Classic Choroidal Neovascularization Research Articles

Classic Choroidal Neovascularization in Young Man

Introduction : Classic choroidal neovascularization (CNV 2) represent a pathological growth of blood vessels and can result in loss of visual function. The most common cause of CNV 2 in elderly patients is age- related macular degeneration, meanwhile in young age it is frequently due to inflammation, high myopia, angioid disks and hereditary disorders. Hence, the presented case reports the characteristic findings as well the management of the disease.
 Case Illustration : A 37-year-old man had two weeks history of metamorphopsia on both eyes. The left eye (LE) had a worse visual acuity, macular fibrosis with pigment epithelial detachment in funduscopy and Optical Coherence Tomography (OCT). A submacular hemorrhage and exudative lesion were recognized on the right eye (RE) with type 2 choroidal neovascularization. Fundus Fluorescence Angiography (FFA) was also performed. Systemic conditions were unremarkable. Intravitreal anti-VEGF injections on RE were given for three consecutive months and showed significant improvement.
 Discussion : The etiology of CNV 2 includes high myopia, and inflammation. However, none was found in this patient. Nonetheless, CNV type 2 is still uncommon in young age without predisposing conditions. As most common lesions involve the macula, symptoms shown include metamorphopsia, central scotoma and floaters. FFA is still considered to be the gold standard to differentiate the types of choroidal vascularization. Neovascularization and submacular hemorrhage can be treated with intravitreal injection of anti-VEGF, as previous studies reported significant improvement.
 Conclusion : This was a case of bilateral CNV type 2 in a young man without any previous predisposing conditions. Three monthly injections of anti-VEGF showed significant improvement.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS OF CLASSIC CHOROIDAL NEOVASCULARIZATION IN POLYPOIDAL CHOROIDAL VASCULOPATHY.

To evaluate the flow signals in subretinal hyperreflective material (SHRM) that represents classic choroidal neovascularization (CNV) on fluorescein angiography in eyes with polypoidal choroidal vasculopathy. We retrospectively reviewed 20 eyes with polypoidal choroidal vasculopathy that appeared to have classic CNV on fluorescein angiography, accompanied by SHRM on optical coherence tomography (OCT) at the same location. Using OCT angiography (OCTA), we analyzed intrinsic flow signals in the SHRM (cross-sectional B-scans and en face). The possible association between pretreatment OCT angiography findings and fibrotic scar formation after antivascular endothelial growth factor (VEGF) treatment was evaluated. Six of 20 eyes (30%) showed vascular SHRM; the remaining 14 eyes (70%) showed avascular SHRM at the classic CNV site at baseline. The SHRM corresponded with polypoidal lesions seen on indocyanine green angiography in 5 of 6 eyes with vascular SHRM and in all 14 eyes with avascular SHRM. After anti-VEGF treatment, all 6 eyes with vascular SHRM left a fibrotic scar, whereas all 14 eyes with avascular SHRM showed no scar formation (P < 0.001). Using OCT angiography, we evaluated the flow signals in SHRM that represented classic CNV in eyes with polypoidal choroidal vasculopathy and successfully differentiated true Type 2 macular neovascularization from pseudo classic CNV.

Outcomes by Baseline Choroidal Neovascularization Features in Age-Related Macular Degeneration: A Post Hoc Analysis of the VIEW Studies

