Geographic Atrophy and Activity of Neovascularization in Retinal Angiomatous Proliferation

Macular Atrophy in Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis

TOPIC

Macular atrophy incidence in neovascular age-related macular degeneration (AMD) patients undergoing anti-vascular endothelial growth factor (VEGF) treatment.

CLINICAL RELEVANCE

Macular atrophy is a significant event that may occur in eyes with neovascular AMD treated with anti-VEGF therapy.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines (PROSPERO, CRD42024474924). A comprehensive literature search of MEDLINE, EMBASE, and Web of Science was performed up to November 1, 2023. Randomized and non-randomized studies of treatment-naïve neovascular AMD patients reporting macular atrophy incidence at 24±3 months after anti-VEGF therapy were eligible for inclusion in this review. Two independent reviewers conducted screening, data extraction, and quality assessment. For randomized controlled trials, the Cochrane Risk of Bias 2 tool was employed, while non-randomized studies were evaluated using the ROBINS-I tool. Random-effects meta-analysis models were used for quantitative synthesis, accounting for study variability. Heterogeneity was assessed with the I2 statistic, and publication bias by funnel plots and Egger's test. The primary outcome was the incidence of new macular atrophy at 24 months post-anti-VEGF therapy, with secondary outcomes at 12 months. Atrophy was diagnosed using color fundus photograph (CFP), fluorescein angiography (FA), fundus autofluorescence (FAF), optical coherence tomography (OCT), or multimodal imaging.

RESULTS

Twenty-three studies met the inclusion criteria for qualitative analysis, with 11 included in the meta-analysis (N=3,013 eyes). The pooled 24-month incidence of macular atrophy was 29% (95% confidence interval [CI]:20%-38%,I2=93%). Subgroup analysis revealed incidence rates of 26% (95% CI:15%-37%,I2=88%) for 814 eyes with Type 1/2 macular neovascularization (MNV), 49% (95% CI:18%-80%,I2=92%) for Type 3 MNV (N=230 eyes), and 29% (95% CI:18%-40%,I2=96%) for all MNV types (N=2,131 eyes). The pooled 12-month incidence among 2,214 eyes was 11% (95% CI:4%-18%,I2=93%). The certainty of evidence regarding the incidence of macular atrophy after anti-VEGF treatment, as assessed by GRADE, was low.

CONCLUSIONS

While this meta-analysis has limitations, including a moderate risk of bias in non-randomized studies, inconsistencies in the results indicated by high heterogeneity, and imprecision due to the different imaging modalities used to diagnose macular atrophy, our results suggest that macular atrophy could be a common complication in neovascular AMD patients receiving anti-VEGF therapy.

Long term follow up of patients with MNV3 treated with intra-vitreal Aflibercept

PURPOSE

MNV3 or Retinal angiomatous proliferation is a subtype of neovascular age-related macular degeneration (nAMD). We present the 5 year long term visual and anatomical outcomes of patients with MNV3 lesions treated with intravitreal Aflibercept.

METHODS

This is a prospective study of treatment naïve patients with reading centre graded MNV3 lesions. After the loading phase, the patients received intravitreal Aflibercept as per the View study up to year 3, thereafter it was given on a prn basis. At each visit, best corrected visual acuity (BCVA) and optical coherence tomography (OCT) central macular thickness (CMT) was measured.

RESULTS

Thirty one patients reached study completion. Mean BCVA of treated eyes had decreased by 0.6 ETDRS letters at the end of year 5 compared with baseline. At study completion, 81% of eyes had stable vision while 19% of eyes had gained 15 letters or more. At study end, 26% of eyes had BCVA of 6/12 or better, while 19% had lost 15 letters or more (all had central foveal photoreceptor loss). There was a maximal mean reduction in CMT of 164 microns (p = <0.0001) while 68% of maculae were fluid free at study completion. Eighty seven percent of treated eyes developed nascent GA, of which in 74% of eyes was involving the fovea.

