Association between three-dimensional morphological features and functional indicators of neovascular age-related macular degeneration

PURPOSE

To investigate the correlation between morphological lesions and functional indicators in eyes with neovascular age-related macular degeneration (nAMD).

METHODS

This was a prospective observational study of treatment-naïve nAMD eyes. Various morphological lesions and impaired retinal structures were manually measured at baseline and month-3 in three-dimensional optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) images, including the volumes (mm3) of macular neovascularization (MNV), avascular subretinal hyperreflective material (avascular SHRM), subretinal fluid (SRF), intraretinal fluid (IRF), serous pigment epithelial detachment (sPED) and the impaired area (mm2) of ellipsoid zone (EZ), external limiting membrane (ELM) and outer nuclear layer (ONL).

RESULTS

Sixty-three eyes were included. The volume of avascular SHRM showed persistent positive associations with the area of EZ damage, both at baseline, month-3, and change values (all P < 0.001). Poor BCVA (month-3) was associated with larger volumes of baseline IRF (β = 0.377, P < 0.001), avascular SHRM (β = 0.306, P = 0.032), and ELM impairment area (β = 0.301, P = 0.036) in multivariate model. EZ and ELM impairment were primarily associated with baseline avascular SHRM (β = 0.374, p = 0.003; β = 0.388, P < 0.001, respectively), while ONL impairment primarily associated with MNV (β = 0.475, P < 0.001).

CONCLUSION

The utilization of three-dimensional measurements elucidates the intrinsic connections among various lesions and functional outcomes. In particular, avascular SHRM plays an important role in prognosis of nAMD.

Fibrosis in age-related neovascular macular degeneration in the anti-VEGF era

The natural history of neovascular age-related macular degeneration (nAMD) leads to scarring and loss of vision. Since the advent of anti-VEGF therapies, which are very effective for controlling exudation, large disciform scars are rarely encountered in the clinic. However long term studies show that smaller and less severe fibrotic scars are not uncommon and develop over time despite optimal treatment. This means that additional mechanisms of action may be required to completely address this condition. To permit new treatments, a proper understanding of the clinical impact of fibrosis is required. This review is focused on clinical aspects of fibrosis and summarises recent data on biomarkers, prevalence, causes, consequences, and therapies, highlighting the most important and urgent topics to tackle in order to advance in the treatment of fibrosis.

Aqueous humor cytokine levels in patients with subretinal fibrosis in neovascular age-related macular degeneration

PURPOSE

To investigate aqueous humor cytokine levels in neovascular age-related macular degeneration (nAMD) patients with subretinal fibrosis and to explore the relationship between cytokine levels and disease severity.

METHODS

The aqueous humor samples were collected from 16 eyes with subretinal fibrosis due to nAMD (SRFi group), 33 eyes with nAMD without subretinal fibrosis (nAMD group) and 28 eyes with cataract patients (control group). Clinical samples were analyzed for 5 cytokines,including vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), basic fibroblast growth factor (bFGF), transforming growth factor-α (TGF-α), platelet-derived growth factor-BB (PDGF-BB).

RESULTS

Aqueous humor cytokines VEGF and bFGF were significantly higher in nAMD patients than controls (all P < 0.05), and VEGF, bFGF and TGF-α levels were significantly higher in SRFi patients than controls (all P < 0.05). No significant differences in 4 cytokine levels were observed between nAMD and SRFi patients in aqueous humor. We also identified a positive correlation between the aqueous humor levels of IL-6 and VEGF in the SRFi group, while bFGF and TGF-α in the nAMD group. Moreover, VEGF levels were strongly related to BCVA, and bFGF levels were positively related to the maximum thickness of subretinal hyperreflective material (SHRM) in fibrosis due to nAMD.

CONCLUSION

VEGF and bFGF levels in aqueous humor were elevated in macular neovascularization with and without subretinal fibrosis. TGF-α levels exclusively differed in neovascular AMD with fibrosis. Cytokines are distributed differently and play a synergistic role in different stages (angiogenesis and fibrogenesis) of nAMD. The bFGF levels could predict the negative prognosis in fibrosis due to nAMD.

Five-year outcomes of treat and extend regimen using intravitreal aflibercept injection for treatment-naïve age-related macular degeneration

PURPOSE

This study evaluated the long-term outcomes of eyes with neovascular age-related macular degeneration (nAMD) treated with aflibercept according to a treat-and-extend (T&E) regimen for up to 5 years. Methods This retrospective study included 112 eyes of 111 patients with nAMD who received aflibercept according to the T&E regimen. The patients received 3 monthly injections of aflibercept followed by a T&E regimen for at least 12 months. Data, including best-corrected visual acuity (BCVA), treatment interval, presence of exudation, central retinal thickness, and central choroidal thickness were analyzed.

RESULTS

Of the 112 consecutive eyes, 66 completed the 5-year follow-up. After 5 years of treatment, BCVA (logMAR) was significantly better than baseline (0.29 ± 0.31 at baseline and 0.18 ± 0.23 at 5 years, P < 0.01). A mean of 7.0 ± 1.5 injections in the first year and 4.9 ± 2.2 injections per year thereafter were required. In eyes with subretinal hyperreflective material (SHRM) at baseline, BCVA at baseline and 5 years were significantly worse than in eyes without SHRM at baseline and 5 years. However, the eyes with SHRM required fewer injections and exhibited greater BCVA improvement.

CONCLUSION

This retrospective study demonstrated the effectiveness of the T&E regimen with aflibercept in managing nAMD over a 5-year period, maintaining significant improvements in BCVA.

Subretinal hyperreflective material in retinal and chorioretinal disorders: A comprehensive review

Subretinal hyperreflective material (SHRM) is a common and remarkable optical coherence tomography (OCT) biomarker whose importance is emerging in several retinal and chorioretinal diseases, including age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, pathologic myopia, posterior uveitis, vitelliform lesions and macular dystrophies, and rarer disorders. Multimodal imaging, also thanks to the introduction of OCT angiography, allowed a deeper characterisation of SHRM components and its morphological changes after treatment, suggesting its usefulness in clinical practice. We discuss and summarize the nature, multimodal imaging characteristics, and prognostic and predictive significance of SHRM in the different retinal and choroidal disorders in which it has been described.

Correlations between subfoveal choroidal thickness, macular thickness, and visual outcome in neovascular age-related macular degeneration using swept source OCT: insights from intravitreal aflibercept treatment

BACKGROUND

Age-related macular degeneration (AMD) is a leading cause of visual impairment among individuals aged 50 and above, often resulting in irreversible vision loss (1). Currently, antiangiogenic therapy is the primary treatment approach for neovascular AMD (2). The choroid has gained significant attention in recent years due to its involvement in various ocular pathologies (7). The objective of this study was to evaluate visual acuity and correlate pre-treatment variables, such as foveal thickness and choroidal thickness, with post-treatment outcomes.

