Five-year real-world outcomes and patterns of MNV-related atrophy after anti-VEGF therapy in eyes with pathologic myopia

We investigated the long-term visual and structural outcomes in eyes with myopic macular neovascularization (MNV) treated with anti-vascular endothelial growth factor (VEGF) therapy and focused on developmental patterns and associated factors of MNV-related atrophy.

This retrospective, observational study included 39 eyes with treatment-naïve myopic MNV who received intravitreal ranibizumab or aflibercept and were followed for at least 5 years. The best-corrected visual acuity (BCVA), central retinal thickness (CRT), and central choroidal thickness (CCT) were measured longitudinally. Color fundus photography classified the atrophy as perilesional and foveal. Factors associated with atrophy and final BCVA were analyzed.

Over 5 years, the mean BCVA significantly improved from baseline and remained significantly better at all time points (P < 0.05); the CRT and CCT decreased significantly from baseline (P < 0.05). MNV-related atrophy developed in 59% of eyes and foveal atrophy in 38%. Three atrophic types were identified: perilesional (74%), patchy atrophy expansion (22%), and atrophy following subretinal hemorrhage (4%). Perilesional atrophy developed in older patients. Eyes with perilesional or foveal atrophy had worse baseline BCVA, thicker baseline CRT, larger greatest linear dimension, more frequent Meta-Analysis for Pathologic Myopia category 3, subfoveal MNV, and more injections than without atrophy, although none remained significant in multivariate analysis. Multivariate analysis showed foveal atrophy to be the strongest determinant of poorer BCVA.

Anti-VEGF therapy was associated with favorable long-term visual outcomes in myopic MNV. However, MNV-related atrophy, particularly foveal atrophy, was associated with visual decline. The presence of multiple atrophic patterns may suggest heterogeneous underlying mechanisms.