To assess the influence of baseline choroidal neovascularization (CNV) features on visual change and fluid resolution after anti-vascular endothelial growth factor (VEGF) treatment of eyes with neovascular age-related macular degeneration (nAMD). Post hoc analysis of 52-week data from the phase 3 Vascular Endothelial Growth Factor VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet Age-Related Macular Degeneration (AMD) Studies (VIEW) 1 and 2 clinical trials. One thousand eight hundred four patients with nAMD. Integrated data from VIEW 1 and 2 of 1804 eyes receiving intravitreal aflibercept injections (IAIs) 2 mg every 4 weeks, IAIs 2 mg every 8 weeks after 3 initial monthly doses, and ranibizumab every 4 weeks with documented baseline CNV type, total area, and leakage area were analyzed. Time to an event and cumulative incidence were evaluated by Kaplan-Meier analysis, and relative risks were estimated using proportional hazards analysis. Cumulative incidence of time to first sustained vision gain of 15 or more Early Treatment Diabetic Retinopathy Study letters, vision loss of more than 5 Early Treatment Diabetic Retinopathy Study letters from baseline, as well as first sustained absence of retinal fluid and intraretinal fluid as evaluated by OCT with respect to CNV type, total CNV, and leakage area. Eyes with predominantly classic CNV (mean best-corrected visual acuity [BCVA], 48.2 letters at baseline) showed a higher incidence rate of first sustained gain of 15 letters or more than eyes with occult CNV (mean BCVA, 57.9 letters at baseline; P < 0.01). Eyes with occult CNV at baseline showed higher incidence rates of first sustained absence of retinal fluid and of intraretinal fluid than eyes with predominantly classic CNV (both P < 0.01). With increasing baseline CNV total area and leakage area, the incidence rate of first sustained gain of 15 letters or more decreased. This post hoc analysis provided additional evidence for the role of baseline CNV features (CNV type, total area, and leakage area) in influencing visual and anatomic outcomes in eyes with nAMD after anti-VEGF treatment.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY CAN CATEGORIZE DIFFERENT SUBGROUPS OF CHOROIDAL NEOVASCULARIZATION SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

Choroidal neovascularization (CNV) is a common complication of patients affected by age-related macular degeneration, showing a highly variable visual outcome. The main aim of the study was, at baseline, to perform a quantitative optical coherence tomography angiography assessment of CNV secondary to age-related macular degeneration and to assess posttreatment outcomes. Seventy-eight naïve age-related macular degeneration-related CNV patients (39 men, mean age 78 ± 8 years) were recruited and underwent complete ophthalmologic evaluation and multimodal imaging. Several OCT and optical coherence tomography angiography parameters were collected, including vessel tortuosity and vessel dispersion (VDisp), measured for each segmented CNV. All patients underwent anti-vascular endothelial growth factor PRN treatment. Vessel tortuosity and VDisp values of CNVs were tested at baseline to establish a cutoff able to distinguish clinically different patient subgroups. Mean best-corrected visual acuity was 0.49 ± 0.57 (20/62) at baseline, improving to 0.31 ± 0.29 (20/41) at the 1-year follow-up (P < 0.01), with a mean number of 6.4 ± 1.9 injections. Our cohort included the following CNV types: occult (45 eyes; 58%), classic (14 eyes; 18%), and mixed (19 eyes; 24%). Observing optical coherence tomography angiography parameters, classic, mixed, and occult CNV revealed significantly different values of VDisp, with classic forms showing the highest values and the occult CNVs showing the lowest (P < 0.01); mixed forms displayed intermediate VDisp values. The ROC analysis revealed that a CNV vessel tortuosity cut-off of 8.40, calculated at baseline, enabled two patient subgroups differing significantly in visual outcomes after anti-vascular endothelial growth factor treatment to be distinguished. A baseline quantitative optical coherence tomography angiography-based parameter could provide information regarding both clinical and functional outcomes after anti-vascular endothelial growth factor treatment in age-related macular degeneration-related CNV.

Эффективность и переносимость комбинированного использования ингибиторов ангиогенеза в клинической практике

Aim: to assess the effectiveness and tolerability of anti-VEGF agents, aflibercept (2.0 mg) and ranibizumab (0.5 mg), in the combined treat-ment for wet age-related macular degeneration (AMD) in routine clinical practice.Patients and Methods: 55 patients (65 eyes) with the late stage of wet AMD were divided into two groups. Group 1 included 32 eyes with classic choroidal neovascularization (CNV) and group 2 included 33 eyes with occult CNV. Best-corrected visual acuity (BCVA), intraocular pressure, and retinal nerve fiber layer (RNFL) thickness were measured. These parameters were compared at different time points during the treatment.Results: overall AMD duration (January 2019) was 36 (19; 47) months being 30 (12; 44) months in group 1 and 36 (23; 48) months in group 2 (р&gt;0.05). The first intravitreal administration of an anti-VEGF drug was performed 7.5 (3.5; 9.5) months after AMD diagnosis in group 1 and 7 (3; 11) months after AMD diagnosis in group 2. Significant differences in intragroup intervals were revealed between various follow-up periods. More differences were identified for the intervals between intravitreal administrations in group 2. Baseline and final BCVA during the entire follow-up which was 29.5 (19.5; 38) months in group 1 and 28 (25; 44) months in group 2 demonstrated neither intragroup nor intergroup differences (р&gt;0.05). Conclusion: our management strategy for wet AMD is somewhat different from conventional guidelines. However, it has no significant impact on visual acuity during the follow-up.Keywords: age-related macular degeneration, anti-VEGF drugs, intravitreal administration, IOP level, aflibercept, ranibizumab.For citation: Kuroyedov A.V., Gapon’ko O.V., Gorodnichiy V.V. et al. Effectiveness and tolerability of the combined use of anti-VEGF agents in clinical practice. Russian Journal of Clinical Ophthalmology. 2020;20(4):209–215. DOI: 10.32364/2311-7729-2020-20-4-209-215.