MATERIALS AND METHODS

This study was designed as a prospective interventional study to investigate the changes in choroidal and macular thickness in patients with neovascular AMD who received intravitreal aflibercept injections. The study utilized medical records and employed Swept Source Optical Coherence Tomography (OCT-SS) for evaluation. The data was collected from patients treated in Presidente Prudente, Brazil, during a three-month load dose period.

RESULTS

The best-corrected mean visual acuity significantly improved from 1.0 logarithm of the minimum resolution angle (logMAR) units to 0.55 logMAR after treatment with aflibercept (p < 0.001). Patients undergoing treatment exhibited a significant decrease in average macular thickness from 323 μm to 232 μm (p = 0.001), as well as a reduction in choroidal thickness from 206 μm to 172 μm (p = 0.031), while maintaining intraocular pressure within the normal range (p = 0.719) without significant variation. Statistically significant associations were found between the difference in pre- and post-treatment choroidal thickness and the pretreatment values of macular thickness (p = 0.005) and choroidal thickness (p = 0.013). There was also a statistically significant correlation between the difference in pre- and post-treatment macular thickness and the pretreatment macular thickness value (p < 0.001).

CONCLUSION

In this study, aflibercept exhibited remarkable effectiveness in reducing macular and choroidal thickness, as evaluated using OCT-SS, and significantly improved visual acuity in patients with neovascular AMD. The assessment of both choroidal and macular changes, as well as their correlations, can provide valuable insights for clinicians, enabling them to make well-informed therapeutic decisions and effectively monitor treatment outcomes. Notably, this study contributes to the existing body of literature as the first to establish a correlation between pretreatment foveal thickness, variation in choroidal thickness, and post-treatment choroidal thickness.

Hyperreflective material in patients with non-neovascular pachychoroid disease

BACKGROUND

This study aimed to report eleven cases of non-neovascular pachychoroid disease with hyperreflective material (HRM) that occurred in Japanese patients.

METHODS

A retrospective review of data from eleven patients who had non-neovascular retinal pigment epithelium (RPE) protrusion with HRM in the neurosensory retina between March 2017 and June 2022 was conducted. Clinical examination, color fundus photography, fluorescein angiography, spectral-domain optical coherence tomography (SD-OCT), and OCT angiography data were analyzed. Main outcome measures were patient characteristics, changes in SD-OCT findings, and symptom outcomes.

RESULTS

All cases had RPE protrusion and HRM with dilated choroidal veins, which were characteristic of pachychoroid disease. However, none of the cases had macular neovascularization (MNV). In 9 eyes (81.8%), HRM improved spontaneously without intervention and resulted in alterations in RPE, referred to as pachychoroid pigment epitheliopathy (PPE) or focal choroidal excavation (FCE). In these cases, symptoms such as metamorphopsia and distortion improved without treatment. In the remaining two cases (18.2%), HRM still persisted during the follow-up period.

CONCLUSION

There are some cases of non-neovascular pachychoroid disorder with HRM, which might be a new entity of pachychoroid spectrum disease or an early stage of PPE or FCE. These cases should not be misdiagnosed as MNV, and careful observation is necessary.

Characteristics and response of subretinal hyperreflective material to anti-vascular endothelial growth factor in myopic choroidal neovascularization

This retrospective study evaluated the characteristics and response of subretinal hyperreflective material (SHRM) to anti-vascular endothelial growth factor (VEGF) treatment in eyes with myopic choroidal neovascularization (CNV). The visual acuity (VA) was assessed at 3, 6, and 12 months after initiating anti-VEGF treatment in 116 patients (119 eyes) with SHRM and myopic CNV. Multimodal imaging, including color fundus photography, fluorescein angiography (FA), and optical coherence tomography angiography (OCT-A), were performed. We compared type 2 neovascularization (NV) (n = 64), subretinal hyperreflective exudation (SHE) (n = 37), NV with hemorrhage (n = 15), and fibrosis (n = 3). The type 2 NV group, and NV with hemorrhage groups showed significant VA improvement after 12 months of treatment (p < 0.05 in both groups); the SHE group failed to show improvement (p = 0.366). All groups showed a significant reduction in central foveal thickness after 12 months of treatment (all p < 0.05). The SHE group had a significantly higher incidence of interrupted ellipsoid zone than the other groups (p < 0.05). Myopic CNV can present as SHRM on OCT-A. Visual prognoses vary in different SHRM types. OCT-A and FA may help predict the outcomes of different subtypes of myopic CNV. SHE is predictive of outer retinal layer atrophy in patients with various SHRM types.

Molecular mechanisms of TGFβ-mediated EMT of retinal pigment epithelium in subretinal fibrosis of age-related macular degeneration

Age-related macular degeneration (AMD) is one of the leading causes of blindness in the elderly, affecting the macula of the retina and resulting in vision loss. There are two types of AMD, wet and dry, both of which cause visual impairment. Wet AMD is called neovascular AMD (nAMD) and is characterized by the formation of choroidal neovascular vessels (CNVs) in the macula. nAMD can be treated with intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors, which help improve vision. However, approximately half the patients do not achieve satisfactory results. Subretinal fibrosis often develops late in nAMD, leading to irreversible photoreceptor degeneration and contributing to visual loss. Currently, no treatment exists for subretinal fibrosis, and the molecular mechanisms of fibrous tissue formation following neovascular lesions remain unclear. In this review, we describe the clinical features and molecular mechanisms of macular fibrosis secondary to nAMD. Myofibroblasts play an essential role in the development of fibrosis. This review summarizes the latest findings on the clinical features and cellular and molecular mechanisms of the pathogenesis of subretinal fibrosis in nAMD and discusses the potential therapeutic strategies to control subretinal fibrosis in the future.

OCT-Derived Radiomic Features Predict Anti-VEGF Response and Durability in Neovascular Age-Related Macular Degeneration

PURPOSE

No established biomarkers currently exist for therapeutic efficacy and durability of anti-VEGF therapy in neovascular age-related macular degeneration (nAMD). This study evaluated radiomic-based quantitative OCT biomarkers that may be predictive of anti-VEGF treatment response and durability.

DESIGN

Assessment of baseline biomarkers using machine learning (ML) classifiers to predict tolerance to anti-VEGF therapy.

PARTICIPANTS

Eighty-one participants with treatment-naïve nAMD from the OSPREY study, including 15 super responders (patients who achieved and maintained retinal fluid resolution) and 66 non-super responders (patients who did not achieve or maintain retinal fluid resolution).

METHODS

A total of 962 texture-based radiomic features were extracted from fluid, subretinal hyperreflective material (SHRM), and different retinal tissue compartments of OCT scans. The top 8 features, chosen by the minimum redundancy maximum relevance feature selection method, were evaluated using 4 ML classifiers in a cross-validated approach to distinguish between the 2 patient groups. Longitudinal assessment of changes in different texture-based radiomic descriptors (delta-texture features) between baseline and month 3 also was performed to evaluate their association with treatment response. Additionally, 8 baseline clinical parameters and a combination of baseline OCT, delta-texture features, and the clinical parameters were evaluated in a cross-validated approach in terms of association with therapeutic response.

