Imaging of Exudative Age-Related Macular Degeneration: Toward a Shift in the Diagnostic Paradigm?

Second eyes to develop neovascular age-related macular degeneration have fewer symptoms and better one-year visual outcomes

BACKGROUND

This study compares the visual and anatomical outcomes for the eyes of patients who developed sequential neovascular age-related macular degeneration (nAMD), both at the time of diagnosis and at one year after treatment.

METHODS

The study comprised a retrospective case series of 52 patients whose eyes were diagnosed sequentially with nAMD. All eyes were treated with three monthly loading doses of anti-vascular endothelial growth factor agents, followed by further intravitreal injections, as required. Baseline characteristics and outcomes at one year after diagnosis and initial treatment were compared between first and second eyes and included visual acuity (VA), central macular thickness (CMT), and pigment epithelial detachment (PED) height on optical coherence tomography (OCT) imaging.

RESULTS

VA at diagnosis was better for second eyes compared with first eyes to develop nAMD (logMAR 0.68 ± 0.51 versus logMAR 0.41 ± 0.34, P = 0.002) and remained so at one year (logMAR 0.61 ± 0.60 versus logMAR 0.42 ± 0.37, P = 0.041). Similarly, PED height at diagnosis was higher in first eyes (225 ± 176 μm versus 155 ± 144 μm, P = 0.003) and also at one year (188 ± 137 μm versus 140 ± 112 μm, P = 0.019). Whereas most patients reported symptoms at first eye diagnosis (71.2%), half as many second eyes were symptomatic (28.8%, P < 0.001). Significantly more symptomatic first eyes experienced visual distortions (32.4% versus 13.3%) or scotomas (29.4% versus 6.7%), compared with a less specific visual complaint of blurry vision (38.2% versus 80.0%, P = 0.006).

CONCLUSIONS

Compared with first eyes to develop nAMD, second eyes tended to have better vision, smaller PED heights, and fewer symptoms likely because monitoring permitted earlier diagnosis.

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

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

Undetectable Macular Neovascularization on OCT Angiography in Age Related Macular Degeneration: Comparison between Different Devices

Background and Objectives: The aim of this study was to report the characteristics of macular neovascularization (MNV) with undetectable flow on optical coherence tomography angiography (OCTA) in neovascular age related macular degeneration (nAMD), and compare them with the characteristics of detectable MNV. Materials and Methods: Patients with a diagnosis of nAMD who underwent dye imaging and OCTA in the same day were included and divided into two groups: undetectable and detectable flow on OCTA. Three OCTA devices were used, two with spectral-domain technology (AngioVue, RTVue 100xAvanti, Optovue, Freemont, CA, USA and Heidelberg OCT2 Beta Angiography Module, Heidelberg Engineering, Germany) and one swept-source OCTA (PlexElite 9000; Carl Zeiss Meditec, Inc., Dublin, CA, USA). We studied the demographics, neovascularization characteristics, and OCTA device and acquisition characteristics for both groups. Results: A global comparison between Group 1 and Group 2 was made, followed by an analysis of variables associated with (un)detectability for each OCTA device. A total of 108 eyes were included: 90 in the detectable group (Group 1) and 18 in the undetectable group (Group 2), corresponding to a global sensitivity of OCTA for the detection of MNV of 83.49%. There was a statistically significant difference between the two groups regarding MNV type (p = 0.02) and PED height (p = 0.017). For the three devices, detection sensitivity with automatic segmentation was significantly lower than with manual segmentation. For Heidelberg, PED Height and scan quality explained 68.3% of the undetectability. For AngioVue, PED Height and absence of hemorrhage explained 67.9% of undetectability. Conclusions: In this study, we found a global sensitivity of 83.49% for the three OCTA devices combined, with a range from 55.5% to 96.26% depending on the segmentation and OCTA device. This means that undetectable/undetected MNV can represent up to 45% of the examinations, eventually misdiagnosing choroidal neovascularization for 1 out every 2 patients.

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.

