Myopic CNVM -DIAGNOSIS AND MGT BY dr ajay dudani

Myopic Choroidal
Neovascularization
Ajay Dudani
Mumbai Retina Center

Pathologic myopia: Classified as high myopia plus
degenerative fundus changes
1. Neelam K, et al. Pro Ret Eye Res 2012;31:495-525
D, dioptre; PM, pathologic myopia
No standard definition for pathologic myopia
An eye with PM exhibits at least one of the following1
 Refractive error of ≥-6D
 Axial length of ≥ 26.5 mm
 Fundus changes consistent with PM
Lacquer cracks
Chorioretinal atrophy
Posterior staphyloma

Staphyloma : A hallmark lesion of PM
1. Curtin BJ. Trans Am Ophthalmol Soc 1977;75:67-86
Staphyloma is an abnormal protrusion of the posterior segment of the globe1
This figure is taken from Curtin BJ. Trans Am Ophthalmol Soc 1977;75:67-86 and republished
with permission of the American Ophthalmological Society

Current methods for identification of staphyloma
are limited
Colour fundus photograph and OCT image kindly provided by Professor Ohno-Matsui. Ultrasonography image reprinted with permission from
Thomas M Aaberg Jr, MD, Michigan State University College of Human Medicine, published by Medscape Reference
(http://emedicine.medscape.com/), 2014, available at: http://emedicine.medscape.com/article/1228865-overview.
Ohno-Matsui K. Ophthalmology 2014;121:1798-809
Colour fundus photography
Ultrasonography
Optical coherence tomography
Entire extent of
staphyloma can not
fit into view
Difficult to
reconstruct the
shape of staphyloma
• Staphylomas are often too wide
to fit into the length of the scan
• Steepened curve due to axial
elongation confused with
staphyloma

3D MRI: imaging the shape of the globe in PM
Moriyama M, Ohno-Matsui K, et al. Ophthalmology 2011;118:1626-37
Images courtesy of Professor Ohno-Matsui
3D MRI examines the shape of the globe from any angle and analyzes the
complete shape
Pathologic myopia
Emmetropia
3D MRI, three-dimensional magnetic resonance imaging

Wide-field fundus imaging by Optos allows 200o
panoramic imaging of the fundus
• New classifications of staphyloma made based on 3D MRI findings
• Compared with wide-angle fundus images by Optos to facilitate
identification and classification under conventional clinical
conditions

Staphyloma formation has a negative effect on
patients with pathologic myopia
CNV, choroidal neovascularization
Without
staphyloma
With
any type of
staphyloma
P value
Visual acuity
(logMAR)
0.30  0.05 0.54  0.06 0.0024
Patchy atrophy 10.2% 43.0% <0.0001
CNV 15.3% 38.0% 0.0005
Traction
maculopathy
34.9% 61.9% 0.001

Disease components of myopia
1. RNIB. www.rnib.org.uk;
2. Neelam K, et al. Prog Retin Eye Res 2012;31:495-525
> -6.0 diopter
Progressive, abnormal
elongation of the eyeball
(axial length >26.5mm)
Degenerative
fundus changes
Presence
of myopic CNV
Visual
impairment
High myopia1,2
Pathologic myopia2
Myopic CNV2
Visual
impairment due
to myopic CNV
Myopic CNV can
also occur at less
than -6.0 D,
although the
data available for
this are limited -
most studies
have a cut off of
-6.0 D
Disease
severity
increases

Progression of myopic maculopathy
Macular
atrophy Hayashi K, Ohno-Matsui K, et al.
Ophthalmology 2010;117:1595-611
Patchy
atrophy
Diffuse
atrophy
Tessellated
fundus
CNV
Lacquer
cracks
Visual impairment

Diagnostic imaging tools are used to identify
typical features of myopic CNV
Neelam K, et al. Prog Retin Eye Res 2012;31:495-525
Fundus color photographs
Fluorescein angiography
Indocyanine green angiography
Fundus autofluorescence

