Would you consider AntiVEGF treatment for this case?

A 79 years old lady presented to me with features of ARMD her BCVA is 20/35. Her Right eye fundus photograph shows multiple geographic atrophy areas in the form of RPE loss and some drusen.

Optical coherence tomography

OCT cross-section shows RPE atrophy areas, which features the absence of the RPE layer with pronounced Bruch’s membrane as light is not reflected and passes through the choroid, increasing its reflectivity.

Another finding of the OCT cross-section is an intraretinal cyst and the presence of drusens and disturbance of ellipsoid zone but a normal central retinal thickness.

OCT cross-section showing geographic atrophy with intraretinal cyst

Fundus fluorescein angiography

FFA shows multiple areas of window defect, which appear as increased hyper fluorescence from the atrophic patches without a leak in the late stages confirms that this is a dry advanced ARMD.

Fundus image shows geographic atrophy with drusen

Early FFA phase shows window defect

Mid phase FFA showing increased fluorescence without increase in size or change in borders of the window defect

Later phase FFA showing fading fluorescence without leak or change in borders of the window defect

This is a case of intraretinal cystic changes in the setting of non-neovascular advanced ARMD. Located in the inner nuclear layer that is not causing macular edema with lack of fibrovascular RPE detachment or subretinal hyperreflective material as it is a feature of a wet ARMD.

Cystic changes can be unique or multiple. Usually, they are associated with geographic atrophy due to Muller cell degeneration or loss in the intermediate stage of the atrophic process.

It is important to differentiate cysts in advanced ARMD from outer retinal tabulation, which presents in SD-OCT as a circular or focal structure in outer retinal layers with hype reflective border contains hyperreflective amorphous material.

In neovascular ARMD or Retinal Angiomatous Proliferation, the cystic changes are combined with increased retinal thickening as the sub retina fluid, subretinal hyperreflective amorphous material, or/and pigment epithelial detachment with the presence of leak on FFA from CNVm.

A take-home message

Intra retinal Cysts without causing macula edema in the settings of advanced ARMD should be interpreted with caution. Especially in the absence of pigment epithelial detachment, subretinal hyperreflective amorphous material and leak from CNVM based on FFA or CNVm is ruled out using ICG or OCTa as those cysts do not warrant any treatment.

Please tell me how you would manage this case. Would you inject antiVEGF?

Please check Clinical guidelines for ARMD

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