Real-world outcomes of anti-VEGF therapy in treatment-naïve neovascular age-related macular degeneration diagnosed on OCT angiography: the REVEAL study

PURPOSE

To compare the 12 months visual and anatomical outcomes of treatment-naïve neovascular age-related macular degeneration (nAMD) patients diagnosed by optical coherence tomography angiography (OCT-A) compared with fluorescein angiography (FA)/indocyanine green angiography (ICGA), after anti-VEGF treatment in a real-world setting.

METHODS

Monocentric, observational, parallel-group study of nAMD patients diagnosed with either FA/ICGA or non-invasive OCT-A methods. Patients were treated with a fixed dosing regimen of intravitreal ranibizumab or aflibercept and followed up for 12 months. Primary outcomes were the 12 months functional (BCVA) and anatomical (CST reduction) gains between the two groups. The stratification of BCVA and CST gains by type of neovascular lesion and by anti-VEGF treatment was also assessed.

RESULTS

Seventy-two patients received FA/ICGA for the initial diagnosis of nAMD, while 73 received OCT-A. Overall, the mean BCVA gain at 12 months was 11.5 ± 9.6 letters. There were no statistically significant differences between the invasive and non-invasive imaging groups in BCVA gain (p = 0.87) or CST reduction (p = 0.76). No statistically significant outcome differences between different lesion types and the two drugs were observed.

CONCLUSION

In a real-world setting, nAMD patients diagnosed with OCT-A showed meaningful improvements in visual and anatomical parameters during 12 months of treatment, without significant differences with those diagnosed by invasive modalities.

[Neovascular recurrences in 42 treatment-naive eyes with neovascular age-related macular degeneration (AMD) followed for over 2 years]

INTRODUCTION

The objective of this study was to analyze the reproducibility or variability of the time period to exudative recurrences in patients who were treated with intravitreal injections (IVT) of anti-VEGF (ranibizumab, aflibercept) for exudative age-related macular degeneration (AMD). The data studied included the number of recurrences per year, the time between the last IVT and the recurrence, fluctuation over time in the same patient, and changes in the therapeutic management of these exudative recurrences with regard to repeat induction therapy of three IVT, changes in monitoring protocols, and switches in anti-VEGF molecules.

MATERIALS AND METHODS

We conducted a retrospective, single center, "real-life" study at the Nantes University Hospital, including 33 patients (42 eyes) between March 2012 and March 2017. These were IVT-naive patients, in whom anti-VEGF IVT treatment was initiated for management of exudative AMD, with a follow-up period of at least two consecutive years. The main outcome was the fluctuation in recurrences times for the same patient.

RESULTS

Of the 33 patients included, 9 had bilateral involvement, for a total of 42 eyes. Twenty were women (60.6 %), the median age at inclusion was 78.5 years with a follow-up period of 3.7 years. The average time to recurrence was 11.6 weeks after the last IVT. The first recurrence occurred within 9.8 weeks after the last IVT. 12.3% of the eyes had consisent recurrence times, with fluctuations of less than 2 weeks between the various relapses over the two years of follow-up. a total of 7.1% of the eyes had no exudative recurrences during follow-up. The first exudative recurrence occurred at a mean of 38.2 weeks after diagnosis of the disease, or 37.2 weeks after the first IVT. 14.3% of the recurrences led to the administration of a repeat induction of three intravitreal anti-VEGF injections, 8.6% led to a change in anti-VEGF molecule, and 7.1% to a modification of the treatment protocol.

DISCUSSION

The goal of this study was to analyze the variability of the time to exudative recurrence in patients treated with anti-VEGF IVT in the context of exudative AMD, because, since the advent of anti-VEGF IVT in 2007, few data have been available on long-term follow-up and fluctuations in recurrence times in patients who will receive treatment for several years.

CONCLUSION

Recurrences times are not reproducible over follow-up, particularly in patients experience their first exudative recurrence beyond 8 weeks and in patients with multiple exudative recurrences.

Diagnostic Value of Optical Coherence Tomography Angiography for Choroidal Neovascularization in Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to evaluate the diagnostic value of optical coherence tomography angiography (OCTA) in detecting the choroidal neovascularization (CNV) in age-related macular degeneration (AMD).

METHODS

A systematic review and meta-analysis was performed by searching Pubmed, Science Direct, Embase, and Web of Science. The pooled sensitivity and specificity with 95% confidence intervals (CIs), area under the summary receiver operator characteristic curve (sROC), and the total accurate classification rate were used to evaluate OCTA's diagnostic value of CNV in AMD patients.