DISCUSSION

Despite initial improvement in mean BCVA, the improvement in BCVA was not maintained despite good overall control of the MNV3 lesions. The loss of BCVA was most likely due to the majority of eyes developing centre involving macular atrophy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CHARACTERISTICS PREDICTIVE OF FELLOW-EYE GEOGRAPHIC ATROPHY WITHOUT NEOVASCULARIZATION IN UNILATERAL TYPE 3 MACULAR NEOVASCULARIZATION

PURPOSE

To evaluate the predictive characteristics of fellow-eye geographic atrophy (GA) without neovascularization in patients with unilateral Type 3 macular neovascularization.

METHODS

This retrospective study included 84 patients who were diagnosed with unilateral Type 3 macular neovascularization. Patients who developed fellow-eye neovascularization and those exhibiting GA without neovascularization at the final follow-up were included in the neovascularization and GA groups, respectively. The patient demographics and baseline fellow-eye characteristics were compared between the two groups.

RESULTS

The mean follow-up period was 40.5 ± 11.5 months after diagnosis. Patients included in the GA group (n = 28) were significantly older (mean 77.4 ± 5.2 years vs. 74.2 ± 5.8 years, P = 0.016), had significantly thinner subfoveal choroidal thickness (mean 109.4 ± 36.8 µ m vs. 173.1 ± 77.6 µ m, P < 0.001), and had a significantly higher incidence of baseline GA (39.3% vs. 16.1%, P = 0.019) than those included in the neovascularization group (n = 56). In the multivariate analysis, subfoveal choroidal thickness showed a close negative association with the risk of GA rather than neovascularization ( P = 0.004, β = 0.982, 95% confidence interval = 0.970-0.994).

CONCLUSION

In patients with unilateral Type 3 macular neovascularization, older age, the presence of GA, and a thin choroid in the fellow eye were found to be indicative of a higher probability of progression toward fellow-eye GA instead of neovascularization may be potential candidates for future complement inhibitor treatments targeting fellow-eye GA.

Distinct Pathways of Macular Atrophy in Type 3 Macular Neovascularization Associated With AMD

Purpose

To explore the occurrence of macular atrophy (MA) in eyes with age-related macular degeneration (AMD)-associated Type 3 macular neovascularization (MNV) treated with anti-vascular endothelial growth factor (anti-VEGF) therapy. Importantly, we aimed at describing the existence of separate pathways leading to MA.

Methods

We analyzed 41 participants (41 eyes) with treatment-naïve Type 3 MNV who were followed up for a duration of 12 months after beginning the anti-VEGF therapy. At the one-year follow-up visit, optical coherence tomography (OCT) scans were reviewed for the presence of MA. MA regions of interest (ROIs) were selected and traced back to their original dominant baseline lesion (i.e., precursor) through previous serially captured OCT scans. Baseline lesions included precursors associated with the development and exudation of MNV and causes external to the neovascularization itself.

Results

At the one-year follow-up visit, MA was graded to be present in 38 (92.7%) out of 41 eyes. These 78 MA ROIs were divided into two subgroups according to the precursor lesion, yielding a group of 53 MA lesions with precursors associated with the development and exudation of MNV (i.e., MA caused by physical harm from Type 3 neovessels, collapse of a serous pigment epithelium detachment, and fibrosis) and 25 MA regions with precursors external to the neovascularization itself (i.e., MA caused by drusen or subretinal drusenoid deposits).

Conclusions

Eyes with Type 3 MNV are commonly complicated by MA and precursors of MA include causes associated with the development and exudation of MNV, as well as lesions unrelated to the neovascularization process itself.

INCIDENCE AND TIMING OF PIGMENT EPITHELIAL DETACHMENT AND SUBRETINAL FLUID DEVELOPMENT IN TYPE 3 MACULAR NEOVASCULARIZATION ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION

PURPOSE

To evaluate the incidence and timing of pigment epithelial detachment (PED) and subretinal fluid (SRF) development in type 3 macular neovascularization.

