Recurrence Rate of Choroidal Neovascularization in Neovascular Age-Related Macular Degeneration Managed with a Treat-Extend-Stop Protocol

Abstract

Purpose: To examine visual outcomes and recurrence rates in patients with choroidal neovascularization (CNV) resulting from neovascular age-related macular degeneration (nAMD) with successful cessation of therapy using a treat-extend-stop (TES) protocol.

Design: Cohort study.

Participants: Three hundred eighty-five eyes of 321 patients with nAMD identified in clinical practice and treated with a TES protocol between 2008 and 2016.

Methods: Retrospective review of patients initially managed with 3 anti-vascular endothelial growth factor (VEGF) injections at 4-week intervals; treatment was extended if the macula remained "dry" based on spectral-domain OCT, using a TES protocol. Treatment was stopped if warranted and was reinitiated if there was a new or recurrent CNV.

Main outcome measures: Percentage of eyes meeting criteria for treatment cessation and percentage experiencing recurrence after treatment cessation, average time to recurrence, and visual function at each of these time points, including recovery of vision after reinstitution of therapy.

Results: A total of 37.3% of eyes met criteria for treatment cessation, with an average follow-up of 27 months. Overall recurrence rate was 29.4% at a mean time interval of 14 months for patients who stopped anti-VEGF therapy. In those patients whose CNV recurred, 54.8% recurred in the first year and 26.2% recurred in the second year after treatment was stopped. Average initial vision was 20/70 and improved to 20/50 (P < 0.001) after patients met criteria for cessation of therapy. A mean loss of vision occurred with recurrence (20/60; P < 0.003). However, once therapy was reinitiated, visual acuity recovered to the level at TES completion and wasn't statistically different than at final treatment (20/50; P < 0.34). Overall, 54.8% of eyes that demonstrated a recurrence of CNV had final vision of 20/40 or better compared with 45% of patients at the time of recurrence and 60% before recurrence.

Conclusions: After completing the TES protocol, 29.4% of patients showed recurrence of CNV. Patients who lost vision with recurrence recovered to the level of vision at treatment cessation with reinstitution of therapy. Patients managed with a TES protocol may stop therapy successfully and maintain improved vision even if the CNV recurs.