Geographic atrophy progression in eyes with age-related macular degeneration: role of fundus autofluorescence patterns, fellow eye and baseline atrophy area

Geographic Atrophy Natural History Versus Treatment: Time to Fovea

BACKGROUND AND OBJECTIVE

The Food and Drug Administration recently approved treatments of geographic atrophy (GA). Our study aims to quantify the time for a lesion to reach the central fovea based on reduction of GA growth rates from therapeutics compared to the natural history.

PATIENTS AND METHODS

A previously published study calculates local border expansion rate of GA lesions at varying retinal eccentricities. In this study, we use these rates to model GA expansion toward the fovea and the effects of treatments that reduce growth in GA area by 15% to 45% on lesions of varying sizes with posterior margin 250, 500, 750, 1000, 1250, 1500, and 3000 µm from the fovea.

RESULTS

Lesions with an area 8 mm2 and posterior edge 500 µm from the fovea will reach the fovea in 5.08 years with no treatment, but the same lesions will reach the fovea in 5.85, 6.52, 7.36, and 8.46 years with a treatment that reduces growth in GA area by 15%, 25%, 35%, and 45%, respectively.

CONCLUSIONS

Distance of the posterior edge of the lesion was the primary factor in GA growth toward the fovea, and lesion size only minimally affects growth rates of GA. Based on the efficacy of current and future therapeutics and distance of GA to the fovea, our study provides the marginal time benefit of treatment to guide patients and clinicians, placing both the natural history of GA and the effects of current and future treatments into clinical context. [Ophthalmic Surg Lasers Imaging Retina 2024;55:576-585.].

Progression Rate of Macular Retinal Pigment Epithelium Atrophy in Geographic Atrophy and Selected Inherited Retinal Dystrophies. A Systematic Review and Meta-Analysis

PURPOSE

To compare the macular retinal pigment epithelium (RPE) atrophy progression rate of selected degenerative and macular inherited retinal diseases (IRD).

DESIGN

Systematic review and meta-analysis.

METHODS

The protocol was registered on the PROSPERO database. Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to September 15, 2023 for articles reporting the RPE atrophy growth rate in treatment-naïve eyes with geographic atrophy (GA), Stargardt disease (STGD1), Best disease, pseudoxanthoma elasticum (PXE), central areolar choroidal dystrophy (CACD), or pattern dystrophies with no previous or current macular neovascularization and a minimum follow-up time of 12 months. Meta-analyses determined mean RPE atrophy growth rates per disease, imaging modality (fundus autofluorescence [FAF], optical coherence tomography [OCT], or color fundus photography [CFP]) and metric (mm2/y or mm/y). The Newcastle-Ottawa scale and the Cochrane Risk-of-Bias tool assessed the risk of bias, and funnel plots were used to evaluate small-study effects.

RESULTS

From 4354 publications, 85 were included for meta-analysis: 69 studies (7815 eyes) on GA, 15 (1367 eyes) on STGD1, and one on both. Two studies on PXE were only eligible for review. No studies for other diseases met our eligibility criteria. The overall mean RPE atrophy growth rate for GA using FAF was 1.65 mm2/y (95% confidence interval [CI], 1.49-1.81) and 0.35 mm/y (95% CI, 0.28-0.41); using OCT, it was 1.46 mm2/y (95% CI, 1.28-1.64) and 0.34 mm/y (95% CI, 0.28-0.40); and on CFP it was 1.76 mm2/y (95% CI, 1.56-1.97) and 0.30 mm/y (95% CI, 0.28-0.31). For STGD1, using FAF it was 1.0 mm2/y (95% CI, 0.77-1.23) and 0.20 mm/y (95% CI, 0.17-0.23); on OCT, it was 0.80 mm2/y (95% CI, 0.72-0.88). No studies on STGD1 reported the growth rate with other imaging modalities or metrics. Growth rates in GA were faster than in STGD1 (p < .05). A larger baseline area of atrophy was generally associated with faster growth rates.

CONCLUSIONS

The RPE atrophy growth rate in GA is faster than in STGD1 but with great variation between studies and imaging modalities. Limited information was available for other macular IRD, suggesting further research is needed.

Geographic atrophy: current and future therapeutic agents and practical considerations for retinal specialists

PURPOSE OF REVIEW

Geographic atrophy (GA) from age-related macular degeneration (AMD) remains a leading cause of vision loss. The purpose of this review is to summarize currently available intravitreal therapeutics, and discuss pipeline therapeutics that are currently in clinical trials.

RECENT FINDINGS

The FDA approval of pegcetacoplan and avacincaptad pegol, both approved in 2023, represent the first therapeutics to treat GA. These are delivered via intravitreal injections, and have been shown to slow progression of GA. Both drugs have a risk of new onset neovascular age-related macular degeneration (nAMD). Initial indications seem to be that pegcetacoplan therapy has higher risks of inflammation, vasculitis, and nonarteritic ischemic optic neuropathy (NAION) as compared to avacincaptad pegol, but more real-world data will help to clarify this further. Pipeline therapeutics that we discuss include intravitreal gene therapy, oral anticomplement therapy, and intravitreal injections of a novel glycoprotein.

