INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR FOR RETINAL ANGIOMATOUS PROLIFERATION IN TREATMENT-NAIVE EYES: Long-term Functional and Anatomical Results Using A Modified PrONTO-Style Regimen

Functional and structural characteristics in patients with type 3 macular neovascularisation treated with anti-VEGF. Three-year results in real world settings

BACKGROUND

To evaluate the long-term anatomical and functional outcomes of anti-Vascular Endothelial Growth Factor intravitreal injections (anti-VEGF IVI) in patients with type 3 macular neovascularisation (MNV) in real-world settings.

METHODS

Retrospective review of patients with type 3 MNV who received anti-VEGF IVI between 2013 and 2020. Primary outcomes were best corrected visual acuity (BCVA) and central macular thickness (CMT). Secondary outcome was the development of new-onset of foveal-involving geographic atrophy (GA) and disciform scars.

RESULTS

We identified 59 eyes from 48 British patients that met the inclusion criteria. Treatment with anti- VEGF IVI resulted in a statistically significant reduction in median CMT, which was maintained throughout the study period. At 36 months, 24 eyes showed more than 50 μm reduction in CMT, 7 eyes remained stable and only 2 eyes showed an increase in CMT by more than 50μm compared to the baseline. At year three, deterioration was noticed in most eyes (52.78%) and vision remained stable or improved in 47.22% of the eyes. However, the median BCVA was not statistically significant different compared to baseline. During the study period new onset of macula-involving atrophy or scar was noted in 10.2% and 4.3% of the eyes, respectively.

CONCLUSION

In this real-world study, anatomic and functional improvement were recorded 12-months post anti-VEGF IVI in type 3 MNV. Despite sustained anatomical improvement, vision returned back to baseline levels at 36-months. The development of GA and macular scar was only partially responsible for this outcome suggesting a more severe nature of this form of nAMD.

Anti-vascular endothelial growth factor monotherapy or combined with verteporfin photodynamic therapy for retinal angiomatous proliferation: a systematic review with meta-analysis

Purpose: To assess functional and anatomical outcomes of intravitreal anti-Vascular Endothelial Growth Factor (anti-VEGF) monotherapy versus combined with verteporfin Photodynamic Therapy (PDT) for Retinal Angiomatous Proliferation (RAP). Methods: Studies reporting outcomes of intravitreal anti-VEGF monotherapy and/or in combination with verteporfin PDT in RAP eyes with a follow-up ≥ 12 months were searched. The primary outcome was the mean change in best corrected visual acuity (BCVA) at 12 months. Mean change in central macular thickness (CMT) and mean number of injections were considered as secondary outcomes. The mean difference (MD) between pre- and post-treatment values was calculated along with 95% Confidence Interval (95% CI). Meta-regressions were performed to assess the influence of anti-VEGF number of injections on BCVA and CMT outcomes. Results: Thirty-four studies were included. A mean gain of 5.16 letters (95% CI = 3.30-7.01) and 10.38 letters (95% CI = 8.02-12.75) was shown in the anti-VEGF group and combined group, respectively (anti-VEGF group vs. combined group, p < 0.01). A mean CMT reduction of 132.45 µm (95% CI = from -154.99 to -109.90) and 213.93 µm (95% CI = from -280.04 to -147.83) was shown in the anti-VEGF group and combined group, respectively (anti-VEGF group vs. combined group, p < 0.02). A mean of 4.9 injections (95% CI = 4.2-5.6) and 2.8 injections (95% CI = 1.3-4.4) were administered over a 12-month period in the anti-VEGF group and combined group, respectively. Meta-regression analyses showed no influence of injection number on visual and CMT outcomes. High heterogeneity was found across studies for both functional and anatomical outcomes. Conclusion: A combined approach with anti-VEGF and PDT could provide better functional and anatomical outcomes in RAP eyes compared with anti-VEGF monotherapy.

