Ten‐year outcomes of anti‐vascular endothelial growth factor treatment for neovascular age‐related macular disease: A single‐centre French study

Long-term results of treatment of neovascular age-related macular degeneration using antiangiogenic drugs: A review of the literature

Age-related macular degeneration (AMD) is one of the main causes of visual acuity (VA) loss in people over 50 years of age worldwide, with neovascular AMD (nAMD) accounting for 80% of cases of severe vision loss due to this disease. Anti-vascular endothelial growth factor (anti-VEGF) drugs have been used for the treatment of this disease for more than a decade, changing drastically the visual prognosis of these patients. However, initial studies reporting data on outcomes were short term. Currently, there are different series published on the long-term results of AMD after treatment with anti-VEGF, and the aim of this review is to synthesize these results. The mean follow-up of the included studies was 8.2 years (range 5-12 years). The mean initial VA was 55.3 letters in the Early Treatment Diabetic Retinopathy Study (ETDRS) (range 45.6-65) and the mean final VA was 50.1 letters (range 33.0-64.3), with a mean loss of 5.2 letters. At the end of follow-up, 29.4% of the patients maintained a VA > 70 letters. The 67.9% of patients remained stable at the end of follow-up (< 15 letter loss), with a severe loss (≥ 15 letters) of 30.1%. Fibrosis and atrophy were the main causes of long-term VA loss, occurring at the end of follow-up in 52.5% and 60.5%, respectively.

The complement pathway as a therapeutic target for neovascular age-related macular degeneration-mediated subretinal fibrosis

Neovascular age-related macular degeneration (nAMD) is the leading cause of blindness in the elderly in developed countries. Intravitreal injection of VEGF inhibitors is the mainstream therapy for nAMD, although nearly 50% of the patients do not respond or respond poorly to the therapy. One of the main reasons for the poor outcome of the therapy is the development of subretinal macular fibrosis, a process of excessive deposition of extracellular matrix proteins around the diseased blood vessels. Currently, there is no medication to prevent or treat the condition. Here, we discussed recent advances in the pathogenesis of nAMD-mediated macular fibrosis, with a focus on the role of the complement system. We further proposed approaches to target the complement system for the management of macular fibrosis and highlighted the area of further research for future clinical applications of complement-based therapy.

Vascular Cell Adhesion Molecule-1 (VCAM-1) contributes to macular fibrosis in neovascular age-related macular degeneration through modulating macrophage functions

BACKGROUND

Neovascular age-related macular degeneration (nAMD) is a major cause of blindness in the elderly. The disease is due to the growth of abnormal blood vessels into the macula, leading to the loss of central vision. Intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors (e.g., anti-VEGF) is the standard of care for nAMD. However, nearly 50% of patients do not respond or respond poorly to the therapy. More importantly, up to 70% of nAMD patients develop macular fibrosis after 10 years of anti-VEGF therapy. The underlying mechanism of nAMD-mediated macular fibrosis is unknown although inflammation is known to play an important role in the development of abnormal macular blood vessels and its progression to fibro-vascular membrane. In this study, we measured the intraocular levels of adhesion molecule VCAM-1, ICAM-1, CD44, CD62L, and CD62P in nAMD patients with and without macular fibrosis and investigated the link between the levels of adhesion molecule and clinical features (e.g., visual improvement, retinal thickness, etc.). We further investigated the effect of VCAM-1 in macrophage function in vitro and the development of subretinal fibrosis in vivo using a two-stage laser-induced protocol.

RESULTS

The aqueous levels of ICAM-1, VCAM-1, CD44, and CD62L were significantly higher in nAMD patients compared to cataract controls. The aqueous level of VCAM-1 (but not other adhesion molecules) was significantly higher in patients with macular fibrosis than those without and the level correlated positively with the retinal thickness. VCAM-1 was highly expressed at the lesion site in the mouse model of subretinal fibrosis. Blocking VCAM-1 or its receptor VLA-4 significantly prevented macrophage infiltration and reduced subretinal fibrosis in vivo. VCAM-1 induced macrophage migration and upregulated the expression of Arg-1, Mmp12 and Il6 but down-regulated the expression of iNOS and Il1b in macrophages.

