Wet ARMD, anti-VEGF treatment, some decisions
This page is aimed at professionals. It is often easy decide when AVF treatment needed, but sometimes difficult. Here are some examples, I hope to develop this page. When I present such cases at meetings, experts say the situation is obvious!!'
Here a patient with an intraretinal cyst was attending as part of the AVF (in this case Lucentis) program, with regular injections. The first OCT scan on the right showed an intraretinal cyst. No treatment was given, but a month later fluid accumulating, as shown on the left OCT.
This indicates AVF should have been given when the first scan (right) was carried out. Generally intraretinal cysts indicate disease activity, and AVF is needed.
Second OCT, one month later, there is now a SRF as below, clearly representing a deterioration, and more antiVEGF is needed. On other cuts the ped was larger than this cut.
First OCT. Intraretinal cyst as in the diagram below. A decision was made not to treat at this visit. Cyst white. enlarge
Red =PED; Blue =SRF/NSD; white=cyst
Cn other occasions cysts are more benign. A suggested management plan, (RCO Congress 2013):
- cysts alone, as below, treat
- if they remain unchanged after 3 injections, have an injection holiday, and monitor without treatment.
- If they get worse again, restart treatment,
- if stable and do not increase, accept.
Another dilemma is deciding how many injections are needed, if treatment is on the PRONTO as needed basis.
Second OCT, 2 months later, there is a lot of fluid. Probably 3 injections are needed. (Also, why was the gap 2 months? There should have just been a 4 week gap.)
First OCT. Has had active CNV and AVF previously. On this OCT looks dry (there may be tiny intraretinal cysts). 4 week appointment should have been given enlarge
Here a patient having antiVEGF regular injections. The first OCT scan on the right showed intraretinal cysts and a small amount of subretinal fluid. Lucentis was given. But this patient has had regular Lucentis, 24 left , 34 right . Vision was Left 0.76 (6/36 May), 0.72 (June).
As this patient is having regular injections, it is probably best that 3 dates for injections are given for this eye. (The right eye was similar and needs similar treatment.) We are now using Eylea for such patients,
Second OCT, 3 months later, more subretinal fluid (red). There is a PED (in pink) but this will not respond to Lucentis.
First OCT. Blue..intraretnal cysts; Red, shallow subretinal fluid / neurosensory detachments enlarge
A patient with good 6/12 vision, and mild recent onset distortion. We thought this patient had early occult CNV. AntiVEGF was started. Below is the FFA.
Same patient's FFA enlarge . Late onset fluorescence of undetermined 'origin'
- after 3 visits, if the is no reduction in fluid, consider stopping treatment
- 4 year follow up BJO 2012
- at time of diagnosis, 16% of wet ARMD is PCV type.
- Other new 'ARMD' may be oedema from a retinal vein occlusion, or MacTel.