MAIN OUTCOME MEASURES

The cross-validated area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity were calculated to validate the classifier performance.

RESULTS

The cross-validated AUC by the quadratic discriminant analysis classifier was 0.75 ± 0.09 using texture-based baseline OCT features. The delta-texture features within different OCT compartments between baseline and month 3 yielded an AUC of 0.78 ± 0.08. The baseline clinical parameters sub-retinal pigment epithelium volume and intraretinal fluid volume yielded an AUC of 0.62 ± 0.07. When all the baseline, delta, and clinical features were combined, a statistically significant improvement in the classifier performance (AUC, 0.81 ± 0.07) was obtained.

CONCLUSIONS

Radiomic-based quantitative assessment of OCT images was shown to distinguish between super responders and non-super responders to anti-VEGF therapy in nAMD. The baseline fluid and SHRM delta-texture features were found to be most discriminating across groups.

Multi-class retinal fluid joint segmentation based on cascaded convolutional neural networks

Objective. Retinal fluid mainly includes intra-retinal fluid (IRF), sub-retinal fluid (SRF) and pigment epithelial detachment (PED), whose accurate segmentation in optical coherence tomography (OCT) image is of great importance to the diagnosis and treatment of the relative fundus diseases. Approach. In this paper, a novel two-stage multi-class retinal fluid joint segmentation framework based on cascaded convolutional neural networks is proposed. In the pre-segmentation stage, a U-shape encoder–decoder network is adopted to acquire the retinal mask and generate a retinal relative distance map, which can provide the spatial prior information for the next fluid segmentation. In the fluid segmentation stage, an improved context attention and fusion network based on context shrinkage encode module and multi-scale and multi-category semantic supervision module (named as ICAF-Net) is proposed to jointly segment IRF, SRF and PED. Main results. the proposed segmentation framework was evaluated on the dataset of RETOUCH challenge. The average Dice similarity coefficient, intersection over union and accuracy (Acc) reach 76.39%, 64.03% and 99.32% respectively. Significance. The proposed framework can achieve good performance in the joint segmentation of multi-class fluid in retinal OCT images and outperforms some state-of-the-art segmentation networks.

The negative impact of COVID-19 pandemic on age-related macular degeneration patients treated with intravitreal bevacizumab injections

Purpose

COVID-19 emerged in the end of 2019 and was declared a worldwide pandemic shortly after. Social distancing and lockdowns resulted in lower compliance in intravitreal injections and office visits. We aimed to assess clinical outcomes among patients who missed these visits compared to those who arrived as planned.

Methods

Patients who missed or were late to office visits or intravitreal injections were defined as non-adherent and were compared to adherent patients. Our main outcomes were the need for subsequent injections, mean change in best-corrected visual acuity (BCVA), and central macular thickness (CMT).

Results

This study included 77 patients (24 adherent and 53 non-adherent). The mean BCVA remained stable during the study period for the adherent group (p = 0.159) and worsened in the non-adherent group (p < 0.001). Changes in CMT and maximum thickness were not significant for either group. A higher proportion of patients in the non-adherent group needed subsequent intravitreal injections (49% vs 20%, p = 0.014).

Conclusion

The findings demonstrate the negative implications of the COVID-19 pandemic and the effect of deferring bevacizumab injections among individuals with age-related macular degeneration. This emphasizes the importance of a scheduled follow-up, also during a pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10792-022-02337-y.

Management of neovascular age-related macular degeneration: Taiwan expert consensus

Neovascular age-related macular degeneration (nAMD) is a leading cause of irreversible vision loss. The present consensus provides suggestions on diagnosis, evaluation, treatment, and follow-up strategies for nAMD from a panel of 11 practicing ophthalmologists. The experts suggest that the baseline visit for nAMD management should include a comprehensive ophthalmologic examination via a multimodal approach consisting of visual and anatomical evaluation. Patients diagnosed with nAMD should be subjected to treatment with the goal of maintaining visual function while diminishing anatomical disease activity and minimizing treatment burden. Currently, anti-VEGF therapy is the main treatment strategy for nAMD, and evaluation involving comprehensive ophthalmologic examination within 1 month of completion of the loading phase comprising three monthly injections is recommended to guide subsequent management. Either a treat-and-extend or pro re nata regimen can be considered for the maintenance phase of anti-VEGF therapy, and the regimen should be chosen and adjusted according to disease activity, reimbursement criteria, financial burden, and patient preferences. In the event of inactive nAMD or poor treatment outcomes, after thorough evaluation and patient education, anti-VEGF therapy may be stopped. The consensus provides practical nAMD management guidelines for ophthalmologists and fellow healthcare professionals.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

Subretinal hyperreflective material morphology in neovascular age-related macular degeneration: A case control study

Purpose:

The aim of this study was to evaluate the association of morphological features of subretinal hyperreflective material (SHRM) with visual acuity (VA), geographic atrophy (GA) and scar formation in eyes with neovascular age-related macular degeneration (neovascular AMD) and to compare with controls of neovascular AMD without SHRM.

Methods:

Retrospective analysis of 157 wet AMD eyes with SHRM and 50 eyes without SHRM treated with Anti-VEGF. Baseline spectral domain-OCT characteristics (SHRM location, height, width, area, reflectivity, border definition) were collected and were correlated with VA at baseline, 3, 6, 12 months and looked for development of scar and geographical atrophy (GA) and were compared to the control group.

Results:

When compared to the control, baseline parameters with a significant predictive value of 12-VA were presence of SHRM, foveal involvement of SHRM, high reflective SHRM, well-defined SHRM borders and thick SHRM. VA was decreased with greater SHRM height, width and area (P < 0.001). Decreasing reflectivity of SHRM lesions and disappearance of SHRM correlated with better VA at 12 months (P < 0.05). At 12 months, scar and GA was present more often in eyes with persistent SHRM than in eyes with SHRM that resolved and those without SHRM in the control group.

Conclusion:

SHRM can be considered as a surrogate OCT biomarker in predicting final visual outcome in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision at 12-follow-up were presence of SHRM involving the fovea, well-defined SHRM borders, greater SHRM height, width and area and persistence of SHRM with Anti-VEGF therapy.