Association of Longitudinal Changes in Drusen Characteristics and Retinal Layer Volumes with Subsequent Subtype of Choroidal Neovascularisation

Aim: To investigate the longitudinal correlation between drusen characteristics and retinal layer volumes pre conversion and subsequent type of choroidal neovascularisation (CNV). Methods: This was a single-centre retrospective study. The study participants were patients with wet age-related macular degeneration (AMD) in one eye who developed wet AMD in the contralateral eye, with at least 2 years of follow-up prior to conversion. The Moorfields Eye Hospital database was searched for eligible patients and their data were recorded. Eyes were classified as occult or classic based on fundus fluorescein angiography. Optical coherence tomography (OCT) images were analysed for drusen characteristics and retinal layer volumes were analysed over time using automated software (Topcon 3D OCT-2000 and Orion, Voxeleron LLC, respectively). All values were obtained at baseline as well as year 1 and year 2 before conversion to wet AMD. Results: Fifty-one eyes with bilateral CNV showed high correlation of type of CNV between eyes (kappa statistic 0.89). A total of 49 wet AMD eyes (29 occult, 20 classic) were analysed for drusen parameters. Two patients with retinal angiomatous proliferation were excluded. Drusen count, area, and volume did not differ by CNV type, but the rates of change of drusen area (p = 0.046) and drusen volume (0.022) were higher in the occult group in the year preceding CNV development. Of the 49 eyes, 17 (10 occult, 7 classic) with available good quality OCT were analysed for retinal layer volumes. There was a progressive reduction in outer nuclear layer (ONL) volume (p = 0.002) and an expansion in outer plexiform layer volume (p = 0.015) in eyes that developed occult CNV. Conclusion: Our study shows that rate of increase in drusen load and reduction in ONL are significant features seen in eyes developing occult CNV, highlighting new imaging markers that need to be replicated in larger studies. These markers provide insight into the pathogenesis of CNV and may serve as prognostic indicators, as classic CNV carries a poorer prognosis compared to occult CNV.

Features and Diagnostic Accuracy of Optical Coherence Tomography Angiography in Neovascular Age-related Macular Degeneration.

IntroductionAge-related macular degeneration (AMD) is one of the important causes of visual impairment in aging population. Fundus fluorescein angiography (FFA) is gold standard for the diagnosis of neovascular AMD (nAMD) while optical coherence tomography (OCT) aids in the diagnosis of nAMD and is very useful for follow-up. OCT angiography (OCTA) is an evolving imaging technology that can be used as a valid diagnostic tool to study morphology of choroidal neovascularization (CNV) that is seen in nAMD. This study was conducted with the objective to determine diagnostic accuracy and OCTA features of occult and classic CNV in patients with nAMD.MethodsIn this prospective observational study, 90 eyes of 58 patients with nAMD were studied with OCT, OCTA and FFA. OCTA scans were analyzed to qualitatively describe the morphological appearance of CNV in terms of location, pattern and configuration. The OCTA sensitivity and specificity for CNV detection were calculated by comparing it with FFA.ResultsFFA detected CNV in 70 of the 90 eyes (77.77%) whereas OCTA identified CNV in 69 eyes (76.7%). Among 69 eyes with CNV, it was well-defined in 51 (73.9%) eyes and poorly defined in 18 (26.1%) eyes. There were four false positive and five false negative cases. The sensitivity, specificity, positive predictive value and negative predictive value of OCTA in detection of nAMD were found to be 92.85%, 80.0%, 94.2 and 76.2, respectively.ConclusionOCTA is a useful, noninvasive, reproducible imaging tool for diagnosing, classifying and localizing CNV. The technique has high sensitivity and specificity and can be used reliably in cases where FFA is contraindicated or inconclusive.

