March/April 2014 · Vol. 45, No. 2 175 ■ BRIEF REPORT ■ Neovascular AMD With Marked Macular Fluid and Rapid Response to Anti-VEGF Therapy Edward Wood, MD; Jonathan S. Chang, MD; Harry W. Flynn Jr., MD; John W. Kitchens, MD ABSTRACT: The authors describe the clinical man- agement and spectral-domain optical coherence tomography (SD-OCT) findings of three unusual cases of neovascular age-related macular degenera- tion (AMD). Each patient presented with decreased vision and a diagnosis of neovascular AMD, with SD-OCT findings of marked macular fluid. Macu- lar fluid was noted to be subretinal fluid, pigment epithelial detachment, or both. In each case, visual acuity improved and the fluid resolved rapidly with monthly anti–vascular endothelial growth factor therapy. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:175-178.] INTRODUCTION Age-related macular degeneration (AMD) is a lead- ing cause of legal blindness in people older than 50 years in the developing world. 1-3 Neovascular AMD is caused by an imbalance between proangiogenic vascular endothelial growth factor (VEGF) and anti- angiogenic pigment epithelial-derived growth factor (PEDF). VEGF overexpression in the retinal pigment epithelium (RPE) leads to choroidal neovasculariza- tion (CNV), and anti-VEGF therapy reduces the to- tal area of CNV and area of leakage from CNV. 1 The anti-VEGF therapeutic options include pegaptanib (Macugen; Valeant Pharmaceuticals International, Laval, QC), a selective inhibitor of VEGF165; off-label bevacizumab (Avastin; Genentech, South San Fran- cisco, CA), a full-length humanized monoclonal an- tibody with two VEGF-A binding sites; ranibizumab (Lucentis; Genentech, South San Francisco, CA), an antibody fragment that binds to and inhibits all VEGF isoforms; and aflibercept (Eylea; Regeneron, Tarry- town, NY), a soluble fusion protein consisting of two extracellular cytokine receptor domains and a human Fc region of immunoglobulin G. 3 Three patients presenting with wet AMD and an unusually large amount of macular fluid who experi- enced rapid visual and anatomic improvement with anti-VEGF therapy are reported (Table, page 178). CASE REPORTS Case 1 An 88-year-old man presented with visual acuity (VA) of 20/200 and distortion in the right eye for 2 months. Examination revealed pseudophakia, with a large serous detachment of the macula and no vis- ible retinal hemorrhage (Figure 1A, page 176). The fellow eye had large drusen. Spectral-domain optical coherence tomography (SD-OCT) showed localized pigment epithelial detachments (PEDs) on the nasal margin of the serous detachment of the macula, with a central foveal thickness (CFT) of 321 μm (Figure 1B, page 2). The patient was diagnosed with neovascular AMD, with large serous detachment of the macula to- gether with small RPE detachments in the right eye. He was started with an intravitreal injection of ra- nibizumab 0.5 mg in the right eye. After five monthly injections of ranibizumab, the SRF improved; the pa- tient received five additional injections of aflibercept 2.0 mg, and the PED improved. Injections were ad- From the University of Kentucky College of Medicine, Lexington, Kentucky (EW); the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (JSC, HWF); and the Retinal Associates of Kentucky, Lexington, Kentucky (JWK). Originally submitted May 21, 2013. Accepted for publication November 1, 2013. Posted online February 10, 2014. Supported by National Institute of Health Center grant P30-EY014801 and an unrestricted grant to the University of Miami from Research to Prevent Blindness. Dr. Flynn is a consultant for Vindico Medical Education. Drs. Wood, Chang, and Kitchens have no inancial or proprietary interest in the materials presented herein. Address correspondence to Jonathan S. Chang, MD, Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; 305-326-6000; fax: 305-326- 6417; email: jchang7@med.miami.edu. doi: 10.3928/23258160-20140205-02