Association between the arm-to-choroidal circulation time and clinical profile in patients with polypoidal choroidal vasculopathy

PURPOSE

To investigate the association between the arm-to-choroidal circulation time (ACT) on indocyanine green angiography (IA) and clinical profile in patients with polypoidal choroidal vasculopathy (PCV).

STUDY DESIGN

Single-center retrospective study.

METHODS

We included 38 eyes of 38 patients with PCV diagnosed using multimodal imaging and did not undergo previous treatment. All patients were treated with monthly aflibercept injections for 3 months and treat-and-extend regimens for the subsequent 12 months. Posterior vortex vein ACT was assessed on the first visit using Heidelberg IA. The patients were divided into two groups: ACT ≥20 s (L group; eight eyes) and ACT <20 s (S group; 30 eyes). The clinical profiles before and after treatment were analyzed to assess associations with ACT.

RESULTS

The mean ACT was 16.39±3.3 s (L group: 21.25±1.49 s, women:men=2:6, mean age: 77.3±6.5 years; S group: 15.10±2.17 s, women:men=7:23, mean age: 75.5±6.9 years). No significant difference was observed in the mean subfoveal choroidal thickness between the L and the S groups (176±75 μm vs. 230±79 μm, P=0.10). However, there were significant differences between the L and S groups in retinal fluid accumulation and hemorrhage recurrence (eight/eight eyes, 100% vs. 13/30 eyes, 43%, P<0.001), mean aflibercept injections (8.8±1.6 vs. 7.0±1.6, P<0.01) during the 12-month period, and the number of polypoidal lesions (1.8±0.7 vs. 1.3±0.5, P<0.05).

CONCLUSION

Patients with PCV and ACT >20 s are more likely to experience exudative change recurrence in the retina during treatment because they have more polypoidal lesions.

ANATOMICAL AND FUNCTIONAL OUTCOMES OF BEVACIZUMAB TREATMENT IN PEDIATRIC AUTOSOMAL RECESSIVE BESTROPHINOPATHY

PURPOSE

The purpose of this study was to report functional and anatomical outcomes of anti-VEGF treatment in eyes with autosomal recessive bestrophinopathy (ARB) presenting in the first decade of life.

METHODS

The study included case series of four eyes from two siblings with compound heterozygous mutations in the BEST1 gene who were treated with eight monthly intravitreal bevacizumab injections. Response to treatment was analyzed using color fundus photography, fundus autofluorescence, optical coherence tomography, OCT angiography, and microperimetry.

RESULTS

Patient 1 (male, age 9 years) had visual acuity of 20/20 in the right eye and 20/50 in the left eye. Patient 2 (female, age 10 years) had visual acuity of 20/25 in the right eye and 20/20 in the left eye. All eyes had multifocal subretinal deposition of lipofuscin and subretinal fluid, and three eyes had choroidal neovascularization (CNV). Lipofuscin material reabsorbed in 2 of 4 eyes, the CNV regressed in 3 of 3 eyes, a bacillary detachment resolved in 1 of 1 eye, but the subretinal fluid did not change. Functional improvement in visual acuity was noted, but MP showed scattered areas of reduced retinal sensitivity. No ocular or systemic side effects were detected.

CONCLUSION

Anti-VEGF treatment of choroidal neovascularization in eyes with ARB resulted in anatomical changes that were only clinically significant in the eye with decreased visual acuity. The hyporeflective subretinal material remained unchanged suggesting a nonexudative cause. These findings provide new insights into the management of ARB, especially in pediatric subjects with CNV.

EFFICACY AND SAFETY OF AFLIBERCEPT FOR THE TREATMENT OF IDIOPATHIC CHOROIDAL NEOVASCULARIZATION IN YOUNG PATIENTS: The INTUITION Study

PURPOSE

To evaluate the mean change in visual acuity at 52 weeks in patients with idiopathic choroidal neovascularization treated with aflibercept.

METHODS

We conducted a prospective noncomparative open-label Phase-II trial. The dosage regimen evaluated in this study was structured into two periods: (1) from inclusion to 20 weeks: a treat-and-extend period composed of three mandatory intravitreal injections, and complementary intravitreal injections performed if needed; (2) from 21 weeks to 52 weeks: a pro re nata period composed of intravitreal injections performed only if needed.

RESULTS

A total of 19 patients were included, and 16 completed the 52-week study. At baseline, the mean best corrected visual acuity was 66.56 (±20.72) letters (≈20/50 Snellen equivalent), and the mean central retinal thickness was 376.74 µm (±93.77). At 52 weeks, the mean change in the best-corrected visual acuity was +19.50 (±19.36) letters [95% confidence interval = +9.18 to +29.82]. None of the patients included lost ≥15 letters at 24 weeks or 52 weeks. The mean change in central retinal thickness was -96.78 µm (±104.29) at 24 weeks and -86.22 µm (±112.27) at 52 weeks. The mean number of intravitreal injections was 5.4 (±3.0) at 52-weeks. No ocular serious adverse events related to the treatment were reported.

CONCLUSION

The present analysis shows clinically significant functional and anatomical treatment effect of aflibercept in case of idiopathic choroidal neovascularization. The treat-and-extend regimen proposed after the first injection seems adequate to treat most neovessels.

LONG-TERM COURSE AND VISUAL OUTCOMES OF PRECHOROIDAL CLEFT IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AND POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To evaluate the regression of prechoroidal cleft, its influence on visual outcomes, and differences in visual outcomes between neovascular age-related macular degeneration and polypoidal choroidal vasculopathy.

METHODS

This retrospective study included 61 patients exhibiting prechoroidal cleft who were treated with antivascular endothelial growth factors. The patients were divided into two groups according to the following categories: 1) regression of prechoroidal cleft: regression group versus nonregression group and 2) type of neovascularization: neovascular age-related macular degeneration group versus polypoidal choroidal vasculopathy group. Changes in the visual acuity during the follow-up period were also compared between the two groups.

RESULTS

During the 52.4 ± 17.4-month follow-up period, regression of prechoroidal cleft was noted in 17 patients (27.9%) at a mean of 25.7 ± 18.3 months after the first identification. The degree of the logarithm of the minimum angle of resolution of visual deterioration was greater in the nonregression group (0.59 ± 0.56, n = 17) than that in the regression group (0.25 ± 0.61, n = 44) (P = 0.007) and in the neovascular age-related macular degeneration group (0.56 ± 0.61, n = 51) than that in the polypoidal choroidal vasculopathy group (0.18 ± 0.33, n = 10) (P = 0.034).

CONCLUSION

Approximately 27.9% of prechoroidal cleft cases eventually regressed, in conjunction with relatively favorable visual outcomes. Considering the poor visual prognosis in neovascular age-related macular degeneration accompanied by prechoroidal cleft, more caution is required for this condition.

OUTCOMES IN PATIENTS RESUMING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOLLOWING TREATMENT DELAY DURING THE CORONAVIRUS-19 PANDEMIC

PURPOSE

To evaluate the outcomes of delay in care secondary to the coronavirus pandemic in patients requiring intravitreal anti-vascular endothelial growth factor therapy.

METHODS

A retrospective review was performed, and subjects were divided into two groups: 1) a study group of patients who experienced a treatment delay of ≥6 weeks from the intended follow-up during the coronavirus pandemic and resumed treatment with ≥2 anti-vascular endothelial growth factor injections over 6 months following treatment delay, and 2) a control group of patients who received regular care throughout the coronavirus pandemic.

RESULTS

Totally, 234 subjects were analyzed. The mean treatment delay from the intended follow-up in the study group was 11.8 (±4.0) weeks. Visual acuity and central macular thickness worsened from baseline to 6 months after resuming anti-vascular endothelial growth factor therapy in the study group (P < 0.0001 and P = 0.001, respectively). Visual acuity and central macular thickness were better in the control group compared with the study group at the end of the 6-month study period (P < 0.0001 for both).

CONCLUSION

Treatment delay in subjects undergoing anti-vascular endothelial growth factor therapy for retina disease during the coronavirus pandemic had worse visual and anatomical outcomes despite reinitiating treatment over 6 months compared with a control group, suggesting irreversibility and permanence of outcomes.

The characteristics of choriocapillaris flow void in the unilateral polypoidal choroidal vasculopathy fellow eyes

To evaluate the morphological characteristics of flow void (FV) in the fellow eyes of the unilateral polypoidal choroidal vasculopathy (PCV). Fifty PCV fellow eyes (PCVF) and 31 age-matched normal ocular circulation controls were recruited in this retrospective study. The number of FV was analyzed according to the size in a centered 5 × 5 mm swept source optical coherence tomography angiography scans. We used indocyanine green angiography images to determine whether choroidal vascular hyperpermeability (CVH) has occurred. For the PCVF, the prevalence rate of CVH was 70% (35 of 50) The number of FVs was significantly lower in 400-25,000 μm2 (P = 0.005), 400-500 μm2 (P = 0.001), 525-625 μm2 (P = 0.001) and 650-750 μm2 (P = 0.018). compared to the controls. And showed no difference in size from 775 to 1125 μm2 between the two groups. The area under the receiver operating characteristic curve of PCVF with CVH and controls was 0.94 (95% CI 0.88-1.00) (P < 0.001). We found that the number of small FVs was significantly lower in the PCV fellow eyes than that in the eyes with control group.

