When Anti-VEGF Therapy Isn’t Helping, Is Exudative AMD the Right Diagnosis?
This retina case study outlines a careful workup for a difficult diagnostic dilemma. What is the correct approach for this 65-year-old woman?
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A 65-year-old woman presented for a second opinion to the Cole Eye Institute Vitreoretinal Service. She had been diagnosed with exudative age-related macular degeneration (AMD) and received four monthly bevacizumab injections, the most recent a month prior at an outside facility.
Her vision had not changed with any of the injections, and she was concerned about the course of treatment. On examination, she had minimal cataracts, and her visual acuity was 20/40 OD and 20/30 OS. Fundus photos revealed a greyish-white lesion OS and relatively normal examination OD without any drusen (Figure 1). The fluorescein angiogram (FA) showed early blocking with late leakage OS (Figure 2). Optical coherence tomography (OCT) showed minimal intraretinal changes and a characteristic subretinal lesion (Figure 3).
Is this examination enough to continue anti-vascular endothelial growth factor (VEGF) injections? Should we switch anti-VEGF agents? Should we add photodynamic therapy? The constellation of findings in this patient led to a differential diagnosis of wet AMD, pachychoroidal neovascularization, chronic central serous chorioretinopathy or adult-onset foveomacular vitelliform dystrophy. OCT angiography (OCTA) is the best option to differentiate these entities.First, the choroid was not thickened, making central serous chorioretinopathy or pachychoroidal neovascularization unlikely. However, it was not thinned as in most wet AMD eyes. OCTA (Figure 4) showed something that was suspicious, but not definitive for a choroidal neovascularization (CNV). This area was devoid of flow in the flow map, making CNV unlikely. Thus, we obtained a fundus autofluorescence image (Figure 5), which revealed the characteristic hyperautofluorescence from the lipofuscin accumulation seen in adult-onset foveomacular vitelliform dystrophy.
We elected to stop the anti-VEGF injections given the lack of neovascularization. The patient has now gone for more than a year without any injections, progression of the lesion or change in vision.
Dr. Kaiser is a retina specialist and the Chaney Family Endowed Chair of Ophthalmic Research.