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David A. Salz, Gary Shienbaum, Jonathan Prenner, Howard Fine, Richard Kaiser; Perfused but not leaking. Invest. Ophthalmol. Vis. Sci. 2012;53(14):2953.
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‘Perfused but not leaking’ (PNL) describes the angiographic state that develops after cessation of leakage following anti-vascular endothelial growth factor (VEGF) therapy. PNL describes an identifiable, persistent choroidal neovascular complex that has stopped leaking but has not regressed. Herein, we present 11 cases exhibiting this clinical phenomenon.
Retrospective, interventional, consecutive case series. Eleven eyes of 11 patients with neovascular age-related macular degeneration (AMD) who achieved PNL status were examined. PNL was defined based on characteristic fluorescein angiographic features, i.e. early hyperfluorescence and absence of late leakage, combined with normalization of intra- and sub-retinal fluid on optical coherence tomography (OCT) following anti-VEGF therapy. Baseline characteristics, treatment course, and outcomes data were collected and analyzed.
The mean age was 76 years old (range, 59 - 87). Baseline mean Snellen visual acuity and OCT central subfield thickness (CST) were 20/79 (range, 20/25 - 2/200) and 301 μm (range, 190 - 477), respectively. Four eyes received bevacizumab and 7 eyes received ranibizumab. The mean number of injections until PNL was recognized was 4.7 (range, 2 - 10). Mean Snellen visual acuity and OCT CST at the time of PNL recognition were 20/50 (range, 20/20 - 6/200) and 258 μm (range, 180 - 303).
PNL is a common but frequently overlooked angiographic finding that demonstrates the antimitogenic and antipermeability effects of anti-VEGF therapy, but also highlights that blocking VEGF alone does not lead to vascular regression. Clinical implications of PNL need to be defined but it could explain the high recurrence rate appreciated when anti-VEGF therapy is discontinued.
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