METHODS

This retrospective study included 84 patients who were diagnosed with treatment-naïve type 3 macular neovascularization who did not show SRF at diagnosis. All patients were initially treated with three loading injections of ranibizumab or aflibercept. After the initial loading injections, as-needed regimen was performed for retreatment. The development of either PED or SRF was identified. The incidence and timing of PED development in patients without PED at diagnosis and that of SRF development in patients with PED at diagnosis were evaluated.

RESULTS

The mean follow-up period was 41.3 ± 20.7 months after diagnosis. Among the 32 patients without serous PED at diagnosis, PED developed in 20 (62.5%) at a mean of 10.9 ± 5.1 months after diagnosis. PED development was noted within 12 months in 15 patients (46.8%; 75.0% among the PED development cases). In 52 patients with serous PED and without SRF at diagnosis, 15 developed SRF (28.8%) at a mean of 11.2 ± 6.4 months after diagnosis. SRF development was noted within 12 months in nine patients (17.3%; 66.6% among the SRF development cases).

CONCLUSION

PED and SRF developed in a substantial proportion of patients with type 3 macular neovascularization. The average period of development of these pathologic findings was within 12 months of diagnosis, suggesting the need for active treatment during the early treatment period to improve treatment outcomes.

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

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

Characterisation of macular neovascularisation subtypes in age-related macular degeneration to optimise treatment outcomes

The aim of this review is to identify the common characteristics and prognoses of different subtypes of neovascular age-related macular degeneration (nAMD). We also propose recommendations on how to tailor treatments to the subtype of neovessels to optimise patient outcomes. The authors, selected members of the Vision Academy, met to discuss treatment outcomes in nAMD according to macular neovascularisation (MNV) subtypes, using evidence from a literature search conducted on the PubMed database (cut-off date: March 2019). This review article summarises the recommendations of the Vision Academy on how the characterisation of MNV subtypes can optimise treatment outcomes in nAMD. The identification of MNV subtypes has been facilitated by the advent of multimodal imaging. Findings from fluorescein angiography, indocyanine green angiography and spectral-domain optical coherence tomography collectively help refine and standardise the determination of the MNV subtype. To date, three subtypes have been described in the literature and have specific characteristics, as identified by imaging. Type 1 MNV is associated with better long-term outcomes but usually requires more intense anti-vascular endothelial growth factor dosing. Type 2 MNV typically responds quickly to treatment but is more prone to the development of fibrotic scars, which may be associated with poorer outcomes. Type 3 MNV tends to be highly sensitive to anti-vascular endothelial growth factor treatment but may be associated with a higher incidence of outer retinal atrophy, compared with other subtypes. Accurately assessing the MNV subtype provides information on prognosis and helps to optimise the management of patients with nAMD.

Clinical features associated with the atrophy of fellow eyes in patients with unilateral type 3 macular neovascularization

PURPOSE

We sought to investigate the clinical features of eyes with unilateral type 3 macular neovascularization (MNV) according to the degenerative features of fellow eyes.

METHODS

We retrospectively reviewed 55 patients with unilateral type 3 MNV and identified degenerative features including geographic atrophy (GA) in fellow eyes using multimodal imaging. Then, the clinical features of eyes with type 3 MNV at baseline and during follow-up with anti-vascular endothelial growth factor treatment and an as-needed regimen were compared according to the degenerative features of fellow eyes.

RESULTS

Eighteen patients (32.7%) had GA in fellow eyes; initial disease manifestations of type 3 MNV eyes including stage, best-corrected visual acuity, and choroidal thickness (CT) did not vary between groups (all P > 0.05). During follow-up, a rate of complete fluid resolution after three monthly loading injections was not associated with GA in fellow eyes (P = 0.703), while a lower rate of early recurrence within 3 months after loading treatment was associated with thinner CT in type 3 MNV eyes and GA over one disc area in fellow eyes (P = 0.025 and P = 0.021).

