Long-term outcome of intravitreal anti-vascular endothelial growth factor therapy with bevacizumab or ranibizumab as primary treatment for subfoveal myopic choroidal neovascularization. Eye (Lond). 2012;26:1004-1011. [PMID: 22595908 DOI: 10.1038/eye.2012.97]

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.

Progression of macular retinoschisis following intravitreal aflibercept injection for myopic macular neovascularization-a case report and review of literature

BACKGROUND

Macular retinoschisis (MRS) and myopic macular neovascularization (mMNV) are both potentially blinding complications of high myopia. In this case report, we highlight the progression of MRS after intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment for mMNV, as well as an extensive review of the literature on this topic.

CASE DESCRIPTION

A 49-year-old woman presented with two weeks of recent onset blurring and metamorphopsia in her right eye. She had high myopia in both eyes (right eye - 20/60 with - 16D, left eye - 20/20 with - 13D). Slit-lamp ophthalmoscopy found a normal anterior segment in both eyes. On fundus examination, features of pathological myopia with posterior staphyloma and peripapillary atrophy were observed in both eyes. An active mMNV, as well as intraretinal fluid, minimal perifoveal inner and outer MRS, and focal posterior vitreous traction along the inferotemporal retinal arcade, were detected on optical coherence tomography (OCT) of the right eye. The patient received an intravitreal injection of Aflibercept (2 mg/0.05 ml).

RESULTS

OCT scans at two- and four-month follow-up visits revealed regressed mMNV with a taut epiretinal membrane, progressive worsening of outer MRS, and the development of multiple perifoveal retinal detachment inferior to the fovea. Pars plana vitrectomy surgery was performed for the progressive MRS with good anatomical (resolved MRS) and functional outcome (maintained visual acuity at 20/60) at the last one-month post-surgery visit.

CONCLUSION

Intravitreal anti-VEGF injections for mMNV can cause vitreoretinal interface changes, exacerbating MRS and causing visual deterioration. Vitrectomy for MRS could be one of several treatment options.

Improved accuracy of spectral-domain optical coherence tomography and optical coherence tomography angiography for monitoring myopic macular neovascularisation activity

BACKGROUND/AIMS

To evaluate the diagnostic accuracy of spectral-domain optical coherence tomography (SD OCT) combined with OCT angiography (OCTA) for myopic myopic macular neovascularisation (MNV) activity.

METHODS

Both eyes of patients with myopic MNV diagnosed with fluorescein angiography (FA), SD OCT and OCTA were assessed by unmasked investigators. The images were deidentified and randomised before graded by masked investigators, who determined the presence of active myopic MNV by using SD OCT together with OCTA without FA and by FA alone, respectively. The findings of masked investigators were compared with unmasked investigators.

RESULTS

213 eyes of 110 patients comprising 499 imaging episodes were eligible for grading. For diagnosing new-onset myopic MNV without FA, combined use of SD OCT and OCTA had a sensitivity of 0.94, specificity of 0.84 and area under the curve (AUC) of 0.92. FA had a sensitivity of 0.52 (p<0.01), specificity of 0.80 (p=0.38) and AUC of 0.66 (p<0.01). For recurrent myopic MNV, the combination of SD OCT and OCTA had a sensitivity of 0.98, specificity of 0.78 and AUC of 0.88. FA had a sensitivity of 0.50 (p=0.04), specificity of 0.76 (p=0.85) and AUC of 0.63 (p=0.01). Myopic traction maculopathy was more frequently associated with recurrent myopic MNV (p<0.01).

CONCLUSION

SD OCT with dense volumetric scan was highly sensitive for diagnosing myopic MNV. The addition of OCTA improved the diagnostic specificity without FA. Monitoring of the longitudinal changes on SD OCT and judicious use of FA is a reliable surveillance strategy for myopic MNV.

Different approaches for treating myopic choroidal neovascularization: a network Meta-analysis

AIM

To evaluate the efficacy of intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), photodynamic therapy (PDT), and laser treatment (LT) for anatomical and functional improvement in myopic choroidal neovascularization (mCNV) patients.

METHODS

Two researchers independently searched PubMed, Cochrane Library, Web of Science, and other databases to screen studies comparing best-corrected vision acuity (BCVA) and foveal center thickness (FCT) changes after mCNV treatment. Post-treatment chorioretinal atrophy (CRA) is a secondary outcome indicator. The retrieval time limit is from the database construction to January 30, 2023.

RESULTS

A total of 1072 eyes in 16 articles were included. In the RCTs, intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) were superior to PDT (MD=0.18, 95%CI: 0.02, 0.40, MD=0.18, 95%CI: 0.01, 0.42) in improving BCVA of mCNV patients (P<0.05). The relative effectiveness in improving BCVA, from high to low, appeared to be IVR, intravitreal aflibercept (IVA), IVB, LT, PDT, and sham first followed by IVA (Sham/IVA). While improving the FCT from high to low was IVA, IVR, IVB, PDT. In retrospective studies, the results of BCVA after long-term treatment showed that all the therapeutic effects from high to low was IVA, intravitreal conbercept (IVC), IVR, IVB, IVB/IVR, PDT with IVB/IVR, PDT. The effect of improving FCT was IVA, IVR, IVC, PDT, and IVB from high to low. And in the effects of improving CRA, the IVB appeared to be higher than IVR, while the PDT was the smallest, but none of the differences in the results were statistically significant.

CONCLUSION

Anti-VEGF has the best effect on long-term vision improvement in mCNV patients, using IVB or IVR alone to treat mCNV may be better than IVB or IVR combined with PDT. There is no significant difference in the improvement of visual acuity, macular edema, and CRA in mCNV patients treated with any different anti-VEGF drugs.

PREDICTIVE ROLES OF QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES IN PROGNOSIS OF MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To explore the predictive roles of the morphologic features of neovascularization in the prognosis of myopic choroidal neovascularization.

METHODS

In this retrospective case series study, quantitative morphologic features of neovascularization were obtained from the optical coherence tomography angiography images. According to the number of anti-vascular endothelial growth factor injections administered within 1 year, the eyes were classified into a stable group (≤2 injections) or an unstable group (>2 injections). Best-corrected visual acuity was recorded before the treatment and at the 1-year follow-up.

