Progression of macular atrophy in patients undergoing anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration

Effect of Pro Re Nata Regimen with Anti-VEGF on Type 3 Macular Neovascularization: Long-Term Outcomes

INTRODUCTION

The purpose of this study was to investigate long-term outcomes of intravitreal injections (IVI) of antivascular endothelial growth factor (VEGF) in neovascular age-related macular degeneration (nAMD) with type 3 macular neovascularization (MNV).

METHODS

This retrospective study included 19 eyes of 17 patients with nAMD and type 3 MNV treated with anti-VEGF IVI with a loading dose and a PRN regimen. Best corrected visual acuity (BCVA), central macular thickness (CMT), presence of macular intraretinal fluid (IRF) and subretinal fluid (SRF), flow area (FA), subfoveal choroidal thickness (CT), and macular atrophy (MA) were assessed at baseline (T0) and during follow-up (T1, post-loading phase; T2, 1 year; T3, 2 years; T4 >2 years). The correlations between MA at the last follow-up and standard deviation (SD) values of CMT and CT during follow-up were assessed. The influence of the number of injections on the change in MA over time was also analyzed. MA differences at T4 were assessed for pseudodrusen presence.

RESULTS

BCVA improved significantly during follow-up (p = 0.013) particularly increasing from baseline to post-loading phase and then did not modify significantly thereafter. CMT significantly reduced from T0 to T1 and remained stable during follow-up (p = <0.001). MNV flow area showed a trend toward an increase in the post-loading phase that was not statistically significant (p = 0.082) and CT decreased significantly during follow-up (p < 0.001). MA changed significantly during follow-up (p < 0.001) with a significant increase from T0 to T3 and from T0 to T4 (p < 0.010). A Cochran-Armitage test for trend showed a significant reduction (p = 0.001) of macular IRF and SRF during follow-up. MA at T4 showed a significant positive correlation with SD (standard deviation) values of CMT (p = 0.040) and CT (p = 0.020). Indeed, the number of injections did not influence the change over time of MA (p = 0.709). MA at T4 was not statistically significantly different between patients with pseudodrusen at baseline (p = 0.497).

CONCLUSIONS

Intravitreal anti-VEGF injections with PRN regimen in MNV type 3 showed functional and anatomical benefits. Variations of retinal thickness and choroidal thickness during treatment were related to MA modification over time.

SUBRETINAL FLUID ASSOCIATED WITH DRUSENOID PIGMENT EPITHELIAL DETACHMENT

PURPOSE

To analyze the clinical characteristics of drusenoid pigment epithelial detachment (PED) with subretinal fluid (SRF) and to evaluate the impact of SRF on the long-term visual and anatomical outcomes.

METHODS

Forty-seven eyes with drusenoid PED (47 patients) who completed >24 months of follow-up were retrospectively analyzed. Intergroup comparisons of the visual and anatomical outcomes with and without SRF were made.

RESULTS

The mean duration of follow-up was 32.9 ± 18.7 months. The group with drusenoid PED with SRF (14 eyes) showed significantly higher PED height (468 ± 130 µ m vs. 313 ± 88 µ m, P < 0.001), larger PED diameter (2,328 ± 953 µ m vs. 1,227 ± 882 µ m, P < 0.001), and larger PED volume (1.88 ± 1.73 mm 3 vs. 1.12 ± 1.35 mm 3 , P = 0.021) than that in the group with drusenoid PED without SRF (33 eyes) at baseline. No significant intergroup difference was found regarding the best-corrected visual acuity at the final visit. In addition, the incidence of complete retinal pigment epithelial and outer retinal atrophy (cRORA; 21.4%) and the development of macular neovascularization (MNV; 7.1%) for the group with drusenoid PED with SRF showed no difference compared with those (39.4% for cRORA development and 9.1% for MNV development) with drusenoid PED without SRF.

CONCLUSION

The size, height, and volume of drusenoid PED were associated with the development of SRF. The SRF in drusenoid PED did not affect the visual prognosis or the development of macular atrophy during long-term follow-up.