Image kindly provided by Professor Ohno-Matsui
Neelam K, et al. Prog Retin Eye Res 2012;31:495-525; Wong TY, Ohno-Matsui K, Leveziel N, Holz F, Lai T, Yu HG, Lanzetta P, Chen Y, Tufail A.
Br J Ophthalmol Published Online First: 1 July 2014, doi:10.1136/bjophthalmol-2014-305131
 Retinal hemorrhage (limited), small lesion

Image kindly provided by Professor Ohno-Matsui
 Hyperfluorescence, discrete leakage

Image kindly provided by Professor Holz
 Dark rim, surrounding CNV

 Hyper-reflective, dome-shaped lesion

Neelam K, et al. Prog Retin Eye Res 2012;31:495-525; Wong TY, et al. Br J Ophthalmol 2014, doi:10.1136/bjophthalmol-2014-305131
 Accumulated lipofuscin within retinal
pigment epithelium
 Hyper-reflective, dome-shaped lesion

Coexisting pathologies should be excluded as
treatment requirements may vary
 Macular hole
 Retinal tear/detachment
 Atrophic changes
 Staphyloma
 Myopic traction maculopathy (MTM)
 Dome-shaped macula
Wong TY, Ohno-Matsui K, Leveziel N, Holz F, Lai T, Yu HG, Lanzetta P, Chen Y, Tufail A.

Other causes of CNV should also be excluded in
order to identify the appropriate treatment
1. Amer R, Lois N. Surv Ophthalmol 2011;56:36-53; 2. Chan WM, et al. Retina 2008;28:71-80;
3. Barisani-Asenbauer T, et al. Orphanet J Rare Dis 2012;7:57; 4. Ozurdex SmPC. August 2013; 5. Avila MP, et al.
Ophthalmology 1984;91:1573–81; 6. Ellies P, et al .J Cataract Refract Surg 2000;26:922-4; 7. Li XX, Tao Y. Chin Med J
2012;125:4424-8; 8. Shi X, et al. Chin Med J 2014;127:2279-85; 9. Kang HM, Koh HJ. Am J Ophthalmol 2013:155:713-9
PDT, photodynamic therapy;
VEGF, vascular endothelial
growth factor
Verteporfin PDT7,8 and anti-VEGF agents9
Lesions often resolve without intervention5,6
Myopic macular hemorrhage due to lacquer cracks
Idiopathic CNV
As a sub-type of uveitis, steroids may be used3,4
Multifocal choroiditis
Submacular surgery, laser photocoagulation, combined intravitreal
steroids with PDT, and anti-VEGF agents used1,2
Punctate inner choroidopathy
These therapies are outside the license of ranibizumab and vPDT

Clinical features of CNV:
myopic CNV versus CNV secondary to AMD
AMD, age-related macular degeneration;
RPE, retinal pigment epithelium
Myopic CNV CNV secondary to AMD
Younger patients Older patients
Age
Morphological features
Small Large
Lesion size
Retinal hemorrhages Scanty Present
Often absent Present
Hard exudates
Neurosensory detachment Shallow and limited Extensive
RPE detachment
Associated features
Absent Present
Lacquer cracks/patchy
atrophy
Occasionally associated with
drusen/pigmentary changes
Fundus fluorescein angiography
Predominantly classic Occult/minimally classic
Minimum Profuse
Angiographic subtype
Dye leakage
Location
Sub/intra-retinal fluid
Type 2 (above RPE layer) Type 1 (below RPE layer)
Negligible Massive
Reprinted from Prog Retina Eye Res, 31/2012, Neelam K, et al, Choroidal neovascularization
in pathological myopia, 495-525, Copyright (2014), with permission from Elsevier

