GEOGRAPHIC ATROPHY INCIDENCE AND PROGRESSION AFTER INTRAVITREAL INJECTIONS OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS FOR AGE-RELATED MACULAR DEGENERATION: A Meta-Analysis

Non-exudative OCT findings in neovascular AMD

In this narrative review we describe the main optical coherence tomography biomarkers appearing in eyes with neovascular age-related macular degeneration (AMD) that do not directly correspond to exudation. We highlight those signs that may mimic exudation and therefore do not require active treatment, such as outer retinal tubulations, pseudocysts, lipid globules, or hyporeflective wedges. Other signs may indicate impending exudation such as hyperreflective foci or shallow irregular retinal pigment epithelium elevation, and therefore should be carefully monitored. We also review and summarize the different origins of subretinal hyperreflective material and describe the main signs of degeneration seen in eyes with AMD, such as outer retinal tubulation, thinning of the retinal layers, outer retinal atrophy, and choroidal changes.

Real-World Outcomes in Pre-Existing Neovascular Age-Related Macular Degeneration Subjects Undergoing Avacincaptad Therapy for Geographic Atrophy

Purpose

To evaluate real-world outcomes in subjects with pre-existing neovascular age-related macular degeneration (AMD) undergoing intravitreal avacincaptad pegol (IVA) treatment for geographic atrophy (GA).

Methods

This study was undertaken as a retrospective, case-controlled assessment of patients undergoing IVA treatment for GA from 2 community-based retina practices. Patients were separated into 1) a Study Group consisting of subjects with pre-existing neovascular AMD prior to initiation of IVA for GA, and 2) a Control Group consisting of AMD subjects without neovascularization prior to initiation of IVA for GA. Study and Control Group subjects had a baseline visual acuity of ≥ 20/200, a total GA lesion area of ≥ 1 mm2 and ≤ 17.5 mm2, and follow-up of 12-months following IVA commencement.

Results

A total of 64 patients were analyzed. No significant differences in baseline characteristics were found between cohorts. The Study Group had a greater decrease in visual acuity [-0.2 (-0.24 to -0.16) logMAR versus -0.04 (-0.06 to 0.02) logMAR; p<0.0001], a greater increase in GA lesion growth [1.36 (1.09-1.63) mm2 versus 0.52 (0.34-0.70) mm2; p<0.0001], and a higher incidence of exudation (p=0.0002) compared to the Control Group during the study period.

Conclusion

This study suggests that patients undergoing IVA therapy for GA with pre-existing neovascular AMD have worse visual and anatomic outcomes at 12-months compared to a matched control group without pre-existing neovascularization; such patients therefore should be carefully counseled prior to initiation of IVA for the management of GA.

Chorioretinal Atrophic Lesions Evolution in Patients with Quiescent Myopic Choroidal Neovascularization Followed for More Than 10 Years

Purpose

To evaluate the progression of chorioretinal atrophic areas associated with myopic choroidal neovascularization (CNV) in high myopic patients followed by a minimum period of 10 years.

Patients and Methods

Patients with myopic CNV lesions that achieved clinical and structural remissions over 10 years of follow-up were included. Medical records were reviewed for CNV characterization and treatment, best-corrected visual acuity at baseline (BCVA0), immediately after the last treatment (BCVA1) and at the latest visit (BCVA2). Fundus autofluorescence (FAF) was used to quantify the amount of atrophic area increase per year associated with the treated myopic CNV lesion. The first FAF performed after treatment suspension (FAF1) was compared with the most recent exam (FAF2).