A Case of Chorioretinitis with Retinal Angiomatous Proliferation

A 48-year-old woman had an acute blurred vision in the right eye immediately after drainage of liver abscess. Her best corrected visual acuity (BCVA) was 8/400; fundus photography suggested the diagnosis of endogenous endophthalmitis with chorioretinitis and vitritis. Due to the bad systemic condition, a systemic antibiotic combined with periocular triamcinolone (TA) was carried out first. Inflammatory cells in the vitreous cavity were decreased after treatment; however, fundus fluorescein angiography (FFA) showed abnormal dilation and leakage of the capillaries and retinal-choroidal anastomose, supporting that there was retinal angiomatous proliferation (RAP). Vitreous interleukin-6 (IL-6) was only slightly elevated; the ratio of interleukin-10 (IL-10) and IL-6 was less than 1, and the etiological test was negative. After receiving intravitreal vancomycin injection combined with periocular TA injection, the patient's BCVA was improved from 16/400 to 20/400 with a reduction in vitreous inflammatory cells. However, the patient's RAP was progressed and her BCVA was dramatically decreased to count finger/30 cm. After intravitreal injection of ranibizumab, the patient's BCVA was 5/400 with a significant shrink in lesions and absorption of hemorrhage, exudation, and fluid. Thus, we suggest that early anti-inflammatory treatment in conjunction with anti-VEGF may achieve a better prognosis in patients with inflammatory retinal angiomatous proliferation (RAP).

Clinical Pathological Features and Current Animal Models of Type 3 Macular Neovascularization

Type 3 macular neovascularization (MNV3), or retinal angiomatous proliferation (RAP), is a distinct type of neovascular age-related macular degeneration (AMD), which is a leading cause of vision loss in older persons. During the past decade, systematic investigation into the clinical, multimodal imaging, and histopathological features and therapeutic outcomes has provided important new insight into this disease. These studies favor the retinal origin of MNV3 and suggest the involvement of retinal hypoxia, inflammation, von Hippel–Lindau (VHL)–hypoxia-inducible factor (HIF)–vascular endothelial growth factor (VEGF) pathway, and multiple cell types in the development and progression of MNV3. Several mouse models, including the recently built Rb/p107/Vhl triple knockout mouse model by our group, have induced many of the histological features of MNV3 and provided much insight into the underlying pathological mechanisms. These models have revealed the roles of retinal hypoxia, inflammation, lipid metabolism, VHL/HIF pathway, and retinoblastoma tumor suppressor (Rb)–E2F cell cycle pathway in the development of MNV3. This article will summarize the clinical, multimodal imaging, and pathological features of MNV3 and the diversity of animal models that exist for MNV3, as well as their strengths and limitations.

Retinal microglia are critical for subretinal neovascular formation

Abnormal subretinal neovascularization is a characteristic of vision-threatening retinal diseases, including macular telangiectasia (MacTel) and retinal angiomatous proliferation (RAP). Subretinal neovascular tufts and photoreceptor dysfunction are observed in very-low-density lipoprotein receptor (Vldlr-/-) mutant mice. These changes mirror those observed in patients with MacTel and RAP, but the pathogenesis is largely unknown. In this study, we show that retinal microglia were closely associated with retinal neovascular tufts in Vldlr-/- mice and retinal tissue from patients with MacTel; ablation of microglia/macrophages dramatically prevented formation of retinal neovascular tufts and improved neuronal function, as assessed by electroretinography. Vldlr-/- mice with retinal pigmented epithelium-specific (RPE-specific) Vegfa had greatly reduced subretinal infiltration of microglia/macrophages, subsequently reducing neovascular tufts. These findings highlight the contribution of microglia/macrophages to the pathogenesis of neovascularization, provide valuable clues regarding potential causative cellular mechanisms for subretinal neovascularization in patients with MacTel and RAP and suggest that targeting microglia activation may be a therapeutic option in these diseases.

Long-Term Treatment Outcomes in Type 3 Neovascularization: Focus on the Difference in Outcomes between Geographic Atrophy and Fibrotic Scarring

