We thank Ng and associates for their interest in our article.
The presence of a subretinal hyperreflective exudation (SHE) at baseline represented an inclusion criterion. Although these data present a clinical significance, we are unable to specify the prevalence of SHE in our myopic eyes with positive fluorescein angiography (FA). Further studies assessing the occurrence of SHE in myopic eyes with active choroidal neovascularization (CNV) on FA would be of great interest.
The mean age of the patients included in our study was older than in most publications on myopic CNV. However, a recent series of French patients with myopic CNV treated with ranibizumab also found a mean age of 64 years. In older patients with pathologic myopia, choroidal neovascular lesions may be more extensive and more exudative than in younger patients and tend to look like age-related macular degeneration (AMD) CNV. In our study, myopic CNV presented small dimensions and few exudations. Indeed, spectral-domain optical coherence tomography (SD OCT) showed intraretinal cysts and/or subretinal fluid in only 18 of 31 eyes. We did not find any correlation between age and hyperreflective exudation thickness. Moreover, all patients with AMD-related fundus alterations were excluded.
This SHE lesion could be a form of exudation and thus is probably related to the CNV size. Indeed, Ores and associates found a higher SHE thickness in AMD than in our study. Moreover, SHE lesions size appears higher in the figures of Shah and associates and Ores and associates than in ours. This SHE in myopic CNV is certainly more difficult to detect on SD OCT compared to AMD. The detection of subretinal lesion appears to represent interesting additional information on neovascular myopic activity.
Thanks to Ng and associates’ suggestion, we performed a Pearson correlation coefficient calculation between SHE thickness and visual outcome. We found a positive correlation (correlation coefficient 0.5103) between SHE thickness and logMAR visual acuity ( P = .0034) at baseline. But there was no significant correlation between visual acuity and subretinal lesion thickness at the first visit after treatment and at 6 months. Patients who needed additional injections did not present a thick SHE at baseline.
The use of a dense macular cube allowed obtaining an extensive amount of comparable material during the follow-up. At each subsequent visit, we attempted to overlay matching scans centered on the SHE using the “follow-up” protocol of the OCT. To improve OCT quality, scans could be oriented either vertically or horizontally or obliquely, depending on the staphyloma topography. In cases of lack of fixation, we reduced the scan number, but it is important to keep a dense scan protocol in order to detect slight retinal changes. All included SD OCT scans presented a sufficient quality to detect and follow up the lesion. Patients with doubtful OCT due to poor quality were excluded. But indeed, in “real-life” conditions, the quality of highly myopic OCT may not be sufficient to detect slight retinal changes, and multimodal imaging remains useful.
We hope that our paper and the very important issues raised by Ng and associates will stimulate further research in this field.