CONCLUSIONS

VCAM-1 may contribute to the development of macular fibrosis in nAMD patients by modulating macrophage functions, including migration and profibrotic polarization.

ALKBH5 causes retinal pigment epithelium anomalies and choroidal neovascularization in age-related macular degeneration via the AKT/mTOR pathway

Retinal pigment epithelium (RPE) dysfunction and choroidal neovascularization (CNV) are predominant features of age-related macular degeneration (AMD), with an unclear mechanism. Herein, we show that RNA demethylase α-ketoglutarate-dependent dioxygenase alkB homolog 5 (ALKBH5) is up-regulated in AMD. In RPE cells, ALKBH5 overexpression associates with depolarization, oxidative stress, disturbed autophagy, irregular lipid homeostasis, and elevated VEGF-A secretion, which subsequently promotes proliferation, migration, and tube formation of vascular endothelial cells. Consistently, ALKBH5 overexpression in mice RPE correlates with various pathological phenotypes, including visual impairments, RPE anomalies, choroidal neovascularization (CNV), and interrupted retinal homeostasis. Mechanistically, ALKBH5 regulates retinal features through its demethylation activity. It targets PIK3C2B and regulates the AKT/mTOR signaling pathway with YTHDF2 as the N⁶-methyladenosine reader. IOX1, an ALKBH5 inhibitor, suppresses hypoxia-induced RPE dysfunction and CNV progression. Collectively, we demonstrate that ALKBH5 induces RPE dysfunction and CNV progression in AMD via PIK3C2B-mediated activation of the AKT/mTOR pathway. Pharmacological inhibitors of ALKBH5, like IOX1, are promising therapeutic options for AMD.

Five-year outcome of aflibercept intravitreal injection in naïve patients with neovascular age-related macular degeneration using a modified treat-and-extend regimen: Results from a prospective observational study

PURPOSE

The purpose is to study the 5-year results of aflibercept monotherapy using an individualized regimen in naïve patients with neovascular AMD (nAMD).

MATERIALS AND METHODS

This is a prospective observational study including naïve nAMD patients who underwent aflibercept injections with at least 5 years of follow-up. All of them received 3 monthly injections at the loading phase, followed by an observation period, then treated with an individualized treat-and-extend regimen. Visual acuity (VA) measurement and optical coherence tomography were performed at each visit.

RESULTS

Forty-eight eyes were included. Of these, 30 were followed up for 5 years. The mean follow-up was 61.7 ± 2.3 months. The mean age was 81 ± 8 years. The visual gain was 7.3 ± 12.7 letters at 1 year, 6.5 ± 12.5 letters at 2 years, 5.2 ± 17 letters at 3 years, 6.2 ± 18.6 letters at 4 years, and 5.6 ± 20 letters at 5 years. At the last observation, 53% of eyes had VA > 70 letters. A complete fluid resolution was obtained in 53% of the eyes. At the 5-year endpoint, the total number of injections was 21.6 ± 13.4. Macular atrophy was observed in 18 eyes (60%) and subretinal fibrosis in 14 eyes (46%).

CONCLUSION

Patients with exudative AMD can maintain their visual function at 5 years with aflibercept using an individualized treatment. The loss of visual gain beyond 2 years could be related to the natural progression of the disease than the direct effect of anti-vascular endothelial growth injections.

Old age promotes retinal fibrosis in choroidal neovascularization through circulating fibrocytes and profibrotic macrophages

BACKGROUND

Retinal fibrosis affects 40-70% of neovascular age-related macular degeneration patients. This study investigated the effect of ageing on subretinal fibrosis secondary to choroidal neovascularization and the mechanism of action.

METHODS

Subretinal fibrosis was induced in young (2.5-month) and aged (15-16-month) C57BL/6J mice using the two-stage laser protocol. Five and 30 days later, eyes were collected and stained for CD45 and collagen-1 and observed by confocal microscopy. Fibrocytes (CD45+collagen-1+) were detected in the bone marrow (BM), blood and fibrotic lesions by flow cytometry and confocal microscopy, respectively. BM-derived macrophages (BMDMs) were cultured from young and aged mice with or without TGF-β1 (10 ng/mL) treatment. The expression of mesenchymal marker αSMA (Acta2), fibronectin (Fn1) and collagen-1 (Col1a1) was examined by qPCR and immunocytochemistry, whereas cytokine/chemokine production was measured using the Luminex multiplex cytokine assay. BM were transplanted from 22-month (Ly5.2) aged mice into 2.5-month (Ly5.1) young mice and vice versa. Six weeks later, subretinal fibrosis was induced in recipient mice and eyes were collected for evaluation of fibrotic lesion size.