Predominantly Persistent Subretinal Fluid in the Comparison of Age-Related Macular Degeneration Treatments Trials

OBJECTIVE

To describe predominantly persistent subretinal fluid (SRF) in eyes receiving ranibizumab or bevacizumab for neovascular age-related macular degeneration and to compare visual acuity (VA) to eyes with nonpersistent SRF.

DESIGN

Cohort within randomized clinical trial.

PARTICIPANTS

Comparison of Age-related Macular Degeneration Treatments Trials patients assigned to pro re nata treatment.

METHODS

Graders evaluated monthly OCT scans for SRF. Predominantly persistent SRF through week 12 was defined as SRF at baseline and weeks 4, 8, and 12. Predominantly persistent SRF through 1 or 2 years was defined as SRF in 80% or more of visits by years 1 or 2, respectively. Linear regression models including baseline predictors of VA and predominantly persistent intraretinal fluid (IRF) were used to evaluate mean differences in vision outcomes.

PRIMARY OUTCOME MEASURES

Predominantly persistent SRF through year 1, adjusted VA score and VA change, and foveal SRF thickness.

RESULTS

Among 406 eyes with baseline SRF, SRF persisted in 108 eyes (26.6%) through week 12, in 94 eyes (23.2%) through year 1, and in 77 eyes (19.0%) through year 2. Adjusted VA means at year 1 were similar between eyes with predominantly persistent versus non persistent SRF by week 12 (68.1 vs. 70.2 letters; P = 0.18), year 1 (67.6 vs. 70.2 letters; P = 0.11), and year 2 (71.4 vs. 70.9 letters; P = 0.78). Adjusted changes in mean VA at year 1 were similar between eyes with predominantly persistent versus nonpersistent SRF by week 12 (6.3 vs. 7.6 letters; P = 0.38), year 1 (5.5 vs. 7.8 letters; P = 0.14), and year 2 (8.1 vs. 7.7 letters; P = 0.78). Among eyes with predominantly persistent SRF through year 1, foveal SRF was absent in 46 eyes (48.9%), thickness was 1 to 200 μm in 48 eyes (50.0%) and more than 200 μm in 1 eye (1.1%) at year 1.

CONCLUSIONS

Eyes with predominantly persistent and nonpersistent SRF through week 12, year 1, or year 2 showed similar VA outcomes after adjustment for baseline covariates and persistent IRF. At the foveal center, predominantly persistent SRF was most commonly absent or present in small quantities.

To evaluate the microcirculation of retinochoroid capillary between acute and chronic central serous chorioretinopathy with OCTA

To investigate the difference in chorioretinal microcirculation between acute central serous chorioretinopathy (aCSC) and chronic central serous chorioretinopathy (cCSC) using optical coherence tomography angiography.In total, 65 patients previously diagnosed with central serous chorioretinopathy (33 aCSC and 32 cCSC) were included in our cross-sectional study. All patients underwent complete ophthalmologic assessment including logarithm of the minimum angle of resolution best-corrected visual acuity, fundus fluorescein angiography, and optical coherence tomography angiography. Sixty eyes of 60 refractive error and age matched healthy people were selected as control.The vessel density of inner retina in patients with aCSC were higher than that in patients with cCSC (51.32 ± 2.01 vs 49.15 ± 3.68, P = .004), however, the vessel density of superficial choroid layer in aCSC were significantly lower than that in cCSC (49.83 ± 6.96 vs 53.42 ± 6.28, P = .033). Further analysis of the data reveals the presence of a distinct choroidal neovascularization (CNV) in 8 patients (25%) with cCSC while there was no evidence of CNV in patients with aCSC.Our study can contribute to a better understanding of the difference in retinochoroid microcirculation between aCSC and cCSC. The vessel density of inner retina was lower and the vessel density of superficial choroid was higher in cCSC, and patients with cCSC were more susceptible to CNV than patients with aCSC.

Unaffected fellow eye neovascularization in patients with type 3 neovascularization: Incidence and risk factors

Purpose

To evaluate the incidence and risk factors of neovascularization in unaffected fellow eyes of patients diagnosed with type 3 neovascularization in Korea.

Methods

This retrospective study included 93 unaffected fellow eyes of 93 patients diagnosed with type 3 neovascularization. For initial type 3 neovascularization diagnosis, optical coherence tomography and angiography were conducted. These baseline data were compared between patients with and without neovascularization in their fellow eyes during the follow-up period.

Results

The mean follow-up period was 66.1±31.1 months. Neovascularization developed in 49 (52.8%) fellow eyes after a mean period of 29.5±19.6 months. In the fellow eye neovascularization group, the incidence of soft drusen and reticular pseudodrusen was significantly higher than that in the non-neovascularization group (83.7% vs. 36.5%, p<0.001; 67.3% vs. 40.9%, p = 0.017, respectively), but the choroidal vascularity index (CVI) showed a significantly lower value (60.7±2.0% vs. 61.7±2.5%; p = 0.047). The presence of reticular pseudodrusen was related with the duration from baseline to development of fellow eye neovascularization (p = 0.038).

Conclusion

Neovascularization developed in 52.8% of unaffected fellow eyes. The presence of soft drusen, reticular pseudodrusen, and lower CVI values can be considered risk factors of neovascularization in unaffected fellow eyes of patients with type 3 neovascularization. The lower CVI values suggest that choroidal ischemic change may affect the development of choroidal neovascularization in these patients.

Laser-induced choroidal neovascularization: A case report and some reflection on animal models for age-related macular degeneration

RATIONALE

Laser induced maculopathy includes retinal photoreceptor disruption, macular hole, macular hemorrhage, and rarely choroidal neovascularization (CNV). Here we report a case of laser induced CNV that was treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and resulted in visual improvement and CNV resolution during 1-year follow up. In addition, the case of laser induced CNV treated with intravitreal anti-VEGF injections are reviewed for the first time in literature.

PATIENT CONCERNS

A 7-year-old boy presented to our department with blurred vision in his right eye for 2 months. The symptom immediately happened after the boy staring at the laser beam for a few seconds. Examination of ocular fundus with slit lamp showed yellowish lesion in macula in his right eye.

DIAGNOSES

CNV was confirmed by fundus examinations, including color fundus photograph, spectral domain optical coherence tomography, fluorescein angiography, and spectral domain optical coherence tomography angiography.

INTERVENTIONS

After the diagnosis of laser induced CNV, intravitreal ranibizumab (LUCENTIS, NOVARTIS) injection was performed.

OUTCOMES

After 1 injection of intravitreal ranibizumab, the best corrected visual acuity improved from 20/50 to 30/50 and CNV gradually regressed during 1-year follow up.

LESSONS

For young patients with laser induced CNV, intravitreal anti-VEGF injections may be helpful in visual improvement and CNV regression. Moreover, age seems to be a significant factor thus we propose that old animals may be more appropriate for laser induced CNV animal models of age-related macular degeneration.

10-YEAR FOLLOW-UP OF A SUBCLINICAL CHOROIDAL NEOVASCULAR MEMBRANE IN A PATIENT WITH AGE-RELATED MACULAR DEGENERATION

PURPOSE

To provide long-term, natural history data of a case of a subclinical choroidal neovascular membrane (CNVM) in the setting of age-related macular degeneration.

METHODS

Retrospective review of the 10-year clinical course of a patient including multimodal imaging.

RESULTS

A 75-year-old white female with macular degeneration presented with visual acuity of 20/25 in the right eye and 20/40 in the left eye. In the left eye, a retinal pigment epithelial detachment with associated subretinal and intraretinal fluid was found on spectral domain optical coherence tomography. Fluorescein angiography was consistent with a predominately classic CNVM, which was well-visualized on indocyanine green angiography. Treatment was initiated with bevacizumab for 10 months that reduced the amount of subretinal and intraretinal fluid, but progressive geographic atrophy developed over the subsequent 9 years reducing vision to 20/100. Interestingly, at initial presentation, a nonexudative fibrovascular pigment epithelial detachment was detected in the right (contralateral) eye. This was monitored with multimodal imaging twice yearly for 10 years without any signs of exudation, and vision remained 20/25. Optical coherence tomography angiography revealed a remarkably similar appearance of the subclinical CNVM compared with indocyanine green angiography 10 years prior, suggesting anatomical stability.

CONCLUSION

The advent of optical coherence tomography angiography has increased the detection of subclinical CNVMs. Recent evidence suggests that subclinical CNVMs have a high rate of progression to exudation over 1 year, which raises the question of whether early treatment is beneficial. This case provides 10-year follow-up with multimodal imaging (fluorescein angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography) of a subclinical CNVM, which remained stable and without exudation, suggesting that they may be closely observed.

OPTICAL COHERENCE TOMOGRAPHY FEATURES OF CHOROIDAL NEOVASCULARIZATION AND THEIR CORRELATION WITH AGE, GENDER, AND UNDERLYING DISEASE

PURPOSE

To investigate the influence of age, gender, and underlying disease on the optical coherence tomography (OCT) features of choroidal neovascularization (CNV) secondary to inflammation, myopia (mCNV), and age-related macular degeneration (AMD-CNV).

METHODS

Demographic and clinical data of eyes with treatment-naive inflammatory CNV, mCNV, and Type 2 AMD-CNV were collected. Optical coherence tomography images were reviewed to determine the presence of pitchfork sign, pigment epithelial detachment, subretinal fluid (SRF), intraretinal cysts, subretinal hyperreflective material, atrophy, and outer retinal disruption graded 1 to 4. The influence of demographics and underlying etiology on OCT signs was investigated.