CONCLUSION

Degenerative features of fellow eyes in patients with unilateral type 3 MNV may be associated with the clinical characteristics of affected eyes.

Chorioretinal thickness and retinal pigment epithelial degeneration of fellow eyes in patients with unilateral neovascular age-related macular degeneration with subretinal drusenoid deposits

Background

We sought to investigate the chorioretinal thickness and retinal pigment epithelial (RPE) degenerative features of eyes with early age-related macular degeneration (AMD) and subretinal drusenoid deposits (SDDs) according to the presence of macular neovascularization (MNV) in the fellow eyes.

Methods

We classified 70 eyes into two groups of 47 eyes with non-neovascular AMD and 23 eyes with neovascular AMD, respectively, according to the presence of MNV in the fellow eyes. The mean macular retinal, ganglion cell–inner plexiform layer (GCIPL), and choroidal thickness values and RPE features of the 6-mm-diameter zone were compared. RPE degeneration was defined as a lesion with an incomplete RPE and outer retinal atrophy (iRORA) or attenuated RPE reflectivity with diffuse basal laminar deposits, which was defined as when the eye showed an attenuated RPE line with granular features and mixed reflectivity in combination with sub-RPE deposits with a lesion ≥ 1,000 µm in length.

Results

Mean retinal, GCIPL, and choroidal thickness values (286.69 ± 15.02 µm, 64.36 ± 4.21 µm, and 156.11 ± 33.10 µm) of the neovascular AMD group were greater than those (278.61 ± 13.96 µm, 61.44 ± 4.63 µm, and 133.59 ± 34.33 µm) of the non-neovascular AMD group (all P < 0.05). RPE degeneration was more prevalent in the neovascular AMD group (65.2%) than the non-neovascular AMD group (38.3%; P = 0.034). Greater mean GCIPL and choroidal thickness values and the presence of RPE degeneration were associated with type 3 MNV in fellow eyes (all P < 0.05).

Conclusions

Different degenerative features according to MNV in fellow eyes of patients with AMD and SDDs suggest that variable degenerative features might be present during disease progression and have an association with the phenotype.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02518-4.

LONG-TERM COURSE AND VISUAL OUTCOMES OF PRECHOROIDAL CLEFT IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AND POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To evaluate the regression of prechoroidal cleft, its influence on visual outcomes, and differences in visual outcomes between neovascular age-related macular degeneration and polypoidal choroidal vasculopathy.

METHODS

This retrospective study included 61 patients exhibiting prechoroidal cleft who were treated with antivascular endothelial growth factors. The patients were divided into two groups according to the following categories: 1) regression of prechoroidal cleft: regression group versus nonregression group and 2) type of neovascularization: neovascular age-related macular degeneration group versus polypoidal choroidal vasculopathy group. Changes in the visual acuity during the follow-up period were also compared between the two groups.

RESULTS

During the 52.4 ± 17.4-month follow-up period, regression of prechoroidal cleft was noted in 17 patients (27.9%) at a mean of 25.7 ± 18.3 months after the first identification. The degree of the logarithm of the minimum angle of resolution of visual deterioration was greater in the nonregression group (0.59 ± 0.56, n = 17) than that in the regression group (0.25 ± 0.61, n = 44) (P = 0.007) and in the neovascular age-related macular degeneration group (0.56 ± 0.61, n = 51) than that in the polypoidal choroidal vasculopathy group (0.18 ± 0.33, n = 10) (P = 0.034).

CONCLUSION

Approximately 27.9% of prechoroidal cleft cases eventually regressed, in conjunction with relatively favorable visual outcomes. Considering the poor visual prognosis in neovascular age-related macular degeneration accompanied by prechoroidal cleft, more caution is required for this condition.

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

PURPOSE

Geographic atrophy (GA) is a complication of advanced neovascular age-related macular degeneration that can lead to permanent vision loss. We sought to estimate the incidence and progression of GA after intravitreal injections of antivascular endothelial growth factor agents in eyes with neovascular age-related macular degeneration.