RESULTS

Under normal conditions, the number of circulating fibrocytes (CD45+collagen-1+) and the expression levels of Tgfb1, Col1a1, Acta2 and Fn1 in BMDMs were significantly higher in aged mice compared to young mice. Induction of subretinal fibrosis significantly increased the number of circulating fibrocytes, enhanced the expression of Col1a1, Acta2 and Fn1 and the production of soluble urokinase plasminogen activator surface receptor (suPAR) but decreased the production of CXCL10 in BMDMs. BMDMs from aged subretinal fibrosis mice produced significantly higher levels of VEGF, angiopoietin-2 and osteopontin than cells from young subretinal fibrosis mice. The subretinal fibrotic lesion in 15-16-month aged mice was 62% larger than that in 2.5-month young mice. The lesion in aged mice contained a significantly higher number of fibrocytes compared to that in young mice. The number of circulating fibrocytes positively correlated with the size of subretinal fibrotic lesion. Transplantation of BM from aged mice significantly increased subretinal fibrosis in young mice.

CONCLUSIONS

A retina-BM-blood-retina pathway of fibrocyte/macrophage recruitment exists during retinal injury. Ageing promotes subretinal fibrosis through higher numbers of circulating fibrocytes and profibrotic potential of BM-derived macrophages.

Review of Fibrosis in Neovascular Age-Related Macular Degeneration

PURPOSE

To report the diagnosis and definitions, epidemiology, risk factors, and visual outcomes of fibrosis in neovascular age-related macular degeneration (nAMD).

DESIGN

Systematic review and meta-analysis.

METHODS

The review was performed using the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Observational studies and randomized controlled trials were included.

RESULTS

Identification of fibrosis is challenging. Optical coherence tomography angiography and polarization-sensitive optical coherence tomography represent novel options in multimodal imaging. The prevalence of fibrosis at baseline, 12, 24, and 60 months was 13%, 32%, 36%, and 56%, respectively. Approximately 60% of the fibrosis burden in nAMD at 5 years was present in the first year of treatment. Fibrosis development was highest in the first 12 months and slowed down over time. The risk factors of fibrosis included classic choroidal neovascularization (CNV), intra-retinal fluid, hemorrhage, hyperreflective material, CNV lesion size, and retinal thickness. Sub-retinal fluid and pigment epithelial detachment may be protective. Treatment-associated factors included disease activity and time to diagnosis. At baseline, the best corrected visual acuity in eyes with fibrosis was poorer than in eyes without fibrosis (-18.50 letters); this difference became larger at 12 months despite treatment (-26.86 letters).

CONCLUSIONS

There is a need to identify effective treatment strategies for fibrosis and to closely monitor at-risk patients. More studies involving multimodal imaging are required to clarify the definitions and grading criteria for fibrosis.

Long-term results (60 months) of anti-VEGF therapy of macular diseases in real clinical practice. Part 2