RESULTS

Overall, 50 eyes with treatment-naive myopic choroidal neovascularization were included; 26 in the stable group and 24 in the unstable group. Multivariate analysis showed that the eyes in the unstable group were associated with a larger lesion area (odds ratio = 2.596, P = 0.012), higher junction density (odds ratio = 1.611, P = 0.014), and higher end point density (odds ratio = 1.435, P = 0.023).The area under the receiver operating characteristic curve of the multivariate model was 0.865, with 91.7% sensitivity and 65.4% specificity. The final best-corrected visual acuity was significantly correlated with the lesion area (β = 0.152, P = 0.032) after adjusted for age, sex, and baseline best-corrected visual acuity.

CONCLUSION

Lesions with larger areas and higher end point and junction densities tended to have more frequent anti-vascular endothelial growth factor injections and worse visual outcomes in eyes with myopic choroidal neovascularization.

Comparison of anatomical and functional outcomes of treating myopic choroidal neovascularization with bevacizumab or ranibizumab

PURPOSE

To compare results of treatment with bevacizumab and ranibizumab injections in myopic choroidal neovascularization (mCNV).

METHODS

Retrospective, observational case series.

PARTICIPANTS

patients with mCNV treated with bevacizumab or ranibizumab injections. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) on optical coherence tomography (OCT) scans were collected at baseline, after 3, 6, 12, 24 months and the last visit.

MAIN OUTCOME MEASURES

mean change in BCVA and CRT.

RESULTS

We included 85 eyes treated with bevacizumab and 125 eyes treated with ranibizumab. There was no difference between the groups regarding BCVA and CRT change. CNV recurrence occurred at the mean time of 66.1 ± 3.7 and 57.3 ± 6.4 months in the bevacizumab- and ranibizumab-treated eyes, respectively (p = 0.006). During the first year 6.9% eyes in the bevacizumab group vs. 27.5% in the ranibizumab group had CNV recurrence (p = 0.001). Risk factors for recurrence of CNV were baseline CNV area (aHR 1.20, 95%CI 1.0-1.32, p = 0.04), subfoveal CNV (aHR 2.13, 95% CI 1.16-3.93, p = 0.01) and ranibizumab treatment (aHR 2.31, 95% CI 1.16-3.93, p = 0.008).

CONCLUSION

Eyes treated with bevacizumab and ranibizumab can achieve similar anatomical and functional improvement. CNV recurrence may occur earlier and more frequently during the first year in eyes treated with ranibizumab.

Vitreoretinal Interface Changes After Anti-vascular Endothelial Growth Factor Treatment in Highly Myopic Eyes: A Real-World Study

INTRODUCTION

To investigate changes in the vitreoretinal interface after anti-vascular endothelial growth factor (anti-VEGF) treatment in highly myopic eyes.

METHODS

Eyes with myopic choroidal neovascularization (mCNV) treated with intravitreal injection of anti-VEGF in a single-center were retrospectively reviewed. Fundus abnormalities and features of optical computed tomography were studied.

RESULTS

A total of 295 eyes from 254 patients were recruited to the study. Prevalence of myopic macular retinoschisis (MRS) was 25.4%, and the rates of progression and onset of MRS were 75.9% and 16.2%, respectively. Outer retinal schisis (β = 8.586, p = 0.003) and lamellar macular hole (LMH) (β = 5.015, p = 0.043) at baseline were identified risk factors for progression and onset of MRS, whereas male sex (β = 9.000, p = 0.039) and outer retinal schisis at baseline (β = 5.250, p = 0.010) were risk factors for MRS progression. Progression of MRS was first detected in outer retinal layers in 48.3% of eyes. Thirteen eyes required surgical intervention. Spontaneous improvements of MRS were observed in five eyes (6.3%).

CONCLUSION

Changes in the vitreoretinal interface, such as progression, onset, and improvement of MRS, were observed after anti-VEGF treatment. Outer retinal schisis and LMH were risk factors of progression and onset of MRS after anti-VEGF treatment. Intravitreal injection of ranibizumab and retinal hemorrhage were protective factors for surgical intervention for vision-threatening MRS.

Optical coherence tomography biomarkers for myopic choroidal neovascularization treated with anti-vascular endothelial growth factor

In recent years, optical coherence tomography (OCT) biomarkers for specific retinal diseases have been found to be associated with treatment outcome and disease recurrence. The main purposes of this study were to identify OCT biomarkers for myopic choroidal neovascularization (mCNV) treated with intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF). OCT features in 43 eyes of 39 patients with mCNV treated with anti-VEGF with at least 1 year of follow-up were retrospectively analyzed. Eyes with subretinal hyperreflective material (SHM) in baseline spectral-domain OCT (SD-OCT) had significantly more visual improvement than eyes without SHM at month 6 (p = 0.007) and had a trend of more visual improvement than eyes without SHM (p = 0.058) at month 12. Eyes with subretinal fluid (SRF) at baseline had significantly more central retinal thickness (CRT) decrease than patients without SRF at month 6 and 12 (p = 0.012 and 0.006 respectively). In univariate regression analysis, dome-shaped macula (DSM), SRF in baseline OCT image and fuzzy border of mCNV when entering pro re nata (PRN) injection protocol tended to have higher risk of disease recurrence in 1 year (odds ratio: 14.86 (p = 0.003), 3.75 (p = 0.049) and 22.92 (p < 0.001) respectively). However, they were not significant in multivariate regression analysis. OCT biomarkers at baseline could provide prognostic information for mCNV management.

Myopic macular diseases: A review

Recent evidence has demonstrated that the global public health burden of myopia is rising rapidly. Highly myopic eyes are associated with increased frequency of eye disorders that can lead to irreversible visual impairment. With recent technological advancement in ophthalmic imaging modalities, various macular complications associated with pathologic myopia are being elucidated. The development and progression of myopic chorioretinal atrophy, myopic macular neovascularization, myopic traction maculopathy and dome-shaped macula are vision-threatening myopic macular diseases. In order to overcome the challenges in managing patients with pathologic myopia, it is important to have a complete understanding in the natural course of these myopic macular diseases. Standardising the classification criteria of pathologic myopia is essential for enhancing clinical surveillance. Personalised pharmaceutical therapy and surgical interventions will help to optimise the treatment outcomes in patients suffering from these myopic macular diseases.

