The long-term effects of anti-vascular endothelial growth factor therapy on the optical coherence tomography angiographic appearance of neovascularization in age-related macular degeneration

Emily S Levine,Caroline R Baumal,Nora Muakkassa,Luísa S M Mendonça,James G Fujimoto,Adil El Maftouhi,Eric Moult,Jay S Duker,Nadia K Waheed,Usha Chakravarthy,M Elizabeth Hartnett,A Yasin Alibhai,Ivana N Despotovic,Shilpa Gulati,Andre J Witkin,Eugenia Custo Greig,Maddalena Quaranta-El Maftouhi

doi:10.1186/s40942-020-00242-z

Abstract

BackgroundThe short-term effects of anti-vascular endothelial growth factor (anti-VEGF) treatment on macular neovascularization (MNV) morphology is well described, but long-term studies on morphologic changes and correlation of such changes to the type of MNV have not been conducted. This study aims to determine if different types of MNVs in neovascular AMD (nAMD) behave differently with anti-VEGF treatment as visualized on optical coherence tomography angiography (OCTA).MethodsTreatment-naïve nAMD patients were retrospectively screened for baseline and follow-up OCTA imaging 10 or more months after initial treatment. Images were graded for MNV type, area, activity, mature versus immature vessels, vessel density, presence of atrophy, atrophy location and area. Growth rate was calculated as the percent change in lesion area from baseline over the years of follow-up. In addition, the occurrence of complete regression and the percent of lesions that grew, remained stable, and shrunk per type was also evaluated.ResultsForty-three eyes from 43 patients with a mean follow-up of 2 years were evaluated. On structural OCT, 26 lesions were classified as pure type 1 MNVs, 12 MNVs had a type 2 component, and 5 MNVs had a type 3 component. Of these cases, 2 mixed-type MNVs were considered to have completely regressed. There was no significant differences in MNV area and growth rate between type 1 and type 2 lesions, but all cases of type 3 lesions shrunk in the follow-up period. There was no correlation between the number of injections per year and growth rate, endpoint MNV area or endpoint activity status for any MNV type. There was no significant association between the development of atrophy and the number of injections, baseline MNV area, baseline vessel density, or lesion growth rate.ConclusionsIn nAMD, complete regression of an MNV network exposed to anti-VEGF is rare. This work emphasizes the role of anti-VEGF as anti-leakage rather than vascular regression agents in nAMD.

Highlights

The short-term effects of anti-vascular endothelial growth factor treatment on macular neovascularization (MNV) morphology is well described, but long-term studies on morphologic changes and correla‐ tion of such changes to the type of MNV have not been conducted
In neovascular AMD (nAMD), complete regression of an MNV network exposed to anti-Vascular endothelial growth factor (VEGF) is rare
Patients were considered for inclusion in this study if they met the following criteria: (1) the patient had a treatment naïve MNV, (2) optical coherence tomography angiography (OCTA) imaging was performed at baseline prior to the initiation of anti-VEGF treatment, (3) OCTA imaging was available at least 10 months after the baseline visit, and (4) the patient received any number of anti-VEGF injections over the follow-up period either per a treat and extend, pro re nata, or a monthly injection protocol

Summary

Introduction

The short-term effects of anti-vascular endothelial growth factor (anti-VEGF) treatment on macular neovascularization (MNV) morphology is well described, but long-term studies on morphologic changes and correla‐ tion of such changes to the type of MNV have not been conducted. This study aims to determine if different types of MNVs in neovascular AMD (nAMD) behave differently with anti-VEGF treatment as visualized on optical coherence tomography angiography (OCTA). Neovascular AMD (nAMD) is an advanced stage of the disease that can lead to vision loss due to macular damage from abnormal blood vessel exudation. There are three main forms of neovascularization that can occur in nAMD based on where the new blood vessels originate and grow [1]. Type 1 and type 2 neovascularizations originate from the choroidal vasculature and are located under the retinal pigment epithelium (RPE) and in the subretinal space, respectively. Type 3 neovascularization is thought to originate from the deep retinal capillary plexus, grow downward into the neurosensory retina, and may form retinal-choroidal anastomoses at later stages [2,3,4]. Mixed and pure type neovascularizations have been grouped together under the umbrella term macular neovascularization (MNV) [5]

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