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Updated: Apr 14, 2026
Author Spotlight: Overcoming Anti-VEGF Resistance Through Advanced Vascular Morphology Assessment in Choroidal Neovascularization
Published on: August 11, 2023
Optical Coherence Tomography Angiography Signs of Vascular Abnormalization With Antiangiogenic Therapy for Choroidal
1Vitreous Retina, Macula Consultants of New York, New York, New York.
Purpose:
To investigate the vascular appearance of choroidal neovascularization (CNV) treated with recurrent intravitreous anti-vascular endothelial growth factor (VEGF) injections, which have been proposed to cause transient vascular normalization along with decreased vascularity and leakage.
Design:
Retrospective case series with perspective on the topic.
Methods:
Patients with treated CNV secondary to age-related macular degeneration from a community-based retinal referral practice were evaluated with optical coherence tomography angiography employing split-spectrum amplitude decorrelation. The choroidal neovascular morphology of the 17 eyes of 14 consecutive patients was described.
Results:
The mean age of the patients, 8 men and 6 women, was 78.4 (standard deviation ± 9.3) years. The mean greatest linear dimension of the lesion was 3600 μm. The mean number of anti-VEGF injections was 47 (±21). The vascular diameter of the vessels in the CNV appeared large even in small lesions, with feeder vessels approaching the size of the major arcade vessels of the retina. The vessels had few branch points and many vascular anastomotic connections among larger vessels. There was a paucity of capillaries visualized within the lesions.
Conclusions:
The findings of this study do not support the hypothesis of vascular normalization in eyes receiving recurrent periodic antiangiogenic treatment. The observed "abnormalization" of the vessels may be explained by periodic pruning of angiogenic vascular sprouts by VEGF withdrawal in the face of unimpeded arteriogenesis. As the eye is a readily accessible VEGF laboratory, features expressed therein may also apply to neovascularization elsewhere in the body, such as in tumors.
Insights
Recurrent anti-vascular endothelial growth factor (VEGF) injections for choroidal neovascularization (CNV) did not normalize vessels. Instead, large, abnormal vessels formed, suggesting periodic pruning of sprouts due to VEGF withdrawal.
Area of Science:
- Ophthalmology
- Vascular Biology
- Medical Imaging
Background:
- Choroidal neovascularization (CNV) is a common cause of vision loss.
- Anti-vascular endothelial growth factor (VEGF) injections are a standard treatment for CNV.
- Vascular normalization is hypothesized to occur with recurrent anti-VEGF therapy.
Purpose of the Study:
- To investigate the vascular morphology of CNV treated with recurrent intravitreous anti-VEGF injections.
- To assess whether anti-VEGF therapy leads to vascular normalization in CNV.
Main Methods:
- Retrospective case series of 17 eyes from 14 patients with treated CNV.
- Optical coherence tomography angiography (OCTA) was used to evaluate choroidal neovascular morphology.
- Split-spectrum amplitude decorrelation imaging was employed.
Main Results:
- Patients received a mean of 47 anti-VEGF injections.
- CNV vessels, including feeder vessels, were large, with few branch points and many anastomoses.
- A paucity of capillaries was observed within the lesions.
Conclusions:
- Findings do not support the hypothesis of vascular normalization with recurrent anti-VEGF treatment.
- "Abnormalization" may result from periodic pruning of sprouts by VEGF withdrawal.
- These vascular changes may have implications for neovascularization in other parts of the body, such as tumors.
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