Occult with no classic subfoveal choroidal neovascular lesions in age-related macular degeneration: clinically relevant natural history information in larger lesions with good vision from the Verteporfin in Photodynamic Therapy (VIP) Trial: VIP Report No. 4

Abstract

Objective: To determine whether data from patients with age-related macular degeneration (AMD) assigned to the placebo group in the Verteporfin in Photodynamic Therapy (VIP) Trial provide a rationale for continuation or cessation of follow-up of individuals with subfoveal occult choroidal neovascularization (CNV) with no classic lesions, presumed recent disease progression, larger lesion size (>4 disc areas), and a higher level of visual acuity (approximate Snellen equivalent, > or =20/50 in the affected eye) in whom no treatment is given at initial examination.

Methods: In a prospective, noncomparative case series, angiograms of participants assigned to a placebo group who had occult with no classic lesion composition at baseline were reviewed to identify conversion to minimally classic (area of classic CNV >0% but <50% of the entire lesion area) or predominantly classic (area of classic CNV > or =50% of the entire lesion area) composition.

Results: Of the 114 patients with AMD assigned to the placebo group, 89 were judged to have occult with no classic lesion composition at baseline in the study eye when fluorescein angiograms were reviewed in late 2001 for this report. By 24 months, 7 (8%) of the 89 patients had lesions that converted to predominantly classic composition, and 41 (46%) had minimally classic composition. Among the 24 patients with a baseline visual acuity better than 20/50(-1) and lesion size greater than 4 disc areas whose lesions did not convert to predominantly classic composition, the visual acuity of 18 (75%) dropped below 20/50. Six of these 18 continued to have occult with no classic CNV with a visual acuity of 20/100 or better and had a lesion size no greater than 9 disc areas at the time that visual acuity dropped below 20/50.

Conclusions: Continued monitoring, rather than cessation of follow-up, is recommended for patients with occult with no classic lesions, similar to those patients enrolled in the VIP Trial who did not initially receive treatment when they had relatively large lesions with good visual acuity. In these cases, if visual acuity decreases or predominantly classic features develop, photodynamic therapy with verteporfin or pegaptanib sodium injections may be considered.