Risk factors for myopic choroidal neovascularization-related macular atrophy after anti-VEGF treatment

Purpose

The study aimed to evaluate risk factors for macular atrophy (MA) associated with myopic choroidal neovascularization (mCNV) during long-term follow-up after intravitreal anti-vascular endothelial growth factor (VEGF) treatment in highly myopic eyes.

Methods

The medical records of patients who received intravitreal injection of anti-VEGF agents as mCNV treatment and were followed-up for more than 36 months were retrospectively reviewed. The risk factors for the development of mCNV-MA, which is the fovea-involving patchy atrophy lesion adjacent to mCNV, were investigated using the Cox proportional hazard model.

Results

A total of 82 eyes (74 patients) were included in the study. The mean age at anti-VEGF treatment was 56.3 ± 12.5 years (range, 26–77), and the mean follow-up period was 76.3 ± 33.5 months (range, 36–154). During follow-up, mCNV-MA developed in 27 eyes (32.9%), and its occurrence was estimated to be 24.5% at 3 years and 37.3% at 5 years after the first anti-VEGF treatment. Old age (hazard ratio [HR] = 1.054, 95% confidence interval [CI]: 1.018–1.091; P = 0.003) and greater CNV size at baseline (HR = 2.396, CI: 1.043–5.504; P = 0.040) were significant factors for mCNV-MA development. Eyes with a thinner subfoveal choroid were more likely to show faster enlargement of the mCNV-MA during follow-up.

Conclusions

In mCNV eyes treated with intravitreal anti-VEGF agents, older age and greater mCNV size at baseline were risk factors for the development of MA during long-term follow-up, which was associated with a poor visual prognosis.

Incidence, predictors and re-treatment outcomes of recurrent myopic choroidal neo-vascularization

Objectives

To evaluate incidence, predictors, and re-treatment outcome of recurrent myopic choroidal neovascularization (m-CNV).

Methods

Retrospective consecutive observational series. From year 2014 to 2019, 167 eyes of 167 patients of treatment naïve m-CNV were enrolled. 59 and 108 eyes were treated with intra-vitreal ranibizumab and bevacizumab mono-therapy, respectively. Recurrence was defined as re-appearance of CNV activity, confirmed on optical coherence tomography (OCT) after at least 3 months of cessation of anti-VEGF therapy. Incidence of recurrence, predictors and re-treatment outcomes were studied.

Results

Overall, mean age and spherical equivalence (SE) was 47.95 ± 14.72 years and -12.19 ± 4.93 D respectively. Males constituted 50.9%. 44 eyes (26.4%) had a recurrence during a mean follow up of 16.5 ± 12.86 months. Kaplan-Meier survival analysis showed the risk of recurrence was 8, 26 and, 33.6% at 6, 12 and 18 months, respectively. Age (p = 0.511), gender (p = 0.218), SE (p = 0.092), anti-VEGF (p = 0.629) and baseline BCVA (p = 0.519) did not influence recurrence. Number of injections administered to control the disease in the first episode was the only significant predictor of recurrence (Cox Proportional Hazard Ratio 2.89–3.07, 95% Confidence Interval: 1.28–7.45; p = 0.005). At 12 months, eyes requiring one injection in first episode had a recurrence rate of 12% versus 45% in eyes requiring 3 or more injections in the first episode. A mean number of 1.9 additional injections per eye was needed during re-treatment. Final BCVA in the recurrence group was similar to that of non-recurrence group (0.53 ± 0.40 versus 0.55 ± 0.36 LogMAR; p = 0.755). Baseline BCVA (p = 0.0001) was the only predictor of final visual outcome irrespective of anti-VEGF drug (p = 0.38).

Conclusion

Eyes requiring greater number of injections for disease control in first episode are “at risk” of early m-CNV recurrence. However, recurrence does not adversely affect visual outcome, if treated adequately.

The efficacy of different anti-vascular endothelial growth factor agents and prognostic biomarkers in monitoring of the treatment for myopic choroidal neovascularization

PURPOSE

To evaluate anatomical and visual results of eyes with naive myopic choroidal neovascularization (mCNV) in patients treated with intravitreal anti-vascular endothelial growth factor (VEGF) therapies.

MATERIAL AND METHODS

This is a retrospective, non-randomized, comperative, intervetional study. One hundred fourteen eyes of 114 patients with mCNV who underwent intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR) or intravitreal aflibercept (IVA) monotherapy injections were enrolled into the study. The best corrected visual acuity (BCVA), central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) were compared among the groups during the follow-up periods at the beginning, months 1, 3, 6, 12, and the final visit.

RESULTS

The mean age of the patients was 47.76 ± 10.57 years (range, 33-72 years) and the mean follow-up period was 23.34 ± 6.81 months (range, 13-38 months). The mean BCVA denoted a significantly improve at each group (p < 0.05). In terms of an inter-group analysis of all 3 groups, at months 1, 6, and 12 and final visit, the BCVA were statistically significantly better in the IVA group when compared to both IVB and IVR groups (p = 0.021, p = 0.032, p = 0.024, p = 0.012). There was a significant decrease in CMT following IVB (236.49 ± 40.91 μm-190.74 ± 50.12 μm), IVA (232.91 ± 46.29 μm-193.73 ± 46.81 μm) and IVR (234.78 ± 45.37 μm-192.21 ± 37.27 μm) between baseline and final visit (p = 0.018, p = 0.002, p < 0.001, respectively). There was a statistically significant decrease in SFCT values between baseline and final examination only in the IVA group (p < 0.001). The mean number of injections were 9.18 ± 3.18 (range; 3 to 13) in IVB, 6.46 ± 2.93 (range; 3-11) in IVR and 4.45 ± 1.42 (range; 2-7) in IVA (p = 0.028).

CONCLUSION

All three anti-VEGFs were found to be effective in terms of visual results in patients with mCNV. However, we demonstrated that IVA reduces the need for anti-VEGF when compared to patients who received both IVB and IVR. Furthermore, IVA induced a prominent reduction in SFCT, whereas IVR and IVB did not have a significant action on SFCT.

Vascular endothelial growth factor inhibitors for predominantly Caucasian myopic choroidal neovascularization: 2-year treatment outcomes in clinical practice: data from the Fight Retinal Blindness! Registry

Purpose

To report the 24‐month outcomes of vascular endothelial growth factor (VEGF) inhibitors for myopic choroidal neovascularization (mCNV) in predominantly Caucasian eyes in routine clinical practice.