RESULTS

One hundred and eighty-five eyes from 179 patients were enrolled. The mean [SD] age was 36 [±14.4], 62 [±18], and 77 [±8] for the inflammatory CNV, mCNV, and AMD-CNV, respectively (P < 0.001). Multiple linear regression showed that the presence of pitchfork sign was negatively associated with age (P < 0.0001), regardless of underlying disease. By contrast, the SRF, pigment epithelial detachment, intraretinal cysts, and the outer retinal disruption were all positively influenced by age, regardless of gender and underlying disease (all P < 0.01). Logistic regression showed that none of the OCT signs increased the likelihood for diagnosis of inflammatory CNV. By contrast, the absence of SRF was suggestive for mCNVs, and the presence of pigment epithelial detachment and SRF was suggestive for AMD-CNVs.

CONCLUSION

The age of the patient had a significant effect on the OCT appearance of the CNV, particularly the presence of a pitchfork sign, regardless of the underlying etiology. The absence of SRF was suggestive for a diagnosis of mCNVs. The presence of SRF and pigment epithelial detachment was suggestive for AMD-CNVs.

PSEUDOXANTHOMA ELASTICUM: SUCCESSFUL LONG-TERM MANAGEMENT OF CHOROIDAL NEOVASCULARIZATION SECONDARY TO ANGIOID STREAKS WITH PRO RE NATA INTRAVITREAL BEVACIZUMAB INJECTIONS

PURPOSE

To demonstrate how a patient with recurrent episodes of choroidal neovascularization (CNV), secondary to angioid streaks, can be managed successfully with a pro re nata regime of intravitreal bevacizumab injection over an eight-year period.

METHOD

A 32-year-old white woman with pseudoxanthoma elasticum has been followed up over an eight-year period for management of recurrent episodes of CNV in both eyes. She was educated to recognize the early signs and symptoms of CNV. Physical examination including visual acuity and slit-lamp examination as well as investigations such as macula optical coherence tomography and optical coherence tomography angiography were performed. Bevacizumab injections were given to her when she was diagnosed with CNV.

RESULTS

Multiple episodes of CNV were successfully treated with pro re nata regimes of intravitreal bevacizumab injections. The patient was able to maintain excellent visual acuity of 0 logarithm of the minimum angle of resolution even after suffering recurrent episodes of CNV.

CONCLUSION

This case report supports that a pro re nata regime of intravitreal bevacizumab injection therapy can be used successfully to treat recurrent episodes of CNV in a patient with pseudoxanthoma elasticum over an eight-year period. Early diagnosis through patient education and the use of appropriate diagnostic tools such as optical coherence tomography angiography have enabled us to deliver early treatment, resulting in an excellent outcome for this patient.

IMPACT OF CORONAVIRUS DISEASE PANDEMIC ON INTRAVITREAL INJECTIONS TREATMENT FOR MACULAR DISEASES: Report From a Referral Hospital in Milan

PURPOSE

To describe our managing strategy for COVID-19 emergency, to evaluate the adherence to intravitreal treatment (AtT) rate during the outbreak in a referral hospital in Milan, and to correlate it with patients' clinical features.

METHODS

The AtT rate of patients with scheduled intravitreal injections during the COVID-19 outbreak from February 23, 2020 to March 31, 2020 was compared with the previous trimester and with March 2019. The impact of age, sex, visual function, and diagnosis on the AtT rate during unlocked/locked weeks (from March 8th) was evaluated.

RESULTS

Of 650 consecutive patients with scheduled intravitreal injections, the AtT rate during the COVID-19 outbreak was 0.37. This was significantly lower compared with AtT registered in the previous trimester (0.92) and in the same weeks in 2019 (0.90) (both P < 0.001). Patients adherent to treatment were significantly younger (P < 0.001) and had a lower best-corrected visual acuity in the fellow eye (P = 0.046). During the lockdown weeks, the AtT rate was significantly lower than in the two unlocked weeks (0.19 vs. 0.73, P < 0.001). In addition, the AtT rate in patients classified as "emergent" during the lockdown weeks was 0.60.

CONCLUSION

These preliminary results can help the retina specialist community to foresee this unique scenario and to develop successful management strategies.

Photodynamic therapy combined with anti-vascular endothelial growth factor therapy for pachychoroid neovasculopathy

This multicenter retrospective study was conducted to evaluate the 1-year treatment outcome of photodynamic therapy (PDT) combined with anti-vascular endothelial growth factor (VEGF) therapy for pachychoroid neovasculopathy (PNV). A total of 42 eyes of 42 patients with treatment-naïve PNV who were treated with PDT combined with intravitreal injections of an anti-VEGF agent (ranibizumab or aflibercept) for 1 year. All eyes showed exudative and/or hemorrhagic changes that affected the fovea at baseline. After the initial combination therapy, subfoveal choroidal thickness (SCT) and central retinal thickness (CRT) were significantly reduced and were maintained as such for 12 months (P < 0.01 in SCT and CRT). The best-corrected visual acuity (BCVA) (0.19 ± 0.30 at baseline) significantly improved at 3 months (0.15 ± 0.29, P < 0.05) and further improved at 12 months (0.10 ± 0.30, P < 0.01) when compared to that at baseline. After the initial combination therapy, 32 eyes (76.2%) required no additional treatments for 12 months. The mean number of additional PDT and intravitreal injections of anti-VEGF agents was 0.1 ± 0.3 and 0.9 ± 1.9, respectively. Of the 42 eyes included in this study, 22 eyes (52.4%) had polypoidal lesions at baseline. No significant differences in SCT, CRT, or BCVA were observed at any time points between eyes with and without polypoidal lesions. Of 20 eyes without polypoidal lesions, only 1 eye (5.0%) needed additional treatments. PNV, especially without polypoidal lesions, can be treated effectively with PDT combined with anti-VEGF therapy with few sessions.

Macular Atrophy Affecting Visual Outcomes in Patients Undergoing Anti-VEGF Treatment in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To explore how baseline macular atrophy (MA) affects visual acuity (VA) in patients receiving intravitreal anti-vascular endothelial growth factor (VEGF) injections for neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

A retrospective, case control series. Patients were grouped into three cohorts based on baseline spectral-domain optical coherence tomography image findings: foveal MA, nonfoveal MA, and no MA. Outcomes were assessed at 1, 2, and 3 years following anti-VEGF therapy.

RESULTS

No differences existed in MA growth between eyes with foveal and nonfoveal MA (0.89 mm² [95% confidence interval (CI), 0.64-1.14] vs. 0.88 mm² [95% CI, 0.72-1.05]) after adjusting for baseline lesion sizes at 3 years. Foveal MA patients lost an average of 19.4 ETDRS letters (95% CI, -30.8 to -8.0) after 3 years. Nonfoveal MA patients gained an average of 1.1 ETDRS letters (95% CI, -6.8 to 9.0), and patients without MA averaged a gain of 9.7 ETDRS letters (95% CI, 5.5-14.0).

CONCLUSION

In patients with nAMD receiving anti-VEGF in routine clinical practice, presence of baseline foveal MA was associated with significant vision loss. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:68-75.].

Long-term Visual Outcomes after Release from Protocol in Patients who Participated in the Inhibition of VEGF in Age-related Choroidal Neovascularisation (IVAN) Trial

PURPOSE

To describe visual outcomes, frequency of treatment and monitoring visits, and anti-vascular endothelial growth factor drugs used in usual care in participants who exited a trial in which treatment for neovascular age-related macular degeneration (nAMD) was initiated with bevacizumab or ranibizumab.

DESIGN

Multicenter cohort study up to 7 years after trial exit.

PARTICIPANTS

Patients enrolled in the Inhibition of VEGF in Age-related choroidal Neovascularisation (IVAN) trial; after excluding participants from 2 sites and who died or withdrew during the trial, 537 were included in this follow-up cohort.

METHODS

Data were collected between May 26, 2016, and August 24, 2017. Distance visual acuity (DVA) (letters read) in both eyes and treatments for nAMD administered to either eye at all usual care visits were extracted from medical records of all participants until the point of data collection (duration of study eye monitoring).

MAIN OUTCOME MEASURES

Rate of change of DVA during active surveillance of the study eye (study eye monitoring), estimated using a multivariable linear random effects model. Other outcome measures were visit and treatment frequency and switches in anti-vascular endothelial growth factor (VEGF) drug.

RESULTS

Data were obtained for 99% (532/537) of eligible participants. The median duration of study eye monitoring after IVAN exit was 3.3 years (interquartile range [IQR], 1.3-4.7), and median DVA was 58.0 letters (IQR, 34.0-73.0). Study eye DVA deteriorated by 4.3 (95% confidence interval [CI], 3.7-4.9) letters per year. Injection rate did not influence the rate of change in DVA after adjusting for key covariates. After IVAN exit, 174 participants (32%) received no treatment; 332 of 358 (93%) were treated first with ranibizumab, 78 (23%) of whom switched to aflibercept. The DVA was similar among participants who switched or did not switch at the end of study monitoring.