Determination of Vascular Endothelial Growth Factor-B Concentrations in Aqueous Humor and Plasma of Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy Patients Before and After Anti-VEGF Therapy

INTRODUCTION

Anti-vascular endothelial growth factor (anti-VEGF) injection was widely used in patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV); however, the systemic and local levels of vascular endothelial growth factor (VEGF)-B were seldom detected before. This study was conducted to detect and compare the aqueous humor and plasma VEGF-B levels in nAMD and PCV before and after anti-VEGF therapy.

METHODS

Concentrations of VEGF-B in aqueous humor and plasma of individuals with nAMD (n = 10), PCV (n = 22), and age-related cataract controls (n = 12) were measured by enzyme-linked immunosorbent assay. Ranibizumab was injected intravitreally in patients monthly for three consecutive months. Before each injection in patients and at the baseline of controls, blood and aqueous humor samples were collected. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were collected before each injection in patient groups. The differences of BCVA, CRT, and VEGF-B levels in aqueous humor and plasma between groups before and after anti-VEGF therapy were compared.

RESULTS

VEGF-B was overexpressed in aqueous humor and plasma of nAMD and PCV groups compared with control group (P < 0.05), but no statistically significant difference existed across nAMD and PCV groups (P > 0.05). Moreover, there were no obvious difference in levels of VEGF-B in aqueous humor and plasma within the treatment groups after anti-VEGF treatment (P > 0.05). The mean CRT in the nAMD group was thinner than that in the PCV group at baseline (P < 0.01). After injections, the CRT obviously declined in both groups (P < 0.05). There was no correlation between CRT reduction and high VEGF-B expression in aqueous humor and plasma of treatment groups.

CONCLUSION

Overexpression of VEGF-B locally and systemically in patients with nAMD and PCV indicated that elevated VEGF-B concentrations were relevant to the disease processes. Ranibizumab did not influence the levels of VEGF-B in the real world. CRT might help to distinguish PCV from nAMD.

Subretinal fluid may protect against macular atrophy in neovascular age‐related macular degeneration: 5 years of follow‐up from Fight Retinal Blindness registry

PURPOSE

The purpose of the study was to assess the association of macular atrophy (MA) according to the activity of macular neovascularization (MNV) (inactive, only subretinal fluid [SRFL], or active, i.e. including intraretinal fluid [IRFL]) using optical coherence tomography (OCT) in patients with neovascular age-related macular degeneration (nAMD).

METHODS

Multicentric observational study. Treatment-naïve nAMD eyes without subfoveal MA or subretinal fibrosis (SF) at baseline were included since 1st January 2010 and 30th September 2016 to allow up to 5 years of treatment follow-up. Eyes were grouped based on their predominant activity status as: (1) mostly inactive, (2) mostly active non-SRFL only [IRFL] or (3) mostly active-SRFL only [onlySRFL]. Kaplan-Meier survival curves estimated the time to development of MA or SF. Cox proportional hazards models evaluated predictors of developing subfoveal MA or SF. The main outcome measure was the risk of developing MA according to predominant MNV activity.

RESULTS

A total of 973 eyes were eligible for analysis. OnlySRFL eyes had lower risk of developing subfoveal MA (HR [95% CI]: 0.56 [0.36, 0.88]; p = 0.024) and extrafoveal MA (HR [95% CI]: 0.41 [0.27, 0.61]; p < 0.001) than IRFL eyes. IRFL eyes had lower visual acuity (VA) (54.5 letters) and the highest proportion of eyes with vision ≤35 letters (25%) at 5 years while onlySRFL eyes had comparable 5-year VA (63.7 letters) to inactive eyes (63.7 letters).

CONCLUSION

Subretinal fluid appears to protect against MA. Distinguishing the compartment of retinal fluid and understanding its relationship with MA and SF can guide the management of nAMD.