Background: To evaluate the difference in the long-term treatment outcomes of type 3 neovascularization between eyes with geographic atrophy and those with fibrotic scars. Methods: This retrospective study included 195 eyes diagnosed with type 3 neovascularization and treated with anti-vascular endothelial growth factor (VEGF) agents. The included eyes were divided into three groups according to the fundus findings at the final visit: patients with fovea-involving geographic atrophy (GA group), patients with fovea-involving fibrotic scars (scar group), and patients with no fovea-involving geographic atrophy or fibrotic scars (non-GA/scar group). The best-corrected visual acuities (BCVA) of the three groups at the final visits were compared. Results: The mean follow-up period was 47.5 ± 20.7 months. The mean logMAR BCVA at the final visit was 1.18 ± 0.58 in the GA group (n = 58), 1.67 ± 0.58 in the scar group (n = 62), and 0.69 ± 0.64 in the non-GA/scar group (n = 75). The BCVA was significantly worse in the scar group than in the GA (p < 0.001) and the non-GA/scar groups (p < 0.001). Conclusion: Eyes with fibrotic scars showed the poorest visual outcomes in type 3 neovascularization among the studied groups. Preventing the development of fibrotic scars should be considered an important treatment goal.

Treatment Effects in Retinal Angiomatous Proliferation Imaged with OCT Angiography

PURPOSE

This prospective case series is aimed at exploring optical coherence tomographic angiography (OCT-A) as a treatment monitoring tool in patients treated for retinal angiomatous proliferation (RAP).

METHODS

Twelve treatment-naïve RAP patients were included, with a median age of 79 years (range 65-90). Patients were imaged with an experimental 1,040-nm swept-source phase-resolved OCT-A instrument before and after treatment. Treatment consisted of either intravitreal bevacizumab or triamcinolone injections with or without photodynamic therapy (PDT). Abnormal blood flow after treatment was graded as increased, unchanged, decreased, or resolved.

RESULTS

OCT-A images before and after treatment could be obtained in 9 patients. The median follow-up period was 10 weeks (range 5-19). After various treatments, the RAP lesion resolved in 7 patients, in 1 patient the OCT-A depicted decreased flow in the lesion, and 1 patient showed unchanged abnormal blood flow. Monotherapy with intravitreal bevacizumab injections resolved RAP in 1 out of 2 patients. Combined therapy of bevacizumab with PDT resolved RAP in 6 out of 7 patients.

CONCLUSIONS

OCT-A visualized resolution of abnormal blood flow in 7 out of 9 RAP patients after various short-term treatment sequences. OCT-A may become an important noninvasive monitoring tool for optimizing treatment strategies in RAP patients.

Morphologic Criteria of Lesion Activity in Neovascular Age-Related Macular Degeneration: A Consensus Article

Intravitreal antivascular endothelial growth factor drugs represent the current standard of care for neovascular age-related macular degeneration (nAMD). Individualized treatment regimens aim at obtaining the same visual benefits of monthly injections with a reduced number of injections and follow-up visits, and, consequently, of treatment burden. The target of these strategies is to timely recognize lesion recurrence, even before visual deterioration. Early detection of lesion activity is critical to ensure that clinical outcomes are not compromised by inappropriate delays in treatment, but questions remain on how to effectively monitor the choroidal neovascularization (CNV) activity. To assess the persistence/recurrence of lesion activity in patients undergoing treatment for nAMD, an expert panel developed a decision algorithm based on the morphological features of CNV. After evaluating all current retinal imaging techniques, the panel identified optical coherent tomography as the most reliable tool to ascertain lesion activity when funduscopy is not obvious.

Incidence and risk factors of massive subretinal hemorrhage in retinal angiomatous proliferation

Objective

To evaluate the incidence and associated risk factors of massive subretinal hemorrhage (SRH) in patients with retinal angiomatous proliferation (RAP).

Methods

A total of 187 eyes of 135 treatment-naıve patients diagnosed with RAP were evaluated retrospectively. Clinical records including the time between the initial visit, last anti-vascular endothelial growth factor (VEGF) treatment, last stable examination, and the date of massive SRH were reviewed. Imaging findings including indocyanine green angiography (ICGA) and optical coherence tomography (OCT) were analyzed.

Results

Massive SRH developed in 18 eyes (9.6%) a median of 20 months after the initial presentation. Kaplan-Meier survival analysis revealed that the incidence (2.8, 5.8, 13.1, and 21.0% after 1,2,5 and 10 years, respectively) continuously increased. Among 14 eyes with discernable vascular anastomosis on baseline ICGA, 13 (92.8%) showed retinal arteriole involvement. On spectral-domain OCT imaging of the last visit prior to the massive SRH, a layered lamellar tissue complex was noted under the retinal pigment epithelium in 9 of 13 eyes, which was significantly associated with massive SRH[hazard ratio(HR),5.883;P = .010]. The average time between the last stable examination/last injection and the massive SRH was 2 and 5 months, respectively. The patients were treated with anti-VEGF, gas and recombinant tissue plasminogen activator injection; however, all except one eye had visual acuity worse than 20/1000 at the final visit.

