Age‐related macular degeneration: using morphological predictors to modify current treatment protocols

Abstract

To assess predictors of treatment response in neovascular age-related macular degeneration (AMD) in an attempt to develop a patient-centric treatment algorithm. We conducted a systematic search using PubMed, EMBASE and Web of Science for prognostic indicators/predictive factors with the key words: 'age related macular degeneration', 'neovascular AMD', 'choroidal neovascular membrane (CNV)', 'anti-vascular endothelial growth factor (anti-VEGF)', 'aflibercept', 'ranibizumab', 'bevacizumab', 'randomized clinical trials', 'post-hoc', 'prognostic', 'predictive', 'response' 'injection frequency, 'treat and extend (TAE), 'pro re nata (PRN)', 'bi-monthly' and 'quarterly'. We only included studies that had an adequate period of follow-up (>1 year), a single predefined treatment regimen with a predetermined re-injection criteria, an adequate number of patients, specific morphological [optical coherence tomography (OCT)] criteria that predicted final visual outcomes and injection frequency and did not include switching from one drug to the other. We were able to identify seven prospective studies and 16 retrospective studies meeting our inclusion criteria. There are several morphological and demographic prognostic indicators that can predict response to therapy in wet AMD. Smaller CNV size, subretinal fluid (SRF), retinal angiomatous proliferation (RAP) and response to therapy at 12 weeks (visual, angiographic or OCT) can all predict good visual outcomes in patients receiving anti-VEGF therapy. Patients with larger CNV, older age, pigment epithelial detachment (PED), intraretinal cysts (IRC) and vitreomacular adhesion (VMA) achieved less visual gains. Patients having VMA/VMT required more intensive treatment with increased treatment frequency. Patients with both posterior vitreous detachment (PVD) and SRF require infrequent injections. Patients with PED are prone to recurrences of fluid activity with a reduction in visual acuity (VA). A regimen that involves less intensive therapy and extended follow-up intervals (4 weekly) can be suggested for patients who show adequate visual response and have both SRF and PVD at baseline. In addition, patients with poor prognostic indicators such as IRC, VMA, large CNV size, older age and poor response at 12 weeks should be extended very cautiously with the possibility of fixed monthly/bimonthly (every 2 months) treatments if they fail to achieve dryness. Patients with PED at baseline should receive monthly/bimonthly injections of anti-VEGF therapy or can be extended very cautiously (two weekly intervals) using a TAE protocol.

Short-term results of early switch from Ranibizumab to Aflibercept in poor or non responder age related macular degeneration in clinical practice

“…This study showed CMT improvement after treatment with intravitreal AFL in patients that were poor or non responders to RBZ, as found in other studies [19,20]. However, the group of non responder patients was proven to have a better response to AFL than the group of poor responder patients.…”

“…The membrane characteristics play a role on treatment outcome. Type 1 [19] and large [20,21] choroidal neovascular membranes were defined as bad predictors for treatment outcome [19] as well as for poor response at 12 weeks [20,21].…”

The role of posterior vitreous detachment on the efficacy of anti-vascular endothelial growth factor intravitreal injection for treatment of neovascular age-related macular degeneration

“…[ 26 ] A recent meta-analysis covering 2212 subjects found better visual and anatomical outcomes, as well as fewer PRN injections required, in patients without VMT/VMA compared to those with VMT/VMA. [ 27 ]…”

Oftalmolojide fotodinamik tedavi

“…YBMD insan ömrünün uzamasıyla birlikte çağımızın görme kaybı sebepleri arasında önemli bir yer tutmaktadır. Altmış beş yaş üzerindeki hastaların yaklaşık %10'nu ve 75 yaş üzerindeki hastaların yaklaşık %25'ini etkilemektedir (7)(8)(9). YBMD temelde kuru ve yaş tip olarak ikiye ayrılmaktadır.…”