Comparison of intravitreal aflibercept and ranibizumab injections on subfoveal and peripapillary choroidal thickness in eyes with neovascular age-related macular degeneration

Prognostic Optical Coherence Tomography Biomarkers in Neovascular Age-Related Macular Degeneration

Optical coherence tomography has revolutionized the diagnosis and management of neovascular age-related macular degeneration. OCT-derived biomarkers have the potential to further guide therapeutic advancements with anti-vascular endothelial growth factor; however, the clinical convergence between these two tools remains suboptimal. Therefore, the aim of this review of literature was to examine the current data on OCT biomarkers and their prognostic value. Thirteen biomarkers were analyzed, and retinal fluid had the strongest-reported impact on clinical outcomes, including visual acuity, clinic visits, and anti-VEGF treatment regimens. In particular, intra-retinal fluid was shown to be associated with poor visual outcomes. Consistencies in the literature with regard to these OCT prognostic biomarkers can lead to patient-specific clinical decision making, such as early-initiated treatment and proactive monitoring. An integrated analysis of all OCT components in combination with new efforts toward automated analysis with artificial intelligence has the potential to further improve the role of OCT in nAMD therapy.

The effect of intravitreal brolucizumab on choroidal thickness in patients with neovascular age-related macular degeneration

In this study we evaluated the effect of intravitreal brolucizumab injections on choroidal thickness in patients with neovascular age-related macular degeneration (nAMD) who previously showed an incomplete response to anti-vascular endothelial growth factor treatment. A total of thirty-four eyes from 34 patients were included in this study. The patients received an average of 2.4 ± 1.1 brolucizumab injections with the mean follow-up period of 4.9 ± 2.0 months. After their first brolucizumab treatment, the central foveal thickness (CFT) and subfoveal choroidal thickness (SFCT) were significantly decreased from 431.6 ± 190.0 μm and 193.9 ± 75.1 μm to 274.6 ± 109.4 μm (P < 0.001) and 169.4 ± 71.1 μm (P < 0.001), respectively. However, there were no improvements in visual acuity. Patients were divided into three subgroups according to the number of brolucizumab treatments: one, two, and three or more injections. In all three subgroups, the CFT and SFCT were significantly reduced compared to baseline at all time points of brolucizumab injections. In conclusion, choroidal thickness was significantly reduced after intravitreal brolucizumab injections as a switching treatment in patients with nAMD.

Brolucizumab Intravitreal Injection in Macular Neovascularization Type 1: VA, SD-OCT, and OCTA Parameter Changes during a 16-Week Follow-Up

INTRODUCTION

The aim of this study was to assess early anatomical and functional changes after brolucizumab intravitreal injection (BIVI) in patients with age-related macular degeneration (AMD) and macular neovascularization type 1 (MNV1).

METHODS

A total of 24 eyes of 24 patients suffering from naïve AMD with MNV1 candidates to BIVI as per label with q12/q8 dosing regimen after the loading dose were enrolled in this prospective study. Main outcome measures during a 16-week follow-up period included changes in best corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal subretinal fluid (SSRF) thickness (SSRFT), subfoveal sub-retinal pigment epithelium (RPE) fluid thickness (SSRPEFT), subfoveal choroidal thickness (SFCT), and pigment epithelial detachment (PED) maximum height (PED-MH). In addition, MNV1 flow area; percentages of eyes with intraretinal fluid (IRF), subretinal fluid, and sub-RPE fluid at different time points; and percentages of eyes candidates to a q8 or q12 injection interval after disease activity assessment at week 16 were evaluated.

RESULTS

BCVA improved significantly from baseline (T0) to week 12 (T3) (p = 0.028). CMT showed a significant reduction from 456 ± 123 µm at T0 to 265 ± 85 µm at T3 (p < 0.001). SSRFT and SSRPEFT reduced significantly as well (p < 0.001 and p = 0.049, respectively). PED-MH and SFCT reduced significantly at the different time points (p = 0.020; p = 0.006, respectively). IRF presence changed significantly from 41.7% of eyes at T0 to 20.8% at T3 (p = 0.045). SSRF reduced significantly during follow-up, being present in 62.5% of eyes at T0 and 4.2% of eyes at T3 (p < 0.001). Subfoveal sub-RPE fluid decreased significantly during time, being present in 20.8% of eyes at T0 and 0% at T3 (p = 0.013). Most of the eyes (18 eyes, 75%) at week 16 after disease activity assessment were shifted in the q12 interval, and only a minority of eyes shifted in a q8 interval (6 eyes, 25%).

CONCLUSION

Brolucizumab is efficient in AMD patients with MNV1 by reducing all retinal fluids during the loading phase and shows reduction of macular thickness, choroidal thickness, and PED height. Most eyes at disease activity assessment (75%) fall into 12-week interval and the minority (25%) into the 8-week interval.

