Choroidal Thickness after Treatment for Myopic Choroidal Neovascularization

Treatment of myopic choroidal neovascularization: a network meta-analysis and review

PURPOSE

This is, to our knowledge, the first network meta-analysis aiming to compare all treatment modalities for myopic choroidal neovascularization (CNV).

METHODS

After the electronic databases were searched, two independent reviewers screened titles, abstracts, full-texts, and extracted information. Primary endpoints were change in visual outcome and central retinal thickness. We used a network meta-analysis to compare treatment outcomes in the early (≤ 6 months) and late (> 6 months) phase.

RESULTS

We included 34 studies (2,098 eyes) in our network meta-analysis. In the early phase, the use of anti-VEGF led to a gain of 14.1 letters (95% CI, 10.8-17.4) compared to untreated patients (p < 0.0001), 12.1 letters (95% CI, 8.3-15.8) to photodynamic therapy (PDT) (p < 0.0001), 7.5 (95% CI, 1.2-13.8) letters to intravitreal triamcinolone acetonide (TCA) (p = 0.019), and - 2.9 letters (95% CI, - 6.0-0.2) to the combination of anti-VEGF and PDT (p = 0.065). In the later phase, these results were largely maintained. There were no significant differences in visual outcomes between patients treated with 1 + PRN and 3 + PRN. However, the 1 + PRN group received 1.8 (SD 1.3), while the 3 + PRN group received 3.2 (SD 0.9) injections within 12 months (p < 0.0001).

CONCLUSION

This network meta-analysis confirms that anti-VEGF is the most effective treatment for myopic CNV using the 1 + PRN treatment strategy.

MACULAR CHORIORETINAL ATROPHY AND VISUAL OUTCOMES IN RANIBIZUMAB- OR AFLIBERCEPT-TREATED MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To investigate the predictors of macular chorioretinal atrophy, consisting of patchy atrophy (PA) at the macula and choroidal neovascularization (CNV)-related macular atrophy (CNV-MA), during treatment with ranibizumab or aflibercept for myopic CNV (mCNV) and its impact on visual outcomes.

METHODS

This retrospective study included 82 eyes with treatment-naïve mCNV who were treated with pro re nata injections of ranibizumab or aflibercept.

RESULTS

Nine eyes (11.0%) presented with macular PA at baseline (PA group), and 73 eyes (89.0%) did not (non-PA group). VA improved during the first year in the non-PA group; a similar trend was noted in the PA group until 3 months after initial treatment. This improvement was maintained until 24 months ( P < 0.001) in the non-PA group, but not in the PA group. In the PA group, macular chorioretinal atrophy progressed faster ( P < 0.0001), and CNV-MA was more frequent during the 2 years of treatments ( P = 0.04). Even non-PA group eyes sometimes developed CNV-MA (42% at Month 24) if they had a larger CNV and thinner subfoveal choroidal thickness at baseline, resulting in poorer visual prognosis ( P < 0.01).

CONCLUSION

Macular PA at baseline was a risk factor for CNV-MA development and was associated with poor visual outcomes.

The Clinical Role of the Choroidal Assessment in High Myopia: Characteristics and Association With Neovascular and Atrophic Complications

Purpose

To investigate the clinical utility of choroidal quantitative assessment associated with the presence of macular neovascularization (MNV) or atrophy in high myopia.

Methods

The study was designed as a retrospective case series with two-year follow-up. We measured choroidal thickness (CT) and the presence and subtype of dome-shaped macula (DSM). In DSM eyes we also calculated the presence and type of choroidal deepening (CD). The eyes were categorized as Subgroup 1 (high myopia without complications), Subgroup 2 (high myopia complicated by MNV), and Subgroup 3 (high myopia complicated by macular or posterior pole atrophy). Main outcome measures were the detection of significant CT cutoffs associated with the three subgroups of eyes and the clinical impact of DSM and CD subtypes.

