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Prashant Parekh, James C Folk, Stephen R Russell, Elliott Sohn, Michael David Abramoff; Does fluorescein angiography add value in the management of suspected choroidal neovascularization?. Invest. Ophthalmol. Vis. Sci. 2017;58(8):1857.
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© ARVO (1962-2015); The Authors (2016-present)
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 in 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 hypothesize that FA alters the management of patients 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 for diagnosing CNV.
We retrospectively reviewed the clinical histories, FA, and OCT of 99 patients (99 eyes) who had an initial presentation of later-confirmed CNV. After de-identification, four retinal specialists masked to each other reviewed, in randomized order, the standardized brief clinical history, the posterior pole color fundus image, and complete OCT of the initial visit. They then chose whether to manage each case by observation or anti-VEGF injection (FA- arm). After re-randomization, corresponding early, mid, and late phase FA images were added to each patient’s case data, and the experts again chose from these two management options (FA+). We determined for each expert, the case concordance (i.e., percentage of cases where the decision agreed between FA- and FA+) and inter-observer concordance (i.e., percentage of cases where all 4 experts agreed).
Among our retina specialists, the average intra-observer concordance was 90.2% (82.2-98.2%, p<0.01). The average inter-observer concordance for the FA- arm was 84.2% (73.1-95.4%, p<0.05) and the average inter-observer concordance for the FA+ arm was 82.8% (70.8-94.8%, p<0.05).
There was a high degree of intra-observer agreement in management whether or not FA was utilized. A similar level of agreement was also seen among specialists in the FA- and FA+ groups, albeit at higher variability. We believe these findings are reflective of nationwide, if not worldwide, practice patterns and further support deferring the use of FA for management of CNV, except in treatment failures and non-standard cases.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
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