Evaluating the Response of Type 1 Choroidal Neovascular Membrane in Neovascular Age-Related

Macular Degeneration to Anti-VEGF Treatment by Optical Coherence Tomography Angiography

Ching J. Chen, MD, Matthew Olson, CRA, Brian Tieu, MD, Jordan Burnham, MD

Department of Ophthalmology, University of Mississippi Medical Center

Objective: To observe the vascular response to anti-VEGF treatment in

neovascular ARMD with type 1 CNV by OCT angiography (OCTA)

Design:Consecutive observational case series

Material and Methods:Retrospective review of SSADA based OCTA on patients received

anti-VEGF treatment in neovascular ARMD with type 1 CNV.

A standard FA was obtained by a digital camera angiography.

OCT images obtained by a 70 KHz wide angle Spectral Domain

(SD)-OCT system with Optovue Avanti RTVue XR SD-OCT (Fremont,

CA), and OCTA images captured by the same SD-OCT equipment

with the light source of 840nm were reviewed. The AngioVue and

AngioAnalytics software were used to detect and calculate the flow

of the CNVs in both 3x3mm and 6x6mm areas. Motion correction

processing was applied while each scan was obtained. The 3D

angiography was reviewed and segmented with the default setting

of superficial retinal, deep retinal, outer retinal and choroid

capillary slabs. Manual segmentation to adjust the segmentation

plan was applied whenever needed.

Results:37 eyes with type 1 CNV were treated with various anti-VEGF

agents. Among them, 10 remained partially active and 7 were

refractory to treatment. 10 were responsive with temporary

inactive, and 10 had permanent remission after treatment. The

OCTA detected blood flow in all types of CNV. In active CNV, the

size and vascular volume of CNV varied. The size of CNV was

smaller in active and temporary inactive CNVs than in refractory

CNVs. The CNV responded to anti-VEGF treatment by partial

closure of peripheral vascular branches, but the main central core

vascular trunk remained unaffected. Recurrent activity also involved

mainly the periphery. In refractory CNV, weekly OCTA showed none

to minimal vascular responses. In quiescent CNV, flow change

analysis showed a steady vascular flow pattern without changes.

Conclusion:Anti-VEGF treated Type 1 CNVs can be divided into exudative and non-

exudative subtypes. Non-exudative type are inactive CNVs. They respond

to the treatment with short term or long term remission. Exudative type

CNVs are active. They may respond temporally or protractedly refractory

to the treatment.

Blood flow is detected by OCTA in all types of CNV after treatment. The

size and flow density of CNV appear to be smaller in short term remission

type and active type CNVs than refractory type CNV.

Vascular response to anti-VEGF treatment appears to occur from the

branch of CNV with closure of peripheral vessels but main vascular trunk

remains unchanged. Recurrent activity of CNV also occurs from the

peripheral branches.

Multi-mode imaging including SD-OCT and OCTA may be the best way to

evaluate the vascular changes after treatment in neovascular ARMD.

Fig 1-c Fig. 1-d

2016 ARVO Annual Meeting Poster Number 1625-C0081

Fig. 3-c Fig. 3-d

Financial interest disclosure:Ching J. Chen, MD: Consultant: Optovue, Clinical advisory board: Allergan. Speaker: Alcon International, Clinico

Mathew Olsen, CRA, Brian Tieu, Jordan Burnham MD: No financial interest to be disclosed

Corresponding Author:

Ching J. Chen, MD

E-mail: cchen@umc.edu

Fig. 1. Treated and active CNV; Color fundus photo, FA, OCT and Choroidal capillary slab of

OCT angiography and weekly flow change analysis after IO Aflibercept injection.

Fig. 2. Refractory type 1 CNV in spite of continuous multiple intraocular injection of Eylea for

more than 2yrs. Color FP, FA, OCT and Choroidal capillary slab of OCT angiography and

weekly flow change analysis (8 scans on the right) after IO Aflibercept injection.

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1a 1b 1c 1d

3a

4a 4b 4c 4d

5a 5b 5c 5d

Active CNV (10 eyes): Treated and partially active CNV, FA showed leakage, OCT showed intra- or sub-retinal fluid Refractory CNV (7eyes): Refractory to monthly treatment with persistent exudation, FA showed persistent leakage and OCT showed intra- or subretinal fluid, frequently with RPEDTreated CNV with short term remission (10 eyes): Temporally respond to intraocular anti-VEGF treatment without exudationTreated CNV with long term remission (10eyes): Treated and remain symptomless without leakage for greater than one year

Table 1: Types of vascular response to anti-VEGF treatment

Fig. 3. Type 1 CNV responded to “Treat and Extend” treatment regimen, and

temporally become inactive. FP, FA, OCT, OCTA, CNV flow density calculation are

shown in first part of the figure. Fow change analysis are demonstrated above.

Fig. 4. Treated type 1 CNV with remission: No I.O. injection for ˃3 years. FA

shows no leakage of dye. OCT shows CNV but without fluid. OCTA confirms a

type 1 CNV at outer retinal and choroid capillary slabs. Flow change analysis of

a different patient shows no significant flow change. Calculation of flow density

in the other patient does show minor change.

4.27.15 Eyelea 6.11 .15 Eyelea 8.7.15 Eylea 8.13 .15 8.20 .15 8.27 .15 9.3.15

4.27.15

FA Early venous 00’:23” FA Mid phase 01’:11”

Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept Aflibercept

Aflibercept Aflibercept Aflibercept

10-23-14 12-4-14 1-15-15 8-13-15 8-20-15 8-27-15 9-2-15

10-01-159-24-159-17-159-10-158-13-158-06-156-18-15

Superficial Deep

Outer retina Choroid Cap

Flow area: 0.835mm²

Aflibercept Aflibercept

5-11-15 6-22-15 08-03-15 9-14-15 10-29-15 12-13-15

Choroid CapOuter RetinaDeepSuperficial

12/18/14 08/01/15 09/24/15 8/27/15 Flor area: 1.878mm² 12/7/15 Flor area: 2.103mm²

Choroid cap

Choroid cap