Predictors of visual outcome in eyes with choroidal neovascularization secondary to age related macular degeneration treated with intravitreal bevacizumab monotherapy

Findings of uncertain significance by optical coherence tomography (OCT) as prognostic factors in neovascular age-related macular degeneration (nAMD) treated with ranibizumab

Background

Biomarkers hold great promise for personalized medicine as information gained from diagnostic or progression markers can be used to tailor treatment to the individual for highly effective intervention in the disease process.

Methods

The aim of this retrospective study was to evaluate the association between visual outcome and the presence of findings of uncertain significance by optical coherence tomography (OCT) pre and post loading dose in patients with neovascular age-related macular degeneration (nAMD) treated with ranibizumab.

Results

Univariate analysis revealed a higher letter gain in those with presence of onion sign (+ 5.6 ETDRS letters, p = 0.04) absence of prechoroidal cleft (+ 3.7 ETDRS letters, p = 0.04), intraretinal pseudocysts (+4.8 ETDRS letters, p = 0.002), subretinal pseudocysts (+ 4.6 ETDRS letters, p = 0.005) and choroidal caverns (+ 4.4 ETDRS, letters p = 0.0065).

Conclusions

The presence of prechoroidal cleft, intraretinal and subretinal pseudocysts and choroidal caverns were associated with lower visual gains. Moreover, we found that the onion sign is related as a biomarker of good prognostics.

Trial registration Registration number: 2021R13B2. Date of registration: 01/05/2020

Baseline Optical Coherence Tomography Parameters That May Influence 6 Months Treatment Outcome of Polypoidal Choroidal Vasculopathy Eyes with Combination Therapy: A Short-Term Pilot Study

Although optical coherence tomography (OCT) parameters have assisted in the diagnosis of polypoidal choroidal vasculopathy (PCV), its potential to evaluate treatment outcomes has not been established. The purpose of this pilot study was to evaluate baseline OCT parameters that may influence treatment outcome in PCV eyes with combination therapy. In this single-centered, prospective study, patients were recruited with at least one treatment-naïve PCV eye and treated with combination therapy of intravitreal anti-vascular endothelial growth factor and photodynamic therapy. Best-corrected distance and near visual acuity (DVA and NVA), and contrast sensitivity (CS) were recorded at baseline and six months after treatment. OCT parameters were determined. Twenty-six eyes of 26 patients aged between 51 to 83 years were evaluated. In eyes that had disrupted external limiting membrane (ELM), photoreceptors inner and outer segment (IS-OS) junction at 1000 micron of fovea at baseline showed low mean visual functions after 6 months of treatment. Eyes with foveal sub-retinal fluid (SRF) and polyp at central 1000 micron of fovea at baseline showed significantly worse DVA and CS after six months. Thus, the presence of foveal SRF, foveal polyp, disrupted ELM, and IS-OS junction at baseline significantly influenced the six months' visual outcome in PCV eyes treated with combination therapy.

Visual Parameters and Retinal Morphology for Polypoidal Choroidal Vasculopathy Pre- and Post-Intravitreal Ranibizumab with or without Photodynamic Therapy: A Short-Term Prospective Study

The objective of this study was to compare visual parameters and retinal layers’ morphology pre-treatment (baseline) and 6 months post-treatment in polypoidal choroidal vasculopathy (PCV) eyes. A single centre, longitudinal, prospective study was conducted at a public tertiary hospital of Malaysia. Visual parameters including distance and near visual acuity (DVA and NVA), contrast sensitivity (CS), reading speed (RS), and different qualitative and quantitative optical coherence tomography (OCT) parameters were evaluated pre- and 6 months post-treatment. Thirty-three naïve PCV eyes of 32 patients (mean age of 67.62 years) were evaluated pre- and post-treatment of intravitreal ranibizumab with and without photodynamic therapy. After treatment, sub retinal fluid decreased from 27 eyes (84.35%) at baseline to 7 eyes (21.88%) at 6 months while pigment epithelium detachment decreased from 32 eyes (100%) at base line to 15 eyes (46.87%) at 6 months. Mean pre-treatment quantitative morphological OCT retinal parameters including thickness and volume of central sub field, center thickness, center minimum, and maximum thickness reduced significantly. Similarly, all visual parameters including DVA, NVA, CS, and RS showed statistically significant improvement. While 89% of the eyes showed improvement in CS, 78%, 71%, and 65% of the eyes showed improvement in NVA, RS, and DVA, respectively. Thus, CS was the most treatment responsive visual parameter.

