Baseline predictors for good long-term visual outcomes in the treatment of neovascular AMD with intravitreal anti-VEGF therapy.

Abstract

 

Purpose

 

To determine factors predictive of good visual acuity (VA) 4 or more years following the initiation of treat and extend (TER) anti-VEGF therapy for neovascular AMD.

 

Methods

 

266 eyes of 232 patients who initiated a TER of intravitreal anti-VEGF therapy by a single physician from January 2006-January 2013 and had the following inclusion criteria: age ≥50 years, VA ≥ 20/60 at 4 year follow-up, and absence of permanent foveal structural damage, were evaluated. Neovascular lesions were classified using fluorescein angiography (FA) alone as well as using FA+optical coherence tomography (OCT). Correlation of long-term good VA with lesion subtype and VA at baseline, 3 months and final 4 year follow-up, was performed.

 

Results

 

Of the original 266 eyes, 78 patients (84 eyes) had 4 years of follow-up. Of these, 43 patients (44 eyes) (47.7% male) fit the inclusion criteria and retained VA≥20/60 (Mean 20/40). The mean age at baseline was 78.48±7.8 years, and the mean number of injections at 4 year follow-up was 32.30±5.8 (range: 13-41). Using FA alone, 43.2% of baseline lesions were occult, 18.2% were classic CNV, 25% were retinal angiomatous proliferation (RAP), and 13.6% were mixed. Using FA+OCT, 47.7% of baseline lesions were type 1 (sub-RPE), 9.1% were type 2 (sub-retinal), 25% were type 3 (intra-retinal), and 18.2% were mixed. Significant positive correlations were found between VA at baseline and at 3 months (r=0.676, p<0.001), as well as between VA at 3 months and 4 years (r=0.350, p=0.021). A positive trend was detected between VA at baseline and the final 4 year VA. Lesion area (p=0.033) and diameter (p=0.031) were associated with good VA at final 4 year follow-up.

 

Conclusions

 

Visual acuity at 3 months appears more predictive of good long-term VA than initial VA. Baseline lesion size (area and diameter) was more predictive of good long-term VA than initial lesion composition.

 

 

Color fundus photo of the right eye (A) demonstrating a choroidal neovascular membrane (CNV), exudate, and edema. Early fluorescein angiogram (B) demonstrating stippled early leakage with late staining (C) classified by the macular photocoagulation study as Occult CNV. With the addition of spectral domain optical coherence tomography, it is clear that there is a sub-retinal pigment epithelium component or Type 1 (lower image, D) and a sub-retinal component or Type 2 (upper image, D).

 

Keywords: 412 age-related macular degeneration • 609 neovascularization • 585 macula/fovea