Results

Thirty-six eyes from 36 patients were included. Mean total follow-up was 12.38 ± 2.68 years. Mean number of intravitreal injections (IVI) was 12.50 ± 12.40 and 25% of the eyes had previous treatment with photodynamic therapy (PDT). Mean improvement between BCVA0 and BCVA1 was 5.58 ± 15.98 letters (p < 0.001). However, a drop of 8.03 ± 12.25 letters was noticed between BCVA1 and BCVA2. FAF1 was 6.34 ± 4.92mm2 and increased to 9.88 ± 7.56mm2 (3.54 ± 3.79mm2 variation p < 0.001). The mean growth rate of the atrophic area was 0.89 ± 0.84mm2 per year. BCVA2 negatively correlated with FAF2 (k = -0.498, p = 0.002) being worse in patients with higher atrophic area growth rate (k = -0.341, p = 0.042). Eyes treated with PDT needed less IVI (5.89 ± 5.21 vs 14.70 ± 13.36, p = 0.008) but had larger FAF1 (9.80 ± 5.33 vs 5.19 ± 4.27, p = 0.013) and FAF2 (16.05 ± 7.10 vs 7.83 ± 6.63, p = 0.003). Hypothyroidism was associated with higher atrophy growth rate (1.55 ± 1.15 vs 0.73 ± 0.67, p = 0.016).

Conclusion

This research demonstrates the importance of chorioretinal atrophy progression after myopic CNV lesions regression and its impact on visual prognosis, reporting a mean yearly growth of 0.89 mm2 in atrophic areas. Previous treatment with PDT and hypothyroidism were identified as risk factors associated with larger atrophic areas and worse visual outcomes.

Impact of Anti-VEGF Treatment and Patient Characteristics on Vision Outcomes in Neovascular Age-related Macular Degeneration: Up to 6-Year Analysis of the AAO IRIS® Registry

Purpose

To evaluate anti-VEGF treatment patterns and the influence of patient demographic and clinical characteristics on up to 6-year vision outcomes in neovascular age-related macular degeneration.

Design

Retrospective, multicenter, noninterventional registry study with up to 6 years of follow-up.

Participants

A cohort of 254 655 eyes (226 767 patients) with first anti-VEGF injection and at least 2 years of follow-up; 160 423 eyes had visual acuity (VA) data.

Methods

Anonymized patient data were collected in the United States through the IRIS® Registry (Intelligent Research in Sight).

Main Outcome Measures

Changes in VA from baseline; frequency of and gaps between intravitreal anti-VEGF injections; treatment discontinuations; switching anti-VEGF agents; and influence of baseline clinical and demographic characteristics on VA.

Results

After a mean VA increase of 3.0 ETDRS letters at year 1, annual decreases led to a net loss from baseline of 4.6 letters after 6 years. Patients with longer follow-ups had better baseline and follow-up VA. From a mean of 7.2 in year 1 and 5.6 in year 2, mean injections plateaued between 4.2 to 4.6 in years 3 through 6. Treatment was discontinued in 38.8% of eyes and switched in 32.3%. When adjusting for differences at baseline, every additional injection resulted in a 0.68 letter improvement from baseline to year 1; thus, multiple injections in a year have the potential to be clinically meaningful. Older age, male gender, Medicaid insurance, and not being treated by a retina specialist were associated with a higher likelihood of vision loss at year 1. Of the patients, 58.5% lost ≥ 10 letters VA at least once during follow-up, with 14.5% of patients experiencing sustained poor vision after a median of 3.4 years.

Conclusions

After modest mean VA improvement with intravitreal anti-VEGF injections at year 1, patients netted a loss of VA by year 6. Injection frequency decreased over time, and this was paired with a relatively high rate of discontinuation. Modeling suggested that more frequent injections were associated with better VA. Difficulty with continuous adherence to frequent intravitreal injections may have contributed to undertreatment resulting in less-than-optimal vision outcomes.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Anti-VEGF Drugs in Age-Related Macular Degeneration: A Focus on Dosing Regimen-Related Safety and Efficacy

Age-related macular degeneration (AMD) is one of the main causes of visual impairment and severe visual loss, and can progress to two advanced forms-neovascularization and atrophic. The field of anti-AMD drugs has undergone huge developments in recent years, from single-target intravitreal administration to current clinical studies with multi-target and non-invasive agents, offering interesting new pharmacological opportunities for the treatment of this disease. Hence, we summarize some of the approved anti-vascular endothelial growth factor (VEGF) drugs for neovascular AMD, especially their structural characteristics, clinical manifestations, dosing regimens, and safety issues of the anti-VEGF drugs highlighted. In addition, advances in atrophic AMD drug research are also briefly described.