If left untreated, most patients will become
legally blind within 5-10 years
Initial 3 years 5 years ≥ 10 years
Snellen VA scores during follow-up
< 20/200 20/200-20/40 > 20/40
%
Eyes
VA, visual acuity
100
90
80
70
60
50
40
30
20
0
10
22.2 18.5
3.7 3.7
48.2
37.0
29.6
44.5
88.9
96.3
7.4
Reprinted from Ophthalmology, 110/2003, Yoshida T, et al, Myopic choroidal neovascularization
A 10-year follow-up, 1297-305, Copyright (2014), with permission from Elsevier

Early diagnosis and treatment are essential to
prevent poor long term outcomes
Wong TY, Ohno-Matsui K, Leveziel N, Holz F, Lai T, Yu HG, Lanzetta P, Chen Y, Tufail A.
Active phase
Direct damage to
photoreceptors causing
central vision loss
CNV regression
Causes fibrous pigmented
scar formation
Late stage
Atrophy forms around the
regressed CNV
Decreasing visual acuity
Limited treatment window during the
active stage to provide optimal
visual benefits

Recent advances in clinical management
of myopic CNV

Anti-VEGF is the standard of care for the
treatment of patients with myopic CNV
1. VIP Study Group. AAO 2001;108:841-852;
2. Wolf S, et al. Ophthalmology 2014;121:682-92
Verteporfin photodynamic
therapy (vPDT)
• Generally stabilizes, but does
not improve vision1
Ranibizumab
• Demonstrated superiority to
vPDT2
• Rapid and sustained vision
gains over 12 months2

Efficacy of ranibizumab in myopic CNV was
first shown by the REPAIR phase II study
1. Tufail A, et al. Eye 2013;27:709-15;
2. Tufail A, et al. Ophthalmology 2013;120:1944-5
Ranibizumab 0.5 mg
(n = 65)
Interim analysis at
Month 61
Month 1-12: Individualized ranibizumab treatment
12 month primary
endpoint analysis2
REPAIR: Phase II, open-label, single arm, multicentre, 12-month, UK-based study
Primary objective: to evaluate the mean BCVA change from baseline to Month 12
in patients with CNV secondary to PM treated with 0.5 mg ranibizumab

Tufail A, et al. Eye 2013;27:709-15; Tufail A, et al. Eye 2013;28:365
REPAIR: treatment algorithm
FA, fluorescein angiography
NO YES
NO YES
NO YES
Treatment with ranibizumab
0.5 mg
Has the patient experienced a decrease
in BCVA by ≥ 5 letters or reported
increased blurring or metamorphopsia?
Retreatment with
ranibizumab 0.5 mg
Retreatment with
ranibizumab 0.5 mg
Continue to
monitor
Continue to
monitor
Perform FA –
Is leakage evident on FA?
Is there evidence of sub- or
intraretinal fluid on OCT?

REPAIR: ranibizumab improved visual acuity over
12 months in patients with myopic CNV
This figure was published in Tufail A, et al. Ophthalmology 2013;120:1944-5, copyright Elsevier
ETDRS, Early Treatment
Diabetic Retinopathy Study
21.5% of patients required only a single injection over 12 months
Mean change from baseline = +13.8
LOCF
BCVA
(ETDRS
letters)
Visit (day)
75
65
55
70
60
Mean injections = 3.6
Median injections = 3.0
V2
(1)
V3
(30)
V4
(60)
V5
(90)
V6
(120)
V7
(150)
V8
(180)
V9
(210)
V10
(240)
V11
(270)
V12
(300)
V13
(330)
V14
(360)

RADIANCE: first large RCT to compare the
efficacy of ranibizumab with vPDT in myopic CNV
Wolf S, et al. Ophthalmology 2014;121:682-92
RCT, randomized controlled trial
Investigator determines eligibility
Randomized 2:2:1, N = 277
vPDT
(Group III)
(n = 55)
Ranibizumab 0.5 mg
(Group II; disease activity**)
(n = 116)
Ranibizumab 0.5 mg
(Group I; VA stabilization*)
(n = 106)
Non-inferiority assessment (Group II vs Group I) at Month 6
Primary endpoint at Month 3: superiority of ranibizumab over PDT
Study completion at Month 12
From Month 3 able to receive
vPDT and/or ranibizumab
treatment at investigator’s discretion
*Ranibizumab on Day 1 and Month 1, thereafter based on stabilization criterion (no change in BCVA as compared to two preceding monthly
visits); **Ranibizumab on Day 1, thereafter based on disease activity criterion (attributable to intra or subretinal leakage secondary to PM as
assessed by OCT and/or FA)