Purpose: to study long-term results of anti-VEGF therapy for macular diseases of patients followed up for 60 months in real clinical practice. Materials and methods. The research group included 57 patients (43 women, 14 men; median age 62 years) who received antiVEGF therapy (ranibizumab, aflibercept) and remained under regular observation for 60 months. Of these, 24 patients had “wet” agerelated macular degeneration (wAMD), 20 had myopic choroidal neovascularization (mCNV), 10 had macular edema due to retinal vein occlusions (MERVO), and 3 patients had diabetic macular edema (DME). Statistical analysis of demographic indicators and treatment results was carried out using STATISTICA 13.3 software: conditions of normality for variables, nonparametric and parametric criteria were determined, and rank analysis of variance was carried out. The characteristics of the study group are given in the first part of this article [ROJ, 2022; 15 (3): 11–17]. Results. Over the research period, the best corrected visual acuity (BCVA) increased from 0.29 0.35 0.42 to 0.47 0.54 0.61 (p < 0.00001); 91.2 % of patients maintained the indicator or improved it with regard to the baseline. The proportion of subjects with BCVA ≥ 0.5 ranged from 61.4 to 73.7 % during the research period. The average number of intravitreal injections (IVI) received by the patients was 8.93 10.84 12.75. We revealed a tendency towards a gradual decrease in the intensity of treatment and confirmed it (p < 0.00001). The proportion of patients who received 4 IVI or more over 12 months of treatment decreased from 57.9 % in the first year to 12.3 % in the fifth year, and the proportion of cases where anti-VEGF therapy did not need to be resumed before the end of the year of treatment increased from 28.1 % (in the second year of research) to 49.1 % (in the fifth year). The need for IVI anti-VEGF drugs in wAMD and DME was significantly greater than in MERVO and mCNV. Conclusion. The results confirm high efficiency of anti-VEGF therapy. To solve the issue of ill-timed or insufficient treatment, it is necessary to start the therapy as early as possible, use the most effective (proactive) regimens, apply individualized approach to the treatment, take organizational measures aimed at facilitation of access to specialized care, and, generally, to change the attitude of the professional community.

Final 4-year results of the RAINBOW real-world study: intravitreal aflibercept dosing regimens in France in treatment-naïve patients with neovascular age-related macular degeneration

Purpose

The purpose of this study is to evaluate real-world treatment outcomes in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal aflibercept (IVT-AFL) in routine clinical practice in France.

Methods

RAINBOW (NCT02279537) was an ambispective, observational, 4-year study assessing IVT-AFL effectiveness, treatment patterns, and safety in patients with nAMD in France. Treatment-naïve patients prescribed IVT-AFL and treated according to local practice (pro re nata or treat-and-extend) were eligible. Three treatment cohorts were retrospectively identified based on their treatment pattern within the first 12 months: regular (3 initial monthly IVT-AFL injections received within 45–90 days after the first injection in month 0 and followed by injections every 2 months), irregular with the initial monthly injections, and irregular without the initial monthly injections. The primary endpoint was mean change in best-corrected visual acuity (BCVA) from baseline to month 12. The 48-month results are described here.

Results

Overall, the study included 516 patients (each with one study eye), and 30.2% of patients completed 48 months of IVT-AFL treatment. Mean change in BCVA from baseline (56.5 letters) to month 48 for patients with an assessment at both time points was + 1.1 (regular cohort, n = 47), + 0.1 (irregular cohort with initial monthly injections, n = 115), and − 1.3 letters (irregular cohort without initial monthly injections, n = 26), representing a decrease from the gains achieved at month 12. Mean number of IVT-AFL injections received by month 48 in the treatment cohorts was 14.9, 13.7, and 11.9, respectively. The safety profile of IVT-AFL was consistent with previous studies.

Conclusion

In RAINBOW, the 48-month results demonstrate a lack of long-term effectiveness of IVT-AFL treatment of nAMD due to progressive undertreatment in routine clinical practice in France. These real-world findings highlight the importance of 3 initial monthly IVT-AFL injections followed by continuous proactive treatment beyond the first year to achieve optimal functional outcomes.

Trial registration number

ClinicalTrials.gov Identifier: NCT02279537.

Long-term outcome of neovascular age-related macular degeneration: association between treatment outcome and major risk alleles

AIMS

To evaluate the long-term functional and anatomical outcomes of neovascular age-related macular degeneration (nvAMD) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) for up to 10 years, and to identify associated risk factors.

METHODS

Clinical and optical coherence tomography findings were retrieved for nvAMD cases treated with intravitreal anti-VEGF compounds using a treat-and-extend protocol. In addition, the major risk alleles for AMD in the CFH (rs1061170), HTRA1 (rs1200638) and C3 (rs2230199) genes were genotyped.