Conclusions

Massive SRH can occur in RAP in the course of anti-VEGF treatment, resulting in severe vision loss. A proactive dosing regimen may be more appropriate for these RAP eyes.

Short-term efficacy of intravitreal Aflibercept injections for retinal angiomatous proliferation

BACKGROUND

To evaluate the short-term efficacy of intravitreal injections of aflibercept (IVA) to treat retinal angiomatous proliferation (RAP) and identify factors related to functional outcomes.

METHODS

This retrospective case series consisted of 19 eyes in 19 patients with RAP. All 19 eyes received 3 monthly consecutive IVA. The primary outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) after the last IVA.

RESULTS

Of the 19 treated eyes, 8 (42%) were pre-treated with 1 dose of bevacizumab one month prior to the initiation of treatment with aflibercept. BCVA was significantly improved and CRT was significantly reduced after 3 consecutive IVAs (P = 0.014 and P = 0.0002, respectively). Stabilization or improvement in BCVA was observed in 17 eyes (90%) treated with IVA. Eyes with baseline fibrovascular pigment epithelial detachment (PED) showed no significant gain in BCVA, and fibrovascular PED was negatively correlated with final BCVA (Spearman's correlation coefficient = - 0.481, P = 0.037). The mean follow-up was 3.5 ± 0.5 months.

CONCLUSIONS

In this short-term study, three consecutive IVAs showed efficacy for improving vision and reducing retinal edema in RAP patients. Eyes with fibrovascular PED showed poorer responses, and the presence of fibrovascular PED at baseline was negatively correlated with visual outcomes.

Treatment of Bilateral Retinal Angiomatous Proliferation with Anti-vascular Endothelial Growth Factor: 12-Month Outcome

Purpose

To evaluate the 12-month outcome of intravitreal anti-vascular endothelial growth factor therapy in eyes with bilateral retinal angiomatous proliferation (RAP).

Methods

This retrospective observational study included 38 eyes of 19 patients with stage 1 or 2 bilateral RAP at diagnosis. The eyes of patients who exhibited different baseline best-corrected visual acuity (BCVA) values in both eyes were assigned to one of two groups—the better (n=13) and worse (n=13) visual acuity groups. The BCVA values in both groups were compared to those at baseline and at 12 months. In addition, the 12-month changes in BCVA were compared between the two groups. The association between the optical coherence tomography findings at diagnosis and the 12-month BCVA was also analyzed.

Results

The values of mean baseline and 12-month BCVA in the better visual acuity group (13 eyes) were 0.48 ± 0.19 and 0.58 ± 0.29, respectively, and those in the worse visual acuity group (13 eyes) were 0.83 ± 0.20 and 0.90 ± 0.31. The 12-month changes in BCVA were not significantly different between the two groups (p=0.786). Among the six patients with equivalent baseline BCVA in both eyes, four patients (66.7%) exhibited 1 to 2 lines or ≥3 lines of difference in BCVA between eyes at 12 months. Eyes without pigment epithelial detachment (PED) at diagnosis exhibited significantly better BCVA at 12 months than eyes with PED (p=0.021).

Conclusions

Better baseline visual acuity was associated with better BCVA at 12 months posttreatment in patients with bilateral RAP. However, equivalent baseline visual acuity in both eyes might not guarantee similar treatment outcomes. In addition, the absence of PED is predictive of better visual outcome.