Short-Term Morphofunctional Changes in Previously Treated Neovascular AMD Eyes Switched to Brolucizumab

The purpose of the study is to explore the morphofunctional fluctuations in eyes treated for neovascular AMD (nAMD) when treatment is switched from aflibercept or ranibizumab to brolucizumab. A total of 31 eyes of 31 patients with nAMD with type 1 macular neovascularization (MNV) were included. All patients were imaged using spectral domain optical coherence tomography (SD-OCT). The OCT acquisition was performed at the following visits: (i) “T1 visit” corresponding to the last follow-up examination in which an intravitreal injection of aflibercept or ranibizumab was performed before switching to brolucizumab because of the lack of improvement and (ii) “T2 visit” corresponding to the examination performed 1 month after T1, the latter visit corresponding to the day when a switch to brolucizumab injection was performed, (iii) and 1 month after the latter injection “(T3)”. The main outcome measures were: (1) central macular thickness (CMT), (2) choroidal vascularity index (CVI), (3) subfoveal choroidal thickness (CT), and best-corrected visual acuity (BCVA). Functional outcome showed significant differences at each time. Mean ± SD BCVA was 0.43 ± 0.12 LogMAR at T1 and 0.56  ±  0.16 LogMAR at T2 (p = 0.038). A significant improvement in BCVA was displayed at T3 (0.34  ±  0.21 LogMAR) as compared with T2 (p  = 0.019). CMT analysis showed fluctuations three times. In detail, T2 displayed a thicker CMT in comparison with T1, although not statistically significant (p = 0.12). Contrariwise, T3 showed a thinner CMT in comparison with T2 (p = 0.002). Analyzing CVI among the three different times, the luminal choroidal area (LCA) and total choroidal area (TCA) showed significantly different values before and after switching to brolucizumab. T2 showed a significant reduction in both vessel lumen and total area compared with T1 (p = 0.032 and p  =  0.046, respectively). Moreover, T3 showed a greater value of both LCA and TCA in comparison with T2 (p = 0.008 and p  =  0.01, respectively). CT did not show significant differences at each time (p > 0.05). Our results reported early experiences on morphofunctional fluctuations in patients with nAMD who switched to brolucizumab. The anatomical impact of brolucizumab administration appears to result in choroidal vascular enlargement, accompanied by the resolution of subretinal fluid (SRF) and intraretinal fluid (IRF).

Choroidal Thickness Changes After Intravitreal Aflibercept Injections in Treatment-Naïve Neovascular AMD

Introduction

Choroidal thickness (CT) plays an important role in the pathogenesis of various ocular diseases, including neovascular age-related macular degeneration (nAMD). Previous studies evaluated the CT variations after anti-vascular endothelial growth factor (VEGF) injections in patients with nAMD, but the results are still controversial. The present study aimed to evaluate the CT at different times (15, 30, 60, 90, and 365 days) after intravitreal aflibercept injections and its correlation with the baseline CT in treatment-naïve patients with nAMD. Secondly, the study evaluated the correlation between CT variation at 365 days and the number of intravitreal injections received.

Methods

This was a prospective, open-label, single-arm pilot study. Twenty-one treatment-naïve nAMD eyes were enrolled. The study population underwent three monthly aflibercept injections (loading phase) and additional injections as needed (pro re nata regimen). A complete ophthalmological examination, including optical coherence tomography (OCT) was performed at each visit. CT was measured manually by two independent observers. All patients were evaluated at baseline and at 15, 30, 60, 90, and 365 days after the first intravitreal injection.

Results

CT showed a statistically significant reduction at days 15, 90, and 365 in comparison to baseline. However, the major reduction of CT was observed at day 15 and in eyes with a thicker choroid at baseline. No significant correlation between CT variation and the number of injections performed was found.

Conclusion

Our findings contribute to clarifying the role of aflibercept injections in choroidal vasculature, confirming its effect after the first 2 weeks. Moreover, CT can be considered as a potential biomarker, as it reflects the pharmacological effect of anti-VEGF drugs.

Subfoveal choroidal thickness after brolucizumab therapy for neovascular age-related macular degeneration: a short-term multicenter study

BACKGROUND/PURPOSE

Observation of choroidal thickness after anti-vascular endothelial growth factor (VEGF) therapy may be important for the ideal management of neovascular age-related macular degeneration (AMD). This study investigated changes in subfoveal choroidal thickness (SCT) during loading doses of intravitreal injections of brolucizumab in eyes with neovascular AMD.

METHODS

This study included 73 eyes of 72 patients with neovascular AMD at five university hospitals in Japan. All 73 eyes underwent three monthly 6.0 mg intravitreal injections of brolucizumab at baseline, 1 month, and 2 months. The SCT at 3 months was evaluated using optical coherence tomography.

RESULTS

The 73 eyes were classified into the treatment-naïve group (43 eyes) and the switched group (30 eyes) that were switched from other anti-VEGF treatments. After three intravitreal injections of brolucizumab, SCT significantly decreased from 236.5 ± 98.8 µm at baseline to 200.4 ± 98.3 µm at 3 months (percent of baseline 84.7%, P < 0.001) in the treatment-naïve group. In the switched group, SCT also significantly decreased from 229.0 ± 113.2 μm at baseline to 216.9 ± 110.2 μm at 3 months (percent of baseline 94.7%, P = 0.039), although the decrease was not as marked compared to that of the treatment-naïve group.

CONCLUSION

Intravitreal injections of brolucizumab for neovascular AMD significantly reduced the SCT in both the treatment-naïve and switched groups. Brolucizumab may cause significant anatomic changes in the choroid, particularly in treatment-naïve AMD eyes, possibly more than that previously reported for other anti-VEGF agents.