SUMMARY

Both pegcetacoplan and avacincaptad pegol are FDA approved to treat GA. The decision to treat patients is still complex and nuanced, but the approval of two treatments for GA is a tremendous advance in our field. Future therapeutics may further refine our ability to treat patients more effectively and safely.

Sequential structural and functional change in geographic atrophy on multimodal imaging in non-exudative age-related macular degeneration

PURPOSE

To investigate the temporal order of photoreceptor atrophy, retinal pigment epithelium (RPE) atrophy and visual acuity loss in patients with center-involving geographic atrophy (GA) in non-exudative age-related macular degeneration (neAMD).

METHODS

Forty eyes of 25 consecutive patients who eventually developed center-involving GA were investigated. Fundus autofluorescence (FAF) and infrared image coupled optical coherence tomography (OCT) were acquired at each visit. Development of RPE atrophy and photoreceptor atrophy was defined as abnormal hyper/hypo-fluorescence on FAF and photoreceptor loss on OCT over 50% of the vertical or horizontal diameters of the center 1 mm circle, respectively. Visual acuity loss was defined as worsening of more than 0.2 logMAR compared to baseline. Kaplan-Meier analyses was performed to compare the sequential order of these three events.

RESULTS

Mean age was 72.72 ± 8.63 years, and follow-up duration was 27.36 ± 17.22 months, with an average number of visits of 3.04 ± 1.54 during follow-up. GA progressed from photoreceptor atrophy on OCT, RPE atrophy on FAF, and then to vision loss (p < 0.001). The median survival time of photoreceptors preceded that of visual acuity by 16.3 months, and the median survival time of RPE preceded that of visual acuity by 7.0 months. At baseline, majority of eyes showed drusen only (57.5%), while the most common feature was incomplete RPE and outer retinal atrophy at 3-year follow-up (40.4%).

CONCLUSION

In the progression of center-involving GA, photoreceptor atrophy on OCT and RPE atrophy on FAF precedes visual decline, and can act as biomarkers predicting future visual decline within the following years.

Compass Fundus-Guided Perimetry in Geographic Atrophy

Purpose

To evaluate compass (CMP), a recently introduced device that combines scanning ophthalmoscopy, automated perimetry, and eye tracking, for fundus-guided perimetry (microperimetry) with the purpose of correlating perimetric retinal sensitivity (PRS) and retinal geographic atrophy (GA) features.

Materials and Methods

A retrospective, cross-sectional study was performed in 56 eyes of 43 patients affected by GA. All patients underwent compass 10-2 perimetry, consisting of a full-threshold visual field on fundus photography and an infrared (IR) image of the central 30° of the retina. Data were exported to an Excel sheet. Binarization with black/white (B/W) variables was applied on the compass photo fundus and matched with visual field scores. Patients underwent autofluorescence (AF) and IR images (Heidelberg, Germany): CMP and Heidelberg IR images were homologated by using GIMP software (https://www.gimp.org), and then atrophic areas were manually measured with the ImageJ program. CMP perimetric grid was overlapped with AF and IR pictures by using GIMP, obtaining composite TIFF images, which were then analyzed with the ImageJ greyscale score (GSS) tool. A hyperautofluorescent halo was identified on the GA edges of some patients. Pearson's correlation between GA size on IR compass and IR Heidelberg and between GSS and PRS values has been calculated; the independent t-test was realized to calculate the correlation between GSS and B/W variables identified on the CMP photo fundus. The Spearman correlation between total deviation and pattern deviation was calculated.

Results

The AUC-ROC score between CMP scores and B/W variables was 93,4%. The Spearman correlation between total deviation and pattern deviation was highly significant (p = 0,00). The correlation between AF GSS values and PRS was significant (p value = 0,00), the correlation between GSS of hyperautofluorescent points and PRS was significant (p value = 0,00), and the correlation between IR GSS and PRS was significant (p value = 0,00). The correlation between AF GSS and B/W variables was significant (p value = 0,002), the correlation between hyperautofluorescent points and B/W was not significant (p value = 0,40), and the correlation between IR GSS and B/W was significant (p = 0,00).

Conclusions

Based on our preliminary results, compass seems to be a reliable, quick, and safe device for the anatomical and functional study of GA. The direct visualization of the visual field on the fundus photography as a background allows a precise assessment and clinical monitoring of this disease.