METHODS

Ovid MEDLINE, EMBASE, and Cochrane CENTRAL were searched from inception to May 2020. Included studies reported on the progression or development of GA in eyes with neovascular age-related macular degeneration after antivascular endothelial growth factor therapy.

RESULTS

Thirty-one articles and 4,609 study eyes (4,501 patients) were included. Eyes received a mean of 17.7 injections over 35.2 months. The prevalence of GA at baseline was 9.7%. The pooled incidence of GA was 30.5% at the end of follow-up. There was a positive, moderate linear correlation between the mean total number of injections and GA incidence at the final follow-up (R2 = 0.30; P = 0.01). Monthly treatment was associated with a significantly higher risk for GA development relative to pro re nata (relative risk = 1.40, 95% confidence interval = [1.21-1.61], P < 0.001). Risk factors for GA development included GA in the fellow eye, retinal angiomatous proliferation, drusen, and reticular pseudodrusen.

CONCLUSION

We found an association between the frequency and number of treatments with antivascular endothelial growth factor agents and the development of GA in neovascular age-related macular degeneration. Future studies should clarify risk factors, population characteristics, and relative contributions of treatment and disease progression on GA development in this context.

The Development of Macular Atrophy in Patients with Wet Age-Related Macular Degeneration Receiving Anti-VEGF Treatment

Age-related macular degeneration (AMD) is a leading cause of blindness. Late AMD can be classified into exudative (commonly known as wet AMD [wAMD]) or dry AMD, both of which may progress to macular atrophy (MA). MA causes irreversible vision loss and currently has no approved pharmacological treatment. The standard of care for wAMD is treatment with anti-vascular endothelial growth factors (VEGF). However, recent evidence suggests that anti-VEGF treatment may play a role in the development of MA. Therefore, it is important to identify risk factors for the development of MA in patients with wAMD. For example, excessive blockade of VEGF through intense use of anti-VEGF agents may accelerate the development of MA. Patients with type III macular neovascularisation (retinal angiomatous proliferation) have a particularly high risk of MA. These patients are characterised as having a pre-existing thin choroid (age-related choroidopathy), suggesting that the choroidal circulation is unable to respond to increased VEGF expression. Evidence suggests that subretinal fluid (possibly indicative of residual VEGF activity) may play a protective role. Patients receiving anti-VEGF agents must be assessed for overall risk of MA and there is an unmet medical need to prevent the development of MA without undertreating wAMD.

Five-Year Reactivation After Ranibizumab or Aflibercept Treatment for Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

Purpose: To evaluate 5-year reactivation after ranibizumab or aflibercept treatment for neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). Methods: This retrospective study included 192 patients (192 eyes) who had been diagnosed with neovascular AMD or PCV and treated with ranibizumab or aflibercept. The incidence and timing of lesion reactivation during the 5-year follow-up period were evaluated, and the factors associated with reactivation were also investigated. Results: During the follow-up period, lesion reactivation was noted in 156 patients (81.3%) at a mean of 9.5 ± 10.5 months after the third antivascular endothelial growth factor injection. The incidence of reactivation was 59.9% during the first 12 months, 33.7% during ≥12 and <24 months, 11.8% during >24 and ≤36 months, 15.5% during >36 and ≤48 months, and 5.3% during >48 and ≤60 months. There was a significant difference in the incidence among the 5 periods (P < 0.001). The proportion of PCV was significantly higher in patients experiencing reactivation (51.9%) than in those who did not (30.6%) (P = 0.021). Conclusions: During the 5-year follow-up, lesion reactivation was noted in approximately four-fifths of the patients. The incidence of lesion reactivation was highest during the first 12 months and decreased thereafter. The incidence was higher in patients with PCV than in those with neovascular AMD, especially after 12 months.

