Poorer Visual Outcomes in nAMD Treatment Linked to Intraretinal Fluid Presence

Marie Krogh Nielsen, MD, PhD

According to new findings, the presence of intraretinal fluid (IRF) and large variations in central retinal thickness (CRT) in patients with neovascular age-related macular degeneration (nAMD) were strong predictors for poor visual outcomes.

However, the study suggested that the presence of subretinal fluid (SRF) at baseline and at follow-up did not significantly affect the visual outcomes for this population, nor did pigment epithelium detachment (PED) at any time point.

“Our results are in line with previous studies in terms of the detrimental effect of IRF on VA outcome, showing that patients that remained free of IRF achieved better functional outcome,” wrote study author Marie Krogh Nielsen, MD, PhD, Department of Ophthalmology, Zealand University Hospital.

Nielsen and the team of investigators analyzed the association of anatomical outcomes and changes in visual acuity in nAMD treated with anti-VEGF. In doing so, they assessed the predictive value of changes in IRF, SRF, and PED on visual outcomes.

The population consisted of all patients with a diagnosis of nAMD that initiated treatment with ranibizumab or aflibercept between January 2015 and December 2018, with a minimum follow-up period of 12 months. The study included only one eye per patient and observations of interest were taken from the database at baseline up to 24 months.

Investigators additionally analyzed the variance and range of repeated CRT during the observation period to describe the association between visual outcomes and CRT variability, excluding the monthly loading phase.

The study included a total of 504 treatment naive eyes from 504 patients. The population had a mean age at onset of nAMD at 80 years and 63% of patients were female.

Investigators observed an initial improvement of 2.7 letters 3 months after baseline followed by a gradual decline to -1.4 letters after 24 months. CRT was shown to decrease by 103.6 μm in 3 months after initiation of treatment and the decrease remained stable throughout the 24 months.

Individuals with IRF at baseline had significant lower visual acuity at baseline compared to those without any IRF, with a mean difference of 8.2 letters (95% CI, 5.0 - 11.4; P <.001). In subsequent visits, eyes free of IRF showed better visual acuity than eyes with IRF (P <.0001).

Investigators added that the mean difference after 3 months was 7.0 letters (95% CI, 3.5 – 10.5), compared with a mean difference of 6.3 letters (95% CI, 2.4 - 10.1) after 2 years.

Meanwhile, patients with SRF at baseline had slightly better visual acuity compared to patients with SRF, despite not reaching statistical significance (mean difference, 3.0 letters; 95% CI, -0.7 to 6.7; P = .057).

After 2 years, patients with SRF had significantly better visual acuity compared to patients without SRF (mean difference, 7.2 letters; 95% CI, 3.3 – 11.2; P <.001). The presence of PED was not associated with visual acuity at baseline or any subsequent visit.

Patients in the upper quartile of CRT variance (mean range, 190.4 um) had a lower VA after 12 months, compared with patients in the lower quartile (mean range, 9.7 um), with the difference remaining after 24 months (P <.001).

“In conclusion, we find that IRF is important to treat aggressively, and stabilization of the CRT is important to obtain a good visual outcome in nAMD patients,” Nielsen wrote.

The study, “Association between structural and functional treatment outcomes in neovascular age-related macular degeneration,” was published in Acta Ophthalmologica.