Accuracy of a Machine-Learning Algorithm for Detecting and Classifying Choroidal Neovascularization on Spectral-Domain Optical Coherence Tomography

Background: To evaluate the performance of a machine-learning (ML) algorithm to detect and classify choroidal neovascularization (CNV), secondary to age-related macular degeneration (AMD) on spectral-domain optical coherence tomography (SD-OCT) images. Methods: Baseline fluorescein angiography (FA) and SD-OCT images from 1037 treatment-naive study eyes and 531 fellow eyes, without advanced AMD from the phase 3 HARBOR trial (NCT00891735), were used to develop, train, and cross-validate an ML pipeline combining deep-learning–based segmentation of SD-OCT B-scans and CNV classification, based on features derived from the segmentations, in a five-fold setting. FA classification of the CNV phenotypes from HARBOR was used for generating the ground truth for model development. SD-OCT scans from the phase 2 AVENUE trial (NCT02484690) were used to externally validate the ML model. Results: The ML algorithm discriminated CNV absence from CNV presence, with a very high accuracy (area under the receiver operating characteristic [AUROC] = 0.99), and classified occult versus predominantly classic CNV types, per FA assessment, with a high accuracy (AUROC = 0.91) on HARBOR SD-OCT images. Minimally classic CNV was discriminated with significantly lower performance. Occult and predominantly classic CNV types could be discriminated with AUROC = 0.88 on baseline SD-OCT images of 165 study eyes, with CNV from AVENUE. Conclusions: Our ML model was able to detect CNV presence and CNV subtypes on SD-OCT images with high accuracy in patients with neovascular AMD.

Association between retinal thickness variation and visual acuity change in neovascular age-related macular degeneration

BACKGROUND

To assess the association between variation in retinal central subfield thickness (CSFT) with best-corrected visual acuity (BCVA) change in patients receiving vascular endothelial growth factor (VEGF) inhibitor therapy for neovascular age-related macular degeneration (nAMD).

METHODS

CSFT measurements were obtained from 141 eyes (total 1300 scans). SD of CSFT was calculated. The eyes were categorised into CSFT variation tertiles. Multiple linear regression was used to examine the association between the CSFT tertiles and BCVA change at 12 mo, adjusting for differences in baseline demographic and clinical characteristics.

RESULTS

At 12 mo, the mean BCVA of the high CSFT variation group (50.6 letters) was significantly lower than the low and moderate CSFT variation groups (57.5 and 59.8 letters, respectively), P = .02. The adjusted mean BCVA gains were +1.7, +7.2, and +7.8 letters in the high, moderate and low CSFT variation groups, respectively (P = .03).

CONCLUSIONS

A greater variation in retinal thickness during VEGF inhibitor therapy for nAMD is associated with a less favourable visual outcome. CSFT stability is useful in prognosticating visual outcomes in VEGF inhibitor therapy for nAMD.

CORRELATION OF SUBRETINAL HYPERREFLECTIVE MATERIAL MORPHOLOGY AND VISUAL ACUITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the association of subretinal hyperreflective material (SHRM) morphological features with visual acuity in eyes with neovascular age-related macular degeneration.

METHODS

Retrospective analysis of treatment-naïve patients with neovascular age-related macular degeneration enrolled in randomized anti-vascular endothelial growth factor (VEGF) and anti-platelet-derived growth factor clinical trials. Standardized spectral domain optical coherence tomography images were graded at baseline, 12-week, and 24-week follow-up visits. Masked readers evaluated the morphology of SHRM (reflectivity, shape, anterior, and posterior boundaries) and measured SHRM height, width, and area at the fovea, within the center 1 mm, and outside the center 1 mm.

RESULTS

Baseline SHRM characteristics that correlated with worse visual acuity at 12 and 24 weeks included layered appearance (P = 0.006, 0.001), hyperreflective spots in SHRM (P = 0.001, 0.011), and separation between SHRM and outer retina (P = 0.03, 0.019). The disappearance of SHRM correlated with better visual acuity at Weeks 12 and 24 (P < 0.001). Layered appearance of SHRM at baseline was significantly associated with increased reflectivity at Weeks 12 and 24 (P = 0.009, 0.003). Decreasing reflectivity of SHRM lesion at Weeks 12 and 24 correlated with better visual acuity (P < 0.01, 0.01). Increased width and area of baseline SHRM at the foveal center correlated with worse visual acuity at 12 (P < 0.001, <0.001) and 24 weeks (<0.001, <0.001).

CONCLUSION

Several attributes of SHRM including, layered appearance, increased reflectivity, larger size, and hyperreflective spots correlated with worse visual acuity at 12- and 24-week follow-ups. Baseline SHRM characteristics can help practitioners predict visual and morphological prognosis and guide therapy.

Predicting Incremental and Future Visual Change in Neovascular Age-Related Macular Degeneration Using Deep Learning

PURPOSE

To evaluate the predictive usefulness of quantitative imaging biomarkers, acquired automatically from OCT scans, of cross-sectional and future visual outcomes of patients with neovascular age-related macular degeneration (AMD) starting anti-vascular endothelial growth factor (VEGF) therapy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Treatment-naive, first-treated eyes of patients with neovascular AMD between 2007 and 2017 at Moorfields Eye Hospital (a large, United Kingdom single center) undergoing anti-VEGF therapy.

METHODS

Automatic segmentation was carried out by applying a deep learning segmentation algorithm to 137 379 OCT scans from 6467 eyes of 3261 patients with neovascular AMD. After applying selection criteria, 926 eyes of 926 patients were analyzed.

MAIN OUTCOME MEASURES

Correlation coefficients (R² values) and mean absolute error (MAE) between quantitative OCT (qOCT) parameters and cross-sectional visual function, as well as the predictive value of these parameters for short-term visual change, that is, incremental visual acuity (VA) resulting from an individual injection, as well as VA at distant time points (up to 12 months after baseline).

RESULTS

Visual acuity at distant time points could be predicted: R² = 0.80 (MAE, 5.0 Early Treatment Diabetic Retinopathy Study [ETDRS] letters) and R² = 0.7 (MAE, 7.2 ETDRS letters) after injection at 3 and at 12 months after baseline (P < 0.001 for both), respectively. Best performing models included both baseline qOCT parameters and treatment response. Furthermore, we present proof-of-principle evidence that the incremental change in VA from an injection can be predicted: R² = 0.14 (MAE, 5.6 ETDRS letters) for injection 2 and R² = 0.11 (MAE, 5.0 ETDRS letters) for injection 3 (P < 0.001 for both).

CONCLUSIONS

Automatic segmentation enables rapid acquisition of quantitative and reproducible OCT biomarkers with potential to inform treatment decisions in the care of neovascular AMD. This furthers development of point-of-care decision-aid systems for personalized medicine.

Optical Coherence Tomography Angiography in Intermediate and Late Age-Related Macular Degeneration: Review of Current Technical Aspects and Applications

Optical coherence tomography angiography (OCTA) is a non-invasive diagnostic instrument that has become indispensable for the management of age-related macular degeneration (AMD). OCTA allows quickly visualizing retinal and choroidal microvasculature, and in the last years, its use has increased in clinical practice as well as for research into the pathophysiology of AMD. This review provides a discussion of new technology and application of OCTA in intermediate and late AMD.

Association between central retinal thickness and low luminance visual acuity in early age-related macular degeneration

PURPOSE/AIM

To examine whether central retinal thickness (CRT) is related to mesopic visual acuity (VA) and low luminance deficit (LLD, difference between photopic and mesopic VA) in eyes with early and intermediate age-related macular degeneration (AMD).