Results

Our cohort (190 eyes affected by high myopia) was categorized as Subgroup 1 (66 eyes), Subgroup 2 (72 eyes) and Subgroup 3 (52 eyes). Baseline CT values allowed to separate the subgroups with myopic-related complications (area under the curve = 0.85; P < 0.05). In Subgroup 1, vertical DSM was the most frequent (54%), with CD absence characterizing the 46% of cases. Round DSM was the most represented subtype in Subgroup 2 (49%), with 55% of sub-dome CD subtypes; in these cases, MNV resulted always localized in the fovea. Subgroup 3 equally shown horizontal or vertical DSM (53% and 47%, respectively), with 80% of cases showing peri-dome CD.

Conclusions

Choroidal quantitative assessment can categorize three high myopia subgroups. MNV subgroup is characterized by intermediate choroidal thinning and higher prevalence of round DSM with sub-dome CD.

Result of intravitreal aflibercept injection for myopic choroidal neovascularization

Background

The current study aimed to evaluate the efficacy of intravitreal aflibercept injections as the primary treatment for subfoveal/juxtafoveal myopic choroidal neovascularization (CNV) by using optical coherence tomography (OCT). Optical coherence tomography angiography (OCTA) was further used for some patients to detect the changes of CNV after treatment.

Methods

In the present study, 21 treatment-naive eyes of 21 patients with subfoveal/juxtafoveal myopic CNV received primary intravitreal aflibercept injections and were under follow-up for a minimum duration of 12 months. Among the 21 patients, 12 underwent OCTA to evaluate the changes in central foveal thickness, selected CNV area, and flow area.

Results

The mean best-corrected visual acuity (BCVA) pertaining to all the patients significantly improved from the baseline value of 0.7 to 0.3 logMAR after treatment for 12 months (P = 0.001). However, the improvements in the median BCVA after treatment for three and 12 months were not statistically significant in the younger group (< 50 years), compared to the older group (≥ 50 years). One aflibercept injection resolved the CNV in 47.6% (10/21) of the patients. The younger group displayed greater improvement in the median central foveal thickness, compared to the older group.

OCTA revealed interlacing or disorganized pattern at the level of the outer retinal layer in 12 subjects with myopic CNV. After 3 months of treatment, both groups displayed a decrease in the size of the selected CNV area and flow area. The interlacing group displayed a trend towards better anatomical improvements.

Conclusion

Intravitreal aflibercept injection provides long-term improvement in visual acuity in patients with myopic CNV. Eyes with the interlacing pattern on OCTA displayed a greater decrease in size and flow after aflibercept injection.

Trial registration

Before data collection, written informed consent was obtained from each participant, whose identity information was protected by encryption and conversion to a non-identifiable format and removing data links. This study was approved by the Institutional Review Board of Kaohsiung Veterans General Hospital (KSVGH21-CT1–17).

Choroidal and Retinal Thickness of Highly Myopic Eyes with Early Stage of Myopic Chorioretinopathy: Tessellation

Purpose

To investigate the choroidal thickness (CT) and retinal thickness (RT) in highly myopic tessellated eyes.

Methods

In this study, 115 highly myopic eyes were recruited and divided as tessellated fundus (n = 93) and normal fundus (n = 22). RT and CT were quantified using optical coherence tomography with enhanced depth imaging (EDI-OCT). Correlation between subfoveal CT (SFCT) and tessellation was analyzed using logistic regression models.

Results

Tessellated fundus eyes had thinner CT than did normal fundus eyes, while RT was not statistically different across groups. The tessellated eyes had a thinner choroid than did the control eyes at all measured macular locations (all P < 0.05). After adjustment for AL, age, and gender, the SFCT was significantly associated with tessellation. The odds ratio (OR) and 95% confidence interval (CI) was 0.975 (0.960–0.990, P = 0.001, binary logistics regression) and 0.991 (0.984–0.999, P = 0.022, Cox regression). The area under the curve (AUC) of SFCT was the greatest for detecting tessellation (AUC = 0.824, P < 0.001). For sensitivity and specificity analyses, SFCT had the highest diagnostic value (sensitivity = 81.8%, specificity = 74.2%).

Conclusions

Highly myopic eyes with tessellation have thinner CT than do normal highly myopic eyes. CT may serve as an early pathologic predictor of high myopia.

