Macular Atrophy Incidence and Progression in Eyes with Neovascular Age-Related Macular Degeneration Treated with VEGF Inhibitors Using a Treat-and-Extend or a Pro-Re-Nata Regimen. Four Year Results of the MANEX Study.

Spooner, Kimberly L; Fraser-Bell, Samantha; Cozzi, Mariano; Staurenghi, Giovanni; Invernizzi, Alessandro; Monteduro, Davide; Munk, Marion R.; Hong, Thomas; Chang, Andrew A (2020). Macular Atrophy Incidence and Progression in Eyes with Neovascular Age-Related Macular Degeneration Treated with VEGF Inhibitors Using a Treat-and-Extend or a Pro-Re-Nata Regimen. Four Year Results of the MANEX Study. Ophthalmology, 127(12), pp. 1663-1673. Elsevier 10.1016/j.ophtha.2020.06.019

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PURPOSE

To compare the incidence and progression of macular atrophy (MA) in eyes with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents using either a treat-and-extend (T&E) or a pro-re-nata (PRN) regimen over 4-years in a real-life setting.

DESIGN

4-year, multicenter, retrospective comparative study PARTICIPANTS: 264 patients with treatment-naïve nAMD.

METHODS

Consecutive patients with nAMD received anti-VEGF therapy according to a T&E (n=163) or PRN (n=101) regimen. Eyes were included if they had received anti-VEGF injections for a period of at least 4-years and had annual fundus autofluorescence (FAF) and optical coherence tomography (OCT) imaging using Heidelberg Spectralis. Two masked graders independently delineated areas of MA from serial FAF images using Heidelberg region finder software, and growth rates were calculated. Incident MA was assessed using proportional hazard ratios.

MAIN OUTCOMES MEASURES

MA incidence and progression over 4-years, association between treatment strategy, and number of injections.

RESULTS

At baseline, MA was present in 24% and 20% of study eyes in T&E and PRN groups, respectively (p=0.32). At year-4, 27% (34/124) and 25% (20/81) eyes without baseline MA had detectable MA, in the T&E and PRN groups respectively. In those with MA at baseline, the mean square root area of MA progressed by a rate of 0.4±0.2 and 0.4±0.1mm/year in the T&E and PRN groups, respectively (p=0. 23). Multivariate analysis for baseline predictors of MA growth demonstrated older age, poorer baseline VA and presence of RAP, had a higher risk of greater MA progression (P=0.03). Regression analysis demonstrated no association between T&E and PRN treatment strategies with the risk of developing new MA during the four years of follow-up or the progression of pre-existing MA at year-4 (p=0.692).

CONCLUSION

Over four years, neither incidence nor progression of macular atrophy in eyes with nAMD treated with anti-VEGF injections was influenced by the treatment regimen and injection frequency. Eyes treated with a T&E regimen received more injections and had better visual outcomes compared to those treated with a PRN approach.

Interest & Impact

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