Age-related macular degeneration: using morphological predictors to modify current treatment protocols

作者：Ashraf Mohammed; Souka Ahmed; Adelman Ron A

来源：Acta Ophthalmologica, 2018, 96(2): 120-133.

DOI：10.1111/aos.13565

<jats:title>Abstract</jats:title><jats:sec><jats:label /><jats:p>To assess predictors of treatment response in neovascular age‐related macular degeneration (<jats:styled-content style="fixed-case">AMD</jats:styled-content>) in an attempt to develop a patient‐centric treatment algorithm. We conducted a systematic search using PubMed, <jats:styled-content style="fixed-case">EMBASE</jats:styled-content> and Web of Science for prognostic indicators/predictive factors with the key words: ‘age related macular degeneration’, ‘neovascular <jats:styled-content style="fixed-case">AMD</jats:styled-content>’, ‘choroidal neovascular membrane (CNV)’, ‘anti‐vascular endothelial growth factor (anti‐VEGF)’, ‘aflibercept’, ‘ranibizumab’, ‘bevacizumab’, ‘randomized clinical trials’, ‘post‐hoc’, ‘prognostic’, ‘predictive’, ‘response’ ‘injection frequency, ‘treat and extend (TAE), ‘pro re nata (PRN)’, ‘bi‐monthly’ and ‘quarterly’. We only included studies that had an adequate period of follow‐up (&gt;1 year), a single predefined treatment regimen with a predetermined re‐injection criteria, an adequate number of patients, specific morphological [optical coherence tomography (OCT)] criteria that predicted final visual outcomes and injection frequency and did not include switching from one drug to the other. We were able to identify seven prospective studies and 16 retrospective studies meeting our inclusion criteria. There are several morphological and demographic prognostic indicators that can predict response to therapy in wet <jats:styled-content style="fixed-case">AMD</jats:styled-content>. Smaller CNV size, subretinal fluid (SRF), retinal angiomatous proliferation (RAP) and response to therapy at 12 weeks (visual, angiographic or <jats:styled-content style="fixed-case">OCT</jats:styled-content>) can all predict good visual outcomes in patients receiving anti‐<jats:styled-content style="fixed-case">VEGF</jats:styled-content> therapy. Patients with larger <jats:styled-content style="fixed-case">CNV</jats:styled-content>, older age, pigment epithelial detachment (<jats:styled-content style="fixed-case">PED</jats:styled-content>), intraretinal cysts (<jats:styled-content style="fixed-case">IRC</jats:styled-content>) and vitreomacular adhesion (<jats:styled-content style="fixed-case">VMA</jats:styled-content>) achieved less visual gains. Patients having <jats:styled-content style="fixed-case">VMA</jats:styled-content>/<jats:styled-content style="fixed-case">VMT</jats:styled-content> required more intensive treatment with increased treatment frequency. Patients with both posterior vitreous detachment (<jats:styled-content style="fixed-case">PVD</jats:styled-content>) and SRF require infrequent injections. Patients with <jats:styled-content style="fixed-case">PED</jats:styled-content> are prone to recurrences of fluid activity with a reduction in visual acuity (VA). A regimen that involves less intensive therapy and extended follow‐up intervals (4 weekly) can be suggested for patients who show adequate visual response and have both <jats:styled-content style="fixed-case">SRF</jats:styled-content> and <jats:styled-content style="fixed-case">PVD</jats:styled-content> at baseline. In addition, patients with poor prognostic indicators such as <jats:styled-content style="fixed-case">IRC</jats:styled-content>,<jats:styled-content style="fixed-case"> VMA</jats:styled-content>, large <jats:styled-content style="fixed-case">CNV</jats:styled-content> size, older age and poor response at 12 weeks should be extended very cautiously with the possibility of fixed monthly/bimonthly (every 2 months) treatments if they fail to achieve dryness. Patients with <jats:styled-content style="fixed-case">PED</jats:styled-content> at baseline should receive monthly/bimonthly injections of anti‐<jats:styled-content style="fixed-case">VEGF</jats:styled-content> therapy or can be extended very cautiously (two weekly intervals) using a TAE protocol.</jats:p></jats:sec>

• 出版日期2018-3