Diagnosis and treatment guideline for myopic choroidal neovascularization due to pathologic myopia

Pathologic myopia is a leading cause of visual impairment. Development of myopic choroidal neovascularization (CNV) is one of the most common complications that leads to central vision loss in patients with pathologic myopia. If left untreated, it can cause scarring with expanding macular atrophy leading to irreversible visual loss in a period as short as 5 years. Advancements in multimodal imaging technology have furthered our understanding of the condition; however, further studies are necessary to extend its utility in the diagnosis of myopic CNV. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has become the standard-of-care and the recommended first-line treatment option for myopic CNV. Long-term studies have demonstrated that early treatment of confirmed myopic CNV cases with an intravitreal anti-VEGF agent is useful to avoid late-stage complications. This strategy has also been shown to achieve visual outcome improvements for up to 4 years and visual stabilization up to 6 years. This review article provides an overview of the current knowledge on myopic CNV and discusses recent updates in the diagnosis and management of the condition. Furthermore, treatment recommendations are provided based on the authors' expert opinions.

Management of Myopic Choroidal Neovascularization: Focus on Anti-VEGF Therapy

Myopic choroidal neovascularization (mCNV) is the second most common form of CNV after age-related macular degeneration (AMD). It is a sight-threatening complication of pathologic myopia (PM) and often affects patients in their working years causing significant impact on quality of life. Previous therapies such as photodynamic therapy with verteporfin have shown limited success. Due to the similarities in pathogenesis of mCNV and AMD CNV, anti-vascular endothelial growth factor therapy (anti-VEGF), which has so far been the mainstay of treatment for AMD CNV, has been shown to be effective in the treatment of mCNV and has become the first-line treatment of choice. This article aims to examine briefly the epidemiology and pathophysiology of mCNV, as well as review the evidence for efficacy, safety, and clinical use of anti-VEGF treatment for mCNV.

[Modern views on myopic maculopathy]

Most of world's scientists consider the fast-growing incidence of myopia a problem of great social importance due to associated increase in complicated myopia that leads to disability among the working-age population. This is a review on complicated myopia and myopic maculopathy that covers the history of research in this field, principles of classification, and etiological factors. It also deals with choroidal neovascularization (CNV), which often follows, and its treatment options, including anti-VEGF therapy. Possible complications of the latter are described as well. Literature search was done using PubMed, eLIBRARY, and Scopus text databases. A total of 61 sources, both Russian and foreign, were analyzed. Current clinical knowledge of different types of myopic maculopathy is still insufficient and the gaps are likely to be filled using modern methods of detailed in vivo examination of both sclera and choroidea. Anti-VEGF therapy has proved most effective in treating myopic maculopathy-associated neovascularization, however, a systematic approach to patient selection and management is yet needed.

Subfoveal choroidal thickness in idiopathic choroidal neovascularization and treatment outcomes after intravitreal bevacizumab therapy

PURPOSE

To determine subfoveal choroidal thickness in idiopathic choroidal neovascularization (CNV) and evaluate visual and anatomical outcomes in patients with idiopathic CNV after intravitreal bevacizumab.

METHODS

Retrospective observation case series. Seventeen eyes of 17 patients with idiopathic CNV were treated with a single intravitreal bevacizumab injection, followed by additional doses based on optical coherence tomography findings, including intraretinal fluid, subretinal fluid, or pigment epithelial detachment. We analyzed best-corrected visual acuity, central subfield thickness, and subfoveal choroidal thickness at presentation and final visit. Seventeen unaffected fellow eyes and 17 healthy eyes constituted the control group for subfoveal choroidal thickness.

RESULTS

The subfoveal choroidal thickness was significantly thinner in eyes with idiopathic CNV (237.59 ± 53.84 μm) than in the unaffected fellow eyes (281.71 ± 59.01 μm, P = 0.001) or normal control eyes (290.38 ± 58.94 μm, P = 0.028). Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.46 initially to 0.26 after treatment (P = 0.024). Mean central subfield thickness decreased from 387.88 ± 97.52 μm at baseline to 261.41 ± 31.18 μm after treatment (P < 0.001).

CONCLUSION

Subfoveal choroidal thickness is reduced and may be associated with the pathophysiology of idiopathic CNV. Intravitreal bevacizumab resulted in significant visual and anatomical improvement in patients with idiopathic CNV.