OSLI Retina

February 2020

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68 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ C L I N I C A L S C I E N C E ■ Macular Atrophy Affecting Visual Outcomes in Patients Undergoing Anti-VEGF Treatment in Routine Clinical Practice Nathaniel B. Rieveschl, MD; Weilin Song, BS; Ang Li, MD; Thais F. Conti, MD; Grant L. Hom, BA; Grace J. Tsai, BA; Felipe F. Conti, MD; Amy S. Babiuch, MD; Rishi P. Singh, MD BACKGROUND AND OBJECTIVE: To explore how baseline macular atrophy (MA) affects visual acu- ity (VA) in patients receiving intravitreal anti-vas- cular endothelial growth factor (VEGF) injections for neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS: A retrospective, case con- trol series. Patients were grouped into three cohorts based on baseline spectral-domain optical coher- ence tomography image findings: foveal MA, non- foveal MA, and no MA. Outcomes were assessed at 1, 2, and 3 years following anti-VEGF therapy. RESULTS: No differences existed in MA growth be- tween eyes with foveal and nonfoveal MA (0.89 mm 2 [95% confidence interval (CI), 0.64-1.14] vs. 0.88 mm 2 [95% CI, 0.72-1.05]) after adjusting for baseline lesion sizes at 3 years. Foveal MA patients lost an average of 19.4 ETDRS letters (95% CI, –30.8 to –8.0) after 3 years. Nonfoveal MA patients gained an average of 1.1 ETDRS letters (95% CI, –6.8 to 9.0), and patients without MA averaged a gain of 9.7 ETDRS letters (95% CI, 5.5-14.0). CONCLUSION: In patients with nAMD receiving anti-VEGF in routine clinical practice, presence of baseline foveal MA was associated with significant vision loss. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:68-75.] INTRODUCTION Age-related macular degeneration (AMD) is a lead- ing cause of blindness among individuals older than 50 years of age, with an estimated prevalence of ap- proximately 8.7% of the world's population. 1,2 As of this year, 196 million people worldwide were pro- jected to have AMD. 2 Late-stage AMD is characterized as either exudative or nonexudative. In exudative AMD, choroidal neovascularization (CNV) develops and causes accelerated vision loss. Intravitreal anti- vascular endothelial growth factor (VEGF) injection is now the gold standard treatment for neovascular AMD (nAMD). 3-8 Atrophy of retinal pigment epithe- lium (RPE), photoreceptors, and choriocapillaris may occur in both the dry and wet forms of late AMD with severe visual consequence. Geographic atrophy (GA) is a term used to describe this phenomenon in nonex- udative AMD when no CNV exists. Macular atrophy (MA) describes incident atrophy in eyes with nAMD and distinguishes this type of atrophy from GA in nonexudative AMD, since the pathogenesis may in- volve separate mechanisms. 9,10 No approved treat- ment has been shown to delay or stop the progression of atrophy from either cause. Although the general effectiveness of anti-VEGF for treating nAMD is clear, there is significant vari- ability in individual responses to the therapy. 3,8 MARINA was a 2-year, multicenter, double-blind, sham-controlled study that assigned 716 patients with nAMD to monthly ranibizumab (Lucentis; Ge- nentech, South San Francisco, CA) injections or sham injections and was designed to measure the efficacy From Case Western Reserve University School of Medicine, Cleveland (NBR, RPS); Cleveland Clinic Lerner College of Medicine at Case Western Reserve University School of Medicine, Cleveland (WS); Cole Eye Institute, Cleveland Clinic Foundation, Cleveland (WS, AL, TFC, GLH, GJT, FFC, ASB, RPS); Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland (TFC, GLH, FFC, ASB, RPS); and School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland (GJT). Originally submitted February 8, 2019. Revision received July 22, 2019. Accepted for publication August 27, 2019. Dr. Babiuch has received personal fees from Vindico and MCME Global, as well as grants from Regeneron Pharmaceuticals, outside the submitted work. Dr. Singh has received grants and personal fees from Regeneron Pharmaceuticals and Genentech/Roche; personal fees from Optos, Zeiss, and Biogen; and grants from Apellis and Alcon/Novartis outside the submitted work. The remaining authors report no relevant financial disclosures. Dr. Singh did not participate in the editorial review of this manuscript. Address correspondence to Rishi P. Singh, MD, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail Code i-32, Cleveland, OH 44195; email: singhr@ccf.org. doi: 10.3928/23258160-20200129-01

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