10.5 10.6 2.2
0
2
4
6
8
10
12
14
Month 3
Ranibizumab 0.5 mg (VA stabilization; Group I; n = 105*)
Ranibizumab 0.5 mg (disease activity; Group II; n = 116)
vPDT (Group III; n = 55)
Mean
average
change
(±SE)
in
BCVA
from
baseline
to
Month
1
through
Month
3
(ETDRS
letters)
p < 0.00001
p < 0.00001
2
Primary endpoint:
both ranibizumab regimens were superior to vPDT up to Month 3
(tested before ranibizumab was allowed in Group III)
Full analysis set (modified last observation carried forward)
*Of the 106 enrolled patients, one patient withdrew from the study before having a post-baseline VA assessment and was
excluded from this analysis; p<0.00001 (both for Groups I and II) vs vPDT; One-sided p-values for treatment difference are
derived from the two-sided stratified Cochran-Mantel-Haenszel test using the row means score statistics; The primary
objective was achieved at the multiple one-sided alpha-level of 0.001
BCVA, best-corrected visual acuity; ETDRS, early treatment diabetic retinopathy study; SE, standard error;
VA, visual acuity; vPDT, verteporfin photodynamic therapy Novartis data on file

2
Key secondary endpoint
Ranibizumab treatment guided by disease activity criteria (1 + PRN inj)
was non-inferior to VA stabilization criteria (minimum 2 + PRN inj)
*Of the 106 enrolled patients, one patient withdrew from the study before having a post-baseline VA assessment and
was excluded from this analysis; p<0.00001 vs Group II; One-sided p-values for treatment difference are derived from
the two-sided stratified Cochran-Mantel-Haenszel test using the row means score statistics
ETDRS, early treatment diabetic retinopathy study; SE, standard error; VA, visual acuity Novartis data on file
11.9 11.7
0
2
4
6
8
10
12
14
Month 6
Mean
average
change
(±SE)
in
BCVA
from
baseline
to
Month
1
through
Month
6
(ETDRS
letters)
p < 0.00001

2
Mean change in BCVA from baseline to
Month 12
Full analysis set (modified last observation carried forward); *Of the 106 enrolled patients, one patient withdrew from
the study before having a post-baseline VA assessment and was excluded from this analysis
BCVA, best-corrected visual acuity; D8, day 8; ETDRS, early treatment diabetic retinopathy study; SE, standard error;
VA, visual acuity; vPDT, verteporfin photodynamic therapy Novartis data on file
-2
0
2
4
6
8
10
12
14
16
0 1 2 3 4 5 6 7 8 9 10 11 12
Ranibizumab 0.5 mg (Group I-VA stabilization; n = 105*)
Ranibizumab 0.5 mg (Group II-disease activity; n = 116)
vPDT (Group III; n = 55) on Day 1;
Rapid and sustained BCVA improvement from baseline to
Month 12 in patients treated with ranibizumab
Months
Mean
change
(±SE)
in
BCVA
from
baseline
to
Month
12
(ETDRS
letters)
13.8
14.4
9.3
D8
12.1
12.5
1.4
vPDT/ranibizumab or both as of Month 3
Less BCVA improvement by PDT treatment at Month 3;
steady increase after allowing ranibizumab after Month 3