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

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

Investigation of the Trend of Selecting Anti-Vascular Endothelial Growth Factor Agents for the Initial Treatment of Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

BACKGROUND: This study aimed to investigate the trend of selecting ranibizumab and aflibercept for the initial treatment of neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). METHODS: This was a retrospective study that included 460 patients who were diagnosed with treatment-naïve neovascular AMD and PCV and were initially treated with either ranibizumab or aflibercept. The patients were divided into two groups: the ranibizumab group (n = 96) and the aflibercept group (n = 324). The patients’ characteristics and the proportion of the subtypes of macular neovascularization (MNV) were compared between the two groups. RESULTS: Patients in the ranibizumab group were significantly older (mean 74.3 ± 8.4 years) than those in the aflibercept group (mean 70.4 ± 8.8 years; p < 0.001). In the ranibizumab group, the proportions of type 1 or 2 MNV, type 3 MNV, and PCV were 50.0%, 27.1%, and 22.9%, respectively. In the aflibercept group, the proportions were 35.2%, 6.8%, and 58.0%, respectively. There was a significant difference in the proportion of MNV subtypes between the ranibizumab and aflibercept groups (p < 0.001). Ranibizumab was used in 54.2% of patients with type 3 MNVs. However, in patients with PCV, aflibercept was used in 89.5% of patients. CONCLUSIONS: Ranibizumab was preferred as an initial treatment agent in older patients and those with type 3 MNV, whereas aflibercept was highly preferred in patients with PCV. The different characteristics and efficacy of the two agents may have partially contributed to this trend.

VEGF Mediates Retinal Müller Cell Viability and Neuroprotection through BDNF in Diabetes

To investigate the mechanism of vascular endothelial growth factor (VEGF) and brain-derived neurotrophic factor (BDNF) in Müller cell (MC) viability and neuroprotection in diabetic retinopathy (DR), we examined the role of VEGF in MC viability and BDNF production, and the effect of BDNF on MC viability under diabetic conditions. Mouse primary MCs and cells of a rat MC line, rMC1, were used in investigating MC viability and BDNF production under diabetic conditions. VEGF-stimulated BDNF production was confirmed in mice. The mechanism of BDNF-mediated MC viability was examined using siRNA knockdown. Under diabetic conditions, recombinant VEGF (rVEGF) stimulated MC viability and BDNF production in a dose-dependent manner. rBDNF also supported MC viability in a dose-dependent manner. Targeting BDNF receptor tropomyosin receptor kinase B (TRK-B) with siRNA knockdown substantially downregulated the activated (phosphorylated) form of serine/threonine-specific protein kinase (AKT) and extracellular signal-regulated kinase (ERK), classical survival and proliferation mediators. Finally, the loss of MC viability in TrkB siRNA transfected cells under diabetic conditions was rescued by rBDNF. Our results provide direct evidence that VEGF is a positive regulator for BDNF production in diabetes for the first time. This information is essential for developing BDNF-mediated neuroprotection in DR and hypoxic retinal diseases, and for improving anti-VEGF treatment for these blood-retina barrier disorders, in which VEGF is a major therapeutic target for vascular abnormalities.

Fluid as a critical biomarker in neovascular age-related macular degeneration management: literature review and consensus recommendations

Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.

Difference in treatment burden of neovascular age-related macular degeneration among different types of neovascularization

PURPOSE

To evaluate the difference in the treatment burden among different types of neovascular age-related macular degeneration (AMD).

METHODS

This retrospective, observational study included 431 patients who were diagnosed with neovascular AMD. Patients were divided into three groups: type 1 or 2 neovascularization group (n = 167), type 3 neovascularization group (n = 50), and polypoidal choroidal vasculopathy (PCV) group (n = 214). The number of hospital visits per year and the number of anti-vascular endothelial growth factor (VEGF) injections per year were compared among these groups. Furthermore, the incidence of bilateral involvement during the follow-up period was compared among the groups.