Neovascular age-related macular degeneration without exudative recurrence over 24 months after initial remission

We investigated the characteristics of neovascular age-related macular degeneration (AMD), which rarely recurs after initial remission. This study retrospectively analyzed 392 neovascular AMD patients treated with anti-vascular endothelial growth factor (VEGF). All patients received three monthly loading doses of anti-VEGF injections, followed by a pro re nata (as needed) regimen for 24 months. The baseline characteristics associated with the odds of having no recurrence within 24 months were evaluated using multivariate modeling. After the initial three loading injections over 24 months, 58 (14.8%) eyes showed no exudative recurrence and did not require additional anti-VEGF injections. These patients without exudative recurrence had significantly better best-corrected visual acuity (P = 0.003) and lower central subfoveal thickness (P = 0.035) at 24 months than those with exudative recurrence. Additionally, the incidence of macular atrophy was significantly lower in the former than in the latter (8.6% vs. 21.9%; P = 0.020). Multivariate analysis revealed that younger age (odds ratio [OR], 0.901; P = 0.033), smaller lesion size (OR, 0.589; P = 0.016), and absence of fibrovascular pigment epithelial detachment (PED) (OR, 1.349; P = 0.028) were associated with higher odds of no recurrence during follow-up. Approximately 15% of the neovascular AMD patients showed no exudative recurrence after initial remission during the 24-month follow-up. The infrequent recurrence after initial remission correlated with younger age, smaller lesion size, and absence of fibrovascular PED.

Celastrol inhibits laser-induced choroidal neovascularization by decreasing VEGF induced proliferation and migration

AIM

To evaluate celastrol's effect on choroidal neovascularization (CNV).

METHODS

In this study, neovascular formation in vitro (tube formation and aortic ring culture) and in vivo (laser induced neovascular in mice) was treated with celastrol to evaluate this natural compound's impact on CNV. Western blot was applied to explore the possible mechanism for it. For in vitro assay, triplicate for each group was repeated at least three times. For in vivo assay, each group contains 5 mice.

RESULTS

Celastrol supressed tube formation and aortic ring sprout neovascularization. In vitro assay exhibited that celastrol inhibiting vascular endothelial growth factor (VEGF)-induced proliferation and migration of human umbilical vein endothelial cells and human choroidal endothelial cells, and by blocking VEGF signaling. Furthermore, intraperitoneal administration of celastrol significantly reduced the area of laser-induced CNV in an in vivo mouse model. By day 14, the area of CNV had decreased by 49.15% and 80.26% in the 0.1 mg/kg celastrol-treated group (n=5) and in the 0.5 mg/kg celastrol treated group (n=5), respectively, compared to the vehicle-treated group (n=5).

CONCLUSION

Celastrol inhibits CNV by inhibiting VEGF-induced proliferation and migration of vascular endothelial cells, indicating that celastrol is a potent, natural therapeutic compound for the prevention of CNV.

Macular neovascularization lesion type and vision outcomes in neovascular age-related macular degeneration: post hoc analysis of HARBOR

Purpose

To characterize relationships between Consensus on Neovascular Age-Related Macular Degeneration Nomenclature (CONAN) Study Group classifications of macular neovascularization (MNV) and visual responses to ranibizumab in patients with neovascular age-related macular degeneration (nAMD).

Methods

This was a post hoc analysis of the phase 3 HARBOR trial of ranibizumab in nAMD. Analyses included ranibizumab-treated eyes with baseline multimodal imaging data; baseline MNV; subretinal and/or intraretinal fluid at screening, baseline, or week 1; and spectral-domain optical coherence tomography images through month 24 (n = 700). Mean best-corrected visual acuity (BCVA) over time and mean BCVA change at months 12 and 24 were compared between eyes with type 1, type 2/mixed type 1 and 2 (type 2/M), and any type 3 MNV at baseline.

Results

At baseline, 263 (37.6%), 287 (41.0%), and 150 (21.4%) eyes had type 1, type 2/M, and any type 3 lesions, respectively. Type 1 eyes had the best mean BCVA at baseline (59.0 [95% CI: 57.7–60.3] letters) and month 24 (67.7 [65.8–69.6] letters), whereas type 2/M eyes had the worst (50.0 [48.6–51.4] letters and 60.8 [58.7–62.9] letters, respectively). Mean BCVA gains at month 24 were most pronounced for type 2/M eyes (10.8 [8.9–12.7] letters) and similar for type 1 (8.7 [6.9–10.5] letters) and any type 3 eyes (8.3 [6.3–10.3] letters).

