Case of the Month | September 2021

Case of the Month
September 23, 2021

The Case

The patient was a 93-year-old woman who complained of decreasing vision in both eyes over the last 6 months. She was last treated for a choroidal neovascular membrane (CNVM) in the left eye in 2016. Her visual acuity was 20/50 OD and 20/50-2 OS. In 2016, her acuity was 20/40 OD and 20/50 OS. The OCT and OCTA of the right eye are provided. What is the most likely diagnosis? What treatment, if any, would you recommend?

Our patient has a broad, shallow pigment epithelial detachment without associated subretinal fluid or macular edema. Ocular coherence tomography angiography (OCTA) shows a large, nonexudative choroidal neovascular membrane (CNVM). These lesions are frequently better defined with OCTA than with fluorescein angiography.(1) A recent study of 76 patients with exudative CNVM related to polypoidal vasculopathy found that 18% had nonexudative CNVM in the contralateral eye.(2)

It is unclear whether or not eyes with nonexudative CNVM should receive anti-VEGF treatment. These eyes frequently progress to exudative disease, requiring treatment.(1) However, it is possible that the neovascularization is an adaptive response to the oxygen and/or nutritional needs of local tissues, and induced regression of the neovascularization might be deleterious. There are ongoing studies to address this question. Unless there has clearly been a loss of vision, we generally do not treat nonexudative CNVM. Our patient had stable Snellen acuity, and we recommended close observation.

1. Bailey ST, Thaware O, Wang J, et al. Detection of nonexudative choroidal neovascularization and progression to exudative choroidal neovascularization using OCT angiography. Ophthalmol Retina 2019;3:629-636.

2, Yanagi Y, Mohla A, Lee W-K, et al. Prevalence and risk factors for nonexudative neovascularization in fellow eyes of patients with unilateral age-related macular degeneration and polypoidal choroidal vasculopathy. Invest Ophthalmol Vis Sci 2017;58:3488-3495.

Case Photos

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Our patient has a broad, shallow pigment epithelial detachment without associated subretinal fluid or macular edema. Ocular coherence tomography angiography (OCTA) shows a large, nonexudative choroidal neovascular membrane (CNVM). These lesions are frequently better defined with OCTA than with fluorescein angiography.(1) A recent study of 76 patients with exudative CNVM related to polypoidal vasculopathy found that 18% had nonexudative CNVM in the contralateral eye.(2)

It is unclear whether or not eyes with nonexudative CNVM should receive anti-VEGF treatment. These eyes frequently progress to exudative disease, requiring treatment.(1) However, it is possible that the neovascularization is an adaptive response to the oxygen and/or nutritional needs of local tissues, and induced regression of the neovascularization might be deleterious. There are ongoing studies to address this question. Unless there has clearly been a loss of vision, we generally do not treat nonexudative CNVM. Our patient had stable Snellen acuity, and we recommended close observation.

1. Bailey ST, Thaware O, Wang J, et al. Detection of nonexudative choroidal neovascularization and progression to exudative choroidal neovascularization using OCT angiography. Ophthalmol Retina 2019;3:629-636.

2, Yanagi Y, Mohla A, Lee W-K, et al. Prevalence and risk factors for nonexudative neovascularization in fellow eyes of patients with unilateral age-related macular degeneration and polypoidal choroidal vasculopathy. Invest Ophthalmol Vis Sci 2017;58:3488-3495.

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