RESULTS

From 276 eligible eyes in 206 patients, 80 eyes (29%) in 66 patients (32.0%) had a follow-up period of ≥8 years and were included in this study. Over a 10-year period, 73.3±28.0 (mean±SD) anti-VEGF injections were administered. Best-corrected visual acuity (BCVA; LogMAR) deteriorated from 0.55±0.53 at baseline to 1.00±0.73 at 10 years (p<0.0005). Central subfield thickness (CST) decreased from 415.8±162.1 µm at baseline to 323±113.6 µm (p<0.0005) after three monthly injections and remained lower than baseline throughout the follow-up period. Visual outcome was associated with BCVA and intraretinal fluid (IRF) at baseline, macular atrophy, and macular thinning at follow-up. The decrease in CST was inversely correlated with the number of CFH and/or C3 risk alleles carried by the patient (Pearson's r: -0.608; p=0.003).

CONCLUSIONS

Patients with nvAMD who received anti-VEGF therapy for 10 years developed substantial vision loss associated with the presence of IRF at baseline and macular atrophy. Major risk alleles for AMD in two complement genes were associated with a reduced long-term reduction in macular thickness.

Patterns of treatment discontinuation in patients receiving anti-vascular endothelial growth factor for neovascular age-related macular degeneration

Purpose:

To report the reasons for treatment discontinuation within 5 years in patients receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD).

Methods:

A retrospective case-notes review of patients commenced on anti-VEGF for nAMD who failed to complete 5 years of follow-up was undertaken. The reasons for treatment discontinuation, baseline age, baseline visual acuity (VA) in Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and the VA change at the last follow-up were recorded. Age-specific all-cause mortality was calculated for deceased patients.

Results:

Of the 1177 patients, 551 patients (46.8%) failed to complete the 5-year follow-up. The reasons for treatment discontinuation were death (251), early discharge due to stable disease (110), further treatment deemed futile (100), failure to attend (15), ill health (14), patient choice (7), and transfer of care (1). In 53 patients, no reason was documented. The mean baseline age of those who completed the 5-year follow-up (77.4 ± 7.8 years, 95% confidence interval (CI): 76.8–77.9) was significantly lower than those who discontinued the treatment for any reason (82 ± 7.7 years, 95% CI: 81.4–82.6) (P < 0.0001). Survival analysis showed that baseline VA was not a factor in treatment discontinuation; however, visual stability (±5 letters from baseline) was associated with treatment continuation. The age-specific all-cause mortality in deceased patients was lower than that in the general population.

Conclusion:

At 5 years, only 53% of patients remained in active care, and death was the most common reason for treatment discontinuation. Lower baseline age and VA stability during therapy were associated with treatment continuation.

A Study of Logistic Regression for Fatigue Classification Based on Data of Tongue and Pulse

Methods

The Tongue and Face Diagnosis Analysis-1 instrument and Pulse Diagnosis Analysis-1 instrument were used to collect the tongue image and sphygmogram of the subhealth fatigue population (n = 252) and disease fatigue population (n = 1160), and we mainly analyzed the tongue and pulse characteristics and constructed the classification model by using the logistic regression method.

Results

The results showed that subhealth fatigue people and disease fatigue people had different characteristics of tongue and pulse, and the logistic regression model based on tongue and pulse data had a good classification effect. The accuracies of models of healthy controls and subhealth fatigue, subhealth fatigue and disease fatigue, and healthy controls and disease fatigue were 68.29%, 81.18%, and 84.73%, and the AUC was 0.698, 0.882, and 0.924, respectively.

Conclusion

This study provided a new noninvasive method for the fatigue diagnosis from the perspective of objective tongue and pulse data, and the modern tongue diagnosis and pulse diagnosis have good application prospects.

A New Approach of Fatigue Classification Based on Data of Tongue and Pulse With Machine Learning

BACKGROUND

Fatigue is a common and subjective symptom, which is associated with many diseases and suboptimal health status. A reliable and evidence-based approach is lacking to distinguish disease fatigue and non-disease fatigue. This study aimed to establish a method for early differential diagnosis of fatigue, which can be used to distinguish disease fatigue from non-disease fatigue, and to investigate the feasibility of characterizing fatigue states in a view of tongue and pulse data analysis.

METHODS

Tongue and Face Diagnosis Analysis-1 (TFDA-1) instrument and Pulse Diagnosis Analysis-1 (PDA-1) instrument were used to collect tongue and pulse data. Four machine learning models were used to perform classification experiments of disease fatigue vs. non-disease fatigue.