Assessment of choriocapillaris/Sattler and Haller layer changes after intravitreal injection in eyes with neovascular age-related macular degeneration: aflibercept vs ranibizumab

PURPOSE

To evaluate the changes in choriocapillaris (CC)/Sattler and Haller layer thicknesses in eyes with neovascular age-related macular degeneration (nAMD) after aflibercept or ranibizumab injections.

STUDY DESIGN

Retrospective.

METHODS

A total of 70 eyes of 70 patients with treatment-naïve exudative nAMD were treated with 3 consecutive injections of aflibercept (IVA) or ranibizumab (IVR). CC/Sattler and Haller layer thicknesses were measured at the nasal and temporal regions 1000 µm from the center of the fovea by enhanced-depth imaging optical coherence tomography at baseline and after the 3 monthly intravitreal injections. In addition, the hyperfluorescence region (HF) was measured as the largest horizontal diameter of the hyperfluorescence area on the early-middle phase fluorescein angiographic images at baseline and after the 3 loading doses.

RESULTS

After the 3 consecutive injections, the mean reductions in the nasal/temporal CC/Sattler layer thicknesses in the IVR and IVA groups were  - 10.1 ± 2.3/ - 8.5 ± 1.8 and  - 25.2 ± 15.2/ - 19.4 ± 12.8 μm, respectively. Also, the mean reductions in the nasal/temporal Haller layer thicknesses in the IVR and IVA groups were  - 6.5 ± 3.6/ - 7.2 ± 7.9 and  - 9.5 ± 8.0/ - 7.0 ± 6.2 μm, respectively. The changes in the CC/Sattler layer thicknesses of the IVA group were greater than those of the IVR group (P < .001); however, the changes in the Haller layer thickness were similar between the groups (P > .05). The mean decrease in the HF size of the IVA group was greater than that of the IVR group (P < .001).

CONCLUSIONS

Aflibercept treatment has a more pronounced effect on the CC/Sattler layer. Such results may indicate that aflibercept treatment influences choroidal neovascularization, possibly by reducing the capillary permeability associated with active neovascularization in the CC layer.

Choroidal Thickness Profile in Chorioretinal Diseases: Beyond the Macula

Enhanced depth imaging optical coherence tomography (EDI-OCT) and swept-source OCT (SS-OCT) have emerged as essential diagnostic tools in the study and management of various chorioretinal diseases. Evidence from early clinical studies using EDI-OCT and SS-OCT indicates that choroidal dysfunction plays a major role in the pathogenesis of chorioretinal diseases. Measurement of choroidal thickness (CT) has already become a major research and clinical method, and CT is considered as an indicator of choroidal status in a variety of ophthalmic diseases. Recently, CT measurement has also been proposed as a non-invasive marker for the early detection and monitoring of various systemic diseases. Among the several possible CT measurement locations, subfoveal CT has rapidly become a reliable parameter for measuring CT in healthy and diseased eyes. Moreover, recent advancements in OCT technology have enabled faster and wider imaging of the posterior part of the eye, allowing the various changes in CT as measured outside the macula to be shown accordingly. In this review, we first provide an overview of the results of clinical studies that have analyzed the healthy macular choroid and that in various chorioretinal diseases, and then summarize the current understanding of the choroid outside the macula. We also examine the CT profile as an index that encompasses both within and outside of the macula. Furthermore, we describe the clinical applications of ultrawide OCT, which enables visualization of the far periphery, and discuss the prospects for the development of more reliable choroidal parameters that can better reflect the choroid's characteristics.

Long-term effect of intravitreal aflibercept treatment on choroidal vascularity index in neovascular age-related macular degeneration

BACKGROUND

Our aim is to examine the effect of intravitreal aflibercept treatment on the choroidal vascularity index in eyes with neovascular age-related macular degeneration (nARMD) using the binarization method.

METHODS

Included in the study were the 38 eyes of 38 patients diagnosed with nARMD and treated with intravitreal aflibercept at our clinic. The patients' 12-month records were reviewed retrospectively. Patients' choroidal thickness (CT) was measured at baseline, 3rd month, 6th month, and 12th month on EDI-OCT images. We calculated luminal area (LA), stromal area (SA), total choroidal area (TCA), and choroid vascular index (CVI) values using binarization.

RESULTS

The mean age of the patients was 70,1 ± 8 years. The mean of injections over 12 months was 5.6 ± 2. Baseline values were CT 224 µm, LA 0,214 mm², SA 0,119mm², TCA 0,333 mm², and CVI 64% respectively. At the 3rd month, values were CT 223 µm, LA 0,212 mm², SA 0,121 mm², TCA 0,332 mm², and CVI 64%, respectively. The 6th-month values were CT 221 µm, LA 0,204 mm², SA 0,116 mm², TCA 0,320 mm², and CVI 64%, respectively, and 12-month values were CT 218 µm, LA 0,204 mm², SA 0,112 mm², TCA 0,318 mm², and CVI 64%, respectively. According to LogMAR, BCVA was 0.59 at baseline, 0.56 at 3 months, 0.52 at 6 months, and 0.51 at 12 months. At the end of month 12, we observed a statistically significant decrease in CT. No significant changes were observed in other parameters. When the number of injections was correlated with CVI, CT, and BCVA, a significant negative correlation was observed with CVI CONCLUSIONS: Aflibercept treatment reduces CT by affecting not only luminal but also stromal areas of the choroid in the long term but does not change the CVI. However, as the number of injections increases, CVI decreases.