RESULTS

Seven studies involving 517 eyes were included in the analysis. The mean age of subjects in each study ranged from 58.5 years to 81.7 years. Fluorescein angiography was applied as the gold standard in 5 studies. There were 350 eyes diagnosed with CNV, OCTA detected 301 eyes correctly, while among the 167 eyes without CNV, OCTA identified 150 correctly. The total accurate classification rate was 87.23%. The Spearman's rank correlation coefficient was 0.5, indicating that there was no significant threshold effect in the current study (S = 8, p = 0.103). The pooled sensitivity and pooled specificity were 0.89 (95% CI: 0.82, 0.94) and 0.96 (95% CI: 0.85, 1.00), respectively. The area under sROC was up to 0.911.

CONCLUSION

The specificity of OCTA for the detection of CNV in AMD patients is extremely high; however, the sensitivity still needs to be improved. In general, the meta-analysis revealed that OCTA had a high diagnostic value for the detection of CNV in AMD patients.

SENSITIVITY OF 840-nm SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN DETECTING TYPE 1 NEOVASCULARIZATION ACCORDING TO THE HEIGHT OF THE ASSOCIATED PIGMENT EPITHELIAL DETACHMENT

PURPOSE

To evaluate the ability of optical coherence tomography angiography (OCTA) to detect abnormal vascular blood flow in Type 1 neovascularization (NV) with or without significant pigment epithelial detachment (PED).

METHODS

Consecutive age-related macular degeneration patients with either treatment-naive or anti-vascular endothelial growth factor-treated Type 1 NV were divided into 2 groups based on the PED height on structural OCT: greater than 250 μm (Group 1) versus less than 250 μm (Group 2). Two independent senior retina specialists analyzed the OCTA images (Zeiss Angioplex OCT, Carl Zeiss AG, Jena, Germany) using the automatic slabs alone (first reader) versus automatic and manual segmentation slabs (second reader).

RESULTS

In Group 1, 15 men and 42 women, aged from 51 years to 97 years (mean: 87.5), were included. Optical coherence tomography angiography was able to show an abnormal blood flow suggestive of Type 1 NV in 23 (40.3%) of 57 eyes for the first reader and in 32 (56.1%) of 57 eyes for the second reader. In Group 2, 7 men and 30 women, aged from 60 years to 96 years (mean: 80.2), were included. The first and second readers were able to observe an image suggestive of Type 1 NV in 33/37 (89.2%) and 37/37 (100%) of eyes, respectively.

CONCLUSION

The ability of OCTA to detect an abnormal blood flow in Type 1 NV was found to highly depend on the height of the associated PED and the use of manual segmentation slabs. Our results suggest that automatic slabs of OCTA should be interpreted with caution for the diagnosis of vascularized PED. The diagnosis of Type 1 NV using OCTA requires the use of manual segmentation and a multimodal imaging approach, especially when the height of the associated PED is >250 μm.

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.

[Indications for fluorescein angiography and optical coherence tomography angiography (OCTA) in medical retina: Changes from 2015 and 2018]

INTRODUCTION

Non-invasive multimodal imaging, including optical coherence tomography angiography (OCTA), has demonstrated high sensitivity and specificity for the management of retinal diseases. Since the availability of OCTA in 2015, we have developed a policy of "as little fluorescein angiography as possible". In this study, we describe the rate of OCTA and fluorescein angiography (FA) performed and their indications.

METHODS

Retrospective descriptive single-centre study. Chart review of patients examined for retinal disorders by one medical retina specialist between January 2015 and June 2018.

RESULTS

3487 patients were examined for a retinal disease. The charts of 651 of these patients (1170 eyes) were randomly selected for analysis (study group). The mean age in the study group was 72 years (60% female). Overall, OCTA and FA were performed in 49.4% and 6.5% of the studied eyes respectively. After the first year, the rate of FA decreased to 2%. The main indications for OCTA were age-related macular degeneration (AMD): 50%, central serous chorioretinopathy (CSC): 12% and retinal vascular occlusion: 10%. The most frequent indications for FA were AMD: 49%, diabetic retinopathy (DR): 18% and CSC: 14%. FA was performed in 16%, 11% and 10% of eyes diagnosed with DR, CSC and AMD respectively (P<0.05).