Retinal Vessel Density in Age-Related Macular Degeneration Patients with Geographic Atrophy

We compared the retinal vessel density and inner retinal thickness in patients who had one eye with geographic atrophy (GA) and a fellow eye with intermediate age-related macular degeneration (iAMD). The vessel density from the superficial vascular complex (SVC) and deep vascular complex (DVC) through optical coherence tomography angiography and the thickness of the nerve fiber layer, ganglion cell-inner plexiform layer (GCIPL), inner nuclear layer (INL), outer nuclear layer (ONL) on a structural optical coherence tomography thickness map were measured in 28 eyes of 14 GA patients with iAMD in the fellow eye. GA eyes had significantly lower vessel density in the SVC (26.2 ± 3.9% vs. 28.3 ± 4.4%; p = 0.015) and DVC (24.2 ± 2.6% vs. 26.8 ± 1.9%; p = 0.003) than fellow eyes (iAMD). GCIPL and ONL were significantly thinner in GA eyes than in the fellow eyes (p = 0.032 and 0.024 in the foveal areas, p = 0.029 and 0.065 in the parafovea areas, respectively). Twenty-four eyes of 12 patients were followed up for 2 years and seven of the fellow eyes (58.3%) developed GA during the follow-up period and showed reduced vessel density in the SVC (26.4 ± 3.0% vs. 23.8 ± 2.9%; p = 0.087) and DVC (25.8 ± 2.2% vs. 22.4 ± 4.4%; p = 0.047) compared to baseline. Vessel density and GCIPL thickness map measurements are potential GA markers in non-neovascular AMD.

Evolving Patterns of Hyperfluorescent Fundus Autofluorescence Accompany Retinal Atrophy in the Rat and Mimic Atrophic Age-Related Macular Degeneration

Purpose

Complex two-dimensional (2D) patterns of hyperfluorescent short-wave fundus autofluorescence (FAF) at the border of geographic atrophy (GA) can predict its expansion in patients with late non-exudative “dry” AMD. However, preclinical models do not phenocopy this important feature of disease. We sought to describe the spatiotemporal changes in hyperfluorescent FAF patterns that occur following acute oxidative stress, potentially in association with GA expansion.

Methods

Sprague Dawley rats (n = 54) received systemic sodium iodate (25–45 mg/kg, n = 90 eyes) or saline (n = 18 eyes) and underwent serial full fundus imaging by confocal scanning laser ophthalmoscopy, including blue FAF and delayed near-infrared analysis. Composite images of the fundus were assembled, and the 2D patterns were described qualitatively and quantitatively. A subset of eyes underwent tissue analysis, and four underwent optical coherence tomography (OCT) imaging.

Results

Reproducibly changing, complex patterns of hyperfluorescent FAF emerge at the borders of toxin-induced damage; however, in the absence of GA expansion, they percolate inward within the region of retinal pigment epithelium loss, evolving, maturing, and senescing in situ over time. Unexpectedly, the late FAF patterns most closely resemble the diffuse tricking form of clinical disease. A five-stage classification system is presented.

Conclusions

Longitudinal, full-fundus imaging of outer retinal atrophy in the rat eye identifies evolving, complex patterns of hyperfluorescent FAF that phenocopy aspects of disease.

Translational Relevance

This work provides a novel tool to assess hyperfluorescent FAF in association with progressive retinal atrophy, a therapeutic target in late AMD.

Local Progression Kinetics of Geographic Atrophy Depends Upon the Border Location

Purpose

To assess the influence of lesion morphology and location on geographic atrophy (GA) growth rate.

Methods

We manually delineated GA on color fundus photographs of 237 eyes in the Age-Related Eye Disease Study. We calculated local border expansion rate (BER) as the linear distance that a point on the GA border traveled over 1 year based on a Euclidean distance map. Eye-specific BER was defined as the mean local BER of all points on the GA border in an eye. The percentage area affected by GA was defined as the GA area divided by the total retinal area in the region.

Results

GA enlarged 1.51 ± 1.96 mm2 in area and 0.13 ± 0.11 mm in distance over 1 year. The GA area growth rate (mm2/y) was associated with the baseline GA area (P < 0.001), perimeter (P < 0.001), lesion number (P < 0.001), and circularity index (P < 0.001); in contrast, eye-specific BER (mm/y) was not significantly associated with any of these factors. As the retinal eccentricity increased from 0 to 3.5 mm, the local BER increased from 0.10 to 0.24 mm/y (P < 0.001); in contrast, the percentage of area affected by GA decreased from 49.3% to 2.3%.

Conclusions

Using distance-based measurements allows GA progression evaluation without significant confounding effects from baseline GA morphology. Local GA progression rates increased as a function of retinal eccentricity within the macula which is opposite of the trend for GA distribution, suggesting that GA initiation and enlargement may be mediated by different biological processes.

Correlation between Topographic Progression of Geographic Atrophy and Visual Acuity Changes

Purpose

To analyze topographic progression of geographic atrophy with different concentric circles centered on the fovea in correlation with decrease of visual acuity.

Methods

We retrospectively analyzed 36 eyes of 26 patients diagnosed with geographic atrophy and followed at least 1 year. One millimeter circular area at the foveal center were defined as zone 1, and doughnut shape areas from between 1 and 2 mm to between 5 and 6 mm were defined as zone 2 to 6. Then, changes of geographic atrophy area in each zone were measured with semi-automatic software. Correlation analysis and regression analysis were performed to determine the relationship between changes in visual acuity and atrophic area in each zone.