RESULTS

The results showed that all the four classifiers over "Tongue & Pulse" joint data showed better performances than those only over tongue data or only over pulse data. The model accuracy rates based on logistic regression, support vector machine, random forest, and neural network were (85.51 ± 1.87)%, (83.78 ± 4.39)%, (83.27 ± 3.48)% and (85.82 ± 3.01)%, and with Area Under Curve estimates of 0.9160 ± 0.0136, 0.9106 ± 0.0365, 0.8959 ± 0.0254 and 0.9239 ± 0.0174, respectively.

CONCLUSION

This study proposed and validated an innovative, non-invasive differential diagnosis approach. Results suggest that it is feasible to characterize disease fatigue and non-disease fatigue by using objective tongue data and pulse data.

Evolving treatment paradigms for PCV

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular AMD (nAMD) that accounts for a significant proportion of nAMD cases worldwide, and particularly in Asia. Contemporary PCV treatment strategies have closely followed those used in typical nAMD, though there are significant gaps in knowledge on PCV management and it remains unclear if these strategies are appropriate. Current clinical trial data suggest intravitreal anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy is effective in managing haemorrhage and exudation in PCV, although the optimal treatment interval, including as-needed and treat-and-extend approaches, is unclear. Newer imaging modalities, including OCT angiography and high-resolution spectral domain OCT have enabled characterisation of unique PCV biomarkers that may provide guidance on how and when treatment and re-treatment should be initiated. Treatment burden for PCV is a major focus of future therapeutic research and several newly developed anti-VEGF agents, including brolucizumab, faricimab, and new modes of drug delivery like the port delivery system, offer hope for dramatically reduced treatment burden for PCV patients. Beyond anti-VEGF therapy, recent developments in our understanding of PCV pathophysiology, in particular the role of choroidal anatomy and lipid mediators in PCV pathogenesis, offer new treatment avenues that may become clinically relevant in the future. This article explores the current management of PCV and more recent approaches to PCV treatment based on an improved understanding of this unique disease process.

Baseline predictors for subretinal fibrosis in neovascular age-related macular degeneration

To find baseline predictors for subretinal fibrosis (SF) in neovascular age-related macular degeneration (nAMD). Forty-five eyes of 45 participants with treatment-naïve nAMD were consecutively enrolled and treated according to a standardized treat-and-extend protocol. Spectral-domain optical coherence tomography (OCT), color fundus photography and fluorescein angiography as well as novel imaging modalities polarization-sensitive OCT and OCT angiography (OCTA) were performed to detect SF after 1 year and find baseline predictors for SF development. Baseline OCTA scans were evaluated for quantitative features such as lesion area, vessel area, vessel junctions, vessel length, vessel endpoints and mean lacunarity. Additionally, the type of macular neovascularization, the presence of subretinal fluid, intraretinal fluid (IRF), subretinal hyperreflective material (SHRM), retinal hemorrhage as well as best-corrected visual acuity (BCVA) were evaluated. After 12 months 8 eyes (18%) developed SF. Eyes with SF had worse baseline BCVA (p = .001) and a higher prevalence of IRF (p = .014) and SHRM at baseline (p = .017). There was no significant difference in any of the evaluated quantitative OCTA parameters (p > .05) between eyes with and without SF. There were no quantitative baseline microvascular predictors for SF in our study. Low baseline BCVA, the presence of IRF and SHRM, however, are easily identifiable baseline parameters indicating increased risk.

Morphologic and Microvascular Differences Between Macular Neovascularization With and Without Subretinal Fibrosis

Purpose

To evaluate morphologic and microvascular differences between eyes with and without subretinal fibrosis (SF) caused by neovascular age-related macular degeneration (nAMD).

Methods

Patients with nAMD with a minimum history of 12 months of anti-VEGF treatment were prospectively included in this cross-sectional study. Patients were imaged using standard imaging, swept-source optical coherence tomography angiography for quantitative microvascular analysis and polarization-sensitive OCT as an ancillary method for automated SF segmentation. The presence of reticular pseudodrusen, hyperreflective foci (HRF), and outer retinal tubulation (ORT) were also evaluated.