An Update on the Ophthalmologic Features in the Phakomatoses

Neurofibromatosis type 1, tuberous sclerosis complex, and Von Hippel-Lindau disease, historically classified as the phakomatoses, are hereditary multisystem disorders characterized by the presence of hamartoma, which carry the risk of malignant transformation. The alteration of tumor suppressor genes seems to be at the basis of their pathophysiogenetic mechanism. Lisch and choroidal nodules in neurofibromatosis type 1, retinal astrocytomas in tuberous sclerosis complex, and retinal capillary hemangioma in Von Hippel-Lindau disease are the principal ophthalmic hamartomatous manifestations. The advent of novel imaging techniques such as near infrared reflectance and optical coherence tomography has provided unprecedented insight on the choroidal and retinal features of these diseases. These methods have improved early diagnosis and the ongoing surveillance in these conditions. Among an array of treatment modalities, antivascular endothelial growth factor therapy has been used in the management of retinal hamartomas but results have been varied. This review is an update on the pathophysiogenetic mechanisms, ophthalmic manifestations, and novel treatment strategies in the phakomatoses with emphasis on the role of imaging techniques.

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.

Neurofibromatosis: an update of ophthalmic characteristics and applications of optical coherence tomography

Neurofibromatosis (NF) is a multisystem disorder and tumor predisposition syndrome caused by genetic mutation on chromosome 17-17q11.2 in NF type 1 (NF1), and on chromosome 22-22q12.2 in NF type 2. The disorder is characterized by considerable heterogeneity of clinical expression. NF1 is the form with the most characteristic ocular manifestations. Lisch nodules of the iris are among the well-known diagnostic criteria for the disease. Glaucoma and associated globe enlargement have been described in a significant proportion of patients with NF1 and orbital–facial involvement. Optic nerve glioma may cause strabismus and proptosis, and palpebral neurofibroma may reach considerable size and occasionally show malignant transformation. Near infrared reflectance has greatly contributed to enhancing our knowledge on choroidal alterations in NF1. Indeed, some authors have proposed to include these among the diagnostic criteria. Optical coherence tomography has given new insight on retinal alterations and is a noninvasive tool in the management of optic nerve gliomas in children. Ocular manifestations in NF type 2 can range from early-onset cataracts in up to 80% of cases to optic nerve hamartomas and combined pigment epithelial and retinal hamartomas.

Guidelines for the Management of Wet Age-Related Macular Degeneration: Recommendations from a Panel of Greek Experts

Purpose

To propose guidelines for the management of patients with wet age-related macular degeneration (wAMD), taking into account the results of large multicenter studies and clinical experience of retina experts.

Method

A team of retina experts developed a consensus paper after three consecutive meetings. The group was focused on guidelines to help clinical decision-making around the definition of successful treatment and the definition of non-response to therapy.

Results

Parameters suggestive of a successful response to treatments included: any gain in best corrected visual acuity (BCVA) or vision loss that is less than 5–10 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, reduction of central retinal thickness, partial or complete absorption of subretinal fluid (SRF), reduction of intraretinal fluid, reduction of pigment epithelial detachment or restoration of the anatomy of outer retinal layers. Non-response to current treatment was considered in the case of loss of BCVA greater than 10 ETDRS letters, increased retinal edema or increase of SRF as evidenced by optical coherence tomography or new bleeding in biomicroscopy.

Conclusion

The introduction of anti-VEGF agents revolutionized the treatment of wAMD. Given the complexity of the disease, the emerging new agents and the difference of cases recruited in clinical trials compared to those appearing in every-day practice, it is essential to individualize treatment options taking into account the results of clinical trials.

Outcomes in Eyes with Retinal Angiomatous Proliferation in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT)

PURPOSE

To compare baseline characteristics, visual acuity (VA), and morphologic outcomes between eyes with retinal angiomatous proliferation (RAP) and all other eyes among patients with neovascular age-related macular degeneration (NVAMD) treated with anti-vascular endothelial growth factor (VEGF) drugs.

DESIGN

Prospective cohort study within the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

PARTICIPANTS

Patients with NVAMD.

METHODS

Reading center staff evaluated digital color fundus photographs, fluorescein angiography (FA) images, and optical coherence tomography (OCT) scans of eyes with NVAMD treated with either ranibizumab or bevacizumab over a 2-year period. Retinal angiomatous proliferation was identified by the intense intra-retinal leakage of fluorescein in combination with other associated features.

MAIN OUTCOME MEASURES

Visual acuity; fluorescein leakage; scar; geographic atrophy (GA) on FA; retinal thickness, fluid, and subretinal hyperreflective material (SHRM) on OCT; and the number of intravitreal anti-VEGF injections at 1 and 2 years.