Results

Mean age was 76.9 years and follow-up period were 3.38 years. The mean atrophic area increased from 8.09 to 16.34 mm² and visual acuity decreased from 0.39 to 0.69 on logarithm of the minimal angle of resolution. Mean change of total geographic atrophy area was not significantly correlated with visual acuity decrease. While geographic atrophy progression within zone 1, 2, and 3 showed significant causal relationship with decrease of visual acuity (all, p < 0.05).

Conclusions

In contrast to the total geographic atrophy area, progression of geographic atrophy in parafoveal area was significantly correlated with decrease of visual acuity.

The Use of Fundus Autofluorescence in Dry Age-Related Macular Degeneration

Fundus autofluorescence (FAF) has been a well-known imaging method for quite some time. However, with developing technologies and novel imaging devices, FAF is being used more often to diagnose and monitor retinal diseases. The density of lipofuscin (LF) and other fluorophores in the retina have a determining role in FAF images. In dry age-related macular degeneration (AMD), hyperautofluorescence is seen in cases of increasing LF in the retina pigment epithelium, whereas hypoautofluorescence is detected in decreasing LF resulting from geographic atrophy. In recent years, studies have shown that FAF images provide prognostic information in patients with AMD. This review aims to highlight the importance of FAF imaging in dry AMD.

Progression of Atrophy and Visual Outcomes in Extensive Macular Atrophy with Pseudodrusen-like Appearance

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Impact of ocular and systemic risk factors on progression of geographic atrophy in age-related macular degeneration

BACKGROUND

Geographic atrophy (GA) corresponds to an end-stage form of age-related macular degeneration and the leading cause of irreversible vision loss. The aim of this study was to investigate the role of fundus autofluorescence (FAF) patterns surrounding GA, baseline GA size, the presence of reticular pseudodrusen (RPD), the condition of the fellow eye and the presence of systemic vascular diseases (diabetes, atherosclerosis, systemic hypertension) on the progression of GA due to age-related macular degeneration.

METHODS

Seventy-five eyes of 52 patients with GA were included into this retrospective study. Digital FAF images were achieved using scanning laser ophthalmoscopy. Areas of GA were measured with the Region Finder software program on an Heidelberg Retinal Angiograph 2. FAF patterns around GA were classified and the presence of RPD and systemic diseases were noted. The median follow-up of the patients was 2.6 years (interquartile range, 1-9.2).

RESULTS

The median progression rate of the banded pattern (median 0.97 mm²/year) was significantly higher than the other patterns (median 0.85 mm²/year) (p = 0.03). Eyes with RPD had a significantly higher progression rate (median 1.21 mm²/year) than those without RPD (median 0.79 mm²/year) (p = 0.007). The presence of systemic diseases was not related with lesion progression rates.

CONCLUSIONS

The results demonstrate that the banded pattern and the presence of RPD accelerate the progression of GA and function as predictive factors.

Geographic Atrophy Growth Is Strongly Related to Lesion Perimeter: Unifying Effects of Lesion Area, Number, and Circularity on Growth

PURPOSE

To investigate the underlying reason for the previously observed impact of baseline lesion size, number, and circularity on geographic atrophy (GA) growth rate.

DESIGN

Retrospective analysis of a multicenter, prospective, randomized controlled trial.

PARTICIPANTS

Age-Related Eye Disease Study participants with GA secondary to nonexudative age-related macular degeneration.

METHODS

We manually delineated atrophic lesions on color fundus photographs of 318 eyes with GA followed up over at least 2 visits (mean follow-up duration, 5.1 ± 3.0 years). We calculated GA area growth rate for each eye based on the first and last visit. GA perimeter-adjusted growth rate was defined as the ratio between GA area growth rate and mean GA perimeter between the first and last visit for each eye.

MAIN OUTCOME MEASURES

GA area growth rate, growth rate of the square root of GA area, and GA perimeter-adjusted growth rate.

RESULTS

GA area growth rate was correlated strongly with mean GA perimeter (r² = 0.66). GA area growth rate was associated with baseline GA area (r² = 0.39; P < 0.001), lesion number (r² = 0.10; P < 0.001), and circularity index (r² = 0.28; P < 0.001). The use of the square root of GA area reduced the influence of baseline GA area (but not lesion number or circularity) on GA growth rate. In comparison, GA perimeter-adjusted growth rate (0.098 ± 0.062 mm/year) was not correlated with baseline GA area (r² = 0.005; P = 0.20), lesion number (r² = 0.00009; P = 0.86), or circularity index (r² = 0.007; P = 0.14). GA perimeter-adjusted growth rate was 50.0% higher in eyes whose fellow eyes showed GA at any visit (0.102 ± 0.062 mm/year) than in eyes whose fellow eyes never demonstrated GA during follow-up (0.068 ± 0.049 mm/year).

