RPE atrophy onset in treated nAMD
Reviewed by Sofia Rokerya

In this study the authors aim to evaluate the role of various factors for the development of retinal pigment epithelium (RPE) atrophy over a period of five years in patients with nAMD. Fifty-two newly diagnosed nAMD patients with complete absence of RPE atrophy prior to anti-VEGF treatment initiation were analysed using spectral domain optical coherence tomography (SD-OCT) for a mean follow-up time of 5.34±1.35 (± standard deviation) years. All patients had at least three years of follow-up. The total number of injections received from baseline until the last available examination was on average 24.46±9.96 with an average of 4.68±1.64 injections per year. Fourteen patients (29.6%) received only ranibizumab during the entire course of the study, whereas 38 patients (73.1%) were treated with various agents (ranibizumab and / or aflibercept and / or bevacizumab). Mean central retinal thickness (CRT) at baseline was 427.31±165.13µm. After six months, 11 of 52 patients (21.2%) developed RPE atrophy. The percentage of patients with newly developed RPE atrophy increased gradually to 28.8% after the first year, 40.4% at the second year, 44.2% at the third year, and 57.7% at the final visit after the third year. There was no statistical difference in the onset of RPE atrophy between patients who received a single-medication therapy with ranibizumab and those who switched medications (p=0.559). Atrophy onset was significantly associated with the duration of nAMD (mean 5.34 years; odds ratio = 1.83, p=0.012). Anti-VEGF injection number, age, C3d/C3 ratio, baseline intraocular VEGF, or delay to the first treatment had no influence on RPE atrophy. RPE atrophy has been suggested to occur as a result of choroidal neovascularisation (CNV)-associated mechanic, ischaemic, and inflammatory effects. Hence, it could be speculated that atrophy appears as a result of long-lasting disease effects and persisting local inflammation, independent of anti-VEGF therapy. Onset of macular atrophy (MA) seems to be an event that is not addressed by current anti-VEGF therapy and might additionally limit the long-term outcome of patients with nAMD. Limitations: Small sample size, a large range of follow-up time (3.13-7.26 years). The possibility of underlying RPE atrophy cannot be excluded in the cases with haemorrhage or exudates. Fundus fluorescein angiography (FFA) was not regularly available in the clinical follow-up, and hence, lack of measurements of atrophy size.

Onset of retinal pigment epithelium atrophy subsequent to anti-VEGF therapy in patients with neovascular age-related macular degeneration.
Sitnilska V, Altay L, Enders P, et al.
OPHTHALMOLOGICA
2019;241:154-60.