3
Proportion of patients gaining ≥ 10 and ≥ 15 letters
(or reaching 84 ETDRS letters) at Month 12
*Of the 106 enrolled patients, one patient withdrew from the study before having a post-baseline VA
assessment and was excluded from this analysis
BCVA, best-corrected visual acuity; ETDRS, early treatment diabetic retinopathy study; VA, visual acuity Novartis data on file
69.5 53.3
69.0 51.7
0
20
40
60
80
100
≥ 10 ETDRS letters ≥ 15 ETDRS letters
Proportion
of
patients
(%)

3
CNV leakage and intraretinal edema
at Month 12
Full analysis set (modified last observation carried forward); *Of the 106 enrolled patients, one patient
withdrew from the study before having a post-baseline VA assessment and was excluded from this analysis
CNV, choroidal neovascularization; VA, visual acuity; vPDT, verteporfin photodynamic therapy Novartis data on file
 Proportion of patients with CNV leakage and intraretinal edema reduced by >70% in
all the three groups from baseline to Month 12
96.2 21.0 84.8 2.9
93.1 19.0 79.3
4.3
100.0 29.1 87.3 1.8
0
20
40
60
80
100
Baseline Month 12 Baseline Month 12
CNV leakage
; vPDT/ranibizumab or both as of Month 3
Intraretinal edema
Proportion
of
patients
(%)

3
Full analysis set (last observation carried forward); CRT data from reading center at Bern *Of the 106 enrolled patients,
one patient withdrew from the study before having a post-baseline VA assessment and was excluded from this analysis
CRT, central retinal thickness; SE, standard error; VA, visual acuity; vPDT, verteporfin photodynamic therapy
Mean change in CRT from baseline to
Month 12
Novartis data on file
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
vPDT (Group III; n = 55) on Day 1
-66.6
-71.3
-60.8
Months
Mean
change
(±SE)
in
CRT
from
baseline
to
Month
12
(µm)
vPDT + ranibizumab as of Month 3
;
Rapid and sustained CRT reduction was noted in
both ranibizumab groups over 12 months
Less pronounced CRT reduction in the vPDT group at Month 3,
after which allowing addition of ranibizumab led to a marked
decline in mean CRT up to month 12

33
Treatment exposure
(full analysis set)
*Three (Group II) and one (Group III) injections could not be classified as sham/active ranibizumab due
to missing/invalid injection ID numbers. These injections are not included in the analysis
SD, standard deviation; VA, visual acuity; vPDT, verteporfin photodynamic therapy Novartis data on file
Full analysis set
Ranibizumab 0.5 mg
(Group I; VA stabilization)
n = 105
Ranibizumab 0.5 mg
(Group II; disease activity)*
n = 116
vPDT
(Group III)*
n = 55
Number of ranibizumab injections (prior to Month 6)
Total 365 289 71
Mean (SD) 3.5 (1.5) 2.5 (1.6) 1.3 (1.2)
Median 3.0 2.0 1.0
Number of ranibizumab injections (prior to Month 12)
Total 488 404 131
Mean (SD) 4.6 (2.6) 3.5 (3.0) 2.4 (2.6)
Median 4.0 2.0 2.0

Ranibizumab provided an average vision gain of
14.4 letters in the DA arm with a median of 2 injections
DA, disease activity
0
4
8
12
16
0 1 2 3 4 5 6 7 8 9 10 11 12
Ranibizumab 0.5 mg VA stabilization (n=105)
Ranibizumab 0.5 mg disease activity (n=116)
vPDT (n=55)
Primary endpoint
Mean
change
(±SE)
in
BCVA
from
baseline
(ETDRS
letters)
Months
Ranibizumab 0.5 mg (VA stabilization, Group I; n = 105)
Ranibizumab 0.5 mg (disease activity, Group II; n = 116)
vPDT (n = 55) Ranibizumab 0.5 mg and/or vPDT as of
Month 3 as per investigators’ discretion
14.4
13.8
9.3
Over 50% of patients needed only 1 or 2 injections
Over 60% of patients needed no further injections in the second 6 months
Reprinted from Ophthalmology, 121/2014, Wolf S, et al, RADIANCE: A Randomized
Controlled Study of Ranibizumab in Patients with Choroidal Neovascularization
Secondary to Pathologic Myopia, 682-92, Copyright (2014), with permission from Elsevier

