Author: Shruti Chandra (United Kingdom)
Co-authors: Deepthy Menon, Eleni Karatsai, Sridevi Thottarath, Sobha Sivaprasad
To describe the rate of development of fibrosis over 10 years and its relationship with visual outcome in eyes with neovascular age-related macular degeneration (nAMD)
Moorfields Eye Hospital, London, UK
Single centre, non-interventional cohort study of nAMD patients initiated on intravitreal anti-VEGF injections in 2008-2009 with follow-up for at least 10 years. All participants were treated according to standard of care. Visual acuity (VA) in Early Diabetic Retinopathy Study (ETDRS) letters, injection records, spectral-domain optical coherence tomography (SD-OCT) scans, colour fundus photos (CFP) and fundus fluorescein angiography (FA) were analysed. The images were graded by 2 retinal physicians and fibrosis was determined based on multimodal imaging. Main outcome measure was incidence of fibrosis and its impact on visual outcome over 10 years.
We included 142 eyes (142 patients) of which 19 (13.4%) had fibrosis at baseline, 72 (50.7%) developed new fibrosis by 10 years and 51 (35.9%) never had fibrosis. The incidence of new fibrosis at 1st, 2nd, 5th, 7th and 10th year of follow up was 9 (7.3%), 19 (16.7%), 32 (33.7%), 7 (11.1%) and 5 (8.9%). The mean (SD) gain in VA in the 1st year was 7.8 (±3.1) in baseline fibrosis group, 8.9 (±3.8) in new fibrosis group versus 12.3 (±2.8) in no fibrosis group (p<0.001). Mean VA change at 10 years was -3.1, -1.1 and 0 letters in baseline fibrosis, new fibrosis and no fibrosis group respectively (p<0.05). The prevalence of macular atrophy at 10 years was 26.3%, 72.2% and 31.4% in the 3 groups respectively. Presence of intraretinal fluid (p<0.05), persistent pigment epithelial detachment (p<0.01) and classic choroidal neovascularization (p<0.01) were significantly associated with fibrosis. There was no statistically significant difference in the number of injections received among all groups. Mean central retinal thickness was significantly less in eyes with no fibrosis 198.5 (±74.1) microns versus eyes with baseline fibrosis 216.3 (±41.1) and new fibrosis 224.9 (±55.6) (p<0.05).
We describe the incidence of fibrosis over long term follow up of eyes with nAMD. The incidence of new fibrosis declines after 5 years and significantly determines VA outcomes at 1 year and 10 year of follow-up as well. Eyes with new fibrosis had the highest prevalence of macular atrophy indicating common factors for development of both morphological outcomes. Intraretinal fluid and persistent pigment epithelial detachment were significant factors determining fibrosis whereas injection frequency had no role. These results emphasize the need for use of antifibrotic agents along with anti-vascular endothelial growth factors for treatment of nAMD.