RESULTS

Retinal angiomatous proliferation was present in 126 of 1183 (10.7%) study eyes at baseline. Mean VA improvement from baseline was greater (10.6 vs. 6.9 letters; P = 0.01) at 1 year, but similar at 2 years (7.8 vs. 6.2 letters; P = 0.34). At 1 year, eyes with RAP were more likely to have no fluid (46% vs. 26%; P < 0.001) on OCT, no leakage on FA (61% vs. 50%; P = 0.03), and greater reduction in foveal thickness (-240 μm vs. -161 μm; P < 0.001). They were more likely to demonstrate GA (24% vs. 15%; P = 0.01) and less likely to have scarring (17% vs. 36%; P < 0.001) or SHRM (36% vs. 48%; P = 0.01). These results were similar at 2 years. The mean change in lesion size at 1 year differed (-0.27 DA vs. 0.27 DA; P = 0.02), but was similar at 2 years (0.49 DA vs. 0.79 DA; P = 0.26). Among eyes treated PRN, eyes with RAP received a lower mean number of injections in year 1 (6.1 vs. 7.4; P = 0.003) and year 2 (5.4 vs. 6.6; P = 0.025).

CONCLUSIONS

At both 1 and 2 years after initiation of anti-VEGF treatment in CATT, eyes with RAP were less likely to have fluid, FA leakage, scar, and SHRM and more likely to have GA than eyes without RAP. Mean improvement in VA was similar at 2 years.

Long-Term Management of RAP Lesions in Clinical Practice: Treatment Efficacy and Predictors of Functional Improvement

PURPOSE

To evaluate the long-term efficacy of ranibizumab in the treatment of retinal angiomatous proliferation (RAP) and to identify predictors of functional outcome.

METHODS

Retrospective case series comprised 79 eyes of 68 consecutive patients with RAP followed up ≥36 months. Primary end-points were best-corrected visual acuity (BCVA) and central macular thickness (CMT) variation at 36 months and at the last visit.

RESULTS

Mean follow-up time was 59.8 ± 16.0 months. All eyes were treated with pro re nata ranibizumab, with (n = 33) or without (n = 46) photodynamic therapy (PDT). Stabilization or improvement in BCVA was observed in 50.6% of the patients at 36 months, and in 40.5% at the end of the follow-up, where 20.3% preserved reading vision. A significant decrease in CMT was observed at 36 months (p < 0.001), but not at the end of the follow-up. Geographic atrophy (GA) was present in 59.5% of the eyes at the final visit. Baseline subretinal fluid was associated with better visual outcomes (p = 0.001). Results of combination treatment with intravitreal ranibizumab and PDT did not significantly differ from ranibizumab monotherapy.

CONCLUSION

Modest functional outcomes can be expected from the long-term treatment of RAP lesions in clinical practice, most likely due to the advent of GA. Baseline subretinal fluid positively correlated with final BCVA.

Phase-Resolved Doppler Optical Coherence Tomographic Features in Retinal Angiomatous Proliferation

PURPOSE

To study patients diagnosed with retinal angiomatous proliferation (RAP) based on conventional imaging techniques with phase-resolved Doppler optical coherence tomography (OCT) to detect and localize blood flow in RAP lesions; and to compare these findings to conventional imaging, which are mostly invasive and give limited information concerning intra- and transretinal blood flow.

DESIGN

Single-center, consecutive observational case series.

METHODS

Twelve treatment-naïve patients diagnosed with RAP based on fundus examination, fluorescein angiography, and indocyanine green angiography were included. Median age was 79 years (range 65-90). Patients were imaged with an experimental 1040 nm swept-source phase-resolved Doppler OCT instrument. Abnormal flow was defined as intraretinal neovascularization or retinal choroidal anastomosis.

RESULTS

In 11 patients adequate phase-resolved Doppler OCT images were obtained showing abnormal blood flow in the RAP lesion. In 4 patients a retinal choroidal anastomosis was found, 3 patients showed intraretinal neovascularization connected with a pigment epithelial detachment, 2 patients showed only intraretinal neovascularization, and in 2 patients flow was limited to the subretinal or sub-retinal pigment epithelial space.

