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Richard F Spaide; Proposal for the Pathophysiology of Type 3 Neovascularization as Based on Multimodal Imaging Findings. Invest. Ophthalmol. Vis. Sci. 2019;60(9):3495.
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© ARVO (1962-2015); The Authors (2016-present)
To investigate the imaging characteristics of early Type 3 neovascularization and propose a new pathophysiologic sequence for early disease.
Patients were evaluated with a comprehensive ophthalmologic examination to include optical coherence tomography (OCT), OCT angiography, fluorescein angiography, and volume rendered OCT angiography. Relevant literature was also reviewed.
There were 10 eyes of 9 patients who had a mean age of 87 (range 79 – 93) years. The patients were seen to have distributed areas of cystoid macular edema, not necessarily contiguous with areas of fluorescein or OCT angiographic evidence of neovascularization, which colocalized with each other. Areas of hemorrhage were not necessarily contiguous with observed neovascularization. In some patients, massive amounts of edema were imaged even though the associated neovascularization invasion was small and did not reach deeper portions of the retina. These findings were readily responsive to intravitreal injections of anti-vascular endothelial growth factor (VEGF) medication. Review of published literature showed conflicting pathophysiologic proposals, many of which did not abide with contemporaneous imaging findings.
Type 3 neovascularization likely grows in response to increased cytokine levels, particularly VEGF, in a permissive environment. Elevated levels of VEGF have been shown to cause hemorrhage, edema, and telangiectasis in the macula, suggesting some of the manifestations of Type 3 neovascularization are related to increased tissue VEGF levels and not necessarily to the neovascularization alone. A proposal based on imaging findings and known physiologic effects of VEGF is presented.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
Baseline. The en face image shows the retinal vasculature in the upper panel and the lower panel shows the B-scan OCT with the projection resolved flow overlay in red of an 84-year-old patient with a history of Type 3 neovascularization in the fellow eye. Four months later there was enlargement of a retinal vessel (green open arrow). The lower panel shows a red area indicative of flow traversing the outer boundary of the outer plexiform layer. Eight months later there was a new retinal vessel (yellow open arrow) leading into a vascular structure. The lower panel shows vascular extension and cystoid spaces of fluid. After 2 intravitreal injections of aflibercept there was regression of the vascular extension.
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