Comparison of 24-month treatment outcomes between as-needed treatment and switching to treat-and-extend in type 3 macular neovascularization

This study aimed to compare 24-month treatment outcomes between patients with type 3 macular neovascularization (MNV) treated using an as-needed regimen and those who switched to treat-and-extend (TAE). This retrospective study included 32 patients who were initially treated with an as-needed regimen but switched to TAE (TAE group) and 74 patients who were treated with an as-needed regimen throughout the follow-up period (as-needed group). The number of anti-vascular endothelial growth factor (VEGF) injections and degree of change in best-corrected visual acuity (BCVA) over 24 months were compared between the two groups. The incidence of fibrotic scarring, tears of the retinal pigment epithelium (RPE), and subretinal hemorrhage was also evaluated. The number of anti-VEGF injections was higher in the TAE group (mean: 11.7) than in the as-needed group (mean: 6.9; P < 0.001). The BCVA outcome (measured using the mean logarithm of the minimal angle of resolution [logMAR]) was significantly better in the TAE group (mean improvement of logMAR 0.15) than in the as-needed group (mean deterioration of logMAR 0.15). The incidence of fibrotic scarring (6.3% vs. 18.9%), RPE tears (3.1% vs. 6.8%), and subretinal hemorrhage (0% vs. 9.5%) was relatively lower in the TAE group. Treatment outcomes of the TAE group were better than those of the as-needed group, suggesting that switching to the TAE regimen would be a useful approach for patients with type 3 MNV requiring efficient treatment.

The Fovea-Protective Impact of Double-Layer Sign in Eyes With Foveal-Sparing Geographic Atrophy and Age-Related Macular Degeneration

Purpose

The purpose of this study was to investigate the impact of double-layer sign (DLS) on geographic atrophy (GA) progression in eyes with foveal-sparing GA and age-related macular degeneration (AMD).

Methods

This is a retrospective, consecutive case series of eyes with foveal-sparing GA secondary to AMD with more than 6 months of follow-up. The size of the foveal-sparing area was measured on the fundus autofluorescence images at the first and last visits. Each eye was evaluated for the presence or absence of DLS inside the foveal-sparing area. We graded eyes based on the presence of DLS within the foveal-sparing area and compared the progression of GA between two groups (DLS (+) versus DLS (-)).

Results

We identified 25 eyes with foveal-sparing GA with at least 2 follow-up visits (average interval = 22.7 ± 11.8 months between visits). The mean foveal sparing area was 1.74 ± 0.87 mm2 (range = 0.42-4.14 mm2) at baseline and 1.26 ± 0.75 mm2 (range = 0.25-2.92 mm2) at the last visit. Seventeen eyes (65.3%) were graded as DLS (+) within the foveal-sparing area. Square root progression of GA toward the fovea was significantly faster in the DLS (-) eyes (0.149 ± 0.078 mm/year) compared to the DLS (+) group (0.088 ± 0.052 mm/year; P = 0.04).

Conclusions

The DLS (-) group showed significantly faster centripetal GA progression than the DLS (+) group. Our data suggest that the presence of DLS in the spared foveal area could be a protective factor against foveal progression of GA in eyes with AMD.

Therapy of Pseudoxanthoma Elasticum: Current Knowledge and Future Perspectives

Pseudoxanthoma elasticum (PXE) is a rare, genetic, metabolic disease with an estimated prevalence of between 1 per 25,000 and 56,000. Its main hallmarks are characteristic skin lesions, development of choroidal neovascularization, and early-onset arterial calcification accompanied by a severe reduction in quality-of-life. Underlying the pathology are recessively transmitted pathogenic variants of the ABCC6 gene, which results in a deficiency of ABCC6 protein. This results in reduced levels of peripheral pyrophosphate, a strong inhibitor of peripheral calcification, but also dysregulation of blood lipids. Although various treatment options have emerged during the last 20 years, many are either already outdated or not yet ready to be applied generally. Clinical physicians often are left stranded while patients suffer from the consequences of outdated therapies, or feel unrecognized by their attending doctors who may feel uncertain about using new therapeutic approaches or not even know about them. In this review, we summarize the broad spectrum of treatment options for PXE, focusing on currently available clinical options, the latest research and development, and future perspectives.