CONCLUSIONS

Approximately 5 years after the IVAN study finished, with unprecedented completeness of follow-up for such a trial, the trajectory of functional decline in the study eye was shown to be greater than that previously reported for incomplete trial cohorts. Anti-VEGF injection rates and treatment switches were not important factors in determining visual acuity outcomes.

Focal Choroidal Excavation Expansion Following Treatment of Associated Choroidal Neovascular Membrane

The authors describe a case of a previously unreported phenomenon of focal choroidal excavation (FCE) expansion, in absence of inflammation, due to treatment of an associated choroidal neovascular membrane (CNVM). A patient with new type 2 CNVM, treated during 43 months of follow-up with aflibercept, experienced significant expansion of an FCE with conversion from nonconforming to conforming type. FCE is part of the pachychoroid spectrum and the regression of an associated CNVM during aflibercept treatment as seen in the authors' patient may elucidate the pathogenesis of some forms of focal choroidal excavation and their evolution over time. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:54-57.].

Long-term follow-up of quiescent choroidal neovascularisation associated with age-related macular degeneration or pachychoroid disease

AIMS

To evaluate the long-term progression of quiescent type 1 choroidal neovascularisation (CNV) associated with age-related macular degeneration (AMD) or with pachychoroid disease.

METHODS

All cases of quiescent type 1 CNV with a minimum follow-up of 12 months seen at the Department of Ophthalmology of University Paris Est, Creteil and at the Centre Ophtalmologique de l'Odeon, Paris, between June 2009 and December 2018 were retrospectively reviewed. Optical coherence tomography angiography (OCT-A) of eyes not showing CNV activation during 24 months was evaluated for quantitative analyses of CNV status biomarkers (fractal dimension, lacunarity, vessel density, aspect ratio, CNV area).

RESULTS

A total of 67 eyes (65 patients, 43 females, mean age 76.63±9.7 years) with quiescent CNV and a mean follow-up of 49.56±27.3 (12-112) months were included. Of 28 eyes showing activation of quiescent CNV, 12 eyes with pachychoroid-associated CNV showed reduced visual loss (-3.28 ETDRS letters, p=0.7 vs -13.03 ETDRS letters, p=0.02), greater choroidal thinning (-59.5 µm, p=0.03 vs - 16.36 µm, p=0.3) and needed less antivascular endothelial growth factor intravitreal injections (IVI) (0.09 vs 0.21, p=0.01) than 16 eyes with AMD-associated CNV. CNV area was the only OCT-A biomarker to significantly change during 24 months in inactive quiescent CNV (+29.5%, p=0.01, in pachychoroid group and +27.1%, p=0.03, in the AMD group).

CONCLUSION

In the long-term follow-up, inactive quiescent CNV showed an increase of CNV area without significant changes of the other OCT-A biomarkers. Quiescent type 1 CNV undergoing activation showed greater response to IVI when associated to pachychoroid.

Experimental Models in Neovascular Age Related Macular Degeneration

Neovascular age-related macular degeneration (vAMD), characterized by the neo-vascularization of the retro-foveolar choroid, leads to blindness within few years. This disease depends on angiogenesis mediated by the vascular endothelial growth factor A (VEGF) and to inflammation. The only available treatments consist of monthly intravitreal injections of antibodies directed against VEGF or VEGF/VEGFB/PlGF decoy receptors. Despite their relative efficacy, these drugs only delay progression to blindness and 30% of the patients are insensitive to these treatments. Hence, new therapeutic strategies are urgently needed. Experimental models of vAMD are essential to screen different innovative therapeutics. The currently used in vitro and in vivo models in ophthalmic translational research and their relevance are discussed in this review.

The association of polypoidal choroidal vasculopathy clinical phenotypes with previously reported genetic markers

PURPOSE

Genetic studies have identified the association of some single-nucleotide polymorphisms (SNPs) with polypoidal choroidal vasculopathy (PCV), but little is known about whether these SNPs are related to PCV clinical features as well. We performed this study to examine the association of 12 SNPs with PCV clinical phenotypes.

METHODS

Sixty-nine PCV eyes of 69 patients were included. Genomic DNA was extracted from peripheral blood. Agilent SureSelect Human ALL Exon V6 was used to sequence the 12 SNPs previously reported to associate with PCV. Baseline best-corrected visual acuity (BCVA), sub-foveal choroidal thickness (SFCT), choroid maximum vascular diameter (MVD), choroidal vascular hyperpermeability (CVH), and greatest linear dimension (GLD) of entire lesion were measured and compared between patients of different genotypes. Fisher's exact test and Mann-Whitney U test were mainly used to compare categorical variables and continuous variables respectively.

RESULTS

HTRA1 rs2293870 was a protective factor of PCV or AMD in the fellow eye (P = 0.040) and was related with greater SFCT in PCV eye after multiple linear regression (P = 0.043). C3 rs17030 was associated with smaller GLD (P = 0.033). CFH rs2274700 was related to lower MVD (P = 0.043) and was a protective factor for CVH (P = 0.034).

CONCLUSION

Multiple PCV-associated SNPs are associated with PCV clinical phenotypes. The involvement of several synonymous SNPs calls for further research on the role of transcriptional alterations and trans-regulation of distant signaling pathways in PCV pathogenesis.

Effectiveness of polypoidal lesion-selective photodynamic therapy with intravitreal antivascular endothelial growth factor for polypoidal choroidal vasculopathy

PURPOSE

To evaluate the 24-month effectiveness of polypoidal lesion-selective photodynamic therapy (PDT) combined with antivascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with branching vascular networks (BVNs) involving the fovea with 1 or more polyps.

STUDY DESIGN

A retrospective case series.

PATIENTS AND METHODS

Twenty-six eyes from 25 PCV patients treated with polypoidal lesion-selective PDT combined with aflibercept were included in the study. The main outcome measure was change in best-corrected visual acuity (BCVA), and the secondary outcome measures were changes in central retinal thickness and subfoveal choroidal thickness on optical coherence tomography (OCT), status of exudation at 24 months, and number of additional treatments.

RESULTS

Fourteen eyes of 14 patients showed treatment-naïve PCV, and 12 eyes of 11 patients were switched from anti-VEGF monotherapy. The baseline mean logMAR BCVA was 0.43, and this had increased significantly, by 0.31, at 24 months (P = .034). The mean central retinal thickness (CRT) and central choroidal thickness (CCT) were significantly lower at all time points than those at baseline. The mean number of additional injections of aflibercept was 3.1 (range, 0-9), and that of additional PDT treatments was 0.5 (range, 0-2).

CONCLUSION

Polypoidal lesion-selective PDT with aflibercept was effective for relatively large, fovea-involved PCV, with significant visual improvement at 24 months.

Comparison of Loading Doses of Ziv-Aflibercept and Aflibercept in Neovascular Age-Related Macular Degeneration

PURPOSE

The aim of this study was to compare outcomes of 3 loading doses of ziv-aflibercept and aflibercept in treatment-naïve neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective, nonrandomized, comparative study.

METHODS

This was a retrospective chart review which included cases with treatment-naïve nAMD. The patients were divided into 2 groups (group 1, ziv-aflibercept; group 2, aflibercept). Groups 1 and 2 received 1.25 mg/0.05 mL of intravitreal ziv-aflibercept and 2 mg/0.05 mL aflibercept, respectively every month for 3 months. Best-corrected visual acuity (BCVA) in Snellen and logarithm of minimum angle of resolution (logMAR), central subfoveal thickness (CSFT), subretinal hyperreflective material height, neurosensory detachment height, and pigment epithelial detachment height were recorded at baseline and 3 monthly follow-up.

RESULTS

Twenty-three eyes of 23 patients were included (males 14, females 9). Twelve and 11 eyes were included in group 1 and group 2, respectively. Group 1 showed statistically significant improvement in BCVA (P < 0.001) and CSFT (P=0.007) through 3 months compared with baseline. There was significant change in BCVA from baseline at 1st month (P = 0.007), 2nd month (P = 0.002) and 3rd month (P = 0.008). In group 2, there was no significant improvement in BCVA, CSFT, subretinal hyperreflective material height, neurosensory detachment, and pigment epithelial detachment height from baseline through 3 months.

CONCLUSIONS

After 3 loading doses, ziv-aflibercept showed efficacy in terms of improved BCVA and reduction of CSFT from baseline whereas aflibercept did not show such improvement. Considering the cost- effectiveness and the proven safety of ziv-aflibercept, it is a viable option for the crucial, initial 3 doses in the treatment of nAMD.

Chronic Dicer1 deficiency promotes atrophic and neovascular outer retinal pathologies in mice

Degeneration of the retinal pigmented epithelium (RPE) and aberrant blood vessel growth in the eye are advanced-stage processes in blinding diseases such as age-related macular degeneration (AMD), which affect hundreds of millions of people worldwide. Loss of the RNase DICER1, an essential factor in micro-RNA biogenesis, is implicated in RPE atrophy. However, the functional implications of DICER1 loss in choroidal and retinal neovascularization are unknown. Here, we report that two independent hypomorphic mouse strains, as well as a separate model of postnatal RPE-specific DICER1 ablation, all presented with spontaneous RPE degeneration and choroidal and retinal neovascularization. DICER1 hypomorphic mice lacking critical inflammasome components or the innate immune adaptor MyD88 developed less severe RPE atrophy and pathological neovascularization. DICER1 abundance was also reduced in retinas of the JR5558 mouse model of spontaneous choroidal neovascularization. Finally, adenoassociated vector-mediated gene delivery of a truncated DICER1 variant (OptiDicer) reduced spontaneous choroidal neovascularization in JR5558 mice. Collectively, these findings significantly expand the repertoire of DICER1 in preserving retinal homeostasis by preventing both RPE degeneration and pathological neovascularization.