Conclusion

Differences in BCVA outcomes between CONAN lesion type subgroups support the use of an anatomic classification system to characterize MNV and prognosticate visual responses to anti-vascular endothelial growth factor therapy for nAMD.

Trial registration

ClinicalTrials.gov identifier: NCT00891735. Date of registration: April 29, 2009.

Neovascular age-related macular degeneration in which exudation predominantly occurs as a subretinal fluid during anti-vascular endothelial growth factor treatment

We investigated the characteristics of neovascular age-related macular degeneration (AMD) in which exudation predominantly occurs as a subretinal fluid (SRF) during anti-vascular endothelial growth factor (VEGF) treatment. A total of 509 treatment-naïve neovascular AMD patients treated with anti-VEGF for 24 months were retrospectively analyzed. The baseline characteristics to determine the odds of occurrence of SRF alone were evaluated using multivariate modeling. SRF was the sole manifestation of lesion activity in 209 (40.9%) eyes during follow-up. The visual outcome of eyes with only SRF occurrence during follow-up was comparable to that of eyes without exudative recurrence. In addition, the incidence of macular atrophy was significantly lower in eyes with only SRF occurrence (9.6%, 20 of 208 eyes) than in eyes without exudative recurrence (16.7%, 9 of 54 eyes, P = 0.018). Multivariate analysis revealed that better best-corrected visual acuity (BCVA) at baseline (odds ratio [OR], 0.306; P = 0.001), presence of SRF alone at baseline (OR, 5.256; P < 0.001), lower pigment epithelial detachment (PED) height (less than 100 µm; OR, 4.113; P = 0.025), and aneurysmal type 1 macular neovascularization (MNV) (OR, 2.594; P = 0.002) were associated with an increased likelihood of SRF occurrence during follow-up. In conclusion, the eyes with only SRF occurrence during anti-VEGF treatment showed more favorable visual outcomes and a lower incidence of macular atrophy. The baseline characteristics, including better baseline BCVA, presence of SRF alone at baseline, lower PED height, and MNV subtype, might influence the predominant development of SRF during anti-VEGF treatment.

Impact of macular fluid features on outcomes of anti-vascular endothelial growth factor treatment for type 3 macular neovascularization

We evaluated the impact of macular fluid features on visual and anatomical outcomes in type 3 macular neovascularization (MNV) patients treated with anti-vascular endothelial growth factor (VEGF). We retrospectively enrolled 89 eyes with type 3 MNV with at least 12 months of follow-up. All patients were treatment-naïve and received a monthly loading injection of anti-VEGF for three months, followed by further injections as required. The association of baseline macular morphology, including intraretinal fluid (IRF) and subretinal fluid (SRF), with visual and anatomical outcomes was analyzed. At baseline, IRF was present in all enrolled patients (100%), and SRF was present in 43.8% (39/89) of them. After 12 months of treatment, no significant difference was found in terms of best-corrected visual acuity (BCVA) and changes in central foveal thickness between the eyes with (39) and without (50) SRF at baseline. In addition, the proportion of improved or worsened (gain or loss of more than three lines in the BCVA) visual acuity at 12 months was not significantly different among the groups. Incidence of macular atrophy during the treatment showed no difference between the groups, regardless of the presence of SRF. In conclusion, the macular fluid morphology, specifically SRF, in type 3 MNV showed no significant correlation with visual and anatomical outcomes during anti-VEGF treatment.

Three-Year Outcomes of Neovascular Age-Related Macular Degeneration in Eyes That Do Not Develop Macular Atrophy or Subretinal Fibrosis

Purpose

To report the 36-month treatment outcomes of eyes with neovascular age-related macular degeneration (nAMD) receiving vascular endothelial growth factor (VEGF) inhibitors in daily practice who did not develop either subretinal fibrosis (SRFi) or macular atrophy (MA).