Methods

Retrospective analysis of treatment‐naïve eyes starting intravitreal injection of VEGF inhibitors of either bevacizumab (1.25 mg) or ranibizumab (0.5 mg) for mCNV from 1 January 2006 to 31 May 2018 that were tracked in the Fight Retinal Blindness! registry.

Results

We identified 203 eyes (bevacizumab–85 and ranibizumab–118) of 189 patients. The estimated mean (95% CI) change in VA over 24 months for all eyes using longitudinal models was +8 (5, 11) letters with a median (Q1, Q3) of 3 (2, 5) injections given mostly during the first year. The estimated mean change in VA at 24 months was similar between bevacizumab and ranibizumab [+9 (5, 13) letters for bevacizumab versus +9 (6, 13) letters for ranibizumab; p = 0.37]. Both agents were also similar in the mCNV activity outcomes, treatment frequency and visit frequency.

Conclusions

The 24‐month treatment outcomes of VEGF inhibitors for mCNV were favourable in this largest series yet reported of predominantly Caucasian eyes in routine clinical practice, with approximately two lines of visual gain and a median of three injections given mostly during the first year. These outcomes are similar to those reported for predominantly Asian eyes. Bevacizumab appeared to be as safe and effective as ranibizumab.

Ten-Year Outcomes of Intravitreal Bevacizumab for Myopic Choroidal Neovascularization: Analysis of Prognostic Factors

The current standard treatment of myopic choroidal neovascularisation (mCNV) is intravitreal injection of VEGF antagonists. This study was proposed to assess efficacy and safety of intravitreal bevacizumab (IVB) for the treatment of mCNV across a 10-year follow-up. Thirty eyes of thirty patients with treatment-naïve mCNV who underwent IVB and were followed up with for a minimum of ten years were recruited for the present retrospective cohort study. All participants were treated with three monthly IVB at baseline and then evaluated and treated under pro re nata (PRN) schedule. Outcome measures were to determine BCVA changes over years and identify the predictive factors of both final visual outcome and need for retreatment. Analysis of the main involved prognostic factors with correlations among variables is reported. Visual acuity remained stable at 10-year follow-up (p = 0.001) with the greatest improvement at 2 years (p < 0.0001) in all CNV locations. Baseline BCVA correlated positively with final BCVA (β = 0.88, p < 0.0001, R²: 0.75). No predictive factors for the need of additional injections were identified. Retinal and choroidal thickness significantly reduced over time but without correlation with the number of injections. CNV max height and area significantly decreased at 10 years (p < 0.0001 and p = 0.003, respectively), with complete regression of mCNV lesion in 40% of subjects. Intravitreal bevacizumab resulted as long-term effective and safe therapy for mCNV with sustained results at 10 years.

Safety review of anti-VEGF therapy in patients with myopic choroidal neovascularization

INTRODUCTION

Anti-angiogenesis therapy with intravitreal anti-VEGF agents is now the standard-of-care treatment for myopic choroidal neovascularization (CNV).

AREAS COVERED

We provide a critical review of the safety of all the anti-VEGF agents currently used for treating myopic CNV including ranibizumab, aflibercept, conbercept, bevacizumab, and ziv-aflibercept.

EXPERT OPINION

Anti-VEGF therapy for myopic CNV with the currently available anti-VEGF drugs generally have favorable safety outcomes in the short-term. Nonetheless, ocular adverse events following anti-VEGF therapy for myopic CNV may develop and these include worsening or new development of myopic traction maculopathy, increased risk of retinal detachment, and progression of chorioretinal atrophy. Clinicians should be aware of these potential complications and evaluate them before and after anti-VEGF therapy.

Anti-VEGF Therapy in Myopic CNV

In this narrative-review, we report the most recent data from the literature of anti-vascular endothelial growth factor treatment for myopic choroidal neovascularization (mCNV). Myopic CNV is the most frequent sight-threatening complication of pathologic myopia. The natural course of mCNV can result in expanding macular atrophy and /or fibrosis, leading to irreversible visual loss after 5 years. Retinal multimodal imaging is mandatory for early diagnosis and monitoring of the disease during treatment. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended as the first-line treatment option for mCNV. Prompt treatment of active mCNV with intravitreal anti-VEGF therapy has been demonstrated to be effective in terms of visual outcome improvements reducing the occurrence of late-stage complications.

IMI Pathologic Myopia

Pathologic myopia is a major cause of visual impairment worldwide. Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia.

Owing to a recent advance in ocular imaging, an objective and accurate diagnosis of pathologic myopia has become possible. Especially, optical coherence tomography has revealed novel lesions like dome-shaped macula and myopic traction maculopathy. Wide-field optical coherence tomography has succeeded in visualizing the entire extent of large staphylomas. The effectiveness of new therapies for complications have been shown, such as anti-VEGF therapies for myopic macular neovascularization and vitreoretinal surgery for myopic traction maculopathy.

Myopia, especially childhood myopia, has been increasing rapidly in the world. In parallel with an increase in myopia, the prevalence of high myopia has also been increasing. However, it remains unclear whether or not pathologic myopia will increase in parallel with an increase of myopia itself. In addition, it has remained unclear whether genes responsible for pathologic myopia are the same as those for myopia in general, or whether pathologic myopia is genetically different from other myopia.

Usefulness of Denoising Process to Depict Myopic Choroidal Neovascularisation Using a Single Optical Coherence Tomography Angiography Image

Quality of single optical coherence tomography angiography (OCTA) images of myopic choroidal neovascularisation (mCNV) is poorer than in averaged images, although obtaining averaged images takes much time. This study evaluated the clinical usefulness of novel denoising process for depicting mCNV. This study included 20 eyes of 20 patients with mCNV. Ten en face images taken in a 3 × 3 mm macular cube were obtained from outer-retina-to-choriocapillaris layer. Three image types were prepared for analysis; single images before and after the denoising process accomplished deep learning (single and denoising groups, respectively) and up to 10 images were averaged (averaging group). Pairwise comparisons showed vessel density, vessel length density, and fractal dimension (FD) were higher; whereas, vessel density index (VDI) was lower in single group than in denoising and averaging groups. Detectable CNV indices, contrast-to-nose ratio, and CNV diagnostic scores were higher in denoising and averaging groups than in single group. No significant differences were detected in VDI, FD, or CNV diagnostic scores between denoising and averaging groups. The denoising process can utilise single OCTA images to provide results comparable to averaged OCTA images, which is clinically useful for shortening examination times with quality similar to averaging.