Quarterly Anti-Vascular Endothelial Growth Factor Dosing for Neovascular Age-Related Macular Degeneration: Real-World Clinical Outcomes

BACKGROUND AND OBJECTIVE

Characterize eyes managed with quarterly intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

Treatment-naïve nAMD eyes managed predominately using a treat-and-extend approach that received five or more consecutive quarterly injections from 2005 to 2017.

RESULTS

One hundred fifty eyes were retrospectively identified. During quarterly dosing, a mean of 9.8 injections were given over a mean of 29 months. Ninety-one eyes (61%) had no exudative disease recurrence during quarterly dosing. Thirty-three eyes (22%) experienced exudative activity recurrence, with a mean cumulative yearly recurrence rate of 12% and a mean 6-letter loss of visual acuity (VA). Twenty-four eyes (16%) stopped quarterly treatments; nine (38%) of these subsequently experienced exudative activity recurrence with a mean 8-letter VA loss.

CONCLUSION

In this real-world analysis of nAMD managed with quarterly dosing over a mean of more than 2 years' follow-up, 22% experienced disease recurrence during quarterly dosing, and 38% of eyes that stopped quarterly dosing experienced subsequent exudative disease recurrence. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e250-e256.].

Macular Atrophy in Neovascular Age-Related Macular Degeneration: A Randomized Clinical Trial Comparing Ranibizumab and Aflibercept (RIVAL Study)

PURPOSE

To investigate differences in the development of macular atrophy (MA) over 24 months between treat-and-extend (T&E) ranibizumab and aflibercept in patients with neovascular age-related macular degeneration (nAMD).

DESIGN

A phase 4 randomized, partially masked, multicenter study.

PARTICIPANTS

Individuals 50 years of age or older diagnosed with active, treatment-naïve subfoveal choroidal neovascularization secondary to nAMD with baseline best-corrected visual acuity (BCVA) of 23 logarithm of minimum angle of resolution letters or more.

METHODS

Patients were randomized 1:1 to receive either intravitreal injections of ranibizumab 0.5 mg or aflibercept 2.0 mg and were treated according to the same reading center-guided T&E regimen after 3 initial monthly injections.

MAIN OUTCOME MEASURES

The primary outcome was mean change in square root area of MA from baseline to month 24. Key secondary outcomes included number of injections and mean change in BCVA from baseline to months 12 and 24.

RESULTS

Two hundred seventy-eight patients were included in the analysis (ranibizumab 0.5 mg, n = 141; aflibercept 2.0 mg, n = 137). Mean change in square root area of MA from baseline to month 24 was +0.36 mm (95% confidence interval [CI], 0.27-0.45 mm) for ranibizumab and +0.28 mm (95% CI, 0.19-0.37 mm) for aflibercept (treatment difference, +0.08 mm [95% CI, -0.05 to 0.21 mm]; P = 0.24). The proportion of patients with MA increased from 7% (10/141) to 37% (43/117) for ranibizumab and from 6% (8/137) to 32% (35/108) for aflibercept from baseline to month 24. The average number of injections received per year was similar between both groups: 9.6 (95% CI, 9.2-10.0) for ranibizumab and 9.5 (95% CI, 9.1-9.9) for aflibercept. The mean change in BCVA from baseline to month 24 was +6.6 letters (95% CI,4.7-8.5 letters) for the ranibizumab group and +4.6 letters (95% CI, 2.7-6.6 letters) for the aflibercept group ( P = 0.15). Rates of adverse events (AEs) were similar between both groups.

CONCLUSIONS

No significant differences in the rate of development or growth of MA over 24 months were observed between ranibizumab and aflibercept in nAMD patients treated using an identical T&E regimen.

Clinical Course of Autosomal Recessive Bestrophinopathy Complicated by Choroidal Neovascularization

The authors report the clinical course of two cases of autosomal recessive bestrophinopathy (ARB) complicated by choroidal neovascularization (CNV). One patient presenting with a novel BEST1 mutation (c.658 C>T, p.Gln220*) underwent anti-vascular endothelial growth factor therapy. Response to treatment was documented on optical coherence tomography angiography (OCTA). Despite initial response to treatment, recurrent CNV exudation with progressive subretinal fibrosis was observed. In the second patient, the CNV was not treated and spontaneous regression was observed. This report indicates that the clinical course of CNV in ARB may vary considerably, ranging from spontaneous regression to progressive subretinal fibrosis despite intervention. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:888-892.].

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

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

Characterization of Patients With Geographic Atrophy in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

Geographic atrophy (GA) affects millions of patients with age-related macular degeneration (AMD) worldwide, leading to significant, irreversible visual impairment. This study aims to characterize the visual impairment of patients with GA in a routine clinical practice.

PATIENTS AND METHODS

This single-center, cross-sectional study used a novel natural language processing to select 1,045 GA cases utilizing the macula examination records from 19,359 patients with AMD.

RESULTS

Patients were classified based on the diagnosis of the fellow-eye as follow: 502 in group 1 (GA:GA), 403 in group 2 (GA : choroidal neovascularization), and 234 in group 3 (GA : early / intermediate AMD). Best-corrected visual acuity (BCVA) in the affected eye was 50.3 (± 22.1) letters in group 1, 52.5 (± 21.3) letters in group 2, and 48.5 (± 23.6) letters in group 3 (P < .05). Visual impairment (ineligibility for an unrestricted driver license) was present in 70.5% of group 1, 59.7% of group 2, and 39.6% of group 3. Legal blindness (BCVA < 20 letters in the best-seeing eye) was seen in 2.2% of group 1, 3% of group 2, and 0.8% of group 3.

CONCLUSION

Differences in visual impairment between subgroups of patients with GA can be seen in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:93-98.].

Quantitative optical coherence tomography angiography biomarkers for neovascular age-related macular degeneration in remission

Purpose

To characterize quantitative optical coherence tomography angiography (OCT-A) parameters in active neovascular age-related macular degeneration (nAMD) patients under treatment and remission nAMD patients.

Design

Retrospective, cross-sectional study.

Participants

One hundred and four patients of whom 72 were in Group 1 (active nAMD) and 32 in Group 2 (remission nAMD) based on SD-OCT (Spectral Domain OCT) qualitative morphology.

Methods

This study was conducted at the Centre Ophtalmologique de l’Odeon between June 2016 and December 2017. Eyes were analyzed using SD-OCT and high-speed (100 000 A-scans/second) 1050-nm wavelength swept-source OCT-A. Speckle noise removal and choroidal neovascularization (CNV) blood flow delineation were automatically performed. Quantitative parameters analyzed included blood flow area (Area), vessel density, fractal dimension (FD) and lacunarity. OCT-A image algorithms and graphical user interfaces were built as a unified tool in Matlab coding language. Generalized Additive Models were used to study the association between OCT-A parameters and nAMD remission on structural OCT. The models’ performance was assessed by the Akaike Information Criterion (AIC), Brier Score and by the area under the receiver operating characteristic curve (AUC). A p value of ≤ 0.05 was considered as statistically significant.

Results

Area, vessel density and FD were different (p<0.001) in the two groups. Regarding the association with CNV activity, Area alone had the highest AUC (AUC = 0.85; 95%CI: 0.77–0.93) followed by FD (AUC = 0.80; 95%CI: 0.71–0.88). Again, Area obtained the best values followed by FD in the AIC and Brier Score evaluations. The multivariate model that included both these variables attained the best performance considering all assessment criteria.

Conclusions

Blood flow characteristics on OCT-A may be associated with exudative signs on structural OCT. In the future, analyses of OCT-A quantitative parameters could potentially help evaluate CNV activity status and to develop personalized treatment and follow-up cycles.

Inhibition of Experimental Choroidal Neovascularization by a Novel Peptide Derived from Calreticulin Anti-Angiogenic Domain

Choroidal neovascularization (CNV) is a key pathological feature of several leading causes of vision loss including neovascular age-related macular degeneration. Here, we show that a calreticulin anti-angiogenic domain (CAD)-like peptide 27, CAD27, inhibited in vitro angiogenic activities, including tube formation, migration of endothelial cells, and vascular sprouting from rat aortic ring explants. In a rat model of laser-induced CNV, we demonstrate that intravitreal injection of CAD27 significantly attenuated the formation of CNV lesions as measured via fundus fluorescein angiography and choroid flat-mounts (19.5% and 22.4% reductions at 10 μg and 20 μg of CAD27 injected, respectively). Similarly, the reduction of CNV lesions was observed in rats that had received topical applications of CAD27 (choroid flat-mounts: 17.9% and 32.5% reductions at 10 μg/mL and 20 μg/mL of CAD27 instilled, respectively). Retinal function was unaffected, as measured using electroretinography in both groups receiving interareal injection or topical applications of CAD27 for at least fourteen days. These findings show that CAD27 can be used as a potential therapeutic alternative for targeting CNV in diseases such as neovascular age-related macular degeneration.