Angiographic Subtypes of Neovascular Age-related Macular Degeneration in Korean: A New Diagnostic Challenge

Neovascular age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly population. Several classifications schemes have been developed to provide subtypes of neovascular AMD, which are known to be associated with visual prognosis. However, there is still a large proportion of patient with ambiguous findings according to current classification criteria. In this study, we classified treatment-naïve neovascular AMD patients using novel angiographic classification system and investigated the incidence and clinical characteristics of AMD subtypes. Among 339 eyes, five AMD subtypes were identified: 41 (12.1%) with classic choroidal neovascularization (CNV), 30 (8.8%) with occult CNV, 91 (26.8%) with microaneurysmal choroidal vasculopathy (MCV), 123 (36.3%) with polypoidal choroidal vasculopathy (PCV), and 54 (15.9%) with retinal angiomatous proliferation (RAP). MCV was younger than RAP (P < 0.001). Classic CNV presented with worse visual acuity compared with MCV at baseline (P < 0.001). Central macular subfield thickness was highest in RAP, and lowest in MCV (P = 0.036). Subfoveal choroidal thickness was highest in MCV, and lowest in RAP (P < 0.001). There was a significant difference in visual acuity at 12 months among five subtypes (P = 0.046). Our results highlight the importance of angiography for identifying AMD subtypes, particularly the novel MCV group being distinct from other subtypes.

Five-year treatment outcomes following intravitreal ranibizumab injections for neovascular age-related macular degeneration in Japanese patients.

To assess the real-world 5-year treatment outcomes of ranibizumab therapy in Japanese patients with neovascular age-related macular degeneration (AMD). This was a retrospective, observational, and open-label effectiveness study that included 295 eyes. The participants were patients with treatment-naïve neovascular AMD who received intravitreal ranibizumab (IVR) monthly injection at least three times as the loading phase, followed by further injections as needed (pro re nata (PRN)) and follow-up assessments for 5years. Outcomes were determined at least 5years after the first ranibizumab injection. Mean logMAR best-corrected visual acuity (BCVA) at baseline was 0.52. The mean BCVA significantly improved after three loading injections; however, it declined gradually. The BCVA at 1year was significantly better than the baseline BCVA, whereas the 3-year, 4-year, and 5-year BCVA values were significantly lower than the baseline values. The average central foveal thickness improved significantly from 366 ± 125μm to 268 ± 134μm (p < 0.0001). Macular atrophy was significantly more likely to occur in cases with classic choroidal neovascularization (CNV) than in cases with other AMD (p = 0.01). IVR is well tolerated in eyes with AMD. However, a PRN regimen for AMD may have limited real-world effectiveness for long-term maintenance of improved visual acuity. Macular atrophy may occur more frequently in classic CNV. To maintain good vision, IVR treatment should be started earlier and performed continuously.

Intravitreal aflibercept versus photodynamic therapy in Chinese patients with neovascular age-related macular degeneration: outcomes of the SIGHT study