Long-term outcomes of the intravitreal injection of ranibizumab for the treatment of choroidal neovascularization secondary to pathologic myopia

PURPOSE

To analyze the long-term outcomes and safety of intravitreal ranibizumab injections in myopic choroidal neovascularization (CNV).

METHODS

A retrospective non-randomized analysis of consecutive cases included 17 eyes from 17 patients with subfoveal myopic CNV, treated with intravitreal ranibizumab with at least 30-month follow-up. The patients received three injections monthly, followed by pro re nata regimen. Best-corrected visual acuity (BCVA) measurement, optical coherence tomography and fluorescein angiography were carried out at the baseline and at monthly intervals thereafter.

RESULTS

Mean follow-up period was 51 months (range 30-98 months). In 12 patients (70.6%), BCVA improved by at least 1 Snellen line, with at least 3-line improvement observed in the case of 8 eyes (47%). Mean central foveal thickness (CFT) decreased from 384.65 ± 103.3 µm at the baseline to 264 ± 86.2 µm at the last follow-up examination (p < 0.001). The final OCT examination revealed 59% (10/17) eyes with CNV-related macular atrophy. Mean number of injections over the follow-up period was 4.82 ± 2.04 per person. Nine patients (53%) required re-injection of the anti-VEGF agent; the mean number of re-injections in this group was 3.44 ± 1.34 per person (range 2-6). No significant adverse events were recorded during the study period.

CONCLUSIONS

Intravitreal ranibizumab is an effective and safe treatment for CNV secondary to pathologic myopia, contributing to long-term vision improvement and CFT reduction.

The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema

BACKGROUND

Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy.

METHODS

The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed.

RESULTS

Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease.

CONCLUSION

Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

Comparison of structural and functional outcome of aflibercept versus ranibizumab in patients with myopic choroidal neovascularization

PURPOSE

To compare visual functional improvement and retinal structural changes of aflibercept versus ranibizumab for the management of treatment-naïve choroidal neovascularization related to pathological myopia.

PATIENTS AND METHODS

A prospective randomized study included patients suffering from myopic choroidal neovascularization. Patients received three intravitreal injections of aflibercept (2 mg) or ranibizumab (0.5 mg) in 1:1 ratio every 4 weeks. Ophthalmic evaluation and optical coherence tomography were performed at baseline, 1, 2, and 3 months after last injection. Primary outcome measure was the visual acuity change from baseline to month 3 after injection. Secondary outcome measures included change in retinal thickness and the relation of morphological and functional changes to baseline assessment parameters.

RESULTS

A total of 48 myopic patients (48 eyes) suffering from myopic choroidal neovascularization were randomly assigned to receive either aflibercept (Group A) or ranibizumab (Group B). In Group A, best-corrected visual acuity significantly improved from 0.53 ± 0.10 logMAR to 0.38 ± 0.11 logMAR, at 3 months, and from 0.55 ± 0.11 logMAR to 0.39 ± 0.12 logMAR in Group B. Whereas, retinal thickness reduced from 317.7 ± 53.6 µm to 164.5 ± 81.9 µm in Group A, and from 321.1 ± 98.8 µm at baseline to 178.9 ± 64.5 µm in Group B at month 3. Changes in best-corrected visual acuity and central macular thickness were statistically insignificant between the two groups at final visit.

CONCLUSION

Both aflibercept and ranibizumab provided a significant improvement in visual acuity and retinal thickness in patients with myopic choroidal neovascularization. Comparable functional and architectural results were achieved by both treatment modalities.

Comparison of Intravitreal Aflibercept and Ranibizumab for Treatment of Myopic Choroidal Neovascularization: One-Year Results-A Retrospective, Comparative Study

Purpose

To compare one-year treatment outcomes of intravitreal aflibercept (IVA) and intravitreal ranibizumab (IVR) for treatment of myopic choroidal neovascularization (mCNV).

Methods

The medical records of a total of 30 eyes diagnosed with mCNV and underwent IVA or IVR treatment for a minimum one-year follow-up were studied retrospectively. All the subjects had an axial length >26 mm and received a 1 + PRN (pro re nata) regimen IVA or IVR. Best-corrected visual acuity (BCVA) and central macular thicknesses (CMT) on optical coherence tomography were evaluated before and after treatment.

Results

There were 12 eyes in IVA group, with a mean age of 60.0 ± 10.2 years. The mean BCVA significantly improved from baseline 1.54 ± 0.76 to 0.85 ± 0.61 and the mean CMT significantly decreased from baseline 384.3 ± 119.1 μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and μm to 305.9 ± 75.4 μm to 305.9 ± 75.4 p : 0.024 and p : 0.024 and p : 0.024 and p : 0.024 and.

Conclusions

Both IVA and IVR treatment modalities resulted in similar anatomical outcomes but IVA had better visual outcomes in treatment of mCNV.

LONG-TERM OUTCOMES OF RANIBIZUMAB TREATMENT OF MYOPIC CHOROIDAL NEOVASCULARIZATION IN EAST-ASIAN PATIENTS FROM THE RADIANCE STUDY

A retrospective cohort study of East-Asian patients previously treated with ranibizumab for myopic choroidal neovascularization in the RADIANCE trial. Clinical charts were reviewed to assess long-term efficacy and safety. Visual acuity was sustained for additional 36 months after trial completion with few patients requiring additional treatment and no new safety concerns observed.

Purpose:

To evaluate long-term efficacy and safety of ranibizumab for treatment of myopic choroidal neovascularization (mCNV) in clinical practice.

Methods:

Noninterventional, retrospective cohort study of East-Asian patients previously treated with ranibizumab during the RADIANCE trial. Forty-one patients who completed the RADIANCE trial were followed-up for up to 48 months (post-RADIANCE observation period). Outcome measures were best-corrected visual acuity changes from baseline (assessed at RADIANCE trial initiation), mCNV recurrences, and ocular adverse events.