Association Between the Cilioretinal Artery and Choroidal Neovascularization in Age-Related Macular Degeneration: A Secondary Analysis From the Age-Related Eye Disease Study

Importance

A hemodynamic role in the pathogenesis of age-related macular degeneration (AMD) has been proposed, but to our knowledge, an association between retinal vasculature and late AMD has not been investigated.

Objective

To determine whether the presence and location of a cilioretinal artery may be associated with the risk of late AMD in the Age-Related Eye Disease Study (AREDS).

Design, Setting, and Participants

Retrospective analysis of prospective, randomized clinical trial data from 3647 AREDS participants. Fundus photographs of AREDS participants were reviewed by 2 masked graders for the presence or absence of a cilioretinal artery and whether any branch extended within 500 μm of the central macula. Multivariate regressions were used to determine the association of the cilioretinal artery and vessel location, adjusted for age, sex, and smoking status, with the prevalence of choroidal neovascularization (CNV) or central geographic atrophy (CGA) and AMD severity score for eyes at randomization and progression at 5 years.

Main Outcomes and Measures

Association of cilioretinal artery with prevalence and 5-year incidence of CNV or CGA.

Results

Among AREDS participants analyzed, mean (SD) age was 69.0 (5.0) years, with 56.3% female, 46.6% former smokers, and 6.9% current smokers. A total of 26.9% of patients had a cilioretinal artery in 1 eye, and 8.4% had the vessel bilaterally. At randomization, eyes with a cilioretinal artery had a lower prevalence of CNV (5.0% vs 7.6%; OR, 0.66; 95% CI, 0.51-0.85; P = .001) but no difference in CGA (1.1% vs 0.8%; OR, 1.33; 95% CI, 0.76-2.32; P = .31). In eyes without late AMD, those with a cilioretinal artery also had a lower mean (SD) AMD severity score (3.00 [2.35] vs 3.19 [2.40]; P = .02). At 5 years, eyes at risk with a cilioretinal artery had lower rates of progression to CNV (4.1% vs 5.5%; OR, 0.75; 95% CI, 0.56-1.00; P = .05) but no difference in developing CGA (2.2% vs 2.7%; OR, 0.83; 95% CI, 0.56-1.23; P = .35) or change in AMD severity score (0.65 [1.55] vs 0.73 [1.70]; P = .11). In patients with a unilateral cilioretinal artery, eyes with the vessel showed a lower prevalence of CNV than fellow eyes (4.7% vs 7.2%; P = .01).

Conclusions and Relevance

The presence of a cilioretinal artery is associated with a lower risk of developing CNV, but not CGA, suggesting a possible retinal hemodynamic contribution to the pathogenesis of neovascular AMD.

Trial Registration

ClinicalTrials.gov Identifier: NCT00000145.

Association of Genetic Variants With Response to Anti-Vascular Endothelial Growth Factor Therapy in Age-Related Macular Degeneration

Importance

Visual acuity (VA) outcomes differ considerably among patients with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) drugs. Identification of pharmacogenetic associations may help clinicians understand the mechanisms underlying this variability as well as pave the way for personalized treatment in nAMD.

Objective

To identify genetic factors associated with variability in the response to anti-VEGF therapy for patients with nAMD.

Design, Setting, and Participants

In this multicenter genome-wide association study, 678 patients with nAMD with genome-wide genotyping data were included in the discovery phase; 1380 additional patients with nAMD were genotyped for selected common variants in the replication phase. All participants received 3 monthly injections of bevacizumab or ranibizumab. Clinical data were evaluated for inclusion/exclusion criteria from October 2014 to October 2015, followed by data analysis from October 2015 to February 2016. For replication cohort genotyping, clinical data collection and analysis (including meta-analysis) was performed from March 2016 to April 2017.

Main Outcomes and Measures

Change in VA after the loading dose of 3 monthly anti-VEGF injections compared with baseline.

Results

Of the 2058 included patients, 1210 (58.8%) were women, and the mean (SD) age across all cohorts was 78 (7.4) years. Patients included in the discovery cohort and most of the patients in the replication cohorts were of European descent. The mean (SD) baseline VA was 51.3 (20.3) Early Treatment Diabetic Retinopathy Study (ETDRS) score letters, and the mean (SD) change in VA after the loading dose of 3 monthly injections was a gain of 5.1 (13.9) ETDRS score letters (ie, 1-line gain). Genome-wide single-variant analyses of common variants revealed 5 independent loci that reached a P value less than 10 × 10-5. After replication and meta-analysis of the lead variants, rs12138564 located in the CCT3 gene remained nominally associated with a better treatment outcome (ETDRS letter gain, 1.7; β, 0.034; SE, 0.008; P = 1.38 × 10-5). Genome-wide gene-based optimal unified sequence kernel association test of rare variants showed genome-wide significant associations for the C10orf88 (P = 4.22 × 10-7) and UNC93B1 (P = 6.09 × 10-7) genes, in both cases leading to a worse treatment outcome. Patients carrying rare variants in the C10orf88 and UNC93B1 genes lost a mean (SD) VA of 30.6 (17.4) ETDRS score letters (ie, loss of 6.09 lines) and 26.5 (13.8) ETDRS score letters (ie, loss of 5.29 lines), respectively, after 3 months of anti-VEGF treatment.

Conclusions and Relevance

We propose that there is a limited contribution of common genetic variants to variability in nAMD treatment response. Our results suggest that rare protein-altering variants in the C10orf88 and UNC93B1 genes are associated with a worse response to anti-VEGF therapy in patients with nAMD, but these results require further validation in other cohorts.

Outcomes and Predictive Factors After Cataract Surgery in Patients With Neovascular Age-related Macular Degeneration. The Fight Retinal Blindness! Project

PURPOSE

To evaluate outcomes and predictive factors of visual acuity (VA) change after cataract surgery in patients being treated for neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective, matched case-control study.

METHODS

We studied eyes undergoing cataract surgery that had been tracked since they first started treatment for nAMD. These eyes were compared with a cohort of unoperated phakic eyes being treated for nAMD (3 per case) matched for treatment duration before cataract surgery, baseline VA, age, and length of follow-up.

RESULTS

We included 124 patients that had cataract surgery and 372 matched controls. The mean (95% confidence interval) VA gained was 10.6 letters (7.8, 13.2; P < .001) 12 months after surgery; 26.0% had gained ≥3 lines and 1.6% had lost ≥3 lines of VA. Visual acuity (mean [standard deviation]) 12 months after surgery was higher in eyes that had cataract extraction compared with controls (65.8 [17.1] vs 61.3 [20.8] letters, respectively, P = .018). The proportion of visits where the choroidal neovascular (CNV) lesion was graded active and the mean number of injections were similar before and after surgery (P = .506 and P = .316, respectively), whereas both decreased in the control group, suggesting that surgery modestly increased the level of activity of the CNV lesion. Mean [SD] VA prior to surgery was lower in eyes that gained ≥15 letters compared with eyes that gained 0-14 letters (40.2 [21.4] vs 62.1 [15.1], P < .001). Patients undergoing cataract surgery within the first 6 months of anti-VEGF therapy were more likely to lose rather than gain vision (20.8% lost vision vs 12.8% and 4.4% gaining ≥15 or 0-14 letters respectively, P = .023). Age, receiving an injection at least 2 weeks before surgery, and the CNV lesion type had no discernible association with VA outcomes.

CONCLUSIONS

We found evidence of a modest effect of cataract surgery on CNV lesion activity in eyes being treated for nAMD. Despite this, visual outcomes were reassuringly good. Cataract surgery within 6 months of starting treatment for nAMD should be avoided if possible.

Photodynamic Therapy with Verteporfin of Choroidal Neovascularization in Angioid Streaks: Conventional versus Early Retreatment

PURPOSE

To evaluate the effectiveness of conventional photodynamic therapy with verteporfin (PDT) in a series of patients with macular choroidal neovascularization (CNV) due to angioid streaks and to compare it to the effectiveness of early PDT retreatment.

METHODS

This is a retrospective study of 24 eyes (22 consecutive patients) with subfoveal or juxtafoveal CNV secondary to angioid streaks treated with PDT from September 2000 through February 2003 and that completed at least the first year of follow-up. Until August 2001, retreatments were performed according to the conventional protocol for PDT every 3 months (Group 1, consisting of 11 eyes of 9 patients). After August 2001 (13 more eyes of 13 new patients), retreatments were performed earlier (every 8 weeks) when indicated (Group 2). The follow-up time ranged from 30 to 42 months and from 12 to 30 months in Groups 1 and 2.

RESULTS

At the end of the follow-up, final best-corrected visual acuity decreased in 21 (87.5%), stabilized in 2 (8.3%), and improved in 1 (4.2%) of the total 24 eyes. In all, 19 of the 24 eyes (79.2%) had a final best-corrected visual acuity equal to or less than 20/400. There were not any statistically significant differences in final visual acuity between the two groups.

CONCLUSIONS

In this large series of patients with macular CNV secondary to angioid streaks, the functional and the anatomic results of PDT were not satisfactory, even when retreatments were performed earlier than the conventional time of 3 months.

Sequential Combined Therapy for Treatment of Choroidal Neovascularization in Age-Related Macular Degeneration: Photodynamic Therapy and Thermal Laser Photocoagulation

PURPOSE

To analyze the results achieved after treating extrafoveal choroidal neovascularization (CNV) recurrences with thermal laser photocoagulation (TLP) in patients who had previously undergone photodynamic therapy (PDT).

