Incidence, Characteristics, and Outcomes of Macular Neovascularization in Extensive Macular Atrophy with Pseudodrusen-like Appearance

Purpose: To report the incidence, features, and clinical outcomes of macular neovascularization (MNV) in a large Italian cohort of patients with extensive macular atrophy with pseudodrusen-like appearance (EMAP). Methods: Retrospective, longitudinal study including 79 EMAP patients (158 eyes) with ≥6 months of follow-up at three retina clinics. Medical records and imaging were reviewed for demographic and clinical data, including age, best-corrected visual acuity (BCVA), MNV features, and retinal pigment epithelium (RPE) atrophy size, measured by short-wavelength autofluorescence and refined with near-infrared and OCT imaging. Main outcomes included cumulative MNV incidence, MNV risk factors, and BCVA and RPE atrophy changes in eyes with and without MNV. Results: Over a mean follow-up of 40.4 months, MNV developed in 14 eyes (10 patients), with a 4-year cumulative incidence of 15.2%. Most MNVs were type 2 (86%) and subfoveal (64%). Cox regression identified younger age, fellow eye involvement, smaller RPE atrophy size, and greater central subfield thickness (all p<0.01) as significant risk factors for MNV. While eyes with MNV had lower baseline BCVA (58.4 vs. 71.4 letters, approximately 20/63 vs. 20/40 Snellen; p=0.005), BCVA decline over time was similar between the two groups (-3.9 vs. -4.1 letters/year, p=0.69). However, RPE atrophy progressed faster in MNV eyes (3.4 vs. 2.8 mm 2 /year, p=0.02). Conclusions: In this EMAP cohort, MNV had a cumulative incidence of 15.2% at 4 years. Although BCVA outcomes were comparable, MNV was associated with faster atrophy progression, potentially due to a more aggressive disease phenotype or fibro-atrophic changes.