Choroidal structural changes determined by the binarization method after intravitreal aflibercept treatment in neovascular age-related macular degeneration

AIM

To assess the choroidal structural alterations after intravitreal injection of aflibercept in neovascular age-related macular degeneration (nAMD).

METHODS

Fifty eyes with treatment-naïve nAMD were evaluated at baseline, 3^rd, and 12^th month. Fifty eyes of 50 healthy subjects were also included as controls. Choroidal thickness (CT) was measured in the subfoveal region. Total circumscribed choroidal area (CA), luminal area (LA), stromal area (SA), and choroidal vascularity index (CVI) was calculated using Image J.

RESULTS

At baseline, subfoveal CT was increased in nAMD patients compared to controls (P=0.321). Eyes with nAMD had a significantly increased total circumscribed CA and SA (P=0.041, 0.005, respectively). The CVI was decreased (P=0.038). In the 3^rd month, the subfoveal CT, LA, and CVI revealed a decrease (P=0.005, P=0.039, 0.043, respectively). In the 12^th month, subfoveal CT, LA, and CVI were decreased in comparison to baseline measures (P<0.001, 0.006, 0.010, respectively).

CONCLUSION

Significant structural alterations are found after intravitreal aflibercept treatment during the 12-month follow-up, in particular at the third month, in eyes with nAMD.

Short-term outcomes of intravitreal brolucizumab for treatment-naïve neovascular age-related macular degeneration with type 1 choroidal neovascularization including polypoidal choroidal vasculopathy

We evaluated the efficacy and safety of loading phase treatment with intravitreal brolucizumab for neovascular age-related macular degeneration (nAMD) with type 1 choroidal neovascularization (CNV). We analyzed consecutive 42 eyes of 40 patients with treatment-naïve nAMD associated with type 1 CNV. Three monthly injections of brolucizumab were completed in 36 eyes (85.7%). In those cases, best-corrected visual acuity (BCVA) was 0.24 ± 0.27 at baseline and improved significantly to 0.12 ± 0.23 after 3 months (P < 0.001). Central macular thickness was 301 ± 110 µm at baseline and decreased significantly to 160 ± 49 µm after 3 months (P < 0.001). Dry macula was achieved in 34 eyes (94.4%) after the loading phase. Central choroidal thickness was 264 ± 89 µm at baseline and decreased significantly to 223 ± 81 µm after 3 months (P < 0.001). Indocyanine green angiography after the loading phase revealed complete regression of polypoidal lesions in 15 of the 19 eyes (78.9%) with polypoidal lesions. Non-infectious intraocular inflammation (IOI) was observed in 8 of 42 eyes (19.0%) during the loading phase, while showing amelioration in response to combination therapy with topical and subtenon injection of steroids. In these eyes, BCVA after 3 months had not deteriorated as compared to that at baseline. These results indicate that loading phase treatment with intravitreal brolucizumab might be effective for improving visual acuity and reducing exudative changes in eyes with nAMD associated with type 1 CNV. Moreover, polypoidal lesions appear to frequently regress after this treatment. However, we must monitor patients carefully for brolucizumab-related IOI, and administer steroid therapy promptly.

Short-term choroidal vascular changes after aflibercept therapy for neovascular age-related macular degeneration

Introduction

The purpose of this study was to evaluate choroidal vascular changes in patients with neovascular age-related macular degeneration (nAMD) treated with aflibercept injection over a 3-month period.

Methods

Enhanced depth imaging optical coherence tomography scans of 60 eyes with treatment-naïve nAMD and 60 unaffected fellow eyes were retrospectively analyzed. Data was collected at baseline and after 3 monthly intravitreal injections of aflibercept. The ImageJ software was used to binarize OCT scans and measure total choroid area (TCA), luminal area (LA), and stromal area (SA). Choroidal vascularity index (CVI) was defined as the ratio of LA to TCA.

Results

After treatment, subfoveal choroidal thickness (CT) in nAMD eyes significantly decreased from 210. 6 ± 61.6 to 194.6 ± 58.7 μm (P < 0.001), TCA from 1.620 ± 0.502 to 1.500 ± 0.451 mm² (P < 0.001), LA from 1.075 ± 0.335 to 0.985 ± 0.307 mm² (P < 0.001), SA from 0.545 ± 0.176 to 0.516 ± 0.153 mm² (P = 0.005), and CVI from 66.36 ± 2.89 to 65.46 ± 2.87% (P = 0.009). The decrease of CVI after treatment was significantly correlated with baseline CVI (Rs = 0.466, P < 0.001), but not with the change in BCVA and presence of dry macula after treatment (always P > 0.05).

Conclusion

Choroidal thickness and vascularity significantly decreased after treatment with aflibercept in nAMD eyes. Besides the pharmacologic effect on the neovascular lesion, aflibercept may induce vascular changes also on the underlying choroid.