Methods

This is a retrospective analysis of data from the Fight Retinal Blindness registry. Treatment-naïve eyes starting intravitreal injection of VEGF inhibitors for nAMD from January 1, 2010, to September 1, 2017, and did not have SRFI and MA at baseline were tracked.

Results

We identified 2478 eligible eyes, of which 1712 eyes did not develop SRFi or MA, 291 developed extrafoveal SRFI or MA, and 475 developed subfoveal SRFi or MA over 36 months. The estimated visual acuity stabilized from 6 months to 36 months in eyes that did not develop SRFI or MA with a mean (95% confidence interval [CI]) change in VA of −1 (−2, 0) letters, whereas eyes that developed extrafoveal (−3 [−5, −2] letters) or subfoveal (−10 [−11, −8] letters) SRFi or MA declined in vision in the same period. Eyes with no or extrafoveal SRFi or MA over 36 months were more likely to maintain their visual improvement from six months to 36 months (odds ratio [OR; 95% CI] = 2.3 [1.5, 3.3] for absence vs. subfoveal SRFi or MA, P ≤ 0.01 and OR = 2.0 [1.2, 3.4] for extrafoveal vs. subfoveal MA or SRFi, P = 0.01).

Conclusions

Treatment-naïve nAMD eyes receiving VEGF inhibitors maintain their initial six-month visual improvement over three years if they do not develop SRFI or MA.

Translational Relevance

The nAMD is still a major cause of blindness despite antiangiogenic treatments. We found that eyes that did not develop subretinal fibrosis or macular atrophy maintained their initial vision improvement for at least three years, suggesting that identifying treatments for these complications is the final barrier to achieving excellent outcomes in nAMD.

Early Predictive Factors of Visual Loss at 1 Year in Neovascular Age-Related Macular Degeneration under Anti-Vascular Endothelial Growth Factor

PURPOSE

To evaluate early predictive factors of visual loss in patients treated with anti-vascular endothelial growth factor (VEGF) injections under an as-needed regimen for neovascular age-related macular degeneration (AMD).

DESIGN

Post hoc analysis from the randomized controlled trial Groupe d'Evaluation Français Avastin versus Lucentis (GEFAL).

PARTICIPANTS

A total of 393 patients with neovascular AMD.

METHODS

The present analysis is based on 1-year data from patients included in the study. Patients were separately categorized according to the best-corrected visual acuity (BCVA) change at 3 months and 1 year into 3 trajectories: (1) patients with no vision loss ≥5 letters at 3 months and 1 year (absence of loss ≥5 letters); (2) patients with no vision loss ≥5 letters at 3 months but loss ≥5 letters at 1 year (secondary loss ≥5 letters); and (3) patients with vision loss ≥5 letters at 3 months and 1 year (initial loss ≥5 letters).

MAIN OUTCOME MEASURES

The following factors were evaluated at baseline and 3 months: age, sex, BCVA, presence of fluid, central macular thickness, angiographic choroidal neovascularization (CNV) subtype, CNV area measured in disc area on fluorescein angiography, and number of intravitreal injections.

RESULTS

An absence of loss ≥5 letters was found in 225 patients (57.3%), a secondary loss ≥5 letters after 3 months was found in 109 patients (27.7%), and an initial loss ≥5 letters was found in 59 patients (15%). Baseline characteristics were comparable among the 3 groups except for the total CNV area, which was larger in the initial and secondary loss groups (P = 0.0412). At 3 months, a significant association was found between presence of subretinal fluid (SRF) (P = 0.0318) and vision loss ≥5 letters, and an even stronger significant association between the presence of intraretinal fluid (IRF) (P = 0.0066) and vision loss ≥5 letters.

CONCLUSIONS

In the present study, we found that a large CNV area at baseline was significantly associated with initial or secondary loss of visual acuity ≥5 letters despite anti-VEGF injection. The presence of fluid, both SRF and IRF, at 3 months was found in patients with poorer trajectories.