VMA associated with poor outcomes in anti-VEGF-treated patients

Reviewed by Márcio B. Nehemy, MD, PhD

Dr. NehemyThe presence of vitreomacular adhesion (VMA) is associated with poorer, short-term anatomic, and functional outcomes in eyes with diabetic macular edema (DME) receiving anti-VEGF therapy, according to Márcio B. Nehemy, MD, PhD.

“We know that anti-VEGF injections can be an effective treatment for DME,” said Dr. Nehemy, professor of ophthalmology, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil. “DME has a complex and multifactorial pathophysiology that could explain differences in response.”

Dr. Nehemy outlined that previous studies have investigated the role of VMA in the response to anti-VEGF treatment for retinal vasculopathies. These studies have been conducted in eyes with age-related macular degeneration.^1-4

“On the other hand, a recent study including patients from READ-3 suggested that eyes with VMA could have a better visual outcome than eyes without VMA.⁵” Dr. Nehemy added. “Our current study was undertaken to further evaluate whether VMA was a biomarker for anti-VEGF outcomes in eyes with DME.”

Study outlined

The study included 195 eyes treated since 2012. Eyes with conditions that could affect the vitreomacular interface or visual acuity were excluded.

The ophthalmic examination in all patients included slit-lamp evaluation, fluorescein angiography, and spectral-domain optical coherence tomography (OCT). Evaluation of the vitreomacular interface was done at the slit lamp and with OCT imaging of the macula and optic disc.

Figure 1. A and B are SD-OCT of two eyes with DME that did not show vitreomacular adhesion. C and D are HD-OCT of the eyes shown in A and B respectively disclosed vitreoschisis with a cortical vitreous attached to the macula. (Images courtesy of Marcio Nehemy, MD)Images from some cases demonstrate the potential for misclassifying eyes as VMA-negative when using macula OCT alone (Figure 1).

“OCT of the macula is not enough to evaluate the vitreomacular interface,” Dr. Nehemy said. “Relying on that technique by itself could explain the different results reported in various studies investigating the association between VMA and response to anti-VEGF therapy.”

At baseline, eyes with VMA had a thicker central retina than eyes without VMA. Other comparisons at baseline showed a higher VMA prevalence in younger versus older patients (mean age of VMA-positive and VMA-negative eyes 58.2 and 62.3 years, respectively) and in men compared with women (55.5 % versus 31.6 %).

Looking at BCVA

Looking at BCVA

Mean BCVA was similar in VMA-negative and VMA-positive eyes at baseline and improved with treatment in both groups at 1 month. However, mean BCVA at 1 month was better in the VMA-negative group than in the VMA-positive group.

Central retinal thickness also improved (decreased) in both groups, but the magnitude of improvement was greater in VMA-negative eyes. Dr. Nehemy explained some illustrative cases, including a patient with bilateral VMA, treated with anti-VEGF in both eyes, that presented a better anatomic and visual outcome in the eye that presented VMA release after six injections (Figure 2).

Figure 2. OCT and visual acuity of the right and left eye of the same patient. After six aflibercept injections in each eye, there was a VMA release in the right eye with improvement in edema, retinal thickness, and visual acuity. In the left eye, the VMA persisted as well as the edema and the vision decreased one line.Dr. Nehemy proposed several explanations for the greater benefit of anti-VEGF treatment observed in eyes without VMA.

“It is possible that persistent VMA favored maintenance of macular edema by preventing diffusion of oxygen and nutrients, confining proangiogenic cytokines, or inducing low grade, chronic inflammation,” he said.

Discussing limitations of the research, Dr. Nehemy noted there was no comparison of outcomes between eyes with focal versus broad VMA, nor analyses considering total vitreous detachment, total vitreous attachment, and vitreoschisis.

References

1. Nehemy MB, Veloso CE, Almeida LN. Importance of vitreomacular adhesion on antiangiogenic treatment for exsudative AMD. Poster presented at AAO meeting ,2011, Chicago, USA

 2. Mayr-Sponer U, Waldstein SM, Kundi M, et al. Influence of the vitreomacular interface on outcomes of ranibizumab therapy in neovascular age-related macular degeneration. Ophthalmology. 2013;120:2620-2629.

3. McKibbin MA, Suter CA, Willis TA. The influence of vitreomacular adhesion on outcomes after aflibercept therapy for neovascular age-related macular degeneration. Retina. 2015;35:1951-1956.

4. Kanadani TC, Dos Reis Veloso CE, Dorairaj S, Nehemy MB. Influence of vitreomacular adhesion on anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration. Ophthalmic Res. 2017 Mar 17. doi: 10.1159/000459626. [Epub ahead of print]

5. Sadiq MA, Soliman MK, Sarwar S, et al. Effect of vitreomacular adhesion on treatment outcomes in the ranibizumab for edema of the macula in diabetes (READ-3) Study. Ophthalmology. 2016; 123:324-329.

Marcio Nehemy, MD, PhD

E: mbnehemy@terra.com.br

This article is based on a presentation delivered by Dr. Nehemy at the 2017 Retina World Congress. He has no proprietary or commercial interest in any materials discussed in this article.