NEI VFQ-25 improved significantly with
ranibizumab at Month 3, compared with vPDT
Ohno-Matsui K, et al. Invest Ophthalmol Vis Sci
2013;54: E-Abstract 1245; Novartis data on file
NEI VFQ-25, National Eye Institute 25-item Visual Functioning Questionnaire
5.3
4.3
0.3
0
2
4
6
8
Month 3
Ranibizumab 0.5 mg (VA stabilization; Group I; n = 105)
Mean
change
from
baseline
in
NEI
VFQ-25
score
(+
SE)
p<0.05
p<0.05
Mean change in composite NEI VFQ-25 scores
6.6
5.1 4.9
0
2
4
6
8
Month 12
Mean
change
from
baseline
in
NEI
VFQ-25
score
(+
SE)

 Retrospective, multi-center, consecutive case series study
 92 highly myopic eyes with subfoveal CNV, treated with anti-VEGF
either Ranibizumab or Bevacizumab
 Injection protocol: 1 or 3 + P.R.N. as per treating physician
preference
 RESULTS:
• Mean age 57 years
• Mean Total Number of injections: 4.9
• BCVA change: + 7 letters.
[ 46.1 (baseline)  55.5 (Month 12)  50.1  54.2  53.1 (Month 48) letters ]

Intravitreal Ranibizumab Versus Bevacizumab for
Treatment of Myopic Choroidal Neovascularization
 Prospective, single-center, randomized double blind study
 55 patients randomized either to Ranibizumab or Bevacizumab
 Dosing regimen: 1 + P.R.N; 18 months follow up
RESULTS Ranibizumab Bevacizumab
Mean BCVA Change from Baseline 1.8 lines 1.7 lines
Mean number of injections 2.76 4.72
Complete CNV stabilization 100 % 84 %
Complete CNV inactivity after a max of 1
or 2 injections at 18 months
56% 16%

CONCLUSION:
 Compared to baseline BCVA, both Intravitreal Ranibizumab as well
Bevacizumab showed significant improvement in BCVA at 18
months follow up (1.8 lines in Ranibizumab vs 1.7 lines in
Bevacizumab)
 “.., Ranibizumab seems to achieve a slightly greater efficacy than
bevacizumab in terms of the mean number of injections and CNV
stabilization”.

Monitoring disease activities*** for re-treatment
Monthly for Months 1 and 2 and then at
least 3-Monthly in first year
Treatment (RS)*
First-line therapy: licenced anti-VEGF**
Diagnosis (RS) of myopic CNV via FA and OCT
Treatment algorithm highlights need for urgent
referral and prompt anti-VEGF therapy
Wong TY, Ohno-Matsui K, Leveziel N, Holz F, Lai
T, Yu HG, Lanzetta P, Chen Y, Tufail A.
Br J Ophthalmol Published Online First: 1 July
2014, doi:10.1136/bjophthalmol-2014-305131
*Ranibizumab is the only licensed anti-VEGF therapy for myopic CNV; **initiated with a
single injection; ***monitoring for disease activity may include clinical examination, OCT
or FA. Further treatment based on disease activity (reduced VA or lesion activity)
Previously treated
patients
Disease activity/
visual acuity loss
Urgent referral to retina specialist (RS)
Within 1 week of presentation
Presentation
(General ophthalmologist/optometrist)
Naïve myopic patients who experience blurred vision, vision loss
and/or metamorphopsia or any symptom of CNV