CONCLUSIONS

The growth rate of GA area is associated strongly with lesion perimeter. This relationship explains the previously observed influences of baseline GA size, lesion number, and circularity on GA growth rate. GA perimeter-adjusted growth rate is uncorrelated with the 3 morphologic factors and may serve as a surrogate outcome measure to monitor GA progression in future studies.

RECLASSIFICATION OF FUNDUS AUTOFLUORESCENCE PATTERNS SURROUNDING GEOGRAPHIC ATROPHY BASED ON PROGRESSION RATE: A Systematic Review and Meta-Analysis

PURPOSE

To reclassify fundus autofluorescence (FAF) patterns around geographic atrophy (GA) based on GA progression rates.

METHODS

MEDLINE, EMBASE, Cochrane Library, Clinicaltrials.gov, and PubMed were searched for studies reporting GA progression rates among different FAF patterns, such as "None," "Focal," "Banded," "Patchy," "Diffuse Nontrickling," and "Diffuse Trickling." The GA radius growth rate among different FAF patterns was compared, and a GA growth function for each group was derived. To account for the patients' different entry times, a horizontal translation factor was introduced to shift each data subset from "time after enrollment" to "duration of GA."

RESULTS

Seven studies with 496 eyes were included. Based on GA radius growth rates, the six FAF patterns were clustered into four groups with a high correlation coefficient within each group: Group 1, None, 0.061 mm/year (r = 0.996), Group 2, Focal, 0.105 mm/year (r = 0.987), Group 3, Banded, Patchy, and Diffuse Nontrickling, 0.149 mm/year (r = 0.993), and Group 4, "Diffuse Trickling, 0.245 mm/year (r = 0.997).

CONCLUSION

This meta-analysis suggested that the six FAF patterns can be coalesced into four groups based on lesion progression rates. Simplification of the reclassified FAF patterns may shed light on the GA natural history and assist in the design of clinical trials.

Risk factors for progression of age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a degenerative disease of the macula, often leading to progressive vision loss. The rate of disease progression can vary among individuals and has been associated with multiple risk factors. In this review, we provide an overview of the current literature investigating phenotypic, demographic, environmental, genetic, and molecular risk factors, and propose the most consistently identified risk factors for disease progression in AMD based on these studies. Finally, we describe the potential use of these risk factors for personalised healthcare.

Recent findings

While phenotypic risk factors such as drusen and pigment abnormalities become more important to predict disease progression during the course of the disease, demographic, environmental, genetic and molecular risk factors are more valuable at earlier disease stages. Demographic and environmental risk factors such as age and smoking are consistently reported to be related to disease progression, while other factors such as sex, body mass index (BMI) and education are less often associated. Of all known AMD variants, variants that are most consistently reported with disease progression are rs10922109 and rs570618 in CFH, rs116503776 in C2/CFB/SKIV2L, rs3750846 in ARMS2/HTRA1 and rs2230199 in C3. However, it seems likely that other AMD variants also contribute to disease progression but to a lesser extent. Rare variants have probably a large effect on disease progression in highly affected families. Furthermore, current prediction models do not include molecular risk factors, while these factors can be measured accurately in the blood. Possible promising molecular risk factors are High‐Density Lipoprotein Cholesterol (HDL‐C), Docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), zeaxanthin and lutein.

Summary

Phenotypic, demographic, environmental, genetic and molecular risk factors can be combined in prediction models to predict disease progression, but the selection of the proper risk factors for personalised risk prediction will differ among individuals and is dependent on their current disease stage. Future prediction models should include a wider set of genetic variants to determine the genetic risk more accurately, and rare variants should be taken into account in highly affected families. In addition, adding molecular factors in prediction models may lead to preventive strategies and personalised advice.

Relationship between proximity of choriocapillaris flow deficits and enlargement rate of geographic atrophy

PURPOSE

To correlate choriocapillaris (CC) flow deficits (FD) in eyes with geographic atrophy (GA) at various distances from the border of the GA lesion with yearly enlargement rate (yER) of GA.

METHODS

In this retrospective study, spectral domain optical coherence tomography (SD-OCT) and SD optical coherence tomography angiography (OCTA) images were collected from patients with GA, who were imaged at Doheny Eye Centers between 2016 and 2018, using the Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA). All enrolled patients had one baseline 6 × 6 mm OCTA scan and two 6 × 6 mm SD-OCT cubes, one at baseline and one at a follow-up visit at least 12 months later. The border of the GA was manually outlined on the en face OCT fundus image and the yER was calculated after square root transformation. A grid composed of 100-μm-wide successive concentric rings was created around the GA lesion on the OCTA CC slab using ImageJ and the FD% was calculated from the binarized image. FD% from each ring was correlated with the yER of GA.

RESULTS

Thirty eyes of 22 patients were included in the study. The mean yER was 0.2 ± 0.15 mm. The FD% in the first five rings (from 0 to 500 μm from the border of GA) was significantly correlated with the yER. However, there was no statistically significant correlation between the yER and CC FD% beyond 500 μm from the GA lesion.