Demographic and Clinical Factors that Influence the Visual Response to Anti-Vascular Endothelial Growth Factor Therapy in Patients with Neovascular Age-Related Macular Degeneration: A Systematic Review

Background

Neovascular age-related macular degeneration (nAMD) is a leading cause of blind registrations in the developed world. Standard therapy includes the use of anti-vascular endothelial growth factor (anti-VEGF) drugs, and whilst the clinical efficacy is well established, there is variability in the clinical effect of visual outcome. The purpose of this systematic review is to identify whether there is evidence for the influence of demographic and clinical factors on the effectiveness of anti-VEGF therapy in patients with nAMD, in settings comparable to the National Health Service (NHS).

Methods

This systematic review followed the PRISMA guidelines for systematic reviews. Electronic databases Medline, EMBASE, Web of Science, CINAHL and the Cochrane Library were searched for studies dated from 2005 onwards. Studies were appraised using the Newcastle–Ottawa Score, and a narrative synthesis was used.

Eligibility Criteria

Population: Patients with nAMD being treated with anti-VEGF therapy. Comparator: Presence or absence of potential predictive demographic and clinical factors. Settings: Comparable settings to NHS hospitals. Outcomes: Predicting demographic and clinical factors. Study designs: Randomised controlled trials, prospective cohort studies, retrospective cohort studies and case series dated from 2005.

Results

Thirty papers were identified in this review. The evidence suggests that the number of anti-VEGF injections that patients receive, age and lesion size at baseline are factors that influence how effective anti-VEGF therapy is in the short and long term. There was also evidence that suggested that baseline visual acuity influenced the effectiveness of anti-VEGF therapy at longer time points of more than 2 years. Due to a lack of standardised statistical reporting among the included studies, it was not possible to undertake a meaningful statistical synthesis or meta-analysis.

Conclusions

This review has demonstrated that there is some evidence of clinical and demographic factors that affect the effectiveness of anti-VEGF therapy and hence variation in visual acuity (VA) outcome. However, this review was unable to identify as wide a range of factors as was hoped. The findings of this review are important because some of the factors, such as VA and lesion size at diagnosis and the number of injections, are potentially modifiable through improvements in early diagnosis and service provision. Future work also needs to focus on the importance of this variation, such as the effect on patients’ quality of life, and how variation can be minimised.

Systematic Review Registration

This review has been registered with PROSPERO (Registration number CRD42018094191).

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00288-0) contains supplementary material, which is available to authorized users.

Neurodegeneration, gliosis, and resolution of haemorrhage in neovascular age-related macular degeneration, a clinicopathologic correlation

BACKGROUND

To analyse cellular and spatiotemporal factors of neurodegeneration and gliosis in a patient with submacular haemorrhage (SMH) secondary to type 1 macular neovascularization in neovascular age-related macular degeneration (nAMD).

METHODS

This is a case study and clinicopathologic correlation of an 84-year-old white man with nAMD treated with antiangiogenic drugs and photodynamic therapy during a 6-year follow-up. Eyes were recovered for histology 8.23 h after death. In vivo multimodal imaging including optical coherence tomography (OCT) and en face modalities was compared with ex vivo OCT and high-resolution histologic images, using a custom image registration procedure. SMH components were defined (intraretinal, subretinal, sub-retinal pigment epithelium (RPE), and dehemoglobinized blood). Neurodegenerative changes in each of these areas were described. One anonymous donor eye with haemorrhagic nAMD was also reviewed as a comparator.

