Good Hope Eye Clinic

Wet ARMD, anti-VEGF treatment, some decisions

David Kinshuck

 

 

 

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!!'

 

Intraretinal cysts

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.

 

wet armd with intraretinal cyst

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

 

 

 

 

armd cyst diagram

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.

 

How many injections?

Another dilemma is deciding how many injections are needed, if treatment is on the PRONTO as needed basis.

3 injections are needed if there is a lot of fluid

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

 

 

 

 

 

SRF ..subretinal fluid

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,

subretinal fluid...AVF needed

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

 

Early occult CNV

intraretinal fluid OCT appears to show cysts as below enlargewhite...intraretinal fluid
red...CNV

 

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.

 

occult ffa

Same patient's FFA enlarge . Late onset fluorescence of undetermined 'origin'

 

early CNV?

enlarge

Consider

  • 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.