Neovascular age-related macular degeneration with advanced visual loss treated with anti-vascular endothelial growth factor therapy: Clinical outcome and prognostic indicators

Purpose: To describe visual outcome and prognostic indicators in neovascular agerelated macular degeneration with advanced visual loss at the initiation of anti-vascular endothelial growth factor therapy. Methods: A retrospective chart review was performed on a consecutive series of 1,410 patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor therapy at the Medical College of Wisconsin. Subjects were included if at the initiation of therapy they had 20/200 or worse visual acuity (VA) with no other visually limiting eye disease and a minimum follow-up of 6 months. The change in VA at 6 months and 12 months was assessed compared with baseline. Visual improvement/worsening was defined as at least ± 0.3 logMAR (equivalent to 15 ETDRS [Early Treatment Diabetic Retinopathy Study] letters) change. Other factors for analysis included number of injections received, drug type, and various clinical and imaging findings. Results: One hundred thirty-one cases met the study criteria, and 97 were followed for 12 months. Baseline VA was 1.38 logMAR (20/480 Snellen equivalent). Mean VA change (logMAR) consisted of an improvement of 0.23 (P, 0.0001) at 6 months and 0.17 (P = 0.003) at 12 months. At 12 months, VA improved in 45% and worsened in 20%. Among subjects with baseline VA worse than 20/400, VA improved in 57% and worsened in 20%. On univariate analysis at either the 6 months or 12 months follow-up, visual improvement was associated with retinal hemorrhage (P = 0.03) and subretinal fluid (P = 0.02), whereas visual worsening was associated with retinal pigment epithelial detachment (P = 0.04) and intraretinal fluid (P = 0.01). With multivariate analysis, visual improvement was predicted by both a larger number of injections received (P = 0.001) and a poorer baseline VA (P = 0.001). Injection medication type did not influence outcome. Conclusion: Statistically significant visual improvement was observed in association with anti-vascular endothelial growth factor therapy in patients with severe neovascular age-related macular degeneration, even in patients whose initial VA was worse than that studied in large anti-vascular endothelial growth factor clinical trials. Numerous clinically discernable or potentially modifiable factors may influence outcome in such patients.