Woronkowicz, MA; (2018) Local and systemic factors impacting on anatomical and functional results of treatment in choroidal neovascularization. Doctoral thesis (M.D(Res)), UCL (University College London).

Abstract

The work in this thesis analyzed anatomical and functional outcomes of treatment in choroidal neovascularization secondary to the three main causes i.e. age-related macular degeneration, pathological myopia and ocular inflammatory conditions. The first study assessed a value of a global macular status of ELM and EZ as a predictor of treatment response in 71 eyes with neovascular AMD switched to aflibercept treatment due to persistent fluid despite ranibizumab injections. Prior to commencement of aflibercept the eyes received a median number of 12 (IQR: 6-18) ranibizumab injections according to a pro-re-nata treatment algorithm over a median follow-up of 23 (IQR: 12.5-30.75) months. At the time of conversion a median size of damaged ELM and EZ area was 5.1 mm² (IQR: 1.3-11.0) and 9.0 mm² (IQR: 3.5-16.3), respectively with a strong association demonstrated between both areas (R=0.91, p<0.001). In addition a size of ELM and EZ damaged area correlated with baseline BCVA, CRT, PED diameter and height as well as anatomical changes over 6-month follow-up. The second study compared treatment results in 210 eyes with myopic CNV which received bevacizumab or ranibizumab injections. BCVA improved at all time points in both groups compared to baseline with no statistically significant difference between the bevacizumab and ranibizumab-treated eyes. Baseline BCVA was found to be the only predictive factor of the final visual acuity and vision improvement. The mean time to CNV recurrence was 66.1±3.7 and 57.3±6.4 months in the bevacizumab and ranibizumab group (log rank test p=0.001), respectively. Risk factors for incidence of CNV recurrence included baseline CNV area (aHR 1.20, 95% CI: 1.0-1.32, p=0.04), subfoveal CNV location (aHR 2.13, 95% CI: 1.16-3.93, p=0.01) and treatment with ranibizumab (aHR: 2.31, 95% CI: 1.16-3.93, p=0.008). No difference in incidence of moderate or severe vision loss was demonstrated between groups. The last study analyzed visual outcomes in 204 eyes with inflammatory CNV which received different methods of treatment over a mean follow-up of 96.3±5.7 months. The main underlying causes were punctate inner choroidopathy and multifocal choroiditis in 71.1% and 14.2% of eyes, respectively. The mean time from diagnosis of uveitis to CNV development was 30.8±4.3 months. BCVA improved by 0.07 logMAR at 6 months (p=0.03) and otherwise remained stable compared to baseline. Factors associated with the final visual acuity were: gender, baseline BCVA, CNV size, presence of CNV in the fellow eye, use of local steroid therapy and second-line immunosuppression. Risk of incidence of CNV recurrence was reduced by oral corticosteroid therapy (aHR: 0.32, 95% CI: 0.17-0.59) and treatment with anti-VEGF drugs (aHR: 0.31, 95% CI: 0.18-0.52).

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