RESULTS

The mean follow-up period was 50.6 ± 11.3 months. The number of hospital visits per year was significantly higher in the type 1 or 2 neovascularization group (mean: 6.1 ± 1.5) and type 3 neovascularization (6.6 ± 1.6) than in the PCV group (6.0 ± 1.5) (P < 0.001). The number of anti-VEGF injections per year was significantly higher in type 3 neovascularization group (3.1 ± 1.7) than in the type 1 or 2 neovascularization group (2.3 ± 1.5) or the PCV group (2.3 ± 1.2) (P = 0.042). There was a significant difference in the incidence of bilateral involvement among patients in type 1 or 2 neovascularization group (20.4%), type 3 neovascularization group (46.0%), and the PCV group (15.4%) (P < 0.001).

CONCLUSIONS

The high frequency of hospital visits and that of anti-VEGF injections in patients with type 3 neovascularization suggests high treatment burden in these patients. The high incidence of bilateral involvement could be one of the primary reasons for high treatment burden in patients with type 3 neovascularization.

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

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

Predictive Factors And Long-Term Visual Outcomes After Anti-Vascular Endothelial Growth Factor Treatment Of Retinal Angiomatous Proliferation

Purpose

To report the results of 9-year follow-up examinations and predictive factors for visual acuity outcome after intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents to treat retinal angiomatous proliferation (RAP).

Methods

We conducted a retrospective observational study of 85 treatment-naïve eyes in 61 patients (21 men, 40 women; age range, 70-95 years; mean age, 84.0 years) treated with intravitreal injections of anti-VEGF agents. All patients received three consecutive monthly injections as an induction treatment. During the maintenance phase, the patients received intravitreal injections as needed or fixed dosing. The primary outcome measures were best-corrected visual acuity (BCVA) during the follow-up period. Furthermore, we investigated potential predictive factors of improvement in visual acuity. The proportion of patients who developed specific complications were also analyzed.

Results

The mean BCVA gradually decreased from 0.58 at baseline to 0.70 at 36 months (P = 0.146), 0.82 at 48 months (P = 0.004), and 0.92 at 108 months (P = 0.021). Improvement in visual acuity at the final visits was associated with baseline visual acuity and central foveal thickness. Massive subretinal hemorrhage, fibrotic scars, and macular atrophy developed in 4 (4.7%), 9 (10.6%), and 50 (56.8%) eyes, respectively, at the final visits, and were all significantly associated with final visual acuity (P = 0.013, P < 0.001, and P = 0.001, respectively).

Conclusion

Long-term stabilization of vision in patients with RAP, regardless of treatment modality, was difficult to achieve by using intravitreal injections of anti-VEGF agents. Earlier detection and treatment are important to maintain visual acuity in patients with RAP.

Focal retinal pigment epithelium atrophy at the location of type 3 neovascularization lesion: a morphologic feature associated with low reactivation rate and favorable prognosis

PURPOSE

To investigate the clinical significance of focal retinal pigment epithelium (RPE) atrophy in the eyes with type 3 neovascularization.

METHODS

This retrospective study included 184 eyes those were diagnosed with type 3 neovascularization and were treated with antivascular endothelial growth factor (VEGF) therapy. Focal RPE atrophy was defined as a localized RPE atrophy found at the same location as the type 3 lesion. The incidence of reactivation after 3 loading injections and the visual outcomes was compared between a focal RPE atrophy group and a nonfocal RPE atrophy group. In the focal RPE atrophy group, the number of injections was compared between before and after the development of RPE atrophy.

RESULTS

The mean follow-up period was 37.6 ± 18.8 months; focal RPE atrophy developed in 24 eyes (13.0%). Reactivation of the lesion after 3 loading injections was significantly less frequent in the focal RPE atrophy group (58.3%) than that in the nonfocal RPE atrophy group (85.0%) (P = 0.004). In the focal RPE atrophy group, the mean best-corrected visual acuity (BCVA) was 0.68 ± 0.28 (Snellen equivalent = 20/95) at diagnosis and 0.70 ± 0.48 (20/100) at the final follow-up. In the nonfocal RPE atrophy group, the values were 0.75 ± 0.34 (20/112) and 1.12 ± 0.68 (20/263), respectively. The BCVA at the final follow-up was significantly better in the focal RPE atrophy group (P < 0.001). The mean number of injections per year was 4.9 ± 1.8 and 1.3 ± 1.6 before and after the development of focal RPE atrophy, respectively (P < 0.001).

