Optical Coherence Tomography Suggested Best Detector of Macular Fibrosis

A recent post hoc analysis has indicated that spectral domain optical coherence tomography (SD-OCT) is a more reliable and beneficial method of detecting macular fibrosis, one of the precipitators of neovascular age-related macular degeneration (nAMD).1

“Persistent, well-defined [hyperreflective material] HRM on SD-OCT could represent a more sensitive method of detection of fibrosis, but this technology remains untested against the established standards,” wrote Lajos Csincsik, Queen’s University Belfast, and colleagues. “The present study was therefore undertaken to test the agreement between the existing reference standard, color imaging and the other commonly used modalities of FA and SD-OCT for detecting HRM as the proxy for fibrosis.”1

The initial study, the Early Detection of Neovascular AMD (EDNA) study, was a 3-year multicenter, prospective, cohort, comparative diagnostic accuracy study that enrolled 552 participants across 24 retina clinics throughout the UK. Participants were ≥50 years of age with newly diagnosed nAMD in 1 eye and an unaffected “fellow eye” with a best-corrected visual acuity of ≥68 ETDRS letters. The conclusion of EDNA stated that SD-OCT should be considered as the primary method of monitoring patients with nAMD.2

Csincsik and colleagues, however, prioritized examination of the eye first affected by nAMD to grade for fibrosis. Using EDNA’s multimodal fundus images (color, fluorescein angiography [FA], and SD-OCT) of 130 individual eyes, each one with nAMD, the team assessed the agreements between the three listed modalities in identifying fibrosis.1

After analysis, the team indicated that fibrosis was found in 38 of 125 eyes on color and 50 of 125 eyes on FA, while HRM was detected in 73 of 130 eyes on SD-OCT. The agreement between color, which is the current standard, and FA was 0.56 – color detected a 29.6% proportion of fibrosis, while FA detected 40% (P <.05). The agreement between color and SD-OCT was .40 (P <.001), which the team indicates is at the bottom of the “fair to good agreement” category.1

Csincsik and colleagues noted that, while sensitivity for color or FA both exhibited high degrees of success (68.8%-87.5%), SPE (sub-retinal pigment epithelium) fibrosis saw a substantial decrease in sensitivity from both FA and color (15.2% for color and 31.3% on FA). Combining the two saw a slight increase in sensitivity (33.3%) for only SR HRMs. Specificity was more consistently high – 79.6% for FA, 77.2% for the combination, and 94.7% for color alone. However, SD-OCT outperformed both modalities consistently.1

The team indicated that these results heavily favor SD-OCT as the superior modality for fibrosis, and therefore nAMD, detection. This is largely because of HRM’s effectiveness as a surrogate for fibrosis compared against those used by color and FA imaging.1

“Based on the findings of our agreement studies, we propose that SD-OCT be used as the imaging modality of choice for the detection of fibrosis, replacing color imaging as the reference standard,” wrote Csincsik and colleagues. “With the recent high levels of interest in evaluating the antifibrotic properties of new therapies, we suggest that using SD-OCT to determine prevalent and incident fibrosis, its location in relation to the RPE, and its dimensions following treatment represent a potentially valuable set of anatomic endpoints.”1

References

1. Csincsik L, Cheung CMG, Bannon F, Peto T, Chakravarthy U. Agreement Between Color, Fluorescein Angiography, and Spectral Domain Optical Coherence Tomography in the Detection of Macular Fibrosis in Neovascular Age-Related Macular Degeneration. Am J Ophthalmol. 2025;272:126-135. doi:10.1016/j.ajo.2025.01.011

2. Sivaprasad S, Banister K, Azuro-Blanco A, et al. Diagnostic accuracy of monitoring tests of fellow eyes in patients with unilateral neovascular age-related macular degeneration. Ophthalmology. 2021;128(12):1736-1747. doi:10.1016/j.ophtha.2021.07.025