CONCLUSIONS

Only the choriocapillaris FD% in the 500-μm region immediately surrounding GA lesions appears to predict the rate of enlargement of these lesions.

Long-term outcomes of switching to aflibercept for treatment-resistant neovascular age-related macular degeneration

PURPOSE

To report 4-year outcomes following the switch to aflibercept in treatment-resistant neovascular age-related macular degeneration (nAMD).

METHODS

In this prospective, open-label, non-controlled, clinical trial, 49 patients with treatment-resistant nAMD received 2 mg intravitreal aflibercept as three loading doses every 4 weeks, followed by injections every 8 weeks for the first 48 weeks, then an individualized regimen for a further 36 months, following previous treatment with ranibizumab and/or bevacizumab. Outcome measures included best-corrected visual acuity (BCVA), central retinal thickness (CRT), pigment epithelial detachment (PED) height and geographic atrophy (GA) surface area.

RESULTS

Of the 49 patients who were initially recruited, data from 39 eyes of 39 patients were available at 48-month follow-up. Mean age was 76.7 ± 7.2 years. Over the 48 months, these eyes received a mean of 32.1 ± 5.6 injections. The mean BCVA improved significantly following 12 months of treatment (4.9 ± 9.0 ETDRS letters, p < 0.001); however, this was not maintained and was similar to baseline after 48 months (mean difference -0.4 ± 13.3 letters between baseline and 48 months, p < 0.001). The reduction in CRT from baseline was 170.3 ± 143.3 μm (p < 0.001) with absence of macular fluid in 56% of the 39 eyes at the end of month 48. PED height reduced by a mean 77.5 ± 20.0 μm, and geographic atrophy increased by a mean of 4.1 ± 3.4 mm² (p < 0.01) over the 48 months.

CONCLUSION

Aflibercept is an effective alternative therapy for treatment-resistant nAMD. Good anatomical and stable functional responses are achievable with continued therapy. The lack of continued visual improvement may be representative of GA progression, reflecting the progression of late-stage nAMD in these patients.

Characterization of Patients With Geographic Atrophy in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

Geographic atrophy (GA) affects millions of patients with age-related macular degeneration (AMD) worldwide, leading to significant, irreversible visual impairment. This study aims to characterize the visual impairment of patients with GA in a routine clinical practice.

PATIENTS AND METHODS

This single-center, cross-sectional study used a novel natural language processing to select 1,045 GA cases utilizing the macula examination records from 19,359 patients with AMD.

RESULTS

Patients were classified based on the diagnosis of the fellow-eye as follow: 502 in group 1 (GA:GA), 403 in group 2 (GA : choroidal neovascularization), and 234 in group 3 (GA : early / intermediate AMD). Best-corrected visual acuity (BCVA) in the affected eye was 50.3 (± 22.1) letters in group 1, 52.5 (± 21.3) letters in group 2, and 48.5 (± 23.6) letters in group 3 (P < .05). Visual impairment (ineligibility for an unrestricted driver license) was present in 70.5% of group 1, 59.7% of group 2, and 39.6% of group 3. Legal blindness (BCVA < 20 letters in the best-seeing eye) was seen in 2.2% of group 1, 3% of group 2, and 0.8% of group 3.

CONCLUSION

Differences in visual impairment between subgroups of patients with GA can be seen in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:93-98.].

Microperimetry for geographic atrophy secondary to age-related macular degeneration

Geographic atrophy (GA) is a progressive, advanced form of age-related macular degeneration leading to visual function impairment and irreversible vision loss. Standard clinical tests to evaluate visual function in patients with GA provide poor anatomic-functional correlation, whereas fundus imaging does not assess the visual function deficit. Microperimetry is a psychophysical visual function test that spatially maps retinal sensitivity and allows for identification of correlation of anatomic features with visual function. In this review, we present an overview of mesopic microperimetry for GA, including commercially available microperimetry devices, strategies to capture a mesopic microperimetry test, and strategies to assess and interpret microperimetry data in patients with GA. We demonstrate the importance of microperimetry data for assessing GA progression and for evaluating visual function loss through anatomic-functional correlations. Although valuable, current microperimetry tests require an extensive time commitment from the patient and examiner, and the development of faster, more reproducible and accessible methods is important to enable broader use of microperimetry in both clinical and research settings.

Fellow Eye Status Is a Biomarker for the Progression Rate of Geographic Atrophy: A Systematic Review and Meta-analysis

TOPIC

Systematic review and meta-analysis of how fellow eye status predicts the progression rate of geographic atrophy (GA).

CLINICAL RELEVANCE

The status of age-related macular degeneration (AMD) in the fellow eye has been used as an indicator of the GA progression rates in primary eyes, but the reported growth rates vary widely in prior clinical studies.