Results:

Mean visual gain from baseline best-corrected visual acuity (56.5 ± 12.1 letters) (20/80) was significant at 12 months (+14.3 ± 11.4 letters, n = 40, P < 0.0001), 24 months (+10.4 ± 22.3 letters, n = 31, P = 0.0143), 30 months (+11.0 ± 22.4 letters, n = 29, P = 0.0134), 42 months (+12.9 ± 20.9 letters, n = 25, P = 0.0051), and 48 months (+16.3 ± 18.7, n = 16, P = 0.0034). Of the 16 patients who completed 48 months of follow-up, 63% gained ≥10 letters and 13% lost ≥10 letters. Over the post-RADIANCE observation period, 83% of patients required no further treatment for mCNV, 10% experienced mCNV recurrences, and 12% experienced a nonserious ocular adverse event. Patients who required additional treatment for mCNV received a mean of 5.0 (SD 5.9, range 1.0–18.0) ranibizumab injections.

Conclusion:

Best-corrected visual acuity gained at the end of the RADIANCE trial was sustained over additional 36 months of follow-up. Few patients required further treatment and no new safety concerns were observed.

Progression and new onset of macular retinoschisis in myopic choroidal neovascularization eyes after Conbercept therapy: a post-hoc analysis

OBJECTIVES

The objective of this study is to evaluate the progression and new onset of macular retinoschisis (MRS) in the patients treated with intravitreal Conbercept injections for myopic choroidal neovascularization (mCNV).

METHODS

Post-hoc analysis of 160 mCNV patients included in SHINY study was performed to evaluate the impact of Conbercept injection on MRS in patients with mCNV undergoing intravitreal Conbercept injections. The patients were 3:1 randomized to the study group (three loading dose and thereafter pro re nata [PRN]) and the control group (3 months' sham injection, then one Conbercept injection at month 4 and thereafter PRN). MRS was assessed with optical coherence tomography by masked graders.

RESULTS

At baseline, 28 of 122 eyes in study group and 10 of 38 eyes in control group had MRS. At month 3, two patients showed MRS progression and one patient had new onset MRS in study group. No MRS progression nor new onset MRS was found in the control group. At final visit, the cumulative incidence of MRS was 1.3% (2/160). Both Spearman's correlation and multiple logistic regression demonstrated no association between the progression and new onset of MRS and intravitreal injection frequency (correlation coefficient = 0.017, P = 0.851 and odds ratio = 0.996, P = 0.982). In addition, baseline vitreoretinal adhesion was the most likely potential risk factor resulting in MRS progression (odds ratio = 4.566, P = 0.027). Furthermore, MRS progression was more likely to take place in outer retinal layers.

CONCLUSIONS

The progression and new onset of MRS was not associated with the frequency of intravitreal Conbercept injections.

Vascular remodeling of choroidal neovascularization in older myopic patients treated with ranibizumab

PURPOSE

To investigate morphological changes in myopic choroidal neovascularization (mCNV) using optical coherence tomography-angiography (OCT-A) after treatment with ranibizumab.

METHODS

Retrospective analysis of consecutive patients over a 24-month period. All treatment-naïve mCNV were imaged at baseline with color pictures, spectral-domain OCT and OCT-A, and fluorescein angiography in selected cases. CNV morphology was classified at baseline and at 6 months. The CNV lesion surface was also compared.

RESULTS

Twenty-nine patients with a mean age of 70.3 ± 10.1 years were included. They received a mean number of 2.65 injections over 6 months. Best-corrected visual acuity improved from 62.2 to 68.5 letters (p = 0.004), with regression of exudation in 24 eyes (82.7%). Baseline CNV was classified into tree-in-bud (16 eyes), medusa (9 eyes), or sea-fan (4 eyes) pattern. At 6 months, no abnormal blood flow was observed in CNV in 13 eyes. Eyes with complete regression or evolution towards an indistinct pattern showed more often a complete regression of exudation than eyes with unchanged pattern (p = 0.007). The mean CNV surface significantly decreased from 0.19 to 0.08 mm² (p < 0.0001).

CONCLUSION

An unchanged pattern was more often associated with exudation persistence, while a complete regression or evolution towards indistinct pattern was always associated with vascular inactivity. However, variable changes in mCNV were observed after anti-VEGF. Thus, OCT-A could be more useful in the diagnosis than in the follow-up of mCNV.

Nine-Year Outcome of Ranibizumab Monotherapy for Choroidal Neovascularization Secondary to Pathologic Myopia

PURPOSE

The aim of this study was to evaluate the 9-year outcome of ranibizumab monotherapy for myopic choroidal neovascularization (mCNV).

METHODS

This was a retrospective, nonrandomized, multicentric study to evaluate the long-term outcomes of mCNV treated with ranibizumab monotherapy for at least 9 years according to a strict pro re nata regimen.

RESULTS

Seventeen eyes of 17 patients (12 women, mean age 57.9 ± 7.7 years) were included. The mean follow-up period was 112.4 ± 3.9 months (range 108-120). The mean difference in best-corrected visual acuity (BCVA) from baseline to the last follow-up was +1.2 ± 15.6 ETDRS letters (p = 0.004, between initial vs. 12 and 24 months). The mean total number of intravitreal injections for each patient was 1.24 ± 1.70 per year (range 2-25). No systemic adverse reactions related to the drug treatment were detected during the 9-year follow-up period.

CONCLUSIONS

Long-term ranibizumab monotherapy treatment induces unchanged or better BCVA compared to baseline after a 9-year treatment in almost all eyes.

Anti-Vascular Endothelial Growth Factor Therapy for Myopic Choroidal Neovascularization

Myopic choroidal neovascularization (CNV) is one of the most vision-impairing complications in patients with pathologic myopia. It is also one of the most frequently encountered non.age-related macular degeneration causes of CNV and affects young patients in the working age group. Fluorescein angiography (FA) and spectral domain optical coherence tomography (OCT) are generally indicated to confirm the diagnosis of active myopic CNV before initiation of treatment. Without treatment, natural history studies have shown that the vision outcome can be very poor. More recently, a number of retrospective, prospective and phase 3, multicenter, randomized controlled trials have established the safety and efficacy of intravitreal anti.vascular endothelial growth factor (VEGF) agents for the treatment of myopic CNV. Long-term follow-up studies have found that some of the initial vision gained after intravitreal anti-VEGF therapy may not be maintained, owing to the presence and progression of chorioretinal atrophy (CRA) adjacent to the CNV. Further research on clinical and imaging characteristics may elucidate the prognostic factors that are crucial to optimizing the treatment and prevention of visual impairment associated with myopic CNV.