PATIENTS AND METHODS

Seven eyes (seven patients: four women and three men) that had been initially treated by PDT for CNV associated with age-related macular degeneration (ARMD) and then developed extrafoveal recurrences were treated with green argon TLP. All patients underwent a complete ophthalmologic evaluation and fluorescein angiography. Mean age was 74.4 +/- 4.4 years (range, 69 to 81 years). Five right eyes and two left eyes were treated. Mean follow-up after the beginning of the treatment with PDT was 18.0 +/- 3.5 months (range, 11 to 22 months). Follow-up after TLP was 6.8 +/- 1.0 months (range, 6 to 8 months).

RESULTS

Mean best-corrected visual acuity (BCVA) before treatment was 20/150 (range 20/400 to 20/40). After PDT it was 20/281 (range, 20/400 to 20/80), with a mean of 3.1 +/- 0.8 treatments (range, 2 to 4). After TLP, BCVA was 20/233 (range, 20/400 to 20/80), with no statistically significant difference from BCVA after PDT (p = 0.06, Student's t-test paired data). In all cases total closure of CNV was achieved after only one session of TLP.

CONCLUSIONS

TLP could be helpful in association with multiple sessions of PDT in order to achieve a complete closure of subfoveal CNV secondary to ARMD. Further studies are required to confirm our findings.

The ARMOUR Study: Anti-VEGF in Neovascular AMD--Our Understanding in a Real-World Indian Setting

PURPOSE

The aim of our study was to share our experience with anti-vascular endothelial growth factor (anti-VEGF) injections in the treatment of neovascular age-related macular degeneration (nAMD) in a real-world setting.

DESIGN

A retrospective, observational study.

METHODS

Patients of Indian origin with nAMD receiving anti-VEGF with a minimum follow-up of 12 months were enrolled in this study. In group 1, patients were treated on a pro re nata (PRN) basis; in group 2, patients received a loading dose (3 injecti Results: Overall, we observed that 77.31% (92/119 eyes) of patients either maintained or had improved visual acuity at 12 months' follow-up. Similar visual outcome was observed in both groups. The average number of injections given in group 1 was 4.98 and in group 2 was 3.7. CDVA at 12 months was significantly correlated with type of drug molecule, CSFT at 3 and 12 months, baseline visual acuity, and CDVA at 3 months.

CONCLUSIONS

PRN treatment with significantly fewer injections achieved similar anatomical and functional outcomes when compared with the loading dose group. The results of this study need to be validated with a larger study group and a longer follow-up.

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 Follow-Up of Nonexudative Choroidal Neovascularization With Multiple Optical Coherence Tomography Angiography Devices: A Case Report

Nonexudative choroidal neovascularization (CNV) is a new phenomenon that has only recently been described in the literature with the advent of optical coherence tomography angiography (OCTA) imaging. The authors present a 1-year longitudinal follow-up of a nonexudative CNV lesion secondary to age-related macular degeneration. This report describes the appearance of the lesion on two commercially available spectral-domain OCTA devices and one prototype swept-source OCTA device. Management of these cases is still debatable. Watchful waiting with regular follow-up using serial OCTA to monitor disease progression has been valuable in this case. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:778-781.].

Intravitreous injection of AAV2-sFLT01 in patients with advanced neovascular age-related macular degeneration: a phase 1, open-label trial

BACKGROUND

Long-term intraocular injections of vascular endothelial growth factor (VEGF)-neutralising proteins can preserve central vision in many patients with neovascular age-related macular degeneration. We tested the safety and tolerability of a single intravitreous injection of an AAV2 vector expressing the VEGF-neutralising protein sFLT01 in patients with advanced neovascular age-related macular degeneration.

METHODS

This was a phase 1, open-label, dose-escalating study done at four outpatient retina clinics in the USA. Patients were assigned to each cohort in order of enrolment, with the first three patients being assigned to and completing the first cohort before filling positions in the following treatment groups. Patients aged 50 years or older with neovascular age-related macular degeneration and a baseline best-corrected visual acuity score of 20/100 or less in the study eye were enrolled in four dose-ranging cohorts (cohort 1, 2 × 10⁸ vector genomes (vg); cohort 2, 2 × 10⁹ vg; cohort 3, 6 × 10⁹ vg; and cohort 4, 2 × 10¹⁰ vg, n=3 per cohort) and one maximum tolerated dose cohort (cohort 5, 2 × 10¹⁰ vg, n=7) and followed up for 52 weeks. The primary objective of the study was to assess the safety and tolerability of a single intravitreous injection of AAV2-sFLT01, through the measurement of eye-related adverse events. This trial is registered with ClinicalTrials.gov, number NCT01024998.

FINDINGS

19 patients with advanced neovascular age-related macular degeneration were enrolled in the study between May 18, 2010, and July 14, 2014. All patients completed the 52-week trial period. Two patients in cohort 4 (2 × 10¹⁰ vg) experienced adverse events that were possibly study-drug related: pyrexia and intraocular inflammation that resolved with a topical steroid. Five of ten patients who received 2 × 10¹⁰ vg had aqueous humour concentrations of sFLT01 that peaked at 32·7-112·0 ng/mL (mean 73·7 ng/mL, SD 30·5) by week 26 with a slight decrease to a mean of 53·2 ng/mL at week 52 (SD 17·1). At baseline, four of these five patients were negative for anti-AAV2 serum antibodies and the fifth had a very low titre (1:100) of anti-AAV2 antibodies, whereas four of the five non-expressers of sFLT01 had titres of 1:400 or greater. In 11 of 19 patients with intraretinal or subretinal fluid at baseline judged to be reversible, six showed substantial fluid reduction and improvement in vision, whereas five showed no fluid reduction. One patient in cohort 5 showed a large decrease in vision between weeks 26 and 52 that was not thought to be vector-related.

INTERPRETATION

Intravitreous injection of AAV2-sFLT01 seemed to be safe and well tolerated at all doses. Additional studies are needed to identify sources of variability in expression and anti-permeability activity, including the potential effect of baseline anti-AAV2 serum antibodies.

FUNDING

Sanofi Genzyme, Framingham, MA, USA.

Comparison between 1-year outcomes of aflibercept with and without photodynamic therapy for polypoidal choroidal vasculopathy: Retrospective observation study

Polypoidal choroidal vasculopathy (PCV) is characterized by polyp-like choroidal neovascularization and a branching vascular network. Intravitreal aflibercept injection (IAI) or photodynamic therapy (PDT) is used for treatment. We retrospectively compared the 1-year outcomes of IAI monotherapy and its combination with initial PDT for PCV. Twelve eyes with naïve PCV received three IAIs and a single PDT after the first IAI and as needed injection (combination group); 11 eyes with naïve PCV received three IAIs and as needed injections (IAI group). Significant improvements in visual acuity after 2 months and in CRT after 1 month were maintained at 12 months in both groups (both P < 0.05); groups did not differ significantly at any time point. CCT significantly reduced after 3 and 12 months in the combination group (both P < 0.05) but not in the IAI group. A mean of 3.7 ± 0.9 and 5.6 ± 2.0 injections was administered to the combination and IAI groups, respectively (P = 0.013). Within a 1-year period, combination therapy was found to yield similar visual acuity and retinal structure improvements and maintenance as IAI monotherapy while requiring fewer IAIs.

Neuropilin 1 Involvement in Choroidal and Retinal Neovascularisation

PURPOSE

Inhibiting VEGF is the gold standard treatment for neovascular age-related macular degeneration (AMD). It is also effective in preventing retinal oedema and neovascularisation (NV) in diabetic retinopathy (DR) and retinal vein occlusions (RVO). Neuropilin 1 (Nrp1) is a co-receptor for VEGF and many other growth factors, and therefore a possible alternative drug target in intra ocular neovascular disease. Here we assessed choroidal and retinal NV in an inducible, endothelial specific knock out model for Nrp1.

METHODS

Crossing Nrp1 floxed mice with Pdgfb-CreERT2 mice produced tamoxifen-inducible, endothelial specific Nrp1 knock out mice (Nrp1ΔEC) and Cre-negative, control littermates. Cre-recombinase activity was confirmed in the Ai3(RCL-EYFP) reporter strain. Animals were subjected to laser-induced CNV (532 nm) and spectral domain-optical coherence tomography (SD-OCT) was performed immediately after laser and at day 7. Fluorescein angiography (FA) evaluated leakage and postmortem lectin staining in flat mounted RPE/choroid complexes was also used to measure CNV. Furthermore, retinal neovascularisation in the oxygen induced retinopathy (OIR) model was assessed by immunohistochemistry in retinal flatmounts.

RESULTS

In vivo FA, OCT and post-mortem lectin staining showed a statistically significant reduction in leakage (p<0.05), CNV volume (p<0.05) and CNV area (p<0.05) in the Nrp1ΔEC mice compared to their Cre-negative littermates. Also the OIR model showed reduced retinal NV in the mutant animals compared to wild types (p<0.001).

CONCLUSION

We have demonstrated reduced choroidal and retinal NV in animals that lack endothelial Nrp1, confirming a role of Nrp1 in those processes. Therefore, Nrp1 may be a promising drug target for neovascular diseases in the eye.

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.