CONCLUSIONS

Phase-resolved Doppler OCT is able to detect and localize abnormal blood flow within RAP lesions. Blood flow was mostly confined to the intraretinal structures with or without a connecting pigment epithelial detachment; in one-third of patients a retinal choroidal anastomosis was detected. The potential of angiography with phase-resolved Doppler OCT to accurately distinguish between normal and pathologic blood flow in addition to structural OCT data without invasive procedures will help to further elucidate both retinal and choroidal vascular pathologies like RAP.

Type 3 neovascularization: evolution, association with pigment epithelial detachment, and treatment response as revealed by spectral domain optical coherence tomography

PURPOSE

To demonstrate the evolution and treatment response of Type 3 neovascularization using spectral domain optical coherence tomography.

METHODS

We retrospectively analyzed 40 eyes treated with intravitreal anti-vascular endothelial growth factor therapy for Type 3 neovascularization over a variable follow-up period.

RESULTS

In 17 eyes, spectral domain optical coherence tomography captured the development of Type 3 neovascularization from punctate hyperreflective foci that preceded any outer retinal defect. The more mature Type 3 lesions were associated with outer retinal disruption and adjacent cystoid macular edema. In addition, 37 of 40 Type 3 lesions (93%) were associated with an underlying pigment epithelial detachment, of which 26 (70%) were drusenoid, 6 (16%) serous, and 5 (14%) mixed. Type 3 vessels appeared to leak fluid into the pigment epithelial detachment cavity, creating serous pigment epithelial detachments as large as 925 μm in maximal height. Treatment with anti-vascular endothelial growth factor agents led to prompt involution of the lesion and resorption of the intraretinal and subretinal pigment epithelium fluid after one or two injections (median = 1).

CONCLUSION

In some eyes with age-related macular degeneration, the earliest sign of Type 3 neovascularization is punctate hyperreflective foci above the external limiting membrane. The mature Type 3 lesions and associated serous pigment epithelial detachments are highly responsive to anti-vascular endothelial growth factor therapy.

Ranibizumab and aflibercept for the treatment of wet age-related macular degeneration

INTRODUCTION

Wet age-related macular degeneration (AMD) is a potentially blinding eye disease that causes vision loss among individuals > 50 years old. The main goal in the treatment of wet AMD is to inhibit the choroidal neovascularization (CNV). Currently, ranibizumab and aflibercept are two available anti-VEGF drug for the treatment of wet AMD. Here, we reviewed the clinical outcome of treatment with ranibizumab or aflibercept in patients with wet AMD from recent studies with a special focus on eyes with unusual presentations or treatment resistant and compared these agents with other available wet AMD therapies.

AREAS COVERED

For this review, a literature search from 2011 to present was performed using the following terms (or combination of terms): anti-vascular endothelial growth factors, anti-VEGF, age-related macular degeneration, AMD, aflibercept, and ranibizumab. The studies were limited to studies used ranibizumab, and especially those switched from ranibizumab to aflibercept. Also the clinical trial website (www.clinicaltrials.gov) was searched for recently completed trials of aflibercept or ranibizumab for wet AMD treatment.

EXPERT OPINION

Ranibizumab and aflibercept are effective for the treatment of wet AMD including those with retinal angiomatous proliferation (RAP) and CNV unresponsive to other anti-VEGF agents. Although high-dose ranibizumab has the potential to treat unresponsive CNV, switching to another anti-VEGF agent may be a preferable option in these eyes.

Treating the untreatable patient: current options for the management of treatment-resistant neovascular age-related macular degeneration

Anti-vascular endothelial growth factor (anti-VEGF) agents represent the current standard of care for neovascular age-related macular degeneration (nAMD). Although effective in a majority of cases, a significant proportion of patients have persisting retinal exudation despite regular anti-VEGF therapy. This exudation is considered to produce poorer visual outcomes in these patients. Some of these patients may have misdiagnosed nAMD variants such as polypoidal choroidal vasculopathy; however, the majority of these eyes have what has been termed treatment-resistant nAMD. Currently, the best way to care for these patients is uncertain. Here, we review the evidence for different approaches to the management of treatment-resistant nAMD, including high-dose anti-VEGF therapy, combination regimes and switching of anti-VEGF agents, and discuss possible therapeutic approaches for patients with treatment-resistant nAMD.