Fluid as a critical biomarker in neovascular age-related macular degeneration management: literature review and consensus recommendations

Abstract

Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.

Bacillary Layer Detachment in a Korean Cohort With Neovascular Age-Related Macular Degeneration

“…Fluid-based prognostication is one of the current major issues in the field of neovascular AMD. 13 In particular, intraretinal fluid is a well-known biomarker that is associated with poor visual outcome. 13,25 Because the location of BALAD is "intraretinal," BA-LAD can be considered as the presence of "intraretinal fluid."…”

“…12 Although anti-VEGF therapy markedly improves the treatment outcome of neovascular AMD, there is no modality to completely "cure" the disease. Because imaging biomarkers are used as an essential index in treating neovascular AMD, 13 investigating potential biomarkers in neovascular AMD would be of great value. To date, only a paucity of knowledge is available regarding the characteristics and clinical features of BALAD in neovascular AMD.…”

Association Between Visual Acuity and Fluid Compartments with Treat-and-Extend Intravitreal Aflibercept in Neovascular Age-Related Macular Degeneration: An ARIES Post Hoc Analysis

“…In clinical trials and routine clinical practice, assessments of treatment efficacy and decisions to re-treat or extend the treatment interval in T&E regimens are typically based on changes in anatomic endpoints such as central retinal thickness (CRT), as assessed by optical coherence tomography (OCT) [ 2 , 6 , 7 ]. Recently, there has been growing interest in exploring how fluid localization in different compartments may offer superior prognostic value to that of CRT in elucidating the relationship between visual outcomes, intraretinal fluid (IRF), and subretinal fluid (SRF) [ 6 – 9 ]. However, to date, most analyses of the relationships between retinal fluid status and visual acuity in the management of nAMD have been based on fixed-dose and PRN regimens [ 10 ].…”

Hypothetical Switch of Anti-Vascular Endothelial Growth Factor in Neovascular Age-Related Macular Degeneration: An ARIES Post Hoc Analysis

“…These results were observed The presence of central SRF, rather than central IRF, was the most common parameter leading to hypothetical switch criteria being met at both week 8 and week 24. We did not define hypothetical switch criteria according to the presence of central IRF only since few guidelines distinguish between the types of fluid when providing recommendations, with the same retreatment approach generally recommended regardless of the type and location of fluid observed [17]. This is interesting given that studies have shown what appears to be an important difference in the relationship between BCVA and either IRF or SRF [18].…”