RESULTS

By in vivo OCT, progressive resolution of the haemorrhage and gradual transformation of sub-RPE fluid to fibrous hyperreflective tissue, progressive macular atrophy, and variation in external limiting membrane (ELM) visibility were observed. Histology showed intense photoreceptor loss with preservation and self-adhesion of macular Müller glia resulting in ELM condensation. The comparator eye exhibited shed cone inner segments among subretinal erythrocytes.

CONCLUSION

This is the most detailed clinicopathologic correlation of nAMD with SMH resolution to date, and the first in the OCT era. Our results reveal profound macular neurodegeneration and gliosis, signified by condensed ELM, soon after haemorrhage begins. Intensified OCT reflectivity of the ELM, an important retinal barrier, has potential as a biomarker for severe photoreceptor loss and gliosis.

Evaluation of outer retinal tubulations in diabetic macular edema underwent anti-VEGF treatment

AIM

To investigate the incidence and subsequent changes of outer retinal tubulations (ORTs) in diabetic macular edema (DME) underwent anti-vascular endothelial growth factor (VEGF) therapy, and to assess the possibility of ORT as a biomarker of DME severity or response to anti-VEGF therapy.

METHODS

This retrospective and descriptive study included a total of 228 patients (435 eyes) with DME and treated with intravitreal anti-VEGF agents between March 2016 and January 2018. Patients were divided into 2 groups according to the presence of ORTs. High-resolution spectral-domain optical coherence tomography (SD-OCT) images acquired by vertical and horizontal scans and over consecutive visits were analyzed. The evolution of ORT over time, type of fluid and subfoveal photoreceptor integrity on OCT imaging was also assessed.

RESULTS

ORTs were identified in 108 eyes of 435 eyes with an overall incidence rate of 24.83% at baseline. ORTs were prone to locate adjacent to the lesions of exudation and/or cystoid edema and possibly situated in outer nuclear layer (ONL), outer plexiform layer (OPL) and/or inner nuclear layer (INL) in eyes with DME. The formation process of ORT led to focal downward displacement of OPL and INL toward RPE near the lesion. During the follow up, 45 eyes had steady ORTs and 63 eyes had dynamic variants in ORTs, including disappearance, reappearance, collapse, diminution, and enlargement. There were higher proportion of closed ORTs and fewer proportion of forming ORTs in eyes with steady ORTs, which showed a statistically significance when compared with eyes with variant ORTs (P=0.006, P=0.017, respectively). The eyes without ORTs had significantly better final best corrected visual acuity (BCVA) and more BCVA change than those eyes with ORTs in DME patients after anti-VEGF therapy (P=0.023, P=0.009, respectively). The disruption of subfoveal photoreceptor integrity in eyes with ORTs was more serious than that in eyes without ORTs (P=0.013). The proportion of stable vision in eyes with ORTs was significantly higher than that in eyes without ORTs, showing statistical significance (P=0.016). ORTs were associated with worse visual prognosis due to damage of the subfoveal photoreceptor integrity.

CONCLUSION

ORTs have a high incidence and changes over time in DME with anti-VEGF treatment and may be located at various retinal layers. Persistent ORT can be as a negative biomarker of outcome of DME.

Age, sex, and type of medication predict the effect of anti-VEGF treatment on central retinal thickness in wet age-related macular degeneration

Purpose

Randomized clinical trials studying the effects of VEGF inhibition on wet age-related macular degeneration (wAMD) are designed so that the effects of individually varying risk factors on the treatment response are eliminated. The influence of these risk factors can be studied in large data sets from real-life experience.

Patients and methods

All 2,255 patients diagnosed with wAMD requiring anti-VEGF treatment in at least one eye over more than 9 years in a defined Danish population with 0.9 million inhabitants were studied. The predictive value of eye laterality, sex, current smoking status, type of anti-VEGF compound, membrane position, membrane type, leakage area, number of injections, number of visits, age, time to follow-up, visual acuity, and central retinal thickness (CRT) at baseline on change in CRT after three monthly injections with anti-VEGF compound followed by treatment pro re nata for up to 12 months was assessed.

