J Korean Ophthalmol Soc.  2017 Oct;58(10):1145-1154. 10.3341/jkos.2017.58.10.1145.

Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection

• Hong JG
• Cho YW
• Jang JH

• KMID: 2393166
• DOI: http://doi.org/10.3341/jkos.2017.58.10.1145

Abstract

PURPOSE
To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection.
METHODS
After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit.
RESULTS
The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group.
CONCLUSIONS
In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow-up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.

Keyword

Disciform retinal scar; End-stage age-related macular degeneration; Fibrovascular pigment epithelial detachment

MeSH Terms

Cicatrix
Endothelial Growth Factors*
Follow-Up Studies
Hemorrhage
Humans
Macular Degeneration*
Retinal Hemorrhage
Retinal Pigment Epithelium
Retinaldehyde
Retrospective Studies
Subretinal Fluid
Tears
Tomography, Optical Coherence
Visual Acuity
Endothelial Growth Factors
Retinaldehyde

Figure

• 

  Figure 1. Representative images of morphologic features of spectraldomain optical coherence tomography (SD-OCT) related to age-related macular degeneration. SD-OCT image (A) and corresponding schematic image (B) show multilayered fibrovascular pigment epithelial detachment (f-PED): a fusiform, or spindle-shaped, complex of organized layers of homogenous hyperreflective bands. SD-OCT image (C) and corresponding schematic image (D) demonstrate irregular f-PED with heterogenous, hyper-reflective, dilated, irregular vascular networks. SD-OCT image (E) and corresponding schematic image (F) depict hyporeflective prechoroidal cleft separating the neovascular tissue complex from the underlying choroid and Bruch's membrane.

• 

  Figure 2. Measurement of features of spectraldomain optical coherence tomography related to age-related macular degeneration using Heidelberg engineering software. Representative image of end-stage age-related macular degeneration (A) and corresponding schematic image (B) show thickness (B, blue left right arrow) and size (red left right arrow) of pigment epithelial detachment (PED), thickness of subretinal hyperreflective materials (B, green left right arrow) and size of defect of photoreceptor layer (B, white left right arrow). PED contains choroidal neovascularization (B, red colored lesion) and subretinal hyperreflective materials (B, yellow colored lesion). Macular 1 mm circle thickness and macular volume is measured by using macular 1 mm circle (C, red arrow), macular 6 mm circle (C, black arrow) of Color-coded thickness map.

• 

  Figure 3. Four types of end-stage age-related macular degeneration. Spectral-domain optical coherence tomography (SD-OCT) images. (A) Shows disciform scar with intra-retinal cystoid fluid. SD-OCT image (B) demonstrates disciform scar with destruction of retinal layers. SD-OCT image (C) shows multilayered pigment epithelial detachment (PED) with broad inner segment/outer segment line disruption. SD-OCT image (D) demonstrates thin irregular fibrovascular PED with atrophy of inner retinal layer and inner segment/outer segment line disruptions.

Reference

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