Results

Sixty eyes of 60 participants (37 female) with nAMD and a mean 3.1 (±2.7)-year history of anti-VEGF treatment were included, 20 (33%) of which were diagnosed with SF. Eyes with SF had a higher prevalence of ORT (P < 0.001) and a lower prevalence of HRF (P = 0.004) than eyes without SF. Fifty eyes were analyzed quantitatively for microvascular biomarkers. Eyes with SF had a larger greatest vascular caliber (P = 0.001) and greatest linear diameter (P = 0.042), a larger microvascular neovascularization (MNV) area (P = 0.026), larger vessel area (P = 0.037), higher number of vessel junctions (P = 0.025), longer total vessel length (P = 0.027), higher number of vessel endpoints (P = 0.007), and higher endpoint density (P = 0.047).

Conclusions

This multimodal imaging approach demonstrated in vivo microvascular and morphological differences in eyes with and without SF. Eyes with SF tend to have larger MNV lesions with thicker vessels and are often associated with the presence of ORT.

Translational Relevance

This study points out imaging biomarkers in patients with SF, which may help identifying high-risk patients.

Five-Year Reactivation After Ranibizumab or Aflibercept Treatment for Neovascular Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy

Purpose: To evaluate 5-year reactivation after ranibizumab or aflibercept treatment for neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). Methods: This retrospective study included 192 patients (192 eyes) who had been diagnosed with neovascular AMD or PCV and treated with ranibizumab or aflibercept. The incidence and timing of lesion reactivation during the 5-year follow-up period were evaluated, and the factors associated with reactivation were also investigated. Results: During the follow-up period, lesion reactivation was noted in 156 patients (81.3%) at a mean of 9.5 ± 10.5 months after the third antivascular endothelial growth factor injection. The incidence of reactivation was 59.9% during the first 12 months, 33.7% during ≥12 and <24 months, 11.8% during >24 and ≤36 months, 15.5% during >36 and ≤48 months, and 5.3% during >48 and ≤60 months. There was a significant difference in the incidence among the 5 periods (P < 0.001). The proportion of PCV was significantly higher in patients experiencing reactivation (51.9%) than in those who did not (30.6%) (P = 0.021). Conclusions: During the 5-year follow-up, lesion reactivation was noted in approximately four-fifths of the patients. The incidence of lesion reactivation was highest during the first 12 months and decreased thereafter. The incidence was higher in patients with PCV than in those with neovascular AMD, especially after 12 months.

Ten-year outcome of anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration

Purpose:

The aim of this study was to report the 10-year visual outcome in eyes treated with anti-vascular endothelial growth factor (anti-VEGF) agents for neovascular age-related macular degeneration (nAMD) and to assess the impact of switching treatment as part of routine clinical care.

Methods:

Electronic records of treatment-naïve eyes initiated on intravitreal ranibizumab between January and December 2009 were accessed. The primary outcome measured was the change in visual acuity (VA) in Early Treatment of Diabetic Retinopathy Study letters. The frequency and reasons for treatment discontinuation during each year of follow-up and the impact of switching from ranibizumab to aflibercept were some of the secondary outcomes.

Results:

Of the 223 eyes (203 patients), 60 eyes completed 10 years of continuous follow-up. After a mean follow-up of 121.4 months, VA declined by 5.6 letters (95% confidence interval [CI] –0.25 to –11.1, P = 0.04). Final VA of ≥70 letters was seen in 20% of eyes and 35% had VA ≤ 35 letters. VA gain of ≥10 letters was seen in 23% and loss of ≥10 letters was seen in 40% of the eyes. Twenty-nine eyes remained on ranibizumab monotherapy and 31 switched to aflibercept. Switched eyes showed a visual decline of 7.1 letters (5.5 letters in monotherapy eyes, P = 0.32) and received a significantly higher number of injections (39.6 ± 9.9 vs. 24.4 ± 13.1, P < 0.0001). Patients discontinuing treatment were older and had lower baseline vision compared to completers.

Conclusion:

VA declined below the baseline after 10 years of follow-up and switching did not have any effect on the final visual outcome.

Real Life Data of Treat and Extend Intravitreal Ranibizumab and Aflibercept Therapy in Wet Age-related Macular Degeneration Patients: 3-Year Results

Purpose

To compare functional and anatomic outcome of intravitreal ranibizumab (IVR) and intravitreal aflibercept (IVA) treatments in neovascular age-related macular degeneration by using the treat and extend (TE) protocol.