Distinct Responsiveness to Intravitreal Ranibizumab Therapy in Polypoidal Choroidal Vasculopathy With Single or Multiple Polyps

PURPOSE

To understand the prognosis of polypoidal choroidal vasculopathy (PCV) by evaluating the responsiveness to intravitreal ranibizumab (IVR) monotherapy according to the presence of a single or multiple polyps.

DESIGN

Retrospective case series.

METHODS

We included 48 treatment-naïve eyes of 48 patients who received IVR monotherapy at the Medical Retina Division Clinic, Keio University Hospital between March 2009 and January 2013 and attended the clinic for at least 12 months. All patients received 3 monthly IVR injections followed by pro re nata injections and were divided into single polyp and multiple polyps groups according to indocyanine green angiography and optical coherence tomography (OCT) findings. The outcome measures included changes in best-corrected visual acuity (BCVA) and OCT findings over 2 years after initial IVR.

RESULTS

At baseline, the multiple polyps group exhibited a poorer BCVA, larger greatest linear dimension, and higher prevalence of fibrovascular pigment epithelial detachment compared with the single polyp group. Over 2 years, the multiple polyps group showed no improvement in BCVA, although the central retinal thickness (CRT) decreased in both groups. The multiple polyps group exhibited a significantly greater CRT at 1 year and required more injections in the first year compared with the single polyp group; furthermore, it included a higher number of nonresponders judged either by BCVA or fundus findings at 1 year and fundus findings at 2 years.

CONCLUSIONS

We propose that the stratification of PCV lesions according to the presence of single or multiple polyps may be valuable to understand the prognosis.

Intravitreal Bevacizumab for Nonsubfoveal Choroidal Neovascularization Associated With Angioid Streaks: 3-Year Follow-up Study

PURPOSE

To assess the effects of intravitreal bevacizumab injections in the treatment of nonsubfoveal choroidal neovascularization (CNV) associated with angioid streaks (AS) in a 3-year follow-up study.

DESIGN

Noncomparative, interventional, prospective case series.

METHODS

Eighteen patients (18 eyes) with juxtafoveal/extrafoveal CNV secondary to AS were recruited. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement on ETDRS chart, optical coherence tomography (OCT), and fluorescein angiography (FA). The protocol treatment included a first injection, followed by repeated injections on the basis of detection of new hemorrhage, any type of fluid on OCT, and/or presence of FA leakage. Primary outcome measures were final mean changes in BCVA and proportion of eyes with 10 ETDRS letters improvement. Secondary outcomes were mean changes of central macular thickness (CMT) and foveal involvement.

RESULTS

After a mean BCVA stabilization over the first year, a statistically significant BCVA worsening was registered at the 24-month (72.8 ± 10.0 ETDRS letters, P = .03) and 36-month examinations (65.8 ± 15.0 ETDRS letters, P = .02) in comparison with the 1-year visual outcomes (80.1 ± 5.4 ETDRS letters); lastly, a substantial stabilization in the BCVA was observed at 36 months in comparison with the baseline value (77.9 ± 10.0 ETDRS letters, P = .22). Two eyes (25%) with juxtafoveal CNV and no eye with extrafoveal CNV experienced a 10-letter improvement at the 3-year examination. Mean CMT at baseline was 220 ± 15 μm and 235 ± 66 μm at 36 months (P = 1.00). During the first and second years of follow-up, 5 juxtafoveal CNVs and 3 extrafoveal CNVs showed foveal involvement.

CONCLUSIONS

Intravitreal bevacizumab can be effective in the management of nonsubfoveal CNV secondary to AS, although monthly monitoring is required to control CNV recurrence or progression.

Malondialdehyde induces autophagy dysfunction and VEGF secretion in the retinal pigment epithelium in age-related macular degeneration

Age-related macular degeneration (AMD) is a major cause of blindness in developed countries and is closely related to oxidative stress, which leads to lipid peroxidation. Malondialdehyde (MDA) is a major byproduct of polyunsaturated fatty acid (PUFA) peroxidation. Increased levels of MDA have been reported in eyes of AMD patients. However, little is known about the direct relationship between MDA and AMD. Here we show the biological importance of MDA in AMD pathogenesis. We first confirmed that MDA levels were significantly increased in eyes of AMD patients. In ARPE-19 cells, a human retinal pigment epithelial cell line, MDA treatment induced vascular endothelial growth factor (VEGF) expression alternation, cell junction disruption, and autophagy dysfunction that was also observed in eyes of AMD patients. The MDA-induced VEGF increase was inhibited by autophagy-lysosomal inhibitors. Intravitreal MDA injection in mice increased laser-induced choroidal neovascularization (laser-CNV) volumes. In a mouse model fed a high-linoleic acid diet for 3 months, we found a significant increase in MDA levels, autophagic activity, and laser-CNV volumes. Our study revealed an important role of MDA, which acts not only as a marker but also as a causative factor of AMD pathogenesis-related autophagy dysfunction. Furthermore, higher dietary intake of linoleic acid promoted CNV progression in mice with increased MDA levels.

New perspectives in retinal imaging - angio OCT

In the last few years, structural and functional optical coherence tomography (OCT) technology has seen new and revolutionary developments. The most important of all is OCT angiography (Angio-OCT). Angio-OCT already plays an important role in clinical ophthalmology as a new, non invasive and dyeless diagnostic tool, which serves as an adjunct to, or even a replacement for fluorescein and indocyanine green (ICG) angiographies. Angio-OCT brings multiple technical and clinical improvements in the study of retinal diseases, glaucoma, and optic nerve disorders. It enables rapid, high-resolution, detailed images of large retinal vessels and capillary networks in seconds by using a strategy called "motion contrast", as opposed to revealing detailed images of large retinal vessels and capillary networks in seconds by using a strategy called "motion contrast" as opposed to the minutes required in conventional fluorescein angiography. These images are uniquely three-dimensional and allow an isolated study of individual capillary beds at different depths of the retina.

Optical Coherence Tomography Angiography of Type 1 Neovascularization in Age-Related Macular Degeneration

Age-related macular degeneration continues to be the leading cause of severe central vision loss in older adults of European descent. Optical coherence tomography angiography (OCT-A) enables more accurate identification of type 1 neovascularization in age-related macular degeneration than traditional fluorescein and indocyanine green angiographies. In addition, OCT-A facilitates the morphological classification of type 1 lesions, including features characteristic of early, mature, and fibrotic lesions. Vessel complex analysis, including lesion area and capillary density quantification, can also be readily measured and monitored over time. Performing this analysis following anti-vascular endothelial growth factor therapy may lead to a better understanding of the efficacies and responses to such treatments. Although some limitations currently exist, OCT-A is a promising imaging modality that could prove to have profound implications if incorporated into regular clinical practice.

Gene therapy with recombinant adeno-associated vectors for neovascular age-related macular degeneration: 1 year follow-up of a phase 1 randomised clinical trial

BACKGROUND

Neovascular, or wet, age-related macular degeneration causes central vision loss and represents a major health problem in elderly people, and is currently treated with frequent intraocular injections of anti-VEGF protein. Gene therapy might enable long-term anti-VEGF therapy from a single treatment. We tested the safety of rAAV.sFLT-1 in treatment of wet age-related macular degeneration with a single subretinal injection.

METHODS

In this single-centre, phase 1, randomised controlled trial, we enrolled patients with wet age-related macular degeneration at the Lions Eye Institute and the Sir Charles Gairdner Hospital (Nedlands, WA, Australia). Eligible patients had to be aged 65 years or older, have age-related macular degeneration secondary to active subfoveal choroidal neovascularisation, with best corrected visual acuity (BCVA) of 3/60-6/24 and 6/60 or better in the other eye. Patients were randomly assigned (3:1) to receive either 1 × 10(10) vector genomes (vg; low-dose rAAV.sFLT-1 group) or 1 × 10(11) vg (high-dose rAAV.sFLT-1 group), or no gene-therapy treatment (control group). Randomisation was done by sequential group assignment. All patients and investigators were unmasked. Staff doing the assessments were masked to the study group at study visits. All patients received ranibizumab at baseline and week 4, and rescue treatment during follow-up based on prespecified criteria including BCVA measured on the Early Treatment Diabetic Retinopathy Study (EDTRS) scale, optical coherence tomography, and fluorescein angiography. The primary endpoint was ocular and systemic safety. This trial is registered with ClinicalTrials.gov, number NCT01494805.

FINDINGS

From Dec 16, 2011, to April 5, 2012, we enrolled nine patients of whom eight were randomly assigned to receive either intervention (three patients in the low-dose rAAV.sFLT-1 group and three patients in the high-dose rAAV.sFLT-1 group) or no treatment (two patients in the control group). Subretinal injection of rAAV.sFLT-1 was highly reproducible. No drug-related adverse events were noted; procedure-related adverse events (subconjunctival or subretinal haemorrhage and mild cell debris in the anterior vitreous) were generally mild and self-resolving. There was no evidence of chorioretinal atrophy. Clinical laboratory assessments generally remained unchanged from baseline. Four (67%) of six patients in the treatment group required zero rescue injections, and the other two (33%) required only one rescue injection each.

INTERPRETATION

rAAV.sFLT-1 was safe and well tolerated. These results support ocular gene therapy as a potential long-term treatment option for wet age-related macular degeneration.

FUNDING

National Health and Medical Research Council of Australia, Richard Pearce Bequest, Lions Save Sight Foundation, Brian King Fellowship, and Avalanche Biotechnologies, Inc.