METHODS

We searched MEDLINE, EMBASE, Cochrane Library, Clinicaltrials.gov, and PubMed up to September 12, 2018, for studies that classified treatment-naive GA patients based on different AMD manifestations in the fellow eyes and that monitored GA progression in the primary eyes. Three fellow eye statuses were analyzed: (1) no GA or choroidal neovascularization (CNV) in the fellow eye, (2) GA in the fellow eye, and (3) CNV in the fellow eye. To account for the patients' different entry times, we introduced a horizontal translation factor to shift each dataset within each group. We determined the translation factor by adjusting it 1 month at a time until the r² in weighted least squares regression (r²_WLS) was maximized for the cumulative linear trend line of all datasets. Heterogeneity and study quality were assessed using the I² statistic and Newcastle-Ottawa scale, respectively. Publication bias was evaluated by funnel plots, the Egger test, and the Begg test.

RESULTS

We included 9 studies with 2134 eyes from 1835 patients. After the introduction of translation factors, the datasets in each fellow eye group fit along a straight line with a high r²_WLS. The GA radius growth rate in fellow eyes with GA (0.179±0.003 mm/year) and fellow eyes with CNV (0.159±0.015 mm/year) was significantly higher than that in fellow eyes without GA or CNV (0.110±0.009 mm/year; P < 0.001 and P = 0.02, respectively). We found no significant difference in the GA radius growth rates between fellow eyes with GA and fellow eyes with CNV (P = 0.42).

CONCLUSIONS

We confirmed that the presence of advanced AMD in the fellow eye, defined as GA or CNV, can serve as a biomarker of the GA enlargement rate in the primary eye. This may assist the design of clinical trials and may shed light on the natural history of GA expansion.

The Progression of Geographic Atrophy Secondary to Age-Related Macular Degeneration

Geographic atrophy (GA) is an advanced form of age-related macular degeneration (AMD) that leads to progressive and irreversible loss of visual function. Geographic atrophy is defined by the presence of sharply demarcated atrophic lesions of the outer retina, resulting from loss of photoreceptors, retinal pigment epithelium (RPE), and underlying choriocapillaris. These lesions typically appear first in the perifoveal macula, initially sparing the foveal center, and over time often expand and coalesce to include the fovea. Although the kinetics of GA progression are highly variable among individual patients, a growing body of evidence suggests that specific characteristics may be important in predicting disease progression and outcomes. This review synthesizes current understanding of GA progression in AMD and the factors known or postulated to be relevant to GA lesion enlargement, including both affected and fellow eye characteristics. In addition, the roles of genetic, environmental, and demographic factors in GA lesion enlargement are discussed. Overall, GA progression rates reported in the literature for total study populations range from 0.53 to 2.6 mm²/year (median, ∼1.78 mm²/year), assessed primarily by color fundus photography or fundus autofluorescence (FAF) imaging. Several factors that could inform an individual's disease prognosis have been replicated in multiple cohorts: baseline lesion size, lesion location, multifocality, FAF patterns, and fellow eye status. Because best-corrected visual acuity does not correspond directly to GA lesion enlargement due to possible foveal sparing, alternative assessments are being explored to capture the relationship between anatomic progression and visual function decline, including microperimetry, low-luminance visual acuity, reading speed assessments, and patient-reported outcomes. Understanding GA progression and its individual variability is critical in the design of clinical studies, in the interpretation and application of clinical trial results, and for counseling patients on how disease progression may affect their individual prognosis.

Fundus Autofluorescence in Age-related Macular Degeneration

: Fundus autofluorescence (FAF) provides detailed insight into the health of the retinal pigment epithelium (RPE). This is highly valuable in age-related macular degeneration (AMD) as RPE damage is a hallmark of the disease. The purpose of this paper is to critically appraise current clinical descriptions regarding the appearance of AMD using FAF and to integrate these findings into a chair-side reference. A wide variety of FAF patterns have been described in AMD, which is consistent with the clinical heterogeneity of the disease. In particular, FAF imaging in early to intermediate AMD has the capacity to reveal RPE alterations in areas that appear normal on funduscopy, which aids in the stratification of cases and may have visually significant prognostic implications. It can assist in differential diagnoses and also represents a reliable, sensitive method for distinguishing reticular pseudodrusen. FAF is especially valuable in the detection, evaluation, and monitoring of geographic atrophy and has been used as an endpoint in clinical trials. In neovascular AMD, FAF reveals distinct patterns of classic choroidal neovascularization noninvasively and may be especially useful for determining which eyes are likely to benefit from therapeutic intervention. FAF represents a rapid, effective, noninvasive imaging method that has been underutilized, and incorporation into the routine assessment of AMD cases should be considered. However, the practicing clinician should also be aware of the limitations of the modality, such as in the detection of foveal involvement and in the distinction of phenotypes (hypo-autofluorescent drusen from small areas of geographic atrophy).

Recent developments in age-related macular degeneration: a review

Background

Visual impairment in elderly people is a considerable health problem that significantly affects quality of life of millions worldwide. The magnitude of this issue is becoming more evident with an aging population and an increasing number of older individuals.