Objective To assess the efficacy and safety of intravitreal aflibercept injection (IAI) compared with photodynamic therapy (PDT) in the treatment of Chinese patients with predominantly classic subfoveal choroidal neovascularization (CNV) lesions secondary to neovascular age-related macular degeneration (nAMD). Methods A randomized, double-blind, multi-center phase-3 clinical trial lasting for 52 weeks (from December 2011 to August 2014). Subjects were randomized in a 3:1 ratio to either IAI group or PDT-to-IAI group. Subjects in the IAI group received 2 mg IAI at baseline and at week 4, 8, 16, 24, 32, 40, 48, with sham injection at week 28, 36. Subjects in the PDT-to-IAI group were forced to receive PDT once at baseline and more time at week 12, 24 if PDT retreatment conditions were met. Sham injections were given in PDT-to-IAI group at baseline and at week 4, 8, 16 and 24, followed by 2 mg IAI at week 28, 32, 36, 40, 48. The primary outcome of efficacy were the change in mean Best Corrected Visual Acuity (BCVA) from baseline to week 28, and that of week 52. Safety evaluation included the percentage of subjects who suffered treatment emergent adverse events (TEAEs). Results Among the 304 subjects enrolled, there were 228 and 76 cases in IAI group and PDT-to-IAI group respectively. At week 28, the changes of mean BCVA in IAI group, PDT-to- IAI group compared to baseline were +14.0, +3.9 letters, respectively. At week 52, the changes of mean BCVA in two groups were +15.2, +8.9 letters respectively with the difference of +6.2 letters (95%CI 2.6−9.9, P=0.000 9). At week 52, the mean foveal retinal thickness in the two groups decreased by −189.6, −170.0 μm, respectively. Subjects with the most BCVA increase in IAI group were those aged <65, and those with active CNV lesion area <50% of total lesion area. The most common TEAEs in IAI group and PDT-to-IAI group are macular fibrosis [11.8% (27/228), 6.6% (5/76)] and BCVA decline [6.6% (15/228), 21.1% (16/76)]. There were 3 cases of arterial thromboembolic events defined in the antiplatelet experimental collaboration group, but all were considered unrelated to interventions. Conclusions The efficacy of aflibercept is superior to that of PDT in nAMD patients in China. The therapeutic effect of aflibercept persisted to week 52 in all subjects. The rate of adverse events was consistent with the safety data of aflibercept known before. Key words: Wet macular degeneration/drug therapy; Choroidal neovascularization/drug therapy; Angiogenesis inhibitors/therapeutic use; Antibodies, monoclonal/therapeutic use; Photochemotherapy

Increased serum levels of soluble CD146 and vascular endothelial growth factor receptor 2 in patients with exudative age-related macular degeneration.

To investigate serum levels of soluble CD146 (sCD146) and vascular endothelial growth factor receptor 2 (VEGFR2) in patients with age-related macular degeneration (AMD). Eighty-eight patients with exudative AMD and 45 sex- and age-matched healthy controls were enrolled in this study conducted in China. Serum samples was obtained from the patients with exudative AMD and from the controls. Serum sCD146 and VEGFR2 protein levels were measured using an enzyme-linked immunosorbent assay. We found that serum sCD146 and VEGFR2 protein levels were significantly higher in the patients with exudative AMD group than in the controls (t=3.859, P<0.001 and t=3.829, P<0.001, respectively). Serum sCD146 levels were significantly higher in patients with classic choroidal neovascularization (CNV) than in those with occult CNV (t=9.899, P<0.001). There was a significant difference in the trend for exudative AMD in the highest versus lowest quartile of circulating sCD146 levels (χ 2=10.29, P=0.001). The receiver operating characteristic curve analysis showed that the area under the curve was 0.696 for sCD146 (95%CI: 0.601-0.791) with an optimum diagnostic cut-off value of 157.16 ng/mL, a sensitivity of 55.7%, and a specificity of 82.2%. The serum sCD146 level increases and may be a biomarker for exudative AMD.

Five-Year Real-World Outcomes of Occult and Classic Choroidal Neovascularization: Data From the Fight Retinal Blindness! Project

To compare 5-year real-world outcomes of eyes with classic and occult choroidal neovascularization (CNV) treated with anti-vascular endothelial growth factor (anti-VEGF) injections. Retrospective analysis from a prospectively designed observational database. Treatment-naïve eyes diagnosed with occult or minimally or predominantly classic CNV that commenced anti-VEGF treatment between January 2007 and December 2012 were identified from a registry of neovascular age-related macular degeneration (nAMD) treatment outcomes. Baseline characteristics, visual acuity (VA) at 5 years, change in VA, time to first inactivation, number of injections, and proportion of visits graded with active nAMD over the 5 years were compared between the 3 groups. A total of 1929 eyes from 1730 subjects (1196 occult, 289minimally classic, and 444 predominantly classic CNV) were analyzed. Baseline VA (mean [standard deviation]) was higher in occult CNVs (56.9 [17.4] letters) than in minimally (52.9 [19.7] letters) and predominantly (49.1 [19.9] letters) classic CNVs (P= .003 and P < .0001, respectively). VA change was similar across the groups. At 5 years eyes with occult CNVs still had better VA than other CNVs. Age, lesion size, and baseline VA, but not CNV type, significantly affected final VA in the multivariate model. Predominantly classic CNVs became inactive sooner and were overall less active than other CNV types. The number of injections received was similar across the groups. Eyes with occult CNVs had overall a better VA than other CNVs. The difference in final VA was not significant after adjusting for baseline VA. Five-year outcomes and treatment patterns were not affected by the lesion type.