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.

VISUAL ACUITY OUTCOMES OF RANIBIZUMAB TREATMENT IN PATHOLOGIC MYOPIC EYES WITH MACULAR RETINOSCHISIS AND CHOROIDAL NEOVASCULARIZATION

Myopic macular retinoschisis (MRS) is a progressive, degenerative alteration in pathologic myopia and may be found in conjunction with myopic choroidal neovascularization. Frequent and continuous ranibizumab treatment effectively control myopic choroidal neovascularization in eyes with MRS and lead to satisfying treatment results.

Purpose:

To investigate visual and morphological outcome in eyes with MRS and choroidal neovascularization (CNV) secondary to pathologic myopia treated with intravitreal (IVT) ranibizumab.

Methods:

Post hoc analysis of the patients included in the RADIANCE trial (n = 277) was performed to evaluate the impact of MRS on the functional outcome in patients with myopic choroidal neovascularization (mCNV) undergoing intravitreal ranibizumab injections.

Results:

Prevalence of MRS in pathologic myopia population is 6%. Respective patients were generally older than patients without MRS. Study eyes with MRS at baseline (BL) showed an initially poor treatment response after 3 months (mean change in best corrected visual acuity (BCVA) was 2.8 ± 12.4 letters, P = 0.009). After 12 months of treatment however, the mean change in BCVA was 7.1 ± 14.5 early treatment diabetic retinopathy study (ETDRS) letters (P = 0.025). Patients with MRS at baseline received more intravitreal injections than the other RADIANCE patients without MRS (MRS, n = 15 eyes: 5.8 ± 2.1 vs. RADIANCE non-MRS [n = 207 eyes]: 4.0 ± 2.9; P = 0.0001).

Conclusion:

Improvement of visual acuity is delayed and reduced after 3 months intravitreal ranibizumab in eyes with MRS and myopic choroidal neovascularization compared to eyes without MRS. More ranibizumab injections are needed in eyes with MRS to gain comparable BCVA at Month 12.

SUBRETINAL FIBROSIS AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EYES WITH MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To assess the incidence and risk factors of subretinal fibrosis and their impact on visual outcome in eyes with myopic CNV.

METHODS

Medical records of 72 eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy in a pro re nata regimen for myopic CNV that followed up for more than 1 year were retrospectively reviewed. The presence of subretinal fibrosis after anti-VEGF therapy was determined using both fundus photographs and optical coherence tomography. The incidence and risk factors of subretinal fibrosis were evaluated, and best-corrected visual acuity was compared between the eyes with and without subretinal fibrosis.

RESULTS

The incidences of subretinal fibrosis during the 1-year and whole follow-up period were 31.9% and 36.1%, respectively. Occurrence of subretinal fibrosis was associated with frequent CNV recurrence (P = 0.005) and poor baseline best-corrected visual acuity (P = 0.044) in a Cox proportional hazard model. Anatomically, the eyes with subretinal fibrosis showed more frequent progression of chorioretinal atrophy (95.7% vs. 71.4%, P = 0.027) and less frequent photoreceptor recovery (17.4% vs. 65.3%, P < 0.001) after anti-VEGF therapy. Occurrence of subretinal fibrosis was associated with poor vision at baseline (P = 0.011) and the final visit (P = 0.008) when compared with the findings in the nonoccurrence group.

CONCLUSION

Development of subretinal fibrosis after anti-VEGF therapy was common in eyes with myopic CNV and was associated with CNV recurrence. Myopic eyes with subretinal fibrosis show progressive chorioretinal atrophy and poor visual outcome.

Pathologic Myopia

Pathologic myopia (PM) is the only myopia that causes the loss of best-corrected visual acuity. The main reason for best-corrected visual acuity loss is complications specific to PM, such as myopic maculopathy, myopic traction maculopathy, and myopic optic neuropathy (or glaucoma). The meta-analyses of the PM study group (META-PM study) made a classification system for myopic maculopathy. On the basis of this study, PM has been defined as eyes having atrophic changes equal to or more severe than diffuse atrophy. Posterior staphyloma and eye deformity are important causes of developing vision-threatening complications. Posterior staphyloma is unique to PM, except for inferior staphyloma due to tilted disc syndrome. It is defined as an outpouching of the wall of the eye that has a radius of curvature that is less than the surrounding curvature of the wall of the eye. The mechanical load onto the important region for central vision (optic nerve and macula) is not comparable between eyes with and without posterior staphyloma. Three-dimensional magnetic resonance imaging is a powerful tool to analyze the entire shape of the eye. When ultra-widefield optical coherence tomography is available, it is expected to be a new tool that will surpass 3-dimensional magnetic resonance imaging. In the future, preventive therapies targeting staphyloma and eye deformity are expected before vision-threatening complications develop and it is too late for patients.

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.

Clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization

BACKGROUND/PURPOSE

This study aims to evaluate the clinical characteristics and visual outcome of macular hemorrhage in pathological myopia with or without choroidal neovascularization.

METHODS

We conducted a retrospective study of 55 patients with macular coin hemorrhage who were followed for at least 3 months from January 1997 to December 2013 at Shin Kong Wu Ho-Su Memorial Hospital (Taipei, Taiwan). All patients were evaluated using fluorescein angiography and optical coherence tomography for the detection of choroidal neovascularization (CNV). We also recorded clinical characteristics such as age, sex, refractory error, and myopic fundus, to determine the relationship between CNV and non-CNV associated macular hemorrhage.

RESULTS

A total of 55 patients (30 females, 54.55%) were reviewed. The mean age was 39.7 years old. The CNV group was found to be significantly older than the non-CNV group (p < 0.05), and there was no significant difference between sex, visual acuity myopic severity, and the prevalence of fundus findings between CNV and non-CNV groups. Twenty one patients (38.18%) were found to have CNV and were all treated with intravitreal antivascular endothelial growth factor (VEGF). The other 34 patients without CNV were not treated. In both groups, the visual acuity significantly improved (anti-VEGF treated, CNV associated group, 0.7 to 0.39, p = 0.002, and untreated, non-CNV associated group, 0.56 to 0.34, p = 0.0018, respectively).