SHORT-TERM EFFICACY OF CONBERCEPT AND RANIBIZUMAB FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To compare the 6-month efficacy of the intravitreal injection of conbercept or ranibizumab for patients with polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective case-control study involved 79 PCV eyes of 77 patients. The PCV eyes were treated with an intravitreal injection of either ranibizumab (n = 44) or conbercept (n = 35). Three monthly loading doses were injected and followed by retreatment as needed. The best-corrected visual acuity and angiographic characteristics were evaluated after 6 months.

RESULTS

The mean logarithm of the minimum angle of resolution best-corrected visual acuity had improved from 0.86 (Snellen equivalent, 20/145) at baseline to 0.70 (Snellen equivalent, 20/100) at 6 months in the conbercept group (P < 0.001), and from 0.74 (Snellen equivalent, 20/110) at baseline to 0.63 (Snellen equivalent, 20/85) at 6 months in the ranibizumab group (P = 0.032), respectively. The central foveal thickness was decreased from 407 ± 146 μm to 230 ± 71 μm in the conbercept group (P < 0.001), and from 394 ± 93 μm to 208 ± 56 μm in the ranibizumab group (P < 0.001). Polyps were completely regressed and in 21 (47.7%) eyes in the conbercept group at 6 months, significant higher than in 10 (28.6%) eyes in the ranibizumab group (P = 0.029).

CONCLUSION

Both conbercept and ranibizumab effectively increased the visual acuity and regressed the polyps of PCV eyes. No significant difference was found in the visual acuity improvement of the patients with PCV between the conbercept group and ranibizumab group at 6 months. However, conbercept was superior to ranibizumab monotherapy in the regression of polyps.

The Efficacy of Intravitreal Conbercept for Chronic Central Serous Chorioretinopathy

Purpose

To evaluate the efficacy and safety of conbercept for patients with chronic central serous chorioretinopathy (CSC).

Methods

A retrospective clinical study. Thirty-one patients (35 eyes) with chronic CSC were given intravitreal injections of conbercept and followed up for at least 6 months. Observed indicators included best-corrected visual acuity (BCVA), central macular thickness (CMT), and resolution of subretinal fluid (SRF). Serial changes in BCVA and CMT were analyzed by using repeated measures analysis of variance.

Results

During the 6-month follow-up, the mean number of injections required and performed was 1.77 ± 0.60. The logMAR BCVA was 0.48 ± 0.26 at the baseline, 0.34 ± 0.26, 0.30 ± 0.26, 0.27 ± 0.26, 0.24 ± 0.26, and 0.23 ± 0.26 at 2-week and 1-, 2-, 3-, and 6-month follow-ups, respectively (F = 27.173, P < 0.05). CMT was 313.74 ± 144.51 μm at the baseline and decreased to 263.49 ± 120.44 μm, 225.91 ± 91.98 μm, 195.77 ± 66.69 μm, 189.74 ± 65.41 μm, and 199.49 ± 81.50 μm at 2-week and 1-, 2-, 3-, and 6-month follow-ups, respectively (F = 18.093, P < 0.05). Full resolution of SRF was achieved in 8 (22.9%) eyes at 1 month, 16 (45.7%) eyes at 2 months, 22 (62.9%) eyes at 3 months, and 27 (77.1%) eyes at 6 months after the initial treatment of anti-VEGF injection. No severe adverse event was noted relevant to the therapy.

Conclusions

Intravitreal injection of conbercept may effectively reduce the CMT and improve the BCVA in chronic CSC in a short term of 6 months.

Long-Term Changes in Submacular Choroidal Thickness after Intravitreal Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration: 14-Mo Follow-Up

Purpose: To study (i) the long-term effects of intravitreal ranibizumab treatment on changes in submacular choroidal thickness and (ii) the relationship between any resulting changes in choroidal thickness and visual outcomes following such treatment in patients with neovascular age-related macular degeneration (n-AMD). Methods: Reviewed were medical records of 30 consecutive, treatment-naïve, patients with unilateral n-AMD (n = 30 eyes) and unaffected fellow eyes (n = 26 eyes) (controls). Monthly injections of 0.5 mg ranibizumab were administered until stabilization of n-AMD, with additional injections as needed over the following 14-mo. Choroidal thickness was determined using enhanced-depth imaging-optical coherence tomography (EDI-OCT) before and after initiation of ranibizumab therapy. Choroidal thickness measurements were generated via manual segmentation. Results: The mean age of patients was 71.9 ± 7.4 (56-83) years; the mean best-corrected visual acuity (BCVA) of affected eyes improved from 51.1 to 59.4 letters (p < 0.001); and the mean number of injections was 9.16 ± 1.75. Subfoveal choroidal thickness decreased from 208.3 ± 73.7 μm at baseline to 185.3 ± 70.1 μm at mo-14 (p < 0.001), with significant (p < 0.001) decreases at all measured time points. Choroidal thickness also tended to decline in fellow eyes but was only statistically significant nasally 1,000 μm (p =0.04). Mean changes in choroidal thickness did not correlate with BCVA at mo-14 (p = 0.76). Disciform scars and geographic atrophy (p = 0.017), and BCVA (p < 001) at baseline were predictive of visual outcome. Age (p = 0.001), reticular drusen (p = 0.004), and size of choroidal neovascularized area (p = 0.042) were predictive of decreases in choroidal thickness. Conclusions: Submacular choroidal thickness appeared to decrease significantly in eyes with n-AMD over a 14-mo period of ranibizumab treatment. No corresponding decrease in choroidal thickness occurred in fellow eyes.