Risk Factors and Outcomes of Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy

We identified clinical characteristics and risk factors of choroidal neovascularization (CNV) in eyes with prior episode of central serous chorioretinopathy (CSC). This retrospective case-control study included those initially diagnosed with CSC and developed CNV secondarily (Group 1, n = 16), those diagnosed with CNV in eyes of previous putative CSC (Group 2, n = 14), and those initially diagnosed with CSC, and did not develop CNV secondarily, as a control group for Group 1 (Group 3, n = 250). Clinical characteristics including treatment outcomes were assessed. Demographics and multimodal imaging at the time of CSC diagnosis of secondary CNV were compared between the groups to identify risk factors. Duration from diagnosis of CSC to development of CNV in Group 1 was 40.2 ± 42.0 months. Classic CNV was noted in 23 (76.7%) eyes. After treatment with intravitreal antiangiogenics with average of 4.9 times, visual acuity improved in Group 1 and Group 2 (p = 0.002). Multivariate analysis revealed that systemic hypertension, pigmentary changes, and double layer sign were associated with development of CNV secondary to CSC (p < 0.05). Hypertension, pigmentary changes, and double layer sign were independent risk factors for CNV secondary to CSC. The CNV’s responded well to treatment, resulting in improved vision.

Spontaneous retinal pigment epithelial tear in type 2 choroidal neovascularization: repair mechanisms following anti-VEGF therapy

BackgroundTo report the clinical course and the multimodal retinal imaging of a spontaneous retinal pigment epithelial (RPE) tear in a type 2 choroidal neovascularization (CNV) secondary to age-related macular degeneration treated with anti-vascular endothelial growth factor (VEGF) treatment.Case presentationA 74 year-old man presented with visual acuity deterioration in the right eye. Multimodal retinal imaging showed a predominantly classic (type 2) CNV complicated by a spontaneous RPE tear. The patient received six intravitreal injections of anti-VEGF which resulted in improvement of the vision and stabilization of the neovascular lesion on optical coherence tomography (OCT). Longitudinal changes of the RPE-photoreceptors interface, including RPE splitting, are reported on OCT.ConclusionRPE tears may spontaneously occur in type 2 CNV. Anti-VEGF treatment should be aimed at promoting RPE repair and limiting the extent of the scarring. The mechanisms of RPE repair during treatment may be documented with OCT.

Assessment of Wet Age-Related Macular degeneration by Optical Coherence Tomography Angiography

Background: to date, fundus fluorescein angiography (FFA), remains the gold standard for the diagnosis of choroidal neovascular membrane (CNV). Optical coherence tomography angiography (OCTA) is a new imaging modality that allows a clear, depth-resolved visualization of the retinal vascular structures. Aim of the Work: to evaluate the role of OCTA in diagnosis of CNV in patients with age-related macular degeneration (AMD). Patients and Methods: this study enrolled 32 patients (40 eyes), including 20 patients (20 eyes) with wet AMD and 12 patients (20 eyes) with dry AMD. All patients underwent swept-source optical coherence tomography (SS-OCT), swept-source OCTA, and fundus fluorescein angiography (FFA). OCTA was used to evaluate neovascular networks in terms of their type, location and extent of visualization. Sensitivity and specificity of the method were assessed separately in a group of 20 CNV eyes and 20 dry AMD based on FFA diagnosis as the gold standard. Results: sensitivity and specificity of en face OCTA were 95% and 100% respectively. Both Sensitivity and specificity of structural OCT were 100%. Conclusion: OCTA enables diagnosis of both classic and occult choroidal neovascularization in patients with AMD. The method has high sensitivity and specificity.

