve compliance by reducing the number of clinic visits compared with existing recommendations.

Choroidal structures in polypoidal choroidal vasculopathy, neovascular age-related maculopathy, and healthy eyes determined by binarization of swept source optical coherence tomographic images

PURPOSE

To evaluate quantitatively the choroidal vascularity in polypoidal choroidal vasculopathy (PCV) and neovascular age-related macular degeneration (AMD) patients compared to healthy controls.

METHODS

All eyes underwent swept source optical coherence tomography (OCT), and choroidal images were binarized into blood vessels lumen and stroma. The choroidal vascular index (CVI) was defined as the ratio of luminal area (LA) over total choroidal area of the subfoveal region with a width of 1500 μm.

RESULTS

The study included 73 patients with neovascular AMD or PCV with mean ± standard deviation (SD) age of 71.8 ± 9.3 years, which was older than the mean age of 65.1 ± 10.8 years of 72 healthy eyes from control group (p < 0.01). The 44 PCV eyes had significantly higher mean SFCT of 214.23 ± 95.21 μm than neovascular AMD eyes (172.74 ± 96.48 μm, p = 0.03) and greater luminal area (0.23 ± 0.09 mm² vs. 0.19 ± 0.08 mm², p = 0.05). After adjusting for age, axial length, and gender in multivariate regression analysis, the SFCT of PCV and neovascular AMD eyes were not significantly different from healthy eyes (195.55 ± 93.11 μm), but the CVI of both PCV (64.94 ± 5.43%, p = 0.01) and neovascular AMD (62.54 ± 5.57%, p = <0.01) were significantly lower than control (68.53 ± 5.91%).

CONCLUSION

Despite physiological changes of choroidal vasculature due to aging, the choroidal morphology is different in PCV, neovascular AMD and healthy eyes, which has implication on disease pathogenesis.

Resistance to anti-VEGF therapy in neovascular age-related macular degeneration: a comprehensive review

As a progressive chronic disease, age-related macular degeneration (AMD) is the leading cause of irreversible vision impairment worldwide. Experimental and clinical evidence has demonstrated that vascular endothelial growth factor (VEGF) plays a vital role in the formation of choroidal neovascularization. Intravitreal injections of anti-VEGF agents have been recommended as a first-line treatment for neovascular AMD. However, persistent fluid or recurrent exudation still occurs despite standardized anti-VEGF therapy. Patients suffering from refractory or recurrent neovascular AMD may develop mechanisms of resistance to anti-VEGF therapy, which results in a diminished therapeutic effect. Until now, there has been no consensus on the definitions of refractory neovascular AMD and recurrent neovascular AMD. This article aims at clarifying these concepts to evaluate the efficacy of switching drugs, which contributes to making clinical decision more scientifically. Furthermore, insight into the causes of resistance to anti-VEGF therapy would be helpful for developing possible therapeutic approaches, such as combination therapy and multi-target treatment that can overcome this resistance.

Age-related macular degeneration and polypoidal choroidal vasculopathy in Asians

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly people globally. It is estimated that there will be more Asians with AMD than the rest of the world combined by 2050. In Asian populations, polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative AMD, while choroidal neovascularization secondary to AMD (CNV-AMD) is the typical subtype in Western populations. The two subtypes share many common clinical features and risk factors, but also have different epidemiological and clinical characteristics, natural history and treatment outcomes that point to distinct pathophysiological processes. Recent research in the fields of genetics, proteomics and imaging has provided further clarification of differences between PCV and CNV-AMD. Importantly, these differences have manifested as disparity in response to intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) treatment between PCV and CNV-AMD, emphasizing the need for accurate diagnosis of PCV and in distinguishing PCV from CNV-AMD, particularly in Asian patients. Current clinical trials of intravitreal anti-VEGF therapy and photodynamic therapy will provide clearer perspectives of evidence-based management of PCV and may lead to paradigm shifts in therapeutic strategies away from those currently employed in the treatment of CNV-AMD. Further research is needed to clarify the relative contribution of specific pathways in inflammation, complement activation, extracellular matrix dysregulation, lipid metabolism and angiogenesis to the pathogenesis of PCV. Findings from this research, together with improved diagnostic technology and new therapeutics, will facilitate more optimal management of Asian AMD.

Refractive Error and the Risk of Age-Related Macular Degeneration in the South Korean Population

PURPOSE

We investigated the association between refractive error and the prevalence of age-related macular degeneration (AMD) in a population-based study.

DESIGN

This was a cross-sectional study.

METHODS

Right eyes were included from 14,067 participants aged 40 years and older with gradable fundus photographs and refraction data from the fourth and the fifth Korea National Health and Nutrition Examination Survey 2008 to 2011. Early and late AMD was graded based on the International Age-Related Maculopathy Epidemiological Study Group grading system. Autorefraction data were collected to calculate spherical equivalent refraction in diopters (D) and classified into 4 groups: hyperopia (≥1.0 D), emmetropia (-0.99 to 0.99 D), mild myopia (-1.0 to -2.99 D), and moderate to high myopia (≤-3.0 D).

RESULTS

After adjustment for potential confounders, each diopter increase in spherical equivalent was associated with a 16% [odds ratio (OR), 1.16; 95% confidence interval (CI), 1.08-1.25] and 18% (OR, 1.18; 95% CI, 1.10-1.27) increased risk of any (early + late) and early AMD, respectively. Mild and moderate to high myopia were associated with lower odds of any and early AMD compared with hyperopia (any AMD: OR, 0.62; 95% CI, 0.4-0.95 for mild myopia; OR, 0.41; 95% CI, 0.21-0.81 for moderate to high myopia; early AMD: OR, 0.63; 95% CI, 0.4-0.99 for mild myopia; OR, 0.36; 95% CI, 0.16-0.77 for moderate to high myopia group). There was no association between refractive status and the likelihood of late AMD (P = 0.91).

CONCLUSIONS

Myopia is associated with lower odds of any and early AMD, but not with late AMD in the South Korean population.

Polypoidal Choroidal Vasculopathy in Asians

Age related macular degeneration (AMD) in Asians has been suggested to differ from their Western counterparts in terms of epidemiology, pathogenesis, clinical presentation and treatment. In particular, polypoidal choroidal vasculopathy (PCV) appears to be the predominant subtype of exudative AMD in Asian populations, in contrast to choroidal neovascularization secondary to AMD (CNV-AMD) in Western populations. Epidemiological data on PCV has been largely limited to hospital-based studies and there are currently no data on the incidence of PCV. Similarities and differences in risk factor profile between PCV and CNV-AMD point to some shared pathogenic mechanisms but also differential underlying mechanisms leading to the development of each phenotype. Serum biomarkers such as CRP, homocysteine and matrix metalloproteinases suggest underlying inflammation, atherosclerosis and deranged extracellular matrix metabolism as possible pathogenic mechanisms. In addition, recent advances in genome sequencing have revealed differences in genetic determinants of each subtype. While the standard of care for CNV-AMD is anti-vascular endothelial growth factor (VEGF) therapy, photodynamic therapy (PDT) has been the mainstay of treatment for PCV, although long-term visual prognosis remains unsatisfactory. The optimal treatment for PCV requires further clarification, particularly with different types of anti-VEGF agents and possible benefits of reduced fluence PDT.