CONCLUSION

Age significantly correlated to the CNV formation in high myopia with macular hemorrhage. Favorable visual outcomes were found in pathological myopic macular hemorrhage either in the anti-VEGF treated, CNV associated group or in the untreated, non-CNV associated group.

Detection of Myopic Choroidal Neovascularization Using Optical Coherence Tomography Angiography

PURPOSE

To assess whether optical coherence tomography angiography (OCTA) can be used as an alternative to conventional fundus fluorescein angiography (FFA) for the detection of myopic choroidal neovascularization (CNV).

DESIGN

Validity and reliability analysis.

METHODS

Twenty-eight eyes of 26 consecutive Japanese patients with exudative lesions associated with pathologic myopia were included in this institutional study. Myopic CNV was detected in 23 eyes of 22 patients; 5 eyes exhibited simple hemorrhage. The main outcome measure was CNV detection by OCTA and FFA. The CNV area was individually measured by FFA and OCTA. Intraclass correlation coefficients (ICCs) for the CNV area, independently measured by 2 investigators using OCTA and FFA, were determined.

RESULTS

OCTA images with sufficient quality for CNV assessment were obtained for 17 eyes with CNV and 4 without. FFA alone detected CNV in all 17 eyes, while OCTA alone detected CNV in 16 (94.1%). The 1 eye for which CNV was not detected by OCTA exhibited a 0.01 mm(2) area on FFA. Both FFA and OCTA did not detect CNV in eyes with simple hemorrhage. The mean CNV areas on FFA and OCTA were 0.59 ± 0.56 mm(2) and 0.51 ± 0.55 mm(2), respectively; the 2 values were significantly correlated (P < .001, r = .86). The ICC (2, 1) values for FFA and OCTA were 0.944 and 0.997, respectively.

CONCLUSIONS

Our results indicate that OCTA can detect most myopic CNVs if high-quality images are acquired and can preclude the requirement for FFA in these settings.

The role of anti-VEGF agents in myopic choroidal neovascularization: Current standards and future outlook

INTRODUCTION

The global prevalence of pathologic myopia is 0.9-3.1%, and visual impairment is found in 0.1-0.5% of European and 0.2-1.4% of Asian studies. Myopic choroidal neovascularization (mCNV) affects 5.2-11.3% of pathologic myopia patients and is a leading cause of vision impairment in the working-age population. Characteristic morphological changes and visual-acuity decrease are diagnostic features. Vascular-Endothelial-Growth-Factor (VEGF) has been identified as a trigger for pathologic neovascularization in these highly myopic patients.

AREAS COVERED

We cover the epidemiology, pathology and diagnostic aspects of mCNV. The history of therapeutic interventions is described, followed by an overview of current standard-of-care (SOC)-blocking VEGF using bevacizumab (off-label), ranibizumab or aflibercept and improving vision up to 13.5-14.4 letters. Despite good efficacy, an unmet medical need remains. We summarize ongoing and future developments of new drugs to treat or potentially cure mCNV.

EXPERT OPINION

mCNV is a major global health concern. Early detection and treatment is key for a satisfying outcome. The current SOC, VEGF inhibitors, affords good therapeutic efficacy and reasonable disease stabilization with few intravitreal treatments per year. However, the long-term prognosis is still unsatisfactory, and side-effects like chorioretinal atrophy development are of concern. Therefore, efforts should be intensified to develop more effective therapies.

Understanding the Determinants of Myopic Choroidal Neovascularization and Response to Treatment

Purpose

The pathophysiologic pathways that govern the development of choroidal neovascularization (CNV) are complex. Patchy atrophy and lacquer cracks are known to be major anatomic risk factors for the development of myopic CNV, but they are not alone and much remains to be understood about other factors that influence development. In addition, a greater understanding of the modifiable and nonmodifiable factors that influence outcome, resolution, and recurrence after intravitreal injection of anti-vascular endothelial growth factor (VEGF) could lead to more personalized treatment algorithms that integrate parameters other than the presence of CNV itself and could help improve clinical outcomes and reduce recurrence.

Methods

We reviewed recently published data on risk factors for CNV and predictors of response to anti-VEGF treatments. In particular, data pertaining to age, sex, genetic predisposition, baseline visual acuity, axial length, staphyloma, lacquer cracks, atrophic lesions, choroidal thickness or choroidal thinning, characteristics of CNV such as duration, localization, and size of CNV, and treatment considerations such as choice of treatment, loading doses, and combination treatments were reviewed.

Results

Our analysis showed that the body of evidence is incomplete.

Conclusions

Additional studies are required to identify high-risk patients and to develop personalized therapeutic approaches.

Aflibercept as primary treatment for myopic choroidal neovascularisation: a retrospective study

AIM The aim of this study is to evaluate long-term efficacy of intravitreal injections of aflibercept as primary treatment for subfoveal/juxtafoveal myopic choroidal neovascularisation (CNV).METHODS Thirty-eight treatment-naive eyes of thirty-eight patients with subfoveal/juxtafoveal myopic CNV received initial intravitreal aflibercept injections and were followed for at least 18 months. Aflibercept was applied again for persistent or recurrent CNV, as required. Statistical analysis was carried out using SPSS.RESULTS Mean patient age was 45.8 years, and mean eye refractive error was -7.79 D. For the total patient group (n=38 eyes), mean logMAR best-corrected visual acuity (BCVA) significantly improved from 0.69 at baseline to 0.15 at 18 months (P<0.01). Over half of the treated eyes obtained resolution with one aflibercept injection. Patients were also grouped according to age, as <50 years (n=20 eyes) and ≥50 years (n=18 eyes). Mean BCVA improvement was significantly greater in eyes of the younger myopic CNV group, compared with those of ≥50 years (0.21 vs 0.35; P<0.05). The mean number of aflibercept injections was 1.8 for the <50 years myopic CNV group, and 3.6 for the ≥50 years myopic CNV group (P<0.001). Correlation between spherical equivalent refraction and final visual acuity reached statistical significance only for the <50 years myopic CNV group (P<0.001; Levene's correlation).CONCLUSIONS Intravitreal aflibercept provides long-term visual acuity improvement in myopic CNV. The <50 years old myopic CNV group had significantly fewer injections, with greater visual acuity improvement. Intravitreal aflibercept in myopic CNV does not require the three-injection loading phase used for aflibercept treatment of neovascular age-related macular degeneration.

[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.