Identifying Macular Neovascular Subtype Improves AMD Outcomes

Clinicians can optimize treatment outcomes for patients with age-related macular degeneration by appropriately identifying macular neovascular subtypes.

Appropriately classifying macular neovascularization (MNV) subtypes can help clinicians optimize treatment outcomes for patients with age-related macular degeneration (AMD), according to a review published in Eye.

Researchers performed a literature search to identify research pertaining to MNV subtypes. A series of keywords identified 75 publications for use in the investigation. Members of the Vision Academy, an international team of retinal physicians who partner to develop shared knowledge and recommendations, examined treatment recommendations for 3 MNV subtypes and indicated their agreement with the proposed treatments on a scale ranging from ‘strongly disagree’ to ‘strongly agree.’ Agreement from 50% or more of the 73 Vision Academy polled members established endorsement for a treatment. 

Type 1 MNV involves MNV beneath the retinal pigment epithelium (RPE) layer. Poorly defined, late leakage may be detected upon fluorescein angiography (FA) analysis and pigmentary epithelial detachment with no disruption of the RPE can be observed via spectral domain- optical coherence tomography (SD-OCT). Photodynamic therapy and more frequent anti-vascular endothelial growth treatments (VEGF) are recommended for these patients. 

Patients with type 2 MNV may exhibit a well-defined neovascular membrane, with intense leakage that increases over time upon FA analysis. SD-OCT reveals a disruption of the RPE–Bruch’s membrane complex and localization of the neovessels above the RPE layer, according to the report. An association with more fibrotic scarring makes patients with type 2 MNV more prone to poor visual outcomes following treatment. Treat and extend anti-VEGF regimens in the first 2 years are recommended with pro re nata treatments and careful monitoring suggested after 2 years. 

Correct assessment of the MNV subtype provides information on a patient’s prognosis and helps to determine the preferred treatment regimen.

Type 3 lesions are more likely to respond to anti-VEGF treatment and individuals with type 3 MNV demonstrated better visual acuity (VA) and VA gains compared with individuals who had type 1 or 2 MVN, according to 1 study. However, geographic atrophy is more likely to develop among these patients. Vision Academy members suggest a strict pro re nata regimen with contralateral eye checks for individuals with stage 1 lesions that have reached stability after 3 treatment initiation doses and a proactive regimen for patients with stage 2 or 3 lesions. 

“Correct assessment of the MNV subtype provides information on a patient’s prognosis and helps to determine the preferred treatment regimen,” according to the study authors. “Additional biomarkers, perhaps as found on [OCT angiography], are needed to better optimize treatment outcomes.”

This review was limited by the exclusion of polypoidal choroidal vasculopathy from the search.

Disclosure: The Vision Academy is an educational initiative that is fully funded by Bayer. Multiple study authors declared affiliations with biotech, pharmaceutical, and/or clinical research organizations. Please see the original reference for a full list of authors’ disclosures.

References:

Mathis T, Holz FG, Sivaprasad S. Characterisation of macular neovascularisation subtypes in age-related macular degeneration to optimise treatment outcomes. Eye. Published online September 14, 2022. doi:10.1038/s41433-022-02231-y