Full-thickness macular hole formation following anti-VEGF injections for neovascular age-related macular degeneration

Abstract

PurposeMacular hole (MH) is part of a group of age-related degenerative diseases characterized by pathology of vitreomacular interface. Similarly, neovascular age-related macular degeneration (nAMD) affects older patients and is a leading cause of irreversible visual loss. The purpose of this case series is to describe the development of full-thickness MH in patients with nAMD, following antivascular endothelial growth factor (anti-VEGF) treatment.MethodsParticipants in this case series were four patients with nAMD, who received anti-VEGF injections with variable therapeutic response to treatment. Patients were examined at baseline (when AMD was diagnosed) and monthly thereafter. The examination included visual acuity measurement, slit-lamp biomicroscopy, and optical coherence tomography.ResultsAll patients were found to develop full-thickness MH within 1–4 months after the last anti-VEGF injection, even in the absence of pre-existing vitreomacular interface abnormalities in some cases. The median number of injections before the MH formation was 3.ConclusionMH formation may represent an adverse effect of anti-VEGF treatment in patients with nAMD and could be also coexisting pathology with nAMD in older individuals.

Simultaneous development of full-thickness macular hole and neovascular age-related macular degeneration

“… 2 , 3 MH secondary to nAMD is also often associated with therapeutic intervention for nAMD, including the injection of anti-vascular endothelial growth factor agent into the vitreous. 4 , 5 , 6 , 7 The pathogenesis of these secondary MHs has been attributed to vitreomacular tractional force, 5 pigment epithelium contraction, 6 or retinal vulnerability due to exudative changes or intervention. 4 In the present case, preoperative examinations suggested total posterior vitreous detachment and no vitreomacular traction was observed during surgery; however, the undetected vitreomacular traction or contractive force of the epiretinal membrane may have been aggravated by exudation at the fovea due to choroidal neovascularization, leading to MH formation.…”

Vitrectomy in full thickness macular holes on top of a pigment epithelial detachment in age-related macular degeneration (AMD). Surgical consideration and review of the literature

“…17 In addition to their primary vascular exudation, most eyes present signs of epiretinal traction or VMT, predisposing tangential or anteroposterior traction after each injection. 18 , 19 , 20 , 21 , 22 , 23 Several epiretinal or SR mechanisms may trigger the formation of MH after intravitreal injections: first, the applied volume of fluid and its chemical compounds modify and liquefy the structure of the vitreous gel (syneresis), 24 leading to incomplete PVD and anteroposterior traction on the VMT. Second, Grigoropoulos et al hypothesised that the mechanical insertion of the injection needle leads to a globe deformation and retinal traction, while the removal of the needle may cause a consecutive vitreous micro-incarceration exacerbating the underlying VMT.…”

“…While several papers described the rare development of MH after intravitreal injections in greater detail postulating the underling pathomechanism, 18 , 19 , 20 , 21 , 22 , 23 only 9 reported eyes have been treated by PPV ( Table 1 ): One of these case reports was previously published by us 7 : This was a 67-year-old female with a subfoveal PED and adjacent occult CNV. During the full up-loading phase by three uneventful intravitreal ranibizumab injections, she developed an accelerating VMT and finally an MH on top of the PED.…”

Simultaneous retinal pigment epithelium tear and lamellar macular hole evolving to a full-thickness macular hole after intravitreal injection

“…On the other hand, several pathogenic mechanisms have been involved in the formation of MH in AMD [4][5][6][7][8]:…”

“…• formation of an epiretinal membrane (ERM) by exudative changes arised from the neovascular complex [4]; • changes on the vitreoretinal interface in patients treated with IVT [5], due to the vitreous incarceration at the puncture point or by vitreous structural changes with syneresis, formation of partial vitreous detachment and vitreomacular traction after injection; • contraction of the neovascular membrane with tangential traction of the retina from the subretinal side [6,7]; • tractional mechanisms do not appear to be found in all patients with MH [5].…”