Correlation between macular structure and function in patients with age-related macular degeneration treated with intravitreal ranibizumab: 12-month-results

PURPOSE

To determine the significance of the correlation between optical coherence tomographic (OCT) findings and focal macular electroretinograms (fmERG) at 12 months after beginning intravitreal injections of ranibizumab (IVR) in eyes with age-related macular degeneration (AMD).

STUDY DESIGN

Prospective, clinical study.

METHOD

We studied 28 eyes of 28 patients with AMD treated with IVR at monthly intervals for the initial three months. Additional IVR was given according to a pro re nata (PRN) regimen. OCT and fmERGs were performed preoperatively and at 3 and 12 months postoperatively. The fmERGs were elicited by a 15° white stimulus spot centered on the fovea. The thickness of the inner, middle, and outer layers of the retina and also of the serous retinal detachment (SRD) and pigment epithelial detachment (PED) in the horizontal and vertical meridians at 1.2 mm from the fovea (parafoveal) were measured in the OCT images.

RESULTS

The b-wave amplitude at 12 months was significantly correlated with the thicknesses of the outer retinal layer, SRD, and PED (P=0.001-0.02). Multiple regression analyses showed that the outer retinal layer thickness was an independent determinant (P= 0.0001). The changes in the b-wave amplitude between the baseline and 12 months were significantly correlated with the changes in the SRD thickness (P=0.006). The changes in the b-wave amplitude during the PRN period were significantly correlated with the changes in the PED thickness (P=0.02).

CONCLUSIONS

At 12 months after beginning treatment, the reduction in the SRD thickness affects macular function recovery. As recurrences of the PED can occur during the PRN period, control of the PED is necessary to obtain good macular function for the long term.

Subfoveal choroidal thickness as a prognostic factor in exudative age-related macular degeneration

AIMS

To investigate the relationship between subfoveal choroidal thickness (SFCT), visual acuity (VA), optical coherence tomography (OCT) features and total anti-vascular endothelial growth factor (VEGF) treatments to determine whether SFCT serves as a prognostic factor in age-related macular degeneration (AMD).

METHODS

This is a retrospective case series of 62 consecutive treatment-naive patients with exudative AMD followed for 1 year and treated with treat-and-extend or pro re nata anti-VEGF protocols. SFCT was measured at three locations using Cirrus HD-OCT (the foveal centre and 500 um nasal and temporal to the fovea) at presentation, 3, 6 and 12 months. Demographic characteristics, OCT imaging biomarkers and VA were recorded.

RESULTS

Mean SFCT at baseline was 187 µm (range: 70-361 µm). There was a trend of decreasing SFCT at 1 year (173 µm) compared with 3 months (175 µm) and baseline (188 µm) (p=0.2). There was no correlation between baseline SFCT and presence of subretinal fluid (p=0.2), intraretinal fluid (p=0.6) or subretinal hyper-reflective material (p=0.4) at baseline. The mean number of injections at 1 year was 6.6 (range: 2-12). Increased SFCT at baseline showed statistically significant correlation with a higher number of intravitreal injections at 1 year (p=0.004). Eyes with SFCT>1 SD above the mean required 50% more injections compared with others. There was no association between SFCT on presentation with baseline and 1 year VA (p=0.7 and p=0.2).

CONCLUSIONS

SFCT in naïve patients with exudative AMD may be an important prognostic tool in determining treatment burden. Patients with thicker subfoveal choroid may require increased intravitreal injections.

Subfoveal Choroidal Thickness in Eyes with Neovascular Age-Related Macular Degeneration Treated with Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

We aimed to assess the subfoveal choroidal thickness (SFChT) and the effect of treatment with anti-vascular endothelial growth factor (anti-VEGF) agents on the SFChT in age-related macular degeneration (AMD) subtypes.

METHODS

We enrolled 128 eyes of 107 patients with neovascular AMD (60 women; 47 men; mean age, 73.6 ± 8.9 years), and prospectively evaluated the best-corrected visual acuity (BCVA) and SFChT at baseline and at 3, 6, and 12 months after treatment with anti-VEGF agents. Patients were assigned to the typical AMD, polypoidal choroidal vasculopathy (PCV), and retinal angiomatous proliferation (RAP) subgroups.

RESULTS

In total, 85 (66.4%), 31 (24.2%), and 12 (9.4%) eyes were assigned to the typical AMD, PCV, and RAP subgroups, respectively. The baseline mean BCVA was 0.75 ± 0.26, 0.72 ± 0.21, and 0.77 ± 0.24 logMAR in the typical AMD, PCV, and RAP subgroups, respectively (p = 0.774). The mean baseline SFChT was 203.20 ± 35.80, 271.80 ± 24.50, and 182.93 ± 31.31 µm, respectively (p < 0.001). Mean SFChT significantly decreased from baseline to 3, 6, and 12 months after treatment. The RAP subtype presented a significantly higher decrease in SFChT compared to the other subtypes (p = 0.01). The percentage reduction in SFChT was not significantly correlated with the number of injections (r = -0.02; p = 0.823). No association was observed between baseline SFChT and final visual acuity at 12 months (r = 0.0; p = 0.586).

