April 2010
Volume 51, Issue 13
ARVO Annual Meeting Abstract  |   April 2010
Sub-Classification of Exudative Age-Related Macular Degeneration Based on Anti-VEGF Therapy Response
Author Affiliations & Notes
  • M. H. Nelson
    North Carolina Macular Consultants, Winston-Salem, North Carolina
  • Footnotes
    Commercial Relationships  M.H. Nelson, Novartis Phamaceuticals, Inc., F; Novartis Pharmaceuticals, Inc., C; Novartis Pharmaceuticals, Inc., R.
  • Footnotes
    Support  None.
Investigative Ophthalmology & Visual Science April 2010, Vol.51, 3500. doi:
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      M. H. Nelson; Sub-Classification of Exudative Age-Related Macular Degeneration Based on Anti-VEGF Therapy Response. Invest. Ophthalmol. Vis. Sci. 2010;51(13):3500.

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      © ARVO (1962-2015); The Authors (2016-present)

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Purpose: : This study proposes a new classification for Exudative Age-Related Macular Degeneration. It is based on the clinical response to anti-VEGF medications.

Methods: : 225 eyes of 175 patients with Exudative Age-Related Macular Degeneration were evaluated by IVFA/ICG videoangiography and spectral domain OCT. Those with evidence of subretinal neovascular membrane formation, either classic or progressive occult, were treated with monthly Lucentis monotherapy. Clinical patterns of persistent or recurrent intraretinal, subretinal or subRPE leakage were appreciated upon monthly OCT and every three month IVFA/ICG over a 12-36 month period.All patients were treatment naive.

Results: : 40.1% of all patients had persistent leakage after anti-VEGF monotherapy. One quarter (9.9%) of those patients were classified as PRIMARY anti-VEGF failures when 100% of all subretinal, intraretinal or subRPE leakage did not completely resolve after three intravitreal injections of Lucentis. Three quarters (30.2%) of those patients were classified as SECONDARY anti-VEGF failures when leakage completely resolved after Lucentis injections, but later recurred. Most of these patients were treated with a ‘treat and extend’ maintenance therapy with Macugen or Lucentis however several displayed new neovascular processes or developed mature vessels that became resistant to anti-VEGF therapy.

Conclusions: : Persistent intraretinal, subretinal and subRPE leakage is common with non-selective anti-VEGF monotherapy. Three classifications of response to this therapy are offered:1. Anti-VEGF SENSITIVE - 15% that respond quickly in a sustained pattern.2. Anti-VEGF DEPENDENT - 75% who need chronic VEGF suppression to maintain a clinical response.3. Anti-VEGF RESISTANT - 10% that do not respond or incompletely respond.ICG videoangiography revealed that all patients who are anti-VEGF failures have the presence of arteriolarized subretinal neovascularization and/or polypoidal vasculopathy. PRIMARY anti-VEGF failures were found in the anti-VEGF resistant group and required combination therapy with intravitreal anti-VEGF medications , intravitreal triamcinolone acetonide and PDT to achieve complete leakage resolution. SECONDARY failures were found in the anti-VEGF DEPENDENT group, however, less than half required combination therapy. Therefore, sub-classifying Exudative ARMD patients by their response to anti-VEGF medication and by their ICG presentation creates an opportunity to perform primary combination therapy which obviates the need for suboptimal monthly anti-VEGF monotherapy.

Keywords: age-related macular degeneration • imaging methods (CT, FA, ICG, MRI, OCT, RTA, SLO, ultrasound) 

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