MATERIALS AND METHODS

In a cross-sectional study, 50 pseudophakic subjects older than 63 years were divided into three groups (no AMD, early AMD and intermediate AMD). Spectral domain optical coherence tomography (SD-OCT) was used to measure CRT in the 1 mm-central-area. Best-corrected distance VA was measured under photopic or mesopic luminance conditions and LLD calculated. Subjects were stratified by VA impairment to compare CRTs across these groups. Relationships were examined by stepwise multiple linear regression.

RESULTS

No significant differences in mean CRT, photopic and mesopic VA or LLD were detected between the groups no AMD, early AMD and intermediate AMD. However, mean CRTs were 20 microns and 18 microns thicker in the eyes with impaired mesopic VA (> 0.3 logMAR) and impaired LLD (⩾ 0.3 logMAR) compared to the eyes with non-impaired VA or LLD respectively (both p < 0.01). CRT and mesopic pupil size were independent predictors of mesopic VA (p = 0.001). CRT emerged as the only independent predictor of LLD (p = 0.004).

CONCLUSIONS

Increased CRT was linked to worse retinal function when measured under mesopic conditions in eyes without AMD and eyes with early to intermediate AMD. SD-OCT imaging combined with VA measurements under low luminance conditions could be a useful tool to detect early AMD.

Quantitative Analysis of OCT for Neovascular Age-Related Macular Degeneration Using Deep Learning

PURPOSE

To apply a deep learning algorithm for automated, objective, and comprehensive quantification of OCT scans to a large real-world dataset of eyes with neovascular age-related macular degeneration (AMD) and make the raw segmentation output data openly available for further research.

DESIGN

Retrospective analysis of OCT images from the Moorfields Eye Hospital AMD Database.

PARTICIPANTS

A total of 2473 first-treated eyes and 493 second-treated eyes that commenced therapy for neovascular AMD between June 2012 and June 2017.

METHODS

A deep learning algorithm was used to segment all baseline OCT scans. Volumes were calculated for segmented features such as neurosensory retina (NSR), drusen, intraretinal fluid (IRF), subretinal fluid (SRF), subretinal hyperreflective material (SHRM), retinal pigment epithelium (RPE), hyperreflective foci (HRF), fibrovascular pigment epithelium detachment (fvPED), and serous PED (sPED). Analyses included comparisons between first- and second-treated eyes by visual acuity (VA) and race/ethnicity and correlations between volumes.

MAIN OUTCOME MEASURES

Volumes of segmented features (mm³) and central subfield thickness (CST) (μm).

RESULTS

In first-treated eyes, the majority had both IRF and SRF (54.7%). First-treated eyes had greater volumes for all segmented tissues, with the exception of drusen, which was greater in second-treated eyes. In first-treated eyes, older age was associated with lower volumes for RPE, SRF, NSR, and sPED; in second-treated eyes, older age was associated with lower volumes of NSR, RPE, sPED, fvPED, and SRF. Eyes from Black individuals had higher SRF, RPE, and serous PED volumes compared with other ethnic groups. Greater volumes of the majority of features were associated with worse VA.

CONCLUSIONS

We report the results of large-scale automated quantification of a novel range of baseline features in neovascular AMD. Major differences between first- and second-treated eyes, with increasing age, and between ethnicities are highlighted. In the coming years, enhanced, automated OCT segmentation may assist personalization of real-world care and the detection of novel structure-function correlations. These data will be made publicly available for replication and future investigation by the AMD research community.

Topical Triamcinolone Acetonide-Loaded Liposomes as Primary Therapy for Macular Edema Secondary to Branch Retinal Vein Occlusion: A Pilot Study

Purpose: To explore safety and therapeutic efficacy of a topical ophthalmic triamcinolone acetonide-loaded liposome formulation (TA-LF) as primary therapy in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods: Twelve eyes of 12 patients with ME secondary to BRVO were exposed to a topical instillation of 1 drop of TA-LF (TA 0.2%) 6 times a day for 12 weeks to evaluate safety and efficacy. Best corrected visual acuity (BCVA) intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit. In addition, the morphology of TA-LF was analyzed using scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Results: Patients presented a significant improvement of BCVA and CFT without significant IOP modification (P = 0.94). Treated eyes showed BCVA improvement from 40 ± 12.05 to 64.83 ± 15.97 letters and CFT reduction from 682.91 ± 278.60 to 271.58 ± 57.66 μm after 12 weeks of TA-LF therapy (P < 0.001). No adverse events, including IOP rising, were registered. SEM analysis of liposomal formulations showed that liposome (LP) size depends on its concentration. As the concentration of TA increased, the average size of LPs and the number of larger particles increased as well. TEM study displayed that LP formulation efficiently solubilizes TA crystals in nanoparticles and encapsulates them. Conclusion: LPs can function as nanocarriers of TA and they could be used as topical ophthalmic primary therapy instead of intravitreal drugs in patients with ME secondary to BRVO.

APPLICATION OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY TO ASSESS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

Using optical coherence tomography (OCT) angiography to assess the therapeutic effect of intravitreal anti-vascular endothelial growth factor on myopic choroidal neovascularization (CNV) by detecting the changes of shape, size, and flow area.

METHODS

Our prospective case series recruited consecutive patients with myopic CNV from January 2016 to August 2016. Intravitreal injections of ranibizumab were conducted on all patients. Patients received OCT angiography on 3 different follow-ups, including before treatment, 1 week after treatment, and 1 month after treatment. At each visit, we measured the best-corrected visual acuity, central macular thickness , greatest linear dimension of CNV, selected CNV area and flow area using OCT angiography.

RESULTS

This study involved 13 eyes of 12 patients, in which 9 eyes were of 9 women and 4 eyes were of 3 men, with mean age of 49.92 ± 14.79 years. Best-corrected visual acuity was significantly improved with decreased central macular thickness, greatest linear dimension, intraretinal fluid, or subretinal fluid 7 days or 30 days after treatment (All P < 0.05). Myopic CNV was presented as irregular or nearly round closed mass at the level of the outer retinal layer in all eyes at the initial visit. Thirty days after treatment, the size of selected CNV area and flow area were further decreased (t = 4.012, P = 0.003).

CONCLUSION

Combined with OCT B-scan, OCT angiography, a new technique, could provide sensitive and intuitive images and quantitative analysis for monitoring and evaluating the therapeutic effect of intravitreal anti-vascular endothelial growth factor for myopic CNV.

Response of Retinal Sensitivity to Intravitreal Anti-angiogenic Bevacizumab and Triamcinolone Acetonide for Patients with Diabetic Macular Edema over One Year

AIM

The aim of this study was to evaluate and compare microperimetry changes in patients with clinically significant diabetic macular edema secondary to diabetes mellitus, following intravitreal injections of bevacizumab or triamcinolone during a follow-up of 1 year after treatment.

MATERIALS AND METHODS

30 patients with clinically significant macular edema were randomized into two groups of 15 patients each. One group initially received three intravitreal injections of 2.5 mg bevacizumab at monthly intervals. The other received a single injection of 8 mg of triamcinolone followed by two sham interventions at monthly intervals. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were measured. Macular function was documented by microperimetry at baseline, 3, 6, 9 months and at the last visit of each patient.