CONCLUSIONS

SFChT was greatest in eyes with PCV and least in eyes with RAP. The reduction in SFChT after treatment was greater in the RAP cases. The decrease in SFChT after 12 months of anti-VEGF treatment was not associated with the number of injections and there was no correlation between the baseline SFChT and visual acuity in all AMD subtypes.

Quantification of Macular Vascular Density Using Optical Coherence Tomography Angiography and Its Relationship with Retinal Thickness in Myopic Eyes of Young Adults

Purpose

To quantify macular vascular density using optical coherence tomography angiography (OCTA) and to investigate its relationship with retinal thickness in myopic eyes of young adults.

Methods

In this cross-sectional study, 268 myopic eyes without pathological changes were recruited and divided into three groups: mild myopia (n = 81), moderate myopia (n = 117), and high myopia (n = 70). Macular vascular density was quantified by OCTA and compared among three groups. Average retinal thickness, central subfield thickness, and macular ganglion cell complex (mGCC) thickness were also evaluated and compared. Correlations among these variables were analyzed.

Results

There was no statistical difference in superficial (62.3 ± 5.7% versus 62.7 ± 5.9% versus 63.8 ± 5.5%) and deep macular vascular densities (58.3 ± 9.6% versus 59.2 ± 9.3% versus 60.9 ± 7.9%) among mild-myopia, moderate-myopia, and high-myopia groups (both P > 0.05). Superficial and deep macular vascular densities both had correlations with mean arterial pressure. Furthermore, superficial macular vascular density was significantly correlated with mGCC thickness.

Conclusions

Varying degrees of myopia did not affect macular vascular density in young healthy adults. In addition, superficial macular vascular density, as an independent factor, was positively correlated with mGCC thickness.

Effects of Aflibercept for Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis of Observational Comparative Studies

Purposes

To compare the effects of aflibercept and other anti-vascular endothelial growth factor (anti-VEGF) medications on both functional and anatomical outcomes for treatment-naïve neovascular age-related macular degeneration (nAMD) in the real world.

Methods

A systematic review and meta-analysis of observational comparative studies.

Results

A total of 18 studies remained after literature selection and quality assessment of 1697 studies. The most common aflibercept treatment regimen was three monthly injections followed by pro re nata (PRN). Aflibercept and ranibizumab had similar effects in 2-year treatment. At 3, 6, 12, and 24 months, the differences in the logarithm of minimum angle of resolution (logMAR) decrease in aflibercept and ranibizumab groups were 0.00 (95% confidence interval [CI]: −0.03 to 0.02); 0.01 (95% CI: −0.02 to 0.05); −0.03 (95% CI: −0.07 to 0.01); and –0.06 (95% CI: −0.30 to 0.17), respectively; the differences in decrease of central retinal thickness (CRT) were 3.25 μm (95% CI: −15.03 to 21.53); 7.89 μm (95% CI: −31.91 to 47.69); 2.89 μm (95% CI: −18.33 to 24.11); and −2.42 μm (95% CI: −77.87 to 73.03), respectively. However, aflibercept was significantly more effective in patients with initial reduced visual acuity (logMAR >0.6 or <55 letters; P = 0.001). In the first year, treatment frequency was not significantly different for aflibercept and ranibizumab, but aflibercept required fewer injections than ranibizumab with PRN regimen (mean −0.90; 95% CI: −1.80 to 0.00).

Conclusions

Aflibercept has comparable effects with ranibizumab for treatment-naïve nAMD in the real world, and may be more effective for patients with initial lower visual acuity.

Peripapillary Choroidal Thickness Change of Polypoidal Choroidal Vasculopathy after Anti-vascular Endothelial Growth Factor

Purpose

To investigate the peripapillary choroidal thickness (PCT) of polypoidal choroidal vasculopathy (PCV) and exudative age-related macular degeneration (AMD) and to evaluate their responses to anti-vascular endothelial growth factor (VEGF).

Methods

Thirty eyes with PCV and 25 eyes with exudative AMD who were treatment naïve were included in this study. PCT and subfoveal choroidal thickness were evaluated both before and after intravitreal anti-VEGF.

Results

The initial mean PCT of PCV (153.78 ± 56.23 µm) was thicker than that of exudative AMD (88.77 ± 23.11 µm, p < 0.001). Temporal, superior, nasal, and inferior PCTs of PCV were all thicker than those observedin exudative AMD (all p < 0.05). After anti-VEGF, the mean PCT of PCV was significantly reduced (134.17 ± 41.66 µm, p < 0.001), but the same was not true not in exudative AMD (86.87 ± 22.54 µm, p = 0.392). PCTshowed a similar tendency in all quadrants.

Conclusions

PCV exhibits a thick choroid in the peripapillary region. PCT decreases after anti-VEGF in PCV but not in exudative AMD. In exudative AMD, subfoveal choroidal thickness decreased, but that in the peripapillary region did not.

