Association between visual acuity, lesion activity markers and retreatment decisions in neovascular age-related macular degeneration

Abstract

Background/objectives: To investigate the association between optical coherence tomography (OCT) markers of lesion activity and changes in visual acuity (VA) during anti-vascular endothelial growth factor (anti-VEGF) therapy of eyes diagnosed with neovascular age-related macular degeneration (nAMD); and how VA and OCT markers are considered in physicians' decision to retreat with anti-VEGFs.

Subjects/methods: Retrospective, non-comparative, non-randomised cohort study involving electronic medical record data collected from 1190 patient eyes with nAMD diagnosis at two sites in the United Kingdom. Two sub-cohorts consisting of 321 and 301 eyes, respectively, were selected for analyses.

Results: In 321 eyes, absence of IRF or SRF at ≥2 clinic visits resulted in a gain of five ETDRS letters from baseline, compared with two letters gained in eyes with <2 clinic visits with absence of IRF (p = 0.006) or SRF (p = 0.042). Anti-VEGF treatment was administered at 421 clinic visits, and 308 visits were without treatment. Comparing treatment visits with non-treatment visits, the maximum difference in frequency of OCT markers of lesion activity were for intraretinal fluid (IRF; 24% versus 5%) and subretinal fluid (SRF; 32% versus 5%). Pigment epithelial detachment (PED) was reported in 58% of treatment visits compared with 36% in non-treatment visits. VA loss was not a consistent trigger for retreatment as it was present in 63% of injection visits and in 49% of non-injection visits.

Conclusions: Retreatment decision making is most strongly influenced by the presence of IRF and SRF and less by the presence of PED or VA loss.

Fig. 1

Selection workflow, patient disposition and definition of the study cohort. ETDRS Early Treatment Diabetic Retinopathy Study, nAMD neovascular age-related macular degeneration, OCT optical coherence tomography, VA visual acuity, VEGF vascular endothelial growth factor.

Fig. 2. Association between absence of IRF and SRF and change in VA from baseline to month 12.

Graphical representation of the association between number of clinic visits (N = 321 eyes) with absence of either IRF (a) or SRF (b) and VA change from baseline at the end of the first year of treatment with anti-VEGF therapies (month 12). ETDRS Early Treatment Diabetic Retinopathy Study, IRF intraretinal fluid, SRF subretinal fluid, VA visual acuity.

Fig. 3

Density plot showing the distribution of number of visits per patient eye (N = 301 eyes, 729 visits) during the study maintenance phase (i.e. months 3–12). Q25 25% quartile, Q75 75% quartile. Dotted lines, 25% and 75% quartiles, respectively; solid line: median.

Fig. 4. Bar graph showing proportions of visits with OCT markers of lesion activity and VA loss since last visit or since best VA at injection (black bars; N = 421) and non-injection (grey bars; N = 308) clinic visits in order of frequency.

Exudate was the least frequently recorded OCT marker of lesion activity, accounting for fewer than 2% of both injection and non-injection visits. VA loss of >5 ETDRS letters since best VA was most frequent at injection visits (panel a). The occurence of combinations of these features observed at injection visits is presented in panel b. The asterisk symbol indicates the VA loss of >5 ETDRS letters since best VA. CRT central retinal thickness, IRC intraretinal cyst, IRF intraretinal fluid, MH macular haemorrhage, OCT optical coherence tomography, PED pigment epithelial detachment, SRF subretinal fluid, VA visual acuity.