RESULTS

In the bevacizumab group, the mean differential light threshold (±standard deviation) under therapy improved significantly from 8.40 (± 3.8) dB to 12.8 (±4.3) dB at the 12-month follow-up visit (p ≤ .05), whereas in the triamcinolone group it increased from 8.0 (± 2.4) dB at baseline to 9.3 (±3.6) dB at the last visit without reaching statistical significance (p > .05). The mean differential light thresholds between the two groups were not statistically significant at baseline or the last visit (p > .05). In the bevacizumab group, the improvement (slope) in mean differential light threshold was significantly superior to the Triamcinolone group (Estimate = 0.588, p ≤ .05).

CONCLUSION

Central macular function as measured by microperimetry in patients with acute DME improved in addition to anatomical restoration after intravitreal bevacizumab and triamcinolone injection. In our clinical study, the measures of the variables in patients receiving bevacizumab were superior to those receiving triamcinolone throughout the one-year observation period.

Consensus Nomenclature for Reporting Neovascular Age-Related Macular Degeneration Data: Consensus on Neovascular Age-Related Macular Degeneration Nomenclature Study Group

PURPOSE

To establish a process to evaluate and standardize a state-of-the-art nomenclature for reporting neovascular age-related macular degeneration (AMD) data.

DESIGN

Consensus meeting.

PARTICIPANTS

An international panel of retina specialists, imaging and image reading center experts, and ocular pathologists.

METHODS

During several meetings organized under the auspices of the Macula Society, an international study group discussed and codified a set nomenclature framework for classifying the subtypes of neovascular AMD and associated lesion components.

MAIN OUTCOME MEASURES

A consensus classification of neovascular AMD.

RESULTS

The study group created a standardized working definition of AMD. The components of neovascular AMD were defined and subclassified. Disease consequences of macular neovascularization were delineated.

CONCLUSIONS

The framework of a consensus nomenclature system, a definition of AMD, and a delineation of the subtypes of neovascular AMD were developed. Establishing a uniform set of definitions will facilitate comparison of diverse patient groups and different studies. The framework presented is modified and updated readily, processes that are anticipated to occur on a periodic basis. The study group suggests that the consensus standards outlined in this article be used in future reported studies of neovascular AMD and clinical practice.

Novel Triamcinolone Acetonide-Loaded Liposomes Topical Formulation for the Treatment of Cystoid Macular Edema After Cataract Surgery: A Pilot Study

Purpose: To report tolerability, safety, and efficacy of a topical triamcinolone acetonide-loaded liposomes formulation (TA-LF) in targeting the macular area in patients with refractory pseudophakic cystoid macular edema (PCME).

Methods: For tolerability, safety and efficacy evaluation, 12 eyes of 12 patients with refractory PCME were exposed to one drop of TA-LF (TA at 0.2%) every 2 h for 90 days or until best-corrected visual acuity (BCVA) was achieved. Intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit.

Results: Patients with refractory PCME under TA-LF therapy showed a significant improvement in BVCA and CFT without significant IOP modification (P = 0.94). On average CFT decreased to 206.75 ± 135.72 μm and BCVA improved to 20.08 ± 10.35 letters (P < 0.0005). BCVA was achieved at 10.58 ± 6.70 weeks (range 2–18). TA-LF was well tolerated in all cases. Neither ocular surface abnormalities nor adverse events were recorded.

Conclusion: TA-LF was well tolerated and improved BCVA and CFT on patients with refractory PCME.

PROGNOSTIC VALUE OF SUBRETINAL HYPERREFLECTIVE MATERIAL IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH BEVACIZUMAB

PURPOSE

To study the correlation between subretinal hyperreflective material (SHRM) seen on spectral domain optical coherence tomography at baseline and visual outcomes after intravitreal bevacizumab injection in neovascular age-related macular degeneration.

METHODS

Consecutive patient charts with treatment-naive center-involved neovascular age-related macular degeneration treated with 3 monthly intravitreal bevacizumab's, continued as needed, from 2011 to 2014 were reviewed. Baseline spectral domain optical coherence tomography SHRM parameters (height, width, area, reflectivity, border definition, and homogeneity) and established optical coherence tomography biomarkers of neovascular activity (intraretinal fluid, subretinal fluid, retinal volume, central retinal thickness, and pigment epithelial detachment presence) were collected. These baseline parameters were correlated with visual acuity at baseline, 3 and 12 months.

RESULTS

Seventy-three eyes of 73 patients, 47 (64.4%) having central SHRM at baseline, were studied. Mean age was 79.2 ± 8.9 years. Mean best-corrected visual acuity was 0.70 ± 0.57 logarithm of the minimum angle of resolution (20/100), 0.73 ± 0.55 (20/107), and 0.76 ± 0.63 (20/115) at baseline, 3 and 12 months, respectively. Baseline parameters with a significant predictive value of 12-month visual acuity by univariate analysis were presence of intraretinal fluid, presence of SHRM, highly reflective SHRM, well-defined SHRM borders, and thick SHRM. These parameters, with the exception of high reflectivity, were significant on multivariate regression analysis. The most predictive baseline parameter was well-defined SHRM borders.

CONCLUSION

This study supports the use of SHRM as a prognostic biomarker when interpreting optical coherence tomography in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision 1 year after intravitreal bevacizumab treatment were as follows: presence of central SHRM, well-defined SHRM borders, intraretinal fluid, and thicker SHRM.

Automated Segmentation of Lesions Including Subretinal Hyperreflective Material in Neovascular Age-related Macular Degeneration

PURPOSE

To evaluate an automated segmentation algorithm with a convolutional neural network (CNN) to quantify and detect intraretinal fluid (IRF), subretinal fluid (SRF), pigment epithelial detachment (PED), and subretinal hyperreflective material (SHRM) through analyses of spectral-domain optical coherence tomography (SD-OCT) images from patients with neovascular age-related macular degeneration (nAMD).

DESIGN

Reliability and validity analysis of a diagnostic tool.

METHODS

We constructed a dataset including 930 B-scans from 93 eyes of 93 patients with nAMD. A CNN-based deep neural network was trained using 11 550 augmented images derived from 550 B-scans. The performance of the trained network was evaluated using a validation set including 140 B-scans and a test set of 240 B-scans. The Dice coefficient, positive predictive value (PPV), sensitivity, relative area difference (RAD), and intraclass correlation coefficient (ICC) were used to evaluate segmentation and detection performance.

RESULTS

Good agreement was observed for both segmentation and detection of lesions between the trained network and clinicians. The Dice coefficients for segmentation of IRF, SRF, SHRM, and PED were 0.78, 0.82, 0.75, and 0.80, respectively; the PPVs were 0.79, 0.80, 0.75, and 0.80, respectively; and the sensitivities were 0.77, 0.84, 0.73, and 0.81, respectively. The RADs were -4.32%, -10.29%, 4.13%, and 0.34%, respectively, and the ICCs were 0.98, 0.98, 0.97, and 0.98, respectively. All lesions were detected with high PPVs (range 0.94-0.99) and sensitivities (range 0.97-0.99).

