Characterisation of poor outcomes of neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor agents

Purpose:To investigate the incidence, characteristics and baseline predictors of poor visual outcomes in eyes with neovascular age-related macular degeneration (nAMD) receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in daily clinical practice. Design:Observational study. Participants:Treatment-naïve eyesstarting anti-VEGF therapy for nAMD between 2007 and 2012 tracked in the Fight Retinal Blindness! registry.Cases had sustained ≥15 letters of loss from baseline without recovery of visual acuity (VA) at final endpoint.A subgroup analysis included eyes thatsustained ≥30 letters of loss. Controls had not sustained ≥15 letters of loss. Methods:Kaplan-Meier curves estimated time to first development of loss of ≥15 letters. Cox-proportional hazards models evaluated predictors of loss of ≥15 letters. Main Outcome Measures: The proportion of eyes with sustained VA loss within5 years, the time to development of sustained VA loss and baseline predictors of sustained VA loss. Results:There were 1760 eyes in total and 856 eyes that completed 5 years follow-up. The proportion of eyes with sustained VA loss of ≥15 letters at 5 years was 22.9% (95%CI, 20.7-25.1) andVA loss of ≥30 letters was 10.8% (95%CI, 9.1-12.5). Factors independently associated with higher incidence of sustained ≥15 letter loss included age >80 years (odds ratio [OR], 1.33 for patients >80 years vs. ≤80 years; 95%CI, 1.05-1.69; P =.02), fewer injections(OR, 0.97 per injection; 95%CI, 0.96-0.98; P=.0005) and more visits at which the choroidal neovascularisation was graded as active (OR, 1.97 for eyes in upper quartile of active visits vs. eyes in lowest quartile of active visits; 95%CI, 1.39-2.79; P=.0001). Baseline VA≥70 letters was associated with reduced risk of sustained ≥30 letter loss (OR, 0.61; 95%CI, 0.38-0.98; P=.04). Baseline angiographic lesion criteria were not significantly associated with sustained VA loss. Conclusions:Twenty-three percent of eyes with nAMD developed sustained VA loss of ≥15 letters over 5 years of anti-VEGF therapy. Baseline predictors of poor outcomes provide more accurate assessment of the potential benefit from anti-VEGF therapy.