Etiologies and Characteristics of Choroidal Neovascularization in Young Chinese Patients

Purpose: To investigate the etiologies and characteristics of choroidal neovascularization (CNV) in young Chinese patients. Methods: A retrospective review of young Chinese patients (< 50 years of age) with CNV from January 2010 to June 2016 was performed. Results: Of the 501 patients (537 eyes) with CNV, 58.7% were female, and 7.2% had bilateral CNV. The mean age was 35 years. The etiologies were idiopathic CNV (ICNV, 43.9%), pathologic myopia (PM, 21.9%), punctate inner choroidopathy (PIC, 17.4%), polypoidal choroidal vasculopathy (4.4%), multifocal choroiditis with panuveitis (3.6%), and other disorders (8.8%). Five hundred and six CNVs (94.2%) showed a predominantly classic CNV composition on fundus fluorescein angiography (FFA) and 316 CNVs (96.6%) were type 2 CNV on optical coherence tomography (OCT). Conclusion: The etiologies of CNV in young Chinese patients were diverse, and ICNV, PM, and PIC were the three most common etiologies. Most CNVs were classic on FFA and type 2 on OCT.

PREDICTORS OF ONE-YEAR VISUAL OUTCOMES AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

To determine predictors of best-corrected visual acuity (BCVA) outcomes 1 year after ranibizumab or bevacizumab treatment for neovascular age-related macular degeneration, within the French Study Group Avastin versus Lucentis for neovascular age-related macular degeneration (GEFAL). Patients aged ≥50 years presenting subfoveal neovascular age-related macular degeneration were randomized to receive ranibizumab or bevacizumab (3 monthly intravitreal injections followed by an as-needed regimen). The main outcome measures were BCVA and its change from baseline at 1 year. Variables with a P value <0.20 in the univariate model and/or which were clinically relevant were included in the multivariate analysis. The following baseline factors were associated with a lower BCVA score at 1 year and with less improvement in BCVA (multivariate analysis): intraretinal fluid, thickness of central subfield macular ≤277 μm, predominantly classic choroidal neovascularization, and total area of choroidal neovascularization (all P ≤ 0.01). Pigment epithelium detachment and high baseline BCVA were associated with less improvement in BCVA (P = 0.03, P = 0.05, respectively). Patients who met retreatment criteria but did not receive the corresponding injection had significantly poorer outcomes (only tested in the univariate analysis). This study confirms the predictors of BCVA score at 1 year posttreatment; the presence of intraretinal fluid was associated with a poor prognosis.

Topographic Correspondence of Macular Atrophy With Choroidal Neovascularization in Ranibizumab-treated Eyes of the TREX-AMD Trial

To quantify the extent of topographic correspondence between baseline (BSL) choroidal neovascularization (CNV) and macular atrophy (MA) at follow-up in eyes with neovascular age-related macular degeneration (NVAMD). Post hoc analysis of randomized controlled clinical trial data. Sixty treatment-naïve NVAMD patients from the TREX-AMD trial were followed for 18months. Regions of month 18 macular atrophy (MA) were graded on fundus autofluorescence (FAF) with guidance of spectral-domain optical coherence tomography (SDOCT). CNV lesions were graded manually on fluorescein angiography (FA) with lesion components including classic and occult CNV delineated. FAF and FA images were registered to quantitate area and location of overlap between CNV and MA. Outcome measures included overlap of month 18 MA to BSL CNV subtype and progression of MA from BSL to month 18. Twenty-six eyes had both MA at month 18 and CNV at BSL. A total of 84.6% of eyes showed evidence of MA and CNV overlap. MA appeared by month 18 in regions corresponding to BSL classic CNV in 36.4% of eyes and occult CNV in 40.9%, and in both regions in 22.7%, with more area of MA (AMA) in regions of occult than classic CNV. MA position at BSL corresponded to BSL classic CNV in 76.9% of eyes and occult CNV in 61.5%, and to both regions in 15.4%, with more AMA in regions of occult than classic CNV. Among eyes with MA and CNV at BSL but with no overlap, 50% progressed to involve regions with BS -CNV. Six eyes had no BSL MA but developed MA at month 18 within regions of BSL CNV. In ranibizumab-treated eyes with NVAMD, more MA lesions develop within the region of baseline CNV (type 1, CNV-based MA) than outside (type 2, CNV-independent MA). Baseline-MA also tends to be located within regions of CNV in the pretreatment phase.

Predictors of visual outcomes in patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor therapy: post hoc analysis of the VIEW studies.