CONCLUSIONS

A CNN-based network provides clinicians with quantitative data regarding nAMD through automatic segmentation and detection of pathologic lesions, including IRF, SRF, PED, and SHRM.

Patterns of retinal thickness prior to and following treatment with fluocinolone acetonide 190 µg intravitreal implant for diabetic macular edema

OBJECTIVES

To compare retinal thickness before and after treatment with the fluocinolone acetonide (FAc) 190 µg intravitreal implant in people with diabetic macular edema (DME) using data from the Iluvien Clinical Evidence study in the UK (ICE-UK).

METHODS

For this retrospective cohort study, data on people attending any one of 13 participating ophthalmology departments and treated with FAc intravitreal implant between April 1, 2013 and April 15, 2015 were collected for 12 months prior to and at least 12 months after implantation. Cross-sectional and longitudinal patterns of central foveal thickness (CFT) were compared before and after FAc implant.

RESULTS

There were 208 people who contributed data from 233 individual eyes treated with the FAc implant. Mean age was 68.1 years and 62% were male. Median (interquartile range) CFT decreased from 462 µm (354-603 µm) at time of implant to 309 µm (222-433 µm) at 12 months post-implant (p < .001). Over the same period, a reduction of ≥10%, ≥25%, and ≥50% in CFT was observed in 113 (65%), 87 (50%), and 37 (21%) treated eyes, respectively. Eyes with a CFT of ≥400 µm at the time of implant were significantly more likely to achieve a reduction in CFT of ≥10%, ≥25%, and ≥50% at 12 months (all p < .001) compared with eyes with a CFT of <400 µm at implant. Both retinal thickness and changes in retinal thickness were loosely correlated with visual acuity.

CONCLUSION

A marked reduction in retinal thickness was observed in people following FAc intravitreal implant for DME. The response was related to the degree of retinal thickness prior to treatment.

Association of Vascular Versus Avascular Subretinal Hyperreflective Material With Aflibercept Response in Age-related Macular Degeneration

PURPOSE

To investigate flow signal within subretinal hyperreflective material (SHRM) using optical coherence tomography angiography (OCTA) and its association with aflibercept treatment responses in treatment-naïve neovascular age-related macular degeneration (nAMD).

DESIGN

Prospective consecutive interventional case series.

METHODS

Forty-four eyes of 44 patients with treatment-naïve nAMD manifesting SHRM on OCT were studied. All patients underwent OCTA and received 3 monthly aflibercept injections. The intrinsic flow signals within SHRM were quantitatively analyzed using OCTA, and eyes were classified into the vascular and avascular SHRM groups.

RESULTS

Of 44 eyes, 21 (47.7%) and 23 (52.3%) showed vascular SHRM and avascular SHRM, respectively. Compared with eyes with avascular SHRM, eyes with vascular SHRM showed higher rates of external limiting membrane (ELM) disruption owing to SHRM (P = .015), classic choroidal neovascularization (CNV) (85.7% vs 26.1%, P = .87 × 10^-4), and intraretinal fluid (P = .008) at baseline. After 3 aflibercept injections, 38 eyes (86.4%) showed dry macula despite persistent SHRM in 24 eyes (54.5%). Compared with the eyes with resolved SHRM, those with persistent SHRM showed higher rate of vascular SHRM (75.0% vs 15.0%, P = .86 × 10^-4), classic CNV (P = .032), absence of polypoidal lesion (P = .020), ELM disruption owing to SHRM (P = .042), and intraretinal fluid (P = .008). Dry macula after loading injections was significantly associated with SHRM resolution (P = .025).

CONCLUSIONS

In nAMD, SHRM can be categorized as vascular and avascular by quantitative OCTA analysis. Vascular SHRM persisted after treatment and was associated with failure to achieve dry macula, suggesting that vascular SHRM is predictive of lower response to anti-VEGF therapy.

Relationship Between Visual Acuity and Retinal Thickness During Anti-Vascular Endothelial Growth Factor Therapy for Retinal Diseases

PURPOSE

To investigate the relationship between best-corrected visual acuity (BCVA) and central retinal thickness (CRT) in eyes receiving ranibizumab for 3 common retinal diseases.

DESIGN

Retrospective analysis of clinical trial data.

METHODS

Early Treatment Diabetic Retinopathy Study BCVA and spectral-domain optical coherence tomography-measured CRT of 387 eyes of 345 patients enrolled in 6 prospective clinical trials for management of neovascular age-related macular degeneration (AMD), diabetic macular edema (DME), and retinal vein occlusion (RVO) were evaluated by Pearson correlation and linear regression.

RESULTS

At baseline, there was a small correlation between BCVA and CRT in pooled AMD trial data (r = -0.24). A medium correlation was identified in pooled DME trial data (r = -0.42). No correlation was found in pooled RVO trial data. At month 12, no correlation was found between changes from baseline in BCVA and CRT in pooled AMD trial data. Medium correlations were identified in both pooled DME (r = -0.45) and pooled RVO (r = -0.35) trial data at month 12. Changes in BCVA and CRT associated with edema recurrence upon transition from monthly to pro re nata (PRN) dosing were correlated in AMD (r = -0.27) and RVO (r = -0.72) trials, but not in DME trial data.

CONCLUSION

DME demonstrated a convincing relationship between BCVA and CRT. Correlations appear to be more complex in AMD and RVO. At the inflection point between monthly and PRN dosing, when recurrence of edema is anticipated in many patients, CRT appears strongly correlated with loss of BCVA in RVO.

Impact of retinal pigment epithelium pathology on spectral-domain optical coherence tomography-derived macular thickness and volume metrics and their intersession repeatability

BACKGROUND

To determine the impact of retinal pigment epithelium (RPE) pathology on intersession repeatability of retinal thickness and volume metrics derived from Spectralis spectral-domain optical coherence tomography (Heidelberg Engineering, Heidelberg, Germany).

DESIGN

Prospective cross-sectional single centre study.

PARTICIPANTS

A total of 56 eyes of 56 subjects were divided into three groups: (i) normal RPE band (25 eyes); (ii) RPE elevation: macular soft drusen (13 eyes); and (iii) RPE attenuation: geographic atrophy or inherited retinal diseases (18 eyes).

METHODS

Each subject underwent three consecutive follow-up macular raster scans (61 B-scans at 119 μm separation) at 1-month intervals.

MAIN OUTCOME MEASURES

Retinal thicknesses and volumes for each zone of the macular subfields before and after manual correction of segmentation error. Coefficients of repeatability (CR) were calculated.

