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Ryan Nicholas Vogel, Drew B. Davis, Brad Kimura, Senthil Rathinavelu, Gabrielle S. Graves, Aniko Szabo, Dennis P Han; Anti-VEGF therapy in neovascular age-related macular degeneration with advanced visual loss: prognostic indicators for therapeutic response. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):1503.
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To assess the efficacy of anti-VEGF intravitreal injections in neovascular AMD with advanced visual loss at the initiation of therapy and to determine factors that predict visual outcome. Most clinical trials on anti-VEGF therapy have excluded subjects with severe degrees of visual loss.
A retrospective chart review was performed on a consecutive series of 1410 cases initiated with anti-VEGF therapy for neovascular AMD between January 2006 and December 2012 at the Medical College of Wisconsin. Of these, 134 cases met the study criteria of having 20/200 or worse best-corrected VA with no other visually limiting eye disease and minimum follow-up of 6 months. Of these, 97 cases were followed for 12 months. Factors for analysis included VA, number of injections received, drug type, ophthalmoscopic findings, fluorescein angiography (FA), and masked evaluation of OCT findings. Visual improvement/worsening was defined as at least ± 0.3 logMAR units change.
Mean patient age was 82.1 years, and baseline logMAR was 1.4 (20/500 Snellen equivalent). Mean logMAR at 12 month follow-up was 1.2. Treat and extend and pro re nata (prn) treatment strategies were primarily used. Visual outcomes were similar at 6 and 12 months. At 12 months, VA improved in 44% and worsened in 22% compared to baseline. Among subjects with baseline VA worse than 20/400, VA improved in 52% and worsened in 22%. On univariate analysis, retinal hemorrhage was associated with greater improvement (p=0.03), while intraretinal fluid on OCT was associated with less improvement (p=0.03) at 12 months. With multivariate analysis, poorer VA at baseline was associated with greater visual improvement (p=0.002), as was the larger the number of injections received (p=0.01). Larger macular lesion size (greatest linear dimension) on FA correlated with worse VA at 6 months (p=0.02), but not at 12 months by both univariate and multivariate analyses. Injection medication type did not influence outcome.
Anti-VEGF therapy may be beneficial for many patients with advanced visual loss from neovascular AMD. Number of injections, macular lesion size, and other clinical abnormalities may influence outcome. Future prospective studies are needed to define the role of anti-VEGF therapy in AMD with severe vision loss.
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