Results

After 12 months, 67 patients had died, 903 had had stable CRT for at least 6 months, and 1,285 patients had not achieved stable CRT. The reduction in CRT was −84.8±118.3 μm, whereas the increase in visual acuity was 2.2±14.7 Early Treatment Diabetic Retinopathy Study letters. The risk factors included contributed to 64% of the variation in CRT reduction. High age and high CRT at baseline predicted high CRT reduction, whereas more injections, treatment with ranibizumab, and male sex predicted a low CRT reduction.

Conclusion

Age, sex, and type of anti-VEGF medication can be used to plan treatment and inform patients about the expected response of anti-VEGF treatment in wAMD.

The potential of spectral domain optical coherence tomography imaging based retinal biomarkers

Background

Biomarker”, a merged word of “biological marker”, refers to a broad subcategory of medical signs that objectively indicate the state of health, and well-being of an individual. Biomarkers hold great promise for personalized medicine as information gained from diagnostic or progression markers can be used to tailor treatment to the individual for highly effective intervention in the disease process. Optical coherence tomography (OCT) has proved useful in identifying various biomarkers in ocular and systemic diseases.

Main body

Spectral domain optical coherence tomography imaging-based biomarkers provide a valuable tool for detecting the earlier stages of the disease, tracking progression, and monitoring treatment response. The aim of this review article is to analyze various OCT based imaging biomarkers and their potential to be considered as surrogate endpoints for diabetic retinopathy, age related macular degeneration, retinitis pigmentosa and vitreomacular interface disorder. These OCT based surrogate markers have been classified as retinal structural alterations (macular central subfield thickness and cube average thickness); retinal ultrastructural alterations (disruption of external limiting membrane and ellipsoid zone, thinning of retinal nerve fiber layer and ganglion cell layer); intraretinal microangiopathic changes; choroidal surrogate endpoints; and vitreoretinal interface endpoints.

Conclusion

OCT technology is changing very quickly and throughout this review there are some of the multiple possibilities that OCT based imaging biomarkers will be more useful in the near future for diagnosis, prognosticating disease progression and as endpoint in clinical trials.

[Visual acuity in anti-VEGF therapy for AMD : Can specific characteristics in the SD-OCT help?]

BACKGROUND

The efficacy of anti-VEGF therapy in exudative AMD has been established in several large clinical trials using a fixed injection regimen as well as a SD-OCT-based PRN regimen. In these studies, after the first three injections, an increase of the mean visual acuity was observed, which could be stabilized with constant treatment for up to 24 months. However, the specific course of the visual acuity is very different between individuals. The aim of the present study was to correlate specific initial SD-OCT parameters with the course of visual acuity in order to characterize factors that may be important for the individual visual prognosis.

PATIENTS AND METHODS

In a prospective case study, the visual course and SD-OCT changes of 156 patients with minimum follow-up of 12 months (mean 80.1 months) were analysed. Visual acuity (LogMar) was investigated at regular intervals and correlated with specific SD-OCT parameters (foveal thickness, height of sub-retinal fluid or presence of associated PED, presence of intra-retinal cysts, length of IS/OS break, choroidal thickness).

RESULTS

The initial increase in visual acuity could be stabilized over time. This effect was associated with a decrease in foveal retinal thickness, which also persisted over time. While sub-retinal fluid, presence of PED, and choroidal thickness showed no prognostic relevance for the change in visual acuity, the presence of more advanced central retinal thickness, of intra-retinal cysts or a longer break in the IS/OS junction were associated with a less favourable development of visual acuity.

CONCLUSION

In the present study, the presence of more advanced central retinal thickness, of intra-retinal cysts or a larger IS/OS break correlated significantly with a worse visual prognosis. These might be clinical signs for more extensive pre-existing intra-retinal changes. Further analysis and new diagnostic tools may prove this and may result in specific additive neuroprotective or regenerative therapeutic approaches in exudative AMD.