RESULTS

Mean (range) age was 57 (21-88) years. Mean central subfield thickness (CST) and total macular volume were 264 and 258 μm (P = 0.62), and 8.0 and 7.8 mm³ (P = 0.31), before and after manual correction. Intersession CR (95% confidence interval) for CST and total macular volume were reduced from 40 (38-41) to 8.3 (8.1-8.5) and 0.62 to 0.16 mm³ after manual correction of segmentation lines. CR for CST were 7.4, 23.5 and 66.7 μm before and 7.0, 10.9 and 7.6 μm after manual correction in groups i, ii and iii.

CONCLUSIONS

Segmentation error in eyes with RPE disease has a significant impact on intersession repeatability of Spectralis spectral-domain optical coherence tomography macular thickness and volume metrics. Careful examination of each B-scan and manual adjustment can enhance the utility of quantitative measurement. Improved automated segmentation algorithms are needed.

Subretinal Hyperreflective Material Imaged With Optical Coherence Tomography Angiography

PURPOSE

The range of subretinal hyperreflective material (SHRM) seen in macular disease includes type 2 macular neovascularization, fibrosis, exudation, vitelliform material, and hemorrhage. The prognostic significance of SHRM has been evaluated retrospectively in clinical trials, but discriminating SHRM subtypes traditionally requires multiple imaging modalities. The purpose of this study is to describe optical coherence tomography angiography (OCTA) flow characteristics and artifacts that might help to distinguish SHRM subtypes.

DESIGN

Validity analysis.

METHODS

Patients with age-related macular degeneration (AMD), myopia, pachychoroid disease, and macular dystrophy, manifesting SHRM on optical coherence tomography (OCT), were recruited. Clinical chart review and multimodal imaging established the SHRM subtype. All patients underwent OCTA. OCT and OCTA images were examined together for (1) intrinsic flow, (2) retinal projection onto the anterior SHRM surface (strong, weak, absent), (3) retinal projection through SHRM onto retinal pigment epithelium (RPE), and (4) masking of choriocapillaris flow.

RESULTS

Thirty-three eyes of 25 patients were included (type 2 neovascularization ×3; fibrosis ×4; exudation ×10; hemorrhage ×5; vitelliform ×17). Mean age per eye was 76 years (standard deviation: 12). Intrinsic flow was strongest in type 2 neovascularization. Subretinal fibrosis showed limited flow in residual large-caliber vessels and branches. Flow was not detected within foci of exudation, hemorrhage, or vitelliform lesions. Retina-SHRM surface projection was strongest onto smooth-surfaced SHRM and weaker onto exudation. Retinal projection was weakest on the surface of vitelliform lesions. Retina-RPE projection was masked by dense hemorrhage and vitelliform material. In compound SHRM, OCTA distinguished between vascular and avascular components.

CONCLUSION

Optical coherence tomography angiography can distinguish vascular from avascular SHRM components. OCTA artifacts may distinguish certain avascular SHRM components.

Spectral-domain Optical Coherence Tomography Retinal and Choroidal Thickness Metric Repeatability in Age-related Macular Degeneration

PURPOSE

To determine the intrasession repeatability of spectral-domain OCT (SDOCT)-derived macular retinal and choroidal metrics in patients with neovascular age-related macular degeneration (nAMD) in the Distance of Choroid Study (DOCS).

DESIGN

Validity and reliability analysis.

METHODS

Enrolled patients underwent repeated SDOCT imaging using the Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany). A single technician certified for clinical trials took 3 macular volume scans. Retinal thicknesses were calculated for each of the 9 Early Treatment Diabetic Retinopathy Study (ETDRS) macular subfields. Center point thickness and total macular volume were also included in the analysis. Manual subfoveal choroidal thickness measurements were made by a masked observer.

RESULTS

A total of 40 eyes of 40 patients were included in this analysis (mean [± standard deviation] age: 74.1 [± 7.2] years, 60% male). The coefficient of repeatability (CR) of the central macular subfield was 30.6 μm (95% confidence interval [CI] 29.8-1.4 μm). The CR for the other macular subfields ranged from 7.0 μm to 38.2 μm. The CR for the total macular volume was 0.212 mm(3) (95% CI 0.206-0.217 mm(3)) and the CR for the center point was 47.5 μm (95% CI 46.2-48.7 μm). Images were also reviewed for the presence of segmentation error in the central macular subfield, and after exclusion of these eyes the revised CR for this subfield was 13.7 μm (95% CI 13.3-14.1 μm). The intrasession CR of subfoveal choroidal thickness was 34.7 μm (95% CI 33.7-35.7 μm).

CONCLUSIONS

This study suggests that a change of greater than 31 μm in Spectralis SDOCT-derived retinal thickness measurement of the central macular subfield and 35 μm in subfoveal choroidal thickness is necessary to detect true clinical change associated with disease progression or improvement in nAMD with a revised figure of 14 μm for central macular retinal subfield thickness in the absence of segmentation error.

Subretinal Hyperreflective Material in the Comparison of Age-Related Macular Degeneration Treatments Trials

PURPOSE

To evaluate the association of subretinal hyperreflective material (SHRM) with visual acuity (VA), geographic atrophy (GA), and scar in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

DESIGN

Prospective cohort study within a randomized clinical trial.

PARTICIPANTS

The 1185 CATT participants.

METHODS

Masked readers graded scar and GA on fundus photography and fluorescein angiography and graded SHRM on time-domain and spectral-domain (SD) optical coherence tomography (OCT) throughout 104 weeks. Measurements of SHRM height and width in the fovea, within the center 1 mm(2), or outside the center 1mm(2) were obtained on SD OCT images at 56 (n = 76) and 104 (n = 66) weeks.

MAIN OUTCOME MEASURES

Presence of SHRM, as well as location and size, and associations with VA, scar, and GA.

RESULTS

Among CATT participants, the percentage with SHRM at enrollment was 77%, decreasing to 68% at 4 weeks after treatment and to 54% at 104 weeks. At 104 weeks, scar was present more often in eyes with persistent SHRM than in eyes with SHRM that resolved (64% vs. 31%; P < 0.0001). Among eyes with detailed evaluation of SHRM at weeks 56 (n = 76) and 104 (n = 66), mean VA letter score was 73.5 (standard error [SE], 2.8), 73.1 (SE, 3.4), 65.3 (SE, 3.5), and 63.9 (SE, 3.7) when SHRM was absent, present outside the central 1 mm(2), present within the central 1 mm(2) but not the foveal center, or present at the foveal center (P = 0.02), respectively. When SHRM was present, the median maximum height under the fovea, within the central 1 mm(2) including the fovea and anywhere within the scan, was 86 μm, 120 μm, and 122 μm, respectively. Visual acuity was decreased with greater SHRM height and width (P < 0.05).

CONCLUSIONS

In eyes with neovascular age-related macular degeneration (AMD), SHRM is common and often persists after anti-vascular endothelial growth factor treatment. At 2 years, eyes with scar were more likely to have SHRM than other eyes. Greater SHRM dimensions were associated with worse VA. In eyes with neovascular AMD, SHRM is an important morphologic biomarker.