Grand Rounds

We report a longitudinally imaged case of a patient with intermediate age-related macular degeneration (AMD) who initially presented with exudative macular neovascularization (MNV) Type 3 in her left eye. Diagnosis was confirmed based on characteristic structural OCT findings, including intraretinal hyperreflective foci, cystoid macular edema, and focal pigment epithelial detachment. Swept-source OCT angiography (SS-OCTA) revealed high-flow intraretinal tufts originating from the deep vascular complex (DVC), consistent with early-stage Type 3 MNV. The patient underwent a sustained anti-VEGF regimen with intravitreal aflibercept (2.0 mg), receiving 22 injections over a 30-month period, yielding partial anatomical and functional response. Ongoing SS-OCTA surveillance revealed not only persistent Type 3 lesion activity but also the emergence of a sub-RPE neovascular network consistent with Type 1 MNV morphology. The new lesion was characterized by a classic double-layer sign (DLS), localized flow on the RPE–Bruch’s membrane slab, and en face OCTA patterns described as "sea-fan" and "medusa," suggesting independent neovascular proliferation rather than morphological transformation of the original lesion. Due to persistent of lesion, treatment was escalated to intravitreal faricimab (6 mg), followed by a transition to high-dose aflibercept (8 mg). While partial anatomical improvement was achieved, the case exemplifies the challenge of treating multifocal, morphologically distinct neovascular lesions within the same eye. This case underscores the critical role of high-resolution longitudinal SS-OCTA in identifying coexisting neovascular subtypes, distinguishing treatment-refractory components, and guiding therapeutic escalation. It also highlights that new lesions may develop independently during anti-VEGF therapy, challenging the notion of linear lesion evolution and emphasizing the dynamic nature of neovascular AMD.

Presentation Date: 05/15/2025
Issue Date: 04/17/2026