Epidemiological and Clinical Baseline Characteristics as Predictive Biomarkers of Response to Anti-VEGF Treatment in Patients with Neovascular AMD

Purpose. To review the current literature investigating patient response to antivascular endothelial growth factor-A (VEGF) therapy in the treatment of neovascular age-related macular degeneration (nAMD) and to identify baseline characteristics that might predict response. Method. A literature search of the PubMed database was performed, using the keywords: AMD, anti-VEGF, biomarker, optical coherence tomography, treatment outcome, and predictor. The search was limited to articles published from 2006 to date. Exclusion criteria included phase 1 trials, case reports, studies focusing on indications other than nAMD, and oncology. Results. A total of 1467 articles were identified, of which 845 were excluded. Of the 622 remaining references, 47 met all the search criteria and were included in this review. Conclusion. Several baseline characteristics correlated with anti-VEGF treatment response, including best-corrected visual acuity, age, lesion size, and retinal thickness. The majority of factors were associated with disease duration, suggesting that longer disease duration before treatment results in worse treatment outcomes. This highlights the need for early treatment for patients with nAMD to gain optimal treatment outcomes. Many of the identified baseline characteristics are interconnected and cannot be evaluated in isolation; therefore multivariate analyses will be required to determine any specific relationship with treatment response.

Choroidal thickness profile in Retinitis Pigmentosa - Correlation with outer retinal structures

Purpose

To compare the choroidal thickness (CT) of subjects with Retinitis Pigmentosa (RP) with age-matched healthy subjects and to correlate the visual acuity with retinal parameters including central macular thickness (CMT), inner segment/outer segment junction (IS/OS junction) integrity, external limiting membrane (ELM) integrity and choroidal thickness in subjects with RP.

Methods

Eighty-eight eyes (69 patients) with typical RP and 188 eyes of 104 healthy subjects were enrolled between September 2012 and January 2013.

All subjects underwent a comprehensive ocular examination including choroidal imaging using enhanced depth imaging with spectral domain optical coherence tomography. Outcome measures were CT difference between RP and age-matched healthy subjects; and correlation of various factors such CMT, IS/OS junction integrity, ELM integrity, and CT with visual acuity.

Results

Among RP subjects, mean age was 31.39 ± 13.4 years with a mean BCVA of 0.99 ± 0.94 logMAR. Mean spherical equivalent was −0.6 ± 1.6D. Mean CMT was 148.48 ± 119 μm. Mean subfoveal CT was 296.9 ± 72 μm. Mean IS/OS and ELM integrity was 42.2 ± 46.6% and 43.75 ± 45.7%, respectively. The mean age was 40.0 ± 13.5 years with a mean spherical equivalent of 0.18 ± 0.6D for the normal age-matched healthy group. Mean subfoveal CT was 283.1 ± 47.8 μm.

CT at various locations in patients of various ages in the RP group did not show any statistical significant difference (P = ≫0.05) in comparison with age-matched healthy subjects. On multivariate regression, ELM percentage integrity had the strongest association with best corrected visual acuity, followed by IS/OS junction percentage integrity. Subfoveal choroidal thickness had very weak correlation with visual acuity as well other retinal parameters.

There was a significant difference in the outer retinal structure integrity (p = 0.002) and CMT (p = 0.02) between the eyes with good (⩾20/200) and poor vision (<20/200), but not in subfoveal choroidal thickness (p = 0.3).

Conclusions

Our study results did not show any significant difference in choroidal thickness between subjects with RP and age-matched healthy subjects. Choroidal thickness correlated better with the age but not with the vision or outer retinal structures in eyes with RP. Outer retinal structure integrity and CMT had a better correlation with visual acuity.

Photoreceptor inner segment ellipsoid band integrity on spectral domain optical coherence tomography

Spectral domain optical coherence tomography cross-sectional imaging of the macula has conventionally been resolved into four bands. However, some doubts were raised regarding authentication of the existence of these bands. Recently, a number of studies have suggested that the second band appeared to originate from the inner segment ellipsoids of the foveal cone photoreceptors, and therefore the previously called inner segment-outer segment junction is now referred to as inner segment ellipsoidband. Photoreceptor dysfunction may be a significant predictor of visual acuity in a spectrum of surgical and medical retinal diseases. This review aims to provide an overview and summarizes the role of the photoreceptor inner segment ellipsoid band in the management and prognostication of various vitreoretinal diseases.

