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Prashant K Parekh, Michael David Abramoff; Does fluorescein angiography add value in the management of suspected choroidal neovascularization?. Invest. Ophthalmol. Vis. Sci. 2016;57(12):1629.
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© 2017 Association for Research in Vision and Ophthalmology.
Fluorescein angiography (FA) has long been the standard modality to diagnose and manage choroidal neovascularization (CNV). However, FA is costly, has a mortality of 1 per 220000, and considerable morbidity from allergic reactions. Since the advent of anti-VEGF therapy for CNV, optical coherence tomography (OCT), a non-invasive imaging method free of these disadvantages, is used extensively to manage CNV, while FA is primarily used to make the initial diagnosis. A recent study found the sensitivity and specificity of OCT compared to FFA in diagnosis of CNV to be 100 and 80.8%, respectively. We believe that FA alters management of patients that are initially suspected of having CNV in less than 10% of cases. If this hypothesis is confirmed, it would cast doubt on the clinical utility and cost-effectiveness of FA in diagnosing CNV, except in treatment failures and non-standard cases.
After retrospective review of the clinical histories, FA, and OCT from 99 patients (99 eyes) who had an initial presentation of confirmed CNV and subsequent de-identification, three retina specialists masked to each other will review, in randomized order, the standardized brief initial clinical history, color fundus image, and OCT scan. They will then choose whether to manage each case by observation or anti-VEGF injection (FA- arm). After re-randomization, corresponding early, mid, and late phase FA images will be added to each patient’s case data, and the three experts will again choose from these 2 management options (FA+). For each expert, the case discordance (i.e., the percentage of cases where management differed between FA- and FA+) and inter-observer discordance (i.e., percentage of cases where all 3 experts differed) will be determined.
For one retina specialist, observation was recommended in 13.1% of cases while anti-VEGF treatment was recommended in the remaining 86.9% for both FFA- and FFA+ groups. The case discordance was 13.1%. Inter-observer reliability, measured through kappa and intra-class correlation parameters, is pending based on the data from the other retina specialists.
Based on the preliminary data, there is a suggestion that FA continues to have an important role in the management of CNV in standard cases; however, as more data is obtained from retina specialists, the discrepancy in management decisions may be further minimized.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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