Patients with exudative age-related macular degeneration (wet AMD) who are treated with ranibizumab may experience lower visual gains if they have certain structural characteristics, according to a poster presented at the American Society of Retina Specialists 2022 meeting in New York, held July 13-16. The study used optical coherence tomography (OCT) to demonstrate an association between findings of uncertain significance and visual gains after treatment with the anti vascular endothelial growth factor (VEGF) injection.

The presence of a prechoroidal cleft, intraretinal or subretinal pseudocysts, or choroidal caverns, were all linked with lower visual gains after treatment, the research shows.

It also notes that an association exists between the presence of the onion sign (layered, hyperreflective subretinal pigment epithelium lines), and good anatomical and functional prognosis.

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The study reviewed 83 eyes of 83 patients (mean age 77±8.36 years, 56.6% women) with baseline best-corrected visual acuities (BCVA) of 29.76±22.66 in Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Following injections with ranibizumab, the cohort’s BCVA was 33.4±24.24 ETDRS, with a mean difference between pre and post-treatment of 3.67±13.68 ETDRS. 

The group was divided according to the presence of any of the structural characteristics of uncertain significance (prechoroidal cleft, intraretinal and subretinal pseudocysts, choroidal caverns, and the onion sign). Researchers noted each group’s change in ETDRS letters after treatment. Those with the onion sign (32 eyes) experienced a +5.6 gain in ETDRS letters (P =.04), while those without it (51) experienced a +2.5 gain (P =.16). 

Patients with a prechoroidal cleft (18) had a +3.6 gain (P =.15), and those without it (65) had a +3.7 gain (P =.04). Patients with a finding of intraretinal pseudocyst (18) experienced a +1.8 ETDRS letter gain (P =.54), while those without it (51) experienced a +4.8 ETDRS letter gain (P =.002). Patients with a subretinal pseudocyst (16) experienced no difference in ETDRS letters after treatment (P =1.0) and those without it (67) experienced +4.6 ETDRS letter gain (P =.0005). Patients with choroidal caverns (17) experienced a +0.9 ETDRS letter gain (P =.83) and those without it experienced a +4.4 ETDRS letter gain (P =.0065).

“The onion sign could significate an active [choroidal neovascularization] that could be beneficiated of treatment, this could be due to chronic exudation trapped in tissue with abundant fibrosis,” the researchers speculate. The other biomarkers of uncertain significance obtained using OCT may be suitable to predict visual acuity in patients with wet AMD, according to the researchers. This data may be used to guide the treatment and follow-up of the patients, the researchers report.


Hayashi-Mercado R, Rios G. Findings of uncertain significance by oct as prognostic factors in wet amd treated with ranibizumab. Poster presented at: The 40th annual meeting of the American Society of Retina Specialists; June 13-16, 2022; New York, NY. Poster 104.