12-month results of the standardised combination therapy for diabetic macular oedema: intravitreal bevacizumab and navigated retinal photocoagulation

AIM

To evaluate the efficacy of a standardised combination therapy for clinically significant diabetic macular oedema using bevacizumab injections followed by navigated laser photocoagulation to stabilise retinal thickness.

METHODS

In this pilot study we retrospectively reviewed charts and imaging of 23 eyes treated with the standardised combination regimen. Eyes initially received monthly bevacizumab injections, followed by navigated laser photocoagulation when central retinal thickness (CRT) was <440 µm. Patients were then followed monthly for 12 months.

RESULTS

At the time of navigated laser after bevacizumab treatment mean vision gain was +10.4 Early Treatment Diabetic Retinopathy Study letters (p<0.01) and CRT reduction was 146 µm (p<0.001). At 12 months from baseline, the vision gain remained stable at +10.6 Early Treatment Diabetic Retinopathy Study letters (p<0.01), and CRT reduction was stable at 137 µm (p<0.001). At 12 months from laser, the vision gain was 7.8 letters from baseline (p<0.01), with no significant change compared with the gain at 12 months from baseline (p=0.108). At 12 months from laser, CRT reduction was 125 µm from baseline (p<0.001), with no significant change compared with CRT reduction at 12 months from baseline (p=0.601). Total injections needed were 4.4 from baseline to month 12, with 1.3 reinjection needed after laser. 57% of the eyes didn't require injections after laser, while 43% needed two additional injections.

CONCLUSIONS

Standardised combination therapy using bevacizumab injections followed by navigated laser treatment for clinically significant diabetic macular oedema demonstrated significant visual gain and CRT reduction after bevacizumab treatment and stabilisation after navigated laser up to 12 months. The number of injections required in 12 months was lower than reported in previous combination studies.

Foveal morphology affects self-perceived visual function and treatment response in neovascular age-related macular degeneration: a cohort study

Objectives

To investigate the relationship between foveal morphology and self-perceived visual function in patients with neovascular age-related macular degeneration (AMD) and whether foveal characteristics are associated with Ranibizumab treatment response on the self-perceived visual function.

Methods

This prospective cohort study included patients with newly diagnosed neovascular AMD found eligible for treatment with Ranibizumab. Foveal morphology of both eyes was assessed using spectral-domain optical coherence tomography and all patients were interviewed using the 39-item National Eye Institute Visual Function Questionnaire (VFQ). Patients were re-interviewed 3 and 12 months after initiation of treatment with Ranibizumab. We evaluated foveal morphology at baseline in relation to VFQ scores at baseline and clinically meaningful changes in VFQ after 3 and 12 months.

Results

VFQ scores correlated with central foveal thickness, central foveal thickness of neuroretina (CFN), foveal RPE elevation, foveal integrity of the photoreceptor inner segment/outer segment junction (IS/OS), and external limiting membrane. In a multiple linear regression model, only best-corrected visual acuity of the better eye (p<0.001) and the IS/OS status in the better eye (p = 0.012) remained significant (Adjusted R² = 0.418). Lower baseline VFQ and a baseline CFN within 170–270 µm in the better eye were both associated with a clinically meaningful increase in the VFQ scores after 3 and 12 months. An absent foveal IS/OS band in the better eye was associated with a clinically meaningful decrease in the VFQ scores at 12 months.

Conclusions

Foveal morphology in the better eye influences the self-perceived visual function in patients with neovascular AMD and possesses a predictive value for change in the self-perceived visual function at 3 and 12 months after initiation of treatment. These findings may help clinicians provide patients more individualized information of their disease and treatment prognosis from a patient-perceived point-of-view.