Conclusions
Results of RADIANCE confirm those of REPAIR: ranibizumab provides rapid and
sustained BCVA improvements among patients with myopic CNV1,2
Majority of patients needed only 1 or 2 injections over 12 months and >60% of
patients did not need any further injections in the second 6 months of the study1
Symptomatic high myopia patients should be referred urgently to a retina
specialist for diagnosis and prompt treatment of myopic CNV3
Ranibizumab is the only anti-VEGF agent licensed for treatment of myopic CNV
and is the recommended first line therapy3
1. Wolf S, et al. Ophthalmology 2014;121:682-92; 2. Tufail A, et al. Ophthalmology 2013;120:1944-5;
3. Wong TY, Ohno-Matsui K, Leveziel N, Holz F, Lai T, Yu HG, Lanzetta P, Chen Y, Tufail A.

Closing comments
1. Ohno-Matsui K. Ophthalmology 2014;121:1798-809; 2. Wolf S, et al.
Ophthalmology 2014;121:682-92; 3. Tufail A, et al. Ophthalmology 2013;120:1944-5
Innovative imaging techniques have advanced our understanding of PM
morphology1
Prompt diagnosis and early treatment are essential to prevent severe vision
loss in patients with myopic CNV
The 12 month RADIANCE and REPAIR studies have shown compelling
evidence for the efficacy and safety of ranibizumab in the treatment of
myopic CNV2,3

LUCENTIS FOR MYOPIC CNVM
 52 YR MALE
 ONE EYED
 STATUS POSTCATRACT 1 MONTH
 METAMORPHOPSIA
 8 LUCENTIS OVER 1YEAR 9 MONTHS TILL DATE
 VISISON AT START 6/9 N6
 TODAY 6/12 N9

-MYOPIC CNVM WITH LAMELLAR MACULAR HOLE
 65 YR LADY ONE EYED
 VISION 6/6 N8
 HIGH MYOPE LATTICE LASERED
 PSEUDOPHAKIC
 MYOPIC CNVM 2009
 15 PRN AVASTINS
 LAMELLAR MACULAR HOLE
 VISION TODAY 6/9P N12

25 YEAR BOY STATUS POST SCLERAL BUCKLING
 ONE EYED
 HIGH MYOPE
 LE LOST TO RD
 RE SCLERAL BUCKLING DONE
 MYOPIC CNVM AFTER 3 YEARS IN 2011
 IV AVASTIN GIVEN PRN ,NO LOADING DOSE
 4 INJ OVER 4 YEARS 2014
 VISION MAINTAINED 6/12

MYOPIC CNVM POST VITRECTOMY WITH OIL
 45 YR FEMALE
 STATUS POST SB, VIT WITH OIL, PHACO WITH IOL
 CNVM POST 2 YEARS
 3 LOADING AVASTIN IN OIL GIVEN
 3 MORE AVASTN PRN OVER 2 YEARS
 VISION NOW 6/60
 DROPPED FROM 6/18

POSTUVEITIS AND SCLERAL BUCKLE CNVM
 MYOPIA 24D
 BILATERAL PANUVITIS IN REMISSION
 RE LASER TO LATTICES
 LE SCLERAL BUCKLING DONE
 LE MYOPIC CNVM 1` YEAR LATER
 3 LOADING AVASTIN TILL Maximum vision
 The prn avastin 5 injections over 4 years
 Vision 6/24 maintained

MYOPIC CNVM
 65 YR LADY
 PSEUDOPHAKIC
 LE MYOPIC CNVM 2011
 RECEIVED 10 AVASTIN PRN TILL DATE
 VISION MAINTAINED 6/18
 RE LOST DUE TO FOSTER FUCH SPOT
 TRIED AVASTIN BUT NO IMPROVEMENT

OCT guided diagnosis and
treatment of pathologic
myopic CNVM
Dr. Ajay Dudani
MS (Bom) DNB (Ophth) F.C.P.S, DOMS (Bom)
VR fellowship (SN, Chennai & National Nagoya Hospital, Japan)
Professor at KJ Somaiya Medical College and Hospital
Consulting VR surgeon & Laser specialist, Bombay Hospital
Dr. Satyanarayanamurthy Ayyori
MS (Ophth)