Identify predictors for response to anti-vascular endothelial growth factor (VEGF) therapy in patients with neovascular (wet) age-related macular degeneration (nAMD). Retrospective, post hoc analysis of VIEW 1/2. Patients were randomized 1:1:1:1 to 0.5mg intravitreal aflibercept (IVT-AFL) injection every 4weeks (0.5q4); 2mg IVT-AFL every 4weeks (2q4); 2mg IVT-AFL every 8weeks (2q8) after an initial three injections at weeks 0, 4 and 8 or 0.5mg intravitreal ranibizumab every 4weeks (0.5q4). 1815 patients [IVT-AFL 2q4 (n=613); IVT-AFL 2q8 (n=607); ranibizumab 0.5q4 (n=595)] were included. Baseline demographics/characteristics were evenly balanced. Younger age (49-69years), lower visual acuity (VA) [10.0-≤45.0 Early Treatment Diabetic Retinopathy Study (ETDRS) letters] and smaller choroidal neovascularization (CNV) size [0.0-≤3.1 disc areas (DA)] at baseline were associated with the most vision gain (≥15 letters) over 52weeks (all nominal p<0.0001).Younger age, higher baseline VA (>64.0-≤83.0 letters) and smaller CNV size were associated with a VA ≥20/40 at week 52. Predominantly classic CNV at baseline (nominal p=0.0007), older age (≥90years), lower baseline VA (10.0-≤ 45.0 ETDRS letters) and larger CNV size (>10.1-≤32.6 DA) were all associated with a VA ≤20/200 at week 52 (all nominal p<0.0001). Along with treatment (nominal p<0.0001), lower VA (p=0.0166) and smaller central retinal thickness (both nominal p=0.0190) were predictors for dry retina development. Younger age, lower VA and smaller CNV size at baseline were all associated with greater vision gains over 52weeks while younger age, higher VA and smaller CNV size at treatment start were more likely to achieve best-corrected VA 20/40 or better after a year's treatment, suggesting the benefit of early anti-VEGF treatment.

Development and Course of Scars in the Comparison of Age-Related Macular Degeneration Treatments Trials

To describe risk factors for scar formation and changes to fibrotic scar through 5 years in the Comparison of Age-related Macular Degeneration Treatments Trials (CATT). Multicenter, prospective cohort study. A total of 1061 subjects in CATT. Color photographic and fluorescein angiographic images from baseline and 1, 2, and 5 years were evaluated. Incidence of scar formation was estimated with Kaplan-Meier curves. Risk factors were assessed with Cox regression models. Scar formation, fibrotic scar area, and macular atrophy associated with fibrotic scar ("atrophy"). Cumulative proportion of eyes with scar was 32%, 46%, and 56% at years 1, 2, and 5, respectively. Baseline factors associated with increased risk (adjusted hazards ratio [aHR] and 95% confidence interval [CI]) were classic choroidal neovascularization (CNV) (aHR, 4.49; 95% CI, 3.34-6.04) versus occult, hemorrhage >1 disc area (DA) (aHR, 2.28; 95% CI, 1.49-3.47) versus no hemorrhage, retinal thickness >212 μm (aHR, 2.58; 95% CI, 1.69-3.94) versus <120 μm, subretinal tissue complex thickness >275 μm (aHR, 2.64; 95% CI, 1.81-3.84) versus ≤75μm, subretinal fluid thickness >25 μm (aHR, 1.31; 95% CI, 0.97-1.75) versus no fluid, visual acuity (VA) in fellow eye 20/20 (aHR, 1.72; 95% CI, 1.25-2.36) versus 20/50 or worse, retinal pigment epithelium elevation absence (aHR, 1.71; 95% CI, 1.21-2.41), and subretinal hyperreflective material (aHR, 1.72; 95% CI, 1.25-2.36). Among 68 eyes that developed fibrotic scar at year 1, VA decreased by a mean of additional 13 letters between years 1 and 5. Mean scar area was 1.2, 1.2, and 1.9 DA at 1, 2, and 5 years, respectively. Atrophy was present in 18%, 24%, and 54% of these eyes at years 1, 2, and 5, respectively; the mean areas were 1.6, 2.0, and 3.1 DA, respectively. Atrophy replaced fibrotic scar in 8 eyes at year 5. There was no significant correlation between scar growth and atrophy growth. The rate of growth for both was similar between the clinical trial and observation periods. Several morphologic features, including classic CNV and large hemorrhage, are associated with scar formation. Rate of new scar formation declined after 2 years. Most fibrotic scars and accompanying macular atrophy expanded over time, reducing VA.