Vascular hypoperfusion in acute optic neuritis is a potentially new neurovascular model for demyelinating diseases

PURPOSE

Optic neuritis is highly correlated with multiple sclerosis and is a major cause of acute visual loss and long-term neuronal degeneration. Primary cerebral hypoperfusion has been reported in brain demyelinating diseases. This study investigated whether peripapillary perfusion is changed in patients with acute optic neuritis (AON).

METHODS

This three-year cohort study was conducted from September 1 2012, to August 31, 2015. Two hundred and forty-one patients with non-glaucomatous acute optic neuropathy were screened, and 42 non-highly myopic patients who had suffered their first episode of unilaterally idiopathic AON were studied. All cases received spectral-domain optical coherence tomography (OCT) examination, general survey, and standard corticosteroid therapy. OCT images were analyzed using a customized MATLAB program for measuring peripapillary choroidal thickness (PCT). Multivariate regression models were constructed to identify factors that are significantly related to peripapillary perfusion.

RESULTS

Decreased PCT was found in eyes experiencing AON combined with disc swelling (the ratio of lesion eye PCT/fellow eye PCT was 0.87 ± 0.08; range, from 0.75 to 1.00). In comparison to the healthy fellow eyes, approximately every 26% increase in the thickness of the retinal nerve fiber layer due to axonal swelling was associated with a 10% decreased thickness of PCT. Thinner PCT is also correlated with poorer trough vision, which may lead to poorer final vision. These findings were obvious in patients with optic papillitis but not in patients with retrobulbar neuritis.

CONCLUSIONS

Peripapillary vascular hypoperfusion was found in patients experiencing AON combined with disc swelling. These findings are unlike those for other ocular inflammatory diseases but are consistent with cerebral hypoperfusion, which is found in brain demyelinating diseases; thus, these findings may represent a new neurovascular model in this field.

Aflibercept in age-related macular degeneration: evaluating its role as a primary therapeutic option

The recent VIEW studies have demonstrated the non-inferiority of monthly and bi-monthly aflibercept in the management of wet age related macular degeneration (AMD) compared with ranibizumab. However, the current data are limited mainly to fixed dosing regimens with few studies looking at flexible dosing regimens of aflibercept in wet AMD. In addition, recent data from the VIEW 96 week extension has shown that patients being shifted from fixed dosing regimens to PRN have shown a drop in visual acuity and increase in central macular thickness. This is an indication that fixed dosing, a non-sustainable option, is only effective as long as it is continued. Regimens such as treat and extend (TAE) and pro-re nata (PRN) have been studied extensively in ranibizumab and bevacizumab and have shown to be effective options. With the presence of effective, established and less costly drugs such as ranibizumab and bevacizumab, the role of aflibercept as a primary treatment modality has yet to be clearly defined. The current review provides an analysis of the VIEW studies, as well as the extension phases. It also looks at post hoc analysis of predictors of response and outcomes. We have also conducted a search on studies comparing between PRN regimens using aflibercept and other anti-VEGF agents. This review also explores cheaper off label aflibercept; ziv-aflibercept in the treatment of wet AMD. The main purpose of the review is to delineate the role of aflibercept as a primary therapeutic option and if there are any significant advantages that would advocate its use over alternative anti-VEGF drugs. Finally, we propose a treatment algorithm for patients being started on aflibercept during the first year and thereafter.

Choroidal Thickness Changes After Intravitreal Ranibizumab for Exudative Age-Related Macular Degeneration

BACKGROUND

The results regarding changes of choroidal thickness following intravitreal ranibizumab injections in the literature are controversial. Vascular endothelial growth factor A is implicated in pathogenesis of neovascular age-related macular degeneration (AMD). The suspected unchanged choroidal layer thickness after intravitreal injections of ranibizumab suggests a possible protection of the outer blood-retinal barrier in the human eye.

OBJECTIVE

The aim was to evaluate choroidal thickness following the first administration of the study drug ranibizumab into the eyes of naïve wet AMD patients (nAMD).

METHODS

In this open label, 3-month, prospective, single-center, interventional, single-arm pilot study, 20 nAMD eyes were included and underwent three consecutive monthly injections of ranibizumab (0.5 mg/0.05 ml). Vital signs (i.e., blood pressure and pulse), ophthalmic examinations, intraocular pressure, best correct visual acuity and subfoveal choroidal thickness as examined with optical coherence tomography using enhanced depth imaging (OCT-EDI) were assessed at each visit. All patients were evaluated at baseline and at 15, 30 60 and 90 days after intravitreal injection. Ten eyes with fibrotic AMD lesions were evaluated as the control group.

RESULTS

In all eyes, the choroidal thicknesses (µm) exhibited no significant changes from the baseline visit to the visits at 15, 30, 60 and 90 days post-injection (P > 0.05). The intravitreal treatment with ranibizumab was well tolerated, and no adverse events were registered.

CONCLUSION

Choroidal thickness appeared to be unmodified following the intravitreal injection of ranibizumab into nAMD eyes. Intravitreal ranibizumab injections probably elicit a pharmacologic effect only in the choroidal neovascularization and not in the choroid circulation under neovascular lesions. Clinical Trials Eudract Registration #: 2013-005091-17.