Methods

In this retrospective chart study, treatment naïve 74 eyes of 74 age-related macular degeneration patients treated with IVR and IVA (38 eyes in IVR and 36 eyes in IVA group) with TE protocol were included. Following three consecutive monthly intravitreal injections, TE protocol was applied to each group. Patients were followed up for at least 36 months. Mean change in best-corrected visual acuity (BCVA), central macula thickness (CMT) and injection numbers over 3 years were compared.

Results

Among 36 months period, the mean number of injections was 17 ± 4 for both groups (p > 0.05). In terms of CMT, there was no statistically significant difference between groups at 36 months compared to baseline. A decrease of 72.55 ± 39.37 μm in CMT was detected in IVR group, whereas the decrease was 70.58 ± 33.96 μm in IVA group (p > 0.05). There was a significant increase in BCVA at 36 months of measurements. In addition, BCVA demonstrated an increase of 4.1 ± 0.44 letters in IVR group and 4.36 ± 0.67 letters in IVA group after 36 months compared to the baseline (p > 0.05).

Conclusions

Both IVR and IVA injections provided significant improvements and stability in BCVA and CMT, however there was no significant difference between IVR and IVA injections with TE protocol of 36 months.

Neovascular age-related macular degeneration: A review of findings from the real-world Fight Retinal Blindness! registry

The use of vascular endothelial growth factor (VEGF) inhibitors has revolutionised the treatment of neovascular age‐related macular degeneration (nAMD) since the pivotal Phase III studies demonstrated their efficacy more than 10 years ago. The Fight Retinal Blindness! project was developed to track the treatment outcomes of patients with nAMD in real‐world practice. Data from this registry have been used to answer several clinically relevant questions related to the treatment of nAMD including the effect of under‐treatment, the comparative effectiveness of different anti‐vascular endothelial growth factor agents, long‐term treatment outcomes, identifying optimal treatment regimens and the rate and outcomes of rare adverse events. Observational studies are a valuable complement to the shortcomings of clinical trials and a combination of data from real‐world settings and clinical trials are necessary to provide evidence on how to achieve the best outcomes for individual patients with nAMD.

Geniposide alleviates choroidal neovascularization by downregulating HB-EGF release from RPE cells by downregulating the miR-145-5p/NF-κB axis

Age-related macular degeneration (AMD), mainly wet AMD, is the major reason for nonreversible vision loss worldwide. Choroidal neovascularization (CNV) is a characteristic pathological manifestation of wet AMD. Stress or injury to the retinal pigment epithelium (RPE) induces proangiogenic factors that drive CNV. An iridoid glycoside extracted from the fruit of gardenia, geniposide (GEN) plays an antiangiogenic role. In this study, GEN inhibited the transcription and expression of heparin-binding epidermal growth factor (HB-EGF), a proangiogenic factor, in hypoxic RPE cells and a mouse laser-induced CNV model. Inhibition of glucagon-like peptide-1 receptor (GLP-1R), a GEN receptor blocker, eliminated the protective effect of GEN. Additionally, GEN decreased the transcription and expression of HB-EGF in hypoxia-exposed RPE cells by downregulating the miR-145-5p/NF-κB axis. Therefore, our research provides a promising novel strategy for wet AMD therapy.

Unravelling the Role of HSP70 as the Unexplored Molecular Target in Age-Related Macular Degeneration

The motive behind writing this paper was to highlight the relationship between heat shock protein 70 (HSP70) and age-related macular degeneration (AMD) to explore the potential role of HSP70 as a molecular target in AMD therapy. We performed a comprehensive literature search in various databases and finally found 43 relevant studies related to our objective. In our research, we found that in AMD, oxidative stress causes increased inflammation and excessive apoptosis due to the accumulation of aberrant proteins in retinal pigment epithelium (RPE) cells. The long-lasting overstimulation of the defence system leads to RPE degeneration and results in visual impairment or vision loss. However, after thorough research, it was found that HSP70's role as an immunomodulator, the guardian of the proteolytic pathway and regulator of apoptosis makes it a potential therapeutic target in AMD.