Nonexudative Macular Neovascularization Tricky to Identify

Double-layer sign (DLS), identified via OCT, consists of an upper RPE layer and a lower Bruch’s membrane layer visually separated by a space. Click image to enlarge. Advancements in technology bring greater precision to diagnosis but that can lead to missed findings for those who don’t have access to the latest tools. Researchers recently examined 550 eyes of age-related macular degeneration (AMD) patients where both OCT and OCT-A were “performed within 30 days of the date of the first anti-VEGF injection to the fellow eye,” according to a paper on the study published in JAMA Ophthalmology. The mean age of participants was 78 years, and women accounted for 57.3% of the cohort. The researchers also noted other visual and health factors, such as “age, gender, ethnicity, smoking status and visual acuity for both eyes,” with patients’ races consisting of Black, Asian (primarily south Asian ethnicities such as Bangladeshi, Indian, and Pakistani), white “or any individual ethnicity not named in the UK 2011 Census” and smoking status being categorized as either current smokers, nonsmokers and previous smokers.Results showed a double-layer sign (DLS)—an OCT finding indicating the presence of type 1 macular neovascularization—in 20.4% eyes, as well as nonexudative macular neovascularization (neMNV) in 8.5% eyes. The prevalence of neMNV was 48% in eyes that experienced thick DLS compared to 16.2% in eyes with thin DLS. In total, DLS also appeared more often in female participants and in eyes that displayed findings in the ellipsoid zone and the external limiting membrane and presence of hyperreflective foci. Higher neMNV rates also occurred in patients younger than 65.The researchers concluded that “although 20% of fellow eyes of unilateral new-onset exudative AMD have DLS, only 8.6% have neMNV, highlighting the need to diagnose neMNV using OCT-A” rather than relying on “the characteristics of DLS” alone.A subsequent invited commentary on the study, also published in JAMA Ophthalmology, pointed out implications for daily practice and clinical trial design because reliance on DLS alone led to incorrect assumptions and diluted preventive study effects. They also noted that despite the benefits and reliability of OCT-A scans over OCT, the technology “is not as readily available as OCT, may be more technically challenging to obtain because of the need for greater duration of fixation by the patient and can be much more time-consuming to analyze and interpret com- pared with OCT.” In addition, the authors expressed criticism of the study’s use of specifically spectral-domain OCT-A, recommending swept-source OCT-A instead due to its “a longer wavelength of light” and better capacity for macular neovascularization detection.Ultimately concluding that “OCT-A and OCT do not always agree and no clear ground truth exists for the presence of MNV on OCT,” the commentary’s authors recommended that clinicians combine both imaging techniques whenever possible, as well as using fluorescein angiography in unclear situations and “tailoring the use and interpretation of unimodal imaging to each individual patient.”Click here for the journal source. Thottarath S, Gurudas S, Kubravi S, et al. Nonexudative Macular Neovascularization in Age-Related Macular Degeneration. JAMA Ophthalmol. April 09, 2026. [Epub ahead of print] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.