 With recent development of SD – OCT, retinal pathological
changes can be observed in greater detail
 It has multiple advantages over FFA
 FFA is an invasive procedure
 Potential side effects range from nausea, pruritis to urticaria
 Visualization of deep retinal and choroidal vessels is limited
using FFA
 Utility of FFA to observe effect of macular edema therapy is
also not well established

Layers on OCT
 From outwards to inwards:
 Internal limiting membrane – visible sometimes
 Retinal nerve fibre layer (RNFL)
 Ganglion cell layer
 Inner plexiform layer
 Inner nuclear layer
 Outer plexiform layer
 Outer nuclear layer
 External limiting membrane (ELM)
 Ellipsoid zone
 Interdigitation zone
 Retinal pigment epithelium

 New terminologies:
 Ellipsoid zone – previously referred to as inner segment/outer
segment junction (IS/OS)
 Interdigitation zone – previously referred to as cone outer
segment tips (COST) or rod outer segment tips (ROST)

 Reflectivity:
 Hyper reflective layers – RNFL, Ellipsoid zone, Interdigitation
zone, RPE
 Moderately reflective layers – plexiform layers, ELM
 Low reflective layers – nuclear layers, inner and outer
segments of photoreceptors

 These lines serve as hallmarks for evaluation of photoreceptor
condition
 Disruption of these outer layers are more reliable indicators in
pathologies like CNV
 FFA only shows presence of leakage in cases of
intraretinal/subretinal fluid collection
 So SD-OCT is a better modality than FFA to assess the activity
and effect of treatment in conditions like myopic CNV

Signs of active CNVM on OCT
 Disruption of Interdigitation zone
 Disruption of Ellipsoid zone
 Disruption of ELM
* Disruption of ELM corresponds to the areas of leakage on FFA

MYOPIC CNV OCT CHANGES
 Earliest histopathological change is seen in Interdigitation zone
 This is followed by Ellipsoid zone
 Then the ELM is disrupted
 Following treatment, layers are restored in reverse order
 First ELM
 Followed by Ellipsoid zone
 Then Interdigitation zone

Studies
 Maurizio Battaglia et al found ELM disruption on SD-OCT in all
30 eyes of their study of active myopic CNVM
 Whereas intraretinal/subretinal fluid was seen in around 85%
of the eyes
 Similarly Pilani et al found that correct diagnosis of myopic
CNVM was reached in 54% eyes with FFA and 94% eyes with FA
assissted OCT

OUR STUDY
 In our study, fluid was seen in 10 eyes and ELM disruption was
seen in all 25 eyes
 Diagnosis and treatment was based on findings of SD-OCT
 Period of follow up was 2 years
 Treatment regimen of Ranibizumab or Bevacizumab was given
as 3-6 injections over 2 years ON PRN BASIS
 Results showed increase in BCVA of two lines on average
 Fluorescein Angiography was not performed in any case

Case 1:
 60 years old female
 High myope with CNVM
 Treatment done with monthly Avastin injection
 Total of 3 injections given

Case 2:
61 years old female patient
One eyed, myopic with CNVM
Pseudophakic

conclusion
 So the presence of undisturbed ELM is a positive predictor of visual
outcome
 Also the restoration of ELM following treatment has better visual
prognosis
 More so important in myopic CNVM where retina is thinner and
shows degenerative changes
 Integrity of ELM is also important in the outcomes of other
conditions like ERM, ARMD, macular holes and retinal detachment

TAKE HOME
 So the condition of retinal layers in various pathologies are well
appreciated on OCT than other investigations
 Hence, OCT is a better modality than FFA for diagnosis and
treatment planning in myopic CNVM
 OCT IS REPEATABLE AND NONINVASIVE
 OCTA WILL OFFER FURTHER REFINEMENTS

Myopic CNVM -DIAGNOSIS AND MGT BY dr ajay dudani

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