Outcomes in Eyes with Retinal Angiomatous Proliferation in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT)

Abstract

Purpose: To compare baseline characteristics, visual acuity (VA), and morphologic outcomes between eyes with retinal angiomatous proliferation (RAP) and all other eyes among patients with neovascular age-related macular degeneration (NVAMD) treated with anti-vascular endothelial growth factor (VEGF) drugs.

Design: Prospective cohort study within the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

Participants: Patients with NVAMD.

Methods: Reading center staff evaluated digital color fundus photographs, fluorescein angiography (FA) images, and optical coherence tomography (OCT) scans of eyes with NVAMD treated with either ranibizumab or bevacizumab over a 2-year period. Retinal angiomatous proliferation was identified by the intense intra-retinal leakage of fluorescein in combination with other associated features.

Main outcome measures: Visual acuity; fluorescein leakage; scar; geographic atrophy (GA) on FA; retinal thickness, fluid, and subretinal hyperreflective material (SHRM) on OCT; and the number of intravitreal anti-VEGF injections at 1 and 2 years.

Results: Retinal angiomatous proliferation was present in 126 of 1183 (10.7%) study eyes at baseline. Mean VA improvement from baseline was greater (10.6 vs. 6.9 letters; P = 0.01) at 1 year, but similar at 2 years (7.8 vs. 6.2 letters; P = 0.34). At 1 year, eyes with RAP were more likely to have no fluid (46% vs. 26%; P < 0.001) on OCT, no leakage on FA (61% vs. 50%; P = 0.03), and greater reduction in foveal thickness (-240 μm vs. -161 μm; P < 0.001). They were more likely to demonstrate GA (24% vs. 15%; P = 0.01) and less likely to have scarring (17% vs. 36%; P < 0.001) or SHRM (36% vs. 48%; P = 0.01). These results were similar at 2 years. The mean change in lesion size at 1 year differed (-0.27 DA vs. 0.27 DA; P = 0.02), but was similar at 2 years (0.49 DA vs. 0.79 DA; P = 0.26). Among eyes treated PRN, eyes with RAP received a lower mean number of injections in year 1 (6.1 vs. 7.4; P = 0.003) and year 2 (5.4 vs. 6.6; P = 0.025).

Conclusions: At both 1 and 2 years after initiation of anti-VEGF treatment in CATT, eyes with RAP were less likely to have fluid, FA leakage, scar, and SHRM and more likely to have GA than eyes without RAP. Mean improvement in VA was similar at 2 years.

Figure 1

Color image of the study eye at baseline (A1). Intra-retinal hyperfluorescence (hot spot) that leaks intensely in late phase-angiogram (A2). Petaloid hyperfluorescence is observed in the fovea (A3) corresponding to the large intraretinal cysts noted on OCT (A4). Sub-RPE fluid (serous pigment epithelial detachment) is also seen on OCT. Color image of another patient at baseline with intraretinal lipid (B1) and an intense hyperfluorescent spot (B2, B3) surrounded by hyperfluorescence in the sub-RPE space consistent with a serous pigment epithelial detachment. The OCT (B4) shows sub-RPE fluid (serous pigment epithelial detachment). At two years, atrophic areas are seen (B5, B6 and B7) with corresponding signal penetration into the choroid on OCT (B8).

Figure 2

Mean visual acuity (VA) change from baseline through two years. Red line = Eyes with Retinal Angiomatous Proliferation (RAP). Blue line = Eyes without RAP.

Figure 3

Mean visual acuity change from baseline through two years in eyes without foveal center geographic atrophy at 2 years. VA=Visual Acuity, RAP=Retinal Angiomatous Proliferation, GA=Geographic atrophy, YR2 =Year 2, FC=Foveal Center.