Objective

The objective of this article was to review the clinical and pathological aspects of age-related macular degeneration (AMD), diagnostic tools, and therapeutic modalities presently available or underway for both atrophic and wet forms of the disease.

Methods

An online review of the PubMed database was performed, searching for the key words. The search was limited to articles published since 1980 to date.

Results

Several risk factors have been linked to AMD, such as age (>60 years), lifestyle (smoking and diet), and family history. Although the pathogenesis of AMD remains unclear, genetic factors have been implicated in the condition. Treatment for atrophic AMD is mainly close observation, coupled with nutritional supplements such as zinc and antioxidants, whereas treatment of wet AMD is based on targeting choroidal neovascular membranes.

Conclusion

Identification of modifiable risk factors would improve the possibilities of preventing the progression of AMD. The role of anti-vascular endothelial growth factor (anti-VEGF) agents has transformed the therapeutic approach of the potentially blinding disease “wet AMD” into a more favorable outcome.

Analysing the Progression Rates of Macular Lesions with Autofluorescence Imaging Modes in Dry Age-Related Macular Degeneration

OBJECTIVES

In this study we aimed to compare the sensitivity of blue-light fundus autofluorescence (FAF) and near-infrared autofluorescence (NI-AF) imaging for determining the progression rates of macular lesions in dry age-related macular degeneration (AMD).

MATERIALS AND METHODS

The study was designed retrospectively and included patients diagnosed with intermediate and advanced stage dry AMD. Best corrected visual acuities and FAF and NI-AF images were recorded in 46 eyes of 33 patients. Lesion borders were drawn manually on the images using Heidelberg Eye Explorer software and lesion areas were calculated using Microsoft Excel software. BCVA and lesion areas were compared with each other.

RESULTS

Patients' mean follow-up time was 30.98±13.30 months. The lesion area progression rates were 0.85±0.93 mm2/y in FAF and 0.93±1.01 mm2/y in NI-AF, showing statistically significant correlation with each other (r=0.883; p<0.01). Both imaging methods are moderately correlated with visual acuity impairment (r=0.362; p<0.05 and r=0.311; p<0.05, respectively). In addition, larger lesions showed higher progression rates than smaller ones in both imaging methods.

CONCLUSION

NI-AF imaging is as important and effective as FAF imaging for follow-up of dry AMD patients.

Geographic atrophy in patients with advanced dry age-related macular degeneration: current challenges and future prospects

Geographic atrophy (GA) of the retinal pigment epithelium (RPE) is a devastating complication of age-related macular degeneration (AMD). GA may be classified as drusen-related (drusen-associated GA) or neovascularization-related (neovascular-associated GA). Drusen-related GA remains a large public health concern due to the burden of blindness it produces, but pathophysiology of the condition is obscure and there are no proven treatment options. Genotyping, cell biology, and clinical imaging point to upregulation of parainflammatory pathways, oxidative stress, and choroidal sclerosis as contributors, among other factors. Onset and monitoring of progression is accomplished through clinical imaging instrumentation such as optical coherence tomography, photography, and autofluorescence, which are the tools most helpful in determining end points for clinical trials at present. A number of treatment approaches with diverse targets are in development at this time, some of which are in human clinical trials. Neovascular-associated GA is a consequence of RPE loss after development of neovascular AMD. The neovascular process leads to a plethora of cellular stresses such as ischemia, inflammation, and dramatic changes in cell environment that further taxes RPE cells already dysfunctional from drusen-associated changes. GA may therefore develop secondary to the neovascular process de novo or preexisting drusen-associated GA may continue to worsen with the development of neovascular AMD. Neovascular-associated GA is a prominent cause of continued vision loss in patients with otherwise successfully treated neovascular AMD. Clearly, treatment with vascular endothelial growth factor (VEGF) inhibitors early in the course of the neovascular disease is of great clinical benefit. However, there is a rationale and some suggestive evidence that anti-VEGF agents themselves could be toxic to RPE and enhance neovascular-associated GA. The increasing prevalence of legal blindness from this condition due to the aging of the general population lends urgency to the search for a therapy to ameliorate GA.

Prognostic implications of imaging in atrophic macular degeneration and its use in clinical practice and clinical trial design

Clinical prognostic markers in atrophic age-related macular degeneration include the extent of existing atrophy, fundus autofluorescence (FAF) patterns and optical coherence tomography changes in the outer retina/retinal pigment epithelium interface. The prognostic implications of these findings may be used to determine not just the rate of disease progression but also influence the likelihood, magnitude and clinical relevance of therapy responses. FAF phenotypes have been extensively investigated; however, the pathophysiological mechanisms behind their appearance have not been fully elucidated. Optical coherence tomography imaging is additive to FAF imaging in atrophic age-related macular degeneration, allowing the visualization of detail not available through FAF imaging whilst also displaying subtle changes correlating with the FAF phenotypes themselves, thereby giving clues to their histological determinates. The developing understanding of these imaging modalities and consequent development of prognostically useful classification systems have widespread implication in clinical care and clinical trial design.