CONCLUSIONS

Development of focal RPE atrophy was associated with a low incidence of reactivation of type 3 neovascularization and was therefore predictive of a favorable visual prognosis.

LONG-TERM VISUAL CHANGES IN INITIALLY STRONGER FELLOW EYES IN PATIENTS WITH UNILATERAL TYPE 3 NEOVASCULARIZATION

PURPOSE

To evaluate long-term visual changes in initially stronger fellow eyes in patients with unilateral Type 3 neovascularization.

METHODS

This retrospective study included 102 patients who were newly diagnosed with unilateral Type 3 neovascularization and in whom the best-corrected visual acuity (BCVA) of the fellow eye was initially better than that of the involved eye. All patients were treated with intravitreal anti-vascular endothelial growth factor injections. The BCVAs were compared at diagnosis, 12 months, 24 months, and the final visit. In patients who experienced ≥3 lines of visual deterioration in the BCVA of the fellow eye, the reason for visual deterioration was also verified.

RESULTS

The patients were followed for 45.9 ± 18.5 months after diagnosis. At diagnosis, the fellow-eye BCVA was better than that of the initially involved eye in all 102 patients. However, the fellow-eye visual acuity was the same or worse than that of the initially involved eye in 13 patients (12.7%) at 12 months, in 20 patients (19.6%) at 24 months, and in 24 patients (23.5%) at the final visit. At the final visit, 53 patients (51.9%) had experienced ≥3 lines of deterioration in the BCVA of the fellow eye. Fellow-eye neovascularization occurred in 42 patients, and geographic atrophy involving the fovea was noted in the remaining 11 patients.

CONCLUSION

Deterioration of the visual acuity of the fellow eye is frequently noted in unilateral Type 3 neovascularization. As a result of this deterioration, the initially stronger fellow eye did not remain stronger in 23.5% of the patients, suggesting the need for long-term strict treatment of the initially involved eye even when the visual acuity of the fellow eye is good.

Incidence and Timing of the First Recurrence in Neovascular Age-Related Macular Degeneration: Comparison Between Ranibizumab and Aflibercept

PURPOSE

To compare the incidence and timing of first recurrence between patients who were treated with ranibizumab and aflibercept in neovascular age-related macular degeneration (AMD).

METHODS

This retrospective study included 120 patients who received the diagnosis of treatment-naive typical neovascular AMD or polypoidal choroidal vasculopathy (PCV) and were treated using either ranibizumab (n = 73) or aflibercept (n = 47). Recurrence within 10 months of the third injection was compared between the 2 treatment groups.

RESULTS

In all 120 patients, there was no difference in recurrence between the ranibizumab and the aflibecept groups (P = 0.846). One hundred five patients completed 12 months follow-up. In typical neovascular AMD, disease recurred in 69.6% (16/23) of patients in the ranibizumab group, with a mean period of 4.4 ± 1.8 months after the third injection. In the aflibercept group, the equivalent values were 68.8% (11/16) and 4.5 ± 1.4 months. In PCV, disease recurred in 72.5% (29/40) of patients in the ranibizumab group, with a mean period of 3.8 ± 1.7 months after the third injection. In the aflibercept group, the equivalent values were 69.2% (18/26) and 4.3 ± 2.0 months.

CONCLUSIONS

Although the incidence of recurrence was slightly higher and the duration between the third injection and the first recurrence was slightly shorter in patients treated using ranibizumab, the differences were not significant. Our results require confirmation in further studies.