CONCLUSION

In routine practice, OCTA was performed in half of the eyes examined for a retinal disorder. The overall rate of FA was 6.5% and dropped to 2% after the first year of OCTA use. DR was the main disorder still requiring FA.

Impact of optical coherence tomography angiography on the non-invasive diagnosis of neovascular age-related macular degeneration

PURPOSE

To investigate the changes in imaging tool practice for the diagnosis of neovascular age-related macular degeneration (nAMD).

METHODS

Retrospective analysis of consecutive patients diagnosed with nAMD in a tertiary care center, over a 6-month period in 2014, 2016, and 2018. Patient demographics were compared. Imaging modalities used in 2014 were fundus photography, fluorescein angiography (FA), and structural spectral-domain optical coherence tomography (SD-OCT), while OCT-angiography (OCT-A) was available from 2015. Imaging tools used in our practice were compared in the 3 cohorts.

RESULTS

The 3 cohorts included 163, 99, and 167 patients, respectively. There was no difference in age or gender (mean age 81.7 years). OCT-A images were analyzable in 60.5% and 89.7% of patients respectively in 2016 and in 2018. In the 3 cohorts, all patients were imaged with fundus photography and structural OCT. FA was performed in 70.2, 28.8, and 22.1% of patients, respectively.

CONCLUSION

This study showed a shift in practice of imaging tools used for the diagnosis of nAMD, non-invasive tools being increasingly used as the first-line imaging, and FA as the second-line imaging.

Vascular remodeling of choroidal neovascularization in older myopic patients treated with ranibizumab

PURPOSE

To investigate morphological changes in myopic choroidal neovascularization (mCNV) using optical coherence tomography-angiography (OCT-A) after treatment with ranibizumab.

METHODS

Retrospective analysis of consecutive patients over a 24-month period. All treatment-naïve mCNV were imaged at baseline with color pictures, spectral-domain OCT and OCT-A, and fluorescein angiography in selected cases. CNV morphology was classified at baseline and at 6 months. The CNV lesion surface was also compared.

RESULTS

Twenty-nine patients with a mean age of 70.3 ± 10.1 years were included. They received a mean number of 2.65 injections over 6 months. Best-corrected visual acuity improved from 62.2 to 68.5 letters (p = 0.004), with regression of exudation in 24 eyes (82.7%). Baseline CNV was classified into tree-in-bud (16 eyes), medusa (9 eyes), or sea-fan (4 eyes) pattern. At 6 months, no abnormal blood flow was observed in CNV in 13 eyes. Eyes with complete regression or evolution towards an indistinct pattern showed more often a complete regression of exudation than eyes with unchanged pattern (p = 0.007). The mean CNV surface significantly decreased from 0.19 to 0.08 mm² (p < 0.0001).

CONCLUSION

An unchanged pattern was more often associated with exudation persistence, while a complete regression or evolution towards indistinct pattern was always associated with vascular inactivity. However, variable changes in mCNV were observed after anti-VEGF. Thus, OCT-A could be more useful in the diagnosis than in the follow-up of mCNV.

[Update from France Macula Federation: Diagnosis of wet AMD]

PURPOSE

To update the recommendations of the France Macula Federation for the diagnosis of wet age-related macular degeneration (AMD).

METHODS

Analysis of literature and expert opinion.

RESULTS

The FMF recommends diagnosing wet AMD by combining the results of fundus examination (or color or monochromatic fundus photographs), optical coherence tomography (OCT) showing exudative signs, and morphological visualization of the neovascular membrane, which may be obtained non-invasively (OCT-angiography) or invasively (fluorescein and/or indocyanine green angiography). Under optimal conditions in which all these tools are available, the FMF recommends using non-invasive methods as first-line tools and resorting to dye angiography if diagnostic doubt remains.

CONCLUSION

As observed in other fields of medical imaging, non-invasive methods are preferred to invasive methods for the diagnosis of wet AMD, while the latter are reserved for more difficult cases.